16977	----	Note: Project Gutenberg also has an HTML version of this file which includes the original illustrations. See 16977-h.htm or 16977-h.zip: (http://www.gutenberg.net/dirs/1/6/9/7/16977/16977-h/16977-h.htm) or (http://www.gutenberg.net/dirs/1/6/9/7/16977/16977-h.zip) FOOD AND HEALTH DO WOMEN READ our little books which come so regularly to their homes? Indeed they do, and if only one is left at a two-family house we are asked to send another at once. We feel sure that they are read from cover to cover. * * * * * LYDIA E. PINKHAM'S MEDICINES Lydia E. Pinkham's Vegetable Compound The original Pinkham medicine and best known of all. It has been on the market for nearly fifty years and is put up in the following forms: Liquid. Dose--One tablespoonful every four hours through the day. Dry (Tablets). Dose--One tablet every four hours through the day. Lydia E. Pinkham's Sanative Wash. FOR LEUCORRHOEA AND INFLAMMATION Liquid, a concentrated extract, ready to dilute and use at once, the most convenient form. Use daily as a vaginal injection. Add one teaspoonful (in severe cases two teaspoonfuls) of the Sanative Wash to one pint of warm water, mix thoroughly and it is ready for use. (Can be had, if preferred, in dry form, to steep.) Lydia E. Pinkham's Blood Medicine. FOR POOR BLOOD We recommend this as a good blood medicine for either men or women. Dose--One tablespoonful three times a day, half an hour before eating. Lydia E. Pinkham's Liver Pills. FOR CONSTIPATION Dose--Take three the first night, two the second, and one the third; and unless there is a regular and healthy movement of the bowels continue taking one every night. FOR SALE BY DRUGGISTS GENERALLY Send for LYDIA E. PINKHAM'S PRIVATE TEXT BOOK UPON AILMENTS PECULIAR TO WOMEN, mailed free on application to THE LYDIA E. PINKHAM MEDICINE CO. Lynn, Mass., Public Inspection of our Laboratories Cordially Invited. HINTS FOR MEALTIME How often do we hear women exclaim, "Oh dear, what shall I have for the next meal?" This little book will aid you in answering that troublesome question. The recipes are carefully selected and we hope you will find them helpful. More important to you than the question of food is that of health. Therefore, in this book we show you many letters from women who have received great benefit by taking Lydia E. Pinkham's Vegetable Compound. You have heard of this splendid medicine, for it has been used by women for nearly fifty years. It is a Woman's Medicine for Women's Ailments. It is prepared from medicinal plants that are especially adapted for the treatment of the troubles women so often have. As you read these letters remember these women are stating for the benefit of other women who are sick just how they felt and just how the Vegetable Compound restored them to health. You know it is bad enough to worry over the various duties of life when you are well and strong. It is a serious matter when you are half sick and all tired out most of the time. So in the following pages you will find suggestions for the next meal that may help you, but more important by far are the letters recommending Lydia E. Pinkham's Vegetable Compound as the splendid medicine for the ailments of women. You will read letters from many classes of women, young and old, mother and daughter. They are genuine expressions of gratitude from one woman to another. Thousands of women by word of mouth and by letter highly praise Lydia E. Pinkham's Vegetable Compound. "Of all the world's wealth The best treasure is health, For without it there's nothing worth while." BAKING OF BREAD AND ROLLS [Illustration] The pans should be well oiled and the loaves should never more than half fill them. Bread should be put into a hot oven and loaves should rise during the first fifteen minutes. It should continue browning for the next twenty minutes then reduce the heat somewhat. Small loaves require 45 minutes, large ones 1 hour. Biscuits and rolls require a hotter oven than bread. They should rise for the first five minutes and then should begin to brown. After 15 minutes reduce the heat and at 30 minutes the biscuits should be golden brown and thoroughly baked inside. Remove bread from the pans as soon as it comes from the oven. Keep covered with a clean cloth until cool then place in a stone jar or tin box. WHAT DOES YOUR DRUGGIST SAY when you ask him if he can recommend any good medicine to you because you are nervous and run-down and not able to get your work done? He suggests that Lydia E. Pinkham's Vegetable Compound is a well-known and well-made medicine and that he knows many women who take it and recommend it. "COULD NOT WORK HALF THE TIME" "For many years I have had troubles with my nerves and have been in a general run down condition for some time. I could not do my work half the time because of troubles every month. I was told of Lydia E. Pinkham's Vegetable Compound by friends and advised to try it. It has done me good and I strongly recommend it. Since I have taken it I have been able to do all my own work, and I also know friends who have found it good. You can use these facts as a testimonial." MRS. ELLEN FLATTERS, Box 761, Cobourg, Ontario. WHITE BREAD [Illustration] Ingredients 1 tablespoon lard 1 tablespoon butter 1-1/2 teaspoons salt 1 tablespoon sugar 1 cup scalded milk 1 cup boiling water 1 yeast cake in 1/4 cup lukewarm water 6 cups sifted flour Method--Put lard, butter, salt and sugar into large bowl. Pour over them the scalded milk and boiling water. When this is lukewarm add the yeast cake dissolved in luke-warm water. Sift in flour gradually, beating with a spoon. Toss on a floured board and knead until smooth. Allow it to rise over night in a moderately warm place or until it doubles its original size. Cut down or knead and allow it to rise until light, then form into loaves or biscuits. Allow these to rise until light, then bake. The amount of yeast used will depend on the length of time the bread is allowed to rise. WHAT DO GIRLS DO who don't have mothers to advise them about their health? "SHE WAS UNABLE TO ATTEND SCHOOL" "Lydia E. Pinkham's Vegetable Compound was recommended to me for my daughter. She had trouble every month which left her in a weak and nervous condition, with weak back and pain in her right side. She had these troubles for three years and frequently was unable to attend school. She has become regular and feels much better since she began taking the Vegetable Compound and attends school regularly. She is gaining steadily and I have no hesitancy in recommending Lydia E. Pinkham's Vegetable Compound and Lydia E. Pinkham's Blood Medicine." MRS. JOHN TOMS, Ball St., Cobourg, Ontario. CORN CAKE [Illustration] Ingredients 2 cups Indian Meal 1 cup flour 1/2 cup sugar 1 teaspoon salt 1 egg 1 teaspoon soda 2 cups sour milk Method--Sift the dry ingredients together except the soda. Add egg slightly beaten. Dissolve the soda in sour milk, stir into the dry ingredients quickly and pour into a greased pan. Bake for half an hour in a moderate oven. EVERY TRUE MOTHER realizes the fact that her baby's health depends upon her own, that the very vitality of her child is influenced by her own physical condition. Lydia E. Pinkham's Vegetable Compound has brought health and strength to thousands of others. "I COULD NOT DO A SINGLE BIT OF WORK" "I was troubled with weak feelings, headache all the time, a cough, fainting spells and pains in my back and side. I could not do a single bit of work and had to be helped out to the hammock where I lay in the fresh air from morning until night and I had to be carried up and down stairs. After other medicines had failed a friend advised me to take Lydia E. Pinkham's Vegetable Compound as she said it was excellent for any one in the family way. Before the first bottle was taken I could walk alone and as I kept on with it I got stronger until I was able to do all of my work. My baby is now six weeks old and is a big fat healthy fellow. I am sure Lydia E. Pinkham's Vegetable Compound has done wonders for me and I recommend it to any woman in that condition." MRS. MURRAY J. BARTON, R.R. No. 1, Cumberland Bay, New Brunswick. TEA BISCUIT [Illustration] Ingredients 2 cups bread flour 4 teaspoons baking powder 1/2 teaspoon salt 1 to 2 tablespoons shortening 3/4 cup milk Method--Sift the dry ingredients together, mix in fat with the tips of fingers, then add the milk a little at a time or cut it in with a knife. The dough should be as soft as can be easily handled. Roll lightly until one inch thick, cut in rounds and bake in a hot oven for 15 or 20 minutes. AN EVIDENCE OF CONFIDENCE in a friend is to follow her advice, especially if it is not hearsay evidence but something which she has tried out on herself and proved. Lydia E. Pinkham's Vegetable Compound merits such confidence. Women all over Canada as well as in the United States take our medicine and tell its worth. "SAVED ME FROM AN OPERATION" "I took Lydia E. Pinkham's Vegetable Compound at the change of life for troubles women often have. I had not been well for a year and was not really able to do my work. A friend who had taken the Vegetable Compound herself recommended it to me and I think its use saved me from an operation. I highly recommend to all women with troubles like mine." MRS. DANIEL J. TRACEY, Knightington, Ontario. "A FRIEND RECOMMENDED IT" "A friend in Rose Valley recommended Lydia E. Pinkham's Vegetable Compound to me, and it has been a great help to me. I recommend it, and you can use this letter as a testimonial if you wish." MRS. PETER NORDIN, Wadena, Saskatchewan. OMELET [Illustration] Ingredients 1 egg 1 tablespoon hot water 1 salt spoon salt Few grains of pepper Method--Separate the white from the yoke of the egg and beat it until stiff. Beat the yolk until thick and add the hot water and salt. Fold the beaten white of the egg in and put into a buttered pan. Cook slowly until puffed and brown. SCRAMBLED EGGS Ingredients 1 egg 1 tablespoon milk or water 1/2 salt spoon salt Few grains of pepper Method--Beat the eggs slightly and add liquid and seasonings. Pour into a warm buttered pan and cook slowly over water. As the egg coagulates on the bottom and sides of the pan lift it with a spoon. Continue until thickened and creamy but not dry. Serve immediately. ONLY A FEW BOTTLES of Lydia E. Pinkham's Vegetable Compound are needed to give surprising results, as so many women tell us. "HAD NO AMBITION" "I suffered greatly from weakness, seemed to be tired all the time, and had no ambition to do anything or go any place. My nerves were in bad shape, I could not sleep at night and then came a breakdown. I read of Lydia E. Pinkham's Vegetable Compound in the newspapers and several of my friends advised me to use it. It surely put new life into me and now I am quite able to do all my own work." MRS. CHAS. WAKELIN, 272 Christie St., Toronto, Ontario. SWEET MILK GRIDDLE CAKES [Illustration] Ingredients 3 cups flour 2 tablespoons sugar 1/2 teaspoon salt 4 tablespoons baking powder 1 egg 2 cups milk 2 tablespoons melted fat Method--Mix and sift dry ingredients. Add beaten egg, milk and fat to make a thin batter. Drop on a hot oiled griddle and brown on both sides. SAVINGS Save all the waxed paper that crackers and bread come wrapped in. It is very handy to roll out pie-crust or biscuits on, also doughnuts and cookies, and saves washing the pastry board. IF YOU HAVE TO WORK you must have good health in order to do your work well. Besides this, you want to be able to play afterwards and both work and play require good health. It is a great handicap to be lacking in energy when you are young and should be strong. Lydia E. Pinkham's Vegetable Compound will help that tired feeling which many girls have. "I HAD TO STAY IN BED" "I suffered for three years with troubles women often have. About every three weeks I had to stay in bed four or five days. I nearly went crazy with pains in my back, and for about a week at a time I could not do my work. I saw Lydia E. Pinkham's Vegetable Compound advertised in the 'Hamilton Spectator' and I took it. Now I have no pain and am quite regular unless I overwork or stay on my feet from early morning until late at night. I keep house and do all my own work without any trouble. I have recommended the Vegetable Compound to several friends." MRS. EMILY BEECROFT, 16 Douglas St., Hamilton, Ontario. VINEGAR [Illustration] A spoonful of vinegar added to the water when cooking corned beef will make it more tender. To make pie-crust flaky try adding one-half a spoonful of vinegar to the cold water before mixing. Add vinegar to the water in which you soak wilted vegetables and they will revive quickly and any little bugs in them will come out. Add vinegar to the water when washing windows or paint or cleaning floors. If paint or varnish is on a window, wet it with hot vinegar and rub it off with a cent. To take the shine from clothing, sponge the shiny places with boiling hot vinegar, rubbing vigorously, then press as usual. IT IS PERFECTLY SAFE for any one to take Lydia E. Pinkham's Vegetable Compound whenever such a medicine is needed. It contains no narcotics nor harmful drugs and is made in the most accurate and sanitary manner. Can a medicine be a fraud that is compounded from nature's own remedies, the roots and herbs of the fields, that has stood the test of time by restoring health and happiness to thousands of suffering women? "FOR WOMEN'S TROUBLES" "I saw Lydia E. Pinkham's Vegetable Compound advertised for women's troubles, and when a friend recommended it to me I tried it, and it has done me so much good in the two years in which I have been taking it that I find I am a different woman since then. I recommend your Vegetable Compound as much as I can and you may use my letter as a testimonial." MRS. WM. J. THOMAS, Melaval, Saskatchewan. CASSEROLE OF RICE AND MEAT [Illustration] Ingredients 2 cups steamed rice 2 cups chopped seasoned meat 1 cup gravy or tomato sauce 1/2 cup buttered crumbs Method--Place in a baking dish a layer of rice, over this sprinkle a layer of chopped meat and repeat until the dish is nearly filled; then pour gravy or tomato sauce over the meat. Cover with the buttered crumbs and bake until brown. HELPFUL HINTS To keep the daily paper from blowing away when it is left on the porch, get the carrier to snap it into a spring clothes-pin which is tied to the railing. WHEN A WOMAN KNOWS that a certain medicine is good she wants no substitute or makeshift. The women who take Lydia E. Pinkham's Vegetable Compound are of this class. They know what they want and they will take nothing else. "COULD NOT SLEEP" "I took Lydia E. Pinkham's Vegetable Compound for weakness of the female organs. I had pains in the back and bearing-down pains in the abdomen and was in a general run-down condition. I could not sleep, rest or work, and was quite unfit to do even light household tasks. A friend told me about your Vegetable Compound and I in my turn truly recommend it, as my severe symptoms vanished and I am better in every way. I do my own work, look after my children and see to chickens, a cow, and my garden. I also recommend it for young girls who are weak and rundown, as my 16-year-old daughter has taken it and is quite her own gay self again." MRS. FRED. WILEY, Viscount, Saskatchewan. FILIPINO ROLL [Illustration] Ingredients 1 sweet green pepper 2 onions 1 lb. Hamburg steak 1 cup bread crumbs 1 egg 2 teaspoons salt 1 tablespoon Worcestershire Sauce 5 or 6 slices of bacon Sauce 1 cup tomato soup 1 tablespoon flour 1 teaspoon sugar 1/2 cup water Method--Wash the pepper and remove the seeds, add onions and chop together. Mix with meat, breadcrumbs and well beaten egg. Add seasonings and form into a roll. Cover with bacon and bake 45 minutes in a moderately hot oven. Remove to platter, add water to make gravy and strain into it the thickened tomato soup. Let it boil a few minutes then pour around the roll. A FEW MINUTES of any woman's time is well spent if she will read what Lydia E. Pinkham's Vegetable Compound does for sick and ailing women. "ONE OF YOUR LITTLE BOOKS" "I took Lydia E. Pinkham's Vegetable Compound for weakness and female disorders. I was so weak at times that I could not stand up. I had been this way for nearly three years, and the different medicines I had taken had not done me any good. I found one of your little books at my door one day and thought I would give your medicine a trial. I am now on my fifth bottle and it is wonderful the way it has helped me. I am feeling much better, have no weak spells, and can do all my work now. I am recommending your Vegetable Compound to all I know." MRS. CASEY LEMERY, 176 Abbott St., Brockville, Ontario. MOCK MEAT CAKES [Illustration] Ingredients 1/2 cup dried peas or beans 5 medium potatoes 1/2 cup grated cheese 1/2 cup fine breadcrumbs 1 egg (beaten) 1 tablespoon melted bacon fat salt and pepper Method--Soak peas or beans over night, then boil until very tender. Boil and mash potatoes. Add mashed beans, grated cheese, bread-crumbs, beaten egg, bacon fat and seasonings. When cool shape into cakes, dip into cornmeal and fry. WHY ARE SOME WOMEN happy, beloved, and successful, while others drag out a negative existence, of no use to themselves or anyone else? Except in a few cases the answer is to be found in a state of freedom from the troubles known as "female." The well woman radiates cheerfulness and serenity, while the ailing one repels you with her despondency. It is not necessary, however, to harbor aches and pains, and the "blues," which make one a detriment to society. The use of Lydia E. Pinkham's Vegetable Compound has brought relief to such women, and given them a new lease of life. "A GENERAL RUN-DOWN CONDITION" "I was in a general run-down condition, with a weak back and tired feeling, so that I did not feel like working. My mother was taking Lydia E. Pinkham's Vegetable Compound and recommended it to me, so I have taken it, and my back is better and I am now able to do my work. I recommend the Vegetable Compound to my neighbors and you may publish this letter." MRS. JOSEPHAT A. GRENIER, Hesketh, Alberta. DRY BEAN CHOWDER [Illustration] Ingredients 1 cup dried beans 2 slices bacon (diced) 1 can corn 1 can tomatoes salt and pepper cracker crumbs Method--Soak the beans over night and boil until tender. Drain into a fire-proof casserole. Try out the fat from the bacon until it is perfectly crisp, care being taken that it is not burned. Then add corn, seasoning and tomatoes. Mix all and add to beans. Sprinkle cracker crumbs over the top and bake twenty-five minutes. Serve from the casserole. IN THIS GENERATION it is 'the style' to be healthy. Our heroines no longer languish and faint. They are all healthy girls and women who do a day's work or play just as a man does. If some of us are not so healthy as this, we try to be and take Lydia E. Pinkham's Vegetable Compound when we feel the need. "I WAS A TOTAL WRECK" "Before using Lydia E. Pinkham's Vegetable Compound I was a total wreck. I had terrible pains in my sides and was not regular. Finally I got so weak I could not go upstairs without stopping to rest halfway up. I saw your medicine advertised in the newspapers and gave it a trial. I took four bottles of the Vegetable Compound and was restored to health. I am married, am the mother of two children, and do all my own housework, milk eight cows and do a hired man's work and enjoy the best of health. I also found the Vegetable Compound a great help for my weak back before my babies were born. I recommend it to all my friends." MRS. HENRY JANKE, Marmion, Ontario. COOKING HINTS [Illustration] Never throw away the feet of a fowl as they are excellent for making soups, broths and jellies. You can buy extra feet from the butcher. Dip them in boiling water for a few seconds and they may be readily skinned. Boil with the chicken until they fall to pieces, then strain the broth. Before baking potatoes let them stand in hot water for fifteen minutes. They will require only half the time to bake. Pour boiling water on oranges and let them stand for five minutes. This will make the white lining come away from the skin and they will be easier to prepare for a pudding. ANY HOSPITAL EXPERIENCE is painful as well as costly and frequently dangerous. Many women have avoided this experience by taking Lydia E. Pinkham's Vegetable Compound in time, thereby relieving the present distress and preventing the development of conditions that might require an operation. "THEY SAID I NEEDED AN OPERATION" "I suffered from the time I was a schoolgirl until I had taken your medicine with pain in my left side and with cramps, growing worse each year until I was all rundown. I was so bad at times that I was unfit for work. I tried several doctors and patent medicines but was only relieved for a short time. Some of the doctors wanted to have an operation, but my father objected. Finally I learned through my mother of Lydia E. Pinkham's Vegetable Compound, and how thankful I am that I tried it. I am relieved from pains and cramps and feel as if it has saved my life. You may use my letter to help other women, as I am glad to recommend the medicine." MRS. H.A. GOODMAN, 14 Rockvale Ave., Toronto, Ontario. HINTS AND HELPS [Illustration] The common nut-cracker makes a splendid little household wrench for cans and bottles with screw tops. Even glass stoppers will yield to it. A pair of scissors in the pantry to cut up raisins, suet, citron, etc., is easier to use then the chopper. A metal shoe-horn that has a hole in the top to hang it up by, makes a good kettle scraper. Use a bicycle pump to clean such parts of the sewing machine as you cannot reach with a cloth or with an old tooth brush. Save the sand-paper which comes on the match-boxes and use it for scraping, cleaning, etc. Ammonia water will remove the cloudy appearance from the preserve jars in which vegetables have been canned. THE BEST ADVERTISED MEDICINE in the world is the medicine which has the most friends. "It HAS DONE SO MUCH FOR WOMEN" "I took Lydia E. Pinkham's Vegetable Compound for years, and it is the only patent medicine I ever recommend. I am a nurse, and if I find a woman is in poor health I always tell her to take it. Although you know doctors and nurses do not use patent medicines I must say that I think there is nothing better than your Vegetable Compound. When I first took it many years ago, I was that tired when I got up in the morning that I was weak and I could not eat nor sleep. My mother-in-law told me that Lydia E. Pinkham's Vegetable Compound was just what I wanted, so I tried it, and only took two bottles when I felt better. Since then I have found that there is nothing that makes me feel so well, for it seems to build my system right up. I don't know any other medicine that has done so much for women." MRS. W.H. PARKER, 19 Wellesley Ave., Toronto, Ontario. DUTCH CHEESE [Illustration] Ingredients 1 quart sour milk 1/3 to 1 teaspoon salt 1/4 cup sour or sweet cream (or 1 large tablespoon butter) Method--The milk should be freshly sour to get the best flavor. This is best obtained by adding a little sour milk to five or six times the amount of sweet milk. It should be kept in a warm place (the back of the stove) until the curd of the milk is thick and smooth and the whey is watery and has risen to the top. Drain in a cheese cloth bag until dry. Add cream (or butter) and salt. If the process needs to be hurried stir into the milk a cup full of nearly boiling water. Leave to settle before draining. As the cheese is very rich in protein it easily becomes tough by overheating. For the same reason it is very nourishing. THE CONTINUED SUCCESS of a medicine depends entirely upon its merit. For nearly fifty years Lydia E. Pinkham's Vegetable Compound has been demonstrating its worth among women as a valuable medicine for the treatment of female ills, and the tremendous volume of letters on file in the Pinkham laboratory at Lynn, Massachusetts, from grateful women in all parts of the United States and Canada is ample proof of its merit. "A LOT OF GOOD" "I had female troubles for two years. I always had a headache and a pain in my side, and sometimes I felt so weak that I could not do my work. A friend advised me to take Lydia E. Pinkham's Vegetable Compound and I have taken six bottles of it. It has done me a lot of good and I am still taking it. I will tell my friends of your medicine and hope they will try it." MRS. CAMILLE DesROCHE, Miscouche, Prince Edward's Island. CAKE-MAKING Success in cake-making depends on careful combining of ingredients, accurate measurements and careful baking. To make cake light and close in texture, thorough beating is necessary. Baking--Small and layer cakes require a hot oven for 10 to 20 minutes. Loaf cakes need a moderate oven from 40 to 60 minutes. In the beginning the oven should be hot enough to cause the cake to rise and then to form a crust which holds the gases. When the cake has risen to its full height decrease the heat so that the cake may finish baking without becoming too brown. If the oven is too hot at first a crust will be formed before the cake is risen. If not hot enough, gas will not be retained in the cake. Either of these conditions will make the cake heavy. Testing--The cake is baked if, when pressed lightly upon the top in the middle, it springs back again. It usually shrinks from the sides of the pan. A deep cake may be tested with a clean straw. Methods of work--First grease and flour the pans. Collect all materials and utensils needed and make sure that the oven will be ready. Do this before combining any materials. WE READ a good deal about "Pre-Natal Care"--the care of the mother before her child is born--and we all agree that a healthy and happy mother is the one to have the best babies. "SO SMART AND HEALTHY" "When I would get out of bed in the morning I could hardly stand on my feet for weakness and a bearing-down pain. I heard of Lydia E. Pinkham's Vegetable Compound and tried it with Lydia E. Pinkham's Liver Pills and used Lydia E. Pinkham's Sanative Wash for the white flow, and was doing fine. This was before my little girl was born. She is so smart and healthy and good-natured that I think the Compound must have made her that way." MRS. RICHARD WILLIAMS, Milltown, New Brunswick. PLAIN CAKE for Loaf or Layer Cake [Illustration] Ingredients 2 eggs 1 cup sugar 3 teaspoons Oleo or butter 1/2 cup milk 1/2 teaspoon salt 1-1/2 cups flour 1-1/2 teaspoons baking powder 1/2 teaspoon vanilla Method--Beat eggs light, add sugar, butter, milk, salt and all but 2 tablespoons of the flour. Beat well, add vanilla, then add the remainder of the flour with the baking powder, sifted together. Bake in loaf or layer cake pans. BROWNSTONE CAKE FILLING Ingredients--1/2 cup sugar, 1 square of chocolate, 1 tablespoon cornstarch, a few grains of salt, 1/2 cup of milk. Method--Mix dry ingredients. Add liquid gradually. Cook in double boiler until thick and creamy. WEAKNESS MAY SHOW in early girlhood and if attended to at that time and not allowed to develop into serious troubles by carelessness or overwork, girls will grow stronger as they grow older. Lydia E. Pinkham's Vegetable Compound is what many mothers give their girls in these early years. "MY MOTHER-IN-LAW TOLD ME" "I took Lydia E. Pinkham's Vegetable Compound for female troubles. I would have headaches, backache, pains between my shoulders and under my shoulder-blades, and bad feelings in the lower parts on each side, in the groins. I was sometimes unable to do my work and felt very badly. My mother-in-law told me about the Vegetable Compound and I got some right away. It has done me more good than any other medicine I ever took, and I recommend it to my neighbors." MRS. EDGAR SIMMONS, R.R. No. 2, Pine Grove, Ontario. SPONGE CAKE [Illustration] Ingredients 2 eggs 1/2 cup sugar 1 teaspoon cold water 1/2 tablespoon lemon juice 1 salt spoon salt 1/2 cup flour Method--Beat yolks until thick and add sugar gradually. Add water and lemon juice. Sift flour and salt into yolk mixture and beat thoroughly. Fold in the stiffly beaten whites of eggs and bake in a moderate oven. CRISPETTES Ingredients--2 eggs, 1/2 cup white sugar, 1/2 cup brown sugar, 1/2 cup chopped walnuts or cocoanut, 1/2 cup flour, 1/2 teaspoon vanilla, 1/2 teaspoon salt. Method--Beat eggs very light, add sugar and remaining ingredients. Beat well and drop by tablespoonfuls on a buttered pan 2 inches apart. Bake in a moderately hot oven. Always use a tin pan. A LITTLE CARE when one is young is not much to pay for good health afterwards. Take Lydia E. Pinkham's Vegetable Compound for any weakness you may have. This well-known medicine is recommended by mothers to their daughters, by sisters to one another, and by friends and neighbors to the woman whose loved ones are far from her when she needs them most. "AM PERFECTLY SATISFIED" "When my husband was called back to England in 1914, I took Lydia E. Pinkham's Vegetable Compound to strengthen me so that I could work. My periods were twice a month and used to make me so weak, but I am able to do my work now and am perfectly satisfied with your medicine. I still get it at the chemist's, and strongly recommend it to any one I hear of suffering as I did." MRS. E. HORNBLOWER, 899 Yonge St., Toronto, Ontario. WAR CAKE [Illustration] Ingredients 1 cup brown sugar 1 cup water 2 cups raisins 1/3 cup fat 1/4 teaspoon grated nutmeg 1 teaspoon ground cloves few grains salt. Method--Boil the above ingredients together for three minutes. Let cool. When cold add 1 teaspoon soda dissolved in 2 tablespoons hot water. Add 2 cups flour in which 1 teaspoon baking powder has been sifted. Bake in a moderate oven. PANTRY HELPS If butter is too hard to serve, heat a bowl with boiling water and turn the empty bowl over the butter. This will not waste or impair the taste of the butter. ARE YOU INTERESTED in a letter from a woman in South Africa who takes Lydia E. Pinkham's Vegetable Compound? "ONE OF YOUR LITTLE BOOKS" "I took Lydia E. Pinkham's Vegetable Compound for weakness and because I felt run down. I tried a lot of medicine before I tried yours. One day I was standing on my stoop when a boy came up to me and handed me one of your little books. I read the book, and the next day my husband went to a chemist and bought me a bottle of Lydia E. Pinkham's Vegetable Compound. I have taken the medicine ever since and I feel quite strong and well now as I am on the sixth bottle. I have written to my sister and told her all about the wonders it has done for me, and I am quite willing for you to use my name, as I cannot thank you enough for what it has done for me." MRS. W.F. RUSH, 128 6th Avenue, Mayfair, Fordesburg, Johannesburg, South Africa. CHOCOLATE CAKE [Illustration] Ingredients 5 tablespoons butter 1 cup sugar 2 eggs 1/2 cup milk 1-1/2 cups flour 2 squares chocolate 1/2 teaspoon vanilla 1/2 teaspoon salt 2-1/2 teaspoons baking powder. Method--Cream butter and sugar. Add yolks of eggs beaten until thick, then milk, and all but 2 tablespoons of the flour. Beat thoroughly, add melted chocolate and vanilla. Add remaining flour, salt and baking powder sifted together. Fold in stiffly beaten whites of eggs. Bake in moderate oven. A PROPRIETARY MEDICINE like everything else that comes before the public, has to prove its merits. The law of the survival of the fittest applies in this field as in others. Lydia E. Pinkham's Vegetable Compound has been used by women for nearly fifty years. "I KNOW WOMEN WHO HAVE BEEN HELPED" "My mother had taken Lydia E. Pinkham's Vegetable Compound, and when I needed something for my periods I took it and got good results. I recommend it to women with any female troubles, and I know other women who have been helped by it." MRS. MAX RETZER, Lumsden, Saskatchewan. "I used to have very bad pains in my back and sides and often was not fit for work. I tried many medicines before I took yours. I saw Lydia E. Pinkham's Vegetable Compound advertised in the 'Toronto Globe,' and now that it has helped me I recommend it to all my neighbors." ELIZABETH CAMPBELL, 13 St. Paul St., Lindsay, Ontario. CHOCOLATE FROSTING [Illustration] Ingredients 1-1/2 squares chocolate 1 cup sugar 1 cup boiling water Method--Cut chocolate into small pieces, add sugar and water and stir until blended. Boil until a soft ball forms when dropped into ice-water. Cool. Beat until creamy and spread on cake. WHITE FROSTING Ingredients 1 egg white 1 cup confectioner's sugar 1/2 teaspoon flavoring Method--Beat the white of egg until stiff. Stir in the sugar and flavoring and beat until creamy. WHEN A MAN comes home from work at night, he wants to find his home clean and comfortable, his supper ready, his children happy and his wife smiling a welcome to him. These are only natural feelings and when things are the reverse and he has to help do the work, he looks for the cause of the trouble and its remedy. Lydia E. Pinkham's Vegetable Compound will help women keep strong and well. "WITH MY HUSBAND'S HELP" "I used Lydia E. Pinkham's Vegetable Compound for pains across the small of my back. They bothered me so badly that I could do my work only with my husband's help. One day we saw the 'ad' in our paper telling what Lydia E. Pinkham's Vegetable Compound is doing for women so I began to take it. It has helped me wonderfully. I am feeling fine, do all my housework and washing for seven in the family. I had been irregular too, and now I am all right. I am telling my friends what it has done for me and am sure it will do good for others. I will stand up for Lydia E. Pinkham's Vegetable Compound any time." MRS. WM. JUHNKE, Foster, Oregon MOCHA FROSTING [Illustration] Ingredients 3 tablespoons butter 1 cup confectioner's sugar 2 tablespoons cold boiled coffee 2 tablespoons cocoa 1/2 teaspoon vanilla Method--Cream the butter and sugar, add the remaining ingredients and enough more sugar to make it creamy. Plain icing may be made by moistening confectioner's sugar with milk or water (either hot or cold) and adding flavoring. Either this or white frosting may be used as a foundation for nuts or chopped fruit. Orange frosting may be made by moistening the sugar with orange juice. HOWEVER BUSY a woman is she always finds time to read the daily papers. And she may read the Bargains first and the Weather Report last, but she always reads the testimonial letters advertising Lydia E. Pinkham's Vegetable Compound. She wants to know what experience other women have had with this great medicine. "WHEN MY DAUGHTER WAS THIRTEEN" "When my daughter was thirteen and until she was fifteen she suffered every month so that she could hardly move around the house and when she would have the pains in school she would have to be carried home. She also had headache, dizzy and faint spells, and soreness in her back. I saw your advertisement in the 'Hamilton Spectator' and got Lydia E. Pinkham's Vegetable Compound for her. She does not have the least bit of trouble now, and we both recommend your medicine. She works in a candy-shop now and seems well and strong. I give you permission to publish this letter as a testimonial." MRS. I.P. CLAUSE, 83 Oxford St., Hamilton, Ontario. LEMON PIE WITH MERINGUE [Illustration] Ingredients 3/4 cup sugar 3 tablespoons cornstarch 1 cup boiling water 3 tablespoons lemon juice and grated rind 1 tablespoon butter 2 egg yolks Method--Mix sugar and corn starch thoroughly, pour boiling water over them, stirring constantly. Cook until thick and until starch is well done. Add lemon juice and butter. Cool slightly and add egg yolks. Pour into plate lined with pastry and bake until paste is cooked. Or pour into crust already baked. MERINGUE Ingredients--2 egg whites beaten stiff, 2 to 4 tablespoons of powdered sugar, a few drops of vanilla. Add sugar gradually to stiffly beaten whites of eggs. Add flavoring. Spread over top of pie and cook until golden brown in a slow oven. "MAN MAY WORK from sun to sun, but woman's work is never done." Women continually overdo and drift along from bad to worse. Lydia E. Pinkham's Vegetable Compound is a standard medicine for women's troubles. "WE HAVE TO DO OUR OWN WORK" "I saw in the newspapers where Lydia E. Pinkham's Vegetable Compound was doing so much good to women, and as I needed something I began to take it. I used to be very sick, but I am not now. I live on a farm in the homestead district and we have to do all our own work. I tell all the women I see what Lydia E. Pinkham's Vegetable Compound does for me. I think it saves me from going to a doctor and is the best medicine women can take." MRS. WILLIAM COULTAS, Fork River, Manitoba. PIE CRUST [Illustration] Ingredients 1-1/2 cups flour 3 tablespoons lard 1/2 teaspoon salt cold water 3 tablespoons butter Method--Wash butter and squeeze until water and salt has been removed. Chill the lard then chop it into the flour, with two knives. Add salt and moisten it to a dough with cold water. (Ice water is not essential but is desirable in summer.) Toss on a floured board and roll out. Fold to make three layers and put the butter between the layers. Turn half way round, pat, and roll out. Cut off the sides of it and roll into shape for the plate. Roll the center for the upper crust, cutting slits in it to let out steam. Fold the upper crust under the edge of the lower crust. Bake in a moderately hot oven 40-50 minutes. Pastry may be used immediately or chilled before using. It must not come in contact with the ice. IF THERE IS ONE THING more than another that a woman should care about it is her health. She may be cheated in her happiest hopes because she does not know that Lydia E. Pinkham's Vegetable Compound can be safely taken by all women. "MY BACK SEEMED THE WORST" "I was so weak that I could hardly do anything and my back seemed the worst. I read so much about Lydia E. Pinkham's Vegetable Compound for women that I thought I would try it. I feel that it did help me. I am looking after my own home now and seem quite strong again. I have recommended your Vegetable Compound to quite a few friends and you can use my name if you wish to do so." MRS. H. PORTER, Box 440, Meaford, Ontario. APPLE PIE [Illustration] Ingredients 4 or 5 sour apples 1/3 cup sugar 1/4 tablespoon grated nutmeg 1/8 teaspoon salt 1 tablespoon lemon juice few gratings lemon rind 1 tablespoon butter Method--Line pie-plate with pastry. Pare, core, and cut apples into eighths. Put row of slices around the plate 1/2 inch from the edge working towards the center until the plate is covered. Then pile on the remainder. Mix sugar, nutmeg, salt, lemon juice and grated rind and sprinkle over the apple. Dot all with butter. Wet the edges of the under crust, cover with the upper crust and press together. Bake for 40-45 minutes in a moderate oven. DO YOU FEEL broken-down, nervous and weak sometimes? Lydia E. Pinkham's Vegetable Compound is excellent to take at such a time. It always helps and if taken regularly and persistently will relieve this condition. "AS IF I MUST SCREAM" "I cannot speak too highly of what Lydia E. Pinkham's Vegetable Compound has done for me. I was a nervous wreck and I just had to force myself to do my work. Even the sound of my own children playing made be feel as if I must scream if they did not get away from me. I could not even speak right to my husband. The doctor said that he could do nothing for me owing to my condition. My husband's grandmother advised me to take Lydia E. Pinkham's Vegetable Compound. I started it right away and everyone noticed what a different woman I was in a short time. I was able to do my work once more, and it was a pleasure, not a burden." MRS. EMILY DAVIS, 721 McGee St., Winnipeg, Manitoba. BAKED FRUIT PUDDING [Illustration] Prepare fruit--apples, peaches,--and sprinkle with sugar, also with cinnamon or nutmeg if apples are used. Place fruit in baking-dish to within one inch of the top. CRUST Ingredients 1 cup flour 1 salt spoon salt 1 teaspoon baking powder 2 tablespoons butter 1/3 cup milk Method--Mix and sift the dry ingredients, cut in butter with knife and add milk. Roll the crust to fit the baking-dish, keeping it 1/2 inch thick and place over the fruit. Press edges of the crust to the rim of the dish and make a small opening in the crust near the center. Bake in a moderate oven 30 minutes. Serve with vanilla sauce. THE RIGHT ROAD to Health is what every ailing woman is looking for and when one woman gets on that road she is always ready to direct some other woman to it. "IT HAD HELPED MY SISTER" "I was a sufferer for three years, not able to do my housework. My husband was discouraged for I was no better and had the doctor all this time and nothing had helped me. I was always sleepy, had no appetite and suffered with my left side. My mother, in England, recommended Lydia E. Pinkham's Vegetable Compound because it had helped my sister, so I have been taking it. I am now able to do my housework and I cannot praise your Vegetable Compound too highly, as I have great hopes for the future. I will tell anyone who writes to me what good it has done me." MRS. HENRY MASSON, St. Henry P.O., Montreal. VANILLA SAUCE [Illustration] Ingredients 1 cup boiling water 2 teaspoons corn-starch 1 tablespoon butter 1/2 cup sugar 1/2 teaspoon vanilla little salt Method--Mix the corn-starch with a little cold water and stir into the hot water, boiling five minutes. Put butter, sugar, flavoring and salt into a bowl and pour the thoroughly cooked cornstarch over it, stirring until the sugar and the butter are dissolved. LEMON JELLY Ingredients--2 oranges, 1 lemon, the rind of one orange grated fine, 1 cup sugar, 1 tablespoon gelatine, 2 cups boiling water. Method--Mix the juices and the fruit gratings with the sugar. Soak 1 tablespoon gelatine in 1 cup of cold water until soft. Stir in 2 cups of boiling water and add the sugar and fruit juices. Stir until the gelatine is dissolved, then pour into a mold to harden. "WOMEN'S TROUBLES AND WOMEN'S WORK" "I was weak and had some troubles women often have and usually I was unfit to do my work. I saw your advertisement and decided to try Lydia E. Pinkham's Vegetable Compound. I am very much pleased with the result and recommend your Vegetable Compound whenever I have a chance." MRS. WANDLESS, 360 Church St., Fredericton, New Brunswick. "I have taken Lydia E. Pinkham's medicines and they have done me a lot of good. Since then I have been able to do my housework, and I have a lot to do as we live on a farm. Seeing your advertisement in the papers was what made me think of writing to you." MRS. WM. B. KEIVER, Upper New Horton, New Brunswick. CHOCOLATE BREAD PUDDING [Illustration] Ingredients 2 cups bread crumbs 4 cups of milk (or 2 of water and 2 of evaporated milk) 2 squares chocolate 2/3 cup sugar 1 salt spoon salt 1 teaspoon vanilla Method--Soak bread crumbs in milk until soft. Melt the chocolate over hot water and add the sugar to it. Beat eggs well and add with the remaining ingredients to the crumbs and milk. Mix well and bake in a buttered pudding-dish in a moderate oven, until thick and firm. A Meringue (see page 23) of egg white and sugar may be spread over the top about 15 minutes before it is done, or it can be served with cream, hard, or foamy sauce. Hard Sauce--1/3 cup butter, 1 cup powdered sugar, 1/3 teaspoon lemon extract, 2/3 teaspoon vanilla. Cream the butter, add sugar gradually, and flavoring. LACK OF ENERGY or 'pep' makes a woman feel old while she is yet young in years and general appearance. "NO SERIOUS TROUBLE" "I had no disease only I felt tired and had headache very often and thought I needed a tonic, so I got Lydia E. Pinkham's Vegetable Compound and the Liver Pills. I am now on the third bottle and have not had headache for over two weeks. Of course I have not had any serious trouble at all." MRS. M.A. WATSON, Victoria St., Cobourg, Ontario. "I was weak and run down, had no appetite and was nervous. The nurse who took care of me told me to try Lydia E. Pinkham's Vegetable Compound, and now I am getting strong. I recommend your medicine to my friends." MRS. D. MAXWELL, R.R. No. 2, Bothwell, Ontario. CUP CUSTARDS [Illustration] Ingredients 1 quart milk 4 eggs 4 tablespoons sugar 1/2 teaspoon salt few grains nutmeg Method--Scald one quart of rich creamy milk. Beat four egg yolks, add sugar and salt and beat until thick like cream. Beat the four egg whites until foamy, not stiff, mix well with the yolks and sugar and add scalded milk. Stand the cups in a shallow pan, stir the foam down, and fill the cups to overflowing or nearly so. Put hot water in the pan and bake in a hot oven, watching them carefully that they do not scorch. Lay buttered paper over if needed. Test with a knife as soon as they begin to puff up and if the blade comes out clean, not milky, they are done. DO WOMEN READ our little books which come so regularly to their homes? We feel sure that they are read from cover to cover. "I SEEMED TO BE SMOTHERING" "I suffered with irregular periods, was weak and run-down, could not eat and had headaches. The worst symptoms were dragging down pains, so bad I sometimes thought I would go crazy and I seemed to be smothering. I was in this condition for two or three years and could not seem to work. I tried all kinds of remedies but received no benefit. I found one of your booklets and felt inclined to try Lydia E. Pinkham's Vegetable Compound. I received the best results from it and now I keep house and go out to work and am like a new woman." MRS. J.F. PEASEY, 387 King St. West, Toronto, Ontario. SUBSTITUTES [Illustration] Use jelly tumblers to bake custards in. Use soldier's long wristers to make gaiters for a baby; just sew an elastic band at the bottom. Use cold cream jars to keep pepper, allspice, and other spices in, and label with a sticker or a piece of surgeon's plaster. Instead of the usual dust cap, cut a three-cornered piece of cheese-cloth, hemming the two sides without selvedge and tie around the head with the point at the back of your neck. To avoid giving out fresh napkins at every meal, write each name on a spring clothes-pin and pin to the napkin. You can name your face towel in this way when camping out. When cleaning fish use scissors in place of a knife and if it is to be scaled dip it first into boiling water. DO YOU KEEP ON TAKING your medicine when you begin to improve, or do you stop taking it, trusting that you are on the road to recovery and no more medicine is needed, even if you have been sick for months and are having your first hours of relief from pains and nervousness? "HAVE TAKEN IT FAITHFULLY" "For five years I suffered with pains in my back and from other troubles women often have. All of this time I was unfit for work and was taking different medicines that I thought were good. I saw the advertisement in the papers of Lydia E. Pinkham's Vegetable Compound and have taken it faithfully. I am now in good health and do all my own work. I recommend it to others and give you permission to publish this letter in your little books and in the newspapers as a testimonial." MRS. D. CASSADY, Box 461, Paris, Ontario. HOUSE-CLEANING HINTS [Illustration] To clean a painted wall wash it with saleratus water; about one tablespoonful of saleratus to a quart of warm water. A piece of zinc placed on the glowing coals will clean the chimney of soot. A little lye put in paste will make wall-paper stick. To drive a nail into plaster, heat it very hot and the plaster will not break. To drive nails or screws into hard wood always rub them over with soap and they will go in easily and will not split the wood. Shellac the inside of all drawers and they will be easy to clean. When you remove the waste from your carpet-sweeper, carefully cut the lint and hair from the revolving rolls and brushes. Then with a cloth dipped in kerosene rub the bristles and the inside of the box clean, and the oil will prevent the dust from rising when you sweep. HAVE YOU EVER THOUGHT of writing to us about what Lydia E. Pinkham's Vegetable Compound has done for you? "I AM STRONGER AND FEEL FINE." "I took Lydia E. Pinkham's Vegetable Compound because I was tired and run down. I had headaches and no appetite and was troubled for two years with sleeplessness. I tried many medicines but nothing did me any real good. While I was living in Washington I was recommended by a friend to take the Vegetable Compound. I am stronger and feel fine since then and am able to do my housework. I am willing for you to use these facts as a testimonial." MRS. J.C. GREAVES, 771 Hornby St., Vancouver, British Columbia. FIRST AIDS [Illustration] For a rusty nail accident pour turpentine at once on the afflicted parts. For burns put on scraped raw potato instantly and change as often as it gets warm, until the pain is relieved. Olive oil will remove gum from a child's hair as if by magic. When a child puts a bean in his nose, don't try to dig it out. Put a little cayenne pepper upon his upper lip and he will sneeze it out. To extract splinters, fill a wide-mouthed bottle almost to the top with very hot water and place the injured part over the mouth of the bottle and press lightly. Suction will draw the flesh down and steam will extract the splinter. TABLE OF MEASURES (dry and liquid) 4 salt spoons 1 teaspoonful 3 teaspoonfuls 1 tablespoonful 16 tablespoonfuls 1 cup 2 cups 1 pint All measures are level. To measure dry materials, take up all a spoon or cup will hold and level it with a knife. To measure liquids, take up all the spoon or cup will hold. "AFTER BEING MARRIED SIXTEEN YEARS" "Seven years ago I took Lydia E. Pinkham's Vegetable Compound and after being married sixteen years became the mother of a sweet little girl. I had longed for children all the while and wept many a day and envied every woman with a child. I was thirty-six years old when my baby was born. I recommend Lydia E. Pinkham's Vegetable Compound to any woman who is ailing with female weakness." MRS. J. NAUMANN, 1517 Benton St., St. Louis, Mo. ATTENTION! AN ATTRACTIVE PRESENT Will be forwarded you free if you will return this page with answers to the following questions: Designate your choice by checking one of the following: TAPE MEASURE MANICURE SET LYDIA E. PINKHAM MEDICINE CO. LYNN, MASS. * * * * * QUESTIONS How many copies of this book were left for you where you found this one? Where did you find this copy? Have you seen other copies of this book in stores or otherwise wasted? If so, please explain what you have seen? Would you like us to send you, with the present, a free copy of LYDIA E. PINKHAM'S PRIVATE TEXT-BOOK UPON AILMENTS PECULIAR TO WOMEN? Name Street Address Town * * * * * * Transcriber's notes: Inside front cover: added period after Pinkham's Blood Medicine. Page 2. added " after: facts as a testimonial. Page 5. Reversed order of MRS. PETER NORDIN, <--> Wadena, Saskatchewan. Page 6. until [added space] puffed Page 11. changed to title case from upper, for consistency: Method page 14. "It HAS DONE SO MUCH FOR WOMEN" corrected case of T to upper Page 17. liqiud corrected to liquid Page 19. corrected double word: one one page 27. corrected buttter to butter 
15069	----	Diet and Health _With_ Key to the Calories By Lulu Hunt Peters, A.B., M.D. Ex-Chairman, Public Health Committee California Federation of Women's Clubs Los Angeles District Chicago The Reilly and Lee Co. 1918 Dedicated by permission to Herbert Hoover Illustrated by The Author's Small Nephew Dawson Hunt Perkins The little rascal Read This First I am sorry I cannot devise a key by which to read this book, as well as a Key to the Calories, for sometimes you are to read the title headings and side explanations before the text. Other times you are supposed to read the text and then the headings. It really does not matter much as long as you read them both. Be sure to do that. They are clever. _I wrote them myself_. I have been accused of trying to catch you coming and going, because I have included in my book the right methods of gaining weight, as well as those for losing weight. But this is not the reason--though I don't object to doing that little thing--the reason is that the lack of knowledge of foods is the foundation for both overweight and underweight. I did want my publishers to get this out in a cheaper edition, thinking that more people could have it, and thus it would be doing more good; but they have convinced me that that idea was a false claim of my mortal mind, and that the more you paid for it, the more you would appreciate it. I have received many times, and without grumbling on my part, ten dollars for the same advice given in my office. Perhaps on this line of reasoning we should have ten dollars for the book. Those of you who think so may send the balance on through my publishers. L.H.P. Los Angeles, California June, 1918 CONTENTS 1 Preliminary Bout 11 2 Key to the Calories 23 3 Review and More Definitions 30 4 More Keys and More Calories 37 5 Vegetarianism vs. Meat Eating 54 6 The Deluded Ones--My Thin Friends 59 7 Exercise 69 8 At Last! How to Reduce 77 9 Autobiographical 88 10 Testimonials 96 11 An Apology and Some Amendments 98 12 Maintenance Diet and Conclusions 102 13 Three Years Later 106 Diet and Health 1 Preliminary Bout _Rule to Find Ideal Adult Net Weight_ Multiply number of inches over 5 ft. in height by 5-1/2; add 110. For example: Height 5 ft. 7 in. without shoes. 7 x 5-1/2 = 38-1/2 + 110 ------- Ideal weight 148-1/2 If under 5 ft. multiply number of inches under 5 ft. by 5-1/2 and subtract from 110. _Are You Thin and Do You Want to Gain?_ [Sidenote: _Don't Read This_] Skip this chapter. It will not interest you in the least. I will come to you later. I am not particularly interested in you anyway, for I cannot get your point of view. How any one can want to be anything but thin is beyond my intelligence. However, knowing that there are such deluded individuals, I have been constrained to give you advice. You won't find it spontaneous nor from the heart, but if you follow my directions I will guarantee that you will gain; providing, of course, you have no organic trouble; and the chances are that by giving proper attention to your diet you will gain anyway, and maybe in passing lose your trouble. Who knows? [Sidenote: _Bad Business_] In war time it is a crime to hoard food, and fines and imprisonment have followed the exposé of such practices. Yet there are hundreds of thousands of individuals all over America who are hoarding food, and that one of the most precious of all foods! _They have vast amounts of this valuable commodity stored away in their own anatomy_. [Illustration: contents noted] Now fat individuals have always been considered a joke, but you are a joke no longer. Instead of being looked upon with friendly tolerance and amusement, you are now viewed with distrust, suspicion, and even aversion! How dare you hoard fat when our nation needs it? You don't dare to any longer. You never wanted to be fat anyway, but you did not know how to reduce, and it is proverbial how little you eat. Why, there is Mrs. Natty B. Slymm, who is beautifully thin, and she eats twice as much as you do, and does not gain an ounce. You know positively that eating has nothing to do with it, for one time you dieted, didn't eat a thing but what the doctor ordered, besides your regular meals, and you actually gained. You are in despair about being anything but fat, and--! how you hate it. But cheer up. I will save you; yea, even as I have saved myself and many, many others, so will I save you. [Sidenote: _Spirituality vs. Materiality_] [Sidenote: _A Long, Long Battle_] It is not in vain that all my life I have had to fight the too, too solid. Why, I can remember when I was a child I was always being consoled by being told that I would outgrow it, and that when I matured I would have some shape. Never can I tell pathetically "when I was married I weighed only one hundred eighteen, and look at me now." No, I was a delicate slip of one hundred and sixty-five when I was taken. I never will tell you how much I have weighed, I am so thoroughly ashamed of it, but my normal weight is one hundred and fifty pounds, and at one time there was seventy pounds more of me than there is now, or has been since I knew how to control it. I was not so shameless as that very long, and as I look back upon that short period I feel like refunding the comfortable salary received as superintendent of an hospital; for I know I was only sixty-five per cent efficient, for efficiency decreases in direct proportion as excess weight increases. Everybody knows it. _The Meeting Is Now Open for Discussion_ Jolly Mrs. Sheesasite has the floor and wants some questions answered. You know Mrs. Sheesasite; her husband recently bought her a pair of freight scales. [Sidenote: _Mrs. Sheesasite_] "Why is it, Doctor, that thin people can eat so much more than fat people and still not gain?" [Sidenote: _Me Answering_] "First: Thin people are usually more active than fat people and use up their food. "Second: Thin people have been proved to radiate fifty per cent more heat per pound than fat people; in other words, fat people are regular fireless cookers! They hold the heat in, it cannot get out through the packing, and the food which is also contained therein goes merrily on with fiendish regularity, depositing itself as fat. [Illustration: Fireless Cookers.] "And there are baby fireless cookers and children fireless cookers. The same dietetic rules apply to them as to the adult." "I recognize Mrs. Tiny Weyaton; then you, Mrs. Knott Little." [Sidenote: _Mrs. Weyaton_] "We have heard you say that fat people eat too much, and still we eat so little?" [Sidenote: _Me Again_] "Yes, you eat too much, _no matter how little it is_, even if it be only one bird-seed daily, _if you store it away as fat_. For, hearken; food, and food only (sometimes plus alcohol) maketh fat. Not water--not air--verily, nothing but food maketh fat. (And between you and me, Mrs. Weyaton, just confidential like--don't tell it--we know that the small appetite story is a myth.)" [Sidenote: _Mrs. Knott Little_] "But, Doctor, is it not true that some individuals inherit the tendency to be fat, and can not help it, no matter what they do?" [Sidenote: _Doctor_] "Answer to first part--Yes. "Answer to second part--No! It is not true that they cannot help it; they have to work a little harder, that is all. It is true that being fat is a disease with some, due to imperfect working of the internal secretory glands, such as the thyroid, generative glands, etc.; but that is not true fat such as you have. Yours, and that of the other members who are interested, is due to overeating and underexercising. [Sidenote: _Not_?] "Those diseased individuals should be under the care of a physician. Probably the secretory glands are somewhat inactive or sluggish in the healthy fat individual. I use the word _healthy_ here in contradistinction to the other type. In reality, individuals very much overweight are not really healthy, and they should also visit their physician." "Yes, Mrs. Ima Gobbler?" [Sidenote: _Mrs. Ima Gobbler_] [Sidenote: _Doctor Dear_] "But, Doctor dear, what's the use of dieting? I only get fatter after I stop." (Answering delicate like, for I'm fond of her and she is sensitive): "You fat--! You make me fatigued! _You never diet long enough_ to get out of the fireless cooker class. _If you did, you wouldn't."_ "Is there anyone else who would like to be recognized? No?" [Sidenote: _Nothing That I Don't Know_] It is well. I will probably answer more as I go along, for there is nothing that I don't know or haven't studied or tried in the reducing line. I know everything you have to contend with--how you no sooner congratulate yourself on your will power, after you have dragged yourself by the window with an exposure of luscious fat chocolates with curlicues on their tummies, than another comes into view, and you have it all to go through with again, and how you finally succumb. I hope sometime it will be a misdemeanor, punishable by imprisonment, to display candy as shamelessly as it is done. Many fond parents think that candy causes worms. It doesn't, of course, unless it is contaminated with worm eggs, but, personally, I wish every time I ate a chocolate I would get a worm, then I would escape them. The chocolates, I mean. I will tell you more about worms when I discuss meat. [Sidenote: _Vampires_] [Sidenote: _Malicious Animal Magnetism?_] I know how you go down to destruction for peanuts, with their awful fat content. It is terrible, the lure a peanut has for me. Do you suppose Mr. Darwin could explain that? Perhaps I was a little too delicate like in my answer to Mrs. Gobbler's question,--What's the use of dieting, she only gets fatter after she stops? So many ask me that question, with the further pathetic addition,--Will they always have to keep it up? And it ever irritates me. The answer is,--Yes! You will always have to keep up dieting, just as you always have to keep up other things in life that make it worth living--being neat, being kind, being tender; reading, studying, loving. You will not have to be nearly so strenuous after you get to normal; _but you might as well recognize now, and accept it as a fact, that neither you nor anybody else will be able to eat beyond your needs without accumulating fat or disease, or both._ I love Billy Sunday's classical answer to the objection that his conversions were not permanent. He responded: "Neither is a bath!" WHEN YOU START TO REDUCE you will have the following to combat: [Sidenote: _A Combat_] First: Your husband, who tells you that he does not like thin women. I almost hate my husband when I think how long he kept me under that delusion. Now, of course, I know all about his jealous disposition, and how he did not want me to be attractive. [Illustration: _Green!_] Second: Your sister, who says, "Goodness, Lou, but you look old today; you looked lots better as you were." [Illustration: _Sweet Peace_] Third: Your friends, who tell you that you are just right now; don't lose another pound! And other friends who tell you cheerful tales of people they have known who reduced, and who went into a decline, and finally died. [Sidenote: _To Avoid Slack in Your Neck, Double and Triple Chins, Massage Vigorously Up and Down, Not Crossways_] [Sidenote: _I Am Interesting_] But you must not mind them. Smile, and tell them that you know all about it, and don't worry. Go serenely on your way, confident in your heart that you will look fully ten years younger when you get down to normal, no matter how you look in the interim. I don't see why women, and men, too, (secretly) worry so much about wrinkles. If the increased wrinkles on the face are accompanied by increased wrinkles in the gray matter, 'tis a consummation devoutly to be wished. I'm sure I am much more interesting with wrinkles than I was without. I am to myself, anyway. However, you will not be any more wrinkled if you reduce gradually, as I advise, and keep up your exercises at least fifteen minutes daily. [Sidenote: _I Have a Beautiful Complexion_] [Sidenote: _I Attended an Art School Six Months Once_] Take care of your face, alternate hot and cold water, glycerine one-quarter, rose water three-quarters, cold cream packs, massage gently, a little ice--you know what to do--you need not fear. You will not only look ten years younger and live twenty years longer--I assert it boldly--but your complexion and efficiency will be one hundred per cent better. [Sidenote: _Joy_!] If there is anything comparable to the joy of taking in your clothes, I have not experienced it. And when you find your corset coming closer and closer together (I advise a front lace, so this can be watched), and then the day you realize that you will have to stitch in a tuck or get a new one! But don't be in a hurry to make your clothes smaller now. If they are loose they will show to the world that you are reducing. A fat person in a tight suit, unless it is perfectly new, should be interned. [Sidenote: _Food Only_] [Sidenote: _Impossible_] I have said that food, and food only, causes fat. That gives you the cue to what you must do to get rid of it. No anti-fat medicines unless under the supervision of your scientific, educated physician. They are dangerous; most of them contain thyroid extract, arsenic, or mercury. Even the vendors of these harmful compounds in their advertisements are now saying to "stop harmful drugging," but urge you to adopt their particular delightful product, and, "without dieting or exercises, you will positively reduce," and so forth. No drastic purges, no violent exercises, especially at first, and not too frequent nor prolonged Turkish baths. Epsom salts baths have little effect. If salts are used habitually internally, they are harmful. All of these are unscientific and unsuccessful, and the things they bring on are worse than the fat. Now, if food is the only source of body substance, you see that you must study that question, and that is what I will give you--some lessons on foods and their values. [Sidenote: _Candy Cake, Pie, Rich Meats, Thick Gravy, Bread, Butter, Nuts, Ice Cream_] [Sidenote: _Whipped Cream, Candied Sweet Potatoes_] Heretofore you have known only in a dumb, despairing sort of way that all the foods you like are fattening, and all the advice you read and hear is that you must avoid them as a pestilence. And you settle down to your joyless fatness, realizing that it is beyond human strength to do that forever, and that you would rather die young and fat, anyway, than to have nothing to eat all your life but a little meat, fish, and sloshy vegetables. Study on, and you will find the reason your favorite foods are fattening. But cast off your dejection. _You don't have to avoid them_! Eat what you like and grow thin? Yes; follow me. I know it will be an exertion, but you must persist and go through with it. Nothing in life worth while is attained without some effort. So begin now; it is the price of liberty. _Review_ 1. Give rule for normal weight. 2. How much excess food have you stored away? 3. Why more important than ever to reduce? 4. Why are fat individuals fireless cookers? 5. Give causes of excess fat. _NOTE: The Reviews which follow the chapters are important and the questions should be answered. To get the full benefit, Little Book must be studied, for it is the only authorized textbook of the "Watch Your Weights_." 2 Key to the Calories Some one page the thin? They come back here. [Sidenote: _Don't Skip This_] Definition to learn: CALORIE; symbol C.; a heat unit and food value unit; is that amount of heat necessary to raise one pound of water 4 degrees Fahrenheit. [Sidenote: _Pronounced Kal'-o-ri_] There is a good deal of effort expended by many semi-educated individuals to discredit the knowledge of calories, saying that it is a foolish food science, a fallacy, a fetish, and so forth. They reason, or rather say, that because there are no calories in some of the very vital elements of foods--the vitamines and the mineral salts--therefore it is not necessary to know about them. They further argue that their grandfathers never heard of calories and they got along all right. That grandfather argument always enrages my mortal mind. [Sidenote: _A Unit of Measure_] Now you know that a calorie is a unit of measuring heat and food. It is not heat, not food; simply a unit of measure. And as food is of supreme importance, certainly a knowledge of how it should be measured is also of supreme importance. [Sidenote: _Yes, They Are Kosher_] You should know and also use the word calorie as frequently, or more frequently, than you use the words foot, yard, quart, gallon, and so forth, as measures of length and of liquids. Hereafter you are going to eat calories of food. Instead of saying one slice of bread, or a piece of pie, you will say 100 Calories of bread, 350 Calories of pie. The following is the way the calorie is determined: An apparatus known as the bomb calorimeter has two chambers, the inner, which contains the dry food to be burned, say a definite amount of sugar, and an outer, which is filled with water. The food is ignited with an electric connection and burned. This heat is transferred to the water. When one pound of water is raised 4 degrees Fahrenheit, the amount of heat used is arbitrarily chosen as the unit of heat, and is called the Calorie. Food burned (oxydized) in the body has been proved to give off approximately the same amount of heat or energy as when burned in the calorimeter. [Sidenote: _Approximate Measures_] 1 oz. Fat = 275 C. --about 255 in the body. 1 oz. Protein (dry) = 120 C. --about 113 in the body. 1 oz. Carbohydrates (dry) = 120 C. --about 113 in the body. (ROSE.) Can you see now why fats are valuable? Why they make fat more than any other food? They give off more than two and one-fourth times as much heat, or energy, as the other foods. [Sidenote: _See Next Chapter for Definitions_] Notice that protein and carbohydrates have the same food value as to heat or energy, each 113 Calories to the dry ounce. However, they are not interchangeable; that is, carbohydrates will not take the place of protein for protein is absolutely necessary to build and repair tissue, and carbohydrates cannot do that. But fats and carbohydrates are interchangeable as fuel or energy foods. _Calories Needed per Day for Normal Individuals_ [Sidenote: _Business of Growing_] This depends upon age, weight, and physical activities; the baby and the growing child needing many more calories per pound per day than the adult, who has to supply only his energy and repair needs. The aged require still less than the young adult. As to weight; I have told you why overweight individuals need so little. As to physical activities; the more active, obviously the more calories needed, for every movement consumes calories. [Sidenote: _Many Know Nothing of This_] The Maine lumbermen, for instance, while working during the winter months, consume from 5000 to 8000 Calories per day. But they do a tremendous amount of physical work. _Mental work does not require added nourishment._ This has been proved, and if an excess be taken over what is needed at rest (if considerable exercise is not taken while doing the mental work) the work is not so well done. [Sidenote: _Calories Required for Normal_] Per pound per day Infants require 40-50 C. Growing Children 30-40 C. Adults (depending upon activity) 15-20 C. Old age requires 15 or less C. _In Round Numbers for the Day_ Child 2-6 1000 to 1600 C. per day Child 6-12 1600 to 2500 C. per day Youth 12-18 2500 to 3000 C. per day [Sidenote: _Growth Demands_] (Remember that in general the boy needs as much as his father, and the girl as much as her mother.) MAN (per day): At rest 1800 to 2000 C. Sedentary 2200 to 2800 C. Working 3500 to 4000 C. WOMAN (per day): At rest 1600 to 1800 C. Sedentary occupations (bookkeeper, etc.) 2000 to 2200 C. Occupations involving standing, walking, or manual labor (general housekeeping, etc.) 2200 to 2500 C. Occupations requiring strength (laundress, etc.) 2500 to 3000 C. (ROSE.) _Example of Finding Number of Calories Needed_ 1. Determine normal weight by rule. 2. Multiply normal weight by number of calories needed per pound per day. For example, say you weigh 220 or 125 lbs., but by the rule for your height your weight should be 150 lbs.; then 150 would be the number you would use. [Sidenote: _Work Out Your Requirements_] By the rule I have given, adults require 15-20 Calories per pound per day, depending upon activity. For example, if you have no physical activities, then take the lowest figure, 15. 150x15--2250. Therefore your requirement, if your weight should be 150, is 2250 Calories per day. Now, if you want to lose, cut down 500-1000 Calories per day from that. Five hundred Calories equal approximately 2 ounces of fat. Two ounces per day would be about 4 pounds per month, or 48 pounds per year. Cutting out 1000 Calories per day would equal a reduction of approximately 8 pounds per month, or 96 pounds per year. These pounds you can absolutely lose by having a knowledge of food values (calories) and regulating your intake accordingly. You can now see the importance of a knowledge of calories. [Sidenote: _1 lb. fat 4000 C_ _1/2 lb. fat 2000 C_ _1/4 lb. fat 1000 C_ _1/8 lb. fat 500 C_ ] If you want to gain, add gradually 500-1000 Calories per day. _Review_ 1. Define Calorie, and tell how determined. 2. How many C. in 1 oz. fat? of carbohydrates? of protein? 3. Why are fats so fattening? 4. How many C. per day do you require? do mental workers? 5. Upon what do C. needed per day for normal individuals depend? Discuss. 3 Review and More Definitions [Sidenote: _This Is Dry but Important_] FOOD: That which taken into the body builds and repairs tissue and yields energy in heat and muscular power. [Sidenote: _Approx. %'s if Normal_] CLASSES OF FOOD: 1. Protein, 18% of body weight. 2. Fats, 16% of body weight. 3. Carbohydrates, 1% of body weight. 4. Mineral matter, 5% of body weight. 5. Vitamines. 6. Water, 60% of body weight. [Sidenote: _Nitrogenous Food Compounds_] PROTEIN: Builds tissue, repairs waste, yields energy, and may help store fat. One-half, at least, of your protein should be from the vegetable kingdom. A large percentage of protein is contained in Eggs Meat Fowl Fish Nuts Milk Cheese Gluten of Wheat Legumes (beans, peas, lentils, peanuts, etc.) [Sidenote: _Protein 113 C. Per Oz._] There is about one-fourth ounce protein in 1 egg 1 glass milk (skim, butter, or whole) 1-1/2 oz. lean meat, or fish or fowl 1 oz. (1-1/5 cu. in.) whole milk cheese 2 slices of bread, 3-1/2 x 3-1/2 x 1/2 (white, whole wheat, corn, etc.) 3 heaping tablespoonfuls canned baked beans or lima beans 17 peanuts [Sidenote: _255 C. Per Oz._] FATS: Yield energy and are stored as fat. Animal Fat: Cream, Butter, Lard Oils: Cottonseed, Olive Almonds, Peanuts, Walnuts Chocolate, etc. [Sidenote: _113 C. Per Oz._] CARBOHYDRATES: Yield energy and are stored as fat. Sugars (candy, honey, syrup, sweet fruits) Starches (breads, cereals, potatoes, corn, legumes, nuts) Vegetable fibre, or cellulose MINERAL MATTER: Shares in forming bones and teeth, and is necessary for proper functioning. Carbon Lime Sodium Potassium, Sulphur Iron Phosphorus Etc. [Sidenote: _Whole Grain Products Not Devitalized_] These elements are contained largely in the outer coatings of grains, fruits, and vegetables, and in animal foods and their products. Do not pare potatoes before cooking. Cook vegetables in a small amount of water, saving the water for soups and sauces. WATER: The universal solvent, absolutely necessary for life. Contained in purest form in all vegetables and fruits. The average person needs, in addition, from three to five pints taken as a drink. If not sure of the purity, boil. Do not drink while food is in the mouth. [Sidenote: _Absolutely Necessary for Growth_] VITAMINES: Health preservers. Vital substances necessary for growth. The chemistry of these products is at present not thoroughly understood, but their importance has been demonstrated by experiments (not torture) on animals. By this work we know that diseases like beri-beri, scurvy, rickets, and probably pellagra, are due to a lack of these vital elements in the food, and from that fact these are called "deficiency" diseases. [Sidenote: _Guinea Pigs vs. Babies_] Of course I realize that nations can be saved from horrible diseases, and hundreds and thousands of babies saved from death, through this experimentation on a few guinea pigs and other animals; but what is the life of a baby compared with the happiness of a guinea pig? Down with animal experimentation! Let us do everything in our power to hamper scientific work of this kind. We are giving up our husbands, fathers, sons, perhaps to die, for the cause of humanity, but a guinea pig! Horrors! It has been found that the vitamines, like the minerals, are most abundant in the outer coverings and the germ of grains, and in fruits and vegetables. They are also present in fresh milk, butter, meat and eggs. Babies fed pasteurized or boiled milk should have fruit juices and vegetable purees early. Begin with one-half teaspoonful, well diluted, and gradually increase the feeding to an ounce or more between meals once or twice daily. Most animal fats have the vitamines, but vegetable fats are deficient in them. That is the reason cod liver oil is better for some therapeutic uses than olive oil. [Sidenote: _Balanced Diet_] BALANCED DIET: Should contain 10-15% Protein (children may need more) 25-30% Fat 60-65% Carbohydrates [Sidenote: _To Get the Elements Necessary for Health_] For example, suppose you are a fairly active woman and need 2500 calories per day. Then for a balanced diet you would need: 10% Protein, or 250 C. 25% Fat, or 625 C. 65% Carbohydrates 1625 C. ------- 2500 C. 250 C. of P. = 2-1/5 oz. dry protein (250 ÷ 113 = 2-1/5, approximately) 625 C. of F. = 2-1/2 oz. of fat (625 ÷ 255 = 2-1/2, approximately) 1625 C. of CH. = 14-1/2 oz. dry carbohydrates (1625 ÷ 113 = 14-1/2, approximately) Two and one-fifth ounces dry protein equals the approximate amount of protein in 10 ounces lean meat, fish, or fowl, or 9 ounces cheese, or 9 eggs. (You should not take all of your proteins in any of these single forms.) Two and one-half ounces fat equals approximately 5 pats of butter. [Sidenote: _If Appetite Not Perverted_] But listen! You don't have to bother with all this fussy stuff. _Be careful not to over-or under-eat of the proteins_, and your tastes will be a fair standard for the rest. You should remember that a balanced diet contains some of all these foods, in about the proportions given, and that, while _watery vegetables and fruits contain very few calories, they contain very important mineral salts, vitamines, and cellulose._ The latter is good for the daily scrub of the intestinal tract. [Sidenote: _A Pretty Nearly Universal Error_] CONSTIPATION is many times caused by a too concentrated diet, or one containing too little roughage. It has also been discovered that some individuals who are troubled with faulty elimination digest this cellulose, and only the more resistant, like bran, is not absorbed. For those, the Japanese seaweed called agaragar in the laboratory, but more familiarly known as agar by the layman, is excellent. The most industrious digestive tract apparently can not digest that. It has the further property of absorbing a large amount of water, thus increasing its bulk. [Sidenote: _C.S._] [Sidenote: _Have Enough Water, Else You'll Choke to Death. I Did Once_] Mineral oils (refined paraffine) also are not absorbable, and they act with benefit in some cases. About the worst thing to do, in general, is to take physics constantly. These are not physics, however; they act mechanically. Even the C.S. (common-sense?) individual can take these. The agar may be taken two or three heaping teaspoonfuls in a large glass of water before retiring, or in the morning before breakfast, or in lieu of 4 o'clock tea. Drink it down rapidly--for goodness' sake, don't try to chew it. Mineral oil will make fine mayonnaise dressing. It has little or no food value, so the constipated overweight individual may indulge freely. For faulty elimination, then-- 1. Correct diet. 2. Exercise--especially brisk walking. 3. Regularity of habit. 4. Possibly the addition of bran, agar, or mineral oils. 5. Sweet disposition. Mean people are always constipated. _Review_ 1. Give classes of food, with examples of each. 2. What are vitamines? How importance discovered? 3. Where most abundant? 4. What is a balanced diet? 5. What should be done for faulty elimination? 4 More Keys and More Calories [Sidenote: _List of Foods to Follow_] The following list probably does not contain all of the foods you might like and want to know about, but from those named you can judge of the food value of others. In general, the caloric value, and therefore the fattening value, depends upon the amount of fat and the degree of concentration. [Sidenote: _Important_] But remember this point: _Any food eaten beyond what your system requires for its energy, growth, and repair, is fattening, or is an irritant, or both_. [Sidenote: _A Moderate Sized Chocolate Cream_] If a food contains much fat, you will know that it is high in food value, for fat has two and one-quarter times the caloric value that proteins and carbohydrates have. Dry foods are high in value, for they are concentrated and contain little water. Compare the quantity of two heaping teaspoonfuls of sugar, a concentrated food, and one and one-half pounds of lettuce, a watery vegetable, each having the same caloric value. A moderate sized chocolate cream is not only concentrated but has considerable fat in the chocolate. [Sidenote: _Enuf Sed_] It is not necessary to know accurately the caloric values. In fact, authorities differ in some of their computations. The list is not mathematically correct, but it will give you a good idea of the relative values, and is accurate enough for our purposes. I have purposely given round numbers, where possible, in order to make them more easily remembered. In reckoning made dishes, such as puddings and sauces, you must compute the different ingredients approximately. About how much sugar it has, how much fat to the dish, and so on. In reckoning any food, if you are reducing, give it the benefit of the doubt on the high count; and if trying to gain, count it low. It is well, if you are much overweight or underweight, to have some of these foods that are given weighed, so that you can judge approximately what your servings will total. [Sidenote: _A Mixture_] A mixture of foods should be used, in order to get the different elements which are necessary for the human machine. It is not wholesome to have many foods at a meal; but the menu should be varied from day to day. Any regimen which does not allow some carbohydrates and fats for the fuel foods is injurious if persisted in for a length of time. [Sidenote: _Thoroughly Masticate Everything_] As to harmful combinations; there are not many, and if your food is thoroughly masticated you need not concern yourself very much about them. However, if you find a food disagrees with you, or that certain combinations disagree, do not try to use them. Underweight individuals sometimes have to train their digestive tracts for some of the foods they need. Coffee, tea and other mild stimulants are not harmful to the majority; but, like everything else, in excess they will cause ill health. Alcoholic drinks make the fat fatter and the thin thinner, and both more feeble mentally. [Sidenote: _I Love Her_] I hope I have stimulated you to an interest in dietetics. There are many books which go into the subject much more deeply. I recommend, especially, "The Home Dietitian," written by my beloved colleague and classmate, Dr. Belle Wood-Comstock. Others I have read that are especially suitable for the home are "Feeding the Family," by Mary Schwartz Rose, and "Dietary Computer," by Pope. There are doubtless many other good ones. The Department of Agriculture publishes free bulletins on the subject. Farmers' Bulletin No. 142, by Atwater, is very comprehensive. Other authorities I have consulted are Lusk, Friedenwald and Ruhräh, Gautier, Sherman, Buttner, Locke and Von Noorden. Measuring Table 1 teaspoon (tsp.) fluid 1/6 oz. 1 dessertspoon (tsp.) 1/3 oz. 1 tablespoon (tbsp.) 1/2 oz. 1 ordinary cup 8 oz. 1 ordinary glass 8 oz. Average helping a.h. _One Hundred Calorie Portions and Average Helpings_ (Approximate Measures) (ATWATER, LOCKE, ROSE) MEATS Beefsteak, lean round..............2 oz. 100 C. A.h....... 3-1/2 oz., 185 C. Beefsteak, tenderloin..............1 oz. 100 C. A.h.................. 285 C. Beef, roast, very lean.............3 oz. 100 C. A.h.................. 150 C. Chicken, roast..................1-2/3oz. 100 C. 1 slice.............. 180 C. Frankfurters, 1 sausage............1 oz. 100 C. Chops, lamb or mutton..........1-1/2 oz. 100 C. Average chops.... 150-300 C. Pork: Bacon, crisp...................1/2 oz. 100 C. 1 small slice, crisp 25 C. Chop.........................1-1/2 oz. 100 C. Medium..........160-300 C. Ham, boiled..................1-1/3 oz. 100 C. A.h..........3 oz., 250 C. Ham, fried.....................3/4 oz. 100 C. A.h..........3 oz., 400 C. Sausage..........................1 oz. 100 C. 1 small, crisp.......60 C. Turkey.........................1-1/3 oz. 100 C. A.h........3-1/3 oz., 260 C. [Sidenote: _Fish Boiled or Broiled_] FISH Fish, Lean, Cod, Halibut...........3 oz. 100 C. A.h........... 4 oz., 135 C. Fish, fat, salmon, sardines ...1 1/2 oz. 100 C. A.h........... 4 oz., 260 C. Lobster............................4 oz. 100 C. A.h.................. 100 C. Oysters.......................... 12 100 C. 1 oyster............... 8 C. Clams, long....................... 8 100 C. 1 clam................ 12 C. SOUPS Cream soups, average...............3 oz. 100 C. A.h........... 4 oz., 125 C. Consommés, no fat.................30 oz. 100 C. A.h........... 4 oz., 15 C. DAIRY PRODUCTS AND EGGS Butter, 1 level tbsp. scant .... 1/2 oz. 100 C. 1 ball............... 120 C. Cheese (American, Roquefort, Swiss, etc.)..... 1-1/8 cu. in 3/4 oz. 100 C. Cottage Cheese.................... 3 oz. 100 C. A.h.................. 100 C. Whole Milk........................ 5 oz. 100 C. 1 glass.............. 160 C. Skim Milk........................ 10 oz. 100 C. 1 glass............... 80 C. Malted Milk (dry).............1 h. tbsp. 100 C. Buttermilk, natural.............. 10 oz. 100 C. 1 glass............... 80 C. Koumiss........................... 6 oz. 100 C. 1 glass.............. 130 C. Condensed, unsweetened............ 2 oz. 100 C. 1 tbsp................ 35 C. Condensed, sweetened, 1-1/4 tbsp....... 100 C. Cream, average.................1-1/3 oz. 100 C. 1 tbsp................ 50 C. Cream, whipped................ 1-1/3 oz. 100 C. 1 h. tbsp............ 100 C. Eggs, 1 large..................... 1 100 C. Average egg........... 80 C. Boiled or poached; if fried, C. depend upon fat adhering. VEGETABLES When not otherwise indicated, the method of cooking is by boiling. The caloric value of sauces served with them not included. Asparagus, large stalks........... 20 100 C. 1 stalk................ 5 C. Beets........................... 1 lb. 100 C. 2 h. tbsp............. 30 C. Beans, Baked, home.............1-1/2 oz. 100 C. 3 h. tbsp............ 300 C. Beans, Baked, canned...........2-1/2 oz. 100 C. 3 h. tbsp............ 150 C. Beans, Lima....................... 3 oz. 100 C. 3 h. tbsp............ 130 C. Beans, String..................... 1 lb. 100 C. 2 h. tbsp............. 15 C. Cabbage....................... 1-1/2 lb. 100 C. 3 h. tbsp............. 10 C. Carrots........................... 1 lb. 100 C. 3 h. tbsp............. 20 C. Cauliflower....................... 1 lb. 100 C. 3 h. tbsp............. 20 C. Celery, uncooked.................. 1 lb. 100 C. 6 stalks.............. 15 C. Corn, canned.................. 3-1/3 oz. 100 C. 2 h. tbsp............ 100 C. Corn, green, 1 ear............ 3-1/3 oz. 100 C. Medium size. Cucumber...................... 1-1/2 lb. 100 C. 10 to 12 thin slices.. 10 C. Lettuce....................... 1-1/2 lb. 100 C. A.h................. 5-10 C. Mushrooms......................... 8 oz. 100 C. Onions, 2 large................... 8 oz. 100 C. Parsnips.......................... 8 oz. 100 C. A.h............ 2 oz., 25 C. Peas, green....................... 3 oz. 100 C. A.h., 3 h. tbsp...... 100 C. Potatoes, sweet............... 1-1/2 oz. 100 C. 1 medium............. 200 C. Potatoes, white................... 3 oz. 100 C. 1 medium............. 100 C. Potato Chips......scant........... 1 oz. 100 C. A.h., 8-10 pieces.... 100 C. Radishes.......................... 1 lb. 100 C. A.h., 6 red button.... 15 C. Spinach....................... 1-1/2 lb. 100 C. A.h., 1/2 cup......... 25 C. Squash............................ 1 lb. 100 C. A.h., 2h. tbsp........ 25 C. Tomatoes.......................... 1 lb. 100 C. A.h., 1 large......... 50 C. Turnips........................... 1 lb. 100 C. A.h., 2 h. tbsp....... 25 C. FRUITS Apple............................. 7 oz. 100 C. 1 average size......... 50 C. Banana............................ 5 oz. 100 C. 1 small............... 100 C. Berries.............average....... 5 oz. 100 C. 1 small cup........... 100 C. Cantaloupe........................ 1 lb. 100 C. A.h., 1/2 melon....... 100 C. Cherries.......................... 5 oz. 100 C. A.h., 1 small cup..... 100 C. Grapes............................ 5 oz. 100 C. A.h., 1 small bunch... 100 C. Lemons (5 oz. each)............... 2 100 C. They won't make you thin. Average size........... 30 C. Oranges (9 oz. each).............. 1 100 C. Peaches (5 oz. each).............. 2 100 C. Average size........... 50 C. Pears (6 oz. each)................ 1 100 C. Average size........... 90 C. Pineapple, fresh.................. 7 oz. 100 C. 2 slices, 1 in. thick. 100 C. Plums, large..................... 3 or 4 100 C. 1 plum................. 30 C. Watermelon.................... 1-1/2 lb. 100 C. Large slice............ 15 C. Dates (dry), large................ 3-4 100 C. 1 large................ 25 C. Figs (dry), large................. 1-1/2 100 C. 1 large................ 65 C. Prunes (dry), large............... 3 100 C. 1 large................ 35 C. Stewed, 4 medium, with 4 tbsp. juice....... 200 C. BREAD AND CRACKERS Brown Bread, 1 slice, 3 in. in diam., 3/4 in. thick 100 C. Corn Bread, 3 x 2 x 3/4 1-1/2 oz. 100 C. Victory Bread, 1 slice, 3 x 4 x 1/2 in. 100 C. White, gluten, rye, whole wheat, etc., practically same caloric value per same weight. There is so little difference between the caloric value of gluten bread and other breads that it is not necessary for reducing to try to get it. (Toasted bread has the same caloric value that it had before toasting. It is more easily digested, but just as fattening. Advised, however, because it makes you chew.) 1 French or Vienna roll 100 C. Zweiback 3/4 oz. 100 C. 1 slice, 3-1/4 x 1-1/4 x 1/2 in., 35 C. Graham Crackers 3 100 C. 1 c., 3 in. sq. 35 C. Oyster Crackers 24 100 C. Soda Crackers 4 100 C. 1 c. 25 C. Pretzels 5 100 C. 1 p. 20 C. BREAKFAST FOODS, ETC. Farina or Cream of Wheat 6 oz. 100 C. 2 h. tbsp 60 C. Force 1 oz. 100 C. 5 h. tbsp 65 C. Grapenuts scant 1 oz. 100 C. 2 tbsp 100 C. Griddle Cakes, 4-1/2 in. in diam. 100 C. A.h., 3 cakes 300 C. (This does not include butter and syrup, remember.) Hominy 4 oz. 100 C. 2 h. tbsp 85 C. Macaroni, plain 4 oz. 100 C. 2 h. tbsp 90 C. Macaroni and cheese (depends on amt. cheese) 2 h. tbsp 200-300 C. Muffin, average 3/4 m. 100 C. 1 muffin 125 C. Oatmeal 5 oz. 100 C. 1 small cup 100 C. Puffed Rice 1 oz. 100 C. 5 h. tbsp 50 C. Popcorn (cups) 1-1/2 100 C. A.h. depends on butter added. Rice, boiled 4 oz. 100 C. 1/2 cup 100 C. Shredded Wheat Biscuit 1 100 C. Triscuits (_2_) 100 C. Waffles scant 1/2 w. 100 C. 1 waffle 225 C. CANDY, PASTRIES AND SWEETS Chocolate creams, medium. 1 100 C. Chocolate, 1 lb 2880 C. Cherries, candied 10 100 C. Cup Custard, 1/3 cup 100 C. Chocolate Nut Caramels 1 x 1 x 4/5 in. 100 C. Other candies, reckon sugar, nuts, etc. Cookies, plain, diam. 3 in. 2 100 C. 1 cookie 50 C. If raisins or nuts in them, count extra. Doughnut scant 2/3 100 C. 1 average size 160 C. Ginger-snap 5 100 C. 1 gingersnap 20 C. Honey h. tbsp. 1 100 C. Thick syrups approximately the same. Ladyfingers scant 1 oz. 100 C. 1 ladyfinger 35-50 C. Macaroons 2 100 C. 1 macaroon 50 C. Pie with top crust, about 1/4 ordinary slice, or 1-1/4 in. 100 C. A.h., 1/6 pie 350 C. Pie without top crust, 2 in. 100 C. Custard, lemon, squash, etc. A.h., 1/6 pie. 250-300 C. Puddings, average cup 1/4 100 C. A.h. 200-350 C. Depends upon richness. Ice Cream h. tbsp. 1 100 C. A.h. 200-350 C. Depends upon richness. Cakes 1 oz. 100 C. A.h. 200-350 C. Depends upon size, icing, fruit, nuts, etc.; compute approximately. Sugar cubes 3 100 C. Granulated h. tsp. 2 100 C. Saccharine, a coal tar product 300 to 500 times sweeter than sugar, but of no food value. Not advisable to use habitually. Better learn to like things unsweetened--it can be done. CONDIMENTS AND SAUCES Mayonnaise m. tbsp. 1 100 C. A.h. 200 C. Olive oil and other oils. dsp. 1 100 C. Olives, green or ripe 6-8 100 C. 1 olive 10-15 C. Tomato Catsup 6 oz. 100 C. 1 tbsp. 10 C. Thick Gravies tbsp. 3 100 C. NUTS Almonds, large 10 100 C. 1 almond 10 C. Brazil, large 2-1/2 100 C. 1 Brazil nut 45 C. Chestnuts, small 20 100 C. 1 chestnut 5 C. Peanuts, large double 10 100 C. 1 bag 250-300 C. Pecans, large 5 100 C. 1 pecan 20 C. Walnuts, large 3-1/3 100 C. 1 walnut 30 C. Cocoanut, prepared 1/2 oz. 100 C. Peanut Butter 2-1/2 tsp. 100 C. _Key to Key_ [Sidenote: _Remember This_] If you will remember the following portions of food, you will have a standard by which to compute your servings: Lean Meat: a piece 3 x 2 x 1/2 (2 oz.) 100 C. Now if your serving of meat or fish is fat, mentally cut in two for same value. If very lean, you should add a little. White Bread: slice 3 x 4x 1/2 100 C. Compute other breads by this. Butter: 1 scant tablespoonful 100 C. Sugar: 1 heaping teaspoonful 50 C. Potatoes: 1 medium, boiled or baked. 100 C. Watery Vegetables: 1 helping 15-35 C. If food is fried, or butter, oil, or cream sauces are added, the C. value increases markedly. _Review_ 1. Why is a mixture of foods necessary? 2. Give the caloric value of the following: 1 glass of milk, skim; buttermilk; 10 chocolate creams; 1 bag peanuts; 1 pat butter; 1 piece pie. 3. Name foods low in caloric value. Why are they valuable? 4. How many calories of bread and butter do you daily consume? 5. Reckon your usual caloric intake. How much of it is in excess of your needs? 6. Memorize caloric value of foods you are fond of. _This Table of Foods, With the C Given Per Oz. Will Help You_ The caloric value of pure fat is 255 C per oz., dry starches and sugars (carbohydrates), and protein (the meat element), is 113. This means fats are 2-1/4 times more fattening than other foods. Most foods contain considerable water, so the following is an approximate table of foods 'as is.' I have given round numbers in the table so you can more easily remember them. _Memorize it_. Calories per oz. Fats 255 Nuts, edible part 200 Sugar 115 Cream cheese 110 Cottage cheese (no fat) 30 Breads 75 Lean meats 50 Lean fish 35 Eggs (per oz.) 40 Milk, whole 20 Milk, skim and buttermilk (no fat) 10 Milk, condensed, sweet 100 Milk, condensed, unsweet. 50 Cream, thin 60 Cream, thick 110 Fruits: Dried 100 Sweet 25 Acid 15 Vegetables: Potatoes, plain (oz.) 30 Cooked Legumes, (peas, beans, etc.) 20-35 Watery and leafy 5-15 5 Vegetarianism vs. Meat Eating [Sidenote: _Protein_] As protein is the only food which builds and repairs tissue, it is the food which has caused the most controversy. First: As to the amount needed. Second: As to whether animal flesh protein is necessary. [Sidenote: _Chittenden_] AMOUNT NEEDED: It was thought for many years that 150 grams or 5 ounces of dry protein (equivalent to about 1-1/2 pounds lean meat) per day was necessary. But experiments of Chittenden and others have proved that considerably less is sufficient, and that the health is improved if less is taken. Chittenden's standard is 50 grams, or 1-2/3 ounces, dry protein (equivalent to 1/2 pound meat per day). This is considered by many as insufficient. A variation from 1-2/3 to 3 ounces dry protein per day will give a safe range. (ROSE.) [Sidenote: _Approx. 240 to 360 C Per Day_] _The amount of protein needed is comparatively independent of the amount of physical exertion_, thus differing from the purely fuel foods, carbohydrates and fats, which should vary in direct proportion to the amount of physical exertion. In general, 10 to 15 per cent of the total calories per day should be taken as protein. An excess is undoubtedly irritant to the kidneys, blood vessels, and other organs, and if too little is taken the body tissues will suffer. Not all of the protein should be taken in the form of animal protein; at least one-half should be taken from the vegetable kingdom. _Animal Flesh Protein_ [Sidenote: _Necessary?_] The following are a few of the chief reasons given by those who object to its use: [Sidenote: _The Negative Side_] First: The animal has just as much right to life, liberty, and pursuit of happiness as we have. Second: They may be diseased, and there is the possibility of their containing animal parasites, such as tapeworms and trichinæ. I would like to tell you more about worms, they are so interesting, but He says not to try to tell all I know in this little book; that maybe he will let me write another sometime, although it is a terrible strain on him, and that I have given enough of the family history, anyway. [Sidenote: _Some Word_] Third: The tissues of animals contain excrementitious material, which may cause excess acidity, raise the blood pressure, and so forth. Fourth: More apt to putrefy and thus give ptomaine poisoning. Fifth: Makes the disposition more vicious. (Honest,--animals eating meat exclusively are more vicious.) [Sidenote: _The Affirmative Side_] Those who believe that animal protein should be eaten answer these points as follows: First: Survival of the fittest. Second: If you give decent support to your health departments they can furnish enough inspectors to prevent the marketing of diseased meat; and if some should slip through, if you thoroughly bake, boil, or fry your animal parasites they will lose their pep. Third: Most of the harmful products are destroyed by the intestines and liver. Fourth: True, but see that you get good meat, and don't eat it in excess. Fifth: Unanswerable--to be proved later by personal experiments. In addition, they say that animal protein is more easily digested, that 97 per cent is assimilated because it is animal, and so it is much more to be desired, especially by children and convalescents; that vegetable protein is enclosed in cellulose, and only 65 to 75 per cent is used by the system; thus the diet is apt to be too bulky if the proper amount is taken. [Sidenote: _Strong Vegetarians_] It has been proved, however, by several endurance tests, that the vegetarian contestants had more strength and greater endurance than their meat-eating competitors, so there is no reason why we should be worried by one or two, or even more, meatless days, especially when animal product protein, such as milk, eggs, cheese, and the vegetable proteins, as in the legumes and the nuts, are available. [Sidenote: _A Confession_] I confess that for quite a while after studying vegetarian books I took a dislike to meat, but now I am in the comfortable state described by Benjamin Franklin in his autobiography. It seems that he had been converted to vegetarianism and had decided that he never again would eat the flesh of animals that had been ruthlessly slaughtered, when they so little deserved that fate. But he was exceedingly fond of fish, and while on a fishing party, as some fish were being fried, he found they did smell most admirably well, and he was greatly torn between his desire and his principle. Finally he remembered that when the fish were opened he saw some smaller fish in their stomachs, and he decided that if they could eat each other he could eat them. [Sidenote: _Most Noted Picture of B. Franklin Extant_] _Protein Calories in 100 C Portions of Food_ In 100 C's Bread, 1 slice, (W.W. the highest) 12 to 16 C's P In 100 C's Cooked Cereals, 1 sm. cup, (oatmeal highest) 10 to 18 C's P In 100 C's Rice, 1 small cup 10 C's P In 100 C's Macaroni, 1 small cup 15 C's P In 100 C's Whole milk, 5 oz. 20 C's P In 100 C's Skim and buttermilk, 10 oz. 35 C's P In 100 C's Cheese, 3 heaping tbsp. Cottage cheese 75 C's P In 100 C's Eggs 1-1/3 36 C's P In 100 C's Meat or fish, Very lean 2-3 oz. 50 to 75 C's P In 100 C's Nuts, peanuts, almonds, walnuts. Peanuts the highest 10 to 20 C's P In 100 C's Beans 1/3 cup average 20 C's P In 100 C's Green peas 3/4 cup average 28 C's P In 100 C's Corn 1/3 cup average 12 C's P In 100 C's Onions 3 to 4 medium 12 C's P In 100 C's Potato 1 medium 12 C's P In 100 C's Tomatoes 1 lb 15 C's P In 100 C's Fresh fruits: berries, currants, rhubarb 10 C's P Others 2 to 5 C's P 6 The Deluded Ones--My Thin Friends [Sidenote: _What!_] I am going to sandwich you in between the food calories and my fat friends, and maybe you can absorb some of them. In the first chapter, you remember, I said I was not particularly interested in you, but I have changed my mind, and I will treat you tenderly and carefully. I will have to preach a little bit first, but I don't mind that; I love to reform people--Yes, you need reforming! The first thing many of you have to do is to learn to accept the trivial annoyances and small misfits of life as a matter of course, for to give them attention _beyond their deserts_ is to wear the web of your life to the warp. Elbert Hubbard never said anything better than that. Have that reproduced in motto form and put it on your bureau, and repeat it fifty times daily. [Sidenote: _Good Philosophy_] Adopt my philosophy. If I have a trivial annoyance I analyze it carefully. Was I to blame? Yes? All right, I am glad, because then I can see that it will not happen again, so I stop worrying. If I am not to blame, if I could not help it in the least, well, then I don't worry about it, for that will not help it any, and I wasn't to blame! If it bobs up in my mind again, I say: "Now, look here, you annoyance, I have given you all the attention you deserve; avaunt, depart, get out!" [Sidenote: _Simple_] Now, how is this philosophy going to help you gain? [Sidenote: _Lost Calories_] When you worry needlessly, notice how tense your muscles are. You are exercising them all of the time and using hundreds of calories of energy. You raise your blood pressure, the internal secretory glands may overact (re-read what I have said about these glands in the fat people), and thus many more calories are used. The intestinal secretions do not flow so freely, you have indigestion and do not assimilate your food, and thus hundreds more calories are lost. It certainly is impossible to gain unless your food is assimilated. [Sidenote: _Develop Poise_] So the first thing you have to learn is this mental control and to relax. Remember that word, relax. After you are better nourished your nervous system will not be on hair-trigger tension, and it will be easier for you. [Sidenote: _No Pain In Matter; No Matter In Pain Why Worry?_] If you are ill in mind or body, remember that it is natural to be well, and that within your body nature has stored the most wonderful forces which are always tending towards the normal, or health, if not obstructed or hindered. Nature sometimes needs help to stimulate those forces, or to reinforce them, or to remove obstructions. This is where the physician comes in. But you yourself can aid nature the most by realizing that _nature is health and it is normal to be well_. By so doing, all of your organs function better and you are restored to normal more rapidly. [Sidenote: _Sleep_] [Sidenote: _Fresh Air_] Second: It is very important to have enough sleep. Dr. Richard Cabot says that probably resistance is lowered as much by lack of sufficient sleep as by any other factor, and that all you can soak into your system in twenty-four hours is not too much. Don't forget the fresh air. You generally suffer from sleeplessness, I believe. The overweights are always advised not to sleep too much. They will find while reducing that they won't want to sleep so much, anyway. They will like to stay awake--they feel so much happier. [Sidenote: _Sometimes_] Now, when you retire and try to sleep but cannot, try this--it works with me. You know when you are passing over your mental images become distorted and grotesque. I artificially induce that state. If I find myself rehearsing about two hundred times, with appropriate gestures, the keen, witty, logical remarks which I could have made in favor of my pet legislation in the club discussion, but didn't, then I begin after this fashion: Pink elephants with green ribbons on their tails--red rhinoceri (is that right, or should it be rhinoceroses?)--smiling peanuts--Woman's City Club--Social Health Insurance--why didn't I say--I wish I had said--(here get out, you annoyance!)--pink elephants--and so forth and so forth. [Sidenote: _Picture of Pink Elephant Adorned_] [Sidenote: _Woe Is Me_] Now I realize I have ruined myself. I am my own worst enemy. I have exposed my whole life before those modern vivisectionists, the army of amateur psycho-analysts. [Sidenote: _Exercise_] Third: Exercise. Great muscular exertion should be avoided, but the setting-up exercises that I advise, if begun with moderation and increased gradually, will undoubtedly stimulate the appetite and help the body functions to be better performed. [Sidenote: _Food_] Fourth: Since food is the only source of body substance, you must gradually train your stomach so that it can care for enough food to not only supply your bodily energy, but to leave a little excess to be stored as fat. [Sidenote: _Your Stomach_] If you have a small appetite--and many of you have--your stomach is undoubtedly contracted, and you must gradually add to the amount you have been eating, even though it may cause some distress, until you have disciplined it so that it can handle what you need without distress. The stomach is a muscular organ and can be trained and exercised somewhat as other organs can. You will not have much appetite at first, but it will develop. Sometimes a short fast for a day or two, drinking nothing but pure water, seems to be beneficial in the beginning. Do not drink much with your meals, unless the drink has food value by the addition of lots of cream or sugar, or both. [Sidenote: _Eat More_] Decide how many calories you need for your activities, gradually add to your dietary until you have reached that number, and then some more, and you will gain as surely as the overweight individual will lose by doing the opposite. It may take a long time, or you may get results very rapidly, depending somewhat upon the individual characteristics. Gradually increase your butter, cream, sugar, chocolate, and so forth, as they are very high in food value. Study the Key to the Calories and reckon your calories every day for a while. You have already noticed that the foods that you like are low in food value. Here are some of the things you can take to add to your fuel: [Sidenote: _Try Some of These_] A glass of milk, hot or cold, taken between meals and before retiring, will add about 500 calories. Cream sauce on your vegetables will add to their value. Cod liver oil, or olive oil, or cream, begun in small doses and gradually increased. One malted milk, made with milk, syrup, egg, ice cream, whipped cream, and the malted milk, will add about 500 calories. [Sidenote: _Learned Phraseology_] You remember the painful time that I spoke of when there was so much more of me than there ought to be? Well, the aforesaid concoction, made with milk, syrup, egg, ice cream, whipped cream, and the malted milk, was accessory before the fact, and also particeps criminis before the law. I absorbed this phraseology by being president of the Professional Woman's Club, with its high-class women attorneys, ministers, dentists, Ph.D.'s, and "Medical Trust" doctors. [Sidenote: _Explanatory Note 1_] "Medical Trust."--The American Medical Association (A.M.A.), a powerful trust you can't get into unless you have a high preliminary education and are a graduate of a high-class medical college. Eleven years' training after the grammar school is their minimum standard now. [Sidenote: _Explanatory Note 2_] "League for Medical Ignorance."--The so-called "League for Medical Freedom"; the opponent of the above mentioned trust. Their standard--any old kind of a medical or religious training, two weeks or longer, engrafted on anyone who has the money to pay for the course. No education, no barrier; in fact, those of limited education make the loudest boosters for the league. In justice, I must say that many splendid, estimable persons belong to this league, not knowing these facts. [Sidenote: _Thorough Mastication_] Fifth: See page 92 in my advice to the fat. It is as important for you as for them. (It always makes me mildly furious when I look up a word and am directed to seek some other locality. If it affects you that way--seek page 60 in my advice to you.) Also have your teeth X-rayed. Blind abscesses at the roots will cause all sorts of aches and pains, as well as underweight. [Sidenote: _Especially About Your Ailments_] [Sidenote: _Organ Recitals Wednesday Evenings Only_] Sixth: _Don't talk so much_. See if you can't leave out two-thirds of the totally unimportant, uninteresting details. A tremendous amount of energy is used in talking. This habit I would not say was confined to you, by any means; it is another one of those pretty nearly universal errors. I will not give you a sample fattening menu, for it might be all out of proportion to what you could handle, and it would upset you. Make out your own menus, realizing that you must work gradually to the desired amount. I am taking it for granted that you are organically sound, that your scientific, educated physician has said there is nothing the matter with you, except perhaps your "nervous" disposition. Have I not been nice to you? All right, relax and watch yourself get into the class of the plumptically adequate. And if you don't succeed after a faithful trial, take the milk-cure, with its three to six weeks' absolute rest. _Recapitulation_ 1. Calm yourself. 2. Sleep. 3. Exercise. 4. Food. 5. Masticate 6. Delete the details. 7. Milk-cure. _Review_ 1. Repeat Elbert Hubbard's advice. 2. Give three reasons why worry can make you thin. 3. Define "Medical Trust" and "League for Medical Freedom." 4. Memorize paragraph about nature 5. Enumerate the things you can eat to increase your calories. 7 Exercise It is practically impossible to reduce weight through exercise alone, unless one can do a tremendous amount of it. For the food that one eats is usually enough to cover the energy lost by the exercise. [Sidenote: _Light On Your Feet_] However, exercise is a very important feature of any reducing program; not because of the fat that is burned up in the exercise--and there is some burned--but for the reason that it is necessary to keep one in a healthy condition. The muscles, the internal organs, the bones, the brain, are all benefited--in fact, the entire system. [Sidenote: _Duty Dances_] The exercises described hereinafter will help make you fat or thin, and they will keep you supple, graceful, and light on your feet, so that when I tell my husband that he must dance with you, Madam, he will not say, "Nothing stirring," and when you, Professor, ask me to dance, I will not curse the day I was born. [Sidenote: _Warning_] If you have not been accustomed to exercise, I warn you to take up only one or two at a time and do each one a few times only. You will be atrociously sore, and you will realize that you have muscles of which you wotted not. However, persist, if you are sure there are no organic reasons why you shouldn't--such as a weak heart. (In case you are very much overweight, I think it advisable to wait until you have reduced somewhat.) [Sidenote: _Or Classic Dancing_] It is splendid if you can belong to a gymnasium or to a physical culture class, but ten to fifteen minutes' systematic daily exercise practiced with vim, and each set followed by deep breathing, will do more good than a gymnasium spasmodically attended. Brisk walking with a long stride isn't so bad; in fact, if taken with a very long stride it will twist 'most every organ you have in your body. There are hundreds of exercises you can take. If you will notice little rascal's illustrations you will find many good ones. Those illustrating the beginning of this chapter are excellent. If possible, it is best to take the exercises on arising in the morning, but if you have a household to care for you may not be able to do so. For those who have to do their own work, it may be well to do the work first. You can do it in half the time if you plan it carefully and speed up. (This advice is not for my thin friends; their speedometers register too high already.) It does not matter so much when the exercises are done as that they are done, and done every day for the rest of your life, with the possible exception of two or three days a month. Gallstones, permanent stiff joints, and other little things like that will have a hard time forming. _My Exercises_ [Sidenote: _They Reach Most of My Muscles_] (The services of my noted artist I was able to obtain with great difficulty, as he was engaged in the more important work of making a swagger stick. I finally secured him by the promise of an ice cream cone and twenty-three cents to go with his two cents so that he could buy a Thrift Stamp. He is given due credit on the title page.) [Sidenote: _Turn On Your Music_] These exercises executed with vim, vigor, and vip--deep breathing between each set--will take ten to fifteen minutes. Re-read my warning. [Sidenote: _Little Movements with Meanings All Their Own_] 1. Feet together, arms outstretched, palms up, describe as large a circle as possible. Fine for round shoulders and fat backs. Do slowly and stretch fifteen times. Smile. 2. Arms outstretched, swing to right and to left as far as possible at least 15 times each. [Sidenote: _Important! Keep Facial Expression Throughout as per Artist's Idea_] 3. Bend sideways, to right and left, alternately, as far as possible at least 15 times each. 4. Revolve the body upon the hips from right to left at least 10 times, and left to right the same. 5. Bend and touch the floor with your fingers, without bending your knees, at least 15 times. 6. Knee-bending exercise, at least 15 times. This is hard at first. 7. Hand on door or wall, swing each leg back and forth at least 15 times. To the side 15 times. Turn head, raise arm, and tense both. [Sidenote: _You Will Soon Be as Graceful as Annette_] 8. Step on chair with each foot at least 10 times. This is good for calf and thigh muscles. After a while you won't look as though you needed a derrick to get onto a street car. 9. Arms on sides of chair. Come down and touch abdomen. Fine for back and abdomen. Fifteen times. [Sidenote: _It Has Been Called to My Attention that Bone Back Brushes Should Not Be Used by Some; i.e., There Is Danger in Affinities_] 10. Brush hair vigorously at least 200 double strokes all over the head, N.S.E.W., using a brush in each hand. [Sidenote: _Good Exercise_] (Military brushes are best. If you can't purloin a set of your husband's, two ordinary brushes will do.) Now shake out the loose dandruff. This is one of the best exercises and must not be omitted, for it accomplishes two purposes. It is a good arm and chest exercise, and it gives a healthy scalp absolutely free from the dammdruff. NOW This for a few minutes, followed by this, the hot preferably at night. 8 At Last! How to Reduce The title of this chapter indicates to whom it is addressed. All others please refrain from reading, for it is strictly private and confidential, and is intended only for those who need it. You thin and you normal had better save it, though, for you may qualify later. You are keeping right on reading now! I'm surprised. I wanted to tell my fat friends that the first thing they have to do is to get control of their will power, and now I can't do it. Somehow, will power with a layer of fat on it gets feeble. Don't laugh, you too thin! It gets worse than feeble, if there is no fat at all and the nervous system is starved, it--well, I won't say what it does, for I don't want to worry you. [Sidenote: _Now That Order Is Restored I Will Resume_] Will power, being feeble to a greater or less degree, must be bolstered and aided a bit, to begin with, so-- _First Order_ [Sidenote: _Watch Your Weight!_] [Sidenote: _Nature Always Counts_] Tell loudly and frequently to all your friends that you realize that it is unpatriotic to be fat while many thousands are starving, that you are going to reduce to normal, and will be there in the allotted time. If you belong to a club, round up the overweights and form a section. Call it the "Watch Your Weight--Anti-Kaiser Class." Tax the members sufficiently to buy a good, accurate pair of scales. Meet once a week to weigh. Wear approximately the same weight clothes, and weigh at the same time in relation to eating. Do this whether or not you belong to a club. Once or twice a week is often enough to weigh. Scales vary, so try to use the same ones. Don't be discouraged if some day after you have dieted well you seem to have gained. Nature sometimes seems fiendish that way. The excess weight is probably due to a retention of water, and will not be permanent. However, don't depend upon this too often! Usually, if you have gained when you think you ought not to, it is because Nature has been counting calories and you haven't. Have the members listed on a weight chart conspicuously placed near the scales, and record accurately the weight weekly. +-------------------------------------------------------+ | WATCH YOUR WEIGHT ANTI-KAISER CLASS | +-------------------------------------------------------+ | |Normal| Weight on | +------------------+------+-----------------------------+ | Members' Names |Weight|Date|Date|Date|Date|Date|Date| +------------------+------+----+----+----+----+----+----+ | | | | | | | | | +------------------+------+----+----+----+----+----+----+ | | | | | | | | | +------------------+------+----+----+----+----+----+----+ | | | | | | | | | +------------------+------+----+----+----+----+----+----+ | | | | | | | | | +------------------+------+----+----+----+----+----+----+ | | | | | | | | | +------------------+------+----+----+----+----+----+----+ [Sidenote: _No Funds for the Red Cross_] Those not reducing at least one pound per week to be fined soundly and the proceeds given to the Red Cross. That won't be a good way to raise funds for the chapter, though, for there will be no fines after the first week or so, when the members find what their maintenance diet should be and are consuming less than that. I will explain this maintenance diet business. You shameless thin ones, call back your more polite comrades--this is important for all of you. (I shall also tell you more fully about this in the last chapter.) [Sidenote: _Maintenance Diet_] The maintenance diet is one which maintains you at your present weight, _i.e.,_ you are not gaining or losing. You may be over or under normal, but are staying there. The intake equals the outgo. When you eat less than your maintenance diet, you are going to supply the deficiency with your own fat. So commit yourself on your honor that you are going to reduce or perish--no joke; you can't tell how near you are to it if you are much overweight. There are two general stages of fatty heart. In the first stage the heart is surrounded by a blanket of fat, and it also penetrates between the muscles. Later, if it goes on too long, the heart muscle itself degenerates to fat, then-- [Sidenote: _Good-night!_] Shakespeare warns you to make thy body less, hence thy grace more; leave gormandizing, and know that the grave doth gape for thee thrice wider than for other men. _Second Order_ [Sidenote: _Shrink Your Stomach_] Your stomach, long used to an excess of food for your needs--it may not be a large amount--but still, I repeat, being used to an excess of food for your needs, your stomach must be disciplined. It is undoubtedly distended, as it should not be. [Sidenote: _Shrink Your Stomach_] A good way to show it that you are master is to fast for at least one day--drink nothing but pure water, hot or cold, as you prefer. It will protest vociferously and will tell all its friends, the different organs of your body, how you are persecuting it, and they will join the league against you and decide they will oust you from your position, and you will feel like--but don't mind it; it will soon know that you mean business, and, much chastened and considerably contracted, will take the next day a very small amount of food very gratefully. [Sidenote: _Shrink Your Stomach_] If you do not want to be so severe with it you can allow it five glasses of hot or cold skim milk or buttermilk, one every three hours, say, at 10,1,4,7, and 10 o'clock. One glass is 80 calories, five equal 400 calories, which is not so much. [Sidenote: _Or Mashed_] The baked potato and glass of skim milk diet, three times a day one day a week, which has its devotees, depends upon its low caloric content for its results. There is no magic in it, no yeast business which reduces. This is most wholesome, however, for potatoes contain a large amount of the potassium salts, which tend to counteract the effects of uric acid, and thus are good for the gouty type. [Sidenote: _Mono-Diets_] The beefsteak, the milk, and the fruit diets are also good. One can gain as well as lose on the milk diet, all depending on number of calories consumed, and it is an excellent method for both. The beefsteak diet is beneficial for a short time, but too much protein over a long period has been shown to be harmful. An exclusive fruit diet is excellent for reduction. Low calorie days can be repeated once a week if necessary in order to keep the stomach in good order. Fruit juice, one-quarter glass, or fresh fruit, can be substituted for the skim milk, and you may prefer it. [Sidenote: _But You Do Not Have To_] You could keep on this for some time, or fast for some time, and probably be much benefited. I fasted five days once, or rather fruit-juiced five days. I lost about ten pounds, I think, and my heart, which had begun to carry on, was relieved. [Sidenote: _Sob Stuff_] It was during that period of which I have spoken, and of which I am ashamed; for I had my M.D. degree then and should have known better. But you know we have good authority that it is easier to teach twenty what were good to be done than to be one of twenty to follow our own teaching. _Third Order_ [Sidenote: _You Are Down to Business_] [Sidenote: _And Maybe Diabetes_] Now you will have to reckon on the amount of food or number of calories you need per day. Review the rule I have given. You find for your age and _normal weight_ that you will need, let us say for example, 2200 calories. You have probably been consuming twice that amount and either storing it away as fat or as disease. (It is surprising how small an excess will gradually add up pounds of fat. For instance, three pats of butter or three medium chocolate creams a day, if over the maintenance limit, would add approximately _27 pounds a year_ to your weight!) Now you are to reduce your maintenance diet--the 2200 calories we are taking for example--to 1200 calories--quite a comfortable lot, you will find. You will be surprised how much 1200 calories will be if the food is judiciously selected. [Sidenote: _After All, Hunger Is Much More Agreeable Than Apoplexy_] You may be hungry at first, but you will soon become accustomed to the change. I find that dry lemon or orange peel, or those little aromatic breath sweeteners, just a tiny bit, seem to stop the hunger pangs; or you may have a cup of fat-free bouillon or half an apple, or other low calorie food. (Count the calories here.) One thousand calories less food per day equals four ounces of fat lost daily--approximately 8 pounds per month. If you do not want to lose so fast, do not cut down so much. _Fourth Order_ [Sidenote: _You Register Joy_] You may eat just what you like--candy, pie, cake, fat meat, butter, cream--but--_count your calories!_ You can't have many nor large helpings, you see; but isn't it comforting to know that you can eat these things? Maybe some meal you would rather have a 350-calorie piece of luscious pie, with a delicious 150-calorie tablespoonful of whipped cream on it, than all the succulent vegetables Luther Burbank could grow in California. My idea of heaven is a place with me and mine on a cloud of whipped cream. [Sidenote: _You Registered Too High_] Now that you know you can have the things you like, proceed to make your menus containing very little of them. _Fifth Order_ This is going to be your chief business and pursuit in life for the next few months, this reducing of your weight. However, keep up your Red Cross and all other activities, fast and furiously, so that you won't be thinking about yourself. [Sidenote: _More Warnings_] Don't reduce more than two or three pounds a week; two or less is better. If you are too cannibalistic, your heart, kidneys and nervous system are liable to suffer--you yourself are supplying too much fat in your dietary, and there are other scientific reasons against reducing too rapidly. However, you may find that the first week or so you may reduce five or seven pounds; but don't worry about this, for that is a slushy, watery fat that goes easily. If a claim like a cold should attack you, and after spraying nose and throat frequently with an antiseptic, and then denying the claim vigorously, it persists in running a severe course, better go back to maintenance diet for a few days. [Sidenote: _Not Even While Cooking_] _Don't "taste"!_ You will find the second taste much harder to resist than the first. If you have allowed in your daily program something between meals (a good plan), take it, but not otherwise. Try not to overeat at any time, and thus undo the work that perhaps has taken you two or three days to accomplish. It will be all right occasionally, possibly one day a week, to eat up to your maintenance diet, but don't, I beg of you, go over it so that you will gain. You will be tempted quite frequently, and you will have to choose whether you will enjoy yourself hugely in the twenty minutes or so that you will be consuming the excess calories, or whether you will dislike yourself cordially for the two or three days you lose by your lack of will power. [Sidenote: _I Ought Not to Do This_] I am afraid I am going to tell a story. I feel as though I were, and I don't want to. It is one I heard years ago at a teachers' convention at Riverside, when I was a tender, unsuspecting young school teacher, so it is perfectly good, albeit senile--and it illustrates my point so well--so well--well, you have to put yourself in the place of the little chaps, Billie and Johnnie, of the kindergarten. [Sidenote: _A Little Anatomical Story_] It seems it was customary to bring a lunch, and Little-new-boy had come without one. Teacher asked Billie would he share? No, sturdily; not he. But little Johnnie, he would. Some time later, Johnnie, with a frantic waving of his hand, and with just pride in his generosity, informed the class that he had shared his lunch with Little-new-boy and he felt good is his little heart. Billie stood his ground and stoutly declared that he ate his and he felt good in his little belly. 9 Autobiographical I did not give our thin friends a sample menu for fear it would upset them; but nothing can upset your digestion, I know. However, I will not give you a sample menu, either, but will tell you what I eat when I go on a reduction regime, which for me is 1200 Calories. You will notice, most of my calories I have at dinner in the evening. You may not like this, but would rather have yours spread over the entire day; and you can suit your fancy, for it makes no difference as long as your total number per day stays within your reduction limit. [Sidenote: _Make Out Several Menus if You Like_] Don't think you have to follow my menu. You might gain on it! Study the Key and select your own. Many will lose by going on the no-breakfast plan, or the no-lunch plan. If they do reduce, it is because they have lowered their daily consumption of food, and not because of the no-breakfast or no-lunch plan _per se._ Fat seems to melt faster when the chief meal is in the middle of the day, and with only 200 or 300 calories of fruit for the evening meal. In this way you slim while you sleep. MY BREAKFAST 1 slice very dry coarse bread toast 1/4 in. thick 50 C. Butter, 1/4 cu. in 25 C. Hot water flavored with coffee 00 C. ----- Total 75 C. [Sidenote: _Slim While You Sleep! Clever?_] You may prefer many more calories for breakfast, or none at all. This may not look good to you, but it means an awful lot in my young life, after my exercise and bath, to sit down to my little breakfast and read the papers. Recently I have found that two cups of moderately hot water with the juice of a lemon answers just as well as the toast and watery coffee, and is probably better. You might like some fruit. MY LUNCHEON 1 corn muffin--I am patriotic 125 C. 1 pat butter 100 C. 1 cup coffee with 1 tbsp. cream 50 C. ------ Total 275 C. If you are patriotic and constipated, substitute one bran muffin. You can see that this is in reality a further extension of my sumptuous breakfast. If I get tired of this, I add a salad of Lettuce, large amount, practically 00 C. Roquefort cheese dressing 100 C. I am very fond of this Roquefort cheese dressing; 1-1/8in. cube of cheese in a little vinegar, no oil, keeps it within the hundred calories. You might prefer a baked apple or two tomatoes, or a dish of prunes, or 3 oz. of cottage cheese. The chief thing is to take what you like, not what I like. Count your calories. MY DINNER [Sidenote: _I Don't Mean Your Husband's Dessert, I Mean My Husband's. My Word! I Got Out of That Quick!_] Vegetable soup, or bouillon, no fat; or small oyster cocktail 25 C. Lean meat, or "unthinking" lobster or fish, 5 or 6 oz 300 C. Large serving of uncooked lettuce or cabbage, practically 00 C. Mayonnaise or oil, 1/2 dsp 50 C. 1 large dish tomatoes, or cauliflower, or string beans, or carrots, or turnips (I hate turnips--just put them down so you can see you can have them if you like) 25 C. 1 medium slice bread, or 1 medium potato 100 C. 1 pat butter 100 C. 100 calories of your husband's dessert 100 C. Water 00 C. 1 cup cereal coffee, clear, practically 00 C. -------- Total 700 C. SUMMARY Breakfast 75 C. Luncheon including salad 375 C. Dinner 700 C. ------- 1150 C. That leaves me 50 more calories to total 1200, to take before retiring if I am hungry. You should leave this 50 calories to take before retiring, because if you are hungry you will find it very difficult to go to sleep. A small cup of hot skimmed milk tends to be a sedative. Hunger, like cold feet, is hard to go to sleep on. [Sidenote: _For Both Sexes_] _If there is one thing more important than another, it is thorough mastication._ [Sidenote: _Sometimes I Take More Than 100 Calories of My Husband's Dessert. I Love Fat Men, But I Don't Want to Be Married to 'Em_] This applies to the thin as well as to the fat, and to the child as well as to the adult. Take a moderate mouthful and rassel with it until it is automatically swallowed. Chew until it is all gone before you put any more in your mouth. There is no better way of jollying yourself into thinking that you have had all you want than this Fletcherizing habit, and it takes the same time to consume one-half the amount of food you have been in the habit of eating. I will allow you all the water you want, in reason; in fact, I advise it while you are reducing, both at the meals and between meals. The only precaution is that at the meals it should not be drunk while food is in the mouth, for this would tend to lessen thorough mastication. Now, Madam and Madam's husband, when are you going to begin this important business of reducing? After the holidays? Tomorrow? _No! Right now._ The sooner you get started, the better. The chief thing to do, and the hardest, is to get started and to get the habit. After the first three days you will not dread it; in fact; you will feel so much better that you will not be willing to go back to your old habits of overeating. Now let's review a bit what you are to do. [Sidenote: _Plan the Day Before_] First: Pledge yourself to yourself, and to someone else, so you will be ashamed to fail. There is a great deal of psychology to reducing. Use strong auto-suggestion. Decide just how much you are going to eat in advance of the meal--so many calories, _no more!_ This sounds foolish, but it helps wonderfully. Second: Begin with a fast or a low caloric diet for the first day; keep it, if necessary, one day weekly. [Sidenote: _Low Bridge on Fats and Pastries_] Third: Study food list and make out menus the caloric totals of which _are less_ than your maintenance diet. Have a fairly balanced diet, some fat, some carbohydrates, some protein, and a good amount of green vegetables and fruit. _Have 200-300 C's of protein._ Fourth: Masticate every morsel with such thoroughness that it is automatically swallowed. Fifth: Keep up your activities--Red Cross and other relief work. Sixth: Remember that you will feel good in your little heart when you resist temptation to overeat, and when you don't, you won't feel good anywhere. Seventh: Some vigorous exercise every day. [Sidenote: _There Is Life Substance and Intelligence in Chocolate Creams!_] NOTE: If there comes a time when you think you will die unless you have some chocolate creams, go on a c.c. debauch. I do, occasionally, and will eat as many as ten or so; but I take them before dinner, then me for the balance of my dinner-- 1 bowl of clear soup 25 C. 1 cracker 25 C. ------ Total 50 C. And thus, you see, every supposed pleasure in sin (eating) will furnish more than its equivalent of pain (dieting) until belief in material life (chocolate creams) is destroyed. _Review_ 1. Describe your stomach. 2. If there is one thing more important than another, what is it? 3. Repeat the five orders in chapter 8. 4. Repeat the warnings. 5. Work the following example: X gains 25 pounds during the year. How many calories has he averaged daily over his maintenance diet? KEY: 25 lbs. fat = 400 oz. fat. 1 oz. fat represents 275 C. food consumed. 400 oz. = 400 x 275, or 110,000 C. 110,000 ÷ 365 = 301 C. _Answer_. X has eaten 301 C. per day more than necessary. 6. How many calories have you averaged daily over your maintenance diet? And what could you have left off your menu and kept from gaining all that weight? 10 Testimonials [Sidenote: _From the Field_] After you have reduced or gained, let me share your joys. Write me a little note. You need not sign your name if you don't want to. I anticipate the following: DEAR DOCTOR: I am so grateful to you, Dr. Lulu Hunt Peters, for what you have done for me. After reading your book, "Diet and Health, with Key to the Calories" my chronic case of meanness--I mean leanness--was absolutely cured. My weight, which was ... now is ... and I am on my way to normal. I am fond of you. * * * * * DEAREST DOCTOR: I cannot be too grateful to you, dear Doctor Lulu Hunt Peters, for your book "Diet and Health, with Key to the Calories," for I have lost ... pounds! My weight was ... and now is ... and I am on my way to normal. I should be ungrateful indeed if I did not mention that while reading the book a chronic case of dammdruff which I had had for years, and which had been given up by six specialists, was absolutely cured. I adore you! * * * * * [Sidenote: _A Wonderful Demonstration_] DEAR DOCTOR: For your book, "Diet and Health, with Key to the Calories," words are inadequate to express my thanks. For I have been delivered from a chronic affliction of many years' duration, for which I had tried all known methods of cure. I refer to the smoking of cheap cigars by my husband. He suddenly found he had no desire for the noxious weed! Your arm and leg exercises are wonderful. * * * * * 11 An Apology and Some Amendments On re-reading this literary gem, humorous classic, and scientific treatise on weight reduction and gaining, I see that I have a very intimate mixture of the thins and the fats. But that is as it should be for balance. I had intended to keep you strictly separate, but the preaching, the exercises, the dry definitions, the Key to the Calories, and so forth, was matter that was applicable to both, so it could not be done. [Sidenote: _Watch Your Weight_] I have just got to bring this to a close now, if I have it ready as I promised, for the lecture, "Watch Your Weight!" I am glad of it, too. I am getting so ... funny it is painful. I will close with the next chapter. It will be beautifully scientific, but not funny, I promise. _Some Amendments_ [Sidenote: _No. 1_] You perhaps have noticed that my first chapter is called "Preliminary Bout," and then I have gone on to describe a club meeting. I am aware that P.B. is a prize fighting term, and I meant it for the picture of me fighting myself, not for the club meeting. I have attended many club meetings, and in none of them have I ever seen any fighting that would have taken any prize anywhere, although I will say I have seen and have myself personally conducted some very classy stuff. [Sidenote: _No. 2_] I do not use slang. I use only the purest, most refined, and cultured English. I leave slang to those who can get by with it and put it over. So where I have used dashes you may use your favorite slang words. Mine were deleted by the censors. [Sidenote: _No. 3 (a)_] Mrs. Ima Gobbler is not really fat enough to be called a fat--! She is only 40 or 50 pounds overweight, but she is fond of me and I took liberties with her. She is a darling. [Sidenote: _No. 3 (b)_] She is a purist, too. I called her up after I put her in my book, and I said, "You are fond of me, aren't you, Mrs. Gobbler?" And she said, "Youbetcha." "And you are a good sport, aren't you?" "Surest thing you know!" "That's good, for I have said a horrid thing to you. I had to, in order to stop the club discussion." And she responded soulfully, "Go to it, Kid!" [Sidenote: _No. 4_] Mrs. Sheesasite's husband did not really have to buy her a pair of freight scales; that is just a gentle josh. The ordinary scales will weigh 300 pounds, I believe. She is also a dear. [Sidenote: _No. 5_] My husband's eyes are not really green, nor is he cross-eyed. They are the loveliest, softest brown. The green eyes belong on the maternal side of this house. [Sidenote: _No. 6_] My artist is not really noted. He is just an ordinary adorable ten-year-old boy kiddie. Aren't his little figures the dearest ever? * * * * * [Sidenote: _Doing My Bit_] All the characters in my book are friends of mine. Perhaps you had better substitute _were_ for _are_. There was one woman mentioned in my original manuscript and my husband said what have you put her in for Pattie? (a corruption of Pettie, a H.moon hangover) she is no friend of yours: she knocks you. And I said loftily like, I want you to know Ijit (corruption of Idiot, also a H.moon hangover) I am above personalities she is prominent and besides she is fat especially in the feet and head and she doesn't know it and he said that doesn't make any difference you do not have to immortalize her and I said I would look up the authorities on the subject and he said he was authority enough and I said I would see what the other authorities said anyway and I did and I found one most eminent that said you should love your enemies but none that said you should immortalize them so I said I'd drop her and he said he should say so and so I did. [Illustration: Dear Enemy Unimmortalised] --All the characters in my book are friends of mine. Perhaps you had better substitute _were_ for _are_. 12 Maintenance Diet and Conclusions [Illustration: Maintenance Diet 1000 C. over 1000 C. under] [Sidenote: _1st Circle_] THE HEAVY circle represents the amount of daily food (number of calories) which will maintain you at present weight. It may be your weight is too much or too little, but this is your maintenance diet for that weight. [Sidenote: _2nd Circle_] THE SECOND circle represents a daily diet containing more than necessary for maintenance; for example, let us say 1000 calories more. This 1000 calories of food is equivalent to approximately 4 ounces of fat [1000÷255 (1 oz. fat = 255 C.)]; 4 ounces of fat daily equals 8 pounds a month which will be added to your weight, and, if not needed by the system, will deposit itself as excess fat. Or the toxins arising from the unnecessary food will irritate the blood vessels, causing arterio-sclerosis (hardening of the arteries), which in turn may cause kidney disease, heart disease, or apoplexy (rupture of artery in the brain), and maybe death before your time. On the other hand, if you are underweight and the added nourishment is gradually worked up to, it will improve the health and cause a gain of so much (theoretically, and in reality if kept up long enough). [Sidenote: _3d Circle_] THE THIRD circle represents a diet containing less than the maintenance; again, for example, say 1000 calories less. Here the 1000 calories must be taken from the body tissue, and fat is the first to go, for fat is virtually dead tissue. This 4 ounces of fat daily which will be supplied by your body equals in six months 48 pounds. There are in America hundreds of thousands of overweight individuals; not all so much overweight as this, but some considerably more so. If these individuals will save 1000 calories of food daily by using their stored fat, think what it would mean at this time. [Sidenote: _Savings_] Not only an immense saving of food to be sent to our soldiers and allies and the starving civilians, and of money which could be used for Liberty Bonds, the Red Cross, and other war relief work, but a great saving and a great increase in power; for there is no doubt that by reducing as slowly and scientifically as I have directed, efficiency and health will be increased one hundred fold. If, as illustrated in the third circle, the 1000 calories or less is eaten and the individual already is underweight, with no excess fat, then this amount will be taken from the muscles and the more vital tissues, and the organism will finally succumb. Before this time is reached there will be a great lowering of resistance, and the individual will be a prey to the infectious diseases. It must be remembered that in children the growth of the whole body is tremendously active, and especially that of the heart and nervous system. If the nervous system is undernourished, it becomes disorganized and undeveloped. This is apt to be expressed in uncertain emotional states, quick tempers, and a predisposition to convulsions. The heart, if undernourished, lays its foundation for future heart disease, and the whole system will be injured for life. Anything that impairs the vigor and vitality of children strikes at the basis of national welfare. [Sidenote: _The Food Administration Emphasizes This_] You can see from this how extremely important it is that, in our need for the conservation of food, only those who can deny themselves and at the same time improve their health and efficiently should do it. It will be no help in our crisis if the health and resistance of our people be lowered and the growth and development of our children be stunted. We, the hundreds of thousands of overweight citizens, combined with the hundreds of thousands of the normal who are overeating to their ill, can save all the food that is necessary. We are anxious, willing, eager to do this. Now we know how, and we will. _Food Will Win the War_ WATCH OUR WEIGHT! 13 Three Years Later _February, 1, 1921_ An Added Chapter in Which Are Offered Twenty-one Suggestive Menus After nearly two years with the American Red Cross in the Balkans I return to find the little book has been carrying on in my absence--I write this for the fifth edition--and my publishers insisting that I must furnish some more menus. They affirm that there are many who do not care to or cannot figure out their own. After being so long under military discipline I obey now instinctively, although I do not want to do this. But you know publishers. They say that if there are menus for those who do not have the desire to compute them, the usefulness of the book will be increased. Publishers are so altruistic. Now far be it from me to scorn the possibility of increased sales myself. So I comply, and after you are reduced you will have the energy and the increased keenness to scout around in the calories and make out your own. * * * * * A little of my Balkan experience in the reducing line may not be amiss. In Albania, where I was stationed most of the time, life is very strenuous. We all had to work hard and expend a great deal of nervous energy. Medical calls on foot in the scorching sun over unkind cobblestones, long distance calls on unkinder mules, long hours in nerve-racking clinics, ferocious man-eating mosquitos, scorpions, centipedes, sandflies, and fleas, and other unspeakable animals kept us hopping and slapping and scratching. But there was one consolation to me. With this work, more intensive and more strenuous than I had ever done before, I would not have to diet--I would not have to watch my weight--I would not have to count my calories! Oh, joy! We lived a community life, we Red Crossers. We had plain blunt food, American canned mostly, supplemented with the fare that could be eked out of Albania, and cooked by an Albanese who could not be taught that we Americans were not Esquimos and did not like food swimming in fat. However, it tasted good to famished Red Crossers, and I ate three meals a day, confident that I would retain my girlish middle-aged slenderness and not have to diet. We had no scales and no mirrors larger than our hand mirrors. Our uniforms were big and comfortable. * * * * * The French who are in charge of Scutari depart, the officers leaving to us some of their furniture, including a full length French plate mirror. Ordinarily when I look in a full-length mirror I don't hate myself so much--so it is with some degree of anticipated pleasure that I complacently approach, to get a life-size reflection of myself after many months of deprivation of that pleasure. "_Mon Dieu!_" I exclaim. "_Bogomi_!" (Serbian--'For the love of Allah!') "This is no mirror," I mutter. "This is one of those musee things that make you look like a Tony Sarg picture of Irvin Cobb." "What's irritating you, Dockie?" asks one of the girls, coming up and standing back of me. I look at her reflection. She does not look like Irvin Cobb! "Peggy," I say tragically, "Peggy, do I look like my reflection?" "Yes, dear, we have all noticed how stout you have been getting. Aren't you supposed to be some shark on the subject of ideal weight?" And the bitter truth is borne in upon me--no matter how hard I work--no matter how much I exercise, no matter what I suffer, I will always have to watch my weight, I will always have to count my calories. This is what I did then: I stopped going to the breakfast table. I kept some canned milk and coffee in my room, and made me two cups of coffee. For lunch I ate practically what I wanted, limiting myself to one slice of bread or one potato (we had no butter), with fruit for dessert. For dinner I came down only when the dessert was being served, and had a share of that with some coffee. I was jeered and derided. You know how in community life we all are as disagreeable as we like, and still love each other. Did not I know the desserts were the most fattening part of the meal? I was some authority on how to reduce, I was! In vain I told them that it did not matter so long as my total caloric intake did not equal the number that I needed. It was not until some months after, when they saw that I was normal weight again, that they began to realize I knew whereof I spoke. Then came our withdrawal from Albania and release from duty. After months of canned goods came Paris with its famous dishes; Crème d'Isigny avec crème! Artichauts an beurre! Patisseries francaises! Oo lala! Again I said calories be _dashed_! I can reduce when I get home. I had no delusions now, you see. * * * * * And now I am home trying to help raise the funds for the starving children of Central Europe, and explaining to my friends that while there is a food shortage in Europe it is not because I was there; and that I am reducing and the money that I can save will help keep a child from starving, and that they can do the same; that for every pang of hunger we feel we can have a double joy, that of knowing we are saving worse pangs in some little children, and that of knowing that for every pang we feel we lose a pound. A pang's a pound the world around we'll say. Every once in a while you hear that the caloric theory has been exploded. There is no caloric "theory." Therefore none to explode. Calories are simply units for measuring heat and energy and never will be exploded any more than the yard or meter "theory" will be exploded. Foods must contain essential salts and the growth and health maintaining elements. These cannot be measured by calories. The quantity of heat or energy production but not the quality of the foods is measured in calories, and one must have a knowledge of the qualities also. No scientifically educated individual has ever thought otherwise. The chief objection to following the advice of the numerous laymen who write eat-and-grow-thin menus is that they advise the elimination of all fats, sugars and starches. They lose sight of the fact, or they do not know, that the obese individual--I dislike that term--will have to have a balanced diet even while reducing if he is to maintain his health. One will lose weight on these menus, but as very many can testify they lose their health also. One cannot live on an unbalanced diet for any length of time without becoming unbalanced also. And furthermore the over-weighter will always have to diet more or less, and will have to have menus which he can continue to use. After normal weight is reached he will not have to be nearly so abstemious, _but_ the same dietetic errors which produced overweight in the first place will produce it again. So he must know something of dietetics and he must have a balanced diet. Now I shall make out some balanced menus, 1200 C's a day, being careful to include a large amount of the leafy vegetables and some milk or its products, the foods that McCollom calls PROTECTIVE FOODS because they contain in a large measure the essential mineral salts, and those vital elements he has called "Fat soluble A" and "Water soluble B"--others call vitamines--which he has proved to be so vital and necessary for growth in the young and the maintenance of health in the adult. I shall also include 200-300 C's of protein. The leafy vegetables, cabbage, cauliflower, celery tops, lettuce, onion, Swiss chard, turnip tops, and other leaves employed as greens, water cress, etc., not only contain these vital elements, but they also exert a favourable influence on sluggish bowels and kidneys. They are low in caloric value, hence are low in fat-producing properties, and can be consumed with indiscretion, properly masticated. It is better while you are reducing to stay away from the dining table when you do not expect to eat. If you are rooming, get a tiny sterno outfit, some substitute or coffee, some canned or dry milk, some sugar if you use it, and you can make a hot drink in your room and be independent for your breakfast and your evening meal, when you decide some day to go without that. Do not take more than 100 calories for your breakfast. That leaves you 1100 calories to be divided during the day if you go on a 1200 calorie schedule. I suggest the following distribution of the calories: Breakfast 100 C's. Lunch 350 " Tea 100 " Dinner 650 " You can reverse the dinner and lunch if you desire. If you do so then have your 100 calories I have allowed for tea time to take just before you retire. On a 1200 calorie schedule arranged as I have it you will not be hungry, I assure you. It will not be more than three or four days before your stomach will be shrunk and this amount I have allowed you will almost seem like overeating! That is the big idea. Shrink your stomach. Go on a fast or low calorie day for a day if necessary to get started. See page 81. I can safely say that any up and around adult will reduce on 1200 calories, for that will not supply the basal metabolism, i.e., the body's internal activities, such as the beating of the heart, respiration, digestion, excretion, etc., and some of the body's stored fat will be called upon to supply the deficiency. How much one will reduce depends on how many calories are actually needed for the internal and the external activities. See pages 26 and 27. It is not advisable to reduce too rapidly. See page 85. Now you have 1200 calories a day to eat. Let us think of this in terms of money. You have a limited amount of money every day to spend for food. You must spend it judiciously and get the food you need and want. If you spend the most of it on one article you have that much less for other things. It is possible that some days you will want to spend more than your allowance and you draw on your next day's supply. That will be all right if you remember that you have done so and will spend that much less the next day to equalize your account. You must study to spend wisely and carefully so as to supply your needs, but you cannot spend more than you have without restitution and retribution. Here are the menus: BREAKFASTS 100 C. Each 1. Fruit 2 med. apples or 1 baked apple with 2 tsps. sugar _or_ 1 large orange _or_ 1/2 large grapefruit _or_ 1 small cup berries _or_ 1/2 good sized cantaloupe _or_ 2 med. figs _or_ 5 prunes 2. 1 cup coffee or cereal coffee.. O 1 tbsp. cream..................50 C 2 small tsp. sugar.............50 C _or_ 2 cups with cream alone or sugar alone ---- Total...........................100 C 3. 10 ozs. skim milk hot or cold _or_ 5 ozs. whole milk.....................100 C 4. 1 cup coffee clear............. 0 1 thin slice toast.............75 C 1/4 pat butter.................25 C ---- Total.............................100 C Note--The skim milk breakfasts and teas are most desirable because of the protein content. TEAS 100 C. Each See lists for breakfasts. Also could have: 1. 1 cup tea with 1 tsp. sugar 1 slice lemon................25 C 3 soda crackers..............75 C ---- Total....................................100 C 2. 2 small plain cookies tea no cream or sugar...............100 C 3. 1 chocolate cream 1 cup tea or hot water no cream or sugar...................100 C * * * * * The following combinations need not be followed arbitrarily. You may change them around if you desire. Look in the calorie lists for substitutes of the same classes of foods, if you do not like my combinations. If you don't care for the 100 C's at tea time you may have that much more for dinner. 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts). 100 C LUNCH 1 medium sized head lettuce 1/3 lb........................... 25 C 1 tbsp. mayonnaise...............100 C 1 med. sweet pickle chopped for mayonnaise....................... 25 C 1-1/8 inch cube cream cheese melted _or_ 3 ozs. cottage cheese............100 C 1 Toasted French roll (no butter) .................................100 C ----- Total.................................350 C TEA 3 crackers with tea and 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim or buttermilk _or_ 100 C. fruit (see list)................100 C DINNER Creamed dried beef on toast Dried beef 4 thin slices 4 x 5.100 C Cut fine and crisped in frying pan with 1/2 tbsp. butter.........50 C 1 tbsp. flour browned with above...........................25 C Add 1 cup skim milk (7 ozs.) cook gently.....................70 C ----- 245 C 2 slices crisp toast (pour above over)..........................200 C 1 large serving raw celery or raw cabbage.....................15 C 1 large baked apple with 1 tbsp. syrup..........................120 C 1 glass skim milk (7 oz.)........70 C Total.......................650 C ------- Grand Total................1200 C 1200 C DAY ON ARISING 2 cups hot water, with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts)...........................100 C LUNCH Celery--eat tender leaves also 10-14 stalks...................30 C Olives--5 good sized ripe.......100 C 1 small slice corn bread........100 C 12 ozs. skim milk or buttermilk.120 C ----- Total...................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C fruit (see list).................100 C DINNER Broiled halibut (or lean beef) steak 4-5 ozs. with lemon.......150 C Lettuce (no oil) average serving....0 1 slice whole wheat bread or roll.100 C 1/2 pat butter.....................50 C Dessert 1-6 pie...................350 C 1 cup clear postum or coffee........0 ----- Total...................650 C ------- Grand Total............1200 C 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts) .........................100 C LUNCH Combination salad Shredded lettuce 10 leaves......0 1 large tomato.................50 C 6 stalks chopped celery........15 C tender leaves included 1/2 med. cucumber..............15 C 1 med. grated carrot...........20 C ---- 100 C 1/2 tbsp. mayonnaise or oil......50 C with vinegar or lemon 1 slice whole wheat bread.......100 C 10 ozs. skim milk or buttermilk.100 C ----- Total..................................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C fruit (see list).................100 C DINNER Croquettes of split peas or beans 1/2 cup mashed beans or peas 1/4 cup toast crumbs 1 tsp. cream or canned milk made into croquettes and baked or broiled.................225 C Stewed tomatoes 8 ozs. _or_ 1 large fresh tomato.............50 C 1 slice bread or 5 small pretzels......................100 C 1 double serving lettuce or chopped cabbage or cauliflower.15 C 1 slice lemon, custard or squash pie, no top crust.............260 C 1 cup clear coffee or postum......0 ----- Total..........................650 C ----- Grand Total...................1200 C 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts)...........................100 C LUNCH Fruit salad 1 large orange.................100 C 1 average apple.................50 C 1 small banana.................100 C 2 tbsps. lemon juice............10 C 2 small teasps. sugar...........40 C ----- 300 C Sprinkle with 1 tbsp. grapenuts..50 C Total.........................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C. fruit (see list)................100 C DINNER 12 moderate sized oysters..............100 C Dipped in 1 beaten egg and crumbs of 3 crackers.........150 C Fried gently in 1 tbsp. of bacon or other fat...........125 C ----- 375 C 2 small slices crisped bacon.....50 C 1 small dish chow chow with lettuce.........................25 C 1 slice bread or its equivalent.100 C 1/2 pat butter...................50 C Dessert 1 medium baked apple with no sugar..................50 C ----- Total.........................650 C ------ Grand Total..................1200 C 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts) .........................100 C LUNCH 2 eggs 160 C fried gently in 1 tsp. bacon fat or butter............40 C _or_ soft boiled or poached eggs with 1 slice crisped bacon....200 C 1 roll or 1 slice whole wheat bread.........................100 C Butter 1/2 pat...................50 C Coffee, postum or tea clear.......0 ----- Total..................................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C fruit (see list).................100 C DINNER 2 toasted shredded wheat biscuits.200 C 2 glasses skim milk...............150 C 1 dish stewed prunes 8 with 1 tbsp. syrup............200 C 10-12 peanuts.....................100 C Coffee, postum or tea clear.........0 C ----- Total..................................650 C ----- Grand Total...........................1200 C 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts) .........................100 C LUNCH 6 oz. cream soup, Potato, tomato, clam chowder, etc. (use skim milk)..........200 C Shredded cabbage, lettuce, celery _or_ any greens--average helping practically.....................0 C 1/2 tbsp. mayonnaise or oil _or_ 1 tbsp. cream dressing...........50 C 2 soda crackers..................50 C 1 average apple..................50 C ----- Total..................................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C fruit (see list).................100 C DINNER Carrot and cottage cheese salad (The Home Dietitian--Comstock) 1/2 cup ground carrots 1-6 cup chopped nuts 3 oz. cottage cheese 3 oz. large lemon (juice of)......250 C 8 ozs. consomme, no fat..............30 C 4 crackers or 1 roll or slice bread 100 C 1/2 pat butter.......................50 C Average helping lettuce or other greens--no oil......................0 Dessert--gelatine pudding, average serving...................120 C Whipped cream 1 heaping tbsp........100 C Coffee or postum or tea clear....... 0 ----- Total....................................650 C ------ Grand Total.............................1200 C 1200 C DAY ON ARISING 2 cups hot water with a little lemon juice. 10-minute exercise at least BREAKFAST Coffee or postum with cream or sugar _or_ 10 ozs. skim milk (see list of breakfasts).........................100 C LUNCH Baked beans if canned 3 h. tbsp., if home baked 1-1/2.......................150 C Pickled beets 5 med. slices......... 25 C Large amount celery or lettuce or other green leaves............. 25 C 1 slice toasted Swedish health bread (made of oatmeal) or 1 roll............................100 C 1 cup coffee or postum clear........ 0 C Medium apple........................ 50 C ----- Total............................350 C TEA 3 crackers with tea with 1 tsp. sugar and 1 slice lemon _or_ 10 ozs. skim milk or buttermilk _or_ 100 C fruit (see list)...................100 C DINNER Cottage cheese omelet 2 med. eggs.......................160 C 3 ozs. cottage cheese.............100 C 1 tbsp. cream _or_ condensed milk.................... 50 C ----- 310 C Salt to taste Bake or fry gently in 1/2 tbsp. fat. 40 C (Can substitute 100 C chopped lean meat for cottage cheese) 1 small head celery tender leaves and all........................... 25 C 1 slice bread or equivalent.........100 C Butter 1/2, pat..................... 50 C 1 dish plain stewed tomatoes, squash, carrots, spinach or onions, etc....................... 25 C 5 almonds or 5 peanuts or 2 large walnuts..................... 50 C 10 raisins.......................... 50 C ----- Total............................650 C ------ Grand Total.....................1200 C _Finished But Not Famished_ +-----------------------------------------------------------------+ | WEEKLY WEIGHT CHART | +-----------------------------------------------------------------+ | Month | 1st Week | 2nd Week | 3rd Week | 4th Week | 5th Week | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ | | | | | | | +----------+----------+----------+----------+----------+----------+ +-----------------------------------------------------------+ | TOTAL C. PER DAY | +-----------------------------------------------------------+ | Month | Sun. | Mon. | Tues.| Wed. | Thur.| Fri. | Sat. | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ | | | | | | | | | +----------+------+------+------+------+------+------+------+ 
18487	----	FOOD REMEDIES HEALTHY LIFE BOOKLETS No. 2. * * * * * HEALTHY LIFE BOOKLETS NO. 1. THE LEAGUE AGAINST HEALTH. By ARNOLD EILOART, B.Sc., Ph.D. NO. 2. FOOD REMEDIES. By FLORENCE DANIEL. _Ready in September, 1908._ NO. 3. INSTEAD OF DRUGS. By ARNOLD EILOART, B.Sc., Ph.D. NO. 4. HEALTHY LIFE COOK BOOK. By FLORENCE DANIEL. _Ready in December, 1908._ NO. 5. MIND _VERSUS_ MEDICINE. By ARNOLD EILOART, B.Sc., Ph.D. NO. 6. DISTILLED WATER. By FLORENCE DANIEL. * * * * * FOOD REMEDIES FACTS ABOUT FOODS AND THEIR MEDICINAL USES BY FLORENCE DANIEL LONDON C. W. DANIEL 11 CURSITOR STREET, E.C. 1908 _PREFACE_ There is a sentence in the Talmud to the effect that the Kingdom of God is nigh when the teacher gives the name of the author of the information that he is passing on. With every desire to fulfil the rabbinical precept and acknowledge the sources of this booklet, I find myself in a quandary. If I make my acknowledgments duly I must begin with my grandmother and Culpeper's Herbal. Following upon those come the results of my own and friends' practical experience. After this I should, perhaps, give a list of the periodicals from whose pages I have culled much helpful information. But as space and memory preclude individual mention I must content myself with this general acknowledgment. Lastly, I desire to record my thanks to Dr. Fernie, whose _Meals Medicinal_, a large and exhaustive collection of facts about food, has afforded not the least valuable assistance. F. D. _CONTENTS_ PART 1.--INTRODUCTORY PAGE While there is Fruit there is Hope 1 Fruit and the Teeth 5 Fruit is Food 6 Objections to Fruit 8 A Pioneer of Food Remedies 10 The Simple Life 12 Fruit or Fasting 13 Acute Illness 14 PART II.--FOODS AND THEIR MEDICINAL USES Almond 15 Apple 16 Asparagus 20 Banana 20 Barley 23 Blackberry 24 Black Currant 26 Brazil Nuts 26 Beans, Peas, and Lentils 27 Beet 28 Cabbage 28 Caraway Seed 29 Carrot 30 Celery 31 Cresses 31 Chestnut 32 Cinnamon 32 Cocoanut 33 Coffee 33 Date 34 Elderberry 34 Fig 38 Grape 39 Gooseberry 43 Lavender 43 Lemon 44 Lettuce 46 Nettle 47 Nuts 47 Oat 51 Olive 52 Onion 53 Orange 56 Parsley 57 Pear 58 Pea Nut 59 Pine-Apple 60 Pine Kernel 64 Plum, Prune 64 Potatoe 66 Radish 67 Raspberry 68 Rice 68 Rhubarb 69 Sage 71 Strawberry 72 Spinach 72 Tomato 73 Turnip 74 Thyme 75 Walnut 75 Wheat 76 PART III.--INDICES Index to Diseases and Remedies 79 Index to Prescriptions and Recipes 86 Index--Miscellaneous 87 FOOD REMEDIES PART I.--INTRODUCTORY _While there is Fruit there is hope._ While there is life--and fruit--there is hope. When this truth is realised by the laity nine hundred and ninety-nine out of every thousand professors of the healing art will be obliged to abandon their profession and take to fruit-growing for a living. Many people have heard vaguely of the "grape cure" for diseases arising from over-feeding, and the lemon cure for rheumatism, but for the most part these "cures" remain mere names. Nevertheless it is almost incredible to the uninitiated what may be accomplished by the abandonment for a time of every kind of food in favour of fruit. Of course, such a proceeding should not be entered upon in a careless or random fashion. Too sudden changes of habit are apt to be attended with disturbances that discourage the patient, and cause him to lose patience and abandon the treatment without giving it a fair trial. In countries where the "grape cure" is practised the patient starts by taking one pound of grapes each day, which quantity is gradually increased until he can consume six pounds. As the quantity of grapes is increased that of the ordinary food is decreased, until at last the patient lives on nothing but grapes.[1] I have not visited a "grape cure" centre in person, but I have read that it is not only persons suffering from the effects of over-feeding who find salvation in the "grape cure," but that consumptive patients thrive and even put on weight under it. The _Herald of Health_ stated, some few years back, that in the South of France where the "grape cure" is practised consumptive patients are fed on grapes alone, and become quite strong and well in a year or two. And I have myself known wonderful cures to follow on the adoption of a fruitarian dietary in cases of cancer, tumour, gout, eczema, all kinds of inflammatory complaints, and wounds that refused to heal. H. Benjafield, M.B., writing in the _Herald of Health_, says: "Garrod, the great London authority on gout, advises his patients to take oranges, lemons, strawberries, grapes, apples, pears, etc. Tardieu, the great French authority, maintains that the salts of potash found so plentifully in fruits are the chief agents in purifying the blood from these rheumatic and gouty poisons.... Dr. Buzzard advises the scorbutic to take fruit morning, noon, and night. Fresh lemon juice in the form of lemonade is to be his ordinary drink; the existence of diarrhoea should be no reason for withholding it." The writer goes on to show that headache, indigestion, constipation, and all other complaints that result from the sluggish action of bowels and liver can never be cured by the use of artificial fruit salts and drugs. Salts and acids as found in organised forms are quite different in their effects to the products of the laboratory, notwithstanding that the chemical composition may be shown to be the same. The chemist may be able to manufacture a "fruit juice," but he cannot, as yet, manufacture the actual fruit. The mysterious life force always evades him. Fruit is a vital food, it supplies the body with something over and above the mere elements that the chemist succeeds in isolating by analysis. The vegetable kingdom possesses the power of directly utilising minerals, and it is only in this "live" form that they are fit for the consumption of man. In the consumption of sodium chloride (common table salt), baking powders, and the whole army of mineral drugs and essences, we violate that decree of Nature which ordains that the animal kingdom shall feed upon the vegetable and the vegetable upon the mineral. FOOTNOTE: [1] This was the original treatment; now other food is added, although excellent results were obtained under the old _régime_. _Fruit and the Teeth._ I mention the above because one of the objections that I have heard cited against the free use of fruit is that "the acids act injuriously upon the teeth." Until I became a vegetarian I used to visit a dentist regularly every six months. I had done this for ten years, and nearly every tooth in my gums had its gold filling. The last time I visited the dentist I told him that I had become a vegetarian, and he replied that he rather thought my teeth would decay quicker in future on account of an increased consumption of vegetable acids. But from that day, now nearly six years ago, to the present time, I have never been near a dentist. My teeth seem to have taken a new lease of life. It is a fact that the acids in fruit and vegetables so far from injuring the teeth benefit them. Many of these acids are strongly antiseptic and actually destroy the germs that cause the teeth to decay. On the other hand, they do _not_ attack the enamel of the teeth, while inorganic acids do. Nothing cleanses the teeth so effectually as to thoroughly chew a large and juicy apple. _Fruit is a Food._ Until quite recently the majority of English-speaking people have been accustomed to look upon fruit not as a food, but rather as a sweetmeat, to be eaten merely for pleasure, and therefore very sparingly. It has consequently been banished from its rightful place at the beginning of meals. But fruit is not a "goody," it is a food, and, moreover, a complete food. All vegetable foods (in their natural state) contain all the elements necessary to form a complete food. At a pinch human life might be supported on any one of them. I say "at a pinch" because if the nuts cereals and pulses were ruled out of the dietary it would, for most people, be deficient in fat and proteid (the flesh and muscle-forming element). Nevertheless, fruit alone _will_ sustain life if taken in large quantities with small output of energy on the part of the person living upon it, as witness the "grape cure."[2] The percentage of proteid in grapes is particularly high for fruit. Those people who desire to make a fruitarian dietary their daily _régime_ cannot do better than take the advice of O. Hashnu Hara, an American writer. He says: "Every adult requires from twelve to sixteen ounces of dry food, _free from water_, daily. To supply this a quarter of a pound of _shelled_ nuts and three-quarters of a pound of any dried fruit must be used. In addition to this, from two to three pounds of any _fresh fruit_ in season goes to complete the day's allowance. These quantities should be weighed out ... and will sustain a full-grown man in perfect health and vitality. The quantity of ripe fresh fruit may be slightly increased in summer, with a corresponding decrease in the dried fruit." FOOTNOTE: [2] Recent years have witnessed a modification of the original cure. Other food is now included, but I have not heard that the results are better. _Objections to Fruit._ Some vegetarians object that it is possible to eat too much fruit, and recommend caution in the use of it to people of nervous temperament, or those who seem predisposed to skin ailments. It is true that the consumption of large quantities of fruit may appear to render the nervous person more irritable, and to increase the external manifestations of a skin disease. But in the latter event the fruit is merely assisting Nature to throw the disease out and off more quickly, while in the former case the real cause lies not in the fruit but in some nerve irritant, tea, for example, the effects of which are more acutely felt under the new _régime_. The nervous system tends to become much more sensitive upon a vegetarian, especially fruitarian, diet, and people often attribute their increased nervousness and irritability to the diet when it is simply that they now react more quickly to poisons. This is not a bad thing, on the contrary, it shows that the system has become more alert. Under the old _régime_ we tend to store up poisons and impurities in the body, but the effect of a vegetable diet, especially when united with the use of distilled water, is to cause all our diseases and impurities to be expelled outwards and downwards. Tea is a slow poison, and so is coffee except under exceptional conditions when it is used as a medicine, and then it should always be pale-roasted. Fruit should always be eaten at the beginning of a meal. Again, when the diet consists of a mixture of cooked and uncooked foods, the uncooked should always be eaten first. Also when the meal consists of two courses, a sweet and a savoury dish, sufferers from indigestion should try taking the sweet course first. I have known several cases where this simple expedient has resulted in a complete cessation of the discomfort of which the patient complained. _A Pioneer of Food Remedies._ The pioneer, in England, of the treatment of all sorts and conditions of disease by means of a vegetable (chiefly fruit) dietary was Dr. Lambe, a contemporary of the poet Shelley. His last book appeared in 1815, and in it and the one preceding are recorded some wonderful cures, especially in cases of cancer. It is only fair to add here that in Dr. Lambe's opinion no system of cure is completely efficacious so long as the patient is allowed to drink the ordinary tap or well water. Distilled water was the only drink he advised. But he held it better still not to drink at all if the necessary liquid could be supplied to the body by means of fresh, juicy fruits. He contended that man is not naturally a drinking animal; that his thirst is a morbid symptom, the outcome of a carnivorous diet and other unwholesome habits. And I think that anyone may prove the truth of this for him or herself if he or she will adopt a fruitarian dietary and abstain from the use of salt and other condiments. I have cited so out-of-date a personage as Dr. Lambe for two reasons. The first is that I know many of the so-called new and unorthodox ideas are more likely to appeal to some readers, if it can be shown that they originated with a duly qualified medical practitioner who recorded the results of his observations and experiments in black and white. The second is that the principles and practices of Dr. Lambe are incorporated with those of the Physical Regeneration Society, a large and ever-increasing body of enthusiasts having its head-quarters in London, to whose annals I must refer those readers who desire up-to-date instances of the efficacy of the use of fruit in disease. Lack of space will not allow me to quote them here. _The Simple Life._ We hear a great deal about the "Simple Life" and "Returning to Nature" nowadays, but most of us are so situated that the proposed simplicity simply spells increased complexity. The "vegetarian chop" costs the housewife more than double the time and labour involved in preparing its fleshly namesake. And when it comes to illness some of the systems of bathing and exercising prescribed by the "naturopath" are infinitely more troublesome to the patient and his friends than the simple expedient of sending for the doctor and taking the prescribed doses. I do not want to be misunderstood here. I am not condemning treatment with water and exercises. On the contrary, I hope to pass on what I have learnt about these methods of treatment. But so many people lack the time, help, and conveniences necessary to carry them out successfully. It is to these that I would say that the patient's cure may be effected just as surely, if more slowly, by means of fruit alone. _Fruit or Fasting._ Treatment of disease by fasting has come into fashion of late, and there is really no lack of proof as to the benefits to be obtained from abstaining entirely from food for a short period. I know of an elderly man who fasts for a fortnight every spring, and gains, not loses, weight during the process! He accounts for this by explaining that certain stored up, undigested food particles come out and are digested while he fasts. Whether this is the correct explanation I do not know, but the fact remains, and it is not by any means a solitary case. Of course, the majority of people lose weight when fasting, but this is very quickly recovered. Now I do not think fasting should be undertaken recklessly, but only under competent direction. But an excellent and safe substitute for a fast is an exclusive fruit diet. _Acute Illness._ The simplest and quickest method of recovering from attacks of acute illness, fevers, inflammatory diseases, etc., is to rest quietly in bed in a warm but well-ventilated room, and to take three meals a day of fresh ripe fruit, grapes by preference. If the grapes are grown out of doors and ripened in the sun so much the better. I have found from two to three pounds of grapes per day sufficient. If there is thirst, barley water flavoured with lemon juice should be taken between the meals. PART II.--FOODS AND THEIR MEDICINAL USES _Almond._ Almond soup is an excellent substitute for beef-tea for convalescents. It is made by simply blanching and pounding a quarter of a pound of sweet almonds with half a pint of milk, or vegetable stock. Another pint of milk or stock is then to be added and the whole warmed. After this add another pint and a half of stock if the soup is to be a vegetable one, or rice water if milk has been used. An emulsion of almonds is useful in chest affections. It is made by well macerating the nuts in a nut butter machine, and mixing with orange or lemon juice. Almonds should always be blanched, that is, skinned by pouring boiling water on the nuts and allowing them to soak for one minute, after which the skins are easily removed. The latter possess irritating properties. Bitter almonds should not be used as a food. They contain a poison identical with prussic acid. _Apple._ It is hardly possible to take up any newspaper or magazine now a days without happening on advertisements of patent medicines whose chief recommendation is that they "contain phosphorus." They are generally very expensive, but the reader is assured that they are worth ten times the price asked on account of their wonderful properties as nerve and brain foods. The proprietors of these concoctions seemingly flourish like green bay trees and spend many thousands of pounds per annum in advertising. From which it may be deduced that sufferers from nervous exhaustion and brain fag number millions. And surely only a sufferer from brain fag would suffer himself to be led blindly into wasting his money, and still further injuring his health, by buying and swallowing drugs about whose properties and effects he knows absolutely nothing. How much simpler, cheaper, and more enjoyable to eat apples! The apple contains a larger percentage of phosphorus than any other fruit or vegetable. For this reason it is an invaluable nerve and brain food. Sufferers from nerve and brain exhaustion should eat at least two apples _at the beginning of each meal_. At the same time they should avoid tea and coffee, and supply their place with barley water or bran tea flavoured with lemon juice, or even apple tea. Apples are also invaluable to sufferers from the stone or calculus. It has been observed that in cider countries where the natural unsweetened cider is the common beverage, cases of stone are practically unknown. Food-reformers do not deduce from this that the drinking of cider is to be recommended, but that even better results may be obtained from eating the fresh, ripe fruit. Apples periodically appear upon the tables of carnivorous feeders in the form of apple sauce. This accompanies bilious dishes like roast pork and roast goose. The cook who set this fashion was evidently acquainted with the action of the fruit upon the liver. All sufferers from sluggish livers should eat apples. Apples will afford much relief to sufferers from gout. The malic acid contained in them neutralises the chalky matter which causes the gouty patient's sufferings. Apples, when eaten ripe and without the addition of sugar, diminish acidity in the stomach. Certain vegetable salts are converted into alkaline carbonates, and thus correct the acidity. An old remedy for weak or inflamed eyes is an apple poultice. I am told that in Lancashire they use rotten apples for this purpose, but personally I should prefer them sound. A good remedy for a sore or relaxed throat is to take a raw ripe apple and scrape it to a fine pulp with a silver teaspoon. Eat this pulp by the spoonful, very slowly, holding it against the back of the throat as long as possible before swallowing. A diet consisting chiefly of apples has been found an excellent cure for inebriety. Health and strength may be fully maintained upon fine wholemeal unleavened bread, pure dairy or nut butter, and apples. Apple water or apple tea is an excellent drink for fever patients. Apples possess tonic properties and provoke appetite for food. Hence the old-fashioned custom of eating an apple before dinner. _Apple Tea._ The following are two good recipes for apple tea:-- (1) Take 2 sound apples, wash, but do not peel, and cut into thin slices. Add some strips of lemon rind. Pour on 1 pint of boiling water (distilled). Strain when cold. (2) Bake 2 apples. Pour over them 1 pint boiling water. Strain when cold. _Asparagus._ Asparagus is said to strengthen and develop the artistic faculties. It also calms palpitation of the heart. It is very helpful to rheumatic patients on account of its salts of potash. It should be steamed, not boiled, otherwise part of the valuable salts are lost. _Banana._ The banana is invaluable in inflammation of all kinds. For this reason it is very useful in cases of typhoid fever, gastritis, peritonitis, etc., and may constitute the only food allowed for a time. Not only does it actually subdue the inflammation of the intestines, but, in the opinion of at least one authority, as it consists of 95 per cent. nutriment, it does not possess sufficient waste matter to irritate the inflamed spots. But great care should be taken in its administration. The banana should be _thoroughly sound and ripe_, and all the stringy portion carefully removed. It should then be mashed and beaten to a cream. In severe cases I think it is better to give this neat, but if not liked by the patient a little lemon juice, well mixed in, may render it more acceptable. It may also be taken with fresh cream. A friend who has had a very wide experience in illness told me that she was once hurriedly sent for at night to a girl suffering from peritonitis. Not knowing what she might, or might not, find in the way of remedies when she arrived at her destination, my friend took with her some strong barley water, bananas, and an enema syringe. She found the girl lying across the bed screaming, obviously in agony. First of all my friend administered a warm water enema. A pint of plain warm water was injected first, and after this had come away as much warm water as could be got in was injected and then allowed to come away. The object of this was to thoroughly wash out the bowels. Then the barley water was warmed, the bananas mashed, beaten to cream, and mixed in with the barley water. A soothing nutrient lotion was thus prepared, and as much as the patient could bear comfortably was injected in the bowel and retained as long as possible. The effect was magical. The pain subsided, and the patient ultimately recovered. In the absence of _perfectly_ ripe bananas, baked bananas may be used. But, although better than no fruit at all, cooked fruit is never so valuable as the fresh fruit, if only the latter be perfectly ripe. Bananas should be baked in their skins, and the stringy pieces carefully removed before eating. From twenty minutes to half an hour's slow cooking is required. Bananas are excellent food for anæmic persons on account of the iron they contain. A very palatable way of taking them is with fresh orange juice. A comparatively old-fashioned remedy, for sprained or bruised places that show a tendency to become inflamed is to apply a plaster of banana skin. _Barley._ Barley is excellent food for the anæmic and nervous on account of its richness in iron and phosphoric acid. It is also useful in fevers and all inflammatory diseases, on account of its soothing properties. From the earliest times barley water has been the recognised drink of the sick. _Barley Water._ When using pearl barley for making barley water it must be well washed. The fine white dust that adheres to it is most unwholesome. For this reason the cook is generally directed to first boil the barley for five minutes, and throw this water away. But in this way some of the valuable properties are thrown away with the dirt. The best results are obtained by well washing it in cold water, but this must be done over and over again. Half-a-dozen waters will not be too many. After the last washing the water should be perfectly clear. When barley water is being used for curative purposes it should be strong. The following recipe is an excellent one. A ½ pint of barley to 2½ pints water (distilled if possible). Boil for three hours, or until reduced to 2 pints. Strain and add 4 teaspoonfuls fresh lemon juice. Sweeten to taste with pure cane sugar. Fine Scotch barley is to be preferred to the pearl barley if it can be obtained. _Blackberry._ Fresh blackberries are one of the most effectual cures for diarrhoea known. Mr. Broadbent records the case of a child who was cured by eating an abundance of blackberries after five doctors had tried all the known remedies in vain. _Blackberry Tea._ In the absence of the fresh fruit a tea made of blackberry jelly and hot water (a large tablespoonful of jelly to half a pint water) will be found very useful. A teacupful should be taken at short intervals. _Blackberry Jelly._ To make blackberry jelly get the first fruit of the season if possible, and see that it is ripe or it will yield very little juice. Put it into the preserving pan, crush it, and allow it to simmer slowly until the juice is well drawn out. This will take from three-quarters to one hour. Strain through a jelly bag, or fine clean muslin doubled will do. Then measure the juice, and to every pint allow ¾ lb. best cane sugar. Return to the pan and boil briskly for from twenty minutes to half an hour. Stir with a wooden spoon and keep well skimmed. To test, put a little of the jelly on a cold plate, and if it sets when cold it is done. While still at boiling point pour into clean, dry, and _hot_ jars, and tie down with parchment covers immediately. _Black Currant._ Black currant tea is one of the oldest of old-fashioned remedies for sore throats and colds. It is made by pouring half a pint of boiling water on to a large tablespoonful of the jelly or jam. To make the jelly use the same recipe as for blackberry jelly. The fresh juice pressed from the fruit is, of course, better than tea made from the jelly, but as winter is the season of coughs and colds the fruit is least obtainable when most needed. _Brazil Nut._ Brazil nuts are excellent for constipation. They are also a good substitute for suet in puddings. Use 5 oz. nuts to 1 lb. flour. They should be grated in a nut mill or finely chopped. _Beans, Peas, and Lentils._ Beans, peas, and lentils are tabooed by the followers of Dr. Haig, the gout specialist, on account of the belief that they tend to increase the secretion of uric acid. But this evil propensity is stoutly denied by other food-reformers. For myself I am inclined to believe that their supposed indigestibility, etc., arises from the fact that they are generally cooked in hard water. They should be cooked in distilled or boiled and filtered rain water. The addition of lemon juice while cooking renders them much more digestible. According to Sir Henry Thomson haricot beans are more easily digested than meat by most stomachs. "Consuming weight for weight, the eater feels lighter and less oppressed, as a rule, after the leguminous dish; while the comparative cost is greatly in favour of the latter." Lentils are the most easily digested of all the pulse foods, and therefore the most suitable for weakly persons. A soup made of distilled water and red lentils may be taken twice a week with advantage. Lentils contain a good percentage of iron, and also phosphates. _Beet._ The red beet is useful in some diseases of the womb, while the white beet is good for the liver. It is laxative and diuretic. The juice mixed with olive oil is also recommended to be applied externally for burns and all kinds of running sores. _Cabbage._ All the varieties of the colewort tribe, including cabbage, cauliflower, brussels-sprouts, broccoli, and curly greens, have been celebrated from very ancient times for their curative virtues in pulmonary complaints. And Athenian doctors prescribed cabbage for nursing mothers. On account of the sulphur contained in them cabbages are good for rheumatic patients. They may be eaten steamed, or, better still, boiled in soft water and the broth only taken. The ordinary boiled cabbage is an indigestible "windy" vegetable, and should never be eaten. _Caraway Seed._ Caraway seeds sharpen the vision, promote the secretion of milk, and are good against hysterical affections. They are also useful in cases of colic. When used to flavour cakes the seeds should be pounded in a mortar, especially if children are to partake thereof. When used medicinally 20 grains of the powdered seeds may be taken in a wineglassful of hot water. But for children half an ounce of the bruised seeds are to be infused in cold water for six hours, and from 1 to 3 teaspoonfuls of this water given. A poultice of crushed caraway seeds moistened with hot water is good for sprains. Caraway seeds are narcotic, and should therefore be used with caution. _Carrot._ Carrots are strongly antiseptic. They are said to be mentally invigorating and nerve restoring. They have the reputation of being very indigestible on account of the fact that they are generally boiled, not steamed. When used medicinally it is best to take the fresh, raw juice. This is easily obtained by grating the carrot finely on a common penny bread grater, and straining and pressing the pulp thus obtained. Raw carrot juice, or a raw carrot eaten fasting, will expel worms. The cooked carrot is useless for this purpose. A poultice of fresh carrot pulp will heal ulcers. Fresh carrot juice is also good for consumptives on account of the large amount of sugar it contains. Carrots are very good for gouty subjects and for derangements of the liver. _Celery._ Celery is almost a specific for rheumatism, gout, and nervous indigestion. The most useful plants for this purpose are small, not too rapidly grown nor very highly manured. It may be eaten raw, or steamed, or in soup. Strong celery broth flavoured with parsley is excellent. _Cresses._ All the cresses are anti-scorbutic, that is, useful against the scurvy. The ancient Greeks also believed them to be good for the brain. The ordinary "mustard and cress" of our salads is good for rheumatic patients, while the water-cress is valuable in cases of tubercular disease. Anæmic patients may also eat freely of it on account of the iron it contains. Care should be taken, however, from whence it is procured, as a disease peculiar to sheep but communicable to man may be carried by it. It should not be gathered from streams running through meadows inhabited by sheep. _Chestnut._ Chestnuts, when cooked, are valuable food for persons with weak digestive powers. They should be put on the fire in a saucepan of cold water and cooked for twenty minutes from the time the water first boils. John Evelyn, F.R.S., a seventeenth century writer, says of them: "They are a lusty and masculine food for rustics at all times, and of better nourishment for husbandmen than cole and rusty bacon, yea, or beans to boot." _Cinnamon._ Cinnamon is a very old-fashioned remedy for soothing the pain of internal or unbroken cancer. One prescription is the following: Take 1 lb. of Ceylon sticks. Simmer in a closed vessel with 1 quart of water until the liquid is reduced to 1 pint. Pour off without straining, and shake or stir well before taking. Take half a pint every twenty-four hours. Divide into small doses and take regularly. Cinnamon has a powerful influence over disease germs, but care must be taken to obtain it pure. It is often adulterated with cassia. Cinnamon tea may be taken with advantage in cases of consumption, influenza, and pneumonia. _Cocoanut._ Cocoanut is an old and very efficacious remedy for intestinal worms of all kinds. A tablespoonful of freshly-ground cocoanut should be taken at breakfast until the cure is complete. The dessicated cocoanut is useless for curative purposes. _Coffee._ Coffee is a most powerful antiseptic, and therefore very useful as a disinfectant. It has been used as a specific against cholera with marvellous results, and is useful in all cases of intestinal derangement. But only the pale-roasted varieties should be taken, as the roasting develops the poisonous, irritating properties. There is _always_ danger in the roasting of grains or berries on account of the new substances that may be developed. I do not recommend coffee as a beverage, but as a medicine. _Date._ The nourishing properties of dates are well known. They are easily digested, and for this reason are often recommended to consumptive patients. According to Dr. Fernie half a pound of dates and half a pint of new milk will make a satisfying repast for a person engaged in sedentary work. _Elderberry._ The elderberry has fallen into neglect of late years, owing to the lazy and disastrous modern habit of substituting the mineral drugs of the chemist for the home-made vegetable remedies of our grandmothers. Nevertheless, the elderberry is one of the most ancient and tried of medicines, held in such great esteem in Germany that, according to the German folk-lore, men should take off their hats in the presence of an elder-tree. In Denmark there is a legend to the effect that the trees are under the protection of a being known as the Elder-Mother, who has been immortalised in one of the fairy tales of Hans Andersen. The berries of the elder-tree are not palatable enough to be used as a common article of food, but in the days when nearly every garden boasted its elder-tree few housewives omitted to make elderberry wine in due season. It is not permitted to "food-reformers" to make "wine," but those readers who are fortunate enough to possess an elder-tree might well preserve the juice of the berries against winter coughs and colds. _Preserved Fruit Juice._ The following is E. and B. May's recipe for preserving fruit juice. Put the fruit into a preserving-pan, crush it and allow it to simmer slowly until the juice is well drawn out. This will take about an hour. Press out the juice and strain through a jelly-bag until quite clear. Put the juice back into the pan, and to every quart add a quarter of a pound of best cane sugar. Stir until dissolved. Put the juice into clean, dry bottles. Stand the bottles in a pan of hot water, and when the latter has come to the boil allow the bottles to remain in the boiling water for fifteen minutes. The idea is to bring the juice inside the bottles to boiling point just before sealing up, but not to boil it. See that the bottles are _full_. Cork _immediately_ on taking out of the pan, and then seal up. To seal mix a little plaster of Paris with water and spread it well over the cork. Let it come a little below the cork so as to exclude all air. The juice of the elderberry is famous for promoting perspiration, hence its efficacy in the cure of colds. Two tablespoonfuls should be taken at bed-time in a tumbler of hot water. The juice of the elderberry is excellent in fevers, and is also said to promote longevity. _Elderberry Poultice._ "The leaves of the elder, boiled until they are soft, with a little linseed oil added thereto," laid upon a scarlet cloth and applied, as hot as it can be borne, to piles, has been said to be an infallible remedy. Each time this poultice gets cold it must be renewed for "the space of an hour." At the end of this time the final dressing is to be "bound on," and the patient "put warm to bed." If necessary the whole operation is to be repeated; but the writer assures us that "this hath not yet failed at the first dressing to cure the disease." If any reader desires to try the experiment I would suggest that the leaves be steamed rather than boiled, and pure olive oil used in the place of linseed oil. It must also be remembered that no outward application can be expected to effect a permanent cure, since the presence of piles indicates an effort of Nature to clear out some poison from the system. But if this expulsion is assisted by appropriate means the pain may well be alleviated by external applications. (Pepper should be avoided by sufferers from piles.) _Fig._ A "lump of figs" laid on the boil of King Hezekiah, as recorded in 2 Kings xx. 7, brought about that monarch's recovery. The figs used were doubtless ripe figs, not the dried figs of our grocers. "This fruit," says Dr. Fernie, "is soft, easily digested, and corrective of strumous disease." The large blue fig may be grown in England, in the milder parts and under a warm wall. The fresh figs were rarely seen at one time outside of the large "high-class" fruit shops, but for the last year or two I have seen them peddled in the streets of London like apples and oranges in due season. Green figs (not unripe) were commonly eaten by Roman gladiators, which is surely a sufficient tribute to the fruit's strength-giving qualities. The best way of preparing dried figs for eating is to wash them very quickly in warm water, and steam for twenty minutes or until tender. _Grape._ The special value of the grape lies in the fact that it is a very quick repairer of bodily waste, the grape sugar being taken immediately into the circulation without previous digestion. For this reason is grape juice the best possible food for fever patients, consumptives, and all who are in a weak and debilitated condition. The grapes should be well chewed, the juice and pulp swallowed, and the skin and stones rejected. In countries where the grape cure is practised, consumptive patients are fed on the sweeter varieties of grape, while those troubled with liver complaints, acid gout, or other effects of over-feeding, take the less sweet kinds. Dr. Fernie deprecates the use of grapes for the ordinary gouty or rheumatic patient, but with all due deference to that learned authority, I do not believe the fruit exists that is not beneficial to the gouty person. One of the most gouty and rheumatic people I know, a vegetarian who certainly never over-feeds himself, derives great benefit from a few days' almost exclusive diet of grapes. Cream of tartar, a potash salt obtained from the crust formed upon bottles and casks by grape juice when it is undergoing fermentation in the process of becoming wine, is often used as a medicine. It has been cited as an infallible specific in cases of smallpox, but I do not recommend its use, as it probably gets contaminated with other substances during the process of manufacture. In any case its value cannot be compared with the fresh, ripe fruit. I have little doubt but that an exclusive diet of grapes, combined with warmth, proper bathing, and the absence of drugs, would suffice to cure the most malignant case of smallpox. Sufferers from malaria may use grapes with great benefit. For this purpose the grapes, with the skins and stones, should be well pounded in a mortar and allowed to stand for three hours. The juice should then be strained off and taken. Or persons with good teeth may eat the grapes, including the skins and stones, if they thoroughly macerate the latter. In the absence of fresh grapes raisin-tea is a restoring and nourishing drink. Dr. Fernie notes that it is of the same proteid value as milk, if made in the proportions given below. It is much more easily digested than milk, and therefore of great use in gastric complaints. Sufferers from chronic gastritis could not do better than make raisin-tea their sole drink, and bananas their only food for a time. _Raisin Tea._ To make raisin-tea, take half a pound of good raisins and wash well, but quickly, in lukewarm water. Cut up roughly and put into the old-fashioned beef-tea jar with a quart of _distilled_ or boiled and filtered _rain_ water. Cook for four hours, or until the liquid is reduced to 1 pint. Scald a fine hair sieve and press through it all except the skins and stones. If desired a little lemon juice may be added. _Gooseberry._ The juice of green gooseberries "cureth all inflammations," while the red gooseberry is good for bilious subjects. But it has been said that gooseberries are not good for melancholy persons. Gooseberries are an excellent "spring medicine." _Lavender._ It is very much to be regretted that the nerve-soothing vegetable perfumes of our grandmothers have been superseded, for the most part, by the cheap mineral products of the laboratory. Scents really prepared from the flowers that give them their names are expensive to make, and consequently high-priced. The cheap scents are all mineral concoctions, and their use is more or less injurious. A penny-worth of dried lavender flowers in a muslin bag is even cheaper to buy, inoffensive to smell--which is more than can be said of cheap manufactured scents--and possesses medicinal properties. Lavender flowers were formerly used for their curative virtues in all disorders of the head and nerves. An oil, prepared by infusing the crushed lavender flowers in olive oil, is recommended for anointing palsied limbs, and at one time a spirit was prepared from lavender flowers which was known as "palsy drops." A tea made with hot water and lavender tops will relieve the headache that comes from fatigue. Dr. Fernie advises 1 dessertspoonful per day of pure lavender water for eczema. The scent of lavender will keep away flies, fleas, and moths. _Lemon._ Lemons are invaluable in cases of gout, malaria, rheumatism, and scurvy. They are also useful in fevers and liver complaints. I have found the juice of one lemon taken in a little hot water remove dizzy feelings in the head, accompanied by specks and lights dancing before the eyes, consequent upon the liver being out of order, in half an hour. The juice of a lemon in hot water may be taken night and morning with advantage by sufferers from rheumatism. In the "lemon cure" for gout and rheumatism, the patients begin with one lemon per day and increase the quantity until they arrive at a dozen or more. But I think this is carrying it to excess. Dr. Fernie recommends the juice of one lemon mixed with an equal proportion of hot water, to be taken pretty frequently, in cases of rheumatic fever. A prescription for malaria, given in the _Lancet_, is the following: "Take a full-sized lemon, cut it in thin transverse slices, rind and all, boil these down in an earthenware jar containing a pint and a half of water, until the decoction is reduced to half a pint. Let this cool on the window-sill overnight, and drink it off in the morning." A Florentine doctor discovered that fresh lemon juice will alleviate the pain of cancerous ulceration of the tongue. His patient sucked slices of lemon. A German doctor found that fresh lemon juice kills the diptheria bacillus, and advises a gargle of diluted lemon juice to diptheric patients. Such a gargle is excellent for sore throat. Dr. Fernie recommends lemon juice for nervous palpitation of the heart. Lemon juice rubbed on to corns will eventually do away with them, and if applied to unbroken chilblains will effect a cure. Lemon juice is also an old remedy for the removal of freckles and blackheads from the face. It should be rubbed in at bedtime, after washing with warm water. _Lettuce._ Lettuce is noted for its sedative properties, although these are not great in the large, highly-manured, commercial specimens. It is very easily digested, and may, therefore, be eaten by those with whom salads disagree in the ordinary way. _Nettle._ The tender tops of young nettles picked in the spring make a delicious vegetable, somewhat resembling spinach. They are excellent for sufferers from gout and skin eruptions. Fresh nettle juice is prescribed in doses of from 1 to 2 tablespoonfuls for loss of blood from the lungs, nose, or internal organs. _Nuts._ Nuts are the true substitute for flesh meat. They contain everything in the way of nourishment that meat contains, minus the poisonous constituents of the latter. They are very rich in proteid (flesh and muscle former) and fat. In addition they possess all the constituents that go to make up a perfect food. Nuts and water form a complete dietary, although I do not suggest that any reader should try it. If he did so he would probably eat too many nuts, not realising how great an amount of nourishment is contained in a concentrated form. No one should eat more than a quarter of a pound of nuts per day, in addition to other food. A pound per day would be more than sufficient if no other food were taken. I have little doubt but that the diet of the future will consist solely of nuts and fresh fruit. After all it is the food most favoured by monkeys, and our teeth and digestive apparatus more nearly resemble those of the monkey than the carnivorous and herbivorous animals so many of us seemingly prefer to imitate. The chief objection to nuts is supposed to be on account of their indigestibility. But this has its foundation, not in the nut, but in the manner of eating it. I recommend all those people who find nuts indigestible to pay a visit to the Zoo and see how the monkey eats his nuts. He chews and chews and chews. And after that he chews! I know, alas! that the majority of people do not possess teeth like the monkey, and to these I can only suggest that they macerate their nuts in a nut butter machine. There are several of these machines on the market, and they are stocked by all large "Food-Reform" provision dealers. They cost anything from six or seven shillings. The daily allowance of nuts may be thoroughly macerated and eaten with fruit in the place of cream. Ordinary people may use a nut-mill, which flakes, not macerates, the nuts. But people with bad teeth and a weak digestion will do better to invest in a nut butter machine. I may add that the nuts will not macerate properly unless they are crisp, and to this end they must be put in a warm oven for a short time, just before grinding. I have found new, English-grown walnuts crisp enough without this preparation. But if the nuts are _not_ crisp enough they will simply clog the machine. Now to our nuts! Almonds are the most nourishing. Next in order come walnuts, hazel or cob nuts, and Brazil nuts. The proteid value of these three does not differ much. After these come the chestnut and cocoanut, and lastly we have the pine kernel. Speaking very roughly, we may liken walnuts, hazel nuts, and Brazil nuts to beef for flesh and muscle-forming value, while pine kernels correspond more nearly to fish. Almonds are nearly double the value of beef. _Nut Cream._ Doctor Fernie recommends the following nut-cream for brain-workers. Pound in a mortar, or mince finely, 3 blanched almonds, 2 walnuts, 2 ounces of pine kernels. Steep overnight in orange or lemon juice. It should be made fresh daily, and may be used in place of butter. _Oat._ The oat is generally cited as the most nourishing of all the cereals, and a good nerve food. The fine oatmeal gruel of our grandmothers has gone almost entirely out of fashion, but its use might be revived with advantage. Like wheat, it is a complete food. A good preparation of groats (ground oats from which the husk has been entirely removed) may be taken by those who find other preparations indigestible. Some persons seem unable to take oatmeal, its use being followed by a skin eruption. This is supposed to be due to a special constituent called "avenin," the existence of which, however, is denied by some authorities. There is little doubt but that persons of weak digestive powers and sedentary habits cannot digest porridge comfortably. In any case quickly-cooked porridge is an abomination. _Olive._ The chief use of the olive, at least in this country, consists in the oil expressed from it. Unfortunately our so-called olive oil is generally cotton-seed oil. Captain Diamond of San Francisco, aged 111, and the oldest living athlete in the world, attributes much of his health to the use of olive oil. But he lays great stress upon the importance of obtaining it pure. Cotton-seed oil consists partly of an indigestible gum, and its continued ingestion tends to produce kidney trouble and heart failure. A simple test for purity is to use, the suspected sample for oiling floors or furniture. If pure, it will leave a beautiful polish minus grease. But if it contains cotton-seed oil, part of it will evaporate, leaving the gummy portion behind. When pure olive oil is shaken in a half-filled bottle, the bubbles formed thereby rapidly disappear, but if the sample is adulterated the bubbles continue some time before they burst. Pure olive oil is pale and a greenish yellow. If equal volumes of strong nitric acid (this may be obtained from any chemist) and olive oil are mixed together and shaken in a flask the resulting product has a greenish or orange tinge which remains unchanged after standing for ten minutes. But if cotton-seed oil is present, the mixture is reddish in colour, and becomes brown or black on standing. Olive oil is slightly laxative, and therefore useful to sufferers from constipation. It is also an excellent vermifuge. Olive oil has been used with great success in the treatment of gall stones. A Dr. Rosenberg reported that of twenty-one cases treated by "the ingestion of a considerable quantity of olive oil, only two failed of complete recovery." _Onion._ The uses of the onion are many and varied. Fresh onion juice promotes perspiration, relieves constipation and bronchitis, induces sleep, is good for cases of scurvy and sufferers from lead colic. It is also excellent for bee and wasp stings. Onions are noted for their nerve-soothing properties. They are also beautifiers of the complexion. But moderation must be observed in their use or they are apt to disagree. Not everyone can digest onions, although I believe them to be more easily digested raw than cooked. A raw onion may be rubbed on unbroken chilblains with good results. If broken, the onion should be roasted. The heart of a roasted onion placed in the ear is an old-fashioned remedy for earache. Raw onions are a powerful antiseptic. They also attract disease germs to themselves, and for this reason may be placed in a sickroom with advantage. Needless to say, they should afterwards be burnt or buried. Culpeper, the ancient herbalist, says that they "draw corruption unto them." It is possibly for this reason that the Vedanta forbids them to devout Hindoos. Garlic possesses the same properties as the onion, but in a very much stronger degree. Leeks are very much milder than the onion. _Onion Juice._ The following prescription is excellent for sufferers from bronchitis or coughs: Slice a Spanish onion; lay the slices in a basin and sprinkle well with pure cane sugar. Cover the basin tightly and leave for twelve hours. After this time the basin should contain a quantity of juice. Give a teaspoonful every now and then until relief is afforded. If too much be taken it may induce headache and vomiting. _Onion Poultice._ An excellent poultice for the chest may be made by placing one or two English onions in a muslin bag and pounding them to a pulp. This should be renewed every three or four hours, and the chest washed. I have been told that, at the age of six weeks old, I was saved from dying of bronchitis by such an onion poultice applied to the soles of my feet. _Orange._ The orange possesses most of the virtues of the lemon, but in a modified form. But it has the advantage of being more palatable. The juice of oranges has been observed to exert such a beneficial influence on the blood as to prevent and cure influenza. Taken freely while the attack is on they seemingly prevent the pneumonia that so often follows. By far the quickest way to overcome influenza is to subsist solely on oranges for three or four days. Hot distilled water may be taken in addition. The peel of the bitter Seville orange is an excellent tonic and remedy in cases of malaria and ague. A drink may be prepared from it according to the prescription under the heading "Lemon." The "orange cure" is used with great success for consumptive patients, for chest affections of all kinds, for asthma, and some stomach complaints. Oranges are taken freely at every meal. The "navel" kind are generally used. Herbalists sell dried orange pips to be crushed to a powder and taken in the proportion of 1 teaspoonful to a cup of hot water. This is a harmless sedative, and useful in hysterical affections. _Marmalade Tonic._ A drink made with half a pint of hot water poured over a tablespoonful of good, home-made marmalade will often give relief in cases of neuralgia and pains in the head. _Parsley._ Parsley is useful in cases of menstrual obstruction and diseases of the kidneys. The bruised leaves applied to the breasts of nursing mothers are said to cure painful lumps and threatened abscess. It may also be taken with advantage by cancerous patients. In all these cases parsley may be taken in the form of a soup, in common use among members of the Physical Regeneration Society, which consists of onions, tomatoes, celery, and parsley, stewed together in distilled water. Dr. Fernie remarks that when uncooked parsley has been eaten to excess it has been observed to produce epilepsy in certain bodily systems. The oil of parsley has also been found useful in cases of epilepsy. This would naturally follow on the homeopathic principle of similars. _Pear._ The pear possesses most of the virtues of the apple. But, unlike the latter, it is credited with producing a constipating effect if eaten without its skin. In an old recipe book I found the following tribute to Bergamot pears. The writer says: "I had for some years been afflicted with the usual symptoms of the stone in the bladder, when meeting with Dr. Lobb's "Treatise of Dissolvents for the Stone and Gravel," I was induced on his recommendation to try Bergamot pears, a dozen or more every day with the rind, when in less than a week I observed a large red flake in my urine, which, on a slight touch, crumbled into the finest powder, and this was the same for several succeeding days. It is ten years since I made the experiment, and I have been quite free from any complaints of that nature ever since. The pears were of the small sort and full of knots." _Pea Nut._ The pea nut--or monkey nut--is especially recommended as a cure for indigestion. I have not been able to find out why. As a matter of fact it is such a highly-concentrated food that, unless taken in very small quantities, it is liable to upset weak digestions. I suspect the secret to lie in the chewing. Almost any kind of nut will cure the habitual indigestion induced by "bolting" the food, if only it be chewed until it is liquid. Hard biscuits will do instead of nuts, although an uncooked food like the nut is the better. But whatever is taken must be "Fletcherised," that is, chewed and chewed and chewed until it is all reduced to liquid. Pea nuts contain a good deal of oil, and for this reason are recommended for consumptives. They are the cheapest nuts to buy, for the reason that they are not really nuts but beans. _Pine-apple._ Pine-apple juice is the specific for diphtheria. This seems to have been first brought to the notice of Europeans by the fact that negroes living round about the swamps of Louisiana were observed to use it with great success. A writer who records this says: "The patient should be forced to swallow the juice. This fluid is of so pungent and corrosive a nature that it cuts out the diphtheria mucous and causes it to disappear." The above direction looks satisfactory enough on paper, and it is eminently cheering to read of how the pine-apple juice causes the diphtheria mucous to disappear, but anyone who knows anything about diphtheria knows that to "force" a diphtheria patient to swallow is more easily written about than accomplished. Fortunately I have been able to obtain the following explicit directions from an experienced nurse and mother: The pine-apple should be cut up and well pounded in a mortar. The juice must then be pressed out and strained through well-scalded muslin. The patient's mouth must be washed out with warm water. The juice may now be given with a silver teaspoon. It is possible that the patient may be quite unable to swallow any of it. If this be so, the juice will serve as a mouth and throat wash. It will gradually dissolve the membrane, and enable it to be scraped gently away with the spoon. The juice should be given, and the throat scraped as far down as the nurse can reach, as often as the patient can bear it. The time will come, sooner or later, when the juice is swallowed. No other food should be given. The nurse may have to work away for some hours before any juice is swallowed, but my friend assures me that if the scraping be done gently and skilfully, even children will bear it patiently. Only a silver or bone spoon should be used, and, needless to say, it must be well scalded in boiling water in the intervals of using. It is a remarkable fact that while pine-apple juice exercises this remarkable corrosive power upon diseased mucous, its effect upon the most delicate, healthy membrane is absolutely harmless. I have seen sweet pine-apple juice given to six-months-old babies as a supplement to the mother's milk, with excellent results. Dr. Hillier, writing in the _Herald of Health_ in 1897, says "Sliced pine-apples, laid in pure honey for a day or two, when used in moderation, will relieve the human being from chronic impaction of the bowels, reestablish peristaltic motion, and induce perfect digestion." "A slice of fresh pine-apple," writes Dr. Fernie, "is about as wise a thing as one can take by way of dessert after a substantial meal." This is because fresh pine-apple juice has been found to act upon animal food in very much the same way that the gastric juice acts within the stomach. But vegetarians should eat fresh fruit at the beginning of meals rather than at the end. The pine-apple is useful in all ordinary cases of sore-throat. One pine-apple of average size should yield half a pint of juice. Tinned or cooked pine-apple is useless for curative purposes. _Pine Kernel._ Pine kernels are recommended to those who find other nuts difficult to digest. They are the most easily digested of all the nuts. They are often used for cooking in the place of suet, being very oily. _Plum, Prune._ The disfavour with which "stone fruits," especially plums, are generally regarded owes its being to the fact that they are too often eaten when unripe. When ripe, they are as wholesome as any other fruit. Unripe they provoke choleraic diarrhoea. The prune, a variety of dried plum, has been recommended as a remedy against viciousness and irritability. An American doctor declares that there is a certain medicinal property in the prune which acts directly upon the nervous system, and that is where the evil passions have their seat. He reports that he tried the experiment of including prunes in the meals of the vicious, intractable youths of a reformatory, and that by the end of a week they were peaceable as lambs. Most writers who comment on this seem to suggest that any fruit which is mildly aperient would produce the same effect. But the mother of a large family tells me that she has observed that prunes seem to possess a soothing property that is all their own. _Prune Tea._ Prune tea is an excellent drink for irritable persons. It is made as follows: To every pint of washed prunes allow 1 quart of distilled water. Soak the prunes all night, and afterwards simmer to rags in the same water. Strain, and flavour with lemon juice if desired. _Potato._ The potato is a cheap and homely remedy against gout, scurvy, and rickets. Dr. Lambe tells how he cured a case of scurvy solely with raw potatoes. One of the favourite dishes of that good old doctor was a salad composed of sliced raw potatoes and olive oil. In order to preserve the medicinal properties of potatoes when cooked, they must always be steamed in their jackets. The skin may be removed before eating, but care should be taken not to allow a particle of the potato to adhere to it. The valuable potash salts chiefly lie just under the skin. A raw potato scraped or powdered to a pulp is an excellent remedy for burns and scalds. Dr. Fernie recommends the following decoction with which to bathe the swollen and inflamed joints of rheumatic sufferers. Take 1 lb. potatoes, cut each into four, but do not peel them. Boil in 2 pints of water until stewed down to 1 pint. Strain, and use the liquid. Eaten to excess potatoes are apt to cause dullness and laziness. _Radish._ The radish is commonly cited as indigestible, but for all that it is commended by old writers as a potent remedy for stone. If not too old, well masticated, and eaten at the beginning of a meal, I do not think it is more indigestible than the majority of vegetables. A syrup made with the juice expressed from pounded radishes and cane sugar is recommended for rheumatism, bronchial troubles, whooping-cough, and pustular eruptions. Dr. Fernie notes that the black radish is especially useful against whooping-cough, probably by reason of its volatile, sulphureted oil. "It is employed in Germany for this purpose by cutting off the top, and then making a hole within the root, which hole is filled with treacle, or honey, and allowed to stand thus for two or three days; afterwards a teaspoonful of the medicated liquid is to be given two or three times in the day, with a dessertspoonful of water, when required." I am not acquainted with the "black radish," but mothers might do worse, in cases of whooping-cough, than give their children the juice of pounded radishes mixed with pure honey. _Raspberry._ Raspberries are excellent against the scurvy, and, like the blackberry, good for relaxed bowels. They are a very wholesome fruit, and should be given to those who have "weak and queasy stomachs." _Rice._ The chief medicinal value of rice lies in the quickness with which it is digested. One authority says that "it can be taken four times a day and the patient still get twenty hours' rest." It is consequently of great value in digestive and intestinal troubles. But it should be _unpolished_, otherwise it is an ill-balanced, deficient food. It should likewise be boiled in only just enough soft water to be absorbed during the cooking. One cup of rice should be put on in a double saucepan with three cups of cold water and tightly covered. When the water is all absorbed the rice will be cooked. The large-grained, unpolished rice sold at "Food-Reform" stores at 3d. per lb. absorbs the water and cooks much more easily than a smaller variety sold at 2d. I have found the latter most unsatisfactory. _Rhubarb._ Rhubarb is a wholesome and cooling spring vegetable, and may well take the place of cooked fruit when the latter is scarce. But it is generally forbidden to rheumatic and gouty patients on account of its oxalic acid. This oxalic acid is supposed to combine with the lime in the blood of the gouty person, and to form crystals of oxalate of lime, which are eliminated by the kidneys. At the same time the general health suffers. "Dr. Prout," writes Dr. Fernie, "says he has seen well-marked instances in which an oxalate of lime kidney attack has followed the use of garden rhubarb in a tart or pudding, likewise of sorrel in a salad, particularly when at the same time the patient has been drinking hard water. But chemists explain that oxalates may be excreted in the urine without having necessarily been a constituent, as such, of vegetable or other foods taken at table, seeing that citric, malic, and other organic acids which are found distributed throughout the vegetable world are liable to chemical conversion into oxalic acid through a fermentation or perverted digestion." I think the moral of the above is: "Do not drink hard water." Especially do not cook fruit and vegetables in hard water. They are nearly always rendered indigestible by such a process, and "vegetarianism," not the hard water, is often blamed for the sufferings of the consumers. Rhubarb is apt to be over-valued as a "spring medicine" on account of its association with the Turkey rhubarb of _materia medica_. It should be thoroughly ripe before eating. I am _not_ recommending Turkey rhubarb. _Sage._ Sage is said to promote longevity, to quicken the senses and memory, and to strengthen the nerves. Sage tea is recommended for pulmonary consumption and for excessive perspiration of the feet. A teaspoonful of dried sage, or rather more if the fresh leaves be used, is steeped in half a pint of water for twenty-four hours. A teacupful is to be taken night and morning. Sage, like so many of the fragrant herbs, is antiseptic. _Strawberry._ The strawberry is exceptionally wholesome on account of its being so easily digested. It is recommended for gout, rheumatism, and the stone. Also for anæmic patients on account of the iron it contains. H. Benjafield, M.B., advises anæmic girls to take 1 quart of strawberries per day, and when these are not obtainable several ripe bananas. _Spinach._ Professor Bunge declared that iron should never be taken in its mineral form, but that those who are in need of an iron tonic should take it as it exists in vegetables and fruit. To this end he especially commends spinach. Dr. Luff puts spinach first on a list of vegetables recommended to those who suffer from gouty tendencies. Spinach is very easily digested, and so juicy that no added water is needed in which to cook it. _Tomato._ The tomato, according to an American physician, is one of the most powerful _deobstruents_ (remover of disease particles, and opener of the natural channels of the body) of the _materia medica_. It should be used in all affections of the liver, etc., where calomel is indicated. The superstition that tomatoes are a cause of cancer is absolutely without foundation. Vegetarian cancer patients who have recovered after being given up as "hopeless" by the orthodox faculty eat tomatoes freely. Another belief, strongly supported by some otherwise "advanced" scientific men, is that tomatoes are bad for those who suffer from a tendency to gout, or uric acid disease. But this has been contradicted by others. The evil agency in the tomato is supposed to be the oxalic salt which it undoubtedly contains. But it has been shown by experiment how certain chemical compounds as obtained from plants act quite differently to the same compounds artificially prepared in the laboratory. So that the contention of those who assert that the tomato is not only harmless, but even beneficial to gouty subjects, is not unreasonable. Speaking from experience, I can only say that one of the goutiest subjects I know eats tomatoes nearly every day of his life, and continues to progress rapidly towards health. A tomato poultice is said to cleanse foul ulcers, and promote their healing. It should be renewed frequently, and applied hot. _Turnip._ Turnips are anti-scorbutic. An old remedy for chronic coughs was turnip juice boiled with sugar. The turnips were grated, the juice pressed out, and 2½ ozs. candied sugar were allowed to 1 pint of juice. This was boiled until it slightly thickened. A teaspoonful to be taken several times a day. The green turnip tops, steamed until tender, are a good "spring medicine." _Thyme._ The common garden thyme, used for flavouring, is credited with many virtues. It is said to inspire courage and enliven the spirits, and for this reason should be taken by melancholy persons. It is good against nervous headache, flatulence, and hysterical affections. It is antiseptic. _Walnuts._ The walnut has been called vegetable arsenic because of its curative value in eczema. An oil obtained from the kernel has been found of great service when applied externally in cases of skin diseases. The leaves of the walnut tree are also used for the same purpose, both externally and internally. One ounce of the leaves to 12 tablespoonfuls of boiling water make a tea, half a tea-cup of which may be taken several times a day. The affected parts should also be washed with it. Walnuts, to be well masticated, have been given to gouty and rheumatic patients with great success. About one dozen per day is the quantity prescribed. It is possible that herein lies the secret of the fact that our ancestors invariably took walnuts with their wine. The green, unripe walnut is useful for expelling worms. _Wheat._ Whole wheat is a perfect food. In the form of white flour, however, it is an imperfect, unbalanced food, on account of its deprivation of the valuable phosphates which exist in the bran. Rickets and malnutrition generally are the outcome of the habitual use of white flour, unless the loss of mineral matter is counter balanced by other foods. Only the very finest wholemeal, such as "Artox," for example, should be used for making bread, etc. The ordinary coarse wholemeals are apt to produce intestinal irritation. _Cracked wheat_, soaked overnight in water and boiled for a couple of hours, is a favourite prescription of American writers for habitual constipation. It may be obtained at most large "Food-Reform" stores. _Bran Tea._ Nervous or anæmic persons will derive great benefit from a course of bran tea. It is made as follows:--To every cup of bran allow 2 cups distilled water. Well wash the bran in cold water; it is generally full of dust. Put in a saucepan with the cold distilled water, cover tightly, and boil for thirty minutes. Strain, and flavour with sugar and lemon juice to taste. Take a teacupful night and morning. PART III.--INDICES INDEX TO DISEASES AND REMEDIES ABSCESS-- PAGE Parsley 58 ACID DYSPEPSIA-- Apple 18 ANÆMIA-- Banana 22 Barley 23 Bran 77 Lentil 27 Spinach 72 Strawberry 72 Water-cress 31 ASTHMA-- Orange 57 BLACKHEADS-- Lemon 46 BOILS-- Green Figs 38 BOWEL IMPACTION-- Pine-apple 63 BRAIN FAG-- Apple 16 BRONCHITIS-- Onion 54 Radish 67 BRUISES-- Banana 23 BURNS-- Beet 28 Potato 66 CANCER-- Cinnamon 32 Lemon 46 Parsley 58 CHEST AFFECTIONS-- Almond 15 Orange 57 CHILBLAINS-- Lemon 46 Onion 54 CHOLERA-- Coffee 34 COLDS-- Black Currant 26 Elderberry 36 COLIC-- Caraway Seed 29 Onion 54 CONSTIPATION-- Brazil Nut 26 Cracked Wheat 77 Olive Oil 53 Onion 54 CONSUMPTION-- Cabbage, etc. 28 Carrot 30 Cinnamon 33 Cresses 31 Date 34 Grape 2, 40 Orange 57 Pea Nut 60 CORNS-- Lemon 46 COUGHS-- Black Currant 26 Elderberry 36 Turnip 75 DIARRHOEA-- Blackberry 24 Raspberry 68 DIPHTHERIA-- Lemon 46 Pine-apple 60 DYSPEPSIA-- Apple 18 Celery 31 Pea Nut 60 ECZEMA-- Lavender 44 Walnut 75 EPILEPSY-- Parsley 58 EYE, INFLAMMATION OF-- Apple 18 FEVER-- Apple 19 Barley 23 Elderberry 37 Grape 40 Lemon 44 FLATULENCE-- Thyme 75 FRECKLES-- Lemon 46 GALL STONE-- Olive Oil 53 GASTRITIS-- Banana 20 Barley 23 GOUT-- Apple 18 Carrot 30 Celery 31 Grape 40 Lemon 44 Potato 66 Spinach 73 Strawberry 72 Walnut 76 HÆMORRHAGE-- Nettle 47 HEADACHE-- Lavender 44 Orange 57 Thyme 75 HEART, PALPITATION OF-- Asparagus 20 Lemon 46 HYSTERIA-- Caraway Seed 29 Orange Pips 57 Thyme 75 INDIGESTION-- Apple 18 Celery 31 Pea Nut 60 INEBRIETY-- Apple 19 INFLAMMATION-- Apple 18 Banana 20 Barley 23 Green Gooseberry 43 INFLUENZA-- Cinnamon 33 Orange 56 IRRITABILITY-- Prune 65 KIDNEY DISEASE-- Parsley 58 LIVER COMPLAINTS-- Apple 18 Carrot 31 Grape 40 Lemon 44 Red Gooseberry 43 Tomato 73 White Beet 28 MALARIA-- Grape 41 Lemon 44 Orange 56 MELANCHOLY-- Thyme 75 MENSTRUAL OBSTRUCTION-- Parsley 57 NERVOUS DYSPEPSIA-- Celery 31 NERVOUS EXCITEMENT-- Onion 54 Sage 71 NERVOUS EXHAUSTION-- Apple 17 NEURALGIA-- Seville Orange 57 PALPITATION OF HEART-- Asparagus 20 Lemon 46 PARALYSIS-- Lavender 44 PERITONITIS-- Banana 20 PILES-- Elderberry 37 PNEUMONIA-- Cinnamon 33 Orange 56 PULMONARY COMPLAINTS-- Cabbage, etc. 28 Carrot 30 Grape 1 _et seq_ Sage 71 RHEUMATISM-- Asparagus 20 Cabbage, etc. 29 Celery 31 Cress 31 Lemon 44 Radish 67 Strawberry 72 Walnut 76 RICKETS-- Potato 66 SCURVY-- Cress 31 Lemon 44 Potato 66 Raspberry 68 Turnip 74 SKIN ERUPTIONS-- Nettle 47 Radish 67 SLEEPLESSNESS-- Lettuce 46 Onion 54 SMALLPOX-- Grapes 41 SORES-- Beet 28 SORE THROAT-- Apple 18 Black Currant 26 Pine-apple 64 SPRAINS-- Banana 23 Caraway Seed 29 STINGS-- Onion 54 STONE-- Apple 17 Pear 59 Radish 67 Strawberry 72 TYPHOID FEVER-- Banana 20 UTERINE DISEASE-- Red Beet 28 ULCERS-- Carrot 30 Tomato 74 VICIOUSNESS-- Prune 65 WEAK DIGESTION-- Chestnut 32 Grape 40 Lettuce 46 Pine Kernal 64 Rice 69 Strawberry 72 WHOOPING COUGH-- Radish 67 WORMS-- Carrot 30 Cocoanut 33 Olive Oil 53 Walnut 76 INDEX TO PRESCRIPTIONS AND RECIPES Almond Soup 15 Apple Tea 19 Banana and Barley Injection 21 Barley Water 23 Blackberry Tea 25 Blackberry Jelly 25 Black Currant Tea 26 Bran Tea 77 Cinnamon Tea 33 Chestnuts, Boiled 32 Elderberry Leaf Poultice 37 Figs, Steamed 39 Fruit Juice, Preserved 36 Lemon Prescription for Malaria 45 Marmalade Tonic 57 Nut Cream 50 Onion Juice 55 Onion Poultice 55 Orange Pips, Dried 57 Pine-apple Juice 60 Potato Lotion 67 Prune Tea 65 Radish Juice 68 Raisin Tea 42 Rice, Boiled 69 Sage Tea 71 Turnip Juice 75 Walnut Leaf Tea 76 INDEX--MISCELLANEOUS Artistic Faculties, to Strengthen 20 Cabbage, for Nursing Mothers 28 Caraway Seeds, promote Secretion of Milk 29 Cresses, good for Brain 31 Lavender, prevents Flies, Fleas, and Moths 44 Nuts, true Substitute for Flesh Meat 47 Nut Butter Machine 49 Olive Oil, Tests for Purity of 52 Pulse, not Indigestible 27 Tomato, not bad for Cancer or Gout 73 * * * * * ADVERTISEMENTS +A WORD ABOUT THE ADVERTISEMENTS.+ Readers of the Healthy Life Booklets will doubtless be glad to know that only those advertisements of foods that can be conscientiously recommended are accepted. This necessarily limits the number of advertisements, but has the advantage of making them really serviceable. The publisher has no pecuniary interest in any of the firms mentioned, and therefore feels quite free to give his testimony to the worth of their goods. +"Artox" Flour.+ This is so finely ground that, although wholemeal, it may be used in the manufacture even of sponge cake, while for bread it is unsurpassable. +Digestive Tea.+ Tea-drinking is considered to be very injurious, but the habit is difficult, apparently impossible, for some people to overcome, and therefore the Universal Digestive Tea supplies a real need. A tea minus tannin is a boon to everyone, but especially to the sufferers from dyspepsia and nervous complaints. +Fry's Cocoa.+ This cocoa has stood the test of time and chemists for so long now as hardly to need further testimony as to its genuineness. +International Health Association.+ They supply thoroughly pure foods, and readers will do well to take advantage of their offer to send samples to test for themselves. +Mapleton's Nut Foods.+ Their Nutter is quite the best vegetable cooking fat on the market, and makes excellent pastry. A pie-crust made of Nutter and "Artox" Flour is a revelation to the uninitiated. The Nut Butters are also very good, especially the uncoloured varieties labelled "Wallaceite." +Shearns.+ Mr. Shearn is the acknowledged "Fruit King" of the Food Reform movement. The grand fruit shop in Tottenham Court Road, to which is now added a vegetarian restaurant, is familiar to most Food Reformers who live in or near London. Others will be glad to know of Shearn's Stores where all the latest "Food Reform" specialities are stocked. A catalogue can be obtained on application. +Wallace Bakery.+ This is the only bakery in existence which supplies bread, cakes, etc., made with very fine wholemeal flour, and entirely free from yeast and chemicals. The Wallace Bakery is a boon and a blessing to Physical Regenerationists. * * * * * +A HEALTHY LIFE BOOKLET FREE+ It has many valuable recipes for Food Reformers and Invalids, and tells all about +"ARTOX" WHOLE MEAL,+ which is made from the finest whole wheat, and is so finely ground by old-fashioned stone mills that it can be digested by the most delicate. It makes the most delicious Bread, Cakes, Biscuits, and Pastry, and is an entire safeguard against Constipation when used regularly in place of white flour. It is strongly recommended by _The Lancet_ and by Mrs. Leigh Hunt Wallace (_Herald of Health_) and is used exclusively in the Wallace Bakery. Sold by Health Stores and Grocers everywhere in 7 lb. sealed linen bags, or 28 lbs. sent direct for 4s. 6d. carriage paid. _Important._--"Artox" Wholemeal is only retailed in our sealed bags, and is _not_ sold loose. +APPLEYARDS, LTD.+ (Dept. M.) Millers, ROTHERHAM. _Mention Healthy Life Booklets._ [Illustration: Grains of Common Sense for Housewife and Epicure.] * * * * * +WILL YOU TRY A CUP OF TEA+ that, instead of injuring your nerves and toughening your food, is +Absolutely Safe and Delightful?+ 2s. 2d.; 2s. 10d.; and 3s. 6d. per lb. +THE UNIVERSAL DIGESTIVE TEA+ is ordinary Tea treated with oxygen, which neutralises the injurious tannin. Every pound of ordinary tea contains about two ounces of tannin. Tannin is a powerful astringent subject to tan skins into leather. The tannin in ordinary tea tans, or hardens, the lining of the digestive organs, also the food eaten. This prevents the healthful nourishment of the body, and undoubtedly eventuates in nervous disorders. On receipt of a post card the UNIVERSAL DIGESTIVE TEA CO., Ltd., Colonial Warehouse, Kendal, will send a sample of this Tea and name of nearest Agent, also a Descriptive Pamphlet compiled by Albert Broadbent, Author of "Science in the Daily Meal," &c. Where no agent, 1 lb. and upwards will be sent post free. _AGENTS WANTED._ * * * * * +Ideal Foods for Every Day.+ The I.H.A. Health Foods are called Health Foods because they do actually build up the body, and make directly for better health all round. They are Ideal Foods because they are made only from such products as wheat, nuts, etc.; because they are thoroughly cooked and easily digested; because they are absolutely pure; because they are manufactured with scrupulous care and cleanliness in an ideal factory in the open country. They are ideal foods for every day because they furnish a wide variety of dishes at a low cost, and because they are all pleasant to the taste. The I.H.A. Health Foods are sold by all Health Food Stores, or direct on easy terms. We offer to send you three liberal samples and a beautifully illustrated price list, containing full details and many valuable recipes, for 2d. stamps, or price list post free on application. The International Health Association Limited. The Factory in the Beech Woods, Stanborough Park, Watford, Herts. _Please write for "Food Remedies."_ * * * * * +A Word about Nut Foods.+ The high value of Nuts has long been known, but until lately no attempt has been made to manufacture them in a form available for domestic use. This, however, is now changed, as a splendid variety of excellent preparations are ready to hand, owing to the enterprise of +Messrs. Mapleton+, in the shape of such useful products as +Nutter+ and +Nutter Suet+, which supersedes Lard, Suet, and Cooking Butter in the kitchen. Also delicious Table Butters--+Walnut+, +Cocoanut+, and +Cashew+--all of which are four times as nutritious as Dairy Butter. Other goods are +Nut Meat, Nut Gravy, Nut Biscuits, Nut Cakes, Fruitarian Cakes,+ &c. A Post Card will bring a Booklet describing these goods, with Recipes for their use, on application to THE MANUFACTURERS: Mapleton's Nut Food Co., Ltd. LANCASHIRE MENTION HEALTHY LIFE BOOKLETS. * * * * * +A GUIDE TO GOOD THINGS.+ There are thousands of folk all over the country who are beginning to feel vaguely that their usual diet is not all it should be, and that it tends to produce discomfort and disease. Many of them would be glad to make a change if they knew how. Our booklet, "A Guide to Good Things," will help them. It contains an interesting article on "How To Start," and gives a complete menu for a week in which the foods that supply the place of the less wholesome fish, bacon, or meat, are clearly indicated. There are also several pages of delightful recipes that will help to gladden the table of any housewife in the kingdom, and in addition there is a complete price list of every health food upon the market that can be recommended, and of the most up-to-date and novel appliances for cooking and preparing food. There is an all but endless array of breakfast foods--bread, cakes, biscuits, etc., etc., that are not only beneficial because of what they contain, but are free from the injurious chemical adulterants so largely used nowadays. But send for our booklet and see for yourself what it contains, or if you are near give us a call. You may shop, lunch, dine, and take tea with us. Our Health Food Stores will supply everything you need for a perfect health diet. Our Fruit Stores will supply you with the choicest fruit on the most moderate terms, and in large quantities at wholesale prices. Our Fruit Luncheon Rooms are the talk of London, and you can get a delightful fruit meal amid flowers and palms from 6d. If you cannot call, send six penny stamps, and in return we will send you, together with the booklet, a sample of our Frunut, reg. (a preparation of selected nuts and fruit that is as delightful as it is sustaining); samples of Stamanut Wholemeal Biscuits (a valuable and most economical food), and of our Afternoon Tea Biscuits, and a good sample of our Special Pale Roasted Coffee. The whole post free for 6d. You will be delighted with it all. Write to-day to B. Shearn & Son, 234, Tottenham Court Road, London, W. Mention this book. * * * * * +A Bakery based on Principle.+ When so many manufactured foods are more or less adulterated--even such everyday articles as Bread and Biscuits being no exceptions--it is good news to know that Delicious Biscuits, Bread, Cakes, &c., can be obtained which are guaranteed, and proved by frequent analysis to be, absolutely free from any impurity whatever. The goods referred to are made by +The WALLACE P.R. FOODS Co.,+ which was founded on certain definite scientific principles, and those principles are unswervingly applied to every detail of its varied activities. Within its clean and airy precincts are manufactured the famous Barley Malt Biscuits (and some thirty other varieties), rich and wholesome Cakes, air-raised Bread, pure Preserves, a specially prepared Barley Malt Meal, Pale Roasted Coffee, and Stamina Food--this last being the best-balanced food for Infants and Invalids yet produced. In the making of these foods only the very choicest ingredients are employed; the only flour used is a very fine wholemeal; the butter and milk are sterilised and the water distilled, while all such impurities as Yeast, Baking Powder, and Chemicals are strictly avoided. The experience of thousands proves that the daily use of "WALLACEITE" (reg.) P.R. Foods is a veritable highway to health. They build up the body and keep it in working order as do no other foods. They can be obtained from all Health Food Stores. 30 Samples of Delicious Bread, Cakes, and Biscuits, Carriage Paid, 1/6 or Box of Larger Samples, 2/6. _Interesting explanatory literature Free._ +THE WALLACE P.R. FOODS CO.,+ +465, Battersea Park Road, London, S.W.+ * * * * * The Open Road An unconventional Magazine concerned with Religion, Psychology, Sociology, Diet, and Hygiene. EDITED BY FLORENCE & C. W. DANIEL. _Price 3d. monthly; postage 1d. Yearly 3/- post free._ * * * * * Love: Sacred and Profane By F. E. WORLAND. A remarkable and original work dealing with the subject of love in all its aspects. All interested in the synthetic treatment of Religion, the Social Question, and the Sex Question, should read this book. _Foolscap 8vo. Cloth, gilt letters, 3/6 net._ LONDON: C. W. DANIEL, 11 CURSITOR STREET, E.C. * * * * * _HOW WE ARE BORN._ A Letter to Parents for their children, setting forth in simple language the truth about the facts of sex. By Mrs. N. J., with Preface by J. H. Badley, Headmaster of Bedales School. Cloth. 2s. net. Postage 3d. "It would be impossible to name any subject of such general importance and interest on which so little has been said." Canon Lyttleton, Headmaster of Eton. * * * * * +CREATIVE LIFE BOOKLETS.+ A series of practical talks to young men and parents. By Lister Gibbons, M.D. Foolscap 8vo. Cloth. 1s. net each. _NOW READY._ NO. 1. WHAT MAKES A MAN OF ME. (_In Preparation._) NO. 2. THE BODY AND ITS CARE. NO. 3. THE MIND AND ITS EFFECT UPON THE BODY. NO. 4. HOW TO CONSERVE MY STRENGTH. NO. 5. CHASTITY AND MARRIAGE. NO. 6. MAN AND HIS POWER. * * * * * LONDON: C. W. DANIEL, 11 Cursitor St., E.C. * * * * * The Works of Mary Everest Boole. LOGIC TAUGHT BY LOVE. Rhythm in Nature and in Education. Crown 8vo., Cloth, 3/6 net. MATHEMATICAL PSYCHOLOGY OF GRATRY AND BOOLE. For Medical Students, showing the light thrown on the nature of the human brain by the evolution of the mathematical process. Crown 8vo., Cloth, 3/6 net. BOOLE'S PSYCHOLOGY As a Factor in Education. Crown 8vo., 6d. net. MISTLETOE AND OLIVE. An introduction for Children to the Life of Revelation. Royal 16mo., Cloth, 1/6 net. MISS EDUCATION AND HER GARDEN. A Panoramic View of the great Educational Blunders of the last half century. Royal 16mo., 6d. net. _Ready October, 1908._ THE MESSAGE OF PSYCHIC SCIENCE TO MOTHERS & NURSES. Crown 8vo., Cloth, 3/6 net. * * * * * LONDON: C. W. DANIEL, 11 CURSITOR STREET, E.C. * * * * * 
18370	----	{Transcriber's Note: Misspellings in the original have been preserved. The text uses a mixture of italics, boldface, enlarged type, and underlining. They are represented here by _lines_ for ordinary emphasis (generally italics), +marks+ for added emphasis (generally bold). Material added by the transcriber is in braces { }. All brackets [ ] are in the original text.} * * * * * * * * * * * * * * {Illustrated Cover: Only Sent When Requested, and then Only When Sealed. GLAD TIDINGS OF GOOD THINGS. THE CIVIALÈ REMEDIES 174 Fulton St., New York } {Illustration: CHEMICAL LABORATORY, CIVIALE REMEDIAL AGENCY.} Manhood Perfectly Restored. Prof. JEAN CIVIALÈ'S SOLUBLE URETHRAL CRAYONS, as a QUICK, PAINLESS and CERTAIN CURE for _IMPOTENCE, LOST MANHOOD, SPERMATORRHOEA, LOSSES,_ _WEAKNESS AND NERVOUS DEBILITY._ Also for PROSTATITIS and VARICOCELE. [The only standard and officially recognized treatment for these diseases of the Sexual and Urinary Organs, endorsed by and adopted in all the Hospitals of Paris, France.--See _Gazette des Hopitaux, Dec._ 8, 1869; also _Dictionnaire des Sciences_, vol. xxiv., p. 565.] FACTS FOR MEN OF ALL AGES. SIXTH EDITION, Enlarged, Revised and Illustrated. ISSUED BY THE CIVIALÈ REMEDIAL AGENCY, 174 FULTON ST., NEW YORK. [_Opposite St. Paul's Church._] 1885. {Transcriber's Note: The text pages cycle through a series of eight headers: (1) _All our Doctors are Regular Graduates, and their Diplomas are Registered in the Office of the County Clerk, City Hall, New York, as required by Law._ (2) _Our Crayons are Inserted without Pain._ (3) _We Cure where a Cure is Possible._ (4) _We hold out no False Hopes._ (5) _Our Treatment is Pleasant, Quick and Lasting._ (6) _When you are Tired of being Humbugged or Experimented on, send to us._ (7) _We Offer Special Help to Impotent Men._ (8) _Strictest Privacy--Perfect Confidence--Certain Cure._ The first set of eight pages has the headers in this order: 1, 2, 3, 5, 6, 3, 7, 8 On one later page, headnote 8 begins _Strict Privacy_.} TO THE READER. It is with great pleasure that we send you a copy of this, the sixth edition of our brochure on Sexual and Urinary Diseases. The success of the Civialè Urethral Method, since its first introduction into America, has been almost unparalleled in Medical History, and we feel that the time has come for replacing the brief pamphlet containing a mere outline of the method, with a work somewhat more full and exhaustive. Aware of the number of worthless and oftentimes actually injurious remedies that are being advertised and recommended for the cure of these affections, and the bogus doctors and worthless firms that infest every large city, we have endeavored to give inquiring patients every proof and assurance of the efficacy of the Civialè Remedies, every facility for investigating our methods, and proving, to their entire satisfaction, both the medical ability of our Consulting Staff, and the honor, honesty and fair dealing of the Agency. We court the fullest and freest investigation, either by patients themselves or any friends of theirs in this city, either of whom we shall be happy to see and satisfy at any time, at our Consulting Rooms, Business Offices or Manufactory. Repeated trials in some of the most severe cases of Spermatorrhoea and Impotency, in both France and America, have proven the Civialè Remedies to be safe, speedy and most satisfactory in all their results, and we feel justly proud of having in our hands so excellent and efficient a means for the radical cure of so obstinate, serious and often dangerous a disease. We take pride in having saved many a young and promising life, in having often stayed the hand bent upon self-destruction, and in having many times cheated the grave or the insane asylum of its expected prey. Nor do we feel less proud in having been able, in cases of not so serious, though often of a more embarrassing nature, to restore to full Sexual Power and Vigor _middle-aged and older men whose desire had out-lived their power_, or who, through early abuse, had become so weakened as to be totally Impotent, incapable of perpetuating their species--ashamed, discomfited, and disappointed at being somewhat less than a man. As every case cured is the very best advertisement that we can have, it is hardly necessary for us to say that we endeavor to exercise the utmost care, skill and discretion in both diagnosing and treating these cases, and assiduity and scientific accuracy in preparing and compounding those remedies of which we are the fortunate possessors. Indeed, we do everything in our power to make success an absolute certainty. A word in closing. Our STAFF OF CONSULTING PHYSICIANS is composed of men selected with great care for their special skill and attainments in this special branch of Medical Science. These gentlemen are handsomely remunerated for their services, and take a pride and interest in every case they treat. Our physicians hold no pecuniary interest in the Agency, and hence prescribe for each case solely on its merits, having nothing to gain by selling less or more to any one under their care. They see and treat each case solely and wholly from a medical standpoint, and hence are never influenced by any pecuniary considerations whatsoever. However great the reputation of our physicians may be, we have, from the first organization of this institution, taken and held the ground that the best interest of the patient is best served by resolutely divorcing the Medical from the Business Department. CIVIALÈ REMEDIAL AGENCY. Mailing and Shipping Departments, Business Offices, Consulting Rooms, 174 FULTON ST., NEW YORK. _Opposite St. Paul's Church._ Office and Consulting Hours: { 8-12 A.M. { 1-6 P.M. Sundays: 9 A.M. to 12 A.M. {Illustration: OFFICES, &c., CIVIALE REMEDIAL AGENCY.} The Civiale Urethral Treatment _CHAPTER I._ SPERMATORRHOEA--IMPOTENCY--STERILITY. The Baneful Effects and Consequences of Masturbation, Marriage Excesses, Venereal and Urinary Diseases on Boys and Men. Could we read the heart of every man and boy we pass upon the street, how few--how very few--there are that would not reveal sickening pictures of lust, disease, melancholy and insanity. Charnel-houses of sin and lust--sloughs of despond and regret--excess of passion offset by lack of power--dread, despair, hopelessness, shame and desperation, making a picture of misery scarcely to be conceived by any but those unfortunate beings who in the thoughtless, careless heyday of youth, or the reckless reliance on more mature vigor, have weakened, emasculated and enslaved themselves by indulgences and excesses that have borne fruit of misery, disease and desperation in after years. How little the youth who, in his ignorance of the terrible consequences of his vice, steals away to the secrecy of his chamber or his bed, leaving his happy, healthy and playful companions, in order that he may let the hot waves of lust and passion run riot in his mind, and dry up every spring of healthy thought and action--how little does he think of the after-time of misery and exhaustion that he is bringing upon himself--how little does he think that the vile demon that he is raising up will, like the vampire, suck his very life-blood, steal away his strength and life and vivacity, besmirch and weaken his mind, take the strength from his muscles, the courage from his heart, sap the very foundation of his existence, unsex and unnerve him, render him feeble, wavering and imbecile, dog his footsteps to the very steps of the altar, to curse and blacken and disappoint those joys of parentage and marital right that should be his. The shadow deepens with him as life advances, and follows him, bringing shame and misery and despair at every step, until the poor victim, driven too far, sinks into an early grave by disease or suicide, or is lost to the world and to all joys and friends behind the doors of an insane asylum. He died of no disease known to medical science. He simply faded away--weaker, more nerveless and hopeless day by day; he faded away until, almost before any one knew it, the grave yawned to receive him. Poor, miserable, hopeless wreck--poor suicide, for his own sin and crime were the real causes of his death. How many such there are at the present day. We meet them on the street, in business and at church. Our insane asylums are full of them. We find their wives unfaithful or unhappy; and their offspring--when they are cursed with any--poor, miserable, weak fledgelings, with aged, wasted faces, water on the brain, with rickets and softening of the bones--idiots or imbeciles--dying early and scarcely regretted even by the parent whose progeny they are, for every wail of the little suffering voice pierced his heart and reminded him of his lustful sin, and passionate, inexcusable indulgence that caused all this misery. "And the sins of the father shall be visited upon the children, even to the third and fourth generations." Alas, how true! how indisputable! The imperative Laws of Nature once broken, the consequences are _inevitable_. Of late years it has become the fashion amongst certain men to scoff at this terrible vice of secret indulgence, and to claim that its evil effects are overrated, are portrayed too vividly. Ask some poor unfortunate whose confidence you may succeed in gaining, and listen to the pitiful tale of lost health and vitality he will tell you. Mark well the wasted hand, the putty-like skin, the black-ringed, lack-lustre eyes, the heavy lip, the labored breath--read the consequences of his sin and crime in his shame-faced way, his shambling gait, his nerveless hands, his fluttering heart, his weakened muscles, and his tottering memory and mind. Must he needs lie dead at our feet before these skeptics can be convinced? Is not such a state a living death? Must these men visit him in the cell of the asylum, watch him as a raving maniac, gaze upon him as a hopeless idiot or a driveling imbecile, before they will be convinced? Such proof is at hand. Not an asylum in any country but has its score of such; not an asylum record-book but chronicles the sad histories of thousands of these poor, lost creatures--male and female; not an asylum nurse or doctor but will sadly point out these creatures to you, bereft of every trace of reason, all sense of shame, still practicing the horrible vice that has driven every semblance of humanity from their faces and the very light of reason from their eyes. True, every boy or man who practices this vice does not come to this end. But who shall discriminate? There are thousands such, and who shall say which it shall be, or at what moment it shall occur? Ah! happy, rosy-cheeked boy, so gay and thoughtless now, so free from misery, disease and care, beware! It may be your turn next. A little thoughtless indulgence, the imitation of friend or companion, though apparently harmless now, may blanch your rosy cheek, destroy your peace and happiness of mind, and make a life-long, hopeless, suffering invalid of you--may shut the door of all earthly enjoyment in your face, blast your hopes, disease or destroy your offspring, alienate you from friends and family, and cut off from all communion with your race, make you an object of shame and disgust to your fellow-men, sink you into an early grave or entomb you for life in the cold stony walls of a lunatic asylum. The day will come, erstwhile, when you will curse the parents who reared you, the friends who surrounded you and the teachers and ministers who taught you, for not warning you of the terrible nature of this indulgence, so secretly common amongst boys and young men. The day will come, when in the midst of your mental, moral and physical agony, with weakened mind and exhausted body, physicians will tell you that masturbation is practically harmless, that its consequences are exaggerated, and that your sufferings are mostly imaginary. Then will you pity their ignorance and bemoan the fact that to such men must sufferers in your terrible extremity apply without any feeling of being understood, appreciated or sympathized with, and, far less, relieved or cured. Happy will you be then, if you can (with your vice and misery staring you in the face and threatening you with some or all of its dire consequences) direct your steps to those who not only can and will sympathize with you, but who are able to aid you with proper remedies and restoratives and set you safely on the way to health and happiness again. For there _are_ proper aids and remedies; there are hope and happiness to be obtained if the affections growing out of this vice be skillfully taken in hand in time. None but the hopeless sufferers who have been lifted from the misery, shame and weakness of their self-inflicted suffering know how much this world owes to the high medical skill, exhaustive study, and persistent search for truth and proper remedies of those two great Frenchmen, +Professors Claude Lallemand+ and +Jean Civiale+. The medical as well as civil honors conferred upon them by their country and their medical brethren, great as they were, could never half repay them for the good they rendered thoughtless youth and suffering manhood by their special discoveries. There can be no question but that the +Civiale Urethral Crayons+, named thus after this great specialist, and endorsed by the most eminent medical men of France (that country in which lust and passion are peculiarly prevalent), are the most far-reaching and reliable specifics for Generative, Sexual and Nervous diseases known. CAUSES OF SPERMATORRHOEA AND IMPOTENCY. SELF-ABUSE NOT THE ONLY CAUSE. Many years' experience in the treatment of these debilitating diseases has proven very surely that there are many causes besides Self-Abuse (Self-Pollution, Secret Vice or Masturbation) for Spermatorrhoea, Impotency and Debility or Lost Manhood. Self-Abuse is the most common cause, and we therefore give it the most prominence. The others we will name briefly in about the order of their frequency. 1. MARRIAGE EXCESSES.--A very common cause, more often producing Impotency (loss of Sexual Desire or Power) and Sterility (inability to beget offspring), than Spermatorrhoea (loss of vital fluid, daily and nightly losses, losses in the urine, nervous prostration, debility, insanity, paralysis, &c. For full description of symptoms, see pages 12-16). Sexual desire was given to mankind, like any other power or appetite--to be enjoyed in reasonable moderation _and for the purpose of insuring a continuance of our species by the birth of offspring_. Many men abuse this power--abuse it inordinately, shamefully--and suffer the consequences. This is especially true of the newly married, and men advanced in years, who push their failing powers too far. As a just retribution for the abuse of so important a function, the Almighty deprives some of desire, some of power, some of both. 2. ONANISM.--By many this is confused with Masturbation or Self-Abuse. While like it in some respects and in many of its consequences, it is still different. It is as hurtful to an adult as abuse is to a young person. God punished Onan for this sin, hence its name. Yet, despite this terrible example so plainly set forth in the Old Testament, probably one-half of the married men of the present day are pursuing it, and hence so many Impotent and Powerless persons, seeking vainly amongst the many cheap, quack remedies for something to re-invigorate and re-vitalize them. This is a terrible vice, terrible in its consequences, and however hardy and robust the man, sooner or later his sexual powers must and will succumb to the strain. Many men write us, saying that they never masturbated, and yet are totally impotent and cannot understand why it is. And yet they have been thus injuring themselves for years! Sexual power and desire were given us for one purpose--the perpetuation of our species, and whoso endeavors to avoid this, must suffer. Many married couples do not want more children, from care, poverty or other causes, and hence the extent to which this terrible practice is indulged. It _must_ be from ignorance, for were it commonly known how injurious this practice is, _but few would dare take the terrible risk_. And yet the resulting weakness can be speedily cured if properly treated. In no class of cases have the Civiale Remedies achieved greater success than in these. 3. ANYTHING DEBILITATING--such as Overwork, Confinement, Sedentary Occupations, Worry, Care, Excitement, &c., &c.--These are much more common causes of Sexual and Generative Diseases than is generally supposed, and usually very obstinate and difficult to treat, because the system is so run down that there is very little stamina or vitality to rely upon. Clerks, business men, lawyers, bankers, ministers and students are very subject to this form of impaired vital and sexual power. Theological students are very prone to it. Many do not have any idea as to what their real trouble is, and lose much valuable time in doctoring for Dyspepsia, Consumption, Neurasthenia and the like, when really their very life and vitality are oozing away from them in their urine or otherwise. 4. WOMEN'S (OR VENEREAL) DISEASES.--Gonorrhoea (clap), Gleet, Stricture, Injury to the Urine Canal from the rough use of sounds, bougies, catheters, &c., &c. Any one or all of these, by extending the inflammation backward to the seminal ducts and neck of the bladder, may cause either Spermatorrhoea or Impotency. Indeed, Stricture (often caused by Self-Abuse) is one of the most common causes of these complaints. It was here that +Lallemand+ and +Civiale+ found the key-note of the true treatment of these diseases. 5. VARICOCELE, or a wormy, swollen or twisted state of the veins in the bag, and of those that run down to the testicles, is a very common cause of both Spermatorrhoea, Impotency and Debility. (For full description of this very common and often unexpected disease, send for our illustrated pamphlet on the subject, or see Chapter XI, page 44 of this book.) No man or boy with Varicocele, no matter how it was produced, can be perfectly sound and strong in his Sexual Organs. 6. UNDEVELOPED, WASTED OR MISSHAPEN PARTS.--A failure to have perfectly developed organs sometimes dates from birth, but in most cases it is caused by self-abuse at a time when the person is growing. In any case, Seminal weakness and Wasted or Misshapen Parts go together as both cause and effect, and the one, when found, will usually very soon lead to the other. _Twisting or Curving_ is one of the most positive signs of previous inflammation, stricture and twisting or distortion of the seminal ducts, and hence sterility or barrenness. In such especially are the remarkable effects of the +Civiale Treatment+ the most noticeable. We can say with positiveness, and prove it by case after case, that by no other method can such rapid and perfect restoration of the organs to a natural and healthy state be obtained as by this. Some of the very worst and apparently most hopeless cases that we have had--cases that have gone from one physician to another without the slightest improvement--have yielded effectually to the +Civiale Remedies+. In some of them the persons thus afflicted would have been totally unfitted for marriage had they failed to find relief. Their children--healthy, happy and finely developed--speak volumes for what our treatment has done for them. (For Treatment refer to page +42+ of this book.) IMPOTENT OLD MEN-- THE SEXUAL DECAY OF ADVANCING AGE. We have thus far given briefly the most common causes of Seminal Disease. There are a few that we have not mentioned: Blows on the Head, Loins (Small of the Back), Testicles, &c.; Weakness caused by prolonged illness, fevers, &c.; Malaria, Consumption, &c.; the abuse of Tobacco, Opium, Alcohol and Chloral, &c., &c.; but these are less common and less important. There is one condition, however, that we have only referred to incidentally, and that is the failure of Sexual Power in men past middle age. No man (if he is reasonably careful and does not abuse himself) should find his powers decaying before he is seventy or eighty years of age. Mind, we do not say "no man does," but no man "_should_," provided he is reasonably careful. But here comes the fact. Most men are _not_ careful, and most men _have_ abused themselves at some period. Many believe and stoutly maintain that they "never had emissions or seminal disease, and it didn't hurt them." But it did, and it is just now that they begin to feel it. It is true they escaped the more acute and direful effects, but it told on them in after years. There are many thousands to-day who are just now feeling the effects of early vices, now almost forgotten. They can be restored to _natural_ power by proper treatment, but they rarely are, because but few of them believe that early self-abuse or later Onanism has anything to do with it. So they spend a fortune almost--and uselessly too--on Stimulants, Nervines, Tonic and the like, but still remain partly or wholly Impotent. Foolish men! _CHAPTER II._ THE VITAL FLUID What it Is, What it Does, and How it is allowed to Drain Away, Weakening, Emasculating and Dementing the Vicious and the Careless. Diurnal (daily) Emissions. Nocturnal (nightly) Emissions. Impalpable Oozings. Losses in the Urine. Losses while at Stool. Mistaken Gleet. There are thousands of weak, nerveless men, who do not know what ails them; thousands of invalids whose physicians are puzzled and perplexed by their symptoms, and cannot account for the rapid waste of strength, energy and vitality, much less check it; and thousands of others, on the street, in the pulpit, on the bench, in the counting room, whose troubles, illness and misery are due to losses of vital fluid. Some know it, many more do not. Some are being properly or improperly treated for it; many are being dosed and drugged for Malaria, Neurasthenia, Consumption, Overwork, Brain Troubles, Paralysis and many equally as foolish and irrational complaints. They sicken, die, destroy themselves in hopeless despair of ever getting well and strong again, verge into hopeless idiocy or go raving mad, simply because their trouble is not understood; because day by day and hour by hour there is draining from them in their urine, at stool and otherwise, that precious vital fluid that represents life, health and energy to them. {Illustration: Fig. 1. A HUMAN TESTICLE. Perfectly Healthy. [From Gray's Anatomy.] Each _lobule_ may be seen (carefully guarded from pressure or injury) in its cell, with a strong fibrous partition on each side. All these _lobules_ empty into small ducts which converging form the _Globus Major_, _Epididymis_ and _Globus Minor_, which finally end in the _Vas Deferens_, _Cord_, _Duct_, or _Tube_ that conveys the fluid to the Seminal Vesicles at the back of the bladder. (See _Figs._ 5, 6.) As the veins of a _Varicocele_ surround these delicate _lobules_ as well as _fine tubing_, it can readily be seen how easily such pressure, weight and crowding may do very serious injury and make the flow of semen irregular, or shut it off altogether.} {Illustration: Fig. 2. HUMAN SPERMATAZOA. [From Gray's Anatomy.] A. Healthy, well developed and active zoa-sperms from the _Vital Fluid_ of a strong, robust man. B. Showing cells and bunches, in which form they are secreted or made by the testicles.} And is it surprising that the continual losses do drain away strength and vitality? This fluid is the only one charged with _life_--actual _life_; capable of producing _life_--of creating offspring--of impregnating and developing into perfect being, with thinking and reasoning brain and mind, pulsating heart, expanding lungs, sentient nerves, motive muscle, and all that beautiful, minute and co-ordinate mechanism that forms a perfect human being--the only secretion in the body capable of propagating species--carrying _life_ within _life_. Surely this was not meant for waste. Surely the influence of its loss upon the system, especially of a boy or young man (growing and not fully developed), must be great, and it is. Many and many a young man thus wastes away before the eyes of his friends from no other cause. Many a one loses health and strength from this cause alone, yet does not know it. How much better if all this false modesty, social hypocrisy, and blundering medical dosing and drugging, without thorough examination and full understanding, were wholly done away with, and the young men, and old men too, were brought to understand two cardinal facts: (a) The immense devitalizing effects of even small continued losses of vital fluid, and, (b) The fact that many apparently strong and healthy, as well as weak and nerveless, men who find their sexual powers gradually or suddenly failing them, can, in nine cases out of ten, trace it directly to losses of vital fluid in the urine or otherwise, that have been going on--perhaps wholly unknown to them--for months or years past. (See also chapter on "Hidden Spermatorrhoea") ANALYSIS OF URINE. At the first symptom of Sexual Decay or Nervous Exhaustion, the person thus affected should have his urine carefully and thoroughly analyzed by some competent person. In saying "competent person," we speak advisedly, for but few chemists and fewer physicians are competent to make such an examination and draw correct deductions from what is to be found there. Any person can, with the proper reagents, test his urine for the presence or absence of semen, but he cannot make the thorough, scientific, chemical and microscopical analysis that is sometimes needed in order to arrive at a full and perfect diagnosis and successful treatment. {Illustration: Fig. 3. URINE OF A YOUNG MAN SUFFERING WITH SPERMATORRHOEA. 1. Epithelial Scales from the Prostate Gland. 2. Scales from the Kidney Tubes. 3, 4. Scales from the Kidney Tubes swollen and degenerated. 5. Spermatazoa, wasted, shriveled, imperfect and dead. (In this case the Varicocele had extended up the cord.)} If losses of semen are taking place in the urine, it would be well to forward a sample of it at once, for a full and extended analysis, which will be made for the nominal fee of $2, merely to cover the cost of chemicals. Our Chemical Laboratory is under the supervision of Mr. G. H. E. Du Bell, Ph.D., a thoroughly competent quantitative and qualitative analytical chemist, a graduate of the French and German Universities and also a licentiate in this country, who, with his able corps of assistants, makes all examinations and reports in full upon them to the Medical Chief of Staff, who in turn submits them with the histories of each to the full Consulting Board or Staff. _CHAPTER III._ THE FORMS, SYMPTOMS AND CONSEQUENCES Of Masturbation, Spermatorrhoea, Nervous Exhaustion and Spinal Irritability. In no disease known to us are the symptoms precisely the same in every case. They vary with the constitutional peculiarities of the individual. Yet in nearly every case there are certain prominent or leading symptoms (signs) that are rarely absent at _some_ stage of the disease. We give here the more noticeable ones at first laid down by +Lallemand+, the great French physician, who first gave us the name "Spermatorrhoea," who first wrote upon this disease, who was the first to discover the connection between the losses of semen and certain symptoms here given, and who, too, was the great originator of that treatment so successfully perfected by his successor, +Prof. Civiale+, and which is now the _standard_ treatment, recognized and adopted in all the French hospitals. OBJECTIVE SYMPTOMS DUE TO MASTURBATION. First, as to the appearance and actions of the +Masturbator+--he who is constantly and recklessly drawing drafts of exhaustion and decay on the nervous energy and strength of his coming manhood, and which are sure to bankrupt the most robust health. If there is a man to be pitied on this earth, it is he who is walking about from day to day conscious of being guilty of ever having practiced this vice. Mark the man who is addicted to it in no matter how light a form; _his face tells the story of his sin_. See his +haggard looks+, his +deep, sunken eyes+, which he throws only half-way into the countenance of his friend. _Note the +blue+ or +black discolorations+ under the +eye+; the +nervousness+ to get away from a crowd, and the extreme +girlishness+ or +backwardness+ when +introduced+ into the +company of ladies+._ The victim of the most dangerous of all vices soon reaches a state which, if not promptly relieved by the proper remedy, will end in life-long misery or an early death. Objectively considered, the masturbator is recognized by a marked facial expression, by a characteristic mannerism, and by a peculiar mental state. THE FACE.--_The +facial expression+ consists of a +pale+ and +sallow tint+ of the skin, unusual +development+ of +acne+,--red pimples,-- especially on the +forehead+; a +dark circle+ around the +orbits+; +dilated+ and +sluggish pupils+; +lustreless eyes+, and an +oblique line extending+ from the +inner angle+ of the +lids transversely+ across the +cheek+ to the +lower margin+ of the +malar+ (cheek) +bone+. The +face+ has a +haggard, troubled, furtive expression+._ THE MANNER.--_The +manner+ of the +masturbator+ is peculiar. He is +listless, shy, retiring+, and +easily confused+; he +avoids society+, preferring +solitude+; there is a want of +steadiness+ and +decision+ in his +locomotion+; his inferior +extremities+ seem +deficient+ in +power+, and all his movements betray +a mind ill at ease+._ THE MIND.--_His +mental operations+ are +confused+; his +speech is embarrassed, awkward+, and +without directness+; his +memory+ is +defective+, and he is +absent-minded+ and +given+ to +reverie+. If the habit has long existed, and been excessively frequent in repetition, +epilepsy+ may be produced; or +serious mental disorder+, as +delusional insanity+, +dementia+, etc., may occur._ THE SEXUAL ORGANS.--The state of the +genital organs+ varies with the length of time the habit has been indulged. In some young subjects, there will be observed an _+extraordinary development+ of the +organ+_, owing to premature excitement; but the disproportion is not maintained. Prof. Barthalow says: "With the progress of the habit the organ becomes _+small+ and +relaxed+, the +erections feeble+, the +corpora cavernosa+ either +waste away+ or their +vessels+ lose their +tonicity+, whereby an apparent +shrinkage takes place+; the +corpus spongiosum+ and the +glands+ also +shrink+, so that the +prepuce+ (fore-skin) appears +unnaturally elongated+. The +testes+ may +increase+ in +size+, become +tender+ and +irritable+_, or they may waste away to nothing but little strings; the latter is the more usual result. "_+Pains+ in the small of the +back+, a sense of +weight+ and +aching+ in the +loins+, around the +anus+, and in the +testes+_ is experienced. _The +appetite is capricious+, the +digestion feeble, and the bowels+ are +constipated+_, or constipation alternates with diarrhoea. "_The+ mind+ is +deficient+ in +power+ of +attention+, the +imagination is constantly pervaded with vague erotic dreams+, the +moral sense+ is +blunted+, and the +perceptions+ are +dull+ and +confused+. +Pains+ in the +head+, in the +occipital+ and +frontal regions+ (front and back of head)_, and a sense of fullness, and in serious cases _alarming +Vertigo+ (dizziness and falling); +pains+ in the course of the +principal nerves+, and an extreme +nervous susceptibility+, are experienced. The +organic nervous system+_ manifests a functional disturbance in harmony with the disorder of the nervous system of animal life. _+Gastralgia+ and +abdominal pain+ (pain in stomach and bowels)_ and +uneasiness+ are in some cases very distressing symptoms. "The distinctiveness of the foregoing symptoms will be determined by the extent and duration of the habit, and by the constitutional peculiarities of the patient. +The more highly developed the nervous system, and the more it preponderates in activity over the muscular and digestive systems, the more serious the effects.+ EFFECTS OF MASTURBATION ON THE MIND "The most serious +mental effects+ are produced by +masturbation+. This vice, commenced at or before the period of puberty, interferes seriously with the development of the brain and the evolution of the mental faculties. "That +spermatorrhoea+ will produce in one class of cases +mental disorders+, and not in another, indicates either that some predisposition to these disorders existed, or that the habit of +self-pollution+ was merely an expression of +mental alienation+ (insanity). The +images+ which pervade the minds of boys possessed of the highly-developed nervous organization of masturbators are those of +delusional insanity+. "There is, however, a +cerebral+ (brain) +phase+ of spermatorrhoea which may be separated from the two preceding classes. It is characterized by _+indistinctness of vision+, +dilatation+ of the +pupil+, +amblyopia+ (near-sightedness), +diplopia+ (double sight); +diminution+ in the +sensitiveness+ of the +auditory apparatus+ (deafness); +feebleness+ of +voice+; +mental preoccupation+, +hebetude+ of +mind+, +confusion+ of +ideas+, and a +profound melancholy+._ "The termination of such cases is in _+suicidal monomania+, +delusional insanity+, etc._ In that variety of the cerebral form in which a decided predisposition must be admitted to exist, to disorder of the intellectual faculties, there are found various forms of mental alienation. The +chronic form+ is the most common, which corresponds to the _+melancholia+ of +Pinel+, or the +lypemania+ of +Esquirol+, terminating in +dementia+._ Several of the most characteristic cases which have happened under my observation correspond to the _+delusional insanity+ of +Bucknill and Tuke+_."--[Manual of Psychological Medicine, Phila. ed., p. 103.] INSANITY FROM SPERMATORRHOEA. Many writers are disposed to underrate the importance of this tendency in spermatorrhoea. The statistics of any of our large insane asylums will illustrate the influence of masturbation in the production of insanity. Mr. Holmes Coote, in a discussion which followed Dr. Drysdale's paper on the "Medical Aspects of Prostitution," read before the Harveian Society of London, remarked that "he still entertained the opinion that there were no worse evils appertaining to human weakness than this. He had opportunities of witnessing the fact that among the young there was no cause of insanity more common than indulging in habits which he would not further particularize, but which were known to result in the most complete bodily and mental prostration."--[British Medical Journal, Feb. 17, 1866.] Dr. John P. Gray, the distinguished Superintendent of the State Asylum at Utica, New York (Twenty-Fourth Annual Report, 1867), thus speaks of the +influence of masturbation+ in the production of +insanity+: "The records of this institution show five hundred and twenty-one cases admitted directly attributable to this vice, and I am well convinced that the number is greatly understated." We might add confirmatory testimony from a variety of sources, but the foregoing is sufficient for our purpose. IMPORTANT.--_Peculiar, numb, dead, aching, or tingling sensations in the hands, arms, legs or feet, and headache and specks before the eyes on stooping or reading; also sleeplessness, too sound sleep, and apprehensive dreams should be watched for, and the moment they appear danger from Paralysis or Insanity is to be apprehended and proper treatment at once taken. These symptoms may mean nothing in some cases, but they are terrible harbingers of ill in others._ A CASE OF INSANITY FROM SELF-ABUSE.--(_Fig. 4._) The following case, taken _verbatim_ from the Care Book of the Insane Asylum at Blackwell's Island, will serve as a _type_ of the many to be found in every hospital for the insane in this country. (_And a terrible and noteworthy fact is, that according to the recent annual reports of these institutions, both in this country and Europe, insanity, idiocy and dementia from Seminal Losses and Sexual Abuses, are increasing from year to year._) {Illustration: Fig. 4. Appearance of James McC----, a few weeks before he died. (See below.)} "James McC----, admitted to the Asylum ten days ago. Single, clerk, born in N.Y. State. Was found on 6th Avenue surrounded by a crowd who were attracted by his violent and frantic efforts to destroy everything within his reach. On being arrested and taken to the 29th Precinct Station House, he was recognized by the Sergeant on duty at the desk as having been arrested twice before within a week--once for violent shouting and disturbance in the street, and once for an attempt at suicide by drowning. As he had attempted his life by hanging the last time he was locked up, and had afterwards seriously injured himself by trying to dash his brains out, he was adjudged insane, and a watch set on him all night. In the morning, when taken before the magistrate, he was violent and abusive, using the most frightfully obscene and profane language. There he was held for examination and sent to Bellevue in a "straight-jacket," which was found to be necessary in order to control him. From the padded cell there he was sent here. "Upon examination he is found to be suffering from acute mania, alternating with periods of intense melancholia in which he invariably attempts to take his own life. His language when excited exceeds in obscenity anything ever heard. During the intervals of quiet he is constantly practicing the vile habit which has undoubtedly been the cause of his insanity. He has lost all sense of shame and continues to practice before visitors, attendants and physicians. He makes no effort to go to the water-closet, and his clothes and cell are in a filthy and disgusting state. Ever since admission he has refused all food, and it has been necessary to feed him with a stomach pump. He is losing flesh and strength every day, and is fast wasting away. "From his relatives who have twice called to see him it was learned that his mental trouble came on very suddenly, although his memory and faculties have been failing for some time past. They say that he complained of sleeplessness, numbness and tingling sensations in the arms and legs, headache, and a peculiar itching of the skin, for months before any distinct symptoms of insanity appeared. They attribute it all to self-abuse, which he has admitted practicing from an early age. "AUGUST 28th.--Is now paralyzed in both lower limbs. Still violent. "SEPT. 3d.--Died this morning about 1 A.M. Is so emaciated that he is little more than skin and bones. _Rigor mortis_ entirely absent. Shortly after death the skin of the whole body changed to a dark chocolate hue." Truth is often stranger than fiction. What end more terrible than this! _CHAPTER IV._ SPERMATORRHOEA, OR LOST MANHOOD. SYMPTOMS. Spermatorrhoea may be conveniently divided into three stages. FIRST STAGE--IRRITATION, CONGESTION. In this stage the sexual organs of the brain and nervous system first begin to feel the strain of early abuse, overwork, confinement, sexual excess, or whatever the cause may be in this particular case. The Prostate Gland (_j_, _b_, _Fig. 5_) the Seminal Vesicles (_l_, _Fig. 5_), Cowper's Duct (_n_, _Fig. 5_), the Testicles and Spermatic Cord (_h_, _f_, _k_, _Fig. 5_), indeed all the sexual apparatus, including the bulbous sympathetic nerves lying just inside the spine, from the small of the back down to the end of the organ, become filled with dark, thick and stagnated blood. The Prostate Gland swells and becomes enlarged, the Seminal Vesicles become weak, baggy and filled with a thin, glairy fluid that oozes out into the urine and urine canal on any little strain, exertion or excitement; especially when, after being in the presence of the opposite sex, weak, feeble erections follow. The testicles become flabby and stringy and no longer make strong, healthy, fecund vital fluid. The constant calls upon them has exhausted them as also the nerves that gave them life, strength and vitality. A heavy dragging +weight+ is often felt in the +groin+, especially after walking or long standing. There is a feeling of +weakness+ and +exhaustion+ in the parts. Often +strange sensations+ shoot through the parts, and they are +cold+ and +clammy+ at one time, while +weak+ and +sweating profusely+ at another. {Illustration: Fig. 5. MALE ORGANS OF GENERATION. [From Acton's Celebrated Work on "The Reproductive Organs."] _Side view of Body cut in half lengthways_ showing the course taken by the +vital fluid+ from the +Testicle+ (where it is made) to the Seminal Vesicles (where it is stored). The penis is shown cut off at dotted line _g_. As shown here the +vital fluid+ secreted in the minute tubules of the healthy testicle is gathered into the vas deferens or conveying tube _k_, which passing through the groin dips behind the bladder _a_ and empties into the Seminal Vesicles or Storehouse _b_. From here it is thrown forcibly into the urethra (urine canal) _e_, when needed, and expelled anteriorly by the ejaculatory muscles of the urethra. To reach the urethra the Seminal Duct _m_ passes directly through the body of the Prostate Gland _j_-_b_. Upon the outside of the testicle, the tube or duct is found twisted and forming a slight bunch, known as the epididymis, _f_, _g_, _h_. It is here that the pressure of a +Varicocele+ is first felt--here that it succeeds _in cutting off the free upward flow of vital fluid_ by pressure on these soft branches of the duct, causing +emissions+ by varying and irregular pressure and +Impotence+ by constant pressure. When the +Varicocele+ becomes very large, it then destroys the delicate tubing or the testicle itself.} The general nervous system also feels the +strain+ and +drain+. +Memory and application+, +good judgment+, +decision of character+, and +clear-sightedness+ are not what they were. +Headaches+ are not uncommon. +Bashfulness and trepidation+, especially in the presence of females, is the rule. The person feels +clumsy+, +embarrassed+ and +ill at ease+. +Sleep+ is sometimes poor, there are occasionally +terrible dreams+, sometimes +lascivious ones+ accompanied by +emissions+, +drowsiness+ and a tired, languid feeling in the morning, and a +disinclination to rise+ and go to work are certain signs of +impending+ nervous exhaustion. +The eyes are dull and heavy+, often +black-ringed+ underneath. The pupils of the eyes are unequal--often very large--sometimes one small and one large. The hands tremble and perspire +easily+. The person is +absent-minded, melancholy, prone to brood, and fears the jests+ or ridicule of his companions. The +skin+, especially of the +face+, sometimes becomes +coarse and red, sometimes is pale and pasty+ and covered with +blotches or pimples+. There is sometimes +spasm at the neck of the bladder+, causing +some delay before the urine will flow freely+. Often it is passed in a +forked or twisted stream+, plainly showing the presence of either organic or spasmodic stricture. +Twitching of the muscles of the eyelid, face and limbs+ is often present, accompanied sometimes by +creeping sensations up the spine+, +flushings of the face+, +chills+ (slight), +dizziness and black spots before the eyes+ on stooping over and occasionally by neuralgic pains in the +head+ and about the heart. If unchecked, or if the baneful habit is still persisted in, the symptoms of the First Stage merge rapidly into those of the SECOND STAGE.--CONGESTION AND INFLAMMATION. Here all the symptoms of the foregoing stage are usually present, only somewhat more intensified. The +congestion+ and +irritation+ are +more decided+, the +weakness+ more marked, the +nervous prostration+ more decided. Any, many, or all of the following symptoms may be present, according to the degree of severity or the rapidity of the disease: +Emissions+ (day or night), +Oozing of a glairy fluid+ under excitement and imaginings, presence of the opposite sex, etc., +Partial+ and +Imperfect Erections, Desire to Masturbate+, Formation of +Evil Pictures in the Mind+, +Flushing and Chilliness+, +Stupidity and Tendency to Doze or Sleep+, +Mental Hebetude+, +Failing Memory+, +Lack of Power of Application, Energy or Concentration+, +Restlessness+, +Pain and Smarting+ in passing urine, +Wetting the Bed+, +Pain in the Kidneys+, +Headache+, +Pimples+ on the face or body, +Itching or peculiar sensations+ about the scrotum (bag), thighs, legs, anus, etc., +Wasting+ of the +Organs+, +Stringiness and Softening+ of the +Testicles+, +Dyspepsia+, +Sluggish Bowels+, +Torpid Liver+, +Failing Sight+, +Pains in the Head+ (front, top and back), Chest, Limbs, etc., Sensation of the +Bowels Falling Out+, +Dizziness+ on stooping over or kneeling, +Specks+ before the +Eyes+, +Erotic Dreams+, +Melancholy+ (developing sometimes into +Insanity+), +Numbness+ of arms, hands, feet or legs (precursors of +Paralysis+), +Twitchings+ of the muscles of the eyelids and elsewhere (sometimes ending in +Epileptic Fits+ or +St. Vitus' Dance+), +Timidity+, +Diabetes+ and +Deposits+ in the +Urine+, +Troubled Breathing+, +Indecision+, +Loss of Will Power+, +Bashfulness+, +Burning+ of the face, +Coldness+ and +Clamminess+ of the feet and hands, also of the +Scrotum+ (or bag), +Palpitation+ of the heart, +Early Loss of fluid during connection+, +Feelings of Gloom, Despondency, Hopelessness+ of a cure, or fear of impending danger or +misfortune+, +Tenderness of the Scalp+ and +Spine+, +Dryness+ and +Itching of the skin+, +Sudden Sweating+, +Sudden Nervous Trembling+, +Noises+ and +Reports+ in the ears and brain, +Weight+ on the brain, +Weak+ and +Flabby Muscles+, easily tired after slight exertion, +Desire to Sleep late+ in the mornings and +failure to be rested+ by sleep, +Weakness+ and +Torpor+ the day after a nightly emission has occurred, the +Oozing of thick white fluid+ from the urethra when +constipated+ or +straining at stool+, +Varicocele+, etc., etc. WEAKNESS AND WASTING OF THE ORGANS. As a rule the +organs waste away+ rapidly or become +curved, twisted, or misshapen+. Oftentimes the testicles +dwindle away+ to almost nothing. +Settled gloom+ and +melancholy+ pervade the mind, and +hallucinations+, +morbid fear+, +unnatural lust+, +groundless jealousy+ and a +morbid desire for solitude+ show themselves. Undoubtedly the list of promotive causes is considerably augmented by maltreatment and the employment of injudicious remedies. We should therefore suggest to all prudent persons the wisdom and importance of consulting _competent authority_ only. Self-enervation in the first instance brings about that irritability which evinces itself in +nocturnal discharges+, afterwards in inappreciable but exhaustive +diurnal discharges+, and subsequently in complete debility of the whole generative system. This seminal fluid, such indeed as it is--weak, effete and devoid of all generative power--is undoubtedly the fluid which the organs suffer to escape; and to prevent further its flow, as well as to give a healthy tone to the secretory and retentive vessels ought to form our first care. COUGH, CONSUMPTION AND GENERAL DEBILITY AND PROSTRATION. It is a curious pathological fact, that during the progress of Spermatorrhoea, difficulty of breathing, cough, and tightness of the chest, arising in many constitutions from the seminal disorder, have sometimes been actually mistaken for pulmonary consumption. The cough is often distressing, occasionally attended by an expectoration of an offensive kind. There is no doubt that many have been maltreated for consumption when Spermatorrhoea was the real malady. That the latter leads to the former is certain enough, but the stages and connections of the respective diseases have been grossly misunderstood by practitioners who have not had sufficient personal acquaintance with the indications of Spermatorrhoea. Remember that these continued seminal discharges of an involuntary character disorder every function of the animal economy, and it may be added that while Spermatorrhoea produces so many ruinous effects peculiar to itself, it aggravates and excites any other disease which may co-exist with it. The +features+ become +pale, emaciated and haggard+. The +eyes are dead, sunken+ and lustreless, and in many cases hold in their depths +a look of wild, unsettled fear that denotes rapidly approaching insanity+. The +bowels+ become +sluggish+, the +appetite capricious+, the +muscles weak+, the +urine pale+ and with +a heavy sediment of semen+ that drains away in it almost constantly. +Emissions+ at night becoming more frequent and copious--sometimes bloody--although the fluid secreted by the wasted testicles is +scarcely stronger than water+. +Sexual incapacity shows itself.+ +Ejaculation+ is either +too quick+ or else very +long delayed+. The +skin+ becomes dry and sallow, the +liver congested and sluggish+. +The heart beats irregularly+, and any sudden sound, movement or fright sets it to beating violently. +Shortness of breath+ is complained of. +The brain becomes weaker and more sluggish day by day.+ {Illustration: Fig. 6. DIAGRAMMATIC REPRESENTATIONS OF THE TESTICLES, DUCTS, &c. Showing where the vital fluid is made and stored and how, and by what means it passes from the +Testes+ (where it is made) to the +Vesicles+ (where it is stored). The heavy black marks on either side of the urine channel, show the relative position of the ejaculatory muscles.} He generally loses flesh, and feels uneasiness in his stomach which suffers from many of the symptoms accompanying dyspepsia. He is easily startled; the slamming of a door, the firing of a cracker, the falling of a book, a sudden touch, or even speaking to him unexpectedly, will cause him to start. Cowardice is a sure consequence of Self-Abuse and involuntary emissions. The appetite is irregular, often poor, sometimes voracious; the bowels are also variable in their action. The prostatic portion of the urethra is frequently irritable and sometimes is very much +inflamed+; oftentimes there is a +thickening, a sponginess or puffiness+ of the parts immediately involving the ejaculatory ducts. The mucous membrane of the vesiculæ seminales becomes inflamed and thickened. The +testicles+ and the +spermatic cord+ are oftentimes very tender and the seminal fluid is much thinner than natural. Such a Patient has generally +dark spots under his eyes+, +a sharp nose+, and often +flushes of hectic color+ in his cheeks, particularly when in the presence of company, and there is more or less palpitation of the heart. In the second stage, as in the first, the pollutions are diurnal and nocturnal; the latter are copious and recur frequently. So insensible is the passage of semen that the patient is usually astonished and horrified on waking to find himself and +bedclothes saturated+ with this fluid, which is easily absorbed by the clothes, and rapidly dries up, because it has become thin, watery and effete. In addition to this loss he is subject to one equally great on almost every occasion of +urinating+ and +defecating+. This also takes place without any consciousness on his part, and his only knowledge of the fact is from the alarming weakness he experiences after passing water or going to stool. Distraction or absence of mind renders the judgment unfit for any extensive enterprise. The sexual powers are greatly weakened; the overtaxed organs refuse to fulfill their legitimate task; their susceptibility and irritability are so great that the power of retention is lost, and the seminal fluid is discharged prematurely. The generative organs are wasted and inactive, or so weakened as to secrete but a ropy, thin and glairy fluid, having few or none of the characteristics of Vital Fluid. Should the individual suffering this way--and either careless or unfortunate enough to go uncured--have offspring, they will assuredly be puny in body and weakly in mind, and will lead a miserable existence through the neglect and indiscretion of their parent. THIRD STAGE.--STAGNATION AND WASTING. This stage is an aggravation of the two preceding stages combined. The emissions are accompanied and followed by a disagreeable and disgusting sensation of shame and misery. The mind is absorbed as much as can be by the one idea of its wretched situation, and the sufferer is haunted by the thought that his condition and its cause are known to the whole world, and that he is pitied or scorned by every person he meets. He is hypochondriacal, and fearful suggestions of self-destruction ever and anon present themselves. The power of mental concentration is entirely gone and the memory is so feeble that the patient continually forgets what he begins to say. The dimness of vision is continual and so great as to be a material annoyance; the eyes are wandering or fixed upon the ground, seldom venturing to meet the gaze of another. The +ringing in the ears+, +pains in the head and over the eyes+ are almost perpetual and frequently accompanied by partial deafness. +The heart is the seat of pain+, +fluttering+ and +throbbing+ with +violent and long-continued palpitation+, his hands shake, his limbs tremble, his knees are weak, so much so that at times it is almost impossible for him to walk erect. He experiences an insatiable desire for sleep, and yet upon retiring he lies awake for hours, tormented by his troubled reflections, and at last falls into an uneasy slumber, of short duration, disturbed by wretched dreams. +Hard, red pimples+ frequently appear on the face, forehead and body, +scaly patches+ round the +ears, eyes, nose and lips+, a +black or bluish semi-circle+ shows itself under the +eyes+, and there is a hollow mark from the corner of the eye in a slanting direction under the cheekbone to the angle of the mouth, which tells its tale. The +skin is livid and clammy+ and the digestion is bad. The patient is tormented with +flatulency+, which he cannot always control and which he justly dreads, as it renders him an object of +disgust+ to all in his presence. The bowels are generally +constipated+, obliging him to strain much at stool, thus aggravating the irritation of the prostate gland vesiculæ seminales and increasing the +seminal losses+. The bladder is irritable and will retain the urine but a short time; the ureters and kidneys are also inflamed and in post-mortem examinations are sometimes found to contain +abscesses+; they are the seat of much pain when pressure is made over the intervertebral spaces of the dorsal and lumbar vertebræ or backbone. The vesiculæ seminales have +been indurated+ and can be felt to be +knotty+ and +hard+. The spinal marrow is very sensitive throughout its whole extent; the cerebellum is the seat of a +dull+ and +heavy pain+, and there is a feeling of pressure upon the brain. Cerebral congestion now and then occurs. This stage of the disease is frequently accompanied by +Bronchitis+ or a continued +Catarrh+, also by disease of the +rectum+ and all the +tissues near the generative organs+. It is hardly necessary to say that the functions of the nervous system are completely deranged, indeed, +nervous twitchings+ of the +eyelids+, +head+ and +limbs+ are the consequences of +Spermatorrhoea+. He is finally either hurried to a premature grave by consumption, epilepsy or apoplexy; or insanity, taking the hopeless form of dementia, has removed him from his home to the madhouse. It is safe to say that of all the cases of incurable insanity, a large majority are caused by Spermatorrhoea. Many, owing to +sheer neglect+ or to +false notions of delicacy+, delay seeking for proper medical relief until they are almost destroyed, and body and mind are nearly in ruins. Pitiable the picture of one who has +reached+ this stage of the disease. The organs are still congested but +irritability+ has given away to +torpor+ and +sluggishness+. Semen drains away by day and night without provocation, these constant losses dragging the person to the very +brink of the grave+, or +standing him+ within that +melancholy shade+ where +suicide+, +insanity+ or +idiocy+ almost certainly stares him in the face. The organs are wasted almost totally away. All +strength+, +vitality+, +erectile+ and +procreative power+ have left them, and the victim is at last totally +impotent+. Of no use to themselves, a curse to their freinds, a disgrace to society, they sink from sight into an early grave or are lost to the world behind asylum doors. It is a sad and terrible picture, but true--too true--to life. The tendency of Nature in most disorders is towards cure, but +here it is towards deterioration+. There is no chance here of the evil "wearing itself out" save in madness and death on the one hand, and on the other by the salutary intervention of the most +vigorous+, +cautious+ and +enlightened treatment+, a treatment pursued in the +full light+ of the aids afforded by the great discoveries in physiological science for which the present age is happily distinguished. Fortunately for humanity, by the aid of Chemistry, as well as Medical Science, it has been reserved for us to present to the public the +Civiale Remedies+, which have proved themselves undeniable blessings to thousands, restoring with unerring power those suffering from this hitherto baffling complaint. LESS SEVERE CASES. There are cases where the effects of early abuse are neither so rapid nor so severe. In many instances the persons, to all outward appearances, are strong and robust. They only complain of certain sexual symptoms that trouble them. But let them beware. Appearances are very deceitful. Let a sudden fit of illness supervene and see how quickly these apparently healthy men succumb and are swept away by it. Then, too, in many of these cases, he who to-day may seem strong and healthy, with the exception of his sexual weakness, may suddenly develop most grave nervous symptoms, and in less than a month be beneath the sod or hopelessly insane. Such cases have occurred, and one particular instance even as we write presents itself to our mind. Poor fellow, he died a raving maniac the very night he was to have been married to one of the most charming young ladies in New Haven. And yet he thought he was perfectly healthy. He only learned his true condition too late for human aid. HIDDEN SPERMATORRHOEA. In many cases the seminal ducts have become so weak and relaxed that the fluid passes off involuntarily with the water and is not perceived; also when straining at stool and when you have an erection. To test its escape in the urine, pass off your water in a clear glass pint bottle and let it stand twenty-four hours in a warm place; then hold up the bottle between yourself and the light, and if you discover a sediment of a +white, fleecy+ nature, resembling cotton, in the bottom, you are suffering from +hidden spermatorrhoea+, from which all your present ailments come. Where this fluid passes off with the urine, it is just as injurious to the system as full emissions, as it is a continual drain day after day, as well as taking that part of the vitality which goes to supply the brain and nerves. Many patients afflicted in this way will notice, shortly after urinating, a +dull pain+ in the forehead, sometimes extending to the +eye-balls+, causing, as well, a feeling of +general debility+, as if they had no strength or will to do anything. If this weakness is allowed to go on unchecked, the mind will become diseased, the eye-sight will be impaired, and the vital forces consumed--thereby causing +partial and complete impotency+. Should you desire greater certainty in testing, either send on a sample of your urine, or test it with our powder. The characteristic symptoms of partial impotency are: an imperfect erection, or, if the erection is sufficiently vigorous, it is of too short a duration, and the vital fluid is discharged prematurely. The erector muscles become paralyzed, and the organ remains inactive at the call of the will. The person thus afflicted is greatly embarrassed and mortified at his paralytic condition. That buoyancy of spirit is gone; the snap, vim and vigor that once held sway has departed--and why? Because that great motive power (amativeness) that gives the push and go-aheaditiveness is checked, or rather, ceases to act. THE CURABILITY OF SPERMATORRHOEA AND IMPOTENCY. Having before us the records of some three thousand cases, grave, simple and severe, that have come under our treatment in this country, as well as the printed copies of the +French Hospital Reports+, and +Civiale's Works+, in which he minutely reviews all phases of this complaint, illustrating them with cases from his own practice, we feel justified in assuring our readers that almost any case can be cured, provided +thoroughness+ is the maxim of treatment. The method of Profs. +Jean Civiale+ and +Lallemand+, as now perfected and extended by us, and so justly named after +Civiale+, stands unrivaled in its +success+ as well as its +simplicity+ and +reasonableness+. To all such as suffer from this harassing complaint we commend, first, a careful reading of the history of this discovery and the eminent medical men and hospitals that endorse it; and, second, a fair trial of these remedies, no matter how +hopeless+, +despondent+ and +despairing+ you may be. (See page 55.) Although the advertising and spreading, and the ringing to full perfection of this treatment is really due to us and our physicians, still we feel in duty bound to always keep in view the two great French surgeons who first discovered the method of +intra-urethral medication+. _CHAPTER V._ IMPOTENCY OR LOST POWER. Scarcely a day passes that we do not have some patient inquiring +"What is Impotence?"+--+"Are Impotence and Spermatorrhoea the same Disease?"+ +Impotency+ (from the Latin words _im_ [not] and _potens_ [to be able] means a condition of the Sexual Organs in which a man is not able to beget his species. It may be because he has lost his erectile power (and this is how it is most commonly understood), or because he has lost all desire, or lastly, because the +vital fluid+ has become so +weakened+ and +degenerated+ as to have lost its +procreative power+. Impotence is most common in men past middle age. It may come on as _the second or third stage of Spermatorrhoea_, or it may develop slowly or suddenly _without any symptoms of Spermatorrhoea_. It may be accompanied by various +nervous+ and +exhausting+ symptoms, or these may be _wholly absent_. If vital fluid is being lost, and the Impotence is due to the weakness thus caused, +nervous exhaustion+ is sure to come sooner or later. Impotence and Spermatorrhoea may exist together in the same person. Many impotent men have no other bad symptoms than simply this failure of the +sexual organs+ to respond when called upon. The trouble in these cases usually lies in the erectile muscles, which are +weakened+ or +paralysed+, and in the +nervous bulbs+ or +ganglia+, that are blunted or exhausted. A perfectly healthy man should be able to beget his species until he is +at least+ 80 years of age. Instances of such power at the age of 97 are on record. In these days of +exhaustion+, +early decay+, +excesses+ and +abuse+, most men begin to lose their power at or before 40. This is not right, and can +certainly+ be remedied by proper treatment. IMPOTENCY, COMPLICATED WITH BLADDER OR PROSTATE DISEASE. In such cases the Prostate Gland is usually congested, enlarged and irritated, and needs prompt and thorough treatment. (See page 26.) The tone of the nervous system is also lowered, even though it may not be apparent to the individual himself. Hence, some good, strong, special, general and sexual tonic, such as +Civiale's Tonic Regulator+ (see page 30) is needed, as is shown by the rapid improvement that follows its use, especially when combined with effective measures for strengthening the +erectile muscles+, invigorating the +Sexual Nerve Ganglia+, and reducing the +Prostatic congestion+. Some of the most remarkable cases of the thorough cure of Impotence and restoration to full sexual vigor that appear in the 53d Volume of the French Hospital Reports, were in men +past 60 years of age+. IMPOTENCY AND WASTING OF THE ORGANS. In many of these cases of impotence (as well as of Spermatorrhoea) the organs were either small and puny from birth or had wasted away as the disease progressed--just as a paralyzed arm or leg will waste away from want of use and exercise. Such cases, as also those where there is twisting or curving of the organ, need thorough developmental treatment. Such organs can be readily developed under proper treatment, just as the breast or a limb may be developed and increased in +size, strength and power+ by the use of the proper treatment. Those who have not kept pace with the advances of medical science abroad can scarcely realize how great her strides have been. To-day it is easy (especially in Sexual, Seminal and Urinary diseases) to do what ten years ago the majority of physicians deemed impossible, and to +Lallemand+ and +Civialè+ belong the highest meed of praise for their unremitting labors in bringing this branch of medical science to its present state of comparative perfection. As an illustration we can cite case after case that has been sent us by physicians in good standing as utterly beyond their skill, and we have returned their patients to them in a few months' time fully and +perfectly restored to sexual strength+ and +vigor+ as they, themselves, were obliged to admit. IMPOTENCY AT ANY AGE IS CURABLE. Do not despair then, reader, if you are thus afflicted and have made several trials and failed to find +health+ and +vigor+. The +Civiale Remedies+, while not infallible, have certainly done wonders for many so-called "+hopeless cases+," and we doubt not that you, too, can be perfectly restored. Submit your conditions and symptoms to our Board of Consulting Physicians, and at least get their opinion upon it. Certain it is that these remedies, brought to light by the eminent French savant, Professor in the greatest medical college in France, and adopted and endorsed by all the large Parisian hospitals and most eminent French physicians, +cannot possibly hurt you+, and +more than likely will cure you+. _CHAPTER VI._ BLADDER, KIDNEY, PROSTATIC AND URINARY DISEASES. Congestions, irritation and even inflammation of the Urinary Organs often occur in men, either alone or as a complication of Seminal Disease and Weakness. The Seminal Vesicles lie just behind the bladder, while the Seminal Ducts pass through the body of the +Prostate Gland+, and open into the urethra (or urine channel) upon its surface (see Fig. 5). Hence, any inflammation or congestion of this large gland that lies at the root of the organ and neck of the bladder, is almost certain to produce +Seminal Weakness+, +Losses+ and +Impotence+. It will be noticed that men past 50 years of age are often forced to rise in the night once or oftener to make water. This, and the delay that sometimes occurs before the stream will start, are usually due to enlarged +Prostate Gland+--a common condition in men past 50. Many and many a man at this age finds his +sexual power declining+ and cannot understand it--+Enlarged Prostate Gland+. As the gland enlarges and becomes stiff and its tissues hardened and brawny, it presses upon and deprives the Sexual Nerves of power and sometimes paralyzes them, causing total Impotency. How useless--worse than useless, even hurtful--are the usual remedies. The Prostate Gland must be softened, cooled and +robbed+ of its +inflammation+ before Anti-Impotency remedies can be of the slightest service. And here it is where the great success of the +Civiale Crayons+ is best shown: +The Prostatic Crayons melt, run down upon, soothe, quiet and allay the inflammatory and hardened gland+, while the +Impotence Crayons+ are +re-toning+, +strengthening+ and +re-vitalizing+ the Sexual Nerves, and strengthening the +erectile+ and +ejaculatory+ muscles. Perfect cure and perfect restoration are possible if +proper+ means are +properly+ applied. Spermatorrhoea likewise is both caused and complicated by +Prostatic+ and +Urinary+ inflammation. The Sexual Nerves are involved and weakened in the same manner as in Impotency, while, in addition the hardened substance of the Prostate Gland keeps the mouths of the Seminal Ducts open, and the +vital fluid+ runs away into the +urethra+ to be swept out with the urine, without let or hindrance. Soon this loss tells, not only upon the brain and nerves and general health, but upon the testicles where this fluid is made. So much is wasted that these two glands, work as they may, cannot supply a sufficiency of good, healthy fluid, and meet the difficulty by making a thin, watery infertile fluid that would flow away even if the mouths of the ducts were healthy. They do this at the cost of a terrible strain upon the whole system--they strain and injure themselves and grow +weak and flabby+ and finally +wasted+--often rupture small vessels in their substance, thus yielding +bloody or black seminal fluid+. The _CAUSES_ of Prostatitis or Prostatorrhoea are many and diverse. The most prominent are: _Gonorrhoea or Gleet_, running backward and settling in the gland or neck of the bladder; _Stricture_, deep in the canal, causing congestion and inflammation; _Masturbation_, by keeping the gland excited, congested and irritated, often causes it; _Exposure to cold and wet_, especially sitting on a cold door-step or damp seat; _Blows and Injuries_ of any kind; _Strong Injections_, and rough jabbing with steel sounds or rough bougies; _Eating Hot Condiments_, or too free indulgence in alcoholic beverages. VARIOUS COMPLICATIONS. If the inflammation extends to the neck of the +bladder+, he has an attack of +cystitis+. If it goes down along the seminal ducts, it produces +swelled testicle+, +clogged duct+, +chronic enlargement+, +cancer+, +cysts+ and hopeless wasting of the +testicles+. If it extends up the +ureters+, it causes +Bright's Disease+, +abscess+ of the +kidneys+, or +lumbar fistula+. If it runs forward along the urine canal, it produces so-called +gleet+. If it settles in the +prostate gland+ and becomes chronic, it may cause +abscess of the gland+, +retention of the urine+, and certainly either or both +Spermatorrhoea+ or +Impotency+. It may thus be seen how exceedingly dangerous a disease this +Prostatitis+ is, and how very important it becomes to check it at the earliest possible moment. SYMPTOMS.--We have space for but the most prominent and frequent ones: a +dull, aching, dragging+ or +throbbing pain+ between the legs, made worse by +standing, walking, jolting+, &c., and sometimes relieved by hard pressure, or lying down with one's feet higher than their head; pain, burning or smarting on passing urine; +twisting+ of the stream; the oozing of a thin, glairy fluid; +sticking+ together of the lips of the mouth of the urinal canal; +soreness, aching or tenderness+ of one or both +testicles+; dull pain or ache in +the small of the back+ or +buttocks+; +dizziness, sudden fits of exhaustion, convulsions, coma and death+. A +microscopical examination+ of the urine will reveal the nature of the difficulty in a moment. There also will be found evidences of great +nervous wear and tear, and seminal losses+, more or less constant. {Illustration: L'ECOLE DE MEDICINE, PARIS. The most celebrated Medical College in France, in which both +Civiale+ and +Lallemand+ were Professors.} GLEET AND STRICTURE AS A CAUSE OF SPERMATORRHOEA AND IMPOTENCY. These two diseases are probably less understood than almost any other equally common. It is safe to say that at least one man out of every ten has, has had, or will have one or both. Neglected gleet often causes stricture; neglected or improperly treated stricture often causes and keeps up a gleet. Another set of statements, equally sweeping and based upon the best of medical evidence, may be made, _i.e._, more cases of gleet and stricture are caused by Self-Abuse (masturbation, Onanism), and sexual excesses than by gonorrhoea--formerly and ignorantly supposed to be about the only cause. Furthermore, the main cause of both Spermatorrhoea and Impotence is Stricture (whether caused by self-abuse, gonorrhoea [clap], or any other excess). It was this very important point that +Lallemand+ guessed at, and that +Civiale+ definitely ascertained to be a fact--proved it by examinations of both living and dead subjects, and demonstrated it before the eyes of every member of the French Academy of Medicine, the most learned body of medical men in the world. Upon this discovery is based the now world-famed +Urethral Crayon Treatment+. It cures--absolutely, thoroughly and +Permanently+ cures--because it is based on truth; because the proper remedies are placed upon the very seat and fountain-head of the disease; where quickly and thoroughly it stamps out the fire (inflammation, from the Latin _in_, and _flamma_, to burn, to be a-fire) and eradicates the cause, at the same time healing the abrasions, releasing and invigorating the nerves, cleansing and unclogging the ducts, strengthening the erectile muscles--in a word restoring the whole Sexual Apparatus to its natural tone and strength; not harshly or violently, but gently, kindly, soothingly. Indeed it is a heavy debt of gratitude the sufferers from Sexual Disease and Weakness owe to +Professor Jean Civiale+--greatest of all French savants!! Were any further proofs necessary, the following facts, the results of recent experimental investigations by such men as ACTON,{1} BLACK,{2} GROSS,{3} HAMMOND,{4} BARTHOLOW,{5} DUPUYTREN,{6} ECKHARD,{7} LOVEN,{8} GALTZ,{9} OLLIVIER,{10} TROUSSEAU,{11} ERB,{12} OTIS,{13} WADE,{14} SIR EVERARD HOME,{15} LIEGEOIS,{16} TERRILLON,{17} FLEISCHMANN,{18} BEARD,{19} GRUNFELD,{20} GUYON,{21} ROSENTHAL,{22} LANDON CARTER GRAY,{23} and many others, could be cited in its favor. {Footnote 1: Diseases of the Reproductive Organs, Phila., 1876.} {Footnote 2: Renal, Urinary and Reproductive Organs, Phila., 1872.} {Footnote 3: Disorders of the Male Sexual Organs, Phila., 1883.} {Footnote 4: Impotence in the Male, New York, 1833.} {Footnote 5: Spermatorrhoea, Phila., 1880.} {Footnote 6: Dictionaire des Sciences, tom. viii, Paris, 1856.} {Footnote 7: Beltrage zur anat-uns Phys., Bd. iv. and Bd. vii.} {Footnote 8: Arbeiten aus der Phys. Austatt, zu Leipsig, 1866.} {Footnote 9: Pflueger's Archlv, Bd. viii.} {Footnote 10: Traite des Maladies de la Moelle Epiniere.} {Footnote 11: Chu. Méd. de l'Hotel-Dieu de Paris.} {Footnote 12: Ziemssen's Cycloped., Amer. Edit., 1876.} {Footnote 13: Stricture of the Male Urethra.} {Footnote 14: Stricture of the Urethra; its Complications and Effects.} {Footnote 15: Practical Observations, &c., &c.} {Footnote 16: Medical Circular and Gazette, 1869, page 381.} {Footnote 17: Annal. de Dermatol, et Syphiligraph.} {Footnote 18: Wiener Med. Presse, 1878.} {Footnote 19: Medical Record, 1879, page 184.} {Footnote 20: Endoskopische Befunde bei Erkrankungen des Samenhugels Wein, 1880.} {Footnote 21: Bulletin Génerales de Thérapie, 1867, page 501.} {Footnote 22: Wiener Klinik, May, 1880.} {Footnote 23: Archives of Medicine, October, 1880, page 191.} STRICTURE THE RESULT OF MASTURBATION, AND THE CAUSE OF WEAKNESS AND IMPOTENCE. In brief it may be stated that +Masturbation+ in early life, and sexual excesses at a later period, may, and do produce +congestion+, +inflammation+, +spasm+, +ulceration+, +granulations+, +ulcers+, and both +spasmodic and organic strictures+ of the urethra; that +Spermatorrhoea+ and +Impotence+ are due to this condition, and that the only really rational treatment is that which directly medicates and heals these parts. This, +Civiale's Soluble Urethral Crayons+ do, better and quicker than anything else. Prof. GROSS,{24} for instance, says: "Exclusive of these cases, my notes show that 13 out of every 100 cases of stricture are due to Onanism;" and OTIS{25} says: "9 per cent. of all cases are traceable to that practice." REEVES, HENRY SMITH, GOULET, PHYSIC and LEROY give masturbation as a cause of stricture. BLACK states a like case leading to sexual incapacity, as a result of the stricture. WADE says: "In several instances of the kind, +where there had been no sexual intercourse+, the strictures, which were at the bulb, proved more than usually refractory from the extreme morbid sensitiveness of the whole urethral canal." Gross goes on to say, that in at least eight out of every ten cases of +Spermatorrhoea+ or +Impotence+, stricture of the urethra is the cause of the trouble, whether the stricture is due to gonorrhoea, gleet, etc., or to +masturbation or excesses+. {Footnote 24 _Op cit., page 25._} {Footnote 25: _Op cit._} THE CIVIALE PERFECTED AND COMBINED TREATMENT. How senseless, then, to endeavor to cure such conditions with stomach medicines. Still, the CIVIALE method does not wholly discard them. They have their place and their purpose, and served it well. It was his practice in many cases to use +Nervines+ and +Tonics+, as well as +Digestives+ and +Laxatives+, by the stomach, and with excellent results, for in many of these cases the +digestion was poor+, the +liver torpid+, the +bowels sluggish+ and +constipated+, and +filled with wind+, the +appetite capricious+ and +uneven+. +Crayons+ in the urethra could not wholly cure these symptoms, although they stopped the drain that originally caused them. Combined with the +Tonic-Regulator+, the results were prompt and satisfactory. +Many patients began to recuperate the moment the inflammation, stricture, ulceration and accompanying losses of vital fluid were stopped, and were soon in robust health again+. In others, however, he found it best, +at the same time that he was healing the diseased+ urethra, to +clear and invigorate the debilitated nerves and weary minds, to tone up the stomach and bowels, set the liver gently working, start the kidneys+ (nearly always congested), +and infuse new life, strength and vigorous impulses into the whole system by means of his Tonic-Regulator+, which is a pleasant and most efficacious combination of +tonics+, +laxatives+ (not purgatives), and +deobstruents+. +Skin, kidneys, lungs, heart, mind, nerves, stomach, liver and bowels, were all set to working right+. And, as a consequence, aided by the urethral remedies, the +losses ceased+, erectile power and +sexual vigor returned, the step became buoyant and elastic, the mind clear, the memory retentive, the eyes clear and bright, the lips and cheeks ruddy with healthful color; the whole system, indeed, renovated, refreshed and re-invigorated.+ _CHAPTER VII._ THE DUTIES, RESPONSIBILITIES AND FAILURES IN AND OF MARRIED LIFE. What more perfect or pleasing picture than that of happy married life. Yet how little of it we see! How the newspapers dish up to us in strong words the misery, despair, wretchedness, infidelity and deceit of the divorce court. How it stares at us from the desolate fireside of friend and acquaintance; is hinted at or suppressed by the records of the Coroner's office; leers at us from the sumptuous mansion of the affluent; lurks in the humble cottage of the mechanic. How sad the contrast between the home where nestle happiness, love, contentment, offspring; and the abode of suspicion, deceit, infidelity or barrenness. And yet men and women are being married every day, every hour--ay, every minute. Men and women incompatible physically, mentally, morally--urged on by lust, cupidity, love; to escape unhappy homes; to hide sad sins--for a thousand reasons, some good, many bad--are constantly marrying. A man selects a wife less carefully than he would a horse; a woman yields herself, her life, her happiness, blindly, unreasoningly, to a man of whom she knows nothing. A man better fitted for the hospital, the infirmary, or the insane asylum, enters the bonds of wedlock with never a thought of the consequences; with never a care as to whether he will wreck his own life and happiness or that of the innocent girl he is deceiving; with never a heed of the ill-starred, diseased, puny or idiotic progeny his act may bring into being, a burden to the community, a curse to himself and a constant reminder of the parent's foolhardiness--ay, even crime! No man who is affected with any form of Sexual or Venereal Disease should for a single instant even think of +marriage+ until every +trace+ of his +weakness+ or +disease+ has disappeared. In these days of medical advance in this special field, there is no excuse for such action. There are few--very few--cases of Seminal Weakness and Impotency that cannot now be cured. Of course, here as elsewhere, there are traps and humbugs, quacks and charlatans, false theories and empty moralizing; but there is also truth and knowledge, hope and certainty for such as are sufficiently in earnest to search for them. Prof. Civiale, by his indomitable perseverance, thorough study and experiment, and final conclusions and discoveries, has placed the means of a perfect restoration to full mental, bodily and sexual vigor within the reach of all, and no man has any right now to enter either blindly or wilfully into so sacred and important a relationship as marriage, and to lower and stultify its ends by blighting the happiness of a fair young wife, exhausting his own vitality in the vain attempt to have offspring, or in having such as shall be a curse to him through life. There are those (let it be hoped they are really honest in their ignorance) who look upon marriage as the only real cure for Seminal Weaknesses. Even if it were a fact that the marital relations did accomplish such a result (and they never do, as bear witness the thousands who are to-day weak, exhausted, ex-sanguinated, unhappy, nerveless, hopeless wrecks, who are cursing the ignorant pretenders who gave this false--this fatal advice); even if such a result was a certainty, what right has any man to besmirch and soil the purity of a happy and innocent maiden for such a purpose? By what law of humanity are woman's hopes and happiness to be hazarded on so fragile a basis, her bark of life to be launched into a pool of such sickening bestiality? Such marriages bear and are bearing deadly fruit before our eyes day by day, in infidelity, abandonment, suicide, insanity, crime and prostitution--in disease and misery, even to the third and fourth generation. A SPECIAL SET OF PRE-MARITAL (Before Marriage) REMEDIES. No more delicate or wonderful piece of mechanism, no more grandly conceived and wonderfully perfected bit of God's handicraft is to be found than the Male and Female Sexual Organs. It is a wonder to those who have made these parts (with their elastic vessels, cavernous sinuses, network of nervous ganglia and fibrillæ, chain of lymphatics, periodical ovulation, timed pubescence, and perfected, co-ordinate functions) a study, that they stand abuse and excess so well; that the fierce blasts of lust and passion that sear and scorch them and well-nigh dry up their fountain springs of vitality and fecundity, do not wholly destroy or hopelessly disarrange their delicate tissues and functions. The first few years of married life, even to a healthy man, are fraught with dangers he knows nothing of. How much more then is the sufferer from a present or even a former Seminal Weakness in danger. No man, be he ever so healthy, ever so conscious of purity and freedom from abuse, should enter the marital state without preparing for the strain naturally to be expected. As the voice, skin, hair, manner and morals of the youth change at the period of puberty (when the sexual power is first developed--when he first becomes a man), so does the system, mental and moral, change when he enters the bonds of matrimony. If at puberty new diseases are prone to show themselves and old ones to be outgrown, so at marriage a like change must be at least expected, and he who blindly or thoughtlessly hazards a leap in the dark is foolish, or rather foolhardy. A SPECIAL COURSE OF NERVE AND SEXUAL TONICS. Especially for the use of young men who have endangered or injured their sexual power by abuse in early years, and for older men who have exhausted themselves by later excesses. +Prof. Civiale+ was wont (very wisely, we know from actual experience) to prescribe, for a few months before marriage, a +Special Tonic and Strengthening Marital Course of Remedies+, having three distinct ends in view, viz.: (a) The strengthening, toning up and fortifying of the general system, nerves and brain, against the unusual call soon to be made upon them; (b) The strengthening, toning up and fortifying of the Sexual Nerves, Ducts, Ganglia, Vesicles and Testes, against the strain soon to be applied to them, and by this and the preceding means putting the individual in the very best and most favorable condition for the production of strong, healthy, robust and creditable offspring; and (c) The steady and perfect eradication from the system, by every pore and viaduct, of all poisonous, contagious, venereal or other material that might in any way endanger the perfectly normal (healthy and strong) condition of parent or offspring above spoken of. Through early abuse, excesses, exposure, neglect, carelessness, imperfect sanitary conditions, wrong methods of living, immoral practices, etc., the blood and liver are liable, even though the skin be clear and the cheeks rosy, to harbor some poisonous humors that might be transmitted to the wife or offspring--poor innocents, too often made to suffer pitiably for the vices or thoughtlessness of the father. Every man about to marry owes this cleansing, purification and strengthening of the system general and the system sexual, to his wife, his fellow men and to himself. _CHAPTER VIII._ THE CIVIALE URETHRAL TREATMENT. For the Radical and Lasting Cure of all Diseases of the Sexual and Urinary Organs. Its Mode of Operation, Application and Advantages. The Civialè Treatment, by means of quickly melting _medicated_ Crayons that are _easily_ and _painlessly_ inserted into the urethra (or urine channel), and thus melt and run down over the irritated, inflamed or strictured parts, the congested Prostate Gland, and into the orifices of the Seminal Ducts, is the most successful treatment ever brought forward for these diseases, and it has met with just appreciation, for it has performed radical cures in some of the most serious and distressing cases. Some of the advantages may be briefly summed up as follows: 1. It combines local and direct medication of the diseased parts of the urethra, seminal ducts and vesicles, as well as of the Generative Nerves, by means of Urethral Crayons, with judicious invigoration of the general Digestive, Nervous, Mental and Circulatory Systems, by means of Stomach Remedies, thus attacking the complaint from all sides. 2. The Civiale Urethral Crayons are easily introduced, melt rapidly, medicate the entire canal, never give the slightest pain, never stain the clothing, are rapid, pleasant and cleanly in their action, could be used by a child without danger of injury, are perfectly soft and flexible, and give uniform satisfaction. 3. They need be used but once, or, at the most, twice daily. 4. The good results of the treatment are apparent within the first five or ten days. 5. Their price is so reasonable as to place them within the reach of all. 6. They may be used to cure gleet, stricture and prostatitis, when complicating Spermatorrhoea or Impotence. 7. They never decompose or lose their strength. 8. They are absolutely free from minerals, mercurials, caustics or irritants. 9. They will do precisely what and all that is claimed for them. +Civiale's+ knowledge of the anatomy, physiology and pathology of the Genito-Urinary (Sexual and Urinary) organs, especially fitted him to study and investigate this subject. It did not take him long to perceive that +Lallemand's+ idea that the deep urethra, where the seminal ducts open into it, was the real seat of the disease in both +Spermatorrhoea+ and +Impotence+, was the true and correct one, and therefore, that any plan of treatment, to be successful, must look to allaying and healing the inflammation, congestion or ulceration of the urethra at the neck of the bladder, and stopping the losses. He reasoned that when the inflammation, irritation and spasm of these parts, and of the seminal ducts, was relieved, the drain of the vital fluid would cease, the dilated mouths of the ducts contract, the vital fluid become thicker and healthier, the organs increase to natural size, and the distressing nervous symptoms, oftentimes dangerous to life or reason, cease to trouble the patient. {Illustration: Fig. 7. Exact Size and Shape of a +Civiale Soluble Urethral Crayon+. (Inserted into canal of organ.)} These Crayons shown here are small, soft, smooth, perfectly flexible, and dissolve as soon as they are pushed into the urethral canal, thus bringing the remedies directly in contact with the ulcerated and eroded parts, it even running down the ducts into the seminal vesicles themselves. The growth, vigor and future prosperity of every nation depend upon the strength and energy of its young men, and if the places of the robust and healthy are to be filled by effeminate, weakened, nervous and physically drained youths, such as the terrible vice of masturbation is yearly giving us, the results cannot be other than disastrous. The advice, warning and guidance of parents and guardians must be looked to for prevention; the method and remedies of +Lallemand+ and +Civiale+ for a cure. A GUARANTEED ASSURANCE. There are some persons who, from having used various forms of medicated bougies--having had sounds, catheters and bougies roughly passed upon them by unskillful persons--or merely from an indistinct belief, based upon hearsay or tradition, feel some hesitancy about passing anything into the organ for fear that it may do harm, cause pain, or give rise to stricture. The majority of these timid people have got this idea from hearing it said that stricture and inflammation have often been caused by gonorrhoea (clap) injections, and they therefore have the idea that anything put into the urethra will do harm. There is not the slightest doubt but that strong injections of nitrate of silver, zinc, copper, carbolic acid and the like (of which these injections are usually made) have, in many instances, caused severe inflammation and, eventually, stricture. But that is no reason why proper and absolutely unirritating and bland medicines, such as those in the +Civiale Crayons+, should do this--and they don't do it. Make up a strong injection of zinc, copper, &c., and take a swallow of it. It will burn and pain your mouth and throat, make you hoarse, and for days afterward you will find it painful to swallow. Put a troche or lozenge, properly medicated for the purpose, into your mouth, and, instead of causing pain, irritation and difficulty in swallowing, it will relieve these symptoms if they exist, cool and calm the membrane, soothe the irritation, and give tone and strength to the vocal chords. So it is with the CIVIALE SOLUBLE CRAYONS. (1.) They are wholly unlike any caustic, metallic or irritating injection. (2.) They do not contain a grain of any mineral, caustic or irritant of any kind. (3.) Their ingredients are purely vegetable. (4.) They soothe, calm and allay irritation, and give strength and tone to the mucous membrane, Seminal Ducts, Generative Nerves and Prostate Gland. (5.) They do not cause stricture, but they cure it if it exists. (6.) Allow one to dissolve in the mouth, eye, ear, nose, or, in fact anywhere. and they will be found to possess only soothing and healing properties. (7.) They can be inserted into the penis without the slightest trouble, and, melting rapidly and easily, flow down in a bland, soothing, healing and strength and life-giving stream, over the diseased parts. These Crayons have been in constant use in Paris for the past 25 years, and have never yet, and never will, cause the slightest pain or irritation. Patients may rest assured, therefore, that in using these standard French Remedies they are absolutely protected, and need not feel the slightest degree of fear. Indeed, so well established is this fact that we are willing to pay $1,000 (one thousand dollars) to any person or persons who can cite a single instance when the Civiale Crayons have ever done the slightest harm. The disease is in the Urethra or Urine Channel, whether it be Spermatorrhoe, Impotence, Prostatitis or gleet, and in order to effect a lasting cure, the remedies must be applied directly to the diseased membrane. In nine cases out of ten, Spasmodic Stricture already exists and must be cured before the person can get well, and the only way to cure it is to apply the medicines directly to it. It would be as silly for a man with an ulcer on his leg, or a crushed finger, to expect to cure it by taking drugs by the stomach and not applying proper lotions and salves directly to it, as to try to cure seminal disease or weakness without going right to the spot, as can be done by the use of the elegant and harmless Crayons of Civiale. It was by establishing the fact of local disease and a local remedy clearly and distinctly, upon both physiological and pathological grounds and data, that +Lallemand+ and +Civiale+ gained such world-wide reputation. And it was the discovery of not only the proper remedies, but an elegant and perfect means of applying them directly to the very seat and root of the disease, that has made the Civiale Method so justly famous, and has crowned its use with such undoubted success in this country, even in cases where every other plan and agent had failed. A REASONABLE AND HONEST GUARANTEE. We feel no hesitation whatever in guaranteeing a perfect and permanent cure of Spermatorrhoea, Impotence, Debility, &c., &c., in any case wherein our Medical Director decides that a cure is possible by any means, if the patient will use reasonable care and diligence in pursuing the treatment, and this is not hard or tiresome; on the contrary, it is easy, simple and direct. We say "in any case wherein our Medical Director decides that a cure is possible by any means," and we say it with a purpose, for it is our aim and desire, at all times, to be perfectly frank and honest with those who consult us. There are cases that no remedy, be it ever so good, can cure, and when such a one occurs in our practice, we endeavor to show the patient his exact condition, and not (as is so often done) try to persuade him to purchase remedies that we know will do him no good, or, at least, be but an experiment. So, in consulting our Physicians, you may be sure of at least an honest opinion, in exact conformity with the facts in your case. _CHAPTER IX._ TREATMENT. The Different Forms of Remedies for Different Forms of Sexual and Urinary Diseases. These Crayons are put up in packages, each of which will last one month. A single package is ordinarily sufficient for mild cases of either Spermatorrhoea or Impotence. From two to three packages are required for chronic, severe or obstinate cases, or where the person is much debilitated or advanced in years. There are five kinds: No. 1--For Spermatorrhoea and Chronic Debility. No. 2--For Impotence or Lost Power. No. 3--For Urinary, Kidney, Bladder or Prostate Troubles. No. 4--For Gonorrhoea. No. 5--For Gleet and Stricture (of Venereal Origin). Also: No. 6--A Before-Marriage Tonic Course. No. 7--A Developing Lotion for Weak and Wasted Organs. The following are the main symptoms of each class, with the kind of course they usually call for. If the patient has the symptoms of both classes he is evidently in an advanced stage, and needs both courses. SPECIAL CAUTION. The reader is warned against confounding the CIVIALE URETHRAL CRAYONS with the American Medicated Bougies, Injections, Pastilles, and the like. The disease is really seated in the Urethra (urine canal), and can be easily and painlessly medicated, and certainly cured, by means of the CIVIALE CRAYONS. {Illustration: Fig. 8. Exact Size and Shape of a +Civiale Soluble Urethral Crayon+. (Inserted into canal of organ).} CIVIALE'S URETHRAL CRAYONS. _COURSE No. 1._ _For Spermatorrhoea, Nervous Debility and Masturbation._ SYMPTOMS: Emissions (day or night), Oozing of a glairy fluid under excitement and imaginings, presence of the opposite sex, etc., Partial and Imperfect Erections, Desire to Masturbate, Formation of Evil Pictures in the Mind, Flushing and Chilliness, Stupidity and Tendency to Doze or Sleep, Mental Hebetude, Failing Memory, Lack of Power of Application, Energy or Concentration, Restlessness, Pain and Smarting in passing urine, Wetting the Bed, Pain in the Kidneys, Headache, Pimples on the face or body, Itching or peculiar sensations about the scrotum (bag), thighs, legs, anus, etc., Wasting of the Organs, Stringiness and Softening of the Testicles, Dyspepsia, Sluggish Bowels, Torpid Liver, Failing Sight, Pains in the Head (front, top and back), Chest, Limbs, etc., Sensation of the Bowels Falling Out, Dizziness on stooping over or kneeling, Specks before the Eyes, Erotic dreams, Melancholy (developing sometimes into Insanity), Numbness of arms, hands, feet or legs (precursors of Paralysis), Twitchings of the muscles of the eyelids and elsewhere (sometimes ending in Epileptic Fits or St. Vitus' Dance), Timidity, Diabetes and Deposits in the Urine, Troubled Breathing, Indecision, Loss of Will Power, Bashfulness, Burning of the face, Coldness and Clamminess of the feet and hands, also of the Scrotum (or bag), Palpitation of the heart, Early loss of fluid during connection. Feelings of gloom, despondency, hopelessness of a cure, or fear of impending danger or misfortune, Tenderness of the scalp and spine, Dryness and Itching of the skin, Sudden Sweating, Sudden Nervous Trembling, Noises and Reports in the ears and brain, Weight on the brain, Weak and flabby muscles, easily tired after slight exertion, Desire to sleep late in the mornings, and failure to be rested by sleep, Weakness and torpor the day after a nightly emission has occurred, the Oozing of a thick white fluid from the urethra when constipated or straining at stool, Varicocele, etc., etc. $5 per Box. Full Course of 3 Boxes, for obstinate and chronic cases, $12. SPECIAL NOTE.--It is a rare thing for any one patient to have all these symptoms, and some may have some not here mentioned, but it is important to know just which they do have. Persons desiring treatment will, therefore, please tear out the proper page, and having crossed out such symptoms as they do not have, return it to us for the consideration of our physician. To save delay, it is best in ordinarily severe cases to send the price of one course, and leave the selection to our physician's discretion. When less is needed than what is paid for, the balance due the patient will be returned to him with the necessary medicine. CIVIALE'S URETHRAL CRAYONS. _COURSE No. 2._ _For Impotence, Failing or Lost Strength and Vigor of the Generative Organs, Sterility, etc., etc._ SYMPTOMS.--(Impotence may arise without any previous symptoms of Spermatorrhoea, and solely as the result of abuse, overwork, confinement, blows, falls, fever, etc., but it is often the direct result of Spermatorrhoea, forming the third stage of that disorder). Loss of Sexual Desire or Power, Imperfect or Rapidly Failing Erections, Too Early Emissions During Connection (denoting irritability), Delayed Emissions (denoting blunting of sensation), Failure to Consummate Marital Duties, Oozing of vital fluid, Unnatural Desire, but not sufficient power, Nervous Exhaustion, etc., Wasting of the Organs, etc., etc., etc. 1 Box, for simple or recent cases, $6. Full Course of 3 Boxes, for severe or chronic cases, men past middle age, feeble subjects, etc., etc., $15. CIVIALE'S URETHRAL CRAYONS. _COURSE No. 3._ _For Kidney, Bladder, Prostatic and Other Urinary Difficulties._ SYMPTOMS.--Frequent urination, Rising at night to urinate, Pain or Scalding in passing water, Dribbling of Urine after completing the act, Pain and aching in the perineum, Mucous oozing from Prostatitis, Gravel, brick-dust deposit, and other sediments, Stone in the bladder, Diabetes, Irritation and Enlargement of the Prostate Gland, Congestion and Inflammation of the Kidneys, Bloody Urination, etc., etc. (Many cases of Seminal Disease are due to or made worse by urinary trouble, especially Prostatic Disease, existing at the same time. Hence, when such is the case, it is important to treat the urinary as well as the seminal disease in order to be certain to permanently and thoroughly cure both. The action of the Civialè Urethral Crayons in these cases is prompt and satisfactory. Indeed, this is the only known means of reaching and curing Prostatic Affections. 1 Box, $5. 2 Boxes, $9. Full Course, 3 Boxes, $12. CIVIALE'S URETHRAL CRAYONS. _COURSE No. 4._ _For Gonorrhoea._ One box a certain cure. Prompt, painless, and leaves no stricture. Constantly used in _L'Hopital du Midi_ and _L'Hopital Lourcine_, the two great venereal disease hospitals of Paris--the one for males, the other for females--as well as in the others. $5 Per Box. CIVIALE'S URETHRAL CRAYONS. _COURSE No. 5._ _For Gleet and Stricture (When the result of Venereal Disease)._ The formula used in preparing these Urethral Crayons is one of the finest the great +Civiale+ conceived. Repeated trials and modifications finally ended in an almost perfect remedy. Gleet or obstinate milky discharge or oozing of from two to twelve years' standing yielded painlessly and permanently to their use. Stricture, too, even when organic, if not so far advanced as to interfere seriously with urination, yielded kindly to this treatment, being gradually dissolved and absorbed until, at last, the canal was left free and clear, and all the symptoms of urinary irritation had disappeared. Testimony from Dr. Lorey, Interne at the _Hopital du Midi_, will give some idea of the popularity of this form of treatment in Paris. With them he cured eighty consecutive cases of Chronic Gleet. $5 Per Box. 2 Boxes, $8. 3 Boxes, $10. _COURSE No. 6._ _CIVIALE'S PRE-MARITAL TONIC COURSE._ This is the course we have already adverted to under the head of marriage, and we believe that enough was there said to make plain both its object and application. This, unlike the preceding courses, is, so to speak, a mixed one, consisting of a combination of (1) Tonics and Sexual Nervines to be taken by the mouth; (2) A Specially Prepared Course of Crayons (tonic, anti-spasmodic and detergent), to be used in the urethra, and (3) a lotion or application which, by being gently applied to the parts once a day with a sponge, soft cloth or the hand, adds greatly to the strength and erectile power, as well as the tone, development and vigor of the testicles. These are put up under the strict personal supervision of our head chemist, Mr. Du Bell, and are exactly in accordance with the formlæ and instructions of the late Prof. Civiale. Price per Set, $25. This Course may be used alone or in connection with any of the other Courses. No man (or woman either) could be injured by it, and many weak and impotent sufferers will find in its use health, strength and bodily and mental vigor. In some instances the Tonic Regulator and Lotion part of this Course are advisable without the Crayons, and hence we quote their price separately. Tonic Regulator, $10. Lotio Fortior, $5. {Illustration: DR. LOREY, Interne at l'Hopital du Midi, Paris.} _CIVIALE'S TONIC-REGULATOR._ Civialé's Tonic-Regulator is all that its name indicates and much more besides. It is composed of Tonics, Nervines, Bitters, Laxatives, Nerve Foods, Cholagogues (acting on the Liver), Diuretics and Diaphoretics (remedies acting on the Kidneys and Skin and thereby increasing their secretions and cleansing and purifying the Blood), Digestives, etc., etc., etc. It will thus be seen that a more complete and uniform General Tonic-Regulator could not be devised, for it acts upon the Brain, Mind, Nervous System, Digestive Organs, Spleen and Pancreas, the Bowels (keeping them in a healthy and regular manner only--not purging or weakening), upon the Heart, Lungs, Skin, Blood and Kidneys. So skillfully is the combination made that no one ingredient interferes with the other, but on the contrary each seems to vie with the other in building up and renovating a shattered, weakened and disordered system. Bilious, soggy, sleepy men, with aching heads, foul breaths, bad tasting mouths on rising, clogged secretions, sense of inability to exertion, furred or yellow tongues, and the like, absolutely need the Tonic-Regulator, and not Blue Mass or Anti-Bilious Pills. Weak, nervous, spiritless, exhausted, debilitated, pale, ambitionless, easily tired, prone to become short of breath and have pain in side on running, who find it hard to get sleep, are restless, brood over their troubles, real or imaginary, start at loud noises or sudden jars, perspire too easily, flush too readily, are not rested by sleep, and who are neuralgic, certainly need the Tonic-Regulator, and will find it rapid in action and very pleasant in its results. Health, strength, vigor, rosy cheeks, elastic step, cheery voice, zest and happiness, hope and ambition, hardy flesh and good ruddy blood, made by a perfect digestion of strong foods, will certainly follow, and as they come, all the old myths and phantoms, the melancholy, dread and brooding will disappear like unhealthy nightly vapors before the sun. Men, young or old, who have let business cares and worries, mental trouble, family jars, overwork and constant brain wear and tear, confinement, or long hours in unhealthy offices, lack of exercise, too rapid bolting of food, and the like, ruin their previously good constitutions; or those who, through youthful abuses committed in ignorance and repented so bitterly, or later excesses from unbridled passions, have drained their vitality, established a condition of sexual atony (_a_, without; _tonos_, tone or strength or vigor), or done serious harm to their nervous systems, brains or minds, will find the very Vital Restorative and Special Generative Tonic they need the most in Civiale's Tonic-Regulator. It does not do one thing; it does many. While it throws open one door to let health, strength and vigor enter, it opens others for poisonous secretions, blood impurities and waste products to escape. It not only makes the blood purer and richer, but it strengthens the organ (the heart) that pumps it everywhere throughout the system. It not only builds up and rejuvenates the general system, but it brings vernal strength and power to the weakened and debilitated organs. It was here that Civiale made Common Sense and Medical Science join hands. (a) With his Medicated Urethral Crayons he healed and strengthened the organs of Generation by direct local application. (b) While with the Tonic-Regulator he sent his powerful yet harmless emissaries (Tonics, Digestives, Cholagogues, Nervines and Nerve Foods, Laxatives, Diuretics, etc., etc.) into the system, by the stomach, with the food, thus guaranteeing their entrance into the blood which carried them to every nerve fibre and tissue and attacked the disease on every side. This is why this double treatment, intelligently carried out, cannot fail to rebuild the most debilitated and exhausted constitution and check the most serious drains and losses. _COURSE No. 7._ _DEVELOPMENTAL LOTION._ As has already been stated, in some persons Seminal Disease and Losses of Vital Fluid lead to a wasting away, shrinking or dwindling of the Generative Organs. It exists in others from birth, and is in no way connected with Seminal Disease. Whichever be the case, it is nevertheless true that a wasted or deformed part of the body, be it arm, leg or what not, cannot in this condition be expected to perform its function in a natural, vigorous and healthy manner. There is a great deal of ignorance upon this subject--ignorance that interferes greatly with the full and proper treatment of cases of Seminal weakness. Many sufferers from Seminal Disease and Impotence seem to think that just as soon as the losses or emissions are stopped, or erectile power returns, the parts will begin to grow and develop, and soon be restored to natural size and proportions. This is not so. In some few instances it does occur, but in the large majority it does not. It is therefore necessary in these cases to take special measures to fully and perfectly develop the defective parts, and it can only be done by giving a new start to growth and circulation to the nervous and nutritive centres of these parts. A breast, a limb, a hand, indeed any part of the human body, especially in persons not past fifty years of age, can be enlarged and developed, and so, too, can the sexual organs. _The Developmental Lotion_ that has been in use for many years, is a local application (viz., applied directly to the organs), and acts by stimulating growth, circulation and nutrition. It is cleanly, easily applied, rapid and satisfactory in its results, and we guarantee that it will give uniform satisfaction in all cases where our Board of Consulting Physicians recommend the case as favorable for it. PRICE OF THE DEVELOPMENTAL LOTION, { Strongest, $15. { Less strong, 10. It is put up in quantity sufficient to accomplish a full and perfect development. Should more than is at first sent be needed to complete the development, we will furnish it at half-price. Full instructions accompany it. It should be used in connection with the remedies for Impotency or Spermatorrhoea in every case where the organs are wasted. Its effects in such cases are wonderful and the results very gratifying. CIVIALE REMEDIAL AGENCY, 174 Fulton Street, New York. _CHAPTER X._ REORGANIZED CONSULTING STAFF. {Transcriber's Note: The names "G. G. Mortimer" and "S. Sorensen" are printed above the text in a different typeface. The original names, crossed out by hand, were "Millard F. (or E.) Flowers" (last four letters unclear) and "George H. Du Bell" (partially illegible). The _curriculum vitae_ associated with each name is unchanged.} G. G. MORTIMER, A.M., M.D., Ph.D., Chief of Staff. RICHARD LEE, A.M., M.D., of the Universities of Oxford, London and Melbourne, Master of Arts, Member of the Royal College of Surgeons, of England; late Consulting Surgeon to the Beechworth Hospital and Professor of Botany and Chemistry at the Tasmanian Institute; Honorary Member of the Victoria Medical Society and Fellow of the Royal Society of Tasmania and of the Anthropological and Physical Societies of London; University Medalist, etc., etc. Chief of Personal Consultation. HENRY H. KANE, A.M., M.D., late Medical Superintendent of the De Quincey Home, Interne at the Roosevelt, New York, Bellevue, Charity and Lenox Hospitals; Physician to the North-Eastern and Good Samaritan Dispensaries; Lecturer at the Women's Medical College, on Urinary and Renal Diseases, etc., etc., etc. S. SORENSEN, A.M., Ph.D., Manufacturing, Analytical and Experimental Chemist, Licentiate of the School of Pharmacy of Heidelberg and Berlin, Germany. (This accomplished chemist has full charge of all analyses of urine, the preparation of our various formulæ, the purchase and importation of all drugs, etc., etc.) LOUIS B. JONES, Business and General Manager. With such a complete and accomplished staff, it will be seen that the case of every person consulting us will receive the most careful and combined opinion, judgment and decision of all these men. We have the greatest and most generally successful remedies known, and by thoroughly understanding every detail of the cases submitted to us, and carefully applying these remedies, we seldom or never fail to perform a pleasant, absolute and lasting cure. PERSONAL CONSULTATION. Patients desiring a consultation with our Chief of Staff will find our offices open and physicians in attendance from 8 A.M. to 6 P.M., daily, and from 9 to 12 Sundays. HOW TO SEND MONEY. Money should be sent by Post Office Order, Postal Note, Check, Draft or Express Order. Checks, etc., may be made payable either to the Civialè Remedial Agency, or, if secresy is desired, to our Superintendent, Mr. L. B. Jones. Please state in your letter to whom the order (when such is sent) is made payable, in order to avoid confusion in indorsing them for banking. HOW TO SEND URINE. In sending urine, bear in mind the following: Never send by Mail--always by Express--charges prepaid. Send morning urine. Write your name on a slip of paper and paste it on the bottle. Pack the bottle securely in a box filled with sawdust or the like. _CHAPTER XI._ VARICOCELE. VARICOSE TESTICLE, OR VARICOCELE. A very Common Disease Amongst Men and Boys, and one that has a very serious effect In Weakening the Sexual Powers, causing Emissions and Losses, and Preventing a Thorough and Permanent Cure of these Complaints. Varicocele (from the Greek, pronounced Var-i-ko-seal, accent on either Var or seal) is a condition of bagging, bunching, bulging or twisting of the veins in the scrotum (bag or testicle sac.) It is most commonly found on the left side of the bag, but sometimes is to be seen on both sides. Usually the scrotum is bulged out on the side and sometimes hangs very low, so long and twisted are the veins. To the touch the veins feel like a bunch of angle-worms. In some cases they can be seen knotted and swollen through the thin skin of the bag. {Illustration: Fig. 9. A VARICOCELE. Showing how the veins are affected and how they press upon the nerve, duct and artery, and waste the testicle. 1. Spermatic Artery. 2, 3. Spermatic Veins. 4. Spermatic Nerve. 5. Vas Deferens or Seminal Duct. 6. Testicle. 7. Converging Tubes. 8. Wormy bunch of Veins.} {Illustration: Fig. 10. VARICOCELE, AND INSTRUMENT IN PLACE. On the right side, the drawing of the instrument is cut away, also the layers of skin and muscle, showing the dilated and knotty veins in the groin, before they reach the scrotum, also the Bell Pad in dotted outline, showing how and where the pressure is properly exerted. When the veins in the groin are thus affected, we have what is known as +Varicocele of the Cord+. On the left side, the Cradle and Compressor is shown in place.} A HIDDEN DANGER. In cases of Varicocele of the Cord (one of the most dangerous of all forms), the veins in the bag are not affected, the trouble being mostly in the groin (in the canal through which the veins run), where the swollen and knotted veins press upon and seriously injure the cord, preventing the free flow of Vital Fluid, and thereby causing Impotence, Wasting of the Testicles, etc. A dull, heavy, aching or dragging pain in the groin, back or legs, is about the only symptom. The great danger of this form of Varicocele lies in the fact that thousands of young men are going about to-day not knowing that they have the disease; not knowing that a persistent evil is nestling in this little canal, gnawing at their vitals, and slowly but surely undermining and destroying their sexual vigor and manhood. We know this to be so because we are daily being consulted by men of different ages, who, until our physician, in the course of the examination, showed it to them, _never suspected its existence_. Many of these men had been "doctoring" for years for seminal weakness and the like, with varying success, never being quite cured, or, if cured, soon relapsing--all because a Varicocele of the Cord existed unsuspected and therefore untreated. {Illustration: Fig. 11. COMPLETE INSTRUMENT. Showing mobility at points so that it will fit any individual.} {Illustration: Fig. 12. SIDE VIEW. Showing Bell Spring, Pad and Pubic Shield.} CAUSES.--The causes of this condition of the veins of the bag are very numerous. Some of the most important are Masturbation or excess, causing weakening of all the parts, the veins included; Falls, Blows, Strains, Excessive Horseback and Bicycle Riding, Running, Jumping, Mumps going to the Testicles, Gonorrhoeal Inflammation settling there, Kick in the Groin, Wearing of Improper Trusses, etc., etc. Masturbation is one of the most common of all the causes. In many instances, even if it does not _directly_ cause the complaint, it weakens the parts, so that blows, strains, etc., that in others would not produce any particular trouble, readily cause it in these persons. SYMPTOMS.--The symptoms are not many unless it has caused seminal weakness and lost vitality, in which case all the symptoms of these complaints may really be attributed to the Varicocele. Pains in the Groin, Limbs and Back; a sense of weight or dragging; Neuralgia of the Testicles, Fetid Perspiration; Itching and peculiar sensations in the Skin of the Bag; Chafing in warm weather; easy tiring under rapid walking or running, are not uncommon. In some very bad cases, however, none of these symptoms, or only a few, are present. Why, we cannot say. PROGNOSIS.--In itself this disease is not dangerous. It is from the fact that the veins may go on bulging until an enormous swelling is produced (we have seen cases where the bag hung as low as the knee and was nearly as large around as a man's arm); that the testicles may be entirely wasted away, and that it may cause Spermatorrhoea, Lost Manhood, Total Impotence, &c., &c., constitute its greatest gravity. TREATMENT.--Cutting and tying operations are exceedingly dangerous, having frequently caused death; and even if successful, the testicles, having their blood supply thus entirely cut off, waste away, and Impotence certainly results. Prof. Chevillot, the great French surgeon, was assassinated by a patient, in whose case he tied the veins on both sides for a double Varicocele. Becoming totally impotent, on the very eve of his marriage with a beautiful and accomplished young lady, this man became desperate and attempted the surgeon's life. To effect a cure, the following obstacles must be overcome: _Weakness and bulging of the walls of the veins._ _Weakness and relaxation of the dartos muscle of the scrotum._ _Over-clogging and stagnation of blood in the veins._ _Healing and strengthening of the ruptured and relaxed valves of the veins._ _Relief of the pressure and weight of the column of blood from above._ Suspensory Bandages are good, because they act as supports. Astringent and Tonic Washes are good, because they strengthen the weakened veins and muscles and heal the relaxed valves. Proper Trusses are good, because they break the great pressure of the blood from above, and act as do the valves in the veins in the groin in health. Also, because they act directly on the disease in cases of Varicocele of the Cord. But neither one alone will cure a really serious case of Varicocele. Combine them, however, properly and scientifically, so that you have the practical outcome of these three sound principles of cure in the one appliance, and ANY CASE, NO MATTER HOW SEVERE OR HOW OLD, CAN BE PERMANENTLY AND PAINLESSLY CURED. Such a perfect and practical combination is to be found in the Elastic self-adjusting and adjustable Cradle and Compressor, which has succeeded in curing many very serious and (apparently) hopeless cases. Patented and thoroughly protected from all infringements and imitations (and many would-be ones, seeing our success and recognizing the merits of the Cradle-Compressor, have lately sprung up), both in this country and Europe, there is nothing like it. It combines all the good points of all previous instruments, and being easy to wear, rapid and pleasing in its results, and certain in its effects, is the only rational means for radically curing this disease. Briefly: It consists of a very light and elastic triangle of tempered steel bands, that rests on the front of the abdomen, and is held in place by a soft silk-elastic waist-band. In each of the slanting arms of the triangle are small holes that admit the central pivot of a bell-pad, having a central spring, and so adjusted that it adapts itself to every movement of the body without being misplaced. By means of a thumb-screw and the perforations, it (the spring bell-pad) can be set at any point in the groin, and can be changed from day to day and hour to hour. {Illustration: Fig. 13. INSTRUMENT ON BODY. _a. a._ Transverse Steel Band; _b. b._ Elastic Waist Belt; _c. d._ Metallic Arms, perforated to permit change of pad pressure; _e._ Pubic Shield to which Elastic Cradle is attached; _f._ Bell Spring Pad.} By means of pivotal joints at the angles, the appliance can be made to fit any one perfectly; moreover, by means of the metallic shoulder below, the arms can be thrown into any lateral variation of the groin line. We thus are able to obtain all the marked benefits of a truss without any of its drawbacks; and that special disadvantage, steady and wearisome pressure at one point, is wholly obviated. The whole appliance is held in place below by means of perineal tubular rubber bands that connect with the waist-belt behind. Attached to the metallic shoulder below is the Elastic, Glove-Fitting, Self-Adjusting Testicle-Cradle, by means of which not only are the testicles perfectly supported and rested, but by the sheet-rubber lining and the elastic tie bands, a constant, easy and perfectly painless elastic pressure is kept up on the dilated and sagging veins, which are thereby emptied of their unhealthy and stagnated blood and allowed to regain their tone, strength and contractility. By means of the elastic bands it is easy to regulate the amount of pressure, thereby constantly adapting it to the improvement that is steadily taking place. The compression is so uniform, yet so elastic, that it is absolutely painless, and no motion of the body, however violent, can disarrange it. This, and the fact that the blood can enter and leave the testicle with perfect freedom, constitute some of its most marked advantages over the Truss. Moreover, the wearer always feels a sense of rest and relief while wearing the Elastic Cradle-Compressor, and from the first day the symptoms of weakness and impotence improve. Being made in different sizes and shapes, and of the most durable yet softest silk, and powerful yet yielding elastic, they will wear perfectly until long after the Varicocele has entirely disappeared. {Transcriber's Note: The left edge of this page was partially illegible. Words and letters in braces { } are conjectural; all came at the beginning of a line.} {Illustration: Fig. 14. ELASTIC TESTICLE CRADLE, {Deta}ched from Compressor, and showing its appearance {when} worn singly. It is lined inside with sheet rubber, and {the t}ie cords are of the very best French elastic. The bag {cover} is of the finest knit silk.} While it compresses the Varicocele, forces out the blood, and allows the veins a chance to regain their strength and proper size again, it simply supports and keeps from injury the testicle, which at once begins to grow larger. In addition to their curative value in Varicocele, they are now being extensively used by the medical profession for the relief of the pain and subduing of the inflammation of "swelled testicle;" also in hydrocele and hæmatocele. Being applied over the whole scrotum, they will cure a Double as readily as a Single Varicocele. In certain recent or simple cases the Elastic Testicle-Cradle alone will effect a perfect cure. If the case is severe or of long standing, if it involves the Cord, or if the sexual organs are affected, the complete instrument should be worn. It is beautifully made and finished, and is strong and durable, yet light and easily worn. PRICE. {Comp}lete Instrument (all attachments) $15.00 {Extra} Central-Spring Bell-Pad, In case of Double Varicocele 3.00 {Elast}ic Glove-fitting Testicle-Sac and Cradle (separate) 6.00 {Sold ne}atly boxed, and with full and explicit directions for applying; as also a {____} prescription for a Tonic, Healing and Astringent Lotion, to be used {in conju}nction with it. In ordering, please state girth around waist, circumference of scrotum, and length of same from root of penis to about the middle of the bottom of the bag. The reason why Varicocele has until within the past ten or fifteen years received so little attention is owing to the fact that up to that time this bagging or bulging of the spermatic veins was looked upon as merely a local affection. No one seemed to be aware of the fact that its effect in nine cases out of ten was to produce Seminal Weakness and Loss of Sexual Power, etc. To-day no fact is so well recognized in medicine, although probably not so well known outside of the profession. Then, too, until very recently, physicians either carelessly dismissed a patient with Varicocele with the advice to "get a suspensory bandage and wear it; the thing don't amount to anything;" or else, when the patient became persistent in his demands for a cure, advised him that the dangerous cutting or tying operations were the only means of relief. But this is all changed now. Physicians have come to know something about the disease, and means for both relief and cure are now speedy and certain, and in no sense painful or dangerous. It is for the purpose of stating in as plain and concise a manner as possible all the more important facts relating to this disease, and pointing out to such as are troubled with it, or have friends so troubled, not only the proper manner of treatment, but also the danger of delay, that this little treatise has been compiled. Many a man well built and apparently healthy, yet totally bereft of manhood--in a word Impotent--can trace his deplorable condition to a neglected Varicocele. Nor are these the only ones who need information upon the subject. Thousands of young men are to-day being treated for seminal troubles who will never be cured, because they are entirely ignorant of the existence of a Varicocele of the Cord, that most insidious and dangerous of all forms of Varicocele, or, if aware of it, do not understand the terrible influence it has on their Sexual Powers, and how great and persistent a stumbling-block it will be in the way of all treatment. It is for the benefit of all such that this little essay is intended. For the sake of clearness we shall consider the subject under the heads of Definition, Frequency, Causes, Dangers, Influence on Sexual Diseases, Wasting of the Organs, Symptoms and Treatment. Consultation with our physicians, by letter or in person, free, References and testimonials promptly and cheerfully furnished. CIVIALE REMEDIAL AGENCY, 174 Fulton Street, New York. _CHAPTER XII._ THE RELIABILITY OF THE CIVIALE REMEDIES, AND THE BUSINESS STANDING AND PROBITY OF OUR AGENCY. In previous editions of this work, we made no attempt whatever to point out to our readers either our reputation as a medical business firm, or proofs of the efficacy or reliability of the remedies we represent and prescribe, supposing that any person at all familiar with the names and reputation of Professors Lallemand and Civiale, and the honors bestowed upon the latter by the French government, would need no such references, etc. We find, however, that there are but few men in this country who are as familiar as they should be with the nature and extent of Lallemand's and Civiale's medical labors, or indeed with French Medical History at all. We, therefore, for the benefit of such, have here transcribed extracts from that most reliable work, _Appleton's Cyclopedia_ (copies of which may be found in many families, and every town and city library), from which may be learned the professional standing and reputation of these great men. Furthermore: Of late years there have sprung up in various parts of the country, physicians and firms who have made it a business to prey upon foolish young men, who took everything that was sent to them for gospel. There are many young men (and old men, too) who do not know us, and for their benefit we have drawn up here and submitted such proofs of our probity, fair dealing and medical capacity, as well as of the reliability of the Civiale Remedies, as will, we believe, carry conviction of our truthfulness and probity to any honest man's mind. We have always been averse to parading before the eyes of the careless, scoffing world the sufferings of the victims of abuse or excess, even when by doing so we might profit largely by such a course. We have a large number of letters from persons who have been cured by this treatment constantly on file in our office, and any sufferer really in earnest will be gladly given permission to examine them, should he so desire. But we certainly shall not parade such letters, written to us in the strictest confidence and secrecy, to every reader of a treatise of this kind, especially when we give an abundance of equally as good proof of another kind. _If we have always dealt fairly and with professional honor and ability with our corresponding and office patients in the past, we certainly shall continue to do so in the future._ First, let us call your attention to two very recent and very flattering extracts from editorial articles that appeared in newspapers of known standing and reputation in the city of New York, both of which articles were wholly unsolicited by us, being the spontaneous testimony of wholly disinterested journals. TESTIMONIALS AND ENDORSEMENTS from the MEDICAL AND LAY PRESS Of this Country and France. A NOTABLE MEDICAL INSTITUTION. _From the New York TRIBUNE AND FARMER, Nov. 22, 1884._ It is a well-recognized fact by writers upon longevity that the men of the present day, both old and young, are less manly and vigorous, less able to resist the attacks of acute disease, and not only less likely to produce healthy and vigorous offspring, but in the majority of instances producing a fewer number as well as a less vigorous and robust progeny. The ratio of births to deaths has fallen off some 12 per cent. in births in the past fifteen years. This fact, coupled with the equally startling consideration that the mortality of infants has increased about 11 per cent. in the past ten years, must needs fill the mind of a lover of his kind with dismay and alarm. Although invested and thickly hedged about by ideas of false modesty and pseudo-propriety, in reality the whole fabric of national and individual prosperity, health, vigor and enjoyment, as well as the very important perpetuation of our species, depend upon perfectly strong, healthy and vigorous procreative powers. As an oak cannot grow from a flower seed, neither can weak, puny and debilitated parents give birth to strong, vigorous and mentally sound and active progeny. The subject of Procreative Pathology deserves more careful and extended study and observation than the majority of our physicians have heretofore been inclined to give it. Most of them have let the more numerous and oftentimes the more trivial cases daily coming under their notice crowd this most serious matter from sight, and when applied to for advice or treatment by sufferers from these disorders or debilities, have either pooh-poohed it or have given some simple (or useless) placebo, believing the trouble to be more imaginary than real. Is it any wonder, then, that such patients have walked blindfold into the arms of quacks and charlatans who profess the most tender interest in even their minutest symptoms? We have been led to make the foregoing remarks by what we have just finished reading in a very interesting and able work upon this subject recently issued from the press of the Civialè Remedial Agency, of 174 Fulton street, this city. The subject matter of this book cannot fail to interest every man, young or old, and must prove of special interest to men just married, and to that large class of middle-aged men who find to their surprise and chagrin that while their bodily health is apparently excellent, their procreative powers have prematurely declined. The fact of the establishment in this city of an original institution under reputable business management, each department of which is presided over by a physician of special skill and qualifications, is something of which every citizen should feel proud. And to judge by the class of patients who may be found in their elegant consulting-rooms, and the very large amount of express and mail matter they are constantly receiving, we believe that they are appreciated. With our magnificent hospitals, second to none in the world, our large medical colleges and dispensaries, and the establishment of so large and excellent an institution as the Civialè Agency, the main offices being now transferred from Paris to this city, New York may justly claim to be the great medical centre of the United States, and sooner or later of the world. We maintain now, as we have always maintained, that the surest and best way to drive quacks and humbugs from any branch of medicine, is to have some of our very ablest and most honorable physicians make such a branch their specialty, and such is the course now being pursued by the Civialè Agency. The very fact that it takes its name from and is engaged in manufacturing and prescribing the remedies of France's most illustrious specialist, Prof. Jean Civialè, is by itself evidence enough of its medical value and professional integrity. Our feelings upon these matters, _i.e._, the great importance of their bearing upon both individual and national vigor and prosperity, the necessity for driving from this field of practice those quacks and humbugs who entrap the foolish and ignorant, those cheap and worthless remedies that flood the drug market--our feelings upon these matters are, we repeat, very strong; and hence, when we find an institution for the treatment of these diseases conducted upon the highest moral, medical and business principles by men of undoubted medical and business standing and integrity, we feel that we cannot endorse them too heartily. The _Tribune and Farmer_, of New York city, in its current issue of July 26th, 1884, says "AN EXCEPTION TO THE RULE." "The propriety of devoting editorial space to the subject-matter of any medical advertisement that may appear in our columns may be doubted by some, and indeed, were it not for our personal knowledge of the skill and integrity of the Medical Director of the Civialè Remedial Agency of New York (whose advertisements will be found elsewhere in this issue), we should deem ourselves more than guilty were we to utter a word of endorsement as to the efficacy of their system of treating that serious class of diseases in men which has been generically termed Nervous Debility, and which for so many years has been, and is at present, made the stalking-horse for impudent swindlers, quacks and impostors to palm off worthless and often injurious compounds on their suffering fellow-men. "Let it be understood, then, that we know whereof we speak, and that our object is simply to furnish those who are afflicted with such reliable information as will enable them to determine the true character of their disease, and the best means to be adopted for a cure. "The method of treating diseases of the Genito-Urinary organs by means of the urethral canal is in the first place no new-fangled experiment, but is identical with the system which has been employed for the past fifteen years in the leading hospitals of France, and more especially in Paris, as the standard treatment, and one that gives uniform satisfaction; and in the history of medical science there are perhaps no two physicians who have done more for the alleviation of human suffering and the cure of Sexual and Seminal Diseases than those eminent French Surgeons, Prof. Jean Civialè and Prof. Claude Lallemand, to whose joint studies and endeavors this system owes its origin. "We believe, in fact, that this theory and practice of medicine is an advance in the right direction, and we predicted, from its first introduction in the United States some time ago, that the people would readily see its truth and accept the wonderful benefits of its practice. And the result has certainly borne out our prediction, for thousands of sufferers from such ills as Impotence, Spermatorrhoea, Kidney, Liver and Urinary troubles have been cured by these remedies." {Illustration: ONE VIEW OF THE HOSPITAL OF THE HOTEL DIEU, PARIS. This celebrated hospital of Paris, the oldest as well as the largest and finest in the city, covers 22,000 square metres of land, has over 1,000 beds, and a corps of over 100 physicians on its medical and surgical staff. It is situated on the _Ile de la Cité_, near the famous church of Notre Dame. It was here that both LALLEMAND and CIVIALÈ studied under the celebrated DUPUYTREN, one of France's greatest surgeons, until, in after years, they themselves became sufficiently great to become its Consulting Surgeons. In France, honors are gained by ability alone, and not, as here, by political influence and wire-pulling.} The following is a list of the French Hospitals with which Civiale and Lallemand were connected during their lives. HOTEL DIEU. LA PITIE. LA CHARITE. LARABOISIERE. St. ANTOINE. HOPITAL NECKAR. HOPITAL COCHIN. HOPITAL St. LOUIS. HOPITAL Du MIDI. HOPITAL LOURCINE. La MATERNITE. HOSPICE BICETRE. We next give extracts from Appleton's Cyclopedia, to which reference has already been made. LALLEMAND, CLAUDE FRANÇOIS, a French physician, born in Metz, Jan. 26, 1790, died in Marseilles, Aug. 25, 1854. After serving as assistant surgeon in the armies of the Empire, he studied in Paris at the Hotel Dieu under Dupuytren, and, from 1819 to 1845, was Professor of Clinical Surgery at Montpelier, with the exception of three years, during which he was suspended for his liberal political expressions. His most important work, _Recherches Anatomica Pathologiques sur l'Encephale et ses Dependances_ (Paris, 1820-1836), established his reputation, and was translated into many languages. In 1845 he was elected to the _Academy of Sciences_, removed to Paris, and was consulted by patients from every part of Europe. He bequeathed 50,000 francs to the Institute. --[_Appleton's Cyclopedia, vol. x, p. 144._ {Illustration: Prof. JEAN CIVIALÈ.} {Illustration: Prof. CLAUDE F. LALLEMAND} CIVIALÈ, JEAN, a French surgeon, the originator of the operation of Lithotrity, born near Thiezac, Auvergne, 1792, died in Paris, June 13, 1867. At a very early age, while a pupil of Dupuytren at the _Hotel Dieu_ hospital in Paris, his attention is said to have been attracted to the subject of his future discovery; and, after many years of perseverance, he succeeded in perfecting and introducing to the profession his new operation of lithotrity. Before that time the only means was the serious and often dangerous operation of lithotomy (SEE STONE). He was the teacher of several generations of lithotriptists, became a member of the MEDICAL ACADEMY, and an officer of the LEGION OF HONOR. His principal publications are: _De la Lithotritie, ou brolement de la pierre_, (_Paris_), 1827); _Lettres sur la Lithotritie, &c._ (1827); _Traite pratique et historique de la Lithotritie_ (1847); _Resultats Cliniques de la Lithotritie pendent les Annes_ 1860-64 (1865). --[_Appleton's Cyclopedia, vol. iv, p. 618._ We also take pleasure in referring--not as patients, but simply as to standing, probity, business capacity and the ability of our Consulting Staff--to the following firms or gentlemen in this city: WEST SIDE PHARMACY, dealers in Drugs, Chemicals, &c., corner Hudson and Charlton streets. COFFIN & ROGERS, 85 John street, New York. AMERICAN DRUG COMPANY, Islip, Long Island. Editor of the "NEW YORK TRIBUNE AND FARMER." E. DUNCAN SNIFFEN, 3 Park Row. A CHARACTERISTIC LETTER. (For once we transgress our rule--never to put a debility patient's letter in print unless the patient urges us to do so--and do it at the request of our Medical Chief of Staff, and with the patient's full consent. The name, however, we omit, simply stating that should any intending patient desire to come and see or send some friend living in the city, to see and verify that letter and many more like it, we shall be most happy to oblige them.) RODNEY, MISS., August 14, 1884. _Dear Sirs:_--My course of treatment being almost all used, I feel it my duty to state to you my present condition, and I can say without hesitation that I am almost a new man, and I thank God that improvement has been so thorough and rapid, may it be but lasting. Sexual desire is now perfect, erections are perfect, emissions come at the right time, oozing of vital fluid at stools and in the urine has stopped, I rest well at night with the exception I shall state further on, appetite is good and digestion almost perfect. I can now approach the presence of the opposite sex with some satisfaction to myself; ambition is returning, and in fact a whole new lease of life seems suddenly to have been allotted to me. The varicocele has almost disappeared. I cannot say enough in praise for this beautiful little appliance, "the Cradle Compressor." Now, if it were not for the urinary disorder which still remains, I should call myself well; that this remains, however, is no fault of the crayons, and could the Course No. 3 have reached me undamaged by heat, as did the Course No. 2, I have not the least doubt I should now be well. The symptoms of this disorder, still present, are dreams at night, not nervous ones as before, but still unpleasant; mucous oozing after straining, also in the morning on rising I find the lips of organ glued, and on forcing apart a drop of this mucous fluid makes its appearance. I have no doubt whatever that had crayons reached me perfectly, this disorder would have been conquered same as the other. Now, in your little circular you guarantee a cure "in all cases wherein your Medical Examiner decides a cure is possible." Now this certainly holds good in my case. Please let me know what you are willing to do about the matter, for I certainly need another course of No. 3 crayons, and if you would furnish them in place of the ones destroyed in transit, I should consider your guarantee fulfilled. The course you sent me last could not be used at all; they were ten times worse than the first ones, and I only wasted them in trying to use same. However, do not send any crayons till you hear from me, and I think the weather cool enough, as they would only be wasted again. Could you furnish me, and at what price, a suspensory, such as you would recommend, if not, where could I get one? I think it advisable to wear one after laying aside the Compressor, as I have to be on my feet all the time. Please excuse encroachment on your time and believe me ever, Yours very truly, ---- SINGER. DOUBLE VARICOCELE AND SPERMATORRHOEA RADICALLY CURED. (These letters are published at the patient's own request, and he will be most happy to correspond with any earnest and honest inquirer). "TIRED OF HUMBUGGING." "ISLIP, Suffolk County, N.Y. "_Manager of the Civiale Remedial Agency,_ "174 Fulton street, New York. "_Dear Sir:_--My attention has been several times called to your method of curing Varicocele of the Bag without any cutting or tying, and I am now going to describe my case to you, and get your idea whether you can cure me or not. I would have done this long ago if I hadn't been afraid of being humbugged, as I often have been by doctors and men who said they could cure me right off without any pain or trouble. But they all fooled me out of my money, and that's all. But I'm going to try once more, and please tell me if you think my case is too bad for your Compress and Cradle. "I'm pretty badly off I know, but it seems to me that this thing ought to be able to be cured by some one. This is how mine was. Eight or nine years ago I fell from the rigging of a schooner, and was laid up for nearly sixteen weeks with a broken thigh. I also had both testicles terribly sore and swollen, and it was a long time after my leg got well before I was able to walk, the pain in the groin, testicles and small of my back was so bad. Sometimes, even when I was sitting quiet, it would cut me like the stab of a knife. The first I noticed of the Varicocele was one day when I was taking a bath I saw there was a sort of bulging there, and come to notice it closer, it felt just like a bunch of angle worms all twisted together. I tried cold water to it and wore a suspension bag for a long time, but it didn't do much good. At first it didn't trouble me much in winter, but was bad in summer. Now it's bad all the time, and I don't believe I could walk half a mile without I wore a supporter. "I have tried most everything I ever heard of, but it's no use. Some of the things helped me for a while, but they didn't last, and now I'm pretty well discouraged, for I don't dare have it operated on; not so much that I'm afraid of the pain, but because a young man I knew went to a hospital in New York to be operated on, and died, because the veins got inflamed from the cutting and tying. "I am willing to pay any one a fair price for curing me, because as I am now I can't do a fair day's work, and my testes are wasting away very fast. But I don't want any more humbugging, and if you treat me, you have got to give me good proofs that you can do as you say." "Truly yours, D. L. B. "I forgot to say that my Varicocele is on _both_ sides, but the left side is much the worse. It is twice as bulgy as the other." "JUST AS REPRESENTED." "ISLIP, N.Y. "_Dear Sir:_--I went to the depot night before last and got the package all right, and when I got up yesterday morning, bathed as the circular said, and put the Cradle and Compressor on me. I write to tell you how pleased I am. I always felt sure some one would find a cure for this thing, and believe I've got hold of the right thing at last, though I'm not going to crow this time till I'm part way out of the woods at least. "Any way, I'm satisfied so far. The appliance is just what it was represented, and I find that it fits me to a t, and is the most easy and comfortable thing I ever wore. I haven't had a bit of pain since I put it on yesterday morning, and I have done some hard work these two days, purposely twisting and wrenching my body about to see if I would get it out of place. "So far it is all right, and I am very thankful to you, for if it never cured me it would be a God-send to wear for relief of that horrid dead ache and dragging pain in my groin and back. I shall want some of your Crayons soon, and will write again in a few weeks. Please tell me how long the wash ought to stand before it is strained, and whether it would hurt me to use it _twice_ a day instead of once. "Very respectfully, D. L. B." "PERFECTLY CURED." "ISLIP, Suffolk County, N.Y., February 13, 1884. "_Dear Sir:_--It is now over two months since I quit wearing the Cradle-Compressor, and I seat myself to tell you that the Varicocele seems to be entirely well. The left side is a trifle larger than the right, but the veins are not wormy as they used to be, and the blood don't stagnate in them any more. The dragging pain is all gone away, and the small of my back hasn't pained me for a long time. When I came to see you in New York, your doctor told me I musn't feel sure that I was cured until every bit of worminess was gone and the canal was free of swelled veins. You can tell him that this is so now, and that the testicles aren't shrunk and wasted the way they used to be. "Our doctor here, who told me I couldn't be cured unless I had it operated on, says it's the most remarkable thing he ever saw. Those are his very words. He didn't seem any too chipper to find out he was wrong about having to get cut. "I am a thousand times grateful to you. You have made me a man again, and I shall not forget it. I am ashamed to think how mean a letter I wrote you last summer about humbugging and the like, but I apologize now, and if you find any other people that don't feel sure you can cure them, send them this letter or get them to write to me. "I shall remember all you wrote in your last letter about not 'presuming too much on my improvement,' and to be careful about jumping, straining and lifting hard, and the like. The Crayons did their work just as well as the Compress Instrument, and I never can tell you how grateful I am to you. There's several men I know here that are going to write you about their cases. One of them, ---- ----, is going down on the train to-morrow, and will bring this letter with him, he says, for introduction. Good bye. Yours respectfully and gratefully, DAVID L. B." REMARKS. The foregoing three letters tell their story plainly and concisely, and need little or no explanation. We only desire to append the following note from our Case Book--"D---- B----; RESIDENCE--Bay Shore, Suffolk County, Long Island, N.Y.; AGE--54; Sex--Male; CIVIL CONDITION--Widower; OCCUPATION--Track-Walker on L.I. Railroad (formerly Bayman and Sailor); DISEASE--Double Varicocele, most pronounced on the left side; glands much softened and wasted; cord also varicose and very painful. COMPLICATION--Impaired powers, losses and commencing Impotence. CAUSE--Indirect and Contributive Abuse in earlier years. DIRECT--Fall from rigging of a vessel. TREATMENT--Medium Cradle and Inguinal Compressor and one No. 2 Course Civiale's Soluble Crayons. RESULT--Perfect cure in about 9 months. REMARKS--As severe and complicated a case as can be found in any records. The symptoms of Impotence were undoubtedly due to the pressure of the dilated veins on the testicles in the scrotum and the seminal duct in the Inguinal Canal. Patient promises to report, in person, at the end of six months, to determine whether the cure remains perfect." Mr. B---- has since moved to Islip, Long Island, where letters of inquiry (containing a stamp for reply) will reach him. CONSULTATION. If you should conclude to place your case in our hands, we shall be pleased to hear from you, and promise you the most careful and thorough attention. Our Consulting Staff is large, each physician has his special department to attend to, and each case is afterwards reviewed by the whole Board, so as to avoid all possibility of error and give each sufferer the benefit of the highest skill and research. Our patients, while numerous, are not such a multitude but that we can and do give each one of them individually the closest attention. Should it be convenient for you to visit us in person you will be cordially welcomed. If you hesitate from ordering, from any cause, we shall be pleased to correspond with you. We try to feel as if we have a personal acquaintance with every patient, and treat him as a valued friend; and, whether you ever order or not, we shall be glad to hear from you and know your conclusions on this subject. Of course, every letter is sacredly private. No one reads these but the Manager, and even our old and trusted medical advisers do not know the names of our patients--only the numbers and descriptions of cases go into their hands. As a further assurance we destroy letters, or return them to the writers, whichever they prefer. We solicit your influence with your friends, and will be ready to reciprocate such favors. You will also be often doing such friends a favor, for which they will always thank you. We shall be particularly pleased to hear from men advanced in years, who feel the necessity of counteracting growing weakness incident to their age, and who know the worse than folly of resorting to pernicious secret preparations, the effect of which is to give unnatural stimulation for a brief time, to be followed by a dangerous, perhaps fatal, reaction. TO THE MEDICAL PROFESSION. We make special terms on our instruments and treatment to physicians, and cordially invite them to correspond with us. We will do all in our power to serve the profession to their satisfaction. We have the benefit of the best medical advice and facilities in certain lines not attainable from any other source on the continent. GENERAL PRACTITIONERS AND FAMILY PHYSICIANS. We cannot refrain, before closing this chapter, from saying a word or two about the incompetency of the large majority of "general practitioners" and "family physicians," and their evident carelessness, and in some instances, even disgust, in the diagnosis and treatment of this class of cases. The readers of this may be among that class who think the "family physician" the embodiment of medical wisdom, and that if he has failed to cure the case or pooh-poohed it away, there is no hope. But no one M.D., however learned, knows all about the ills of flesh. In this, as in the legal and other learned professions, a man may practice a score of years, and still know little or nothing about various peculiar cases, because they don't come under his notice; he has no opportunity to study them practically, and little inducement to theorize. And the class of cases we are now considering, it may surprise the sufferer to know, are deemed by many "regular" physicians beneath their attention. The physician's calling is a noble one, and he justly takes a high ground regarding his duties. We honor the scruples of our medical friends, but we do not understand nor approve the spirit which leads them to meet these cases with ridicule or evasive answers. That they do thus meet this class of cases, and that their course is censured by the most eminent of the profession, we have abundant evidence. One of the best known medical writers of England, F. B. Courtnay, member of the Royal College of Surgeons, etc., says in one of his works ("True and False Spermatorrhoea" pp. 20-21): "Again, some medical men * * * * affect to consider these cases 'objectionable,' and on these grounds seek to avoid them. Others boldly declare, that as most of such cases are the result of unnatural and immoral habits, the sufferers are justly punished for their conduct, and are unworthy of the attention and sympathy of any one. "Now I conceive this to be a monstrous fallacy; for surely it is entirely beyond the scope of any medical man's duty to sit in judgment on the applicants for his professional services. According to my idea of professional duty, every man is bound to do all in his power to afford relief to every sufferer who seeks it at his hands, without question as to the causes and nature of the malady." Speaking of one of his patients the same writer says: "He had consulted one of the most eminent members of the medical profession; and this gentleman evidently listened to his narration of his case with great impatience and indifference, and upon the conclusion of his history handed him a prescription, saying: 'There, take that for six weeks, and if it does not do you any good, I don't know what will.' The interpretation the patient put on his conduct and the remarks was, that he need not trouble himself to call again. "Now, I have the pleasure of personally knowing the professional gentleman here referred to, and during the last twenty years have been in the constant habit of meeting him in consultation, and I am sure, from my knowledge of him, that his behavior resulted from no intentional unkindness on his part, but solely from the unfortunate feeling of reluctance to attend to such cases, which, both from my own observations and from information obtained from patients, I know to be entertained by too many members of the profession. * * * I am well aware that patients of this class are often most tedious in the narration of their cases; that the details they conceive themselves bound to enter upon are most painful, not to say disgusting, to hear; nevertheless we must, as in many other instances in the discharge of our duties, submit with patience, taking the rough and smooth with the same equanimity, and in the special cases in question, we should endeavor to forget the patient's vices in his woes." Another distinguished physician writes: "I cannot disregard the appeals of unhappy and humiliated people. Men have come to me who were ashamed to show their organs because of their diminutiveness, and who practiced masturbation and lived in celibacy rather than bear the humiliation of exposure of the parts. Nothing can be more pitiable than such a condition." If these very moral and dainty practitioners, who, as Dr. Courtnay says, affect to consider these cases "objectionable" and the sufferers "unworthy of the attention or sympathy of any one"--if these moralists could sit at our desk, and day after day, week after week, read the affecting stories of enforced celibacy, shattered health, broken family ties, the anguish of jealousy, despair, misanthropy, the consciousness of physical, mental and moral inferiority begotten by this sad condition--we think that then these gentlemen would agree with us that medical science and philanthropy can have no higher object than the saving of these wrecks. OUR PATIENTS' LETTERS AND TESTIMONIALS. Our correspondents are candid--they cannot well afford to be otherwise--and it is seldom we read one of their letters without feeling all the interest in the writer that one can for an honest suffering fellow being. We would not feel this interest did they not evince an earnest desire to profit by their misfortunes. Our aid is not sought by those wishing a brute's power for excesses, for we hold out no inducements to this class, but plainly tell them that they will inevitably pay the penalty for abuse of nature's laws. Nor are our patrons among the vicious and imaginative youth, or the class termed "greenhorns." We confine our advertising almost wholly to the daily press, thus reaching the most intelligent class of citizens only. We regret that, for obvious reasons, we cannot present some of the letters we have received from those who have been treated by our method. We are pledged to secresy with our correspondents, however, and cannot use their names publicly; we cannot publish testimonials, although we have scores of such a nature as to satisfy the most incredulous, yet all must understand that it would be a breach of confidence on our part to make these public, and would ruin our practice besides, as we can only do business of this nature under guarantee of strict privacy. But of the many hundreds we have successfully treated, a number have voluntarily given us permission to refer to them in correspondence with interested parties. We will cheerfully furnish, on conditions named below, a list of some of the persons who have taken this mode of treatment, been thoroughly developed in size and strength of the organs, and relieved of every trace of seminal disease or weakness, and from gratitude and good hearts have volunteered to answer any questions addressed to them by interested persons, who are, of course, expected to hold such correspondence confidential. Bear in mind that we use these names only by permission, which was given us unsought by patrons who paid for our services, and now tender this privilege more through kindness to sufferers than a desire to benefit us financially. To save these gentlemen annoyance and useless correspondence, we prefer not to furnish their names except to those who have had previous correspondence with us and who will accompany the request with references. BASHFULNESS AND FALSE MODESTY. We are sorry to note in some of our patrons a feeling of shame in taking this treatment. Such feeling we cannot but regard as absurd, and the outgrowth of false ideas. If their present condition has been brought on by evil habits, it is well enough to be ashamed of that fact, but it is certainly altogether creditable to make use of the first opportunity to restore or attain a perfectly natural condition and check such disastrous losses, and in many cases it is absolutely necessary for the welfare and happiness of themselves and others. A well-known medical writer says: "This treatment does not interfere with any regular habits or employment, and may be followed without the knowledge or suspicion of any person whatever. It is beneficial to the general health and quite pleasant in its effects, giving the person a rejuvenated, buoyant feeling, infusing new life and manhood; seemingly dashing young strong blood through all the sluggish veins and arteries of the form." To those who really need this treatment its importance cannot be overestimated. Each sufferer can answer to himself how very different life would be if free from his infirmity. Would you not be better capacitated for business, labor or pleasure? Is not your mind on the rack often--perhaps always? Have you not at this time, and in consequence of this deficiency, a tendency to misanthrophy, a bitter feeling that you are the victim of an unkind Providence, or else bowed by humiliation due to your own ignorance or vices? Does not your very incapacity keep your mind filled with lewd thoughts, which in a state of perfect manhood would not exist? From the confession of hundreds we know how each of you will answer most or all of these questions. Is not the means, then, which will raise you above these deplorable conditions, a blessing inestimable? Is it not an agent of moral as well as physical regeneration? When this means of deliverance is offered, will you hesitate in availing yourself of its benefits and making it known to others who are sufferers like yourself? Let an honest heart and candid judgment answer for you. THE FALLACY OF CHEAP REMEDIES. There are many men who are affected more or less seriously with Diseases of the Sexual Organs who are constantly on the look-out for so-called cheap remedies, and in the course of a few years manage to spend upon these cheap and trashy medicines and appliances twice or three times as much money as would have been necessary to thoroughly cure them. And what have they got to show for it? Nothing--absolutely nothing, aye, even worse than nothing, _i.e._, positive injury to the organs, for, in nine cases out of ten, these cheap, clap-trap potions, by over stimulating, imitating and often inflaming the organs, do them actual harm, hasten and aggravate the disease and leave the patient in a much worse condition than if he had taken no treatment at all. How often have we had cases referred to us for diagnosis and treatment, where irreparable injury had been done by wrong treatment. Some were in such a state that no treatment, however excellent, could possibly help them; in others we have had to labor for months to eliminate these poisonous medicines from the system and get the Sexual Organs into proper condition to admit of a restorative treatment; and in still others the effect of our usually quick and thorough-going remedies were delayed and interfered with by the ignorance or botchwork of some quack or bungler, or the well-meant but stupid doctoring of some "family physician" who thinks himself competent to treat these diseases. No more delicate, complicated or easily injured or disarranged piece of mechanism than the Sexual Organs exists. In health, they must be treated with care and reason--in disease, with the utmost circumspection. This branch of medicine, least of all, should be the parade ground of ignorance, carelessness or false economy. A man's very health, life, happiness and vigor, his power to procreate his species, to perpetuate his name, his ability to make his wife happy and his children strong and vigorous, all depend upon the treatment he selects. What is worth doing at all is worth doing well, and he who jeopardizes health and happiness, present and future, on the mistaken basis of false economy, is far from wise. Everything has a value. If a man offers to sell to another a gold watch worth $150 for $5, you would at once set him down as an impostor, and the watch as injured or worthless or fraudulent. Yet there are thousands of men who try to find for a few dollars a remedy for a most serious and complicated disease. In medicine, as elsewhere, Common Sense plays an important part. Such remedies cannot possibly do what is claimed for them. Reputable, honest men, educated and skilled physicians who have spent thousands of dollars in obtaining a proper medical education, cannot afford to waste their time for such slight remuneration. Hence, unscrupulous scoundrels, who have no reputations either to make or lose, who make most glaring promises in their printed matter, who are willing to guarantee anything to anybody, infest this field. They know how great is man's cupidity, and trade upon it willingly, caring nothing for the consequences. OUR REMEDIES ARE RELIABLE AND REASONABLE. We not speak thus disparagingly of cheap remedies because ours are dear, for no patient who has gone the round of cheap remedies, and has at last profited by Civiale's method, but will tell you that our treatment is cheap at any price. We charge what we consider a fair and reasonable profit on our remedies. Our entire institution is conducted on the very highest and most ethical medical basis. The Physicians comprising our Consulting Staff are men of the best standing, of fine education, and having special experience in this branch of medical science; our remedies are made up under the direct personal supervision of one of the most expert chemists in this country, and precisely after Civiale's formulæ; our drugs are purchased from such firms as McKesson & Robbins, Schieffelin, etc., and are of the purest and best, and our aim at all times is to give the patient consulting us the full value of his money. For such skill and services we charge fairly and reasonably, and we have yet to find a patient who is dissatisfied. Our cases get well, provided our advice is followed and a cure is possible. If it is not, we frankly and candidly tell the truth. We cannot afford to make false statements or false promises, to hold out hopes we cannot justify, to ruin our established and well-known reputation for honesty, fair dealing and medical skill in order to make a few dollars. We find that one man cured is the very best advertisement we can have, and that one such case makes us one warm friend and advocate, and brings us many patients, where one man deceived and defrauded would make us one bitter enemy and injure us in the eyes of many. Thus, every other consideration of honor and honesty aside, it pays us better to deal fairly with our patrons. This treatment has been thoroughly tried in the most desperate and adverse cases, and has stood the test of time and repeated trials, has stood these tests as no other remedy or remedies ever have or ever will, and in them men of all ages and all conditions may find strength, health and vigor. THE CIVIALE REMEDIAL AGENCY, MAIN OFFICES AND LABORATORY, 174 FULTON STREET, NEW YORK CITY. --> Please address all Medical and Business Letters to Offices, 174 Fulton street. They may be addressed to CIVIALE AGENCY, or Mr. L. B. Jones, our Business Manager. (From the New Orleans _Weekly Picayune_, May 23, 1885.) CIVIALE REMEDIAL AGENCY.--Every man, whether he be young, middle aged, or old, suffering from weakness, debility, or impotency, will be made healthy and happy by writing to this excellent concern, at 174 Fulton street, New York. The advertisement should be read, which will show skeptics that the agency is worthy of confidence. The press and medical profession indorse the gentlemen connected with it in strong terms. A SPECIAL AND IMPORTANT ANNOUNCEMENT. STRICT MORALITY vs. FALSE MODESTY. In preparing both the first and later editions of this little work (that has brought happiness to so many by opening the way to knowledge of a proper means of cure and methods of regaining health and vigor), +the utmost care and circumspection have been exercised in an endeavor to exclude from its pages anything that could be construed by the most fastidious as immodest, obscene, or in any way offensive to decency, morality or good breeding+. Indeed, although purely and essentially +a medical work, and intended solely for such persons whose duty it is to be acquainted with the facts given+, in order to understand their complaint, to place themselves under proper treatment, and to avoid the dangers of quackery, we have in many instances wholly excluded or materially modified the wording of passages in order to comply with our original ideas of the strictest purity of thought and speech commensurate with a truthful and honest statement of facts. We wish it distinctly understood that +this treatise is intended solely for persons suffering from Genito-Urinary Diseases+, and that it is +never mailed to any person who has not voluntarily requested us to send it+, and then +not to boys+ or to members of the +opposite sex+. (Our application books show a large number of such refusals.) We look upon our special mission in the field of medicine as +distinct+, +laudable+ and +holy+. There are those who look down upon this special branch of medicine, and some ignoramuses who assert that such diseases only exist in the imaginations of such patients as a result of reading the pamphlets of quacks who paint frightful pictures of insanity, idiocy, etc. To such men as these we have only this to say: Consult the works of Hammond, Black, Acton, Wilson, Lallemand, Civialè, Courtenay, Lee etc., etc., the authors of which have world-wide reputations, not only as physicians, but as truthful, honest and moral men. They will then see how really grave are such affections and how needful of aid. God knows that the misery, despondency and actual organic disease, as a result of early vices, are prevalent enough even to-day to make a lover of his fellow men sincerely pity and desire to help them. And we claim (and every honest man cannot but admit) that it is only by the +widespread dissemination of a knowledge of certain facts+ to young and old, especially the former, that such vice and its consequences can be met and overcome. We are daily spreading such knowledge throughout the length and breadth of this land, not only warning and advising the young and cautioning the older, but also pointing out to all such as need it a perfect and easy means of cure and restoration to health and vigor. Our mission is as real, noble and important as that of preaching the Gospel, and aside from its bearing on the enlightenment of those who would otherwise go astray, and offering the means of relief to those who have already sinned against Nature, it is of a broader and even more sweeping importance. As every whole must needs be the sum total of its integrals, so +each nation+ and +people must+--in mental, moral and physical traits--+be that which its individual members make it+. Hence, if perfect general health, full procreative ability and healthy offspring mark the majority of the individuals, so naturally must the health, vigor, populousness and power of the nation be accordingly. +As secret vice diminishes, public virtue and morality become greater.+ Diseases of the Prostate Gland, Urinary Organs and Sexual Apparatus are as +real, as embarassing+ and +as needful of cure+ as those of the lungs, heart, stomach, or any other organ--indeed, more important, for the latter only affect the life or health of the individual immediately concerned, while the former concern not only the person affected, but his offspring also. There is no reason why false modesty or pseudo-delicacy should reign supreme here. If the Almighty had intended these matters to be viewed and treated in the light which some fanatics and extremists seem to desire, we would certainly have been created without the power of procreation entirely. As it is, such organs and such diseases +do exist+, are of the greatest (individual and national) importance, and provided a +full knowledge of the causes and consequences of vice and abuse as related to these parts can be brought vividly and strongly before the mind of every man, young or old, in a chaste, decent and strictly professional manner+, the result can only be a good one, and those who deny it are engaged in moral hair-splitting. We felt that the foregoing remarks were both +apropos+ and necessary with a view to contradicting some statements recently made regarding the uselessness and demoralizing effects of everything concerning this branch of medical practice, and as due ourselves in distinctly recording our belief and practice in the matter; more especially to refute the false accusation that special medical treatises were being scattered broadcast over the land and made to invade the privacy of homes, and coming into the hands of young boys and females. THE CIVIALÈ REMEDIAL AGENCY. {Illustration (Civiale Agency)} * * * * * * * * * * * * * * {Errors and irregularities noted by transcriber: Civiale : Civialè _inconsistent spellings in original_ the secrecy of his chamber or his bed or, if secresy is desired the strictest confidence and secrecy We are pledged to secresy _variant spellings in original_ HUMAN SPERMATAZOA. ... well developed and active zoa-sperms to their freinds +Impotency+ (from the Latin words _im_ [not] and _potens_ [to be able] _no closing parenthesis_ {Footnote 7: Beltrage zur anat-uns Phys., Bd. iv. and Bd. vii.} {Footnote 20: Endoskopische Befunde bei Erkrankungen des Samenhugels Wein, 1880.} _Spelling and punctuation of all footnotes as in original._ _Footnotes 1-25 were printed in a block, although the text referencing 24 and 25 was on the following page._ Bloody Urination, etc., etc. (Many cases of _no closing parenthesis_ in accordance with the formlæ [_Appleton's Cyclopedia, vol. x, p. 144._ [_Appleton's Cyclopedia, vol. iv, p. 618._ _open-ended brackets in original_ _"vol. iv" illegible_ (_Paris_), 1827) _extra parenthesis in original_ Again, some medical men * * * * affect to consider too many members of the profession. * * * I am well aware _asterisks in original_ your doctor told me I musn't feel sure a tendency to misanthrophy as +real, as embarassing+ and +as needful of cure+ } 
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27203	----	[Note: many of the people quoted in this text are identified only by their initials along with either a dash or three periods. For consistency's sake, I have used four dashes for each person instead of periods. I have also added quotation marks where appropriate. Finally, I have made the following spelling change: I congraulate you to I congratulate you.] SELF MASTERY THROUGH CONSCIOUS AUTOSUGGESTION by EMILE COUÉ AMERICAN LIBRARY SERVICE PUBLISHERS 500 FIFTH AVENUE NEW YORK Copyright 1922 _by_ AMERICAN LIBRARY SERVICE _All Translation Rights Reserved_ CONTENTS Self Mastery Through Conscious Autosuggestion, by _Emile Coué_ 5 Thoughts and Precepts, by _Emile Coué_ 36 Observations on What Autosuggestion Can Do, by _Emile Coué_ 43 Education As It Ought To Be, by _Emile Coué_ 50 A Survey of the "Séances" at M. Emile Coué's 55 Letters from Patients Treated by the Coué Method 62, 72, 75 The Miracle Within, by _M. Burnet-Provins_ 80 Some Notes on the Journey of M. Coué to Paris in October, 1919 85 Everything for Everyone! by Mme. Emile Leon 88 [Illustration of Emile Coué] SELF MASTERY THROUGH CONSCIOUS AUTOSUGGESTION Suggestion, or rather Autosuggestion, is quite a new subject, and yet at the same time it is as old as the world. It is new in the sense that until now it has been wrongly studied and in consequence wrongly understood; it is old because it dates from the appearance of man on the earth. In fact autosuggestion is an instrument that we possess at birth, and in this instrument, or rather in this force, resides a marvelous and incalculable power, which according to circumstances produces the best or the worst results. Knowledge of this force is useful to each one of us, but it is peculiarly indispensable to doctors, magistrates, lawyers, and to those engaged in the work of education. By knowing how to practise it _consciously_ it is possible in the first place to avoid provoking in others bad autosuggestions which may have disastrous consequences, and secondly, consciously to provoke good ones instead, thus bringing physical health to the sick, and moral health to the neurotic and the erring, the unconscious victims of anterior autosuggestions, and to guide into the right path those who had a tendency to take the wrong one. THE CONSCIOUS SELF AND THE UNCONSCIOUS SELF In order to understand properly the phenomena of suggestion, or to speak more correctly of autosuggestion, it is necessary to know that two absolutely distinct selves exist within us. Both are intelligent, but while one is conscious the other is unconscious. For this reason the existence of the latter generally escapes notice. It is however easy to prove its existence if one merely takes the trouble to examine certain phenomena and to reflect a few moments upon them. Let us take for instance the following examples: Every one has heard of somnambulism; every one knows that a somnambulist gets up at night _without waking_, leaves his room after either dressing himself or not, goes downstairs, walks along corridors, and after having executed certain acts or accomplished certain work, returns to his room, goes to bed again, and shows next day the greatest astonishment at finding work finished which he had left unfinished the day before. It is however he himself who has done it without being aware of it. What force has his body obeyed if it is not an unconscious force, in fact his unconscious self? Let us now examine the alas, too frequent case of a drunkard attacked by _delirium tremens_. As though seized with madness he picks up the nearest weapon, knife, hammer, or hatchet, as the case may be, and strikes furiously those who are unlucky enough to be in his vicinity. Once the attack is over, he recovers his senses and contemplates with horror the scene of carnage around him, without realizing that he himself is the author of it. Here again is it not the unconscious self which has caused the unhappy man to act in this way? [*] [*] And what aversions, what ills we create for ourselves, everyone of us and in every domain by not "immediately" bringing into play "good conscious autosuggestions" against our "bad unconscious autosuggestions," thus bringing about the disappearance of all unjust suffering. If we compare the conscious with the unconscious self we see that the conscious self is often possessed of a very unreliable memory while the unconscious self on the contrary is provided with a marvelous and impeccable memory which registers without our knowledge the smallest events, the least important acts of our existence. Further, it is credulous and accepts with unreasoning docility what it is told. Thus, as it is the unconscious that is responsible for the functioning of all our organs but the intermediary of the brain, a result is produced which may seem rather paradoxical to you: that is, if it believes that a certain organ functions well or ill or that we feel such and such an impression, the organ in question does indeed function well or ill, or we do feel that impression. Not only does the unconscious self preside over the functions of our organism, but also over _all our actions whatever they are_. It is this that we call imagination, and it is this which, contrary to accepted opinion, _always_ makes us act even, and _above all_, against _our will_ when there is antagonism between these two forces. WILL AND IMAGINATION If we open a dictionary and look up the word "will", we find this definition: "The faculty of freely determining certain acts". We accept this definition as true and unattackable, although nothing could be more false. This will that we claim so proudly, always _yields_ to the imagination. It is an _absolute_ rule that admits of no _exception_. "Blasphemy! Paradox!" you will exclaim. "Not at all! On the contrary, it is the purest truth," I shall reply. In order to convince yourself of it, open your eyes, look round you and try to understand what you see. You will then come to the conclusion that what I tell you is not an idle theory, offspring of a sick brain but the simple expression of a _fact_. Suppose that we place on the ground a plank 30 feet long by 1 foot wide. It is evident that everybody will be capable of going from one end to the other of this plank without stepping over the edge. But now change the conditions of the experiment, and imagine this plank placed at the height of the towers of a cathedral. Who then will be capable of advancing even a few feet along this narrow path? Could you hear me speak? Probably not. Before you had taken two steps you would begin to tremble, and _in spite of every effort of your will_ you would be certain to fall to the ground. Why is it then that you would not fall if the plank is on the ground, and why should you fall if it is raised to a height above the ground? Simply because in the first case you imagine that it is easy to go to the end of this plank, while in the second case you _imagine_ that you _cannot_ do so. Notice that your will is powerless to make you advance; if you _imagine_ that you _cannot_, it is _absolutely_ impossible for you to do so. If tilers and carpenters are able to accomplish this feat, it is because they think they can do it. Vertigo is entirely caused by the picture we make in our minds that we are going to fall. This picture transforms itself immediately into fact _in spite of all the efforts of our will_, and the more violent these efforts are, the quicker is the opposite to the desired result brought about. Let us now consider the case of a person suffering from insomnia. If he does not make any effort to sleep, he will lie quietly in bed. If on the contrary he tries to force himself to sleep by his _will_, the more efforts he makes, the more restless he becomes. Have you not noticed that the more you try to remember the name of a person which you have forgotten, the more it eludes you, until, substituting in your mind the idea "I shall remember in a minute" to the idea "I have forgotten", the name comes back to you of its own accord without the least effort? Let those of you who are cyclists remember the days when you were learning to ride. You went along clutching the handle bars and frightened of falling. Suddenly catching sight of the smallest obstacle in the road you tried to avoid it, and the more efforts you made to do so, the more surely you rushed upon it. Who has not suffered from an attack of uncontrollable laughter, which bursts out more violently the more one tries to control it? What was the state of mind of each person in these different circumstances? "_I do not want_ to fall but I _cannot help_ doing so"; "I _want_ to sleep but I _cannot_ "; "I _want_ to remember the name of Mrs. So and So, but I _cannot_ "; "I _want_ to avoid the obstacle, but I _cannot_ "; "I _want_ to stop laughing, but I _cannot_." As you see, in each of these conflicts it is always the _imagination_ which gains the victory over the _will_, without any exception. To the same order of ideas belongs the case of the leader who rushes forward at the head of his troops and always carries them along with him, while the cry "Each man for himself!" is almost certain to cause a defeat. Why is this? It is because in the first case the men _imagine_ that they must go _forward_, and in the second they _imagine_ that they are conquered and must fly for their lives. Panurge was quite aware of the contagion of example, that is to say the action of the imagination, when, to avenge himself upon a merchant on board the same boat, he bought his biggest sheep and threw it into the sea, certain beforehand that the entire flock would follow, which indeed happened. We human beings have a certain resemblance to sheep, and involuntarily, we are irresistibly impelled to follow other people's examples, _imagining_ that we cannot do otherwise. I could quote a thousand other examples but I should fear to bore you by such an enumeration. I cannot however pass by in silence this fact which shows the enormous power of the imagination, or in other words of the unconscious in its struggle against the _will_. There are certain drunkards who wish to give up drinking, but who cannot do so. Ask them, and they will reply in all sincerity that they desire to be sober, that drink disgusts them, but that they are irresistibly impelled to drink against their _will_, in spite of the harm they know it will do them. In the same way certain criminals commit crimes _in spite of themselves_, and when they are asked why they acted so, they answer "I could not help it, something impelled me, it was stronger than I." And the drunkard and the criminal speak the truth; they are forced to do what they do, for the simple reason they imagine they cannot prevent themselves from doing so. Thus we who are so proud of our will, who believe that we are free to act as we like, are in reality nothing but wretched puppets of which our imagination holds all the strings. We only cease to be puppets when we have learned to guide our imagination. SUGGESTION AND AUTOSUGGESTION According to the preceding remarks we can compare the imagination to a torrent which fatally sweeps away the poor wretch who has fallen into it, in spite of his efforts to gain the bank. This torrent seems indomitable; but if you know how, you can turn it from its course and conduct it to the factory, and there you can transform its force into movement, heat, and electricity. If this simile is not enough, we may compare the imagination--"the madman at home" as it has been called--to an unbroken horse which has neither bridle nor reins. What can the rider do except let himself go wherever the horse wishes to take him? And often if the latter runs away, his mad career only comes to end in the ditch. If however the rider succeeds in putting a bridle on the horse, the parts are reversed. It is no longer the horse who goes where he likes, it is the rider who obliges the horse to take him wherever he wishes to go. Now that we have learned to realize the enormous power of the unconscious or imaginative being, I am going to show how this self, hitherto considered indomitable, can be as easily controlled as a torrent or an unbroken horse. But before going any further it is necessary to define carefully two words that are often used without being properly understood. These are the words _suggestion_ and _autosuggestion_. What then is suggestion? It may be defined as "the act of imposing an idea on the brain of another". Does this action really exist? Properly speaking, no. Suggestion does not indeed exist by itself. It does not and cannot exist except on the _sine qua non_ condition of transforming itself into _autosuggestion_ in the subject. This latter word may be defined as "the implanting of an idea in oneself by oneself." You may make a suggestion to someone; if the unconscious of the latter does not accept the suggestion, if it has not, as it were, digested it, in order to transform it into _autosuggestion_, it produces no result. I have myself occasionally made a more or less commonplace suggestion to ordinarily very obedient subjects quite unsuccessfully. The reason is that the unconscious of the subject refused to accept it and did not transform it into _autosuggestion_. THE USE OF AUTOSUGGESTION Let us now return to the point where I said that we can control and lead our imagination, just as a torrent or an unbroken horse can be controlled. To do so, it is enough in the first place to know that this is possible (of which fact almost everyone is ignorant) and secondly, to know by what means it can be done. Well, the means is very simple; it is that which we have used every day since we came into the world, without wishing or knowing it and absolutely unconsciously, but which unfortunately for us, we often use wrongly and to our own detriment. This means is _autosuggestion_. Whereas we constantly give ourselves unconscious autosuggestions, all we have to do is to give ourselves conscious ones, and the process consists in this: first, to weigh carefully in one's mind the things which are to be the object of the autosuggestion, and according as they require the answer "yes" or "no" to repeat several times without thinking of anything else: "This thing is coming", or "this thing is going away"; "this thing will, or will not happen, etc., etc. . . ." [*] If the unconscious accepts this suggestion and transforms it into an autosuggestion, the thing or things are realized in every particular. [*] Of course the thing must be in our power. Thus understood, _autosuggestion_ is nothing but hypnotism as I see it, and I would define it in these simple words: _The influence of the imagination upon the moral and physical being of mankind_. Now this influence is undeniable, and without returning to previous examples, I will quote a few others. If you persuade yourself that you can do a certain thing, provided this thing be _possible_, you will do it however difficult it may be. If on the contrary you _imagine_ that you cannot do the simplest thing in the world, it is impossible for you to do it, and molehills become for you unscalable mountains. Such is the case of neurasthenics, who, believing themselves incapable of the least effort, often find it impossible even to walk a few steps without being exhausted. And these same neurasthenics sink more deeply into their depression, the more efforts they make to throw it off, like the poor wretch in the quicksands who sinks in all the deeper the more he tries to struggle out. In the same way it is sufficient to think a pain is going, to feel it indeed disappear little by little, and inversely, it is enough to think that one suffers in order to feel the pain begin to come immediately. I know certain people who predict in advance that they will have a sick headache on a certain day, in certain circumstances, and on that day, in the given circumstances, sure enough, they feel it. They brought their illness on themselves, just as others cure theirs by _conscious autosuggestion_. I know that one generally passes for mad in the eyes of the world if one dares to put forward ideas which it is not accustomed to hear. Well, at the risk of being thought so, I say that if certain people are ill mentally and physically, it is that they _imagine_ themselves to be ill mentally or physically. If certain others are paralytic without having any lesion to account for it, it is that they _imagine_ themselves to be paralyzed, and it is among such persons that the most extraordinary cures are produced. If others again are happy or unhappy, it is that they imagine themselves to be so, for it is possible for two people in exactly the same circumstances to be, the one _perfectly happy_, the other _absolutely wretched_. Neurasthenia, stammering, aversions, kleptomania, certain cases of paralysis, are nothing but the result of unconscious autosuggestion, that is to say the result of the action of the _unconscious_ upon the physical and moral being. But if our unconscious is the source of many of our ills, it can also bring about the cure of our physical and mental ailments. It can not only repair the ill it has done, but cure real illnesses, so strong is its action upon our organism. Shut yourself up alone in a room, seat yourself in an armchair, close your eyes to avoid any distraction, and concentrate your mind for a few moments on thinking: "Such and such a thing is going to disappear", or "Such and such a thing is coming to pass." If you have really made the autosuggestion, that is to say, if your unconscious has assimilated the idea that you have presented to it, you are astonished to see the thing you have thought come to pass. (Note that it is the property of ideas autosuggested to exist within us unrecognized, and we can only know of their existence by the effect they produce.) But above all, and this is an essential point, the will must not be brought into play in practising autosuggestion; for, if it is not in agreement with the imagination, if one thinks: "I will make such and such a thing happen", and the imagination says: "You are willing it, but it is not going to be", not only does one not obtain what one wants, but even exactly the reverse is brought about. This remark is of capital importance, and explains why results are so unsatisfactory when, in treating moral ailments, one strives to _re-educate_ the will. It is the _training of the imagination_ which is necessary, and it is thanks to this shade of difference that my method has often succeeded where others--and those not the least considered--have failed. From the numerous experiments that I have made daily for twenty years, and which I have examined with minute care, I have been able to deduct the following conclusions which I have summed up as laws: 1. When the will and the imagination are antagonistic, it is always the imagination which wins, _without any exception_. 2. In the conflict between the will and the imagination, the force of the imagination is in _direct ratio to the square of the will_. 3. When the will and the imagination are in agreement, one does not add to the other, but one is multiplied by the other. 4. The imagination can be directed. (The expressions "In direct ratio to the square of the will" and "Is multiplied by" are not rigorously exact. They are simply illustrations destined to make my meaning clearer.) After what has just been said it would seem that nobody ought to be ill. That is quite true. Every illness, whatever it may be, _can_ yield to _autosuggestion_, daring and unlikely as my statement may seem; I do not say _does always yield_, but _can yield_, which is a different thing. But in order to lead people to practise conscious autosuggestion they must be taught how, just as they are taught to read or write or play the piano. _Autosuggestion_ is, as I said above, an instrument that we possess at birth, and with which we play unconsciously all our life, as a baby plays with its rattle. It is however a dangerous instrument; it can wound or even kill you if you handle it imprudently and unconsciously. It can on the contrary save your life when you know how to employ it _consciously_. One can say of it as Aesop said of the tongue: "It is at the same time the best and the worst thing in the world". I am now going to show you how everyone can profit by the beneficent action of _autosuggestion_ consciously applied. In saying "every one", I exaggerate a little, for there are two classes of persons in whom it is difficult to arouse conscious autosuggestion: 1. The mentally undeveloped who are not capable of understanding what you say to them. 2. _Those who are unwilling to understand_. HOW TO TEACH PATIENTS TO MAKE AUTOSUGGESTIONS The principle of the method may be summed up in these few words: _It is impossible to think of two things at once_, that is to say that two ideas may be in juxtaposition, but they cannot be superimposed in our mind. _Every thought entirely filling our mind becomes true for us and tends to transform itself into action_. Thus if you can make a sick person think that her trouble is getting better, it will disappear; if you succeed in making a kleptomaniac think that he will not steal any more, he will cease to steal, etc., etc. This training which perhaps seems to you an impossibility, is, however, the simplest thing in the world. It is enough, by a series of appropriate and graduated experiments, to teach the subject, as it were the A. B. C. of conscious thought, and here is the series: by following it to the letter one can be absolutely sure of obtaining a good result, except with the two categories of persons mentioned above. _First experiment_.[*] _Preparatory_.--Ask the subject to stand upright, with the body as stiff as an iron bar, the feet close together from toe to heel, while keeping the ankles flexible as if they were hinges. Tell him to make himself like a plank with hinges at its base, which is balanced on the ground. Make him notice that if one pushes the plank slightly either way it falls as a mass without any resistance, in the direction in which it is pushed. Tell him that you are going to pull him back by the shoulders and that he must let himself fall in your arms without the slightest resistance, turning on his ankles as on hinges, that is to say keeping the feet fixed to the ground. Then pull him back by the shoulders and if the experiment does not succeed, repeat it until it does, or nearly so. [*] These experiments are those of Sage of Rochester. _Second experiment_.--Begin by explaining to the subject that in order to demonstrate the action of the imagination upon us, you are going to ask him in a moment to think: "I am falling backwards, I am falling backwards. . . ." Tell him that he must have no thought but this in his mind, that he must not reflect or wonder if he is going to fall or not, or think that if he falls he may hurt himself, etc., or fall back purposely to please you, but that if he really feels something impelling him to fall backwards, he must not resist but obey the impulse. Then ask your subject to raise the head high and to shut his eyes, and place your right fist on the back of his neck, and your left hand on his forehead, and say to him: "Now think: I am falling backwards, I am falling backwards, etc., etc. . ." and, indeed, "You are falling backwards, You . . . are . . . fall . . . ing . . . back . . . wards, etc." At the same time slide the left hand lightly backwards to the left temple, above the ear, and remove very slowly but with a continuous movement the right fist. The subject is immediately felt to make a slight movement backwards, and either to stop himself from falling or else to fall completely. In the first case, tell him that he has resisted, and that he did not think just that he was falling, but that he might hurt himself if he did fall. That is true, for if he had not thought the latter, he would have fallen like a block. Repeat the experiment using a tone of command as if you would force the subject to obey you. Go on with it until it is completely successful or very nearly so. The operator should stand a little behind the subject, the left leg forward and the right leg well behind him, so as not to be knocked over by the subject when he falls. Neglect of this precaution might result in a double fall if the person is heavy. _Third experiment_.--Place the subject facing you, the body still stiff, the ankles flexible, and the feet joined and parallel. Put your two hands on his temples without any pressure, look fixedly, without moving the eyelids, at the root of his nose, and tell him to think: "I am falling forward, I am falling forward . . ." and repeat to him, stressing the syllables, "You are fall . . . ing . . . for . . . ward, You are fall . . . ing . . . for . . . ward . . ." without ceasing to look fixedly at him. _Fourth experiment_.--Ask the subject to clasp his hands as tight as possible, that is to say, until the fingers tremble slightly, look at him in the same way as in the preceding experiment and keep your hands on his as though to squeeze them together still more tightly. Tell him to think that he cannot unclasp his fingers, that you are going to count three, and that when you say "three" he is to try to separate his hands while thinking all the time: "I cannot do it, I cannot do it . . ." and he will find it impossible. Then count very slowly, "one, two, three", and add immediately, detaching the syllables: "You . . . can . . . not . . . do . . . it. . . . You . . . can . . . not . . . do . . . it. . . ." If the subject is thinking properly, "I cannot do it", not only is he unable to separate his fingers, but the latter clasp themselves all the more tightly together the more efforts he makes to separate them. He obtains in fact exactly the contrary to what he wants. In a few moments say to him: "Now think: 'I can do it,'" and his fingers will separate themselves. Be careful always to keep your eyes fixed on the root of the subject's nose, and do not allow him to turn his eyes away from yours for a single moment. If he is able to unclasp his hands, do not think it is your own fault, it is the subject's, he has not properly thought: "I cannot". Assure him firmly of this, and begin the experiment again. Always use a tone of command which suffers no disobedience. I do not mean that it is necessary to raise your voice; on the contrary it is preferable to employ the ordinary pitch, but stress every word in a dry and imperative tone. When these experiments have been successful, all the others succeed equally well and can be easily obtained by carrying out to the letter the instructions given above. Some subjects are very sensitive, and it is easy to recognize them by the fact that the contraction of their fingers and limbs is easily produced. After two or three successful experiments, it is no longer necessary to say to them: "Think this", or "think that"; You need only, for example, say to them simply--but in the imperative tone employed by all good suggestionists--"Close your hands; now you cannot open them". "Shut your eyes; now you cannot open them," and the subject finds it absolutely impossible to open the hands or the eyes in spite of all his efforts. Tell him in a few moments: "You can do it now," and the de-contraction takes place instantaneously. These experiments can be varied to infinity. Here are a few more: Make the subject join his hands, and suggest that they are welded together; make him put his hand on the table, and suggest that it is stuck to it; tell him that he is fixed to his chair and cannot rise; make him rise, and tell him he cannot walk; put a penholder on the table and tell him that it weighs a hundredweight, and that he cannot lift it, etc., etc. In all these experiments, I cannot repeat too often, it is not _suggestion_ properly so-called which produces the phenomena, but the _autosuggestion_ which is consecutive to the suggestion of the operator. METHOD OF PROCEDURE IN CURATIVE SUGGESTION When the subject has passed through the preceding experiments and has understood them, he is ripe for curative suggestion. He is like a cultivated field in which the seed can germinate and develop, whereas before it was but rough earth in which it would have perished. Whatever ailment the subject suffers from, whether it is physical or mental, it is important to proceed always in the same way, and to use the same words with a few variations according to the case. Say to the subject: Sit down and close your eyes. I am not going to try and put you to sleep as it is quite unnecessary. I ask you to close your eyes simply in order that your attention may not be distracted by the objects around you. Now tell yourself that every word I say is going to fix itself in your mind, and be printed, engraved, and encrusted in it, that, there, it is going to stay fixed, imprinted, and encrusted, and that without your will or knowledge, in fact perfectly unconsciously on your part, you yourself and your whole organism are going to obey. In the first place I say that every day, three times a day, in the morning, at midday, and in the evening, at the usual meal times, you will feel hungry, that is to say, you will experience the agreeable sensation which makes you think and say: "Oh! how nice it will be to have something to eat!" You will then eat and enjoy your food, without of course overeating. You will also be careful to masticate it properly so as to transform it into a sort of soft paste before swallowing it. In these conditions you will digest it properly, and so feel no discomfort, inconvenience, or pain of any kind either in the stomach or intestines. You will assimilate what you eat and your organism will make use of it to make blood, muscle, strength and energy, in a word: Life. Since you will have digested your food properly, the function of excretion will be normal, and every morning, on rising, you will feel the need of evacuating the bowels, and without ever being obliged to take medicine or to use any artifice, you will obtain a normal and satisfactory result. Further, every night from the time you wish to go to sleep till the time you wish to wake next morning, you will sleep deeply, calmly, and quietly, without nightmares, and on waking you will feel perfectly well, cheerful, and active. Likewise, if you occasionally suffer from depression, if you are gloomy and prone to worry and look on the dark side of things, from now onwards you will cease to do so, and, instead of worrying and being depressed and looking on the dark side of things, you are going to feel perfectly cheerful, possibly without any special reason for it, just as you used to feel depressed for no particular reason. I say further still, that even if you have real reason to be worried and depressed you are not going to be so. If you are also subject to occasional fits of impatience or ill-temper you will cease to have them: on the contrary you will be always patient and master of yourself, and the things which worried, annoyed, or irritated you, will henceforth leave you absolutely indifferent and perfectly calm. If you are sometimes attacked, pursued, haunted, by bad and unwholesome ideas, by apprehensions, fears, aversions, temptations, or grudges against other people, all that will be gradually lost sight of by your imagination, and will melt away and lose itself as though in a distant cloud where it will finally disappear completely. As a dream vanishes when we wake, so will all these vain images disappear. To this I add that all your organs are performing their functions properly. The heart beats in a normal way and the circulation of the blood takes place as it should; the lungs are carrying out their functions, as also the stomach, the intestines, the liver, the biliary duct, the kidneys and the bladder. If at the present moment any of them is acting abnormally, that abnormality is becoming less every day, so that quite soon it will have vanished completely, and the organ will have recovered its normal function. Further, if there should be any lesions in any of these organs, they will get better from day to day and will soon be entirely healed. (With regard to this, I may say that it is not necessary to know which organ is affected for it to be cured. Under the influence of the autosuggestion "Every day, in every respect, I am getting better and better", the unconscious acts upon the organ which it can pick out itself.) I must also add--and it is extremely important--that if up to the present you have lacked confidence in yourself, I tell you that this self-distrust will disappear little by little and give place to self-confidence, based on the knowledge of this force of incalculable power which is in each one of us. It is absolutely necessary for every human being to have this confidence. Without it one can accomplish nothing, with it one can accomplish whatever one likes, (within reason, of course). You are then going to have confidence in yourself, and this confidence gives you the assurance that you are capable of accomplishing perfectly well whatever you wish to do, --_on condition that it is reasonable_,--and whatever it is your duty to do. So when you wish to do something reasonable, or when you have a duty to perform, always think that it is _easy_, and make the words _difficult, impossible, I cannot, it is stronger than I, I cannot prevent myself from_. . . , disappear from your vocabulary; they are not English. What is English is: "_It is easy and I can_ ". By considering the thing easy it becomes so for you, although it might seem difficult to others. You will do it quickly and well, and without fatigue, because you do it without effort, whereas if you had considered it as difficult or impossible it would have become so for you, simply because you would have thought it so. To these general suggestions which will perhaps seem long and even childish to some of you, but which are necessary, must be added those which apply to the particular case of the patient you are dealing with. All these suggestions must be made in a monotonous and soothing voice (always emphasizing the essential words), which although it does not actually send the subject to sleep, at least makes him feel drowsy, and think of nothing in particular. When you have come to the end of the series of suggestions you address the subject in these terms: "In short, I mean that from every point of view, physical as well as mental, you are going to enjoy excellent health, better health than that you have been able to enjoy up to the present. Now I am going to count three, and when I say 'Three', you will open your eyes and come out of the passive state in which you are now. You will come out of it quite naturally, without feeling in the least drowsy or tired, on the contrary, you will feel strong, vigorous, alert, active, full of life; further still, you will feel very cheerful and fit in every way. 'ONE--TWO--THREE--' At the word 'three' the subject opens his eyes, always with a smile and an expression of well-being and contentment on his face." Sometimes,--though rarely,--the patient is cured on the spot; at other times, and this is more generally the case, he finds himself relieved, his pain or his depression has partially or totally disappeared, though only for a certain lapse of time. In every case it is necessary to renew the suggestions more or less frequently according to your subject, being careful always to space them out at longer and longer intervals, according to the progress obtained until they are no longer necessary,--that is to say when the cure is complete. Before sending away your patient, you must tell him that he carries within him the instrument by which he can cure himself, and that you are, as it were, only a professor teaching him to use this instrument, and that he must help you in your task. Thus, every morning before rising, and every night on getting into bed, he must shut his eyes and in thought transport himself into your presence, and then repeat twenty times consecutively in a monotonous voice, counting by means of a string with twenty knots in it, this little phrase: "EVERY DAY, IN EVERY RESPECT, I AM GETTING BETTER AND BETTER." In his mind he should emphasize the words "_in every respect_" which applies to every need, mental or physical. This general suggestion is more efficacious than special ones. Thus it is easy to realize the part played by the giver of the suggestions. He is not a master who gives orders, but a friend, a guide, who leads the patient step by step on the road to health. As all the suggestions are given in the interest of the patient, the unconscious of the latter asks nothing better than to assimilate them and transform them into autosuggestions. When this has been done, the cure is obtained more or less rapidly according to circumstances. THE SUPERIORITY OF THIS METHOD This method gives absolutely marvelous results, and it is easy to understand why. Indeed, by following out my advice, it is impossible to fail, except with the two classes of persons mentioned above, who fortunately represent barely 3 per cent of the whole. If, however, you try to put your subjects to sleep right away, without the explanations and preliminary experiments necessary to bring them to accept the suggestions and to transform them into autosuggestions you cannot and will not succeed except with peculiarly sensitive subjects, and these are rare. Everybody may become so by training, but very few are so sufficiently without the preliminary instruction that I recommend, which can be done in a few minutes. Formerly, imagining that suggestions could only be given during sleep, I always tried to put my patient to sleep; but on discovering that it was not indispensable, I left off doing it in order to spare him the dread and uneasiness he almost always experiences when he is told that he is going to be sent to sleep, and which often makes him offer, in spite of himself, an involuntary resistance. If, on the contrary, you tell him that you are not going to put him to sleep as there is no need to do so, you gain his confidence. He listens to you without fear or any ulterior thought, and it often happens--if not the first time, anyhow very soon--that, soothed by the monotonous sound of your voice, he falls into a deep sleep from which he awakes astonished at having slept at all. If there are sceptics among you--as I am quite sure there are--all I have to say to them is: "Come to my house and see what is being done, and you will be convinced by fact." You must not however run away with the idea that autosuggestion can only be brought about in the way I have described. It is possible to make suggestions to people without their knowledge and without any preparation. For instance, if a doctor who by his title alone has a suggestive influence on his patient, tells him that he can do nothing for him, and that his illness is incurable, he provokes in the mind of the latter an autosuggestion which may have the most disastrous consequences; if however he tells him that his illness is a serious one, it is true, but that with care, time, and patience, he can be cured, he sometimes and even often obtains results which will surprise him. Here is another example: if a doctor after examining his patient, writes a prescription and gives it to him without any comment, the remedies prescribed will not have much chance of succeeding; if, on the other hand, he explains to his patient that such and such medicines must be taken in such and such conditions and that they will produce certain results, those results are practically certain to be brought about. If in this hall there are medical men or brother chemists, I hope they will not think me their enemy. I am on the contrary their best friend. On the one hand I should like to see the theoretical and practical study of suggestion on the syllabus of the medical schools for the great benefit of the sick and of the doctors themselves; and on the other hand, in my opinion, every time that a patient goes to see his doctor, the latter should order him one or even several medicines, even if they are not necessary. As a matter of fact, when a patient visits his doctor, it is in order to be told what medicine will cure him. He does not realize that it is the hygiene and regimen which do this, and he attaches little importance to them. It is a medicine that he wants. In my opinion, if the doctor only prescribes a regimen without any medicine, his patient will be dissatisfied; he will say that he took the trouble to consult him for nothing, and often goes to another doctor. It seems to me then that the doctor should always prescribe medicines to his patient, and, as much as possible, medicines made up by himself rather than the standard remedies so much advertised and which owe their only value to the advertisement. The doctor's own prescriptions will inspire infinitely more confidence than So and So's pills which anyone can procure easily at the nearest drug store without any need of a prescription. HOW SUGGESTION WORKS In order to understand properly the part played by suggestion or rather by autosuggestion, it is enough to know that the _unconscious self is the grand director of all our functions_. Make this believed, as I said above, that a certain organ which does not function well must perform its function, and instantly the order is transmitted. The organ obeys with docility, and either at once or little by little performs its functions in a normal manner. This explains simply and clearly how by means of suggestion one can stop haemorrhages, cure constipation, cause fibrous tumours to disappear, cure paralysis, tubercular lesions, varicose, ulcers, etc. Let us take for example, a case of dental haemorrhage which I had the opportunity of observing in the consulting room of M. Gauthé, a dentist at Troyes. A young lady whom I had helped to cure herself of asthma from which she had suffered for eight years, told me one day that she wanted to have a tooth out. As I knew her to be very sensitive, I offered to make her feel nothing of the operation. She naturally accepted with pleasure and we made an appointment with the dentist. On the day we had arranged we presented ourselves at the dentist's and, standing opposite my patient, I looked fixedly at her, saying: "You feel nothing, you feel nothing, etc., etc." and then while still continuing the suggestion I made a sign to the dentist. In an instant the tooth was out without Mlle. D---- turning a hair. As fairly often happens, a haemorrhage followed, but I told the dentist that I would try suggestion without his using a haemostatic, without knowing beforehand what would happen. I then asked Mlle. D---- to look at me fixedly, and I suggested to her that in two minutes the haemorrhage would cease of its own accord, and we waited. The patient spat blood again once or twice, and then ceased. I told her to open her mouth, and we both looked and found that a clot of blood had formed in the dental cavity. How is this phenomenon to be explained? In the simplest way. Under the influence of the idea: "The haemorrhage is to stop", the unconscious had sent to the small arteries and veins the order to stop the flow of blood, and, obediently, they contracted _naturally_, as they would have done artificially at the contact of a haemostatic like adrenalin, for example. The same reasoning explains how a fibrous tumour can be made to disappear. The unconscious having accepted the idea "It is to go" the brain orders the arteries which nourish it, to contract. They do so, refusing their services, and ceasing to nourish the tumour which, deprived of nourishment, dies, dries up, is reabsorbed and disappears. THE USE OF SUGGESTION FOR THE CURE OF MORAL AILMENTS AND TAINTS EITHER CONGENITAL OR ACQUIRED Neurasthenia, so common nowadays, generally yields to suggestion constantly practised in the way I have indicated. I have had the happiness of contributing to the cure of a large number of neurasthenics with whom every other treatment had failed. One of them had even spent a month in a special establishment at Luxemburg without obtaining any improvement. In six weeks he was completely cured, and he is now the happiest man one would wish to find, after having thought himself the most miserable. Neither is he ever likely to fall ill again in the same way, for I showed him how to make use of conscious autosuggestion and he does it marvelously well. But if suggestion is useful in treating moral complaints and physical ailments, may it not render still greater services to society, in turning into honest folks the wretched children who people our reformatories and who only leave them to enter the army of crime. Let no one tell me it is impossible. The remedy exists and I can prove it. I will quote the two following cases which are very characteristic, but here I must insert a few remarks in parenthesis. To make you understand the way in which suggestion acts in the treatment of moral taints I will use the following comparison. Suppose our brain is a plank in which are driven nails which represent the ideas, habits, and instincts, which determine our actions. If we find that there exists in a subject a bad idea, a bad habit, a bad instinct,--as it were, a bad nail, we take another which is the good idea, habit, or instinct, place it on top of the bad one and give a tap with a hammer--in other words we make a suggestion. The new nail will be driven in perhaps a fraction of an inch, while the old one will come out to the same extent. At each fresh blow with the hammer, that is to say at each fresh suggestion, the one will be driven in a fraction further and the other will be driven out the same amount, until, after a certain number of blows, the old nail will come out completely and be replaced by the new one. When this substitution has been made, the individual obeys it. Let us return to our examples. Little M----, a child of eleven living at Troyes, was subject night and day to certain accidents inherent to early infancy. He was also a kleptomaniac, and, of course, untruthful into the bargain. At his mother's request I treated him by suggestion. After the first visit the accidents ceased by day, but continued at night. Little by little they became less frequent, and finally, a few months afterwards, the child was completely cured. In the same period his thieving propensities lessened, and in six months they had entirely ceased. This child's brother, aged eighteen, had conceived a violent hatred against another of his brothers. Every time that he had taken a little too much wine, he felt impelled to draw a knife and stab his brother. He felt that one day or other he would end by doing so, and he knew at the same time that having done so he would be inconsolable. I treated him also by suggestion, and the result was marvelous. After the first treatment he was cured. His hatred for his brother had disappeared, and they have since become good friends and got on capitally together. I followed up the case for a long time, and the cure was permanent. Since such results are to be obtained by suggestion, would it not be beneficial--I might even say _indispensable_--to take up this method and introduce it into our reformatories? I am absolutely convinced that if suggestion were daily applied to vicious children, more than 50 per cent could be reclaimed. Would it not be an immense service to render society, to bring back to it sane and well members of it who were formerly corroded by moral decay? Perhaps I shall be told that suggestion is a dangerous thing, and that it can be used for evil purposes. This is no valid objection, first because the practice of suggestion would only be confided [by the patient] to reliable and honest people,--to the reformatory doctors, for instance,--and on the other hand, those who seek to use it for evil ask no one's permission. But even admitting that it offers some danger (which is not so) I should like to ask whoever proffers the objection, to tell me what thing we use that is not dangerous? Is it steam? gunpowder? railways? ships? electricity? automobiles? aeroplanes? Are the poisons not dangerous which we, doctors and chemists, use daily in minute doses, and which might easily destroy the patient if, in a moment's carelessness, we unfortunately made a mistake in weighing them out? A FEW TYPICAL CURES This little work would be incomplete if it did not include a few examples of the cures obtained. It would take too long, and would also perhaps be somewhat tiring if I were to relate all those in which I have taken part. I will therefore content myself by quoting a few of the most remarkable. Mlle. M---- D----, of Troyes, had suffered for eight years from asthma which obliged her to sit up in bed nearly all night, fighting for breath. Preliminary experiments show that she is a very sensitive subject. She sleeps immediately, and the suggestion is given. From the first treatment there is an enormous improvement. The patient has a good night, only interrupted by one attack of asthma which only lasts a quarter of an hour. In a very short time the asthma disappears completely and there is no relapse later on. M. M----, a working hosier living at Sainte-Savine near Troyes, paralyzed for two years as the result of injuries at the junction of the spinal column and the pelvis. The paralysis is only in the lower limbs, in which the circulation of the blood has practically ceased, making them swollen, congested, and discolored. Several treatments, including the antisyphilitic, have been tried without success. Preliminary experiments successful; suggestion applied by me, and autosuggestion by the patient for eight days. At the end of this time there is an almost imperceptible but still appreciable movement of the left leg. Renewed suggestion. In eight days the improvement is noticeable. Every week or fortnight there is an increased improvement with progressive lessening of the swelling, and so on. Eleven months afterwards, on the first of November, 1906, the patient goes downstairs alone and walks 800 yards, and in the month of July, 1907, goes back to the factory where he has continued to work since that time, with no trace of paralysis. M. A---- G----, living at Troyes, has long suffered from enteritis, for which different treatments have been tried in vain. He is also in a very bad state mentally, being depressed, gloomy, unsociable, and obsessed by thoughts of suicide. Preliminary experiments easy, followed by suggestion which produces an appreciable result from the very day. For three months, daily suggestions to begin with, then at increasingly longer intervals. At the end of this time, the cure is complete, the enteritis has disappeared, and his _morals_ have become excellent. As the cure dates back twelve years without the shadow of a relapse, it may be considered as permanent. M. G----, is a striking example of the effects that can be produced by suggestion, or rather by autosuggestion. At the same time as I made suggestions to him from the physical point of view, I also did so from the mental, and he accepted both suggestions equally well. Every day his confidence in himself increased, and as he was an excellent workman, in order to earn more, he looked out for a machine which would enable him to work at home for his employer. A little later a factory owner having seen with his own eyes what a good workman he was, entrusted him with the very machine he desired. Thanks to his skill he was able to turn out much more than an ordinary workman, and his employer, delighted with the result, gave him another and yet another machine, until M. G----, who, but for suggestion, would have remained an ordinary workman, is now in charge of six machines which bring him a very hand some profit. Mme. D----, at Troyes, about 30 years of age. She is in the last stages of consumption, and grows thinner daily in spite of special nourishment. She suffers from coughing and spitting, and has difficulty in breathing; in fact, from all appearances she has only a few months to live. Preliminary experiments show great sensitiveness, and suggestion is followed by immediate improvement. From the next day the morbid symptoms begin to lessen. Every day the improvement becomes more marked, the patient rapidly puts on flesh, although she no longer takes special nourishment. In a few months the cure is apparently complete. This person wrote to me on the 1st of January, 1911, that is to say eight months after I had left Troyes, to thank me and to tell me that, although pregnant, she was perfectly well. I have purposely chosen these cases dating some time back, in order to show that the cures are permanent, but I should like to add a few more recent ones. M. X----, Post Office clerk at Luneville. Having lost one of his children in January, 1910, the trouble produces in him a cerebral disturbance which manifests itself by uncontrollable nervous trembling. His uncle brings him to me in the month of June. Preliminary experiments followed by suggestion. Four days afterwards the patient returns to tell me that the trembling has disappeared. I renew the suggestion and tell him to return in eight days. A week, then a fortnight, then three weeks, then a month, pass by without my hearing any more of him. Shortly afterwards his uncle comes and tells me that he has just had a letter from his nephew, who is perfectly well. He has taken on again his work as telegraphist which he had been obliged to give up, and the day before, he had sent off a telegram of 170 words without the least difficulty. He could easily, he added in his letter, have sent off an even longer one. Since then he has had no relapse. M. Y----, of Nancy, has suffered from neurasthenia for several years. He has aversions, nervous fears, and disorders of the stomach and intestines. He sleeps badly, is gloomy and is haunted by ideas of suicide; he staggers when he walks like a drunken man, and can think of nothing but his trouble. All treatments have failed and he gets worse and worse; a stay in a special nursing home for such cases has no effect whatever. M. Y---- comes to see me at the beginning of October, 1910. Preliminary experiments comparatively easy. I explain to the patient the principles of autosuggestion, and the existence within us of the conscious and the unconscious self, and then make the required suggestion. For two or three days M. Y---- has a little difficulty with the explanations I have given him. In a short time light breaks in upon his mind, and he grasps the whole thing. I renew the suggestion, and he makes it himself too every day. The improvement, which is at first slow, becomes more and more rapid, and in a month and a half the cure is complete. The ex-invalid who had lately considered himself the most wretched of men, now thinks himself the happiest. M. E----, of Troyes. An attack of gout; the right ankle is inflamed and painful, and he is unable to walk. The preliminary experiments show him to be a very sensitive subject. After the first treatment he is able to regain, without the help of his stick, the carriage which brought him, and the pain has ceased. The next day he does not return as I had told him to do. Afterwards his wife comes alone and tells me that that morning her husband had got up, put on his shoes, and gone off on his bicycle to visit his yards (he is a painter). It is needless to tell you my utter astonishment. I was not able to follow up this case, as the patient never deigned to come and see me again, but some time afterward I heard that he had had no relapse. Mme. T----, of Nancy. Neurasthenia, dyspepsia, gastralgia, enteritis, and pains in different parts of the body. She has treated herself for several years with a negative result. I treat her by suggestion, and she makes autosuggestions for herself every day. From the first day there is a noticeable improvement which continues without interruption. At the present moment this person has long been cured mentally and physically, and follows no regimen. She thinks that she still has perhaps a slight touch of enteritis, but she is not sure. Mme. X----, a sister of Mme. T----. Acute neurasthenia; she stays in bed a fortnight every month, as it is totally impossible for her to move or work; she suffers from lack of appetite, depression, and digestive disorders. She is cured by one visit, and the cure seems to be permanent as she has had no relapse. Mme. H----, at Maxéville. General eczema, which is particularly severe on the left leg. Both legs are inflamed, above all at the ankles; walking is difficult and painful. I treat her by suggestion. That same evening Mme. H---- is able to walk several hundred yards without fatigue. The day after the feet and ankles are no longer swollen and have not been swollen again since. The eczema disappears rapidly. Mme. F----, at Laneuveville. Pains in the kidneys and the knees. The illness dates from ten years back and is becoming worse every day. Suggestion from me, and autosuggestion from herself. The improvement is immediate and increases progressively. The cure is obtained rapidly, and is a permanent one. Mme. Z----, of Nancy, felt ill in January, 1910, with congestion of the lungs, from which she had not recovered two months later. She suffers from general weakness, loss of appetite, bad digestive trouble, rare and difficult bowel action, insomnia, copious night-sweats. After the first suggestion, the patient feels much better, and two days later she returns and tells me that she feels quite well. Every trace of illness has disappeared, and all the organs are functioning normally. Three or four times she had been on the point of sweating, but each time prevented it by the use of conscious autosuggestion. From this time Mme. Z---- has enjoyed perfectly good health. M. X----, at Belfort, cannot talk for more than ten minutes or a quarter of an hour without becoming completely aphonous. Different doctors consulted find no lesion in the vocal organs, but one of them says that M. X---- suffers from senility of the larynx, and this conclusion confirms him in the belief that he is incurable. He comes to spend his holidays at Nancy, and a lady of my acquaintance advises him to come and see me. He refuses at first, but eventually consents in spite of his absolute disbelief in the effects of suggestion. I treat him in this way nevertheless, and ask him to return two days afterwards. He comes back on the appointed day, and tells me that the day before he was able to converse the whole afternoon without becoming aphonous. Two days later he returns again to say that his trouble had not reappeared, although he had not only conversed a great deal but even sung the day before. The cure still holds good and I am convinced that it will always do so. Before closing, I should like to say a few words on the application of my method to the training and correction of children by their parents. The latter should wait until the child is asleep, and then one of them should enter his room with precaution, stop a yard from his bed, and repeat 15 or 20 times in a murmur all the things they wish to obtain from the child, from the point of view of health, work, sleep, application, conduct, etc. He should then retire as he came, taking great care not to awake the child. This extremely simple process gives the best possible results, and it is easy to understand why. When the child is asleep his body and his conscious self are at rest and, as it were, annihilated; his unconscious self however is awake; it is then to the latter alone that one speaks, and as it is very credulous it accepts what one says to it without dispute, so that, little by little, the child arrives at making of himself what his parents desire him to be. CONCLUSION What conclusion is to be drawn from all this? The conclusion is very simple and can be expressed in a few words: We possess within us a force of incalculable power, which, when we handle it unconsciously is often prejudicial to us. If on the contrary we direct it in a conscious and wise manner, it gives us the mastery of ourselves and allows us not only to escape and to aid others to escape, from physical and mental ills, but also to live in relative happiness, whatever the conditions in which we may find ourselves. Lastly, and above all, it should be applied to the moral regeneration of those who have wandered from the right path. THOUGHTS AND PRECEPTS OF EMILE COUÉ _taken down literally by Mme. Emile Leon, his disciple._ Do not spend your time in thinking of illness you might have, for if you have no real ones you will create artificial ones. *** When you make conscious autosuggestions, do it naturally, simply, with conviction, and above all _without any effort._ If unconscious and bad autosuggestions are so often realized, it is because they are made without effort. *** Be sure that you will obtain what you want, and you will obtain it, so long as it is within reason. *** To become master of oneself it is enough to think that one is becoming so. . . . Your hands tremble, your steps falter, tell yourself that all that is going to cease, and little by little it will disappear. It is not in me but in yourself that you must have confidence, for it is in yourself alone that dwells the force which can cure you. My part simply consists in teaching you to make use of that force. *** Never discuss things you know nothing about, or you will only make yourself ridiculous. Things which seem miraculous to you have a perfectly natural cause; if they seem extraordinary it is only because the cause escapes you. When you know that, you realize that nothing could be more natural. *** When the will and the imagination are in conflict, it is always the imagination which wins. Such a case is only too frequent, and then not only do we not do what we want, but just the contrary of what we want. For example: the more we try to go to sleep, the more we try to remember the name of some one, the more we try to stop laughing, the more we try to avoid an obstacle, while _thinking that we cannot do so,_ the more excited we become, the less we can remember the name, the more uncontrollable our laughter becomes, and the more surely we rush upon the obstacle. It is then the imagination and not the will which is the most important faculty of man; and thus it is a serious mistake to advise people to train their wills, it is the training of their imaginations which they ought to set about. *** Things are not for us what they are, but what they seem; this explains the contradictory evidence of persons speaking in all good faith. *** By believing oneself to be the master of one's thoughts one becomes so. *** Everyone of our thoughts, good or bad, becomes concrete, materializes, and becomes in short a reality. We are what we make ourselves and not what circumstances make us. *** Whoever starts off in life with the idea: "I shall succeed", always does succeed because he does what is necessary to bring about this result. If only one opportunity presents itself to him, and if this opportunity has, as it were, only one hair on its head, he seizes it by that one hair. Further, he often brings about unconsciously or not, propitious circumstances. He who on the contrary always doubts himself, never succeeds in doing anything. He might find himself in the midst of an army of opportunities with heads of hair like Absalom, and yet he would not see them and could not seize a single one, even if he had only to stretch out his hand in order to do so. And if he brings about circumstances, they are generally unfavorable ones. Do not then blame fate, you have only yourself to blame. *** People are always preaching the doctrine of effort, but this idea must be repudiated. Effort means will, and will means the possible entrance of the imagination in opposition, and the bringing about of the exactly contrary result to the desired one. *** Always think that what you have to do is easy, if possible. In this state of mind you will not spend more of your strength than just what is necessary; if you consider it difficult, you will spend ten, twenty times more strength than you need; in other words you will waste it. *** Autosuggestion is an instrument which you have to learn how to use just as you would for any other instrument. An excellent gun in inexperienced hands only gives wretched results, but the more skilled the same hands become, the more easily they place the bullets in the target. *** Conscious autosuggestion, made with confidence, with faith, with perseverance, realizes itself mathematically, within reason. *** When certain people do not obtain satisfactory results with autosuggestion, it is either because they lack confidence, or because they make efforts, which is the more frequent case. To make good suggestions it is absolutely necessary to do it _without effort._ The latter implies the use of the _will,_ which must be entirely put aside. One must have recourse _exclusively_ to the imagination. *** Many people who have taken care of their health all their life in vain, imagine that they can be immediately cured by autosuggestion. It is a mistake, for it is not reasonable to think so. It is no use expecting from suggestion more than it can normally produce, that is to say, a progressive improvement which little by little transforms itself into a complete cure, when that is possible. *** The means employed by the healers all go back to autosuggestion, that is to say that these methods, whatever they are, words, incantations, gestures, staging, all produce in the patient the autosuggestion of recovery. Every illness has two aspects unless it is exclusively a mental one. Indeed, on every physical illness a mental one comes and attaches itself. If we give to the physical illness the coefficient 1, the mental illness may have the coefficient 1, 2, 10, 20, 50, 100, and more. In many cases this can disappear instantaneously, and if its coefficient is a very high one, 100 for instance, while that of the physical ailment is 1, only this latter is left, a 101st of the total illness; such a thing is called a miracle, and yet there is nothing miraculous about it. *** Contrary to common opinion, physical diseases are generally far more easily cured than mental ones. Buffon used to say: "Style is the man." We would put in that: "Man is what he thinks". The fear of failure is almost certain to cause failure, in the same way as the idea of success brings success, and enables one always to surmount the obstacles that may be met with. *** Conviction is as necessary to the suggester as to his subject. It is this conviction, this faith, which enables him to obtain results where all other means have failed. *** It is not the person who acts, it is the method. *** . . . Contrary to general opinion, suggestion, or autosuggestion can bring about the cure of organic lesions. Formerly it was believed that hypnotism could only be applied to the treatment of nervous illnesses; its domain is far greater than that. It is true that hypnotism acts through the intermediary of the nervous system; but the nervous system dominates the whole organism. The muscles are set in movement by the nerves; the nerves regulate the circulation by their direct action on the heart, and by their action on the blood vessels which they dilate or contract. The nerves act then on all the organs, and by their intermediation all the unhealthy organs may be affected. Docteur Paul Joire, _Président of the Societe universelle d'Etudes psychiques_ (Bull. No. 4 of the S. L. P.) *** . . . Moral influence has a considerable value as a help in healing. It is a factor of the first order which it would be very wrong to neglect, since in medicine as in every branch of human activity it is the _spiritual forces_ which lead the world. Docteur Louis Renon, _Lecturing professor at the Faculty of Medicine of Paris, and doctor at the Necker Hospital._ *** . . . Never lose sight of the great principle of autosuggestion: _Optimism always and in spite of everything, even when events do not seem to justify it._ René de Drabois, (Bull. 11 of the S. L. P. A.) *** Suggestion sustained by faith is a formidable force. Docteur A. L., Paris, (July, 1920.) To have and to inspire unalterable confidence, one must walk with the assurance of perfect sincerity, and in order to possess this assurance and sincerity, one must wish for _the good of others_ more than one's own. "Culture de la Force Morale", by C. Baudouin. OBSERVATIONS ON WHAT AUTOSUGGESTION CAN DO Young B----, 13 years old, enters the hospital in January 1912. He has a very serious heart complaint characterized by a peculiarity in the respiration; he has such difficulty in breathing that he can only take very slow and short steps. The doctor who attends him, one of our best practitioners, predicts a rapid and fatal issue. The invalid leaves the hospital in February, _no better._ A friend of his family brings him to me and when I see him I regard him as a hopeless case, but nevertheless I make him pass through the preliminary experiments which are marvelously successful. After having made him a suggestion and advised him to do the same thing for himself, I tell him to come back in two days. When he does so I notice to my astonishment a _remarkable_ improvement in his respiration and his walking. I renew the suggestion and two days afterwards, when he returns the improvement has continued, and so it is at every visit. So rapid is the progress that he makes that, three weeks after the first visit, my little patient is able to go _on foot_ with his mother to the plateau of Villers. He can breathe with ease and almost normally, he can walk without getting out of breath, and can mount the stairs, which was impossible for him before. As the improvement is steadily maintained, little B---- asks me if he can go and stay with his grandmother at Carignan. As he seems well I advise him to do so, and he goes off, but sends me news of himself from time to time. His health is becoming better and better, he has a good appetite, digests and assimilates his food well, and the feeling of oppression has entirely disappeared. Not only can he walk like everybody else, but he even runs and chases butterflies. He returns in October, and I can hardly recognize him, for the bent and puny little fellow who had left me in May has become a tall upright boy, whose face beams with health. He has grown 12 centimeters and gained 19 lbs. in weight. Since then he has lived a perfectly normal life; he runs up and down stairs, rides a bicycle, and plays football with his comrades. Mlle. X----, of Geneva, aged 13. Sore on the temple considered by several doctors as being of tubercular origin; for a year and a half it has refused to yield to the different treatments ordered. She is taken to M. Baudouin, a follower of M. Coué at Geneva, who treats her by suggestion and tells her to return in a week. When she comes back the sore has healed. Mlle. Z----, also of Geneva. Has had the right leg drawn up for 17 years, owing to an abscess above the knee which had had to be operated upon. She asks M. Baudouin to treat her by suggestion, and hardly has he begun when the leg can be bent and unbent in a normal manner. (There was of course a psychological cause in this case.) Mme. Urbain Marie, aged 55, at Maxéville. Varicose nicer, dating from more than a year and a half. First visit in September, 1915, and a second one a week later. In a fortnight the cure is complete. Emile Chenu, 10 years old, Grande-Rue, 19 (a refugee from Metz). Some unknown heart complaint with vegetations. Every night loses blood by the mouth. Comes first in July, 1915, and after a few visits the loss of blood diminishes, and continues to do so until by the end of November it has ceased completely. The vegetations also seem to be no longer there, and by August, 1916, there had been no relapse. M. Hazot, aged 48, living at Brin. Invalided the 15th of January, 1915, with _specific_ chronic bronchitis, which is getting worse every day. He comes in to me in October, 1915. The improvement is immediate, and has been maintained since. At the present moment, although he is not completely cured, he is very much better. M. B----, has suffered for 24 years from frontal sinus, which had necessitated eleven operations!! In spite of all that had been done the sinus persisted, accompanied by intolerable pains. The physical state of the patient was pitiable in the extreme; he had violent and almost continuous pain, extreme weakness; lack of appetite, could neither walk, read nor sleep, etc. His nerves were in nearly as bad a state as his body, and in spite of the treatment of such men as Bernheim of Nancy, Dejerine of Paris, Dubois of Bern, X---- of Strasburg, his ill health not only continued but even grew worse every day. The patient comes to me in September, 1915, on the advice of one of my other patients. From that moment he made rapid progress and at the present time (1921) he is perfectly well. It is a real resurrection. M. Nagengast, aged 18, rue Sellier, 39. Suffering from Pott's disease. Comes to me in the beginning of 1914, having been encased for six months in a plaster corset. Comes regularly twice a week to the "séances," and makes for himself the usual suggestion morning and evening. Improvement soon shows itself, and in a short time the patient is able to do without his plaster casing. I saw him again in April, 1916. He was completely cured, and was carrying on his duties as postman, after having been assistant to an ambulance at Nancy, where he had stayed until it was done away with. M. D----, at Jarville. Paralysis of the left upper eyelid. Goes to the hospital where he receives injections, as a result of which the eyelid is raised. The left eye was, however, deflected outwards for more than 45 degrees, and an operation seemed to be necessary. It was at this moment that he came to me, and thanks to autosuggestion the eye went back little by little to its normal position. Mme. L----, of Nancy. Continuous pain in the right side of the face, which had gone on for 10 years. She has consulted many doctors whose prescriptions seemed of no use, and an operation is judged to be necessary. The patient comes to me on the 25th of July, 1916, and there is an immediate improvement. In about ten days' time the pain has entirely vanished, and up to the 20th of December, there had been no recurrence. T---- Maurice, aged 8 and a half, at Nancy: club feet. A first operation cures, or nearly so, the left foot, while the right one still remains crippled. Two subsequent operations do no good. The child is brought to me for the first time in February, 1915; he walks pretty well, thanks to two contrivances which hold his feet straight. The first visit is followed by an immediate improvement, and after the second, the child is able to walk in ordinary boots. The improvement becomes more and more marked, by the 17th of April the child is quite well. The right foot, however, is not now quite so strong as it was, owing to a sprain which he gave it in February, 1916. Mlle X----, at Blainville. A sore on the left foot, probably of specific origin. A slight sprain has brought about a swelling of the foot accompanied by acute pains. Different treatments have only had a negative effect, and in a little while a suppurating sore appears which seems to indicate caries of the bone. Walking becomes more and more painful and difficult in spite of the treatment. On the advice of a former patient who had been cured, she comes to me, and there is noticeable relief after the first visits. Little by little the swelling goes down, the pain becomes less intense, the suppuration lessens, and finally the sore heals over. The process has taken a few months. At present the foot is practically normal, but although the pain and swelling have entirely disappeared, the back flexion of the foot is not yet perfect, which makes the patient limp slightly. Mme. R----, of Chavigny. Metritis dating from 10 years back. Comes at the end of July, 1916. Improvement is immediate, the pain and loss of blood diminish rapidly, and by the following 29th of September both have disappeared. The monthly period, which lasted from eight to ten days, is now over in four. Mme. H----, rue Guilbert-de-Pivérécourt, at Nancy, aged 49. Suffers from a varicose ulcer dating from September, 1914, which has treated according to her doctor's advice, but without success. The lower part of the leg is enormous (the ulcer, which is as large as a two franc piece and goes right down to the bone, is situated above the ankle). The inflammation is very intense, the suppuration copious, and the pains extremely violent. The patient comes for the first time in April, 1916, and the improvement which is visible after the first treatment, continues without interruption. By the 18th of February, 1917, the swelling has _entirely subsided,_ and the pain and irritation have disappeared. The sore is still there, but it is no larger than a pea and it is only a few millimeters in depth; it still discharges very slightly. By 1920 the cure has long been complete. Mlle. D----, at Mirecourt, 16 years of age. Has suffered from attacks of nerves for three years. The attacks, at first infrequent, have gradually come at closer intervals. When she comes to see me on the 1st of April, 1917, she has had three attacks in the preceding fortnight. Up to the 18th of April she did not have any at all. I may add that this young lady, from the time she began the treatment, was no longer troubled by the bad headaches from which she had suffered almost constantly. Mme. M----, aged 43, rue d'Amance, 2, Malzéville. Comes at the end of 1916 for violent pains in the head from which she has suffered all her life. After a few visits they vanish completely. Two months afterwards she realized that she was also cured of a prolapse of the uterus which she had not mentioned to me, and of which she was not thinking when she made her autosuggestion. (This result is due to the words: _"in every respect"_ contained in the formula used morning and evening.) Mme. D----, Choisy-le-Roi. Only one general suggestion from me in July, 1916, and autosuggestion on her part morning and evening. In October of the same year this lady tells me that she is cured of a prolapse of the uterus from which she had suffered for more than twenty years. Up to April, 1920, the cure is still holding good. (Same remark as in the preceding case.) Mme. Jousselin, aged 60, rue des Dominicains, 6. Comes on the 20th of July, 1917, for a violent pain in the right leg, accompanied by considerable swelling of the whole limb. She can only drag herself along with groans, but after the "séance," to her great astonishment, she can walk _normally_ without feeling the least pain. When she comes back four days afterwards, she has had no return of the pain and the swelling has subsided. This patient tells me that since she has attended the "séances" she has also been cured of white discharges, and of enteritis from which she had long suffered. (Same remark as above.) In November the cure is still holding good. Mlle. G. L.----, aged 15, rue du Montet, 88. Has stammered from infancy. Comes on the 20th of July, 1917, and the stammering ceases instantly. A month after I saw her again and she had had no recurrence. M. Ferry (Eugène), aged 60, rue de la Côte, 56. For five years has suffered from rheumatic pains in the shoulders and in the left leg. Walks with difficulty leaning on a stick, and cannot lift the arms higher than the shoulders. Comes on the 17th of September, 1917. After the first "séance," the pains vanish completely and the patient can not only take long strides but even _run._ Still more, he can whirl both arms like a windmill. In November the cure is still holding good. Mme. Lacour, aged 63, chemin des Sables. Pains in the face dating from more than twenty years back. All treatments have failed. An operation is advised, but the patient refuses to undergo it. She comes for the first time on July 25th, 1916, and four days later the pain ceases. The cure has held good to this day. Mme. Martin, Grande-Rue (Ville-Vieille), 105. Inflammation of the uterus of 13 years standing, accompanied by pains and white and red discharges. The period, which is very painful, recurs every 22 or 23 days and lasts 10-12 days. Comes for the first time on the 15th of November, 1917, and returns regularly every week. There is visible improvement after the first visit, which continues rapidly until at the beginning of January, 1918, the inflammation has entirely disappeared; the period comes at more regular intervals and without the slightest pain. A pain in the knee which the patient had had for 13 years was also cured. Mme. Castelli, aged 41, living at Einville (M.-et M.). Has suffered from intermittent rheumatic pains in the right knee for 13 years. Five years ago she had a more violent attack than usual, the leg swells as well as the knee, then the lower part of the limb atrophies, and the patient is reduced to walking very painfully with the aid of a stick or crutch. She comes for the first time on the 5th of November, 1917. She goes away _without the help of either crutch or stick._ Since then she no longer uses her crutch at all, but occasionally makes use of her stick. The pain in the knee comes back from time to time, but only very slightly. Mme. Meder, aged 52, at Einville. For six months has suffered from pain in the right knee accompanied by swelling, which makes it impossible to bend the leg. Comes for the first time on Dec. 7th, 1917. Returns on Jan. 4th, 1918, saying that she has almost ceased to suffer and that she can walk normally. After that visit of the 4th, the pain ceases entirely, and the patient walks like other people. EMILE COUÉ. EDUCATION AS IT OUGHT TO BE It may seem paradoxical but, nevertheless, the Education of a child ought to begin before its birth. In sober truth, if a woman, a few weeks after conception, makes a mental picture of the sex of the child she is going to bring forth into the world, of the physical and moral qualities with which she desires to see it endowed and if she will continue during the time of gestation to impress on herself the same mental image, the child will have the sex and qualities desired. Spartan women only brought forth robust children, who grew to be redoubtable warriors, because their strongest desire was to give such heroes to their country; whilst, at Athens, mothers had intellectual children whose mental qualities were a hundredfold greater than their physical attributes. The child thus engendered will be apt to accept readily good suggestions which may be made to him and to transform them into autosuggestion which later, will influence the course of his life. For you must know that all our words, all our acts, are only the result of autosuggestions caused, for the most part, by the suggestion of example or speech. How then should parents, and those entrusted with the education of children avoid provoking bad autosuggestions and, on the other hand, influence good autosuggestions? In dealing with children, always be even-tempered and speak in a gentle but firm tone. In this way they will become obedient without ever having the slightest desire to resist authority. Above all--above all, avoid harshness and brutality, for there the risk is incurred of influencing an autosuggestion of cruelty accompanied by hate. Moreover, avoid carefully, in their presence, saying evil of anyone, as too often happens, when, without any deliberate intention, the absent nurse is picked to pieces in the drawing-room. Inevitably this fatal example will be followed, and may produce later a real catastrophe. Awaken in them a desire to know the reason of things and a love of Nature, and endeavor to interest them by giving all possible explanations very clearly, in a cheerful, good-tempered tone. You must answer their questions pleasantly, instead of checking them with--"What a bother you are, do be quiet, you will learn that later." Never on any account say to a child, "You are lazy and good for nothing" because that gives birth in him to the very faults of which you accuse him. If a child is lazy and does his tasks badly, you should say to him one day, even if it is not true, "There this time your work is much better than it generally is. Well done". The child, flattered by the unaccustomed commendation, will certainly work better the next time, and, little by little, thanks to judicious encouragement, will succeed in becoming a real worker. At all costs avoid speaking of illness before children, as it will certainly create in them bad autosuggestions. Teach them, on the contrary, that health is the normal state of man, and that sickness is an anomaly, a sort of backsliding which may be avoided by living in a temperate, regular way. Do not create defects in them by teaching them to fear this or that, cold or heat, rain or wind, etc. Man is created to endure such variations without injury and should do so without grumbling. Do not make the child nervous by filling his mind with stories of hob-goblins and were-wolves, for there is always the risk that timidity contracted in childhood will persist later. It is necessary that those who do not bring up then children themselves should choose carefully those to whom they are entrusted. To love them is not sufficient, they must have the qualities you desire your children to possess. Awaken in them the love of work and of study, making it easier by explaining things carefully and in a pleasant fashion, and by introducing in the explanation some anecdote which will make the child eager for the following lesson. Above all impress on them that Work is essential for man, and that he who does not work in some fashion or another, is a worthless, useless creature, and that all work produces in the man who engages in it a healthy and profound satisfaction; whilst idleness, so longed for and desired by some, produces weariness, neurasthenia, disgust of life, and leads those who do not possess the means of satisfying the passions created by idleness, to debauchery and even to crime. Teach children to be always polite and kind to all, and particularly to those whom the chance of birth has placed in a lower class than their own, and also to respect age, and never to mock at the physical or moral defects that age often produces. Teach them to love all mankind, without distinction of caste. That one must always be ready to succor those who are in need of help, and that one must never be afraid of spending time and money for those who are in need; in short, that they must think more of others than of themselves. In so doing an inner satisfaction is experienced that the egoist ever seeks and never finds. Develop in them self-confidence, and teach that, before embarking upon any undertaking, it should be submitted to the control of reason, thus avoiding acting impulsively, and, after having reasoned the matter out, one should form a decision by which one abides, unless, indeed, some fresh fact proves you may have been mistaken. Teach them above all that every one must set out in life with a very definite idea that he will succeed, and that, under the influence of this idea he will inevitably succeed. Not indeed, that he should quietly remain expecting events to happen, but because, impelled by this idea, he will do what is necessary to make it come true. He will know how to take advantage of opportunities, or even perhaps of the single opportunity which may present itself, it may be only a single thread or hair, whilst he who distrusts himself is a Constant Guignard with whom nothing succeeds, because his efforts are all directed to that end. Such a one may indeed swim in an ocean of opportunities, provided with heads of hair like Absalom himself, and he will be unable to seize a single hair, and often determines himself the causes which make him fail; whilst he, who has the idea of success in himself, often gives birth, in an unconscious fashion, to the very circumstances which produce that same success. But above all, let parents and masters preach by example. A child is extremely suggestive, let something turn up that he wishes to do, and he does it. As soon as children can speak, make them repeat morning and evening, twenty times consecutively: "Day by day, in all respects, I grow better", which will produce in them an excellent physical, moral and healthy atmosphere. If you make the following suggestion you will help the child enormously to eliminate his faults, and to awaken in him the corresponding desirable qualities. Every night when the child is asleep, approach quietly, so as not to awaken him, to within about three or four feet from his bed. Stand there, murmuring in a low monotonous voice the thing or things you wish him to do. Finally, it is desirable that all teachers should, every morning, make suggestions to their pupils, somewhat in the following fashion. Telling them to shut their eyes, they should say: "Children, I expect you always to be polite and kind to everyone, obedient to your parents and teachers, when they give you an order, or tell you anything; you will always listen to the order given or the fact told without thinking it tiresome; you used to think it tiresome when you were reminded of anything, but now you understand very well that it is for your good that you are told things, and consequently, instead of being cross with those who speak to you, you will now be grateful to them. "Moreover you will now love your work, whatever it may be; in your lessons you will always enjoy those things you may have to learn, especially whatever you may not till now have cared for. "Moreover when the teacher is giving a lesson in class, you will now devote all your attention, solely and entirely to what he says, instead of attending to any silly things said or done by your companions, and without doing or saying anything silly yourself. "Under these conditions as you are all intelligent, for, children, you are all intelligent, you will understand easily and remember easily what you have learned. It will remain embedded in your memory, ready to be at your service, and you will be able to make use of it as soon as you need it. "In the same way when you are working at your lessons alone, or at home, when you are accomplishing a task or studying a lesson, you will fix your attention solely on the work you are doing, and you will always obtain good marks for your lessons." This is the Counsel, which, if followed faithfully and truly from henceforth, will produce a race endowed with the highest physical and moral qualities. Emile Coué. A SURVEY OF THE "SÉANCES" AT M. COUÉ'S The town thrills at this name, for from every rank of society people come to him and everyone is welcomed with the same benevolence, which already goes for a good deal. But what is extremely poignant is at the end of the séance to see the people who came in gloomy, bent, almost hostile (they were in pain), go away like everybody else; unconstrained, cheerful, sometimes radiant (they are no longer in pain!!). With a strong and smiling goodness of which he has the secret, M. Coué, as it were, holds the hearts of those who consult him in his hand; he addresses himself in turn to the numerous persons who come to consult him, and speaks to them in these terms: "Well, Madame, and what is your trouble? . . ." Oh, you are looking for two many whys and wherefores; what does the cause of your pain matter to you? You are in pain, that is enough . . . I will teach you to get rid of that. . . . --- And you, Monsieur, your varicose ulcer is already better. That is good, very good indeed, do you know, considering you have only been here twice; I congratulate you on the result you have obtained. If you go on doing your autosuggestions properly, you will very soon be cured. . . . You have had this ulcer for ten years, you say? What does that matter? You might have had it twenty and more, and it could be cured just the same. --- And you say that you have not obtained any improvement? . . . Do you know why? . . . Simply because you lack confidence in yourself. When I tell you that you are better, you feel better at once, don't you? Why? Because you have faith in me. Just believe in yourself and you will obtain the same result. --- Oh, Madame not so many details, I beg you! By looking out for the details you create them, and you would want a list a yard long to contain all your maladies. As a matter of fact, with you it is the mental outlook which is wrong. Well, make up your mind that it is going to get better and it will be so. It's as simple as the Gospel. . . . --- You tell me you have attacks of nerves every week. . . . Well, from to-day you are going to do what I tell you and you will cease to have them. . . . --- You have suffered from constipation for a long time? . . . What does it matter how long it is? . . . You say it is forty years? Yes, I heard what you said, but it is none the less true that you can be cured to-morrow; you hear, to-morrow, on condition, naturally, of your doing exactly what I tell you to do, in the way I tell you to do it. . . . --- Ah! you have glaucoma, Madame. I cannot absolutely promise to cure you of that, for I am not sure that I can. That does not mean that you cannot be cured, for I have known it to happen in the case of a lady of Chalon-sur-Saône and another of Lorraine. Well, Mademoiselle, as you have not had your nervous attacks since you came here, whereas you used to have them every day, you are cured. Come back sometimes all the same, so that I may keep you going along the right lines. --- The feeling of oppression will disappear with the lesions which will disappear when you assimilate properly; that will come all in good time, but you mustn't put the cart before the horse . . . it is the same with oppression as with heart trouble, it generally diminishes very quickly. . . . --- Suggestion does not prevent you from going on with your usual treatment. . . . As for the blemish you have on your eye, and which is lessening almost daily, the opacity and the size are both growing less every day. --- To a child (in a clear and commanding voice): "Shut your eyes, I am not going to talk to you about lesions or anything else, you would not understand; the pain in your chest is going away, and you won't want to cough any more." --- _Observation.--_It is curious to notice that all those suffering from chronic bronchitis are immediately relieved and their morbid symptoms rapidly disappear. . . . Children, are very easy and very obedient subjects; their organism almost always obeys immediately to suggestion. --- To a person who complains of fatigue: Well, so do I. There are also days when it tires me to receive people, but I receive them all the same and all day long. Do not say: _"I cannot help it." "One can always overcome oneself."_ _Observation.--_The idea of fatigue necessarily brings fatigue, and the idea that we have a duty to accomplish always gives us the necessary strength to fulfill it. The mind can and must remain master of the animal side of our nature. --- The cause which prevents you from walking, whatever it is, is going to disappear little by little every day: you know the proverb: _Heaven helps those who help themselves._ Stand up two or three times a day supporting yourself on two persons, and say to yourself firmly: _My kidneys are not so weak that I cannot do it, on the contrary I can. . . ._ --- After having said: "Every day, in every respect, I am getting better and better," add: "The people who are pursuing me _cannot_ pursue me any more, they are not pursuing me. . . ." --- What I told you is quite true; it was enough to think that you had no more pain for the pain to disappear; _do not think then that it may come back or it will come back. . . ._ (A woman, sotto voice, "What patience he has! What a wonderfully painstaking man!") --- ALL THAT WE THINK BECOMES TRUE FOR US. WE MUST NOT THEN ALLOW OURSELVES TO THINK WRONGLY. --- THINK "MY TROUBLE IS GOING AWAY," JUST AS YOU THINK YOU CANNOT OPEN YOUR HANDS. The more you say: _"I will not,"_ the more surely the contrary comes about. You must say: _"It's going away,"_ and think it. Close your hand and think properly: "Now I cannot open it." Try! (she cannot), you see that your will is not much good to you. _Observation.--This is the essential point of the method._ In order to make auto-suggestions, you must eliminate the _will_ completely and only address yourself to the _imagination,_ so as to avoid a conflict between them in which the will would be vanquished. --- To become stronger as one becomes older seems paradoxical, but it is true. --- For diabetes: Continue to use therapeutic treatments; I am quite willing to make suggestions to you, but I cannot promise to cure you. _Observation._--I have seen diabetes completely cured several times, and what is still more extraordinary, the albumen diminish and even disappear from the urine of certain patients. --- This obsession must be a real nightmare. The people you used to detest are becoming your friends, you like them and they like you. Ah, but to _will_ and to _desire_ is not the _same_ thing. --- Then, after having asked them to close their eyes, M. Coué gives to his patients the little suggestive discourse which is to be found in "Self Mastery." When this is over, he again addresses himself to each one separately, saying to each a few words on his case: To the first: "You, Monsieur, are in pain, but I tell you that, from to-day, the cause of this pain whether it is called arthritis or anything else, is going to disappear with the help of your unconscious, and the cause having disappeared, the pain will gradually become less and less, and in a short time it will be nothing but a moment." To the second person: "Your stomach does not function properly, it is more or less dilated. Well, as I told you just now, your digestive functions are going to work better and better, and I add that the dilatation of the stomach is going to disappear little by little. Your organism is going to give back progressively to your stomach the force and elasticity it had lost, and by degrees as this phenomenon is produced, the stomach will return to its primitive form and will carry out more and more easily the necessary movements to pass into the intestine the nourishment it contains. At the same time the pouch formed by the relaxed stomach will diminish in size, the nutriment will not longer stagnate in this pouch, and in consequence the fermentation set up will end by totally disappearing." To the third: "To you, Mademoiselle, I say that whatever lesions you may have in your liver, your organism is doing what is necessary to make the lesions disappear every day, and by degrees as they heal over, the symptoms from which you suffer will go on lessening and disappearing. Your liver then functions in a more and more normal way, the bile it secretes is alcaline and no longer acid, in the right quantity and quality, so that it passes naturally into the intestines and helps intestinal digestion." To the fourth: "My child, you hear what I say; every time you feel you are going to have an attack, you will hear my voice telling you as quick as lightning: 'No, no! my friend, you are not going to have that attack, and it is going to disappear before it comes. . . .'" To the fifth, etc., etc. When everyone has been attended to, M. Coué tells those present to open their eyes, and adds: "You have heard the advice I have just given you. Well, to transform it into reality, what you must do is this: _As long as you live,_ every morning before getting up, and every evening as soon as you are in bed, you must shut your eyes, so as to concentrate your attention, and repeat twenty times following, moving your _lips_ (that is indispensable) and counting _mechanically_ on a string with twenty knots in it the following phrase: _'Every day, in every respect, I am getting better and better.'"_ There is no need to think of anything in particular, as the words _"in every respect"_ apply to everything. This autosuggestion must be made with confidence, with faith, with the certainty of obtaining what is desired. The greater the conviction of the person, the greater and the more rapid will be the results obtained. Further, every time that in the course of the day or night you feel any physical or mental discomfort, _affirm_ to yourself that you will not consciously contribute to it, and that you are going to make it vanish; then isolate yourself as much as possible, and passing your hand over your forehead if it is something mental, or on whatever part that is painful if it is something physical, repeat _very quickly,_ moving the lips, the words: "It is going, it is going . . ., etc., etc." as long as it is necessary. With a little practice, the mental or physical discomfort will disappear in about 20 to 25 seconds. Begin again every time it is necessary. For this as for the other autosuggestions it is necessary to act with the same confidence, the same conviction, the same faith, and above all without effort. M. Coué also adds what follows: "If you formerly allowed yourself to make bad autosuggestions because you did it unconsciously, now that you know what I have just taught you, you must no longer let this happen. And if, in spite of all, you still do it, you must only accuse yourself, and say _'Mea culpa, mea maxima culpa.'"_ And now, if a grateful admirer of the work and of the founder of the method may be allowed to say a few words, I will say. "Monsieur Coué shows us luminously that the power to get health and happiness is within us: we have indeed received this gift." Therefore, suppressing, first of all, every cause of suffering _created or encouraged by ourselves,_ then putting into practice the favorite maxim of Socrates: "Know thyself," and the advice of Pope: "That I may reject none of the benefits that Thy goodness bestows upon me," let us take possession of the entire benefit of autosuggestion, let us become this very day members of the "Lorraine Society of applied Psychology;" let us make members of it those who may be in our care (it is a good deed to do to them). By this means we shall follow first of all the great movement of the future of which M. E. Coué is the originator (he devotes to it his days, his nights, his worldly goods, and refuses to accept . . . but hush; no more of this! lest his modesty refuses to allow these lines to be published without alteration), but above all by this means we shall know exactly the days and hours of his lectures at Paris, Nancy and other towns, where he devotedly goes to sow the good seed, and where we can go too to see him, and hear him and consult him personally, and with his help awake or stir up in ourselves the personal power that everyone of us has received of becoming happy and well. May I be allowed to add that when M. Coué has charged an entrance fee for his lectures, they have brought in thousands of francs for the Disabled and others who have suffered through the war. E. Vs----oer. _Note._--Entrance is free to the members of the Lorraine Society of applied Psychology. EXTRACTS FROM LETTERS ADDRESSED TO M. COUÉ The final results of the English secondary Certificate have only been posted up these two hours, and I hasten to tell you about it, at least in so far as it concerns myself. I passed the viva voce _with flying colors,_ and scarcely felt a trace of the nervousness which used to cause me such an intolerable sensation of nausea before the tests. During the latter I was astonished at my own calm, which gave those who listened to me the impression of perfect self-possession on my part. In short, it was just the tests I dreaded most which contributed most to my success. The jury placed me Second, and I am infinitely grateful to you for help, which undoubtedly gave me an advantage over the other candidates . . ., etc. (The case is that of a young lady, who, on account of excessive nervousness, had failed in 1915. The nervousness having vanished under the influence of autosuggestion, she passed successfully, being-placed 2nd out of more than 200 competitors.) Mlle. V----, _Schoolmistress, August,_ 1916. *** It is with very great pleasure that I write to thank you most sincerely for the great benefit I have received from your method. Before I went to you I had the greatest difficulty in walking 100 yards, without being out of breath, whereas now I can go miles without fatigue. Several times a day and quite easily, I am able to walk in 40 minutes from the rue du Bord-de-l'Eau to the rue des Glacis, that is to say, nearly four kilometers. The asthma from which I suffered has almost entirely disappeared. Yours most gratefully. Paul Chenot, _Rue de Strasbourg,_ 141 _Nancy, Aug.,_ 1917. *** I do not know how to thank you. Thanks to you I can say that I am almost entirely cured, and I was only waiting to be so in order to express my gratitude. I was suffering from two varicose ulcers, one on each foot. That on the right foot, which was _as big as my hand,_ is entirely _cured._ It seemed to disappear by magic. For weeks I had been confined to my bed, but almost immediately after I received your letter the ulcer healed over so that I could get up. That on the left foot is not yet absolutely healed, but will soon be so. Night and morning I do, and always shall, recite the prescribed formula, in which I have entire confidence. I may say also that my legs were as hard as a stone and I could not bear the slightest touch. Now I can press them without the least pain, and I can walk once more, which is the greatest joy. Mme. Ligny, _Mailleroncourt-Charette (Haute Saône), May,_ 1918. *** N. B.--It is worthy of remark that this lady never saw M. Coué, and that it is only thanks to a letter he wrote her on April 15th, that she obtained the result announced in her letter of May 3rd. *** I am writing to express my gratitude, for thanks to you I have escaped the risk of an operation which is always a very dangerous one. I can say more: you have saved my life, for your method of autosuggestion has done alone what all the medicines and treatments ordered for the terrible intestinal obstruction from which I suffered for 19 days, had failed to do. From the moment when I followed your instructions and applied your excellent principles, my functions have accomplished themselves quite naturally. Mme. S----, _Pont à Mousson, Feb.,_ 1920. *** I do not know how to thank you for my happiness in being cured. For more than 15 years I had suffered from attacks of asthma, which caused the most painful suffocations every night. Thanks to your splendid method, and above all, since I was present at one of your séances, the attacks have disappeared as if by magic. It is a real miracle, for the various doctors who attended me all declared that there was no cure for asthma. Mme. V----, _Saint-Dié, Feb.,_ 1920. *** I am writing to thank you with all my heart for having brought to my knowledge, a new therapeutic method, a marvellous instrument which seems to act like the magic wand of a fairy, since, thanks to the simplest means, it brings about the most extraordinary results. From the first I was extremely interested in your experiments, and after my own personal success with your method, I began ardently to apply it, as I have become an enthusiastic supporter of it. Docteur Vachet, _Vincennes, May,_ 1920. *** For 8 years I have suffered from prolapse of the uterus. I have used your method of autosuggestion for the last five months, and am now completely cured, for which I do not know how to thank you enough. Mme. Soulier, _Place du Marchè Toul, May,_ 1920. *** I have suffered terribly for 11 years without respite. Every night I had attacks of asthma, and suffered also from insomnia and general weakness which prevented any occupation. Mentally, I was depressed, restless, worried, and was inclined to make mountains out of mole hills. I had followed many treatments without success, having even undergone in Switzerland the removal of the turbinate bone of the nose without obtaining any relief. In Nov., 1918, I became worse in consequence of a great sorrow. While my husband was at Corfu (he was an officer on a warship), I lost our only son in six days from influenza. He was a delightful child of ten, who was the joy of our life; alone and overwhelmed with sorrow, I reproached myself bitterly for not having been able to protect and save our treasure. I wanted to lose my reason or to die. . . . When my husband returned (which was not until February), he took me to a new doctor who ordered me various remedies and the waters of Mont-Dore. I spent the month of August in that station, but on my return I had a recurrence of the asthma, and I realized with despair that _"in every respect"_ I was getting worse and worse. It was then that I had the pleasure of meeting you. Without expecting much good from it, I must say, I went to your October lectures, and I am happy to tell you that by the end of November I was cured. Insomnia, feelings of oppression, gloomy thoughts, disappeared as though by magic, and I am now well and strong and full of courage. With physical health I have recovered my mental equilibrium, and but for the ineffaceable wound caused by my child's loss, I could say that I am perfectly happy. Why did I not meet you before? My child would have known a cheerful and courageous mother. Thank you again and again, M. Coué. Yours most gratefully, E. Itier, _Rue de Lille, Paris, April,_ 1920. *** I can now take up again the struggle I have sustained for 30 years, and which had exhausted me. I found in you last August a wonderful and providential help. Coming home to Lorraine for a few days, ill, and with my heart full of sorrow, I dreaded the shock which I should feel at the sight of the ruins and distress . . . and went away comforted and in good health. I was at the end of my tether, and unfortunately I am not religious. I longed to find some one who could help me, and meeting you by chance at my cousin's house you gave me the very help I sought. I can now work in a new spirit, I suggest to my unconscious to re-establish my physical equilibrium, and I do not doubt that I shall regain my former good health. A very noticeable improvement has already shown itself, and you will better understand my gratitude when I tell you that, suffering from diabetes with a renal complication, I have had several attacks of glaucoma, but my eyes are now recovering their suppleness. Since then my sight has become almost normal, and my general health has much improved. Mlle. Th----, _Professor at the Young Ladies' College at Ch----, Jan.,_ 1920. *** I read my thesis with success, and was awarded the highest mark and the congratulations of the jury. Of all these "honours" a large share belongs to you, and I do not forget it. I only regretted that you were not present to hear your name referred to with warm and sympathetic interest by the distinguished Jury. You can consider that the doors of the University have been flung wide open to your teaching. Do not thank me for it, for I owe you far more than you can owe me. Ch. Baudouin, _Professor at the Institut. J.-J. Rousseau, Geneva._ *** . . . I admire your courageousness, and am quite sure that it will help to turn many friends into a useful and intelligent direction. I confess that I have personally benefited by your teaching, and have made my patients do so too. At the Nursing Home we try to apply your method collectively, and have already obtained visible results in this way. Docteur Berillon, _Paris, March,_ 1920. *** . . . I have received your kind letter as well as your very interesting lecture. I am glad to see that you make a rational connection between hetero and autosuggestion, and I note particularly the passage in which you say that the will must not intervene in autosuggestion. That is what a great number of professors of autosuggestion, unfortunately including a large number of medical men, do not realize at all. I also think that an absolute distinction should be established between autosuggestion and the training of the will. Docteur Van Velsen, _Brussels, March,_ 1920. *** What must you think of me? That I have forgotten you? Oh, no, I assure you that I think of you with the most grateful affection, and I wish to repeat that your teachings are more and more efficacious; I never spend a day without using autosuggestion with increased success, and I bless you every day, for your method is the true one. Thanks to it, I am assimilating your excellent directions, and am able to control myself better every day, and I feel that I am _stronger. . . ._ I am sure that you would find it difficult to recognize in this woman, so active in spite of her 66 years, the poor creature who was so often ailing, and who only began to be well, thanks to you and your guidance. May you be blessed for this, for the sweetest thing in the world is to do good to those around us. You do much, and do a little, for which I thank God. Mme. M----, _Cesson-Saint-Brieuc._ *** As I am feeling better and better since I began to follow your method of autosuggestion, I should like to offer you my sincere thanks. The lesion in the lungs has disappeared, my heart is better. I have no more albumen, in short I am quite well. Mme. Lemaitre, _Richemont, June,_ 1920. *** Your booklet and lecture interested us very much. It would be desirable for the good of humanity that they should be published in several languages, so that they might penetrate to every race and country, and thus reach a greater number of unfortunate people who suffer from the wrong use of that all-powerful (and almost divine) faculty, the most important to man, as you affirm and prove so luminously and judiciously, which we call the Imagination. I had already read many books on the will, and had quite an arsenal of formulae, thoughts, aphorisms, etc. Your phrases are conclusive. I do not think that ever before have "compressed tablets of self confidence."--as I call your healing phrases--been condensed into typical formulae in such an intelligent manner. Don Enrique C----, _Madrid._ *** Your pamphlet on "the self-control" contains very strong arguments and very striking examples. I think that the substitution of imagination for the power of the will is a great progress. It is milder and more persuasive. A. F----, _Reimiremont._ *** . . . I am happy to be able to tell you that my stomach is going on well. My metritis is also much better. My little boy had a gland in his thigh as big as an egg which is gradually disappearing. E. L----, _Saint-Clément (M-et-M.)_ *** After I had undergone three operations in my left leg on account of a local tuberculosis, that leg became ill again in September, 1920. Several doctors declared that a new operation was necessary. They were about to open my leg from the knee to the ankle, and if the operation had failed, they would have had to perform an amputation. As I had heard of your wondrous cures I came and saw you for the first time on the 6th of November, 1920. After the séance, I felt immediately a little better. I exactly followed your instructions and went three times to you. At the third time, I could tell you that I was completely cured. Mme. L----, _Henry (Lorraine)._ *** . . . I will not wait any longer to thank you heartily for all the good I owe you. Autosuggestion has positively transformed me and I am now getting much better than I have been these many years. The symptoms of illness have disappeared little by little, the morbid symptoms have become rarer and rarer, and all the functions of the body work now normally. The result is that, after having become thinner and thinner during several years I have regained several kilos in a few months. I cannot do otherwise than bless the Coué system. L----, _Cannes (A. M.)._ *** Since 1917, my little girl has been suffering from epileptic crises. Several doctors had told me that about the age of 14 or 15 they would disappear or become worse. Having heard of you, I sent her to you from the end of December till May. Now her cure is complete, for during six months she has had no relapse. Perrin (Charles), _Essey-les Nancy._ *** For eight years, I had suffered from a sinking of the uterus. After having practiced your autosuggestion for five months, I have been radically cured. I don't know how to express my deep gratitude. Mme. Soulie, 6, _Place du Marchè, Toul._ *** . . . Having suffered from a glaucoma since 1917, I have consulted two oculists who told me that only an operation would put an end to my sufferings, but unfortunately neither of them would assure me of a good result. In the month of June, 1920, after having attended one of your séances I felt much better. In September I ceased to use the drops of pilocarpine which were the daily bread of my eye, and since then I have felt no more pain. My pupil is no more dilated, my eyes are normal; it is a real miracle. Mme. M----, _à Soulosse._ *** A dedication to M. Coué by the author of a medical treatise: To M. Coué who knew how to dissect the human soul and to extract from it a psychologic method founded on conscious autosuggestion. The master is entitled to the thanks of all; he has cleverly succeeded in disciplining the vagrant (Imagination) and in associating it usefully with the will. Thus he has given man the means of increasing tenfold his moral force by giving him confidence in himself. Docteur P. R., _Francfort._ *** . . . It is difficult to speak of the profound influence exercised on me by your so kindly allowing me to view so often your work. Seeing it day by day, as I have done, it has impressed me more and more, and as you yourself said, there seems no limits to the possibilities and future scope of the principles you enunciate, not only in the physical life of children but also in possibilities for changing the ideas now prevalent in punishment of crime, in government, in fact, in all the relations of life. . . . Miss Josephine M. Richardson. *** . . . When I came, I expected a great deal, but what I have seen, thanks to your great kindness, exceeds greatly my expectation. Montagu S. Monier-Williams, M. D., _London._ FRAGMENTS FROM LETTERS Addressed to Mme. Emile Leon, Disciple of M. Coué For some time I have been wanting to write and thank you most sincerely for having made known to me this method of autosuggestion. Thanks to your good advice the attacks of nerves to which I was subject, have entirely disappeared, and I am certain that I am quite cured. Further, I feel myself surrounded by a superior force which is an unfaltering guide, and by whose aid I surmount with ease the difficulties of life. Mme. F----, _Rue de Bougainville,_ 4, _Paris._ *** Amazed at the results obtained by the autosuggestion which you made known to me, I thank you with all my heart. For a year I have been entirely cured of articular rheumatism of the right shoulder from which I had suffered for eight years, and from chronic bronchitis which I had had still longer. The numerous doctors I had consulted declared me incurable, but thanks to you and to your treatment, I have found with perfect health the conviction that I possess the power to keep it. Mme. L. T----, _Rue du Laos,_ 4, _Paris._ *** I want to tell you what excellent results M. Coué's wonderful method has produced in my case, and to express my deep gratitude for your valuable help. I have always been anaemic, and have had poor health, but after my husband's death I became much worse. I suffered with my kidneys, I could not stand upright, I also suffered from nervousness and aversions. All that has gone and I am a different person. I no longer suffer, I have more endurance, and I am more cheerful. My friends hardly recognize me, and I feel a new woman. I intend to spread the news of this wonderful method, so clear, so simple, so beneficent, and to continue to get from it the best results for myself as well. M. L. D----, _Paris, June,_ 1920. *** I cannot find words to thank you for teaching me your good method. What happiness you have brought to me! I thank God who led me to make your acquaintance, for you have entirely transformed my life. Formerly I suffered terribly at each monthly period and was obliged to lie in bed. Now all is quite regular and painless. It is the same with my digestion, and I am no longer obliged to live on milk as I used, and I have no more pain, which is a joy. My husband is astonished to find that when I travel I have no more headaches, whereas before I was always taking tablets. Now, thanks to you, I need no remedies at all, but I do not forget to repeat 20 times morning and evening, the phrase you taught me: "Every day, in every respect, I am getting better and better." B. P----, _Paris, October,_ 1920. *** In re-reading the method I find it more and more superior to all the developments inspired by it. It surpasses all that has been invented of so-called scientific systems, themselves based on the uncertain results of an uncertain science, which feels its way and deceives itself, and of which the means of observation are also fairly precarious in spite of what the learned say, M. Coué, on the other hand, suffices for everything, goes straight to the aim, attains it with certainty and in freeing his patient carries generosity and knowledge to its highest point, since he leaves to the patient himself the merit of this freedom, and the use of a marvellous power. No, really, there is nothing to alter in this method. It is as you so strikingly say: a Gospel. To report faithfully his acts and words and spread his method, that is what must be done, and what I shall do myself as far as is in any way possible. P. C. *** I am amazed at the results that I have obtained and continue to obtain daily, by the use of the excellent method you have taught me of conscious autosuggestion. I was ill mentally and physically. Now I am well and am also nearly always cheerful. That is to say that my depression has given way to cheerfulness, and certainly I do not complain of the change, for it is very preferable, I assure you. How wretched I used to be! I could digest nothing; now I digest perfectly well and the intestines act naturally. I also used to sleep so badly, whereas now the nights are not long enough; I could not work, but now I am able to work hard. Of all my ailments nothing is left but an occasional touch of rheumatism, which I feel sure will disappear like the rest by continuing your good method. I cannot find words to express my deep gratitude to you. Mme. Friry, _Boulevard Malesherbes, Paris._ EXTRACTS FROM LETTERS _Addressed to Mlle. Kaufmant, Disciple of M. Coué_ As I have been feeling better and better since following the method of autosuggestion which you taught me, I feel I owe you the sincerest thanks, I am now qualified to speak of the great and undeniable advantages of this method, as to it alone I owe my recovery. I had a lesion in the lungs which caused me to spit blood. I suffered from lack of appetite, daily vomiting, loss of flesh, and obstinate constipation. The spitting of blood, lessened at once and soon entirely disappeared. The vomiting ceased, the constipation no longer exists, I have got back my appetite, and in two months I have gained nearly a stone in weight. In the face of such results observed, not only by parents and friends, but also by the doctor who has been attending me for several months, it is impossible to deny the good effect of autosuggestion and not to declare openly that it is to your method that I owe my return to life. I authorize you to publish my name if it is likely to be of service to others, and I beg you to believe me. Yours most gratefully. Jeanne Gilli, 15, _Av. Borriglione, Nice, March,_ 1918. *** I consider it a duty to tell you how grateful I am to you for acquainting me with the benefits of autosuggestion. Thanks to you, I no longer suffer from those agonizing and frequent heart stoppages, and I have regained my appetite which I had lost for months. Still more, as a hospital nurse, I must thank you from my heart for the almost miraculous recovery of one of my patients, seriously ill with tuberculosis, which caused him to vomit blood constantly and copiously. His family and myself were very anxious when heaven sent you to him. After your first visit the spitting of blood ceased, his appetite returned, and after a few more visits made by you to his sick bed, all the organs little by little resumed their normal functions. At last one day we had the pleasant surprise and joy of seeing him arrive at your private séance, where, before those present, he himself made the declaration of his cure, due to your kind intervention. Thank you with all my heart. Yours gratefully and sympathetically, A. Kettner, 26, _Av. Borriglione, Nice, March,_ 1918. *** . . . From day to day I have put off writing to you to thank you for the cure of my little Sylvain. I was in despair, the doctors telling me that there was nothing more to be done but to try the sanitorium of Arcachon or Juicoot, near Dunkirk. I was going to do so when Mine. Collard advised me to go and see you. I hesitated, as I felt sceptical about it; but I now have the proof of your skill, for Sylvain has completely recovered. His appetite is good, his pimples and his glands are completely cured, and what is still more extraordinary, since the first time that we went to see you he has not coughed any more, not even once; the result is, that since the month of June he has gained 6 lbs.; I can never thank you enough and I proclaim to everyone the benefits we have received. Mme. Poirson, _Liverdun, August,_ 1920. *** How can I prove to you my deep gratitude? You have saved my life. I had a displaced heart, which caused terrible attacks of suffocation, which went on continually; in fact they were so violent that I had no rest day or night, in spite of daily injections of morphia. I could eat nothing without instant vomiting. I had violent pains in the head which became all swollen, and as a result I lost my sight. I was in a lamentable state and my whole organism suffered from it. I had abscesses on the liver. The doctor despaired of me after having tried everything; blood letting, cupping and scarifying, poultices, ice, and every possible remedy, without any improvement. I had recourse to your kindness on the doctor's advice. After your first visits the attacks became less violent and less frequent, and soon disappeared completely. The bad and troubled nights became calmer, until I was able to sleep the whole night through without waking. The pains I had in the liver ceased completely. I could begin to take my food again, digesting it perfectly well, and I again experienced the feeling of hunger which I had not known for months. My headaches ceased, and my eyes, which had troubled me so much, are quite cured, since I am now able to occupy myself with a little manual work. At each visit that you paid me, I felt that my organs were resuming their natural functions. I was not the only one to observe it, for the doctor who came to see me every week found me much better, and finally there came recovery, since I could get up after having been in bed eleven months. I got up without any discomfort, not even the least giddiness, and in a fortnight I could go out. It is indeed thanks to you that I am cured, for the doctor says that for all that the medicines did me, I might just as well have taken none. After having been given up by two doctors who held out no hope of cure, here I am cured all the same, and it is indeed a complete cure, for now I can eat meat, and I eat a pound of bread every day. How can I thank you, for I repeat, it is thanks to the suggestion you taught me that I owe my life. Jeanne Grosjean, _Nancy, Nov.,_ 1920. *** . . . Personally the science of autosuggestion--for I consider it as entirely a _science--_has rendered me great services; but truth compels me to declare that if I continue to interest myself particularly in it, it is because I find in it the means of exercising true charity. In 1915 when I was present for the first time at M. Coué's lectures, I confess that I was entirely sceptical. Before facts a _hundred times_ repeated in my presence, I was obliged to surrender to evidence, and recognize that autosuggestion always acted, though naturally in different degrees, on organic diseases. The only cases (and those were very rare) in which I have seen it fail are nervous cases, neurasthenia or imaginary illness. There is no need to tell you again that M. Coué, like yourself, but even more strongly, insists on this point: "that he never performs a miracle or cures anybody, but that he shows people how to cure themselves." I confess that on this point I still remain a trifle incredulous, for if M. Coué does not actually cure people, he is a powerful aid to their recovery, in "giving heart" to the sick, in teaching them never to despair, in uplifting them, in leading them . . . higher than themselves into moral spheres that the majority of humanity, plunged in materialism, has never reached. The more I study autosuggestion, the better I understand the divine law of confidence and love that Christ preached us: "Thou shalt love thy neighbor" and by giving a little of one's heart and of one's moral force to help him to rise if he has fallen and to cure himself if he is ill. Here also from my Christian point of view, is the application of autosuggestion which I consider as a beneficial and comforting science which helps us to understand that as the children of God, we all have within us forces whose existence we did not suspect, which properly directed, serve to elevate us morally and to heal us physically. Those who do not know your science, or who only know it imperfectly, should not judge it without having seen the results it gives and the good it does. Believe me to be your faithful admirer. M. L. D----, _Nancy, November,_ 1920. THE MIRACLE WITHIN _(Reprinted from the "Renaissance politique, littéraire et artistique" of the 18th of December,_ 1920) HOMAGE TO EMILE COUÉ In the course of the month of September, 1920, I opened for the first time the book of Charles Baudouin, of Geneva, professor at the Institute J. J. Rousseau in that town. This work, published by the firm of Delachaux and Niestle, 26, rue Saint-Dominique, Paris, is called: "Suggestion et Autosuggestion". The author has dedicated it: _"To Emile Coué, the initiator and benefactor, with deep gratitude"._ I read it and did not put down the book until I had reached the end. The fact is that it contains the very simple exposition of a magnificently humanitarian work, founded on a theory which may appear childish just because it is within the scope of everyone. And if everyone puts it into practice, the greatest good will proceed from it. After more than twenty years of indefatigable work, Emile Coué who at the present time lives at Nancy, where he lately followed the work and experiments of Liébault, the father of the doctrine of suggestions, for more than twenty years, I say, Coué has been occupied exclusively with this question, but particularly in order to bring his fellow creatures to cultivate _autosuggestion._ At the beginning of the century Coué had attained the object of his researches, and had disengaged the general and immense force of autosuggestion. After innumerable experiments on thousands of subjects, _he showed the action of the unconscious in organic cases._ This is new, and the great merit of this profoundly, modest learned man, is to have found a remedy for terrible ills, reputed incurable or terribly painful, without any hope of relief. As I cannot enter here into long scientific details I will content myself by saying how the learned man of Nancy practises his method. The chiselled epitome of a whole life of patient researches and of ceaseless observations, is a brief formula which is to be repeated morning and evening. It must be said in a low voice, with the eyes closed, in a position favourable to the relaxing of the muscular system, it may be in bed, or it may be in an easy chair, and in a tone of voice as if one were reciting a litany. Here are the magic words: _"Every day, in every respect, I am getting better and better"._ They must be said twenty times following, with the help of a string with twenty knots in it, which serves as a rosary. This material detail has its importance; it ensures mechanical recitation, which is essential. While articulating these words, _which are registered by the unconscious,_ one must not think of anything particular, neither of one's illness nor of one's troubles, one must be passive, just with the desire that all may be for the best. The formula _"in every respect"_ has a general effect. This desire must be expressed without passion, without will, with gentleness, _but with absolute confidence._ For Emile Coué at the moment of autosuggestion, _does not call in the will in any way, on the contrary;_ there must be no question of the will at that moment, but the _imagination,_ the great motive force infinitely more active than that which is usually invoked, the imagination alone must be brought into play. "Have confidence in yourself," says this good counsellor, "believe firmly that all will be well". And indeed all is well for those who have faith, fortified by perseverance. As deeds talk louder than words, I will tell you what happened to myself before I had ever seen M. Coué. I must go back then to the month of September when I opened M. Charles Baudouin's volume. At the end of a substantial exposition, the author enumerates the cure of illnesses such as enteritis, eczema, stammering, dumbness, a sinus dating from twenty years back which had necessitated eleven operations, metritis, salpingitis, fibrous tumours, varicose veins, etc., lastly and above all, deep tubercular sores, and the last stages of phthisis (case of Mme. D----, of Troyes, aged 30 years, who has become a mother since her cure; case was followed up, but there was no relapse). All this is often testified to by doctors in attendance on the patients. These examples impressed me profoundly; _there_ was the miracle. It was not a question of nerves, but of ills which medicine attacks without success. This cure of tuberculosis was a revelation to me. Having suffered for two years from acute neuritis in the face, I was in horrible pain. Four doctors, two of them specialists, had pronounced the sentence which would be enough, of itself alone, to increase the trouble by its fatal influence on the mind: "Nothing to be done!" This "nothing to be done" had been for me the worst of autosuggestions. In possession of the formula: "Every day, in every respect . . .", etc., I recited it with a faith which, although it had come suddenly, was none the less capable of removing mountains, and throwing down shawls and scarves, bareheaded, I went into the garden in the rain and wind repeating gently _"I am going to be cured,_ I shall have no more neuritis, it is going away, it will not come back, etc. . . ." The next day I was cured and never any more since have I suffered from this abominable complaint, which did not allow me to take a step out of doors and made life unbearable. It was an immense joy. The incredulous will say: "It was all nervous." Obviously, and I give them this first point. But, delighted with the result, I tried the Coué Method for an oedema of the left ankle, resulting from an affection of the kidneys reputed incurable. In two days the oedema had disappeared. I then treated fatigue and mental depression, etc., and extraordinary improvement was produced, and I had but one idea: to go to Nancy to thank my benefactor. I went there and found the excellent man, attractive by his goodness and simplicity, who has become my friend. It was indispensable to see him in his field of action. He invited me to a popular "séance." I heard a concert of gratitude. Lesions in the lungs, displaced organs, asthma, Pott's disease (!), paralysis, the whole deadly horde of diseases were being put to flight. I saw a paralytic, who sat contorted and twisted in his chair, get up and walk. M. Coué had spoken, he demanded confidence, great, immense confidence in oneself. He said: "Learn to cure yourselves, you can do so; I have never cured anyone. The power is within you yourselves, call upon your spirit, make it act for your physical and mental good, and it will come, it will cure you, you will be strong and happy". Having spoken, Coué approached the paralytic: "You heard what I said, do you believe that you will walk?" "Yes."--"Very well then, get up!" The woman got up, she walked, and went round the garden. The miracle was accomplished. A young girl with Pott's disease, whose vertebral column became straight again after three visits, told me what an intense happiness it was to feel herself coming back to life after having thought herself a hopeless case. Three women, cured of lesions in the lungs, expressed their delight at going back to work and to a normal life. Coué in the midst of those people whom he loves, seemed to me a being apart, for this man ignores money, all his work is gratuitous, and his extraordinary disinterestedness forbids his taking a farthing for it. "I owe you something", I said to him, "I simply owe you everything. . . ." "No, only the pleasure I shall have from your continuing to keep well. . . ." An irresistible sympathy attracts one to this simple-minded philanthropist; arm in arm we walked round the kitchen garden which he cultivates himself, getting up early to do so. Practically a vegetarian, he considers with satisfaction the results of his work. And then the serious conversation goes on: "In your _mind_ you possess an _unlimited_ power. It acts on matter if we know how to domesticate it. The imagination is like a horse without a bridle; if such a horse is pulling the carriage in which you are, he may do all sorts of foolish things and take you to your death. But harness him properly, drive him with a sure hand, and he will go wherever you like. Thus it is with the mind, the imagination. They must be directed for our own good. Autosuggestion, formulated with the lips, is an order which the unconscious receives, it carries it out unknown to ourselves and above all at night, so that the evening autosuggestion is the most important. It gives marvelous results." When you feel a physical pain, add the formula _"It is going away . . .",_ very quickly repeated, in a kind of droning voice, placing your hand on the part where you feel the pain, or on the forehead, if it is a mental distress. For the method acts very efficaciously on the mind. After having called in the help of the soul for the body, one can ask it again for all the circumstances and difficulties of life. There also I know from experience that events can be singularly modified by this process. You know it to-day, and you will know it better still by reading M. Baudouin's book, and then his pamphlet: _"Culture de la force morale",_ and then, lastly, the little succinct treatise written by M. Coué himself: _"Self Mastery."_ All these works may be found at M. Coué's. If however I have been able to inspire in you the desire of making this excellent pilgrimage yourself, you will go to Nancy to fetch the booklet. Like myself you will love this unique man, unique by reason of his noble charity and of his love for his fellows, as Christ taught it. Like myself also, you will be cured physically and mentally. Life will seem to you better and more beautiful. That surely is worth the trouble of trying for. M. Burnat-Provins. SOME NOTES ON THE JOURNEY OF M. COUÉ TO PARIS IN OCTOBER, 1919 The desire that the teachings of M. Coué in Paris last October should not be lost to others, has urged me to write them down. Putting aside this time the numerous people, physically or mentally ill, who have seen their troubles lessen and disappear as the result of his beneficent treatment, let us begin by quoting just a few of his teachings. _Question._--Why is it that I do not obtain better results although I use your method and prayer? _Answer._--Because, probably, at the back of your mind there is an _unconscious doubt,_ or because you make _efforts._ Now, remember that efforts are determined by the will; if you bring the will into play, you run a serious risk of bringing the imagination into play too, but in the contrary direction, which brings about just the reverse of what you desire. _Question._--What are we to do when something troubles us? _Answer._--When something happens that troubles you, _repeat_ at once "No, that does not trouble me at all, not in the least, the fact is rather agreeable than otherwise." In short, the idea is to work ourselves up in a good sense instead of in a bad. _Question._--Are the preliminary experiments indispensable if they are unacceptable to the pride of the subject? _Answer._--No, they are not indispensable, but they are of great utility; for although they may seem childish to certain people, they are on the contrary extremely serious; they do indeed prove three things: 1. That every idea that we have in our minds becomes _true_ for us, and has a tendency to transform itself into action. 2. That when there is a conflict between the imagination and the will, it is always the imagination which wins; and in this case we do exactly the _contrary_ of what we wish to do. 3. That it is easy for us to put into our minds, _without any effort,_ the idea that we wish to have, since we have been able without effort to think in succession: "I cannot," and then "I can." The preliminary experiments should not be repeated at home; alone, one is often unable to put oneself in the right physical and mental conditions, there is a risk of failure, and in this case one's self-confidence is shaken. _Question._--When one is in pain, one cannot help thinking of one's trouble. _Answer._--Do not be afraid to think of it; on the contrary, do think of it, but to say to it, "I am not _afraid_ of you." If you go anywhere and a dog rushes at you barking, look it firmly in the eyes and it will not bite you; but if you fear it, if you turn back, he will soon have his teeth in your legs. _Question._--And if one does a retreat? _Answer._--Go backwards. _Question._--How can we realize what we desire? _Answer._--By often repeating what you desire: "I am gaining assurance," and you will do so; "My memory is improving," and it really does so; "I am becoming absolutely master of myself," and you find that you are becoming so. If you say the contrary, it is the contrary which will come about. What you say persistently and very quickly _comes to pass_ (within the domain of the reasonable, of course). Some testimonies: A young lady to another lady: "How simple it is! There is nothing to add to it: he seems inspired. Do you not think that there are beings who radiate influence?" . . . An eminent Parisian doctor to numerous doctors surrounding him: "I have entirely come over to the ideas of M. Coué." . . . A Polytechnician, a severe critic, thus defines M. Coué: "He is a Power." . . . Yes, he is a Power of Goodness. Without mercy for the bad autosuggestions of the "defeatist" type, but indefatigably painstaking, active and smiling, to help everyone to develop their personality, and to teach them to cure themselves, which is the characteristic of his beneficent method. How could one fail to desire from the depths of one's heart that all might understand and seize the "good news" that M. Coué brings? "It is the awakening, possible for everyone, of the personal power which he has _received_ of being happy and well." It is, _if one consents,_ the full development of this power which can transform one's life. Then, and is it not quite rightly so? it is the strict duty (and at the same time the happiness) of those who have been initiated, to spread by every possible means the knowledge of this wonderful method, the happy results of which have been recognized and verified by _thousands_ of persons, to make it known to those who suffer, who are sad, or who are overburdened . . . to all! and to help them to put it into practice. Then, thinking of France, triumphant but bruised, of her defenders victorious but mutilated, of all the physical and moral suffering entailed by the war; may those who-have the power (the greatest power ever given to man is the power of doing good [Socrates]) see that the inexhaustible reservoir of physical and moral forces that the "Method" puts within our reach may soon become the-patrimony of all the nation and through it of humanity. Mme. Emile Leon, _Collaborator, in Paris, of M. Emile Coué_ "EVERYTHING FOR EVERYONE" By Mme. Emile Leon, Disciple of M. Coué. When one has been able to take advantage of a great benefit; when this benefit is within reach of everyone, although almost everyone is ignorant of it, is it not an urgent and absolute duty (for those who are initiated) to make it known to those around them? For all can make their own the amazing results of the "Emile Coué Method." To drive away pain is much . . . but how much more is it to lead into the possession of a new life _all_ those who suffer. . . . Last April we had the visit of M. Emile Coué at Paris, and here are some of his teachings: _Question._--Question of a theist: I think it is unworthy of the Eternal to make our obedience to his will, depend on what M. Coué calls a trick or mechanical process: conscious autosuggestion. _M. Coué._--Whether we wish it or not, our imagination always overrules our will, when they are in conflict. We can lead it into the right path indicated by our reason, by _consciously_ employing the mechanical process that we employ _unconsciously_ often to lead into the wrong. And the thoughtful questioner says to herself: "Yes, it is true, in this elevated sphere of thought, conscious autosuggestion has the power to free us from obstacles _created by ourselves,_ which might as it were put a veil between us and God, just as a piece of stuff, hanging in a window, can prevent the sun from coming into a room." _Question._--How ought one to set about bringing those dear to one who may be suffering, to make themselves good autosuggestions which would set them free? _Answer._--Do not insist or lecture them about it. Just remind them simply that I advise them to make an autosuggestion with the _conviction_ that they will obtain the result they want. _Question._--How is one to explain to oneself and to explain to others that the repetition of the same words: "I am going to sleep. . . . It is going away . . ." etc., has the power to produce the effect, and above all so powerful an effect that it is a certain one? _Answer._--The repetition of the same words forces one to think them, and when we think them they become true for us and transform themselves into reality. _Question._--How is one to keep inwardly the mastery of oneself? _Answer._--To be master of oneself it is enough to think that one is so, and in order to think it, one should often repeat it without making any effort. _Question._--And outwardly, how is one to keep one's liberty? _Answer._--Self mastery applies just as much physically as mentally. _Question_(Affirmation).--It is impossible to escape trouble or sadness, if we do not do as we should, it would not be just, and autosuggestion, cannot . . . and ought not to prevent _just suffering._ _M. Coué_(very seriously and affirmatively).--Certainly and assuredly it ought not to be so, but it is so often . . . at any rate for a time. _Question._--Why did that patient who has been entirely cured, continually have those terrible attacks? _Answer._--He expected his attacks, he feared them . . . and so he _provoked_ them; if this gentleman gets well into his mind the idea that he will have no more attacks, he will not have any; if he thinks that he will have them, he will indeed do so. _Question._--In what does your method differ from others. _Answer._--The differ not the _will_ which rules us but the _imagination;_ that is the basis, the fundamental basis. _Question._--Will you give me a summary of your "Method" for Mme. R----, who is doing an important work? _M. E. Coué._--Here is the summary of the "Method" in a few words: Contrary to what is taught, it is not our will which makes us act, but our imagination (the unconscious). If we often do act as we _will,_ it is because at the same time we think that we can. If it is not so, we do exactly the reverse of what we wish. Ex: The more a person with insomnia _determines_ to sleep, the more excited she becomes; the more we _try_ to remember a name which we think we have forgotten, the more it escapes us (it comes back only if, in your mind, you replace the idea: "I have forgotten", by the idea "it will come back"); the more we strive to prevent ourselves from laughing, the more our laughter bursts out; the more we _determine_ to avoid an obstacle, when learning to bicycle, the more we rush upon it. We must then apply ourselves to directing our _imagination_ which now directs us; in this way we easily arrive at becoming masters of ourselves physically and morally. How are we to arrive at this result? By the practice of conscious _autosuggestion._ Conscious autosuggestion is based on this principle. Every idea that we have in our mind becomes true for us and tends to realize itself. Thus, if we _desire_ something, we can obtain it at the end of a more or less long time, if we often repeat that this thing is going to come, or to disappear, according to whether it is a good quality or a fault, either physical or mental. Everything is included by employing night and morning the general formula: "Every day, _in every respect,_ I am getting better and better". _Question._--For those who are sad--who are in distress? _Answer._--As long as you think: "I am sad", you _cannot_ be cheerful, and in order to think something, it is enough to say without effort: "I do think this thing--"; as to the distress it will disappear, however violent it may be, _that_ I _can_ affirm. A man arrives bent, dragging himself painfully along, leaning on two sticks; he has on his face an expression of dull depression. As the hall is filling up, M. E. Coué enters. After having questioned this man, he says to him something like this: "So you have had rheumatism for 32 years and you cannot walk. Don't be afraid, it's not going to last as long as that again." Then after the preliminary experiments: "Shut your eyes, and repeat very quickly indeed, moving your lips, the words: 'It is going, it is going' (at the same time M. Coué passes his hand over the legs of the patient, for 20 to 25 seconds). Now you are no longer in pain, get up and walk (the patient walks) quickly! quicker! more quickly still! and since you can walk so well, you are going to run; run! Monsieur, run!" The patient runs (joyously, almost as if he had recovered his youth), to his great astonishment, and also to that of the numerous persons present at the séance of April 27th, 1920. (Clinic of Dr. Berillon.) A lady declares: "My husband suffered from attacks of asthma for many years, he had such difficulty in breathing that we feared a fatal issue; his medical adviser, Dr. X---- had given him up. He was almost radically cured of his attacks, after only one visit from M. Coué". A young woman comes to thank M. Coué with lively gratitude. Her doctor, Dr. Vachet, who was with her in the room, says that the cerebral anaemia from which she had suffered for a long while, which he had not succeeded in checking by the usual means, had disappeared as if by magic through the use of conscious autosuggestion. Another person who had had a fractured leg and could not walk without pain and limping, could at once walk normally. No more pain, no more limping. In the hall which thrills with interest, joyful testimonies break out from numerous persons who have been relieved or cured. A doctor: "Autosuggestion is the weapon of healing". As to this philosopher who writes (he mentions his name), he relies on the _genius_ of Coué. A gentleman, a former magistrate, whom a lady had asked to express his appreciation, exclaims in a moved tone: "I cannot put my appreciation into words--I think it is admirable--" A woman of the world, excited by the disappearance of her sufferings: "Oh, M. Coué, one could kneel to you--You are the merciful God!" Another lady, very much impressed herself, rectifies: "No, his messenger". An aged lady: It is delightful, when one is aged and fragile, to replace a feeling of general ill health by that of refreshment and general well-being, and M. E. Coué's method can, I affirm for I have proved it, produce this happy result, which is all the more complete and lasting since it relies on the all-powerful force which is within us. A warmly sympathetic voice calls him the modest name he prefers to that of "Master": Professor Coué. A young woman who has been entirely won over: "M. Coué goes straight to his aim, attains it with sureness, and, in setting free his patient, carries generosity and knowledge to its highest point, since he leaves to the patient himself the merit of his liberation and the use of a marvellous power". A literary man, whom a lady asks to write a little _"chef d'oeuvre"_ on the beneficent "Method" refuses absolutely, emphasizing the simple words which, used according to the Method, help to make all suffering disappear: "IT IS GOING AWAY--_that_ is the _chef-d'oeuvre!"_ he affirms. And the thousands of sick folks who have been relieved or cured will not contradict him. A lady who has suffered much declares: "In re-reading the 'Method' I find it more and more superior to the developments it has inspired; there is really nothing to take away nor add to this 'Method'--all that is left is to spread it. I shall do so in every possible way." And now in conclusion I will say: Although M. Coué's modesty makes him reply to everyone: I have no magnetic fluid-- I have no influence-- I have never cured anybody-- My disciples obtain the same results as myself-- "I can say in all sincerity that they tend to do so, instructed as they are in the _valuable 'Method',_ and when, in some far distant future, the thrilling voice of its author called to a higher sphere can no longer teach it here below, the 'Method', his work, will help in aiding, comforting, and curing thousands and thousands of human beings: it must be _immortal,_ and communicated to the entire world by generous France--for the man of letters was right, and knew how to illuminate in a word this true simple, and marvellous help in conquering pain: 'IT IS GOING AWAY--! _There is the chef-d'oeuvre!'"_ B. K. (Emile-Leon). Paris, June 6th, 1920. 
29339	----	THE PRACTICE OF AUTOSUGGESTION BY THE METHOD _of_ EMILE COUÉ _Revised Edition_ BY C. HARRY BROOKS WITH A FOREWORD BY EMILE COUÉ "For what man knoweth the things of a man save the spirit of the man which is in him?" 1 CORINTHIANS ii. 11. NEW YORK DODD, MEAD AND COMPANY 1922 COPYRIGHT 1922 BY DODD, MEAD AND COMPANY, INC. First Printing, May, 1922 Second Printing, June, 1922 Third Printing, June, 1922 Fourth Printing, July, 1922 Fifth Printing, July, 1922 Sixth Printing, Aug., 1922 Seventh Printing, Aug., 1922 Eighth Printing, Aug., 1922 Ninth Printing, Sept., 1922 Tenth Printing, Sept., 1922 Eleventh Printing, Nov., 1922 Twelfth Printing, Nov., 1922 Thirteenth Printing, Dec., 1922 Fourteenth Printing, Jan., 1923 PRINTED IN THE U. S. A. BY The Quinn & Boden Company BOOK MANUFACTURERS RAHWAY NEW JERSEY TO ALL IN CONFLICT WITH THEIR OWN IMPERFECTIONS THIS LITTLE BOOK IS DEDICATED PREFACE TO THE AMERICAN EDITION To my American readers a special word of gratitude is due for their generosity to this little book. I hope that it has given them as much encouragement and help as they have given me. In America, the home of so many systems of mental healing, it is perhaps even more necessary than in Europe to insist on the distinctive features of M. Coué's teaching. It is based, not on transcendental or mystical postulates, but on the simple and acknowledged facts of psychology. This does not mean that it has no relation to religion. On the contrary it has a very close one. Indeed I hope in a future volume to point out its deep significance for the Christian churches. But that relationship remains in M. Coué's teaching unexpressed. The powers he has revealed are part of the natural endowment of the human mind. Therefore they are available to all men, independently of adherence or non-adherence to any sect or creed. The method of M. Coué is in no sense opposed to the ordinary practice of medicine. It is not intended to supplant it but to supplement it. It is a new ally, bringing valuable reinforcements to the common crusade against disease and unhappiness. Induced Autosuggestion does not involve, as several hasty critics have assumed, an attack upon the Will. It simply teaches that during the actual formulation of suggestions, that is for a few minutes daily, the Will should be quiescent. At other times the exercise of the Will is encouraged; indeed we are shown how to use it properly, that is without friction or waste of energy. C. H. B. 19 _October_, 1922. AUTHOR'S PREFACE The discoveries of Emile Coué are of such moment for the happiness and efficiency of the individual life that it is the duty of anyone acquainted with them to pass them on to his fellows. The lives of many men and women are robbed of their true value by twists and flaws of character and temperament, which, while defying the efforts of the will, would yield rapidly to the influence of autosuggestion. Unfortunately, the knowledge of this method has hitherto been available in England only in the somewhat detailed and technical work of Professor Charles Baudouin, and in a small pamphlet, printed privately by M. Coué, which has not been publicly exposed for sale. To fill this gap is the aim of the following pages. They are designed to present to the layman in non-technical form the information necessary to enable him to practise autosuggestion for himself. All readers who wish to obtain a deeper insight into the theoretical basis of autosuggestion are recommended to study Professor Baudouin's fascinating work, _Suggestion and Autosuggestion_. Although in these pages there are occasional divergences from Professor Baudouin's views, his book remains beyond question the authoritative statement on the subject; indeed it is hardly possible without it to form an adequate idea of the scope of autosuggestion. My own indebtedness to it in writing this little volume is very great. My thanks are due for innumerable kindnesses to M. Coué himself. That he is the embodiment of patience everyone knows who has been in contact with him. I am also indebted to the Rev. Ernest Charles, of Malvern Link, who, though disclaiming responsibility for some of the views expressed here, has made many extremely valuable suggestions. C. H. B. MALVERN LINK, 21 _February_, 1922. FOREWORD The materials for this little book were collected by Mr. Brooks during a visit he paid me in the summer of 1921. He was, I think, the first Englishman to come to Nancy with the express purpose of studying my method of conscious autosuggestion. In the course of daily visits extending over some weeks, by attending my consultations, and by private conversations with myself, he obtained a full mastery of the method, and we threshed out a good deal of the theory on which it rests. The results of this study are contained in the following pages. Mr. Brooks has skilfully seized on the essentials and put them forward in a manner that seems to me both simple and clear. The instructions given are amply sufficient to enable anyone to practise autosuggestion for him or herself, without seeking the help of any other person. It is a method which everyone should follow--the sick to obtain healing, the healthy to prevent the coming of disease in the future. By its practice we can insure for ourselves, all our lives long, an excellent state of health, both of the mind and the body. E. COUÉ. NANCY. CONTENTS PREFACE FOREWORD I COUÉ'S NANCY PRACTICE CHAPTER I THE CLINIC OF EMILE COUÉ II A FEW OF COUÉ'S CURES III THE CHILDREN'S CLINIC II THE NATURE OF AUTOSUGGESTION IV THOUGHT IS A FORCE V THOUGHT AND THE WILL III THE PRACTICE OF AUTOSUGGESTION VI GENERAL RULES VII THE GENERAL FORMULA VIII PARTICULAR SUGGESTIONS IX HOW TO DEAL WITH PAIN X AUTOSUGGESTION AND THE CHILD XI CONCLUSION I COUÉ'S NANCY PRACTICE CHAPTER I THE CLINIC OF EMILE COUÉ The clinic of Emile Coué, where Induced Autosuggestion is applied to the treatment of disease, is situated in a pleasant garden attached to his house at the quiet end of the rue Jeanne d'Arc in Nancy. It was here that I visited him in the early summer of 1921, and had the pleasure for the first time of witnessing one of his consultations. We entered the garden from his house a little before nine o'clock. In one corner was a brick building of two stories, with its windows thrown wide to let in the air and sunshine--this was the clinic; a few yards away was a smaller one-storied construction which served as a waiting-room. Under the plum and cherry trees, now laden with fruit, little groups of patients were sitting on the garden seats, chatting amicably together and enjoying the morning sunshine while others wandered in twos and threes among the flowers and strawberry beds. The room reserved for the treatments was already crowded, but in spite of that eager newcomers constantly tried to gain entrance. The window-sills on the ground floor were beset, and a dense knot had formed in the doorway. Inside, the patients had first occupied the seats which surrounded the walls, and then covered the available floor-space, sitting on camp-stools and folding-chairs. Coué with some difficulty found me a seat, and the treatment immediately began. The first patient he addressed was a frail, middle-aged man who, accompanied by his daughter, had just arrived from Paris to consult him. The man was a bad case of nervous trouble. He walked with difficulty, and his head, arms and legs were afflicted with a continual tremor. He explained that if he encountered a stranger when walking in the street the idea that the latter would remark his infirmity completely paralysed him, and he had to cling to whatever support was at hand to save himself from falling. At Coué's invitation he rose from his seat and took a few steps across the floor. He walked slowly, leaning on a stick; his knees were half bent, and his feet dragged heavily along the ground. Coué encouraged him with the promise of improvement. "You have been sowing bad seed in your Unconscious; now you will sow good seed. The power by which you have produced these ill effects will in future produce equally good ones." The next patient was an excitable, over-worked woman of the artisan class. When Coué inquired the nature of her trouble, she broke into a flood of complaint, describing each symptom with a voluble minuteness. "Madame," he interrupted, "you think too much about your ailments, and in thinking of them you create fresh ones." Next came a girl with headaches, a youth with inflamed eyes, and a farm-labourer incapacitated by varicose veins. In each case Coué stated that autosuggestion should bring complete relief. Then it was the turn of a business man who complained of nervousness, lack of self-confidence and haunting fears. "When you know the method," said Coué, "you will not allow yourself to harbour such ideas." "I work terribly hard to get rid of them," the patient answered. "You fatigue yourself. The greater the efforts you make, the more the ideas return. You will change all that easily, simply, and above all, without effort." "I want to," the man interjected. "That's just where you're wrong," Coué told him. "If you say 'I want to do something,' your imagination replies 'Oh, but you can't.' You must say 'I am going to do it,' and if it is in the region of the possible you will succeed." A little further on was another neurasthenic--a girl. This was her third visit to the clinic, and for ten days she had been practising the method at home. With a happy smile, and a little pardonable self-importance, she declared that she already felt a considerable improvement. She had more energy, was beginning to enjoy life, ate heartily and slept more soundly. Her sincerity and naïve delight helped to strengthen the faith of her fellow-patients. They looked on her as a living proof of the healing which should come to themselves. Coué continued his questions. Those who were unable, whether through rheumatism or some paralytic affection, to make use of a limb were called on, as a criterion of future progress, to put out their maximum efforts. In addition to the visitor from Paris there were present a man and a woman who could not walk without support, and a burly peasant, formerly a blacksmith, who for nearly ten years had not succeeded in lifting his right arm above the level of his shoulder. In each case Coué predicted a complete cure. During this preliminary stage of the treatment, the words he spoke were not in the nature of suggestions. They were sober expressions of opinion, based on years of experience. Not once did he reject the possibility of cure, though with several patients suffering from organic disease in an advanced stage, he admitted its unlikelihood. To these he promised, however, a cessation of pain, an improvement of morale, and at least a retardment of the progress of the disease. "Meanwhile," he added, "the limits of the power of autosuggestion are not yet known; final recovery is possible." In all cases of functional and nervous disorders, as well as the less serious ones of an organic nature, he stated that autosuggestion, conscientiously applied, was capable of removing the trouble completely. It took Coué nearly forty minutes to complete his interrogation. Other patients bore witness to the benefits the treatment had already conferred on them. A woman with a painful swelling in her breast, which a doctor had diagnosed (in Coué's opinion wrongly), as of a cancerous nature, had found complete relief after less than three weeks' treatment. Another woman had enriched her impoverished blood, and increased her weight by over nine pounds. A man had been cured of a varicose ulcer, another in a single sitting had rid himself of a lifelong habit of stammering. Only one of the former patients failed to report an improvement. "Monsieur," said Coué, "you have been making efforts. You must put your trust in the imagination, not in the will. Think you are better and you will become so." Coué now proceeded to outline the theory given in the pages which follow. It is sufficient here to state his main conclusions, which were these: (1) Every idea which exclusively occupies the mind is transformed into an actual physical or mental state. (2) The efforts we make to conquer an idea by exerting the will only serve to make that idea more powerful. To demonstrate these truths he requested one of his patients, a young anaemic-looking woman, to carry out a small experiment. She extended her arms in front of her, and clasped the hands firmly together with the fingers interlaced, increasing the force of her grip until a slight tremor set in. "Look at your hands," said Coué, "and think you would like to open them but you cannot. Now try and pull them apart. Pull hard. You find that the more you try the more tightly they become clasped together." The girl made little convulsive movements of her wrists, really doing her best by physical force to separate her hands, but the harder she tried the more her grip increased in strength, until the knuckles turned white with the pressure. Her hands seemed locked together by a force outside her own control. "Now think," said Cone, "'I can open my hands.'" Slowly her grasp relaxed and, in response to a little pull, the cramped fingers came apart. She smiled shyly at the attention she had attracted, and sat down. Coué pointed out that the two main points of his theory were thus demonstrated simultaneously: when the patient's mind was filled with the thought "I cannot," she could not in very fact unclasp her hands. Further, the efforts she made to wrench them apart by exerting her will only fixed them more firmly together. Each patient was now called on in turn to perform the same experiment. The more imaginative among them--notably the women--were at once successful. One old lady was so absorbed in the thought "I cannot" as not to heed the request to think "I can." With her face ruefully puckered up she sat staring fixedly at her interlocked fingers, as though contemplating an act of fate. "Voilà," said Coué, smiling, "if Madame persists in her present idea, she will never open her hands again as long as she lives." Several of the men, however, were not at once successful. The whilom blacksmith with the disabled arm, when told to think "I should like to open my hands but I cannot," proceeded without difficulty to open them. "You see," said Coué, with a smile, "it depends not on what I say but on what you think. What were you thinking then?" He hesitated. "I thought perhaps I could open them after all." "Exactly. And therefore you could. Now clasp your hands again. Press them together." When the right degree of pressure had been reached, Coué told him to repeat the words "I cannot, I cannot...." As he repeated this phrase the contracture increased, and all his efforts failed to release his grip. "Voilà," said Coué. "Now listen. For ten years you have been thinking you could not lift your arm above your shoulder, consequently you have not been able to do so, for whatever we think becomes true for us. Now think 'I can lift it.'" The patient looked at him doubtfully. "Quick!" Coué said in a tone of authority. "Think 'I can, I can!'" "I can," said the man. He made a half-hearted attempt and complained of a pain in his shoulder. "Bon," said Coué. "Don't lower your arm. Close your eyes and repeat with me as fast as you can, 'Ca passe, ça passe.'" For half a minute they repeated this phrase together, speaking so fast as to produce a sound like the whirr of a rapidly revolving machine. Meanwhile Coué quickly stroked the man's shoulder. At the end of that time the patient admitted that his pain had left him. "Now think well that you can lift your arm," Coué said. The departure of the pain had given the patient faith. His face, which before had been perplexed and incredulous, brightened as the thought of power took possession of him. "I can," he said in a tone of finality, and without effort he calmly lifted his arm to its full height above his head. He held it there triumphantly for a moment while the whole company applauded and encouraged him. Coué reached for his hand and shook it. "My friend, you are cured." "C'est merveilleux," the man answered. "I believe I am." "Prove it," said Coué. "Hit me on the shoulder." The patient laughed, and dealt him a gentle rap. "Harder," Coué encouraged him. "Hit me harder--as hard as you can." His arm began to rise and fall in regular blows, increasing in force until Coué was compelled to call on him to stop. "Voilà, mon ami, you can go back to your anvil." The man resumed his seat, still hardly able to comprehend what had occurred. Now and then he lifted his arm as if to reassure himself, whispering to himself in an awed voice, "I can, I can." A little further on was seated a woman who had complained of violent neuralgia. Under the influence of the repeated phrase "ça passe" (it's going) the pain was dispelled in less than thirty seconds. Then it was the turn of the visitor from Paris. What he had seen had inspired him with confidence; he was sitting more erect, there was a little patch of colour in his cheeks, and his trembling seemed less violent. He performed the experiment with immediate success. "Now," said Coué, "you are cultivated ground. I can throw out the seed in handfuls." He caused the sufferer first to stand erect with his back and knees straightened. Then he asked him, constantly thinking "I can," to place his entire weight on each foot in turn, slowly performing the exercise known as "marking time." A space was then cleared of chairs, and having discarded his stick, the man was made to walk to and fro. When his gait became slovenly Coué stopped him, pointed out his fault, and, renewing the thought "I can," caused him to correct it. Progressive improvement kindled the man's imagination. He took himself in his own hands. His bearing became more and more confident, he walked more easily, more quickly. His little daughter, all smiles and happy self-forgetfulness, stood beside him uttering expressions of delight, admiration and encouragement. The whole company laughed and clapped their hands. "After the sitting," said Coué, "you shall come for a run in my garden." Thus Coué continued his round of the clinic. Each patient suffering from pain was given complete or partial relief; those with useless limbs had a varying measure of use restored to them. Coué's manner was always quietly inspiring. There was no formality, no attitude of the superior person; he treated everyone, whether rich or poor, with the same friendly solicitude. But within these limits he varied his tone to suit the temperament of the patient. Sometimes he was firm, sometimes gently bantering. He seized every opportunity for a little humorous by-play. One might almost say that he tactfully teased some of his patients, giving them an idea that their ailment was absurd, and a little unworthy; that to be ill was a quaint but reprehensible weakness, which they should quickly get rid of. Indeed, this denial of the dignity of disease is one of the characteristics of the place. No homage is paid to it as a Dread Monarch. It is gently ridiculed, its terrors are made to appear second-rate, and its victims end by laughing at it. Coué now passed on to the formulation of specific suggestions. The patients closed their eyes, and he proceeded in a low, monotonous voice, to evoke before their minds the states of health, mental and physical, they were seeking. As they listened to him their alertness ebbed away, they were lulled into a drowsy state, peopled only by the vivid images he called up before the eyes of the mind. The faint rustle of the trees, the songs of the birds, the low voices of those waiting in the garden, merged into a pleasant background, on which his words stood out powerfully. This is what he said: "Say to yourself that all the words I am about to utter will be fixed, imprinted and engraven in your minds; that they will remain fixed, imprinted and engraven there, so that without your will and knowledge, without your being in any way aware of what is taking place, you yourself and your whole organism will obey them. I tell you first that every day, three times a day, morning, noon and evening, at mealtimes, you will be hungry; that is to say you will feel that pleasant sensation which makes us think and say: 'How I should like something to eat!' You will then eat with excellent appetite, enjoying your food, but you will never eat too much. You will eat the right amount, neither too much nor too little, and you will know intuitively when you have had sufficient. You will masticate your food thoroughly, transforming it into a smooth paste before swallowing it. In these conditions you will digest it well, and so feel no discomfort of any kind either in the stomach or the intestines. Assimilation will be perfectly performed, and your organism will make the best possible use of the food to create blood, muscle, strength, energy, in a word--Life. "Since you have digested your food properly, the excretory functions will be normally performed. This will take place every morning immediately on rising, and without your having recourse to any laxative medicine or artificial means of any kind. "Every night you will fall asleep at the hour you wish, and will continue to sleep until the hour at which you desire to wake next morning. Your sleep will be calm, peaceful and profound, untroubled by bad dreams or undesirable states of body. You may dream, but your dreams will be pleasant ones. On waking you will feel well, bright, alert, eager for the day's tasks. "If in the past you have been subject to depression, gloom and melancholy forebodings, you will henceforward be free from such troubles. Instead of being moody, anxious and depressed, you will be cheerful and happy. You will be happy even if you have no particular reason for being so, just as in the past you were, without good reason, unhappy. I tell you even that if you have serious cause to be worried or depressed, you will not be so. "If you have been impatient or ill-tempered, you will no longer be anything of the kind; on the contrary, you will always be patient and self-controlled. The happenings which used to irritate you will leave you entirely calm and unmoved. "If you have sometimes been haunted by evil and unwholesome ideas, by fears or phobias, these ideas will gradually cease to occupy your mind. They will melt away like a cloud. As a dream vanishes when we wake, so will these vain images disappear. "I add that all your organs do their work perfectly. Your heart beats normally and the circulation of the blood takes place as it should. The lungs do their work well. The stomach, the intestines, the liver, the biliary duct, the kidneys and the bladder, all carry out their functions correctly. If at present any of the organs named is out of order, the disturbance will grow less day by day, so that within a short space of time it will have entirely disappeared, and the organ will have resumed its normal function. "Further, if in any organ there is a structural lesion, it will from this day be gradually repaired, and in a short period will be completely restored. This will be so even if you are unaware that the trouble exists. "I must also add--and it is extremely important--that if in the past you have lacked confidence in yourself, this self-distrust will gradually disappear. You will have confidence in yourself; I repeat, _you will have confidence_. Your confidence will be based on the knowledge of the immense power which is within you, by which you can accomplish any task of which your reason approves. With this confidence you will be able to do anything you wish to do, provided it is reasonable, and anything it is your duty to do. "When you have any task to perform you will always think that it is easy. Such words as 'difficult,' 'impossible,' 'I cannot' will disappear from your vocabulary. Their place will be taken by this phrase: 'It is easy and I can.' So, considering your work easy, even if it is difficult to others, it will become easy to you. You will do it easily, without effort and without fatigue." These general suggestions were succeeded by particular suggestions referring to the special ailments from which Coué's patients were suffering. Taking each case in turn, he allowed his hand to rest lightly on the heads of the sufferers, while picturing to their minds the health and vigour with which they would soon be endowed. Thus to a woman with an ulcerated leg he spoke as follows: "Henceforth your organism will do all that is necessary to restore your leg to perfect health. It will rapidly heal; the tissues will regain their tone; the skin will be soft and healthy. In a short space of time your leg will be vigorous and strong and will in future always remain so." Each special complaint was thus treated with a few appropriate phrases. When he had finished, and the patients were called on to open their eyes, a faint sigh went round the room, as if they were awaking reluctantly from a delicious dream. Coué now explained to his patients that he possessed no healing powers, and had never healed a person in his life. They carried in themselves the instrument of their own well-being. The results they had seen were due to the realisation of each patient's own thought. He had been merely an agent calling the ideas of health into their minds. Henceforth they could, and must, be the pilots of their own destiny. He then requested them to repeat, under conditions which will be later defined, the phrase with which his name is associated: "Day by day, in every way, I'm getting better and better."[1] The sitting was at an end. The patients rose and crowded round Coué, asking questions, thanking him, shaking him by the hand. Some declared they were already cured, some that they were much better, others that they were confident of cure in the future. It was as if a burden of depression had fallen from their minds. Those who had entered with minds crushed and oppressed went out with hope and optimism shining in their faces. But Coué waved aside these too insistent admirers, and, beckoning to the three patients who could not walk, led them to a corner of the garden where there was a stretch of gravel path running beneath the boughs of fruit trees. Once more impressing on their minds the thought of strength and power, he induced each one to walk without support down this path. He now invited them to run. They hesitated, but he insisted, telling them that they could run, that they ought to run, that they had but to believe in their own power, and their thought would be manifested in action. They started rather uncertainly, but Coué followed them with persistent encouragements. They began to raise their heads, to lift their feet from the ground and run with greater freedom and confidence. Turning at the end of the path they came back at a fair pace. Their movements were not elegant, but people on the further side of fifty are rarely elegant runners. It was a surprising sight to see these three sufferers who had hobbled to the clinic on sticks now covering the ground at a full five miles an hour, and laughing heartily at themselves as they ran. The crowd of patients who had collected broke into a spontaneous cheer, and Coué, slipping modestly away, returned to the fresh company of sufferers who awaited him within. [1] The translation given here of Coué's formula differs slightly from that popularised in England during his visit of November, 1921. The above, however, is the English version which he considers most suitable. CHAPTER II A FEW OF COUÉ'S CURES To give the reader a better idea of the results which Induced Autosuggestion is yielding, I shall here describe a few further cases of which I was myself in some part a witness, and thereafter let some of Coué's patients speak for themselves through the medium of their letters. At one of the morning consultations which I subsequently attended was a woman who had suffered for five years with dyspepsia. The trouble had recently become so acute that even the milk diet to which she was now reduced caused her extreme discomfort. Consequently she had become extremely thin and anaemic, was listless, easily tired, and suffered from depression. Early in the proceedings the accounts given by several patients of the relief they had obtained seemed to appeal to her imagination. She followed Coué's remarks with keen interest, answered his questions vivaciously, and laughed very heartily at the amusing incidents with which the proceedings were interspersed. About five o'clock on the same afternoon I happened to be sitting with Coué when this woman asked to see him. Beaming with satisfaction, she was shown into the room. She reported that on leaving the clinic she had gone to a restaurant in the town and ordered a table d'hôte luncheon. Conscientiously she had partaken of every course from the hors d'oeuvres to the café noir. The meal had been concluded at 1.30, and she had so far experienced no trace of discomfort. A few days later this woman returned to the clinic to report that the dyspepsia had shown no signs of reappearing; that her health and spirits were improving, and that she looked upon herself as cured. On another occasion one of the patients complained of asthma. The paroxysms destroyed his sleep at night and prevented him from performing any task which entailed exertion. Walking upstairs was a slow process attended by considerable distress. The experiment with the hands was so successfully performed that Coué assured him of immediate relief. "Before you go," he said, "you will run up and down those stairs without suffering any inconvenience." At the close of the consultation, under the influence of the suggestion "I can," the patient did this without difficulty. That night the trouble recurred in a mild form, but he continued to attend the clinic and to practise the exercises at home, and within a fortnight the asthma had finally left him. Among other patients with whom I conversed was a young man suffering from curvature of the spine. He had been attending the clinic for four months and practising the method at home. His doctor assured him that the spine was gradually resuming its normal position. A girl of twenty-two had suffered from childhood with epileptic fits, recurring at intervals of a few weeks. Since her first visit to the clinic six months previously the fits had ceased. But the soundest testimony to the power of Induced Autosuggestion is that borne by the patients themselves. Here are a few extracts from letters received by Coué: "At the age of sixty-three, attacked for more than thirty years by asthma and all the complications attendant upon it, I spent three-quarters of the night sitting on my bed inhaling the smoke of anti-asthma powders. Afflicted with almost daily attacks, especially during the cold and damp seasons, I was unable to walk--I could not even _go down hill_. Nowadays I have splendid nights, and have put the powders in a drawer. Without the slightest hesitation I can go upstairs to the first floor." D. (Mont de Marsan.) 15 _December_, 1921. "Yesterday I felt really better, that is to say, of my fever, so I decided to go back to my doctor, whom I had not seen since the summer. The examination showed a normal appendix. On the other hand, the bladder is still painful, but is better. At any rate, there is at present no question of the operation which had worried me so much. I am convinced that I shall cure myself completely." M. D. (Mulhouse.) 24 _September_, 1921. "I have very good news to give you of your dipsomaniac--she is cured, and asserts it herself to all who will listen. She told me yesterday that for fourteen years she had not been so long without drink as she has been lately, and what surprises her so much is that she has not had to struggle against a desire; she has simply not felt the need of drink. Further, her sleep continues to be splendid. She is getting more and more calm, in spite of the fact that on several occasions her sang-froid has been severely tested. To put the matter in a nutshell, she is a changed woman. But what impresses me most is the fact that when she took to your method she thought herself at the end of her tether, and in the event of its doing her no good had decided to kill herself (she had already attempted it once)." P. (a Paris doctor.) 1 _February_, 1922. "For eight years I suffered with prolapse of the uterus. I have used your method of Autosuggestion for the last five months, and am now completely cured, for which I do not know how to thank you enough." S. (Toul).[1] "I have a son who came back from Germany very anaemic and suffering from terrible depression. He went to see you for a short time, and now is as well as possible. Please accept my best thanks. I have also a little cousin whom you have cured. He had a nervous illness, and had become, so to speak, unconscious of what was going on around him. He is now completely cured." S. E. (Circourt, Vosges.) 19 _October_, 1921. "My wife and I have waited nearly a year to thank you for the marvellous cure which your method has accomplished. The very violent attacks of asthma from which my wife suffered have completely disappeared since the visit you paid us last spring. The first few weeks my wife experienced temporary oppression and even the beginnings of an attack, which, however, she was able to ward off within a few minutes by practising Autosuggestion. In spite of her great desire to thank you sooner my wife wished to add more weight to her testimony by waiting for nearly a year. But the bad time for asthma has not brought the slightest hint of the terrible attacks from which you saved her." J. H. (Saarbruck.) 23 _December_, 1921. "All the morbid symptoms from which I used to suffer have disappeared. I used to feel as though I had a band of iron across my brain which seemed to be red-hot; added to this I had heartburn and bad nights with fearful dreams; further, I was subject to severe nervous attacks which went on for months. I felt as though pegs were being driven into the sides of my head and nape of my neck, and when I felt I could not endure these agonies any longer a feeling would come as if my brain were being smothered in a blanket. All these pains came and went. I had sometimes one, sometimes others. There were occasions when I wanted to die--my sufferings were so acute, and I had to struggle against the idea with great firmness. At last, having spent five weeks at Nancy attending your kindly sittings, I have profited so well as to be able to return home in a state of normal health." N. (Pithiviviers le Vieil.) 16 _August_, 1921. "After having undergone four operations on the left leg for local tuberculosis I fell a victim once more to the same trouble on 1 September, 1920. Several doctors whom I consulted declared a new operation necessary. My leg was to be opened from the knee to the ankle, and if the operation failed nothing remained but an amputation. Having heard of your cures, I came to see you for the first time on 6 November, 1920. After the sitting I felt at once a little better. I followed your instructions exactly, visiting you three times. At the third time I was able to tell you that I was completely cured." L. (Herny, Lorraine.) "I am happy to tell you that a bunion that I had on my foot, which grew to a considerable size and gave me the most acute pain for over fifteen years, has gone." L. G. (Caudéran, Gironde.) "I cannot leave France without letting you know how grateful I feel for the immense service you have rendered me and mine. I only wish I had met you years ago. Practically throughout my career my curse has been a lack of continuous self-control. I have been accused of being almost brilliant at times, only to be followed by periodic relapses into a condition of semi-imbecility and self-indulgence. I have done my best to ruin a magnificent constitution, and have wasted the abilities bestowed upon me. In a few short days you have made me--and I feel permanently--master of myself. How can I thank you sufficiently? The rapidity of my complete cure may have been due to what at the time I regarded as an unfortunate accident. Slipping on the snow-covered steps of the train when alighting, I sprained my right knee badly. At the breakfast table, before paying you my first visit, a fellow-guest said to me: 'Tell Monsieur Coué about it. He will put it all right.' I laughed and said 'Umph!' to myself, and more for the fun of the thing than anything else did tell you. I remember you remarking 'That's nothing,' and passing on to the more serious part of our conversation, preliminary to commencing your lecture to the assembled patients. I became more than interested, and when at the conclusion you suddenly turned round and asked me: 'How's your knee?' (not having alluded to knees in particular), and I discovered there _wasn't_ a knee, I laughed again, as did those who saw me hobble into your room; but I laughed this time from a sense of bewildered surprise and dawning belief. This belief you very soon firmly implanted in me." G. H. (London.) 11 _January_, 1922. [1] This letter, together with the two quoted on page 34, is reprinted from the _Bulletin de la Société Lorraine de Psychologie Appliquée_ of April, 1921. They were received by Coué during the preceding three months. The other letters were communicated to me privately by Coué and bear their original dates. CHAPTER III THE CHILDREN'S CLINIC In different parts of France a little band of workers, recruited almost exclusively from the ranks of former patients, is propagating the ideas of Emile Coué with a success which almost rivals that of their master. Among these helpers none is more devoted or more eminently successful than Mlle. Kauffmant. She it is who, at the time of my visit, was managing the children's department of the Nancy clinic.[1] While Coué was holding his consultations on the ground floor, young mothers in twos and threes, with their babies in their arms, could be seen ascending to the upper story, where a little drama was performed of a very different nature from that going on below. In a large room, decorated with bright pictures and equipped with toys, a number of silent young women were seated in a wide circle. Their sick children lay in their arms or played at their feet. Here was a child whose life was choked at the source by hereditary disease--a small bundle of skin and bone with limbs like bamboo canes. Another lay motionless with closed eyes and a deathly face, as if pining to return to the world it came from. A little cripple dragged behind it a deformed leg as it tried to crawl, and near by a child of five was beating the air with its thin arms in an exhausting nervous storm. Older children were also present, suffering from eye and ear trouble, epilepsy, rickets, any one of the ailments, grave or slight, to which growing life is subjected. In the centre of this circle sat a young woman with dark hair and a kindly keen face. On her lap was a little boy of four years with a club foot. As she gently caressed the foot, from which the clumsy boot had been removed, she told in a crooning tone, mingled with endearing phrases, of the rapid improvement which had already begun and would soon be complete. The foot was getting better; the joints were more supple and bent with greater ease; the muscles were developing, the tendons were drawing the foot into the right shape and making it straight and strong. Soon it would be perfectly normal; the little one would walk and run, play with other children, skip and bowl hoops. He would go to school and learn his lessons, would be intelligent and receptive. She told him too that he was growing obedient, cheerful, kind to others, truthful and courageous. The little boy had put one arm round her neck and was listening with a placid smile. His face was quite contented; he was enjoying himself. While Mlle. Kauffmant was thus engaged, the women sat silent watching her intently, each perhaps mentally seeing her own little one endowed with the qualities depicted. The children were quiet, some dreamily listening, some tranquilly playing with a toy. Except for an occasional word of advice Mademoiselle was quite indifferent to them. Her whole attention was given to the child on her knee; her thought went out to him in a continual stream, borne along by a current of love and compassion, for she has devoted her life to the children and loves them as if they were her own. The atmosphere of the room was more like that of a church than a hospital. The mothers seemed to have left their sorrows outside. Their faces showed in varying degrees an expression of quiet confidence. When this treatment had continued for about ten minutes, Mlle. Kauffmant returned the child to its mother and, after giving her a few words of advice, turned to her next patient. This was an infant of less than twelve months. While suffering from no specific disease it was continually ailing. It was below normal weight, various foods had been tried unsuccessfully, and medical advice had failed to bring about an improvement. Mademoiselle resumed her seat with the child on her lap. For some time the caresses, which were applied to the child's head and body, continued in silence. Then she began to talk to it. Her talk did not consist of connected sentences, as with the elder child who had learned to speak, but of murmured assurances, as if her thoughts were taking unconsciously the form of words. These suggestions were more general than in the previous case, bearing on appetite, digestion, assimilation, and on desirable mental and moral qualities. The caress continued for about ten minutes, the speech was intermittent, then the infant was returned to its mother and Mademoiselle turned her attention to another little sufferer. With patients who are not yet old enough to speak Mlle. Kauffmant sometimes trusts to the caress alone. It seems to transmit the thoughts of health quite strongly enough to turn the balance in the child's mind on the side of health. But all mothers talk to their children long before the words they use are understood, and Mlle. Kauffmant, whose attitude is essentially maternal, reserves to herself the same right. She adheres to no rigid rule; if she wishes to speak aloud she does so, even when the child cannot grasp the meaning of her words. This is perhaps the secret of her success: her method is plastic like the minds she works on. Coué's material--the adult mind--is more stable. It demands a clear-cut, distinct method, and leaves less room for adaptation; but the aim of Mlle. Kauffmant is to fill the child within and enwrap it without with the creative thoughts of health and joy. To this end she enlists any and every means within her power. The child itself, as soon as it is old enough to speak, is required to say, morning and night, the general formula: "Day by day, in every way, I'm getting better and better." If it is confined to its bed, it is encouraged to repeat this at any time and to make suggestions of health similar to those formulated in the sittings. No special directions are given as to how this should be done. Elaborate instructions would only introduce hindersome complications. Imagination, the power to pretend, is naturally strong and active in all children, and intuitively they make use of it in their autosuggestions. Moreover, they unconsciously imitate the tone and manner of their instructress. But the centre of the child's universe is the mother. Any system which did not utilise her influence would be losing its most powerful ally. The mother is encouraged during the day to set an example of cheerfulness and confidence, to allude to the malady only in terms of encouragement--so renewing in the child's mind the prospect of recovery--and to exclude as far as possible all depressing influences from its vicinity. At night she is required to enter the child's bedchamber without waking the little one and to whisper good suggestions into its sleeping ear. Thus Mlle. Kauffmant concentrates a multiplicity of means to bring about the same result. In this she is aided by the extreme acceptivity of the child's mind, and by the absence of that mass of pernicious spontaneous suggestions which in the adult mind have to be neutralised and transformed. It is in children, then, that the most encouraging results may be expected. I will quote three cases which I myself investigated to show the kind of results Mlle. Kauffmant obtains: A little girl was born without the power of sight. The visual organs were intact, but she was incapable of lifting her eye-lids and so remained blind to all intents and purposes up to her seventh year. She was then brought by the mother to Mlle. Kauffmant. After a fortnight's treatment the child began to blink; gradually this action became more frequent, and a month after the treatment began she could see well enough to find her way unaided about the streets. When I saw her she had learnt to distinguish colours--as my own experiments proved--and was actually playing ball. The details supplied by Mlle. Kauffmant were confirmed by the mother. A child was born whose tuberculous father had died during the mother's pregnancy. Of five brothers and sisters none had survived the first year. The doctors to whom the child was taken held out no hope for its life. It survived, however, to the age of two, but was crippled and nearly blind, in addition to internal weaknesses. It was then brought to Mlle. Kauffmant. Three months later, when I saw it, nothing remained of its troubles but a slight squint and a stiffness in one of its knee-joints. These conditions, too, were rapidly diminishing. Another child, about nine years of age, also of tuberculous parents, was placed under her treatment. One leg was an inch and a half shorter than the other. After a few months' treatment this disparity had almost disappeared. The same child had a wound, also of tuberculous origin, on the small of the back, which healed over in a few weeks and had completely disappeared when I saw her. In each of the above cases the general state of health showed a great improvement. The child put on weight, was cheerful and bright even under the trying conditions of convalescence in a poverty-stricken home, and in character and disposition fully realised the suggestions formulated to it. Since the suggestions of Mlle. Kauffmant are applied individually, the mothers were permitted to enter and leave the clinic at any time they wished. Mademoiselle was present on certain days every week, but this was not the sum of her labours. The greater part of her spare time was spent in visiting the little ones in their own homes. She penetrated into the dingiest tenements, the poorest slums, on this errand of mercy. I was able to accompany her on several of these visits, and saw her everywhere received not only with welcome, but with a respect akin to awe. She was regarded, almost as much as Coué himself, as a worker of miracles. But the reputation of both Coué and Mlle. Kauffmant rests on a broader basis even than autosuggestion, namely on their great goodness of heart. They have placed not only their private means, but their whole life at the service of others. Neither ever accepts a penny-piece for the treatments they give, and I have never seen Coué refuse to give a treatment at however awkward an hour the subject may have asked it. The fame of the school has now spread to all parts not only of France, but of Europe and America. Coué's work has assumed such proportions that his time is taken up often to the extent of fifteen or sixteen hours a day. He is now nearing his seventieth year, but thanks to the health-giving powers of his own method he is able to keep abreast of his work without any sign of fatigue and without the clouding of his habitual cheerfulness by even the shadow of a complaint. In fact, he is a living monument to the efficacy of Induced Autosuggestion. It will be seen that Induced Autosuggestion is a method by which the mind can act directly upon itself and upon the body to produce whatever improvements, in reason, we desire. That it is efficient and successful should be manifest from what has gone before. Of all the questions which arise, the most urgent from the viewpoint of the average man seems to be this--Is a suggester necessary? Must one submit oneself to the influence of some other person, or can one in the privacy of one's own chamber exercise with equal success this potent instrument of health? Coué's own opinion has already been quoted. Induced Autosuggestion is _not_ dependent upon the mediation of another person. We can practise it for ourselves without others being even aware of what we are doing, and without devoting to it more than a few minutes of each day. Here are a few quotations from letters written by those who have thus practised it for themselves. "For a good many years now a rheumatic right shoulder has made it impossible for me to sleep on my right side and it seriously affected, and increasingly so, the use of my right arm. A masseuse told me she could effect no permanent improvement as there was granulation of the joints and a lesion. I suddenly realised two days ago that this shoulder no longer troubled me and that I was sleeping on that side without any pain. I have now lost any sensation of rheumatism in this shoulder and can get my right arm back as far as the other without the slightest twinge or discomfort. I have not applied any remedy or done anything that could possibly have worked these results except my practise of Coué." L. S. (Sidmouth, Devon). 1 _January_, 1922. "At my suggestion a lady friend of mine who had been ill for a good ten years read _La Maîtrise de soi-meme_. I encouraged her as well as I could, and in a month she was transformed. Her husband, returning from a long journey, could not believe his eyes. This woman who never got up till midday, who never left the fire-side, whom the doctors had given up, now goes out at 10 a.m. even in the greatest cold. Other friends are anxiously waiting to read your pamphlet. L. C. (Paris). 17 _December_, 1921. "I am very much interested in your method, and since your lecture I have, every night and morning, repeated your little phrase. I used to have to take a pill every night, but now my constipation is cured and the pills are no longer necessary. My wife is also much better in every way. We've both got the bit of string with twenty knots." H. (a London doctor). 7 _January_, 1922. "Your method is doing me more good every day. I don't know how to thank you for the happiness I now experience. I shall never give up repeating the little phrase." E. B. Guiévain (Belgium). 23 _November_, 1921. "I have followed your principles for several months and freed myself from a terrible state of neurasthenia which was the despair of my three doctors." G. (Angoulême). 23 _January_, 1922. "My friend Miss C. completely cured herself of a rheumatic shoulder and knee in a very short time, and then proceeded to turn her attention to her eyesight. She had worn spectacles for 30 years and her left eye was much more short-sighted than her right. When she began she could only read (without her glasses and with her left eye) when the book was almost touching her face. In six weeks she had extended the limit of vision so that she saw as far with the left as formerly with the right. Meanwhile the right had improved equally. She measured the distances every week, and when she was here a few days ago she told me she had in three days gained 4 centimetres with her left and 6 centimetres with her right eye. She had done this on her own." G. (London). 5 _January_, 1922. [1] Since this time (July, 1921), the clinic has been in some respects reorganized and Mlle. Kauffmant is now pursuing her work independently. II THE NATURE OF AUTOSUGGESTION CHAPTER IV THOUGHT IS A FORCE Autosuggestion is not a pseudo-religion like Christian Science or "New Thought." It is a scientific method based on the discoveries of psychology. The traditional psychology was regarded by the layman, not without some cause, as a dull and seemingly useless classification of our conscious faculties. But within the past twenty-five years the science has undergone a great change. A revolution has taken place in it which seems likely to provoke a revolution equally profound in the wider limits of our common life. From a preoccupation with the conscious it has turned to the Unconscious (or subconscious), to the vast area of mental activity which exists outside the circle of our awareness. In doing so it has grasped at the very roots of life itself, has groped down to the depths where the "life-force," the élan vital, touches our individual being. What this may entail in the future we can only dimly guess. Just as the discovery of America altered the balance of the Old World, shifting it westward to the shores of the Atlantic, so the discovery and investigation of the Unconscious seems destined to shift the balance of human life. Obviously, this is no place to embark on the discussion of a subject of such extreme complexity. The investigation of the Unconscious is a science in itself, in which different schools of thought are seeking to disengage a basis of fact from conflicting and daily changing theories. But there is a certain body of fact, experimentally proven, on which the authorities agree, and of this we quote a few features which directly interest us as students of autosuggestion. The Unconscious is the storehouse of memory, where every impression we receive from earliest infancy to the last hour of life is recorded with the minutest accuracy. These memories, however, are not inert and quiescent, like the marks on the vulcanite records of a gramophone; they are vitally active, each one forming a thread in the texture of our personality. The sum of all these impressions is the man himself, the ego, the form through which the general life is individualised. The outer man is but a mask; the real self dwells behind the veil of the Unconscious. The Unconscious is also a power-house. It is dominated by feeling, and feeling is the force which impels our lives. It provides the energy for conscious thought and action, and for the performance of the vital processes of the body. Finally the Unconscious plays the part of supervisor over our physical processes. Digestion, assimilation, the circulation of the blood, the action of the lungs, the kidneys and all the vital organs are controlled by its agency. Our organism is not a clockwork machine which once wound up will run of itself. Its processes in all their complexity are supervised by mind. It is not the intellect, however, which does this work, but the Unconscious. The intellect still stands aghast before the problem of the human body, lost like Pascal in the profundities of analysis, each discovery only revealing new depths of mystery. But the Unconscious seems to be familiar with it in every detail. It may be added that the Unconscious never sleeps; during the sleep of the conscious it seems to be more vigilant than during our waking hours. In comparison with these, the powers of the conscious mind seem almost insignificant. Derived from the Unconscious during the process of evolution, the conscious is, as it were, the antechamber where the crude energies of the Unconscious are selected and adapted for action on the world outside us. In the past we have unduly exaggerated the importance of the conscious intellect. To claim for it the discoveries of civilisation is to confuse the instrument with the agent, to attribute sight to the field-glass instead of to the eye behind it. The value of the conscious mind must not be underrated, however. It is a machine of the greatest value, the seat of reason, the social instincts and moral concepts. But it _is_ a machine and not the engine, nor yet the engineer. It provides neither material nor power. These are furnished by the Unconscious. These two strata of mental life are in perpetual interaction one with the other. Just as everything conscious has its preliminary step in the Unconscious, so every conscious thought passes down into the lower stratum and there becomes an element in our being, partaking of the Unconscious energy, and playing its part in supervising and determining our mental and bodily states. If it is a healthful thought we are so much the better; if it is a diseased one we are so much the worse. It is this transformation of a thought into an element of our life that we call Autosuggestion. Since this is a normal part of the mind's action we shall have no difficulty in finding evidence of it in our daily experiences. Walking down the street in a gloomy frame of mind you meet a buoyant, cheery acquaintance. The mere sight of his genial smile acts on you like a tonic, and when you have chatted with him for a few minutes your gloom has disappeared, giving place to cheerfulness and confidence. What has effected this change?--Nothing other than the idea in your own mind. As you watched his face, listened to his good-natured voice, noticed the play of his smile, your conscious mind was occupied by the idea of cheerfulness. This idea on being transferred to the Unconscious became a reality, so that without any logical grounds you became cheerful. Few people, especially young people, are unacquainted with the effects produced by hearing or reading ghost-stories. You have spent the evening, let us say, at a friend's house, listening to terrifying tales of apparitions. At a late hour you leave the fireside circle to make your way home. The states of fear imaged before your mind have realised themselves in your Unconscious. You tread gingerly in the dark places, hurry past the churchyard and feel a distinct relief when the lights of home come into view. It is the old road you have so often traversed with perfect equanimity, but its cheerful associations are overlooked and the commonest objects tinged with the colour of your subjective states. Autosuggestion cannot change a post into a spectre, but if you are very impressionable it will so distort your sensory impressions that common sounds seem charged with supernatural significance and every-day objects take on terrifying shapes. In each of the above examples the idea of a mental state--cheerfulness or fear--was presented to the mind. The idea on reaching the Unconscious became a reality; that is to say, you actually became cheerful or frightened. The same process is much easier to recognise where the resultant is not a mental but a bodily state. One often meets people who take a delight in describing with a wealth of detail the disorders with which they or their friends are afflicted. A sensitive person is condemned by social usage to listen to a harrowing account of some grave malady. As detail succeeds detail the listener feels a chilly discomfort stealing over him. He turns pale, breaks into a cold perspiration, and is aware of an unpleasant sensation at the pit of the stomach. Sometimes, generally where the listener is a child, actual vomiting or a fainting fit may ensue. These effects are undeniably physical; to produce them the organic processes must have been sensibly disturbed. Yet their cause lies entirely in the idea of illness, which, ruthlessly impressed upon the mind, realises itself in the Unconscious. This effect may be so precise as to reproduce the actual symptoms of the disease described. Medical students engaged in the study of some particular malady frequently develop its characteristic symptoms. Everyone is acquainted with the experience known as "stage fright." The victim may be a normal person, healthy both in mind and body. He may possess in private life a good voice, a mind fertile in ideas and a gift of fluent expression. He may know quite surely that his audience is friendly and sympathetic to the ideas he wishes to unfold. But let him mount the steps of a platform. Immediately his knees begin to tremble and his heart to palpitate; his mind becomes a blank or a chaos, his tongue and lips refuse to frame coherent sounds, and after a few stammerings he is forced to make a ludicrous withdrawal. The cause of this baffling experience lay in the thoughts which occupied the subject's mind before his public appearance. He was afraid of making himself ridiculous. He expected to feel uncomfortable, feared that he would forget his speech or be unable to express himself. These negative ideas, penetrating to the Unconscious, realised themselves and precisely what he feared took place. If you live in a town you have probably seen people who, in carelessly crossing the street, find themselves in danger of being run down by a vehicle. In this position they sometimes stand for an appreciable time "rooted," as we say, "to the spot." This is because the danger seems so close that they imagine themselves powerless to elude it. As soon as this idea gives place to that of escape they get out of the way as fast as they can. If their first idea persisted, however, the actual powerlessness resulting from it would likewise persist, and unless the vehicle stopped or turned aside they would infallibly be run over. One occasionally meets people suffering from a nervous complaint known as St. Vitus' Dance. They have a disconcerting habit of contorting their faces, screwing round their necks or twitching their shoulders. It is a well known fact that those who come into close contact with them, living in the same house or working in the same office, are liable to contract the same habit, often performing the action without themselves being aware of it. This is due to the operation of the same law. The idea of the habit, being repeatedly presented to their minds, realises itself, and they begin to perform a similar movement in their own persons. Examples of this law present themselves at every turn. Have you ever asked yourself why some people faint at the sight of blood, or why most of us turn giddy when we look down from a great height? If we turn to the sufferers from neurosis we find some who have lost their powers of speech or of vision; some, like the blacksmith we saw in Coué's clinic, who have lost the use of their limbs; others suffering from a functional disturbance of one of the vital organs. The cause in each case is nothing more tangible than an idea which has become realised in the Unconscious mind. These instances show clearly enough that the thoughts we think do actually become realities in the Unconscious. But is this a universal law, operating in every life, or merely something contingent and occasional? Sometimes irrelevant cheerfulness seems only to make despondency more deep. Certain types of individual are only irritated by the performance of a stage comedy. Physicians listen to the circumstantial accounts of their patients' ailments without being in the least upset. These facts seem at first sight at variance with the rule. But they are only apparent exceptions which serve to test and verify it. The physical or mental effect invariably corresponds with the idea present in the mind, but this need not be identical with the thought communicated from without. Sometimes a judgment interposes itself, or it may be that the idea calls up an associated idea which possesses greater vitality and therefore dislodges it. A gloomy person who meets a cheerful acquaintance may mentally contrast himself with the latter, setting his own troubles beside the other's good fortune, his own grounds for sadness beside the other's grounds for satisfaction. Thus the idea of his own unhappiness is strengthened and sinking into the Unconscious makes still deeper the despondency he experienced before. In the same way the doctor, listening to the symptoms of a patient, does not allow these distressful ideas to dwell in his conscious mind. His thought passes on immediately to the remedy, to the idea of the help he must give. Not only does he manifest this helpfulness in reasoned action, but also, by Unconscious realisation, in his very bearing and manner. Or his mind may be concentrated on the scientific bearings of the case, so that he will involuntarily treat the patient as a specimen on which to pursue his researches. The steeplejack experiences no giddiness or fear in scaling a church spire because the thought of danger is immediately replaced by the knowledge of his own clear head and sure foot. This brings us to a point which is of great practical importance in the performance of curative autosuggestion. No idea presented to the mind can realise itself unless the mind accepts it. Most of the errors made hitherto in this field have been due to the neglect of this fundamental fact. If a patient is suffering from severe toothache it is not of the slightest use to say to him: "You have no pain." The statement is so grossly opposed to the fact that "acceptation" is impossible. The patient will reject the suggestion, affirm the fact of his suffering, and so, by allowing his conscious mind to dwell on it, probably make it more intense. We are now in a position to formulate the basic law of autosuggestion as follows:-- _Every idea which enters the conscious mind, if it is accepted by the Unconscious, is transformed by it into a reality and forms henceforth a permanent element in our life_. This is the process called "Spontaneous Autosuggestion." It is a law by which the mind of man has always worked, and by which all our minds are working daily. The reader will see from the examples cited and from others which he will constantly meet that the thoughts we think determine not only our mental states, our sentiments and emotions, but the delicate actions and adjustments of our physical bodies. Trembling, palpitation, stammering, blushing--not to speak of the pathological states which occur in neurosis--are due to modifications and changes in the blood-flow, in muscular action and in the working of the vital organs. These changes are not voluntary and conscious ones, they are determined by the Unconscious and come to us often with a shock of surprise. It must be evident that if we fill our conscious minds with ideas of health, joy, goodness, efficiency, and can ensure their acceptation by the Unconscious, these ideas too will become realities, capable of lifting us on to a new plane of being. The difficulty which has hitherto so frequently brought these hopes to naught is that of ensuring acceptation. This will be treated in the next chapter. To sum up, the whole process of Autosuggestion consists of two steps: (1) The acceptation of an idea. (2) Its transformation into a reality. Both these operations are performed by the Unconscious. Whether the idea is originated in the mind of the subject or is presented from without by the agency of another person is a matter of indifference. In both cases it undergoes the same process: it is submitted to the Unconscious, accepted or rejected, and so either realised or ignored. Thus the distinction between Autosuggestion and Heterosuggestion is seen to be both arbitrary and superficial. In essentials all suggestion is Autosuggestion. The only distinction we need make is between Spontaneous Autosuggestion, which takes place independently of our will and choice, and Induced Autosuggestion, in which we consciously select the ideas we wish to realise and purposely convey them to the Unconscious. CHAPTER V THOUGHT AND THE WILL If we can get the Unconscious to accept an idea, realisation follows automatically. The only difficulty which confronts us in the practice of Induced Autosuggestion is to ensure acceptation, and that is a difficulty which no method prior to that of Emile Coué has satisfactorily surmounted. Every idea which enters the mind is charged, to a greater or less extent, with emotion. This emotional charge may be imperceptible, as with ideas to which we are indifferent, or it may be very great, as when the idea is closely related to our personal interests. All the ideas we are likely to make the subjects of Induced Autosuggestion are of the latter class, since they refer to health, energy, success or some goal equally dear to our hearts. The greater the degree of emotion accompanying an idea, the more potent is the autosuggestion resulting from it. Thus a moment of violent fright may give rise to effects which last a lifetime. This emotional factor also plays a large part in securing acceptation. So far as one can see, the acceptation or rejection of an idea by the Unconscious depends on the associations with which it is connected. Thus, an idea is accepted when it evokes similar ideas charged with emotion of the same quality. It is rejected when it is associated with contrary ideas, which are, therefore, contrary in their emotional charge. In the latter case, the original idea is neutralised by its associations, somewhat in the same way as an acid is neutralised by an alkali. An example will serve to make this clearer. You are on a cross-channel boat on a roughish passage. You go up to a sailor and say to him in a sympathetic tone: "My dear fellow, you're looking very ill. Aren't you going to be sea-sick?" According to his temperament he either laughs at your "joke" or expresses a pardonable irritation. But he does not become sick because the associations called up are contrary ones. Sea-sickness is associated in his mind with his own immunity from it, and therefore evokes not fear but self-confidence. Pursuing your somewhat inhumane experiment you approach a timid-looking passenger. "My dear sir, how ill you look! I feel sure you are going to be sea-sick. Let me help you down below." He turns pale. The word "sea-sickness" associates itself with his own fears and forebodings. He accepts your aid down to his berth and there the pernicious autosuggestion is realised. In the first case the idea was refused, because it was overwhelmed by a contrary association; in the second the Unconscious accepted it, since it was reinforced by similar ideas from within. But supposing to a sick mind, permeated with thoughts of disease, a thought of health is presented. How can we avoid the malassociation which tends to neutralise it? We can think of the Unconscious as a tide which ebbs and flows. In sleep it seems to submerge the conscious altogether, while at our moments of full wakefulness, when the attention and will are both at work, the tide is at its lowest ebb. Between these two extremes are any number of intermediary levels. When we are drowsy, dreamy, lulled into a gentle reverie by music or by a picture or a poem, the Unconscious tide is high; the more wakeful and alert we become the lower it sinks. This submersion of the conscious mind is called by Baudouin the "Outcropping of the Subconscious." The highest degree of outcropping, compatible with the conscious direction of our thoughts, occurs just before we fall asleep and just after we wake. It is fairly obvious that the greater the outcropping the more accessible these dynamic strata of the mind become, and the easier it is to implant there any idea we wish to realise. As the Unconscious tide rises the active levels of the mind are overflowed; thought is released from its task of serving our conscious aims in the real world of matter, and moves among the more primal wishes and desires which people the Unconscious, like a diver walking the strange world beneath the sea. But the laws by which thought is governed on this sub-surface level are not those of our ordinary waking consciousness. During outcropping association by contraries does not seem readily to take place. Thus the mal-association, which neutralised the desired idea and so prevented acceptation, no longer presents itself. We all know what happens during a "day-dream" or "brown-study," when the Unconscious tide is high. A succession of bright images glides smoothly through the mind. The original thought spins itself on and on; no obstacles seem to stop it, no questions of probability arise; we are cut off from the actual conditions of life and live in a world where all things are possible. These day-dreams cause very potent autosuggestions, and one should take care that they are wholesome and innocent; but the important point is that on this level of consciousness association seems to operate by similarity, and emotion is comparatively intense. These conditions are highly favourable to acceptation. If, on getting into bed at night, we assume a comfortable posture, relax our muscles and close our eyes, we fall naturally into a stage of semi-consciousness akin to that of day-dreaming. If now we introduce into the mind any desired idea, it is freed from the inhibiting associations of daily life, associates itself by similarity, and attracts emotion of the same quality as its own charge. The Unconscious is thus caused to accept it, and inevitably it is turned into an autosuggestion. Every time we repeat this process the associative power of the idea is increased, its emotional value grows greater, and the autosuggestion resulting from it is more powerful. By this means we can induce the Unconscious to accept an idea, the normal associations of which are contrary and unfavourable. The person with a disease-soaked mind can gradually implant ideas of health, filling his Unconscious daily with healing thoughts. The instrument we use is Thought, and the condition essential to success is that the conscious mind shall be lulled to rest. Systems which hitherto have tried to make use of autosuggestion have failed to secure reliable results because they did not place their reliance on Thought, but tried to compel the Unconscious to accept an idea by exercising the Will. Obviously, such attempts are doomed to failure. By using the will we automatically wake ourselves up, suppress the encroaching tide of the Unconscious, and thereby destroy the condition by which alone we can succeed. It is worth our while to note more closely how this happens. A sufferer, whose mind is filled with thoughts of ill-health, sits down to compel himself to accept a good suggestion. He calls up a thought of health and makes an effort of the will to impress it on the Unconscious. This effort restores him to full wakefulness and so evokes the customary association--disease. Consequently, he finds himself contemplating the exact opposite of what he desired. He summons his will again and recalls the healthful thought, but since he is now wider awake than ever, association is even more rapid and powerful than before. The disease-thought is now in full possession of his mind and all the efforts of his will fail to dislodge it. Indeed the harder he struggles the more fully the evil thought possesses him. This gives us a glimpse of the new and startling discovery to which Coué's uniform success is due; namely, that when the will is in conflict with an idea, the idea invariably gains the day. This is true, of course, not only of Induced Autosuggestion, but also of the spontaneous suggestions which occur in daily life. A few examples will make this clear. Most of us know how, when we have some difficult duty to perform, a chance word of discouragement will dwell in the mind, eating away our self-confidence and attuning our minds to failure. All the efforts of our will fail to throw it off; indeed, the more we struggle against it the more we become obsessed with it. Very similar to this is the state of mind of the person suffering from stage-fright. He is obsessed with ideas of failure and all the efforts of his will are powerless to overcome them. Indeed, it is the state of effort and tension which makes his discomfiture so complete. Sport offers many examples of the working of this law. A tennis-player is engaged to play in an important match. He wishes, of course, to win, but fears that he will lose. Even before the day of the game his fears begin to realise themselves. He is nervy and "out of sorts." In fact, the Unconscious is creating the conditions best suited to realise the thought in his mind--failure. When the game begins his skill seems to have deserted him. He summons the resources of his will and tries to compel himself to play well, straining every nerve to recapture the old dexterity. But all his efforts only make him play worse and worse. The harder he tries the more signally he fails. The energy he calls up obeys not his will but the idea in his mind, not the desire to win but the dominant thought of failure. The fatal attraction of the bunker for the nervous golfer is due to the same cause. With his mind's eye he sees his ball alighting in the most unfavourable spot. He may use any club he likes, he may make a long drive or a short; as long as the thought of the bunker dominates his mind, the ball will inevitably find its way into it. The more he calls on his will to help him, the worse his plight is likely to be. Success is not gained by effort but by right thinking. The champion golfer or tennis-player is not a person of herculean frame and immense will-power. His whole life has been dominated by the thought of success in the game at which he excels. Young persons sitting for an examination sometimes undergo this painful experience. On reading through their papers they find that all their knowledge has suddenly deserted them. Their mind is an appalling blank and not one relevant thought can they recall. The more they grit their teeth and summon the powers of the will, the further the desired ideas flee. But when they have left the examination-room and the tension relaxes, the ideas they were seeking flow tantalisingly back into the mind. Their forgetfulness was due to thoughts of failure previously nourished in the mind. The application of the will only made the disaster more complete. This explains the baffling experience of the drug-taker, the drunkard, the victim of some vicious craving. His mind is obsessed by the desire for satisfaction. The efforts of the will to restrain it only make it more overmastering. Repeated failures convince him at length that he is powerless to control himself, and this idea, operating as an autosuggestion, increases his impotence. So in despair, he abandons himself to his obsession, and his life ends in wreckage. We can now see, not only that the Will is incapable of vanquishing a thought, but that as fast as the Will brings up its big guns, Thought captures them and turns them against it. This truth, which Baudouin calls the Law of Reversed Effort, is thus stated by Coué: "_When the Imagination and the Will are in conflict the Imagination invariably gains the day._" "_In the conflict between the Will and the Imagination, the force of the Imagination is in direct ratio to the square of the Will._" The mathematical terms are used, of course, only metaphorically. Thus the Will turns out to be, not the commanding monarch of life, as many people would have it, but a blind Samson, capable either of turning the mill or of pulling down the pillars. Autosuggestion succeeds by avoiding conflict. It replaces wrong thought by right, literally applying in the sphere of science the principle enunciated in the New Testament: "Resist not evil, but overcome evil with good." This doctrine is in no sense a negation of the will. It simply puts it in its right place, subordinates it to a higher power. A moment's reflection will suffice to show that the will cannot be more than the servant of thought. We are incapable of exercising the will unless the imagination has first furnished it with a goal. We cannot simply will, we must will _something_, and that something exists in our minds as an idea. The will acts rightly when it is in harmony with the idea in the mind. But what happens when, in the smooth execution of our idea, we are confronted with an obstacle? This obstacle may exist outside us, as did the golfer's bunker, but it must also exist as an idea in our minds or we should not be aware of it. As long as we allow this mental image to stay there, the efforts of our will to overcome it only make it more irresistible. We run our heads against it like a goat butting a brick wall. Indeed, in this way we can magnify the smallest difficulty until it becomes insurmountable--we can make mole-hills into mountains. This is precisely what the neurasthenic does. The idea of a difficulty dwells unchanged in his mind, and all his efforts to overcome it only increase its dimensions, until it overpowers him and he faints in the effort to cross a street. But as soon as we change the idea our troubles vanish. By means of the intellect we can substitute for the blank idea of the obstacle that of the means to overcome it. Immediately, the will is brought into harmony again with thought, and we go forward to the triumphant attainment of our end. It may be that the means adopted consist of a frontal attack, the overcoming of an obstacle by force. But before we bring this force into play, the mind must have approved it--must have entertained the idea of its probable success. We must, in fact, have thought of the obstacle as already smashed down and flattened out by our attack. Otherwise, we should involve ourselves in the conflict depicted above, and our force would be exhausted in a futile internal battle. In a frontal attack against an obstacle we use effort, and effort, to be effective, must be approved by the reason and preceded, to some extent, by the idea of success. Thus, even in our dealings with the outside world, Thought is always master of the will. How much more so when our action is turned inward! When practising autosuggestion we are living in the mind, where thoughts are the only realities. We can meet with no obstacle other than that of Thought itself. Obviously then, the frontal attack, the exertion of effort, can never be admissible, for it sets the will and the thought at once in opposition. The turning of our thoughts from the mere recognition of an obstacle to the idea of the means to overcome it, is no longer a preliminary, as in the case of outward action. In itself it clears away the obstacle. By procuring the right idea our end is already attained. In applying effort during the practice of Induced Autosuggestion, we use in the world of mind an instrument fashioned for use in the world of matter. It is as if we tried to solve a mathematical problem by mauling the book with a tin-opener. For two reasons then, effort must never be allowed to intrude during the practice of autosuggestion: first because it wakes us up and so suppresses the tide of the Unconscious, secondly because it causes conflict between Thought and the will. One other interesting fact emerges from an examination of the foregoing examples. In each case we find that the idea which occupied the mind was of a final state, an accomplished fact. The golfer was thinking of his ball dropping into the bunker, the tennis-player of his defeat, the examinee of his failure. In each case the Unconscious realised the thought in its own way, chose inevitably the means best suited to arrive at its end--the realisation of the idea. In the case of the golfer the most delicate physical adjustments were necessary. Stance, grip and swing all contributed their quota, but these physical adjustments were performed unconsciously, the conscious mind being unaware of them. From this we see that we need not suggest the way in which our aim is to be accomplished. If we fill our minds with the thought of the desired end, provided that end is possible, the Unconscious will lead us to it by the easiest, most direct path. Here we catch a glimpse of the truth behind what is called "luck." We are told that everything comes to him who waits, and this is literally true, provided he waits in the right frame of mind. Some men are notoriously lucky in business; whatever they touch seems to "turn to gold." The secret of their success lies in the fact that they confidently expect to succeed. There is no need to go so far as the writers of the school of "New Thought," and claim that suggestion can set in motion transcendental laws outside man's own nature. It is quite clear that the man who expects success, of whatever kind it may be, will unconsciously take up the right attitude to his environment; will involuntarily close with fleeting opportunity, and by his inner fitness command the circumstances without. Man has often been likened to a ship navigating the seas of life. Of that ship the engine is the will and Thought is the helm. If we are being directed out of our true course it is worse than useless to call for full steam ahead; our only hope lies in changing the direction of the helm. III THE PRACTICE OF AUTOSUGGESTION CHAPTER VI GENERAL RULES With our knowledge of the powerful effect which an idea produces, we shall see the importance of exercising a more careful censorship over the thoughts which enter our minds. Thought is the legislative power in our lives, just as the will is the executive. We should not think it wise to permit the inmates of prisons and asylums to occupy the legislative posts in the state, yet when we harbour ideas of passion and disease, we allow the criminals and lunatics of thought to usurp the governing power in the commonwealth of our being. In future, then, we shall seek ideas of health, success, and goodness; we shall treat warily all depressing subjects of conversation, the daily list of crimes and disasters which fill the newspapers, and those novels, plays and films which harrow our feelings, without transmuting by the magic of art the sadness into beauty. This does not mean that we should be always self-consciously studying ourselves, ready to nip the pernicious idea in the bud; nor yet that we should adopt the ostrich's policy of sticking our heads in the sand and declaring that disease and evil have no real existence. The one leads to egotism and the other to callousness. Duty sometimes requires us to give our attention to things in themselves evil and depressing. The demands of friendship and human sympathy are imperious, and we cannot ignore them without moral loss. But there is a positive and a negative way of approaching such subjects. Sympathy is too often regarded as a passive process by which we allow ourselves to be infected by the gloom, the weakness, the mental ill-health of other people. This is sympathy perverted. If a friend is suffering from small-pox or scarlet fever you do not seek to prove your sympathy by infecting yourself with his disease. You would recognize this to be a crime against the community. Yet many people submit themselves to infection by unhealthy ideas as if it were an act of charity--part of their duty towards their neighbours. In the same way people deliver their minds to harrowing stories of famine and pestilence, as if the mental depression thus produced were of some value to the far-away victims. This is obviously false--the only result is to cause gloom and ill-health in the reader and so make him a burden to his family. That such disasters should be known is beyond question, but we should react to them in the manner indicated in the last chapter. We should replace the blank recognition of the evil by the quest of the means best suited to overcome it; then we can look forward to an inspiring end and place the powers of our will in the service of its attainment. Oh, human soul, as long as thou canst so, Set up a mark of everlasting light Above the heaving senses' ebb and flow ... Not with lost toil thou labourest through the night, Thou mak'st the heaven thou hop'st indeed thy home. Autosuggestion, far from producing callousness, dictates the method and supplies the means by which the truest sympathy can be practised. In every case our aim must be to remove the suffering as soon as possible, and this is facilitated by refusing acceptation to the bad ideas and maintaining our own mental and moral balance. Whenever gloomy thoughts come to us, whether from without or within, we should quietly transfer our attention to something brighter. Even if we are afflicted by some actual malady, we should keep our thought from resting on it as far as we have the power to do so. An organic disease may be increased a hundredfold by allowing the mind to brood on it, for in so doing we place at its disposal all the resources of our organism, and direct our life-force to our own destruction. On the other hand, by denying it our attention and opposing it with curative autosuggestions, we reduce its power to the minimum and should succeed in overcoming it entirely. Even in the most serious organic diseases the element contributed by wrong thought is infinitely greater than that which is purely physical. There are times when temperamental failings, or the gravity of our affliction, places our imagination beyond our ordinary control. The suggestion operates in spite of us; we do not seem to possess the power to rid our minds of the adverse thought. Under these conditions we should never struggle to throw off the obsessing idea by force. Our exertions only bring into play the law of reversed effort, and we flounder deeper into the slough. Coué's technique, however, which will be outlined in succeeding chapters, will give us the means of mastering ourselves, even under the most trying conditions. Of all the destructive suggestions we must learn to shun, none is more dangerous than fear. In fearing something the mind is not only dwelling on a negative idea, but it is establishing the closest personal connection between the idea and ourselves. Moreover, the idea is surrounded by an aura of emotion, which considerably intensifies its effect. Fear combines every element necessary to give to an autosuggestion its maximum power. But happily fear, too, is susceptible to the controlling power of autosuggestion. It is one of the first things which a person cognisant of the means to be applied should seek to eradicate from his mind. For our own sakes, too, we should avoid dwelling on the faults and frailties of our neighbours. If ideas of selfishness, greed, vanity, are continually before our minds there is great danger that we shall subconsciously accept them, and so realise them in our own character. The petty gossip and backbiting, so common in a small town, produce the very faults they seem to condemn. But by allowing our minds to rest upon the virtues of our neighbours, we reproduce the same virtues in ourselves. But if we should avoid negative ideas for our own sakes, much more should we do so for the sake of other people. Gloomy and despondent men and women are centres of mental contagion, damaging all with whom they come in contact. Sometimes such people seem involuntarily to exert themselves to quench the cheerfulness of brighter natures, as if their Unconscious strove to reduce all others to its own low level. But even healthy, well-intentioned people scatter evil suggestions broadcast, without the least suspicion of the harm they do. Every time we remark to an acquaintance that he is looking ill, we actually damage his health; the effect may be extremely slight, but by repetition it grows powerful. A man who accepts in the course of a day fifteen or twenty suggestions that he is ill, has gone a considerable part of the way towards actual illness. Similarly, when we thoughtlessly commiserate with a friend on the difficulty of his daily work, or represent it as irksome and uncongenial, we make it a little harder for him to accomplish, and thereby slightly diminish his chances of success. If we must supervise our speech in contact with adults, with children we should exercise still greater foresight. The child's Unconscious is far more accessible than that of the adult; the selective power exercised by the conscious mind is much feebler, and consequently the impressions received realise themselves with greater power. These impressions are the material from which the child's growing life is constructed, and if we supply faulty material the resultant structure will be unstable. Yet the most attentive and well-meaning mothers are engaged daily in sowing the seeds of weakness in their children's minds. The little ones are constantly told they will take cold, will be sick, will fall down, or will suffer some other misfortune. The more delicate the child's health, the more likely it is to be subjected to adverse suggestions. It is too often saturated with the idea of bad health, and comes to look on disease as the normal state of existence and health as exceptional. The same is equally true of the child's mental and moral upbringing. How often do foolish parents tell their children that they are naughty, disobedient, stupid, idle or vicious? If these suggestions were accepted, which, thank Heaven, is not always the case, the little ones would in very fact develop just these qualities. But even when no word is spoken, a look or a gesture can initiate an undesirable autosuggestion. The same child, visited by two strangers, will immediately make friends with the one and avoid the other. Why is this?--Because the one carries with him a healthful atmosphere, while the other sends out waves of irritability or gloom. "Men imagine," says Emerson, "that they communicate their virtue or vice only by overt actions, and do not see that virtue and vice emit a breath every moment." With children, above all, it is not sufficient to refrain from the expression of negative ideas; we must avoid harbouring them altogether. Unless we possess a bright positive mind the suggestions derived from us will be of little value. The idea is gaining ground that a great deal of what is called hereditary disease is transmitted from parent to child, not physically but mentally--that is to say, by means of adverse suggestions continually renewed in the child's mind. Thus if one of the parents has a tendency to tuberculosis, the child often lives in an atmosphere laden with tuberculous thoughts. The little one is continually advised to take care of its lungs, to keep its chest warm, to beware of colds, etc., etc. In other words, the idea is repeatedly presented to its mind that it possesses second-rate lungs. The realisation of these ideas, the actual production of pulmonary tuberculosis is thus almost assured. But all this is no more than crystallised common-sense. Everyone knows that a cheerful mind suffuses health, while a gloomy one produces conditions favourable to disease. "A merry heart doeth good like a medicine," says the writer of the Book of Proverbs, "but a broken spirit drieth the bones." But this knowledge, since it lacked a scientific basis, has never been systematically applied. We have regarded our feelings far too much as _effects_ and not sufficiently as _causes_. We are happy because we are well; we do not recognise that the process will work equally well in the reverse direction--that we shall be well because we are happy. Happiness is not only the result of our conditions of life; it is also the creator of those conditions. Autosuggestion lays weight upon this latter view. Happiness must come first. It is only when the mind is ordered, balanced, filled with the light of sweet and joyous thought, that it can work with its maximum efficiency. When we are habitually happy our powers and capabilities come to their full blossom, and we are able to work with the utmost effect on the shaping of what lies without. Happiness, you say, cannot be ordered like a chop in a restaurant. Like love, its very essence is freedom. This is true; but like love, it can be wooed and won. It is a condition which everyone experiences at some time in life. It is native to the mind. By the systematic practice of Induced Autosuggestion we can make it, not a fleeting visitant, but a regular tenant of the mind, which storms and stresses from without cannot dislodge. This idea of the indwelling happiness, inwardly conditioned, is as ancient as thought. By autosuggestion we can realise it in our own lives. CHAPTER VII THE GENERAL FORMULA We saw that an unskilled golfer, who imagines his ball is going to alight in a bunker, unconsciously performs just those physical movements needful to realise his idea in the actual. In realising this idea his Unconscious displays ingenuity and skill none the less admirable because opposed to his desire. From this and other examples we concluded that if the mind dwells on the idea of an accomplished fact, a realised state, the Unconscious will produce this state. If this is true of our spontaneous autosuggestions it is equally true of the self-induced ones. It follows that if we consistently think of happiness we become happy; if we think of health we become healthy; if we think of goodness we become good. Whatever thought we continually think, provided it is reasonable, tends to become an actual condition of our life. Traditionally we rely too much on the conscious mind. If a man suffers from headaches he searches out, with the help of his physician, their cause; discovers whether they come from his eyes, his digestion or his nerves, and purchases the drugs best suited to repair the fault. If he wishes to improve a bad memory he practises one of the various methods of memory-training. If he is the victim of a pernicious habit he is left to counter it by efforts of the will, which too often exhaust his strength, undermine his self-respect, and only lead him deeper into the mire. How simple in comparison is the method of Induced Autosuggestion! He need merely think the end--a head free from pain, a good memory, a mode of life in which his bad habit has no part, and these states are gradually evolved without his being aware of the operation performed by the Unconscious. But even so, if each individual difficulty required a fresh treatment--one for the headache, one for the memory, one for the bad habit and so on--then the time needful to practise autosuggestion would form a considerable part of our waking life. Happily the researches of the Nancy School have revealed a further simplification. This is obtained by the use of a general formula which sets before the mind the idea of a daily improvement in every respect, mental, physical and moral. In the original French this formula runs as follows: "Tous les jours, à tous points de vue, je vais de mieux en mieux." The English version which Coué considers most satisfactory is this: "_Day by day, in every way, I'm getting better and better_." This is very easy to say, the youngest child can understand it, and it possesses a rudimentary rhythm, which exerts a lulling effect on the mind and so aids in calling up the Unconscious. But if you are accustomed to any other version, such as that recommended by the translators of Baudouin, it would be better to continue to use it. Religious minds who wish to associate the formula with God's care and protection might do so after this fashion: "Day by day, in every way, by the help of God, I'm getting better and better." It is possible that the attention of the Unconscious will thus be turned to moral and spiritual improvements to a greater extent than by the ordinary formula. But this general formula possesses definite advantages other than mere terseness and convenience. The Unconscious, in its character of surveyor over our mental and physical functions, knows far better than the conscious the precise failings and weaknesses which have the greatest need of attention. The general formula supplies it with a fund of healing, strengthening power, and leaves it to apply this at the points where the need is most urgent. It is a matter of common experience that people's ideals of manhood and womanhood vary considerably. The hardened materialist pictures perfection solely in terms of wealth, the butterfly-woman wants little but physical beauty, charm, and the qualities that attract. The sensitive man is apt to depreciate the powers he possesses and exaggerate those he lacks; while his self-satisfied neighbour can see no good in any virtues but his own. It is quite conceivable that a person left free to determine the nature of his autosuggestions by the light of his conscious desire might use this power to realise a quality not in itself admirable, or even one which, judged by higher standards, appeared pernicious. Even supposing that his choice was good he would be in danger of over-developing a few characteristics to the detriment of others and so destroying the balance of his personality. The use of the general formula guards against this. It saves a man in spite of himself. It avoids the pitfalls into which the conscious mind may lead us by appealing to a more competent authority. Just as we leave the distribution of our bodily food to the choice of the Unconscious, so we may safely leave that of our mental food, our Induced Autosuggestions. The fear that the universal use of this formula would have a standardising effect, modifying its users to a uniform pattern, is unfounded. A rigid system of particular suggestions might tend towards such a result, but the general formula leaves every mind free to unfold and develop in the manner most natural to itself. The eternal diversity of men's minds can only be increased by the free impulse thus administered. We have previously seen that the Unconscious tide rises to its highest point compatible with conscious thought just before sleep and just after awaking, and that the suggestions formulated then are almost assured acceptation. It is these moments that we select for the repetition of the formula. But before we pass on to the precise method, a word of warning is necessary. Even the most superficial attempt to analyse intellectually a living act is bound to make it appear complex and difficult. So our consideration of the processes of outcropping and acceptation has inevitably invested them with a false appearance of difficulty. Autosuggestion is above all things easy. Its greatest enemy is effort. The more simple and unforced the manner of its performance the more potently and profoundly it works. This is shown by the fact that its most remarkable results have been secured by children and by simple French peasants. It is here that Coué's directions for the practice differ considerably from those of Baudouin. Coué insists upon its easiness, Baudouin complicates it. The four chapters devoted by the latter to "relaxation," "collection," "contention," and "concentration," produce in the reader an adverse suggestion of no mean power. They leave the impression that autosuggestion is a perplexing business which only the greatest foresight and supervision can render successful. Nothing could be more calculated to throw the beginner off the track. We have seen that Autosuggestion is a function of the mind which we spontaneously perform every day of our lives. The more our induced autosuggestions approximate to this spontaneous prototype the more potent they are likely to be. Baudouin warns us against the danger of setting the intellect to do the work of intuition, yet this is precisely what he himself does. A patient trying by his rules to attain outcropping and implant therein an autosuggestion is so vigilantly attentive to what he is doing that outcropping is rendered almost impossible. These artificial aids are, in Coué's opinion, not only unnecessary but hindersome. Autosuggestion succeeds when Conscious and Unconscious co-operate in the acceptance of an idea. Coué's long practice has shown that we must leave the Unconscious, as senior partner in the concern, to bring about the right conditions in its own way. The fussy attempts of the intellect to dictate the method of processes which lie outside its sphere will only produce conflict, and so condemn our attempt to failure. The directions given here are amply sufficient, if conscientiously applied, to secure the fullest benefits of which the method is capable. Take a piece of string and tie in it twenty knots. By this means you can count with a minimum expenditure of attention, as a devout Catholic counts his prayers on a rosary. The number twenty has no intrinsic virtue; it is merely adopted as a suitable round number. On getting into bed close your eyes, relax your muscles and take up a comfortable posture. These are no more than the ordinary preliminaries of slumber. Now repeat twenty times, counting by means of the knots, the general formula: "Day by day, in every way, I'm getting better and better." The words should be uttered aloud; that is, loud enough to be audible to your own ears. In this way the idea is reinforced by the movements of lips and tongue and by the auditory impressions conveyed through the ear. Say it simply, without effort, like a child absently murmuring a nursery rhyme. Thus you avoid an appeal to the critical faculties of the conscious which would lessen the outcropping. When you have got used to this exercise and can say it quite "unself-consciously," begin to let your voice rise or fall--it does not matter which--on the phrase "in every way." This is perhaps the most important part of the formula, and is thus given a gentle emphasis. But at first do not attempt this accentuation; it will only needlessly complicate and, by requiring more conscious attention, may introduce effort. Do not try to think of what you are saying. On the contrary, let the mind wander whither it will; if it rests on the formula all the better, if it strays elsewhere do not recall it. As long as your repetition does not come to a full-stop your mind-wandering will be less disturbing than would be the effort to recall your thoughts. Baudouin differs from Coué as to the manner in which the formula should be repeated. His advice is to say it "piously," with all the words separately stressed. No doubt it has its value when thus spoken, but the attitude of mind to which the word "pious" can be applied is unfortunately not habitual with everyone. The average man in trying to be "pious" might end by being merely artificial. But the child still exists in the most mature of men. The "infantile" mode of repeating the formula puts one in touch with deep levels of the Unconscious where the child-mind still survives. Coué's remarkable successes have been obtained by this means, and Baudouin advances no cogent reason for changing it. These instructions no doubt fall somewhat short of our ideal of a thought entirely occupying the mind. But they are sufficient for a beginning. The sovereign rule is to make no effort, and if this is observed you will intuitively fall into the right attitude. This process of Unconscious adaptation may be hastened by a simple suggestion before beginning. Say to yourself, "I shall repeat the formula in such a manner as to secure its maximum effect." This will bring about the required conditions much more effectively than any conscious exercise of thought. On waking in the morning, before you rise, repeat the formula in exactly the same manner. Its regular repetition is the foundation stone of the Nancy method and should never be neglected. In times of health it may be regarded as an envoy going before to clear the path of whatever evils may lurk in the future. But we must look on it chiefly as an educator, as a means of leavening the mass of adverse spontaneous suggestions which clog the Unconscious and rob our lives of their true significance. Say it with faith. When you have said it your conscious part of the process is completed. Leave the Unconscious to do its work undisturbed. Do not be anxious about it, continually scanning yourself for signs of improvement. The farmer does not turn over the clods every morning to see if his seed is sprouting. Once sown it is left till the green blade appears. So it should be with suggestion. Sow the seed, and be sure the Unconscious powers of the mind will bring it to fruition, and all the sooner if your conscious ego is content to let it rest. _Say it with faith_! You can only rob Induced Autosuggestion of its power in one way--by believing that it is powerless. If you believe this it becomes ipso facto powerless for you. The greater your faith the more radical and the more rapid will be your results; though if you have only sufficient faith to repeat the formula twenty times night and morning the results will soon give you in your own person the proof you desire, and facts and faith will go on mutually augmenting each other. Faith reposes on reason and must have its grounds. What grounds can we adduce for faith in Induced Autosuggestion? The examples of cures already cited are outside your experience and you may be tempted to pooh-pooh them. The experiment of Chevreul's pendulum, however, will show in a simple manner the power possessed by a thought to transform itself into an action. Take a piece of white paper and draw on it a circle of about five inches' radius. Draw two diameters _AB_ and _CD_ at right angles to each other and intersecting at _O_. The more distinctly the lines stand out the better--they should be thickly drawn in black ink. Now take a lead pencil or a light ruler and tie to one end a piece of cotton about eight inches long; to the lower end of the cotton fasten a heavy metal button, of the sort used on a soldier's tunic. Place the paper on a table so that the diameter _AB_ seems to be horizontal and _CD_ to be vertical, thus: [Illustration: Autosuggestion diagram] Stand upright before the table with your miniature fishing-rod held firmly in both hands and the button suspended above the point _O_. Take care not to press the elbows nervously against the sides. Look at the line _AB_, think of it, follow it with your eyes from side to side. Presently the button will begin to swing along the line you are thinking of. The more your mind dwells easily upon the idea of the line the greater this swing becomes. Your efforts to _try_ to hold the pendulum still, by bringing into action the law of reversed effort, only make its oscillations more pronounced. Now fix your eyes on the line _CD_. The button will gradually change the direction of its movement, taking up that of _CD_. When you have allowed it to swing thus for a few moments transfer your attention to the circle, follow the circumference round and round with your eyes. Once more the swinging button will follow you, adopting either a clock-wise or a counter clock-wise direction according to your thought. After a little practice you should produce a circular swing with a diameter of at least eight inches; but your success will be directly proportional to the exclusiveness of your thought and to your efforts to hold the pencil still. Lastly think of the point _O_. Gradually the radius of the swing will diminish until the button comes to rest. Is it necessary to point out how these movements are caused? Your thought of the line, passing into the Unconscious, is there realised, so that _without knowing it_ you execute with your hands the imperceptible movements which set the button in motion. The Unconscious automatically realises your thought through the nerves and muscles of your arms and hands. What is this but Induced Autosuggestion? The first time you perform this little experiment it is best to be alone. This enables you to approach it quite objectively. CHAPTER VIII PARTICULAR SUGGESTIONS The use of particular suggestions outlined in this chapter is of minor importance compared with that of the general formula--"Day by day, in every way, I'm getting better and better." The more deeply Coué pursues his investigations, the more fully he becomes convinced that all else is secondary to this. It is not difficult to make a guess as to why this should be. In the general formula the attention is fully absorbed by the idea of betterment. The mind is directed away from all that hinders and impedes and fixed on a positive goal. In formulating particular suggestions, however, we are always skating on the thin ice round our faults and ailments, always touching on subjects which have the most painful associations. So that our ideas have not the same creative positiveness. However that may be, it is a matter of experience that the general formula is the basis of the whole method, and that all else is merely an adjuvant, an auxiliary--useful, but inessential to the main object. We have seen that a partial outcropping of the Unconscious takes place whenever we relax our mental and physical control, and let the mind wander; in popular language, when we fall into a "brown study" or a "day-dream." This outcropping should be sought before the special suggestions are formulated. But again we must beware of making simple things seem hard. Baudouin would have us perform a number of elaborate preparatives, which, however valuable to the student of psychology, serve with the layman only to distract the mind, and by fixing the attention on the mechanism impair the power of the creative idea. Moreover, they cause the subject to exert efforts to attain a state the very essence of which is effortlessness, like the victim of insomnia who "tries his hardest" to fall asleep. In order to formulate particular suggestions, go to a room where you will be free from interruption, sit down in a comfortable chair, close your eyes, and let your muscles relax. In other words, act precisely as if you were going to take a siesta. In doing so you allow the Unconscious tide to rise to a sufficient height to make your particular suggestions effective. Now call up the desired ideas through the medium of speech. Tell yourself that such and such ameliorations are going to occur. But here we must give a few hints as to the _form_ these suggestions should take. We should never set our faith a greater task than it can accomplish. A patient suffering from deafness would be ill-advised to make the suggestion: "I can hear perfectly." In the partial state of outcropping association is not entirely cut off, and such an idea would certainly call up its contrary. Thus we should initiate a suggestion antagonistic to the one we desired. In this way we only court disappointment and by losing faith in our instrument rob it of its efficacy. Further, we should avoid as far as possible all mention of the ailment or difficulty against which the suggestion is aimed. Indeed, our own attention should be directed not so much to getting rid of wrong conditions as to cultivating the opposite right ones in their place. If you are inclined to be neurasthenic your mind is frequently occupied with fear. This fear haunts you because some thwarted element in your personality, surviving in the Unconscious, gains through it a perverse satisfaction. In other words, your Unconscious enjoys the morbid emotional condition which fear brings with it. Should you succeed in banishing your fears you would probably feel dissatisfied, life would seem empty. The old ideas would beckon you with promises, not of happiness truly, but of emotion and excitement. But if your suggestions take a positive form, if you fill your mind with thoughts of self-confidence, courage, outward activity, and interest in the glowing and vital things of life, the morbid ideas will be turned out of doors and there will be no vacant spot to which they can return. Whatever the disorder may be, we should refer to it as little as possible, letting the whole attention go out to the contrary state of health. We must dwell on the "Yes-idea," affirming with faith the realisation of our hopes, seeing ourselves endowed with the triumphant qualities we lack. For a similar reason we should never employ a form of words which connotes doubt. The phrases, "I should like to," "I am going to try," if realised by the Unconscious, can only produce a state of longing or desire, very different from the actual physical and mental modifications we are seeking. Finally, we should not speak of the desired improvement entirely as a thing of the future. We should affirm that the change has already begun, and will continue to operate more and more rapidly until our end is fully attained. Here are a few examples of special suggestions which may prove useful. For deafness: Having closed the eyes and relaxed body and mind, say to yourself something of this nature: "From this day forth my hearing will gradually improve. Each day I shall hear a little better. Gradually this improvement will become more and more rapid until, in a comparatively short space of time, I shall hear quite well and I shall continue to do so until the end of my life." A person suffering from unfounded fears and forebodings might proceed as follows: "From to-day onward I shall become more and more conscious of all that is happy, positive and cheerful. The thoughts which enter my mind will be strong and healthful ones. I shall gain daily in self-confidence, shall believe in my own powers, which indeed at the same time will manifest themselves in greater strength. My life is growing smoother, easier, brighter. These changes become from day to day more profound; in a short space of time I shall have risen to a new plane of life, and all the troubles which used to perplex me will have vanished and will never return." A bad memory might be treated in some such terms as these: "My memory from to-day on will improve in every department. The impressions received will be clearer and more definite; I shall retain them automatically and without any effort on my part, and when I wish to recall them they will immediately present themselves in their correct form to my mind. This improvement will be accomplished rapidly, and very soon my memory will be better than it has ever been before." Irritability and bad temper are very susceptible to autosuggestion and might be thus treated: "Henceforth I shall daily grow more good-humoured. Equanimity and cheerfulness will become my normal states of mind, and in a short time all the little happenings of life will be received in this spirit. I shall be a centre of cheer and helpfulness to those about me, infecting them with my own good humour, and this cheerful mood will become so habitual that nothing can rob me of it." Asthma is a disease which has always baffled and still baffles the ordinary methods of medicine. It has shown itself, however, in Coué's experience, pre-eminently susceptible to autosuggestive treatment. Particular suggestions for its removal might take this form: "From this day forward my breathing will become rapidly easier. Quite without my knowledge, and without any effort on my part, my organism will do all that is necessary to restore perfect health to my lungs and bronchial passages. I shall be able to undergo any exertion without inconvenience. My breathing will be free, deep, delightful. I shall draw in all the pure health-giving air I need, and thus my whole system will be invigorated and strengthened. Moreover, I shall sleep calmly and peacefully, with the maximum of refreshment and repose, so that I awake cheerful and looking forward with pleasure to the day's tasks. This process has this day begun and in a short time I shall be wholly and permanently restored to health." It will be noticed that each of these suggestions comprises three stages: (1) Immediate commencement of the amelioration. (2) Rapid progress. (3) Complete and permanent cure. While this scheme is not essential, it is a convenient one and should be utilised whenever applicable. The examples are framed as the first autosuggestions of persons new to the method. On succeeding occasions the phrase "from this day forth," or its variants, should be replaced by a statement that the amelioration has already begun. Thus, in the case of the asthmatic, "My breathing is already becoming easier," etc. Particular suggestions, though subsidiary in value to the general formula, are at times of very great service. The general formula looks after the foundations of our life, building in the depths where eye cannot see or ear hear. Particular suggestions are useful on the surface. By their means we can deal with individual difficulties as they arise. The two methods are complementary. Particular suggestions prove very valuable in reinforcing and rendering permanent the effects obtained by the technique for overcoming pain, which will be outlined in the next chapter. Before commencing the attack we should sit down, close our eyes and say calmly and confidently to ourselves: "I am now going to rid myself of this pain." When the desired result has been obtained, we should suggest that the state of ease and painlessness now re-established will be permanent, that the affected part will rapidly be toned up into a condition of normal health, and will remain always in that desirable state. Should we have obtained only a lessening of the trouble without its complete removal our suggestion should take this form: "I have obtained a considerable degree of relief, and in the next few minutes it will become complete. I shall be restored to my normal condition of health and shall continue so for the future." Thus our assault upon the pain is made under the best conditions, and should in every case prove successful. We should employ particular suggestions also for overcoming the difficulties which confront us from time to time in our daily lives, and for securing the full success of any task we take in hand. The use of the general suggestion will gradually strengthen our self-confidence, until we shall expect success in any enterprise of which the reason approves. But until this consummation is reached, until our balance of self-confidence is adequate for all our needs, we can obtain an overdraft for immediate use by means of particular suggestion. We have already seen that the dimensions of any obstacle depend at least as much upon our mental attitude towards it as upon its intrinsic difficulty. The neurasthenic, who imagines he cannot rise from his bed, cannot do so because this simple operation is endowed by his mind with immense difficulty. The great mass of normal people commit the same fault in a less degree. Their energy is expended partly in doing their daily work, and partly in overcoming the resistance in their own minds. By the action of the law of reversed effort the negative idea they foster frequently brings their efforts to naught, and the very exertions they make condemn their activities to failure. For this reason it is necessary, before undertaking any task which seems to us difficult, to suggest that it is in fact easy. We close our eyes and say quietly to ourselves, "The work I have to do is easy, quite easy. Since it is easy I can do it, and I shall do it efficiently and successfully. Moreover, I shall enjoy doing it; it will give me pleasure, my whole personality will apply itself harmoniously to the task, and the results will be even beyond my expectation." We should dwell on these ideas, repeating them tranquilly and effortlessly. Soon our mind will become serene, full of hope and confidence. Then we can begin to think out our method of procedure, to let the mind dwell on the means best suited to attain our object. Since the impediments created by fear and anxiety are now removed our ideas will flow freely, our plans will construct themselves in the quiet of the mind, and we shall come to the actual work with a creative vigour and singleness of purpose. By a similar procedure the problems of conduct which defy solution by conscious thought will frequently yield to autosuggestion. When we are "at our wits' ends," as the saying goes, to discover the best path out of a dilemma, when choice between conflicting possibilities seems impossible, it is worse than useless to continue the struggle. The law of reversed effort is at work paralysing our mental faculties. We should put it aside, let the waves of effort subside, and suggest to ourselves that at a particular point of time the solution will come to us of its own accord. If we can conveniently do so, it is well to let a period of sleep intervene, to suggest that the solution will come to us on the morrow; for during sleep the Unconscious is left undisturbed to realise in its own way the end we have consciously set before it. This operation often takes place spontaneously, as when a problem left unsolved the night before yields its solution apparently by an inspiration when we arise in the morning. "Sleep on it" still remains the best counsel for those in perplexity, but they should preface their slumbers by the positive autosuggestion that on waking they will find the difficulty resolved. In this connection it is interesting to note that autosuggestion is already widely made use of as a means of waking at a particular hour. A person who falls asleep with the idea in his mind of the time at which he wishes to wake, will wake at that time. It may be added that wherever sleep is utilised for the realisation of particular suggestions, these suggestions should be made in addition to the general formula, either immediately before or immediately after; they should never be substituted for it. With some afflictions, such as fits, the attack is often so sudden and unexpected that the patient is smitten down before he has a chance to defend himself. Particular suggestions should be aimed first of all at securing due warning of the approaching attack. We should employ such terms as these: "In future I shall always know well in advance when a fit is coming on. I shall be amply warned of its approach. When these warnings occur I shall feel no fear or anxiety. I shall be quite confident of my power to avert it." As soon as the warning comes--as it will come, quite unmistakably--the sufferer should isolate himself and use a particular suggestion to prevent the fit from developing. He should first suggest calm and self-control, then affirm repeatedly, but of course without effort, that the normal state of health is reasserting itself, that the mind is fully under control, and that nothing can disturb its balance. All sudden paroxysms, liable to take us unexpectedly, should be treated by the same method, which in Coué's experience has amply justified itself. Nervous troubles and violent emotions, such as fear and anger, often express themselves by physical movements. Fear may cause trembling, palpitation, chattering of the teeth; anger a violent clenching of the fists. Baudouin advises that particular suggestions in these cases should be directed rather against the motor expression than against the psychic cause, that our aim should be to cultivate a state of physical impassibility. But since a positive suggestion possesses greater force than a negative, it would seem better to attack simultaneously both the cause and the effect. Instead of anger, suggest that you will feel sympathy, patience, good-humour, and consequently that your bodily state will be easy and unconstrained. A form of particular suggestion which possesses distinct advantages of its own is the quiet repetition of a single word. If your mind is distracted and confused, sit down, close your eyes, and murmur slowly and reflectively the single word "Calm." Say it reverently, drawing it out to its full length and pausing after each repetition. Gradually your mind will be stilled and quietened, and you will be filled with a sense of harmony and peace. This method seems most applicable to the attainment of moral qualities. An evil passion can be quelled by the use of the word denoting the contrary virtue. The power of the word depends largely upon its aesthetic and moral associations. Words like joy, strength, love, purity, denoting the highest ideals of the human mind, possess great potency and are capable, thus used, of dispelling mental states in which their opposites predominate. The name Reflective Suggestion, which Baudouin applies indifferently to all autosuggestions induced by the subject's own choice, might well be reserved for this specific form of particular suggestion. The field for the exercise of particular suggestions is practically limitless. Whenever you feel a need for betterment, of whatever nature it may be, a particular suggestion will help you. But it must once more be repeated that these particular suggestions are merely aids and auxiliaries, which may, if leisure is scant, be neglected. CHAPTER IX HOW TO DEAL WITH PAIN Pain, whether of mind or body, introduces a new element for which we have hitherto made no provision. By monopolising the attention it keeps the conscious mind fully alert and so prevents one from attaining the measure of outcropping needful to initiate successfully an autosuggestion. Thus if we introduce the "no-pain" idea into the conscious, it is overwhelmed by its contrary--pain, and the patient's condition becomes, if anything, worse. To overcome this difficulty quite a new method is required. If we speak a thought, that thought, while we speak it, must occupy our minds. We could not speak it unless we thought it. By continually repeating "I have no pain" the sufferer constantly renews that thought in his mind. Unfortunately, after each repetition the pain-thought insinuates itself, so that the mind oscillates between "I have no pain" and "I have some pain," or "I have a bad pain." But if we repeat our phrase so rapidly that the contrary association has no time to insert itself, we compel the mind willy-nilly to dwell on it. Thus by a fresh path we reach the same goal as that attained by induced outcropping; we cause an idea to remain in occupation of the mind without calling up a contrary association. This we found to be the prime condition of acceptation, and in fact by this means we can compel the Unconscious to realise the "no-pain" thought and so put an end to the pain. But the sentence "I have no pain" does not lend itself to rapid repetition. The physical difficulties are too great; the tongue and lips become entangled in the syllables and we have to stop to restore order. Even if we were dexterous enough to articulate the words successfully, we should only meet with a new difficulty. The most emphatic word in the phrase is "pain"; involuntarily we should find ourself stressing this word with particular force, so strengthening in our minds the very idea we are trying to dislodge. We shall do best to copy as closely as we can Coué's own procedure. The phrase he uses, "ça passe," makes no mention of the hurt; it is extremely easy to say, and it produces an unbroken stream of sound, like the whirr of a machine or the magnified buzz of an insect, which, as it were, carries the mind off its feet. The phrase recommended by Baudouin, "It is passing off," produces no such effect, and in fact defies all our attempts to repeat it quickly. On the whole, the most suitable English version seems to be "It's going." Only the word "going" should be repeated, and the treatment should conclude with the emphatic statement "gone!" The word "going," rapidly gabbled, gives the impression of a mechanical drill, biting its way irresistibly into some hard substance. We can think of it as drilling the desired thought into the mind. If you are suffering from any severe pain, such as toothache or headache, sit down, close your eyes and assure yourself calmly that you are going to get rid of it. Now gently stroke with your hand the affected part and repeat at the same time as fast as you can, producing a continuous stream of sound, the words: "It's going, going, going ... gone!" Keep it up for about a minute, pausing only to take a deep breath when necessary, and using the word "gone" only at the conclusion of the whole proceeding. At the end of this time the pain will either have entirely ceased or at least sensibly abated. In either case apply the particular suggestions recommended in the previous chapter. If the pain has ceased suggest that it will not return; if it has only diminished suggest that it will shortly pass away altogether. Now return to whatever employment you were engaged in when the pain began. Let other interests occupy your attention. If in a reasonable space, say half an hour, the pain still troubles you, isolate yourself again; suggest once more that you are going to master it, and repeat the procedure. It is no exaggeration to say that by this process any pain can be conquered. It may be, in extreme cases, that you will have to return several times to the attack. This will generally occur when you have been foolish enough to supply the pain with a cause--a decayed tooth, a draught of cold air, etc.--and so justify it to your reason, and give it, so to speak, an intellectual sanction. Or it may be that it will cease only to return again. But do not be discouraged; attack it firmly and you are bound to succeed. The same procedure is equally effective with distressing states of mind, worry, fear, despondency. In such cases the stroking movement of the hand should be applied to the forehead. Even in this exercise no more effort should be used than is necessary. Simply repeat rapidly the word which informs you that the trouble is going, and let this, with the stroking movement of the hand, which, as it were, fixes the attention to that particular spot, be the sum and substance of your effort. With practice it will become easier, you will "drop into it"; that is to say, the Unconscious will perform the adaptations necessary to make it more effective. After a time you should be able to obtain relief in twenty to twenty-five seconds. But the effect is still more far-reaching; you will be delivered from the fear of pain. Regarding yourself as its master, you will be able with the mere threat of treatment to prevent it from developing. You will hang up a card, "No admittance," on the doors of your conscious mind. It may be that the pain attacks you in the street or in a workshop; in some public place where the audible repetition of the phrase would attract attention. In that case it is best to close the eyes for a moment and formulate this particular suggestion: "I shall not add to this trouble by thinking about it; my mind will be occupied by other things; but on the first opportunity I shall make it pass away," Then as soon as you can conveniently do so make use of the phrase "It's going." When you have become expert in the use of this form of suggestion you will be able to exorcise the trouble by repeating the phrase mentally--at any rate if the words are outlined with the lips and tongue. But the beginner should rely for a time entirely on audible treatment. By dropping it too soon he will only court disappointment. It sometimes happens that a patient is so prostrated by pain or misery that he has not the energy to undertake even the repetition of the word "going." The pain-thought so obsesses the mind that the state of painlessness seems too remote even to contemplate. Under these circumstances it seems best to employ this strategy. Lie down on a bed, sofa, or arm-chair and relax both mind and body. Cease from all effort--which can only make things worse--and let the pain-thought have its way. After a time your energies will begin to collect themselves, your mind to reassert its control. Now make a firm suggestion of success and apply the method. Get another person to help you, as Coué helps his patients, by performing the passes with the hand and repeating the phrase with you. By this means you can make quite sure of success. This seemingly contradictory proceeding is analogous to that of the angler "playing" a fish. He waits till it has run its course before bringing his positive resources into play. Baudouin recommends an analogous proceeding as a weapon against insomnia. The patient, he says, should rapidly repeat the phrase, "I am going to sleep," letting his mind be swept away by a torrent of words. Once more the objection arises that the phrase "I am going to sleep" is not such as we can rapidly repeat. But even if we substitute for it some simple phrase which can be easily articulated it is doubtful whether it will succeed in more than a small percentage of cases. Success is more likely to attend us if we avail ourselves of the method of reflective repetition mentioned in the last chapter. We should take up the position most favourable to slumber and then repeat slowly and contemplatively the word "Sleep." The more impersonal our attitude towards the idea the more rapidly it will be realised in our own slumbers. CHAPTER X AUTOSUGGESTION AND THE CHILD In treating children it should be remembered that autosuggestion is primarily not a remedy but a means of insuring healthy growth. It should not be reserved for times when the child is sick, but provided daily, with the same regularity as meals. Children grow up weakly not from lack of energy, but because of a waste and misapplication of it. The inner conflict, necessitated by the continual process of adaptation which we call growth, is often of quite unnecessary violence, not only making a great temporary demand on the child's vital energy, but even locking it up in the Unconscious in the form of "complexes," so that its future life is deprived of a portion of its due vitality. A wise use of autosuggestion will preclude these disasters. Growth will be ordered and controlled. The necessary conflicts will be brought to a successful issue, the unnecessary ones avoided. Autosuggestion may very well begin before the child is born. It is a matter of common knowledge that a mother must be shielded during pregnancy from any experience involving shock or fright, since these exert a harmful effect on the developing embryo, and may in extreme cases result in abortion, or in physical deformity or mental weakness in the child. Instances of this ill-effect are comparatively common, and the link between cause and effect is often unmistakable. There is no need to point out that these cases are nothing more than spontaneous autosuggestions operating in the maternal Unconscious; since during pregnancy the mother moulds her little one not only by the food she eats but also by the thoughts she thinks. The heightened emotionality characteristic of this state bespeaks an increased tendency to outcropping, and so an increased suggestibility. Thus spontaneous autosuggestions are far more potent than in the normal course of life. But, happily, induced autosuggestions are aided by the same conditions, so that the mother awake to her powers and duties can do as much good as the ignorant may do harm. Without going into debatable questions, such as the possibility of predetermining the sex of the child to be born, one can find many helpful ways of aiding and benefiting the growing life by autosuggestive means. The mother should avoid with more than ordinary care all subjects, whether in reading or conversation, which bear on evil in any form, and she should seek whatever uplifts the mind and furnishes it with beautiful and joyous thought. But the technical methods of autosuggestion can also be brought into action. The mother should suggest to herself that her organism is furnishing the growing life with all it needs, and that the child will be strong and healthy in mind, in body, and in character. These suggestions should be in general terms bearing on qualities of undoubted good, for obviously it is not desirable to define an independent life too narrowly. They need consist only of a few sentences, and should be formulated night and morning immediately before or after the general formula. Furthermore, when the mother's thoughts during the day stray to the subject of her child, she can take this opportunity to repeat the whole or some part of the particular suggestion she has chosen. These few simple measures will amply suffice. Any undue tendency of the mind to dwell on the thought of the child, even in the form of good suggestions, should not be encouraged. A normal mental life is in itself the best of conditions for the welfare of both mother and child. For her own sake however the mother might well suggest that the delivery will be painless and easy. The only direct means of autosuggestion applicable to the child for some months after birth is that of the caress, though it must be remembered that the mental states of mother and nurse are already stamping themselves on the little mind, forming it inevitably for better or worse. Should any specific trouble arise, the method of Mlle. Kauffmant should be applied by the mother. Taking the child on her knee she should gently caress the affected part, thinking the while of its reinstatement in perfect health. It seems generally advisable to express these thoughts in words. Obviously, the words themselves will mean nothing to an infant of two or three months, but they will hold the mother's thought in the right channel, and this thought, by the tone of her voice, the touch of her hand, will be communicated to the child. Whether telepathy plays any part in this process we need not inquire, but the baby is psychically as well as physically so dependent on the mother that her mental states are communicated by means quite ineffective with adults. Love in itself exerts a suggestive power of the highest order. When the child shows signs of understanding what is said to it, before it begins itself to speak, the following method should be applied. After the little one has fallen asleep at night the mother enters the room, taking care not to awaken it, and stands about a yard from the head of the cot. She proceeds then to formulate in a whisper such suggestions as seem necessary. If the child is ailing the suggestion might take the form of the phrase "You are getting better" repeated twenty times. If it is in health the general formula will suffice. Particular suggestions may also be formulated bearing on the child's health, character, intellectual development, etc. These of course should be in accordance with the instructions given in the chapter devoted to particular suggestions. On withdrawing, the mother should again be careful not to awaken the little one. Should it show signs of waking, the whispered command "sleep," repeated several times, will lull it again to rest. Baudouin recommends that during these suggestions the mother should lay her hand on the child's forehead. The above, however, is the method preferred by Coué. This nightly practice is the most effective means of conveying autosuggestions to the child-mind. It should be made a regular habit which nothing is allowed to interrupt. If for any reason the mother is unable to perform it, her place may be taken by the father, the nurse, or some relative. But for obvious reasons the duty belongs by right to the mother, and, when a few weeks' practice has revealed its beneficent power, few mothers will be willing to delegate it to a less suitable agent. This practice, as stated above, may well begin before the child has actually learned to speak, for its Unconscious will already be forming a scheme more or less distinct of the significance of the sounds that reach it, and will not fail to gather the general tenor of the words spoken. The date at which it should be discontinued is less easy to specify. Growth, to be healthy, must carry with it a gradual increase in independence and self-sufficiency. There seems to be some slight danger that the practice of nightly suggestions, if continued too long, might prolong unduly the state of dependence upon parental support. Reliable indications on this point are furnished, however, by the child itself. As soon as it is able to face its daily problems for itself, when it no longer runs to the parent for help and advice in every little difficulty, the time will have arrived for the parental suggestions to cease. As soon as a child is able to speak it should be taught to repeat the general formula night and morning in the same way as an adult. Thus when the time comes to discontinue the parent's suggestions their effect will be carried on by those the child formulates itself. There is one thing more to add: in the case of boys it would seem better at the age of seven or eight for the father to replace the mother in the rôle of suggester, while the mother, of course, performs the office throughout for her girls. Should any signs appear that the period of puberty is bringing with it undue difficulties or perils, the nightly practice might be resumed in the form of particular suggestions bearing on the specific difficulties. It must be remembered, however, that the child's sexual problem is essentially different from that of the adult, and the suggestions must therefore be in the most general terms. Here as elsewhere the end alone should be suggested, the Unconscious being left free to choose its own means. As soon as the child has learnt to speak it should not be allowed to suffer pain. The best method to adopt is that practised by Coué in his consultations. Let the child close its eyes and repeat with the parent, "It's going, going ... gone!" while the latter gently strokes the affected part. But as soon as possible the child should be encouraged to overcome smaller difficulties for itself, until the parent's help is eventually almost dispensed with. This is a powerful means of developing self-reliance and fostering the sense of superiority to difficulties which will be invaluable in later life. That children readily take to the practice is shown by these examples, which are again quoted from letters received by Coué. "Your youngest disciple is our little David. The poor little chap had an accident to-day. Going up in the lift with his father, when quite four feet up, he fell out on his head and on to a hard stone floor. He was badly bruised and shocked, and when put to bed lay still and kept saying: 'ça passe, ça passe,' over and over again, and then looked up and said, 'no, not gone away.' To-night he said again 'ça passe' and then added, 'nearly gone.' So he is better." B. K. (London). 8 _January_, 1922. Another lady writes: "Our cook's little niece, aged 23 months--the one we cured of bronchitis--gave herself a horrid blow on the head yesterday. Instead of crying she began to smile, passed her hand over the place and said sweetly, 'ça passe.' Hasn't she been well brought up?" All these methods are extremely simple and involve little expenditure of time and none of money. They have proved their efficacy over and over again in Nancy, and there is no reason why a mother of average intelligence and conscientiousness should not obtain equally good results. Naturally, first attempts will be a little awkward, but there is no need for discouragement on that account. Even supposing that through the introduction of effort some slight harm were done--and the chance is comparatively remote--this need cause no alarm. The right autosuggestion will soon counteract it and produce positive good in its place. But any mother who has practised autosuggestion for herself will be able correctly to apply it to her child. At first glance the procedure may seem revolutionary, but think it over for a moment and you will see that it is as old as the hills. It is merely a systematisation on a scientific basis of the method mothers have intuitively practised since the world began. "Sleep, baby, sleep. Angels are watching o'er thee,"--what is this but a particular suggestion? How does a wise mother proceed when her little one falls and grazes its hand? She says something of this kind: "Let me kiss it and then it will be well." She kisses it, and with her assurance that the pain has gone the child runs happily back to its play. This is only a charming variation of the method of the caress. CHAPTER XI CONCLUSION Induced Autosuggestion is not a substitute for medical practice. It will not make us live for ever, neither will it free us completely from the common ills of life. What it may do in the future, when all its implications have been realised, all its resources exploited, we cannot say. There is no doubt that a generation brought up by its canons would differ profoundly from the disease-ridden population of to-day. But our immediate interest is with the present. The adult of to-day carries in his Unconscious a memory clogged with a mass of adverse suggestions which have been accumulating since childhood. The first task of Induced Autosuggestion will be to clear away this mass of mental lumber. Not until this has been accomplished can the real man appear and the creative powers of autosuggestion begin to manifest themselves. By the use of this method each one of us should be able to look forward to a life in which disease is a diminishing factor. But how great a part it will play depends upon the conditions we start from and the regularity and correctness of our practice. Should disease befall us we possess within a potent means of expelling it, but this does not invalidate the complementary method of destroying it from without. Autosuggestion and the usual medical practice should go hand in hand, each supplementing the other. If you are ill, call in your doctor as before, but enlist the resources of Induced Autosuggestion to reinforce and extend his treatment. In this connection it must be insisted on that autosuggestion should be utilised for every ailment, whatever its nature, and whether its inroads be grave or slight. Every disease is either strengthened or weakened by the action of the mind. We cannot take up an attitude of neutrality. Either we must aid the disease to destroy us by allowing our minds to dwell on it, or we must oppose it and destroy it by a stream of healthful dynamic thought. Too frequently we spontaneously adopt the former course. The general opinion that functional and nervous diseases alone are susceptible to suggestive treatment is at variance with the facts. During Coué's thirty years of practice, in which many thousands of cases have been treated, he has found that organic troubles yield as easily as functional, that bodily derangements are even easier to cure than nervous and mental. He makes no such distinctions; an illness is an illness whatever its nature. As such Coué attacks it, and in 98 per cent. of cases he attains in greater or less degree a positive result. Apart from the permanently insane, in whose minds the machinery of autosuggestion is itself deranged, there are only two classes of patient with whom Induced Autosuggestion seems to fail. One consists of persons whose intelligence is so low that the directions given are never comprehended; the other of those who lack the power of voluntary attention and cannot devote their minds to an idea even for a few consecutive seconds. These two classes, however, are numerically insignificant, together making up not much more than 2 per cent. of the population. Autosuggestion is equally valuable as an aid to surgical practice. A broken bone--the sceptic's last resource--cannot of course be treated by autosuggestion alone. A surgeon must be called in to mend it. But when the limb has been rightly set and the necessary mechanical precautions have been taken, autosuggestion will provide the best possible conditions for recovery. It can prevent lameness, stiffness, unsightly deformity and the other evils which a broken limb is apt to entail, and it will shorten considerably the normal period of convalescence. It is sometimes stated that the results obtained by autosuggestion are not permanent. This objection is really artificial, arising from the fact that we ignore the true nature of autosuggestion and regard it merely as a remedy. When we employ autosuggestion to heal a malady our aim is so to leaven the Unconscious with healthful thoughts, that not only will that specific malady be excluded, but all others with it. Autosuggestion should not only remove a particular form of disease, but the tendency to all disease. If after an ailment has been removed we allow our mind to revert to unhealthy thoughts, they will tend to realise themselves in the same way as any others, and we may again fall a victim to ill-health. Our sickness may take the same form as on the preceding occasion, or it may not. That will depend on the nature of our thought. But by the regular employment of the general formula we can prevent any such recurrence. Instead of reverting to unhealthy states of mind we shall progressively strengthen the healthy and creative thought that has already given us health, so that with each succeeding day our defence will be more impenetrable. Not only do we thus avoid a relapse into former ailments but we clear out of our path those which lie in wait for us in the future. We saw that in the Nancy clinic some of the cures effected are almost instantaneous. It would be a mistake, however, to embark on the practice of Induced Autosuggestion with the impression that we are going to be miraculously healed in the space of a few days. Granted sufficient faith, such a result would undoubtedly ensue; nay, more, we have records of quite a number of such cases, even where the help of a second person has not been called in. Here is an example. A friend of mine, M. Albert P., of Bordeaux, had suffered for more than ten years with neuralgia of the face. Hearing of Coué, he wrote to him, and received instructions to repeat the general formula. He did so, and on the second day the neuralgia had vanished and has never since returned. But such faith is not common. Immediate cures are the exception, and it will be safer for us to look forward to a gradual and progressive improvement. In this way we shall guard against disappointment. It may be added that Coué prefers the gradual cure, finding it more stable and less likely to be disturbed by adverse conditions. We should approach autosuggestion in the same reasonable manner as we approach any other scientific discovery. There is no hocus-pocus about it, nor are any statements made here which experience cannot verify. But the attitude we should beware most of is that of the intellectual amateur, who makes the vital things of life small coin to exchange with his neighbour of the dinner-table. Like religion, autosuggestion is a thing to practise. A man may be conversant with all the creeds in Christendom and be none the better for it; while some simple soul, loving God and his fellows, may combine the high principles of Christianity in his life without any acquaintance with theology. So it is with autosuggestion. Autosuggestion is just as effective in the treatment of moral delinquencies as in that of physical ills. Drunkenness, kleptomania, the drug habit, uncontrolled or perverted sexual desires, as well as minor failings of character, are all susceptible to its action. It is as powerful in small things as in great. By particular suggestions we can modify our tastes. We can acquire a relish for the dishes we naturally dislike, and make disagreeable medicine taste pleasant. So encouraging has been its application to the field of morals that Coué is trying to gain admittance to the French state reformatories. So far, the official dislike for innovations has proved a barrier, but there is good reason to hope that in the near future the application of this method to the treatment of the criminal will be greatly extended. By way of anticipating an objection it may be stated that the Coué method of Induced Autosuggestion is in no sense inferior to hypnotic suggestion. Coué himself began his career as a hypnotist, but being dissatisfied with the results, set out in quest of a method more simple and universal. Conscious autosuggestion, apart from its convenience, can boast one great advantage over its rival. The effects of hypnotic suggestion are often lost within a few hours of the treatment. Whereas by the use of the general formula the results of Induced Autosuggestion go on progressively augmenting. Here we touch again the question of the suggester. We have already seen that a suggester is not needed, that autosuggestion can yield its fullest fruits to those who practise it unaided. But some persons cannot be prevailed on to accept this fact. They feel a sense of insufficiency; the mass of old wrong suggestions has risen so mountain-high that they imagine themselves incapable of removing it. With such the presence of a suggester is an undoubted help. They have nothing to do but lie passive and receive the ideas he evokes. Even so, however, they will get little good unless they consent to repeat the general formula. But as long as we look on autosuggestion as a remedy we miss its true significance. Primarily it is a means of self-culture, and one far more potent than any we have hitherto possessed. It enables us to develop the mental qualities we lack: efficiency, judgment, creative imagination, all that will help us to bring our life's enterprise to a successful end. Most of us are aware of thwarted abilities, powers undeveloped, impulses checked in their growth. These are present in our Unconscious like trees in a forest, which, overshadowed by their neighbours, are stunted for lack of air and sunshine. By means of autosuggestion we can supply them with the power needed for growth and bring them to fruition in our conscious lives. However old, however infirm, however selfish, weak or vicious we may be, autosuggestion will do something for us. It gives us a new means of culture and discipline by which the "accents immature," the "purposes unsure" can be nursed into strength, and the evil impulses attacked at the root. It is essentially an individual practice, an individual attitude of mind. Only a narrow view would split it up into categories, debating its application to this thing or to that. It touches our being in its wholeness. Below the fussy perturbed little ego, with its local habitation, its name, its habits and views and oddities is an ocean of power, as serene as the depths below the troubled surface of the sea. Whatever is of you comes eventually thence, however perverted by the prism of self-consciousness. Autosuggestion is a channel by which the tranquil powers of this ultimate being are raised to the level of our life here and now. What prospects does autosuggestion open to us in the future? It teaches us that the burdens of life are, at least in large measure, of our own creating. We reproduce in ourselves and in our circumstances the thoughts of our minds. It goes further. It offers us a means by which we can change these thoughts when they are evil and foster them when they are good, so producing a corresponding betterment in our individual life. But the process does not end with the individual. The thoughts of society are realised in social conditions, the thoughts of humanity in world conditions. What would be the attitude towards our social and international problems of a generation nurtured from infancy in the knowledge and practice of autosuggestion? If fear and disease were banned from the individual life, could they persist in the life of the nation? If each person found happiness in his own heart would the illusory greed for possession survive? The acceptance of autosuggestion entails a change of attitude, a revaluation of life. If we stand with our faces westward we see nothing but clouds and darkness, yet by a simple turn of the head we bring the wide panorama of the sunrise into view. That Coué's discoveries may profoundly affect our educational methods is beyond question. Hitherto we have been dealing directly only with the conscious mind, feeding it with information, grafting on to it useful accomplishments. What has been done for the development of character has been incidental and secondary. This was inevitable so long as the Unconscious remained undiscovered, but now we have the means of reaching profounder depths, of endowing the child not only with reading and arithmetic, but with health, character and personality. But perhaps it is in our treatment of the criminal that the greatest revolution may be expected. The acts for which he is immured result from nothing more than twists and tangles of the threads of thought in the Unconscious mind. This is the view of eminent authorities. But autosuggestion takes us a long step further. It shows how these discords of character may be resolved. Since Coué has succeeded in restoring to moral health a youth of homicidal tendencies, why should not the same method succeed with many of the outcasts who fill our prisons? At least the younger delinquents should prove susceptible. But the idea underlying this attitude entails a revolution in our penal procedure. It means little less than this: that crime is a disease and should be treated as such; that the idea of punishment must give place to that of cure; the vindictive attitude to one of pity. This brings us near to the ideals of the New Testament, and indeed, autosuggestion, as a force making for goodness, is bound to touch closely on religion. It teaches the doctrine of the inner life which saints and sages have proclaimed through all ages. It asserts that within are the sources of calm, of power and of courage, and that the man who has once attained mastery of this inner sphere is secure in the face of all that may befall him. This truth is apparent in the lives of great men. Martyrs could sing at the stake because their eyes were turned within on the vision of glory which filled their hearts. Great achievements have been wrought by men who had the fortitude to follow the directions of an inner voice, even in contradiction to the massed voices they heard without. Suppose we find that the power Christ gave to his disciples to work miracles of healing was not a gift conferred on a few selected individuals, but was the heritage of all men; that the kingdom of heaven within us to which He alluded was available in a simple way for the purging and elevation of our common life, for procuring sounder health and sweeter minds. Is not the affirmation contained in Coué's formula a kind of prayer? Does it not appeal to something beyond the self-life, to the infinite power lying behind us? Autosuggestion is no substitute for religion; it is rather a new weapon added to the religious armoury. If as a mere scientific technique it can yield such results, what might it not do as the expression of those high yearnings for perfection which religion incorporates? 
30162	----	CONTRIBUTIONS FROM THE MUSEUM OF HISTORY AND TECHNOLOGY: PAPER 10 OLD ENGLISH PATENT MEDICINES IN AMERICA _George B. Griffenhagen_ and _James Harvey Young_ ORIGINS OF ENGLISH PATENT MEDICINES 156 ENGLISH PATENT MEDICINES COME TO AMERICA 162 COMPLEX FORMULAS AND DISTINCTIVE PACKAGES 166 SOURCE OF SUPPLY SEVERED 168 PHILADELPHIA COLLEGE OF PHARMACY FORMULARY 174 ENGLISH PATENT MEDICINES GO WEST 176 THE PATENT MEDICINES IN THE 20TH CENTURY 179 OLD ENGLISH PATENT MEDICINES IN AMERICA _By George B. Griffenhagen and James Harvey Young_ _Bateman's Pectoral Drops, Godfrey's Cordial, Turlington's Balsam of Life, Hooper's Female Pills, and a half-dozen other similar nostrums originated in England, mostly during the first half of the 18th century. Advertised with extravagant claims, their use soon spread to the American Colonies._ _To the busy settler, with little time and small means, these ready-made and comparatively inexpensive "remedies" appealed as a solution to problems of medical and pharmaceutical aid. Their popularity brought forth a host of American imitations and made an impression not soon forgotten or discarded._ THE AUTHORS: _George B. Griffenhagen, formerly curator of medical sciences in the Smithsonian Institution's U.S. National Museum, is now Director of Communications for the American Pharmaceutical Association. James Harvey Young is professor of history at Emory University. Some of the material cited in the paper was found by him while he held a fellowship from the Fund for the Advancement of Education, in 1954-55, and grants-in-aid from the Social Science Research Council and Emory University, in 1956-57._ In 1824 there issued from the press in Philadelphia a 12-page pamphlet bearing the title, _Formulae for the preparation of eight patent medicines, adopted by the Philadelphia College of Pharmacy_. The College was the first professional pharmaceutical organization established in America, having been founded in 1821, and this small publication was its first venture of any general importance. Viewed from the perspective of the mid-20th century, it may seem strange if not shocking that the maiden effort of such a college should be publicizing formulas for nostrums. Adding to the novelty is the fact that all eight of these patent medicines, with which the Philadelphians concerned themselves half a century after American independence, were of English origin. Hooper's Female Pills, Anderson's Scots Pills, Bateman's Pectoral Drops, Godfrey's Cordial, Dalby's Carminative, Turlington's Balsam of Life, Steer's Opodeldoc, British Oil--in this order do the names appear in the Philadelphia pamphlet--all were products of British therapeutic ingenuity. Across the Atlantic Ocean and on American soil these eight and other old English patent medicines, as of the year when the 12-page pamphlet was printed, had both a past and a future. Origin of English Patent Medicines When the Philadelphia pharmacists began their study, the eight English patent medicines were from half a century to two centuries old.[1] The most ancient was Anderson's Scots Pills, a product of the 1630's, and the most recent was probably Dalby's Carminative, which appeared upon the scene in the 1780's. Some aspects of the origin and development of these and similar English proprietaries have been treated, but a more thorough search of the sources and a more integrated and interpretive recounting of the story would be a worthy undertaking. Here merely an introduction can be given to the cast of characters prior to their entrances upon the American stage. [1] Unless otherwise indicated, the early English history of these patent medicines has been obtained from the following sources: "Proprietaries of other days," _Chemist and Druggist_, June 25, 1927, vol. 106, pp. 831-840; C. J. S. Thompson, _The mystery and art of the apothecary_, London, 1929; C. J. S. Thompson, _Quacks of old London_, London, 1928; and A. C. Wootton, _Chronicles of pharmacy_, London, 1910, 2 vols. The inventor of Anderson's Scots Pills was fittingly enough a Scot named Patrick Anderson, who claimed to be physician to King Charles I. In one of his books, published in 1635, Anderson extolled in Latin the merits of the Grana Angelica, a pill the formula for which he said he had learned in Venice. Before he died, Anderson imparted the secret to his daughter Katherine, and in 1686 she in turn conveyed the secret to an Edinburgh physician named Thomas Weir. The next year Weir persuaded James II to grant him letters patent for the pills. Whether he did this to protect himself against competition that already had begun, or whether the patenting gave a cue to those always ready to cut themselves in on a good thing, cannot be said for sure. The last years of the 17th century, at any rate, saw the commencement of a spirited rivalry among various makers of Anderson's Scots Pills that was long to continue. One of them was Mrs. Isabella Inglish, an enterprising woman who sealed her pill boxes in black wax bearing a lion rampant, three mallets argent, and the bust of Dr. Anderson. Another was a man named Gray who sealed his boxes in red wax with his coat of arms and a motto strangely chosen for a medicine, "Remember you must die." [Illustration: Figure 1.--THE PHILADELPHIA COLLEGE OF PHARMACY in 1824 set forth in this pamphlet formulas for eight old English patent medicines. (_Courtesy, Philadelphia College of Pharmacy and Science, Philadelphia, Pennsylvania._)] Competition already had begun when Godfrey's Cordial appeared in the record in a London newspaper advertisement during December 1721. John Fisher of Hertfordshire, "Physician and Chymist," claimed to have gotten the true formula from its originator, the late Dr. Thomas Godfrey of the same county. But there is an alternate explanation. Perhaps the Cordial had its origin in the apothecary shop established about 1660 by Ambroise (Hanckowitz) Godfrey in Southampton Street, London.[2] According to a handbill issued during the late 17th century, Ambroise Godfrey prepared "Good Cordials as Royal English Drops." [2] "How the patent medicine industry came into its own," _American Druggist_, October 1933, vol. 88, pp. 84-87, 232, 234, 236, 238. [Illustration: Figure 2.--ANTHONY DAFFY EXTOLLED THE VIRTUES OF HIS ELIXIR SALUTIS in this pamphlet, published in London in 1673. (_Courtesy, British Museum._)] With respect to his rivals, the 18th-century Hertfordshire vendor of the Cordial warned in the _Weekly Journal_ (London), December 23, 1721: "I do advise all Persons, for their own Safety, not to meddle with the said Cordial prepared by illiterate and ignorant Persons, as Bakers, Malsters, [sic] and Goldsmiths, that shall pretend to make it, it being beyond their reach; so that by their Covetousness and Pretensions, many Men, Women, and especially Infants, may fall as Victims, whose Slain may exceed Herod's Cruelty...." In 1726 King George I granted a patent for the making and selling of Dr. Bateman's Pectoral Drops. The patent was given not to a doctor, but to a business man named Benjamin Okell. In the words of the patent,[3] Okell is lauded for having "found out and brought to Perfection, a new Chymicall Preparacion and Medicine..., working chiefly by Moderate Sweat and Urine, exceeding all other Medicines yet found out for the Rheumatism, which is highly useful under the Afflictions of the Stone, Gravell, Pains, Agues, and Hysterias...." What the chemicals constituting his remedy were, the patentee did not vouchsafe to reveal. [3] Benjamin Okell, "Pectoral drops for rheumatism, gravel, etc.," British patent 483, March 31, 1726. The practice of patenting had begun in royal prerogative. Long accustomed to granting monopoly privileges for the development of new industries, the discovery of new lands, and the enrichment of court favorites, various monarchs in 17th-century Europe had given letters patent to proprietors of medical remedies which had gained popular acclaim. In France and the German States, this practice continued well through the 18th century. In England, where representative government had progressed at the expense of the personal prerogative of the sovereign, Parliament passed a law in 1624 aimed at curbing arbitrary actions like those of James I and Charles I. The statute declared all monopolies void except those extended to the first inventor of a new process of manufacture. To such pioneers the king could grant his letters patent bestowing monopoly privileges for a period of 14 years. That the machinery set up by this law did not completely curb the independence of English sovereigns in the medical realm is indicated by the favor extended Dr. Weir, who successfully sought from James II a privileged position for Anderson's Scots Pills. This kingly grant is not included in the regular list, and the Glorious Revolution of 1688 brought an end to such an exercise of royal power without consent of Parliament. A list of patents in the medical field later published by the Commissioners of Patents[4] includes only six issued during the 17th century, four for baths and devices, one for an improved method of preparing alum, and one for making epsom salts. The first patent for a compound medicine was granted in 1711, and only two other proprietors preceded Benjamin Okell in seeking this particular legal form of protection and promotion. As early as 1721, Bateman's Pectoral Drops were being regularly advertised in the _London Mercury_. The advertisements announced: "Dr. Bateman's Pectoral DROPS published at the Request of several Persons of Distinction from both Universities...." The Drops, priced at "1 s. a Bottle," were "Sold Wholesale and Retail at the Printing-house and Picture Warehouse in Bow Churchyard," and likewise "in most Cities and celebrated Towns in Great Britain." "Each Bottle Seal'd with the Boar's Head." So stated the advertisement, which itself contained a crude cut of this Boar's Head seal.[5] Elsewhere in this issue of the _Mercury_, we learn that John Cluer, printer, was the proprietor of the Bow Churchyard Warehouse. This same John Cluer, along with William Dicey and Robert Raikes, were named in the 1726 patent as "the Persons concerned with the said Inventor," Benjamin Okell, who, with him, should "enjoy the sole Benefit of the said Medicine." It was this partnership which was to find the field of nostrum promotion especially congenial and which was to play an important transatlantic role. Soon after securing their patent, the proprietors undertook to inform their countrymen about the remedy by issuing _A short treatise of the virtues of Dr. Bateman's Pectoral Drops_.[6] [4] British Patent Office, _Patents for inventions: abridgements of specifications relating to medicine, surgery, and dentistry, 1620-1866_, London, 1872. [5] _London Mercury_, London, August 19-26, 1721. [6] _A short treatise of the virtues of Dr. Bateman's Pectoral Drops_, New York, 1731. A 36-page pamphlet preserved in the Library of the New York Academy of Medicine. This is an American reprint of an English original, date unknown. It was the 18th century, and the essay was in fashion. The proprietors prepared a didactic introduction to their treatise, phrased in long and flowery sentences, in which modesty was not the governing tone. The arguments ran like this: that the "Universal Good of Mankind" should be the aim of "every private member"; that nothing is so conducive to this general welfare as "HEALTH"; that no hazards to health are more direful than diseases such as "the Gout; the Rheumatism; the Stone; the Jaundice," etc., etc.; that countless men and women have succumbed to such afflictions either because they received no treatment or suffered wrong treatment at "the Hands of the Learned"; that no medicine is so sure a cure as that inexpensive remedy discovered as a result of great "Piety, Learning and Industry" by one "inspir'd with the Love of his Country, and the Good of Mankind," to wit. "Dr. BATEMAN'S Pectoral Drops." Then followed seven chapters treating the multitude of illnesses for which the Drops were a specific. Finally, the pamphlet cited "some few, out of the many thousands of Certificates of Cures effected by these DROPS...." Even so early was the testimonial deemed a powerful persuader. No more could Okell, Cluer, Dicey, and Raikes escape competition than could the proprietors of other successful nostrums. In 1755 they went to court and won a suit for the infringement of their patent, but the damages amounted to only a shilling. Even after the patent expired, the tide of publicity flowed on.[7] [7] A broadside, issued in London, _ca._ 1750, advertising "Dr. Bateman's Drops," is preserved in the Warshaw Collection of Business Americana, New York. Later reprints of this same broadside are preserved in the private collection of Samuel Aker, Albany, New York, and in the Smithsonian Institution. Competition was also lively in the 1740's among some half a dozen proprietors marketing a form of crude petroleum under the name of British Oil. Early in the decade Michael and Thomas Betton were granted a patent for "An Oyl extracted from a Flinty Rock for the Cure of Rheumatick and Scorbutick and other Cases." The source of the oil, according to their specifications, was rock lying just above the coal in mines, and this rock was pulverized and heated in a furnace to extract all the precious healing oil.[8] This Betton patent aroused one of their rivals, Edmund Darby & Co. of Coalbrook-Dale in Shropshire. Darby asserted that it was presumptuous of the Bettons to call their British oyl a new invention.[9] For over a century Darby and his predecessors had been marketing this self-same product, and it had proved to be "the one and only unrivall'd and most efficacious Remedy ever yet discovered, against the whole force of Diseases and Accidents that await Mankind...." For the Bettons to appropriate the process and patent it--and even to claim in their advertising cures which really had been wrought by the Darby product--was scandalous. Worse than that, said Darby, it was illegal, for in 1693 William III had granted a patent to "Martin Eele and two others at his Nomination for making the same Sort of Oyl from the same Sort of Materials." Evidence to substantiate his belief in the Betton perfidy was presented by Darby to George II, who had the matter duly investigated.[10] Being persuaded that Darby was right, the king and his councillors, in 1745, vacated the Betton patent. This victory seems not to have boomed the Darby interests, and this defeat seems not to have ruined the Bettons. During the succeeding century, the Betton patent was published and republished in advertising, just as if it had never fallen afoul the law. From their battles with the Oil from Coalbrook-Dale and other British Oils marketed by other proprietors, the Bettons emerged triumphant. In the years to come, patent or no, the Bettons British Oil was to dominate the field. [8] Michael and Thomas Betton, "Oil for the cure of rheumatic and scorbutic affections," British patent 587, August 14, 1742. [9] Edmund Darby & Co., _Directions for taking inwardly and using outwardly the company's true genuine and original British Oil; prepared by Edmund Darby & Co. at Coalbrook-Dale, Shropshire_, ca. 1745. An 8-page pamphlet preserved in the Library of the College of Physicians, Philadelphia, Pennsylvania. [10] _London Gazette_, London, March 1, 1745. The year after the Bettons had secured their patent, another was granted to John Hooper of Reading for the manufacture of "Female Pills" bearing his name.[11] Hooper was an apothecary, a man-midwife, and a shrewd fellow. This was the period in which the British Government was increasing its efforts to require the patentee to furnish precise specifications with his application.[12] When Hooper was called upon to tell what was in his pills and how they were made, he replied by asserting that they were composed "Of the best purging stomatick and anti-hysterick ingredients," which were formed into pills the size of a small pea. This satisfied the royal agents and Hooper went on about his business. In an advertisement of the same year, he was able to cite as a witness to his patent the name of the Archbishop of Canterbury.[13] [11] John Hooper, "Pills," British patent 592, July 21, 1743. [12] E. Burke Inlow, _The patent grant_, Baltimore, 1950, p. 33. [13] _Daily Advertiser_, London, September 23, 1743. Much less taciturn than Hooper about the composition of his nostrum was Robert Turlington, who secured a patent in 1744 for "A specifick balsam, called the balsam of life."[14] The Balsam contained no less than 27 ingredients, and in his patent specifications Turlington asserted that it would cure kidney and bladder stones, cholic, and inward weakness. He shortly issued a 46-page pamphlet in which he greatly expanded the list.[15] In this appeal to 18th-century sensibilities, Turlington asserted that the "Author of Nature" has provided "a Remedy for every Malady." To find them, "Men of Learning and Genius" have "ransack'd" the "Animal, Mineral and Vegetable World." His own search had led Turlington to the Balsam, "a perfect Friend to Nature, which it strengthens and corroborates when weak and declining, vivifies and enlivens the Spirits, mixes with the Juices and Fluids of the Body and gently infuses its kindly Influence into those Parts that are most in Disorder." [14] Robert Turlington, "A Specifick balsam, called the balsam of life," British patent 596, January 18, 1744. [15] Robert Turlington, _Turlington's Balsam of Life_, ca. 1747. A 46-page pamphlet preserved in the Folger Shakespeare Library, Washington, D.C. [Illustration: Figure 3.--LABEL FOR STOUGHTON'S ELIXIR as manufactured by Dr. Jos. Frye of Salem, Massachusetts. (_Courtesy, Essex Institute, Salem, Massachusetts._)] Testimonials from those who had felt the kindly influence took up most of the space in Turlington's pamphlet. In these grateful acknowledgments to the potency of the patent medicine, the list of illnesses cured stretched far beyond the handful named in the patent specifications. Just as for Bateman's Pectoral Drops and the Darby brand of British Oil, workers of many occupations solemnly swore that they had received benefit. Most of them were humble people--a porter, a carpenter, the wife of a gardener, a blanket-weaver, a gunner's mate, a butcher, a hostler, a bodice-maker. Some bore a status of greater distinction: there were a "Mathematical Instrument-Maker" and the doorkeeper of the East India Company. All were jubilant at their restored good health. The Balsam's well-nigh sovereign power could not protect it from one ailment of the times, competition. Various preparations of similar composition, like Friar's Balsam, already were on the market, but before long even the Turlington name was trespassed upon, and the inventor's niece was forced to advertise that she alone had the true formula and that any person who took a dose of the spurious imitations being offered did so at great hazard to his life. A quarter of a century after the patenting of the Balsam, there appeared for sale to British ailing a remedy called Dr. Steer's Celebrated Opodeldoc. Dr. Steer is a shadowy rider of a vigorous steed, for although the doctor has left but a faint personal impact upon the historical record, Opodeldoc has pranced through medical history since the time of Paracelsus. This 16th-century continental chemist-physician, who introduced many mineral remedies into the materia medica, had coined the word "opodeldoc" to apply to various medical plasters. In the two ensuing centuries the meaning had changed, and the _Pharmacopoeia Edinburgensis_ of 1722 employed the term to designate soap liniment. It is presumed that Dr. Steer appropriated the Edinburgh formula, added ammonia, and marketed his proprietary version. In 1780, a London paper carried an advertisement listing the difficulties for which the Opodeldoc was a "speedy and certain cure." These included bruises, sprains, burns, cuts, chillblains, and headaches. Furthermore, the remedy had been "found of infinite Use in hot Climates for the Bite of venomous Insects."[16] Dr. Steer seems not to have secured a patent for his slightly modified version of an official preparation. He died in 1781, but Opodeldoc, indeed Steer's Opodeldoc, went marching on.[17] [16] _Daily Advertiser_, London, February 18, 1780. [17] Broadsides, _ca._ 1810-1822, advertising "Steer's Chemical Opodeldoc, for bruises, sprains, rheumatism, etc., etc.," are preserved in the American Antiquarian Society, Worcester, Massachusetts; the Library of the New York Academy of Medicine; and the Warshaw Collection of Business Americana, New York. About the same time that Dr. Steer began advertising, newspaper promotion was launched in behalf of another remedy, called Dalby's Carminative. The inventor, J. Dalby, was a London apothecary, and his unpatented concoction was designed to cure "Disorders of the Bowels." One early advertisement[18] added details: "This Medicine, which is founded on just Medical Principles, has been long established as a most safe and effectual Remedy, generally affording immediate Relief in the Wind, Cholocks [_sic_], Convulsions, Purgings, and all those fatal Disorders in the Bowels of Infants, which carry off so great a number under the age of 2 years. It is also equally efficacious in gouty Pains in the Intestines, in Fluxes, and in the cholicky Complaints of grown Persons, so usual at this Season of the Year." Dalby, like Steer, failed long to survive the appearance of his medicine on the market. [18] _Daily Advertiser_, London, January 4, 1781. Such were the origins of the eight remedies which the Philadelphia pharmacists were to take account of in 1824. Besides these eight, two other patent medicines, both elixirs, were destined for roles of such special interest that a brief look at their English background is warranted. One of them, Daffy's Elixir, was the invention of a clergyman, Rev. Thomas Daffy soon after 1650. Daffy had his troubles during that troubled century, losing a pastorate because he offended a powerful Countess. When the rector first sought to minister unto men's bodies as well as to their souls is not known. According to a pamphlet issued in 1673, after the Rev. Daffy had passed from the scene, the formula had been "found out by the Providence of the Almighty." By this time a London kinsman of the inventor, named Anthony Daffy, was vending the remedy. The full name of the medicine, according to the pamphlet's title, was "Elixir Salutis: The Choice Drink of Health, or Health-Bringing Drink," and among the ailments for which it was effective were gout, the stone, colic, "ptissick," scurvy, dropsy, rickets, consumption, and "languishing and melancholly." The Elixir Salutis proved immensely popular. It was too much to expect that Anthony should hold the field uncontested; in the 1673 pamphlet one false fabricator was called by name, and in 1680 Anthony advertised to warn against "diverse Persons" who were not only counterfeiting the medicine but spreading the malicious rumor that Anthony was dead. Early in the new century, Catherine, the daughter of the original Rev. Daffy, insisted that she as well as her cousin Anthony had received the valuable formula. But it was Anthony's line that was to prove the more persistent. In 1743, one Susannah Daffy advertised the "Original and Famous Elixir," asserting that she had a brother Anthony who also knew the secret.[19] This Anthony died in 1750 and willed the formula to his niece. But there were others outside the family who long had been making and selling the medicine. For example, the Bow Churchyard Warehouse advertised Daffy's Elixir in the _London Mercury_ during 1721. Without hiding the fact that others were also compounding this "safe and pleasant Cordial ... well-known throughout England, where it has been in great Use these 50 Years," the advertisement concluded: "Those who make tryalof That sold at this [Bow Churchyard] Warehouse will never buy anywhere else."[20] [19] _Ibid._, September 7, 1743. [20] _London Mercury_, London, August 19-26, 1721. Although once lauded by a physician to King Charles II, Daffy's Elixir was never patented. The Elixir invented by Richard Stoughton was, in 1712, the second compound medicine to be granted a patent in England.[21] Stoughton was an apothecary who had a shop at the Sign of the Unicorn in Southwark, Surrey. It was evidently competition, the constant bane of the medicine proprietor's life, that drove him to seek governmental protection. In his specifications he asserted that he had been making his medical mixture for over twenty years. Stoughton was less precise about his formula; indeed, he gave none, but was generous in indicating the remedy's name: "Stoughton's Elixir Magnum Stomachii, or the Great Cordial Elixir, otherwise called the Stomatick Tincture or Bitter Drops." In a handbill, the apothecary did tip his hand to the extent of asserting that his Elixir contained 22 ingredients, but added that nobody but himself knew what they were. The dosage was generous, 50 to 60 drops "in a glass of Spring water, Beer, Ale, Mum, Canary, White wine, with or without sugar, and a dram of brandy as often as you please." This, it was said, would cure any stomach ailment whatever.[22] [21] Richard Stoughton, "Restorative cordial and medicine," British patent 390, 1712. [22] From a broadside, _ca._ 1750, advertising "Dr. Stoughton's Elixir Magnum Stomachum," preserved in the American Antiquarian Society, Worcester, Mass. The inventor died in 1726, and his passing precipitated a perfect fury of competitive advertising. As in the case of Daffy's, there was a family feud. A son of Stoughton and the widow of another son argued vituperously in print, each claiming sole possession of Richard's complicated secret, and each terming the other a scoundrel. The daughter-in-law accused the son of financial chicanery, and the son condemned the daughter-in-law for having run through two husbands and for desperately wanting a third. In the midst of this running battle, a third party entered the lists as maker of the Elixir. She was no Stoughton--though a widow--and her quaint claim for the public's consideration lay in this, that her late husband had infringed Stoughton's patent until restrained by the Lord Chancellor. These ten medicines--Stoughton's and Daffy's Elixirs and the eight which the Philadelphia pharmacists were later to select--were by no means the only packaged remedies available to the 18th-century Englishman who resorted to self-dosage for his ills. Between 1711, when the first patent was granted for a compound medicine, and 1776, some 75 items were patented in the medical field.[23] And, along with Godfrey's Cordial and Daffy's Elixir, there were scores of other remedies for which no patents had been given. A list of nostrums published in _The Gentleman's Magazine_ in 1748 totaled 202, and it was admittedly incomplete.[24] The proprietor with a patent might do his utmost to keep this badge of governmental sanction before the public, but the distinction was not great enough in such a crowded field to make things clear. The casual buyer could not keep track of which electuary had been granted a patent and which lozenge had not. They were all bottles and boxes upon the shelf. In use they served the same purpose. One term arose in common speech to apply to both, and it was "patent medicine." [23] British Patent Office, _op. cit._ (see footnote 4). [24] Poplicola, "Pharmacopoeia empirica or the list of nostrums and empirics," _The Gentleman's Magazine_, 1748, vol. 18, pp. 346-350. English Patent Medicines Come to America When the first English packaged medicine, patented or unpatented, came to the New World, cannot be told. Some 17th-century prospective colonist, setting forth to face the hazards of life in Jamestown or Baltimore or Boston, must have packed a box of Anderson's Scots Pills or a bottle of Daffy's Elixir to bring along, but no record to substantiate such an incident has been encountered. It would seem that the use of English packaged remedies in America was most infrequent before 1700. Samuel Lee, answering questions posed from England in 1690 about the status of medicine and pharmacy in Massachusetts, mentions no patent medicines.[25] Neither does the 1698 account book of the Salem apothecary, Bartholomew Brown.[26] [25] George L. Kittredge, "Letters to Samuel Lee and Samuel Sewall relating to New England and the Indians," _Colonial Society of Massachusetts, Transactions_, 1913, vol. 14, pp. 142-186. [26] Bartholomew Brown, Apothecary day book, Salem [1698]; manuscript original preserved in the Library of the Essex Institute, Salem, Massachusetts. [Illustration: Figure 4.--PATRICK ANDERSON, M.D., from a box of Anderson's Scots Pills. From Wootton's _Chronicles of pharmacy_, London, 1910. (_Smithsonian photo 44286-C._)] In the _Boston News-Letter_ for October 4, 1708, Nicholas Boone, at the Sign of the Bible, near the corner, of School-House-Lane, advertised for sale: "DAFFY'S Elixir Salutis, very good, at four shillings and sixpence _per_ half pint Bottle." This may well be the first printed reference in America to an English patent medicine, and it certainly is the first newspaper advertisement for a nostrum. Preceding the _News-Letter_ in colonial America, there had been only one paper, the _Publick Occurrences Both Foreign and Domestic_.[27] This journal had lasted but a single issue. Then its printer had returned to England, where he took up the career of a patent medicine promoter, vending "the only Angelical Pills against all Vapours, Hysterick Fits." The _News-Letter_ had begun with the issue of April 27, 1704, about 4 years before Boone's advertisement for Daffy's remedy made its appearance, but during that time, only one advertisement for anything at all in the medical field had appeared, and that was for a home-remedy book, _The English physician_, by Nicholas Culpeper, Doctor of Physick.[28] This volume was also for sale at Boone's shop. [27] Frank L. Mott, _American journalism_, New York, 1941, pp. 9-10. [28] _Boston News-Letter_, Boston, February 9, 1708. Patent-medicine advertising in the _News-Letter_ prior to 1750 was infrequent. Apothecary Zabdiel Boylston, who a decade later was to earn a role of esteem in medical history by introducing the inoculation for smallpox, announced in 1711 that he would sell "the true Lockyers Pills."[29] This was an unpatented remedy first concocted half a century earlier by a "licensed physitian" in London. The next year Boylston repeated this appeal,[30] and in the same advertisement listed other wares of the same type. He had two varieties, Golden and Plain, of the Spirit of Scurvy-Grass; he had "The Bitter Stomach Drops," worm potions for children; and a wonderful multipurpose nostrum, "the Royal Honey Water, an Excellent Perfume, good against Deafness, and to Make Hair grow...." The antecedents of this regal liquid are unknown. Boylston also announced for sale "The Best [Daffy's] Elixir Salutis in Bottles, or by the Ounce." This is a provocative listing. It may mean merely that the apothecary would break a bottle to sell a dose of the Elixir, which was often the custom. But it also may suggest that Boylston was making the Elixir himself, or was having it prepared by a journeyman. This latter interpretation would place Boylston well at the head of a long parade of American imitators of the old English patent medicines. [29] _Ibid._, March 12, 1711. [30] _Ibid._, March 24, 1712. Other such shipments of the packaged English remedies may have come to New England on the latest ships from London during the next several decades, but they got scant play in the advertising columns of the small 4-page _Boston News-Letter_. Another reference to "Doctor Anthony Daffey's Original Elixer Salutis" occurs in 1720.[31] Ten years later, Stoughton's Drops were announced for sale "by Public Vendue," along with feather beds, looking glasses, and leather breeches.[32] Nearly a decade more was to pass before Bateman's Pectoral Drops showed up in the midst of another general list, including cheese, and shoes, and stays.[33] Not until 1748 did an advertisement appear in which several of the old English nostrums rubbed shoulders with each other.[34] Then Silvester Gardiner, at the Sign of the Unicorn and Mortar, asserted that "by appointment of the Patentee" he was enabled to sell "Genuine British Oyl, _Bateman's_ Pectoral Drops, and _Hooper's_ Female Pills, and the True _Lockyer's_ Pills." [31] _Ibid._, November 14, 1720. [32] _Ibid._, March 12, 1730. [33] _Ibid._, January 4, 1739. [34] _Ibid._, November 14, 1748. Although nearly a century old, Anderson's Scots Pills were not cited for sale in the pages of the _Boston News-Letter_ until August 23, 1750, two months after the much more recent Turlington's Balsam of Life first put in its appearance.[35] During the same year, the British confusion over British Oil was reflected in America. Boden's and Darby's variety preceded the Betton brand into the _News-Letter_ pages by a fortnight.[36] It was the latter, however, which was to win the day in Boston, for almost all subsequent advertising specified the Betton Oil. Godfrey's Cordial was first mentioned in 1761.[37] Thus, of the ten old English patent medicines which are the focus of the present study, eight had been advertised in the _Boston News-Letter_. The other two, Steer's Opodeldoc and Dalby's Carminative, did not reach the market before this colonial journal fell prey to the heightening tensions of early 1776. [35] _Ibid._, June 7, 1750. [36] _Ibid._, May 24, 1750. [37] _Ibid._, December 31, 1761. By the 1750's, the names of several old English nostrums were appearing fairly frequently in the advertising of colonial apothecaries, not only in Boston but in other colonial towns. In Williamsburg, for example, a steady increase occurs in the number of references and the length of the lists of the English patent medicines advertised in the _Virginia Gazette_ from their first mention into the early 1760's.[38] This journal--which later had competing issues by different editors--was launched in 1736, and the next year George Gilmer advised customers that, in addition to "all manner of Chymical and Galenical Medicines," he could furnish, at his old shop near the Governor's, "Bateman's Drops, Squires Elixir, Anderson's Pills."[39] The other remedies appeared in due time, Stoughton's and Daffy's Elixirs in 1745, Turlington's Balsam in 1746, Godfrey's Cordial in 1751, Hooper's Pills in 1752, and Betton's British Oil in 1770. [38] Lester J. Cappon and Stella F. Duff, _Virginia Gazette index, 1736-1780_, Williamsburg, 1950, 2 vols. [39] _Virginia Gazette_, Williamsburg, May 27, 1737. A spot check of newspapers in Philadelphia and New York reveals a pattern quite similar. Residents of the middle colonies, like those to the north and the south, could buy the basic English brands, and it was during the 1750's that the notices of freshly-arrived supplies ceased to be rare in advertising columns and became a frequent occurrence. Thomas Preston, for example, announced to residents of Philadelphia in 1768 that he had just received a supply of Anderson's, Hooper's, Bateman's, Betton's, Daffy's, Stoughton's, Turlington's, and Godfrey's remedies.[40] Not only were these medicines for sale at apothecary shops, but they were sold by postmasters, goldsmiths, grocers, hair dressers, tailors, printers, booksellers, cork cutters, the post-rider between Philadelphia and Williamsburg, and by many colonial American physicians. [40] _Pennsylvania Gazette_, Philadelphia, December 1, 1768. It is a matter for comment that American newspaper advertising of the English packaged medicines was singularly drab. In the mother country, the proprietors or their heirs were faced with vigorous competition. It behooved them to sharpen up their adjectives and reach for their vitriol. In America the apothecary or merchant had no proprietary interest in any of the different brands of the imported medicines which were sold. Moreover, there was probably no great surplus of supply over demand in America as in Britain, so the task of selling the stock on hand was less difficult and required less vigorous promotion. Also, advertising space in the few American weeklies was more at a premium than in the more frequent and numerous English journals. With rare exceptions, therefore, the old English patent medicines were merely mentioned by name in American advertising. Seldom did one receive the individual attention accorded by Samuel Emlen to Godfrey's Cordial in Benjamin Franklin's _Pennsylvania Gazette_ for June 26, 1732. The ad ran like this: "Dr. Godfrey's General Cordial. So universally approved of for the Cholick, and all Manners cf Pains in the Bowels, Fluxes, Fevers, Small-Pox, Measles, Rheumatism, Coughs, Colds, and Restlessness in Men, Women, and Children; and particularly for several Ailments incident to Child-bearing Women, and Relief of young Children in breeding their Teeth." [Illustration: Figure 5.--PAMPHLET, DATED 1731, ON BEHALF OF BATEMAN'S PECTORAL DROPS. It was published by John Peter Zenger in New York. Original preserved in the New York Academy of Medicine Library. (_Smithsonian photo 44286-D._)] Emlen's venturesomeness may have lain in the fact that he was not only a retailer, but also an agent for the British manufacturer, for he cited the names of those who sold Godfrey's Cordial in nearby towns. Even at that, this appeal, consisting merely of a list of illnesses, lacked the cleverness of contemporary English nostrum advertising. In the whole span of the _Boston News-Letter_, beginning in 1704, it was not until 1763 that a bookstore pulled out the stops with half a column of lively prose in behalf of Dr. Hill's four unpatented nostrums.[41] It seems a safe assumption that not only the medicines but the verbiage were imported from London, where Dr. Hill had been at work endeavoring to restore a Greek secret which "converts a Glass of Water into the Nature and Quality of Asses Milk, with the Balsamick Addition...." [41] _Boston News-Letter_, Boston, November 24, 1763. The infrequency of extended fanciful promotion in behalf of the old English nostrums in American newspaper advertising may have been compensated for to some degree in broadside and pamphlet. A critic of the medical scene in New York in the early 1750's asserted that physicians used patent medicines which they learned about from "London quack bills." This doctor complained, these were often their only reading matter.[42] Such a judgment may be too severe. Certainly it is difficult to validate today. Such pamphlets and broadsides do appear in American archival collections. The Historical Society of Pennsylvania contains a 2-page Turlington broadside,[43] while the Folger Shakespeare Library in Washington has an earlier 46-page Turlington pamphlet with testimonials reaching out toward America.[44] One such certificate came from "a sailor before the mast, on board the ship Britannia in the New York trade," and another cited a woman living in Philadelphia who gave thanks for the cure of her dropsy. [42] James J. Walsh, _History of the Medical Society of the State of New York_, New York, 1907. [43] Robert Turlington, "Turlington's Balsam of Life," 1755-1757. A later reprint of this same circular is preserved in the Warshaw Collection of Business Americana. [44] _Turlington's Balsam of Life_ (see footnote 15). A broadside in the Warshaw Collection touting Bateman's Drops noted that "extraordinary demands have been made for Maryland, New-York, Jamaica, etc. where their virtues have been truely experienced with the greatest satisfaction."[45] That such promotional items are extremely rare does not mean they were not abundant in the mid-18th century, for this type of printed matter, then as now, was likely to be looked at and thrown away. A certain amount of nostrum literature was undoubtedly imported from Britain. For example, in 1753 apothecary James Carter of Williamsburg ordered from England "3 Quire Stoughton's Directions" along with "1/2 Groce Stoughton Vials."[46] These broadsides or circulars served a twofold purpose. Not only did they promote the medicine, but they actually served as the labels for the bottles. Early packages of these patent medicines which have been discovered indicate that paper labels were seldom applied to the glass bottles; instead, the bottle was tightly wrapped and sealed in one of these broadsides. [45] "Dr. Bateman's Drops" (see footnote 7). [46] James Carter, Apothecary account book, Williamsburg [1752-1773]. Manuscript original preserved at Colonial Williamsburg, Virginia. American imprints seeking to promote the English patent medicines were certainly rare. The most significant example may be found in the Library of the New York Academy of Medicine.[47] In 1731 James Wallace, a New York merchant, became American agent for the sale of Dr. Bateman's Pectoral Drops. To help him with his new venture, Wallace took a copy of the London promotional pamphlet to a New York printer to be reproduced. The printer was John Peter Zenger, not yet an editor and three years away from the events which were to link his name inextricably with the concept of the freedom of the press. This 1731 pamphlet may well have been the earliest work on any medical theme to be printed in New York.[48] [47] _A short treatise of the virtues of Dr. Bateman's Pectoral Drops_ (see footnote 6). [48] Gertrude L. Annan, "Printing and medicine," _Bulletin of the Medical Library Association_, March 1940, vol. 28, p. 155. Now and then a physician might frown on his fellows for reading such literature and prescribing such remedies, but he was in a minority. Colonial doctors, by and large, had no qualms about employing the packaged medicines. It was a doctor who first advertised Anderson's Pills and Bateman's Drops in Williamsburg;[49] it was another, migrating from England to the Virginia frontier, who founded a town and dosed those who came to dwell therein with Bateman's Drops, Turlington's Balsam, and other patent medicines.[50] [49] Wyndham B. Blanton, _Medicine in Virginia in the eighteenth century_, Richmond, Virginia, 1931, pp. 33-34. [50] Maurice Bear Gordon, _Aesculapius comes to the colonies_, Ventnor, New Jersey, 1949, p. 39. Complex Formulas and Distinctive Packages Indeed, the status of medical knowledge, medical need, and medical ethics in the 18th century permitted patent medicines to fit quite comfortably into the environment. As to what actually caused diseases, man knew little more than had the ancient Greeks. There were many theories, however, and the speculations of the learned often sound as quaint in retrospect as do the cocky assertions of the quack bills. Pamphlet warfare among physicians about their conflicting theories achieved an acrimony not surpassed by the competing advertisers of Stoughton's Elixir. The aristocratic practitioners of England, the London College of Physicians, refused to expand their ranks even at a time when there were in the city more than 1,300 serious cases of illness a day to every member of the College. The masses had to look elsewhere, and turned to apothecaries, surgeons, quacks, and self-treatment.[51] The lines were drawn even less sharply in colonial America, and there was no group to resemble the London College in prestige and authority. Medical laissez-faire prevailed. "Practitioners are laureated gratis with a title feather of Doctor," wrote a New Englander in 1690. "Potecaries, surgeons & midwifes are dignified acc[ording] to successe."[52] Such an atmosphere gave free rein to self-dosage, either with an herbal mixture found in the pages of a home-remedy book or with Daffy's Elixir. [51] Fielding H. Garrison, _An introduction to the history of medicine_, Philadelphia, 1924, pp. 405-408; and Richard H. Shryock. _The development of modern medicine_, New York, 1947, pp. 51-54. [52] Kittredge, _op. cit._ (footnote 25). In the 18th century, drugs were still prescribed that dated back to the dawn of medicine. There were Theriac or Mithridatum, Hiera Picra (or Holy Bitters), and Terra Sigillata. Newer botanicals from the Orient and the New World, as well as the "chymicals" reputedly introduced by Paracelsus, found their way into these ancient formulas. Since the precise action of individual drugs in relation to given ailments was but hazily known, there was a tendency to blanket assorted possibilities by mixing numerous ingredients into the same formula. The formularies of the Middle Ages encouraged this so-called "polypharmacy." For example the _Antidotarium Nicolai_, written about A.D. 1100 at Salerno, described 38 ingredients in Confectio Adrianum, 35 ingredients in Confectio Atanasia, and 48 ingredients in Confectio Esdra. Theriac or Mithridatum grew in complexity until by the 16th century it had some 60 different ingredients. It was in this tradition of complex mixtures that most of the patent medicines may be placed. Richard Stoughton claimed 22 ingredients for his Elixir, and Robert Turlington, in his patent specification, named 27. Although other proprietors had shorter lists or were silent on the number of ingredients, a major part of their secrecy really lay in having complicated formulas. Even though rivals might detect the major active ingredients, the original proprietor could claim that only he knew all the elements in their proper proportions and the secret of their blending. Not only in complexity did the patent medicines resemble regular pharmaceutical compounds of the 18th century. In the nature of their composition they were blood brothers of preparations in the various pharmacopoeias and formularies. Indeed, there was much borrowing in both directions. An official formula of one year might blossom out the next in a fancy bottle bearing a proprietor's name. At the same time, the essential recipe of a patent medicine, deprived of its original cognomen and given a Latin name indicative of its composition or therapeutic nature, might suddenly appear in one of the official volumes. For example, the formula for Daffy's Elixir was adopted by the _Pharmacopoeia Londinensis_ in 1721 under the title of "Elixir Salutis" and later by the _Pharmacopoeia Edinburghensis_ as "Tinctura sennae composita" (Compound Senna Tincture). Similarly the essential formula for Stoughton's Elixir was adopted by the _Pharmacopoeia Edinburghensis_ as early as 1762 under the name of "Elixir Stomachium," and later as "Compound Tincture of Gentian" (as in the _Pharmacopoeia of the Massachusetts Medical Society_ of 1808). Only two years after Turlington obtained his "Balsam of Life" patent, the _Pharmacopoeia Londinensis_ introduced a recipe under the title of "Balsamum Traumaticum" which eventually became Compound Tincture of Benzoin, with the synonym Turlington's Balsam. On the other hand, none of these early English patent medicines, including Stoughton's Elixir and Turlington's Balsam, offered anything new, except possibly new combinations or new proportions of ingredients already widely employed in medicine. Formulas similar in composition to those patented or marketed as "new inventions" can in every case be found in such 17th-century pharmacopoeias as William Salmon's _Pharmacopoeia Londinensis_. [Illustration: Figure 6.--BOTTLES OF BATEMAN'S PECTORAL DROPS, 19th century (left) and early 20th century (right), from the Samuel Aker, David and George Kass collection, Albany, New York. (_Smithsonian photo 44287-A._)] Whatever similarities existed between the canons of regular pharmacy and the composition of patent medicines, there was a decided difference in the methods of marketing. Although patent medicines were often prescription items, they did not have to be. The way they looked on a shelf made them so easily recognizable that even the most loutish illiterate could tell one from another. As the nostrum proprietor did so much to pioneer in advertising psychology, so he also blazed a trail with respect to distinctive packaging. The popularity of the old English remedies, year in and year out, owed much to the fact that though the ingredients inside might vary (unbeknownst to the customer), the shape of the bottle did not. This was the reason proprietors raised such a hue and cry about counterfeiters. The secret of a formula might, if only to a degree, be retained, but simulation of bottle design and printed wrapper was easily accomplished, and to the average customer these externals were the medicine. This fundamental fact was to be recognized by the committee of Philadelphia pharmacists in 1824. "We are aware" the committeemen reported, "that long custom has so strongly associated the idea of the genuineness of the Patent medicines, with particular shapes of the vials that contain them, and with certain printed labels, as to render an alteration in them an affair of difficulty. Many who use these preparations would not purchase British Oil that was put up in a conical vial, nor Turlington's Balsam in a cylindrical one. The stamp of the excise, the king's royal patent, the seal and coat of arms which are to prevent counterfeits, the solemn caution against quacks and imposters, and the certified lists of incredible cures, [all these were printed on the bottle wrappers] have not even now lost their influence." Nor were they for years to come. Thus after 1754 the Turlington Balsam bottle was pear-shaped, with sloping shoulders, and molded into the glass in crude raised capitals were the proprietor's name and his claim of THE KINGS ROYAL PATENT.[53] Turlington during his life had made one modification. He explained it in a broadside, saying that "to prevent the Villainy of some Persons who buying up my empty Bottles, have basely and wickedly put therein a vile spurious Counterfeit-Sort," he had changed the bottle shape. The date molded into the glass on his supply of new genuine bottles was January 26, 1754.[54] This was, perhaps, a very fine point of difference from the perspective of the average customer, and in any case the bottle was hidden under its paper wrapper. [53] "From past times an original bottle of Turlington's Balsam," _Chemist and Druggist_, September 23, 1905, vol. 67, p. 525; Stewart Schackne, "Bottles," _American Druggist_, October 1933, vol. 88, pp. 78-81, 186-188, 190, 194; Frederick Fairchild Sherman, "Some early bottles," _Antiques_, vol. 3, pp. 122-123; and Stephen Van Rensselaer, _Early American bottles and flasks_, Peterborough, New Hampshire, 1926. [54] Waldo R. Wedel and George B. Griffenhagen, "An English balsam among the Dakota aborigines," _American Journal of Pharmacy_, December 1954, vol. 126, pp. 409-415. The British Oil bottle was tall and slender and it rested on a square base. Godfrey's Cordial came in a conical vial with steep-pitched sides, the cone's point replaced by a narrow mouth.[55] Bateman's Pectoral Drops were packaged in a more common "phial"--a tall and slender cylindrical bottle.[56] Dalby's Carminative came in a bottle not unlike the Godfrey's Cordial bottle, except that Dalby's was impressed with the inscription DALBY'S CARMINATIV.[57] Steer's Opodeldoc bottles were cylindrical in shape, with a wide mouth; some apparently were inscribed OPODELDOC while others carried no such inscription. At least one brand of Daffy's Elixir was packaged in a globular bottle, according to a picture in a 1743 advertisement.[58] Speculation regarding the size and shape of the Stoughton bottle varies.[59] At least one Stoughton bottle was described as "Round amber. Tapered from domed shoulder to base. Long 5 in. bulged neck. Square flanged mouth. Flat base."[60] [55] Sherman, _op. cit._ (footnote 53). [56] Schackne, _op. cit._ (footnote 53). [57] George S. and Helen McKearin, _American glass_, New York, 1941. [58] _Daily Advertiser_, London, October 29, 1743. [59] George Griffenhagen, "Stodgy as a Stoughton bottle," _Journal of the American Pharmaceutical Association, Practical Pharmacy Edition_, January 1956, vol. 17, p. 20; Mitford B. Mathews, ed., _A dictionary of Americanisms on historical principles_, Chicago, 1951, 2 vols.; Bertha Kitchell Whyte, _Wisconsin heritage_, Boston, 1954; Charles Earle Funk, _Heavens to Betsy! and other curious sayings_, New York, 1955. [60] James H. Thompson, _Bitters bottles_, Watkins Glen, New York, 1947, p. 60. Hooper's and Anderson's Scots Pills were, of course, not packaged in bottles (at least not the earliest), but were instead sold in the typical oval chip-wood pill boxes. On the lid of the box containing Hooper's Pills was stamped this inscription: DR. JOHN HOOPER'S FEMALE PILLS: BY THE KING'S PATENT 21 JULY 1743 NO. 592. So far no example or illustration of Anderson's Scots Pills has been found. At least one producer, it will be remembered (page 157), sealed the box in black wax bearing a lion rampant, three mallets argent, and the bust of Dr. Anderson. Source of Supply Severed On September 29, 1774, John Boyd's "medicinal store" in Baltimore followed the time-honored custom of advertising in the _Maryland Gazette_ a fresh supply of medicines newly at hand from England. To this intelligence was added a warning. Since nonimportation agreements by colonial merchants were imminent, which bade fair to make goods hard to get, customers would be wise to make their purchases before the supply became exhausted. Boyd's prediction was sound. The Boston Tea Party of the previous December had evoked from Parliament a handful of repressive measures, the Intolerable Acts, and at the time of Boyd's advertisement, the first Continental Congress in session was soon to declare that all imports from Great Britain should be halted. [Illustration: Figure 7.--BOTTLES OF BRITISH OIL, 19th and early 20th century, from the Samuel Aker, David and George Kass collection, Albany, New York. (_Smithsonian photo 44201-B._)] This Baltimore scare advertising may well have been heeded by Boyd's customers, for trade with the mother country had been interrupted before; in the wake of the Townshend Acts in 1767, when Parliament had placed import duties on various products, including tea, American merchants in various cities had entered into nonimportation agreements. Certainly, there was a decided decrease in the Boston advertising of patent medicines received from London. With respect to imports of any kind, it became necessary to explain, and one merchant noted that his goods were "the Remains of a Consignment receiv'd before the Non-Importation Agreement took place."[61] When Parliament yielded to the financial pressure and abolished all the taxes but the one on tea, nonimportation collapsed. This fact is reflected in an advertisement listing nearly a score of patent medicines, including the remedies of Turlington, Bateman, the Bettons, Anderson, Hooper, Godfrey, Daffy, and Stoughton, as "Just come to Hand and Warranted Genuine" on Captain Dane's ship, "directly from the Original Warehouse kept by DICEY and OKELL in Bow Street, London."[62] [61] _Massachusetts Gazette_, Boston, December 21, 1769. [62] _Ibid._, April 25, 1771. The days of such ample importations, however, were doomed, as commerce fell prey to the growing revolutionary agitation. The last medical advertisement in the _Massachusetts Gazette and Boston Weekly News-Letter_, before its demise the following February, appeared five months after the Battles of Lexington and Concord.[63] The apothecary at the Sign of the Unicorn was frank about the situation. He had imported fresh drugs and medicines every fall and spring up to the preceding June. He still had some on hand. Doctors and others should be advised. [63] _Ibid._, September 7, 1775. Implicit in the advertisement is the suggestion that the securing of new supplies under the circumstances would be highly uncertain. That pre-war stocks did hold out, sometimes well into the war years may be deduced from a Williamsburg apothecary's advertisement.[64] W. Carter took the occasion of the ending of a partnership with his brother to publish a sort of inventory. Along with the "syrup and ointment pots, all neatly painted and lettered," the crabs eyes and claws, the Spanish flies, he listed a dozen patent medicines, including the remedies of Anderson, Bateman, and Daffy. [64] _Virginia Gazette_ (edited by Dixon and Nicholson), Williamsburg, June 12, 1779. Even the British blockade failed to prevent patent medicines from being shipped from wholesaler to retailer. In the account book of a Salem, Massachusetts, apothecary,[65] the following entry appears: 4 cases Containing 1 Dozn Bottles Godfreys Cordial 4/ 5 Dozn Do Smaller Turling Bals 18/ 8 Dozn Bettons British Oil 8/ 6-1/2 Dozn Hoopers Female Pills 10/ 4 Dozn nd 8 Boxs And. Pills 10/ SALEM APRIL 8th 1777 The above 13 packages and 4 cases of medicines are ship'd on Board the Sloop Called the Two Brothers Saml West Master. On Account and [illegible word] of Mr. Oliver Smith of Boston Apothecary and to him consigned. The cases are unmarked being ship'd at Night. Error Excepted Jon. Waldo. [65] Jonathon Waldo, Apothecary account book, Salem, Massachusetts [1770-1790]. Manuscript original preserved in the Library of the Essex Institute, Salem, Mass. [Illustration: Figure 8.--DALBY'S CARMINATIVE, two sides of a bottle from the McKearin collection, Hoosick Falls, New York. (_Smithsonian photo 44287-C._)] The sloop was undoubtedly one of the small coastal type ships employed by the colonists, and the British blockade required such ominous precautions as "unmarked cases" and "ship'd by Night." Such random assortments of prewar importations could hardly have met the American demand for the old English patent medicines created by a half century of use. Doubtless many embattled farmers had to confront their ailments without the accustomed English-made remedies. However, as early as the 1750's, at least two of the English patent medicines, Daffy's and Stoughton's Elixirs, were being compounded in the colonies and packaged in empty bottles shipped from England. Apothecary Carter of Williamsburg ordered sizable quantities of empty "Stoughton Vials" from 1752 through 1770, and occasionally ordered empty Daffy's bottles.[66] In 1774 apothecary Waldo of Salem noted the receipt from England of "1 Groce Stoughton Phials" and "1 Groce Daffy's Do."[67] Joseph Stansbury, who sold china and glass in Philadelphia, advertised "Daffy's Elixir Bottles" a week after the Declaration of Independence.[68] Stoughton's and Daffy's Elixirs, therefore, were being compounded by the American apothecaries during the Revolutionary War. Formulas for both preparations were official in the London and Edinburgh pharmacopoeias, as well as in unofficial formularies like Quincy's _Pharmacopoeias officinalis extemporanea_ of 1765. All these publications were used widely by American physicians and apothecaries. [66] Carter, _op. cit._ (footnote 46). [67] Waldo, _op. cit._ (footnote 65). [68] _Pennsylvania Gazette_, Philadelphia, July 11, 1776. It is not known how extensively, during the struggle for independence, this custom was adopted for English patent medicines other than Daffy's and Stoughton's. However, imitation of English patent medicines in America was to increase, and it contributed to the chaos that beset the nostrum field when the war was over and the original articles from England were once more available. And they were bought. An advertisement at a time when the fighting was over and peace negotiations were still under way indicated that the Baltimore post office had half a dozen of the familiar English remedies for sale.[69] Two years later a New York store turned to tortured rhyme to convey the same message:[70] Medicines approv'd by royal charter, James, Godfry, Anderson, Court-plaster, With Keyser's, Hooper's Lockyer's Pills, And Honey Balsam Doctor Hill's; Bateman and Daffy, Jesuits drops, And all the Tinctures of the shops, As Stoughton, Turlington and Grenough, Pure British Oil and Haerlem Ditto.... [69] _Maryland Journal and Baltimore Gazette_, Baltimore, October 29, 1782. [70] _New York Packet and the American Advertiser_, New York, October 11, 1784. Later in the decade, the Salem apothecary, Jonathon Waldo, made a list of "An assortment [of patent medicines] Usually Called For." The imported brand of Turlington's Balsam, Waldo stated, was "very dear" at 36 shillings a dozen, adding that his "own" was worth but 15 shillings for the same quantity. The English original of another nostrum, Essence of Peppermint, he listed at 18 shillings a dozen, his own at a mere 10/6.[71] Despite the price differential, importations continued. A Beverly, Massachusetts, druggist, Robert Rantoul, in 1799 ordered from London filled boxes and bottles of Anderson's Pills, Bateman's Drops, Steer's Opodeldoc, and Turlington's Balsam, along with the empty vials in which to put British Oil and Essence of Peppermint.[72] For decades thereafter the catalogs of wholesale drug firms continued to specify two grades of various patent medicines for sale, termed "English" and "American," "true" and "common," or "genuine" and "imitation."[73] This had not been the case in patent medicine listings of 18th-century catalogs.[74] [71] Waldo, _op. cit._ (footnote 65). [72] Robert Rantoul, Apothecary daybooks, 3 vols., Beverly, Massachusetts [1796-1812]. Manuscript originals preserved in the Beverly Historical Society. Also see Robert W. Lovett, "Squire Rantoul and his drug store," _Bulletin of the Business Historical Society_, June 1951, vol. 25, pp. 99-114. [73] Joel and Jotham Post, _A catalogue of drugs, medicines & chemicals, sold wholesale & retail, by Joel and Jotham Post, druggists, corner of Wall and William-Streets_, New York, 1804; Massachusetts College of Pharmacy, _Catalogue of the materia medica and of the pharmaceutical preparations, with the uniform prices of the Massachusetts College of Pharmacy_, Boston, 1828; George W. Carpenter, _Essays on some of the most important articles of the materia medica ... to which is added a catalogue of medicines, surgical instruments, etc._, Philadelphia, 1834. [74] John Dunlap, _Catalogus medicinarum et pharmacorum_, Philadelphia, 1771; John Day, _Catalogue of drugs, chymical and galenical preparations, shop furniture, patent medicines, and surgical instruments sold by John Day and Company, druggists and chymists in second-street_, Philadelphia, 1771; George Griffenhagen, "The Day-Dunlap 1771 pharmaceutical catalog," _American Journal of Pharmacy_, September 1955, vol. 127, pp. 296-302; also _The New York Physician and American Medicine_, May 1956, vol. 46, pp. 42-44; Smith and Bartlett, _Catalogue of drugs and medicines, instruments and utensils, dyestuffs, groceries, and painters' colours, imported, prepared, and sold, by Smith and Bartlett, at their druggists store and apothecaries shop_, Boston, 1795. [Illustration: Figure 9.--GODFREY'S CORDIAL, 19th-century bottles from the Samuel Aker, David and George Kass collection, Albany, New York. (_Smithsonian photo 44201-C._)] In buying Anderson's and Bateman's remedies from London in 1799, Robert Rantoul of Massachusetts specified that they be secured from Dicey. It will be remembered that 60 years earlier William Dicey, John Cluer, and Robert Raikes were the group of entrepreneurs who had aided Benjamin Okell in patenting the pectoral drops bearing Bateman's name. Then and throughout the century, this concern continued to operate a warehouse in the Bow Churchyard, Cheapside, London. In 1721, it was known as the "Printing-house and Picture Warehouse" of John Cluer, printer,[75] but by 1790, it was simply the "Medicinal Warehouse" of Bow Churchyard, Cheapside. This address lay in the center of the London area whence came nearly all of the British goods exported to America.[76] It had been the location of many merchants who had migrated to New England in the 17th century, and these newcomers had done business with their erstwhile associates who did not leave home. Thus were started trade channels which continued to run. The Bow Churchyard Warehouse may have been the major exporter of English patent medicines to colonial America, although others of importance were located in the same London region, in particular Robert Turlington of Lombard Street and Francis Newbery of St. Paul's Churchyard. The significance of the fact that there were key suppliers of patent medicines for the American market lies in the selection process which resulted. Out of the several hundred patent medicines which 18th-century Britain had available, Americans dosed themselves with that score or more which the major exporters shipped to colonial ports. [75] _London Mercury_, London, August 19-26, 1721. [76] Bernard Bailyn, _The New England merchants in the seventeenth century_, Cambridge, Massachusetts, 1955, pp. 35-36. Not only did the Bow Churchyard Warehouse firm have Bateman's Drops. It will be remembered that in 1721 they advertised that they were preparing Daffy's Elixir. In 1743, they and Newbery were made exclusive vendors of Hooper's Pills.[77] By 1750, the firm was also marketing British Oil, Anderson's Pills, and Stoughton's Elixir.[78] Turlington in 1755 was selling not only his Balsam of Life, but was also vending Daffy's Elixir, Godfrey's Cordial, and Stoughton's Elixir.[79] After the tension of the Townshend Acts, it was the Bow Churchyard Warehouse which supplied a Boston apothecary with a large supply of nostrums, including all the eight patent medicines then in existence of the ten with which this discussion is primarily concerned.[80] On November 29, 1770, the _Virginia Gazette_ (edited by Purdie and Dixon) reported a shipment, including Bateman's, Hooper's, Betton's, Anderson's, and Godfrey's remedies, just received "from Dr. Bateman's original wholesale warehouse in London" (the Bow Churchyard Warehouse). When Dalby's Carminative and Steer's Opodeldoc came on the market in the 1780's, it was Francis Newbery who had them for sale. Both the Newbery and Dicey (Bow Churchyard Warehouse) firms continued to operate in the post-Revolutionary years. Thus, it was no accident but rather vigorous commercial promotion over the decades, that resulted in the most popular items on the Dicey and Newbery lists appearing in the Philadelphia College of Pharmacy pamphlet published in 1824. And although the same old firms continued to export the same old medicines to the new United States, the back of the business was broken. The imitation spurred by wartime necessity became the post-war pattern. [77] _Daily Advertiser_, London, September 23, 1743. [78] "Dr. Bateman's Drops" (see footnote 7). [79] Turlington, _op. cit._ (footnote 15). [80] _Massachusetts Gazette_, Boston, December 21, 1769. The key recipes were to be found in formula books. Beginning in the 1790's, even American editions of John Wesley's _Primitive physic_ included formulas for Daffy's, Turlington's, and Stoughton's remedies which the founder of Methodism had introduced into English editions of this guidebook to health shortly before his death.[81] [81] John Wesley, _Primitive physic_, 21st ed., London, 1785; _ibid._, 22nd ed., London, 1788; _ibid._, 16th Amer. ed., Trenton, 1788; _ibid._, 22nd Amer. ed., Philadelphia, 1791; George Dock, "The 'primitive physic' of Rev. John Wesley," _Journal of the American Medical Association_, February 20, 1915, vol. 64, pp. 629-638. The homemade versions, as Jonathon Waldo had recorded (see p. 171), were about half as costly. The state of affairs at the turn of the new century is illustrated in the surviving business papers of the Beverly druggist, Robert Rantoul. In 1799 he had imported the British Oil and Essence of Peppermint bottles. In 1802 he reordered the latter, specifying that they should not have molded in the glass the words "by the Kings Patent." Rantoul wrote a formula for this nostrum in his formula book, and from it he filled 66 bottles in December 1801 and 202 bottles in June 1803. About the same time he began making and bottling Turlington's Balsam, ordering bottles of two sizes from London. His formula book contains these entries: "Jany 4th, 1804 filled 54 small turlingtons with 37 oz. Balsam," and "Jany 20th, 1804 filled 144 small turlingtons with 90-1/4 oz. Balsam and 9 Large Bottles with 8-1/4 oz."[82] [82] Rantoul, _op. cit._ (footnote 72). Two decades later the imitation of the English proprietaries was even bigger business. In 1821 William A. Brewer became apprenticed to a druggist in Boston. A number of the old English brands, he recalled, were still imported and sold at the time. But his apprenticeship years were heavily encumbered with duties involving the American versions. "Many, very many, days were spent," Brewer remembered, "in compounding these imitations, cleaning the vials, fitting, corking, labelling, stamping with fac-similes of the English Government stamp, and in wrapping them, with ... little regard to the originator's rights, or that of their heirs...." The British nostrums chiefly imitated in this Boston shop were Steer's, Bateman's, Godfrey's, Dalby's, Betton's, and Stoughton's. The last was a major seller. The store loft was mostly filled with orange peel and gentian, and the laboratory had "a heavy oaken press, fastened to the wall with iron clamps and bolts, which was used in pressing out 'Stoughton's Bitters,' of which we usually prepared a hogshead full at one time." A large quantity was needed. In those days, Brewer asserted, "almost everybody indulged in Stoughton's elixir as morning bitters." [83] [83] William A. Brewer, "Reminiscences of an old pharmacist." _Pharmaceutical Record_, August 1, 1884, vol. 4, p. 326. [Illustration: Figure 10.--GODFREY'S CORDIAL, early 20th century bottles manufactured in the U.S.A. (_U.S. National Museum cat. Nos. M-6989, and M-6990; Smithsonian photo 44287 B._)] Other drugstores certainly followed the practice of Brewer's employer, in cleaning up and refilling bottles that had previously been drained of their old English medicines. The chief source of bottles to hold the American imitations, however, was the same as that to which Waldo and Rantoul had turned, English glass factories. It was not so easy for Americans to fabricate the vials as it was for them to compound the mixtures to fill them. In the years before the War of 1812, the British glass industry maintained a virtual monopoly of the specially-shaped bottles for Bateman's, Turlington's, and the other British remedies. When in the 1820's the first titan of made-in-America nostrums, Thomas W. Dyott of Philadelphia, appeared upon the scene, this venturesome entrepreneur decided to make bottles not only for his own assorted remedies but also for the popular English brands. In time he succeeded in improving the quality of American bottle glass and in drastically reducing prices. The standard cost for most of the old English vials under the British monopoly had been $5.50 a gross. By the early 1830's Dyott had cut the price to under two dollars.[84] [84] _Democratic Press_, Philadelphia, July 1 and October 28, 1824; Thomas W. Dyott, _An exposition of the system of moral and mental abor, established at the glass factory of Dyottsville_, Philadelphia, 1833; and Joseph D. Weeks, "Reports on the manufacture of glass," _Report of the manufactures of the United States at the tenth census_, Washington, D. C, 1883. [Illustration: Figure 11.--AN ORIGINAL PACKAGE OF HOOPER'S PILLS, from the Samuel Aker, David and George Kass collection, Albany, New York. (_Smithsonian photo_ 44201.)] Other American glass manufactories followed suit. For example, in 1835 the Free Will Glass Manufactory was making "Godfrey's Cordial," "Turlington's Balsam," and "Opodeldoc Bitters bottles."[85] An 1848 broadside entitled "The Glassblowers' List of Prices of Druggist's Ware," a broadside preserved at the Smithsonian Institution, includes listings for Turlington's Balsam, Godfrey's Cordial, Dalby's and Small and Large Opodeldoc bottles, among many other American patent medicine bottles. [85] Van Rensscalar, _op. cit._, (footnote 53), p. 151. In the daybook of the Beverly, Massachusetts, apothecary,[86] were inscribed for Turlington's Balsam, three separate formulas, each markedly different from the others. A Philadelphia medical journal in 1811 contained a complaint that Americans were using calomel in the preparation of Anderson's Scots Pills, and that this practice was a deviation both from the original formula and from the different but still all-vegetable formula by which the pills were being made in England.[87] Various books were published revealing the "true" formulas, in conflicting versions.[88] [86] Rantoul, _op. cit._ (footnote 72). [87] _Philadelphia Medical Museum_, new ser., vol. 1, p. 130, 1811. [88] _Formulae selectae; or a collection of prescriptions of eminent physicians, and the most celebrated patent medicines_, New York, 1818; John Ayrton Paris, _Pharmacologia; or the history of medicinal substances, with a view to establish the art of prescribing and of composing extemporaneous formulae upon fixed and scientific principles_, New York, 1822. Philadelphia College of Pharmacy Formulary As the years went by and therapeutic laissez-faire continued to operate, conditions worsened. By the early 1820's, the old English patent medicines, whether of dwindling British vintage or of burgeoning American manufacture, were as familiar as laudanum or castor oil. With the demand so extensive and the state of production so chaotic, the officials of the new Philadelphia College of Pharmacy were persuaded that remedial action was mandatory. In May 1822, the Board of Trustees resolved to appoint a 5-man committee "to select from such prescriptions for the preparation of Patent Medicines ..., as may be submitted to them by the members of the College, those which in their opinion, may be deemed most appropriate for the different compositions." The committee chose for study "eight of the Patent Medicines most in use," and sought to ascertain what ingredients these ancient remedies ought by right to contain. Turning to the original formulas, where these were given in English patent specifications, the pharmacists soon became convinced that the information provided by the original proprietors served "only to mislead." If the patent specifications were perhaps intentionally confusing, the committee inquired, how could the original formulas really be known? This quest seemed so fruitless that it was not pursued. Instead the pharmacists turned to American experience in making the English medicines. From many members of the College, and from other pharmacists as well, recipes were secured. The result was shocking. Although almost every one came bolstered with the assertion that it was true and genuine, the formulas differed so markedly one from the other, the committee reported, as to make "the task of reformation a very difficult one." Indeed, in some cases, when two recipes bearing the same old English name were compared, they were found to contain not one ingredient in common. In other cases, the proportions of some basic ingredient would vary widely. All the formulas collected for Bateman's Pectoral Drops, for instance, contained opium, but the amount of opium to liquid ingredients in one formula submitted was 1 to 14, while in another it was 1 to 1,000. Setting forth boldly to strip these English nostrums of "their extravagant pretensions," the committee sought to devise formulas for their composition as simple and inexpensive as possible while yet retaining the "chief compatible virtues" ascribed to them on the traditional wrappers. Hooper's Female Pills had been from the beginning a cathartic and emmenagogue. However, only aloes was common to all the recipes submitted to the committee. This botanical, which still finds a place in laxative products today, was retained by the committee as the cathartic base, and to it were added "the Extract of Hellebore, the Sulphate of Iron and the Myrrh as the best emmenagogues." Anderson's Scots Pills had been a "mild" purgative throughout its long career, varying in composition "according to the judgement or fancy of the preparer." Paris, an English physician, had earlier reported that these pills consisted of aloes and jalap; the committee decided on aloes, with small amounts of colocynth and gamboge, as the purgatives of choice. Of Bateman's Pectoral Drops more divergent versions existed than of any of the others. The committee settled on a formula of opium and camphor, not unlike paragoric in composition, with catachu, anise flavoring, and coloring added. Godfrey's Cordial also featured opium in widely varying amounts. The committee chose a formula which would provide a grain of opium per ounce, to which was added sassafras "as the carminative which has become one of the chief features of the medicine." English apothecary Dalby had introduced his "Carminative" for "all those fatal Disorders in the Bowels of Infants." The committee decided that a grain of opium to the ounce, together with magnesia and three volatile oils, were essential "for this mild carminative and laxative ... for children." Instead of the complex formula described by Robert Turlington for his Balsam of Life, the committee settled on the official formula of Compound Tincture of Benzoin, with balsam of peru, myrrh, and angelica root added, to produce "an elegant and rich balsamic tincture." On the other hand, the committee adopted "with slight variations, the Linimentum Saponis of the old London Dispensatory" to which they, like Steers, added only ammonia. The committee found two distinct types of British Oil on the market. One employed oil of turpentine as its basic ingredient, while the other utilized flaxseed oil. The committee decided that both oils, along with several others in lesser quantities, were necessary to produce a medicine "as exhibited in the directions" sold with British Oil. "Oil of Bricks" which apparently was the essential ingredient of the Betton British Oil, was described by the committee as "a nauseous and unskilful preparation, which has long since been banished from the Pharmacopoeias." Thus the Philadelphia pharmacists devised eight new standardized formulas, aimed at retaining the therapeutic goals of the original patent medicines, while brought abreast of current pharmaceutical knowledge. Recognizing that the labeling had long contained "extravagant pretensions and false assertions," the committee recommended that the wrappers be modified to present only truthful claims. If the College trustees should adopt the changes suggested, the committee concluded optimistically, then "the reputation of the College preparations would soon become widely spread, and we ... should reap the benefit of the examination which has now been made, in an increased public confidence in the Institution and its members; the influence of which would be felt in extending the drug business of our city."[89] [89] Philadelphia College of Pharmacy, _Formulae for the preparation of eight patent medicines, adopted by the Philadelphia College of Pharmacy_, May 4, 1824; Joseph W. England, ed., _The first century of the Philadelphia College of Pharmacy_, 1821-1921, Philadelphia, 1922. The trustees felt this counsel to be wise, and ordered 250 copies of the 12-page pamphlet to be printed. So popular did this first major undertaking of the Philadelphia College prove that in 1833 the formulas were reprinted in the pages of the journal published by the College.[90] Again the demand was high, few numbers of the publication were "more sought after," and in 1839 the formulas were printed once again, this time with slight revisions.[91] [90] "Patent medicines," _Journal of the Philadelphia College of Pharmacy_, April 1833, vol. 5, pp. 20-31. [91] C. Ellis, "Patent medicines," _American Journal of Pharmacy_, April 1839, new ser., vol. 5, pp. 67-74. Thus had the old English patent medicines reached a new point in their American odyssey. They had first crossed the Atlantic to serve the financial interests of the men who promoted them. During the Revolution they had lost their British identity while retaining their British names. The Philadelphia pharmacists, while adopting them and reforming their character, did not seek to monopolize them, as had the original proprietors. They now could work for every man. English Patent Medicines Go West The double reprinting of the formulas was one token of the continuing role in American therapy of the old English patent medicines. There were others. In 1829 with the establishment of a school of pharmacy in New York City, the Philadelphia formulas were accepted as standard. The new labels devised by the Philadelphians with their more modest claims of efficacy had a good sale.[92] It was doubtless the Philadelphia recipes which went into the Bateman and Turlington and Godfrey vials with which a new druggist should be equipped "at the outset of business," according to a book of practical counsel.[93] To local merchants who lacked the knowledge or time to do it themselves, drummers and peddlers vended the medicines already bottled. "Doctor" William Euen of Philadelphia issued a pamphlet in 1840 to introduce his son to "Physicians and Country Merchants." His primary concern was dispensing nostrums bearing his own label, but his son was also prepared to take orders for the old English patent medicines.[94] Manufacturers and wholesalers of much better repute were prepared to sell bottles for the same brands, empty or filled. [92] England, _op. cit._ (footnote 89), pp. 73, 103. [93] Carpenter, _op. cit._ (footnote 73). [94] William Euen, _A short exposé on quackery ... or, introduction of his son to physicians and country merchants_, Philadelphia, 1840. [Illustration: Figure 12.--ENGLISH AND AMERICAN BRANDS OF HOOPER'S FEMALE PILLS, an assortment of packages of from the Samuel Aker, David and George Kass collection, Albany, New York. (_Smithsonian photo 44201-D._)] In the early 1850's a young pharmacist in upstate New York,[95] using "old alcohol barrels for tanks," worked hard at concocting Bateman's and Godfrey's and Steer's remedies. John Uri Lloyd of Cincinnati recalled having compounded Godfrey's Cordial and Bateman's Drops, usually making ten gallons in a single batch.[96] Out in Wisconsin, another druggist was buying Godfrey's Cordial bottles at a dollar for half a gross, sticking printed directions on them that cost twelve cents for the same quantity, and selling the medicine at four ounces for a quarter.[97] He also sold British Oil and Opodeldoc, the same old English names dispensed by a druggist in another Wisconsin town, who in addition kept Bateman's Oil in stock at thirteen cents the bottle.[98] Godfrey's was listed in the 1860 inventory of an Illinois general store at six cents a bottle.[99] [95] James Winchell Forbes, "The memoirs of an American pharmacist," _Midland Druggist and Pharmaceutical Review_, 1911, vol. 45, pp. 388-395. [96] John Uri Lloyd, "Eclectic fads," _Eclectic Medical Journal_, October 1921, vol. 81, p. 2. [97] Cody & Johnson Drug Co., Apothecary daybooks, Watertown, Wisconsin [1851-1872]. Manuscript originals preserved in the State Historical Society of Wisconsin, cataloged under "Cady." [98] Swarthout and Silsbee, Druggists daybook, Columbus, Wisconsin [1852-1853]. Manuscript original preserved in the State Historical Society of Wisconsin. [99] McClaughry and Tyler, Invoice book, Fountain Green, Illinois [1860-1877]. Manuscript original preserved in the Illinois State Historical Society, Springfield. Farther west the same familiar names appeared. Indeed, the old English patent medicines had long since moved westward with fur trader and settler. As early as 1783, a trader in western Canada, shot by a rival, called for Turlington's Balsam to stop the bleeding. Alas, in this case, the remedy failed to work.[100] In 1800 that inveterate Methodist traveler, Bishop Francis Asbury, resorted to Stoughton's Elixir when afflicted with an intestinal complaint.[101] In 1808, some two months after the first newspaper began publishing west of the Mississippi River, a local store advised readers in the vicinity of St. Louis that "a large supply of patent medicines" had just been received, among them Godfrey's Cordial, British Oil, Turlington's Balsam, and Steer's "Ofodeldo [sic]."[102] [100] Harold A. Innis, _Peter Pond, fur trader and adventurer_, Toronto, 1930. [101] Peter Oliver, "Notes on science, medicine and public health in the United States in the year 1800," _Bulletin of the History of Medicine_. 1944, vol. 16, p. 129. [102] Isaac Lionberger, "Advertisements in the Missouri Gazette, 1808-1811," _Missouri Historical Society Collections_, 1928-1931, vol. 6, p. 21. Turlington's product played a particular role in the Indian trade, thus demonstrating that the red man has not been limited in nostrum history to providing medical secrets for the white man to exploit. Proof of this has been demonstrated by archaeologists working under the auspices of the Smithsonian Institution in both North and South Dakota. Two pear-shaped bottles with Turlington's name and patent claims embossed in the glass were excavated by a Smithsonian Institution River Basin Surveys expedition in 1952, on the site of an old trading post known as Fort Atkinson or Fort Bethold II, situated some 16 miles southeast of the present Elbowoods, North Dakota. In 1954 the North Dakota Historical Society found a third bottle nearby. These posts, operated from the mid-1850's to the mid-1880's, served the Hidatsa and Mandan Indians who dwelt in a town named Like-a-Fishhook Village. The medicine bottles were made of cast glass, light green in color, probably of American manufacture. More interesting is the bottle from South Dakota. It was excavated in 1923 near Mobridge at a site which was the principal village of the Arikara Indians from about 1800 to 1833, a town visited by Lewis and Clark as they ascended the Missouri River in 1804. This bottle, made of English lead glass and therefore an imported article, was unearthed from a grave in the Indian burying ground. Throughout history the claims made in behalf of patent medicines have been extreme. This Turlington bottle, however, affords one of the few cases on record wherein such a medicine has been felt to possess a postmortem utility.[103] [103] Wedel and Griffenhagen, _op. cit._ (footnote 54). Fur traders were still using old English patent medicines at mid-century. Four dozen bottles of Turlington's Balsam were included in an "Inventory of Stock the property of Pierre Chouteau, Jr. and Co. U[pper], M[issouri]. On hand at Fort Benton 4th May 1851...."[104] In the very same year, out in the new State of California, one of the early San Francisco papers listed Stoughton's Bitters as among the merchandise for sale at a general store.[105] [104] A. McDonnell, _Contributions to the Historical Society of Montana_, 1941, vol. 10, pp. 202, 217. [105] _California Daily Courier_, San Francisco, April 25, 1851. Newspaper advertising of the English proprietaries--even the mere listing so common during the late colonial years--became very rare after the Philadelphia College of Pharmacy pamphlet was issued. Apothecary George J. Fischer of Frederick, Maryland, might mention seven of the old familiar names in 1837,[106] and another druggist in the same city might present a shorter list in 1844,[107] but such advertising was largely gratuitous. Since the English patent medicines had become every druggist's property, people who felt the need of such dosage would expect every druggist to have them in stock. There was no more need to advertise them than there was to advertise laudanum or leeches or castor oil. Even the Supreme Court of Massachusetts in 1837 took judicial cognizance of the fact that the old English patent medicine names had acquired a generic meaning descriptive of a general class of medicines, names which everyone was free to use and no one could monopolize.[108] [106] _Political Examiner_, Frederick, Maryland, April 19, 1837. [107] _Frederick Examiner_, Frederick, Maryland, January 31, 1844. [108] _Massachusetts Supreme Court_, Thomson vs. Winchester, 19 Pick (Mass.), p. 214, March 1837. As the years went by, and as advertising did not keep the names of the old English medicines before the eyes of customers, it is a safe assumption that their use declined. Losing their original proprietary status, they were playing a different role. New American proprietaries had stolen the appeal and usurped the function which Bateman's Drops and Turlington's Balsam had possessed in 18th-century London and Boston and Williamsburg. As part of the cultural nationalism that had accompanied the Revolution, American brands of nostrums had come upon the scene, promoted with all the vigor and cleverness once bestowed in English but not in colonial American advertising upon Dalby's Carminative and others of its kind. While these English names retreated from American advertising during the 19th century, vast blocks of space in the ever-larger newspapers were devoted to extolling the merits of Dyott's Patent Itch Ointment, Swaim's Panacea, and Brandreth's Pills. More and more Americans were learning how to read, as free public education spread. Persuaded by the frightening symptoms and the glorious promises, citizens with a bent toward self-dosage flocked to buy the American brands. Druggists and general stores stocked them and made fine profits.[109] While bottles of British Oil sold two for a quarter in 1885 Wisconsin, one bottle of Jayne's Expectorant retailed for a dollar.[110] It is no wonder that, although the old English names continue to appear in the mid-19th-century and later druggists' catalogs and price currents,[111] they are muscled aside by the multitude of brash American nostrums. Many of the late 19th century listings continued to follow the procedure set early in the century of specifying two grades of the various patent medicines, _i.e._, "English" and "American," "genuine" and "imitation," "U.S." and "stamped." American manufactories specializing in pharmaceutical glassware continued to offer the various English patent medicine bottles until the close of the century.[112] [109] James Harvey Young, "Patent medicines: the early post-frontier phase," _Journal of the Illinois State Historical Society_, Autumn 1953, vol. 46, pp. 254-264. [110] Cody and Johnson Drug Co., _op. cit._ (footnote 97). [111] Van Schaack, Stevenson & Reid, _Annual prices current_, Chicago, 1875; Morrison, Plummer & Co., _Price current of drugs, chemicals, oils, glassware, patent medicines, druggists sundries ..._, Chicago, 1880. [112] Hagerty Bros. & Co., _Catalogue of Druggists' glassware, sundries, fancy goods, etc._, New York, 1879; Whitall, Tatum & Co., _Annual price list_, Millville, New Jersey, 1898. [Illustration: Figure 13.--OPODELDOC BOTTLE from the collection of Mrs. Leo F. Redden, Kenmore, New York. (_Smithsonian photo 44201-E._)] In a thesaurus published in 1899, Godfrey's, Bateman's, Turlington's, and other of the old English patent remedies were termed "extinct patents."[113] The adjective referred to the status of the patent, not the condition of the medicines. If less prominent than in the olden days, the medicines were still alive. The first edition of the _National Formulary_, published in 1888, had cited the old English names as synonyms for official preparations in four cases, Dalby's, Bateman's, Godfrey's and Turlington's. [113] Emil Hiss, _Thesaurus of proprietary preparations and pharmaceutical specialties_, Chicago, 1899, p. 12. [Illustration: Figure 14.--OPODELDOC BOTTLE as illustrated in the 1879 Catalog of Hagerty Bros., New York City, New York.] Thus as the present century opened, the old English patent medicines were still being sold. City druggists were dispensing them over their counters, and the peddler's wagon carried them to remote rural regions.[114] But the medical scene was changing rapidly. Improvements in medical science, stemming in part from the establishment of the germ theory of disease, were providing a better yardstick against which to measure the therapeutic efficiency of proprietary remedies. Medical ethics were likewise advancing, and the occasional critic among the ranks of physicians was being joined by scores of his fellow practitioners in lambasting the brazen effrontery of the hundreds of American cure-alls which advertised from newspaper and roadside sign. Journalists joined doctors in condemning nostrums. Samuel Hopkins Adams in particular, writing "The Great American Fraud" series for _Collier's Weekly_, frightened and aroused the American public with his exposure of cheap whiskey posing as consumption cures and soothing syrups filled with opium. Then came a revolution in public policy. After a long and frustrating legislative prelude, Congress in June of 1906 passed, and President Theodore Roosevelt signed, the first Pure Food and Drugs Act. The law contained clauses aimed at curtailing the worst features of the patent medicine evil. [114] Robert B. Nixon, Jr., _Corner druggist_, New York, 1941, p. 68. The Patent Medicines In The 20th Century Although the old English patent medicines had not been the target at which disturbed physicians and "muck-raking" journalists had taken aim, these ancient remedies were governed by provisions of the new law. In November 1906 the Bureau of Chemistry of the Department of Agriculture, in charge of administering the new federal statute, received a letter from a wholesale druggist in Evansville, Indiana. One of his stocks in trade, the druggist wrote, was a remedy called Godfrey's Cordial. He realized that the Pure Food and Drugs Act had something to do with the labeling of medicines containing opium, as Godfrey's did, and he wanted to know from the Bureau just what was required of him.[115] Many manufacturing druggists and producers of medicine were equally anxious to learn how the law would affect them. The editors of a trade paper, the _American Druggist and Pharmaceutical Record_, issued warnings and gave advice. It was still the custom, they noted, to wrap bottles of ancient patent medicines, like Godfrey's Cordial and Turlington's Balsam, in facsimiles of the original circulars, on which were printed extravagant claims and fabulous certificates of cures that dated back some two hundred years. The new law was not going to permit the continuation of such 18th-century practices. Statements on the label "false or misleading in any particular" were banned.[116] [115] Letter from Charles Leich & Co. to Harvey Washington Wiley, Bureau of Chemistry, Department of Agriculture, November 2, 1906. Manuscript original in Record Group 97, National Archives, Washington, D.C. [116] _American Druggist and Pharmaceutical Record_, 1906, vol. 49, pp. 343-344. A few manufacturers, as the years went by, fell afoul of this and other provisions of the law. In 1918 a Reading, Pennsylvania, firm entered a plea of guilty and received a fifty dollar fine for putting on the market an adulterated and misbranded version of Dr. Bateman's Pectoral Drops.[117] The law required that all medicines sold under a name recognized in the _United States pharmacopoeia_ or the _National formulary_, and Bateman's was included in the latter, must not differ from the standard of strength, quality, or purity as established by these volumes. Yet the Bateman Drops produced in Reading, the government charged, fell short. They contained only 27.8 percent of the alcohol and less than a tenth of the morphine that they should have had. While short on active ingredients, the Drops were long on claims. The wrapper boasted that the medicine was "effective as a remedy for all fluxes, spitting of blood, agues, measles, colds, coughs, and to put off the most violent fever; as a treatment, remedy, and cure for stone and gravel in the kidneys, bladder, and urethra, shortness of breath, straightness of the breast; and to rekindle the most natural heat in the bodies by which they restore the languishing to perfect health." Okell and Dicey had scarcely promised more. By 20th-century standards, the government asserted, these claims were false and fraudulent. [117] Department of Agriculture, Bureau of Chemistry, Notices of Judgment under the Food and Drugs Act, Notice of Judgment 6222, United States vs. Pabst Pure Extract Co., 1919. Other manufacturers sold Bateman's Drops without running afoul of the law. In 1925, ninety-nine years after the Philadelphia College of Pharmacy pamphlet was printed, one North Carolina firm was persuaded that it still was relevant to tell potential customers, in a handbill, that its Drops were being made in strict conformity with the College formula.[118] For Compound Tincture of Opium and Gambir Compound, however, most manufacturers chose to follow the _National formulary_ specifications, which remained official until 1936. [118] Original handbill, distributed by Standard Drug Co., Elizabeth City, North Carolina, 1925, preserved in the files of the Bureau of Investigation, American Medical Association, Chicago, Ill. Another old English patent medicine against which the Department of Agriculture was forced to take action was Hooper's Female Pills. Between 1919 and 1923, government agents seized a great many shipments of this ancient remedy in versions put out by three Philadelphia concerns.[119] Some of the packages bore red seals, others green seals, and still others black, but the labeling of all claimed them to be "a safe and sovereign remedy in female complaints." This theme was expanded in considerable detail and there was an 18th-century ring to the promise that the pills would work a sure cure "in all hypochondriac, hysterick or vapourish disorders." No pill made essentially of aloes and ferrous sulphate, said the government experts, could do these things. Nor did the manufacturers, in court, seek to say otherwise. Whether the seals were green or red, whether the packages were seized in Washington or Worcester, the result was the same. No party appeared in court to claim the pills, and they were condemned and destroyed. [119] Multiple seizures were made of products shipped by the Horace B. Taylor Co., Fore & Co., and the American Synthetic Co. The quotations are from Notice of Judgment 8868; see also 8881, 8914, 8936, 8956, 8974, 9134, 9147, 9203, 9510, 9586, 9785, 10203, 10204, 10629, 11519, 11669. In one of the last actions under the 1906 law, a case concluded in 1940, after the first federal statute had been superseded by a more rigorous one enacted in 1938, two of the old English patent medicines encountered trouble.[120] They were British Oil and Dalby's Carminative, as prepared by the South Carolina branch of a large pharmaceutical manufacturing concern. [120] Federal Security Agency, Food and Drug Administration, Notice of Judgment 31134, United States vs. McKesson and Robbins, Inc., Murray Division, 1942. According to the label, the British Oil was made in conformity with the Philadelphia College of Pharmacy formula given in an outdated edition of the _United States dispensatory_. But instead of containing a proper amount of linseed oil, if indeed it contained any, the medicine was made with cottonseed oil, an ingredient not mentioned in the Dispensatory. Therefore, the government charged, the Oil was adulterated, under that provision of the law requiring a medicine to maintain the strength and purity of any standard it professed to follow. More than that, the labeling contravened the law since it represented the remedy as an effective treatment for various swellings, inflammations, fresh wounds, earaches, shortnesses of breath, and ulcers. Dalby's Carminative was merely misbranded, but that was bad enough. Its label suggested that it be used especially "For Infants Afflicted With Wind, Watery Gripes, Fluxes and Other Disorders of the Stomach and Bowels," although it would aid adults as well. The impression that this remedy was capable of curing such afflictions, the government charged, was false and fraudulent. Moreover, since the Carminative contained opium, it was not a safe medicine when given according to the dosage directions in a circular accompanying the bottle. For these and several other violations of the law, the defending company, which did not contest the case, was fined a hundred dollars. Throughout the 19th century, occasional criticism of the old English patent medicines had been made in the lay press. One novel[121] describes a physician who comments on the use of Dalby's Carminative for babies: "Don't, for pity's sake, vitiate and torment your poor little angel's stomach, so new to the atrocities of this world, with drugs. These mixers of baby medicines ought to be fed nothing but their own nostrums. That would put a stop to their inventions of the adversary." [121] John William De Forest, _Miss Ravenel's conversion from secession to loyalty_, New York, 1867. Opium had been lauded in the 17th and 18th centuries, when the old English proprietaries began, as a superior cordial which could moderate most illnesses and even cure some. "Medicine would be a one-armed man if it did not possess this remedy." So had stated the noted English physician, Thomas Sydenham.[122] But the 20th century had grown to fear this powerful narcotic, especially in remedies for children. This point of view, illustrated in the governmental action concerning Dalby's Carminative, was also reflected in medical comment about Godfrey's Cordial. During 1912, a Missouri physician described the death of a baby who had been given this medicine for a week.[123] The symptoms were those of opium poisoning. Deploring the naming of this "dangerous mixture" a "cordial," since the average person thought of a cordial as beneficial, the doctor hoped that the formula might be omitted from the next edition of the _National formulary_. This did not happen, for the recipe hung on until 1926. The Harrison Narcotic Act, enacted in 1914 as a Federal measure to restrict the distribution of narcotics,[124] failed to restrict the sale of many opium-bearing compounds like Godfrey's Cordial. In 1931, a Tennessee resident complained to the medical journal _Hygeia_ that this medication was "sold in general stores and drug stores here without prescription and is given to babies." To this, the journal replied that the situation was "little short of criminal."[125] The charge leveled against his competitors by one of the first producers of Godfrey's Cordial two centuries earlier (see page 158) may well have proved a prophecy broad enough to cover the whole history of this potent nostrum. "... Many Men, Women, and especially Infants," he said, "may fall as Victims, whose Slain may exceed Herod's Cruelty...." [122] Charles H. LaWall, _The curious lore of drugs and medicines (Four thousand years of pharmacy)_, Garden City, New York, 1927, p. 281. [123] W. B. Sissons, "Poisoning from Godfrey's Cordial," _Journal of the American Medical Association_, March 2, 1912, vol. 58, p. 650. [124] Edward Kremers and George Urdang, _History of pharmacy_, Philadelphia, 1951, pp. 170, 278. [125] "Godfrey's Cordial," _Hygeia_, October 1931, vol. 9, p. 1050. [Illustration: Figure 15.--TURLINGTON'S BALSAM OF LIFE bottles as pictured in a brochure dated 1755-1757, preserved in the Pennsylvania Historical Society, Philadelphia, Pa. According to Turlington, the bottle was adopted in 1754 "to prevent the villainy of some persons who, buying up my empty bottles, have basely and wickedly put therein a vile spurious counterfeit sort."] For those who persist in using the formulas of the early English patent medicines, recipes are still available. Turlington's Balsam remains as an unofficial synonym of U.S.P. Compound Tincture of Benzoin. Concerning its efficacy, the _United States dispensatory_[126] states: "The tincture is occasionally employed internally as a stimulating expectorant in chronic bronchitis. More frequently it is used as an inhalent ... It has also been recommended in chronic dysentery ... but is of doubtful utility." [126] _The dispensatory of the United States of America_, 25th ed., Philadelphia, 1955, p. 158. A formula for Godfrey's Cordial, under the title of Mixture of Opium and Sassafras, is still carried in the _Pharmaceutical recipe book_.[127] _Remington's practice of pharmacy_[128] retains a formula for Dalby's Carminative under the former _National formulary_ title of Carminative Mixture. [127] _The Pharmaceutical recipe book_, 2nd ed., American Pharmaceutical Association, 1936, p. 121. [128] Eric W. Martin and E. Fullerton Cook, editors, _Remington's practice of pharmacy_, 11th ed., Easton, Pennsylvania, 1956, p. 286. In the nation of their origin, the continuing interest in the ancient proprietaries seems somewhat more lively than in America. The 1953 edition of _Pharmaceutical formulas_, published by the London journal _The Chemist and Druggist_, includes formulas for eight of the ten old patent medicines described in this study. This compendium, indeed, lists not one, but three different recipes for British Oil, and the formulas by which Dalby's Carminative may be compounded run on to a total of eight. Two lineal descendents of 18th-century firms which took the lead in exporting to America still manufacture remedies made so long ago by their predecessors. May, Roberts & Co., Ltd., of London, successors to the Newbery interests, continues to market Hooper's Female Pills, whereas W. Sutton & Co. (Druggists' Sundries), London, Ltd., of Enfield, in Middlesex, successors to Dicey & Co. at Bow Churchyard, currently sells Bateman's Pectoral Drops.[129] [129] Letter from Owen H. Waller, editor of _The Chemist and Druggist_, to George Griffenhagen, January 15, 1957. In America, however, the impact of the old English patent medicines has been largely absorbed and forgotten. During the past twenty years a revolution in medical therapy has taken place. Most of the drugs in use today were unknown a quarter of a century ago. Some of the newer drugs can really perform certain of the healing miracles claimed by their pretentious proprietors for the old English patent medicines. A more recent import from Britain, penicillin, may prove to have an even longer life on these shores than did Turlington's Balsam or Bateman's Drops. Still, two hundred years is a long time. Despite the fact that these early English patent medicines are nearly forgotten by the public today, their American career is none the less worth tracing. It reflects aspects not only of medical and pharmaceutical history, but of colonial dependence, cultural nationalism, industrial development, and popular psychology. It reveals how desperate man has been when faced with the terrors of disease, how he has purchased the packaged promises offered by the sincere but deluded as well as by the charlatan. It shows how science and law have combined to offer man some safeguards against deception in his pursuit of health. The time seems ripe to write the epitaph of the old English patent medicines in America. That they are now a chapter of history is a token of medical progress for mankind. [Illustration: Figure 16.--TURLINGTON'S BALSAM OF LIFE BOTTLE (all four sides) found in an Indian grave at Mobridge, South Dakota; now preserved in the U.S. National Museum. (_Cat. No. 32462, Archeol.; Smithsonian photo 42936-A._)] 
37326	----	Turkish and Other Baths A Guide to Good Health and Longevity By Gordon Stables Illustrations by Messrs Allen Published by Dean and Son, London. Turkish and Other Baths, by Gordon Stables. ________________________________________________________________________ ________________________________________________________________________ TURKISH AND OTHER BATHS, BY GORDON STABLES. PREFACE. No apology surely is needed for a work like this, and its preface need be but brief. Small is the book, in size little more than a pamphlet; yet mayhap it contains hints that will not be thrown away on any reader, and may be invaluable to many who wish to secure health, long life and happiness. The Author. Christmas Morning, 1882. CHAPTER ONE. THE SKIN--ITS USES AND GREAT IMPORTANCE IN THE ANIMAL ECONOMY. Apart from any consideration of the bath as a remedial measure, in cases of disease, its importance as an agent for preserving the health, and granting to those who use it judiciously a reasonable hope of long life, cannot easily be over-estimated. But in order to understand properly the beneficial action of baths on the system, we must have some little knowledge of the physiology of the skin. Without such knowledge, all arguments that we could adduce in favour of the constant use of the bath in some shape or form, would be of the _post hoc propter hoc_ kind, and therefore of little value. What, then, we may ask, are the uses of the skin, for what ends has Nature designed it, and what is its _modus operandi_? Briefly stated, the uses of the skin are as follows:--Firstly, it covers and protects from violence the surface of the whole body, and the various tender and sensitive parts that lie immediately beneath it; secondly, it is the organ of touch; thirdly, it is the great regulator of the heat of the body; fourthly, it performs the duties of a great emunctory, and by means of its millions of sudoriferous, or sweat glands, each with its efferent duct; it carries off and out of the body a vast quantity of effete matter, which, if retained in the blood, would poison it, and therefore unfit it for the healthful performance of its functions; fifthly, the skin acts as an absorbent; and, sixthly, it is to some extent an organ of respiration. The use of the skin as a protective covering to the body is apparent to every one, and we cannot help admiring its great and perfect adaptability for the purpose. On the soles of the feet, and palms of the hands, it is thicker than in other places, being thereon subjected to more wear and tear; on the trunk of the body, and on the arms it is soft and smooth, and it is everywhere wonderfully elastic and pliable. Moreover, it is lined throughout with a base work of fat, which gives extra support and security to the muscles, and, wherever in the body protection from the results of pressure is needed, we find that this fat is deposited in actual cushions, as under the heels, under the balls of the toes, on the hips, etc. And here we may remark that, whenever the elasticity of the skin is impaired, as it is in the bodies of those who do not accustom themselves to the bath and perfect ablution, loathsome diseases are apt to be the result, which not only interfere with the actions of the skin itself, but lower the vitality of the whole system. The use of the skin as an organ of touch is equally apparent. Being supplied with a most intricate network of blood vessels and nerves, the skin is all over a most sensitive organ, and thus serves to warn us in time of the approach of anything likely to be detrimental to our health. If we sit in a draught, the skin of the body chills almost at once; it begins to creep, as it were, warning us that it is time to move, time to seek shelter, or protect ourselves by an extra garment. Some portions of the skin are far more sensitive than others; that of the eyelids, for instance, which is agitated by the slightest breath of air, or by a touch communicated to it by the least pressure on the eyelashes. By means of, or through, the medium of its vast number of sweat glands, the skin regulates the amount of heat in our bodies. This is a function which is much more important than most people might at first imagine. The temperature of the body in health is about 99 degrees Fahrenheit, if it rises much above this--even a few degrees, indeed--or if it falls much below it, severe illness is indicated, danger is apparent, danger even to life itself. An equable temperature of the body it is therefore evident is alone compatible with perfect health, but if it were not for the perspiratory system, when any extra strain is put upon the body, as by hard work, or hard exercise, heat would accumulate in the system, and the temperature of the body would be raised, to our discomfort, detriment, and danger. But the pores of the skin are our safety valves; from exertion the blood is determined to the surface, the sweat glands are thus excited to increased action, and perspiration is thrown off in abundance, which, passing off in steam, carries with it--in obedience to a law too well known to need explanation--all the extra caloric. In hot weather, a great deal of heat is thus expended through the skin; in cold weather the kidneys are more active, and they excrete the water which otherwise would have passed through the pores, and by storing it for a time in a reservoir designed for the purpose, conserve the heat of the system, and prevent lowering of the animal temperature. By means of these same sweat glands with their ducts or pores, an immense amount of effete matter is carried off from the body in the course of twenty-four hours, which, as already stated, if retained in the system, would tend to lower vitality by poisoning the blood. If the reader recollects that the lungs also perform a renovating function on the blood, and thus on the body, that oxygen is inhaled, and that air loaded with carbonic acid, water, etc, exhaled, he will readily understand how much assistance the respiratory organs receive from a healthy acting skin. Nor can the intelligent reader be unaware that the nutrient portion of the food we eat, after undergoing the process of digestion performed in the mouth--where it is masticated and mingled with the solvent saliva-- in the stomach, where it is reduced by muscular action, and the gastric juices to the pulp called chyme--in the upper portions of the intestines--where it receives the secretions of liver and pancreas and becomes chyle, is collected by a series of absorbent vessels which unite at last to form the thoracic duct, or grand chyle canal, which empties itself of its valuable contents directly into one of the largest veins in the body, and is thus mingled with the general circulation. He knows, too, that the pure life-giving arterial blood, which, rushing onwards from that mighty force-pump, the heart, is distributed to every atom of the system, returns at last laden with the used up particles of the tissues; that, in fact, a constant change is going on in the system, a constant deposit of new matter, a constant discharge of old. And that the dark venous blood, containing the effete matter, rushes through the lungs, therein to be spread out, and chemically united to the oxygen of the air that we breathe, before it is again pumped out towards the tissues to supply them with heat and life. But it must not be forgotten, that not the lungs only, but the kidneys, the liver, and the spleen have each and all of them their duties to perform towards the blood; and last, but not least, that the skin, when in a state of health, assists them in no small degree in performing their several functions. But there are other glands which receive assistance from the skin in the performance of their duties. We refer to those distributed here and there in the frame-work of the body, notably in the axilla, the groin, and under the skin of the neck, and whose functions are to purify, in some way or other, the matter collected by a series of vessels called the lymphatics, before it is again applied to the purposes of nutrition. "The amount of fluid," says a well-known physiologist, "exhaled from the skin and lungs in twenty-four hours, averages about three or four pounds. And there is good reason to think that this excretion is of the greatest importance in carrying off certain substances that would prove injurious if allowed to remain in the blood. "That which is called the Hydrophatic system, proceeds upon the plan of increasing the cutaneous exhalation to a very large amount; and there seems much evidence that certain deleterious matters, the presence of which in the blood gives rise to gout, rheumatism, etc, are drawn off from it more speedily and certainly in this way than in any other." If space permitted, the utility of the skin as one of the greatest emunctories of the system might be much enlarged upon; we trust, however, we have said quite enough to establish its importance in the animal economy. CHAPTER TWO. HOW TO MAINTAIN THE SKIN IN HEALTH. If the skin then, is an emunctory of so much consequence, as we have endeavoured to shew it to be, it stands to reason, that even the impartial performance of its functions, is incompatible with healthful existence. One might go farther and boldly aver, that a person who is a stranger to the bath, is as much to be pitied as a being with only one lung; both may exist, neither live. On the other hand, it cannot be denied that there are thousands of men and women in these islands, who seem to enjoy a large share of robust health, and who possess what assurance companies would call, "good lives," but who never indulge in the luxury of either a bath or a bedroom tub. But it will generally be found, that these people belong to the out-door working classes, who take abundant exercise in the open air, people whose pores are kept patent by the toil they undergo, and who, moreover, possess capacious lungs, substantial livers and healthy kidneys. Nevertheless, did these same persons make a practice of constantly using some form of bath, they would throw far less strain upon their internal organs, their blood would be purer, and their minds consequently lighter, and they would stand far less chance of catching cold, and succumbing to inflammation of some vital part. A person whose skin is not in easy working order, and who depends upon exertion and exercise alone, for keeping it up to the mark, must, if thrown on a bed of sickness, have a harder struggle for life than one whose skin is, in every sense of the word, a healthy one. Everything seems to point to the conclusion that the health of the skin is a matter of paramount importance to the individual, we cannot therefore be wrong if we devote this chapter to the consideration of the best means within our reach, of maintaining it in a sound and vigorous condition. So intimate is the connection between the skin and internal organs of the body, and so constantly and incessantly do they act and re-act on each other, that the state of the former may generally be taken as a key to the condition of the whole system. If the skin be dry, harsh, hot or in any way possessed of an uncomfortable feeling, the general health is, for the time being, out of order, or if it be cold or rough and chilly, the health must be below par, even although that state of being should be but momentary. A feeling of warmth, comfort and geniality, pervades the skin of the man who is well; deprived of this feeling he is deprived of health, he is ill, acutely subacutely, or chronically ill. DIET:--The influence of diet on the skin is very great. This is a fact which should be borne in mind by all, but especially by those who are subject to any kind of skin complaint, or to gout or rheumatism. The latter disease, from which so many people suffer periodically, is, with a good show of reason, believed to be caused by a superabundance of acid in the blood. This acid is easily got rid of at most times, by means of the sensible and insensible perspiration; but if, through some error in diet, an irritable condition of the mucous membrane of the alimentary canal is produced, and a larger proportion of acid than usual is the result; and if at or about the same time something--a cold, or chill, for instance--interferes with the free action of the skin, it stands to reason that an attack of the old enemy, gout, or rheumatic gout will supervene, and the character of the attack will greatly depend on the condition of the patient's system at the time. If he be full blooded and robust it may be acute or sub-acute. Thus it often happens that at the very time when a man of rheumatic diathesis is in finest form, he is suddenly laid prostrate by the return of his foe. If, on the other hand, he be not of a full habit, the disease will be less violent in its nature, and this probably accounts for the fact, that men of spare habit are, as a rule, capable of weathering more rheumatic storms than men who have been cast in a larger mould. No medical man now-a-days thinks of prescribing for a patient without at the same time giving him advice as to what he should eat, drink, or avoid. Some hundred years ago, physicians were, we may presume, not so skilled as we are now-a-days, but neither were they so apt to lose themselves in that labyrinth we may call _causae morborum_, and they never lost sight of the state of the stomach and bowels. Indeed, the exhibition of aperients was often a kind of sheet anchor with them, with which they held on with determination when everything else failed them, and we can scarcely doubt that they were often right in doing so. Nor is the belief so common with the illiterate, that if a man can eat and drink moderately well, there cannot be much the matter with him, so very erroneous after all. Diet is of paramount importance with all of us, for the simplest reason possible. Our blood is generated from the food we eat, and as the blood is, so will the system be, which it has to nourish. No matter how clever a mania, or how rich, or how eminent, if he is guilty of errors in diet, he is but a golden calf with feet of clay. But he who lives judiciously in the matter of diet, possesses a truly marvellous advantage over his fellows who do not. A man in health should begin the day early. He ought to have his morning tub by half-past seven at the latest. He ought to dress leisurely, and have, if possible, a five or ten minutes' walk in the open air, before he sits down to breakfast. Well-made tea is probably the best beverage for breakfast, and if between meals a man requires some refreshment, a cup of coffee or tea will be found more sustaining and less dangerous than either beer or wine. The breakfast maybe a moderately hearty one, and the dinner should be an early one, and nothing ought to be partaken of which is known to disagree. Supper should be early and light, but not necessarily sloppy. Solid food is more likely to be quietly digested than slops. A biscuit and glass of milk, or beer, may be partaken about half an hour before retiring, if it is found that sounder sleep is acquired by such indulgence. The errors in diet which should be avoided are:--First, eating too fast; second, taking stimulants of any kind to provoke an appetite; third, the use of rich sauces and peppers; fourth, eating too much; and fifth, partaking of too many varieties at one meal. A man should eat with _regularity_ and _moderation_, and _frequently change his diet_. ------------------------------------------------------------------------ DRINK.--Pure water is the best, but water that will not wash is unfit for drinking or making food, withal. Cocoa, coffee, tea, and milk in moderation, and in summer whey and buttermilk are healthful drinks. Iced waters, cooling cups, and too many effervescing mixtures are to be avoided. ------------------------------------------------------------------------ Regularity in the times of going to bed and getting up should be studied. PURE AIR.--One cannot have too much of this. The air in rooms ought to be kept pure and sweet, and that of the bedroom moderately warm. Bedrooms ought to be large, and not overfilled with furniture, especially things likely to collect dust. Curtains about beds do more harm than good. DRESS AND CLOTHING.--No more should be worn than is necessary to keep the surface of the body agreeably comfortable. It should not be tight, and mackintoshes and goloshes are injurious to health. Bed clothes should be light and warm. People, as a rule, heap their beds with far too much clothing, and sleep is thus often banished. SLEEP.--Secure it by natural means; _never_, unless under medical advice, by taking draughts, or "night-caps." Regularity in living, exercise, and the bath, are the best narcotics, but a pipe of mild tobacco last thing may often do good. EXERCISE.--Exercise, to be beneficial, should be pleasant, the mind should be free and happy. Exercise does little or no good unless enjoyed, hence work is not exercise. It should never be carried to the verge of fatigue, and if the under-clothing has been damped by perspiration, it ought to be changed before sitting or lying down. As to under-clothing, no one over thirty, who values his health and life, should neglect to wear it in some form, wool is warmer than cotton, silk better than either. The best form of exercise is that which maintains the largest number of muscles in play, and does not over-sweat the body, nor over-heat the head. It ought to be varied, too, but whether it be walking, riding, driving, rowing, playing games, or those most exhilarating exercises bicycling and tricycling, it ought to be taken regularly, day after day, and we may add, all the year round. While taking exercise, the clothing ought to be as loose as possible, in order to permit of the full play of the muscles, and avoid dangerous contractions of the internal vital organs. ------------------------------------------------------------------------ Note 1. See, "Tea, the Drink of Pleasure and of Health," by same author, published by Messrs. Field and Tuer, Leadenhall Street. CHAPTER THREE. THE LUXURY OF THE TURKISH BATH--ITS USES AND PHYSIOLOGICAL ACTION--THE AILMENTS IT TENDS TO CURE. Next to the pleasure of enjoying an Anglo-Turkish bath oneself, _in propria persona_, is that of hearing some one dilate on its merits. And few who have ever tried it, will be found unwilling to expatiate freely on the topic of Turkish bathing; of its great and manifold advantages over all other systems of bathing, of the delights they experienced while _in_ the bath, and of the feelings of lightness and comfort, calmness of mind and positive happiness induced thereby. This prince of baths would, we verily believe, change the dullest clodhopper to a wit for a time, and convert the prosiest old antiquarian into a poet. If it has such a transforming power on the brains of the by-no-means brilliant, is it any wonder that men of bright intellect like Sir Erasmus Wilson and David Urquhart, should write or talk so prettily about this, their favourite mode of bathing. As a rule there is not much room for poetry in the medical profession, albeit Dr Jenner, carried away by a pardonable enthusiasm, described the vaccination pustule of the ninth day, with its crimson areola as "the pearl upon the rose." Yet we cannot read the glowing and graphic description given by the great dermatologist, concerning his visit to the bath at Riverside, without wishing that he had marshalled his thoughts, for once in a way, in the splendid hexameters of a Longfellow. A bath like that of Mr Urquhart's, from which one emerged with "the body shining like alabaster, fragrant as the cistus, sleek as satin and soft as velvet," is surely worthy of the high honours of blank verse. And this thermal paradise is sketched by Sir Erasmus in language as brilliant and beautiful, as any that ever the _other_ professor Wilson puts into the month of the bard of Ettrick, in his inimitable Noctes Ambrosianae. We must be forgiven, if we pick a plum or two from the description, and hand them round to our readers, there are plenty more on the tree which they may cull for themselves [Note 1]. At the door of the Frigidarium or cool room, the would-be bather loosens the latchets of his shoes, and leaves them behind the lintel; the portal opens and he enters. This apartment though not large is sunny and bright. It is a morning in early summer, and, through the glass doors, can be seen a balcony festooned with roses; beyond the parapet of the balcony are terraces of which the rose is still the favoured flower, while further on can be seen the rippling surface of a noisy stream, then meadows with grazing herds and flocks, and beyond these the wooded hill arching like an eyebrow around the bright spot in which as the apple of the eye, sparkles the bath. By his side is a _dureta_ over against him a reclining chair, around the sides of the apartment are cushioned divans; books, and chibouques, and many a Turkish ornament are around, and the floor is spread with carpets of Persia, and the clean fresh mattings of India. Opposite the glass doors is an immense sheet of plate glass; through it are seen marble steps, and in the aqueous depths to which these steps descend, is the reflection of the morning sun. Here he may court the rays of Phoebus, smiling through festoons of roses to visit the deepest pool of his bath. Here he can swim while the sun glistens in the crystal drops that linger on his skin, or makes mimic rainbows in the spray that he dashes before him in his plunging revel. The author passes on through a door by the side of the immense barrier of glass. This door closes behind him, then onwards through a second door to be greeted by a delightful atmosphere, and experience tells him that no place of terrestrial existence save _the_ bath can yield that warm, soft and balmy aether. Two steps down and then a platform. Two steps more, the heat increases, and he has reached the tropical line of the bath. But the hottest room was enveloped in scarlet hangings, a fiery tent, where the temperature stood at from 240 to 250 degrees. On a divan at a later stage of the hath, under a less degree of heat, he spends many minutes of genuine enjoyment. Just overhead is a plug to withdraw in order to admit a breath of fresh air if desired, and this delicious gush of ambrosial air comes to him, perfumed with the sweet breath of flowers over which it has been contrived that it shall pass. Then comes a deeper descent of four steps, with a still warm but lower temperature, where on the clear marble edge of the Lavatorina he seats himself, while his host plies the soft pad of _gazul_ over his head and back and sides. Then basin after basin of warm water, rinses the gazul and the loosened epidermis from the surface, and he rises from the bath to recommence his observations, visiting in turn all the soft, the warm, the perfumed, the hot, the cool and the cold nooks he can find, and thus the time flies by and the breakfast hour draws near; but before he can quit the bath, it is necessary that the pores of the body, which all this time have been filtering the waste fluids of the body through their numberless apertures, should be made to close, and with this intent he descends into the marble pool or _piscina_, whose waters in summer are cooled with ice, and crouches under the tap, and lets the cold current encircle him, then a pail of hot water rushes on him like an avalanche, followed immediately by one of cold, and this is many times repeated. Upward now, to the Frigidarium, with a mantle round his shoulders after being rubbed down with soft Turkish towels, therein, reclined on a softly cushioned sofa, to enjoy half-an-hour's suggestive and instructive conversation, before going to breakfast with an appetite like--like a man. Sir Erasmus does not tell us how much he enjoyed that breakfast, but we can easily fancy that part of the performance. We can easily believe, that his manly onslaught upon the viands set before him, would have been highly appreciated by Christopher North himself, with Tickler and the Shepherd "settling down to serious eating." But it is not merely as a luxury that, in this little work of ours, we venture to recommend the Anglo-Turkish bath to our readers although taken simply for the sake of enjoyment, a man never fails to cherish the memory of his first bath, as does a maiden that of her first ball. But our recommendation has a far wider scope than this. We look upon the bath as the best means mankind has:-- ONE.--For maintaining the body in a state of perfect health. TWO.--For averting the many ailments incidental to life and-- THREE.--For the cure of not a few diseases. Few there are in our own country, or probably in any other, who enjoy really good and robust health, constantly. Apart from inherited illnesses, the wear and tear of life, end the worry that naturally attends the struggle for existence is very hard upon most of us, and if it were not for weekly periods of rest, the average span of our existence would be a much shorter one than it really is. And, alas! as a rule, our periods of rest seem far too short, our one day's toil seems hardly well over, until another one begins, and thus our existences are fretted away. To many amongst us life seems one long drawn-out weariness; from year's end to year's end the back must ache, and the temples throb, till the very heart grows "tired of its own sad beat, and yearns for rest." But to live like this, or in any way akin to it, is not to be in a state of health. If a man be really healthy, he is reasonably happy, if he does not feel reasonably happy, he is not in a condition of health. In health there is a complete freedom from ache or pain, from bruise or blemish, from heat or cold; every joint is supple, every muscle capable of contraction and extension. And the mind should feel as light and buoyant as the body, a healthy man should feel a pleasure in merely living, he should be capable of taking an interest in everything that goes on around him, in all he sees, in all he hears, in all he reads, and in all that concerns the well-being of his fellow creatures, and honest toil itself should be an enjoyment to him, and not a worry, not a penance. It is the custom in England, and a terribly wrong and fatal one it is, to fly to stimulants for the relief of temporary-exhaustion; that is, at the very time when our bodies are tired, and nature courts a brief rest, we dig in the spur, we wield the whip, and keep her at it invariably to her detriment. The very fact that the amount of stimulant taken requires to be increased after a time proves how deleterious is this plan, the modest glass of sherry, or mildest ale, needs after a time to be replaced by fiery brandy or heart-corroding gin. This last is putting an extra thong on the whip, and it is no wonder if, after a time, some important internal organ gives way, and one more is added to the list of incurable invalids. How much better would it be if tea and coffee took the place of dangerous stimulants, and the balance of health was sought to be retained by the daily use of the morning tub, and a bi-weekly indulgence in an Anglo-Turkish Bath. It is not too much to hope for, and it certainly is not too much to pray for, that public baths upheld in a great measure by Government, may yet be one of the institutions of our beloved land. What a blessing these would be to hard working men, and to the tired and weary among all classes. I venture to predict, that if people were to make a habit of using the Turkish Bath, say on the Saturday afternoons only, gin palaces and dram saloons that now reek with filth and disease would lose many a customer. Persons would find out that there was no real way consonant with the acknowledged rules of health and hygiene of banishing fatigue, of dispelling aches and pains, of calming the nervous system, and preparing the mind for the perfect enjoyment of that day of blessed rest called Sunday. As a prophylactic against innumerable diseases, we have recommended the use of the Anglo-Turkish Bath. It is almost unnecessary to enlarge upon this head, but a word or two may not be thrown away. Two, then, of the great _causae norborum_, or disease inducers in this country are cold and indigestion. Now, so long as the skin is a healthy one, and in good working order, it is next to impossible for any one to catch cold through it, if he only takes care to clothe it not heavily but judiciously in warm woollens or light soft silks. It stands to reason that an organ, an instrument or machine--call it what we may--which is perfect in workings, is not so easily thrown out of gear or out of order as one not so perfect. We could fill a volume with cases of people who are constantly in the habit of using Baths, who can stand exposure to both cold and wet with but little inconvenience; and we also know a vast number of votaries of the Bath who do at times catch cold like other people, being probably constitutionally susceptible to its influence-- but who get clear of their colds in quite a remarkably short time. The reason undoubtedly is that they have the power to "throw them off," as the common saying is. Well, now, as to indigestion. As the reader knows, the whole internal surface of the body is lined with a mucous membrane, which is analagous to the skin or external covering, and as the one is so will the other be; mucous indigestion, therefore, it may be clearly perceived is averted by the use of the Bath. But indigestion may proceed from loss of nerve power, or from a badly acting liver or spleen, or from weakness of the heart, etc. And the Bath strengthens and tones the nervous system far more than any tonic we wot of, moreover its constant use makes the work which the liver and spleen have to perform, mere play, so to speak; and if the Bath invigorates muscle--and we know it does--it must act as a roborant or tonic to the heart itself, which is composed for the most part of muscular tissues. Many people produce a species of irritable indigestion, by the use of stimulants, for this the Anglo-Turkish bath is an almost certain cure, as it relieves internal congestions, steadies the nerves and produces refreshing sleep. Many poisons are generated in the system, to which if free vent be not given by means of the pores of a healthily acting skin, mischief is sure sooner or later to arise, such mischief for instance as gout and rheumatism, to which reference has already been made. But the condition of the kidneys is seldom or never studied by anyone and yet if they do not act sufficiently well to expel urea from the blood, a more or less injurious effect is caused upon the brain and nerve centres. This the periodical use of the Anglo-Turkish bath, would tend to remove. We all know the demoralising effect that the first glass of spirits is said to have upon a man inclined to the abuse of intoxicants; it so affects his brain that he no longer knows, or he disregards right form wrong as far as his health is concerned. But a similar demoralisation of brain tissue, may be produced by poisons positively generated in the system; at least this is our opinion. Those, for example, who have been given to alcohol, often keep "steady" as they phrase it for a month or months, then suddenly or gradually, as the case may be, break out again. This is doubtless caused by the play of some accumulated system-propagated poison on the brain and nerves. This poison may be urea, or it may be some acid, it matters not, it is in the blood and it ought to be eliminated and we earnestly advise those, who would be abstainers but who find it difficult to long remain so, to fly at once for relief to the hot-air bath, whenever the "_tempter_," as platform orators call it, seems to urge them to take once more to stimulants. We think it highly probable, that many inherited diseases such as consumption, scrofula, etc, may be kept at bay by the constant use of the bath under consideration, if only for the simple reason that the blood poisoning is thus constantly being driven off, before it has power to accumulate in quantities large enough to do mischief; not to mention the fact that the bath causes healthful activity of all the secretions. The diseases which the Turkish bath may be the means of curing or alleviating, are really too numerous to mention. Among them may be enumerated gout, rheumatic gout, rheumatism, acute and chronic, colds and coughs, indigestion in some of its worst forms, bowel affections, piles, chronic liver and spleen ailments, kidney complaints, incipient delirium tremens, melancholy and depression of spirits, nervousness, irritability of temper, sleeplessness, _ennui_, the diseases of sedentary and also of fashionable life, adiposity, etc. That condition of body and mind generally caused by indiscretion of some kind, and usually known by the expression "out of sorts," or "out of condition," when weariness and depression are predominant, when sleep is unrest, and every duty of life is performed with a feeling of extreme irksomeness, and when the nerves seem given as a punishment, is almost invariably cured by a course of Turkish Bathing taken in conjunction with some nervine tonic, and an occasional well-chosen aperient. Diseases and debilities of the reproductive organs, are by the same means equally benefited, but in these cases galvanism in some form is often required to effect a complete cure. ------------------------------------------------------------------------ Note 1. See--"The Eastern Bath," published by Messrs. J. and A. Churchill, New Burlington Street. CHAPTER FOUR. THE TURKISH BATH: IN THEORY AND PRACTICE--THE PORTABLE TURKISH BATH. Let us now endeavour to explain the theory of the Turkish Bath, and the why and wherefore of the different operations the bather subjects himself to therein. If he be a person who has bathed many times and oft, he steps across the threshold of the great natural Sanatorium with a light heart and a step as springy as though he were entering a ball-room, for well he knows that all his care and trouble whether mental or bodily, will melt away in the glorious atmosphere of the _calidarium_ or hot room, and that when he comes out again he will feel so new a man, that a giant refreshed would have no chance with him. He parts with his ticket or half-crown with pleasure, feeling in his inmost heart that he has the best of the bargain. And so he enters his little sanctum and begins to undress. He would fain hurry off his garments: he longs to be free but he remembers that everything ought to be done leisurely for his good. But now the last article of apparel is laid carefully aside and he smiles to himself--a happy smile--as he dons the cummerbund, or cotton pyjamas, and issues forth to enter the calidarium. He will not have long remained here until beads of perspiration appear on chest and brow, and arms, gradually extending downwards until limbs and even feet are covered with a warm moisture. A mouthful or two of cold water will cause the drops of perspiration to accumulate and increase in size, until uniting, they trickle "in burns"--as the Scotch call it, from the body. He has very likely assumed a reclining position on a wooden cane-bottomed settee. Here he may read if so minded, he will hardly care to talk, if he does he ought not to. A strange dreamy kind of happiness steals over him, not wild exciting thoughts like those of the opium-eater. No, his is now indeed the _dolce far niente_; he has eaten the lotus leaf, all worldly cares, if he has any, are for the time being forgotten, he even wonders that he permitted anything sublunary to worry him. And so the time passes all too quickly away. Perhaps the attendant now warns him it is time to retire, or to enter even a hotter room in which he will stay a shorter time, then thence to the lavatory. How pleasant the trickling of the warm shower bath, how delightful the soap shampoo, that removes every bit from top to toe of the unhealthy, or at least superfluous scarf skin. Every particle of impurity may be said to have exuded from the blood, which is now pure as the constitution of the bather can permit it to be, and every particle of impurity has been washed by shampooing from the outer surface. The warm shower completes the cleansing. But now the gaping pores must be made to contract, their fibres are relaxed they must be closed. But however cold the water douche may be, by which this operation is performed, to the bather it seems most pleasant and delicious. Wrapped in a sheet from head to heel he once more passes through the calidarium, on his way to the cooling room. He may linger here for a few moments if so minded but not for long, only just to restore a gentle warmth to the surface of the body. In the cool room he will remain reclining and enwrapped in his sheet for about a quarter of an hour and probably the attendant will come and knead every muscle of the body getting back the lagging blood, if indeed it does lag, heart-wards and rendering the whole body as supple and pliant and elastic as life. Then to dress most slowly. And while dressing, to leisurely imbibe a cup of warm, not hot, tea or coffee. When he emerges at last from the Sanatorium and goes bounding along the street, he--well he does not feel inclined to change places with anyone he meets, not even if the Lord Mayor's carriage rolls past him. We have thus stated briefly, the various operations a bather goes through in the ordinary Turkish bath of our towns and cities. Leisurely undressing, especially necessary if there has previously been a brisk walk, (thus the heart has time to tone down ere subjected to the excitement of the calidarium) the repose in the hot room with frequent small draughts of cold water to encourage the flow of the perspiration, the gradual softening of the scarf skin and thorough opening of every pore, the warm shower and shampoo by which every obnoxious particle is removed from the outer surface as it has already been from the inner, the cold douche to contract the pores, and thus prevent subsequent danger from cold. The gradual cooling down, the leisurely resumption of ordinary wearing apparel lest perspiration should again be induced, and last, but not least, the calm and comforting cup of coffee or tea. And after all what is this Turkish bathing? Is it something so very new? Nay, new in its processes probably, but it is but carrying out an old, old law, old as the days of Moses himself, the law of perfect cleanliness and perfect cleansing. We have visited a large number of the hydropathic establishments and Turkish bathing sanatoria, and there is much to be praised in all we have seen and little to be blamed. Some are of course, far more luxuriantly fitted up than others, and these are the baths we prefer to visit. Could we, however, have such a splendid thermal temple as that of Riverside attached to our own home, we would certainly never wander away from it to worship at another shrine. We ourselves may be over fastidious, but we think the following are among some of the drawbacks to the general run of Turkish bathing places. They are usually in out of the way places, so that one is not always able to find the time to get there when he wants to. The weekly expenditure incurred by taking a course of baths would certainly be a consideration with many; and on the other hand, there is a lack of privacy which renders such establishments distasteful as a rule. But the benefits that accrue from a course of Turkish baths, depend in a great measure upon the regularity with which they are taken. And it is this regularity which is often so difficult to keep up. The Sanatorium is at a distance. Something intervenes to prevent the intended visit,-- business--a call from home in another direction--bad weather, or any one of fifty other things. And so a visit comes to be omitted, or may be two, there is accordingly a hole in the hygienic ballad, a step or two wanting in the ladder that would have led upwards to health. It is some two or three years now since we first came to realise the fact, that one might enjoy the luxury and reap the benefits of a Turkish bath, without going a step beyond the confines of the bedroom and dressing-room. We had received by the railway carrier a box. A box! Whatever could it be, we wondered. It was not the season for sending anything particular from the country. Christmas was a long way ahead, and grouse shooting not begun. We undid the outer covering and exposed it to view. It was shaped liked a spirit-case, but it could not be that. "That box may contain," we mused, as we gazed on it, "untold luxury in the shape of tea, or a new patent photographic apparatus, or a magic lantern, or an English concertina, or--yes--or--or--or a land torpedo sent by a Fenian, that will explode when we lift the lid, blow the roof off the house, and send us sailing away skywards, accompanied by the furniture and things." We clapped a cautious ear to the lid and listened. There was no suspicious ticking audible within, so we summoned up courage and--opened the box, and lo! and behold, Allen's portable Turkish bath. Since then we have visited public baths but seldom. We are content, for the portable bath as we use it, serves every useful purpose. As the Messrs. Allen have lent the blocks to embellish this chapter, it will be nothing more than courteous to let them describe it in their own way. Referring to (Plate One) they say:-- "This illustrates our Apparatus as used under the chair, for giving a hot-air bath only, or hot-air and vapour combined, also for either a Medicated or Mercurial bath. "At the back of the top rail of chair is fixed a socket, with a set screw, a square rod slides up and down this socket, and a folding ring fits into the top of the rod. "By this arrangement the hoop for keeping the cloak extended, can be raised or lowered to be either level with the shoulders leaving the head exposed, or, if preferred, raised sufficient to cover the head. "The person about to take the bath puts the apparatus ready for use under the chair, and placing the cloak lightly over the hoop, sits down, slips the two ends of the hoop together, draws the cloak round, tying it down the front with the strings provided, and adjusting it round the neck, may take the bath comfortably from fifteen to forty minutes, according to inclination." But it is possible that the bather may prefer to recline while enjoying this calming and luxuriant bath. This is easily done, and if the reader will glance at Plate Two, he will see the modus operandi. Nothing could be more simple, nothing more effective. We are not, however, the first to have discovered the merits of Messrs. Allen's luxurious invention. It is in general use now all over the country, and medical men are constantly in the habit of recommending the bath to their patients. So also is the professional press, and among these such well-known Journals as "The London Medical Record"; "The Medical Times and Gazette"; "The Medical Examiner"; "The Medical Press and Circular"; "The Lancet"; and "The British Medical Journal" are loud in their praises of the apparatus. It will be especially observed by the intelligent reader that Allen's bath may be used entirely as a dry hot air bath, or as a mixed hot air and vapour bath. Well, this in our opinion is a capital idea, because one can use it as either. We, ourselves, perspire freely, and therefore use only the hot air, but as Sir Erasmus says: "The great purpose to be arrived at, so far as temperature is concerned, is to obtain one which shall be agreeable to the sensations." The following is what Messrs. Allen and Sons write me themselves concerning their bath:-- "Our idea is, that the hot air and vapour bath combined is the truest approach to the Eastern Turkish bath, in which, after the bather has been in the heated room some little time, and begins to feel somewhat oppressed, they (the attendants) come round, sprinkle the heated floor with water; this produces a vapour, and it is almost immediately after this that the body begins to perspire freely, the vapour also relieves the breathing very much with some. There are those who will not perspire in the hot-air bath at all, but do with the hot-air and vapour bath, which, mingling with the hot-air, produces a moist heat, softens the skin, and produces perspiration much more quickly." There is one advantage which the portable bath possesses over the regular sanatorium Turkish:--the head is not covered, it is not in the heated atmosphere, and therefore purer air can be breathed, although both face and scalp perspire as freely as any other part of the body. The head, however, may be covered if this is thought more pleasant. Dr L.E. Turner, it would seem believes in having the head exposed during the bath. "By the use of your bath," he says "the patients can breathe pure air uncontaminated by the foetid humours pouring forth from the seven millions of pores in your neighbour's skin as he sits by your side in the ordinary Turkish or Russian bath. Besides there is no risk from over expansion of the pulmonary tissues of the lungs; as when people are compelled to breathe a heated atmosphere; nor risk from rupture of the delicate blood vessels of the brain. There are many other advantages which tend to make me, and not only myself but all other professional men who have tried them, strong advocates for their use, in place of all other kinds of Turkish, Russian, or herbal baths." CHAPTER FIVE. THE TURKISH BATH--CONTINUED. THE TRAVELLER'S BATH. In chapter third we enumerated briefly a few of the ailments likely to be either entirely removed, or, at all events, alleviated, by the use of the Turkish Bath. We think that Sir Erasmus Wilson mentions that terribly distressing ailment eczema among those which yield to the emollient and cleansing effects of the bath. Kidney ailments, and even dropsy itself, have succumbed to its power. "I have just," writes a medical man, "retired from the post of medical officer of H.M. Convict Prison at Portland, and my late Assistant Surgeon has kindly informed me how admirably it acts in kidney affections, and I am anxious to have one as soon as possible." The following are the words of Sir Erasmus Wilson himself:-- "The bath is a preventative of disease, by hardening the individual against the effects of variations and vicissitudes of temperature, by giving him power to resist miasmatic and zymotic affections, and by strengthening his system against scrofula, consumption, gout, rheumatism; diseases of the digestive organs, cutaneous system, muscular system, including the heart; nervous system including the brain; and reproductive system." "The bath," he continues, "has the property of hardening and fortifying the skin, so as to render it almost insusceptible to the influence of the cold. A Doctor of Divinity told me, that during the winter time he was scarcely ever free from cold, often so severe as to lay him up for several weeks, and that he also suffered from attacks of neuralgia; but that since he had adopted the use of the bath twice a week, all disposition to colds and neuralgia had ceased; and for the first time in sixteen years, he had passed the winter without a cold." Dr Wood writes as follows:-- "Dr Wood had a severe trial case to use Messrs. Allen and Son's. It was a case of heart disease and kidney affections where it was dangerous to give the patient a bath, or anything that would excite the circulation, and yet essential to have copious sweating. The patient was delirious. He has got well." A great sanitary authority, Dr Richardson, said the other evening at a public meeting, that if it were possible to attain perfect cleanliness of person and surroundings, disease would become an obsolete term. These are not the exact words, but they convey the sense. But independent of the use the bath may be put to, for the purpose of curing or alleviating disease, for thoroughly cleansing the body and sweetening the system, or simply as a luxury, there are at least two other uses to which it can be put. It is a means of banishing fatigue, and also of producing refreshing sleep. And this fact may be turned to good account on many occasions. A person may have been out all day on the hill, or hunting, or he may have been on the river or lake rowing, or by its banks fishing. He returns tired and weary, and very probably, wet. A wash and change of clothes, followed by a stimulant, are the usual remedies for such fatigues. How much better is it both for the comfort and health if he can spare a short half-hour, and enjoy the advantageous comforts of the Turkish Bath. Why, he feels double the individual afterwards, and if he is not all throughout the evening after as bright as a new florin, he must be a dullard at the very best, that is all. Well, but a person may be a mere guest at some country Squire's, how about his Turkish Bath then? This is a difficulty that is easily overcome. We have the Tourist's or Traveller's bath, handy, convenient, useful and cheap. This little contrivance will be of great benefit in dispelling the fatigue usually felt after a long journey in train or steamboat. While out boating or touring in any way it will be found invaluable. Indeed it is so small and compact that a tricyclist might easily take it in his bag. Plate Three represents the apparatus set up ready for use for a hot-air or vapour bath, to be placed under a chair, the body to be well enveloped in blankets. The apparatus may also be used for boiling water for making tea and coffee, as well as for frying bacon, chop, steak, or cooking omelets, etc. The Turkish bath is a calmative to the nervous and the vascular systems, and therefore of great utility in cases of sleeplessness. We advise those who are troubled with this disagreeable complaint to give it a fair trial. For female complaints, of nearly all kinds, unless especially forbidden by the family physician, this bath may be also used with marked benefit. ------------------------------------------------------------------------ We earnestly hope that this little guide of ours will fall into the hands of many sufferers, whose ailments are likely to be relieved, or banished entirely, by the regular use of this prince of baths; we cannot therefore do better, we believe, than finish this short chapter with some useful advice to those who may intend to give it a fair trial. But first, let us endeavour to dispel a phantom that stands at the threshold of every Turkish bathing establishment, and tries to prevent those who have never bathed before from entering. We allude to the phantom fear. This bogle stood at the doorway when we ourselves went to have our first Turkish bath. "Oh!" he cried, "don't come in, don't come in, you'll catch your death of cold from the douche, don't come in, don't come in, I beseech you, I'm sure you have heart disease." "Bother!" was our curt reply. "Well," cried the bogle, extending his ghostly arms over his head, "_do_ go and see a doctor first." But we pushed the bogle boldly aside. That bogle looked very small indeed as we strode out again, about an hour afterwards. Now, dear reader, the phantom will treat you precisely as it treats everyone else. Are you to fear it? That is a question which must be answered in no bantering mood. We honestly believe that ninety-five people at least out of every hundred, can enter an ordinary Turkish bathing establishment and go through all the processes with perfect safety. Well, we will suppose that we are conversing in the consulting-room with some one who means to try the Turkish bath. He will ask such questions as:-- 1. When should I begin to take the bath? 2. How long should I stay in the heat? 3. How often should I take it? 4. What is the best time of the day to have the bath? 5. Can you give me some general instructions to guide me in using it. To question Number 1 we should reply: Begin to-morrow. Question Number 2: Until you are in a glorious perspiration, and all aches and pains, and all sense of weariness forgotten. From a quarter of an hour to twenty minutes will be enough at first. Question Number 3: How often should you take it? Once or twice a week, or even three times, or whenever required to banish ennui, fatigue, aches or pains, or incipient cold, or biliousness, or lassitude, etc, etc. To question 4, the reply is: The bath must not be taken on a full stomach, about three hours after a meal is the best time. But those who dine about six or seven in the evening should take the bath before _dinner_. People who are engaged all day, may with advantage use it either before retiring for the night, or after getting up in the morning, following it by the usual cold sponge. If the cold bath is forbidden, then the best time is going to bed. Now comes your last question, (but let me here say parenthetically that we may be consulted about everything connected with the bath, and baths of all kinds, or about any ailment, chronic or otherwise, that bathing in some forms is likely to cure or alleviate.) What you want then, in order to enjoy the luxury of a bath in your own room, is first, one of the portable baths; secondly a shallow bath like the one here depicted; (Plate Four.) Thirdly a good big sponge; fourthly, a small hand shower bath, cost I believe is 5 shillings from Messrs. Allen and Sons, (Plate Five); fifthly, a flesh brush; sixthly a piece of good soap (Pears' transparent tablet is by far and away the best, and really least expensive in the long run,--it is _so_ well made, and lasts so long); and seventhly, a few good rough towels. All being ready, you light your lamp and fix up the apparatus according to instructions given with every portable bath. The shallow bath is to be half filled with nice hot water, all ready. After you have perspired enough, turn out and turn into the shallow bath. Here you are to lather and sponge, and use the flesh brush well. Next use the hand shower, or the sponge if you prefer it, filled with cold water, do not be afraid of this, it is life and luxury combined. Then to dry, and dress leisurely, to loll on the sofa for a while, and quietly sip your tea or coffee, while the fresh breeze from an open window is playing around you. This is indeed enjoyment. People who use the bath for the purpose of gaining health and strength, should live temperately, both as regards eating and drinking, take abundant suitable exercise in the open air, and make use of some tonic, with now and then a gentle aperient. Both the tonic and aperient must be carefully chosen to suit individual idiosyncrasies and cases, but we have seen very much good indeed accrue from this conjunction of tonics, with mild and suitable aperients while taking a course of Turkish baths. CHAPTER SIX. ON THE USES OF THE VARIOUS MEDICATED BATHS. It will be as well for the generality of our readers, if we confine ourselves in this chapter to a brief consideration of those medicated baths only, which have been proved to be efficacious in the amelioration and cure of illnesses, whether chronic or acute. We must preface our remarks, however, by stating that no course of baths is likely to be of the slightest avail to a sufferer, unless he first and foremost makes up his mind to adhere to certain rules of living, and endeavours to conform to the laws of health. Exercise must be taken in the open air, he must also be most careful to study his diet and his clothing, and to secure sound sleep by every natural means in his power, narcotics however being avoided as poisons (see pages 21, 22, and 23). Tonics, taken with judgment, assist a patient to recover strength, but they must be administered or prescribed by a medical man, who is acquainted with the symptoms and nature of the case. It is really surprising the amount of good that can be done by a well-regulated course of Turkish or other baths, combined with some carefully adapted plan of constitutional treatment and regulation in living. If this were only more generally known, thousands would soon be enjoying all the blessings of health, who are now languishing on beds of sickness, or confined to warm and stifling rooms, instead of breathing the free fresh air of heaven. It would seem that Professor Lionel Beale is somewhat of the same opinion as ourselves, and he even goes somewhat further, for he deprecates foreign travel, or at least considers wandering abroad in search of health, is, in many cases, a needless expense. "If," writes this learned authority, "patients could be induced to retire to a pleasant part of the country where they would take moderate exercise, and be free from mental anxiety, meet with agreeable society, live regularly, take small doses of alkalies, and bathe themselves for an hour or two a day in warm water, in which some carbonate of soda has been dissolved, they would receive as much benefit as by travelling hundreds of miles away; and at much less trouble and expense." There is a great deal in these words _free from mental anxiety_. It is to obtain this very needful aid to the cure of chronic complaints, especially those brought about by over-work or fast living, that we ourselves are in the habit of recommending to our patients a short sea voyage, such as that to America or Madeira and back. But very great benefit results in numerous cases from a short residence at some of the innumerable hydropathic establishments, which, like small terrestrial paradises, are scattered here and there in our beautiful island home. Those actually sick may go there, as well as the languishing invalid or _the over-worked_ man of business, or worn-out pleasure hunter. To those resorting to these sanatoria, we can confidently recommend a handy and useful invention, recently brought out by Messrs. Allen and Son (Plate Six). It is a portable electric bell, the cords can be passed under or over the doors, from one room to another, and by this means the nurse or attendant can be called immediately and _quietly_ at any hour of the day or night. We do not mean here to say much about the mercurial bath, because it must only be used under medical advice, but while reminding the reader that there is provision made for this kind of bath in the portable Turkish bath (page 44) there is (see Plate Seven) a nice handy little apparatus which can be used for this purpose used for this purpose or any other kind of fumigatory bath which the physician considers it right to recommend. Some of the most efficacious medicated bath in common use are:-- 1. THE BORAX BATH.--This is soothing and calmative in many irritable forms of skin disease. It is made in the proportion of four ounces of borax and three of glycerine, to thirty gallons of hot water. 2. THE AMMONIA BATH, used as a skin stimulant and derivative. The following is Mr Grantham's formula:--Two ounces of strong hartshorn in two gallons of water, used in a hip bath. An excellent hip bath, very useful for people to whom stooping is objectionable is that made by the Messrs. Allen (Plate Eight). One glance at the figure will show its many advantages, and we strongly recommend it. People who suffer from cutaneous eruptions ought to take skilled advice before using a course of baths, but the following sentences excerpted from E. Wilson's "Diseases of the Skin" may be read with profit by all. "Aqueous remedies," says the dermatologist, "present themselves in the form of simple water in its various states of cold, tepid, warm, hot and steam; water impregnated with saline matter as in the sea-bath, and saline solutions; in lotions, fomentations and poultices. Water may be sedative, emollient, or stimulant, according to the manner in which it is employed. As a tepid bath or fomentation it is sedative, and its sedative action is increased by the addition of various substances, such as oatmeal, starch, gelatine, and soda in small quantities. It is emollient when used as a water dressing or in the condition of steam, and it is stimulant when cold or hot. When hot it is the best means known of relieving pruritus (itching), and in its cold state it refreshes and gives vigour to the skin; hence, the morning bath, the sea-bath, and daily ablutions with soap. On this principle it is that we advise daily cold ablutions with soap of the face in cases of acne (pimples), and to other parts of the body, particularly the _axilla_ and _perinaeum_ in chronic eczema or chronic pruritus. Aqueous lotions of _liquor plumbi_ (sugar of lead) are refrigerant and sedative, while lotions of carbolic acid, sulphurate of _potash, acetate_ of _ammonia_, and _bicarbonate_ of _ammonia_ are anti-pruritic. Warm fomentations are sedative and anodyne, and their properties are increased by the addition of poppy heads. Poultices are emollient and sedative, but their protracted use, as of all aqueous applications, macerates and weakens the skin, and tends _to perpetuate_ the disease or cause boils. As a rule, all aqueous applications except simple bathing, must be employed with great caution in skin diseases. Saponaceous ablutions generally aggravate eczematous affections; but certain forms and stages of that disease are benefitted by their use." As a means of using the hip bath, whether medicated or otherwise, and for female complaints and irregularities, there is nothing to equal the bidet herewith figured (Plate Nine). 3. FOMENTATIONS are simply local baths and are used to relieve pain and reduce inflammation, as in the poppy head or laudanum fomentation to painful swellings, or the turpentine fomentation to redden the chest in severe colds. The water must be very hot, and two pieces of flannel must be used, wrung from the water, time about. These may be sprinkled with laudanum or turpentine as the case may demand. 4. THE MUSTARD FOOT-BATH is useful in cases of incipient colds, headaches, or languor and listlessness with restless nights. A bucketful of hot water with a handful of mustard in it is all that is wanted; in this the legs are to be bathed for twenty minutes before going to bed. 5. THE OAK BATH is made by adding a pound of bruised oak bark to a quart of cold water and boiling for half an hour; the half of this maybe put in the morning tub as a tonic bath. 6. THE PINE BALSAM BATH is good in cases of rheumatism and great nervousness. The balsam is a distillation front the leaves of pines, and is simply added to the bath. 7. THE ALKALINE BATH may be used twice or three times a week by gouty or rheumatic subjects. Two ounces of the bicarbonate of soda are added to three gallons of warm water, and the bath is ready. 8. THE PEAT WATER Bath is a German invention, and seems to be of great value to sufferers from gout and rheumatism, swelling of the joints, congestion of the liver, etc. Why the peat of this country should not be as efficacious as that from German bogs we fail to understand. 9. THE ELECTRIC BATH is a good deal used at seaside places, and often with advantage, especially in cases where the tone of the system has been much lowered. 10. THE VINEGAR SPONGE BATH consists of one part of vinegar to three of cold water, the body or hands and arms, feet and legs, are then sponged with it. 11. THE IRON BATH is sometimes used as a tonic, and is of considerable efficacy, especially to delicate females and children. It is composed of half an ounce of sulphate of iron, in four gallons of cold or tepid water. 12. SULPHUR BATHS, CREASOTE BATHS, and NITRO-HYDROCHLORIC BATHS are all good in their way, but must only be used under medical advice. CHAPTER SEVEN. THE ORDINARY HOME BATHS--SEASIDE BATHING. The morning tub is a bath that people in ordinary health should take every morning. It is not only invigorating but it so tones the skin and nerves as to render catching cold all but impossible. A far better tonic for those who can bear it, is the shower bath. A cheaper sort of Shower Bath is that represented underneath. (Plate NINE.) From a recent Magazine Article of ours, we cull the following hints which may be found of use. In speaking of House Baths we say:-- 1.--Then you must consult your own feelings as to whether or not you ought to continue the bath through the livelong winter. We should say, "Try to do so." 2.--Let the first spongeful of cold water be applied to the head and shoulders and adown the spine. 3.--If you feel too much exhausted in the morning for a cold bath, from having been up late, raise the temperature of the cold bath several degrees. 4.--Be guided by your own feelings as to the temperature of hot and cold water. From 32 to 60 degrees would be right for the cold bath, and about 90 degrees for the water in the basin. 5--A cold bath may be taken with advantage when the body is heated, from whatever cause, so long as there is no exhaustion or fatigue; but never go into the water if there be the slightest feeling of chilliness, nor after a full meal. Plate Twelve represents a useful kind of bed bath which has been a source of comfort to many an invalid. (All these baths are manufactured by Messrs. Allen and Son.) In bathing at home, after lathering the whole body with warm water and soap, a cold sponge bath containing a handful or two of either Tidman's or Brill's Sea Salt will be found very invigorating. We have before us a splendidly got up work entitled "Luxurious Bathing," published by Messrs. Field and Tuer, Leadenhall Street, E.C. The book is beyond praise, its well-executed etchings entitle it to a place on the drawing-room table, and its advice to those who value health, is simply invaluable. Those who suffer from weakness, or who dread the winter's cold, would do well to combine a course of bathing, with one of tonics and cod liver oil. De Jongh's light brown is the only oil we ever use. Those who wish to regain health in a month, "by the sad sea waves," cannot err by taking the following rules as a guide. They are from a Magazine article of ours:-- _Simple Rules for Seaside Enjoyment_. 1.--Before leaving home, study your trains, pack trunks the day before, don't forget anything, and avoid hurry and excitement. 2.--Look for rooms quietly, in a clean, quiet street or suburb, and see that the rooms are clean and airy. 3.--Rise early every morning, soap down and tub from head to heel, eat a biscuit, and go for a walk. 4.--Regular hours, regular exercise, regular meals, and regular medicine (if you need it). 6.--Enjoy yourself all you can, but 'ware excitement and fatigue. 6.--Strong men may bathe before breakfast, but the best average time is about three hours after breakfast. 7.--Walk at a moderate pace to the bathing ground, so as to be neither too hot nor too cold, and undress as speedily as possible. 8.--It is better to plunge at once into deep water; don't unless you can swim, however, but after bending down and laving the face and both arms, drop right underneath the first wavelet. 9.--If you can swim, swim and nothing else; if you cannot, you can at least tumble about and keep moving, and also rub your limbs with the hands. 10.--Come out before you have actually ceased to enjoy yourself. 11.--It is better to have your own towel, one at least, and let it be moderately rough. 12.--Rub your face, shoulders, limbs, and body, using moderate friction, and finish drying with a smoother towel. 13.--When quite dry, dress, and it ought not to be at all necessary to dress quickly. 11.--If faintness or sickness comes on, which must be looked upon as quite an accident, lie down for a few minutes. 15.--After dressing, a brisk walk should be taken; and now a lunch biscuit will do you service. 16.--Remember that the glow after the bath is the grand event to be looked for. 17.--If instead of this glow a decided chill takes place, and is not removed by a brisk walk, a small drop of brandy taken along with a biscuit becomes a necessity, or for ladies a glass of some cordial. 18.--If you are an invalid, try to forget it; if a Hercules or a Webb, forget that. 19.--Don't forget flannel under-clothing if at all delicate. There are various other kinds of baths which we have not mentioned, but trust we have said enough to prove that the baths in some form--and more especially the Turkish--should be taken constantly by all who value good health and hope for longevity. 
27128	----	DR. DEWEY'S BOOKS. =The True Science of Living; or, The New Gospel of Health.= $2.25, sent postpaid. "Dr. Dewey's logic seems unanswerable."--_Alexander Haig, M.A., M.D. Oxon., F.R.C.P._, London, Eng. author of "Uric Acid as a Factor in the Causation of Disease," "Diet and Food." "I am glad to find myself in general accord with the views of Dr. Dewey."--_A. Rabagliati, M.A., F.R.C.P._, Edinburgh, Scotland, author of "Air, Food, and Exercises." "Dr. Dewey has written an epoch-making book."--_Emmett Densmore, M.D._, New York. "'The True Science of Living,' in its adaptation to the needs of humanity, ranks, in my estimation, with the writing of the Egyptian prince, the Jewish law-giver, the inspired Moses."--_Amos R. Collins, M.D._, Westerly, R. I. "To live according to the teaching of either of these books would soon make a new race."--_J. W. 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"The last line of 'A New Era for Women' has been read, and I wish, with all my heart and soul, that every woman in the world could read Dr. Dewey's words with that burning conviction which is mine."--_Alice McClellan Birney_, President of Woman's Congress. "Taken altogether, 'The New Era for Women' will be found worthy of a place in every household, and should be read by every woman in the world."--_Chester County Times._ "Plain, common sense, devoid of puzzling, technical terms. Every woman who cares for ideal health should purchase this book, and help to inaugurate the 'new era' for her sex."--_The Search Light._ =Chronic Alcoholism.= Price, 50 cents. [Illustration: (signed) E. H. Dewey.] THE NO-BREAKFAST PLAN AND THE FASTING-CURE. BY EDWARD HOOKER DEWEY, M. D. MEADVILLE, PA., U. S. A.: PUBLISHED BY THE AUTHOR. 1900. COPYRIGHT, 1900, BY EDWARD HOOKER DEWEY. REGISTERED AT STATIONERS' HALL, LONDON, ENGLAND. _All Rights Reserved._ TO GEORGE S. KEITH, M.D., LL.D., F.R.C.P.E., SCOTLAND, A. RABAGLIATI, M.A., M.D., F.R.C.P., EDINBURGH, AND ALEXANDER HAIG, M.A., M.D., OXON., F.R.C.P., LONDON, ENGLAND, WHO HAVE COMMENDED THE WRITINGS OF THE AUTHOR IN THEIR OWN PUBLISHED WORKS, THIS BOOK IS GRATEFULLY DEDICATED. PREFACE. This volume is a history, or a story, of an evolution in the professional care of the sick. It begins in inexperience and in a haze of medical superstition, and ends with a faith that Nature is the all in all in the cure of disease. The hygiene unfolded is both original and revolutionary: its practicality is of the largest, and its physiology beyond any possible question. The reader is assured in advance that every line of this volume has been written with conviction at white heat, that enforced food in sickness and the drug that corrodes are professional barbarisms unworthy of the times in which we live. E. H. DEWEY. MEADVILLE, PA., U. S. A., _November, 1900_. CONTENTS. THE NO-BREAKFAST PLAN. I. PAGE Introduction--Army experiences in the Civil War--Early years in general practice--Difficulties encountered--Medicinal treatment found wanting as a means to superior professional success 13 II. A case of typhoid fever that revolutionized the Author's faith and practice--A cure without drugs, without food--Resulting studies of Nature in disease--Illustrative cases--A crucial experience in a case of diphtheria in the Author's family 26 III. A study of the brain from a new point of view--Some new physiology evolved illustrated by severe cases of acute disease 34 IV. The error of enforced food in cases of severe injuries and diseases illustrated by several striking examples 42 V. An apostrophe to physicians 56 VI. The origin of the No-breakfast Plan--Personal experience of the Author as a dyspeptic--His first experience without a breakfast--Physiological questions considered--A new theory of the origin and development of disease and its cure--The spread of the No-breakfast Plan--Interesting cases 60 VII. Digestive conditions--Taste relish--Hunger relish--The moral science involved in digestion as a new study--Cheer as a digestive power--Its contagiousness--The need of higher life in the home as a matter of better health--Cheer as a duty 81 VIII. The No-breakfast Plan among farmers and other laborers--A series of voluntary letters to an eminent divine, and the writer put down as a crank--The origin of the Author's first book--How the eminent Rev. Dr. George N. Pentecost was secured to write the introduction--His no-breakfast experience--The publisher converts a prominent editor--The case of Rev. W. E. Rambo, a returned missionary--The publishers' missionary work among missionaries-- The utility of the morning fast--Its unquestionable physiology-- Why the hardest labor is more easily performed and for more hours without a breakfast 85 IX. The utility of slow eating and thorough mastication unusually illustrated by Mr. Horace Fletcher, the author--What should we eat?--The use of fruit from a physiological standpoint 105 X. Landscape-gardening upon the human face--A pen-picture-- Unrecognized suicide--Absurdity of the use of drugs to cure diseases--A case of blood-letting--Mission of homoeopathy-- Predigested foods 110 THE FASTING-CURE. XI. The forty-two day fast of Mr. W. W. C. Cowen, of Warrensburg, Ill., and its successful end--Press account--The twenty-eight day fast of Mr. Milton Rathbun, of New York, and its successful end--Press account--A second fast of Mr. Milton Rathbun, of thirty-five days, in the interest of science, and its successful end--Press account--Adverse comments of Dr. George N. Shrady, an eminent New York physician 117 XII. The remarkable fast of forty-five days of Miss Estella Kuenzel, of Philadelphia, resulting in a complete cure of a case of melancholia--Press accounts--A still more remarkable fast, of fifty days, of Mr. Leonard Thress, of Philadelphia, resulting in a complete cure of a bad case of general dropsy--Press accounts--General dropsy in a woman of seventy-six relieved by a fifteen-day fast, with the cure permanent--Rev. Dalrymple's fast of thirty-nine and one-half days without interruption of pastoral duties 136 XIII. Insanity--A study from a new point of view--Its radical cure deemed probable in most cases by protracted fasts--Feeding the insane as practised in the hospitals sharply criticised--Some direct words to physicians in charge 157 XIV. The evolution of obesity, and its easy relief by fasting-- Overweight prevented by a limitation of the daily food and without lessening any of the powers or energies--The evolution and prevention of apoplexy 177 XV. Chronic alcoholism--The evolution of the drunkard--His complete, easy, rational cure by fasting--No case so grave as to be beyond cure by this means--Asthma; Its cure through dietary means--A railroad tragedy--The need of railroad men to save their brains from needless waste of energy in their stomachs--An illustrative case--Some of the Author's troubles from the ignorance of the people--The death of Mrs. Myers, of Philadelphia, on the thirty-fifth day of her fast--Adverse press accounts and comments--Adverse comments of Prof. H. C. Wood, M. D., L. L. D., on fasting and fasters 183 XVI. A successful sixty-day fast under the Author's care--More about predigested foods--Bathing from a physiological standpoint--The error of drinking water without thirst--Some earnest words to the mothers of this land--What the No-breakfast Plan means for them and their children--Concluding words 199 ILLUSTRATIONS. PORTRAIT OF THE AUTHOR _Frontispiece._ MRS. A. M. LICHTENHAHN, THIRTY-SIXTH DAY WITHOUT FOOD Opposite p. 54 REV. GEORGE SHERMAN RICHARDS " 94 MRS. E. A. QUIGGLE " 104 MR. MILTON RATHBUN SHORTLY AFTER HIS FAST " 132 MISS E. F. KUENZEL, FORTY-FIRST DAY OF FAST " 146 MR. LEONARD THRESS, FIFTIETH DAY OF FAST " 152 MISS E. W. A. WESTING, FORTIETH DAY OF FAST " 154 THE NO-BREAKFAST PLAN. I. A hygiene that claims to be new and of the greatest practicality, and certainly revolutionary in its application, would seem to require something of its origin and development to excite the interest of the intelligent reader. Methods in health culture are about as numerous as the individuals who find some method necessary for the health: taking something, doing something for the health is the burden of lives almost innumerable. Very few people are so well that some improvement is not desirable. The literature on what to eat and not to eat, what to do and not to do, on medicines that convert human stomachs into drug-stores, is simply boundless. If we believe all we read, we must consider the location we are in before we can safely draw the breath of life; we must not cool our parched throats without the certificate of the microscope. We must not eat without an ultimate analysis of each item of the bill of fare, as we would take an account of stock before ordering fresh goods; and this without ever knowing how much lime we need for the bones, iron for the blood, phosphorus for the brain, or nitrogen for the muscles. In short, there is death in the air we breathe, death in the food we eat, death in the water we drink, until, verily, we seem to walk our ways of life in the very valley and shadow of death, ever subject to the attack of hobgoblins of disease. How many lives would go down in despair but for the miracles of cure promised in the public prints, even in our best journals and monthlies, we cannot know. It is the hope for better things that sustains our lives; suicide never occurs until all hope has departed. Even our medical journals are heavily padded with pages of new remedies whose use involves the most amazing credulity. Perhaps it is well, in the absence of a sound physiological hygiene, that the people who are sick and afflicted shall be buoyed up by fresh, printed promises. Perhaps it is also well for the physician to be able to go into the rooms of the sick inspired from the advertising pages of his favorite medical journals. Are they not new stars of hope to both physician and the people? Why should we not hope when new remedies are multiplying in such infinite excess over newly discovered diseases? _New diseases?_ What is there essentially new that can be treated with remedies, in the coated tongues, foul mouths, high temperature and pulse, pain, discomfort, and acute aversion to food, that is to be found in the rooms of the sick? Are there really specifics for these conditions? The hygiene to be unfolded in these pages is so new, so revolutionary, that its first impress has never failed to excite every form of opposition known to language, and yet its practicality is so great that it is rarely questioned by those who fairly test it. It has not been found wanting in its physiology, nor has it failed to grow wherever it has found lodgement. The origin and development of this new way in health culture seem to require something of professional autobiography, that it may be seen that it is a matter of evolution and not of chance, not a fad that has only its passing hour. After receiving my medical degree from the University of Michigan, and serving a term as house physician to the U. S. Marine Hospital at Detroit, Michigan, I entered one of the large army hospitals at Chattanooga, Tenn., at the beginning of the Sherman campaign in Georgia, where I found a ward of eighty sick and wounded soldiers fresh from the battle of Resacea. My professional fitness for duties so grave and so large in extent was of a very questionable order, and I did not in the least overestimate it. It had not escaped my notice, even before I began the study of medicine, that whether disease were coaxed with doses too small for mathematical estimate, or whether blown out with solid shot or blown up with shells, the percentage of recoveries seemed to be about the same regardless of the form of treatment. I was reared in a large family in a country home, several miles from a physician, where all but the severest sicknesses were treated with herb-tea dosage, and this was true of all other country homes. With all this in mind I had begun the study of medicine with a good deal less than the average faith in the utility of dosage, and it was not enlarged by my professor of materia medica. I entered upon my serious duties as did good, rare, old Bunyan into his pulpit, with a feeling fairly oppressive that I was "the least of all the saints." My materia medica was in my vest pocket; my small library in my head, with its contents in a very hazy condition. With a weak memory for details, and marked inability to possess truth except by the slow process of digestion and assimilation, my brain was more a machine-shop than a wareroom; hence capacity of retail dealing was of the smallest. I was not in the least conscious at this time that a large wareroom amply stored by virtue of a retentive memory was not the most needed as an equipment for all the practical affairs of life. I have ever found it necessary to dodge some memories, when there was lack of time to endure a hailstorm of details. That I did not become a danger to the hapless sick and wounded only less than their diseases and wounds, was wholly due to my small materia medica, to utter lack of pride in knowledge that had not become a power with me, and to that lofty ambition for professional success which moved me to seize aid from no matter where or whom, as the drowning man a straw. It was my great professional fortune that the medical staff of this hospital of more than a thousand cots was of a very high order of ability and experience, and that I entered at the beginning of a campaign in which for more than three months there was a fitful roar of artillery and rattle of musketry every day; hence a continuous influx to cots vacated by deaths or recoveries. In all respects it was the best equipped hospital for professional experience of any that I knew anything about. There was one rigid rule that I believe was not carried out in any other hospital: post-mortems in all cases, numbering from one to a dozen daily, and all made with a thoroughness I have never seen in private practice. The features of my hospital service that impressed me most were the post-mortem revelations and the diverse treatments for the same disease. I soon found that, no matter what the disease, every surgeon was a law to himself as to the quality, quantity, and times of his doses, with the mortality in the wards apparently about the same. Post-mortem examinations often revealed chronic diseases whose existence could not have been suspected during life, and yet had made death inevitable. Another advantage in army hospital practice was the stability of the position and the absence of the harassing anxiety of friends, thus affording the highest possibilities of the judgment and reason. And still another advantage was the high social relations existing between the medical officers, due to the absence of all causes for jealousy, neither the position nor salary depending on superior endowments or professional success. I was aware that, in spite of my lack of experience and the presence of a most painful sense of general insufficiency, my sick and wounded were about as safe in my hands from professional harm, even from the first, as the patients of the most experienced medical officer in the hospital. With high professional ideals, with no ability to make use of hazy conceptions or ideas, having no pride in knowledge that had not become my own, I began at once to reinforce myself from the experience and wisdom of my brother officers, whose advisory services were always readily and kindly rendered. From the first and all through my military service my severely sick had the advantage of all the borrowed skill and experience I could command. As for surgical operations, they were all performed in the presence of most of the medical staff, some of whom were of great experience. The surgery of the army hospitals of 1864 was of the highest character in skill and in careful attention to all the details involved, and the fatalities were generally due to the gravity of the wounds requiring operations and lack of constitutional power for recovery, rather than to the absence of the germ-killer. At that time the microbe was not a factor in the probabilities of life or death. In all else the care of the wounds could hardly be surpassed. As for the medicinal treatment of my sick, it was unsatisfactory from first to last. After all the years since I cannot believe that, except for the relief of pain, any patient was made better by my dosage; and in all fatalities the post-mortem revealed the fact that the wisest dosage would have been without avail. But in the study of the history of disease as revealed by symptoms my hospital experience was invaluable. I have since found that my greatest service at the beds of the sick is as an interpreter of symptoms rather than a vender of drugs. The friends of the sick read indications for good or bad with wonderful acuteness, as a rule; and I have rarely found myself mistaken in my ability to read the condition of patients in the faces of the friends, even before I enter the rooms of the sick. As my experience enlarged so did my faith in Nature; and, since there was no similarity in the quality, sizes, and times of the doses for like diseases, my faith in mere remedies gradually declined. After a year and a half of large opportunities to study the diseases of men in the early prime of life, in the care of the simple surgery of shot and shell, I left the army with such familiarity with grave diseases and death in various forms as to enable me ever after to retain complete self-possession in the presence of dying beds in private practice. I began the general practice of medicine in Meadville in the autumn of 1866. Among the many physicians located in the city at that time were men of ability and large experience. There were those who administered with sublime faith doses too small for mathematical estimate; those who with equal faith administered boluses to the throat's capacity for deglutition; those who fully believed in whiskey as nourishment, that milk is liquid food, and who with tremendous faith and forceful hands administered both until human stomachs were reduced to barren wastes and death would result from starvation aggravated by disease. Most of the cases of disease that fall to the care of the physician are trivial, self-limited, and rapidly recover under even the most crucifying dosages; Nature really winning the victories, the physician carrying off the honors. This is so nearly true that it may be stated that, aside from the domain of surgery, professional success in the general sense depends upon the personal qualities and character of the physician rather than the achievements of the materia medica. People have a confidence in the power of medicine to cure disease scarcely less than the dusky warrior has in the Indian medicine-lodge of the Western wilderness, and a confidence about as void of reason. The physician goes into the rooms of the sick held to the severest accountability in the matter of dosage; and the larger his own faith in medicines the greater his task; and, if he is of my own, the so-called "old school," or Allopathic, the more dangerous he is to the curing efforts of Nature. With the people the disease is simply an attack, and not the summing up of the results of violated laws going on perhaps from birth. With the people the symptoms are merely evidences of destruction, and not the visible efforts to restore the normal condition. Hence the failures to relieve always raise more or less questioning, among friends in painful concern, as to the ability of the physician to discharge his grave duties. This unreasoning, unreasonable "blind faith" in remedial means is as strong in the most intelligent as in the most ignorant, and it has ever given me more trouble than the care of the sick. Another serious complication of the sick-room arises from near-by friends who are very certain that their own physicians are better fitted by far for the serious work of prescribing for the sick. In addition to the serious work of attacking the symptoms of disease as so many foes to life, there is also a care as to what unbidden food shall go into unbidden stomachs, that the system shall be supported while life seems to be in the hands of its greatest enemy. The universal conception of disease as a foe to life, and not as a rational process of cure; the boundless faith in remedies as means to resist the attack, revealed by symptoms, makes the professional care of the sick the gravest of all human occupations, and the most trying to both head and heart. With all these taxing conditions confronting me, I opened an office in a field which seemed to be more than occupied by men of large experience. With all my army experience I still had a hazy conception as to Nature in disease. That the vital forces needed the support of all the food the stomach of the sick could dispose of, was not a question of the remotest consideration. That medicine did in some way act to cure disease I could not fully question. I was now to enter a service in which, from the care of infancy in its first breathings to old age in its last, every resource of the materia medica, of the reason, judgment, and of the soul itself, was to be called in in every grave case, and to be held to a responsibility measured by preposterous faith in medicines. I entered upon my duties with a determination to win professional success by the most thorough attention to all the details of service upon the sick and their friends, and I confined my efforts almost wholly to acute cases. None of my professional colleagues were winning laurels by the treatment of chronic diseases, and not having faith in drugs for such I had my scruples about fees for failures that seemed inevitable. And yet with the most painstaking service fortune would play with me at times in the most heartless manner. At one time four of my adult patients were awaiting burial within the radius of a half mile. As they were all physical wrecks, and died after short illnesses, there could be no question raised in any just sense as to the character of my services, but the fatalities were scored against me. Such fortune would be annihilating but for the fatalities inevitable with all practitioners. For full ten years I visited the sick and dosed them according to the books, but with far less force of hands and faith than any of my brethren, and all were enjoined to take nourishment to keep up the strength for the combat with disease. My doses were confined to only a few Sampsons of the materia medica, and these were administered with a watching for favorable results that could hardly be surpassed, and yet always with disappointment. I was innocent enough to believe that a large practice could only be built up by the most painstaking and persistent effort; later on I found that a large practice was but little dependent upon the skill and learning displayed in the sick-room. One physician could immediately secure a large patronage because she was a woman; another, because he belonged to this or that nationality, or there was something in the personal outfit rather than in the professional that incited large hopes for the ailing. In all my cases of acute sickness there was always a wasting of the body no matter how much they were fed; a like increase of general strength when a normal desire for food occurred no matter how little they were fed. I saw this with eyesight only; but I saw with insight that a large practice could be carried on by doctors too ignorant to know that there was an alphabet in medical science. I was not then so fully aware of the depths of ignorance among the people as to what cures disease, did not know that faith in doses was so large, as child-like even with the most cultured as with the ignorant. I was not so well aware, as I became later, that the physician himself must have such energy of faith in the materia medica as to reveal it in every line of his countenance when in the rooms of the sick. As the years went on, my faith in remedies did not increase; but I had to dose to meet the superstitious needs of the people. My practice, though far short of what it seemed to merit from the pains bestowed upon it, was large enough for all the needs of profitable study had I been in a condition for thought and reflection. It was not to my encouragement that there were those doing a far larger business with doses simply crucifying, and because crucifying, a far larger attendance was the direct result. I now see, as I did not then so clearly, that Nature's victories are often won against the desperate odds of treatments that are simply barbarous; and yet Nature is so powerful, so persistent in the attempts to right all her wrongs, that she wins the victory in the great majority of cases no matter how severely she may be taxed with means that hinder. The great majority of the severely sick of a hundred years ago recovered in spite of the bloody lancet and treatments that are the barbarism of to-day. II. I was called one day to one of the families of the poorest of the poor, where I found a sick case that for once in my life set me to thinking. The patient was a sallow, overgrown girl in early maturity, with a history of several months of digestive and other troubles. I found a very sick patient, so sick that for a period of three weeks not even one drink of water was retained, not one dose of medicine, and it was not until several more days that water could be borne. When finally water could be retained my patient seemed brighter in mind, the complexion was clearer, and she seemed actually stronger. As for the tongue, which at first was heavily coated, the improvement was striking; while the breath, utterly foul at first, was strikingly less offensive. In every way the patient was very much better. I was so surprised at this that I determined at once to let the good work go on on Nature's own terms, and so it did until about the thirty-fifth day, when there was a call, not for the undertaker, but for food, a call that marked the close of the disease. The pulse and temperature had become normal, and there was a tongue as clean as the tongue of a nursing infant. Up to this time this was the most severely sick case I ever had that recovered, and yet with not apparently more wasting of the body than with other cases of as protracted sickness in which more or less food was given and retained. And all this with only water for thirst until hunger came and a _complete cure_! Such ignoring of medical faith and practice, of the accumulated wisdom and experience of all medical history, I had never seen before. Had the patient been able to take both food and medicine, and I had prohibited, and by chance death had occurred, I would have been held guilty of actually putting the patient to death--death from starvation. Feed, feed the sick whether or not, say all the doctors, say all the books, to support strength or to keep life in the body, and yet Nature was absurd enough to ignore all human practice evolved from experience, and in her own way to support vital power while curing the disease. I could recall a great many cases in which because of intense aversion to food patients had been sick for many days, and even weeks, with not enough nourishment taken to account for the support of vital power; but the fact did not raise a question with me. The effect of this case upon my mind was so profound that I began to apply the same methods in Nature to other patients, and with the same general results. The body, of course, would waste during the time of sickness; but so did the bodies of sick that were fed. As for medicines, they were utterly ignored except where pain was to be relieved, though unmedicated doses were alike a necessity with all. Not a single medicine was given except for pain, and occasionally in cases in which I had reason to think the entire digestive tract needed a general clearing of foul sewage. Thence on, that supreme work, the cure of disease, in my hands became the work of Nature only. In a general practice I was able to carry out the non-feeding plan by permitting the various meat teas or the cereal broths, none of which can be taken by the severely sick in quantities to do harm. By withholding milk I was enabled to secure all the fasting Nature required, while satisfying the ever-anxious friends with tea and broth diversions. This was a line of investigation that I felt ought to be of the deepest interest to every thinking, high-minded physician, to every intelligent layman; and very early the evidences of the utility of withholding food from the sick during the entire time of absence of desire for it, its absolute safety, were beyond any questioning. I had no fatalities that were apparently in any way due to the enforced lack of food. In cases of chronic disease in which death was inevitable, such as cancer, consumption, etc., patients were permitted to take what they could with the least offence to the sense of relish. In every case of recovery there was a history of increasing general strength as the disease declined, of an actual increase of vital power without the support of food that had no more relish than the dose that crucified the nerves of taste. In all America milk is the chief reliance to support vital power when no other food can be taken. Milk in one stage of normal digestion gets into the form of tough curds ready for the press, and curds should always be thoroughly masticated before swallowing. Sir William Roberts, of England, in his exhaustive work on _Digestion and Diet_, asserts that milk-curds are not digested in the stomach during sickness, but are forced into the duodenum, where, he asserts, they are digested, but he gives no reason for his faith that there is power to digest in the duodenum where there is none in the stomach. It was not difficult to make the mothers in the homes understand that taking milk by the drink was equivalent to swallowing green cheese-curds without due mastication. With these hygienic conceptions and methods I continued to visit the sick as a mere witness of Nature's power in disease rather than as an investigator, yet without being able to understand the secret of the support of vital power without food. But whatever risk there might be, or how strong my faith when my patrons were the subjects of what might be called foolhardy experiments, there came a time when this faith was to have the severest of all tests. An epidemic of diphtheria broke out among my nearest neighbors, and after four deaths in as many families within a stone's throw of my residence a son of mine aged three years was taken. I had never given him in all his life even a cross look, and whatever sin there was in making idols of children in this I was the worst of all sinners, and I did not quite believe, as some Christian folks would have me, that my happiness through him was not the very incense of gratitude to the great Author for the gift of such a treasure of the heart. In my hour of trial two of my ablest and most experienced medical friends came to me. Quinine and iron in solution were their verdict--and the little throat was not copper-lined; and, in addition, all the strong whiskey possible to force into the stomach: all this would have required manacled wrists and the prying apart of set jaws. He had never received anything from me more violent than caresses, and this abomination of dosage was to be sent down a bleeding, ulcerated way, over raw surfaces that would writhe and quiver under the added torture. This would not be rational treatment for ulcerations on the body, and the loss of strength through resistance and structural injury to the throat had no promise of redemption except in the minds of my medical friends. It happened that I left home without getting the prescription filled, and, not getting back as soon as expected, the anxious wife procured the medicines and succeeded in getting one dose into the stomach, and also in raising a nervous hurricane that took an hour to allay. She was then informed that such a dose would be cruel even to a horse. Thence on he took nothing into his stomach but the water that thirst compelled, and a little dosage with it to meet the mother's need; and so I stood beside the suffering idol of my heart, with the entire medical world against me--strong enough, only rejoicing in my strength to defend him against the barbarism of authorized treatment. My only comfort was that in his time of supreme need I could give him supreme kindness, and if death must come there would not be the additional laceration of avoidable cruelty inflicted; and Nature, with every possible aid that could add comfort to the suffering body, won the victory. Since then the medical world has advanced to antitoxin as a specific, leaving me nearly alone to plodding ways that are by sight and not by faith. That the treatment of my sick son in the absence of the only supposed specific was in advance of my time, the medical world cannot now question. As the months and years went on, it so happened that all my fatalities were of a character as not to involve in the least suggestions of starvation, while the recoveries were a series of demonstrations as clear as anything in mathematics, of evolving strength of all the muscles, of all the senses and faculties, as the disease declined. No physician whose practice has been extensive has failed to have had cases in which the same changes occurred, and in which the amount of food taken did not explain this general increase of strength. Believing I had made a most important discovery in physiology, one that would revolutionize the dietetic treatment of the sick, if not ultimately abolish it, my visits to the sick became of unsurpassed interest, I watched every possible change as an unfolding of new life, seeing the physical changes only as I would see the swelling buds evolve into the leaves or flowers, reading the soul- and mind-changes in the more radiant lines of expression. I saw all these things with the naked eye, and more and more marvelled at the bulk of our materia medicas, the size of our drug-stores, and the space given to healing powers in all public and medical prints. For years I saw my patients grow into the strength of health without the slightest clue to the mystery, until I chanced to open a new edition of Yeo's _Physiology_ at the page where I found this table of the estimated losses that occur in death after starvation: Fat 97 per cent. Muscle 30 " Liver 56 " Spleen 63 " Blood 17 " Nerve-centres 0 And light came as if the sun had suddenly appeared in the zenith at midnight. Instantly I saw in human bodies a vast reserve of predigested food, with the brain in possession of power so to absorb as to maintain structural integrity in the absence of food or power to digest it. This eliminated the brain entirely as an organ that needs to be fed or that can be fed from light-diet kitchens in times of acute sickness. Only in this self-feeding power of the brain is found the explanation of its functional clearness where bodies have become skeletons. I could now go into the rooms of the sick with a formula that explained all the mysteries of the maintenance and support of vital power and cure of disease, and that was of practical avail. I now knew that there could be no death from starvation until the body was reduced to the skeleton condition; that therefore for structural integrity, for functional clearness, the brain has no need of food when disease has abolished the desire for it. Is there any other way to explain the power to make wills with whispering lips in the very hour of death, even in the last moments of life, that the law recognizes as valid? I could now know that to die of starvation is a matter not of days, but of weeks and months; certainly a period far beyond the average time of recovery from acute disease. III. There fell to my care a very much worn-out mother, who took to her bed with an attack of inflammatory rheumatism, with the joints so involved as to require the handling of a trained nurse. The agony was such that the hypodermic needle was required to make existence endurable, and it was used with the idea that the brain would be less injured by the remedy than by the agony with its inevitable loss of sleep. I know of no disease in which treatment has been more savage than in this. The remedies in common use at that time were mainly new and of supposed specific powers; but they were so violent, and proved to be so futile, that they have all been given up since by the majority of the profession. As the days went on the disease declined in spite of the enforced comfort through the needle; there were easier movements, a clearing of the skin from sallow to a tint of redness, and finally, after a month, the armchair could be used for a change. On the morning of the forty-sixth day there was revealed in the face the perfect color of health, and happiness marked every line of the expression. There was ability to walk through several rooms of her home. But it was not until the afternoon that the first food was desired and taken, and never before was plain bread and butter, the supreme objects of desire, so relished. In the following few months there was an actual gain of forty pounds. My next marked case is a wonderful illustration of the self-feeding power of the brain to meet an emergency, and a revelation, also, of the possible limitations of the starvation period. This was the case of a frail, spare boy of four years, whose stomach was so disorganized by a drink of solution of caustic potash that not even a swallow of water could be retained. He died on the seventy-fifth day of his fast, with the mind clear to the last hour, and with apparently nothing of the body left but bones, ligaments, and a thin skin; and yet the brain had lost neither weight nor functional clearness. In another city a similar accident happened to a child of about the same age, in whom it took three months for the brain to exhaust entirely the available body-food. I will now enter upon a study of the brain and its powers along these lines, to be enlivened by illustrative evidence. What reason and physiology had I with me that I should use methods in the sick-room wherein the entire medical world was against me, and with severest condemnation? The head is the power-house of the human plant, with the brain the dynamo as the source of every possible human energy. We think, love, hate, admire, labor with our hands, taste, hear, smell, see, and feel through the brain. Broken bones and wounds heal, diseases are cured through energy evolved in the brain or the brain system as a whole. The other so-called vital organs and the muscles are only as so many machines that are run by the brain power, with the stomach an exceedingly important machine. That powers so rare do not originate in the bones, ligaments, muscles, or fats, does not need argument; that when the nerve-trunks that supply the arm or leg are severed power of movement and feeling is lost, is known to all; and equally would the power of the stomach be abolished were the nerve-trunks cut off. In a general way, then, it may be stated that the strength of the body is directly as the strength of the brain. With this physiology, who in or out of the medical profession can fail to see clearly that the digestion of even an atom of food is a tax upon the strength of the brain for whatever of power needed by the stomach, the machine, for this purpose? Unless it can be proved that the stomach has powers not derived from the brain system, this will have to be admitted. How is the strength kept up in the light of this physiology? The universal belief is that it is kept up by the daily food. In proportion to the prostration of sickness, so are physicians anxious to conserve the energies by working the stomach to the limit of its powers. The impression that there must be something digested to support the vitality of the system is a belief, a conviction that has always been too self-evident to suggest a doubt. If the well need food to keep up the strength, the sick need it all the more; this is the logic that has been displayed upon this question. Let us keep it clear in mind that, if the nerves going to the stomach are severed, paralysis will result as in the case of the arm, in order more definitely to conceive the stomach as a _machine_ that requires power to run it even to a tiringout degree. This is strikingly illustrated by the exhausted feeling that invites the after-dinner nap for rest, which, however, does not rest overfilled stomachs, overfilled brains. The brain gets no rest while getting rid of food-masses with more of decomposition than of digestion. If food really has power to keep up the strength, there should not be so much strength lost by the general activities--indeed, it would seem that fatigue should be impossible. But the fact remains that from the first wink in the morning to the last at night there is a gradual decline of strength no matter how much food is taken, nor how ample the powers of digestion; and that there comes a time with all when they must go to bed, and not to the dining-room, to recover lost strength. The loss of a night of sleep is never made up by any kind of care in eating on the following day, and none are so stupid as not to know that rest is the only means to recover from the exhaustion of excessive physical activity. The brain is not only a self-feeding organ when necessary, but it is also a self-charging dynamo, regaining its exhausted energies entirely through rest and sleep. There is no movement so light, no thought or motion so trivial, that it does not cost brain power in its action--and this is true of even the slightest exercise of energy evolved in digestion. Why, then, do we eat? For two reasons, or perhaps three: we eat because we are hungry. We rarely fail to eat excessively to satisfy the sense of relish after the normal hunger sense has been dissipated; we may eat to satisfy relish as we eat ice cream, fruits, and the enticing extras that beguile us to put more food into the stomach after it is already overfilled for its working capacity. But our actual need of food, the best reason for taking it, is to make up for the wastes from the general activities; and this is a process in the order of Nature that actually tires the entire brain system, or, in the common phrase, the whole body, unless the stomach has powers not derived from the brain system. Now as we need not, cannot feed the brain in time of sickness, what can we feed? In all diseases in which there are a high pulse and temperature, pain or discomfort, aversion to food, a foul, dry mouth and tongue, thirst, etc., wasting of the body goes on, no matter what the feeding, until a clean, moist tongue and mouth and hunger mark the close of the disease, when food can be taken with relish and digested. This makes it clearly evident that we cannot save the muscles and fat by feeding under these adverse conditions. Another very important, unquestioned fact is that disease in proportion to its severity means a loss of digestive conditions and of digestive power. Cheer is to digestion what the breeze is to the fire. It may well be conceived that there are electric nerve wires extending from the depths of the soul itself to each individual gland of the stomach, with the highest cheer or ecstacy to stimulate the highest functional activity, or the shock of bad news to paralyze. From cheer to despair, from the slightest sense of discomfort to the agony of lacerated nerves, digestive power goes down. Affected thus, digestive power wanes or increases, goes down or up, as mercury in a barometer from weather conditions. Digestive conditions in their maximum are revealed in the school-yard during recess, when Nature seems busy recovering lost time. How compares the ramble of a June morning, with the blue and sunshine all above, the matchless green of the trees, and all the air fragrant with the perfume of flowers and alive with music from the winged singer, in digestive conditions, with those in the rooms of the sick, where there is only distress felt in the body and seen in the faces of the friends? In time of health, if we eat when we are not hungry, or when very tired, or in any mental worriment, we find that we suffer a loss of vital power, of both physical and mental energy. How, then, can food be a support to vital power when the brain is more gravely depressed by disease? Yet from the morning of medical history the question of how vital power is supported in time of sickness has never been considered, because there has never been any doubt as to the support coming from food. I assume this to be a fact, since all works on the practice of medicine of to-day enjoin the need to feed the sick to sustain their depressed energies--all this without a question as to whether there is not a possibility of adding indigestion to disease when food is enforced against Nature's fiat. Since vital power is centred in the brain, do we need to feed, can we feed, for other than brain reasons? This physiology admitted, there is no other conclusion possible than that feeding the sick is a tax on vital power when we need all that power to cure disease. With all this physiology behind me, for more than a score of years I have been going into the rooms of the sick to see the evolutions of health from disease, as I see the evolutions from the dead wastes of March to the affluence of June, and from the first I had the exceeding advantage of being able to study the natural history of disease, a history in which none of the symptoms were aggravated by digestive disturbances. As there was no wasting of vital power in the hopeless effort to save the body from wasting, I had a clear right to presume that my patients recovered more rapidly and with less suffering. With no perplexing study over what foods and what medicines to give, I could devote my entire attention to the study of symptoms as evidences of progress toward recovery or death; and in addition to all this there was the great satisfaction of being strictly in line with Nature as to when and what to eat. As to the danger of death from mere starvation, the following remarkable case reveals how remote it is in the ordinary history of acute diseases. The late Rev. Dr. Merchant, of Meadville, Pa., a short time before his death, which occurred some months ago, informed me that a brother entered the army during the War of the Rebellion with a weight of one hundred and fifty-nine pounds. He was sent home so wasted from ulceration of stomach and bowels that he actually spanned his thigh with thumb and finger. He lived ten days only, to astonish all by the clearness of his mind even on the last day of his life, when he could think on abstruse questions as he had never been known to do in health. At death his body weighed only sixty pounds. It was Dr. Merchant's opinion, from a history of the case, that no food was digested during the last four months of his life; but it is my opinion that it took a much longer time than this for the brain to absorb more than ninety pounds of the body. That life was shortened by the more rapid loss of the tissues from the disease is to be taken into account in estimating time in starvation. IV. Feeding the sick! Who that rule in kitchens and feed the well do not realize with weariness of brain the demands of the stomach that at each meal there shall be some change in the bill of fare? The chief reliance of physicians for the maintenance of strength while sick bodies are being cured is milk. As a food, milk was mainly destined for the calf, and not for man--certainly not after the coming of the molars. It is not a food that will start the saliva in case of hunger, as the odors from the frying-pan or from roasting fowl, yet because it plays such an important part as a complete food for some months in the life of the calf, and because it can be taken without especial aversion when the odors of the cooking-stove are an offence to the nostrils; it is given by the hour, day after day, and in some cases week after week; and there are physicians by the thousands who reinforce this inflexible bill of fare by the strongest alcoholics, whiskey being generally selected. In this connection I shall say of alcoholics that they contain not an atom that can be converted into living atoms; they congest and irritate the stomach, and hence lessen digestive power; and benumb all the brain powers and faculties. As a daily ration without change, this combination, strictly adhered to, would prostrate the energies of a giant, and he would find himself mustered out of all active service in less time than the hapless sick are often compelled to endure such feeding. Does Nature so conveniently reverse herself to meet an emergency that the sick can be built up and sustained by such feeding as would debilitate the well? In the city where I live the physicians average well in learning, ability, character, and experience. Among them are the extremists in dosage: those with a hundred remedies for a hundred symptoms; others with such boluses as would writhe the face of an ox. There are some with extraordinary force of command in the rooms of the sick, who believe that whiskey is nourishing and that milk is liquid food; that doses go into human stomachs to travel the rounds of the circulation, and finally drop off at the right place for either patchwork or original work. Whatever there is in drugs to cure disease, whatever in milk and the strongest alcoholics to sustain the strength, every protracted case has been made to reveal in their forceful hands. I have no reason to believe they exceeded authorized treatments. I have no reason to doubt that in all countries, in all lands, where there are educated physicians, the same appliances are in common use, appliances that will make the next short step from the lancet and bolus of a darker age the estimate of the time to come. The treatments of the sick are always changing, while the process of cure remains the same. Only in the case of broken bones are we compelled to let Nature do all the curing, while we may take pride in some progress in the mechanical appliances. As milk and stimulants are a common, authorized means to sustain the sick, and as they are poured into human stomachs with all the faith with which lancets were once forced into congested veins, their efficiency for good or evil must be studied by comparison. Treatments must lessen both the severity and the duration of disease to be of permanent benefit. For a study by comparison, this opportunity came to me. There was a call to attend a case of typhoid fever in a young girl. In the same vicinity there had been under the care of one of my forceful brethren a woman in middle life, whose stomach was habitually rejecting all the milk and alcoholics poured into it, the doctor having a theory that good would result no matter how brief the time they were retained. For a month my patient swallowed only the desired water and doses which did not corrode, a desire for food coming at the end of the month. The only day and night nurse was an overwrought mother, who got into bed with the same disease as soon as the daughter got out of it. There was another month of severer sickness, when without food and without the horror of dosage, as before, the call for food marked the close of the disease. My services ended here some days before the undertaker took charge of the doctor's case. A girl in her later teens, with a mild, so-called malarial fever, fell into the same forceful care. There was a true history in this case of nearly two gallons of whiskey, and daily milk from the quart at first down to inability to take the least nourishment at last. Then there were more than a month of days when vital power sustained itself without the ways of violence, death occurring during the _nineteenth week_. The ravenous brain had absorbed the lips to such thinness that the depressions between the teeth were clearly revealed. From the first dose to the last breath this was a case of dying, and the most persistent fight for life against immense odds I have ever become aware of in an acute case. In this case the stomach had become so seared by the alcoholic that digestion was impossible, as would have been the case in a body that was not sick. Near this home there was a more delicate girl of about the same age taken with the same fever; but with mild dosage and no food--in Nature's care--hunger came at the close of the fourth week. Later on in the same family there was a case of la grippe, in which for several years there had been chronic, ulcerative bronchitis that bid defiance to blisters and inhalations, the various specifics of another forceful predecessor, who also was a believer in large doses and full rations of alcoholized milk. The coughing was so persistent, so continuous, that only the hypodermic needle met the need. To prevent the tearing of a raw surface in the bronchial tubes by the cough was as necessary as to apply splints to a broken bone. There was no food for six weeks, and Nature made most of her opportunity, not only to cure the acute disease, but also the chronic disease, which for nearly ten years since has remained cured. I was summoned to Asheville, N. C., to see a young man in the last stage of consumption. I found him nearly a skeleton, though he had been eating six times daily for several months by the decree of a really learned physician. The belchings from gas were loud and frequent; the sputa by actual measure was about six ounces during every twenty-four hours. A fast was ordered, and on the third day a mass of undigested food was thrown up. As soon as the stomach and bowels became empty there was comfort all along the line, and the cough was so diminished, that less than an ounce of sputa was raised in twenty-four hours. After a week of fasting there came a natural desire for food, and thence on he enjoyed without distress of stomach all he wished to take. Thence on he lived with only the least discomfort, and with whispering lips he dictated to me his will, conveying large property. He could look with meaning when the power to whisper was gone, and life ended as the going out of a candle. For months his sufferings had nearly all been due to food masses in a state of decomposition. He saw clearly and mentioned often that his had been a case of starvation from overfeeding. Nature finally had to succumb because she was not also able to deal with a clearly avoidable disease, indigestion; but she kept up a brave fight until the body was nearly absorbed. As soon as the stomach and bowels became empty the friends noticed that nervousness largely disappeared. His sleeps were much longer, because not broken by coughing as before; and as the brain was not taxed with food masses there was an accumulation of power that was clearly revealed in the cheer of expression and a calmness as if heavenly rest had come at last. A few years ago an attorney in this city had to endure a course of fever to which was added all the known barbarism of the times. Under enforced food and stimulants his mind at last became so weak that the dosings were forced down his throat. There were many weeks of life at lowest ebb before the man of torture (the doctor) was compelled to discontinue his evil work, and there were then months, extending to years, during which there appeared a colorless ghost of his former self on the streets--and this in spite of a wood-chopper's daily eatings, which were far in excess of power to digest. At last he was brought to his couch with a mild fever complicated with a variety of other ailings. Not one of his friends who knew him intimately expected his recovery, as it was believed by them that there were chronic conditions that were beyond cure, and this because there had been death in manner, movements, and looks for months. And yet he had been able to take a stomach to his office every morning for many weeks filled with pancakes, sausage, fried potatoes, etc., only to shiver before the stove between his stomach-fillings. To this possibly hopeless case I was called, and from that time he was to suffer only from the disease. For nearly three weeks no food was called for; and yet power so increased that he became able to dress himself; and on the morning before hunger finally called for food he came down from his bedroom with a son on his back who weighed not less than seventy-five pounds. Thence on, life, color, mind, muscle, rapidly came until there was such regeneration as to reveal a new body and a new soul. Some years before this event an only son was taken sick with a mild fever. A young physician and friend of the patient was called whose faith in drugs, milk, and whiskey was boundless. He was fresh from his university, and therefore Nature had no part, through experience at the sick-bed, in the cure of disease. For many weeks these remedies of torture were vigorously and persistently enforced. But the time came when Nature would bear no longer. The father, a personal friend, came to see me simply to unburden himself, and as he was not able to give me the case I was unprofessional enough to advise that the attendance should go on, but that there should be a complete rest the physician should not know of. This was done, and in a few days there was a call for food, the first call in more than two months. Of course, there was a recovery, which was an exceeding victory for Nature against extraordinarily adverse conditions, but it required many months to restore the wrecked balance. As I write this experience the following comes to me as a still stronger indictment against authorized medical method. A. B., when in the early maturity of his physical manhood, was stricken with a partial paralysis that sent him to his bed. It was simply the case of a wound of the brain requiring rest as the chief condition for cure. But milk, whiskey, and drugs were used with the greatest persistence, and after three months he became able to be about, no less feeble in mind than in body, and with teeth utterly ruined by the dosage. For fully five years he went about his home and along the streets as one in a dream. For ten years there was inability to attend to his ordinary business. Life came at last through the no-breakfast plan. The most remarkable fight for life on the part of Nature against the adverse conditions of drugs, alcoholics, and milk I have ever known was in the following case: A spare woman, of perhaps forty years, came to her bed the victim of habitual bromidia and chloral, invited by severe headaches. The treatment of this case was as follows: whiskey every hour, milk every other hour; corrosive medication and powerful brain sedative every night, which would have paralyzed digestive energy for many days. There was not an hour during the twenty-four in which there was not dosing either to cure the disease or to sustain the system. The average quantity of whiskey was six ounces daily, and of milk nearly a quart. This treatment was borne for weeks, merging into months. There was no disease not caused by the treatments, and the battle went on until there was only the shadow of a woman left when Nature rebelled against further violence. A few days of peace were granted because hope had departed; but it took Nature more than a year to recover from the damage. A man of iron and steel, in the early prime of life, was the victim of a severe injury. With the agony of lacerated nerves and the hypodermic needle to make the digestion of food impossible, milk and whiskey were poured into an unwilling stomach from the first, and both were used until neither could be retained; and then the lower bowel was extemporized into a stomach. For one hundred and forty-six days, from three to seven doses of morphine were put into the arm daily; and morphine dries both mouth and stomach and lessens all energies of the brain. The body itself was not sick; there was no hint of disease in it; yet there were drugs prescribed that cost dollars by the score, and there were alcoholics by the gallon. For months the pain, alcoholics, and morphine kept the mind in such a daze that there were only the imbecilic mutterings of a dreamer in trouble. The only treatment indicated in this case was the best of surgery for the injury, and some easing doses for a short while at first, to relieve pain. No food would be desired or digested; so the fast would go on until there would be a natural hunger, which would only manifest itself when there would be marked relief from pain. The meals, thence on, would be so far apart that all would be keenly relished; and there could be no loss of weight when meals would be so taken. It is not surprising when I say that a seared stomach and a brain converted into a whiskey pickle had no part in the digestion of milk: else why did the weight of one hundred and sixty pounds at the time of the accident fall to eighty-five at the time of hunger? And all this drugging and alcoholics for a man who was not really sick! and the bill of fare that was not changed during one hundred and sixty days! and the time lost, and the expense entailed, and the anxious, aching hearts that were nearest the bed of horrors--of horrors, torments clearly invited. By way of contrast the following case is given. During vacation a lad of twelve years of one of my families took to his bed with appendicitis in severe form. A learned physician was called, and there were many days of morphine, with other medication and all the food that could be coaxed into an unwilling stomach. Enough morphine was given daily to paralyze digestive energy for at least two or three days in one in ordinary health. There was a month of this war against Nature, when the violence of the acute attack subsided and a partial victory was gained against great odds. On my return I found him under heavy dosage for the recovery of strength and lost appetite. Colorless, anæmic, languid--he was barely able to walk. He was immediately put under my care, and therefore under a fast that ended in a few days in such hunger as had not been felt in several months; and color, cheer, energy, weight evolved in a month. But there was also a developing abscess deep in the groin, and the time came when a grave operation was necessary to save life. He was made ready for the surgeon's knife that cut its way down, down many inches to relieve walls ready to burst from the tension. The wound remained in the care of the surgeon, but the life in my care. Who deny that the anæsthetic, the shock of the operation, and the subsequent pain will not abolish all power to digest as well as all the desire for food? Here was a patient waiting for Nature to rally, which she did on the third day in a call for food; and thence on one daily meal was keenly relished, and the wound was healed--a wound that was three inches long on the surface and six inches deep. On the fifteenth day the lad was able to be dressed and able to walk about his room, and with a freshness of color that was never observed in him before. What law of body was violated in the preliminary treatment intended to prepare Nature for the ordeal and to enable her to rally from it? This fresh tragedy in one human life has become known to me while I write. A man, a giant, in his eighty-eighth year, lost his appetite, and was put to death by the following means: A pint of whiskey and from one to two quarts of milk daily to keep him nourished. Five months passed without any change in the bill of fare--five months of delirium, of imbecilic muttering before the last breath was drawn. These tragedies are common the world over. Do I cry against them with too loud a voice? Would that I had a voice of thunder! I have given a few examples of the crucifixions of the sick and the afflicted, whereof I have many, and they are the real history of cases known, and are constantly occurring in every community. The cure of disease and injury by fasting--the mode of Nature--made the greatest impression in families in which there was intelligence enough to comprehend it; but the victories of Nature were complicated by cases in which death was inevitable. With a feeling that I must give the new hygiene to the world in printed form, I did not enlarge in public over a method that would be certain to be suggestive of starvation, where food was supposed to be of the greatest importance. My sick-room success failed to enable me to draw larger checks; but the satisfaction of going into the rooms of the sick and not having to rack my mind over what medicine to give, what food to be taken, was a great compensation for the absence of a large bank account. Professional attainments and abilities play only a small part in the mere business side of the medical profession. An innocent public believes with intense convictions in the efficacy of dosage; and with distorted vision, as the famous knight of La Mancha, sees giants in professional healers who are really only windmills, with whom personal contact in the sick-room is only too often a danger measured by its closeness. Think of the wasting of the body during sickness; of the brain system, which is life itself, that does not waste: think of the cases of recovery in which for weeks no food is possible for stomach reasons; of the more frequent cases in which recoveries take place after weeks of such scant food as not to be taken into account as a support to vital power by minds governed by reason. Think how disease, in proportion to its severity, is a loss of digestive power, and with cure energy entirely of the brain, how serious a matter it is to lessen it by waste of energy in forcing decomposing food masses through a digestive channel nearly two rods long, food masses that the brain will have none of, and that do not save the fat and muscles; think of all this physiology, and raise this question: "Is this man alone in his faith and practice, or is Nature so in line with him that the entire medical profession is wrong in their dosings and feedings?" I conclude these cases with an illustration. Think of all this enforced feeding, of the doses to relieve, of the wasting of brain power, and compare with the following illustration, in which case no food was taken for thirty-six days, and yet it was possible for the patient to be about during the greater part of the time. NOTE.--In this case severe indigestion and nervous troubles and almost daily headaches had been a torture for years. On the morning of the thirty-sixth day, on which the photograph was taken, a visit to the dentist for the extraction of a tooth revealed no fear, as had formerly been the case. Eating was resumed on the thirty-eighth day with no inconvenience. Since then (over six months ago) no trace of the former troubles has reappeared. Loss of weight about twenty pounds. [Illustration: Photograph, by Henry Ritter. MRS. A. M. LICHTENHAHN, THIRTY-SIXTH DAY WITHOUT FOOD.] V. "Physician, heal thyself!" There is a world of sarcasm in these three words; for about the only advantage the physician has over the laity is that he can do his own dosing. As a general fact, he does no more to prevent bodily ailings than other people, and is just as liable to become the victim of bad habits. It is my impression that, in proportion, as many physicians become the slaves of tobacco, opium in some form, and alcoholics as are to be found in any other class of people; they are quite as likely to be the victims of various chronic ailings as other people, and with equal impotency to relieve. Every day I see physicians going to the homes of the sick with cigars on fire, signals of the brain system in distress undergoing the lullaby of nicotine; going into rooms where the purest air of heaven ought to prevail, as animated tobacco-signs. Where is there virtue in this world that is of any practical good whose vital force is not to be found in example rather than in precept? Who has more need to go into the room of the sick with the purest breath, the cleanest tongue, the brightest eyes, the purest complexion, the most radiant countenance, and with a soul free from the bonds of ailings or habits that offend and disable, than the physician? Where is the logic of employing the sick to feed the sick? Is not that a sick doctor whose nerves are so full of plaints as to need the frequent soothings only found in a cigar, that also sears the nerves of taste? Is he not very sick when those nerves require the stronger alcoholic? There is contagion in good health and sound morals, when daily illustrated, no less than in courage and fear. No physician can be at his best in the rooms of the sick if he be under any bondage from disease or habit. "Physician, heal thyself!" Physician, how does it happen that you have need to be healed, and of what worth are you if you can neither prevent disease nor cure yourself with your dosings? What availeth it to a man to talk righteously when virtue is not in him? Ailings, habits blunt all the special senses and the finer instincts and tastes, and impair the power to reason clearly, to infer correctly, to conclude wisely. Only the well have that hopefulness that comes from power in reserve, power that is not wasted through acquired disease and acquired habits. The contagion of health is a power no less than courage or fear. That man, self-poised, void of fear, General Grant, crushed the Rebellion with a single sentence, "I will fight it out on this line if it takes all summer." That sentence made every man in his army a Grant in courage and confidence. Grant in his prime could puff his cigar while commanding all the armies of his country; but the cigar ultimately destroyed his life, and there was no physician to interpose to prevent one of the most torturing of deaths. Where is the logic of the sick trying to heal the sick? This question will be more frequently asked in that time to come when the drug-store annex to the sick-room will be much smaller than is now thought necessary. Human expression is studied in the rooms of the sick as nowhere else; and if the lines are not obscured by the fogs and clouds of disease the signs can be much more clearly distinguished. A man is now under my care whose soul is of the largest mould, and who is so supremely endowed by reason of intellect, varied tastes and acquirements, as to make life on earth well worth living. His long chronic local ailment has not impaired his power to read me for signs of hope as it seems to me I have never been read before; and never before have I so felt the need to enter a room of the sick with a larger stock of general health. For the time I seem to him to be holding before his eyes the keys of life or death. The physician should be able to go into the room of the sick to see with clearest vision whatever is revealed to the natural eye; and no less to see with eyes of understanding that he may be an interpreter of conditions that indicate recovery or death. He is the historian of disease, and therefore before he can write he must see clearly all that can be known about the process of cure as revealed by symptoms. The eye is at its best only in perfect health no less than the reason, the judgment, and the spirits. A few years ago a drouth of many weeks occurred; in some meadows and pastures the grass seemed dead, beyond the possibility of growth. Every shade of the green had departed; but warm rains came, and in a few days there was a green carpet plush-like in its softness and delicacy. So the progress of cure may be read on the tongue, on the skin, in the eyes, where there are both eyesight and insight to see and to study. VI. For many years I entered the rooms of the sick a sick man myself; I was the victim of that monster of hydraheads, dyspepsia, or, to call it by a more modern title, indigestion. In my later teens my stomach began seriously to complain over its tasks, and a pint of the essence of bitterness was procured to restore it to power. My mouth was filled with teeth of the sweet kind; hence my horror for the doses far exceeded the milder protests of the stomach. Not the slightest benefit came from my medicinal sufferings, and this ended all routine treatment of my stomach. My intense aversion to the flavor of strong medicines caused me to inflict them as rarely as possible upon other mouths during the drug period of my practice. Mine seemed to be a weary stomach, in which the tired sense was a close approach to acute pain for hours after each meal. When a medical student I found nothing in the books, in the advice of my preceptor, nor in the lectures at the university, but what proposed to cure me through drugs that were abhorrent. As I never encountered any cures nor received the slightest benefit from my experiments, I was deterred from injuring myself through persistent dosage. In the early part of my student career I was behind a drug-counter, where I had ample experience in putting up prescriptions, and had an excellent opportunity to measure medical men as revealed in their formulas and the results in many cases in which failure was the rule in chronic ailings; and I was not encouraged to abuse myself through the results as revealed by any form of medication. For the benefit of those who suffer from complainings of the stomach I give a condensed summing-up of myself. I was born with a wiry constitution, but of the lean kind, and a weak stomach, the chiefest ancestral legacy. With ability to see with intense sense very much to enjoy in this world, my resources in this way were boundless, hence I was always full of hope and cheer. All the senses of my palate were of the acute kind, and so were a continual source of the penalties of gluttony. Whatever else there might be alack with me, there was never a lack of appetite. I was able to eat at each meal food enough which, if fully digested, would have redeemed the wastes of any day of labor; and not only this, but also enough of sugar-enticing foods to anticipate the wastes of the following day. Growing up in the country and with an intense fondness for the tart sweetness of apples, pears, and peaches, and the harmlessness of eating them no matter how full the stomach with hearty food, without question my stomach was never void of pomace during the entire fruit season. Whenever I sat down to eat there was an onrush of all the senses of the palate as the outrush of imprisoned children to the ecstatic activities of the school-yard; hence over-eating always, with never a sense of satiety. The penalties were realized in painful digestion, with the duodenum the chiefest of protesting voices. A time came when gas would so accumulate as to make the heart labor from mere pressure, the inevitable insufficiency of breath causing a lack of aëration of the blood. With a constant waste of power in the stomach there was always a sense of weariness; hence I was never able to know the luxury of power in reserve. All through life my best efforts were the result of intellectual inebriation, with always corresponding exhaustion as the direct result. This weakness compelled me to waste the least time on people who could not interest me, and to spend much time alone to recharge my exhausted batteries. For such a case as mine there is not to-day to be found an intelligent hint in any medical text-book as to the physiological way to recovery. The breakfasts in my house were of a character that, without ham, sausage, eggs, steaks, or chops, they would not have been considered worth spending time over. I had reached a time when a general collapse seemed to be impending; but it was stayed for a few years by the new life that came to me through the evolutions of health in the rooms of the sick that seemed to portend possible professional glories: but as the years went on I suffered more and more from nervous prostration through waste of power in the stomach. My friends began to enlarge upon my wretched looks, and with no little concern; but none were wise enough to realize that my need was for words that reminded of life and not of death. By chance I met an old friend on the street when he happened to be thinking about ways in daily food in Europe, from which he had just returned, and at once he began to talk, not about my wretched looks, but about the exceedingly light breakfasts customary in all the great centres where he had been. They consisted only of a roll and a cup of coffee. I was impressed just enough not to forget the fact, but without there being a hint in it to set me to thinking. But the time came, "the fulness of time." There came a morning when for the first time I remembered that when in ordinary health I had no desire to breakfast; but there was a sense of such general exhaustion from power wasted over an unusual food mass not needed at the previous evening meal that my morning coffee was craved as the morning dram by the chronic toper. Only this, and a forenoon resulted of such comfort of body, such cheer, and such mental and physical energy as had never been realized since my young manhood was happy in the blessed unconsciousness of having a stomach that, no matter how large or how numerous the daily meals, never complained. As for the dinner that followed, it was taken with an acuteness of relish and was handled with a power of digestion that were also a new, rich experience; but the afternoon fell far short of the forenoon. The experience was so remarkable that I at once gave up all eating in the morning, and with such reviving effects upon all my powers that the results began to be noticed by all friends. So originated the no-breakfast plan. Up to this time I had never had a thought of advising anyone to do without food when desired; much less that any of the three daily meals should be given up. My war was against feeding when acute sickness had abolished all desire for food, and this I had been able to conduct many years without exciting suspicion of a general practice of homicide. The improvement in my own case was so instant and so marked that I began to advise the same to others, and with the result that each would make known the redeeming work to suffering friends, and so the idea spread in a friend-to-friend way. Now the American breakfast, in point of sheer necessity, is believed to be the most important meal of the day, as the means for strength that is to be called out for the forenoon of labor, and believed with a force of insistence that warrants a conclusion that a night of sleep is more exhausting to all the powers than the day of labor. To go into the fresh air, to do anything with an empty stomach, is to invite a fainting by the way, is the general impression; but there were scarcely any cases in which there was not sufficient improvement to prevent all possibility of a return to the heavy breakfasts that had been abandoned. How did this scheme affect me in a professional way, that is, in the reputation as a physician of average balance of brain functions? Some of my professional brethren of strong conviction and ready command of language began at once to try to abolish the dangerous heresy by suggesting that on this one subject I was absolutely crazy. Of course, their patrons took up this idea with avidity; and so there was a babble of tongues, with myself the central point of attack as crank-in-chief of all cranks. This is not the language of exaggeration; for whatever the law and modern civilization permitted to abolish me professionally was inflicted with tongues by the thousands, the war being made all the more exciting and interesting by the enthusiasm of new recruits to the heresy from the professional domains of my medical brethren. What did I gain by this professionally? Mostly the odium of heresy during the first few years; but with it was the supreme satisfaction that came from seeing more additions to bright eyes and happy faces than medicine ever gave, and in a way that would redound to my own good at some time. The fact is, that as a means to better health, no matter what nor where the disease, there is no limit to its application. As a universal panacea its powers are matchless. For a time I saw no farther than a cure of stomach condition and resulting general comfort. That any disease was to be cured otherwhere than in the stomach by means so simple, did not occur as an original conception; but the fact that giving up the morning meal was attended with improvement of all local diseases set me to thinking. Many of my patients became thin under the regime; but as this was attended by an increase of strength, not even the alarm of anxious friends without faith was ever able to induce a return fully to the old ways. But how explain the loss of weight? A clue came from the following case: The first-born of a young mother had an habitual diarrhoea from birth lasting many months; and yet it seemed well nourished, for it was unusually fat and heavy for its age; but the days and nights were long in the care of this apparently well-nourished child. The symptoms were heedless to the every-hour dosing of pellets, or from the tumblers of apparently purest water. Now this mother, young as she was, was a woman of convictions, and with courage to follow each to an ultimate conclusion. She had heard of miracles resulting from only three feedings per day during the nursing period; and so, notwithstanding a storm of opposition from a vast circle of relatives, she put this first-born rigidly on the three-meal plan, with the result of immediate cessation of the bowel trouble, but with rapid decline in weight. This caused anxiety, and I was called upon for advice. In every respect except the weight-loss the improvement was wonderful. After much thought there was a sudden flash of the truth: there were an abnormal weight and bulk, due to the general dropsy of debility, similar in character to the swelling of the feet and limbs in the old and feeble. The thickened walls of the bloodvessels, toned with health, caused absorption; but the eyes of the friends would not open to the miracle for a very long time, and so render justice to the heroine, the young mother. As an aider and abettor of such a flagrant system of starvation, I had my full share of opprobrium; but, aided by the strong-minded, sensible mother, Nature gained a sweeping victory, and thus this case cleared my mind from confusion as to the anomaly. One of my medical friends with whom calomel was as a sheet-anchor often asserted that babies would actually get fat on it. That bulk would actually increase by use of the forceful medicine is likely; but that the increase would be dropsical I think is unquestionable. The dropsy of debility is due to a loss of tone of the vascular system; the walls of the vessels become thinner and therefore dilate. In the feet and limbs of the old and greatly enfeebled by disease the veins become distended to abnormal size by the force of gravity, resulting in effusion of water into the cellular tissues, which increases when in the upright position during the day and decreases when in the horizontal position at night. A toning up of the entire vascular system, by which a reverse current from the tissues into the bloodvessels is made possible, is the only means for relief. This flash-light upon the part physics plays in the cure of disease put me upon the true lines of investigation, and furnished a key for the solution of many problems. From this time on I was to be kept busy, not in winning victories, but in studying them. This new physiology was not fully apprehended until long after the no-breakfast plan was taken up. It came to me link by link; but the missing link was the fact that food only restores waste, that lost strength is only restored by sleep; and it now seems to me that I was very dull not to have found it out long before I did. It seems to me that no method of health culture, none in the treatment of disease can have any physiological basis where these facts are not taken into account. For a time I failed to look beyond the ailments of the stomach for curative results, until really surprising news began to reach me from many sources. There would come to me those who had to tell about clearer vision, acuter hearing, a stronger sense of smelling, etc., senses that were not thought to be affected by disease; or there would be news that chronic, local ailings, as nasal or bronchial catarrhs, skin diseases, hemorrhoids, or other intractable disease, in some mysterious manner, were undergoing a decline under the new regime. In the domain of drugs we have medicines that vivid imagination has endowed with presumed affinities for locations that are diseased. They enter the circulation and happily get off at the right spot, to act curatively; but no theories are advanced as to how they aid in the construction of new cells or atoms, or how they aid in the disposal of the old ones. Construction, destruction! There is no death of atoms: really nothing is generated, nothing destroyed: the change is but the rearranging of ultimate elements; and how is a drug to influence any more than would be in case of the affinities of chemistry? Hazy conceptions, crude means! The ultimate cell multiplies by division to become bone, nails, hair, ligaments, muscles, fat, the brain, the whole body. Where along the line in the reconstructive work called by a disease or injury is a medicine to apply with power to aid? In what way the need to be expressed, in what operative way the helpful assistance made clear, that faith without works that are seen can be made strong? The chemist never rushes into print with news that another element has been discovered until demonstrative evidence has placed the matter beyond all question. If anything new is discovered in the firmaments, adequate means to an end will be able to reveal it to all interested eyes. The impressions of science are quite different from the impressions of the materia medica; and the miracles of cure that are displayed by the column in even the highest class public prints are never in reach of scientific explanation. A new element is announced; we know instantly that it has been actually discovered. A new cure is announced; we instantly may know that the evidences will never be displayed along the lines of science. I now unfold a theory of my own of the origin and development of disease, and the development of cure, in which the physical changes involved in some of the processes are in reach of the microscope. It is my impression that, with rare exceptions, people are born with actual structural weaknesses, local or general, that may be called ancestral legacies. These are known as constitutional tendencies to disease. In parts structurally weak at birth the bloodvessels, because of thin and weak walls, are larger than in normal parts, and because of dilatation the blood circulates slower. There is an undue pressure upon all between-vessel structures, a pressure that must lessen the nutrient supply more or less, according to its degree. The death of parts in boils and abscesses is due, I believe, to strangulation of the nerve-supply. The bloodvessels are elastic, and capable of contraction and dilatation, a matter regulated by the brain. Now in these weaknesses always lie the possibilities of disease; they may be supposed the weak links in the constitutional chain, and can no more be made stronger than the constitutional design than can the body as a whole. By whatever means brain power is lessened abnormality is incited in the weak parts; hence gradually from the original weakness there is a summing up, as a bronchial or nasal catarrh, or other acute or chronic local or general disease. The first step in any disease is the impression that lessens brain power; the slightest depressing emotion, the slightest sense of discomfort, lessens brain power, and to a like degree the tone of all the bloodvessels; hence dilatation in degree. That the stomach, as the most abused organ of the body, plays the largest part in over-drafts upon the brain is not a matter of doubt. Let us develop a chronic disease along these lines, with nasal catarrh for an illustration. As tone is regulated entirely by the brain system, all taxing of the brain increases the debility of the nasal structures. In course of time the debility so increases through whatever also debilitates the brain, that a stage is reached when water in the blood begins to escape through the thin walls of the vessels and mingles with the natural secretion of the membrane, and a catarrhal discharge is the result. In severe cases a time may be reached when death of parts from the strangling pressure may occur, and then we have an ulcerative catarrh. This evolution will go on as determined by the gravity of the ancestral weakness, by the natural strength of the dynamo, the brain, and the severity of the debilitating forces to which it may be subjected. No one is ever attacked by a nasal or any other catarrh, nor by any other chronic ailings. They all start from structural weaknesses that are inherited, and they are the evolutionary results of brain-wearying forces. If a specialist were asked to express the actual condition of a diseased structure that seems to call for medicinal aid, and to tell just how medicated sprays, washes, and douches are to reach all the parts involved, with healing power, and in what way that power is exercised--in other words, what work actually is to be done, and how medicine is to do it--he would not be able to enlighten his questioner no matter how fertile his conception, how dexterous his use of language. In fact, the healing power of drugs exists in fertile imaginations rather than among those ultimate processes where disease is cured, where disease destroys. As the care moves by the power evolved in the dynamo, so do the bloodvessels contract and relax as determined by brain conditions. Dilating bloodvessels, effusion of water from thinning walls, the between-vessels starving pressure, increasing general debility of all the structures involved--this is the gradual evolution of catarrh and of all other chronic diseases. From this it was seen that no form of local treatment can avail to relieve the operative cause in cases of this kind. Tone must be added to all the weakened, dilated vessels, in order to contract and thicken their walls so as to stop the leakage, and to relieve that pressure upon the between structures that have become anæmic through lack of nourishment. That an evolution in reverse is the one need scarcely calls for argument. It is the brain that needs our attention, and we meet its need by saving its rare powers from wasting. We will do this by cutting down, as far as possible, all the activities for which it furnishes power, even as we would diminish the number of cars where power in the dynamo had become deficient; we will either sever the wires that connect with the stomach, or make a marked reduction in the labor to be performed in the stomach. With power accumulating in the brain, power will reach the utmost recesses of debility and disease, with Nature to do all the healing. To reinforce this physiology, this statement may be made with the strongest emphasis: the medical treatment of chronic disease fails inevitably because it fails to consider the vital force involved. The brain has no part in the treatment of chronic disease by the specialist, where drugs are a means to an end never reached: there are only a disappointment and an interchange of pocket-books. In all parts suffering with pain there is congestion, swelling. The bloodvessels are distended; hence the nerves suffer violence in stretching or from pressure. The pain simply adds to the abnormal conditions by causing an active determination of the blood to the involved parts. To relieve pain, then, is curative, because it lessens the abnormal congestion. The no-breakfast plan with me proved a matter of life unto life. With my morning coffee there were forenoons of the highest physical energy, the clearest condition of mind, and the acutest sense of everything enjoyable. The afternoons were always in marked sluggishness by contrast, from the taxing of digestion. Without realizing that the heavy meals of the day were a tax upon the brain, I would scarcely get away from the table before I began to feel more generally tired out than the severest taxing from a long forenoon of general activity ever made me. With the filled stomach, fatigue, general exhaustion, came as a sudden attack rather than as an evolution from labor, and there would be several hours of unfitness for doing any kind of service well. In the application of this method to others I had the great satisfaction of good results without any exceptions; and the missionary work was begun by friends among friends, fairly spreading better health and adding thereby more and more disaster to my name. More and more I became a focus of adverse criticism in all matters where level-headedness was deemed important. My acute cases began to be watched with hostile interest, as if homicide from starvation were the inevitable result in all cases. My country had become the country of an enemy. Not being able to give my patients clearly defined reasons for the general and local improvements resulting from a forenoon fast as a method in hygiene, it had to be spread from relieved persons to suffering friends; and according to the need, the sufferers from various ailings would be willing to try anything new where efforts through the family physician or patent medicines had completely failed; it was spread as if by contagion, among the failures of the medical profession. Among those to become interested at an early date was a prominent minister who wore the title of D. D., and for a time his interest was intense. He came to me one day with word that a member of his household, well known to me as a young woman of unusual ability and culture, had not been able to take solid food at his table for a year, and he believed that my treatment would avail in her case. To this she was very averse, since every treatment her hapless stomach had received had only added to the debility, until disability had become the result. She finally came to me to be relieved from the forceful importunity of her reverend friend, who had excited my eager interest with a prophecy that unusual literary distinction would follow a cure, as there were abilities of the very highest order, in his estimation. She came, and I had no difficulty in securing such a vacation for the worn-out stomach that it could begin with solid food when the time to eat arrived. The vacation was so brief and power had accumulated so rapidly that almost any food could be taken without discomfort, and no trouble ever came not invited by a relapse from the better way of living that had really created a new stomach. This case caused more notoriety over the no-breakfast plan than any that ever occurred in the city. As a writer of biographies and of articles in high-class journals and magazines, this talented woman has been a miracle of patient, persistent study and investigation. This endorsement in high places greatly added to my reputation as a physician with distorted mind, for the idea that any good could come from a short fast, to be followed by the giving up of that needed morning meal, was too absurd for sober reflection, too violently revolutionary to be even patiently considered. The no-breakfast plan was not so very long in becoming known over the entire city; a bridge had been crossed, and every plank taken up and destroyed; thence the ways into new families were nearly closed. I am enlarging a little upon the opposition that met me from all points, because all who are to be convinced that these are the true ways in health culture will begin at once to enlighten their ailing friends, and will, therefore, encounter the same opposition. "Sir, you have not had enough opposition," said bluff, old Samuel Johnson. There will be no need to complain of any lack of this kind in the efforts to render suffering friends the only aid possible, that will be in persistent efforts of Nature. My medical brethren considered the scheme only as they would consider an invasion of smallpox or a heresy whose methods were a danger to life. One physician, a woman specialist, informed me that she was continually importuned as to her professional opinion of the new craze that had invaded the city. That all other physicians were equally called upon, that they would condemn, was inevitable; and I permitted them the largest liberty without the least resentment; but there was the sustaining cheer of seeing the happiest faces that only increased as the heresy spread. My attendance upon the severely sick became more taxing because of the exceeding concern in the immediate environment, that the pangs of starvation were being added to the pangs of disease. As none of my professional brethren ever manifested any desire to be enlightened on this subject, I did not volunteer, since I felt the wiser way would be to wait an adequate amount of evidence before making any public announcements of presumed important discoveries in practical hygiene. My experiences in the rooms of the sick had convinced me, long before I gave up my morning meal, that death from starvation was so remote as practically to exclude it from consideration; hence with the great improvement that was the immediate result in my own case I could from the first speak with a "thus saith the Lord" emphasis on the safety of going through a forenoon "on an empty stomach." As no one could come into my office without my being able to give the assurance of at least some relief that would be immediately realized, that would be felt even to the finger-ends, my office became more and more a lecture-room, a school of health culture for the education of missionaries, for a friend-to-friend uplifting into higher life. All I needed for my own sake was that missing link to clothe my words with all the desired power. With so much to enliven, to encourage, it was as if I were sitting at the very feet of Nature, so thrilled by her wonderful stories that I was utterly unconscious of the storm of ridicule and epithet to which I was subjected. Once in a while Nature would favor me with a miracle in the way of an inspiring change. A man in the early prime of life had reached a condition in which he habitually rejected every breakfast. Two trips to Europe and a year in the hands of a Berlin specialist for the stomach failed to relieve; and yet he was not so disabled as to prevent him attending to his ordinary business affairs; the stomach seemed to be eccentric in being merely irritable without structural disease. I asked him if he felt that the breakfasts which would not stay down were doing him any good. To this he had to assent that they were not. I told him if the breakfast only to result in a heave-offering were omitted he would be better able for his duties of the forenoon. He began at once to raise his brows. It was not difficult for him to see that if no breakfasts were put into his stomach none would have to be thrown up with sickening effort, and hence he could not but be better for the forenoon services if the sick spell were omitted. The fact was, the breakfast would soon be rejected, and then the hours of rest would enable the stomach to handle the dinner without the repetition of the morning sickness. Only a few words from me of this kind, and thence on there were no breakfasts; and from the first all the complaints from the stomach ceased, and he used to remark that he began to get well as soon as I began to talk to him. Now this man with his family was a recent arrival in this city, and his first intimate acquaintance was one who had been relieved of weekly headaches of a skull-bursting kind through the no-breakfast plan--thus the missionary contagion. For many years I was content to allow people to have the morning coffee or tea as desired, with the largest liberty of dinner gluttony; and this was really the only means possible for the introduction of an innovation so radical. To have given nothing to relieve the morning want for something in the stomach to set the wheels of life in motion would have been a failure from the first. With all the coffee break of the fast was attended by so marked an increase of cheer and general strength, and the enjoyment of the general meal at or before noon was so immeasurably increased, that the method spread as a contagion against which professional denouncement and ridicule were in vain. And with all converts I found that the experiences in the penalties of gluttony were so enlightening, so restraining, that there was apparently little need to say much more as to the quantity or quality of food, what and how to eat. The enthusiasm of all over the forenoons of power and comfort, to be followed by a luxury of meals never before realized, fully satisfied my pride in professional success; and all the more because the penalties of gluttony were seldom charged to my account. It was only after the missing link was found and added to the chain that I could fully realize the enormous waste of strength and the mental and moral degradation from eating food in excess, because the enticements of relish are taken for the actual needs of the body. Think of it! Actual soul power involved in ridding the stomach and bowels of the foul sewage of _food in excess_, _food_ in a state of decomposition, to be forced through nearly two rods of bowels and largely at the expense of the soul itself!! Oh, gluttony, with its jaws of death, its throat an ever-open gate to the stomach of torment! VII. When I finally arrived at a point of vision where I could see the stomach as a mere machine, that it could no more act without brain-power than brawny arms with their nerves severed could wield a sledge, I began a study of digestion with new interest, with a view to save power from undue waste. It is the _sense of relish_, of flavor, that is behind all the woes of indigestion, and not the sense of hunger. The sweetened foods; the pies, cakes, puddings, etc., that are eaten merely from a sense of relish after the sense of hunger has become fully sated, and generally by far more of the plainer foods than waste demands, is the wrecking sin at all but the humblest tables. _Rapid eating_, by which there is imperfect solution of the tougher solids and a filling of the stomach before the hunger sense can naturally be appeased, is the additional evil to insure serious consequences to the stomach and brain. For merely _practical purposes_, all that is necessary to know about the digestive process is that by a peculiar arrangement of the muscle forces of the stomach the food is made to revolve in such a way as to wipe the exuding digestive juice from the walls; that, therefore, the finer the division of the solids by mastication the more rapid the solution to the absorbing condition. That meat in finer particles will sooner dissolve than meat in large, solid masses is clearly seen. It will be recalled that digestive conditions are really soul conditions, as if there were actual wires extending from the very depths of the soul itself to each individual gland, with power to ebb and flow as the mental condition shall determine. It may be presumed that _power_ to digest is the power to revolve food in the stomach and the power to generate the gastric juice as determined by the power of the brain, the glands themselves not holding their juice in mere reserve, but power to generate in reserve. Thus it is seen that food in excess is in every way exhaustive as the immediate result. These may be called the subjective conditions of digestion. Now let us consider some of the objective conditions from the standpoint of moral science. What the sunshine of a warm day is to all growing things on the earth, so is that shining seen in other faces that reaches the depths of the human soul with brightness and life. _Overeating_ is so universal from the general ignorance of practical physiology that few stomachs have a time for a full clearing with the needed rest before the time of another filling arrives. It is therefore a matter of sheer necessity not only to attain and maintain the utmost possible cheer of soul, but it is also a necessity to have cheer in other souls with whom relations are intimate. As a matter of extraneous _digestive aid_, a cheerful soul in a family is an abiding source of digestive energy to all in social contact. It affects the digestive energy of all, as the breeze the fire, as the clearing sky the low spirits from the gloom of chill and fogs. The eyes that do not glisten with higher life, the lines upon the face that are not alive with cheerful, kindly emotions, the frowning look, the word that cuts deeply, have their repressive effects upon digestive energy within their remorseless reach. The _moral science_ of digestive energy is a new study; it is not known as a factor in the process of digestion; but the time is coming when cheer of soul will become a study as of one of the finer arts, and then human homes will not be so much like lesser lunatic asylums without the restraining hands of a wise superintendent. Life will be different in homes when all within the age of reason shall realize that their words without kindness, their looks without cheer, are forces that tend to physical and moral degradation, really nothing less than death-dealing energies upon all lives within their reach. The power of human kindness has ever been a favorite theme with the moralist, but it has not been considered with reference to its power upon digestion. _Anger_ is mental and moral chaos; it is insanity; it is revenge in the fury of a hurricane; and sensitive natures have the greatest need for the largest measure of health in order that these human tempests shall be under larger restraint. The gloomy, the irritable, the dyspeptic Christian is a dispenser of death and not of the higher life, and his religious faith does not spread by the contagiousness of example: and because of the solemnity, of the exceeding importance of his sense of the possibilities of the life beyond death he has all the more need to have that physical and moral strength that his daily walk, conversation, and mien may be consistent, forceful, and uplifting. To this great end study, study to see _cheer_ everywhere, and above all things to possess it. Good health is also contagious, and, no less than disease, has a reflex impression. Only above the chill dampness, the fogs, and clouds is the clear sky with the blazing sun. There are undreamed-of possibilities of getting above the worriments of life through an intelligent understanding and application of the physiology of cheer as the chief force in the life of the body, mind, and soul. VIII. Having finally arrived at the conviction that from the first wink in the morning until the last at night strength departs, not in any way to be kept up by food, that from the last wink at night until the first in the morning strength returns, I became fully endowed to tell all the sick and afflicted in the most forceful way that with the strength of the brain recharged by sleep is all the labor of the day performed, and that no labor is so taxing upon human muscles that it cannot be performed longer without fatigue when the breakfast is omitted. That this is possible came to me as a great surprise and in this way: a farmer with a large assortment of ailments came to me for relief through drugs. He was simply advised to take coffee mornings, rest mainly during forenoons, and when a normal appetite and power to digest would come he would be able to work after resuming his breakfasts. This man, who was more than fifty years old, was the first manual laborer to be advised to observe a morning fast. Several months after, he came to me with news that his ailing had all departed, and that he had been able to do harder work on his coffee breakfasts than ever before with breakfasts of solids. And if he so worked with power during forenoons, why not others? Why not all? This no-breakfast plan was so contagious that I was not long in finding that farmers in all directions were beginning to go to their labors with much less food in their stomachs than had been their wont, and in all cases with added power of muscle. Only recently three farmers went into the field one hot morning to cradle oats, the most trying of all work on the farm; two of them had their stomachs well filled with hearty foods. With profuse sweating and water by the quart because of the chemical heat arising from both digestion and decomposition, these toiled through the long hours with much weariness. The third man had all his strength for the swinging of the cradle, the empty stomach not even calling for water; with the greatest ease he kept his laboring friends in close company and when the noon hour came he was not nearly so tired as they. A man who had been a great sufferer from indigestion, a farmer, found such an increase of health and strength from omitting the morning meal that he became able to cradle rye, a much heavier grain than oats, during an entire forenoon "on an empty stomach." Later he went from one December to the following April on one daily meal, and not only with ease, but with a gain in weight in addition. During these months this man did all the work usual in farm-houses, besides riding several hours over a milk route during the forenoons. In this city resides a carpenter, formerly subject to frequent sicknesses, who for the past five years has walked nearly a mile to the shop where he is employed without even as much as a drink of water for breakfast; and this not only without any sicknesses, but with an increase in weight of fifteen pounds also. More than a dozen years ago a farmer who was not diseased in any way, but who had been in the habit of eating three times a day at a well-spread table, and at mid-forenoon taking a small luncheon for hunger-faintness, omitted his breakfast and morning luncheon, and has been richly rewarded since then in escaping severe colds and other ailings. He conclusively felt that his forenoon was the better half of the day for clear-headedness and hard labor; he has added nearly a score of pounds to his weight, and his case has been a wonder to all his farmer friends, who see only starvation in cutting down brain and needless stomach taxing. I must now ask the reader to bear with me while I apply the principles of this new hygiene with a good deal of reiteration, trying to vary them in utterance as far as possible. The need of daily food is primarily a matter of waste and supply, the waste always depending upon the amount of loss through the general activities, manual labor being the most destructive. Across the street from where I live a new house is being built: for many days during the chilly, windy month of March several men have been engaged high in the air, handling green boards, studs, and joists for ten hours each day; and yet these men are not eating more food daily than hundreds of brain-workers who never have general exercise. The workmen across the street eat to satisfy hunger; the brain-workers, to satisfy the sense of relish; and the meals of the latter are habitually in excess of the real demands because of wasted bodies. In spite of the apparent overeating of the brain-worker, I believe the farmer and the manual laborer break down at an earlier age, for the reason that they overwork and generally eat when too tired to digest fully: the farmer is rarely content to do one day's work in one day when the crop season invites him to make the most of fair days. With successes rapidly multiplying in all directions within my circuit, the desire became urgent for some way to make my new hygiene known to the public. My first thought was to get some eminent divine interested through a cure that would compel him to a continual talk as to how he became saved. At a great denominational meeting in Chicago I chanced to hear a splendid address from a sallow-faced professor of a divinity school, the Rev. Dr. G. W. N.; and after a great deal of reflection I resolved, without consulting him, to write him a series of letters on health culture, hoping that he would become so immediately interested as to permit me a complete unfolding of my theory and practice. I began the series, taking all the chances to be considered a crank; they were continued until the end without response, when later I received a brief note with sarcasm in every line. At least my letters had been read; for he informed me that he had no confidence in my theory, giving me a final summing up with his estimate that there were more "cranks" in the medical profession than in any other. I was not in the least cast down at this long-range estimate, since I had become quite used to close-at-hand ridicule. There was before me the unknown time when a still more eminent D. D. would both accept and practise my theory, and also give the world his estimate in an elaborate preface to a book that in the fulness of time the ways opened to me to write and have published. I was sent for by a man who had become a moral and physical wreck, his body being reduced to nearly a skeleton condition from consumption. As he was taking an average of two quarts of whiskey per week, I accepted the charge of his case with reluctance. I was not able in any way to change his symptoms for the better; there had been no hint of hunger for many weeks, and the mere effort to swallow or even taste the most tempting dainties was painful to witness. He was taken with a severe pain in his side, which was fully relieved with the hypodermic needle, and there followed several hours of general comfort and no desire for the alcoholic. Seeing this I was strongly impressed that by continuing the dosings for a time the seared stomach might get into a better condition and the fast be followed by a natural hunger. This is what actually followed: in about a week the dosings were reduced to mere hints, and without any desire for stimulants there came a desire for broiled steak and baked potatoes, which were taken with great relish. Thence on this was mainly the bill of fare, and the half-filled bottle remained on his table _untouched_, undesired; and in time there were added more than a score of pounds to his wasted body. Now it chanced that this regenerative work was seen day after day by his friend, who was badly in need of an all-round treatment to meet the needs of his case; he was a man of keen intellect, of real ability of both mind and muscle. Becoming deeply interested in the theory behind the miracle he saw unfolding day after day, and all the more because of a total extinction of the drink-habit that was deep seated through long duration, he began to omit his morning meals. He saw more than his own case. He had been a manager of book agencies, and when he found also his desire for the cigar undergoing a rapid decline, he became possessed with the idea that a book might be written on the subject. The time came when he could sit down in the office of the Henry Bill Publishing Company, Norwich, Conn., a picture of health, to interview Mr. Charles C. Haskell on the subject of publishing a book. Mr. Haskell had known him in less healthful years, and he marvelled at the change. I had duly suggested, and with great emphasis, that no publisher would listen to him unless he were sick enough to be interested in the theory and would give a test by actual trial. He found Mr. Haskell in very low health. Experts had sent him on a tour through Europe in search of that health he failed to find; his body was starving on three meals a day that were not digested, and he began to arrange his affairs with reference to a near-at-hand breakdown. To this man was made such an appeal as men are rarely able to make, because a regenerated life was also vocal in utterance. To him a miracle seemed to have been wrought, and he listened to each word as if to a reprieve from a death seemingly inevitable. As there was no disease of the stomach, it required only a few days for Mr. Haskell to acquire so much of new life that he felt as one born again, and a week had not passed before I had his earnest request to put my hygiene into a book, he taking all chances of failure. He began to advise all ailing friends to give up their breakfasts or to fast until natural hunger came, getting many marvellous results. One of his first thoughts was to have the forthcoming book introduced by some eminent divine who could write through the inspiration of experience. In a visit to Norwich of that evangelist of world-wide eminence, George F. Pentecost, D. D., then of London, Eng., the opportunity came, and for a case of "special conversion" he was made the guest of Mr. Haskell. He was easily persuaded to the system, and his need is expressed in the following from the introduction of _The True Science of Living_, which was actually written without his having read a single line of the manuscript. "Taking the theory upon which this system of living is based into account--and even to my lay mind it seemed most reasonable--and the testimony which I personally received from both men and women, delicate and biliously strong, workingmen, merchants, doctors, and preachers, delicate ladies for years invalided and in a state of collapse, and some who had never been ill, but were a hundred per cent. better for living without breakfast, _I resolved to give up my breakfast_. I pleaded at first that it might be my luncheon instead, for I have all my life enjoyed my breakfast more than any other meal. But no! it was the breakfast that must go. So on a certain fine Monday morning I bade farewell to the breakfast-room. For a day or two I suffered slight headaches from what seemed to me was the want of food; but I soon found that they were just _the dying pains of a bad habit_. After a week had passed I never thought of wanting breakfast; and though I was often present in the breakfast-rooms of friends whom I was visiting, and every tempting luxury of the breakfast was spread before me, I did not desire food at all, feeling no suggestion of hunger. Indeed now, after a few months, the thought of breakfast never occurs to me. I am ready for my luncheon (or breakfast if you please) at one o'clock, but am never hungry before that hour. "As for the results of this method of living, I can only relate them as I have personally experienced them: "1. I have not had the first suggestion of a sick headache since I gave up my breakfast. From my earliest boyhood I do not remember ever having gone a whole month without being down with one of these attacks, and for thirty years, during the most active part of my life, I have suffered with them oftentimes, more or less, every day for a month or six weeks at a time, and hardly ever a whole fortnight passed without an acute attack that has sent me to bed or at least left me to drag through the day with intense bodily suffering and mental discouragement. "2. I have gradually lost a large portion of my surplus fat, my weight having gone down some twenty pounds, and my size being reduced by several inches at the point where corpulency was the most prominent; and I am still losing weight and decreasing in size. "3. I find that my skin is improving in texture, becoming softer, finer, and more closely knit than heretofore. My complexion and eyes have cleared, and all fulness of the face and the tendency to flushness in the head have disappeared. "4. I experience no fulness and unpleasantness after eating, as I so often did before. As a matter of fact, though I enjoy my meals (and I eat everything my appetite and taste call for) as never before, eating with zest, I do not think I eat as much as I used to do; but I am conscious of better digestion; my food does not lie so long in my stomach, and that useful organ seems to have gone out of the gas-producing business. "5. I am conscious of a lighter step and a more elastic spring in all my limbs. Indeed, a brisk walk now is a pleasure which I seek to gratify, whereas before the prescribed walk for the sake of exercise was a horrible bore to me. "6. I go to my study and to my pulpit on an empty stomach without any sense of loss of strength mentally or physically--on the other hand, with freshness and vigor which is delightful. In this respect I am quite sure that I am in every way advantaged." Rev. George Sherman Richards, after more than fifteen years of frequent severe headaches that were supposed to be due to heredity, has had entire freedom during the five years of the No-breakfast Plan. He can hardly be surpassed as a picture of perfect health. One of the first prominent converts who finally surrendered to Mr. Haskell, whose persistence was beyond fatigue, was the editor of the Norwich, Conn., _Bulletin_, a special friend. There was no want of conviction on his part, but the evil day to begin the morning fast was continually postponed. Finally, one morning when he was specially busy and charged with impatience, the beaming and hopeful face of Mr. Haskell appeared. Said the busy man, "Mr. Haskell, if you will walk right out of that door, I will promise you to begin tomorrow morning to do without breakfasts." Mr. Haskell walked out--the breakfasts were given up, and some years later I was personally informed that he believed that his life had been saved thereby. [Illustration: REV. GEORGE SHERMAN RICHARDS, Rector of Christ Church, Meadville, Pa.] One of the expedients was to send a circular about the book to every foreign missionary of every denomination, and as a result one of these fell into the hands of Rev. W. E. Rambo, in India. He had become a mere shadow of his former self from ulcerated bowels, the sequel of a badly treated case of typhoid fever. For seven months there had been daily movements tinged with blood; the appetite was ravenous, and large meals were taken without any complainings from the stomach. Before a well-spread table his desire to eat would become simply furious, and it was indulged regardless of quality and quantity. His brain system had become so exhausted that reason and judgment had no part in this hurricane of hunger. There were seven successive physicians in this case, some of them with many titles. The first one he called on reaching New England cut his food down to _six bland meals daily_. All of them had tried to cure the offending ulcers by dosings. Think whether bleeding ulcers on the body would get well with their tender surfaces subjected to the same grinding, scratching process from bowel rubbish! He was in condition on his arrival to lose six pounds during the first week of six "bland" daily meals. After reading the _True Science of Living_ he discharged his physician and came under my personal care. These ulcers were treated with the idea of giving them the same rest as if each had been the end of a fractured bone. To relieve pain, to hold the bowel still, and to abolish the morbid hunger, a few doses with the hypodermic needle were a seeming necessity. In less than two weeks this starving man of skin and bones was relieved of all symptoms of disease, and there seemed a moderate desire for food of the nourishing kind. Less than two weeks were required for all those ulcers to become covered with a new membrane: but for full three weeks only those liquid foods were given that had no rubbish in them to prove an irritant to the new, delicate membrane covering the ulcers. For a time after the third week there was only one light daily meal, with a second added when it seemed safe to take it. In a little more than three months there was a gain of forty-two and a half pounds of flesh, as instinct with new, vigorous life as if freshly formed by the divine hand. My last word from this restored man was after he, his wife, and four children had been back in India for a year and a half, where they were all living on the two-meal plan without any sicknesses, and he had a class of one hundred and sixty native boys on the same plan. Who can fail to see the science and the sense to relieve all diseases of the digestive tract? There are no cases of hemorrhoids not malignant in character, in which total relief will not be the result if fasts are long enough; no cases of anal fistula that will not finally close if they can have that rest from violence that is their only need; and equally all ulcers and fissures that make life a history of torture. No case with structural disease of any part of the digestive tract not malignant has yet come under my care in which there has not been a cure, or in which there has not been a cure in sight. Through a fast we may let the diseased parts in the digestive tract rest as we would a broken bone or wound on the body. Several missionaries have regained health on these new lines, who have returned to preach and practise a larger gospel than before. One returned from the Congo region of Africa with such wreckage of health as to make any active service impossible. Mr. Haskell met him in New York, and in time he returned with twenty-four missionaries, all as converts to the new gospel of health, and to have that sustained health only possible through a larger obedience to the laws of God "manifest in the flesh"--obedience that takes into account the moral science, the physics and the chemistry of digestion. These and those others who have had their lives redeemed from lingering death through the simple, easy ways of Nature never suffer their enthusiasm to wane. Not to volunteer aid when unintentional suicide is going on seems nothing less than criminal. As a means to better health the utility of the morning fast is beyond estimate. In all other modes of health culture there is a great deal of time consumed in certain exercises that are certain to be given up in time. What the busy world requires is a mode to gain and maintain the health that requires neither time nor thought--one that is really automatic. We arise in the morning with our brain recharged by sleep, and we go at once about our business. If we take a walk or go to the gymnasium, we simply waste that much time, and we also lessen the stored-up energy by whatever of effort is called out. We can skip the dumb-bells and perform any other kind of exercise that is good for the health; and always with the certainty that we shall have more strength for the first half of the day if none is wasted in this way. As a matter of mere enjoyment, walks in fresh air are beneficial, but not as an enforced exercise for the reason of health. For the highest possibilities for a day of human service there must be a night of sound sleep; and then one may work with muscle or with mind much longer without fatigue if no strength is wasted over untimely food in the stomach, no enforced means to develop health and strength. When one has worked long enough to become generally tired there should be a period of rest, in order to regain power to digest what shall be so eaten as to cause the brain the least waste of its powers through failure to masticate. One need not always wait until noon to eat the first meal. Those in good health have found that they can easily go till noon before breaking the fast; but in proportion as one is weak or ailing the rule should be to stop all work as soon as fatigue becomes marked, and then rest until power to digest is restored. To eat when one is tired is to add a burden of labor to all the energies of life, and with the certainty that no wastes will be restored thereby. For the highest efforts of genius, of art, of the simplest labors of the hands, the forenoon with empty stomach and larger measure of stored-up energy of the brain is by far the better half of the day; and, more than this, it is equally the better for the display of all the finer senses of the tastes, the finer emotions of soul life. In addition to these--and what is vastly more important--it is by far the better half of the day for the display of that energy whereby disease is cured. All this with no power lost in any special exercise for the health! The time to stop the forenoon labor is when the need to rest has become clearly apparent; and there must be rest before eating, to restore the energy for digestion. This always determines Nature's time when the first meal shall be taken, and not the hour of the day. This is especially important to all who are constitutionally weak or have become disabled through ailings or disease. Disappointments have come to hundreds who have given up breakfasts, because of the mistaken idea that they must wait till noon before breaking the fast, and hence had become too tired to digest; and therefore experienced a loss rather than a gain from the untimely noon meals. The desire for morning food is a matter of habit only. Morning hunger is a disease under culture, and they who feel the most need have the most reason to fast into higher health. They who claim that their breakfasts are their best meals; that they simply "cannot do one thing" until they have eaten, are practically in line with those who must have their alcoholics before the wheels can be started. Now it has been found by the experience of thousands that by wholly giving up the morning meal all desire for it in time disappears, which could hardly be the case if the laws of life were thereby violated; and the habit once fully eradicated is rarely resumed. To give up suddenly the use of alcoholics or of tobacco in any of its forms is to call out loudest protests from the morbid voices that have been kept silent by those soothing powers; and yet no one would accept those loud cries as indicating an actual physiological need. The difficulties arising from giving up the morning meals--even as those from giving up the morning grog--are an exact measure of the need that they shall be given up in order that health, and not disease, shall be under culture. I once heard a Rev. Mrs. tell a large audience of ministers that for more than a week she spent most of her forenoons in bed to endure better the headaches and other angry, protesting voices that were averse to the no-breakfast plan. She won her case, and thence on a hint of headache or other morbid symptoms was a matter of humiliation and fasting, with prayer for forgiveness and for greater moral strength against the temptations of relish. With many people the breaking of the breakfast habit costs only less of will-power than is called out by attempts to break the alcoholic or tobacco habit; but by persistence a complete victory is certain for all, and the forenoons become a luxury of power in reserve. Now, I must warn all that very many persons who adopt the No-breakfast Plan are disappointed, because they have become chronic in the ways of unwitting sin: they are like thin-soiled farms long-cropped without soil culture. Harvests in either case can only come by the study and practice of the laws of nutrition. The besetting sin against all such ailing mortals, the lines of whose lives are frequently of the hardest, is that the friends all oppose cutting down the daily food from the dreadfully mistaken impression that weakness and debility from disease are the measure of the need to eat, not the measure of the inability to digest. Scores of times I have been written to by this class of patients as to their troubles from friends in this way. Scores of times I have been consulted as to the safety of this method in daily living for the old, as if it were a tax upon the constitutional powers to stop sinning against them! As well ask whether one may get too old as to make it dangerous to cut down daily whiskey or daily labor that is clearly beyond the reasonable use of the powers. Those who are the victims of chronic diseases and have become greatly enfeebled by overwork of body, mind, or stomach, will have to work out their salvation with most discouragingly slow progress; but not to work, not to try, is to invite the processes of disease culture. Now, as to the time when that first meal of the day shall be taken. Since the best meal of the day in all America with the great majority of the people is at noon, this time may well be selected as the most fitting. Since the man of muscle loses no time in taking his breakfast, he should be able with good sense to rest an hour before this noon meal. Those whose general energies give out earlier in the morning and do not care to have general meals prepared in advance of the usual hour, can put in the time in the best possible way by resting into power of relish and digestion, the evil of eating when tired being that the exhausted feeling is only increased. Now think what forenoons may be had with no time lost over breakfasts, none in thinking about the health or in doing anything for it, and not only to have the best and strongest use of the reason, judgment, and muscles, but also to have the best possible conditions for the cure of ailings! Think, too, what it would be to the mothers of the land not to have any need to go into their kitchens until the time to prepare the noon meal arrived! Can children while growing rapidly do without breakfasts? They certainly can without a hint of discomfort, and be all the better for it in every way. A few months ago I spent some hours in Illinois, where the no-breakfast plan had been practised for two years. When the plan was begun there was a pale, delicate mother of four children, who was enduring a life that had no cheer. During the first year the battle was a severe one, not a little aggravated by the assurance of all sympathetic friends that resulting evil was making its mark on all the lines of expression; but health with its life and color finally came to silence the uttered disapproval. There was a boy in the home who was subject to the severest headaches every week, and who was much wasted in his body when he began: he had become robust and wholly relieved of all his ailings. There was a plump, rosy-cheeked girl of fourteen who for a year had taken only one daily meal, and yet a better nourished body I never saw. Now in this family the only warm, general meal, and this a plain one, was at noon. The evening meal was entirely of bread and butter taken without even a sitting at the table. What happy, healthy children they were! And the mother was in a great deal better health to do all the work of the kitchen: work, she strongly asserted, which was not nearly half of what it formerly was. For her there was a cure, a great increase of strength, and a great reduction of the most taxing of all the duties of the home-life. If there is such a thing as an attack of disease, it cannot occur in the forenoon when there is an empty stomach and all the powers are at their best for resisting disease; and where children are fed as these are, disease, acute or chronic, is only a remote possibility. I belong to a family of seven; the oldest is beyond seventy, the youngest beyond fifty. This No-breakfast Plan has been very closely adhered to with all for not less than twelve years, and during this time not one of us has had any acute sickness; and I am not aware that any have diseases of the chronic kind. The accompanying illustration is that of Mrs. E. A. Quiggle, sister of the Author, after twelve years' trial of The No-breakfast Plan. [Illustration: MRS. E. A. QUIGGLE, Chicago, Ill.] IX. The utility of eating with thoroughness is strongly illustrated in the following cases: Mr. Horace Fletcher, the author and traveller, took to the one-daily-meal plan to cut down his abnormal weight, having the patience to masticate all sense of taste from each mouthful before swallowing. I saw him after he had been on this plan for some months: there had been a weight loss of some forty pounds; a nasal catarrh of many years had been cured, and he strongly asserted that in every way he felt himself twenty-five years younger. He had been living a week on baked potatoes for experimental reasons when I met him, and without experiencing any morbid sensations: a more perfect specimen of physical health I never gazed upon. To all dyspeptics who are willing to work for their health through pains and patience, his little work, _Glutton or Epicure_, is strongly recommended. A dyspeptic from Vermont came to me who for ten years had eaten three hearty meals daily, none of which had ever satisfied his hunger. He was in a very low mental state when he came, and feeble in body: for fully ten years both himself and physician had held the stomach accountable for all its complainings, and with no thought of avoidable cause. I put him on one meal a day, as there was still some power of digestion, and with the following list for the daily bill of fare: baked potatoes well buttered, bread and butter, beans dressed with butter, fish or lamb chops, and rice or oatmeal only if strongly desired; all sugar foods debarred, and no drinks except water as thirst called for it between the meals. The constipated bowels were permitted their own times for action. The mouthfuls were small and far apart--like dashes between words--not less than forty-five minutes were spent in masticating. Very soon there was a general rousement of new life in every way. His first surprise was in an unwonted sense of relish and a complete sating of hunger long before he had eaten the old-time amounts. There was a fresh revelation to me in this, as I had not before been so impressed that by slow eating the hunger-spell is also dissipated in part by time, and hence there is much less danger of eating to excess. Hunger comes in part from habit, and it is appeased, with or without eating, with equal completeness. The hunger-habit can be trained to come at almost any fixed time. Not long since I read of a farmer who kept his horses in apparently perfect condition on one feeding, and only at night: they had become so trained that they had no desire for food until their labors were over. At night they both ate and rested, and made good the waste of the day; they were fully nourished and rested by morning, and could labor all the forenoon without loss of energy diverted to digestion: at noon they would rest--become strong for the labors of the day. There can be no doubt, I think, that the strongest sense of hunger at the regular eating-time could be dissipated by a fast not longer in duration than that of an ordinary meal-time. My patient's bowels gave no hint of their locality until the eighteenth day, when they acted with little effort; on the twenty-fourth day again in a perfect way, and thereafter daily. The mind became ecstatic through perfect relief from mental and physical depression; there were no wants for other than those simple foods, and at the end of a month he left me with new views as to Nature's power of selection to meet her needs and of the vast utility of using both time and food to dissipate hunger. The waste with most people is so small that the cost of the food, the cost of time in preparation, could be reduced to a startling fraction if the need could be actually known, and the pleasures of the palate increased by an inverse ratio. There is no redemption for women on the earth who have the care of kitchens except through simpler, smaller meals--meals so very far apart that there shall be a maximum of the hunger-sense of relish and the resulting maximum of power to convert them into tissues instinct with life. It may be that the waste is so very trifling, especially with brain-workers, that one may be a vegetarian, fruitarian, or even an eater of pork, without positive violence to practical physiology. There is this further very practical consideration, that when Nature is so fairly dealt with that she can speak in natural tones she will call only for those foods easily available along geographical lines. There is this to be said about fruits, that all those containing acids decompose the gastric juice, as they all contain potash salts in union with fruit acids. As soon as they reach the stomach the free hydrochloric acid of the gastric juice unites with the potash, setting the fruit acid free to irritate the stomach. There is never any desire for acid fruits through real hunger, especially those of the hyperacid kinds: they are simply taken to gratify that lower sense--relish. The tropical fruits are without acids, and therefore are well adapted to a class of people who have only the least use for muscle and brains. Acid fruits can only be taken with apparent impunity by the young and old, who can generate gastric juice copiously. Because of the general impression that they are healthful and no tax, human stomachs are converted into cider-mills at will, regardless of between meal-times. By their ravishing flavor and apparent ease of digestion apples still play an important part in the "fall of man" from that higher estate, the Eden without its dyspepsia. What shall we eat? The fig-leaved savage under his bread-fruit tree, the fur-clad Eskimo in his ice-hut, need not be asked: the needed food is in all due supply with little cost of muscle and less of mind--and he has no mental condition that can disturb the digestion. The simpler waste-restoring foods have a flavor of their own that needs little reinforcement if developed by due mastication and with adequate hunger. In my own case butter duly salted seems to be my only natural appetizer aside from hunger; and yet I must own that at times new honey has a wonderful effect on the mouth-glands. The difference between eating from hunger and mere relish, as fruits and the various sweetened foods are eaten, is a new study in dietetics, and one more important can scarcely be conceived. It can hardly be intelligently studied without taking into due account this new physiology. With rarest exceptions the need of food is estimated by the mere pleasure that comes from relish--that kind of relish that is evolved from the pies, puddings, ice creams, the last course in Sunday dinners, never taken until the limits of stomach expansion are nearly reached. X. Some of the external evidences of that general regeneration which comes through Nature will now be given. We will study the human face as we study the earth when the favoring conditions of Spring rouse all Nature to newness of life. The face shall be our human landscape. I select a face in which the eyes are dull from debility, in which there is no sparkle of soul, and beneath are the dark venus-hanging clouds. The face has a dull, lifeless cast; the veins are all enlarged from debility, and cover the larger arteries as with a mourner's pall, save where there are patches as of clouds on fire, where disease of the skin enlivens the drear landscape. There are pimples large and small, some with overflowing volcanoes; there are no lines of expression: these are changed to lines of morbid anatomy. We listen, and there are no echoes of departed joys; look as we will, and we see no evidence of the existence of a soul. The ultimate of this picture is death from unrecognized suicide; death, a slow dying to every sense that made life worth living. There is this about these deaths that go on through the months and years: they exaggerate the worst instincts of the soul as it is dragged down--down through brain-wasting largely avoidable if only understood. The instant result of a total suspension of the use of the brain power in the digestive tract is the evolution of life: new life is sent to the remotest cell as by an electric charge. The nutrient vessels of the eye tone down in size, and there is polish, sparkle where there was only dimness; and on the face the venus clouds, black and red, begin to disappear; the toning of the veins condenses the skin, and thereby the ruddy arteries are uncovered, and a color that has life appears; the pimples, the hillocks, even have a brighter look as they slowly shrink from sight. Finally, the skin becomes of a plush-like texture, soft, condensed, and with tints that compare as the tints of flowers with the faded colors of the house-painter, or as the matchless tint and plush of the perfect peach to the spotted, colorless, wilted, degenerated representative awaiting the garbage-barrel; and the cherry lips, the cherry gums, and the whiter teeth--Nature does not match them otherwheres. Landscape gardening upon the human face has the largest, most inspiring possibilities; and there are no eyes so dull, no faces so void of light and life, no skin degraded to a parchment, for a public display of an assorted collection of evidences of physical poverty, in which these changes to a higher life are not in some degree easily possible. Face culture becomes of the profoundest interest when it is realized that whatever there is in eyes and lines of expression that reveals a soul in higher life, whatever there is in softness and delicacy of texture, in color that is alive with life, is only the external revelations of the higher life within. Nature is always at work over her waste places, whether about the roots in the mouth, or in the depths of the organs; and the aches, the pains of the living, and the agonies of the dying are only evidences of the earnestness and persistence of her efforts to right all her wrongs. In what ways are drugs available in this kind of landscape culture; how sent through the crystalline structures of the eye with clearing effect; how to polish the retina and the surfaces to a sparkle? What drugs for such culture? And yet the materia medica needs a hoist to place it on the shelf. These external changes that become clearly apparent to even dull eyes are the changes that also go on in the very depths of diseased structure, in all the special senses, in all those higher instincts and tastes that make man the best for self, for home, State and Nation--the image of his Creator. Is this high estate ever reached through dosage? Let this matter be again considered. In the days of the lancet, roots and herbs, of bleedings and sweatings, of fevers without water for parched tongues, throats, and stomachs, Nature had no part in the cure of disease in the professional or lay mind, except in rare instances in which there were those specially gifted with insight as well as eyesight. Now such barbarism was inflicted with intense force of conviction, and it was patiently endured with the largest faith. When a mere child I was a witness of the bleeding treatment upon my mother of saintly memory, and my child hands carried into the back yard nearly a quart of blood drawn for a bilious attack that lasted but a few days. There is this to be taken into account in the dose treatment of diseases--that most cases recover regardless of the time of treatment, even whether it is the most crucifying or whether there is no dosing. Therefore, the good effect of dosing is at best a matter of hazy inference, where real evidence is not possible. The lack of uniformity in the character and times of doses for similar diseases is a burlesque on science. What would a text-book on chemistry be worth with nothing more in the way of demonstrative evidence than we find in our materia medica in the summing up of the "medical properties" of drugs. In modern times homoeopathy has come in as a protest against the drawing of blood and the administration of drugs that corrode. For a form of skin disease sulphur has been given by the teaspoonful by my brethren of the "regular" school; with equal faith, my brethren of the homoeopathic school will give the fraction of a grain whose denominator will cross an ordinary page: at which extreme is the science of dosage, if any; or where between? I can hardly resist the conclusion that faith in dosage is, by as much, inability for the deduction of science. "I know whereof I believe," is the language of Science. "I believe," is the language of credulity--with all the ways back to cause too hazy for the perception of even the assuring guide-boards. Said that prince of American humorists, Artemus Ward, "I have known a man who drank one drink of whiskey every day, and yet lived to be one hundred years old; but do not believe, therefore, that by taking two drinks a day you will live to be two hundred years old." "I have known a man who had not a single tooth, and yet he could play a bass drum better than any man I ever knew;" but do not infer that the pulling of sound teeth will aid in bringing out all the possibilities of harmony, melody, and delicacy of tone of this particular instrument of song without words. I have seen a man seemingly in perfect health at one hundred years old who had eaten three meals a day; but may I infer that on four meals a day he would have lived to be one hundred and thirty-three and a third years old? A hundred times I have been told by physicians that they have had the best results from certain drugs; but in not one instance was any reason for their faith advanced. If I am to be governed by impressions as to the utility of what I may do for the sick, what is more impressive than to draw blood as they of old did, with recovery in most cases? Have we reduced the mortality of disease by a change in dosage? If so, how much, apart from the better sanitary conditions of living and from those involved in the care of the sick? I can easily see or believe there is utility in clearing the digestive tract at an early date in the case of severe sickness; I know that stomach and bowels are as machines run by brain power; but beyond this the materia medica is summed up in this way, "I dose my sick: they get well: therefore my treatment is successful; or if they die, it is the providence of God"--and with no thought that it may have been the providence of bad treatment. Men and brethren of the medical profession, you believe me a heretic in all my professional modes, and only endure me because I do not carry violent hands; but you would bar the sick-room from the bleeder of old. I may attack the lancet, the herbs, the ground-roots, whose doses were only as kindling-wood and sawdust a little more refined, and you will say "Amen" with emphasis. "But we, we live in a more enlightened age: our doses are more refined"--yes, but you administer them with the same force of conviction as to their utility in the cure of disease, and with little thought as to just why they are given and how they act. It is my present conception that feeding the sick as now very generally practised will be held, in a more enlightened age, as we now hold the lancet of a darker age--a twin relic of barbarism; and there will be only wonder that attempts were ever made to convert the lower bowel into a temporary stomach _thirty feet away_. How discriminating this deputy stomach that it selects the predigested food-ration from its unutterable lower bowel involvements; sending it pure and undefiled as ready-made flesh into the blood, only requiring it to be placed as bricks to a wall. Fortunately, these lower stomachs are not subject to nausea no matter how capable of otherwise rebelling, as they so often do. Predigested foods! If they nourish the sick, why not feed the well; why not abolish our kitchens at an immense saving in the time, expense, and worry of cooking, and live on them at an immense saving of the tax of digestion and the indigestive processes? Brethren of the medical profession, make haste to let the world know when you have found a case in which you have made use of the lower bowel so to nourish the sick body that it did not waste while the cure was going on. THE FASTING-CURE. XI. NOTES AND PRESS COMMENTS ON VOLUNTARY FASTS. The first voluntary protracted fast for the cure of chronic ailing to reach the public prints as a matter of interesting news occurred in the case of Mr. C. C. H. Cowan, of Warrensburg, Ill., early in 1899. He had been on the two-meal plan for a time, and wishing for something more radical wrote to me as to his entering upon a fast. I probably wrote him as I now find it necessary to write all who feel that fasts are necessary and cannot have my personal care, "Go on a fast and stick to it until hunger comes or until your friends begin to suffer the pangs of sympathetic starvation; then compromise with the sin of ignorance by eating the least that will bring peace to their troubled souls." The results were summed up by the _Morning-Herald Dispatch_, Decatur, Ill., April 16, 1899: "A few years ago Dr. Tanner, in New York City, fasted for forty days and forty nights, and all the world wondered. Up to that time the feat was considered impossible. From day to day the papers told of his actions and his condition, and the entire people became deeply interested in the performance. Medical men and scientists became interested in the performance, and the laity watched the faster through curiosity. Tanner's accomplishment was considered marvellous by the medical profession and laymen alike, but Dr. Tanner has long since been a back number, and his performance is not now regarded as remarkable, although there are not many persons who would care to attempt the fast. Tanner was simply trying to prove that the thing could be done. He did it, and within a year the man who held the attention of the people of the country for forty days was a visitor to this city. What Tanner did has been more than accomplished by a Macon County man, but he went about his undertaking quietly, and the fact that he was fasting was known to only a few of his friends. The man is C. C. H. Cowan, of Warrensburg, and for forty-two days and nights he abstained from the use of food in solid or liquid form. He began his fast on March 2 and broke it on the evening of April 13 at supper-time. With the exception of the loss of thirty pounds of flesh, which materially changed his personal appearance, Mr. Cowan shows no ill-effects of his undertaking. When he began he weighed one hundred and sixty-five pounds, and when he quit he weighed one hundred and thirty-five pounds. Before his fast he was inclined to be fleshy, and now, while still in fairly good flesh, his clothing manifests a desire not to hold close communion with his body. Mr. Cowan was in the city Saturday, and some of his friends did not know him. He related his experience to some of them, but he did this cautiously, and with the oft-expressed hope that the papers would not devote any attention to the affair, because he was not seeking and did not want notoriety. At different times during his fast the _Herald-Dispatch_ has referred to the fact in short items. Cowan is a disciple of a Dr. Dewey, living at Meadville, Pa., who is an advocate of fasting as a means of curing many of the ills to which the body is heir. Dr. Dewey has many pamphlets touching the subject, and has also written some books for his belief, and his reasons have been made so plausible that a number of persons have coincided with him. Cowan says the efficacy of the treatment has been established in many instances, a fact that he can prove by ample testimony. During his long abstinence from food he had numerous letters and telegrams from Dr. Dewey, encouraging him in the undertaking. When asked why he had fasted, Cowan explained that for years he had suffered from chronic nasal and throat catarrh which would not yield to medical treatment. His appetite was splendid, and he ate many things that he really did not want. He read Dr. Dewey's ideas, and became convinced that his system needed general overhauling, and that this could be accomplished through faithful adherence to the theory of Dr. Dewey. One of these theories is to the effect that fasting rests the brain, which is ofttimes overworked as a result of heavy feeding. It is also supposed that the body throws off old mucous membrane of the stomach and bowels, and that these are immediately supplanted by new lining. Believing that he could get rid of his catarrhal trouble and get the new lining referred to, Cowan decided to fast, and without noise about the matter he commenced, and up to Thursday evening he did not allow a bite of food to pass his lips. The only thing that he took was water. Of this he did not drink much, and he claims that he suffered no pain or pangs of hunger. Looking at the matter now, it does not seem to have been much of an accomplishment. After he once got started he said it was an easy matter to carry out his plan except for the worry of his family and some of his friends. They thought that he was losing his mind and tried to induce him to relinquish his idea, but he took some of them under his wing and reasoned with them on the beauties of the treatment, expounded the strong points, gave them reasons, showed them testimony of others, and kept on fasting. When he began he had no idea that he would continue for forty days; but as he progressed he had no desire for food, and therefore did not desist. Thursday evening he began to feel hungry, and that night he ate a reasonably good supper. The return of hunger, according to his theories, was the signal of the return of health. He feels confident that his stomach has been relined, and for the present he knows that his catarrh has left him. He is a firm believer in the new method of curing bodily ailments, and says that during his fast he was able to be around the village of Warrensburg every day, and was able to perform his duties. His abstinence from food apparently has not weakened his constitution. Since breaking his fast he has partaken sparingly of food. Cowan's friends are very much interested in the recital of his experience." It so chanced that during this fast much more than his ordinary business came to him, and without the least inability to perform it. I saw him several months later, and found his physical condition seemingly perfect. He had found out that for the best working conditions a nap at noon was better than even a light luncheon, and that one meal a day taken after his business was over was the best practice. This fast was not in the right locality to excite the attention it deserved. The second voluntary fast was destined to reach the ends of the earth through the public prints. The following appeared in the _New York Press_ of June 6, 1899: "Twenty-eight days without nourishment and without letting up for a moment on the daily routine of his business is the unequalled record of Milton Rathbun, a hay and grain dealer at No. 453 Fourth Avenue, and living in Mount Vernon. He is a man of wealth, has many employés, and has been in the same business in this city for thirty-nine years. "He fasted because he wanted to reduce his weight, fearing that its gradual increase might bring on apoplexy. He succeeded in his efforts. He weighed two hundred and ten pounds when he stopped eating; when he resumed he tipped the scales at one hundred and sixty-eight pounds, a loss of forty-two pounds of flesh. "Mr. Rathbun's description of how he felt as the days and weeks wore along and the pounds of avoirdupois slipped away one by one is interesting. The remarkable point about it is that he continued his work and kept well. He gave his account of it yesterday to a reporter for _The Press_. Mr. Rathbun is known by the business men for blocks around his own place of business, and they all know of his fast. "Every day his friends would come in and talk to him about it. At first they told him he was foolish; that nobody could fast that length of time, much less continue his work without interruption. Then as the days went on and he kept up without a break they began to be frightened. "A crowd would gather about him every night at 6.30 o'clock, when he would leave his office, for that was his hour for weighing. Some days he would lose two or three pounds from the weight of the day before; some days only one, but always something. And as the record was scored up on the book each night his friends would shake their heads and warn him to beware. "Finally, on the fifteenth day, his friends and employés got together and made up their minds that something had to be done. They were afraid that Rathbun would die. They appointed a committee to wait on him in his office and beg him to eat something. The committee took dainties to Mr. Rathbun, told him their fears, and offered the good things to tempt him, but all to no purpose. "It was the night of April 23 that Mr. Rathbun took his last bit of nourishment. He made no attempt to eat a large meal in preparation for his fast. He ate his regular supply just as if he had meant to continue eating on the following day. Then for twenty-eight days he absolutely abjured all food. He drank water, but that was all. Before going to bed he would take a pint of Apollinaris. "Had he remained at his home in bed or taken perfect rest, his achievement would have been less remarkable. That is the course which always has been adopted by the professional fasters. Dr. Tanner, and the Italian, Succi, in their fasts were surrounded by attendants who allowed them scarcely to lift a hand, so that every ounce of energy might be conserved. "Rathbun pursued a course diametrically opposite to this. He worked, and worked hard. He came down earlier to his office and went away later than usual. He made no effort to save himself. On the contrary, he seemed determined to make his task as hard as possible. On four of his fast days he spent the afternoons in a dentist's chair, at which times his nerves were tried as only dentists know how to do it. "It was his idea to continue the fast until he began to feel hunger. After the first twenty-four hours his hunger disappeared, and he had no desire for food until the end of the fourth week, when the craving set in, and he immediately set about satisfying it in a moderate and careful manner. He consulted two physicians while the fast was going on, to see that he was suffering no injury that he could not appreciate himself. One was Dr. F. B. Carpenter, of Madison Avenue and thirty-eight Street, and the other, Dr. George J. Helmer, of Madison Avenue and Thirty-first Street. He saw Dr. Carpenter on the eighteenth and the twenty-first days, and Dr. Helmer on the twenty-fifth day. Both expressed surprise at his long fast and astonishment at his excellent condition. "Mr. Rathbun is fifty-four years old, and five feet six inches in height. He does not look more than forty years old, and he is as active as a man of that age. He says he never felt better than when he was fasting, and that he has experienced no bad effects of any kind, while, on the other hand, he has reduced his weight to a normal limit and removed all danger of apoplexy. "He got the idea of the fast from the new theory exploited by Dr. Edward Hooker Dewey, a practising physician of Meadville, Pa., who recommends fasting as a cure for many ailments, and advises all persons to go without breakfast and eat only two meals a day. "'I became intensely interested in this new system,' said Mr. Rathbun yesterday, 'and I decided to put it to a practical test. Dr. Dewey had said that he had many patients fasting all the way from ten to thirty and forty days, and I concluded that if it did them so much good it would be just the thing for me. So I tried it. "'On April 23 I ate my last meal, and from then until May 24 I had absolutely nothing to eat. I drank water, of course, for that is a matter of necessity. One cannot do without drink; but I took no nourishment. For the first twenty-four hours I was very hungry, and would have liked very much to take a square meal; but I resisted the temptation, and after the expiration of one day I had no desire to eat. "'I had been in the habit of getting to my office about 8; now I get there at 7. I generally had left at 5.30; I now stayed until 6.30. I had been in the habit of taking an hour or an hour and a quarter for luncheon. The luncheon was now cut off, so I stayed in the office and worked. I sat there at my desk and put in a long, hard day's work, constantly writing. "'At night I drank a bottle of Apollinaris, and went to bed at 8.30 and slept until 4 in the morning. I never enjoyed better sleep than in those four weeks. And I was in excellent condition as far as I could see in every other way. My mind was clear, my eye was sharper than usually, and all the functions were in excellent working order. "'I had many amusing experiences. I went to a dentist on the first day. I had some work requiring several hours' labor on the part of the dentist. I said nothing to the doctor on the first day. Four or five days afterward I kept a second appointment with the dentist, and he asked me how the teeth worked which he had fixed before. I said to him: "I haven't tried them yet." "'You can imagine the look of surprise on his face. When I told him that I was fasting, and had been since he had seen me before, he showed the greatest concern, and said he did not think I could go on with the dental work on account of the weakness of my nerves. He solicited me to go out and have just a bite of something. I refused, of course, and he continued the work. I visited him on two days after that until he had finished the work. "'The men in my employ were greatly concerned about me, and thought I would break down. I used to weigh every night before leaving the office, and as they saw my constant wearing away they became more and more frightened, and finally appointed a committee to wait on me. The committee was headed by my manager, who begged me to eat. He brought along some fine ripe cherries to tempt me. I told him I would not eat them for one thousand dollars, for I was interested thoroughly in the fast by that time and would not have stopped. "'After that they made no more attempts to stop the fast; but my friends all shook their heads, and said that when I started in to eat again I would find I was without a proper stomach. "'On the twenty-eighth day the hunger began to come on again, and I began to eat under the advice of Dr. Carpenter. On the twenty-ninth day I drank a little bouillon, and afterward from day to day increased the amount of food to the normal. I suffered no inconvenience.' "Mr. Rathbun says he is a firm believer in the no-breakfast system of hygiene advocated by Dr. Dewey, and that neither himself, his wife, nor any of the servants in his house eat breakfast, and as a result all are remarkably well. His two sons, one of whom was graduated at Harvard in 1896, and a second, who is still at Harvard, practise the no-breakfast system. "Just before beginning his fast Mr. Rathbun ordered a suit of clothes at his tailor's. He did not go for it until the end of his long fast. Being something of a practical joker, besides a man of great nerve, he walked into the tailor-shop and let the tailor try his new suit on to see if it was all right. "When he slipped on the coat the tailor stood aghast. There was apparently the same man he had measured twenty-eight days previously standing before him in perfect health, but as to dimensions not at all the same man. "'It doesn't fit any part of you,' said the tailor, after the suit had been tried on. In the tailor's book Rathbun's measurement was entered: 'Forty-three inches around the waist and forty-two around the chest.' When he went for his suit his measurements were thirty-eight around the waist and thirty-eight around the chest. "Dr. Dewey's theory, which led Rathbun to make his long fast, is that the brain is the centre of every mind and muscle energy, a sort of self-charging dynamo, with the heart, lungs, and all the other parts only as so many machines to be run by it; that the brain has the power of feeding itself on the less important parts of the body without loss of its own structure, and that as the operation of digestion is a tax on the brain, a long period of fasting gives the brain a rest, by which means the brain is able to build itself up, which means the upbuilding of the whole body. "In this way, it is asserted, the alcohol habit is cured and other diseases eradicated. "Dr. F. B. Carpenter said yesterday to a reporter for _The Press_ that he had not recommended Mr. Rathbun to take the fast, but had advised him while it was going on and after it was over. The doctor said he was inclined to believe there might be something in the no-breakfast system, as a great many persons eat and drink altogether too much. "Dr. Helmer said he had examined Rathbun on the twenty-fifth day, and had found him in surprisingly good condition." Mr. Rathbun had been on the no-breakfast plan for several years, and he was one of the first to write me after my book came out. It was not without reason he feared apoplexy, for Ex-Gov. Flower, an over-weighted man, had gone down to instant death though seemingly in perfect health and in the prime of business energy and mental capacity. During his fast my only trouble with him was in his drinking so much water without thirst, thus greatly and needlessly adding to the work of the kidneys. Mr. Rathbun was so disappointed over the skepticism of New York physicians as to the reliability of the fast that he determined to undergo a longer one under such surveillance as would enforce conviction. He was mainly actuated, however, to go through the ordeal in the interests of science. Again I had trouble with him on the water question, wishing him to drink only as thirst incited. He was differently advised by an eminent Boston physician, who, taking a great interest in the case, wrote him that he should have great care to drink certain definite amounts for the necessary fluidity of the blood. I had to respond that thirst would duly indicate this need; that in my cases of protracted fasts from acute sicknesses not one had been advised to take even a teaspoonful of water for such reasons; that at the closing days before recovery of such cases there was only the least desire for water, and this with no indication of need from the blood. Mr. Rathbun did not escape some trouble from overworked kidneys, and he became convinced that my theory and practice were more in line with physiology. This fast was made a matter of daily record by the leading New York journals, and he became such a subject of general interest that in addition to his ordinary business he was greatly overtaxed, and was compelled to give up the fast on the thirty-fifth day, in part from the exhaustion of over-excitement. This case was summed up as follows by the _New York Press_, February 27, 1900: "Milton Rathbun has ended his long fast. "After thirty-five days, in which solid food or any liquid other than water was a stranger to his palate, he became extremely hungry on Sunday night. At first he resisted the longing to eat and tried to sleep it off. But he awoke in a few hours hungrier than ever, and then he decided he had fasted as long as was good for him. "He ate a modest, light meal and went back to bed, only to awake still hungry. Then he ate an orange, and was asleep again in a jiffy. A bowl of milk and cream and crackers sufficed for his breakfast, and at noon yesterday he enjoyed his first hearty meal. "As he walked around the parlor of his home in Mount Vernon, lighter by forty-three pounds than he was on January 21, this man of fifty-five years and iron will said: "'I feel like a boy again. I think I could vault over a six-foot fence.' "Mrs. Rathbun herself knows what it is to fast. For five years such a thing as breakfast has been an unknown quantity in her house, save when guests were present or for the servants. To this abstinence Mrs. Rathbun attributes the curing of catarrh, from which she had suffered previously. And as she and her husband do, so do their two sons. "After the first few days of abstinence he had felt no desire to eat until Sunday evening. Then he became hungry--ravenously so. His first fast of a year ago--it was twenty-eight days then--had taught him that sleep took away the longing for food, and, too, he had said he would make his fast last forty days this time. So he went to bed and to sleep. "But he awoke at 11 o'clock; he was hungrier than ever, and he decided not to resist his inclination for food. Calling his wife he asked her for an orange, and ate it; then he took another. His next demand was for oysters, and a dozen large, juicy ones disappeared rapidly, to the accompaniment of five soda crackers. Then he drank about two-thirds of a cup of beef-tea, and some Oolong tea. His appetite was not sated by any means, but he knew the danger of overloading his stomach, so he stopped. "He soon was slumbering again, but he was wide awake at 2 o'clock in the morning. And his hunger was with him still. He ate an orange to appease the craving, and again sought his pillow. He slept again until 6 o'clock, and then, breaking some crackers in a bowl of milk and cream, he ate again. "At noon a meal was served to the still hungry man. He began with a little clam-broth; then came half a dozen steamed clams, followed by a small portion of mock-turtle soup. Of a squab he ate one-half, and with it some canned pease and fried potatoes; while for dessert he had a little lemon ice. "'That was good,' he exclaimed, as he finished. The remark was unnecessary; the relish with which he had eaten was convincing testimony of his enjoyment. Asked why he had decided not to fast for the full forty days, he said: "'I ate just because I was hungry.' "Asked how the weather affected him, he said: "'When I began there was a spell of cold weather, and I found it rather hard to keep warm at night. But it soon passed away, and I made it a point to wear the same underclothing and outer garments as usual. Oh, yes; I did wear a different pair of trousers. I had them made five years ago, but they were so tight around the waist I could never wear them. They are as loose as can be now, however.' "'From a scientific standpoint,' said Professor R. Ogden Doremus yesterday, 'it is the most interesting and valuable experiment I have known. Mr. Rathbun is a man of great nerve force. The very fact that he attended to his business was what saved him, in keeping his mind away from the thought of food. He could not have done it had he been on exhibition or if he had remained at home. If he had been at sea, in an open boat, he could not have lasted more than ten days. He would have had nothing to think of but his hunger.' "Dr. George J. Helmer, who has given no little attention to Mr. Rathbun, said: "'I have examined him several times; I did so when his thirty days were up. Well, it was remarkable. It's a wonderful exhibition, that will attract the attention of the medical world. His heart is as clear as a bell and his kidneys are perfect. He is in absolutely rugged health. His temperature was normal, his eye clear, and to-day, upon examination, any insurance company would rate him as an A1 risk.' "Following is from the diary kept during his fast, and furnished by Milton Rathbun to _The Press_: "_First Day_, Jan. 22, 8.45 A. M.--Weight, 207 pounds; height, 5 ft. 6-1/2 inches; chest measure, 43-1/2 inches; waist measure, 43-1/2 inches; hip measure, 46-1/2 inches; calf measure, 17 inches; biceps measure, 14 inches; forearm, 12 inches. 3 P. M., feels well, but hungry. In the evening felt well, not being hungry or thirsty. Have taken no water. "_Tuesday_, Jan. 23.--Slept well until 6 A. M. Rested a while, then took sponge bath and rubdown. At 8.45 weighed 200 pounds. Feel good, but a little weak. 12 o'clock M., no appetite and feverish. 4 P. M., weighed 199 pounds; went home; drank one pint of water during the evening. "_Wednesday_, Jan. 24.--Slept well for nine hours. Got up at 6 A. M., drank one glass of water and took train to the city. 8.30 A. M., weighed 198-1/2 pounds; only half pound lost, which shows how greedily the tissues absorb moisture and add to weight. 12 o'clock M., have no appetite nor thirst, and no fever. Retired at 9 o'clock, feeling comfortable but a little feverish. "_Thursday_, Jan. 25.--After having slept seven and one-half hours took a sponge bath and brisk rubdown. Came to the city, and at 8.25 A. M. weighed 195 pounds. Feeling good, with no fever nor appetite. 4.45 P. M., weighed 193 pounds. At home during the evening drank two and one-half glasses of water. "_Friday_, Jan. 26.--Slept eight hours. No appetite and feeling stronger. Examined by Professor Doremus and Dr. Carpenter. Retired at 9 o'clock, feeling first class. "_Saturday_, Jan. 27.--Came to the city on the 7.45 A. M. train. Weighed 191 pounds. Feeling good. No fever and no appetite. "_Sunday_, Jan. 28.--Drank one glass of water when I got up. During the day and evening drank three more glasses of water. Retired feeling first class. "_Monday_, Jan. 29.--Slept eight hours last night, and came to the city on the 7.45 A. M. train. At 8.25 weighed 189 pounds. 4 P. M., was examined by Dr. F. B. Carpenter, who found the temperature 98-1/2° F., pulse regular, tongue clean. Measurements were: waist, 41 inches; chest, 41 inches; hip, 45 inches; calf, 16 inches; biceps, 13-1/2 inches; forearm, 11-1/2 inches. 5.15 P. M., weighed 188 pounds. "_Tuesday_, Jan. 30.--Slept eight hours; weighed 188 pounds, same as the night before; feeling good. 5.30 P. M., weighed 185-1/2 pounds. "_Wednesday_, Jan. 31.--Slept 7-1/2 hours, drank one and one-half glasses of water; weighed at 8.25 A. M. 187 pounds; Dr. Carpenter found temperature 98° F., and pulse 88; Professor Doremus called a little later; weighed 184-1/2 pounds. "_Thursday_, Feb. 1.--Rested quietly when not asleep; drank only one and three-quarters glasses of water all day; weighed 184 pounds; retired feeling good. "_Friday_, Feb. 2.--Not feeling any hunger; was examined by F. B. Carpenter; temperature, 98° F.; pulse, 84; weighed 183 pounds; retired feeling well, but tired. "_Saturday_, Feb. 3.--Somewhat wakeful during the night. 5.45 P. M., weighed 182 pounds. "_Sunday_, Feb. 4.--Read all day and felt well. "_Monday_, Feb. 5.--2 P. M., temperature, 98.4° F.; pulse, 82; tongue clean. Measurements were: waist, 41 inches; chest, 41 inches; hip, 43 inches; calf, 14-1/2 inches; biceps, 13-1/2 inches; forearm, 11-1/2 inches; went to bed feeling a trifle feverish. "_Tuesday_, Feb. 6.--Wakeful during the night. 11 A. M., had my eyes examined by Dr. L. H. Matthez, oculist, and found a marked improvement in my sight over same tests of two months previous, being 7 degrees stronger; felt a little weak, but no fever or appetite; weighed 180 pounds; feeling somewhat exhausted from the day's labor and in entertaining guests. "_Wednesday_, Feb. 7.--Slept about seven hours during the night; when I awoke felt rested; temperature, 98.2° F.; pulse, 80; have felt well all day; went to bed at 9.30; some fever. "_Thursday_, Feb. 8.--Woke up two or three times during the night. Drank water during the night and first thing this morning when I got up. Came to the city, and at 9 o'clock weighed 182 pounds, showing a gain of two pounds over last night. Not feeling so well owing to the amount of water I drank last night, which was induced by feverishness. "_Friday_, Feb. 9.--Feeling first rate. At 8.25 A. M. weighed 180 pounds. Heart action normal. No enlargement of the spleen or liver. "_Saturday_, Feb. 10.--Lost nothing in weight during the day and have felt well all the while. "_Sunday_, Feb. 11.--Passed the day in reading and drank frequently of water. "_Monday_, Feb. 12.--This being a holiday, did not go to the city. Passed the day in entertaining callers. Have not felt quite so well owing to a slight cold settling in my left kidney. "_Tuesday_, Feb. 13.--Measurements: waist, 38-1/2 inches; chest, 40 inches; hip, 43 inches; calf, 14-1/2 inches; biceps, 12-1/2 inches; forearm, 11 inches; weight, 177-1/2 pounds. "_Wednesday_, Feb. 14.--I attribute the cause of loss of sleep to a hard day's work and in reading too long last evening. "_Thursday_, Feb. 15.--Somewhat wakeful during the night. Retired at 7.30 o'clock, after a hard day's work. "_Friday_, Feb. 16.--3.30 P. M., temperature, 98.5° F.; pulse, 74; tongue clean; weighed 172-1/2 pounds. During the evening drank one cup of hot water. "_Saturday_, Feb. 17.--After a restful night felt well all day. "_Sunday_, Feb. 18.--Retired at 9 o'clock and have rested a good deal during the day. "_Monday_, Feb. 19.--Weighed 169-1/2 pounds, and retired feeling well. "_Tuesday_, Feb. 20.--Weighed 168-1/2 pounds; was examined by Dr. Helmer, who found me in excellent condition; 4.30 P. M., weighed 169-1/2 pounds, a gain of one pound during the day, on account of drinking a little more water than usual. "_Wednesday_, Feb. 21.--Temperature, 98.5° F.; pulse, 69; 4 P. M., weighed 168-1/2 pounds; have not felt quite so well during the day. "_Thursday_, Feb. 22.--Occupied the day--holiday--in reading and reclining, and went to bed feeling pretty well. "_Friday_, Feb. 23.--At 8.30 A. M. weighed 166 pounds; 3.30 P. M., temperature, 99° F.; pulse, 98; lung expansion, 2-3/4 inches; went home and to bed, feeling considerably exhausted owing to a hard day's work and too many callers. "_Saturday_, Feb. 24.--Did not rest very well from overtaxing the brain yesterday. Do not feel quite so well this morning owing to that fact and from drinking too much water during the past twenty-four hours. At 8.25 A. M. weighed 166 pounds; went home not feeling well to-day on account of some stomach disturbance, which probably comes from drinking too much water; did not drink any water during the evening; feeling quite tired at bedtime. "_Sunday_, Feb. 25.--Slept nine hours and rested well, and did not drink any water during the night. Kept quiet all day, lying down most of the time, and felt the coming of hunger about 6 o'clock. 12 o'clock noon, pulse regular; tongue clean; temperature, 98.2°F.; weighed 164 pounds. Measurements were: waist, 36-1/2 inches; chest, 38 inches; hip, 40-1/2 inches; calf, 14 inches; biceps, 11 inches; forearm, 10 inches. Was in bed at 8 o'clock, still feeling hungry, and after a short sleep woke up at 11 o'clock with a sharp appetite, and ate a dozen raw oysters, two oranges, two-thirds cup of beef-tea, five crackers, and part of a cup of Oolong tea. I insert a photograph of Mr. Rathbun taken shortly after his second fast. There had been five years' trial of the No-Breakfast Plan before these fasting demonstrations." One of the hardest things on earth as a mental operation is to be fair to the opposition. Now lest I have beguiled my readers overmuch by the force of my convictions even to the point of danger, I will give an estimate of the danger of fasting by one of the most eminent physicians of New York City, Dr. George F. Shrady. I quote from an interview reported in the New York _Sun_: "The strange case of Milton Rathbun, of Mt. Vernon, who, to reduce his flesh and generally tone up his system, is said to have gone without food of any sort for thirty-six days, still continues to be the subject of more or less discussion among the medical men of the city. Dr. George F. Shrady, in speaking last evening of Mr. Rathbun's remarkable exploit, said: [Illustration: MR. MILTON RATHBUN, SHORTLY AFTER HIS FAST.] "'There are three things to say about it. In the first place, the fact, if it be a fact, as it seems to be, is astonishing; secondly, it was very foolish; and thirdly, it would be a very unfortunate and dangerous thing to popularize such experiments. Now as to whether the gentleman in question actually did go thirty-six days without taking nourishment of any sort is a matter I will not discuss. If he were a professional faster, I would hardly hesitate to say his claim was fraudulent, for I am fully convinced that all the professional fasters are frauds. They are simply adept sleight-of-hand men. They work out some adroit trick by which they may get nourishment into their systems in spite of the always more or less negligent or suspicious watchers, and then advertise for a forty days' or sixty days' 'fast.' * * * * * "'Now, mind you, I do not say this Mt. Vernon case is anything of this sort. I only say that if it is true it is most astounding. It is in flat contradiction of all the authorities on the subject of a human being's ability to do without food. The extreme limit of all well-authenticated cases of total abstinence from nourishment is from nine to ten days. Imprisoned miners have been known to go that time and survive. * * * * * "'But at all events it was a very foolish thing for Mr. Rathbun to do. About that there can be no manner of doubt. What will be the future effect upon him--upon his heart action, upon his impoverished blood, upon his nervous system, upon his organs of nutrition, necessarily paralyzed for days? These are grave questions, the answers to which may be unpleasant to Mr. Rathbun as they reveal themselves to him in the future. You cannot fly in the face of Nature and ignore all her laws in that way with impunity. She exacts her penalties and there is no court of appeals in her realm. "'When I say that the extreme limits of abstinence from nourishment in clearly authenticated cases is from nine to ten days, you must not get the impression that all persons can last that long. * * * * * "'It is a question of environment, of mental condition--whether buoyed by hope or stimulated by ambition to do a great feat--and above all, of course, of the physical condition of the faster. Without food the body absorbs its own tissues. Mr. Rathbun, I am told, was a very heavy man with a superabundance of tissue. Naturally he could go longer without nourishment than a weak, attenuated, thin-blooded man. * * * * * "'Yet Mr. Rathbun was exercising daily and about his usual avocations, and he abstained from food for thirty-six days! Well, it's remarkable! * * * * * "'But I sincerely hope Mr. Rathbun will have no imitators. It would be a very unfortunate thing, fraught with grave possibilities, if the newspaper accounts of his reduction in weight and general improvement in health were to move others to follow his example. Many persons would be injured for life, physically wrecked, and perhaps actually killed if they conscientiously did the fifth part of what he is said to have done. * * * * * "'And right here it may be said that there is a great deal of exaggeration in the sweeping statements made about people eating too much. If a man sleeps well, goes about his business in a cheerful frame of mind, and does not get what is called "out-of-sorts," he may be pretty sure he is not eating too much, even though he eat a good deal. My observation is that the average man who works and gets a proper amount of exercise does not eat too much. If you want to get work done by the engine, you have got to stoke up the furnace. If a man wants to keep his vital energies up to par he has got to put in the fuel--that is, the food. "'Of course, there are those who lead sedentary lives who get too much absorbed in the pleasures of the table and overfeed. There are a sufficient number of these, to be sure, but I think they are the exception. But it will be a sad mistake if even they seek a road to health by Mr. Rathbun's starvation methods.'" The doctor is astonished, and so am I that he is astonished. This would seem to imply that he has never had cases of acute sickness in which the amount of food taken during many days or even weeks was too small to play any part as a life-prolonging factor. "It was a foolish, even dangerous experiment." How foolish or dangerous? What vital organs suffered? Was there evidence of a loss of anything but fat? What organs were "necessarily paralyzed" during the fast? Evidently not the brain, else longer days of labor would not have been possible; and the grave future possibilities in heart action, impoverished blood, nervous system, upon organs of nutrition "necessarily paralyzed" for days; and the extreme limit of nine or ten days before death from starvation; and that without food the _body_ lives on its own tissues! One can easily see that the earnest doctor is full of strong impressions that have little of the flavor of science: truth that is not self-evident should have the instant logic in easy reach. I may here say that my hygienic scheme has from the first been subject to similar attacks by physicians from the standpoint of impressions, but no physician has ventured into print against it after becoming aware of its physiologic basis. I am happy to assure all readers that in all the involuntary fasts of my cases of acute sickness or in the voluntary fasts in chronic disease, has there been any other than improved general health as the result. Notably was this the case in a man who fasted ten years ago for forty days for an ulcer of the stomach, and who had been troubled with indigestion for more than forty years. He had become nearly a mental and physical wreck when he took to his bed with an abolished appetite. There have since been some ten years of nearly perfect health, and now in his seventy-seventh year he is the youngest-looking man for his age I have ever seen. He walks the streets with the gait of a youth of twenty. To do without food without hunger does not tax any vital power, as Dr. Shrady may yet become aware. XII. The next fast to have a brief notoriety as the "most remarkable on record" occurred in Philadelphia, the medical center of America, and beneath the very shadow of its great medical schools; in Philadelphia, a city that surpasses all other cities for the wisest conservatism, for all-around level-headedness. Its journals are rarely equalled for their clean, winnowed columns; there is no "yellow" journalism in that great, fair city, known as the "Quaker City." Miss Estella Kuenzel, a lady of twenty-two years, of acutest, finest sensibilities, born to live in June and not in March, lost her mental health to a degree that death became the final object of desire. She had a friend in a bright young man of the name of Henry Ritter, chemist and photographer at the Drexel Institute, a born scientist, and who possesses the very genius of the pains and persistence of science. Well versed in the science of the morning fast, he believed that a fast which would merely end with hunger would result in all-around improvement. A fast was instituted which he thought would not last more than a few days, but went on until the days merged into weeks: it went on because only general improvement attended it. I first heard of it in a letter written by him on the thirty-eighth day of the fast, during which there had been a walk of seven miles. On the forty-second day of the fast I had a brief letter from Miss K., in which every line was radiant with cheer. At the Asylum five feedings per day were ordered, and at first were rejected; but finally she accepted them as a means to end her unhappy life; took them in bed, and in the last weeks seemed to be fleshing up, as there was a gain of seventeen pounds above the normal, of water--she had become dropsical. The last professional expert in her case advised a half-gallon of milk daily in addition to the three regular meals--making a five-meal plan. To carry out an unopposed fast it was necessary to take her to a home where the parents would be ignorant of this radical means to a cure. The following is from Mr. Ritter's letters: "I had made my views known to the parents and daughter when the case commenced, and after the failure of these methods they decided to let me have charge of the case, which was on Sept. 30, 1899. I at once requested them to send her to the house of some friends to whom I made my views known. We then discharged the nurse who had gone with her. With doctor and nurse gone there was free room for Nature's victory (the young lady being as deeply interested as any). We put her upon the rest, which was the only needed sign since her first signs of breakdown appeared Oct. 2, at the supper table, being the last meal she has taken up to to-day, Nov. 9, this being, as you will see, the thirty-eighth day of her fast, with cheerfulness and strength holding full sway. I put her to bed on the first day, to which she kept, with an occasional day in the rocker, until the eleventh day, when she took a walk of about one mile. Then she rested indoors until the twentieth day, when we went to church, walking a little over two miles, with no fatigue or tired feelings. I forgot to mention that we had been out driving in the bracing air for over three hours in the afternoon. On the twenty-first and twenty-second days, indoors, walking and working around the house, reading, etc. On the twenty-third day walked through the country for three miles, stopping at friends to enlighten them upon 'Nature's Laws;' twenty-fourth day, eight miles, no fatigue; twenty-fifth day, between seven and eight miles, no fatigue; twenty-sixth day, walked one and a half hours; twenty-ninth day, rainy, no walks; thirtieth day, walked in the evening for two and a half hours; thirty-first day, walked seven miles, no fatigue; thirty-second day, rainy, no walks; thirty-third day, went to the Exposition, walked all day from 2 P. M. until 11.30 P. M. (with rest while at the performance we attended of not over one and a quarter hours), this being the only resting, possibly two hours, during the whole time. "Weight taken at the start, one hundred and forty pounds; at the Exposition one hundred and twenty-five and three-quarters pounds; no sense of tired feeling, but hunger started to assert itself for a period of about three hours, after which it passed over. "On the thirty-fourth day went driving; thirty-fifth day, walked one mile, then went to the asylum to show the results. The physicians in charge were simply astounded, and would hardly believe it possible for one to be so active while taking no food. I believe we have done quite a little good there, as they have expressed the desire to try the same on others. They examined the tongue and took the pulse, finding both in good, normal state; in the evening walked another mile, visiting the other doctors whom her parents called in. On the thirty-sixth day walked one and a half miles; thirty-seventh day, walked seven miles, hunger sensation becoming decided. "I have given you a sketch of this case because it seems to me an unusual one owing to the great activity." "November 18, 1899. "Miss Kuenzel's hunger arrived as per Nature's demand on the forty-fifth day at noon. One poached egg and two slices of toast (whole wheat). There was an intense relish for her simple fare, but not the least sign or desire for haste in eating. She was amply satisfied for the day, and relished the same bill of fare and quantity for the forty-sixth day, with a very slight luncheon in the evening. We had been to the Exposition the night of the forty-fourth day, when the tongue again started cleaning and a most distinct craving for food presented itself. It persisted on retiring, and also on the next morning, when she felt that Nature again was ready for her wonderful chemistry of digestion. I had her weight taken after her first meal, which revealed a loss of twenty pounds. We called to see the professor under whom she was last placed, and he was surprised with the clearness of her mental condition and good general appearance, though he observed she had gotten a trifle thinner, but which he had also in view to accomplish upon a five-meal plan per day. He tried his best to confuse and trouble her with questions, etc., but found her too intensely awake, and she won the victory by cornering him in his own set traps. We received his congratulations and were made to promise to call again. I have now been with her to seven physicians who were interested, and have shown them Nature's own unhampered work. "Miss Kuenzel has now an intense desire to help others. You are at liberty to make use of Nature's work in her case for the benefit of others, and I shall be only too glad to give you any desired information that may be of use. The good work you have started will, I am sure, never end; and it will prove a pleasure to me indeed to work with added interest for the benefit of those in need of the same in the future." The forty-fourth day of the fast was the busiest of all with her. She arose at 8.30 A. M. to attend to her affairs until the late afternoon, when she and her friend met a sister, by appointment from her home, at the Exposition. Several hours were spent there, and when they took the street car for return the only vacant seat was accepted by the sister, because she was tired, and not knowing that there were forty-four days without food with her sister, who was not tired. A striking feature of these daily walks was that they did not cause marked fatigue. Miss Kuenzel retired near midnight without unusual fatigue, and so ended the forty-fourth day of the fast. I quote from the _Chester County Times_ of Feb. 12, 1899: "'Conclusive evidence is being multiplied as to the wonderful power of fasting in the restoration of health, but it is only more recently that its power in the case of insanity is even yet more wonderful. A recent case is as near home as the city of Philadelphia, and those interested are very willing that others may know of it, so that its usefulness may be extended and its value appreciated. The discovery was made by Dr. E. H. Dewey, of Meadville, Pa., and tidings of the good work are being spread by Charles C. Haskell & Son, of Norwich, Conn. The editor of this paper knows somewhat the value of the discovery by an experience of several years. We give a letter from the lady who was cured. "'PHILADELPHIA, PA., Dec. 12, 1899. "'_My Dear Mr. Haskell:_ "'I have received your letter of the 9th inst., and at last find time to fulfil the request for a statement. In regard to my _wonderful cure_ through "The New Gospel of Health," I would state that the second week after Christmas, 1898, I first had a paralyzing effect which affected the right side of face, body, and limbs, also tongue, which nearly prevented my speaking. This passed over and I again began working at my position as milliner in a large establishment, and after a short while became so dizzy and confused that I was compelled to ask my friends to direct me home. (This was around Easter, 1899.) I was then taken to a doctor, who at once requested me to stop working, and to take a _complete rest_, but not for the stomach, as he prescribed a severe and exacting master to stimulate the _tired and overworked stomach_ to _renewed life_, and so give the nerves plenty of pure food, as they were in need of same. I then, after getting a ravenous hunger, weakened myself still more and became worse. My stomach felt numb and paralyzed, as did also my other internal organs, but this was put down against me as an illusion. So a _professor of nervous diseases_ was called in consultation, owing to my many desires to die (as life had no sunshine, flowers, or music for me); I was simply living a living death of torture which these professors would have were illusions. My parents were then informed that I must be sent to an asylum, where I was for ten long weeks. _They_ also told me that my feelings were illusions, and proceeded to banish the same by giving the _tired-out nerves a little rest_ and _plenty of nourishment_ on a _five-meal_ plan per day. If refused (owing to a loss of appetite), I was threatened to have nature helped by the aid of a stomach or nasal tube. I lost none of my illusions while there, as I could not feel any improvement in my feelings. I left the institution June 28, 1899, feeling no better; in fact, worse than when I arrived there. I was then taken from one doctor to another, the one wishing to operate, the other not; one advising me to go to the seashore, country, etc., but _none_ to give my stomach the needed vacation. "'It was then that my friend, Mr. Ritter, stepped in, as he saw the failures of professors and specialists, and begged my parents to let him have a chance to demonstrate what Dr. Dewey's method would do for melancholy illusions and tired-out stomachs and nerves. I then went to friends, and, in entire ignorance of my parents, began under directions of Mr. Ritter the most natural, sensible, and cheapest of all cures. I began my fast on Oct. 3, and broke the same on Nov. 16. During the first week of my fast I was in bed; during the second (excepting the eleventh day, when I took my first walk of seven-eighths of a mile) I was in bed, in rocker, reading, etc. On the twentieth day, after a drive of three hours, went to church, walking two and one-sixteenth miles. I then stayed indoors again on the twenty-first and twenty-second days, and then started taking daily walks (weather permitting). I went out walking twenty-three out of the forty-five days of my fast, and during that time walked one hundred and twelve miles. This was besides the carriage-drives, Exposition, and evening gatherings (walking to same included). I did not in the least feel tired or weak, but happier and brighter each day of the fast, as I could feel the effects of a new life throughout my whole body. My mind also became clearer and dizziness became a thing of the past. This was indeed _joy supreme to me_, and life became once more a joy instead of a burden. Sunshine, trees, flowers, etc., again made an impression, and my parents, sisters, and friends are rejoiced to see me in my happy normal state of health. "'I have gone through a year of unspeakable torture brought on by overwork and _human-wise professors_; but at last, through the wonderful teachings Dr. Dewey has given to mankind, and through a friend, who was able to preach the "New Gospel of Health," am now well, strong, and happy. May God only help and bless the many sufferers throughout the world (especially in the asylums) with the rays of this Gospel. I have been saved, no doubt, from a gloomy future, and may such be the realization of many more unfortunate souls is the sincere wish through experience of "'Yours very sincerely, "'ESTELLA F. KUENZEL.'" This case was summed up in the Philadelphia _Public Ledger_ of Dec. 25, 1899, whose columns are guarded with unsurpassed care, as follows: "One of those cases which a judicious editor ponders in no little perplexity is that of a young lady who was taken out of an insane hospital and subjected to a protracted fast, without medical supervision, and with results that appear to have been quite successful. On the one hand, there is the benefit that may be derived by having the attention of the profession called to the subject, with possibly good results; on the other hand, there is the danger of having a lot of ignorant or impulsive people risking their lives by starving themselves for this or that real or fancied disease, forgetting the adage that a little knowledge is a dangerous thing, especially in therapeutics. "The mind of the young lady referred to became affected about a year ago, and after what was regarded by her parents as an unprofitable period of treatment for two and a half months in a hospital for the insane she has been apparently cured by fasting--some would call it starvation. The case has been attracting attention and discussion lately in a growing circle that has included a few physicians. "The subject is a Miss K., aged twenty-two years. Henry Ritter, who has charge of the Photography Department of the Drexel Institute, and who is better acquainted with the matter than any one else, furnished a _Ledger_ reporter with the particulars as they are here given, the name and address of the young lady, for obvious reasons, being omitted. Mr. Ritter was at first loath to have any publicity given the case, but felt upon reflection that the results were properly a subject matter for inquiry by physicians, at least, not to speak of others who may be interested. "Miss K., by the advice of specialists who had treated her at home, was put under treatment for melancholy in an institution for the insane. Mr. Ritter, being an intimate friend of the family, visited her, and, he says, found her retrograding. She was receiving three meals a day, with two luncheons between them. Having built up his own digestive powers by following the tenets laid down by Dr. Dewey, a Crawford county physician, he had become a student and advocate of the latter's theory, briefly stated, that no food should be given to a patient except in response to a natural call or appetite for it. Believing that no improvement could result from the course Miss K. was receiving in the hospital, he prevailed upon her parents to permit him to have her placed in the home of a friend, and suggested the fasting process. This was the more readily done as the physicians in whose care she had been advised her parents to leave their daughter as much as possible among strangers. "This young lady, according to Mr. Ritter, was absolutely without food for forty-five days, beginning October 3 and ending November 16. He says he did not fear, as others did, that she would starve, as the authority he depended on had never fed a sick patient during a practice covering twenty-two years, no matter how protracted the case might have been, and claimed to have had only the best results. 'This,' said Mr. Ritter, 'is on the theory that, since all bodily energy is the result of the brain, by abstaining from feeding in the absence of appetite there is all the energy of cure undiverted by needless waste in the stomach. Feeding the sick, this physician contends, is a tax on their vital power, adding indigestion to whatever other troubles exist: because the brain has the power in sickness to absorb nourishment from the body, as predigested food, so that it never loses weight, even in death from starvation.' "The patient herself became interested, Mr. Ritter says, and evidenced great relief from abstinence from enforced periodic feeding. Gradually a numb feeling of which she had complained as affecting her internal organs, and which had been ascribed to her illusions, left her, and she appeared to gain daily in strength and brightness. Mr. Ritter's narrative proceeds: "'On the eleventh day of her fast a walk was suggested, and she covered about seven-eighths of a mile; on the twentieth day she was taken for a carriage drive of three hours in the afternoon, and in the evening she walked to church and back, a distance of something more than two miles. From the twenty-third day she took walks daily, excepting on October 31 and November 3, when rain prevented. She visited friends and the theatre and the Exposition, went to church several times, to the hospital where she had been a patient--this on the thirty-fifth day of her fast--and to the Drexel Institute on the thirty-ninth and forty-second days. A table of dates shows that she walked from two or three to six and eight and as high as nine miles a day during the period of forty-five days that she abstained from food, with a general increase of strength and cheer and no sign of fatigue. Hunger sensations were marked on the forty-fourth day and night, and on the morning of the forty-fifth day Miss K. broke the fast by eating a poached egg and two slices of buttered whole wheat toasted bread. "'During her fast she was seen by seven physicians and medical professors, President MacAlister and professors of the Drexel Institute, and many others.' "The young lady's weight at the beginning of the fast, Mr. Ritter says, was one hundred and forty pounds, and just after the meal with which she broke the fast she weighed one hundred and twenty pounds. By December 15 she had regained nine pounds, meanwhile eating one meal daily and sometimes two, with an occasional light luncheon. "Dr. Chase, medical director of the institution above referred to, was visited on Saturday by a _Ledger_ reporter in regard to the case of Miss K. He had been informed of her long fast and of its results, and had seen Miss K. herself when she called at the asylum on the thirty-fifth day of the fast. He said that when she was first brought to the asylum she was suffering from melancholia, and was put under the treatment which all the leading alienists had found most beneficial for persons suffering from nervous disorders, viz., quiet, rest of mind and body, and full, nourishing diet, carefully selected to produce the best results. During the time she remained at the asylum she improved both in bodily and mental health. "Referring to the treatment she had received under Mr. Ritter's supervision since leaving the asylum, Dr. Chase said he had first heard of the system through a work published two years ago by Dr. George S. Keith, of London, from which he first learned of Dr. Dewey, who also uses the fasting cure. In all the cases cited by Dr. Keith none had been afflicted with any mental disorder. He looked upon the cases, however, as showing some remarkable results, warranting a careful study. But it would not do to adopt such a system without a most thorough examination. As 'one swallow does not make a summer,' neither will one case nor half a dozen cases cured by such a method prove anything. No universal method can be adopted for treating disease. Hardly two cases are alike. Cures also may be brought about in different ways if the exact condition of the patient is understood. "'Mr. Ritter says the patient lent herself very willingly to the treatment, which was a great deal to start out with in her case. But I am surprised that a young man with no medical knowledge would do a thing like that. The treatment might easily have resulted differently. If he had been a doctor, he would have had that fact to sustain him in case he got into trouble. The case might very well have resulted fatally, because the treatment was so contrary to what would naturally be pursued by physicians in nervous cases. "'I do not ridicule the system. There have been cases which were cured by ways not recognized by the general practitioner after they had been given up. I am a firm believer that in selected cases the fasting method would be efficacious, but I do not believe in its general application. "'Mr. Ritter is evidently an enthusiast, and apt to overstate the points in favor of the method, neglecting those which tell against it. It is too early yet to say what the outcome of Miss K.'s case will be. I think the matter ought to be looked into more fully. Mr. Ritter could not have been with the patient at all times. It is a remarkable thing that she should have kept up and had the strength reported, unless she had some food. He may have been deceived in that.'" During several months since the fast there have been the best physical _health_ and mental condition, the weight having increased several pounds above the former average. Mr. Ritter conducted this case in a blaze of publicity. He showed it to no less than seven physicians, some of whom were college professors, and one of them at near the close of the fast suggested that if food were not soon taken a sudden collapse would be the result. There seemed to have been less danger of this calamity on the forty-fourth day than on any other. The reliability of the fast was so clearly evident that the leading papers of the city accepted it as authentic news and of the most startling kind. _The Times_ gave several columns of its first page to an illustrated article.[1] The accompanying illustration shows Miss Kuenzel on the forty-first day of her fast. She walked seven miles on this day without any signs of fatigue. [Illustration: Copyrighted 1900, by Henry Ritter. MISS ESTELLA F. KUENZEL, FORTY-FIRST DAY OF FAST.] The following table of miles walked were measured from exact diary notes with bicycle and cyclometer after the fast was broken. The table gives the total sum of each day, walks being taken both afternoon and evenings of same day. Date. Miles. October 3 " 4 " 5 " 6 " 7 " 8 " 9 " 10 " 11 " 12 " 13 7/8 " 14 " 15 " 16 " 17 " 18 " 19 " 20 " 21 " 22 2-1/16 " 23 " 24 " 25 3 " 26 6-5/8 " 27 5-7/8 " 28 4-1/2 " 29 4-1/8 " 30 5-5/8 " 31, rain November 1 6-3/4 " 2 8 " 3 rain " 4 9 " 5 6 " 6 3-3/4 " 7 1-1/2 " 8 7-1/4 " 9 7 " 10 4-1/4 " 11 2-5/8 " 12 7 " 13 2-1/4 " 14 3-1/4 " 15 5 " 16 5-3/4 -------- 112-1/16 The next fast, under the care of Mr. Ritter, still holds the record as being the most remarkable for its number of days and the miracle of results. The following account of it appeared in the _North American_, one of whose editors had personal knowledge of its history: "Leonard Thress, of 2618 Frankford Avenue, has learned how to live without eating. By physical experience he has proved not only that food is not a daily necessity of the human system, but that abstinence therefrom for protracted periods is beneficial. Indeed, it saved his life. He has just finished a fifty days' fast. When he began it he was on the brink of the grave and his physicians had abandoned hope. When he ended it he was in better health than he had enjoyed for years, although in the meantime he had lost seventy-six pounds, falling away from two hundred and nine to one hundred and thirty-three pounds. "Thress, who is about fifty-seven years old, was attending the Grand Army Encampment at Buffalo in the fall of 1898, when he caught a violent cold, which settled in his bronchial tubes. It proved so stubborn that his general health became affected, and a year later dropsy developed. His condition grew steadily worse, and at Christmas time, 1899, it was such that he could neither walk nor lie prostrate, but was compelled to sit constantly in an armchair. His doctors exhausted their skill in the effort to bring relief, and eventually, in the early part of last January, they told him that their medicines refused to act, and that his death was a question of only a few days. "Up to this time Thress had been subsisting on the meagre diet permitted to a man in his condition, but his stomach rebelled even at that. He had heard of the Dewey fasting cure and its boasted efficacy against all human ills, and, though he had little faith, death was already looming before him, and he knew that he could lose nothing by the experiment. "He began to fast on January 11 by taking in the morning a portion of Henzel's preparation of salts in a glass of water and the juice of two oranges, and in the evening a hot lemonade. For twenty-five days he also drank a teaspoonful of a tonic consisting chiefly of iron, but the rest of the diet he continued until two weeks ago, when he discontinued the salts and orange juice and confined himself to a hot lemonade at morning and evening. This was his only sustenance until last Thursday. "According to Thress's own recital, the effects of this course of treatment were amazing. He says that the natural craving for food was gone after the first day. Three days later he had regained so much strength that he was able to go upstairs to bed and enjoyed a good night's sleep. From that time on, although he steadily lost in weight, his vitality grew greater, and on January 22 he left the house and took a half-mile walk. "Before three weeks of his fast had elapsed his dropsy had disappeared, and thereafter he took almost daily walks, increasing the distance with his strength. Some days he covered as many as five miles, and never less than two, even while he was growing thinner and thinner, as the accompanying table shows. "For the first time since the beginning of his fast he became hungry last Thursday, March 1, and he felt that he should like some pigs' feet jelly. It is one of the prescriptions of the fasting cure that when hunger finally comes the patient shall eat whatever he craves, so Thress consumed two slices of the jelly and one piece of gluten bread, with butter. He says he enjoyed it and felt well afterward. "He ate no more that day, but at noon yesterday he became hungry again, and this time his appetite was for something more substantial. He disposed of a dish of mashed potatoes, some red cabbage, another portion of pigs' feet jelly, apple sauce, and a cream puff for dessert. He even smoked a cigar after the meal, enjoyed it, and felt still better. He says he will eat no regular meals, but only when he becomes hungry. "While he looks haggard and worn from the loss of flesh, Thress declares that all his ailments have left him and that he never felt healthier and heartier in his life." * * * * * "The following table shows how Thress grew stronger and walked miles while he was constantly losing weight from a fifty-days' fast: Weight. January 11 209 " 12 207 " 13 205 " 14 202 " 15 201 " 16 200 " 17 199 " 18 196 " 19 192 " 20 190 " 21 188 " 22 186 Walked 1/2 mile. " 23 180 " 2 miles. " 24 177 " 2 " " 25 172 " 3 " " 26 167 " 3 " " 27 165 " 3 " " 28 162 " 2-1/2 " " 29 160 " 3 " " 30 157 " 31 155 " 3 " February 1 154 " 2 153 " 3 152 " 3 " " 4 151 " 5 149 " 3 " " 6 147 " 3 " " 7 146 " 3 " " 8 145 " 9 145 " 4 " " 10 145 " 4 " " 11 145 " 12 145 " 4 " " 13 145 " 14 145 " 3 " " 15 144 " 2 " " 16 142 " 17 140 " 18 140 " 19 140 " 20 138 " 2 " " 21 137 " 4 " " 22 135 Walked 3 miles. " 23 135 " 3 " " 24 135 " 25 135 " 26 135 " 27 133 " 2 " " 28 133 March 1 133 A. H. Potts, Editor of the _Chester County Times_, a man who has the largest faith in eating only to restore the wastes of the body, thus gives vent to his emotions after seeing the case by invitation of Mr. Ritter: "On January 10 there sat in his home, at 2618 Frankford Avenue, Philadelphia, Mr. Leonard Thress, with dropsy, hopelessly given up to a speedy death by the many physicians he had vainly sought and paid well for relief. His weight was two hundred and nine pounds. His limbs were at the bursting point, and the water was close up to the top of his chest. He could not lie down nor even lay his head back without choking, and to walk across the room completely exhausted him. At that critical moment a friend of his heard of Miss Kuenzel's miraculous cure, and told him of it. He at once sent for Mr. Ritter, who thought that a cure was in his reach, and on January 11 Thress commenced a fast that has been absolute up to yesterday, the only things passing his lips being water, a little lemonade, and rarely the juice of an orange. Learning through the _Chester County Times_ that we were interested in Dr. Dewey's discovery, he invited us to come and see the cases now under his care, and on Friday of last week we gladly availed ourselves of the opportunity to see the living proof of what we believed but had never seen. We were very cordially received at Mr. Ritter's home, and instead of meeting a pompous, egotistic, big man, as we might expect, we met a young gentleman of small stature, like ourselves, modest, retiring, and claiming no credit for his own part in these remarkable cures; but insisting that he is only observing the progress of cases, following in the line of truths discovered only by Dr. Dewey, giving such advice as he is enabled to do from his thorough knowledge of chemistry, anatomy, and hygiene. He took us to the house of Mr. Thress, and the startling impressions we received can never be effaced. We seemed to be in the presence of one who had arisen from the dead, and could not realize the truth of what we saw and heard from him and his estimable wife, who shows the happiness she feels in receiving her husband back to life. Impossible as it seems, yet on the previous day, as well as many other days, that man had walked three miles after six hours given to his business as a baker, which he now attends to personally. All traces of dropsy have disappeared, and his weight is now less than one hundred and thirty-five pounds, having lost this nearly seventy-five pounds of water through the natural channels at the rate of five or six pounds per day at times. His eyesight has grown younger and his hand is firm. He sleeps soundly several hours out of each twenty-four, and is almost a cured man, although the curative action is still going forward throughout his system, and his many friends are now awaiting the arrival of his normal healthy appetite, which in these cases does not arrive until the cure is entire, and then it comes in such a way as not to be mistaken. On Monday of this week we again visited him, taking a friend who has long suffered similarly to what he did, that she might see results for herself. We found him looking even better than on Friday, and it is very interesting to hear him tell his experience, which he will be glad to impart to those who are seeking after the truth, and interested in the cure of disease of themselves or their friends by this natural and without price (but priceless) means. We also visited two other of the five cases over which Mr. Ritter is at present keeping watch, and every one bore evidences of the great truth. No one should undertake the fast on their own responsibility, as certain conditions may arise requiring the eye of one who has made the matter a study, and no one should pass an opinion on the matter until they read Dr. Dewey's _New Gospel of Health_, wherein the reasons are made so plain that all can understand." [Illustration: Copyrighted 1900, by Henry Ritter. MR. LEONARD THRESS, FIFTIETH DAY OF FAST.] Mr. Thress has regained his normal weight and has been in the best of health in the several months since the fast.[2] The following case was deemed a miracle by all friends: Mrs. H. B., a woman of seventy-six, became exceedingly breathless, due, it was supposed, to defective heart action that had been chronic for many years. The final result was general dropsy. The eyelids had become so heavy that reading could be indulged only a short time because of their weight; the throat was also charged with water so as to make swallowing difficult. Beneath the eyes and jaws were pockets of water--in short, the skin of the entire body was distended, a condition that had deceived the friends as revealing only an increase of her natural stoutness. The real condition became known through a call to treat a bad cold. What had authorized medical art to promise in such a case? Absolutely nothing, as she had become too old and weak to be subjected to the ordinary means for such a general condition. As for a fast for one so old, that was the last thing that would have been thought of: her age and debility would only have seemed to invite more daily food than she had been taking. She was put on a fast, or rather the fast was continued, the cold having abolished her appetite. It went on until the fifteenth day, with increasing general strength and diminishing weight. The last days before hunger came she was able to go up a long flight of stairs without the aid of the railing and without marked loss of breath, the heart-murmur had nearly disappeared, and water by the gallon seemed to have been absorbed. On the fifteenth day there was a desire for food, that was taken with relish through the enlarged throat without difficulty; the water pockets had become emptied, and the lids so thin and light as to reveal no fatigue in reading. Thence on one meal a day became the rule; and since there have been five years without any recurrence of the conditions--five years of remarkable general health and girl-time relish for her daily food. How often has the cutting down of the daily food by the old and weak been condemned as too severe an ordeal to be safe! For this woman there have been these acquired years of nearly perfect health, and the end will be in the natural, easier death of old age. The following is inserted as additional evidence of Nature's power over disease, and that brain-workers may go on with their labors with increasing power while waiting for natural hunger in cases in which hunger is possible: Rev. C. H. Dalrymple, of Hampden, Mass., has just completed a fast, of which he says, February 5, 1900: "My fast continued thirty-nine and one-half days. My appetite came on me about 9 o'clock at night, and I thought I would wait until the next day; but two boiled eggs and some dry toast would not retire before my presence. I have never had such an assault upon my will power as that imagined egg and toast made on me. I was finally compelled to surrender. My tongue had been clearing up that day, and the next day I was hungry at noon. I have not missed a first-class appetite at noon since. My tongue has kept clear and my taste has remained sweet. I have had no chills nor fevers this winter, nor cold in any form. I have made no allowance for my sickness and have never worked harder. My flesh came back rapidly, and now I think I must weigh about fifteen pounds more than last summer. _I gained strength beyond all question about three weeks before my appetite returned. I would work all day long finally._ It was good to get well." Mr. Ritter conducted over twenty cases, some being able to carry on their usual avocations. I give the most important ones: Mr. A. H., forty-five days; Miss B. H., forty-two days; Mrs. L., thirty-eight days; Mr. L. W., thirty-six days; Miss L. J., thirty-five days; Mrs. M., thirty-one days; Miss E. S., twenty-six days; Mr. G. R., twenty-five days; Mr. P. R., twenty-four days; and Miss E. Westing, forty-two days, who, on the fortieth day, was able to sing with unusual clearness and power, and ended her fast without losing a day from her duties as a teacher of music.[3] Wonderful are these fasts? Not in the physiological sense. These fasts went on with only increasing comfort by day and more refreshing sleep at night. It is quite another thing to endure the fasts of acute sickness, for such they all are. That life is maintained for days and weeks, even months, under pain, discomfort--under all the torturing conditions of such diseases as pneumonia, typhoid fever, or inflammatory rheumatism, is far more a matter to wonder over. I may well wonder that Nature is powerful enough to cure the sick at all even under the wisest aid; but with me the abiding wonder is that physicians do not see that acute sickness is a loss of all the natural conditions of digestion, with the wasting bodies the clearest evidence that food is neither digested nor assimilated. I wonder with only increasing impatience that the stomach is not understood as a machine that Nature wills shall not be run to tax her resources when life is in the throes of disease. [Illustration: Copyrighted 1900, by Henry Ritter. MISS ELIZABETH W. A. WESTING, FORTIETH DAY OF FAST.] FOOTNOTES: [1] The fasts conducted by Mr. Ritter constitute performances of the most impressive kind as demonstrative evidence of the practical physiology I have been teaching for many years. For the copyrighted photographs he has kindly furnished I am very thankful, and to all who have been willing to enhance the value and interest of this volume by such eyesight illustrations. [2] The accompanying illustration shows Mr. Thress on the fiftieth day of his fast; weight loss, seventy-six pounds. Does the picture reveal any skeleton condition? [3] The accompanying illustration is a reproduced copyrighted picture of Miss E. Westing. This picture was taken on the return home from her duties at church on the fortieth day during the cold of winter; the weight at the start being one hundred and ten pounds, at the close on the forty-second day ninety-three pounds--loss, seventeen pounds. XIII. I had not been long engaged in observing the evolution of cure through Nature when I began to suspect strongly, as before intimated, that fasting is the true "medicine for the mind diseased." Not less evident than the cure of various ailings would be the emergence of the soul into higher life, and in some instances from the depth of despair. As the scope of my vision constantly enlarged through multiplying experiences, I began to see great hopes of the cure of the gravest of all diseases--insanity--through a rigid application of this method in Nature. I gave the matter so much thought and study that I wrote a monograph on the subject with the idea of publishing it, but gave it up to the idea of telling my impressions in "The No-breakfast Plan." There are the same structural changes in the evolution of insanity as in that of catarrh. There is a morbid structural basis in minds diseased, the abnormal mentality or morality being merely symptoms of a physical disease. Of all human legacies, structural weakness of the mental or moral sense is the most unfortunate. I shall say no more about the forms of mental disease than that there is distinctively both intellectual and moral insanity as a direct result of disease of the intellectual and moral centres. This will be more clearly seen when I recall the fact that moral insanity in its worse form--the suicidal--often exists with such intellectual clearness that there is the greatest ingenuity displayed in carrying out self-destruction. These mind and soul centres are often gravely diseased without impairment of muscle energy: the furious strength of the insane is an abiding fear with all. It is clear that weakness of structure so soft as brain, a substance which is on the dividing-line between liquids and solids, must be of the gravest form from the first: grave because so fragile, grave because the sick centres cannot rest as the broken arm, the sick body: these centres, regardless how sick, must continue to serve, even in abnormal ways. The possibility of insanity must always be a matter of the degree of the primary structural weakness and the energy and persistence of the operative forces; on these must depend the mere gentle, persistent illusion, or that fury of mania which transforms man, the "image of the Creator," into a wild beast. That insanity, no matter what its form or degree, is an evolution from an ancestral structural legacy, not essentially different from the structural conditions evolved from those of any other chronic disease, I cannot have the slightest doubt, any more than I can have for the structural means for the cure. There is nothing that so illustrates the civilization, the benevolence of the age and of the nations as these palaces we call hospitals for the insane. Whatever there is that can add comfort to the body, or charm to the tastes, or new life to the soul has its culmination in these palaces of wood and stone, with one great exception: the structural condition of the diseased centres indicating rest, even as the ulcer, wound, or fracture, has no part in the methods of cure. The feeding is all done not at the time of hunger, but at the time of day. All patients are expected to eat no less than three meals a day, regardless of any desire for food and whether the patient spends all his time in bed in mindless apathy, whether pacing his room with meaningless tread, whether active in light service in the building or in heavy labor without. When there is refusal to eat it seems to be taken for granted that suicide by starvation is the design, and the pumping of food into the stomach through the nose is the common resort. There seems to be no thought that there may be no hunger in such cases, and no apprehension of any danger from not eating; that in this they follow the instincts of brutes. Would the desire for food not come and with a saner condition of mind if they were permitted their own ways of eating? A physically strong woman, whom I knew well, was sent to a hospital for the insane in a generally bad state of mind, with destructive propensities marked. With no desire for food, and certainly with no mind to realize the need to eat without hunger, she naturally refused to eat. But for a time her meals were forced down her throat, a proceeding that taxed the strength of several strong arms. Why were the meals not omitted long enough to cause such a reduction of strength as to make feeding less expensive in the outlay of others' muscle? The persistent refusal to eat resulted in a cessation of all efforts to enforce food; left to the gentler hands of Nature for a time, the mental hurricane subsided in great degree on the return of hunger, and long before there was an appreciable loss of weight or strength. In a few months this woman was able to return to her home, and with restored mind to tell me of the violent feedings she had endured. Now let us look again to the structural conditions involved in diseases of the mind. There are those soft, pulpy centres from which emanate the highest powers of life: power to think, to admire, to rejoice, or to suffer; and we know how digestive power varies along the scale between ecstacy and despair. In mental disease there is the same abnormal structural change as in other local diseases; but for these sick mind-centres there is no rest. There must be still thinking and feeling, no matter how chaotic, to tax them, and there is no cheer to electrify the stomach into easy display of power. We may well marvel that powers so wonderful as the power to think, love, admire, see, hear, and feel are located in structures so fragile as the brain; and we may well marvel at the provision of the turret of flinty hardness to protect it from violence. Now we are to consider these centres of energy as abnormally weak in all their structures at birth in those who become insane: these are the luckless legacies from the fathers and the mothers, and for how far back in the ancestral line we do not know. We are to consider that there is the same abnormal condition of the cerebral bloodvessels and of the softer inter-vascular structures as in other local diseases; and when you recall the fact that everything that worries, that adds discomfort to either mind or muscles, is a force that tends to develop weakness and disease, you will see how it applies in the evolution of insanity. Shall these fragile centres be permitted to rest when overwork has made them sick, or is there any other rational means for their recovery? Shall they not be permitted to rest when abundantly able to keep physically nourished in a way that does not cause even the slightest shade of discomfort? Again, let it be borne in mind that recovery from acute disease is attended with a revival of strength in every power that makes life worth living, and that every person not acutely sick who has fasted under my care or who has cut down the waste of brain power by less daily food has found the same revival of power. To this there have been no exceptions. What do we fear in sickness? Is it disease or the wasting pounds? Since they will disappear when Nature would have the food-gate closed, since they reappear when there is the highest possible reach of mere relish, and when all the other senses have become more acute, and also when existence has become almost ecstatic, why ever oppress the weak or sick centres when Nature wills a rest? The literature on the disease of the mind has become so massive in mere bulk, in its physiological refinements, that it would require time with a long reach into eternity to go through it; but it has not come to my knowledge that it contains any reference to the brain as a self-nourishing, self-charging dynamo; that therefore the stomach is only a machine whose use can well be omitted for long periods when these centres of moral and intellectual energy have become worried into disease, with rest the only means, the only need for all the recovery possible. "Oh, you giants of the medical profession!" You who have been elected to preside over these great homes of the mentally wrecked because of your eminence in character, ability, experience, and professional attainments, do you deny the soundness of the physiology involved in this method of reaching health through Nature? Then let me array against you Alexander Haig, M. A., M. D. Oxon., F. R. C. P., Physician to the Metropolitan Hospital, and the Royal Hospital, and for Children and Women; late Casualty Physician to St. Bartholomew's Hospital. I quote from his exhaustive work, _Uric Acid in the Causation of Disease_: "And now I come to the causes which led me to take too much albumen and to suffer severely; in _Fads of an Old Physician_, Dr. Keith refers to another work on diet, by Dr. Dewey, of Meadville, Pa., _The True Science of Living_, and the chief point in this book is that temporary, complete starvation till there is once more a healthy appetite is the best cure for a host of dyspepsia, debilities, depression, mental and bodily, and numerous other troubles, and that for similar less severe disturbances of nutrition the great remedy is to leave out the breakfast, so as to give the stomach a long rest of sixteen hours or more, with the object of allowing it to recuperate and accumulate secretions after the last meal of the previous day. "It seems from internal evidence in Dr. Dewey's book, a copy of which I owe to Dr. Keith, that his plans have been completely successful in a large number of cases, _and it seems to me that his logic is unanswerable_, and that in his main contentions he is perfectly right. "Having arrived at this conclusion, I proceeded forthwith to put the matter to the test of experience by placing myself on two meals a day--that is, I left out my breakfast--and the result was I ate such a good lunch at 1 P. M. that it was impossible to take anything more till dinner-time, 7.30 or 8 P. M.; so that I reduced myself at once from four meals a day to two. The result was exactly what Dr. Dewey describes. I felt extremely bright and well in the morning, and capable of very good work, both mental and bodily. At 1 P. M. I had keen hunger, even for dry bread; such hunger as I had not experienced for years. After lunch (breakfast) I felt a little bit dull and occasionally sleepy, and the mental work for the first hour or two after it was not as good as usual. About 5 P. M. I was very thirsty and had to have a drink of water, but there was not the least desire for food until several hours later; though by 7.30 or 8 P. M. I was able to manage another fairly good meal; and thus my meals automatically, so to speak, reduced themselves to two." I also quote from his work on _Diet and Food_, page 10: "It is also possible, by introducing more food than can possibly be digested, to overpower digestion so that nothing is digested and absorbed, and starvation results, a fact that has been brought to the front in the most interesting manner in the writings of Dr. Dewey." And who is Dr. Keith? You know that he is one of the youngest physicians in all Scotland, even if he does possess eighty years that are no burden to him. I quote him from his _Fads of an Old Physician_: "Dr. Dewey's grand means of cure now is abstinence for the time from all food, and this he carries out to a degree which must astonish most physicians of the present day, as well as their patients. During times of sickness, when there is no desire for food, he gives none till the desire comes, and then only if the state of the tongue and general condition show that the power of digestion has returned. This may be in a few days, or in severe cases, as of rheumatic fever, it may not be for forty days or even longer. He points out very forcibly that we have all a store of material laid up in the body which supplies what is required for keeping necessary functions of the system going, while no food can be usefully taken in the stomach. I had mentioned this provision in my _Plea_, and had stated that so long as it lasts it is sufficient to preserve life. I also suggested that it might be found that the waste of the body was less when this internal supply was alone trusted to, than when it was supplemented by food from without which the organs of nutrition were not in a condition to utilize. This, to my mind, Dr. Dewey has proved to be the fact, and no one can read his case without being convinced that it is so. He gives a most interesting table from Dr. Yeo, showing what textures of the body waste most rapidly in disease. Fat is at one end of the scale, and at the other the brain, which does not waste till all the other textures and organs are depleted to the utmost. "In cases of slighter disease where the patient is able to be about or to carry on his business, but with discomfort, the same abstinence from all food is recommended. It is usually found that work can be done more easily, and that strength actually increases, although the starving may have to be kept up for several days. But the great _coup_ in Dr. Dewey's practice is, that to improve or to preserve health he advises all to give up breakfast, and to fast till the mid-day meal. In this he has had a very large number of followers, very much to their advantage. It may be that the omission of breakfast is more needed and has greater effect in America than it would have on this side of the Atlantic. In America the meal is generally a very full one, made up in a large measure of a variety of hot cakes, also flesh food and tea or coffee. The other two meals of the day are full, 'square' meals likewise. I have seen much overfeeding in this country, but never to such a degree, and so generally, as I have seen in America and on American steamers. In one of the latter the cooking was the worst I ever met with, but the hard meat was swallowed all the same, and the consequences must have been grievous." Are you still without any questioning of your authorized, established methods of treating the mentally sick? Then let me quote against you another man across the ocean, whose ability, learning, and professional attainments are of the highest order. I quote from _Air, Food, and Exercise_, by A. Rabagliati, M. A., M. D., F. R. C. S., Edin., a man with whom patient, exhaustive investigation is only a recreation: "It has been shown by physiologists that certain tissues are absorbed and used before others. Dr. Dewey, of Pennsylvania, with whose views I am glad to find myself in general accord, and who seems to have made the same attempt as the writer to view the facts of medical practice from an independent--and may I say, original?--standpoint, quotes a table of great significance from Dr. Yeo. Besides quoting it in the text of his book, _The True Science of Living_, Dr. Dewey places it in capital letters in the frontispiece of his book. He calls it Nature's Bill of Fare for the Sick; and he shows that in illness, when we are using up the materials accumulated in our bodies, we may use as much as 99 per cent. of our fat (practically all of it), that of muscle we may use as much as 30 per cent., that the spleen may waste to the extent of 63 per cent., the liver as much as 56 per cent., and the blood itself be absorbed to the extent of 17 per cent. of its total amount. But even when wasting to this extent has occurred the curious and significant fact is emphasized that the _brain and nerve-centres may not have wasted at all_. The controlling nervous system thus does not lose its powers till the very last. Generally, however, the wasting process does not require to be carried to the very last, the chronic inflammatory deposit (and in rare cases even a cancerous infiltration) being absorbed and got rid of before this point is reached. "As most, if not all, of the chronic diseases depend upon the deposition of waste, unassimilated materials in various situations; or, in other words, depend upon a blocking of the local circulation in this way, a little wholesome starvation is generally of vast benefit by inducing the economy to use up some of its waste stuff. Nature herself points the way to us in this matter, because when things have gone as far as she can bear, and when, were things to go on in the same way, death must ensue, she generally throws the patient into bed with a digestive system entirely disorganized, taking away all appetite for food and all power of assimilation for the time being. We may, in such circumstances, do much harm by efforts too persistently made to feed our patients; but generally they refuse all sustenance for some time. After a while (Dr. Dewey does not seem to be afraid if his patients refuse all food even for as long on some occasions as thirty days continuously, or even longer) they right themselves, the tongue cleans, appetite returns, the power of assimilation is reëstablished, and recovery takes place. It strikes me as somewhat curious (and yet, if we both look at the facts of life candidly and impartially, perhaps it is not curious) that observers so wide apart, and in circumstances so very different as the conditions of human life must be in Yorkshire from what they are in Pennsylvania, should come to conclusions so practically similar as Dr. Dewey and the writer have reached." Gentlemen, masters in the medical profession, to what good end are you pumping food into human stomach, where there is no hunger and no mind left to know the need? Is it to maintain that strength which costs you so much muscle at every feeding. Or is it that it would be a danger to lose a few pounds of body while Nature gets ready to ask for food in the gentlest and most persuasive way? Whatever there is in appeal to the best in any human life to uplift it from the deepest depths, you have at the readiest command. You seem amply equipped to reach everything but those sick, afflicted, oppressed brain-centres. You treat everything but these, but to these you are worse than the Egyptian task-masters in that you force needless labor where rest alone is the need. It is not bricks without straw, but labor with exhausted power; and for all your efforts you simply maintain weight at a tremendous cost to the energy of cure. In no class of patients is rest for the brain more indicated than in yours; in none are the means so at command and the results for good so promising. With your patients the importance of time for business or social use is no more a concern; the abnormal is all due to disease. Let us consider those rooms of bedlam you call the "excitable wards." They who enter leave all hope (of the friends) behind. Is there special need in these regions of despair and mental chaos that the mere pounds and strength shall be kept up? What will be lost by protracted fasts? Nothing in the kitchen. As for the brain and those sick centres, they will feed themselves until the last heart-beat sends the last available nourishment to the remotest cell. Will the functions of the brain grow more abnormal by a suspension of digestive drafts upon it? Does rest to anything that is tired tend to the abnormal? Again I ask, What will be lost by protracted fasts in such cases? Nothing but weight, of which the fat will be by far the larger part. Would there be worry about starvation? With most of the cases there is not mind enough to worry over anything from the standpoint of reason. The very fact of the absence of the sense of the importance of daily food would render fasts in the highest degree practical and successful. The fasts could be instituted with the certainty of a calmer condition of mind as soon as the digestive tract would cease to call upon the brain for power, and with the probability that a surprising degree of improvement would be manifest in all, and long before the available body-food for the brain would be exhausted. Gentlemen, you have treated acute sickness in all its forms, and you have had many cases in which, because of irritable stomachs, neither food nor medicine could be given. Day after day you have seen the wasting of the bodies, and you have also seen mental aberration or stupor lessen day by day as the disease lessened its grasp upon the brain-centres, and finally when the point of natural hunger was reached, you never found the lost pounds a matter of physical discomfort or mental abnormality or weakness; rather you have always found at this point a mental condition in every way the most highly satisfactory. I never saw brighter eyes, a happier expression on every line, than revealed by a woman after a fast of forty-four days, in which acute disease had reduced the weight forty pounds. All overweight not due to dropsy or other disease is due to eating more food than the waste demands. As an abnormal condition overweight has received a great deal of attention in the way of misguided effort to both prevention and cure. These efforts are such conspicuous failures that even the patent medicine man has not found his "anti-fat nostrums" the happy means to fortune. There have been all kinds of limits built around bills of fare, but sooner or later Nature revolts and they are given up. The reason that certain people take on weight easily and become "stout," is because of constitutional tendency, good digestion, and excess of food. As a general fact, the overweights are "large feeders," and they not only look well but feel well, for they have much less stomach trouble than the average mortal, and in cheerful endowment of soul they rank the highest among all the people. In spite of my philosophy, I, who am one of the leanest of the kind, look upon the stoutness of those in the early prime of life with something of both envy and admiration; they seem so ideally conditioned to enjoy the best of all things on earth. But it is quite a serious matter when the muscles and brain have to deal with pounds in excess by the score, even as if the victim were doomed to wear clothes padded with so many pounds of shot. Why some people take on fat easily even with the smallest of meals, why some of the largest eaters are of the leanest, are matters to talk about but not to know about. For my purpose it is sufficient that I assert that overweight can be prevented by an habitual limitation of the daily food to the daily need; that it can be cut down to any desired degree by stopping the supply, a method that is not attended with any violence to the constitution, nor even to comfort or power. This plan has the great advantage of adding to the curative energy of disease as well; and more than this, there is a change attending the loss that seems at first phenomenal, as involving a physiological contradiction--there is an actual increase in muscle-weight as the bloat and fat weight go down. How is this, you ask? Here is the explanation: As the fat weight increases by surplus food, so decrease the disposition and ability for general exercise. As it declines, so do muscle and all the other energies increase, and the use of muscle within physiological limit tends to restore the normal weight and strength. There are no overweights who would not receive the greatest benefit by a fast that would diminish the pounds to that of the ripest maturity of life, a fast that would be determined by the time required to reach the desired number of pounds. As a means this method is available to all, and practical where due physiological light will enable it to be carried out with no starving concern to disable vital power. As a general fact, the No-breakfast Plan has been attended by a highly satisfactory reduction of surplus pounds; where there has been a failure it has been due to such an increase of digestive power as really to add to both an increase of the average amount of daily food and of power to digest it. For instance, one of my fellow citizens, weighing not less than three hundred and thirty pounds some years ago, gave up his morning meals. This was attended with entire relief from frequent bilious spells; but the average of daily food was increased and the business of a barber did not add anything to muscle development. Finally from mere excess of weight he became a prisoner to his house and yard, unable to walk a square without the greatest difficulty; and yet there were two enormous meals put into a stomach daily that did not complain, and the weight increased until the three hundred and seventy-five pound notch was nearly reached. He heard about the Rathbun fast, and I was able to persuade him to come down to one light meal daily, and day after day bonds were loosened. After a year there have been nearly seventy-five pounds lost, and there is ability to labor and to walk several miles daily. Very many thin persons have gained as high as forty pounds by reason of the larger degree of muscle exercise. Since last writing, this word has come from Miss K., who one year ago was at the asylum eating several meals a day in bed with suicidal intent. She left that bed with a weight of one hundred and forty pounds, and, as I have mentioned before, lost twenty pounds of it by her fast. My last news is from a letter written the day after a twenty-five-mile ride among the mountains with a soul as free and joyous as there are freedom and joy with the birds whose songs greeted her rapt ears from every treetop. She writes of a gain of twenty-four pounds since the fast, and states that the glasses she has worn for thirteen years are wanted no longer! I feel that I need not multiply words as to the ability and utility of bringing all overweight down to the physiological normal and of keeping it there. I could fill hundreds of pages with the joyous testimonies of those who have been relieved of many surplus pounds, with numerous accompanying ailings; they all tell the same story, and I will only add this, that there is no physiological excuse for any mortal to carry around weight that disables. Not very many months ago ex-Governor Flower, of New York, a statesman of national fame, a man of largest public spirit, a most valuable citizen, and Colonel Robert Ingersoll, an orator of world-wide fame and of great nobility of soul, dropped as beeves beneath the stroke of an ax because of a fracture of brittle bloodvessels. In both of these cases not many less pounds than a hundred had needlessly accumulated. Could I have had the Colonel's ear when I last saw him as a listener to almost matchless oratory, whose rotundity of belt was to be measured by the yard, I would have addressed him as follows: "My dear Colonel, when I last saw you you were just filled out enough to be the joy of your tailor, and as a picture of health in form and looks you were ideal. You were then eating the meals of a woodchopper; and merely because food tastes good and does not seem to hurt you, you have been doing the same during the nearly score and a half of years since I have seen you. You have been eating more food every day in proportion to general muscle exercise than the hardest toiler does in a week, and your vast bulk evidences against you." After explaining to him the structural possibilities of apoplexy as a legacy, as I have to you in the cases of insanity, I would continue: "Now by virtue of a possible ancestral weakness of your brain arteries this may happen: the arterial walls, because of habitual food in excess, may undergo a fatty, limy degeneration that will make a rupture possible, with death or paralysis of one-half or more of the body as the direct result; or the small arteries may have their walls so thickened as not to permit enough blood to circulate in order duly to nourish parts of the brain they supply; hence softening of the structure and more or less imbecility. "The history of all overweights is that of a decline of muscle energy, and very generally of the amount of muscle activity as the pounds and years increase; but no cut in the amount of daily food so long as it can be taken with relish and disposed of without any special protesting from the stomach. This is the history of by far the largest majority of those sudden deaths due to cerebral hemorrhage, and also the history of most of the cases of imbecility with the overweights. "Now, Colonel, you should make a radical parting with those surplus pounds by a fast that may extend into months, or take one of the lightest of meals once a day. Follow this out rigidly until you have lost a hundred pounds, and then by as much will you be not only free from disease, but free also from the danger of disease." My experience with cases of epilepsy, or "fits," is confined to a half dozen cases, in which permanent relief seems to be assured. There is an acquired structural abnormality behind the spasms, acquired from surplus food, with a cure to be reached ultimately in most cases along these physiological lines. XIV. I shall not take time in telling the evils of alcoholics. It would not be more enlightening were I to spend hours in telling of wrecked lives, of wrecked homes, of prisons filled with their victims, of the immense loss to states and nations from the loss to sufferers and the loss they inflict. Alcoholism has no sense for frowning, ominous statistics, for it is a disease to be rationally treated, a disease to be rationally avoided. In the light of later science the word "stimulants" has become a misnomer as applied to alcoholics; the term, no doubt, came into use from the fact that under their use there is more endurance to both physical and mental ills, an endurance or indifference ascribed to stimulation. If power is stimulated by their use, then there should be a rise in temperature whereby severe cold is better endured; but this is not the fact any more than that temperature is lowered whereby extreme heat is endured; in either case the endurance is due to benumbed brain-centres. The alcoholic simply lessens the power to suffer mentally or physically; hence in degree it is an anæsthetic, and as such it also affects the moral sense and lessens the power of reason and judgment. They are habitually taken for no other reason than for the temporary relief they give to some ill of life. It seems the very depths of total depravity when there is no bread for the hungry family, that the price of a loaf will rather be spent for a drink; but it is not so much moral depravity as depravity of brain-substance. The lethal drink is taken because without it there is more acute suffering than from the want of a loaf of bread by the entire family. In my practice an ordinarily sober father would always get drunk and stay drunk while any member of his family was sick, and for the sole reason that he could not endure the worry of apprehension. This was not so much depravity as an acute sense of the suffering and danger involved, a painful rousing of the best instincts of the soul, those instincts that raise man above the brute and make him the noblest work of the divine hand. That is not a bad man at heart who has such a sense of affection for his wife or child when they seem dangerously sick that he must have artificial aid to endurance; and if you shall detect the alcoholic odor in his breath at the funeral you may know that there is heart agony under repression. The fact that alcoholics are anæsthetics, and not stimulants, has become known to a few of the scientists in the medical profession; but it can scarcely be said to have become known to the profession generally. That the habitual drinker partakes for any other reason than to drown his woes that will not stay drowned, and that the drowning is not stimulation, do not need argument. The alcoholic in proportion to its strength is mental chaos and paralysis to power, and it has not the virtue to contain an atom that can be converted into a living atom. In not the least sense is it a tissue-builder, and its use by the medical profession is without the shadow of a reason, and is all the more reprehensible in cases of shock. Let us see: shock in degree is brain paralysis; alcoholics in degree are brain paralyzers; shock is simply a state of exhaustion with rest the supreme need. All the rousement that is necessary and that can avail will be called into action by the need of oxygen. There are cases of disease in which breathing goes on hour after hour, when the soul seems to have departed and with it every life sense. The patient has become dead beyond reviving, and yet breathes hour after hour. Now can one for one moment think that an alcoholic can add to the power of the respiratory centres of the brain to respond to the calls for oxygen and so prolong life? Shock in its gravest degree is to be considered the extreme of the tired-out condition, with rest the only restorative means; and rest may be permitted with the certainty that for mere breathing purposes alcoholics are dangerous in proportion to the gravity of the shock. In health the alcoholic only adds discomfort, because there are no complaints to soothe; hence it is the duty of every mother so to train her sons in health-habits that those first drinks will be discouraging because they bring no cheer of contrast, but rather sensations that are not suggestive of a better physical condition. Alcoholics have a corroding effect upon the mucous membrane of the stomach, a congestive effect by which the glands are subjected to starving pressure; hence their use always disables the mere mechanics and the chemistry involved in digestion, and so prolongs disease, and this applies to all medicines that corrode. This corroding power of the alcoholics upon the walls of the stomach and its paralyzing effect upon the brain-centres, with the additional fact that there is nothing in it that adds force to any life power or that can be converted into living atoms, should make its use in the stomach of the sick a crime scarcely to be excused by ignorance. The evolution of the drunkard is a process of culture, and involves something of a constitutional tendency as in other diseases. I conceive that there is an alcoholic temperament, or a temperament in which the inability to bear with patience the various mental and physical woes of life is marked even from childhood. Indigestion and every cause that lowers vital power only add to the importance of such a nervous system. The first step in the evolution of the drunkard is the first untimely meal drawn from the breast of the mother. By irregular nursings and the nursings merely to stop crying the nervous system is continually overtaxed. There are the untimely meals to prevent gluttony; there are the between-meal lunches to incite nervousness, irritability, a feeling of unrest that nothing seems to satisfy. This goes on year after year until the time comes when that first drink has power to soothe many discordant voices, and the die is cast. Other drinks follow, with each to lessen the power of the dynamo and to disable the machine. At first, drink is indulged not without a sense of wrongdoing, but with that feeling of power in reserve to keep within the limits of safety. The gradual corrosion of the stomach adding to the labors of the brain in the matter of food mass decomposition as well as digestion marks the decline of power to abstain and the degradation of every sense that makes life worth living. Now add to the corrosion of the membrane and the paralysis of the brain-centres from alcoholics the other inciting causes in the culture of disease, and you have the evolution of the drunkard. How is he to be cured? Only through a fast that shall let that diseased stomach become new from regeneration, that will let the brain accumulate rest in reserve. For a time you will need to have him under bonds, for his will power is abolished. Put him where there will be deaf ears to the cries of morbid nature, for there is to be a conflict at first; but long before hunger will come the storm will subside; and finally, when food will be really desired, there will be a new stomach and a new brain to which an alcoholic will be no temptation. This is no figure of speech, because there is such a continual change of life and death going on in the soft tissues of the body that in a month or more of fasting it may be assumed that much of the tissues which is left has undergone reconstruction, and both brain and stomach act as if they are new when the time comes to restore the lost pounds. The ways of the kitchen and dining-room are the ways of disease and death, ways whose ends are prisons, asylums, scaffolds, to a far larger extent than is dreamed of by the fathers and mothers of the land. A new crusade against intemperance, the intemperance of the dining-room, is the only one that will ever settle this so-called liquor question. The rum-seller will only pull down his sign through the starvation of his business. With brains and stomachs kept in the highest order, the alcoholic has only the least power of the beguiling kind; it is rather a dose whose effects do not invite repetition. But for all who have the drink disease seemingly beyond hope a fast of a month, or two months if necessary, will cure any stomach or brain, no matter how pickled they are with alcoholic soaking, and with only the least disturbance in the habit breaking; even within a week the hardest of the fighting should be over when the fast is made absolute. XV. I have now to consider briefly a most distressing disease, one that perhaps was never cured by the power of doses, and that most happily illustrates the structural changes in the cure of disease. Asthmatic distress is caused by congestion of the terminals of the bronchial tubes, by which entrance of air into the cells is made difficult, even in some cases to the point of suffocation. This condition as a disease may be called bronchial catarrh, as in most cases there is such a condition of the larger tubes as to cause the habitual raising of a discharge. As to the disease itself, you have only to recall what has been said about nasal catarrh in order to understand its origin and development. It would be as trivial a disease were it not for the fact that those smaller and ultimate tubes, because of flabby walls and weak vessels, become congested, with resulting narrowing of the air-ways of life. For this most distressing disease local treatments are as futile and void of intelligence as the physiology and anatomy involved in cause and cure of other local diseases. Is it not a great thing that those too narrow ways of life may be reached through a fast which shall so charge the brain with power that the flabby walls will be condensed; that most cases of asthma may be cured, with marked relief for every case? This is as certain as a result, as that rest restores strength. With the toning of the brain through rest, a catarrh of the bronchial tubes is certainly curable in most cases. With a large opportunity to know I am able to say this with intense conviction. Only a few months ago, just before the break of day, a freight train took a side track; in a few moments, with nearly a mile-a-minute speed, a limited passenger train took the same track, and in the time of a second five men were hurled into eternity. Why? How? The conductor and his brakeman were in such heavy sleep when the switch was opened that they were not awakened to close it. Why? How? There was the torpor of indigestion holding the tired brains of those two men in its fatal grasp; their stomachs were full of food when they were already tired out by their long trip that was nearly at its close, and for them those untimely meals were the last. Of all men who ought to work with empty stomachs for the sake of the best possible reach of the memory it is the railroad engineer and conductor; so also every man who is in any way responsible for the safety of the trains. If we had the history of all the derailments, collisions, of cars with human freight converted into funeral pyres, a frightful percentage of them could be traced to where "some one had blundered" because of the torpor from handling meals when the brain was compelled to higher services. Digestive, indigestive torpor is also torpor of the sense of _responsibility_. In the city where I live is the point between two divisions of the Erie Railroad, each somewhat more than a hundred miles long. Before I began the agitation of the No-breakfast Plan all trainmen felt that filling their stomachs was the last duty before entering upon their taxing trips, and tired wives would have to get up at all times of the night to prepare general meals. In this city a mighty revolution for the good of wives, for the good of men themselves, and for the safety of the trains and the hapless passengers has been going on for some years. In former times when these men came home from their rounds generally tired out, and with a feeling that in proportion to the sense of exhaustion was the need to eat, general meals had to be prepared at any time of night. All this is changed in a large measure. Trainmen have been finding out that the less food in their stomachs they take into bed with them and on to their trains, the better it is for them in every way. More and more they are getting into the way of having a general meal when they can eat it with leisure and leisurely digest it; and I predict that a time will come when all who are in any way responsible for the running of trains will have to know how to take care of their stomachs, in order that they shall attain and maintain the highest efficiency for services where human lives so much depend on the best there is in memory, reason, and judgment. This will be a part of their preparatory education. The "block system" has wonderfully added to the safety of the trains, but there should be a block system added to the stomachs of the dispatchers and all whose duties are so grave as the handling of human freight. There is no division so long that it cannot be doubled with less fatigue and better mental condition if the stomach be not on duty at the same time. In this I speak with the authority that comes from the study of the experiences of trainmen during many years: with one accord they speak of their trips as taken with clearer heads and stronger muscles than when large meals were thought a necessity while on duty. With an empty stomach it takes a very long time to get into such torpor--drowsiness--as compels the after-dinner sleep. That engineer who once told me of such sleepiness as made him nod while on duty was not suffering from either lack of sleep or overwork of his body: it was simply a case of the torpor of indigestion, and this was when there was no block system to lessen the danger of such services. There is a great deal of imperfection in what man does for man that comes from the indifference arising from the torpor of untimely food, and far more than there is any conception in what man does against man from the destruction of power in this way. There is now one of the Erie conductors who five years ago was losing at least half of his time from asthma; there is another who was equally disabled from sudden head symptoms that would immediately disable. These men have lost no trips since they began to run their stomachs with the same care as their trains. And there is an engineer whose trips to the physician and to the drug-store for many years were as frequent as those to his engine. There has since been a half dozen years of wiser care of his stomach, and his wife says that the change for the better in his disposition is beyond description. These men have rendered far more service, and who cannot see that these services have been of far higher character for the company, and that they have been infinitely better husbands, fathers, and citizens? The following case will interest trainmen: D. S., a brakeman, reached the burden of two hundred and forty-six pounds, with resulting breathlessness and other ailings that taxed all his resources to perform his duties. He was induced to cut down his daily food as the only means for relief, and to add to his strength. It took him a long time to master the fact that his strength was not kept up by food, but the gradual loss of weight with the general improvement made this more and more evident. He finally reached a time when he was able to make his round trip of one hundred and ninety-six miles without a morsel of food the while, and with much less fatigue than when there was a midnight meal from a lunch-pail. Within a year the weight has gone down to one hundred and eighty-eight pounds. To my professional eye there is beauty in the bright eyes, in the condensed, smooth face, in the body enfolded with clothes that flap in the breeze like the sails of a ship. No accident will happen to precious human freight through his brain kept free from digestive torpor while on duty. Ever since my book has been out I have been in more or less trouble with cases that badly needed my personal care, and not few in which death was inevitable. For instance, there is a woman in Illinois who has been ailing for years, and in spite of the No-breakfast Plan has had to take to her bed with acute aversion to food. Medical art had utterly failed before she changed her dietary methods. Her dietary views are known, and so she is held in severe censure because the sick stomach is not compelled to a futile service; and though I am informed of an enlargement in the region of the bowels that has been perceptible and tender for years, her death will be considered suicidal from _starvation_. A Warrensburg, Ill., editor began his fast by throwing up his food and continued it to the end; yet because he had talked about a fast it was supposed to be a case of suicide of the stupid kind; and though the post-mortem revealed a diseased gall-bladder, the doctors who made it did nothing to lessen the suicidal impression, and the death from "starvation" appeared under large headlines in the public prints. When men as learned, able, and eminent as Dr. Shrady, of New York, go into print to inform the public that people may starve to death in ten days, and when such men as Prof. Wood, of the University of Pennsylvania, do not see any starvation in the wasting pounds of acute disease, the care of acute sickness as Nature would have it is a grave matter for the physician. In five fatal cases under my care in which there was no possibility of feeding, there was such agitation over the question of starvation as would have subjected me to violence had my city been nearer the equator. In all these cases I was compelled to have a post-mortem to silence heathen raging. In one case in which a young man had died after weeks of inability to take food, even one of my medical brethren carried the conviction with him for years, and without seeking to inform himself, that there was a death from starvation. In this case there were spells of hunger in a fury, when meals would be taken, only to be soon thrown up, and he finally took to his bed to starve slowly to death. There was mind enough left to make a will, though the body had lost apparently more than half the normal weight; the post-mortem revealed a stomach seared, thickened, and not more than a third of the normal size. The physiology of fasting in time of sickness is so entirely new to the medical world that every death that occurs with those who practise it is certain to be attributed to starving. Early in this year (1900) a woman of seventy, in high circles, died from an obscure stomach trouble. For thirty-eight days there averaged nearly a half-dozen spells of vomiting; and yet it was generally believed that it was clearly a case of death from starvation, believed by those whose power to receive impressions is far stronger than their power to consider. Fasting, because it is Nature's plan, will win the victory in all cases in which victory is possible; and yet wherever it is adopted, to become known about, there will be the same confusion of tongues as would be were violent hands laid upon gods of wood and stone in heathen temples. "Starved to death" is the verdict. Fasting during sickness, because of the vast utility and from the impetus arising from the cases in Philadelphia, is bound to spread as by contagion; but when death occurs, all friends involved will be charged as abettors of homicide. To be fair to the opposition, and to let all readers know what chances for public censure will be theirs, whenever they see fit to let their friends recover on Nature's plan or die natural deaths, the following case is given. I quote from the Philadelphia _Press_ of May 7, 1900: "In the death notices of April 26 appeared the name of Mrs. Hermina Meyer, fifty years of age, of 1233 North Howard Street. At the time this short and simple record of the passing away of an ordinary, obscure woman attracted no more attention than the hundred similar names that constituted the necrological annals of April 25. But there is a startling aftermath that at once gives significance to this brief record, and rude and bitter awakening to the followers of the so-called 'Starvation Cult,' that has gained a considerable acceptance in the northeast section of the city. "Mrs. Meyer was a believer in the fasting treatment. She was apparently a victim of this strange and heretical therapeutical faith. Kensington is buzzing with gossip concerning the deplorable death of the unfortunate woman. C. F. Meyer, the husband of the victim, accepts the death of his wife as due to heart-failure, and apparently is not disposed to complain. "Mr. Meyer talked freely with a _Press_ reporter yesterday concerning the sickness and death of his wife. He said that Mrs. Meyer had been ill for about a year, her malady having been diagnosed as chronic rheumatism. She had been treated by the family physician for this disease, but without relief. In despair she turned to the fasting treatment. "From time to time she had read of the remarkable cures claimed to have been effected by complete abstention from food. Through a friend she met and talked with the family of Leonard Thress, of 2618 Frankford Avenue, whose case is proclaimed as one of the most remarkable that had been successfully treated by the fasting system. Thress was widely advertised as a victim of dropsy, who, after a complete fast of more than a month, was restored to sound health. "Mrs. Meyer believed, and sent for Henry Ritter, the chief advocate and adviser of the fasting cult in Philadelphia. His belief in the weird treatment of disease he has adopted is seemingly unshakable. "Ritter has superintended many cases of starvation treatment, wherein, according to his own statements, the patients have totally abstained from actual food for periods of from four to six weeks. He claims that in every case the afflicted person has completely recovered health--with the single exception of Mrs. Meyer. "In response to her request, Ritter called upon Mrs. Meyer. She at once began her fast. Nothing was allowed to pass her lips but a small quantity of tonicum and some physiological salts, dissolved in water. Of each of these she was permitted to take sparingly every day. It is claimed by Ritter, a fact well-known to physiologists, that there is no actual food in either of these thin condiments. They are simply stimulants. These liquids, according to Ritter, are the only things given to any of the patients whose cases he has supervised. "For twenty-five days, so says Mr. Meyer, his wife fasted and improved. At the expiration of that time, he says, her health was very much improved. She was able to walk about her room, a thing she had not been able to do for many weeks. Then there was a sudden and violent change for the worse. The patient was seized with convulsive vomiting. "For sixteen days she suffered the excruciating pains of these convulsions. But, under Ritter's advice, Mrs. Meyer continued her fast. Till the thirty-fifth day she tasted no food. The vomiting continued unabated. On the thirty-sixth day she felt a craving for food for the first time since her long fast began. She was given oatmeal porridge. But the vomiting continued unabated. "She grew weaker and weaker. From one hundred and fifty pounds weight she was reduced to a gaunt skeleton. When, upon the resumption of a food diet, the vomiting did not cease, the family was alarmed. The family physician was sent for in dismay. But he could do nothing. Flesh-building foods were prescribed, but they accomplished nothing. The vomiting continued, and three weeks following the breaking of the fast Mrs. Meyer died. "The death was put down to a depleted blood-supply, or heart-failure. Ritter claimed that this unexpected turn could not have been anticipated, as the fact that the patient was subject to heart disease was previously unknown. "He had treated her for rheumatism, and the cure was apparently in sight when heart-failure carried the patient to her grave. "These facts were detailed by Mr. Meyer. He added that Mr. Ritter was not a physician; that he charged no fees; that he did not claim to prescribe remedies, but only advised. "So ends the case of Mrs. Hermina Meyers, first victim of the starvation cult." The following is from the _Press_ of May 8: "The death of Mrs. Hermina Meyer, after undergoing the fasting treatment for thirty-five days, has not at all shaken the faith of the adviser responsible for the ordeal, Henry Ritter, who claims to have restored tireless persons to health. He affirmed that the ravages of chronic disease had progressed too far for his treatment to conquer them, and that his attendance was advised by the family physician. "Against this comforting declaration, however, stands the fact that the certificate of death, signed by Dr. James Chestnut, Jr., gave as the cause prolonged abstinence from food; in other words, _starvation_. Dr. Chestnut also has stated that the case was taken out of his hands, and Ritter installed as medical adviser, by what was virtually a dismissal. Dr. Chestnut was summoned again when the condition of the woman became critical, after twenty-five days of fasting, but she became rapidly weaker with violent convulsions and vomiting, and was beyond medical aid. "She had never been treated for cancer of the stomach, which Ritter says he thinks she may have had, although she had a valvular affection of the heart which had existed for some time. But the fact that the cause of her death was officially attested by the family physician as due to her long fast contradicts flatly the position taken by the self-constituted healer, who made the following statement last night: "'I have seen all the members of Mrs. Meyer's family to-day, and they are entirely satisfied that my treatment was in no way responsible for her death. I was called in at their urgent request, as their own relatives were numbered among the cures to the credit of the fasting treatment, as well as Mr. Thress. I accept no money for my work; they knew it was a labor of love, and the family physician, Dr. Chestnut, agreed with them as to the advisability of this system which they had seen tested. "'Mrs. Meyer improved rapidly for a time, her chronic rheumatism causing her less trouble than in years, after the first three weeks of fasting. She had been treated previously for catarrh of the stomach, and it is probable that a cancer afflicted her. I am using no new system. The method has been used with very notable success by Dr. Edward H. Dewey, of Meadville, whose reputation and standing are distinguished. This is the first case I have lost out of twelve patients who had been given up as hopeless by regular physicians. It is Nature's cure, nothing more; but it was applied too late in the case of Mrs. Meyer.' "Dr. Chestnut would not allow himself to be quoted because of the rigid rules of medical ethics. It may be stated, however, in addition to what has been said, that he does not wish to be considered as having encouraged the experiment, and that the death certificate defined his view of the responsibility." A verdict on the part of the doctor _without a post-mortem_. Against the doctor is the following, from the daughter, Miss Kate Meyer. I quote from an article in the _North American_ of May 8, 1900: "Mrs. Hermina Meyer, devotee of an odd cult, that regards starvation as a sure cure for all bodily ills, fasted for nearly forty days because she was suffering from rheumatism. "The rheumatism disappeared. "But after twenty-five days of total abstinence from food she sickened. Violent nausea came to her. She died. "Nevertheless, Miss Kate Meyer, daughter of the dead woman, says: "'My mother did not die because she fasted. The fasting did her good. When she began it she had been ill with rheumatism for more than a year. She could hardly walk. Her left arm was powerless. She could not lift it from her side. After two weeks of fasting she was active. She could walk. The power came back to her arm. She suffered little pain. She looked well. Then came the attacks of nausea. "'But Dr. Chestnut, who is our family physician, was attending mother all the time. He called once a week. He said himself that the fast cure seemed to be doing mother good. When she got nausea he did not lay it to her fasting. He said it was heart trouble. That's what mother died of. Dr. Chestnut said so. "'Do you remember the case of Leonard Thress? He cured himself of dropsy by fasting. Mother heard of it. She was introduced to Mr. Thress. He told her that all he knew of the fast cure he had learned from Henry Ritter. Mother sent and asked Mr. Ritter about the cure. Then she began it. Mr. Ritter never charged mother for anything. Dr. Chestnut consented that mother should try the Ritter cure.' "Mrs. Meyer was the wife of Charles F. Meyer, of 1233 North Howard Street. Meyer, like his daughter, has only friendliness for Ritter, and also favors the fast cure. Mrs. Meyer, past middle age, had been sorely tried by her ailment. For more than a year Dr. Chestnut attended her, but her condition did not improve. Prescription after prescription was tested, only to fail. "'There is little hope for me,' said the woman to her daughter. 'I'm tired of taking medicines. They do me no good.' "She became more melancholy as the days passed. She regarded her case as hopeless. Dr. Chestnut acknowledged defeat. He had only a change of climate--a long stay in Colorado--to recommend. A very domestic woman was Mrs. Meyer. She looked with horror upon a journey. She said she would remain at home and die. "But one day last March there gathered at a banquet in the home of Leonard Thress about a dozen persons, very happy, very healthy (or believing themselves to be so), all members of the 'starvation cure' cult. "Each had to tell the story of a long fast that brought a remarkable cure. Newspapers gave publicity to the dinner of the little band with the odd faith in fasting. Mrs. Meyer heard of it. Here was a chance--a gleam of hope! She came to know Leonard Thress, and, through him, Henry Ritter, the apostle of the fast cure. He told her of remarkable recoveries. She caught his enthusiasm. "But, according to Mr. Meyer, the young man was careful first that the family physician should consent. He never hinted at compensation for his services; never got it. Aside from advising total abstinence from food, he supplied small quantities of tonicum and salts dissolved in water. These contained no food matter; they were merely stimulative. "In two weeks hope was strong with Mrs. Meyer; with all the family. Certainly, she was improving. She could walk; her arm that had been stiff and painful moved with ease--hurt no more. She still suffered occasional twinges, and decided to continue her self-imposed starvation until every rheumatic germ in her body was eradicated. "She regarded herself as almost cured, when, after twenty-five days, she was attacked with nausea. She was very ill. It lasted sixteen days. After the first few days of fasting all desire for food had vanished. But on the thirty-sixth day she was hungry. "Oatmeal porridge was given her sparingly. The nausea, however, did not cease. She began to grow alarmingly emaciated. She had weighed one hundred and fifty pounds. Her weight had fallen to one hundred. "The family physician prescribed light food, but her stomach repulsed it. She grew very weak. "On April 26 she died. Dr. Chestnut unhesitatingly issued a death certificate, ascribing her death to heart-failure. He also suspected a cancer of the stomach, but was not sure. "Mrs. Herman Reinhardt, a cousin of the deceased woman, is firmly convinced that fasting had nothing to do with her death. "'For more than fifteen years Mrs. Meyer suffered from some acute stomach trouble,' Mrs. Reinhardt said yesterday, 'and it is my belief that it caused her death. Her general health had been greatly benefited by abstaining from all food, but the disorder from which she suffered most could not be cured. My husband fasted for twenty-five days and was completely cured of stomach trouble, and there were no ill effects in his case.'" The impression of this death and of these fasts upon the minds of the medical profession was perhaps fairly summed up by the eminent Horatio C. Wood, M. D., LL. D., Clinical Professor of Nervous Diseases in the University of Pennsylvania. He disregarded the legal phase of the question, the question of the legality of a layman dealing out words of cheer and comfort in cases in which the medical profession had retired in total defeat. The question had been seriously raised as to whether Mr. Ritter had not committed a crime against the laws of Pennsylvania, and for what? For simply advising these people to stop all eating until there would come a natural desire for food! Professor Wood thus gave utterance in the _Press_ of May 10: "'These people are falsifying,' he said, 'There have been liars, you know, and they are not all dead. I don't believe for an instant such stories as fasting totally for forty or fifty days and keeping up energy and activity. It is contrary to common sense as well as to all we know about the human body. I don't know the object of deception, but somebody must be making money out of it, or having a craving for notoriety. It is preposterous. I understand that one of these fasters walked ten miles a day, after doing altogether without nourishment for a month or so. If these persons did what they claim to have undergone, more than one death would have been charged against the treatment, you may be sure. "'You will remember that the professional forty-day fasters, Tanner and Suci, were reduced to mere skin and bone, were almost helpless, carefully husbanded every bit of their vital energy, and took no exercise. They were _watched_ and studied scientifically. And here is a woman, weighing only one hundred pounds when she started fasting, claims she began to eat after thirty-eight days of starvation, and had more energy and took more exercise than in years. It is all amazingly absurd, whatever the motive may be.'" Tanner and Suci, "skin and bones?" Cowen weighed one hundred and seventy-five pounds when he began his forty-two day fast, and lost only thirty pounds. My case of acute rheumatism revealed a loss of only forty pounds after a forty-six days' fast; and the woman of fifty-seven who began eating on the forty-third day was so well padded with muscle and fat as not to reveal the slightest suggestion of starvation as she sat down to the first meal. "Skin and bones?" This is a matter for months, and not for days. "Falsifiers, these fasters?" Science settles important questions by investigation, not by epithet. XVI. As I write the closing pages of this book, the most taxing case of fasting that ever came under my care has ended in hunger, and I insert it that all may know what tribulations will be theirs if they have any part in letting their sick get well or die in that peace God and Nature clearly design for all. A man of large mould came to me, unknown, unbidden, from a distant city on the seventeenth day of his fast. His appetite had been abolished by a severe throat and bronchial attack, both of which had been relieved before reaching me. Well posted in the theory of fasting, he came with the declared intention of fasting until hunger or death would come. For two or three weeks he was able to be about the city with his nearly two hundred pounds of flesh; but there was an unknown, unknowable disease of the bowels and stomach in slow development. There were a dryness of the mouth and such aversion to food as to forbid all eating, and he was deaf to my suggestion that he should at least taste some of the liquid foods from time to time, to save me in the eyes of his friends from a verdict of homicide, were we to fail to win a victory. After more than fifty days without even a taste of food nausea and vomiting were added to his woes, and when his friends became aware of the many days without food no words I could utter saved me from the severest condemnation. The anxiety that involved the sick bed only depressed the patient, and when another physician had to be called to relieve the pressure the last hope with him nearly departed. The adviser was a man of high character and of unusual general and professional acquirements. Behind him was the entire medical profession and all its literature: behind me were only Nature, many-voiced--and the patient. With us there was no lack of mutual respect, except in matters of faith and practice; but he no more tolerated my "crankiness," lunacy--perhaps imbecility--in withholding food from the sick than I his paganism in enforcing it. For the sake of the agony of friends my noble patient accepted one severe dose of medicine and one ration of predigested food. The instant response of the digestive powers was, "We have stopped business down here for repairs: when we are ready we will let you know." Next a ration of food was sent into the sick bowels, only to cause hours of pain. The enemy having been expelled with disaster from all points of attack, there simply had to be a waiting on Nature, and in one day after the last vomiting spell there was a natural call for food--and this on the _sixtieth day of the fast!_ Had this man died--such was his prominence--I should have been paraded as a criminal of the stupid kind in the entire press of America, except in the papers of my own city. For this man of sixty-five, who with marvellous faith in Nature patiently waited upon her time, there promises to be many years of the days of his youth restored to him. As for me, with authorized medicine driven from the field, I see only new life unfolding in him daily, and my reward is exceeding. Men and brethren of the medical profession: This man read his favorite _Sun_ during every one of those sixty long days, and not one day was there revealed a hint of mental loss in clearness of apprehension. He lived because he knew that starving to death was his remotest danger; he lived also because he was made to see evidences that a cure was evolving in many ways. There was at no time apprehension, except when he felt unable to resist his friends with a _No_ in thunder tones when it was proposed to torture him with drugs and foods. Brethren, are you going into print to denounce the physiology or the practicality of this old method in Nature, this new method in humanity, to the sick and afflicted? Not one of you can advance arguments that will convince those who reason. To what good end are you now enforcing your _predigested_ foods? Are they relished better than other foods? Can they be taken with less aversion in cases of nausea and vomiting? Do they really nourish the brain so as to add clearness and strength to the mind? Do they ever prevent the uncovering of bones that makes the ways of acute sickness? If food actually can be so digested out of the body as to be ready for instant absorption, we should be able to abolish our kitchens, and at once enter upon that golden age in which there would be no dyspepsia hydraheaded; no disease of any kind, not even drunkenness, and where death would be only as the last flicker of the burned-up candle. In this case, as in all other cases, the desire for water was abolished before hunger became marked. In this connection I will suggest to the reader that thirst is a morbid condition to be avoided as far as possible; that water is its only need, and no mortal ever needs a drop for health's sake except when thirsty. Making water-tanks of human stomachs is without the shade of physiological reason, and the alleged results for good are not based on a shade of scientific evidence: these are based wholly in the minds of the credulous enthusiasts who prescribe them. Taking large quantities of water without thirst only entails added work upon the kidneys, and thus it becomes a factor in the development of Bright's disease and other forms where the tendency exists. The actual need of water is always made clear in every case; the need always disappears before hunger can become possible. As to the use of water on the body, this physiology has to be taken into account. The skin is covered with scales that are constantly dropping off as they mature, each to uncover a bright, clean one. As the skin is not an absorbent membrane, and as old scales are constantly dropping off, the need of frequent baths is more a need to satisfy the personal sense of cleanliness than a physiological need. These scales should not be either soaked off or brushed off in a wholesale way; the oil in the skin is a protection against weather-changes, and is also a necessity to its functional integrity, and therefore should not be dissolved and washed off by soaps that are strongly alkaline. The body itself is very sensitive to contact with water below the natural temperature of the skin. The plunge bath is specially depressing to every human energy, and should never be indulged by the debilitated. The daily bathings of nursing children are cruel and life-depressing. Their little bodies are always clean in the physiological sense when their clothes are kept clean; hence once a week ought to satisfy all mothers. The question of how often to bathe must be considered along these physiological lines. They whose employments soil their clothes and bodies spend the least time in cleansing their bodies; and yet in no medical work that treats of diseases and their causes is there to be found a hint that any special disease has its origin in uncleansed skin as a chronic condition. That will be a small-minded reader who draws conclusions from these statements that the author is not highly in favor of having bodies and clothes kept so habitually clean as not to be an offence to the finest fibred olfactory nerve at close range. In the use, then, of water on the body be physiologically sensible, and not the slaves of the bath-tub or "medicated" waters. Lay readers, I draw my message to a close. I have addressed it to you because your minds are open and free. Draw near and listen while I talk rather than write. Let me look into your eyes, see the play on all the lines of expression, as I would were you in my consulting-room. Mine has reached your ears as a lone voice from the depths of some wilderness; I have tried so to speak with my pen that you could catch an echo as if from between the lines of every page. You will not banish your medical adviser, for you still need his knowledge of the workings of disease, if you do not need the drugs you formerly believed necessary; but you will now be able in a more intelligent way to diminish the possibilities of the future need of him. Since these wonderful fasts in Philadelphia others are occurring over the country from the contagion of example. Many are certain to be undertaken as a last resort where hope has departed; and death will come; and then there will be the confusion of tongues, as in the case of Mrs. Meyer. Her case has been the third one that I know of where the press has spread the news of death from starvation. I have given you the case of Mrs. Meyer that you may know that no matter how hopeless any case may be considered, no matter how given up by venders of drugs, if a fast be advised and death come, death from starvation will be the general verdict. Hence on as fasts multiply, so will the press continue to make special note of all who chance to die because they had ceased to add distress to their bodies by foods that were only taken as the medicinal dose. All this you need to take into account in those cases you would advise where the medical faculty has retired in defeat. Never in my entire professional life have I been so depressed by discordant voices as during this sixty-day fast just ended. All the air has been charged, darkened with frownings--even threats of what would happen in case of death; and as never before has this question come to me, "Why do the heathen rage and the people imagine vain things?" Again I must tell you that the No-breakfast Plan, the plan not to eat in time of health until there are a normal need and desire for food, that are only developed after several hours of morning labor, and not to eat at all during acute sickness, is the easiest of all means to maintain health, and to regain it when lost. In my message I have had the greatest good for the greatest number of the world's busy people, who have no time to indulge abnormal, artificial ways in the recovery and maintenance of health--ways that are a real tax on time and taxing in the means involved. Passing few are they of the world's workers who have the time for all this, and especially they who are the slaves of the kitchen. Again I must suggest to you that the actual need of daily food as a matter to meet the actual daily need is a new question in practical physiology. It may be very much less than is supposed, a matter to be determined by the scales. There are none who can eat at all with relish who are not more governed by relish than the hunger sense, as to the amount of food eaten. The real amount of daily food needed may be so small that enough of nourishment can be extracted from almost any of the easiest available foods, the main question being one of slow eating, restful eating, and with the most thorough mastication. For those who have the leisure and tastes for study over what to eat there are the works of Haig, Hoy, Hensel, Sir Henry Thompson, and others, that may be read with both interest and profit. And now I address my last words to the mothers of the land. For you the No-breakfast Plan means the highest possible health, the greatest possible relief from the slavery of toil. On no other plan are there such promises of relief and prevention of all your sex ailings. On this plan only can you become man's equal in the hours of leisure that are his by a feeling of divine right; you also should consider the possibilities of a day of eight or ten hours as needing the reduction all the more because of your weaker bodies. The No-breakfast Plan means for your children the best possibilities for the conservation of all the higher instincts and powers that will tend to save them from the saloon, the prison, the electric chair. If the Garden of Eden was abolished because you enticed man to eat the wrong food, it is for you to restore a new race of Adams in all the ways of health, of such health as will make the entire earth a "Paradise regained." Readers, lay and professional, let me reiterate in my parting words, words at white heat with conviction as to their soundness and utility. Enforced food is a danger always to be measured by the gravity of the local or general disease; a danger always to be measured also by the feebleness of old age--by feebleness no matter how caused. This physiological righteousness will remain unquestioned, its practicality unsurpassed, while man remains on the earth to violate the laws of his Creator manifest in his own body. The penalties of disobedience are as certain as that every cause is followed by a definite effect. There are no remissions in the various antitoxins; there is no hope for you through hollow needles. Nature is exacting, but she is merciful. Obey her laws that your ways may be toward Paradise, and not away from it. [Transcriber's Note: The following words were spelled/hyphenated inconsistently in the original text and have not been changed: over-eating, overeating; centre, center; Cowan, Cowen; Suci, Succi. The following corrections have been made to the original text. Page 64: insistance changed to insistence Page 65: abandaned changed to abandoned -- 'had been abandoned' Page 67: opprobium changed to opprobrium Page 74: constrast changed to contrast -- 'sluggishness by contrast' Page 122: satifsying changed to satisfying -- 'about satisfying it' Page 160: now changed to no -- 'no matter' Page 186: frieght changed to freight -- 'human freight' Page 191: wierd changed to weird -- 'weird treatment'] 
28549	----	A TREATISE ON FOREIGN TEAS, _ABSTRACTED_ FROM An ingenious WORK, lately published, ENTITLED _AN ESSAY ON THE NERVES_; ILLUSTRATING Their efficient, formal, material, and final Causes; with the Manner of the Liquids being corrupted by corrosive Acids, and stagnated by obtuse Alkalies: IN WHICH ARE OBSERVATIONS ON MINERAL WATERS, COFFEE, CHOCOLATE, _&c._ AND An Investigation of the Nature and Preparation of Foreign Teas, with their pernicious Effects in debilitating the Nervous System: INTERSPERSED WITH THE AUTHOR'S REMARKS, Arising from an Analysis of such Preparations as may be most beneficially substituted for INDIA TEA. THIS SELECTION, containing the Sentiments of the many eminent Physical Professors who have written on Foreign Teas, is designed to shew, by the most forcible Arguments and distinguished Authorities, the extreme Danger to which the Public are exposed from the continual Use of an Article so pernicious and destructive to the Constitution. [Price Six-pence.] Dr. SOLANDER's SANATIVE ENGLISH TEA. UNIVERSALLY APPROVED and RECOMMENDED BY THE MOST EMINENT PHYSICIANS, IN PREFERENCE TO FOREIGN TEA, As the most Pleasing and POWERFUL RESTORATIVE, IN ALL NERVOUS DISORDERS, HITHERTO DISCOVERED. Our first aliment at breakfast, being designed to recruit the waste of the body from the night's insensible perspiration; an inquiry is important, whether INDIA TEA, which the Faculty unanimously concur in pronouncing a Species of Slow Poison, that unnerves and wears the substance of the solids, is adequate to such a purpose--If it be not--the inquiry is further necessary to find out a proper substitute. If an Apozem PROFESSIONALLY approved and recommended for its nutritive qualities, as a general aliment, has claim to public attention, certainly Dr. SOLANDER'S TEA, so sanctioned, is the most proper morning and afternoon's beverage. Prepared for the Proprietor by an eminent Botanist. Sold Wholesale and Retail by the Proprietor's Agent, Mr. T. GOLDING, at his Warehouse for Patent Medicines, No. 42, Cornhill, London; and Retail by Mr. F. NEWBERY, No. 45, St. Paul's Church-Yard; Messrs. BAILEY'S, Cockspur-street; Mr. W. BACON, No. 150, Oxford-street; Mr. OVERTON, No. 47, New Bond-street; and by Mr. J. FULLER, South Side of Covent Garden. Also by the Venders of Patent Medicines in most Cities and Towns, in England, Ireland, and Scotland. Sold in Packets at 2s. 9d. and in Canisters at 10s. 6d. each, Duty included. Liberal Allowance for Exportation, to Country Venders, and to Schools. The native and exotic Plants which chiefly compose Dr. Solander's Tea, being gathered and dried with peculiar attention, to the preserving of their sanative Virtues, must render them far more efficacious than many similar Preparations, which by being reduced to Powder, must have those Qualities destroyed they might otherwise possess. A Packet of this Tea at 2s. 9d. is sufficient to breakfast one Person a Month. ADVERTISEMENT TO THE FOREIGN TEAS. Having, in the preceding enquiry, traced, from the system of the nerves, that on their state the health of the constitution chiefly depends, our immediate concern is next to ascertain what kind of food we either adopt from choice, custom, or necessity, is the most likely to destroy the economy of the nerves. And as Foreign Teas have long been censured as being the cause of many disorders which arise from the nerves being disarranged or debilitated, an impartial enquiry is here made into the nature, preparation, and effects, of these Teas. By this investigation it will appear, that Teas imported from China and India are the most injurious of any beverage that can possibly be taken as a general and constant aliment. But, not prematurely to anticipate any part of the following subject, the Reader is most respectfully referred to the following pages for further evidence. INTRODUCTION. As two of the four meals that form our daily subsistence are chiefly composed of tea, an enquiry into what kind is the most salutary must be as necessary as it may prove interesting and beneficial; for, on the choice of proper or improper tea must greatly depend the health or disease of the public in general. To this may be attributed the constitution being either preserved from that innumerable train of afflictions, which arise from too great a relaxation of the nervous system by acute distempers, misfortunes, &c. or being so debilitated by excessive drinking of India Tea, as to render it alone the prey of melancholy, palsies, epilepsies, night-mares, swoonings, flatulencies, low spirits, hysteric and hypochondriacal affections. For tea that is pernicious is not only poison to those who, from any cause of corporal debility or mental affliction, are liable to the above diseases;--but it is also too frequently found to render the most healthy victims of these alarming complaints. And as nervous disorders are the most complicated in their distressing circumstances, the greater care should be taken to avoid such aliments as produce them, as well as to choose those which are the most proper for their relief and prevention. Those who are now suffering from the inconsiderate use of improper tea, what pitiable objects of distress and disease do they not represent for the caution of those who may timely preserve themselves? Nervous disorders are the most formidable, by being the most numerous in their attacks upon the human frame. Every moment, comparatively speaking, produces some new distress of mind or body. The imagination cannot avoid the horrors of its own creation, while the memory is harrassed with the shadows of departed pleasures, which serve but to encrease the pain of existing torments. All the endearments of life are vanished to the poor wretch who sees himself surrounded by the spectres of dismay, terror, despondency, and melancholy. And such is but the thousandth part of the afflictions that are to be avoided or produced by the choice of the prevailing beverage of tea. Not only the innumerable train of nervous afflictions, but all those disorders that arise from an improper temperature of the fluids, may be produced from the action, corrosion, and stimulation of pernicious teas. In proportion to the state of the fluids, in particular constitutions, they may either prove too relaxing or astringent, too condensing or attenuating, and too acrid or viscid; for India teas, that to some constitutions are very diluting, may produce in others contrary effects: therefore such should be chosen as possess a combination of quality that may render them, as nearly as possible, to a general specific. But this cannot be well expected where one single ingredient is used, and that is distinguished for its particular qualities, which, if wholesome, can only be such to those whose fluids are so, by nature or circumstances, as to require such a particular assistant; for to every other state of the fluids they must be pernicious. It is consequently evident, that if teas imported from India have any virtues, they cannot be such as to render them worthy of being universally adopted as a general aliment. If wholesome to a few, they must be pernicious to the rest of mankind, with whose constitutions they have no congeniality, medicinal or alimentary virtue. Supposing they may possess some physical properties, like all other medicines, they can only benefit such disorders as nature particularly formed them to relieve. Those who have been advocates for their positive virtues have, in this instance, but more confirmed the impropriety of adopting them as a general morning and evening beverage. This only explains more evidently the cause of so many being injured, where one is benefited, by drinking constantly India tea. There cannot possibly be stated a more self-evident proposition than where any simple or combined matter is adopted for a particular purpose, it must, in every opposite instance, prove injurious. In proportion, therefore, to such particular qualities, they are the more improper to be generally and indiscriminately adopted. This observation, although it may be applied to every art or science, is still more applicable to physic. Thus is it found that no medicine can be safely taken as a constant and general aliment. Even those who, at first, might find it beneficial in their respective complaints, have too frequently found the constant use of it afterwards hurtful to the constitution it had before relieved. It may be deduced, from the above considerations, that India teas, however physically beneficial, to allow them all their best of praise, must be as an aliment generally injurious. Instead of preserving health, they sow innumerable disorders, which can only be cured by substituting a beverage from such salutary native or exotic herbs as are formed for the particular afflictions the former have so pitiably brought upon the too greater part of mankind. As almost every disorder to which the human frame is liable may be retarded in its cure, if not confirmed in the constitution, by the power of secretion being weakened, India teas are the most dangerous that can be possibly used as a general beverage. By too much dilating the canals, the concussive force of the sides is increased, which destroys the oscillatory motion, and thus are the secretions altered and disturbed; and as the action of medicines consists in removing impediments to the equal motion of the fluids, the greater care should be taken to abstain from all food or drink that may increase those impediments. That India teas not only increase but occasion such evils is evident, from their having been experienced to relax the tone and reduce the consistence of the solids. As the powers of secretion depend upon the just equilibrium of force between the solids and the liquids, the latter must, in the above instance, make a greater _impetus_ upon one part than another, from which proceeds that morbid state so justly and emphatically termed Disease. Thus, according to the learned Boerhaave, to heal is to take away the disease from the body; that is, to remove and expel the causes which hinder the equal motion or transflux. Medicines, he says, are those mechanical instruments by which an artist may remove the causes of the balance being destroyed, and thus re-instate the lost equilibrium of solids and liquids. He therefore concludes, that a medicine supposes a flowing of the humours or liquids; that it operates mechanically; that it acts only mediately; that its good or bad effects depend entirely on the bulk, motion, and figure of the acting particles, and that the destruction of the balance must be deduced from the solids. So that, as it has been found that the solids are wasted and impaired by the constant use of India tea, the chief cause of disease, in general, may be attributed to such a pernicious custom; even the properties which he ascribes to medicines are in direct opposition to what have been found to be the prevailing effects of teas imported into Europe. It is consequently evident, that the drinking of this injurious tea being not only, in its operation, productive of disease in its general sense, but also repugnant to the salutary operation of medicine, it is the most dangerous beverage that can be generally taken; for it appears, from the above consideration, that its pernicious effects are not confined to any system of disorders; it is found inimical to the first principles of health, and therefore may be justly dreaded as capable of being the source of disease indefinitely understood. Having thus stated, as an Introduction to this Essay on Teas, the general tendency of those imported from India, under the titles of Green, Souchong, and Bohea, to injure the constitution, the following pages will be particularly devoted to the consideration of the nature, preparation, and manner of using, and the effects of such foreign teas. ESSAY ON TEAS. There is, perhaps, no subject on which there has been more declamation, for and against its properties and effects, than those of teas imported into this country by the companies trading from the different maritime nations of Europe to China and India. Nor has there been a controversy in which the health of the community has been so materially concerned, that has afforded so little direction of moment to those who would wish to ascertain the truth of such teas being either beneficial, injurious, or innocent in their effects. Amidst a mass of declamatory assertion so little intelligence is to be gained, that those who have had the greatest interest in being informed of the real qualities of teas, have most abandoned the enquiry before they obtained the least knowledge of what they sought. Either perplexed with abstruse science, or dissatisfied with assertion equally unfounded and unsupported, thousands have discontinued the research, and committed themselves to fatal experience. Thus have too many acquired a knowledge of the detrimental qualities of teas, by the ruin of their constitution. To avoid therefore such an inconvenience, the greatest care will be taken to prevent an indiscriminate reference to authors, whose sentiments can neither sanction adduced arguments or illustrate technical allusions. The enquiry will be made with some reference to science, but more to convince by demonstration than to confound by abstruse perplexities. So that, while empty declamation is avoided, the principles of truth are meant to be investigated by reason and experience. With this view, the Nature of Green, Souchong, and Bohea teas is first considered. To judge of the nature of these herbs with equal candour and propriety, it may be necessary to consider their qualities in relation to what are ascribed them, and what have been discovered by their analysis, and what have resulted from experience. The virtues that have been ascribed to them are chiefly, being a greatful diluent in health, and salutary in sickness, by attenuating viscid juices, promoting natural excretions, exciting appetite, and proving particularly serviceable in fevers, immoderate sleepiness, and head-aches after a debauch. It is also added to the list of their ascribed virtues, that there is no plant yet known, the infusions of which pass more freely from the body, or more speedily excite the spirits. To a person of any physical knowledge, these qualities will either appear contradictory in themselves, or rather ultimately injurious, than absolutely beneficial. As the full examination of these assumed qualities, by the rules of science, would require a volume, instead of a few pages, which the limits of this Essay will afford, the enquiry must be made as perspicuous as the necessity of brevity will admit. Allowing they are diluting in health, their constant use may so attenuate the liquids as to destroy their natural force and tensity. But Boerhaave says, there is no proper diluent but water; it is therefore evident it is the water, and not the tea, which is the diluting medium. With respect to its being an attenuative of viscid humours, it can never possess this virtue from being a diluent, for an attenuant acts _specially_ on the particles, by diminishing their bulk, while the diluent acts upon the whole mass of the fluid. The general body of the liquid may be diluted while the viscid humours remain unresolved. Indeed, the operation of an attenuant is not easily known; for many are surprised that a slight inflammation should be so difficult to dissipate. But their surprise would cease, were they to consider, that medicines act more generally upon the whole body than abstractedly upon the part affected. Suppose to attenuate some coagulated blood, six grains of volatile salt were given, how small a proportion must come to the part diseased, when these grains, by the laws of circulation, will mix with the entire mass of blood, consisting at least of thirty pounds! Teas being said to promote natural excretions, can be no recommendation of what is generally used; for this constant effect must render them too copious, and thus, according to all physical experience, the blood must be thickened in the greater vessels, which frequently terminates in an atrophy. The appetite being excited by the drinking of tea, is more a proof of its attrition of the solids than any stimulus to a wholesome desire of food. This quality accounts for the acrimonious effects too many have experienced by its use. Many have not only had their blood impoverished, but corrupted by the constant drinking of these teas. Whether it arises from any positive acrimonious salt it naturally possesses, or from any acquired corrosiveness from its mode of drying, is not here necessary to enquire: it is only requisite to state that a pernicious effect is too fatally experienced by those who are unfortunately its slaves. How India tea can be serviceable in fevers is not easy to be understood; for, if it has that effect upon the nerves to excite watchfulness, it must greatly tend to increase, instead of diminish feverish symptoms. Dr. Buchan attributes even one cause of the palsy to drinking much tea or coffee, &c. and, in a note, he subjoins: "Many people imagine that tea has no tendency to hurt the nerves, and that drinking the same quantity of warm water would be equally pernicious. This, however, seems to be a mistake, many persons drinking three or four cups of warm milk and water daily, without feeling any bad consequences; yet the same quantity of tea will make their hands shake for twenty-four hours. That tea affects the nerves is likewise evident from its preventing sleep, occasioning giddiness, dimness of the sight, sickness, &c." With regard to India teas possessing the quality of exciting the spirits, this, like every other stimulus, either by constant use loses its effect, or unnerves the system it is meant to strengthen. The nerves through which the animal spirits circulate being, like the strings of a violin or harpsichord, too frequently braced, lose, at last, their natural tensity, and thus render the human frame one system of debility. Having thus, as briefly as possible, stated that even their ascribed virtues are either derogatory to all physical principle, or else destructive to the constitution, from their constant use, the nature of India teas is next considered, with respect to what appears to be their chief component parts, from analyzation. Teas have been found to consist principally of narcotic salts, some astringent oil, and earth. These being found in greater quantities in bohea than in green teas, those who have very sensible and elastic nerves must be seized with a greater tremor after drinking the former than the latter. The continual and regular influx of the nervous juices is stopped by their component fibres being contracted from the roughness and restringency of such decoctions. The force of the heat, or the brain's propulsion of its nervous juice, being inferior to the resistance of the whole ramified fibres thus encreased by the sudden contraction and unequal motion, the flow of the animal spirits must be greatly impeded and disordered. In fact, the influx suffers a suspension, until the fibres, by relaxing again, admit their empty tubes to receive their appropriated liquids. Thus even green tea must, especially if taken strong and often, stop the natural circulation of humours, and produce the attendant defects of depression of spirits, deficiency of secretion, loss of appetite, decrease of strength, waste of body, and, finally, a total want of effective vigour in all the animal functions. But, as above observed, bohea tea possessing in greater quantity the pernicious ingredients, the vessels are thrown into momentary spasms and convulsive vibrations, by the relaxing power of the narcotic salts, and the contracting force of the astringent oil and earth. And here it must be noticed, that oil mixed with salt is rendered astringent: thus all vegetables, where a mixture of both prevails, are reckoned stimulating. The narcotic power of the salt is derived from its hindering the flux of the animal spirits through the nerves. The stomach and bowels being weakened by the above causes, windy complaints or flatulencies are consequently produced. This caused Dr. Whytt, in his advice to patients afflicted with such diseases, to desire they would abstain from India tea, as one of the flatulent aliments chiefly to be avoided. If the slightest external motion alone produces the following changes in the body, what effects may not be ascribed to the constant use of teas, which we find, as before stated, operate internally? A person in perfect health, having his nostrils only touched with a feather, cannot avoid his body being so convulsed as to produce what is commonly called sneezing. But if the number of muscles agitated, the force and straining of the body by sneezing, are considered; the slightness of the cause must excite no little astonishment; for this action is occasioned by the muscles of the scapula, abdomen, diaphragm, thorax, lungs, &c. and if the sneezing continues, an universal explosion of the liquids ensues: tears, mucus, saliva, and urine, are excreted. Thus, without any moist, cold, hot, dry, sulphur, salt, or any other internal or external application, an involuntary motion of all the solids and fluids is produced by a feather touching, in the slightest manner, the inside of our nostrils. But Boerhaave relates further, "That if sneezing continues a long time, as it will by taking one hundredth part of a grain of euphorbium up the nose, grievous and continued convulsions will arise, head-aches, involuntary excretions of urine, &c., vomitings, febrile heats, and other dreadful symptoms; and, at last, death itself will ensue." It is therefore evident that the slightest bodies produce the greatest changes in the human frame. Such is the power of certain particles upon the nerves, that the stomach will be thrown into convulsions that almost threaten an inversion, by taking only four ounces of a wine in which so small a portion of glass of antimony as one scruple is infused in eight pounds of the former. And what is still more remarkable is, that the glass of antimony remains not only undissolved, but, comparatively speaking, undiminished in its weight. These being a few of the fatal afflictions which experience shews to be frequently the consequence of drinking India teas, its injurious nature is too evident to require any further investigation of either their ascribed or positive qualities. The next subject to be considered, relative to India teas, is their Preparation. Among the different authors of any consequence that have written on the culture, preparation, and virtues of foreign teas, may be ranked Kampfer, Postlethwaite, Dr. Cunningham, Priestley, Lemery, Franchus, Meister, and Sigesbeck; as the limits of this Treatise will not permit a detail of observations from the whole of these writers, remarks can only be selected from the most principal of them. Most of the above, and many other, authors agree that the leaves are spread upon iron plates, and thus dried with several little furnaces contained in one room. This mode of preparation must greatly tend to deprive the shrub of its native juices, and to contract a rust from the iron on which it is dried. This may probably be the cause of vitriol turning tea into an inky blackness. We therefore do not think with Boerhaave, that the preparers employ green vitriol for improving the colour of the finer green teas. It may however be concluded, from the colour of bohea, souchong, and such as are called black teas, that they may be thus tinctured, by the means of vitriol, after they have been dried upon the iron plates in the furnace room; and this may likewise particularly cause that astringent quality which is more experienced in all the black than any of the green teas. According to Sigesbeck, the colours of these teas are artificial; so that if these pernicious arts are used even to give the tea a particular colour, there is no difficulty in ascribing the cause of their injurious effects. That the native virtues of these teas are liable to considerable perversion is evident from the manner in which Meister relates they are prepared. He says the leaves are put into a hot kettle just emptied of boiling water, and that they are kept in this closely covered until they are cold, when they are strewed upon the hot plates above mentioned for drying. It is easy to conceive how the virtues of a leaf, however salutary by nature, must be destroyed by such a process. Being thus put into a steaming kettle, and suffered to remain there until they are cold, must cause the greatest part of their Virtues to evaporate, and the leaves to imbibe an unwholesome taint from the effluvia of the steaming metal. It cannot, therefore, be ascertained whether teas that are imported in Europe, after such a mutating preparation, have the least remains of their original odour or flavour, no more than they have of their qualities; but, on the contrary, it seems impossible but that the original nature of this shrub is entirely destroyed by an artificial preparation. Some falsely suppose that this species of management is only to soften such of the leaves as are grown too dry, and are therefore liable to break in the curling; but this will evidently appear not the cause, when it is considered that the greater part of the teas must dry in such a hot climate while they are gathering: and as they are particularly anxious to send them in as curious a curled state as possible, such teas must be thus moistened again, in order to curl them afterwards in that perfect manner which is performed on the iron plates of the furnace. The opinion, therefore, of teas deriving their green colour from being dried upon copper being founded on a misrepresentation of the manner in which they are really prepared, a few observations upon the subject are indispensibly necessary. For those who have always understood that the detrimental qualities of foreign teas were the consequence of their being dried upon copper, may perhaps imagine they cannot be so pernicious if they were dried upon iron; but this opinion cannot be entertained by any persons who have the least knowledge of the manner in which the vegetable acid will corrode iron. Those who are acquainted with culinary processes must know in what manner the acid of onions will operate upon any steel instrument; it corrodes a knife so as to turn the onions black with the particles eaten away from the edge and the face of the blade. To avoid this unwholsome and unseemly inconvenience, a wooden instrument is generally used in all instances where onions form a part of the cookery appendages. It is consequently evident, that although iron utensils are now greatly used instead of copper, yet many injurious effects may happen from their being liable to be corroded by the acid of several vegetables. And if the nitrous acid of the air will corrode iron so as to cause rust, when it will not produce the proportionate effect upon copper, it is a demonstration that iron is the most liable to such a corruption. The corrosions of copper are undoubtedly pernicious; but the damage that tea would derive from its being dried upon sheets of this metal would not operate so injuriously to those who drink it as it does now by lying dried upon iron. For the latter bring more liable to the power of the mineral, vegetable, or animal acid, must impart more particles of its reduced calax to the tea than copper would. And, in order to shew how susceptible of corrosion iron is, the following instance is farther adduced: in Ireland, where some persons practise the art of tanning leather with fern, which possesses a very strong acid, particular care is taken to avoid using any iron vessels in the tannage, lest the colour of the leather should be blackened by the corroding particle of the metal. As it is the peculiar property of iron or steely particles, even in their most perfect state, to operate as too great an astringent for an aliment that is taken twice a day constantly, tea, when dried upon it, must be rendered proportionably pernicious. But admitting that the popular opinion of their being dried upon copper was just, the teas must be rendered proportionably injurious to the quantity of copperas or crude vitriol they imbibe from their acidity corroding the metal. Preparations of steel, that are, in many instances, considered as most salutary, yet in all pulmonary disorders the most eminent physicians have deemed them exceedingly dangerous. And in a country, like Great Britain, Holland, and other places, where a cloudy atmosphere, caused from their marshy soil or watery situation, renders most of the inhabitants subject to complaints of the lungs, foreign teas, contaminated by these iron corrosions, must be particularly detrimental. It is therefore, from these considerations, evident, that foreign teas, by being dried upon iron, have their bad qualities so increased as to render them the most pernicious of any morning and evening liquid that has yet been taken.----To return from whence we began this short digression. It is remarkable that no satisfactory account has yet been given in what the bohea differs from the green tea. Dr. Cunningham, physician to the English settlement at Cimsan, and Kampfer assert, that the bohea is the leaves of the first collection. This, however, being contrary to the general report of all travellers, that none of the first produce is brought to Europe, must be discredited; for these are all preserved for the Princes, to whom they are sold, even in China, at an immense price. Another proof is, that the boheas are brought here in the most considerable quantities, at a price greatly inferior to what even the second, third, and fourth crops are sold for in China. This not only evinces how inferior in quality the black tea must be, but also how little they are valued among those who must be acquainted with their properties. Although the European dealers divide the green teas chiefly into three sorts, and the boheas into five, yet it is unknown from what province they are brought, of what crop they are the produce, and to which of the Chinese sorts they belong. Added to their abuse of preparation may be that of their package. It is impossible but to know that their bad qualities must be considerably augmented by being so closely packed, for such a length of time, in such slight wooden chests, lined with a composition of wood and lead. Considerable quantities are likewise damaged by salt water and other causes, which, by the management of the tea dealers, are mostly mixed, and sold under different denominations. How the tea must be affected by the corrosion of the lead and tin by the marine acid, those of the least chemical knowledge will easily determine. To what danger must, therefore, the constitution of those who are in the constant habit of drinking such an empoisoned drug be exposed, may easily be imagined. Surely, when all these circumstances are considered respecting the pernicious mode of preparation, and particularly the poisonous qualities they are also liable to contract from the nature of their package, every person must be convinced to what a loss of health, if not of life, the constant use of such teas must expose them. Such evidence of their deleterious tendency is almost sufficient to alarm mankind against so prevailing an evil, without any further arguments; but as health is too precious not to require every possible proof that can persuade us to avoid what so immediately threatens our existence, the following arguments and testimonies of the bad qualities of foreign teas must not be omitted. Previous, however, to an investigation of their effects, it may be necessary to say a few words respecting THE MANNER OF USING. Foreign tea, as before observed, being taken as two principal meals of our daily aliment, is undoubtedly one great reason of the constitution of the people having suffered an entire change in its system. That vigour, spirits, and longevity, which characterised us in the last century, is totally subverted; disease, dismay, and debility, now lead us prematurely to the grave, where we end an existence too deplorable to excite the least desire for a longer continuance. Dr. Priestley states, very justly, in his Medical Essays, that it is curious to observe the revolution which hath taken place, within this century, in the constitutions of the inhabitants of Europe. Inflammatory diseases more rarely occur, and in general are much less rapid and violent in their progress than formerly; nor do they admit of the same antiphlogistic method of cure which was practised with success a hundred years ago. The experienced Sydenham makes forty ounces of blood the mean quantity to be drawn in the acute rheumatism; whereas this disease, as it now appears in the London hospitals, will not bear above half that evacuation. Vernal intermittents are frequently cured by a vomit and the bark, without venæsection, which is a proof that, at present, they are accompanied with fewer symptoms of inflammation than they were wont to be. This advantageous change, however, is more than counterbalanced by the introduction of a numerous class of nervous aliments, in a greater measure, unknown to our ancestors, but which now prevail universally, and are complicated with almost every other distemper. The bodies of men are enfeebled and enervated; and it is not uncommon to observe very high degrees of irritability under the external appearance of great strength and robustness. The hypochondriac, palsies, cachexies, dropsies, and all those diseases which arise from laxity and debility, are, in our days, endemic every where; and the hysterics, which used to be peculiar to the women, as the name itself indicates, now attacks both sexes indiscriminately. It is evident that so great a revolution could not be effected without the concurrence of many causes; but amongst these, I apprehend, the present general use of tea holds the first and principal rank. The second cause may perhaps be allotted to excess in spirituous liquors. This pernicious custom owes its rise to the former, which, by the lowness and depression of spirits it occasions, renders it almost necessary to have recourse to what is cordial and exhilarating; and hence proceeds those odious and disgraceful habits of intemperance with which too many of the softer sex of every degree are now, alas! chargeable. These are the sentiments of a character distinguished for his elaborate researches and judicious discoveries in almost every branch of liberal science. It may therefore be safely concluded, that the general manner of using India tea morning and evening has been, and is, the principal cause of the greater part of the diseases with which the natives of Europe are now afflicted. When it is considered that the first meal which is taken to recruit the body, after the loss it sustains from the insensible perspiration of the preceding night, and to prepare it for the avocations of the succeeding day, is India tea, who can be surprised that nature should rapidly become the victim of disease? Thus, instead of being supported by nutritious aliment, its nerves are enfeebled, its spirits diminished, and all its functions enveloped with the gloom of melancholy. Even in the afternoon, when nature is exhausted by care and fatigue, we fly for refreshment to tea, which, instead of bracing, still further relaxes the unnerved system. Such are the evil effects of the imprudent manner in which this pernicious drug is so constantly and universally used. But how must these evils appear in their extent, when the following view is taken of India teas, with regard to their variety of injurious EFFECTS. In all the physical experiments that have been made upon India teas, there is, perhaps, none that shews its acid astringency more than one tried by the above writer, Dr. Priestley. Endeavouring to trace the differences and ascertain the astringency and bitterness of vegetables reciprocally bear to each other, he imagined he had found they were distinct and separate properties, by the following experiment: Taking two pieces of calf-skin just stripped from the calf, he immerged them in cold infusions of green and bohea tea; at the expiration of a week he found they were hard and curled up, and that there was no sensible difference between them. He therefore concluded, that this experiment afforded a striking proof of India tea differently affecting a dead and a living fibre; this he considered as the greatest effect of a medicine. But, with deference to so distinguished an author, I cannot but attribute this astringency of the skin to the particular properties of India tea; for all physical as well as medical experience proves that vegetable produce afford some that are astringent, and others that are relaxant, of the dead as well as the living fibre. Oak bark is equally astringent, and hardens the fibres of the hide, as well as it braces the living nerve of our bodies; therefore the effect produced by the India tea upon the dead skin only proves, what we have before related, that an infusion of it has a peculiar effect, which, being too frequently applied to the nerves, destroys their tensity by their fine fibres being either broken or relaxed by overbracing. Were any astringent to be constantly taken, it must ultimately produce more or less such an effect; so that while the above experiment of the learned Philosopher demonstrates that India tea has the power of astringing the dead as well as the living fibres, it does not prove that astringency bitterness are separate qualities. On the contrary, bitterness seems to be the characteristic taste of all that has the tendency to contract whatever is the subject of its application. Thus galls, bark, rhubarb, camomile tea, &c. &c. are all bitter and astringent. It is, therefore, the immoderate use of such an astringent that ultimately relaxes and debilitates: like the too frequent bracing of a drum, or any other stringed musical instrument, destroys its tensity, the body is unnerved by the overstretching of its fibres. Although we sometimes differ with the celebrated Doctor in part of the conclusion he has drawn from his experiment, yet the following sentiments so perfectly coincide with all our observations upon India teas, that we are happy to have the opportunity of corroborating our own with the sentiments of so eminent a Philosopher. He says, from his experiments, "it appears that green and bohea teas are equally bitter, strike precisely the same black tinge with green vitriol, and are alike astringent on the simple fibre. From this exact similarity in so many circumstances, one should be led to suppose that there would be no sensible diversity in their operation on the living body; but the fact is otherwise: green tea is much more sedative and relaxant than bohea; and the finer the species of tea, the more debilitating and pernicious are its effects, as I have frequently observed in others, and experienced in myself. This seems to be a proof that the mischiefs ascribed to this oriental vegetable do not arise from the warm vehicle by which it is conveyed into the stomach, but chiefly from its own peculiar qualities." Dr. Hugh Smith, in his Treatise on the Action of the Muscles, justly says, that an infusion of India tea not only diminishes, but destroys the bodily functions. _Thea infusum, nervo musculove ranæ admotum, vires motices minuit perdit._ Newman, in his Chemistry, says, when fresh gathered, teas are said to be narcotic, and to disorder the senses; the Chinese, therefore, cautiously abstain from their use until they have been kept twelve months. The reason attributed for bohea tea being less injurious than green is, being more hastily dried, the pernicious qualities more copiously evaporate. "Tea," says Dr. Hugh Smith, in his Dissertation upon the Nerves, "is very hurtful both to the stomach and nerves. Phrensies, deliriums, vigilation, idiotism, apoplexies, and other disorders of the brain, are all produced by the nerves being thus disarranged and debilitated. If the digestive faculty of the stomach be weakened, the body, failing of recruiting juices, must tend to emaciation, and the whole frame be rendered one system of distress and infirmity. The nerves, being thus deprived of a sufficiency of their animal spirits, must become languid, and leave every sense void of the first means of conveying to the mind the only enjoyments of our temporal existence. "But if there be any class of persons to whom India tea is more particularly hurtful than to any other, it is that which includes the studious and sedentary, and especially those who are enfeebled with gout, stone, and rheumatism; age, accident, or avocation, cause many persons to be unfortunately ranked amongst those of the latter description. These, from their intensity of thought, want of exercise, injurious position of body, respiration of unwholesome air, and a variety of other causes, have not only their animal spirits exhausted, but their liquids corrupted from the loss of a necessary circulation. With these evils India tea operates as an absolute poison. Indeed, it frequently renders those incurable, who might, by other means, have been relieved. "When a view is taken of the dismal effects produced by India teas, the mind seems to be bewildered in searching for the cause of using so generally a drug that is so universally destructive. It chiefly originated in a fundamental mistake of physical principles. About the time that India tea was introduced to Europe, a grievous error crept into the practice of medical professors; they falsely imagined that health could not be more promoted than by increasing the fluidity of the blood. This opinion once established, it is no wonder that mankind, with one accord, adopted the infusion of India tea, which was then a novelty to Europe, as the best means of obtaining the above effect. By the advice of Bentikoe chiefly was the pernicious custom of drinking warm liquors, night and day, established. To this man, and the introduction of India tea, may be ascribed that revolution in the health of Europeans which has happened since the last century. The present age, therefore, have great cause to lament, in what they suffer in nervous complaints, that their forefathers did not attend more to the scientific and judicious advice of the illustrious Duncan, Boerhaave, and the whole school of Leyden, who proscribed this error. Although they could not entirely prevent this physical abuse, yet their zealous endeavours did, in some degree, at first impede its progress; but, however, so powerful did novelty plead in favour of India teas, that, at last, general custom and prejudice bore away every barrier that had been erected by these learned and experienced physicians. This error, instead of diminishing, has increased: most valetudinarians are now of opinion that a thick blood is the sole cause of their complaints; with this impression they adopt what they call the diluent beverage of India teas. It can scarcely be imagined how many disorders this practice produces; it may be justly termed the box of Pandora, without even hope remaining at the bottom." Tissot says, "They are the prolific sources of hypochondriac melancholy, which both adds strength to and is one of the worst of disorders." He adds, "with regard to studious men, who are naturally weak and feeble, such warm beverages are more hurtful to them than to others; for they are not troubled with an over thick, but, on the contrary, too thin a blood. You are all aware," continues he, "respectable auditors, that the density of the blood is as the motion of the solids; the fibres of the learned are relaxed, their motions are slow, and their blood, of consequence, thin. Bleed a ploughman and a doctor at the same time; from the first there will flow a thick blood, resembling inflammatory blood, almost solid, and of a deep red; the blood of the latter will be either of a faint red, or without any colour, soft, gelatinous, and will almost entirely turn them to water. Your blood, therefore, men of learning, should not be dissolved, but brought to a consistence; and you should in general be moderate in the article of drinking, and cautiously avoid warm spirituous liquors. "Amongst the favorite beverages of the learned," the same Tissot observes, "is the infusion of that famous leaf, so well known by the name of India tea, which, to our great detriment, has every year, for these two centuries past, been constantly imported from China and Japan. This most pernicious gift first destroys the strength of the stomach, and if it be not soon laid aside, equally destroys that of the viscera, the blood, the nerves, and of the whole body; so that malignant and all chronical disorders will appear to increase, especially nervous disorders, in proportion as the use of India tea becomes common; and you may easily form a judgment, from the diseases that prevail in every country, whether the inhabitants are lovers of tea or the contrary. How happy would it be for Europe, if, by unanimous consent, the importation of this infamous leaf was prohibited, which is endued only with a corrosive force derived from the acrimony of a gum with which it is pregnant." Having thus considered the dismal and too frequently fatal consequences of the nerves being affected, it is presumed this part of the Essay cannot be more interestingly concluded than by a summary of the distinct symptomatic effects attending, more or less, complaints of the nerves; and although the following symptoms are alarming with regard to their number and variety, yet the reader may be assured there is not one specified but what is either the immediate or ultimate effect of a nervous affection, and which is too frequently the consequence of the violent astringency of foreign tea taken injudiciously as a constant aliment:--A faintness, succeeded with a delusive vision of motes, mists, and clouds, falling backwards and forwards before the distempered sight--A yawning, gaping, stretching out of the arms, twitching of the nerves, sneezing, drowsiness, and contraction of the breast--Dulness, debility, distress, and dismay, with a great sense of weariness--A wan complexion, a languid eye, a loathing stomach, and an uncertain appetite, which, if not immediately satisfied, is irremediably lost--Heartburning, bilious vomitings, belchings, pains in the pit of the stomach, and shortness of breath--Dizziness, inveterate pains in the temples and other parts of the head, a tingling noise in the ear, a throbbing of the brain, especially of the temporal arteries--Symptoms of asthma, tickling coughs, visible inflations, and unusual scents affecting the olfactory nerves--Sometimes costive and sometimes relaxed--Sudden flushings of heat, and suffusions of countenance--In the night, alternate sweats and shiverings, especially down the back, which seems to feel as if water was poured down that part of the body--A ptyalism, or discharge of phlegm from the glands of the throat, which generally attends all the symptoms--Troublesome pains between the shoulders, pains attended with hot sensations, cramps and convulsive motions of the muscles, or a few of their fibres--Sudden startings of the tendons of the legs and arms--Copious and frequent discharges of pale and limpid urine--Vertigoes, long faintings, and cold, moist, clammy sweat about the temples and forehead--Wandering pains in the sides, back, knees, ancles, arms, wrists, and somewhat resembling rheumatic pains--The head generally warm, while the rest of the body is cold or chilly--Obstinate watchinqs, disturbed sleep, frightful dreams, the night mare, startings when awake, and the mind filled with the most terrific apprehensions--Tremors of the limbs, and palpitations of the heart--A very variable and irregular pulse--Periodical pains in the head--A sense of suffocation, frequent sighings, and shedding of tears--Convulsive spasms of the muscles, tendons, nerves of the back, loins, arms, hands, and a general convulsion of the stomach, bowels, throat, legs, and indeed almost every other part of the body--A quick apprehension, forgetful, unsettled, and constant to nothing but inconstancy--A wandering and delirious imagination, groundless fears, and an exquisite sense of his sufferings--A gradually sinking into a nervous atrophy or consumption--A perpetual alarm of approaching death--Sometimes cheerful, and sometimes melancholy--Without present enjoyment or future expectation of any thing but increasing misery and debility.--If these symptoms are inconsiderately suffered to continue, they soon terminate in palsy, hip, madness, epilepsy, apoplexy, or in some mortal disease, as the black jaundice, dropsy, consumption, &c. Having ascertained, from this enquiry, the injurious properties of India tea, it may naturally be expected that I should propose some article that might prove more beneficial. With this requisition I shall most readily comply, although I may expose myself to the invidious censure of having directed all my efforts to establish the celebrity of whatever article I may recommend. But being convinced, that, by publishing the virtue of a tea that I have investigated from physical analysis and particular observation, I may essentially serve the public, I am content to suffer the obloquy, provided it is productive of a general benefit. Having, as before observed, examined, with the greatest attention, the nature of most articles that have been offered as morning and afternoon beverage, there are two which claim most particularly the preference of all others that are sold under the denomination of Tea: these are, 1st, that which was discovered by that eminent botanist Sir Hans Sloane; and the other, by a botanist and physician equally celebrated, Dr. Solander. I therefore, without considering in what manner the interest of the proprietors of these teas may be individually affected, propose two articles, in order to shew that my partiality or opinion of the virtues of the one could not prejudice me so far as to prevent my allowing due praise to any other possessing qualities deserving approbation. I am happy to state that, from my analysis of that invented by Sir Hans Sloane, called British Tea, I found it possesses most singular virtues for relieving many nervous complaints; but, from the same trials and experiments made on that invented by Dr. Solander, I have been convinced that, although the qualities of the former are exceedingly salutary, they are not so general in their restoration and nutritious effects as the latter. Being thus convinced of the extraordinary properties of Dr. Solander's Tea, I have been induced to state, in a Treatise upon their Nature, Preparation, and Effects, reasons founded on chemical analysis, physical efficiency, and experimental observation, in support of their most eminent virtues. After every trial I have made of coffee, chocolate[1], and most other preparations that have been, and are at present, offered to the public as a substitute for tea, none seem to claim the preference so eminently as that invented by Dr. Solander. From their analysis, I find their virtues are of the most corrective and balsamic kind; they strengthen the tone of the stomach, not by astringing the solids, but by lubricating the vessels, sheathing the acrids, and attenuating the liquids. [1] "_Coffee.--In bilious habits it is very hurtful._" Dr. Carr's Med. Epist. p. 25. "_Coffee.--I cannot advise it to those of hardness of breathing._" Ibid. p. 29. "_Coffee, according to Paule, a Danish physician, enervates men and renders them incapable of generation, which injurious tendency is certainly attributed to it by the Turks. From its immoderate use they account for the decrease of population in their provinces, that were so numerously peopled before this berry was introduced among them. Mr. Boyle mentions an instance of a person to whom Coffee always proved an emetic. He also says that he has known great drinking of it produce the palsy._ "_Chocolate is too gross for many weak stomachs, and exceedingly injurious to those liable to phlegm and viscid humours._" Saunders's Nat. & Art. Direct. for Health. "_Chocolate overloads the stomach, and renders the juices too slow in their circulation._" Smith on the Nerves. In this manner they restore the equilibrium of the oscillatory motions, which establish the tone of the nervous system. This being strengthened, the animal spirits are enabled to dispense their reviving influence to the sensitive, digestive, and intellectual powers. And these being thus restored to their vigour of operation, a simple and moderate portion of food is rendered the most nutritious, and the body is consequently established in the enjoyment of health and happiness. The above virtues of the sanative tea are not here asserted as a declamatory panegyric, but as the result of a physical analysis of their nature, and a serious examination into their mode of operating as a restorative and constant aliment. Without presuming their qualities to be an unlimited remedy for all complaints, the nature of the preparation of this tea is compared with the causes and effects of nervous disorders: from this comparison their relative virtue to such diseases are most clearly evinced: and thus is this invaluable discovery proved to be the most effectual remedy for all those complaints caused by drinking foreign teas, that was ever yet or may be hereafter invented. In proposing to the public any simple or compound, for the preserving, increasing, or restoring health, the first object should be to explain its nature. This is the principal test by which its merits can be known, or mankind rationally induced to try its virtues. And as this sanative tea is offered as a substitute for what is generally used as two fourths of our aliment, and which, from the preceding enquiry, has been found the principal cause of our present infirmities, the greater necessity there is for a candid investigation of its nature. Impressed with the above conviction, it is fairly stated that the nature of this sanative tea is not from any combination of the animal or mineral kingdom, but a collection of the most salutary native and exotic herbs that are produced in the vegetable empire of nature. These have not been collected by the fanatic devotees of occult qualities, but by the scientific researches and personal experience of a character that is equally and justly admired for his philosophical, medical, and botanical knowledge. The discoverer, Dr. Solander, of this tea, inquired into the virtues of each native and exotic herb of which it is composed, not only by abstract reasoning upon its relative qualities, but by the more immediate evidence of his senses: by submitting each vegetable to his taste and smell, he derived the most certain physical proof of its qualities. Thus he knew the particular virtues of each, and what salutary effects they must, from their preparation as a compound, produce when applied as a relief for the innumerable diseases caused by drinking foreign teas. Not confining himself to _English Plants_, he studied and examined the virtues of _Exotics_, among which he discovered some that possess virtues he had not found in those of his own country: by adopting these, he has increased the salutary effects of his invaluable tea. From reading Hippocrates, Discorides, and Galen, he found the ancients derived all their knowledge of plants by their taste and smell. With these examples before him, and his own propensity to study, joined to his penetrating judgement, it is no wonder he should have so well succeeded. Thus he recurred to the original mode of inquiry, which first established and raised the eminence of physic; neglecting that delusive principle of Aristotle's philosophy, which has since taught too many physicians to express the virtue of medicines by hot, cold, moist, and dry, without deriving the least information from their senses Dr. Solander, aided by chemical analysis, distinguished the virtue by the taste or odour of every plant. By this means their specific juices he found tasted either earthy, mucilaginous, sweet, bitter, aromatic, fetid, acrid, or corrosive. From this experience he found the observation of some botanists to be true, "That there is no virtue yet known in plants but what depends on the taste or smell, and may be known by them."[2] With this infallible means of pursuing his enquiry, he formed a tea composed of herbs that are in their nature astringent, balsamic, aromatic, cephalic, and diaphoretic. These virtues combined may be said to form one of the most incomparable specifics, as a nutritive and restoring aliment, that has been discovered. [2] _Floyer, Malpighus, Epew, Harvey, Willis, Lower, Needham, Glisson, &c._ In the astringent, the acid fixing upon the more earthly parts, the nutritious oil is more easily separated, which renders them also pectoral, cleaning, and diuretic. This part of the tea is in its nature particularly serviceable in all cases where vulnerary medicines are requisite. They particularly amend the acid in the nervous juice, and thus restore the equal motion of the spirits, which were obstructed or retarded by spasms or convulsions. By the volatile oil and volatile pungent salt, obstructions are opened, and the motions of the languid blood increased to a healthy degree of circulation. They resolve coagulated phlegm in the stomach, preserve the fluidity of the juices, and promote digestion, by assisting the bile in its operation. And with regard to their balsamic and aromatic nature, these qualities warm the stomach and expel wind, by rarefying the flatuous exhalations from chyle in the prima viæ. These, by their sweetness, allay the sharpness of rheums, and lenify their acrimony. Being filled with an oily salt, they open the passage of the lungs and kidnies. By opening the pores, they extraordinarily discuss outward tumours, and attenuate the internal coagulation. All these virtues may be said to be derived from the union of their balsamic oil and volatile salt. By a second class of aromatics, with which Dr. Solander composed this sanative tea, is such as have a bitter astringency joined to their volatile oil and salt. These united qualities correct acids in the stomach, cleanse the lungs, and open obstructions in the glands caused by coagulated serum; and the saline pungent oil altering the acids in the glands of the brain, by correcting and attenuating its lympha and succus nervosus, produces the same effect; for the lympha and nervous juice are, like other glandulous humours, liable to acidity and stagnation; therefore these aromatics, by exciting their motion and correcting their acidities, render the liquids of the nerves more volatile, and are therefore justly termed cephalics. And as it is the property of volatiles to ascend, the reason is evident of the brain being assisted by their salutary qualities. These aromatics likewise evacuate serum from the blood, promote its circulation, and attenuate the coagulations of chyle, lympha, and succus nervosus. And here, it is proper to add, that all aromatics, by rarefying the blood, are cordial. There being aromatic astringents in this tea, its infusion strengthens the fibres and membranes of the stomach, and all the nervous system, in such a manner as not to destroy their tensity by that too great contraction caused by the foreign teas; and, having no acid in their astringency, the blood is preserved from too great a rarefaction, which would otherwise happen from the pungency of their oily qualities. These also excite the appetite, by stimulating the natural progress of the chyle, and thus prevent its too rapid fermentation of its spirituous parts into windy flatulencies. For the same reason vinegar is taken with hot meats and herbs. Having mentioned vinegar, it may not be improper to state this vegetable acid is the best antidote against the poison of any acrid herbs. That part of the tea which has a mucilaginous taste is inwardly cooler than oil, although it be different in nature. Such herbs defend the throat from the sharpness of rheums, the stomach from corrosive humours of disease or acrimonious medicines; the ureters from sharp, choleric, or acid urine, and lubricate the passage for the stony gravel. Their crude parts cool the heat of scorbutic blood, lessen its violent motion, and sheathe its acrid saline particles. By their different mucilaginous principles they produce the following various salutary effects: The earthy repel and cool outward inflammations. The watery, which is thick and gummose, stop fluxes and correct sharp humours. Those of an oily odour alleviate pains. Those of a pungent acrid dissolve tartareous concretions in the kidnies. From these and a variety of other salutary properties, it is evident the general nature of Dr. Solander's tea is such as to correct acrid humours, promote the secretions, restore the equilibrium between the fluids and solids, and finally to brace every part of the relaxed nervous system. The body being thus relieved from obstructions, its circulations restored, the digestive faculties invigorated, and the spirits re-animated, the debilitated constitution is reinstated in all its enjoyments of health and hilarity. It may be therefore observed, that the principle of this tea is to nourish as a general aliment, while it renovates the human constitution, without having recourse to the nauseous portions of galenical preparation, or the hazardous trial of chalybeate waters. As this tea is particularly salutary in all cases where mineral waters are generally recommended, it is very proper the Public should be cautioned against the danger which too frequently attends the constant drinking of them. Chalybeate waters, it must be acknowledged, have effected very extraordinary cures in certain cases. But when so great an author as Helmont says, that such waters are fatal to all those who are afflicted with peripneumonic complaints, it is surely necessary they should be resorted to with the greatest caution; and even in complaints where they may be serviceable, it is necessary to observe whether they really possess those chalybeate qualities for which they are commended. Those who have written upon their virtues assert, and with seeming propriety, that where they deposit an ochreous sediment, they are certainly dispossessed of their steely virtues; for ochre being no other than the calx of iron, such a residue evinces the evaporation of the more eminent properties of the chalybeate, by the phlogiston of the mineral escaping by its extreme volatility. Every metal deprived of this igneous principle is immediately reduced to a calx, and thus deprived of its splendour, fusibility, and other properties, until restored again by the readmission of its phlogiston. Calcined lead having lost this inflammable quality, is reduced to a red calx or mineral earth, which, if fluxed with any igneous body, such as oil, pitch, wax, fat, wood, bone, or mineral oil or bitumen, the fiery principle is resorbed, and the lead restored to its essential qualities; from these physical observations the reader may be convinced of those mineral waters as afford such a sediment being in a state of decomposition. They are thus deprived of one of the four elements or principles of which they are all more or less composed. Every analysis of mineral waters in their perfect state has demonstrated that they possess a fixed air, a volatile alkali, a volatile vitriolic acid, and the phlogiston. If, therefore, either of these essential qualities is evaporated or corrupted, the water, being in a state of decomposition, must lose the virtues of a medicinal chalybeate. It is only necessary to add a few further remarks, in order to shew in what particular complaints chalybeates, even in their most perfect state, are pernicious. By this means many of the diseased will be guarded against a fatal error: and as the prejudice in favour of such applications is so universally prevalent, it is hoped a few pages allotted to this subject will be deemed a most essential service to a deluded community. By removing such a pernicious partiality, the health, if not the lives of thousands, may be saved, to the great enjoyment of themselves and their relatives. Dr. Knight says very justly, "that the explication of the manner of the operation of chalybeate medicines in human bodies is grounded upon false principles, and not matters of fact; to wit, that all chalybeate preparations, in a liquid form, owe their medicinal efficacy to the metal dissolved, whether in an aqueous or spirituous menstruum, retaining its metallic texture." To avoid entering into the whole detail of this interesting argument, it is only here stated in support of the above assertion, that as mineral waters are impregnated with a combination of sulphurs, salts, and earth, their virtues cannot be properly ascribed, as they have been, to the metals which they contain. It might be further proved, that iron cannot possibly enter the blood, retaining its essential qualities; for metals in general, except mercury, are suspended in liquids in _solutis principiis_, or principles disengaged, which are thus deprived of their metallic properties. Iron, entering the body as a volatile vitriolic acid, cannot act by its specific gravity as mercury does; it therefore acts _per accidens_, and not _per se_. But admitting that waters, however impregnated with iron, are efficacious in checking all diarrhoea and other profuse evacuations, by closing the relaxed vessels, and incrassating the fluids, yet as they prove sometimes so astringent as to stop the natural secretions, the consequences are frequently cramps, dangerous convulsions, which often end in fevers, inflammations, and mortifications, their indiscriminate use should be most cautiously avoided. Chalybeates, thus contracting the least pervious glands, should not be taken in acute inflammations, or in any complaints that are attended with a quick and strong pulse, a plethora, or extravasation of humours. They are equally dangerous in all nervous contractions, or where the blood is got into the arteriolæ, or capillary vessels. Thus, instead of acting like the sanative tea, which softens, smoothes, and unbends the two constringed fibres, the vitriolic salts of this mineral water but more contract the fibrillæ, by operating like so many wedges, which ultimately tear, rend, or divide the tender filaments. It must, however, be admitted that mineral waters are very beneficial in cachexies, scurvies, jaundice, hypochondriacal and hysterical affections. Having paid this tribute to their virtues, it is evident that what is above stated respecting their pernicious effects has been dictated by candour, and with no illiberal disposition to deny their absolute virtues[3]. These few remarks have only been made in order to warn the community against a prevailing and indiscriminate use which might otherwise, in many complaints, prove at least fatal to their health, if not to their existence. And as the tea discovered by Dr. Solander possesses all the virtues of the chalybeate, without its dangerous principles, it was an immediate duty not only to warn but direct the Public in their adoption of an aliment so essential to their health, and consequently temporal happiness. [3] _Waters drank at their source are efficacious in many complaints that are not accompanied with inflammatory symptoms; but if they are drank after a long or short conveyance, their effects must be proportionably injurious instead of beneficial._ PREPARATION. As the native and exotic herbs of this tea are dried in a pure air, without any artificial means of preparation to improve their colour or increase their natural astringency, they must be free from those deleterious, corrosive, and violent contractive effects with which we have observed the general and indiscriminate use of foreign teas and mineral waters are attended. In the first part of this Essay, it was stated that foreign teas were dried upon iron, and thus produced those astringent effects we have seen to characterize chalybeate waters. It is therefore evident, that the simple preparation of these salutary herbs being free from what renders teas and mineral waters in many cases pernicious, must leave their qualities pure and unadulterated, according to the intent and principle of nature in their production. They are, therefore, found particularly free from those injurious properties which render green tea so destructive to emaciated constitutions. Instead of being, like the above foreign tea, hurtful to those worn down by a long fever, or such as have weak and delicate stomachs, their qualities are in such complaints essentially nutritious and restorative. That stimulating roughness, which foreign teas imbibe from their iron preparation, is not to be found in the sanative tea discovered by Dr. Solander; the latter is therefore very beneficial where the mucous coat of the bowels is very thin, or the ramification of the nerves numerous, extensive, and exquisitely sensible of impression. The cholic, gripes, or painful prickings of the nervous coat by the India teas, are allayed by the drinking of the sanative tea, from its tepid and lubricating nature not being perverted by any corrosive preparation. To thin and meagre bodies, which are greatly affected by green and bohea teas, the above is a most restorative aliment. The atrophy and diabetes, so frequently caused by the foreign teas, are, from the herbs of Dr. Solander's tea possessing their natural nutritious qualities uncontaminated by metallic preparation, often cured by using it as a morning and evening beverage; and the depression of spirits occasioned by green and bohea, and which induces many of its drinkers to take sal volatile, or spirits of hartshorn, is avoided by the sanative tea; for the latter is found one of the greatest and most salutary exhilarators of the nervous system. And thus those who drink it as a constant aliment, are saved from the dangers that attend rendering the blood too thin by the use of the above volatile alkalies, or drams, which are too frequently taken to avoid that lowness of spirits caused by the great, sudden, and violent contraction of the nervous fibrillæ. As the inconveniencies of the foreign teas arise from the metallic properties derived from their preparation, the advantages of the sanative tea are evidently seen to arise from the preparation being such as leaves every herb possessed of its natural and essential quality. This clearly evincing the superiority of Dr. Solander's tea to every herbal beverage, it only remains to proceed to the two remaining enquiries respecting the mode of using and the effects of this salutary combination of vegetables. The next subject, therefore, of investigation is the MANNER OF USING. As the time of drinking this tea is morning and evening, it is necessary to enquire whether its qualities are such as are calculated to suit the temporary necessities of nature at those periods. From what has been observed respecting foreign teas, it is evident that their properties are diametrically opposite to those which nature at such times requires. When the body is exhausted by insensible perspiration, the most requisite aliment is that which can equally restore the loss of the solids and the languid flow of the animal spirits. What is then taken ought therefore to be neither too heavy for the state of the unbraced system; nor too volatile, to afford a sufficient quantity of nutritive juices to the whole animal economy. Nor should the aliment be so stimulating as to disorder instead of re-establishing the equalized motion of the yet perturbed state of the animal spirits. What is then given should have the power of sedating the nervous fluids, while it disseminates through the viscera the elements of nutrition. These being the requisite properties of what is taken as a breakfast, it remains to consider whether those of the sanative tea are adequate to such indispensible purposes. In the preceding part of this enquiry, it has been found that the principal qualities of this tea are moderately astringent, balsamic, and aromatic; it is therefore evident, that, from a combination of these eminent medical principles, this tea must operate as a sedator of perturbation, a renovator of exhausted solids, and an exhilarator of nervous depression. It may therefore be used as a morning beverage with the greatest advantage, for the preservation and re-establishment of health; for never were the qualities of any aliment so particularly adapted to the necessities of the body at any stated period as those of the sanative tea are at the time of breakfast. Without loading the exhausted viscera, they afford it a sufficiency of balsamic and nutritive aliment; nor does the sanative tea, by sedating the fluttering spirits, destroy their vigour; but, on the contrary, by calming their motion, they contribute more active energy by promoting their equalized progress; and thus is the animal economy restored to the proper use and enjoyment of its functions. And in proportion as the spirits are restored to an equilibrium of motion and fluidity, the relaxed tone of the nerves is recovered, and the whole functions of man rendered capable of exercise and enjoyment. The above being stated as the advantages attending the use of the sanative tea in the morning, it is next expedient to consider what benefit is derived from the use of it in the afternoon. At this time the body is in a very different state of temperature from that of the morning. By the toil, care, study, or amusement of the former part of the day, the solids are wasted, and the fluids in a state of ferment and evaporation. Added to this, the aliment which is taken at dinner time so exhausts the animal warmth, as to leave the whole body in a state of refrigeration. What is therefore taken in this situation should be neither relaxing, constipating, nor heating; it should possess a genial warmth, a cordial assistant, and a restorative nutriment. The first should be such as to supply the deficiency of warmth which the body feels by the act of digestion, without inflaming the blood, or too greatly increasing the pulse. The second, or cordial assistant, should rather increase the powers of the body than those of the heart; for the force of the heart may be increased to the detriment of health. This is evident from a weakness of the body being the consequence of the force of the heart being increased in an inflammatory fever. And with regard to what is taken in the afternoon requiring a restorative nutriment, it is necessary that it should be light, pure, and wholesome, lest its solidity and heaviness should oppress the bowels at a time when their tone is relaxed by recent fatigue and digestion. These qualities being the most proper to produce fresh animal spirits, are the most fit to be taken when a new accession of them is necessary. It has been observed those are the most robust whose serum resembles most the white of an egg. It has therefore been most rationally concluded, that the origin of the animal spirits is from aliments capable of being changed into a similar substance, but so attenuated by incalation as to concrete by fire. For this reason the greatest support of the spirits is afforded by light and nourishing meats and drinks, which in taste and smell are even agreeable to infants. All cordials and aromatics are consequently the most proper for such purposes, and at such times, when heavier foods would impress, instead of recruiting, the exhausted solids and fluids. It is therefore Boerhaave recommends such aromatics, for the reviving and recruiting the animal spirits, as have the most pleasing taste and smell. Agreeably to this opinion, Dr. Solander employed his researches to form an afternoon beverage of such herbs as should possess all the above cardiac and balsamic qualities. The use of the sanative tea between dinner and supper operates as the most reviving and wholesome aliment that can, at such a time, be possibly taken. An enquiry having been made into the nature, preparation, and manner of using the sanative tea, there only remains to conclude this Second Part of the Essay with the consideration of its EFFECTS. From the view that has been taken of the nature, preparation, and manner of using, the salutary effects are most clearly and easily to be ascertained. As the basis of this tea is the combined principle of the most balsamic oils, nutritious salts, and animating sulphurs, which the vegetable world produces, their effects must be proportionably salutary. And as their combination is such as to correct the pernicious qualities of each other, their conjoint effect must be the most wholesome that can possibly be administered for the health of human nature. As every simple, however specific in certain cases, possesses qualities that are pernicious in other respects, it has been the first principle of physical enquiry not only to find the basis of a medicine, but to form compounds or ingredients that corrected the injurious tendency of each other. With this scientific principle Dr. Solander having composed his sanative tea, has rendered it the most general specific in its effects of any medicinal aliment. This tea affording a compound oil, which is formed of the most aromatic vegetables the earth affords, it is no wonder its effects, like honey, should approach so near a general specific. The invaluable oils, uniting with the sulphurs of the sanative tea, recruit, soften, and lubricate the juices, diminish the too great elasticity, dryness, and crispness of the nervous fibres, and afford the exhausted liquids fresh supplies. Their effects are consequently exceedingly restorative in all cases, where the force of the fibres and the vessels are too strong, the circulation too rapid, and the blood too attenuated or diminished; as it prevents the too quick action of the solids, and the too rapid motion of the blood, the body is nourished, and the mind prepared for the refreshment of sleep when the approach of night invites to repose. In spitting of blood its effects are particularly beneficial. The oil being easily detached from the earth of the plant is, in such cases, exceedingly nutritive, and, by its checking the stimulation, and sheathing the acrimony of the humours, the blood is replenished with the most healing and balsamic virtues. In pleurisies, ulcers, and abscesses of the lungs, hectic fevers, dry coughs, night sweats, and difficulty of breathing, the balsamic oil and sulphur of this tea is most salutary. The dropsical, phlegmatic, corpulent, cathetic, and all such as are in their stamina relaxed, will find the greatest relief in its constant use; and to those who are emaciated, either from hereditary or acquired disease, it is particularly beneficial. In seasons when experience informs us that the blood requires cleansing and attenuating, this tea will be of considerable service to the healthy as well as the diseased. By these means the constitution will be preserved and restored from all those chronic and acute afflictions, which are the consequences of acrimonious humours and foulness of blood. As this tea produces the effects of cleansing the stomach, promoting digestion, diluting the chyle, and invigorating the whole viscera, it should be constantly drank by those who live freely. Unlike most medicinal applications, this tea requires no previous preparation of the body. Such are its nature and progression of effects, that it first renders the body in a state suitable to receive succeeding benefits; nor is it dangerous, like mineral waters, to which persons afflicted with nervous complaints generally resort. Persons suffering acute or inflammatory diseases, or who have their vessels too greatly constringed, need not be under the apprehensions of suffering scirrhuses, or even death, which is the confluence of drinking, in such cases, mineral waters; but, on the contrary, they may expect to receive, from the use of the sanative tea, the most beneficial effects, not only in the above, but also in the gout and rheumatism, from its moderate use producing a gentle perspiration. To account for the variety of salutary effects that this valuable discovery produces, we shall now proceed to consider its operation as a medicine and an aliment, which will afford the most convincing and conclusive arguments that can be possibly adduced in favour of its sanative qualities. To consider its medicinal properties or effects, it is necessary to state in what manner it acts first upon the solids, next upon the fluids, and lastly, how it operates upon both together; for on these three principles the power and quality of a medicine solely depend. In acting upon the solids, it either alters their texture and cohesion, or, by diluting the canals, change the figure of the sides. But a medicine acting upon fluids only either alters their properties, or brings them out of the body. All medicines, however, act as well upon the solids as the fluids; for the latter can scarcely be altered without in some degree affecting the former. As all medicines derive the greatest qualities from their filling, evacuating, or altering the smallest parts, the sanative tea possesses the most restorative properties from its action upon the smallest nervous vessels, and not in the arteries, veins, glands, lymphatic and adipose vessels. Thus, as all augmentation and accretion of the greater depend on the extension of the smallest lateral vessels, which are nervous tubuli, the nutrition and restitution of what is wasted must be considerably derived from the constant use of this beverage morning and evening. From this the medicinal effects of the tea upon the solids are found to be consistent with the first of physical principles; for the nutrition of the solids, which is made by the application of any part to the place of a wasted part, is always effected in the smallest canals, of which the greater consist. And as every salutary change of the fluids is made in the smallest vessels, the sanative tea possessing the power of conveying nutrition into the most minute channels of the body, the liquids must derive from it the greatest renovation. From this combined effect upon the solids and liquids, the strength of the greater vessels is increased, and thus is the whole aggregate body invigorated; for every artery derives its energy from its sides, which are composed of the minutest vessels. To enter into a complete detail of its medicinal principles, would require a volume itself; we must therefore avoid any further enquiry of its effects as a physical remedy, in order to leave a few lines for its consideration as an aliment. The qualities of an aliment chiefly depend on their nature affording that nourishment which is proper to the time of taking and the state of the body. Indeed, without their possessing these relative properties, either meats or drinks are injurious instead of beneficial. For this reason physical necessity, more than tyrant custom, has caused a thinner aliment to be taken in the morning and evening than what forms the meals of dinner and supper. This necessity arises from the state of the body being in the morning just recovering its spirits from a comparative state of relaxation and imbecility, and in the afternoon from the stomach being enfeebled by recent digestion. That the body, immediately after sleep, is in a relaxed state, may be perceived by the perturbation the spirits experience from any surprise or violent action instantly succeeding. Fits and faintings have frequently been the consequence of persons of quick sensibilities being wakened. In such a state of relative debility, gross and solid food must oppress the spirits, and thus render the body incapable of deriving nourishment from such an untimely aliment. But if what is taken is light, pure, and apt for producing chyle, the stomach being capable of digesting it, must turn it to the most wholesome nutrition. To attain this end, foreign teas, from their lightness, have been universally adopted; but, as we have found, from their nature, how ill adapted they are to be given when the nerves are already too weak to bear their violent astringency, such should be used as are possessed of the most nutrition, without a tendency to irritate the relaxed fibrillæ. When the stomach is enfeebled by recent digestion in the afternoon, to take then another meal of solid aliment must evidently tend to depress the digestive powers, and thus prevent the body from having that nourishment it might receive from a lighter aliment. The sanative tea being found, from the preceding enquiries, to possess the most active, subtle, penetrating, and balsamic compound oils, salts, and sulphurs, which pervade, without irritation, the minutest canals, must afford that species of aliment which the body in a morning and afternoon requires. While it attenuates, it restores the tone and substance of the juices, strengthens the solids, invigorates every natural function, and thus affords the means of enjoying all the comfort that a healthy body and a happy mind can bestow. THE END. DR. SOLANDER's SANATIVE ENGLISH TEA. UNIVERSALLY APPROVED AND RECOMMENDED BY THE MOST EMINENT PHYSICIANS, IN PREFERENCE TO FOREIGN TEA, As the most Pleasing and POWERFUL RESTORATIVE, IN ALL NERVOUS DISORDERS, HITHERTO DISCOVERED. Our first aliment at breakfast, being designed to recruit the waste of the body from the night's insensible perspiration; an inquiry is important, whether INDIA TEA, which the Faculty unanimously concur in pronouncing a species of Slow Poison, that unnerves and wears the substance of the solids, is adequate to such a purpose--If it be not--the inquiry is further necessary to find out a proper substitute. If an Apozem PROFESSIONALLY approved and recommended for its nutritive qualities, as a general aliment, has claim to public attention, certainly Dr. SOLANDER'S TEA, so sanctioned, is the most proper morning and afternoon's beverage. Prepared for the Proprietor by an eminent Botanist. Sold Wholesale and Retail by the Proprietor's Agent, Mr. T. GOLDING, at his Warehouse for Patent Medicines, No. 42, Cornhill, London; and Retail by Mr. F. NEWBERY, No. 45, St. Paul's Church-Yard; Mess. BAILEY'S, Cockspur-street; Mr. W. BACON, No. 150, Oxford-street; Mr. OVERTON, No. 47, New Bond-street; and by Mr. J. FULLER, Covent-Garden, near the Hummums. Also, by the Venders of Patent Medicines in every City and Town, in England, Ireland and Scotland. Sold in Packets at 2s. 9d. and in Cannisters at 10s. 6d. each, Duty included. Liberal Allowance for Exportation, to Country Venders and to Schools. The native and exotic Plants which chiefly compose Dr. Solander's Tea, being gathered and dried with peculiar attention, to the preserving of their sanative Virtues, must render them far more efficacious than many similar Preparations, which by being reduced to Powder, must have those Qualities destroyed they might otherwise possess. A Packet of this Tea at 2s. 9d. is sufficient to Breakfast one Person a Month. DIRECTION FOR MAKING DR. SOLANDER's TEA. Two or three tea-spoonfuls of this Tea being put into a tea-pot, or a covered bason, pour boiling water upon it, and let it remain a short time in a state of infusion.--After using milk and sugar agreeably to the taste, drink it moderately warm. A few tea-cups full are sufficient for breakfast, tea in the afternoon, or any other time a person may think proper. * * * * * The native and exotic Plants which chiefly compose this Tea, being gathered and dried with peculiar attention to the preserving their Sanative Virtues, must render them far more efficacious than many similar Preparations, which, by being reduced to Powder, must have those qualities destroyed they might otherwise possess. * * * * * A CAUTION. The high estimation in which Dr. Solander's Tea is held, by the first circles of fashion, as a general beverage--the many cures it has effected--and the pleasantness of its flavor having induced several unprincipled persons to prepare and vend a base and spurious preparation under a similar title; the Proprietor, in justice to the known efficacy of this Tea, and to secure his property from further depredations, has thought proper to have an engraved copper-plate affixed to the canisters and packets of the genuine and original preparation of Dr. Solander's Sanative English Tea. This plate being entered at Stationer's Hall as the Act directs, Aug. 20, 1791, will subject such persons as imitate the same to a consequent prosecution. The Public are therefore cautioned from purchasing any article but what is distinguished by the said plate, and to observe thereon the words specified as above, of its being entered according to Act of Parliament. DR. SOLANDER's TEA. This CELEBRATED TEA is peculiarly efficacious in most inward wasting, loss of Appetite, Hysterical Disorders and Indigestion, depression of Spirits, trembling or shaking of the Hands or Limbs, obstinate Coughs, Shortness of Breath, and Consumptive Habits; it purifies the Blood, eases the most violent pains of the Head and Stomach, and is a wonderful Assuager of the excruciating pains of the Gout and Rheumatism, by promoting gentle Perspiration. By the NOBILITY and GENTRY this Tea is much admired as a fashionable BREAKFAST; being pleasant to the taste and smell, gently astringing the fibres of the stomach, and giving them that proper tensity, which is requisite to a good digestion; and nothing can be better adapted to help and nourish the Constitution after late hours, or making too free with wine. This Sanative Tea is highly esteemed in the East and West Indies, being unlike INDIA TEA, which the Faculty unanimously concur in pronouncing a species of Slow Poison that unnerves and wears the substance of the solids; on the contrary, this nourishes and invigorates the Nervous System, acts as a GENERAL RESTORATIVE CORDIAL, upon debilitated Constitutions, and is a sovereign remedy in Bilious Complaints contracted in hot climates. In the Measles and Small Pox, nothing need be given but a plenty of this Tea; drank warm at Night it promotes refreshing rest, and, as such, is a regular afternoon's beverage with many aged and infirm Persons. Being of peculiar service to children, and such who are weakly, many Parents, and others, having the care and education of Females, exclude the use of any other than this salubrious Tea. By the Studious and Sedentary, this CELEBRATED TEA is justly considered as a MENTAL PANACEA, from its sovereign efficacy in removing complaints of the head, invigorating the mind, improving the memory, and enlivening the imagination. The Proofs of Efficacy of Dr. SOLANDER'S TEA, being so numerous, would far exceed the limitation of a Pamphlet; the Public are therefore required to accept the following abridged List of Cures as Specimens: CASE I. _To the Proprietor of Dr._ SOLANDER'S TEA. HAVING long languished under a severe depression of spirits, an almost continual cough, and to all appearance, a confirmed consumption, being afflicted with violent pains in my head and breast, together with a total lassitude of body and limbs.--I was so weak and emaciated that all my friends and acquaintance apprehended, I could not survive many Weeks. In that unhappy condition, an eminent Physician recommended me to your SANATIVE ENGLISH TEA, in the use of which I persevered for several weeks, with the happiest effect, and am now perfectly cured by that salutary and invaluable Medicine. Happy in the opportunity of contributing my endeavours to alleviate the distresses of humanity, I hereby authorise you to publish my case, with my earnest recommendation of your Sanative Tea, to all persons afflicted with nervous and other consumptive disorders, and am, Sir, your humble servant, NICHOLAS SANDYS. N.B. My near relation SAMUEL SANDYS, Esq. No. 61, Berner-street, and many of my friends, will testify to the truth of the above. CASE II. Mrs. JONES, of Hammersmith, was for several years afflicted with a bilious and nervous complaint, being recommended by a friend, who (in an obstinate cough attended with spitting of blood) had experienced the peculiar efficacy of Dr. Solander's Tea, was at last persuaded to make trial of it, when in a few months she was perfectly restored to health and spirits, by the use of this celebrated Tea. CASE III. Mr. BRYANT, No. 7, King-street, Bethnal-green, for twenty years was violently afflicted with a nervous disorder, but by the constant drinking the Sanative English Tea is now enjoying a good state of health. CASE IV. CAPT. R. SMITH, of Liverpool, after a severe nervous fever, was very much afflicted with violent Pains in his breast, attended with a continual cough and excruciating head-ache, which entirely deprived him of rest, and reduced him to a mere skeleton; being persuaded to drink Dr. Solander's tea, was recovered to health and strength by that salubrious panacea. CASE V. _To the Proprietor of Dr._ SOLANDER'S TEA. FOR some Years past I had been violently afflicted with a slow nervous fever attended by a continual head-ache, a total loss of appetite, and a very bad digestion, by which I was reduced to a deplorable state of languor and dejection of spirits. After being attended by many Doctors, and taking a variety of Medicines, my husband, Mr. JOHN TOD, hearing from several persons with whom he was acquainted, of the wonderful effects your excellent Tea had done in nervous disorders, in various Families with whom, in his extensive acquaintance, he was well known, urged me much to drink the Tea; which I began in the Morning for breakfast, and in a few days I found myself much better, and was much pleased with so grateful a remedy. I continued it for some time; and I do assure you I am now entirely recovered, and enjoy a perfect state of health, without any medical assistance whatever. I am therefore prompted to send you this, in gratitude for the benefit I have received, requesting you will make what use of it you think proper, as it may be of the same benefit to others. I am, Sir, your very humble servant, FRANCES TOD. Rum and Brandy Warehouse, No. 8, Little Carter-lane, Doctor's Commons, Feb. 20, 1790 CASE VI. _To the Proprietor of the Sanative Tea._ WHEN I arrived in England some time ago, I was distressed with a severe depression of the spirits, a very violent cough, and as all my friends thought in a declining consumptive habit of body; my brother hearing the efficacy of your Sanative Tea much praised, bought me a cannister, and begged I would use it according to the directions given with it, which I did, and had a tea-pot of it standing at my bed-side every night, (for as I was very restless and very feverish) drinking it at intervals, and likewise in the morning; before it was all out I was entirely recovered, and have at this time good spirits, good appetite, and good health. I therefore recommend it much. I am, Sir, &c. MARY MULLARKY. No. 11, York-street, London-road, Sept. 29, 1792 CASE VII. _To the Proprietor of Dr._ SOLANDER'S _Sanative Tea_. A near relation of mine being afflicted with a violent nervous disorder, owing to a fright which happened to her in her lying-in, so much so, as nearly to deprive her of reason; her intellects were for some time, very much impaired, and she was reduced to a state of despondency; she was attended by many eminent physicians, and took many of her apothecary's draughts, &c. but without success, until she was persuaded to try your Sanative Tea, by several of her acquaintances, who had proved its good qualities, which she made use of six weeks, and in which time she found herself perfectly recovered from such alarming disorder. In justice to so valuable and elegant a medicine, I cannot omit giving you this information, that it may be published for the benefit of the community at large, being fully persuaded of its excellent qualities. I am, Sir, &c. RICHARD ANDREWS. No. 20, Cross-street, Surry, Oct. 16, 1792. CASE VIII. _To the Proprietor of the_ SANATIVE TEA. FOR a long time I was frequently afflicted with a nervous disorder in my head and stomach, was exceedingly ill and low spirited, and often confined to my bed; I had a variety of things prescribed for me by gentlemen of the faculty, but without effect, my disorder still returning; till your Sanative Tea was recommended to me: I resolved to try it, and it so much pleased me in taste and satisfaction of drinking, that I made it my constant morning and evening Tea, and continued it for some time, and quickly found my health better, my spirits good, and have now entirely got rid, by its means, of all my illness, and am in good health; therefore I am glad to send this information, in justice to the virtues of the Sanative Tea, recommending it to every one who may be afflicted with any such dreadful complaints I laboured under. I remain, Sir, your humble servant, MARY SMYTH, Mistress of the School. Blackfriars School, near Ludgate-Hill, Nov. 16, 1792. CASE IX. _To the Proprietor of Dr. Solander's_ SANATIVE TEA. ABOUT twelve months ago, my daughter was afflicted with violent pains in her stomach, occasioned as was supposed, by drinking strong green tea for breakfast, without eating therewith--I had the assistance of several gentlemen of the faculty, but to no purpose; as her complaint grew worse almost daily; and it was the general opinion that she was in a decline. Anxious for the safety of my child, I tried many advertised medicines without success; till seeing in the County Chronicle the many cures performed by your Sanative Tea, I wrote to a Friend in London to procure me some of it; he readily acquiesced, and sent me a few packets of the Tea as a present: In a short time her complaint was much abated, and continuing the use of it a few weeks, she was restored to perfect health:--in justice to the merits of your Tea, you have my consent to make whatever use you please of this token of acknowledgement. I remain, Sir, your obliged humble servant, FRED. BLAKELEY. Barsford, near Needham, Suffolk, March 10, 1793. CASE X. _To the Proprietor of Dr. Solander's_ SANATIVE TEA. HAVING been afflicted with obstructions, attended with a continual cough and violent pains in my head and breast--I applied to many physicians and apothecaries, without finding relief, till I drank your Sanative Tea, which has entirely cured me. I think it my duty to send you this acknowledgement, in justice to you and the Public at large. I am, Sir, &c. ANN ROYAL. No. 63, St. John street, near the Green-Walk, Christ-church, Surry, March 18, 1793. CASE XI. _To the Proprietor of the_ SANATIVE TEA. BEING much afflicted with a slow fever, very nervous, and much subject to fits, a violent oppression at my stomach, and total loss of appetite; I was continually taking physic of various descriptions, but found no relief. Having heard your Sanative Tea highly praised, I resolved to try it, and found myself in a short time much better. I have continued drinking it ever since, and at present enjoy so perfect a state of health, that I cannot sufficiently express my gratitude for the benefit I have experienced. I therefore send you this, recommending it much to every person so afflicted with illness as I was, giving you full liberty to make this known as you may think proper. I am, &c. CATHARINE CLOVER. Ormond-Place, Queen-square, Bloomsbury, March 24, 1793. CASE XII. _To the Proprietor of the_ ENGLISH SANATIVE TEA. HAVING had recourse to several medicines and prescriptions, for internal weakness and indigestion, without the desired effect, I was advised to make trial of your Sanative Tea, as a medicine. I accordingly furnished myself with two parcels, and found it very agreeable and pleasant; and in a short time I had the satisfaction of feeling the good effects of this pleasing and salutary medicine; and to confirm the services received from it, I am determined, for the future, to drink it instead of foreign teas, because I think it more grateful than any thing yet presented to the public as a stomatic; therefore in justice to your valuable discovery for the public good, you are welcome to communicate this information to the world at large; with the sincerest wishes for the general use of your excellent Tea. I am, Sir, &c. RICHARD EDWARDS. No. 37, Baldwin's-gardens, Holborn, June 13, 1793 CASE XIII. _To the Proprietor of the_ SANATIVE TEA. BEING very much afflicted with a violent head-ache for a great many years, I some time ago heard a great praise of the Sanative Tea; I tried it and thought it did me good, and by continuing the use of it, it has entirely taken away my old head-ache, and I find myself much better, and am now quite well. Indeed it has done me more good than I could expect, as the head-ache is particularly our family complaint. I likewise recommended it to my brother, James Robertson, of Bradfield, Essex, and it has had the same good effects on him. Also my sister, Mrs. Shibley, of Battle-bridge, has experienced its salutary effects; therefore in justice to so excellent a thing, I send you this, hoping others troubled with a constitutional head-ache, will make use of it. I am, Sir, your obedient servant, RATCLIFF ROBERTSON. No. 10, Great Shire-lane, Temple-bar, June 26, 1793 CASE XIV. _To the Proprietor of the_ SANATIVE TEA. ABOUT two years ago, I was attacked with a nervous disorder in my head, which violently afflicted my whole frame. I had no rest, and oftentimes, for want of sleep, at intervals, lost my senses--being much troubled with frights and startings, the disorder increased, till most of my friends expected I should soon die. I took many things without benefit, till an acquaintance recommended me to use the Sanative Tea. I began to drink it in the night, being always very thirsty; I thought in two or three nights that I was easier; I therefore continued it, and not only drank it in the night, but used it constantly, and left off drinking India tea. I gradually got better, and am now quite recovered, having got rid of head-ache, startings, &c. I therefore wish to recommend it for its excellence to all my sex; and beg you will accept of this, hoping it may be useful. I am, Sir, your humble servant, MARY SHAW. No. 24, Cross-street, St. George's-Fields, July 10, 1793. CASE XV. _To the Proprietor of Dr. Solander's Tea_. INDUCED by a friend of mine to make use of your Tea, as an excellent medicine for the loss of appetite, bad digestion, and great relaxation of the whole frame, with which I had been afflicted a long time, I have found more relief from it, than from any other medicine I have yet had recourse to, and am convinced it has qualities superior to any thing of the kind; and considering it as worthy of public attention, I give you my approbation of the services it has done me. I am, your humble servant, JOHN MIDDLETON, Pencil-maker. No. 11, Turnagain-lane, Snow-hill, July 19, 1793. CASE XVI. _To the Proprietor of Dr._ SOLANDER's TEA. HEARING of the virtues of your Tea, in nervous complaints and indigestions, and being among my friends much persuaded to try it, I soon found, by drinking it for breakfast, the good effects arising from it; your Sanative Tea having operated entirely to my wish, from its pleasing as well as its medicinal qualities. I continued to use it, at least once a day, and as a means of disclosing its virtues shall continue to recommend it in the circle of my acquaintance. Your humble servant, PETER CAPPER. No. 14, Lambeth-walk, Aug. 8, 1793. CASE XVII. _To the Proprietor of the English Sanative_ TEA. A Servant of mine having been in a continual state of pain, from what the doctors deemed a rheumatic complaint, for the space of eight months, and appearing to be of a consumptive habit of body, attended with a total depression of spirits, a perpetual cough, and extreme weakness of limbs; which threatened her dissolution. Hearing frequently of the surprising efficacy of your Sanative Tea, I bought some for her, and the happy effects it has produced, urges me strongly to speak in its great praise; therefore, I send you this, hoping her case may be of service to make the virtues of your Sanative Tea, universally known. I am, SIR, &c. JOSEPH SWALLOW. No. 3, Clarence-place, St. George's, Southwark, Aug. 20, 1793. CASE XVIII. _To the Proprietor of the_ SANATIVE TEA. BEING afflicted with a nervous head-ache, and trembling of the hands, lowness of spirits, and bad appetite, a friend of mine wished very much I would drink the Sanative English Tea; which upon drinking, instead of other Tea for breakfast, I found myself much better, and am now quite well; my hands being perfectly steady, which is of great advantage to me, I being a writing stationer; besides my appetite is good, and I feel myself in every respect so well, that I am persuaded I do good to the community, in begging you will make this publicly known. Yours, &c. J. CLARKE No. 16, Newcastle-court, Butcher-row, Temple-bar, Sept. 6, 1793. CASE XIX. _To the Proprietor of Dr._ SOLANDER'S SANATIVE TEA. FOR many years I had been violently afflicted with acute pains in my head, a nervous disorder, and lowness of spirits, and took many medicines from apothecaries, but found no benefit; till lately a friend speaking very much in praise of the Sanative Tea; it induced me to drink it, instead of other tea; and I have found it so happily relieved me, that I am induced to send you this, to recommend it for such complaints, to all nervous people. I am, &c. ROSANNAH WYNNE. No. 62, South Audley-street, Grosvenor-square, Sept. 10, 1793. CASE XX. _To the Proprietor of the._ SANATIVE TEA. I cannot with-hold my praise of your Sanative Tea, having received so much benefit by its efficacy; for having been a long time oppressed with a severe head-ache, and low spirits, and little or no appetite, I was recommended to drink your tea, which, to my great surprise, very soon restored me to health; I therefore wish this to be made public for the good of others. ALICE MASON. No. 18, Upper ground, Blackfriars-Bridge, Sept. 18, 1793. CASE XXI. _To the Proprietor of the Sanative Tea._ Mrs. HAYDEN being much affected with an oppression at her stomach, very low spirits, and other complaints attending a nervous disorder, for a long time past, after taking various prescriptions of her doctors, without effect, she was persuaded to try your Sanative Tea, which proved most salutary, and she is now perfectly restored to health; and takes this method to recommend it to Ladies troubled with the same complaints. I am, Sir, your obedient servant, ROBERT HAYDEN, Sadler. Knightsbridge, Sept. 19, 1793. CASE XXII. _To the Proprietor of Dr. Solander's_ TEA. I was a considerable time much afflicted with a nervous fever and depression of spirits, till hearing of the efficacy of your Sanative Tea, in similar complaints, induced me to make trial of it--by which, in a few weeks, I was restored to perfect health. I am, SIR, your humble servant, R. JONES. Aldersgate-street, Nov. 27, 1793. CASE XXIII. _To the Proprietor of the Sanative Tea._ MY mother having been afflicted, for some time past, with a nervous complaint and a bad head-ache, she took several medicines without effect; till a lady of her acquaintance, recommended to her your Sanative Tea, and advised her to drink it, instead of green or bohea tea; which advice she followed; and as it relieved her of those complaints, I send you this, in order that the good qualities of this Tea may be known to those afflicted with similar complaints. I am, SIR, Your obedient servant, GEORGE QUIN, Hydrometer-maker. No. 12, London-road, Sept. 19, 1793. CASE XXIV. _To the Proprietor of the_ SANATIVE TEA. SOME time ago being recommended to drink your Sanative Tea for a troublesome head-ache, and a nervous disorder in my stomach, I am so pleased with its good qualities, and efficacy, in removing those complaints, that I am induced to recommend it as a restorative in such cases. I am, &c. WM. FILBY. No. 3, Pilgrim-street, Ludgate-hill, Oct. 1, 1793. CASE XXV. _To the Proprietor of the_ SANATIVE TEA. MY business obliging me for many years to be concerned in spirituous liquors, and under the unavoidable necessity of drinking too much, I have suffered greatly from the ill effects of the same; till recommended to drink your Sanative Tea, which after a little time did me so much good, that I am induced to wish that every Person would drink the Tea who have suffered the same infirmities from the too frequent use of spirituous liquors. I therefore send you this, in hopes others may be benefited as I have been. I am, SIR, &c. JOSEPH WELLS. Guy Earl of Warwick, Upper Ground, Blackfriars-road, Oct. 7, 1793. CASE XXVI. _To the Proprietor of the Sanative Tea._ ABOUT six weeks ago, I was attacked with a violent sore throat, and fever, being attended by my apothecary, and taking a number of medicines which he sent me, a physician was advised to be called in, but nothing they prescribed did me any good, and the doctor gave me up as entirely lost. I was then pressed by a relation to drink a quantity of the Sanative Tea, which I immediately did, and continued thro' the night; I found, after a long sleep, that I was much better: I therefore continued it for a day or two afterwards, and I was still better and better; and in the space of three weeks, I found myself restored to perfect health. I therefore recommend it strongly to all who may be attacked in the same manner, and am most assuredly convinced that the Sanative Tea contains many efficacious and excellent properties, from the great benefit I have so astonishingly experienced by it. I am, SIR, &c. SAMUEL ROBINSON. No. 15, Clifford's-Inn, Oct. 8, 1793. CASE XXVII. _To the Proprietor of Dr. Solander's_ TEA. YOUR Sanative Tea being recommended to me for a nervous disorder and a consumptive habit of body, with which I was afflicted a considerable time, I accordingly gave it a trial, and found myself in a short time so much better, that I continued to drink it regularly, and am now in exceeding good health. In gratitude to so excellent a remedy, I send you this acknowledgement, and am, SIR, your humble servant, JOHN LAMB. Clifford's-Inn, Oct. 12, 1793. CASE XXVIII. _To the Proprietor of Dr. Solander's_ TEA. FOR some years past, I have been afflicted with a nervous disorder, attended with a bad head-ache, and violent spasms in the stomach. I was for a long time attended by an apothecary, and took much medicine, till taking to drink the Sanative Tea, which I had heard was sold in Cornhill, it did me much good, and so pleased me in taste, that I continued the use of it, and am now quite well. You may as you think fit, make use of this my poor praise. I am, SIR, your humble servant, JOHN WANNOCK. No. 2, Fountain-court, Cateaton-street, Oct. 14, 1793. CASE XXIX. _To the Proprietor of the Sanative English_ TEA. I was suddenly seized with a violent fever, and attended by a physician; but grew worse. My friends, on enquiry the next day, found me very bad; and so I remained the whole of that night; in the morning a neighboring gentlewoman stepped in, made me some of your Sanative Tea; which as she afterwards informed me, I drank greedily, and asked for more, which was given me. I then fell into a pleasing sleep, and on waking found myself so refreshed and well, that I am determined to drink it constantly. In gratitude for the benefit I have experienced from your Tea, you may depend upon my recommendation and custom. I am, SIR, your most humble servant, GEORGE BROWN. White Lion-street, Pentonville, Islington, Oct. 16, 1793. CASE XXX. _To the Proprietor of Dr._ SOLANDER'S TEA. BEING afflicted with a violent head-ache, a considerable time, till hearing of the Sanative Tea having cured many persons of that complaint, I was induced to make trial of it, and accordingly sent for some, which I liked so well, that I continued to drink it every morning for breakfast; and I declare, since drinking that Tea and leaving off green tea, I have been entirely freed from my former complaint--If therefore this my acknowledgement of its efficacy should induce any of my sex, who are so liable to that, so general a disorder, I don't doubt of its doing them as much service as I have experienced. I am, SIR, your humble servant, E. MACKRILL. No. 1, Basing-lane, Nov. 21, 1793. CASE XXXI. _To the Proprietor of the English Tea._ IT is with the utmost pleasure I inform you, that my sister who has lingered these eight months under a decline of the most alarming kind, is now perfectly restored to health by drinking frequently and regularly your Sanative English Tea. I am, SIR, your respectful servant, T. I. UPTON, Watch-maker. No. 8, Bell-yard, Temple-bar. Dec. 15, 1793. CASE XXXII. _To the Proprietor of Dr. Solander's Tea._ IT is the duty of every individual member of society, whose health may be renovated by the use of any medicine, freely to communicate its efficacy for the public good, in order that it may be better-known and disseminated amongst his fellow-creatures.--Being from the nature of my profession (my inclination perhaps also conducing that way) necessarily accustomed to a sedentary life, I became the unhappy victim of all those horrible maladies incident to a debility of the nervous system, augmented by inattention to myself, accompanied with a depression of spirits, verging to an almost absolute despondency. A gentleman, whose goodness and philanthropy eminently characterise him, recommended to me Dr. Solander's Tea, and happily by the use of it I have experienced the most unspeakable relief, and my health is completely re-established, my nerves have assumed their natural tone, and my animal spirits that hilarity they formerly possessed. With all the fervor of gratitude for the salutary effects of this incomparable Tea, I sincerely recommend its use to those who may be afflicted in the same way. I am, SIR, &c. BUTLER FITZGERALD. Attorney at Law and Solicitor in Chancery. Dec. 27, 1793. CASE XXXIII. _To the Proprietor of the Sanative_ TEA. I was for some time supposed to be in a decline, and medicine had no effect, till seeing an advertisement of a cure, performed by your Sanative Tea, in a case similar to my own, I made trial of it, and received so much benefit from its use, that I take this opportunity to acknowledge its merit in having restored me to perfect health. I am, SIR, your humble servant, BENJAMIN BAKER. Clifford's Inn Coffee-house, Jan. 3, 1794. CASE XXXIV. _To the Proprietor of Dr. Solander's Tea._ TWO of my children being very ill, I was recommended to try Dr. Solander's Tea, which in a short time did them so much good, that I am induced to send you this, believing it to be a most excellent remedy for many disorders. I am, SIR, your most obedient servant, E. ALLEN. No. 13, Cross-street, Hatton-garden, Feb. 2, 1794. CASE XXXV. _To the Proprietor of the Sanative English Tea._ HAVING been for a long time troubled with a bad cough, violent cold, a poor appetite, and in a very low nervous way; I took much physic, but found no relief; till several of my acquaintance speaking greatly in praise of the Sanative Tea, and recommending it particularly, I drank it for some time, and finding it do me so much good, I continued the use of it, and am now perfectly restored to health. I therefore send you this acknowledgment of its efficacy. I am, SIR, your most obedient servant, JOHN WHEELER. No. 7, Lamb's Conduit-passage, Red Lion-square, Feb. 18, 1794. CASE XXXVI. _To the Proprietor of Dr._ SOLANDER'S TEA. ONE of my daughters being lately very ill with an intermitting head-ache, a nervous fever, and seemingly in a decline, at the particular desire of a friend, I was induced to buy some of the Sanative Tea, which she continued to drink for some time, and I am happy in this opportunity to acknowledge that it has perfectly recovered her. I am, SIR, your obliged humble servant, JAMES GENT. No. 14, Watling-street, May 2, 1794. CASE XXXVII. _To the Proprietor of the Sanative English_ TEA. BEING much afflicted with violent pains in my stomach and bowels, attended with a loss of appetite, I was recommended to try your English Tea, which, by the time I had taken three packets, restored me to perfect health. I therefore send you this as a testimony of its virtues. And am, Sir, your humble servant, W. JORDAN. The Corner of Harpur-street, Red Lion-square, May 8, 1794. CASE XXXVIII. _To the Proprietor of the English Tea._ I was a long time afflicted with a nervous disorder, attended with such lowness of spirits, that at times rendered me incapable of business--By the advice of a friend I made trial of your Tea, which entirely removed my complaint, and I now enjoy a good state of health. I remain, SIR, your humble servant, WM. FAIRCLOTH. No. 50, Little Russell-street, near Duke-street, Bloomsbury, May 12, 1794. CASE XXXIX. _To the Proprietor of Dr._ SOLANDER'S TEA. HAVING been a considerable time afflicted with a nervous head-ache, attended with violent pains in my stomach, for which I took several medicines without experiencing any beneficial effect; being tired of such, I bought some of your Sanative Tea, which by using a short time, I experienced such a material change in my complaint, as induced me to continue it, and am now free from my former pains and nervous affections. I remain Sir, your obedient servant, RICHARD LOVEDAY. No. 105, Bermondsey-street, May 20, 1794. CASE XL. _To the Proprietor of Dr. Solander's Sanative_ TEA. MY wife being much afflicted with a nervous complaint, a bad appetite, and depression of spirits, she was recommended to drink the English Tea, which in a short time restored her to health--I therefore send you this acknowledgment of its merit. I am, Sir, your obedient servant, R. CLARKE. No. 9, Ward's Place, Islington, June 18, 1974. CASE XLI. _To the Proprietor of Dr._ SOLANDER'S TEA. HAVING heard your Sanative Tea spoke of with much praise, and it being recommended to me by a friend who had experienced its efficacy in eruptions of the skin--I was induced to make trial of it to my daughter who had frequently been troubled with a similar complaint, and am happy to inform you, that she has received much benefit from its use, and make no doubt that in a short time it will have the desired effect so long wished for. And am, Sir, your humble servant, JOHN ROBERTS. Prospect-Place, Newington, Surry, June 30, 1794. CASE XLII. _To the Proprietor of the English Tea._ BEING in the Liquor Trade and liable to live irregular, I contracted a violent pain and trembling of my limbs, which often rendered me incapable of attending to business. By taking your Tea at night and for breakfast, it has entirely removed my complaint. I therefore send you this as a testimony of its good qualities. I remain, SIR, &c. JAMES RAVERTY. No. 12, Cross-street, Hatton-Garden, July 28, 1794. CASE XLIII. _To the Proprietor of Dr. Solander's Tea._ I was a considerable time afflicted with a consumptive cough and inward wasting which induced me to have recourse to many gentlemen of the faculty, without receiving any benefit from their advice or medicine. At last I was recommended to try your Sanative Tea, and am happy to inform you, that a few packets of it entirely removed my cough, and at present find myself in as good a state of health as ever I enjoyed. I am, SIR, &c. THOMAS GALLANT. No. 10, Peter-lane, West Smithfield, Aug. 4, 1794. CASE XLIV. _To the Proprietor of the Sanative Tea._ I have been for ten years very much afflicted with a rheumatic gout for which I have taken much medicine without being relieved; fortunately, I was advised last March to try Dr. Solander's Tea; the first two packets I took, greatly eased my pains; and the three next parcels cured me. Since the pains not returning, you have my authority to make this public for the good of society. I remain, SIR, &c. JAMES JOHNSTON. Lambeth-Butts, 12th August, 1794. CASE XLV. _To the Proprietor of Dr. Solander's_ SANATIVE TEA. HAVING for a long time suffered greatly with a severe bilious complaint, I was persuaded to make trial of your Sanative Tea, from which I have experienced such good effects as induces me to recommend it to such who are afflicted with a similar disorder. I am, &c. RACHAEL JAMES. Aug. 12, No. 2, Cloysters, near Smithfield. CASE XLVI. _To the Proprietor of Dr._ SOLANDER'S TEA. I should not think I discharged my duty to the public, were I to conceal for a moment the great benefit I have received from Solander's Tea, as well as two of my children, who were weakly for some months, after the measles. My own case was violent trembling of my hands, attended with lowness of spirits, for which I took various prescriptions from many eminent of the faculty, without any visible benefit, till by the advice of one of them, I took to drink your Tea, which in a few weeks entirely cured me. Finding it so efficacious, and withal so pleasant to the taste, I gave it to my children to drink, who I am happy to say are perfectly recovered. I remain, SIR, &c. WM. HOSKINS Croydon, Aug. 13, 1794. CASE XLVII. _To the Proprietor of the English Sanative Tea._ BEING long afflicted with a nervous complaint, and great depression of spirits, I was advised to try the Sanative Tea, from which I received so much benefit, as induces my recommending it as a pleasant and comfortable remedy. I am, SIR, &c. ARABELLA DEVROAX. No. 49, Gloucester-street, Queen-square, Bloomsbury, Aug. 13, 1794. CASE XLVIII. _To the Proprietor of the Sanative Tea._ IN justice to your Sanative Tea, I approve of its utility in nervous hysterical disorders and lowness of spirits, having seen its good effect in cases under my own inspection. I also approve of it for children in the measles. I am, SIR, your humble servant, &c. JAMES FELL, Surgeon and Apothecary. No. 36, Pratt's place, Camden Town, St. Pancras, Aug. 14, 1794. CASE XLIX. _To the Proprietor of Dr._ SOLANDER'S TEA. HAVING been for several years troubled with violent nervous head-aches, I had recourse to many remedies without effect, till I tried the Sanative Tea, a few packets of which effectually cured me. I remain, SIR, &c. M. LAWSON. No. 7, New Compton-street, Aug. 16, 1794. CASE L. _To the Proprietor of Dr. Solander's Sanative Tea._ IN gratitude for the benefit I have received from your Tea, I acknowledge its having recovered me from a bilious and nervous disorder with which I was afflicted. I am, SIR, &c. ANN MARTIN. Pitt-street, Blackfriars, Aug. 18, 1794. CASE LI. _To the Proprietor of Dr. Solander's_ TEA. I was for some years attacked with a violent cough, which threatened a consumption, for which I tried several medicines in vain, till I used your Sanative Tea, which has effectually cured me. I am, SIR, &c. CATHARINE BROWNE. Blewit's-buildings, Fetter-lane, Aug. 25, 1794. CASE LII. _To the Proprietor of Dr. Solander's Sanative English Tea._ HAVING been much troubled with a nervous disorder, attended with a sick head-ache, particularly after breakfast and tea: I was strongly advised to try your English Tea, which by persevering in its use, has recovered me from my complaints. I remain, SIR, your's, &c. F. MARSHALL. Duke's-row, Somers Town, Sept. 27, 1794. CASE LIII. _To the Proprietor of Dr. Solander's_ ENGLISH TEA. BEING long afflicted with a slow nervous complaint, that brought on such a debility of my frame as rendered me incapable of my business; I was persuaded by a friend to the use of the Sanative Tea, and purchased two packets, from which I found great relief, and by continuing its use, am perfectly restored to health and strength. I am, SIR, &c. H. I. DOBSON. No. 62, Kingsland-road, Oct. 16, 1794. CASE LIV. _To the Proprietor of Dr. Solander's Tea._ YOUR Sanative Tea having cured me of a violent bilious complaint with which I had been afflicted above six months, induces me to send you this acknowledgement of its efficacy. I am, Sir, &c. WM. LANE. Hackney Terrace, Oct. 27, 1794. CASE LV. _To the Proprietor of Dr. Solander's Sanative Tea._ BEING for some time past afflicted with a weakness at my stomach, attended with a violent pain in my head, I was recommended to make trial of your Sanative Tea, which has removed my complaints, and I would wish to recommend it to others for the same disorder. I remain, Sir, your humble servant, H. MEIRICK. Shore-place, Hackney, Dec. 3, 1794. CASE LVI. _To the Proprietor of Dr. Solander's Sanative_ ENGLISH TEA. MY daughter being afflicted with violent pains in her head and stomach, I purchased some of your Tea, which has entirely relieved her from her complaints. I am, Sir, &c. JAMES BENNETT. Bagnigge Marsh, opposite the Bull, Dec. 10, 1794. CASE LVII. _To the Proprietor of Dr. Solander's_ TEA. BEING greatly troubled with a weakness of stomach, indigestion and loss of appetite, I was strongly recommended to try the Sanative Tea, which has had so good an effect in restoring me to health, that I wish to be the means of promoting the more general use of it in all complaints of that nature. I am, Sir, &c. L. FEGAN. No. 2, Union-row, London Road, St. George's Fields, Dec. 30, 1794. CASE LVIII. _To the Proprietor of the_ ENGLISH TEA. SIR, MY daughter being in a poor state of health, in consequence of a weak and bilious Stomach, I was advised to try your Sanative Tea, which produced so good an effect, that I take this opportunity of acknowledging it, and am, SIR, Your humble Servant, JAMES JARVIS. No. 21, Chapman-street, New Road, St. George's in the East, Feb. 18, 1795. CASE LIX. _To the Proprietor of Dr._ SOLANDER'S SANATIVE TEA. SIR, BEING greatly afflicted with a violent head ach and lowness of spirits, I was recommended to the use of Dr. SOLANDER'S TEA, which effectually cured me, I am, SIR, Your obedient servant, EVAN EVANS. No. 7, Winsay-row, St. George's-Fields, March 29, 1795. CASE LX. _To the Proprietor of Dr._ SOLANDER'S TEA. SIR, THE considerable benefit I have received from your Sanative Tea in a nervous disorder, with which I was afflicted, induces me to send you this acknowledgement of it's merit, and am SIR, Your very humble servant, JOHN RICHARDSON. Church-street, Mile End, April 3, 1795. CASE LXI. _To the Proprietor of Dr._ SOLANDER'S ENGLISH TEA. SIR, YOUR Sanative English Tea, as a corrector of a weak and bilious stomach, attended with loss of appetite, with which I was long afflicted, has proved so peculiarly efficacious, that I wish it was more generally known by such as are troubled with that too common and cruel complaint, I am, SIR, Your most humble servant, RICHARD COX. No. 8, Paradise-street, Finsbury-square, April 12, 1795. CASE LXII. _To the Proprietor of Dr._ SOLANDER'S TEA. SIR, BEING troubled with a depression of spirits in consequence of a bilious complaint and indigestion, in justice to the merits of your Tea in removing the phlegm from my stomach, and enlivening my spirits, I send you this acknowledgment of its virtues. I am, Sir, Your humble Servant, ROBERT GRIBBLE. Portland Place, Walworth, July 4, 1795 CASE LXIII. _To the Proprietor of Dr.._ SOLANDER'S TEA. SIR, AFTER a long and severe illness my brother was afflicted with a nervous complaint, attended with lowness of spirits; being advised to drink your celebrated Tea, he has experienced so much benefit from its use, that it is but justice to acknowledge its efficacy. I am, Sir, Your most humble servant, JAMES GILBERT. Charles Street, Whitechapel. CASE LXIV. _To the Proprietor of the_ ENGLISH TEA. SIR, I was a considerable time much afflicted with a bilious complaint and very nervous, till fortunately hearing of the many Cures performed by your Sanative Tea, in similar complaints, induced me to make trial of it, and to persevere in its use. I now find myself so perfectly restored to health, that I shall embrace every opportunity to recommend it in the circle of my acquaintance. I am, Sir, Your obedient servant, WILLIAM MARSH. Seward Street, Old Street Road. July 20, 1795. CASE LXV. _To the Proprietor of the_ SANATIVE TEA. SIR, I have the satisfaction to inform you, that I have just cause to approve your Sanative Tea, from its having cured me of a severe nervous head-ache, after the unsuccessful prescriptions of several of the faculty. I am, Sir, Your most obliged servant, BARBARY STARR. No. 6, Golden Lane, Barbican. August 17, 1795. CASE LXVI. _To the Proprietor of the_ SANATIVE TEA. SIR, A friend of mine having drank your Sanative Tea, and approved it, I was induced to try it, and have experienced its efficacy in a bilious complaint, I am, Sir, Your humble servant, ALLAN WILSON. Corn Chandler, &c. Tottenham Court Road, May 15, 1795 CASE LXVII. _To the Proprietor of Dr._ SOLANDER'S ENGLISH TEA. SIR, IN the course of my practice I have had several opportunities to observe the sanative efficacy of your English Tea, in nervous and bilious cases; I also approve of its use in hysterical disorders and lowness of spirits, and shall recommend for such. I am, Sir, Your humble servant, THOMAS LANGFORD, Apothecary. Strand, near Exeter Change, October 16, 1795. CASE LXVIII. _To the Proprietor of the_ SANATIVE TEA. SIR, FROM the benefit I have experienced in drinking your Sanative Tea for a bilious complaint, bordering on the jaundice, I send you this acknowledgment of its merit. I am, Sir, Your obedient servant, CHARLES WARWICK. No. 17, Baker's Buildings, Old Bethlem, Nov. 25, 1795. CASE LXIX. _To the Proprietor of the_ ENGLISH TEA. SIR, MY apothecary, Mr. Thomas Langford, of the Strand, having prescribed my drinking Dr. Solander's Tea for a nervous fever and head-ache with which I was afflicted, I persevered in its use some time, and am now happily restored to health by that pleasant remedy. I am Sir, Your humble servant, C. RICHARDSON. No. 9, Mount Row, opposite the Paragon, Deptford Road, Nov. 14, 1795. CASE LXX. _To the Proprietor of Dr._ SOLANDER'S TEA. SIR, I approve of your English Tea as a general beverage, particularly in nervous hysterical cases, and for children in the measles and small-pox, and shall recommend for such in the course of my practice. I am, Sir, Your humble servant, O. FAIRCLOUGH, Surgeon, &c. Beaumont Street, Portland Place, Jan. 25, 1796. T. GOLDING, Wholesale Agent to the Proprietor of this TEA, respectfully informs the Nobility, Gentry, and the Public in general, that for convenience of the Country, it is appointed to be sold by _Mr._ And by one principal Vender of Medicines in every other City and Town in England, Ireland, and Scotland. The native and exotic Plants which chiefly compose this Tea, being gathered and dried with peculiar attention to the preserving their Sanative Virtues, must render them far more efficacious than many similar Preparations, which, by being reduced to Powder, must have those qualities destroyed they might otherwise possess. * * * * * _A CAUTION._ The high estimation in which Dr. Solander's Tea is held, by the first circles of fashion, as a general beverage--the many cures it has effected--and the pleasantness of its flavour having induced several unprincipled persons to prepare and vend a base and spurious preparation under a similar title; the Proprietor, in justice to the known efficacy of this Tea, and to secure his property from further depredations, has thought proper to have an engraved copper-plate affixed to the canisters and packets of the genuine and original preparation of Dr. Solander's Sanative English Tea. This plate being entered at Stationer's Hall as the Act directs, August 20, 1794, will subject such persons as imitate the same to a consequent prosecution. The public are therefore cautioned from purchasing any article but what is distinguished by the said plate, and to observe thereon the words specified as above, of its being entered according to Act of Parliament. DIRECTIONS FOR MAKING DR. SOLANDER's TEA. TWO or three tea-spoonfuls of this Tea being put into a tea-pot, or a covered bason, pour boiling water upon it, and let it remain a short time in a state of infusion.--After using milk and sugar, agreeably to the taste, drink it moderately warm. A few tea-cups full are sufficient for breakfast, tea in the afternoon, or any other time a person may think proper. CONTENTS. IN THE INTRODUCTION. 1 Health or Disease, greatly depend on the Choice of salutary or unwholesome Tea. 2 Dreadful Afflictions of nervous Disorders caused by foreign Tea. 3 The Manner of India Tea affecting the Constitution. * * * * * IN THE ESSAY ON TEAS. 1 Foreign Teas frequently cause an Atrophy or Consumption. 2 The acrimonious Effects of foreign Teas explained. 3 Foreign Teas not only impoverish, but corrupt the Blood. 4 Palsy caused by drinking foreign Teas. 5 Narcotic Salts in foreign Teas, very injurious. 6 Foreign Teas a chief Cause of all windy Complaints. 7 Opinions of different celebrated authors on foreign Teas. * * * * * IN THE MANNER OF USING. 1 The Use of foreign Teas has entirely changed the Constitution of the Europeans, within the last Century. 2 Dr. Priestley's physical Experiment on foreign Teas. 3 Dr. Hugh Smith's Opinion of their injurious Effects. 4 Tissot's Opinion of their pernicious Qualities. 5 Symptomatic Effects and Diseases caused by using them. 6 Sir Hans Sloane's British and Dr. Solander's English Tea considered. 7 Effects of Coffee and Chocolate. 8 Virtues of Dr. Solander's Sanative Tea, proved by physical Analization. 9 Aromatic Nature of the Sanative Tea. 10 The sanative Manner of its acting on the Constitution. 11 Dr. Solander's Tea superior to Chalybrates, in all nervous Complaints. * * * * * IN THE PREPARATION OF THE SANATIVE TEA. 1 How the natural and nutritious Qualities of the respective Plants are preserved, &c. &c. * * * * * MANNER OF USING THE SANATIVE TEA. 1 The Qualities of the Plants peculiarly adapted to the Time of using them, so as to prove the most salutary of any Morning or Evening Beverage whatever. The Whole concludes with a brief physical Demonstration of their beneficial and restorative Effects on the Constitutions of all Ages who use them instead of foreign Teas. * * * * * The native and exotic Plants which chiefly compose Dr. Solander's Tea, being gathered and dried with peculiar Attention, to the preserving of their sanative Virtues, must render them far more efficacious than many similar Preparations, which by being reduced to Powder, must have those Qualities destroyed they might otherwise possess. A Packet of Dr. Solander's Tea at 2s. 9d. is sufficient to breakfast one Person a Month. 
23729	----	* * * * * +--------------------------------------------------------+ | Transcriber's Note: | | | | Inconsistent hyphenation and archaic spelling in | | the original document has been preserved. | | | | Obvious typographical errors have been corrected. | | For a complete list, please see the end of this | | document. | | | +--------------------------------------------------------+ * * * * * ON THE LUNAR CAUSTIC. AN ESSAY ON THE APPLICATION OF THE LUNAR CAUSTIC, IN THE _CURE OF CERTAIN_ WOUNDS AND ULCERS. BY JOHN HIGGINBOTTOM, _NOTTINGHAM_, MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF LONDON. LONDON: PRINTED FOR LONGMAN, REES, ORME, BROWN, AND GREEN, _PATER-NOSTER ROW_. 1826. T. WHEELHOUSE, PRINTER, NOTTINGHAM. TO MY BROTHER-IN-LAW, MARSHALL HALL, M.D. F.R.S.E. &c. &c. THIS LITTLE WORK IS INSCRIBED WITH GREAT AFFECTION. _Nottingham, Jan. 6, 1826._ PREFACE. The following pages are presented to the medical public with very humble pretensions. It is chiefly with the minor accidents or diseases that they have to do; but I shall not consider that I have laboured in vain, if I am enabled to mitigate even these little evils of human life. In these prefatory observations, however, I would suggest the question whether the caustic may not be employed with benefit even in some of the severer diseases to which the human frame is liable. Indeed I consider the investigation as only just begun, and many other uses of the lunar caustic, besides those detailed in the following pages, have suggested themselves to me. May not the caustic, for instance, be of greater efficacy, because of greater power and of quicker operation, than ordinary blisters, in some internal diseases? It is repeatedly stated hereafter, that the application of the lunar caustic is a means, in certain circumstances, of subduing external inflammation. Might it not, on this principle, be of service in the treatment of some of the internal phlegmasiæ? It may be observed, that the lunar caustic may be regarded, almost without further trial, as an effectual preventive of those cases of irritative fever which arise from local injuries, and probably of the effects of poisoned wounds in general. I would not, however, in the latter cases, fail to render "sure doubly sure" by free excision. Might not an adherent eschar be easily formed in those cases of compound fracture in which the external wound is of moderate size, so as effectually to exclude the external air and prevent cutaneous inflammation, and in more respects than one, to reduce the case to the state of a simple fracture? This object, if attained, would be important indeed, and I hope the suggestion will be submitted to the most assiduous and cautious trial. I can have no doubt that the use of the lunar caustic admits of being still further extended; and, as I intend to pursue the inquiry, I hope at some future period to publish something more worthy of the attention of the medical public. In the mean time, the plans hereafter suggested must not be adopted without that degree of care, attention, and perseverance, which are obviously necessary to render them successful. CONTENTS. CHAPTER I. PAGE ON HEALING BY ESCHAR 1 I. _Of the Adherent Eschar_ 3 II. _Of the Unadherent Eschar_ 14 III. _On the Treatment by Eschar and Poultice_ 21 CHAPTER II. OF THE APPLICATION OF THESE MODES OF TREATMENT TO DIFFERENT CASES 24 I. _Of Punctures, Bites, &c_ 24 II. _Of Bruised Wounds_ 64 III. _Of Ulcers_ 82 IV. _Of some Anomalous cases_ 120 CHAPTER III. OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE 130 CHAPTER I. ON HEALING BY ESCHAR. Having been led, by several circumstances, to try the effects of the Lunar Caustic in the treatment of Wounds and Ulcers, and having great reason, from these trials, to think that this remedy may be used with much advantage far more extensively than has hitherto been done, I lay the results of my experience before my medical brethren. A very natural mode of healing certain wounds and ulcers, is by scabbing; but this mode of treatment is attended by many disadvantages, as will be pointed out shortly; yet it may be supposed to have suggested to me some of those trials of the treatment by eschar, which I am about to detail. I. ON THE ADHERENT ESCHAR. It appears scarcely necessary to describe the immediate and well known effects of the application of the lunar caustic to the surface of a wound or ulcer. It may, however, be shortly observed that the contact of the caustic induces, at first, a white film or eschar which, when exposed to the air, assumes in a few hours a darker colour, and at a later period, becomes black; as the eschar undergoes these changes of colour it gradually becomes harder and resembles a bit of sticking plaster; in the course of a few days, according to the size and state of the wound, the eschar becomes corrugated and begins to separate at its edges, and at length peels off altogether, leaving the surface of the sore underneath, in a healed state. In the formation of this eschar several things require particular attention. The application of the caustic should be made over the whole surface of the sore; and indeed no part requires so much attention as the edges; to make a firmer eschar the caustic should even be applied beyond the edge of the wound, upon the surrounding skin, for the eschar in drying is apt to contract a little, and in this manner may leave a space between its edges and that of the adjacent healthy skin. At the same time, much attention must be paid to the degree in which the caustic is applied. In cases of recent wounds unattended by inflammation, it may be applied freely; but when inflammation has come on, too severe an application of the caustic induces vesication of the surrounding skin, and the edges of the eschar may in this manner also be loosened and removed. If every part is touched, a slight application of the caustic is generally sufficient. The importance of avoiding all causes which might detach the edges of the eschar will be apprehended by the following interesting observation, which I have been enabled to deduce from very extensive trials of the caustic; it is, that, in every instance in which the eschar remains adherent from the first application, the wound or ulcer over which it is formed, invariably heals. Not only the cause just mentioned, but every other by which the eschar might be disturbed, must, therefore, be carefully avoided; and especially, as the eschar begins to separate from the healed edges of the sore, it should be carefully removed by a pair of scissors. To the surface of the wound the eschar supplies a complete protection and defence, and allows the healing process to go on underneath uninterruptedly and undisturbed. It renders all applications, such as plasters, totally unnecessary, as well as the repeated dressings to which recourse is usually had in such cases; and it at once removes the soreness necessarily attendant on an ulcerated surface being exposed to the open air. In many cases too, in which the patients are usually rendered incapable of following their wonted avocations, this mode of treatment saves them from an inconvenience, which is, to some, of no trifling nature. It has already been stated how important it is that the eschar should be preserved adherent. To secure this still more effectually, I have found it of great utility to protect it by a portion of gold-beater's skin. The skin surrounding the wound is simply moistened with a drop of water, and the gold-beater's skin is then to be applied over it and over the eschar, to which it soon adheres firmly, but from which it may be removed at any time, by again moistening it for a moment with water; the same bit of gold-beater's skin admits of being again and again reapplied in the same manner. The other circumstances which render the eschar unadherent will be mentioned hereafter. In the mean time the fact stated p. 6, will sufficiently establish the propriety of treating distinctly of the adherent eschar. I now proceed to mention some other effects of the application of the caustic. The first is that, in cases in which there would be much and long continued irritability and pain, as in superficial wounds along the shin, all this suffering, and its consequences in disabling the patient, are completely avoided. A blush of inflammation forms around the eschar, but this gradually subsides without any disagreeable consequences, and the inflammation which would otherwise have been set up is entirely prevented by the due formation of the eschar. If inflammation be previously established, it is increased, at first, by the application of the caustic. But if this inflammation be not severe, and if the eschar remain adherent, all inflammation, both that induced by the application of the caustic, and that existing previously, entirely subsides. When the previous inflammation round the ulcer is considerable, however, the application of the caustic would induce vesication, and it should in such a case of course be avoided, and another mode of treatment to be described hereafter must be adopted. I would introduce in this place some observations on the comparative effects of healing by eschar and by scabbing. On the subject of scabbing I must refer my reader to the well known work of Mr. John Hunter. The advantage of healing by eschar over that by scabbing is quite decided. By comparative trials, I have found that whilst the scab is irritable and painful, and surrounded by a ring of inflammation, the adherent eschar is totally free from pain and inflammation; and that whilst the scab remains attended by inflammation and unhealed, the eschar is gradually separating, leaving the surface underneath completely healed. To these observations I may add that the success of the plan of healing by eschar is infinitely more certain as well as more speedy than that by scabbing. I shall, in conclusion, briefly recapitulate the advantages of this mode of treatment. In the first place, it will be found far more efficacious and speedy than any other; secondly, it has the great advantage of saving the patient much suffering and inconvenience; and thirdly, it renders the repeated application of dressings and ointments quite unnecessary. Its utility is extremely great, therefore, where the time of the poor, the expense of an establishment, and the labours of the medical officer, as well as the sufferings of the patient, require to be considered; and it will I imagine be found of no little advantage, in all these respects, in many cases which are incident to the soldier and sailor. II. ON THE UNADHERENT ESCHAR. The eschar is generally adherent in cases of recent injuries, and in small ulcers, when they are nearly even with the skin and attended by little inflammation. In other cases the eschar is too apt to be unadherent, and this arises from the formation of pus or of a scab underneath. If the eschar be unadherent by subjacent pus, it may be ascertained in the space of from twelve to twenty-four hours; the centre is generally observed to be raised and to yield to the pressure of a probe; sometimes the subjacent fluid has partly escaped by an opening at the side of the eschar. When a scab forms underneath the eschar, which does not happen except the fluid has been allowed to remain too long under the eschar without being evacuated, there are pain and some inflammation, the eschar does not separate, but remains long over the sore, and there is no appearance of healing. When it is ascertained that there is fluid underneath the eschar, a slight puncture is to be made by the point of a penknife, the fluid is to be gently pressed out, and the caustic is then to be applied to the orifice thus made. The same plan is to be adopted if the fluid ooze out at the edge of the eschar; it is to be fully evacuated by pressure, and the orifice is to be touched with the caustic. The healing process goes on best however when the orifice is in the centre of the eschar. After this treatment the eschar occasionally remains adherent, but more frequently the fluid requires to be evacuated repeatedly, and this should be done every twelve hours, or once a day, according to the quantity of fluid formed, taking care that the eschar be not needlessly separated by allowing the fluid to accumulate underneath. If, from accident, the eschar is separated before the sore be healed I would reapply the caustic. At length the eschar becomes adherent, and in due time begins to peel off, leaving the surface healed. In every case in which the eschar does not separate favourably, I begin to suspect the formation of a scab underneath, in which case the whole must be removed by the application of a cold poultice for two or three days; this has not only the effect of removing the eschar but of allaying any inflammation or irritation; afterwards the caustic must be reapplied as before. The gold-beater's skin is more useful as a protection to the unadherent than to the adherent eschar, as the former would be more liable to be torn off by accident than the latter. The gold-beater's skin must be removed in the manner already described, whenever the subjacent fluid is to be evacuated, and must be reapplied after touching the orifice with caustic. The pain experienced on the application of the caustic is greater or less according to the sensibility and size of the wound. In small wounds it is trifling, and of short duration; it is more severe in recent wounds than in ulcers; it soon subsides in every case, and then the patient enjoys greater ease than would be experienced under any other mode of treatment. Little or no pain is caused on applying the caustic after evacuating the subjacent fluid of an unadherent eschar. Altogether the pain inflicted by the caustic is far less than is generally imagined, and forms scarcely an obstacle to its employment. It may be proper, in this place, to notice such circumstances as render the employment of the caustic improper or inefficient. It is improper to employ the caustic when the ulcer is too large to admit of the formation of a complete eschar; or when it is so situated as to render it impossible that the eschar should remain undisturbed, as between the toes, unless, indeed, the patient be confined to his bed;--or in cases attended by much inflammation, or by much oedema. I have found no kind of caustic so manageable as the lunar caustic; and this is best applied in the solid form. I have thought too, that the newly prepared lunar caustic is more apt to dissolve on being applied than that which has been longer made and more exposed to the air; the latter is therefore to be preferred. III. ON THE TREATMENT BY ESCHAR AND POULTICE. In many cases in which it is impossible to adopt either the mode of treatment by the adherent or the unadherent eschar, it is of great utility to apply the caustic first and then a cold poultice made without lard or oil: this plan is particularly useful in cases of punctured wounds attended by much pain and swelling, and in cases of recently opened abscesses. By this application the pain and swelling are much subdued and a free issue is secured for the secreted fluid; and in no case have I seen the original inflammation increased by it. It is generally necessary to repeat the application of the caustic every second or third day, or every day if the inflammation and swelling of the part be considerable, and the cold poultice may be renewed about every eight hours. At length, however, the inflammation having subsided, the attempt may be made to form an adherent eschar. I have seen many cases, in which, by this mode of treatment, much suffering and perhaps the loss of some of the smaller joints have been prevented, particularly cases of deep seated inflammation of the fingers, which, having been neglected, have issued in severe inflammation, abscess, and terrible fungous growths. In these cases it is not only necessary to apply the caustic to the surface of the sore, but in every cavity or orifice which may be formed by the disease. CHAPTER II. ON THE APPLICATION OF THESE MODES OF TREATMENT TO PARTICULAR CASES. I. OF PUNCTURES ETC. In cases of recent punctured wounds the orifice and surrounding skin should be moistened with a drop of water; the caustic should then be applied within the puncture until a little pain be felt, and then over the surrounding skin, and the eschar must be allowed to dry. In this manner it is astonishing how completely the terrible effects of a punctured wound are prevented; the eschar usually remains adherent, and the case requires no further attention. At a later period after the accident, when the caustic has been neglected, some degree of inflammation is usually present, the orifice is nearly closed with the swelling, and a little pus or fluid is formed within. A slight pressure will evacuate this fluid, the caustic may then be applied within the puncture, and over the surrounding skin, beyond the inflammation, and must be allowed to dry. In this manner we frequently succeed in forming an adherent eschar, and all inflammation subsides. Any slight vesication which may be raised around punctured wounds is not of the same consequence as when an adherent eschar is wished to be formed over a sore or ulcer; one or more small punctures may be made to evacuate the fluid and the part may be allowed to dry. If there is reason to think that an abscess has actually formed under the puncture to any extent, it must be opened freely by a lancet and treated with caustic and poultice, keeping the poultice moist and cold with water. In cases of puncture where the orifice is healed and where an erysipelatous inflammation is spreading, attended with swelling, I have applied the caustic freely over and beyond the inflamed parts, and I have had the satisfaction to find that the inflammation has been arrested in its progress and has shortly subsided. This mode of treatment is particularly useful in cases of punctured and lacerated wounds from various instruments, such as needles, nails, hooks, bayonets, saws, &c. and in the bites of animals, leech-bites, stings of insects, &c. In considerable lacerations the same objection would exist to this treatment as in large ulcers. The dreadful effects of punctures from needles, scratches from bone, or other injuries received in dissection, are totally prevented by this treatment. I have for the last five years had frequent opportunities of trying it in these cases and have the most perfect confidence in its success. The advantage of these modes of treating punctured wounds will however be best explained and established by a selection of cases, to which I can add particular remarks as they may be suggested by peculiarities in the cases themselves. CASE I. A.B. received a severe punctured wound by a hook of the size of a crow-quill, which pierced into the flesh between the thumb and fore-finger on the outside of the hand; scarcely a drop of blood followed, but there was immediately severe pain and tumefaction. The lunar caustic was applied without loss of time, deep within the orifice and around the edge of the wound; and the eschar was left to dry. The smarting pain induced by the caustic was severe for a time but gradually subsided. On the ensuing day, the eschar was adherent and there was little pain; but there was more swelling than usual after the prompt application of the caustic, owing to the mobility of the part. On the third day the swelling remained as before, and there was a little sense of heat. On the fourth day the swelling and heat had subsided, and the eschar remained adherent. On the succeeding day the eschar had been removed by washing the hand, and the puncture was unhealed but free from pain and irritation. The caustic was reapplied. From this time the eschar remained adherent, and at length gradually separated leaving the part perfectly well. It is quite certain that under any other mode of treatment this severe puncture would have greatly inflamed and have proved very painful and troublesome; and it is not improbable but that suppuration and much suffering might have ensued. All this is effectually and almost certainly prevented if the caustic be applied promptly, as in this case. When time has been lost, the case is very different as will appear hereafter; but even in these cases, the caustic proves an invaluable application. CASE II. Mrs. Middleton, aged 40, wounded her wrist, on the ulnar side, by the hook of a door post; there was a considerable flow of blood at first, but this ceased suddenly and the arm immediately became affected with great pain and swelling. The lunar caustic was applied in half an hour after the accident. On the following day the eschar was observed to be adherent, and the patient reported that she had suffered scarcely any pain, after the smarting of the caustic had ceased. There was a slight swelling round the puncture but that of the arm had totally subsided. The caustic was applied over and beyond the swelling. On the third day all tumefaction had subsided and there was no complaint whatever. I hoped that this case would have required no further attention or remedy. But my patient contrived unfortunately to rub off the eschar about a week after its formation, and so to expose the subjacent wound unhealed; she suffered however no pain or inconvenience from it; and it was again shielded by means of a fresh eschar, which remained adherent until removed by the healing process underneath. This puncture was so severe that the arm was in a state of ecchymosis for six or eight inches upwards, and I doubt not that without the caustic, there would have been severe and long continued suffering, and perhaps painful suppurations. CASE III. A female servant punctured the end of the finger by a pin; there succeeded much pain and swelling, and it appeared that the nail would separate, and the cuticle all round the finger was raised by the effusion of fluid. This fluid was evacuated and a poultice applied. On the third day the cuticle was removed, and the exposed surface was found to be ulcerated in several spots. The lunar caustic was passed slightly over the excoriated surface, which was then left exposed to dry. On the succeeding day the eschar was adherent and the pain had almost subsided. On the next day, the eschar still remained adherent, and as there was neither pain nor soreness, the patient used her finger. The eschar was at length removed by the healing process and was separated together with the nail, and the case was unattended by any further inconvenience or trouble either to the patient or myself. It is scarcely necessary to contrast the advantage of this mode of treatment with that by plasters, poultices, &c. It is at once more speedy and secure, and less cumbersome to such patients as are obliged to continue domestic avocations. CASE IV. The present case is somewhat more severe than those which have been already given, and what is of great importance, the caustic was not applied immediately after the accident. William Chantry, aged 50, received a stab in the wrist with a hay-fork yesterday and applied a poultice; to-day there are great pain and swelling, and the wounded orifice is very small. I applied the lunar caustic within the puncture, and directly a cold poultice to be worn over it; the arm was kept in a sling. The next day the swelling and pain were diminished, and a little lymph flowed from the wound. I again applied the caustic and continued the poultice. Two days afterwards, the swelling and pain were nearly gone. The poultice was merely continued, the caustic not being requisite from the subsidence of the inflammation. The patient came to me again in four days more quite free from pain and swelling. The poultice was discontinued, and the caustic was then applied in order to form an adherent eschar, in which I was successful. This case illustrates many important points; 1. it shows the efficacy of the caustic with the poultice as a remedy against inflammation; 2. it presents an instance of a labouring man returning to work on the sixth or seventh day after a severe accident, even when the application of the caustic had been unfortunately delayed; 3. it points out the proper treatment, when all hope of the treatment from the first by adherent eschar is lost from such delay,--for had this been attempted in this case, suppuration would doubtless have taken place from the closed state of the puncture by the swelling;--our objects must therefore be, to open the puncture and to subdue the inflammation, and these objects are admirably attained by means of the caustic. The following case is not less instructive. CASE V. Mr. Cocking's son, aged 12, received a stab in the palm of the hand from a penknife three days ago, which has been followed by much swelling and pain, the punctured orifice being nearly closed. I applied the lunar caustic as deep as possible within the puncture and directed a cold poultice to be laid over the whole hand. On the next day I found that the poultice had not been applied; there were more pain and swelling; an eschar was formed over the puncture which I removed and thus gave issue to a considerable quantity of pus; I again enjoined the application of a cold poultice kept constantly moist and cold with water. On the succeeding day, the inflammation had greatly subsided. I repeated the application of the caustic and poultice. On the fourth day the inflammation had nearly disappeared and on the fifth entirely. In such cases the caustic unites the advantages of at once opening the puncture and of subduing the inflammation, thus preventing the formation of deep-seated abscesses. CASE VI. A little boy, aged 12, received a stab by a penknife a few days ago, in the fore part of the thigh; there are now great pain and swelling, the orifice is nearly closed, and he has feverishness with headach. I applied the lunar caustic deeply in the wound, and directed a poultice and a cold lotion to be kept upon the inflamed parts; and suspecting fascial inflammation, I took away ten ounces of blood and administered purgative medicine. On the next day, the inflammation had greatly subsided; the cataplasm and lotion were continued. On the third day, there was some inflammation round the puncture which appeared to be closing; I repeated the application of the caustic within the orifice of the wound. On the fourth day the swelling was subsiding and there was no pain. The poultice and lotion were continued.--From this time there was no occasion for any remedy, and the little patient speedily recovered. CASE VII. Mr. Parr, aged 30, of delicate habit, trod upon a needle which pierced the ball of the great toe; a free crucial incision was made but the needle could not be found; a poultice was applied to the wound and over the poultice a cold lotion. In the course of a week part of the needle came away. He did not rest as he was enjoined to do, and, in consequence, severe inflammation came on, and in two days time, fluctuation was perceived over the joint, opposite to the puncture; a free incision was made, and some pus was evacuated. On the following day there was a free discharge, but very considerable inflammation had taken place on the side of the ball of the toe; a free incision was made in this part, and a fresh quantity of pus was evacuated. On the succeeding day, the inflammation was somewhat abated; but on the next day, it had again become exasperated, and the openings made for the evacuation of matter were somewhat closed by the swelling. I now introduced the lunar caustic very freely into these openings, and reapplied a cold poultice and lotion. On the following day, I found that my patient had slept well for the first time since the developement of inflammation, and had suffered far less, after the smarting pain from the application of the caustic had subsided, than before; the punctured orifices were open, and the skin, which was extremely tense the day before, was become soft and flexible. From this time, I found nothing necessary but to repeat the application of the caustic about every third day to subdue inflammation and to keep the wounds open, which it always effected. The joint ever afterwards remained stiff, from which we may infer the violence of the inflammation; and when we consider what was the constitution of my patient, we cannot, I think, doubt that the caustic prevented many serious events usually consequent in such cases under the ordinary treatment. It is highly worthy of remark, that the good effects of the application of the caustic, in this case, were too immediate and distinct to be mistaken. CASE VIII. This case illustrates the mode of treatment by the lunar caustic, of those terrible effects of punctured wounds which have been neglected in the beginning. B. Unwin, aged 40, washerwoman, applied to me on July the 10th, 1820, with severe inflammation and ulceration of the middle finger, arising from a puncture by a pin or needle some time before; there was much painful tumefaction, and the integuments had burst along nearly half of the length of the finger, on the ulnar side, and over the middle joint on the radial side; the probe did not however pass to the bone or into the joint. I applied the lunar caustic deep in every part, and over the whole surface, and enveloped the finger in a cold poultice covered with cold water. On the 11th she reported that she had slept well for the first time during the last fortnight; to-day there is scarcely any pain, but she complains of soreness; the swelling has greatly subsided. The caustic was again applied and the poultice and lotion continued. On the 12th there were still swelling and pain; there was considerable bleeding from the wound, so that I could not apply the caustic well. On the 13th the swelling and pain were nearly gone. I repeated the caustic which induced bleeding from the fungous flesh. On the 14th the swelling had nearly subsided; the cuticle was separating all over the finger. The lunar caustic was applied extensively over the wound and abraded parts and induced little bleeding or pain. On the 15th the fungous was nearly removed; the wound presented an appearance of slough over its surface.--The caustic was applied to the remaining fungous. On the 17th the wound was much smaller and the slough separating. The caustic and cataplasm were applied as before.--A similar report was made on the succeeding day. On the 20th the slough was separating. The caustic and cataplasm were applied.--A similar report was made on the 22d. On the 24th the slough having separated the integuments over it were flabby and loose; the caustic was applied to them. By a continuation of this plan the wound gradually contracted, and, at length, when there was no further use for the cataplasm, the eschar became adherent and the sore healed underneath. It appeared highly probable to me that, under ordinary treatment, the finger, in this case, would have been lost. * * * * * I shall in this place, introduce a few observations on wounds received during dissection. It is not in my power to give any cases in illustration of the treatment of the severer accidents resulting from these wounds; for since I began the free use of the lunar caustic all the terrible effects of such wounds have been invariably prevented. I may here mention that in the years 1813 and 1819, respectively, I was myself exposed to great danger from inoculation during the examination of dead bodies. Since the latter period I have repeatedly been exposed to the same danger from inoculation, but in every instance, the danger has been completely averted by the prompt and free application of the lunar caustic. The following is the exact mode of treatment which I would adopt in such cases. In recent punctures the caustic should be applied in the manner already described in cases of simple punctured wounds. When the case has been neglected, a small tumour is usually formed underneath the skin with smart stinging pain; this tumour should be removed entirely by the lancet, and the caustic should be applied, both to the surface of the wound and over the surrounding skin, to form an adherent eschar. When the case has been still longer neglected, and inflammation of the absorbents has supervened, a free crucial incision is to be made, the caustic is to be very freely applied, and afterwards a cold poultice and lotion, the usual constitutional remedies being actively enforced. * * * * * In connexion with punctured wounds I here subjoin several cases of the bites of animals. CASE IX. James Joynes, aged 12, was bitten by an ass, on each side of the middle finger; the wounds were severe, and almost immediately followed by swelling and great pain. The lunar caustic was well applied within half an hour after the accident. On the succeeding day, the eschar was found to be quite adherent, and the pain and swelling had subsided. The eschar separated in about twelve days and the wounds were healed. CASE X. Mr. Worth's daughter, aged six, was thrown down by a dog and bitten severely on the face and forehead in three places; one of the wounds in the cheek was deep from the penetration of the dog's front teeth, and the parts were much bruised. The lunar caustic was well applied in half an hour after the accident to each of the wounds, and the eschar was covered with gold-beater's skin. On the next day the eschars were adherent. There was some swelling from the severity of the bruise; but the child made little complaint. On the third day, the swelling remained as before and the eschar adherent. On the fourth, the swelling had nearly disappeared.--The eschar separated in nine days from the infliction of the wound, leaving the parts healed and free from scar. CASE XI. Mrs. G. was bitten by a little dog on forefinger about a fortnight ago. There is now a very irritable, inflamed, fungous sore. I removed the fungous by a pair of scissors and applied the lunar caustic to form an eschar. On the succeeding day, I found that the patient had applied a little lint before the eschar was dry, which had prevented it from remaining adherent. I reapplied the caustic and desired that the eschar might be exposed to dry. The eschar remained adherent, the inflammation subsided and the case gave no further trouble. CASE XII. A servant maid was bitten by a dog in four places--severely on the forearm--three days ago. Adhesive plaster had been applied. There is a wound across the arm two inches in length and three-fourths of an inch in breadth, attended by dull pain, and swelling of the arm. I applied the caustic to form an eschar, covering it with goldbeater's skin. On the following day the eschar remained adherent round the edges, but had a puffy feel in the centre; I pierced it with a penknife and a little bloody fluid escaped, and I touched the orifice thus made with the caustic. The swelling remained as before, with a degree of soreness. On the next day the swelling had subsided. The eschar had the same character; a little fluid was again evacuated and the caustic applied to the orifice as before. This mode of treatment was pursued for nine successive days when the eschar remained adherent in every part. This patient continued her usual avocations all along. Under any other plan of treatment I think it impossible that she should not have been compelled to rest for a number of days. Adherent eschars were formed on the other three bites which were less severe, from the first application. A very irritable sore sometimes forms after the application of leeches. I knew one lady who was confined during five weeks with several sores on her foot from such a case. I have no doubt that the application of the caustic would have prevented all the inconvenience and suffering she experienced. This observation will be confirmed by the following case. CASE XIII. Am old man applied leeches to the instep for inflammation occasioned by a bruise. Several very irritable sores were produced with some swelling. I applied the lunar caustic to form an eschar. On the following day, the eschars were adherent, the swelling had subsided, and he had slept well for the first time of several nights. I do not, however, think the lunar caustic would succeed in such cases if attended by great inflammation, without the previous application of a cold poultice with rest for a day or two. II. ON BRUISES. It has been already observed, p. 9, that the caustic is an invaluable remedy in cases of bruised wounds of the shin. In these, as in all other cases, the value of this remedy is greatly enhanced by an early application. In bruises on the shin I have not had a single instance in which I was not enabled to effect a cure by the adherent eschar, if application was made to me early. The difficulty of forming an adherent eschar is always increased by delay; but in these bruises along the shin there is an additional reason for this increased difficulty, arising out of the tendency observed in them, to the formation of a slough. In this place I have, indeed, to make an observation of particular interest, both in a pathological and curative point of view; it is, that the formation of this slough has always been prevented by an early application of the caustic, in the cases which have hitherto fallen under my care. This fact may probably admit of explanation in the following manner; the bruise partially destroys the organization of the part, and the subsequent inflammation completing what the injury had partially effected, a loss of vitality takes place, and the slough is formed. The early application of the caustic has already been shown to have the remarkable effect of preventing the inflammation consequent upon certain wounds, and thus the part is suffered to recover from the injury done to its organization, and its vitality is preserved. Whether this mode of explaining the fact be correct or no, the fact itself is extremely important, for the formation of a slough, which the early application of the caustic can alone prevent, renders it quite impossible to effect the formation of an adherent eschar. When the patient applies too late after the accident to prevent the formation of a slough we must still treat the case by the caustic. It is to be applied over the bruised and inflamed part. The eschar remains adherent round the part occupied by the slough and prevents or moderates the inflammation, and when the slough separates an eschar is to be formed over the exposed sore. In the neglected and severer cases of bruise attended by much inflammation, it will be found best to treat the part for a day or two by a cold poultice to give time for the inflammation to subside; otherwise the caustic might induce vesication of the skin, as I have mentioned already, p. 5, and the eschar could not be adherent. CASE XIV. The first case of bruise which I shall detail was not severe, but will serve to illustrate the mode of treatment by the adherent eschar. Mr. Symons, aged 60, slipped off a chair and bruised the shin, last evening; the skin was removed to the extent of an inch in one part and a square inch in another. He applied a common poultice. During the night he had much pain, and to-day there is much inflammation round the wounds. I applied the lunar caustic over both wounds and covered the eschar with gold-beater's skin to prevent the contact of the stocking. On the following day the eschar was found to be perfect. The pain had entirely ceased. There was a little vesication round one of the wounds. I simply evacuated the fluid of the vesication and left the part exposed to dry. On the third day there was no pain or inflammation, and the eschar remained adherent. From this time no remedy was required. The eschar separated leaving the surface healed, in about a month from the occurrence of the accident. The patient suffered no sort of inconvenience nor was he confined from his labours a single day. CASE XV. The following case was far more severe, but the mode of treatment was not less efficacious. Mr. Granger, aged 36, was exposed to a severe bruise by a great weight of stones which had been piled up, falling upon the outside of the leg; he was extricated from this situation with much difficulty. Besides the bruise, the skin was removed from the outside of the leg to the extent of ten or twelve inches in length, and in some parts an inch and half in breadth; and in the forepart of the ankle a deep furrow was made by the rough edge of one of the stones. I applied the caustic in about half an hour after the accident, over the whole surface of the wounds, and protected the eschar by the gold-beater's skin. The patient was directed to keep the leg cool and exposed to the air. He took no medicine. On the succeeding day the leg was a little swelled, but the patient did not complain of any acute pain but only of a sense of stiffness. An adherent and perfect eschar was found to be formed over the whole extent of the wound. There was no fever. On the third day, the swelling had abated. No further remedy. The patient was still enjoined to rest. On the fourth day the swelling was nearly gone. The eschar remained adherent. The patient walks about. From this time the patient pursued his avocation of a stone-mason; no further remedy was required; no inconvenience experienced; and the eschar separated in about a month. I think it totally impossible to have cured this wound, by any other remedy, in less than a month; during which period the patient must have suffered much pain and fever, and have been quite confined. It is also quite certain, I think, that there would have been an extensive slough, from the severity of the bruise. This was doubtless prevented by the application of the caustic. CASE XVI. J. Jennings, bricklayer, aged 26, fell through the roof of a house and bruised and lacerated his shin rather severely to the extent of an inch and half in one part and in several other places in a less degree. I applied the lunar caustic to the wound immediately. On the following day the eschar was found to be adherent, and there was neither pain nor swelling. The eschars separated in nine days leaving the wounds healed. It is remarkable that the eschar remains a greater or less time over the wound according to the severity and exigency of the case. This case being less severe than the former one the eschar remained upon the wound during a much shorter period of time. CASE XVII. An old man, aged 60, received a bruise upon the occiput from a fall; the skin was lacerated and removed to the extent of half-a-crown. I applied the lunar caustic soon after the accident. On the next day an adherent eschar was formed. There was neither pain nor swelling.--The eschar separated in a fortnight. CASE XVIII. Mrs. C. aged 40, was detained on a journey by a bruised wound on her knee, received a fortnight before, which was healing very slowly under the usual mode of treatment. The inflammation was subsiding but the sore was extremely irritable and painful, and she was prevented from moving. From the degree of inflammation still present, I applied the lunar caustic very slightly over the sore and not over the inflamed skin; I left the eschar to dry, but was very doubtful, from the same cause, whether it would be adherent or no. On the succeeding day I found that the eschar did remain adherent and that the inflammation was diminished, and the soreness had entirely subsided after that induced by the caustic had ceased. On the next day, the lameness was gone, and there was no sort of inconvenience from the wound. My patient continued her journey on the following day, so that I do not know when the eschar separated. In regard to the inflammation attendant on these wounds, I would remark that slight inflammation is relieved by the application of the lunar caustic and does not prevent the formation of an adherent eschar; but very severe inflammation requires the application of the cold poultice and lotion over the wound, and it is necessary to watch for the period when an eschar may be attempted with the lunar caustic. This a little experience will readily teach. It is further to be particularly observed that the inflammation attendant on a recent wound is removed by the caustic, when the same degree of inflammation at a later period, and with suppuration, would be aggravated and require the cold poultice and lotion, and render the formation of an adherent eschar impossible. This fact, the result of much experience, is extremely interesting, and, I think, not easy to be explained. It is illustrated by the following case. CASE XIX. Robert Hill, aged 16, received a blow yesterday from a bone which was thrown at him, upon the outer condyle of the humerus. He complains of extreme pain and there are much redness and swelling. I applied the lunar caustic and directed the part to be exposed to the cold air. On the succeeding day, I found that the eschar was quite adherent, and that the pain, redness and swelling had much subsided, although there was some stiffness of the elbow. On the third day there was still further amendment. From this time no remedy or attention was required. CASE XX. It frequently occurs to surgeons to receive slight wounds upon the hands which prove very troublesome. Of this kind is the following. Mr. L.C. had an irritable and inflamed sore on the ulnar side of the third finger, occasioned by a bruise a fortnight ago. Many applications had been made during this fortnight but the sore had no disposition to heal. I applied the lunar caustic to form an adherent eschar. From this time the pain and inflammation subsided. The eschar remained firm and adherent, and in six days separated leaving the wound healed. III. ON ULCERS. From the preceding observations it would naturally be concluded that the lunar caustic would afford a remedy for the treatment of ulcers. This conclusion is perfectly just. Yet there are many circumstances which render the mode of treating ulcers by the caustic, efficacious or the contrary. In order that the treatment by eschar may be successful, there must be the following conditions in regard to the ulcer: first, the surface occupied by the ulcer must not be too extensive; secondly, it must not be exposed to much motion or friction; and thirdly, it must not be attended by a profuse discharge; for all these circumstances have a direct effect in, preventing the formation of an adherent eschar or of removing it if formed. I observe, therefore, that I have not found the mode of treatment by eschar to succeed in large ulcers of the legs. But in small ulcers, and especially in those irritable and painful little ulcers which are so apt to form about the ankle and occasionally occur near, the tendo achillis, and in which Mr. Baynton's plan is inadmissible, the caustic is invaluable; in these cases the cold poultice and lotion should precede the application of the caustic, for a few days, that the irritability and inflammation of the sore and surrounding skin may be first subdued; and after the eschar is formed, the part must be kept exposed to the air and defended from external injury, by enjoining the patient to wear trowsers and to be careful not to disturb the eschar. The plan of curing ulcers is exactly what has been described in the treatment by the unadherent eschar. For in these cases the eschar is generally unadherent at first. It is necessary therefore in all cases, except those of very small ulcers, to examine the eschar, making a small puncture or rather smooth incision in its centre, so as to evacuate the subjacent fluid if there be any, taking great care not to break down or bruise the eschar so as to leave its inferior surface at all ragged. This operation should be repeated daily until the eschar proves to be quite adherent. And if the ulcer be rather large, rest should be enjoined until the adherent eschar be fully and safely formed, and a dose of saline purgative may be interposed. It must also be particularly borne in mind, that the eschar must be constantly defended by the gold-beater's skin, which must be removed and reapplied at each examination. I have here spoken of ulcers upon the legs. But the same observations apply to ulcers on other parts of the body, and these are, in general, far more manageable than the former, and do not require the same rest during the unadherent state of the eschar. CASE XXI. Mrs. Butcher, aged 52, has two ulcers a little above the outer ankle, one the size of half-a-crown, the other, of a shilling, of four months duration, which are now in a healing state by the application of cerate and poultice; the healing process is going on very slowly. These ulcers were caused by a fall which bruised the part but made no wound at the time; two small spots, which she compared to the pustules of small-pox, formed, broke, and gave rise to the ulcers. I applied the lunar caustic to form eschars. At this time I had not begun to defend the eschar by the gold-beater's skin, and in consequence both these eschars were torn by the patient's stocking having adhered to them, and there was an oozing of fluid from the centre of each eschar on examination on the following day. I again applied the lunar caustic. On the succeeding day, I found that the large eschar had again been disturbed, the patient having applied a little linen, instead of leaving it exposed. I reapplied the lunar caustic. On the next day both eschars were complete, but there was a little fluid under the centre of each, which required to be evacuated by an incision. There was little inflammation or pain. On the following day, my patient expressed herself as astonished at the rapid amendment. A little fluid was again evacuated from beneath the centre of the eschar. On the next day the smaller eschar was quite adherent; under the large one, there was still a very little fluid. About the ninth day, both the eschars were perfectly adherent. In two days afterwards the eschars began to separate round the edges, and in a few days more, it was necessary to remove the separating portion by the scissors.--In the course of time the eschar separated completely, leaving the ulcers healed. Mrs. Butcher had no pain after the first four days from the application of the caustic, and in a week was able to attend to her household affairs. CASE XXII. J. Copeland, blacksmith, aged 38, came to me with many deep ulcerations, from the size of a horse bean to that of a pea, attended with great pain, heat, itching and excoriations of the surrounding skin, obliging him to rest at different times, for several days together. These ulcers came without any apparent cause, have continued for many weeks, and have only been a little benefitted by rest, although he has applied many kinds of ointment, the last consisting of equal parts of mercurial and of the tar ointment. I applied the lunar caustic upon each ulcer, but not over the excoriation, and I enjoined the patient to leave the whole exposed to dry. On the following day, I was gratified to find that eschars had formed upon every ulcer; upon examination, a little fluid was found to subsist under several of the larger eschars; this I evacuated, and I then applied the lunar caustic to the points from which it had issued to make up the breach of continuity of the eschars over the surface of the ulcers. There was far less inflammation and scarcely any pain, and he has continued his occupation of blacksmith. On the third day nearly all the eschars were adherent; three, however, had unfortunately been removed by an accident; I renewed them by again applying the caustic. In four days after the last report, most of the eschars had separated from the smallest ulcers leaving the parts healed. In a day or two more, my patient took cold and was affected with hoarseness and cough, and the skin round the eschar became excoriated a little. I directed a saline purgative and applied the lunar caustic to the excoriated parts. On the succeeding day his cold was better and the eschars adherent. I directed five grains of the Plummer's pill to be taken night and morning, which he continued about a week. Five days after this period, I again observed a disposition to excoriate. I applied the caustic. In two days more, the eschars were adherent, and there was no further appearance of excoriation. In ten more days, the eschars had separated and all the ulcers and excoriations were completely healed. This case occurred several years ago, and there has been no return of the affliction whatever. CASE XXIII. Mr. Marshall, aged 60, had a troublesome ulcer under the outer ankle, of an oblong form and of the size of sixpence. He has been long subject to ulcers of the legs, and he had a similar ulcer to the present one in the same situation, some years ago, which proved extremely difficult to heal under usual remedies. The veins are varicose.--From the small size of the ulcer, I applied the lunar caustic and protected the eschar by the gold-beater's skin. On the following day, I found the eschar complete but unadherent by the effusion of a little fluid; this I evacuated daily in the manner already described, for about a fortnight, when the eschar became adherent. During the progress of the cure a little excoriation formed round the eschar. I touched the parts with the caustic, and the eschar thus formed served to support that formerly made, and so to do good. The whole adhered until the sore was very nearly healed; but as it was situated in a part greatly exposed, it was removed by accident. The caustic was again applied; fluid formed underneath the eschar as before and required evacuating thrice; but at length the eschar adhered, and in due time separated leaving the ulcer quite healed. The same patient has since been affected by similar ulcers at different times in different parts of the leg. He applied early and they were each time easily cured by one application of the caustic. He has also twice had injuries upon the shin, which were readily cured in the same manner. CASE XXIV. The following case must not be regarded as altogether trifling. For such sores are very apt to spread and to remain long very troublesome. An old gentleman came to me with an oblong ulcer on the shin about an inch in length; it was very painful and inflamed. I applied the lunar caustic to form an eschar and requested him to call on the following morning. He did not come, however, but on seeing him the next day it was requisite to evacuate a little fluid; this was repeated on they third day, after which period the eschar remained adherent, and the part totally free from pain. The eschar separated in about three weeks leaving the part healed. CASE XXV. The following case illustrates the superior efficacy of the lunar caustic over the ordinary modes of treatment in some ulcers of the legs, and will, I trust, be found particularly interesting. Mr. G.B. aged 60, a very tall and stout person, had two ulcers, one of the size of a shilling upon the back of the leg just above the tendo achillis, the other rather less, on the outside of the leg; they were caused by his scratching the parts severely three months before; and he had used various remedies in the interval. There were some oedema of the leg to which he is subject, and much pain and inflammation of the ulcers. I directed the application of a cold poultice and lotion, and prescribed the pil. hydrarg. every second night with an aperient draught the following morning. This plan of treatment was continued for a number of days without any appearance of healing in the ulcers. As the inflammation had subsided I proposed to adopt the mode of treatment recommended by Mr. Baynton, fearing that any attempt to heal the ulcers by eschar would fail on account of the oedema. This project was deferred, however, by the patient's wish to try the effect of sea-bathing. After a month's residence on the sea shore I was, on the return of my patient, again requested to examine these ulcers, which I found very nearly in the same state as before, only with the addition of some excoriations. I recommended the cold poultice for a few days to allay inflammation, and then tried Mr. Baynton's plan, dressing the leg myself daily; on the fourth day, however, the sore above the tendo achillis became so irritable that I was compelled to desist and to remove the plaster and bandage, and I again directed the cold poultice with rest, for a few days. When the inflammation had again subsided, I ventured, notwithstanding the oedema, to apply the lunar caustic to form an eschar, enjoining rest and the horizontal position. On the following day complete but unadherent eschars were formed over each sore. There, had been no pain after the smart of the caustic had ceased. On carefully making an incision into the centre of each eschar, a little fluid was evacuated. On the second day, rather more fluid was evacuated in the same manner. There was a little more inflammation round the eschar than yesterday. On the third day the sores were exactly in the same state. On the fourth, the patient having used his leg a little, rather more fluid was evacuated from the centre, and there was rather more inflammation round the edges, of the eschars. I enjoined the strictest rest. On the fifth day, there were less inflammation and discharge. From this day until the tenth the fluid required daily evacuation; the eschar became adherent, and I allowed my patient to walk about. In about six weeks the eschar was nearly separated and I removed it by the scissors, leaving only a portion adherent of the size of a pea. It had been prevented from being removed from the beginning, by the gold-beater's skin. The smaller eschar had dropped off leaving the ulcer quite healed. In a week more the last portion of eschar separated from the larger sore, leaving it also quite well. CASE XXVI. The following case occurred in the person of a lady with varicose veins and far advanced in pregnancy. Its speedy cure by the caustic was, therefore, the more remarkable, and saved her much trouble and suffering. Mrs. C. aged 40, had two small irritable and inflamed ulcers, under the inner ankle. I applied the lunar caustic to form an eschar. It was requisite to evacuate a little fluid from under the eschars for three successive days; they then remained adherent. About the usual time the eschars separated, leaving a small point of the size of a pin's head, unhealed; this I again touched with the caustic. The case required no further attention. This case leads me to caution my readers always to examine the parts carefully after the separation of the eschars, and if there be the slightest ulcer remaining to apply the caustic to it. CASE XXVII. Mrs. Wakefield, aged 36, had an extensive ulceration with excoriation on the upper part of the right breast, of two months continuance; it had been greatly aggravated by improper treatment. I applied the lunar caustic over the whole ulcerated and excoriated surface. It gave much pain. On the following day I was concerned to find that part of the eschar had been separated by the patient's dress. I repeated the application of the caustic and again directed the part to be exposed and carefully protected from being disturbed. The breast required to be supported being full of milk. On the succeeding day an adherent eschar existed over all the ulcerated parts, and the pain, redness, and irritation had nearly subsided. On the fourth day there was still less pain and inflammation. On the eight the eschars had separated and the breast was quite well. CASE XXVIII. Mrs. U. aged 60, has been subject to ulcerated legs for several years. She has one ulcer on the outer ankle of the size of a shilling, and another behind it of the size of a horse-bean; they have been extremely troublesome and under surgical treatment for the last year, but during the last few weeks she has tried cerate, poultice, and the cold lotion. The leg is much swollen and inflamed, the redness extending several inches round the wound and over the instep; the oedema increases towards night. She has been in the habit of taking saline purgatives frequently. I directed my patient to continue the cold poultice and lotion, and to rest completely for several days. At this period, the inflammation having somewhat abated, I applied the lunar caustic to form eschars and protected the parts with gold-beater's skin. On the following day there was a slight increase of redness round the eschars. Upon making an incision into their centre some fluid was evacuated. The same report was made on each of the two following days. On the seventh day, the eschars having been neglected, fluid had escaped from beneath the eschars at their edges, and my patient complained of more pain. A little more fluid escaped in the same manner on the following day on making a little pressure upon the eschars. I applied the caustic to make up the breach. Subsequently to this day there was an increase of inflammation. From this circumstance, and from the neglect of the eschars for two or three days already mentioned, I suspected the formation of a scab under them. It was impossible to pierce the eschars by the penknife without breaking them, as they had become too hard and thick by delay and the addition of the scab. I again directed the cold poultice for four or five days. On examining the wounds on the separation of the eschars, I found the healing process going on. I reapplied the lunar caustic to form eschars, and I evacuated a little fluid from their centre for three successive days. At this time the patient took cold and a smart attack of fever came on, and the part round the eschars became much inflamed. I prescribed an emetic and purge, and a cold poultice and lotion. In the space of a week I again attempted to form an eschar over the larger wound, for the smaller one had quite healed. The next day I discharged a little fluid from the centre, and again on the eight or nine succeeding days, giving saline purgatives. After this time the eschar remained adherent, and no further remedy was required. This case is particularly interesting and important, as it illustrates the plans to be adopted in two circumstances of no unfrequent occurrence; 1. when there is an attack of fever and increased inflammation, and 2. when a scab forms underneath the eschar. In both cases we must relinquish our attempt to form an adherent eschar for a time,--apply the poultice,--and recur to the caustic in the course of a few days. In the beginning of my trials of the treatment of the ulcers by the caustic, I was repeatedly betrayed by the smooth appearance of the eschar, to think that all was going on well, when in fact a scab was all along forming underneath. In these cases inflammation soon followed, and it was only by carefully and daily evacuating the fluid effused under the eschar that I at length succeeded in effecting an adherent eschar free from surrounding inflammation. This remark cannot be too often repeated. CASE XXIX. The peculiarity of the present case arose from neglect in evacuating the fluid effused under the eschar the day succeeding its formation, the consequence of which was that the edges of the eschar became raised all round, without however being entirely detached. Mr. Draper, aged 50, had a small irritable ulcer of the size of a horse-bean, upon the shin, of a month's duration, with surrounding inflammation to the extent of several inches. I applied the lunar caustic to form an eschar and protected it with gold-beater's skin. On the following day, it appeared from the flatness of the surface, that the eschar was adherent; the inflammation remained as before. On the next day the eschar was raised all round its borders, presenting the appearance of an elevated ring. I made an opening in one point of this ring by a penknife and evacuated the fluid, and I again applied the caustic all round in order to give firmness to the edges of the eschar. On the succeeding day an opening was made in the centre of the eschar and a little more fluid was evacuated. This mode of treatment was continued daily for about a week, the inflammation gradually subsiding and the eschar becoming adherent and corrugated. In about three weeks, the patient thinking the sore quite well detached the eschar; there was still, however, a minute ulcer left, which was touched with the caustic. CASE XXX. C. Cocking, aged 17, has an ulcer of the size of half-a-crown on the inner part of the knee, occasioned by an accident. He had been a month under surgical care in the country when he applied to me, but the ulcer continued without disposition to heal, and fungous; it had apparently been treated by a solution of sulphate of copper. I applied the lunar caustic over the surface of the sore and upon the surrounding skin. On the following day, the eschar was unadherent and puffy, and on piercing it a little fluid escaped. The incision into the eschar was repeated three or four successive days, but the eschar still retained its puffy character; I therefore directed a poultice to be applied to remove it. In two days the eschar was separated leaving the ulcer with its fungous appearance. I removed the fungous part by scissors, and directed the poultice to be applied and to be continued for two days. I then formed another eschar. This required a daily puncture for the evacuation of subjacent fluid, for six days; it then remained adherent, and in about a fortnight it separated leaving the ulcerated surface healed. This patient was not at all confined. CASE XXXI. Mr. S. aged 30, had a sore two inches in length in the groin, the remains of a phagedenic ulcer. It had remained stationary a whole fortnight under the ordinary treatment by bandage. I applied the lunar caustic to form an eschar and then the gold-beater's skin. The day afterwards, I found the eschar incomplete and I applied the caustic again. The eschar was still incomplete on the following day, and the caustic was again required to be applied to the denuded parts. On examination two days afterwards I found the eschar complete and adherent. On the fourth following day, great part of the eschar had separated leaving the ulcer healed, and I had no occasion to see the patient again. IV. OF SOME ANOMALOUS CASES. 1. _Of Whitlow._ The lunar caustic is very useful in the treatment of this painful affection. Patients seldom apply to the surgeon before suppuration has taken place. It is then, I think, the best plan to open the abscess freely, to apply the caustic well within the cavity, and then to envelope the part by the cold poultice and lotion. In this manner the pain and irritation are almost immediately removed, after the smart of the caustic has subsided. A second application is seldom necessary. In some cases, however, there is an increase of inflammation in a day or two, which requires the caustic to be again applied. When the inflammation has subsided, the loose cuticle may be removed, and the caustic must be applied to form an eschar. In slight cases the lunar caustic may be passed over the inflamed part, and in this manner suppuration and the continuance of inflammation is often prevented. In those cases in which the suppuration is artificial and attended with severe diffused inflammation, the pus should be evacuated and a cold poultice applied for a day or two; for the too early application of the caustic would only add to this kind of inflammation; see p. 11; afterwards the skin may be removed, and if there be excoriations the caustic may be lightly applied. 2. _Of Inflammation of the Finger._ The following case of inflammation of the finger occurred without any assignable cause. CASE XXXI. A young man, aged 18, came to me with a painful swelling of the middle finger of the right hand; suspecting deep-seated abscess, I made a free incision and evacuated a little pus. I then applied the lunar caustic within the cavity and directed a cold poultice to be applied with lotion. On the fourth day my patient had returned to his occupation as a dyer. CASE XXXII. Miss B. aged 23, had a slight scratch on the inside of the index finger, which issued in severe inflammation extending over the back of the hand. I made a free incision in the part first affected, evacuated a little pus, and directed a poultice to be applied. On the following day, there was less pain but still great swelling at the back of the hand, which, I think, would have been removed had the caustic been used. I now applied the caustic freely within the orifice. On the following day there was less swelling and discharge. Two days afterwards, the caustic was again applied, and in eight days from the first application of the caustic the hand was quite well. 3. _Of Fungous Ulcer of the Navel in Infants._ It sometimes occurs that a little fungous sore exists upon the navel in infants which is difficult of cure in the ordinary way. I had one case which had subsisted for two years, and another, which had continued for two months, and were, during those periods, a source of great trouble and uneasiness to the mothers of the little patients. These ulcers are easily cured in the following manner. The fungus is to be completely removed by a pair of scissors, and when the bleeding has quite ceased, the lunar caustic is to be applied, and the part defended by the gold-beater's skin and kept carefully from any moisture. In one of the cases mentioned above the eschar was accidentally separated twice and required to be renewed; but both cases were cured in the space of a few days. 4. _Of Inflammation of the Knee._ Servant women, I suspect from much kneeling in scouring stairs, &c. are subject to a species of inflammation of the knee which is frequently extremely troublesome. In one case suppuration of the integuments took place in the forepart of the knee, and the patient was obliged to leave her situation and go to her friends at a distance, although every antiphlogistic means was tried for her relief. In two other cases, after the application of twenty leeches and the administration of an emetic and purgative medicine, I applied the lunar caustic freely over the whole surface of the knee previously moistened with water. In a few hours the cuticle was raised and vesicated; I evacuated a viscid puriform fluid, and I directed the constant application of the cold poultice and lotion. In a few days all inflammation subsided and the patients remained well. These three cases having occurred to me at the same time, and being apparently equally severe, I was enabled to judge of the efficacy of this use of the caustic, and I can strongly recommend it to a future and further trial. Its application causes more pain than a blister, but not so much as to form an obstacle to its employment. It may not be unimportant, here, to suggest the trial of the caustic in other cases of inflammation, in which a more than usually active local remedy is required. 5. _Of Tinea Capitis, &c._ In this place I have only to observe that I have in some cases completely succeeded, in others completely failed, in the cure of tinea capitis, by the lunar caustic. As I have not hitherto distinguished these cases from each other; and as I could only offer conjectures on the subject, I think it best to leave it for future inquiry. The same observation applies to some other cutaneous affections which I need not specify more particularly at the present. CHAPTER III. OF SOME CASES IN WHICH THE CAUSTIC IS INAPPLICABLE. It is by no means my intention to recommend the application of the lunar caustic as an infallible remedy for all local diseases. I am quite aware of the propensity, in recommending a favourite remedy, to extend its use beyond its true limits. The caustic, like all other remedies, requires to be employed with discrimination; and it is therefore my object in this little work, to state in which cases it is, and in which cases it is not, useful and successful. With this object, I have thought it not improper to add, in a concluding chapter, some observations on those cases in which I have found the lunar caustic to be inadmissible. It will, at the same time, be found that such cases, in the course of their treatment by the ordinary measures, not unfrequently become fit cases for the application of the caustic, with the view of more speedily completing the cure. This observation is particularly applicable to the cases of burns, of large ulcers, of fungous ulcers, &c. The caustic is inapplicable in extensive lacerations, for the same reason that it is so in extensive ulcers. I have found the caustic of little use in incised wounds, and should not employ it except in such wounds received in dissection. I have failed in my attempts to heal scrofulous sores by the adherent eschar; I would propose the trial with the lunar caustic and poultice. In erysipelatous inflammation, where vesicles are formed, the caustic does injury, as in recent burns. I have always found that the caustic has done injury in boils, aggravating rather than diminishing the affection. 1. _Of Burns._ The application of the lunar caustic in recent burns or scalds, has always appeared to me to increase the inflammation and vesication, even inducing blisters where there were none before. The caustic must not, therefore, be applied in these cases, until the inflammation has entirely subsided; but when there remains only a small superficial ulceration, the caustic may be passed lightly over the ulcerated surface to form an eschar which is to be defended by the gold-beater's skin; for the affection is then reduced to the state of a common superficial ulcer. An adherent eschar is generally readily formed, and no further application is required. If the ulceration be more extensive and deeper, the lunar caustic may be applied, and the eschar treated, exactly as in common ulcers. It may be well to illustrate these points, by the following cases. CASE XXXIII. A little girl, aged 10, scalded her breast a week ago and has treated it with the ordinary remedies. There remained a superficial ulceration of the size of half-a-crown. I applied the lunar caustic lightly over the surface of the sore, and then the gold-beater's skin. On the following day, an adherent eschar had formed, and in five days more it dropped off leaving the ulcer quite healed. CASE XXXIV. Mr. C. aged 51, scalded his leg ten days ago on the instep. He applied ointments and poultices. The surface remained ulcerated to the extent of three inches in length and an inch and a half in breadth, and presented a considerable thick slough in the centre; the inflammation continued to be considerable with some oedema towards the toes. In such a case I should now recommend a cold poultice to be applied for several days; but the present case occurring early in my trials of the caustic, the latter remedy was applied forthwith over both the ulcer and slough. On the following day I learnt that the pain after the application of the caustic had been considerable for two hours. It then ceased and the eschar became complete; and there was rather less inflammation and swelling. The patient had kept in bed. I prescribed a pill with the hydrarg. submurias, to be followed by an aperient draught. On the succeeding day my patient went down stairs and disturbed the eschar, and experienced more pain. The inflammation and swelling were still less. I applied the caustic to the parts of the ulcer exposed by the injury done to the eschar. During the two following days the inflammation subsided entirely; I evacuated a little fluid from beneath the eschar. On the next day the eschar appeared adherent, except in the centre which was occupied by the slough. On the succeeding day, I evacuated a little fluid from beneath the slough. On the next day I removed the slough entirely by means of a pair of scissors. The subjacent ulcer had a healthy granulated appearance. I applied the lunar caustic to it to form an eschar. From this time it was necessary to evacuate a little fluid from under the eschar for ten successive days. It then became adherent, and in about a fortnight it separated, leaving the ulcer healed. CASE XXXV. The following case will present a specimen of my trials of the lunar caustic in larger ulcers. Anthony Knowles, aged 44, was kicked by a horse on the leg, above the inner ankle, two years ago. The part has never healed, but still remains in the state of an open ulcer, attended by some inflammation. When I first saw this ulcer it was about two inches in diameter and nearly circular, with high edges, a surface of a greenish colour, and without any healthy granulations. I applied the lunar caustic to form an eschar. The pain from the caustic was severe for several hours. An eschar had formed round the edges, but in the middle part it was quite wanting; the inflammation surrounding the ulcer had abated, and the green hue of its surface had disappeared. I reapplied the caustic in the central part. On the following day the eschar appeared tolerably complete in the centre but had separated at one part of the circumference. I again applied the caustic to the defective part. On the following day the eschar was defective in several parts, but the inflammation was quite removed, there was no pain, and there had been less smarting after each successive application of the caustic. I again applied the caustic. On the succeeding day, I learnt that my patient had been intoxicated, and I found the ulcer attended by inflammation. The eschar was by no means complete; some part of it was in a detached state. I removed the loose portions and repeated the application of the caustic. This sort of treatment was continued for a fortnight without my being able to effect the formation of a complete eschar. I therefore relinquished the idea of healing the ulcer by the adherent eschar; I eventually succeeded in doing so by applying the caustic every third day and the poultice continually, and I had hopes that the cure might be permanent, but he made application to me in two years afterwards with a similar ulcer on the same part. In another similar case, I removed the elevated hard edges of the ulcer by the lancet, and then tried the caustic, without better success. CASE XXXVI. The last case I have to give is one of great interest, as it clearly shows the influence of the lunar caustic in subduing the inflammation surrounding ulcerations, and in promoting the healing process, even in cases of phagedenic ulcer. In such cases its influence eminently deserves a still further trial. Mrs. H. aged 56, has had very extensive phagedenic ulcerations on the legs and thighs during three years, which began in little red spots and then spread rapidly, destroying the integuments. One of these ulcers, on the thigh, was twelve inches in length and five in breadth, and exhibited the appearance of a deep corroding furrow; it was surrounded by a fiery redness and was attended by extreme pain. There were many other ulcers of the same kind, several nearly of the same magnitude; and the poor patient was compelled to take large doses of laudanum several times in the day. She had formerly been treated for syphilis, and had afterwards taken the sarsaparilla freely; amongst a great variety of local applications, the white bread poultice had afforded most relief. I applied the lunar caustic to two of the smaller ulcers. On the following day the eschars were complete. I applied the caustic to the large sore above described to the extent of three inches square, avoiding its application on the inflamed skin. On the next day I found the eschar last made complete, and I passed the caustic over the ulcer to the extent of three inches more. On the succeeding day, the eschar was complete, adherent at those edges which adjoined the cuticle, and floating at the other edges over the ulcer, and in the latter part allowing the escape of matter; round the adherent edges of the eschar the inflammation had entirely disappeared, while it remained fiery as before round every other part of the ulcer. I continued my trials with the caustic in this case, but it gave so much pain, and I had so little hope of final success, that I altogether relinquished the attempt to treat these ulcers by eschar. Some of the small ulcers were healed, however, and the larger one assumed a more healthy character wherever the caustic had been applied. It may, therefore, remain a question whether the lunar caustic may not still prove useful in phagedenic ulcers of a smaller size. FINIS. T. Wheelhouse, Printer, Nottingham. * * * * * +--------------------------------------------------------+ | Typographical errors corrected in text: | | | | Page 41: cautic replaced with caustic | | Page 65: eurative replaced with curative | | Page 107: smuch replaced with much | | Page 120: ANOMOLOUS replaced with ANOMALOUS | | | +--------------------------------------------------------+ 
27181	----	[Illustration: DR. ROBERT KOCH.] PROF. KOCH'S _METHOD TO CURE_ TUBERCULOSIS _POPULARLY TREATED_ BY DR. MAX BIRNBAUM. _TRANSLATED FROM THE GERMAN_ BY DR. FR. BRENDECKE. _With an Appendix being Prof. Koch's First Communication on the Subject, translated from the_ _DEUTSCHE MEDICINISCHE WOCHENSCHRIFT_ _and explanatory notes by the author._ MILWAUKEE, WIS., H. E. HAFERKORN, PUBLISHER. 1891. COPYRIGHT 1890, BY H. E. HAFERKORN. PRESS OF THE HARTMANN PRINTING CO., 126 Reed St., MILWAUKEE, WIS. Translators Preface. Consumption is curable. From time to time the news of some great discovery rushes over the land like a mighty wave; but never before has the intelligence of a great achievement been received with such universal delight. There is hardly a man, woman or child that does not bewail the loss of some dear relative taken away by Tuberculosis, the most terrible of all foes. More terrible because it stealthily creeps into the system and takes a firm hold before its presence can even be surmised. Now the appearance of a deliverer is hailed as would the advent of the Messiah. Koch, formerly a poor and obscure student, being especially interested in bacteriology has plodded and worked for years. Even in the year 1882 he has made known to the world the evil spirit in describing the tubercle-bacillus as the specific generator of tuberculosis. We then knew the enemy but had no weapon to fight him. Now Koch has also manufactured the sword with which to combat the evil genius. The experimental tests thus far have not tended to lessen the merits of Koch's remedy. Added applications have resulted in additional success. The investigations are not yet complete; only meager particulars have thus far been given to the public from authorized sources. To guard against misleading representations the translator has undertaken to give to the American public only what has actually been achieved. He felt himself called upon to do this not only because he has followed the progress of Koch's labors with the keenest interest, but also because he himself has worked and labored on this field for many years. Justly has a vast excitement taken hold of all classes of the people, an excitement that has caused all other contemporary events to fall back. The search for an actual remedy for that exceedingly ravaging disease, tuberculosis, has at last been crowned with success, and even the most uneducated will be able to estimate the significance of this event. We need but consider, that pulmonary consumption, the most frequent form of tuberculosis, annually demands over 30,000 victims in the cities of the German Empire over 15,000 inhabitants, and out of every 100 deceased 12-13 have fallen prey to this sickness. The number of sufferers from pulmonary consumption can not nearly be determined, it certainly exceeds all other diseases by far. In the case of many people we can only infer from their appearance and hereditary tendencies, before visible signs can be discovered, that they will succumb to this terrible disease. And this disease is now curable. Millions of people who have considered themselves doomed, will be given back to life; their regained strength will greatly increase the national wealth. In short, we look forward to an era, such as was not dreamt of even by the most vivid imagination only a few years back. But rather than be carried too far by our enthusiasm, let us study Koch's new method to cure, as far as we are now enabled to pass judgement on it. First of all we must explain: _What is tuberculosis? What relation does it bear to pulmonary consumption?_ Pulmonary consumption is only one form of tuberculosis, by far the most frequent. This is the reason why pulmonary consumption, pulmonary tuberculosis, consumption and tuberculosis are used as _synonymous_ terms. Tuberculosis is the _general_ expression. By that we understand a disease which is generated by a certain kind of organism belonging to the class of bacteria. These organisms are the tubercle bacilli, which were discovered by Koch in the year 1882. Now these tubercle bacilli settle most frequently in the lungs and here cause serious derangements of the lung tissue. _Pulmonary consumption_ is the result. But the tubercle bacilli will also settle in any other portions of the body and cause tuberculosis. Frequently the tubercle bacilli nestle in the _larynx_ and the result is _laryngeal consumption_. They may infect the mucous lining of the tongue and nasal passages and cause the rarely occurring diseases--_tuberculosis of the tongue and nose_. More frequently tuberculosis of the intestines results, the well-known _intestinal consumption_. The spreading of tuberculosis in the brain is of especial importance on account of the importance of this organ. Very frequently small children are attacked by _tuberculosis_ of the _cerebral membranes_, a disease that has heretofore unexceptionally resulted in _death_. Much oftener than is generally supposed the _kidneys_ are the seat of tuberculosis; and also the _suprarenal capsules_, whose functions are as yet entirely unknown, have in postmortem examinations been found to be tubercularly degenerated. In the diseases of the _bones_ and _joints_ tuberculosis forms an important part. Those infinitely small and weak tubercle-bacilli have the power to destroy the hard and firm substance of the bones, to soften it and change it to pus. Whole portions of bone may disappear in this way. Tuberculosis can also destroy parts of the _skin_. In this case it is called _Lupus_. Finally tuberculosis is found in the _generative organs_. Tubercular derangements are frequently met with in the _testicles_ of men, less often in the _ovaries_ of women. The well known children's disease _Scrofula_ is considered a preceding stage of tuberculosis by many physicians. This much is certain that Scrofula inclines to tuberculosis. Let us study the several forms of tuberculosis after this general synopsis; we will begin with pulmonary consumption. Pulmonary Consumption. Even before the discovery of the tubercle-bacillus by Koch, different scientists had claimed that pulmonary consumption was caused by the immigration of bacteria into the lungs, and several of them had found bacteria of that kind. But it remained for Koch to bring light upon the conjectures of other scientists, and he established the fact, that the bacillus discovered by him was the real generator of pulmonary consumption. Millions of these bacilli exist in the lungs of the diseased, and millions of them are thrown out with the sputum. If we take a very small quantity of this thrown out matter and examine it with a microscope, we will find a greater or smaller number of these tubercle bacilli. Of course the preparation to be microscopically examined must previously be colored with some coloring matter, otherwise it is very difficult, well nigh impossible, to detect the infinitely small bacilli. The method of coloring now generally in use consists in discoloring the preparation after the coloring has been completed, it is found that the bacilli tenaciously cling to the coloring matter, and in this way it is easy to recognize the tubercle-bacilli under the microscope. These bacilli are infinitely minute, they are 2/1000 to 8/1000 millimeters long, and about 5/100000 millimeters in width. Therefore it is absolutely impossible to recognize them with the naked eye. Generally they are somewhat bent, sometimes slightly nicked at one end. The temperature of boiling water destroys the vitality of the bacilli under all circumstances. Even a temperature of 70° C. is able to lessen the efficacy of the bacilli. Unhappily this temperature is too high to be applied against the tubercle-bacilli in the human body without causing the most serious injury to it. Nevertheless it has been tried, we will speak of this later on. Then the drugs that kill the bacteria, such as Carbolic Acid, Alcohol, Iodoformether, Ether, Sublimate, Thymol, destroy the tubercle-bacilli so slowly and only in such high concentrations that their application is impossible without endangering the patient. Therefore the prospects of directly destroying the bacilli in the human body had to be given up as impossible. We are now confronted with two questions: 1. In what manner does the tubercle-bacillus enter into the human organism? 2. Under what conditions is the tubercle-bacillus able to generate pulmonary consumption after it has entered the human organism? All investigations, both of earlier and later date have established the fact that the tubercle-bacillus is inhaled with the air, and then it is mainly the foul air which is accused. But foul air is especially found in such places where people congregate, as in rooms, barracks, factories, etc. As it is a fact that there are always several consumptives among a number of people, so in this case there will always be occasion to inhale the tubercle-bacilli that have been cast out by the consumptives. Therefore it is not the foul air in itself which generates pulmonary consumption, but the circumstance that in this connection there are always people present which are able to spread and scatter the bacilli. Luckily the physical qualities of the tubercle-bacilli are such that they mostly adhere to the ground or floor and are rarely scattered in the air as dust; otherwise pulmonary consumption would be much more frequent than it is at present. Unfortunately the bacilli are very often spread through uncleanliness of the people, because they touch objects with their fingers to which the tubercle-bacilli chance to stick and then they touch their mouth or nose with these fingers. In this way bacilli can be taken into the system especially easily with the food. Children are particularly exposed to contamination, crawling about on the ground, on which, perhaps but recently, a consumptive has spit, and more so because they often have the habit to put all sorts of things and also the generally dirty fingers into their mouth. On the other hand there are various obstacles in the way of tubercle-bacilli entering the lungs. The distance from the mouth to the lungs is long and narrow; all sorts of projections check the further penetration of the bacilli. The trachea and the air-passages of the lungs possess equipments arranged for the purpose of ejecting small foreign substances, thus also to throw out the bacilli. In short it is not too easy a matter for the bacilli to penetrate into the lungs. And yet this happens only too often. For instance, in some people the passage from the mouth down may be a wide one, so that the bacilli can enter more easily; the protective arrangement by which foreign substances are removed may be deranged, it may be wanting in some place or its functionary qualifications may be bad; especially frequent this is the case after enfeebling diseases, which are associated with severe cough, as measles, whooping-cough, etc. This is the reason why pulmonary consumption is strikingly often observed to follow just these diseases. But the tubercle-bacillus can also enter the body with the food, as stated before. The acid gastric juice is a protective agent which considerably lessens the danger of infection by tuberculosis. It has not been definitely decided at the present time whether the drinking of milk from tuberculous cows brings with it the danger of tuberculosis for mankind. It will certainly be best to avoid such milk, especially when the cow's udder is found to be tuberculously diseased or when tubercle-bacilli can be traced in the milk. The use of meat as food may also become dangerous to man, but this is a rare occurrence. It is particularly dangerous to eat the liver, kidneys and lymphatic glands of tuberculous animals. The boiling heat while cooking generally destroys the bacilli contained therein and so lessens the danger from this source. It is of no little importance, to call particular attention to the fact that our chickens are very often severely infected with tuberculosis. The question, whether a consumptive can _infect his surroundings_, may be answered thus, that this does _not_ happen as a rule. Several unhappy circumstances must come together to make this possible. Above all things a direct transmission of tubercle-bacilli in some way into the body of the healthy person, then the bacilli must cling and propagate in the same, which is only possible when there is an inclination to this disease, of course this inclination is quite common. Pulmonary consumption is _not hereditary_ in the strict sense of the word. Only an inclination to this disease is transmitted. As the danger of contagion of those having such disposition is very great, so as a rule the disease makes its appearance sooner or later. On the other hand it must be considered that the penetration _only_ of the tubercle-bacilli into the body is _not_ sufficient to generate tuberculosis. If they do not find the ground adapted to their nourishment and propagation they perish. It may be assumed that every person is placed in such circumstances at some time that he will take in tubercle-bacilli; but only a certain percentage will get consumption. In the remainder the bacilli perish without leaving even a trace. Very often the inclination to pulmonary consumption may be recognized from the external characteristics. As a rule the respective individuals have a slight body, thin lean skin, weak muscles, delicate skeleton, a long, narrow, flat chest, flattening of the regions over and below the shoulderblades, wide intercostal spaces, a winglike projecting of the scapulæ, long neck, clubby, knoblike appearance of the ends of the fingers. Furthermore it has been found, that pulmonary consumptives on an average have a _smaller heart_ than is essential to a healthy body. On the other hand the volume of the lungs of consumptives is very often abnormally large. There are a large number of _diseases_ that predispose to pulmonary consumption. It is mainly the _enfeebling_ action of the same, which brings about such results. For this reason the _chronic_ diseases contribute so much toward the multiplication of the number of consumptives, because they stipulate a continuous weakening of the organism and an emaciation of the system. To these belong Bright's disease, which very often turns into pulmonary consumption, greensickness or chlorosis, anaemia, continued febrile diseases, severe chronic suppuration, chronic catarrh of the stomach, frequent pregnancies, childbed diseases. Thus we may often see young chlorotic girls afflicted with consumption, especially when they marry young and enjoy the honeymoon to its utmost limits. Then also women will easily become consumptive when they give birth to a child every year, especially when the social conditions in which they live are of an unfavorable nature, and they are perhaps inclined to consumption already. Childbed on the whole inclines to arousing the dormant inclination toward pulmonary consumption. Of other diseases we have mentioned measles and whooping cough, as diseases that are only too easily succeeded by consumption. To these may be added typhus, especially when it is of a more protracted nature, and the reconvalescence is slow and incomplete. Furthermore all those workmen that have to do with dust, are exposed to the danger of being stricken with pulmonary consumption. The dust enters the lungs, irritates and injures the same and so produces a favorable soil for any tubercle bacilli that may happen to penetrate. On the whole metal dust is more injurious than mineral dust. Workmen, that are exposed to animal dust, as furriers, saddlers, brushmakers, fall prey to consumption much oftener than those, that fulfill their vocation in air pregnant with vegetable dust. According to statistics workingmen are stricken with pulmonary consumption as follows: of glass workers 80 per cent., needle grinders 70, filemakers 62, stone cutters 40, mill grinders, lithographers, cigarmakers, brushmakers, stone-polishers 40-50, millers 10, coal workers 1 per cent. Pneumonia may culminate in pulmonary consumption: but on the whole this rarely happens. Much oftener it is the case with Pleurisy. But it is assumed and rightly, that most people who are attacked by pleurisy, are already consumptive. A hemorrhage of the lungs may nearly always be considered a sure sign that consumption has taken hold of the respective individual; but such a hemorrhage certainly forms considerable danger to falling a victim to tuberculosis, if the individual is as yet free from the same. Age has a particularly decided influence on the origin of consumption; it is extremely rare before the third or fourth year, from that to the seventh it is more frequent; it most frequently occurs in the age from the fifteenth to the thirtieth year, and from there on the chances are again fewer. In very old age it is again very rare. There seems to be no essential difference as regards sex. _Insufficient_ or _defective nourishment_ acts as a promoter in various ways. Even the nourishing of infants with poor milk, with bread or flour-pap increases the disposition to pulmonary consumption. If this defective nourishment is continued, scrofula will surely follow and this is a stage antecedent to consumption. Pulmonary consumption is relatively more frequent among the _poorer_ than the _well to do people_, this is partly due to the meagre and scanty food of the poorer, and that they are obliged to subsist almost exclusively on vegetable diet. The higher the meat prices rise and the less the majority of the people can afford to procure meat, the larger will be the number of consumptives. The poorly nourished offer a good soil for the tubercle bacilli in consequence of their weakness. The tissue offers little or no resistance to the growth of the bacilli, these propagate and destroy the powerless and yielding organism with fearful rapidity. The _frequency_ of pulmonary consumption increases with the _size of the cities_, or, which is the same, with the number of proletarians. Extreme hunger and want are less frequent in the country than in the city. That the climate has an important influence on the appearance of pulmonary consumption has long been known. In certain elevated regions this disease seldom or never appears. This experience has been attained in Switzerland and many other mountain regions. Furthermore the Plateaux of Peru and Mexico are considered free from consumption, but also lowlands like Iceland, the Kirgheez steppes and the interior of Egypt are known to be exempt. _Damp and windy climate_, especially with very high temperature, or abrupt changes in the temperature promotes consumption; on the other hand it is less frequent in the more moderated climates, especially if they are dry. Now when the tubercle bacilli have settled in the lungs, they cause various symptoms. One of the most frequent is _cough_. In the beginning of the disease a short, clear but light, very often dry cough appears. During the further development of pulmonary consumption the cough becomes more periodic; it appears early after awaking, in the afternoon after dinner, and evenings at lying down; it may disappear entirely in the meantime or may be light only; but then as a rule it is no longer dry, but may be attended by expectorations of a varied nature. [Illustration: Section of a tuberculous knot in the lungs, in which two cavities are seen filled with numerous bacilli. The bacilli distinctly appear as dark lines as a result of the coloring. Enlargement 900.] [Illustration: Tubercle bacilli, Enlargement 2000. To the left bacilli without spores, to the right bacilli with colorless sections which are thought to be spores.] The tubercle bacilli destroy the lung tissue and change it into pus, which is coughed out. In this way larger and smaller cavities are formed in the lungs; finally the cavities may even take more space than the remaining lung tissue. When cavities have already been formed, coughing comes easy and with abundant expectoration. Toward the end of life the coughing and spitting stops as a result of the extreme feebleness and weakness. The violence and frequency of the cough depends mainly whether the larger bronchial tubes and the trachea are affected; the more this is the case, the more violent the inclination to cough. Further the strength of the cough depends on the excitability of the patient; the greater this is, the more as a rule will he cough. Sometimes the position of the patient is of influence; if he lies mostly on the diseased side the expectoration becomes more difficult and coughing increases. Coughing is generally that symptom which soonest attracts the attention of the patient and his surroundings. For that very reason consumption is in its beginning stages easily confounded with such other diseases as are also accompanied by cough. At the same time we know of exceptional cases where cough was entirely absent in the first stages of the disease, or was at least so slight that it was overlooked, and under such conditions the pale and poor appearance and reduced strength is mistaken for chlorosis or some other anaemic affection, also the existing febrile excitements are wrongly judged, or on account of lack of appetite or light derangements of the stomach a stomachic affection is surmised, until suddenly a hemorrhage of the lungs clearly defines the true nature of the ailment. On the other hand the cough may become so violent that vomiting is caused at the same time. Nevertheless many consumptives describe their cough as very unimportant on account of their innate sorrowless nature, and they will not even be discouraged by the gravest symptoms. Often however it is fear that induces the patients to make light of their coughing, their spitting blood, their losing flesh and to place but little importance on these circumstances. A _hoarse_ cough is a sure sign of a diseased _larynx_. Many consumptives complain of cutting pains between the shoulderblades, under the clavicles or in the side; but these are rarely intense and are often entirely wanting. Unfortunately it is unknown to the average layman that the internal organs may suffer extensive tearing down without an indication of pain. The _Expectoration_ of consumptives which is thrown out by coughing with great exertion, is but scant in the beginning, as a rule phlegmy, glassy transparent and sticky. It is one of the suspicious symptoms of developing pulmonary consumption if this lasts for any greater length of time. Sometimes sharply defined, yellowish stripes, at times branching, appear in the same. Later on the expectoration becomes more purulent, and of greenish-yellow or greenish-gray color. Still later the patients throw out rounded lumps of greenish yellow or yellowish green color, which flatten out like a coin in the spittoon. They sink in water which is a sign of forboding evil. _Blood_ appears in different quantities in the sputum of consumptives. Bloody streaks are of no importance; they may appear with every violent cough. On the other hand the casting out of _pure blood_ is indeed serious. The _quantity_ of blood thrown out during an attack may be very different, varying from a few drops hardly a teaspoonful, to hundreds of grammes, even more than a liter. It is generally light red, filled with airbubbles, foamy, and is largely coughed out in coagulated lumps. The coughing of blood is sometimes preceded by a feeling of oppression, rushing of blood to the head and palpitation. Some patients experience a sweet taste in the mouth even before the bleeding. In many cases all preceding symptoms are missing and the patient is suddenly attacked by blood coughing during some more vigorous movement, during the exertion of coughing or even without any direct cause. _Blood coughing_ seems to appear somewhat more frequently with the _female_ sex than with the male and has with them unmistakable relations to menstruation, as with the sick it often sets in before, often after or even during the same and at such times more frequently than at others. It is of great importance for the layman to know that a hemorrhage rarely leads to inevitable death. Fatal hemorrhages are always preceded by warning attacks. Blood coughing may appear at any stage of consumption. In some cases it is particularly lasting. Sometimes the patients experience considerable relief from their feeling of oppression after a hemorrhage. A number of the consumptives as a rule complain of _difficulty_ in _deglutition_. This is caused by ulcers on the posterior wall of the larynx. With many patients the _appetite_ is _undisturbed_ for a long time, and there are consumptives that will eat a comparatively large dinner during an attack of fever reaching 40° C. Generally the desire to eat disappears during the course of the disease, especially toward the end of the sickness. The _stool_ may be normal or costive, but is very often diarrhoetic. Twelve or more evacuations may take place during a day; as a rule they are much increased by gasses and are of bad odor. They weaken the patient very much and hasten the end. One of the most constant attendants during the course of consumption is the _Fever_. It is rather irregular. In cases of slow process the fever is often very insignificant; often it is only a state of general excitement that takes hold of the patient afternoons, slight dizziness, increased lustre of the eyes, slightly flushed appearance, somewhat increased pulse, which invites to test the temperature of the body by means of a thermometer, which by the way shows it to be about 38° C. With quick consumption the fever is generally high. _Sweat_ is also a characteristic sign. The exceedingly debilitating effect of night-sweats is well known. During the course of pulmonary consumption extreme _emaciation_ of the patient is brought about. All tissues are subject to the same, most marked is the disappearance of adipose tissue. This symptom is of the greatest importance as a continued increase in weight means improvement and even cure. Therefore weighing the patient from time to time gives a sure meter for the course of the disease. The _course_ of pulmonary consumption is very different. With quick consumption the end comes within two or three months. Chronic pulmonary consumption may last for years. With this improvements in the fine season alternate with deterioration in the winter. Concerning the former _treatment_ of pulmonary consumption, this will also be applied in the future in the same manner as far as preventive means and general hygiene is referred to. For every one will prefer to remain exempt from consumption although it may now be possible to cure those afflicted. The lately published and popularly treated precautionary measures, especially with reference to the expectoration of consumptives retain their full value. Henceforth the sputum is also to be thrown in a _spittoon_ which is either entirely empty or on account of easier cleansing has the bottom covered with a thin layer of water. It should not be permitted to fill the spittoons with sand or sawdust as the tubercle bacilli can be easily thrown up with the dust. In the case of a _sudden attack_ of _cough_ a _cloth_ should be held to the mouth to hinder spreading of the fine spray, the same should also be used for wiping the mouth. However the cloth must soon be dampened and cleaned. As bits of the sputum easily stick to the _beard_ especially the moustache overhanging the lips, therefore lung consumptives are advised to wear a short or no beard. _Glasses_, _spoons_, etc. used by consumptives must only be used by other persons after a thorough cleaning with hot water. The lungdiseased person should abstain from all active and passive _kissing_, in unavoidable cases kissing should be done on the forehead or cheek only, or hold out those parts only to be kissed. In the same way he should avoid to touch objects with his mouth that may possible be put in the mouth by other persons, especially children, for instance toy-trumpets. In the case of _death_ from pulmonary consumption, the walls of all rooms and apartments used by the deceased should be rubbed down with fresh baked bread, which is a sure method of removing the bacilli. The bread crumbs that may have dropped on the floor may be removed by a thorough scrubbing with soap, brush and lye. Upholstered furniture, beds, clothes and wash should be cleaned in a disinfecting place. Do not wait with precautionary measures till some member of the family has been attacked by pulmonary consumption, but make preparation to prevent the infection while everybody is still sound and healthy. This care ought to begin in a measure with the _birth of a child_. The same should not be nursed by a mother with diseased lungs nor by a wet-nurse with like affections. Generally wet-nurses are only tested for syphilis; scrofula and tuberculosis receive altogether too little attention. An important precautionary measure consists in the supervision of the _food_. The abattoirs and dairies should be placed under the supervision of practical physicians, and the sale of products derived from tuberculous cattle be prohibited. This refers to the milk in the first instance. Tuberculous cows should be excluded from dairy-farms. Raw milk should be avoided as much as possible as boiled milk has the same value. The _meat inspection_ must be strictly conducted especially with reference to tuberculosis in the case of beef, pork and chickens. Sheep are not subject to tuberculosis. The _associations_ of children in school and on the play-ground should be watched; do not let them visit in strange families before making thorough investigation as to their sanitary relations. The health of _servant girls_ should receive greater attention than formerly, as the disease is often carried into the house by them as investigation has proven. In the _schools_ and kindergartens the teacher ought to insist that children do not spit on the floor or in the handkerchief; in case of necessity he should keep sick children out of school and he should especially follow these precautionary measures as regards his own person. The _cleaning of the floor_ of a room should always be done in a damp way. _Moving_ into another house it is advised to rub down the walls with fresh baked bread. As regards _societies_, every society and every health resort without exception and if possible every hospital should be obliged to have its own apparatus for disinfection and to make extensive use of it. Smaller societies may unite to procure an apparatus of the kind. Especial attention should be given to the _sprinkling of the streets_ during the dry season. The state and the larger congregations should make it a point to maintain _institutions for consumptives_, beyond the city limits if possible, a healthy location in the country preferred. Every one individually protects himself best from consumption by a methodic habit of _washing with cold water_, cold rubbing and baths. River and sea baths are generally of excellent results; short shower baths with cool water lasting 20-40 seconds are to be applied later on; they do not only harden the skin but excite deep inhalations and exhalations and in that way act as gymnastics of the lungs. More direct is the action of muscular exercise, such as gymnastics, riding horseback or bicycle, driving, skating, rowing, etc. The carriage of children must be regulated, the drooping forward of their shoulders must be corrected by strengthening the muscles of the back and shoulders by means of dumbbell and other exercises. All this must still be observed in the future. On the other hand above all the numberless remedies will be dropped that have heretofore been applied as presumably specific remedies for consumption. Creosote, which was so much praised at its appearance a few years ago and still applied, because of the non-existence of a better remedy, will be dropped into obliteration and with it Guajacol which was just getting to be the "fashion". All the various inhalation methods that have matured in later years will disappear from the picture plane as far as this has not ever now happened. The medical remedies, which were given for the torturing cough, for hemorrhage of the lungs, sweats etc., will in most cases be superfluous after this. Hemorrhages will now and then still be experienced as the same may set in unexpectedly. The diatetic cures with whey, koumiss, grapes etc. will retain their importance and also the bathing resorts will be hunted up by patients as formerly. The owners also of special institutes for curing pulmonary consumption need not despair with the idea that they will not be needed in the future. On the contrary, those needing cure will flock to them in all the greater numbers, as they now know that they certainly will be restored to health within a definitely limited time. The other forms of Tuberculosis. Of the other forms of tuberculosis _laryngeal consumption_ is very often combined with pulmonary consumption. It is estimated that this is true of at least one-fourth of all cases of pulmonary consumption. At first laryngeal consumption can not in any way be distinguished from an ordinary inflammation of the larynx. A certain weakness and sensitiveness of the organs however is suspicious, also great liability to hoarseness. On the other hand laryngeal consumption may exist without any sort of ailing to the patient. These appear later, however, when lung tuberculosis is progressing. The larynx shows more distinct outlines on the lean throat, difficulty in swallowing is experienced, pains radiate toward the ear. Food and drinks come up again after being swallowed. The painful cough has a hollow, barking, harsh sound, provokes vomiting, and the sputum together with foul breath consists of foamy, slimy, purulent lumps. Breathing gradually becomes more difficult and louder. As regards the duration of laryngeal consumption it generally runs parallel with pulmonary consumption. If the latter progresses more rapidly so also will the destruction of the larynx by the tubercle-bacilli be a more rapid one and vice versa. In several cases it has been observed that, if pulmonary consumption progressed or remained without any extraordinary symptoms, those with diseased larynx have lived for years, with alternating improvements and diminutions, and also an occasional suspension of all symptoms, till on account of often only a trivial, evil influence a new stimulus is given and the disease found an unexpectedly rapid completion of its course. Until now only few cases of laryngeal consumption could be looked upon as really cured. Lately it has been tried to accomplish cures especially by the application of caustics. This will not now be necessary. But those afflicted in this way, will henceforth be obliged to try and live in air free from dust, to travel south during the winter and to subject themselves to a general strengthening treatment. _Tuberculosis_ of the _tongue_ is relatively very scarce. The individual in such a case nearly always shows pronounced pulmonary tuberculosis. Sometimes tuberculosis of the tongue is combined with tuberculous sores on the lips and also on the anus. Tongue tuberculosis forms small ulcers, generally on the rim, very seldomly on the back of the tongue. They always are very small, generally about the size of lentils or peas. They often remain unchanged for months. At times they are very painful, though as a rule the pain is mild. The male sex is attacked by tongue tuberculosis especially frequently. The treatment before this consisted in cutting out all the diseased parts; now it will be much simpler. _Nasal tuberculosis_ appears similar to the common stopping up of the nose. But when ulcers are formed, the secretions from the nose take on a purulent somewhat malodorous character. But if the affection is neglected, the secretion becomes bloody and of very bad odor. Until now nasal tuberculosis had been treated by applying caustics to the ulcerated portions. _Tuberculosis of the intestines_ or _intestinal consumption_ is especially found in _children_. The appearance of the same is already characteristic; the limbs are emaciated and withered; the old-looking wrinkled face shows a harsh contrast with the immoderately expanded body (frog-belly) which is caused by an accumulation of gases in the limp intestines which are then filled to bursting. Many such children have succumbed to gradually progressing emaciation and weakness. Probably it will not be possible to save all children in the future that have been stricken with this disease as many are wanting in sufficient vitality to resist all external influences. With adults intestinal consumption makes itself known by everlasting diarrhoea, a result of the numerous ulcers in the intestines which have been caused by the tubercle-bacilli. _Tuberculosis of the brain and of the cerebral membranes_ also attack children especially. Before this no attempts have been made to try whether it is now possible to cure the _tuberculous inflammation of the cerebral membranes_ which has previously been unconditionally fatal. The decision will certainly soon be made. We will give a fuller description of the symptoms of this disease to thus enable timely summons of medical interference. This disease will be known to many as "acute hydrocephalus." As a rule children of 2-7 years of age are attacked by this fearful disease. The antecedents are extremely peculiar and manifold. Even two or three weeks before the outbreak of the real sickness, emaciation takes place from which the face is strangely enough entirely exempt, so that children, when dressed show no signs of a change. Attentive mothers and nurses, however, regularly notice the same and especially the appearance of the ribs causes no little anxiety. With this a slight pallor of the face is associated and a peculiar lustre of the eyes. The children lose their former feeling of gayety and activity. They sleep more than usual, withdraw from their favorite game, they become grumbly and shy toward their surroundings and cry for the slightest reason. It also is very peculiar that they avoid trying their former little tricks, such as climbing up on chairs, opening of door bolts that are almost out of their reach, they even will not try to look through a latticed window and asked to do so, decidedly refuse. Boys, that would not stand anything from their associates, that fought and wrestled as long as their strength permitted it, sneak away cowardly and crying from such attacks. Other children again become extraordinarily tender-hearted and affectionate, they hug their parents continually and can hardly console themselves when they leave them. In the case of older children that have already learnt something, teachers notice unusual inattention and indifference, committing to memory comes harder than usual and what is finally learnt is recited in an awkward and stammering way. The children sleep unusually much and often by day; on the other hand their sleep at night is less sound and is interrupted by horrid dreams, frequent turning over in the bed and frequent clamorous outcries. The appetite is lessened, and often a craving is noticed for stimulating food of which, however, little is eaten. Thirst is not increased. Urinal secretion is somewhat diminished and the urine is characterized by a brick-colored precipitate. The stool is rather costive, especially with larger children; but diarrhoea may attend this disease. The latter is principally the case with small children that are in the stage of first teething. Headache is rarely felt and hardly ever complained of even by larger children; dizziness and unsteady walking is frequently observed. The children quite often complain of stomach-ache, which is very much increased by pressure on the abdomen. Fever is not generally attendant, but the same may be present. The symptoms just described, separately or collectively, gradually increase; the children finally take to their bed and now the _real cerebral affection_ developes. Now the principal symptoms are: vomiting, constipation, slow pulse, irregular abrupt breathing, increased temperature of the skin, contracted abdomen, headache, great excitement alternating with drowsiness, beginning decrease of reason, and deranged ability of moving the limbs. As regards _vomiting_, this is almost a continuous symptom and generally appears in the earlier stages. But the duration of vomiting is very different. Some children vomit only for one or more days and not all they have eaten, while others vomit continuously from the beginning of the disease till they are relieved by death, and no food can be found that is not thrown up shortly after its being eaten. In this connection it is a peculiar fact that vomiting will not recur if it has once ceased for twenty-four hours. Very important for the recognition of the disease is the manner of vomiting. For a child suffering from a spoiled stomach will be troubled with nausea, belching, choking and cold sweat long before it is forced to vomit, while children with acute hydrocephalus will throw up without any previous symptoms of that kind, just as though they filled the mouth with water and spit it out again. Vomiting is facilitated when children are raised or placed on their side. It ceases for the time the stomach is empty, but as soon as fluid or even solid food is taken in it will be cast out at once without causing any particular distress or inconvenience to the child. Gall is very rarely mixed with the vomit. A second and nearly as constant a symptom is _constipation_ from which nearly three-fourths of the diseased children suffer. As a rule cathartics have no effect and are generally thrown out through the mouth. This constipation will not last till the end, for a few pappy stools appear later on whether purgatives are administered or not. Violent diarrhoea resulting from intestinal tuberculosis may be discontinued at the beginning of acute hydrocephalus. But the later stools will again be thin and of cadaverous odor. During the latter stages of the disease children will often _fail to pass urine_ for twenty-four hours, so that the physician is obliged to draw it off with a catheter. The appetite does not disappear entirely as a rule. There may not be any desire for food, but generally little difficulty is experienced in inducing children to take milk or broth, which is all the more surprising as vomiting regularly follows. The _fever_ is generally not very intense. The temperature of the head, especially the forehead, is considerably increased in all cases and remains so until death ensues, while the feet have great tendency to getting cold. The _pulse_ is characteristic in many cases. In the beginning of the disease the pulse is quickened only to slacken after a few days. The number of beats may be reduced to 40-60 a minute (normal 90-100), however it does not commonly remain at a certain figure, but varies, often inside of an hour, so that at one time 40, then 60 and again 80 beats may be counted inside of twenty-four hours. The pulse again increases 1-3 days before death and then to such a rate that it is almost impossible to count it. It may reach 180 and 200 beats a minute. As soon as this rate of the pulse follows one of the reductions described above a speedy death may be predicted. Of great importance are the variations in respiration. In the beginning stages of the disease breathing is normal except in such case where tuberculosis has made great progress in the lungs and in the case of high fever. Then of course breathing becomes more rapid. Acute hydrocephalus influences respiration in such a way that it slackens and becomes irregular. In one minute children may breath fifteen times, in another thirty, then again 20 times; at one time breathing may be very slight with almost invisible expansion of the chest and without any noise whatever, then again it may consist of deep sighs; these are also characteristic of this particular disease. Sometimes breathing is completely discontinued for ten seconds and more. If the pulse attains that extreme rate shortly before death the rate of breathing will also be increased. As regards the _skin_, the same is generally damp from the beginning of the disease; severe sweats are observed on the head; with progressing disease the skin becomes dry, brittle, comes off in flake-like scales and only when the death-predicting increase of the pulse sets in, there appears a profuse sweat, the cold sweat of death. _Headache_ is also a prominent and pretty nearly constant symptom. As has been mentioned before, it does not as a rule attend the precursory symptoms. It generally begins with vomiting and soon becomes so violent that older children constantly cry aloud and lament, while the smaller ones put their little hands up to their head, pull their hair and ears and restlessly roll about on the pillow. These expressions of pain last as long as children retain consciousness, a particular part of the head is not commonly pointed out, but asked about it the majority point to the forehead. With small children automatic movements are noticed that also seem to refer to headache, and which consist in rapidly placing the hand on the head and then drawing it back. The larger children complain of _pains in the bowels_, especially in the region of the stomach, which remarkably often, though not regularly, become more intense by pressing and may become so violent that the children cry out aloud with pain, when the stomach or other portion of the abdomen is but slightly touched. But these pains do not last as long as the headache, they often stop suddenly, at times return. The shape of the _abdomen_ is extraordinarily characteristic. In the beginning nothing remarkable can be noticed, but after the symptoms of acute hydrocephalus, vomiting, constipation, etc., have lasted for some time, the abdomen gradually decreases in size, becomes wrinkled and collapses until it finally assumes a scaphoid shape and by slight pressure the large iliac artery can be felt on the spinal column. This contraction of the abdomen is attendant in every case of tuberculous meningitis. If the large _fontanel_ on the head is not yet closed, the same will gradually bulge out as the disease progresses. The _mental activity_ suffers premature derangements, such as have been fully mentioned in the description of the precursory symptoms. The most striking is the confused, staring look, the peevish and surly behavior, and again in other cases the extreme indifference toward otherwise well-liked persons and things. Later on actual delirium sets in, but generally of a quiet nature. A very common symptom is a loud, plaintive outcry, that is repeated at longer or shorter intervals. Children often cry out at partly regular intervals during a whole night; these cries are always accompanied by a loud sigh. These symptoms of excitement being extremely tormenting and depressing for the sympathizing relatives, fortunately last no longer than 6-8 days at the most, and are succeeded by a deep _stupor_. If the children have once become _unconscious_, they do not recover again as a rule but remain so until death; delirium and stupor may alternate with each other in certain cases, but the former process is by far the most frequent. _Convulsions_ appear only in the later stages. At first the interval between the attacks are long, often as many as three or four days intervene. Commonly however they come much oftener and may in some cases last for hours. All extremities are affected by these convulsions, the eyes become red, are rolled in every direction and turning way up are fixed so that nothing but the whites is visible. After several minutes, often after two or three hours, these general convulsions subside, the children, now very pale, drop into a deep sleep and their general condition appears much reduced. Different muscular groups especially those of the face are subject to _local cramps_. The upper lip may become distorted, convulsive smiles have been observed, also peculiar sucking motions. The children point their lips and flatten them again, sometimes for hours in succession. In the latter stages a squinting of one or both eyes may be noticed but this may again disappear. _Grinding of the teeth_ is another very peculiar symptom which is well-known and feared by experienced nurses. The _arms_ are subject to various motions, at times sweeping automaton like, then again convulsive contractions, sometimes trembling of the muscles, at others a throbbing of the tendons. Many patients put their hands to their sexual organs and make motions tending to onanism. The _legs_ are not subject to cramps as much as the arms; they are mostly bent and drawn up in a half paralyzed condition. The _muscles of the neck and back_ are very much contracted and most children, when raised or laid on their side, bend the head far back. In most children an extreme sensibility at being touched is observed. They may be handled with the greatest possible care and lifted most tenderly, a slight pressure on the head, body or hands in changing their position will be violently resisted with obvious expressions of pain. In the latter stages this extreme sensibility gives way to _insensibility_. Then the children may be pinched and poked, they may be turned and moved from one side to the other without any consideration, they will not resist and only give expression to the remaining sensibility by a low whimper. The lack of sensibility may be especially marked in the eyes; these can be touched with the fingers, without causing a closing of the lids. The sense of _hearing_ seems to continue its functions until very late. Children show that they hear as long as they are not completely unconscious; even when addressed in a low tone of voice they react somewhat. The sense of _smell and taste_ also are lost toward the very end of the disease. _Paralytic_ affections appear during the final stages. It has been observed in some cases that the arm and limb are paralyzed on one side only. Often one upper eyelid is paralyzed and hangs down on one side of the face and the muscles of the tongue may be affected. Generally the patient dies after violent general convulsions that last for hours. Exceptionally only the paralytic symptoms increase gradually and cause death without any agony or struggle, simply a discontinuance of the functions constituting life. The duration of the disease varies from 2-4 weeks from the beginning of the characteristic symptoms. Generally the day when the children take to the bed is fixed as the beginning of the disease. The former methods of treatment have been a signal and absolute failure in every case. Every child that has once been attacked with this disease has heretofore died. Until now Koch has not been able to make any experiments with acute hydrocephalus, so that it remains an open question whether it is now possible to cure this disease. Besides tuberculosis of the cerebral membranes with which children are afflicted, _tuberculosis of the brain_ may occur, although this disease is very rare. Tuberculosis of the brain appears in the shape of small tumors in all parts of the brain. After longer duration of tuberculosis of the brain, tubercular meningitis appears. The process of this disease may be varied. In some cases the development of cerebral tuberculosis is manifested by the sudden appearance of high fever temperatures or violent headache; to this may be added, slackening of the pulse, vomiting, stiff neck and isolated cases of palsy; sometimes an attack of convulsions is the first manifestation. In other cases the beginning can not be accurately determined, as the beginning symptoms of the disease are so slight as to escape notice. Impaired process of nutrition, languor and headache are symptoms from which the existence of some serious affliction may be inferred without being able to determine its nature in the earlier stages. Again in other cases the disease may proceed through all its stages without any cerebral appearances whatever. This is especially true of small tubercles and of diseases of infants. However, we more frequently observe in children than in adults convulsions of varied intensity and distribution. Nutrition is more and more impaired as the disease progresses, in isolated cases only, a temporary improvement may be observed. The _end_ of cerebral tuberculosis has been _death_ before this. Ten days to two weeks, even three weeks may pass from the first appearance of tubercular meningitis to the completion of the process of the disease, attended by feverish motions characteristic of this condition and by cerebral symptoms, first with the character of excitement, later on with that of palsy. The treatment of cerebral tuberculosis has been entirely insufficient before this. Let us hope that it will be possible to effect a cure by means of Koch's new method. _Tuberculosis of the Kidneys_ is met with from the earliest childhood till old age. Most frequently the male sex is afflicted during manhood. In most cases tuberculosis also exists in other organs, especially in the urinary and sexual apparatus. The existence of pulmonary or intestinal tuberculosis is not essential. The symptoms of renal tuberculosis are of such general and indefinite character, that it is often impossible to fully determine the disease. Now, however, it will be more easily possible on account of Koch's discovery. The _urine_ may, but need not contain pus and blood. Sometimes small lumps are found in the urine. _Pains_ are only sometimes felt in the renal regions; _fever_ may be occasionally attendant. The disease lasts for months and years; though before now it has inevitably resulted in death, though it has in exceptional cases taken ten years or more. The internal treatment of renal tuberculosis was ineffectual, surgical treatment has been attended with greater success. This consisted in removing the diseased kidney. Now good results will possibly be attained by the application of Koch's method to cure and resource to surgery will be taken in exceptional cases only. _Tuberculosis of the suprarenal capsules_ is of very rare occurrence. It leads to a peculiar change in the color of the skin; the same turns dark brown or bronze color. Sooner or later death results. Perhaps the application of Koch's method will, besides curing the disease, give us information regarding the functions of the suprarenal capsules about which nothing whatever is as yet known. A large space in the realm of disease is claimed by _tuberculous affections of the bones and joints_. These afflictions appear particularly in childhood though manhood is by no means exempt. They may appear in all portions of the body, although a marked preference is shown for certain parts. Although the tubercle-bacilli are infinitely small, they possess the power to cause suppuration of the bones and joints and to produce acute inflammation of these parts. Most frequently tubercular affections of the bones are found in the hip-joints, the knee and the spinal column. _Tuberculous inflammation of the hip-joint_ is principally a disease occurring in childhood; though it rarely appears before the third year. It is most frequent from the fifth to the tenth year. Inflammation of the hip-joint developes very slowly in children, it generally takes months before the slightest beginning symptoms reach a threatening appearance. The first sign is _lameness_; among laymen tuberculous inflammation of the hip-joints is known as "voluntary limping." By limping we understand that mode of walking in which one leg is spared and by this the trunk is supported only a short time by one extremity and all the longer by the other. In every painful affection of the lower extremity limping results as the weight of the body increases the pain. The lameness in the case of diseased hip-joint has something peculiar about it, inasmuch as not only a part of the extremity but the whole of it is dragged. For this very reason parents of children afflicted with inflammation of the hip-joint use the expression "the child draws" or "drags the leg". In the beginning even the examining physician finds no symptoms of disease in the joint. No swelling, no abnormal position, no restriction of the freedom of motion, no pain from pressure or while moving, in short nothing can be found that would otherwise indicate the beginning of an inflammation of the joints. Yet _lameness only_ is sufficient data from which we may infer the probable beginning of hip-joint inflammation. It is much better to overestimate the significance of this symptom than to miss the proper time for calling in the aid of a physician by placing too little confidence on it. The second symptom, _pain_, rarely attends the beginning of lameness, generally it comes several weeks later and in the case of very slow development of tubercularly inflamed hip-joint several months later. In very small children the attendance of pain is manifested by the fact that they will not play and they often wake up in the night and begin to cry. Children from the fourth and fifth year upward definitely point out the hip as the seat of pain, sometimes, however, the knee-joint on the diseased side is designated with great determination. This pain in the knee has often been the cause of mistakes. Later on painfulness of the hip-joint is experienced from pressure and at about the same time the movements are impeded. Then the leg takes a peculiar position. The thigh is slightly bent and rolls outward. For convenience the child drops the half of the pelvis corresponding to the diseased hip-joint, and naturally raises the other half. From this apparently a curvature of the spinal column results in the lumbar region. Apparently only, for when the child is laid down and the morbid position of the thigh is restored the curvature of the lumbar column disappears. During the further progress of the disease the pain is increased, and the sensibility may become so acute that the slightest movement of the limb, even a shaking of the bed in which the patient lies will cause the most intense pain. In the previous stage walking could only be done for short distances and then awkwardly, now it is entirely impossible. Children are obliged to lie in bed night and day, and under these altered conditions there is a change of the position of the extremity. The increased sensibility induces the child to seek the medium position, the leg is bent more than in the position mentioned above, it is halfway straightened. To this is added, that the child can not lie well on the sensitive and swollen hip; with right side hip-joint inflammation it turns on the left. As the diseased and bent thigh does not then rest on the mattress the same is placed on the healthy limb for support and for protection from movements, in the same manner as we lay one leg on the other in a healthy condition when we sleep on our side. The actual danger to life in tuberculous hip-joint inflammation begins with the time when the child takes to his bed. The fatal end comes almost without exception after suppuration has commenced, very rarely before that time. Total suppuration of the hip-joint is an almost absolutely fatal process. If this suppuration sets in suddenly, it may result in an early death with attendance of acute fever. In other cases several weeks may elapse from beginning suppuration till death. A complete cure of tuberculous hip-joint inflammation may come about spontaneously. But often the knee remains bent and unserviceable for walking, so that crutches or machines must be used. Even before this the beginning stages were treated with fair prospects of success, and it is a lamentable fact that in many cases the import of these seemingly trivial symptoms has been underestimated. _Rest_ is of the greatest importance during the very first stages of the disease in which the attending symptoms are of so indefinite a character that it is almost impossible to know whether hip-joint inflammation will develop or not; the child must not be allowed to walk. Aside from this the application of brine-, malt- and sea-water baths is advised. An abundance of nourishing food is of just as great importance. All this will also retain its significance in the future. Formerly recourse to surgery has been taken during the later stages of the disease in which suppuration of the internal parts of the joint has commenced and large parts of the diseased bones may have become mortified. An incision is made into the joint, the same is exposed and all diseased portions are carefully removed. In the future this operation must probably also be performed, although with the difference that the prospects of success are now much more certain than formerly when relapses only too often followed the operation. _Tuberculous inflammation of the knee-joint_ is, as said before, very frequent with children and is rather lingering in the beginning. Here also a slight dragging or limping of the diseased leg can be noticed. The child when asked about the limping, or of its own accord, complains of pain in the joint after walking or when the part is pressed; at first nothing abnormal can be seen on the knee by the layman. On closer examination, however, by comparing the two knees it will be found that the grooves on each side of the patella, which give the healthy knee-joint the beautifully modeled shape, have nearly or quite disappeared; nothing more can be noticed. The hinderance in motion may be so insignificant, that the children may slightly limp about for weeks and months and complain but little. Generally the physician is not called until the limb begins to hurt and swell after continued exertion. The swelling which in the beginning is hardly noticeable is now more plainly visible, the knee-joint is evenly rounded and quite sensitive to pressure. If the disease is not now properly treated, its further course will be as follows: the patient may perhaps linger for several months; then comes a period when he must keep to his bed uninterruptedly because moving results in too much pain; generally the limb becomes more and more bent. Now particularly painful points appear on the joint, especially on the inner or outer side or in the bend of the knee; on one of these points a soft portion distinctly developes, the skin becomes reddened and finally suppurates from the internal parts outward and breaks after a few months; thin purulent matter mixed with flakes is discharged. The pains now cease, and the condition is improved; but this improvement does not last; soon another abscess is formed and thus it continues. Meanwhile perhaps two or three years may have elapsed; the general condition becomes greatly reduced. The child, formerly strong and healthy, has now become lean, the discharges of matter have often been attended by acute febrile attacks; the patient becomes exhausted, loses his appetite and digestion becomes more impaired from week to week. Even now a spontaneous change for the better is possible, though this happens very rarely; more frequently the disease progresses and leads to death from exhaustion resulting from severe suppuration and continual attacks of fever. Restoration to health is indicated by decreased suppurative discharges; the openings of the fistulae contract, the general condition is improved, the appetite is restored, etc. Finally the fistulae heal, the joint becomes fixed at an angle or bent or otherwise crippled, but painfulness disappears and the patient escapes with his life and a stiff leg. This is the most favorable result known to have been obtained in severe cases. The joint may become a solid bony immovable mass or may admit of slight movements. The whole process may last from two to four years. The former treatment of tuberculous inflammation of the knee-joint was either of a general or a local nature. The general treatment was designed to strengthen and nourish, and will continue to be applied in the future. The local treatment consisted in the application of salves, brushing with tincture of iodine, spanish fly plasters, wet and dry bandages. As with inflamed hip-joint absolute rest by lying in bed is of the greatest importance. If after a certain period of rest and application of the above-named remedies no improvement in the state of health could be noticed, the diseased joint was laid in plaster or confined with splints. If even then, after such treatment for months, no improvement could be noticed but rather that the general state of health was reduced, nothing remained to be done excepting an operation, by which all the diseased parts of the knee-joint were removed, or amputation, that is, the taking off of the diseased limb. The latter method was generally adopted in the case of feeble and emaciated individuals and those who had passed the age of early manhood, as with these the removal of the diseased parts did not, as a rule, result in an improvement of the general condition, which was especially intended. Now tuberculous inflammation of the knee-joint will be treated by Koch's method and in extreme cases only will operation be necessary. At all rates, an absolute cure will be easily effected. Aside from the hip- and knee-joint the _spinal column_ is most frequently attacked by tuberculosis. Here also it is the youthful age, from the third year upward, that has to suffer most from this serious disease. Adults are rarely attacked by it and with them it generally appears in connection with general tuberculosis. The tubercle-bacilli penetrate into the substance of the vertebrae, destroy the same and transform it into purulent matter. As a result the destroyed vertebrae sink or rather settle down and cause a curvature of the spine, in other words a humpback. In the beginning the symptoms of diseased spine are very indefinite and misleading. The patient rarely complains of pain at first, and it is only noticed that the sick child easily tires of standing or walking and tends to hold on to chairs and similar objects with his hands to relieve the spinal column of the weight. From such uncertain data it is of course impossible to recognize the disease. Only then when the softened vertebrae give way under the weight of the body, that is when the humpback begins to develop, can tuberculous inflammation of the spine be surmised with any degree of certainty. As a rule two other characteristic phenomena appear which are dependent on the pain in the affected spinal column. The child, while standing, places his hand on the thighs and thus directly supports part of the weight of the trunk with the lower extremities; at the same time he avoids bending the spinal column forward. This anxious care for the diseased vertebrae is especially noticeable when the child attempts to pick up an object from the floor. While the healthy child bends freely forward, the sick one crouches down and while bending the knee and hip keeps the spinal column as straight and stiff as possible. Frequently a small spot on the spinal column is found to be extremely sensitive to pressure in this stage; but such a subjective symptom must be considered with caution especially with children. This humpback, which is a result of tuberculous inflammation of the spine, must not be confounded with the humpback caused by rickets. With the latter the curvature is more uniform as a rule, and in the start at least, disappears while in a horizontal position. Besides the humpback resulting from rickets appears between the first and fourth years of age, while tuberculous inflammation of the spine rarely begins before the fourth year. And finally rickets never causes suppuration while this is always the case with inflammation of the spine. The progress of suppuration is downward as a rule and does not admit of examination until it gets near to the surface of the body; before this the feverish conditions toward evening are the only signs that indicate beginning suppuration. Ardent fever is not attendant during this time; the temperature does not exceed 38 or 38.6° C. and even such trifling increase of temperature may be wanting. As soon as the skin is reached by the originally deepseated centres of suppuration, it gradually becomes red and later on also suppurated. If the skin is broken and the matter discharged, great care must be taken to keep the wound clean, as otherwise the suppurative cavities may suddenly become ichorous and lead to rapid death. In other cases this extreme result is not caused and fistulae are formed from which the ichor constantly flows. Small bits of mortified and broken off bones may be thrown out with the matter. As a result of the sinking and settling of the vertebrae the spinal chord may suffer from pressure and contusion as it is contained in a channel formed by the vertebrae. Aside from certain pain it may result in paralysis of certain parts. Formerly the diagnosis of tuberculous inflammation of the spine in its beginning stages was very uncertain. A great number of afflicted are at present cured by surgical treatment; in former times this was not possible, as the majority of patients died in whose case the disease had progressed to suppuration. But the curvature of the spine could not be removed by any former treatment and can not be by Koch's new method. Vertebrae once destroyed can in no way be restored to their normal condition. Nevertheless the number of patients whose life is spared will be a still greater one and the number of complete cures will also be increased in a short time. Formerly tuberculous inflammation of the spine was treated as follows: the abscesses were opened and antiseptics carefully applied: mechanical apparatus and corsets were used to aid in a natural cure. These apparatus will surely be of inestimable value at the application of Koch's method. As has been stated before tuberculosis may attack all other bones and joints and there cause the most serious derangement. Formerly these tuberculous afflictions were treated surgically or by means of iodoform, which has produced pretty good results in certain cases. However it will certainly be possible to produce still better results with Koch's method of treatment, especially in the restoration of the functions of the afflicted parts. Here, as in all tuberculous affections, it is particularly essential to subject the respective case to treatment in as early a stage as possible and before incurable destruction of the tissues of the bones and joints have been caused. A certain disease of the skin called _lupus_ (ringworm) must be counted in with the number of diseases generated by the tubercle-bacillus. Lupus may begin in two different ways. Either in the form of a purple spot, which is raised above the level of the skin and which has no definite limits but blends with the healthy parts; or as a slightly raised, moderately firm, darkred grain, sharply limited and about the size of a pinhead or millet seed. If the disease has begun in the shape of spots, the afflicted portions of the skin gradually swell during the process of the disease. Several isolated knots appear around which the disease spreads more and more. While the disease thus takes possession of greater area and developes new centers, a uniform scaling off of all knots begins. After prolonged existence, sometimes after short duration, decay and casting off of the epidermis in its entire thickness supercedes the scaling process, and suppuration transforms the ringworm into an ulcer covered by a dirty-brown rind and disagreeably colored serum. The ulcers of lupus are of various, generally irregular shape, the rims not hard, the ground flat and covered with purulent matter and decayed tissue; they are commonly surrounded by a faint reddish areola. These ulcers gradually become epulotic and form irregular, generally slightly protruding white scars in which new tubercles may appear. Lupus appears most frequently in the face and especially frequent on the nose. Sometimes its appearance is indicated only by an inflammation and swelling of the mucous membranes of the nose and at the same time a reddening of the epidermis. The nostrils are stopped up by a thin rind which, if torn off, is replaced by a thicker one below which an ulcer is formed that spreads with greater rapidity on the mucous membranes of the nose than on the external epidermis of the same. Sometimes the whole process on the nose is so rapid, that very often the physician is not called to the patient, before a large part of the wing of the nose or of the nasal epidermis is destroyed and deep ulcers have developed under the rind. New tubercles of lupus are commonly noticed to spring up on the margins of these ulcers; the cartilage as a rule resists the progress of the disease for a longer period and may be unhurt, while the skin on the wing of the nose may be completely destroyed. Frequently the process is extended to the mucous lining of the hard palate and to the gums. Lupus generally appears on the lips in the same manner as in the nose. The upper lip especially appears very much swollen and covered with ulcers after a prolonged existence of the affection. Sometimes even the aperture of the mouth itself is reduced in size by the development of ulcers and scars on the surrounding parts. If the process extends to the lower eyelid, the connective tissue as a rule becomes much swollen and reddened. The malady especially attacks the inner angle of the eye, destroys the entrance of the lachrymal duct, and from there the lupous tubercles appear on the connective tissue. Gradually tubercular formations develop on the cornea and sight becomes impaired. On other parts of the face lupus generally appears in the form of small knots, about the size of millet seeds, which remain for a time then multiply and spread. The epidermis swells between these knots and irregular ulcers develop on a hard swollen and glossy ground, and are covered by dark brown rinds. Tubercles appear anew on the margins of the ulcers and in the spaces between them, isolated whitish spots of sunken or raised scab tissue are observed on which very frequently lupous tubercles again develop. Lupus appears on the throat, neck, back, breast, and the extremities, most frequently in serpentine form i. e. swellings of the skin develop, being arranged in curves, they progress in the same manner, these are transformed into just so many ulcers. Between these whitish scarred spots are noticeable on which small red lupous tubercles again appear. Lupus is more frequently found on the extremities than on the trunk. The surface of the skin is found to be tense and glossy on a firm base which is affected by lupus. Deep ulcerous formations of lupus are sometimes observed on the fingers and toes, particularly on the finger-joints, these may at times penetrate into the inner parts of the joints, secreting whitish pus and covered with a thick rind. As regards the difference between lupus and syphilitic diseases it has been found that lupus commonly developes before puberty while syphilis appears in the mature age. The ulcers of lupus are often round like those of syphilis with sharply defined margins, but at the same time they are flat accompanied by little or no pain; rim and base of the same are loose, red, rank, and bleed easily. On the other hand syphilitic ulcers are very painful and rim and base are covered with greasy matter. Lupus appears only in the form of knots, which are deeply inbedded, from size of a pinhead to that of a lentil, but never as large knots in the beginning. Syphilis produces large and palpable knots from the start. Loss of the bony part of the nose or destruction of the hard palate are observed, but rarely and after protracted existence of lupus, and often in the case of syphilis. The indicated peculiarities however refer only to typical cases of lupus and of syphilis. In other cases it was almost impossible to show a difference. As regards the course of lupus, the same begins, as has been stated before, in earliest childhood, sometimes only in the form of scaly spots and knots. Less often lupus developes after complete development of manhood. It is more frequent with women than with men. Sometimes some of the knots remain isolated and disappear again after a time; in other cases additions appear in the course of time, which may affect larger portions of the body and lead to more or less dangerous ulcers. As a rule the course of lupus, even of great extent, is not malignant and at the most the alliance with _traumatic erysipelas_ and possibly the appearance of _pulmonary consumption_ may succeed the affliction. In cases of not too rare occurrence it has been observed that lupus has developed into _cancer_, which has always resulted fatally. The _treatment_ of lupus has principally been a _local_ one. Caustics were applied to destroy lupous tubercles by direct action, and furthermore recourse has been taken to the so-called mechanical treatment, in which the ringworm was scraped out. Our experiences relating to the mechanical treatment of lupus have taught us the following. Lupus can not be cured without destroying and removing the diseased and affected tissue. That method which effects the most radical destruction, protects most from relapses. Therefore the best method of treating lupus is to cut out the diseased skin. But with the superficial spreading peculiar to many cases of lupus this method can only be applied within certain limits. Then again the secondary growths after an operation may be of serious consequences. Unfortunately it has not been possible before this to remove all diseased portions, no matter what method was applied, because often tiny lupous tubercles spring up which are almost invisible to the naked eye. These tubercles will again be the starting point for another spreading of lupus. We will see that Koch's new method to cure has the advantage both to make visible all tubercles, even those that have escaped our notice and also to effect a cure in the shortest time even in old chronic cases that have before this been considered incurable. It is especially possible in this form of tuberculosis to follow the specific action of the new remedy, as we will learn later on. _Tuberculosis of the testicles_ is not so very rare, it is found in about 2-1/2 per cent. of all men afflicted with pulmonary consumption. It is more rarely met with in children than in men. The conditions under which tuberculosis of the testicles and epididymis developes are various inflammatory processes with existing disposition. It is mostly gonorrhea or some other inflammation of the urethra, or injured testicle. It occurs less frequently without any apparent cause. According to the starting point of tuberculosis the symptoms are varied. If it starts in the testicle, this appears normal or larger in size, but never reaches extraordinary dimensions. The surface of the testicle is at first smooth in the case of increased tension, later only does it become irregular, bumpy and of unequal consistency. If the starting point is in the epididymis, hard, rounded lumps are formed generally in the head or tail of the epididymis, rarely in the body. These increase in size and cause a swelling often of extraordinary dimensions, the surface of which appears hard, irregular, bumpy and in certain parts yielding and elastic. If the process is extended to the testicle, this also increases in size. Then both together form an oval swollen mass and can not be distinguished from each other. Striking changes appear only later and consist in the softening of the lumps and in the development of abscesses. Very soon the lobuli are affected. The same are then thickened in the septa, are hard and form an irregular, bumpy swelling surrounded by more or less thickened tissue. Very soon tuberculous changes are caused in the prostate gland, an organ situated near the intestine and the functions of which are to dilute the semen. A hardening is often the first sign, this is followed by increase in size and then softening. With the affection of the prostate gland, that of the urethra also begins, which passes through the middle of the prostate gland. This disease often appears in the form of a yellowish secretion, which is more and more increased and becomes ichorous with the decay of the urethra and the prostate gland. This secretion must be distinguished from that which as a venereal affection caused the whole process. The tubercular derangements do not only extend forward but also upward. The bladder, the ureters and the kidneys are affected and show extreme derangements with altered urinal secretions and excretions. Of other symptoms of tuberculosis of the testicles pain deserves especial mention. The same is slight in the beginning, but often becomes insufferable. The symptoms here related often increase very slowly. Essential changes are caused during the chronic course of tuberculosis of the testicles if suppuration sets in. The skin is perforated and fistulae are formed. If there is no halt in the process, general tuberculosis results and this has until now always caused death. According to the time in which the general derangements come about, a chronic and acute tuberculosis of the testicles has been distinguished. The former is the more frequent, the latter of rare occurrence. The sexual functions may remain unchanged if only one testicle is diseased, but are generally ruined if both epididymes are affected, because the secretion of the semen is then interrupted by the stopping up of the vas deferens. In some cases the sexual function may be interrupted for a time only and may then be resumed. The treatment before this has been surgical, in which the diseased parts were carefully removed, and where this was impossible, even castration (removal of the testicle) was performed. Without doubt Koch's method will cause great changes in the method of treatment here also. Finally we must include in our reflection the well-known disease of children, _scrofula_. Although the same is not a form of tuberculosis in the sense of the diseases just considered, still tuberculosis and scrofula have the most intimate relations. Scrofula is only too often a precursory stage of tuberculosis. The manifold scrofulous affections, such as inflamed eyes, diseased ears, skin diseases, catarrh of the nose, pharynx or bronchials, inflammation of the joints and suppuration are not caused through the cooperation of tubercle-bacilli. But here the same find an excellent soil for growth and propagation, and they use the same to the full extent and so give the impetus for the development of tuberculosis. Scrofula is one of the most frequent diseases, it is spread over the whole world. It occurs more seldom in the tropics than in the north. Furthermore it is more frequent in a cold and damp climate than in a dry one. Elevation has no influence on the development of this disease. Scrofulous individuals are found in the mountains as well as in the plains. Scrofula principally attacks children; it occurs most frequently in the time from the second to the fifteenth year. Rarely earlier developed scrofula drags beyond the age of puberty or more advanced manhood. Sex has no particular influence on the development of scrofula. In many cases this particular disease is _inherited_. The following causes are considered in the inheritance of scrofula: great age, close relationship and infirmity of the parents; but the germ of scrofula is planted in the child by parents that are themselves afflicted with tuberculosis or scrofula. This is most frequently observed in children that have descended from parents, who were scrofulous in their youth and remained so, or that became tuberculous later on and at the time of generation were afflicted by advanced scrofula or tuberculosis, or that were suffering from oft-treated but never entirely cured syphilis. Some scientists claim to have observed the inheritance of scrofula by children, whose parents at the time of generation were afflicted with tuberculosis or were suffering from general debility resulting from hunger and want. In the majority of cases scrofula is acquired, as a rule the development of this disease is favored by indigence and poor hygienic conditions according to the coinciding experience of all scientists; _nutrition_, especially in the first year of life, has the greatest influence on the origin of scrofula. In _infancy_ the most frequent cause of scrofula is the premature giving of _farinaceous_ food besides the mother's milk, or the feeding of children with so-called pap, especially when this is done in the _first month of their life_. In later months the excessive eating of bread, potatoes or vegetables instead of milk has an injurious effect. Furthermore the development of scrofula is favored by the breathing of _foul damp air_ such as is frequently found in newly built or damp houses and also by _deficient care of the skin_. Scrofula thrives in the narrow tenement dwellings in which is found a close, overheated, foul air pregnant with smoke, kitchen fumes and mustiness from the damp walls. Frequently the development of scrofula has been observed to succeed measles, diphtheria, scarlatina or whooping-cough. The opponents of vaccination also designate vaccination as a frequent cause of scrofula. It is supposed that a poison is transferred into the system with the lymph which is enabled to generate the phenomena of scrofula. However the supposition has not as yet been proven. Of course the fact cannot be denied, that cases of developing scrofula have been at times observed as succeeding vaccination. But the circumstances are the same as in the case of the contagious diseases mentioned above. No one will probably maintain that in those cases in which the development of scrofula had been succeeding those diseases, that this has resulted from a poison generated by the preceding disease. The attempt to designate symptoms by which to recognize a scrofulous constitution has at all times been made. Many physicians have for a long time distinguished a _torpid_ and an _erethistic_ scrofulous constitution. With a _torpid_ constitution the body is pale, spongy and bloated, the nose and lips are thick, the abdomen swelled, there is plenty of fat and but weak muscles. Such children are indolent, at times peevish and indifferent, they do not sleep quietly, have no appetite or may be voracious and suffer from derangements of digestion. An examination of all organs indicates no change. The children are easily afflicted with eruptions of the skin, with inflammation of the eyes and ears, and catarrh of the mucous membranes, which are characterized by great obstinacy. The derangements in nutrition here described are caused by the lymphatic glands though a swelling of the same can not be found. In the case of _erethistic_ scrofula the children are found to be of slight and lean structure, with fine hair and long eyelashes; they are active, easily excited, gifted and extremely sensitive to physical pain. The face is pale and becomes easily flushed by physical or emotional excitements. They are easily subject to palpitation and short breath; and are attacked by high fevers from the slightest reason. The lymphatic glands, especially the deepseated ones, are as a rule more or less swelled. In most cases, however, the characteristics of these two forms are blended. The phenomena of scrofula are manifold and extend over the entire body. The _skin_ is frequently the seat of scrofulous affections. These are particularly found on the head and face and are characterized by great obstinacy and tendency to return. Most frequently herpes appear, the parts especially affected are the scalp, face, auricular passages, eyelids and the nose with its surrounding parts. Pustules are sometimes developed under the skin and may appear in great numbers. These pustules may either break through the skin or shrink into a caseous mass. Of all _mucous membranes_ that of the _nose_ becomes most frequently diseased; in a great number of cases this happens in the form of a chronic catarrh; the mucous membrane of the nose is reddened and swollen and a profuse, thick, purulent, ichorous and easily drying fluid is secreted. Often the external parts of the nose are swollen as a result of the catarrh and the nostrils are stopped up with thick yellowish-green rinds. Inflammation of the skin is caused by the flowing out of the purulent and ichorous liquid secreted. In many other cases the disease appears in the form of scrofulous ulcers on the mucous membranes of the nose; in such cases it is found that the nose is stopped up with numerous yellowish brown crusts; after removing the same the mucous membrane appears swollen and moderately reddened, on several places ulcers, the size of lentils, are found which are covered with a yellowish gray coating. At the slightest touch bleeding of the nose is caused; often also the external parts are reddened and swollen. In such cases erysipelas frequently developes, starting from the nose and spreading over the whole face. Frequently a repetition of erysipelas occurs. The scrofulous catarrh just described is generally of a very protracted nature and is marked by many relapses. Sometimes the fluid secretion of the nose is of very bad odor. The mucous membrane of the _throat_ becomes diseased at the same time as that of the nose. The same is found to be moderately reddened and swollen; the lymphatic glands especially those on the posterior wall of the throat are increased to swellings the size as large as peas. The _tonsils_ also become inflamed frequently and become enlarged through the repeated rather chronic inflammation. _Inflammations of the ear_ are a common occurrence with scrofula. These originate most frequently by means of the eustachian tube, which connects the ear with the back part of the mouth as a result of the catarrh of the nose and throat. In a majority of cases the inflammations of the ears lead to perforation of the tympanum and may even result in fatal cerebral meningitis. The _eye_ is as frequently affected by scrofula. Swelling of the lids and inflammation of the glands are the lighter forms. Pustules on the connective tissue of the eye and on the cornea, accompanied by photophobia, cramp in the lids and flowing of tears are those severe forms that are so frequently observed in scrofula, and that often leave opaque and incurable spots on the cornea of the eye. Swelling of the _glands_ has at all times been a characteristic phenomenon of scrofula. A swelling is merely the result of diseases of the mucous membrane of the throat or nose, of herpes of the scalp or face, of inflammations of the ears, eyes, periosteum, bones, etc. In the beginning the swelling of the glands is painless and results in flat swellings of about the size of filberts, which may be moved back and forth; such glandular swellings may exist for years, without showing the slightest alterations. With renewed attacks they enlarge and may become of considerable size. At times single glands become inflamed, hurt when pressed and develop abscesses which perforate the skin after it has become inflamed and reddened. These abscesses may heal within a few days. In the majority of cases, however, they remain for a longer period, months and even years and result in the well-known tumid, hard and immovable scars. Inflammation of the periosteum and of the bones is one of the instances of scrofula. Most frequently _spina ventosa_ is found; the same consists of a gradual, painless swelling of the diseased bones, most frequently on the fingers and toes, so that they become bottle-shaped. The skin covering these swellings is pale and tense. The swelling may gradually disappear or begin to suppurate. Besides this hip- and knee-joint inflammation are observed, also inflammations of the ankle, elbow-joint, spine, etc.; especially in the case of diseased bones it is extremely difficult to fix a dividing line between scrofula and tuberculosis. The frequence of anaemia with scrofula is only a _result_ of the disease and not a symptom. As a result of scrofula nutrition and assimilation become impaired, mostly in the cases of extreme suppuration. Scrofula is a chronic disease. In many cases it is completely cured, the lighter cases after several months and the more malignant after several years. Extreme scrofula may often remain until puberty and may be completely healed. _Fatal_ results are due to scrofulously diseased bones, joints or glands, and it can not be denied that a large number of children succumb in this manner. Fatal results may also be due to additional diseases, such as pneumonia, pleurisy, intestinal catarrh, etc. It has been frequently observed that _tuberculosis_ succeeds scrofula. It is a well-known fact that scrofula furnishes the largest contingent for tuberculosis. As a precautionary measure against scrofula a careful regulation of the diet is recommended. During the first nine months of life children should be fed with human milk exclusively if possible. If scrofula is hereditary in a family, or if the mother exhibits symptoms of the disease, she should not be allowed to nurse the child but a strong and healthy nurse should be engaged. Recourse to artificial nourishment must only then be taken, when nursing the child is absolutely impossible. For this purpose exceptionally pure cow's-milk ought to be selected. All substitutes, that appear under various names, such as infant's food, condensed milk, etc., contribute much toward the development of scrofula. Children 1-2 years of age are to be fed with milk, meat and eggs. Only strong children, that show no sign of scrofula may be fed once or twice a day with small quantities of rice, tapioca, sago, green vegetables, pulse, etc., beside the food above mentioned. To prevent scrofula it is essential not to give the food of adults to children during the first years of life; avoid exclusively solid food and prepare the same in a pappy form as much as possible. Of course a proper regulation of meal-time and a careful avoidance of overfeeding is by all means to be observed. It is of no less importance for a successful treatment of scrofula to provide surroundings of as favorable conditions as possible. First of all _pure air_ containing plenty of _oxygen_. Therefore the _sea-coast_ is recommended as a proper place for scrofulous children. The children ought to stay there until the signs of scrofula have disappeared and the entire nutrition has been improved. The results obtained in the sanitary stations (vacation colonies) along the sea-shore for scrofulous children have received much favorable comment. _Mountain air_ has a similarly favorable effect especially when _salt water baths_ are used at the same time; even the plain, pure _country air_ proves beneficial to scrofulous children. _Very dry_ locations and dwellings ought to be selected. The children should remain _out of doors_ as much as possible. Of great importance for scrofulous children, furthermore, is a suitable course in _gymnastics and rubbing-down with cold water_. To begin with the water may be 72° but should gradually be reduced to the natural temperature of well water. Just how far Koch's new method will take the place of former remedies used for scrofula can not be told at present as experiments in this direction are wanting. Nevertheless it will be possible to prevent the dangerous transition of scrofula into tuberculosis and thus save the lives of a great many persons. Anyone who has informed himself through the foregoing as to the great number of diseases and forms of disease that are directly or indirectly connected with tuberculosis, will now be able to estimate the farreaching import of Koch's discovery. It will now be clear to him that pulmonary consumption constitutes only a part, although a great part of tuberculosis and that there are a great many diseases besides that can now be surely cured, it is hoped, with the aid of Koch's method. But this much should be remembered by everyone that this remedy also acts best and surest during the _beginning_ of a disease. We hope that no one will allow valuable time to slip unimproved; it may easily happen that it is too late for successful treatment. Everyone will be able to recognize the symptoms of diseases, which Koch has taught to cure, from the foregoing complete description, and it is better to apply the remedy once too often than miss the proper time for application. Koch's first communications relating to the subject have just been published and will be given unabridged in the following pages. As these communications are written for physicians we will add such explanatory notes as are deemed essential for general intelligence. [Illustration: DR. KOCH IN HIS LABORATORY] THE FIRST COMMUNICATION _Relating to a Method to Cure_ TUBERCULOSIS, BY Prof. R. KOCH, Berlin. In a lecture, delivered by me several months ago, at the International Medical Congress, I referred to a remedy, which makes animal subjects impervious to the inoculation of Tubercle-bacilli, and in the case of diseased animals, checks the progress of the tuberculous disease. In the meantime experiments have been made with human subjects, about which I will report in the following. Originally I intended to complete my investigations and especially gain sufficient experience concerning the practical application of the remedy and its production on a larger scale before I published anything concerning it. In spite of all precautions too much has already been published about it, and that distorted and exaggerated, so that I was obliged, in a way, to prevent false conceptions, to give even now a synopsis of the method as far as it has progressed at the time being. Under present circumstances it must necessarily be short and leave unanswered many important questions. The experiments have been, and are still being made under my direction by Dr. A. Libbertz and Stabsarzt Dr. E. Pfuhl. The necessary subjects and material have been provided by Prof. Brieger from his Polyclinic, Dr. W. Levy in his Private Surgical Clinic, Geheimrath Fraentzel and Oberstabsarzt R. Koehler in the Charite-Hospital, and Geheimrath Herr v. Bergmann in the Surgical University Clinic. To all these gentlemen and their assistants I here tender my heartfelt thanks for their untiring interest which they manifested for this subject and also for the disinterested help and aid which they have offered at all times and without which it would have been impossible for me to make such progress in a few months in this difficult and responsible investigation. As my work is far from being completed, I can not as yet make any statements relating to the origin and preparation of this remedy and reserve these for some future time.[1] The curative is composed of a clear brown fluid, which in itself is not perishable, even without special precautionary measures. For use this fluid must be more or less diluted and these dilutions are perishable when made with distilled water; Bacterian vegetation soon develops in them and they become turbid and are no longer fit for use. To prevent this the dilutions must be sterilized through heat and be kept under cotton batting or be prepared with a 5 per cent. phenol solution which is much simpler. Through repeated heating as also through the mixture with the phenol the efficiency of the diluted solution appears to be curtailed after a time and for that reason I have always used solutions as fresh as possible. The remedy does not act through the stomach; to effect a reliable action it must be applied subcutaneously. For our experiments we have exclusively used a syringe decided upon by myself for bacteriological purposes, which is supplied with a small india-rubber ball and which has no stamp. Such a syringe can be easily kept positively aseptic by rinsing with absolutely pure alcohol and on this we base the fact that not a single abscess has sprung from over a thousand injections. After trying various parts of the body as places for application we selected the skin of the back between the shoulderblades and in the lumbar region, because at these places the injection was almost painless and caused the least and in most cases no local reaction. Even at the beginning of our experiments we found that in one particularly important point the human subject was affected by the curative in a way decidedly differing from that of the animal subject generally used, the guinea pig. Therefore another confirmation of the rule for experimentors upon which hardly enough stress can be laid, not to rely upon a like effect upon the human being from the experiments on the animal without further confirmatory inquiry. Man proved himself much more sensitive to the effects of the remedy than the guinea pig. Up to two cubic centimeters and even more of the undiluted fluid could be injected under the skin of a healthy guinea pig without causing any particularly disparaging effect. In the case of a fullgrown man on the other hand, 25 ccm. are sufficient to produce intense results. In proportion to weight of body therefore 1/1500 of the amount which has no noticeable effect on the guinea pig has a decidedly strong effect on the man. From an injection that I have made on my upper arm I have experienced the symptoms which arise in man after an injection of 25 ccm., in short they were the following: Three or four hours after the injection a raking pain in the joints, languor, inclination to cough, oppressed breathing, which rapidly increased; in the fifth hour I experienced intense chills which lasted nearly an hour, at the same time nausea, vomiting, increase of the temperature of the body to 39.6° C. After about 12 hours all these affectations ceased. The temperature sank and reached the normal height the next day. Heaviness of the limbs and languor lasted for a few more days, and for the same length of time the place of injection remained red and painful. The lower limit of effect of the curative for a healthy man is about .01 ccm. (= 1 cubic centimeter diluted with a 100 parts) as numerous trials have shown. The majority reacted on this dose with only light pain in the joints and passing languor. With a few a slight rise in temperature set in, to 38° C. or a trifle higher. Although there is a marked difference as regards the dose of the curative (according to relative weight of body) between the animal subject and man, an evident resemblance is shown in several other qualities. The most important of these qualities is _the specific action of this remedy on tuberculous processes of whatever kind they may be_. I will not relate the effects on the animal subject in this connection, as it would lead too far, but will at once turn to the peculiar effects on tuberculous human beings. As we have seen, a healthy man reacts but little or not at all on .01 ccm. The same is true of diseased persons, provided they are not tuberculous. But the relations are entirely different with those afflicted with tuberculosis; a marked general and also a local reaction resulted from an injection of the same dose of the remedy (.01 ccm.)[2]. The general reaction consists of an attack of fever, which, beginning mostly with chills, raises the temperature to over 39°, often up to 40° and even 41°. Other noticeable symptoms are pains in the joints, a tendency to cough, great languor, and often nausea and vomiting. Several times we observed a faint icteric coloring and in some cases the appearance on neck and breast of an exanthema resembling measles. As a rule the attack begins 4-5 hours after the injection and lasts 12-15 hours. In exceptional cases it may begin much later, but then it is not nearly so intense. The patients experience remarkably little weakness from the attack and feel relatively well as soon as it is over, generally better than they did before it came on. The local reaction can best be observed on those patients whose tuberculose affection is plainly visible, for instance those afflicted with lupus. In them changes take place that prove the specific antitubercular action of the remedy in a most surprising way. The diseased portions of the skin in the face, etc. begin to swell and turn red even before the attack of chills set in, although the injection is made under the skin of the back, a point decidedly remote from the affected parts. The swelling and reddening increases during the fever and can attain a very marked degree so that the lupus-tissue turns reddish brown and necrotic. In the case of more sharply defined lupus centres the more swollen and dark red parts were edged by a white seam nearly a centimeter wide and this again was surrounded by a wide bright red border. The swelling of the diseased parts gradually decreases after the cession of fever and may have entirely disappeared after 2 or 3 days. A serum exudes from these lupus-centres and, drying, forms a crust on them which changes into scabs that fall off in 2-3 weeks and sometimes leave a smooth red scar after a single injection. Generally several injections are necessary to effect a complete removal of the lupose tissue, but of this I will speak further on. It is very important to note that the changes during this process are exclusively limited to the portions of the skin affected by lupus; even the faintest and smallest bits of diseased tissue go through the entire process and become visible on account of their swelling and reddening, while the actual scab-tissue in which the various stages of lupus have been completed remains unchanged. The observation of the treatment of lupus with the remedy is so instructive and must be so convincing as regards the specific nature of the remedy that every one wishing to occupy himself with the study of this remedy should if possible make his first experiments with lupus. Less marked, but still apparent to the eye and touch are the local reactions in tuberculosis of the lymphatic glands, of the bones and joints, etc., in which case swelling and increased painfulness, and in the more superficial parts also a reddening can be observed. The reaction in the inner organs, especially the lungs is removed from our observation unless we consider the increased coughing and expectoration of the patients after the first injection a local reaction. At the same time we must assume that these parts undergo changes directly observed in the case of lupus. The different forms of reaction described have appeared without exception in previous trials on the dose of .01 ccm. when any form of tuberculosis prevailed in the system, and therefore I trust that I am justified in assuming, that in the future this remedy will constitute an indispensible diagnostic auxiliary. We will be enabled to diagnose in doubtful cases of phthisis even then, when it is impossible to obtain reliable information concerning the nature of the ailment, by the presence of bacilli or elastic fibres in the sputum or by a physical examination. Glandular affectations, hidden tuberculosis of the bones, doubtful tuberculosis of the skin and the like will easily and reliably prove to be such. In case of apparently completed processes of tuberculosis of the lungs or joints it will be possible to show whether the process of the disease is in reality a complete one or establish the existence of centres from which later on the disease may spread like a fire from a live coal in the ashes. But much more important are the specific qualities of the remedy than the aids it offers for the diagnosis. While describing the changes, that are caused by hypodermic injections of the remedy, on the parts of the skin affected by lupus, attention was called to the fact that the lupose tissue does not return to its original condition after the swelling and reddening have ceased, but is more or less destroyed and disappears. On some places, as observation teaches, the process is such, that after a single injection the diseased tissues undergo mortification and are cast off as dead matter later on. On other places it seems that a diminution or rather a kind of melting of the tissue is caused, and to effect a complete disappearance a repeated application of the remedy is necessary. As the required histological investigation is wanting, it is impossible at the present time to state with certainty how this result is brought about. Only this much is known that it is not a destruction of the tubercle bacilli, but that only the tissue containing the tubercular bacilli is affected by the application of the remedy. In this, as the visible swelling and reddening show, greater circulatory derangements are caused and with these vital changes in the _assimilation_ which result in a more or less rapid and thorough mortification of the tissue according to the manner in which the remedy is allowed to act. To make a short repetition, the remedy therefore does not destroy the tubercle bacilli, but the tuberculous tissue; on dead tissue, for instance, gangrenous cheesy matter, necrotic bones, etc., it does not act; nor on tissue that has undergone mortification through the action of the remedy itself. Living bacilli can still linger in such dead masses of tissue, which are either cast out with the necrotic tissue, or may possibly migrate under special conditions into the adjoining living tissue. This quality of the remedy must be particularly observed, if its full specific action is to be obtained. Therefore we must first cause the mortification of the tuberculous tissue, and then effect its removal as soon as possible, for instance, by means of a surgical operation; but where this is impossible and the excretion by the organisms themselves is necessarily slow, we must attempt by continued application of the remedy to protect the endangered living tissue from the immigration of the parasites. As the remedy acts only on living tissue and causes mortification of tuberculous tissue, we can readily explain another exceedingly peculiar property of the remedy, namely, that it can be given in rapidly increased doses. This may apparently be explained as being based on inurement. But noting that in about three weeks the dose may be increased to 500 times the strength of the first one, it is unquestionably something more than habit, as we know of nothing analogous confirming such a rapid and farreaching adaptation to any powerful drug. This fact can rather be explained thus: in the beginning there is an abundance of living tuberculous tissue and only a minute quantity of the effective substance is sufficient to cause a strong reaction; through each injection a certain quantity of this responsive tissue disappears, and then relatively larger doses are required to cause the same degree of reaction as before. Aside from this adaptation may assert itself within certain limits. As soon as the patient is treated with such increased doses, and that he reacts no more than one not afflicted with tuberculosis, we may assume that all the reactive tuberculous tissue is dead. It is then only necessary to continue the treatment at intervals and with gradually increased doses as long as any bacilli remain in the system, to protect the patient from a new infection. It remains to be learnt in the future whether this conception and the deductions based thereon are correct. For the present I have directed the manner of application of the remedy on this basis, which in our experiments resulted as follows: To begin again with the simplest case, namely lupus, we injected the full dose of .01 ccm. in nearly all such patients to begin with, and allowed the reaction to take its full course, after 1-2 weeks we again injected .01 ccm. and so forth until the reaction became less and less and finally ceased. In the case of two patients with facial lupus three respectively four injections in this manner resulted in a clean, smooth scar in place of the affected parts; the remaining patients of this kind have also improved in a measure proportioned to the time of treatment. All the patients have suffered from their afflictions for years and have been treated by various methods without success. Tuberculosis of the glands, bones and joints has been treated in a very similar manner, as in these cases larger doses were applied at longer intervals. The result was the same as with lupus, a rapid cure in the lighter and milder cases and a slowly progressing improvement in the severer ones. With the majority of our patients, those suffering from pulmonary consumption, the conditions are somewhat different, patients with decided pulmonary tuberculosis are very much more responsive to this remedy, than those afflicted with surgical tubercles. We were forced to reduce the quantity of the first dose of .01 ccm. as prepared for the phthisicist, and we found that as a rule he reacted strongly on a dose of .002 and even .001 ccm., but that the quantity could be rapidly increased from this low initial dose to that which could be easily tolerated by the other patients. We generally proceeded in such a manner that the patient at first received an injection of .001 ccm. and if a rise in the temperature set in this dose was repeated once daily until the reaction ceased. Only then the dose was increased to .002 ccm. and applied till the reactions failed to appear. And so forth, always increasing the dose only .001 or at the most .002 up to .01 ccm. and higher. This mild procedure seemed to me imperative, especially with such patient as were in a weak and feeble condition. Proceeding in the manner just described we can easily attain the application of very light doses with but slight attacks of fever and hardly perceptible to the patient. Some of the stronger consumptives were treated with larger doses from the beginning, partly with a forced increase in the dosing when it seemed as though the favorable result was obtained in a correspondingly shorter time. The action of the remedy on the phthisicist generally seemed to be such that cough and expectoration increased somewhat after the first injection, then gradually diminished and in favorable cases disappeared entirely; the sputum lost its purulent nature and became slimy. The number of bacilli as a rule did not decrease until the sputum had attained a phlegmy appearance (only such patients were selected for these experiments in whose expectorations bacilli were contained). They entirely disappeared temporarily, but were again met with from time to time until the expectoration had completely stopped. At the same time the night-sweats left off, and the patients improved in appearance and gained in weight. All patients treated in the first stages of phthisis were freed from all symptoms of disease in the course of 4-6 weeks so that they could be considered as cured. Even patients with cavities not too large were considerably improved and nearly healed. But in the case of such consumptives, whose lungs contained many and large cavities no objective improvement could be marked, although the expectoration diminished and they appeared to feel much better. I am inclined to assume on the basis of these experiences, that the _earliest stages of phthisis can with certainty be cured by this remedy_.[3] This may also hold good in cases that are not too far advanced. In exceptional cases only will pulmonary consumptives, with large cavities, derive continued benefits through the application of the remedy, when other complications exist, for instance, the penetration of other supurative micro-organisms, irremovable pathological changes in other organs, etc. Even such patients were in most cases temporarily improved. It must follow that even in them the original process of the disease, tuberculosis, is influenced in the same manner by this remedy as in other patients, but that it is impossible to remove the gangrenous masses of tissue and also the secondary supurative processes. Naturally we are led to think that perhaps in some of these severe cases cures may be effected by means of a combination of this healing process together with surgical aid (after the manner of operating empyema) or some other curative means. I would not advise anyone however, to apply this remedy without discrimination in every case of tuberculosis. The simplest mode of application will certainly be required in treating the first stages of phthisis and simple surgical affections, but in all other forms of tuberculosis medical science should draw on all its resources and individualize carefully to supplement and sustain the action of the remedy. In many cases I have had the decided impression that the attendance to and nursing of the patient was of no little influence on the curative process, and therefore I would prefer the application of the remedy in suitably adapted institutions, where a close observation of the patient and the adequate attention to them is possible, to the ambulant or home treatment. No estimate can at present be made as to the extent in which a profitable combination can be made between this new method to cure and those modes of treatment that have thus far been considered beneficial, the application of mountain climate, the free air treatment, specific nourishment, etc.; but I trust, that these remedial factors will be of considerable use in conjunction with the new method in many cases, especially the severe and neglected as also in the convalescent stages.[4] The nucleus of this new curative method lies in the earliest possible application. The proper objects of treatment ought to be the first stages of phthisis, because here the remedy can fully develop its curative qualifications. Therefore it is of vital importance, more so in the future, than it has been in the past, that practical physicians employ all possible means to diagnosticate phthisis in as early a stage as possible. Until lately the finding of tubercle bacilli existing in the sputum was rather considered as an interesting incidental evidence, which, although it insured the diagnosis, was of no further benefit to the patient and therefore was only too often omitted, as I have only lately discovered in numerous cases of phthisis which had passed through the hands of several physicians without having their sputum examined once. This must be different in the future. Any physician who fails to search for tubercle bacilli in the sputum, to establish phthisis in as early a stage as possible, commits gross negligence toward his patient, because his life may depend on this diagnosis and the specific treatment which has hurriedly been introduced on this basis. In doubtful cases the physician should gain certainty as to the existence or absence of tuberculosis through a trial injection. Only then will the new mode of treatment truly become a panacea for suffering mankind when that period is reached, where all cases of tuberculosis are treated in as early a stage as possible, to prevent the development of neglected severer cases which have heretofore formed a continual unlimited source of new infection. In conclusion I would remark, that I have intentionally omitted all numerical statistics and descriptions of individual cases in this communication, because the physicians to whose material the patients provided for our experiments belonged, have themselves undertaken the description of their respective cases and I did not wish to anticipate them in an objective representation of their observations. FOOTNOTES: [1] Physicians who wish to experiment with the remedy, can get the same of Dr. A. Libbertz (Berlin, N. W., Lueneburgerstrasse 28 II.), who has undertaken the production of the remedy with Dr. Pfuhl's and my assistance. But I must state that the present stock is very limited, and that larger quantities can only be disposed of at the end of several weeks. [2] We gave children of 3-5 years of age one tenth of this dose, that is .001 and very weak children .0005 ccm. and obtained a strong though not alarming reaction. [3] This statement is necessarily confined in so far as we have no conclusive experiences, and can not have at present, that show whether the cure is a permanent one, recidivations of course are not excluded for the present. But we may assume that these will be removed as easily and quickly as the first attack. On the other hand it is possible from analogy with other infectious diseases that those who are once cured become permanently exempt. This must also be considered an open question for the present. [4] It was impossible to collect data referring to cerebral-laryngeal-and miliary-tuberculosis, as we did not have sufficient material. Explanatory Notes. Koch states that he can not at the present make any statement about the origin and preparation of the remedy, as his labors are not yet completed. We may assume that it is very probably a substance that corresponds in a way to the lymph used for vaccination. As vaccine lymph represents variolous poison greatly reduced in strength, as the remedy for hydrophobia is composed of a substance which is weakened hydrophobic poison, so Koch probably obtains his remedy for tuberculosis by artificially reducing the tuberculous poison by means of various processes. A number of years ago it has been tried with syphilis in a similar way to obtain a substance that would not only cure syphilis but would also guard against infection from it. At that time however the experiment was not successful. From several intimations I am inclined to believe that Koch was successful in finding a way in which a substance may be produced for contagious diseases, a substance that cures these diseases and also protects from infection. It is not impossible, since Jenner found the vaccine virus, Pasteur the hydrophobic lymph and now Koch the tubercle lymph. To be sure there is this difference for the present between the substances named, that the vaccine virus only protects healthy person from infection by small pox but it does not cure those sick, while the hydrophobic lymph and tubercle lymph cure the afflicted. However Koch seems to believe that his tubercle lymph has a certain power of producing immunity. According to Koch, his remedy, consisting of a brownish liquid, is easily perishable as soon as it is diluted with water; he recommends the preparation of the dilution of the remedy with a 5 per cent. phenol solution. Phenol is equivalent to carbolic acid. The dilution of the remedy for use must be considerable, as only small quantities of the same are used. Koch tells us that his remedy does not act through the stomach, that is taken in through the mouth. On one hand it may be that this is due to the extremely small quantities necessary for an effect, on the other hand and principally all the substances probably act only when they are directly applied and brought in contact with the circulation of the blood. For a long time small syringes with fine needle points were used to inject strong acting drugs under the skin. This is done in a measure to have a guarantee of a sure effect which is not had by giving through the mouth. For instance, it is known that emetics given through the mouth often remain without results; if however the emetic apomorphine is injected anywhere under the skin, vomiting surely follows within a very short time. It is well known that morphine is injected under the skin in preference to taking it through the mouth as its action as a pain killer is much prompter. Koch's liquid can also be injected under the skin with the aid of a so-called Pravaz syringe. Koch uses a somewhat differently formed syringe. The result remains the same, no matter what kind of syringe is used. At the same time it makes but little difference, on what part of the body the injection is made, as the fluid injected under the skin is distributed at once over the entire system. Koch chose the skin of the back between the shoulderblades and the loins because here the injection could be made without causing pain or inflammation. The production of the liquid must be attended with great difficulties as Koch plainly remarks that his stock at present is very limited and he can only furnish larger quantities at the end of several weeks. The price of a small bottle to be 25-30 Marks about 6-8 Dollars. The human being is much more sensitive to Koch's remedy than the guinea pig, which is commonly used for experiments of this kind. It seems that no experiments have as yet been made with other animals. Koch has tried the remedy on himself and has passed through all the symptoms of a poisoning. He certainly injected into his arm a considerable quantity of the liquid; twenty-five times as much as he injected in his patients. But here also there is a difference. In sick people much smaller quantities act than in the healthy. One cubic centimeter of the liquid has hardly any effect on a healthy person, but quite a marked one on those afflicted with tuberculosis. In the case of the latter one cubic centimeter produces about the same symptoms as twenty-five times the quantity would in a healthy person. The same must also be considered as symptoms of poisoning; but they are only of short duration and are accompanied with magnificent success. Of all diseases based on tuberculosis only ringworm or lupus is perceivable by the eye, as it is a disease of the skin, all other tuberculous diseases take their course in the internal parts of the body, and therefore are not perceptible to the eye. The symptoms that follow an injection of Koch's liquid can be best observed in the case of lupus. Koch therefore selected for his first illustration patients afflicted with lupus that is ringworm. Even a few hours after the injection the first perceptible changes begin to show in the diseased parts. These begin to swell and redden; in other words an inflammation is caused, through which the diseased tissue is obviously brought to mortification. Soon the inflammation stops. The gangrenous tissue changes into crusts or scabs which drop off in a short time and the patient is cured of his ringworm. Koch places particular importance on the fact that the inflammation is restricted to the diseased parts only, and that it does not attack sound and healthy parts. Even the smallest otherwise invisible knots are made perceptible through the inflammation. We have similar illustrations for this specific action of Koch's remedy for lupus (ringworm). So for instance a syphilitic ulcer on the thigh may be cured in a few days with iodide of potassium. In a similar manner a morbidly enlarged spleen may be reduced to the normal size by taking quinine. The observation is very interesting indeed, as it may be shown whether a person is tuberculous in any organ or not by the injection of .01 ccm. In case he is tuberculous the poisoning symptoms appear in a marked degree; if he is not, hardly any effect is noticeable. Although we have had excellent methods for a long time to detect pulmonary consumption, although Koch added the discovery of the tubercle bacilli, it occasionally happens that the disease can not be recognized in its beginning stages, because its progress is too slight. Now the reaction following an injection is to be the deciding medium. Also with other tuberculous affections physicians will welcome this diagnostic auxiliary, for in the beginning of the same it often happens that no certain diagnosis could be made and valuable time was lost. We must call particular attention to the further statements of Koch, that through his remedy the tubercle bacilli are _not_ killed. With this it is admitted that the remedy will not be able to effect cures, without any more ado, yes, even the tubercle bacilli may continue to infect parts of the body even in spite of the action of the remedy. Therefore the application of Koch's remedy only, is not sufficient to effect a cure. Provision must be made to remove the gangrenous tissue from the body as rapidly as possible, because it contains the still living tubercle bacilli. As a rule surgical aid is necessary to remove the mortified tissue. Where this is impossible Koch advises the continued application of the remedy to protect the endangered living tissue from the re-immigration of the tubercle bacilli. Koch thereby believes that he can protect the tissue, perhaps in the manner as vaccination protects from small pox. The rapid increase in the quantity of the remedy applied in the course of time is something that has no parallel. Koch gives an explanation, but leaves it to the future to be confirmed. We have no previous instance in case that his explanation should prove correct. Reasoning from analogous application of our remedy, we are led to assume that _smaller_ quantities of the substance would suffice to cause mortification of the remaining tuberculous tissue. Koch on the other hand uses larger and larger doses to reach a result. He admits inurement to the remedy within certain limits only. Koch has made a difference between pulmonary consumptives and those suffering from tuberculosis of the bones and joints, etc. He was able to inject larger quantities in the latter than the former, for the quantity injected in the case of pulmonary consumptives was .001 ccm.; in other tuberculous cases .01 ccm. Koch selected pulmonary consumptives for his experiments, whose sputum contained tubercle bacilli, so as to make no error in the diagnosis, and to ascertain by killing the bacilli contained in the sputum, whether the diseased tend toward restoration. As the remedy does not kill the bacilli, so a diminution of the bacilli can only be obtained in that manner, that the tissue of the lungs undergoes certain changes, which cause its properties to be such, that the bacilli are no longer able to exist or propagate in them. Then a so-called immunity results which we know of in other similar diseases. We know that anyone who has had the measles or scarlet fever rarely is again attacked by the same, as a rule he is permanently proof against them. In the same way as vaccination protects from small pox, an injection of Koch's remedy acts against pulmonary consumption. Koch makes a cautious statement: "On the other hand it is possible, from analogy with other infectious diseases that those who are once cured become permanently exempt." Koch reaches this result, that beginning phthisis can with certainty be cured with his remedy. On the other hand, advanced consumptives, in whose lungs large cavities already exist, may possibly be improved but can not be cured. However he provokes the idea, that perhaps his method of treatment together with a surgical operation, that removes all gangrenous matter from the lungs, may yet have beneficial results in the end. The idea is not entirely new to treat lung diseases with the aid of surgery; unfortunately the operations have heretofore been thought too risky. Perhaps we will now have a new branch in operative technic, surgery of the lungs. Koch advises to conduct this lung surgery after the manner of operating empyema. This is an operation performed in the case of suppurative pleurisy to remove the pus from the pleural cavity. This operation has been successfully carried out for a long time. Koch makes it of especial importance, that while treating consumption with the new remedy, the general attendance and nursing is not to be neglected. Koch also calls attention to what has been said before, that the general hygienic factors, good hospital treatment, mountain climate, etc., will never be dispensed with, on the contrary will be indispensible to the furtherance of cure. In conclusion Koch again remarks that brilliant results are only promised in the early stages of pulmonary consumption (phthisis). Physician and patient must move all levers as to the existence or non-existence of tuberculous diseases. Then those daily pictures of extreme wretchedness from consumption will be a thing of the past. Then the danger of contagion will be lessened resulting from the decrease of the number of tuberculous persons and of the tubercle-bacilli, and perhaps it will soon be possible to name the day on which with the last tubercle-bacillus the ravaging pest, tuberculosis, will be extirpated. +-------------------------------------------------------------+ | Transcriber's Note: | | | | Inconsistent use of develops/developes, and centres/centers | | has been retained as in the original. | +-------------------------------------------------------------+ 
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33102	----	SMITHSONIAN STUDIES IN HISTORY AND TECHNOLOGY/NUMBER 41 BLOODLETTING INSTRUMENTS IN THE NATIONAL MUSEUM OF HISTORY AND TECHNOLOGY Audrey Davis and Toby Appel Smithsonian Institution Press City of Washington 1979 ABSTRACT Davis, Audrey, and Toby Appel. Bloodletting Instruments in the National Museum of History and Technology. _Smithsonian Studies in History and Technology_, number 41, 103 pages, 124 figures, 1979.--Supported by a variety of instruments, bloodletting became a recommended practice in antiquity and remained an accepted treatment for millenia. Punctuated by controversies over the amount of blood to take, the time to abstract it, and the areas from which to remove it, bloodletters employed a wide range of instruments. All the major types of equipment and many variations are represented in this study of the collection in the National Museum of History and Technology. OFFICIAL PUBLICATION DATE is handstamped in a limited number of initial copies and is recorded in the Institution's annual report, _Smithsonian Year_. COVER DESIGN: "Phlebotomy, 1520" (from Seitz, 1520, as illustrated in Hermann Peter, _Der Arzt und die Heilkunst_, Leipzig, 1900; photo courtesy of NLM). Library of Congress Cataloging in Publication Data Davis, Audrey B Bloodletting instruments in the National Museum of History and Technology. (Smithsonian studies in history and technology; no. 41) Bibliography: p. Supt. of Docs, no.: SI 1.28:41 1. Bloodletting--Instruments--Catalogs. 2. Bloodletting--History. 3. National Museum of History and Technology. I. Appel, Toby, 1945--joint author. II. Title. III. Series: Smithsonian Institution. Smithsonian studies in history and technology; no. 41 [DNLM: 1. Bloodletting-- History. 2. Bloodletting--Instrumentation--Catalogs. 3. Bloodletting-- Exhibitions--Catalogs. RM182.D38 617'.9178 78-606043 CONTENTS Page Preface v Introduction 1 Sources 2 Bleeding: The History 3 How Much Blood to Take 5 When to Bleed 7 Barber-Surgeons 8 Bloodletting and the Scientific Revolution 9 Instrumentation and Techniques 10 Spring Lancets 12 The Decline of Bleeding 15 Cupping 17 Early Cupping Instruments 17 Instruments of the Professional Cupper 21 Cupping Procedure 24 Nineteenth Century Attempts to Improve Cupping Technology 25 Dry Cupping 31 Breast Cupping 32 The Decline of Cupping 34 Leeching 34 Leeches 34 Artificial Leeches 36 Veterinary Bloodletting 40 Physical Analysis of Artifacts 41 Catalog of Bloodletting Instruments 42 Phlebotomy 44 Flint and Thumb Lancets 44 Spring Lancets 44 Bleeding Bowls 47 Extra Blades and Cases 47 Cupping 48 Scarificators 48 Cups 50 Cupping Sets 50 Cupping Apparatus 52 Breast Pumps 52 Leeching 53 Veterinary Bloodletting 53 Fleams 53 Spring Lancets 54 Related Artifacts 55 Notes 57 List of Trade Catalogs Consulted 63 Figures 26-124 64 PREFACE Among the many catalogs of museum collections, few describe objects related to the practice of medicine. This catalog is the first of a series on the medical sciences collections in the National Museum of History and Technology (NMHT). Bloodletting objects vary from ancient sharp-edged instruments to the spring action and automatic devices of the last few centuries. These instruments were used in a variety of treatments supporting many theories of disease and therefore reflect many varied aspects of the history of medicine. Beginning with an essay sketching the long history of bloodletting, this catalog provides a survey of the various kinds of instruments, both natural and man-made, that have been used throughout the centuries. It is a pleasure to thank the Smithsonian Research Foundation, the Commonwealth Foundation, and the Houston Endowment for their financial support of this project. Miss Doris Leckie, who did much of the preliminary research and organized part of the collection that led to a draft of this catalog with special emphasis on the cupping apparatus, receives our highest gratitude. Her public lectures on the topic drew much praise. The usefulness of this catalog is due in no small part to her devoted efforts. For photographing the Smithsonian objects so well we thank Richard Hofmeister, John Wooten, and Alfred Harrell of the Smithsonian Office of Printing and Photographic Services. For analyzing selected objects and answering our requests promptly we thank Dr. Robert Organ, chief; Barbara Miller, conservation director; and Martha Goodway, metallurgist, of the Conservation Analytical Laboratory. To those who helped us to solve specific problems we extend appreciation to Dr. Arthur Nunes; Dr. Uta C. Merzbach, curator of mathematics, NMHT (especially for finding the poem by Dr. Snodgrass); and Silvio Bedini, deputy director, NMHT, whose enthusiasm and unmatched ability for studying objects has sustained us throughout the period of preparation. While it is traditional to add a reminder that various unnamed people contributed to a publication, it is imperative to state here that numerous people are essential to the collection, conservation, preservation, and exhibition of museum objects. Without them no collection would survive and be made available to those who come to study, admire or just enjoy these objects. We hope this catalog brings out some of the joy as well as the difficulties of maintaining a national historical medical collection. BLOODLETTING INSTRUMENTS IN THE NATIONAL MUSEUM OF HISTORY AND TECHNOLOGY AUDREY DAVIS and TOBY APPEL[A] Introduction Bloodletting, the removal of blood from the body, has been practiced in some form by almost all societies and cultures. At various times, bloodletting was considered part of the medical treatment for nearly every ailment known to man. It was also performed as punishment or as a form of worship to a Superior Power or Being. It still retains therapeutic value today, although only for an extremely limited range of conditions. In early attempts to extract blood from the body, the skin was penetrated in various places with a sharp instrument made of stone, wood, metal, bristle, or any other rigid material. When it was recognized that a vein visible on the surface of the skin as a blue-green stripe contained blood, the vein was incised directly. To facilitate "breathing a vein" and to provide greater safety, more refined and sharper instruments were devised. As theories supporting bloodletting grew more complex, so too did the instruments. Spontaneous forms of bleeding, including nosebleed, menstruation, and those instances produced by a blow to any part of the body, apparently inspired the earliest human bloodletters. The Egyptians claimed that the hippopotamus rubbed its leg against a sharp reed until it bled to remove excess blood from its body.[1] The Peruvians noted that a bat would take blood from the toe of a sleeping person when the opportunity presented itself. A deer, and goat, would pick a place near its diseased eye for relief.[2] The methods employed by animals increased interest in using artificial methods for letting blood in man. The devices man has employed to remove blood from the body fall into two major categories: (1) those instruments used for general bloodletting, that is, the opening of an artery, or more commonly a vein, and (2) those instruments used in local bloodletting. Instruments in the first category include lancets, spring lancets, fleams, and phlebotomes. Associated with these are the containers to collect and measure the blood spurting from the patient. In the second category are those instruments associated with leeching and cupping. In both of these methods of local bloodletting, only the capillaries are severed and the blood is drawn from the body by some means of suction, either by a leech or by an air exhausted vessel. Instruments in this category include scarificators, cupping glasses, cupping devices, and many artificial leeches invented to replace the living leech. Much effort and ingenuity was expanded, especially in the eighteenth and nineteenth centuries, to improve the techniques of bloodletting. In the eighteenth century, delicate mechanical spring lancets and scarificators were invented to replace the simpler thumb lancets and fleams. In the nineteenth century, as surgical supply companies began to advertise and market their wares, many enterprising inventors turned their hand to developing new designs for lancets and scarificators, pumps, fancy cupping sets, rubber cups, and all manner of cupping devices and artificial leeches. If we also consider treatments related to bloodletting, in which blood is transferred from one part of the body to another, without actual removal from the body, then we can add the many inventions devoted to dry cupping, irritating the body, and exhausting the air around limbs or even the entire body. Although many physicians continued to use the traditional instruments that had been used for centuries, many others turned eagerly to the latest gadget on the market. Bloodletting instruments, perhaps the most common type of surgical instrument little more than a century ago, are now unfamiliar to the average person. When one sees them for the first time, one is often amazed at their petite size, careful construction, beautiful materials, and elegant design. One marvels at spring lancets made of silver, thumb lancets with delicate tortoise shell handles, and sets of hand-blown cups in the compartments of a mahogany container with brass and ivory latches and a red plush lining. Those finding such instruments in their attic or in a collection of antiques, even if they can determine that the instruments were used for bloodletting, often have no idea when the instruments were made or how they were used. Frequently a veterinary spring lancet or fleam is mistaken for a human lancet, or a scarificator for an instrument of venesection. Almost nothing has been written to describe these once common instruments and to place them in historical context. Historians who study the history of medical theory usually ignore medical practice, and they rarely make reference to the material means by which a medical diagnosis or treatment was carried out. It is hoped that this publication will fill a need for a general history of these instruments. This history is pieced together from old textbooks of surgery, medical encyclopedias, compilations of surgical instruments, trade catalogs, and the instruments themselves. The collection of instruments at the National Museum of History and Technology of the Smithsonian Institution contains several hundred pieces representing most of the major types of instruments. Begun in the late nineteenth century when medical sciences were still part of the Department of Anthropology, the collection has grown steadily through donations and purchases. As might be expected, it is richest in bloodletting instruments manufactured in America in the nineteenth century. One of its earliest acquisitions was a set of four flint lancets used by Alaskan natives in the 1880s. A major source for nineteenth-century instruments is the collection of instruments used by the members of the Medical and Chirurgical Faculty of Maryland, a medical society founded in 1799. The Smithsonian collection also includes patent models of bloodletting instruments submitted to the U.S. Patent Office by nineteenth-century inventors and transferred to the Smithsonian in 1926. Because we have made an effort to survey every major type of instrument related to bloodletting, it is hoped that this publication will serve as a general introduction to bloodletting instruments, and not merely a guide to the Smithsonian collection. With this goal in mind, the catalog of bloodletting instruments has been preceded by chapters surveying the history of bloodletting and describing, in general terms, the procedures and instruments that have been used since antiquity for venesection, cupping, leeching, and veterinary bloodletting. In the course of our research we have consulted several other collections of bloodletting instruments, notably the collections of the Wellcome Museum of London, the Armed Forces Institute of Pathology, the College of Physicians in Philadelphia, the Institute of the History of Medicine at the Johns Hopkins University, the Howard Dittrick Medical Museum in Cleveland, and the University of Toronto. Illustrations from these collections and references to them have been included in the cases where the Smithsonian collection lacks a particular type of instrument. Sources While primary sources describing the procedures and presenting theoretical arguments for and against bloodletting are plentiful, descriptions of the instruments and their manufacture are often difficult to find. Before the nineteenth century, one may find illustrations of bloodletting instruments in the major textbooks on surgery, in encyclopedias such as that of Diderot, and in compendia of surgical instruments written by surgeons. The descriptions following the drawings are often meager and give little indication of where, when, and how the instruments were produced. Until well into the nineteenth century, the tools used by barber-surgeons, surgeons, and dentists were made by blacksmiths, silversmiths, and cutlers. These craftsmen generally left little record of their work. As the demand for surgical instruments increased, specialized surgical instrument makers began to appear, and the cutler began to advertise himself as "Cutler and Surgical Instrument Maker" rather than simply "Cutler and Scissor Grinder." A few advertising cards dating from the eighteenth century may be found, but the illustrated trade catalog is a product of the nineteenth century. Among the earliest compendia/catalogs of surgical instruments written by an instrument maker, rather than by a surgeon, was John Savigny's _A Collection of Engravings Representing the Most Modern and Approved Instruments Used in the Practice of Surgery_ (London, 1799). This was followed a few decades later by the brochures and catalog (1831) of the famous London instrument maker, John Weiss. By the 1840s John Weiss, Charrière of Paris, and a few other instrument makers had begun to form surgical supply companies that attempted to market instruments over a wide area. While there are a handful of company trade catalogs dating from the 1840s, 1850s, and 1860s, the great influx of such catalogs came after 1870. Trade catalogs, a major source of information on the new instruments of the nineteenth century, provide the historian with line drawings, short descriptions indicating the mechanism and the material of which the instrument was composed, prices, and patent status. For more details on nineteenth-century instruments one must turn to brochures and articles in medical journals introducing the instruments to the medical profession. These sources provide the most detailed descriptions of how the instruments were constructed, how they were used, and why they were invented. For many American instruments, the descriptions available at the U.S. Patent Office offer illustrations of the mechanism and a discussion of why the instrument was considered novel. One finds specifications for many bizarre instruments that never appear in trade catalogs and may never have been actually sold. A final source of information is the instruments themselves. Some are engraved with the name of the manufacturer, and a few are even engraved with the date of manufacture. Some have been taken apart to study the spring mechanisms and others examined in the Conservation Analytical Laboratory of the Smithsonian Institution to determine their material content. The documentation accompanying the instruments, while sometimes in error, may serve to identify the individual artifact by name, place and date of manufacture, and to augment our knowledge of the historical setting in which these instruments were used. Bleeding: The History The history of bloodletting has been marked by controversy. The extensive literature on bloodletting contains numerous polemical treatises that both extol and condemn the practice. Bloodletting was no sooner criticized as ineffective and dangerous than it was rescued from complete abandonment by a new group of zealous supporters. From the time of Hippocrates (5th century B.C.)--and probably before, although no written record is available--bloodletting had its vocal advocates and heated opponents. In the 5th century B.C. Aegimious of Eris (470 B.C.), author of the first treatise on the pulse, opposed venesection, while Diogenes of Appolonia (430 B.C.), who described the vena cava with its main branches, was a proponent of the practice. Hippocrates, to whom no specific text on bloodletting is attributed, both approved and recommended venesection.[3] The anatomist and physician Erasistratus (300-260 B.C.), was one of the earliest physicians to leave a record of why he opposed venesection, the letting of blood from a vein. Erasistratus, who practiced at the court of the King of Syria and later at Alexandria, a celebrated center of ancient medicine, recognized that the difficulty in estimating the amount of blood to be withdrawn and the possibility of mistakenly cutting an artery, tendon, or nerve might cause permanent damage or even death. Since Erasistratus believed that only the veins carried blood while the arteries contained air, he also feared the possibility of transferring air from the arteries into the veins as a result of venesection. Erasistratus was led to question how excessive venesection differed from committing murder.[4] Through the writings of Aulus Cornelius Celsus (25 B.C.-?), the Roman encyclopedist, and Galen (ca. A.D. 130-200) venesection was restored as a form of orthodox medical treatment and remained so for the next fifteen hundred years. By the time of Celsus, bloodletting had become a common treatment. Celsus remarked in his well-known account of early medicine: "To let blood by incising a vein is no novelty; what is novel is that there should be scarcely any malady in which blood may not be let."[5] Yet criticism of bloodletting continued, for when Galen went to Rome in A.D. 164 he found the followers of Erasistratus opposing venesection. Galen opened up discussion with these physicians in two books, _Against Erasistratus_ and _Against the Erasistrateans Dwelling in Rome_. These argumentative dialectical treatises, together with his _Therapeutics of Venesection_, in which he presented his theory and practice of venesection, established Galen's views on bloodletting, which were not effectively challenged until the seventeenth century.[6] The fundamental theory upon which explanations of health and disease were based, which had its inception in ancient Greek thought and lasted up to the eighteenth century, was the humoral theory. Based on the scientific thought of the Pre-Socratics, the Pythagoreans, and the Sicilians, this theory posited that when the humors, consisting of blood, phlegm, yellow bile, and black bile, were in balance within the body, good health ensued. Conversely, when one or more of these humors was overabundant or in less than adequate supply, disease resulted. The humors were paired off with specific qualities representing each season of the year and the four elements according to the well-accepted doctrine of Empedocles, in which all things were composed of earth, air, fire, and water. Thus, yellow bile, fire, and summer were contrasted to phlegm, water, and winter, while blood, air, and spring were contrasted to black bile, earth, and autumn. When arranged diagrammatically, the system incorporating the humors, elements, seasons, and qualities appears as shown in Figure 1. The earliest formulation of humoralism was to be found in the physiological and pathological theory of the Hippocratic treatise, _On the Nature of Man_.[7] Plethora, an overabundance of body humors, including blood, which characterized fevers and inflammations, was properly treated by encouraging evacuation. This could be done through drugs that purged or brought on vomiting, by starvation, or by letting blood. During starvation the veins became empty of food and then readily absorbed blood that escaped into the arteries. As this occurred, inflammation decreased. Galen suggested that instead of starvation, which required some time and evacuated the system with much discomfort to the patient, venesection should be substituted to remove the blood directly.[8] Peter Niebyl, who has traced the rationale for bloodletting from the time of Hippocrates to the seventeenth century, concluded that bloodletting was practiced more to remove excess good blood rather than to eliminate inherently bad blood or foreign matter. Generally, venesection was regarded as an equivalent to a reduction of food, since according to ancient physiological theory, food was converted to blood.[9] [Illustration: FIGURE 1.--Chart of elements, seasons, and humors.] Galen defined the criteria for bloodletting in terms of extent, intensity, and severity of the disease, whether the disease was "incipient," "present," or "prospective," and on the maturity and strength of the patient.[10] Only a skilled physician would thus know when it was proper to bleed a patient. Venesection could be extremely dangerous if not correctly administered, but in the hands of a good physician, venesection was regarded by Galen as a more accurate treatment than drugs. While one could measure with great accuracy the dosages of such drugs as emetics, diuretics, and purgatives, Galen argued that their action on the body was directed by chance and could not easily be observed by the physician.[11] However, the effects of bloodletting were readily observed. One could note the change in the color of the blood removed, the complexion of the patient, and the point at which the patient was about to become unconscious, and know precisely when to stop the bleeding. Galen discussed in great detail the selection of veins to open and the number of times blood might be withdrawn.[12] In choosing the vein to open, its location in respect to the disease was important. Galen recommended that bleeding be done from a blood vessel on the same side of the body as the disease. For example, he explained that blood from the right elbow be removed to stop a nosebleed from the right nostril.[13] Celsus had argued for withdrawing blood near the site of the disease for "bloodletting draws blood out of the nearest place first, and thereupon blood from more distant parts follows so long as the letting out of blood is continued."[14] Controversy over the location of the veins to be opened erupted in the sixteenth century. Many publications appeared arguing the positive and negative aspects of bleeding from a vein on the same side (derivative--from the Latin _derivatio_ from the verb _derivare_, "to draw away," "to divert") or the opposite side (revulsion--from the Latin _revulsio_, "drawing in a contrary direction") of the disordered part of the body. This debate mirrored a broader struggle over whether to practice medicine on principles growing out of medieval medical views or out of classical Greek doctrines that had recently been revived and brought into prominence. The medieval practice was based on the Moslem medical writers who emphasized revulsion (bleeding from a site located as far from the ailment as possible).[15] This position was attacked in 1514 by Pierre Brissot (1478-1522), a Paris physician, who stressed the importance of bleeding near the locus of the disease (derivative bleeding). He was declared a medical heretic by the Paris Faculty of Medicine and derivative bleeding was forbidden by an act of the French parliament. In 1518, Brissot was exiled to Spain and Portugal. In 1539, the celebrated anatomist, Andreas Vesalius, continued the controversy with his famous _Venesection Letter_, which came to the support of Brissot.[16] Only with the gradual awareness of the implications of the circulation of the blood (discovered in 1628) did discussion of the distinction between derivative and revulsive bloodletting become passé.[17] Long after the circulation of the blood was established, surgical treatises such as those of Lorenz Heister (1719) recommended removing blood from specific parts of the body--such as particular veins in the arm, hand, foot, forehead, temples, inner corners of the eye, neck, and under the tongue. In the nineteenth century this practice was still challenged in the literature as a meaningless procedure.[18] (Figure 2.) _How Much Blood to Take_ According to Galen, safety dictated that the first bloodletting be kept to a minimum, if possible. Second, third, or further bleedings could be taken if the condition and the patient's progress seemed to indicate they would be of value. The amount of blood to be taken at one time varied widely.[19] Galen appears to have been the first to note the amount of blood that could be withdrawn: the greatest quantity he mentions is one pound and a half and the smallest is seven ounces. Avicenna (980-1037) believed that ordinarily there were 25 pounds of blood in a man and that a man could bleed at the nose 20 pounds and not die.[20] The standard advice to bloodletters, especially in the eighteenth and nineteenth centuries, was "bleed to syncope." "Generally speaking," wrote the English physician and medical researcher, Marshall Hall, in 1836, "as long as bloodletting is required, it can be borne; and as long as it can be borne, it is required."[21] The American physician, Robley Dunglison, defined "syncope" in his 1848 medical dictionary as a "complete and, commonly, sudden loss of sensation and motion, with considerable diminution, or entire suspension of the pulsations of the heart and the respiratory movements."[22] Today little distinction is made between shock and collapse, or syncope, except to recognize that if collapse or syncope persists, shock will result. We know today that blood volume is about one-fifteenth to one-seventeenth the body weight of an adult. Thus an adult weighing 150 pounds has 9 or 10 pounds of blood in his body. Blood volume may increase at great heights, under tropical conditions, and in the rare disease polycythemia (excess red blood cells). After a pint of blood is withdrawn from a healthy individual, the organism replaces it to some degree within an hour or so. However, it takes weeks for the hemoglobin (the oxygen-bearing substance in the red blood cells) to be brought up to normal. If blood loss is great (more than 10 percent of the total blood volume) there occurs a sudden, systemic fall in blood pressure. This is a well-known protective mechanism to aid blood clotting. If the volume of blood lost does not exceed 30 to 40 percent, systolic, disastolic, and pulse pressures rise again after approximately 30 minutes as a result of various compensatory mechanisms.[23] [Illustration: FIGURE 2.--Venesection manikin, 16th century. Numbers indicate locations where in certain diseases venesection should be undertaken. (From Stoeffler, 1518, as illustrated in Heinrich Stern, _Theory and Practice of Bloodletting_, New York, 1915. Photo courtesy of NLM.)] If larger volumes than this are removed, the organism is usually unable to survive unless the loss is promptly replaced. Repeated smaller bleedings may produce a state of chronic anemia when the total amount of blood and hemoglobin removed is in excess of the natural recuperative powers. _When to Bleed_ Selecting a time for bleeding usually depended on the nature of the disease and the patient's ability to withstand the process. Galen's scheme, in contrast to the Hippocratic doctrine, recommended no specific days.[24] Hippocrates worked out an elaborate schedule, based on the onset and type of disease, to which the physician was instructed to adhere regardless of the patient's condition. Natural events outside the body served as indicators for selecting the time, site, and frequency of bloodletting during the Middle Ages when astrological influences dominated diagnostic and therapeutic thought. This is illustrated by the fact that the earliest printed document relating to medicine was the "Calendar for Bloodletting" issued in Mainz in 1457. This type of calendar, also used for purgation, was known as an _Aderlasskalender_, and was printed in other German cities such as Augsburg, Nuremberg, Strassburg, and Leipzig. During the fifteenth century these calendars and _Pestblatter_, or plague warnings, were the most popular medical literature. Sir William Osler and Karl Sudhoff studied hundreds of these calendars.[25] They consisted of a single sheet with some astronomical figures and a diagram of a man (_Aderlassmann_) depicting the influence of the stars and the signs of the zodiac on each part of the body, as well as the parts of the anatomy suitable for bleeding. These charts illustrated the veins and arteries that should be incised to let blood for specific ailments and usually included brief instructions in the margin. The annotated bloodletting figure was one of the earliest subjects of woodcuts. One early and well known _Aderlassmann_ was prepared by Johann Regiomontanus (Johannes Müller) in 1473. It contained a dozen proper bleeding points, each suited for use under a sign of the zodiac. Other _Aderlassmanner_ illustrated specific veins to be bled. The woodcut produced by the sixteenth-century mathematician, Johannes Stoeffer, illustrated 53 points where the lancet might be inserted.[26] "Medicina astrologica" exerted a great influence on bloodletting. Determining the best time to bleed reached a high degree of perfection in the late fourteenth and fifteenth centuries with the use of volvella or calculating devices adopted from astronomy and navigation. These were carried on a belt worn around the waist for easy consultation. Used in conjunction with a table and a vein-man drawing, the volvella contained movable circular calculators for determining the accuracy, time, amount, and site to bleed for an illness. The dangers of bloodletting elicited both civic and national concern and control. Statutes were enacted that required every physician to consult these tables before opening a vein to minimize the chance of bleeding improperly and unnecessarily. Consultation of the volvella and vein-man was more important than an examination of the patient.[27] (Figure 3.) For several centuries, almanacs were consulted to determine the propitious time for bleeding. The "woodcut anatomy" became a characteristic illustration of the colonial American almanac. John Foster introduced the "Man of Signs," as it was called, into the American almanac tradition in his almanac for 1678, printed in Boston. Other examples of early American almanacs featuring illustrations of bleeding include Daniel Leed's almanac for 1693, printed in Philadelphia, and John Clapp's almanac for 1697, printed in New York. As in many of the medieval illustrations, the woodcut anatomy in the American almanac consisted of a naked man surrounded by the twelve signs of the zodiac, each associated with a particular part of the body (the head and face with Aries, the neck with Taurus, the arms with Gemini, etc.). The directions that often accompanied the figure instructed the user to find the day of the month in the almanac chart, note the sign or place of the moon associated with that day, and then look for the sign in the woodcut anatomy to discover what part of the body is governed by that sign. Bloodletting was usually not specifically mentioned, but it is likely that some colonials still used the "Man of Signs" or "Moon's Man" to determine where to open a vein on a given day.[28] [Illustration: FIGURE 3.--Lunar dial, Germany, 1604. Concentric scales mark hours of the day, days, months, and special astrological numbers. In conjunction with other dials, it enables the user to determine the phases of the moon. (NMHT 30121; SI photo P-63426.)] The eighteenth-century family Bible might contain a list of the favorable and unfavorable days in each month for bleeding, as in the case of the Bible of the Degge family of Virginia.[29] _Barber-Surgeons_ Even though it was recognized that bleeding was a delicate operation that could be fatal if not done properly, it was, from the medieval period on, often left in the hands of the barber-surgeons, charlatans, and women healers. In the early Middle Ages the barber-surgeons flourished as their services grew in demand. Barber-surgeons had additional opportunities to practice medicine after priests were instructed to abandon the practice of medicine and concentrate on their religious duties. Clerics were cautioned repeatedly by Pope Innocent II through the Council at Rheims in 1131, the Lateran Council in 1139, and five subsequent councils, not to devote time to duties related to the body if they must neglect matters related to the soul.[30] By 1210, the barber-surgeons in England had gathered together and formed a Guild of Barber-Surgeons whose members were divided into Surgeons of the Long Robe and Lay-Barbers or Surgeons of the Short Robe. The latter were gradually forbidden by law to do any surgery except bloodletting, wound surgery, cupping, leeching, shaving, extraction of teeth, and giving enemas.[31] The major operations were in the hands of specialists, often hereditary in certain families, who, if they were members of the Guild, would have been Surgeons of the Long Robe. [Illustration: FIGURE 4.--Bleeding bowl with gradations to measure the amount of blood. Made by John Foster of London after 1740. (Held by the Division of Cultural History, Greenwood Collection, Smithsonian Institution; SI photo 61166-C.)] To distinguish his profession from that of a surgeon, the barber-surgeon placed a striped pole or a signboard outside his door, from which was suspended a basin for receiving the blood (Figure 4). Cervantes used this type of bowl as the "Helmet of Mambrino" in Don Quixote.[32] Special bowls to catch the blood from a vein were beginning to come into fashion in the fourteenth century. They were shaped from clay or thin brass and later were made of pewter or handsomely decorated pottery. Some pewter bowls were graduated from 2 to 20 ounces by a series of lines incised around the inside to indicate the number of ounces of fluid when filled to that level. Ceramic bleeding bowls, which often doubled as shaving bowls, usually had a semicircular indentation on one side to facilitate slipping the bowl under the chin. Bowls to be used only for bleeding usually had a handle on one side. Italian families had a tradition of passing special glass bleeding vessels from generation to generation. The great variety in style, color, and size of bleeding and shaving bowls is demonstrated by the beautiful collection of over 500 pieces of Dr. A. Lawrence Abel of London and by the collection of the Wellcome Historical Museum, which has been cataloged in John Crellin's _Medical Ceramics_.[33] These collections illustrate the stylistic differences between countries and periods. The barber-surgeons' pole represented the stick gripped by the patient's hand to promote bleeding from his arm. The white stripe on the pole corresponded to the tourniquet applied above the vein to be opened in the arm or leg. Red or blue stripes appeared on early barber poles, but later poles contained both colors.[34] The dangers posed by untutored and unskilled bleeders were noted periodically. In antiquity Galen complained about non-professional bleeders, and in the Middle Ages, Lanfranc (1315), an outstanding surgeon, lamented the tendency of surgeons of his time to abandon bloodletting to barbers and women.[35] Barber-surgeons continued to let blood through the seventeenth century. In the eighteenth and nineteenth centuries, the better educated surgeon, and sometimes even the physician, took charge of bleeding. _Bloodletting and the Scientific Revolution_ The discovery of the blood's circulation did not result in immediate changes in the methods or forms of bloodletting. William Harvey, who published his discovery of circulation in 1628, recognized the value of investigating the implications of his theory. Harvey could not explain the causes and uses of the circulation but he believed that it did not rule out the practice of bloodletting. He claimed that daily experience satisfies us that bloodletting has a most salutary effect in many diseases, and is indeed the foremost among all the general remedial means: vitiated states and plethora of blood, are causes of a whole host of disease; and the timely evacuation of a certain quantity of the fluid frequently delivers patients from very dangerous diseases, and even from imminent death.[36] The English scientist Henry Stubbe brought to the surface what would appear to be an obvious dilemma: How could one bleed to produce local effect if the blood circulated? Stubbe commented in 1671: I do say, that no experienced Physician ever denied the operation of bloodletting though since the tenet of the Circulation of the Blood the manner how such an effect doth succeed admits of some dispute, and is obscure. We the silly followers of Galen and the Ancients do think it an imbecility of judgement, for any to desert an experienced practice, because he doth not comprehend in what manner it is effected.[37] In the early nineteenth century the physiologist François Magendie (1783-1855), who argued against bloodletting, showed that the physiological effects of opening different veins was exactly the same, and therefore the choice of which vein to bleed did not affect the procedure.[38] The first serious modern challenges to bloodletting were made in the sixteenth and seventeenth centuries under the leadership of the German alchemist Paracelsus and his Belgian follower, Van Helmont. The medical chemists or iatrochemists espoused explanations for and treatments of diseases based on chemical theories and practices. They believed that the state of the blood could best be regulated by administering the proper chemicals and drugs rather than by simply removing a portion of the blood. Iatrochemistry provided a substitution in the form of medicinals to quell the flow of blood for therapeutic purposes.[39] The revival of Hippocratic medicine in the late seventeenth and eighteenth centuries also led to questioning the efficacy of bloodletting. The Hippocratic treatises, while they occasionally mentioned bloodletting, generally stressed nature's power of cure. This school of medicine advocated a return to clinical observation and a reduction of activist intervention. Treatments such as bloodletting, it was felt by the neo-Hippocratists, might merely serve to weaken the patient's strength and hinder the healing processes of nature.[40] A rival group of medical theorists also flourished in this period. The iatrophysicists, who concentrated on mechanical explanations of physiological events, remained adherents of bloodletting. Their support of the practice ensured its use at a time when the first substantial criticism of it arose. _Instrumentation and Techniques_ Sharp thorns, roots, fish teeth, and sharpened stones were among the early implements used to let blood.[41] Venesection, one of the most frequently mentioned procedures in ancient medicine, and related procedures such as lancing abcesses, puncturing cavities containing fluids, and dissecting tissues, were all accomplished in the classical period and later with an instrument called the phlebotome. _Phlebos_ is Greek for "vein," while "tome" derives from _temnein_, meaning "to cut." In Latin, "phlebotome" becomes "flebotome," and in an Anglo-Saxon manuscript dating from A.D. 1000, the word "fleam" appears. The phlebotome, a type of lancet, was not described in any of the ancient literature, but its uses make it apparent that it was a sharp-pointed, double-edged, and straight-bladed cutting implement or scalpel similar to the type later used for splitting larger veins.[42] Several early Roman examples of phlebotomes have been collected in European museums. One, now in the Cologne Museum, was made of steel with a square handle and blade of myrtle leaf shape. Another specimen, made of bronze, was uncovered in the house of the physician of _Strada del Consulare_ of Pompeii. This specimen, now in the Naples Museum, is 8 cm long and 9 mm at the broadest part of the blade, and its handle bears a raised ring ornamentation.[43] A number of copies of Roman instruments have been made and some have passed into museum collections. Some of the copies were commissioned by Sir Henry Wellcome for the Wellcome Historical Medical Museum collection and the Howard Dittrick Historical Medical Museum in Cleveland. They emulate the size, color, and aged condition of the originals and make it very difficult for the inexpert to distinguish an original from its replica. It is, however, impossible to fully duplicate the patina of ancient bronze.[44] Seventeenth-century and later bloodletting instruments usually have not been copied.[45] From the earliest examples of the fleam, such as the specimen found at Pompeii, this instrument has been associated with the veterinarian. Since early practitioners, particularly the Roman physician, performed the duties of the surgeon as well as those of the veterinarian, it is possible that they used the same instrument to open blood vessels in humans and animals.[46] In the seventeenth and eighteenth centuries a type of fleam (German _fliete_, French _flamette_), which had a pointed edge at right angles to the handle, was in use in Germany, Holland, and Vienna, Austria.[47] Since the specimens found in museums vary in size, it is likely that this type of fleam was used on both animals and humans. In about the fifteenth century the thumb lancet, also called a _gladiolus_, _sagitella_, _lanceola_, _lancetta_, or _olivaris_, was introduced.[48] It soon became the preferred instrument for opening a vein in any part of the body. The double-edged iron or steel blade was placed between two larger covers, usually made of horn or shell, and all three pieces were united at the base with a riveted screw. The blade could be placed at various angles of inclination when in use. The shape of the blade, whether broad or narrow, determined the ease with which the skin and vein could be penetrated. A long slender blade was essential to pierce a vein located below many layers of fatty tissue.[49] These tiny and delicate thumb lancets were often carried in small flat cases of silver, tortoise shell, shagreen, or leather with hinged tops and separate compartments for each lancet. (Figure 5.) A surgeon was advised to carry lancets of various sizes and shapes in order to be prepared to open veins of differing sizes and in different locations. Even Hippocrates had cautioned bloodletters not to use the different size lancets indiscriminately, "for there are certain parts of the body which have a swift current of blood which it is not easy to stop."[50] For vessels that bled easily, it was essential to make narrow openings; otherwise it would be difficult, if not impossible, to stop the flow of the blood. For other vessels, lancets that made larger openings were required or the blood would not flow satisfactorily. The blood as it spurted from the vein would be collected in a container and measured. When enough blood was removed, the bleeding would be stopped by a bandage or compress applied to the incision. [Illustration: FIGURE 5.--18th-19th century lancets and lancet cases. The cases are made of mother-of-pearl, silver, shagreen, and tortoise shell. (NMHT 308730.10. SI photo 76-9116.)] Teaching a medical student how to bleed has had a long tradition. Before approaching a patient, the student practiced opening a vein quickly and accurately on plants, especially the fruits and stems.[51] The mark of a good venesector was his ability not to let even a drop of blood be seen after the bleeding basin was removed.[52] It required some degree of skill to strike a vein properly. The most common vein tapped was in the elbow, although veins in the foot were also popular. The arm was first rubbed and the patient given a stick to grasp. Then a tourniquet would be applied above the elbow (or, if the blood was to be taken from the foot, above the ankle), in order to enlarge the veins and promote a continuous flow of blood. Holding the handle between the thumb and the first finger, the operator then jabbed the lancet into the vein. Sometimes, especially if the vein was not close to the surface of the skin, the instrument was given an extra impetus by striking it with a small mallet or the fingers to insure puncturing the vein.[53] The incisions were made diagonally or parallel to the veins in order to minimize the danger of cutting the vein in two.[54] For superficial veins, the vein was sometimes transfixed, that is, the blade would be inserted underneath the vessel so that the vessel could not move or slip out of reach. The transfixing procedure ensured that the vein would remain semi-divided so that blood would continuously pass out of it, and that injury to other structures would be avoided. Deep-lying veins of the scalp, for example, could not be transfixed. They were divided by cutting through everything overlying them since there were no important structures to injure.[55] The consequences of puncturing certain veins incorrectly were discussed by many early writers including Galen, Celsus, Antyllus, and Paul of Aegina.[56] Injury to a nearby nerve, muscle, or artery resulted in convulsions, excessive bleeding, or paralysis. Bloodletting was at its most fashionable in the eighteenth and early nineteenth centuries. In this period it was considered an art to hold the lancet properly and to support the arm of the patient with delicacy and grace.[57] Many patients had by repeated bloodlettings become inured to its potential danger and unpleasantness. In the mid-eighteenth century one British physician declared: "People are so familiarized to bleeding that they cannot easily conceive any hurt or danger to ensue, and therefore readily submit, when constitutional fear is out of the question, to the opening of a vein, however unskillfully advised."[58] In England in the early nineteenth century people came to the hospital to be bled in the spring and fall as part of the ritual for maintaining good health. At some periods there were so many people undergoing prophylactic bloodletting that they could be seen lying on the floor of the hospital while recovering from the faintness induced by venesection.[59] The lancet was perhaps the most common medical instrument. _The Lancet_ was the name of one of the oldest and most socially aware English medical journals, founded by Thomas Wakeley in 1823.[60] In America, Benjamin Rush (1746-1813) promoted vomits, purges, salivation, and especially bleeding. Rush, a signer of the Declaration of Independence, is notorious in medical history for his resorting to massive bleedings during the epidemics of yellow fever at the end of the eighteenth century. Rush told a crowd of people in 1793: "I treat my patients successfully by bloodletting, and copious purging with calomel and jalop and I advise you, my good friends, to use the same remedies." "What?" called a voice from the crowd, "Bleed and purge everyone?" "Yes," said the doctor, "bleed and purge all Kensington."[61] The alternatives to bleeding in this period included administering mercury (calomel) to promote salivation and tartar emetic to induce vomiting. These substitutes could be as hazardous as bleeding and offered little choice to the patient who had to bear the unpleasant effects. Thus, the late eighteenth and early nineteenth century has been referred to by historians as the era of heroic medicine because of the large amounts of strong medications given and excessive bloodletting.[62] One of the most notable victims of heroic medicine during this period was George Washington (1732-1799), who was bled four times in two days after having contracted a severe inflammation of the throat. Washington's physician, Dr. Craik, admitted that the removal of too much blood might have been the cause of his death. Additional bleeding was prevented only by Washington's request to be allowed to die without further medical intervention, since he believed that his illness was incurable.[63] Bloodletting was especially resorted to in times of crisis. One woman, Hannah Green, had been anesthetized in 1848 by chloroform before undergoing a minor operation on her toe. The physician bled her in a futile attempt to revive her, but she died, becoming the first known victim of inhalation anesthesia.[64] _Spring Lancets_ The great vogue in phlebotomy inspired the invention of ingenious instruments. From Vienna came the automatic or spring lancet, originally called a _Schnepper_ or _Schnepperlein_, which permitted the operator to inject the blade into a vein without exerting manual pressure.[65] It was widely adopted if the variety of models now extant is a proper indication. In the spring lancet, the blade was fixed into a small metal case with a screw and arranged to respond to a spring that could be released by a button or lever on the outside of the case. The blade was positioned at right angles to the spring and case, thus adopting the basic shape of the fleam. The case of the spring lancet was usually made of copper, silver, brass, or an alloy. It was often decorated with engraved furbelows or embossed with political or other symbols depending on the preference of the owner and the fashion of the period. The mechanism of this handsome implement has been described by a modern collector (Figures 6, 7): The curved projection (1) is the continuation of a heavy coiled spring. When pushed up it catches on a ratchet. A razor sharp blade (2), responding to the pressure of a light spring placed under it, follows the handle as it goes up. A lever (3) acting on a fulcrum (4) when pressed down, releases handle which in turn strikes the lancet down with lightning speed.[66] The spring lancet was initially described by Lorenz Heister in 1719.[67] Another early description appeared in 1798 in the first American edition of the _Encyclopedia or Dictionary of Arts and Sciences_, in which the spring lancet was called a "phleam."[68] The spring lancet for use on humans was a rather tiny instrument. Its casing was about 4 cm long and 1.5 to 2 cm wide. The blade added another centimeter in length. Larger size instruments, often with a metal guard over the blade, were made for use on animals. Eighteenth- and early nineteenth-century spring lancets are found in a wide variety of shapes. Mid- and late nineteenth-century spring lancets are more uniform in shape, most having the familiar knob-shaped end. In most lancets the blade was released by a lever, but in the late nineteenth century, the blade of a more expensive model was released by a button. [Illustration: FIGURE 6.--Spring lancet, 19th century. (NMHT 321636.01; SI photo 73-4236.)] [Illustration: FIGURE 7.--Interior of spring lancet. (NMHT 308730.10; SI photo 76-13535.)] In general, German, American, and Dutch surgeons preferred the spring lancet to the simple thumb lancet. In contrast, the French tended to prefer the thumb lancet. Ristelhueber, a surgeon in Strasbourg, maintained in 1819 that the simple lancet was preferable to the spring lancet both in terms of simplicity of design and application. While allowing German surgeons some credit for attempting to improve the spring lancet, Ristelhueber remained firm in his view that the spring lancet was too complicated and performed no better than the thumb lancet. The only advantage of the spring lancet was that it could be used by those who were ignorant of anatomy and the art of venesection. Untutored bleeders could employ a spring lancet on those veins that stood out prominently and be fairly confident that they could remove blood without harming other blood vessels. The bagnio men (bath attendants), who routinely bled the bathers in public baths, preferred the spring lancet.[69] It was more difficult to sever a vein with a spring lancet and thereby cause serious hemorrhaging. However, since the spring lancet was harder to clean because of its small size and its enclosed parts, it was more likely to induce infection (phlebitis). While the French and British surgeons remained critical of the spring lancet, it became popular in the United States. John Syng Dorsey, a noted Philadelphia surgeon, wrote in 1813: The German fleam or spring lancet I prefer greatly to the common English lancet for phlebotomy; it is now in some parts of the United States almost exclusively used. In a country situated like the United States, where every surgeon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring-lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instrument; and no one can calculate with certainty the depth to which it will enter. To sharpen a lancet, is regarded by the cutler as one of his nicest and most difficult jobs; it is one to which few surgeons are competent. The safety of using the fleam is demonstrated by daily experience; there is no country in which venesection is more frequently performed than in the United States, and perhaps none where fewer accidents from the operation have occurred, of those few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used. Among the advantages of the spring-lancet economy is not the least. A country practitioner who is constantly employing English lancets, and who is particular in using none but the best, must necessarily consume half the emoluement derived from the operation, in the purchase of his instruments. One spring-lancet, with an occasional new blade, will serve him all his life.[70] This popularity is also reflected in various medical dictionaries of the eighteenth and nineteenth centuries that described the instrument and in the wide variety of spring lancets in the Smithsonian collection. One American user of the spring lancet, J. E. Snodgrass of Baltimore, was inspired to compose a poem about the instrument, which appeared in the _Baltimore Phoenix and Budget_ in 1841. He wrote: To My Spring-Lancet Years have passed since first we met, Pliant and ever-faithful-slave! Nobly thou standest by me yet, Watchful as ever and as brave. O, were the power of language thine, To tell all thou hast seen and done, Methinks the curious would incline, Their ears to dwell they tales upon! I love thee, bloodstain'd, faithful friend! As warrior loves his sword or shield; For how on thee did I depend When foes of Life were in the field! Those blood spots on thy visage, tell That thou, thro horrid scenes, hast past. O, thou hast served me long and well; And I shall love thee to the Last! A thousand mem'ries cluster round thee In all their freshness! thou dost speak Of friends far distant-friends who found thee Aye with thy master, prompt to wreak Vengeance on foes who strove to kill With blows well aim'd at heart or head-- Thieves that, with demon heart and will, Would fain have on they vials fed. O, They have blessed thee for thy aid, When grateful eyes, thy presence, spoke; Thou, anguish'd bosoms, glad hast made, And miser's tyrant sceptre broke. Now, when 'mong strangers, is our sphere, Thou, to my heart, are but the more Endear'd--as many a woe-wring tear Would plainly tell, if from me tore! There was little change in the mechanism of the spring lancet during the nineteenth century, despite the efforts of inventors to improve it. Approximately five American patents on variations of the spring lancet were granted in the nineteenth century. One patent model survives in the Smithsonian collection. Joseph Gordon of Catonsville, Maryland, in 1857 received patent No. 16479 for a spring lancet constructed so that three different positions of the ratchet could be set by the sliding shield. The position of the ratchet regulated the force with which the blade entered the vein. This also had the advantage of allowing the blade to enter the vein at the same angle irrespective of the depth to which it penetrated.[71] _The Decline of Bleeding_ Throughout the seventeenth, eighteenth, and nineteenth centuries, most physicians of note, regardless of their explanations of disease, including Hermann Boerhaave, Gerard Van Swieten, Georg Ernst Stahl (phlogiston), John Brown and Friedrich Hoffmann (mechanistic theories), Johann Peter Frank, Albrecht von Haller, Percival Pott, John Pringle, William Cullen, and Francois Broussais, recommended bloodletting and adjusted their theories to provide an explanation for its value. At the end of the eighteenth century and in the early nineteenth century, the practice of bloodletting reached a high point with the theories of F.-J.-V. Broussais (1772-1838) and others. After 1830, however, the practice gradually declined until, by the end of the century, it had all but disappeared. This decline occurred even though many medical theories were brought to the defense of bleeding. A French medical observer commented in 1851 that "l'histoire de la saignée considerée dans son ensemble, constituerait presque à elle seule l'histoire de toutes les doctrines médicales" (the history of bloodletting, considered in its totality, would constitute almost by itself the history of all medical doctrines).[72] There was no crisis of medical opinion, and no one event to account for this decline. The French physician, Pierre Louis's statistical investigation (numerical method) into the effect of bloodletting in the treatment of pneumonia has often been cited as a cause for the downfall of venesection,[73] but the results of Louis's research showed only that bloodletting was not as useful as was previously thought. Louis's work, however, was typical of a new and critical attitude in the nineteenth century towards all traditional remedies. A number of investigators in France, Austria, England, and America did clinical studies comparing the recovery rates of those who were bled and those who were not.[74] Other physicians attempted to measure, by new instruments and techniques, the physiological affects of loss of blood. Once pathological anatomy had associated disease entities with specific lesions, physicians sought to discover exactly how remedies such as bloodletting would affect these lesions. In the case of pneumonia, for example, those who defined the disease as "an exudation into the vessels and tissues of the lungs" could not see how bloodletting could remove the coagulation. John Hughes Bennett, an Edinburgh physician, wrote in 1855: "It is doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the pulmonary capillaries--that it can directly affect the coagulated exudation is impossible."[75] Bennett felt that bloodletting merely reduced the strength of the patient and thus impeded recovery. Bloodletting was attacked not only by medical investigators, but much more vehemently by members of such medical sects as the homeopaths and botanics who sought to replace the harsh remedies of the regular physicians by their own milder systems of therapeutics.[76] As a result of all this criticism the indications for bleeding were gradually narrowed, until at the present time bloodletting is used in only a few very specific important instances. In England and America, in the last quarter of the nineteenth century, a last serious attempt was made to revive bloodletting before it died out altogether. A number of Americans defended the limited use of bleeding, especially in the form of venesection. The noted American physician, Henry I. Bowditch, tried in 1872 to arouse support for venesection among his Massachusetts Medical Society colleagues. He noted that venesection declined more than any other medical opinion in the esteem of the physician and the public during the previous half century. At the beginning of his career, he had ignored the request of his patients who wanted annual bloodlettings to "breathe a vein" to maintain good health. He eventually found that to give up the practice entirely was as wrong as to overdo it when severe symptoms of a violent, acute cardiac disease presented themselves. Lung congestion and dropsy were other common disorders that seemed to him to be relieved, at least temporarily, by venesection.[77] In 1875 the Englishman W. Mitchell Clarke, after reviewing the long history of bloodletting and commenting on the abrupt cessation of the practice in his own time, wrote: Experience must, indeed, as Hippocrates says in his first aphorism, be fallacious if we decide that a means of treatment, sanctioned by the use of between two and three thousand years, and upheld by the authority of the ablest men of past times, is finally and forever given up. This seems to me to be the most interesting and important question in connection with this subject. Is the relinquishment of bleeding final? or shall we see by and by, or will our successors see, a resumption of the practice? This, I take it, is a very difficult question to answer; and he would be a very bold man who, after looking carefully through the history of the past, would venture to assert that bleeding will not be profitably employed any more.[78] An intern, Henri A. Lafleur of the newly founded Johns Hopkins Hospital, reported on five patients on whom venesection was performed between 1889 and 1891. Lafleur defended his interest in the subject by calling attention to other recent reports of successes with bleeding, such as that of Dr. Pye-Smith of London. He concluded that at least temporary relief from symptoms due to circulatory disorders, especially those involving the pulmonary system, was achieved through venesection. Pneumonia and pleurisy were the primary diseases for which venesection was an approved remedy.[79] It had long been believed by bloodletters that these complaints were especially amenable to an early and repeated application of the lancet.[80] Austin Flint had explained in 1867 that bloodletting "is perhaps more applicable to the treatment of inflammation affecting the pulmonary organs than to the treatment of other inflammatory affections, in consequence of the relations of the former [pulmonary organs] to the circulation."[81] Thus, while bloodletting for other diseases declined throughout the nineteenth century, it continued to be advocated for treating apoplexy, pneumonia, and pulmonary edema.[82] The merit of phlebotomy for those afflicted with congestive heart failure was emphasized again in 1912 by H. A. Christian. This condition led to engorgement of the lungs and liver and increased pressure in the venous side of the circulation. Articles advocating bloodletting continued into the 1920s and 1930s.[83] Bloodletting is currently being tested as a treatment for those suffering from angina or heart attacks. Blood is removed on a scheduled basis to maintain the hematocrit (the percentage of red blood cells in the blood) at a specified level. Keeping the hematocrit low has provided relief to those being tested.[84] Other benefits of removing blood, including the lowering of blood pressure, can be obtained by the use of antihypertensive drugs. Thus the valid indications for bleeding are being supplanted by the use of modern drugs that accomplish the same end. By the twentieth century the lancet was replaced in some quarters by safer devices for removing blood and injecting fluids into the bloodstream. Heinrich Stern improved Strauss's special hyperdermic needle. In 1905 Stern designed a venepuncture or aspirating needle that was 7 cm long with a silver cannula of 4 cm. Attached to the handle was a thumb-rest and a tube for removing or adding fluids and a perforator within the cannula. He recommended that the forearm be strapped above the elbow and that the instrument be thrust into the most prominent vein. This streamlined vein puncturing implement reduced the possibility of injecting air and bacteria into the blood.[85] It was, and continues to be, used to withdraw blood for study in the laboratory, to aid in diagnosis of disease, and to collect blood for transfusing into those who need additional blood during an operation or to replace blood lost in an accident or disease. The blood is collected in a glass or plastic graduated container and stored under refrigeration. The study of blood donors has, incidentally, given insights into the physiology of bloodletting since the volume customarily removed from a donor is about the same in volume as that taken by a bleeder (one pint or 500 cc).[86] The annual physical examination today includes taking a small amount of blood from the finger or a vein in the elbow. This blood is then analyzed for the presence of biochemical components of such diseases as diabetes, anemia, arteriosclerosis, etc. A tiny sterile instrument called a blood lancet may be used by the technician who draws the blood, who is still called by the historical name, phlebotomist. Cupping "Cupping is an art," wrote the London cupper Samuel Bayfield in 1823, "the value of which every one can appreciate who has had opportunities of being made acquainted with its curative power by observing its effects on the person of others, or by realizing them in his own."[87] The curious operation of taking blood by means of exhausted cups had been part of Western medicine since the time of Hippocrates, and has been found in many other cultures as well. It is still practiced in some parts of the world today. Since antiquity medical authors have distinguished two forms of cupping, dry and wet. In dry cupping, no blood was actually removed from the body. A cup was exhausted of air and applied to the skin, causing the skin to tumefy. In wet cupping, dry cupping was followed by the forming of several incisions in the skin and a reapplication of the cups in order to collect blood. It was possible to scarify parts of the body without cupping--through the nineteenth-century physicians recommended scarifying the lips, the nasal passages, the eyes, and the uterus. In order to remove any sizeable amount of blood, however, it was necessary to apply some sort of suction to the scarifications, because capillaries, unlike arteries and veins, do not bleed freely. (Figure 8.) Cupping was generally regarded as an auxiliary to venesection. The indications for the operation were about the same as the indications for phlebotomy, except that there was a tendency to prefer cupping in cases of localized pain or inflammation, or if the patient was too young, too old, or too weak to withstand phlebotomy. "If cutting a vein is an instant danger, or if the mischief is still localised, recourse is to be had rather to cupping," wrote the encyclopedist Celsus in the first century A.D.[88] As noted above, the ancients usually recommended cupping close to the seat of the disease. However, there were several examples in ancient writings of cupping a distant part in order to divert blood. The most famous of these examples was Hippocrates' recommendation of cupping the breasts in order to relieve excessive menstruation.[89] As was the case for phlebotomy, the number of ills that were supposedly relieved by cupping was enormous. Thomas Mapleson, a professional cupper, gave the following list of "diseases in which cupping is generally employed with advantage" in 1801: Apoplexy, angina pectoris, asthma, spitting blood, bruises, cough, catarrh, consumption, contusion, convulsions, cramps, diseases of the hip and knee joints, deafness, delirium, dropsy, epilepsy, erysipelas, eruptions, giddiness, gout, whooping cough, hydrocephalus, head ache, inflammation of the lungs, intoxication, lethargy, lunacy, lumbago, measles, numbness of the limbs, obstructions, ophthalmia, pleurisy, palsy, defective perspiration, peripneumony, rheumatism, to procure rest, sciatica, shortness of breath, sore throat, pains of the side and chest.[90] _Early Cupping Instruments_ Mapleson believed that cupping was first suggested by the ancient practice of sucking blood from poisoned wounds. In any case, the earliest cupping instruments were hollowed horns or gourds with a small hole at the top by which the cupper could suck out the blood from scarifications previously made by a knife. The Arabs called these small vessels "pumpkins" to indicate that they were frequently applied to a part of the body in which the organs contained air or that they were vessels that had to be evacuated before they could be applied.[91] The use of cattle horns for cupping purposes seems to have been prevalent in all periods up to the present. When Prosper Alpinus visited Egypt in the sixteenth century, he found the Egyptians using horns that were provided with a small valve of sheepskin to be maintained in place by the cupper's tongue and serving to prevent the intake of air once the cup was exhausted.[92] In nineteenth-century America, at least one physician still recommended horns as superior to glass cups for rural medical practice. A Virginia physician, Dr. W. A. Gillespie, disturbed by the high cost of cupping instruments, suggested to his readers in _The Boston Medical and Surgical Journal_ for 1834 that since glass cups were often broken when carried from place to place, "an excellent substitute can be made of a small cow horn, cornicula, which may be scraped or polished until perfectly diaphanous or transparent."[93] The Smithsonian collection contains a cow's horn from Madaoua, Niger Republic (West Africa), used for drawing blood in the 1960s. The director of the Baptist Mission, who sent the horn, noted that he had often seen Africans sitting in the market place with such horns on their backs or their heads. Scarifications were made with a handmade razor.[94] [Illustration: FIGURE 8.--Scarification without cupping in Egypt in the 16th century. To obtain sufficient blood, 20 to 40 gashes were made in the legs and the patient was made to stand in a basin of warm water. (From Prosper Alpinus, _Medicina Aegyptorum_, Leyden, 1719. Photo courtesy of NLM.)] In addition to horn cups, the ancients employed bronze cups in which a vacuum was obtained by inserting a piece of burning flax or linen into the cup before its application to the skin. Most Greek and Roman cups were made of metal.[95] Although Galen already preferred glass cups to metal cups for the simple reason that one could see how much blood was being evacuated, metal cups were used until modern times. Their main virtue was that they did not break and thus could be easily transported. For this reason, metal cups were especially useful to military surgeons. Brass and pewter cups were common in the eighteenth century, and tin cups were sold in the late nineteenth century. Since the latter part of antiquity, cups have been made of glass. The Smithsonian possesses two Persian opaque glass cups dating from the twelfth century, called "spouted glasses" because of the spout protruding from the side of the cup by which the cupper exhausted the air with his mouth. Similar spouted glasses were illustrated by Prosper Alpinus (sixteenth century), so designed that the blood would collect in a reservoir instead of being sucked into the cupper's mouth. Like the horn cups illustrated by Alpinus, the glass cups were provided with a small valve made of animal skin. It appears that the sixteenth-century Egyptians were not familiar with the use of fire for exhausting cups. (Figure 9.) Cupping and leeching were less frequently practiced in the medieval period, although general bloodletting retained its popularity.[96] When the eastern practice of public steam baths was reintroduced into the West in the late sixteenth and early seventeenth centuries, cupping tended to be left in the hands of bath attendants (Bagnio men) and ignored by regular surgeons. Some surgeons, such as Pierre Dionis, who gave a course of surgery in Paris in the early eighteenth century, saw little value in the operation. He felt that the ancients had greatly exaggerated the virtues of the remedy.[97] Another French surgeon, René de Garengeot, argued in 1725 that those who resorted to such outdated remedies as cupping had studied the philosophical systems of the ancients more than they had practiced medicine. He accused the admirers of the ancients of wishing to kill patients "with the pompous apparatus of wet cupping."[98] (Figure 10.) [Illustration: FIGURE 9.--Persian spouted cupping glass, 12th century. (NMHT 224478 [M-8037]; SI photo 73-4215.)] Nineteenth-century cuppers tended to blame the baths for the low status of cupping among surgeons. Dionis had described the baths in Germany as great vaulted halls with benches on two sides, one side for men and the other for women. Members of both sexes, nude except for a piece of linen around the waist, sat in the steamy room and were cupped, if they so desired, by the bath attendants. The customers' vanity was satisfied by making the scarifications (which left scars) in the form of hearts, love-knots, and monograms.[99] Mapleson's complaint against the baths in 1813 was typical of the reaction of the nineteenth-century professional cupper: The custom which appears to have become prevalent of resorting to these Bagnios, or Haumaums, to be bathed and cupped, appears to have superseded the practice of this operation by the regular surgeons. Falling into the hands of mere hirelings, who practiced without knowledge, and without any other principle than one merely mercenary, the operation appears to have fallen into contempt, to have been neglected by Physicians, because patients had recourse to it without previous advice, and disparaged by regular Surgeons, because, being performed by others, it diminished the profits of their profession.[100] [Illustration: FIGURE 10.--Cupping in the bath, 16th century. (From a woodcut held by the Bibliotheque Nationale. Photo courtesy of NLM.)] After a period of neglect, cupping enjoyed renewed popularity in the late eighteenth and early nineteenth centuries. In that period a number of professional cuppers practiced in the cities of Europe and America. Both Guy's and Westminster Hospitals in London employed a professional cupper to aid physicians and surgeons. Of these hospital cuppers, at least four, Thomas Mapleson, Samuel Bayfield, George Frederick Knox, and Monson Hills published treatises on the art of cupping, from which we gain the clearest account of cupping procedure.[101] Knox, who succeeded Mapleson as Cupper at Westminster Hospital, was petitioned by 59 medical and surgical students to write his practical and portable text.[102] _Instruments of the Professional Cupper_ Cupping instruments in the eighteenth and nineteenth centuries were generally simple dome-shaped glass cups provided with thick rims so that the cups would be less painful when applied and removed. Cups were sold in various sizes, ranging from about 45 mm to 75 mm high. Some were made with a smaller diameter and a larger belly for cupping on parts of the body with a limited surface area. For the same reason, cups with an oval rim were recommended. (Figure 11.) There were several common methods for exhausting cups, of which the simplest and most widely used was that of throwing burning lint or tow (the coarse part of flax, hemp, or jute) inside the glass before applying the glass to the skin of the patient. The professional cuppers vehemently disapproved of this clumsy practice, for the patient could easily be scorched.[103] Various improvements were suggested to avoid burning the patient. Dionis (1708) had recommended placing a small card with lighted candles over the scarifications, and then applying the cup.[104] Other methods included the brief introduction of a wire holding a bit of sponge soaked with alcohol and ignited, or attaching a bit of sponge to the inside of the glass by means of wax and a piece of wood. All such methods were deemed "clumsy expedients" by professional cuppers,[105] who preferred to employ a lamp or torch especially made for cupping. Eighteenth-century surgical texts illustrated brass grease lamps with covers to regulate the flame. Probably less difficult to maneuver was the alcohol lamp first introduced in the 1790s. Alcohol lamps for cupping were made of metal, shaped like teapots, and contained a heavy cotton wick protruding from the spout.[106] [Illustration: FIGURE 11.--Typical glass cupping cups, late 19th century. (NMHT 152130 [M-4766-68]; SI Photo 61135-C.)] Although Mapleson (1813) employed an alcohol lamp, the cuppers writing after him preferred the more recently-introduced cupping torch. This consisted of a piece of hollow metal tubing cut obliquely at one end and provided with a metal bulb or ring at the other end. A cotton wick was stuffed as compactly as possible into the tube so that a small piece of wick protruded from the oblique end. The wick was dipped in alcohol, ignited, and inserted briefly into the cup. The torch was more convenient than the older teapot lamp because it was easier to insert into the cup, and was small enough to hold in the hand at the same time as one held the scarificator.[107] The introduction of the scarificator represented the major change in the art of cupping between antiquity and the nineteenth century. Unlike later attempts at improving cupping technology, the scarificator was almost universally adopted. Previous to its invention, the cupper, following ancient practice, severed the capillaries by making a series of parallel incisions with a lancet, fleam, or other surgical knife.[108] This was a messy, time consuming, and painful procedure. Ambroise Paré (1510?-1590) was the first to employ the word "scarificator" and the first to illustrate a special instrument for scarification in his compendium of surgical instruments.[109] However, a precursor to the scarificator had been suggested by Paulus of Aegina (625-690), who described an instrument constructed of three lancets joined together so that in one application three incisions could be made in the skin. The instrument, recommended for the removal of coagulated blood in the wake of a blow, was considered difficult to use and was not generally adopted.[110] Paré's scarificator had a circular case and eighteen blades attached to three rods projecting from the bottom. A pin projecting from the side may have served to lift the blades and a button on the top to release them although Paré did not describe the spring mechanism.[111] Paré did not recommend the instrument for cupping, but rather for the treatment of gangrene. Several sixteenth- and seventeenth-century surgical texts made reference to Paré's instrument, among them Jacques Delechamps (1569) and Hellkiah Crooke (1631).[112] It is not known who made the first square scarificator and adapted it to cupping. The instrument was not found in Dionis (1708), but it did appear in Heister (1719) and in Garengeot (1725). Thus it appears that the scarificator was invented between 1708 and 1719. Garengeot disliked cupping in general and he had little good to say of the new mechanical scarificator. "A nasty instrument," he called it, "good only for show."[113] The German surgeon, Lorenz Heister, was more appreciative of the innovation. After describing the older method of making sixteen to twenty small wounds in the skin with a knife, he announced that "The modern surgeons have, for Conveniency for themselves and Ease to the Patient, contrived a Scarificator ... which consists of 16 small Lancet-blades fixed in a cubical Brass Box, with a Steel Spring."[114] Heister noted that while Paré had used the scarificator only for incipient mortification, it was now "used with good success by our Cuppers in many other Diseases, as I myself have frequently seen and experienced."[115] The earliest scarificators were simple square brass boxes, with cocking and release levers and 16 pointed blades. By 1780, illustrations in surgical works showed that the bottom of the scarificator was detachable. Thus, although the illustrations do not show the screw for regulating the height of the blade cover, provision may already have been made for adjusting the depth of cut of the blades.[116] Square or German-style scarificators continued to be sold in Germany throughout the nineteenth century. The earlier models (late eighteenth, early nineteenth century) were frequently embellished with ornate decoration, and had pointed blades. Some were quite tall. A specimen dated 1747, in the Wellcome Medical Museum collection, is 14.4 cm high and 4.5 cm wide at the base. (Figure 12.) [Illustration: FIGURE 12.--Lavishly decorated scarificator, 18th century. (Held by the Wellcome Institute of the History of Medicine, London. Photo courtesy of the Wellcome.)] The later models (mid- to late nineteenth century) were wider and plainer and had arched or crescent shaped blades (which made a cleaner lesion), but the internal mechanism remained the same. Square scarificators all had 16 steel blades that cut in the same direction and were arranged on three rods of five, six, and five blades respectively. At one end of each rod was a gear pinion. The cocking lever, protruding through an aperture at the top of the scarificator, broadened out into a flat plate with as many gear sectors as blade rods. The plate was held against the interior of the scarificator by a heavy support rod running the width of the scarificator, in such a way that the gear sectors of the cocking lever meshed with the pinions on the blade rods. Pulling up on the cocking lever turned the blades 180 degrees. A heavy flat cantilever spring, attached at one end to the bottom of the case, was caught under a protuberance on the cocking lever and bent as the cocking lever was pulled. As the blades were turned, a catch slipped over a tooth on the cocking lever, and held the blades in place. Nineteenth-century octagonal scarificators generally had two catches, the first exposing the blades, and the second rotating them a full 180 degrees. Pressure on the release lever pushed the catch off the tooth on the cocking lever, thereby releasing the lever and allowing the spring to snap the apparatus back to its original position. Releasing the spring brought the blades around so quickly that their movement could not be seen. (Figure 13.) [Illustration: FIGURE 13.--Interior of square scarificator. (NMHT 152130 [M-4771]; SI photo 76-9111.)] In the square scarificators, the top and two sides were detachable from the bottom and the other two sides. Turning the wing-tip nut on the top of the scarificator lowered, by means of a yoke, the bottom of the scarificator that was fitted by grooves into the top. By raising and lowering the bottom, one could regulate the length of blade protruding beyond the bottom, and hence the depth of cut. In the 1790s, the octagonal scarificator that was to become the standard English-American model began to appear in surgical texts. The early octagonal scarificator, as illustrated in Latta (1795) and Bell (1801), had sixteen rounded blades arranged as in the square scarificator, an iron triggering lever similar to that of the square scarificator, a button release on the side, and a flat key on top for regulating depth of cut.[117] Early in the nineteenth century the flat keys were replaced by round screws. Only the bottom or blade cover of the octagonal scarificator was detachable. In some of the octagonal scarificators, the round screw on top ran the height of the scarificator and screwed directly into an internally threaded post inside the blade cover. In other scarificators, the screw raised and lowered a yoke whose two sides were attached by additional screws to side projections of the blade cover. A notable improvement was made in the early nineteenth century when John Weiss, a London instrument maker, introduced a 12 blade octagonal scarificator whose blades, arranged on two rods or pinions, were made to cut in opposite directions. This advance was mentioned by Mapleson in 1813 and adopted by London professional cuppers thereafter. The advantage of the innovations was that the skin was thereby stretched, and a smoother, more regular cut could be made. Weiss's Improved Scarificator also featured blades that could easily be removed for cleaning and repair. In place of two rows of six blades, one could insert a single row of four blades to adopt the scarificator for cupping on small areas such as the temple.[118] The feature of inserting a pinion with clean and sharp blades permitted the cupper to own only two scarificators. For cleansing the blades the manufacturer supplied a thin piece of wood covered with wash leather or the pith of the elder tree.[119] Scarificators in which the blade rods turned in opposite directions (called "reversible" scarificators in trade catalogs) were more complicated to manufacture and therefore somewhat more expensive than unidirectional scarificators. The cocking lever meshed directly with only the first blade rod. To make the second blade rod turn in the opposite direction, an extra geared plate (or idler lever) was necessary to act as an intermediary between the cocking lever and the second blade pinion. The cocking lever turned the idler lever, which then turned the second pinion. Two support rods and two cantilever springs were needed in place of the one in unidirectional scarificators. The brass, octagonal scarificator with 8, 10, and particularly 12 blades became the standard scarificator sold in England and America.[120] Both unidirectional ("plain") and reversible scarificators were offered through trade catalogs. Smaller octagonal scarificators with four to six blades were sold for cupping parts of the body with limited surface area. _Cupping Procedure_ The art of cupping, it was generally agreed, required a high degree of dexterity that could be maintained only by constant practice. Professional cuppers were concerned with avoiding any appearance of clumsiness, else the patient might come to fear an operation essential to his health. In the hands of an inexperienced physician or surgeon, cupping could be highly painful to the patient, and yet fail to produce the requisite amount of blood. While expert cuppers were usually available in cities, the rural doctor was not trained in the operation. It was to these rural practitioners that the treatises of the professional cuppers were addressed. One cupper, George Frederick Knox, offered in addition personal instruction in cupping procedures. His charge was a guinea for medical students and three guineas for non-medical students for a three month course.[121] Physicians and surgeons took a renewed interest in cupping in the early nineteenth century. Cupping was no longer regarded as merely a useful substitute for bloodletting. Recent physiological research seemed to prove to the advocates of cupping that the effects of slow withdrawal of blood from the capillaries produced a different effect on the constitution than the quick withdrawal of blood from a vein. Thus, Knox was convinced by the results of this research that, while phlebotomy was indicated in cases of high fever, "particular phlegmasiae" specifically required the intervention of cupping.[122] The procedure that the experts followed in wet cupping was as follows. First, the cups were immersed in hot water. Bayfield recommended that one glass be used for every four ounces of blood required. Thus, to abstract 18 to 20 ounces, as was common in cupping on the back or abdomen, four or five glasses were needed. The spot chosen for placement of the cups should be free of bone, but also not overly fatty. Cupping over the belly of a muscle was especially recommended. After the spot was fomented with hot water, the torch was dipped in alcohol, lit, and inserted into the cup for about two seconds. Once the torch was removed, the cup was allowed to sink of its own weight into the skin. During the minute that the skin was allowed to tumefy under the cup, the scarificator was warmed in the palm of the hand in preparation for the most difficult part of the operation. It required great skill to manage torch, scarificator, and cups in such a way as to lift the cup, scarify, and recup before the tumefaction had subsided. Monson Hills (1834) described the manipulations involved thus: The torch is held in and across the palm of the right hand, by the little and ring finger, leaving the thumb, the fore and middle fingers free to hold the scarificator, which may be done by the thumb and fore finger only; the glass is then grasped by the thumb, fore and middle fingers of the left hand, leaving the little and ring fingers free; the edge of the glass is then detached from the skin by the middle finger of the right hand; the scarificator being set, care must be taken not to press upon the button with the thumb too quickly; directly the glass comes off, we apply the scarificator, spring it through the integuments, and then placing it between the free little and ring fingers of the left hand, we apply the torch to the glass, and glass to the skin over the incisions, as before recommended.[123] Hills recommended practicing on a table, "taking care, of course, that the lancets are not allowed to strike the table." According to Bayfield, the blades of the scarificator were generally set at 1/4". If cupping behind the ears, they should be set at 1/7", if on the temple at 1/8", and if on the scalp at 1/6". When the cups were two-thirds full, they were removed and reapplied if necessary. This, too, was no easy task. One had to manipulate cup and sponge deftly in order to avoid spillage. Cupping was to be not merely a neat operation, but an elegant one. After cupping, the wound was dabbed with alcohol or dressed, if necessary. Scarificator blades could be used some twenty times. After each use, the scarificator was to be cleaned and greased by springing it through a piece of mutton fat.[124] A great variety of bodily parts were cupped, just about any part that had sufficient surface area to hold a small cup in place. Knox, for example, gave directions for cupping on the temple, back of the head, behind the ears, throat, back of the neck, extremities, shin, chest, side, abdomen, back and loins, back of the thighs, perineum, sacrum, and on buboes.[125] In reply to those who wondered if cupping hurt, Knox asserted that "those who calculate the pain incurred in cupping by comparison with a cut finger are very much deceived." The scarificator itself produced little pain, he claimed, but he admitted that the pressure of the rims of the glasses could cause a degree of discomfort.[126] _Nineteenth Century Attempts to Improve Cupping Technology_ The story of nineteenth-century attempts to improve cupping technology is an interesting one, in that a great deal of effort was expended on comparatively short-lived results. For those who were adept at cupping, the cups, torch, and standard scarificator were quite adequate. Innovations were thus aimed at making the operation more available to the less practiced. The new gadgets could not rival the traditional instruments in the hands of an experienced cupper, and, moreover, they were usually much more expensive. Most of the attempts at innovation centered in eliminating the need for an alcohol lamp or torch to exhaust the cups. As far back as Hero of Alexandria,[127] we find directions for the construction of "a cupping-glass which shall attract without the aid of fire." Hero's device combined mouth suction with a system of valves. Another famous inventor of assorted devices, Santorio Santorii (1561-1636), described a cup that contained a syringe in the early seventeenth century.[128] From the 1780s on, cups with brass syringes began to appear in compendia of instruments. A cup with brass fixings would be screwed onto a brass pump, placed on the skin, and the air within removed by a few strokes of the piston.[129] This sounded better in theory than it worked in practice. Expert cuppers agreed that they thoroughly disliked using the syringe. Mapleson (1813) offered three strong objections to the instrument. First, exhaustion could easily be carried too far, so as to obstruct the flow of blood. Second, the operation become tedious and fatiguing to the bloodletter because of the repeated screwing and unscrewing of syringe and glasses. Third, the valves were liable to malfunction.[130] Twenty-three years later Knox continued to disapprove of the syringe for the very same reasons. Of all the new inventions for cupping, he declared in 1836, "the worst is the syringe, as it makes that a most complicated and bungling operation that which, with common care and attention is one of the most simple in surgery."[131] Despite rejection by experienced cuppers, manufacturing of an air-tight syringe continued to challenge inventors throughout the nineteenth century. Some attempted to substitute stopcocks for valves, and some to place long flexible tubes between pump and glasses so that the pumping motions would not be communicated to the patient. Pumps were gradually improved, and, although rarely recommended by experts, were sold in great numbers as part of fancy and expensive cupping sets. These sets, with prices as high as fifteen dollars, consisted of a mahogany or leather box with brass latches, lined in plush, and containing compartments for scarificators, a brass pump, and an assortment of glasses provided with metal attachments. Some of the most elegant of the cupping sets were those made by Maison Charrière of Paris. Today the luxury of these cupping sets seems rather incongruous with the bloody purposes for which the instruments were used. Yet, the beauty of the instruments and their containers must have added to the esteem of the physician or surgeon in the mind of the patient. Syringes were not only useful in cupping but also were employed in a wide variety of medical and surgical operations. Creating an all-purpose syringe that would extract or inject liquids into any part of the body was yet another inventor's dream. Two of the earliest English surgical patents were awarded to two such syringes. John Read (1760-1847), surgical instrument maker for the British Army and the East India Company, patented a pump in 1820 for use in "extracting poison from the stomach, administering clysters, introducing tabacco fumes into the bowels, transfusion of blood, draining off the urine, injecting the bladder, female injection, anatomical injection, administration of food and medicine, cupping, drawing the breasts ... &c."[132] John Weiss, inventor of the improved scarificator, invented his own patent syringe in 1825, which he claimed to be superior to all previous syringes because it employed stopcocks in place of valves, which were subject to leakage and clogging. Cupping was only one of many operations that could be performed with its aid. The Truax Surgical Pump is an example of a late nineteenth-century all-purpose patent pump outfit that included cups among its numerous optional attachments.[133] (Figure 14.) Those who went a step further in their efforts to improve cupping procedure attempted to combine cup, lancet, and exhausting apparatus all in one instrument. Bayfield described and rejected several such devices in 1823, including perhaps the earliest, that of the Frenchman, Demours. Demours' instrument, first introduced in 1819, consisted of a cupping glass with two protruding tubes, one containing a lancet, and the other an exhausting syringe. The lancet, surrounded by leather to keep air out of the cup, could be supplemented by a cross with four additional blades, if more than one puncture was desired.[134] In 1819, Thomas Machell, a member of the Royal College of Surgeons in London, described a similar apparatus in which the glass cup was separated from the tin body of the apparatus by a flexible tube. The facility and precision of the instrument, claimed Machell, "are incalculably surpassed by the power of its application to any part whatever of the surface, under any circumstances indicating its propriety, and by any person untrained to the manual dexterity of a professed cupper."[135] Professional cuppers who took pride in their skill naturally avoided such novelties. Bayfield found the complex instruments objectionable because even "the most trifling degree of injury is generally sufficient to render the whole apparatus useless."[136] The Smithsonian collection contains two patent models of American wet cupping devices. The first is an ingenious cupping set patented by a Philadelphia navy surgeon, Robert J. Dodd, in 1844. It consisted of a metal syringe provided with a plate of lancets that screwed on to a glass tube with a protuberance for collecting blood. The most interesting feature of the apparatus was the provision made for cupping internal parts of the body such as the vagina, throat, or rectum. One could attach to the pump either a curved or a straight tapering glass tube, seven to eight inches long, and corresponding flexible metal lancet rod. The pump could also be adapted for extracting milk from the breasts of women by attaching a metal cap with a hole just large enough to accommodate the nipple.[137] The second patent model is that of W. D. Hooper of Liberty, Virginia, who invented in 1867 an apparatus combining cup, pump, and scarificator. The novel part of the instrument was the tubular blades that were injected into the flesh and then left in place while the blood was being removed, "by which means the punctures are kept from being closed prematurely, as frequently happens with the ordinary device."[138] It is unlikely that any of these ingenious devices were marketed in quantity. For those skilled in the art of cupping, the torch, cups, and scarificator were more effective. For those not experienced in the art, the new devices were simply too expensive, inconvenient to carry about, and fragile. While doubtless some surgeons bought fancy equipment in order to impress their patients, other surgeons, and the professional cuppers, realized that expensive and unfamiliar gadgets could inspire more dread than awe, especially among rural patients. The cupper Monson Hills advised his readers: A person about to be cupped, is often needlessly alarmed by the arrival of his operator, with a capacious box of instruments; and he measures the severity of the pain he is about to undergo, by the seeming multitude of instruments required to inflect it. If, on the contrary, the few implements used are carried in the pocket, and produced when about to be used, unobserved by the patient, this evil is easily avoided.[139] In seconding Hills' sentiments, W. A. Gillespie, the Virginia country physician mentioned earlier, went a step further. Gillespie felt that the rural physician could dispense with the glass cups, torch, and scarificator and substitute in their place a simple thumb lancet and cow's horn. Not only would these instruments save money, but they would also "excite less dread in the mind of the patient than a formidable display of numerous and complicated instruments."[140] Some inventors concentrated on more modest improvements in cupping technology, namely, modification of cups and scarificators. One of the simplest improvements was that of Dr. Francis Fox, House Surgeon to the Derbyshire General Dispensary. In 1827, Dr. Fox introduced a new glass cup with a short, curved, wide neck and an oval belly that hung downwards. When applied to the skin, the glass hung in the manner of a leech, and so the glass was called "The Glass Leech." Since the burning tow could be placed in the hanging belly of the glass, away from the skin, it was easier to apply and remove the ordinary cup.[141] Other modifications of the cupping cup included the addition of a stopcock to let the air back in, graduations to measure the blood, and the attachment of a metal bar inside the cup in order to hold the burning sponge or wick away from the body of the patient.[142] (Figure 15.) [Illustration: FIGURE 14.--Weiss's improved patent cupping apparatus. Illustrated are Weiss's patent syringe applied to cupping and Weiss's improved scarificator. (From John Weiss, _Surgical Instruments_, 2nd edition, London, 1831. SI photo 73-5184.)] The most significant innovation in cups came with the manufacture of cups of vulcanized rubber in the 1840s. Rubber cups could be easily exhausted without need of a torch, and they were far cheaper and easier to manipulate than cups attached to a pump. Most surgical catalogs in the late nineteenth century offered both all-rubber cups and glass cups to which a rubber bulb was attached. In the late nineteenth century, sets of cups were sometimes sold with rubber rims because the rubber fit more comfortably against the skin and prevented air from entering the cup. Museum collections contain few rubber cups because nineteenth-century rubber tended to deteriorate in time. However, the appearance of these cups in all surgical catalogs indicates that they were widely sold.[143] [Illustration: FIGURE 15.--Fox's glass leech. Cupping set contains two hanging "glass leeches," a scarificator, a bottle of alcohol, and a torch with a ring handle such as the cupper Knox recommended. (Set held by the Academy of Medicine, Toronto. Photo courtesy of the Academy.)] Several inventors tried to improve upon the scarificator. The defects of the ordinary scarificator were widely recognized. It was too bulky and heavy, and it cost too much--the most inexpensive scarificator offered by George Tiemann & Co. in 1889 cost $4.50.[144] A strong hand was required to trigger the blades, and when the trigger was released, the force of the spring was so great that the lever moved back with great force and produced a loud, unpleasant click. The force of the lever moving against the case of the scarificator made it impossible to use any but expensive materials (brass and German silver) in making the scarificator casing. Furthermore, the springs were liable to break. Finally, the scarificator was difficult to clean.[145] Late in the century, when sterilization became important, some cuppers went back to the lancet because the scarificator could not be surgically cleansed. The surprising thing is, that despite all the defects, the same scarificator was sold in 1930 as in 1830. Either the claims of the inventors of improved scarificators were unjustified, or cuppers were unwilling to try novel instruments in what was becoming an old-fashioned and increasingly less popular operation. (Figure 16.) A few British and American surgical supply companies sold special models of scarificator, but always in addition to the common scarificator. The special models were generally higher in price. For example, the Englishman, James Coxeter, announced in 1845 a new scarificator with a rotating lever on the side instead of a cocking lever on the top. The roto-lever, according to Coxeter, could be turned to set the scarificator by a child of six. Furthermore, the scarificator was so constructed that when the spring was released only internal parts moved. There was no lever that snapped back and no resounding click. This special model of scarificator continued to be sold by Coxeter and Son (London) until late in the nineteenth century.[146] Coxeter did not patent the roto-lever scarificator. In fact, through 1852 there were no British patents on scarificators. In contrast, there were eight French patents on scarificators before 1860.[147] Of these, the most important was the 1841 patent of Joseph-Frédéric-Benoit Charrière (1803-1973), a Swiss-born cutler who founded a major surgical supply company in Paris. Charrière's octagonal scarificator substituted two flat coiled springs (like watch springs) for the two cantilever springs normally found in "reversible" scarificators. One end of each coiled spring was attached to the scarificator casing and the other to one of the support rods. As the cocking lever was pulled, the support rods turned and wound the springs more tightly about the rods. According to Charrière, these springs were more efficient and less likely to break than the ordinary springs.[148] Charrière's company later employed the coiled springs in the making of a circular scarificator. The circular scarificators, associated particularly with French manufacture, were the most elegant of nineteenth-century scarificators and a fitting complement to the Charrière cupping sets.[149] They were generally not sold by British and American surgical supply companies, but a number of them appear to have reached the hands of American physicians. In America, there were five patents on scarificators, of which the Smithsonian possesses three patent models. The most significant American patent was that of George Tiemann in 1846. Tiemann's scarificator had a flattened base and an ebony handle, which contained a coiled spring. The blades were moved by a rack and pinion mechanism, and triggered by a knob at the end of the handle. The advantages claimed by the inventor were ease in handling, ease in cleaning, and the diagonal cut of the blades that allowed the blood to flow more freely and the wounds to heal more readily. Tiemann & Co. was still selling their patent scarificator as late as 1889 for a price of $7.00.[150] The Smithsonian possesses a marketed version in addition to the patent model. The two other patent scarificators in the Smithsonian collection were both invented by Frederick M. Leypoldt of Philadelphia. The first, patented in 1847, was similar in external appearance to the common scarificator. The novelty consisted of a new arrangement of the cocking lever and cantilever spring that allowed use of a lighter and cheaper casing. Although the patent model was made of brass, Leypoldt claimed that with his improvements in the internal mechanism, the case could, with safety, be made of tin.[151] Leypoldt's second patent, issued in 1851, was for a scarificator with a greatly simplified inner mechanism allowing for a substantially smaller and lighter case. The cocking lever was placed horizontally in the casing and engaged the blade rods through a rack and pinion mechanism. According to Leypoldt, this scarificator was more convenient, more portable, cheaper, safer, and more reliable than the common scarificator.[152] Leypoldt probably marketed his scarificators, there being in the Smithsonian collection other bloodletting instruments with his name, but he did not form a major surgical supply company as did George Tiemann. [Illustration: FIGURE 16.--Advertisement for phlebotomy and cupping instruments. Note the rubber cups. (From George Tiemann & Co., _American Armamentarium Chirurgicum_, New York, 1889. SI photo 76-13542.)] After 1860, interest in inventing new scarificators declined as wet cupping decreased in popularity. The improved cups and scarificators, while they had achieved a limited success, had still failed to supplant the common octagonal scarificator and the plain glass cup. As interest in wet cupping declined, medical attention shifted to the therapeutic virtues of dry cupping. Dry cupping offered even greater opportunities for inventors, who sought means to bring the effects of the vacuum to more areas of the body for greater lengths of time. _Dry Cupping_ Dry cupping, in its simplest form, was said to act as a "revulsive" or "derivant." By the nineteenth century these once hotly debated terms had become nearly interchangeable in discussions of cupping. In cupping for revulsive purposes, one cupped on a distant part to relieve excess of blood in the affected part. In applying cupping as a "derivant," one cupped closer to the affected part. In either case, the source of pain was presumed to be somewhere below the skin, and the pain was relieved by bringing blood away from the affected part to the surface of the body. Thus, one nineteenth-century cupper concluded, revulsion was only derivation at a distant point.[153] If dry cupping was applied for ten minutes or longer so that the capillaries burst, the action of the cups was said to be that of a counter-irritant. According to ancient medical theory, the counter-irritant was a means of relieving an affected part by deliberately setting up a secondary inflammation or a running sore in another part. Counter-irritations were traditionally produced in a number of ways, among them, blisters, cautery, setons, moxa, and dry cupping.[154] One of the most popular counter-irritation devices commonly associated with cupping instruments in catalogs of surgical goods, was Baunscheidt's _Lebenswecker_, sold by most American surgical supply houses in the second half of the nineteenth century. The _Lebenswecker_, or "Awakener of Life," was the mainstay of the mystical medical system known as _Baunscheidtismus_, after the founder of the device, Carl Baunscheidt of Prussia (1809-1860).[155] The system apparently gained much notoriety in Germany, England, and America, for Baunscheidt's book went through ten German editions and several British and American editions. At least two Americans patented improvements on the _Lebenswecker_.[156] The device was made of ebony, about 250 mm long, and contained a coiled spring attached to a handle. At the other end of the spring was a place about 20 mm in diameter, with about thirty projecting needles. By pushing upon the handle, one sent the needles into the skin. The ability of the instrument to create blisters was enhanced by the application of Baunscheidt's special oil to the irritation (Figure 17). [Illustration: FIGURE 17.--Venus and Adonis with marks showing where Baunscheidt's _Lebenswecker_ should be applied. (From Carl Baunscheidt, _Baunscheidtismus, by the Inventor of the New Curing Method_, Bonn, 1859(?). Photo courtesy of NLM.)] Dry cupping stimulated much theoretical debate in the nineteenth century as well as a number of physiological experiments.[157] Although physicians generally agreed that dry cupping had curative value if employed properly, they disagreed widely on when to employ the remedy, and on the manner in which the remedy operated. Did application of cups affect only the surface vessels, or could cupping affect the entire nervous system, and through the nerves, the action of the secretory organs? Were the effects of dry cupping of only a temporary nature, or were they permanent? An interesting series of investigations in Europe and America sought to ascertain the value of dry cupping in checking the absorption of poison. An American, Dr. Casper Wistar Pennock, replying to investigations performed by Martin Barry, an Edinburgh physician residing in Paris, carried out an impressive series of physiological experiments in 1827, in which he administered strychnine and arsenic under the skin of dogs and rabbits and then cupped over the wounds. He concluded that while dry cupping prevented almost certain death from the poisons, once the cups were removed, death would ensue, unless the poisons were surgically removed.[158] Interest in dry cupping led to attempts to apply the therapeutic effects of the operation to larger areas of the body than could be accommodated by a cup. In France, Victor-Théodore Junod (1809-1881) adapted cupping to entire limbs. Shortly after receiving his degree in medicine in 1833, Junod presented at the Academy of Sciences his apparatus, known thereafter as Junod's boot. Junod believed that actual extraction of blood was a dangerous remedy and that the benefits of bleeding might as easily be obtained by his "derivative method," which withdrew blood from the general circulation but allowed it to be returned at will. Junod's boot and Junod's arm, which sold for as much as $25.00 apiece,[159] were constructed of metal and secured against the limb by a silk, and later a rubber, cap. To the boot was attached a flexible tube, stopcock, pump, and if desired, a manometer for measuring the vacuum produced. In chronic illnesses, Junod recommended that the boot be applied for an hour. So much blood was withdrawn from the circulation by use of the apparatus that the patient might easily faint. To explain how his boot worked, Junod invented a theory that he called "hemospasia," meaning the drawing of blood.[160] This was typical of a number of attempts to introduce sophisticated terminology into discussions of traditional remedies. Junod's arm and boot were widely available through American surgical supply companies. As late as 1915, Heinrich Stern, previously mentioned as a latter-day proponent of bloodletting, had no doubt that application of the boot to the foot would relieve congested states of the abdominal viscera.[161] (Figure 18.) Americans patented a number of modifications of the arm and boot, and in addition they patented a number of whole body devices called "depurators." Junod had introduced such a device along with his boot--a metal casing in which a patient would be placed leaving only his face showing. The air inside would then be exhausted by means of a gigantic syringe. In America such "depurators" may have been regarded more as quackery than as a legitimate extension of cupping, for despite the fact that Americans patented some twenty of these devices, surgical supply houses did not sell them and little was written about them. In the last decade of the nineteenth century, Dr. August Bier, professor at the University of Bonn, developed another sophisticated theory supporting the use of blood-suction devices, known as the theory of hyperemia, meaning "excess of blood." According to the doctrine, lesions are always accompanied in nature by hyperemia, "the most widespread of auto-curative agents."[162] If we, therefore, wish to imitate nature, we create an artificial hyperemia. Bier recommended several means of increasing the blood supply of an affected part, including hot-air baths, suction devices such as Junod's boot, and dry cupping. Several American surgical suppliers sold Bier's Hyperemic Cups in the early twentieth century. These were glass cups, of a great variety of shapes and sizes including some with curved rims, each fitted with a rubber tube and bulb for exhausting the air. A major function of these cups was to collect wound secretions from boils or furuncles.[163] [Illustration: FIGURE 18.--Junod's boot applied to a baby in the cradle. (From Victor Theodore Junod, _A Theoretical and Practical Treatise on Maemespasia_. London, 1879. Photo courtesy of NLM.)] _Breast Cupping_ Related to cupping by its technology is the practice of drawing milk from the breasts by means of breast pumps. Mothers with underdeveloped or inflamed breasts posed a frequent problem for the nineteenth-century physician, who treated them with either large doses of tartar emetic, a strong purgative, or with cupping.[164] Breast pumps were small glass cups with fluted edges made to accommodate the nipple. While some surgeons, as the American Samuel Gross, recommended using a bottle with a long neck in which the air had been rarified by means of hot water,[165] most breast pumps were exhausted by mechanical means. For reasons of modesty, the pumps were usually designed so that the woman could draw her breasts herself. Perhaps the simplest design of a breast pump was a glass cup having a long spout extending in such a way that the woman could perform suction herself. Such all-glass cups were illustrated in the eighteenth century.[166] A few, reputedly made centuries earlier, are found in the Wellcome Historical Medical Museum. Early in the nineteenth century, breast pumps, just as glass cups for bleeding, were attached to brass syringes, and were often included among the variety of cups in cupping sets provided with syringes. Read's and Weiss's patent syringe as well as Thomas Machell's cupping device were adapted for breast pumping. With the invention of vulcanized rubber, the breast pump was frequently attached to a large rubber bulb. A glass protuberance was often added to pumps exhausted by syringes or rubber bulbs, in order to collect the milk so that it could be fed to the infant. In the 1920s some breast pumps were attached to electric motors.[167] Breast pumps have continued to be employed up to the present day. Of all instruments employing the principle of the cupping device, breast pumps were the most frequently patented. From 1834 to 1975, more than 60 breast pumps were patented, the majority in the period from 1860 to 1920.[168] _The Decline of Cupping_ Cupping died out in America in the early twentieth century, but its disappearance was gradual and scarcely noticed. Some of the most complex of cupping devices were invented in a period when most physicians regarded cupping as ineffectual. Patents for cupping devices continued to be issued as late as 1916 when Joel A. Maxam of Idaho Springs, Colorado, patented a motorized pump, which by means of various sizes of cups, could subject a part of the patient's body to either a prolonged suction or a prolonged compression.[169] One of America's last advocates of bloodletting, Heinrich Stern, writing in 1915, also advocated the use of an electrical suction pump to evacuate cups. With an electric motor, he declared, one could prolong hyperemia for 15, 30, or more minutes. Stern also invented a theory to account for the therapeutic effects of his inventions, namely, the theory of phlebostasis. Instead of pumping air out of a device, Stern pumped air into a device, for the same purpose of removing a portion of blood from the general circulation. His "phlebostate," manufactured by Kny-Scheerer of New York, was quite similar to a sphygmomanometer. It consisted of a set of cuffs that fit about the thighs, rubber tubes, a manometer, and a suction bulb or an electric force pump. For stubborn cases, such as migraine headaches, Stern recommended using the cuffs for 30 minutes or more. To facilitate the application of the cuffs, Stern invented a "phlebostasis chair," one of the most complex "cupping" devices ever made. Like an electric chair, the phlebostasis chair was supplied with cuffs for both arms and legs. Air was pumped into the cuffs by means of an electric motor. According to Stern, compression of the upper segment of both arms withheld 300 cc of blood from circulation, while compression of the thighs withheld as much as 600 cc.[170] In addition to these sophisticated devices, simple cupping, especially dry cupping, continued well into the 1930s. Although cupping was no longer generally recommended by physicians, most surgical companies advertised cups, scarificators, and cupping sets in the 1920s and even the 1930s. The last bastions of cupping in the United States were the immigrant sections of large cities. In the lower East Side of New York, in particular, cupping was still flourishing in the 1920s. By then cupping was no longer performed by the physician, but had been relegated back to the lowly barber, who advertised in his shop window, "Cups for Colds."[171] Leeching _Leeches_ The word "leech" derives from the Anglo-Saxon _loece_, "to heal." Thus, the Anglo-Saxon physician was called a "leech" and his textbook of therapeutic methods a "leechdom." The animal itself was already known to the ancients under its Latin name _hirudino_. It appears, however, that the introduction of leeches into Western medicine came somewhat later than that of phlebotomy or cupping, for Hippocrates made no mention of them. The earliest references to the use of leeches in medicine are found in Nicander of Colophon (2nd century B.C.) and in Themison (1st century B.C.). Thereafter they were mentioned by most Greek, Roman, and Arabic medical writers.[172] The leech is a fresh-water parasitic invertebrate belonging to the Phylum Annelida. On one end of its worm-like body is a large sucker by which the animal fastens itself to the ground, and at the other end is a smaller sucker, in the middle of which is a chitinous mouth that makes a triangular puncture. As items of _materia medica_, leeches were described in dispensatories, or compilations of medicaments, and sold by apothecaries, both to physicians and directly to patients. The species most commonly used for bleeding was _Hirudo medicinalis_, indigenous to the streams and swamps of Central and Northern Europe, and known in commerce as the Swedish or German leech. It was 50-75 mm long, with a dull olive green back and four yellow longitudinal lines, the central two broken with black. Somewhat less popular was the Hungarian leech, indigenous to Southern Europe. In addition, there was an American species of leech, _Hirudo decora_, which was gathered principally from the lower Delaware River, but, since it drew much less blood than the Swedish leech, it was regarded as greatly inferior.[173] Most American physicians imported their leeches. In the late nineteenth century, one could buy Swedish leeches for $5.00 per hundred.[174] Leeches were gathered in the spring of the year either by means of a pole net, or, more primitively, by wading into the water and allowing the leeches to fasten themselves onto the legs. Sometimes horses and cattle were driven into the water to serve as bait for the leeches.[175] (Figure 19.) [Illustration: FIGURE 19.--Lithograph published in London in 1814 showing three women gathering leeches by a stream. (NMHT 320033.08; SI photo 76-7741.)] Leeching, like other forms of bloodletting, enjoyed a revival in the early nineteenth century, particularly in France, where the doctrines of heroic medicine preached by Broussais[176] led to an increase of leech usage from about 3 million in 1824 to 41.5 million in 1833.[177] Leechers, although not as high in status as professional cuppers, practiced in many large cities, and numerous tracts were written on the care and breeding of leeches. "Leech farms" were unable to increase the leech supply to meet the rising demand, and most leechers complained of the scarcity and great expense of the little animals.[178] Leeching and cupping each had their advocates. The major advantage of the leech over the cup was that the leech could be employed on almost any part of the anatomy, including around the eyes, in the mouth, the anus, and the vagina. In fact, leeching the internal membranes enjoyed quite a vogue in the early nineteenth century. Leeches were applied to the larynx and the trachea for bronchitis and laryngitis and for relieving the cough of phthisis. For inflammations of the conjunctiva (the membrane lining the eyelids) they were applied to the nasal membrances of the adjacent nostril, and for inflammations of the ear they were applied to the meatus of the ear and behind the ear. The French popularized the practice of leeching the anus to treat inflammations of the mucous membranes of the bowel. To prevent leeches from getting lost in the body cavities, Jonathan Osborne, a British physician, recommended in 1833 that a thread should be passed through the leech's tail. In addition, he invented a device, which he called a "polytome," specifically for introducing leeches into the rectum.[179] In the mid-nineteenth century, special leech tubes were widely sold for applying leeches to internal membranes.[180] A second advantage of leeches over cupping was that leeches could extract blood more readily. Not only was dexterity not required in order to apply a leech, but also it was soon noticed that leech bites continued to bleed even after the leech let go, while scarificator incisions often coagulated before any blood was obtained. In 1884 it was shown by John Berry Haycroft, a Birmingham chemist, that this phenomenon was due to an anti-coagulant, now called "hirudin," that the leech injected into the blood.[181] To apply a leech, the animal was first dried with a bit of linen, and the skin of the patient was prepared by washing with warm water and then shaving. To direct it to the right spot, the leech was often placed in a small wine glass that was inverted over the area to be bitten. Since leeches were sometimes perversely unwilling to bite, they were enticed by the placement of a bit of milk or blood on the patient's skin. Small children were given one or two leeches, and adults 20 or more. Broussais employed up to 50 leeches at one time.[182] The leech was usually allowed to drop off of its own accord when it had satiated itself, which took about an hour. Sometimes the tail of the leech was cut off so that it would continue to suck. Once used, leeches could not be reused for several months unless they were made to disgorge their meal by dropping them in salt water or weak vinegar. A healthy leech drew one or two fluid drachms of blood, and as much would flow after the leech had dropped off. Thus a good Swedish leech could remove about an ounce of blood. This quantity could be increased by employing a cupping glass over the bite.[183] Leeches were kept in a glass container of water covered with gauze or muslin and placed in a cool, dark room. The water had to be changed frequently, as much as every other day in summer. Pebbles or moss were placed in the bottom of the vessel to aid the leech in removing the slimy epidermis that it shed every four or five days. In the nineteenth century leeches were often sold in drug stores from large, elegant containers with perforated caps. Actually, only the day's supply of the pharmacist's leeches was kept in the attractive storefront jars; the rest were kept out of sight. While most leech jars were simple white crockery pieces with "leeches" lettered in black on the front, some leech jars were over two feet tall and decorated with elegant floral and scroll work. Among the most ornate leech jars were those made in Staffordshire, England.[184] (Figure 20.) _Artificial Leeches_ One of the characteristics of nineteenth-century technology was the attempt to replace natural materials and processes by imitations and mechanisms. Considering the properties of the natural leech, it is no wonder that very early in the nineteenth century inventors began to seek a mechanical substitute. The disadvantages of the leech were many. Wrote one inventor of an artificial leech: In the first place the appearance of the animal is repulsive and disgusting, and delicate and sensitive persons find it difficult to overcome their repugnance to contact with the cold and slimy reptile. This is especially the case when it is a question of their application about or within the mouth. Then again, their disposition to crawl into cavities or passages results sometimes in very annoying accidents. Another source of annoyance is that they are often unwilling to bite--the patience of all concerned being exhausted in fruitless efforts to induce them to take hold. The expense, too, of a considerable number is by no means trifling.[185] [Illustration: FIGURE 20.--Staffordshire leech jars, 19th century. (NMHT 263554 [M-11504]; SI photo 73-4231.)] In addition, leeches were often difficult to obtain, and the rural physician could not easily carry them about. Leech bites could have unfortunate consequences, for many times the bleeding could not be stopped. For these and other reasons, several inventors in Europe and America sought to create a mechanical or artificial leech.[186] Such artificial leeches are often difficult to distinguish from cupping devices, because both sorts of instruments employed some form of scarification and suction. Artificial leeches however, were usually adaptable to small areas of the anatomy, and the puncture wound generally attempted to imitate a leech bite. Perhaps the earliest instrument offered as a substitute for leeches was Sarlandière's "bdellometer," from the Greek _bdello_, "leech." Sarlandière, a French manufacturer, introduced his instrument in 1819 and, incidentally, had the prototype sent to New Orleans. The bdellometer consisted of a glass bell with two protruding tubes, one perpendicular for performing scarification, and the other oblique, for attaching the aspirating pump. A plug could be removed to allow air to enter the bell after the operation was completed, and a faucet allowed for drainage of blood without having to remove the apparatus from the body. A curved cannula could be attached to the bdellometer for bleeding in the nasal passages, the mouth, the vagina, and the rectum. For internal bloodletting, the disk, with lancets, normally used for scarification, was replaced by a small brush of hog bristles.[187] Sarlandière's bdellometer attracted sufficient attention in America to be included in the numerous editions of Robley Dunglison's medical dictionary,[188] but it was ultimately no more successful than the complicated cupping devices discussed in the previous chapter. A second French invention, also given a pretentious name, was Damoiseau's "terabdella" (meaning "large leech"), or pneumatic leech. This invention, introduced some time before 1862, met with skepticism at the outset on the part of the reviewers at the French Academy of Medicine. It consisted of two pistons attached to a plate to be placed on the floor and held down by the feet of the operator. Each piston was connected by a tube to a cup, and the whole apparatus was operated by means of a hand lever connected with both pistons. More a cupping device than an artificial leech, the terabdella met with little success beyond the French province where Damoiseau practiced.[189] (Figure 21.) Perhaps the most successful of the mechanical leeches was known as Heurteloup's leech, after its inventor, the Frenchman, Charles Louis Heurteloup (1793-1864). Sold in most late nineteenth-century surgical catalogs for as much as $15.00, the device consisted of two parts, one a spring scarificator that made a small circular incision (about 5 mm in diameter) and the other, a suction pump, holding an ounce of blood, whose piston was raised by means of a screw. For the treatment of eye ailments, one of the major purposes for which the device was invented, it was applied to the temples.[190] A similar two-part mechanical leech was sold under the name "Luer's Leech." One of the most interesting leech substitutes, sold by George Teimann & Co. as its "Patent Artificial Leech," employed ether in exhausting the glass "leeches." Patented by F. A. Stohlmann and A. H. Smith of New York in 1870, the "leech" consisted of a glass tube, either straight or with a mouth on the side so that the tube would hang somewhat like a living leech. To expel air from the tube, a few drops of ether were placed in it, after which it was immersed to its mouth in hot water until the ether vaporized. The tube was then applied to the skin and allowed to cool, thus sucking blood from a wound made by the scarificator, a long metal tube that was rotated to make a circular incision. One of the patentees explained the advantages of the device: In all previous attempts at an artificial leech the vacuum has been produced by the action of a piston. This renders the instrument too heavy to retain its position, and necessitates its constantly being held. This precludes the application of any number at once, even if the cost of half-a-dozen such instruments were left out of the account. But in the case of this leech, the tubes, being exceedingly light, attach themselves at once, remaining in position until filled; and as the cost of them is but a few cents, there is no limit to the number which may be applied.[191] To take the place of leeches in the uterus, quite a number of uterine scarificators were sold. These were generally simple puncturing instruments without spring mechanisms. If insufficient blood flowed from the scarification, Thomas's Dry Cupper, a widely available vulcanite syringe, could be inserted into the vagina to cup the cervix before puncturing.[192] At least one attempt was made to combine puncture and suction in a device for uterine application. This was Dr. William Reese's "Uterine Leech," introduced in 1876. It consisted of a graduated glass cylinder 190 mm long and 12 mm in diameter containing a piston and a rod with a spear point. The rod was surrounded by a spring that withdrew the blade after it punctured the cervix. Several American companies, including George Tiemann & Co., offered the device for sale.[193] [Illustration: FIGURE 21.--Damoiseau's terabdella. (From Damoiseau, _La Terabdelle ou machine pneumatique_, Paris, 1862. Photo courtesy of NLM.)] Despite all the efforts to find a suitable substitute, the use of natural leeches persisted until the practice of local bloodletting gradually disappeared in America. By the 1920s leeches were difficult to find except in pharmacies in immigrant sections of large cities like New York or Boston. One of the last ailments to be regularly treated by leeches was the common black eye. Leeches commanded rather high prices in the 1920s, if they could be found at all. One Brooklyn pharmacist, who deliberately kept an old-fashioned drugstore with the motto "No Cigars, No Candy, No Ice Cream, No Soda Water, But I Do Sell Pure Medicines," wrote in 1923: Here in this atmosphere free from the lunch room odor my armamentarium consists of drugs and preparations from the vegetable, mineral and animal kingdoms. Among the latter are leeches, prominently displayed in a number of glass jars in different parts of the store, including one in the show window. Anything moving, anything odd, arouses the curiosity of the public, and my reputation as a "leecher" has spread far beyond the "City of Churches." Besides, this leech business is also profitable, as they are retailed at $1.00 per head without any trouble; in fact patients are only too glad to be able to obtain them.[194] Veterinary Bloodletting The same theories and practices that prevailed for human medicine were applied to the treatment of animals. Not only were horses routinely bled, they were also cupped and leeched.[195] Manuals of veterinary medicine gave instructions for the bleeding of horses, cows, sheep, pigs, dogs, and cats.[196] There was one major difference between bleeding a man and bleeding a horse or cow, and that was the amount of strength required to open a vein. The considerable force needed to pierce the skin and the tunic of the blood vessel made the operation much more difficult to perform than human phlebotomy.[197] As in the case of cupping, the simplest instruments, those most often recommended by experts, were not easy to use by those without experience. Although a larger version of the thumb lancet was sometimes employed, most veterinarians opened the vein of a horse with a fleam, that is, an instrument in which the blade (commonly double beveled) was set at right angles to the blade stem. These are enlarged versions of the fleam employed in human bloodletting. The fleams sold in the eighteenth and nineteenth centuries consisted of one or more blades that folded out of a fitted brass shield. In the late nineteenth century fleams with horn shields were also sold. The largest blades were to be used to open the deeper veins and the smaller blades to open the more superficial veins. To force the fleam into the vein, one employed a bloodstick, a stick 35-38 cm long and 2 cm in diameter. The blade was held against the vein and a blow was given to the back of the blade with the stick in such a way that the fleam penetrated but did not go through the vein. Immediately the fleam was removed and a jet of blood came forth that was caught and measured in a container. When enough blood had been collected, a needle would be placed in the vein to stop the bleeding. Horses were most frequently bled from the jugular vein in the neck, but also from veins in the thigh, the fold at the junction of breast and forelegs, the spur, the foreleg, the palate, and the toe. Since applying the bloodstick required a degree of skill, the Germans attempted to eliminate its use by adapting the spring lancet to veterinary medicine. The common veterinary spring lancet (which sometimes was also called a "fleam" or "phleme") was nothing but an oversized version of the brass, nob end spring lancet used on humans. Sometimes the lancet was provided with a blade guard that served to regulate the amount of blade that penetrated the skin. Although the veterinary spring lancet was quite popular in some quarters, the French preferred the simple foldout fleam as a more convenient instrument.[198] (Figure 22.) [Illustration: FIGURE 22.--Knob end spring lancet used on humans compared to a knob end lancet used on horses and cattle. Note the blade guard on the veterinary spring lancet. (NMHT 302606.09 and NMHT 218383 [M-9256]: SI photo 76-7757.)] In contrast to the few attempts made to modify the human spring lancet, there were a large number of attempts to modify the veterinary spring lancets. Veterinary spring lancets can be found with a wide assortment of shapes and a wide variety of spring mechanisms. In the enlarged knob end spring lancet, pushing upon the lever release simply sent the blade forward into the skin. By a more complex mechanism, the blade could be made to return after it was injected, or the blade could be made to sweep out a curve as do the blades of the scarificator. Perhaps one of the earliest attempts to introduce a more complex internal mechanism into the veterinary spring lancets is found in John Weiss's "patent horse phlemes" of 1828. The first model invented by Weiss was constructed on the principle of the common fleam and bloodstick. As in the knob end spring lancet, the spring acted as a hammer to drive the blade forward. In a second improved "horse phleme," Weiss mounted the blade on a pivot so that the blade swept out a semicircle when the spring was released.[199] The Smithsonian collection contains a number of different types of veterinary spring lancets. Perhaps this variety can best be illustrated by looking at the two patent models in the collection. The first is an oval-shaped lancet patented in 1849 by Joseph Ives of Bristol, Connecticut.[200] By using a wheel and axle mechanism, Ives had the blade sweep out an eccentric curve. The lancet was set by a detachable key (Figure 23). The second patent lancet was even more singular in appearance, having the shape of a gun. This instrument, patented by Hermann Reinhold and August Schreiber of Davenport, Iowa, in 1880, featured a cocking lever that extended to form a coiled spring in the handle portion of the gun. Also attached to the cocking lever was an extended blade with ratchet catches, so that by pulling on the cocking lever, the blade was brought inside the casing and the spring placed under tension. Pushing upon the trigger then shot the blade into the vein.[201] (Figure 24.) Physical Analysis of Artifacts The Conservation Analytical Laboratory of the Smithsonian Institution analyzed selected bloodletting instruments and one drawing from the Museum's collection. Instruments were chosen on the basis of their unique appearance and as representative examples of the major types of instruments in the collection. Six lancets and cases, two scarificators, and one pen and ink drawing were analyzed. [Illustration: FIGURE 23.--Patent model, J. Ives, 1849. (NMHT 89797 [M-4292]: SI photo 73-4211.)] [Illustration: FIGURE 24.--Patent model, Reinhold and Schreiber, 1880. (NMHT 89797 [M-4327]; SI photo 73-4210.)] X-ray fluorescence analysis, response to a magnet, reaction to nitric acid, and the Vickers pyramid hardness test were among the methods of analysis used that involved no damage to the objects. The instrument for X-ray fluorescence analysis has been modified to permit analysis of selected areas on the objects. This instrument produces, detects, and records the object's X-ray fluorescence spectrum, which is characteristic of its composition. X-rays produced by a target in the instrument strike the object and cause it, in turn, to fluoresce, or emit, X-rays. This fluorescence is detected by a silicon crystal in the detector and dispersed into a spectrum, which is displayed on an oscilloscope screen. The entire spectrum--from 0 to 40 Ke V--can be displayed or portions of it can be expanded and displayed at an apparently higher resolution that permits differentiation between closely spaced fluorescent peaks, such as those from iron and manganese. The spectrum may be transferred from the oscilloscope to a computer for calculation of the percentage of composition and for comparison with spectra of other samples. During analysis the objects can be supported and masked by sheets of plexiglas or metal foils to limit the radiation to a certain area of the object. Masks also prevent scattering of radiation off other parts of the object and off the instrument itself, which otherwise might be detected and interpreted as less concentrated components in the object. Brass was the most common metal used in the fabrication of eighteenth- and nineteenth-century lancets and scarificators. Upon analysis the brass was found to contain 70%-75% copper, 20%-30% zinc, and other trace elements. The blades, cocking levers, and button releases of lancets and scarificators were found to be made of ferrous metal (iron or steel). In addition to the typical brass pieces, a number of "white metal" pieces were analyzed. (The term "white metal" is used to designate any undetermined silver-colored metal alloy.) Those white metal pieces dating from the eighteenth century (a Swiss or Tyrolean fleam and an English veterinary spring lancet) were found to be composed entirely of ferrous metal. The hardness of the fleam metal indicated that it was carburized sufficiently to be made of steel. Two of the spring lancets, dating from the late nineteenth century, were found to be made of a silver-copper composition that was not rich enough in silver to be sterling silver. These lancets were probably typical of the lancets advertised as silver in the late nineteenth-century trade catalogs. About 1850 an alloy imitating silver began to be widely used in the making of surgical instruments. This was German silver or nickel-silver, an alloy containing no silver at all, but rather copper, zinc, and nickel. A patent model scarificator dating from 1851 was found to contain about 63% copper, 24% zinc, and 13% nickel. This alloy is presently called "nickel-silver 65-12" alloy. The French made scarificators out of their own version of nickel-silver that was called "maillechort." The French circular scarificator was found to contain copper (55%-70%), nickel (10%-20%), zinc (20%-30%), and tin (less than 10%). The cases in which the lancets and scarificators were carried were covered with leather, despite the fact that several appeared to be covered with paper. X-ray analysis revealed that several cases contained tin, leading to the possibility that a tin salt was used in the dye-mordant for leather. The clasps on the cases were made of brass. One case was trimmed in gold leaf. The most difficult item to analyze was the pen and ink drawing in black and red of a bloodletting man purported to be a fifteenth-century specimen (1480) from South Germany. The text is in German (Figure 25). The watermark of the paper--a horned bull (ox) with crown--is believed to have appeared in 1310 and was used widely for two hundred years. The paper was heavily sized and no feathering of the black ink or red paint appears. The paper fluoresced only faintly under ultraviolet light and much less brightly than new paper, leading to the conclusion that the paper is not modern. Various stains on the paper fluoresce yellow, which also indicates a considerable history for the document. The guard strip is vellum. Red stains on this strip may have been made by blood. The inks (brown and red) may have come from different sources or been applied at different times because of their various compositions and densities. Iron and lead were found in an area of writing on the left foot. Iron is typical of an iron gall ink. Some of the lighter lines contain graphite. The red lines contain mercury and lead suggesting a mixture of vermilion and red lead. Analysis of the ink and paper indicates that the document has had a varied history and seems not to have been a deliberate production intended to simulate age. Catalog of Bloodletting Instruments Several systems of catalog numbers have been employed for instruments in the collections. The earliest instruments were originally collected by the Division of Anthropology and were given a six-digit number in the division catalog (referred to as "Anthropology"). Later objects in the collections have been given a six-digit National Museum of History and Technology (NMHT) accession number, which serves for all items obtained from one source at a given date. Before 1973, the Division of Medical Sciences used a system of numbering individual items by M numbers (e.g., "M-4151"). Since 1973, individual items have been distinguished by adding decimal numbers to the accession numbers (e.g., "308730.10"). Objects on loan have been marked as such and given a six-digit number. Other institutional abbreviations are as follows: SI = Smithsonian Institution; USNM = the former United States National Museum; NLM = National Library of Medicine. [Illustration: FIGURE 25.--Bloodletting manikin. (NMHT 243033 [M-10288]; SI photo 76-13536.)] Photograph numbers are labeled "BW" for black and white negative and "CS" for color slide. (Copies of photographs or slides may be purchased through the Office of Printing and Photographic Services, Smithsonian Institution, Washington, D.C. 20560.) Abbreviations for dimensions of objects are as follows: D = diameter; L = length; W = width; H = height. Instruments within each group are arranged chronologically as accessioned by the museum. _Phlebotomy_ FLINT AND THUMB LANCETS Flint lancets (4). Pieces of flint used to let blood by native doctors in Alaska in the 1880s. Donated by William J. Fisher late 19th century. L 22 mm, 35 mm, 43 mm, 50 mm. Anthropology vol. 30, catalog no. 127758. Neg. 73-4208 (BW, CS). (Figure 30.) Thumb lancet, 19th century. Typical thumb lancet with steel blade and tortoise shell shield, engraved with a crown and "Evans/Old Change/London" (manufacturer). Purchased 1898. Shield: L 56 mm. Blade: L 50 mm. Anthropology vol. 30, catalog no. 143079. Flint lancet. "Indian scarificator" collected by the Section of Ethnology of the Smithsonian 1902. L 44 mm. Anthropology vol. 30, catalog no. 143166. Thumb lancets (4) with case, 19th century. Lancets are engraved "S. Maw" (manufacturer). The case is made of cardboard covered with brown leather and has four compartments. Used by the donor's father while a missionary in Samoa in the 1830s. Donated in 1936 by the Rev. Robert G. Harbutt. Lancets: L 55 mm. Case: L 60 mm, W 28 mm, H 10 mm. Neg. 73-4230 (BW) four lancets with case; negs. 73-4226, 73-4227, 73-4228, 73-4229 (BW & CS), individual lancets. NMHT 139980 (M-4151). (Figure 38.) Thumb lancets (2), 19th century. Lancets are typical 19th century thumb lancets. Shell shields are broken. Second lancet is engraved with a crown denoting British manufacture. Owned by S. K. Jennings of Baltimore (1771-1854). Donated by the Medical and Chirurgical Faculty of Maryland 1976. First lancet: L 54 mm; L of blade 46 mm. Second lancet: L 58 mm; L of blade 42 mm. NMHT 302606.062. Thumb lancets (2), 19th century. Shell shields. One shell is marked "A. L. Hernstein." Purchased 1976. First lancet: L 60 mm. Second lancet: L 70 mm. NMHT 1977.0789. Bloodletting knife, 19th century. Handle is cylindrical and made of carved wood, which has been turned, a brass ring, and an ivory tip with a hole bored through it. Blade is double beveled and engraved "Rodgers/Cutlers to Her Majesty," which indicates that the piece is Victorian. It could have been used for many purposes, including bloodletting. Purchased 1976. L 129 mm; L of blade 30 mm. Neg. 76-76108 (BW). NMHT 321697.39. Thumb lancets in cases (8), 19th century. Seven of the cases have silver trimming and are closed by a hinged cap. These are similar in appearance to cigarette lighters. The first case, made of tortoise shell, contains four thumb lancets (with tortoise shell sheaths). Two blades are marked "Savigny & Co.," two are marked with a cross on top of crown symbol. The second case is made of mother-of-pearl carved with an intricate floral design. It has space for four lancets but contains only one lancet marked "Thompson" on the inner side of the shell cover, and a silver pincers. The scroll initials "J H" appear on the side of the case. The third case is silver, decorated with a floral relief, and contains two lancets. The fourth case is made of shagreen and contains six lancets, three engraved "Savigny" and one "Morgan." The fifth case is made of shagreen. One blade is inscribed "STODART." Blades are rusted. The sixth case is made of shagreen. It contains one shell-covered lancet of a possible six. The blade is marked Paris. "J. P. Honard" is engraved on the silver top of the case. The seventh case is made of shagreen. It contains two lancets, one with a pearl shield and one with a shell shield. On the blade of the shell encased lancet is inscribed "B. Radford, 9 Patrick St. Conn." The last case is made of leather, which is worn. It contains one shell-encased lancet. The blade is marked "Gouldig & Ford, N.Y." Purchased 1976. Case one: L 70 mm, W 36 mm. Case two: L 69 mm, W 33 mm. Case three: L 65 mm, W 30 mm. Case four: L 74 mm, W 50 mm. Case five: L 71 mm, W 33 mm. Case six: L 75 mm, W 43 mm. Case seven: L 68 mm, W 32 mm. Case eight: L 75 mm, W 17 mm. Neg. 76-9116 (BW). NMHT 1977-0789. (Figure 5.) SPRING LANCETS NOTE: Lancets are measured to the tip of the casing rather than to the tip of the blade. The blade length depends upon the setting, and varies from an additional 8 to 13 mm. Spring lancet, 19th century. Brass Knob end lancet with brass lever release. Purchased 1898. L 42 mm, W 20 mm. Anthropology vol. 30, catalog no. 143078. Spring lancets (2) with case, 19th century. One lancet is plain with a brass lever release. Second lancet is brass with a steel lever release and has a floral design on the front and back panels. There are three settings for the height of the blade instead of the usual two. Blade is broken off. Case is square and made of wood covered with black leather and lined with rose plush. It is stamped "Braumiller, jun." Wood is broken. Leather and plush are badly torn. Donated by George B. Roth 1925. Both lancets: L 44 mm, W 20 mm. Case: L 62 mm, W 64 mm, H 20 mm. NMHT 88734 (M-2099). Spring lancet, patent model, 1857. Lancet has a cupped end instead of the usual knob end. According to analysis by the Conservation Laboratory, the lancet is made of silver-copper alloy. A screw on the back regulates the depth of cut by moving the spring mechanism back and forth inside the outer casing. Patented by James W. W. Gordon (U.S. patent 16479). Transferred from the U.S. Patent Office 1926. L 36 mm, W 25 mm, H 6 mm. Neg. 73-10318 (BW) and 73-116 (CS), front view; 73-10319 (BW) and 73-11147 (CS), back view. NMHT 89797 (M-4298). (Figures 48, 49.) Spring lancet, 19th century. Lancet is brass and has a brass lever release. It is engraved with the initials "A. F." Donor claimed it was a 17th-century import from Wales, but it appears to be a standard 19th century lancet. Donated by Edward Pryor 1930. L 45 mm, W 19 mm. Neg. 73-4235 (BW & CS). NMHT 112827 (M-2995). (Figure 105.) Spring lancet, 19th century. Lancet is brass with a brass lever release. Engraved "Wiegand & Snowden/Philadelphia" (manufacturer). Donated by Dr. H. S. West 1934. L 44 mm, W 22 mm. NMHT 131386 (M-3636). Spring lancet with case, 19th century. Standard 19th century lancet with typical case made of wood, covered with brown leather and lined with chamois. Case closes by a latch, and is stamped "Traunichtessticht," which translates, "Do not trust, it stabs." Many 19th century cases were stamped with this motto. Donated by Fred G. Orsinger 1937. Lancet: L 41 mm, W 20 mm. Case: L 71 mm, W 35 mm, H 18 mm. Neg. 73-4237 (BW & CS), without case. NMHT 145365 (M-4510). Spring lancet blade with case, 19th century. The case is made of wood and covered with red paper, and has "F D" stamped on the bottom. A piece of paper with the date "1877" is affixed to the top of the case. This is the date that the donor received the blade from his mother, daughter of the owner, Dr. Joseph S. Dogan (1793-1870), who practiced as a country doctor in South Carolina. Donated by B. F. Arthur 1937. Blade: L 42 mm. Case: L 64 mm, W 20 mm, H 15 mm. NMHT 145290 (M-4513). NOTE: In the Wellcome Museum there are two spring lancets in a case. (R 3689/1936) One of these is marked "F. D." and the other "Fischer Peter," which may indicate that this is the name of the maker of all instruments so marked. The Wellcome instruments were part of the Hamonic Collections. Dr. Hamonic listed them as 18th century instruments. Another lancet that appears to be veterinary, because of its size, is stamped "P. Fischer" (Wellcome 13516). Note that several items in this catalog are so marked. Spring lancet with case, late 19th-early 20th century. Tiemann & Co.'s spring lancet, a modified lancet sold by George Tiemann & Co. and advertised in the Tiemann catalogs of 1879 and 1889. Lancet is made of German silver and has a domed rather than a knob end. It is stamped "Tiemann" on the back panel. Release lever is a short bar across the top. Leather case is lined in red plush and has a partition in which four extra lancet blades are contained. Lancet was one of various instruments in a medical bag used by Dr. Augustus Stabler of Brighton, Maryland, who practiced from 1889 to 1914. Donated by Sidney Snowden Stabler 1942. Lancet: L 34 mm, W 16 mm. Case: L 62 mm, W 40 mm, H 23 mm. Neg. 73-5644 (BW). NMHT 163863 (M-5141). (Figure 47.) Spring lancet with case, 19th century. Brass lancet with brown leather case. Lancet was a part of the Squibb Ancient Pharmacy, a collection of medical and pharmaceutical objects brought by E. Squibb and Sons to the United States in 1932. On deposit from the American Pharmaceutical Association 1945. Lancet: L 40 mm, W 19 mm. Case: L 70 mm, W 38 mm, H 24 mm. NMHT 170211 (M-6385). Spring lancets (2) with case, 19th century. Lancets are made of brass and have steel lever releases. They are engraved front and back with a floral pattern. Tip of the blade of one of the lancets is broken. Case is wood covered with red leather and is missing the top. Donated by the University of Pennsylvania 1959. First lancet: L 43 mm, W 21 mm. Second lancet: L 75 mm, W 49 mm, H 11 mm. NMHT 218383 (M-9260). Spring lancet with case, 19th century. Brass lancet with brass lever release. Case is covered with red cloth and lined with black plush. Used by Dr. Samuel Fahnestock (1764-1836) or by his son, Dr. William Baker Fahnestock (1804-1886) of Pennsylvania. Donated by Capt. Henry Fahnestock MacComsey, U.S.N., and Dr. G. Horace Coshow 1968. Lancet: L 40 mm, W 20 mm. Case: L 74 mm, W 40 mm, H 26 mm. NMHT 280145 (M-12341). Spring lancet with case, 19th century. Lancet has a steel lever release and is stamped "F. D." on the back panel. Other lancets have been found with these initials but so far no manufacturer has been traced. Leather of case is damaged. Owned by Dr. Harry Friedenwald of Baltimore, Maryland (b. 1864). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 40 mm, W 20 mm. Case: L 72 mm, W 34 mm, H 20 mm. NMHT 302606.008. Spring lancet with case, 19th century. Brass spring lancet with a brass lever release. Case is stamped "Traunichtessticht" (see NMHT 145365 [M-4510]). Used by Dr. Wilbur Phelps, Baltimore, Maryland (1841-1922). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 38 mm, W 34 mm. Case: L 71 mm, W 34 mm, H 17 mm. Neg. 76-7757 (BW & CS), compares lancet to a veterinary spring lancet. NMHT 302606.009. (Figure 22.) Spring lancet with case, 19th century. Brass spring lancet with a brass release. Case is covered with navy blue leather, lined with chamois, and stamped with a small flower and leaf design. Owned by Dr. Launcelot Jackes of Hancock, Maryland (b. late 18th century). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 40 mm, W 22 mm. Case: L 66 mm, W 34 mm, H 20 mm. NMHT 302606.039. Spring lancet with case, 19th century. Lancet and case are very similar to NMHT 302606.039. The case is more rounded on top, is covered with black leather, and bears the same floral motif. Lancet blade is broken. Owned by Dr. George Washington Crumm of Clearspring and Jefferson, Maryland (1811-1896). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 42 mm, W 22 mm. Case: L 66 mm, W 38 mm, H 22 mm. NMHT 302606.056. Spring lancet, 19th century. Brass lancet with steel lever release. Owned by Dr. Joseph Tate Smith of Baltimore, Maryland (1850-1930). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 42 mm, W 20 mm. NMHT 302606.057. Spring lancets (2) with case, 19th century. Wood case, covered with brown leather and lined with brown velvet, has space for two rectangular lancets. One brass lancet, knob end, does not belong with the set. It has a steel lever release and three settings for blade height. The rectangular lancet, also made of brass, with an iron lever release and three settings for the height of the blade, is unusual in that it is triggered by a slide catch on the facing side rather than by a lever on top. The set was owned by Dr. Charles W. Owen of Maryland (1823-1857). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Rectangular lancet: L 50 mm, W 16 mm. Knob end lancet: L 42 mm, W 18 mm. Case: L 150 mm, W 34 mm, H 22 mm. NMHT 302606.058. Spring lancet with case, 19th century. Lancet and case are similar to NMHT 302606.039. The leather of the case is torn and the lancet blade is broken. Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 42 mm, W 22 mm. Case: L 66 mm, W 38 mm, H 24 mm. NMHT 302606.061. Spring lancet with case, 19th century. The Conservation Analytical Laboratory found the lancet to be made of a silver-copper alloy with an iron or steel lever release. It has a border around the top and along the edge and is marked "Reinhardt & C{o}/Balt{o}." Case is covered with black leather and lined in pink plush. It is decorated by a gold border and a small scroll motif. Donated by Harry L. Schrader 1972. Lancet: L 42 mm, W 21 mm. Case: L 68 mm, W 34 mm, H 20 mm. NMHT 302607 (M-14682). Spring lancet with case, late 19th-early 20th century. Lancet is similar to the preceding lancet. It is made of white metal[B] (probably silver-copper) and has a border decoration along the top and around the edge. Case, which is badly rotted from water damage, is a folding style case and is closed by a clasp. There is a pocket for extra blades. Donated by John and James Draper 1973. Lancet: L 42 mm, W 21 mm. Case: L 74 mm, W 40 mm, H 18 mm. NMHT 304826.067. Spring lancet with case, late 19th-early 20th century. Brass knob end lancet with brass lever release. Case is covered with brown leather and lined with chamois. Case is stamped "Traunichtessticht" (See NMHT 145365 [M-4510]). Owned by Dr. F. L. Orsinger of Chicago (1852-1925). Donated by Dr. William Orsinger 1973. Lancet: L 43 mm, W 22 mm. Case: L 70 mm, W 30 mm, H 20 mm. Neg. 74-4088 (BW & CS); 76-13535 (BW), interior view of spring mechanism. NMHT 308730.10. (Figures 7, 39.) Spring lancet with case, 19th century. Brass Lancet with steel lever release. Leather of case is water damaged and is stamped "Traunichtessticht." Latch is missing. Donated by Peter H. Smith Jr., 1975 Lancet: L 50 mm, W 25 mm (w/ blade extended), H 15 mm. Case: L 75 mm, W 42 mm, H 23 mm. NMHT 316508.01. Spring lancet with case, 18th-early 19th century. Wooden case has a hand-carved space for lancet. Lancet is brass and has an unusual boot shape. The short lever release operates a catch at the very top of the lancet casing. The large blade has a guard that is regulated by a screw on the side. Purchased 1976. Lancet: L 35 mm, W 24 mm. Case: L 68 mm, W 33 mm, H 20 mm. Neg. 76-9114 (BW). NMHT 316478. (Figure 46.) Spring lancet, late 18th-early 19th century. Unusually shaped large brass and steel spring lancet, nicely decorated and engraved with the name "M. A. Prizzi." Lancet is set by a slide cocking lever on the facing side and released by another lever. A brass plate at the top of the lancet can be moved back and forth by a screw in order to regulate the depth of cut of the lancet blade. Lancet comes with a spare blade. Purchased 1975. Lancet: L 86 mm. Neg. 76-7763 (BW, CS). NMHT 320033.06. (Figure 45.) Spring lancet with case, 19th century. Lancet is brass with a steel lever release and has a zig-zag decoration on the front and back panels. Case is covered with brown leather and lined with chamois and has a small basket of flowers stamped on the top. Purchased 1976. Lancet: L 42 mm, W 19 mm. Case: L 71 mm. W 34 mm. H 19 mm. Neg. 73-4236 (BW & CS). NMHT 321636.01. (Figure 6.) Spring lancet, 19th century. Lancet is engraved "F. D." on back (see NMHT 302606.008). Analysis by the Conservation Laboratory shows that the lancet is made of brass composed of 70% copper and 30% zinc plated with a tin-lead alloy. Most of the plating has been rubbed away. The blade, cocking lever, and release lever are of iron or steel. Purchased 1976. Lancet: L 43 mm. W 21 mm. NMHT 321636.02. Spring lancet with case, 19th century. Lancet is brass and has a brass lever release. Engraved "Goulding/New York" (manufacturer). Case is made of wood, covered with black leather and lined with light brown plush. It has a tab closure. Lancet and case were not originally a set; the case was designed for a larger lancet. Donated by the American Pharmaceutical Association 1970. Lancet: L 40 mm, W 20 mm. Case: L 74 mm. W 38 mm. H 12 mm. NMHT 321641 (M-13060). Spring lancet with case, late 19th century. Silver lancet with a button release and a border decorating the top and edge. Button release lancets were sold in the late 19th century for slightly more than lever release lancets. Analysis by the Conservation Laboratory shows that the silver is not sterling but a silver-copper alloy containing twice as much copper as sterling silver. The button release is made of ferrous metal plated with silver. The blade and cocking lever are also of ferrous metal. The case is made of wood, covered with brown leather and trimmed with gold leaf. It is closed by an ornate clasp made of ferrous metal plated with brass. Donated by the American Pharmaceutical Association 1970. Lancet: L 42 mm, W 22 mm. Case: L 73 mm, W 40 mm, H 11 mm. NMHT 321641 (M-13060.1). Spring lancet with case, 19th century. Silver lancet with lever release described by seller as dating from 1800, although it is probably of a later date. Lancet has a border decoration, and the back plate is opened by a shell-design protuberance. The case is covered with brown leather with gold leaf edging, and is stamped "A. St." Case is lined with rose plush below and white silk above. Lancet is engraved "Cotzand." Purchased 1976. Lancet: L 42 mm, W 17 mm. Case: L 68 mm, W 37 mm, H 20 mm. Neg. 76-7752 (BW, CS). NMHT 321687.02. (Figure 44.) Spring lancet with case, late 19th century. Silver lancet with a button release and a border decorating the top and the edge. Mechanism is frozen. Purchased 1976. Lancet: L 40 mm. NMHT 321697.01. Spring lancet, late 19th century. White metal including the blade, which may have been a replacement for the original. The blade is more highly polished than the case. The black case is worn so that an indistinct mark appears on its cover. It is lined with chamois. Lancet: L 41 mm, W 17 mm, blade extends 10 mm. Case: L 65 mm, W 38 mm. NMHT 1977.0789.13. Spring lancet with case, 19th century. Brass lancet with steel lever release. Case is covered with brown leather and lined with chamois. Leather is torn and latch is missing. Owned by Dr. Launcelot Jackes of Hancock, Maryland (b. late 18th c.). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Lancet: L 40 mm, W 20 mm. Case: L 72 mm, W 42 mm, H 24 mm. NMHT 302616.040. Spring lancets (2) with case, late 18th-early 19th century. Pair of brass lancets in a hand-carved wooden case. First lancet has a steel lever release and is engraved with a zig-zag pattern and the initials "F. D." Second lancet is shorter than usual and missing the lever release and cocking lever. Case has space cut for each lancet and an additional space for extra blades or a thumb lancet. Purchased 1976. First lancet: L 40 mm. Second lancet: L 30 mm. Case: L 84 mm, W 56 mm, H 17 mm. NMHT 321697.02. Spring lancet, late 19th century. Brass decorated with flowers, has tulip and leaves on reverse side with iron blade and lever. Lancet: L 39 mm, W 21 mm. Case: L 65 mm, W 33 mm. NMHT 1977.0789.14. Spring lancet, late 19th century. Brass case is unmarked. The leather case had a red lining and a top that slips off. Lancet: L 44 mm, W 18 mm. Case: L 77 mm, W 35 mm. NMHT 1977.0789.15. Spring lancet, late 19th century. Brass case with unclear lettering "WIEGANL Phila Powten." Leather case has red lining and closes with a hook. Lancet: L 41 mm, W 22 mm. Case: L 70 mm, W 33 mm. NMHT 1977.0789.9. Spring lancet, late 19th century. Brass case. Leather case has a chamois lining and closed with a hook. An eagle on the cover is worn. Lancet: L 43 mm, W 19 mm. Case: L 70 mm, W 35 mm. NMHT 1977.0789.10. Spring lancet, late 19th century. Light yellow brass case. Case is leather (worn) with a chamois lining and hook closure. Lancet: L 41 mm, W 20 mm. Case: L 71 mm, W 35 mm. NMHT 1977.0989.11. Spring lancet, late 19th century. Brass case with small guard over blade. Cover on the back appears to be a replacement for the original. Crude wooden case is red and worn. Lancet: L 45 mm, W 33 mm. NMHT 1977.0789.12. Spring lancet, late 19th century. Brass case with cover of the lancet missing. Leather case has a chamois lining and hook closure. Lancet: L 38 mm, W 20 mm. Case: L 70 mm, W 34 mm. NMHT 1977.0789.7. Spring lancet, late 19th century. Lancet is of white metal including the blade. The leather case has a gold decoration around the edges. Lancet: L 41 mm, W 22 mm. Case: L 70 mm, W 36 mm. NMHT 1977.0789.8. NOTE: For additional spring lancets, see "Cupping Sets" (NMHT 268719 [M-11878]) and "Related Artifacts" (NMHT 199536 [M-6689] and NMHT 285125 [M-12352]). BLEEDING BOWLS Bleeding bowl, after 1740. Pewter bowl with horizontally projecting handle. Handle is decorated with cut out tracery, a coat of arms, and the name of the London maker, John Foster. Bowl has graduated rings every 2 ounces from 2 to 16. Held by Division of Cultural History, Smithsonian Institution (Greenwood Collection). L 200 mm to tip of handle, D 132 mm, H 45 mm. Neg. 61166-C (BW). (Figure 4.) Barber's basin, 18th century. Blue faience basin with green, red, and blue floral decoration. Used for shaving and probably for phlebotomy as well. Bowl is indented to fit against the neck. Purchased 1959. L 260 mm, W at indentation 173 mm, H 68 mm. Neg. 73-4220 (BW, CS). NMHT 225114 (M-9399). Bleeding bowl. Circular bleeding bowl made of pewter and typical of the bowls used to collect and measure blood in the 18th century. Such bowls were no longer generally used in the 19th century. Bowl has a plain, flat, horizontally projecting handle and graduated circles marking every 4 ounces from 4 to 24. Purchased 1976. L 233 mm to tip of handle, D 166 mm, H 55 mm. NMHT 322691.01. Bleeding bowl. Pewter bowl with a cut out tracery handle. Bowl has graduated markings every 2 ounces from 2 to 16. Purchased 1976. D 127 mm, H 64 mm. NMHT 322691.02. EXTRA BLADES AND CASES Spring lancet blades (2), 18th-19th century. Used by Dr. John Cooper, Easton, Pennsylvania, great-grandfather of the donor. Donated by the Rev. J. V. Cooper 1936. Blades: L 44 mm, W 14 mm. NMHT 139877 (M-4145). Spring lancet case, 19th century. This case is unlike other lancet cases in the collection in that the top half is a cap which slips off. The bottom half opens lengthwise and has space for a lancet and two pockets for extra blades. Case, made of cardboard and covered with black leather, is lined in tan plush. Purchased 1963. Case: L 62 mm, W 32 mm, H 22 mm. NMHT 251481 (M-10463). Spring lancet case, 1827. Case is handmade of wood, with fabric panels covered with glass on five sides. In the top panel, a spring lancet has been hand drawn in blue. The bottom panel contains several symbolic images and the motto, "Memento Mori." The end panel has the name of the owner, "W. M. Bonwill's/1827." The case opens by a hinge and has space carved out for two knob end lancets. Pasted to the lid is a leather pocket containing two lancet blades of different sizes. The Smithsonian Institution also owns a matching toilet case, given by the same donor. Donated by the University of Pennsylvania 1959. Case: L 87 mm, W 48 mm, H 18 mm. Neg. 73-5847, 73-5848, 73-5849, 73-5850 (BW, various views with toilet case)/73-7680 to 73-7693 (CS, various views with toilet case). NMHT 218383 (M-9261). Spring lancet case, 19th century. Two part red leather case. Inner box has space for a knob end spring lancet and two spare blades. Box slides into an outer shell with a tab closure. Owned by Dr. Robert Moore (1764-1844), who served as President of the Medical and Chirurgical Faculty of Maryland from 1820 to 1826. Donated by the Medical and Chirurgical Faculty of Maryland 1976. Case: L 78 mm, W 50 mm, H 12 mm. NMHT 302606.054. _Cupping_ SCARIFICATORS NOTE: Height is measured to the top of the casing. The height may vary by a few millimeters because setting the depth of cut of the blades is accomplished by raising or lowering the bottom of the scarificator. Scarificator, 12 blades, 19th century. Octagonal brass scarificator with blades arranged on two rods which cut in opposite directions. This is a standard English-American 19th c. scarificator. As is true of all scarificators, the blades and cocking lever are made of ferrous metal (iron or steel). Two small stars on one side indicate how the top and bottom of the scarificator fit together. Purchased 1898. L 46 mm, W 42 mm, H 30 mm. Anthropology vol. 30, catalog no. 143080. Scarificator with case, 12 blades, 19th century. Standard scarificator with blades cutting in opposite directions. Case is wood covered with red leather, lined in purple plush and closed by a latch. On top of the case is an American eagle. Donated by Dr. D. H. Welling 1925. Scarificator: L 52 mm, W 46 mm, H 36 mm. Case: L 61 mm, W 56 mm, H 77 mm. NMHT 86124 (M-2087). NOTE: American eagles of this type were imprinted on many objects at the time of the Centennial (1876). Scarificator, 12 blades, patent model, 1846. Patented by George Tiemann of New York (U.S. patent 4705). Engraved "Geo. Tieman[_sic_]/No. 63 Chatham Street/New York/March 1846." The novel feature of the scarificator was the addition of an ebony handle in which a coiled spring was contained. See NMHT 254866 (M-10700), which is the same instrument as marketed by George Tiemann & Co. Transferred from the U.S. Patent Office 1926. Overall L 176 mm. Base: L 42 mm, W 42 mm, H 18 mm. Neg. 76-9115 (BW). NMHT 89797 (M-4289). (Figure 76.) Scarificator, 13 blades, patent model, 1847. Patented by Frederick M. Leypoldt of Philadelphia (U.S. Patent 5111). Scarificator is brass, octagonal with three rods containing 4, 5, and 4 blades respectively. Blades turn in same direction. The innovation consisted of a new arrangement of the cocking lever and spring. Engraved "F. Leypoldt/Philada." Transferred from the U.S. Patent Office 1926. L 44 mm, W 44 mm, H 40 mm. Neg. 73-4213 (BW & CS). NMHT 89797 (M-4290). (Figure 77.) Scarificator, 10 blades, patent model, 1851. Patented by Frederick Leypoldt of Philadelphia (U.S. patent 8095). This is a flattened model of scarificator made of a copper-zinc-nickel alloy known as "nickel-silver," or German silver. The innovation in this patent model was a flat lever extending from the side instead of the top, which fits into slots in two racks which move back and forth and turn the pinions of the blade rods. Blades cut in opposite directions. Transferred from the U.S. Patent Office 1926. L 42 mm, W 40 mm, H 16 mm. Neg. 76-9112 (BW). NMHT 89797 (M-4293). (Figure 78.) Scarificator, 12 blades, 19th century. Octagonal scarificator in which blades cut in the same direction. Donated by Dr. George B. Roth 1928. L 44 mm, W 40 mm, H 38 mm. Neg. 76-7744 (BW, CS). NMHT 99749 (M-2336). (Figure 106.) Scarificator, 12 blades, late 19th century. Octagonal scarificator; blades cut in opposite directions. Used by the donor's father. Donated by Aida Doyle 1932. L 48 mm, W 42 mm, H 34 mm. NMHT 118000 (M-3182). Scarificator, 10 blades, early 19th century. Octagonal scarificator with blades cutting in the same direction. Donated by H. S. West 1934. L 46 mm, W 44 mm, H 34 mm. NMHT 131386 (M-3635). Scarificator, 16 blades, early 19th century. This scarificator is typical of Germanic manufacture during the late 18th and early 19th centuries. It is square, hand engraved, and has pointed blades. Blades are arranged on three rods that turn in the same direction. Engraved "J. T./Wien." Vienna was the center of early scarificator manufacture. Scarificator said by donor to date from 1806. Donated by the University of Pennsylvania 1959. L 35 mm, W 34 mm, H 39 mm. Neg. 73-4212 (BW, CS). NMHT 218383 (M-9257). (Figure 60.) Scarificator, 16 blades, 19th century. Square scarificator, made somewhat later than the previous one because the blades are no longer pointed. Donated by the University of Pennsylvania 1959. L 36 mm, W 36 mm, H 32 mm. NMHT 218383 (M-9258). Scarificator, 16 blades, late 18th-early 19th century. Square scarificator. Donated by the University of Pennsylvania 1959. L 40 mm, W 30 mm, H 32 mm. Neg. 61130-B (BW). NMHT 218383 (M-9259). Scarificator with case, 4 blades, 19th century. Small octagonal scarificator used for cutting the temples. Bottom of scarificator is engraved with an American eagle. Case is covered with navy blue leather, lined with purple plush, and closed by a latch. Purchased 1960. Scarificator: L 28 mm, W 26 mm, H 26 mm. Case: L 42 mm, W 40 mm, H 60 mm. Neg. 76-7745 (BW, CS). NMHT 233056 (M-9639). (Figure 107.) Scarificator, 12 blades, 19th century. This octagonal scarificator is significant in that it bears a French patent. Turning the large wing-shaped handle on the top of the instrument cocks the blades, and turning a small key on the side regulates the depth of cut of the blades. Blades cut in opposite directions. Scarificator engraved "Breveté, S.G.D. Gouv." Purchased 1964. L 42 mm, W 38 mm, H 32 mm. NMHT 254866 (M-10695). Scarificator with case, 12 blades, 19th century. This is the market version of Tiemann's patent scarificator (NMHT 89797 [M-4289]), with a bone handle. Engraved "Geo. Tiemann/Patent/August 20/1846." This scarificator was advertised as late as 1889. Purchased 1964. Scarificator: L 172 mm, W 45 mm, H 45 mm. Neg. 73-4237-D (CS). NMHT 254866 (M-10700). Scarificator, 13 blades, 19th century. Octagonal scarificator with unusual number of blades arranged on three rods and cutting in the same direction. Purchased 1964. L 51 mm, W 46 mm, H 34 mm. NMHT 254866 (M-10706). Scarificator with case, 10 blades, 19th century. Used by Mary Fueurstien Kuhn, who practiced as a midwife in Ohio and also cupped and bled people during the period 1850-1890. Scarificator was brought to the United States from Germany by Mrs. Kuhn's father, who was a doctor. Blades cut in opposite directions. Case is covered in brown leather and lined in rose plush. Donated by Mrs. Arthur Peterman 1964. Scarificator: L 45 mm, W 42 mm, H 32 mm. Case: L 58 mm, W 55 mm, H 71 mm. NMHT 255254 (M10892). Scarificator, 16 blades, late 18th-early 19th century. Square scarificator. Top cap has a scalloped edge. Blades appear to be pointed. Mechanism is frozen. Donated by Harry L. Schrader 1972. L 34 mm, W 34 mm, H 34 mm. NMHT 302607 (H-14681). Scarificator, 16 blades, late 18th-early 19th century. Square scarificator. Mechanism is frozen. Donated by John and James Draper 1973. L 38 mm, W 35 mm, H 32 mm. NMHT 304826.066. Scarificator with case, 12 blades, late 19th-early 20th century. Octagonal scarificator with blades cutting in opposite directions. Two stars are engraved on the top and the bottom of one side. Case is cardboard covered with leather. Owned by Dr. F. L. Orsinger of Chicago (1852-1925). Donated by Dr. William Orsinger 1973. Scarificator L 45 mm, W 40 mm, H 35 mm. Case L 54 mm, W 48 mm, H 80 mm. Neg 74-4089 (BW, CS). NMHT 308730.11. Scarificator with case, 12 blades, 19th century. Octagonal scarificator with blades cutting in the same direction. There are two star markings on the top and the bottom of one side. Case is made of cardboard covered with black leather. Donated by Ada and Grace Abrahamson 1975. Scarificator: L 43 mm, W 40 mm, H 34 mm. Case: L 56 mm, W 47 mm, H 73 mm. NMHT 318916.01. Scarificator, 13 blades, 1973. Unusual hand-made brass and iron scarificator, engraved with decoration and the name "Domenico Pica" and date "1793." Blades are set on three rods of four, five, and four blades (see NMHT 254866 [M-10706]). The scarificator is octagonal but much taller than the standard octagonal model. Unlike all other scarificators in the collection, the bottom opens by a hinge, and a key on top raises and lowers the interior mechanism so as to regulate the depth of cut. Blades are cocked by a lever on top and released by a button on the side. Purchased 1975. L 50 mm, W 42 mm, H 60 mm. Neg. 76-7742 and 76-7743 (BW, CS). NMHT 320033.01. (Figure 66.) NOTE: The earliest marked scarificator known to the authors is one in the Wellcome Medical Collection (Wellcome number R 2.852/1930 C.H.M.), inscribed 1747. The case and blade are made entirely of iron or steel. L 144 mm, W 45 mm. Another one with a brass case (Wellcome number 290 or 6 7/36, in the Hamonic Collection) is inscribed Johann Darmreuther in Vendelstein 1769. A third one with a brass case and thirteen blades (Wellcome number 13555) is marked "Jo. Bat. Boeller _Fece anno_ 1762." Scarificator, 16 blades, late 18th-early 19th century. Square scarificator with 16 pointed blades engraved, in script, "Joseph Plunger in Brünn." Case is covered with brown leather. Purchased 1975. L 32 mm, W 32 mm, H 30 mm. NMHT 320033.02. Scarificator, 12 blades, 19th century. Standard octagonal scarificator with blades cutting in opposite directions. Stamped on the bottom with an American eagle, similar to that of NMHT 233056 (M-9639). This may mean the scarificators were made around the time of the Centennial. Purchased 1975. L 48 mm, W 45 mm, H 28 mm. NMHT 320033.03. Scarificator, 12 blades, 19th century. Standard octagonal scarificator with blades cutting in opposite directions. Engraved "H & H Hilliard/Edinburgh." Purchased 1975. L 54 mm, W 47 mm, H 35 mm. NMHT 320033.04. Scarificator, 16 blades, mid-late 19th century. Circular scarificator with fluted sides of the type manufactured by Maison Charrière in Paris. Seller describes instrument as French, mid-19th century. Analysis by the Conservation Laboratory shows that the instrument was made of an alloy of copper, zinc, nickel, and tin--probably the alloy that the French called "maillechort." Winged lever on top triggers the sixteen small blades arranged on two rods and cutting in opposite directions. A round knob on the side is pushed downward to release the blades. Presumably by turning the bottom, one can regulate the depth of cut. However, the bottom is frozen. Purchased 1975. H 31 mm, D 45 mm. Neg. 76-7746. NMHT 320033.05. (Figure 74.) Scarificator, 12 blades, 19th century. Standard octagonal scarificator with blades cutting in opposite directions. Used by Dr. G.W.M. Honberger (b. 1819). Donated by the Medical and Chirurgical Faculty of Maryland 1976. L 46 mm, W 44 mm, H 32 mm. NMHT 302606.006. Scarificator with case, 12 blades, 19th-20th century. Standard octagonal scarificator. Mechanism is frozen. Case covered with brown leather and lined with brown plush. Used by Dr. Jesse O. Purvis (b. 1880). Donated by the Medical and Chirurgical Faculty of Maryland 1976. Scarificator: L 48 mm, W 46 mm, H 32 mm. Case: L 61 mm, W 54 mm, H 79 mm. NMHT 302606.059. Scarificator, 10 blades, late 19th century. Standard scarificator, blades cutting in opposite directions, owned by Dr. Charles Carroll Shippen of Baltimore (b. 1856). Donated by the Medical and Chirurgical Faculty of Maryland 1976. L 48 mm, W 44 mm, H 34 mm. NMHT 302606.060. Scarificator, 12 blades, 19th century. Donated by the Medical and Chirurgical Faculty of Maryland 1976. L 48 mm, W 44 mm, H 36 mm. NMHT 302606.217. Scarificator, 10 blades, 19th century. Octagonal scarificator of white metal with an iron lever. Purchased 1976. L 41 mm, W 39 mm, H 31 mm. NMHT 1977.0789.40. Scarificator, 16 blades, 19th century. Purchased 1976. L 41 mm, W 35 mm, H 32 mm. NMHT 1977.0789.41. NOTE: Additional scarificators are found under "Cupping Sets" and in the "Barber-surgeon's kit" listed under "Related Artifacts." CUPS Cupping cup, glass, 19th century. Large dome-shaped cup. Purchased 1898. H 82 mm, D 66 mm. Anthropology vol. 30, catalog no. 143081. Cupping cup, glass, 18th-19th century. Hand-blown bellied cup from Hebron, Palestine. Donated by Dr. Cyrus Adler 1902. H 53 mm, diameter 31 mm. Anthropology vol. 30, catalog no. 143155. Neg. 59139-A (BW). Cupping cup, 12th century. Cup is made of opaque greenish glass and is triangular in shape. A vacuum is created in the cup by sucking air from the cup through a tubular extension on the side. This 12th century cup was recovered in Nishapur, Persia, by Dr. Richard Ettinghausen. On loan from Dr. Ettinghausen 1955. H 68 mm, D 42 mm. Neg. 73-4205 (BW, CS). NMHT 207389 (M-6836). (Figure 108.) Cupping cups (2), Pewter, 18th century. These cups are similar to those found in a Revolutionary War surgeon's kit held by the Smithsonian, and may therefore be of military issue. Metal cups were often preferred to glass for military purposes because they were unbreakable. Donated by Hattie Brunner 1955. M-6829 H 42 mm, D 34 mm. M-6830 H 38 mm, D 34 mm. Neg. 76-9109 (BW), includes German brass cup. NMHT 207399 (M-6829 and M-6830). Cupping cup, 12th century. A second Persian spouted cup (cf. NMHT 207389 [M-6836]), also made of opaque greenish glass, but more dome shaped. Purchased 1959. H 52 mm, D 50 mm. Neg. 73-4215 (BW). NMHT 224478 (M-8037). Cupping cups (3), glass, 18th-19th centuries. Cups of smaller diameter such as these were used for cupping on the temples and other parts of the body with limited surface area. Cups are molded and slightly bellied. Purchased 1964. First cup: H 54 mm, D 36 mm. Second and third cups: H 56 mm, D 36 mm. NMHT 254866 (M-10694). Cupping cup, horn, 20th century. A horn of a cow from Madaoua, Niger Republic, West Africa, used for drawing blood as late as the 1960s. There is a small foramen at the tip for exhausting the air by sucking. Purchased 1966. L 88 mm, D 52 mm. Neg. 73-5643 (BW, CS). NMHT 270023.01 (M-11998). (Figure 37.) Cupping cups, glass, 19th century. Set of five dome-shaped cups ranging from 50 mm to 60 mm in diameter and 64 mm to 72 mm in height. They were dated by the seller as 1895. Purchased 1969. NMHT 287162 (M-12872). Cupping cups (2), glass, 20th century. These two small cups were purchased about 1912 by Mr. Harry Zucker from a drug supply company on 2nd Street and Avenue B on the Lower East Side of New York City. Mr. Zucker used the cups for dry cupping only. Donated by Ruth Zucker 1972. H 54 mm, D 34 mm. NMHT 302834.1 and 302834.2. Cupping vessels (5), glass, 19th-20th centuries. Set of five dome-shaped cups ranging from 52 mm to 56 mm in height and 44 mm to 48 mm in diameter. Owned by Dr. E. L. Orsinger of Chicago (1852-1925). Donated by Dr. William Orsinger 1973. Neg. 74-4087 (BW, CS). NMHT 308730.09. Cupping vessels (3), glass, 18th-19th centuries. These three cups have button like protuberances on top for ease in handling. Cups were often pictured in 18th century surgical texts with such protuberances. In the 19th century most cups lacked them. Purchased 1976. NMHT 314016.236-.239. (Figure 109.) Cupping vessel, glass, 19th century. Slightly bellied, hand-blown cup. Donated by Ada and Grace Abrahamson 1975. H 47 mm, D 43 mm. NMHT 318916.02. Cupping vessel and bloodletting knife, 17th century. Persian brass conical cupping cup with a small hole at the tip for mouth suction. Knife has a wood and brass handle and a folding blade. Seller gives date as 17th century. Purchased 1976. Knife L 110 mm (folded). Cup L 86 mm, D 46 mm. Neg. 76-7749 (BW, CS). NMHT 320033.07. (Figure 110.) Cupping vessel, brass, 18th century. German brass cupping vessel. Purchased 1976. H 30 mm, D 35 mm. Neg. 76-9109 (BW), includes two pewter cups. NMHT 321697.22. (Figure 111.) Cupping vessels, glass, 19th century. Five small, hand-blown, green glass cupping cups. All are approximately the same size. Purchased 1976. Average dimensions: H 44 mm, D 35 mm. NMHT 321697.23-.27. Cupping vessels, glass, 19th and 20th centuries. Assortment of 22 cupping cups, either dome-shaped or slightly bellied. Various sizes. Purchased 1976. NMHT 321697.28-.49. CUPPING SETS Cupping set, 19th-20th century. Set consists of three cupping glasses, two dome-shaped and one bellied (M-4766, M-4767, M-4768), a 16 blade square scarificator (M-4771), a candle in a metal holder used to ignite the alcohol (M-4769), and a bit of sponge in a wire holder (M-4770). Presumably, the sponge would be dipped in alcohol, ignited, and inserted into the glasses. Used by Dr. Fred L. Orsinger of Chicago in the early 20th c. Donated by Fred G. Orsinger 1939. Scarificator: L 46 mm, W 37 mm, H 33 mm. Sponge and holder: L 78 mm. Neg. 61135-C (cupping glasses); 61130-B and 61130-C (scarificator), front and back views; 61164-B (candle in metal holder); 61129-D (sponge with wire holder); 76-9111 and 76-9113, internal views of scarificator. All negatives BW. NMHT 152130 (M-4766-71). (Figures 13, 43, 62.) Cupping set, 19th century. Contained in a mahogany case with red velvet lining are two glass cups without valves, a square model 16 blade scarificator with a leather case top, a braided leather tourniquet, a standard brass spring lancet in a case with an American eagle stamped in gold, and two lancets used on the gums with tortoiseshell shields. One gum lancet is engraved "Kuemerle & Kolbe," a Philadelphia manufacturer. Case was originally intended for a set of six brass valved cupping glasses and a pump. Owned and used by Dr. Elam Dowden Talbot of Barlow County, Virginia (1810-1881). Donated by Elam D. Talbot through Edna G. Dorr 1966. Case: L 204 mm, W 140 mm, H 110 mm. NMHT 268719 (M-11878). Cupping set, late 19th century. Set of four cupping glasses with brass fixtures, a pump, and two octagonal scarificators. Three of the cups are identical in size, and the fourth is slightly larger. One scarificator has 13 blades arranged on three rods turning in the same direction (cf. NMHT 254866 [M-10706]). Scarificator is engraved "Schively/Philad." (manufacturer). The other scarificator has 10 blades turning in opposite directions. Used by Dr. Robert Evans Bromwell, Port Deposit, Maryland, in the late 19th century. Donated by Dr. Bromwell's daughter, Roberta Bromwell Craig, 1970. Case: L 203 mm, W 135 mm, H 110 mm. NMHT 290051 (M-13113). Cupping set, 19th century. Mahogany case lined in rose plush has six compartments holding 5 valved cups of slightly varying shapes. One cup and pump are missing. Used by Dr. Launcelot Jackes, a member of the Medical and Chirurgical Faculty of Maryland. Donated by the Medical and Chirurgical Faculty of Maryland 1976. Case L 184 mm, W 143 mm, M 94 mm. NMHT 302606.005. Cupping set, 19th century. This elegant set was manufactured by Charrière of Paris. Set includes a circular scarificator with fluted sides similar to NMHT 320033.05 but made of brass. Scarificator is engraved "Breveté S.G.D. Gouv." Also in the set are a brass pump, tubing, and three distinctive mushroom shaped glasses provided with stopcocks. Case is made of wood and lined with fabric. All pieces except tubing and scarificator are engraved with the Charrière name. Set was said to have been purchased in Paris in 1850 by Dr. Asa Shinn Linthicum. Donated by the Medical and Chirurgical Faculty of Maryland 1976. Case: L 240 mm, W 150 mm, H 94 mm. First glass: H 110 mm, D 74 mm. Second glass: H 130 mm, D 80 mm. Third glass: H 94 mm, diameter 54 mm. Pump: L 160 mm, D 26 mm. Scarificator: H 32 mm, D 46 mm. Tube: L 450 mm. Neg. 75-090 (BW & CS), 75-4237-C (CS). NMHT 302606.007. (Figure 70.) Cupping set, 19th century. Mahogany case lined in purple plush has compartments for eight cups and space for a pump. Seven cups with valves remain, one of them a narrow necked fluted cup for cupping the breasts. Found in the case, though not part of the set, are an envelope with a lancet blade and a packet of six lancet blades, each of slightly different shape. On the packet is handwritten "American/25 each." Donated by the Medical and Chirurgical Faculty of Maryland 1976. Case: L 249 mm, W 130 mm, H 100 mm. NMHT 302606.035. Cupping set, mid-19th century. Charrière cupping set with four mushroom-shaped glass cups (the largest two with round edges and the smaller two with oval edges) with brass stopcocks, a pump, and a scarificator. Two of the cups and the scarificator are engraved with the Charrière name. The scarificator is octagonal and has twelve small blades cutting in opposite directions. Internally it has two rolled springs as described in the Charrière patent of 1841. Brass wrench case is mahogany and lined with a reddish chamois above. Pasted to the chamois is a bit of leather with wording in gold which reads "Paris/Charrière/Frabricant/Des/ Hopitaux/Civils/et/Mil. Rue de l'�cole de Méd. No. 7 (Bis)." Purchased 1976. Scarificator: L 42 mm, W 40 mm, H 34 mm. Pump: L 180.8 mm. Wrench: L 76.2 mm. Case: L 250 mm, W 133 mm, H 105 mm. Neg. 76-9117 (BW); 76-9110 (BW), scarificator showing springs. NMHT 1977.0789.44. Cupping set, 19th century. Set may date from early to mid 19th century. Wooden case, lined with brown velvet, contains two glass cups, two scarificators, a ball handled torch stuffed with a cotton wick, and a cut glass alcohol bottle. Large scarificator has eight blades, almost pointed in shape and cutting in opposite directions. Smaller scarificator has four blades on one rod. Both scarificators are engraved, in script, "H. Johnson/31 King Street/Borough." On top of the case is a silver plate with the name of the owner, "Mr. Sam Richards." Purchased 1976. Torch: L 111 mm. Bottle: H 65 mm. Large scarificator: L 54 mm, W 48 mm, H 37 mm. Small scarificator: L 36 mm, W 35 mm, H 29 mm. Case: L 248 mm, W 109 mm, H 94 mm. Neg. 76-9119 (BW). NMHT 1977.0789.48. (Figure 68.) Cupping set, 19th century. This unique set consists of a red leather case lined in purple velvet, four cups with brass fittings, a large octagonal scarificator, and a pump. The most interesting piece in the set is the pump, an oval cylinder enameled in yellow with a gold and black floral design on front and back. On top of the cylinder are both the brass pump and the attachment to the cups. The scarificator has twelve blades cutting in opposite directions and is engraved, in script, "J & W Wood/74 King Street/Manchester." The four cups vary widely in size, the largest having a diameter of 73 mm, the smallest a diameter of 43 mm. Purchased 1976. Pump: H 170 mm, L 78 mm, W 56 mm. Case: L 300 mm, W 150 mm, H 113 mm. Neg. 76-9118 (BW). NMHT 1977.0789.47. Cupping set, 19th century. Case is mahogany with two ivory keyholes and a brass handle. It is lined in red plush. Set includes nine glass cups of various sizes (including an oval cup), each with screw threads covered by a brass cap. Pump is brass, 142 mm long, and has a bit of leather wrapped around the outside of the screw threads. There is an extra compartment in the case that might have held a tenth cup, but now contains only the key. In a compartment lined with silver paper and covered by a red plush top with ivory handle are two octagonal scarificators. The first is a common twelve blade scarificator in which the blades cut in opposite directions. It is engraved with a crown and "Evans/London." The second is unusual in that it has eleven blades arranged on two rods. It is also engraved "Evans/London," and on top is engraved, in script, "W Tothill," and in block letters, "Staines No 2." The mechanism is frozen. Purchased 1976. Case: L 285 mm, W 210 mm, H 106 mm. Neg. 76-7747 (BW, CS), pieces in case; 76-7748 (BW, CS), pieces out of case. NMHT 321697.21. (Figure 112.) Cupping set, 19th century. Case is mahogany, lined in red velvet, with brass bindings on the corners and is incomplete. A brass plate on the cover is blank. The key is missing. Set includes two glass cups without fittings, two brass stopcocks, one 12-blade scarificator, and a brass holder for a wick, which is missing. The scarificator bears the inscription on one side, "Salt & Son/Birmingham." Purchased 1976. Brass wick holder: L 101.6 mm. Cups: D 53.8 mm and 52.3 mm. Case: L 223 mm, W 127 mm, H 103 mm. NMHT 1977.0789.45. Cupping set, 19th century. Case is mahogany with brass "straps" and a brass handle that rests flush with the lid on the case. The key is missing. Set contains two glass cups, one alcohol lamp, and one octagonal bladed scarificator. One cup is shaped like the early bronze cups. Purchased 1976. Alcohol lamp: L 67 mm, D of base 45 mm, D of top 20 mm. First Cup: L 90 mm, D at opening 50 mm. Second cup: L 63 mm, D of base 45 mm. Case: L 260 mm, W 105 mm, H 98 mm. NMHT 1977.0789.46. Cupping set, 19th century. Case is red leather and closes with two brass hooks. It contains two glass cups with fittings, a brass syringe, a small glass bottle shaped like a test tube, and a brass three-point scarifier with a spring setting and a button release. The set is unusual for its small size. Purchased 1976. Case: L 154 mm, W 108 mm, H 42 mm. Syringe: L (closed) 101 mm, D 25 mm. Cups: L 60 mm and 67 mm, D 28 mm and 23 mm. Scarificator: L 52 mm, D 20 mm. NMHT 1977.0789.49. CUPPING APPARATUS Cupping apparatus with case, patent model, 1844. Cupping set patented by Dr. R. J. Dodd. Surgeon, U.S.N. (U.S. patent 3537). Brass syringe with ivory handle is stamped "Dr. Dodd's Improved Cupping Apparatus." Syringe can be fitted with either a large or small plate with blades. To operate an internal part, a straight or curved glass tube is attached to the syringe along with a flexible metal lancet that runs the length of the tube. Straight glass tube is broken in two parts. Case is mahogany and lined with red velvet. On hinge is stamped "Horne Patent." Transferred from the U.S. Patent Office 1926. Case: L 307 mm, W 178 mm, H 80 mm. Neg. 73-4237B (CS). NMHT 89797 (M-4288). Cupping apparatus, patent model, 1856. Patented by Mr. Loyall Tillotson of Thompson, Ohio (U.S. patent 15626). Model of plunger apparatus is made of wood, though the actual instrument would have been made of metal. The body of the instrument was to be attached to a cup (not included in the model) with a spiral wire to which a battery would be attached. The novelty of the apparatus was that electricity would be employed in conjunction with dry cupping. Transferred from the U.S. Patent Office 1926. H 160 mm, D 60 mm. NMHT 89797 (M-4296). Cupping apparatus, patent model, 1867. Patented by Mr. William D. Hooper of Liberty, Virginia (U.S. patent 68985). Model consists of a brass syringe attached to a wooden cup. In the working instrument the cup would be made of glass. Model does not contain the diaphragm and cutting blades. The novelty was that blades were to be tubular with adjustable length and that they would remain in the skin while blood was being removed. Transferred from the U.S. Patent Office 1926. Overall L 202 mm. Cup: L 47 mm, D 36 mm. Neg. 73-4214 (BW, CS). NMHT 89797 (M-4309). Cupping apparatus with case, late 19th century. Invented by the Drs. W. S. Black and F. Black and manufactured by Wm. B. Stewart, Trenton, New Jersey, this set includes a hard rubber pump, three glass cups, the smallest for cupping the breasts, a valve, and a head for the pump. Missing are a nipple shield and rubber tubing. Case is made of wood and has a label attached to the inside top with an illustration of the set, the title, "Drs. W. S. & F. Black's Combined Cupping Apparatus, Breast Pump, Stomach Pump, Aspirator, Atomizer, Etc., Etc.," the name of the manufacturer, and directions for use. Donated by the Medical and Chirurgical Faculty of Maryland 1976. Case: L 250 mm, W 120 mm, H 78 mm. NMHT 302606.036. Cupping apparatus with case, late 19th century. Another example of the previous all-purpose cupping set with the same pieces and three fragments of rubber tubing. Donated by the Medical and Chirurgical Faculty of Maryland 1976. NMHT 302606.037. BREAST PUMPS Breast pump, patent model, 1879. Patented by William Kennish of Philadelphia (U.S. patent 219738), this breast pump consists of a glass receiver with a hanging glass globe to catch the milk, and a rubber bulb to provide suction. The innovation was the addition of an internal valve and a valve at the bottom of the globe in such a way that continued compression and expansion of the large rubber bulb would cause milk to flow out of the valve at the base of the globe. Transferred from the U.S. Patent Office 1926. L 141 mm. NMHT (M-4343). Breast pump. Glass breast cup with brass fittings and brass pump in a wooden case lined with green felt. Donated by the College of Physicians, Philadelphia, 1958. Cup: L 99 mm, W 72 mm at widest point. Pump: L 88 mm. Case: L 132 mm, W 121 mm, H 82 mm. Neg. 76-7761 (BW, CS). NMHT 220170 (M-7435). (Figure 113.) Breast pump. Glass breast pump with tube for self-suction of the breasts. Tip is broken. Purchased from the Medizinhistorisches Institut, Universität, Zurich, 1960. L 305 mm, H 80 mm. NMHT 232067 (M-9578). Breast pump. Glass breast cup with protuberance for holding milk, attached to a rubber bulb. Top of bulb is stamped "Union India Rubber Co/Goodyear's Patent/New York/1844 & 48." Part of the original cardboard carton is extant. Donated by Mr. and Mrs. Elliston P. Morris 1964. L 205 mm, W of bulb 87 mm. Neg. 76-7762 (BW, CS). NMHT 252497 (M-10510). (Figure 84.) Breast pump. Hand blown breast pump with glass tube for self-suction. Purchased 1965. L 233 mm, W 103 mm at widest point, D 70 mm. Neg. 76-7759 (BW, CS); 76-7760 (BW, CS). NMHT 260557 (M-11467). (Figure 83.) Breast pump, 19th century. Glass breast cup with protuberance for holding milk attached to a vulcanite pump. Purchased 1965. L 242 mm. NMHT 260557 (M-11467.1). Breast pump. Glass cup with "white metal" syringe similar to Meig's Piston Breast Pump that was sold through surgical and pharmaceutical catalogs towards the end of the 19th century. Handle is missing. Donated by George Watson 1968. L 200 mm. NMHT 281244 (M-12343). Breast pump. Another example similar to the one above. Used by Dr. Robert E. Bromwell, Port Deposit, Maryland (d. 1906). Donated by Roberta Craig 1972. L 168 mm, D of bulb 79 mm, D 35 mm. NMHT 299502 (M-14703). _Leeching_ Leeches. Two leeches (Hirudo medicinalis) purchased in 1898, preserved and later mounted in plastic. L of leeches 83 mm. Anthropology vol. 30, catalog no. 143077. Neg. 73-4233 (BW, CS). (Figure 91.) Leech jar, 19th century. White ceramic leech jar typical of jars found in late 19th century pharmacies. Word "leeches" is painted in black with the symbol of medicine below in gold. Top is missing. On loan from Dr. Frederick D. Lascoff 1954. H 242 mm, D 229 mm. Neg. 73-4232 (BW, CS). NMHT 201821 (M-6712). (Figure 114.) Leech jars, 19th century. Elegant pair of tall Staffordshire leech jars. They are light blue, ornamented with gold bordered leaves in relief, and marked "Leeches" in gold on a dark blue decorated panel. Covers are perforated and have flower-shaped finials. Donated by Smith, Kline, and French Laboratories 1965. H 460 mm, D at widest point 215 mm. Neg. 73-4231 (BW, CS). NMHT 263554 (M-11504). (Figure 20.) Leech jar, 19th century. In contrast to the other jars in the Smithsonian collection, this one is small and plain, and perhaps more typical of 19th century leech jars. It is a white ceramic jar shaped like a canister with two knob handles and a perforated lid with its own knob handle. Jar is labeled "Leeches" in black and stamped "Germany" and "IQ" below. Purchased 1976. It was formerly owned by Dr. Sydney N. Blumberg. H 175 mm, D 107 mm. NMHT 1977.0789.43. Leech jars, 19th century. Pair of tall Staffordshire leech jars with royal blue handles and royal blue perforated canopy tops. The jars are decorated with a multi-colored floral design upon a magenta background. Purchased 1976. H 710 mm, W 265 mm. Neg. 76-7765 (BW, CS). NMHT 321697.18-19. (Figure 115.) Lithograph, 1814. Framed colored lithograph dated "London/1814" and titled "Leech Finders." Picture shows three women gathering leeches by a stream. Purchased 1975. W 454 mm, H 363 mm. Neg. 76-7741 (BW, CS). NMHT 320033.08. (Figure 85.) Artificial leech, 19th century. Brass, cylindrical "scarificator" has three pointed blades arranged in a triangle so as to simulate a leech bite. Blades are cocked by pulling on the handle of the device, and released by pushing a small button on the cylinder. Set also includes two small oval glass cups with brass stopcocks and a brass pump, a glass tube with cork lid for collecting blood, and a mass of silvery thread. The use of the thread is uncertain. Case is made of wood covered with red leather and lined with black plush. Unfortunately there are no manufacturer markings or other clues to the provenance of this unusual set. Purchased 1976. "Leech:" L 61 mm, D 20 mm. Pump: L 102 mm. Case: L 155 mm, W 107 mm, H 45 mm. Neg. 76-9120 (BW). NMHT 316478. (Figure 98.) Leech cage, 19th century. Tin, nickel, lead composition. The surface is worn and five holes are punctured in the hinge at one end. Purchased 1976. L 120 mm, H 32 mm, W 31 mm. Neg. 77-13984 (BW, CS). NMHT 1977.0576.02. (Figure 116.) _Veterinary Bloodletting_ FLEAMS NOTE: Widths are measured at the widest point. Fleam, 18th-19th century. Fleam has a brass shield and three fold out blades of different sizes. Donated by M. Lamar Jackson 1932. L 80 mm, W 27 mm. Neg. 73-4206 (BW, CS). NMHT 121573 (M-3462). (Figure 100.) Fleam, 19th century. Fleam has a brass shield, one blade, and a tenaculum (hook). Shield is engraved "Proctor" (manufacturer). Donated by Joseph L. Clough 1947. L 84 mm, W 27 mm. Neg 73-4209 (BW). NMHT 176124 (M-6480). Fleam, 19th century. Fleam has a brass shield, three blades, and a knife. Donated by the University of Pennsylvania 1959. L 81 mm, W 25 mm. Neg. 61125-A (BW). NMHT 218383 (M-9255). (Figure 117.) Fleam, 19th century. Fleam has a brass shield and three blades, each marked with a crown denoting British manufacture and a "W." Said to have been made in Sheffield, England. Purchased 1960. L 97 mm, W 33 mm. Neg. 59139-H (BW), case open, blades displayed; 59139-G (BW), case closed. NMHT 233570 (M-9665). (Figure 118.) Fleam, 17th or 18th century. Hand-made curved bar with projecting blade, described by seller as Swiss or Tyrolean. Case is wooden and hand-carved. It is not clear whether this fleam was used for human or for animal bloodletting. Purchased 1960. Fleam: L 129 mm. Case: L 146 mm, W 47 mm at widest point. Neg. 59139-E (BW). NMHT 233570 (M-9666). (Figure 42.) NOTE: There are two interesting early fleams in the Medical Historical Collection of Zurich University. One has a plain wooden handle and one has a turned metal handle with a metal extension. Fleam, 19th century. Fleam has a horn shield and three blades. The first blade is stamped "Borwick," an English manufacturer. Purchased 1964. L 82 mm, W 28 mm. NMHT 254866 (M-10696). Fleam, 19th century. Fleam has a brass shield and two blades. First blade is stamped "Harmer & Co's/Cast Steel Fleams/Sheffield." Donated by H. J. Hopp 1970. L 82 mm, W 27 mm. NMHT 291361 (M-13828). Fleam, 19th century. Fleam has brass shield and three blades. First blade is stamped "W. Harmar & Co. Cast Steel fleams Sheffield." Purchased 1976. L 80 mm, W 27 mm. NMHT 321697.24. Fleam, 18th century. Five-bladed fleam said to have been made in Denmark. Instrument appears to be hand-made. Brass shield has a hinged piece covering the blades that is held closed by a brass latch. Purchased 1976. L 89 mm, W 30 mm, H 17 mm. NMHT 321697.16. Fleam with case, 19th century. Fleam has a brass shield and three blades, engraved with a "W" over the name "Pepys." Fitted leather case. Purchased 1976. Fleam: L 102 mm, W 40 mm. NMHT 321697.03. Fleam with case, 19th century. Fleam has a brass shield, two blades, and a knife. Fitted leather case. Purchased 1976. L 94 mm, W 26 mm. NMHT 321697.04. Fleam with case, 19th century. Fleam has a horn shield, two blades, and is engraved "Green & Pickslay." Fitted black leather case. Purchased 1976. L 100 mm, W 32 mm. Neg. 76-7758 (BW, CS). NMHT 321697.05. (Figure 101.) Fleam with case, 19th century. Fleam has a brass shield and four blades. Fitted leather case. Owner's name, "C. Famell Isleworth[?]," is written in ink on the case. Purchased 1976. L 79 mm, W 27 mm. NMHT 321697.06. Fleam, 19th century. Brass shield, four blades, and one hook. Purchased 1976. L 122 mm, W 30 mm, W with pocket for hook 15 mm. NMHT 1977.0789.17. Fleam, 19th century. Brass shield with five blades. An arrow is stamped on one side of the shield. Purchased 1976. L 88 mm, W 27 mm. NMHT 1977.0789.18. Fleam, 19th century. Brass shield with three different sized blades. Case is inscribed "Gorham Parsons, Byfield." Purchased 1976. L 88 mm, W 30 mm. NMHT 1977.0789.19. Fleam, 19th century. Brass case with three different sized blades. Purchased 1976. L 82 mm, W 26 mm. NMHT 1977.0789.20. Fleam, 19th century. Brass shield with five blades and one hook. On one side of the case appears indistinctly, "HOW: IN London" on each of the blades except the straight blade and the hook. Purchased 1976. L 85 mm, W 23 mm. NMHT 1977.0789.21. Fleam, 19th century. Five blades in a brass case. On two of the blades appears "How: in LONDON." Purchased 1976. L 80 mm, W 22 mm. NMHT 1977.0789.23. Fleam with case, 19th century. Four blades in brass case. Purchased 1976. L 95 mm, W 25 mm. NMHT 1977.0789.22. Fleam, 19th century. Brass case with three blades. Purchased 1976. L 94 mm, W 32 mm. NMHT 1977.0789.25. Fleam, 19th century. Three blades in brass case. Purchased 1976. L 83 mm, W 29 mm. NMHT 1977.0789.26. Fleam, 19th century. Single blade in brass case. On blade is marked "ARNOLD & SONS LONDON." Purchased 1976. L 98 mm, W 38 mm. NMHT 1977.0789.27. Fleam, 19th century. Fleam has a horn shield and two blades engraved "J & S Maw/London." Horn shield is broken on one side, and has openings for a thumb lancet on each side. Only one thumb lancet with tortoise shell shield remains. Purchased 1976. L 84 mm, W 28 mm. NMHT 321697.12. Fleam, 19th century. Fleam has a horn shield and three blades. Purchased 1976. L 83 mm, W 26 mm. NMHT 321697.13. Fleam, 19th century. Fleam has a horn shield and three blades; "G. Gregory Cast Steel." Purchased 1976. L 87 mm, W 31 mm. NMHT 321697.14. Fleam, 19th century. Fleam has a horn shield and one blade. Blade is engraved "Arnold and Sons/Smithfield." Purchased 1976. L 97 mm, W 37 mm. NMHT 321697.15. Fleam, 19th century. Fleam has a horn shield, two blades, and is engraved "Borwick." Purchased 1976. L 82 mm, W 27 mm. NMHT 321697.16. SPRING LANCETS Spring lancet, patent model, 1849. Lancet is brass and oval shaped. A wheel and axle mechanism allows the blade to sweep out an elliptical curve. Lancet is set by a detachable key and released by a lever protruding from the side. Lever is missing or hidden inside the case and the mechanism is frozen. Patented in 1849 by Joseph Ives of Bristol, Connecticut (U.S. patent 6240). Transferred from the U.S. Patent Office 1926. L 97 mm, W 33 mm, H 14 mm. Neg. 73-4211 (BW, CS). NMHT 89797 (M-4292). (Figure 23.) Spring lancet, patent model, 1880. Instrument is made of brass and shaped like a gun. The cocking lever is attached to both a coiled spring in the handle of the gun and an extension of the blade. Pushing the trigger injects the blade. Blade is dart form with double beveled edges, as was typical of veterinary fleams. Patented by Hermann Reinhold and August Schreiber of Davenport, Iowa (U.S. patent 236084). Transferred from the U.S. Patent Office 1926. L 105 mm (to tip of blade), H 77 mm. Neg. 73-4210 (BW, CS). NMHT 89797 (M-4327). (Figure 24.) Spring lancet with case, 19th century. Brass knob end lancet, a larger version of the spring lancet used in human phlebotomy. Case is also similar to the spring lancet cases for human use. It is made of wood covered with brown leather, lined with chamois, and closed by a latch. Case has a chalice decoration on top. Donated by Dr. A. J. Olmstead 1945. Lancet: L 74 mm, W 38 mm. Case: L 133 mm, W 60 mm, H 33 mm. NMHT 171080 (M-6418). Spring lancet, 19th century. Veterinary lancet similar to the previous lancet except that the blade is larger and provided with a blade guard. Blade guard can be set by a screw in order to regulate the size of the blade. Stamped on back panel is "F. Leypoldt/Phila." This is presumably the same Frederick Leypoldt who patented two scarificators, one in 1847 and one in 1851. Donated by the University of Pennsylvania 1959. L 74 mm, W 34 mm. Neg. 76-7757 (BW, CS), compares lancet to one used in human phlebotomy, NMHT 218383 (M-9256). (Figure 22.) Spring lancet with case, 19th century. Brass knob end lancet with large blade and blade guard. Lancet has a rim around the top and a lever release molded to resemble a torch. Case is lined with black plush and covered with black cloth. Purchased 1976. Lancet: L 85 mm (not including blade), W 40 mm. Case: L 142 mm, W 78 mm, H 39 mm. NMHT 316478. Spring lancet with case, 19th century. Instrument is made of brass and has a ball-shaped handle. The blade is double beveled, typical of blades for veterinary bleeders. The ball handle contains a spring that is attached to a small projecting cylinder with string tied to it. By pulling on the string, one can pull the blade in, and by pushing a button one can inject the blade. Case is made of wood covered with leather and is coffin-shaped. Purchased 1976. L 95 mm (to tip of blade), D of ball 34 mm. Neg. 76-7750 (BW, CS). NMHT 321697.07. (Figure 104.) Spring lancet with case, 19th century. Lancet is brass and has a triangular shape. It is triggered by a slide catch on the front of the instrument. The triggering handle is a detachable piece that lifts off a square peg. Hinged from the side is a curved piece for ease in holding. Screw on front of the instrument probably regulates blade depth and a rectangular button at the top corner probably releases the blade. Mechanism is jammed and the blade is hidden within the instrument. Only the bottom half of the case remains. Purchase 1976. L 83 mm, W 59 mm. Neg. 76-7756 (BW, CS). NMHT 321697.08. (Figure 119.) Spring lancet, late 18th-early 19th century. Triangular-shaped lancet made of brass and iron and decorated with a floral design. Blade (missing) is attached to an iron lever, which, when pulled back, is held in place by a lever with ratchets attached to the facing side of the instrument. Pressing upon this same lever releases the ratchets and injects the blade. Purchased 1976. H 97 mm, W 80 mm. Neg. 76-7755 (BW, CS). NMHT 321697.09. (Figure 120.) Spring lancet with case, 18th century. This rather elegant lancet consists of a body and a detachable handle. According to analysis by the Conservation Laboratory, the lancet is made of ferrous metal (iron or steel). Blade is screwed into a curved lever. Pulling upon the handle pulls back the lever with the blade, and releasing the handle releases the blade. Case is made of wood, covered with black leather and lined with green silk and green plush. Seller says that the lancet was made in England, ca. 1700. This date seems somewhat too early. Purchased 1976. H 112 mm, W 72 mm (to tip of blade). Neg. 76-7753 (BW, CS). NMHT 321697.10. (Figure 121.) Spring lancet, 19th century. Instrument is made of brass and has an odd, irregularly curved shape. A large blade with a blade guard protrudes from the side. Blade is triggered by an iron slide catch on the front of the instrument and released by a brass lever release similar to that found in knob end lancets. Purchased 1976. L 138 mm, W 82 mm (to tip of blade). Neg. 76-7754 (BW, CS). NMHT 321697.11. (Figure 103.) Spring lancet, 19th century. Instrument is made of brass with steel screws. It is inscribed on one side: "Weiss improved bleeding instrument 33 Strand London." There is a brass guard on the blade that can be moved along the blade by a screw attached directly opposite the blade. It fits into a red leather case with beige velvet lining. The case closes with two brass hooks. Purchased 1976. Case: L 92 mm, W 75 mm. Height without lever 66 mm, Width at widest point 64 mm, overall width 12 mm. Neg. 77-13961 (BW, CS). NMHT 1977.0576.01. (Figure 122.) _Related Artifacts_ Counter-irritation device, patent model, 1860. Improved version of Baunscheidt's _Lebenswecker_ patented by Alfred Stauch of Philadelphia (U.S. patent no. 28697). Stauch added a brush around the needles and an additional spring to force the needles back after they had entered the skin. The brush could be oiled before the operation, thus saving the need to oil the wound afterwards. The device is similar to the _Lebenswecker_ in size and construction, except that it was made of a lighter colored wood and was trimmed in brass. Transferred from the U.S. Patent Office 1926. L 245 mm, D 20 mm. Neg. 72-11290 (BW). NMHT 89797 (M-4299). Counter-irritation device, patent model, 1866. Patented by Friederich Klee of Williamsburg, New York (U.S. Patent 55775), this instrument is another modification of Baunscheidt's _Lebenswecker_. It is made of wood and brass, and is much shorter than the _Lebenswecker_ but operated in the same manner. A screw on the handle served to regulate the length of the needles. A further innovation was the addition of a diaphragm of leather through which the needles pass. The leather could be saturated with oil before the operation, thus again saving the need to apply oil afterwards. Transferred from the U.S. Patent Office 1926. L 92 mm. Neg. 72-11274. NMHT 89797 (M-4305). (Figure 123.) Barber-surgeon's kit, late 18th-early 19th century. Kit includes a teakettle lamp (M-6991), a deck of playing cards to amuse customers, four standard glass cupping cups (M-6686), two scarificators (M-6687, M-6688), two rectangular spring lancets in a case (M-6689), a dental kit, a barber kit, a tourniquet (M-6692), and a comb. Scarificators are both 16 blade square models. One is unusual in that only the bottom is detachable as in octagonal scarificators. The spring lancets are of an unusual shape, with straight edges and curved tops and bottoms. Donated by Mrs. Frank J. Delinger, Jr., through Mrs. Paul J. Delinger, 1953. Lamp: D of base 65 mm, W 145 mm, H 95 mm. Spring lancets: L 49 mm, W 18 mm. Tourniquet: L 1260 mm, W 35 mm. Neg. 73-4207, entire kit plus barber's basin (NMHT 225114 [M-9399]), which is not part of kit; 73-4225, cups; 73-4219, two scarificators; 73-4221, dental set; 73-4222, barber set; 73-4223, deck of cards; 73-4224, tourniquet; 73-4234, set of spring lancets; 73-4218, teakettle lamp. All negatives BW, CS. NMHT 199536 (M-6684 to M-6693). Barber-surgeon's sign (replica). Reproduction of a 1623 barber-surgeon's sign (original is in Wellcome Medical Museum) illustrating the various specialties of the barber-surgeon of the period. Phlebotomy is shown in the upper right hand corner. Made by Richard Dendy of London and donated by him 1958. L 724 mm, W 624 mm. Neg. 44681 (BW). NMHT 215690 (M-7343). (Figure 32.) Greek votive tablet (replica). Reproduction of a Greek votive tablet found on the site of the Temple of Aesculapius. The original is in the Athens Museum. Illustrated are two metal cupping cups and a case containing six scalpels. Replica made by Dorothy Briggs of the Smithsonian Institution 1960. W 400 mm, H 295 mm, Thickness 30 mm. Neg. 73-4217 (BW, CS). NMHT 233055 (M-9617). (See Figure 54.) Greek vase (replica). Reproduction of a small Greek vase depicting a 5th century B.C. medical "clinic," including a Greek physician bleeding a patient. Original is in the Louvre. Made by Dorothy Briggs of the Smithsonian Institution 1960. H 85 mm, W 75 mm. Neg. 73-4216 (BW, CS); 73-4216-A (CS), red background. NMHT 233055 (M-9618). (Figure 26.) Bloodletting manikin, 15th century. Pen and ink drawing in black and red inks on a folded sheet of paper with the watermark "Ochsenkapf mit Krone" reportedly made in Southern Germany in 1480. The paper is backed at the fold by a piece of vellum. Drawing is of a man with astrological signs and instructions in German in balloons pointing at 25 points of his body, of which 4 are symmetrical. Such a drawing used in conjunction with a dial would be used to determine when and where to bleed. On the reverse are astronomical tables. According to analysis by the Conservation Laboratory at the Smithsonian, the paper might well date from the 15th century and the ink has been applied at various times. Purchased 1962. L 310 mm, W 225 mm. Neg. 76-13536 (BW). NMHT 243033 (M-10288). Surgeon's kit, late 18th century. Revolutionary War surgeon's kit includes a leather case with brass handle, three pewter cupping cups, a spring lancet, syringe, two trocars, knife, probe, and scraper. There is space for two other missing instruments, one of which may have been a scarificator. Lancet has an unusual boot shape and is decorated with a floral design. It is made of brass and has a steel lever release. Purchased 1969. Neg. 73-4237-A (CS). NMHT 285125 (M-12352). Baunscheidt's _Lebenswecker_, mid 19th-early 20th century. Carl Baunscheidt of Bonn exhibited his _Lebenswecker_ ("Life Awakener") at the Great Exhibition in London in 1851. It consists of a long hollow tube made of ebony and containing a coiled spring attached to a handle. A cap covers a plate with some thirty sharp needles. Pushing upon the handle injects the needles into the skin. The devise was used with Baunscheidt's special oil, which was applied to the skin after the needles had irritated it. Donated by Grace Sutherland 1970. L 250 mm, W 30 mm. Neg. 76-7751 (BW). NMHT 287885 (M-12936). (Figure 79.) Baunscheidt's _Lebenswecker_, mid 19th-early 20th century. Another example of the previous instrument. Donated by Mrs. William F. Press 1970. L 245 mm, W 20 mm, H 25 mm. NMHT 290304 (M-13832). Baunscheidt's _Lebenswecker_, mid 19th-early 20th century. Another example of the previous instruments. Purchased 1976. NMHT 1977.0789. Alcohol lamp, late 19th-early 20th century. Glass lamp with glass cap and cotton wick, used in exhausting air from cups. Used by Dr. F. L. Orsinger of Chicago (1852-1925). Donated by Dr. William H. Orsinger 1973. H 100 mm, D 83 mm. Neg. 74-4086 (BW, CW). NMHT 308730.08. Junod's boot, 19th-early 20th century. Copper boot first introduced by Victor-Theodore Junod in the 1830s. The boot fits tightly about the foot and air is exhausted from it by means of a pump. John S. Billings described the boot as "An apparatus for enclosing a limb, and from which air can be exhausted so as to produce the effect of a large cupping glass." (_The National Medical Dictionary._ Philadelphia, 1890 p. 732.) On loan from the Armed Forces Institute of Pathology. L 280 mm, H 430 mm. Neg. 73-7885 (BW). (Figure 81.) Barber pole, ca. 1890-1900. This small, red, white, and blue striped pole, with a newel post and no globe on the top, was used in Binghamton, New York. The colors are faded into an orange and tan color. Purchased 1974. Pole L 2600 mm, W at widest point 900 mm. NMHT 312616. Barber pole, ca. 1920. A red, white, and blue striped pole full size. It has a silver wooden top. It was used in New Jersey. Pole: L 63 mm, W at widest point 20 mm. Top: L 33 mm. Gift of H. E. Green. NMHT 322,655.01. Footnotes: [A] _Audrey Davis, Department of History of Science, National Museum of History and Technology, Smithsonian Institution, Washington, D.C. 20560. Toby Appel, Charles Willson Peale Papers, National Portrait Gallery, Smithsonian Institution, Washington, D.C. 20560._ [B] "White metal" is the technical term for an undetermined silver colored metal alloy. See discussion of materials at beginning of index. NOTES [1] Julius Gurlt's bibliographical essay on bloodletting, originally published in 1898, is a prime source for tracing in detail the specific contributions of European and Asian authors in the ancient, medieval, and Renaissance periods. See JULIUS GURLT, _Geschichte der Chirurgie und ihrer Ausuebung_ (Hildesheim: Georg Olms, 1964), volume 3, page 556-565. [2] GEORGE F. KNOX, _The Art of Cupping_ (London, 1836), page 30. [3] For a general history of bloodletting, see TOWNSEND W. THORNDIKE, "A History of Bleeding and Leeching," _British Medical and Surgical Journal_, volume 197, number 12 (September 1927), pages 437-477. For a detailed account of ancient bloodletting, see RUDOLPH SIEGEL, "Galen's Concept of Bloodletting in Relation to His Ideas on Pulmonary and Peripheral Blood Flow and Blood Formation" (chapter 19 in volume 1 of _Science, Medicine and Society in the Renaissance_ edited by Allen Debus, New York: Science History Publications, 1973), pages 247-275. [4] ROBERT MONTRAVILLE GREEN, "A Translation of Galen's Temperaments and Venesection" (manuscript, Yale Medical Library, New Haven, Connecticut), page 102. [5] Ibid., page ii-iv. [6] CELSUS, _De Medicina_, translated by W. G. Spencer (Cambridge: Harvard University Press, 1960), volume 1, book 2, page 155. [7] HENRY E. SIGERIST, _A History of Medicine_ (New York: Oxford University Press, 1961), volume II, pages 317-335. [8] GREEN, op. cit. [note 4], page 105. [9] PETER H. NIEBYL, "Galen, Van Helmont and Blood Letting," (chapter 21 in volume 2 of _Science, Medicine and Society in the Renaissance_ edited by Allen Debus, New York: Science History Publications, 1972); PETER NIEBYL, "Venesection and the Concept of the Foreign Body: A Historical Study in the Therapeutic Consequences of Humoral and Traumatic Consequences of Diseases" (doctoral dissertation, Yale University, 1969), page 156. [10] GREEN, op. cit. [note 4], page 171. [11] Ibid., page 114. [12] Ibid., page 173. [13] Ibid., pages 174, 180. [14] CELSUS, op. cit. [note 6], page 163. [15] CHARLES H. TALBOT, _Medicine in Medieval England_ (London: Oldbourne, 1967), pages 127-131. [16] CHARLES D. O'MALLEY, _Andreas Vesalius of Brussels 1514-1564_ (Berkeley and Los Angeles: University of California Press, 1964), pages 66-67. [17] See, for example, M. DAVID, _Recherches sur la manière d'agir de la saignée et sur les effets qu'elle produit relativement à la partie ou on la fait_ (Paris, 1762), page iv. [18] LORENZ HEISTER, _Chirurgie, in welcher alles, was zur wund artzney gehöret ..._ (Nuremberg, 1719). [19] GREEN, op. cit. [note 4], page 179. [20] JOSEPH T. SMITH, SR., "An Historical Sketch of Bloodletting," _Johns Hopkins Hospital Bulletin_, volume 21 (1910), page 312. [21] MARSHALL HALL, _Observations on Bloodletting Founded upon Researches on the Morbid and Curative Effects of Loss of Blood_ (London, 1836), page 280. [22] ROBLEY DUNGLISON, _Medical Lexicon--A Dictionary of Medical Science_ (Philadelphia, 1848), page 820. [23] JAMES E. BOWMAN, "Blood," _Encyclopaedia Britannica_ (Chicago: William Benton, 1972), volume 34, pages 795-800. [24] GREEN, op. cit. [note 4], page 187. [25] KARL SUDHOFF, _Deutsche medizinische Inkunabeln_ (Leipzig, 1908); Studien zur Geschichte der Medizin heft 2/3. SIR WILLIAM OSLER, _Incunabula Medica: A Study of the Earliest Printed Medical Books, 1467-1480_ (Oxford: Oxford University Press, 1923). [26] FRANCISCO GUERRA, "Medical Almanacs of the American Colonial Period," _Journal of the History of Medicine and Allied Sciences_, volume 16 (1961), pages 235-237. The number of veins illustrated in the vein man varied a great deal but became fewer after the seventeenth century. [27] TALBOT, op. cit. [note 15], pages 127-131. [28] GUERRA, op. cit. [note 26], pages 237; MARION BARBER STOWELL, _Early American Almanacs: The Colonial Weekday Bible_ (New York: Burt Franklin, 1977). The latter work contains numerous illustrations of "anatomies" from colonial almanacs. [29] "Original Letters," General William F. Gordon to Thomas Walker Gilmar, 11 December 1832, _William and Mary Quarterly_, volume 21 (July 1912), page 67. [30] TALBOT, op. cit. [note 15], pages 50, 51. For another view of the religious impact upon medieval medical and surgical practices, see JAMES J. WALSH, _The Popes and Science_ (New York: Fordham University Press, 1908), pages 167-198. [31] THORNDIKE, op. cit. [note 3], page 477. [32] MIGUEL DE CERVANTES SAAVEDRA, _Don Quixote de la Mancha_, translated by Walter Starkie (New York: Mentor, 1963), pages 91, 92. [33] CHARLES ALVERSON, "Surgeon Abel's Exotic Bleeding Bowls," _Prism_, volume 2 (July 1974), pages 16-18; JOHN K. CRELLIN, "Medical Ceramics," in _A Catalogue of the English and Dutch Collections in the Museum of the Wellcome Institute of the History of Medicine_ (London: Wellcome Institute of the History of Medicine, 1969), pages 273-279. [34] THORNDIKE, op. cit. [note 3], page 477; CAREY P. MCCORD, "Bloodletting and Bandaging," _Archives Environmental Health_, volume 20 (April 1970), pages 551-553. [35] LEO ZIMMERMAN and VEITH ILZA, _Great Ideas in the History of Surgery_ (New York: Dover Books, 1967), page 126. [36] WILLIAM HARVEY, _Works_, edited by Robert Willis (London: Sydenham Society, 1847), page 129. Harvey reaffirmed later: "I imagine that I shall perform a task not less new and useful than agreeable to philosophers and medical men, if I here briefly discourse of the causes and uses of the circulation, and expose other obscure matters respecting the blood" (page 381). [37] HENRY STUBBE, _The Lord Bacons Relation of the Sweating-Sickness Examined ... Together with a Defense of Phlebotomy ..._ (London, 1671), page 102. [38] FIELDING H. GARRISON, "The History of Bloodletting," _New York Medical Journal_, volume 97 (1913), page 499. Magendie was firmly opposed to bloodletting and ordered physicians working under him not to bleed. However, their belief in the practice was so strong that they disobeyed his instructions and carried out the procedure. See ERWIN ACKERKNECHT, _Therapeutics from the Primitives to the 20th Century_ (New York: Hafner, 1973), pages 111-112. [39] AUDREY B. DAVIS, _Circulation Physiology and Medical Chemistry in England, 1650-1680_ (Lawrence, Kansas: Coronado Press, 1973), pages 135, 167, 219. For the history of injecting remedies into the blood, see HORACE M. BROWN, "The Beginnings of Intravenous Medication," _Annals of Medical History_, volume 1 (1917), page 182. [40] ARTURO CASTIGLIONI, _A History of Medicine_, translated from Italian by E. B. Krumbhar, 2nd edition, revised and enlarged (New York: Alfred A. Knopf, 1958), page 444; NIEBYL, "Venesection" [note 9], page 414. [41] JOAN LILLICO, "Primitive Bloodletting," _Annals of Medical History_, volume II (1940), page 137. [42] C.J.S. THOMPSON, _Guide to the Surgical Instruments and Objects in the Historical Series with Their History and Development_ (London: Taylor and Francis, 1929), page 40. [43] JOHN STEWART MILNE, _Surgical Instruments in Greek and Roman Times_ (New York: Augustus M. Kelley, 1970), reprint of 1907 edition, pages 32-35. A bronze knife of this type is illustrated in THEODOR MEYER-STEINEG, _Chirurgische Instrumente des Altertum_ (Jena: Gustav Fischer, 1912), page iv, figure 9. The instrument was donated by Dr. Nylin of the Kardinska Institute in Stockholm, who used a lancet until 1940. Replicas of the early bronze medical instruments were sold in 1884 by Professor Francesco Scalzi of Rome. He exhibited 45 of them at the Exposition Universelle de Paris in 1878. He won an honorable mention award, "Collezione di Istrumenti Chirurgici de Roma Antica," 1884. [44] S. HOLTH, "Greco-Roman and Arabic Bronze Instruments and Their Medico-Surgical Use," _Skriften utgit an Videnskapsselskapet I Kristrania_ (1919), page 1 (below). Holth lists the content of lead, tin, zinc, iron, copper, and cobalt found in a number of ancient bronze medical items in his collection, which formerly belonged to Baron Ustinov of Russia. These instruments were unearthed in Syria and Palestine from 1872 to 1890. [45] An occasional curious item like the spring lancet on display in the Welch Medical Library of the Johns Hopkins University is an exception. [46] MILNE, op cit. [note 43], pages 35-36. [47] LAURENCE HEISTER, _A General System of Surgery in Three Parts_, translated into English (London, 1759), 7th edition, page 294. [48] GURLT, op. cit. [note 1], volume III, page 558. [49] G. GAUJOT and E. SPILLMAN, _Arsenal de la Chirurgie Contemporaine_ (Paris: J. B. Bailliere et fils, 1872), pages 274-276. [50] MILNE, op. cit. [note 43], page 33. [51] GARRISON, op. cit. [note 38], page 433. [52] SIR WILLIAM FERGUSON, _Lectures on the Progress of Anatomy and Surgery during the Present Century_ (London: John Churchill & Sons, 1867), page 284. [53] JAMES EWELL, _The Medical Companion_ (Philadelphia, 1816), pages 405, 406. [54] For an illustration of incisions, see HEISTER, (1759), op. cit. [note 47]. [55] MILNE, op. cit. [note 43], page 36. [56] GURLT, op. cit. [note 1], volume III, page 556. [57] P. Hamonic describes an eighteenth-century Naples porcelain figure of a woman being bled that illustrates the elegant manner in which the operation was performed. P. HAMONIC, _La Chirurgie et la medécine d'autrefois d'aprés une première série d'instruments anciens renfermes dans mes collections_ (Paris: A. Maloine, ed., 1900), pages 91, 93. [58] THOMAS DICKSON, _A Treatise on Bloodletting with an Introduction Recommending a Review of the Materia Medica_ (London, 1765), page 1. [59] SIR D'ARCY POWER, editor, _British Medical Societies_ (London: The Medical Press Circular, 1939), page 23. [60] Wakeley was a heretic wealthy doctor who led the campaign in Britain against the monopoly of surgical training and practice held by the Royal College of Surgeons of London. ALAN ARNOLD KLASS, _There's Gold in "Them Thar Pills"_ (Baltimore: Penguin Books, 1975), pages 158-159. [61] JOHN HARVEY POWELL, _Bring Out Your Dead_ (Philadelphia: University of Pennsylvania Press, 1949), page 123. [62] See, e.g., RICHARD SHRYOCK, _Medicine and Society in America: 1660-1860_ (New York: New York University Press, 1960), pages 67, 111-112. [63] JAMES T. FLEXNER, _George Washington: Anguish and Farewell_ (Boston: Little, Brown, 1972), pages 457-459. [64] BARBARA DUNCUM, _The Development of Inhalation Anesthesia_ (The Wellcome Historical Medical Museum, Oxford University Press, 1947), page 195. [65] HAMONIC, op. cit. [note 57], pages 95-96. [66] DONALD D. SHIRA, "Phlebotomy Lancet," _Ohio State Medical Journal_, volume 35 (1939), page 67. [67] HEISTER, (1719) loc. cit. [note 18]. [68] _Encyclopedia or Dictionary of the Arts and Sciences_, 1st American edition (Philadelphia, 1798). [69] RISTELHUEBER, "Notice: sur la flammette, phlébotome des Allemands, Fliete, Schnepper oder gefederte Fliete, phlebotomus elasticus, Flamme ou flammette," _Journal de Médecine, chirurgie et pharmacologie_, volume 37 (Paris, 1816), pages 9-17. [70] JOHN SYNG DORSEY, _Elements of Surgery: For the Use of Students_, volume 2 (Philadelphia, 1813), pages 279-281. [71] Patent specifications, U.S. patent 16479. [72] M. MALGAIGNE, "Esquisse historique sur la saignée considérée au point de vue opératoire; extrait des leçons du Professeur Malgaigne," _Revue Medico Chirurgicale de Paris_, volume 9 (1851), page 123. [73] GARRISON, op. cit. [note 38], page 501. [74] Some of these studies are cited in B. M. RANDOLPH, "The Bloodletting Controversy in the Nineteenth Century," _Annals of Medical History_, volume 7 (1935), page 181. [75] Quotation cited by LESTER S. KING, "The Blood-letting Controversy: A Study in the Scientific Method," _Bulletin of the History of Medicine_, volume 35 (1961), page 2. [76] MARTIN KAUFMANN, _Homeopathy in America_ (Baltimore: Johns Hopkins Press, 1971), pages 1-14. Other references on the decline of bloodletting include: LEON S. BRYAN, JR., "Blood-letting in American Medicine, 1830-1892," _Bulletin of the History of Medicine_, volume 38 (1964), pages 516-529; B. M. RANDOLPH, op. cit. [note 74], pages 177-182; JAMES POLK MORRIS, "The Decline of Bleeding in America, 1830-1865" (manuscript, Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, Texas), 11 pages. [77] HENRY I. BOWDITCH, _Venesection, Its Abuse Formerly--Its Neglect at the Present Day_ (Boston: David Clapp & Son, 1872), pages 5, 6. [78] W. MITCHELL CLARKE, "On the History of Bleeding, and Its Disuse in Modern Practice," _The British Medical Journal_ (July 1875), page 67. [79] HENRY LAFLEUR, "Venesection in Cardiac and Arterial Disease," _The Johns Hopkins Hospital Bulletin_, volume 2 (1891), pages 112-114. [80] See, for example, JOHN REID, _"Bleeding," Essays on Hypochondriasis and Other Nervous Affections_ (London, 1821), essay 22 page 334. [81] AUSTIN FLINT, _A Treatise on the Principles and Practice of Medicine_, 3rd edition (Philadelphia, 1868), page 150. [82] MARTIN DUKE, "Arteriosclerotic Heart Disease, Polychthenic and Phlebotomy--Rediscovered," _Rhode Island Medical Journal_, volume 48 (1965), page 477. [83] SAMUEL LEVINE, Editorial, "Phlebotomy, An Ancient Procedure Turning Modern?," _Journal of the American Medical Association_ (January 26, 1963), page 280. [84] GEORGE BURCH and N. P. DEPASQUALE, "Phlebotomy Use in Patients with Erythrocytosis and Ischemic Heart Disease," _Archives of Internal Medicine_, volume 3 (June 1963), pages 687-695. See also GEORGE BURCH and N. P. DEPASQUALE, "Hematocrit, Viscosity and Coronary Blood Flow," _Diseases of the Chest_, volume 48 (September 1965), pages 225-232. [85] HEINRICH STERN, "A Venepuncture Trocar (Stern's Trocar)," _Medical Record_ (December 1905), pages 1043, 1044. [86] DELAVAN V. HOLMAN, "Venesection, Before Harvey and After," _Bulletin New York Academy of Medicine_, volume 31 (September 1955), pages 662, 664. [87] SAMUEL BAYFIELD, _A Treatise on Practical Cupping_ (London, 1823), page 11. [88] CELSUS, _De Medicina_, op. cit. [note 6], page 169. For bibliography on cupping, see WILLIAM BROCKBANK, _Ancient Therapeutic Arts_ (London: William Heinemann, 1954); JOHN HALLER, "The Glass Leech: Wet and Dry Cupping Practices in the Nineteenth Century," _New York State Journal of Medicine_ (1973), pages 583-592; BROCHIN, "Ventouses," _Dictionnaire encyclopédique des sciences médicales_, series 5, volume 2 (1886), pages 750-752; and, the _Index Catalogue of the Library of the Surgeon-General's Office, U.S. Army_. [89] HIPPOCRATES, _Aphorisms_, V, page 50. [90] THOMAS MAPLESON, _A Treatise on the Art of Cupping_ (London, 1813), opposite page 1. [91] GURLT, op. cit. [note 1], volume 3, page 151. [92] CHARLES COURY, "Saignées, ventouses et cautérisations dans le médecine orientale à l'époque de la Renaissance," _Histoire de la médecine_, volume 11 (November-December 1961), pages 9-23. [93] W. A. GILLESPIE, "Remarks on the Operation of Cupping, and the Instruments Best Adapted to Country Practice," _Boston Medical and Surgical Journal_, volume 10 (1834), page 28. [94] Letter from Rev. Robert Richards to Dr. Sami Hamarneh, 1 September 1966 (Division of Medical Sciences, Museum of History and Technology). [95] On ancient cups, see CELSUS, op. cit. [note 6], pages 165-167; MILNE, op. cit. [note 43], pages 101-105 and plates; and BROCKBANK, op. cit. [note 88], pages 65-72. The Institute of the History of Medicine, Johns Hopkins University, has several metal cups dating from about A.D. 100. [96] CASTIGLIONI, op. cit. [note 40], page 380. [97] PIERRE DIONIS, _Cours d'opérations de chirurgie demonstrées au Jardin Royal_ (Paris, 1708), page 584. [98] R�N� JACQUES CROISSANTE DE GARENGEOT, _Nouveau Traité des Instrumens de Chirurgie les plus utiles_ (The Hague, 1725), page 342. [99] DIONIS, op. cit. [note 97], page 585. [100] MAPLESON, op. cit. [note 90], pages 27-28. See also GEORGE FREDERICK KNOX, op. cit. [note 2], page 29. [101] MAPLESON, op. cit. [note 90]; BAYFIELD, op. cit. [note 87]; KNOX, op. cit. [note 2]; and MONSON HILLS, "A Short Treatise on the Operation of Cupping," _Boston Medical and Surgical Journal_, volume 9 (1834), pages 261-273. [102] KNOX, op. cit. [note 2], page vi. [103] BAYFIELD, op. cit. [note 87], page 125. [104] DIONIS, op. cit. [note 97], page 587 and figure 57 on page 583. [105] KNOX, op. cit. [note 2], page 33. [106] JOHN H. SAVIGNY, _A Collection of Engravings representing the Most Modern and Approved Instruments Used in the Practice of Surgery_ (London, 1798), plate 7. For the earlier grease lamp, see J. A. BRAMBILLA, _Instrumentarium Chirurgicum Viennense oder Wiennerliche Chirurgische Instrumenten Sammlung_ (Vienna, 1780), plate 2. [107] BAYFIELD, op. cit. [note 87], page 123; KNOX, op. cit. [note 2], page 33; HILLS, op. cit. [note 101], page 263. [108] See DIONIS, op. cit. [note 97], page 587 and figure 58 on page 583; and LAURENCE HEISTER, op. cit. [note 47], page 329 and plate 12. The parallel incisions were described in antiquity by Oribasius (ca. A.D. 360), the most important medical author after Galen and the friend of the emperor Julian. See GURLT, op. cit. [note 1], volume 3, page 563. [109] AMBROISE PAR�, _The Collected Works of Ambroise Paré_, translated by Thomas Johnson (London, 1634). Reprint edition (Pound Ridge, New York: Milford House, 1968), page 446. The drawing first appeared in Paré's treatise "Methode de traiter des playes de la teste" in 1561. [110] PAULUS AEGINETA, _Medicinae Totius enchiridion_ (Basileae, 1541), page 460. [111] ALBERT WILHELM HERMANN SEERIG, _Armamentarium chirurgicum oder möglichst vollständige Sammlung von Abbildungen und Beschreibung Chirurgischer Instrument alterer und neuerer Zeit_ (Breslau, 1838), page 598. [112] JACQUES DELECHEMPS, _Chirurgie Françoise Recueillie_ (Lyon, 1564, page 174); HELLKIAH CROOKE. _Micrographia: A Description of the Body of Men ... with an Explanation of the Fashion and Use of Three & Fifty Instruments of Chirurgy_ (London, 1631). [113] GARENGEOT, op. cit. [note 98], pages 347, 351. [114] HEISTER (1719), op. cit. [note 18], page 329. Lorenz Heister _... Chirurgie ..._ (Nuremberg, 1719) includes the same picture of the scarificator as the 1759 English translation. [115] HEISTER (1759), op. cit. [note 47], page 330. [116] See BRAMBILLA, op. cit. [note 106], plate 2; DENIS DIDEROT, _Dictionnaire risonné des sciences, arts et métiers. Recueil des planches_ (Lausanne and Berne, 1780), volume 2, plate 23; and BENJAMIN BELL, _A System of Surgery_, 5th edition (Edinburgh, 1791), volume 1, plate 5. [117] JAMES LATTA, _A Practical System of Surgery_ (Edinburgh, 1795), volume 1, plate I; BENJAMIN BELL, _A System of Surgery_, 7th edition (Edinburgh, 1801), volume 3, plate 7. [118] JOHN WEISS, _An Account of Inventions and Improvements in Surgical Instruments Made by John Weiss, 62, Strand_, 2nd edition (London, 1831), pages 12-13. A Mr. Fuller introduced a similar improvement, which Weiss claimed Fuller had pirated from him. The only difference between Weiss's Improved Scarificator and Fuller's Improved Scarificator was that the blades in Weiss's were arch shaped and those of Fuller's crescent shaped. The cupper, Knox, preferred the crescent blades because they gave a sharper cut. In any case, most nineteenth-century scarificators were made with crescent-shaped blades. On Fuller's scarificator, see BAYFIELD, op. cit. [note 87], pages 99-100; and, SEERIG, op. cit. [note 111], pages 604-605 and plate 56. [119] _Extract du Catalogue de la maison Charrière_ (Paris, 1843), page 30; KNOX, op. cit. [note 2], pages 39, 40. [120] This statement is based on the perusal of a wide variety of nineteenth-century trade catalogs. See "List of Trade Catalogs Consulted." [121] KNOX, op. cit. [note 2], page xii. [122] Ibid., pages 14-15. [123] HILLS, op. cit. [note 101], page 266. [124] BAYFIELD, op. cit. [note 87], page 116. [125] KNOX, op. cit. [note 2], pages 53-64. [126] Ibid., page 68. [127] HERO OF ALEXANDRIA, _The Pneumatics of Hero of Alexandria_, translated by Bennet Woodcroft (London, 1851). [128] GURLT, op. cit. [note 1], volume 2, page 565 and plate X. [129] BRAMBILLA, op. cit. [note 106], page 42, mentioned but did not picture a cup with air pump. One of the earliest illustrations of a cup with pump is found in SAVIGNY, op. cit. [note 106], plate 7. [130] MAPLESON, op. cit. [note 90], page 63. [131] KNOX, op. cit. [note 2], page 32. [132] JOHN READ, _A Description of Read's Patent Syringe Pump_ (London, no date). See also JOHN READ, _An Appeal to the Medical Profession on the Utility of the Improved Patent Syringe_, 2nd edition (London, ca. 1825). [133] WEISS, op. cit. [note 118], page 87; CHAS. TRUAX, GREENE & CO., _Price List of Physicians' Supplies_, 6th edition (Chicago, 1893), pages 989-1010. [134] "Notice sur l'acupuncture et sur une nouvelle espèce de ventouse armée de lancettes, inventée par A.-P. Demours," _Journal universal des sciences médicales_, volume 15 (1819), pages 107-113; BAYFIELD, op. cit. [note 87], pages 73-81. [135] THOMAS MACHELL, "Description of an Apparatus for Cupping, Dry Cupping, and Drawing the Breasts of Females; With some Observations Respecting Its Use," _London Medical and Physical Journal_, volume 42 (1819), pages 378-380; BAYFIELD, op. cit. [note 87], pages 81-89. [136] BAYFIELD, op. cit. [note 87], pages 92-93. [137] ROBERT J. DODD, "Improved Cupping Apparatus," _The American Journal of the Medical Sciences_, new series, volume 7 (1844), page 510. See also patent specifications, U.S. patent 3537. [138] Patent specifications, U.S. patent 68985. [139] HILLS, op. cit. [note 101], page 261. [140] GILLESPIE, op. cit. [note 93], page 29. [141] FRANCES FOX, JR., "A Description of an Improved Cupping Glass, with Which from Five to Eight Ounces of Blood May Be Drawn, with Observations," _The Lancet_, volume 12 (1827), pages 238-239. KNOX, op. cit. [note 2], pages 36-37, recommended these glasses especially for use on young ladies who feared scars left by cupping. One of the "glass leeches" fixed below the level of the gown could draw all the blood necessary. [142] See JOHN GORDON, "Remarks on the Present Practice of Cupping; With an Account of an Improved Cupping Glass," _The London Medical Repository_, volume 13 (1820), pages 286-289. J. WELSH, "Description of a Substitute for Leeches," _The Edinburgh Medical and Surgical Journal_, volume 11 (1815), pages 193-194; P. MOLONEY, "A New Cupping Instrument," _Australia Medical Journal_, new series, volume 1 (1879), pages 338-340. At least two American patents were given for improved cups, one to C. L. Myers in 1884 (U.S. patent 291388) and one to Jaime Catuela in 1922 (U.S. patent 1463458). [143] SAVIGNY, op. cit. [note 106], plate 18, illustrated in 1798 "elastic bottles" that could be attached to glass cups for drawing the breasts; however, not until Charles Goodyear's discovery of the vulcanization process in 1838 was rubber widely used in cupping. An American surgeon, Samuel Gross, wrote in 1866 that the glass cup with a bulb of vulcanized rubber was the "most elegant and convenient cup, by far." See SAMUEL GROSS, _A System of Surgery_, 4th edition, 2 volumes (Philadelphia, 1866), volume 1, page 451. [144] GEORGE TIEMANN & CO., _American Armamentarium Chirurgicum_ (New York, 1889), page 825. [145] For one listing of the disadvantages of the common scarificator, see BLATIN, "Scarificator nouveau," _Bulletin de l'Académie Royale de Medècine_, volume 11 (1845-1846), pages 87-90. Blatin patented a new scarificator in 1844 that supposedly overcame the difficulties he listed. [146] JAMES COXETER, "New Surgical Instruments," _The Lancet_ (November 15, 1845), page 538; JAMES COXETER & SON, _A Catalogue of Surgical Instruments_ (London, 1870), page 48. Coxeter sold his scarificator for 2 pounds, 2 shillings, while he offered his "best scarificator, with old action" for two pounds. [147] GREAT BRITAIN PATENT OFFICE, _Subject-Matter Index of Patents of Invention_, 1617-1852, 2 volumes (London, 1957); U.S. PATENT OFFICE, _Subject Matter Index of Patents for Invention (Brevets d'invention) Granted in France from 1791 to 1876 Inclusive_ (Washington, 1883). [148] CHARRI�RE [firm], _Cinq notices réunies presentées a MM. les membres des jurys des expositions françaises de 1834, 1839, 1844, et 1849, et de l'exposition universelle de Londres en 1851_ (Paris, 1851), page 56. [149] MAISON CHARRI�RE, ROBERT ET COLLIN, SUCCESSEURS, [Catalogue générale] (Paris, 1867), pages 42, 44, and plate 9. [150] Patent specifications, U.S. patent 4705; TIEMANN & CO., op. cit. [note 144], page 115. Tiemann was awarded an earlier patent for a scarificator in 1834 (unnumbered U.S. patent, 26 August 1834), which seems to have employed a coiled spring similar to that found in the Charrière scarificator. The fifth U.S. patent for a scarificator was issued in 1846 to A. F. Ahrens of Philadelphia (U.S. patent 4717) for a circular scarificator in which all the blades were attached to a movable plate. [151] Patent specifications, U.S. patent 5111. [152] Patent specifications, U.S. patent 8095. [153] DYCE DUCKWORTH, "On the Employment of Dry-Cupping," _The Practitioner: A Monthly Journal of Therapeutics_, volume 2 (1869), page 153. [154] Ibid., page 155. For more information on counter-irritation, see BROCKBANK, op. cit. [note 88]. Blisters were substances (including mustard and cantharides) that when applied to the skin, occasioned a serous secretion and the raising of the epidermis to form a vesicle. Cautery was the application of a red-hot iron to the skin. A seton was a long strip of linen or cotton thread passed through the skin by a seton needle. Each day a fresh piece of thread was drawn through the sore. Moxa were cones of cotton wool or other substances which were placed upon the skin and burned. [155] CHARLES BAUNSCHEIDT, _Baunscheidtismus, by the Inventor of the New Curing Method_, 1st English edition, translated from the 6th German edition by John Cheyne and L. Hayman (Bonn., 1859?). [156] The patent models are in the Smithsonian collection. See "Catalog" herein. The Aima Tomaton, a device invented and manufactured by Dr. L. M'Kay, was yet another American variation on the Lebenswecker. See L. M'KAY, _Aima Tomaton: Or New Cupping and Puncturing Apparatus_ (Rochester, 1870). An example can be found in the collection of the Armed Forces Institute of Pathology. [157] See DUCKWORTH, op. cit. [note 153]; ISAAC HOOVER, "An Essay on Dry Cupping," _Transactions of the Belmont Medical Society for 1847-48-49-50_ (Bridgeport, 1851), pages 30-32; MARSHALL HALL, _Practical Observations and Suggestions in Medicine_ (London, 1845), pages 51-53; and B. H. WASHINGTON, "Remarks on Dry Cupping," _The New Jersey Medical Reporter and Transactions of the New Jersey Medical Society_ (1852-53), pages 278-281. [158] CASPER WISTAR PENNOCK, "Observations and Experiments on the Efficacy and Modus Operandi of Cupping-Glasses in Preventing and Arresting the Effects of Poisoned Wounds," _The American Journal of Medical Sciences_, volume 2 (1828), pages 9-26. For a discussion of the debate over absorption, see KNOX, op. cit. [note 2], pages 21-24. [159] TIEMANN, op. cit. [note 144], pages 116, 800. [160] VICTOR-TH�ODORE JUNOD, _A Theoretical and Practical Treatise on Hemospasia_, translated by Mrs. E. Howley Palmer (London, 1879). [161] HEINRICH STERN, _Theory and Practice of Bloodletting_ (New York: Rebman Co., 1915), pages 71-72. [162] AUGUST BIER, _Hyperemia as a Therapeutic Agent_ (Chicago, 1905), page 21. [163] WILLY MEYER and VICTOR SCHMIEDEN, _Bier's Hyperemic Treatment_, 2nd edition (Philadelphia, 1909). [164] HALLER, op. cit. [note 88; see also note 72], page 585. [165] GROSS, op. cit. [note 143], volume 2, page 906. [166] Such a breast pump was illustrated by HEISTER (1719), op. cit. [note 17], plate 14. All glass breast pumps were probably more typical of the eighteenth than the nineteenth century. In the nineteenth century the glass tube was replaced by a flexible tube with a mouthpiece. [167] For example, see THE J. DURBIN SURGICAL SUPPLY CO., _Standard Surgical Instruments_ (Denver, 1929), page 59. [168] Data on the numbers of breast pumps patented was obtained from the files of the U.S. Patent Office in Arlington, Virginia. [169] Patent specifications, U.S. patent 1179129. For other illustrations of late nineteenth- and early twentieth-century patents for cupping devices, see HALLER, op. cit. [note 88]. [170] STERN, op. cit. [note 85], page 74. [171] MABELLE S. WELSH, "'Cups for Colds': The Barber, the Surgeon and the Nurse," _The American Journal of Nursing_, volume 19 (1918-19), pages 763-766. See also HALLER, op. cit. [note 88], and J. EPSTEIN, "The Therapeutic Value of Cupping: Its Use and Abuse," _New York Medical Journal_, volume 112 (1920), pages 584-585. [172] THORNDIKE, op. cit. [note 3], page 477. For bibliography on leeching, see BROCKBANK, op. cit. [note 88]; MERAT, "Sangsue," _Dictionnaire des sciences médicales_, volume 49 (1820), pages 520-541; G. CARLET AND EMILE BERTIN, "Sangsue," _Dictionnaire encyclopédique des sciences médicales_, 3rd series, volume 6 (1878), pages 660-681; and the _Index Catalogue of the Library of the Surgeon-General's Office_, U.S. Army. [173] ALFRED STILLE AND JOHN M. MAISCH, _The National Dispensatory_, 2nd edition (Philadelphia, 1880), page 713; JAMES THACHER, _The American Dispensatory_, 2nd edition (Boston, 1813), page 230; C. LEWIS DIEHL, "Report on the Progress of Pharmacy," _Proceedings of the American Pharmaceutical Association_, volume 25 (1876), page 205. [174] W. H. SCHIEFFELIN & CO., _General Prices Current_ (New York, 1887), page 39. [175] DIEHL, op. cit. [note 173]; JOHN C. HARTNETT, "The Care and Use of Medicinal Leeches in 19th Century Pharmacy and Therapeutics," _Pharmacy in History_, volume 14 (1972), page 133. [176] Broussais offered the following explanation for the effectiveness of leeching. Congestion of blood vessels in a healthy person gives rise to a sympathetic irritation in the mucous surfaces of bodily orifices. Equilibrium may be restored naturally by hemorrhage through the nose. Without this release of blood, congestion builds up into an inflammation. Local bloodletting relieves the congestion when applied on a portion of the skin corresponding to the inflamed organ. Broussais's favorite remedy was the application of leeches to the stomach and head. For this purpose he ordered hundreds of leeches daily. See F.J.V. BROUSSAIS, _A Treatise on Physiology Applied & Pathology_, translated by John Bell and R. La Roche, 2nd American edition (Philadelphia, 1828), page 414, and Castiglioni, op. cit. [note 40], page 609. [177] THORNDIKE, op. cit. [note 3], page 477. See also KARL-OTTO KUPPE, _Die Blutegel in der Aerztlichen Praxis_ (reprint, Stuttgart: Hippocrates-Verlag, 1955), pages 9-11. [178] HARTNETT, op. cit. [note 175], page 132. [179] JONATHAN OSBORNE, "Observations on Local Bloodletting, and on Some New Methods of Practicing It," _Dublin Journal of Medical and Chemical Science_, volume 3 (1833), pages 334-342. [180] See, for example, MAISON CHARRI�RE, ROBERT ET COLLIN, op. cit. [note 149], page 42 and plate 9. [181] JOHN BERRY HAYCRAFT, "On the Coagulation of the Blood," 9 pages, extracted from _Proceedings of the Royal Society of London_, volume 231 (1884). [182] THORNDIKE, op. cit. [note 3], page 477. MERAT, op. cit. [note 172], page 528, cited an extreme case in which a woman suffering from peritonitis was given a total of 250 leeches in 24 hours. She died soon after. [183] STILLE AND MAISCH, op. cit. [note 173], page 715; THACHER, op. cit. [note 173], page 231. [184] HARTNETT, op. cit. [note 175], page 132; J. K. CRELLIN, op. cit. [note 33], pages 127-134. [185] ANDREW H. SMITH, "An Artificial Leech," _Medical Record_, volume 4 (1869-70), page 406. [186] In addition to the references below, articles on artificial leeches include DR. MONTAIN, "Considérations thérapeutiques sur l'emploi du pneumo-derme, nouvel instrument destiné à remplacer les sangsues et les ventouses," _Bulletin Général de thérapeutique_, volume 11 (1836), pages 311-315; J. J. TWEED, "A Description of the Apparatus for Employing the Mechanical Leeches," _Medical Times_, volume 21 (1850), pages 36-37; and SAMUEL THEOBALD, "An Improved Method of Applying the Artificial Leech," _American Journal of Medical Science_, new series, volume 70 (1875), pages 139-142. [187] SARLANDI�RE, "Ventouse," _Dictionnaire des sciences médicales_, volume 57 (Paris, 1821), pages 174-178; PAULET, "Bdellometre," _Dictionnaire encyclopédique des sciences médicales_, series 1, volume 8 (Paris, 1868), pages 632-633; L. GRESELY, "Dissertation sur les sangsues, le nouveau scarificateur, et sur leur emploi en médecine" (Paris: Faculty of Medicine, 1820), dissertation no. 202. [188] ROBLEY DUNGLISON, _Medical Lexicon: A New Dictionary of Medical Science_, 3rd edition (Philadelphia, 1842). The bdellometer was listed in later editions of this dictionary throughout the nineteenth century. [189] DAMOISEAU, _La terabdelle ou machine pneumatique operant a volonté la saignée locale et la revulsion aux principales regions du corps humains_ (Paris, 1862), 60 pages. See also GAUJOT and SPILLMAN, op. cit. [note 49], pages 194-195. [190] L. WECKER, "De la sangsue artificielle (modéle du baron Heurteloup), et de son emploi dans le traitment des maladies des yeux." _Bulletin général de thérapeutique médicale et chirurgicale_, volume 62 (1862), pages 107-116. For price information, see CASWELL, HAZARD & CO. (W. F. Ford), _Illustrated Catalogue of Surgical Instruments and Appliances_ (New York, 1874), page 18. An example of Heurteloup's leech as well as a larger, modified Heurteloup's leech can be found in the collection of the Armed Forces Institute of Pathology. [191] SMITH, op. cit. [note 185], page 406; TIEMANN, op. cit. [note 144], page 116; Patent specifications, U.S. patent 100210. An example of this artificial leech can be found in the collection of the Armed Forces Institute of Pathology. [192] TIEMANN, op. cit. [note 144], page 506. [193] WILLIAM REESE, "Uterine Leech and Aspirator," _Medical Record_, volume 11 (1876), page 596. [194] OTTO RAUBENHEIMER, "Leeches--How to Dispense Them," _Journal of the American Pharmaceutical Association_, volume 12 (1923), page 339. THORNDIKE, op. cit. [note 3], page 477, notes that in 1927, leeches still could be had in Boston for 75¢ apiece. In Cleveland they were still obtainable in the 1950s. [195] _Dictionnaire usuel de chirurgie et de médicine vetérinaire_, 2 volumes (Paris, 1835-36), articles "Ventouses" and "Sangsues." [196] Ibid., article "Saignée." [197] _Encyclopédie méthodique: Médecine_, volume 9 (Paris, 1816), page 478. [198] _Dictionnaire usuel_, op. cit. [note 195], volume 2, page 605. [199] WEISS, op. cit. [note 118], page 100, plate 27. [200] Patent specifications, U.S. patent 6240. [201] Patent specifications, U.S. patent 236084. LIST OF TRADE CATALOGS CONSULTED Aloe, A. S. Company. _Illustrated and Priced Catalogue of Surgical Instruments, Physicians' Supplies and Hospital Furnishings._ 6th edition. St. Louis, 1891. ----. _Catalogue of Superior Surgical Instruments and Physicians' and Surgeons' Supplies._ 6th Edition. St. Louis, 1895. Becton, Dickinson & Co. _Trade Catalogue of Gold, Silver and Plated Instruments for Surgeons and Veterinarians._ New York, 1904. ----. [Catalogue.] Rutherford, N.J., 1911. ----. _Illustrated Catalog of Druggists, Surgical, and Veterinary Specialties._ Rutherford, N.J., 1917. Caswell, Hazard & Co., W. F. Ford. _Illustrated Catalogue of Surgical Instruments and Appliances._ New York, 1874. Ch. Dubois. _Catalogue illustre des instruments de chirurgie._ Paris, 1884. Charles Lentz & Sons. _Illustrated Catalogue and Price List of Surgical Instruments._ 3rd edition. Philadelphia, ca. 1888. Charles Henry Truax. _The Mechanics of Surgery, Comprising Detailed Descriptions, Illustrations and List of the Instruments, Appliances and Furniture Necessary in Modern Surgical Arts._ Chicago, 1899. Codman and Shurtleff. _Illustrated Catalogue of Surgical Instruments and Appliances._ Boston, 1879. ----. _Illustrated Catalogue of Surgical Instruments and Appliances._ Boston, 1886. ----. _Illustrated Catalogue of Surgical Instruments and Appliances._ Boston, 1890. Coxeter, J., & Son. _Surgical Instruments Catalogue._ London, 1870. Down Bros. _Catalogue of Surgical Instruments and Appliances._ London, 1885. Dubois, Ch. See Ch. Dubois. Durbin, J., Surgical Supply Co. (Catalogue.) Denver, 1929. Feick Bros. _Illustrated Catalogue and Price List of Surgical Instruments._ Pittsburgh, 1896. Fred Haslam & Co. _Standard Surgical Instruments._ Brooklyn, 1922. Fr. Lindstaedt. _Illustrirter Catalog chirurgischer Instrumente._ Bremen, 1882. George Tiemann & Co. _American Armamentarium Chirurgicum._ New York, 1879. ----. _The American Armamentarium Chirurgicum._ New York, 1882. ----. _The American Armamentarium Chirurgicum._ New York, 1889. Haslam & Co. See Fred Haslam & Co. John Reynders & Co. _Illustrated Catalogue and Price List of Surgical Instruments, Orthopaedical Apparatus, Trusses, etc._ 5th edition. New York, 1884. John Weiss. _An Account of Inventions and Improvements Made by John Weiss._ 2nd edition. London, 1831. John Weiss & Son. _Weiss and Son's Catalogue of Surgical Instruments for 1836._ London, 1836. ----. _A Catalogue of Opthalmic Instruments and Appliances, etc._ London, 1863. ----. _A Catalogue of Opthalmic Instruments and Appliances._ Manchester, 1898. Kennedy, J. E., & Co. _Illustrated Catalogue of Surgical Instruments and of Allied Lines._ New York, 1917. Kny-Scheerer Co., The. _Illustrated Catalogue of Surgical Instruments._ 3 volumes. New York, 1899. ----. _Illustrated Catalogue of Surgical Instruments._ 16th edition. New York, no date (20th century). Krohne & Sesemann. _Catalogue of Surgical & Orthopedic Instruments._ London, 1878. Lentz & Sons. See Charles Lentz & Sons. Lindstaedt, Fr. See Fr. Lindstaedt. Maison Charrière, Robert et Collin, Successeurs. [Catalogue.] Paris, 1867. ----. _Catalogue générale illustre._ Paris, 1879. ----. _Catalogue générale illustre._ Paris, 1885. ----. _Catalogue générale illustre._ Paris, 1890. ----. _Catalogue générale illustre._ Paris, 1894. Maison Luër (H. Wulfing-Luër). _Catalogue générale Illustre._ Paris, ca. 1904. Mathay Hospital Supply Co. _Surgical Instruments._ Los Angeles, ca. 1937. Maison Mathieu. _Arsenal Chirurgical._ 15th edition. Paris, ca. 1905. Matthews Bros. _A Catalogue of Surgical Instruments._ London, ca. 1875. Maw, S., Son & Thompson's. _Surgical Instruments, etc._ London, 1882. Obstetrical Society of London. _Catalogue and Report of Obstetrical and Other Instruments Exhibited at the Converzatione of the Obstetrical Society of London_, 1867. Pittsburgh Physicians' Supply Co. _Illustrated Catalogue._ Pittsburgh, 1908. Reiner, H. _Catalog medicinisch-chirurgischer Instrumente und Apparate._ Vienna, 1885. Reynders, John, & Co. See John Reynders & Co. Robert et Collin. See Maison Charrière. Scheffelin, W. H., & Co. _General Prices Current._ New York, 1887. Sharp and Smith. _Surgical Instruments._ 16th edition. Chicago, ca. 1892. Shepard & Dudley. _Descriptive Catalogue._ New York, 1873. Tiemann, George, & Co. See George Tiemann & Co. Truax, Charles Henry. See Charles Henry Truax. Truax, Green & Co. _Price List of Physicians Supplies._ 6th edition. Chicago, 1893. Weiss & Son. See John Weiss & Son. W. H. Wigmore. _Surgical, Dental and Veterinary Instruments._ Philadelphia, no date (pre-1895). W. Windler. _Preis-Verzeichniss der Fabrik chirurgischer Instrumente und Bandagen._ Berlin, 1888. Figures 26-124 [Illustration: FIGURE 26.--Reproduction of a Greek vase showing a 5th century B.C. medical "clinic." Original is in the Louvre. Patient is about to undergo venesection in the arm. Bronze bleeding bowl catches the blood. (NMHT 233055 [M-9618]; SI photo 73-4216.)] [Illustration: FIGURE 27.--Bloodletting man from a New York almanac, 1710. (From Daniel Leeds, _The American Almanack for the Year of Christian Account, 1710_. Photo courtesy of the Library of Congress.)] [Illustration: FIGURE 28.--Phlebotomy manikin in Johannes de Ketham _Fascicules Medicinae_. Venice, 1495. (From the Dibner Library of the History of Science and Technology, NMHT.)] [Illustration: FIGURE 29.--Lionel Wepfer, a 17th century traveler, described the Indian method of bloodletting as follows: "The patient is seated on a stone in the river, and one with a small bow shoots little arrows into the naked body of the patient, up and down, shooting them as fast as he can and not missing any part. But the arrows are guarded, so that they penetrate no farther than we commonly thrust our lancets; and if by chance they hit a vein which is full of wind, and the blood spurts out a little, they will leap and skip about, shewing many antic gestures, by way of rejoicing and triumph." (From Lionel Wepfer, _A New Voyage and Description of the Isthmus of America_, London, 1699. Photo courtesy of NLM.)] [Illustration: FIGURE 30.--Flint lancets used by native doctors in Alaska, 1880s. (Anthropology Catalog 127758; SI photo 73-4208).] [Illustration: FIGURE 31.--Instruments and technique of phlebotomy: Fig. 1 shows an arm about to be bled. A ligature has been applied to make the veins swell. The common veins bled--cephalic, basilic, and median--are illustrated. Fig. 2 shows several types of incisions. Fig. 3 is a fleam, Fig. 4 a spring lancet, and Fig. 5 a "French lancet." (From Laurence Heister, _A General System of Surgery_, London, 1759. Photo courtesy of NLM.)] [Illustration: FIGURE 32.--Replica of a barber-surgeon's signboard dated 1623. Top left corner shows a phlebotomy being performed. (NMHT 215690 [M-7343]; SI photo 44681.)] [Illustration: FIGURE 33.--Instruments for bleeding from the arm, 1708: A, a serviette to cover the patient's clothing; B, a cloth ligature to place around the arm; C, a lancet case; D, a lancet; E and F, candles to give light for the operation; G, a baton or staff for the patient to hold; H, I, and K, basins for collecting blood; L and M, compresses; N, a bandage to be placed over the compress; P, _eau de la Reine d'Hongrie_ that can be used instead of vinegar to revive the patient if he faints; Q, a glass of urine and water for the patient to drink when he revives; R, S, T, implements for washing the hands and the lancets after the operation. (From Pierre Dionis, _Cours d'opérations de chirurgie demontrées au Jardin Royal_, Paris, 1708. Photo courtesy of NLM.)] [Illustration: FIGURE 34.--Two 18th century trade cards advertising lancets. (Photo courtesy of Wellcome Institute, London.)] [Illustration: FIGURE 35.--Lithograph, London, 1804, showing a phlebotomy. (On loan from Armed Forces Institute of Pathology; SI photo 42579.)] [Illustration: FIGURE 36.--18th-century cutler's illustrations for making lancets. Note the variations in the shape of the lancet blades. (From Jean Jacques Perret, _L'Art du Coutelier_, Paris, 1772. Photo courtesy of NLM.)] [Illustration: FIGURE 37.--Thumb lancet, 16th century. (From Leonardo Botallo, _De Curatione per Sanguinis Missionem_, Antwerp, 1583. Photo courtesy of NLM.)] [Illustration: FIGURE 38.--Typical 19th-century thumb lancets, engraved "S. Maw, London." (NMHT 139980 [M-4151]; SI photo 73-4230.)] [Illustration: FIGURE 39.--Typical 19th-century brass spring lancet and case. The case is stamped "Traunichtessticht," which translates, "Watch out, it stabs." (NMHT 308730.10; SI photo 74-4088.)] [Illustration: FIGURE 40.--Spring lancets, dated 1775. (Held by Rhode Island Medical Society; SI photo 73-5762.)] [Illustration: FIGURE 41.--Fleam, 16th century. (From Leonardo Botallo, _De Curatione per Sanguinis Missionem_, Antwerp, 1583. Photo courtesy of NLM.)] [Illustration: FIGURE 42.--Hand-forged fleam with hand-carved wooden case, 17th and 18th century, Swiss or Tyrolean. (NMHT 233570 [M-9666]; SI photo 59139-E.)] [Illustration: FIGURE 43.--Fleam made by E. Dalman, London. Note unusual curved shape to blade. (From the original in the Wellcome Museum by courtesy of the Trustees, photo L. 1346.)] [Illustration: FIGURE 44.--Silver spring lancet in case. Case is lined with white silk and rose plush and has a gold leaf border. (NMHT 321687.02; SI photo 76-7752.)] [Illustration: FIGURE 45.--Unusual spring lancet with extra blade, engraved "M.A. Prizzi," 18th century. (NMHT 320033.06; SI photo 76-7763.)] [Illustration: FIGURE 46.--Unusual spring lancet in hand-carved wooden case, 18th century. Note the large blade and blade guard regulated by a screw. (NMHT 321.697.12; SI photo 76-9114.)] [Illustration: FIGURE 47.--George Tiemann & Co.'s spring lancet, late 19th century. (NMHT 163863 [M-5141]; SI photo 73-5644.)] [Illustration: FIGURE 48.--Patent model spring lancet, patented by J.W.W. Gordon in 1857. Back view. (NMHT 89797 [M-4298]; SI photo 73-10319.)] [Illustration: FIGURE 49.--Patent model spring lancet, patented by J.W.W. Gordon in 1857. Front view. (NMHT 89797 [M-4298]; SI photo 73-10318.)] [Illustration: FIGURE 50.--Wet cupping for a headache. (From Frederik Dekkers, _Exercitationes Practicae Circa Medendi Methodum_, Leyden, 1694. Photo courtesy of NLM.)] [Illustration: FIGURE 51.--Dry cupping for sciatica. (From Frederik Dekkers, _Exercitationes Practicae Circa Medendi Methodum_, Leyden, 1694. Photo courtesy of NLM.)] [Illustration: FIGURE 52.--Horn cups used in Egypt in the 16th century. (From Prosper Alphinus, _Medicina Aegyptorum_, Leyden, 1719. Photo courtesy of NLM.)] [Illustration: FIGURE 53.--Horn cup used in the Niger Republic of West Africa in the 1960s. (NMHT 270023 [M-11998]; SI photo 73-5643.)] [Illustration: FIGURE 54.--Replica of a Greek votive tablet found in the remains of the Temple of Aesculapius. Pictured are two metal cups and a set of scalpels. (NMHT 233055 [M-9617]; SI photo 73-4217.)] [Illustration: FIGURE 55.--Egyptian spouted cupping cups, 16th century. (From Prosper Alpinus, _Medicina Aegyptorum_, Leyden, 1719. Photo courtesy of NLM.)] [Illustration: FIGURE 56.--Cupping instruments illustrated by Dionis, 1708: A, cups made of horn; B, lamp for exhausting air; C, fleam for making scarifications; D, horns with holes at the tip for mouth suction; E, balls of wax to close the holes in the horn cups; F, G, glass cups; H, candle to light the tow or the small candles; I, tow; K, small candles on a card which is placed over the scarifications and lit in order to exhaust the cup; L, lancet for making scarifications; M, scarifications; N, plaster to place on the wound. (From Pierre Dionis, _Cours d'opérations de chirurgie demontrées au Jardin Royal_, Paris, 1708. Photo courtesy of NLM.)] [Illustration: FIGURE 57.--Teapot lamp, 18th century. (NMHT 199536 [M-6691]; SI photo 73-4218.)] [Illustration: FIGURE 58.--13th-century Arabic cupping scene. (From a manuscript held by the Freer Gallery. SI photo 43757-J.)] [Illustration: FIGURE 59.--Paré's scarificator, 16th century. (From _The Workes of that Famous Chirurgeon, Ambrose Parey_, translated by Thomas Johnson, London, 1649. Photo courtesy of NLM.)] [Illustration: FIGURE 60.--Square scarificator, engraved "J.T./Wien," late 18th-early 19th century. Vienna was an early center for the making of scarificators. (NMHT 218383 [M-9257]; SI photo 73-4212.)] [Illustration: FIGURE 61.--An early illustration of the scarificator. Also pictured are a fleam for making scarifications, the pattern of scarifications, a metal cup, and a leech. (From Laurence Heister, _A General System of Surgery_, 7th edition, London, 1759. SI photo 73-4182.)] [Illustration: FIGURE 62.--Square scarificator taken apart. (NMHT 152130 [M-4771]; SI photo 76-9113.)] [Illustration: FIGURE 63.--Cupping and bleeding instruments, 1780. Illustrated are spring lancets, thumb lancets, cups, a square scarificator with pointed blades, and a lamp in which animal fat was burned. Figs. 16, 17, and 18 are unrelated to bloodletting. (From J. A. Brambilla, _Instrumentarium Chirurgicum Viennense_, Vienna, 1780. Photo courtesy of NLM.)] [Illustration: FIGURE 64.--Set of scarificator blades. Each row of blades may be inserted in place of those in need of cleaning or repair. (From the original in the Wellcome Museum by courtesy of the Trustees. Photo L. 2418.)] [Illustration: FIGURE 65.--An early illustration of the octagonal scarificator, 1801. This plate also includes one of the earliest illustrations of the syringe applied to cupping cups. (From Benjamin Bell, _A System of Surgery_, 7th edition, volume 3, Edinburgh, 1801. SI photo 73-5181.)] [Illustration: FIGURE 66.--An unusual octagonal scarificator made by Domenico Pica in 1793. The blade cover is attached by a hinge, and the turnkey on top raises and lowers the entire interior chassis in order to regulate depth of cut. (NMHT 320033.01; SI photo 76-7742.)] [Illustration: FIGURE 67.--Scarificator marked Dom{o} Morett, 1813. (From the original in the Wellcome Museum, by courtesy of the Trustees. Wellcome R2909/1936; photo L 1159.)] [Illustration: FIGURE 68.--Cupping set with base handled torch, 8 blade scarificator, 4 blade scarificator for cupping on temples, 2 cups and alcohol bottle. (NMHT, SI photo 76-9119.)] [Illustration: FIGURE 69.--Calling card, ca. 1860. (SI photo.)] [Illustration: FIGURE 70.--Cupping set manufactured by Charrière of Paris, mid-19th century. Note the tubing used to connect the pump to the cups, and the circular scarificator with blades cutting in opposite directions. (NMHT 302606.007; SI photo 75-090.)] [Illustration: FIGURE 71.--W. D. Hooper's patent cupping apparatus with tubular blades. (From patent specifications, U.S. patent no. 68985. SI photo 73-5193.)] [Illustration: FIGURE 72.--Demours' device for combining cup, scarifier and exhausting apparatus. (From Samuel Bayfield, _A Treatise on Practical Cupping_, London, 1823. Photo courtesy of the NLM.)] [Illustration: FIGURE 73.--R. J. Dodd's patent cupping apparatus. Figs. 4 and 5 are the tubes for cupping the uterus. Fig. 3 is the flexible match scarifier. (From patent specifications, U.S. patent no. 3537. SI photo 73-5192.)] [Illustration: FIGURE 74.--Circular scarificator. (NMHT 320933.05; SI photo 76-7746.)] [Illustration: FIGURE 75.--Scarificator for vaccination. Mallam's, made by Arnold & Sons, London. Patent 1406. (From the original in the Wellcome Museum by courtesy of the Trustees. Wellcome 13557; photo 125/1960.)] [Illustration: FIGURE 76.--Patent model of Tiemann's scarificator. (NMHT 89797 [M-4289]; SI photo 76-9115.)] [Illustration: FIGURE 77.--Patent model of Leypoldt's scarificator, 1847. (NMHT 89797 [M-4290]; SI photo 73-4213.)] [Illustration: FIGURE 78.--Patent model of Leypoldt's scarificator, 1851. (NMHT 89797 [M-4293]; SI photo 76-9112.)] [Illustration: FIGURE 79.--Baunscheidt's _Lebenswecker_, a counter-irritation device. (NMHT 287885 [M-12936]; SI photo 76-7751.)] [Illustration: FIGURE 80.--Depurator patented by A. F. Jones, 1866. (From patent specifications, reissue 2276. SI photo.)] [Illustration: FIGURE 81.--Junod's boot. (On loan from the Armed Forces Institute of Pathology. SI photo 73-7885.)] [Illustration: FIGURE 82.--Woman cupping her breast. (From Maw, Son & Thompson, _Surgeon's Instruments, etc._, London, 1882. SI photo 76-13540.)] [Illustration: FIGURE 83.--Glass breast pump with spout for self application. (NMHT 260557 [M-11467]; SI photo 76-7759.)] [Illustration: FIGURE 84.--Goodyear's patent breast pump, manufactured by the Union India Rubber Co. (NMHT 252497 [M-10510]; SI photo 76-7762.)] [Illustration: FIGURE 85.--Brier's Hyperemia Apparatus, 1930s. (From Matthay Hospital Supply Co., _Surgical Instruments_, Los Angeles, 1937(?). SI photo.)] [Illustration: FIGURE 86.--Patent for a complex cupping pump, J. A. Maxam, 1916. (From patent specifications, U.S. patent 1179129. SI photo 73-5186.)] [Illustration: FIGURE 87.--Heinrich Stern's phlebostasis chair, 1915. (From Heinrich Stern, _Theory and Practice of Bloodletting_, New York, 1915. SI photo.)] [Illustration: FIGURE 88.--Old-fashioned cupping in a German physician's office, Chicago, Illinois, 1904. (SI photo 45726-B.)] [Illustration: FIGURE 89.--A man employing leeches to reduce his weight, 16th century. (From P. Boaistuau, _Histoire Podigieuses_, Paris, 1567. Photo courtesy of NLM.)] [Illustration: FIGURE 90.--Osborne's instrument for inserting leeches into the rectum. (From J. Osborne, "Observations on Local Bloodletting," _Dublin Journal of Medical and Chemical Science_, volume 3 (1833). Photo courtesy of NLM.)] [Illustration: FIGURE 91.--Two leeches (_Hirudo medicinalis_) preserved in plastic. (Anthropology Catalog no. 143,077; SI photo 73-4233.)] [Illustration: FIGURE 92.--Satire on the theories of Broussais. The caption read, "But, I haven't a drop of blood left in my veins! No matter, another fifty leeches." (Undated print. Photo courtesy of NLM.)] [Illustration: FIGURE 93.--Woman using leeches, 17th century. (From Guillaume van den Bossche, _Historica Medica_, Brussels, 1639. Photo courtesy of NLM.)] [Illustration: FIGURE 94.--Heurteloup's leech. (From George Tiemann & Co., _American Armamentarium Chirurgicum_, New York, 1889. SI photo 76-13541.)] [Illustration: FIGURE 95.--Tiemann & Co.'s patent artificial leech. (From George Tiemann & Co., _American Armamentarium Chirurgicum_, New York, 1889. SI photo 76-13541.)] [Illustration: FIGURE 96.--Reese's uterine leech. (From George Tiemann & Co., _American Armamentarium Chirurgicum_, New York, 1889. SI photo 76-13539.)] [Illustration: FIGURE 97.--Sarlandière's bdellometer. Fig. 13 and Fig. 14 are a teapot lamp and a glass for measuring the blood taken in cupping. All the other figures illustrate variations on the bdellometer. Fig. 19 and Fig. 20 are attachments for bleeding the internal membranes. (From Sarlandière, "Ventouse," _Dictionnaire des sciences médicales_, volume 57, 1821. Photo courtesy of NLM.)] [Illustration: FIGURE 98.--An artificial leech. Note the three blades on the scarificator that simulate the triangular puncture of the leech. (NMHT; SI photo 76-9120.)] [Illustration: FIGURE 99.--An 18th-century cutler's illustration of veterinary instruments. Shown are a spring lancet and a fleam. Knives and hooks were often added to the bloodletting blades in foldout fleams. (From Jean Jacques Perret, _L'Art du Coutelier_, Paris, 1772. Photo courtesy of the NLM.)] [Illustration: FIGURE 100.--Fleam with brass shield, 18th-19th century. (NMHT 121573 [M-3462]; SI photo 73-4206.)] [Illustration: FIGURE 101.--Fleam with horn shield, 19th century. (NMHT 321697.05; SI photo 76-7758.)] [Illustration: FIGURE 102.--Phlebotomy knife by Rodgers & Co., London. (Loan no. 316478; SI photo 76-9108.)] [Illustration: FIGURE 103.--Unusual shaped brass spring lancet set by a sliding catch and released by a release lever. (NMHT 321697.11; SI photo 76-7754.)] [Illustration: FIGURE 104.--Brass spring lancet that is set by pulling on the string and released by pushing upon the button. (NMHT 321697.07; SI photo 76-7750.)] [Illustration: FIGURE 105.--Spring lancet. (NMHT 112827; SI photo 73-4235.)] [Illustration: FIGURE 106.--Scarificator, 12 blades. (NMHT 99749 [M-2336]; SI photo 76-7744.)] [Illustration: FIGURE 107.--Temple scarificator with case. (NMHT 233056 [M-9639]; SI photo 76-7745.)] [Illustration: FIGURE 108.--Persian cupping glass, 12th century. (NMHT 207389 [M-6836]; SI photo 73-4205.)] [Illustration: FIGURE 109.--Cupping cups, glass. (NMHT 308730.09; SI photo 74-4087.)] [Illustration: FIGURE 110.--Persian cupping cup and razor. (NMHT 320033.07; SI photo 76-7749.)] [Illustration: FIGURE 111.--Brass cup (1) and pewter cups (2). (NMHT 321697.22 and NMHT 207399 [M-6829 and M-6830]; SI photo 76-9109.)] [Illustration: FIGURE 112.--Cupping set. (NMHT 321697.21; SI photo 76-7747.)] [Illustration: FIGURE 113.--Breast pump. (NMHT 220170 [M-7435]; SI photo 76-7761.)] [Illustration: FIGURE 114.--Leech jar, minus top. (NMHT 201821 [M-6712]; SI photo 73-4232.)] [Illustration: FIGURE 115.--Staffordshire leech jars. (NMHT 321697.18 & .19; SI photo 76-7765.)] [Illustration: FIGURE 116.--Leech cage. (NMHT 1977.0576.02; SI photo 77-13984.)] [Illustration: FIGURE 117.--Veterinary fleam. (NMHT 218383 [M-9255]; SI photo 61125-A.)] [Illustration: FIGURE 118.--Veterinary fleam. (NMHT 233570 [M-9665]; SI photo 59139-H.)] [Illustration: FIGURE 119.--Veterinary spring lancet. (NMHT 321697.08; SI photo 76-7756.)] [Illustration: FIGURE 120.--Veterinary spring lancet. (NMHT 321697.09; SI photo 76-7755.)] [Illustration: FIGURE 121.--Spring lancet, 18th century. (NMHT 321697.10; SI photo 76-7753.)] [Illustration: FIGURE 122.--Spring lancet, 19th century. (NMHT 1977.0576.01; SI photo 77-13961.)] [Illustration: FIGURE 123.--Counter-irritation device. (NMHT 89797 [M-4305]; SI photo 72-11274.)] [Illustration: FIGURE 124.--Barber surgeon's set, 18th century. (NMHT 199536 [M-6684-6692]; SI photo 73-4207.)] REQUIREMENTS FOR SMITHSONIAN SERIES PUBLICATION =Manuscripts= intended for series publication receive substantive review within their originating Smithsonian museums or offices and are submitted to the Smithsonian Institution Press with approval of the appropriate museum authority on Form SI-36. 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The following misprints have been corrected: missing "a" added (Abstract) "sacrificator" corrected to "scarificator" (page 2) "Ristelheuber" corrected to "Ristelhueber" (page 14) "Pheonix" corrected to "Phoenix" (page 14) missing note marker 127 added "canula" corrected to "cannula" (page 38) "rachet" corrected to "ratchet" (page 41) "ocilloscope" corrected to "oscilloscope" (page 41) "NHMT" corrected to "NMHT" (page 44) "Divison" corrected to "Division" (page 47) "Pennyslvania" corrected to "Pennsylvania" (page 48) "Federick" corrected to "Frederick" (page 48) "has has" corrected to "has (page 48) "sacrificator" corrected to "scarificator" (page 48) "Sacrificator" corrected to "Scarificator" (page 48) "cylindical" corrected to "cylindrical" (page 53) "Septemper" corrected to "September" (Note 3) "Hypochrondriasis" corrected to "Hypochondriasis" (Note 80) "chirurguscher" corrected to "chirurgischer" (page 63) "Joseph-Frédéric-Benoit Charrière (1803-1973)" is presented as in the original text. Other than the corrections listed above, printer's inconsistencies in spelling and hyphenation usage have been retained. 
50660	----	ENCYCLOPEDIA OF DIET _A Treatise on the Food Question_ IN FIVE VOLUMES EXPLAINING, IN PLAIN LANGUAGE, THE CHEMISTRY OF FOOD AND THE CHEMISTRY OF THE HUMAN BODY, TOGETHER WITH THE ART OF UNITING THESE TWO BRANCHES OF SCIENCE IN THE PROCESS OF EATING SO AS TO ESTABLISH NORMAL DIGESTION AND ASSIMILATION OF FOOD AND NORMAL ELIMINATION OF WASTE, THEREBY REMOVING THE CAUSES OF STOMACH, INTESTINAL, AND ALL OTHER DIGESTIVE DISORDERS BY EUGENE CHRISTIAN, F. S. D. VOLUME V NEW YORK CITY CORRECTIVE EATING SOCIETY, INC. 1917 COPYRIGHT 1914 BY EUGENE CHRISTIAN ENTERED AT STATIONERS HALL, LONDON SEPTEMBER, 1914 BY EUGENE CHRISTIAN, F. S. D. ALL RIGHTS RESERVED PUBLISHED AUGUST, 1914 CONTENTS VOLUME V _Lesson XVI_ _Page_ ADAPTING FOOD TO SPECIAL CONDITIONS 1145 Infant, Old Age, and Athletic Feeding; Sedentary Occupations, Climatic Extremes 1147 Normal Diet 1152 Infant Feeding 1154 General Rules for the Prospective Mother 1157 Special Rules for the Prospective Mother 1159 The Nursing Mother 1162 Care of the Child 1164 Constipation 1169 Exercise 1171 Clothing 1171 Temperature of Baby's Food 1173 Bandage 1173 Emaciation 1173 General Instructions for Children after One Year 1174 General Diet from Ages One to Two 1174 Simplicity in Feeding 1175 Old Age 1178 Three Periods of Old Age 1181 Athletics 1188 Sedentary Occupations 1194 General Directions for Sedentary Worker 1198 Climatic Extremes 1199 _Lesson XVII_ NERVOUSNESS--ITS CAUSE AND CURE 1209 Causes 1213 The Remedy 1217 Suggestions for Spring 1220 Suggestions for Summer 1222 Suggestions for Fall 1223 Suggestions for Winter 1224 _Lesson XVIII_ POINTS ON PRACTISE 1231 Introduction to Points on Practise 1233 Suggestions for the Practitioner 1236 Value of Experience 1239 Value of Diagnosis 1241 Educate Your Patient 1242 Effect of Mental Conditions 1245 Publicity 1247 Be Courteous and Tolerant 1250 _Lesson XIX_ EVOLUTION OF MAN 1253 What is Evolution? 1255 The Three Great Proofs of the Evolution of Animal Life 1261 Man's Animal Kinship 1265 _Lesson XX_ SEX AND HEREDITY 1277 The Origin of Sex 1279 A Rational View of Sexual Health 1285 Embryological Growth--Prenatal Culture 1289 Heredity 1293 What Heredity Is 1295 Summary of Facts regarding Sex and Heredity 1297 _Lesson XXI_ REST AND SLEEP 1299 Rest 1301 The Old Physiology 1305 Rest and Recreation 1306 Sleep 1308 Some Reasons 1310 Oxidation and Air 1312 _Lesson XXII_ A LESSON FOR BUSINESS MEN 1315 A Good Business Man 1320 The Routine Life of the Average Business Man 1322 Some Suggestions for a Good Business Man 1324 _Lesson XXIII_ EXERCISE AND RE-CREATION 1327 Exercise 1329 Constructive Exercises 1330 Exercise for Repair 1331 Physiology of Exercise 1333 Systems of Physical Culture 1338 Program for Daily Exercise 1343 Re-creation 1346 LESSON XVI <sc>Adapting Food to Special Conditions</sc> INFANT, OLD AGE, AND ATHLETIC FEEDING, SEDENTARY OCCUPATIONS, CLIMATIC EXTREMES Diet may be divided into three distinct classes--normal, preventive, and curative. In order to understand the application of diet to these several conditions, it is necessary to observe the following rules: 1 Foods must be selected which contain all the desired nutritive elements. 2 They must be so combined as to produce chemical harmony, or should at least produce no undesirable chemical action. 3 They must be proportioned so as to level or balance their nutritive elements; that is, to prevent overfeeding on some elements of nourishment, and underfeeding on others. Many fine specimens of men and women have been produced without knowledge of these laws, but in nearly every case it may have been observed that the person was normal as to habits, and temperate in eating, therefore led aright by instinct. If one lives an active life, spending from three to five hours a day in the open air, the body will cast off and burn with oxygen much excess nutrition, and will also convert or appropriate certain nutritive elements to one purpose, which, according to all known chemical laws, Nature intended for another. Much better results, however, will be obtained by giving Nature the right material with which to work, thus pursuing lines of least resistance. What foods to select, how they should be combined and proportioned, is determined mainly by laws dependent upon the following conditions: 1 Age. 2 Temperature of environment--time of year or climate. 3 Work or activity. (1) As to age: If we wish the best results we must select and proportion our food according to age, because the growing child or youth needs much structural material--calcium phosphates--with which to build bone, teeth, and cartilage. This is found in cereals and in all grain foods. The middle-aged person needs but little of these--just enough for repair, and the aged person needs practically none. While the growing child needs calcium phosphate, he also needs milk and natural sweets, which named in the order of their preference are honey, maple-sugar, dates, figs, and raisins. This does not mean that a generous quantity of vegetables and fruit cannot be taken, but that the articles first mentioned (cereals and starchy foods) should form a conspicuous part of the child's diet. The adult needs a much less quantity of the heavier starchy foods, because the structural part of the body has been built up. The diet of the adult should consist of vegetables, nuts, and a normal quantity of sweets, a normal quantity of fruits, milk and eggs, with rather a limited amount of cereal or bread products, while the aged, or those having passed sixty, could subsist wholly upon a non-starch diet (non-cereal starch), such as vegetables, milk, nuts, eggs, salads, and fruits, including bananas, which is not a fruit, but a vegetable, and which contains a splendid form of readily soluble starch. (2) As to time of year: In selecting and proportioning our food we should observe the laws of temperature or time of the year. We should not eat foods of a high caloric or heating value at a time when the sun is giving us this heat direct, thus building a fire inside, while the sun is giving us the same heat outside. The violation of this simple law is the cause of all sunstroke and heat prostrations. On the contrary, if we are going to be exposed to zero weather, we should build a fire inside by eating foods of a high caloric value. (3) As to work or activity: We should select and proportion our food according to the work we do, because eating is a process of making energy, while work is a process of expending energy, and we should make these two accounts balance. THE NORMAL DIET [Sidenote: Effects of overfeeding on starchy foods and sweets] While in some respects each body is a law unto itself, there are a few fundamental rules and laws that apply to all alike. For instance, overeating of starchy foods, in every case, will produce too much uric acid, and finally rheumatism. Also the overeating of sweets and starches will cause the stomach to secrete an over-supply of fermentative acids, the effects of which have been discussed in a previous lesson. [Sidenote: Temporary disturbances caused by radical changes in diet] In laying out the diet, under all conditions, the practitioner must be governed by the above-named rules. He should exercise his judgment, however, in each case according to the prevailing conditions. In prescribing diet it is well to remember that Nature will not tolerate, without protest, any radical change. It often occurs, therefore, that the most correct and thoroughly balanced menu will cause violent physical disturbances which the inexperienced may consider as unfavorable symptoms, but in a majority of cases this is merely the adjusting process, similar to that which occurs when the body is suddenly deprived of narcotics and stimulants after their habitual use. The practitioner should exercise much care in diagnosis. He should study all symptoms and lay out the diet so as to counteract prevailing conditions, and to produce normality. [Sidenote: The stomach should agree with natural food] The tendency of the body, that has been incorrectly fed for many years, to protest against the right kind and the right combinations of food, is often very deceptive. It is not always correct to say that the food did not agree with the stomach, but more correct to say that the different foods did not agree with themselves. The patient should be thoroughly acquainted with these facts, and mentally prepared for some temporary discomforts or physical protest against the new system. INFANT FEEDING [Sidenote: Large percentage of infant mortality due to incorrect feeding] The tremendous mortality among infants and children is due to incorrect feeding more than to all other causes. In the process of reproducing animal life, nearly all abnormal conditions are eliminated. The best that is in the mother is given to the child. The trend of Nature is upward toward higher intelligence and more perfect physical development. For this reason infants are usually healthier than their parents, though millions of babies are rapidly broken in health by improper feeding. The economy of Nature is perfect, therefore all natural forces conspire to preserve the life of the young. This is the natural law governing the preservation and the development of human life, and that this condition does not obtain is the most striking evidence of our lack of knowledge in feeding the young. [Sidenote: Point of view to be considered in infant feeding] Infant feeding must be considered from two points of view: (1) Dealing with the child or infant as we find it, where the mother has so violated Nature's laws of nutrition and hygiene as to afford no breast-milk for her child; (2) where this condition does not prevail, and the child receives ample nourishment from the breast of the mother. We will first consider the diet and the conduct of the mother during pregnancy and prior to it. Preparation for motherhood is one of woman's most sacred duties, because it involves not only the happiness and health of herself, but it shapes, in a large degree, the mental and the physical conditions of another being which will wield an influence over its whole life. [Sidenote: The unwelcome child] The common error of most women is that they do not desire children when they are first married, and in the pursuit of other pleasures they violate and disregard the laws of Nature; the baby is a mere accident--probably unwelcome. During the entire embryonic period the same old habits and diet are indulged in; the mental and the physical condition of the being-to-be has received no consideration, and, unwelcome in a strange world, the little eyes are opened. Then the instinctive love of the mother is kindled and lavished; the child's every want is law; it needs maternal nourishment and the mother desires to give it, but the natural fountain is insufficient, and probably dry. The mother's thoughts and inspirations can no longer become a part of the child, except through education in later years--they are two separate beings; the opportunity to endow it with a part of her life is forever gone. [Sidenote: Resistance to infant life should be removed as much as possible] Under the most favorable conditions we meet a constant resistance to life, and the higher we ascend in the scale of civilization the greater is the resistance encountered. It is therefore the duty of the mother, as also of the father, to remove every obstacle that would offer resistance to the physical and mental growth of the child. In order to do this it is necessary to carry out certain well-established laws concerning diet, exercise, fresh air, sunshine, and mental training. GENERAL RULES FOR THE PROSPECTIVE MOTHER From the time conception is recognized the following general rules should be observed: 1 The corset or all tight-fitting garments that would in any way interfere with freedom of exercise and thorough development of the abdominal muscles should be discarded. 2 As much time as possible--at least two hours each day--should be spent in the open air, and a system of moderate trunk exercises followed, together with deep breathing, calculated to expand the lungs to their fullest cell capacity, which is Nature's method of burning or oxidizing waste matter, and thereby keeping the blood pure. 3 The mental occupation should be an important factor in the daily regimen. Some congenial study should be chosen with the view of making it useful, while some remunerative employment should be sought and indulged in for a portion of each day. Avoid idleness by all means, or an idle roaming of the mind and spirit. Learn to think, to concentrate, to work, and to do something for others, as it is from these things that all happiness is gained. 4 The diet of the future mother should be governed somewhat by the laws laid out in the first part of this lesson; that is, age, temperature of environment, and occupation should be considered in its selection. SPECIAL RULES FOR THE PROSPECTIVE MOTHER [Sidenote: Suggestions for the diet] There are some specific rules in regard to diet, however, which every mother should observe. The diet should be balanced so as to contain all the needed elements of nourishment in approximately the right proportions. The proportions, however, should differ in many cases from that which she would take if she were in a normal state, especially in regard to starchy foods or calcareous matter. An abundance of green salads, sweet ripe fruits, fresh vegetables in season, eggs, milk, nuts, and not more than two ounces of bread, potatoes, or dried beans should be taken daily. If flesh food or something salty is craved, tender chicken, or fish, may be allowed in small quantities. [Sidenote: Abnormal appetite during pregnancy] It should be borne in mind that I do not advocate the use of flesh foods, but during pregnancy the appetite is varying and sometimes tyrannical, and it has been found better to compromise with this condition than to combat it. The use of a limited quantity of tender meat, or any other article of good food for which there should arise a craving, is therefore advisable. [Sidenote: Flesh of young animals preferred] In the selection of meats, the flesh of young animals is best, for the reason that young animals are more healthy and less liable to contamination by dis-ease. The meat of either fowl or fish is rather appetizing, and often satisfies the craving that many pregnant women have for the heavier meats such as pork or veal, which are, of course, very much more difficult to digest. There is, notwithstanding the opinion foolishly held by many doctors, no difference in the nutritive qualities of white or dark meat, as either variety is nourished by identically the same blood supply, and contains the same sort of protoplasm. So it is a mistaken idea to think that there is any appreciable difference in the digestibility of white meat as compared with dark, except as the effect of mental suggestion may be operative. Of course, we know that if you tell a person often enough that a certain thing is true, eventually he will act upon it automatically. And so it is with the white and dark meat fetich. THE NURSING MOTHER [Sidenote: Breast milk vs. artificial foods] If the mother supplies enough milk, this is infinitely superior to any artificial combination of so-called infant foods. Unfortunately a large majority of children are not breast-fed, and must depend upon the various commercial infant-foods, or upon the judgment of the untrained nurse, or the mother. [Sidenote: The lives of babies often depend upon the mother's diet] The majority of mothers, if so disposed, could, by studying their own diet, supply the most robust child with ample breast-nourishment until it is ten or twelve months old, after which period the infantile crisis would be passed, and millions of little lives would thereby be saved. However, the confinement and the trouble to which the mother is subjected by the nursing baby causes the majority of infants to be weaned within a few weeks after birth, and turned over to the hazard of prepared food, soporific drugs, and nurses. [Sidenote: Child-love stimulated by nursing] If mothers could realize the love that is daily kindled and strengthened; if they could be made to know how much more their children would love them, and they would love their children; if they could look into the years and see how the link of love between them and their children had been shaped, molded, and fashioned by the simple act of nurturing them from the breast (to say nothing of the lives that would be saved), the artificially-fed baby would be a rarity, and the mother would be queen in the hearts of the nation's children. The most beautiful thing that ever graced the canvas of art, or shed its love into the cold realism of nature, is a nursing baby pushing from its satisfied lips the mother's breast, and smiling its sweet content into her face. It is almost criminal to withdraw the breast from an infant, and to turn it over to the treachery of prepared foods, when, by devoting a little time each day to the study of the science of eating, it is possible for the mother to supply the child with her own milk. CARE OF THE CHILD The following are general rules for feeding the infant from birth to about one year of age. These rules cannot be made inflexible because all children differ in temperament, vitality, and as to prenatal influences, but if the mother will observe these instructions with reasonable care, her child can be brought healthfully through the most critical period of its life, and will enter the solid food age with good digestion, a strong body, and an excellent chance to withstand all children's dis-eases. Where artificial feeding becomes necessary, then the preparation of the baby-food is of primary importance. Cow's milk is, of course, the logical food, but taken whole, that is, the entire milk, it is too high in proteids, and deficient in sugar; therefore, in order to make a healthful infant-food, it must be modified according to the requirements of the infant body. The nurse or the mother should prepare a quantity sufficient for only one day's supply at a time, after the following formula: Cream 2 ounces Milk 2 ounces Water 15 ounces Milk-sugar 4 level teaspoonfuls Lime-water 2 teaspoonfuls or 1/2 ounce This should be thoroughly mixed, placed in the bottle, and set in warm water until it is brought to the temperature of breast-milk. The above formula may be used during the first month of the baby's life. The quantity and the frequency of feedings should be according to the following table: AGE FEEDINGS OUNCES INTERVALS OF 1st day 5 to 6 1 3 or 4 hours 2d day 7 to 8 1 2-1/2 to 3 hours 3d to 7th day 9 to 10 1-1/4 2 to 2-1/2 hours 2d, 3d, and 4th weeks 10 2 to 3 2 hours Formula for the second and the third months: Cream 3-1/2 ounces Milk 1-1/2 ounces Water 14 ounces Milk-sugar 5 teaspoonfuls Lime-water 2-1/2 teaspoonfuls Quantity and frequency of feeding should be about as follows: MONTHS FEEDINGS OUNCES INTERVALS 2d and 3d 7 to 8 3 to 4 2 or 3 hours Formula for period from the fourth to the twelfth month: Cream 6 to 8 ounces Milk 2 to 3 ounces Water 10 ounces Milk-sugar 5 to 6 teaspoonfuls Lime-water 2 to 3 teaspoonfuls Quantity and frequency of feedings should be about as follows: MONTHS FEEDINGS OUNCES INTERVALS 4th, 5th, and 6th 5 to 6 4 to 6 3 to 3-1/2 hours 7th, 8th, and 9th 5 6 to 7 4 to 4-1/2 hours 10th, 11th, and 12th 5 6 to 8 4 to 4-1/2 hours The above formulas for infant-food are the best that can be made from ordinary cow's milk. The milk-sugar and the lime-water herein named can be purchased at any first-class drug store. [Sidenote: Avoid too frequent feeding] These tables are not given as exact. The mother should exercise careful vigilance and judgment, especially in reference to the quantity of each feeding, and the frequency. The moment the child shows symptoms of overfeeding, which symptoms are usually evidenced by vomiting or discomfort, the quantity of cream and the amount at each feeding should be reduced. In fact, it is healthful, and often necessary for the child to allow it the opportunity to get hungry. The digestion of many a baby is totally ruined by continuous feeding, which is done out of motherly sympathy, or merely to keep it quiet. [Sidenote: Importance of cleanliness in preparing child's food] The mother or the nurse should exercise great care in the cleanliness and the hygienic preparation of children's foods. Milk should be fresh, and of the very best. It should not be left uncovered or exposed. It should be kept continually on ice until ready for use. The cream should be taken from the top of the bottle, or from fresh milk. This insures better quality of butter-fat than is generally supplied in ordinary commercial daily cream. As the child advances in age, whole milk, cereal gruel, and egg mixture (two whites to one yolk) may be administered according to the child's normal appetite and digestion. The egg may be prepared by whipping the whites and the yolks separately, adding to the yolk a teaspoonful of cream and one of sugar, then whipping the beaten whites into this, and serving. CONSTIPATION The stools of natural, healthy children should be bright yellow and perfectly smooth. If grainy and soft, food should be made richer. If in curds, it evidences too rapid coagulation; therefore an alkali should be added. If the stools are white and oily, it indicates an excess of cream. If hard and dry, it indicates an insufficient amount of cream. If green, reduce the quantity of milk, or omit it altogether, and increase the quantity of barley-water. The majority of bottle-fed children suffer greatly from constipation, caused largely by the milk, or the failure to modify the milk properly, or to make it contain the constituent elements of breast-milk. This condition can be relieved by giving the child sweet orange juice every night and morning, or the juice from soaked prunes, if preferred. This should be administered in quantities ranging from a dozen drops to two or three teaspoonfuls, according to the age of the child and the severity of the condition. Intestinal congestion can often be relieved, however, by giving the abdomen gentle massage, preferably with a rotary or kneading motion. In cases of diarrhea, infants from three to eight months old should be given first an enema, and then a diet entirely of boiled milk mixed with rice or barley-water. EXERCISE All infants need some exercise. They should be gently rubbed and rolled about after the morning bath, before they are dressed. There is nothing more healthful than exposure of the baby-skin to fresh air in a normal temperature. CLOTHING Next in importance to the food of the infant is its clothing. The usual style of dressing babies the first three months of their lives is positively barbaric; not that it imitates uncivilized people, but because it evidences the grossest ignorance and cruelest vanity. The mother seems to have no way of expressing her pride in her child except by bedecking it with elaborate garments. These usually consist of three long skirts, two of them attached to bands which are fastened around the body. The weight of this clothing prevents the free use of the baby's feet and legs, putting it into a kind of civilized strait-jacket, thus preventing it from exercising the only part of its anatomy that it can freely move. It is nothing uncommon to see a beautiful baby sore, irritated, and broken out with heat all over its little body by being heavily enveloped in barbaric rags. The child, therefore, is made to suffer merely that it may please a proud mother, and conform to an ignorant custom a thousand years old. The only purpose clothing should serve is that of bodily warmth. When it is made the instrument of painful adornment it is serving the same purpose as "rings in the ears and bells on the toes," and the mind of the mother who thus afflicts her child is in the same class as that of the ignorant barbarian whom she imitates. TEMPERATURE OF BABY'S FOOD It should be remembered that all liquid food for a child up to twelve or fifteen months old should be administered at a temperature no lower than blood-heat. The liquid mixtures named herein may be made in advance of the needs, and placed upon ice merely to preserve them, but should be warmed to a temperature of at least ninety-nine degrees Fahrenheit before administering to the child. Pure water should be given to all children from the time they are two weeks old. BANDAGE The bandage should be removed about the close of the third month. EMACIATION In case of slight emaciation or lack of fat, the child should be given an olive-oil rub once or twice a week, rubbing gently into the skin about one teaspoonful of oil. GENERAL INSTRUCTIONS FOR CHILDREN AFTER ONE YEAR All children, whether breast-fed or bottle-fed, are subject to practically the same health rules after they are about one year old. Therefore I will now consider all children in the same class, and lay out for them what may be termed general instructions in health and hygiene. Care should be exercised to omit from the diet of children just beginning to take solid food, all articles that will not dissolve readily without mastication. GENERAL DIET FROM AGES ONE TO TWO The diet from the first to the second year should consist of: Baked apples Baked potatoes--sweet or white Cereal--limited quantity (thoroughly cooked) Cream soups--home-made, such as: Cream of celery Onion Potato Rice Tomato, etc. Eggs Milk Pulp of soft ripe fruits Vegetables--thoroughly mashed, such as: {Asparagus Fresh {Squash {Spinach The above vegetables contain much cellulose or pulp which should be entirely discarded, leaving only the meat or purée; but to the child from eleven to fifteen months old, they should be administered in very limited quantities. SIMPLICITY IN FEEDING Especial attention should be given to simplicity in feeding: 1 Avoid giving too many things at the same meal; from three to four articles at one time are sufficient 2 Mothers should be especially cautioned against giving a child bread made with yeast, or baking powder, and against the old diet of milk toast 3 All meat, flesh food, stimulants or narcotics of every kind should be omitted from the diet of children 4 The crowning mistake of the doting mother is often made in feeding her child from the conventional table, on such things as weakened coffee or tea, meats, and condiments 5 The custom of giving children an excess of sweets has ruined millions of little stomachs, and has given them a heritage of dis-ease and suffering before they have entered their 'teens 6 All condiments, such as pepper, salt, vinegar, pickles, and all pungent things should be eliminated from the diet of children--the taste of the child is very susceptible to cultivation, and with very little encouragement it will accept things that have no place in the human economy, and which are positively harmful 7 When a child begins teething, it may be given a small piece of hard water-cracker with safety If the above rules are observed, it is reasonable to assume that normal hunger of the child will guide it very correctly in selecting, proportioning, and combining its food through the period of childhood until it enters the period of youth. OLD AGE [Sidenote: Necessity for old age diet] There seems to be two critical periods in every life--the ages of thirty and sixty. If the sixtieth year can be turned with good digestion, normal assimilation and excretion, it is fair to assume that with reasonable care the century mark may be easily reached. It is also reasonable to assume that experience will have taught most thoughtful people what to eat and what not to eat, but the mortality tables of nearly all civilized countries, of which the writer has made a careful study, prove that a majority of people do not reach their sixtieth year, and but a very small per cent of those who do are blessed with good digestion. Therefore an old age diet is quite as important to the student as infant feeding. For purposes of convenience, I will put all cereal products, legumes, and white potatoes in the starch or bread class, and henceforth they will be referred to as such. [Sidenote: Meat and bread produce old age] The majority of disorders that mark the difference between youth and age may be traced directly to the overconsumption of meat and bread, especially cereal starch. The hardening of the arteries, the stiffening of the cartilage, the enlargement of the joints, and the general lack of flexibility throughout the body is due almost wholly to the overconsumption of these two staples. [Sidenote: Uric acid in rheumatic conditions] Uric acid is always present in gouty and rheumatic conditions, but it is there as Nature's defense against our sins, and not as a primary cause. Meat is not the cause of uric acid as has been popularly taught. Uric acid is one of the constituent elements of all animal bodies, and when the normal supply in the human body is supplemented by that which is contained in the body of the animal upon which we prey, we are oversupplied. This is as far as meat-eating contributes toward uric acid poisoning. [Sidenote: Soluble starches desirable] When the body is young and growing, it can consume and appropriate a considerable quantity of starchy or structural material, but when it is fully grown, or has turned forty, it can subsist healthfully upon a diet containing only from three to five per cent of starch, and as one becomes older the more soluble forms of starch should be taken, such as the starch contained in green peas, beans, and corn, which, immature, is readily soluble and assimilable. The starch in the banana is also easily appropriated and easily oxydized, and will be found to agree with many who cannot eat starch in any other form without producing fermentation. After the fiftieth year the diet becomes more and more a factor needing special attention in the daily regimen, both as to selection and quantity; and with advancing age the quantity of food should be gradually reduced until the minimum which will support life healthfully is reached. [Sidenote: Importance of diet with advancing age] In old age the diet should be governed by the same general rules as those of younger people; that is, elderly people should select, combine, and proportion their food according to temperature of environment, labor, and age. Those performing manual labor can use and eliminate food material which would produce uric acid and other poisons in the body of the sedentary worker. THREE PERIODS OF OLD AGE [Sidenote: Diet from fifty to sixty] Old age may be divided into three periods. From fifty to sixty the diet should consist of a very limited quantity of bread products (not more than two per cent); fresh green vegetables, fresh mild fruits, nuts, a normal quantity of milk and eggs, a limited quantity of sugar, and a moderate amount of fats. [Sidenote: Diet from sixty to seventy] From sixty to seventy the amount of cereal starch should be reduced to one per cent, or not more than two per cent, while the other articles named may be taken as suggested from fifty to sixty, gradually eliminating starchy foods, and increasing foods containing proteids, casein, and albumin. [Sidenote: Diet from seventy to one hundred] Between the ages of seventy and one hundred, the same general suggestions as those above laid out should be followed, eliminating entirely all cereal products. The more soluble forms of starchy or carbohydrate foods, such as potatoes, bananas, and green peas, beans, corn, etc., may be taken. (See Lesson XIII, Vol. III, p. 632.) The necessary amount of fats, albumin, casein, and proteids must be governed by activity and temperature of environment. The following are suggestions for one day's menu, in spring and summer, age between fifty and sixty. Choice of menus may be exercised, but each menu should be taken in its entirety. MENU I MENU II BREAKFAST Melon or subacid fruit One or two very ripe bananas, One egg--coddled with figs, cream, A potato or a very little and nuts coarse bread Choice of fruit--non-acid A glass of clabbered milk or Two glasses of milk buttermilk Two tablespoonfuls of raisins, with cream and nuts LUNCHEON Choice of peas, corn, beans, Choice of carrots, parsnips, or creamed onions beans, squash, or asparagus Eggs or buttermilk A baked sweet or a white A baked potato potato A salad or something green, A glass of buttermilk with nuts Cream cheese, dates, and A banana, with cream, nuts nuts and dates A very small portion of green salad, with grated nuts DINNER One fresh vegetable--spinach, A green salad cooked ten minutes Two fresh vegetables One egg or a very small A sweet or a white potato, portion of fish with sweet butter A baked potato A glass of sour milk Choice of dates, figs, or raisins, with cream cheese and nuts In cases of constipation, two or three tablespoonfuls of coarse wheat bran (cooked, if desired) should be taken with the breakfast and the evening meal, and a spoonful just before retiring, taken in a glass of water. Such fruits as plums, peaches, or berries should be taken daily, just after rising and just before retiring. The following are suggestions for fall and winter menus, for a person between the ages of fifty and sixty: BREAKFAST Oranges, apples, pears, or soaked prunes An egg and a small portion of either plain boiled wheat or rice A very ripe banana, with nuts and raisins NOTE: Sweet fruits may be taken instead of the acid fruits suggested, and milk instead of eggs. LUNCHEON One or two fresh vegetables, such as carrots, onions, turnips, cabbage, or beans Celery or any coarse plant A potato or a very small portion of corn If not very active, the luncheon may consist of two glasses of buttermilk and a spoonful of wheat bran. DINNER Choice of two fresh vegetables A baked potato Choice of fish, eggs, or buttermilk Corn bread or a very small portion of coarse cereal All fresh, watery vegetables should be cooked in a casserole dish. A sufficient quantity of water should be drunk at each of these meals to bring the moisture up to about sixty-six per cent of the meal--two to three glasses. These meals are mere suggestions, and are therefore subject to many variations. All green salads may be substituted for one another; all starchy products--grain, potatoes, and legumes--may also be substituted for one another. ATHLETICS [Sidenote: Every diet should be an athletic diet] The diet for the athlete really differs but little from that which should be taken by every person in normal health, the object in all cases being to secure the greatest degree of energy from the least quantity of food. In order to do this, the laws governing the selecting, the combining, and the proportioning of foods should be observed. When the digestive, the assimilative, and the excretory organs are properly performing their functions, the object should be to gain the highest efficiency in food with the least amount of loss or waste. Every diet, therefore, should be made an athletic diet. In dealing with the public at large, the work of the practitioner will be confined very largely to prescribing for those who, by violation of Nature's laws, have become dis-eased, or in some way physically abnormal, and in these cases, of course, a remedial or counteractive diet first becomes necessary. [Sidenote: General diet for normal athlete] In dealing with the athlete as a special class, however, we must consider him as a normal creature, somewhere between the ages of twenty and forty. We must also consider that his digestion and assimilation of food, and elimination of waste are normal. Under these conditions, the diet should consist of highly nitrogenous and proteid compounds, leveled or balanced by the requisite amount of carbohydrates and fats. [Sidenote: Quantity of fat required at different seasons] If the athlete is training for action in summer, the quantity of fat should be reduced according to temperature or climate. When the thermometer ranges in the seventies and eighties, one ounce of fat each twenty-four hours would probably be sufficient, while if the mercury is down in the twenties or thirties, from two or three ounces may be required to keep up bodily heat. The following are suggestions for summer athletic diet: BREAKFAST Fruit or melon *Corn, or boiled wheat, with nuts and cream Eggs, whipped, with sugar and cream--lemon juice flavor LUNCHEON Break from four to six eggs into a bowl, adding a heaping teaspoonful of sugar to each egg; whip five minutes; while whipping, add slowly one teaspoonful of lemon juice to each egg; to this add half a glass of milk to each egg, and drink slowly *Corn or a potato DINNER Fruit, berries, or melon A salad of lettuce, tomato, and grated carrots; serve with dressing of lemon juice, grated nuts and olive-oil One fresh vegetable An egg or tender fish A baked potato Buttermilk [Footnote: NOTE: Corn to be prepared as follows: Cut lightly from cob with a sharp knife and scrape down with a dull one; serve uncooked with a little salt, sugar and cream.] The following are suggestions for winter athletic diet: BREAKFAST A baked apple or an orange One coarse cereal, with nuts and cream Two eggs, either whipped or boiled two minutes Very ripe bananas, with dates, nuts and cream (If bananas are not very ripe, they should be peeled and baked) See recipe, Vol. III, p. 677 LUNCHEON Beans or lentils Carrots, turnips, squash, or corn Fish or eggs A baked potato Buttermilk DINNER Two fresh vegetables A green salad, with oil Omelet, with grated nuts A banana, with nuts and cream, and either dates or raisins Buttermilk These menus, like those given for summer, are merely for the purpose of suggesting selections, combinations, and proportions of food that will meet the exigencies of temperature, environment, and work. The quantity of food required will depend largely upon the size (physique) of the individual, the severity of training, and the feats to be performed. It is especially important that these suggestions be well considered at least one day before engaging in any athletic event or work requiring extraordinary physical effort, as the human body appropriates or uses food from twenty-four to thirty-six hours after it is eaten. [Sidenote: Exposure to extreme cold or exertion] If one is to be exposed to extreme cold, an excess of fats should be taken, beginning thirty-six hours before exposure. If much physical effort is to be exerted, the diet should be balanced as to all nutritive elements, with an excess of nitrogenous foods. In fact, these rules should be observed by every one who desires to make feeding scientific, and to make food his servant instead of his master, as our civilized habits have a tendency to do. SEDENTARY OCCUPATIONS [Sidenote: Cessation of activity means disintegration] Nature demands from every form of life a certain amount of activity or motion. Any transgression of this law means disintegration. Rest is merely the process adopted by Nature to reconvert matter into its original elements. To whatever extent one ceases activity, Nature, under normal conditions, inflicts this penalty. [Sidenote: The penalty of civilization] Man's civilized habits and customs have produced a class of workers who, while at work, are deprived of their requisite amount of motion, and who, therefore, pay the penalty by shortened periods of life, and by numerous disorders which we have come to characterize as dis-ease. There is but one method known to science by which these penalties may be avoided, and by which the worker whose occupation must be sedentary may become as healthful as his brother who can order his life in conformity with Nature's laws. That method lies in the ordering of his diet. [Sidenote: Dis-ease is merely congestion] All dis-ease may be called _congestion_, or the failure of the body to eliminate poisons and waste matter. The process of elimination is assisted by activity (work or play). The accumulation of waste and poisons in the body is measured or determined almost wholly by the diet. [Sidenote: Diet governed by work] The man who is swinging a pick or a sledge hammer in the open air may eat or drink almost anything, because his powers of eliminating waste are aided by his work. It follows, therefore, that those whose work is of a sedentary nature must procure their nutrition from substances containing the minimum of waste, and producing the maximum of energy, and the quantity must be measured accurately by the demands of the body, or autointoxication (self-poisoning) will result. Intestinal congestion (constipation), which is almost universal among sedentary workers, is caused in nearly all cases by consuming a quantity of food in excess of the physical demands, and which cannot be thrown off owing to the lack of exercise. It is at this point that science must lay out the dietetic regimen so as to make it conform to the occupation, or to the lack of physical activity. The following are suggestions for a spring or summer diet for the average sedentary worker: BREAKFAST Cantaloup, berries or peaches, with sugar and cream An egg One or two bananas, with nuts, cream, and raisins (Bananas should be baked, if not very ripe) LUNCHEON Peas, beans, or asparagus A heaping tablespoonful of nuts A salad of lettuce and tomatoes, with nuts A baked potato, tender corn, or a very little coarse bread DINNER Melon or cantaloup Two tablespoonfuls of nuts One or two fresh vegetables, including an ear of tender corn Fish, eggs, or buttermilk Plain ice-cream, if something sweet is desired GENERAL DIRECTIONS FOR SEDENTARY WORKER The student will recognize that in these menus the heavier foods are prescribed sparingly, while the lighter or the more readily soluble articles predominate. From these suggestions a fair idea of a fall and winter diet can be drawn. Indigestion, sour stomach (hyper-chlorhydria), constipation, malassimilation, and general anemia are the disorders with which the sedentary worker is most commonly afflicted. In dealing with each and all of these conditions, including obesity, which is often the result of sedentary habits, the first thing to be done is to limit the quantity of food to the normal requirements of the body, and in extreme cases a diet below the normal should be observed; no one was ever made ill by underfeeding. Then, with proper care as to the selection, combination, and proportions of food, and an increased amount of exercise and deep breathing, the person of sedentary habits should be made as healthy and strong as the outdoor worker in the fields of manual labor. CLIMATIC EXTREMES In considering a diet to meet the requirements of climatic extremes, either hot or cold, it is necessary to reckon from normality, both as to climate and as to the health of the individual. All the foregoing lessons, taken as a whole, are designed to teach one method or theory, involving two principles: 1 Selections, combinations, and proportions of food that will counteract and remove the causes of unnatural conditions called dis-ease 2 Selections, combinations, and proportions of food that will bring the body up to its highest degree of development and there maintain it Under normal conditions the temperature of the body may be thoroughly controlled by feeding. The principal process of metabolism is that of making heat out of the fuel given to the "human boiler." The amount of heat, therefore, that a given quantity of food will produce is determined very largely by the amount of resistance that is met from natural environment. [Sidenote: Amount of fat required in different temperatures] The human body, under ordinary conditions, in a temperature of 60° Fahrenheit, will use about two ounces of pure fat every twenty-four hours. If the temperature should drop to 30° Fahrenheit, it would require about three ounces of fat every twenty-four hours to keep the temperature of the body at normal. Under certain conditions of exposure it might require as much as five and even six ounces of pure fat to maintain normal temperature of the body, and in the extreme north, where the temperature ranges in winter from 25° to 30° below zero, the natives often take as much as sixteen ounces of fat during the day. Fat being the principal heat-producing element, it is, therefore, the most necessary thing to consider in a temperature of extreme cold. The student will readily understand that, in order to maintain a normal standard of vitality and endurance, the selection of foods must be made according to age, activity, and temperature. For a person undergoing a reasonable amount of exposure, and working in a climate where the temperature is ranging between 20° and 30° Fahrenheit, the following menus, covering one day, may be suggested: Immediately on rising, drink a cup of hot water, then take vigorous deep breathing exercises, followed by a cool sponge bath and rub down. BREAKFAST (An hour later) Add half an ounce of sugar to two or three eggs, and whip five minutes; add a tablespoonful of lemon juice while whipping; mix with this two glasses of rich milk A tablespoonful of nuts One very ripe banana, with cream LUNCHEON One fresh vegetable Lima or navy beans A salad, with either olive-oil or nuts A baked potato or boiled wheat (A liberal supply of butter or cream) DINNER A baked sweet potato One or two vegetables Eggs, or buttermilk, unskimmed A baked white potato, with either olive-oil or butter Dates, with cream cheese, or gelatin, with cream As the temperature becomes lower, the amount of fats and proteids should be increased according to exposure and activity. The student should bear in mind that carbohydrates, proteids, and fats are the most important factors in the winter dietary. Other articles can be held level over a wide range of temperature, provided these three staple nutrients are taken in the requisite proportions. [Sidenote: Summer diet requires scientific consideration] Nearly all people in normal health instinctively avoid heat-producing foods in hot weather, and as in warm or hot climates people live more in the open air, oxidation is therefore more perfect, and has a tendency to aid elimination, so the errors of diet are not so serious. Nevertheless, the food to be taken in hot climates, or the heated term of summer, should receive scientific consideration. Anthropoid life, of which man is the highest type, originated in the tropics, and nearly everything necessary for his highest physical development grew prodigally in that country. His natural or primitive diet was nuts, fruits, and salads (edible plants). Civilization has transplanted him in the north, and has laid heavier burdens upon him, therefore he needs, in many instances, heavier and different foods, such as the carbohydrates, proteids, fats, and the albumin and the phosphorus in eggs. As the temperature becomes warmer, the heat-producing factors, such as fats and carbohydrates (starch and sugar), should be gradually reduced. The following menus are suitable for the average person, in normal health, between the ages of thirty and sixty, when the temperature is ranging from 70° to 90° Fahrenheit: BREAKFAST Cantaloup, peaches, or berries Very ripe bananas, with grated nuts and cream A glass of milk LUNCHEON One whipped egg A fresh vegetable A teaspoonful of nuts A lettuce and tomato salad A baked sweet or white potato DINNER Peas, beans, asparagus, or corn A salad, with grated nuts and carrots A potato One whipped egg Half a glass of milk A service of gelatin These menus are mere suggestions, not invariable, and in following them it should be remembered that all green salads may be substituted for one another, and as a general rule such underground articles as beets, carrots, turnips, and parsnips may be substituted for one another. Also green corn, peas, and beans are in the same general class. (See "Constipation," Vol. III, p. 761.) Observation of these rules will give the student rather a wide range of articles to draw upon in selecting a diet for the normal person. LESSON XVII NERVOUSNESS ITS CAUSE AND CURE The nerves of the human body are the most important, the most complex, and probably the least understood of any part of the human anatomy. In conditions of health they are never heard from, therefore every expression of the nervous system is a symptom of some abnormal physical condition. [Sidenote: True meaning of nervousness] The usual term "nervousness" conveys to the mind of the average person such conditions as sleeplessness, restlessness, lack of mental and physical tranquillity, but to the trained mind of the food scientist or physician, it means mental aberration, hallucinations, morbidity, mental depression, lack of self-confidence, uncertainty, loss of memory, fear of poverty, anticipation of accident, tragedy, death, insanity, and a multitude of things that never happen. Language cannot adequately describe or convey to the mind of another person the strange impressions that sweep o'er the mind--the mental anguish caused by an ordinary case of nervous indigestion. Those only who can understand why many good men and women sometimes take their own lives, or commit some great crime, are those who have experienced the same affliction. If we could correctly interpret the various symptoms given to the brain from the nervous system, and would heed these symptoms, the body might be kept in almost perfect health under all conditions of civilized life. [Sidenote: Relation of nutrition to nervousness] The lack of fresh air and exercise is always told by nervous expression, but the most important and significant message conveyed by the nerves at the brain is that concerning food and general nutrition. Instinct often leads us to fresh air and exercise, but with our food it is vastly different. We acquire a taste for certain things; the habit grows upon us, and though the nerves tell the story to our senses over and over, we heed it not because we are held behind the bars of habit by the tyranny of appetite. In this respect the tobacco fiend, the drug fiend, and the food fiend are all in the same class. CAUSES Nervousness usually has its origin in disorders of the functions of metabolism, assimilation and elimination. In other words, somewhere between the time the food is first taken into the system, and the time the poisonous débris of the food and the body waste is finally eliminated, there are some grievous faults of function. Some deficiency in the activity and in the secreting power of any of the digestive organs; some defect in the assimilation of the finished pabulum; some short-coming in the process by which oxygen is carried through the system to convert the "end-products" into less toxic substances for final excretion--any or all of these causes may conspire to produce nervousness. These may again, in their turn, be due to causes that arise within the mind, inhibiting the proper functional activity of the body. But overfeeding, or eating the wrong combinations of food, and lack of proper elimination, are probably the most frequent causes of nervousness. When we take into the system more food than the body requires, there is bound to be a certain amount of it which cannot be utilized to build tissue, or furnish heat, or supply mineral salts. This excess food, under the influence of fermentative processes, breaks down into various poisonous products. This is especially true of the albuminous elements of the food. For these, in the heat and moisture of the small intestine, rapidly undergo a process of rotting--this is exactly what it is--and develop some of the most virulent organic poisons known to man. They exercise a profound depression upon all the physiological functions, and cause an actual toxic degeneration of the nervous protoplasm. This, in turn, causes nerve irritability, insomnia, and many of those protean symptoms roughly grouped under the head of neurasthenia. To completely relieve the condition means that a thorough reform in habits,--and particularly in dietetic habits--must be undertaken. Excesses of every kind--even of play or work--must be stopped. All possible sources of worry must be removed. Rest and recreation should be made quite as important--in fact more so, than house-work or business. Sleep, and plenty of it, should be secured at all costs. Eight hours are none too many--although ten would be better. Needless to say, the question of diet is of prime importance. The use of tea, coffee, tobacco, alcohol, and all stimulant beverages, as well as condiments, should be discontinued. Plain, wholesome food--with an ample supply of lecithin (or nerve fat) such as eggs, milk, olive oil, etc., should be taken liberally. All sources of fermentation--especially those forms due to an excess of starch, sugars, and acids, should be avoided. Careful attention should be given to securing free bowel movement. And, above all, an equable frame of mind should be cultivated; the way to defeat this purpose is to overwork and worry in order to accumulate the thing called property. [Sidenote: Working for wealth alone defeats its purpose] The desire to accumulate property has for its excuse immunity from work at some future time so that we can enjoy life, but experience teaches us that the physical cost of this effort defeats the very purpose for which we are striving. THE REMEDY The victim of nervousness should first seek a complete change of environment, and engage in pleasant, and, if possible, profitable occupation. [Sidenote: Therapeutic value of working for the public good] Thousands of people become nervous wrecks by pursuing work for which they have no natural taste or ability, and many become nervous from the monotony of environment. This is especially true with women, and while it is exceedingly difficult for countless housewives and mothers to escape from this monotony, yet they can secure relief by becoming interested in some work of a public or quasi-public nature, or by taking up a "hobby" that has for its purpose some form of public good. All people love the plaudits and esteem of their fellow-creatures, and there is nothing that will relieve the monotony and bring that satisfaction which all of us desire more quickly than earnest labor in a worthy cause. Therefore, this is one of the first and the best remedies for that character of nervousness caused by the monotony and narrowed life of the average woman. [Sidenote: The effects of wrong eating and drinking] The most prolific cause of nervousness, however, is incorrect, unnatural habits of eating and drinking, therefore, the logical remedy must be found in simplifying, leveling, and making the diet conform to the requirements of the body governed, of course, by age, occupation, etc. The nervous person should eliminate from the diet acids, sweets (see Lesson VIII, Vol. II, pp. 313 and 332), flesh foods, and all stimulating beverages. The following menus, with variations according to the available supply of fruits and vegetables in season, should be adopted: SUGGESTIONS FOR SPRING Choice of the following menus: MENU I MENU II BREAKFAST A cup of hot water Very little farina or oatmeal, Two baked bananas with cream Steamed wheat--cream A glass of buttermilk LUNCHEON Corn hominy, with butter A white potato, baked or cream A large, boiled onion Raisins, nuts, cream cheese Corn bread One or two glasses of water A glass of milk DINNER A pint of junket One egg or a morsel of fish Bran gems A baked potato A coddled egg (For bran Choice of carrots, parsnips, meal and coddled eggs, or onions see Vol. III, pp. 677 and (A green salad or spinach 683) may be eaten at this Hot water meal, if desired) One or two glasses of water should be drunk at each of these meals. If there is a tendency toward constipation, a liberal portion of wheat bran, thoroughly cooked, should be taken at both the morning and the evening meal. Bran possesses valuable nutritive properties, such as mineral salts, iron, protein and phosphates, and it harmonizes chemically with all other foods. SUGGESTIONS FOR SUMMER BREAKFAST Melon, or any mild subacid or non-acid fruit, such as pears, baked apples, sweet grapes, very ripe peaches, Japanese plums, or persimmons Choice of whipped egg or junket A banana--natural, or baked, if the digestion is slightly impaired LUNCHEON A fresh green salad, such as celery or lettuce, with oil or nuts Onions, uncooked A whipped egg Carrots, peas, or beans DINNER Corn, carrots, peas, beans, or squash Half a cup of plain wheat bran, cooked A baked potato A glass of water SUGGESTIONS FOR FALL In adopting the two-meals-a-day system, the noon meal should be omitted. This gives the stomach and the irritated nerves a rest, and creates natural hunger which augments both digestion and assimilation. (See Lesson XIII, p. 630). BREAKFAST Melon or peaches A very ripe banana, with soaked prunes and cream A spoonful of nuts One or two spoonfuls of whole wheat, cooked very thoroughly One egg, prepared choice--preferably whipped One glass of water A green salad or some sweet fruit may be eaten at noon if very hungry. DINNER Squash or pumpkin, cooked en casserole Fresh string beans A baked sweet potato One or two tablespoonfuls of nuts--choice Junket or gelatin A glass of water SUGGESTIONS FOR WINTER FIRST DAY: On rising, drink two cups of cool water, and devote from five to ten minutes to vigorous exercises and deep breathing. BREAKFAST A cup of hot water or thin chocolate A small portion of boiled wheat One exceedingly ripe banana, eaten with cream One or two eggs, whipped--cream and sugar added One or two figs, with cream and either nuts or nut butter LUNCHEON Two eggs, whipped; add a flavor of sugar, orange juice, and a glass of milk A cup of hot water DINNER Turnips, carrots, parsnips, onions--any two of these A baked potato or baked beans A small portion of fish, white meat of chicken, or an egg Just before retiring, take exercises as prescribed for the morning, and, if constipated, two or three tablespoonfuls of wheat bran. SECOND DAY: The same as the first, slightly increasing the quantity of food if hungry. THIRD DAY: The same as the second, adding one or two baked bananas to the morning meal, and varying the vegetables according to the appetite for the noon and the evening meal. Nearly all vegetables such as turnips, beets, carrots and parsnips may be substituted for one another. FOURTH DAY: BREAKFAST Tokay or Malaga grapes A cup of hot water Two eggs, lightly poached, or a very rare omelet A whole wheat muffin or a bran gem A cup of chocolate A liberal portion of wheat bran (one-fourth oatmeal), cooked and served as an ordinary cereal, eaten with butter LUNCHEON Choice of either _a_ or _b_: _a_ Two eggs, prepared as follows: Break into a bowl. Add a teaspoonful of sugar to each egg. Whip five minutes very rapidly with a rotary egg beater. Add a glass of milk and a teaspoonful of orange juice to each egg _b_ A quart of milk and half a cup of bran One baked banana DINNER Any green salad--celery or shredded cabbage (very little), with salt and nuts Choice of any two fresh vegetables Choice of: _a_ One or two exceedingly ripe bananas, baked, eaten with butter or cream _b_ Figs or raisins, with cream A glass of water Exercise the same as prescribed for the first day. FIFTH DAY: The same as the fourth day. SIXTH DAY: The same as the first, repeating these menus for a period of three or four weeks. The nervous person should eat very sparingly of bread and cereal products, with the exception of bran and a few coarse articles, such as flaked or whole wheat or rye, and these should be taken sparingly while under treatment. A generous quantity of water should be drunk at meals, and mastication should be very thorough. If the body is overweight or inclined toward obesity, the diet should consist of fewer fat-producing foods, such as grains, potatoes, milk, eggs, and an excess of vegetable proteids. If underweight or inclined toward emaciation, the fat-producing foods should predominate. Under all conditions of nervousness the patient should take an abundance of exercise and deep breathing in the open air, and sleep out of doors, if possible. An abundance of fresh air breathed into the lungs is the best blood purifier known, and if the blood is kept pure, and forced into every cell and capillary vessel of the body by exercise, the irritated nerves will share in the general improvement. The cool shower or sponge bath in the morning, preceded and followed by a few minutes' vigorous exercise, is a splendid sedative for irritated nerves. RECREATION The nervous person should divide the day as nearly as possible into three equal parts--eight hours' pleasant but useful work; eight hours' recreation, and eight hours' sleep. [Sidenote: Necessity for true recreation] Under modern civilized conditions the majority of people do not seem to understand recreation. The summer seashore resorts, with their expensive attractions and whirling life, the great hostelries in the hills and mountains, and the lakes where thousands of people congregate, entail upon them certain duties, anxieties, expectations, disappointments, and often financial strain that deprive these places of all features of recreation, and make the sojourn there one of labor and strife. The real purpose that takes most people to these resorts is to be seen; to "star" themselves before the multitude, which in its last analysis is a kind of vanity, and it is obvious that from any effort in this direction no recreation can be obtained. The nervous person should seek a few congenial and thoughtful companions, and get back into the great heart of nature where everything moves in obedience to supreme law. Associate intimately with animals; study their habits, and notice how they respond to kindness; admire their honesty; analyze the love and fidelity of a dog. This is true diversion and recreation. This defines the purpose of life, if there be purpose behind it. This draws a sharp distinction between the condition that makes nervousness and the condition that makes honest, thoughtful, useful human beings. LESSON XVIII POINTS ON PRACTISE INTRODUCTION TO POINTS ON PRACTISE The preceding lessons were written through a period of many years' active practise in treating dis-eases by scientific feeding. They were intended as a normal course to qualify doctors, nurses, and those who wished to treat dis-ease by this method. However, the demand for this class of information has come from people in every walk of life, therefore the lessons, and all technical matter composing this entire work have been most carefully revised and rewritten in simple language so that any person of ordinary intelligence can comprehend them. The following lesson is intended for the guidance of the practitioner in beginning his work in this branch of the healing art. Inasmuch as nearly all human ills are caused by errors in eating, the preceding lessons have been confined almost wholly to dis-eases that originate in the digestive organs. Lesson XVIII POINTS ON PRACTISE [Sidenote: Dietetic treatment is reconstructive] There are a great many abnormal conditions of the human body classed as dis-eases that bear a very remote relation to diet, but in practise the student will soon learn that many of these conditions, which have not been considered in these lessons, will entirely disappear when the diet is perfected. This is true because dietetic treatment, based upon the fundamental laws of nutrition, is reconstructive, hence every part of the anatomy shares in the general improvement. [Sidenote: Scope of scientific feeding] There are many logical arguments to support the theory that there are no incurable dis-eases. There are many cases, however, where the vitality has become so low that recovery from dis-ease is impossible, but if the patient could be taken in time, the correct diagnosis made, and the proper food, air, and exercise given, Nature would begin her work of rebuilding at once. In view of these facts it is somewhat difficult to fix a limit to the scope of scientific feeding. SUGGESTIONS FOR THE PRACTITIONER [Sidenote: The value of letters] The science of prescribing diet is a work that can be best conveyed to the patient in writing, hence one of the first and most important things for the new practitioner to do is to study the art of polemics--acquire the ability to write plain, convincing literature and letters. This is one of the greatest arts within the scope of human learning, and is probably susceptible of greater development than any other branch of human endeavor. Every person has his own individual method of expression that should be preserved and cultivated. Select some good author and copy his logic, but not his language. For this purpose I would recommend the works of Henry George, the great economic philosopher--and probably one of the greatest polementitians that ever lived. [Sidenote: Writing is mental calisthenics] The student should begin by taking up some simple branch or certain subject of his work, and writing a short argument or essay upon it, using every fact that he can possibly command to convince imaginary readers of the correctness of his theories. Select a new subject and write something on it every day. This is merely mental calisthenics, and after a month's training the thoughts and the language will flow with a freedom that will enable the student to write just as he feels. [Sidenote: A booklet describing your work] It would be well to arrange an argument based upon each lesson separately, dividing it into short chapters. These arguments or essays should be logically arranged to form a booklet, with proper title, as such representative literature is vitally necessary to the growth and the success of your work. It will also be found that this will be splendid mental exercise, and will serve well in presenting your work, either orally, or by letter. [Sidenote: The personality of the writer] Every one should endeavor to be original in his literature; in other words, no special effort should be made to quote any "authority" or to copy the style of other writers. Put your own personality into your work, for the most successful writer is not always the one who uses the most learned, polished or scholarly language, but the one who can convey his thoughts to the minds of others in the simplest and the most comprehensive language. Language at best is but a vehicle for conveying the thoughts of one person to the mind of another, and while there are accepted standards in literature and letters, from which one should not make too radical a departure, yet the ability to present one's convictions, or position convincingly should be of first consideration. The most important thing in writing is to have something to say; then to say it so that it can be understood. VALUE OF EXPERIENCE Experience is the only method by which theory can be converted into knowledge. The best possible source of information, therefore, is personal experimentation. If the student should have any disorder, especially of digestion and assimilation of food, or elimination of waste, he should experiment upon himself along the lines laid out in this course. He should keep an accurate record of selections, combinations, and proportions of food, with results or symptoms. He may thus be able to arrange menus for himself, even more effective than those given as examples or guides throughout the course. If there are no personal disorders that will permit of such experiments, then they should be made upon some other person with whom the student is sufficiently familiar in order that accurate information concerning the results may be secured. Though the student may be normal and healthy, it is possible to make many valuable experiments in regard to special adaptations of diet, such as combinations to induce natural sleep; to produce and to relieve constipation and diarrhea; to produce excessive body-heat when exposed to cold, or the minimum of heat in summer, or in warm climates. VALUE OF DIAGNOSIS Correct diagnosis is one of the most important factors in the practise of applied food chemistry, and when a correct diagnosis has been made the remedy will suggest itself if the student has a thorough understanding of causes. [Sidenote: Causes sometimes very remote] In diagnosis it is often necessary to ascertain the patient's general habits of eating during the few years prior to the appearance of the disorders. As an example, rheumatic conditions are often superinduced by an overconsumption of starch, usually cereal starch and acids. This overindulgence may have continued for several years before the appearance of any rheumatic symptoms. The primary causes being residual in the body, exposure, low vitality, or extreme climatic changes may give expression to them in the form of rheumatism, or some kindred trouble. [Sidenote: Value of limited feeding] After determining the causes, a diet should be designed which will counteract existing conditions. This may usually be accomplished by limiting the quantity of food somewhat below the demands of normal hunger. This will give the digestive organs less work to do, and the body an opportunity to take up or consume any excess of food matter that may have become congested. In cases accompanied by loss of hunger, it is sometimes necessary to put the patient upon an absolute fast from one to three days, but in the majority of cases a semi-fast is best, prescribing light, nutritious foods of a remedial character. EDUCATE YOUR PATIENT In beginning treatment each patient should be made acquainted with the fact that the radical change in diet may bring slight discomfort. While the system is adjusting itself to the new regimen, there is usually a slight loss of weight and a feeling of weakness or lassitude. [Sidenote: Curing a slow process] It should be impressed upon the mind of the patient that regaining health and strength is in reality a process of growth or evolution, hence slow and gradual; that when one has violated the laws of health for many years, Nature will not, or probably cannot forgive all these sins and repair all these wrongs in a month or two. However, when one gets in harmony with the physical universe, and conforms to the laws of his organization, Nature will construct (cure) much more rapidly than she formerly destroyed (produced dis-ease). [Sidenote: The patient should agree with the diet] The practitioner may have many cases that for some seemingly mysterious reason will not respond to a perfectly natural diet and will, therefore, be called upon to change the diet from time to time in the vain hope of finding combinations of food that will agree. In these cases the student should not be led to deviate too far from what he knows to be a natural and chemically harmonious regimen. If such a diet does not produce the desired results, it is not always the fault of the food, but the fault of the patient. If the food is right, and does not agree, it is the patient that is wrong, hence the logical thing to do is to make the rebellious patient agree with the food, instead of searching for a food to agree with the patient. These facts should be impressed strongly upon the mind of the one under treatment, and he should be prevailed upon, if possible, to conform strictly to a correct diet until Nature is given time and opportunity to bring about an adjustment between the individual and his food. It has been the custom of the medical profession for centuries to shroud its work in mystery, to write prescriptions in a dead language, to keep patients in ignorance of the remedies being applied. This seems to be necessary, probably because an intelligent discussion of allopathic drugs, their sources and their constituent elements would, no doubt, prove fatal to their administration. The food scientist should follow exactly the opposite course. He should make a very careful diagnosis, taking into account the diet, habits of exercise and exposure to fresh air prior to the appearance of the dis-ease, as well as at the time of treatment. By giving the patient a thorough understanding of your work, you gain his confidence and faith, which wield a very powerful influence over the body. EFFECT OF MENTAL CONDITIONS [Sidenote: Worry or fear causes stomach trouble] A very careful examination should also be made of the mental conditions. Worry, fear, or anxiety often produce serious digestive trouble which is generally attributed to other causes, and which should be treated very differently from the same trouble caused by errors in eating. During my professional work many patients have come to me laden with fear, caused by the thoughtless or perhaps reckless statement of some physician. It is indeed as great a crime for a doctor to pass the "sentence of death" upon a man who comes to him for help as it would be for the judge of a court to pronounce the death sentence upon a prisoner without hearing the evidence, and some day when the power of the mind or suggestion is understood, it will be so considered. [Sidenote: What Christian Science has done] It is impossible to fully estimate the effects of fear on the human body. Each year, I become more and more impressed with the fact that fear is one of the most potent factors in the cause of dis-ease. Christian Science has relieved thousands of people through the simple presentation of a philosophy that induces the individual to throw off this burden of fear. It matters not whether this burden is cast upon the Gentle Nazarene or John Doe, the fact that it has been disposed of often leads to relief and recovery. Christian Science has done the world a great service--it has put out the fires of an orthodox hell by pouring into it orthodox medicine. With a clear knowledge of the powerful psychological law, and the laws of human nutrition, the student has at his command two of the greatest forces in Nature for the relief of human suffering. PUBLICITY [Sidenote: Value of truthful advertising] Judicious and truthful advertising is another important factor in the success of the food scientist. Advertising has been considered unethical by medical men for years. It has been discredited, not because it is wrong, or because there is any harm in telling the public the truth about one's business, but because so many spurious nostrums and patent medicines were exploited by "quack" doctors, that the respectable physician deemed it best to adopt the other extreme in his effort to keep entirely out of this class. Advertising, however, is rapidly acquiring a more honest and upright character. The best magazines and some weekly newspapers will no longer accept advertisements of a questionable character, especially regarding medical remedies. Many of these excellent publications go so far as to vouch for and guarantee the honesty of everything exploited in their pages. Such methods are gradually purifying the advertising atmosphere. [Sidenote: Advertising both virtuous and necessary] There is no logical reason why anybody who has a virtuous and useful article, or who has discovered anything in the realm of science that would be a benefit to humanity, as well as a profit to himself, should not make it known as widely as possible through the instrumentality of advertising. In preparing advertising literature, whether for magazines, booklets, or letters, facts and truth concerning your work are all that is necessary. No statement should be made that can in any way jeopardize your reputation; nothing should be stated or claimed that cannot actually be made good. For many years it has been my policy to keep my advertising conservatively below the full limit of facts; in other words, the whole truth concerning that which can be accomplished by scientific feeding sometimes seems so startling to the lay mind that the experienced advertiser will not state it as it really is. A patient of mine who had been in a wheel chair for twelve years, and afflicted for twenty years with locomotor ataxia, was so much improved within a year's time that he walked from Brooklyn to my office in New York City to exhibit himself. He gave me a testimonial letter and the privilege of using it in my advertisements. I wrote up the facts in regard to his case and submitted them to my agent, who was an expert advertiser, and he advised me not to state the facts as they were; the public, he contended, would not accept them as true. BE COURTEOUS AND TOLERANT It is almost impossible to estimate the moral effect of a broad-minded, tolerant and courteous attitude toward others engaged in the practise of the healing art. Medical doctors seldom agree, especially those of different schools. They accuse each other of ignorance and incompetence, and the public is sometimes inclined to concede that they are right. In certainty and in truth one has confidence and strength which is always conducive to tolerance. The food scientist, knowing the laws of cause and effect in regard to nutrition, and knowing the proper use of natural methods of diet and hygiene in the prevention and the cure of specific dis-eases, needs neither to dispute with a fellow practitioner, nor to argue with his patient. He can afford to state his position and quietly allow Nature to prove his claims. LESSON XIX EVOLUTION OF MAN The following lessons, while they do not treat directly of either the chemistry of food or the chemistry of the body, are so closely allied to these subjects that this work would not be complete without them. LESSON XIX EVOLUTION OF MAN WHAT IS EVOLUTION? If a resident of a city, who is not familiar with modern farm machinery, should see a grain-binder at work, he would be impressed with the skill and the ingenuity of man. In all probability he would think that the machine was the product of one inventive mind. In this, however, he would be mistaken. The reaper in its modern form is the result of gradual development or growth. [Sidenote: An example of evolution] The earliest method of gathering grain was pulling it up by the roots. Later, as cutting tools were invented, a rough knife was used to sever the stalks just above the ground. An improvement upon this method was the cycle; then came the scythe, then the cradle; and next came the mower which was operated by horse-power. From the mower was developed the self rake, which bunched the grain so that the hand-binders could work with greater facility. The next improvement was a self-binding machine. In the present machine we have all of these and many other improvements, which give greater speed with less waste of labor and time. This development of the grain-binder is a process of evolution. In order to understand a machine so as to use it intelligently, or to make improvements upon it, it is necessary not only to know the machine as it actually is, but also to know the history of its development up to its present form. [Sidenote: To know man is to know evolution] The story of the evolution of a machine is, at best, but a crude illustration of the evolution of man. Nevertheless, the conclusion is the same. If we are to understand man, we must study not only his present physical and mental state, but also the history of his development. Yet those whose work is concerned directly with man--whether they be teachers, guiding the growth of the child; statesmen, formulating the laws and regulations by which men are to be controlled in their public actions; or physicians, who are supposed to instruct and to guide men in the care of their physical well-being--are often densely ignorant of the most rudimentary knowledge of the evolution of man as it is now known and understood by the leading scientists of the world. Our entire system of education, our ideas of health and dis-ease, our social customs, the principles of our form of government; our ideas of right and wrong, of rewards and punishments, are all fundamentally concerned with the evolution of man, and when this knowledge is studied with as much application as are the ancient languages, we may expect to see humanity progress at a rate hitherto unknown. [Sidenote: Significance of the term "evolution"] The evolution of man has been very much misunderstood. The term "evolution" is a broad one. It may refer to the growth of the individual, or to the race. It may mean the development of strictly physical organs, or of mental habits, of social customs, or of material products of man's genius, as the great works of civilization in the form of recorded learning, and the wonderful products of man's building ingenuity as seen in modern cities. The subject of the evolution of the human race may be grouped into three general kinds of development or growth: 1 The development of the physical man 2 The development of the mind 3 The development of custom and of external civilization Evolution in these three directions has taken place simultaneously. The mind and the body depend upon each other for their life and actions; while customs are merely the product of many minds working together and communicating their ideas to each other. * * * * * The human race is but the sum of the individuals composing it. We cannot consider the development of the individual without considering him in his relation to the race, neither can we understand the development of the race without understanding the growth of the individual. [Sidenote: Difference between inherited and acquired characteristics] One distinction too often overlooked by those who are not familiar with physiological science is the difference between actual physical inheritance and external customs. I wish to dwell at length upon this distinction, because a lack of understanding upon this point has been the source of many errors of judgment on the part of those who have been interested in the subject of physical training and food science. At birth the individual inherits an organism with certain tendencies, both physical and mental, but this inheritance should not be confused with the physical habits which the child acquires by training from its parents and its associates. Thus, the child may inherit a brilliant mind, a weak stomach, or a sixth finger, but the child does not inherit a liking for broiled lobster, or a fondness for golf, or for driving an aeroplane. These are acquired and developed as habits, the same as the child would learn English or French, or would cultivate a fancy for parting his hair in the middle, or on the left side. THE THREE GREAT PROOFS OF THE EVOLUTION OF ANIMAL LIFE At the present time scientists are agreed upon the general theory of the evolution of man. The discussions pro and con regarding this, which exist today, are either discussions of minor points which have not yet been clearly worked out, or are the discussions of people who have grasped only a portion of the idea of evolution, and who are ignorant of its broader conception and of the facts which science has brought to the light of day. The three great proofs of evolution are: 1 The actual history of the past recorded as fossils in the rocks and in the relics of pre-historic races 2 The existence in the world today of a range of animals and plants which shows living examples of earlier types 3 The repetition of the development of man as found in the growth of the individual These three separate records of the development of living beings are considered by scientists as a most conclusive proof of the truth of evolution. Recorded as fossils in the rocks, we find the story of the development of all life upon the earth, from its simplest to its highest forms of plants and animals that live today, among which is man. [Sidenote: The earliest forms of animal life] The first forms of animal life were, in all probability, minute one-celled organisms; these left no visible fossil remains. As soon as animals developed hard parts in their bodies, such as shells and bones, we find a record of their existence as fossils. The earliest recorded forms of life were various kinds of sea-creatures, of which the modern crustacea (lobsters, etc.), snails, clams, and various shell-fishes are types. Later were developed boneless fishes, on the order of skates. After these came true fishes; then amphibia (frogs, etc.); then reptiles, birds, and, last of all, mammals, including man. The facts are the same, whether we take the history of the successive forms as recorded as fossils in the rocks, or the living representatives that remain to tell the story in another form. [Sidenote: The single cell is the nucleus] The third proof, which is the story of evolution recorded in the growth and development of the individual, is yet more interesting. As life developed from simpler forms, each individual animal or plant became more complex, or carried a little further the process of growth. But the method of reproduction of new individuals remained fundamentally the same. Each individual began, like its ancestors, as a single-cell being. By the process of nutrition these single cells in each case would grow, divide, and produce various tissues and organs, but always repeating the general story of the development of the race. [Sidenote: Gills in the human embryo] The growth of the human embryo offers many proofs of evolution, which are wholly unexplainable upon any other theory of the origin of man, and would in themselves prove the truth of this view of man's creation were the proofs of geology entirely lacking. A single example will serve as an illustration. The human embryo at a certain period develops gill slits in the neck, the same as the embryo of a fish. This formation of unused or rudimentary organs which are afterwards outgrown, is very common throughout the animal world. In the upper jaw of a calf there are formed at a certain period incisor teeth, which never grow through the gums, but are reabsorbed and disappear as the calf develops. I will not go further into the proofs and facts of the general theory of the evolution of animal life, but will now consider the later period of the development of man, which will show us his relation to other animals, and from which we can derive much valuable information regarding his natural physiological requirements. MAN'S ANIMAL KINSHIP The conception of man being descended from a monkey has been the subject of much wit and mirth. [Sidenote: Man's relation to anthropoid apes] The scientist is not concerned with this theory; he only claims that man is very closely related to certain monkey-like forms known as anthropoid apes. The proofs of this assertion are abundant and conclusive. In fact, anthropoid apes, such as gorillas, chimpanzees and orang-outangs, are much more closely related to man than they are to other kinds of monkeys. This relation is shown by very close resemblance between the anatomy of man and apes, especially as to the teeth and digestive organs. Other facts are now known, of which Darwin and early investigators were ignorant, which prove this relation in a much more striking manner. [Sidenote: Comparison of blood from man and apes] Late studies upon the growth of the embryo of anthropoid apes have shown that they were at certain periods almost indistinguishable from human embryos. Another proof, quite striking and interesting, is in the similarity of the parasites and dis-eases of men and apes. Scientists have, within the past few years, made a series of comparative investigations upon the blood and serum of men and apes, which have resulted in most remarkable discoveries. There are certain accurate tests known to the physiological chemist by which human blood may be distinguished from the blood of all other animals, but the blood of these man-like apes is an exception to this, and cannot be distinguished from human blood. [Sidenote: Difference in the development of man and apes] From these facts it is clear that the earlier types of men were creatures whose physical development and whose habits were not very different from those of apes. The development that has taken place since that time is truly very wonderful and has resulted in a widening gap between man and apes that today seems very great. The truth remains, however, that this gap is not so much one of anatomy and physiology as it is one of mentality and of external habits and material aids to living that have resulted from man's greatly developed mental faculties. [Sidenote: Power of speech a factor in man's evolution] Thus, when the mind of man reached the stage of development in which the use of articulate speech became possible, the evolution of intelligence proceeded at a very much more rapid pace than had been possible before. He could communicate his ideas to his fellow-creatures; concerted action became possible, and the faculty of reason, or the ability to think was multiplied by the number of beings who could communicate with each other. The power of reason and the ability to communicate ideas resulted in the formation of those habits which distinguish man from other animals. When one primitive man learned the use of a club as a weapon, found how to use sharp-edged stones as cutting tools, or discovered the wonders and power of fire, he communicated his new-found knowledge to the other members of his tribe, with the result that new ideas became common property. [Sidenote: Man's bad habits have kept pace with his progress] This spreading of habits or customs took place very rapidly among men and was the source of the various changes which distinguished civilized life from savage life. But we must here point out that not only good habits were so spread, but bad ones as well. The origin and the use of opium and of alcohol, the injuries of fashionable dress and the economic wrongs of tyrannical government originated along with the birth of language, art, science, and all that uplifts and benefits mankind. Clearly, then, that man is misinformed who defends a wrong by referring to its age and reasons that, if certain things were harmful, they would not have survived. To the young thinker the existence of harmful ideas and habits among mankind may at first seem inconsistent with the principles of the survival of the fittest, but this difficulty will disappear upon further investigation. [Sidenote: Factors that determine the survival of races] Since the beginning of recorded history many factors have helped to determine what kind of individuals and races should survive. War, economic wealth and poverty, intellectual beliefs, religions, and social institutions have all been potent factors in determining who should survive. With wealth and conquest came the opportunity to gratify tastes and passions of which the poor individuals of weaker races could not avail themselves. [Sidenote: Many habits and customs detrimental to life and health] Many of the habits and customs which man has developed are not necessary to life, and may be positively detrimental to health and longevity. They have been handed down from generation to generation, not because of their benefit to man, but in spite of their detriment. Such condition of affairs would not be possible if man were not the dominant animal. Man's intellectual supremacy has given him power over the rest of nature, which has resulted in making his struggle for existence much less severe. His use of weapons and of artificial protection from natural destructive forces, as severe heat or cold, has made it possible for him to live and to produce offspring in spite of wrong habits and wrong methods of living, and the natural resistance of life. [Sidenote: Man's organs have a limited power of adaptation] A prevalent error that is due to an incomplete knowledge of the facts of evolution is the belief that organs readily change or adapt themselves to the habits or environment of the individual. This is not true to the extent that it is ordinarily believed. Each individual has a certain limited power of adaptation. He may develop his lungs to a greater breathing capacity, or train his hand for certain skilled work, but these particular acquired habits of the individual are not inherited. Evolution of the race proceeds by the law of natural selection. Thus, if those who are born with great vigor and strong lungs are enabled to live where their weak-lunged neighbors will die, the result will be that their offspring, having greater lung capacity, will form a race with increased lung capacity. But the individual training of the lungs, or of the hand, or of any other organ of the body, will not of itself change the inherited tendency, or, to use a common term of the scientist, the germ-plasm of the race. Organs and functions will change or become evolved by natural selections; that is, where it is a matter of life and death. But where the selective agencies depend upon other things, an organ may be used or abused for thousands of successive generations, and yet the natural inherited organ of the new-born child will be identical in development and function to that of the remote ancestor. [Sidenote: Acquired characteristics are not inherited] There are abundant proofs that so called "acquired characteristics" are not inherited. Were acquired characteristics inherited, Chinese women would be born with small feet and the babies of the Flathead Indians would inherit the flat head which has for generations been produced by binding a flat stone on the soft skull of the new-born infant. In the light of this fact we may understand how it has been possible for man to live through the varying dietetic habits and customs that the constantly changing ideas and tastes of civilization have thrust upon his physical organism. Each individual has transmitted to his offspring the same type of digestive organs and functions that he himself inherited from his remote anthropoid ancestors. [Sidenote: Meaning of expression "natural" diet] Thus, such terms as "back to nature," "natural diet," etc., only mean to the food scientist the habits of life or the dietary which is most suited to the unperverted physical organism of man. They do not imply the meaning that is popularly given to the term, of casting aside all the habits and customs of civilized man, but only the adapting of these customs to the inherited physiological organism of man. Indeed, science may actually improve upon primitive conditions, and still not be inconsistent with the requirements of the inherited physiological machine. No intelligent man will dispute the advantage of a house in a snowstorm. Yet the house is artificial. It is not "natural" in the sense that the term is commonly used. Or, again, man has by the aid of civilization rendered it possible for us to use foods far removed from their source of production, or, by preservation, to have them at seasons of the year when nature does not provide them. These artificial results of civilization are good. They are a part of the story of evolution, the benefit of which no one can question. [Sidenote: Man's dietetic development] But the great majority of the dietetic "frills" of modern man are actually unsuited to his physiological make-up, and exceedingly harmful. They have been developed as have habits of drink or personal adornment and may be in direct antagonism to the ultimate well-being of the human race. I have briefly reviewed the history of the evolution of man. The facts to be remembered are: 1 That men are descended from earlier and more primitive types of beings and are governed by the same general laws of heredity and nutrition as are other forms of animals 2 Man, being a distinct species of animal, has particular laws that apply only to him, and therefore we should be careful not to judge him too closely by facts regarding other forms of animal life 3 Man has changed very materially in the few thousand years of his civilization, in his external habits and customs, but very little in his fundamental physiological processes; therefore we should be able to judge what will be best suited for his needs by studying the process of the development of his organs during the millions of years that preceded the historic period. This plane of life is best seen today in the case of savages unacquainted with fire, and in the case of anthropoid apes. With this general survey of evolution, and a clear understanding of the principles involved, I trust the reader will consider the facts here presented in the unprejudicial spirit of the true scientist. LESSON XX SEX AND HEREDITY THE ORIGIN OF SEX That part of human life and living that is associated with the functions of sex and reproduction is at once the cause of the world's greatest misery and the world's greatest happiness. It is the subject of the greatest popular ignorance and superstition, and at the same time the field of the most wonderful of all scientific knowledge. For the origin of sex we must look back into the remote ages of creation in the early stages of organic evolution. [Sidenote: Fundamental function of the cell] The first essential property of matter that makes life possible is the power of nutrition, which means the ability of the living cell to transform other chemical substances into its own protoplasm or living substances. But this world would have remained a barren mass of igneous rock if nutrition had been the only function with which the earlier forms of life were endowed. Not only must the living cell be enabled to grow by absorbing other substances, but it must reproduce itself, or multiply the number of living individuals. [Sidenote: First form of reproduction] The first method by which this was accomplished was undoubtedly one of simple division; that is, the living cell grew by absorbing other substances and when sufficient size had been attained, divided, forming two daughter-cells. This division process of reproduction is the form by which all bacteria (so-called dis-ease germs) and many other lower forms of life increase their numbers. [Sidenote: Second form of reproduction] [Sidenote: Strength in fusion of cells] This process of reproduction, by simple division, was early supplemented by another process of reproduction in which two living cells first fused or combined and then divided to form two or more daughter-cells. This form of reproduction seems to have added stimulus or vitality to the organisms. The supposed reason for this is that the isolated cell was inclined to weaken or lose its chemical balance or tone. The exact nature of this deterioration is not very clearly understood, but in a higher form of life it is well illustrated by the tendency of certain plants to "run out" when grown continually in the same soil, or of animals to become weakened when inbred. At least, all scientists concede that with the process of fusion or the combining of two cells there is added a stimulating and invigorating force which enables life to combat more successfully the unfavorable elements of its environment, and to change or evolve into higher forms. [Sidenote: Sexual reproduction in plants] [Sidenote: Fertilization of orchids] Throughout the range of plant and animal life this process of cell union, or sexual reproduction, has grown and become elaborated into most varied and wonderful forms. Large volumes could be written describing the many wonderful adaptations of plant and animal life, the purpose of which is to secure sexual reproduction. All those who have studied botany are familiar with the many ways in which the seeds of plants are fertilized by pollen. For instance, certain species of orchids have a receptacle in the blossom, shaped like a teapot, which is filled with a fluid resembling water. This little teapot has an entrance and an exit. Near the entrance is sweet-scented nectar which attracts the bee. As the bee passes through this gateway he is tripped up on a little trap-door arrangement and precipitated into the fluid. His wings having become wet, he is obliged to crawl out through the exit. [Sidenote: The wonderful process of flower fertilization] The object of this elaborate device is as follows: In the entrance passageway is located the stigma (female organ), while in the exit passageway the male or pollen-bearing organ of the orchid is found. The bee visits several of these flowers consecutively, and, as he makes his exit from each flower, he bears away on his body a portion of the pollen, which is transferred to the stigma of the next flower visited; while the bee, being forced to go through a "plunge bath" before visiting another flower, acquires a fresh load of pollen in each case. This scheme is a certain means of securing fertilization or sexual reproduction, and positively prevents inbreeding (the fertilization of a flower by its own pollen). This is merely one of the wonderful adaptations of nature in the solution of the sex problem. [Sidenote: Reproduction among fishes] [Sidenote: Nature's wasteful methods] In the animal kingdom the methods of sexual reproduction are also varied and wonderful. In many of the lower forms of animals, such as the various sea-creatures, the methods of reproduction may be those of division, as first mentioned, or a method combining division with true sexual reproduction. In the case of fishes, the eggs of the female are deposited in the bottom of a stream and are later fertilized by the sperm-cells of the male fishes. This involves a tremendous waste of reproductive cells, scarcely less extravagant than the waste of pollen in plants, such as is seen in a corn-field when the ground becomes yellow, during the tasseling season, with the myriads of pollen grains that failed to secure lodgment upon the silks of the young ears of corn. [Sidenote: Reproduction in higher forms of life] In the types of animals that are of higher form than fishes, that is, reptiles, birds, and mammals, the fertilization of the germ-cell (egg) takes place within the body of the female. In the case of the latter group--mammals--the true egg is hatched within the body of the female, and the offspring, or embryo as it is known to scientists, grows there for a considerable period before birth. A RATIONAL VIEW OF SEXUAL HEALTH The anatomy and the physiology of reproduction will not be considered in detail in this work, as this would require a very lengthy and technical treatise. The remainder of the lesson will be devoted to the relation of the reproductive functions to general health and happiness. [Sidenote: Development of reproductive instincts] In the process of evolution this function of reproduction was vitally essential to the life of the race. As a result there developed in all animal life strong sexual or reproductive instincts. As is plainly evident, all animals, including man, with such instincts most strongly developed would be the most successful in producing young, and through these offsprings the race or species would inherit like reproductive desires. [Sidenote: Kinship of the sexual, paternal and social instinct] In the case of man and the higher form of animals, this general instinct, the purpose of which was to produce offspring, became diversified in to many instincts. Not only does the reproductive instinct in this broad sense include what is commonly known as sexual passion in man, but it may very truly be said to be the essence of sexual love and parental love. Broad-minded scientists are even inclined to believe that the so-called social instinct or love for our fellowmen is but a distant reflection or shadow, as it were, of the original or natural instinct to produce offspring. There has arisen among civilized man a tendency to separate and class as two distinct things the strictly physical element of sexual desire, and the associate emotion of intellectual love between the sexes. As a matter of fact there is no distinct line of demarcation. [Sidenote: Overindulgence, degenerating and destructive] That the former instinct has grown into disrepute and has come to be considered a forbidden topic in polite society, is due to the fact that sexual passion, like all other human acts which may be a source of gratification, can degenerate by overindulgence into a destructive and demoralizing vice. This is equally true of other forms of appetite, but the reason that the instinct of sex, when degenerated, becomes such a tremendous source of destruction and death is because of the important part played in the game of life by the reproductive function. [Sidenote: Relation of sexual functions to the nervous system] The functions of reproduction are, in both sexes, very intimately and closely associated with the nervous or vital mechanism of the entire body. For this reason, when the sexual function are perverted or abused the result is serious injury to the general nerve tone or vital force of the system. Likewise the contrary proposition is true; therefore, when for any reason, the general nervous tone or vital force of the body is deranged, the associated result is frequently abnormal passion or weakened sexual functions. [Sidenote: Necessity for popular knowledge concerning sex] A great deal of literature has been written and circulated throughout the country by well-intentioned individuals purporting to give popular knowledge regarding the subject of sex. But such literature has greatly exaggerated the evils and the dangers connected with sexual health. Outside of specific germ dis-eases transmitted through the sexual organs, and which, while serious, have been painted much darker than the facts justify, there is little excuse for all this horror and scare about sexual weakness and perversion. [Sidenote: Relation of nutrition to sexual health] Sexual health, like mental or muscular health, is a matter of common sense and right living. Proper feeding, proper oxidation, proper circulation (exercise), perfect elimination of waste-products, and a suitable distribution of both mental and physical work will result in perfect nutrition. This means normal, wholesome body-fluids and body-cells. With these things gained, the sexual organs and sex-function will have a fair opportunity for normal existence, and the matter of sexual health, and the consequent happiness which accompanies it, is then simply a matter of temperance, common decency, and self-control. EMBRYOLOGICAL GROWTH--PRENATAL CULTURE [Sidenote: Superstition concerning prenatal culture] Upon the growth of the human embryo, or so-called prenatal culture, there exists a great deal of popular superstition, which is utterly groundless from the standpoint of accurate science. The views that have been promulgated regarding prenatal culture are for the main part harmless, and, for that matter, may be productive of good. [Sidenote: Theory of prenatal culturists] The idea of the prenatal culturist is that the mental as well as the physical growth and development of the unborn child can be controlled by the mother. The only ground for this belief is as follows: The child is nourished from the blood or nutritive fluid of the mother, with the result that the growth and the development of the child may be very readily influenced by the nutrition of the mother. [Sidenote: Influence of fright, anger, etc.] The mental condition of the mother has an influence on the growth of the child, but it is indirect. All organs and functions of the human body are controlled by the nervous system, and if the nervous impulse be deranged or weakened it may result in a serious impairment of nutrition. For this reason fright, anger, and other strong passions may result in lasting injury to the unborn child, but this injury is at most a matter of stunting or malnutrition, and cannot result in the voluntary mental life of the mother being transmitted to the child. [Sidenote: Mother's nutrition the only factor in influencing her child] As evidence of these assertions, I would call the reader's attention to the fact that there is no nervous connection whatever between the embryo and the mother, but after the fertilization of the germ-cell, the only way in which the mother can influence the growth of the child is by the nutrition which her blood supplies to the growing tissue of the embryo. [Sidenote: Birthmarks] As further proof of these statements, I will cite the investigations of Darwin in regard to the popular superstition of birthmarks. At the instance of Mr. Darwin, some seven or eight hundred women of a London hospital were very carefully questioned before the birth of the child, as to any incidents which had happened that, according to popular notions, might result in birthmarks or deformities. In no instance was any incident given which resulted in the expected deformity; but the most interesting feature of the investigation was that several women whose children were born with birthmarks recalled, upon seeing the deformity, some incident which seemed to give a possible explanation, thus showing to the mind of anyone familiar with psychology that the true explanation of all so-called remarkable incidents of birthmarks and of prenatal influence is merely one of superstition or self-deception. HEREDITY How often we hear someone remark upon the wonders of heredity. People are astonished because John should look like John's father. As a matter of fact, the astonishment should come the other way. The child is but a continuation of the life of the parents. The cells from which the child develops have within them the power to grow and to produce individuals like the parents. This is wonderful, but it is only another form of the wonder of a willow twig growing into a willow tree when placed in moist earth. [Sidenote: Why the child is not identical with parents] To the scientist, then, the wonder comes, not in the fact that the child resembles the parent, but in the fact that the child is not identical with the parent. Part of the explanation of this lack of identity, or, as it is known to science, variation, is due to the fact of sexual reproduction; that is, to the fact that the child has two parents instead of one. [Sidenote: Microscopic study of reproductive cells] The physiological process which takes place in the union of two reproductive cells is truly most wonderful. Of late years this has been studied under powerful microscopes and has resulted in some very wonderful revelations of the mysteries of Nature. [Sidenote: Chromosoms in different species] The nucleus (center of growth) of the parent cells contains little thread-like structures known as chromosoms. These chromosoms are considered to be the physical basis of heredity. In each species of animal there is a definite and a different number. [Sidenote: Action of the chromosom] When the sperm-cell unites with the female or germ-cell, these thread-like chromosoms pair off and unite each chromosom with the corresponding structure from the other cell. The combined structures then divide, and half of each chromosom is cast out of the cell-nucleus, and plays no part in the life of the future being; the other half is retained and divides as each new cell is formed. Thus we see that every part of the new individual is the result of the fusion or combination of the two parents. This explains the variation of inheritance, and through this source must be traced all traits of heredity. After the original fusion of these microscopic physical elements of heredity, the future development of the individual is wholly a matter of environment and nutrition. WHAT HEREDITY IS [Sidenote: General characteristics due to heredity] What heredity is and what it is not will now be considered in a practical way. It is clearly a matter of heredity that a man is born a man and not a monkey. Likewise, it is clearly a matter of heredity that distinguishes the various races of men. We could go farther and trace out and describe many of the physical distinctions which mark families, and even individuals, such as general size of frame, form of countenance, color of hair and eyes, etc. [Sidenote: Characteristics not attributed to heredity] Among mental traits we can safely ascribe to heredity only general distinctions. Intellectual parents are more likely to give birth to intellectual children than are parents whose natural mental faculties are less developed. There is also no doubt that certain natural characteristics of mind, such as quick temper, musical ability, etc., may be inherited. The belief, however, in the inheritance of many less distinct features, both physical and mental, is not well established by scientific investigation. Strength of muscle, control of the nervous system, susceptibility to, or freedom from dis-ease, etc., are more matters of nutrition and environment than of inheritance. The idea that consumption, alcoholism, etc., are inherited, or that the education or training of parents along certain lines will result in children with faculties adapted to similar education, is not in accordance with scientific knowledge. SUMMARY OF FACTS REGARDING SEX AND HEREDITY 1 The function of sex has been developed in the process of evolution for the purpose of perpetuating life. 2 The sexual functions are very closely related to the life of the individual, and can be normal only when the laws of nutrition and of general hygiene are observed. 3 The idea of prenatal culture as commonly taught is a delusion; the only method that the mother can employ to control the growth of her unborn child is to live a wholesome, normal life, physically and mentally, and thus supply her own body and that of the child with perfect material for the building of living cells. 4 The powers of heredity are often overestimated, and many of the weaknesses and disorders of life supposed to be inherent can be overcome by proper nutrition and environment. All life, whatever be the inherited tendencies, will be developed to the highest possible capacity by obeying the laws of individual growth, for in the individual, as in the race, Nature is always striving to bring the products of her work to the highest degrees of perfection. LESSON XXI REST AND SLEEP REST [Sidenote: Opposing forces in nature] Throughout all nature we observe the phenomena of universal rhythm, manifested in opposing forces, such as heat and cold, light and darkness, construction and destruction, etc. The human body is as much affected by this rhythm as is any other form of life. [Sidenote: Opposing forces in human system] There are two forces continually at work within us, one toward destruction and disintegration, and the other toward construction and upbuilding. The common physiological terms for these activities are "waste" and "repair," and we observe them as one of the distinct manifestations of the universal laws of growth, progress, and evolution. History moves in cycles. Even the life of nations depends somewhat upon this same principle of the interplay of the positive and negative forces of life. [Sidenote: Life and death in changes of seasons] We see the same thing in the changes of the seasons upon the face of the earth. Throughout autumn and winter there is a process of decay, death, and disintegration; leaves fall; plants and vegetables die; fruits ripen, fall and decay. This process continues until former beautiful and symmetrical bodies of matter are thoroughly disintegrated, and the particles once composing them are separated into their original elements, to be appropriated in new manifestations of life in springtime and summer. [Sidenote: Human body compared to a machine] We are inclined to think of the human body as a machine--a marvelous, intricate, and complex mechanism which serves our will and our desires; as a tool with which we work out our earthly destiny. But unlike man-made machines, it is self-repairing, self-adjusting, and contains within itself the forces of construction, which are constantly tending toward perfection, while our industrial machines are constantly tending toward their own disintegration and destruction. [Sidenote: Constant changes in body-tissue] Every movement of the body, conscious or unconscious, even thought and emotion, use up some part of the body-tissue which must be replaced by new material. This constant change in the texture and the make-up of the body we call "metabolism," involving the functions of digestion, absorption, assimilation, and elimination. While we may regard the body as a machine, there are many points in which the favorite comparison to a steam-engine is not exact. [Sidenote: Favorite comparison of the body with the steam-engine] The inert metal composing the steam-engine has no power in itself, nor does power act through the different particles of metal, but it is controlled by the external application of force, which is the result of chemical changes caused by combustion in the fire-box. The metal of the engine has no part in the production of this energy. It does not need to take periods for rest, and if it were possible to supply it continually with water and fuel, it could run steadily from the time it was started until one or more of its essential parts were destroyed through friction. [Sidenote: Necessity for rest] But the engineer and the fireman who drive the engine find it necessary to rest from their labors at certain intervals, not merely for fuel and water, but to prevent serious destruction of body-tissue. This is true because man is compelled by hitherto unrecognized laws to give his body an opportunity, not only for readjustment in its composition, but also for the actual renewal of that power which animates him and makes him an intelligent, self-adjusting, and self-controlled being. THE OLD PHYSIOLOGY [Sidenote: The stomach as a fire-box] [Sidenote: Phenomenon of rest and sleep] According to the teachings of the old physiology, our stomachs were fire-boxes of the human engine; food was fuel, and the stomach was supposed to transform this fuel into work or energy by a process not entirely clear. Just as it is impossible for the lifeless iron and steel, within itself to transform coal and water into dynamic power, and to apply that power to its own locomotion, so it is impossible and entirely incompatible with reason for mere muscular tissue of the body to extract enough energy from the food we eat to perform the work necessary for that transformation itself, besides enough more to carry on all the functional activities of the system, and at the same time to do hundreds of foot-tons of physical labor. In this fact lies the key to some understanding of the phenomenon of rest and sleep. The old physiology was really never able to explain how it was possible for the digestive apparatus to extract, from the amount of food consumed, the enormous amount of energy which the average person expends each day. REST AND RE-CREATION [Sidenote: Change of occupation not re-creation] These terms are often confused. When one is engaged in some occupation or activity other than his regular vocation, it is commonly called "re-creation." This is a misconception, because it is merely a change in activity and must also be more or less destructive to other sets of nerves or muscular tissue. It is not in reality re-creation--it simply throws the life-power into a new channel, which is more responsive, and calls for less action from those parts of the mechanism which have been employed in the work from which one is seeking relief. It is for this reason that we find some pleasure in a new and different activity, though it, too, may be destructive to the human cell. [Sidenote: Specialization in business not conducive to health] One may alternate from one kind of activity to another indefinitely, which would be better than _no_ change, but the human mechanism would finally give way under such violation of fundamental law. The mental worker may change, however, to any manual labor requiring little thought, and the physical worker to some form of mental labor, with far better effect. But, in our present civilization, specialization has become so far advanced that the physical laborer is seldom qualified for mental work, and the mental worker has almost neglected manual training. _True rest and re-creation is found in mental tranquility and sleep._ SLEEP From observation and study of the state we call sleep, we notice that as night approaches and the activities of the day wear upon us, both the nervous and the muscular organisms relax, so that it becomes more and more difficult to maintain a positive and an active attitude of mind. There is a tendency toward cessation and rest, which gradually brings upon us that passive condition called sleep. [Sidenote: Evidence of acquired energy during sleep] In spite of the fatigue often experienced before we retire, we awake again on the morrow with renewed strength and power. From these and other reasons we are led to believe that during the hours of activity the body is constantly expending vital energy in both internal and external work, and that during the hours of sleep, through some unknown process, the body is charged with vital energy which is stored up and used gradually for carrying on the various functions and activities of the system. [Sidenote: The mystery of energy] Just what this energy is, just where it comes from, just how it is stored, just the manner in which it is delegated to the body, we cannot say. We can only observe its workings, or effects, and formulate therefrom a theory. We are led to believe, however, that this energy is stored in the nervous organism, perhaps most largely in the brain, as brain tissue is the last to break down or waste away in sickness, ill health, dis-ease, or starvation, often maintaining its full weight up to the point of death. [Sidenote: Vital processes expend energy during sleep] Even in sleep the expenditure of energy in the vital processes continues vigorously, depending upon conditions immediately preceding sleep, but usually in a much more passive degree than in the waking hours. These activities, however, are no more pronounced in their constructive action or repair, than in ordinary periods of rest during the waking hours. SOME REASONS [Sidenote: Food furnishes but a fraction of the total body-energy] The processes of nutrition, alone, demand the expenditure of much energy, and the degree of energy available from foods, even by perfect combustion, would yield but a fraction of the energy expended by the body. [Sidenote: Energy required for work in excess of energy obtained from food] The average laborer in shoveling coal, swinging an axe or a pick, expends energy far in excess of the amount that could possibly be obtained from his food. A day laborer may eat a piece of beefsteak, two or three potatoes, and a few slices of bread, and will shovel twenty tons of earth to a height of five feet; a Japanese soldier will carry a heavy load and walk all day, subsisting only on a handful of rice, and besides this, will do some thinking, which consumes energy. [Sidenote: Evidence gained from "fasts" and "no breakfast" plan] We also have on record fasts, of from thirty to forty days, which, in some cases, show a slight gain in strength. There are also hundreds of students of natural living who adopted the "no breakfast plan" and again many, only one meal a day, limiting their consumption of food to comparatively small quantities of nuts, fruits, and vegetables, who have found thereby a remarkable increase in vitality, strength, and general physical and mental power. [Sidenote: Relation of sleep to expenditure of energy] Since the processes of nutrition, including digestion, circulation, assimilation and excretion consume energy, and notwithstanding this we are able to perform hundreds of foot-tons of labor a day besides; since we have found it possible to continue to live, and in some cases to even increase the amount of strength and work-power on a very limited diet; since it is a mathematical impossibility to produce as much energy from the food consumed as the body expends, we are forced to the conclusion that we do not obtain all our energy from food. Therefore, from a careful analysis of the phenomenon of sleep, we conclude that it is very closely connected with this mystery. OXIDATION AND AIR [Sidenote: Relative importance of air, food and water] One of the most important of the vital functions is breathing. Physiologists, teachers, and lecturers continually remind us of the comparative time we could live without food or water, and the remarkably short time we could live if entirely deprived of air. [Sidenote: Oxygen not the only required element in breathing] Oxygen is vitally necessary for the purpose of purifying the blood and supplying the various tissues and fluids in the body, of which oxygen forms an important constituent. However, oxygen is not the only necessary element which is utilized by the system in the process of breathing, as human beings die immediately upon being placed in a receptacle of undiluted oxygen. Just what this other factor is, science has not clearly defined, but that it is concerned with rest and sleep we have at least unconsciously recognized, as shown by our often referring to periods of rest as "breathing spells"; from the fact that we have found it of great importance to keep the air we are breathing moving constantly about us, especially while asleep. From all these facts we are forced to believe that sleep plays an important part in producing and maintaining body-energy, besides constantly recharging the system with oxygen. LESSON XXII A LESSON FOR BUSINESS MEN That which tends to make a good business man, in the popular mind, is the establishment of great industries and enterprises, coupled with accumulation of money by the individual. A careful review of the history of business men who have made a success along these lines shows that the majority of them sacrificed their health and their lives to their business. In the last and final analysis, therefore, these were not good business men. The best musician is he who can bring more sounds into harmony. The best artist is he who can best harmonize colors and reproduce nature. Likewise, the best business man is he who can best harmonize or balance the affairs under his control. Health being entirely under and within his control, if he disregards it--gives it no thought--violates the laws that govern it, and finally wrecks it, he is not a good business man, as all business depends upon the power of the individual, and the powers of the individual depend upon his health. [Sidenote: Examples of poor business men] The man who, from a cheap tin store, founded "The Fair" in Chicago, and allowed the business to dethrone his reason, and to send him to his death before he was sixty, could hardly be considered a good business man. Measured on the same scale, Marshall Field, the merchant prince, was not a good business man. President Roberts, who arose from the ranks of a car-wheel molder, to the presidency of the Pennsylvania railroad, and died at the age of fifty, was not a good business man. J. P. Morgan, who accumulated many millions of dollars, and who died when he should have been in his prime, was not a good business man. [Sidenote: Wealth at the expense of health] The accumulation of money and the founding of great industries is only one requisite of the business man, and by no means the most important one. What profiteth a man to make a great fortune; to put in motion a million spindles; to chain continents together with cables; to flash his silent voice over oceans and continents on currents of common air; to make the ocean's billowed bosom a commercial highway; to transform the oxcart into a palace, and set it on wheels and hitch it to the lightning; to build sky-scraping structures of stone and steel; to transfix human figures and faces on sensitized glass; to direct the methods of burrowing in the earth for coal and gold until his name is known around the world, and his fortune is a power in the land?--what boots it, I say, to know all these things and to glide blindly into the shambles of unrest and dis-ease, or to furnish a fashionable funeral at forty? [Sidenote: The abnormal, or one-idea man] The religious fanatic who robes himself in sackcloth and eschews the razor; the food crank who cries out "back to nature," and takes to grass; the one-idea social reformer who preaches on the curb, and the business man who allows his business to become his absolute master and governor, are in reality all in the same class. The unfortunate thing is that the business man sits him down and weaves about himself the meshes of a prison. Every year puts in a new bar, every month a new bolt, and every day and hour a new stroke that rivets around him what he calls business, until he feels and really thinks he cannot escape. A GOOD BUSINESS MAN A good business man is the man who can direct the wheels of industry, who can draw a trial balance between his income and his expenses, and who can measure his own ability on the yardstick of endurance. [Sidenote: Qualities of a good business man] He is a good business man who gives as much study to the laws of his own physical organization as he does to the organization of his business, and in the final analysis I doubt if he would not consider himself a better business man, "Penniless," and in good health at ninety, than sojourning in a sanatorium with a million at his call, but out of the fight at fifty. [Sidenote: Knowledge of health-laws a public necessity] It is truly unfortunate that the general laws of health and hygiene are not more universally taught and understood. We learn that best with which we are thrown in most frequent contact. The business man would absorb enough information on these subjects to extend his period of longevity and usefulness many years, if they were taught in our public schools, or were matters of general knowledge. THE ROUTINE LIFE OF THE AVERAGE BUSINESS MAN [Sidenote: Bad habits of the business man] He rises between six and seven a. m., takes no exercise or fresh air; eats a breakfast composed largely of acid fruit, cereal starch, meat, and coffee. He then goes at once to his business, sits at a desk until noon, takes luncheon at a neighboring cafe. This repast is composed of meat, cereal, or potato starch, beer, or coffee. He hurries back to his business, sits at his desk five or six hours longer, hurries home, takes a dinner composed of more meat, more starch, more tea or coffee--no exercise, no diversion, no association with the great authors; no music, no poetry, no change. [Sidenote: The ancient remedy for Nature's warnings] A friend may come in, or he may go out to visit; then comes the soothing and soporiferous cigar which may have been his companion since breakfast. The market, the business, the chances for making or losing dollars are the topics of discussion. He is in the power of his master, "business," and must do him continual obeisance. Within the domain of the tyrant he lives, moves, and has his being. If he has a headache, sour stomach, indigestion, a tinge of rheumatism, dizziness, insomnia, nervousness, or any one of the thousand symptoms or warnings that Nature gives him for the violation of her laws, instead of thinking a little and trying to ascertain the cause, he sends, with "chesty pride," for His physician, and his physician writes out something in a dead language--the only suitable language. The local druggist sends over the "stuff," and it is swallowed with that childish confidence that fitly becomes the modern business man who knows a great deal about business, but nothing about himself. The days and the months go on, the symptoms or signals become more numerous, more expressive, more impressive, more painful. His physician is called more often; the dead language paper goes to the druggist more frequently, and with faith he still swallows the drugs; they relieve him for a little while, usually by paralyzing the little nerve fibers that are carrying to the brain the messages of warning. [Sidenote: The ancient system declared a failure] HIS physician finally acknowledges a trip, or a sanatorium. It is either this procedure or the fate that befell Messrs. Roberts, Morgan, Colonel Ingersoll, and the uncounted thousands who had no reputation beyond the domain of their own locality, and of whom we never hear. SOME SUGGESTIONS FOR A GOOD BUSINESS MAN [Sidenote: Twelve health rules for the business man] Don't allow your business to become your master. Don't discuss business at home, or in social life. Immediately on rising, take a cool shower bath, followed by vigorous exercise before an open window. Eat a very light breakfast an hour after rising, eliminating tea, coffee, white bread and meat. Walk to your business, if possible; breathe deeply. Eliminate woolen underwear; dress as lightly as possible. Take an hour for luncheon. Omit tea, coffee, tobacco, beer, and sweets. Keep your office well ventilated. Secure competent help and trust them. Love some one or some thing--a dog will do. Leave your office early enough to walk home, or at least a part of the way. Masticate your food infinitely fine, and by all means _do not overeat_. This is the crowning sin of the civilized table. Take from ten to fifteen minutes exercise before retiring; sleep in a cold, thoroughly ventilated room. Spend as much time as possible in the sunshine and open air. Drive an automobile, play golf, join a gymnasium, dance, sing, kick and play with the boys, for it is infinitely better to dig in the ditch for your dinner and be able to digest and enjoy it, than to lie invalid in your self-made prison, and perhaps die. (Probably if the truth were written on your tombstone, it would read: There was a fool who made a fortune, but he died; The world called him great, but it lied.) LESSON XXIII EXERCISE AND RE-CREATION PROGRAM FOR DAILY EXERCISE _Every morning, just after arising, take a cup of water, and go through the following deep breathing exercises_: EXERCISE No. 1 [Illustration] Stand erect, feet about 30 inches apart, extend arms above head, clasping hands and holding elbows rigid, inhale deeply. Bend toward the left and try to touch the floor with the clasped hands as far from the foot and to the rear as possible. Exhale while returning to position. Inhale deeply, reversing motion to the right. This movement should be repeated about 24 times. EXERCISE No. 2 [Illustration] Rest the body upon tips of toes and the palms of the hands. Move the body up and down as far as possible, bending only at the waist line. If this position is too strenuous the tension can be reduced by resting on the elbows, knees, or both, while executing the movement. Inhale deeply while taking this exercise, and exhaust the breath suddenly, as if coughing, with the downward motion. This movement should be repeated about 12 times. EXERCISE No. 3 [Illustration] Rest the hands on the rim of a bathtub or on two chairs placed about 2 feet apart. Assume position shown by cut. Lower the body until chest touches the knee; rise, bringing the other knee under the chest, repeating the movement. Execute this movement rapidly as if running, rising first on one foot and then on the other, from 50 to 100 times. If sufficiently strong, this can be taken without support for the hands. This exercise is especially recommended for those suffering from constipation. _Every evening, just before retiring, take a glass of water and go through the following movements and deep breathing exercises_: EXERCISE No. 3.--Same as in the morning. [Illustration] EXERCISE No. 4 Stand erect, feet about 30 inches apart, inhale deeply and strike a blow toward the left with the right fist, passing the left fist behind the back. Alternate this movement, striking toward the right with the left fist, giving the body a swinging and twisting movement. EXERCISE No. 5 [Illustration] Stand erect, feet about 30 inches apart, hands clasped over head, elbows rigid, inhale deeply. Bend toward the left, describe a complete circle with the clasped hands. Exhale when erect. Reverse, describing a circle in the opposite direction completes the movement. LESSON XXIII EXERCISE AND RE-CREATION EXERCISE [Sidenote: Civilization prevents the play instinct] The child from the time it begins to walk until it is ten or twelve years old, or until the pressing hand of necessity forces upon it the power of restraining duty, will in a great measure obey the play instinct or the natural laws of exercise. However, our complex industrial organism forces most of us into its vortex at the very time we are beginning to change the body from the youth to the adult, and the responsibilities with which we are laden, the struggles we carry on, prevent the majority from giving attention to and maintaining a system of development exercises which is so vitally important, and which would provide a great store-house of energy to be drawn upon in after years. Inasmuch, therefore, as the conditions under which we exist prevent the free play of our instincts, and the exercise of our natural desire for certain kinds of play or motion, it becomes necessary for us to devise a method of overcoming the repressing influences that crush out the play instinct of civilized man. CONSTRUCTIVE EXERCISES [Sidenote: Constructive period of life from ages 15 to 25] Constructive exercises should be taken and practised regularly between the ages fifteen and twenty-five. It is largely during this period that the physical condition of the body for the balance of life is determined. [Sidenote: Poisoning and purifying the blood] Many a college youth, endowed by Nature with a sound physical body and a healthy brain, has irreparably injured both by sitting on the end of his spine with his feet higher than his head, poisoning his blood with tobacco narcotics from a stylish pipe and failing to keep it purified by obeying the laws of motion and of oxidation. Constructive exercises should employ every muscle in the body long enough once in every twenty-four hours to generate sufficient heat to cause perspiration, or at least to force twice the normal quantity of blood to the lungs for purification. Exercise thus taken up to the point of fatigue, and of sufficient duration to use all the nutrition taken in the form of food, will, under favorable conditions, build the body to its highest degree of physical strength, provided we keep Nature supplied with the right kind of material (food) with which to do her work. EXERCISE FOR REPAIR [Sidenote: In mature life exercise only for repair] After the body has reached maturity, or attained its full growth, the only exercise needed is for repair. This it must have or Nature will inflict her inexorable sentence in some form of congestion. [Sidenote: Why the "trunk" requires exercise] In various industrial and professional pursuits the legs, neck, and arms are used enough to keep them in a fair state of repair. That part of the body, therefore, that suffers most for want of motion, or exercise, is the trunk. In this part of the anatomy are located the vital organs controlling not only the circulation and the oxidation of blood, but also those organs upon whose normal action depend solely the questions of digestion, assimilation of food, and elimination of waste. [Sidenote: If properly nourished the body will demand a certain amount of exercise] If the food is selected, combined, and proportioned so as to produce chemical harmony in the stomach, and to meet the requirements of age, temperature of environment, and work, the body will be kept sufficiently charged with energy to demand a certain amount of exercise. If the command is obeyed the body can be trained to work automatically, as it were, but where the vocation is sedative, or prevents obedience to these demands, the trunk should be exercised in the open air from thirty to forty minutes daily by flexing, tensing, twisting and bending in every possible way, long enough and rapidly enough to double the normal heart action and inhalations of air. PHYSIOLOGY OF EXERCISE [Sidenote: Necessity of motion for body development] By motion (exercise) the muscles are stimulated in growth, becoming larger and more firm, thus giving strength and symmetry to the body. Food, without proper motion, will not develop muscular tissue to its highest degree. Exercise must be taken to stimulate the growth of the tissues forming the muscle-cells. Among the benefits derived from exercise, the following may be noted: [Sidenote: Growth produced by exercise] First: Surplus nitrogen is usually cast from the body as waste matter when it is not deposited as muscle tissue by proper exercise. If the diet is balanced, regular exercise will add this nitrogenous substance to the muscle-cells far beyond normal growth, thus causing an actual increase in the size and the number of fibres. [Sidenote: Brain and nerve force increased] Second: A second benefit derived from muscle activity is the consequent change that occurs in brain and in nerve activity. There are certain cells in the brain and in the nervous system which control the movements of the muscles. When these cells are not used, they degenerate, but their use in exercise is not only beneficial in developing a well-rounded nervous mechanism, but also in strengthening the brain-cells that are used in intellectual work. [Sidenote: Blood circulation increased] Third: A third and perhaps most important of all the benefits to be derived from exercise is the general increase in the circulation of the blood. The muscles form a larger proportion of the body-weight than any other group of organs. When general exercise involving the larger muscles is participated in, the demand for food material in this particular muscular tissue is so great as to cause a notable increase in the strength and in the rapidity of the heart beat, and consequent deep breathing. This acceleration of the circulation continues long after the exercise has ceased, thus replenishing and building up the muscles. As a result of the better circulation of the blood, all organs receive an increased blood-supply, and every part of the body shares in the general improvement. This explains why one can do better brain work, or digest food with greater ease after taking moderate exercise. [Sidenote: Evil effect of long-continued exercise] Exercise is constructive up to the point of fatigue, but beyond that point it is destructive. The waste products of all cell-metabolism are harmful and poisonous. When exercise is long continued, the waste matter accumulating therefrom weakens or poisons the cells that secrete them. [Sidenote: Different forms of exhaustion] The products of cell-metabolism are of two classes, and each class has different effects. The first is due to oxidation. A runner, who falls exhausted from shortness of breath, has simply been suffocated by the excess of carbon dioxid in his muscles. After the breath is regained, or, in other words, after the body has had time to throw off the carbon dioxid, the runner is in nearly as good condition as before. A more lasting and serious form of exhaustion is due to the accumulation of nitrogenous decomposition products, which, not being in a gaseous form, cannot be thrown off from the lungs, and hence are not as rapidly or as easily removed from the tissues. The presence in the tissue of these waste-products is the cause of extreme weakness and fatigue. [Sidenote: The causes of soreness or stiffness of the muscles] The well-trained muscles contain only healthy protoplasm, and give off but a small percentage of nitrogenous decomposition products. Let the well-fed person who takes but little exercise, run half a mile, or play a simple game of ball, and the following day the muscles will be stiff and sore; this unusual exertion has caused the breaking down of much loosely organized tissue which could have been made firm and healthy by daily muscular activity. [Sidenote: Why vegetarians have more endurance than meat eaters] Those subsisting upon a low nitrogenous diet, especially vegetarians, are affected much less by fatigue than meat eaters whose muscles contain larger quantities of unnecessary nitrogen and nitrogenous decomposition matter. [Sidenote: The diet governs the production and the accumulation of body-waste] The common laws of health demand that sufficient motion be taken every day to prevent the accumulation of carbon dioxid or waste matter throughout the body. Both the production and the accumulation of waste matter depend very largely upon the diet. All animal flesh (food) is undergoing gradual decomposition, and adds its waste matter to that of the body, therefore meat eaters require a much greater amount of exercise to maintain a given standard of blood-purity than do vegetarians. SYSTEMS OF PHYSICAL CULTURE Numerous schools of physical culture and artificial methods of exercise have flourished in all civilized countries within the past few years. This fact emphasizes the pressing need for a general change in our methods of living. The various systems of indoor exercise popularly taught are at the best weak substitutes for the more natural and wholesome forms of combined exercise and re-creation found in outdoor life and outdoor sport. Some of the methods referred to are as follows: [Sidenote: Tensing] Tensing, which consists of slow movements in which opposite muscles are made to pull against each other. The student can easily grasp the principle involved in this system, and from his own ingenuity extend it as fully as he desires. [Sidenote: Vibratory exercises] Vibratory exercises, which are somewhat similar to the tensing system; however, instead of slow movements, the arms or other portions of the body are moved with a rapidly vibrating motion. The effect produced is essentially the same as in the tensing system. [Sidenote: Heavy-weight exercises] Heavy-weight exercises, consisting in the use of heavy dumb-bells or other apparatus in which the actual physical pull exerted by the body in moving the weights is sufficient to try the muscles to their maximum capacity. This system of exercise should be discouraged; while it may add to the mere lifting strength, it takes from the muscles their flexibility, and from the body its agile and supple activity. [Sidenote: Indoor exercises] Indoor exercise with light apparatus such as wooden dumb-bells, Indian clubs, wands, Swedish and Delsartic movements. These forms of exercise, which compose most physical culture drills, as given in schools and gymnasiums, are to be highly recommended. For adults, however, such exercises require considerable indulgence in order to gain much physical benefit therefrom. [Sidenote: Exercise for school children] [Sidenote: Dancing as an exercise] Exercises of this nature are especially well adapted to school children. They depend upon the rhythm of the music, the good fellowship of their companions, and the pride of keeping up with the class to make them interesting. For this reason they are not suitable to the individual who must exercise alone in his room. Dancing can well be considered in this class, and could be highly recommended as an important exercise and re-creation, were it not so frequently associated with loss of sleep and other forms of intemperance. [Sidenote: Importance of outdoor exercise] [Sidenote: Exercise for the city dweller] All of the above systems are not only at the best imperfect, but poor substitutes for natural exercise, and not likely to be kept up by the ordinary sedative worker. Every individual should, so far as possible, indulge in some form of outdoor exercise, which gives all the advantages of the indoor systems, together with the added advantages of fresh air, mental pleasure, long range of vision, and the general exhilaration that comes from close contact with nature. However, for the city man outdoor exercises are too difficult to be practised with sufficient regularity to bring the desired results; therefore, it is best to adopt some definite daily program of vigorous muscular exercise which will keep the body in fair physical condition. Exercises of this kind should be made a regular daily habit, and though at times a little tiresome, can, by practise, be made to become the expected thing, so that the day will not seem complete until the daily exercises have been taken. [Sidenote: Exercises giving the best results] From long experience I have found that the following exercises give the greatest benefits with the least expenditure of time and labor. They are all especially designed to promote healthy action of the vital and the abdominal organs which are so much neglected by the average person. PROGRAM FOR DAILY EXERCISE Every morning, just after rising, and every night, just before retiring, take a glass or two of pure cool water and execute vigorously the following movements: EXERCISE NO. 1 EXERCISE No. 1--Stand erect, feet about thirty inches apart. Extend arms above head; clasp the hands; hold elbows rigid, and inhale deeply. Bend toward the left and try to touch the floor with the clasped hands, as far from the foot, and as far to the rear as possible. Exhale while returning to position. Inhale deeply, reversing motion to the right. This movement should be repeated from 25 to 50 times. EXERCISE NO. 2 EXERCISE NO. 2--Rest upon the tips of the toes and the palms of the hands. Move the body up and down as far as possible, bending only at the waist line. If the movement is too difficult in this position, the tension may be reduced by resting on the elbows, or on the knees, or on both. Inhale deeply, and exhaust the breath suddenly as if coughing, with the downward motion. This movement should be repeated from 20 to 30 times. EXERCISE NO. 3 EXERCISE NO. 3--Rest the hands on the rim of a bathtub, or on two chairs placed about two feet apart. Assume position shown in cut. Lower the body until the chest touches the right knee; rise, and lower the body until the chest touches the left knee. Execute this movement rapidly as if running, rising first on one foot and then on the other, swinging the body from side to side with each step or movement. This exercise is especially recommended for those suffering from torpidity of the liver, or from constipation. It should be executed from 100 to 500 times. EXERCISE NO. 4 EXERCISE NO. 4--Stand erect, feet about thirty inches apart. Inhale deeply, and strike a blow toward the left with the right fist, passing the left fist behind the back. Alternate this movement, striking toward the right with the left fist, giving the body a swinging and twisting movement. EXERCISE NO. 5 EXERCISE NO. 5--Stand erect, feet about thirty inches apart, hands clasped overhead, elbows rigid; inhale deeply. Bend toward the left, describing a complete circle with the clasped hands. Exhale when erect. Reverse; describing a circle in the opposite direction completes the movement. This exercise should be executed from 25 to 50 times. RE-CREATION [Sidenote: Idleness contrary to natural law] [Sidenote: Exercise necessary for assimilation and elimination] The small boy who described work as "anything you don't want to do," and play as "anything you do want to do," had in his mind the fragment of a great truth. True re-creation should afford DIVERSION, ENTERTAINMENT, and WORK. The average business man who is threatened with a breakdown, and who goes away for a rest, should in reality go to work, but it should be a different kind of work from his routine duties. No one was ever benefited by idleness; it is contrary to nature--contrary to the universal laws of construction which govern all forms of life. If digestion and assimilation have been impaired, if, from errors in eating, or from sedative habits, congestion has taken place in the alimentary tract, then muscular work becomes absolutely necessary in order to use more nutrition, to eliminate more poison and waste, and to increase and normalize the peristaltic activity of the intestinal tract. [Sidenote: Hunting and fishing] The business man who likes to hunt and to kill innocent animals; who runs, walks, and thinks, and perspires in the effort, is taking a good kind of re-creation--perhaps the best he knows; but the fat man who sits in a boat all day and catches fish that he cannot use, or slays a cart-load of ducks that he has deceived with a decoy, has received neither benefit nor re-creation; he has only yielded to his primeval instincts to secure his food by slaughter and has been merely entertained--probably debased. [Sidenote: True re-creation] [Sidenote: Worthless objects for which men struggle] True re-creation for the mental worker is manual work--labor in the open air that requires but little thought. Every business man who values the sacred heritage of health, should provide himself with a place where he can go one day out of each week and chop wood, prepare soil, plant or harvest something, get close to Mother Nature, and receive the blessings of her life-giving sun by day, and rest in her open arms at night. Men are but big children, and, like the child who cries and reaches for the bubble because it reflects the prismatic colors of the sun, most of the things for which they struggle are equally as worthless and deceptive. [Sidenote: The triad of all that is best in life] Mental supremacy, which means the keenest sense of love, justice, and mercy, that great triad of all that is best in man, is all that really pays. If, at the close of every life, the question, "What has brought most happiness?" could be answered, it would be, "THE GRATITUDE OF MY FELLOW MEN." The average business pursuit is not conducive to this end. It is unfortunate that commercial and financial success are too often secured by methods that produce just the opposite results, therefore the whole life-work of the average man is really reduced to no higher object than that of securing food and shelter, which is the primitive occupation of the lowest forms of life. [Sidenote: Rest in solitude] One day in the week spent close to the soil with gentle cows and horses, affectionate cats and admiring dogs that have no "axe to grind," and one night every week spent in thought and reflection under the wilderness of worlds that whirl through the abyss of space, will sharpen the senses of love, justice, and mercy, give true diversion, true entertainment, true work, and true rest. INDEX A ACETANILID _Vol._ _Page_ composition of, II 358 effects of, II 358 ACIDITY sub, symptoms of, II 462 ---- remedy for, II 463 ---- diet in, II 464 super, chart indicating dis-eases caused by, I 9 ACIDS nitric, I 62 ---- properties of, I 63 hydrochloric, I 64 ---- uses of, I 65 ---- preparation of, I 66 ---- elements of, I 67 ---- purpose of, I 149 ---- formation of, I 149 bases of, I 68 ---- tests for, I 69 ---- neutralization of, I 70 Relation of bases to, I 69 organic, I 94 ---- properties of, I 94 acetic, I 95 ---- process of making, I 95 oxalic, I 97 lactic, I 97 malic, I 97 tartaric, I 97 citric, I 98 uric, in rheumatism, V 1179 AIR composition of, I 32 liquefaction of, I 35 and oxidation, V 1312 relative importance of food, water and, V 1313 ALBUMIN sources of, I 129 solubility of, I 129 coagulation of, I 129 ALCOHOL varieties of, I 91 effect of, II 367 a poison, II 368 ALDEHYDES and ethers, I 93 ALKALIS principles of neutralization of, I 71 rules governing neutralization of, I 71 AMIDO compounds, I 128 AMMONIA composition of, I 60 uses of, I 60 AMYLOPSIN properties of, I 154 APPENDIX (VERIFORM) dis-eases of (see Appendicitis), II 580 functions of, II 581 APPENDICITIS symptoms of, II 582 treatment of (mild cases), II 583 a natural remedy for, II 583 diet in, II 584 list of foods for, II 585 chronic cases of, II 586 ---- treatment for, II 587 ---- causes of, II 588 diet a factor in, II 589 coarse food a factor in, II 590 old diagnosis of, II 582 menus for, IV 1029 APPETITE lack of, IV 1081 difference between hunger and, IV 1081 ARTERIO-SCLEROSIS causes of, I 170 food in, I 171 ASSIMILATION definition of, III 630 ASTHMA described, II 519 causes of, II 533 symptoms of, II 533 remedy for, II 634 diet in, II 534 foods to eat in, II 535 foods to omit in, II 535 ATHLETES selection, combination and proportioning of food for, V 1188 summer diet for, V 1191 winter diet for, V 1192 suggestions regarding diet in exposure to extreme cold or for exertion, V 1201 AUTOINTOXICATION defined, I 247 bacteria in, I 247 meat a factor in, I 247 B BACTERIA discussed, I 166 origin of, I 167 not all harmful, I 168 species of, I 168 producers of, I 168 fermentation produced by, I 169 growth of, I 169 meat a producer of, I 259 BANANAS varieties of, III 675 how to select and ripen, III 676 how to bake, III 677 BILE defined, I 153 function of, I 153 purposes of, I 153 BILIOUSNESS cause of, II 466 symptoms of, II 466 remedy for, II 466 what to eat, II 467 what to omit, II 467 BRAN meal, composition of, III 683 ---- bread made from, III 683 wheat, composition of, III 681 ---- medicinal properties of, III 681 BLOOD, THE Antipepsin in, I 152 glucose in, I 204 process of oxidation of, II 346 corpuscles of, II 386 automatic action of, II 388 incorrect feeding cause of impurity of, II 397 defective circulation of, II 398 exercise a factor in poisoning and purification of, V 1331 increase of circulation of, V 1335 BRIGHT'S DIS-EASE described, II 550 causes of, II 551 symptoms of, II 551 prevention of, II 552 treatment for, II 553 general suggestion in feeding in, II 554 foods to eat in, II 555 foods to omit in, II 555 BROMIN defined, I 73 BUSINESS MAN a lesson for, V 1317 examples of poor, V 1318 wealth at the expense of health for the V 1319 the abnormal, V 1320 what is a good, V 1320 qualities of a, V 1321 routine life of the average, V 1322 bad habits of the average, V 1322 the ancient remedy for the average, V 1322 the physician of the average, V 1324 twelve rules of health for the, V 1324-1326 BUTTER composition of, I 283 its value as a food, I 284 caloric value of, I 285 cocoa, how made, II 338 cocoanut, composition of, II 339 home-made, how to make, III 674 BUTTERMILK how made, III 674 BUTYRIN defined, I 123 C CALORIES definition of, I 199 method of determining numbers of, I 202 CARBOHYDRATES classification of, I 106 monosaccharids, I 109 disaccharids, I 112 polysaccharids, I 114 purpose of, III 625 CARBON sources of, I 81 forms of, I 82 properties of, I 83 monoxid, properties of, I 87 combining power of, I 88 and hydrogen compounds, I 88 dioxid of, I 83 nature of, I 81 CASEIN sources of, I 130 vegetable, I 130 CATARRH described, II 519 causes of, II 527 symptoms of, II 528 remedy for, II 528 diet for, II 529 foods to eat in, II 530 foods to omit in, II 530 nasal, IV 922 ---- food a factor in, IV 922 ---- water drinking in the treatment of, IV 923 ---- menus for, IV 925 CELLULOSE in nutrition, I 119 value of, I 119 CHART showing number of so-called dis-eases caused by superacidity, I 9 CHEESE processes of making, I 282 ripening of, I 283 digestive value of, I 283 limburger, I 283 manufacture of, I 283 CHEMISTRY its relation to food science, I 25 combustion in, I 26 common elements of, I 27 number of elements in, I 28 examples of changes due to, I 29 symbols of, I 31 list of elements in, I 32 organic, I 81 of foods, I 105 of digestion, I 139 of metabolism, I 193 COLDS described, II 519 causes of, II 520, IV 915 symptoms of, II 521 overeating a cause of, II 521 exposure a cause of, II 522 remedy for, II 523 foods to use for, II 524 turkish baths for, II 525 value of fresh air for, II 525 foods to eat for, II 526 foods to omit for, II 526 COCAIN habit, II 354 uses of, II 354 in medicines, II 355 COFFEE composition of, II 363 effect of drinking, II 364 COOKING chemical changes produced by, III 593 starch, reasons for, III 598 of food, an excuse, III 599 food for animals, government experiments on, III 602 a habit of civilization, III 603 object of, III 669 grains, III 669 vegetables, III 670 en casserole, III 671 rice and macaroni, III 672 fruits, III 672 ---- canned, III 672 CHLOROFORM uses of, II 372 CHLORIN sources of, I 63 properties of, I 64 uses of, I 64 CHOCOLATE see (cocoa), II 366 COAL TAR PRODUCTS evil effects of, II 359 COCOA analyzed, II 366 COMPOUNDS chemical, I 29 ---- derivatives, I 31 carbon, I 83 ---- inorganic, I 83 ---- action of, I 85 ---- organic, I 87 ---- and hydrogen, I 88 ---- organic, classification of, I 89 ---- hydro, I 89 alcohols, I 91 glycerin, I 92 aldehydes, I 93 ethers, I 93 organic acid, I 94 ---- nitrogenous, I 99 ---- ---- importance of, I 100 amido, I 128 vegetable, II 373 CONFECTIONS evil effects of, II 332 from the standpoint of food value, II 333 allowable, II 333 prohibited, II 334 CONGESTION defined, V 1195 CONSTIPATION milk a relief for, I 188 relation of milk to, I 278 milk diet for, I 278 wheat bran, laxative effects in, II 299 whole rye a remedy for, II 300 ---- wheat, a remedy for, II 300 ---- barley, a remedy for, II 300 ---- oats, a remedy for, II 300 causes of, II 434 remedy for, II 436 suggestions for relief of, II 437 menus for, II 438 exercise in, II 444 beverages causing, II 446 what to eat for, II 447 what to omit for, II 447 in infants, V 1169 a factor in nervousness, V 1214 CONSUMPTION conflicting opinions regarding the cause of, II 560 conditions and occupations predisposing causes of, II 561 modern treatment of, II 563 general diet in, II 564 spring and summer diet in, II 565 special suggestions for treatment in mild cases of, II 566 hygienic rules in, II 567 breathing in, II 567 sleep in, II 568 what to eat in, II 568 what to omit in, II 568 nature's remedy for, IV 989 foods in, IV 990 the use of the spirometer in, IV 990 D DIABETES described, II 556 causes of, II 556 symptoms of, II 557 remedy for, II 557 diet for, II 558 diet in extreme cases of, II 558 foods to eat in, II 559 foods to omit in, II 559 special instructions regarding, II 560 DIAGNOSIS purpose of, II 381 only correct, II 382 of "lump" in the stomach, II 419 DIARRHEA causes of, II 474 cathartics in, II 475 treatment of, II 476 diet in, II 476 DIET important considerations regarding, I 164 importance of correct standards in, I 221 of primitive man, I 238 flesh, unnecessary, I 238 milk and eggs not a balanced, I 272 wheat, II 290 for constipation, II 429 for nervous indigestion, II 458 in subacidity, II 464 suggestions in obesity, II 496 in neurasthenia, II 509 in catarrh, II 529 in hay fever, II 531 in asthma, II 534 in influenza, II 537 in insomnia, II 541 in rheumatism, II 547 in diabetes, II 560 in consumption, II 564 in heart trouble, II 573 in dis-eases of the skin, II 579 in appendicitis, II 584 errors in, II 586 for cold weather, IV 1133 for hot weather, IV 1134 three classes of, V 1147 the normal, V 1152 radical changes in, V 1152 make patient agree with, V 1153 during embryonic period, V 1156 FOR CHILDREN (ages 1 to 2 years), V 1174 special instructions regarding simplicity in feeding, V 1176-1177 in old age, V 1178 ---- importance of, V 1181 for normal athlete, V 1189 (summer) for athletes, V 1191 (winter) for athletes, V 1192 in climatic extremes, V 1193-1199 under normal conditions, V 1200 DIGESTION chemistry of, I 139 uses of, I 139 malt in, I 140 energy required in, I 161 mental influence upon, I 162 secretion of juices in, I 163 important rules to observe to insure good, I 164 experiments in, I 175 mechanics of, I 180 action of enzyms during, I 181 food prepared for, I 186 during sleep, I 188 how affected, I 188 x-ray experiment in, I 188 comparative, of cooked and uncooked grain, III 597 true interpretation of the word, III 630 necessity for thorough mastication an aid to, I 181 "bolting" of food in, I 181 secretion of enzyms in, I 182 DIGESTIVE EXPERIMENTS to determine the amount of food the body uses, I 175 to determine percentage of waste in food, I 176 to determine amount of time required to pass through the body, I 176 to measure what percentage of food taken is digested, I 177 to determine what foods aid digestion, I 178 to determine what foods hinder digestion, I 178 to determine the laws governing the production of chemical harmony, I 178 to approximately determine the amount of undigested food, I 179 to determine the digestibility of each particular food, I 179 DIGESTIVE JUICES gastric juice, I 144 ---- composition of, I 147 ---- formation of, I 148 ---- action of, I 148 pancreatic juice, I 153 ---- composition of, I 153 ---- action of, I 154 amylopsin, properties of, I 154 trypsin, properties of, I 164 steapsin, properties of, I 154 bile, I 153 ---- function of, I 153 pepsin, I 155 ---- action of, I 155 saliva, I 161 ---- secretion of, I 161 the influence of the mind upon the action of the, I 162 DIGESTIVE ORGANS chemical changes in, I 165 peristaltic action of, I 187 DISACCHARIDS cane sugar, I 112 beet sugar, I 112 maltose, I 113 lactose, I 113 DIGESTIVE TABLES inaccuracy of, I 145 DIS-EASE difference between ease and, I 14 indications of, II 394 true diagnosis of, II 396 defined, II 407 classification of, II 412 nature's warning, II 674 DIS-EASES OF THE SKIN kinds of, II 575 causes of, II 575 eczema, II 577 ---- treatment of, II 578 ---- diet for, II 579 DISORDERS (COMMON) their causes and cure, I 405 DRUGS analysis of, II 343 declining use of, II 346 alkaloids in, II 349 opium, II 350 morphin, II 351 cocain, II 353 nux vomica, II 356 strychnin, II 356 quinin, II 356 acetanilid, II 358 laudanum, II 360 paregoric, II 360 codein, II 360 lyoscine, II 360 atropin, II 360 hellebore, II 360 chloroform, II 372 ether, II 372 chloral, II 372 mercury, II 373 potassium iodid, II 374 purgatives and cathartics, II 375 authentic information on, II 377 supposed magical effect of, II 384 E EATING flesh produces appetite for stimulants, I 243 ---- habit disappearing, I 249 correctly a cure for the drink habit, II 369 over, II 413 ---- causes of, II 414 scientifically, III 667 ECZEMA described, II 577 treatment of, II 578 chronic, diet in, II 579 menus in, IV 1023 EGGS food value of, I 269 composition of, I 271 nutritive contents of, I 271 as a diet for convalescents, I 272 tables of digestive harmonies and disharmonies of, III 610 how to coddle, III 677 uncooked, III 678 baked omelet (how made), III 678 ELEMENTS chemical, in the body, I 3 chemical, I 27 ---- number of, I 28 mineral sulphur, I 73 hydrogen sulfid, I 74 carbon disulfid, I 74 EMACIATION (UNDERWEIGHT) effects of, II 477 causes of, II 479 mental factors in, II 480 symptoms of, II 481 remedy for, II 482 important factors in, II 483 foods in, II 484 milk and eggs in, II 484 constipation a factor in, II 485 chronic, its cause and remedy, II 486 extreme, diet in, II 489 weight, tables in, II 492 in infancy, V 1173 ENERGY food, a producer of, I 199 how measured, I 200 fat chief source of, I 209 grain a source of, II 295 explained, III 639 determined, III 640 the mystery of, V 1309 food and, V 1310 required for work, V 1311 relation of sleep to expenditure of, V 1312 ENZYMS properties of, I 139 fermentation due to, I 140 malt, a digestive, I 140 ETHER uses of, I 94 EVOLUTION OF MAN evolution, what it is, V 1255 study of man in the, V 1255 significance of the term, V 1258 difference between inherited and acquired characteristics in the, V 1260 the three great proofs of the, V 1261 early forms of animal life in the, V 1262 the single cell, nucleus in, V 1263 development of the human embryo in the, V 1264 animal kinship in, V 1265 blood comparisons in man and apes, V 1266 difference in the development of man and apes, V 1267 power of speech a factor in, V 1267 habits and progress in, V 1268 factors that determine survival of races during the, V 1269 habits and customs detrimental to life in, V 1270 changes of organs in, V 1271 "natural" diet in, V 1273 dietetic development in, V 1274 facts regarding the, V 1275 EXERCISE a necessity, II 444 in infancy, V 1171 in childhood, V 1329 constructive ages 15-25, V 1330 for purifying the blood, V 1331 properly nourished body demands a certain amount of, V 1332 physiology of, V 1333 growth produced by, V 1334 brain and nerve force produced by, V 1334 blood circulation increased by, V 1335 evil effects of long continued, V 1336 different kinds of exhaustion produced by, V 1336 the causes of soreness or stiffness of the muscles due to, V 1337 endurance of vegetable composition with meat eaters, V 1337 body waste in, V 1338 tensing as an, V 1339 vibratory, V 1339 heavyweight, V 1340 indoor, V 1340 for school children, V 1341 dancing as an, V 1341 importance of outdoor, V 1341 for the city dweller, V 1342 that give best the results, V 1342 EXERCISE PROGRAM FOR DAILY EXERCISES exercise No, 1, V 1343 exercise No, 2, V 1344 exercise No, 3, V 1344 exercise No, 4, V 1345 exercise No, 5, V 1345 EXHAUSTION causes of, II 399 F FASTING (AND NO BREAKFAST PLAN) data secured from, V 1311 FATS composition of, I 122 formation of, I 122 mineral, I 123 olein, I 123 butyrin, I 123 butter dairy, I 123 butter artificial, I 123 stearin, I 123 oleomargarin, I 123 rancid, I 125 digestion of, I 156 unwholesome, I 157 metabolism of, I 205 absorption of body, I 206 human, I 207 distinction between tallow, lard, olive oil, I 207 animal, I 254 chemical change in frying, I 255 chemical difference in, I 256 effects of heat on, III 595 tables of digestive harmonies and disharmonies of, III 609 purpose of, III 626 a source of heat, I 209 the chief source of energy, I 209 FERMENTATION causes of, I 172, II 425 symptoms of, II 426 results of, II 427 remedy for, II 428 diet for, II 428 FISH nutrients in, I 260 as brain food, I 261 superior to flesh food, I 261 selection of, III 678 preparation of, III 678 FLUORIN a gas, I 73 action of, I 73 FOOD preparation of, I 15 chemistry of, I 15, I 21 how to select, I 16 how to combine, I 16 how to proportion, I 16 how to determine quantity, I 16 science, I 19, I 20 importance of, I 4 classes of, I 105 analysis of, I 106 maltose in, I 118 predigested, I 141 manufacture of, I 141 predigested, comparison of, I 146 mastication of, I 150-183 digestibility of, comparative, I 159 fermentation of, I 164 decomposition of, I 173 determining quantity of, I 177 values, I 178 breakfast, I 182 tissue builder as, I 195 importance of protein in, I 209 standards of, I 217 endurance tests of, I 219 government standards of, I 220 dietary standards of, I 222 correct dietary standards of, I 225 quantity required, I 226 proportion of fat required in, I 228 fallacy of nitrogenous, I 229 influence of religion on, I 235 a factor in producing physical and mental power, I 240 unscientific to use meat as, I 241 rare meat unfit for, I 258 in contagious dis-eases, I 258 fish as a, I 260 superiority of fish as a, I 261 oysters as a, I 262 clams as a, I 262 shell-fish as a, I 262 poultry as a, I 262 superiority of poultry as a, I 263 comparative analyses of, I 264 feeding of poultry for, I 265 cheese as a, I 282 butter considered as a, I 283 wheat considered as a, II 290 grain as a remedial, II 298 white potato as a, II 321 relative value of salads as, II 321 relative value of water melon as a, II 323 relative value of musk melon as a, II 323 honey compared as a, II 330 life dependent upon, II 345 substitution of, II 439 staples, II 440 list of constipating, II 446 list of laxative, II 446 that reduces fat, II 498 in obesity, II 502 in locomotor ataxia, II 519 to eat in case of colds, II 524 to eat in catarrh, II 530 in hay fever, II 532 combinations, III 602 quantity an important factor, III 604 instinct a safe guide in selecting, III 605 tables, how to interpret, III 607 tables of digestive harmonies and disharmonies, III 609 fats, III 609 eggs, III 610 milk, III 611 nuts, III 612 grains, III 613 vegetables, III 614 acid fruits, III 615 sweet fruits, III 616 sugars, III 617 simple classification of, III 621 based on principal nutritive substances, III 624 purposes of different classes of, III 625 difference between digestibility and assimilability of, III 630 table showing comparative assimilability carbohydrate and water content of various classes of food, III 632 purpose of the vieno table in, III 634 vieno system of, III 645 values, measurement of, III 639 values, measurement of--(old system), III 642 amount of nitrogen in, incorrect standards, III 645 incorrect standards of measurement of, III 646 what constitutes a true, III 647 explanation of vieno system of food measurement, III 648 edible portion of, III 650 how to reduce foods to vienos, III 651 nitrogen factor in, III 651 direct method of calculating available nitrogen in, III 655, III 663 curative value of, III 668 for children (see menus for children), III 687 in cirrhosis of the liver, III 823 in consumption, IV 989-990 in pregnancy, IV 1033 selection, combination and proportion of, V 1149, V 1152 according to age, V 1149 according to time of year, V 1151 according to work or activity, V 1151 and energy, V 1310 relative importance of air, water and, V 1313 FORMALDEHYDE uses of, I 93 an artificial preservative, I 93 a poison to the human system, I 93 FOWL selection of, III 678 preparation of, III 678 FRUITS composition of, II 309 dietetic value of, II 310 effect of acid, II 312 classification according to acidity, II 312 evils of acid, II 314 value of sub-acid, II 315 value of non-acid, II 316 canned, II 316 evaporated, II 316 fresh, II 317 tables of digestive harmonies and disharmonies of acid, III 615 tables of digestive harmonies and disharmonies of sweet, III 616 bananas, III 675 G GALACTOSE formation of, I 111 GAME as a food, I 268 GAS DILATATION (GASTRITIS) symptoms of, II 432-447 what to eat in, II 432 what to omit in, II 433 causes of, II 449 remedy for, II 450 food to be used in treatment of, II 452 GASTRIC JUICE composition of, I 147 formation of, I 148 its action on fat, I 148 rennet of the, I 151 GASTRITIS (also see gas dilatation), II 432 causes of, II 449 symptoms of, II 449 diagnosis of, II 450 treatment of, II 450 diet in, II 450 food in, II 452 what to eat in, II 452 what to omit in, II 452 GLOBULINS sources of, I 129 properties, I 129 types of, I 130 GLUCOSE percentage in the blood, I 204 function of, I 204 manufacture of, II 328 composition of, II 328 uses of, II 329 an article of food, II 329 GLYCOGEN sources of, I 118 formation of, I 118 GOUT causes of, II 546 symptoms of, II 547 remedy for, II 547 diet in, II 548 what to eat in, II 550 what to omit in, II 550 GRAIN cooked, I 184 government experiments with, I 185 uncooked, I 185 nutritive value of, II 289 wheat, II 290 rye, II 291 barley, II 292 oats, II 293 corn, II 293 rice, II 294 buckwheat, II 294 uses of, II 295 as a remedial food, II 298 tables of digestive harmonies and disharmonies of, III 613 GUMS varieties of, I 120 H HABITS man a creature of, I 223 HAY FEVER described, II 519 symptoms of, II 531 remedy for, II 531 diet for, II 531 foods to eat in, II 532 foods to omit in, II 532 HEALTH influence of mind on, II 385 laws of, II 396 definition of, II 405 HEART TROUBLE gas, a cause of, II 448-572 early symptoms of, II 570 medical misconceptions of, II 570 causes of, II 571 diet for, II 573 exercise for, II 574 HEAT production of, I 41 body determination of, I 42 a measure of energy, I 198 units, I 199 HEMOGLOBIN component parts of, I 130 HEMORRHOIDS (see Piles), II 471 HEREDITY, V 1293 so-called wonders of microscopic study of reproductive cells in, V 1294 chromosoms in different species, V 1294 action of, V 1294 what it is, V 1295 characteristics not due to, V 1296 summary of facts regarding sex and, V 1297 HERNIA causes of, II 443 HONEY food value of, II 330 composition of, II 331 HUMAN ILLS chiefly due to dis-eases and conditions originating in the stomach, I 4 (see chart showing dis-eases caused by superacidity), I 9 HYDROCARBONS definition of, I 89 uses of, I 89 where found, I 89 how formed, I 90 HYDROCHLORIC ACID how formed, I 64 action of, I 65 its importance in digestion, I 66 chemical symbols of, I 67 HYDROGEN where found, I 42 physical properties, I 43 chemical properties of, I 43 gas, I 45 I INDIGESTION (ACUTE) important suggestions regarding, III 807 treatment for, III 807 what to eat in, III 807 INFANT FEEDING great mortality due to wrong, V 1154 two points of view on, V 1155 mothers' milk in, V 1162 general rules to be observed in, V 1164 modification of milk in, V 1165 preparation of food in, V 1165 quantity of food in, V 1166 frequency of feeding, V 1166 disastrous results of too frequent, V 1168 importance of cleanliness in preparation of food, V 1168 constipation in, V 1169 composition and color of stools in, V 1169 temperature of food in, V 1173 general instructions in health and hygiene, V 1174 INFLUENZA described, II 519 causes of, II 536 symptoms of, II 537 remedy, II 537 diet for, II 537 food in, IV 939 INSOMNIA causes of, II 538 remedy for, II 539 diet for, II 541 foods to eat in, II 542 foods to omit in, II 542 similarity of symptoms in nervousness and, II 542 INTESTINAL JUICES definition of, I 157 action of, I 158 INULIN value of, I 121 IODIN description of, I 73 IRON salts of, I 77 in patent medicines, I 78 L LACTOSE where found, I 113 indigestion, I 114 LAWS natural, I 11 LAXATIVES loss of vitality due to, II 376 harmful results due to use of, II 436 LEGUMES defined, II 307 familiar types of, II 307 rich in nitrogen, II 307 require thorough mastication, II 308 LEVULOSE composition of, I 111 defined, I 111 LITMUS SOLUTION tests for, I 69 LIVER, THE, I 137 functions of, I 203 cirrhosis of, II 468 ---- causes of, II 468 ---- symptoms of, II 468 ---- treatment for, II 469 ---- stimulants in, II 469 ---- what to eat in, II 469 ---- atrophic, III 822 ---- hypertrophic, III 822 ---- food in treatment for, III 823 LOCOMOTOR ATAXIA causes of, II 511 drug treatment harmful in, II 513 symptoms of, II 514 remedy for, II 515 diet for, II 516 exercise in, II 517 massage in, II 517 cured, obstinate case of, II 518 foods to eat, II 519 foods to omit, II 519 LUNGS, THE functions of, II 390 M MALNUTRITION cause of, II 511 remedy for, II 511 MALTOSE composition of, I 112 how formed, I 113 MEAT fallacy of lean, I 228 source of autointoxication, I 247 classified, I 250 composition of lean, I 250 extractives of, I 252 prejudice against pork, I 253 cold storage of, I 256 decomposition of cold storage, I 257 "ripened", I 257 scientific objections to use of, I 258 MEDICINES effects of, II 343 ancient belief concerning, II 344 unscientific uses of, II 377 MENUS FOR NORMAL CHILDREN (_From 2 to 5 Years of Age_) spring, III 687 summer, III 688 fall, III 689 winter, III 690 (_From 5 to 10 Years of Age_) spring, III 692 summer, III 693 fall, III 694 winter, III 695 (_From 10 to 15 Years of Age_) spring, III 696 summer, III 697 fall, III 698 winter, III 699 FOR NORMAL PERSONS (_From 15 to 20 Years of Age_) spring, III 700 summer, III 701 fall, III 702 winter, III 703 (_From 20 to 33 Years of Age_) spring, III 704 summer, III 705 fall, III 706 winter, III 707 (_From 33 to 50 Years of Age_) spring, III 708 summer, III 709 fall, III 710 winter, III 711 (_From 50 to 65 Years of Age_) spring, III 712 summer, III 713 fall, III 714 winter, III 715 (_From 65 to 80 Years of Age_) spring, III 716 summer, III 717 fall, III 718 winter, III 719 (_From 85 to 100 Years of Age_) spring, III 720 summer, III 721 fall, III 722 winter, III 723 MENUS, CURATIVE introduction, III 724 FOR SUPERACIDITY (ABNORMAL APPETITE) spring, III 726 summer, III 728 fall, III 729 winter, III 730 FOR SOUR STOMACH AND IRRITATION OF STOMACH AND INTESTINES spring, III 731 summer, III 733 fall, III 734 winter, III 736 FOR SOUR STOMACH, INTESTINAL GAS AND CONSTIPATION spring, III 738 summer, III 740 fall, III 742 winter, III 745 STOMACH AND INTESTINAL CATARRH spring, III 747 summer, III 750 fall, III 751 winter, III 752 FERMENTATION, INTESTINAL GAS, FEVERED STOMACH AND LIPS, CANKERS ON TONGUE spring, III 753 summer, III 755 fall, III 757 winter, III 759 CONSTIPATION (CHRONIC) NERVOUSNESS spring, III 761 summer, III 765 fall, III 767 winter, III 769 CONSTIPATION, AUTOINTOXICATION, LOW VITALITY spring, III 771 summer, III 773 fall, III 775 winter, III 777 GASTRITIS spring, III 779 summer, III 781 fall, III 782 winter, III 783 NERVOUS INDIGESTION spring, III 784 summer, III 785 fall, III 786 winter, III 787 NERVOUSNESS FOR BUSINESS MAN, THIN, NERVOUS, IRRITABLE--INSOMNIA--STOMACH AND INTESTINAL TROUBLE spring, III 789 summer, III 790 fall, III 793 winter, III 798 FOR SUBACIDITY INDIGESTION (CHRONIC) spring, III 801 summer, III 803 fall, III 804 winter, III 805 BILIOUSNESS HEADACHE--SLUGGISH LIVER spring, III 809 summer, III 811 fall, III 812 winter, III 813 HEADACHE--TORPID LIVER spring, III 814 summer, III 815 fall, III 816 winter, III 820 CIRRHOSIS OF THE LIVER general remarks, III 822 food to be used in, III 823 MENU NO, 1 spring, III 824 summer, III 825 fall, III 826 winter, III 827 MENU NO, 2 spring, III 828 summer, III 829 fall, III 830 winter, III 831 DIARRHEA spring, III 832 summer, III 833 fall, III 834 winter, III 835 DIARRHEA--DYSENTERY spring, III 836 summer, III 840 fall, III 841 winter, III 842 EMACIATION--UNDERWEIGHT--RATHER ANEMIC spring, III 845 summer, III 847 fall, III 848 winter, III 850 RUN DOWN CONDITION--FLATULENCY--UNDERWEIGHT spring, III 852 summer, III 856 fall, III 858 winter, III 861 LOW VITALITY--UNDERWEIGHT--WEAK DIGESTION spring, IV 863 summer, IV 864 fall, IV 865 winter, IV 866 OBESITY--IRREGULAR HEART ACTION--NERVOUSNESS spring, IV 870 remarks, IV 871 summer, IV 872 fall, IV 872 winter, IV 877 ABNORMAL APPETITE--OBESITY--DROWSINESS spring, IV 882 summer, IV 884 remarks, IV 885 fall, IV 886 remarks, IV 887 winter, IV 891 DECREASING WEIGHT--INCREASING STRENGTH spring, IV 893 summer, IV 894 fall, IV 895 winter, IV 896 NEURASTHENIA spring, IV 897 summer, IV 898 fall, IV 899 winter, IV 900 MALNUTRITION spring, IV 901 summer, IV 902 fall, IV 903 winter, IV 904 FOR A YOUTH ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE spring, IV 905 summer, IV 907 fall, IV 908 winter, IV 910 LOCOMOTOR ATAXIA spring, IV 911 summer, IV 912 fall, IV 913 winter, IV 914 COLDS spring, IV 917 summer, IV 918 fall, IV 920 winter, IV 921 NASAL CATARRH late spring }, IV 925 early summer} late summer }, IV 927 early fall } late fall }, IV 928 early winter} late winter }, IV 930 early spring} HAY FEVER spring, IV 931 summer, IV 932 fall, IV 933 winter, IV 934 ASTHMA spring, IV 935 summer, IV 936 fall, IV 937 winter, IV 938 INFLUENZA Foods in, IV 939 Menus for (see menus for colds, catarrh, hay fever and asthma), II 519 INSOMNIA--NERVOUSNESS--LOW VITALITY spring, IV 940 summer, IV 942 fall, IV 943 winter, IV 945 RHEUMATISM--GOUT--LUMBAGO--SCIATICA--ARTHRITIS spring, IV 947 summer, IV 949 fall, IV 951 winter, IV 953 ANEMIA--SLUGGISH LIVER--RHEUMATIC TENDENCY spring, IV 955 summer, IV 957 fall, IV 962 winter, IV 964 STIFFNESS AND PAIN IN JOINTS--STOMACH TROUBLE--CONSTIPATION--INTESTINAL GAS--IRREGULAR HEART ACTION spring, IV 967 summer, IV 968 fall, IV 970 winter, IV 975 BRIGHT'S DIS-EASE spring, IV 979 summer, IV 980 fall, IV 981 winter, IV 982 DIABETES spring, IV 983 summer, IV 985 fall, IV 987 winter, IV 988 WEAK LUNGS--CONSUMPTION general menu, IV 991 TUBERCULAR TENDENCY--CONSTIPATION--NERVOUSNESS--CATARRH spring, IV 994 summer, IV 998 fall, IV 1000 winter, IV 1003 TENDENCY TOWARD INTESTINAL CONGESTION spring, IV 1005 summer, IV 1007 fall, IV 1008 winter, IV 1011 DIS-EASES OF THE SKIN--ECZEMA spring, IV 1013 summer, IV 1015 fall, IV 1016 winter, IV 1019 WEAK DIGESTION--NERVOUSNESS--SLIGHT ECZEMA spring, IV 1023 summer, IV 1025 fall, IV 1026 winter, IV 1027 APPENDICITIS spring, IV 1029 summer, IV 1030 fall, IV 1031 winter, IV 1032 FOR THE PREGNANT WOMAN food in pregnancy, IV 1033-1035 MENUS spring, IV 1036 summer, IV 1037 fall, IV 1038 winter, IV 1039 FOR THE NURSING MOTHER foods to omit, IV 1040 foods to use, IV 1041 MENUS FOR THE NURSING MOTHER spring, IV 1042 summer, IV 1043 fall, IV 1044 winter, IV 1045 MISCELLANEOUS WEAK DIGESTION (ALMOST INVALID) spring, IV 1046 summer, IV 1048 fall, IV 1049 winter, IV 1051 BUILDING UP THE NERVOUS SYSTEM--INCREASING VITALITY spring, IV 1053 summer, IV 1056 fall, IV 1058 winter, IV 1060 FOR AGED PERSON--BUILDING GENERAL HEALTH spring, IV 1061 summer, IV 1065 fall, IV 1066 winter, IV 1068 (Healthy Person) STRENGTH AND ENDURANCE spring, IV 1069 summer, IV 1070 fall, IV 1071 winter, IV 1073 MALASSIMILATION AND AUTOINTOXICATION spring, IV 1074 summer, IV 1076 fall, IV 1078 winter, IV 1080 NO APPETITE distinction between appetite and hunger, IV 1081 spring, IV 1081 summer, IV 1084 fall, IV 1085 winter, IV 1086 ATHLETIC DIET spring, IV 1088 summer, IV 1089 fall, IV 1090 winter, IV 1091 (Chiefly Uncooked) spring, IV 1093 summer, IV 1094 fall, IV 1095 winter, IV 1097 FOR INVALID CHILD--MAKING MUSCULAR TISSUE--REGULATING BOWELS spring, IV 1098 summer, IV 1100 fall, IV 1101 winter, IV 1104 FOR MENTAL WORKER--TO INCREASE BRAIN EFFICIENCY spring, IV 1106 summer, IV 1108 fall, IV 1110 winter, IV 1113 FOR SCHOOL TEACHER--ANEMIA--SLUGGISH LIVER--UNDERWEIGHT--NERVOUSNESS spring, IV 1115 summer, IV 1117 fall, IV 1118 winter, IV 1120 LABORING MAN UNDERWEIGHT--ANEMIC (LUNCH IN SHOP) spring, IV 1122 summer, IV 1124 fall, IV 1126 winter, IV 1129 diet for cold weather, IV 1133 diet for hot weather, IV 1134 hot weather menu for the prevention of sunstroke and heat prostration, IV 1135 suggestions for the prevention of sunstroke, IV 1136 MENUS FOR BUILDING UP SEXUAL VITALITY spring, IV 1138 summer, IV 1139 fall, IV 1140 winter, IV 1141 SUGGESTIONS FOR PERSONS UNDERGOING MODERATE AMOUNT OF EXPOSURE, V 1201 MENUS between temperature 20 and 30° F, V 1203 between temperature 70 and 90° F, V 1206 MENUS FOR NERVOUSNESS spring, V 1220 summer, V 1222 fall, V 1223 winter, V 1224-1227 MENUS Curative and Remedial, III 667, IV 1143 for constipation, II 438 for obesity, II 500 choice of, III 683 normal, III 685 introduction to, III 685 MERCURY and its salts, II 373 METABOLISM chemistry of, I 193 process of, I 193 described, I 194 liberation of energy through, I 199 carbohydrates in, I 202 of fat, I 205 of proteids, I 209 METALS salts of, I 76 uses of, I 77 iron, I 77 MILK sour, discussed, I 174 mothers, I 246 food values of, I 270 a perfect food, I 273 cows, I 274 composition of cows, I 274 varieties of cows, I 274 nutritive value of, I 275 coagulation of casein in, I 276 harmonies, I 276 adulteration of, I 276 in sour stomach, I 277 preservatives in, I 280 pasteurization of, I 280 natural souring of, I 281 why constipating, II 442 tables of digestive harmonies and disharmonies, III 611 MORPHIN habit, II 351 uses of, II 352 MOTHER, THE PROSPECTIVE general rules for, V 1157 the corset, V 1158 exercise, V 1158 deep breathing, V 1158 mental occupation, V 1158 special rules for, V 1159 suggestions for the diet for abnormal appetite during pregnancy, V 1160 selection of food, V 1161 starchy foods during pregnancy, V 1161 N NARCOTICS classification of, III 349 NASAL CATARRH, IV 922 NERVOUSNESS true meaning of, V 1211 relation of nutrition to, V 1212 causes of, V 1212 constipation a factor in, V 1214 primary causes of, V 1215 effect of stimulants in, V 1215 overwork not a factor in, V 1216 remedy for, V 1217 effects of wrong eating and drinking in, V 1218 special instructions for persons suffering from, V 1227 recreation in, V 1228 relation of sexual functions to, V 1228 NERVOUS INDIGESTION described, II 453 causes of, II 454 symptoms of, II 455 remedy for, II 458 diet for, II 458 remarks on, III 784 NEURASTHENIA described, II 503 a final warning, II 503 causes of, II 505-507 symptoms, II 506 remedy, II 506 importance of diet in, II 508 mental attitude in, II 508 what to eat in, II 510 what to omit in, II 510 NITROGEN described, I 58 properties of, I 59 compounds of, I 59 daily amount required, I 231 body requirement of, I 232 grain a source of, II 297 proportion in lean meat, III 641 in food, how to compute, III 645 a factor in food, III 651 method of calculating available amount in food, III 655 NUTRITION science of, I 14 relation of sexual health in, V 1289 NUTS pine, II 301 ----, composition of, II 301 almonds, II 303 pecans, II 304 brazil, II 304 walnut, English, II 304 hazel, II 305 butter, II 305 beech, II 305 cocoa, II 305 peanuts, II 306 as heat producers, II 301 nitrogen factor in, II 302 tables of digestive harmonies and disharmonies of, III 612 O OBESITY prevention of, I 208 remedies for, I 208, II 495 unnatural, II 491 the law governing, II 491 weight tables in, II 492 causes of, II 493 eating in, II 494 drinking in, II 494 exercise in, II 495 use of fats in, II 496 chronic, diet suggestions in, II 496 foods that produce, II 497 foods that prevent, II 498 foods in, II 500 menus for, II 500 symptoms resulting from change of food in, II 502 foods to eat in, II 502 foods to omit in, II 502 OILS formation of, I 122 composition of, I 122 olive, I 123 cotton seed, manufacturing of, I 123, II 337 vegetable, I 123 vegetable, value of, II 335 poisonous, I 124 grades of olive, II 336 peanut, value of, II 338 palm, II 339 linseed, II 340 OLD AGE meat and bread as articles of diet in, V 1179 uric acid in rheumatic conditions in, V 1179 soluble starches desirable in, V 1180 importance of diet in, V 1181 DIET FOR THE THREE PERIODS IN OLD AGE From 50-60 years of age, V 1181 From 60-70 years of age, V 1182 From 70-100 years of age, V 1182 SPECIAL SPRING AND SUMMER MENUS For ages 50-60, V 1184 FALL AND WINTER MENUS For ages 50-60, V 1186 How food should be prepared for people between ages of 50-60, V 1186 OLEIN defined, I 123 OLEOMARGARIN described, I 285 how made, I 286 OPIUM composition of, II 350 effect of, II 351 OXYGEN a substance, I 32-33 manufacture of, I 33 production of, I 36 properties of, I 36 chemical action of, I 36 effect of, I 36 a heat determiner, I 40 not the only required element in breathing, V 1313 OXID nitrous, I 62 OXIDATION of the blood, I 39 of waste matter, I 39 laws governing, I 41 and air, V 1312 OYSTERS (AND CLAMS) unfit for food, I 262 P PANCREAS, THE functions of, I 138 PAIN a warning, I 12 PATENT MEDICINES Defined, II 347 why alcohol is used in, II 370 per cent of alcohol in, II 371 PENTOSES from the standpoint of human food, I 110 PEPSIN action of, I 155 PHOSPHORUS uses of, I 75 PHYSICAL CULTURE systems of, V 1333 tensing in, V 1339 vibratory exercise, V 1339 heavy weight exercise, V 1340 indoor exercises, V 1340 PHYSIOLOGY the old, V 1305 PILES causes of, II 471 symptoms of, II 472 treatment for, II 472 diet for, II 473 POISONS body, I 245 generated by fear, I 246 alkaloid, II 349 narcotic, II 349 POLYSACCHARIDS starch, I 114 glycogen, I 118 cellulose, I 119 gums, I 120 inulin, I 121 POTASSIUM IODID effect of, II 374 POULTRY method of fattening domestic, I 265 marketing undrawn, I 266 "hanging", I 267 PRACTISE OF DIETETICS, THE Introduction, V 1233 general treatment in, V 1235 scope of scientific feeding in, V 1236 the value of letters in, V 1236 the art of polemics in, V 1236 value of booklet describing your work, V 1238 ability to prepare your own copy, V 1238 value of experience in, V 1239 diagnosis in, V 1241 diet in, V 1242 educate your patient in, V 1242 patient should agree with the diet, V 1243 mental factors in, V 1245 publicity necessary in, V 1246 value of truthful publicity, V 1248 some cures too remarkable to advertise, V 1250 courtesy an asset in, V 1250 PRENATAL CULTURE embryological growth in, V 1289 superstition concerning, V 1290 theory on, V 1290 influence of fright, anger, etc, in, V 1291 mother's nutrition the only factor in, V 1291 birthmarks, V 1292 PROTEIDS defined, I 125 classified, I 128 peptones, I 130 proteoses, I 130 uses of, I 211 replace worn-out cells, I 212 action of, I 213 converted into peptones, I 214 composition of, I 215 form body fat, I 215 excess of, I 216 animal requirements of, I 230 digestibility of grain, II 298 effect of heat on, III 595 purpose of, III 626 PTOMAINS formation of, I 128 PURGATIVES salts as, II 375 Q QUININ uses of, II 357 R RECIPES for coddled eggs, III 677 uncooked eggs, III 678 baked omelet, III 678 for preparing green peas in the pod, III 679 pumpkin, III 680 vegetable juice, III 680 sassafras tea, III 680 REST forces at work during, V 1301 changes during, V 1302 human body at, V 1303 change in body tissue during, V 1303 comparisons regarding necessity for, V 1304 confusion of terms, V 1306 REST AND RE-CREATION necessity for, II 400 phenomenon of sleep and, V 1306 where found, V 1308 idleness in, V 1346 exercise necessary for assimilation and elimination, V 1347 hunting, V 1347 fishing, V 1347 true re-creation, V 1348 worthless objects for which men struggle fail to give, V 1348 the triad of all that is best in man the goal to strive for, V 1348 in solitude, V 1349 RHEUMATISM described, II 543 causes of, II 544 symptoms of, II 545 remedy for, II 547 diet in, II 548 ---- natural versus artificial, II 548 perspiration in, II 549 what to eat in, II 550 what to omit in, II 550 S SACCHARIN food value of, I 91 SALIVA secretion of, I 142 mastication and, I 142 SALT common, I 69 in the body, I 73 magnesium, I 77 mineral origin of vegetable, I 131 SEX relation of sexual functions to the nervous system, V 1288 necessity for popular knowledge concerning, V 1288 relation of nutrition to sexual health, V 1289 summary of facts regarding heredity, and V 1297 SILICON in the body, I 76 SLEEP evidence of acquired energy during, V 1308 the mysterious production of energy during, V 1309 expenditure of energy during, V 1310 and its relation to the expenditure of energy, V 1312 SOAP process of making, I 96 SOLUTION in nutrition, I 50 in assimilation, I 51 examples of, I 51 STARCH sources of, I 114 potato, I 115 solubility of, I 116 corn, I 116 changing of, I 117 STOMACH, THE, I 137 functions of, II 389 disorders originating in, II 417 "lump" in, II 419 catarrh of, III 747 STRYCHNIN effect of, II 356 SUGAR grape, I 109 ---- sources of, I 109, II 327 pentose, I 110 levulose, I 111 galactose, I 111 cane, I 112 maltose, I 112 lactose, I 113 effects of heat on, III 594 tables of digestive harmonies and disharmonies, III 617 food value of, II 324 beet sugar, II 325 cane, value of, II 326 process of refining, II 326 maple, genuine, II 327 ---- imitation, II 327 milk, II 327 SULFUR in the human body, I 75 SUNSTROKE prevention of, IV 1136 SUPERACIDITY chart indicating dis-eases caused by, I 9 cause of, I 7, II 421 diagnosis of, II 418 symptoms of, II 421 remedy for, II 423 despondency produced by, II 430 SWEETS relative order of, II 332 application of term, II 334 SYMPTOMS comparison of, II 389 T TABLE OF WEIGHTS AND MEASURES, III 664 TEA composition of, II 365 TEMPERATURE fat requirements according to, V 1200 TISSUE BUILDING food a factor in, I 195 process of, I 196 generation of heat and energy in, I 197 proteids a factor in, I 210 TOBACCO effect of nicotin in, II 361 general effect of, II 362 TREATMENT by disinfection, II 347 TRICHINOSIS described, I 259 TRYPSIN action of, I 155 V VEGETABLES groups of, II 318 succulent, II 319 ---- value of, II 320 juices of, II 321 white potato, II 321 sweet potato, II 322 carrots, II 322 parsnips, II 322 turnips, II 322 beets, II 322 tomatoes, II 323 tables of digestive harmonies and disharmonies of, III 614 VEGETARIANISM from animal standpoint, I 236 from standpoint of scientific living, I 237 W WATER composition of, I 44 properties of, I 45 rain, I 46 hard, I 46 mineral, I 47 salt, I 47 effervescent, I 47 sulphur, I 47 distilled, I 48 as a solvent, I 49 chemical uses of, I 48 proportion in the body, I 52 uses in the body, I 54 drinking, I 54 necessity for drinking, II 434 WHEAT composition of, II 291 * * * * * +---------------------------------------------------------------------+ | Transcriber's notes: | | | | Added 'D' to index heading of D words. | | 'shall fish' in index need be 'shell-fish', changed. | | Added 'G' to index heading of G words. | | Added 'H' to index heading of H words, misplaced. | | Index HUMAN ILLA 'orginating' need be 'originating' in the stomach. | | Taken out hyphen in 'Re-creation' from index. | | Put in hypen in 'diseases' in index as in main text. | | Both 'Re-creation' and 'Recreation' present, leaving. | | Taken out hyphen in 'stand-point'. | | Taken out hyphen in 'tea-pot'. | | P.1145. Removed duplicate chapter heading in html file. | | Index, O - Old Age: From 70-100 years of age V '1181' | | need be '1182', changed. | | Fixed various punctuation. | | Note: underscores to surround _italic text_. | +---------------------------------------------------------------------+ 
6752	----	STUDY AND STIMULANTS; OR, THE USE OF INTOXICANTS AND NARCOTICS IN RELATION TO INTELLECTUAL LIFE, AS ILLUSTRATED BY PERSONAL COMMUNICATIONS ON THE SUBJECT, FROM MEN OF LETTERS AND OF SCIENCE. EDITED BY A. ARTHUR READE. INTRODUCTION. The real influence of the intoxicants and narcotics in common use has been a matter of fierce and prolonged controversy. The most opposite opinions have been set forth with ability and earnestness; but the weight they would otherwise carry is lessened by their mutually contradictor-y character. Notwithstanding the great influence of the physician's authority, people are perplexed by the blessings and bannings bestowed upon tobacco and the various forms of alcohol. What is the real influence of stimulants and narcotics upon the brain? Do they give increased strength, greater lucidity of mind and more continuous power? Do they weaken and cloud the intellect, and lessen that capacity for enduring a prolonged strain of mental exertion which is one of the first requisites of the intellectual life? Would a man who is about to enter upon the consideration of problems, the correct solution of which will demand all the strength and agility of his mind, be helped or hindered by their use? These are questions which are asked every day, and especially by the young, who seek in vain for an adequate reply. The student grappling with the early difficulties of science and literature, wishes to know whether he will be wiser to use or to abstain from stimulants. The theoretical aspect of the question has perhaps been sufficiently discussed; but there still remains the practical inquiry,--"What has been the experience of those engaged in intellectual work?" Have men of science--the inventors, the statesmen, the essayists, and novelists of our own day--found advantage or the reverse in the use of alcohol and tobacco? The problem has for years exercised my thoughts, and with the hope of arriving at _data_ which would be trustworthy and decisive, I entered upon an independent inquiry among the representatives of literature, science, and art, in Europe and America. The replies were not only numerous, but in most cases covered wider ground than that originally contemplated. Many of the writers give details of their habits of work, and thus, in addition to the value of the testimony on this special topic, the letters throw great light upon the methods of the intellectual life. To each writer, and especially to Dr. Alex. Bain, Mr. R. E. Francillon, Mark Twain, Mr. E. O'Donovan, Mr. J E. Boehm, Professor Dowden, the Rev. Dr. Martineau, Count Gubernatis, the Abbe Moigno, and Professor Magnus, who have shown hearty interest in the enquiry, I tender my best thanks for contributing to the solution of the important problem of the value of stimulants; also to Mr. W. E. A. Axon for suggestive and much appreciated help. I should, however, be glad of further testimonies for use in a second edition. _January_, 1883. CONTENTS. I. Introduction II. LETTERS FROM: Abbot, The Rev. Dr. Allibone, Mr. S. Astin Argyll, The Duke of, F. R. S. Arnold, Mr. Matthew Ayrton, Professor Bain, Dr. Alexander Ball, Professor Robert S., LL. D., F. R. S. Bancroft, Mr. Hubert Howe Baxendell, Mr. Joseph, F. R. A. S. Beard, Dr. G. M. Bert, Professor Paul Blackie, Professor John Stuart Blanc, M. Louis Boehm, Mr. J. E., R. A. Bredencamp, Dr. Brown, Mr. Ford Madox, R. A. Buchanan, Mr. Robert Buddenseig, Dr. Burnaby, Captain Fred Butler, Lieut. Col. W. F. Burnton, Dr. Lauder, F. R. S. Camp, Madame du Carpenter, Dr. W. B., C. B., LL. D., F. R. S. Chambers, Mr. William, LL. D Childs, Mr. George W. Claretie, M. Jules Clarke, Mr. Hyde, F. S. S. Collins, Mr. Wilkie Conway, Mr. Moncure D., M. A. Dallenger, Rev. W. H., F. R. S Darwin, Professor Dawkins, W. Boyd, M. A., F. R. S., F. G. S. D'Orsey, The Rev. Alex. J. D., B. D. O'Donovon, Mr. Edmund Dowden, Professor, LL. D. Edison, Professor Ellis, Mr. Alex. J., F. R. S., F. S. A. Everett, Professor Fairbairn, Professor R. M. Francillon, Mr. R. E. Freeman, Mr. Edward A., D. C. L., LL. D. Furnivall, Mr. F. J., M. A. Gardiner, Mr. Samuel R., Hon. LL. D. Gladstone, Rt. Hon. W. E., M. P. Greville, Mdlle. II Gubernatis, Count Guenin, M. L. P. Guy, Dr. William Haeckel, Professor Ernst Hamerton, Mr. Philip Gilbert Hardy, Mr. Thomas Harrison, Mr. Frederic Henty, Mr. G. A. Holmes, Mr. Oliver Wendell Holyoake, Mr. George Jacob Hooker, Sir J. D., F. R. S. Howells, Mr. W. D. Joule, Dr. J. P. Lansdell, The Rev. Henry Leathes, Rev. Stanley, D. D. Lecky, W. E. H. Lees, Dr. F. R. Levi, Mr. Leone, F. S. A. Lubbock, Sir John, Bart. M. P. Magnus, Professor Maitland, Mr. Edward, B. A. Martin, Sir Theodore, K. C. B. Martineau, The Rev. James, D. D. Maudsley, Dr. Henry May, Sir Thomas Erskine, K. C. B., D. C. L. Mayor, Rev. John E. B., M. A. Moigno, The Abbe Morrison, Rev. J., D. D. Mongredien, Mr. Augustus Murray, Dr. J. A. H. Murray, Mr. D. Christie. Newman, Professor Pattison, The Rev. Mark, B. D. Payn, Mr. James Pitman, Mr. Eizak Plaute, M. Gaston Plummer, The Rev. A. Pocknell, Mr. Edward Rawlinson, Professor George Reade, Mr. Charles Reed, Mr. Thomas Allen Rodenberg, Dr. Julius Russell, Dr. W. H. Ruskin, Mr. John Sen, Keshub Chunder Simon, M. Jules Skeat, Professor St. Hilaire, M. Barthelemy Spottiswoode, Mr. W., D. C. L., LL. D. Siemens, Dr. C. W., D. C. L., F. R. S. Smith, Mr. G. Barnett Taine, M. Trollope, Mr. Anthony Thomson, Sir William, M. A., LL. D., D. C. L., F. R. S. Trantmann, Professor Tyndall, Professor, LL. D., F. R. S. Tourgueneff, Mr. Ivan Twain, Mark Walford, Mr. Cornelius, F. S. S., F. I. A. Watts, Mr. G. F., R. A. Wilson, Professor Andrew, Ph. D., F. R. S. E. Winser, Mr. Justin Wurtz, M. III. APPENDIX TESTIMONIES OF: Bennett, Dr. Risdon Brooke, The Rev. Stopford A., M. A. Bryant, William C. Chambers, Dr. King Fraser, Professor Thomas R. Herkomer, Hubert, A. R. A. Higginson, Colonel Thomas Wentworth Howitt, William Kingsley, The Rev. Charles Martineau, Harriet Miller, Professor Proctor, Mr. R. A., F. R. S. Richardson, Dr. B. W., F. R. S. Sala, Mr. George Augustus Temple, Bishop Thompson, Sir Henry, F. R. C. S. Williams, Mr. W. Mattieu, F. R. A. S., F. C. S. Yeo, Dr. Bumey, M. D. IV. CONCLUSION STUDY AND STIMULANTS THE REV. DR. ABBOT, EDITOR OF THE "CHRISTIAN UNION," NEW YORK. I have no experience whatever respecting tobacco: my general opinion is adverse to its use by a healthy man; but that opinion is not founded on any personal experience, nor on any scientific knowledge, as to give it any value for others. My opinion respecting alcohol is that it is a valuable and necessary ingredient in forming and preserving some articles of diet--yeast bread, for example, which can only be produced by fermentation--and that its value in the lighter wines, those in which it is found in, a ratio of from 5 to 10 per cent., is of the same character. It preserves for use other elements in the juice of the grape. As a stimulant, alcohol is, in my opinion, at once a deadly poison and a valuable medicine, to be ranked with belladonna, arsenic, prussic acid, and other toxical agents, which can never be safely dispensed with by the medical faculty, nor safely used by laymen as a stimulant, except under medical advice. As to my experience, it is very limited; and, in my judgment, it is quite unsafe in this matter to make one man's experience another man's guide: too much depends upon temperamental and constitutional peculiarities, and upon special conditions of climate and the like. 1. I have no experience respecting distilled spirits; I regard them as highly dangerous, and have never used them except under medical advice, and then only in rare and serious cases of illness. 2. Beers and the lighter wines, if taken before mental work, always--in my experience--impair the working powers. They do not facilitate, but impede brain action. 3. After an exceptionally hard day's work, when the nervous power is exhausted, and the stomach is not able to digest and assimilate the food which the system needs, a glass of light wine, taken with the dinner, is a better aid to digestion than any other medicine that I know. To serve this purpose, its use--in my opinion-- should be exceptional, not habitual: it is a medicine, not a beverage. 4. After nervous excitement in the evening, especially public speaking, a glass of light beer serves a useful purpose as a sedative, and ensures at times a good sleep, when without it the night would be one of imperfect sleep. I must repeat that my experience is very limited; that in my judgment the cases which justify a man in so overtaxing his system that he requires a medicine to enable him to digest his dinner or enjoy his sleep must be rare; and that my own use of either wine or beer is very exceptional. Though I am not in strictness of speech a total abstinence man, I am ordinarily a water drinker. LYMAN ABBOT. March 11, 1882. MR. S. AUSTIN ALLIBONE, NEW YORK. I have no doubt that the use of alcohol as a rule is very injurious to all persons--authors included. In about 17 years (1853-1870), in which I was engaged on the "Dictionary of English Literature and Authors," I never took it but for medicine, and very seldom. Moderate smoking after meals I think useful to those who use their brains much; and this seems to have been the opinion of the majority of the physicians who took part in the controversy in the _Lancet_ about ten or twelve years since. An energetic non-smoker is in haste to rush to his work soon after dinner. A smoker is willing to rest (it should be for an hour), because he can enjoy his cigar, and his conscience is satisfied, which is a great thing for digestion; the brain is soothed also. S. AUSTIN ALLIBONE. March 27, 1882. THE DUKE OF ARGYLL, F. R. S. In answer to your question, I can only say that during by far the greatest part of my life I never took alcohol in any form; and that only in recent years I have taken a small fixed quantity under medical advice, as a preventive of gout. Tobacco I have never touched. ARGYLL. October 2, 1882. MR. MATTHEW ARNOLD. In reply to your enquiry, I have to inform you that I have never smoked, and have always drunk wine, chiefly claret. As to the use of wine, I can only speak for myself. Of course, there is the danger of excess; but a healthy nature and the power of self-control being presupposed, one can hardly do better, I should think, than "follow nature" as to what one drinks, and its times and quantity. As a general rule, I drink water in the middle of the day; and a glass or two of sherry, and some light claret, mixed with water, at a late dinner; and this seems to suit me very well. I have given up beer in the middle of the day, not because I experienced that it did not suit me, but because the doctor assured me that it was bad for rheumatism, from which I sometimes suffer. I suppose most young people could do as much without wine as with it. Real brain-work of itself, I think, upsets the worker, and makes him bilious; wine will not cure this, nor will abstaining from wine prevent it. But, in general, wine used in moderation seems to add to the _agreeableness_ of life--for adults, at any rate; and whatever adds to the agreeableness of life adds to its resources and powers. MATTHEW ARNOLD. November 4, 1882. PROFESSOR AYRTON Has no very definite opinions as to the effects of tobacco and alcohol upon the mind and health, but as he is not in the habit of either taking alcohol or of smoking, he cannot regard those habits as essential to mental exertion. April 21, 1882. DR. ALEXANDER BAIN, LORD RECTOR OF ABERDEEN UNIVERSITY. I am interested in the fact that anyone is engaged in a thorough investigation of the action of stimulants. Although the subject falls under my own studies in some degree, I am a very indifferent testimony as far as concerns personal experience. On the action of tobacco, I am disqualified to speak, from never having used it. As to the other stimulants--alcohol and the tea group--I find abstinence essential to intellectual effort. They induce a false excitement, not compatible with severe application to problems of difficulty. They come in well enough at the end of the day as soothing, or cheering, and also as diverting the thoughts into other channels. In my early intercourse with my friend; Dr. Carpenter, when he was a strict teetotaler, he used to discredit the effect of alcohol in soothing the excitement of prolonged intellectual work. I have always considered, however, that there is something in it. Excess of tea I have good reason to deprecate; I take it only once a day. The difficulty that presses upon me on the whole subject is this:--In organic influences, you are not at liberty to lay down the law of concomitant variations without exception, or to affirm that what is bad in large quantities, is simply less bad when the quantity is small. There may be proportions not only innocuous, but beneficial; reasoning from the analogy of the action of many drugs which present the greatest opposition of effect in different quantities. I mean this--not with reference to the inutility for intellectual stimulation, in which I have a pretty clear opinion as regards myself--but as to the harmlessness in the long run, of the employment of stimulants for solace and pleasure when kept to what we call moderation. A friend of mine heard Thackeray say that he got some of his best thoughts when driving home from dining out, with his skin full of wine. That a man might get chance suggestions by the nervous excitement, I have no doubt; I speak of the serious work of composition. John Stuart Mill never used tobacco; I believe he had always a moderate quantity of wine to dinner. He frequently made the remark that he believed the giving up of wine would be apt to be followed by taking more food than was necessary, merely for the sake of stimulation. Assuming the use of stimulants after work to aid the subsidence of the brain, I can quite conceive that tobacco may operate in this way, as often averred; but I should have supposed that any single stimulant would be enough: as tobacco for those abstaining entirely from alcohol, and using little tea or coffee. ALEXANDER BAIN. March 6, 1882. PROFESSOR ROBERT S. BALL, LL. D., F. R. S., ANDREWS PROFESSOR OF ASTRONOMY IN THE UNIVERSITY OF DUBLIN, AND ROYAL ASTRONOMER OF IRELAND. I fear my experience can be of little use to you. I have never smoked except once--when at school; I then got sick, and have never desired to smoke since. I have not paid particular attention to the subject, but I have never seen anything to make me believe that tobacco was of real use to intellectual workers. I have known of people being injured by smoking too much, but I never heard of anyone suffering from not smoking at all. ROBERT S. BALL. February 13, 1882. MR. HUBERT HOWE BANCROFT, SAN FRANCISCO. In my opinion, some constitutions are benefited by a moderate use of tobacco and alcohol; others are not. But to touch these things is dangerous. H. H. BANCROFT. May 6, 1882. MR. JOSEPH BAXENDELL, F. R. A. S. I fear that my experience of the results of the use of stimulants will not aid you much in your enquiry. Although I am not a professed teetotaler or anti-smoker, practically I may say I am one: and when I am engaged in literary work, scientific investigations, or long and complicated calculations, I never think of taking any stimulant to aid or refresh me, and I doubt whether it would be of any use to do so. JOSEPH BAXENDELL. February 20, 1882. DR. G. M. BEARD, FELLOW OF THE NEW YORK ACADEMY OF MEDICINE. In reply to your enquiries, I may say--first: I do not find that alcohol is so good a stimulant to thought as coffee, tea, opium, or tobacco. On myself alcohol has rather a benumbing and stupefying effect, whatever may be the dose employed; whereas, tobacco and opium, in moderate doses, tea, and especially coffee, as well as cocoa, have an effect precisely the reverse. Secondly: there are many persons on whom alcohol in large or small doses has a stimulating effect on thought: they can speak and think better under its influence. The late Daniel Webster was accustomed to stimulate himself for his great speeches by the use of alcohol. Thirdly: these stimulants and narcotics, according to the temperament of the person on whom they are used, have effects precisely opposite, either sedative or stimulating; while coffee makes some people sleepy, the majority of persons are made wakeful by it. Some are made very nervous by tobacco in the form of smoking, while on others it acts as a sedative, and induces sleep. General Grant once told me 'that, if disturbed during the night, or worried about anything so that he could not sleep, he could induce sleep by getting up and smoking a short time--a few whiffs, as I understood him, being sufficient. If I were to judge by my own experience alone--which it is not fair to do--I should say that coffee is the best stimulant for mental work; next to that tobacco and quinine; but as I grow older, I observe that alcohol in reasonable doses is beginning to have a stimulating effect. GEORGE M. BEARD. March 13, 1882. PROFESSOR PAUL BERT. My views on tobacco and alcohol, and their action on the health, may be summed up in the following four propositions:-- 1.--Whole populations have attained to a high degree of civilization and prosperity without having known either tobacco or alcohol, therefore, these substances are neither necessary nor even useful to individuals as well as races. 2.--Very considerable quantities of these drugs, taken at a single dose, may cause death; smaller quantities stupefy, or kill more slowly. They are, therefore, poisons against which we must be on our guard. 3.--On the other hand, there are innumerable persons who drink alcoholic beverages, and smoke tobacco, without any detriment to their reason or their health. There is, therefore, no reason to forbid the use of these substances, while suitably regulating the quantity to be taken. 4.--The use of alcoholic liquors and of tobacco in feeble doses, affords to many persons very great satisfaction, and is altogether harmless and inoffensive. We ought, therefore, to attach no stigma to their consumption, after having pointed out the danger of their abuse. In short, it is with alcohol and tobacco as with all the pleasures of this life--a question of degree. As for myself, I never smoke, because I am not fond of tobacco: I very seldom drink alcoholic liquors, but I take wine to all my meals because I like it. PAUL BERT. March 1, 1882. PROFESSOR JOHN STUART BLACKIE. My idea is, that work done under the influence of any kind of stimulants is unhealthy work, and tends to no good. I never use any kind of stimulant for intellectual work--only a glass of wine during dinner to sharpen the appetite. As to smoking generally, it is a vile and odious practice; but I do not know that, unless carried to excess, it is in any way unhealthy. Instead of stimulants, literary men should seek for aid in a pleasant variety of occupation, in intervals of perfect rest, in fresh air and exercise, and a cultivation of systematic moderation in all emotions and passions. J. S. BLACKIE. February 9, 1882. M. LOUIS BLANC. In answer to your letter, I beg to tell you that I do not know by experience what may be the effects of tobacco and alcohol upon the mind and health, not having been in the habit of taking tobacco and drinking alcohol. LOUIS BLANC. March 9, 1882. MR. J. E. BOEHM, R. A. It will give me great pleasure if I can in any way contribute to your so very interesting researches, and I shall be glad to know whether you have published anything on the subject you have questioned me on. I find vigorous exercise the first and most important stimulant to hard work. I get up in summer at six, in winter at seven, take an hour and a half's hard ride, afterwards a warm bath, a cold douche, and then breakfast. I work from ten to seven generally; but twice or thrice a week I have an additional exercise--an hour's fencing before dinner, which I take at 8 p.m. I take light claret or hock to my dinner, but never touch any wine or spirits at any other times, and eat meat only once in twenty-four hours. I find a small cup of coffee after luncheon very exhilarating. I smoke when hard at work--chiefly cigarettes. After a long sitting (as I do not smoke while working _from nature_), a cigarette is a soother for which I get a perfect craving. In the evening, or when I am in the country doing nothing, I scarcely smoke at all, and do not feel the want of it there; nor do I then take at evening dinner more than one or two glasses of wine, and I have observed that the same quantity which would make me feel giddy in the country when in full health and vigour, would not have the slightest effect on me when taken after a hard day's work. I also observed that I can work longer without fatigue when I have had my ride, than when for any reason I have to give it up. I have carried this mode of life on for nearly twenty years, and am well and feel young, though forty-eight. I never see any one from ten to three o'clock; after that I still work, but must often suffer interruption. I found that temperament and constitution are rarely, if ever, a legitimate excuse for departure from abstinence and sober habits. I have the conviction that in order to have the eye and the brain clear, you ought to make your skin act vigorously at least once in twenty-four hours. J. E. BOEHM. February 20, 1882. DR. BREDENCAMP, ERLANGEN. In reply to your letter, I am accustomed to smoke. If I do not smoke, I cannot do my work properly; and it is quite impossible to do any work in the morning without smoking. Strong drink I do not need at all, but I drink two glasses of Bavarian beer, which contains very little alcohol. E. BREDENCAMP. April 18, 1882. MR. FORD MADOX BROWN, R. A. I have smoked for upwards of thirty years, and have given up smoking for the last seven years. Almost all my life I have taken alcoholic liquors in moderation, but have also been a total abstainer for a short period. My experience is that neither course with either ingredient has anything to do with mental work as capacity for it; unless, indeed, we are to except the incapacity produced by excessive drinking, of which, however, I have no personal experience. F. M. BROWN. Feb. 28, 1882. MR. ROBERT BUCHANAN. I am myself no authority on the subject concerning which you write. I drink myself, but not during the hours of work; and I smoke-pretty habitually. My own experience and belief is, that both alcohol and tobacco, like most blessings, can be turned into curses by habitual self-indulgence. Physiologically speaking, I believe them both to be invaluable to humankind. The cases of dire disease generated by total abstinence from liquor are even more terrible than those caused by excess. With regard to tobacco, I have a notion that it is only dangerous where the vital organism, and particularly the nervous system, is badly nourished. ROBERT BUCHANAN. March 7, 1882. DR. BUDDENSEIG, DRESDEN. I have no decided opinion whatever as to the question you ask. I can only say that I am a very small smoker, taking one or two cigars daily, and I drink Rhine wine, but not daily, as most scholars or those working with their brains generally do. There can be, I should think, no question that immoderate use of alcohol produces most destructive results. E. BUDDENSEIG. Feb. 20, 1882. CAPTAIN FRED BURNABY. In my humble opinion, every man must find out for himself whether stimulants are a help to his intellectual efforts. It is impossible to lay down a law. What would, perhaps, enable one man to write brilliantly would make another man write nonsense. I myself, although not an abstainer, should think it a great mistake to seek inspiration in either tobacco or alcohol. F. BURNABY. March 2, 1882. LIEUT.-COL. W. F. BUTLER. In reply to your communication, asking for a statement of my experience as to the effects of tobacco and alcohol upon the mind and health, I beg to inform you that as I have not been in the habit of using the first-named article at any period of my life, I am unable to speak of its effects, mental or otherwise. With regard to alcohol, I have found that although the brain may receive a temporary accession to its production of thought, through the use of wine, etc., such increased action is always followed by a decided weakening of the thinking power, and that on the whole a far greater amount of _even_ mental work is to be obtained without the use of alcohol than with it. W. F. BUTLER. Feb. 18, 1882. DR. LAUDER BURNTON, F. R. S. I am unable to give you personal experience as to the use of tobacco, inasmuch as I do not use it in any form. From observation of others it appears to me that, when not used to excess, it is serviceable both as a stimulant during work, and as a sedative after work is over. LAUDER BURNTON. Feb. 9, 1882. MAXIME DU CAMP. I have never been able to make any experiences on the influence of alcohol upon the mind. I never drink it, and have never been tipsy. I smoke very much, but only the pipe and cigarette. I take two meals every day--one at eleven, consisting of a mutton chop, vegetables, and a cup of tea. I make a hearty dinner at seven, and drink a bottle of Bordeaux wine. I never work in the evening; and go to bed at half-past ten. I think the use of tobacco very useless and rather stupid. As to alcohol, I consider it very hurtful for the liver, and highly injurious to the mind. The life of mental workers should be well regulated and temperate in all respects. Bodily exercises, such as riding, walking and hunting, are very necessary for the relaxation of the mind, and must be taken occasionally. In my opinion, all intellectual productions are due to a special disposition of the cerebro-spinal system, upon which tobacco and alcohol can have no salutary action. I fear that my answer will be of little help to you; for in these matters I esteem theory nothing. There are, as the Germans say, _idiosyncrasies_. MAXIME DU CAMP. Feb. 17, 1882. DR. W. B. CARPENTER, C. B., LL. D., F. R. S. In reply to your enquiry, I have to inform you that I have never felt the need of alcoholic stimulants as a help in intellectual efforts; on the contrary, I have found them decidedly injurious in that respect, except when used with the strictest moderation. For about eleven years of the hardest-working period of my life, that in which I produced my large treatises on Physiology, edited the Medical Quarterly Review, and did a great deal of other literary work, besides lecturing, I was practically a total abstainer, though I never took any pledge. I undoubtedly injured myself by over-work during that period, as I have more than once done since under the pressure of official duty; but the injury has shown itself in the failure of appetite and digestive power. After many trials, I have come to the practical conclusion that I get on best, while in London, by taking with my dinner a couple of glasses of very light Claret, and simply as an aid in the digestion of the food which is required to keep up my mental and bodily power. But when "on holiday" in Scotland, or elsewhere, I do not find the need of this. I have never smoked tobacco, or used it in any form. I need scarcely say that I have never used any other "nervine stimulants." You are at perfect liberty to make use of this communication. WM. B. CARPENTER. Feb. 17, 1882. MR. WILLIAM CHAMBERS, LL. D. In reply to your note, I have only time to say that I never used tobacco in any form all my life, and I can say the same thing regarding my brother, Robert. WILLIAM CHAMBERS. February 10, 1882. MR. GEORGE W. CHILDS, PHILADELPHIA. I fear I shall be unable to add to your fund of information. Never having used spirituous or vinous stimulants, or tobacco in any form, I have no personal "experience" of the way they affect the mental faculties of those who use them. G. W. CHILDS. Sept. 30, 1882. M. JULES CLARETIE, PARIS. I should have been glad to reply to your question from my personal experience, but I do not smoke, and have never in all my life drunk as much as a single glass of alcohol. This plainly shows that I require no "fillip" or stimulant when at work. Tobacco and alcohol may cause over-excitement of the brain, as does coffee, which I am very fond of; but, in my opinion, that alone is thorough good work which is performed without artificial stimulant, and in full possession of one's health and faculties. The reason we have so many sickly productions in our literature arises probably from the fact that our writers, perhaps, add a little alcohol to their ink, and view life through the fumes of nicotine. M. JULES CLARETIE. Feb. 26, 1882. MR. HYDE CLARKE, F. S. S. As I am not an adherent of the teetotal abstinence movement, I beg that everything I write may be accepted with this reservation. I have never seen that any great thinker has found any help or benefit from the use of stimulants-either alcohol or tobacco. My observations and experiences are unfavourable to both classes of stimulants. In my own case, I gave up smoking before my scientific work began. Alcoholic drinks I used moderately, but I was a water drinker chiefly. Of late years, from illness, I have given up alcoholic drinks; but were I in full health, I should use them moderately. In the course of a public life of about forty years, I have seen the ill-effects of drinking upon many journalists and others; but it appears to me that smoking produces still greater evil. A man knows when he is drunk, but he does not know when he has smoked too much, until the effects of accumulation have made themselves permanent. To smoking are to be traced many affections of the eyes, and of the ears, besides other ailments. I have heard much said in favour of smoking and drinking, but never saw any favourable result. The communication of the evil results of these stimulants to offspring appears to me to constitute a further serious objection to them, I approve fully of your object, but as I do not go to the length of total abstinence advocates, I am desirous not to be misunderstood. Several years of my life were spent in the East, and my experience there only confirms me the more. I have known many drunkards among literary men, and the stimulants they took never helped their work; and it was only because they were men of exceptionally strong brain that their excesses did not incapacitate them. There are many excesses of this kind that are equally misunderstood by those who indulge in them, and by temperance writers. There are, in fact, many men of enormous power, who can smoke and drink all day long. They constitute no standard: so far as I have seen, the consequences show themselves only in the offspring, though in this case it must be taken into account, that the children are sometimes born before a man's health has been seriously injured. A man of exceptional strength misleads and encourages others to indulge. HYDE CLARKE. October 14, 1882. MR. WILKIE COLLINS. When I am ill (I am suffering from gout at this very moment) tobacco is the best friend that my irritable nerves possess. When I am well, but exhausted for the time by a hard day's work, tobacco nerves and composes me. There is my evidence in two words. When a man allows himself to become a glutton in the matter of smoking tobacco, he suffers for it; and if he becomes a glutton in the matter of eating meat, he just as certainly suffers in another way. When I read learned attacks on the practice of smoking, I feel indebted to the writer--he adds largely to the relish of my cigar. WILKIE COLONS. February 10, 1882. MR. MONCURE D. CONWAY, M. A. My experience of stimulants has been insufficient to enable me to give any important opinion about them. As to tobacco, my strong hope is that my own sons will never use it; but if they should develop peculiar and excitable nerves, or become very emotional, or have much trouble, it is so likely that they might take to some worse habit that I would prefer they should smoke. M. D. CONWAY. February 22, 1882. REV. W. H. DALLINGER, F. R. S. I am not a pledged abstainer: I have used both tobacco and alcohol in various forms. Neither is at all necessary to my vigour of either body or mind. My use of tobacco has been but slight. I have never Used alcohol for years. I could never think deeply after the use of tobacco; I have felt a quickening of thought at times after a slight use of good wine; but I know, from physiological evidence, what practice has certainly proved, that no permanent benefit to either body or mind must be sought from its use. I have employed it with great benefit at times--that is, where it was better to afford the exhaustion following a mere stimulant, than to submit to an exhaustion which the stimulant could for the moment counteract. This is the only advantage, save to the palate, that I have known to be derived personally from the use of alcohol. W. H. DALLINGER. February 11, 1882. PROFESSOR DARWIN. I drink a glass of wine daily, and believe I should be better without any, though all doctors urge me to drink wine, as I suffer much from giddiness. I have taken snuff all my life, and regret that I ever acquired the habit, which I have often tried to leave off, and have succeeded for a time. I feel sure that it is a great stimulus and aid in my work. I also daily smoke two little paper cigarettes of Turkish tobacco. This is not a stimulus, but rests me after I have been compelled to talk, with tired memory, more than anything else. I am 73 years old. CH. DARWIN. February 9, 1882. W. BOYD DAWKINS, M. A., F. R. S., F. G. S. PROFESSOR OF GEOLOGY, OWENS COLLEGE, MANCHESTER. I have received your note asking about the effect of alcohol on my health and work. I cannot say that they influence either; I find, however, that I cannot drink beer when I am using my brain, and, therefore, do not take it when I have anything of importance to think about. I look upon tobacco and alcohol as merely luxuries, and there are no luxuries more dangerous if you take too much of them. I find quinine the best stimulant to thought. W. BOYD DAWKINS. February 16, 1882. The Rev. ALEX. J. D. D'ORSEY, B. D., LECTURER ON PUBLIC READING AND SPEAKING AT KING'S COLLEGE, LONDON. For my own part, I am decidedly averse to the use of tobacco and stimulants. I am myself a total abstainer (not pledged), and I have never smoked in my life. I always do my utmost to dissuade young and old alike to abstain from even the moderate use of tobacco and stimulants, as in the course of a long and laborious life, speaking much and preaching without notes, I have always felt able to grapple with my subject, with pleasure to myself and with profit, I trust, to my hearers. A. J. D. D'ORSEY. March 17, 1882. MR. EDMUND O'DONOVAN, SPECIAL CORRESPONDENT OF THE "DAILY NEWS." As far as my experience goes, the use of stimulants enables one at moments of severe bodily exhaustion to make mental efforts of which, but for them, he would be absolutely incapable. For instance, after a long day's ride in the burning sun across the dry stony wastes of Northern Persia, I have arrived in some wretched, mud-built town, and laid down upon my carpet in the corner of some miserable hovel, utterly worn out by bodily fatigue, mental anxiety, and the worry inseparable from constant association with Eastern servants. It would be necessary to write a long letter to the newspapers before retiring to rest. A judicious use of stimulants has, under such circumstances, not only given me sufficient energy to unpack my writing materials, lie on my face, and propped on both elbows, write for hours by the light of a smoky lamp; but also produced the flow of ideas that previously refused to come out of their mental hiding places, or which presented themselves in a flat and uninteresting form. I consider, then, the use of alcoholic and other stimulation to be conducive to literary labours under circumstances of physical and mental exhaustion; and very often the latter is the normal condition of writers, especially those employed on the press. Perhaps, too, in examining into the nature of some metaphysical and psychological questions the use of alcohol, or some similar stimulant, aids the appreciation of _nuances_ of thought which might otherwise escape the cooler and less excited brain. On the other hand, while travelling in the East during the past few years, and when, as a rule, circumstances precluded the possibility of obtaining stimulants, I found that a robust state of health consequent on an out-door life, made the consumption of alcohol in any shape quite unnecessary. In brief, then, my opinion is, that at a given moment of mental depression or exhaustion, the use of stimulants will restore the mind to a condition of activity and power fully equalling, and in some particular ways, surpassing its normal state. Subsequently to the dying out of the stimulation the brain is left in a still more collapsed situation than before, in other words, must pay the penalty, in the form of an adverse reaction, of having overdrawn its powers, for having, as it were, anticipated its work. E. O'DONOVAN. Feb. 17, 1882. PROFESSOR DOWDEN, LL. D. I distinguish direct and immediate effect of alcohol on the brain from its indirect effect through the general health of the body. I can only speak for myself. I have no doubt that the direct effect of alcohol on me is intellectually injurious. This, however, is true in a certain degree, of everything I eat and drink (except tea). After the smallest meal I am for a while less active mentally. A single glass even of claret I believe injures my power of thinking; but accepting the necessity of regular meals, I do not find that a sparing allowance of light wine adds to the subsequent dulness of mind, and I am disposed to think it is of some slight use physically. From one to two and a half _small_ wine glasses of claret or burgundy is the limit of what I can take--and that only at dinner--without conscious harm. One glass of sherry or port I find every way injurious. Whisky and brandy are to me simply poisons, destroying my power of enjoyment and of thought. Ale I can only drink when very much in the open air. As to tobacco, I have never smoked much, but I can either not smoke, as at present, or go to the limit of two small cigarettes in twenty-four hours. Any good effects of tobacco become with me uncertain in proportion to the frequency of smoking. The good effects are those commonly ascribed to it: it seems to soothe away small worries, and to restore little irritating incidents to their true proportions. On a few occasions I have thought it gave me a mental fillip, and enabled me to start with work I had been pausing over; and it nearly always has the power to produce a pleasant, and perhaps wholesome, retardation of thought--a half unthinking reverie, if one adapts surrounding circumstances to encourage this mood. The only sure brain stimulants with me are plenty of fresh air and tea; but each of these in large quantity produces a kind of intoxication: the intoxication of a great amount of air causing wakefulness, with a delightful confusion of spirits, without the capacity of steady thought; tea intoxication unsettles and enfeebles my will; but then a great dose of tea often does get good work out of me (though I may pay for it afterwards), while alcohol renders all mental work impossible. I have been accustomed to make the effects of tea and wine a mode of separating two types of constitution. I have an artist friend whose brain is livelier after a bottle of Carlowitz, which would stifle my mind, and to him my strong cup of tea would be poison. We are both, I think, of nervous organization, but how differentiated I cannot tell. My pulse goes always rather too quickly; a little emotional disturbance sets it going at an absurdly rapid rate for hours, and extreme physical fatigue follows. My conviction is that no one rule applies to all men, but for men like me alcohol is certainly not necessary, and at best of little use. I have a kindlier feeling towards tobacco, though I am only occasionally a smoker. P.S.--Since writing the above, I have asked two friends (each an intellectual worker of extraordinary energy) how alcohol affects them. Both agreed that a large dose of alcohol stimulated them _intellectually_, but that the subsequent _physical_ results were injurious. E. DOWDEN. March 3, 1882. PROFESOR EDISON. I think chewing tobacco acts as a good stimulant upon anyone engaged in laborious brain work. Smoking, although pleasant, is too violent in its action; and the same remark applies to alcoholic liquors. I am inclined to think that it is better for intellectual workers to perform their labours at night, as after a very long experience of night work, I find my brain is in better condition at that time, especially for experimental work, and when so engaged I almost invariably chew tobacco as a stimulant. THOS. A. EDISON, April 4, 1882. MR. ALEX. J. ELLIS, F. R. S., F. S. A., PRESIDENT OF THE PHILOLOGICAL SOCIETY. I am 67 3/4. I never took tobacco in any shape or form. For twenty-five years I have taken no sort of stimulant, not even tea or coffee. But for eight years in and amongst these twenty-five, but not part of them, I took a little wine. This is eight years ago. I did not find wine increased my power of work. I have led a working literary life, always occupied, except when obliged to rest from over work. The longest of these rests was three years, from 1849, while I was still drinking wine. It is possible that wine may whip one up a bit for a moment, but I don't believe in it as a necessity. I am not a teetotaler or temperance man in any way, and my rejection of all stimulants (my strongest drink being milk and much water) is a mere matter of taste. A. J. ELLIS. February 22, 1882. PROFESSOR EVERETT. In reply to your letter, I have to say that I think all stimulants, whether in the form of alcoholic drinks, tea or coffee, or tobacco, should be very moderately used. For my own part, I have never smoked or snuffed, and my daily allowance of alcoholic drinks is a so-called pint bottle of beer or two glasses of wine. I have more frequently suffered from nervous excitability due to tea or coffee, than from any other kind of stimulant. I can compose best when my brain is coolest and my digestion easiest. I do not believe in artificial stimulus to literary effort. J. D. EVERETT. February 22, 1882. PROFESSOR R. M. FAIRBAIRN, CHAIRMAN OF THE CONGREGATIONAL UNION OF ENGLAND AND WALES. I cannot say anything as to the effects of tobacco and alcohol upon the health. I never use either, and so can only say that in my case work has been done without their help. In the absence of data for comparison as to the effects of indulgence and abstinence, it would be foolish in me to express any comparative judgment; but it is only fair to say that so far as I am capable of forming any opinion on the matter, the abstinence has been altogether beneficial. R. M. FAIRBAIRN. February 16, 1882. MR. R. E. FRANCILLON. It so happens that your question belongs to a class of topics in which I have taken much theoretical interest. For my general views, I cannot do better than refer you to a paper of mine in the Gentleman's Magazine of March, 1875, called "The Physiology of Authorship;" but I fully agree with you that the settlement of the question can only depend upon the collection of individual experience. I have consciously studied my own, and can state it shortly and plainly. I am a very hard, very regular, and not seldom an excessive worker; and I find that my consumption of tobacco, and my production of work are in 'almost exact pro-portion, I cannot pretend to guess whether the work demands the tobacco or whether the tobacco stimulates the work; but in my case they are inextricably and, I believe, necessarily combined. When I take a holiday, especially if I spend it in the open air, I scarcely smoke at all; indeed, I find that bodily exercise requires no stimulant of any kind whatever. If I read, I smoke little; but if I produce, tobacco takes the form of a necessity, I believe--for I am indolent by _nature_, and tobacco seems to me to be the best machine for making work go with the grain that I can find. [Footnote: The wisdom of occasionally using these various stimulants for intellectual purposes is proved by a single consideration. Each of us has a little cleverness and a great deal of sluggish stupidity. There are certain occasions when we absolutely need the little cleverness that we possess. The orator needs it when he speaks, the poet when he Versifies, but neither cares how stupid he may become when the oration is delivered and the lyric set down on paper. The stimulant serves to bring out the talent when it is wanted, like the wind in the pipes of an organ. "What will it matter if I am even a little duller afterwards?" says the genius; "I can afford to be dull when I have done." But the truth still remains that there are stimulants and stimulants. Not the nectar of the gods themselves were worth the dash of a wave upon the beach, and the pure cool air of the morning.-- Philip G. Hamerton, in _Intellectual Life_, p. 21.] I have a very strong suspicion that if I did not smoke (which I find harmless) I should have to conquer really dangerous temptations. As things are, though I am a very moderate wine-drinker (spirits I never touch, and abhor), alcohol, practically speaking, bears no appreciable part in my life's economy. I believe that to some people tobacco is downright poison; to some, life and health; to the vast majority, including myself, neither one thing nor the other, but simply a comfort or an instrument, or a mere nothing, according to idiosyncrasy. My general theory is, that _bodily_ labour and exercise need no stimulant at all, or at most very little; but that intellectual, and especially creative, work, when it draws upon the mind beyond a quickly reached point, requires being a non-natural condition non-natural means to keep it going. I cannot call to mind a single case, except that of Goethe, where great mental labour has been carried on without external support of some sort; which seems to imply an instinctive knowledge of how to get more out of the brain machine than is possible under normal conditions. Of course the means must differ more or less in each individual case; and sometimes the owner of a creative brain must decide whether he will let it lie fallow for health's sake, or whether for work's sake he will let life and health go. I always insist very strongly upon brain work-beyond an uncertain point-being _non-natural_, and, therefore, requiring non-natural conditions for its exercise. I can quite believe the feat of the Hungarian officer [Footnote: The surprising endurance of the Hungarian officer, who lately swam a lake in Hungary, a distance of eleven miles, is ascribed to his abstinence from alcohol and tobacco.-- _Thrift_, for February, 1882.] would be impossible to a man who smoked or drank. But I cannot at all believe in that officer's powers of writing, instead of swimming, with a mind at full stretch, for the half of eleven hours. As to economy, tobacco costs me a good deal; but I look upon it as the investment of so much capital, bearing better interest than any other investment could bear. R. E. FRANCILLON. April 4, 1882. MR. EDWARD A. FREEMAN, D. C. L., LL. D. I can tell you nothing of the effects of smoking tobacco, having had no experience. I tried once or twice when young, but, finding it nasty, I did not try again. _Why_ people smoke, I have no notion. If I am tired of work, a short sleep sets me up again. I really have nothing to say about alcohol--I have never thought about it. I drink wine like other people, and I find brandy an excellent medicine on occasion. I used to drink beer, but some of the doctors say it is not good for me, and some have recommended whisky instead; but I really have no views on the subject. I have drunk wine and beer, as I have eaten beef and mutton, without any theories one way or another. E.A. FREEMAN. October 29, 1882. MR. F. J. FURNIVALL, M. A. Though I have no claim to be considered as one of the great thinkers and popular authors, I am a small thinker and a decidedly unpopular author, who has nevertheless done some work, I answer, that I have been a teetotaler since the summer of 1841, when I was 16, and I have never smoked except as a lark at school. I was a Vegetarian for about 25 years. I believe alcohol to be highly detrimental to head work. Tobacco has, I think, done good in only one case that has come under my notice during 40 years; it quieted an excitable man. My father, who was a medical man of wide practice, was very strong against much use of tobacco. He knew two cases of speedy death from the oil in the bowl of a tobacco-pipe being applied to aching teeth. He had several cases of much impaired digestion from smoking. F. J FURNIVALL. March 8, 1882. MR. SAMUEL R. GARDINER, HON. LL. D. PROFESSOR OF MODERN HISTORY IN KING'S COLLEGE. In reply to your letter, I beg to say that I never smoked in my life, and don't intend to begin. I take beer at luncheon and dinner, and occasionally a glass or two of wine, but very often I am four or five days without doing that. SAMUEL R. GARDINER. March 9, 1882. RT. HON. W. E. GLADSTONE, M. P. In answer to your questions, I beg to say that Mr. Gladstone drinks one glass or two of claret at luncheon, the same at dinner, with the addition of a glass of light port. The use of wine to this extent is especially necessary to him at the time of greatest intellectual exertion. Smoking he detests, and he has always abstained from the use of very strong and fiery stimulants. HERBERT J. GLADSTONE. November 29, 1882. MDLLE. H. GREVILLE. Being a lady, though my _nom de plume_ be a man's, I have little experience of either alcohol or tobacco. I must fairly say that though claret agrees with my constitution when properly mixed with water, wine without water, and every kind of liqueurs, makes me very ill, especially when taken between my meals, which are only two in number-- breakfast at twelve, and dinner at seven. I never use any stimulant. My sleep being scanty, I want sedatives rather than stimulants. I must add, nevertheless, that once or twice in a year, when I felt very tired, and had some work to conclude, especially at night, I happened to smoke one cigarette or Russian papyrus, which revived me promptly, and enabled me to finish my work. If you may be interested in my fashion of working, I may inform you that I work very fast, two hours at once, and then take a rest, or dinner. After resting two hours, I can write two hours again. I write without scratching, or blotting, about 100 lines of any French newspaper feuilleton, not the _Temps_, which is larger, but the _Figuro_, or any similar paper, in half-an-hour's time. I don't think that any-body could write more quickly; I seldom make any corrections, and never copy my work, which is sent to the printer as I write it. I use no stimulants of any kind, but sometimes eat an orange or two. After working towards midnight, I sometimes feel hungry, but I never eat for fear of spoiling my night's rest. I lived many years in Russia, and my experience is, that people who smoke too much suffer from their throat. Emile Augrer has been very ill with his stomach, from smoking too many strong cigars. He ceased, and has been completely healed. H. GREVILLE. April 28, 1882. COUNT GUBERNATIS. In reply to your favour of the 28th ult., I have the honour to inform you that I do not smoke, because nicotine acts upon my system as a most powerful poison. At the age of ten I had a Havana cigar given me to smoke; after smoking it I fainted and did not come to myself till after a _deep sleep, which lasted twenty-four hours._ When I was twenty, the third part of a cigar was given me to smoke as a remedy for the toothache. I could not finish it. A cold perspiration attended with vomiting and fainting ensued. I therefore judge from the effects of tobacco upon myself that it cannot be such a benefactor of mankind as people have tried to make it out. I am convinced that in any case, smoking lulls the mind to sleep, and when carried to excess tends to produce stupefaction or idiotcy. Perhaps you are aware that in Little Russia, the people call tobacco the _Devil's herb_; and it is related that the devil planted it under the form of an idolater. For my part I am quite prepared to adopt the opinion of the Russian people. Before the time of Peter the Great, smoking was strictly prohibited in Russia. The Poet Prati sang one day: Fuma, passagia e medita E diverrai poeta. (Smoke, ramble alone and think, and thou will soon become a poet.) That is what he himself does, but my belief is that owing to the abuse of cigars, he so frequently raves (dotes) and his poetry is often cloudy. As for alcohol, I take it to be proved beyond all doubt, that when taken in very small quantities it may, in certain cases, do good, but that taken in large quantities it kills. After having burnt the stomach, it deprives it of its power of digestion. I have seen a great many persons begin to use alcoholic beverages in the hope of acquiring tone, and afterwards get so accustomed to their use, that the best Chianti wine passed into their stomach like water. In this case, as in so many other cases, it is a question of measure. Alcohol has a like injurious effect upon the brain as upon the stomach. I am by no means an authority on the question which you have been good enough to address to me, and can therefore only give you briefly a statement of my own personal experience. Speaking of stimulants, I would mention, for instance, the strange effect produced upon my rather sensitive organism by a single cup of coffee. If I take a cup of coffee at six o'clock in the evening I cannot get to sleep before six in the morning. If I take it at noon I can get to sleep at midnight I know that many people take coffee to keep awake when working through the night. My own opinion is that you cannot work any better with these stimulants. There is a sort of irritation produced by drinking coffee which I do not consider helpful to serious and sustained work. It is possible, however, that works of genius may be produced sometimes in a state of nervous excitement, I suppose when the shattered nerves begin to relax. Manzoni wrote his master pieces when in a state of painful nervous distraction, but alcohol had nothing to do with it; perhaps he had recourse to other stimulants. (1) When we read that literary producers of any power have gone on working up to the last, even in the near approach of death, we usually find the work done has been of a not unwelcome kind, and often that it has formed part of a long-cherished design. But when the disease of which the sufferer is dying is consumption, or some disease which between paroxysms of pain leaves spaces of ease and rest, it is nothing wonderful that work should be done. Some of the best of Paley's works were produced under such conditions, and some of the best of Shelley's. Nor, indeed, is there anything in mere pain which necessarily prevents literary work. The late Mr. T. T. Lynch produced some of his most beautiful writings amid spasms of _angina pectoris_. This required high moral courage in the writer.... It is a curious, though well-known fact, however, that times of illness, when the eyes swim and the hand shakes, are oftentimes rich in suggestion. If the mind is naturally fertile--if there is stuff in it--the hours of illness are by no means wasted. It is then that the "_dreaming_ power" which counts for so much in literary work often asserts itself most usefully.--_The Contemporary Review_, vol. 29, p. 946. (2) When the poet Wordsworth was engaged in composing the "White Doe of Rylstone," he received a wound in his foot, and he observed that the continuation of his literary labours increased the irritation of the wound; whereas by suspending his work he could diminish it, and absolute mental rest produced perfect cure. In connection with this incident he remarked that poetic excitement, accompanied by protracted labour in composition, always brought on more or less of bodily derangement He preserved himself from permanently injurious consequences by his excellent habit of life.--Hamerton. _The Intellectual Life_. I know that certain authors think they can write better when taking artificial stimulants. I do not, however, believe that an artificial irritation of the nerves can have any good effect upon our faculty of apprehension. I am even inclined to think that when we write best, _it is not owing_ to nervous _excitement_, but rather because our nerves, after a period of extreme irritation, _leave us a few moments respite_, and it is during these moments the divine spark shines brightly. When creative genius has accomplished its task, the nerves once more relapse into their former irritability and cause us to suffer; but at the time of creation there is a truce of suffering. I never use any stimulant to help me in my labours; yet when I have been writing works of fiction, for instance my Indian and Roman Plays, I have nearly always been subject to great nervous agitation. When I suffered most from spasms, I had short intervals of freedom from pain, during which I could write, and those around me asked in astonishment how I could, in the midst of such suffering, write scenes that were cheerful, glowing and impassioned. I have occasionally in my time enjoyed these luminous intervals. I do not know whether those who use alcohol as a stimulant have experienced the same. No doubt they have succeeded in exciting their nervous sensibilities; but I assert that the real work of creative genius is accomplished in the intervals of this purturbation of the nerves which by some is deemed so essential to intellectual labour. When the nerves are excited to the highest pitch, they occasionally suffer, the transitory cessation from which is the divine moment of human creation. It seems to me, however, that this ought to be left to nature, and that every attempt to produce artificial excitement, for the purpose of producing creations of a higher class, is futile and beset with danger. ANGELO DE GUBERNATIS. March 4, 1882. M. L. P. GUENIN, REVISING STENOGRAPHER TO THE FRENCH SENATE. I thank you for having asked my opinion upon the effects of tobacco and alcohol on the mind and the health of men who give themselves up to intellectual work; and hasten to comply with your request. I am not a very resolute adversary of tobacco, because I must admit that I smoke, and at home use wine also: but if their use appears useful or agreeable, I ought to add that whenever I have to undertake any long arduous work, and above all, the reproduction of stenographic law or parliamentary reports, of which the copy is required without delay, I then make use of nothing but pure water. I limit myself as to stimulant to the use of coffee, which enables me to pass whole days and nights without feeling any want of sleep and, so to say, without fatigue, notwithstanding the labour of the stenographic translations. As you see, I consider that tobacco and alcohol do not act as stimulants, but rather as narcotics. With me they induce after the first moment of excitement a sort of calm and somnolence altogether incompatible with severe work; and I prefer coffee, always on the condition that as soon as the effort to be accomplished is finished the use of it must cease. I will not invoke the precedents of the celebrated men who have been led to make great use of coffee without impairing their health. It is after many years' experience that I have acted as I have indicated. L. P. GUENIN. March 11, 1582. DR. WILLIAM GUY. In answer to your enquiry, I may state the result of my personal experience and observation thus :-1. Alcoholic liquors, when taken in such quantity as to excite the circulation, are unfavourable to all inquiries requiring care and accuracy, but not unfavourable to efforts of the imagination. 2. Tobacco taken in small quantities is not unwholesome in its action on mind or body. When taken in excess it is not easy to define or describe its action, the chief fact relating to it being that it increases the number of the pulse, but lessens the force of the heart. 3. My personal experience of such quantities of wine as two or more glasses of port a day at my age (72) is that it produces no perceptible or measurable effect when taken for, say, three weeks or a month at a time, when compared with the like period of total abstinence. 4. It may be said in favour of temperance or even of extreme abstinence, that some of those men who have done most work in their day--John Howard, Wesley, and Cobbett, for example--have been either very moderate, or decidedly abstemious. But on the other hand, such men as Samuel Johnson, who was a free liver and glutton, and Thackeray, who drank to excess, have also got through a great amount of work. WILLIAM A. GUY. Feb. 25, 1882. PROFESSOR ERNST HAECKEL, JENA. I find strong coffee very useful in mental work. Of alcohol, I take very little, because I find it of no value as a stimulant. I have never smoked. E. HAECKEL. November 4, 1882. MR. PHILIP GILBERT HAMERTON. I am quite willing to answer your question about tobacco. I used to smoke in moderation, but six years ago, some young friends were staying at my house, and they led me into smoking more in the evenings than I was accustomed to. This brought on disturbed nights and dull mornings; so I gave up smoking altogether--as an experiment--for six months. At the end of that time, I found my general health so much improved, that I determined to make abstinence a permanent rule, and have stuck to my determination ever since, with decided benefit. I shall certainly never resume smoking. I never use any stimulants whatever when writing, and believe the use of them to be most pernicious; indeed, I have seen terrible results from them. When a writer feels dull, the best stimulant is fresh air. Victor Hugo makes a good fire before writing, and then opens the window. I have often found temporary dulness removed by taking a turn out of doors, or simply by adopting Victor Hugo's plan. I am not a teetotaler, though at various times I have abstained altogether from alcoholic stimulants for considerable periods, feeling better without them. I drink ale to lunch, and wine (Burgundy) to dinner; but never use either between meals, when at home and at work. At one time I did myself harm by drinking tea, but have quite given up both tea and coffee. My breakfast in the morning is a basin of soup, invariably, and nothing else. This is very unusual in England, but not uncommon in France. I find it excellent, as it supports me well through the morning, without any excitement. My notion of the perfect physical condition for intellectual work is that in which the body is well supported without any kind of stimulus to the nervous system. Thanks to the observance of a few simple rules, I enjoy very regular health, with great equality and regularity of working power, so that I get through a great deal without feeling it to be any burden upon me, which is the right state. I never do any brain work after dinner; I dine at seven, and read after, but only in languages that I can read without any trouble, and about subjects that I can read without any trouble, and about subjects that are familiar to me. P.G. HAMERTON. February 13, 1882. MR. THOMAS HARDY. I fear that the information I can give on the effect of tobacco will be less than little: for I have never smoked a pipeful in my life, nor a cigar. My impression is that its use would be very injurious in my case; and so far as I have observed, it is far from-beneficial to any literary man. There are, unquestionably, writers who smoke with impunity, but this seems to be owing to the counterbalancing effect of some accident in their lives or constitutions, on which few others could calculate. I have never found alcohol helpful to novel-writing in any degree. My experience goes to prove that the effect of wine, taken as a preliminary to imaginative work, is to blind the writer to the quality of what he produces rather than to raise its quality. When walking much out of doors, and particularly when on Continental rambles, I occasionally drink a glass or two of claret or mild ale. The German beers seem really beneficial at these times of exertion, which (as wine seems otherwise) may be owing to some alimentary qualities they possess, apart from their stimulating property. With these rare exceptions, I have taken no alcoholic liquor for the last two years. T. HARDY. Dec. 5, 1882. MR. FREDERIC HARRISON. Frederick Harrison never has touched tobacco in any form, though much in the society of habitual smokers, but finds many hours in a close smoking room rather depressing. Has always taken a moderate amount of alcohol (pint of claret) _once_ in the day, and finds himself rather stronger with than without it. Age fifty, health perfect; accustomed to much open-air exercise, long sleep, and little food. Reads and writes from eight to ten hours per diem, and never remembers to have been a day unfit for work. March, 1882. MR. G. A. HENTY. In answer to your question, certainly in my own case I should find stimulants destructive to good work. I get through an immense deal of literary work in the course of the day. I rise at eight, and seldom put out my light until three in the morning. With lunch and dinner I drink claret and water, and never touch stimulants of any kind except at meals. On the other hand, I smoke from the time I have finished breakfast until I go to bed, and should find it very difficult to write unless smoking. I have a great circle of literary friends, and scarce but one smokes while he works. Some take stimulants--such as brandy and soda water-while at work; some do not, but certainly nineteen out of twenty smoke. I believe that smoking, if not begun until after the age of twenty-one, to be in the vast majority of cases advantageous alike to health, temper, and intellect; for I do not think that it is in any way deleterious to the health, while it certainly aids in keeping away infectious diseases, malaria, fever, &c. While I consider a moderate use of wine and beer advantageous-except, of course, where beer, as is often the case, affects the liver, I regard the use of spirits as wholly deleterious, except when medically required, and should like to see the tax upon spirits raised tenfold. A glass of spirits and water may do no harm, but there is such a tendency upon the part of those who use them to increase the dose, and the end is, in that case, destruction to mind and body. G. A. HENTY. February 22, 1882. MR. OLIVER WENDELL HOLMES Prefers an entirely undisturbed and unclouded brain for mental work, unstimulated by anything stronger than tea or coffee, unaffected by tobacco or other drags. His faculties are best under his control in the forenoon, between breakfast and lunch. The only intellectual use he could find in stimulants is the quickened mental action they induce when taken in company. He thinks ideas may reach the brain when slightly stimulated, which remain after the stimulus has ceased to disturb its rhythms. He does not habitually use any drink stronger than water. He has no peremptory rule, having no temptation to indulgence, but approaching near to abstinence as he grows older. He does not believe that any stimulus is of advantage to a healthy student, unless now and then socially, in the intervals of mental labour. MR. GEORGE JACOB HOLYOAKE. I never took enough of stimulants to tell whether it is good or ill for "thinking and working." Tobacco is only good when you have a habit of working too much, as it makes you lazy-minded. G. J. HOLYOAKE. April 3, 1882. SIR J. D. HOOKER, F. R. S. I have had no experience on the subject of the use of tobacco and alcohol that is of any value, or you should be welcome to it. Jos. D. HOOKER. Feb. 13, 1882. MR. W. D. HOWELLS. If you will allow me to count myself out of the list of "great thinkers "and _very_ "popular authors," I will gladly contribute my experience in the points you publish. I never use tobacco, except in a very rare, self-defensive cigarette, where a great many other people are smoking; and I commonly drink water at dinner. When I take wine, I think it weakens my work, and my working force the next morning. W. D. HOWELLS. March 2, 1882. DR. J. P. JOULE. I am afraid that my experience can be of little use to you, because I have lived a very uniform life; and am therefore unable to compare the consequences from following various _regimes_.. I use alcoholic beverages moderately. I do not think they ever assisted or retarded my mental work. As for tobacco, it is the object of my aversion, as it must be to all non-smokers to whom the habits of the consumers of the weed must always appear more or less as an impertinence. Besides, it is difficult to imagine how the use of narcotics can be indulged in with impunity to the health. J. P. JOULE. February 11, 1882. THE REV. HENRY LANSDELL. In reply to your note, I beg to say--1st, that I have never been a smoker. 2nd, that I became a total abstainer from alcoholic liquors before I had attained the age of twenty. 3rd, that I have never kept my bed, I am thankful to say, for a day, in my life. 4th, that up to the age of twenty-four I rose at seven; and up to the age of twenty-seven, at six; since twenty-seven, at five a.m. 5th, that it is a common occurrence for me to have been (for some years past) at mental employment from six a.m., to seven p.m. 6th, that I do not find the least necessity for stimulants in the form either of tobacco or of alcohol. HENRY LANSDELL. March 13, 1882. REV. STANLEY LEATHES, D. D. I am not an habitual smoker, and therefore cannot speak about its effects; I find it an irritant rather than a sedative. But I am quite sensible of the virtue of an occasional glass of good wine, and am certain I can work better with than without it. STANLEY LEATHES. April 15, 1882. W. E. H. LECKY. I am not a smoker, and am therefore unable to give you any evidence on the subject. W. E. H. LECKY. February 7, 1882. DR. F. R. LEES. I have travelled in various parts of the world, from Greece to the Pacific, and from the Coasts of Labrador to the Southern States of North America, perhaps as much as any man living, and have never, in heat or cold, felt any inconvenience from my forty-eight years of abstinence. I have lectured for many nights consecutively on various topics during the intervals of that time, and have written thousands of articles on philosophy, temperance, physiology, politics and criticisms in papers and magazines, and published pamphlets and volumes equal to 25 octavos of small print; but have never required anything stronger than tea or coffee as a stimulant. The Alliance _Prize Essay_ (100 guineas) of 320 pages was composed and written in 21 days. I never smoke, snuff, or chew. I have known _many_ literary men ruined by smoking, and in all cases the continued use of tobacco is most injurious to the mind, as well as to the body. It _slays_ the nervous recuperative energy. F. R. LEES. November 17, 1882. MR. LEONE LEVI, F. S. A., BARRISTER-AT-LAW, Professor of the Principles and Practice of Commerce and Commercial Law, King's College, London. I have no hesitation in saying that I have never found the need of either tobacco or alcohol, or any other stimulants, for my intellectual efforts. I have never used tobacco in any form, and though occasionally, when my physical forces are much exhausted, I have derived benefit from a single glass of wine or ale, as a rule, and in my ordinary diet, I use nothing whatever but fresh water. This is my personal experience, and though I have worked very hard-often sixteen hours a day of continuous labour--I have always enjoyed, thanks to Providence, the best of health. LEONE LEVI. SIR JOHN LUBBOCK, BART. M. P. I beg to say that in my opinion the use of tobacco is, in the great majority of cases, prejudicial. As to alcohol, I would rather not express any opinion. JOHN LUBBOCK. February 17, 1882. PROFESSOR MAGNUS. In reply to your enquiry respecting the use of tobacco and alcohol, I shall be glad to give you all the information I possess on this subject; though, of course, I am not in a position to judge whether my few remarks will be of any service to you. In the first place, as regards the influence of tobacco and alcohol upon the health in general, it is clearly ascertained that under certain circumstances, it may become highly injurious. Apart from the disturbance produced in the whole nervous system, there are serious diseases affecting certain organs of the body, which arise solely from the abuse of both these stimulants. We note a serious affection of the visual organs, which we plainly designate by the name of: "Emblyopia ex abusu nicotiano et alcoholico." The symptoms of this complaint consist chiefly in a gradual and steady decline of the power of sight, coupled with partial colour blindness. I cannot here enter into details as to the manner in which the range of sight is affected as regards each of the different colours, and can only refer to the characteristic weakening of the power to distinguish red from other hues. It will not be necessary, I presume, to extend my remarks to the evil effects of tobacco and alcohol upon the human body, as you are sufficiently acquainted with them, especially as far as alcohol is concerned. Now as to the relation in which both stand to mental work. If I may be allowed to state first of all the result of observations in my own case, I must tell you that I have not found these drugs to be in any degree helpful in the performance of mental labour. I find it absolutely impossible to put any sensible thoughts on paper when I am smoking. In former years I frequently tried to smoke a pipe or a cigar over my work, but had always to give it up; I only got into proper working condition after putting tobacco aside. Indeed, of late years I have felt a growing antipathy to tobacco, so that, whilst I was formerly passionately fond of smoking, I new, very rarely, indeed, indulge in the practice. My experience with regard to alcohol is precisely similar. I am very fond of a little beer, but not when at work. The current of my thoughts flows much more clearly and rapidly when I have had no drink. I have a special aversion for wine, which, indeed, I do not drink at all. Generally speaking, I can therefore say, that, in my own case, tobacco and alcohol have a disturbing effect, when doing mental work. This you will, of course, take as applying to myself alone. I know some very respectable scholars in this town and neighbourhood who are only capable of thinking and working properly when under the influence of tobacco. MAGNUS. Breslau, February 28, 1882. MR. EDWARD MAITLAND, B. A. In reply to your enquiries, I have to say that my experience of the effects of alcohol and tobacco upon intellectual work is a very limited one, owing to the very moderate use I have made of either. So far, however, as my experience goes, my conclusions are as follows: tobacco, though it may, indeed, give a momentary fillip to the faculties, lessens their power of endurance; for by lowering the action of the heart, it diminishes the blood supply to the brain, leaving it imperfectly nourished, and flaccid, and unable, there-fore, to make due response to the demands of its owner, the man within, who seeks to manifest himself through the organism. Of an organism thus affected, as of an underpitched musical instrument, the tones will be flat. Of stimulants, the effect is the contrary. Owing to the over-tension of the strings, the music will be sharp. It is apt also to be irregular and discordant, owing to the action set up in the organism itself--an action which is not that of the performer or man. That which alone ought to find expression, is the central, informing spirit of the individual; and for both idea and expression to be perfect, the first essential is purity, mental as well as physical. Hence, however great a man and his work may be, under the influence of alcohol or tobacco, or on a diet of flesh, they would be still greater on pure natural regimen. Of course, there are cases in abundance in which persons have become so depraved by evil habits, as to be utterly incapacitated through the disuse of that to which they have been accustomed. But no sound argument in favour of the abuse can be founded on this. EDWARD MAITLAND. March 20, 1882. SIR THEODORE MARTIN, K. C. B. To myself tobacco is simply poison, and I believe it is so to very many who use it. I have seen proofs that it is so among the friends of my youth, who certainly hurt their health and shortened their lives by smoking. But, on the other hand, I have known others who smoked with impunity, and even with benefit to their nervous system. These, however, are, in my experience, exceptional cases. Wine in moderation is, I am sure, beneficial to brain workers; and I feel confident that it is far better, as a rule, to assist the system by this, than by food without wine or alcohol, which, in my experience, seems always to lead to eating to an extent that is very apt to cause derangement of the functions of the body. But, really, I have not made my observations either with such care or on so wide a scale as to give them any value. THEODORE MARTIN. February 18, 1882. THE REV. JAMES MARTINEAU, D. D. Having kept no record of my dietary and health, I can give you no more exact report than my memory supplies. Of tobacco, I have nothing to say, except that my intense dislike of it has restricted my travelling to a minimum, and kept me from all public places where I am liable to encounter its sickening effects. My first prolonged experience of abstinence from wine and malt liquor ran through about seven years, dating, I think, from 1842. The change was not great in itself, and I always thought it favourable in its effects. At no time of my life did I sustain a heavier pressure of work and of anxiety. But in the spring of 1849, when I was living with my family in Germany, I fell into a low state of health, indicated by fluttering circulation in going upstairs, or up-hill; and, under medical advice, I adopted the habit of taking, daily, I suppose about half-a-pint bottle of _Vin ordinam._ I recovered completely, and adhered for several years to the allowance (or its equivalent) which had been prescribed to me. Under this regimen, however, I became, after a time, subject to occasional slight attacks of gout, and to some disturbance of digestion and of sleep. In spite of medical advice, I determined to revert to the abstinence in which I had never lost faith. For a time of, I suppose, from twelve to fifteen years, I have persisted in this rule; not, indeed, being under any vow, but practically not taking more than half-a-dozen glasses of wine per annum. During this time, I have escaped, apparently, all tendency to gouty affections; have returned to untroubled sleep and digestion; and, notwithstanding the advance of old age (I am now 77), have retained the power of mental application, with only this abatement perceptible to myself, that a given task requires a somewhat longer time than in fresher days. Though the sedentary life of a student is not very favourable to the maintenance of muscular vigour, it has not yet forbidden me the annual delight of reaching the chief summits of the Cairn Gorm mountains during my summer residence in Inverness. I will only add that I have never found the slightest difficulty, physical or moral, in an instantaneous change of habit to complete abstinence. Instead of feeling any depressing want of what I had relinquished, I have found a direct refreshment and satisfaction in the simpler modes of life. Few things, I believe, do more, at a minimum of cost, to lighten the spirits and sweeten the temper of families and of society, than the repudiation of artificial indulgences. JAMES MARTINEAU. December 1, 1882. DR. HENRY MAUDSLEY. I don't consider alcohol or tobacco to be in the least necessary or beneficial to a person who is in good health; and I am of opinion that any supposed necessity of one or the other to the hardest and best mental or bodily work, by such a person, is purely fanciful. He will certainly do harder and sounder work without them. I am speaking, of course, of a person in health; by a person not in health they may be used properly, from time to time, as any other drug would be used. HENRY MAUDSLEY. February 13, 1882. SIR THOMAS ERSKINE MAY, K. C. B., D. C. L. In reply to your inquiries, I can give you my experience in a few words. I can offer no opinion as to the effects of tobacco, as I have never been a smoker. My experience of many years favours the view that moderation in food and drink is the great secret of physical health, mental activity and endurance. On several occasions while working twelve and fourteen hours a day, I tried total abstinence, but I found myself dyspeptic and stupid, and was obliged to resume my accustomed potations. I have found that any unusual amount of alcohol, while stimulating mental activity for a time, soon produced lassitude and sleepiness. T. ERSKINE MAY. February 23, 1882. REV. JOHN E. B. MAYOR, M. A. FELLOW OF ST. JOHN'S COLLEGE, AND PROFESSOR OF LATIN IN THE UNIVERSITY OF CAMBRIDGE. When I was a school-boy of eight or nine, I was persuaded to buy some cigars and put one to my mouth for a moment. I threw it away, and have never touched tobacco since. I compute that I must have saved some 1500 pounds by abstaining from this narcotic. My two brothers--one 3rd wrangler, the other 2nd classic--have also abstained for life. I know no indulgence which leads people to disregard the feelings of others so utterly as smoking does; nor can I believe a deadly poison can be habitually taken without great injury to the nerves. Alcohol I have not touched for more than two years, nor flesh meat, nor tea, nor coffee. All my life long I have had no difficulty in adopting any diet whatever; but I am sure that since I confined myself to fruits and farinacea, life has gone easier with me. No one ever heard me complain of the want of a dinner, or of the quality of what was set before me; but I now know that a day or two's fasting will do me no sort of harm, [Footnote: Twice in my life I have tried the experiment of a _strictly_ vegetarian diet (_without milk, batter, eggs, fish or flesh_)-once when I was about twelve years old, and again, for forty-eight days, beginning On the 25th June, 1878. I had been for some months taking regular exercise (a rare thing with me), walking on four miles every morning from six to seven, so that I was in rude health. I was just beginning a stiff piece of literary work on Juvenal, which involved the daily examination of several hundred passages of authors, chiefly Greek and Latin; and I wished to try how far vegetarian diet would enable me to resist the depressing influence of fasting. I mapped out my forty-eight days into four divisions of twelve each, intending (if all went well) to fast every other day for the first twelve; every third for the second; every fourth for the third; and every sixth for the last twelve. I thought it prudent to consult a doctor (a thing which I have scarcely ever had occasion to do), who bid me go to the prison to be weighed every two or three days and to show myself to him twice a week. I did not quite carry out my scheme, but I did complete more than half--and the severer half--with no ill effects, fasting June 25, 27, 29, July 2, 5, 7. 10, 13, completing that is, two-thirds of my design for the first twelve days, and the whole of that for the second. I drank water freely on the fasting days, but ate nothing for a period varying from twenty-eight to about thirty-five hours. On the eating days, and for the remainder of the forty-eight, I lived on fruits, vegetables, or wholemeal biscuits or wheatmeal or oatmeal porridge. I never was more fiercely eager for work in my life, nor did my pulse give way, but I lost flesh rapidly, and had never much to spare. On the whole I lost 13 lbs., and was advised by the doctor to stay there, as it is much easier to let yourself down than to pick up again. For years I have been striking off one luxury after another in my diet when alone, till at last I have come to dry bread (or biscuit or porridge) and water.-- _Herald of Health, September, 1881_.] and that whether I dine in hall with my brother fellows, or take two or three biscuits in my own room, makes no odds. I am more independent, and certainly more able to influence the habits of the poor than I was. JOHN E. B. MAYOR. March 2, 1882. THE ABBE MOIGNO. I am grateful to you for thinking of me in your generous enquiry about the best conditions of literary and scientific composition. I can hardly offer myself as an example, because my constitution is rather too exceptional, but my experience may have some degree of usefulness. I have already published a hundred and fifty volumes, small and great. I scarcely ever leave my writing table. I never take a walk, nor recreation, even after meals; and yet have not felt any head-ache, constipation, or any derangement in the urinary organs. I have never had occasion to have recourse to stimulants, coffee, alcohol, tobacco, &c., in order to work, or to obtain clearness of mind. On the contrary, stimulants give rise in my case to abnormal vibrations in the brain, which are adverse to its quick and regular working. Several times in my life I fell into the habit of taking snuff. It is a fatal habit, dirty to begin with, since it puts a cautery to the nose, filth in the pocket, is extremely unwholesome; for he who takes snuff finds his nose stopped up every morning, his breathing difficult, his voice harsh and snuffling, because the action of tobacco consists in drawing the humours to the brain; fatal, at last, because the use of snuff weakens and destroys, by degrees, the memory. This last effect is fully proved by my own professional experiences, and that of many others. I learned twelve foreign languages by the method I published in my "_Latin for all;_" that is to say, I draw up the catalogue of 1,500, or 1,800 radical or primitive simple words, and engraved them upon my mind by means of mnemonic formulas. In that way I had learned about 41,500 words, whose meaning is generally, or most frequently, without connection with the word itself, and from 10,000 to 12,000 historical facts, with their precise date. All this existed simultaneously in my mind, always at my disposal when I wanted the meaning of a word or the date of an event. If anyone asked me who was the twenty-fifth king of England, for instance, I saw in my brain that it was Edward, surnamed Plantagenet, who ascended the throne in 1154. With respect to philology or chronology, I was the most extraordinary man of my time, and Francis Arago jokingly threatened to have me burnt like a wizard. But I had again fallen into the practice of snuff-taking during a stay of some weeks in Munich, where I spent my evenings in a smoking room with the learned Bavarians, each of whom ate four or five meals a day, and drank two or three jugs of beer. The most illustrious of these learned men, Steinhein, boasted of smoking 6,000 cigars a year. I attained to smoking three or four cigars a day. While drawing up my treatise on the Calculus of Variations, the most difficult of my mathematical treatises, I unconsciously emptied my snuff-box, which contained twenty-five grammes (nearly an ounce) of snuff; and one day I was painfully surprised to find that I was obliged to have recourse to my dictionary for the meaning of foreign words. I found that the dates of the numerous facts I had learnt by heart had fallen from my mind. Such a thing has rarely or seldom happened before. Distressed at this sorrowful decay of my memory, I made an heroic resolution, which nothing has disturbed since. On the 1st of August, 1863, I smoked three cigars and used twenty-five centimes (2-1/2d.) worth of snuff; from the following day to June, 1882, I have neither taken a pinch of snuff nor smoked a single cigarette. It was for me a complete resurrection, not only of memory, but of general health and well-being. It was only necessary for me to do, what I did eighteen years later, to lessen nearly one-half the quantity of food which I took every day, to eat less meat and more vegetables, to obtain such incomparable health, of which it is hardly possible to form any idea, unlimited capacity of labour, perfect digestion, absence of wrinkles, pimples; and I beg leave to affirm that those who tread in my footsteps will be as sound as I am. Add to this the habit, irrevocably established, of never saying, I _shall_ do, nor I am doing, but I _have done_, and you have the secret of the enormous amount of work I have been able to accomplish, and am accomplishing every day, in spite of my eighty years. Nobody will dispute me the honour of being the greatest hard-working man of my century. I ought, finally, to add that I find it well for me to take at breakfast a small half-cup of coffee without milk, to which, when only two or three teaspoonful remain at the bottom of the cup, I add a small spoonful of brandy, or other alcoholic liquor. That is my whole allowance of stimulants. How happy would those be who should adopt my _regime_. They would be able, without harm, to sit at their desk immediately after breakfast, and to stay there till dinner-time. No sooner would they be in bed, at about nine o'clock, but they would be softly asleep a few minutes later, and could rise at five in the morning, full of strength, after a nourishing sleep of eight hours. ABBE F. MOIGNO. July 20, 1882. REV. J. MORRISON, D. D., PRINCIPAL OF THE EVANGELICAL UNION COLLEGE. For my kind of work, I have found it absolutely necessary to abstain altogether from the use of both alcohol and tobacco. J. MORRISON. May 11, 1882. MR. AUGUSTUS MONGREDIEN. I am 75 years of age. I have smoked moderately all my life; and for the last fifty years have never, except in rare and short instances of illness, retired to bed without one tumbler of whiskey toddy. You will therefore see that I am utterly incompetent to pronounce on the respective effects, on the mind and body, of moderate indulgence, and of total abstinence, for I have never tried the latter. A. MONGREDIEN. March 10, 1882. DR. J. A. H. MURRAY, EX-PRESIDENT OF THE PHILOLOGICAL SOCIETY, AND EDITOR OF ITS ENGLISH ETYMOLOGICAL AND HISTORICAL DICTIONARY. I use no stimulants of any kind, and should be very sorry to do so. I thought it was now generally admitted that the more work a man has to do, the less he can afford to muddle himself in any way. But as I have never tried the experiment in using either alcohol or tobacco, and cannot afford to do it, I have no comparative experience to offer. It might be beneficial; I do not believe it would, and prefer not to risk the chance. _Fiat experimentum in corpore viliore_. J. A. H. MURRAY. March 2, 1882. MR. D. CHRISTIE MURRAY. I should have thought that the universal experience of mankind had already been set on record without much ambiguity. It has been my practice to smoke at work, and I do not think I could get along without tobacco now, unless I made an effort, the profit of which could scarcely justify the pains. As a matter of nature, I do not believe that a man works either better or worse for the use of tobacco, unless he smokes so much as to injure his general health. Alcoholic drinks are, of course, mentally as well as physically stimulative, and I have found them useful at a pinch. But everybody knows that stimulants are reactionary, and it is pretty certain that in the end they take more out of a man than they put into him. Under extraordinary pressure they have their uses, but their habitual employment muddles the faculties, and the last state of the man who constantly works on them is worse than the first. Continually taken alone, and as a stimulant to mental exertion, their influences on a man of average formation are fatal. But I should have thought all these things settled long ago, unless it were in junior debating societies. D. CHRISTIE MURRAY. April 11, 1882. PROFESOR NEWMAN. In boyhood, I perceived that to my younger sisters mere drops of wine caused coughing and spitting, and the heat of wine to my own palate and throat was offensive. Beer, ale, and porter disgusted me by their bitterness. Porter was peculiarly nauseous to me. I early saw the ill-effects of wine on youths, and was frightened by accounts of college drunkenness. For this reason, as well as from economy, I never became a wine-drinker, further than to drink healths by just colouring water in a glass. I have never dreamed of needing wine, though often in old time ordered by physicians to drink it. Not having then the same power to look over their heads-which experience of their changes and their follies has brought to me-I used to obey a little while, but quickly reverted to my glass of water, and never had reason to believe, from my own case, that there was any advantage from the wine. In 1860-1, the Parisian experiments proved that all alcohol arrests digestion. Since then I have called myself a teetotaler. To me it seems clear that love of the drink, or fear of losing patients by forbidding it, are the true cause of the fuss made in its favour. I grieve that so noble a fruit as grapes should be wasted on wine. The same remark will hold of barley, of honey, of raisins, of dates: from which men make intoxicating drinks. As to tobacco-while I was in Turkey more than fifty years ago, I learned to smoke Turkish tobacco in a long Turkish pipe, partly to relieve evil smells, partly because it is uncivil there to refuse the proffered pipe. I never was aware of good or evil from it, and with perfect ease laid it aside when I quitted the soil of Asia. After this, a cigar was recommended to me in England, as a remedy for loss of sleep, but the essential oil of tobacco so near to my nose disgusted me, and the heat or smoke distressed my eyes. I have never felt any pleasure, rather annoyance, from English smoking; and since the late Sir Benjamin Brodie published his pamphlet against it (perhaps in 1855), I have learned that the practice is simply baneful. They say "it soothes"--which I interpret to mean--"it makes me inattentive and dreamy." FRANCIS W. NEWMAN. March 2, 1882. THE REV. MARK PATTISON, B. D. The story of my personal experiences of alcohol is one which would require more time than I can now command to write properly. I can now only say that I did not begin wine, as a habit, till I was thirty-seven; that, at first, an occasional effect was favourable to the brain power, but always followed by corresponding reaction towards feebleness. About fifty-seven, I was obliged to give up wine altogether; I found great general advantage from doing so, and no disadvantage whatever as regards mental activity. I am now sixty-eight, and take a glass of claret every third day, or oftener. This medicine does not produce any perceptible effect on the brain directly, but I have a fancy that I sleep better after wine; and sleep I have always looked to as the best brain restorative. [Footnote: SLEEP IS THE BEST STIMULANT.--The best possible thing for a man to do when he feels too weak to carry anything through is to go to bed and sleep for a week, if he can. This is the only recuperation of brain-power, the only recuperation of brain-force; because during sleep the brain is in a state of rest, in a condition to receive and appropriate particles of nutriment from the blood, which take the place of those that have been consumed in previous labour, since the very act of thinking consumes or burns up solid particles, as every turn of the wheel or screw of the steamer is the result of the consumption by fire of the fuel in the furnace. The supply of consumed brain-substance can only be had from the nutritive particles in the blood, which were obtained from the food eaten previously; and the brain is so constituted that it can best receive and appropriate to itself those nutritive particles during a state of rest, of quiet, and stillness of sleep. Mere stimulants supply nothing in themselves; they goad the brain, and force it to a greater consumption of its substance, until the substance has been so exhausted that there is not power enough left to receive a supply, just as men are so near death by thirst and starvation that there is not power enough left to swallow anything, and is over.--_Scientific American_.] Spirits I have never drunk; Though I have been a smoker for many years, I cannot say anything as to its effects. MARK PATTISON. March 16, 1882. MR. JAMES PAYN. In common with nine-tenths of my literary brethren, I am a constant smoker. I smoke the whole time I am engaged in composition (three hours _per diem_), and after meals; but very light tobacco-- _latakia_. [Footnote: Latakia, or Turkish, are called mild tobaccos, and although they produce dryness of the tongue, from the ammonia evolved in their smoke, they do not upset the digestion so materially, nor nauseate so much as the stronger tobaccos, unless they are indiscriminately used.--DR. B. W. RICHARDSON. ("_Diseases of Modern Life_")] That it stimulates the imagination, I have little doubt; and as I have worked longer and more continuously for thirty years than any other author (save one); I cannot believe that tobacco has done me any harm. Those who object to it have never tried it, or find it disagrees with them. How can they, therefore, be in a position to judge? I find cigars disagree with me but I do not on that account pronounce them unwholesome for everybody. I drink very little alcohol--only light claret, and occasionally dry champagne--but I do not know what effect drinking alcohol has upon composition. JAMES PAYN. MR. EIZAK PITMAN, AUTHOR OV "FONOGRAFI OR FONETIK SHORTHAND," AND ORIJINATER OV THE SPELING REFORM. If a breef skech ov mei leif, and the deietetik maner ov it, wil be ov servis tu you, ei gladly giv it. Your rekwest abzolvz me from the impiutashon ov boasting. If you make it publik, pray let it be printed in the parshiali reformd speling in hwich it iz riten. Ei hav been an abstainer from the stimiulant alkohol nearli all mei leif, and ei hav alwayz refraind from the seduktiv influens ov the sedativ tobako. Ei hav therefor no eksperiens tu ofer ov their use, eksept that about 1838 ei woz rekomended tu take a glas ov wein per day az a tonik, and az a remedi for dispepsia, hwich then began tu trubel me. After obeying this medikal preskripshon for a year or two, and feinding no releef from it, ei gave up both the wein and the use ov flesh, "the brandi ov deiet;" the dispepsia disapeard, and haz never vizited me sins. Ei am nou verjing on seventi. Ei intensli enjoi leif and labor, and rekweir nuthing beyond the laborz ov the day, and the walk tu and from mei ofis, hwich iz a meil, tu indius refreshing sleep. Ei keep up mei leif-long praktis ov reteiring at ten o'klok, and being at mei desk at siks. About three yearz ago ei adopted the kustom ov taking a siesta for half an our after diner. It iz wel, az Milton obzervz, tu giv the bodi rest diuring the ferst konkokshon ov the prinsipal meal. The uzhual sumer vizit tu the sea-seid woz unnon tu me til ei woz fifti yearz ov aje. From 1837 (the date ov the publikashon ov "Fonografi") tu 1861 (the date ov mei sekond maraje), nearli a kworter ov a sentiuri, ei wurkt on from siks in the morning til bed-teim, ten o'klok, without an intervening thought ov a holiday. Ei felt no wont ov a temporeri respit from labor bekauz ei tuk no ekseiting food or drink; and ei shud az soon hav meditated a breach in the Dekalog az a breach in mei daili round ov diutiz bei eidling at the sea-seid. In 1861 ei relakst, and komenst the praktis ov leaving mei ofis at siks in the evening. At the same teim ei komenst viziting the variiis watering plasez, or going tu the Kontinent in the sumer for four or feiv weeks. This rekriashon ei have taken more for the sake ov mei weif and two sunz than from eni feeling ov nesesiti for it on mei own part. From mei own eksperiens ov the benefits ov abstinens from the sedativ alkohol, and the stimulants tobako and snuf; and mei obzervashon ov the efekts ov theze thingz on personz who indulj in them, ei hav a ferm konvikshon that they ekserseiz a dedli influens on the hiuman rase. EIZAK PITMAN. March 25, 1882. M. GASTON PLANTE. I am much flattered by the interest that you attach to my opinion on the subject of the influence that certain substances can have upon thought and upon intellectual work. I must tell you frankly that I have not found that tobacco or alcohol have an advantageous influence. It is true that I have not made much use of them--I have never taken pure spirits, such as brandy, but only of wine containing a little. I have been obliged sometimes, in trying to fortify my health, to take some Bordeaux wine, and I have not observed that any appreciable effect resulted from it upon the facility of intellectual work. From the point of view of health, I counted particularly upon the iron contained in good Bordeaux wine, but I have found that the alcohol in the wine over-excited the nervous system, provoked sleeplessness and cramps; and I have finally adopted as a drink wine mixed with water, and even this in very small quantities. As to tobacco, I have also tried it; and far from thinking that it favours intellectual work, I believe, with one of our learned writers (the Abbe Moigno, Editor of the "_Journal du Mondes_"), that its use tends to weaken the memory. Neither do I make use of coffee, which equally excites the nervous system, although, like all the world, I have observed that this substance gives a certain intellectual activity. What I have found out most clearly is what everyone has observed from time immemorial--that the clearest ideas, the happiest and most fruitful expressions, come in the morning, after the repose of the night, and after sleep--when one has it, but of which I have not a very large share. I attach so much importance to the ideas which come during the night or in the morning, that I have always at the head of my bed paper and pencil suspended by string, by the help of which I write every morning the ideas I have been able to conceive, particularly upon subjects of scientific research. [Footnote: Curtis, I think, says that whenever Emerson has a "happy thought," he writes it down, be it dawn or midnight, and when Mrs. Emerson, startled in the night by some unusual sound, cries, "What is the matter? Are you ill?" the philosopher's soft voice answers, "No, my dear, only an idea."-- _Appleton's New York Journal, Nov., 1873.] I write these notes in obscurity, and decipher and develop them in the morning, pen in hand. This is the reply I can make to your interesting enquiry. I shall be happy to know the conclusion to which you will be conducted by the information which you will have been able to collect. GASTON PLANTE. THE REV. A. PLUMMER, HEAD MASTER OF THE DURHAM COLLEGE. University Tutor and Lecturer, and University Proctor. I am a firm believer in the value of a moderate use of tobacco and alcohol for the brain worker. I generally smoke one pipe in the morning, _before_ work, and one at night, _after_ work (or the equivalents of a pipe). I seldom smoke _while_ I work, and do not find it helpful. I drink two glasses of sherry (or their equivalents), as a rule daily, and take them at late dinner--not at lunch. If troubled with sleeplessness, I find a glass of sherry, and a few biscuits, followed by smoking, a tolerably safe cure, but not always to be relied upon. I should be very sorry to attempt to do without these two helps. Of the two I believe the smoking to be the more valuable, especially when (what is far worse than heavy work) _worry_ is pressing upon one. I am wholly sceptical as to the value of work before breakfast. Let a man get up as early as he likes: but don't let him try to work on an empty stomach. The Irishman was wise who said that when he worked before breakfast, he always had something to eat first. A. PLUMMER April 6, 1882. MR. EDWARD POCKNELL, (POCKNELL'S PRESS AGENCY AND LONDON ASSOCIATED REPORTERS.) In reply to your letter, I should say that tobacco has some action on the brain; but I think its action different in different people, and at different times in the same person. I think the action soothing after food, but exciting on an empty stomach. In the former case I think it promotes thinking in this way:--that the mind concentrates its attention better during the mechanical operation of "puffing", than when it is liable to be disturbed when not so occupied. For this reason I should say that smoking does help to get through work late at night. I find frequently that having commenced to write with a fresh pipe in my mouth, I go on a long time after it goes out; but as it remains in my mouth, it seems to have almost the same effect till the discovery, at some pause, that my pipe is out; and then it is a relaxation to spare a moment to refill it. I do not look upon smoking as a necessity to mental labour; but it seems to me, as a smoker, an agreeable and useful method for concentrating thought upon any subject. But I think it would be difficult to lay down any general rule for persons of different constitutions. E. POCKNELL. March 10, 1882. PROFESSOR GEORGE RAWLINSON. Although it does not appear to me that the method of your enquiry can lead to any important results, you are quite welcome to any information that I can give you on the subject. I was brought up to take daily a moderate amount of beer or wine, and have continued to do so all my lifetime, with the exception that my beer has been cut off, and I have been recommended to take a little brandy and soda-water, or whiskey and soda-water instead. I smoked an occasional cigar when I was young, but never much liked tobacco, and gave up the practice entirely when I was about five and twenty. I have never tried leaving off alcoholic liquors, being advised medically that it would probably be injurious to me to do so. I am, therefore, quite unable to say what effect my doing so would have on my powers of thought and work. GEORGE RAWLINSON. March 28, 1882. MR. CHARLES READE. Your subject is important, and your method of enquiry sound. I wish I could throw any light, but I cannot more than this. I tried to smoke five or six times, but it always made me heavy and rather sick; therefore, as it is not a necessary of life, and costs money, and makes me sick, I spurned it from me. I have never felt the want of it. I have seen many people the worse for it. I have seen many people apparently none the worse for it. I never saw anybody perceptibly the better for it. C. READE. Feb. 2, 1882. MR. THOMAS ALLEN REED. You ask me whether I have found tobacco or wine a help to me in my work. No! As to the first, for the sufficient reason that I have never tried it. I never smoked a pipe or a cigar in my life, and have no intention of commencing the practice. When, more than thirty years ago, I entered upon my profession, I was told by my _confreres_ that I should soon follow their example, and they smiled at my innocence when I declared that I thought they were mistaken. As to alcohol, I am not a teetotaler, but I think I can truly say that I never found the least benefit from wine or beer in my daily or nightly work. Indeed, I consider them rather a hindrance, having a tendency to make one heavy and sleepy. I have been, and am still, a tolerably hard worker, without the use of artificial stimulants, and judging from my own experience, and that of many others with whom I have been connected in my professional labours, I don't believe in their efficacy. If I take a glass of wine occasionally (not a frequent indulgence with me) it is because I like it, not because I think it helps me in my work. T. A. REED. Feb. 18, 1882. DR. JULIUS RODENBERG. I have smoked from my seventeenth year, and could not do without it now. On the whole, I am but a moderate smoker, and seldom smoke whilst walking, but at work I must have my cigar, and find it agrees very well with my health. Most of my learned and literary friends smoke; but two or three of them have given it up in their later years without visible effect upon their health or mental strength. As to alcohol, I could not stand to drink brandy. Sometimes I drink a glass, but only as an exception. I find it much more convenient for me, and a good help to work, to take now and then a bottle of hock or champagne; but, as a rule, I drink half a bottle of claret at dinner, and a pint of beer at supper. I generally write in the morning from nine to half-past one, when I dine; and from five o'clock in the afternoon to nine, when I take supper, but I could not bear to drink either wine or beer while at work. JULIUS RODENBERG. March 12, 1882. DR. W. H. RUSSELL. I am not able to give you any very positive expression of opinion on the matter respecting which you write, but I can say that I have smoked tobacco and taken wine for years, and though I cannot aver that I should not have done as well without them, I have felt comforted and sustained in my work by both at times, especially by the weed. However, I was very well in the last campaign in South Africa, where for some time we had neither wine nor spirits. Climate has a good deal to say to the craving for a stimulant, and men in India, who never drink in England, there consume "pegs" and cheroots enormously. Of course, tobacco is to be put out of account in relation to great workers and thinkers up to the close of the middle ages, but the experience of antiquity would lead one to infer that the moderate use of wine, at all events, was not unfavourable to the highest brain development and physical force. Bismarck and Moltke are very great smokers; neither is a temperance man. In effect, I am inclined to think that tobacco and stimulants are hurtful mostly in the case of inferior organizations of brain physique, where their use is only a concomitant of baser indulgences, and uncontrolled by intelligence and will. I am quite in favour, therefore, of legislative interference, and almost inclined to supporting the Permissive Bill. W. H. RUSSELL. Feb. 23, 1882. (For) MR. JOHN RUSKIN. You are evidently unaware that Mr. Ruskin entirely abhors the practice of smoking, in which he has never indulged. His dislike of it is mainly based upon his belief (no doubt a true one) that a cigar or pipe will very often make a man content to be idle for any length of time, who would not otherwise be so. The excessive use of tobacco amongst all classes abroad, both in France and Italy, and the consequent spitting everywhere and upon everything, has not tended to lessen his antipathy. I have heard him allow, however, that there is reason in the soldiers and the sailors' pipe, as being some protection against the ill effects of exposure, etc. As to the effect of tobacco on the brain, I know that he considers it anything but beneficial. Feb. 12, 1882. KESHUB CHUNDER SEN. The problem you have undertaken to solve is, indeed, one of intense importance and interest, and all who can ought to help its solution in the interests both of science and morality. I feel thankful for the honour you have done me in inviting my opinion on the subject. As a teetotaler I abstain wholly from intoxicating drinks and stimulants, and discourage the use of the same in others. From boyhood up to the present time--I am now 44--I have never been in the habit of drinking or of smoking, nor did it ever occur to me that such habits were essential to health or helpful to brain work. It is my firm conviction that neither the head nor the hand derives any fresh power from the use of stimulants. It is only habits already contracted which give to alcohol and tobacco their so-called stimulating properties, and engender a strong craving for them, which those who are not enslaved by such habits never experience. I must not, however, place alcohol and tobacco on the same level. The latter is comparatively harmless; the former is a prolific source of evil in society, and often acts like deadly poison. KESHUB CHUNDER SEN. July 29, 1882. M. JULES SIMON. Some twenty years ago I had occasion to study the condition of the working classes, when I did not fail to observe the pernicious effects produced upon their health and morals by the use of Strong liquors. I remember that one of the most painful results of my inquiry was that whilst some look for pleasure in the abuse of intoxicating liquor, others, unable to procure sufficient food, seek to blunt the edge of their appetite by drinking a little brandy. As my researches were made so long ago, my testimony will now be of little value. Everything changes in twenty years, and I would fain hope that during this period a change for the better has taken place in the habits of the people. I have not much to say on the use of tobacco. I believe that when taken in excess, it has a stupefying effect. I know that it may act as a poison, for a friend of mine, a member of the Senate, who has just died, assured me repeatedly that he was dying from the effects of constant smoking. I look upon the use of tobacco, as a practice much to be deprecated, as its tendency is to separate men from the society of women. JULES SIMON. March 8, 1882. PROFESOR SKEAT. As to the benefit of alcohol and tobacco, my opinion is that there is no _general_ rule. As for myself, my experience is, that the less stimulant I take, the better--I have given up beer with benefit to myself, and I have almost given up wine. I take, on an average, about five glasses of claret per week, more by way of luxury than of use. Tobacco I never use, as smoking seems to me to be rather a waste of time. WALTER W. SKEAT. March 18, 1882. M. BARTHELEMY ST. HILAIRE. I have no difficulty in making known to you my views on the effects of tobacco and alcohol. I believe both to be extremely injurious, as they are the cause of many diseases, even when taken in small quantities, and much more so when indulged in to excess. I have never used them personally, but I have only too often observed their baneful influence on individuals of my acquaintance. I do not even consider wine to be harmless, especially as it is most usually adulterated. I have abstained from it for many years, indeed for nearly a lifetime, with great advantage. In our climate none of these stimulants are needed, and I very much question whether they are more necessary elsewhere. Accept my thanks for the questions you have addressed to me. B. ST. HlLAIRE. Feb. 24, 1882. MR. W. SPOTTISWOODE, D. C. L., LL. D., PRESIDENT OF THE ROYAL SOCIETY. In reply to your enquiry, I beg to say that I have never smoked, and that I take wine only at meals, and in moderation. I have never observed any noticeable effect from wine so taken on mental work, but should think it quite insignificant. W. SPOTTISWOODE. DR. C. W. SIEMENS, D. C. L., F. R. S. My experience has only extended to a very moderate use of alcohol and tobacco. I find that even the most moderate use of tobacco is decidedly hurtful to energetic mental effort. With regard to alcohol, a very moderate amount does not appear to depress the mental condition, under ordinary circumstances, but I find that although I never indulged in its use I can do very well without it, and I am doing with less and less. Under certain conditions, however, I find that alcohol has a beneficial effect in restoring both mind and body to a state of power and activity. C. W. SIEMENS. Dec. 4th, 1882. MR. G. BARNETT SMITH. I should probably not be accepted as an authority upon the tobacco question, as I have never smoked a pipe or cigar in my life. As to the use of alcohol, the moderate quantity I have taken has not been detrimental to me, and, in consequence of the state of my health, it has sometimes been necessary. No doubt a larger quantity of stimulant than is essential is taken by many literary men, and by other classes of the community; but a moderate quantity would, I believe, be found beneficial by most writers. Of course, if a man finds that he can do quite as well without alcohol, he is undoubtedly wise in discarding it. G. BARNETT SMITH. March 28, 1882. M. TAINE. I regret that it is not in my power to give you the information you ask. I have not made the question a study, and have no fixed opinion about it. All that I can say is that I have never made use of alcohol in any form as an essential stimulant. Coffee suits me much better. Alcohol, so far as I can judge, is good only as a physical stimulant after great physical fatigue, and even then it should be taken in very small quantities. As for tobacco, I have the bad habit of smoking cigarettes, and find them useful between two ideas,--when I have the first but have not arrived at the second; but I do not regard them as a necessity. It is probable that there is a little diversion produced at the same time, a little excitement and exhilaration. But every custom of this kind becomes tyrannical, and the observations which accompany your letter are very judicious. Among the men of letters and men of science around me there is not one to my knowledge who in order to think and to write has recourse to spirituous liquors; but three-fourths of them smoke, and almost all take before their work a cup of coffee. I have seen English journalists writing their articles by night with the aid of a bottle of champagne. With us, the articles are written in the day time, and our journalists have, therefore, no necessity to resort to this stimulant. H. TAINE. March 28, 1882. MR. ANTHONY TROLLOPE. I have been a smoker nearly all my life. Five years ago I found it certainly was hurting me, causing my hand to shake and producing somnolence. I gave it up for two years. A doctor told me I had smoked too much (three large cigars daily). Two years since I took to it again, and now smoke three small cigars (very small), and, so far as I can tell, without any effect. ANTHONY TROLLOPE. Feb. 11, 1882. SIR WILLIAM THOMSON, M. A., LL. D., D. C. L., F. R. S. The question of usefulness or the reverse of tobacco or alcohol is one of health, and to be answered by medical men, if they can. It seems to me that neither is of the slightest consequence as a stimulus or help to intellectual efforts, but that either may be used without harm or the reverse if in small enough quantities, so as not to hurt the digestion. WILLIAM THOMSON. Feb. 13, 1882. PROFESSOR TRANTMANN, BONN UNIVERSITY. I am not a smoker, so that I am unable to make any statement regarding the effect of tobacco. As to alcohol, I never make use of spirits in order to stimulate my brain, but often, after working hard, I drink a glass of beer or wine, and immediately feel relieved. M. TRANTMANN. March 14, 1882. PROFESSOR TYNDALL, LL. D., F. R. S. With regard to the use of alcohol and tobacco, I do not think any general rule can be laid down. Some powerful thinkers are very considerable smokers, while other powerful thinkers would have been damaged, if not ruined, by the practice. A similar remark applies in the case of alcohol. In my opinion, the man is happiest who is so organised as to be able to dispense with the use of both. JOHN TYNDALL. Feb. 14, 1882. MR. IVAN TOURGUENEFF. In answer to your enquiry I have to state that I have no personal experience of the influence of tobacco and alcohol on the mind, as I do not smoke or use alcoholic drinks. My observations on other people lead me to the conclusion that tobacco is generally a bad thing, and that alcohol taken in very small quantities can produce a good effect in some cases of constitutional debility. Iv. TOURGUENEFF. March 14, 1882. MARK TWAIN. I have not had a large experience in the matter of alcoholic drinks. I find that about two glasses of champagne are an admirable stimulant to the tongue, and is, perhaps, the happiest inspiration for an after dinner speech which can be found; but, as far as my experience goes, wine is a clog to the pen, not an inspiration. I have never seen the time when I could write to my satisfaction after drinking even one glass of wine. As regards smoking, my testimony is of the opposite character. I am forty-six years old, and I have smoked immoderately during thirty-eight years, with the exception of a few intervals, which I will speak of presently. During the first seven years of my life I had no health--I may almost say that I lived on allopathic medicine, but since that period I have hardly known what sickness is. My health has been excellent, and remains so. As I have already said, I began to smoke immoderately when I was eight years old; that is, I began with one hundred cigars a month, and by the time I was twenty I had increased my allowance to two hundred a month. Before I was thirty, I had increased it to three hundred a month. I think I do not smoke more than that now; I am quite sure I never smoke less. Once, when I was fifteen, I ceased from smoking for three months, but I do not remember whether the effect resulting was good or evil. I repeated this experiment when I was twenty-two; again I do not remember what the result was. I repeated the experiment once more, when I was thirty-four, and ceased from smoking during a year and a half. My health did not improve, because it was not possible to improve health which was already perfect. As I never permitted myself to regret this abstinence, I experienced no sort of inconvenience from it. I wrote nothing but occasional magazine articles during pastime, find as I never wrote one except under strong impulse, I observed no lapse of facility. But by and by I sat down with a contract behind me to write a book of five or six hundred pages--the book called "Roughing it"-- and then I found myself most seriously obstructed. I was three weeks writing six chapters. Then I gave up the fight, resumed my three hundred cigars, burned the six chapters, and wrote the book in three months, without any bother or difficulty. I find cigar smoking to be the best of all inspirations for the pen, and, in my particular case, no sort of detriment to the health. During eight months of the year I am at home, and that period is my holiday. In it I do nothing but very occasional miscellaneous work; therefore, three hundred cigars a month is a sufficient amount to keep my constitution on a firm basis. During the family's summer vacation, which we spend elsewhere, I work five hours every day, and five days in every week, and allow no interruption under any pretext. I allow myself the fullest possible marvel of inspiration; consequently, I ordinarily smoke fifteen cigars during my five hours' labours, and if my interest reaches the enthusiastic point, I smoke more. I smoke with all my might, and allow no intervals. MARK TWAIN. March 14, 1882. MR. CORNELIUS WALFORD, F. S. S., F. I. A. The subject you enquire about is one of vital consequence to brain-workers. I am distinctly of opinion that all stimulants are decidedly injurious to the physical system, and that as a consequence they tend to weaken and destroy the mental powers. I believe tobacco to be a more insidious stimulant than alcoholic beverages. It can be indulged in more constantly without visible degradation; but surely it saps the powers of the mind. In this view I gave it up some years ago. Many men say they smoke to make them think. I notice that a number of them seem to think to very small purpose, either for themselves or mankind generally. I am not a total abstainer, and theoretically have had a belief that pure wine ought to be beneficial to the human system. In practice I have not found it so, though I have always been a very moderate drinker. I certainly never drank a glass of wine or any other liquor in view of mental stimulus, and did not know it was ever seriously regarded as having any such effect, except in so far as it might invigorate the body, which I now find it does not do; but in case of sedentary occupations is positively injurious in its effects. Until mankind can rise above beer and tobacco, the race will remain degraded, as it now is, mentally, socially and physically. P.S.--I have never had so large an amount of mental labour on hand as now--three works in the press (including an encyclopedia, whereof all the articles are written by myself), all requiring much thought and research. I am taking no stimulants whatever. CORNELIUS WALFORD. March 9, 1882. MR. G. F. WATTS, R. A. In answer to your letter asking for my experience and opinion as a worker, on the subject of tobacco and alcoholic stimulants, I must begin by saying that reflection and experience should teach us the truth of the adage that "What is one man's meat is another man's poison," and that what may be wisely recommended in some cases is by no means desirable in all; in fact, that it is equally unwise and illiberal to dogmatise upon any subject that is not capable of scientific proof. Being myself a total abstainer from tobacco, and equally so, when not recommended by my doctor, from wine and all stimulants, I confess to having a strong prejudice against them. The use of wine seems to be natural to man, and it is possible he would be the better for it if it could be restrained within very moderate limits; but I have good reason for concluding that the more active stimulants are altogether harmful. It is natural as time goes on that new wants should be acquired, and new luxuries discovered, and doubtless it is in the abuse, and not in the use, of such things that the danger lies; but we all know how prone humanity is to abuse in its indulgences. It is, I believe, an admitted fact that even people who are considered to be strictly temperate as a rule, habitually take more wine than is good for them. With regard to tobacco, I cannot help thinking that its introduction by civilised races has been an unmixed evil. History shows us that before it was known the most splendid mental achievements were carried put, and the most heroic endurance exhibited, things done which if it be possible to rival, it is quite impossible to excel. The soldier, and sailor, the night-watchman especially in malarious districts may derive comfort and benefit from its use, and there I think it should be left; for my observation has induced me to think that nothing but evil results from its use as a luxurious habit. The subject is doubtless one of vital interest and importance; but I must end as I began by disclaiming a right to dogmatise. G. F. WATTS. Feb. 19, 1882. PROFESSOR ANDREW WILSON, Ph. D., F. R. S. E. The question you ask concerning the effects of alcohol and tobacco upon the health of brain-workers, relatively (I presume) to myself, is a complex one. Personally, I find with often excessive work in the way of lecturing, long railway journeys, and late hours, writing at other times, that I digest my food with greater ease when I take a little claret or beer with meals. Experiment has convinced me that the slight amount of alcohol I imbibe in my claret is a grateful stimulus to digestion. As to smoking, I take an occasional cigar, but only after dinner, and never during the day. As to health, I never suffer even from a headache. I usually deliver 18 lectures a week, often more; and I have often to make journeys of over 50 miles after a hard day's work here, to lecture in the country. My writing is done at night chiefly, but as a rule, I don't sit after 12-30. My work is exceptionally constant, yet I seem to be exceptionally healthy. I regard my claret or wine to meals in the same light in which others regard their tea, as a pleasant stimulus, followed in my case by good effect. At the same time, there may be others who may do the same amount of work as abstainers. My position in this matter has always been that of recognising the individual phases of the matter as the true basis of its settlement. What I can urge is, that I am an exceptionally healthy man, doing what I may fairly claim to be exceptionally hard work, and careful in every respect of health, finding that a moderate quantity of alcohol, with food, is for me better than total abstinence. Whiskey, or alcohol, in its strong forms I never taste. ANDREW WILSON. Feb. 14, 1882. MR. JUSTIN WINSER. Referring to your note, I may say that I have never used stimulants to incite intellectual work, but have found occasionally in social gatherings a certain intellectual exhilaration arising from its use, which conduces to quickness of wit, etc., but perhaps not so much from alcoholic liquors as from coffee, a cup of coffee being with me a good preparation for an after-dinner speech. My moderate use of a stimulant has not disclosed to me beneficial or hurtful effects. I often go long intervals without it; and have never indulged in it, to great extent, so that my testimony is of a narrow experience. My use of tobacco is so inconsiderable as to show nothing. JUSTIN WlNSER. March 9, 1882. M. WURTZ, PARIS. In reply to your letter of the 7th February, I have the honour to recall you the opinion which is current to-day among doctors of the highest authority, namely, that the abuse of alcohol and tobacco offers the greatest inconvenience from the point of view of health. Alcoholism produces a state of disorder of the organism to which a great number of maladies attach themselves. It is not a question of the moderate use of excitants, but the limit between use and abuse is difficult to trace, because it varies according to the country, the climate, and the habits of the individual constitution. A. WURTZ. March 14, 1882. APPENDIX. DR. RISDON BENNETT. "There are few people, I believe, who are aided in the actual performance of brain-work by alcohol; not that many, nay, most persons, are not rendered more ready and brilliant in conversation, or have their imagination quickened for a time. But the steady, continued exercise of the mental powers demanded of professional men is more often impeded than aided at the time by alcohol." _Contemporary Review_, vol. 34, p. 343. THE REV. STOPFORD A. BROOKE, M. A. "It has been said that moderate doses of alcohol stimulate work into greater activity, and make life happier and brighter. My experience, since I became a total abstainer, has been the opposite. I have found myself able to work better. I have a greater command over any powers I possess. I can make use of them when I please. When I call upon them, they answer; and I need not wait for them to be in the humour. It is all the difference between a machine well oiled and one which has something, among the wheels which catches and retards the movement at unexpected times. As to the pleasure of life, it has been also increased. I enjoy Nature, books, and men more than I did--and my previous enjoyment of them was not small. Those attacks of depression which come to every man at times who lives too sedentary a life rarely visit me now, and when depression does come from any trouble, I can overcome it far more quickly than before. The fact is, alcohol, even in the small quantities I took it, while it did not seem to injure health, injures the fineness of that physical balance which means a state of health in which all the world is pleasant. That is my experience after four months of water-drinking, and it is all the more striking to me, because for the last four or five years I have been a very moderate drinker. However, the experience of one man is not that of another, and mine only goes for what it is worth to those to whom, as much alcohol as is contained in one glass of sherry, or port, alters away from the standard of health. I have discovered, since abstinence, that that is true of me. And I am sure, from inquiries, I have made, that it is true for a great many other people who do not at all suspect it. Therefore, I appeal to the young and the old, to try abstinence for the very reasons they now use alcohol--in order to increase their power of work and their enjoyment of life. Let the young make the experiment of working on water only. Alcohol slowly corrupts and certainly retards the activity of the brain of the greater number of men. They will be able to do all they have to do more swiftly. And this swiftness will leave them leisure--the blessing we want most in this over-worked world. And the leisure, not being led away by alcohol into idleness, into depression which craves unnatural excitement, into noisy or slothful company, will be more nobly used and with greater joy in the usage. And the older men, who find it so difficult to find leisure, and who when they find it cannot enjoy it because they have a number of slight ailments which do not allow them perfect health, or which keep them in over-excitement or over-depression, let them try--though it will need a struggle--whether the total abandonment of alcohol will not lessen all their ailments, and by restoring a better temper to the body--for the body with alcohol in it is like a house with an irritable man in it--enable them not only to work better, but to enjoy their leisure. It is not too much to say that the work of the world would be one-third better done, and more swiftly done, and the enjoyment of life increased by one-half, if no one took a drop of alcohol." Speech at Bedford Chapel, July 20th, 1882. WILLIAM C. BRYANT. (BORN 1794; DIED 1878.) I promised to give you some account of my habits of life, so far, at least, as regards diet, exercise, and occupation. I have reached a pretty advanced period of life, without the usual infirmities of old age, and with my strength, activity, and bodily faculties generally in pretty good preservation. How far this may be the effect of my way of life, adopted long ago, and steadily adhered to, is perhaps uncertain. I rise early, at this time of the year about 5 1/2; in summer, half an hour, or even an hour, earlier. Immediately, with very little incumbrance of clothing, I begin a series of exercises, for the most part designed to expand the chest, and at the same time call into action all the muscles and articulations of the body. These are performed with dumb-bells, the very lightest, covered with flannel; with a pole, a horizontal bar, and a light chair swung around my head. After a full hour, and sometimes more, passed in this manner, I bathe from head to foot. When at my place in the country, I sometimes shorten my exercises in the chamber, and, going out, occupy myself for half an hour or more in some work which requires brisk exercise. After my bath, if breakfast be not ready, I sit down to my studies until I am called. My breakfast is a simple one--hominy and milk, or in place of hominy, brown bread, or oat-meal, or wheaten grits, and, in the season, baked sweet apples. Buckwheat cakes I do not decline, nor any other article of vegetable food, but animal food I never take at breakfast. Tea and coffee I never touch at any time. Sometimes I take a cup of chocolate, which has no narcotic effect, and agrees with me very well. At breakfast I often take fruit, either in its natural state or freshly stewed. After breakfast I occupy myself for awhile with my studies, and then, when in town, I walk down to the office of _The Evening Post_, nearly three miles distant, and after about three hours, return, always walking, whatever be the weather or the state of the streets. In the country I am engaged in my literary tasks till a feeling of weariness drives me out into the open air, and I go upon my farm or into the garden and prune the trees, or perform some other work about them which they need, and then go back to my books. I do not often drive out, preferring to walk. In the country I dine early, and it is only at that meal that I take either meat or fish, and of these but a moderate quantity, making my dinner mostly of vegetables. At the meal which is called "tea," I take only a little bread and butter, with fruit, if it be on the table. In town, where I dine later, I make but two meals a day. Fruit makes a considerable part of my diet, and I eat it at almost any part of the day without inconvenience. My drink is water, yet I sometimes, though rarely, take a glass of wine. I am a natural temperance man, finding myself rather confused than exhilarated by wine. I never meddle with tobacco, except to quarrel with its use. That I may rise early, I, of course, go to bed early: in town, as early as 10; in the country, somewhat earlier. For many years I have avoided in the evening every kind of literary occupation which tasks the faculties, such as composition, even to the writing of letters, for the reason that it excites the nervous system and prevents sound sleep. My brother told me, not long since, that he had seen in a Chicago newspaper, and several other Western journals, a paragraph in which it is said that I am in the habit of taking quinine as a stimulant; that I have depended upon the excitement it produces in writing my verses, and that, in consequence of using it in that way, I had become as deaf as a post. As to my deafness, you know that to be false, and the rest of the story is equally so. I abominate all drugs and narcotics, and have always carefully avoided every thing which spurs nature to exertions which it would not otherwise make. Even with my food I do not take the usual condiments, such as pepper, and the like. March 30, 1871. _Hygiene of the Brain_, New York, 1878. DR. KING CHAMBERS, HONORARY PHYSICIAN TO H. R. H. THE PRINCE OF WALES. "The physiology of the action of alcohol has a very practical bearing on the physical regimen of the mental functions. Alcohol has the power of curbing, arresting, and suspending all the phenomena connected with the nervous system. We feel its influence on our thoughts as soon as on any other part of the man. Sometimes it brings them more completely under our command, controls and steadies them; sometimes it confuses or disconnects them; then breaks off our power and the action of the senses altogether. The first effect is desirable, the others to be avoided. When a man has tired himself with intellectual exertion a moderate quantity of alcohol taken with food acts as an anaesthetic, stays the wear of the system which is going on, and allows the nervous force to be diverted to the due digestion of the meal. But it must be followed by rest from mental labour, and is, in fact, a part of the same regimen which enforces rest--it is an artificial _rest_. To continue to labour and at the same time to take the anaesthetic is an inconsistency. It merely blunts the painful feeling of weariness, and prevents it from acting as a warning. I very much doubt the quickening or brightening of the wits which bacchanalian poets have conventionally attributed to alcohol. An abstainer in a party of even moderate topers finds their jokes dull and their anecdotes pointless, and his principal amusement consists in his observation of their curious bluntness to the groundlessness of their merriment. There is no more fatal habit to a literary man than that of using alcohol as a stimulant between meals. The vital powers go on getting worn out more and more without their cry for help being perceived, and in the end break down suddenly, and often irrevocably. The temptation is greater perhaps to a literary man than to any other in the same social position, especially if he has been induced by avarice, or ambition, to work wastefully against them; and if he cannot resist it, he had better abjure the use of alcohol altogether.... Mental activity certainly renders the brain less capable of bearing an amount of alcohol, which in seasons of rest and relaxation does not injuriously affect it. When any extraordinary toil is temporarily imposed, extreme temperance, or even total abstinence, should be the rule. Much to the point is the experience of Byron's Sardanapalus:-- "The _goblet_ I reserve for hours of ease, I war on _water_." "It is true that Byron assumes in his poetry the character of a _debauche_, and says he wrote Don Juan under the influence of gin and water. But much of that sort of talk is merely for stage effect, and we see how industrious he was, and read of his training vigorously to reduce corpulence, and of his being such an exceptionally experienced swimmer as to rival Leander in crossing the Hellespont.... The machinery of sensitive souls is as delicate as it is valuable, and cannot bear the rough usage which coarse customs inflict upon it. It is broken to pieces by blows which common natures laugh at. The literary man, with his highly-cultivated, tightly-strung sensations, is often more than others susceptible of the noxious, and less susceptible of the beneficial results of alcohol. His mind is easier to cloud, and there is a deeper responsibility in clouding it.... Equally when we descend into the lower regions of Parnassus, the abodes of talent and cleverness, and the supply of periodical literary requirements, we find the due care of the body absolutely essential to the continued usefulness of the intellect. The first thing to which one entering the profession of literature must make up his mind is to be healthy, and he can only be so by temperance.... Tobacco should not be indulged in during working hours. Whatever physiological effect it has is sedative, and so obstructs mental operations." _Manual of Diet in Health and Disease_. 1876, p. 162. PROFESSOR THOMAS R. FRASER, EDINBURGH. "The stimulating action on the brain of quantities far short of intoxicating, is accompanied with a paralysing action which seems most rapidly and powerfully to involve the higher faculties. Mental work may seem to be rendered more easy, but ease is gained at the expense of quality. The editor of a newspaper will tell you that, if he has been dining out, he cannot with confidence write a leading article until he has allowed sufficient time to elapse from the effect of the wine he has drunk, in moderation, to pass away; and even the novelist, whose brain-work is in the regions of imagination, will relate a similar experience.... In a person accustomed to the use of tobacco the intellectual work is difficult when smoking cannot be indulged in, the mind cannot easily be concentrated on a subject, and unrest is produced--but this disappears when recourse is had to smoking; and probably some of its reputation as a soothing agent has on this account been acquired. The circulation is also a little excited, and no doubt this assists in rendering brain work more easy. In a short time, however, the circulation is slightly depressed, the pulse becoming smaller; and this may assist in producing the soothing effect generally experienced." _The Use and Abuse of Alcoholic Stimulants and Tobacco_. 1881 HUBERT HERKOMER, A. R. A. "It is no credit to me for being an abstainer. The credit is due to my father, who gave up smoking, drinking, intoxicating drinks, and eating meat at the same time, about twenty years ago; and as I was only ten years old then, I naturally grew into my father's habits (I now eat meat, however). The blessings of that reform have come down upon my children." Sherlock's _Heroes in the Strife_. COLONEL THOMAS WENTWORTH HIGGINSON. "I have been a busy worker with the brain all my life, and have enjoyed very unusual health. I am now fifty-three, and have not been confined to the house by illness since I was seventeen, except for a short time during the war, when suffering from the results of a wound. This favourable result I attribute to (1) a good constitution--and an elastic temperament; (2) simple tastes, disinclining me to stimulants and narcotics, such as tea, coffee, wine, spirits, and tobacco; (3) a love of athletic exercises; (4) a life-long habit of writing by daylight only; (5) the use of homoeopathic medicines in the early stages of slight ailments. I have never been a special devotee of health, I think, but have followed out my natural tastes; and have certainly enjoyed physical life very much. It may be well to add that, though, as I said, my constitution was good and my frame always large, I had yet an unusual number of children's diseases, and have often been told that my life was several times preserved, in infancy, against all expectation, by the unwearied care and devotion of my mother. This may encourage some anxious parents." Nov. 11, 1877. _Hygiene of the Brain_, N.Y., 1878. WILLIAM HOWITT. I have read with very great pleasure the letter of Mr. Bryant.... Let me observe that while the modes of my own life and those of Mr. Bryant very much accord, in a few particulars they differ, as, I suppose, must be the case in almost any two individuals. Mr. Bryant never takes coffee or tea. I regularly take both, find the greatest refreshment in both, and never experienced any deleterious effects from either, except in one instance, when, by mistake, I took a cup of tea strong enough for ten men. On the contrary, tea is to me a wonderful refresher and reviver. After long-continued exertion, as in the great pedestrian journeys that I formerly made, tea would always, in a manner almost miraculous, banish all my fatigue, and diffuse through my whole frame comfort and exhilaration, without any subsequent evil effect. I am quite well aware that this is not the experience of many others, my wife among the number, on whose nervous system tea acts mischievously, producing inordinate wakefulness, and its continued use, indigestion. But this is one of the things that people should learn, and act upon, namely, to take such things as suit them, and avoid such as do not. It is said that Mithridates could live and flourish on poisons, and if it be true that tea or coffee is a poison, so do most of us. William Hutton, the shrewd and humorous author of the histories of Birmingham and Derby, and also of a life of himself, scarcely inferior to that of Franklin in lessons of life-wisdom, said that he had been told that coffee was a slow poison, and, he added, that he had found it very slow, for he had drunk it more than sixty years without any ill effect My experience of it has been the same. Mr. Bryant also has recourse to the use of dumb-bells, and other gymnastic appliances. For my part, I find no artificial practices necessary for the maintenance of health and a vigorous circulation of the blood. My only gymnastics have been those of Nature--walking, riding, working in field and garden, bathing, swimming, etc. In some of those practices, or in the amount of their use, Nature, in my later years, has dictated an abatement. In Mr. Bryant's abhorrence of tobacco, I fully sympathize. That is a poisoner, a stupefier, a traitor to the nervous system, and, consequently, to energy and the spirit of enterprise, which I renounced once and for ever before I reached my twentieth year. The main causes of the vigor of my constitution and the retention of sound health, comfort, and activity to within three years of eighty, I shall point out as I proceed. First and foremost, it was my good fortune to derive my existence from parents descended on both sides from a vigorous stock, and of great longevity. I remember my great-grandmother, an old lady of nearly ninety; my grandmother of nearly as great an age. My mother lived to eighty-five, and my father to the same age. They were both of them temperate in their habits, living a fresh and healthy country life, and in enjoyment of that tranquillity of mind which is conferred by a spirit of genuine piety, and which confers, in return, health and strength. The great destroyers of life are not labor and exertion, either physical or intellectual, but care, misery, crime, and dissipation. My wife derived from her parentage similar advantages, and all the habits of our lives, both before and since our marriage, have been of a similar character. My boyhood and youth were, for the most part, spent in the country; and all country objects, sports, and labors, horse-racing and hunting excepted, have had a never-failing charm for me. As a boy, I ranged the country far and wide in curious quest and study of all the wild creatures of the woods and fields, in great delight in birds and their nests, climbing the loftiest trees, rocks and buildings in pursuit of them. In fact, the life described in the "Boy's Country Book," was my own life. No hours were too early for me, and in the bright, sunny fields in the early mornings, amid dews and odour of flowers, I breathed that pure air which gave a life-long tone to my lungs that I still reap the benefit of. All those daily habits of climbing, running, and working developed my frame to perfection, and gave a vigor to nerve and muscle that have stood well the wear and tear of existence. My brain was not dwarfed by excessive study in early boyhood, as is too much the case with children of to-day. Nature says, as plainly as she can speak, that the infancy of all creatures is sacred to play, to physical action, and the joyousness of mind that give life to every organ of the system. Lambs, kittens, kids, foals, even young pigs and donkeys, all teach the great lesson of Nature, that to have a body healthy and strong, the prompt and efficient vehicle of the mind, we must not infringe on her ordinations by our study and cramping sedentariness in life's tender years. We must not throw away or misappropriate her forces destined to the corporeal architecture of man, by tasks that belong properly to an after-time. There is no mistake so fatal to the proper development of man and woman, as to pile on the immature brain, and on the yet unfinished fabric of the human body, a weight of premature and, therefore, unnatural study. In most of those cases where Nature has intended to produce a first-class intellect, she has guarded her embryo genius by a stubborn slowness of development. Moderate study and plenty of play and exercise in early youth are the true requisites for a noble growth of intellectual powers in man, and for its continuance to old age. My youth, as my boyhood, was spent in the country, and in the active exercise of its sports and labors. I was fond of shooting, fishing, riding, and walking, often making long expeditions on foot for botanical or other purposes. Bathing and swimming I continued each year till the frost was in the ground and the ice fringed the banks of the river. As my father farmed his own land, I delighted in all the occupations of the field, mowing and reaping with the men through the harvest, looking after sheep and lambs, and finding never-ceasing pleasure in the cultivation of the garden. When our literary engagements drew us to London, we carefully avoided living in the great Babel, but took up our residence in one of its healthy suburbs, and, on the introduction of railways, removed to what was actual country. A very little time showed us the exhausting and unwholesome nature of city life. Late hours, heavy dinners, the indulgence of what are called jovial hours, and crowded parties, would soon have sent us whither they have sent so many of our literary contemporaries, long, long ago. After an evening spent in one of the crowded parties of London, I have always found myself literally poisoned. My whole nervous system has been distressed and vitiated. I have been miserable and incapable the next day of intellectual labor. Nor is there any mystery about this matter. To pass some four or five hours in a town, itself badly ventilated, amid a throng of people just come from dinner, loaded with a medley of viands, and reeking with the fumes of hot wines--no few of them, probably, of very moral habits, was simply undergoing a process of asphyxia. The air was speedily decomposed by so many lungs. Its ozone and oxygen were rapidly absorbed, and in return the atmosphere was loaded with carbonic acid, carbon, nitrogen, and other effluvia, from the lungs and pores of the dense and heated company; this mischievous matter being much increased from the products of the combustion of numerous lamps, candles, and gas-jets. The same effect was uniformly produced on me by evenings passed in theatres, or crowded concert or lecture rooms. These facts are now well understood by those who have studied the causes of health and disease in modern society; and I am assured by medical men that no source of consumption is so great as that occasioned by the breathing of these lethal atmospheres of fashionable parties, fashionable theatres, and concert and lecture halls; and then returning home at midnight by an abrupt plunge from their heat into damp and cold. People have said to me, "Oh! it is merely the effect of the unusual late hour that you have felt!" But, though nite hours, either in writing or society, have not been my habit, when circumstances of literary pressure have compelled me occasionally to work late, I have never felt any such effects. I could rise the next day a little later, perfectly refreshed and full of spirit for my work. Another cause to which I attribute my extraordinary degree of health, has been not merely continued country exercise in walking and gardening, but, now and then, making a clean breach and change of my location and mode of life. Travel is one of the great invigorators of the system, both physically and intellectually. When I have found a morbid condition stealing over me, I have at once started off on a pedestrian or other journey. The change of place, scene, atmosphere, of all the objects occupying the daily attention, has at once put to flight the enemy. It has vanished as by a spell. There is nothing like a throwing off the harness and giving mind and body a holiday--a treat to all sorts of new objects. Once, a wretched, nervous feeling grew upon me; I flung it off by mounting a stage-coach, and then taking a walk from the Land's End, in Cornwall, to the north of Devon. It was gone for ever! Another time the "jolly" late dinners and blithely-circulating decanter, with literary men, that I found it almost impossible to avoid altogether without cutting very valuable connections, gave me a dreadful dyspepsia. I became livingly sensible of the agonies of Prometheus with the daily vulture gnawing at his vitals. At once I started with all my family for a year's sojourn in Germany, which, in fact, proved three years. But the fiend had left me the very first day. The moment I quitted the British shore, the tormentor quitted me. I suppose he preferred staying behind, where he was aware of so many promising subjects of his diabolical art. New diet, new and early hours, and all the novelties of foreign life, made his approach to me impossible. I have known him no more, during these now thirty years. Eighteen years ago I made the circumnavigation of the globe, going out to Australia by the Cape of Good Hope, and returning by Cape Horn. This, including two years of wandering in the woods and wilds of Australia, evidently gave a new accession of vital stamina to my frame. It is said that the climate of Australia makes young men old, and old men young. I do not believe the first part of the proverb, but I am quite certain that there is a great deal in the second part of it. During those two years I chiefly lived in a tent, and led a quiet, free, and pleasant life in the open forests and wild country, continually shifting our scene as we took the fancy, now encamping in some valley among the mountains, now by some pleasant lake or river. In fact, pic-nicing from day to day, and month to month, watching, I and my two sons, with ever new interest, all the varied life of beast, bird, and insect, and the equally varied world of trees, shrubs, and flowers. My mind was lying fallow, as it regarded my usual literary pursuits, but actually engaged with a thousand things of novel interest, both among men in the Gold Diggings, and among other creatures and phenomena around me. In this climate I and my little party enjoyed, on the whole, excellent health, though we often walked or worked for days and weeks under a sun frequently, at noon, reaching from one hundred to one hundred and fifty degrees of Fahrenheit; waded through rivers breast high, because there were no bridges, and slept occasionally under the forest trees. There, at nearly sixty years of age, I dug for gold for weeks together, and my little company discovered a fine gold field which continues one to this day. These two years of bush life, with other journeys on the Australian Continent, and in Tasmania, and the voyages out and back, gave a world of new vigor that has been serving me ever since. During the last summer in Switzerland, Mrs. Howitt and myself, at the respective ages of sixty-eight and seventy-six, climbed mountains of from three to five thousand feet above the level of the sea, and descended the same day with more ease than many a young person of the modern school could do. As to our daily mode of life, little need be said. We keep early hours, prefer to dine at noon, are always employed in "books, or work, or healthful play;" have no particular rules about eating and drinking, except the general ones of having simple and good food, and drinking little wine. We have always been temperance people, but never pledged, being averse to thraldom of any kind, taking, both in food and drink, what seemed to do us good. At home, we drink, for the most part, water, with a glass of wine occasionally. On the Continent, we take the light wines of the country where we happen to be, with water, because they suit us; if they did not, we should eschew them. In fact, our great rule is to use what proves salutary, without regard to any theories, conceits, or speculations of hygienic economy; and, in our case, this following of common sense has answered extremely well. At the same time it is true that many eminent men, and especially eminent lawyers, who in their early days worked immensely hard, studied through many long nights, and caroused, some of them, deeply through others, yet attained to a good old age, as Lords Eldon, Scott, Brougham, Campbell, Lyndhurst, and others. To what are we to attribute this longevity under the circumstances? No doubt to iron constitutions derived from their parentage, and then to the recuperative effect of those half-yearly flights into the Egypt of the country, which make an essential part of English life. To a thorough change of hours, habits, and atmosphere in these seasons of villeggiatura. To vigorous athletic country sports and practices, hunting, shooting, fishing, riding, boating, yachting, traversing moors and mountains after black-cock, grouse, salmon, trout and deer. To long walks at sea-side resorts, and to that love of continental travel so strong in both your countrymen and women, and ours. These are the _saving_ causes in the lives of such men. Who knows how long they would have lived had they not inflicted on themselves, more or less, the destroying ones. There is an old story among us of two very old men being brought up on a trial where the evidence of "the oldest inhabitant" was required. The Judge asked the first who came up what had been the habits of his life. He replied, "Very regular, my lord; I have always been sober, and kept good hours." Upon which the Judge dilated in high terms of praise on the benefit of regular life. When the second old man appeared, the Judge put the same question, and received the answer, "Very regular, my lord; I have never gone to bed sober these forty years." Whereupon his lordship exclaimed, "Ha! I see how it is. English men, like English oak, wet or dry, last for ever." I am not of his lordship's opinion; but seeing the great longevity of many of our most eminent lawyers, and some of whom in early life seemed disposed to live fast rather than long, I am more than ever confirmed in my opinion of the vitalizing influences of temperance, good air, and daily activity, which, with the benefits of change and travel, can so far in after life save those whom no original force of constitution could have saved from the effects of jollity, or of gigantic efforts of study in early life. For one' of such hard livers, or hard brain-workers who have escaped by the periodical resort to healthful usages, how many thousands have been "cut off in the midst of their days?" A lady once meeting me in Highgate, where I then lived, asked me if I could recommend her a good doctor. I told her that I could recommend her three. She observed that one would be enough; but I assured her that she would find these three more economical and efficient than any individual Galen that I could think of. Their names were, "Temperance, Early Hours, and Daily Exercise." That they were the only ones that I had employed for years, or meant to employ. Soon after, a gentleman wrote to me respecting these "Three Doctors," and put them in print. Anon, they were made the subject of one of the "Ipswich Tracts;" and on a visit, a few years ago, to the Continent, I found this tract translated into French, and the title-page enriched with the name of a French physician, as the author. So much the better. If the name of the French physician can recommend "The Three Doctors" to the population of France, I am so much the more obliged. May 20, 1871. _Hygiene of the Brain_, New York, 1878. THE REV. CHARLES KINGSLEY Found great benefit from the use of tobacco, though several times he tried to give it up. He smoked the poorest tobacco, however, and Mr. C. Kegan Paul thus describes the care Charles Kingsley took to minimise the dangers of the habit:-- "He would work himself into a white heat over his book, till, too excited to write more, he would calm himself down by a pipe, pacing his grass-plot in thought, and in long strides. He was a great smoker, and tobacco was to him a needful sedative. He always used a long and clean clay pipe, which lurked in all sorts of unexpected places. But none was ever smoked which was in any degree foul, and when there was a vast accumulation of old pipes, they were sent back again to be rebaked, and returned fresh and new. This gave him a striking simile, which in 'Alton Locke,' he puts into the mouth of James Crossthwaite, 'Katie here believes in Purgatory, where souls are burnt clean again, like 'bacca pipes.'" HARRIET MARTINEAU. I was deeply impressed by something which an excellent clergyman told me one day, when there was nobody by to bring mischief on the head of the narrator. This clergyman knew the literary world of his time so thoroughly that there was probably no author of any mark then living in England with whom he was not more or less acquainted. It must be remembered that a new generation has now grown up. He told me that he had reason to believe that there was no author or authoress who was free from the habit of taking pernicious stimulants, either strong green tea or strong coffee at night, or wine, or spirits, or laudanum. The amount of opium taken to relieve the wear and tear of authorship was, he said, greater than most people had any conception of, and all literary workers took something. "Why, I do not," said I; "fresh air and cold water are my stimulants." "I believe you," he replied, "but you work in the morning, and there is much in that!" I then remembered, when I had to work a short time at night, a physician who called on me observed that I must not allow myself to be exhausted at the end of the day. He would not advise any alcoholic wines, but any light wines that I liked might do me good. "You have a cupboard there at your right hand," said he; "keep a bottle of hock and a wine glass there, and help yourself when you feel you want it." "No, thank you," said I; "if I took wine it should not be when alone, nor would I help myself to a glass; I might take a little more and a little more, till my solitary glass might become a regular tippling habit; I shall avoid the temptation altogether." Physicians should consider well before they give such advice to brain-worn workers. --_Autobiography_. PROFESSOR MILLER. "In labour of the head, alcohol stimulates the brain to an increase of function under the mental power, and so effects a concentrated cerebral exhaustion, without being able to afford compensating nutrition or repair. ....There is the same common fallacy here as in the case of manual labour. The stimulus is felt--to do good. 'I could not do my work without it.' But at what cost are you doing your work? Premature and permanent exhaustion of the muscles is bad enough; but premature and permanent exhaustion of brain is infinitely worse. And when you come to a point where work must cease or the stimulus be taken, do not hesitate as to the right alternative. Don't call for your pate ale, your brandy, or your wine. Shut your book, close your eyes, and go to sleep: or change your occupation, so as to give a thorough shift to your brain; and then, after a time, spent, as the case may be, either in repose or recreation, you will find yourself fit to resume your former task of thought without loss or detriment.... Look to the mental workers under alcohol. Take the best of them. Would not their genius have burned not only with a steadier and more enduring flame, but also with a less sickly and noxious vapour to the moral health of all around them, had they been free from the unnatural and unneeded stimulus? Take Burns, for example. Alcohol did not make his genius, or even brighten it.... Genius may have its poetical and imaginative powers stored up into fitful paroxysms by alcohol, no doubt: the control of will being gone or going, the mind is left to take ideas as they come, and they may come brilliantly for a time. But, at best, the man is but a revolving light. At one time a flash will dazzle you; at another, the darkness is as that of midnight; the alternating gloom being always longer than the period of light, and all the more intense by reason of the other's brightness. While imagination sparkles, reason is depressed. And, therefore, let the true student eschew the bottle's deceitful aid. He will think all the harder, all the clearer, and all the longer!" _Alcohol: its Place and Power_. 866, p. 122. MR. R. A. PROCTOR, F. R. S. "I would venture to add an expression of my own firm conviction that a life of study is aided by the almost entire avoidance of stimulants, alcoholic as well as nicotian, I do not say that the moderate use of such stimulants does harm, only that so far as I can judge from my own experience it affords no help. I recognise a slight risk in what Abbe Moigno correctly states--the apparent power of indefinite work which comes with the almost entire avoidance of stimulants; but the risk is very slight, for the man must have very little sense who abuses that power to a dangerous degree. Certainly, if the loss of the power be evidence of mischief, I would say (still speaking of my own experience, which may be peculiar to my own temperament) that the use of stimulants, even in a very moderate degree, is mischievous. For instance, I repeatedly have put this point to the test:--I work say from breakfast till one o'clock, when, if I feel at all hungry, I join my family at lunch; if now at lunch I eat very lightly, and take a glass of ale or whisky-and-water, I feel disposed, about a quarter of an hour later, to leave my work, which has, for the time, become irksome to me; and perhaps a couple of hours will pass before I care for steady work again: on the other hand, if I eat as lightly, or perhaps take a heartier lunch, but drink water only, I sit down as disposed for work after as before the meal. In point of fact, a very weak glass of whisky-and-water has as bad an influence on the disposition for work as a meal unwisely heavy would have. It is the same in the evening. If I take a light supper, with water only, I can work (and this, perhaps, is bad) comfortably till twelve or one; but a glass of weak whisky-and-water disposes me to rest or sleep, or to no heavier mental effort than is involved in reading a book of fiction or travel. These remarks apply only to quiet home life, with my relatives or intimate friends at the table. At larger gatherings it seems (as Herbert Spencer has noted) that not only a heartier meal, but stimulants in a larger quantity, can be taken without impairment of mental vivacity, and even with advantage, up to a point falling far short, however, of what in former times would have been regarded as the safe limit of moderation. Under those circumstances, "wine maketh glad the heart of man," and many find the stimulus it gives pleasant,--perhaps dangerously so, unless the lesson is soon learned that the point is very soon reached beyond which mental vivacity is not increased but impaired. "I must confess it seems to me that if we are to admit the necessity or prudence of adopting total abstinence principles, because of the miseries which have been caused by undue indulgence--if A, B, and C, who have no desire to make beasts of themselves, are to refrain from the social glass because X, Y, and Z cannot content themselves till they have taken half-a-dozen social glasses too many--society has an additional reason to be angry with the drunkards, and with those scarcely less pernicious members of the social body who either cannot keep sober without blue ribbons or pledges, or, having no wish to drink, want everyone to know it. I admit, of course, if it really is the case that the healthy-minded must refrain from the innocent use of such stimulants as suit them, in the interest of the diseased, it may be very proper and desirable to do so: but only in the same way that it might be very desirable to avoid in a lunatic asylum the rational discussion of subjects about which the lunatics were astray. For steady literary or scientific work, however, and throughout the hours of work (or near them), it is certain that for most men something very close to total abstinence from stimulants is the best policy." _Knowledge_, July, 29, 1882. "I have recently had rather interesting evidence of the real value of the use of so-called stimulants. When lecturing daily, and also travelling long distances, I always adopt a very light diet: tea, dry toast, and an egg for breakfast; nothing then till six, when I take tea, dry toast, and a chop; after lecturing I take a biscuit or so with cheese, and a glass of whisky-and-water, 'cold without.' I tried this season the effect of omitting the whisky. Result--sleeplessness till one or two in the morning. No other harm, but weariness during following day. Taking the whisky-and-water again, after trying this a night or two, acted as the most perfect sedative." _Knowledge_, Dec. 1, 1882. DR. B. W. RICHARDSON, F. R. S. "The evidence is all perfect that alcohol gives no potential power to brain or muscle. During the first stage of its action it may enable a wearied or a feeble organism to do brisk work for a short time; it may make the mind briefly brilliant: it may excite muscle to quick action, but it does nothing substantially, and fills up nothing it has destroyed, as it leads to destruction. A fire makes a brilliant sight, but leaves a desolation. It is the same with alcohol.... The true place of alcohol is clear; it is an agreeable temporary shroud. The savage, with the mansions of his soul unfurnished, buries his restless energy under its shadow. The civilised man, overburdened with mental labour, or with engrossing care, seeks the same shade; but it is shade, after all, in which in exact proportion as he seeks it, the seeker retires from perfect natural life. To search for force in alcohol is, to my mind, equivalent to the act of seeking for the sun in subterranean gloom until all is night.... In respect to the influence of smoking on the mental faculties, there need, I believe, be no obscurity. When mental labour is being commenced, indulgence in a pipe produces in most persons a heavy, dull condition, which impairs the processes of digestion and assimilation, and suspends more or less that motion of the tissues which constitutes vital activity. But if mental labour be continued for a long time, until exhaustion be felt, then the resort to a pipe gives to some _habitues_ a feeling of relief; it soothes, it is said, and gives new impetus to thought. This is the practical experience of almost all smokers, but few men become so habituated to the pipe as to commence well a day of physical or mental work on tobacco. Many try, but it almost invariably obtains that they go through their labours with much less alacrity than other men who are not so addicted. The majority of smokers feel that after a hard day's labour, a pipe, supposing always that the indulgence of it is moderately carried out, produces temporary relief from exhaustion." _Diseases of Modern Life_. "I gave up that which I thought warmed and helped me, and I can declare, after considering the whole period in which I have subjected myself to this ordeal, I never did more work; I never did more varied work; I never did work with so much facility; I never did work with such a complete sense of freedom from anxiety and worry, as I have done during the period that I have abstained altogether." Speech at Exeter Hall, Feb. 7, 1877. MR. GEORGE AUGUSTUS SALA. "As to smoking stupefying a man's faculties or blunting his energy, that allegation I take to be mainly nonsense. The greatest workers and thinkers of modern times have been inveterate smokers. At the same time, it is idle to deny that smoking to excess weakens the eyesight, impairs the digestion, plays havoc with the nerves, and interferes with the action of the heart. I have been a constant smoker for nearly forty years; but had I my life to live over again I would never touch tobacco in any shape or form. It is to the man who sits all day long at a desk, poring over books and scribbling 'copy,' that smoking is deleterious." _Illustrated London News_, Sep. 30, 1882. BISHOP TEMPLE. "I can testify that since I have given up intoxicating liquors I have felt less weariness in what I have to do. I have been busy ever since I was a little boy, and I therefore know how much I can undertake, and I certainly can testify that since I gave up intoxicating liquors-- although I did not like the giving them up, inasmuch as I rather enjoyed them, when I used them, and inasmuch as I never felt the slightest intention to exceed, nor am I at all among those who cannot take one glass, and only one, but must go on to another--I have certainly found that I am very much the better for it. Whatever arguments I may hear about it, it is impossible for me to escape from the memory of the fact that I have found myself very much better able to work, to write, to read, to speak, and to do whatever I may have to do, ever since I abstained totally and entirely from all intoxicating liquor." Speech at Torquay, Sept 10, 1882. SIR HENRY THOMPSON, F. R. C. S., SURGEON-EXTRAORDINARY TO THE KING OF THE BELGIANS. "I will tell you who can't take alcohol, and that is very important in the present day. Of all the people I know who cannot stand alcohol, it is the brain-workers; and you know it is the brain-workers that are increasing in number, and that the people who do not use their brains are going down, and that is a noteworthy incident in relation to the future. I find that the men who live indoors, who have sedentary habits, who work their nervous systems, and who get irritable tempers, as such people always do, unless they take a large balance of exercise to keep them right (which they rarely do), I say that persons who are living in these fast days get nervous systems more excitable and more irritable than their forefathers, and they cannot bear alcohol so well." Speech at Exeter Hall, Feb. 7, 1877. MR. W. MATTIEU WILLIAMS, F. R. A. S., F. C. S. "I have just read your quotations from the Abbe Moigno, and your own comments thereon. I have tried experiments very similar to those you describe, with exactly the same results; in fact, so far as intellectual work is concerned, I might describe my own experience by direct plagiarism of your words. Besides these, I have tried other experiments which may be interesting to those who, without any partizan fanaticism, are seeking for practical guidance on this subject. As many of your readers may know, I have been (when of smaller girth) an energetic pedestrian, have walked over a large part of England, Scotland, Wales, and Ireland, crossed France twice on foot, done Switzerland and the Tyrol pretty exhaustively; in one walk from Paris taking in on the way the popular lions of the Alps, and then proceeding, via, Milan and Genoa, to Florence, Rome, Naples, and Calabria, then from Messina to Syracuse, and on to the East. All this, excepting the East, on foot. At another time from Venice to Milan, besides a multitude of minor tours, and my well-known walk through Norway. In the course of these, my usual average rate, when in fair training, was 200 miles per week. The alcohol experiments consisted in doing a fortnight at this rate on water, scrupulously abstaining from any alcoholic drink whatever, and then a fortnight using the beverages of the country in ordinary moderate quantity. I have thus used British ales and porter, Bavarian beer, French wines, Italian wines, Hungarian wine in the Tyrol, Christiania ol, &c., according to circumstances, and the result has been the same, 'or with very little variation. With the stimulant I have, of course, obtained a temporary exhilaration that was pleasant enough while it lasted, but after the first week I found myself dragging through the last few miles, and quite able to appreciate the common habit of halting at a roadside "pub." or wine-shop, for a drink on the way. No such inclination came upon me when my only beverage was water, or water plus a cup of coffee for breakfast _only_ (no afternoon tea). Then I came in fresh, usually finishing at the best pace of the day, enjoying the brisk exercise in cool evening air. Physical work of this kind admits of accurate measurement, and I was careful to equalise the average of these experimental comparative fortnights. The result is a firm conviction that the only beverage for obtaining the maximum work out of any piece of human machinery is water, as pure as possible; that all other beverages (including even tea and coffee), ginger-beer, and all such concoctions as the so-called "temperance drinks," are prejudicial to anybody not under medical treatment. To a sound-bodied man there is no danger in drinking any quantity of cold water in the hottest weather, provided _it is swallowed slowly_. I have drunk as much as a dozen quarts in the course of a stiff mountain climb when perspiring profusely, and never suffered the slightest inconvenience, but, on the contrary, have found that the perspiration promoted by frequent and copious libations at the mountain streams enabled me to vigorously enjoy the roasting beat of sun-rays striking so freely and fiercely as they do through the thin air on the southward slopes of a high mountain. I am not a teetotaler, and enjoy a glass of light wine, but always take it as I sucked lollypops when a child, not because "it is good for my complaint," or any such humbug, but simply because I am so low in the scale of creation, as imperfect, as far from angelic, as to be capable of occasionally enjoying a certain amount of purely sensual indulgence, and of doing so from nothing higher than purely sensual motives. If all would admit this, and freely confess that their drinking or smoking, however moderate, is simply a folly or a vice, they would be far less liable to go to excess than when they befool themselves by inventing excuses that cover their weaknesses with a flimsy disguise of medicinal necessity, or other pretended advantage. In all such cases the physical mischief of the alcohol is supplemented by the moral corruption of habitual hypocrisy." _Knowledge_, August 18, 1882. DR. BURNEY YEO, M. D. "With regard to the effect of moderate doses of alcohol on mental work much difference of opinion exists. Many students find that, instead of helping them in their work, it hinders them. It dulls their receptive faculties. Others, on the contrary, find real help in moderate quantities of wine. These differences of effect would seem to depend greatly on differences in constitutional temperament. It is certainly capable, for a time, of calling some of the mental faculties into increased activity. Some of the best things that have ever been said have been said under the influence of wine. The circulation through the brain is quickened, the nervous tissue receives more nourishment, the imagination is stimulated, and ideas flow more rapidly, but it is doubtful if the power of close reasoning be not always diminished. It is useful for reviving mental power, when from accidental circumstances, such as want of food, &c., it has been exhausted, but it should never be relied upon as an aid to continuous effort or close application." _Fortnightly Review_. Vol. 21, p. 547. CONCLUSION. From a review of the 124 testimonies, including those which appear in the Appendix, I find that 25 use wine at dinner only; 30 are abstainers from all alcoholic liquors; 24 use tobacco, out of which only 12 smoke whilst at work; one chews and one took snuff. Not one resorts to alcohol for stimulus to thinking, and only two or three defend its use under special circumstances--"useful at a pinch," under "physical or mental exhaustion." "Not one resorts to alcohol" for inspiration. This is an important discovery, and indicates the existence of more enlightened views in reference to the value of alcohol, since Burns sang the praise of whisky:--"It kindles wit and weakens fear." That some literary men still "support" themselves by alcoholic stimulants, is no doubt true; and, if M. Taine is not mistaken, some of the leader writers of the London papers can write their articles only by the aid of a bottle of champagne. When the creative faculty flags, or the attention wanders, a writer, who is working against time, is strongly tempted to fly to stimulants for aid. But leader writing, or any other kind of writing, done under the influence of any kind of stimulants, is, remarks Blackie, unhealthy work, and tends to no good. "It may safely be affirmed," thinks the editor of the _Contemporary Review,_ "that no purely conscientious writing was ever produced under stimulation from alcohol. Harriet Martineau was one of those workers who could not write a paragraph without asking herself, 'Is that wholly true? Is it a good thing to say it? Shall I lead anyone astray by it? Had I better soften it down, or keep it back? Is it as well as I can say it?' Writing like that of Wilson's 'Noctes,' or Hoffman's madder stories, may be produced under the influence of wine, but 'stuff of the conscience', not." The workman himself is injured, as well as the quality of his work lessened. Mr. Hamerton says he has seen terrible results from the use of stimulants at work; and anyone who has read literary history, or who has had any experience of literary life in London, knows that the rock upon which many men split is--drink. Whatever journalists may gain from alcohol, other writers who have tried it say nothing in its favour. Mr. Howells does not take wine at all, because it weakens his work and his working force. To Mark Twain wine is a clog to the pen, not an inspiration. "I have," he says, "never seen the time when I could write to my satisfaction after drinking even one glass of wine." Dr. Bain finds abstinence from alcohol and the tea group essential to intellectual effort. They induce, he says, a false excitement, not compatible with severe application to problems of difficulty; and the experience of other workers, whether literary or scientific, is precisely similar. But the use of alcoholic stimulants at work is one thing; at dinner, another. The former practice is absolutely injurious; and the highest medical authorities have pronounced against the latter. Some of the most vigorous thinkers and laborious workers, however, find that wine aids digestion and conduces to their power of work. To Mr. Gladstone it is "especially necessary at the time of greatest intellectual exertion." As a rule, it is taken at the end of the day, when work is over; but when he resumes literary composition the quality of a writer's work seems deteriorated. One of the most esteemed novelists of the present day informs Dr. Brunton that, although he can take a great deal of wine without its having any apparent effect on him, yet a single glass of sherry is enough to take the fine edge off his intellect. He is able to write easily and fluently in the evening, after taking dinner and wine, but what he then writes will not bear his own criticism next morning, although curiously enough it may seem to him excellent at the time of writing. The perception of the fingers, as well as the perception of the mind, seems blunted by the use of alcohol. Dr. Alfred Carpenter relates that a celebrated violin player, as he was about to go on the platform, was asked if he would take a glass of wine before he appeared, "Oh, no, thank you," he replied, "I shall have it when I come off." This answer excited Mr. Carpenter's curiosity, and he inquired of the violinist why he would have it when he came off in preference to having it before his work commenced, and the reply was, "If I take stimulants before I go to work, the _perception of the fingers is blunted,_ and I don't feel that nicety and delicacy of touch necessary to bring out the fine tones requisite in this piece of music, and therefore I avoid them." "But to touch these things is dangerous, "says Mr. Hubert Bancroft, though less dangerous to touch them _after_ work than _before_ work. The most careful man is sometimes thrown off his guard, and drinks more than his usual allowance. It is, Mr. Watts believes, an admitted fact that even people who are considered strictly temperate habitually take more than is good for them. What quantity _is_ good for every man, no one can say with certainty. So far as wine is taken to aid digestion, Blackie, who considers that wine "may even be necessary to stimulate digestion," holds that "healthy _young_ men can never require such a stimulus." A belief exists that men who abstain from alcohol indulge to excess in some other stimulant. There is some foundation for this belief. Balzac, for instance, abstained from tobacco, which he declared injured the body, attacked the intellect, and stupefied the nations; but he drank great quantities of coffee, which produced the terrible nervous disease which shortened his life. Goethe was a non-smoker, but, according to Bayard Taylor, he drank fifty thousand bottles of wine in his life-time. Niebuhr greatly disliked smoking, but took a tremendous quantity of snuff. A great number of teetotalers "make up for their abstinence from alcohol by excessive indulgence in tobacco," and abuse their more consistent brethren who venture to expostulate with them. John Stuart Mill "believed that the giving up of wine would be apt to be followed by taking more food than was necessary, merely for the sake of stimulation." Sir Theodore Martin, also, thinks the absence of alcohol likely to lead to increased eating, and to an extent likely to cause derangement of the body. The power of alcohol to arrest and preserve decomposition may, it is admitted by temperance writers, retard to some extent the waste of animal tissue, and diminish accordingly the appetite for food; but they contend that the effete matter which has served its purpose and done for the body all that it can do is retained in the body to its loss and damage. "The question comes to be," says Professor Miller, "whether shall we take alcohol, eat less, and be improperly nourished, or take no alcohol, eat more, and be nourished well? Whether shall we thrive better on a small quantity of new nutritive material with a great deal of what is old and mouldy, or on a constant and fresh supply of new material? ... The most perfect health and strength depend on frequent and complete disintegration of tissue with a corresponding constant and complete replacement of the effete parts by the formation of new material." "This is not a question which can be settled by reasoning: it must be decided entirely by experience. No one who has always been in the habit of using stimulants can be heard on this point, because, having had no experience of life without alcohol, such a person cannot draw a comparison between life with and life without that agent." These are the words of Dr. Buckle, of London, Ontario, and this practical way of testing the question will commend itself to all. What is the experience, then, of those who have tried both moderation and total abstinence? The Rev. Canon Farrar found that "even a single glass of wine, when engaged in laborious work, was rather injurious than otherwise." Mr. A. J. Ellis did not find that wine increased his power of work, and Professor Skeat says the less stimulant he takes the better. Contrary to medical advice, Dr. Martineau reverted to abstinence, and for twelve or fifteen years he has been practically a total abstainer, and, at 77, he retains the power of mental application. For many years, the Rev. Mark Pattison found great advantage from giving up wine. Lieutenant-Colonel Butler finds that a greater amount of _even_ mental work is to be obtained without the use of alcohol. The belief that alcohol invigorated the body was held by Mr. Cornelius Walford, but he now finds that it does not do so, and believes that in sedentary occupations it is positively injurious even when taken with meals. Professor Skeat has given up beer with benefit to himself, and has almost given up wine. M. Barthelemy St. Hilaire has abstained from wine for many years, indeed, for nearly a life-time, with great advantage. Mr. Hamerton has abstained for long periods from stimulants, feeling better without them. Mr. Oliver Wendell Holmes's practice approaches nearer to abstinence as he grows older. The Bishop of Durham finds that, on the whole, he can work for more consecutive hours, and with greater application, than when he used stimulants. This, too, is the testimony of Bishop Temple. The Rev. Stopford Brooke is enthusiastic in his praise of total abstinence: it has enabled him to work better; it has increased the pleasure of life; and it has banished depression. Sir Henry Thompson declares himself better without wine, and better able to accomplish his work. Dr. Richardson declares that he never did more work, or more varied work; that he never did work with so much facility, or with such a complete sense of freedom from anxiety and worry as he has done during the period he has abstained from alcohol. On the other hand, Sir Erskine May's experience of abstinence was that it made him "dyspeptic and stupid;" and Dr. W. B. Carpenter "can get on best, while in London, by taking with his dinner a couple of glasses of very light claret, as an aid to digestion." But when on holiday, he says, he does not need it. A _natural_ stimulant then takes the place of an artificial one; and so long as a man is healthy, eating well, and sleeping well, he is, Dr. Brunton declares, better without alcohol. Although there is no comparison between the evils of smoking and those of drinking, most of the writers seem to attach more importance to the question of smoking, and some regard the question of alcohol as of no consequence. Mr. Cornelius Walford considers tobacco a more insidious stimulant than alcoholic beverages. It can, he points out, be indulged in constantly without visible degradation; but surely it saps the mind. Mr. Hyde Clarke is of the same opinion, and remarks, "a man knows when he is drunk, but he does not know when he has smoked too much, until the effects of accumulation have made themselves permanent." There is a growing conviction that tobacco does quite as much harm to the nervous system as alcohol. [Footnote: There can be no room to question the presumption that an excessive use of tobacco _does_ occasionally deteriorate the moral character, as the inordinate use of chloral or bromide of potassium may deprave the mind, by lowering the tone of certain of the nervous centres, in narcotising them and impairing their nutrition. Whether the nicotine of the tobacco can act on nerve-cells as alcohol acts may be doubtful, but the victim of excess in the use of tobacco certainly often very closely resembles the habitual drinker of small drams--the tippler who seldom becomes actually drunk--and he readily falls into the same maudlin state as that which seems characteristic of the subject of slow intoxication by chloral, or of the victim of bromide.--_The Lancet_, Nov. 12, 1881.] The question is often asked, "Does tobacco shorten life?" No evidence has yet been adduced proving that moderate smoking is injurious, though Sir Benjamin Brodie believed that, if accurate statistics could be obtained, it would be found that the value of life in inveterate smokers is considerably below the average; and the early deaths of some of the men whose names are so frequently quoted in defence of smoking, favours the idea that all smoking is injurious. Few literary men live out their days. It is a matter of general belief that Mr. Edward Miall weakened his body and shortened his life through his habit of incessant smoking. "Bayard Taylor," says Mr. James Parton, "was always laughing at me for the articles which I wrote in the _Atlantic Monthly_, one called 'Does it pay to smoke?' and the other, 'Will the Coming Man drink Wine?' I had ventured to answer both these questions in the negative. He, on the contrary, not only drank wine in moderation, but smoked freely, and he was accustomed to point to his fine proportions and rosy cheeks, comparing them with my own meagre form, as an argument for the use of those stimulants. 'Well,' he would say, on meeting me, glancing down at his portly person, and opening wide his arms, with a cigar in his fingers, 'doesn't it pay to smoke? How does _this_ look? The coming man may do as he likes; but the man of the present finds it salutary."' Commenting on Mr. Taylor's early death, Mr. Parton points out that some fifty New York journalists have either died in their prime or before reaching their prime. A similar mortality, he notes, has been observed in England. Dickens died at 58, and Thackeray at 52. A "great number of lesser lights have been extinguished that promised to burn with long-increasing brightness." Mr. Parton asks, "Is there anything in mental labour hostile to life? Was it over-work that shortened the lives of these valuable and interesting men?" He thinks not, but that they died before their time because they did not know how to live. Like Carlyle, William Howitt was scandalised by the tippling habits of some of the literary men whom he met, and equally scandalised by their smoking habits. Replying to a correspondent who urged that most literary men and artists smoke, he said, "No doubt; and that is what makes the lives of literary men and artists comparatively so short. May not too much joviality and too much smoking have a good deal to do with it? I myself, who have not smoked for these seventy years, have seen nearly the whole generation of my literary contemporaries pass away. The other day (Dec. 7, 1878), I ascended in the Tyrol, a mountain of 5,000 feet, inducting a walk of six or seven miles to it, and as many back, in company with some friends. I did it easily, and felt no subsequent fatigue. I would like to see an old smoker of eighty-six do 'that." There can be no doubt that excessive smoking is one of the causes of the early deaths of literary men, though not the greatest The opponents of tobacco have tried to make capital out of the early death of Jules Noriac, who is reported to have died of smoker's cancer; but it transpired that he lived very irregularly. [Footnote: Considerable difference of opinion would appear to exist among the "chroniqueurs" of the Parisian press as to the real nature of the malady to which M. Jules Noriac, the witty, humorous, and observant writer of "The Hundred and First Regiment," the essay on "Human Stupidity," and numerous dramatic pieces of a more or less ephemeral kind, has just fallen a victim. It has been generally understood that M. Noriac died from a mysterious malady which has not long since been recognised by French physicians as the "smoker's cancer." It is alleged that the deceased man of letters suffered for two whole years from the ravages of this dreadful and occult disease, and that his countenance became so transformed through the wasting action of the ailment that he could scarcely be recognised even by his most intimate friends. This statement, could it be substantiated, would serve as a very powerful argument to those who inveigh against the use of tobacco. Hitherto the fundamental point on which the opponents of the weed have dwelt is that as the active principle of tobacco, nicotine, is acknowledged to be in its isolated form a poison, its introduction into the system in any shape or form must be injurious, and that it is difficult to point to any human organ which may not be detrimentally affected by smoking, snuffing, or chewing. From a cognate point of view, it is worthy of remark that a contemporary, in a curiously interesting study of the originals of the characters in the famous "Scenes de la Vie de Boheme," draws attention to the circumstance that Henri Murger's consumption of coffee was so excessive as to bring on fever and delirium. Exhaustion and nervousness followed; and finally he was attacked by an obscure disorder of the sympathetic nerves which control the veins, at times turning his whole body to the colour of purple. The doctors who treated him seem to have known nothing of the ailment, for they dosed him with sulphur and aconite. He died a horrible--and very painful death, at the age of thirty-eight. This was in 1860; but only four years afterwards we find the English physician quoted above, Dr. Anstie, in his "Stimulants and Narcotics," recognising "a kind of chronic narcotism, the very existence of which is usually ignored, but which is, in truth, well marked and easy to identify as produced by habitual excess in tea and coffee." The common feature of the disease is muscular tumour; and out of fifty excessive consumers of tea and coffee whose cases were noted by Dr. Anstie, there were only five patients who did not exhibit the symptom named. They were suffering, in fact, from "theine" poisoning. The paralysing effects of narcotic doses of tea was further displayed by a particularly obstinate kind of dyspepsia; while the abuse of coffee disordered the action of the heart to a distressing degree. The friends and biographers of M. Jules Noriac are unanimous as to the fact that he was inveterate in the use of tobacco. He was wont to smoke to the butt-end, one after the other, the huge cigars sold by the French "Regie," and known as "Imperiales," and a cynic might opine that if the deceased gentleman had smoked fragrant Havanas in lieu of the abominable stuff vended by the "Regie" he would not have been afflicted with the "cancer des fumeurs," nor with any kindred ailment He kept fearfully late hours, he worked only at night and he smoked "all the time." If towards morning he felt somewhat faint he would refresh himself with crusts of bread soaked in cold water, thus imitating to a certain extent our William Ptynne, who would from time to time momentarily suspend his interminable scribble to recruit exhausted nature with a moistened crust; only the verbose author of "Histriomastix" used to dip his crusts in Strong ale. And the bitter old pamphleteer, for all that his ears had been cropped and his cheeks branded by the Star Chamber, lived to be nearly seventy. Jules Noriac was never to be seen abroad until noon. His breakfast, like that of most Frenchmen, was inordinately prolonged; and afterwards rehearsals, business interviews, dinner, and the play would occupy him until nearly midnight. His delight was to accompany some friend home, and then walk the friend, arm-in-arm, backwards and forwards in front of his, the friend's, door, discoursing of things sublunary and otherwise until two in the morning. Then he would enter his own house and sit down, pipe in mouth, to the hard labour of literature until six or seven in the morning. What kind of slumber could a man, leading such a life as this, be expected to enjoy? On the whole, it would appear that M. Jules Noriac's habits were diametrically opposed to the preservation of health and the prolongation of life, and that he died quite as much from too much Boulevard and too much night work, as from too much smoking. There are vast numbers of French journalists and men of letters who, without being necessarily "Bohemians," consume their health and shorten their lives by this continuous and feverish race against time. Their days are spent chiefly on the Boulevards or in the cafes, and it is only at the dead of night that they devote themselves to serious work. The French "savant," On the other hand, is rarely seen on the Boulevards. It is by day that he works, and he spends his evening in some tranquil "salon," and lives, as a rule, till eighty. The painter, again, must be a day worker, if he wishes to excel as a colourist. He is but a holiday "flaneur" on the Boulevards. They are but a part of his life; but of the "chroniqueur" and the "feuilletonniste" out of the small hours devoted to fagging at the production of "copy," those Boulevards are the whole existence.--_Daily Telegraph_, October 9, 1882.] On the other hand, the advocates of tobacco cite Carlyle as a proof that tobacco does not shorten life. They credit him with saying that he could never think of this miraculous blessing without being overwhelmed by a tenderness for which he could find no adequate expression. No wonder, therefore, that he called his doctor a "Jackass," who advised him to give up smoking in order to cure dyspepsia. In Carlyle's case long life was a doubtful advantage, and in the matter of smoking he did not practice what he preached. [Footnote: Describing the German Smoking Congress, he said:--Tobacco, introduced by the Swedish soldiers in the Thirty-years' War, say some, or even by the English soldiers in the Bohemian or Palatine beginnings of said war, say others, tobacco once shown them, was enthusiastically adopted by the German populations, long in want of such an article, and has done important multifarious functions in that country ever since. For truly in politics, morality, and all departments of their practical and speculative affairs we may trace its influences, good and bad, to this day. Influences generally bad; pacificatory but bad, engaging you in idle, cloudy dreams; still worse, promoting composure among the palpably chaotic and discomposed; soothing all things into lazy peace; that all things may be left to themselves very much, and to the laws of gravity and decomposition. Whereby German affairs are come to be greatly overgrown with funguses in our time, and give symptoms of dry and of wet rot wherever handled.--_History of Frederick the Great,_ vol. I, p. 387.] Many cases are known to us, however, where dyspepsia in smokers has been completely cured by the abandonment of smoking. The most recent case is that of Dr. Richardson, who was a dyspeptic during the whole time he was a smoker. "At length," he says, "I resolved to give up smoking. It was hard work to do so, but I eventually succeeded, and I have never been more thankful than for the day on which it was accomplished." In Carlyle's case a six months' abstinence could not drive out his enemy, which he declared was the cause of nine-tenths of his misery. A more successful illustration of the "harmlessness" of stimulants is supplied in Mr. Augustus Mongredien, well-known as an able expositor of the principles of Free Trade. He is now 75 years of age, and has smoked moderately all his life, and for the last fifty years has never, except in rare and short instances of illness, retired to bed without one tumbler of whiskey-toddy. But this is an exceptional case of longevity. All the evidence favours the opinion that tobacco, like alcohol, shortens life. It is certain that abstinence is beneficial, as shown by the long lives of some of our hardest brain-workers. It is worthy of note, too, that all the tough old Frenchmen still in the enjoyment of unimpaired mental faculties never smoked. M. Dufaure, M. Barthelemy St. Hilaire, Victor Hugo, M. Etienne Arago, brother of the astronomer, Abbe Moigno, belong to the non-smoking school of public men. So did M. Thiers, M. Guizot, M. Cremieux, M. Raspail, and the octogenarian, Comte Benoit-D'Azy, who died in full possession of his mental faculties. Reference has been made to idiosyncrasy, a matter of great importance, which should be borne in mind when considering the influence of any habit on the organism, whether animal or human. Professor Christison cites a remarkable case in which a gentleman unaccustomed to the use of opium took nearly an ounce of laudanum without any effect. This form of idiosyncrasy is very rare. Not only are some constitutions able to bear large doses of poison, but others cannot take certain kinds of food. Milk, for instance, cannot be taken by one person; pork by a second; porridge by a third. In the use of the various stimulants, as in the use of the various foods, the Same difference prevails among men. "The more I see of life," says Sir Henry Thompson, "the more I see that we cannot lay down rigid dogmas for everybody;" and I have come to the same conclusion that it is unsafe to make one man's experience another man's guide. Kant could work eight hours a day after drinking a cup of tea and smoking a pipe of tobacco. Professor Mayor finds that a day or two's fasting does him no harm, and he thrives on "dry bread and water." Professor Boyd Dawkins finds quinine the best stimulant; Darwin found a stimulant in snuff; Edison finds one in chewing; Professor Haeckel finds coffee the best, and Mr. Francillon and Mark Twain bear testimony to the value of smoking. These differences point to the conclusion that the same rules cannot be laid down for all. One thing is clear, however, that our best writers, clearest thinkers, and greatest scholars do not regard the use of alcohol as essential to thinking, and very few find tobacco an aid. With one or two exceptions, the writers take care to minimise the dangers incurred in the use of stimulants. Though they smoke, they smoke the weakest tobacco; though they drink, they drink only at meals. They work in the day time, take plenty of out-door exercise, and rest when they are tired. Many regard tobacco as a snare and a delusion; and all regard it as unnecessary for the brain of the youthful student. The greatest workers and thinkers of the middle ages, Dr. Russell remarks, never used it; [Footnote: Homer sang his deathless song, Raphael painted his glorious Madonnas, Luther preached, Guttenberg printed, Columbus discovered a New World before tobacco was heard of. No rations of tobacco were served out to the heroes of Thermopylae, no cigar strung up the nerves of Socrates. Empires rose and fell, men lived and loved and died during long ages, without tobacco. History was for the most part written before its appearance. "It is the solace, the aider, the familiar spirit of the thinker," cries the apologist; yet Plato the Divine thought without its aid, Augustine described the glories of God's city, Dante sang his majestic melancholy song, Savonarola reasoned and died, Alfred ruled well and wisely without it. Tyrtaeus sang his patriotic song, Roger Bacon dived deep into Nature's secrets, the wise Stagirite sounded the depths of human wisdom, equally unaided by it Harmodius and Aristogeiton twined the myrtle round their swords, and slew the tyrant of their fatherland, without its inspiration. In a word, kings ruled, poets sung, artists painted, patriots bled, martyrs suffered, thinkers reasoned, before it was known or dreamed of.--_Quarterly Journal of Science_, 1873.] and Mr. Watts thinks that its introduction by civilised races has been an unmixed evil. It is a remarkable fact that out of 20 men of science, only two smoke, one of whom, Professor Huxley, did not commence until he was forty years of age. Even among those who smoke there is a considerable difference in the times chosen for smoking. Though the Rev. A. Plummer declares himself a firm believer in the use of tobacco, he smokes _before_ work, _after_ work, rarely while at work. Mr. Wilkie Collins smokes after work, and Mr. James Payn smokes all the time he is working. Mr. Francillon's consumption of tobacco, and his power of work, are in almost exact proportion. Similar testimony comes from Mark Twain. Assuming that the prince of American humorists is not joking, his experience of cigar-smoking is unique. When Charles Lamb was asked how he had acquired the art of smoking, he answered, "By toiling after it as some men toil after virtue." I hope that young smokers will not conclude that by following the example of Mark Twain, their brain will become as fertile as his. To them tobacco is bad in any form. It poisons their blood, stunts their growth, weakens the mind, and makes them lazy. "It is not easy," says Mr. Ruskin, "to estimate the demoralizing effect of the cigar on the youth of Europe in enabling them to pass their time happily in idleness." It has been forbidden at Annapolis, the Naval School, and at West Point, the Military Academy of the United States, having been found injurious to the health, discipline, and power of study of the students. "At Harvard College," says Dr. Dio Lewis, "no young man addicted to the use of tobacco has graduated at the head of his class;" and at the lycees of Douai, Saint Quentin, and Chambery it has been found that the smokers are inferior to non-smokers. No public enquiry has yet been made as to the influence of tobacco upon English youths, but I am assured by several leading schoolmasters that the smokers are invariably the worst scholars. It cannot be too widely known, therefore, that tobacco, like alcohol, is of no advantage to a healthy student, and I advise young men to avoid it altogether. Darwin regretted that he had acquired the habit of snuff taking, and Mr. Sala says that had he his life to live over again, he would never touch tobacco in any shape or form. Never begun, never needed. "I do not advise you, young man," says Oliver Wendell Holmes, "to consecrate the flower of your life to painting the bowl of a pipe, for, let me assure you, the stain of a reverie-breeding narcotic may strike deeper than you think. I have seen the green leaf of early promise grown brown before its time under such nicotian regimen, and thought the amber'd meerschaum was dearly bought at the cost of a brain enfeebled and a will enslaved." My conclusions, then, are as follows:-- 1.--Alcohol and tobacco are no value to a healthy student. 2.--That the most vigorous thinkers and hardest workers abstain from both stimulants. 3.--That those who have tried both moderation and total abstinence find the latter the more healthful practice. 4.--That almost every brain-worker would be the better for abstinence. 5.--That the most abstruse calculations may be made, and the most laborious mental work performed, without artificial stimulus. 6.--That all work done under the influence of _alcohol_ is unhealthy work. 7.--That the only pure brain stimulants are _external_ ones-- fresh air, cold water; walking, riding, and other out-door exercises. INDEX. Abstinence and dyspepsia Do. benefits of Alcohol dangerous Do. a stupefier Do. and speech-making Do. not a necessity Do. hurtful to the liver Do. a restorative Do. useful under exceptional circumstances Do. and digestion Do. as a medicine Do. and gout Do. bad for rheumatism Do. as a soother Do. as a stimulant to the brain Do. necessity of, to aid the subsidence of the brain Do. abstinence from, followed by over-eating Do. and longevity Air, fresh, importance of American boys, tobacco forbidden to Athletics, love of Balzac quoted Best time for working Brain-work non-natural Brain-work and biliousness Byron's temperament Carlyle, inconsistency of Carpenter, Dr. Alfred, quoted Chewing as a stimulant City life, exhausting and unwholesome nature of Cobbett's abstemiousness Coffee, a slow poison Do. as a stimulant College drunkenness Conscientious writing Country pursuits, value of Depression, the remedy for Drunkards among literary men Dyspepsia, cures for Early rising, value of Exercise, importance of, to brain-workers Eyesight injured by alcohol and tobacco French boys, smoking forbidden to Do. literature, the cause of the sickly productions in Frenchmen, a group of old Genius and alcohol German smokers Goethe quoted Gout and alcohol Hoffman's stories Howard's, John, abstemiousness Hugo, Victor, value of fresh air to Holmes, Oliver Wendell, quoted Idiosyncracy Idleness induced by smoking Do. do. drinking Imagination, the, stimulated by tobacco Indigestion and smoking Infection, tobacco a protection against Johnson, Dr., a glutton Journalists, use of alcohol by Juvenile smoking, evils of Lamb, Charles, quoted Leisure, how to gain Life, agreeableness of, promoted by the use of alcohol Do. do. do. non-use of alcohol Literary life in London, dangers of Longevity and alcohol Do. and tobacco Lynch, T. T., quoted Manzoni and nervous distraction Mill, John Stuart, practice of Miall, Edward, an incessant smoker Mortality of literary men Nervous excitement and composition Niebuhr's habits Night thoughts Night work, value of Noriac, Jules, habits of Opium, use of, by literary men Pain no drawback to mental work Parton, James, quoted Permissive Bill Physicians, advice of, to brain-workers Quinine as a stimulant Riding, value of Rules, impossibility of laying down, for all Ruskin, Mr., quoted Sleep the best stimulant Smoking, first effects of Smoking and working Smoking and digestion Smoking a sedative Do. a vile and odious practice Do. a cure for excitable nerves Do. a disinfectant Do. a greater evil than drinking Smoke drunk Smoking and longevity Snuff as a stimulant Snuff-taking and the memory Speech-making and alcohol Stimulants and unhealthy work Do. reactionary Do. a judicious use of Do. a taste for, imparted to children Taylor, Bayard, quoted Tea, effects of Teetotalism, a generator of due disease Thackeray, value of alcohol to Tobacco, soothing influences of Tobacco and exposure Do. and nerve Do. cost of Do. and longevity Do. and sleeplessness Do. and the memory Travelling, benefits of Vegetarianism, practice of Walking, value of Webster, Daniel, value of alcohol to Wilson's "Noctes," how produced Wordsworth on poetic excitement Wesley's abstemiousness Working, best time for Youths injured by smoking 
47439	----	THE NEW GLUTTON OR EPICURE HORACE FLETCHER'S WORKS THE A. B.-Z. OF OUR OWN NUTRITION. 462 pp. THE NEW MENTICULTURE; OR, THE A-B-C OF TRUE LIVING. Forty-fifth thousand. 310 pp. THE NEW GLUTTON OR EPICURE; OR, ECONOMIC NUTRITION. 344 pp. HAPPINESS AS FOUND IN FORETHOUGHT MINUS FEARTHOUGHT. Tenth thousand. 251 pp. THAT LAST WAIF; OR, SOCIAL QUARANTINE. 270 pp. THE NEW GLUTTON OR EPICURE BY HORACE FLETCHER NEW YORK FREDERICK A. STOKES COMPANY 1906 COPYRIGHT, 1899, 1903 BY HORACE FLETCHER Published November, 1903 Reprinted October, 1904, September, 1905 December, 1905 THE UNIVERSITY PRESS CAMBRIDGE · U. S. A. PREFACE The original "Glutton or Epicure" has been completely revised and much enlarged, including considerable new matter added in the form of testimony by competent investigators, which confirms the original claims of the book and supplements them with important suggestions. The "New Glutton or Epicure" is now issued as a companion volume to the "A.B.-Z. of Our Own Nutrition," in the "A. B. C. Series," and is intended to broaden the illustration of the necessity of dietetic economy in the pursuit of an easy way to successful living, in a manner calculated to appeal to a variety of readers; and wherein it may suggest the scrappiness and extravagance of an intemperate screed, the author joins in the criticism of the purists and offers in apology the excuse that so-called screeds sometimes attract attention where more sober statement fails to be heard. Especial attention is invited to the "Explanation of the A.B.C. Series," at the back of this volume, as showing the desirability of regard for environment in all its phases; and also to the section, "Tell-tale Excreta," on page 142, an evidence of right or faulty feeding persistently neglected heretofore, but of utmost importance in a broad study of the nutrition problem. The professional approval of Drs. Van Someren, Higgins, Kellogg, and Dewey, representing wide differences of points of view and opportunity of application, are most valuable contributions to the subject. The confirmation of high physiological authority strengthens this professional endorsement. The testimony of lay colleagues given is equally valuable and comes from widely separated experiences, and from observers whose evidence carries great weight. The commandante of a battleship cruising in foreign waters and representing the national descent of Luigi Cornaro; a general manager of one of the largest insurance companies of the world; a cosmopolitan artist of American farm birth and French matrimonial choice and residence; and a distinguished _bon vivant_, each with a world of experience, testifying in their own manner of expression, is appreciated as most valuable assistance to the cause of economic dietetic reform. During the original experiments in Chicago, and in Dayton, Ohio, the originator was much indebted to James H. Lacey, Esquire, of New Orleans, La., and Cedar Rapids, for helpful suggestions, which his early training as a pharmaceutical chemist rendered him able to give. There are also numerous altruistic, self-sacrificing women, who have been active colleagues of the author in testing the virtues of an economic nutrition, and who have greatly assisted in making the economy an added new pleasure of life, instead of being a restraint or a deprivation. This is accomplished easily by a change of attitude towards the question, and in such reform women must have an important part to play. To their kindly meant, but hygienically unwise, aggressive hospitality, in begging friends to eat and drink more than they want, just to satisfy their own generous impulses, is due much of the milder gluttony that is prevalent. Imposition upon the body of any excess of food or drink is one of the most dangerous and far-reaching of self-abuses; because whatever the body has no need of at the moment must be gotten rid of at the expense of much valuable energy taken away from brain-service. Hence it is that when there is intestinal constipation the energy-reserve is lowered enormously, and even where there is no painful obstruction, the mere passage of waste through some twenty to twenty-five feet of convoluted intestinal canal is a great tax upon available mental and physical power; and this disability is often imposed on innocent men by well-meaning women in the exercise of a too aggressive hospitality. Mention of constipation suggests another reference to one of the specially new features of this discussion, insisted upon by a truly economic and æsthetic nutrition, and herein lifted out of the depths of a morbid prejudice to testify to the necessity of care in the manner of taking food for the maintenance of a respectable self-respect. So firmly rooted is the fallacy that a daily generous defecation is necessary to health that less frequent periodicity is looked upon with alarm, whereas a normally economic nutrition is _proven_ by greater infrequency, accompanied by an entire absence of difficulty in defecating and by escape from the usual putridity due to the necessity of bacterial decomposition. To illustrate the prevailing ignorance relative to this most important necessity of self-care, and also a traditional prejudice, even among physicians, the following extract from a letter just received is given: "You ask me to define more exactly what I mean by constipation; this is not at all difficult; I mean skipping a day in having a call to stool. There was no trouble about it, and the quantity was not large, but when I mentioned it to my doctor he advised me to stop chewing if it interfered with the regular daily stools. I must confess that I never felt so well as while I was chewing and sipping, instead of the hasty bolting and gulping which one is apt to do on thoughtless or busy occasions, but I don't think it is worth while for a chap to monkey with his hygienic department when he is employing a professional regularly to tell him the latest kink about health." To this surprising state of ... the evidence of "professionals" like Van Someren, Kellogg, Higgins, and Dewey, as well as that of the great men of physiology who have spoken herein, and in the "A.B.-Z. of Our Own Nutrition," gives hopeful answer, but suggests a warning. The author has noticed that immediately folk begin to give attention to any new _régime_ relative to diet, exercise, mental discipline, or whatever else, they begin to charge all unusual happenings to the change of habit, whereas before the same things were common but unnoticed. Even among men of scientific habit of thought, unduly constipated by stale conservatism, the old, old corpse of tradition, "The accumulated experience of the whole race must be correct," is revived and used in argument contentiously; but to this relapse into non-scientific reasoning comes the reply: "If the accumulated experience of the human race is evidence that crime and disease are natural, then disease and crime are good things and should not be discouraged." There are many sorts of constipation, the worst of which are constipation of affection, of appreciation, of gratitude, and of all the constructive virtues which constitute true altruism. Let us avoid sinning in this regard! In pursuit of this thought the following is _àpropos_: SPECIAL RECOGNITION The author wishes here, also, to express gratitude to many who have not figured by name in the "A.B.-Z.," or elsewhere herein, but whose assistance, encouragement, criticism, and example have helped the cause along in one way or another. Of these many friends a few are quickly recalled, but not necessarily in the order of their friendly service. To John H. Patterson, Esquire, of Dayton, Ohio; Col. James F. O'Shaughnessy, of New York; Stewart Chisholm, Esquire, of Cleveland, Ohio; Fred E. Wadsworth, Esquire, of Detroit, Michigan; and Henry C. Butcher, Esquire, of Philadelphia, are due much for encouragement in pursuing the investigation at critical moments of the struggle; as well as to Hon. William J. Van Patten, of Burlington, Vermont, whose interest in the "A.B.C. Series" began with "Menticulture" and has continued unabated. In Dr. Swan M. Burnett, of Washington, D. C., has been enjoyed a mentor with great scientific discrimination and a sympathy in the refinements of art and sentiment, as expressed in Japanese æsthetic civilisation, which has been extremely encouraging and most inspiring in relation to the whole A.B.C. idea. From Gervais Kerr, Esquire, of Venice, came one of the important suggestions incorporated in the A.B.-Z. Primer; and the young Venetian artist, E. C. Leon Boehm, rendered great service in studying habits of dietetics among the peoples of the Balkan Peninsular, in Turkey, along the Dalmatian Coast, and in Croatia. Prof. William James, of Harvard University, in his Gifford Lectures at the University of Edinburg, Scotland, published under the title of "The Varieties of Religious Experience," gave the practical reformatory effort of the "A.B.C. Series" a great impetus by quoting approvingly from "Menticulture" and "Happiness." Coming from a teacher of philosophy and psychology, with a physiological training and an M.D. degree to support the approval, recognition is much appreciated; but, in addition to his published utterances, Dr. James has followed the psycho-physiological studies of the movement with interest, and has given much valued encouragement. This does not begin to complete the list of those to whom the author owes a debt of especial gratitude. The argus-eyed vigilance of the collectors and doctors of world-news, who mould public opinion in a great measure, has brought to the cause of dietetic reform established upon an æsthetic basis their kindly assistance, but, as usual, they prefer to remain _incog._ In this seclusion, however, Ralph D. Blumenfeld, Esquire, of London, and Roswell Martin Field, Esquire, of Chicago, cannot be included; neither can Charles Jay Taylor, the originator of the Taylor-Maid girl. James P. Reilly, Esquire, of New York, has lightened the labours of the investigator, and has strengthened his arm in many ways; as have also Messrs. B. F. Stevens and Brown, of London, not alone as most efficient agents, but as friends interested in the cause in hand. In the various books of the series opportunity has occurred to express appreciation of many sympathetic friendships, and in heart and memory they hold perpetual carnival. To Major Thomas E. Davis, of the _New Orleans Picayune_, is due more than mere expression of gratitude for excellent editorials on our subject; and across the ocean, Sir Thomas Barlow, the private physician of King Edward VII, Dr. Leonard Huxley, Prof. Alfred Marshall, of Cambridge University, and Reginald Barratt, Esquire, of London, have been most sympathetic and assistful. On both sides of the waters, William Dana Orcutt, Esquire, of The University Press, Cambridge, Massachusetts, and Frederick A. Stokes, Esquire, of New York, have added friendship for the cause to much appreciated practical assistance. These and many others are preferred-creditors of gratitude, in addition to those whose mention is embodied elsewhere in the various books of the "Series." As attempted to be shown in the "A.B.-Z.," under the caption "Bunching Hits and Personal Umpiring," this study of menticulture from the basis of economic and epicurean nutrition, in connection with a purified exterior and interior environment, is "team-work," as in football, cricket, or base-ball, and a laudable enthusiasm is an important feature of the game; hence, to conclude, this especial book, being a personal confession, relaxation, effusion, expansion, as it were, of the practical benefits of economic body nutrition and _menti-nutrition_, it seems the appropriate place to offer personal tribute outside and inside the intimate family relations, as freely as menticultural impulse may suggest. HORACE FLETCHER. PREFACE TO 1906 EDITIONS Since the former introductions were written much success has been attained in further advancing the reforms advocated in the _A. B. C. Life Series_. Professor Chittenden has published his report on the Yale experiments in book form in both America[1] and England,[2] and his results have been accepted in scientific circles the world over as authoritatively conclusive. [Footnote 1: Physiological Economy in Nutrition: The Frederick A. Stokes Company, New York.] [Footnote 2: William Heinemann: London.] At the present writing the most important Health Boards of Europe[3] are planning to put the new standards of dietary economy into practical use among public charges in a manner that can only result in benefit to the wards of the nations as well as make an important saving to the taxpayers. In the most important of these foreign public health departments the Health Officer of the Board has himself practised the newly established economy for two years, and his plans are formulated on personal experience which fully confirms Professor Chittenden's report and that of the author as herein related. [Footnote 3: The author is not yet permitted to publish the particulars of these reforms in process, but he has official information regarding them and is in full sympathy with them.] At a missionary agricultural college, situated near Nashville, Tenn., where the students earn their tuition and their board while pursuing their studies, a six months' test of what is termed "Fletcherism" resulted in a saving of about one half of the drafts on the commissary, immunity from illness, increased energy, strength and endurance, and general adoption of the suggestions published in the several books of the author included in the _A. B. C. Life Series_. In the various departments and branches of the Battle Creek Sanitarium in America, and widely scattered over the world, some eight hundred employees and thousands of patients have been accumulating evidence of the efficacy of "Fletcherism" for more than three years, and scarce a month passes without a letter from Dr. Kellogg to the author containing new testimony confirming the _A. B. C._ selections and suggestions. The author has received within the past two years more than a thousand letters bearing the approval of the writers with report of benefits received which seem almost miraculous, and these include the leaders in many branches of human occupation--physiologists, surgeons, medical practitioners, artists, business men, literary workers, athletes, working men and women, and almost every degree of mental and physical activity. One of the medical advisers of King Edward, of whom the King once said: "He is a splendid doctor but a poor courtier," follows the suggestions of these books in prescribing to his sumptuous clients. CONTENTS PAGE PREFACE i SPECIAL RECOGNITION xii THE NEW GLUTTON OR EPICURE 1 THE PERSONAL CASE AND ENDORSEMENT OF DR. ERNEST VAN SOMEREN 10 EXPERIMENTS UPON HUMAN NUTRITION. NOTE BY SIR MICHAEL FOSTER, K.C.B., M.P., F.R.S. 18 PROFESSOR CHITTENDEN'S REPORT ON THE AUTHOR 25 'VARSITY-CREW EXERCISES UNDER DR. WILLIAM G. ANDERSON, OF YALE UNIVERSITY GYMNASIUM 32 THE ATWATER-BENEDICT CALORIMETER-MEASUREMENT 39 MILITARY-SCIENTIFIC COÖPERATION 42 DR. KELLOGG'S APPRECIATION 46 EXTRACTS FROM DR. EDWARD HOOKER DEWEY 73 AN AGREEABLE ENDURANCE TEST 84 EDWARD W. REDFIELD'S EVIDENCE 90 GENERAL OBSERVATIONS 101 OUR NATURAL GUARDIANS 106 OBJECTIONS CONSIDERED 117 THE MIND POWER-PLANT 132 TELL-TALE EXCRETA 142 SCIENTIFIC OBSERVATION OF A LITERARY TEST-SUBJECT 147 WHAT SENSE? TASTE 151 DR. MONKS, BOSTON; AND PROF. METCHNIKOFF, PARIS;--ELONGATED INTESTINES 176 AUTHOR'S PERSONAL EXPERIENCE 188 SOME PERTINENT QUERIES 195 IMPORTANT CONFIRMATION: COMMANDANTE CESARE AGNELLI 206 CLARENCE F. LOW, ESQUIRE 211 A FIVE YEARS' LAY EXPERIENCE: BARON RANDOLPH NATILI 215 DR. HUBERT HIGGINS' CASE AND COMMENT 226 QUARANTINE 236 GIVE THE BABIES A CHANCE 265 "MUNCHING PARTIES" AND THE "CHEWING FAD" 270 SPECIMEN ECONOMIC DINNER 283 DIET IN THE YALE EXAMINATION OF THE AUTHOR 296 INFLUENCE OF SUGGESTION 300 "FLETCHERISING:" COMPLETE MEANING 308 EXPLANATION OF THE A. B. C. SERIES 315 THE NEW GLUTTON OR EPICURE It is now five years since the first section of this crude little announcement of a great physiological discovery was published; and while the author has spent all the intervening years in unremitting study of the subject of which it treats, with the heads of many of the great physiological laboratories of the world assisting him with their best facilities and information, as to the "reasons for things," there is but small correction to make. This does not imply that the "last word" upon the subject has been herein stated, or that corrections may not be made as the study progresses, but it means, that as an honest description of an effort to get to understand the natural requirements in our own nutrition, it is perhaps better put than the same author could now do; that is, if intended for the enlightenment of persons whose curiosity has not yet been excited, or whose interest in their nutritive welfare is still young and inexperienced. With regard to the statement that "whatever has no taste is not nutritious," copied from a high educational authority, correction certainly must be made. Pure proteid has no perceptible taste as measured by taste-bud appreciation, any more than pure water has specific taste, and yet who may not say that "water tastes good" when one is really thirsty. Taste is a very subtle sense and is closely allied to feeling. Things are often said to taste good because they feel good in the mouth or to the throat as they descend to the stomach. Regarding also the advice to remove from the mouth refractory substance that the teeth and saliva cannot reduce to a condition to excite the Swallowing Impulse. There is theoretical and actual nutriment in the cottony fibre of tough lobster, or poor fish, or lean pork, and there is good reason to believe that a strong digestive apparatus _can_ take care of such tough substance _after a fashion_ and get nutriment out of it. In the same way the hard, woody fibre of old nuts is the identical material that was rich in juicy oils and proteid when the nuts were fresh, but if swallowed in the toughened condition that age brings to nuts, it is but slowly reduced in the stomach and intestines and only at enormous expense. If putrifactive bacterial decomposition has to be resorted to to get rid of the stuff the process is then poisonous as well as difficult. According to physiological authority which we must, for the moment, accept, proteid is a vitally-necessary material and we cannot afford to waste it. Our life depends upon proteid to replace the waste of muscular tissue which occurs with every movement, but when even good proteid is found by the mouth to be in a form that is too refractory for the teeth to handle, it is poor policy to send it on to the toothless stomach and intestines for the accomplishment of the reduction. If the mouth cannot handle what its guardian senses don't like, it can spit it out and get rid of it immediately; but if the stomach or intestines are afflicted with something that is harder than they can easily take care of, they have to call in the assistance of bacterial scavengers whose method is poisonous decomposition, and whose fee is putridity of odour penetrating the whole system and issuing at every pore, making Cologne water a large commodity even in so-called Polite Society. There are discernible in the mouth distinct senses of discrimination against substance that is undesirable for the system. If the mouth senses are permitted to express an opinion, their antipathy is easily read. It is far safer to spit out what the natural impulse of swallowing hesitates at, or fails to suck up with avidity, than it is to force a swallowing to get rid of it simply to satisfy a prudish "table manner" objection. To avoid "impolite" condemnation we really make "hogs of ourselves" "on the sly," and vulgar slang alone is appropriate to express the shameful confession. As a matter of fact, if one faithfully practise mouth thoroughness in connection with all his food for a term of a few weeks, he will find that the appetite ceases to invite the sort of things that have to be spit out. The appetite gradually but unfailingly inclines to foods that are profitable all the way through, and in which there is little or no waste. This revelation alone shows a delicate usefulness of Appetite that has escaped students of the human senses. In the matter of the insalivation of liquids, evidence continues to accumulate to show that in the present prevalence of liquid or soft foods lies the great danger to the digestive economy of man. Through them, mouth work becomes neglected, and the tendency is to force the stomach and intestines to take on the work of the powerful mouth muscles and glands in addition to their own work, and in the straining that ensues trouble begins. There is _now_ no doubt but that taste is evidence of a chemical process going on that should not be interrupted or transferred to the interior of the body. Tried upon milk for so long a period as seventeen days, during which nothing was taken but milk, not even water, thorough insalivation secured more than a twenty-five per cent economy in actual assimilation; not alone with one subject, but with no less than five persons, living on milk from the same cow, and all of whose strict test history was recorded. It seems also to be the only way in which a practically odourless solid excreta is obtainable, and this is certainly evidence worth considering and a desideratum worth striving for. While it is an excellent thing to give thorough mouth attention to anything taken into the body, to solids alone, even if liquids are neglected, the best economic and cleanly results are only obtained when all substances, both liquid and solid, are either munched or tasted out of existence, as it were, and have been absorbed into a waiting and willing body; a body with an _earned_ appetite. With liquids one simply has to do as the wine-tasters and the tea-tasters do. Small sips are intaken and the liquid is tasted between the top of the tongue (the spoon end) and the roof of the mouth until all the taste is tasted out of it, and the Swallowing Impulse has claimed it. This is by no means a disagreeable task, and as soon as the unnaturally acquired habit of greed and impatience is conquered, the reward of following this natural requirement is very great and increases with practice. Five years of experience has taught the author that a really keen appreciation of taste and its delicacy of possible refinement is not known to persons of ordinary habits of life. The pleasure which comes with conformity with the natural requirements is truly Epicurean and disregard of them is as surely gluttonous. The author still claims discovery of a distinct physiological function which he first named "Nature's Food Filter." Van Someren preferred the name of a "New Reflex of Deglutition." It is, in fact, the "Natural Swallowing Impulse," _invited only_ by food mechanically and chemically _prepared_ for passing on to the interior, call it by whatever name you like or may. At the time this little book was first published, the only note in favour of giving special attention to "buccal digestion," that had been sounded, was the advice of Mr. Gladstone to his children, "Chew your food thirty-two times to each mouthful," or words to that effect. The "Masticate well" prescription of the physician when given at all, had meant little or nothing, to either the patient or to the prescriber, except that one must not swallow hard food whole. For two years after its publication little heed was given to the suggestion because the author happened not to be a medical man, but, finally, the reserve of indifference was broken, first by Dr. Joseph Blumfeld, in a review of the book in the London _Lancet_, and soon after by Dr. Ernest Van Someren of Venice, Italy, an English physician residing and practising in Venice. Dr. Van Someren's interest and experience are best stated in his _own words_, as follows: THE PERSONAL "CASE" AND "ENDORSEMENT" OF DR. ERNEST VAN SOMEREN AN ENGLISH PHYSICIAN AND SURGEON, PRACTISING IN VENICE, ITALY "MY DEAR MR. FLETCHER: "It would be almost _àpropos_ to send you, as an endorsement of your principles, the dictum of the ragged and dirty tramp in the advertisement of Pear's soap. I would have to amend it slightly and say: 'I used your {principles} three years {soap} ago; since when I have used no other.' I say '_almost àpropos_' advisedly, for, while the soap claims to keep the outer man clean, the practice of your principles justly claims to keep the inner man sweet and clean, so lessening the need to cleanse the outer man! "A well-known English surgeon (I think Sir Wm. Mitchell Banks) recommends physicians and surgeons to take a leaf from the book of patent-medicine vendors, and make their patients testify to their successful treatment. I will take the hint and give you, as my 'doctor,' a testimonial of how personally I am benefited by your advice. "Three years ago, when I first met you, though under thirty years of age, and myself a practising physician and surgeon, I was suffering from gout, and had been under the _régime_ of a London specialist for the treatment of that malady. Though vigorously adhering to the prescribed diet, I suffered from time to time. My symptoms were typical--paroxysmal pain in my right great toe and in the last joints of both little fingers, the right one being tumefied with the well-known 'node.' From time to time, generally once a month, I suffered from incapacitating headaches. Frequent colds, boils on the neck and face, chronic eczema of the toes, and frequent acid dyspepsia were other and painful signs that the life I was leading was not a healthy one. Yet I was accounted a healthy person by my friends, and was, withal, athletic. I fenced an hour daily, took calisthenic exercises every morning, forcing myself to do them, and I rowed when I obtained leisure to do so. In spite of this exercise and an inherent love of fresh air, which kept all the windows of my house open throughout the year, I suffered as above. Worse still, I was losing interest in life and in my work. "In one or two conversations you laid down your simple principles of economic nutrition. You told me that my food ought to be masticated thoroughly, until taste was eliminated, and that (my) liquid nourishment, if taken, ought to be similarly treated. You also told me that, taking food in this way, I might, without fear of consequences, give free rein to my appetite. To shorten my story, I'll say that in three months after the practice of these principles my symptoms had disappeared. Not only had my interest in my life and work returned, but my whole point of view had changed, and I found a pleasure in both living and working that was a constant surprise to me. For this, my dear Mr. Fletcher, I can never repay you. My only desire has been and is, to try and do for others in my practice what you did for me. "Now I have since that time had occasional colds, headaches, and gouty pains; but, whereas formerly I could not explain their causes, I can now invariably trace them to carelessness in the buccal digestion of my food, and can soon shake them off. So much for my testimonial. Now for other matters. "I do not know what may be the extent of the claims you are advancing in regard to the benefits accruing from the practice of your principles. If you, as you in justice may, claim even the widest benefits as surely following the practice of these principles, many will relegate these claims to the limbo where all such 'panaceas' are soon forgotten. They will err greatly if they do so. The seemingly simple procedure of insalivating one's food most carefully is not calculated to impress people with the fact that great permanent benefit follows. The subtlety of the changes that occur is due to the greatly increased action of a vital process, _i. e._, of the admixture with the food-stuffs of saliva, in such quantities as to alter the chemical reaction of the initial stage of digestion. This initial change causes a consequent change of all the processes following it, and a change also in the final products of the entire process of digestion; the greatest change being, perhaps, the elimination of last-resort digestion by the intestinal flora (digestion by decomposition caused by bacteria), and consequent elimination from the body, of the toxins they produce. The life of an organism has been defined as 'the sum of all those inter-actions which take place between the various cells constituting the organism and their several environments.' (Harry Campbell.) The final products of digestion are absorbed into the blood stream, and go to form part of the 'several environments' of the cells. The individual cell, the various groups of specialised cells, such as the brain, nerves, muscles, bones, etc., in short, the whole organism is beneficially influenced and made more resistent to disease by the purity of a blood stream that no longer contains the toxins of bacterially digested food. "The further investigation of your discovery by those competent will, I am confident, result in such a simplification of the rules for a healthy life that the medical profession, at present forced by a lack of knowledge of the vital processes of nutrition to base their treatment on the veriest empiricism, will then be able to teach all and sundry how to live. At present, all we can do is to treat and perchance cure for a time certain symptoms, allowing the patient to return afterwards to a mode of life that is really responsible for his malady. 'Disease is an abnormal mode of life.' (Harry Campbell.) The three factors in its causation are: "(_a_) Cell structure. "(_b_) Internal cell environment. "(_c_) External body environment. "Heredity determines, to a very large extent, our cell structure, and consequently our body structure. "Sanitary science regulates our external body environment as much as the artificial and noxious habits of so-called civilisation will allow. The mental and physical external body environments have also their effect on the organism. "Your discovery of simple rules for an Economic Nutrition will control the internal cell environment. In doing this, the predisposition to disease is materially affected. The internal cell environment being free from toxic material, and the cell itself better nourished, the cell's resistance to disease is increased, the possible source of disease being limited to the external body environment. "In concluding this endorsement I can promise, to each and all who may intelligently practise the principles of Thorough Buccal-Digestion, a complete knowledge of their body's food requirements, or, as a patient of mine tersely put it, they will learn the way to 'run their own machines.' "Yours ever, "ERNEST VAN SOMEREN." * * * * * Dr. Van Someren and the author, assisted by Dr. Professor Leonardi, of Venice, as Consulting Physiological-Chemist, and several colleagues, pursued some experiments during the winter of 1900-1901; and Dr. Van Someren read a paper on our work, entitled, "Was Luigi Cornaro Right?", before the meeting of the British Medical Association the following August. The paper is too long to reprint here but it will be found in full in another volume, entitled, "The A.B.-Z. of Our Own Nutrition." The following "Note" by Dr. Professor, Sir Michael Foster, K.C.B., M.P., F.R.S. etc., is a further link in the chain of development of appreciation of the need of serious attention to the science of human nutrition excited by this initiative. (Dr. Foster is the Permanent Honorary President of the International Congress of Physiologists.) EXPERIMENTS UPON HUMAN NUTRITION NOTE BY SIR MICHAEL FOSTER, K.C.B., M.P., F.R.S. "In 1901 Dr. Ernest Van Someren submitted to the British Medical Association, and afterwards to the Congress of Physiologists at Turin, an account of some experiments initiated by Mr. Horace Fletcher. These experiments went to show that the processes of bodily nutrition are very profoundly affected by the preliminary treatment of the food-stuffs in the mouth and indicated that great advantages follow from the adoption of certain methods in eating. The essentials of these special methods, stated briefly and without regard to certain important theoretical considerations discussed by Dr. Van Someren, consist of a specially prolonged mastication which is necessarily associated with an insalivation of the food-stuffs much more thorough than is obtained with ordinary habits. "The results brought to light by the preliminary experimental trials went to show that such treatment of the food has a most important effect upon the economy of the body, involving in the first place a very notable reduction in the amount of food--and especially of proteid food--necessary to maintain complete efficiency. "In the second place this treatment produced, in the experience of its originators, an increase in the subjective and objective well-being of those who practise it, and, as they believe, in their power of resistance to the inroads of disease. These secondary effects may indeed be almost assumed as a corollary of the first mentioned; because there can be little doubt that the ingestion of food--and perhaps especially of proteid food--in excess of what is, under the best conditions, sufficient for maintenance and activity, can only be deleterious to the organism, clogging it with waste products which may at times be of a directly toxic nature. "In the autumn of 1901 Mr. Fletcher and Dr. Van Someren came to Cambridge with the intention of having the matter more closely inquired into, with the assistance of physiological experts. The matter evoked considerable interest in Cambridge, and observations were made not only upon those more immediately interested, but upon other individuals, some of whom were themselves medical men and trained observers. "Certain facts were established by these observations, which, however, are to be looked upon as still of a preliminary nature. The adoption of the habit of thorough insalivation of the food was found in a consensus of opinion to have an immediate and very striking effect upon appetite, making this more discriminating, and leading to the choice of a simple dietary and in particular reducing the craving for flesh food. The appetite, too, is beyond all question fully satisfied with a dietary considerably less in amount than with ordinary habits is demanded. "Numerical data were obtained in several cases, but it is not proposed to deal with these in detail here, as they need the supplementary study which will be shortly referred to. "In two individuals who pushed the method to its limits it was found that complete bodily efficiency was maintained for some weeks upon a dietary which had a total energy value of less than one-half of that usually taken, and comprised little more than one-third of the proteid consumed by the average man. "It may be doubted if continued efficiency could be maintained with such low values as these, and very prolonged observations would be necessary to establish the facts. But all subjects of the experiments who applied the principles intelligently agreed in finding a very marked reduction in their needs, and experienced an increase in their sense of well-being and an increase in their working powers. "One fact fully confirmed by the Cambridge observations consists in the effect of the special habits described upon the waste products of the bowel. These are greatly reduced in amount, as might be expected; but they are also markedly changed in character, becoming odourless and inoffensive, and assuming a condition which suggests that the intestine is in a healthier and more aseptic condition than is the case under ordinary circumstances. "Although the experiments hitherto made are, as already stated, only preliminary in nature and limited in scope, they establish beyond all question that a full and careful study of the matter is urgently called for. "For this fuller study the Cambridge laboratories do not possess at present either the necessary equipment or the funds to provide it. For the detailed study of the physical efficiency of a man under varying conditions, elaborate and expensive apparatus is required; and the advantages claimed for the special treatment of the food just discussed can only be fully tested by prolonged and laborious experiments calling for a considerable staff of workers. "It is of great importance that the mind of the lay public should be disabused of the idea that medical science is possessed of final information concerning questions of nutrition. This is very far indeed from being the case. Human nutrition involves highly complex factors, and the scientific basis for our knowledge of the subject is but small; where questions of diet are concerned, medical teaching, no less than popular practice, is to a great extent based upon empiricism. "But the scientific and social importance of the question is clearly immense, and it is greatly to be desired that its study should be encouraged. "M. FOSTER. "April 26th, 1902." * * * * * The interest excited in Professor Foster was coincident with that espoused by Dr. Professor Henry Pickering Bowditch, Professor of Physiology of Harvard Medical School, and Dean of American Physiologists. Under the ægis of such encouragement the later developments are not at all surprising. In order to extend and verify the findings of Dr. F. Gowland Hopkins, of Cambridge University, England, as stated in the preceding note by Professor Foster, Professor Russell H. Chittenden, President of the American Physiological Society, Director of the Sheffield Scientific School of Yale University, and one of the leading chemico-physiological authorities of the world, as measured by accepted research work, volunteered to submit the author to further test. The report of this test is too long for reproduction here. It was first published in the _Popular Science Monthly_ of June 1903, but will be found in full in the "A. B.-Z." just referred to. The special reference to the author's case and the quoted report of Dr. William G. Anderson, Director of the Yale Gymnasium which tells the story of efficiency, was as follows: Extract from an article by Professor Russell H. Chittenden in _Popular Science Monthly_, June, 1903. "The writer has had in his laboratory for several months past a gentleman (Horace Fletcher) who has for some five years, in pursuit of a study of the subject of human nutrition, practised a certain degree of abstinence in the taking of food and attained important economy with, as he believes, great gain in bodily and mental vigour and with marked improvement in his general health. Under his new method of living he finds himself possessed of a peculiar fitness for work of all kinds and with freedom from the ordinary fatigue incidental to extra physical exertion. In using the word abstinence possibly a wrong impression is given, for the habits of life now followed have resulted in the disappearance of the ordinary craving for food. In other words, the gentleman in question fully satisfies his appetite, but no longer desires the amount of food consumed by most individuals. "For a period of thirteen days, in January, he was under observation in the writer's laboratory, his excretions being analysed daily with a view to ascertaining the exact amount of proteid consumed. The results showed that the average daily amount of proteid metabolised was 41.25 grams, the body-weight (165 pounds) remaining practically constant. Especially noteworthy also was the very complete utilisation of the proteid food during this period of observation. It will be observed here that the daily amount of proteid food taken was less than one half that of the minimum Voit standard, and it should also be mentioned that this apparent deficiency in proteid food was not made good by any large consumption of fats or carbohydrates. Further, there was no restriction in diet. On the contrary, there was perfect freedom of choice, and the instructions given were to follow his usual dietetic habits. Analysis of the excretions showed an output of nitrogen equal to the breaking down of 41.25 grams of proteid per day, as an average, the extremes being 33.06 grams and 47.05 grams of proteid. "In February, a more thorough series of observations was made, involving a careful analysis of the daily diet, together with analysis of the excreta, so that not alone the proteid consumption might be ascertained, but likewise the total intake of fats and carbohydrates. The diet consumed was quite simple, and consisted merely of a prepared cereal food, milk and maple sugar. This diet was taken twice a day for seven days, and was selected by the subject as giving sufficient variety for his needs and quite in accord with his taste. No attempt was made to conform to any given standard of quantity, but the subject took each day such amounts of the above foods as his appetite craved. Each portion taken, however, was carefully weighed in the laboratory, the chemical composition of the food determined, and the fuel value calculated by the usual methods. "The following table gives the daily intake of proteids, fats and carbohydrates for six days, together with the calculated fuel value, and also the nitrogen intake, together with the nitrogen output through the excreta. Many other data were obtained showing diminished excretion of uric acid, ethereal sulphates, phosphoric acid, etc., but they need not be discussed here. +-----+-----------------------------------------+---------------------+ | | | | | | Intake. | Output of Nitrogen. | | | | | | +--------+------+-------+--------+--------+------+-------+------+ | | | | | | | | | | | |Proteids| Fats |Carbohy|Calories|Nitrogen|Urine | Fæces |Total | | | | | | | | | | | +-----+--------+------+-------+--------+--------+------+-------+------+ | | Grams. |Grams.| Grams.| | Grams. |Grams.| Grams.|Grams.| | | | | | | | | | | |Feb 2| 31.3 | 25.3 | 125.4 | 900 | 5.02 | 5.27 | 0.18 | 5.45 | | 3| 46.8 | 40.4 | 266.2 | 1690 | 7.50 | 6.24 | 0.81* | 7.05 | | 4| 48.0 | 38.1 | 283.0 | 1747 | 7.70 | 5.53 | 0.81* | 6.34 | | 5| 50.0 | 40.6 | 269.0 | 1711 | 8.00 | 6.44 | 0.81* | 7.25 | | 6| 47.0 | 41.5 | 267.0 | 1737 | 7.49 | 6.83 | 0.81* | 7.64 | | 7| 46.5 | 39.8 | 307.3 | 1852 | 7.44 | 7.50 | 0.17 | 7.67 | | | | | | | | | | | +-----+--------+------+-------+--------+--------+------+-------+------+ |Daily| | | | | | | | | |Av. | 44.9 | 38.0 | 253.0 | 1606 | 7.19 | 6.30 | 0.60 | 6.90 | +-----+--------+------+-------+--------+--------+------+-------+------+ *Average of the four days. "The main things to be noted in these results are, first, that the total daily consumption of proteid amounted on an average to only 45 grams, and that the fat and carbohydrate were taken in quantities only sufficient to bring the total fuel value of the daily food up to a little more than 1,600 large calories. If, however, we eliminate the first day, when for some reason the subject took an unusually small amount of food, these figures are increased somewhat, but they are ridiculously low compared with the ordinarily accepted dietary standards. When we recall that the Voit standard demands at least 118 grams of proteid and a total fuel value of 3,000 large calories daily, we appreciate at once the full significance of the above figures. But it may be asked, was this diet at all adequate for the needs of the body--sufficient for a man weighing 165 pounds? In reply, it may be said that the appetite was satisfied and that the subject had full freedom to take more food if he so desired. To give a physiological answer, it may be said that the body-weight remained practically constant throughout the seven days' period, and further, it will be observed by comparing the figures of the table that the nitrogen of the intake and the total nitrogen of the output were not far apart. In other words, there was a close approach to what the physiologist calls nitrogenous equilibrium. In fact, it will be noted that on several days the nitrogen output was slightly less than the nitrogen taken in. We are, therefore, apparently justified in saying that the above diet, simple though it was in variety, and in quantity far below the usually accepted requirement, was quite adequate for the needs of the body. In this connection it may be asked, what were the needs of the body during this seven days' period? This is obviously a very important point. Can a man on such a diet, even though it suffices to keep up body-weight and apparently also physiological equilibrium, do work to any extent? Will there be under such condition a proper degree of fitness for physical work of any kind? In order to ascertain this point, the subject was invited to do physical work at the Yale University Gymnasium and placed under the guidance of the director of the gymnasium, Dr. William G. Anderson. The results of the observations there made, are here given, taken verbatim from Dr. Anderson's report to the writer. "'On the 4th, 5th, 6th and 7th of February, 1903, I gave to Mr. Horace Fletcher the same kind of exercises we give to the Varsity Crew. They are drastic and fatiguing and cannot be done by beginners without soreness and pain resulting. The exercises he was asked to take were of a character to tax the heart and lungs as well as to try the muscles of the limbs and trunk. I should not give these exercises to Freshmen on account of their severity. "'Mr. Fletcher has taken these movements with an ease that is unlooked for. He gives evidence of no soreness or lameness and the large groups of muscles respond the second day without evidence of being poisoned by carbon dioxide. There is no evidence of distress after or during the endurance test, _i. e._, the long run. The heart is fast but regular. It comes back to its normal beat quicker than does the heart of other men of his weight and age. "'The case is unusual and I am surprised that Mr. Fletcher can do the work of trained athletes and not give marked evidences of over exertion. As I am in almost constant training I have gone over the same exercises and in about the same way and have given the results for a standard of comparison. (The figures are not given here.) "'My conclusion given in condensed form is this. Mr. Fletcher performs this work with greater ease and with fewer noticeable bad results than any man of his age and condition I have ever worked with.' "To appreciate the full significance of this report, it must be remembered that Mr. Fletcher had for several months past taken practically no exercise other than that involved in daily walks about town. "In view of the strenuous work imposed during the above four days, it is quite evident that the body had need of a certain amount of nutritive material. Yet the work was done without apparently drawing upon any reserve the body may have possessed. The diet, small though it was, and with only half the accepted requirement in fuel value, still sufficed to furnish the requisite energy. The work was accomplished with perfect ease, without strain, without the usual resultant lameness, without taxing the heart or lungs, and without loss of body-weight. In other words, in Mr. Fletcher's case at least, the body machinery was kept in perfect fitness without the consumption of any such quantities of fuel as has generally been considered necessary. "Just here it may be instructive to observe that the food consumed by Mr. Fletcher during this seven days' period--and which has been shown to be entirely adequate for his bodily needs during strenuous activity--cost eleven cents daily, thus making the total cost for the seven days seventy-seven cents! If we contrast this figure with the amounts generally paid for average nourishment for a like period of time, there is certainly food for serious thought. Mr. Fletcher avers that he has followed his present plan of living for nearly five years; he usually takes two meals a day; has been led to a strong liking for sugar and carbohydrates in general and away from a meat diet; is always in perfect health, and is constantly in a condition of fitness for work. He practises thorough mastication, with more complete insalivation of the food (liquid as well as solid) than is usual, thereby insuring more complete and ready digestion and a more thorough utilisation of the nutritive portions of the food. "In view of these results, are we not justified in asking ourselves whether we have yet attained a clear comprehension of the real requirements of the body in the matter of daily nutriment? Whether we fully comprehend the best and most economical method of maintaining the body in a state of physiological fitness? The case of Mr. Fletcher just described; the results noted in connection with certain Asiatic peoples; the fruitarians and _nut_arians in our own country recently studied by Professor Jaffa, of the University of California; all suggest the possibility of much greater physiological economy than we as a race are wont to practise. If these are merely exceptional cases, we need to know it, but if, on the other hand, it is possible for mankind in general to maintain proper nutritive conditions on dietary standards far below those now accepted as necessary, it is time for us to ascertain that fact. For, if our standards are now unnecessarily high, then surely we are not only practising an uneconomical method of sustaining life, but we are subjecting ourselves to conditions the reverse of physiological, and which must of necessity be inimical to our well being. The possibility of more scientific knowledge of the natural requirements of a healthy nutrition is made brighter by the fact that the economic results noted in connection with our metabolism examination of Mr. Fletcher is confirmatory of similar results obtained under the direction and scrutiny of Sir Michael Foster at the University of Cambridge, England, during the autumn and winter of last year; and by Dr. Ernest Van Someren, Mr. Fletcher's _collaborateur_, in Venice, on subjects of various ages and of both sexes, some account of which has already been presented to the British Medical Association and to the International Congress of Physiologists at its last meeting at Turin, Italy. At the same time emphasis must be laid upon the fact that no definite and positive conclusions can be arrived at except as the result of careful experiments and observations on many individuals covering long periods of time. This, however, the writer hopes to do in the very near future, with the coöperation of a corps of interested observers. "The problem is far-reaching. It involves not alone the individual, but society as a whole, for beyond the individual lies the broader field of the community, and what proves helpful for the one will eventually react for the betterment of society and for the improvement of mankind in general." This test of work was accomplished on food of the nitrogen value of less than 7 grams daily, whereas the text-books declare that from 16 to 25 grams of nitrogen are necessary to human existence. The heat value of the food consumed during the test, and which was like in amount to what had been habitually taken by the author for about five years previously (less than 1600 large Calories), was only _half the amount_ set down by the majority of the presently-accepted authorities as necessary to run the body of a man of the author's weight and activity. The heat-economy-showing was verified a week or two later in a 32-hour calorimeter measurement in the apparatus of Professors Atwater and Benedict at Middletown, Conn. Evidence of even more significant value has accumulated outside the field of the author's own experiments and tests. After more than a year of careful trial among some thousands of patients and among some hundreds of earnest employees, Dr. James H. Kellogg, of the great Battle Creek Sanitarium, has adopted the suggestions contained in this book as the first requirement of the treatment at the Sanitarium. In like manner, Dr. Edward Hooker Dewey, the sturdy advocate of dietary-economy for the past thirty years, author of the "No-Breakfast" regimen, and various books upon the subject of auto-nutrition and dietary-rest, bent his attention upon the effect of thorough buccal digestion prescribed after a period of rest from outside feeding, and here follows his appreciation as extracted from personal letters. Before quoting from the high appreciation of Dr. Dewey and Dr. Kellogg it may be well to state that the author stands simply for a test-subject-factor in a commonweal natural inquiry and no praise of the subject attaches to the person of the author. Whatever the author is, in the enjoyment of health and strength, is the result of natural causes which have developed during his study of the natural requirements in our nutrition. Please forget the personal element and consider that what is the author's gain in efficiency as related, is the possible possession of the reader as well, and whatever work or test the author performs is done as much for the reader as for the author himself. The several extracts from the letters of Drs. Kellogg and Dewey; the statement relative to an endurance-test made on the author's fiftieth birthday, on a bicycle in France, volunteered by Edward W. Redfield, last year's Medal-of-Honorist at the Pennsylvania Academy of Fine Arts, Philadelphia, as well as medalist of last Exposition Universale, Paris; are appreciated and accepted for the subject they endorse; and, as before stated, are entirely impersonal. Instead of using dumb animals for test subjects and getting their unwilling, and sometimes abnormally deranged, participation, the author takes pleasure in submitting to the tests himself, and is thus able to state "symptoms" and "feelings" more accurately, perhaps, than any dog could do. Were vivisection necessary the author would willingly submit to that inconvenience also; but thanks to the skill of a Pawlow, and the ingenuity of a Bowditch coupled with the patience and persistence of a Cannon, as fully related in the "A.B.-Z.," we not only get the economic results but we are able to know and even see some of the "reasons for things" as well. Interesting testimony and comment relative to the present study will be found at the end of the volume in communications from Commandante Cesare Agnelli, Clarence F. Low, Esquire, Baron Randolph Natili, and one of unusual suggestiveness, as evidence of the need of further study of nutrition, from Dr. Hubert Higgins of Cambridge, England. MILITARY-SCIENTIFIC COÖPERATION With the evidence and interest just outlined, it was not difficult for the author to enlist the coöperation of Surgeon-General O'Reilly of the United States Army and the endorsement of General Leonard Wood for larger investigation of the subject. These officers, both of them surgeons and medical doctors, had supported the militant-martyr-scientist, Dr. Major Walter Reed, in his great sanitary accomplishment; had fought yellow fever to a finish together in Cuba; had traced its spread to a specific cause; and were thereby encouraged to tackle even so common and powerful enemies as Indigestion and Mal-Assimilation. The investigation now in progress at Yale University, under the direction of Professor Chittenden and under the fostering auspices of the Trustees of the _Bache Fund_, which is administered by the National Academy of Sciences, and other contributed support, is a Militant-Scientific campaign which will not cease until we know as much about human nutrition, at least, as we know about the nutrition of our domestic animals. In this little book, however, is an account of the first distress and war cry, (to appropriate an expression of the Salvation Army), and while the workers in Science may take a considerable time to make observations and investigate the "reasons for things," the underlying claims herein stated will, it is believed, ultimately be established as fundamental facts of both Hygiene and Physiology. The psychic factor in digestion is even more important than originally claimed by the author, and fully accounts for the strength attained by the Christian Science movement. In the "A.B.-Z. of Our Own Nutrition" are reprinted, for recent scientific reports, in addition to the papers of Dr. Van Someren and Professor Chittenden, before mentioned, articles and lectures by Dr. Professor Pawlow, the great Russian physiologist and one of the Board of Assessors in the International Nutrition Investigation, described in the "A.B.-Z.," (reprinted from the fine English Translation by Dr. W. H. Thompson, of Trinity College, Dublin; English publishers, Griffin & Co.; American publishers, Lippincott & Co.), on the mental influence over the salivary, gastric, and intestinal secretions. Also, nearly an hundred pages of most virile, readable, and important "Observations on Mastication," by Dr. Harry Campbell, M.D., F.R.C.P., of the North-west London Hospital; reprinted by courteous permission of the author and of the editor of the _Lancet_. Also, a description of the digestive process in animals as seen by aid of the Röntgen, or X-Ray; a most readable account of the infinite patience and application of Dr. W. B. Cannon, of the Harvard Medical School, devoted to learning the "reasons for things" done in the closed and secret laboratory of the stomach and intestines. The above is a necessary advertisement of another volume in the A.B.C. Life Series; because the details of this particular attempt to reduce the philosophy of every-day life to profitable simples is linked-up in several volumes developed in the course of study of the subject for location of the germinal causes. "Menticulture" was the first of the series and relates to the individual. "Happiness" came next and located the chief enemy of happiness in _Fearthought_, the unprofitable element of forethought. "That Last Waif" treated the question as related to the Social Whole, children in particular, and recommended _Social Quarantine_; by extension of infant education to the extreme of allowing no child to escape educational care. This present treatise deals with the first requirement of such infantile care and education, right feeding. DR. KELLOGG'S APPRECIATION The great Battle Creek Sanitarium, under the inspiration and direction of Dr. J. H. Kellogg, has grown to enormous proportions in thirty-seven years. It began with one patient in a two-storey frame house in a country village, and has been largely influential in creating the present proud distinction of Battle Creek, Michigan, with its millions upon millions of invested industrial capital. The "cure" is based upon the establishment in the patient of right nutrition, right functioning of the bodily organs and secretions, and thereby assisting Nature to perform the cure in a natural manner. Pure foods and other conditions of right nutrition have been the particular study of the institution staff, and large and finely furnished chemical and bacteriological laboratories have been installed for the study of nutrition in a scientific manner. The Battle Creek Sanitarium is a purely humanitarian and philanthropic institution. By perpetual charter, all of the profits of the concern in all of its ramifications are dedicated to the extension of the American Medical Missionary Cause, and there have been already established more than sixty branches of the parent institution in different parts of the world, principally in or near the chief cities of America, and all are occupied with saving and regenerating the physical body of the sick as a foundation for possible moral awakening and spiritual cultivation. The work done by these humanitarian institutions is most practical, and the best evidence of the practicality is their growth. Patients are charged what they can conveniently pay, but none who need are refused attention. Branches are made self-supporting as soon as possible, but are first nurtured by the parent sanitarium. There are some hundreds of physicians, nurses, and other attachés of the different institutions, and these are enthusiasts in the humanitarian work, taking as wages only what they need for most economical support, "a mere pittance," and deriving their chief compensation from satisfaction gained in the service. All in all, it is an expression of inspirational altruism worthy of the example of the Good Samaritan and a practical demonstration of the Sermon on the Mount. The special attention of the writer was called to the work of the Battle Creek Sanitarium organisation by an American banker, Edwin C. Nichols, Esquire, in London, at the time of the last Coronation. The banker was conversant with the growth and methods of the Sanitarium, and had seen the result of its missionary and sanitary work. He exacted a promise from the writer to visit Battle Creek on his first opportunity, and Mr. Nichols has our everlasting gratitude for leading us to a more intimate acquaintance with so splendid an illustration of humanitarian possibilities when properly directed. It is not alone the great Sanitarium and its hospitals, and clinics, and shelters, and refuges, and baths, and reading-rooms, that are doing the greatest possible good work, in demonstrating their effective Christianity; but it is the private waif-family of Dr. and Mrs. Kellogg which shows what neglected children are capable of when given a chance, and which appeals to the author especially as giving support to his ideal of a possible effective _Social Quarantine_ as presented in his book, "That Last Waif." Twenty-four neglected and sick children of unfortunate parents have been rescued from an almost hopeless condition, and have been adopted into the best of surroundings and culture, all promising to become splendid wealth-productive citizens and ornaments to society. For more than a year Dr. Kellogg and his staff of earnest workers have been testing the suggestions offered in "Glutton or Epicure," and in the treatise of Dr. Van Someren, and appreciation of these suggestions and the work that has since been done to stimulate interest in the question in high scientific circles will be found in some extracts from Dr. Kellogg's letters which the author has received permission to print herewith. "BATTLE CREEK, MICH., Nov. 26, 1902. "DEAR MR. FLETCHER: "I have your kind note of November 20th. Thank you very much for your appreciative words. Your visit here was a great inspiration to all of us. It is not often we find a man who enters into the things which we love so heartily as you have done. The thing that interested us especially was the fact that you are the founder of a new and wonderful movement, which is bound to do far more for the advancement of the principles for which we are working than all that we have done or anything we can do. I shall await with great interest the development of your work and shall expect to receive great light from your efforts. We are all in training to find our reflexes, and are expecting to make a great deal out of this." "BATTLE CREEK, MICH., Dec. 21, 1902. "MY DEAR FRIEND: "I have received the beautiful book which you sent me, 'That Last Waif, or Social Quarantine.' It is a charming volume. I devoured it eagerly, and I find myself in the position of an eager disciple sitting at the feet of a master. Your ideas of social regeneration strike deeper than those of any other modern author, and I shall be glad to coöperate with you in any way possible in promulgating these principles. You have made your book talk in a most impressive way. From cover to cover it is simply admirable and must do a world of good. I shall write a little notice of it for my journal, _Good Health_. "Again thanking you for this interesting volume, I remain, "Most sincerely and respectfully yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., Jan. 22, 1903. "DEAR FRIEND: "I have shamefully neglected you. I want to assure you how much I appreciate your encouraging notes. I read them to my colleagues, and they were so much affected that tears came into their eyes. I assure you we feel that you are indeed a brother to us in our work, and that God has providentially sent you to be a friend to us and to the principles which we represent. "I had a letter from Dr. Haig a few days ago in which he mentioned you and your work, and said he was much interested in it. Dr. Haig, you know, has done a great deal in calling attention to uric acid in meats and other foods. His work has not all been accepted by great laboratory men, but Dr. Hall, of Owen's Medical College in Manchester, has recently reinforced his results. I have at different times repeated his experiments with interesting results. "I assure you we shall be glad to receive any suggestions from any scientific authority who may visit us, and if there is any part of our work which can be improved, we shall be glad to put it there as soon as our attention is called to it. "Again thanking you for your kindly interest in our work, I remain, "Most sincerely yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., Feb. 22, 1903. "MY DEAR FRIEND: "I have yours of January 29th. I am much interested in what you write about your demonstration at New Haven. I want to give the widest publicity possible to your work. I find great good in it. I am talking to my patients continually about it. I know from my experience that you are right. For many years I have required my patients to give special attention to chewing, and have made it a written prescription for each patient to chew a saucerful of dry granose flakes at the beginning of each meal. I have seen great good from this method. "With kindest regards, I remain, as ever, "Most sincerely yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., March 16, 1903. "DEAR FRIEND: "I am exceedingly interested in the facts which you communicate, especially Dr. Anderson's report. It is quite remarkable. I am verifying the same ideas in my own personal experience. I am confident you have discovered a great and important principle and I shall watch with interest future developments. I am going to get our students interested in it. If you feel disposed to do so, I shall be glad to have you make out a little line of experiments which will tally with the experiments which you have been conducting, so the results may be compared. "I have in hand a translation of Cornaro's work which I have been thinking of publishing. It occurred to me that perhaps you would be able to write a little chapter for this work, or an introduction. I am going to get it out in nice shape, and I trust it may be the means of doing good in inclining those who read it toward a simpler life. I am greatly interested in the ideas which you present in your various books. "I hope you will have a safe journey to Italy and back. "I remain, as ever, "Very sincerely and respectfully yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., March 22, 1903. "MY DEAR MR. FLETCHER: "I have yours of March 19th. I thank you very much for promising to write an introduction for the edition of Luigi Cornaro's life. You are just the man to do it. I propose to get the book out in neat, tasty shape. Shall be glad to have suggestions from you on this point. The manager of a large denominational publishing house in Chicago is interested and wants to publish it with us. He has promised to help about the artistic features. "As regards our medical college, I ought to have told you that we are incorporated in the State of Illinois. Our medical school is really legally located in Chicago. We always have one or more classes down there for dissection, clinical work, and doing dispensary and missionary work in the city. Our school is officially recognised. Our diplomas are recognised in this country and in most foreign countries; our diplomas are recognised, in fact, in all countries which recognise American diplomas. The work done in our school is recognised by the best schools. Jefferson accepts students from our third year into their fourth, the graduating year, without examination. Kings College in Kingston, Canada, does the same; also Trinity College in Toronto, and other leading schools in this country. Our College is a member of the American Medical Association along with Bellevue, University of Pennsylvania, University of Michigan, Rush Medical College, and other leading schools. We have placed our standard high so that no one could object to the reform features of our work on account of incompetency. Our students are admitted to practice in New York, having passed the examinations of the State Board. Our best reason for believing that our diplomas are recognised everywhere is because of students from the College having passed the examinations in nearly every State. One of our students recently graduated from the University of Dublin after having spent a year there, as they require five years instead of four years as with us. "Your experiments are surpassingly interesting. Your performance with Dr. Anderson was phenomenal. I confess you are a physiological puzzle. If chewing accomplishes these wonderful things for you, it is certainly worth the while. I am training myself from day to day to masticate my food more and more thoroughly and I confess there is greater good in it than I ever imagined. "I am sending you a little box of foods that I think you will like, especially the protose roast, the gluten biscuit, and the chocolates. "I would like to get hold of a list of your books; I want to put them into the hands of our students to read. Kindly give me a list of the names and the publishers and I will esteem it a favour. "I might have said further in reference to our College that it is listed by the New York Board of Regents as well as by the Illinois State Board of Health. We are going to make considerable improvement in our school the next year. We are trying to put up a new building. We need $100,000 very much, as our work has no endowment and it requires very great sacrifice and most strenuous effort to keep it going. Our teachers work for a mere pittance and our students are compelled to save and economise in every way to get through. Nearly all of them have to pay their way in work of some sort. "By the way, I am taking liberty to send you with this, copies of some little booklets which I have just gotten out in reference to our work. "I am, as ever, "Your friend, "J. H. KELLOGG." "BATTLE CREEK, MICH., June 24, 1903. "MY DEAR FRIEND: "I have your kind note of June 21st. I am happy to be remembered by you tho I have neglected writing you. I was afraid my letter would not find you on your journeys. "We are chewing hard out here at Battle Creek, chewing more every day. We are continually thinking and talking of you and the wonderful reform you set going. We have gotten up a little 'chewing song' which we sing to the patients. It is only doggerel but it helps to keep the idea before our people. We dedicated it to you and I am going to send you a copy of it as soon as the printers get it ready. If you feel too much disgraced I will take your name off. "That little book on 'Cornaro' is not out yet. We have been waiting for the introduction from you. We can wait as much longer as is necessary, as you are the man to furnish this introduction. "I hope you will come West some time this summer so you can drop in and see us in our new building. We are not quite in perfect running order yet, but we shall soon be fixed in good shape and will be delighted to have you with us. You have helped us greatly in calling our attention to the great importance of chewing. We had known it for a long time but had not practised it. You demonstrated the thing in such a graphic way that the whole world is constrained to listen. "Thanking you for your kind note, "I remain, very sincerely yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., July 23, 1903. "MY DEAR MR. FLETCHER: "I have your kind favour of July 14. You are doing me altogether too much honour. I am only a plodding, humble doctor, and have never had any opportunity to do any great thing, because of the limits of my abilities, and because I have not the opportunity to devote my energies to any one special thing; but have so many things to do that I can do nothing very well. "I remember Dr. Krauss very well. He has for some years been assistant to Prof. Winternitz, the Professor of Nerve Diseases in the Medical Department of the Royal and Imperial University of Austria. He seemed a very able physician and a delightful gentleman. I was very glad to meet him. "I have already sent you a copy of a little booklet entitled 'The Building of a Temple of Health.' "We will be most happy to have a visit from you. I would like to know about what time you are coming, and I will endeavour to be here. I have a call to give an address at Chautauqua, N. Y., early in August, and if I do not know when you will be here, I might possibly be away, which I should consider a great misfortune. "We have nothing here, I am sure, which will be new to scientific men, and I apprehend that they will have a very different opinion of our work than you have. "I have a little book which I think I have not sent you, entitled 'The Living Temple.' I will send a copy to you; also a copy of the 'Chewing Song,' which is now out. It is nothing but a cheap thing, intended only for my own little folks; but it got out, and several people wanted it, so I have allowed it to be put in print. The purpose was, of course, simply to impress the chewing idea. Of course you are well, as you are apt to be well by chewing well. "By the way, I met a disciple of yours a day or two ago. He was Senator Burrows, from Kalamazoo. He called with his wife and some other ladies, and Mr. Rose, the chief clerk of the U. S. Senate, to make us a little visit. I had a very delightful chat with them. On remarking to the Senator that he did not look any older than when I saw him last, but seemed to be very well, he told me he was in perfect health, and he expected to live for ever. He had recently gotten hold of something that was doing him so much good that he believed he should never be sick. I begged to know his secret, and found it was chewing. I asked him how he discovered it, and he told me he had learned it from your delightful book. You are certainly promoting the most important hygienic reform which has been brought forward in modern times. When you visit us again, you will see in our dining-room of our new building more Horace Fletcher disciples, and more hard chewers than you ever saw together in one place in your life before. Our doctors and helpers are taking hold of it with great enthusiasm, and I trust we shall be able to render you some good service in promoting this good idea, for which you certainly deserve the gratitude of the whole world. "Hoping to have the pleasure of a visit from you soon, I remain, as ever, "Yours most sincerely and respectfully, "J. H. KELLOGG." "BATTLE CREEK, MICH., Aug. 13, 1903. "DEAR FRIEND: "Your kind notes of August 7th and 11th received. I have asked the Publishing Department to open an account with you and send you everything you order promptly at publisher's discount. "'The Living Temple' is published for the benefit of the Sanitarium. Everything received from it goes toward paying for the new building. The cost of printing, paper, and binding is paid for by contributions, so all the money received goes toward the building fund for the Sanitarium. I hope by this and other means to get the building paid for before I die. "I think your chewing reform is of more importance to the world than you realise. You must have a great fund of good cheer with you; doubtless because you chew! I told our patients here that I had heard from you that King Edward was chewing. It interested and amused them very greatly. The idea of 'munching parties' is a good one. "As ever, "Your friend, "J. H. KELLOGG." "BATTLE CREEK, MICH., August 21, 1903. "DEAR MR. FLETCHER: "I have yours of August 20th with the list of persons to whom you desire to have 'The Living Temple' sent. The books are already sent together with a little note calling attention to them. "Your continued courtesies are putting us under obligations which we can never repay. "There are a lot of devils of different sorts to be cast out, and I am sure the dyspeptic devil is about the worst and the meanest of them all. "A quartette sang the 'Chewing Song' just before my lecture in the parlour last evening. The great parlour was filled to its utmost capacity. The people cheered heartily, not at the singing nor the song, but the sentiment. I took occasion to tell them I thought Mr. Horace Fletcher, in inaugurating the chewing reform, had done more to help suffering humanity than any other man of the present generation, and that I felt very much mortified that we had neglected this important matter to such an extent here that you had to come to the Sanitarium and be a missionary of good health and urge this important matter upon our attention. I feel that we are all greatly indebted to you, and seem to be getting continually more and more into your debt, and I do not know any way to discharge the obligation; but if any accident should ever happen to you so you get ill, it will certainly be a delight to us to have the opportunity to minister to you if you will permit us so to do. "I am glad you have postponed your visit until October, as by that time we shall have many things in better working order, and our medical class will be here. I want to have our medical students meet you. "I told Mr. Nichols the other day you were coming to visit us. He was greatly delighted to hear this. He feels as I do that the work which you have inaugurated is the most important movement which has been started in modern times. "I remain, as ever, "Fraternally yours, "J. H. KELLOGG." "BATTLE CREEK, MICH., Sept. 30, 1903. "DEAR FRIEND: "I have your kind note of the 23d inst. I am sure that one of my letters to you has been lost. I wrote promptly telling you that you were at liberty to use anything I have written you respecting your work. "I am more and more enthusiastic respecting the value of thorough chewing. I have read with great interest Dr. Harry Campbell's articles, and am republishing in _Modern Medicine_ a large part of what he has written. "I have been thinking whether I might dare ask permission from you to publish your article 'What Sense' as a tract. Possibly it is already printed in that way. I would like to circulate it widely among my patients, and our nurses and doctors. I am doing my best to get them all to chewing, and have had great benefit myself from thorough mastication. "Our Medical School has just begun again, and I have one nice class of sixteen students who are going to devote themselves to the study of applied physiology, and all of them will experiment on the effects of thorough mastication in relation to the quantity of food; also in relation to the quantity of proteids. If you would like the details of the results of the experiments, I will give them to you later. "By the way, if you have any written or printed outline of data which you think it desirable to collect, I will be glad to have it as a help to us in researches of this sort. We have prepared our laboratory to do almost anything that needs to be done, and we have a whole lot of enthusiastic young men and women who will enter into this thing with great zeal, and we will be glad to coöperate with you thoroughly as I feel that you have introduced a line of research and investigation which is of immense importance. I have read with great interest Prof. Chittenden's article in the _Popular Science Monthly_, and I can but feel that you are a heaven-sent missionary to the world in this matter of diet reform. "I remain, "As ever your friend, "J. H. KELLOGG." "P. S.--I have for many years given a good deal of attention to the matter of mastication. It has been my regular prescription for all my patients for many years to eat at the beginning of each meal some Granose Flakes. The purpose of this was to secure increased activity of the salivary glands, and to encourage the habit of mastication. I have found immense benefit from this practice. "I appreciate exceedingly all the good things you are sending me. What a delightful time you must have had in the Adirondacks! I have never had such a pleasure in my life, as I have had my nose continually on the grindstone at work since I was ten years of age, with no vacations at all. It is a remarkable spectacle that these great men, these learned professors and scientists, and army medical men, should be coöperating so enthusiastically with a layman to learn the true philosophy of life; but it has always been so. The great discoveries have not been made by great scientists and great doctors, but by men whose minds were above the bias of prescribed education, and who were able to learn from the great book of nature, which is the book of God. "When you come again I hope you will have time to stay with us a little while so we can have some good chats. I would like to sit down and go into the heart of things with you, when I think we should find our ideas running very close together. We shall expect to see you next month. I have to be away for a few days sometime during the month, so I hope you will let me know a little while before you come about what time to expect you. "J. H. K." EXTRACTS FROM DR. EDWARD HOOKER DEWEY (At the first writing Dr. Dewey had had the method of treating food commented on in his letters under trial for three years; it having been communicated to him by the author among the first.) "MEADVILLE, PENN., Nov. 17th, 1901. "MY DEAR MR. FLETCHER: "In the line of dietary form you have done better work than the entire medical profession has done from the dawn of History. This matter of eating the way you preach and practise, serves wonderfully to save the waste of energy, which is a direct robbery of brain power, in the stomach. It also saves an undue waste of food, the burden of over-weight, and above all things, the _waste of disease_. You should enlarge 'Glutton or Epicure' and push it. My allusion to this little book in my last book has brought me many letters of inquiry, and I always commend it as a work of the highest practical importance. "I have received the article of Dr. Van Someren, and I wish I had scores of them to send to my patients. I have read it with the greatest interest, and shall keep it most of the time in the mail pouches. "In these latter times I am becoming more and more impressed with the results of over-food even with the well, until now I feel that the pussy belly is a matter so clearly attributable to gluttony as to be a cause of shame, at least, in the physiological sense.... "I hope you will feel it a duty to enlarge and expand the usefulness of 'Glutton or Epicure.' The people are ripe in this country for just such a book.... I feel that you are doing the most important work in physiological investigation of any living man, and we in this country, especially, need all your new material as an addition to the book...." (Two years later; after five years' test.) July 20th, 1903. "What you have done to unfold physiologic mastication means more for human weal than all the mere medical prescribers have given the world from Adam to the present moment. I have tested the method you advise with the ailing, as you could not have had so large an opportunity to do. I have been having the care of fasters for the past twenty-six years, and now all of them, when they return to their healthy appetite and feeding, have to 'Fletcherise' every morsel. Just now a man has ended a thirty-two day fast under my care, and has begun taking food again, with an appetite and a relish that his memory does not recall having enjoyed before. He swallows nothing that is not reduced to thin liquid. Only occasional abstinence from food for a time and such attention to mastication, makes health possible with the majority of people, tempted by quantities of soft and rich foods. No other one has taught so wisely how available brain power can be saved from wastage in the stomach, as have you--the value is beyond all estimate. "It has been given to me to become a teacher among those who have neither time nor means to cultivate health; mine to teach them how to get all the health possible, without the use of any of the health arts. In dispensing the new physiology of dietary rest I have had need of all the time possible, with none left for the experiments of science, hence I have done little or nothing to speak of in the experiment way suggested in your letters. "I am very glad to hear from you again, and shall be pleased to have you indicate the number of the _Popular Science Monthly_, in which Professor Chittenden's article on your work at Yale appeared, so that I can send for it. Think of this, my dear Mr. Fletcher, what a conservation there is of energy, brain-power-reserve and even soul-force, in saving it from waste in worrying about and literally pushing quantities of avoidable rubbish through thirty feet of the alimentary canal; and this is just what is accomplished by your method of making the jaw muscles and salivary glands do all their whole duty in the matter of daily food." September 3d, 1903. "I send you a whole cargo of thanks for the fine book you sent me (Dr. J. H. Kellogg's 'Living Temple') and the 'Chewing Song' (taught and used as a reminder at the Battle Creek Sanitarium). The latter is the most important kind of a song ever voiced during the age of man. I have been trying to get time to write you some physiology, but am very busy with my correspondence with distant patients. Will do so soon." September 12th, 1903. " ... What I would like best to express to you is my appreciation of the exceeding good you have done me in teaching how to save energy available for brain-power by 'Fletcherising' all foods before swallowing. In the case of dropsy, I have previously written about, I am confident the sole means of success that is being accomplished now, is due to the 'Fletcherising' of all morsels. The patient spends never less than an hour and a half over his one meal a day. At the end of his former fast, with his weight of 250 lbs. cut down to 125 lbs., he was permitted to take six meals a day, and in a few weeks he was nearly as bad as ever, with his weight raised to 180 lbs. Under my care, and after only a seventeen-days' fast (dietary rest), he was reduced again to 122-1/2 lbs. There has since been a month of feeding one meal a day by your method, with weight restored to 156 lbs. and no hint of returning dropsy--and you are guilty of this, for no other than the practice of thorough mastication has been capable of such curing work. "Your experiences, as detailed in the _Popular Science Monthly_ (June, 1903), were read with absorbing interest. There is no more important work for man to do than that which you are doing. I have not the patience for details, and since the 'No Breakfast Plan' has become somewhat known to the world, I have been too busy; but the more I study, and study you in particular, the more I see and realise what of crimes and of evil desires are due to over-food--to bolting food. "Now for something new! In an article on 'The Mystery of Migrations' in the _Saturday Evening Post_ of August 22d (1903), it is given out that all migrating birds let their last meal get thoroughly digested, that they may start on their long flight with empty stomachs; that no power may be diverted to the digesting machinery of their stomach. What is the significance of this in relation to the 'No Breakfast Plan?' It is the true physiology of Instinct!" (In response to a request for permission to quote his appreciation.) September 17th, 1903. "DEAR MR. FLETCHER: "You may freely state my views of the value of the work you have done for humanity better than I have done. Know this; I am not able to adequately express my own appreciation of it, as revealed in the rooms of the ailing throughout several years of experience, by any language at my command. Here is something formal, if you like to use it. "Yours with admiration and gratitude, "E. H. DEWEY." "P. S. The matter of thorough mastication, as unfolded and insisted on by Horace Fletcher, is the greatest practical physiology that a dyspeptic, gluttonous world ever has received. The mouth-work, in saving the strain of overwork in the stomach and in the intestines, will do more to prevent disease than all other precautions. This is all the more wonderful when it is considered that Mr. Fletcher is a layman.[4] [Footnote 4: Dr. Dewey's expression of surprise at the lay incompetence of the author is interesting in view of the fact that he himself is responsible for the untitled, unprofessional deficiency at which he wonders. When the author met Dr. Dewey, in Dayton, Ohio, where he was conducting some experiments, in 1898, he was then on the point of taking up a complete medical course with a post-graduate course of research-physiology in order to give character to his authority in advancing the cause of his amateurish discovery, as related in this book. There were the time, the energy, the means and the inclination of a student's craving inviting him to take the whole course to M.D. degree; but Dr. Dewey advised "no." "Don't you do it," said he, "you are doing good work as it is; you will be more or less influenced by existing standards which may be errors, and you may get switched off the natural track. Study your physiology _after_ you have made your observations." Dr. Dewey has forgotten his advice of five years ago, but it was followed. Living almost constantly in an open-air and open-mind atmosphere of research in alimentary physiology ever since, thanks to Dr. Dewey's suggestion, the author has escaped the abnormal physiology which medicine deals with, and he is more and more thankful for the escape as time reveals that open-air and open-mindedness are good, both for the soul and for bodily comfort and health.] "Here is the physiology involved, as I find the effect of it in the sick-room. Theoretically, digestion may take place far down in the digestive tract, but it is practically found that when this possibility is resorted to, by reason of neglect of the earlier buccal or gastric digestion, trouble soon happens, and we doctors are called in to try to effect cures by medicine or otherwise. For every one horse-power of work, as it were, that is slighted in the mouth, it requires perhaps ten horse-power of energy to repair the neglect further on, and all of this waste of energy is charged against the brain-power, pleasure-power reserve on storage. "As I read the account of Mr. Fletcher's showing of heat-economy, reported by Professor Chittenden in his _Popular Science Monthly_ article, and which was verified in the calorimeter measurement at Middletown, I see at once, from my own observations, that half the heat commonly used in the human engine is occupied in forcing the unnecessary waste through thirty feet of intestinal folds and convolutions." The author feels very grateful to Dr. Dewey, not alone for his encouragement, but for the service he has rendered humanity by his heroic stand for temperance in feeding. He is one of the sturdy Esculapian Luthers, whose cry of reform comes from the impulse of an inborn Christian Altruism. When it becomes generally known, as it some day will be, that overeating and wrong-eating are the prime causes of temptation to intemperance in drinking, the measure of Dr. Dewey's service to the Temperance Cause will be better appreciated. AN AGREEABLE ENDURANCE TEST After this volume was published in 1898, the field of experiment was changed from the United States to Europe. The physical exercise and mental recreation of the summer of 1899 consisted partly of bicycling. We landed in Holland, toured Holland, Belgium, and Northern France, and reached Paris in the course of about two months and with upwards of five hundred miles' wheeling. For another month we bicycled leisurely around Paris and added two or three hundred miles to our cyclometer record. During the month of July the author further rode some seven hundred miles in and about the Forest of Fontainebleau. The idea of an endurance-test was suggested to the author by the ease with which he accomplished a century of miles on the Fourth of July, 1899. Being in Paris, and wishing to celebrate a most beautiful summer day and our National Holiday at the same time, an early start was made and the beauty of the day, the charm of the golden harvest fields lying between Paris and the Forest of Fontainebleau, and the noble forest itself, led us on and on until the cyclometer showed a distance, for the forenoon run, of slightly more than eighty kilometers (fifty miles) in a straight-away line from hotel and home in Paris. Two years before, fifty miles on bicycle, even when accustomed to riding daily during the craze for bicycling, which was then at its zenith, if done in one day, would have completely "done the author up" and would have called for several days of rest for recuperation. In the present case, however, no fatigue had yet been experienced and the day was still young. The forest studio-home of friend Redfield, the Philadelphia landscapist, was found on the edge of the forest bordering the Seine at Brolles, and we went for a spin together and finally returned awheel to Paris. To make a "century run" in a day had always seemed to the author a feat for athletes and experts only, and when he found that he had made it without any inconvenience and was in no way painfully conscious of it next day, the ambition to see _what really could be done_ was born. It would give practical measure of the improvement due to an economical nutrition. It was known what the newly ambitious contestant for a record _could not do_ two years before, but it was now uncertain what he _might be able to do_ under changed condition of health even with two years' additional handicap of age; besides, it happened to be the half-century year of the author's life and a good time to jot down a record of a new start in life. Reference to "economical nutrition" in connection with a full measure of recreation needs some explanation. To be economical means to most persons privation of pleasure. It is true that the economic standard attained by Luigi Cornaro had been maintained with ease by the author since the beginning of his experiments in the summer of 1898. This was not accomplished by trying to emulate Cornaro's example, but was reached by a method of taking food, and developed in the course of a special study of the economic natural requirements. The author ate _just what his appetite called for_, as nearly as circumstances of supply permitted, he ate _all that his appetite would allow_; enjoyed a gustatory pleasure that _had never been equalled_ under old habits of taking food, and was a distinct epicurean gainer by the economy learned and practised. But--and in this "but" lies the secret--the solid food had been munched appreciatively until it was liquefied and a strong Swallowing Impulse compelled its deglutition. The sapid and nutritious liquids were tasted as the wine tasters taste wine, as tea tasters taste tea, and as all experts test, or "Get the Good" out of, anything. Instead of being drunk down in a flood like water, which has no taste and no reason to stay in the region of taste, delicious country milk was sipped and tasted with the end of the tongue, where the best taste-buds are, until it disappeared by natural absorption. In this way the milk was fully enjoyed, largely assimilated, and, as the result of almost subsisting on bread and milk alone, at times, in response to the country appetite, the disproportionately excessive waste usually encountered when pursuing a milk-diet was not experienced; the digestion-ash (solid excreta) was extremely small and averaged only about one-tenth of the amount commonly wasted in the digestive process in ordinary habits of taking bread and milk hastily and carelessly. It is significant that, while the quantity of food habitually taken was about one-third of the text-book normal-average prescription, the solid waste was _only a tenth_ of the usual amount, showing a much more economical digestion and a better assimilation. This possibility of a profitable and an agreeable economy was afterwards verified in the Venice experiments. An æsthetic result was attained in connection with these experiments which cannot be too often advertised. All putrid bacterial decomposition was avoided in the process of digestion, and all sense of muscular fatigue was absent, even following strenuous and unusual exercise. Instead of involving deprivation and asceticism, that mid-summer month in the Forest of Fontainebleau, occupied in making an _economy_ and an _endurance_-test, was a carnival of tempting plenty in the way of good food enjoyed to the full satisfaction of a healthy appetite. The endurance-test recounted in the letter following is evidence of the effect of such sumptuousness when approached by different methods of gratification. The powerful young artist who volunteers the story lived in the ordinary way and the aged reformer and research-dietetician, whom the young athlete paced, treated his food as recommended in this book. EDWARD W. REDFIELD'S EVIDENCE (In response to an invitation to recount his remembrance of the test after a lapse of four years.) "CENTRE BRIDGE, PENN. "MY DEAR MR. FLETCHER: "My remembrance of the trip is as follows: On August 10th, 1899, I was spending the summer at Brolles, on the border of the Forest of Fontainebleau in France, when you came to visit me and enjoy the forest at the same time that you were conducting some chewing exercises and planning an endurance-test on bicycle on the fiftieth anniversary of your birthday. You were quietly living then according to the regimen with which your name is now connected and I was pursuing the ordinary habits of life which are common to artists abroad. The test was not only to determine the endurance of yourself, but to furnish a contrast with ordinary conditions of nutrition. We were eating at the same table, with the same food available to each, and were taking about the same amount of physical exercise. We turned in at night at the same time, as people are apt to do in the country, and it was my custom to rise at or before daylight. This habit of early rising came natural to me from my farmer education and habitual practice, and yet I never could surprise you early enough to catch you asleep. My first thought on getting out was to stop under your window and chant the refrain, 'Mr. Fletcher, are you up?' in imitation of the catch-line of a popular song of the year. Frequently the click of your typewriter warned me that you were already at work, but you were always awake and ready for 'anything doing.' "I was, at the time, thirty years of age and thought myself in good condition and strong even for a farmer's boy; had previously done considerable long-distance road-riding, including League of American Wheelmen runs, etc., in competition with the 'cracker jacks'; and, to be frank with you, thought the agreement to pace you on that particular day a 'snap,' and I expected to lose you in the woods before long. "The day was perfect, rather warm, as I remember it, and with little or no breeze. Our start was made at 3.55 A. M. (arose at 3.30). Course selected: To Fontainebleau and thence across country to Orleans, about one hundred kilometers distant from Brolles. I considered Orleans the limit and fully expected to have you return by railway from there. "We were running at the rate of twenty to twenty-two kilometers the hour, and from time to time I would look back for Fletcher, but he was always at the same place at my rear wheel. A puncture delayed us for some fifteen minutes, but when the great cathedral bell of Orleans struck nine we were already there taking our first food of the day, coffee and crescent rolls. "We again started, after a short rest, down the Loire, always holding the pace of twenty kilometers or better the hour in spite of the undulations. We stopped occasionally for water and milk, a single tumblerful of which satisfied both the thirst and the hunger of yourself. "To me, the ride, at about this period, became a grind, but Fletcher seemed to get stronger and stronger and occasionally led the pace at a terrific clip. My condition, as we neared Blois, became more than bad with cramps in the legs. I had to dismount but couldn't stand up, and for awhile, I thought they would have to carry me home. I appreciated the kind inquiries sympathetically made and oft-repeated by yourself as to my condition, but had you known, at the time, how I was cussing your healthy appearance and impatience to proceed, you wouldn't have bothered me so much with your sympathy. After a partial recovery and the slow ride into Blois, six kilometers away, I left you, taking the train back to Paris, you having decided to go it alone for the rest of the day and thus complete the test. "The arrival at Blois was about 1.30 P. M. (170 kilometers--a little above 100 miles) and took about nine hours, including stops, to accomplish. The next morning we received your dispatch from Saumur, nearly another hundred miles down the Loire, telling us that the run to that point had been completed by 10.10 P. M. that night, and Mr. Fletcher returned the next day as fresh and as strong as I had ever seen him at any time during the summer. "Starting the day following with wife and daughter for a bicycle ride through France to Switzerland I accompanied your party as far as Geneva, and the only thing I couldn't discover was how a man who ate so little could travel so far and seem never to get tired. (Signed) "Very sincerely, "E. W. REDFIELD." "Sept. 17th, 1903." TEST COMPLETED The experience of the author on that eventful fiftieth birthday, as registered in the successive sensations, is worthy of record. In starting out in the cool of the morning as the day was dawning, and speeding through the beautiful Forest of Fontainebleau, the feeling of exhilaration was indescribable. An hour or two passed before there was any sense of unpleasantness attaching to the steady grind of duty which led us to pass reluctantly by inviting spots and scenes without stopping. In the beginning there was the keenest feeling of pleasure in the mere movement, without any exertion, over and among an enchanting landscape. It was what one might call a birdlike sensation of freedom of movement which bicycling and skating, among the common means of locomotion, alone give. Redfield did not let up on the pace and I was determined not to beg for respite. Between fifty and sixty kilometers of distance only had been made when I felt that the day was not propitious for an endurance-test, and I fully expected to be compelled to return from Orleans leisurely in the afternoon and evening by wheel with only a slight addition to the century-run of the preceding Fourth of July accomplished. Before Orleans was reached, however, all sense of strain passed, and second-wind and second-strength had become installed for the day. When I left Redfield at Blois I felt stronger than any time before, and as eager to kick the pedals as when we started in the morning and as one always is prompted to do when one is filled with surplus energy. I had no objective point and was guided only by tempting roads and favouring breezes. The river road down the Loire was most promising at first, but a head wind sprang up and made a _détour_ the other side of Blois more tempting by argument of a fair wind that blew down one of the roads leading away from the river. For a time I made full twenty-five kilometers an hour, but the wind died out and I returned to the river road and reached Tours in time for the enjoyment of a magnificent sunset effect and a most appetising and satisfying _table d'hôte_ dinner. Before dining I jumped into a tub and had a good refreshing dip and a vigorous rub which made me feel like going out to take a walk or mount my wheel again. My appetite for dinner was not large, centred on a salad richly dressed with olive oil, and was quickly appeased; immediately after which I mounted my wheel again and proceeded down the beautiful road towards Saumur. My ambition was here raised to complete 300 kilometers and the distance to Saumur just about filled that ambition. I rode leisurely for a time after dining and then gradually increased the speed to about eighteen kilometers an hour, which brought me to my destination a little past ten, with a feeling of sleepiness that invited to a hasty falling into bed, but with surprisingly little or no sense of muscular fatigue. My cyclometer registered a little more than 304 kilometers, or 190 miles; not much for experts, under the conditions, to be sure, but a revelation of possibilities to a man of fifty who had once, not many years before, been denied life insurance on account of health disability. This was worth more than millions of money to me; and no one knows how much it will signify to the human family when the knowledge of a truly economic nutrition is attained and established. I was bright awake at daylight the next morning and had the impulse to mount my wheel and see how "fit" I was in consequence of my exertion of the day before. This I did, and rode eighty kilometers (fifty miles) before breaking my fast at nine o'clock. I believe I could have ridden as far that day had the conditions been favourable. My weight, on return to my balances at Brolles, was reduced two kilograms (nearly five pounds), but a generous thirst for a day or two, and a slightly increased appetite put the loss back again inside a week even while riding my wheel daily on the way to Geneva. Since reaching Italy, and abiding in Venice, there have been long periods when no systematic physical exercise has been indulged in. Once, after nearly a year of physical inactivity, I took with me an attendant and made an average of seventy-five miles a day in the mountain districts of southern Germany for observation of increase of food requirement during hard work. Neither muscular soreness, nor muscular fatigue, except the periodical weariness of sleepiness, were experienced as the result of the sudden change from the most restful environment to strenuous activity; and herein lies a physiological question that is far-reaching in its significance. It would seem that Appetite, in its normal condition, assisted in its discrimination by careful mouth-treatment of food, guards the body from excess and keeps it always "in training." The later experience at Yale University under Dr. Anderson and Professor Chittenden showed the same immunity from muscular disability, and has brought the question to good hands for solution. The author has voluminous data relative to his work, but it is not applicable to any other person. Each person is a law unto himself and no two sets of conditions are alike. Treat your food as advised herein and get surprising new experiences for yourselves, is the advice and moral of the story. GENERAL OBSERVATIONS HEALTH, HARMONY AND HAPPINESS Health, Harmony and Happiness are the natural heritage of man. The human body is the most perfect piece of mechanism possible to imagine. The human body is intended to nourish Health, maintain Harmony, and conserve Happiness. * * * * * The body machine is self-building or self-growing, self-lubricating and self-repairing. A simple knowledge, only, is necessary for proper (preventive) care of the body machine. All that Nature requires of man is to supply fuel preferred and, therefore, prescribed by Normal Appetite and to direct the energy generated along alluring lines of usefulness. * * * * * Nature requires no sacrifices and imposes no penalties for obeying her beneficent demands. Natural Laws are easily comprehended if studied objectively. Ill health, inharmony and unhappiness come only from disobeying Nature. God (obeyed) is Only Good. NATURE STUDY Nature cannot be profitably studied alone through books. Nature has a separate message for each intelligence. Each body machine has peculiarities which the possessor alone can understand. Object lessons, personally experienced or observed, are the best. "Once seeing (or feeling) is worth an hundred times telling about," is a wise Japanese proverb; and it is true. As the swinging pendulum taught Galileo, and the falling apple suggested to Sir Isaac Newton, the law of gravity, in like manner the modern electric power-plant teaches us, by analogies, suggestions useful in the study of ourselves--our own Mind Power-Plant. OLD AND NEW THE OLD IDEAS The old religion condemned man, even though unenlightened, to perdition and saved him only through special dispensation. The old education insisted on narrow formulas and tried to cram all mentality into prescribed moulds. The old physiology presupposed disease and glorified pathology. THE NEW STUDY The new religion glorifies Love, stimulates Appreciation and preaches only Optimism. The new pedagogy aims to discover the useful tendency with which each creature is equipped at birth and to cultivate this God-given inclination as designed by the Creator. The new physiology studies Hygiene and assists Nature by securing Prevention to avoid the necessity of correction and cure. SAFE HYPOTHESES Assuming that Nature's intentions are only right, ill-health is unnatural. If Nature's invitations, as expressed by Normal Appetite, are rightly interpreted, good health must result. When there is bad health Nature has been disobeyed. A REASONABLE CONCLUSION If Physiology has failed to teach a way to maintain perfect health some of her hypotheses must be wrong. If any of the hypotheses of Physiology are discredited any one of them may be doubted.[5] [Footnote 5: Since this was written, the then accepted standards of human food requirements have not only been questioned but have been discredited and disproved. The great importance of mouth-work in the economics of digestion has been demonstrated and accepted.] OUR NATURAL GUARDIANS THE SENSES GUIDING SUPPOSITIONS The stomach and other hidden parts of the body have automatic functions independent of the will that perform digestion; these functions are beyond the scope of control, and hence means of preventing ill-digestion must be studied by the aid of the exterior sensations. Sight, Appetite, Touch and Taste are the senses useful in selection of food and in the prevention of indigestion. Sight and Appetite relate to invitation and selection, while Touch and Taste are discriminators and indicators of conditions. Appetite and Taste are the sense functions that are most important to health, and hence they are the most important to study and understand. They are the guide in nutrition and the guard of the body machine--the Mind Power-Plant. Smell also is an important aid in selection and discrimination and is an effective assistant of Appetite. APPETITE AND TASTE ANALYSED Appetite should be dignified and recognised as a distinct sense. Normal Appetite is Nature's means of indicating her fuel and repair requirements for the Mind Power-Plant. Study Normal Appetite and heed its invitation. It prescribes wisely. Its mark of distinction, to differentiate it from False Appetite, is "watering of the mouth" for _some particular thing_. False Appetite is an indefinite craving for _something_, ANYTHING! to smother disagreeable sensations and frequently is expressed by the symptom of "faintness" or "All-gone-ness." [Vide the "A.B.-Z. of OUR OWN NUTRITION."] Taste is the chemist of the body; of the Mind Power-Plant. More correctly, perhaps, it is the report of a chemical process relating to nutrition. Taste is an evidence of nutrition. While taste lasts a necessary process is going on. Taste should, therefore, be carefully studied and understood. Both Taste and Appetite differ in different individuals and in the same individual under different conditions of thought or activity. Taste is also dependent on supply of the mouth juices usually called saliva, and these differ materially in individuals, necessitating self-study, self-understanding, and self-care to insure prevention of indigestion and disease. The most important part of nutrition is the right preparation of food in the mouth for further digestion. The most important discovery in physiology is the relation of compulsory or involuntary swallowing to the right preparation of food for digestion. * * * * * Taste is evidence of nutrition. Whatever does not taste, such as glass or stone, is not nutritious.[6] [Footnote 6: Pure proteid or albumin is quite tasteless but is always accompanied by tasting substance, and separation of the proteid molecule from enveloping material is an important function of mouth-capacity in digestion.] Taste is excited by the dissolving of food in the mouth, and while it lasts a necessary process of preparation for digestion is going on. The juices of the mouth have the power to transform any food that excites taste into a substance suitable for the body. Nothing that is tasteless, except water and pure proteid, only by distinct invitation of appetite, should be taken into the stomach. If we swallow only the food which excites the appetite and is pleasing to the sense of taste, and swallow it only after the taste has been extracted from it, removing from the mouth the tasteless residue, complete and easy digestion will be assured and perfect health maintained. * * * * * NATURE'S FOOD FILTER Nature has provided an Automatic Food Filter which, if rightly used, will prevent the introduction of any harmful substance into the stomach. * * * * * At the entrance to the throat there are certain muscular folds or convolutions, including the palate, which, when in repose, form an organ that is nothing less than a Perfect Food Filter. This filter has also automatic qualities which compel it to empty itself by the process we call "Involuntary Swallowing." Involuntary swallowing is really compulsory swallowing; unless a voluntary effort to restrain it is set up against it. The real Swallowing Impulse is so strong that it is practically compelling. The Food Filter, when rightly performing its protective function, is impervious to anything except pure water at the right temperature for admission to the stomach and to nutriment which has been properly dissolved and chemically converted by salivation (mixture with saliva) into a substance suitable for further digestion. IMPORTANCE OF MASTICATION If we masticate--submit to vigorous jaw action--everything that we take into the mouth, liquid as well as solid, until the nutritive part of it disappears into the stomach through compulsory or involuntary swallowing, and remove from the mouth all fibrous, insoluble and tasteless remainder, we will take into the body, thereby, only that which is good for the body. * * * * * The first thought that will arise in the reader's mind on perusal of the above declaration will undoubtedly be, "What! masticate milk, soups, wines, spirits, and other liquids; nonsense! That is impossible!" It is not, however, impossible, and, furthermore, it is _absolutely necessary to protection against abuse of the stomach and possible disease_. Liquid for adults, for anyone after the eruption of teeth, is an artificial and unnatural sustenance; something not taken into consideration when the human body was planned. Liquid food (drunk without mixing with saliva) is a sort of nutritive self-abuse, and the only way to avoid the ill effect is to give it the same chance to encounter saliva that the constituent ingredients would have had in a more solid state. For the importance of this see Dr. Campbell's able treatise on mastication reprinted from the London _Lancet_ in the "A.B.-Z. of OUR OWN NUTRITION." * * * * * The only things necessary to life that we are compelled to take into the body that do not excite the sense of taste are pure air and pure water. These are necessary to life, but are not what is called nutrition. They do not, alone, replace waste tissue. They do not challenge the sentinel, Taste, and hence do not require retention in the field of taste. If water be pure and tasteless you cannot masticate it, as it will not submit to more than one action of the jaw before causing involuntary swallowing. If it have taste it is a sign that it contains mineral or vegetable substance that needs treatment of some sort to render it suitable for the body, and it will then resist some mastication, some mouth-treatment, as in tasting, before compelling swallowing, just as the sapid liquids do. Anything that has taste, even soup, wine, spirits or whatsoever is tried, will resist numerous mastications before being absorbed by the Food Filter. Above all things, milk, wines, etc., should be sipped and tasted to the limit of compulsory swallowing. * * * * * In considering the reasonableness of masticating everything that has taste until it is absorbed by Nature's Food Filter, it must be remembered that the only liquid food provided for man that is not artificial is milk, and the natural means provided for taking milk into the stomach is by sucking, which is like mastication.[7] The milk of fruits, such as cocoanut milk, for instance, is found, in liquid form, only in the unripe fruit, and remains liquid only while it is ripening into pulp. [Footnote 7: Before the eruption of teeth in a child there is no secretion of saliva, only mucous; but mother's milk is strongly alkaline, and hence has no need of saliva to prepare it for digestion. All milk that has "stood" or has been mixed with water is acid, and requires saliva to give it the quality of mother's milk.] * * * * * Insalivation does not seem to be complete without jaw action, although saliva (sometimes only mucous) flows freely into the mouth without it under conditions which we term "watering of the mouth" excited by keenness of appetite. (See Pawlow's, Campbell's, Van Someren's, and other evidence in "A.B.-Z. of OUR OWN NUTRITION.") The normal perviousness or natural opening of the Food Filter for swallowing food is directly assisted and affected by movement of the jaws exercised in vigorous manner. Mastication, or mouth-treatment, therefore, even of liquids that excite taste, seems to be a necessary part of thorough insalivation. * * * * * Nature has a good reason for everything she plans. It is asserted by physiological chemists that saliva, taken from the mouth and kept at normal temperature, will dissolve breads and similar foods and convert the starch in them into maltose, glucose or sugar. The converted form is that which is suitable for further digestion. Saliva also converts some acids into alkali and readily neutralises all acids. It is also asserted that saliva does not dissolve some things (proteid substances) nor chemically affect them as visibly as it does starch and acid, but, even if this be true, it is no less essential that the juices provided in the mouth should have an opportunity, through mastication, or, movement about in the mouth, to do what they are able to do in assisting digestion. Experiment shows that if all foods are submitted to the examination and action of these juices until involuntary swallowing takes place, the results in aiding subsequent digestion are important in promoting healthy nutrition. Separation, neutralisation, alkalination, saccharidation, of the proteid and carbohydrate elements of common foods and perhaps a partial emulsification of fats are all possible in the mouth and are more easily and quickly done there than inside the body. Much care in Mouth-Treatment is an assurance of economy and safety in Alimentation. OBJECTIONS CONSIDERED One of the objections usually provoked by the suggestion that all tasteless residue remaining in the mouth after the taste or nutriment has been dissolved out of it should be removed is generally expressed in this wise, "How is it possible to remove refuse from the mouth while eating without appearing disgusting to others at table? You have to swallow things to get rid of them." This is merely a bugbear prejudice. It has no good reason. Do you not remove cherry pits, grape skins, the shell of lobster, bone, etc., when you encounter them? Then why not remove the fibrous matter found in tough lean meat, the woody fibre of vegetables or anything rejected by instinctive desire to discard it after taste has been exhausted, and which is a protection provided by beneficent Nature? In well selected and well cooked food there is little found that the juices of the mouth in connection with the teeth cannot take care of and prepare so as to be acceptable to Nature's Food Filter. If fibre is found in the food it can be put upon the fork in the same manner that a cherry pit is usually handled and transferred to the plate without observation. Another fancied objection to thorough mastication is that it interferes with the sociability of a meal. This is also a senseless bugbear. It is true that one cannot converse freely with large morsels of food in the mouth. It is also true that it is nothing less than a _gluttonous_ custom to greedily take a big mouthful of food, and, if accosted with a question, to bolt it in order to answer. It will be found easy to carry on conversation without disagreeable interruption and yet follow Nature's demands in properly masticating food by taking small morsels into the mouth. It will be found also to add to the real pleasure of eating, and eventually will become a habit by choice. Another objection raised by those who are afflicted with the habit of gluttony is the lack of time permitted by their business occupation. The time needed to appease the natural appetite of a hearty and active man, to compensate for the daily waste and keep the weight at normal, is from thirty to forty-five minutes for twenty-four hours.[8] This requires attention and industrious mastication. Divided into three meals it is less than a quarter of an hour for each meal. [Footnote 8: The actual time required by the author during the Yale tests to secure full alimentation, maintain weight, and fully appease a "workingman's appetite," was from twenty-four to twenty-six minutes, divided into two meals for each day. The common habit is to bolt food and waste time afterwards in torpid inactivity, while all the energy is busy in the stomach and intestines trying to get rid of the great excess loaded upon them.] Epicurean habits, however, incline one away from three meals a day and make two meals sufficient for ordinary activity. One objector, on the spur of momentary discussion, claimed that in travelling by railway the time allowed for eating would not permit Epicurean methods. The author arrived at Mobile, Ala., recently with a workingman's appetite and had only twenty minutes in which to get off the train, on again, and satisfy the appetite. There is an excellent lunch counter now at Mobile, and on the counter there was a tempting array of things to eat and drink. Appetite chose at once a fat, rich ham sandwich,[9] a glass of creamy milk and a hexagonal segment of a mince pie. The twenty minutes was ample time for disposing of the sandwich and the milk, and meantime the mince pie had been wrapped in silk paper and placed in a paper bag to furnish Epicurean enjoyment for twenty miles on the road, enhanced by the beauty of a panoramic landscape. [Footnote 9: Five years of Epicurean enjoyment and study of the food instincts and food economics have taught the author to like many things better than slices of dead pig sandwiched between slices of delicious bread. Vegetarian extremist and faddist the author is not, but an attention to natural leadings inclines one away from dead meat, which is believed to induce much uric acid, and in favour of first-hand food elements as fresh from the heart and the breast of Mother Nature as possible, leaving the second-hand, once-digested, already decaying, natural food of the savage _carnivora_ and the emergency food of savage man for emergency occasions or a vegetable famine. Much meat excites lust, intemperance, and savagery in man and gives explosive, non-enduring force. The question is, do we need such force in the twentieth century, especially when we know that it tends to shorten life and predispose to disease?] If I had crammed the pie and the sandwich and the milk into my stomach in seven or eight minutes, which, by actual observation, is the gluttonous rate of despatching a station meal, I would have lost two-thirds of nutriment, more than one-half of taste and would have perhaps taken on twenty-four hours of discomfort, possibly inviting a cold. I would have created an "open door" for any migrating microbes that were floating about in my atmosphere looking for strained tissue or fermenting food in which to build their disease nests. Observation proves that you do not get much more nutriment out of your food than saliva prepares in some way for digestion, gulp though you may, but you can take in a load of disease possibilities in trying to force the food past or otherwise evade proper salivation. SPIT IT OUT Whatever does not insalivate easily is surely dangerous. There is nothing more pronounced of expression by its influence on inclination than the impulsive desire to spit out of the mouth anything that seems unprofitable to the senses. INSTINCTIVE DISCRIMINATION Muscles have been provided for this purpose (separating, collecting, and spitting-out anything which the instincts protest against) that are more facile than those of an elephant's proboscis, and these muscles move things to and fro in the mouth or expel them if they are undesirable. If you acquire the habit of consulting the Swallowing Impulse and practise only involuntary swallowing in eating you will find that these muscles are very discriminating and will instinctively assist in the rejection of unprofitable matter. Their sense of touch will soon discriminate against unprofitable food even when the sense of taste is fooled by some alluring sauce or condiment. Nature is truly a marvel of good sense if you give her a chance to express her likes and dislikes without restraint. Natural Appetite is the best possible judge of what the system needs, and the senses which Nature's Food Chemist employs in her work are unerring in their selection whenever they are permitted to act as intended by Nature. * * * * * GIVE NATURE A TRIAL Try Nature's way for a week or a month and you will never have a desire to be even mildly gluttonous again. One week of faithful trial without lapses should fix a habit of consulting involuntary swallowing as an automatic guide in eating so that attention will not have to be strained to heed it. One week of constant attention to obeying Nature's demands in eating will so impress its usefulness on the student of Epicureanism that an accidental act of forced swallowing will be a shock to the sensibility. One week of obedience of Nature's simple requirements will demonstrate that she imposes no penalties for following her natural requirements, but only for disobedience of her protective laws. One week of earnest, open-minded study of Nature's first principle of life--nutrition--will convert a pitiable glutton into an intelligent and ardent Epicurean. DIFFERENCES Individuals differ greatly in the quantity of the supply of the juices of the mouth which are active in salivation. They differ so much that it is safe to say that no two have equal provision. One person may dispose of a morsel of bread in thirty mastications so that the last vestige of it has disappeared by involuntary process into the stomach. Another person, of similar general health appearance, selecting as nearly as possible an equal morsel of bread, may require fifty acts of mastication before the morsel has disappeared. The next week, by some change of conditions this order may be reversed. While there may be some structural or chemical difference in the two morsels of bread, this is not sufficient to account for the different mastications required. The dissimilarity lies in the difference of the copiousness and strength of the secretions at the time of trial. This liability to changed conditions would constitute a serious danger if it were not for the protective Food Filter, or, Reflex of Deglutition, which Van Someren has so well described in the "A.B.-Z;" and whenever mouth-treatment of anything to be ingested is neglected, and forced swallowing--hasty bolting of food or gulping of liquid food--is indulged in, this protection is eluded and the danger is converted into actual internal self-abuse. WARNING Above all things don't _strain_ to be careful. Strain inhibits--paralyses--all of the glandular functions and deranges the nervous nicety of adjustment. Just eat slowly, deliberately, small morsels, and sip and taste small quantities of liquids and observe what happens. You will soon learn to Know yourself and "Know Thyself" has been the advice of all the sages from the beginning of time. GLADSTONE'S RULE Numbers of mastications as related to given quantities and kinds of foods are no guide to be relied upon. Gladstone's dictum, "Chew each morsel of food at least thirty-two times," was of little value except as a general suggestion. Some morsels of food will not resist thirty-two mastications, while others will defy seven hundred. The author has found that one-fifth of an ounce of the midway section of the garden young onion, sometimes called "challot," has required seven hundred and twenty-two mastications before disappearing through involuntary swallowing. After the tussle, however, the young onion left no odour upon the breath and joined the happy family in the stomach as if it had been of corn-starch softness and consistency. It will be difficult, without actual demonstration, to convince the advocates of "Total Abstinence" that any whisky can be taken in a seemingly harmless form, but it is true that thorough insalivation of beer, wine or spirits, until disappearance by involuntary swallowing, robs them of their power to intoxicate, partly because appetite will _tolerate but little_. TEMPERANCE PROMOTED As a matter of fact, whisky taken in this analytical way is a sure means of breaking up desire for it, and it is an excellent protection in drinking as well as eating. Many of our test-subjects have been steady and some have been heavy drinkers but persistent attention to Buccal-Thoroughness has cured all of them of any desire for alcohol and in time it surely leads to complete intolerance of it. It is also true that, taken in the way suggested, the body refuses to tolerate more than sips and thimblefuls of these liquids and then only on rare occasions, so that the Epicurean habit is the best possible insurance of temperance. NORMAL CONDITIONS RESTORED While the difference in the supply of the juices of the mouth is an important factor in digestion, insufficiency need not cause alarm. Nature is so gladly and quickly recuperative that the moment abuses of her functions are stopped she begins to repair damages and re-establish normal conditions. One of the subjects who submitted himself to experiment was found to be woefully deficient in saliva and, was a pitiable dyspeptic, but, as the result of patient mastication, the secretions gradually increased until they were ample, and dyspeptic symptoms disappeared even long before the secretions became normal. The strain of excessive and (acid) fermenting food being removed, the acute discomfort was at once allayed even before the repair was complete. "KNOW THYSELF" "Know Thyself" has been the admonition of sages from earliest times. "Become acquainted with your Normal Instincts, with Appetite and with your food chemist, Taste, and follow their directions with implicit confidence," is the admonition taught by our experiments, for they can lead you to robust health and greatly increased vigour of body and mind. Study and heed them patiently for a week and you will follow their invitations and warnings through life. Thorough repair of an impaired body may not be effected immediately, although wonderful results--almost miraculous--have been attained in three months; but a week's faithful and attentive study of the possibilities of Epicureanism, with right alimentation as its basic requirement, in adding to the comfort and enjoyment of life will result in right eating being made philosophically and religiously habitual, and will give a backbone of Epicurean character that will not easily succumb to gluttonous impetuosity. THE MIND POWER-PLANT A USEFUL ANALOGY All of the functions of the body are operated by something very much akin to electricity--mental energy--so that aside from the fermentation which gluttony makes possible, the mere drag of handling of dead material in the body, that the body cannot use, for two or three days, is a wasteful draught on the available mental capacity. Using an electric power-plant as analogous to the Mind Power-Plant of the brain, and a trolley railroad as analogous to the machinery of the body--analogies which are very close by consistent similarity--the loading of the stomach with unprepared food, as in gluttony, is like loading flat cars with pig iron and running them around the line of the road in place of passenger cars, thereby using up valuable energy and wearing out the equipment without any profit resulting from the expenditure. To those who are familiar with the modern electric power-plant the analogy between it and the human individual equipment, or Mind Power-Plant, seems very remarkable. To those, however, who have not visited an electric power-plant a description is necessary. DESCRIPTION OF A MODERN ELECTRIC POWER-PLANT Fuel, of course, is the source of the power. Furnaces which are capable of producing heat with the least consumption of fuel, tubes within the boilers that permit the freest possible contact of the heat produced and the water to be turned into steam, steam pipes that are flexible and yet strong, machinery that moves with the least friction in order to concentrate and utilise the power of the steam, and dynamos out of which electricity is evolved, together with auxiliary pumps and hoists and blowers and whatnot other devices to help create, control and economise the energy, are the essential parts of an electric power-plant. To insure economy and accuracy these are made as nearly automatic as possible. At one end of the furnace house there is sunk in the cement floor a large iron scoop or tray into which cartloads of lump coal are dumped. This scoop-shaped receptacle is also the platform of a weighing machine so that each load is weighed. In the bottom of the scoop there is a trap-door, which, being opened, permits the coal to drop through between the teeth of a crusher where the large lumps are reduced, usually to the size of a small nut. From the crusher the coal falls into the buckets of an endless chain-hoist and is conveyed aloft to great hopper-shaped bins which occupy the entire space under the roof over the furnaces. Leading back from each bin to the constantly moving grate bars of the furnace underneath is a pipe which delivers the crushed coal to the grate bars and distributes it evenly over their surface as fast as it can be received into the furnace, regulated, of course, by the consumption that is going on inside the furnace. To accomplish this automatic feeding each set of grate bars is constructed in hinged sections, and forms a wide endless iron belt which revolves and carries the coal within the cavity of the furnace. The coal crusher, bucket hoist, movable grate bars, ash collectors and sifters, pumps, blowers, lights and all other utilities of the plant, as well as the great travelling crane which can hoist and carry many tons' weight--any part of the enormous dynamos--from place to place, are operated by electricity which is generated in the dynamos. Automatic gauges that measure and indicate, and switch-boards that regulate the energy created and stored in the dynamos play important parts in the economy and working of the plant and are analogous to appetite and taste in man. ANALOGY ILLUSTRATED The full analogy may be best illustrated by arranging the similar functions of the two energy-creating machines opposite each other in parallel columns. ELECTRIC AND MIND POWER-PLANTS COMPARED ELECTRIC POWER-PLANT MIND POWER-PLANT Fuel. Food. * * * * * Selection of fuel as to Selection of food for steam-making and economic nutritive value; normal qualities. appetite serving as an exact guide and gauge. * * * * * Crushing coal so as to Masticating food so render combustion as that the juices of the easy and complete as mouth can act on the possible. substance with greatest freedom; taste being evidence of the working of the process. * * * * * Automatic conveyal of Automatic reception of the prepared fuel, first to properly masticated and the bins and then on to thoroughly insalivated the furnace as required. food into Nature's Food Filter and emptying into the furnace of the stomach by Involuntary, or Compulsory Swallowing. * * * * * Combustion in the furnace. Digestion in the stomach and intestines. * * * * * Generation of steam in Generation of material the boiler tubes and storage for vital energy and storage in the boilers. in the body. * * * * * Steam. Blood in circulation. * * * * * Steam Gauge. Pulse. * * * * * Engine. Heart. * * * * * Dynamo, with its numerous Brain, with its complex coils and extensive convolutions in constant friction surfaces. frictional activity. * * * * * Volt Gauge, indicating Strength, indicating the the power available. available energy. * * * * * Electricity. Mind. Energy. Nervous Force. AUXILIARY OPERATING MOTORS Electric motors attached Nerve-cell motors attached to the separate to glands and parts or machines of the muscles, connected with plant, connected by wires the brain by nerve-fibres and drawing power from and drawing on the mental the dynamos. or nervous energy for power. * * * * * Automatic switches Sensitive nerve ends regulating the transmission terminating in each cell of of power to the motors the body and penetrating in response to their each gland, signalling, on fluctuating requirements. being touched, for power to eject digestive secretions or oily mucus as demanded by the needs of digestion, also, supplying automatic power to muscles employed in exterior work or in moving the food substance on through the process of digestion and afterward disposing of the excreta--ashes and clinkers, as it were. The ganglions are the switch boards of the body. * * * * * Automatic demand for Appetite, indicating fuel as required in the requirements of the Mind progress of combustion Power-Plant for replacing to supply the waste or the constant waste of useful consumption of the tissue consumed in running electricity. the machine. * * * * * Good Draught, forced Optimistic Thinking, if necessary. forced if necessary, for _it is_ necessary to health. * * * * * PROFITABLE MANAGEMENT Intelligent Engineering. Intelligent Self-Knowledge and Self-Care, assisting Nature in her good intentions. * * * * * Economic stoking. Feeding only what is actually required for sustenance. UNPROFITABLE MANAGEMENT Overloading and choking Overloading and choking the furnace with irregular the stomach with and dirty coal. unmasticated, unsolved, unconverted, and, therefore indigestible food. * * * * * Neglect of cleaning, Nature is not neglectful; oiling and repairs. she does well and quickly all the lubricating and repairing of the Mind Power-Plant whenever strain is removed and she is given the required rest, or time to accomplish the work between meals. * * * * * Unnecessary ashes and Unnecessary fermenting clinkers, encumbering the excreta, resulting from plant, depositing dust in unfiltered and unprepared the journals of the machines food, depositing and requiring poisonous sediment in the much power to handle blood channels, straining and remove. the intestines, ossifying the cartilages, crystallising in the kidneys and bladder and drawing excessively upon the available energy of the nervous centres and the available brain energy for power to handle and discharge. PROFITABLE DIRECTION AND USE OF ENERGY Good wires leading to Creditable aims in life. profitable uses. * * * * * Good insulation or isolation Concentration of purpose. of circuit wires. * * * * * Resistance Coils. Self-Control. Reserve force. * * * * * Success, evidenced by Success, evidenced by profit. energy conserved and happiness secured. UNPROFITABLE DIRECTION AND USE OF ENERGY Small wires leading Aimlessness of purpose anywhere or nowhere. and timid, lazy or selfish isolation from sympathetic currents and constructive occupation. * * * * * Current carelessly Energy wasted in idleness grounded and electricity or worry. wasted. * * * * * Crossing of wires resulting Crossed temper--Anger--wasting in waste of power valuable energy and and possibly causing fire. possibly leading to rash acts causing life-long regrettable foolishness. * * * * * Placing flat cars on Importing worry an electric trolley line, through anticipated evil for instance, loading them on an hundred-to-one with pig iron and chance of its being realised, purposelessly running them thereby wasting aimlessly around the circuit, energy and paralysing the thereby wasting the digestive and repair electricity and wearing out functions of the body; the cars and the line. painfully wearing out the body itself. * * * * * Allowing cars to run Permitting Anger to wild instead of keeping run away with cool them under control. discretion. TELL-TALE EXCRETA It is unfortunate that the perpetuation of early ignorant abuses of Nature's pure intentions has led to a too prudish attitude toward the one infallible evidence of health conditions as shown by the refuse of repair and digestion, as it is only by the excreta that ultimate indication of the results of nutrition are observable. They are the reliable report relative to the most important thing in health--digestion--and they must be understood in order to be read. There is no knowledge so valuable in its relation to health as that which enables one to read health bulletins by means of the excreta. Different foods contain different elements of waste material and to be able to identify or judge the economic value of food previously consumed a knowledge of its digestion-ash is essential. A child should be taught the difference between healthy and unhealthy excreta in order to be on guard at the first warning of disorder, rather than be allowed to remain ignorant until disease has taken firm hold of the system. The knowledge is not complicated and can be easily acquired by even young children. When the possibility of perfect protection in the matter of nutrition is generally known, one mission of the physician will be to teach prevention of abuses of feeding by evidence of the excreta. The healthy fæces of many wild animals is comparatively dry, odourless and cleanly; and a farm barn yard or a decently kept city stable is not an offence to even prudish prejudice. Not so the vicinage of an open receptacle for the waste of human indigestion. In animals, offensive egesta are evidence of digestive disturbance owing to some unintelligent feeding on the part of attendants; in humans the cause and effect of offensive excreta are the same. When a race-or work-animal shows digestive disturbance the least intelligent owner or keeper knows that it is not fit for work or racing, and yet this symbol of unfitness is common to the human race. One of the most noticeable and significant results of economic nutrition gained through careful attention to the mouth-treatment of food, or buccal-digestion, is, not only the small quantity of waste obtained but its inoffensiveness. Under best test-conditions the ashes of economic digestion have been reduced to one-tenth of the average given as normal in the latest text-books on Physiology. The economic digestion-ash forms in pillular shape and when released these are massed together, having become so bunched by considerable retention in the rectum. There is no stench, no evidence of putrid bacterial decomposition, only the odour of warmth, like warm earth or "hot biscuit." Test samples of excreta, kept for more than five years, remain inoffensive, dry up, gradually disintegrate and are lost. The following observation by an eminent eye specialist and _litterateur_ illustrates the opening paragraph of this chapter. PERIODICITY The question of "when" or "how often" the solid excreta should be voided or released is one that immediately presents itself when the subject is under discussion. The common opinion is that "once-a-day" periodicity is the proper and only healthy thing, and should a day pass there would be immediate fear of "constipation." Under the best test conditions, before referred to, the ash accumulated in sufficient quantity to demand release only at the end of six, eight, or ten days, the longer periods of rest being the evidence of the best economic and health results. Under ordinary conditions of carelessness and strenuous environment, say an exciting and exacting city occupation, twice a week is as often as one should accumulate a deposit of digestion-ash and feel sure that the strain on the system is not excessive and dangerous. Young people seem to thrive even when delivering daily a large quantity of smelly excreta; but it is an abuse of the "ten-horse reserve"[10] with which the human engine is supplied; and along in the "forties" or the "fifties" or the "sixties" the body shows signs of premature wear when it should be but in its prime. [Footnote 10: Dr. Meltzer's estimate of human reserve strength and resistance which must be out-worn or over-strained before death calls a settlement.] Another important matter should be mentioned in this exchange of sanitary confidences. When the ashes of digestion are dumped the body should assume the shape of the letter Z. It is the natural position of primitive man (squatting on his heels), and the body was originally constructed on that plan. If otherwise poised (sitting erect) the delivery of digestion-ash is performed with the same difficulty as would be experienced when trying to force a semi-solid through a bent or a kinked hose. The publication of the observation of Dr.----, here following, is a breakaway from the prudery of a diseased and disgusting age,--a protest jointly shared by the scientific observer and the voluntary test-subject, whose only aim in the pursuit of the study to "a finish" is the ultimate benefit of the human race. SCIENTIFIC OBSERVATION OF A LITERARY TEST-SUBJECT "During his sojourn in Washington in July, 1903, I saw much of Mr.----, and in a very intimate way. The weather at that period was very hot, sometimes near 100°, and very sultry. For ten days or two weeks in the midst of this season he was busily engaged in constructive writing, turning out on an average some eight thousand words on his typewriter daily, which meant a close application for ten or fourteen hours each day. He usually began his work at from two to five o'clock in the morning, continuing often until three or four o'clock in the afternoon, when we would commonly go together to a ball game, which he enjoyed with the enthusiasm of a boy of twelve. Later in the evening he would resume his work for from one to three hours, retiring at from ten to about midnight. His food consisted of a glass of milk with a trace of coffee, and corn 'gems,' four of which he consumed in the twenty-four hours. Occasionally he would add in very hot weather a glass of lemonade. There was at no time any evidence of mental or physical fatigue. That such an amount of work, with the maintenance of perfect health, could be accomplished on such a small quantity of food can be accounted for only on the assumption of a complete assimilation of the ingested material. As the degree of combustion is indicated by the ashes left, so the completeness of digestion is to be measured by the amount and character of the intestinal excreta. A conclusive demonstration of thorough digestion in Mr. ----'s case was afforded me. There had, under the _régime_ above mentioned, been no evacuation of the bowels for eight days. At the end of this period he informed me that there were indications that the rectum was about to evacuate, though the material he was sure could not be of a large amount. Squatting upon the floor of the room, without any perceptible effort he passed into the hollow of his hand the contents of the rectum. This was done to demonstrate human normal cleanliness and inoffensiveness; neither stain nor odour remaining, either in the rectum or upon the hand.[11] The excreta were in the form of nearly round balls, varying in size from a small marble to a plum. These were greenish-brown in colour, of firm consistence, and covered over with a thin layer of mucus; _but there was no more odour to it than there is to a hot biscuit_. "The whole mass weighed 56 grams. The next day there was a further deposit of the same kind of dry-waste, making 135 grams (about 4-3/4 ounces) for the nine days. It seems to me there could be no more conclusive evidence of complete digestion and assimilation than this. The existence of perfect nutrition is indicated by his ability to continue, without fatigue and under trying conditions, work which could only be accomplished in an ideal condition of health. "WASHINGTON, D. C., July 31, 1903." [Footnote 11: Similar specimens of digestion-ash have been kept for five years without change other than drying to dust.] WHAT SENSE? TASTE[12] [Footnote 12: "Glutton or Epicure" was originally composed of two smaller booklets entitled "Nature's Food Filter; or, What and When to Swallow" and "What Sense? or, Economic Nutrition;" bound together. In this revision the order has been retained with some repetitions, but with different applications.] The Sense of Taste has a value in relation to nutrition that has not fully been appreciated. Taste has been considered the lowest, in usefulness, of all the senses. On the contrary, if properly understood, taste is one of the most important of all the faculties man possesses. Taste has lacked appreciation, for the reason that it has been supposed that it catered to sensuality, in the vulgar sense, and performed the function of devilish temptation rather than that of natural invitation and protection. Upon an examination, that any one can make for himself, however, it is revealed that taste is the faithful servant of appetite; the sentinel of the stomach, of the intestines, of the tissues and of the brain, whose guidance and warning, if heeded, will give heretofore unknown enjoyment of eating, and at the same time insure perfect health and the maximum of strength. * * * * * TASTE IS THE GUIDE AND GUARD OF NUTRITION The more we learn, the more evident it is that there is a _Perfect Way_ locked, or, rather, enfolded, in all of Nature's secrets, and that it is intended that man shall sometime discover them. Taste, in its normal condition, when allowed to direct or advise, serves several important functions, not the least of which is as first-assistant to Appetite. Appetite craves the kind of nourishment the body needs, invites to eating, gives enjoyment during the whole time needed for the fluids of the mouth and the stomach to do their part of the digestive process. Taste ceases when the food is ready for the stomach and thereafter fails to recognise the indigestible sediment which remains in the mouth after nutriment has been extracted; and, in these discriminations, if consulted and obeyed, Taste and Appetite prevent indigestible matter from entering the system to burden and clog the lower intestines, form deposits in bone, cartilage and kidneys, inflame the tissues, and otherwise create conditions favourable to the propagation of the microbes of disease. The normal sensitiveness of taste can be recovered, if already lost, in the course of a week, or two weeks at most, by means of the stimulating and regenerating influence of natural body-repair, if the method of taste and appetite cultivation recommended in this book is followed. Those who now enjoy good health will find a new joy in living when they have discovered the intelligent use of taste and submit the fuel of their Mind Power-Plant and strength to the analysis and selection of Nature's instinctive agents. LATEST DEFINITION Dr. William T. Harris, in his latest contribution to the "International Education Series," _Psychologic Foundations of Education_, defines the presently appreciated value of the sense of taste, as follows: "The lowest form of special sense is taste, which is closely allied to nutrition. Taste perceives the phase of assimilation of the object, which is commencing with the mouth. The individuality of the object is attacked and it gives way, its organic product or inorganic aggregate suffering dissolution--taste perceives the dissolution. Substances that do not yield to the attack of the juices of the mouth have no taste. Glass and gold have little taste as compared with salt or sugar. The sense of taste differs from the process of nutrition in the fact that it does not assimilate the body tasted, but reproduces ideally the energy that makes the impression on the sense organ of taste. Even taste, therefore, is an ideal activity, although it is present only when the nutritive energy is assimilating--it perceives the object in a process of dissolution. "Smell is another specialisation which perceives dissolution of objects in a more general form than taste. Both smell and taste perceive chemical changes that involve dissolution of the object." If this is the recognised estimate of taste, which is true as widely as I have been able to inquire, both among physicians and among the latest books on health, it is certainly a case of neglected appreciation such as the world has not witnessed up to the present time. * * * * * PRESUMED CAUSES OF DISEASES On the undisputed authority of physiologists it is known that all diseases are made possible by derangement which is favourable to the propagation of the microbes of disease, or by deposits of inharmonious matter which are not thrown off. Derangement of all the substance of the internal body is effected mainly, and probably entirely, by deposit of indigestible food or of tissue which is broken down and is not thereafter expelled from the system by the ordinary means provided for the discharge of waste. These inharmonious deposits which cause so much direct and indirect trouble are mainly, and probably entirely, the result of excess of eating, or of wrong eating, so that the digestive organs of the body cannot take care of what is forced on them; or, of admitting substances which they are powerless to make into good blood or discharge by the regular means provided by nature. Right eating and right food are, then, the all-important considerations of health, as far as the tissues are concerned; and, as the tissues are themselves the stored food or fuel of the brain and the nerve centres, the importance of perfect nutrition extends to the most vital functions and interests of life. TARDY APPRECIATION All experience warns against overeating and improper eating as the most common causes of disease; and troubles of the stomach and intestines are known to be the parents of all other bodily ills; yet no fixed guide has been set to determine what is "overeating" and what is "improper food." The reason for this is probably because no two bodies require the same quantity or kind of nourishment, and, "What is one man's food is another man's poison." Nature has not been so unkind, however, as to leave man without a means of knowing just how to gauge the quantity of food required for her best service, and probably, when we learn the secret, has equally well provided us with certain discrimination relative to the quality of food that is best for harmonic development. Investigation never fails to find provision for both guard and guide in all of Nature's plans and man's nutrition is of such importance that she surely has not left it out of the list of the protected. Of the power of taste to discriminate accurately in the matter of comparative value of foods I am not sure as yet, although I am confident the power rests somewhere within our reach if we can only discover it; but I have the best evidence possible that taste has the power to advise accurately in the matter of the _kind_ of food and the _quantity_ required; and, having selected what it wants or needs out of a morsel of food, rejects the rest by ceasing to taste. The message or warning which taste gives in connection with eating is, "THAT WHILE ANY TASTE IS LEFT IN A MOUTHFUL OF FOOD IN PROCESS OF MASTICATION OR SUCKING, IT IS NOT YET IN CONDITION TO BE PASSED ON TO THE STOMACH; AND WHAT REMAINS AFTER TASTE HAS CEASED IS NOT FIT FOR THE STOMACH." WHAT SENSE? When one comes to think about it, what sense is there in throwing away a palatable morsel of food when the taste is at its best, or while taste lasts at all, even if the purpose of the meal is merely to contribute to the pleasure of eating? "Some people live to eat and others eat to live" is a saying that is familiar to everyone, and yet how few appreciate that the perfection of living includes the perfection of both these desiderata! Such is the impetuosity of uncultivated or perverted human tendencies that the desire for acquisition, sometimes called greed, impels one to swallow one mouthful of food to take in another, without ever dreaming that the very last contribution of taste to the last remnant of a delicious morsel is like the last flicker of a candle, more brilliant than any of the preceding ones. In eating, the last taste, when saliva, the medium of taste, is most perfectly in possession of the solution, is better than all the other stages of the process. It is the choicest and sweetest expression of the incident, as related to each mouthful. Then why not court it and obey, thereby, Nature's first law of health? * * * * * Before proceeding further with a description of its functions it may be well to state briefly the certain result of following the guidance and heeding the warnings of taste. Taste determines the mastication of food so that the requisite quantity of saliva and other juices of the mouth are added in transit, so that the stomach and the intestines will have the least possible to do in the matter of conversion of the food to blood, and so that the brain and nerve centres will be taxed the least possible to assist the stomach and intestines in their work. If Taste is heeded in its invitation and its warnings, that which passes into the stomach will be so suitable and ready for nourishment of the body that the smallest possible quantity will serve the purpose and almost no waste will be left to tax and disease the lower intestines, while the absence of fatally inharmonious deposits in the tissue and bone will cease to exist in proportion to the skill with which one interprets the warnings of Taste, and in response to the care taken in following them. DISEASE PREVENTED It is said that none of the microbes of disease can live an instant, and hence cannot propagate, in a perfectly healthy human tissue. It _is possible_ to secure the perfectly healthy human tissue, to both the generally healthy and to those who are afflicted, unless too far gone to reform, by keen attention to the direction of Taste, and the reward of the attention is manifold. The actual pleasure derived from eating under the direction of the method suggested herein cannot be equalled by any other means. * * * * * While cheerfulness, hopefulness, good nature, charity and all the mental good qualities are splendid forced-draughts of oxygenised impulse that assist the stomach in consuming and otherwise in taking care of any erratic or excessive food supply, and are able to help take care of a moderate glut of material; Taste, if allowed to serve its full purpose, furnishes its own draught of cheerfulness by means of the very pleasure it distributes, and at the same time it prevents, instead of inducing, gluttony. * * * * * There are two ways of putting a limit to a meal--to eating. One--the wrong one--comes in the shape of a protest on the part of a too full stomach while the appetite is yet ravenous. The right one comes naturally from a perfectly satisfied feeling--a ceasing of desire for anything more, no matter how previously alluring to the palate, before the stomach is overburdened. The former is evidence of glut, or gluttony, and the latter is Nature's way, for which there is every desired reward. SOME EASY EXPERIMENTS It is a very easy matter to prove for one's self that ample saliva is essential to the most economic and perfect digestion; and also, that no two mouthfuls of food require the same quantity. Experiment will be doubly interesting in that it reveals pleasure of taste in eating that has not before been enjoyed. The function of saliva in digestion has commonly been understood to be the lubrication of the food so as to enable it to be swallowed. The truth is that it is the first and most important solvent necessary to digestion, the good offices of which are to separate, make alkaline, neutralise, saponify, and otherwise render the succeeding processes within the delicate organs of the body as easy as their delicacy requires, and thus not to strain and inflame them into festering breeding grounds for the myriads of microbes of diseases which we are compelled to draw in with every breath of air we inhale. Drawn into a perfectly clean and healthy organism, some microbes aid and are a part of life, but taken into a system clogged by dirt and strained by overwork, these same harmless creatures become agents of destruction. Bacilli may be either friends or enemies and we have the choice. * * * * * NATURAL LIFE LIMIT It is said that the natural life of all animals, left to pursue a natural existence by being protected from the enemies of their species, and in reach of sufficient nourishment, is six times the growing period. If this is so no man need die or move his soul to another habitation until he has occupied the present one for from one hundred and ten to one hundred and forty years. If the proper use of the instincts and senses be conserved in children, the growing period may be prolonged to probably twenty-five years with a resultant tenure of life of one hundred and fifty years. I have personally interviewed a patriarch, who, at sixty-five, was awaiting death with constant expectancy, and was helping to attain it by every sort of favourable suggestion. It happened that he had his portrait taken in a photograph gallery on his sixty-fifth birthday as a last souvenir to be distributed among his friends. Shortly after that, in the fruity and salubrious foothills of the Pacific Coast of California, he met with accidental suggestion which changed his habits of living, and, very soon, his attitude toward life and death. I sat with the patriarch on his one hundredth birthday in the same photograph gallery, examined the portraits of sixty-five and one hundred years, conversed with the subject in a low tone of voice, looked upon a man who felt that he was yet in middle life, and in possession of an enjoyment of life that he said had never been equalled in the early years of his bondage to the ignorance and impatience of youth.[13] [Footnote 13: The rejuvenated patriarch is still alive in 1903.] * * * * * STUDY NATURE Watch good Nature, observe her methods, try to imitate them by way of experiment, and you will find that, as heretofore stated, there is a _perfect way_ enfolded in all of Nature's problems and that man has only to discover the way to have it freely accessible to him. Watch a child take its nourishment in natural manner. The sucking action is like the act of mastication in that it excites the glands which supply fluids to the mouth. Whatever number of these fluids there may be, I will class them all as saliva. Certainly in the case of milk being taken into the stomach, saliva is not needed to lubricate it. It is, therefore, reasonable to suppose that saliva is intended as a part of the mixture necessary to digestion; that is, to the conversion of the food into nutriment. In the case of children nourished at the breast of the mother--the only natural way--the food is already alkaline and ready for digestion in the stomach and intestines as related previously. Remember also that, in the case of invalids with very weak stomachs, physicians recommend taking milk and broth through a straw or through a glass tube. Taking fluid this way requires a sucking action of the mouth and thereby induces a flow of saliva. _Of course_, the fluid is better digested than when drunk because Nature's way has been followed, and it is no wonder that milk and often soups of different kinds are indigestible, if taken contrary to the natural way, except in digestive systems which have not yet exhausted their ten-horse-power resistance capacity. I have tried milk and soups upon a stomach trained down so fine that it was like a pair of apothecary's balances, sensitive to the least inharmony, to find that if they are drunk there is a mild protest--a sort of a shrug of the shoulders, as it were--and that when the same liquids have been moved about in the mouth for the time necessary to naturally excite the Swallowing Impulse, they have passed into the stomach without the owner being conscious afterwards of their presence except by feeling of complete satisfaction. It would seem, therefore, that the perfection of nutrition requires the proper mixture of saliva added to _all_ food substances, and that mastication is not only a means of separation in order to give saliva a chance but a valve opener for salivary glands in order to make the proper solution for the stomach; and, that taste exists, in one of its important functions, to indicate how long the process should continue and when it has effected its healthful purpose. Any one who tries it, no matter how perverted the taste has become by abuse, will find that Nature is not only kind but alluring. Meat or bread, without sauces or butter, are tasteless, in a degree, when first taken into the mouth dry. It is for this reason that butter, sauces, salt, sugar, etc., are used to make them what is called palatable. It is the salt or the sugar or other spices in these which excites the palate immediately when the dry morsel would not do so in such marked degree. If you take the meat or the dry bread and masticate sufficiently, allowing the nutriment to become thoroughly solved by the saliva and separated from the _dirt_,--the indigestible, tasteless remainder--the taste will become more and more delicious as the saliva gets possession of the solution, and will have a final delicacy which sauces cannot equal, as a reward for pursuing Nature's invitation and rendering her the appointed service. An easy experiment that will prove the above statement to be correct is to take a variety of breads, white and brown, toasted and untoasted, crust and soft, and afterwards some of the same soaked in soup or milk, or, in the juice of whatever meat you happen to have at your meal. Taken dry, toast will only reduce and disappear, without effort of swallowing, into the stomach, leaving no tasteless dregs behind, after about thirty actions of the jaw. This is probably the reason why toast is an invalid's best diet; because mastication is required to crush it, saliva is liberated by the acts of mastication, less saliva is required to prepare toast for the stomach than any other form of bread, and therefore, the proper conditions are attained _perforce_, and easy digestion is promoted. Crust of French bread will do the same by means of about forty jets let loose by mastication; the soft inside of French bread will require fifty, or more; crust and inside of biscuits and of "home-made" bread somewhat more than the French bread; while "Boston brown bread" requires as many as seventy to eighty jets turned on by action of mastication to dissolve it. The above refers to moderate mouthfuls. The process is incomplete until all is dissolved, taste ceases, and natural swallowing occurs. Will it not be observed that mastication, as far as crushing or mangling is concerned, has small part in the reduction of "Boston brown bread," and little seeming use except to turn on the jets of the solving saliva, for the material itself is soft, and sometimes "mushy"? Saliva has little use as a lubricant in this case, for the reason that the brown bread experimented with can be easily swallowed when first taken in the mouth. Abundant experiment has been made by those to whom "Boston brown bread" was formerly little less than a poison, to prove the assertion that, sufficiently mixed with saliva, it is perfectly digestible and that the delicious taste of the bread after forty or fifty bites (1/3 to 1/2 minute) gets sweeter and sweeter, and attains its greatest sweetness and most delicate taste at the very last, when it has dissolved into liquid form and most of it has escaped into the stomach. It will be noticed that the time, or attention, required to solve these different problems of nutrition as embodied in different sorts of breads is exactly proportionate to their recognised digestibility, and explains the reason why hot and "soggy" biscuits, after the American fashion, and "Boston brown bread" have been classed as not easily digestible. Still further proof of my contention in favour of the importance of taste as a guide and guard in the process of nutrition is that, if you soak soft bread, or even toast, in the juice or gravy of any meat, the number of masticatory or tasting movements necessary to fit it for the stomach and satisfy the taste will be about the number required to masticate raw meat from which the juice has come and not such only as would seem requisite on account of the softness of the substance when made pulpy by soaking and which might be forcibly swallowed at once. Tests like these alone are sufficient to prove my contention, but, when the result of the experiments is so immediate for good in every direction, as it has proved itself to be in all cases tried, there is no longer doubt but that Nature's most important secret relative to human alimentation has been heretofore practically undiscovered; that is, as far as any inquiry I have been able to make sheds light upon the subject. The result, in all the cases of my observation, has been an immediate response of naturally increased energy; approach of weight toward the normal, whether the subject was over-weight or under-weight; a great falling off of the waste to be discharged by the avenue of the lower intestines and also through the kidneys; relief of bleeding hemorrhoids and catarrh--the diseases suffered by the patients; emancipation from headaches; clearing of the tongue of the yellow deposit--usually called fur--that is an indication of rotten conditions in the stomach; and return of the energy for work which all men and women should have, and which finds expression in healthy children in the form of great energy for play. The tax upon the lower intestines has been, in my experiments, reduced so that there was no invitation to relief more frequently than once in four or five days, and the quantity of the deposit was less than half the quantity of a usual daily contribution to waste under former methods of taking in nourishment, thereby proving the fact that appetite and taste, when given full chance to serve, serve us well. This feature (quantity of waste) differed in the cases of the different persons experimented with according to the carefulness with which they obeyed the test injunctions. In some, greed abnormality could not quickly be overcome, but, as the subjects were selected in part from the stratum of society where want is the constant dread, it is not to be wondered at that a lifetime habit of tremor and greed should resist even the dictates of their reason. But it was in these that the revelation excited the highest appreciation at last when they were put in possession of faculties and strength that they had supposed the Creator had denied them in a world of suffering. There is no doubt but that it is possible to introduce nutrition into the system wherein, or rather wherewith, there is little or no waste material. One physician, to whom I applied for information, suggested that too fine an application of my method might finally do away with the lower intestines altogether from the same cause that any unused member of the body, and also unnourished members, shrivel and disappear in time. While this is possible, the means taken towards it are productive of marvellous good results; and, if there were no further use, what purpose would they serve?[14] [Footnote 14: Dr. George Monks of Boston, Massachusetts, has recently called the attention of the author to the fact that the length of the intestines in man have been known to vary from nine feet to twenty-nine feet. In the longer ones the _papillæ convenenti_ which serve for absorption and which line the inside of the intestines extended only part way down the channel, but in the shorter ones they lined the channel throughout its entire length, giving inferential evidence that the strain of continued excess of waste material had lengthened the intestines for the sole purpose of providing storage room for the waste. Metchnikoff, the head of the Pasteur Institute, Paris, has even proposed removing some eighteen feet of intestine by surgical operation, including the troublesome vermiform appendix, as being unnecessary in connection with cooking and the prevalence of partly predigested foods.] Think of the number of separate complaints that are attributable to trouble of the lower intestines, and think of the relief coming with their return to normal conditions in performing infrequent service with the ease of rejuvenated strength! Such was the case with all of the subjects under test, and it was a revelation which was as the opening of a new life to even those who had suffered least, and had thought themselves fortunate as to health conditions. I hope I will be excused for using the terms "dirt," "rotten," "glutton," etc. I know they will give a shock to sensitive conventionality, but is it not better to shock conventionality with a proscribed term, if it means just what it says, and nothing else, than to shock the delicate organism of our machinery of life by throwing dirt into its furnace with good fuel, and thereby allowing the glut of ashes therefrom to encumber the journals of our mechanism, to the waste of our power and to the wearing out of our machinery? * * * * * Disease is nothing but dirt in the system and the result of dirt. It is our own dirt at that, having been introduced by our own carelessness or as the result of combined ignorance and greed. Ignorance has excused and does excuse the responsibility; but, when we have providentially been provided a way by Nature to select and sift and prepare perfect fuel for the furnace of our Life-Power-Plant, there can be no further excuse for not following the teaching to the extreme of the last possible refinement. * * * * * I will not presume to say what and whom good Doctor Appetite, with the assistance of Doctor Taste, can cure. They have both cured and greatly relieved rheumatism, gout, eczema, obesity, under-weight, bleeding-piles, blotches and pimples, catarrh, "that tired feeling," muddy complexion, indigestion, and yellow-tongue, within four months. It has been revealed that attention to their invitation and warning cures unnatural craving and beautifully appeases appetite desires with one-third the usual food; and, at the same time, they teach an appreciation and enjoyment of food quite new even to _bon vivants_. Any person can employ Dr. Normal Appetite and consult Dr. Good Taste _free of all charge_, and make endless discoveries in the possibility of delightful and healthfully economic nutrition. The suggestion was originally given by the author in crudest form with the assurance of physiologists that trial of it involved no risk, but, on the contrary, that it led in the right direction toward preventing disease. I felt that it was too important to be withheld from those who do not know the existence of Nature's _perfect way_ provided by the Senses of Appetite and Taste. Record of careful tests and results will probably follow in another volume. The author has entered the field of investigation to find deterrents to Nature's perfect development and will not rest while any remain.[15] [Footnote 15: At the present time, five years after this promise was made, the author is happy to say that it has been faithfully kept and with important results steadily accruing.] With even the crude hint, _that health can be secured and maintained by consulting and respecting Appetite and Taste_, each person having either can assist in the investigation. SUGGESTION AND DIRECTIONS For initial experiment, do not change any of your present habits of living as to time of meals, kind of food, etc. Following the directions given hereafter will undoubtedly lead to just the right thing for you in these regards. There is no doubt but that the early morning meal is not productive of the best results in nutrition and strength, but it is better to have Appetite suggest the necessary change in accustomed habits. Dr. Dewey's advice in the "No-Breakfast" regimen is excellent. The getting-up craving is not an _earned_ appetite. Forced abstinence from a heavy morning meal will _surely_ bring about normal conditions of appetite which are best adapted to perfect nutrition, so that if the invitation to give up the morning gorge voluntarily does not overcome perverse habit, the heroic denial may be tried. The value of the discovery lies in recognising the fact that Taste still has important work to do with passing food while yet there is taste, and that what remains after Taste ceases to express itself should _not_ go into the stomach. The ease with which one will learn to enjoy and "hang on" to food in the mouth, even milk and soup, after he has learned a good reason for doing so, will quickly create a counter habit which is in accordance with Nature's _perfect way_. When one has discovered the delight of _that last indescribably sweet flash of taste_, which Taste offers as a _pousse café_ to those who serve it with respect, he will find _any_ food that Appetite selects is needed for his nutrition, and is good. Remember this! Salt, sugar, some sauces and spices which are used to make food palatable may be in themselves nutritious, but do not let them mislead you. The tendency is to relish them and think that they represent the food they disguise, which, however, is often only an excuse for them, and has very little nutrition itself. In this case a morsel of food is taken into the mouth, the sauce or spice which it carries meets immediate response from Taste and disappears, whereupon the indigestible food morsel is swallowed in indigestible condition so as to admit another sauce-laden supply. The most nutritious food does not require sauces. It may seem dry and tasteless to the first impression, but, as the juices of the mouth get possession of it, warm it up, solve its life-giving qualities out of it and coax it into usefulness, the delight of a new-found delicacy will greet the discoverer. It may be difficult, at first, to avoid swallowing food before it is thoroughly separated, the nutriment dissolved and the dirt rejected, but after a little practice there will be no difficulty. On the contrary, there will be an involuntary habit of retention established that will be as tenacious of a morsel of food till that last and sweetest taste has been found, as a dog is tenacious of a savory bone. Did it ever occur to gum chewers that the gum is simply an exciter of saliva, and that the sweet taste is the nutritious dextrin in the saliva and has nothing to do with the gum? In the ordinary "watering of the mouth" the same sweet taste is experienced. Another important fact in this connection, and which belongs in the list of "directions" because it is a leader, is, that perfect nutrition is a source of ample saliva, the effect thereby reproducing the cause in friendly reciprocity. It will be found that, when normal conditions have been attained through attention to the inspection, selection and rejection of Taste, when the tongue has lost its malarial yellow scum and when Hunger is represented by healthful Appetite and has dismissed bilious and insatiable Craving from its service, there will at all times be a delicately sweet taste in the mouth which will prevent craving for anything else. For instance, a person in possession of normal taste conditions may pass a confectionery shop or a fruit stand without temptation to eat of their wares, for they would _spoil_ the taste already in possession of the mouth. The expert wine tasters in Rhineland, where the full flavour of the luscious fruit is retained in the wine as Nature put it there, never _drink_ wine. They breathe it into the mouth and atomise it on the tongue with utmost relish. To them the swallowing of the precious juice without dissipation by taste is an unpardonable sacrilege. The Bavarians also, whose beer is the best in the world, practically do not drink beer as Americans are accustomed to seeing it drunk. They sit over a _stein_ of beer for an hour, reading or chatting with friends. The epicurean drinkers of what has been termed _eau de vie_ in France sit and sip a "pony" of their beloved Cognac while they enjoy a view of pastoral loveliness or a throng of passers-by in a boulevard of Paris. None of these people drink anything but water and hence are not drunkards; and, at the same time, they have full enjoyment of Nature's most stimulating and delicious compounds in a form preserved by Nature for the use of man. The taste of these students of nutrition becomes so discriminating that they can distinguish a wine or a beer or a cognac, as they would distinguish between intimate friends and strangers. The year, the vineyard, the state of the weather, or any accident that may have surrounded the development of the fruit are as distinguishable to these epicures in the essential juices as are the marks on men which indicate prosperity, happiness or any stamp of environment whatever. An epicurean cannot be a glutton. There may be gluttons who are less gluttonous than other gluttons, but epicureanism is like politeness and cleanliness, and is the certain mark of gentility. A physiological chemist, a friend of the author, who is responsible for the suggestion that the function of saliva in turning the starches of our food into nutritious glucose may never have been fully given a chance to act, thus accounts for the last delicate sweet taste which is attained by complete mastication. It is then a _perfect_ solution, and hence the delicacy of the taste. For illustration, try a ship's biscuit--commonly called hardtack--and keep it in the mouth, tasting it as you would a piece of sugar, till it has disappeared entirely, and note what a treasure of delight there is in it. Taste will teach the experimenter more than I can even suggest. I simply offer an introduction to Doctor N. Appetite and to Doctor G. Taste and state some of their excellences that I have discovered through their attentions to myself and others under my direction. I will, however, give a _resumé_ of my own experience as a guide. PERSONAL CASE, INITIAL CONDITION Age, 49 years; height, 5 feet 7 inches. Extremes of weight for fifteen years (in ordinary clothing) minimum, 198 lbs.; maximum, 217 lbs. Chest measure, varying but little, if any, 42 inches; waist measure (tailor's) 43 to 44 inches. Usual weight during the time, about 205 lbs. My experiments began near the middle of June, but with no systematic application until the middle of July, 1898; weight on June 1st, probably over 205 lbs., in summer clothing. SPEEDY IMPROVEMENT On October 10th, as a result of the experiments, weight 163 lbs., and stationary; chest measure same as before, but waist measure reduced to 37 inches, or one inch below the "tailor's ideal," and nearly down to the "athlete's ideal." The energy and desire for activity with immunity from fatigue, which was the characteristic equipment of twenty years ago returned, but not, of course, the trained muscular strength or suppleness of athletic days. The food invited by Appetite at this stage, the nutriment in which counter-balanced the waste in each twenty-four hours, consisted of about thirty ordinary mouthfuls of potato, bread, meat, or anything selected by Appetite, masticated and manipulated to the end. One meal a day was taken for convenience, and because it seemed, under the then existing circumstances, hot summer weather, to be the time set by Nature for eating. "I rise in the morning," as a champion pugilist once put it, "when my bed gets tired of me," which at the time was usually before, or at, daylight, and began writing or other work. By one o'clock I usually was "worked out," but had already disposed of practically a day's work. Then, in the middle of the day, when all the animals rest and some of them chew the cud, I took my meal. I had not, meantime, experienced a moment of craving for _anything_ since the meal of the day before, but I sat down with an epicurean appetite. The article of food on the _menu_ that first attracted me, I fixed my desire upon. At the time it was usually a meat or a fish, and there accompanied it only a cup of coffee, nine-tenths milk, bread and butter, and potato. Sometimes the meat selected was an _entrée_, and was garnished with rice and other fruits or vegetables. About thirty mouthfuls of these, disposed of in something less than twenty-five hundred acts of mastication or other movement of the mouth, and taking about thirty minutes to thirty-five minutes, satisfied the appetite so perfectly that all the ices and desserts on a sumptuous bill of fare had no attraction. In the meantime, water was drunk, in small portions slowly, and ice water at that, without restriction, to satisfy thirst, _but not_ when any food was in process. In the mouth the water was almost instantly brought to body-temperature and its coolness was very agreeable to all the senses. I now rarely take any water except in very hot weather when perspiration is active and then only enough to quench thirst, excess giving discomfort and necessitating more perspiration. Water injures digestion by being taken with meals only because it is used to wash down food not yet prepared for the stomach. It is the unfit food that is carried down by it and not the water that does the harm. One cup of _café au lait_, well sweetened, sipped and enjoyed according to the epicurean method, satisfied all desire for other sweets and created a harmony of variety that was simply perfect, while it was perfectly simple. I did not try to work, or think, for some time after the meal; that is, I did not force thought; but reading, a cat nap, a walk, a matinée, a ball game, or a ride in a trolley car were recreations which I was able to enjoy as a sort of _pousse café_ for two or three hours after the meal, and then the energy for work returned, so that if there were something yet to be done in the time before the accustomed bed hour, another day's work was easily accomplished. Athletic work, physical labour, extreme activity in any form, all benefit by the same treatment, as I have since been able to prove both personally and by experiment with others. The only difference is the greater waste of tissue, and the greater need for restorage, demanding an evening meal and possibly an earlier midday meal. Exercise, work, activity--anything that creates a demand for nutriment is the especial friend of Taste. It gives healthy appetite and hence there is plenty for Taste to do and he likes to be of service. At first, rules have to be followed in order to serve Economic Nutrition to the best advantage, but they soon become habits of life, or living, that will naturally come of themselves from attention to Taste according to these directions. It has been our experience, that if there are any diseases growing out of overstraining of the lower intestines, kidneys, liver, etc., they will soon disappear. Perfect nutrition does away with the waste until there will be no invitation to discharge oftener than once in four or five days, when the response will be easy and final, with less than half the quantity of an ordinary daily contribution. There are wealth, health, strength, long life, abundant usefulness and much resultant happiness offered as a reward for learning and following Nature's Perfect Way. When we learn that obeying Nature's Laws emancipates us from the slavery to cravings of unnatural appetite, releases us from constant attention on meals, does away with at least half the drudgery of woman's work and makes us immune from the attacks of microbes of disease, it is then no hardship to take a few lessons in the Art of Economic Nutrition. Every artificial method that has been suggested to coax Nature into changing her problems to suit man's poor interpretation has failed, but Nature has been patient withal. Her door to reform is never closed, and her patience is boundless towards prodigal and foolish children. Nature has put the keenest of the senses at the threshold of life to serve both as hosts and servants, but Appreciation has heretofore failed to recognise their true office, while Ignorance, blinded by Greed, has spurned and abused the best of servants.[16] [Footnote 16: The "symptoms" in the personal case of the author described above persist after five years' test and experience. The endurance-test of the half-century birthday in France, the observations of Dr. Burnett in Washington, and the examinations in the laboratories of Cambridge and Yale all tell the same story of a reformed and increasing efficiency even with five years of added age handicap, so that the logic of the advice originally given in this book stands proved, so far. I have had my weight reduced from 217 pounds to 130 pounds and felt best when lightest. I carry my weight at any figure desired, but most of the time carry a 20-pound handicap in winter and sometimes in summer to calm the fears of solicitous friends, who think I must be ill when I am not looking "robust." Extreme robustness is a great danger to life. A partner of the author in early days in California, several years his junior and just in the prime of life and fortune, passed away from over-robustness, as have many of the world's brightest and best citizens. Six of the author's chums of ten years ago have died because of too much robustness and worry. They heeded not. The author may follow them, any moment, but meantime he is enjoying life as never before.] SOME PERTINENT QUERIES If Nature has revealed a _perfect way_ to the easy solution of all of her problems, as related to the affairs of animals and plant life, WHAT SENSE is there in thinking that she has discriminated against her Chief Assistant in Cultivation, Man? If Nature has provided animals with keen discrimination in the matter of healthful food, WHAT SENSE is there in doubting her good intentions toward the highest form of animal in this regard? If Taste is the sentinel of the stomach and also the purveyor and inspector of nutrition, WHAT SENSE is there in ascribing to it the lowest place in the list of the senses? If we enjoy eating, and are eating, partly, for the pleasure of it, WHAT SENSE is there in throwing away a morsel until the taste has been extracted? If "dirt" is "matter out of place," which is the accepted definition, WHAT SENSE is there in calling unnutritious food by any other name? If taste is the evidence of nutrition, and ceases to act upon dirt, WHAT SENSE is there in hurrying food past the sentry-box of Taste without giving the inspector time to select the nutrition and reject the dirt? If the last flash of taste in dealing with a morsel of food is the best of all, WHAT SENSE in believing that Nature did not furnish that allurement for the wise purpose of inducing mastication to the end of taste? If saliva is the medium of Taste, without which there is no expression of taste, WHAT SENSE is there in thinking that it is nothing but a lubricant, to enable food to be easily swallowed? WHAT SENSE is there in slighting nutrition in the beginning when we know that the derangement of the process will continue throughout all the involuntary stages within the digestive organs, inviting disease and causing suffering? THERE IS SENSE in carefully attending to the voluntary preparation of the food for the stomach, so that the involuntary functions of digestion and of assimilation may be performed with natural ease and freedom, thereby defying and preventing disease! If we can save two-thirds of present consumption and yet furnish all that is necessary for perfect nutrition, WHAT SENSE is there in wearing out our Mind-Power Plant with a glut of surplus? Unless a person has a pressing engagement with his own funeral, WHAT SENSE is there in hurrying with his meals? If we can devote ten thousand actions of the jaw, daily, to senseless or vicious gossip, WHAT SENSE is there in denying adequate jaw service to the most important function of living? WHAT SENSE is there in a rich person glutting his Mind-Power Plant with more food-fuel than it needs, just because he happens to have an abundance to glut with, or glut on? WHAT SENSE is there in calling any glutton "a gentleman"? WHAT SENSE is there in calling any glutton "a lady"? If what Taste rejects, after having selected nutriment out of a morsel of food is _dirt_, WHAT SENSE is there in allowing it to contaminate and burden the delicate organs of digestion? An indigestible morsel of food is like a runaway team in a crowded street. WHAT SENSE is there, then, in demoralising things in the thoroughfare of our life organism by admitting unruly substance? An indigestible morsel of food in the stomach, and all the way through the intestines, is like a "bull in a china shop." WHAT SENSE is there, then, in smashing the delicate utensils in the laboratory of our Mind-Power Plant by rushing "bulls" past Sentinel Taste? A SCIENTIFIC POINT Physiological Chemistry declares that an important function of saliva is turning the starch of foods into dextrose--sugar--which is one of the high forms of nutrition. An eminent physiological chemist, who is a friend of the author, and who has been experimenting with the suggestions offered by the discovery of new uses for Taste in securing perfect economic nutrition, says that the inexpressibly sweet flavour which comes with the last expression of Taste in connection with a morsel of food, especially dry breads, which are largely starch, is evidence of perfect conversion of the starch to sugar by the action of the saliva. The sweet taste spoken of begins to be apparent in dry French bread after about twenty movements of the mouth, and increases until the whole morsel is dissolved and disappears into the stomach, leaving behind it a most delicious after-flavour. According to the quantity in the mouthful this process will take from fifty to one hundred movements of the mouth and require from half a minute to one minute. In this connection remember, please, that if you bolt a whole slice, or a whole loaf of bread in the meantime, as soon as it is wet enough to swallow, you will get little, if any, more nutriment out of it, and none of the exquisite taste that Nature's way offers as an allurement for obeying her beneficent demands. The way of Nature is the epicurean way; the other way is nothing less than piggish gluttony. Even if time for eating is limited, nothing is gained by bolting food. Thirty mouthfuls of bread thoroughly dissolved in the mouth will supply nutriment for a strong man for twenty-four hours, and the eating of it in the way recommended will give pleasure unknown in hurry. My physiological chemist friend assures me that I am right in asserting that man should _not drink anything_ but pure water, and _that_ for the purpose of quenching thirst. If anything is good enough to drink at all it is too good to waste on an unwilling stomach when grateful and hungry taste-buds are eager for it. Don't drink soup! Don't drink milk! Don't drink beer! Don't drink wine! Don't drink syruped sodas for the taste of the syrups! _Sip everything that has taste_ so that Taste can inspect it and get the good out of it for you! TASTE'S APPEAL Water has no taste, therefore, Taste does not call it to a halt, but says, "Go right on and do your work, there is nothing in you that I can improve; thank you for giving me a freshening up in passing. If people only knew what you and I know they would be wiser, wouldn't they? They would learn a thing or two about keeping their Mind-Power Plant in fine order and get rid of all their physical ailments, and be strong and happy, and live to be a hundred and fifty years of age with their faculties unimpaired. I say! you are on the outside and can give people a hint; why don't you tell them what I am here for! They set me down for a 'capper,' like one of those fellows that stand outside of cheap restaurants and invite passers to come in and eat. They don't know I am an expert in nutriment and can protect them from any harm in eating. I offer them also a first-class _bonbon_ taste, at the finish of my work to induce them to stay by and help me to do proper work, but they are all in such a blamed hurry that they never wait for the _bonbon_, and the result is that loads of dirt and indigestible stuff get by me and make endless mischief in the machine. I hear about it often enough you may be sure. All the sewer gas the indigestion produces comes back this way, spoils my comfort, and dulls my strength. You see, you can have a chance, perhaps, to learn for yourself and tell the people what I can do for them. I'm lodged in here in the dark where they can't see me and I have no means of informing them. "I wonder why it is that Mother Nature makes such a mystery of her blessings. She never advertises and never exhibits her best things plainly. All her precious metals are hidden away in narrow seams in the ground; her pearls are guarded by close-mouthed oysters at the bottom of the ocean; electricity is as slippery as an eel and absolutely invisible; in fact, Nature is the most retiring, in her habits, of all the expressions of Deity; and, consistent with herself, she has put me in here, in the dark and speechless, provided with powers of selection and discrimination, which, if understood and made thorough use of, will do for man all that he can desire. "The funny part of it is that the animals, other than man, use me instinctively and live their appointed time; while man, in his usual big-headed way, centuries and centuries ago, gave me the lowest place among the Senses, classed my chief agent and assistant, Saliva, as merely a 'pusher' of food into the stomach, and ever since he has been in too much of a hurry to live _quick_ to take the time to live _long_; and that's what's the matter with the world."[17] [Footnote 17: Thus ended the first edition; but in the revision its position has been changed.] IMPORTANT CONFIRMATION COMMANDANTE CESARE AGNELLI Commandante Cesare Agnelli, of His Italian Majesty's battleship, "Garibaldi," has been an earnest colleague of the authors in the Nutrition Study since the summer of 1900. Like the authors, he received in the course of experimentation such personal benefits that the continued observations have been a source of great pleasure ever since. I take from a letter, dated Taranto, Italy, some excerpts that are good evidence of the caprice of appetite under different climatic conditions together with some irrelevant matter, quoted for its good reading:-- "What a good, long, friendly letter! If it was your intention to spoil me, it certainly proved a success; and I feel so much obliged and thank you so much for the interesting description of all you saw and did during your absence from Venice this summer. "You are too good in remembering the few words of encouragement I said to you when you first spoke to me about your experiments. The fact is that I have always regretted that my assistance in the experiments could not be of greater service; and, really, of us two I am the indebted for gratitude for the great service your discovery has done to me since the lucky day I had the pleasure of your acquaintance. "My bad luck would not have it to allow my ship to go to England for the Coronation, though at first she was selected to be one of the three. Only two days ago I met one of our officers who was on the 'Carlo Alberto,' and he confirmed all that you wrote and all that has been printed about the magnificence of the naval review at Spithead. "I wish now that I were with you, to be able to talk about what happened to me during this last cruise of ours, in relation to observations of nutrition. I can only report facts and feelings, and you may be able to connect them and assign the causes. You know I do not usually drink wine, only water; well, on the coast of Africa I had such a distaste for the latter that I was compelled to take beer to quench thirst, nor could I even endure mineral waters. My desire for food was quite changed, my physiological craving dictating to me quite plainly, as in a doctor's prescription, what I wanted. Even the best fish in the Mediterranean did not satisfy me. To-day it was eggs and to-morrow it was cocoa, but never meat that I felt the wish for. But what is a new caprice of desire relates to my smoking. I could not smoke a single pipe nor a cigar; only could I tolerate cigarettes, and those quite without pleasure. At Smyrna I almost fed on ices and lemonades, but always and ever I could _eat_ (not drink) my cup of cocoa in the morning. The heat on the coast of Africa at Tripoli and Ben Ghari was intense, 108° and 110° Fahrenheit, with perspiration in proportion. "So it seems to me that appetite is changed to suit latitude or climatic conditions, and all that we call our exotic pleasures of appetite, such as smoking, etc., are dependent on our nutrition. Anyhow, even in the hottest days, my strength never gave way, and I never felt that lassitude and general unfitness for work that was my companion in past years in hot climates, as in the West Indies in '86 and '87. "I never miss an opportunity to spread the virtues of mastication, but most people are too indifferent to apply the practice long enough to get the habit established as we have acquired it. "The first part of our cruise brought a great deal of suffering to those who are not assisted by a proper discrimination in nutrition. There was a scant supply of good food, and the bad food was very bad. I managed to get the best out of it with the assistance of my curious appetite, and did not suffer inconvenience as did the others. But we were largely rewarded in Turkish Asia,--a really blessed part of the world,--and especially at Smyrna. My day began in the bazaar and ended there, my eyes enjoying Turkish and Persian art in all their manifestations, from the rich Bokhara and Khorassan carpets to the Damaseo inlaid works, Rhodes embroideries, and so on. One sees that art has come from the East, and in every branch of it the influence of the meridian is always discovered and perceived. My great regret was not to be able to take it all away with me to Venice and divide it with my esteemed friends there for our mutual enjoyment. Curiously enough, at Smyrna I found a good bit of Italian pottery that I secured for almost nothing. It would have been a great thing if you could have been there to pass those ten days in Smyrna with me. "I gave an order for some carpets to be made on measure, but it will take months to have them ready. Many people do not appreciate the old carpets, but to my taste modern ones do not have the velvety look or the _souplesse_ and the softness of the old ones. "I am sorry circumstances prevented my filling your commission. Had Dr. Van Someren been there, he is so fond of old things, I am sure he would have ruined himself. "It seems as if we would remain here the whole of this month, and then I hope for a fortnight's leave to go to Venice; and I look forward to the pleasure of a long chat together. (_Signed_) "C. AGNELLI." CLARENCE F. LOW, ESQUIRE THE VEGETARIAN TENDENCY CONFIRMED The relator of the following experience was conversant with the early researches of the elder author and gave mastication a trial for a time. He gave it too painful attention, as is apt to be the case with beginners, and the strain made the practice tedious and undoubtedly inhibited the secretion of the digestive juices, the same as worry and other distractions are known to do. After a very short trial Mr. Low declared that he could not get enough nourishment within reasonable time and came to the conclusion that much chewing did not agree with him although it might with others. With the issue of the reports of the Cambridge and Yale tests, however, the suggestion was given another trial, with the result, up to date, as reported below: "I thank you very much for the copy of Dr. Kellogg's book, the 'Living Temple,' just received. I have not had time to read it, but in looking over the chapter headings and knowing Dr. Kellogg's worth as an authority on matters of foods and diet I know that there is much of value for me in the book. I am much interested in that 'Chewing Song' that has been dedicated to you by Dr. Kellogg and think the idea an excellent one. "I have for some time been chewing _à la Fletcher_ and find it of great advantage. It is getting to be automatic and is losing its irksomeness. Indeed it already seems natural and produces some results not 'set down in the book.' For instance, I have no desire for meats and foods which do not lend themselves to the Fletcher method. This in itself is a great advantage. "By the way, I have not eaten meat since the 20th of last October (nearly a year), and I find I have gained greatly. I only desire two meals a day except when the exigencies of travel make a _light_ breakfast agreeable and desirable. By these means I have gained nerve force wonderfully and my muscular strength and endurance have increased so that I walk long distances and climb mountains easily. In fact, I do now with pleasure and avidity what I could not formerly do at all. They are the sort of things that are supposed to require a 'strong meat diet' but which under such a diet were impossible to me. Mastication and thorough mouth-treatment seem to allow the appetite to prescribe what my body needs and this is the essence and substance of your discovery. It pleases me very much that Drs. Kellogg and Dewey have confirmed your researches and find that your claims are not over-drawn. They have such splendid opportunities to test things dietetic and are such open-minded, natural-born altruists that their confirmation counts for even more than that of the very conservative men in Science who stand for scientific authority and who want a thing thrice proven before they give it endorsement. "I think my experience will be especially comforting to you because of my repeated trials and lapses. I can see now how important it is for one to practise careful mouth-treatment until the habit is acquired and the performance becomes automatic. There is no doubt in my mind but what there is a natural protection given us by nature which has been lost by perversion. I feel confident that you will get ultimate credit for the re-establishment of a rational habit of eating which, under normal conditions of food supply, is a protector against premature swallowing of food. "G---- has seen the result in me and he is dropping meat to a great extent and his breakfasts have dwindled to a mere fraction of what they formerly were. The same is true of M----." A FIVE YEARS' LAY EXPERIENCE The good fortune of yesterday, July 29, 1903, brought a telephone message from an old and very dear friend who has been impressed with the virtues of buccal digestion for the past five years. Five years ago my friend was a sick man, past fifty years of age. During his youth and early manhood he had been an optimist among optimists, leading a congenial life among agreeable friends, with the best the world had to offer in the way of recreation and fare. His great misfortune at the time was indigestion and the troubles that accompany indigestion. If he drank a small cup of coffee at night he could not sleep, and he was subject to the constant uncertainty of health and frequent recurrence of acute diseases that are common to the victims of luxury. The very ill-health emergency and dilemma of my friend led him to catch at any stray straw of hope or comfort. When we met, some months after the beginning of my experiments, he was compelled to note a great difference in my appearance; the portly and robust but heavy, short-winded and unwieldy friend of bygone years in sumptuous New Orleans had become "spare" and active, and told of improvement in health-conditions that seemed almost miraculous. The still-suffering friend was interested to the point of listening and trying the remedy. Half as a joke and half in earnest the regimen recommended by me was adopted and carried forward far enough to secure some noticeable good results. Following up these favourable results with continuance of the regimen brought progressive improvement of health and increasing conviction of the merits of thorough buccal digestion. The evidence of physical improvement resulting from five years' attention to buccal thoroughness in the ordinary course of an adventurous life is here given briefly from memory fresh from the telling: "You remember the state of health I was in when we met here in the Waldorf five years ago. The benefit of the recovery that I had secured at Sierra Blanca had been gradually lost, and I was pretty well down to my last legs again. If I hadn't been struck by the marvellous alteration in your appearance from what it was when I had seen you last, I should have been terribly bored by your relation of your experience, for I was sick to death of mention of cures and diet-regimens of all sorts. But you astonished me so by your changed appearance, and I was in such a hopeless condition, that I thought I would give your scheme a trial. Next day, my breakfast, which was also my lunch, for I was feeling too badly to get up earlier, brought me some sweet corn as one of the several items I habitually ordered. In giving this corn thorough chewing before swallowing I noticed that, while the inside of the corn liquefied readily and was quickly swallowed, there remained in my mouth a collection of the hulls, and these invited the bad table-manners of 'spitting out.' I removed this collection of refuse as delicately as possible, and, on examination, found that it consisted of hard substance that I had never noticed before in connection with cooked sweet corn. This set me to thinking. What had I not been putting into my stomach all these years in my ignorance of the constituents of this one kind of common food, and what not in other foods that I had not yet observed? "In continuing the observation further, I discovered that many of the foods that I was accustomed to take contained hard, insoluble ingredients or cottony fibre that got more and more cottony and refractory with mastication. In trying coffee, my favourite beverage, as you told me I might do if I handled it rightly in the mouth, I tasted it until it was absorbed or swallowed involuntarily just as you told me the expert wine-tasters and tea-tasters do. I sipped and enjoyed my small cup of coffee as I had never done before in my life, and knew afterwards that it had not hurt me as usual, as no immediate protest came from the stomach, which formerly had been the case. I slept the 'sleep of the just' that night, and awoke in fine form next morning. From that day to this I have not been troubled with indigestion, and during these five years I have not been sick a day or an hour or a moment, and have slept like a babe. I haven't kept my weight quite down where it ought to be for best comfort, but I have supported the burden with my general good health and digestion. My temptations to lapse have been enormous, for I have had the good fare of two continents thrown at me by most enticing invitation, and I have run the gantlet of extraordinary _menus_ without phasing, with the results I have recounted. "Do you remember the day of the public funeral of General Grant, when his tomb on the Riverside Drive--Morningside Heights--was dedicated? You remember that we had been invited to Mr. H----'s to witness the parade and take lunch? How we were caught on the wrong side of the procession on Fifth Avenue and were hurrying to get ahead of the column and across to the other side of the Avenue? Well! do you remember how we puffed and blowed when we had run a couple of blocks and how we were red in the face and nearly knocked up? We were both fat then and short-winded, and we never would have been able to get to our destination if I had not hypnotised a policeman and persuaded him to lead us across the Avenue like a pair of emergency hospital cases or disorderly arrests. "Since then you have had your experience of recovery as the result of your deliberate experiment made for a purpose, and I have had mine as the result of noting the improvement in you, and for all of which I owe you my life, whatever that may be worth. "At the time of the great Naval Review, or something of the sort--I have forgotten what--a party of us went to the pier of the Southern Pacific Company to see the show. There were Ned H----, and Captain H----, and two other men, and myself, with four ladies. On coming up town we were booked for another engagement, the time for which had not yet arrived. We were in the vicinity of the Hoffman House and drifted in there and into the ball-room. The floor was most tempting and the orchestrion willing. It was too suggestive a combination for the ladies, who were young and fine dancers, and they exclaimed with one voice, 'Oh, how lovely! I wish we might dance.' It proved that I was the only dancing-man among the men. I had been a dancer in my younger days, but I had let up on it since I had become stout. However, by way of a joke and to please the young ladies, I offered to be a partner. My offer was accepted, also as a joke, but the sequel was a surprise. We set the orchestrion going on a Waldteufel waltz, and I grabbed one of the young ladies for a round. Really, I was amazed. I danced as easily as I did when a youngster, and round and round we went. Finally, my partner begged for a rest, so I waltzed her to a seat, and, excited with the revelation of an endurance I did not know I possessed, I grabbed the next lady from her seat and repeated the tiring-out process as easily as in the first attempt. There were yet two ladies fresh and eager to assist in 'doing Uncle Nat up,' and I repeated the performance with them, also, dancing the last to a dead standstill on account of her determined obstinacy. _She_ had to complete the 'doing up' of the old man, or Age would win a battle from Youth, which would never do. Well, to make a long story short, and to get to the illustration. I was warm and ruddy, but I was less fatigued than I remember to have been as a youngster when I had danced for a long time. "Since then I have not balked at any feat of physical endurance, and I feel as young to-day as my white hair will let me. I have tried to get my friends to chewing their food persistently, and have gained many adherents to your cause, but I have had to stand an immense amount of chaffing meanwhile. I tried to get Mr. H---- to chew his bread and milk, but he always laughed at me, and chaffed me constantly when I was with him about my chewing fad. One man, whom I saw much of, and who needed your advice more than anybody else, got so sick of the subject that when I received a letter from you, telling of some new discovery and some new triumph of the cause of chewing, I would attempt to read it to him; but he would not listen, and persisted in calling it rot, although he knew that I had become a remarkably well man, whereas I was formerly a very sick man. Both of these scoffers have gone and I am left, as chipper and as fit as a fiddle new-strung for the music of a happy life. If we don't catch up with Luigi Cornaro on our record it will not be for want of good digestion." This is a little bit of intimacy that the good Baron Randolph Natili will not object to offer in evidence in our cause; for no one living has a heart and a will to do a favour or spread a benefit more than he. Only yesterday he said, in a burst of enthusiasm, "How is it possible for me to dislike any one, feeling the way I do? I have likes immensely stronger than other likes on account of similar or closer sympathies, but it seems to me now that to really dislike any one that the Creator has made, or anything that he has created, would do violence to the Memory of My Mother." DR. HIGGINS' CASE AND COMMENT "DEAR MR. FLETCHER: "You ask me to write you a short account of my experiences with economical nutrition with comments, and a few words about my physical and mental history. "_Previous History_:--The best period of health that I can remember in my life was that between seventeen and twenty-one, during the time I was preparing for the medical profession. I had a small breakfast at about 7.30 A.M. and then went up to London to St. George's Hospital, which was about fourteen miles from my home. My parents gave me 2/6 for my midday meal but I fortunately economised and only spent 6_d_-10_d_ of it on food. After finishing my work I usually arrived home at 5.30 and had a 'meat tea'; this allowed me to devote six hours to reading. During the whole of this period I was in excellent mental and physical condition. I was made house surgeon at twenty-one, obtained my degree in under four years besides obtaining several valuable prizes. "After this I lived in the Hospital where three meat meals were provided. These I conscientiously ate 'to keep up my strength' during the performance of my exhausting duties. I consider that this period was the commencement of my degeneration. I put on twenty-four pounds in weight and lost much of my mental energy. "To condense, as much as possible: my strong hereditary tendency to gout with the excessive meat eating, the hurried eating during some three and one-half years at St. George's Hospital, London, and at Addenbrooke's Hospital, Cambridge, resulted in constant suffering from headache, lumbago, rheumatic pains, and all those distressing symptoms known under the generic name of 'goutiness.' After seven or eight years I weighed two hundred and twenty-four pounds and complained of increasing symptoms of gout. I then became a patient of Dr. H----, of London, whose system requires one to abstain from meat, fish, poultry, beans, tea, coffee, in other words, from foods containing uric acid or its equivalent. For about five years, till the end of 1901, when I first met you, I fluctuated considerably in health, on the whole I am bound to say, in a steadily downward direction, till I was overloaded with the excessive weight of two hundred and eighty-two pounds. "_History of Period of Regeneration_:--I commenced under your advice, masticating my food thoroughly at the end of December, 1901. After practising this method till the present date September, 1903, I have lost one hundred and four pounds in weight and consider that I have gained very considerably in mental and physical fitness. I prefer to divide this period into two parts: (_a_) _The first eight months._ During this time I followed my appetite, but with a strong mental bias in favour of keeping up as nearly as possible to the daily 'physiological ration' of nitrogenous food. I lost notwithstanding some sixty-four pounds in weight in spite of having an inordinate appetite for butter, and generally taking two pints of milk daily. During this period I undertook some very severe work in the Laboratory of Physiological Chemistry, with the object of trying to devise some method of measuring the extent of a person's departure from their optimum health. This led almost unconsciously to a stronger mental bias in favour of prescribing the amount of food one should eat, and to a certain number of experiments in feeding. Towards the end of this period I got rather exhausted in consequence of my severe work and complained of occasional headaches. Following the suggestions of some friends I added fifty grams of casein to my daily diet for two or three weeks. This was followed by a return of rheumatism and considerable sickness and inability to work. (_b_) _The subsequent six months._ I resolved to devote this period to a careful study of my desires for food--to take no notes--to make no experiments--in short, to allow my body to run itself, and to try to make my brain interpret the wants of the body. I had moved for the purpose of this experiment into a small house, with a boy and a woman who came daily to clean the house--(I mention these details because practically one finds that a woman has usually such quick sympathy about matters concerning food, that their agitation and fears are enough in themselves to cause you to modify your diet). I only kept bread, butter, and milk in the house, all other foods I was obliged to send for, and if I required a dish to be cooked, I first learned how to do it myself and then taught the boy. I had no fixed times for meals, and did not have a table laid, my food always being brought up on a tray; usually I did not interrupt the work I was doing. I deliberately adopted all these precautions because I had become aware by experience of the extraordinary influence suggestion, and other mind influences, such as habit, had in one's selection of food and the amount one ate. During the first two months in conscientiously eating what I wished, as much of it as I wanted and when my appetite demanded food, my desires were very irregular, ranging over meats and fish, (occasionally) chocolate, sweets, cream, cheese, butter, milk, bread, potatoes, oranges, bananas, sugar, etc., but during the final period my desires were much more simple and regular, confining themselves to bread, Gruyère cheese, butter, cream, bananas, potatoes, occasionally milk. During and subsequent to this period I have become convinced that provided you eat your food slowly and follow your appetite, without guidance from any other knowledge whatever, one gets marked preferences for simple foods with increasing health and happiness, the contentment that comes from the inestimably valuable possession of simple desires. "_Comments on the System_:--The great attraction the system has for me is its frank admission that: (1) One knows practically nothing of those chemical processes that occur during digestion. (2) The guidance for the conduct of life afforded by such vague phrases as 'the collective wisdom of mankind' leave one on the most superficial examination in a state of great doubt, to say the least of it. (3) The guidance afforded by the dogmas of science are open to the most disquieting criticism. (_a_) In the prescription of method without a knowledge of the mysteries of digestion. (_b_) In those observations on insufficient standards of mental and physical optimum efficiency, and of short periods of observation based solely on nitrogenous equilibrium and output of work that you have already shown to be fallacious and variable. (_c_) In short, that one can say that none of the physiological dogmas based on chemistry are not open to criticism. "If this is admitted, and the choice of the quantity and quality of food thrown on taste and appetite, we are at once provided with a natural means of ascertaining the body's actual wants from day to day. The phenomena that have resulted from the more thorough insalivation and mastication of food can only be described as remarkable and of the highest importance for the progress of that most important of all sciences, the right conduct of life. The great advantage of finely dividing the food in the mouth so as to present as large a surface as possible for the action of the intestinal juices, is obvious when one reflects on the rapidity with which bacteria can and do act on pieces having a smaller area in consequence of their larger bulk. When one reflects that Dr. Mott attributes the main cause of insanity to the absorption by the body of the cleavage products produced by microbes in the intestines, and the increasing recognition of such poisons in the causation of chronic disease and disturbances of health, this factor alone would afford an explanation of some of the phenomena induced by the practice of economical nutrition. "A method having the results that this has it need scarcely be said is revolutionary; all one's preconceived notions of the conduct of life are found to be based on grounds open to grave criticism and it throws a great responsibility on all those concerned in its study to endeavour by all the means in their power to present a more completely demonstrated and unanswerable case to those who are responsible for the world's guidance in these matters, with as little delay as possible, "Yours faithfully, "HUBERT HIGGINS, M. A. CANTAB. M.R.C.S., L.R.C.P. "Late House Surgeon to St. George's Hospital, London, and the Addenbrooke's Hospital, Cambridge. Demonstrator of Anatomy to the University of Cambridge and Assistant Surgeon to Addenbrooke's Hospital." QUARANTINE THE NECESSITY OF PROTECTION NOTE: A paper, read before members of the Unity League and other guests of Mr. and Mrs. William S. Harbert, at Tre-Brah, Williams Bay, Geneva Lake, Wisconsin, in August, 1898. It is pertinent to the subject of this book, but was written when the investigations described herein were just beginning. Progress of Civilisation is accelerated by constantly extending systems of individual, moral, social and sanitary quarantine. It is not what man adds, for he can _add_ nothing, but what he prevents, that aids growth. Man creates nothing, but he assists Creation by removing deterrents to growth. Growth is spontaneous, constant and ever stronger if obstructions are removed. Creation does _all the growing_, but _cultivates_ nothing; the seed falling upon good soil or upon stony waste without other direction than that given by the caprice of the winds. On the other hand, Man is the _only cultivator_ in Nature, and at the same time he can add nothing to growth--to Creation. Visible, or conscious, growth consists of cell building or thought producing. Man never has created a cell, neither has he been able to determine the origin of a thought; yet, he is a necessary factor in evolution and a prime factor in cultivation, which is civilisation. Man removes deterrents to growth. Nature "does the rest." Thought and cell creation are spontaneous and are never-ceasing if all obstructions are removed from about them. Civilised man places a quarantine against the enemies of growth, of progress, and of harmony, and thereby promotes civilisation. Man is, therefore, the Chief Assistant to Creation, the Architect of Civilisation and a _Full Partner_ with Nature in Evolution. This distinction, adequately appreciated, lifts Man above the animal plane and gives him a place among the gods; his material form, composed of muscle, hands, powers of locomotion and speech, being but tools with which to harness and coöperate with the other forces in Nature, under the direction of the godlike attribute of the Mind, in the removal of deterrents to free growth, and the cultivation of that Harmony which is the symbol of God. * * * * * Having assumed as an hypothesis that Man is Full Partner with Nature in Evolution; and having discovered his proper function in the "Division of Labour" in Nature, it is time for each of us to analyse the conditions which environ us as Man units, select those which seem to be useful to our scheme of construction and harmony, declare all deterrents to the growth of our selection to be weeds, and then proceed to remove them without delay, first, by pulling those which now exist, and following that by establishing strict quarantine against them. * * * * * I can teach only that which I have learned, and pronounce good only that which has led to happiness. I will therefore note the progress of my own discoveries and describe those which have brought increasing happiness, in order that they may serve as beacons and monuments to such as may seek the same goal along the same lines of inquiry. The first forty-five years of my present life were spent in seeking happiness by means of personal accumulation. Money, friends, distinction, acquaintance with art in all its various expressions, lands, luxurious homes in favoured localities, pictures, rare porcelains, lacquers and other possessions, isolated for my own use, and for the enjoyment of chosen friends, seemed to be the necessary desiderata of happiness. In turn, all of these came to me in sufficient abundance to give, at least, a taste of their quality and their efficacy in promoting happiness; but, in the midst of them were always obstructions to unhampered enjoyment, increasing with possession and accumulation of the coveted means, and constantly mocking, as with a mirage, the ultimate ideal desired. During these forty-five years of quest of happiness there were constantly appearing above the horizon of my search flashes of hope, leading in new directions, which proved in turn to be but will o' the wisps, until the night--the morning--of my awakening, as related in my book "Menticulture." It was then, for the first time, I heard that it was possible to _get rid_ of anger and worry, the _bêtes noires_ of my existence, which were, as I then believed and as I now know, the dreaded barriers between me and perfect happiness; not because the mere removal of these particular deterrents to happiness will accomplish happiness, but because the certain result of the removal of any principal mental obstructions leads to the disappearance of contingent errors, and permits freedom of growth of the elements of true happiness. * * * * * It is proper to state here the definition of happiness which is the result of my progressive quest. There is only one quality of true happiness, as there can only be one kind of quarantine, and the former is dependent on the latter. If both are not _perfect_, both fail. True happiness is _the evidence and fruit of conscious usefulness, and quarantine against obstructions to normal altruistic energy is the best means of attaining happiness_. In view of the establishment of the status of the Man unit in the Nature-Man partnership, the above definition and assertion may be extended to declare that there can be no genuine happiness short of _usefulness in assisting other units to be strong and useful in the partnership of which each is a member_. True happiness cannot exist if there is present an element of indifference. Next to destructive aggression, indifference, which leads to neglect and waste, is the worst fault that a member of the Nature-Man partnership can be guilty of. Neglect _nothing_ that will aid growth in any useful form, and happiness will surely follow, for Nature and the God of Nature will "do the rest." * * * * * In qualifying for the Nature-Man partnership, it is of first importance that our personal equipment should be understood and cared for so as to give us the greatest strength. The body may appropriately be likened to an electric power plant--a Mind-Power Plant; the body being the engine, the stomach the furnace, the arteries and veins the boiler tubes, the blood in circulation the steam, the brain the dynamo, and the mind electricity. Mind is the all-important factor of our equipment, for it is the commander that will lead and direct better and wiser than we can now imagine if we allow it a chance to act with freedom. To secure this freedom we must know its habitat, its requirements, its nourishment, and learn to allow it to recharge itself sufficiently and to concentrate itself on its chosen usefulness without imposing upon it also the drudgery of useless work. This must be done with the same idea of economy that a _chef_ is relieved of the drudgery of washing dishes and emptying slops. According to Dr. Edward Hooker Dewey, a pharmacist, army surgeon and tireless investigator of forty-five years' experience, whose revelations have been before the medical profession of the world for many years without a single challenge, the brain is a dynamo which accumulates energy during sleep, and uses it during the waking hours of its possessor. The brain manages everything for man that he accomplishes. It brings messages from the Creator, which are sometimes called intuition, sometimes inspiration, and by various other names. Emerson calls these messages the "Over-Soul." My own appreciation of the attribute that distinguishes the Spiritual Man from the animal man is better satisfied by the name "Spiritual Cerebration," which I have defined in my book "Happiness" as: "Intelligence not derived from experience, principally obtained during sleep, and, seemingly supernaturally clear to consciousness on awaking in the natural manner." The brain also directs all action, and, with encouragement, will take up the messages from the Creator and analyse, arrange, and develop them into useful accomplishments, and then file them away in the archives of the memory as additions to the equipment which is necessary to greatness in the pursuit of usefulness. Dr. Dewey gives the bill of fare of the brain in seeking its own nourishment, and also describes the work it performs in transforming the fuel we supply it with into the tissues on which it feeds. This is undoubtedly a very important discovery and locates the source of strength and teaches how to conserve it. I will not give the technical bill of fare of the brain, for you would not remember it better than I do, but it is all composed of tissues of the body, fat predominating to the quantity of ninety-seven per cent, but the important announcement is that neither the brain itself nor any of the nervous centres diminish during consumption of tissue, neither do they lose any of their power, even in cases of what is called starvation, up to the point of death, when all of the fatty and muscular tissues of the body are wasted away, leaving the brain and nerve centres to flicker and go out, as a candle does, brighter than usual with the parting flash of their brilliancy. Dr. Dewey gives President Garfield as an illustrious example of proof of the accuracy of his deduction. The martyr President lived eighty days without the addition of an ounce of nutriment to his life, carried the usual clearness of mind to the last moment, and passed on only when the last muscular tissue had been consumed by the brain. Dr. Dewey's assertion that starvation, so-called, is never a cause of disease, and never dangerous to life and health until there is no more tissue left on which to feed the brain and other nerve centres, was published some years ago and I have the authority of the Doctor himself that his contention has not been once disputed by the medical profession. Three eminent English physicians, Drs. A. M. Haig, George S. Keith and A. Rabigliati, and many American physicians, have experimented with what is called starvation for the cure of chronic diseases which have their origin in excess of inharmonious deposits caused by overeating or careless eating. The results in all instances recorded have been successful in modifying or curing the disease. When patients have understood that they were suffering no injury from not taking food they have ceased to have hunger cravings. These hunger cravings usually come from fear or from disorder caused by fermenting food in an overloaded stomach. We can, then, on undisputed and practical authority, treat craving for food or drink as a disease and therefore not rational, and starvation as merely drawing upon the stored fuel--fatty tissue--by the dynamo of the brain, restorable at will at any time before complete exhaustion, without injury-- with benefit, in fact--to the machinery of the body. The brain must first turn food into tissue, and then derive its own nourishment from the tissue. If the right quantity of nourishment can be introduced into the stomach, if the quality is of the right kind, and if it is fed into the furnace of the stomach with relatively the same wisdom that a competent fireman uses in feeding his furnace, the brain is required to use the least possible effort in this direction, and has its stored energy available for directing other useful action and serving the partnership which employs it with an efficiency, the possibility of which may be well illustrated by the herculean accomplishments of the battleship "Oregon" in the late war in steaming thirteen thousand miles and engaging in a great battle without a stop or an accident, and without "starting" a rivet. I will not tell you much of what Dr. Dewey has revealed, because I want you to read all he has written,[18] as well as the books of the English physicians mentioned, but I must say this much: Very little digestion goes on during sleep, and, whether it does or not the brain has from sixty to one hundred days' nourishment stored up within each of us, and can feed on that without inconvenience to us, except in the form of what is called habit craving or imaginary hunger, for the whole of that time. A person who has been without food for an unusual time, if he does not gorge his stomach when the first opportunity of breaking the fast arrives, is not only better for the rest the brain has had, but the health does not suffer in any way. [Footnote 18: Dr. Dewey is the author of numerous books: notably, the "No-Breakfast Plan" which he supplies to inquirers direct from his home address, Meadville, Pa.] It is, then, no serious deprivation to ask a person to go without what we call breakfast--the getting-up or habit-craving--and give the brain a chance to clean up the remnants of the last day's supply of food fuel, and express new desires in an _earned_ appetite. There is available, on waking from sleep, a fresh charged brain ready to serve its proprietor with great efficiency. Incidentally it has to do some "chores," rake out the clinkers, dispose of the ashes, relieve the grate bars, attend to any little repairs, brush out the chimney and generally get ready for the work of another day. The hunger of the morning is necessarily but a _habit-hunger_. The best evidence of this is that, when busily employed, we forget it without trouble; and also is that European peoples, where the disease dyspepsia is not known in the list of physical derangements, perform the chief physical or mental effort of the day before their breakfast, the morning coffee scarcely meaning anything in the way of what we call a meal. Dr. Dewey's firm assertion is that when the stomach has had a chance to "clean up" and is ready for more fuel, it will make it known in healthy manner by a healthy appetite, and that it is rarely normal before noon; and not really before one has done what might be called a "day's work." I can assert boldly, as the result of experience, that the time to get work out of the brain is between the morning awakening and the first meal, and it is the same relative to endurance draughts on the physical strength. Then, in the heat or the glare of the day, having accomplished something useful and disposed of pressing duties, so as not to feel the irritation of hurry, the first meal of the day can be taken with restful ease and it will be found that the supply demanded by the appetite will not be so great as that demanded by the unhealthful, habit-inflamed early morning call. It may not seem so, but this digression from psychics to physics is very germane to my subject and to my own experience. Without knowing that Dr. Dewey and the other eminent physicians who endorse his theories were living in the world, I, in the summer of 1894, blundered into a personal experience of diet that produced wonderful results which I now recall with all the vividness of the high lights of extreme pleasure met in foreign travel. I was in a Southern city for two months during an unusually hot summer, watching some developments that could not be hurried, and the fruition of which was important to my interests. I had nothing to do in connection with this business but to "watch and wait." I had some writing to do, however, in the mean time, which could not be well or comfortably done in the heat of the day, hence I arose at daylight and began to write. At that time of the morning nothing to eat was to be had, which compelled me to start work without it. My subject was an absorbing one, so that, once under way, I would not be diverted until I had "written myself out;" or in other words, had exhausted the consideration of the morning messages which I now designate "Spiritual Cerebration." It happened, under these circumstances, that my habit-hunger was not given a hearing and it was nearly noon before I felt the fatigue or even the heat of the burning day, for I worked in my pajamas, and had no time to look at the thermometer, to get an exaggerated suggestion of heat by which to start my blood chasing itself through my veins. I not only noticed that my midday breakfast was a deliciously grateful meal, but that appetite became satisfied far short of the formally customary abnormal early morning gorge, and, what was more remarkable yet, I wanted nothing during the rest of the day, and not even until midnight, except, after vigorous exercise of some sort, I might desire a little fruit or a bit of bread or cracker; but never a full course dinner. I wore a belt at my trousers, as was the custom of the place, and in a few days decreased the girth of my corpulency one hole in the belt; and before the summer was over, four holes, with only the most comfortable feeling accompanying the loss of weight. When my family returned from Europe, I settled back into the American and English habit of a meat breakfast, because I did not want to be "different," and at the same time I half doubted but that my experience was nothing more than an abnormal one, attributable to the inertia of summer heat, literary absorption and lack of physical exercise. Twice, when I have been left alone since then, away from the restraint of custom, and also in the midst of abundant athletic exercise, I have again cultivated the same habit of missing breakfast through desire to do early morning work, with the same splendid results. The last time referred to is the present. My search for a lost waif through the framing of an appeal for him, has given me such absorbing thought that meals have been of no consideration beside it, and in the midst of it I find Dr. Dewey's book, the books of the English physicians indorsing him; and have secured results of health, comfort and strength to myself which I did not know I possessed; to corroborate my accidental experience. As I said before, this seems a very wide digression from the psychical to the physical, but it is really no digression at all, for it is in the service of the brain, and the brain is the direct agent of communication between the Creator and our consciousness, assisting us to work together in the Nature-Man partnership with useful efficiency. * * * * * Now, let me return to the aim of my address, and pursue the thread of my personal experience in search of the fundamental principles of True Living, which, to be proven, must be vouched for and tested by resultant happiness. When I attacked the tap-roots of trouble and shut the door in the face of anger and worry for ever, I saw among the bones of their decomposition the skeleton of fear. It proved to be their backbone. Fear, then, was the support of all the deterrent passions that beset brightest manhood and womanhood and pursue it to an untimely death. My book "Happiness" deals with the separation of fearthought from forethought in order to show that it is possible to smother a vital stimulant of energy with a resemblance of it which is as deadly a poison as carbonic acid gas. While I have been engaged in pursuing germs of disorder to their beginnings, during the past three or four years, I have uncovered many a beautiful possession that formerly I did not appreciate. _Appreciation of the full value of Appreciation_ is one of these discoveries of priceless value and usefulness. I have spoken of this in "Happiness," but not as much as it deserves, for it truly is "The Appreciation of God and of Good that gives birth to Love, and which is the only true and adequate measure of wealth." Nothing else, however, in the whole quest, has approached the beauty of the love for children that has come to me; the appreciation of them as Messages from the Creator, consigned to the cultivation of the environment society provides for them; as likely as not, any one of them bringing into the world a great intelligence by means of the humblest of parents. During observation of social questions in Europe, my interest has been drawn constantly to children, as by a powerful magnet, so that when I was called back to this country to attend to a detail of business and met the adventure which is the cause of my present focalised interest in neglected ones, as expressed in a book to be called, when published, "That Last Waif; or, Social Quarantine,"[19] it was but natural that I should put all the force of my sympathy into the cause of rescue, and that I should find in that service more happiness than in any of the luxurious amusements which had claimed me as a devotee in times gone by. [Footnote 19: Published, and proceeds dedicated to the cause of the waifs, October, 1898.] True _happiness is the result of conscious usefulness_. This I can assert with the confidence of knowledge, not alone from my own experience, but from observation of the great army of kindergartners and child-savers whom I have met in my travels, and especially within the past year; and it is evident that the service attaching to protecting little neglected angels from the evil suggestions and the cruel conditions that may make of them, not men, but beasts, is one of the avenues of usefulness in which these "Angels of the State" meet with the smile of the Master, who was the first Great Kindergartner; whose teachings centred about and dwelt upon the care of children as of first consideration, and who said, "Suffer Little Children to come unto me, and forbid them not, for of such is the Kingdom of Heaven." Childhood has suffered, manhood has suffered, progress has suffered, for lo! these ages, the cruel assumption that mankind is naturally depraved. In recent years public conscience has been dulled by the anæsthetic that there must be a Have-To-Be-Bad Class in all communities. This has been formulated into the assumption that there is in every group of the Heaven-Sent Angels of Purity, a full ten per cent that must be depraved and unredeemable except by the interposition of special dispensation, which is a direct contradiction of all of the observed Laws of Creation to which intelligence now subscribes. The motto of this assumption is couched in this vicious legend: "The hopelessly submerged ten per cent stratum of society." Half an hour's walk from this hospitable mansion, on the shore of the beautiful Geneva Lake, is a place called "Holiday Home." There are now housed and thoughtfully cared for at the "Home" about one hundred of the "Hopelessly Submerged Ten Per Cent Stratum of (Chicago's) Society." During the summer half a thousand of these unfortunates will come for two weeks each. When we touched at the wharf last evening after coming from the concert given in their interest at Mr. Chalner's lakeside home, the waifs met us with a merry class-yell, and greeted us with an intelligence, a buoyancy, and a freedom, born of their holiday, such as was not excelled at any of the other landings where only the children of rich summer residenters were met. We all saw these "waifs" and we marvelled at them, for, with the grime of the slum washed from their sweet faces, and with clean, though sometimes ragged clothing, they might have figured in the mix-up of "Pinafore," or have starred in a dramatic representation of the "Prince and the Pauper," with all the grace required of princelings. They haven't been long from God, and they are god-like or not, as we have welcomed and protected them, or rebuffed or neglected them. Let me assure you in the most practical way that there are two sides to this child question. There is a sentimental side, than which there is no other so worthy; and there is a practical side, than which there is none so profitable. The best and most profitable service in the whole gamut of useful occupations that I know about is in learning to know children, and in connection with a Quarantine movement which is now started, and which aims to not let one of these wards of the Christ escape the best care known to Love and the Science of Child-Life. The crèche and the kindergarten and the manual training schools, and domestic training classes, as well as institutions similar to the "Holiday Home" across the Bay, have demonstrated within the past thirty years that fully ninety-eight per cent of the "Hopelessly Submerged Ten Per Cent" can be rescued after they have been warped by evil surroundings. What will not the same effort effect if directed toward prevention and protection, instead of being squandered in careless and soulless correction? Christ said: "And a little child shall lead them." Let us awake to the call. It is the way to Heaven; for, "_Of such_ is the Kingdom of Heaven." FIVE YEARS' CONFIRMATORY EVIDENCE The spirit of the preceding address to the good members of the Unity League organisation on the shores of beautiful Lake Geneva has been the inspiring motive of the quest for scientific endorsement of Economic Nutrition for the benefit of the present generation of children, and, incidentally, of their elders. In Economic Nutrition lies protection from sexual morbidity, alcoholic intemperance, bodily disease, savage passions and all the brood of evil contamination and temptation. In Economic Nutrition lie possibilities of physical and mental energy and optimistic happiness such as the world has not been accustomed to in the memory of history. Economic Nutrition is what children want to be taught with their first indelible impressions, and the present great movement of which this little book treats, for which it was first responsible, and for which it is republished in a new and extended edition, is expected to furnish authoritative knowledge relative to the most Economic Nutrition, so that mothers and kindergartners may meet the little waifs from the Creator on the threshold of this present life with words of wisdom and examples of sanitary perfection, instead of confronting them at once with the poison of ignorance relative to their most important concern,--their own Economic Nutrition. That the contentions uttered in "That Last Waif; or, Social Quarantine," referred to in the Lake Geneva Address, are reasonable is evidenced by the experience of Dr. and Mrs. Kellogg and their adopted family of twenty-four waifs, the acquaintance of which has since been made. All of the altruists who have engaged in kindergardenry among the neglected, Dr. Barnardo, Dr. Kellogg and the rest, are full of confidence in the possibility and efficacy of a perfect quarantine as outlined in "That Last Waif." It is an _Epicurean_ method of promoting _Menticulture_, killing _Fearthought_, denouncing _Gluttony_, saving that _Last Waif_, and attaining _Happiness_ through learning the _A.B.-Z. of Our Own (Economic) Nutrition_. GIVE THE BABIES A CHANCE THE INSPIRING MOTIVE The enthusiasm excited by a persistent study of the problem of human nutrition is inspired by the need of an intelligent scheme of information and instruction which may be understood by mothers and teachers for the benefit of children. Unlike the young of the lower animals, the babes of mankind have some years of dependent existence during which much unconscious murder is committed, and during which the innocents are more or less poisoned with bad suggestions that weaken them all through life. Colts, calves, pigs, chickens, and the like survive the period of dependence in much greater proportion than do the young of their human masters survive the infantile stage of existence, and this is largely due to the lack of basic or parent knowledge on the part of mothers relative to their own nutrition, and also a pitiable ignorance concerning the nutrition of their children, the double ignorance constituting a double crime. Even if careless about ourselves, is it not shameful that we do not concentrate effort in learning the truth about our instinctive means of protection in our own alimentation and in classifying the knowledge in a way that will make it available to children, through their proper guardians, when they arrive in the world "as helpless as a babe"? If knowledge which seems to be protective had not been evolved out of recent experiment, or if the hope of gaining such knowledge had not been collected from good authority, the appeal might seem futile; but this is not the case. The most intelligent and studious investigators are united in the belief that the problem can be scientifically solved and the confusion of ideas settled by concentrated personal and collective study of economic nutrition, through observation of the natural requirements, and by trial of the care in taking food which is necessary to secure the most profitable economies. ILLUSTRATION Here is an illustration, both of the present need of better knowledge and the hope of its attainment. It is an account of one accidental experience which showed that _excess of food_ may be as detrimental to a tiny baby dependant, as it is generally conceded to be harmful to grown persons. The case was described by Dr. Chadwick of Boston to Professor Bowditch, and by the latter repeated to the author. An infant was not progressing as it should and failed to gain normally in weight. It was under the charge of a nurse and was being carefully watched. A certain quantity of milk was prescribed for daily nourishment, at prescribed times, in a prescribed manner; but the child did not increase in weight and was "doing poorly." For some reason the nurse was changed and instructions were repeated by the old to the new nurse. In the course of a week the little patient showed signs of marked improvement, both in gain of weight and in general condition. In order to record the particulars of the change the physician questioned the nurse and learned that only one half the nourishment originally prescribed had been given, the new nurse having forgotten or misunderstood the orders. The reason the little fellow had been "doing so poorly" under the original prescription was because he had been using up his puny strength getting rid of the excess of food that had been forced upon his little stomach and intestines. When the excess was stopped, so that his digestive apparatus could occupy itself with his real needs, the babe had a surplus of energy for growth and thrived as a rightly nourished child should do. NOTE: In connection with the foregoing, reference is invited to the author's conception of how attention to one's personal economies, beginning with the economy of personal nutrition, is interrelated to general menticulture and the child-saving phase of our personal responsibility in child culture. Even if we are carelessly suicidal ourselves, we owe better care to innocent and dependent children. This will be found in the "Explanation of the A. B. C. Life Series" at the end of the book. MUNCHING PARTIES AND THE CHEWING FAD To the scientific person of ultra conservative bent of mind this free and easy screed, offered as the exponent of a great economic idea, will seem offensive, and justly so; but it has been written with a purpose, and happily the purpose is being effected as speedily as the author hoped for when his own discovery relative to the profitableness of an epicurean, economic nutrition became a reality of experience and suggested publication. To this free presentation, couched in a variety of class expression, is due, in a large measure, the new revival of feeding reform which has spread far over the civilised world, where it was most needed, within the past five years. Up to five years ago, and to some extent now, the prescription method of recommending diets was and is common. In fact it was universal up to a few years ago; for no one, as far as is known, had yet suggested that normal appetite was the _only_ competent prescriber, and that it was the office of the physician to teach his clients and patients how to normalise the appetite. It required two years of the circulation of the original publications and the constant, persistent, personal assertion of the author before any continued credence of his assertions was secured, with the one exception of a lay friend in New York who happened to be in a state of great need of reform at the time, as related under the heading of "A Five Year's Lay Experience." It was only about two years ago that the new claims had received sufficient recognition to admit of explaining them to busy men of prominence in the medical profession. After the confirmation at the laboratories of the University of Cambridge, England, the author had an opportunity to make a statement and give a demonstration to Sir Thomas Barlow, the private physician of King Edward VII. Sir Thomas was most sympathetic with the physiological possibilities, and there has been frequent evidence since to show that he pursued thought of the suggestions, and that his interest has been responsible for the aristocratic lay interest which originated the so-termed "Munching Parties" in London. The English term "munching," signifying chewing or masticating, is an excellent amendment, which is gladly adopted. "Masticating" is technical and formal. "Chewing" has been disgraced by its application to gum and to tobacco, and the other English expression, "biting," suggests the carnivorous, savage use of the jaws and teeth, while "munching" implies enjoyment, as the munching of delicacies by children. As reported from London, "Munching Parties" were inaugurated to teach attention, to encourage mouth preparation of food for digestion, and also for the æsthetic purpose of gaining all the gustatory pleasure possible from food while conserving the economies of nutrition. The method employed was most ingenious, and with some modification is approved by the author. When a course was served at "Munching Lunches," the manager of the ceremony employed a stop watch to time the treatment of the first morsel of food taken by each of the guests. Five minutes was prescribed for consideration of the morsel. It was an extravagantly long delay over any one morsel, but it set the pace of deliberation, and time, under the circumstances of a social function, was not a matter of moment. A five minute, or even a one minute consideration of a morsel of delicious food, tends to give a new appreciation of its taste value and suggests more careful enjoyment than is usual when nervous conversation is the main business of a meal and food is a mere accompaniment. Industrious munching performs about one hundred acts of mastication to the minute, and from twelve to fifteen mouthfuls of ordinary food is sufficient to satisfy completely a hearty appetite. Tender or well-prepared or well-cooked food is fully treated by munching for natural swallowing in even much less time than a minute. The necessary time ranges from one-twentieth to one-fifth of a minute, or ordinary food is reduced so as to excite the natural Swallowing Impulse by from five to twenty masticatory acts; and this applies equally to the tasting movements required by sapid liquids. Hard or coarse breads, and even potato, may require more attention and longer time, and deficiency of saliva delays the process; but it is a very refractory food that will require more than half a minute to the ordinary mouthful. Small sips and small mouthfuls demand less proportionate time, so that the actual time necessary to satisfy a good appetite does not exceed twelve or fifteen or at most twenty minutes when the secretion of saliva is ample, as in the case of _real_ hunger; but the enjoyment of taste does not stop short with the actual cessation of the psychological sensation. The memory of taste continues after the actual sensibility has ceased, and one of the most agreeable compensations of a meal is enjoyed in the form of _complete satisfaction_ following the act of eating. It is a very different and a very much more agreeable sensation than that attending a distended stomach, and must be felt and understood to be fully appreciated. "Munching Party Functions," then, reveal more possible pleasure and benefit than the mere tickling of the palate, so-called, and diffuse their benefits to cover the mechanical act and a long-continued feeling of satisfaction that is more subtly pleasing than the immediate physiological cause of the contentment. The "Munching Party" scheme of education and enjoyment has been carried to America, and has received the name of the "Chewing Fad." As such it has been cartooned in the newspapers, but in no matter what form the suggestion is spread it can do only good. Appreciation of the suggestion has been generously expressed in the letters of Dr. Kellogg of the great Battle Creek Sanitarium and by Dr. Dewey, the author of the "No Breakfast Plan," as well as by the author's intimate colleagues, Drs. Van Someren and Higgins, of Venice, Italy. There are many physicians from whom the author has heard report, and perhaps thousands who have not yet been heard from, who are conveying the slow-eating and appreciative-attention suggestions to their patients; and as the reform in dietetic _technique_ has sprung up since the publication of the booklets of the author--"What Sense? or, Economic Nutrition," and "Nature's Food Filter; or, What and When to Swallow," which were afterwards coupled together under the title of "Glutton or Epicure"--he has good reason to suppose that the spread of the idea originated with the publication of his discovery even where the personal influence had not been given direct. While visiting recently in Cambridge, Massachusetts, the author met a distinguished professor of Harvard University who had been suffering from nervous prostration. He had spent some time in Europe consulting the most eminent neurologists, but with little or no relief. On his return to the United States he was advised to go to a sanitarium in Bethel, Me., under the direction of Dr. Gehring, where effective cures of cases of nervous prostration have been performed. The professor was given "Menticulture" and "Glutton or Epicure" to read, and was recommended to practise the advice of the books in connection with his treatment. These two books are an account of the way the author promoted his own salvation from the uncertainty relative to physical health and mental control, and it is by these means that the psychic, mechanical, and chemical necessities of nutrition are satisfied. The author spent an hour with Dr. Alexander Haig, of London, while undergoing the Cambridge University Examination reported upon by Sir Michael Foster, and exhaustively argued the claims of thorough mouth treatment of nutriment to that distinguished dietetic specialist. The argument met with much incredulity, as has been the case in all first presentations of the idea. Dr. Haig pronounced the appeal to even a normalised appetite dangerous, and clung to the prescription theory of regulating food. He seems, however, to have since learned the efficacy of munching and tasting in assisting the empirical prescription method, and now recommends it as enthusiastically as do Drs. Van Someren, Higgins, Kellogg, and Dewey. He has even sent patients to a resort in the country in England to acquire the habit of munching where there was present in them the strong pernicious habit of nervous haste and inattention in connection with their ingestion of food. This is bound to be the case with physicians where the subject is given attention and the method is accorded a fair trial without lapses. Credit for the origination of the suggestion is here taken to increase the effectiveness of the claims presented in the "A. B.-Z. of Our Own Nutrition" and in this book. Readers are recommended not to imitate the prevalent error of thinking that so simple a suggestion is not important or otherwise scientists would have proclaimed it long before now. The ancient hypotheses of text-book physiology were mainly based upon the study of nutrition, beginning in the stomach, and after the danger of indigestion had been forced upon the alimentary system; and hence they often dealt with confused, abnormal, and pathologic conditions, and they rarely had opportunity to observe the normal condition intended by Nature. Professor Pawlow, of St. Petersburg, confirmed the necessity of a right psychic environment; Dr. Cannon, of the Harvard Medical School, showed the influence of mechanical thoroughness and nervous shock upon digestion; and Dr. Harry Campbell, of London, explained the mechanical and salival efficacy of mastication in procuring good assimilation of nutriment and an economic nutrition. The work of Professor Pawlow and Dr. Cannon was independent scientific research, and so was that of Dr. Campbell; but the latter was undoubtedly suggested or stimulated by Dr. Van Someren's presentment of his paper to the British Medical Association. The investigations of Sir Michael Foster, Professor Chittenden, Drs. Higgins, Kellogg, and Dewey were directly inspired by the author in connection with his Venetian colleague, Dr. Ernest Van Someren. The papers, reports, articles, and lectures of these authorities are given in the "A. B.-Z. of Our Own Nutrition," and are repeatedly mentioned in this volume because this book is revised and reissued as an extended explanatory companion of the larger scientific presentation. In pursuit of true menticulture the personality of the individual should be completely suppressed. He becomes the agent of his inspirations, his revelations, or his altruistic convictions, and as such speaks for the ideas presented, and in no immodest spirit of vain egotism. In descending from the plane of high literary propriety to impress by simile and analogy, the object foremost in mind is to attract a variety of sympathies. The author reveres the dignified in art and in demeanour, and deplores the necessity of personal association to spread the merits of what he believes to be fundamental truths of the philosophy of true living. But so strong is the conviction of the author that he possesses fundamental truths which have been overlooked in the rapid progress of the race in the luxuries of living, that where it is seemingly desirable to employ unusual means to attract attention he feels compelled to do so. SPECIMEN ECONOMIC DINNER IN A SUMPTUOUS MODERN AMERICAN HOTEL The author was invited to dine with some friends one evening in summer at a hotel in New York, and the invitation concluded with "Menu _à la_ Fletcher." The dinner was to be served in the sitting-room of my host, and when I arrived had not yet been ordered. "You must order the dinner for us," said my host, "and we will agree to your selection." "But I cannot order for any one but myself," said I in reply. "The chief contention I make for natural nutrition is that the appetite is the only true indication of the bodily need, and you must interpret your own appetite both as to estimated quantity required and the sort of food craved." After some discussion I agreed to stand as go-between and take the symptoms of appetite from each and give the order. The waiter was standing by with pencil in hand and urged a number of expensive dishes that were the specialties of the day. I asked him to "be quiet, please, and let us make our own selection." I first placed the bill of fare in the hands of the daughter of my host and asked her to name the first thing that came into her mind in connection with the order. She replied, "Baked potatoes and--" "Stop," said I; "baked potatoes it is; now it is your turn to choose, R----. What comes first to your mind?" "Green corn," was the answer. "Very well, waiter; one order of baked potatoes, one order of green corn, and a lemon ice. Bring these and we will order more if we require." The waiter hesitated and was about to protest something when I stopped him with the assurance that the order given was all that we would specify at first, and that if the service was unusual and caused trouble we would submit to an extra service charge to square accounts. While the order was being filled there was considerable funmaking, but I would give no explanations. The waiter returned shortly with the order as given, and it was laid out to the accompaniment of a complete dinner utensil service. I asked the young lady to please prepare one of the potatoes in the way she liked best, and this was done by taking the mealy heart out of the jacket and mixing it with butter, salt, and pepper to taste. In the meantime the father had taken an ear of corn and was prepared to enjoy it in response to his appetite the same as he would if he were in the woods with a lumberman's appetite and only corn to be had. The large glass of lemon ice was then placed between us as a "centrepiece." "Aren't you going to take your ice now?" queried the young lady. "Not now," replied I. "I must attend to your method of taking your potato to see that you do it economic justice, and I must see that your father does not waste any of that delicious corn. Now, Mary, let me see how much good you can munch out of your first mouthful. Do not swallow any of it until it is actually sucked up by the Swallowing Impulse, and when that happens you will note that only a portion of it is taken and the rest will naturally return to the front of the mouth, if you do not restrain it, and will still be a delicious liquid most agreeable to taste." This happened as suggested, and there were three distinct swallowing acts before the last of the mouthful had disappeared in response to the Swallowing Impulse. "My! but I never realised that potato was so good," exclaimed the young lady; and "Gracious! isn't this corn bully!" echoed the father. "Good!" added I. "If that is true of the first mouthful, I think you will find it true of the other mouthfuls until your appetite for potato and corn is satisfied; and as long as your appetites hold good for them, you are being nourished as your body-needs require." With the slow eating, the appetite of each for the chosen food was soon quieted; one, we will say for illustration of the principle, with a single potato and the other with a single ear of corn. "I think I should relish a little of your second potato if you are not going to take it," said the father, addressing his daughter; and she replied, "Your corn seems nice, father; may I have your second ear in exchange for my potato?" This was agreeable to each, and each partook somewhat of the other's original selection until the appetite of each was so completely satisfied that neither could more than taste a little of my lemon ice as a final delicacy; and as I did not want all of it, the one order sufficed for us. I had breakfasted quite heartily at one o'clock in the afternoon, after having written several thousand words of correspondence, and really wanted but half the generous portion of ice that had been brought. I had ordered it set into ice-water, after placing it ceremonially as a centrepiece, and it had kept its icy consistency waiting for what I thought was likely to happen. Both my host and my hostess declared that they had never enjoyed a summer evening meal more, and yet all that was ordered was not consumed, while the cost, for the three, was less than a dollar for the food alone. The method employed to interpret appetite was a revelation to my friends. They were accustomed to ordering several courses for each person, although they thought they were "small eaters" and economic feeders. Had they ordered for us three without my assistance, the dinner would not have cost less than four or five dollars, and with a plethora of food on the table all would have felt it necessary to eat as much as possible, in order to get value received. The above, as related, was an actual happening, but it in no way indicates what another _trio_ would have ordered in response to their appetites. That is immaterial. The principle of consulting the leanings of appetite is the thing of first importance, and giving appetite a chance to naturally discriminate is the second natural requirement. Had the weather been cooler, and had the appetite earned been like that of a labouring man, more food and more variety might have been required to satisfy appetite, and hence the needs of the body. In that case, after plying the appetite to repletion on the first dish ordered, a second or a third could easily have been added. With this principle of learning the real demands of appetite, any number of combinations can be had for variety. In summer, with light physical exercise, very little proteid-bearing food is needed; but in winter, with vigorous exercise or hard physical labour, the appetite will crave foods that have proteid and fat whether one knows what proteid is or the difference between carbohydrate elements and fat. Any empirical idea of the possible elemental requirements is likely to lead to false suggestion and do harm. It is difficult to stand by and let Nature do the ordering if there is too much elemental intelligence, and that is where the animals, when allowed free choice of food, get on better with their nutrition than man himself, and man's only protection is to carefully heed the delicate discrimination of appetite. This is not a difficult thing to do, for appetite can be easily satisfied within a small range of simple foods. With any desired variety of sumptuous food to choose from, and no restraint from any cause whatever, the author fed himself nine-tenths of the time during the examination at Yale University, in cold winter weather, on griddle cakes well buttered and accompanied with an abundance of maple syrup. Occasionally more proteid would be demanded,--say once a week, or once in five days,--and then baked beans was the preferential choice. I am now relating the experiences of a student of hygienic epicureanism and am not considering money economy alone. Were mental or even physical improvement in efficiency to be purchased at high prices, and lack of efficiency could be had for nothing, the high-priced article would be well worth its cost, no matter what it might be, for the reason that total lack of efficiency is equivalent to death and any proportionate lack is the next thing to death. Hence it is not a money economic reform that is being advocated, and this must be borne in mind. When I am in New York I very often take a room at the Waldorf-Astoria because it has become, by common consent, the suburban and country business and social clearing house of the whole United States; and hence, coming from Europe periodically as I do, and always anxious to meet old friends from San Francisco, New Orleans, Boston, Washington, the great cities of the Middle West, or elsewhere, it is more easily accomplished by camping at the Waldorf than in any other way. I cannot be a profitable guest of this or any hotel kept on the European plan, but I try to make up for this deficiency in other ways. Just across Sixth Avenue from the Waldorf, on Thirty-Fourth Street, is one of the most pretentious of the so-called "dairy lunches." In these places good, appetising, wholesome food is served quickly and in _decently small portions_. For this very reason alone, I _prefer_ the crowd and the noise of the dairy lunch to the quiet and the luxury of the Waldorf café or dining-room. One would not object to paying a larger price at the more quiet place of service, but prodigality seems to be the present great American sin. Were it a mere waste of money or even of the food, it would not be worthy of great discussion; for when the fool and his money are parted the laugh is on him with no grain of sympathy, and there already being a great surplus of food in the land, there is no fear of famine. But with this prodigality prevalent, so that to have a decent variety one must have put before him enough for a family, the temptation to grossly overeat is great and the abuse is criminal. It is the hope of the author that some enterprising Boldt will inaugurate an epicurean service and charge well enough for it to pay for the trouble, or better yet, in proportion to the quantity wanted. In this regard the poor do not suffer directly, but the example of the rich is the perverter of the poor in many ways, and surely in this item of dietetic abuse. When it comes to quantities of food to be prescribed, the author avoids giving even suggestions. This has been the trouble with the past attempts at reform. Had Luigi Cornaro told us in his autobiography the manner of taking his food with other particulars, instead of giving alone a maximum weight to which he limited himself, he might have saved the world three hundred years of uncertainty and confusion. His twelve ounces of solid food and fourteen ounces of new wine (fresh grape juice) means little. The solid food might have been almost water free or might have contained 50 per cent of moisture. The new wine contained a trifle of sugar and probably more than 95 per cent of water and supplied moisture to the body instead of water. During the Yale tests reported elsewhere, and more fully in the "A. B.-Z. of Our Own Nutrition," the daily ration did not exceed the reported amount of Cornaro, even with the most generous allowance for moisture. I have steadily refused to prescribe by weight or quantity or to suggest the best kinds of foods for any one, but there are so many questions arising from the publicity already given by the Yale experiment, that it will do no harm to give some outline. DIET IN THE YALE EXAMINATION OF THE AUTHOR In the first place the selection of food for this test is no basis of general choice. The analysis of food for its elemental molecule values, and for its heat content, is a very difficult thing to do and takes much time; hence to bring a large variety into a diet during a test would entail enormous labour on the laboratory staff. Knowing this difficulty, when I was requested to choose something which would entirely satisfy my sense of taste gratification so as to best stimulate the flow of the digestive juices, I chose a cereal with a known content value. That is to say, I fed from different brands of cereals, the content value of which was known. A quart of fresh milk a day furnished the moisture required, and was not every day entirely consumed. Maple sugar was the most variable ingredient of the diet in regard to quantity. Of the milk I took nearly or quite one quart each day, of the cereal I averaged about 150 grams, or say 5 ounces, and the demand for the sugar varied from 150 grams to 200 grams, or say 5-7 ounces. This food was taken in at two meals daily,--12-1 and 6-7 P.M.,--and the time required in taking was 12-14 minutes to the meal, including any delay necessitated in taking notes and in weighing the food. These delays were inconsiderable, however, as facilities for weighing and taking notes were perfected and their use well accustomed by the subject. The 26-28 minutes per day, then, may be set down as the careful but industrious eating time required to satisfy the waste and appetite of a man doing 'Varsity Crew work, as reported by Dr. Anderson and Professor Chittenden. The activity outside the prescribed gymnasium exercises and any supplementary work consisted of awaking very early in the morning and doing considerable writing upon my typewriter. The agitation of this nutrition investigation has involved an immense amount of correspondence to keep the interest stimulated, and for the exchange of information between the interested parties; hence in addition to serving as test-subject, there was always much else to do to keep from getting hopelessly behind in the work. The writing began anywhere from four to six in the morning in winter, which was the season of the test, and continued until about seven or eight, when the exercises were commenced and continued until finished. Meantime the mail of the morning had come in and frequently demanded immediate attention, which used up the time until between twelve and one o'clock, when a first-class appetite had been earned (no craving of hunger or "all-goneness" in the common form due to the persistence of habit hunger), and this insured a keen appreciation of taste and fulfilled all the requirements of a healthy digestion. The afternoon was always busy, sometimes with a lengthy walk around town, or a game of billiards when the weather discouraged outside work. The evenings were strenuous or restful, and were usually employed with conversation, reading, or a lecture. Fortunately the simple food selected continued to be agreeable to the end, and cost an average of only eleven cents per day. When it was given up to accommodate the service furnished by social meals it was missed, the habit of supply having become somewhat fixed and expected by appetite. In London, in search of the lowest possible economy, the author has subsisted on about half the cost of the Yale supply; and it is entirely possible to those needing strictest economy. INFLUENCE OF SUGGESTION A friend of the author, who is an enthusiast in regard to the profitableness of an economic nutrition in assisting the strenuous life, went to lunch with a generous host in New York the other day, when the following conversation about the lunch to be ordered was heard. It partook of Wall-Street brevity, which is thought to be necessary in the rush of a midday snack or meal. "What will you have? What! only a baked potato and a bottle of ginger ale? All right for a starter; but what are you really going to have? Nothing more! what is the matter with you? Come, now; tell me what you want for lunch? Stocks are badly off, but I haven't reached the starvation point yet. Don't treat me like that when I'm trying to treat you right and white. Brace up, old man, and have something to eat." The intermediate replies can be imagined as in an overheard telephone conversation. The host ordered for himself, as usual, a portion of tongue and a generous garniture of side dishes, and watched his guest with amused tolerance. The lunch proceeded, interlarded with talk about topics of mutual interest, and when a final halt was called the host had not taken more than one-quarter of his cold tongue and very sparingly of the accompanying side dishes. The guest had finished one of his baked potatoes, and had sipped his ginger ale enjoyingly, but had not taken more than half of the pint ordered. The appetites of both host and guest were amply satisfied, but without any of the heaviness which follows an unrestrained "hearty" meal. In tones of surprise the one-sided conversation, relative to the strangeness of the proceeding, continued as follows: "Well, I'll be switched! How in Wall Street did that happen! I haven't eaten half my usual lunch, and yet I have killed my appetite deader than the Ship Building Trust. I'm blessed if I can understand it. The blamed thing is uncanny. I don't believe it's true, but I'm satisfied all right even if I am hypnotised. Come and lunch with me every day. You're engaged as a regular companion boarder, and Freddie will pay the freight. You're cheaper than nobody. Come again! Come again!! Come always!!!" The above is not an unusual case. The personal influence of the author and of his active colleagues has been visibly noted among parties where there was no sympathy with the "starving fad," and where there was even stubborn opposition to the thought of such a thing. But these same groups of non-interested objectors have visibly decreased their accustomed lunches and dinners, and some of them have found that a cup of coffee and a roll, the same as is habitually taken in Europe, outside England, serves as a breakfast better than the full meat affair formerly taken. They persist in declaring that they are not influenced by the chewing suggestion, but they show signs of _some_ restraining influence, and observation reveals that in such groups the common annual and quarterly attacks of illness are less frequently or less severely suffered. There is no doubt that Luigi Cornaro gave appreciative attention to his four three-ounce meals a day, and in giving attention properly insalivated his food. The inference is warranted. A man full of vigour and health and constructive energy such as Cornaro reports that he had in unusual abundance is not likely to confront a three-ounce ration of delicious food and proceed to bolt it as a dog bolts a piece of stolen meat. It is a matter of easy observation that a child given a single piece of sugar or sweet in any form will make it last as long as possible and get all of the taste out of it by most ingenious conservation; but the same child, if offered a box of "goodies" as it is passed around, or whenever the time given for possession of its contents is limited, will show the greed of a predatory or hunted or habitually maltreated animal and will not only grab as much as possible but will cram all possible into his stomach to satisfy the sense of greed, and then usually suffers the consequences of the double sin in the sickening re-taste of the gases of indigestion. Cornaro undoubtedly made his three-ounce meals last as long as possible in order to enjoy the maximum of taste, and in so doing satisfied the natural requirements of appreciative attention and thorough insalivation. In like manner two small tumblers of the fresh grape juice (new wine--fourteen ounces), which he took as his sapid liquid in the course of a day in connection with his four meals, would allow only a sherry glass quantity to each meal, and with such a limited supply a person is not likely to toss off the liquid in great gulps as water is drunk to satisfy thirst, but it rather would be enjoyed as the wine-tasters enjoy wine, by their sipping practice, in pursuit of their profession. The influence of visible supply or of passing or permanent opportunity of possession is a most powerful suggestion in the cultivation of economy or prodigality, of greed or moderation, of healthy nouriture or plethoric indigestion. Man was constructed and intended to hunt his food among the grains, nuts, roots, and other fruits of earth, and in hunting food to earn a keen appetite. He found his food scattered and ate it as he found it, with the true appreciation that difficulty of possession gives. In the primitive state the requirements of natural digestion are safeguarded; but with a plethora of food cooked and spiced and furnished with superfacilities for ingestion, the natural protection of difficulty is removed, and the victims of the luxury drop unconsciously into habits of abuse, like the overeating of to-day. In order to escape the surrounding temptations it is necessary to have always in mind protective counter-suggestions which intelligently make use of the abundant and easy supply but limit the intake to the needs of the body as expressed by appetite when permitted to discriminate in its natural deliberate manner, and which only keeps pace with the natural dissipation of taste in the process of requisite insalivation. The chewing practice is but a means to this natural end, but it is a most important means, the same now as when teeth were used instead of patent grinders, and when taste took the place of spices and sauces and manufactured its own delights by the chemical action of saliva. Among the Zuni Indians, observed by even recent travellers, it is the custom of the young girls of the _pueblos_ to masticate wheat up to a given point of sweetness of taste and then to withdraw it from the mouth and collect it in a wooden dish until a sufficient quantity is secured, when the jaw-ground and saliva-sweetened "mess" is baked in the sun or by fire and becomes the "sweet cake" of the family. The change of the starch of the wheat or corn into sugary dextrose by the action of saliva, which is necessary to be done somewhere in the alimentary canal before it is assimilable nutriment, gives the sweet-cake quality to the food which is the dietary delicacy of these primitive people. By proper insalivation we perform the delectable service for ourselves instead of having it done for us by good young teeth aided by healthy saliva furnished by beautiful feminine assistance. "FLETCHERISING" FOOD WHAT IT REALLY MEANS The term "Fletcherising," or "Fletcherizing," as applied to food has come into use without the suggestion of the nominee to a new filtering fame, and promises to spread; hence it is well to explain just what the term means. Under the so-called "Fletcherizing" process, the mouth becomes a filter with most facile appliances for protecting the delicate alimentary canal from straining and poisoning. Instead of the "Pasteur Filter" for the purification of water and the "pasteurisation" of foods by sterilisation, the "Fletcher Filter" both separates and prepares whatever is given it to treat more perfectly than any mechanical or chemical device can do. Dr. Kellogg appears in evidence often in this volume, and also with much appreciated strength of indorsement in the "A. B.-Z. of Our Own Nutrition"; but it is because he knows the value of the discovery of the natural food filter, has enormous chance to test it practically, and generously assists the reform with the might of his conviction. Hence the author has still another letter of his in hand from which to quote. "BATTLE CREEK, MICH., Oct 26, 1903. "MR. HORACE FLETCHER, NEW YORK. "DEAR FRIEND:--I have yours of October 4th. I should have answered it before, but have been away from home. "I appreciate very much your offer to send me a memorandum of the work done in Cambridge, also a plan of the work at Yale. You have had a most interesting experience with eminent physiologists, and it has led you deep into the question of nutrition. I shall appreciate very much suggestions from you with reference to subjects for experimental work, and other suggestions which may occur to you respecting the methods, etc. I am sure your wide experience will be a great help to us. The more I test your ideas the more confidence I have in them. "What you say about the wonderful effect of mastication is certainly correct. I observed it right away as soon as I began to practise _Fletcherizing_. By the way, I wrote an article for the last number of my journal, GOOD HEALTH, about "Fletcherizing" food, and I see our colleagues are already taking it up. One of my most able associates, Dr. J. A. Read, who has charge of our sanitarium in Philadelphia, gave a lecture last Thursday night to his patients on "Fletcherizing" food, and his audience was greatly interested. I am sure you deserve to have your name immortalised, as Pasteur's has been. I mention "Fletcherizing" in almost every lecture I give to our patients. I think most of our patients are "Fletcherizing" and are getting great good from it, also a large proportion of our six hundred nurses and other employees. "Awaiting a letter of suggestions at your convenience, I remain, "As ever your friend, "(Signed) J. H. KELLOGG." "Fletcherizing" does not consist only and merely of careful chewing. Careful chewing, with cheerful attention, will secure the comminution, insalivation, and all necessary chemical preparation for perfect digestion, and will separate hard and indigestible matter from the food mass put into the mouth for treatment; but it is the whole environment of the act which counts the best results. Cheerfulness is as important as chewing; and if persons cannot be cheerful during a meal they had better not eat. Not eating will not hurt them in the least, but lack of cheerfulness will defeat the object of the meal by causing more or less indigestion; and hence it not only _does no good to eat when not cheerful, but actually does harm_. Haste and lack of cheerfulness are about the same in effect on digestion. You have no idea how much real nutriment you can get into your system in five minutes if you are industrious with your munching and are cheerful about it; so don't hurry when you have full ten minutes, or perhaps twenty minutes, for taking nourishment. You cannot go faster than Nature will let you, and it is profitable to study Nature and watch her constantly for her proper cue. Don't try to get ahead of her or you may sink in mud or into deep water. Hence the author begs of those who heed his suggestions, especially if they give them his name, to respect them in all their essentials. Don't chew anything when you are mad or when you are sad, but only when you are glad that you are alive and glad that you have the appetite of a live person and one that is well earned. That is as much a part of the "Fletcherizing" process as munching, and one should never forget it. So, please, when you "Fletcherize," if you "Fletcherize" at all, do it well and completely and do not half do it and then condemn the method. The method is all right, notwithstanding the name which has been attached to it, for it is simply Nature's method. Explanation of The A. B. C. Life Series THE ESSENTIALS AND SEQUENCE IN LIFE It would seem a considerable departure from the study of menticulture as advised in the author's book, "Menticulture," to jump at once to an investigation of the physiology and psychology of nutrition of the body and then over to the department of infant and child care and education as pursued in the _crêche_ and in the kindergarten; but as a matter of fact, if study of the causation of human disabilities and misfortunes is attempted at all, the quest leads naturally into all the departments of human interest, and first into these primary departments. The object of this statement is to link up the different publications of the writer into a chain of consistent suggestions intended to make life a more simple and agreeable problem than many of us too indifferent or otherwise inefficient and bad fellow-citizens make of it. It is not an altogether unselfish effort on the part of the author of the A. B. C. Life Series to publish his findings. In the consideration of his own mental and physical happiness it is impossible to leave out environment, and all the units of humanity who inhabit the world are part of his and of each other's environment. It would be rank presumption for any person, even though gifted with the means to circulate his suggestions as widely as possible, and armed with the power to compel the reading of his publications, to think that any suggestions of his could influence any considerable number of his fellow-citizens of the world, or even of his own immediate neighbourhood, to accept or follow his advice relative to the management of their lives and of their communal and national affairs; but while the general and complete good of humanity should be aimed at in all publications, one's immediate neighbours and friends come first, and the wave of influence spreads according to the effectiveness of the ideas suggested in doing good; that is, in altering the point of view and conduct of people so as to make them a better sympathetic environment. For instance, the children of your neighbours are likely to be the playmates of your own children, and the children of degenerate parents in the slum district of your city will possibly be the fellow-citizen partners of your own family. Again, when it is known that right or wrong nutrition of the body is the most important agent in forming character, in establishing predisposition to temperance or intemperance of living, including the desire for intoxicating stimulants, it is revealed to one that right nutrition of the community as a whole is an important factor in his own environment, as is self-care in the case of his own nourishment. The moment a student of every-day philosophy starts the study of problems from the A. B. C. beginning of things, and to shape his study according to an A. B. C. sequence, each cause of inharmony is at once traced back to its first expression in himself and then to causes influenced by his environments. If we find that the largest influences for good or bad originate with the right or wrong instruction of children during the home training or kindergarten period of their development, and that a dollar expended for education at that time is worth more for good than whole bancs of courts and whole armies of police to correct the effect of bad training and bad character later in life, it is quite logical to help promote the spread of the kindergarten or the kindergarten idea to include all of the children born into the world, and to furnish mothers and kindergarten teachers with knowledge relative to the right nutrition of their wards which they can themselves understand and can teach effectively to children. If we also find that the influence of the kindergarten upon the parents of the infants is more potent than any other which can be brought to bear upon them, we see clearly that the way to secure the widest reform in the most thorough manner is to concentrate attention upon the kindergarten phase of education, advocate its extension to include even the last one of the children, beginning with the most needy first, and extending the care outward from the centre of worst neglect to finally reach the whole. Experience in child saving so-called, and in child education on the kindergarten principle, has taught the cheapest and the most profitable way to insure an environment of good neighbours and profit-earning citizens; and investigation into the problem of human alimentation shows that a knowledge of the elements of an economic nutrition is the first essential of a family or school training; and also that this is most impressive when taught during the first ten years of life. One cannot completely succeed in the study of menticulture from its A. B. C. beginning and in A. B. C. sequence without appreciation of the interrelation of the physical and the mental, the personal and the social, in attaining a complete mastery of the subject. The author of the A. B. C. Life Series has pursued his study of the philosophy of life in experiences which have covered a great variety of occupations in many different parts of the world and among peoples of many different nations and races. His first book, "Menticulture," dealt with purging the mind and habits of sundry weaknesses and deterrents which have possession of people in general in some degree. He recognised the depressing effect of anger and worry and other phases of _fearthought_. In the book "Happiness," which followed next in order, _fearthought_ was shown to be the unprofitable element of forethought. The influence of environment on each individual was revealed as an important factor of happiness, or the reverse, by means of an accidental encounter with a neglected waif in the busy streets of Chicago during a period of intense national excitement incident to the war with Spain, and this led to the publication of "That Last Waif; or, Social Quarantine." During the time that this last book was being written, attention to the importance of right nutrition was invited by personal disabilities, and the experiments described in "Glutton or Epicure; or, Economic Nutrition" were begun and have continued until now. In the study of the latter, but most important factor in profitable living, circumstances have greatly favoured the author, as related in his latest book, "The A. B.-Z. of Our Own Nutrition." The almost phenomenal circulation of "Menticulture" for a book of its kind, and a somewhat smaller interest in the books on nutrition and the appeal for better care of the waifs of society, showed that most persons wished, like the author, to find a short cut to happiness by means of indifference to environment, both internal and external, while habitually sinning against the physiological dietetic requirements of Nature. In smothering worry and guarding against anger the psychic assistance of digestion was stimulated and some better results were thereby obtained, but not the best attainable results. Living is easy and life may be made constantly happy by beginning right; and the right beginning is none other than the careful feeding of the body. This done there is an enormous reserve of energy, a naturally optimistic train of thought, a charitable attitude towards everybody, and a loving appreciation of everything that God has made. Morbidity of temperament will disappear from an organism that is economically and rightly nourished, and death will cease to have any terrors for such; and as _fear_ of death is the worst depressant known, many of the _worries_ of existence take their everlasting flight from the atmosphere of the rightly nourished. The wide interest now prevalent in the subjects treated in The A. B. C. Life Series is evidenced by the scientific, military, and lay activity, in connection with the experiments at the Sheffield Scientific School of Yale University and elsewhere, as related in the "A. B.-Z. of Our Own Nutrition" and in "The New Glutton or Epicure" of the series. The general application is more fully shown, however, by the indorsement of the great Battle Creek Sanitarium, which practically studies all phases of the subject, from health conservation and child saving to general missionary work in social reform. HORACE FLETCHER. Instructions Issued by the United States Army Medical Department For the Students of the Army Medical Schools METHOD OF ATTAINING ECONOMIC ASSIMILATION OF NUTRIMENT AND IMMUNITY FROM DISEASE, MUSCULAR SORENESS, AND FATIGUE 1. Feed only when a distinct appetite has been earned. 2. Masticate all solid food until it is completely liquefied and excites in an irresistible manner the swallowing reflex or swallowing impulse. 3. Attention to the act of mastication and insalivation, and appreciation of the taste thereby secured, are necessary, meantime, to excite the flow of gastric juice into the stomach to meet the food, as demonstrated by Pawlow. 4. Strict attention to these two particulars will fulfil the requirements of Nature relative to the preparation of the food for digestion and assimilation; and this being faithfully done, the automatic processes of digestion and assimilation will proceed most profitably and will result in discarding very little digestion-ash (fæces) to encumber the intestines or to compel excessive draft upon the bodily energy for excretion. 5. The evidence of this economy is observed in the small amount of excreta and its peculiar, inoffensive character, showing escape from putrid bacterial digestion such as brings indol and skatol into evidence offensively. 6. When the digestion and assimilation has been normally economic the digestion-ash should be formed into little balls ranging in size from a pea to a so-called Queen Olive, according to the food taken, should be quite dry, and have only the odour of moist clay or a hot biscuit. This inoffensive character remains indefinitely after excretion until the ash completely dries or disintegrates like rotten stone or wood. 7. The weight of the digestive-ash should range (moist) from 10 grams a day to not more than 40-50 grams a day, according to the food; the latter estimate being based on a vegetarian diet and may not call for excretion for many days (3 to 8); infrequency indicating best conditions. The aseptic condition of the excreta renders retention in the intestines quite harmless and gives opportunity for perfect assimilation of the nutriment. 8. Fruits may hasten peristalsis, but not necessarily, if they are thoroughly treated in the mouth as sapid liquids rather than as solids, and are insalivated, sipped, tasted, into absorption in the same way wine tasters test and take wine and tea tasters test tea. The latter spit out the tea after tasting, as otherwise it vitiates their taste and ruins them for their discriminating profession. 9. Milk, soups, wines, beer, and all sapid liquids or semi-solids should be treated in this manner for the best assimilation and digestion as well as for the best gustatory results. The care recommended will reduce the quantity tolerable by the appetite and lead to habits of healthy temperance, but secures maximum satisfaction. 10. This would seem to entail a great deal of care and bother and lead to the waste of time. 11. Such, however, is not the case. To restore the natural protective reflexes in the beginning does require strict attention and persistent care to overcome life-long habits of nervous haste, but if the attack is earnest the habits of mouth-treatment and appetite discrimination soon become fixed and guide the deliberation in taking food unconsciously to the feeder. 12. Food of a proteid value of 5-7 grams of nitrogen and 1500-2000 k. calories of fuel value, paying strict attention to the appetite for selection and carefully treated in the mouth, has been found to be the quantity best suited to metabolic economy and efficiency of both mind and body in sedentary pursuits and ordinary business activity; and, also, such habits of economy have given practical immunity from the common diseases for a period extending over more than five years, whereas the same subject was formerly subject to periodical illness. The same economy and immunity have shown themselves consistently in the cases of many test subjects, covering periods of three years, and applies equally to both sexes, all ages, and other idiosyncratic conditions. 13. The time necessary for satisfying complete body needs and appetite daily, when the habit of attention, appreciation, and deliberation have been installed, is less than half an hour, no matter how divided as to number of rations. This necessitates industry of mastication, to be sure, and will not admit of waste of much time between mouthfuls. 14. Ten minutes will completely satisfy a ravenous appetite if all conditions of ingestion and preparation are favourable. 15. Both quantitive and qualitive supply of saliva is an important factor in buccal (mouth) preparation of nutriment, but attention to these fundamental requirements soon regulates the supply of all of the digestive juices, and, in connection with the care recommended above, insures economy of nutrition, and, probably, immunity from disease. (Signed) HORACE FLETCHER. * * * * * Transcriber's Notes Typographical errors have been silently corrected and hyphenation standardised. Variations in spelling and punctuation are as in the original. In order to minimise the width, full stops have been removed from the headings of the table on page 29. The following alterations have been made: Pages 49 and 120 Preceeding corrected to preceding. Page 66 United Army changed to United States Army. Page 138 Replaceing corrected. Italics are represented thus, _italic_. 
47701	----	Transcriber's Note: ################### This e-text is based on the 1914 edition. Inconsistent hyphenation (e.g., 'semi-acid'/'semiacid') and spelling ('purée'/'puree') have been retained. Italic passages in the original version has been placed between underscores (_italic_); text in small caps have been symbolised by forward slashes (/small caps/). The following passages have been corrected: # Table of Contents: 'Low Vitality (continued)' has been added # Table of Contents: Page number for 'Colds' changed to match the original; corresponding header added to the text # p. 921: 'LaGrippe' --> 'La Grippe' # p. 971: 'cyicken' --> 'chicken' ENCYCLOPEDIA OF DIET ENCYCLOPEDIA OF DIET _A Treatise on the Food Question_ IN FIVE VOLUMES /Explaining, in Plain Language, the Chemistry of Food and the Chemistry of the Human Body, together with the Art of Uniting these Two Branches of Science in the Process of Eating, so as to Establish Normal Digestion and Assimilation of Food and Normal Elimination of Waste, thereby Removing the Causes of Stomach, Intestinal, and All Other Digestive Disorders/ BY /Eugene Christian/, F.S.D. /Volume IV/ NEW YORK THE CHRISTIAN DIETETIC SOCIETY 1914 /Copyright, 1914 by EUGENE CHRISTIAN ALL RIGHTS RESERVED /Published August, 1914/ CONTENTS /Volume IV/ _Lesson XV_ (Continued) _Page_ Low Vitality (continued) 863 Obesity 870 Neurasthenia 897 Malnutrition 901 Anemia 905 Locomotor Ataxia 911 Colds 915 Nasal Catarrh 925 Hay Fever 931 Asthma 935 Influenza 939 Insomnia 940 Rheumatism and Gout 947 Bright's Dis-ease 979 Diabetes 983 Consumption 989 Dis-eases of the Skin 1013 Appendicitis 1029 Menus for the Pregnant Woman 1033 Importance of Food during Pregnancy 1033 The Nursing Mother 1040 Menus for the Nursing Mother 1042 Miscellaneous Menus: Weak Digestion 1046 Building up Nervous System 1053 For Aged Person 1061 Strength and Endurance 1069 Malassimilation and Autointoxication 1074 No appetite 1081 Athletic Diet 1088 For Invalid Child 1098 For Mental Worker 1106 For School Teacher 1115 For Laboring Man 1122 For Cold Weather 1133 For Hot Weather 1134 To Build Up Sexual Vitality 1138 LESSON XV CURATIVE AND REMEDIAL MENUS CONCLUDED LOW VITALITY (continued) SPRING MENU _LOW VITALITY--UNDERWEIGHT WEAK DIGESTION_ Take a cool sponge or a shower bath, a few minutes' vigorous exercise, and a cup of hot water just after rising. BREAKFAST Strained orange juice, diluted--one-half water One egg whipped five or six minutes with a rotary egg beater, to which add a spoonful of sugar, a flavor of pineapple juice, and a glass of milk Half-cup of wheat bran, cooked, and a spoonful or two of steamed wheat LUNCHEON Three eggs prepared as for breakfast, adding two glasses of milk. Drink slowly DINNER A two-egg omelet rolled in cream and grated nuts Puree of peas or beans A small baked potato Take sufficient wheat bran night and morning to keep the bowels in normal action. SUMMER MENU _LOW VITALITY--UNDERWEIGHT WEAK DIGESTION_ A very ripe peach or plum, a cup of cool water, exercise and deep breathing on rising. BREAKFAST Cantaloup, peaches, cherries, or any very ripe sweet fruit Buttermilk or egg, prepared choice A baked sweet potato LUNCHEON Three glasses of milk, taking one-half glass every five or six minutes A small portion of wheat bran, cooked DINNER A green salad An ear of tender corn One or two fresh vegetables such as onions, beans, spinach, beets FALL MENU _LOW VITALITY--UNDERWEIGHT WEAK DIGESTION_ BREAKFAST A small portion of wheat bran, well cooked A cup of warm milk One egg, whipped very fine, to which add a very little sugar and lemon juice. Take this uncooked A few baked chestnuts eaten with butter LUNCHEON String beans or carrots--masticate very thoroughly A large Spanish onion, boiled A baked potato Wheat bran DINNER Choice of tender fish or chicken A portion of spinach A baked potato Onions, en casserole A small portion of wheat bran WINTER MENU _LOW VITALITY--UNDERWEIGHT WEAK DIGESTION_ /First Day/: Drink two glasses of water immediately after rising. Eat one-fourth pound of grapes or some juicy fruit. Devote from three to four minutes to deep breathing exercises. BREAKFAST (Half hour later) Whole wheat, cooked; serve with cream or butter A baked sweet potato A cup of milk A small portion of wheat bran eaten with thin cream LUNCHEON A large, boiled Spanish or Bermuda onion A small portion of carrots, thoroughly cooked A spoonful or two of wheat bran DINNER A cream soup made from celery or onions Rice made into a thick purée, or a baked potato, carrots, onions, or turnips A spoonful or two of wheat bran Just before retiring, take a spoonful or two of wheat bran, uncooked, in a little water, and devote as much time as possible to deep breathing exercises. From one to two glasses of water should be drunk at each of the above meals. It may be taken hot if preferred. If something hot is desired, as a beverage, take a cup of sassafras tea with a little cream and sugar. /Second Day/: The same as the first. /Third Day/: The same as the second, slightly increasing the quantity of food if demanded by normal hunger. /Fourth Day/: Exercises, water-drinking, and fruit as prescribed for the first day. BREAKFAST Two extremely ripe bananas, eaten with thin cream and nut butter or nuts masticated very fine. (They should be baked if not exceedingly ripe) A cup of sassafras tea or chocolate LUNCHEON Three glasses of buttermilk Two beaten egg whites with three teaspoonfuls of sugar A tablespoonful of wheat bran DINNER A portion of boiled onions and tender carrots, cooked until very soft Two baked white potatoes eaten with a little butter Two egg whites prepared any way they are most appetizing A cup of water, hot or cold /Fifth Day/: The same as the fourth. /Sixth Day/: The same as the first, repeating the menus for a week or two. Such vegetables as sweet potatoes, parsnips, baked beans and pumpkin may be added as digestion and assimilation improve. For recipe for baked bananas, see p. 677; for cooking vegetables, see p. 670. MENUS FOR OBESITY SPRING MENU _OBESITY--IRREGULAR HEART ACTION NERVOUSNESS_ Fruit-juice, a glass of water, and ten minutes devoted to vigorous exercise and deep breathing just after rising. BREAKFAST Choice of fruit A cup of hot water Two or three exceedingly ripe bananas (red variety preferred), eaten with raisins, nuts, and cream LUNCHEON A portion of fresh fish and a new baked potato DINNER A green salad with dressing and nuts Peas or asparagus A rare omelet with a dash of grated nuts A bit of crisp corn bread or a bran meal gem Most people afflicted with obesity are also afflicted with abnormal appetite, therefore at the outset they may undergo some deprivation, but if this is not yielded to, hunger will soon become normal. The appetite for an excessive quantity of food is very much like the appetite for coffee, intoxicants, or tobacco, and when the appetite once becomes abnormal and is not held under control, either obesity or chronic autointoxication will be the result. Luncheon should be omitted unless very hungry. SUMMER MENU _OBESITY--IRREGULAR HEART ACTION NERVOUSNESS_ BREAKFAST Melon, peaches, or berries Tender fish, broiled A new potato or a bran muffin LUNCHEON Corn or beans A salad--lettuce or celery DINNER A light soup--vegetable Eggplant, okra, beans, or squash Bran gems or a potato Nuts, with a lettuce salad FALL MENU _OBESITY--IRREGULAR HEART ACTION NERVOUSNESS_ /First Day/: Immediately on rising, drink a cup of hot water, followed by a cup of cool water. Devote as much time as possible (from three to ten minutes) to such exercises as can be endured. (See Vol. V, pp. 1343 to 1346.) Inflate lungs to their utmost capacity every third or fourth movement. Secure a spirometer and increase the lung capacity until it registers about two hundred and fifty cubic inches. This is exceedingly important. BREAKFAST A cantaloup or soaked, evaporated peaches Baked chestnuts Bananas with cream Bran meal gems LUNCHEON A salad Carrots, squash, beets, parsnips, or turnips A potato or lima beans SUPPLEMENTARY LUNCHEON (To be taken in office) Two exceedingly ripe bananas, with nut butter and raisins Two glasses of water (Or the following at a restaurant or cafe) Choice of the following vegetables--boiled onions, carrots, parsnips, squash, or tender corn A baked potato A glass of water DINNER Choice of two vegetables from the selection given for luncheon A green salad A baked sweet or a white potato Two egg whites and one yolk very lightly poached Two glasses of water Devote about ten minutes to exercising and deep breathing just before retiring. /Second Day/: The same as the first, slightly increasing or decreasing the quantity of food according to normal hunger. It will probably be necessary to draw a very sharp distinction between appetite and hunger. (See Spring Menu, "No Appetite," p. 1081.) /Third Day/: The same as the first, if entirely agreeable. If the bowels should become too lax, a small portion of rice, cooked in milk, might be taken with both the morning and the evening meal, omitting a similar quantity of other foods. /Fourth Day/: BREAKFAST Two eggs, whipped from five to eight minutes, into which whip a rounded teaspoonful of sugar, and a dessert-spoonful of lemon juice Half a glass of water LUNCHEON A vegetable salad, with a few nuts A baked sweet potato (These two articles should compose the entire meal) DINNER Spinach (cooked), or a salad of lettuce and celery with English walnuts, masticated infinitely fine Choice of one or two fresh vegetables, including a small, baked white potato /Fifth Day/: The same as the fourth. /Sixth Day/: The same as the first, repeating the diet for about two weeks. WINTER MENU _OBESITY--IRREGULAR HEART ACTION NERVOUSNESS_ /First Day/: Immediately after rising, drink a glass of cool water, and the juice of a sweet orange. Devote as much time as possible (five to ten minutes) to vigorous exercises. BREAKFAST A cup of hot water One banana Two egg whites and one yolk very lightly poached A small, baked white potato, with butter; eat skins and all A small portion of wheat bran cooked five minutes /Note/: If the quantity seems insufficient, a corn-meal muffin may be eaten. LUNCHEON Boiled onions, carrots, or turnips A baked potato--eat skins and all One egg boiled two minutes DINNER Celery, endive, or lettuce, with nuts or a simple dressing Turnips, carrots, spinach, boiled onions--any two of these A baked white potato, served hot with butter and salt A portion of wheat bran cooked five minutes A portion of gelatin, with thin cream Just before retiring, devote from three to five minutes to exercising. Drink a glass of water, take a spoonful or two of wheat bran, and either a few California grapes or the juice of an orange. /Second Day/: The same as the first, slightly varying the meals by choosing different vegetables from the following selections: Beans Potatoes Beets Pumpkin Cabbage Spinach Carrots Squash Onions Turnips Parsnips /Third Day/: The same as the second, adding one very ripe banana, eaten with thin cream and raisins, to the morning meal, and a few nuts, if desired. Banana, nut butter, raisins, and cream make a delicious combination. The entire breakfast could be made of these with good results. /Fourth Day/: Exercise, water-drinking, and deep breathing just before retiring and just after rising, as prescribed for the first day. BREAKFAST A few Malaga grapes or a sweet orange Two exceedingly ripe bananas, eaten with thin cream and nut butter A cup of junket, or a small portion of gelatin with a very little sugar and thin cream One egg prepared as per recipe in "Introduction to Menus" if the appetite will accept it. (See p. 678.) LUNCHEON A green salad A small portion of fish or chicken A baked potato A cup of hot water DINNER One or two fresh vegetables--choice A glass of buttermilk with a small piece of corn bread A small portion of gelatin with thin cream If the bowels are not normal, a portion of wheat bran should be taken at the morning and the evening meal. Both digestion and assimilation of food can be largely increased by daily taking exercise No. 3 (see Vol. V, p. 1344), vigorously, for ten or fifteen minutes just after rising and just before retiring. /Fifth Day/: Same as the fourth, slightly increasing or decreasing the quantity of food according to hunger. /Sixth Day/: Same as the first, repeating, for a period of two or three weeks, the menus as given, varying the meals by choosing different vegetables in the same class as those prescribed. SPRING MENU _ABNORMAL APPETITE OBESITY--DROWSINESS_ MENU I MENU II BREAKFAST The juice of a sweet orange, Fruit--choice or a dish of very ripe One whole egg berries, with sugar only A bran meal gem or a small Two very ripe bananas portion of corn bread eaten with thin cream, One extremely ripe banana dates, and nuts, masticated with figs, thin cream, and exceedingly fine nuts Two glasses of water or a cup of thin cocoa LUNCHEON A lettuce and tomato salad, One very ripe banana with nuts A spoonful or two of nuts One vegetable--fresh peas, One or two figs, or two beans, spinach, or onions dates One very small, baked One glass of water potato One glass of water DINNER A salad of lettuce and tomatoes A salad Choice of two vegetables--asparagus, Asparagus, or peas cooked beans, beets, and served in the pod onions, peas A baked white potato A small, baked potato A very small portion of fish, or white meat of chicken Menus No. 1 are slightly heavier than Menus No. 2. Choice may be exercised between them, according to hunger, or according to activity or amount of work done. One glass of water should be drunk at each of the dinner meals. Two or three tablespoonfuls of wheat bran should be taken twice a week with both the morning and the evening meal. The bran should be cooked five minutes, and eaten with a spoonful of cream. SUMMER MENU _ABNORMAL APPETITE OBESITY--DROWSINESS_ MENU I MENU II BREAKFAST A cantaloup Two or three very ripe One exceedingly ripe red peaches with sugar and banana, eaten with nut cream butter; masticate very A cantaloup fine Bran gems or whole wheat Three egg whites and one yolk, poached lightly, eaten with corn or a small potato LUNCHEON A lettuce and tomato salad, Two glasses of buttermilk eaten with nuts Onions, en casserole Carrots, peas, or beans DINNER A very small portion of Two ears of tender corn fresh fish An egg, with cooked spinach, A small, baked potato or a small portion Green corn of green salad Spinach and corn, cooked From one to two glasses of water should be drunk at each of these meals. The accumulation of gas after meals can be largely controlled by extreme mastication, very slow, deliberate eating, and copious water-drinking at meals. If constipated, take, immediately on rising and just before retiring, a half pound of grapes, swallowing the skins, seeds and pulp. Do not masticate the seeds or pulp. If preferred, half a cup of coarse wheat bran may be taken twice daily instead of grapes. If the bowels should become slightly lax, the seeds of the grapes should be omitted at night. Health is Nature's gift to the young; after that, it is a thing that must be earned. FALL MENU _ABNORMAL APPETITE OBESITY--DROWSINESS_ /First Day/: BREAKFAST One glass of water A melon Two or three extremely ripe peaches Three egg whites, poached very lightly A bran meal gem One exceedingly ripe red banana (must be black spotted), with nut butter and thin cream LUNCHEON One egg, whipped, mixed with a large glass of milk (A half hour later, eat two or three exceedingly ripe peaches) DINNER Half a glass of water Half a cantaloup A lettuce and tomato salad Two medium ears of tender corn A small portion of tender fish /Note/: I would advise a spirometer for measuring the capacity of the lungs. The normal lung capacity for a man 5 feet 7 to 10 inches in height should be about 300 cubic inches, and for a woman 5 feet 3 inches, 180 to 200 cubic inches. The ability to use surplus food, which the appetite will continue to demand for some time, will depend upon the amount of exercise and deep breathing taken, and the consequent lung capacity. /Second Day/: Same as the first, slightly increasing the quantity of food taken at each meal, if demanded by /Normal Hunger/. /Third Day/: BREAKFAST One glass of water Choice of melon, peaches, or plums An exceedingly ripe banana, eaten with thin cream One whole egg, or a small piece of broiled fish A very small baked potato--sweet or white LUNCHEON One or two glasses of buttermilk An ear of corn DINNER One glass of water A small ear of tender corn--boiled Choice of fresh green beans or tender lima beans Spinach, or a salad or anything green A very small portion of broiled fish (If preferred, chicken may be eaten at this meal) A baked potato Just before retiring, eat a few peaches or some grapes. If sleepy or drowsy after meals, devote from one to two minutes to exercises Nos. 3 and 5 (see Vol. V, pp. 1344 and 1345), together with deep breathing, before an open window or in the fresh air. /Fourth Day/: Same as the third. /Fifth Day/: Same as the first, repeating these menus for about thirty days, making such variations in vegetables and fruits as demanded by normal hunger. These menus will seem insufficient in quantity measured by appetite, but appetite, which comes from irritation of the mucous surface of the stomach, is not a safe guide. See menus for "No Appetite," p. 1081. The greatest difficulty will be experienced the first week. After that, nature will begin her process of adjustment, and the patient will begin to reduce in weight and gain in strength; sleep will become more restful and the sleepy and drowsy feeling after meals will gradually disappear. The following natural laws should be rigidly observed: 1 Limit the quantity of food to the actual needs of the body 2 Thorough and complete mastication 3 An abundance of deep breathing 4 A given amount of vigorous exercise every day WINTER MENU _ABNORMAL APPETITE OBESITY--DROWSINESS_ MENU I MENU II BREAKFAST Bananas, very ripe, baked, Boiled wheat, eaten with eaten with thin cream thin cream A spoonful or two of wheat A spoonful of nuts, with bran anything green in the One egg, whipped, to which way of a salad--celery, add a very little sugar lettuce, or romaine and a few drops of lemon (Anything green may juice be taken with Menu I--breakfast) A cup of hot water, chocolate, cocoa, or sassafras tea may be taken after either one of these meals. LUNCHEON Carrots, squash, pumpkin, Same selections as Menu I beets, or turnips (luncheon); select one Sweet or white potatoes vegetable, or omit vegetables entirely, and take two eggs, whipped with a little sugar and lemon juice; add a glass or two of milk DINNER A bit of anything green--celery, One or two of the same spinach, or lettuce vegetables as in Menu I eaten with oil, salt and (dinner) nuts Anything green, as a salad Choice of any fresh vegetable One egg, or a bit of fish, if named for luncheon desired A baked sweet or a white potato A few nuts, and one extremely ripe banana as a dessert For recipe for baked bananas and whipped eggs, see pp. 677 and 678, Vol. III. SPRING MENU _FOR DECREASING WEIGHT AND INCREASING STRENGTH_ BREAKFAST Whole wheat, thoroughly cooked Two bananas, baked, if not very ripe; serve with cream and either nut butter or nuts LUNCHEON Baked beans, with sauce of olive-oil, lemon juice and sugar A cup of chocolate DINNER A green salad Smelts, or any young or tender fish A potato An onion Gelatin, with fruit Vigorous exercise and deep breathing are very necessary both in decreasing weight and increasing strength. At least three hours daily should be spent in the open air, and the lungs should be filled to their utmost capacity. The bowels should be kept in normal condition. (See Menus for Constipation.) SUMMER MENU _FOR DECREASING WEIGHT AND INCREASING STRENGTH_ BREAKFAST Cherries, berries, cantaloup, or melon A red banana, with nuts One or two eggs, whipped--dash of sugar; flavor with lemon or pineapple juice LUNCHEON Green beans, with onion Corn or a potato DINNER Celery or shredded cabbage, with nuts and oil Sweet potatoes--butter Corn Melon A glass of water or thin cocoa may be taken at each of the above meals. FALL MENU _FOR DECREASING WEIGHT AND INCREASING STRENGTH_ BREAKFAST A cantaloup A banana, with raisins, cream, and nuts An egg, cooked two minutes A bran gem or a whole wheat cracker, or whole wheat bread LUNCHEON A pint of junket or two glasses of buttermilk DINNER A green salad, with oil and nuts A rare omelet, rolled in scraped corn A potato--sweet or white A cantaloup WINTER MENU _FOR DECREASING WEIGHT AND INCREASING STRENGTH_ Immediately on rising devote five minutes to exercises and deep breathing. BREAKFAST Wheat bran and flaked wheat, cooked together; use a liberal service of cream A cup of cocoa LUNCHEON Spinach, with egg white A bran gem or a whole wheat muffin A vegetable or fruit salad, with oil and nuts DINNER Boiled onions, parsnips, or carrots--any two of these A baked potato A very small portion of fish or white meat of chicken A cup of hot water MENUS FOR NEURASTHENIA SPRING MENU _NEURASTHENIA_ BREAKFAST Three or four egg whites, whipped and mixed with a pint of rich milk Bran meal gems LUNCHEON Onions, en casserole A potato DINNER Peas or asparagus A morsel of dried herring and an onion, uncooked Bran meal gems or a potato Cheese, raisins, and nuts SUMMER MENU _NEURASTHENIA_ BREAKFAST Cantaloup, peaches, plums, or berries--no sugar Whole wheat, boiled Half a cup of wheat bran, with cream LUNCHEON Spinach or turnip-tops Onions, uncooked, and a bit of dried fish A potato DINNER Lettuce or celery, with nuts Fish Vegetable soup Squash, carrots, or onions A potato FALL MENU _NEURASTHENIA_ BREAKFAST Cantaloup or peaches Baked bananas, with cream One egg, boiled two minutes A bran meal gem LUNCHEON Two glasses of buttermilk A muffin--graham or gluten DINNER Vegetable soup Celery or lettuce, with nuts Turnips, carrots, okra, cauliflower--choice A bran meal gem A sweet potato WINTER MENU _NEURASTHENIA_ BREAKFAST Prunes or a very ripe banana Nuts, with raisins and cream A sweet potato LUNCHEON An onion, uncooked, and a very small portion of dried fish A bran gem Cocoa DINNER Celery or slaw Nuts Cabbage, cauliflower, or Brussels sprouts Carrots, parsnips, or onions Baked beans or a potato The person afflicted with neurasthenia should omit all beverages, except water, which should be drunk only at meals. By all means avoid overeating. MENUS FOR MALNUTRITION SPRING MENU _MALNUTRITION_ Menus for the treatment of malnutrition should be limited in quantity, and composed of the most soluble and readily digestible articles that will afford the required elements of nourishment. BREAKFAST Very ripe berries, without sugar and cream Two or three egg whites, whipped, and mixed with a pint of skimmed milk Two heaping tablespoonfuls of wheat bran, cooked, and served with a little cream LUNCHEON A raw Spanish onion, with a bit of dried fish A baked potato--eat skins and all Bran meal gems, with butter DINNER Lettuce or young onions Peas or asparagus Spinach or turnip-greens, with yolk of egg A baked potato A tablespoonful of wheat bran, cooked SUMMER MENU _MALNUTRITION_ BREAKFAST Melon, peaches, or berries Two very large, ripe bananas, baked; serve with cream (See recipe, page 677) A glass of milk LUNCHEON Spinach or turnip-greens, with egg yolk Bran meal gems or corn bread A bit of onion, uncooked DINNER A light vegetable soup String beans, fresh peas, tender corn--any two of these A potato or lima beans Gelatin (lemon or vanilla), if something sweet is desired FALL MENU _MALNUTRITION_ BREAKFAST Cantaloup or peaches One or two bran meal gems or a corn muffin A glass or two of rich milk LUNCHEON Celery or lettuce, with either nuts or oil Tender corn or lima beans A potato--sweet or white DINNER Vegetable or cream soup Celery, with ripe olives and nuts Carrots, and either onions or squash (These should be cooked in a casserole dish; see page 671) Bran meal gems or a potato WINTER MENU _MALNUTRITION_ BREAKFAST Strained orange juice--half water Whole wheat, boiled, and served with butter (omit cream) LUNCHEON Three to four glasses of rich milk Two or three tablespoonfuls of wheat bran DINNER Celery or vegetable salad, with nuts and oil Turnips, carrots, winter squash, or onions; preferably en casserole A bit of very tender fish or white meat of chicken A potato or a corn muffin For cooking en casserole, see p. 671, Vol. III. MENUS FOR ANEMIA SPRING MENU FOR A YOUTH _ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE_ The following menus should be carefully adhered to for two or three days, or until normal hunger is produced: BREAKFAST Prunes or dried peaches Bananas, nuts, or nut butter A pint of rich milk LUNCHEON A light vegetable, such as boiled onions, peas, or new potatoes A glass or two of milk DINNER Two eggs, coddled A baked white potato SPRING MENU FOR A YOUTH _ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE_ When good digestion and normal hunger are restored, the following menus should be given: BREAKFAST Farina, rice, or corn hominy, with butter and a very little sugar Fresh milk--one or two glasses LUNCHEON Baked potatoes Milk DINNER Peas or beans, creamed onions A potato Rice or corn bread Gelatin or boiled custard Vigorous exercise and outdoor sport should be encouraged. SUMMER MENU FOR A YOUTH _ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE_ BREAKFAST Cantaloup, peaches, or plums A very rare omelet or a coddled egg A corn-meal gem Milk LUNCHEON Milk or buttermilk--buttermilk preferred A bran gem or a whole wheat gem DINNER One or two vegetables Rice or corn Milk A cantaloup Drink an abundance of water. Spend all the time possible out of doors. FALL MENU FOR A YOUTH _ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE_ Choice of the following: MENU I MENU II BREAKFAST Two or three egg whites, One exceedingly ripe banana, whipped three or four eaten with nut minutes, into which whip butter, cream, and figs a teaspoonful each of or dates olive-oil and lemon juice, A glass or two of milk and a heaping teaspoonful of sugar. Add a cup of rich milk LUNCHEON Turnips, carrots, parsnips, Boiled onions squash--any two of these A bit of tender fish or an A bit of whole wheat bread egg. (The egg might be or a baked potato whipped as for morning) Milk A baked potato--sweet or white Milk DINNER Choice of one vegetable (see An egg, or clabbered milk, luncheon) with a little sugar One egg whipped, or a glass A baked potato of milk. (Both, if the One fresh vegetable appetite will accept them) A baked potato--sweet or white It would be preferable to make the entire meal (dinner) upon whipped eggs, if they appeal to the taste. For "Choice of Menus," see p. 683, Vol. III. WINTER MENU FOR THE YOUTH _ANEMIA--MALASSIMILATION--UNDERWEIGHT--NO APPETITE_ BREAKFAST A cup of chocolate or cocoa, or warm milk Steamed wheat, farina, or corn hominy LUNCHEON Vegetable soup Fish or a potato Milk DINNER One fresh vegetable A potato Chicken or fish Ice-cream--very little For primary causes of Anemia, see Lesson I, "Chart showing different dis-eases caused by Superacidity," p. 9. MENUS FOR LOCOMOTOR ATAXIA SPRING MENU _LOCOMOTOR ATAXIA_ BREAKFAST Three egg whites and one yolk, whipped, mixed with a pint of rich milk Two or three tablespoonfuls of wheat bran, cooked, and served with thin cream LUNCHEON Plain wheat, boiled thoroughly, eaten with Pignolia (pine) nuts DINNER Fresh peas or baked beans Buttermilk Cheese, nuts, and raisins Wheat bran SUMMER MENU _LOCOMOTOR ATAXIA_ BREAKFAST Melon or peaches--no sugar Three or four glasses of fresh milk A corn muffin Wheat bran LUNCHEON Fresh corn, peas, or beans Milk; two to four glasses Bran DINNER Shelled peas or beans A potato Fish, eggs, or buttermilk Bran FALL MENU _LOCOMOTOR ATAXIA_ BREAKFAST A pint of clabbered milk, with a sprinkle of sugar Corn hominy or corn bread LUNCHEON Fish, chicken, or turkey A potato Cheese and nuts DINNER Celery with nuts Two or three glasses of milk; buttermilk preferred A potato Bran Raisins, cheese, and nuts WINTER MENU _LOCOMOTOR ATAXIA_ BREAKFAST California grapes or prunes Two eggs, whipped, and mixed with two or three glasses of milk Bran meal gems LUNCHEON Celery with nuts Turnips, carrots, or parsnips A baked potato DINNER Boiled plain wheat or corn bread Fish, chicken, or two or three glasses of milk (Wheat bran, if milk is taken) COLDS [Sidenote: Cause 1] A cold, in its last analysis, is merely a form of congestion throughout the capillary vessels of the body. It may have been caused by exposure--a draft of cold air blowing upon some exposed part of the body, in which case Nature closes the pores of the skin in self-defense. The poisons that are constantly being eliminated through the pores are thus prevented from escaping through these channels, and are picked up by the circulation, and carried to the lungs to be burned with oxygen. The lung capacity being too limited, or the amount of poison too great, Nature suppurates these poisons and throws them off in the form of mucus. [Sidenote: Cause 2] When a quantity of food, greater than the body can use, is taken and ingested into the circulation, the excess is carried to the lungs in the same manner as above described, and the same form of congestion and elimination takes place; therefore, colds caused by _exposure_ and _overeating_ are alike in every respect except their origin. The experience of the writer has been that congestion, which we term colds, is caused much more frequently from overeating than from exposure. The logical remedy in either case is to limit the quantity of food to the minimum and to confine the diet, as nearly as possible, to readily soluble and readily digestible foods, such as nuts, fruit salads, and fresh watery vegetables, taking only sufficient nitrogenous and carbohydrate compounds to balance the daily bill of fare. The following menus given for colds may be also used in cases of la grippe, influenza, etc.: MENUS FOR COLDS SPRING MENU BREAKFAST A cup of hot water An apple, with nuts or berries, in season Two egg whites to one yolk, whipped or lightly poached Clabbered milk, with a sprinkle of grated maple-sugar A few raisins and nuts LUNCHEON One tuber vegetable A baked potato or baked beans A salad (green), with nuts or cheese DINNER Asparagus, turnips, beets, onions--any two of these A potato Whole wheat, well cooked, or a portion of wheat bran, cooked Nut butter or thin cream In the late spring, such vegetables as new beets, radishes, lettuce, onions, or any green salad may be eaten at either the noon or the evening meal. These meals may be varied by choosing fresh vegetables or fruit in season. SUMMER MENU _COLDS_ BREAKFAST Choice of fruit--a liberal quantity A banana--very ripe; serve with raisins, nuts, and cream (If the banana is not very ripe, it should be baked) LUNCHEON A generous green salad, with grated nuts Choice of one or two fresh vegetables A poached egg, dropped into a baked potato DINNER A liberal green salad Smelts, broiled Tender corn One or two fresh vegetables A dessert of peaches, plums, berries, or any juicy fruit From one to two glasses of water should be drunk at meals. A liberal quantity of fruit or berry juice should be taken between meals. Vegetable soup may be served at either the noon or the evening meal, using but little fats. Acid fruits, such as oranges, grapefruit, pineapples, lemons, and strawberries should be omitted if there is a tendency toward superacidity, intestinal fermentation, or rheumatism. FALL MENU _COLDS_ BREAKFAST Melon or choice of fruit Baked squash or a banana Flaked wheat or a bran meal gem A spoonful or two of nuts, with raisins LUNCHEON Two shirred eggs An ear of tender corn A green salad DINNER Choice of two fresh vegetables Choice of corn or lima beans Choice of a baked sweet or a white potato A green salad--liberal portion Gelatin or junket WINTER MENU _COLDS_ Juice of orange or grapes just after rising. BREAKFAST A cup of hot water, sassafras tea, or malted milk Two coddled eggs, or very tender fish, broiled A potato or a bran gem[*] LUNCHEON Any fresh vegetable: Cauliflower, Brussels sprouts, cabbage, turnips Spinach or endive Malted milk or a cup of cocoa DINNER A bit of slaw or celery Liberal portion of boiled onions Spinach, with egg A potato; prepared choice All of the menus for Colds can be taken in cases of La Grippe and Influenza. [* See "Bran Meal," p. 683.] NASAL CATARRH The following menus, in their various groups, are composed of the most easily digested foods that will give to the body all the elements of nourishment it requires, during the several seasons of the year. The calories of energy, remedial elements and counteractive properties these menus contain, have been very carefully compiled from long experience in the treatment of catarrh. The nutritive factors they contain are proportioned or leveled so that under ordinary conditions there will be no deficiency to produce unnatural craving, and no surplus to be decomposed and converted into mucous or catarrhal discharges. These menus contemplate a normal body, living under normal conditions. If one should be exposed to excessive cold, the carbohydrates (sugar and starches) and fats may be slightly increased, and if exposed to excessive heat these articles should be limited somewhat below the amount prescribed. If one is engaged in heavy manual labor the proteid factor such as is contained in beans, eggs, fish, and cheese may be increased, and if performing no labor, these things should be reduced even below the amount prescribed. These menus will have a tendency to establish normal digestion and assimilation of food, and normal elimination of waste. When this is accomplished, the instincts and various senses will suggest the quality and the quantity of food, the kind and amount of exercise, and all other natural laws that govern and control the physical organism. WATER-DRINKING IN THE TREATMENT OF NASAL CATARRH Sufficient water should be drunk at each of these meals to bring the moisture up to about 66 per cent of the whole. This will require from one to three ordinary glasses, depending largely upon the amount of residual water in the foods composing the meal. See "Uses of Water in the Body," Lesson II, Vol. I, p. 53. See also "Water-drinking in Cases of Superacidity," Vol. II, p. 434. Water performs another very valuable service. When one eats too many sweets, he should drink an abundance of water. This prevents stomach-acidity, and consequent fermentation and irritation of the mucous lining of the stomach. It also prevents torpidity of the liver, which usually follows the excessive use of sweets. Two or three glasses of water taken at an ordinary meal will all be retained and used by the body, while the same quantity of water taken from two to three hours after a meal, will nearly all pass off in the form of urine. MENUS FOR NASAL CATARRH LATE SPRING AND EARLY SUMMER _NASAL CATARRH_ Sweet orange, cherries, or very ripe grapefruit just after rising. BREAKFAST Three or four egg whites, whipped five minutes, to which add two teaspoonfuls each of lemon juice and sugar, while whipping One very ripe banana, or plain boiled wheat, with nuts LUNCHEON A green salad, with tomatoes and oil One fresh vegetable--peas or beans Corn bread--butter Buttermilk DINNER Spinach, kale, young cabbage, or turnip-tops, cooked One fresh vegetable, in season A baked sweet potato Choice tender fish, chicken, or three egg whites and one yolk, whipped, with spoonful each of sugar and of lemon juice These menus are composed largely of proteids in their most soluble and digestible forms--a most important factor in remedial feeding, especially in cases of either stomach or nasal catarrh. One or two glasses of water should be drunk at each of these meals. Mastication should be perfect before any water is taken into the mouth. The bowels should be kept normal by the use of wheat bran. LATE SUMMER AND EARLY FALL _NASAL CATARRH_ For many patients suffering with nasal catarrh, the following combinations have been prescribed by the author with much success. Choice of the following: MENU I MENU II BREAKFAST Peaches or pears A cantaloup or grapes A baked sweet potato One or two eggs, lightly Half a glass of milk cooked A baked banana A whole wheat gem or a baked white potato A cup of cocoa LUNCHEON A lettuce salad Peas, beans, or carrots One fresh vegetable, in season A sweet or a white potato A baked potato or a very Buttermilk, with two egg little whole wheat bread; whites, whipped potato preferred A banana with cream cheese and dates DINNER A lettuce and tomato salad Young onions, radishes, or Choice of two fresh vegetables celery Tender fish Beets, carrots, corn, parsnips, A baked potato Spanish onion, or Plain ice-cream, provided string beans--any two salad is omitted of these Choice--fish, chicken, or eggs A baked potato A cantaloup LATE FALL AND EARLY WINTER _NASAL CATARRH_ MENU I MENU II BREAKFAST Grapes One very ripe banana with Bran gems thin cream and nut butter One egg whipped with sugar A pint of clabbered milk and lemon juice A small portion of coarse A baked sweet potato cereal--plain wheat boiled LUNCHEON A salad, or celery, with Onions cooked in a casserole either nuts or oil dish Baked beans A potato; prepared choice Boiled onions or carrots DINNER Carrots, onions, parsnips, One fresh vegetable squash, turnips--any two A baked sweet or a white of these potato Choice of one of the following A very ripe banana, with proteid foods: either nuts and raisins Eggs Chicken or figs and cream (white meat) Fish Turkey (white meat) A baked potato /Note/: If the weather is very cold a dessert-spoonful or more of olive-oil should be taken just before each of these meals, and a cup of hot water at the close. LATE WINTER AND EARLY SPRING _NASAL CATARRH_ MENU I MENU II BREAKFAST A sweet orange Whole wheat or corn--boiled A rare omelet rolled in soft or simmered grated nuts and cream over night; serve with Whole wheat bread or corn butter or cream muffins A cup of chocolate A cup of chocolate LUNCHEON Baked sweet potatoes with A boiled Spanish onion butter A white potato, baked A cup of chocolate Two eggs, either whipped or coddled DINNER Cream of tomato soup (Christmas or New Year's Celery or slaw dinner) Nuts Cream of celery soup Carrots, parsnips, or turnips A vegetable salad A baked potato Baked or creamed potatoes Cocoa or hot water Turkey or chicken--white meat--very little Baked chestnuts Cranberry sauce Ice-cream Hot chocolate MENUS FOR HAY FEVER SPRING MENU _HAY FEVER_ BREAKFAST Bananas, baked Whole wheat or rye, boiled five or six hours Thin cream LUNCHEON Any fresh vegetable--cabbage, onions, carrots Whole wheat bread Thin cocoa DINNER One egg, coddled Rice or a potato Boiled onions or squash Spinach or lettuce, with nuts For recipe for baked bananas and coddled eggs, see p. 677, Vol. III. See "Bran Meal," p. 683, Vol. III. SUMMER MENU _HAY FEVER_ BREAKFAST Cantaloup or peaches--no sugar A potato--sweet or white Clabbered milk LUNCHEON Corn or peas Lima beans A potato A melon DINNER Lettuce and tomato salad, with nut-butter sauce Peas, beans, carrots, squash, or onions A potato--sweet or white An egg or a very small portion of fish FALL MENU _HAY FEVER_ BREAKFAST Persimmons or grapes Bran meal gems or corn bread A glass of milk LUNCHEON Winter squash or a sweet potato Baked beans or a white potato DINNER Lettuce or celery, with nuts Carrots or string beans A raw onion A baked potato or corn bread A spoonful or two of bran, cooked WINTER MENU _HAY FEVER_ BREAKFAST The juice of a sweet orange Three baked bananas or two very ripe bananas, with cream, raisins, and nuts LUNCHEON Eggplant and a boiled onion A bran meal gem or a corn muffin Nuts, with raisins DINNER A light vegetable soup Turnips or cabbage, en casserole A baked potato or bran meal gems One or two figs, with cheese and nuts The bowels should be kept in normal condition by the liberal use of wheat bran at each meal. The free action of the bowels is very important in all such disorders as hay fever, influenza, and colds. MENUS FOR ASTHMA SPRING MENU _ASTHMA_ BREAKFAST Grapefruit or an orange--very ripe Baked bananas--must be very ripe A glass of milk LUNCHEON Peas or asparagus Bran meal gems A glass of milk DINNER Spinach or turnip-tops Corn bread or bran meal gems Peas or asparagus A potato SUMMER MENU _ASTHMA_ BREAKFAST Peaches, plums, or berries, without cream One egg, either lightly poached or boiled two minutes A small baked potato LUNCHEON An ear of tender corn A Spanish onion, uncooked, with a morsel of dried fish DINNER Fresh peas, beans, or carrots Tender corn or a baked potato Lettuce, romaine, or watercress, with nuts FALL MENU _ASTHMA_ BREAKFAST Grapes or a melon Two egg whites, whipped, and mixed with a pint of milk Baked chestnuts, with cream LUNCHEON Okra or a boiled onion A baked potato Half a glass of milk DINNER Celery, with nuts Cauliflower, squash, or a stewed pumpkin A potato or lentils A cup of cocoa or a glass of milk WINTER MENU _ASTHMA_ BREAKFAST Pineapple--eliminate the pulp Plain boiled wheat; serve with fresh butter LUNCHEON A pint of clabbered milk, with a sprinkle of sugar Two tablespoonfuls of wheat bran DINNER Vegetable soup Celery, with nuts and ripe olives Carrots or baked squash A potato--sweet or white The juice of a sweet orange an hour after eating. Where milk is not prescribed in the above menus, from one to two glasses of water should be drunk. The bowels should be kept in normal condition by the use of wheat bran. INFLUENZA In treating influenza heavy starchy foods such as white flour products should be omitted, and the diet confined largely to fresh vegetables and the more soluble proteids, such as egg whites and buttermilk, with now and then a limited quantity of fish or fowl for a change. Fats and sugars should be limited very materially and a liberal quantity of coarse articles such as wheat bran, celery, grapes, and green salads eaten when in season. The patient should exercise great care in regard to quantity, endeavoring always to limit the quantity of food somewhat below the demands of normal hunger. The menus for colds, catarrh, hay fever, and asthma may be used for influenza. See pp. 917 to 938, inclusive. MENUS FOR INSOMNIA SPRING MENU _INSOMNIA--NERVOUSNESS_ _LOW VITALITY_ Both insomnia and nervousness are symptoms of the same conditions. The following menus, therefore, are for the purpose of removing primary causes, which are usually either stomach or intestinal fermentation. The logical remedy for fermentation is to limit the diet to the fewest number of articles that will give to the body the necessary elements of nutrition. BREAKFAST A cup of hot water Corn hominy or boiled wheat A banana, baked, or sliced and broiled in butter A cup of cool water LUNCHEON A liberal portion of peas in the pod A baked potato DINNER Light vegetable soup Peas or asparagus Baked potatoes A cup of hot water Half-cup of wheat bran, cooked /Note/: New peas should be cooked in the pod, as the shell contains better nutrition than the pea. For recipe, see p. 679. SUMMER MENU _INSOMNIA--NERVOUSNESS LOW VITALITY_ BREAKFAST Cantaloup or very ripe pear, with cream A baked sweet potato, with butter A pint of rich milk Wheat bran LUNCHEON An ear or two of tender corn A green salad One egg, whipped DINNER Lettuce and tomato salad, with grated nuts String beans, with raw onion Tender corn, scraped from the cob, cooked with very little rich milk and the white of an egg Cantaloup The quantity of food prescribed is sufficient for one performing very light labor. If the duties should be strenuous, the quantity may be slightly increased, but the proportions and the combinations should be observed. FALL MENU _INSOMNIA--NERVOUSNESS LOW VITALITY_ Vigorous exercise, deep breathing, and a glass or two of water should be taken on rising. BREAKFAST (Half hour later) Cantaloup, pears, or persimmons Baked bananas, served with cream Steamed figs, with thin cream A spoonful of nuts LUNCHEON Corn on the cob or boiled wheat String beans Spinach DINNER Romaine and tomato salad A liberal portion of baked white potato or tender corn Carrots or parsnips Cheese with hard cracker A cup of thin cocoa If there should be congestion of the bowels, a liberal service of Concord or blue grapes should be eaten the first thing after rising, and the last thing before retiring. The pulp and seeds should be swallowed, and the skins well masticated. WINTER MENU _INSOMNIA--NERVOUSNESS LOW VITALITY_ A cup or two of hot water, deep breathing, and vigorous exercise immediately after rising. BREAKFAST Half a pound of Tokay or Malaga grapes, masticating and swallowing both skins and seeds Two fresh eggs, whipped very thoroughly, slightly sweetened with honey or maple-sugar, and flavored with fruit-juice. Add half a glass of milk to each egg and drink slowly LUNCHEON A small portion of wheat bran, cooked A pint and a half of junket, taken slowly One bran meal gem DINNER Carrots or winter squash A small portion of tender fish or a whipped egg A baked potato A cup of cool water To increase vital energy depends not so much upon the quantity as upon the amount of food ingested or assimilated. These menus are rather light for one of low vitality, but they are made to meet the requirements of one suffering from nervousness and insomnia. If, however, these conditions do not prevail, the quantity may be increased, but the combinations should be carefully observed. MENUS FOR RHEUMATISM AND GOUT SPRING MENU _RHEUMATISM--GOUT--LUMBAGO SCIATICA, ARTHRITIS_ BREAKFAST Choice of the following: _a_ Two or three bananas, baked; serve with cream or butter _b_ A baked sweet potato Half a dozen steamed figs, with cream LUNCHEON Asparagus or peas A small portion of new potatoes--preferably baked DINNER Potato, steamed wheat, or bran gems A glass of milk; buttermilk preferred One fresh vegetable, such as carrots, turnips, parsnips, or onions Nuts or cream cheese A generous quantity of pure water should be drunk immediately on rising, and from one to two glasses at each of these meals. Mastication should be very thorough. At least two hours' vigorous exercise or useful labor should be performed each day, in the open air. Omit all acids, such as grapefruit, oranges, pineapples, lemons, and rhubarb; also eggs and all flesh foods. If the bowels are constipated, take a tablespoonful of wheat bran in half a glass of hot water immediately on rising, and half a cup of bran, cooked, at each meal; also, two or three tablespoonfuls in hot water just before retiring. Continue this until the bowels become normal, then reduce the quantity according to the severity of the case. SUMMER MENU _RHEUMATISM--GOUT--LUMBAGO_ _SCIATICA, ARTHRITIS_ BREAKFAST Melon or peaches--very ripe Two or three large, very ripe bananas, peeled, and baked ten minutes; serve with cream or fresh butter A bran meal gem LUNCHEON A very small portion of green salad An ear or two of tender corn A pint of buttermilk DINNER A small portion of green salad Peas, beans, corn, or any fresh vegetable A very small portion of fish (Buttermilk or junket may be taken instead of fish, if preferred) A baked potato Melon or cantaloup From two to three glasses of water should be drunk at each of these meals. If the bowels are constipated, observe the instructions given for the Spring Menu. Exercise, in all rheumatic conditions, is very important, and while the temperature of the summer weather aids in eliminating poisons from the body, vigorous exercise should be taken in order to give Nature all the help possible. Rheumatism is merely a form of congestion throughout the capillary vessels of the body. The cure, therefore, is first to remove the causes by taking into the body only such foods as it will use, and use completely; secondly, to aid Nature in casting out all poisons, thereby establishing perfect elimination. FALL MENU _RHEUMATISM--GOUT--LUMBAGO_ _SCIATICA, ARTHRITIS_ BREAKFAST Melons or persimmons Whole wheat gems or bran gems An exceedingly ripe banana, with cream, nuts, and raisins LUNCHEON Green corn or fresh string beans Either a baked potato or a very little whole wheat bread Two or three tablespoonfuls of olive-oil, with lettuce DINNER Vegetable soup or cream soup Corn, lima beans, turnips, carrots, parsnips, squash, onions--any two of these A baked potato Half a pound of grapes may be eaten an hour after either meal, or just before retiring. Two glasses of water should be drunk at each of these meals. For general instructions, see Spring Menu. WINTER MENU _RHEUMATISM--GOUT--LUMBAGO_ _SCIATICA, ARTHRITIS_ /First Day/: On rising, drink two glasses of water. Devote as much time as possible to vigorous exercises and deep breathing. BREAKFAST Corn muffins or bran meal gems, with cream or fresh butter A cup of cocoa--half milk LUNCHEON A large portion of boiled onions A baked white potato Raisins, with nuts and cream cheese DINNER A fresh vegetable soup Squash, pumpkin, cabbage, Brussels sprouts, cauliflower, eggplant--any two of these A very small portion of white meat of chicken Salted nuts with steamed figs Just before retiring drink a glass of water, and exercise as already suggested. /Second Day/: Very much the same as the first, slightly increasing the quantity of food, if the amount prescribed does not seem sufficient to satisfy normal hunger. Take great care, however, not to overeat. /Third Day/: BREAKFAST Bran gems, or a baked potato, with butter Two glasses of milk LUNCHEON A liberal portion of baked sweet potatoes, with butter A cup of hot water, into which put a little sugar and cream Figs, cream, and nuts DINNER A salad of lettuce, celery, or endive, with nuts One fresh vegetable A bit of chicken or turkey--white meat; or shell-fish, such as lobster or crab, may be eaten A baked potato /Note/: The meats are given only in case there is a craving for something salty. Exercise and water-drinking just before retiring. /Fourth Day/: Same as the third, varying the meals by changing vegetables according to hunger. /Fifth Day/: Same as the first, repeating these menus for a period of from fifteen to twenty days, making such variations in the vegetables as normal hunger requires. SPRING MENU _ANEMIA--SLUGGISH LIVER_ _RHEUMATIC TENDENCY_ Drink two glasses of water just after rising, to which add a spoonful or two of lemon juice. Devote as much time as possible (from three to five minutes) to vigorous exercises, as shown in Vol. V, pp. 1343 to 1346. Hold the breath while executing three or four movements. In this way the lung capacity can be much increased. Choice of the following: MENU I MENU II BREAKFAST A cup of hot water Grapes or orange juice Half a cup of wheat bran, Whole wheat, boiled; serve cooked with thin cream An egg white, poached Wheat bran A banana, baked LUNCHEON Spinach One glass of water A potato or steamed wheat Boiled onions A baked white potato DINNER A salad of lettuce and tomatoes, A green salad with oil Carrots, spinach, or onions--any Choice of peas, beans, or two of these asparagus A baked sweet or a white A small, baked white potato potato One egg or a very small portion Baked beans or rye bread of tender fish One glass of water One glass of water Apple tapioca or gelatin The bowels should be kept in normal condition by the use of clean, coarse wheat bran. SUMMER MENU _ANEMIA--SLUGGISH LIVER_ _RHEUMATIC TENDENCY_ /First Day/: On rising, take two sweet, ripe plums, and a glass of water. Devote from one to three minutes to exercises Nos. 3 and 5 (see Vol. V, pp. 1344 and 1345), and practise deep breathing, filling the lungs to their utmost capacity every third or fourth movement. Also take a short, brisk walk in the open air. BREAKFAST (An hour later) Four or five extremely ripe peaches, with just a sprinkle of sugar--no cream Two or three egg whites and one yolk, whipped with a teaspoonful of sugar One extremely ripe banana (black spotted), with nuts LUNCHEON Two medium ears of tender green corn, thoroughly masticated; serve with either a very little nut butter or fresh dairy butter DINNER Cream of pea soup; crisp cracker--very little A lettuce and tomato salad, or cooked spinach An ear or two of tender green corn, or lima beans (cooked) A grilled sweet potato Water should be taken as follows: Half a glass at the beginning, a glass during the progress of the meal, and half a glass at the close. Just before retiring, eat half a pound of very ripe grapes, swallowing skins, seeds and pulps, or take four or five extremely ripe Japanese plums, if they are not sweet and well ripened; grapes are preferred. Devote about three minutes to exercises Nos. 3 and 5, together with deep breathing. /Second Day/: Same as the first, very slightly increasing the quantity of food if there is the least symptom of weakness. Every morning, immediately on rising, eat two or three peaches or plums, and drink a glass of water. /Third Day/: BREAKFAST Cantaloup A cup of cocoa or chocolate Choice of: _a_ Two extremely ripe bananas, baked; serve with thin cream (bananas must be black spotted) _b_ A baked potato Two egg whites, whipped with a sprinkle of sugar and a little lemon juice and cream LUNCHEON Tender corn String beans or squash Spinach or a green salad A cantaloup or two exceedingly ripe peaches, with a little sugar--no cream DINNER A small portion of fish or white meat of chicken, provided there is a craving for this kind of food; if not, confine to Tender corn (One whole poached egg, eaten with the corn) One boiled onion or cooked spinach Two glasses of water This entire meal should be masticated very thoroughly. This is one method of preventing supersecretion of acid, premature fermentation and the consequent accumulation of gas. /Fourth Day/: The same as the third, with the exception of the evening meal, which should consist of-- A baked sweet potato--butter Carrots or string beans, or Spanish onion /Fifth Day/: The same as the first. /Sixth Day/: The same as the second, repeating the diet as given for a week or ten days. After the fourth day these meals may be slightly varied by choosing from the following, where vegetables are prescribed: Beans Parsnips Beets Peas Carrots Squash Corn Turnips The patient should retire at a reasonable hour, say 10 o'clock, and rise about 6 or 6.30; have breakfast between 7.30 and 8; luncheon between 12 and 1, and dinner not later than 6.30 or 7. Masticate well every mouthful of food, whether it seems to need it or not. Even bananas need much mastication, not for the purpose of reduction, but for the purpose of insalivation. The same rule should apply to all cooked vegetables and soft foods. FALL MENU _ANEMIA--SLUGGISH LIVER_ _RHEUMATIC TENDENCY_ Choice of the following: MENU I MENU II BREAKFAST Cantaloup, melon, or pears Farina, rice, or boiled wheat Steamed whole wheat or One tablespoonful of nuts rice--sugar and cream (choice) A tablespoonful of nuts Cream and figs (choice) A liberal portion of wheat Half a glass of sour milk bran LUNCHEON Spinach or boiled onion One vegetable--corn, carrots, Corn bread with sweet squash, or lima butter beans Two tablespoonfuls of nuts Two spoonfuls of nuts (choice) A potato One glass of sour milk DINNER Choice of lima beans or corn Corn, spinach, or a lettuce Corn bread and sweet butter salad Lettuce and fresh tomato, Rye bread or a potato with dressing Whites of two eggs, whipped or poached Plain ice-cream, gelatin, or junket may be eaten with either of the dinner menus. Omit all laxative medicines. Use coarse clean wheat bran liberally, especially with the morning and the evening meal. WINTER MENU _ANEMIA--SLUGGISH LIVER_ _RHEUMATIC TENDENCY_ /First Day/: Immediately on rising, drink two glasses of water, and eat a small bunch of grapes, or two or three soaked prunes. Devote two or three minutes to exercises Nos. 3 and 5 (see Vol. V, pp. 1344 and 1345). The exercises should be taken before an open window, or in a well-ventilated room. BREAKFAST A cup of hot water Three or four egg whites and two yolks, whipped rapidly four or five minutes with a rotary egg beater. Whip into this a heaping teaspoonful of sugar and a teaspoonful of olive-oil, and whip again for two or three minutes Flaked wheat, eaten with thin cream--small portion A cup of hot water Wheat bran LUNCHEON Carrots or parsnips Baked potatoes, with butter A boiled onion DINNER Cream of tomato soup Fish--small portions Carrots, onions, parsnips, squash, turnips--one or two of these Potatoes, prepared choice One exceedingly ripe banana, eaten with thin cream and raisins Just before retiring take two tablespoonfuls of wheat bran, and devote four or five minutes to the above-named exercises. /Second Day/: The same as the first. /Third Day/: The same as the second, slightly varying the meals according to choice of vegetables, adhering closely, however, to the number of eggs prescribed. If olive-oil is not pleasant to the taste, it may be omitted, and a larger quantity of butter taken with the potatoes. It would be well to take a tablespoonful of olive-oil just before eating, followed by half a cup of hot water, especially if the weather is cold. /Fourth Day/: BREAKFAST Whole wheat, thoroughly steamed or boiled; serve with butter A cup of hot water LUNCHEON Vegetable soup Corn bread--butter Cocoa DINNER One fresh vegetable--carrots, parsnips, turnips, etc. A bit of fish A baked potato A small portion of plain ice-cream, if something sweet is desired /Fifth Day/: The same as the fourth. /Sixth Day/: The same as the first, and so on for a period of fifteen to twenty days. SPRING MENU _STIFFNESS AND PAIN IN JOINTS_ _STOMACH TROUBLE--CONSTIPATION--INTESTINAL GAS--IRREGULAR HEART ACTION_ Immediately on rising, drink two cups of hot water. BREAKFAST A cup of wheat bran, cooked ten minutes; serve with butter, cream, and a very little salt A cup of hot water One or two exceedingly ripe bananas, baked, eaten with thin cream Two egg whites, very lightly poached A baked potato or bran meal gems A glass of water LUNCHEON A cup of junket or fresh buttermilk A small, new potato, baked; serve with butter A glass of water DINNER Choice of two of the following vegetables: Asparagus Green peas Beans Spinach Baked new potatoes A very small portion of either fish or chicken A small cup of wheat bran, prepared as for breakfast A glass of water SUMMER MENU _STIFFNESS AND PAIN IN JOINTS_ _STOMACH TROUBLE--CONSTIPATION--INTESTINAL GAS--IRREGULAR HEART ACTION_ Choice of the following Menus: MENU I MENU II BREAKFAST Melon Choice of peaches, plums, One very ripe banana, or melon baked Rice or oatmeal One or two spoonfuls of Two very ripe bananas, steamed whole wheat baked; serve with cream Two glasses of water Half a cup of bran LUNCHEON Choice of lima beans or Green corn baked potato Rich milk One glass of milk--clabbered or buttermilk A glass of water DINNER Lima beans or corn Two vegetables--choice A fruit salad (made of Sweet butter with either sweet fruit), with whipped corn bread or green corn cream One glass of milk Two or three egg whites One or two tablespoonfuls of nuts--choice Cantaloup or melon All sweets may be omitted if they do not appeal to the taste. However, if something sweet is desired, make either the luncheon or the dinner of vegetables and home-made ice-cream, omitting all other articles. EMERGENCY MEAL (To be taken in lieu of luncheon or dinner, if languid or stupid) Two ears of tender corn Two glasses of milk One whipped egg A small portion of ice-cream Wheat bran FALL MENU _STIFFNESS AND PAIN IN JOINTS_ _STOMACH TROUBLE--CONSTIPATION--INTESTINAL GAS--IRREGULAR HEART ACTION_ /First Day/: On rising, drink a cup or two of hot water, and eat a half pound of grapes, the Concord or blue grapes preferred, swallowing seeds and pulp whole, masticating and swallowing the skins. Devote as much time as possible (from three to five minutes) to deep breathing exercises before an open window, or in a thoroughly ventilated room. BREAKFAST (Half an hour later) Half a cup of coarse wheat bran, served as an ordinary cereal A bowl of clabbered milk, with a sprinkle of maple-sugar Bran meal gems LUNCHEON A glass of cool water Baked potatoes or corn One fresh vegetable, such as carrots, parsnips, turnips, beets, boiled onions, or squash Half a cup of hot water DINNER One or two fresh vegetables (See list suggested for luncheon) Choice of green salad, cooked spinach, or celery A baked white potato--eat skins and all One egg white, or a very small portion of either fish or white meat of chicken; egg preferred From one to two glasses of water should be drunk at each of these meals--half a glass of cool water at the beginning of the meal, and a cup of hot water at the close, would be sufficient; drink enough, however, to make the total moisture about 66 per cent of the whole. A tablespoonful of wheat bran should also be taken at each of the above meals, either with a little water at the close of the meal, or cooked and served as a cereal at the beginning of the meal. A spoonful or two should be taken just after rising, and just before retiring, until the bowels act normally, when the quantity may be regulated to meet the severity of the condition. /Second Day/: Same as the first. /Third Day/: Same as the second, slightly increasing the food if demanded by normal hunger, or decreasing it if there is a sense of fullness after meals. It is always well to cease eating before hunger is thoroughly satisfied. When the body is kept slightly hungry, it assimilates all the food eaten, and insures natural digestion and elimination of waste. /Fourth Day/: BREAKFAST One or two exceedingly ripe bananas, with cream and nut butter, and either raisins or soaked prunes A glass of milk One egg white Boiled wheat, with thin cream and either nuts or nut butter LUNCHEON A sweet potato, with butter Corn, fresh A glass of milk DINNER Spinach, with egg white A very small portion of fish or white meat of chicken A baked sweet or a white potato A tablespoonful of olive-oil may be taken at the beginning of each of these meals, and a cup of hot water at the close. If the bowels have not become normal, continue taking the wheat bran and grapes according to directions for the first day. Observe the general rules of exercise and water-drinking just after rising and just before retiring. /Fifth Day/: Same as the fourth. /Sixth Day/: Same as the first, repeating the diet herein given, day by day, for two or three weeks. WINTER MENU _STIFFNESS AND PAIN IN JOINTS_ _STOMACH TROUBLE--CONSTIPATION--INTESTINAL GAS--IRREGULAR HEART ACTION_ /First Day/: On rising, drink a glass or two of pure water. Take a short, brisk walk in the open air. BREAKFAST A cup of hot water One tablespoonful of olive-oil or nut oil Two exceedingly ripe bananas (must be black spotted), eaten with thin cream and nut butter (A few dates, if something sweet is desired) Two or three tablespoonfuls of wheat bran, cooked A potato--eat skins and all LUNCHEON Baked potatoes, with butter. Eat skins and all (Make entire meal upon this) DINNER Stewed pumpkin or winter squash Corn bread Choice of beans or a baked potato Wheat bran, cooked A glass of milk Just before retiring, take a brisk walk for five minutes and practise deep breathing. Eat five or six soaked prunes. /Second Day/: Same as the first, slightly increasing or decreasing the quantity of food to meet the demands of normal hunger. /Third Day/: BREAKFAST Prunes or dried peaches, stewed--no sugar One egg, whipped very fine Coarse cereal or wheat bran LUNCHEON Liberal portion of baked sweet or white potatoes DINNER Choice of two of the following vegetables: Beans Onions Beets Pumpkin Carrots Squash Corn Turnips A potato, prepared choice /Fourth Day/: Same as the third, increasing or decreasing the quantity of food according to hunger. /Fifth Day/: Same as the first, repeating these menus for twelve or fifteen days. While the yolks of eggs are conducive to rheumatic tendencies, only that portion, however, that is not naturally appropriated by the body affect these conditions. In other words, it is the excess that is harmful. MENUS FOR BRIGHT'S DIS-EASE SPRING MENU _BRIGHT'S DIS-EASE_ BREAKFAST Clabbered milk or two or three egg whites Baked bananas LUNCHEON A Spanish onion, en casserole Turnips or fresh peas in the pod Two egg whites DINNER An onion, uncooked--small portion Corn bread and a very small portion of dried fish Peas, asparagus, or turnips A potato SUMMER MENU _BRIGHT'S DIS-EASE_ BREAKFAST A melon or peaches, omitting cream Two glasses of fresh milk Bran meal gems LUNCHEON Peas or beans Young onions A small piece of corn bread A glass of buttermilk DINNER Lettuce, with nuts Corn or string beans New potatoes or lima beans Two egg whites, coddled, or cottage cheese FALL MENU _BRIGHT'S DIS-EASE_ On rising Concord (blue) grapes. BREAKFAST An omelet of two whites and one yolk, rolled in cream and grated nuts; cook lightly Corn-meal muffins LUNCHEON A sweet potato, with fresh butter DINNER A light vegetable soup Celery or tender slaw Carrots, parsnips, or turnips A potato or fresh corn WINTER MENU _BRIGHT'S DIS-EASE_ BREAKFAST A pint of clabbered milk--lukewarm Whole wheat, boiled Two tablespoonfuls of bran LUNCHEON A pint and a half of fresh milk Corn bread--not sweetened DINNER Slaw, with nuts Carrots, cauliflower, or winter squash A potato or bran meal gems MENUS FOR DIABETES SPRING MENU _DIABETES_ The diabetic patient should observe the usual rules for vigorous exercise and deep breathing, and for copious water-drinking just after rising and just before retiring. The diet should consist as nearly as possible of foods in their natural condition, such as extremely ripe fresh fruits and fresh vegetables, and of the proteid group such as eggs, milk, cheese, gelatin, legumes, and now and then a limited quantity of fish. BREAKFAST Cherries, berries, or a baked apple, without sugar Two or three extremely ripe bananas, with thin cream A spoonful or two of nuts, or nut butter A glass of milk; clabbered milk preferred LUNCHEON A small portion of plain wheat, or oat groats (grains), boiled until well done One fresh vegetable--preferably onions, carrots, or peas DINNER A liberal green salad, with nuts and oil One or two fresh vegetables, such as peas, asparagus, or okra An egg or a bit of fish A baked potato Gelatin or junket The bowels should be kept in normal condition at all times, either by vigorous exercising or by the liberal use of wheat bran. Avoid extreme acids, sweets, white bread, and heavy starches found in cereal products. SUMMER MENU _DIABETES_ A glass of water and one or two very ripe peaches just after rising and just before retiring. Devote thirty minutes, if possible, to deep breathing and vigorous exercise. BREAKFAST Melon, peaches, or any sweet fresh fruit Two eggs, whipped very thoroughly, or two glasses of clabbered milk Corn or a whole wheat muffin LUNCHEON Cauliflower, cabbage, or okra Tender corn or string beans Fish, chicken, egg, or clabbered milk A baked potato The fish, the chicken and the milk should be taken in limited quantities; vegetables should predominate. Mastication should be very thorough, and a glass or two of water should be drunk at each meal. DINNER Vegetable soup Salad, with nuts or oil Corn or lima beans A potato--sweet or white FALL MENU _DIABETES_ A glass or two of water and a bit of fruit just after rising, followed by vigorous exercises and deep breathing. BREAKFAST Peaches, plums, or persimmons Eggs, boiled two minutes A bit of corn bread, bran meal gems, or a baked potato A cup of milk or chocolate LUNCHEON Two or three glasses of buttermilk A whole wheat gem or a muffin, with nuts DINNER Two fresh vegetables, such as beans, beets, Brussels sprouts, cauliflower, okra, eggplant, or lima beans Sliced tomatoes A bit of green salad Two exceedingly ripe bananas, baked--eaten with nuts and cream Half a cup of wheat bran WINTER MENU _DIABETES_ BREAKFAST A cup of hot water Wheat bran, cooked Two eggs, whipped One exceedingly ripe banana, eaten with nuts and cream Half a glass of cool milk LUNCHEON A cup of hot water A baked potato A large creamed onion A cup of chocolate DINNER Onions, beans, carrots, or parsnips--any two of these One or two eggs, whipped A portion of wheat bran, cooked, or the whole wheat might be boiled until the grains burst open, and served with butter and cream. This is the best form in which cereal can be taken MENUS FOR CONSUMPTION _WEAK LUNGS--CONSUMPTION_ For many centuries consumption, or the various forms of tuberculosis have preyed upon the human race, yet science has so far failed to give us one reliable artificial remedy. We must perforce turn to Nature, the only remedy now known being oxygen or common air. The consumptive or tubercular patient should provide some way to live out-of-doors, day and night, winter and summer, unless the weather is extremely cold. The next important factor in treating this dis-ease is food. The diet should consist of the richest and the most readily digestible foods, in the following groups, given in the order of their importance: PROTEIDS CARBOHYDRATES FATS FRUIT-SUGARS Eggs Honey Nuts Figs Oranges Milk Maple-sugar Olive-oil Raisins Pears Legumes Whole wheat Cream Grapes Plums Rice Butter Persimmons Peaches Potatoes Bananas Apples Corn FRESH VEGETABLES GREEN SALADS Asparagus Beets Lettuce Peas Carrots Romaine Beans Parsnips Parsley Green corn Squash Watercress Tomatoes Celery Turnips Cabbage The patient should drink an abundance of water, take vigorous exercise and deep breathing, and eat liberally of grapes before breakfast, when they are in season. A spirometer should be secured, and an effort made to increase the capacity of the lungs one cubic inch each day until their utmost capacity has been reached. The following menus are merely suggestive. They may be changed, selecting the articles mentioned in the foregoing tables, when available during the several seasons of the year: GENERAL MENUS FOR WEAK LUNGS--CONSUMPTION /First Day/: BREAKFAST A glass of clabbered milk, with a sprinkle of sugar Two eggs whipped very thoroughly (See recipe, p. 678) If constipated, take half a cup of coarse wheat bran, cooked. Serve as a breakfast cereal with butter or cream. LUNCHEON Three eggs prepared as per recipe, p. 678; add two glasses of milk; mix well; drink slowly DINNER Choice of two of the following vegetables: Beets Cabbage or celery Carrots Fresh corn or corn hominy Lentils Navy or lima beans Parsnips Turnips A baked white potato, rice, or corn One egg, prepared any way acceptable to the taste--preferably whipped Something green should be taken at this meal, if possible, such as lettuce, spinach, kale, parsley, or watercress Home-made ice-cream, in summer, or a tablespoonful of honey, in winter, may be eaten, if something sweet is desired Drink from one to two glasses of water at each of these meals, but take no water into the mouth until mastication is perfect. Just before retiring, drink a glass of water, and eat half a pound of grapes, then devote from ten to fifteen minutes to deep breathing exercises. /Second Day/: Same as the first, slightly increasing or decreasing the quantity of food according to hunger. Take an additional egg the second day for the noon meal; another the third day, then gradually decrease the quantity if the appetite rebels against them. Do not overeat. Assimilation is the primary object to be obtained. /Fourth Day/: On rising, drink water and eat grapes, as prescribed for the first day. Devote much time to moderate exercise and deep breathing. BREAKFAST Two extremely ripe bananas, eaten with thin cream and either nuts or nut butter; also two or three figs or an equivalent quantity of raisins A spoonful or two of whole wheat, thoroughly cooked LUNCHEON A large boiled onion, and a baked white potato, with butter and a dash of salt (If the onion cannot be procured, take carrots or parsnips) Drink two or three glasses of milk If the bowels are not acting normally, drink a glass of water and take a spoonful or two of wheat bran, after each meal. DINNER A liberal portion of baked white potatoes, eaten with butter Four or five egg whites and two yolks, prepared as per recipe given for the first day A small portion of any two fresh vegetables (A little ice-cream may be taken at this meal, if there is a craving for something sweet) /Fifth Day/: Same as the fourth, omitting ice-cream. /Sixth Day/: Same as the first, repeating these menus for about sixteen or eighteen days. SPRING MENU _TUBERCULAR TENDENCY_ _CONSTIPATION--NERVOUSNESS--CATARRH_ /First Day/: Immediately on rising, drink a glass of cool water, eat a few cherries or the juice of an orange, and devote five or ten minutes to exercises Nos. 3 and 5, as shown in Vol. V, pp. 1344 and 1345. BREAKFAST (Half an hour later) A cup of hot water Very ripe berries, with sugar--no cream One exceedingly ripe banana, with nuts or nut butter A small, baked white potato, eaten with butter One egg, boiled two minutes A small portion of wheat bran, cooked LUNCHEON One or two large Spanish onions, boiled A small, baked white potato, eaten with butter One or two whole eggs, whipped DINNER Choice of string beans, peas, or asparagus; if these cannot be obtained, take choice of: Beets Carrots Cabbage Parsnips Turnips Spanish onions, boiled A baked white potato Three egg whites, whipped One glass of water, taken during the meal Just before retiring, take two tablespoonfuls of wheat bran, drink a glass of water, and devote from five to ten minutes to exercises as prescribed for the morning. /Second Day/: Same as the first. /Third Day/: Same as the second, slightly increasing the quantity of food if necessary. Changes in the vegetables may be made, confining, however, to the vegetables mentioned, as nearly as possible, always taking fresh vegetables in preference to canned. /Fourth Day/: BREAKFAST Fruit--choice A small portion of plain boiled wheat, with butter and cream A cup of hot water Two eggs, whipped or boiled two minutes LUNCHEON Three glasses of milk Two eggs, whipped Wheat bran, cooked (Take milk and eggs very slowly) DINNER One green vegetable A tablespoonful or two of "Protoid" nuts Junket, gelatin, or eggs Just before retiring, devote from five to ten minutes to exercises prescribed for the first day. If the bowels have not become normal, continue taking the wheat bran just before retiring, and a spoonful or two just after rising. /Fifth Day/: The same as the fourth. /Sixth Day/: Same as the first, and so on, repeating the diet so long as it appeals to the taste. If digestion will permit, the eggs and the milk may be increased. SUMMER MENU _TUBERCULAR TENDENCY_ CONSTIPATION--NERVOUSNESS--CATARRH_ Choice of the following menus: MENU I MENU II BREAKFAST Cantaloup or peaches One banana Three or four egg whites, Melon or peaches with thin whipped--mix with two cream glasses of fresh milk Three eggs, whipped with A spoonful of nuts (choice) very little sugar and fruit juice LUNCHEON Choice of lima beans or a A very small piece of fish baked potato Boiled corn, beets, or a A salad of lettuce and fresh baked potato tomatoes, eaten with One fig, with cream cheese lemon juice, sugar, and a spoonful of mixed nuts Two eggs, whipped DINNER Choice of squash, boiled An ear of corn onions, or corn One and one-half glasses A salad of anything green of buttermilk with egg One glass of buttermilk, whites mixed with two whipped Two or three very ripe egg whites peaches with cream and One or two tablespoonfuls sugar of nuts (choice) Home-made ice-cream I would advise two or three very ripe peaches just before retiring at night, and just after rising in the morning. SUPPLEMENTARY DINNER (To be taken if there is a craving for flesh or salty food) One ear of corn (boiled) Fish, lobster, or white meat of chicken A small baked potato A salad of lettuce or endive FALL MENU _TUBERCULAR TENDENCY_ _CONSTIPATION--NERVOUSNESS--CATARRH_ On rising, devote from three to five minutes to deep breathing exercises before an open window, preferably movements 3 and 5, as shown in Vol. V, pp. 1344 and 1345. Eat a bunch of grapes, thoroughly masticating the skins, swallowing seeds and pulp whole. Drink two glasses of water. If the weather is cold, the water should be heated. BREAKFAST Half a cup of wheat bran, cooked, eaten with cream A small bunch of grapes Two eggs, whipped about six or seven minutes; add a teaspoonful of sugar and a tablespoonful of olive-oil, while whipping One extremely ripe banana; serve with cream and either nut butter or nuts (The banana should be baked, if not very ripe) LUNCHEON One fresh vegetable--carrots, parsnips, or turnips A boiled onion A baked potato One egg, cooked two minutes, eaten with the potato skins Fresh butter A cup of hot water at the close of the meal DINNER Half a cup of wheat bran, cooked Two or three eggs, prepared as for breakfast One extremely ripe banana and a few soaked prunes (A very small, baked white potato may be taken if something salty is desired) A bunch of grapes Just before retiring, eat a small bunch of grapes and drink a cup of hot water. Devote from three to five minutes to exercises which have already been prescribed for the morning. These meals may be varied by changing the vegetables, and now and then substituting for the eggs a portion of fresh fish or a glass of buttermilk. If the quantity of food prescribed does not seem sufficient, it might be slightly increased; however, do not increase it beyond the limits of normal hunger. The best combinations of food, when taken in excess of the bodily needs, undergo a form of decomposition, and become a prolific source of dis-ease. WINTER MENU _TUBERCULAR TENDENCY CONSTIPATION--NERVOUSNESS--CATARRH_ BREAKFAST Two very ripe, red bananas, baked Nuts, cream, raisins Two whipped eggs; sugar; flavor to taste A spoonful of wheat bran LUNCHEON Three fresh eggs, whipped about six minutes, with sugar; pineapple juice added after whipping A small portion of wheat bran, cooked DINNER Celery A tablespoonful of olive-oil One fresh vegetable A potato Whole wheat bread (very little) Buttermilk or gelatin The above menus have been selected and combined so as to counteract constipation, catarrh, nervousness, biliousness, etc. There is no specific remedy in foods for consumption. Foods will aid in curing this dis-ease only through the natural process of building up healthy tissue, and increasing the power of the body to resist all dis-eases. SPRING MENU _WEAK LUNGS_ _TENDENCY TOWARD INTESTINAL CONGESTION_ Immediately on rising drink a glass or two of water and take a very little of some juicy fruit. Also take a brisk walk in the open air before breakfast. BREAKFAST The strained juice of one sweet orange, or a few very ripe berries, without cream Two or three coddled eggs A small whole wheat cracker One baked banana A spoonful of wheat bran LUNCHEON A whole wheat muffin with butter, and a dessert-spoonful of honey A glass or two of milk Wheat bran DINNER Bean soup or pea soup Peas, asparagus, spinach, or any fresh vegetable Corn bread or a very small portion of whole wheat One coddled egg A small portion of wheat bran, slightly cooked From one to two glasses of water should be drunk at each of the above meals. If there is a marked tubercular tendency, from six to nine eggs may be taken daily for about three days in each week, taking with the eggs a small quantity of acid fruits at each meal--either orange juice, berries, or a spoonful of strained pineapple juice. The acids should be diluted (half water), and taken without sugar. SUMMER MENU _WEAK LUNGS_ _TENDENCY TOWARD INTESTINAL CONGESTION_ Take a brisk walk and deep breathing exercises before breakfast. BREAKFAST A cantaloup or a pear Wheat bran, cooked A liberal portion of baked sweet potatoes One whole egg, either coddled or whipped A pint of sour milk or a cup or two of chocolate LUNCHEON A liberal portion of tender corn, steamed in the husk A lettuce and tomato salad Nuts DINNER String beans, corn, or carrots A baked potato A very small portion of tender fish, an egg, or clabbered milk Melon or peaches If the patient is performing labor that would require more food than herein prescribed, the quantity may be increased. FALL MENU _WEAK LUNGS_ _TENDENCY TOWARD INTESTINAL CONGESTION_ The following menus are laid out with the view of giving the greatest amount of tissue-building food which require the least effort in digestion. There is nothing more valuable in the treatment of lung trouble than extreme deep breathing. After pure blood is made, the way to keep it pure is to keep it charged with oxygen, and the only way to do this is to breathe an abundance of fresh air into the lungs. BREAKFAST A bunch of grapes Three or four eggs, whipped five or six minutes, into which whip a teaspoonful of sugar, and a teaspoonful of Cognac brandy or lemon juice, to each egg /Note/: The brandy is germicidal and aids in the digestion of the egg yolks. LUNCHEON From three to four eggs, prepared as for breakfast, slightly increasing the quantity of sugar and brandy. Put in a heaping teaspoonful of sugar and a dessert-spoonful of brandy, and add a full glass of milk to each egg DINNER Any one or two fresh vegetables, including something green, as spinach or lettuce The fresh vegetables may consist of: A baked potato Squash Onions Turnips Parsnips The patient may have a few grapes between meals and a few an hour after dinner. He should swallow the seeds and pulp whole, and masticate and swallow the skins. He should eat plenty of fresh eggs, fresh milk, and ripe, sweet grapes. The milk and the eggs are good tissue-building foods, while sugar is a carbohydrate and makes a good winter food. The grapes are full of grape-sugar, which is an excellent nutrient, and also an aid to the digestion of other foods. /Note/: These menus were given to a consumptive patient, and in a period of six weeks he had made a very substantial gain in both weight and strength. WINTER MENU _WEAK LUNGS_ _TENDENCY TOWARD INTESTINAL CONGESTION_ Take a bit of fruit, a glass of water, and a brisk walk immediately after rising. BREAKFAST One or two exceedingly ripe bananas, baked, eaten with cream A service of corn hominy One coddled egg, if desired A cup of chocolate, or hot water, if preferred LUNCHEON Vegetable soup One fresh vegetable; preferably boiled onion or carrots One or two glasses of fresh buttermilk Wheat bran DINNER Celery, slaw, or any green salad Steamed rice or plain boiled wheat A whipped or coddled egg, or buttermilk Nuts and raisins A small portion of wheat bran should be taken at breakfast and just before retiring. Bran contains valuable mineral salts, and in winter can replace the chemistry of green salads. From one to two glasses of cool water should be drunk at each of these meals. MENUS FOR DIS-EASES OF THE SKIN SPRING MENU _ECZEMA_ Whether or not eczema is a dis-ease caused by bacteria, it is obvious that the weapon with which to combat this disorder is pure blood with an abundance of the white corpuscles. These phagocytes of the blood may be properly called the police of the body. The patient should observe the following general rules: Drink an abundance of pure water both at meals and between meals. Omit cane-sugar and all acids. Dress as lightly as possible, and do not wear woolen garments next to the skin. Take sufficient vigorous exercise each day to cause perspiration. If this cannot be done, the Turkish bath should be resorted to once a week. Spend as much time in the open air as possible. The meals should be substantially as follows: BREAKFAST A few spoonfuls of wheat bran, cooked, and eaten with cream Two or three bran meal gems Two or three egg whites, whipped very thoroughly, to which add a spoonful of cream One ripe banana LUNCHEON A green salad, with nuts--liberal portion A fresh vegetable; preferably boiled onions or carrots A baked potato DINNER A salad of any green succulent plant Young onions Peas or asparagus A baked potato or baked beans SUMMER MENU _ECZEMA_ BREAKFAST Raspberries, blackberries, grapes, or cantaloup A potato--sweet or white A cup of cocoa or sassafras tea (See recipe, p. 681) LUNCHEON Beets, asparagus, cabbage, cauliflower, Brussels sprouts, or okra A potato--prepared choice DINNER Two fresh vegetables; choice of: Asparagus Corn Beans Eggplant Beets Onions Carrots A very ripe peach or a cantaloup Just before retiring, eat a few very ripe peaches, and take a tablespoonful of wheat bran. FALL MENU _ECZEMA_ Either of the following menus may be chosen for a period of ten or twenty days. They are designed especially for the removal of all forms of autointoxication or self-poisoning which sometimes manifest themselves by skin eruptions. While autointoxication may not be the primary cause of eczema, it augments all zymotic conditions. The chief purpose of these menus is to give to the body an opportunity to throw off the dis-ease by removing all obstacles. I would therefore advise that the use of tobacco, tea, coffee, and all alcoholic stimulants be omitted. MENU I MENU II BREAKFAST Two egg whites, whipped Three extremely ripe bananas very thoroughly, adding baked in a casserole a little heavy cream and dish; serve with thin a spoonful of sugar cream Take this as a sauce over two exceedingly ripe bananas, with nuts or nut butter A bunch of California grapes (Malagas) A cup of hot water at the beginning of the meal, and a glass of cool water at the close LUNCHEON Spinach or a green salad Squash or turnips String beans or corn A salad (green) A potato Baked beans DINNER A green salad or cooked A small portion of fish, spinach white meat of chicken, or Boiled onions, carrots, or an egg--egg preferred turnips A boiled onion and a baked A baked potato with fresh potato butter A bit of green salad From one to two glasses of water should be drunk at each of these meals, preferably a cup of hot water at the beginning, and a glass of cool water at the close. I would especially advise vigorous exercises night and morning, and deep breathing before an open window. WINTER MENU _ECZEMA_ /First Day/: On rising, drink two or three glasses of water, eat a few grapes, and devote from three to five minutes to any one of the exercises shown in Vol. V, pp. 1343 to 1346, inclusive. BREAKFAST Baked white potatoes or bran meal gems A glass of rich milk LUNCHEON Baked beans Bermuda onions A potato or corn bread DINNER Any two of the following: Beans Pumpkin Beets Squash Carrots Turnips Parsnips A green salad--either lettuce and tomatoes, or celery; very small portion A baked white potato--eat skins and all (A cup of very thin cocoa may be taken, if something hot is desired; however, pure water would be preferable) Just before retiring, devote from three to four minutes to the above-prescribed exercises. The lungs should be inflated to their extreme capacity. Do not carry any of these exercises, however, to a point beyond ordinary fatigue. Divide the exercise period, both night and morning, into three or four two-minute heats. Exercise and deep breathing are second in importance to diet, and should be taken daily, night and morning. Drink from one to two glasses of water at each meal, but do not take water into the mouth until mastication is perfect. /Second Day/: The same as the first, slightly increasing the quantity of food until normal hunger is satisfied. /Third Day/: Practically the same as the first, varying the luncheon according to hunger. The luncheon may consist of any one or two fresh vegetables, such as carrots, turnips, beets, baked white or sweet potatoes. /Fourth Day/: BREAKFAST A cup of hot water A sweet potato or two bran meal gems Two or three tablespoonfuls of wheat bran, with thin cream LUNCHEON Boiled onions A baked potato Choice of fish or an egg Eat a pound of grapes ten minutes after this meal. The skins may be eliminated, but swallow the seeds and pulp. If grapes cannot be obtained, the juice of a sweet orange may be taken. DINNER String beans or spinach, with egg, and a liberal piece of Bermuda or Spanish onion, uncooked (The onions and the beans should be made exceedingly hot with red pepper) A baked sweet or a white potato A small piece of corn bread, with one-half glass of buttermilk From one to two glasses of water should be drunk at each of these meals. Just before retiring, devote from three to five minutes to the exercises prescribed for the first day. /Fifth Day/: The same as the fourth, slightly increasing the quantity of food if there is a return of normal hunger; if not, continue to follow the diet as herein given, until natural hunger is felt. /Sixth Day/: The same as the first, repeating the diet from eighteen to twenty days. SPRING MENU _WEAK DIGESTION--NERVOUSNESS_ _SLIGHT ECZEMA_ The following menus for spring, summer and fall are laid out on the two-meal-a-day plan. In addition to the purposes named in the heading, they are designed to promote vitality and endurance, thus enabling one to meet the requirements of hot weather. In order to aid the body in appropriating all the nourishment these menus contain, one should take, each day, at least one hour's vigorous exercise and deep breathing. MENU I MENU II BREAKFAST One or two very ripe Peaches or cherries bananas baked in a casserole One whole egg dish; eat with Steamed wheat--well Tunis dates and thin cooked; serve with thin cream cream One whole egg, whipped A very ripe banana with Half a glass of milk Tunis dates, cream, and nuts DINNER Two vegetables--choice of A salad peas, beans, asparagus, Peas in the pod (see recipe, onions, or beets page 679) A baked potato A white potato, baked A very small portion of A small portion of ice-cream either fish or white meat (optional) of chicken One or two glasses of water should be drunk at each of the dinner meals. If constipated, two or three tablespoonfuls of wheat bran should be taken about twice a week with both the morning and the evening meal. This could be cooked five minutes, and may be made very palatable if eaten with a spoonful of cream. SUMMER MENU _WEAK DIGESTION--NERVOUSNESS_ _SLIGHT ECZEMA_ MENU I MENU II BREAKFAST (About 9:30) Very ripe peaches--no sugar A cup of hot water A cup of hot water One whipped egg Whole wheat, cooked very A portion of gelatin, with thoroughly cream A medium-sized baked potato, with butter DINNER (About 5:30) Fresh peas, and either beans Two of the following or asparagus vegetables--peas, Baked potatoes or tender beans, asparagus, boiled onions, corn spinach, or carrots One whole egg or an A baked potato omelet--Spanish style Half a glass of buttermilk, One glass of water with one egg white whipped into it One glass of water Just before retiring, drink a cup of hot water, and take two tablespoonfuls of bran. FALL MENU _WEAK DIGESTION--NERVOUSNESS_ _SLIGHT ECZEMA_ MENU I MENU II BREAKFAST A very ripe banana with Fruit--choice soaked prunes Two tablespoonfuls of One dessert-spoonful of nuts--choice nuts--choice Two very ripe baked bananas, One or two spoonfuls of with cream and steamed whole wheat nut butter Two eggs--prepared choice One egg A glass of water One or two glasses of milk Wheat bran DINNER Two or three fresh vegetables Choice of two fresh vegetables Tender corn A baked sweet or a white A baked sweet or a white potato potato A salad--lettuce or celery Junket or gelatin A small portion of ice-cream All sweets may be omitted if they do not appeal especially to the taste, and other foods proportionately increased. If there is a tendency toward sour stomach or intestinal gas, all fruit except bananas should be omitted. WINTER MENU _WEAK DIGESTION--NERVOUSNESS_ _SLIGHT ECZEMA_ BREAKFAST (Very light) California grapes, or the strained juice of a sweet orange A baked sweet potato, with butter A cup of hot water into which put a spoonful of sugar and two tablespoonfuls of cream LUNCHEON Choice of the following: _a_ Three whipped eggs. Add a tablespoonful each of sugar and lemon juice _b_ A bowl of clabbered milk, with a sprinkle of sugar A cup of hot water, with sugar and cream DINNER Boiled onions, and either cabbage or carrots One egg, or an omelet A baked potato A cup of hot water or cocoa If small portions of the above foods are eaten, two egg whites and one yolk may be taken at the close of the evening meal. (See recipe, Vol. III, p. 678). This makes an excellent dessert, delegating to the body much warmth, and aiding in the general digestion of other foods. MENUS FOR APPENDICITIS SPRING MENU _APPENDICITIS_ BREAKFAST A cup of hot water Two tablespoonfuls of wheat bran, cooked thirty minutes; serve with thin cream A portion of prunes, soaked in clear hot water until soft A small, baked potato LUNCHEON Peas in the pod A cup of hot water DINNER Peas or asparagus Carrots or turnips A potato A spoonful of bran SUMMER MENU _APPENDICITIS_ Just after rising take a tablespoonful of olive-oil and a cup of hot water. BREAKFAST A cantaloup A tablespoonful of wheat bran, well cooked An egg A new potato, baked A glass of water LUNCHEON Lettuce or spinach Boiled onions and carrots Wheat bran DINNER A salad of lettuce, with nuts Spinach, string beans, or new peas A potato Two tablespoonfuls of bran FALL MENU _APPENDICITIS_ On rising one-half pound of Concord grapes. BREAKFAST A small portion of whole wheat, well cooked; serve with thin cream Two egg whites, lightly poached A tablespoonful of wheat bran LUNCHEON Celery hearts A baked potato Wheat bran, with cream DINNER Bran meal gems Parsnips, en casserole Onions, en casserole A potato A cup of hot water and a tablespoonful of olive-oil may be taken before each of these meals. WINTER MENU _APPENDICITIS_ BREAKFAST A cup of hot water Soaked prunes Bran meal gems, with nuts A baked banana LUNCHEON Winter squash or stewed pumpkin A tablespoonful of bran DINNER A Spanish onion, en casserole Carrots or parsnips Bran meal gems or a potato (An hour after this meal, drink half a glass of prune juice) In cases of appendicitis the following articles should be omitted: Tea, coffee, tobacco, all stimulants and intoxicants, white bread, rice, oatmeal, cornbread, sweets and confections of every kind. MENUS FOR THE PREGNANT WOMAN AND FOR THE NURSING MOTHER IMPORTANCE OF FOOD DURING PREGNANCY There is nothing so important, or that wields so much influence over the comfort, the health, and the life of the pregnant woman as her food, and there is nothing, perhaps, to which she gives so little attention. The diet of the prospective mother, of course, governs her digestion and assimilation of food, and elimination of waste matter from the body. These things control her health almost completely, and inasmuch as all mental conditions are principally governed by health, the intellectual faculties of the child are shaped largely by the condition of the mother's digestion. It is obvious, therefore, that the health of the mother and the entire future of the child depend more upon her diet during pregnancy than upon any other one thing. During pregnancy the prospective mother should avoid all such articles of food as she would withhold from her baby after birth. This would eliminate from her diet meat, condiments, sweets, especially pastries and rich desserts; tea, coffee, and all stimulating and intoxicating beverages. The pregnant woman should balance her diet carefully as to the proportion of proteids, carbohydrates, fats, and mineral salts. As leading foods containing these nutrients, I would recommend the following: VEGETABLES RICH IN MINERAL PROTEIDS CARBOHYDRATES FATS SALTS Milk Potatoes Nuts Lettuce Eggs Wheat (whole) Butter Celery Pine nuts Corn Cream Carrots Peanuts Rice Olive-oil Parsnips Cheese Oats Cream cheese Onions Fish Dried beans Beets Fowl Dried peas Fresh beans Dried beans Chestnuts Fresh peas Dried peas Honey Okra Cream cheese Sugar Eggplant Sirups Turnips Cauliflower Some articles are listed under two headings. This is because they are rich in both classes of nutrition. The amount of grain products eaten by the prospective mother should be somewhat limited, ranging between four and eight ounces a day, governed by work or activity. Cereals, especially corn, rice, and oats, are rich in phosphate of lime, which is the bone-making or structural food. While enough of this should be eaten to give the child sufficient bone-building material, too much makes birth difficult, and sometimes fatal. The following menus contain suggestions as to the selections, combinations, and proportions of food that would compose a healthy bill of fare for both mother and child for the several seasons of the year: SPRING MENU _FOR THE PREGNANT WOMAN_ BREAKFAST Two eggs, cooked two minutes One whole-wheat muffin A glass or two of rich milk LUNCHEON Peas, asparagus, or turnips Potatoes--two medium-sized One pint of clabbered milk DINNER Vegetable soup Any two fresh vegetables named in the list above A potato Milk or a very small portion of fish If constipated, take wheat bran at both the morning and the evening meal. SUMMER MENU _FOR THE PREGNANT WOMAN_ BREAKFAST Cantaloup Three or four egg whites and one yolk Whole wheat, boiled; serve with butter or cream A glass or two of milk LUNCHEON String beans, peas, or asparagus Tender corn or a potato Milk DINNER Vegetable soup Two green vegetables; selection from list given above Corn, lima beans, or a potato Milk or tender fish A small portion of ice-cream (optional) FALL MENU _FOR THE PREGNANT WOMAN_ BREAKFAST Cantaloup or pears Rice, with cream Milk Two tablespoonfuls of wheat bran LUNCHEON Celery Turnips or cauliflower Fish or fowl A potato DINNER A light vegetable soup Lettuce, or celery, with nuts Two fresh vegetables A baked potato Cheese, raisins, and nuts WINTER MENU _FOR THE PREGNANT WOMAN_ BREAKFAST Two or three baked bananas, with cream (See recipe, p. 677) Two eggs or two glasses of milk Oatmeal--a small portion LUNCHEON A sweet potato Two or three glasses of milk DINNER Cream of rice soup Two fresh vegetables A potato or bran meal gems Milk or cheese Nuts and raisins THE NURSING MOTHER SUGGESTIONS FOR THE DIET The nursing mother should omit all acid fruits, pickles, and condiments containing vinegar. She should eat sparingly of sweets, especially of the pastry and soda-fountain variety. She should omit such vegetables as radishes, cucumbers, cabbage, and sourcrout. Fresh corn and dried beans often produce serious intestinal trouble in the young child. Eggs should never be eaten when there is the slightest fever. The diet of the nursing mother should be confined chiefly to the more readily digestible foods such as are named in the menus which follow. SUGGESTIONS FOR NURSING The mother should remember that her baby should never be nursed when she is tired, fatigued, overheated, angry, frightened, excited, or laboring under any mental disturbance. Both her mental and her physical condition are instantly conveyed to the child, through her milk, often in exaggerated form. Children are sometimes thrown into convulsions by nursing the breast of an excited mother. SUGGESTIONS FOR RELIEVING INTESTINAL CONGESTION If either mother or child has a tendency toward intestinal congestion (constipation), the mother should take wheat bran, thoroughly cooked, with both the morning and the evening meal; or, a few drops of prune juice, given to the child, will often relieve this condition, while affording an excellent source of nourishment. SPRING MENU _FOR THE NURSING MOTHER_ BREAKFAST Plain boiled wheat, with cream Fresh milk A baked potato or a baked banana LUNCHEON Fresh milk or eggs; milk preferred Corn bread or bran meal gems Onions, en casserole DINNER Cream of corn soup Spinach or turnip greens A potato, peas, or asparagus Plain gelatin, with cream SUMMER MENU _FOR THE NURSING MOTHER_ BREAKFAST Cantaloup or a very ripe, sweet peach One egg Flaked wheat, very thoroughly cooked A glass or two of milk LUNCHEON Vegetable soup Corn bread or bran gems Carrots, parsnips, or squash Fresh milk A potato DINNER Fresh peas, beans, squash, asparagus, or beets A baked potato Milk A whole wheat gem FALL MENU _FOR THE NURSING MOTHER_ BREAKFAST Cantaloup or a very ripe banana, with cream and figs Boiled rice or whole wheat Milk LUNCHEON Soup--cream of corn, peas, or rice Broiled fish A baked potato DINNER Celery, or lettuce, with nuts Fresh beans, turnips, carrots, or squash Corn bread or a baked potato Milk or cocoa WINTER MENU _FOR THE NURSING MOTHER_ BREAKFAST A dish of cereal, well cooked--simmered over night Eggs or milk Whole wheat gems or a corn muffin LUNCHEON Vegetable or cream soup Winter squash or carrots A sweet or a white potato Milk DINNER Parsnips, turnips, or squash A potato Bran gems Milk (Egg custard, if something sweet is desired) MISCELLANEOUS MENUS SPRING MENU _WEAK DIGESTION (ALMOST INVALID)_ On rising, drink a cup of hot water. Take deep breathing before an open window, and such exercises as the patient is able to perform. LATE BREAKFAST Choice of the following: _a_ Baked bananas--very ripe _b_ Baked omelet, served very rare (For recipe, see p. 678) A cup of hot water LUNCHEON A cup of vegetable juice from peas or asparagus (See recipe, p. 680) DINNER Vegetable juice Peas or asparagus A baked potato As digestion becomes stronger, the quantity of food may be increased, and a puree of carrots, turnips, parsnips, or squash added in limited quantities. RECIPE FOR VEGETABLE JUICE Grind vegetables fine, cover with water, cook ten to fifteen minutes, drain off the juice or water and serve. SUMMER MENU _WEAK DIGESTION (ALMOST INVALID)_ On rising, drink two cups of water and eat one very ripe peach. Take deep breathing and such exercises as will not cause too much fatigue. LATE BREAKFAST A cup of hot water Very ripe cantaloup, masticated exceedingly fine Three or four egg whites, whipped thoroughly; add a dessert-spoonful of sugar while whipping A baked white potato LUNCHEON Vegetable juice (See recipe, p. 1047) DINNER Cantaloup or watermelon, discarding the pulp Summer squash, or purée of tender peas or beans A cup of vegetable juice One or two egg whites FALL MENU _WEAK DIGESTION (ALMOST INVALID)_ Immediately on rising, drink a cup of hot water. Take exercise and deep breathing, if possible. BREAKFAST A cup of hot water Two egg whites, whipped, and mixed with a cup of lukewarm milk One or two small, baked potatoes, eaten with fresh butter LUNCHEON A cup of hot water A large boiled onion A baked potato One vegetable, such as carrots or parsnips, put through a colander DINNER A cup of hot water A baked potato A boiled onion or any other fresh vegetable Vegetable juice or purée (See recipe, p. 680) This menu is for the purpose of building tissue. It contains enough carbohydrate matter to give a reasonable amount of fat and bodily warmth, provided it can be assimilated. Eggs are an excellent proteid food, when taken uncooked, whipped with a very little sugar. The number may be increased as digestion improves. WINTER MENU _WEAK DIGESTION (ALMOST INVALID)_ On rising, drink a cup of hot water, and devote a few minutes to deep breathing and such exercises as can be taken. LATE BREAKFAST A cup of hot water Choice of the following: _a_ An extremely ripe banana, peeled, and baked in a very hot oven _b_ A baked potato, with butter LUNCHEON A baked omelet (See recipe, p. 678) DINNER Soup--cream of pea or celery; very small portion A whipped egg or shad roe A small baked potato If the bowels should become slightly constipated, a spoonful of wheat bran, thoroughly cooked, and served as an ordinary cereal, should be taken with both the morning and the evening meal. The quantity of food should be governed by the condition of the patient as to strength, and as to powers of digestion and assimilation. SPRING MENU _BUILDING UP THE NERVOUS SYSTEM INCREASING VITALITY_ On rising, drink two glasses of water, eat a little of some juicy fruit, and devote as much time as possible to vigorous deep breathing exercises before dressing. In taking these movements, inflate the lungs to their fullest capacity, and hold the breath for half a minute while executing one or two movements. In this way the cell capacity of the lungs can, in many instances, be doubled. Large lung capacity is of primary importance in cases of nervousness. Choice of the following menus: MENU I MENU II BREAKFAST Half a cup of boiled wheat, Cherries or berries with with cream and nuts sugar and cream Two "dead ripe" bananas, One whole egg, eaten with baked, eaten with thin a new potato cream and three or four A small portion of wheat Tunis dates (The dates flakes, eaten with cream may be omitted, if desired) or butter A cup of sassafras tea, or One very ripe banana, with cocoa three or four dates, or an equivalent quantity of raisins A cup of sassafras tea, or cocoa LUNCHEON One vegetable--choice of (To be taken in the office) boiled onions, carrots, or Two extremely ripe bananas, spinach with nuts or raisins A baked potato Cream cheese with dates One glass of buttermilk DINNER A salad, if desired A green salad Two of the following vegetables: Two of the following vegetables: Asparagus Beans Beans Peas Boiled onions Peas Beets Spinach Baked new white potatoes Boiled onions One or two gems made from An egg, junket, or a very corn-meal or wheat bran small portion of fish Half a glass of buttermilk A baked white potato--eat skins and all About two glasses of water should be drunk at each of these meals--half a glass at the beginning, a glass during the progress of the meal, and half a glass at the close. These meals are rather liberal, and if there should be the slightest fullness experienced after eating, the quantity should be reduced. The breakfasts are light, and one might add slightly to them if they do not satisfy normal hunger. Mastication should be perfect. Eating should be very deliberate. Avoid heavy reading or earnest conversation while eating; these disturb the flow of saliva and prevent thorough mastication. A cup of wheat bran, well cooked, should be taken with the morning and the evening meal about twice or three times a week. A glass of water and the juice of a sweet orange may be taken just before retiring, and exercises as prescribed. SUMMER MENU _BUILDING UP THE NERVOUS SYSTEM INCREASING VITALITY_ BREAKFAST A melon or peaches Two or three tablespoonfuls of nuts One very ripe banana--red variety A baked sweet potato One egg, either cooked two minutes, or whipped with a little sugar and lemon juice LUNCHEON One fresh vegetable--beans, beets, or corn A baked sweet or a white potato A glass of milk; buttermilk preferred A melon or very ripe peaches DINNER A small green salad, with oil Lima beans, okra, or corn A baked potato Figs, with cream and nuts SUPPLEMENTARY DINNER If there is a desire for something salty or more pungent in taste and flavor, the following menu may be used: Fish or chicken A potato A fruit salad Ice-cream--home-made If the two-meal-a-day plan is desired, luncheon may be omitted entirely, and the proportions composing the morning meal slightly increased. FALL MENU _BUILDING UP THE NERVOUS SYSTEM_ _INCREASING VITALITY_ Choice of the following menus: MENU I MENU II BREAKFAST A cantaloup or peaches One or two red bananas, A small portion of boiled eaten with soaked prunes whole wheat, with cream and cream Two tablespoonfuls of nuts A liberal portion of with cream and figs gelatin--very little sugar One egg, either whipped or cooked two minutes LUNCHEON An ear or two of tender corn One fresh vegetable--choice A baked sweet potato One egg, cooked two minutes Nuts and raisins, with cream A baked potato or baked beans DINNER Endive or celery Fish or lobster--a very Lima beans and corn small portion Whole wheat bread with A baked potato butter A fruit salad A cantaloup Corn bread Two egg whites, whipped with a particle of sugar and eaten with gelatin WINTER MENU _BUILDING UP THE NERVOUS SYSTEM INCREASING VITALITY_ BREAKFAST A very little sweet juicy fruit--winter pears or grapes One egg, prepared choice One or two exceedingly ripe bananas, baked, eaten with cream, dates, figs, or raisins A cup or two of cocoa LUNCHEON Any one or two fresh vegetables, such as: Beans Peas Carrots Squash Onions Turnips A slice of coarse bread, or preferably a baked sweet or white potato DINNER One or two fresh vegetables Choice of eggs or fish; eggs preferred A green salad A few nuts One extremely ripe banana, with cream Gelatin, with cream SPRING MENU _FOR AGED PERSON BUILDING UP GENERAL HEALTH_ /First Day/: BREAKFAST A full glass of cool water A cup of junket, unsweetened One whole egg, lightly poached A very small, baked white potato A cup of hot water LUNCHEON A large, boiled Spanish onion A very rare omelet or a potato A cup of hot water DINNER Green peas, served in the pod A boiled onion Steamed rice Two egg whites, whipped, served with a glass of fresh milk Just before retiring, drink half a glass of water, and devote from three to five minutes to some of the exercises shown in Vol. V, pp. 1343 to 1346. Give special attention to deep breathing. /Second Day/: Same as the first, slightly increasing the quantity of food, if the quantity named does not seem sufficient. /Third Day/: BREAKFAST Oatmeal simmered over night Two extremely ripe bananas, baked, eaten with thin cream Raisins, nut butter, and cream LUNCHEON A small portion of asparagus or green peas, with a baked white potato A cup of junket DINNER Asparagus, green peas, or beans Fish, lobster, white meat of chicken, or whipped eggs A potato From one and one-half to two glasses of cool water should be drunk at each of the above meals, or, if preferred, a cup or two of hot water. Just before retiring, take vigorous deep breathing exercises. /Fourth Day/: Same as the third, varying the menus by changing vegetables or fruits. /Fifth Day/: Same as the first, repeating these menus so long as they appeal to the taste and satisfy normal hunger. SUMMER MENU _FOR AGED PERSON BUILDING UP GENERAL HEALTH_ BREAKFAST Peaches or cantaloup Corn hominy, with cream Two glasses of milk LUNCHEON Spinach or lettuce Lima beans or boiled corn A potato--sweet or white DINNER One fresh vegetable--choice Buttermilk or fish A potato Sliced peaches or a melon Where milk is not prescribed, I would advise drinking from one to two glasses of water at each meal. Masticate every atom of food to extreme fineness. FALL MENU _FOR AGED PERSON BUILDING UP GENERAL HEALTH_ BREAKFAST A baked apple or soaked prunes One extremely ripe banana Plain wheat, boiled until the grains burst open A pint of rich milk Half a cup of wheat bran, cooked LUNCHEON A baked potato or baked beans Cooked spinach or a morsel of anything green in the way of a salad One fresh vegetable--carrots, string beans, parsnips, squash, or onions. String beans, with a Spanish onion, preferred DINNER Vegetable soup A potato Carrots, parsnips, or beans Junket or gelatin The following are emergency meals which may be taken once or twice a week: EMERGENCY BREAKFAST Whole wheat gems A pint of milk A cup of cocoa (Inasmuch as milk, in small quantities, may be constipating, some bran should be taken at this meal) EMERGENCY DINNER Choice of the following: _a_ Tender fish, with baked or mashed potatoes (If something sweet is desired a very simple dessert, such as plain ice-cream, may be eaten) _b_ Chicken or turkey Mashed or baked potatoes A cup of chocolate WINTER MENU _FOR AGED PERSON BUILDING UP GENERAL HEALTH_ BREAKFAST A cup of hot water A few Malaga grapes or the juice of a very sweet orange Two medium-sized, baked sweet potatoes, eaten with butter A glass of clabbered milk, or a cup of junket, with very little sugar A small portion of wheat bran LUNCHEON A small quantity of something green--endive, lettuce, or celery, eaten with nuts, oil, and a very little salt Boiled onions, carrots, or parsnips A baked potato A liberal portion of gelatin A cup of hot water DINNER Spinach, or a salad with oil Turnips, beets, carrots, parsnips--any two of these A baked potato, with baked beans or rice A portion of junket, fish, or chicken A portion of gelatin, with cream--optional SPRING MENU _STRENGTH AND ENDURANCE (HEALTHY PERSON)_ BREAKFAST Half a glass of water Choice of fruit--a small portion Gems, cakes, or muffins made from coarse corn-meal or bran meal; serve with butter A red banana, with cream, nuts, and raisins Milk LUNCHEON Peas, beans, or lentils--dried One green vegetable Corn bread and butter Buttermilk DINNER Cabbage, celery, lettuce, or romaine, with oil One or two fresh vegetables--peas, potatoes, etc. An egg, milk, fish, or gelatin--any two of these proteid foods Rice, with honey, or raisins with cream, if something sweet is desired Sufficient wheat bran should be taken to keep the bowels in normal condition. SUMMER MENU _STRENGTH AND ENDURANCE (HEALTHY PERSON)_ BREAKFAST Peaches, plums, cantaloup, or berries Steamed corn, scraped from the cob. Recook lightly with whipped egg, stirring constantly A peeled banana, baked--cream LUNCHEON Okra, beets, or eggplant Salad--tomato, cucumber, and lettuce Peas or corn A potato--sweet or white /Note/: The salad, with one vegetable, is sufficient if one is not engaged in strenuous work. DINNER Salad--green Rice or corn hominy One or two fresh vegetables Buttermilk, junket, or fresh eggs Cantaloup, melon, or peaches FALL MENU _STRENGTH AND ENDURANCE (HEALTHY PERSON)_ The following menus should be adhered to for about thirty days, choosing such vegetables from the selections named as appeal most to the taste. Choice of either set of menus may be made; that is, Menu I may be followed by Menu II at noon, returning to Menu I for dinner and so on: MENU I MENU II BREAKFAST Two eggs, cooked very Choice of the following: lightly _a_ Two medium-sized A small portion of boiled sweet or white potatoes, rice or whole wheat, eaten with butter eaten with cream and a or cream very little salt _b_ Corn muffins, or corn A cup of wheat bran, with hominy, with either cream cream or fresh butter Two eggs, cooked two minutes LUNCHEON A large, boiled onion Gems or whole wheat bread A liberal portion of baked A pint of rich milk beans Half a cup of wheat bran DINNER Choice of two of the following Baked navy or lima beans vegetables: A baked white potato Carrots Parsnips A green salad--a very small Beets Stewed portion pumpkin One fresh vegetable A boiled white potato A glass of buttermilk Choice--fish, buttermilk, or eggs Half a cup of wheat bran If something sweet is desired, plain ice-cream, egg custard, or gelatin may be eaten at either of the evening meals. From one to two glasses of water should be drunk at each of these meals. A cup of sassafras tea may be taken at breakfast. See recipe, Vol. III, p. 681. WINTER MENU _STRENGTH AND ENDURANCE (HEALTHY PERSON)_ BREAKFAST California grapes or soaked prunes Two eggs--prepared choice Muffins of coarse cereal meal--butter LUNCHEON Corn hominy, with butter Figs, cream, nuts DINNER Bean or pea soup Whole wheat bread Turnips, carrots, or onions Potatoes or rice Choice of eggs, fish, chicken, buttermilk Gelatin or junket Nuts, raisins, or cheese, with hard cracker SPRING MENU _MALASSIMILATION AND AUTOINTOXICATION_ Manual labor or physical exercise is almost as important in these conditions as diet, therefore at least two hours during the day should be devoted to labor or vigorous motion of some kind, preferably useful labor, such as wood-chopping or cultivating the soil. BREAKFAST A bran meal gem or boiled whole wheat One very ripe banana, baked in a very hot oven; eat with a very little butter or cream Half a glass of rich milk A spoonful of nut-meats LUNCHEON One fresh vegetable--choice; or a vegetable salad Boiled corn, or hominy, with either butter or cream A small portion of wheat bran DINNER A fresh green salad Any fresh vegetable in season A new baked potato One egg, cooked two minutes, or a glass of kuymiss If there is a slight tendency toward constipation, a tablespoonful of wheat bran should be taken immediately on rising and just before retiring. This may be taken cooked as an ordinary cereal, or uncooked in hot water. SUMMER MENU _MALASSIMILATION AND AUTOINTOXICATION_ Vigorous exercise and water-drinking before breakfast. BREAKFAST A melon or a very ripe peach A banana, with cream and figs--very ripe A liberal portion of nuts A glass or two of milk /Note/: The nuts should be masticated exceedingly fine. LUNCHEON Two fresh vegetables, such as: Asparagus Eggplant Beans Okra Carrots Peas Corn A potato, prepared choice, except fried A small green salad DINNER A light vegetable soup Choice of: Asparagus Onions Beans Peas Beets Spinach Corn or a baked potato Very tender fish, game, or chicken, if flesh food or something salty is desired If the weather is extremely warm, all fat foods should be reduced to the minimum, and an abundance of water drunk both at meals and between meals. At least an hour during the day should be devoted to moderate exercise and deep breathing. In all conditions of malassimilation, there is more or less autointoxication. If the diet has been leveled or balanced, the next most important thing is exercise. The best balanced menus will not be effective in removing the causes of these conditions unless there is sufficient time devoted to exercise to create natural hunger. FALL MENU _MALASSIMILATION AND AUTOINTOXICATION_ BREAKFAST A bunch of grapes (Thoroughly masticate the skins, swallowing the seeds and pulp whole) Two eggs or one glass of buttermilk A small, baked potato, sweet or white, with fresh butter A cup of hot water or chocolate LUNCHEON One fresh vegetable--carrots, parsnips, squash, or boiled onions A baked potato A glass of buttermilk A cup of hot water /Note/: If the occupation is sedative, the milk should be omitted. DINNER Cooked spinach or a very small portion of green salad Fish, chicken, or buttermilk A baked potato Boiled onions, or any fresh vegetable Corn or corn bread A cup of hot water Every atom of solid food herein named should be masticated to infinite fineness. Do not overeat; eat slowly and do not engage in animated conversation while eating. Every morning and every evening, immediately on rising and just before retiring, devote from three to five minutes to vigorous deep breathing exercises. If the bowels are constipated, take a tablespoonful of wheat bran on rising; also a small bunch of grapes and a glass of water. Take a spoonful or two of wheat bran, cooked, with the breakfast and evening meals, and another spoonful in hot water just before retiring. The quantity of bran taken should be governed by the severity of the condition. When the bowels are once regulated, the quantity may be modified, or perhaps omitted entirely. WINTER MENU _MALASSIMILATION AND AUTOINTOXICATION_ On rising, drink two cups of hot water. This should be followed by vigorous exercise in a thoroughly ventilated room. BREAKFAST The strained juice of a sweet orange (Florida seedling preferred) Two eggs, whipped very thoroughly, to which add one glass of milk and a tablespoonful each of sugar and of lemon juice Half a cup of wheat bran LUNCHEON A liberal portion of baked beans A cup of hot water or cocoa DINNER Carrots, parsnips, squash, or pumpkin--any two of these Celery or slaw A very rare omelet, rolled in grated nuts and cream A baked potato SPRING MENU _NO APPETITE_ A very sharp distinction should be drawn between appetite and hunger. Appetite is a cultivated desire expressed through a sense of /Craving/. Hunger is the normal demand for food, expressed through the salivary glands. Appetite is the desire for liquor, coffee, tobacco, morphin, etc., and for food when one habitually overeats. It is expressed by an empty feeling or craving in the stomach, while hunger is felt only in the salivary glands, and in the region of the throat and the mouth. Appetite weakens the body; hunger stimulates thought and action. Normal hunger can be produced by limiting the quantity of food below the actual needs of the body, for three or four days, or perhaps a week. When normal hunger returns, the quantity may be increased, but the combinations should be observed for a week or two. The following are limited menus composed of foods that will produce hunger after the third or fourth day: On rising, devote at least five minutes to vigorous deep breathing exercise before an open window, or in the open air. Take a bit of juicy fruit and a glass of water. BREAKFAST Cherries or berries (very ripe); neither cream nor sugar A banana, very ripe, eaten with two egg whites, thoroughly whipped, and a very little thin cream LUNCHEON A green salad One fresh vegetable; peas or asparagus preferred A new potato DINNER A green salad, with nuts Two fresh vegetables A whipped egg or a cup of junket It may be well to omit the noon meal for the first three or four days. If there is the slightest tendency toward constipation, a tablespoonful or two of wheat bran, cooked, should be taken at both the morning and the evening meal. A glass of water should be drunk just before retiring, and at least ten minutes devoted to exercise and deep breathing. As appetite returns, the quantity of food may be increased, and a few heavier articles added, such as coarse cereal for breakfast, and a bit of fish or an omelet for dinner. SUMMER MENU _NO APPETITE_ A cup of water and a very ripe peach or plum followed by vigorous deep breathing exercises, immediately after rising. BREAKFAST Melon or peaches, with a very little cream Tender ear of boiled corn, scraped from the cob, and served with butter or a spoonful of cream LUNCHEON Lettuce and tomato salad, with grated nuts and dressing Corn or beans DINNER Cucumber and lettuce salad, with dressing Summer squash Lima beans Melon FALL MENU _NO APPETITE_ BREAKFAST A cup of hot water A bunch of grapes or a baked apple, without sugar One extremely ripe banana, eaten with cream, figs, and nuts LUNCHEON A large Spanish onion, boiled A baked potato (The potato should be made very hot with red pepper) DINNER Anything green, in the way of a salad, or a bit of spinach, cooked A bran meal gem--fresh butter; or a baked potato One extremely ripe banana, with cream and nuts A bunch of grapes an hour after eating. WINTER MENU _NO APPETITE_ On rising, take the juice of an orange, a glass of water, and such exercises as have been already prescribed in the Spring Menu. BREAKFAST A teaspoonful of olive-oil A pint of clabbered milk or junket Half a cup of wheat bran, cooked, served with cream One egg, either whipped or coddled LUNCHEON Soup, either vegetable or cream of tomato A small piece of a crisp cracker A tablespoonful of olive-oil DINNER Two or three bananas, peeled, and baked in a hot oven; eat with one whipped egg, to which might be added a very little whipped cream A glass of rich milk Half a cup of wheat bran A glass of cool water or a cup of hot water should be drunk at each of these meals, and, as the appetite becomes normal, the egg and the milk products may be increased, and the heavier vegetables, such as sweet potatoes, baked beans, corn hominy, and plain boiled wheat may be added. SPRING MENU _ATHLETIC DIET_ An orange or an apple, on rising BREAKFAST Plain wheat, boiled Eggs or buttermilk Nuts and raisins LUNCHEON Lettuce and tomatoes, with oil Corn bread or corn hominy Baked beans, with butter DINNER Soup--cream of rice or corn Peas, asparagus, or carrots A potato Baked beans or lentils A red banana, with raisins and cream SUMMER MENU _ATHLETIC DIET_ Berries, melon, or peaches, on rising BREAKFAST Three or four whipped eggs; add sugar to taste, and flavor with fruit-juices A pint of milk A corn muffin or a small portion of coarse cereal--flaked wheat LUNCHEON Fresh corn or shelled beans Buttermilk Raisins and nuts Peaches and cream DINNER A small salad Choice of one fresh vegetable: Beans Peas Lentils Corn bread A sweet potato Cottage cheese and either raisins or currants Nuts Plain ice-cream FALL MENU _ATHLETIC DIET_ Grapes, melons, or pears, on rising BREAKFAST Corn hominy or steamed barley; serve with butter or cream A pint of milk A red banana, with cream, figs, and nuts LUNCHEON Lentil soup Sweet potatoes, with butter Whole wheat bread Dates, cream cheese, and nuts DINNER A salad of lettuce, tomatoes, and nuts Green corn Onions, en casserole Rice steamed with raisins; serve with butter or cream WINTER MENU _ATHLETIC DIET_ An orange, on rising BREAKFAST Baked chestnuts, with butter Two or three eggs, whipped; add sugar to taste A whole wheat muffin A banana, with dates and cream LUNCHEON Baked beans Milk DINNER Soup--cream of pea or corn Squash or stewed pumpkin Fish or an omelet Corn bread, with butter or oil Ripe olives, celery, nuts, and raisins The primary purpose of fat in the diet is to produce body-heat. About three ounces of fat will maintain normal heat in the average-sized body for a period of twenty-four hours. The amount of fat taken by the athlete should be governed by exposure and temperature of the atmosphere. The best sources of fat are butter, nuts, and salad oil. SPRING MENU _ATHLETIC DIET_ (_CHIEFLY UNCOOKED_) BREAKFAST Berries or cherries Three or four eggs, whipped eight minutes--sugar to taste; flavor of lemon or pineapple juice. Add a pint of milk, after whipping Very ripe bananas, with cream, nuts, and raisins LUNCHEON A green salad, with oil Boiled wheat, corn hominy, or rice Asparagus, onions, or peas Nuts, raisins, cream cheese DINNER Boiled wheat Three or four eggs, prepared as for breakfast Ice-cream, plain Wheat bran SUMMER MENU _ATHLETIC DIET_ (_CHIEFLY UNCOOKED_) BREAKFAST Melon or peaches A pint of junket or clabbered milk Two eggs, whipped Two red bananas, with cream and nuts LUNCHEON Two or three ears of tender corn, boiled One fresh vegetable--peas, beans, or carrots DINNER A green salad, with oil and nuts A baked potato Corn, peas, or beans Fish or eggs A banana, with dates Melon or peaches FALL MENU _ATHLETIC DIET_ (_CHIEFLY UNCOOKED_) BREAKFAST Exceedingly ripe bananas, eaten with nut butter, dates, and cream Two or three eggs, whipped. Add to each egg a rounded teaspoonful of sugar, and a scant spoonful of lemon juice. Whip thoroughly, and add a glass of milk to each egg LUNCHEON Two or three eggs, whipped, into which whip a teaspoonful each of honey and lemon juice; add a glass of milk to each egg One or two exceedingly ripe bananas, eaten with nut butter and raisins DINNER A green salad or celery A fresh vegetable, cooked--squash, carrots, parsnips, or onions Baked beans and a baked potato Sufficient water should be drunk at each of these meals to bring the moisture up to 66 per cent of the whole. Tender carrots or cabbage, uncooked, may be eaten, with nuts and salt, at both luncheon and dinner. WINTER MENU _ATHLETIC DIET (CHIEFLY UNCOOKED)_ BREAKFAST An orange or an apple, with olive-oil Oatmeal or boiled wheat Three eggs, whipped--sugar to taste; fruit flavor Cream and nuts, with raisins LUNCHEON Corn bread--buttermilk A banana, with either seedless raisins or currants; cream, and either nuts or nut butter Milk or chocolate DINNER Celery Baked beans or lentils Eggs or fish A potato Nuts, raisins, and either cream or ice-cream SPRING MENU _FOR INVALID CHILD--MAKING MUSCULAR TISSUE--REGULATING BOWELS_ On awaking, have the child take a glass of water and the strained juice of an orange, or a few cherries or berries; deep breathing in the open air, and such exercises as it is able to endure. BREAKFAST (Late) Cherries or berries--very few Half a cup of hot water A heaping tablespoonful of boiled wheat, oatmeal, or rice A whipped egg, sweetened and flavored to taste Half a glass of milk LUNCHEON Two glasses of fresh milk, taken slowly--half a glass every ten or fifteen minutes A heaping tablespoonful of wheat bran, cooked, served with cream DINNER Vegetable soup A cup of water Green peas New potatoes Eggs whipped, same as for breakfast--all the child will take; milk, if preferred (If milk is chosen, a tablespoonful of wheat bran should be taken to prevent constipation) SUMMER MENU _FOR INVALID CHILD--MAKING MUSCULAR TISSUE--REGULATING BOWELS_ A very ripe peach or a bunch of grapes on awaking; exercise and deep breathing. BREAKFAST Cantaloup or peaches--very little sugar and cream Whipped eggs, junket, or gelatin--all the child will take of either, or a portion of all LUNCHEON Tender corn, scraped from cob, made into a purée; season to taste Milk and either eggs or gelatin DINNER Cantaloup or melon A pint of milk, with one whipped egg A spoonful of bran Deep breathing in the open air just before retiring. FALL MENU _FOR INVALID CHILD--MAKING MUSCULAR TISSUE--REGULATING BOWELS_ /First Day/: The first thing after rising, give the body a thorough rubbing with a coarse towel or flesh brush, and a gentle massage. Do not use water except on the face and hands. BREAKFAST Whip two fresh eggs very fine, adding slowly, while whipping, two teaspoonfuls of sugar, two and one-half teaspoonfuls of lemon juice, and two tablespoonfuls of cream. Add half a glass of milk to each egg and mix thoroughly At usual breakfast hour begin taking not more than half a glass at first; in ten or fifteen minutes another half glass. Continue taking half a glass every ten or fifteen minutes until the full amount is consumed LUNCHEON A small, baked potato Two eggs, prepared as for breakfast DINNER A glass of milk A baked potato Bit of any fresh vegetable that appeals to the taste Drink liberally of water between meals or at meals. Just before retiring, rub the body with a flesh brush, or give it a massage as prescribed for the morning. Take about one tablespoonful of coarse wheat bran at the beginning of each meal. To keep the intestines thoroughly cleansed is of primary importance. Increase the quantity until the desired result is produced, which should be an action once or twice a day. /Second Day/: The same as the first, decreasing the eggs and increasing the milk. /Third Day/: The same as the second, slightly varying the menus by increasing the quantity of eggs and milk, if these are agreeable, reducing the other articles correspondingly. /Fourth Day/: BREAKFAST A glass or two of clabbered milk, slightly sweetened until it is palatable Wheat bran, cooked LUNCHEON Choice of any fresh vegetable, especially such as sweet potatoes, pumpkin, or red banana, eaten with nut butter A little cream and either dates or figs DINNER Fruit and nuts, prepared any way they are palatable /Fifth Day/: The same as the first, repeating the diet herein given so long as it is agreeable. The body should be rubbed with a flesh brush and given massage every morning and evening. WINTER MENU _FOR INVALID CHILD--MAKING MUSCULAR TISSUE--REGULATING BOWELS_ Choice of the following menus: MENU I MENU II BREAKFAST Two egg whites and one Rice boiled until very soft. yolk whipped rapidly Put through a colander about two minutes. and make into a thin Add two teaspoonfuls of purée by adding milk; sugar and whip three sugar and cream to taste minutes longer; then add slowly, while whipping, a teaspoonful of strained lemon juice or pineapple juice, and a very little olive-oil. Serve two egg yolks and three whites, if the appetite will accept them LUNCHEON Any fresh vegetable of the A boiled onion sweet variety, such as A potato--sweet or white parsnips, sweet potatoes, Carrots or parsnips, eaten squash, or pumpkin. with butter and salt (These may be made into A cup of chocolate a purée by putting through a colander and adding cream and sugar to taste) DINNER One or two fresh vegetables--carrots, Purée of rice and one egg parsnips, turnips, prepared as for breakfast or onions, prepared (Menu I) anyway that will make them palatable Clabbered milk with a sprinkle of sugar The articles composing these meals should be served in very small portions. SPRING MENU _FOR MENTAL WORKER TO INCREASE BRAIN EFFICIENCY_ Immediately on rising, take two or three tablespoonfuls of orange juice and drink two glasses of water. If there is a tendency toward fermentation, the orange juice should be omitted. Exercise in the open air before breakfast. BREAKFAST Two eggs, cooked two minutes A small, baked potato--sweet or white One glass of milk A cup of water LUNCHEON A large, boiled onion and either green peas or asparagus A glass of water DINNER A small portion of fish A baked white potato--eat skins and all; masticate thoroughly One or two vegetables, such as peas, beans, or asparagus One egg white in half a glass of milk Half a glass of water Luncheon should be omitted unless quite hungry. SUMMER MENU _FOR MENTAL WORKER TO INCREASE BRAIN EFFICIENCY_ Choice of the following menus: MENU I MENU II BREAKFAST Peaches or plums A portion of wheat flakes. Oatmeal, rice, or boiled (A spoonful or two of wheat wheat bran cooked with Two glasses of milk the wheat flakes) One whole egg One banana, baked A glass of milk /Note/: A few very ripe berries or the juice of an orange may be taken at the beginning of each of these meals. LUNCHEON One fresh vegetable Choice of one or two fresh A baked sweet or white vegetables potato A glass of buttermilk A very small portion of fish Corn bread--a very little DINNER Choice of two fresh vegetables Choice of two fresh vegetables Two glasses of milk or a A baked white potato small portion of fish Two or three egg whites Two medium-sized baked Baked peas, beans, or lentils white potatoes or baked beans Every atom of food composing these meals should be masticated to exceeding fineness, and two glasses of water drunk at every meal. If something sweet is desired, a spoonful of raisins and nuts might be taken at the close of the dinner meal. FALL MENU _FOR MENTAL WORKER TO INCREASE BRAIN EFFICIENCY_ /First Day/: On rising, take a bunch of grapes (swallow seeds and pulp without mastication), a glass of water, and devote from eight to ten minutes to exercises Nos. 3 and 5. See Vol. V, pp. 1344 and 1345. BREAKFAST One or two exceedingly ripe bananas (red variety preferred), eaten with thin cream, raisins or figs, and butter Two glasses of milk LUNCHEON One whole egg, boiled two minutes Whole wheat, thoroughly cooked; nut butter Two glasses of milk /Note/: If not hungry, omit both the whole wheat and the egg and take from two to three glasses of milk. For gaining weight, this would be preferable. DINNER Choice of carrots, squash, turnips, or parsnips One whole egg, boiled two minutes; or an omelet Two medium-sized baked white potatoes One glass of milk /Note/: From one to one and one-half glasses of water should be drunk at each of these meals. If constipated, eat two medium bunches of Concord grapes, swallowing skins, seeds and pulp without mastication. Drink a glass of water and spend from five to ten minutes in active exercise and deep breathing just before retiring. /Second Day/: The same as the first, slightly increasing the quantity of food if normal hunger requires it. Bran biscuits may be taken instead of whole wheat if preferred. /Third Day/: The same as the first, omitting the egg at dinner time, and substituting a small quantity of fish (smelts preferred). /Fourth Day/: BREAKFAST A cantaloup Half a glass of water A small portion of oatmeal, very thoroughly cooked Two exceedingly ripe bananas, eaten with figs, cream, and nuts A cup of chocolate LUNCHEON Two eggs--prepared choice Two medium-sized potatoes DINNER A salad with oil and nuts Corn, beans, carrots, cabbage--any two of these A potato Junket or gelatin /Fifth Day/: The same as the fourth, with the exception of dinner. At this meal a bit of fish, chicken, or an egg may be eaten. /Sixth Day/: The same as the first, repeating these menus for about two weeks, making such changes as the appetite demands in vegetables and fruit only. WINTER MENU _FOR MENTAL WORKER TO INCREASE BRAIN EFFICIENCY_ Eggs, milk, and sugar are the most readily convertible nutrients known to the science of food chemistry. In combination they represent the highest form of the nitrogenous (proteids and the carbohydrate) compounds, therefore to increase physical efficiency one should take as much of these as possible. If one is under weight, it would be advisable, especially during the cold weather, to take three eggs for breakfast, four eggs with a quart of milk for luncheon, and a vegetable dinner as laid out in Menu II. Choice of the following menus: MENU I MENU II BREAKFAST A bunch of grapes Two or three eggs, whipped, One very ripe banana with to which add a teaspoonful cream and nut butter of lemon juice, a teaspoonful A whole wheat gem, eaten each of olive-oil with one or two very soft and sugar, and one-half eggs glass of milk to each egg LUNCHEON One fresh vegetable Two eggs prepared as for A baked potato breakfast, Menu II Boiled onions and a bit of fish A glass of milk or a cup of hot chocolate DINNER Spinach or a bit of salad The same as dinner, Menu Clabbered milk or a bit of I, choosing either clabbered fish milk, fish, eggs, or Baked beans or baked white meat of chicken potatoes Boiled onions or carrots A cup of chocolate Where as many as four eggs are taken at once, a tablespoonful of cognac brandy will make the yolks more digestible and more assimilable, therefore in curative feeding its purpose is medicinal. SPRING MENU _FOR A SCHOOL TEACHER_ _ANEMIA--SLUGGISH LIVER--UNDERWEIGHT_ _NERVOUSNESS_ Choice of the following menus: MENU I MENU II BREAKFAST Cherries--sweet Berries Corn bread, with butter Farina, or oatmeal with A cup of hot water cream A glass of milk One whole egg Two cups of chocolate LUNCHEON Boiled rice, or corn hominy, A large, boiled onion with butter or cream. (A A baked white potato spoonful of sugar may be Corn bread added, if desired) Buttermilk One or two glasses of water DINNER A pint of junket A small portion of fish or A small piece of corn bread chicken Two or three glasses of milk A baked white potato Half a cup of wheat bran Choice of carrots or onions A green salad or a very small portion of spinach may be eaten at this meal, if desired Drink one or two glasses of water at each of these meals. If the breakfast has not digested well, the noon meal should be very light. Bran gems or plain wheat bran may be eaten at each meal until the liver is performing its normal functions. SUMMER MENU _FOR A SCHOOL TEACHER_ _ANEMIA--SLUGGISH LIVER--UNDERWEIGHT_ _NERVOUSNESS_ MENU I MENU II BREAKFAST A cantaloup Peaches or cantaloup Tender corn scraped from Two medium-sized baked cob--lightly cooked potatoes, with butter; A glass of milk; buttermilk eat skins and all preferred Two eggs or two glasses of One extremely ripe banana, milk eaten with nut butter, cream, and raisins LUNCHEON A vegetable salad A green salad Tender corn, boiled One fresh vegetable A bran gem Junket or gelatin DINNER A green salad or spinach Choice of two fresh vegetables Choice of two vegetables: A baked potato Beans Corn A bit of fish or buttermilk Boiled onions Peas One baked banana, with A baked potato cream and nut butter A liberal quantity of water should be drunk at each of these meals. FALL MENU _FOR A SCHOOL TEACHER_ _ANEMIA--SLUGGISH LIVER--UNDERWEIGHT_ _NERVOUSNESS_ On rising, take the juice of one sweet orange Choice of the following menus: MENU I MENU II BREAKFAST Bran meal gems, with butter A small portion of boiled Milk wheat, with cream One egg, either whipped or boiled two minutes LUNCHEON Two extremely ripe bananas, Two bananas eaten with nut butter Half a dozen dates and raisins (Cream Cream cheese or cream cheese may be An ounce of nuts added, if desired) A cup of milk A whole wheat cracker and nut butter A glass of milk, if convenient DINNER Boiled onions, and either Spinach or a green salad carrots or turnips Baked beans or a baked A baked white potato potato A glass or two of milk Onions, carrots, turnips, or squash One egg or a very small portion of fish Immediately after dinner, eat a bunch of grapes and drink a cup of hot water. If there is a tendency toward constipation, take wheat bran just before retiring. WINTER MENU _FOR A SCHOOL TEACHER_ _ANEMIA--SLUGGISH LIVER--UNDERWEIGHT_ _NERVOUSNESS_ MENU I MENU II BREAKFAST Boiled wheat, with cream One exceedingly ripe banana, Two or three glasses of milk with thin cream and nut butter Two glasses of milk One egg LUNCHEON Two exceedingly ripe bananas, with cream cheese and raisins Whole wheat bread sandwiches, with nut butter; nuts or cream cheese, if preferred DINNER A green salad One or two fresh vegetables--choice A baked potato or corn bread Half a cup of wheat bran, cooked; serve with cream If the bowels should act too freely, rice, chestnuts, or sweet potatoes may be eaten liberally with the morning and the evening meal. SPRING MENU _LABORING MAN_ (_LUNCH IN SHOP_) _UNDERWEIGHT--ANEMIC_ BREAKFAST A baked apple Boiled wheat or oatmeal Wheat bran, cooked Two whole eggs, either whipped or lightly poached A glass or two of milk or a cup or two of chocolate LUNCHEON A pint of milk Whole wheat bread Two very ripe bananas, with nut butter or dates DINNER A cup of hot water Choice of two fresh vegetables: Asparagus Carrots Beans Onions Beets Peas A green salad A bit of fish One egg or a glass of buttermilk A new potato--baked A spoonful or two of wheat bran A spoonful of nuts and a few dates may be eaten at each of these meals. They should be masticated very thoroughly. SUMMER MENU _LABORING MAN_ (_LUNCH IN SHOP_) _UNDERWEIGHT--ANEMIC_ On rising, take two glasses of water, a spoonful or two of wheat bran, and a bit of fruit. /First Day/: BREAKFAST Two glasses of fresh milk Two eggs, whipped or boiled A small dish of whole wheat, cooked A spoonful of wheat bran LUNCHEON Four glasses of milk, with hard crackers Two eggs, cooked A spoonful or two of wheat bran Corn bread (Drink two glasses of milk an hour before dinner) DINNER Two whipped eggs Two glasses of milk Two medium-sized, baked white potatoes; eat skins and all A sauce-dish of wheat bran, cooked Just before retiring, take two or three tablespoonfuls of wheat bran, in a little water, provided there is a tendency toward constipation; if not, this should be omitted. /Second Day/: The same as the first, adding another egg to the morning meal, and a bit of fish to the evening meals. /Third Day/: The same as the second. /Fourth Day/: The same as the first, and so on for a period of a week or ten days. FALL MENU _LABORING MAN_ (_LUNCH IN SHOP_) _UNDERWEIGHT--ANEMIC_ The following menus are composed of but few articles; all of them, however, have a specific purpose. Immediately on rising, drink a glass of water and eat a bunch of grapes, swallowing skins, seeds and pulp. Do not masticate the seeds or pulp. Choice of the following menus: MENU I MENU II BREAKFAST Melon or pears A melon or a bunch of Two or three eggs, cooked grapes one and a half minutes Two or three eggs cooked A portion of whole wheat, one and a half minutes boiled or simmered over Two medium-sized baked night; serve with cream white potatoes A small portion of wheat bran, cooked LUNCHEON Two or three eggs, taken Two eggs uncooked from the shell, Two exceedingly large bananas, with a little salt with either nut Whole wheat bread with butter or nuts, and dates nut butter or raisins A banana, eaten with either cream cheese or nut butter, and raisins or dates DINNER Boiled onions, carrots, Same as dinner Menu I, squash, corn, turnips, or substituting chicken for beets--any two of these the egg or the fish, if A green salad or cooked desired spinach, with egg A very small portion of fish or an egg A liberal portion of baked potatoes From one to two glasses of water should be drunk at each of these meals. Mastication should be very thorough. In the selection of articles composing the dinner, do not make them too numerous. Three or four things are sufficient. About once a week take-- One fresh vegetable A baked potato One egg Home-made ice-cream as dessert The noon meal could consist of three or four eggs whipped with a little sugar, adding a glass of milk to each egg. Place this in a bottle and take a glass every fifteen or twenty minutes, from 12 until 2 /P. M./ WINTER MENU _LABORING MAN_ (_LUNCH IN SHOP_) _UNDERWEIGHT--ANEMIC_ /First Day/: Immediately on rising, drink a glass of water, eat a bit of fruit, and devote from five to eight minutes to exercising and deep breathing. BREAKFAST Boiled wheat, with cream and nuts, or nut butter, if convenient; if not, use dairy butter From three to four glasses of milk (A tablespoonful of ordinary wheat bran at the close of the meal) LUNCHEON A pint of milk A sandwich of whole wheat bread, with nut butter and cream cheese One or two bananas, with cream cheese, nuts, and dates DINNER Celery or a green salad Carrots and boiled onions Baked white potatoes or baked beans A glass of buttermilk An egg served on a baked potato It would be advisable to drink a glass of water at the close of each meal, and, just before retiring, to drink another glass of water and to eat a bit of fruit. Take exercises as already suggested. /Second Day/: Same as the first. /Third Day/: Same as the second, varying the vegetables according to appetite or hunger. /Fourth Day/: BREAKFAST Two very ripe bananas, eaten with cream and nut butter Four or five figs, eaten with cream and nuts Two eggs, very softly boiled, or whipped, if preferred A potato, if something salty is desired LUNCHEON A sandwich, as for luncheon first day Two eggs Soaked prunes, or figs, with nut butter or dairy butter DINNER Fish, eggs, or chicken Choice of two fresh vegetables: Beets Squash Carrots Turnips, etc. A baked white potato or baked beans A cup of thin cocoa or gelatin A cup of hot water A bit of fruit, exercise, and deep breathing just before retiring. /Fifth Day/: The same as the fourth, slightly increasing or decreasing the quantity of food according to normal hunger. /Sixth Day/: The same as the first, repeating the diet until there is a perceptible gain in both strength and weight. It should then be changed or modified so as to prevent the appetite from rebelling against the general plan. These changes may be made by selecting different vegetables and fruits. The heavy or proteid part of the diet should be kept about the same as prescribed so long as the work is strenuous. DIET FOR COLD WEATHER BREAKFAST A cup of hot water A baked apple or persimmons An omelet, lightly cooked, rolled in grated nuts and whipped cream A coarse, cereal-meal waffle or corn bread and butter A heaping tablespoonful of coarse wheat bran, cooked (Honey, if something sweet is desired) LUNCHEON Baked beans, with olive-oil or butter DINNER A vegetable soup Cabbage, cauliflower, or Brussels sprouts A lettuce and tomato salad A potato, corn, or lima beans Corn bread and buttermilk Gelatin or junket Wheat bran Nuts, raisins, and cheese DIET FOR HOT WEATHER BREAKFAST Melon, peaches, or cantaloup A whole wheat muffin or a gem A banana, with raisins, nuts, and cream LUNCHEON Peaches, with sugar and cream An ear of tender corn A glass of milk DINNER A green salad, with nuts Two fresh vegetables--peas, beans, or corn Ice-cream or ices--fruit flavor (A melon or a cantaloup, before retiring) Two glasses of cool water should be drunk at each of these meals. HOT WEATHER MENU _FOR THE PREVENTION OF SUNSTROKE AND HEAT PROSTRATION_ BREAKFAST Cantaloup Peaches, or a small portion of berries, without sugar One or two extremely ripe bananas, eaten with nuts, cream, and raisins Fresh milk LUNCHEON A green salad or spinach Any fresh vegetable, such as squash, onions, turnips, beets, carrots, or parsnips A new baked potato--eat skins and all DINNER A green salad, with tomatoes and nuts Two vegetables--corn, peas, beans, or asparagus (The vegetables to be cooked in a casserole dish) A potato--prepared choice One very ripe banana, with figs and either cream cheese or fresh cream SUGGESTIONS FOR THE PREVENTION OF SUNSTROKE From one to two glasses of cool water should be drunk at each of these meals. Mastication of every atom should be complete. Hurried eating is the most prolific cause of fermentation. Fermentation is the cause of intestinal gas, sour stomach and indigestion, also constipation and torpid liver. Avoid stimulants such as tea, coffee, tobacco, beer, or liquors. These things excite heart activity, which causes excessive body-heat. Avoid sweets, especially sweet soda-fountain drinks. Sugar is composed largely of carbon, and carbon is one of Nature's greatest heat-makers. Confine the diet largely to semi-acid fruits, fresh vegetables, green salads, milk, eggs, nuts, and a very limited quantity of bread and cereal products. Cereal starch is the most difficult of all carbohydrate matter to digest. Drink an abundance of pure water at meals and between meals. Avoid all mixed-up, sweetened and charged water. There is nothing better than plain spring or distilled water. Do not eat too many things at the same meal. Three or four articles are sufficient. Avoid meat of all kinds, and eat a very limited quantity of fats. By all means do not overeat. Every atom of food taken into the body that is not used must be cast off at a tremendous expense of energy. The casting-off process is what we call dis-ease. Every housewife and mother should know enough about the chemistry of food to avoid serving at the same meal things which are chemically inharmonious. If these simple laws were observed, sunstrokes and heat prostrations would be almost unheard of. Summer is the time when Nature is rebuilding and revitalizing all forms of animal life; it is also the time when she is producing all of the material with which to do this building in its best and purest form, therefore summer should be the time when people are at their best. The reason they are not is because they do not understand the simple laws that govern human nutrition. SPRING MENU _TO BUILD UP SEXUAL VITALITY AND MAINTAIN IT_ BREAKFAST Very ripe berries, with sugar Rare omelet, rolled in whipped cream and grated nuts Whole wheat bread or boiled whole wheat Rich milk Wheat bran LUNCHEON Two or three eggs, whipped; add a pint of fresh milk, a dash of sugar, and a flavor of pineapple juice; drink slowly DINNER Fish or lobster, broiled Potato and peas Junket or gelatin Nuts, raisins, and cream cheese Chocolate Only plain water should be drunk at these meals. SUMMER MENU _TO BUILD UP SEXUAL VITALITY AND MAINTAIN IT_ BREAKFAST Peaches, plums, or any semiacid fruit Whole wheat or a coarse cereal, cooked Whipped eggs or tender fish A whole wheat cracker LUNCHEON A green salad, with oil and nuts Oysters, crabs, or lobster A potato or whole wheat DINNER Carrots, peas, beans, corn--any two of these A Spanish omelet or white meat of chicken A potato A glass of rich milk A cantaloup or peaches FALL MENU _TO BUILD UP SEXUAL VITALITY AND MAINTAIN IT_ BREAKFAST Peaches or cantaloup Two or three eggs, whipped six or seven minutes; sweeten to taste and flavor with fruit-juice A cup of junket or gelatin, unsweetened LUNCHEON Fish, broiled One fresh vegetable A potato DINNER Corn and either peas or beans Fish or chicken Buttermilk A potato WINTER MENU _TO BUILD UP SEXUAL VITALITY AND MAINTAIN IT_ On rising, take half a glass of grape juice and a glass of cool water. Devote about fifteen minutes to vigorous exercise and deep breathing. Before eating, take a brisk walk, thinly clad, in the open air. /First Day/: BREAKFAST Grapes or grape juice A small portion of plain wheat, boiled very thoroughly; serve with cream Three fresh eggs (See Fall Menu) A cup of junket or buttermilk Half a glass of water LUNCHEON One egg, prepared as for breakfast Two glasses of junket or buttermilk A liberal portion of gelatin DINNER Celery Broiled fish; young variety--very tender A baked potato One egg whipped as for breakfast Gelatin or junket--a liberal portion /Second Day/: Same as the first, reducing--unless the digestion is perfect--the amount prescribed for the noon meal. /Third Day/: Same as the second, varying the meals by changing fruits, or by adding another fresh vegetable to the evening meal; but, before adding another article, eat the full amount of proteids prescribed: eggs, fish, and gelatin. /Fourth Day/: BREAKFAST One or two ripe bananas Raisins or figs; or nuts or nut butter Two or three glasses of fresh milk LUNCHEON Baked beans or lentils, with olive-oil or fresh butter Two or three eggs; preferably uncooked DINNER Two or three eggs, with two teaspoonfuls of sugar; whip seven or eight minutes; add two glasses of milk; mix thoroughly; drink slowly Bran meal gems Half a cup of bran, cooked /Fifth Day/: Same as the fourth. /Sixth Day/: Same as the first. /Seventh Day/: Same as the second, repeating the menus for a period of thirty to forty days, varying them by selecting such vegetables as appeal most to the taste. If the bowels should become constipated, take half a cup of cleansed wheat bran, cooked, with the breakfast, and, just before retiring, another half cup in hot water. If possible, spend from two to three hours each day in the open air, taking vigorous exercise. Oxygen is nature's great stimulant and life-giver. Eat slowly and masticate very thoroughly. If there is a tendency toward obesity, sugar should be omitted from the meals entirely. Proteid foods should predominate in the diet. The following are the most soluble and readily assimilable group of proteid foods suitable for these menus, given in the order of richness and importance: Eggs Shell-fish Gelatin Milk Fish Fowl--white meat Milk products 
26774	----	test alcohol shows up in its true nature as a poison, and not a food. Alcohol destroys healthy normal action of all the bodily functions, and builds up impure fat, fatty degeneration, instead of strong, firm muscle. Dr. Parkes, one of the most famous of English students of alcohol, says:-- "These alcoholic degenerations are certainly not confined to the notoriously intemperate. I have seen them in women accustomed to take wine in quantities not excessive, and who would have been shocked at the imputation that they were taking too much, although the result proved that for them it was excess." Dr. Ezra M. Hunt, late secretary of New Jersey State Board of Health, remarks:-- "The question of excess occurs in sickness as well as in health, and all the more because its determination is so difficult and the evil effects so indisputable. The dividing line in medicine, even between use and abuse, is so zigzag and invisible that common mortals, in groping for it, generally stumble beyond it, and the delicate perception of medical art too often fails in the recognition." All non-alcoholic writers assert that the continuous use of alcohol as a medicine is equally injurious to all the bodily functions as the employment of it as a beverage. Calling it medicine does not change its deadly nature, nor does the medical attendant possess any magical power by which a destructive poison may be converted into a restorative agent. Dr. Noble, writing recently to the _London Times_, said:-- "The internal use of alcohol in disease is as injurious as in health." Since foods induce healthy, normal action of all the bodily functions, and alcohol injures every organ of the body in direct proportion to the amount consumed, by this test it is proved to not be a food. _Foods give strength._ Alcohol weakens the body. This has been determined again and again by experiments upon gangs of workmen and regiments of soldiers. These experiments always resulted in showing that upon the days when the men were supplied with liquor they could neither use their muscles so powerfully, nor for so long a time, as on the days when they received no alcoholic drink. Of the results of such tests Sir Andrew Clark, late Physician to Queen Victoria, said:-- "It is capable of proof beyond all possibility of question that alcohol not only does not help work but is a serious hinderer of work." So satisfied are generals in the British army of the weakening effect of alcohol that its use is now forbidden to soldiers when any considerable call is to be made upon their strength. The latest example of this was in the recent Soudan campaign under Sir Herbert Kitchener. An order was issued by the War Department that not a drop of intoxicating liquor was to be allowed in camp save for hospital use. The army made phenomenal forced marches through the desert, under a burning sun and in a climate famous for its power to kill the unacclimated. It is said that never before was there a British campaign occasioning so little sickness and showing so much endurance. Some Greek merchants ran a large consignment of liquors through by the Berber-Suakim route, but Sir Herbert had them emptied upon the sand of the desert. A reporter telegraphed to England:-- "The men are in magnificent condition and in great spirits. They are as hard as nails, and in a recent desert march of fifteen miles, with manoeuvring instead of halts, the whole lasting for five continuous hours, not a single man fell out!" This was in decided contrast to the march in the African war some years before when, as they passed through a malarial district, and a dram was served, men fell out by dozens. Dr. Parkes, one of the medical officers, prevailed upon the commander-in-chief to not allow any more alcoholic drams while the troops were marching to Kumassi. Experiments in lifting weights have also been tried upon men by careful investigators. In every case it was found that even beer, and very dilute solutions of alcohol, would diminish the height to which the lifted weight could be raised. As an illustration of the deceptive power of alcohol upon people under its influence, it is said that persons experimented upon were under the impression, after the drink, that they could do more work, and do it more easily, although the testing-machine showed exactly the contrary to be true. Athletes and their trainers have learned by experience that alcohol does not give strength, but is, in reality, a destroyer of muscular power. No careful trainer will allow a candidate for athletic honors to drink even beer, not to speak of stronger liquors. When Sullivan, the once famous pugilist, was defeated by Corbett, he said in lamenting his lost championship, "It was the _booze_ did it"; meaning that he had violated training rules, and used liquor. University teams and crews have proved substantially that drinking men are absolutely no good in sports, or upon the water. Football and baseball teams, anxious to excel, are beginning to have a cast-iron temperance pledge for their members. So practical experience of those competing in tests of strength and endurance teach eloquently that alcohol does not give strength, but rather weakens the body, by rendering the muscles flabby. Sandow, the modern Samson, wrote his methods of training in one of the magazines a few years ago, and stated that he used no alcoholic beverages. The ancient Samson was not allowed to taste even wine from birth. A question worthy of serious consideration is: how are the sick to be strengthened and "supported" by drinks which athletes are warned to specially shun as weakening to the body? Either the sick are mistakenly advised, or the athletes are in error. Which seems the more likely? Dr. Richardson says in _Lectures on Alcohol_:-- "I would earnestly impress that the systematic administration of alcohol for the purpose of giving and sustaining strength is an entire delusion." In another place he says:-- "Never let this be forgotten in thinking of strong drink: that the drink is strong only to destroy; that it never by any possibility adds strength to those who drink it." Sir William Gull, late physician to the Prince of Wales, said before a Select Committee of the House of Lords on Intemperance:-- "There is a great feeling in society that strong wine and other strong drinks give strength. A large number of people have fallen into that error, and fall into it every day." Any unprejudiced person can readily see that experience and experiment unite in testifying that alcohol does not give strength, hence differs radically from most substances commonly classed as foods. Yet millions of dollars are spent annually by deluded people upon supposedly strength-giving drinks, and thousands of the sick are ignorantly, or carelessly, advised to take beer or wine to make them strong and to _support_ them when solid food cannot be assimilated. Truly, "My people is destroyed for lack of knowledge." _Foods give force to the body._ Dr. Richardson says:-- "We learn in respect to alcohol that the temporary excitement is produced at the expense of the animal matter and animal force, and that the ideas of the necessity of resorting to it as a food, to build up the body or to lift up the forces of the body, are ideas as solemnly false as they are widely disseminated." Dr. Benjamin Brodie says in _Physiological Inquiries_:-- "Stimulants do not create nerve power: they merely enable you, as it were, to use up that which is left." Dr. E. Smith:-- "There is no evidence that it increases nervous influence, while there is much evidence that it lessens nervous power." Dr. Wm. Hargreaves, of Philadelphia:-- "It is sometimes said by the advocates and defenders of alcohol, that by its use force is generated more abundantly. This it certainly cannot do, as it does not furnish anything to feed the blood or to store up nourishment to replenish the expenditure. For by their own theory, the increase of action must cause an increase of wear and tear; hence alcohol instead of sustaining life or vitality, must cause a direct waste or expenditure of _vital force_." Dr. Auguste Forel, of Switzerland:-- "All alcoholic liquors are poisons, and especially brain-poisons, and their use shortens life. They cannot therefore be regarded as sources of nourishment or force. They should be resisted as much as opium, morphia, cocaine, hashish and the like." Dr. W. F. Pechuman, of Detroit, in his valuable little treatise, _Alcohol--Is it a Medicine?_ says clearly:-- "When alcohol or any other irritant poison is put into the system, the conservative vital force, recognizing it as an enemy, at once makes an effort through the living matter to rid the system of the offender;--the heart increases in action and new strength seems to appear. Now, right here is where the great mass of people and a large number of physicians are deluded. They mistake the extra effort of the vital force to preserve the body against harmful agencies for an actual increase in strength as the result of the agent given; we wonder that they can be so blind as not to see the reaction which invariably occurs soon after the administration of their so-called stimulant." Dr. F. R. Lees, of England:-- "All poisons lessen vitality and deteriorate the ultimate tissue in which force is reposited. Alcohol is an agent, the sole, perpetual and inevitable effects of which are to avert blood development, to retain waste matter, to irritate mucous and other tissues, to thicken normal juices, to impede digestion, to deaden nervous sensibility, to lower animal heat, to kill molecular life, _and to waste, through the excitement it creates in heart and head, the grand controlling forces of the nerves and brain_." If alcohol is a destroyer of bodily force, as any ordinary observer of drinking men can readily see, it is a problem beyond solving, how it is going to give force to, or sustain vitality in, the patient hovering between life and death. Too often has it been the means of hastening into eternity those who, but for its mistaken use, might have recovered from the illness affecting them. _Food gives heat to the body._ Alcohol does not, but really robs the body of its natural warmth. This finding of science was received with the utmost incredulity when first presented to the medical world, but the invention of the clinical thermometer settled it beyond controversy. It is now believed by all but a very few of those who have knowledge of the physiological effects of alcohol. While Dr. N. S. Davis, of Chicago, was the first to demonstrate this fact, it was Dr. B. W. Richardson, of England, who succeeded in putting it prominently before the attention of physicians. The normal temperature of the human body is a little over 98 degrees by Fahrenheit's thermometer. If the temperature is found to be much above or below 98 degrees the person is considered out of health; indeed by this condition alone physicians are able to detect serious forms of disease. By the use of the clinical thermometer, placed under the tongue, it is easy to determine what agents acting upon the body will cause the temperature to vary from the natural standard. When alcohol is swallowed there is at first a decided feeling of warmth induced; if the temperature be taken now it will be found that in a person unaccustomed to alcohol the warmth may be raised half a degree; in one accustomed to alcohol the warmth may be raised a full degree, or even a degree and a half beyond the natural standard. But this warmth is only temporary, and is soon succeeded by chilliness. Dr. Richardson says in his _Temperance Lesson Book_:-- "The sense of warmth occurs in the following way: When the alcohol enters the body, and by the blood-vessels is conveyed to all parts of the body, it reduces the nervous power of the small blood-vessels which are spread out through the whole of the surface of the skin. In their weakened state these vessels are unable duly to resist the course of blood which is coming into them from the heart under its stroke. The result is that an excess of warm blood fresh from the heart is thrown into these fine vessels, which causes the skin to become flushed and red as it is seen to be after wine or other strong drink has been swallowed and sent through the body. So, as there is now more warm blood in the skin than is natural to it, a sense of increased warmth is felt. The skin of the body is the most sensitive of substances and the sense of warmth through, or over the whole surface of the skin is conveyed from it to the brain and nervous centres of the body, by which we are enabled to feel. "The warmth of surface which seems to be imparted by alcohol, only _seems_ to be imparted. Positively the warmth is not imparted by the alcohol, but is set free by it. "In a short time the sense of warmth is succeeded by a feeling of slight chilliness. Unless the person is in a very warm room, or has recently partaken of food, the thermometer will now show a decided decrease in temperature, reaching often to a degree. Should the person go out into a cold air, and especially should he go into a cold air while badly supplied with food, the fall of temperature may reach to two degrees below the natural standard of bodily heat. In this state he easily takes cold, and in frosty weather readily contracts congestion of the lungs, and that disease which is known as bronchitis. If the person drinks to drunkenness his temperature will be found to be from two and a half to three degrees below the natural standard. It takes from two to three days, under the most favorable circumstances, for the animal warmth to become steadily re-established after a drunken spree. "The excitement of the mind in the early stages of drunkenness is not natural; it is exhaustive of the bodily powers, and exhaustive for no useful purpose whatever. * * * * * "As nothing has been supplied by the alcohol to keep up the supply of heat the vital energy is rapidly exhausted, and if the person is exposed to cold, the exhaustion becomes extreme, sometimes fatal. All great consumers of alcohol are chillier during winter than are abstainers, and as they labor under the delusion that they must take wine or ale or spirits to keep them warm, they keep on making matters worse by constantly resorting to their enemy for relief." Dr. Newell Martin makes this very clear in his physiology, _The Human Body_. "Our feeling of being warm depends on the nerves of the skin. We have no nerves which tell us whether heart or muscles or brain, are warmer or cooler. These inside parts are always hotter than the skin, and if blood which has been made hot in them flows in large quantity to the skin, we feel warmer because the skin is heated. As alcoholic drinks make more blood flow through the skin, they often make a man feel warmer. But their actual effect upon the temperature of the whole body is to lower it. The more blood that flows through the skin, the more heat is given off from the body to the air, and the more blood, so cooled, is sent back to the internal organs. The consequence is that alcohol, in proportion to the amount taken, cools the body as a whole, though it may for a time heat the skin." If other evidence that alcohol is not heat-producing in the body were necessary it could be found in the fact that the products of combustion are decreased when it is present in the body. The quantity of carbonic acid exhaled by the breath is proportionately diminished with the decline of animal heat. Arctic explorers learned by experience what science discovered by experiment. Dr. Hayes, the explorer, says:-- "While fresh animal food, and especially fat, is absolutely essential to the inhabitants and travelers in Arctic countries, alcohol, in almost any shape, is not only completely useless, but positively injurious." Lieutenant Johnson, who accompanied Nansen upon his northern expedition, said, when interviewed by a reporter of the London _Daily News_:-- "The common opinion that alcohol becomes in some way a necessity in cold countries is entirely a mistaken one. This has been conclusively proved by the expedition. In making up his list of the _Fram's_ equipments, Nansen did not include any spirits, with the exception of some spirits of wine for lamps and stoves." In the list of stores taken upon the long sledging expedition after leaving the _Fram_ no liquors are mentioned. See _Farthest North_, by Nansen. The omission of spirits was not because of any "temperance fanaticism," but because the experience of former Arctic expeditions had shown clearly that men freeze more readily after partaking of alcohol than when they totally abstain from it. That wine is not a fuel-food was shown conclusively in the Franco-Prussian war during the siege of Paris. Food was scarce in the French Army, and wine was liberally supplied. The men complained bitterly of the extreme chilliness which affected them. Dr. Klein, a French staff surgeon, was reported in the _Medical Temperance Journal_ of England, October 1873, as saying of this:-- "We found most decidedly that alcohol was no substitute for bread and meat. We also found that it was no substitute for coals. We of the army had to sleep outside Paris on the frozen ground. We had plenty of alcohol, but it did not make us warm. Let me tell you there is nothing that will make you feel the cold more, nothing which will make you feel the dreadful sense of hunger more, than alcohol." There is no evidence against alcohol stronger than that which shows it to be not heat-producing, as commonly believed, but a reducer of heat in the body. Indeed, this question of bodily temperature is used in recent times to decide whether a man who has fallen upon the street is troubled by apoplexy, or influenced by alcoholism. If the clinical thermometer shows the temperature to be above normal, it is apoplexy; if below normal, it is alcoholism. "Alcohol is clearly proved to be not a fuel-food, for if it were it would enable the body to resist cold, instead of making it colder; and in the extreme degrees of cold it would go on burning like other fuel-foods, and would maintain, instead of helping to destroy, life."--Richardson's _Lesson Book_. Yet because it creates a glow of warmth in the skin immediately after drinking it, thousands of people will discredit all evidence that it is a reducer of bodily heat. Clinical thermometers, and after-sensations of chilliness, are unheeded, for "Wine is a mocker," and multitudes are willing to be deceived by it. So, also, with the conclusions against it as a strengthening agent; because it dulls the sense of hunger and of fatigue, those who crave it will declare in the face of all scientific testimony that it strengthens them, and takes the place of food. They will cite, too, the cases of people who "lived upon whisky" during an illness of greater or less duration. Of the sustaining of life upon alcohol only, Dr. N. S. Davis has said:-- "The falsity of all such stories is made apparent by the fact that nineteen-twentieths of all the alcoholic drinks given to the sick are given in connection with sugar, milk, eggs or meat-broths, which furnish the nutriment, and would support the patients better if given with the same perseverance without the alcohol than with it. While we have quite a number of examples of men living on nothing but water forty or fifty days, I have never seen or learned of a well-authenticated case of a man's taking or receiving into his system nothing but alcohol for half of that length of time, without becoming sick with either gastro-duodenitis, nephritis, or delirium tremens." _Some of the defenders of the medicinal use of alcohol claim that since it has been shown to reduce tissue waste it should be classed as an indirect food, a conserver of tissue._ Of this claim, Dr. N. S. Davis says in the _Bulletin of the A. M. T. A._, November, 1895:-- "A careful study of the conditions and processes necessary for both tissue building or nutrition, and tissue waste or disintegration, in all the higher order of animals, will show that neither process can be materially retarded without retarding or preventing the other. Both processes take place only in bioplasm or vitalized matter, supplied with oxygen, water and heat. Neither the assimilation of new material food, nor its use in tissue building can be effected without the presence of free oxygen and nuclein, or corpuscular elements of the blood. And without the presence of the same elements we can have no natural tissue disintegration and removal of the waste. The processes of tissue building and tissue disintegration, are therefore, so intimately related, and dependent upon the same materials and forces, that neither can be hastened or retarded from day to day without influencing the other. When alcohol or any other substance, introduced into the blood, retards the tissue waste, as shown by the diminished amount of excretory products, it must do so by either diminishing the amount of free oxygen in the blood, by impairing the vasomotor and trophic nerve functions or by direct impairment of the properties of the nuclein or protogen elements of the blood and tissues. The popular idea, both in and out of the profession is, that the alcohol, by further oxidation in the blood, lessens the amount of oxygen to act on the tissues, and generates heat or 'some kind of force.' Those who advocate this theory of saving the tissues by combining the oxygen with alcohol seem to forget that in doing so they are diverting and using up the only agent, oxygen, capable of combining with, and promoting the elimination of, all natural waste products as well as the various toxic elements causing disease. "But the theory that alcohol directly combines with the oxygen of the blood by which it would be converted into carbonic acid and water with evolution of heat is completely refuted by the well-known fact that its presence in the blood diminishes both temperature and elimination of carbonic acid as already stated. Physiologists of the present day very generally agree that the capacity of the blood to receive oxygen from the lungs, and convey it to the systemic capillaries and various tissues, depends chiefly on its hemoglobin (red coloring matter), protein, or albuminous and saline elements. "Both experimental and clinical facts in abundance show that alcohol at all ordinary temperatures displays a much stronger affinity for these elements of the blood and tissues, than it does for oxygen. And when present in the blood, it rapidly attracts both water and hemoglobin from the corpuscular and albuminoid elements of that fluid, and thereby diminishes its reception and distribution of oxygen. We are thus enabled to see clearly how the alcohol diminishes the oxygenation and decarbonization of the blood, and retards all tissue changes both of nutrition and waste without itself undergoing oxidation with evolution of heat. Consequently, instead of acting as a shield or conservator of the tissues by simply combining with the oxygen, the alcohol directly impairs the properties and functions of the most highly vitalized elements of the blood itself, and thereby not only retards tissue waste but also equally retards the highest grades of nutrition, and favors only sclerotic, fatty and molecular degenerations, as we see everywhere resulting from its continued use. Can an agent displaying such properties and effects be called a _food_, either direct or indirect, without a total disregard for the proper meaning of words?" In another place he says:-- "This lessening of the elimination of tissue waste is simply an evidence of the accumulation of poisonous substances within the body, through the lessened activity of liver and kidneys and the impairment of the blood." Dr. Ezra M. Hunt says in _Alcohol as Food and as Medicine_, page 37:-- "It sounds conservative of health to say of a substance that it delays the breaking down of tissue, but the physiologist does not allow a substance which occasions such delay, to possess, because of that, either dietetic or remedial value. To increase weight by prolonged constipation is not a physiological process." Dalton says:-- "The importance of tissue change to the maintenance of life is readily shown by the injurious effects which follow upon its disturbance. If the discharge of the excrementitious substances be in any way impeded or suspended, these substances accumulate either in the blood or tissues, or both. In consequence of this retention and accumulation they become poisonous, and rapidly produce a derangement of the vital functions. Their influence is principally exerted upon the nervous system, through which they produce most frequent irritability, disturbance of the special senses, delirium, insensibility, coma, and finally, death." The power to retard the passage of waste matter from the system is one of the gravest objections to the use of alcohol in sickness, as the germs of disease are thereby caused to remain longer in the body than they would, were no alcohol or drug of similar action, used. Thus recovery is delayed, if not effectually hindered. The preponderance of scientific evidence is all against alcohol as possessing food qualities. It contains no elements capable of entering into the composition of any part of the body, hence cannot give strength; it is not a fuel-food as it does not supply heat to the body, but decreases temperature; and its classification as indirect food because it retards the passage of waste matter is shown to be utterly unscientific, as any agent which interferes with the natural processes of assimilation and disintegration is a dangerous agent, a poison rather than a food. The question naturally arises:-- If these drinks are not liquid food, as we have been taught to believe, how is it, since they are made from food, as barley, corn, grapes, potatoes, etc? These drinks are not food, although made from food, because in the process of manufacturing them the food principle is destroyed. The grain is malted to change starch into sugar--loss of food principle begins here--then the malted grain is soaked in water to extract the saccharine matter. When the sugar is all in the water the grain goes to feed cattle or hogs, and the sweetened water is fermented. The fermentation changes the sugar into alcohol. Analyses of beer by eminent chemists show an average of 90 per cent. water, 4 per cent. alcohol, and 6 per cent. malt extract. The malt extract consists of gum, sugar, various acids, salts and hop extract. Starch and sugar are all of these capable of digestion, and the amount of them would be equal to 39 ounces to the barrel of beer. Liebig, the great German chemist, said:-- "If a man drinks daily 8 or 10 quarts of the best Bavarian beer, in a year he will have taken into his system the nutritive constituents contained in a 5 pound loaf of bread." Eight quarts a day for a year would be 2,920 quarts, or a little more than 23 barrels. If sold to the consumer at the low rate of five cents a pint, it would cost him $292; a high price for as much nourishment as in a 5 pound loaf! Analyses of wine by reliable chemists show that the consumer must pay $500 for the equivalent in nourishment of a 5 pound loaf of bread, wine being higher priced than beer. Wines average 80 per cent. water, about 15 per cent. alcohol, and 5 per cent. residue. This residue is composed of sugar, tartaric, acetic and carbonic acids, salts of potassium and sodium, tannic acid, and traces of an ethereal substance which gives the peculiar or distinguishing flavor. The only one of these ingredients possessing food value is sugar; this exists chiefly in what are called sweet wines. Yet how many thousands of people spend money they can ill afford for wines and beers to build up the failing strength of some loved one! A costly delusion, and too often a fatal one! "Distilled liquors, if unadulterated, contain literally nothing but water and alcohol, except traces of juniper in gin, and the flavor of the fermented material from which they have been distilled."--_Influence of Alcohol_, by N. S. Davis, M. D. It is the solemn duty of those to whom the people look for instruction in matters of health to undeceive the toiling masses as to the food-value of alcoholic liquids. Some of the medical profession are faithful in this regard, but too many others are themselves deceived, or care not for the destruction of the people. IS ALCOHOL A STIMULANT? A lady asked her family physician several years ago what he thought of the views of those medical writers who class alcohol as a narcotic, and not a stimulant. He answered with some heat, "Any one who says alcohol is not a stimulant is either a fool or a knave!" He could not have been aware that some of the most distinguished professors in American medical colleges teach that alcohol is not, properly speaking, a stimulant, but a narcotic. The accepted definition of a stimulant in medical literature is some agent capable of exciting or increasing _vital activity_ as a whole, or the natural activity of some one structure or organ. Dr. N. S. Davis has said repeatedly that both clinical and experimental observations show that alcohol directly diminishes the functional activity of all nerve structures, pre-eminently those of respiration and circulation, thus decreasing the internal distribution of oxygen, which is nature's own special exciter of all vital action. "Consequently it is antagonistic to all true stimulants or remedies capable of increasing vital activity. Instead, therefore, of meriting the name of _stimulant_, alcohol should be designated and used only as an anæsthetic and sedative, or depressor of vital activity." The following is taken from an editorial article in the _American Medical Temperance Quarterly_ for January, 1894:-- "Drs. Sidney Ringer and H. Sainsbury in a carefully executed series of experiments on the isolated heart of the frog, found that all the alcohol when mixed with the blood circulating through the heart, uniformly diminished the action of that organ in direct proportion to the quantity of alcohol used, until complete paralysis was induced. In closing their report in regard to the action of different alcohols, they say that 'by their direct action on the cardiac tissue these drugs are clearly _paralyzant_, and that this appears to be the case from the outset, _no stage of increased force of contraction preceding_.' "Professor Martin, while in connection with the Johns Hopkins University, performed an equally careful series of experiments in regard to the action of ethylic, or ordinary alcohol, directly on the cardiac structures of the dog, and with the same results. He makes the following explicit statement of the results obtained by him. 'Blood containing one-fourth per cent. by volume, that is two and a half parts per 1000 of absolute alcohol, almost invariably diminishes, within a minute, the work done by the heart; blood containing one-half per cent. always diminishes it, and may even bring the amount pumped out by the left ventricle to so small a quantity that it is not sufficient to supply the coronary arteries.' "In 1883, R. Dubois, by direct experimenting upon animals, found that the presence of alcohol in the blood much intensified the action of chloroform and thereby rendered a much less dose fatal. "Prof. H. C. Wood of the University of Pennsylvania, in an address upon Anæsthesia to the Tenth International Medical Congress, of Berlin, in 1890, said: 'In my own experiments with alcohol, an eighty per cent. fluid was used largely diluted with water. The amount injected into the jugular vein varied in the different experiments from 5 to 20 c. c.; and in no case have I been able to detect any increase in the size of the pulse or in the arterial pressure produced by alcohol, when the heart was failing during advanced chloroform anæsthesia. On the other hand, on several occasions, the larger amounts of alcohol apparently greatly increased the rapidity of the fall of arterial pressure, and aided materially in extinguishing the pulse. "Sir Henry Thompson says: 'That alcohol is an anæsthetic and paralyzant is a fact too well established to be questioned or contradicted.' "Dr. J. J. Ridge, of London, has published elaborate tables, showing that even small doses of alcohol, averaging one tablespoonful of spirits--not quite half a wineglass of claret or champagne, and not quite a quarter of a pint of ale--impair vision, feeling, and sensibility to weight, without the subject's being conscious of any alteration. Dr. Scougal, of New York, has repeated and confirmed these experiments, and also demonstrated that the hearing was similarly affected. "Drs. Nichol and Mossop, of Edinburgh, conducted a series of experiments on each other, examining the eye by means of the ophthalmoscope while the system was under the influence of various drugs. They found that the nerves controlling the delicate blood-vessels of the retina were paralyzed by a dose of about a tablespoonful of brandy. "Dr. T. D. Crothers, of Hartford, Conn., has deduced some valuable facts from his experiments with the sphygmograph, upon the action of the heart. He has found by repeated experiments that while alcohol apparently increases the force and volume of the heart's action, the irregular tracings of the sphygmograph show that the real vital force is diminished, and hence its apparent stimulating power is deceptive."--Extract from the Annual Address before the Medical Temperance Association at San Francisco, Cal., June 8, 1894, by Dr. I. N. Quimby, of Jersey City, N. J. Dr. J. H. Kellogg, of Battle Creek, Mich., has made extensive experiments as to the effects of alcohol. In summing up the results of these he says:-- "It would seem that no further evidence could be required that alcohol is a narcotic and an anæsthetic, rather than a stimulant, and that its use as a supporting and tonic remedy is a practice without foundation in either scientific theory or natural clinical experience." Sir B. W. Richardson at a medical breakfast in London in 1895, stated that though alcohol produced an increase in the motion of the heart it was ultimately weaker in its action, so he resolved to give up using such an agent. Dr. A. B. Palmer of the University of Michigan prepared a "Report" upon alcohol in 1885 for the Michigan State Medical Society in which he cited experiments showing that the opinion that alcohol stimulates the heart by an increase of real force, is an error. It creates a flutter, but decreases power. "Increased frequency of pulsation is often the strongest evidence of diminished power--as the fluttering pulse of extreme weakness." He classes alcohol with chloroform. "If chloroform is a narcotic, alcohol is a narcotic. If chloroform is an anæsthetic, alcohol is an anæsthetic. If one is essentially a depressing agent, so is the other. Their strong resemblance no one can question. The chief difference is that the alcoholic narcosis is longer continued, and its secondary effects are more severe." In closing his summary of the changes in scientific knowledge of this drug he says:-- "We said it was a direct heart exciter. We now know it is a direct heart depressor. We said, and nearly all the text-books still say, it is a direct cardiac stimulant. We know from most conclusive experiments it is a direct _cardiac paralyzant_." The following is taken from one of the many excellent papers upon alcohol written by that Nestor among physicians, Dr. N. S. Davis:-- "Alcoholics are very generally prescribed in that weakness of the heart sometimes met with in low forms of fever and in the advanced stage of other acute diseases. It is claimed that these agents are capable of strengthening and sustaining the action of the heart under the circumstances just named, and also under the first depressing influence of severe shock. "There is nothing in the ascertained physiological action of alcohol on the human system, as developed by a wide range of experimental investigation, to sustain this claim. I have used the sphygmograph and every other available means for testing experimentally the effects of alcohol upon the action of the heart and blood-vessels generally, but have failed in every instance to get proof of any increased force of cardiac action. "The first and very transient effect is generally increased frequency of beat, followed immediately by dilatation of the peripheral vessels from impaired vasomotor sensibility, and the same unsteady or wavy sphygmographic tracing as is given in typhoid fever, and which is usually regarded as evidence of cardiac debility. Turning from the field of experimentation to the sick-room, my search for evidences of the power of alcohol to sustain the force of the heart, or in any way to strengthen the patient has been equally unsuccessful. I was educated and entered upon the practice of medicine at a time when alcoholic drinks were universally regarded as stimulating and beat-producing, and commenced their use without prejudice or preconceived notions. But the first ten years of direct clinical or practical observation satisfied me fully of the incorrectness of those views, and very nearly banished the use of these agents from my list of remedies. While it is true that during the last thirty years I have not prescribed for internal use the aggregate amount of one quart of any kind of fermented or distilled drinks, either in private or hospital practice, yet I have continued to have abundant opportunity for observing the effects of these agents as given by others with whom I have been in council; and simple truth compels me to say that I have never yet seen a case in which the use of alcoholic drinks either increased the force of the heart's action or strengthened the patient beyond the first thirty minutes after it was swallowed. * * * * * "Nothing is easier than self-deception in this matter. A patient is suddenly taken with syncope, or nervous weakness, from which abundant experience has shown that a speedy recovery would take place by simple rest and fresh air. But in the alarm of patient and friends something must be done. A little wine or brandy is given, and, as it is not sufficient to positively prevent, the patient in due time revives just as would have been the case if neither wine nor brandy had been used." In the _Medical Pioneer_ of November, 1895, Prof. E. MacDowel Cosgrave, Professor of Biology, Royal College of Surgeons in Ireland, says:-- "The result of all recent investigation is to show that the use of alcohol when a stimulant effect is desired, is an error; and that, from first to last alcohol acts as a narcotic." Dr. Edmunds, of London, said in an address given in Manchester:-- "By giving alcohol as a stimulant in exhausting diseases, I believe we always do as we should in giving a dose of opium and brandy and water to comfort a half suffocated patient; i. e., increase his danger. If that be so, we reduce alcohol not only from the position of food medicine, but we reduce it from the position of a goad; and we say that the supposititious stimulating or goading influence of alcohol is a mere delusion; that in fact alcohol always lessens the power of the patients, and always damages their chance of recovery, when it is a question of their getting through exhausting diseases." Many more such quotations might be adduced. Enough are given to show that the popular use of alcohol, when a stimulant is required, is considered a grave error by those who have most thoroughly studied the effects of this drug. ALCOHOL AS A TONIC. Dr. J. J. Ridge, of London, says:-- "The action of alcohol in relaxing unstriped muscular fibre, which entitles it to be called an anti-spasmodic, robs it of all claim to give tone. The sense of exhilaration which follows small doses of alcohol has been mistaken for real strength and increase of vitality. It is well known that relaxation of the blood-vessels throughout the body is one of the first effects of alcohol. The arteries of the retina have been observed to dilate after very small doses of alcohol. The diminution of tone is well seen in the tracings of the pulse under the influence of alcohol. If one needs a tonic, therefore, alcohol is one of the things to be shunned altogether. "But alcoholic beverages contain other things beside alcohol. Beer contains infusion of hops, or other bitter stomachics. Some wines contain tannin. These ingredients, by creating or stimulating the appetite, increase the strength and vital power in certain cases. But we have a large number of drugs which will do the same without the disadvantages arising from the presence of alcohol, and, if the flavor be objected to, many of them can be taken in the form of coated pills. "The external use of cold, either by a dripping sheet, cold sponging, or a shower-bath, according to the power of reaction, is a valuable means of giving real tone. "Wine is frequently prescribed for those young persons who are growing rapidly, and whose strength does not seem to keep pace with their growth. It is important to know that alcohol is not desirable in such circumstances. There is often found in such cases a defective appetite, perhaps even sub-acute gastric catarrh, which may be due to imperfect mastication through bad teeth, or aggravated by it. There are other causes, such as late hours, bad habits, improper food or irregular meals. In such cases those means must be resorted to which are so effectual in improving the condition and strengthening the heart of athletes. Regular and regulated meals, exercise in the fresh air, a good amount of rest and sleep--these will do more than anything else to invigorate the bodily health." Dr. N. S. Davis says:-- "Although I was taught, like all others, to use alcohol as a tonic when patients were sick, to hasten their recovery and promote their strength, yet it did not take me very long to find out that here and there was one already a teetotaler who would not take wine long, nor any kind of alcoholic drink unless prescribed, just as castor-oil, dose by dose, but who, when he got beyond the necessity of having it as a medicine, took no more. What was the comparison? My patients who refused, or did not take alcohol, got strong quicker and had less tendency to relapse than those who continued its use. Here was the first step in progress, and consequently I came soon to cease the recommending it merely to hasten recovery of strength. As a tonic, I found it of no value." Dr. James Miller, of Edinburgh, says in _Alcohol, Its Place and Power_, written many years ago:-- "It may be well here to correct an important error, yet very current, in regard to the medicinal use of alcohol. People regard it as a simple and common tonic; and are ready to accept its supposed help as such in every form of weakness and general disorder of health. But it is ordinarily, no true tonic." Dr. Ernest Hart, editor of the _British Medical Journal_, stated some years ago at a meeting of the British Medical Temperance Association that "the medical profession were nearly all agreed that alcohol is neither a food nor a tonic." Many drunkards have been made, especially among women, by the delusion that alcohol has tonic effect. As a sample of these sad cases the following is given, taken from a recent number of _The National Advocate_:-- "There is in the jail at Elizabeth, N. J., a woman who was arrested while participating in wild drunken orgies with a gang of tramps in the woods near the town. She appears nothing but a besotted hag, but was only a short time ago a dutiful wife of a respectable man, and the mother of three beautiful children. Her father, who is said to be living in a village in New York State, is a highly respected minister of the Methodist Episcopal Church. Her children are in an asylum, and her husband is a wanderer in the West. The cause of her ruin was beer, prescribed for her by the family physician as a tonic. At first she refused to take it, having always been a teetotaler, but persuaded to obey the physician, she soon acquired a taste for the drink that speedily developed into the overmastering appetite, which has brought her and hers to this sad condition." ALCOHOL AS A SEDATIVE. Dr. J. J. Ridge says in the _Medical Pioneer_, April, 1893:-- "Alcohol, chiefly in the form of spirits, is often given to procure sleep and to relieve pain, such as that of neuralgia, dyspepsia, colic and diarrhoea. It is as a sedative that alcohol is so insidious and seductive in cases of chronic disease, as, if frequently resorted to, the drink craving is almost certainly developed. Hence the importance in many cases of rather bearing the ills we have than of flying to others that we know not of. It is clear that other narcotics, such as opium, morphia, chorodyne, chloral, are open to the same objection, and the victims of these drugs are terribly numerous. * * * * * In many instances some form of dyspepsia is the cause of the sleeplessness, palpitation or other uneasy feeling for which a sedative is desired, and when this is cured the symptoms vanish." A prominent minister in a large American city was afflicted with insomnia a few years ago, and, after trying various remedies, was advised by a physician to try whisky "night-caps." He became a hopeless drunkard. A young medical student in New York appealed to one of his professors for aid in overcoming aggravated insomnia. The professor advised whisky and morphine! The advice led to the ruin of the young man. ALCOHOL AS AN ANTIPYRETIC. "By the power of alcohol to retard the evolution of heat in retarding molecular changes in the tissues, the liquids containing it may be used as antipyretics when the temperature is too high, and to retard the processes of waste when these are too rapid. But the antipyretic influence of alcohol is so feeble in comparison with the proper application of water to the surface, or with the internal administration of sulphate of quinia, salicylic acid, digitalis, etc. that no one thinks of using it for antipyretic purposes."--Dr. N. S. Davis in _Principles and Practice of Medicine_. PROFESSOR ATWATER'S CONCLUSIONS UPON ALCOHOL AS A FUEL-FOOD. In 1899 a decided sensation was caused by the announcement that Prof. Atwater, of Middletown, Conn., had proved that alcohol is a fuel-food equal in value to carbohydrates and fats. The study later of Prof. Atwater's report of his investigations led to prolonged discussions among medical men interested in the alcohol question, and his theory that alcohol is a food because it is oxidized in the body was vigorously opposed by many scientists of high standing. Professor Abel, of Johns Hopkins University, Baltimore, an investigator of alcohol who worked with the Committee of Fifty, said on this point:-- "Oxidizability cannot be made the measure of usefulness in regard to this substance." Professor Gruber, president of the Royal Institute of Hygiene, Munich, said:-- "Does alcohol truly deserve to be called a food substance? Obviously, only such substances can be called food material, or be employed for food, as, like albumen, fat, and sugar, exert non-poisonous influence in the amounts in which they reach the blood and must circulate in it in order to nourish * * * * Although alcohol contributes energy it diminishes working ability. We are not able to find that its energy is turned to account for nerve and muscle work. Very small amounts, whose food value is insignificant, show an injurious effect upon the nervous system." Sir Victor Horsley, the well-known London surgeon, said:-- "We know that alcohol lowers the temperature of the body. It can only do that by diminishing the activity of the vital processes. It also diminishes very greatly the power of the muscles, and it diminishes the intellectual power of the nervous system. To call an agent that causes such diminution of activity throughout the whole body a food is ridiculous." An editorial in the _Journal of the American Medical Association_ said: "The fallacy of the reasoning which would place alcohol among the foods is very apparent when we put it in the form of a syllogism: All foods are oxidized in the body; alcohol is oxidized in the body; therefore alcohol is food. As logically we might say: 'All birds are bilaterally symmetrical; the earthworm is bilaterally symmetrical; therefore the earthworm is a bird.' Oxidation within the body is simply one of several important properties of food, as bilateral symmetry is one of several important characteristics of a bird." Schafer's Physiology says:-- "It cannot be doubted that any small production of energy resulting from the oxidation of alcohol is more than counterbalanced by its deleterious influences as a drug upon the tissue elements, and especially upon those of the nervous system." The _Bulletin_ of the A. M. T. A. for July, 1899, contained an article upon Prof. Atwater by Dr. J. H. Kellogg, from which the following is taken:-- "Starch, sugar and fats become foods or fuels only through their assimilation. Abundant physiological evidence attests that no substance can act as a food, or as a true source of energy, unless it has first entered into the composition of the body. It must be assimilated. The forces manifested by the body, the muscular forces, or nervous energy, are the result of the breaking down of organized structure into simpler forms. For example, in the case of nervous energy, material from which nerve energy is derived is stored up in the nerve cell, and can be seen with the microscope in the form of minute granules, which disappear as the cell energy is expended, leaving the cell blank and shriveled when in a state of extreme fatigue from overwork. The same is essentially true of the muscle cell. The source of muscular energy is glycogen, an organized substance which becomes a part of the muscle tissue in a well-nourished muscle in a state of rest. "Experiments have clearly shown that fat, sugar and starch must all alike be converted into the form of glycogen and enter into the muscle structure before they can become a source of energy. "Professor Atwater tells us that alcohol can not form tissue, hence the query is pertinent, How can it be a source of vital energy? The body does not burn food as a stove does fuel. Food can be called fuel only in a highly figurative sense. The oxidation of food in the body does not take place directly. Food is assimilated, becoming a part of the tissue. Oxygen is also assimilated, entering into the composition of the tissue along with the food elements under the action of special organic ferments brought into play by nervous impulses received from the central ganglia. "The molecules of these residual tissues which form the storehouse of energy in the body are rearranged in simpler forms, thereby giving up a portion of the energy which holds them together in the state in which they exist in the tissues, and this energy thus set free appears as muscle force, mental activity, glandular work and various other forms of functional activity." CHAPTER VII. ALCOHOL IN PHARMACY. In the _Journal of the American Medical Association_ for November 13, 1897, Dr. T. D. Crothers, editor of the _Journal of Inebriety_, says in a paper upon "Concealed Alcohol in Drugs":-- "A very important question has been repeatedly raised, and answered differently by persons who claim to have some expert knowledge. The question is, can strong tinctures of common drugs be given in all cases with safety; tinctures of the various bitters which contain from 10 to 40 per cent. of alcohol, and are used very freely by neurotic and debilitated persons? It is asserted with the most positive convictions that such tinctures are more sought for the narcotic effect of the alcohol than for the drugs themselves. "In my experience a large number of inebriates who are restored, relapse from the use of these tinctures given for their medicinal effects. * * * * * "The question is asked, how much alcohol can be used as a solvent in drugs without adding a new force more potent than that which is brought out by the alcohol? Opinions of experts differ. One writer thinks 10 per cent. of alcohol in any drug will, if given any length of time, develop the physiologic effect of alcohol in addition to that of the drug. An English writer says that in some cases a 5 per cent. tincture is dangerous from the alcohol which it contains. "There is some doubt expressed by many authorities as to the potency of a drug which is covered up in a strong tincture. It is clear that the value of a drug is not enhanced, and it is certain that a new force-producing, or exploding agency, has been added to the body. "In experience, any drug which contains alcohol can not be given to persons who have previously used it without rousing up the old desire for drink, or at least producing a degree of irritation and excitement that clearly comes from this source. It is also the experience of persons who are very susceptible to alcohol, that any strong tincture is followed by headache and other symptoms that refer to disturbed nerve centres. "In many studies I have been surprised at the increased action of drugs when given in other forms than the tincture. Gum and powdered opium, have far more pronounced narcotic action than the tincture. Yet the tincture is followed by a more rapid narcotism, but of shorter duration, and attended with more nerve disturbance at the onset. "I am convinced that a more exact knowledge of the physiologic action of alcohol on the organism will show that its use in drugs as tinctures is dangerous and will be abandoned. "There are many reasons for believing that its use in proprietary drugs will be punished in the future under what is called the poison act." Dr. J. J. Ridge published in May, 1893, in the _Medical Pioneer_, the following statement of the pharmacy of the London Temperance Hospital:-- "When the Temperance Hospital was first opened, it became a question of practical importance, what should be done with regard to the alcohol so largely employed as a vehicle and drug excipient. Not that the principle of the treatment of disease without the ordinary administration of alcoholic beverages precludes the employment of alcoholic tinctures, but it was felt that in such a test case as this it was important to obviate the objection that while withholding alcohol as a beverage, it was given in the medicine. As a matter of fact, it is surprising, when one looks into it, how much alcohol is often given merely as a vehicle for other drugs, and without the special action of alcohol being required or desired. In prescriptions which are to be seen in many text-books, it is not uncommon to find from one to two or three, or even four drachms of rectified spirit in the form of tinctures or spirits. This is very undesirable. If alcohol is needed it should be given in proper measured dose. But if it is not indicated, then it is not well to administer it in this indirect manner. "Experiments were therefore made, partly at the hospital and specially by Messrs. Southall Bros. & Barclay, of Birmingham, with the result that new non-alcoholic tinctures were made replacing the following alcoholic tinctures and wines:-- Tinct. Aloes. " Arnicæ. " Aurantii. " Belladonnæ. " Buchu. " Calumbæ. " Camph. Co. " Capsici. " Cascarillæ. " Catechu. " Chiratæ. " Cinchonæ Co. " " Flav. " Cinnamomæ. " Colchici Sem. " Conii. " Digitalis. " Ferri Acet. " Ferri Perchlor. " Gentiani Co. " Hyosciami. " Kino. " Krameriæ. " Limonis. " Lobeliæ. " Nucis Vomicæ. " Opii. " Quassiæ. " Rhei. " Scillæ. " Serpentariæ. " Stramonii. " Valerianæ. " " Ammon. Vin. Aloes. " Colchici Rad. " " Sim. " Ipecac. " Opii. " Rhei. "These were made by extracting the principles of the drugs in the usual way except that instead of alcohol a mixture of glycerine and water was used in the proportion of one-fourth to one-third part of glycerine, and about five per cent. of acetic acid. These made very elegant preparations, and in the majority of cases appeared to have just the same, and just as great physiological action. Subsequently the ordinary tinctures were distilled, and the extracts thus obtained dissolved in the above menstruum, as far as was possible, in most cases the residuum being found to be inert. "Gum resins and essential oils were found to be insoluble in this menstruum, and hence such drugs have been given in the form of pill, powder or mixture. Such tinctures are those of assafoetida, benzoin, cannabis indica, cantharides, castor, cubebs, lavender, myrrh, pyrethrum, sumbul, tolu and ginger. Out of 62 tinctures it was found that 46 made good preparations, and 16 did not. "These were employed for several years. But for some time past, somewhat more reliable preparations have been made for us which contain _all_ the constituents of the alcoholic tinctures without the alcohol. They are for the most part made by taking standardized tinctures, mixing with them sugar of milk, and distilling off the alcohol. The alcoholic extract remains behind in a finely divided condition mingled with sugar of milk. This is broken up, pulverized and compressed into tabloids of a definite dose, which can be taken either in that form or rubbed up and dissolved or suspended in gum water. "The following have been made up in this form: aconite, belladonna, camph. co., cannabis indica, capsicum, cinchon. co., and cinchon. simpl., digitalis, gelseminum, hyosciamus, nux vomica, opium, strophanthus, ginger and Warburg. Other tinctures will be gradually added to this list. "As external liniments those commonly used are the linimentum terebinthinæ and the linimentum terebinthinæ aceticum, which do not contain alcohol. A strong solution of iodine is made with iodide of potassium. "The spiritus ammoniæ aromaticus is made without the spirit, the aromatic oils being emulsionized by means of rubbing up with fine sand, but most of these subsequently rise to the surface. The spiritus etheris nitrosi is impossible without alcohol, but nitrite of amyl, and nitrites of potash or soda can be substituted. The spiritus chloroformi is replaced by aqua chloroformi, or as a sweetening agent by solution of saccharin. Thus a favorite expectorant mixture contains carbonate of ammonia five grains, acetum ipecac, ten minims, and solution of saccharin in each dose. "As a special stimulant a subcutaneous injection of a drachm of pure ether has been given in a few cases; in others digitalis, or caffeine or ammonia in some form, such as the carbonate dissolved in a cup of hot coffee; or hot solution of Liebig's extract, or rectal injections of hot water." It may be objected by some that glycerine belongs to the family of alcohols, hence hospitals using glycerine tinctures are not, strictly speaking, non-alcoholic. To this the answer is, that while glycerine certainly is classed in the family of alcohols, it is of a very different nature from ethyl alcohol, which is used for beverage purposes. Ethyl alcohol, the alcohol in all intoxicating beverages in common use, and the alcohol generally used in medicine, creates a fatal craving for itself, and is injurious to the body. Glycerine does not create any craving for itself, and has not been demonstrated to have injurious properties, and is not used for beverage purposes. At the annual meeting of the New York State Medical Society, held in New York City, in October, 1898, a discussion was held upon the use of alcohol as medicine. Dr. E. R. Squibb, a leading pharmacist of Brooklyn, stated that during the last two or three years much had been accomplished in retiring alcohol as a menstruum for exhausting drugs. Of the other menstrua experimented with up to the present time, that which had given the best results was acetic acid, in various strengths. It had been discovered that a ten per cent. solution of acetic acid was almost universal in its exhausting powers. There were now in use in veterinary practice, and in some hospitals, extracts made with acetic acid. They were made according to the requirements of the pharmacopoeia, except that acetic acid was substituted for alcohol. Acetic acid, when used with alkaloids gives the physician some advantages in prescribing, owing to there being fewer incompatibles. In small doses, the percentage of acetic acid in the extract is so small as to be hardly appreciable, and when larger doses are required, the acetic acid can be neutralized by the addition of potash or soda. Dr. Noble said, in article to _London Times_ before referred to:-- "Modern science has shown that those drugs which are soluble in alcohol only, are, in all probability, more hurtful than useful." The following from Dr. Jas. R. Nichols, editor Boston _Journal of Chemistry_, is too good to be omitted, although it should be familiar to temperance students:-- "The facetious Dr. Holmes has said, that if the contents of our drug-stores were taken out upon the ocean and thrown overboard, it would be better for the human race, but worse for the fishes. This statement may be a little sweeping; but it is true that all the showy bottles in drug-stores which contain alcoholic decoctions and tinctures might be submerged in the ocean, and invalids would suffer no detriment. Since the active alkaloidal and resinoidal principles of roots, barks and gums have been isolated and put in better and more convenient forms, there is no longer need of alcoholic tinctures and elixirs. Laudanum, which is a tincture of opium, might be banished from the shelves of every apothecary, as it is not needed. It is now known that the valuable narcotic and hypnotic principles of opium are contained in certain crystalline bodies, which can be isolated, and used in minute and convenient forms, and that they can be held in aqueous solutions. Alcohol is no longer needed to hold the active principles of opium, Peruvian bark or other indispensable drugs. As regards the vegetable tonics so called, the best among them is the columbo (Radix columbo) and this readily yields its bitter principle to water, as does quassia, gentian, senna, rhubarb and most other valuable substances. A careful survey of the contents of a well-appointed modern pharmacy leads to the conclusion that there is no one indispensable medicinal preparation which requires alcohol as a free constituent. "The catalogue of modern remedies is almost endless, and many of them hold alcohol in some form; but every intelligent physician knows that 90 per cent. of these alleged remedies have little or no intrinsic value. The nostrums of the quack, the bitters, elixirs, cordials, extracts, etc. nearly all contain alcohol, and this is the ingredient which aids their sale. The whole unclean list might, with advantage to mankind, be thrown to the fishes. "The chemist, more particularly the pharmaceutical chemist, may inquire how he is to conduct his processes without alcohol. It is from the pharmaceutical laboratory we derive some of the most important substances used in medicines and the arts. Among them may be named ether, chloroform and chloral hydrate, three of the most indispensable agents known to science, and the employment of alcohol is essential to their production. Alcohol is a laboratory product; it is a chemical agent which belongs to the laboratory; it is the handmaid of the chemist, and, so long as it exists, should be retained within the walls of the laboratory. In the manufacture of most of the important products in which alcohol is either directly or indirectly used, its production may be made simultaneous with the production of the agent desired. In the manufacture of ether and chloroform, the apparatus for alcohol may be made a part of the devices from which the ultimate agents, ether and chloroform, result. Fermentation and distillation may be conducted at one end, and the anæsthetics received at the other. It is true that in a chemical laboratory alcohol is an agent very convenient in a thousand ways. But, if it were banished utterly, what would result? There are other methods of fabricating the useful products named, and many others, without the use of alcohol, but the processes would be rather inconvenient and more costly. The banishment of alcohol would not deprive us of a single one of the indispensable agents which modern civilization demands, and neither would chemical science be retarded by its loss." "It must be remembered that modern science has given us glycerine, naptha, bisulphide of carbon, pyroligneous products, carbolic acid and a hundred other agents which are capable of taking the place of alcohol in a very large number of appliances and processes." The sale of liquor in drug-stores is beginning to be deplored by the more respectable pharmacists. At the annual meeting of the Massachusetts State Pharmacists' Association in 1895 the president said in his address:-- "One thing that every pharmacist, who has the best interests of his calling at heart, must bear in mind is that the liquor part of their business is being, and must be, slowly crowded out. Public sentiment has changed greatly in the last few years, and instead of all being classed alike, the line has been sharply drawn, and the stores that sell the least amount of liquor that they possibly can are gaining the confidence and esteem of the public, and consequently their business is growing from year to year, while the others are losing ground and dropping lower and lower." The _Evening Record_ of Boston contained the following in its issue of March 7, 1896:-- "The number of flagrant offences on the part of druggists in certain no-license towns--offences not only against the liquor laws, but also against the laws of decency and humanity--brought before the board of pharmacy, would appall the public if they were known. The Looker-On has seen the record of several of these druggists as transcribed from the police courts and they are very black records. One druggist after selling liquor over and over again to one customer, and several times getting him completely intoxicated, finally deposited him one night in a snowbank, in a state of frozen stupor, where he would have frozen to death had not the wife of the druggist's clerk threatened to complain to the police unless he was rescued. "The story is told of one of the druggists of a neighboring no-license town. A man came in and asked for a pint of whisky. He was asked what he wanted it for. His reply was that he wanted it to soak some roots in. He got it, and as he went out he dryly remarked, 'I should have told you that it was the roots of me tongue that I want to soak.'" CHAPTER VIII. DISEASES, AND THEIR TREATMENT WITHOUT ALCOHOL. The question, "What shall I take instead of wine, beer or brandy?" is frequently asked by those who have been trained to think some form of alcohol really necessary to the cure of disease, but, who, from principle would prefer other agents, if they knew of any equal in effect. This chapter deals somewhat with the answer to that question. ALCOHOLIC CRAVING:--The craving for alcohol may be present for a time after a person has commenced to abstain from all beverages containing it. Or, it may occur periodically, as a sort of irresistible impulse. For the periodical craving Dr. Higginbotham, of England, recommends that a half drachm of ipecacuanha be taken so as to produce full vomiting. He says the desire for intoxicating drinks will be immediately removed. The craving is caused by vitiated secretions of the stomach; the vomiting removes these. Dr. Higginbotham says:-- "If a patient can be persuaded to follow the emetic plan for a few times when the periodical attacks come on, he will be effectually cured." Some men in trying to abstain have found the use of fresh fruit, especially apples, very helpful. Nourishing and digestible food should be taken somewhat frequently. A cup of hot milk or hot coffee taken at the right moment has saved some. AN�MIA:--In this complaint there is a deficiency of the red corpuscles of the blood. It may be the result of some fever or exhausting illness; it may accompany dyspepsia, and is then due to imperfect digestion and assimilation of the food. The poverty of the blood produces shortness of breath, and often palpitation of the heart also, especially on a little exertion. There is generally more or less weariness, languor and debility, sometimes also giddiness, sickness, fainting and neuralgia. "In the treatment of anæmia, port wine and other alcoholic liquors are worse than useless."--DR. J. J. RIDGE, London. "The common prescription of wine or some form of spirits for states of general exhaustion and anæmia, is a serious mistake. It assumes that the temporary increase in the action of the heart is renewed vigor, and that some power is added to the failing energies. This theory rests solely on the statement of the patient that he feels better. In reality the exhaustion is intensified, though covered up."--_Medical Pioneer._ "Deficiency of nutrition, of light and of pure air may be mentioned as common causes of anæmia. * * * * * It is evident that the first step in the treatment of this disease is to remove the cause. If the cause is dyspepsia, this must receive attention; if intestinal parasites, they must be dislodged; if prolonged nursing, nursing must be interdicted; if too little food, a larger quantity of nourishing, wholesome food must be employed. Such simple and easily digested foods as eggs, poached or boiled, boiled milk, kumyzoon, good buttermilk, purée of peas, beans or lentils, boiled rice, well-cooked gruels and other preparations of grains are suitable. Beef tea and extracts are worthless. * * * * * "A careful course of physical training is essential to securing perfect recovery in cases of chronic anæmia due to indigestion, or any other serious disturbance of the nutritive processes."--DR. J. H. KELLOGG. APPETITE, LOSS OF:--"There is often disinclination for food because _it is not required_. Many cannot eat much breakfast, because they have had a hearty supper. Or having had both a hearty breakfast and luncheon, they feel but little desire for a dinner of four or five courses. Generally the stomach is right and the habits wrong. What is to be done then, for such lack of appetite? Simply go without food until appetite comes. "When ale or beer is taken regularly with meals the stomach learns to expect them, and the food is not relished without them. The appetizing power of beer and bitter ales is chiefly due to the hop or other bitter ingredients which they contain. When it seems necessary to assist the appetite temporarily, a small quantity of simple infusion of hops may be taken. "Sometimes appetite fails because of exhaustion of body and mind. This may be nature's warning against overwork, and cannot be neglected with impunity. Life will inevitably be shortened if it is found necessary to rely upon the aid of alcohol in any form in order to do a day's work. "Bouillon, or beef soup, at the beginning of a meal are incentives to appetite. Change of scene, and life in the open air are the very best aids to appetite, when aids are really required." APOPLEXY:--"There is a popular idea that whenever a person is taken ill with giddiness, fainting or insensibility, brandy should be at once procured and poured down his throat. Nothing can be more dangerous in apoplexy. This disease is due to the bursting of some blood-vessel in the head, and the poured-out blood presses on the brain and leads to more or less insensibility. If fainting occurs, it may possibly save the patient's life, because then the blood-vessels contract, and the flow of blood ceases immediately; time is thus given for the ruptured blood-vessel to became sealed up by a clot, which will prevent further loss of blood. If brandy is given, there is, first, great risk of choking the patient; if that danger is escaped and the brandy is swallowed and absorbed, the vessels become relaxed and the heart recovers its force; hence the ruptured vessel, if not sufficiently sealed by clot, may be started again, and fatal hemorrhage result. "The only _treatment_ which unskilled hands can adopt is to lay the patient on his back on the floor or sofa with the head and shoulders somewhat raised; to loosen all the dress round the neck and body; to apply cold to the head and hot flannels or a hot bottle to the feet and hands, or to soak them in hot mustard and water, and to gently rub the arms and legs."--DR. J. J. RIDGE. Dr. Alfred Smee, surgeon to the Bank of England, says:-- "Give nothing by the mouth. Apply a stream of cold water to the head. If the feet are cold apply warm cloths. If relief is not soon obtained, apply hot fomentations to the abdomen, keeping the head erect." BED-SORES:--Some object to using alcohol even as an outward application. Dr. Ridge recommends that when a patient is confined to bed the parts pressed on be well washed every day with strong salt and water or alum water, and carefully dried. _Glycerine of Tannin_ may then be applied. If any redness appears, especially if any dusky patch is formed, _collodion_ may be applied with a brush, and all pressure should be taken off the part by a circular air-pillow or by a cushion; or small bran or sand-bags may be made and carefully arranged. If the skin is broken, _zinc_ or _resin ointment_ may be applied. Some recommend finely powdered iodoform sprinkled over the surface of the sore. BOILS AND CARBUNCLE:--"In many cases these troubles result from an overloaded condition of the system, which is the result of taking too much food, or some error in diet. The boils are an effort of nature to be rid of offending matter. In some cases they are due to the use of impure water, or the presence of sewer gas in the house. In others, overwork, or other debilitating causes, may have produced the state of the digestive organs which usually causes the boils. Carbuncle is, essentially, an extensive boil. "Apply iodine early or a piece of belladonna plaster. The diet should be plain and unstimulating, condiments being avoided and plenty of fresh vegetables taken, if possible. Fresh-air, exercise and proper rest should be obtained, and late hours avoided. "Medical advice is requisite in carbuncle. The popular notion that port wine is absolutely necessary is both erroneous and mischievous."--RIDGE. CATARRH:--Among the causes are repeated colds; errors in diet, especially excess in the use of fats and sugar, and an inactive state of the liver. Cut off from your bill of fare all salted foods, avoid fats and condiments; drink freely of pure water; live in the open-air and sunshine as much as possible, taking much out-door exercise. Take a cold sponge or towel bath every morning, beginning at the face and finishing by plunging the feet into a foot-tub. Follow with vigorous rubbing with a crash or Turkish towel. Those subject to sore throat should hold the head over a basin of cold water and lave the neck with the water for about two minutes. The writer was formerly subject to frequent sore throats, but has had none for over two years, as she believes, because of the adoption of this measure, together with the towel bath every morning, summer and winter. Care should be taken to avoid exposure to draughts, or any other means which will produce liability to cold. Care in diet, good ventilation and the morning cold bath are essential if a radical cure is desired. Local measures, while giving relief, will not remove the predisposing causes. Dr. Kellogg recommends saline solutions in the form of the nasal douche, a teaspoonful of salt to a pint of soft water, adding twenty to thirty drops of carbolic acid, if there is offensive odor, as a relief measure. Sleeping in a poorly ventilated room is said to be one cause of catarrh. _Hay Fever_ is a form of catarrh. The vapor bath is recommended as very helpful in this trouble. _Nature Cure_ says that two vapor baths and a two or three days' fast will cure any case of hay fever. The use of pork and other clogging foods should be avoided by those afflicted with this trouble. The bowels should be kept in good condition. If constipated, the use of prunes, figs, grapes, apples and other such fruits will be very beneficial; walking, and massage of the bowels, being added if the fruits are not sufficient. No one able to walk should depend upon drugs to relieve a constipated condition. COLDS:--"If the bowels are constipated, the skin over-burdened and clogged with bilious matter, and the lungs weak, it is as easy to take cold as to roll off a log. If, on the contrary, the lungs are well developed, and the respiratory power large, providing abundant oxygen to keep bright the internal fires, the colon clean, the skin daily washed, and the system hardened by the cold bath, taking cold is next to impossible. "The first remedial agent for a cold should be a copious enema. Then open the pores of the skin by a hot bath; take a glass of hot lemonade and go to bed."--_The New Hygiene._ CHILLS:--For chill, take a hot foot and hand bath, with mustard in the water, 1/4 pound to a gallon; then go to bed in a well ventilated room. Drink freely of hot lemonade or hot water. Catarrh, colds and hay fever may all be effectually relieved by hot baths. Relief may be gained also from inhaling the vapor from pine needles or hemlock leaves. Put them in a bowl, pour boiling water over them, hold the face down over the bowl, the head being covered, and inhale the vapor well up into the nostrils and head. A few drops of hemlock oil in the hot water will do as well. COUGHS AND HOARSENESS:--Boil flaxseed in 1 pint water, strain, add two teaspoons honey, 1 ounce rock candy, and juice 3 lemons. Drink hot. Also; roast a lemon till hot, cut, and squeeze on 3 ounces powdered sugar. COLIC:--This may arise from cold, or from error in diet. If the latter it is desirable to induce vomiting. For the pain, apply hot flannels or fomentations; drink hot water. In severe cases, sprinkle a little turpentine on flannel, wrung from hot water, and apply to abdomen. Colic resulting from the accumulation of fecal matter should be treated with hot enemas until relieved. A hot hip-bath is sometimes necessary to relief. The colic of children and infants should never be treated with alcoholics. In infants it generally arises from excessive or improper feeding; care should be taken that the milk provided them is not sour. In severe cases the babe should be immersed in warm water, keeping the head above water, of course. This is also the best remedy in convulsions. The hot bath, with a copious enema of warm water, has saved the lives of many babes. For adults, hot water, with a pinch of red pepper added, will do all that brandy can do, and more. CHOLERA:--Brandy has been considered by many a really necessary medicine in cholera. The following is a discussion upon Alcohol in Cholera which was held at the annual meeting of the British Medical Temperance Association, in May, 1893, and is taken from the _Medical Pioneer_ of June, 1893:-- "Dr. Richardson opened a discussion on Cholera in relation to Alcohol. He said he would bring forward five points on the subject. 1. The negligence among the people at large produced by alcohol in the presence of a cholera epidemic. There was no doubt on the part of any who had seen an epidemic of cholera as to the mischief done by alcohol, apart from its action as a remedy. People rush to the public houses and take it to ward off the danger, or to relieve them when they begin to feel ill, and the result is very bad morally. He had seen this in different epidemics. Or people got in spirits to face the danger, and many became intoxicated and less able to resist. 2. Its misuse by those affected. It was often given to cheer them up and remove their fear and nervousness. In his opinion it invariably produced mischief. 3. He was unable to find any physiological reason for giving it. There was a constant drain of fluid, causing spasms and cramp, both of the muscles and blood-vessels, and difficult circulation through the lungs. Spasm may be relaxed by alcohol, but, on the other hand, alcohol is exceedingly greedy of water, and so increases the flux. But it also reduces animal temperature, which is a strong feature of cholera, so much so that he could almost diagnose cholera blindfold in the stage of collapse, by the icy coldness. 4. Its uselessness as a remedy during the acute stage. He had seen a great deal of cholera and never saw alcohol do any good whatever. There was a temporary glow which passed away in a few minutes, and then the evil it does in other ways was brought out. Water was far better, even if cold. The College of Physicians had given some instructions and ordered great care in the administration of alcohol; this was not far enough, but good as far as it went. The recoveries were best where the treatment was simplest, such as external warmth with plenty of diluents. He had given creasote largely. 5. Its injuriousness during the stage of reaction. The reactive fever following collapse caused a great number of deaths. In this stage alcohol was absolutely poisonous. He could recall many such cases in which he had given alcohol through ignorance, and always with disaster. "Brigade-Surgeon Pringle said that when he went out to India he thought alcohol was something to stand by, but he had soon found out his mistake; he had himself suffered from it. He could confirm what Dr. Richardson had said as to the demoralization produced by alcohol to which men resort to keep up their spirits, and men seized under these circumstances were in the greatest danger. Nature effects a cure in many cases without assistance, and often with wonderful rapidity. People apparently dead and about to be buried, he had known to get up and recover. When alcohol is given during collapse there is often no absorption until reaction occurs, and then the quantity accumulated speedily produces intoxication. It was the same with opium: he had found pills unchanged in the stomach for hours. He recommended hot drinks; he had tried every kind of medicine and had little faith in it. The nursing was very important, and it was important that the nurses should abstain. "Dr. Morton said it was easy to see that on physiological grounds alone, alcohol, with its strong affinity for water and its tendency to lower temperature, could not be a useful drug in the treatment of cholera collapse, and with its powers of paralyzing vascular inhibition and checking elimination of effete matter, could not be otherwise than harmful in the stage of reaction. As these conclusions were corroborated by practical experience he did not think members would hesitate to banish it from their equipment against cholera. "Dr. Ridge said it should be remembered that Doyen had made experiments on guinea-pigs and had found they were proof against cholera, unless they had previously had a dose of alcohol. This explained why drunkards and hard drinkers were so much more liable to have cholera, and have it badly as all observers declared to be the case. Another reason might be that small quantities of alcohol, such as would be found circulating in the blood, favored the growth and multiplication of bacteria, certainly those of decomposition, and probably those of cholera. Hence, other things being equal, the abstainer had a great advantage. "Dr. Norman Kerr said that he had observed both in America and Glasgow that not only notorious drunkards but free drinkers suffered; abstainers were less liable unless they took contaminated water, and the less liquid taken the less chance of taking cholera; beer-drinkers often took more than abstainers. The alcohol-drinker uses up more water from his blood and so has less to flush out the system. Alcohol, given to a patient, disguised his condition so that he might seem better though really worse. Hence it is better and safer not to give any. The doctors and nurses ought to be abstainers. A doctor after dinner was more likely to take a roseate view of a case, looking at it through an alcoholic pair of spectacles. Alcohol was not really a stimulant, but a depressant, and this is a very depressing disease; it was important to have our vital resisting power as vigorous as possible. Hot water both relaxes and stimulates, and the whole cry of the sufferer is for water. Many persons who died in cholera did not die of the disease, but of the drugs such as alcohol and opium. Acid drinks should be given, as the bacilli could not live in acid mixtures. Cholera might come, but he believed we were better prepared to meet it and to treat it. "Surgeon-General Francis sent a communication which was read by the Honorable Secretary. He said: 'Having had many opportunities of treating cholera in various parts of India and amongst all classes, I have no hesitation in affirming that alcohol in any shape is one of the very worst remedies. Life is, so to speak, paralyzed, and we give a remedy which, apparently stimulating, is in reality, a paralyzer and therefore mischievous; the death-rate might be considerably reduced provided alcohol were rigidly excluded.'" Dr. Norman Kerr in a valuable paper upon Cholera says:-- "The first thing is to get rid of the poison. How? By assisting it out; but alcohol keeps it in by blocking the doors, just as the doors were blocked in the terrible calamity at Sunderland not long ago. The alcohol makes the heart and circulation labor more. Alcohol not only retains the cholera poison, but retards the action of the heart. Brandy and opium used to be employed, but the records show that if the object had been to make cholera as fatal as possible, that object was achieved by the indiscriminate administration of brandy and opium. Better leave the victim alone, and his chances of recovery will be greater than if he have a thousand doctors, and as many nurses, administering to him brandy and opium. Alcohol is especially dangerous in the third stage, that of reactive fever, because it adds to the fever. Then, alcohol is not only unsafe in the three stages of genuine cholera, but especially unsafe in the premonitory diarrhoea stage, which gives nearly every one warning before they are attacked by genuine cholera. Brandy is taken simply because it puts away the pain. If there are only the pain and slight diarrhoea, speaking medically, it is all right, but if there is anything behind the pain, it is all wrong. After the alcohol, the mischief is going on, only the patient does not know it, and valuable time is lost. All the alcohol does is to deaden sensation. * * * * * Here I can thoroughly recommend ice and iced water. I have always treated cholera patients with these. Let them drink iced water to their hearts' content; they can never drink too much; and this opinion is fortified by that of Professor Maclean, of Netley. There is no need of a substitute for brandy in cholera, because in ordinary circumstances in that disease the action of a stimulant is bad. Flushing of the blood is required, and water will do it. Milk will not do it, because it is too thick--nothing but pure, cold water, all the better if iced." In 1893 Dr. Ernest Hart, editor of the _British Medical Journal_, read an able paper upon Cholera before the American Medical Association. His argument was that the introduction of such a substance as alcohol, itself being a product of germ action, into a system already suffering from the toxic influence of a ptomaine, could not be otherwise than pernicious. CHOLERA MORBUS:--Dr. Kellogg says: "The stomach should be washed by means of the stomach-tube when possible. A large hot enema should be given after each evacuation of the bowels. The addition of tannin, one drachm to a quart of water, is serviceable. When the vomited matter no longer shows signs of food, efforts should be made to stop the vomiting. Give the patient bits of ice the size of a bean to swallow every few minutes. At the same time apply hot fomentations over the stomach and bowels. If the patient suffer much from cramp, put him into a warm bath. The first food taken should be farinaceous. Oatmeal gruel, well boiled and strained, is useful." CHOLERA INFANTUM:--"Iced water may be given in very small quantities every few minutes. Give the stomach entire rest for at least twenty-four hours. There will be no suffering for want of food as long as the stomach is in such a condition. Withhold milk until nature has had time to rid the alimentary canal of the poison-producing germs. White of egg dissolved in water is an excellent preparation in these cases. Egg enemata may also be advantageously used. "Warm baths, the hot blanket pack when the surface is cold, and the hot enema are all useful. Keep the child wrapped warmly. "Great care should be taken in returning to the milk diet. The milk should be thoroughly sterilized by boiling for half an hour, and should be mixed with some barley water so as to avoid the formation of large curds in the stomach. Cream, diluted with water, may be used instead of milk." CONSUMPTION. Dr. Koch, the celebrated German microscopist, pronounces consumption contagious, because during its progress a very minute bacterium is developed which may be transmitted from one person to another. It is said that a person with healthy lungs might daily breathe millions of tubercle bacilli without any danger, and that the best preventive of this disease is to live much in the open air, or if this is impossible to spend ten or fifteen minutes a day in deep breathing exercises in the open air. "Fresh-air and disease-germs are antagonistic." Alcohol, chiefly in the form of whisky, was for many years considered of great value in the treatment of consumption of the lungs. Indeed, it was looked upon not only as a curative, but also as a prophylactic, or preventive, of great service to those predisposed to this disease by reason of narrow chest and weak lungs. Sir Benjamin Ward Richardson was the first medical scientist who showed plainly that alcohol, instead of being a preventive of consumption, is really the sole cause of one type of this disease, the type now classed under the head of "alcoholic phthisis." For this kind of phthisis there is no hope of cure. French physicians some years ago came to the conclusion that alcohol was a prolific cause of tuberculosis and that the administration of alcoholic liquors in tubercular troubles was a great error, and in the International Anti-Tuberculosis Congress held in Paris in 1905, about 2000 medical scientists being present, they presented the following resolution, which was adopted: "In view of the close connection between alcoholism and tuberculosis, this Congress strongly emphasizes the importance of combining the fight against tuberculosis with the struggle against alcoholism." Since that time a great crusade against tuberculosis has been carried on by means of exhibits and lectures, and in connection with these, almost invariably the people are warned against intemperance. For example, a pamphlet sent out by the Boston Association for the Relief and Control of Tuberculosis says: "Do not spend money for beer or other liquors, or for quack medicines or 'cures.' Self-indulgence and intemperance are very bad. Vice which weakens the strong kills the weak." The New York State Charities Aid Association, working with the State Board of Health, says in a pamphlet: "Patent medicines do not cure consumption. They are usually alcoholic drinks in disguise, and the use of alcoholic drinks is dangerous to the consumptive." At the great exhibit in Washington in September, 1908, in connection with the International Anti-Tuberculosis Congress different warnings against alcohol were upon the walls. Among these was a large poster of white cloth on which was printed the opinions on alcohol, in brief, of some of the best-known authorities on consumption. The opinions as given on that poster are given here, with others, in order to show the great change of sentiment regarding alcohol and consumption which has come about within a few years:-- "Alcohol has never cured and never will cure tuberculosis. It will either prevent or retard recovery. It is like a two-edged weapon; on one side it poisons the system, and on the other it ruins the stomach and thus prevents this organ from properly digesting the necessary food."--S. A. KNOPF, M. D., New York, Honorary Vice-President of the British Congress on Tuberculosis. Dr. Knopf in his prize essay on "Tuberculosis and How to Combat It," says in several places: "Avoid all alcoholic beverages." He says also, "Alcohol should never be given to children even in the smallest quantities." "It is a recognized fact in the medical profession that the habitual use of alcoholic drinks predisposes to tubercular infection. It is also recognized, I think, by most physicians that alcohol as a medicine is harmful to the tubercular invalid."--FRANK BILLINGS, M. D., Chicago, Ill., Former President American Medical Association. "Alcoholic liquors are of damage to consumptives because they tend to impair nutrition, disturb the action of the stomach, and give a false strength to the invalid on which he is sure to presume. Besides, we know that in countries where drinking prevails most, the ravages of tuberculosis are most marked."--EDWARD L. TRUDEAU, M. D., Adirondacks Sanitarium for Consumptives, Saranac Lake, N. Y. "In my judgment whisky should not be used by people who have consumption, and in my practice I prohibit its use absolutely. At the White Haven Sanitarium and Henry Phipps Institute we do not use alcohol in any form in the treatment of our patients."--LAWRENCE F. FLICK, M. D., Vice-President of the National Association for the Study and Prevention of Tuberculosis, Philadelphia, Pa. "I do not feel that I can emphasize strongly enough the harm that can be done by the use of alcohol in tuberculosis, and the indiscriminate use of it certainly borders on the criminal. I do not believe that any legitimate reason can be given for the routine employment of alcohol in the treatment of tuberculosis. I furthermore know of no emergency in which it is indispensable. My experience with patients who have been accustomed to the use of alcohol, especially moderately, is very unsatisfactory. They seem to show an abnormally low resisting power to the tubercle bacillus. The fact has been established that alcoholism is a very potent factor in the causation of tuberculosis. I find it not only unnecessary in treatment but believe it to be contraindicated."--F. M. POTTENGER, M. D., Superintendent the Pottenger Sanitarium for Diseases of the Lungs and Throat, Monrovia, California. "I have met with a small class of consumptive patients who could take alcoholic liquors freely for a length of time, without deranging either the stomach or the brain, and with a decided amelioration of the pulmonary symptoms, and an arrest of the emaciation. Some of these have actually increased in _embonpoint_, and for three to six months were highly elated with the hope that they were recovering. But truth compels me to say that I have never seen a case in which this apparent improvement under the influence of alcoholic drink was permanent. On the contrary, even in those cases in which the emaciation seems at first arrested, and the general symptoms ameliorated, the physical signs do not undergo a corresponding improvement; and after a few months the digestive function becomes impaired; the emaciation begins to increase rapidly; and in a short time the patient is fatally prostrated."--DR. NATHAN S. DAVIS, SR., of Chicago. "The use of whisky in this disease positively interferes with digestion which must under all circumstances be kept as perfect as possible in order that the patient may assimilate the food which is so necessary to the upbuilding of the system and to gain strength to fight the onslaught of the disease. "Its constant use would not only interfere with digestion but would have a tendency to create disease in other organs of the body so that we therefore consider the use of whisky in tuberculosis positively contraindicated. "Wishing you success in your laudable campaign."--DR. M. COLLINS, Superintendent National Jewish Hospital for Consumptives, Denver, Colorado. "It is difficult for many people to adapt themselves to a methodical plan of life long enough to establish a permanent cure in consumption. I have known many a young fellow with only a slight trouble in his lungs to die in the Adirondacks more from the effects of whisky than from the disease itself."--DR. HENRY P. LOOMIS, of New York City, in a Lecture on Consumption. (See page 232, of Handbook, on the Prevention of Tuberculosis.) "The majority of our patients receive no medication whatsoever. The stomach is rarely in condition to bear excessive medication, and the promiscuous use of creosote and similar preparations is to be condemned. Milk and raw eggs are the best articles of diet in addition to a regular diet of simple food."--JAMES ALEXANDER MILLER, M. D., of the Vanderbilt Clinic, New York. (From Medical Record.) "In my specialty, the treatment of pulmonary diseases, I rarely prescribe alcohol in any form, and in the sanitaria with which I have been connected it is the exception where alcohol in any form is prescribed. I have advised against its use where such has been the custom, believing that as a rule alcoholic liquors do more harm than good in the treatment of this disease."--PROF. VINCENT Y. BOWDITCH, M. D., Harvard Medical School, Boston. "From personal experience in handling pulmonary tuberculosis, not only at the Nordrach Ranch Sanitorium, for the past five years, but in an active practice of thirteen years, I am more than convinced that whisky and liquor, in any form, are absolutely poisonous to the consumptive. "Whenever we admit a patient to the Nordrach Ranch Sanitorium, we ascertain whether the individual is an alcoholic or not; and we invariably find that such an individual is lacking in vitality enough to combat the disease. They may look fat and strong, pulmonary tuberculosis usually makes quick work of them. "It is also a noticeable fact, proven by various statistics, that a very large percentage of alcoholics become tubercular; and if we ever stamp out tuberculosis, we will also have to stamp out intemperance. "Trying to cure consumption with whisky is like trying to put out a fire with kerosene. This is very easy to understand when we stop to consider the nature of this disease. In the first place, we have a very rapid heart's action, dating from the very earliest manifestations of the disease. The pulse is often in excess of 100, even in incipient cases, and if the stimulation of alcohol is added, we have what might be called a 'runaway heart'; and if there is one thing needed in the long combat against tuberculosis, it is a good heart."--JOHN E. WHITE, M. D., Medical Director Nordrach Ranch Sanitorium, Colorado Springs, Colorado. "You ask me my opinion as to the use of whisky in the treatment of consumption. In reply permit me to say that I regard its use in this disease as most universally pernicious."--PROF. CHARLES G. STOCKTON, M. D., Buffalo Medical College, Buffalo, N. Y. "It was formerly thought that alcohol was in some way antagonistic to tuberculous disease, but the observations of late years indicate clearly that the reverse is the case, and that chronic drinkers are more liable to both acute and pulmonary tuberculosis. It is probably altogether a question of altered tissue soil, the alcohol lowering the vitality and enabling the bacilli more readily to develop and grow."--DR. OSLER, formerly Professor of Medicine in Johns Hopkins University, Baltimore, Md., now of Oxford University, England. "Upon investigation I found 38 per cent. of our male tubercular patients were excessive users of alcohol, 56 per cent. moderate users. From my study of the cases I am led to believe that in a vast majority of these cases drink has been a large factor in producing the disease, by exposure, lowering of vitality, etc. I believe that alcohol has no place in the treatment of tuberculosis. Many patients are deceived by the false strength it gives them."--O. C. WILLHITE, M. D., Superintendent of Cook County Hospital for Consumptives, Dunning, Ill. "In tuberculosis there is a state of over-stimulation of the circulatory system due to the toxins. The use of alcoholics simply makes the condition worse. It reduces resistance and makes the person more susceptible to the disease."--H. J. BLANKMEYER, M. D., Sanatorium Gabriels, in the Adirondacks, N. Y. "The practice of taking alcoholics of any sort, and in any quantity, over a considerable length of time, is certain to produce more or less injury to a tubercular patient, and their use by tubercular people cannot be too strongly condemned."--H. S. GOODALL, M. D., Lake Kushaqua, N. Y. Most of these opinions were written for the author of this book in response to letters of inquiry. Are they not indicative of a day when the medical profession will lay aside alcoholic liquors in the treatment of all diseases? It is acknowledged that the past usage of giving whisky and cod-liver oil to consumptives was an error; some day, it may be not far distant, a larger acknowledgment may be made, and the medical use of alcoholic liquors will be entirely a thing of the past. Rev. J. M. Buckley, D.D., editor of _The Christian Advocate_, was in early manhood considered an incurable consumptive. Being a man of great will power and indomitable perseverance, he resolved to try the open-air cure, together with the use of an inspirator. The result was perfect restoration to health, so that, as is well known, he can be easily heard by audiences of thousands at Chautauqua and other places where he is greatly in request for lectures. He has written a pamphlet giving a full history of his case. It can be obtained from Eaton & Mains, 150 Fifth Avenue, New York, for fifty cents, and should be read by all consumptives who have any "grit" in their composition. Dr. Forrest, a hygienic physician, says:-- "What is to be done if the germs have already obtained lodgement in the lungs? Increase the general nutrition of the body in every way, and then the lungs can resist the inroads of the disease. The first thing necessary to improve the nutrition of the body is to stimulate the digestive and absorbent functions of the stomach and intestines. Naturally then, you must throw the so-called cough medicines out of the window. The drugs used to stop a cough are sedatives. Now, no sedative or nauseant is known that does not lock up the natural secretions and thus lessen the digestive powers. The cough is nature's method of expelling offending matter from the lungs and bronchial tubes. It is infinitely better to have this stuff thrown out of the lungs than retained there." Keep the bowels clean is this physician's next recommendation. Sweet cream is preferable to cod-liver oil as it is not so likely to derange the stomach. Easily digested food is necessary, as the organs of digestion are in weakened condition. Again Dr. Forrest says:-- "The consumptive should live as much as possible in the open air. "Dr. Trudeau inoculated twelve rabbits with tubercle or consumptive germs. Six of these he turned loose on an island where they ran wild. The other six were kept confined in hutches such as rabbits are usually kept in. Results--All the six rabbits in the open air recovered from the inoculation and remained well. Five of the confined rabbits died of tubercles in the lungs and different parts of the body. The sixth was still lingering, badly diseased, when the experiment was brought to a close. Fresh air and exercise enabled the first six to overcome the disease germs. Confinement gave full play to the disease in the others. "Now, you house lovers, sleepers in close bedrooms, people afraid of cold air, you are the rabbits in the hutches. Beware, lest the verdict be in your case, 'Died of tubercles in the lungs.' If you are not able to leave your home, live with open windows, day and night, summer and winter. "Exercise systematically, especially those exercises, accompanied by deep breathing, that open and strengthen the lungs--exercises without fatigue. "If you are hoping that some wonderful, mysterious drug has been or will be discovered, a drug that will cure consumption without your help, you are hoping against hope. Improved nutrition is your salvation, and that must come through exercise, diet and fresh air." Dr. J. H. Kellogg, in his _Home Hand-Book of Hygiene and Medicine_, recommends a salt sponge bath upon retiring, to arrest night sweats, or sponging with hot water. He adds:-- "It is important that patients should know that the sweats are greatly aggravated by opium in any form, and hence are increased by cough mixtures of any sort which contain this drug. Very simple remedies are often effective to relieve the most distressing cough, such as gargling of water in the throat, holding bits of ice in the mouth, taking occasional sips of strong lemonade, and similar remedies. As a general rule, patients run down and the disease progresses much more rapidly, after beginning the use of opium in any form. Sometimes it is best that the cough should be encouraged instead of being repressed. When the patient expectorates very freely, the cough is a necessary means of relieving the chest of matters which would seriously interfere with the functions of the lungs if retained, by filling up the bronchial tubes and air-cells. The kind of cough needing relief is an irritable, ineffective cough, unaccompanied by any considerable degree of expectoration. Loaf sugar, honey or a mixture of honey and lemon juice, and other simple, familiar remedies are often effective in relieving such a cough. * * * * * "It is perhaps needless to add that the numerous quack remedies for consumption advertised in the newspapers are wholly without merit. There is no known drug which will cure this disease, or in any certain degree influence its progress. Numerous remedies have been recommended as curative, but not one has thus far stood the test of experience." DISPLACEMENTS OF THE UTERUS:--These conditions are not among those for which alcoholic liquors are likely to be advised by a physician, but women frequently resort to Lydia Pinkham's Compound and other alcoholic preparations in the vain hope of finding the relief so positively promised in the nostrum advertisements. Women are sometimes seriously injured by using the nostrums specially advised for uterine weaknesses, for this reason: a drug which may be of service in an anæmic condition of the womb may do much damage in an inflamed or engorged condition, yet the nostrum vendors advise their preparations for all alike, without a word of warning as to possible dangers. Ordinary displacements may be recovered from by cleanliness of the parts and by exercises which strengthen the muscles in the pelvic region. The writer has known a considerable number of women who have been restored to health by exercises after months, in some cases, and several years in others, of weakness and misery. One of these women was a close relative of a celebrated specialist in women's diseases. He said he could not do any more for her, and gave permission for her to try the exercises, which were given her by a well-equipped teacher of physical training. There are three kinds of displacements: anteversion, retroversion, and prolapsus. The causes of these troubles are various; lack of proper care in child-bearing, miscarriages, heavy lifting, a hard fall, jumping out of a carriage, straining, too violent exercise in gymnasium work, and tight-lacing, also gradual weakening of the ligaments which sustain the uterus in position. An abdominal supporter should be worn constantly during the day for a year or so, then left off gradually an hour or two at a time. It should be worn during the second year whenever any extra work is to be done. There is a supporter sold by the Battle Creek Sanitarium which is highly recommended, but any physician can get one for a patient. Perfect cleanliness is necessary. For this purpose a hot vaginal douche should be taken two or three times a day. This douche should be made astringent by adding to a pint of water a quarter ounce of alum or tannin. The hot astringent injections tone up the lower supports of the uterus, and cleanse the passage. The patient should remain in a recumbent position for some hours after the douche if possible. Considerable rest hastens a cure. Take the rest in the fresh air when weather permits. Persistent use of sitz baths will be found helpful. For prolapsus the simplest form of internal supporter is a small roll of cotton. After the organ is carefully put into position this supporter should be pressed up against the mouth of the womb, the patient meanwhile lying upon her back. The ball of absorbent cotton should be large enough to be retained in position, and should be saturated with a weak solution of glycerine and alum or glycerine and tannin before being applied. A piece of white cord should be tied firmly around the centre of this tampon by which it may be removed. Remove before taking the douche. Persons who feel unable to purchase an elastic or other abdominal supporter can make a substitute (not so good, but of considerable service) from unbleached muslin made in the shape of the letter T, and having the cloth double. It should go up to the waist and be made to fit over the hips, then should be fastened firmly in front with safety-pins, and the cross-piece be drawn up from the back and fastened securely in front. The daily exercises are the most important part of the treatment. They must be begun gradually, and taken at greater length as strength is gained. Those for prolapsus will be given first:-- The patient should lie upon a rug, or on a firm long sofa or couch. The feet should be drawn up as close to the body as possible. Now lift the lower part of the body so that the hips and lower portion of the trunk will have no support but what comes from the feet and shoulders. Hold this position for a minute or two (longer when able without much fatigue). After a few minutes' rest repeat. This exercise may be continued from twenty to thirty minutes, according to patient's strength. The elevation of the hips in this exercise aids in the restoration of the organ to its natural position. This exercise should be continued daily, the number of times being increased as strength increases. A second exercise which is very helpful in prolapsus is to support the body on the toes and elbows with the face downward, and the hips raised as high as possible. Another exercise may be taken with an assistant; the patient should lie face downward, supporting the body by the chest, and keeping the limbs rigid while the assistant lifts the feet as high as possible without hurting. These movements strengthen the abdominal muscles and draw fresh blood to the weakened parts, and cause quickened circulation in addition to restoring the displaced organ to natural position. They should be taken at night just before retiring after a hot douche. The bowels should be kept open by the free use of fruit. The patient should sleep with the hips elevated as much as can be endured without real discomfort and sit with the feet on a stool. When strength sufficient is acquired the exercises for anteversion will be found useful, and any other exercises which strengthen the abdominal muscles, such as bending backward and forward, and sideways. Kneading and percussing the abdomen by an osteopath or masseur strengthens, and also relieves constipation. Rest during the day should be taken with the feet higher than the head. Prolapsus due to laceration in child-birth may require a surgical operation. In case of antiflexions the first exercise given for prolapsus should be taken daily. (The advice for the prolapsus treatment and the exercises are taken from the writings of Dr. J. H. Kellogg, superintendent of the Battle Creek Sanitarium.). ANTEVERSION:--Persons suffering from anteversion or retroversion should sleep without pillows under the head, and lie flat upon the back; they should sit with the feet as high as convenient and avoid high seats which hinder the feet from touching the floor. They should discard corsets and tight stocking supporters which push or hold down the organs which need to be replaced. Stocking supporters should be fastened over the hips and comfort waists can be bought in place of corsets. It is well to have an attendant to prepare weak patients for first exercises in all uterine troubles by the use of towels wrung from hot water applied to the back and abdomen for a few minutes to relax the muscles, or a hot water bottle, or hot salt bag may be used. Then, with the patient lying with head low, the attendant should give the abdomen and small of the back a thorough rubbing or kneading for ten minutes or less according to strength of patient. Olive oil can be used on the hand in the rubbing. FIRST EXERCISE FOR ANTEVERSION:--Lie on bed or rug; fold arms on chest; hold trunk of body still; stretch legs, and hold the position about half a minute, then relax at the knee and ankle. Then point the toes down and stretch upper leg muscles; relax; then stretch under leg muscles by stretching heel out. The patient will feel the exercise as far as the shoulders, and should be careful not to lift the body from the floor at first. When patient can hold stretching exercise for a minute then lift first the right, then the left leg, and take same exercise until the person can give a quick little kick for, say, twelve times, as the leg is straightened. SECOND EXERCISE:--Lying on the back, stretch to full length; move the left leg out at the side, then up and back to position, forming a semi-circle, keeping muscles tense throughout. Then move right leg out at the side--left--stretch toes long--relax--stretch heel--, lift a little higher and bring back to place in a circle and rest. Same with left leg and then both together. Few people can do this easily at first, the weight of the legs is too much for the weak muscles at the back; but some one can hold the foot at first. When the patient can do this easily without bringing on any pain or ache, she may sit in a low chair and take arm lifting exercises. Raise both arms out at the sides, then slowly raise them up close to the head and consciously lift all the organs of the body up, relax, and lower arms down front and repeat slowly, six or ten times at first, until for five minutes the patient can do this sitting. Then take it standing for ten minutes or more. Stand with feet wide apart. Dr. Anderson says, "A woman who will do this twenty times each day can never have anteversion, if she dresses properly, for it lifts the organs in place each time." It lifts the chest and abdomen up, and brings a feeling of exhilaration if done in the open air. After the patient has taken exercises for five or six weeks she may lie flat on the back, fold arms and raise body up to sitting position without unfolding arms. Then turn on right side and do the same, then on left side and do the same. This is fine for back and abdomen muscles. Anteversion needs the Rest Cure, and resting with the body in a position in which nature can right things is an important thing to remember. Rest always after exercise, either with a pillow under the knees or with the legs hanging over a low foot-board, or lying on a couch with the feet higher than the head. Exercise will relax the muscles and call for blood which will revitalize and stimulate the weakened conditions. A woman with this trouble should be careful about bending quickly over, or climbing stairs, until she gains strength. RETROVERSION:--Place the patient with face downward on bed or mat and with a small pillow under the lower part of the abdomen. Relax the muscles by applying a hot towel, hot salt bag or hot water-bottle just below the small of the back, and lower part of the abdomen for ten or fifteen minutes. (Hot salt bags are most effective and are easy to handle.) Then rub the back briskly with a circular movement; if tender in front, do not rub the abdomen. The circulation will gradually carry away any inflammation as soon as the muscles reach a normal condition, though kneading of back and abdomen, using sweet oil on the hand, is helpful if the patient can bear it. The patient must remember that these conditions have been months in coming and only painstaking work and time can restore the weakened organs. The manner of dress is very important; loose, comfortable clothing must be worn. Sleep with the face down as much as possible; nature will correct itself, if allowed, many times. FIRST EXERCISE:--Fold arms under forehead and draw right knee up close to body and hold two minutes (unless painful) and slowly straighten, and stretch very slowly. Do the same with the left leg until the patient can repeat the exercise twelve times with each leg and hold five minutes instead of two, with the knee close to the body. It will probably take two weeks to gain strength for this. After that time raise the body up on hands, and move legs just as a baby does when creeping, except that the patient only follows the movement and does not move along. SECOND EXERCISE:--Patient take sitting position on floor and clasp hands under knees, and bring knees up, so that chin and knees meet and hold. Then straighten legs, slide hands toward the heels as far as hands can reach, (stretch hands toward heels); make a continuous movement of this. THIRD EXERCISE:--Sit on floor. Place the hands on floor at sides, legs straight out in front, lift the body from the floor with the arms, up and down. This is a fine exercise for raising up the misplaced organs. FOURTH EXERCISE:--Place the patient flat on back and push the body up to sitting position with hands quite far back and palms down, recline again, up and down until arms and back are very tired. Then sit up, legs straight in front, raise the body from the floor, (an inch) and move backward, resting weight on hands, then move over on knees as at first exercise and creep, then sit up and move backward again. These will take a month to perfect. Begin by exercising five minutes and gradually work up to half an hour, rest between, always. The patient must have the right mental attitude, must think that she is trying to replace the uterus by lifting it to its natural position. The exercises must not be lazily done. Sitting in a tub of hot water is most helpful where there is much tenderness, or inflammation. Witch-hazel in hot water douches or a weak solution of hot salt water is a wonderful tonic in some cases. EXERCISE FOR REPLACING UTERUS TO BE TAKEN JUST BEFORE RETIRING:--Kneel on the bed; bend forward until the chest is touching the bed and the hips are elevated as high as possible. The inlet of the vagina should then be opened so as to admit air. As soon as the air enters the womb falls into position. Lie down at once and give nature a chance to regain strength while you sleep. The tampon soaked in glycerine and alum, and the douches of hot water, in which a little alum is dissolved, are both of great service in controlling the flooding which so frequently accompanies change of life and miscarriages. (Exercises for anteversion and retroversion supplied by a successful teacher of such work.) The writer of this book asked a well-known medical writer why physicians do not advise exercises for the cure of displacements instead of operations. He said it is because women are not willing to do anything to help themselves. They expect the physician to cure them, and the only way a physician can "cure" is to operate. Sensible women, however, will be glad to practice helpful exercises. DEBILITY:--"The debility of convalescence requires fresh air, easily digested food, the avoidance of over-exertion, with a gradually increasing amount of exercise. Such debility is only aggravated by alcohol, though it may for a time be partially masked thereby. Milk, eggs, fresh fruit and farinaceous articles are the best foods. General debility without obvious cause, may be treated by cold or tepid bathing. Salt added to the bath is helpful. Change of air is a good tonic. Port wine and other alcoholics while giving a false sensation of increased vigor, really _reduce the tone of the pulse_, and therefore tend to enfeeble the system. Alcohol is a relaxant, _not a tonic_." DEPRESSION OF SPIRITS:--"Learn the Delsarte exercise for the 'blues,' and practice them daily. Hot air baths. Avoid rich food. Take out-door exercise." DIARRHOEA:--"This is a symptom of the presence of an irritant of which the stomach is trying to be rid. Do not arrest it prematurely, but assist it. If it persists, arrowroot, or corn starch, or flour, mixed with cold water to the consistency of cream may be taken, a tablespoonful at a time. 2. Bread charcoal with cold milk. 3. A tablespoonful of cinnamon water with a teaspoonful of lime water, mixed, every one, two or three hours. Smaller dose for a child. Diet should be confined to toast, milk toast, milk, cold or boiled. Tea, broth, meat, etc., are sure to renew the trouble. Diarrhoea in infants is generally due to errors in feeding, either over-feeding or the use of improper kinds of food. Boiled milk thickened with flour is a simple remedy in light cases. Alcoholics are utterly unnecessary in diarrhoea, and to order them for young children is quite wrong. A full enema of water, as hot as can be borne, will remove offending substances from the bowels. "Beware of diarrhoea medicines containing opium in any form. They are unnecessary and dangerous, particularly for young children." DYSENTERY:--"At the beginning of the disease the stomach should be relieved by the use of a large warm-water emetic. The quantity of food should be restricted to the smallest amount compatible with comfort. Ripe fruits, especially grapes, and most stewed fruits, may be used in abundance to keep the bowels regular. Salads, spices and other condiments, fats and fried foods should be strictly avoided, together with tea, coffee, alcoholics and all other narcotics. "The diet should consist chiefly of simple soups, well boiled oatmeal gruel, egg beaten with water or milk, and similar foods. In many cases regulation of the diet is sufficient. Either the hot or the cold enema may be employed. "The use of opium, which is exceedingly common in this disease, is not advisable, as it produces a feverish condition of the system, decidedly prejudicial to recovery. Herroner, an eminent German physician, very strongly discourages the use of opium in this disease."--DR. J. H. KELLOGG. DYSPEPSIA:--"It is commonly supposed that a little good whisky or brandy aids digestion, while on the contrary it has been proved conclusively by observing the processes of digestion upon persons who have fistula of the stomach, or by evacuating the contents of the stomach by means of a stomach-pump about an hour after taking a meal--in one instance after taking an ounce of alcohol, and in another where no alcohol was taken--that alcohol coagulates the albuminoids, throws down the pepsin, decreases the acidity (the combined chlorin and free hydrochloric acid), and increases the fixed chlorids. Any one can make the observation upon himself, that a meal taken without alcohol is more quickly followed by hunger than one with it. "Blumenau says: 'On the whole, alcohol manifests a decidedly unfavorable influence on the course of normal digestion even when ingested in relatively small quantities, and impairs the normal digestive functions.' "Dr. Chittenden, professor of physiologic chemistry in Yale College, as a result of some investigations made by himself and Dr. Mendel, states in the _American Journal of Medical Sciences_, that he finds that as small a quantity as three per cent. of sherry, porter, or beer lessens the activity of the digestive powers."--_Bulletin of A. M. T. A._ "It should be observed that doses of alcohol which have no appreciable effect in delaying digestion, are so small as to be practically useless for any beneficial action."--_Medical Pioneer._ One doctor writes:-- "What makes dyspepsia so hard to cure? This very alcohol taking. The best cure is to refuse all alcoholic drinks, at meals and all other times, and drink nothing but water." The causes of dyspepsia are various; errors of diet being the most common. Others are mental worry, care and anxiety, and the use of drugs. An eminent writer upon this disease says: "My main object in the treatment is to prevent the sufferers from resorting to drugs, which in such cases, not only produce their own morbid conditions, but also confirm those already existing. "The extensive and often habitual use of alkalies for acidity, of purgatives for constipation, nervines and opiates for sleeplessness, and after-dinner pills to goad into action the lagging stomach, has been a potent factor in the production of a large class of most inveterate dyspepsias." Underdone bread, cake, and pie, are unfit for any stomach, yet are seen upon many tables. "Breakfast foods," cooked for ten or twenty minutes, are also dyspepsia producers. All breads, cakes, pies and cereals, require thorough cooking to fit them for digestion. Most cereals are better for supper than for breakfast, as they should be cooked in a double boiler for several hours. A young man, troubled with dyspepsia, learned to his amazement that the oatmeal, which he supposed was his best food, had much to do with the giddiness which often overcame him. He was advised to use dry foods, such as toast, zwieback and shredded wheat. This diet, together with the abandonment of nostrums, led to a cure. Zwieback is bread sliced, and dried in a moderate oven until light brown. Whole wheat bread is best. It is very delicious and is quite easily digested. In the case of the young man, it is probable that the difficulty with the oatmeal was the lack of sufficient cooking. Oatmeal made into gruel, well cooked, and diluted with a large quantity of scalded milk is easy of digestion. Eating between meals, and excess in eating, lead to stomach derangement. "The best remedy for acidity of the stomach is hot-water drinking. Two or three glasses should be taken as hot as can be sipped, one hour before each meal, and half an hour before going to bed. The effect of the hot water is to wash out the stomach, and so remove any fermenting remains of the previous meal. Heartburn may be treated the same as acidity." Persons troubled with slow digestion are better to eat only two meals a day. The writer has personal knowledge of a goodly number of women who have been benefited wonderfully by adopting the two meal a day plan. Some persons, much troubled with dyspepsia, have adopted the plan of prolonged fasting advocated by Dr. Dewey, and testify to a cure by this method. While heroic, it is certainly more rational than drug treatment. For acute dyspepsia a fast is requisite. All that alcoholics can do for dyspepsia is to allay the uneasy sensations for a time, while adding to the trouble. It has been abundantly proved that alcohol must pass from the stomach before digestion can begin. Dr. Ridge says:-- "Many cases which seem to be relieved by the use of beer are really benefited by the hop, or other bitter, which the ale or beer contains. _Hop tea_ is a useful stomachic, and a quarter of a pint, or half that quantity, may be taken cold. It is made in the same way as tea, using a handful of hops to a pint of boiling water. Make fresh every day." Dr. Kellogg says:-- "In cases of chronic dyspepsia the use of alcohol seems to be particularly deleterious, although not infrequently prescribed, if not in the form of alcohol or ordinary alcoholic liquors, in the form of some so-called 'bitters,' 'elixir' or 'cordial.' Nothing could be further removed from the truth than the popular notion that alcohol, at least in the form of certain wines, is helpful to digestion. Roberts showed, years ago, that alcohol even in small doses, diminishes the activity of the stomach in the digestion of proteids. Gluzinski showed, ten years ago, that alcohol causes an arrest in the secretion of pepsin, and also of its action upon food. Wolff showed that the habitual use of alcohol produces disorder of the stomach to such a degree as to render it incapable of responding to the normal excitation of the food. Hugounencq found that all wines, without exception, prevent the action of pepsin upon proteids. The most harmful are those which contain large quantities of alcohol, cream of tartar or coloring matter. Wines often contain coloring matters which at once completely arrest digestion, such as methylin blue and fuchsin. "A few years ago I made a series of experiments in which I administered alcohol in various forms with a test meal, noting the effect upon the stomach fluid as determined by the accurate chemic examination of the method of Hayem and Winter. The result of these experiments I reported at the 1893 meeting of the American Medical Temperance Association. The subject of experiment was a healthy young man whose stomach was doing a slight excess of work, the amount of combined chlorin being nearly fifty per cent. above normal, although the amount of free hydrochloric acid was normal in quantity. Four ounces of claret with the ordinary test meal reduced the free hydrochloric acid from 28 milligrams per 100 c. c. of stomach fluid to zero, and the combined chlorin from .270 to .125. In the same case the administration of two ounces of brandy with the ordinary test meal reduced the combined chlorin to .035, scarcely more than one eighth of the original amount, the free hydrochloric acid remaining at zero. Thus it appears that four ounces of claret produced marked hypopepsia in a case of moderate hyperpepsia, whereas two ounces of brandy produced practically apepsia." FAINTING OR SYNCOPE:--The following letter from the late Sir B. W. Richardson was addressed to a lady who had sought the great physician's advice on the subject:-- "25 Manchester Square, W., July 18, 1896. "DEAR MADAM: There is no substance which acts as a substitute for alcohol, nor is anything like it wanted. The human body is a water engine, as I have often described it, and alcohol plays no part in its natural motion. The idea that when it begins to fail, a stimulant has to be called for, springs merely from habit, and if, whenever any of the symptoms of fainting you speak of occur, the person merely lies down on the side or back and drinks a glass of hot water, or hot milk and water, all that can be done is done. In the London Temperance Hospital I have been treating the sick for diseases of all kinds and during all stages, and have never administered a minim of alcohol, or any substitute for it, and we have got on better than when I--feeling it at all times at command--made use of it in the ordinary way. "I am, dear Madam, faithfully yours, "B. W. RICHARDSON." TREATMENT:--"Lay the patient down in a current of air with the feet raised higher than the head, preferably on one side in case of sickness occurring, or bend the head down to the knees, to restore the flow of blood to the brain. Loosen all clothing. Rub the limbs, chest and over the heart with the hand or a rough towel. Sprinkle cold water on the head and face. Smell ammonia, strong vinegar, smelling salts or any pungent odor. Put hot bottles to the feet, and in severe cases a mustard plaster over the heart. Sip hot milk, hot water, hot tea, hot black coffee, beef tea or a meat essence. Crowding round the patient and all excitement should be avoided. In 999 cases out of 1,000, no medicine is necessary. "Faintness often proceeds from indigestion, flatulence inducing pressure on the heart." FAINTNESS, WEAKNESS, EXHAUSTION, FATIGUE:--"The truth is that for simple weakness, faintness, exhaustion, fatigue, cold or wet, the best remedies are simple fresh air, pure water, digestible food and rest. These are nature's restoratives, and the sooner both physicians and people learn to rely upon them instead of upon drugs the better it will be for all parties. And as the effect of alcoholic liquors are directly depressing to the strength and activity of all the natural functions and processes of life, as shown by the most varied and scientific investigations, it is important that this fact be taught to both doctors and people everywhere."--DR. N. S. DAVIS. FITS:--"Whether the fit be apoplexy or epilepsy all alcoholics are extremely bad, both at the time and afterwards. Alcohol, the 'genius of degeneration,' is the chief cause of apoplexy, and also a cause of epilepsy, especially when taken in the form of beer. It diminishes the tone of the arteries and blood-vessels, and thus tends to cause, aggravate and maintain a congested state of the capillaries throughout the whole body. In the treatment of epilepsy, therefore, neither alcohol nor any so-called substitute should be given. * * * * * "In the convulsions of children alcohol is equally injurious."--DR. RIDGE. FLATULENCE:--"Many uneasy sensations or pains, even in distant parts of the body, are due to wind in the bowels, resulting from indigestion. Asthma, cramps, depression of spirits, faintness, giddiness, hiccough, prostration, sinking sensations and sleeplessness, are all frequently due to the same cause. The diet needs careful attention where there is much flatulence; tea is often a cause. Charcoal biscuits are useful in some cases; lemon juice in others. Fluid Magnesia may be taken. Watch for the cause and remove it." HEADACHE:--_The New Hygiene_ says: "This is the manifestation of a deeper-seated trouble, usually in the stomach. The use of stimulants is a sure promoter of headache. All users of alcoholic liquors are, I believe, subject to headache, and it is also a sure result of overindulgence in tea and coffee. "To prevent the attacks, live regularly, avoid late hours and excessive brain work; avoid tea, coffee and alcoholic beverages, also sweets of all kinds, including sauces and pastries, and anything fried in fat. Eat plenty of good, plain food, including fruit, especially oranges. Eat none late at night. Exercise regularly in such a way as to bring all the muscles into play, at least once a day. "To relieve an attack flush the colon. "Headaches, which so largely result from the retention of impure matter in the body, will be cured if a good quantity, say two or three glasses, of hot water be drank in the morning or at night, and then the next regular meal omitted, so that an interval of house-cleaning can be had before other material is moved in."--_Life and Health._ "Avoid pills and powders. Persons suffering from headache need to be warned against taking remedies that contain opium and alcohol, and also against the use of a recent popular remedy, usually called a 'white powder' or 'white tablet.' They take the latter readily because the druggist or physician says it contains no opium. This is true, but it is one of the lately discovered coal tar preparations (anti-febrine, acetanilid, etc.) and is very depressing to the human system. Headache is usually a symptom of trouble somewhere else, often in the alimentary canal, an overloaded stomach, constipation, or tight clothing. Learn the cause and remove that, and the headache will disappear."--DR. H. J. HALL, Franklin, Ind. "Gentle massage is helpful and the use of cold compresses. Lack of sufficient sleep will cause headache. Women often bring on nervous headache by overwork and worry." HEMORRHAGE:--"Never give alcohol in a case of profuse hemorrhage. The faint feeling, or irresistible inclination to lie down is nature's own method of circumventing the danger, by quieting the circulation and lessening the expulsive force of the heart, thus favoring the formation of clot at the site of the injury."--_Clinique._ "For uterine hemorrhage an emetic to induce vomiting is the best cure."--Dr. Higginbotham in _British Medical Journal_. "If the faint is dispelled too quickly, and the blood-vessels are relaxed by alcohol, or the heart aroused to energetic action by any remedy, the hemorrhage may recommence, and may prove fatal. Quiet, the application of cold, pressure, the elevation of the wound where possible, and the absence of stimulants, are the cardinal points of treatment in most cases."--DR. RIDGE. "If then, it seems absolutely necessary to rouse a person out of a dead faint, what can be done? Swallowing is out of the question, lest the patient choke. The head must be laid low, and the face and chest flapped with a cold wet cloth, or alternately with hot wet cloths; smelling salts (not too strong) may be applied to the nose. "When the faint has been recovered from, but the hemorrhage continues so much that it is feared another faint may occur, and, perhaps, be fatal, it may be warded off by drinking any hot liquid; if Liebig's extract of meat, or strong beef tea, is at hand and can be given hot, there is nothing better." HEART DISEASE:--Dr. Ridge says: "I trench here on a delicate subject, because, when there is real disease of the heart, medical advice will of course have been obtained, and very probably a doctor may have said that some alcoholic liquor is essential. There are, also, several different forms of heart disease which require altogether different treatment, and only a physician can tell the difference, or appreciate the necessity for the particular treatment required. But it may be pointed out that alcohol is utterly unable to 'strengthen' the heart, or give tone to the blood-vessels, or to the system at large. "The alteration in the pulse due to alcohol is chiefly owing to its paralyzing action on the blood-vessels, and when they are too contracted, and thereby cause the weakened heart to labor too much, the alcohol will give relief for the time. But we have in nitrite of amyl, a fluid which will act more quickly and more powerfully; but this must not be employed without medical direction. It is very useful in cases of _angina pectoris_, or _breast pang_, but is rarely required in the majority of cases in which the valves of the heart are diseased. The paralyzing action of alcohol is not generally produced by less than half a wine-glassful of brandy or whisky, or twice that quantity of wine, and often much more is required. The relief to uneasy sensations which much smaller quantities sometimes produce is due to their anæsthetic or benumbing action, by which the nerves of the patient are rendered less sensible, although the danger is by no means diminished. * * * * "The only sensible way to avert the evil consequences of heart disease is to strengthen the heart, and that is to be done by strengthening the body generally. The amount of exercise, the kind of baths, etc., which should be taken, have to be modified in accordance with the nature of the case. If these natural health-giving measures cannot be employed nothing is an effectual substitute. "_Weak_ or _feeble heart_ is a common complaint, and is as ordinary an excuse for resorting to alcoholic liquors as 'Timothy's stomach.' If there is no organic disease; if the valves of the heart are healthy and act properly, all anxiety on this point may be entirely banished. The slow pulse, the feeble pulse, the cold feet, the want of energy, these are not to be got rid of by such a mere temporary agent as alcohol, even if relief can be thus obtained from day to day. The constant application of alcohol to the tissues of the body alters them gradually by its chemical action. In addition to this, the balance of the nervous system is altered, an unnatural condition is produced, and the unhappy patient becomes more liable to disease and more easily succumbs when attacked. "Many of these 'feeble hearts' mean too little exercise, very often also, too much or improper food and drink. "The best remedies are cold sponging (according to the season); avoidance of coddling; plain, wholesome food; abstinence from tea, hot drinks and condiments; regular out-of-doors exercise and all similar true _tonic_ measures." Dr. Kellogg says:-- "Persons subject to attacks of _angina pectoris_ should carry with them a small bottle containing a sponge saturated with nitrite of amyl, and place it to the nose when necessary. "Sympathetic palpitation may be relieved by bending the head downward, allowing the arms to hang down. The effect of this measure is increased by holding the breath a few seconds while bending over. Another ready means of relief is to press strongly upon the large arteries on either side of the neck. "Palpitation of the heart is often mistaken for real organic disease of the organ. * * * * * A careful regulation of the diet is in most cases all that is necessary to effect a cure." Dr. Edmunds, of London, was asked during a medical discussion what he thought of the use of alcohol in heart disease. His answer is embodied in the following:-- "With regard to the use of brandy in cases of heart disease, he was convinced it was a mistake to use it in such cases. There were many forms of heart disease, but the most common kind arose from the heart being too fat. Excess of fat debilitated the heart and injured its working, just as a piece of wax attached to a tuning fork would impair its usefulness. In such cases he dieted his patients in order to reduce their weight. Every dose of brandy taken for heart disease increased the evil. The moment brandy was taken for heart disease, or any other chronic complaint of a similar kind, the disease was increased. If doctors recommended alcohol to their patients, he had been asked what abstainers should do. In such cases, as had been suggested, he thought the patients might ask what the alcohol was to do for them, and if the reply was not satisfactory, they should get another doctor." Dr. T. D. Crothers, of Hartford, Conn., has deduced some valuable facts from his experiments with the sphygmograph, upon the action of the heart. He has found by repeated experiments that while alcohol apparently increases the force and volume of the heart's action, the irregular tracings of the sphygmograph show that the real vital force is diminished, and hence its apparent stimulating power is deceptive. Dr. C. W. Chapman, of the National Hospital for Diseases of the Heart, wrote in the _Lancet_:-- "The very thing (alcohol) which they supposed had kept their heart going was responsible for many of its difficulties." Of cases of palpitation and irregularity caused by business anxieties or indigestion, he said:-- "To give alcohol is only to add fuel to the fire." HEART FAILURE:--"In cases of cardiac weakness, the thing needed is not simply an increased rate of movement of the heart, or an increased volume of the pulse, but an increased movement of the blood current throughout the entire system. In the application of any agent for the purpose of affording relief in a condition of this kind, the peripheral heart as well as the central organ must be taken into consideration. In fact, the whole circulatory system must be regarded as one. The heart and the arteries are composed of essentially the same kind of tissue, and have practically the same functions. The arteries as well as the heart are capable of contracting. "Both the heart and the arteries are controlled by excitory and inhibitory nerves. These two classes of nerves are kindred in structure and in origin, the vagus and the vasodilators being medullated, while the accelerators of the heart and the vasoconstrictors of the arteries are non-medullated and pass through the sympathetic ganglia on the way to their distribution. "Winternitz and other therapeutists have frequently called attention to the value of cold as a cardiac stimulant or tonic. The tonic effect of this agent is greater than that of any medicinal agent which can be administered. The cold compress applied over the cardiac area of the chest may well replace alcohol as a heart tonic. The thing necessary to encourage the heart's action is not merely relaxation of the peripheral vessels, but, as Winternitz has shown, increased activity of the peripheral circulation in the skin, muscles and elsewhere. Alcohol paralyzes the vasoconstrictors, and so dilates the small vessels and lessens the resistance of the heart action; but at the same time it lessens the activity of the nerve centres which control the heart, diminishes the power of the heart muscle, and lessens that rhythmical activity of the small vessels whereby the circulation is so efficiently aided at that portion of the blood circuit most remote from the heart. A continuous cold application applied to that portion of the chest overlying the heart stimulates the nerves controlling the walls of the vessels, and at the same time energizes the corresponding cardiac nerves. It is wise to remember that the vasoconstrictor nerves are one in kind with the excitor nerves of the heart, while the vasodilators are in like manner associated with the vagus. With this in mind, it is clear that while alcohol paralyzes the vasoconstrictors, it at the same time weakens the nerves which initiate and maintain the activity of the heart; while, on the other hand, cold excites to activity those nerves which produce the opposite effect. "The apparent increase of strength which follows the administration of alcohol in cases of cardiac weakness is delusive. There is increased volume of the pulse for the reason that the small arteries and capillaries are dilated, but this apparent improvement in cardiac action is very evanescent. This is a natural result of the fact that while the heart is relieved momentarily by sudden dilation of the peripheral vessels, the accumulation of the blood in the venous system, through the loss of the normal activity of the peripheral heart, gradually raises the resistance by increasing the amount of blood which has to be pushed along in the venous system. This loss of the action of the peripheral heart more than counterbalances the temporary relief secured by the paralysis of the vasoconstrictors. "Thermic applications, general and local, may safely be affirmed to be the true physiological heart tonic. In the employment of the cold pericardial compress as a heart tonic, the application should generally be continued not more than half an hour at a time, and its use may be alternated with general cold applications to the surface. A cold towel rub, or the cold trunk pack is the best form for application if the patient is very feeble. "The cold towel rub is applied thus: wring a towel as dry as possible out of very cold water, and spread it quickly and evenly over the surface; rub vigorously outside until the skin begins to feel warm; then remove, dry the moistened surface, rub until it glows, and make the same application to another part; and so on until the whole surface of the body has been gone over. The procedure should be rapid and vigorous. "If the cold trunk pack is employed, a sheet of not more than one thickness should be wrung as dry as possible out of very cold water, and wrapped quickly about the body, after first dipping the hands in water, and rubbing the trunk vigorously. In cases of extreme cardiac weakness, very cold and very hot applications may be alternately applied over the region of the heart. The duration of the hot and cold applications should be about fifteen seconds each. "Any one who has ever witnessed the marvelous effects of applications of this sort in reviving a flagging heart will never doubt their efficacy, and will have no occasion to resort to alcohol, or any other intoxicant, to stimulate a flagging heart. The writer has employed these measures for stimulating the heart for more than twenty years, and might cite hundreds of instances in which their efficiency has been demonstrated. They are applicable not only to the cardiac depression encountered in the adynamic stage of typhoid and other fevers, but in cases of heart failure from hemorrhage, of surgical shock, collapse under chloroform or ether, opium poisoning, coal gas asphyxia, drowning, etc."--Dr. J. H. Kellogg, in _Bulletin of the A. M. T. A._, Jan., 1899. Dr. N. S. Davis tells of a case of threatened collapse where he was called in consultation. Patient was in a small, unventilated room. "It was easy to see that what she needed was fresh air in her lungs. Instead of giving alcohol in any form she was moved into a large, well-ventilated room. All symptoms of 'heart failure' disappeared. Had she begun to take whisky or brandy, physician and friends would have attributed her recovery to that, when in fact it would have retarded recovery by hindering oxygenation of the blood." "It would also be a very great mistake to suppose that when reaction follows collapse, in cases in which alcohol has been given, this result is always due to the alcohol. I have seen so many cases of severe collapse recover without alcohol that I cannot but be skeptical as to its necessity, and even as to its value. I was much struck many years ago by a case of post partum hemorrhage which was so severe that convulsions set in. I should then have given brandy if there had been any to give, but there was none in the house and none to be got. I administered teaspoonfuls of hot water and the patient revived and recovered; next day, except for anæmia, she was as well as ever, with no reactionary fever or other disturbance, as would almost certainly have been the case if brandy had been given. "In collapse from hemorrhage, we have learned the value of injections of warm saline water, either into the veins, the skin or the rectum, and the same treatment is available in other cases of collapse with contracted vessels. "Another measure which has proved most efficacious is the _inhalation of oxygen_ gas. This is especially useful in cases in which alcohol is decidedly injurious, namely, those in which there is increasing congestion of the lungs, which the heart, though doing its utmost, is unable to overcome. Alcohol only increases the congestion, and the heart is already over-exerted and nearly exhausted. The effect of the oxygen is apparent in a few seconds, and cases have been rescued in which death appeared to be inevitable and imminent."--DR. RIDGE. HEART STIMULANTS:--"The advantage of beef extract over alcohol as a stimulant was demonstrated on a large scale in the Ashantee war."--DR. RIDGE, London. For those who must have a drug: aqua ammonia, 8 drops to 1/2 cup of hot water, or 20 grains carbonate ammonia to 1/2 cup water. Hot water alone is a useful stimulant; also water, hot or cold, with a few grains of Cayenne pepper added. The latter is good, not only to start the heart's action in collapse, but also to relieve violent pain. Hot milk is a most valuable stimulant. Many persons to whom hot milk has been given during the extreme weakness of acute disease have testified afterward to its good effects in comparison with the wine formerly administered. The wine caused an after-feeling of chilliness and weakness, while the milk gave warmth and added strength. INSOMNIA OR SLEEPLESSNESS:--"A person who suffers from sleeplessness should avoid the use of tea and coffee, tobacco, alcoholic liquors and all other disturbers of the nervous system. Eating immediately before retiring has been recommended, but the ultimate result may be an aggravation of the difficulty instead of relief. If a person suffers from 'all gone feelings' so that he cannot sleep, he should take a few sips of cold water or a glass of lemonade. As complete relief will generally be obtained as from eating, and the stomach will be saved work when it should be resting. A warm bath just before retiring, a wet-hand rub, a cool sponge bath, gentle rubbing of the body with the dry hand, a moist bandage worn about the abdomen during the night, are all useful measures. When the feet are cold, they should be thoroughly warmed by a hot foot or leg bath, and thorough rubbing. When the head is congested, these measures should be supplemented by the application of cold to the head, as the cold compress or the ice-cap." A walk in the evening, or gentle calisthenics, may help those of sedentary habits. Bicycle riding and horse-back riding in the evening have helped many. The practice of long deep breathing will often put persons to sleep when all other devices fail. The lungs should be filled to their utmost capacity, and then emptied with equal slowness, repeating the respiration about ten times a minute, instead of eighteen or twenty, the natural rate. Those who fall asleep upon first going to bed, and after a few hours awake, and are unable to sleep again, may find relief by getting out of bed, and rubbing the surface of the body with the dry hand. Or walk about the room a few minutes, exposing the skin to the air, go back to bed and try the deep breathing. "The use of drugs for the purpose of inducing sleep should be avoided as much as possible. Opium is especially harmful. Sleep obtained by the use of opiates is not a substitute for natural sleep. The condition is one of insensibility, but not of natural refreshing recuperation. Three or four hours of natural sleep will be more than equivalent to double that amount of sleep obtained by the use of narcotics. When a person once becomes dependent upon drugs of any kind for producing sleep, it is almost impossible for him to dispense with them. It is often dangerous to resort to their temporary use, on account of the great tendency to the formation of the habit of continuous use. The use of opiates for securing sleep is one of the most prolific means by which the great army of opium-eaters is annually recruited. Chloral, bromide of potash, whisky and other drugs are to be condemned almost as strongly as opium."--DR. KELLOGG. Dr. Furer, of Heidelberg, Germany, in a paper before the International Congress against alcohol, held in Basle, Switzerland, in Sept., 1895, said:-- "The sleep from alcohol does not act as a mental tonic, but leaves the mind weaker next day." Some noble specimens of manhood have become wrecks through accepting the advice to try "whisky night-caps." Edison recommends manual labor, instead of going to rest, for aggravated insomnia. He says sleep will soon come naturally. LA GRIPPE:--"Alcohol has no place in the treatment of _la grippe_; on the contrary it is because of the too frequent use of this, and other narcotics, that epidemics make such fearful headway in our land, and such must be the rule until the people study the laws of health and obey them. Profuse sweating, followed by a careful bathing of the body in tepid water, gradually cooling it to a normal temperature, and avoiding unnecessary exposure, will relieve. The patient should sleep in pure air and eat as little as possible, and that only when hungry. * * * * * Quinine is essentially a nerve poison, and capable of producing a profound disturbance of the nervous centres. A drug of such potency for evil should be employed with the greatest care, and never when a milder agency will secure the result. Exceedingly pernicious is the habit of dosing children with this drug."--DR. CHARLES H. SHEPARD, Brooklyn, N. Y. "A late surgeon of the gold coast of Africa wrote the following to the London _Lancet_ of Jan. 2, 1890: 'Some of the worst cases of this disease, the grippe, remind me of an epidemic I saw among the natives of the swamps of the Niger. * * * * * Irrespective of disinfectants and inhalations there is a simple, effective and ready remedy, the juice of oranges in large quantities, not of two or three, but of dozens. The first unpleasant symptoms disappear, and the acid citrate of potash of the juice, by a simple chemic action decreases the amount of fibrine in the blood to an extent which prevents the development of pneumonia.'" The Syracuse (N. Y.) _Post-Standard_ contained the following during the epidemic of 1899:-- "Dr. George D. Whedon declared to a _Post-Standard_ reporter yesterday that there is practically no subsiding of the grippe in this city. Dr. Whedon said that the weather conditions have little, if anything, to do with the disease, and that it is impossible to define the conditions which produce it. It is some morbific agency, the influence of which, Dr. Whedon said, is exerted upon the pneumogastric nerve. "_Dr. Whedon was emphatic in denouncing treatment by means of alcoholic stimulants, and coal tar derivatives._ In discussing the subject at some length he said:-- 'I find that infants and young children are practically exempt from the disease, and the liability increases with age. In my own experience, which has since 1889 amounted to an aggregate of 3,000 cases, alcoholic stimulants have appeared to be usually of little or no value; their usual stimulating effect does not seem to be realized in this condition. Unless malarial complications exist quinine appears of no benefit, and then should not be used in larger than two grain doses. Large doses depress the weakened heart, and in all cases increase the terrible confusion and headache constantly present in severe cases. 'From the views I entertain of its pathology, and from the terrible fatality which has attended the extensive use of the coal tar derivatives in treatment of _la grippe_, I argue that the manner in which they have been prescribed in the beginning of the disease, to reduce fever, and relieve the often intense suffering, lowers the heart's action, which is already sufficiently incapacitated by the toxic agent producing the disease. 'The intention is usually to stimulate later, but later is in many cases unfortunately too late. The heart being overwhelmed by the poison, and by the added depression of all coal tar preparations, cannot keep up the pulmonary circulation. The swelling of the lungs increases, and the result is fatal. 'I am aware of the weight of authority for their administration and of the relief they afford, but am just as well assured that were their use discontinued, the greatly increased death-rate from _la grippe_ would cease to appear. 'These coal tar remedies are being used everywhere, and the medical journals recommend them despite the fatal results. They are being used every hour in the day in Syracuse, and, as a result, are knocking out good people. Among the most popular coal tar derivatives I might mention anti-kamnia, salol-phenacetine, anti-pyrine and salicylate of soda. 'Prognosis is favorable at all ages. Patients should be kept warm, and perfectly quiet in bed, and supplied with such nutritious and easily digested food, at frequent intervals, as the partially paralyzed stomach can take care of. All nourishment must be fluid and warm rather than cold.'" The _Journal of Inebriety_ for April, 1889, says:-- "The present epidemic of influenza has proved to be very fatal in cases of moderate and excessive alcoholic drinkers. "Pneumonia is the most common sequel, breaking out suddenly, and terminating fatally in a few days. Heart failure and profound exhaustion, is another fatal termination. One case was reported to me of an inebriate, who, after a full outbreak of all the usual symptoms, drank freely of whisky and became stupid and died. It was uncertain whether cerebral hemorrhage had taken place, or the narcotism of the alcohol had combined with the disease and caused death. "A physician appeared to have unusual fatality in the cases of this class under his care. "It was found that he gave some form of alcohol freely, on the old theory of stimulation. Another physician gave all drinking cases with this disease alcohol, on the same theory, and had equally fatal results. It has been asserted that alcohol, as an antiseptic, was useful in these bacterial epidemics, but its use has been followed by greater depression, and many new and complex symptoms. The frequent half domestic and professional remedy, hot rum and whisky, has been followed by more serious symptoms, and a protracted convalescence. Many facts have been reported showing the danger of alcohol as a remedy, also the fatality in cases of inebriates who were affected with this disease. "The first most common symptom seems to be heart exhaustion and feebleness, then from the catarrhal and bronchial irritation, pneumonia often follows." The vapor or Turkish bath is the best means of "breaking up" this disease, together with hot lemonade and rest in bed for a day or two. The inhalation of hot steam should be tried when there is much bronchial irritation. LIFE-SAVING STATIONS, THE USE OF ALCOHOL IN:--"There is no possible useful place for alcoholic liquors in connection with a life-saving station. Applied externally the rapid evaporation of alcohol reduces the temperature; taken internally it diminishes the efficiency of both respiration and circulation, and by increasing congestion of the kidneys it directly increases the danger of secondary bad effects from exposures of any kind. To restore warmth and circulation to the surface, light, rapid friction and the wrapping with dry flannel is the safest, cheapest and most efficient, while free breathing of fresh air, and frequent small doses of milk, beef-tea, ordinary tea or coffee, or even simple water, will afford the greatest amount of strength and endurance, and leave the least secondary bad consequences. It is just as easy to keep at hand a jug or flask of any one of the articles named as it is to keep a flask of whisky or brandy. There is no need of keeping them hot, as they act well at any temperature at which they can be drunk."--DR. N. S. DAVIS, Chicago. MEASLES:--"In mild cases, very little treatment is required, except such as is necessary to make the patient comfortable. Good nursing is much more important than medical attendance. If the eruption is slow in making its appearance, or is repelled after having appeared, the patient should be given a warm blanket pack. "The old-fashioned plan of keeping the patient smothered beneath heavy blankets, and constantly in a state of perspiration is wholly unnecessary. The irritation of the skin, as well as the sensitiveness to cold, may be relieved by rubbing the skin gently two or three times a day with vaseline or sweet oil. There is no danger from the application of cold water to the surface except in the last stages of the disease, after the eruption has disappeared. "The patient should be allowed cooling drinks as much as desired. During the disease a simple but nutritious diet should be allowed, but _stimulants of all kinds should be prohibited_." "It is wholly unnecessary, and dangerous as well, to give whisky to bring out the eruption."--DR. I. N. QUIMBY, Jersey City. "Any hot drink, such as ginger tea or hot lemonade, may be used to hasten the eruption, if delayed." MALARIA:--Observers of this disease in such regions as the gold coast of Africa have noted the fact that malarial attacks are generally preceded by impaired digestion. The disease is said to be due to animal parasites. These parasites are supposed to generate in the soil of certain regions, and thence, through the drinking water, or otherwise, find entrance to the human body. "A healthy stomach is able to destroy germs of all sorts, hence the best protection from malaria is the boiling of all drinking water, and the maintenance of sound digestion and purity of blood by an aseptic dietary." Dr. J. H. Kellogg says in _The Voice_:-- "It must be understood, however, that fruit in malarial regions, especially watermelons, may be thickly covered with malarial parasites and the parasites may sometimes find entrance to the fruit when it becomes over-ripe, so that the skin is broken. It is evident, then, that care must be taken to disinfect such fruit by thorough washing, or by dipping in hot water, which is the safer plan. The same remark applies to cucumbers, lettuce, celery, cabbage and other green vegetables which are commonly served without cooking. Not only malarial parasites but small insects of various kinds are often found clinging to such food substances, their development being encouraged by the free use of top dressing on the soil, a process common with market gardeners. "The treatment of malarial disease is too large and intricate a subject for proper treatment in these columns. We will say briefly, however, at the risk of being considered very unorthodox, that the majority of cases of malarial poisoning can be cured without the use of drugs of any sort. In fact, in the most obstinate cases of chronic malarial poisoning, drugs are of almost no use whatever. Quinine, however, is certainly of value as a curative agent in these cases, either in destroying the parasites, or in preventing their development; but as it does not remove the cause, its curative effect is likely to be very transient. The practice of habitually taking quinine as a preventive of malarial disease is a most injurious one, as quinine is itself a non-usable substance in the system, and therefore must be looked upon as a mild poison, to be dealt with by the liver and kidneys the same as other poisons. By habitual use it may itself become a cause of disease. One or two periodical doses of quinine often prove of great service in interrupting the paroxysms of an intermittent fever, but other treatment must also be employed to develop the bodily resistance, and fortify the system against disease. The morning cold bath, followed by vigorous rubbing, is a most excellent measure for this purpose, but the old-fashioned German wet-sheet pack is one of the best remedies known. The paroxysm itself can generally be avoided by means of the dry pack, begun before the chill makes its appearance; but this requires the services of an expert nurse. In not a few cases it is wise for a person who suffers frequently from malarial disease to seek a change of climate to some non-malarial region. "Col. T. W. Higginson of the First South Carolina Volunteers, in 1862, said of Dr. Seth Rogers, an eminent Southern physician, who was surgeon of the regiment: 'Fortunately for us, he was one of that minority of army surgeons who did not believe in whisky, so that we never had it issued in the regiment while he was with us, and got on better, in a highly malarial district, than those regiments which used it.'" MATERNITY:--Dr. Ridge says:--"It is one of the greatest mistakes to make use of alcoholic beverages to 'keep up the strength' during labor. It is, of course, impossible to predict at the commencement how long the labor will last; if then brandy, or other similar drink, is resorted to early, it acts most injuriously. The desire for food is often entirely removed; the demand of the system being therefore unperceived, and so not supplied, a state of weakness and prostration is in time produced, if the labor should be protracted, which may be really serious. The nervous system becomes exhausted by the repeated action of the alcohol. If a fatal result is not occasioned, yet the prostration of body and mind after delivery is aggravated, and convalescence thereby retarded. Alcoholic drinks produce paralysis and congestion of the blood-vessels, and in this way largely increase the liability to flooding after the labor is over. Alcohol also increases the liability to a feverish condition. "It is necessary to take small quantities of plain, nourishing food at regular intervals, and nothing is of greater value than well-cooked oatmeal: other farinaceous food may be substituted, if preferred. If there is much prostration, meat extracts or beef tea are of great value. Tea tends to produce flatulence and to prevent sleep. "After the labor is over, the best restorative is a cup of hot beef tea or an egg beaten up in warm milk or a cup of warm gruel. Rest, and absence of excitement and worry are essential and alcohol is specially injurious." MENSTRUATION, PAINFUL:--Young girls often resort to the use of brandy during the monthly period, and parents ask anxiously, "What can they use instead of the brandy?" The very best thing that can be done is to go to bed, wrapped in flannels, with a hot-water bottle or other hot application to the abdomen, and to the feet. Take hot ginger tea, or pepper tea. A warm hip-bath taken at the beginning may give relief, or a large hot enema retained for half an hour or so. Rest is necessary. For those who must go to work, Dr. Ridge recommends five drops of oil of juniper, to be taken on sugar. NEURALGIA:--"The principal cause of neuralgia is defective nutrition of the nerves. Disorders of digestion are very often accompanied by neuralgia in various parts of the body. It may also result from taking cold, from loss of sleep, from dissipation, and also from the use of tobacco, alcohol, tea and coffee. "The patient's general health must be improved by a wholesome, simple diet, and the employment of tonic baths, as a daily sponge bath, and massage in feeble cases. Sun-baths and exercise in the open air are of first importance. Ordinary neuralgia may almost always be relieved by either moist or dry heat. In some cases, cold applications give more relief than hot. As a rule, abnormal heat requires cold, and unnatural cold requires hot applications. In many cases it is necessary to give the patient a warm bath of some kind. Electricity often succeeds when all other remedies fail. "For facial neuralgia apply hot fomentations, together with the use of sitz baths, or hot foot baths. The head may be steamed by holding it over hot water, adding pieces of hot brick occasionally to keep water steaming, head being covered. "There is no complaint, perhaps, in the treatment of which the use of port wine will be more strongly urged by kind friends, with the assurance that it is impossible to get well without it. This is quite untrue, as thousands can testify."--DR. RIDGE. "Avoid opiates of all sorts. 'It is better to bear the ills we have than fly to others that we know not of.' The pangs of neuralgia are as nothing to endure compared with the sufferings of an opium wreck. Build up the general health, and the neuralgia will disappear." NAUSEA.--"A feeling of sickness is not uncommonly due to indigestion. If it is caused by rich food take a pinch of bicarbonate of soda in a little water, or a teaspoonful of fluid magnesia. The acidity of the food will thus be neutralized, and this course is far preferable to benumbing the stomach with brandy. If indigestion is the cause, it is often salutary to miss one or two meals, so as to allow the stomach to recover. "When due to pregnancy, a little aërated water, or soda water is useful; sometimes a small wafer or a crust, eaten before rising in the morning, will check it. An early morning walk, if the weather is pleasant, is helpful. "The moist abdominal bandage is a very excellent means of relieving nausea during pregnancy. It should be worn constantly for a week or two, and then omitted during the night. Daily sitz baths are also of great advantage. In many cases electricity relieves this symptom very promptly. In very urgent cases in which the vomiting cannot be repressed, and the life of the patient is threatened, the stomach should be given entire rest, the patient being nourished by nutritive injections. Fomentations over the stomach, and swallowing small bits of ice, are sometimes effective when other measures fail."--DR. J. H. KELLOGG. OUTGROWING THE STRENGTH:--"There is sometimes debility or weakness in rapidly growing boys and girls which is attributed to this cause. It is popularly supposed that port wine or beer, is the great remedy; but nothing can be worse. It is true that gin given continuously to puppies will keep them small, but no one would advocate the amount of spirit required in proportion by a lad or girl to produce the same effect. If the growth could be checked by chemicals it would be most injurious to do so. "In the treatment of such cases fresh air by day and night is essential; cold sponging, followed by friction with a rough towel, and exercise are desirable." PNEUMONIA. Dr. Julius Poheman says in _Medical News_:-- "The effect of alcohol upon nearly all the organs of the body has been carefully investigated. But, strange to say, literature contains only a few straggling hints upon the action of alcohol on the pulmonary tissue. It has long been known that the abuse of alcohol is a predisposing cause of death when the drinker is attacked with pneumonia. No experimental evidence has been published of the action of alcohol in producing pathological conditions in the lungs. In order to determine this action, a series of experiments was made upon dogs in the winters of 1890-1891 and 1892-1893. The dogs were a mixed lot of mongrels gathered in by the city dog catchers. They varied in weight from fifteen to twenty-five pounds, and were apparently in good health. In all, thirty animals were experimented on. "The experiments were performed as follows:--A carefully etherized animal had injected into his trachea just below the larynx a quantity of commercial alcohol varying from one dram to one ounce in amount. The effects of equal amounts of alcohol upon animals of the same weight varies greatly. Two dogs, weighing twenty-five pounds each, were injected with two drams of alcohol. One died in one hour, and the other in six hours after the injection. Four other dogs, two weighing twenty-four pounds each, another eighteen pounds, and the fourth fifteen pounds, were all injected with the same amount, two drams. All four survived, and were as well as usual in four weeks. Another dog of eighteen pounds died five minutes after an injection of two drams, while another of fifteen pounds took one ounce and recovered. "The symptoms in the dogs were all alike, dyspnea, increasing as the inflammation increased, until the accessory muscles of respiration were called into play. The stethoscope showed that air had great difficulty in entering the bronchi and air vesicles, and showed also the tumultuous beating of the heart in pumping blood through the lung. It was impossible to take the temperatures. Post-mortem examinations showed the lungs dark, congested and solid in some places. The air passages were filled with frothy, bloody mucus, even in the dog that died in five minutes. On section, the lungs were dark, congested, and full of bloody mucus. This shows how acutely sensitive the respiratory passages are to the action of alcohol. On microscopic examination of the lungs, the air tubes and vesicles were found filled with immense numbers of red and white corpuscles and much mucus. The same picture was presented as in a slide from the lungs of a broncho-pneumonic child. "The striking similarity between the two is enough to prove that the pathological condition is the same, and that alcohol has produced a lesion very closely resembling, if not absolutely like, that of broncho-pneumonia in the human subject. This to some extent explains why drunkards attacked by pneumonia succumb more readily than the temperate. The sensitive lung tissue is enveloped in alcohol--flowing through the capillaries of the lung on one side, and exhaled, filling the air vesicles and tubes on the other. The condition must create a state of semi-engorgement or of mild inflammation, similar to the drunkard's red nose, or his engorged gastric mucous membrane. Such a state will reduce the vitality of the pulmonary tissue, and its power of resistance to external influences. Add to this an inflammation such as a pneumonia, and the lungs find themselves unable to stand the pressure." As previous chapters contain much showing the reasons why alcohol is dangerous in pneumonia, space need not be taken here to do more than indicate briefly some points of non-alcoholic treatment. Pneumonia is generally supposed to result from a cold; it is ushered in by the symptoms of a chill, followed by fever, headache, shortness of breath, pain in chest, etc. It sometimes occurs as a complication of typhoid fever and other acute diseases. "It is not a very fatal disease in young and healthy subjects, but in weak children, old persons and habitual drinkers, it is a very fatal malady." _Nature Cure_ recommends a vapor bath immediately upon the appearance of the first symptoms, together with copious drinking of hot lemonade, and a good supply of pure fresh air in the room, together with the application of alternating hot and cold compresses, _and no drugs_. Dr. Kellogg says:-- "Cool compresses or ice-bags, alternated every three hours by hot fomentations for ten minutes, should be applied to the chest, particularly to the affected side, the seat of pain. The hot fomentations relieve the pain, and the cold compresses check the diseased process. The compresses should be wrung out of cold water, and changed every five to eight minutes, or as often as they become warm. Although the cool compresses are not usually liked by the patient, they will soon give relief if their use is continued, and they do much towards shortening the course of the disease. Care should be taken to keep the patient's body from being wet except where the treatment is applied. The cold compress is much used in the large hospitals of Germany. When the pulse becomes as rapid as 95 to 110 or more, cool sponging, the wet-sheet pack, the cool full bath or the cool enema should be employed. When much chilliness is produced by the contact of water with the skin, the cold enema is a most admirably useful measure. The amount of water required is from half a pint to a pint. The temperature may be 40 to 60 degrees. The apartment should be kept as cool as possible without discomfort, and an abundance of fresh air should be continually supplied. "The diet of the patient should consist of milk, oatmeal gruel, ripe fruit, and similar easily digested food. No meat, eggs or other stimulating food should be allowed. "Discontinue the cold treatment after the first twenty-four to forty-eight hours. If the surface is cold, apply hot sponging or a hot pack. Avoid causing chilliness." PRE-NATAL INFLUENCE OF ALCOHOL:--"The use of beer as a medicine during pregnancy is without doubt perilous to the health and vigor of the offspring. Children born under such conditions are sickly and feeble, and suffer from disease more severely than others, or die early. Alcoholic prescriptions to pregnant women are, from all present knowledge of the facts, both dangerous and reprehensible in the highest degree."--DR. T. D. CROTHERS, Hartford, Conn. "M. Fere, an eminent French physician, recently reported to the Biological Society of Paris the results of experiments which he had been conducting for the purpose of throwing light upon this question. These experiments demonstrate that the exposure of hen's eggs to the influence of the vapor of alcohol, previous to incubation, retards the development of the embryo, and favors the production of malformations. It is evident from these experiments that alcohol may act directly upon the embryo when there is no marked influence of alcoholism in the parent." PAIN AFTER FOOD:--"This may occur in acute or chronic gastric catarrh, or in a neuralgic or oversensitive condition of the stomach, or in ulcer or cancer of that organ. In all these it comes on soon after food has been swallowed; but, if occurring a long time after a meal, it is probably due to atonic dyspepsia. Alcohol will undoubtedly sometimes relieve this kind of pain by deadening the nerves of the stomach so that the pain is not felt so much; but this effect soon passes off, and if the cause of the malady is not removed by other means, increasing quantities of alcohol will be required to give relief. Many cases of drink-craving have originated in this way. Medical aid will generally be required. A small mustard poultice over the pit of the stomach is often useful, especially in inflammatory cases, or any other outward application of heat. Food should be fluid, or semi-fluid, and digestible. Ginger tea, or peppermint water, may serve to disperse gas." POISON, ANIMAL. The following by Dr. Chas. H. Shepard, of Brooklyn, who introduced the Turkish bath into America, is taken from the _Journal of the A. M. A._, for Nov. 13, 1897:-- "Animal poison is by no means uncommon, and so quick and mysterious is its action that a prompt remedy is a vital necessity. There is good reason to believe that the numerous remedies that have been recommended from earliest times as antidotes for animal poison are worthless, as they have not the properties commonly ascribed to them. The paucity of remedies is so great that alcohol is the one which comes most quickly to the mind of those who have been taught in the traditions of the past, and who are not fully aware of its action on the human system. We shall endeavor to show that the action of alcohol is not helpful, but on the contrary is really detrimental; and also that there is a better way out of the difficulty. "If we get a splinter in the body, vital energy is aroused to get rid of the offending substance, inflammation is set up, and sloughing goes on until the splinter is voided. If the splinter is covered with acrid material, the same process is intensified, and nature endeavors to eliminate the offending substance through the natural excretions. Upon the peculiarity of the material depends the direction of this elimination. "It is well known that some poisons are thrown off by the kidneys, some by the lungs, while others again are attacked by all the emunctories. The difference in the power of the system to absorb different substances, appropriate whatever can be utilized, and throw off whatever can not be used, is sometimes called idiosyncrasy, but more properly it may be called vital resistance, and upon the integrity of this power rests the ability to combat disease in all its forms, whether it be the absorption of any animal virus or the poison resulting from undigested food. This ability is in proportion to the integrity and soundness of every tissue and organ of the body. This may be illustrated by the fact that with a person suffering from kidney disease, which necessarily impedes elimination, the ordinary effects of a poison are intensified; therefore whatever aids in the promotion of good health, or in other words, the normal action of all the functions, will contribute to the safety of the individual in any and every emergency. "When a person dies from the effect of poisoning, it is simply because the system was unable to eliminate the offending substance and was exhausted in the effort. There is a tolerance of some substances which frequently results in chronic disease, and again it is shown in what is called the cumulative effect or acute disease. "Those who would hold that a substance is at one time a medicament, and at another time a poison, have much trouble in drawing the line between the beneficial and the poisonous effect. The idea that poisonous substances act on the system is responsible for many grave mistakes, whereas always, and under all circumstances, it is the system that does all the action. "There might be some excuse for the idea that disease is an entity, from the facts that have been brought to light by the germ theory, but this theory is of recent date, while the entity theory is as old as superstition. "Snake poison, which may be cited as a type of other animal poisons, takes effect through the circulation, and acts by paralyzing the nerve centres, and by altering the condition of the blood. In ordinary cases death seems to take place by arrest of respiration, from paralysis of the nerves of motion. The poison also acts septically, producing at a later period sloughing and hemorrhage. "Dr. Calmette, a noted French scientist, claims that what is poisonous in the snake's bite, is not the venom absorbed into the blood, but a principle which the blood itself has developed out of the poison. This would necessitate very quick action when the poison is inserted in one of the large veins, as that is followed by instant death. "The following cases fairly represent some of the tragedies that are occurring in our everyday life. "A man 60 years old falls and dislocates his finger, he goes to the hospital, where in a short time he dies from blood poisoning. * * * * * Another man 48 years old, many years a wine merchant, whose great toe was severely crushed by a heavy man stepping on it, was taken with blood-poisoning and in spite of all treatment, even to the amputation of the leg, he soon succumbed to the disease. * * * * * A young woman 24 years old, picks a pimple on her chin and at once her face begins to swell. In vain was all medical treatment, for in a few days she died in terrible agony. * * * * * About a year ago there died in Brooklyn, N. Y., a physician in his 38th year, who six days previously received a slight scratch in his hand while performing a post-mortem examination. All that medical science could suggest was done to no avail. * * * * * In the summer of 1896 a young woman 22 years of age was bitten on the leg by an insect. Several physicians were called in but their treatment gave no relief; blood-poisoning set in; it was decided to amputate the leg, but before it could be done she died. * * * * * In July, 1896, a veterinary surgeon 34 years of age, while removing a cancer from a horse pricked his finger with his knife. The wound was so slight that he forgot all about it. A few days later blood-poisoning set in and in a short time his end came. * * * * * Some forty years ago a man named Whitney was teasing a rattlesnake in a Broadway barroom, was bitten by it, and, though whisky was poured down his throat by the quart, he soon died. "Such results seem entirely unnecessary were the proper course pursued, and at the same time they are a fearful commentary on the medical resources of the day. "The latest researches in regard to alcohol reveal it as a poison to the human system in whatever way it may be diluted or disguised. Its effect is always the same in proportion to the amount taken. It is impossible to habitually use it in any form, even in small quantities, without disease and degeneration resulting therefrom. When taken into the stomach the action is the same as with any other narcotic; the meaning of this word is _to become torpid_. It benumbs the nerves of sensation, and thus the vital resistance to any offending material is reduced, and while the patient _feels_ less of any disturbance the real harm goes on with accumulated force because of the lack of vitality and non-resistance of the nervous system. "When the body is in the throes of a vital struggle with a virulent poison it would seem, to any unprejudiced mind, the height of folly to further weaken the vital resistance by the administration of any narcotic, and especially alcohol. "The eminent German, Professor Bunge, says: 'All the results which on superficial observation appear to show that alcohol possesses stimulant properties, can be explained on the ground that they were due to paralysis.' * * * * * Professors S. Weir Mitchell and E. T. Reichert, in _Researches on Serpent Poison_, make this notable statement: 'Despite the popular creed, it is now pretty sure that many men have been killed by the alcohol given to relieve them from the effects of snake bite, and it is a matter of record that men dead drunk with whiskey and then bitten, have died of the bite.' "As a great contrast to the weakness of the mass of our people who are drug-takers and alcohol-consumers, and who are liable to almost any epidemic that comes along, and quickly succumb to a serious injury, may be mentioned the Turkish soldiers of to-day, who know nothing of drugs as we use them and never use alcohol in any form. During the late controversy with the Greeks, one of them who was reported as having been shot in the stomach, remained in the ranks, and afterward walked ten miles. Another one who was wounded twice in the legs and once in the shoulder, continued attending to his duties for twenty-four hours, until an officer noticed his condition and ordered him to the hospital. The heat was tremendous, but the troops endured it without complaint, and the doctors were astonished at the wonderful vitality of the wounded Turks, who recovered with remarkable rapidity. This, with good reason, is attributed to their abstemious lives. "It has been stated that the Moqui Indians handle the rattlesnake with impunity, and are not inconvenienced by its occasional bite. "The rational treatment of animal poison is to endeavor to prevent the entry of the virus into the circulation and to neutralize it in the wound before it is absorbed; but when it has entered the system everything should be done for its elimination. "The most powerful aid to the human system, and the most perfect eliminator known to man is heat. It is used with much advantage, and great success by means of water, both internally and externally, but above all is its use by hot air, as in the Turkish bath, which works in harmony with every natural function, promoting the action of all the secretions, and more particularly the excretions. By this means will the system unload itself of an accumulation of impurities in an incredibly short space of time, while the heat aids in destroying whatever there may be of virus therein. "Calmette, whom we have previously quoted, has shown that whatever be the source of snake venom, its active principle is destroyed by being submitted to a temperature of about 212 degrees for a variable length of time. "In the not remote future thousands of human beings will owe to the Turkish bath not only an immunity from disease in general, but also an escape from the horrors of a premature death from hydrophobia, the poison of snake bite, or the slower action of infectious disease. "The mass of testimony that has been accumulating for over thirty years past is more than sufficient to convince any reasonable mind that is willing to examine the facts. "The medical profession has searched the world over and under for the means of controlling disease, while within the human body itself lies the vital power which needs only to be cultivated and exalted to its true function to banish the mass of disease from the land." Dr. Shepard states in another article that Turkish baths are now used in London and Paris for the cure of hydrophobia. Dr. J. H. Kellogg says:-- "A great number of remedies have acquired the reputation of being cures for snake bites. The partisans of each one of these have been able to produce a large number of cases, which apparently supported their claims; the uniform testimony of all scientific authorities upon this subject, however, is that all these so-called antidotes are worthless. Prof. W. Watson Cheyne, M. B., F. R. C. S., surgeon of Kings College Hospital, London, England, states, in the _International Encyclopedia of Surgery_, that 'there is no known antidote by which the venom can be neutralized, nor any prophylactic.' This eminent authority also remarks further: 'Hence medication with this view is to be avoided altogether, and the aim of treatment should be to prevent the poison from gaining access to the general circulation, and to avoid its prostrating effects if its entrance has already taken place.' The same writer asserts that the only aim of the constitutional treatment should be 'to sustain the strength until the poison shall have been eliminated.' The idea that the saturation of the body with whisky to the point of intoxication, if possible, is beneficial in these cases, is in the highest degree erroneous. Whisky intoxication, according to Dr. Cheyne, actually 'favors the injurious effect of the poison. What is required is to keep the patient alive until the poison has been eliminated.' Whisky will not do this, but actually aids the poison in its fatal work by lessening the resistance of the patient, and hence lessening his chances for recovery. "The reputation of whisky as a remedy in these cases is due to the fact that on an average only one person in eight who is bitten by a rattlesnake is really poisoned; the reasons for this were fully explained in an interesting paper on 'Rattlesnakes,' by the eminent Dr. S. Weir Mitchell, and published in the Smithsonian Contributions to _Knowledge_ for 1860. If the snake strikes several times before inflicting a wound, the sacs containing the venom may be emptied, so that the succeeding bite will introduce only the most minute quantity of poison--not enough to produce serious, or fatal results. If the part bitten is covered by clothing, the poison may be absorbed by the clothing, so that but very little enters the circulation. In various other ways the snake is prevented from inflicting a fatal wound. The popular idea, that every bite of a rattlesnake is necessarily poisonous, is thus shown to be erroneous. It is not at all probable that the administration of whisky has ever in any case contributed to the long life of a person bitten by a rattlesnake. "Whisky is often recommended by physicians with the idea that it will sustain the energies of the patient, or will stimulate the heart, etc.; but it has been clearly shown that alcohol in all forms is not only useless for these purposes, but does actual damage, since it lessens the resistance of the patient, weakens the heart, and helps along the prostration which is the characteristic effect of the rattlesnake venom. Alcohol has, for many years, been used as an antidote for collapse under an anæsthetic administered for surgical purposes, but no intelligent physician nowadays thinks of using alcohol for such a purpose; instead, alcohol is given before the anæsthetic for the purpose of facilitating its effect. Errors of this sort which have once become established are very hard to uproot. Probably some physicians will continue to use alcohol for shock, exhaustion, general debility and similar conditions as well as for rattlesnake poisoning for another quarter of a century, but such use of alcohol does not belong to the domain of rational medicine and is not supported by scientific facts." "Under the Pasteur method, a man who did not take alcohol was much more likely to recover from the bite of a mad dog than one bitten under the same conditions, who used that drug; while in lock-jaw there was absolute failure to secure immunity if the patient had taken alcohol. In India it used to be given in large quantities for snake bite, but it was found that it had a direct effect in interfering with the processes of repair, and so is being abandoned."--DR. SIMS WOODHEAD, of the Royal College of Physicians and Surgeons, London, Eng. "Nothing could be more irrational and dangerous than the popular notion concerning the antagonism of whisky and snake-bites, and Willson reports that several of the fatalities in his series were directly due to alcohol rather than to the bite."--_Editorial, Journal of the American Medical Ass'n._ RHEUMATISM:--"Unquestionably, the most active cause of rheumatism, as well as of migraine, sick-headache, Bright's disease, neurasthenia and a number of other kindred diseases, is the general use of flesh food, tea and coffee, and alcoholic liquors. As regards remedies, there are no medicinal agents which are of any permanent value in the treatment of chronic rheumatism. The disease can be remedied only by regimen,--that is, by diet and training. A simple dietary, consisting of fruits, grains, and nuts, and particularly the free use of fruits, must be placed in the first rank among the radical curative measures. Water, if taken in abundance, is also a means of washing out the accumulated poisons. "An individual afflicted with rheumatism in any form should live, so far as possible, an out-of-door life, taking daily a sufficient amount of exercise to induce vigorous perspiration. A cool morning sponge bath, followed by vigorous rubbing, and a moist pack to the joints most seriously affected, at night, are measures which are worthy of a faithful trial. Every person who is suffering from this disease should give the matter immediate attention, as it is a malady which is progressive, and is one of the most potent causes of premature old age, and general physical deterioration. American nervousness is probably more often due to uric acid, or to the poisons which it represents, than to any other one cause."--_Good Health._ "Alcohol favors the development of rheumatism. It does this by preventing waste matter from leaving the system. Beer and wine, because they contain lime and salts, are said to cause rheumatism, or at least to aid in its development. These salts are absorbed into the system, unite with the uric acid, and form an insoluble urate of lime, which is deposited around the joints, thus causing them to become enlarged and stiff. * * * * * "The success of the Turkish bath treatment has been phenomenal. Of over 3,000 cases treated here at least 95 per cent. have been entirely relieved, or greatly helped. Some who were treated over twenty years ago have stated that they have not had a twinge of rheumatism since. Very few have persevered in the use of the bath without experiencing permanent relief."--DR. CHARLES H. SHEPARD, Brooklyn. "Those having a bath cabinet can have a good substitute at home for the Turkish bath. Remember that if tobacco and alcohol are indulged in, there can be no permanent relief." _The New Hygiene_ says:-- "Under no circumstances take any of the thousand and one nostrums advertised as sure cures for this disease. Pure unadulterated blood is the only remedy. This can only be produced by cleansing the system of impurities, and giving it the right kind of material out of which to make it. Keep out the poisonous physic, clean out the colon, strengthen the lungs, and feed the system with proper food, and this disease will vanish like a fog before the rising sun." The same book in advocating the use of the Turkish bath for rheumatism, says:-- "The fact, which is well attested, that when a person enters the bath the urine may be strongly acid, but, on leaving the bath, after half an hour, it is markedly alkaline, shows that the bath has a strong effect upon the system." Dr. Ridge says of _rheumatic fever_:-- "I would urge most strongly the desirability of avoiding every form of alcoholic liquor, from the very commencement of the disease, as affording the best chance for a speedy and safe recovery. The highest authorities are agreed on this point, but there is a lingering practice which makes reference necessary in order to confirm the wavering." In Mt. Sinai Hospital, New York, the hot blanket pack is used in acute rheumatism, almost to the exclusion of other methods. The pack should be continued two to four hours at least, and may be repeated two or three times within the twenty-four hours with advantage. _Nature Cure_ says that thorough massage, and half a dozen cups of hot lemonade will cure a severe case of sciatica:-- "The massage should be commenced moderately, and increased as the patient can bear it. Rubbing and slapping of the muscles with bare hands will hasten a cure, and be agreeable to the patient. One to two hours treatment, if _vigorous_, will effect a cure." SEA-SICKNESS:--Brandy is a common resort in this trouble, many taking it under such circumstances who would under no other. Yet it frequently adds to the sickness, instead of relieving it. "Be sparing in diet for two or three days before the expected voyage. If very sensitive, take to your berth as soon as you go on board, or lie down on deck; get near the centre of the vessel, and lie with your feet to the stern. Go to sleep if possible. Iced water may be sipped, but nothing solid should be taken at first; after a while a cracker or wafer may be taken." It is said upon good authority that if two or three apples are eaten shortly before going on board, or before rough water is encountered, sea-sickness is entirely averted. It will be well to partake of no other food for some hours previous to the voyage when trying this. _Good Health_ says:-- "If any of our readers have occasion to cross the ocean in the stormy season, we recommend three things; keep horizontal, with the head low; put an ice-bag to the back of the neck, keep the stomach clean, free from greasy foods and meats, and eat nothing till there is an appetite for food. A habitually clean dietary before going on board is doubtless a good preparation for such a voyage, as well as for any other nerve strain, or test of endurance. It pays to be good--to your stomach, as well as in other ways." The following is guaranteed by a Russian physician to be an effective cure and a means of avoiding sea-sickness when the symptoms first make their appearance. Take long and deep inspirations. About twenty breaths should be taken every minute, and they should be as deep as possible. After thirty or forty inspirations the symptoms will be found to abate. This is recommended for dyspepsia also. SORE NIPPLES:--"Alum water, or tannin, used for several months in advance will harden as effectually as brandy. If there is soreness on commencing to nurse, put a pinch of alum into milk, and apply the curd to the nipple." SPASMS:--"These are caused by flatulence, as a result of indigestion. A little hot ginger tea, or capsicum tea, may do all that is required. If these are not at hand, loosen every tight band, rub well the region of the heart and stomach, slap the face with the corner of a wet towel, and give sips of cold water." SHOCK:--"In shock, or collapse, the state is similar in some respects to that which is present in fainting. Every function is almost at a standstill; absorption from the stomach and elsewhere is at its lowest point, because the circulation of the blood is so much interfered with. Hence much of the brandy which is so often given, and to such a wonderful amount, with very little apparent effect of intoxication, is really not absorbed at all, and is very often rejected from the stomach by vomiting, when reaction does occur, if not before. "The patient should be wrapped up warmly, and put to bed as soon as possible. The limbs may be rubbed with hot flannels, and hot water bottles put to hands and feet. In some cases, also, towels wrung out of hot water may be wrapped around the head. Hot milk and water, hot water slightly sweetened, or with a little peppermint water in it, should be given as soon as the patient can swallow. Hot beverages will warm the skin more rapidly and powerfully than any alcoholic liquor. "If the patient cannot swallow, an enema of hot water, or hot, thin gruel, should be administered, and may be of use in addition to hot drinks. Beef extract may be added to the hot water with advantage. "In the vast majority of cases there need be no anxiety so far as the shock is concerned; reaction will occur in due time if ordinary care be taken, and will be more natural and steady if the system is not embarrassed by the presence of the narcotic alcohol. In the state of collapse the voluntary nervous system is depressed; alcohol diminishes the power and activity of the nervous centres of the brain, hence its action is undesirable in shock or collapse."--DR. J. J. RIDGE, London. "No procedure could be more senseless than the administering alcohol in shock. A stimulant of some kind is necessary in such cases, and alcohol, instead of being a stimulant is a narcotic. * * * * * Alcohol causes a decrease of temperature, the very thing to be avoided in cases of shock."--DR. J. H. KELLOGG. "I am perfectly sure that a large dose of alcohol in shock puts a nail in the coffin of the patient."--DR. H. C. WOOD of the University of Pennsylvania. SINKING SENSATIONS:--Many women have a feeling of weakness or "goneness" at about eleven o'clock in the morning, and are led by it to the injurious practice of eating between meals. It is often due to indigestion, or to the use of beer or wine. A few sips of hot milk, of fruit juice, or even of cold water will often relieve it, especially if total abstinence is persevered in. SUDDEN ILLNESS:--"Those taken suddenly ill are likely to fare best if placed in a recumbent position, with head slightly elevated, all tightness of garments about the neck or waist relieved, and a little cold water given in case of ability to swallow. A mustard plaster on the back of the neck, or over the stomach, and hot water or hot bottles to the feet, are never out of place, while vinegar, or smelling salts, or dilute ammonia to the nostrils is reviving."--EZRA M. HUNT, M. D., late secretary of New Jersey State Board of Health. "Both the popular and professional beliefs in the efficacy of alcoholic liquids for relieving exhaustion, faintness, shock, etc. are equally fallacious. All these conditions are temporary, and rapidly recovered from by simply the recumbent position, and free access to fresh air. Ninety-nine out of every hundred of such cases pass the crisis before the attendants have time to apply any remedies, and when they do, the sprinkling of cold water on the face, and the vapor of camphor or carbonate of ammonia to the nostrils, are the most efficacious remedies, and leave none of the secondary evil effects of brandy, whisky or wine."--DR. N. S. DAVIS. SUNSTROKE:--"There has lately been a correspondence in the _Morning Post_ on the subject of 'Sunstroke and Alcohol.' We quite agree with the statement that 'nothing predisposes people to sunstroke so much as this pernicious habit of taking stimulants (so-called) during the hot weather.' As far as this country is concerned, nearly every case of sunstroke might be more appropriately designated 'beerstroke.' One effect of alcohol is to paralyze the heat-regulating mechanism; the blood becomes overloaded with waste material, and the narcotism, and vasomotor paralysis, produced by the alcohol, is added to that produced by the heat. Abstainers, other things being equal, can always endure extremes of temperature better than consumers of alcohol."--_Medical Pioneer_, England. "During the month of January, 1896, there occurred over three hundred deaths from sunstroke in Australia. When called upon to offer suggestions relative to its prevention, the medical board promptly informed the Colonial government that, of all the predisposing causes, none were so potent as indulgence in intoxicating liquors, and in its treatment nothing seemed to have a more disastrous effect than the administration of alcoholic stimulants."--_Medical News._ The _Bulletin of the A. M. T. A._ for August, 1896, contained the following:-- "Recently a leading medical man, a teacher in a college, warned his student audience against the anti-alcoholic theories urged by extremists and persons whose zeal was greater than their intelligence. He affirmed positively that the value of alcohol was well known in medicine, and established by long years of experience. "Not long afterward a man was brought into his office in a state of collapse from sunstroke, and this physician and teacher ordered large quantities of brandy to be administered; the patient died soon after." Dr. T. D. Crothers tells of a case where alcohol was administered to a child for partial sunstroke, and says, "there were many reasons for believing that the profound poisoning from alcohol gave a permanent bias and tendency that developed into inebriety later." "When a person falls with sunstroke (or heatstroke) he should at once be carried to a cool, shady place. His clothing should be removed, and cold applications made to the head, and over the whole body. Pieces of ice may be packed around the head, or cold water may be poured upon the body. Cold enema may also be employed. In case the face is pale, hot applications should be made to the head and over the heart and the body should be rubbed vigorously."--DR. J. H. KELLOGG. TYPHOID FEVER. As many lives are lost by this disease, its treatment must ever be one of intense interest, not only to physicians, but also to all humanity. Since non-alcoholic treatment has reduced the death-rate in typhoid to five per cent., the views regarding such treatment expressed by leading practitioners will doubtless be read with eagerness. The following is a paper by Dr. N. S. Davis taken from the _Medical Temperance Quarterly_. "ALLEGED INDICATIONS FOR THE USE OF ALCOHOL IN THE TREATMENT OF TYPHOID FEVER:--On the first page of the first number of a new medical journal bearing date July, 1895, may be found the following statement: 'The question of administering alcohol comes up in every case of typhoid fever. In mild cases, especially when the patient is young, healthy and temperate, stimulants are not needed so long as the disease follows the typical course. Here, as elsewhere, alcohol should be avoided when not absolutely demanded. There is, however, generally such a dangerous tendency toward nervous exhaustion, that in a majority of cases more or less alcohol is required. The indication which calls for its use is an inability to administer enough food. * * * * * Again, the existence of high temperature nearly always makes it necessary to stimulate the patient, as does threatened nervous exhaustion and heart failure, for immediate effect; likewise a weak, small, compressible, rapid pulse, with impaired cardiac impulse and systolic sound, is a frequent indication; other remedies may be required, but alcohol cannot be dispensed with.' The next paragraph continues: 'It is necessary to give alcohol in serious complications of typhoid fever, such as pneumonia, pleurisy, hemorrhage and severe bronchitis or diarrhoea. It is best to begin giving it early and in small quantities: two to six ounces is a moderate amount, eight to twelve ounces daily is not too much for adynamic or complicated cases.' "The foregoing quotations purport to have been condensed from one of our recent authoritative works on practical medicine, and doubtless fairly represent the prevailing opinions concerning the use of alcohol in the treatment of typhoid and other fevers, both in and out of the profession. A careful reading will show that the whole is founded on the following four assumptions: "1. That alcohol when taken into the living body acts as a general stimulant, and especially so to the cardiac and vasomotor functions. 2. That in mild, uncomplicated cases of typhoid fever in young and previously healthy subjects, stimulants are not required and no alcohol should be given. 3. That in a 'majority of cases' the tendency toward dangerous 'nervous exhaustion' and 'heart failure' is so great that the giving of 'more or less alcohol is required.' 4. The amount required may vary from two to twelve or more ounces per day. "In the two preceding numbers of this journal, I have endeavored to show that the chief causes of nervous exhaustion and heart failure, in typhoid and other fevers were impairment of the hemoglobin and corpuscular elements of the blood, deficient reception and internal distribution of oxygen, and molecular degeneration of the muscular structures of the heart itself. These important pathological conditions are doubtless caused by the specific toxic agent or agents giving rise to the fever. Consequently the rational objects of treatment are to stop the further action of the specific cause, either by neutralization, or elimination, or both; to stop the further impairment of the hemoglobin and other elements of the blood; and to increase the reception and internal distribution of oxygen, by which we will most effectually prevent further fatty or granular degeneration of cardiac and other structures. The language of the paragraphs I have quoted, fairly assumes that alcohol is a _stimulant_ capable of relieving nervous exhaustion and cardiac failures, regardless of the causes producing those pathological conditions, and consequently its use is necessary in the 'majority of cases' of typhoid fever. "Can such an assumption be sustained by either established facts, or correct reasoning? Can nervous and cardiac exhaustion, induced by the presence of toxic agents in the blood, with deficiency of both hemoglobin and oxygen, be relieved by a simple _stimulant_, that neither neutralizes nor eliminates the toxic agents, nor increases either the hemoglobin or oxygen? That alcohol does not neutralize or destroy toxic ptomaines, or tox-albumins, is proved by abundant clinical experience, and also by the fact that chemists use it freely in the processes for separating these substances from other organic matters for experimental purposes. That its presence in the living body retards metabolic changes generally, and thereby aids in retaining instead of eliminating toxic agents of all kinds, has been so fully shown in the pages of preceding numbers of the _Medical Temperance Quarterly_, that the leading facts need not be repeated here. That its presence does not increase the hemoglobin, or favor oxy-hemoglobin or increased internal distribution of oxygen, but decidedly the reverse, has been equally well demonstrated by numerous and reliable experimental researches in this and other countries. "Then it must be conceded that alcohol is not capable of fulfilling either of the important indications presented in the treatment of typhoid fever as stated above. Nevertheless, the advocates of its use apparently recognize but two ideas or factors in these cases, namely, the popularly inherited assumption that alcohol is a _stimulant_, and as the patient is in danger from nervous and cardiac weakness, therefore the alcohol must be given, _pro re nata_ without the slightest regard to the existing causes of the weakness, or the _modus operandi_ of the so-called stimulant. "This is proved by the fact that they group together as stimulants, and give to the same patient in alternate doses, remedies of directly antagonistic action, as alcohol and strychnine, or digitalis, etc. "The accepted definition of a stimulant in medical literature, is some agent capable of exciting or increasing _vital activity_ as a whole, or the natural activity of some one structure or organ. "For instance, both clinical and experimental observations show that strychnine directly increases the functional activity of the respiratory, cardiac and vasomotor nervous systems, and thereby increases the internal distribution of oxygen, which is nature's own special exciter of all vital action. Therefore it is properly a direct respiratory, cardiac and vasomotor stimulant and indirectly a stimulator of all vital processes. But the same kind of clinical and experimental observations show that alcohol directly diminishes the functional activity of all nerve structures, pre-eminently those of respiration and circulation, and also of all metabolic processes, whether respirative, disintegrative or secretory. Consequently it not only acts as directly antagonistic to strychnine, but equally so to all true stimulants or remedies capable of increasing vital activity. Instead, therefore, of meriting the name of _stimulant_, alcohol should be designated and used only as an anæsthetic and sedative, or depressor of vital activity. "And a thorough and impartial investigation will show that its use in the treatment of typhoid and other fevers, while deceiving both physician and patient, by its anæsthetic effect in diminishing restlessness, both prolongs the duration and increases the ratio of mortality of the disease, by its impairment of vital activity in the organizable elements of both blood and tissues." Equally interesting is the following outline of treatment pursued by Dr. W. H. Riley, of the Battle Creek Sanitarium. "The purpose of the present paper is to give briefly an outline of the method of treatment of typhoid fever as used by the writer in a considerable number of cases. "A consideration of the pathology of this disease does not properly come under this head, but we wish simply to call attention to the well-known fact that typhoid fever is a germ disease. The germ which causes this fever has generally been supposed to be the bacillus of Eberth. More recent bacteriological studies rather indicate that the bacillus coli may also cause the disease. These germs are usually carried into the body in food or drink, and, lodging in the small intestines, begin to grow and multiply, and by their life produce poisonous ptomaines which are absorbed and carried by the circulation to all the organs and tissues of the body. "It is these ptomaines, thus carried to all parts of the body, that are largely the immediate cause of the pyrexia and attending symptoms. The organisms which produce these poisons for the most part remain in the intestines, although they have been found in the spleen. "The indications for treatment are:-- "1. To remove or destroy the cause (to eliminate the germs and ptomaines from the body). "2. To sustain the vital and resisting powers of the patient. "If the patient is seen early in the disease, it has been my practice to immediately put him to bed and give a free dose of magnesium sulphate. This is preferably given in the morning or forenoon, and may be repeated once or twice on successive days. Besides this the patient should have a large enema of water at a temperature of from 75° to 80° F.; and this may be repeated daily or even oftener, for some time, if necessary, to keep the bowels empty of the poisonous substances. "The salines and enemas thus used carry out bodily a large number of germs and ptomaines that are present in the intestines; and further, the salines, by producing an increased secretion of the mucous membrane of the intestines, tend to disentangle and set free many of the germs that have found a lodging place in the walls of the intestines. "For the elimination of the ptomaines which have been absorbed into the circulation and carried to the tissues, nothing is better than the internal use of water. From three to five pints should be drunk during every twenty-four hours. It should be taken in small quantities--six to eight ounces every hour or two during waking hours, except when food is taken. I will refer to this point more in detail later. "A consideration of the general care of the patient properly comes under the second head of the indications for treatment as given above. The patient should be put to bed in a large, light, well-ventilated room. At least two sides of the room should communicate directly by windows with out-of-doors, in order that the room may be properly ventilated. "All unnecessary articles of furniture, such as carpets, couches, upholstered chairs, pictures, etc. should be removed. "The room should be thoroughly cleaned before the patient is put into it. "There should be two beds in the room for the use of the patient. These should be, preferably, narrow and so placed in the room that there is a free approach to both sides of the bed, for the convenience of the nurse in giving treatment. Iron bedsteads are preferable to wooden. The bedding should be firm, yet soft and smoothly drawn. There should be just sufficient covering to protect the body. The patient should be changed from one bed to the other daily. This may be done by placing the two beds side by side and carefully moving the patient from one to the other. The sheets on the bed from which the patient has been taken should be washed and disinfected at each change of the beds, and all other bedding should be thoroughly aired and exposed to the sunlight daily. "The patient should have the care of a thoroughly educated, careful and competent nurse, one who understands perfectly the various methods of using water in the treatment of fevers. "There is no other single remedy that I consider so valuable in the treatment of fever as the internal use of water. As above stated, the patient should drink six or eight ounces every hour during the waking hours, except for about two hours after food is taken. The water should be thoroughly sterilized, and as a rule may be taken either cool or hot. Ice water is objectionable. Hot water is often preferable. This is a simple remedy, but nevertheless is efficacious. It should be given to the patient whether he calls for it or not, and it should be considered an important part of his treatment. When water is taken into the stomach and absorbed into the circulation, it throws into solution the ptomaines which have been absorbed from the intestines and are present in the circulation and tissues, and thereby puts them in a favorable condition for elimination. It increases the activity of the kidneys, and thus hastens and increases the elimination of the poisons in the system. "In the early stage of the fever, when the pulse is full, and the action of the heart increased, it is best to give the patient cool water. Later in the disease, when the action of the heart is weak, and the patient feeble, it is best to give the water hot. "Winternitz, many years ago, demonstrated that hot water taken into the stomach acts as a cardiac stimulant, and the increased heart's action is immediate, or at least before the water has time to absorb, which indicates that the water in the stomach acts reflexly as a cardiac stimulant. The water after absorption also increases the circulation by filling the blood-vessels, and increasing arterial pressure. The writer has frequently noticed a decided increase in the fullness, and rapidity of the pulse, after a patient has drunk a glassful of hot water. "The external use of water also forms an important part of the treatment. The patient should be sponged off with tepid water every hour or two when the temperature is 103°, or above. When the temperature is less than this, it is not necessary to sponge the body so frequently. Sometimes a hot sponge bath is more efficacious in reducing the temperature than the tepid or cool bath. The sponge bath reduces the temperature, relieves many of the distressing nervous symptoms, is refreshing to the patient, and promotes sleep. The temperature of the body may also be reduced by the use of cool compresses placed over the abdomen, and changed frequently. "The matter of diet is an important factor in the treatment of typhoid fever. The diet should be aseptic, easily digested, and should contain the necessary food elements. Probably no one article of diet meets all these requirements as well as sterilized milk. The patient should take from two to three pints daily. The milk is best taken four times during the day at intervals of four hours, taking eight to ten ounces at a time. Should the patient become tired of the milk, gluten gruel may be substituted for the milk. "The diarrhoea and bowel symptoms, when present, may be relieved by the application of hot fomentations to the abdomen, warm or hot enemas and twenty grains of subnitrate of bismuth given every four hours. "The patient should be kept as quiet as possible, and should be turned in bed at intervals, to prevent hypostatic congestion and the formation of bed-sores. The bony prominences which are apt to become eroded should be sponged frequently with a solution of tannic acid in equal parts of alcohol and water; a dram of the tannic acid to a pint of alcohol and water, is about the proper strength to use. "By the methods briefly outlined above--that is by the free use of water internally and externally, by keeping the intestines thoroughly emptied of poisonous material by the free and frequent use of enemas, by proper feeding and the careful attention of a good nurse to the patient and his surroundings--the duration of the fever may be shortened and the severity of the disease lessened; heart failure, and other complications will seldom occur, and the patient will in nearly every instance make a good recovery. The best method to pursue to prevent heart failure is to keep the poisons which are generated in the bowels and absorbed into the body, and which are the direct cause of the heart failure, eliminated from the body. Should the heart become weak, it may be effectually stimulated by giving hot water to drink, applying heat to the heart in the form of a fomentation, and the application of fomentations to the upper spine. "In the treatment of a large number of cases of typhoid fever, extending over several years' practice, the writer has never made use of alcohol internally to support the action of the heart, or for any other purpose. "The number of cases of death from typhoid fever coming under the writer's observation, where the method of treatment pursued has been similar to that briefly indicated above, have been very few, a much smaller per cent. than in practice where alcohol has been used as a 'cardiac stimulant.' I believe that the use of alcohol in the treatment of typhoid fever is not only useless, but absolutely harmful." Dr. Kate Lindsay, of Battle Creek Sanitarium and Hospital, contributed an article upon Typhoid Fever to the _Bulletin of the A. M. T. A._ for January, 1896, from which a few notes are here taken:-- "The chief toxic centre is evidently the intestinal tract, especially the termination of the ileum. The ulcerations, necroses, perforations and hemorrhages are most frequently found in the last twelve inches of the small intestine, and may extend into the large intestine. The ulcerated surface and open vessels increase the facility with which the poison finds entrance into the circulation. The microbes, blood clots, necrosed tissue and pus, furnish abundant supplies of toxic matter, which, saturating the system, over-power and stop the activity of the functions of all the organs of the body, causing degeneration of tissues. Death is said to take place from heart, lung or brain failure, but the failure involves every other organ as well. "Regarding the intestinal tract as any other abscess at this time, the physician should seek for methods of treatment or remedies which will remove the morbid matters, and destroy, or at least inhibit their action, thus decreasing the fever and stimulating the circulation. Secondary toxic centres often develop in the course of this disease, notably in the glands, lungs and dependent organs, the hypostatic congestion resulting from lying in one position, causing stasis of blood, death and necrosis of tissue, both of the external and internal organs. All vessels connected with the dying tissues carry toxins to other parts of the body. Suppurating glands, and phlebitis of the femoral veins are examples of this secondary infection, and are accountable for the heart failure and collapse so often fatal during the second, third and fourth weeks of typhoid fever. * * * * * "The old idea that in peristaltic action lay the great danger of increase of the hemorrhage and perforation of the bowels, is giving way to the more rational view that gaseous distention and septic absorption, are what bring about fatal results from these complications, and that the moderate peristalsis of the intestinal walls lessens these dangers by closing the gaping ends of the injured vessels, and expelling the septic matter and foul gases. To meet these indications I have found lavage of the bowels, even during hemorrhage, with water of 105° to 110° F. or even hotter, given in moderate quantity of from one pint to three, to give great relief by freeing the large intestines of blood clots, fecal matter and other morbid matter. It also increases peristaltic action in the small intestines, thus favoring the expulsion of gas. The heat stimulates the circulation in the peripheral vessels of the intestines, and overcomes the tendency to blood stasis. "In the cases cited, ice-bags, alternated with fomentations, were used over the abdomen externally, and heat, or hot and cold, to spine. The extremities were kept warm. From ten to thirty minims of turpentine, in an ounce of gum acacia or starch water, increased the efficiency of the enemata, and aided in expelling the gas and checking hemorrhage. "The tendency to hypostatic congestion and bed-sores, was prevented by frequent change of position, and the use of hot and cold to the spine by fomentations and compresses, or better still, hot fine spraying, or the alternate hot and cold spray. In one grave case, spraying was kept up for about twelve hours, with only short intermissions. The heart was stimulated by heat applied over it, whenever depression and collapse threatened, and by hot and cold sponging of the spine." Dr. Noble said some time ago in the _London Times_:-- "Although it is true that alcohol is an antipyretic, yet its exhibition neither shortens nor modifies (favorably) the diseases of which the fever is but a symptom. The paralysis of the brain which is so frequent a cause of death in typhoid fever, is more often brought about by alcohol than any other cause, and more than one woman suffering from puerperal fever has been done to death by the administration of this substance, which, not being _convenienter naturæ, is contra naturam_." J. S. Cain, M. D., in an able paper, read at the Nashville Academy of Medicine, on "Rational Suggestions in the Treatment of Typhoid Fever," dissents from the practice, which still obtains largely in the medical profession, of administering alcoholic liquors, in the belief that they are "stimulants, conservators of force and even nutrients," and says:-- "After a careful and thoughtful study of this subject, I have reluctantly, and against firm early convictions, been forced to the conclusion that these theories with regard to the beneficial effects of alcohol in disease are wholly fallacious. The only rational conclusion at which I can arrive is that the agent is ever, and under all circumstances, a depressor of temperature; that it arrests the physiological interchange of carbonic acid gas and oxygen in the tissues, as well as in the air vesicles of the lungs; that it impedes the elimination of tissue waste, and causes the accumulation of this refuse in the system; that it is lethal anæsthetic in all quantities; that it is not stimulant in the true sense, and never exerts that influence; and that it supplies no element to the diseased and vitiated system calculated to antagonize disease, repair waste, or invigorate lowered vital forces, and therefore for these purposes is not called for in the rational treatment of typhoid fever." At the annual meeting of the American Medical Association held in Atlanta, Georgia, in 1896, Dr. G. B. Garber, of Dunkirk, Ind., read a paper upon "Alcohol in Typhoid Fever" from which a few points are here taken:-- "The fact that the mortality from typhoid fever seems to be gradually lowering is no doubt due in great measure to the non-use of alcohol in the treatment of the disease. Hardly a week passes that some of our journals do not report a series of cases treated without the aid of alcohol in any form. I used alcohol in the treatment of the disease until two years ago, when I became alarmed at the mortality; so I changed my plan, and in 1894 I treated thirty-seven well marked cases of varying degrees of intensity. I had two fatal cases, and in both of them I had used alcohol. In 1895 I treated thirty cases of about the same type, with no death. I only used alcohol in one of them, and it caused me more trouble than any of the others. As this case was in the family of a saloon-keeper, I could not control the matter, as they would give it during my absence. On my return I would find the face flushed, the temperature high, the pulse rapid and the patient nervous. By close inquiry I would find that some of the family had given 'just a little good whisky' which had been in the house for twenty years. "In closing, I wish to state that I am well convinced that in the treatment of typhoid fever our patients will do better and stand a greater chance of recovery, if we abstain entirely from the use of alcohol in the treatment of the disease." Prof. J. Burney Yeo, of London, in a paper read before the International Medical Congress held at Rome, Italy, said:-- "In order to maintain the intestinal antisepsis which forms an essential part of this method of treatment, I insist on the necessity of scrupulous attention and caution in feeding patients suffering from enteric fever, great danger arising from a failure to note the extremely limited digestive and absorptive capacity exhibited by such patients. "In conclusion, the use of alcoholic stimulants, and the common employment of depressing antipyretic agents, must be condemned." In a report of the treatment of typhoid fever by seventy-two physicians of Connecticut, thirty-eight declared that they did not use alcohol in any stage of this disease. The remainder used it sparingly in the last stages, and only two considered it valuable from the beginning of the disease. In a discussion of typhoid fever by a medical society meeting in Rochester, N. Y., recently, sixty physicians being present, only three spoke in favor of using alcohol in this disease. Hygienic physicians all insist upon a rigid fast as long as the high temperature continues, or until the patient is sufficiently hungry to eat a piece of plain, stale, graham bread, "dry upon the tongue." Dr. Charles E. Page of Boston says there would be very few relapses if this plan were carefully carried out. He contends that the whisky and milk diet, together with the not over-fresh air of the average sick room is enough to produce fever in a healthy person, hence is not likely to be conducive to recovery in one already infected with the disease. In an article in the _Arena_ of September, 1892, Dr. Page says:-- "In my fever practice I have frequently observed the effect of fasts of six, eight, ten and twelve days to be in the highest degree productive of the health and comfort of patients, as, on the other hand I have, during the past twenty years observed the deplorable effects of the almost universal plan of constant feeding. In some of the most distressing cases that have happened to be thrown in my way, when all hope in the minds of friends had been abandoned, I have found that withdrawal of food, drugs and stimulants, and the substitution of simple, fresh, soft water, has produced results that seemed almost miraculous." Fruit juices are now permitted by many physicians in fever, a few drops of lemon or orange juice, being a grateful addition to the water. Grape juice, unfermented, is highly recommended by some. A young minister of great promise died recently of typhoid fever. His young wife, only one year married, is in settled melancholy, because she cannot understand why "God took her husband." Inquiry developed the fact that the physician in attendance was a believer in alcohol as a remedy, and used it in this case. In view of the better chances of recovery under non-alcoholic treatment shown by comparative death-rates, may it not be that the alcohol was responsible for the young man's death, instead of its being "God's will to take him?" The Author of all good has too frequently been held responsible for the errors of physicians, and the carelessness of nurses. VOMITING:--"If the vomiting is due to undigested food, and the sickness can be traced to excess, or to improper diet, draughts of hot water should be taken in order to be rid of offending matter in the stomach. After the stomach is empty bits of ice may be sucked, or cold water sipped. A quarter of a Seidlitz powder may be taken. A flannel, folded to four thicknesses, dipped in hot water, and wrung dry in a towel, may be applied to the pit of the stomach. Cover the flannel with a hot plate, being careful to have the flannel large enough to prevent the plate's burning the skin. Pin a dry towel over all, around the body. This may be renewed every half-hour or hour, as required. Sometimes a cold wet compress on the pit of the stomach, covered with a dry towel is more efficacious, heat developing by reaction. Fluid magnesia is often helpful."--DR. RIDGE. CHAPTER IX. ALCOHOL AND NURSING MOTHERS. It frequently happens that the nursing mother is unable by reason of defective digestive apparatus, or imperfect assimilative powers, to supply sufficient nourishment for her babe. In such case she is often advised to drink ale or beer. It is true that these liquors will excite the secretions of the mammary gland, but it is increase in quantity, not in quality, for the milk is impoverished by the added water and alcohol, taken in the beer. Milkmen sometimes salt cows heavily so that they will drink largely of water, and thus give more milk, but one quart of good, rich milk is worth three quarts of the poor, thin stuff resulting from such method. It is proper feeding, and care, that ensure good milk. When women complain that they are unable to nurse their babies the cause is often an error in diet. Too great reliance is put upon meat as strength-giving. While meat, used in moderation, may be valuable to many persons, the nursing mother should not depend upon it to any great extent. She will find farinaceous foods, with plenty of warm milk, what she most requires. At bedtime she should have a bowl of well-cooked oatmeal gruel, diluted with rich milk, and sweetened, if she prefer it so. The milk should be added to the gruel while it is boiling, as it digests more readily if scalded. People who cannot, or think they cannot, take milk of itself, often find it easy to digest it, after it is scalded in the gruel. Anything that a mother can do in the way of nourishing her babe will be done upon such a diet, that is, farinaceous foods and milk. Sweet fruits are of course valuable also, as tending to keep the system in good order. It is well to bear in mind that it is not the quantity of food eaten, but that which is digested, and assimilated, that goes to build up the tissues of the body. So the habit of eating between meals is pernicious, as it disturbs the digestive processes, and robs the stomach of much-needed rest. This habit is the cause, in many cases, of the falling off in the milk after the first month or two. As nourishment for both mother and babe can come from food only, good appetite, and good digestion are essential to health and strength. The very best help towards gaining a good appetite is exercise in the open air. All mothers recognize the need of keeping their little ones out of doors a while every day, but all do not see the necessity of the same mode of life for themselves. Dr. Nathan S. Davis has said: "I have persuaded thousands of mothers to try fresh air, instead of wine or beer, with gratifying results." The mother who takes her babe out, herself, for its daily airing, is laying up stores of health and vitality, to aid her in providing for the needs of the little one, dependent upon her. Good digestion is as essential as good appetite. Alcohol, whether in beer, wine, whisky, or any other form, is injurious to the stomach, and a hinderer of digestion, hence must do harm, rather than good, to the mother in search of added nourishment for her babe. Dr. Condi says:-- "The only drink of the nurse should be water or milk. All fermented and distilled liquors, as well as strong tea and coffee, she should strictly abstain from. Never was there a more absurd or pernicious notion than that wine, ale or porter is necessary to a nursing mother in order to keep up her strength, or to increase the quantity, and improve the properties of her milk. So far from producing these effects, such drinks, when taken in any quantity, invariably disturb more or less the health of the stomach, and tend to impair the quality, and diminish the quantity, of nourishment furnished by her to her infant." Dr. William Hargreaves says:-- "Every farmer knows that all a healthy cow requires to give good milk and butter is, to give her good feed, and pure water; and he also knows that the way to make a cow give poor watery milk, which they might churn until doomsday without obtaining butter, is to feed her on distillery slops, or grains from the brewery. It is also well known that cheese cannot be made from such milk, it being deficient in curd, or casein. "Alcohol is not only useless but injurious; for children whose mothers try to keep themselves upon beer, etc., very frequently suffer from vomiting and diarrhoea, and often from convulsions. Sometimes a single glass of whisky, taken by the mother, will produce sickness and indigestion in the child, for twenty-four hours after. "In the milk of a healthy woman the water ranges from 879 to 905 parts in 1,000. The oily substance ranges from 25 to 42; casein from 15 to 39; sugar of milk from 31 to 45, and the salts from 1 to 4 parts in 1,000. "Alcoholic drinks materially alter these proportions, for, on the analysis of the milk of the same woman, a few hours before and after the use of a pint of beer, it was found that the alcohol increases the proportion of the water, and diminishes that of casein; and that alcohol is very perceptible in it." "The only rational way to be adopted by mothers to increase the supply of nutrition for their infants, is to secure plenty of suitable nutritious food, prepared in the way that will most fit it for digestion, while they at the same time, avoid as far as possible all fatigue, and mental excitement. It is impossible that alcoholic beverages can add anything to the nutrition of either the infant or mother."--Dr. Bussey, in _Stimulants for Nursing Mothers_. Dr. E. G. Figg, in _The Physiological Operation of Alcohol_, gives the analyses of the milk of a temperate woman in good health, and of a drinking woman as follows:-- Milk of temperate mother. Milk of drinking mother. Salts, " " 8.50 Salts, " " 5.50 Casein, " " 3.0 Casein, " " 2.0 Oil, " " 7.50 Oil, " " 6.5 Water, " " 81.0 Water, " " 84.0 Alcohol, " " 2.0 ------ ------ 100.00 100.00 Dr. Edward Smith says in his _Practical Dietary_:-- "Alcoholics are largely used by many women in the belief that they support the system, and maintain the supply of milk for the infant; but I am convinced that this is a serious error, and is not an infrequent cause of fits and emaciation in the child." Dr. James Edmunds, of the Lying-In Hospital, London, Eng., says in _Diet for Nursing Mothers_:-- "The nursing mother is peculiarly placed, in that she has to provide a supply of nutriment for the child which is dependent upon her, as well as for the ordinary requirements of her own system. The nutrition of the child is to be provided for upon the same principles, and by the same food-elements, as is the nutrition of the mother, the only difference being that the young child is possessed of less perfect masticatory and digestive powers, and therefore requires food to be presented to it in a state more simple, uniform, and readily assimilable than the adult, who is furnished with strong teeth, and possessed of a fully-grown stomach. The mastication, digestion, and primary assimilation of the nursing infant's food is thrown upon the mother's organs; but the tissues of the child are nourished precisely as are the tissues of the mother, and a nursing mother requires simply to digest a larger supply of wholesome, and appropriate food. As a matter of course mothers with imperfect teeth, or weak stomachs, cannot perform the digestion of extra food for the infant so well as those mothers who have an abundance of reserve power in their digestive apparatus; and with such patients, the question arises, how are they to make up for the deficiency which they soon experience in the supply of milk? Such mothers appeal to their medical advisers to prescribe some stimulant which will enable them to overcome the difficulty which they experience, and often are greatly dissatisfied if informed that there is no drug in the _materia medica_ which will make up for structural weakness in the organs which masticate, digest or assimilate the food. The proper course for such women to adopt is a simple and rational one. They should assist their digestive apparatus as much as possible by securing an abundance of suitable and nutritious food, prepared in the best way, and as is most digestible, while they should lessen the demands of their own system by the avoidance of bodily fatigue, and mental excitement. These means, aided by that philosophical hygiene which is at all times essential to the preservation of pure and perfect health, will enable them to supply a maximum quantity of pure and wholesome milk; and further calls by the child require proper artificial food. Unfortunately such advice fails to satisfy many anxious mothers who refuse to admit, or believe, that they are less robust, or less capable, than other ladies of their acquaintance, and such mothers fall easy victims to circulars vaunting the nourishing properties of 'Hoare's Stout,' 'Tanqueray's Gin,' or Gilbey's 'strengthening Port,' circulars which are always backed up by the example, and advice, of lady friends, who themselves have acquired the habit of using these liquors, and who view as a reproach to themselves the practice of any other lady who may not keep them in countenance, as the perfection of all moral and physical propriety. Unfortunately the pressure of such lady friends is often so persistent as to paralyse the influence of a conscientious and thoughtful medical adviser, while the appetites and beliefs of such friends often throw them into active antagonism to any medical adviser, who may not endorse the habits in which, as they believe, and no doubt conscientiously, duty to their child requires them to indulge. The only course that a medical practitioner, whose family is dependent upon his practice, can safely take with veteran mothers on this question, is to let them have their own way without reiterated admonition. When once they have acquired the habit of depending upon large quantities of beer for nursing their children, they become perfectly infatuated, and are practically incapable of passing through the probationary fortnight which takes place before the digestive apparatus can work under its natural, but to them strange, conditions, while the temporary longing for beer, and the sudden lessening of the quantity of milk afforded by their strained and impoverished systems, are at once set down as clear proofs that their medical adviser is a crochetty, and dangerous person, who must be superseded at the first convenient opportunity. Facts and arguments have no more influence on such mothers than they have upon opium-eaters, drunkards, or inveterate consumers of tobacco; while the extreme propriety of conduct which these ladies manifest, and the encouragement they receive from other medical men, make the convictions based upon their own personal sensations incontrovertible, and their position practically unassailable. I think I might fairly say that among the comfortable middle classes of society the views at present held on this question are so deplorable that a large proportion of children are never sober from the first moment of their existence until they have been weaned; while often after a few years the use of alcohol is again introduced to the children as a 'medical comfort,' as a part of their regular diet, or as an invariable accompaniment of all their juvenile visitation, and company-keeping. Under such circumstances, it is not surprising that temperance reformers appeal in vain on this question, and that their facts and arguments are viewed with plausible indifference, or insidious opposition, by persons whose appetites and instincts have been undergoing debasement, and perversion from the very dawn of their lives. My own deliberate conviction is that nothing but harm comes to nursing mothers, and to the infants who are dependent upon them, by the ordinary use of alcoholic beverages of any kind. "Infants nursed by mothers who drink much beer also become fatter than usual, and to an untrained eye sometimes appear as 'magnificent children.' But the fatness of such children is not a recommendation to the more knowing observer; they are extremely prone to die of inflammation of the chest (bronchitis) after a few days' illness from an ordinary cold. They die, very much more frequently than other children, of convulsions and diarrhoea, while cutting their teeth, and they are very liable to die of scrofulous inflammation of the membranes of the brain, commonly called 'water on the brain,' while their childhood often presents a painful contrast--in the way of crooked legs, and stunted or ill-shapen figure--to the 'magnificent,' and promising appearance of their infancy. "Those ladies who adopt the general views I have thus expressed in relation to the nursing of their children, will want to know what is the 'proper artificial food' with which to supplement their milk when it is deficient in quantity. With some patients the milk will fall off in quantity at the end of two or three months. With others, although the quantity may not fall off, the child seems unsatisfied; and there is a third class with whom a profusion of milk is supplied, and the child thrives exceedingly, but the mother gets flabby, weak, nervous, pale and exhausted. In the last case, the mother is simply goaded on by susceptibility of her nervous system, or by inordinate activity of the breasts to yield an amount of milk which her digestive powers are not equal to providing for. The treatment of such cases should be simply repressive. The mother should separate herself somewhat more from the child, and make a rule of only nursing it from five to eight times in the twenty-four hours, while the neck of the mother should be kept cool in regard to dress, and cold sponging may be practiced carefully night and morning. Her attention should be diverted by outdoor exercise on foot, and additionally in a carriage if necessary. When the mother's milk, though apparently not deficient in quantity, proves unsatisfying to the child, great attention should be paid to varying the diet of the mother, while such staple foods should be taken as are most easily and thoroughly assimilated into milk. The unsatisfying quality of the milk will generally be remedied by taking a more varied diet, together with three or four half pints of milk in the course of the day, accompanied with farinaceous matter, as in the shape of well-made milk gruel; and in case these measures fail, the only alternative is to supplement the mother's milk by obtaining a wet-nurse to suckle the child three or four times a day alternately with the mother, or by feeding the child with proper artificial food. The same measures may be resorted to where the milk, though satisfying in character, is deficient in quantity; and in preparing artificial food for the child it must always be remembered that the food requires to be adapted to the stage of development which is manifested by a young infant's digestive organs. The infant's digestive apparatus is, in fact, designed to digest milk, and to digest nothing else, but when the teeth are cut farinaceous matter of a more or less solid character should be gradually mixed with the milk. Almost all the illnesses of infants under twelve months of age are caused by some gross impropriety of diet, or otherwise, on the part of the mother, for which the child suffers through the medium of the milk, or they are caused by feeding the child with improper artificial food. Thick sop, and many other articles often given as food are as indigestible to an infant of three months old as beefsteaks would be to a horse; and, until the child has cut its teeth, it should have nothing but food resembling the mother's milk as closely as possible. "The proper way to feed an infant of three months old, whose mother is only able to partially support it, is as follows: When the child wakes in the morning it should not go to the mother, but should be taken away by the nurse, and immediately fed from the bottle, sucking its milk through a suitable teat. After the mother has breakfasted the child may go to the breast, and during the day it should be alternately fed from the bottle, and nursed by the mother. At six o'clock the baby should invariably be placed in its crib, by the side of the mother's bed, and fed just before going to sleep, and the habit of going to bed at six o'clock should be strictly and invariably enforced. If once the child be allowed to come down to the family circle after dark, the habit of going to sleep will be broken, and the child will continuously cry to come down. In the course of the evening the mother may nurse the child once, and at ten or eleven o'clock, when the mother goes to bed, the child should be again fed from the bottle, and the mother should have a basin of well-made milk-gruel; and by her bedside should be placed, at the last moment, as much gruel as she is likely to drink with relish during the night. Whenever the child is restless it should be taken out of its crib, gently, by the mother, and nursed, say two or three times during the night, and put back again into its crib, the child never being allowed to sleep with the mother. When the night is fairly over, and the child awakens, it should be fetched by the nurse, and have its first morning meal from the bottle. This plan of feeding should be persisted in continuously until the child has cut its teeth; and it is only when every means have been taken to ensure the sweetness, freshness and niceness, not only of the milk and water, but of the bottle and of the teat, and the child still fails to get on, that, in rare cases, I advise the admixture of a little farinaceous matter, in the way of food containing one part milk, and two parts of properly sweetened barley-water. As the milk teeth come through, other farinaceous matter may be gradually blended with the milk, and there is nothing better than to begin at about eight months with a teaspoonful of baked flour, well boiled in a pint of milk and water, or in the water, to be afterwards cooled with milk. Oftentimes a little salt, as well as sugar, will materially help its digestion. The child will do well on that food--the quantity being duly increased--until it has cut almost all its milk teeth, when it may eat bread and butter, rice, and egg puddings, and occasionally eat a boiled egg once a day. I believe that it is a great mistake to give red flesh meat to children in their early years, unless there be some very special reason for it, and then it should only be temporarily used; but nice potatoes, flavored with fresh gravy from a joint, may be given at dinner, as the child becomes able to feed itself. * * * * * "Bear in mind that when you take wine, beer or brandy, you are distilling that wine, beer or brandy into your child's body. Probably nothing could be worse than to have the very fabric of the child's tissues laid down from alcoholized blood." Another English physician deplores "the pernicious habit of drinking large quantities of ale or stout by nursing mothers, under the idea that they thereby increase and improve the secretion of milk, whereas they are in reality deteriorating the quality of that upon which the infant must depend for health and life." Dr. Edis says:-- "Infant mortality is mainly due to two causes, the substitution of farinaceous food for milk, and the delusion that ale or beer is necessary as an article of diet for nursing mothers. * * * * * Countless disorders among infants are due simply and solely to the popular fallacy, that the nursing mother cannot properly fulfil her duties, unless she resorts to the aid of alcoholics." Dr. N. S. Davis says:-- "The opinion prevails quite extensively among certain classes of people, and with some physicians, that a liberal use of beer is beneficial to women while nursing their children. They drink it under the impression that it will both strengthen them and make their milk more abundant. But I have never seen a case in which it had been used regularly for any considerable period of time, where it did not result in more or less indigestion from gastric irritation and disordered secretions, and an early failure in the secretion of milk. It probably never increases the flow of milk any more than would the drinking of the same quantity of pure water; while the alcohol it contains, by daily repetition, induces congestion of the gastric mucous membrane, with disordered gastric and hepatic secretions. "A case strikingly illustrating these results was examined by me to-day. The patient was a young married woman who was nursing her first child, now nine months old. At the time of her confinement she was in fair health, rather nervous temperament, weight 120 pounds. During the first few days her milk did not flow very freely, and she says her physician advised her to drink beer. Consequently she commenced to drink a glass of beer at each mealtime, and a bottle during the night. During the first six months she had sufficient milk for her baby; but before the end of that time she had begun to suffer from flatulency, constipation, gaseous and acid eructations, what she calls 'heart-burn,' and sometimes vomiting. During the last three months she has suffered, in addition to the preceding symptoms, one or two attacks each week of extreme pain, from the lower point of the sternum to the back between the scapula, accompanied by retching, or severe efforts to vomit. To relieve these attacks she has taken liberal doses of gin, in addition to her regular supply of beer. Now at the end of nine months, her milk has nearly ceased to flow, her bowels are costive, her stomach tolerates only small quantities of the simplest nourishment, her flesh and strength are very much reduced, her weight being only 96 pounds; and yet she thinks both the beer and gin make her feel better every time she takes them. Such is the delusive power of the anæsthetic effect of alcohol. A persistence in the same management would probably terminate fatally in from six to twelve months more, from chronic gastritis, and inanition. But if she will rigidly abstain from all alcoholic remedies, and take only the most bland, unirritating nourishment, aided by mildly soothing and antiseptic remedies, and fresh air, she will slowly recover." In a clinical lecture delivered before the Senior Class in the Northwestern University Medical School, Dr. Davis told of a case similar to the preceding:-- "The flow of milk in her breasts has also diminished to such a degree that she does not have half enough for her baby. Yet she says the _beer_ makes her feel better after each drink, and that the _gin_ helps to relieve the severe attacks of pain, and consequently she thinks she could not do without them. It is undoubtedly true that the patient feels temporary relief from the anæsthetic effect of the alcohol in her beer and gin, just as she would from any anæsthetic or narcotic. And it is equally true that so long as the alcohol is present in her blood it so modifies the hemoglobin and albuminous constituents, as to diminish the reception and internal distribution of oxygen, and thereby retards metabolic changes. But the combined influence of the alcohol in retarding the internal distribution of oxygen and the drain upon the nutritive elements of her blood, in furnishing milk for her baby, led to rapid impoverishment of the blood and tissues, and the early establishment of a sufficient grade of gastritis to cause indigestion, frequent vomiting, and, later, paroxysms of severe gastralgia, with general emaciation, and loss of strength. "In accordance with the present popular ideas, both in and out of the profession, this patient tells me she has tried a great variety of foods, peptonized, sterilized, and predigested, but all to no purpose. And why?--Simply because her troubles are not in the kind of food she takes, but in the morbid condition of her blood, and of the mucous membrane and nerves of her stomach. Consequently the rational indications for treatment are: (_a_) to get her stomach and blood free from the alcohol of beer and gin; (_b_) to encourage the reception and internal distribution of oxygen by plenty of fresh air; (_c_) to give her the most bland, or unirritating food in small, and frequently repeated doses, of which good milk with lime-water, and milk and wheat-flour gruel are the best; (_d_) such medicines as possess sufficient antiseptic, and anodyne properties to allay the irritability of the gastric mucous membrane, and lessen fermentation." CHAPTER X. COMPARATIVE DEATH-RATES WITH AND WITHOUT THE USE OF ALCOHOL AS A REMEDY. A study of statistics relating to the difference in results of the treatment of disease with and without the use of alcohol, cannot but be of great interest to all students of the alcohol question. The appended statistics are culled mainly from the _Medical Pioneer_ of England, now, _Medical Temperance Review_, the journal of the British Medical Temperance Association, and from the _Bulletin of the American Medical Temperance Association_. A paragraph in the _British Medical Journal_, for Dec. 2, 1893, says:-- "An interesting fact has been noted by Dr. Claye Shaw, at the London County Asylum, Banstead, for the Insane. Since the withdrawal of _beer_ from the dietary, the rate of recovery has gone up. During the past year, for example, the recoveries reached 46.97 per cent. Nearly one half of the patients had thus recovered during the period stated. The inmates take their food better without the liquor, and they are thus taught that intoxicants are not a necessity of ordinary health." In the _Medical Pioneer_ for January, 1894, Dr. John Mois, medical superintendent of West Haven Infectious Diseases Hospital, states that prior to 1885 he had treated 2,148 cases of smallpox "in the usual routine method, with the use of alcohol when the heart's action seemed to indicate it;" resulting in a mortality of 17 per cent. But since 1885 he has treated 700 additional cases under similar circumstances except that the use of alcoholic preparations was entirely omitted, and the resulting mortality was only 11 per cent. In the same journal, Dr. J. J. Ridge states that he had treated the 200 cases of scarlet fever admitted into the Enfield Isolation Hospital during the years 1892 and 1893, without alcohol in any form, with a mortality of only 2.5 per cent.; while the mortality in the hospitals under the Metropolitan Asylums Board in 1893, in which alcohol was used in accordance with the usual practice in scarlet fever, was 6.3 per cent. Dr. J. J. Ridge says later:-- "In January, 1894, I published the result of the treatment of the first 200 cases of scarlatina admitted into the temporary wards of the Enfield Isolation Hospital during 1892 and 1893. I stated that there had been five fatal cases, but that one was dying when admitted and only lived a few hours. The mortality was 2 per cent., or 2.5 if the later case is included. "Since then 300 more cases have been admitted and discharged and among these there have been 7 fatal. Hence there have been 14 deaths in 500 consecutive cases extending over a period of a little more than four years. One of these ought to be excluded, no time having been given for treatment. Hence the mortality has been just 2.6 per cent. This, I think it will be admitted, is a low mortality, although it is possible it may be even lower when the cases are treated in a permanent hospital about to be erected. "It may be interesting to state that 4 of the cases died on the third day after admission; 1 on the fourth; 1 on the sixth; 1 on the tenth, with pneumonia; 1 on the thirteenth; 1 on the fifteenth; 1 on the sixteenth; 1 on the eighteenth; 1 on the thirty-sixth, with nephritis and pleuropneumonia; and 1 on the forty-sixth, with otitis and meningitis. "All the cases have been treated without alcohol either as food or drug, although many have been of great severity with various complications. It is certain that the absence of alcohol has not been detrimental, since the mortality is less than three-fourths of that of the mortality among all notified cases in England and Wales. I am bound to say that it is my firm conviction that had alcohol been given in the usual fashion, the death-rate would have been higher. Cases have been admitted to which alcohol has been given previous to admission, apparently with harm, as they have improved without it. One case was particularly noticeable in this respect. A child, aged 6, had had a good deal of whisky, and was supposed to be dying when admitted on the fourth day of the disease, so that the doctor who had seen it was surprised, when he called the following day to inquire, to find it was still alive. Without a drop of alcohol it began to improve and made a good recovery. I may say that delirium is very rare, even in the worst cases treated non-alcoholically." Dr. Norman Kerr says:-- "In my paper on 'The Medical Administration of Alcohol,' read to the section of medicine at the Sheffield meeting in 1876, I cited several medical testimonies in favor of non-alcoholic treatment of fevers, notably that of my friend, the late Dr. Simon Nicolls, who had a mortality of less than 5 per cent. in 230 cases. "The record of the results of a greatly lessened administration of alcohol in the treatment of smallpox in the London hospital ships, is of deep interest. Having been requested to inquire into the effects of this diminished alcoholic stimulation on mortality and convalescence, Dr. Birdwood stated that though the gravity of the cases had increased, with a mortality of 15 per 100 in the metropolis, the ship's death-rate had remained at less than 7 per 100. Convalescence had been more rapid, and there had been fewer and less serious complications from abscesses and inflammatory boils. Other causes had contributed to this improvement, but the medical officers attributed a considerable share in the amelioration to a greatly diminished prescription of alcohol." The _Medical Pioneer_ says:-- "In 1872 there appeared in the _Saturday Review_ an article in which the medical practitioners of this country were accused of inciting their patients to free drinking, and in the discussion which this article called forth, Dr. Gairdner, of Glasgow, said that fever patients in that city, when treated with milk and without alcohol, did much better than those reported as having been treated by Dr. Todd with large doses of alcohol; the latter resulting in a mortality of about 25 per cent., while those treated by Dr. Gairdner with milk had had a death-rate of only 12 per cent. About this time the British Medical Temperance Association was founded, owing to the exertions of Dr. Ridge, of Enfield, and in 1876 it was enrolled, under the presidency of Sir B. W. Richardson. It now contains 269 members in England and Wales, 53 in Scotland and 80 in Ireland, or more than 400 altogether, all professional men and women. This, I think, is but a sign of the change of opinion on the use of alcoholic fluids in medical practice, for all who remember what medical practice was in London thirty years ago know that the use of wine and brandy in hospital practice was so common that it was quite a rarity in some hospitals to find a patient who was not ordered, by some of the staff, from three to four ounces of brandy or six to eight fluid ounces of wine. The expense caused to the hospitals by this practice was, of course, great, and increased notably between 1852 and 1872, owing to the prevalence of the views of Liebig and his follower, Dr. Todd. The writings of Parkes, Gairdner, Dr. Norman Kerr and of Sir B. Ward Richardson, Dr. Morton and others, gradually lessened this predilection for treating diseases by alcohol, and accordingly between 1872 and 1882 a great change came over the practice of London hospitals. Thus the sum paid for milk in 1852 in Saint Bartholomew's Hospital was £684, and in 1882 it was £2,012; whilst alcohol in that hospital cost in 1852, £406; in 1862, £1,446; in 1872, £1,446; and in 1882 only £653. Westminster Hospital in 1882 spent £137 on alcohol and £500 on milk. One hospital, St. George's, long continued to use large quantities of alcohol. That hospital in 1872 had the high mortality among its typhoid fever patients of 24 per cent., which was twice as high as that noted by Dr. Gairdner as occurring in Glasgow, when alcohol was abandoned and milk used instead. Dr. Meyer, who reported these cases of typhoid treated in Saint George's Hospital at that time, mentioned that alcohol in large doses was given to 87 per cent. of the patients. Three-fifths of these patients took daily eight ounces of brandy when there was danger of sinking from failure of the heart's action. One-fourth of the number took sixteen fluid ounces of brandy in the 24 hours." "In 230 typhoid cases in St. Mary's Hospital, Dr. Chambers reduced the ratio of deaths from 1 in 5 with alcohol to 1 in 40 without it. Dr. Perry, of Glasgow, found that of 534 cases treated with alcohol, 138 died, while of 491 treated without alcohol, only 9 died." In a recent text-book on medicine occurs the following:-- "English physicians use spirits in fevers, and all experience sustains the conviction that no substitute has been found for them." In a late number of the _Temperance Record_, Dr. Smith gives a different view of the experience of English physicians:-- "When Bentley Todd was at King's College, and leading his profession, brandy was the rule in febrile cases. Then the mortality varied from twenty-five to thirty-five per cent. That the treatment was as fatal as the disease, experience demonstrates:-- "1. Professor W. T. Gairdner, of Glasgow, writing to the Lancet (1864), gave his experience as follows:-- Fever cases Average of treated. wine and spirits. Mortality. 1,829 34 oz. to each 17.69 per cent. 595 2-1/2 oz. to each 11.93 per cent. 212 none 1 death only. (young lives) "These were mostly typhus cases, but the rationale, so far as alcohol is concerned, is the same as in typhoid. "2. At the British Medical Association in 1879, Professor H. MacNaughton Jones gave particulars of 340 cases of typhus, typhoid and simple fever. I append a summary:-- Cases. Deaths. Mortality per cent. Given brandy 58 19 32.7 Given claret 51 2 3.8 Given no alcohol 231 4 1.7 "3. Dr. J. C. Pearson writes to the _Lancet_ (Dec. 5 and 26, 1891), giving his experience of typhoid. He had treated several hundreds of cases without a single death, and never prescribed stimulants in any shape or form in the disease. "4. Dr. Knox Bond writes to the _Lancet_ (Nov. 25, 1893), giving his experience of typhoid at the Liverpool Fever Hospital. He says: 'As a resident for some years in the fever hospitals, my views of the value of alcohol in fever underwent, solely as a result of the experience there gained, entire modification. The conviction became forced upon my mind that in no case in which it was used did benefit to the patient ensue; that in a proportion of cases its use was distinctly hurtful; and that in a small but appreciable number of cases the resultant harm was sufficient to tilt the balance as against the recovery of the patient.' "In plain terms, alcohol tended to the destruction of the patients. Dr. Bond's figures are:-- No. of cases. No. of deaths. Given alcohol 71 18 Given no alcohol 309 15 --- --- 380 33 In May, 1890, Dr. Nathan S. Davis, read a paper before the American Medical Association upon the use of certain drugs in disease. Among the drugs mentioned was alcohol, and comparative death-rates were given in typhoid fever and pneumonia, between Mercy Hospital, Chicago, during a term of years when no alcohol was used in the medical wards, Dr. Davis being in charge of them, and some of the large metropolitan hospitals using alcohol. In Mercy Hospital without alcohol, the death-rate in typhoid fever was only five per cent.; in pneumonia only twelve per cent. "Of 161 cases of typhoid fever treated in Cook County Hospital during 1889, 27 died, or one in six--nearly 17 per cent. "According to the annual report of the Cincinnati Hospital for 1886, 47 cases of typhoid fever were treated during that year, with seven deaths, a mortality rate of 16 per cent. "The Garfield Memorial Hospital, at Washington, reported for the year 1889, 22 cases of typhoid fever, with 5 deaths--or 22 per cent. "In the Pennsylvania Hospital the mortality rate in pneumonia for the years 1884-1886, was 34 per cent. "The mortality of pneumonia in the Massachusetts General Hospital, between the years 1822 and 1889, comprising 1,000 cases, was 25 per cent.; but a gradual increase in mortality had been noted from 10 per cent. in the first decade of the seventy years represented by this report, to 28 per cent. in the last decade. "According to the report of the Supervising Surgeon General of the U.S. Marine Hospital Service for 1888, the number of cases of pneumonia treated between 1880 and 1887 was 1,649, with 311 deaths--nearly 19 per cent. "The Cincinnati Hospital reported for 1886 a mortality rate in pneumonia of 38 per cent. "The mortality rate in the Cook County Hospital, Chicago, for 1889, according to Dr. Heltoin, relating to 80 cases of pneumonia, was 36 per cent." Only a five per cent. death-rate in typhoid fever without alcohol, and from sixteen to twenty-two per cent. with alcohol; only a twelve per cent. death-rate in pneumonia without alcohol, and from 19 to as high as 38 per cent. with alcohol. Such are the comparative death-rates given by Dr. Davis. They should be committed to memory by every opposer of the use of alcohol, as they show clearly that people have many more chances for recovery, other things being equal, in the diseases mentioned, if alcohol is not used than if it is. It is worthy of mention in this connection that Cook County Hospital contains in its report for 1897 the following items: Number of patients 19,536; cost of liquors $80.00; per cent. of deaths from all causes, 5.7. The cost of liquors is only .004 for each patient. This shows a decided advance in the disuse of alcohol, when so very little is used in a great hospital, with so large a number of patients. Dr. A. L. Loomis, in the treatment of 600 typhus fever cases on Blackwell's Island in 1864, excluded alcoholics, with the result of reducing the mortality rate to only six per cent. whereas it had previously been twenty-two per cent., in Bellevue Hospital from which the patients had been removed. In Battle Creek Sanitarium no alcohol is used in any disease, simply because the management believe better results are obtained by the use of other agencies. In the October, (1893) number of the _American Medical Temperance Quarterly_ now _Bulletin of the A. M. T. A._, Dr. J. H. Kellogg gives statistics of deaths from various diseases in the Battle Creek Sanitarium. The total of these statistics is as follows: la grippe, 827 cases, 4 deaths--or two per cent.; scarlet fever, 83 cases, 2 deaths--less than three per cent.; 333 cases of typhoid fever, 9 deaths--or 2.7 per cent.; 82 cases of pneumonia, 4 deaths--or 4.9 per cent. These exceptional results are not attributed solely to the non-use of alcohol. The nursing and surroundings were of the best. But these results certainly show that the use of alcohol as a remedy in acute diseases is not necessary, and that patients have a much better chance for life, other things being equal, where alcohol is not used than where it is. Dr. Kellogg says of the surgical cases:-- "In a hospital of 100 beds, connected with the institution, more than 3,000 surgical cases have been treated, to whom alcohol has never been administered except in connection with chloroform anæsthesia; my uniform custom being to administer an ounce of brandy or whisky five minutes before beginning the administration of the anæsthetic, when chloroform is used. "The surgical cases include more than 300 cases of ovariotomy, and over 300 other cases involving the peritoneal cavity, such as operations for strangulated hernia, the radical cure of hernia, etc. The statistics of death and recoveries are certainly as good as can be produced by any hospital in the world, dealing with the same class of cases. The total mortality from the operation of ovariotomy, including nearly 300 cases, is less than three per cent., and for the last few years, in which the antiseptic measures have been perfected, the record is still better, showing a succession of 172 cases of laparotomy for the removal of ovarian tumors, or diseased uterus and ovaries, without a death. These cases include a number of hysterectomies, and many cases so desperate that those who trust in alcohol as a heart stimulant, and as a means of supporting the vital energies, would certainly have considered it necessary to resort to the use of this drug. Nevertheless, it was not administered in a single case, and I have seen no reason to regret its non-use in a single instance." Dr. T. D. Crothers, of Hartford, Conn., tells the following:-- "In a large hospital a study of the mortality of pneumonia indicated a greater fatality at intervals of six months. There were five per cent. more deaths during periods of two months at a time, twice during the year. This extended back for two years, and was finally narrowed down to the service of an eminent physician who gave spirits freely in all cases of pneumonia from their entrance to the hospital. The other visiting physicians gave very little spirits, and only in the later stages. The physician was skeptical of these statistics, but finally consented to test them by giving up spirits practically in all cases of pneumonia. This was continued for a year, and the mortality went back to the average statistics. That physician has abandoned alcohol as a food and a medicine, only in very limited degree. He writes, 'My stupidity in accepting theories and statements of others, concerning spirits, which I could have tested personally, is a source of deep sorrow, and I do not know but it could be called criminal. I certainly feel that punishment would be just.'" Brandy has been considered the great necessity in cholera, yet the use of it and other alcoholics are known to expose people to greater danger when this disease prevails. The _Bulletin of the A. M. T. A._ is authority for the following:-- "During the epidemic of 1832, Dr. Bronson said: 'In Montreal 1,000 persons have died of cholera, only two of whom were teetotalers.' A Montreal paper said: 'Not a drunkard who has been attacked has recovered from the disease, and almost all the victims have been at least moderate drinkers.' "In Albany, N. Y., the same year, cholera carried off 366 persons above sixteen years of age, all but four of whom belonged to the drinking classes. Packer, Prentice & Co., large furriers in Albany, employed 400 persons, none of whom used ardent spirits, and there were only two cases of cholera among them. Mr. Delevan, a contractor, said: 'I was engaged at the time in erecting a large block of buildings. The laborers were much alarmed, and were on the point of abandoning the work. They were advised to stay and give up strong drink. They all remained, and all quit the use of strong drink except one, and he fell a victim to the disease.' He says also: 'I had a gang of diggers in a clay bank, to whom the same proposition was made; they all agreed to it, and not one died. On the opposite side of the same clay bank were other diggers who continued their regular rations of whisky, and one third of them died.' "In New York City there were 204 cases in the park, only six of whom were temperate, and these recovered, while 122 of the others died. In many parts of the city the saloon keepers saw and acknowledged the terrible connection between their business and the spread of the disease, and, becoming alarmed for their own safety, shut up their saloons and fled, saying: 'The way from the saloon to hell is too short.' "In Washington the Board of Health was so impressed with the terrible facts that they declared the grog shops nuisances, ordered them closed, and they remained closed for three months. "A prominent physician of Glasgow reported: 'Only nineteen per cent. of the temperate perished, while ninety-one and two-tenths per cent. of the intemperate died.' One extensive liquor dealer of Glasgow, said, 'Cholera has carried off half of my customers.' "In Warsaw ninety per cent. of those who died from cholera were wine drinkers. "At Tifels, Prussia, a town of 20,000 inhabitants, every drunkard died of cholera." The _St. Paul Medical Journal_, of September, 1899, gives the following report of a railway surgeon, Dr. Kane:-- "From June 1, 1898, to June 1, 1899, the author performed a few more than four hundred operations. Forty-nine abdominal sections, fifty odd more operations of a graver sort, one hundred miscellaneous of less gravity than above, over one hundred operations upon female perineum and uterus. Of the four hundred, more than three hundred demanded anæsthesia. There were but three deaths, making the mortality a little less than one per cent. "The author does not claim a phenomenally low mortality, nor does he claim specially brilliant results. He has to contend with unreasoning fear on the part of the patients for hospital surgeons, and also most of his cases had been in the hands of quacks, and had subjected themselves to remedies prescribed by old women. Many cases came after the family physician had exhausted his resources. He thinks his results are considerably better than the average in hospitals and in country districts. Alcohol medication was dispensed with entirely after the patients came under his care, and to this he attributes much of his success. He does not believe that alcohol is a stimulant, or a tonic. On the contrary, he believes that it retards digestion, arrests secretion, and hinders excretion. The courage and fortitude of his patients were lessened instead of increased by the use of alcoholic medication. "Pain is better borne, endured longer and more patiently when alcohol is not used. "He urges the practical surgeon to carefully weigh the subject of alcohol, and verify for himself the expediency of its use." Dr. B. W. Richardson in the report of his practice for 1895 in the London Temperance Hospital refers to non-alcoholic treatment of rheumatism. He said:-- "Out of seventy-one cases of acute or subacute rheumatism--the large majority acute, and attended with temperatures moving up to 104° F.--sixty-nine recovered, and two, although they were discharged without being put on the recovery list, were so far relieved that a few days' change in country air seemed all that was required to induce full restoration. Comparing the experience of the treatment of acute rheumatic disease without alcohol with that which I have previously observed with alcohol, I can have no hesitation in declaring that it is of the greatest advantage to follow total abstinence absolutely in this disease. The pain and swelling of joints is more quickly relieved under abstinence, the fever falls more rapidly, there is less frequent relapse, and there is quicker recovery. In brief, the experience of treatment of rheumatic fever minus alcohol, presents to me as much novelty as it does pleasure, and I am convinced that if any candid member of the profession could have witnessed what I have witnessed in this matter, he would agree with me that alcohol in rheumatic fever, however acute, is altogether out of place. I am also under the conviction, though I express it with great reserve, that in acute rheumatism, treated without alcohol, the cardiac complications, endocardial and pericardial, are much less frequently developed than where alcohol is supplied." Dr. Pechuman in _Alcohol--Is It a Medicine_, published in 1891, says:-- "There is no disputing that many deaths occur each day as the result of the administration of alcohol in acute diseases, to say nothing of the deaths caused by its habitual use; and those who give it ignore the very fundamental principles of physiology and the many published statistics. The Boston Hospital report tells a sad story in this connection; it shows that out of 1,042 cases treated with alcoholics 386 died, while out of the same number treated without alcohol only 81 died. Using plain English 305 were actually killed by it." Dr. T. D. Crothers, in the January, 1899, _Bulletin of the American Medical Temperance Association_, gave the following Hospital Statistics, showing a decline in the use of spirits in hospitals:-- "Evidently a great change is going on in the use of alcohol as a remedy in large hospitals. The annual reports of ten hospitals in the New England and the Middle States show the following widely varying figures. The spirits used include beers, wines, whiskies and brandies, and vary from eleven to sixty-one cents a person for all the cases treated. These hospitals treat from eighty to seven hundred cases a year, both surgical and medical, and the medical staff are the leading physicians of the towns and cities where they are located. The hospital where the largest amount of spirits was used is not different from others, nor is the one where the lowest amount is reported. The conclusion is that this difference is due entirely to the judgment of the medical men. The lowest rate (eleven cents each) was in a hospital where one hundred and twenty-one cases had been under treatment. The highest rate (sixty-one cents) was in a hospital of five hundred and forty cases. The mortality from typhoid fever and pneumonia was eight per cent. higher in this hospital than in the one where only eleven cents a head had been expended for spirits. The general mortality did not vary greatly in any of these hospitals, and the records of one year could not be expected to show this. In the remaining hospitals the mortality of the fever and the septic cases was about the same. The free use of spirits did not show any improvement, but rather an increase of the death-rate, while the same amount of spirits used showed but little change, and that in the line of improvement of death-rate. These are only the figures of one year, but they indicate a change of practice, and show the passing of alcohol as a remedy." CHAPTER XI. REASONS WHY ALCOHOL IS DANGEROUS AS MEDICINE. In the chapter upon "The Effects of Alcohol upon the Human Body" are cited some of the reasons assigned by scientific investigators for their disuse of alcohol as a remedy in disease. In this chapter the same may be briefly hinted at, while others, some the results of quite recent research, will be added. In the _Bulletin of the A. M. T. A._, for January 1898, Dr. N. S. Davis says:-- "The supposed effects of alcohol as a medicine were originally based solely on the sensations and actions of the patients taking it. The first appreciable effect of the alcohol after entering the blood is that of an anæsthetic; that is, it diminishes the sensibility of the brain and nerve structures, in the same direction as ether and chloroform. And, as the brain is the material seat of man's consciousness, the alcohol renders him less conscious of cold or heat, of weariness or pain, and less conscious of his own weight or of any external resistance. Consequently, when under the influence of small doses, he feels lighter and less conscious of any external impressions, and thinks he could do more than without it. It was these effects that led both the patient and his physician to regard the alcohol as a general stimulant or tonic, notwithstanding the fact that by simply increasing the doses of alcohol the sensibility soon became entirely suspended, and the patient helpless and altogether unconscious. * * * * * "Simple increased frequency of the heart action is no evidence of either increased force or efficiency in promoting the circulation of the blood. Indeed, it may be stated as a physiological law, that the more frequent the heart action above the normal standard, the less efficiently does it promote the circulation and strength of the living system. But the effect of a moderate dose of alcohol in increasing the frequency of the heart-beat and of blood pressure is so temporary that the doses must be repeated so often that the alcohol accumulates in the blood and tissues, and extends its paralyzing effects to all the vasomotor, cardiac and respiratory nerves. Indeed, all the investigators agree that alcohol in any dose capable of producing an appreciable effect, diminishes the function of the lungs in direct proportion to the quantity taken; and as the lungs are the only channel through which free oxygen reaches the blood, and such oxygen is the natural exciter of all vital activities in the living body, it is not possible to explain how alcohol, or any other drug that diminishes the function of the lungs can, at the same time, act as a cardiac, or any other kind of tonic. "The truth is that all intelligent physicians and writers on therapeutics of the present day agree in stating that alcohol in large doses directly diminishes all the vital processes in the living body, and in still larger doses suspends the life of the individual by paralyzing the cerebral, vasomotor, respiratory and cardiac functions, generally in the order named. If large doses produce such effects, we must logically claim that small doses act in the same direction, but in less degree. In other words, alcohol is as truly and exclusively an anæsthetic as is ether or chloroform, and, like them, is to be used as a medicine only temporarily to relieve pain, or suspend nerve sensibility. But as for these purposes it is less efficient than either ether or chloroform, and other narcotics, there is no necessity for using it as a remedy in the treatment of disease. And in health its use in any dose can be productive of nothing but injury. The only legitimate fields for the uses of alcohol are in chemistry, pharmacy and the arts." In another issue of the same magazine, Dr. Davis writes of the investigations pursued by M. Robin of France in regard to the chemistry of respiration. These investigations, he says, afford conclusive proof that the acts of oxidation are defensive processes of the organism in its struggle with bacteria, and therefore that the physician should favor in every possible way the absorption of oxygen in every infection, especially when there are typhoid complications. He then speaks of the researches of other scientists in the same line, concluding thus:-- "If we add to the foregoing investigations the results obtained by Dr. A. C. Abbott, demonstrating that the presence of alcohol directly diminished the vital resistance to infections, we cannot fail to see that the administration of alcohol in diphtheria, typhoid fever, pneumonia and other infectious diseases, is directly contraindicated. If, as shown by M. Robin, 'the acts of oxidation are defensive processes' against bacterial infections, then certainly the administration of alcohol to patients with such infections is in the highest degree illogical and injurious. The oxygen being obtained for oxidation purposes in the blood and tissues, through the respiratory process, it would be equally absurd to administer alcohol in all cases in which it is desirable to increase the processes of oxidation, as a long series of experiments has shown that the presence of alcohol diminishes the efficiency of the respiratory process in direct proportion to the quantity used. "How much longer will practical writers continue to recommend for the same patient on the same day, fresh air, sponge baths, and vasomotor and respiratory tonics to increase the absorption of oxygen and oxidation processes, and alcohol in the form of wine, whisky and brandy to directly diminish the respiratory function and all the oxidations of the living system?" In his address before the Medical Congress for the Study of Alcohol, held at Prohibition Park, Staten Island, July 15, 1891, Dr. Davis said:-- "If the foregoing views regarding the effects of alcoholic liquids on the human system in health, are correct, what can we say concerning their value as remedies for the treatment of disease? If it be true that the alcohol they contain acts directly upon the corpuscular elements of the blood, and so far diminishes the metabolic processes of nutrition and disintegration as to lessen nerve sensibility and heat production, and favor tissue degenerations, their rational application in the treatment of any form of disease must be very limited. And yet the same errors and delusions concerning their use in the treatment of diseases and accidents are entertained and daily acted upon by a large majority of medical men as are entertained by the non-professional part of the public. Throughout the greater part of our medical literature they are represented as stimulating and restorative, capable of increasing the force and efficiency of the circulation, and of conserving the normal living tissues by diminishing their waste; and hence they are the first to be resorted to in all cases of sudden exhaustion, faintness or shock; the last to be given to the dying; and the most constant remedies through the most important and protracted acute general diseases. Indeed, it is this position and practice of the profession that constitutes, at the present time, the strongest influence in support of all the popular though erroneous and destructive drinking customs of the people. "The same anæsthetic properties of the alcohol that render the laboring man less _conscious_ of the cold or heat or weariness, also render the sick man less conscious of suffering, either mental or physical, and thereby deceive both him and his physician by the appearance, temporarily, of more comfort. But if administered during the progress of fevers or acute general disease, while it thus quiets the patient's restlessness and lessens his consciousness of suffering, it also directly diminishes the vasomotor and excito-motor nerve forces with slight reduction of temperature, and steadily diminishes both the tissue metabolism and the excretory products, thereby favoring the retention in the system of both the specific causes of disease and the natural excretory materials which should have been eliminated through the skin, lungs, kidneys and other glandular organs. Although the immediate effect of the remedy is thus to give the patient an appearance of more comfort, the continued dulling or anæsthetic effect on the nervous centres, the diminished oxygenation of the blood, and the continued retention of morbitic and excretory products, all serve to protract the disease, increase molecular degeneration, and add to the number of fatal results. "I am well aware that the foregoing views, founded on the results of numerous and varied experimental researches and well-known physiological laws, and corroborated by a wide clinical experience, are in direct conflict with the very generally accepted doctrine that alcohol is a cardiac tonic, capable of increasing the force and efficiency of the circulation, and therefore of great value in the treatment of the lower grades of general fevers. But there have been many generally accepted doctrines in the history of medicine that have been proved fallacious. And the more recent experiments of Professors Martin, Sidney Ringer, and Sainsbury, Reichert, H. C. Wood and others, have clearly demonstrated that the presence of alcohol in the blood as certainly diminishes the sensibility of the vasomotor and cardiac nerves in proportion to its quantity until the heart stops, paralyzed, as that two and two make four. "After an ample clinical field of observation in both hospital and private practice for more than fifty years, and a continuous study of our medical literature, I am prepared to maintain the position that the ratio of mortality from all the acute general diseases has increased in direct proportion to the quantity of alcoholic remedies administered during their treatment. How can we reasonably expect any other result from the use of an agent that so directly and uniformly diminishes the cerebral respiratory, cardiac and metabolic functions of the living human body?" The _Medical Pioneer_ of January, 1896, contained a very interesting article by Dr. J. H. Kellogg upon "The Influence of Alcohol upon Urinary Toxicity, and its Relation to the Medical Use of Alcohol." He gives the results of many of his own experiments to determine the effects of alcohol in hindering the elimination of poisonous matter by the kidneys. The subject of one experiment was a healthy man of 30 years, weighing 66 kilos. For fifty days prior to the experiment he had taken a carefully regulated diet, and the urotoxic coefficient had remained very nearly uniform. The urine carefully collected for the first eight hours after the administration of 8 ounces of brandy diluted with water, showed an enormous diminution in the urotoxic coefficient, which was, in fact, scarcely more than half the normal coefficient for the individual in question. The urine collected for the second period of eight hours showed an increase of toxicity, and that for the third period of eight hours showed still further increase of toxicity, the coefficient having nearly returned to its normal standard. Of this Dr. Kellogg says:-- "The bearing of this experiment upon the use of alcohol in pneumonia, typhoid fever, erysipelas, cholera and other infectious diseases, will be clearly seen. In all the maladies named, and in nearly all other infectious diseases, which include the greater number of acute maladies, the symptoms which give the patient the greatest inconvenience, and those which have a fatal termination, when such is the result, are directly attributable to the influence of the toxic substances generated within the system of the patient as the result of the specific microbes to which the disease owes its origin. The activity of the liver in destroying these poisons, and of the kidneys in eliminating them, are the physiologic processes which stand between the patient and death. In a very grave case of infectious disease, without this destructive and eliminative activity the accumulation of poison within the system would quickly reach a fatal point. The symptoms of the patient vary for better or worse in relation to the augmentation or diminution of the quantity of toxic substances within the body. "In view of these facts, is it not a pertinent question to ask how alcohol can be of service in the treatment of such disorders as pneumonia, typhoid fever, cholera, erysipelas and other infections, since it acts in such a decided and powerful manner in diminishing urinary toxicity--in other words, in lessening the ability of the kidney to eliminate toxic substances? In infectious diseases of every sort, the body is struggling under the influence of toxic agents, the result of the action of microbes. Alcohol is another toxic agent of precisely the same origin. Like other toxins resulting from like processes of bacterial growth, its influence upon the human organism is unfriendly; it disturbs the vital processes; it disturbs every vital function, and, as we have shown, in a most marked degree diminishes the efficiency of the kidneys in the removal of the toxins which constitute the most active factor in the diseases named, and in others of analogous character. If a patient is struggling under the influence of the pneumococcus, Eberth's bacillus, Koch's cholera microbe or the pus-producing germs which give rise to erysipelatous inflammation, his kidneys laboring to undo, so far as possible, the mischief done by the invading parasites, by eliminating the poisons formed by them, what good could possibly be accomplished by the administration of a drug, one of the characteristic effects of which is to diminish renal activity, thereby diminishing also the quantity of poisons eliminated through this channel? Is not such a course in the highest degree calculated to add fuel to the flame? Is it not placing obstacles in the way of the vital forces which are already hampered in their work by the powerfully toxic agents to the influence of which they are subjected? "In his address before the American Medical Association at Milwaukee, Dr. Ernest Hart, editor of the _British Medical Journal_, very aptly suggested in relation to the treatment of cholera, the inutility of alcohol, basing his suggestion upon the fact that in a case of cholera, the system of the patient is combating the specific poison which is the product of the microbe of this disease, and hence is not likely to be aided by the introduction of a poison produced by another microbe; namely, alcohol. This logic seems very sound, and the facts in relation to the influence of alcohol upon urinary toxicity or renal activity, which are elucidated by our experiment, fully sustain this observation of Mr. Hart. "In a recent number of the _British Medical Journal_, Dr. Lauder Brunton, the eminent English physiologist and neurologist, in mentioning the fact that death from chloroform anæsthesia rarely occurs in India, but is not infrequent in England, attributed the fact to the meat-eating habits of the English people, the natives of India being almost strictly vegetarian in diet, partly from force of circumstances doubtless, but largely also, no doubt, as the result of their religious belief, the larger proportion of the population being more or less strict adherents to the doctrines of Buddha, which strictly prohibit the use of flesh foods. "The theory advanced by Dr. Lauder Brunton in relation to death from chloroform poisoning, is that the patient does not die directly from the influence of chloroform upon the nerve centres, but that death is due to the influence of chloroform upon the kidneys, whereby the elimination of the ptomaines and leucomaines naturally produced within the body, ceases, their destruction by the liver also ceasing, so that the system is suddenly overwhelmed by a great quantity of poison, and succumbs to its influence, its power of resistance being lessened by the inhalation of the chloroform. "The affinity between alcohol and chloroform is very great. Both are anæsthetics. Both chloroform and alcohol are simply different compounds of the same radical, and the results of our experiment certainly suggest the same thought as that expressed by Dr. Brunton. How absurd, then, is the administration of alcohol in conditions in which the highest degree of kidney activity is required for the elimination of toxic agents! "In a certain proportion of chronic cases there is a tendency to tissue degeneration. Modern investigations have given good ground for the belief that these degenerations are the result of the influence of ptomaines, leucomaines and other poisons produced within the body, upon the tissues. It is well known that many of these toxic agents, even in very small quantity give rise to degenerations of the kidney. It is this fact which explains the occurrence of nephritis in connection with diphtheria, scarlet fever and other infectious maladies. Dana has called attention to the probable role played by ptomaines produced in the alimentary canal in the development of organic disease of the central nervous system. "It is thus apparent that the integrity of the renal functions is a matter of as great importance in chronic as in acute disease, hence any agent which diminishes the efficiency of these organs in ridding the system of poisons, either those normally and regularly produced, or those of an accidental or unusual character, must be pernicious and dangerous in use." Among the more recent findings of science in regard to the effects of alcohol are the action of this drug upon the leucocytes or "guardian cells" of the body. Leucocytes are defined to be "minute, nucleated, colorless masses of protoplasm, capable of ameboid movements, found swimming freely in blood and lymph, in the reticulum of lymphatic glands, and in bone-marrow and other connective tissue." The white corpuscles of the blood are leucocytes. "The work of these cells is to prey upon and take into their substance bacteria and other micro-organisms within the blood and tissues. This destruction of bacteria, and other noxious organisms, has the biological name of phagocytosis." Dr. Alonzo Brown in _Physician and Surgeon_ says of phagocytosis:-- "Recently a brilliant theory has been projected into the histological world. It is the principle of phagocytosis. The beauty of it is so great that we are attracted by it, and its reasonings have riveted general attention. It is said that certain cells have the power to absorb and so destroy other cells. This is phagocytosis. It is said that 'the cells which are known to possess phagocytocic properties are the leucocytes, mucous corpuscles, connective tissue cells, endothelia of blood vessels and lymphatic vessels, alveolar eypithelium of the lungs, and the cells of the spleen, bone, marrow and lymphatic glands.' (Senn). This is a very significant array of colloid matter; and it has been repeatedly affirmed by the highest authorities that alcohol is poisonous to the colloid element. "Now, among the most important of the phagocytes just enumerated are the leucocytes. They embrace and enfold the pathogenic germs with which they come in contact by what is known as an ameboid force. They enclose, disintegrate and absorb the enemy. It is well known that the moment the leucocytes are submitted to an alcoholic solution, their ameboid movements cease, and their function is arrested. It is plain that their phagocytocic power is immediately destroyed. It is possible, also, that the fixed tissue-cells are likewise impaired or killed by alcoholic imbibition. How deleterious, and even deadly, must the internal administration of alcoholic liquors then be in the treatment of diphtheria, and of other diseases having a germinal origin? It therefore follows, to my mind, that all the diseases which are the result of germinal infection, are most badly treated when alcohol is used in their therapy. "With extreme brevity I advert to another view in the field. It is that of adynamic disease. It has been conclusively proven that alcohol decreases the muscular power. It decreases (from the minimum dose to the maximum) the power of the heart as well as that of all other muscles. I say this has been absolutely demonstrated by Richardson and others. In death from adynamia it is through failure of muscle, that is, of the heart, of the scaleni and intercostals, of the diaphragm, and of the laryngeal muscles, et cetera. All of the muscles may gradually fail, become wearied unto death. How pernicious then must alcohol be in adding its influence to bring about the tragic end! "It is my belief that it is in diphtheria that the most dire results are to be observed. In that disease the vast majority of cases die by asthenia, or else by sudden failure of the heart. To what is this sudden cardiac paralysis due? The elucidation is as follows. In the grave cases there is almost invariably a subnormal temperature, together with great muscular prostration. Also it is a physiological fact that a decrease of the temperature slows nervous conduction. As the system is made colder, the nervous force flows slower and slower. In diphtheria the heart muscle is very weak, the temperature falls, the lessened nervous energy but feebly animates the muscular fibres, and so actual paralysis ensues, death closing the scene almost instantaneously. Now, in such a state of imminent danger, brought about by such causes, what could be worse than to administer an agent which notably reduces temperature, and at the same time enfeebles muscular power? May I add, what could be the remedy in such a condition? and I answer, _External heat freely applied to the whole surface of the body_. This will prevent the cardiac paralysis whenever it is preventable." The _Medical Pioneer_ of Dec., 1892, contained an editorial article upon "The Toxine Alcohol," which deals with leucocytes and their functions. The following is the article:-- "Dr. Broadbent's introductory address at the opening of the session at Owen's College, Manchester, deserves more attention than most of these formal deliveries. He dwelt on the intellectual interest which attaches to the study of medical science, and illustrated it, among other ways, by the interest excited by recent observations on the action of bacilli and the combat which goes on between these invading hosts and the guardian cells or leucocytes of the living body. Inflammation surrounding a wound is regarded as caused by the influx and multiplication of leucocytes to engulf and destroy septic bacilli which have gained entrance from the air, a 'local war' of defence. The issue of this pitched battle will depend on the relative number and activity of the respective hosts. Inflammation round a poisoned wound is an evidence of vital power and a means of protecting the system at large from invasion and devastation. If this first line of defence is broken through, the bacilli pass through the lymphatic spaces and ducts to the glands, and another battle ensues which produces glandular swelling and inflammation and possibly abscess. This second line of defence may be insufficient and then we get general septicæmia. It is now well proven that the injury is done, not by the bacilli themselves but by the toxines which they secrete or excrete. Dr. Broadbent very properly points out that the action of the bacilli of fever in the body is strictly comparable to the action of yeast in a fermentable liquid. The yeast cells grow and multiply at the expense of the sugar, in destroying which they produce alcohol, carbonic dioxide and other substances. When the alcohol amounts to some 17 per cent. of the liquid the process is stopped by the poisonous action of the alcohol on the yeast cells. In just the same way the toxines produced by the bacilli at length stop their further multiplication and put an end to the disease. Alcohol is in fact, the toxine produced by yeast, and, like many other toxines, it is not only poisonous to cells which produce it, but to any animal into whose veins it may happen to get. "There can be little doubt that the state of immunity which one attack of certain fevers confers against future attacks depends partly upon what is called the phagocytic action of leucocytes. These have been actually observed to draw into their interior and destroy bacilli which would otherwise have multiplied and produced their special effects. There can be little doubt, either, that we are continually taking into our systems bacilli of all sorts, and that, again, disease is averted by the activity of the germ-devouring leucocytes. Dr. Broadbent describes an experiment which proves that power of resisting disease is largely dependent on the activity of these cells. A rabbit, having had a certain quantity of bacilli injected under its skin, suffers from inflammation at the spot, and perhaps abscess, but recovers. At the same time, another rabbit is treated in precisely the same way, but, simultaneously, a dose of chloral is injected into another part of the body. The chloral, circulating in the blood, is known to paralyze leucocytes, and, as a result of this, they do not collect and wage war on the bacilli injected under the skin; there is very little local reaction, the bacilli get free course into the lymph and blood, and the animal dies. But, in the words of Dr. Broadbent, 'alcohol in excess has a similar action on the leucocytes, and this, as well as the deteriorating influence of chronic alcoholism on the tissues, predisposes to septic infection. A single debauch, therefore, may open the door to fever or erysipelas.' A similar experiment of Doyen confirms this. He found that guinea pigs can be killed by the cholera microbe, when introduced by the mouth, if a dose of alcohol has been previously administered. It has been the general testimony of observers in cholera epidemics that those addicted to much alcohol are far more liable to fatal attacks. But while large doses of alcohol are, of course, more obviously injurious, it would be absurd to imagine that lesser quantities are entirely without influence in the same direction. It has, indeed, been shown by Dr. Ridge, that even infinitesimal quantities of alcohol, such as one part in 5,000, cause a more rapid multiplication of the _bacillus subtilis_ and other bacilli of decomposition, while, by the same quantities, the growth of both animal and vegetable protoplasm is retarded. Hence there can be no longer any question that alcohol renders the body more liable to conquest by invading microbes, less able to resist and destroy them. Alcohol, a toxine injurious to living cells, is destroyed or removed from the body as fast as nature can effect it, but while it remains, and while able to affect the cells at all, its action is detrimental to healthy growth and healthy life, and the less we take of such an agent the better for us. This is a dictum which it becomes the profession to enunciate far and wide. 'The less, the better' is a watchword which all may use, and the wise will interpret it in a way which will infallibly preserve them altogether from all possible danger from such a source." On the sixteenth of December, 1897, Dr. Sims Woodhead, president of the British Medical Temperance Association, gave a masterly address in London upon "Recent Researches on the Action of Alcohol." The lecture was illustrated by lantern slides. From the report given in _The Medical Temperance Review_ of Jan., 1898, the following is culled:-- "In a series of drawings of kidney you will notice first that there is a condition known as cloudy swelling; this is one of the first changes that can be observed. Notice the characteristic features of this cloudy swelling in the cells of all these specimens. The large swollen cells are granular, and very frequently there is a granular mass in the lumen of the tubule. In some cases the cells are so much swollen that the lumen of the tubule is represented merely by a 'star-shaped' radiating chink. The nucleus is usually somewhat obscured, that this alcoholic cloudy swelling (similar to that met with as the result of the administration of certain poisons) is the first change observed in the parenchymatous cells of the organs of animals that have died of acute alcoholic poisoning. This condition, unless the cause is removed, goes on to a condition of fatty-degeneration, as shown in the next specimen in which we have, in addition to the granular appearance of the protoplasm of the cell, a deposition of masses of fat in and at the expense of this protoplasm. "There is another series of changes to which I wish to draw your attention. In the tubules of the kidney we have, in addition to the granular appearance of the protoplasm of the cells, an increase in the number of leucocytes, and connective tissue cells between the tubules around the glomeruli and along the course of the blood-vessels. This condition of small cell infiltration, we know, is constantly associated with inflammatory conditions of the kidney as in other organs. Here then are the changes in the epithelium plus increase in the number of leucocytes. "I show you too a specimen of heart muscle, in which the granular degeneration, or cloudy swelling is well marked whilst here and there the process is going on to fatty degeneration, similar to that seen in the kidney. Here again, then, the active elements of the organ are becoming broken down, or, at any rate, losing their normal structure and affording evidence of fundamental changes in these cells. Such changes are set up, not by any one poison alone, or by any single disease toxin, but by members of many groups of poisons, by alcohols, ethers, etc. indeed by very various poisons--animal, vegetable and mineral. "Now, it is a peculiar fact, as shown by Massart, Bordet and others, in researches on chemiotaxis, that nearly all these poisons have the power of repelling leucocytes, and of seriously interfering with them in the performance of their functions, and this power assumes a special significance in connection with our subject this afternoon. "Now, two of the great functions of leucocytes under ordinary conditions are those of policing and scavenging. Massart and Bordet showed, under the action of certain substances, alcohol amongst others, these functions are lost, but following up Metchnikoff and others they observed that after a time these same leucocytes became accustomed to the presence of these poisons, gradually becoming 'acclimatized' as it were. At first paralyzed or repelled, they after a time pluck up courage to attack the invading substances and carry on or renew their accustomed work of scavenging; they try to get rid of both poisons and poison-producers, and even acquire the power of forming substances (anti-toxins) which can neutralize the poison and allow the cells to devote their energy to doing their own proper work. "Here are drawings of minute abscesses that have formed in the wall of the heart. We see at once the part that the leucocytes play in attacking micro-organisms, and of localizing their action. Look at the blood-vessel in the wall of the heart with its plug of micro-organism (staphylococci) in the centre of a clear space; here the leucocytes are not numerous, indeed they are very sparsely scattered, and appear to have been driven back by the organisms or their toxics. Then a little distance away from the toxin and toxin-forming organisms, the leucocytes are coming up in large numbers, forming a sort of protecting army, as it were. This is known as leucocytosis. In the small patent vessels around this commencing abscess numerous leucocytes, far in excess of the usual proportion, may be seen--the nearer the abscess, the more numerous they become. Thus the leucocytes make their way to what is to become the wall of the abscess, and form a layer around a mass of micro-organisms, localizing, or attempting to localize, such mass. So long as the leucocytes can make their way to this mass, and shut it off from the surrounding tissue, so long we shall have no extension of the abscess. "Now, if you add something--alcohol in the case we are considering--which not only exerts a negative chemiotaxic action--i. e., which drives the leucocyte away--but which, as we have seen, also causes degeneration of nerve, muscle and epithelial cells, shall we not injure the infected patient both directly and indirectly by interfering with the return of the leucocytes driven away, by diminishing or altering the functional activity of these cells, and indirectly by interfering with the excretion of the poisons (owing, as we have seen, to a degenerated condition of the secretory epithelium)? Have we not, in fact, a cumulative action of two substances, either of which alone would do damage, but not in the same proportion as do the two when acting together. "Now let us see what we may learn from a series of experiments carried out by Dr. Abbott, working in the Laboratory of Hygiene of the University of Pennsylvania, under the auspices of the committee of fifty, to investigate the Alcohol Question. "These are his conclusions:-- 1. "That the normal vital resistance of rabbits to infection by streptococcus pyogenes is markedly diminished through the influence of alcohol when given daily to the stage of acute intoxication. 2. That a similar, though by no means so conspicuous, diminution of resistance to infection and intoxication by the bacillus coli communis also occurs in rabbits subjected to the same influences. "Throughout these experiments, with few exceptions, it will be seen that the alcoholized animals not only showed the effects of the inoculations earlier than did the non-alcoholized rabbits, but in the case of the streptococcus inoculations, the lesions produced (formation of miliary abscesses) were much more pronounced than are those that usually follow inoculations with this organism. "With regard to the predisposing influence of the alcohol, one is constrained to believe that it is in most cases the result of structural alterations consequent upon its direct action on the tissues, though in a number of animals no such alterations could be made out by microscopic examinations. I am inclined, however, to the belief, in the light of the work of Berkley and Friedenwald, done under the direction of Professor Welch, in the pathological laboratory of the Johns Hopkins University, that a closer study of the tissues of these animals would have revealed in all of them structural changes of such a nature as to indicate disturbances of important vital functions of sufficient gravity fully to account for the loss of normal resistance. "Following up Dr. Abbott's experiments, Dr. Deléarde, working in Calmette's laboratory in the _Institut Pasteur_ at Lille, made a series of observations which are, from many points of view, of very great interest and importance as he attacks it from an entirely new standpoint, one that will, I hope, ere long, be taken up by those working in this country. It has already been demonstrated that 'alcoholics' suffer far more seriously from microbic affections than do those of sober life, and it is now accepted that amongst them the mortality from this class of disease is higher than amongst those who are not accustomed to take alcohol regularly or to excess. "It is pointed out, as most of us have from time to time had the opportunity of observing, that, taking pneumonia as an example of this class of disease, there can be no doubt that the alcoholic patient has not merely an appreciably smaller chance for recovery, but an apparently slight attack becomes one in which the chances of recovery come to be against the patient rather than in his favor. I well remember when I was House Physician in the Royal Infirmary at Edinburgh that Dr. Muirhead, who almost invariably treated his pneumonic patients without alcohol, used to say that an ordinary case of acute pneumonia should always recover under careful treatment, but that cases of pneumonia in 'alcoholics' were always most anxious cases and in every way unsatisfactory. (Slides were shown on screen to illustrate the changes taking place in pneumonia, the conditions of leucocytosis, and the very important part which leucocytes play in the process of 'clearing up' during the course of the patient's recovery). Dr. Deléarde in an admirable summary gives the principal features of pneumonia in alcoholics. He describes it as running a comparatively prolonged course, as being often accompanied by a violent delirium, following which is a period of prostration or of coma; even in those who recover, abscesses frequently occur in the liver, or in other organs. He also points out that there may be a similar chain of events in other infective conditions such as erysipelas and typhoid fever, but as he insists that, until Abbott's experiments on the streptococcus,[A] staphylococcus[A] and bacterium coli,[A] in alcoholized and non-alcoholized animals, little attempt has been made to indicate the mechanism, or, at any rate, the process by which alcoholized individuals are rendered more susceptible to the invasion and action of micro-organisms. [Footnote A: Microbes or bacteria of different kinds.] "As we have already seen, Abbott's experiments prove beyond doubt that attenuated disease-producing organisms, which in healthy animals do not kill immediately, bring about a fatal result when the animal has previously been treated with alcohol. In order to determine which was the most important factor in the destruction or weakening of the resisting agents in the body, Dr. Deléarde conceived the idea of experimenting with those diseases in which it has been found possible to produce, artificially, as it were, and under controlled conditions, an immunity or insusceptibility in healthy animals. He carried out a series of experiments on rabbits, immunizing against and infecting with the virus of hydrophobia, tetanus and anthrax.[B] To these rabbits he first administered a quantity of alcohol, from 6 to 8 c.c. at first, and gradually rises to 10 c.c. doses per diem. [Footnote B: Carbuncle.] "There is in the first instance a slight falling off in weight of the animal, but after a time this ceases, and the animal may again become heavier, until the original weight is reached. He then took a series of animals and vaccinated them against hydrophobia. In one set the animals were afterwards alcoholized and then injected with a considerable quantity of virulent rabic cord. It was here found that immunity against rabies had not been lost. "In a second set the vaccination and alcoholization were carried on simultaneously, a fatal dose (as proved by control experiment) of rabic cord was then injected, when it was found that little or no immunity had been acquired. In a third series the alcohol was stopped before the immunizing process was commenced. In this case marked immunity was acquired. "As regards rabies, then, acute alcoholism, especially when continued for comparatively short periods, simply has the effect of preventing the acquisition of immunity when alcohol is administered during the period when the immunizing process ought to be going on. This indicates that the action of the alcohol in acute alcoholism is direct, and that although its administration prevents the acquisition of immunity it does not alter the cells so materially that they cannot regain some of their original powers, whilst once the immunity has been gained by the cells, alcohol cannot, immediately, so fundamentally alter them that they lose the immunity they have already acquired. When we come to the consideration of the case of tetanus, however, we are carried a step further. Dr. Deléarde repeating his immunizing and alcoholizing experiments, but now working with tetanus virus in place of rabic virus, found--and, perhaps, here it may be as well to give his own words:-- (1) "'That animals vaccinated against tetanus and afterwards alcoholized lose their immunity against tetanus; (2) "'That animals vaccinated against tetanus and at the same time alcoholized do not readily acquire immunity; (3) "'That animals first alcoholized and then vaccinated may acquire immunity against tetanus if alcohol is suppressed from the commencement of the process of vaccination.' "In the case of anthrax too, as we gather from another series of experiments, it is almost impossible to confer immunity, if the animal is alcoholized during the time that it is being vaccinated, and although the animals, first alcoholized and then vaccinated, may acquire a certain amount of immunity, they rapidly lose condition and are certainly more ill than non-alcoholized animals vaccinated simultaneously. "We have already mentioned that Massart and Bordet some years ago pointed out that alcohol, even in very dilute solutions, exerts a very active negative chemiotaxis, i. e., it appears to have properties by which leucocytes are repelled or driven away from its neighborhood and actions. Alcohol thus prevents the cells from attacking invading bodies or of reacting in the presence of the toxins which also, as is well known, exert a more or less marked negative chemiotaxis, i.e., the cells appear to be paralyzed. In all diseases, then, in which the leucocytes help to remove an invading organism or in which they have the power of reacting or of carrying on their functions in the presence of a toxin, we should expect that alcohol would to a certain extent deprive them of this power or interfere with their capacity for acquiring a greater resisting power or of reinforcing the powers of resistance. It appears indeed to reinforce the poison formed by pathogenic organisms. Dr. Deléarde maintains moreover that chronic alcoholism increases enormously the difficulty of rendering an animal immune to anthrax, whilst as those who have had any experience of cases of anthrax know full well alcoholics, whether acute or chronic, manifest a remarkable susceptibility both as regards attacks of anthrax and the fatality of the disease when once contracted. Further as clinical proof of the correctness of another of these sets of experiments, Dr. Deléarde instances two cases of rabies which have come under observation in the Institut Pasteur--one, a man of 30 years of age, of intemperate habits who after a complete treatment of 18 days after a bite in the hand died of hydrophobia; the other, a child of 13 years who was bitten on the face by the same dog that had attacked the other patient, and on the same day--who underwent the same treatment remained perfectly well. In this case the more severe bite (the face being the most serious position in which a person can be bitten) was received by the child; indeed the intemperate habits of the man, who even took alcohol during treatment, appear to have been the only more serious factor in his case as compared with that of the child. "From all this Dr. Deléarde draws the practical conclusion that patients who have been bitten by a mad dog should as far as possible abstain from the use of alcohol not only during the process of treatment, but also for some time afterwards, even for a period of eight months, during which period, apparently, increase of immunity may be going on. Beyond this he maintains that doctors often commit a grave error in administering strong doses of alcohol to patients suffering from certain infectious diseases such as pneumonia, or from certain intoxications such as those produced by snake-bite, during which an increase in the number of leucocytes appear to be a necessary part of any process that leads to the cure of the patient. Finally, he points out how necessary it is that we should respect the integrity of the leucocytes in the presence of microbic infections or intoxications. We may accept these statements all the more readily as Dr. Deléarde states that 'although we must recognize that small doses of dilute alcoholic beverages are indicated in certain cases where it is necessary to stimulate the nervous system, one must guard oneself against an abuse which may certainly be prejudicial to the putting into operation of the mechanism of defence against the organisms of disease.' "In so far as these conclusions rest on a series of exact experiments we are justified in accepting them as being a most valuable contribution to the question; where there is no experimental basis, we must exercise our own judgment. To show the very strong impression that exists that there is some connection between severe cases of pneumonia and alcohol I may mention that the other day I heard a gentleman (not a medical man) say, 'It is well known that most men (of a certain profession) die from alcoholism.' When asked to explain he said, 'They all die from cirrhosis or pneumonia, and if those conditions are not due to alcoholism, what is?' "There can be no doubt that in addition to its specific action, alcohol has a general action--the mal-nutrition, which is usually associated with the use of alcohol, especially as a result of its action on the mucous membranes of the stomach, etc." That the "guardian cells" of the body play a part in a considerable number of diseases was illustrated by Dr. Woodhead by drawings and photographs, shown on the lantern screen. The photographs included cells containing anthrax, typhoid and tubercle bacilli, the spirilla of relapsing fever, specimens from cases of anthrax. Specimens were shown in which the cells were actually ingesting and digesting the specific micro-organisms. In a case of typhoid, showing large masses of typhoid bacilli in one of Peyer's patches, there were seen certain of the cells which contained the typhoid bacilli, some of them undergoing degenerative changes, and showing unequal standing. Of the researches made by Dr. Abbott referred to in the foregoing lecture Dr. N. S. Davis says:-- "Thus we have another and direct positive demonstration of the fact that the presence of alcohol in living bodies not only impairs all the physiological processes, but also impairs their vital resistance to the effects of all other poisons. It was hardly necessary, however, to trouble the rabbits to obtain proof of this; for such evidence may be found in abundance by examining the vital statistics of every civilized country. The late Frank H. Hamilton, in his valuable work on military hygiene, gives an interesting account of an experiment executed, not on a few rabbits, but on whole regiments of human beings, who were being exposed to the inhibition, not of the streptococcus pyogenes, but to the infections of malarial and typho-malaria fever. And, as many were attacked with sickness, it was thought by some of those in authority that if the soldiers were given a specified ration of alcoholic liquor two or three times a day, it might enable them to resist the morbid influences to which they were exposed. The proposed ration was accordingly ordered, and Dr. Hamilton informs us that the soldiers taking the liquor ration succumbed to the morbific influences surrounding them so much more rapidly than before, that in less than sixty days the order was countermanded, and the liquor ration stopped. And that eminent surgeon and sanitarian added, with peculiar emphasis, that he wished never to see the same experiment tried again." Dr. J. J. Ridge, of London, has learned through his experiments that alcohol not only hinders the leucocytes in their war upon disease germs, but also tends to the multiplication of germs. Of this he says:-- "The antagonism of alcohol to the fundamental functions of life is further exhibited by its action on the cellular elements of living tissues and the free cells or leucocytes of the blood. Dr. Lionel Beale long ago pointed out how it affected the protoplasm of cells, and diminished the movements of amoebae, to which leucocytes are apparently analogous. "But while alcohol is thus injurious to living protoplasm, or _constructive protoplasm_ as it may be called, that which builds up, and forms all kinds of structures, and living beings of all higher types, I accidentally discovered that in minute quantities, under about one per cent., and even in such almost incredible amounts as 1 part in 100,000, (1/10 millilitre in 10 litres) it favors the growth and multiplication of many microbes whose function is antagonistic to the protoplasm of organized beings, and which may therefore be called _destructive protoplasm_. We know that these microbes are kept at bay by the vitality of the tissues; if this vitality is lowered they may prevail: as soon as life departs they set to work, and decomposition is the result. It is, therefore, not very surprising that an agent, like alcohol, which, we have seen, lowers the vitality of constructive protoplasm, should, on the other hand increase the vitality of destructive protoplasm. At any rate such is the fact. In the presence of these minute quantities of alcohol, decomposition goes on more rapidly, and the micrococci and bacilli, thrive and swarm more abundantly. This is easily demonstrable by the more rapid, and thicker, cloudiness of any clear decomposable liquor in the course of a day or two, or in a few days, according to circumstances. But I have demonstrated the more rapid multiplication of some forms by means of plate cultivations, of which I show specimens. It is true of the bacteria of decomposition, of the streptococci, and staphylococci of pus, and of diphtheria. Time alone has been wanting to demonstrate this in other cases, which I hope to do." The _Medical Week_ some time ago contained this paragraph:-- "Dr. Viala, in collaboration with Dr. Charrin, says: 'I have carried out a series of researches on the toxicity of various alcoholic beverages in common use, such as wines and brandies of all brands, from those which are reputed the best to those of very inferior quality. All these products have been analyzed with the greatest care. Our experiments were carried out on fifty animals. Intravenous injections confirm Dr. Daremberg's statement that liquors considered as the best are the most toxic, more particularly as regards their immediate effects.'" Although the foregoing statement directs the reader's attention to the comparative effects of different alcoholic liquors, it also plainly implies several facts of great importance. The first is, that all alcoholic liquors, fermented or distilled, are toxic or poisonous; and the more pure alcohol they contain, the more poisonous are they, the qualities of liquor differing only in the rapidity of their injurious effects. In the same number of the _Medical Week_, Professor Gréhant states that after injecting a quantity of alcohol into the venous circulation of a dog equal to one twenty-fifth, or four per cent., of the estimated weight of the blood of the animal, he found by several analyses at different times that it required "a little over twenty-three hours for complete elimination of the alcohol from the blood." If we consider these results obtained by Viala, Charrin, Daremberg and Gréhant, with those obtained by Dr. A. C. Abbott, showing the direct effect of alcohol in diminishing the normal vital resistance of the living body to infection, we see excellent reasons why the liberal use of alcohol in the treatment of such infectious diseases as diphtheria, typhoid fever and pneumonia, under the supposition that it was a cardiac tonic, has resulted in so great a mortality as from thirty to sixty per cent. Dr. A. Pearce Gould, a London hospital surgeon of the first rank, has made special study of the surgery of the blood-vessels, and of the chest. He was one of the earliest to practice and advocate the careful removal of the axillary glands in all operations for cancer of the breast. He is a strong believer in the value of total abstinence as promoting robust health of body and mind. He regards the value of alcohol in disease as exceedingly small, and prescribes it only very rarely. He thinks that alcohol increases the activity of cancer and other malignant growths, an opinion which is of great importance from one with such exceptional opportunities for observation in these complaints. Dr. N. S. Davis in the _American Medical Temperance Quarterly_ of January, 1895, gives reports of cases which came under his observation as a consulting physician, where the use of alcoholics throughout an extended illness favored the continuance of delirium, or mild mental disorder, after convalescence was established. In each case the withdrawal of the alcohol was followed by a cessation of the mental delusion. One of these cases may be taken as an example:-- "The third case was that of a woman over sixty years of age, who had suffered from a mild grade of fever and protracted diarrhoea, somewhat resembling a mild grade of enteric typhoid fever. "As she became much reduced in strength during the latter part of her diarrhoea, her friends began to give her wine, and sometimes stronger alcoholic drink, under the popular delusion that these could strengthen her. Her mind soon became wandering, and she was troubled with illusions, which were attributed to her weakness, and the so-called stimulants were increased. But the mental disorder increased also, and continued after the fever and diarrhoea had ceased, until the question was raised concerning the propriety of her removal to an asylum for the insane. "Being consulted at that time, and listening to an accurate history of the case, I suggested that the anæsthetic effect of the alcohol on the cerebral hemispheres, in connection with its effect on the hemoglobin, and other elements of the blood, in lessening the reception and internal distribution of oxygen, might be the cause of both the perpetuation of her weakness, and her mental disorder. I advised a trial of its entire omission, and the giving of only simple nourishment, and moderate doses of strychnine and digitalis, as nerve tonics. My advice was followed, though not without much hesitation on the part of her friends. The result, however, was entire recovery from the mental disorder, and some improvement in her general health." Puerperal mania resulted in one case cited, from the use of a moderate amount of wine at mealtimes; when the wine was abandoned the mania subsided. CHAPTER XII. WHY DOCTORS STILL PRESCRIBE ALCOHOLICS. Workers in the department of Medical Temperance of the Woman's Christian Temperance Union are told repeatedly by the better class of physicians that they would be glad often not to prescribe alcohol if patients and their friends would not insist upon its use. There is a deep-rooted prejudice in favor of alcohol as a remedy in the minds of the great multitude of people, and they are ready to distrust as fanatical, or incompetent, any physician who does not use it. Dr. Norman Kerr, a well-known physician of England, says, that during a ten years' residence in America, he found people unwilling to pay him as much for his services as they were willing to pay one who prescribed alcoholics. Even those who were abstainers from liquors as beverages distrusted him for not using these things as medicines. Indeed, this prejudice goes so far with many that they will refuse to employ a non-alcoholic physician, if they know him to be such. In consequence of this latter fact, there are great numbers of skilful physicians who say nothing about alcohol lest they be considered "faddists," and lose practice, but who never prescribe it unless it is asked for by the patient or his friends. Again, consulting physicians will sometimes insist upon the use of alcohol, and thus seeds of distrust of the non-alcoholic physician will be sown. Dr. J. J. Ridge says of medical prescriptions:-- "Hundreds of medical men order alcoholic liquors from habit, from ignorance of their real effect, from fashion, or from a desire to please, or not to offend, their patients. Port-wine is constantly being ordered when persons are recovering from various diseases; day by day they regain their strength, and the port-wine gets all the credit of it, especially since each glass seems to diffuse a comfortable glow over the whole body. They forget that the process of recovery would have gone on without the port, and that hundreds and thousands of people do get well without it. They often ignore the fact that they are taking real tonics in addition. They are misled by the sensations which the alcohol causes; they do not know that it relaxes the blood-vessels instead of improving their tone; that it exhausts the heart by making it beat away more rapidly to no profit. Hence the convalescence is actually more prolonged than it would otherwise be. Gentle exercise, regulated baths, good food, balmy sleep, these are the true restoratives of the exhausted system, and no jugglery with sedatives, such as alcohol, can produce the desired result. "It is by its sedative action that alcohol has obtained its position in public opinion. It will render persons insensible to various uneasy sensations, and the majority prefer to continue the bad habits which produce the uneasy sensations, and then to take them away by a dose or two of some alcoholic liquor, or, indeed, to take this before the uneasy sensations come on. In this way they do themselves injury and make themselves unconscious of it. Dr. Beaumont, who had the opportunity of examining the interior of Alexis St. Martin's stomach, and of seeing how digestion went on, was astonished to see how inflamed the mucous membrane could be without any consciousness of it. He observed, as a matter of fact, that alcoholic drinks of all kinds hindered the process of digestion, and produced this morbid condition of the mucous membrane. The relief, therefore, which can be obtained by alcohol is delusive and dangerous. "But some persons say they are afraid to abandon the use of alcohol because they have been in the habit of taking it for a long period. This fear is entirely groundless. The alcohol will be missed for a time, just as a person who has been using crutches would miss them if thrown away; but they will do better without both after a little while. There is no kind of constitution which renders a person unable to do without alcohol. The prisoners in all our jails have to leave off their drink at once, and altogether, on entering there, and no harm ever ensues in consequence. But some say that this is because their diet is so carefully arranged, and the hygienic condition of the prison so perfect. Quite so. This shows us clearly that when total abstainers become ill outside the prison, their illness is to be attributed to some error in diet or hygiene, or to some accidental circumstance. It is absurd to think that the infraction of one law of health can be nullified by breaking another; that if you eat too much, or too fast, or too often, or what is not good for you, you can escape the consequences by injuring yourself with alcohol." Dr. N. S. Davis was for many years openly sneered at by many of his professional brethren as "a cold-water fanatic." Since his views are now being rapidly adopted by progressive medical men all over the civilized world, it may be that soon those physicians who cling to alcohol will deserve the soubriquet of "alcohol fanatics." Dr. Davis said:-- "If I am asked why the profession continues to prescribe these drinks, I answer; simply from the force of habit and traditional education, coupled with a reluctance to risk the experiment of omitting them while the general popular notions sanction their use. Nothing is easier than self-deception in this matter. A patient is suddenly taken with syncope, or nervous weakness, from which abundant experience has shown that a speedy recovery would take place by simple rest and fresh air. But in the alarm of friends something must be done. A little wine or brandy is given, and as it is not sufficient to positively prevent, the patient in due time revives just as would have been the case if neither wine nor brandy had been used. "Of course both doctor and friends will regard the so-called stimulant as the cause of the recovery. So, too, when patients are getting weak, in the advanced stage of fever, or some other self-limited disease, an abundance of nourishment is regularly administered, in the greater part of which is mixed some kind of alcoholic drink. The latter will always occupy the chief attention, and if, after a severe run, the fever, or disease, finally disappears, it will be said that the patient was sustained or 'kept alive' for over two or three weeks, as the case may be, 'solely by the stimulants,' when, in fact, if the same nourishment and care had been given without a drop of alcohol, he would have convalesced sooner, and more perfectly, as I have seen demonstrated a thousand times in my experience." Dr. Casgrau, of Dublin, says that physicians who make personal use of alcohol are not able to give an unbiased opinion about its action, as one of its most marked effects is that of a narcotic to the mental powers; such physicians are not so acute to observe the action of this, or any drug. Sir B. W. Richardson, M. D., in an address upon the reasons why physicians still prescribe alcoholics, says that the magnetism of public opinion has great weight with professional men. "All professions are under that subtle influence. All professions whatever their duties, whatever their learning may be, are sensitive and obedient to that influence. In their pride they think they lead public opinion; it is a mistake, they always follow it on every question in which the people, at large, have a voice. They can assist in influencing the public voice, and sometimes, to quote the words of Abbé Purcelle, spoken in the dawn of the great French Revolution, they may prove that 'respect for sovereign power sometimes consists in transgressing its orders,' but as a general rule not merely the orders but the inclinations are obeyed. We have to wait on, and for, public opinion, and in nothing so much as on the subject of alcohol. The use of alcoholic beverages rests not on argument but on habit, custom. To those whom it affects personally it is an absolute monarch. It makes its own empire. By the very action which it has upon the body of those who receive it into themselves it rules and governs. The joke of the inebriate man that when he had taken his potation he was quite another man and that then he felt it his duty to treat that other man, is literally true, a terse and faithful expression of a natural fact. The man or woman born and bred under the influence of alcohol is of the race of alcohol, and as distinct a person as any racial peculiarity can supply. The reason, the judgment, the temper, the senses are attuned by it. It is loved by its lovers like life. The grape to them is no longer a luscious fruit; it is 'the mother of mighty wine,' and he who is bold enough to disown that motherhood must stand apart. How can a profession however strong, march all at once against such an overwhelming influence? Itself born, perchance, under the influence bred under it, how shall it immediately be transformed? Why disobey the influence? It is in the _interest_ of the doctor to obey, in a worldly sense of view; but more--it is in his _nature_ to obey. The strong bands of nature and interest go hand in hand. Is it wonderful that the genius of a professional man so situated should, according to the quality of his genius, uphold, root and branch, the rôle of his nativity? On the contrary the wonder is that he has ever done anything else. It is most natural that he should be amongst the last to take up what revolutionizes all the manners, and customs, and faiths, of society. A lady will ask her physician the question, May I take wine, Sir? As much as you like Madam; it is very bad for you and I take none, but that is your business entirely. Henceforth that gentleman is said to be one who prescribes alcohol in any quantity. In fact, he never prescribes it, for although when forbidding is hopeless, there is all the difference in the world between prescribing and permitting, permitting goes down as if it were prescribing. Often a patient will try to compromise. On an ocean of whisky and water, brandy and soda, or other poisonous mixture, he is floating into fatal paralysis. You tell him so faithfully, and he says he knows it and will drop down to claret. If you assent, he tells his friends you have changed his brandy or whisky to wine; if you dissent, he says you have left your duty as a doctor undone, in order to become an advocate for abstaining temperance, about which he is as competent a judge as you are, and he won't pay fees for that advice. He pays to be cured of his disease, not to be dragooned into a system peculiar in its tenets. In an alcoholic world there is a strong argument in this decision. It rolls splendidly, especially down hill." After speaking of non-alcoholic physicians, and their opinions of the harmfulness of alcohol, he adds:-- "On the other side, there are practitioners who, under the magnetism of public opinion, as earnestly believe the opposite in relation to alcohol, who declare they could not, conscientiously, practice their profession if they were debarred the use of alcohol, and who look on the advance and the growth of scientific abstaining principles--which they cannot avoid recognizing--with positive dread. The extremists on this side are indeed extreme in their fanaticism. They shut their eyes to the most obvious facts, and do not hesitate in their blindness to misrepresent the most obvious truths. They affirm that under the influence of total abstinence and, by inference, because of total abstinence, the yearly decreasing death-rate of the population is accompanied by reduction of vitality; that people who live long are more enfeebled than those who live short lives and merry; that under abstinence from alcohol fearful diseases are being developed; that the total abstainers have less power for resisting disease than the moderate temperate; and that under the current system of advance towards total abstinence, a very small advance yet by the way, diseases of a low type have developed and extended their ravages." It is only physicians of large conscientiousness, or of great independence of character, who will dare to go counter to the prejudices of the people. Consequently, it is necessary to educate _the people_ in the teachings of those physicians, whose eminence in the profession has permitted them, or whose conscientiousness has driven them, to expose the delusions concerning the medical value of alcoholic beverages. When the people cease to believe in alcoholic remedies, physicians will no longer prescribe them. But while the majority desire the "physicians' prescription" as a cover for indulgence, there will be found physicians willing to give such prescriptions. That the prescription of alcohol by physicians is largely a matter of routine may be seen from the following two cases, reported to the writer by county superintendents of the department of Medical Temperance. In the first case, the physician said to the nurse, "If the patient's heart becomes weak, you might give a little brandy or whisky." Seeing reluctance expressed upon the nurse's countenance, he added hastily, "Or coffee, strong coffee will do just as well." The nurse in reporting this to the writer, said, "Why couldn't he have ordered coffee in the first place if he thought it equally good?" The second case was that of an aged woman whose physician ordered whisky as a tonic. Her granddaughter ventured to ask, "Would not whisky have a narcotic rather than a tonic effect?" He replied thoughtfully, "Well, tell the truth, I suppose it would." CHAPTER XIII. ALCOHOLIC PROPRIETARY OR 'PATENT' MEDICINES. America has been called the Paradise of Quacks, and with good reason. For years patent medicine manufacturers had such complete control of the American press, both secular and religious, that it was almost impossible to reach the public with information as to the real nature of these concoctions. Consequently the people accepted with amazing credulity the startling claims to miraculous cures of various pills and potions as set forth under glaring headlines in the daily papers. The publicity of the last few years has hurt the traffic seriously, but it still has a great hold upon the ignorant and credulous part of the population, and there is still a very large number of these preparations upon the market. Many persons think that the Pure Food Law guarantees every drug preparation now sold to be perfectly safe for use. This is a great error. The guarantee means simply that the manufacturer guarantees that his preparation is as he states upon the label; the government guarantees nothing concerning the matter. That the guarantee of the manufacturer is not always truthful has been shown by analyses of some preparations made by state and national chemists. All the advantage that the public has through the Pure Food Law, so far as drug preparations are concerned, is that the percentage of alcohol must be printed upon the label, and the presence of certain dangerous drugs, such as morphine, cocaine, and acetanilid must be indicated. Thus persons intelligent as to the nature of these drugs will avoid medicines which the label says contains them. The ignorant are not protected. It was difficult to secure even this small restriction upon the sale of proprietary medicines because of the opposition of a large number of newspaper publishers who were sharing the ill-gotten gains of the medical fakirs. A careful compilation of manufacturers' announcements list 1,806 so-called patent medicines sold in open markets, in which alcohol, opium or other toxic drugs form constituent parts. 675 of the preparations are known as "bitters," stomachics, or cordials, and alcohol enters into their composition in quantities varying from fifteen to fifty per cent.; 390 are recommended for coughs and colds, nearly all of which contain opium. Sixty remedies are sold for the relief of pain, and no other purpose. 120 are for nervous troubles, and of this number, sixty-five have entering into their composition coca leaves, or kola nut, or both, or are represented by their respective active principles, cocaine or caffeine. 129 are offered for headaches, and kindred ailments, and usually with a guarantee to give immediate relief. In these are generally compounded phenacetine, caffeine, antipyrine, acetanilid, or morphine, diluted with soda, or sugar of milk. Dysentery, diarrhoea, cholera morbus, cramp in bowels, etc., have 185 quick reliefs or "cures" to their credit, nearly all of which contain opium, many of them in addition, alcohol, ginger, capsicum or myrrh in various combinations, and there are numerous cases on record where children and adults have been narcotized by their excessive use. Some manufacturers print on the labels covering these goods, words of caution limiting the amount to be taken. Forty-eight compounds for asthma contain caffeine and morphine. Sufferers from toothache have their choice from thirty-eight remedies, and thirty-six soothing, or teething, syrups are provided for infants. Many people have ignorantly and innocently formed an alcohol, morphine, or cocaine habit through the use of patent medicines. Many deaths have occurred from headache powders of which acetanilid is the chief ingredient. Dr. Harvey W. Wiley, chief of the Bureau of Chemistry, says of these headache powders:-- "A woman has a headache and she uses one of these remedies. It relieves the pain. When she has another attack she uses it again and again with the same result. After a while she finds the usual amount of the remedy does not cure the pain. She uses two portions, and so the habit is formed until absolute danger is confronted. For one thing must not be forgotten: these remedies are powerful, for if they were not they would be of no effect. They are in certain doses deadly; they depress the nervous system; they disturb the digestion; they interfere with natural sleep; they require to be used in increasingly larger quantities as the system becomes accustomed to their use; they are almost without exception excreted by the kidneys, thus adding an additional burden to organs already badly overworked. They produce a habit of gaining relief which becomes an obsession and incapable of being resisted." It may be asked, "How is it if these mixtures are harmful only, that so many people profess to have received benefit from them?" There are different reasons for this. 1. The nature of such drugs as alcohol, opium and cocaine is to benumb sensation, so that pain is stilled, and the pain, or functional disturbance forgotten for the time, because the nerves are drugged into insensibility. The person _feels_ better while under the influence of the drug, so thinks it is benefiting him. 2. There are people who imagine they have diseases which they do not have; since trained physicians occasionally err in diagnosis, it is not strange if the laity should do likewise. Such persons are always ready to aver that a certain medicine "cured" them. A ludicrous example of this is a woman out West, whose picture graces the advertisements of a certain nostrum, accompanied by a testimonial that said nostrum cured her of a "polypus"! Upon being written to as to how such a preparation could effect such a cure, she answered that, after giving the testimonial, she found that she had not had a polypus! 3. Some of the cures attributed to drugs, are doubtless due to Nature. It is estimated that from 30 to 90 per cent. of ailments are cured by Nature, unassisted, and often in spite of, the drugs swallowed. Many of the books advertising these remedies (?) give excellent rules of health, which, if followed, would restore persons to vigor more speedily without the accompanying medicine, than they can be restored while the system has the poisonous drugs to throw off. It may be reasonably assumed that a goodly number of recoveries ascribed to drug treatments are due, in reality, to the resisting force of a good constitution, or to obedience to the laws of health given in the circular. 4. It is not uncommon for people suffering from certain diseases to have temporary remissions in the course of the disease. No doubt, some of the cases reported as cures are such spontaneous remissions, which are followed, after the testimonials have been written, by relapse. The majority of people are ignorant of the natural course of diseases--of what happens when no treatment is taken. They do not know that a great many affections are characterized by periods of apparent recovery. For instance in some varieties of paralysis, as well as in consumption, the sufferer may to appearance recover completely for a few months or longer; if a remedy was being used at the time, it would naturally get the credit of causing the favorable change. However, all of the glowing testimonials of wonderful benefits accruing from patent medicines are not what they seem to be. Dr. J. H. Kellogg says in his _Monitor of Health_:-- "The average manufacturer of patent medicines regularly employs a person of some literary attainment whose duty it is to invent vigorous testimonials of sufferings relieved by Dr. Charlatan's universal panacea. In many instances persons are hired to give testimonials, and answer letters of inquiry in such a way as to encourage business. The shameless dishonesty and ingenious villainy exhibited are beyond description." Recently an advertisement of one of these nostrums stated in the headlines that said nostrum was used in the Frances Willard Temperance Hospital, Chicago. The testimonial appended purported to be from a nurse in that hospital, _but the testimonial did not state, as did the headlines_, that the preparation was ever used in that hospital. The president of the hospital board of trustees states that the nurse positively denies having given any testimonial to the company thus advertising. She did give one to another patent medicine concern, but not to this, and never said either was used in the hospital, nor have they been. Suit could be brought for damages, but unfortunately the patent medicine people have unlimited money, and the hospital has not. Early in the present year there appeared in many daily papers a large advertising picture of a man whose name was appended as a professional nurse of a western city. The following testimonial accompanied the picture:-- "Mr. ---- of ----, who is a professional nurse of experience, writes,--'My friend is improving, thanks to ----, and you. I am called on to nurse the sick of all classes. I recommend ---- to such an extent that I am nicknamed ---- (giving name of nostrum) by nearly everybody.'" As the writer of this book was acquainted with a physician residing in the small city mentioned in the advertisement, she wrote to him, requesting that he investigate this testimonial. He replied that he found the chief part of the advertisement, namely, that Mr. ---- was a professional nurse, false; "First, by his own statement as he told me this morning that he never claimed to be a professional nurse. And my personal acquaintance with him, as well as that of a number of other physicians in our little city, and reliable men and women of this community who are acquainted with him, all testify to the same thing, namely; that he is not a professional nurse, neither is he a nurse, or even a reliable man. He is an innocent, ignorant man, very close to the pauper class. He told me when I read the commendation to which his name is affixed, that it was all true except the professional nurse part, and that was entirely false, as stated above." As the picture was of a fine-looking, intelligent-appearing man it probably was as _genuine_ as the testimonial. The following was clipped from a copy of _Merck's Report_, April, 1899, a druggists' paper published in New York city:-- MANY DRUGGISTS INDIGNANT. A PATENT-MEDICINE ADVERTISEMENT CONTAINS UNAUTHORIZED ENDORSEMENTS. "Fully a score of East-side druggists are up in arms over the unauthorized use of their names in a full-page newspaper advertisement of a widely-known specific. This advertisement appeared recently in certain New York daily papers, and retail druggists who have made it a rule of their business never to recommend any particular proprietary article, found themselves quoted in unqualified laudation of the article so liberally advertised. The names and addresses of the druggists were given in full, and when several of the men quoted conferred together they found that the most barefaced misrepresentation had been resorted to. "One of the pharmacists thus misrepresented, happened to be Sidney Faber, the secretary of the Board of Pharmacy. He was not selling this particular specific, and had never said a word for or against it, nevertheless, six or eight lines of endorsement of the article were directly attributed to him. He called on some of his druggist neighbors whose names he saw in the advertisement, and ascertained that they, too, had been falsely and unwarrantably quoted. Mr. Faber promptly wrote to the proprietors of the specific in question, and denounced the published endorsements bearing his name, as a forgery. His indignation was by no means appeased when he received a letter from the proprietary concern, couched in the following language: 'We regret to learn that you have been annoyed by any statements that have appeared in New York city papers. We will forward your letter to them.' "Within the past few days several of the druggists whose names were used in this advertisement without authority, have been considering the advisability of taking legal proceedings in order to ascertain their rights in the matter. It is contrary to pharmaceutical ethics for a pharmacist to specially endorse any proprietary article, or patent medicine. Some of the offended druggists propose to contribute to a fund for the purpose of publicly, and widely, advertising this unwarranted use of their names." When patent medicine advertisers would dare to resort to such a wholesale fraud as this, what may they be expected to refrain from? As an illustration of how commendations from notable persons are sometimes obtained, the following is cited: In the winter of 1899, appeared an advertising picture of the lovely Christian lady from Denmark, the Countess Schimmelmann, who was spending some time in Chicago. Below her picture were the words:-- "Adeline, Countess Schimmelmann, whose portrait is here given, in a recent letter to the ---- company, (mentioning proprietors of nostrum) speaks of friends of hers who have been benefited by ---- (mentioning nostrum), and who first advised her to recommend it to her sick friends. "The Countess, as is well known, is a prominent member of the Danish court. Her coming to this country has been much talked of. Her real object is one of charity. She is stopping in Chicago, _and from there writes her straightforward endorsement of_ ---- (mentioning nostrum)." The italics are the writer's. The picture and the testimonial were cut from the paper, and sent to the countess, asking if she had so spoken of this medicine, and, if so, did she, a strong total abstinence woman, know that this mixture contains a large percentage of alcohol. She responded as follows:-- "Thank you for asking me about the enclosed. A white-ribbon lady came and asked me if I would do her the great kindness to recommend ---- compound (made up of the juice of celery). I said I could not personally recommend it as I neither use, nor want, medicine. But some very reliable friends of mine (_temperance people_, and _true Christians_) told me I would do a good thing in recommending it as they used it, and found it excellent. Then I wrote the following: 'I myself cannot recommend ---- compound as I do not suffer from any of the ailments it is said to be good for, but reliable friends of mine tell me that it is excellent, and I would do a good thing in recommending it to my friends. Adeline, Countess Schimmelmann.' "I will only consent to the publishing of this letter if you publish the _whole_ letter, and no extract from it, as the white-ribbon lady did for the ---- compound." If a white-ribboner played this mean trick upon this distinguished Christian worker she is unworthy of membership in the Woman's Christian Temperance Union. It is more than likely that the "white-ribbon lady," was a paid advertising agent of the patent medicine manufacturer, and wore a white-ribbon to gain the confidence of the Countess. Whether patent medicine manufacturers know how to doctor all ills to which human flesh is heir may be doubted, but that their advertising agents are skilful "doctors" of testimonials is very evident to any one acquainted with the facts. The Department of Public Charities of New York city in a "Report on the use of so-called Proprietary Medicines as Therapeutic Agents," says:-- "In connection with this subject it might be mentioned that, for years past, the name of Bellevue Hospital has been taken in vain by a number of persons and firms, without any authority whatever. It is a common occurrence that samples of proprietary medicines, foods, mineral waters, plasters, etc., etc. are sent to the hospital, or to members of the house-staff for 'trial,' whereupon the subsequent advertisements of the articles in question often assert that the latter are 'used in Bellevue Hospital,' leaving the impression upon the mind of the reader that the article, or articles, have been used with the sanction of some member of the Medical Board. It is probably impossible to find a remedy for this evil, from which many other institutions of repute likewise suffer. To publish a denial of such false assertions would only aggravate the evil. The utmost that can be done appears to be, to caution the medical staff against any entanglements with, or encouragement of, the agents of the interested parties." This report, which was adopted by the Medical Board of Bellevue Hospital, classifies proprietary preparations as "Objectionable" or "Unobjectionable" according to the following rules:-- "Unobjectionable preparations are those, the origin and composition of which is not kept secret, and which are known to serve a useful and legitimate purpose. Malted Milk is an example. Objectionable proprietary preparations, by far the largest group of the whole class, comprise all those which are aimed at under the medical code of ethics under the term 'secret nostrum,' which term may be more closely defined thus: "A secret nostrum is a preparation, the origin or composition of which is kept secret, the therapeutic claims for which are unreasonable or unscientific, or which is not intended for a legitimate purpose. "Examples: The various 'Soothing Syrups,' 'Female Regulators,' 'Blood Purifiers,' and thousands of others." Dr. A. Emil Hiss, Ph. G., says of the secrecy of these preparations:-- "A secret compound with a meaningless title is presumptively a fraud. Why a secret if not to permit extravagant, or fraudulent, claims as to therapeutic merit? * * * * * The ruling motive of the secret being essentially false and dishonest, its employment in the interest of any remedy is clearly a sufficient cause for its condemnation and ostracism." Mothers sometimes wonder why their boys take so readily to cigarettes, or their daughters to cocaine, never thinking that the soothing syrup, or cough mixture given freely by themselves to their children developed a craving for something stronger later on. Mrs. Winslow's Soothing Syrup, advertised for years in church as well as secular papers as "invaluable for children," is cited in the report for 1888 of the Massachusetts State Board of Health as containing opium; also Ayer's Cherry Pectoral, Dr. Bull's Cough Syrup, Jayne's Expectorant, Hooker's Cough and Croup Syrup, Moore's Essence of Life, Mother Bailey's Quieting Syrup, and others too numerous to mention. The report says:-- "The sale of soothing syrups, and all medicines designed for the use of children, which contain opium and its preparations should be prohibited. Many would be deterred from using a preparation known to contain opium, who would use without question a soothing syrup recommended for teething children." Again, on page 149 the following is quoted from a prominent physician:-- "Among infants, and in the early years of life, soothing syrups are the cause of untold misery; for seeds are doubtlessly sown in infancy only to bear the most pernicious fruit in adult life. It is said that one of the best known soothing syrups contains from one to three grains of morphia to the ounce of syrup. I believe that stringent legal measures should immediately be taken to stop the sale of so-called soothing syrups containing opium, morphia or codeine." The writer has known mothers so ignorant of the nature of these soothing syrups as to deliberately put the baby to sleep upon them in order to insure relief from care for some hours. Prof. J. Redding, M. D., says on this point:-- "While it may be true that an adult, of his own free will, and without incentive, or predisposing causes, does occasionally become a drunkard, I am convinced that nine hundred and ninety-nine out of every one thousand individuals who become drunkards are made so in embryo, infancy, or childhood, by the use of alcoholic decoctions, soothing syrups, opiates, calomel, etc. which are given as medicines to allay pain, obtund nerve sensibility, to cure the little sufferer of his _vital manifestations_, of his _mental discomforts_, but leave the actual disease and its, perhaps, putrid causation to time and debilitated vitality to remove." Of the danger and harmfulness of patent cough mixtures _The American Therapist_ says:-- "Cough mixtures as a rule, do more harm than good. Nine times out of ten the principal ingredient is opium. It is true that opium may lessen the tendency to cough, but it does great damage by arresting the normal secretions, and the system becomes affected by the poisons from the kidneys, skin, stomach, intestines and the mucous membrane lining the upper air passages. Not only do these mixtures arrest every secretion in the body, but they also show their deteriorating and degrading effect through the stomach. They contain substances which tend to disorder and derange digestion." Several years ago the Post-Office Department at Washington was led to take an interest in the question of fraudulent "patent" medicines, and an examination of many of these nostrums was undertaken by government chemists. Fraud orders were issued against some of the most flagrant offenders, forbidding them the use of the mails. This has not done away with the evil, however, for they usually move to another city, and begin business again under another name. The examinations made for the Post Office Department revealed the fact that a great many of the so-called medicines on the market were intoxicating beverages in disguise. The Internal Revenue Department then took up the matter and a long list of these beverage medicines was sent out to internal revenue agents with instructions that these must not be sold henceforth unless by persons paying a special tax for the sale of alcoholic beverages. Some of the manufacturers of these nostrums availed themselves of opportunity given to add a recognized medicinal agent to their flavored alcohol and water and such preparations were stricken from the list of those requiring a whisky license for their sale. Peruna and Hostetter's Bitters were the best-known of these. Peruna had been up to this time what government chemists called "a cheap cocktail." The report of the pure food commissioner of North Dakota for 1906 gives on page 157 an analysis of it as now upon the market: "Alcohol by volume, 21.25 per cent.; total solids, 3.846 per cent.; ash, .158 per cent." The report says:-- "The only thing of a medicinal nature that we could find in this preparation appeared to be a small amount of senna combined with a bitters of some kind." Proprietary "Foods" have not escaped attention from chemists. Dr. Charles Harrington, for several years secretary of Massachusetts Board of Health, was the first to publish an analysis of these preparations showing their alcoholic strength and their small nutritive content. He lists "foods" examined by him as follows:-- "Liquid Peptonoids 23.03 alcohol; maximum amount recommended will yield less than one ounce of nutriment per day, and the equivalent of 3.50 oz. of whisky. Hemapeptone 10.60 alcohol; Hemaboloids 15.81 alcohol; the maximum dose recommended yields about 1/4 oz. of nutriment, and the equivalent of about 1-1/2 oz. of whisky daily. Tonic Beef 15.58 alcohol; doses recommended yield about 1/2 oz. nutriment daily, and the equivalent of one ounce of whiskey. Mulford's Predigested Beef 19.72 alcohol; doses recommended yield about 1-1/4 oz. nutriment daily, and the alcoholic equivalent of about 6 oz. of whisky. There were "Foods" for the sick examined which were non-alcoholic, but their nutritive value was about nothing in comparison to their cost." The Committee on Pharmacy of the American Medical Association reports on the following foods thus:-- Carpanutrine 17.3 alcohol; Liquid Peptones (Lilly & Co.) 22.0; Nutrient Wine of Beef Peptone (Armour) 21.5; Nutritive Liquid Peptone 23.0; Panopepton 18.5; Peptonic Elixir 18.8; Tonic Beef 16.1. The report on these says: "There are no fatty substances present in these products; their food value from this point of view is, therefore, _nil_." A prominent physician of Philadelphia said of these "Foods" in the Journal of the A. M. A.:-- "I have long been convinced that many a patient has suffered severely when preparations such as these were being used, and that not a few of them have died, chiefly of starvation. * * * A very important disadvantage of these foods is their alcoholic content. Even in the small doses customarily used, the quantity of alcohol is often irritating to the stomach, and may be disadvantageous in other ways." The Committee on Pharmacy also reported on cod-liver oil preparations. They said: "A preparation claiming to represent cod-liver oil which does not contain oil in some form is fraudulent. Waterbury's Metabolized Cod-Liver Oil and Hagee's Cordial of Cod-Liver Oil are cited as examples. It is claimed by the manufacturers that the latter represents 33 per cent. of pure Norwegian cod-liver oil, but in neither of these preparations did the tests made by the committee show any oil. Analysis revealed sugar, alcohol, and glycerine, none of which is contained in cod-liver oil." Vinol is advertised as Wine of Cod-Liver Oil, but is admittedly without oil, and according to analysis contains 18.8 per cent. alcohol. Wampole's Tasteless Preparation of Cod-Liver Oil showed 20.05 per cent. of alcohol. Cod-Liver Oil is considerably out of date now as a prescribed remedy because physicians have found that it impairs appetite. Cream and fresh butter and olive oil are advised instead. Australia has been such a harvest field for patent medicine manufacturers that a government commission was appointed to study the subject. This commission presented a voluminous report to the parliament of 1907. This report gives an analysis of most of the extensively advertised medicines. Doan's Backache Kidney Pills are said to be made of oil of juniper 1 drop, hemlock pitch 10 grains, potassium nitrate 5 grains, powdered fenugreek (Greek hay) 4 grains, wheat flour 4 grains, maize starch 2 grains. The report says: "The stuff is the cheapest kind of skin-plaster made up into pills." The seeds of fenugreek are used mainly for poultices. Doan's Dinner Pills contain two drastic purgatives, podophyllin and aloin. Both of these are dangerous drugs. Aloin frequently produces hemorrhoids (piles). The _British Medical Journal_ says that the material in forty of the Kidney Pills and four Dinner Pills would cost one English halfpenny (one cent). Vitae-Ore is given as consisting of ordinary sulphate of iron (green vitriol) to which a little Epsom salts has been added. Munyon's Kidney Cure, which claims to cure Bright's disease, gravel, and all urinary diseases, is given as composed entirely of sugar. Dr. Williams' Pink Pills are said to be an iron pill much the same as the ordinary Blaud's Pills which are sold in drug-stores for half, or less than half, the price of the proprietary article. (Iron is said by recent investigators to be very injurious to the stomach.) The Committee on Pharmacy of the American Medical Association has analyzed many proprietary medicines; from their reports the following analyses are taken. "Health Grains," which are claimed to be a remedy for "Dyspepsia, Indigestion, Nervousness, etc.," were found to consist of 87.50 per cent. of coarse quartz sand, and 12.50 per cent. of rock candy and syrup. "Hoff's Consumption Cure consists essentially of sodium cinnamate and extract of opium, a mixture at one time suggested for the treatment of tuberculosis, but which has been discarded by physicians. A medicine which depends on opium for whatever therapeutic effect it may have is, when sold indiscriminately to the laity, inherently vicious." Sartoin Skin Food for "sunburn, and all skin blemishes" was made of Epsom salts colored with a pink dye. The government prosecuted the company sending out Epsom salts as a "food," and they were fined $20 for thus seeking to dupe silly women. Malt extracts are very extensively used at the present time, under the popular notion that they are an aid to starch digestion. That they are a product of the brewery has caused them to be looked upon with suspicion by cautious people, but the multitude has apparently given no thought, or care, as to whether or not they may be alcoholic. Dr. Charles Harrington presented the results of an examination of these preparations at a meeting of the Boston Society of Medical Sciences, held Nov. 17, 1896. The following is quoted from the journal of the society for November, 1896:-- "Twenty-one different brands of liquid malt extract were obtained and analyzed. That they were not true malt extracts is shown by the fact that in no one was there the slightest diastatic power; all were alcoholic, some being stronger than beer, ale, or even porter. In a number of specimens a large amount of salicylic acid was detected." Dr. J. H. Kellogg, in commenting upon this report, said in the Dec., 1896, _Bulletin of the A. M. T. A._:-- "In the light of these facts, it is apparent that ale or lager beer might as well be prescribed for a patient as these so-called malt extracts, which are practically nothing more than concentrated ale or lager." There are malt extracts, made up like honey, or syrup, in consistency, which are valuable. The following list of malt extracts, with accompanying letter from Prof. Sharples, is taken from a paper published by Hon. Henry H. Faxon, of Quincy, Mass.:-- "Boston, Mass., March 20, 1897. "I enclose a list of the malt extracts examined in this office during the past year or two. These samples were all in original packages, obtained by officers in various parts of Eastern Massachusetts. They probably very fairly represent the various malt extracts on the market. I have added two samples of Porter and one of Old Brown Stout for purposes of comparison. "Yours respectfully, "S. P. SHARPLES. "State Assayer." Name. Solids. Alcohol. 5193 English Malt Extract 9.70 5.63 5214 Old Grist Mill Malt Extract 10.57 5.54 5418 Old Grist Mill Malt Extract 9.98 5.63 5490 Old Grist Mill Malt Extract 12.28 5.86 5626 Old Grist Mill Malt Extract 9.63 5.00 5207 Liquid Food, a Malt Extract 10.47 4.27 5225 Pure Malt, a Liquid Food, a Tonic 9.71 5.00 5416 Pure Malt, a Liquid Food, a Tonic 10.76 6.32 5619 King's Pure Malt[C] 9.52 6.60 [Footnote C: The label on King's Malt states that for a strong, healthy person, with a good appetite, a pint with each meal and another on retiring at night will not be too much.] 5421 A Nutritious Tonic, Pure Malt Extract 10.88 6.24 5226 Noris' Extract of Malt 11.57 5.94 5258 Noris' Extract of Malt 9.31 6.55 5397 Noris' Extract of Malt 10.63 6.24 5485 Noris' Extract of Malt 10.50 6.63 5620 Noris' Extract of Malt 12.55 5.90 5229 Pabst Malt Extract, The Best Tonic 10.43 5.16 5230 Hoff's Malt Extract (Tarrant's) 11.33 8.88 5489 Hoff's Malt Extract (Tarrant's) 12.25 7.17 5231 Johann Hoff'sches Malz-Extract, Gesundheit's Beir 11.31 4.34 5491 Johann Hoff'sches Malz-Extract, Gesundheit's Beir 11.02 4.85 5621 Johann Hoff'sches Malz-Extract, Gesundheit's Beir 10.49 4.50 5408 Johann Hoff'sches Malz-Extract, Gesundheit's Beir 11.47 4.78 5340 Haffenreffer & Co. Malt Wine 11.02 6.65 5423 Haffenreffer & Co. Malt Wine 11.71 5.63 Liquid Bread, A Pure Extract of Malt 6.78 6.63 5395 Durgin's Malt, Liquid Extract of Malt 7.12 5.94 5433 Durgin's Liquid Extract of Malt 6.49 5.55 5396 Wyeth's Liquid Malt Extract 14.80 3.35 5488 Wyeth's Liquid Malt Extract 15.50 2.86 5622 Wyeth's Liquid Malt Extract 15.73 2.35 5406 Wampole's Concentrated Extract of Malt 9.84 9.86 5407 Anheuser-Busch's Malt Nutrine 15.98 3.00 5600 Anheuser-Busch's Malt Nutrine 15.82 2.25 5417 Malt Extract (Sterilized), John L. Gleeson 7.97 4.71 5422 Malt Extract (Sterilized), Charles C. Hearn 8.58 5.00 5436 Burkhart Brewing Co.'s Malt Extract 10.73 7.01 5486 Menzel's Extract of Malt 5.90 5.24 5625 Menzel's Extract of Malt 6.75 4.35 5623 King of Malt Tonics, Lion Tonic 10.95 7.05 5624 Teutonic, "A concentrated Extract of Malt and Hops" 9.95 7.45 5409 Van Nostrand's Old Stout Porter, "a pure malt extract" 7.97 6.55 5233 Philadelphia Porter 5.34 6.63 5232 Burke's Guiness Stout 6.66 7.17 The alcohol in the above table represents the cubic centimeters of alcohol in a 100 cubic centimeters of the liquid. The solids are the number of grams of solid extract in each 100 centimeters of the liquid. S. P. SHARPLES. The _British Medical Journal_, and the _British Medical Temperance Review_ have been calling attention to the danger in coca wines. Intemperance among invalids is said to be greatly on the increase from the use of these wines. In every case the basis of these preparations is strongly alcoholic wine, ranging from 18 to 20 per cent. The coca added is either the leaves, or liquid extract of coca, or hydrochlorate of cocaine. Dr. Frederic Coley says in the _British Medical Journal_:-- "Coca, and its chief alkaloid, cocaine, are drugs which possess some power of removing the sense of fatigue, just as analgesics remove the consciousness of pain. But they no more remove the physical condition of muscles, and nerve centres, of which the sense of pain gives us warning, than a dose of morphine, which removes the pain of toothache, removes the offending tooth, or even arrests the caries in it. The truth of this will be obvious to any one who remembers enough of physiology to know what fatigue really means. A muscle which is tired out is different chemically from the same muscle in its more normal condition, when it is ready to respond vigorously to ordinary stimuli. It has lost something, and is, besides, overcharged (poisoned, in fact) with the products of its own activity, and it can only be restored by a fresh supply of the material which it requires, and the carrying away of the poisonous waste products. Fatigue of nerve centres is no doubt strictly analogous to fatigue of muscles. "It is practically impossible for us, by voluntary exertion, to reach the degree of absolute fatigue, which the physiologist produces by electric stimulation of a nerve-muscle preparation. The sense of fatigue becomes so intense that voluntary effort cannot overcome it. So no man can produce asphyxia by simply holding his breath, because the _besoin de respirer_ becomes irresistible; but it is quite possible for a narcotic to so dull the sensory part of the respiratory reflex mechanism as to permit asphyxia to take place. "The sense of fatigue, and the _besoin de respirer_ are both Nature's danger signals. Drugs which hide such signals from us are a more than doubtful benefit. If it were possible for us to suppose that a fraction of a grain of cocaine could afford to exhausted nerve centres, and muscles, the nutriment which they require for their restoration, and at the same time eliminate the poisonous waste products, then it would be reasonable to prescribe the drug for use by all who are overworked, and perhaps suffering from the malnutrition consequent upon, 'nervous dyspepsia,' as well as mere want of rest. "In this go-ahead century it is no wonder that many are but too ready to experiment with a drug which professes to be able to remove fatigue, and to enable a man to go on working when, without its aid, weariness had become unendurable. Cocaine claims all this; and it is most dangerous just because, for a time, it seems able to keep its promise. That is how victims to cocainism are made. Let us be honest with our overworked patients, who want us to help them with drugs; let us tell them that rest is the only safe remedy for weariness. "To combine such a drug as coca, or cocaine, with an alcoholic stimulant, is to multiply the dangers of cocainism by those of alcoholism. It would be impossible to find terms sufficiently severe in which to condemn the recklessness of those who promiscuously recommend such a compound for all who are overworked or debilitated. One firm actually has the assurance to advertise a preparation of this kind as a remedy for dipsomania. Truly this is casting out devils by Beelzebub, with a vengeance. Invoking Beelzebub for such a purpose has never been a success. And I suspect that any form of coca wine will make a great many more dipsomaniacs than it will cure." Dr. Walter N. Edwards, F. C. S., says of coca wines:-- "These wines are sold as being useful in an immense variety of ailments. The following are a few of the many that are named upon the bottles or in the circulars accompanying them:-- "Weakness after illness, "Nervous disorders, "Sleeplessness, "Influenza, "Whooping cough, "Exhaustion of mind and body, "Allays thirst, "Restores digestive function, "Enables great physical toil to be undergone, "Great value in excesses of all kinds, "General debility, "Prevents colds and chills, "Makes pure, rich blood, "Anæmia, "Invaluable after pleurisy, pneumonia, etc., "Aid to the vocal organs. "This is a fairly respectable list of complaints, and the very fact that these preparations of coca wine are put forward as a cure for so wide a range of various complaints is in itself a condemnation of them. "When any particular remedy is said to be of universal application for a large number of different complaints it may be looked upon with great suspicion. "It must always be remembered that there is the commercial side to this question. The proprietors have no particular regard for the welfare of the people; their business is to make a profit, and many of them gain enormous fortunes. By skilful and lavish advertisements, and by carefully worded testimonials, they appeal to the credulity of the public, and often deceive even those who regard themselves as belonging to the thinking classes. "There are two specific dangers in regard to these wines. They are ordinary wines, either port or sherry for the most part, and therefore strongly alcoholic. The user of them is in considerable danger of cultivating a taste for alcohol, and certainly, there is the greatest possible danger to any one having had the appetite, of reviving it. "The dose is an elastic one, it can be repeated with considerable frequency three or four times a day. "What would be said of growing girls or youths having recourse three or four times a day to the wine bottle? This is exactly what they are doing when coca, and the so-called food wines are placed in their hands as medicine. They like the pleasant taste, there is the call of habit and appetite, and so there arises the greatest possible danger of a general liking for alcoholic liquors being set up. The ailing man or woman of set years is in similar danger, for they are having recourse to alcohol when their powers of mind and body are to some extent exhausted, and they are thus less able to resist the fascination for alcohol that may so quickly be brought into existence. "Another element of danger is that the recourse to coca and kola is an attempt to get more out of the body, and the mind, than nature intended. Overwork, overstrain, worry, all produce exhaustion of physical and nervous power. Nature pulls us up by asserting herself, and we feel run down and seedy, and, perhaps, quite unwell. What is wanted is rest, proper diet, and change. These would quickly be restorative, and once again we should be fit for the duties of life. "In a busy age there is the strongest possible temptation to seek a restorative by some occult method, rather than to give the rest and refreshment that nature demands. It is upon this that the whole trade in these so-called restoratives depends. "There is no food quality in alcohol, cocaine or kola, but there is in them all a narcotizing influence that in its lesser stages is hurtful, and in its greater stages disastrous. "The cocaine habit may be cultivated as easily as the alcohol habit, and the two forms of disease, alcoholism and cocainism, are by no means rare. The great factor in each of them is the loss of will power, and when that is accomplished the descent to complete moral and physical ruin is quite easy. "A pure and simple life, in accord with the laws of health and hygiene, is the panacea both for the maintenance, and the restoration of health, and that is what we should strive to aim at, rather than having recourse to drugs that are not only ineffective, but positively dangerous."--_United Temperance Gazette._ In Dr. Milner Fothergill's _Practioners' Hand-book of Treatment_, fourth edition, the following statement is made:-- "Coca wine, and other medicated wines are largely sold to people who are considered, and consider themselves, to be total abstainers. It is not uncommon to hear the mother of a family say, 'I never allow my girls to touch stimulants of any kind, but I give them each a glass of coca wine at 11 in the morning, and again at bedtime.' Originally coca wine was made from coca leaves, but it is now commonly a solution of the alkaloid, in a sweet and strongly alcoholic wine. This is really the gist of the whole matter; coca wine is largely consumed by people who fondly believe themselves to be total abstainers, and who are active enough in denouncing those who take a little wine, or a glass of beer at their meals. The sooner their delusion is dispelled the better for themselves, and for the unfortunate children over whom they exercise supervision." Another physician tells of seeing a distinguished ecclesiastical dignitary, a sworn foe of alcohol and its congeners, giving his young child a generous daily allowance of one of these wines. The user of coca wines runs a double risk--an alcohol craving may be revived, or created; and, at the same time, cocainism may be set up, and nothing but physical, mental and moral ruin follow. The _British Medical Journal_ of January 23rd, 1897, says:-- "There can be no doubt that in many parts of the world cocaine inebriety is largely on the increase. The greatest number of victims is to be found among society women, and among women who have adopted literature as a profession; and there is no doubt that a considerable proportion of chronic cocainists have fallen under the dominion of the drug from a desire to stimulate their powers of imagination. Others have acquired that habit quite innocently from taking coca wines. The symptoms experienced by the victims of the cocaine habit are illusions of sight and hearing, neuromuscular irritability, and localized anæsthesia. After a time insomnia supervenes, and the patient displays a curious hesitancy, and an inability to arrive at a decision on even the most trivial subjects." Dr. F. Coley says later on in the article before referred to:-- "There is another combination which, though utterly absurd from a therapeutical point of view, is not in itself quite so dangerous as coca wine. It will probably do a larger amount of mischief, however, because more people take it. I refer to the various preparations, so largely advertised, which profess to be compounded of port wine, extract of malt, and extract of meat. To the medically uneducated public this doubtless seems a most promising combination: extract of meat for food, extract of malt to aid digestion, port wine to make blood. Surely the very thing to strengthen all who are weak, and to hasten the restoration of convalescents. Unfortunately what the advertisements say--that this stuff is largely prescribed by medical men--is not wholly untrue. "I do not suppose that any physician of anything like front rank would make such a mistake. But busy general practitioners may be excused if they prove to be a bit oblivious of physiology, and so become attracted by a formula which is more plausible than sound. In the first place, we all know that extract of meat is not food at all. From the manner of its production, it cannot contain an appreciable quantity of proteid material. It consists mainly of creatin, and creatinin, and salts. These are, it is needless to say, incapable of acting as food. Extract of meat, and similar preparations, have their uses however; made into 'beef-tea,' their meaty flavor often enables patients to take a quantity of bread, which would otherwise be refused; or lentil flour, or some other matter may be added. In this way, though not food itself, it becomes a most useful aid to feeding. It is besides, a harmless stimulant, especially when taken, as it always should be, hot. It should be needless to add that to combine extract of meat with port wine is simply to ignore its real use. The only intelligible basis for such an invention must be the wholly erroneous notion that extract of meat is a food." The prices asked for "secret nostrums" are said by chemists to be ofttimes far beyond the value of the materials. Of one article the _New Idea_, a druggists' paper, says:-- "It retails at $1.50 per bottle. Such an article could be put up for less than fifteen cents, including bottle, leaving by no means a small margin for the profit of its manufacturers." The same paper says of a cure for catarrh, neuralgia, etc. sold in the form of a small ball:-- "This cure costs $2.50 per ball. A handsome profit could be made upon it at 5 cents a ball." Some proprietary preparations are not harmful, but are positively inert. The Mass. State Board of Health in report of 1896 gives _Kaskine_ as an example of these. Although sold at a dollar an ounce it was found to consist of nothing but granulated sugar of the fine grade used in homeopathic pharmacy, without any medication or flavoring whatever. Dr. Edward Von Adelung in an article in _Life and Health_, Dec., 1897, tells of a well advertised cure for consumption, the analysis of which showed it to be composed of water, slightly colored by the addition of a very small quantity of red wine, and two mineral acids, muriatic and impure sulphuric, in quantities just sufficient to lend it a taste! He says:-- "Fortuitously I had the opportunity of observing the influence of this remedy on a consumptive who took it regularly, and who was so enamored of its favorable action that he gave up his business to conduct an agency for its sale. It was not long after he had entered upon his new vocation that I received word of his death, due to pulmonary hemorrhage." The "returned missionary" fraud has been exposed by different druggists' papers, among them the _New Idea_. The "missionary" would advertise a "free cure," if people would send to him. The "cure" would be in the form of a prescription. There being no drugs in any drugstore bearing the names given in the prescription, the dupe was expected to pay an exorbitant price for them to the philanthropic "missionary." In one case of this kind the "medicinal plants brought from South America, the only place where they grew," were upon examination by chemists of the _New Idea_ found to be ordinary drugs, not one of which comes from South America. The same paper tells of another "South American" fraud, 60,000 bottles of which were said to be sold in Detroit in a few weeks, by an itinerating vendor. A certain liver, and kidney, and constipation cure, sold in the form of herbs, is said by _New Idea_ to be chiefly couch grass, and senna leaves. Yet it sells for 25 cents for a small package. To this paper the public is also indebted for the information that a kind of wafer advertised to "cure in a few days all coughs, colds, irritation of the uvula and tonsils, influenza, bronchitis, asthma, sore throat, consumption, and all diseases of the lungs and chest" was found to consist wholly of sugar and corn starch! _Medical World_ recently told of the investigation of "H----" by Prof. John Uri Lloyd of Cincinnati. It was advertised as a plant discovered by a doctor traveling in Florida. Its juices were said to be antidotal to snake poisoning, and would also cure the opium habit. Prof. Lloyd found it to be a liquid consisting of a solution of sulphate of morphine and salicylic acid, in alcohol and glycerine, with suitable coloring matter. Another fraud exposed by _New Idea_ was a "cure" for the peculiar ills of women. The cure is put up in the form of little oblong blocks about a half inch in length. "A circular accompanies them, and is well calculated to produce alarm in the young. It is another sample of the demoralizing documents which unscrupulous quacks are continually circulating among the laity, in order to create alarm, and profit by this alarm." After giving a description of the diseases peculiar to the sex it is stated that all of these are curable by using eight dollars worth of this wonderful medicine. _New Idea_ continues:-- "The _cure_ consists, according to our examination, of nothing but flour, made into a paste and allowed to harden in the form of small oblong blocks. Evidently the quack relied upon the faith-cure principle, and his auxiliary treatment, as set forth in the rules of living given in the circular." While these inert preparations are of the nature of frauds, they will not injure the health, nor make drunkards, or opium fiends, as the disguised preparations of whisky and morphine are likely to do. That the use of patent medicines has made many drunkards is a fact well attested. The American Association for the Study of Inebriety appointed a committee several years ago to investigate the various nostrums advertised especially for the benefit of alcohol and opium inebriates. The report of this committee, prepared by Dr. N. Roe Bradner, late of the Pennsylvania Hospital for the Insane, in speaking of the marvelous cures advertised in connection with the use of these mixtures, calls them "volumes of gilded falsehood, designed for an innocent, unsuspecting public," and adds:-- "The use of such nostrums would do more toward confirming than eradicating the habit, if it existed, and would invite and create addiction to an almost hopeless fatality, where the habit had not previously existed. Insanity, palsy, idiocy, and many forms of physical, moral and mental ruin have followed the sale of these nostrums throughout our land." Dr. E. A. Craighill, President of the Virginia State Pharmaceutical Association, is quoted in the July (1897) _Journal of Inebriety_, as saying:-- "In my experience I have known of men filling drunkards' graves who learned to drink taking some advertised bitters as legitimate medicine. It would be hard to estimate the number of young brains ruined, and the maturer opium wrecks from nostrums of this nature. I could write a volume on the mischief that is being done every day to body, mind and soul, all over the land, by the thousands of miserable frauds that are being poured down the throats of not only ignorant people, but, alas, intelligent ones, too." A lady informed the writer recently that her brother had taken forty bottles of one of these preparations, and had become a drunkard through it. Many seem unaware that the ethics of the medical profession restrain reputable physicians from advertising themselves or their remedies, so that these much-lauded patent medicines are put upon the market by quacks, never by physicians of good standing. It is purely a money-making enterprise, without consideration of the health or destruction of the people. It is popularly supposed that physicians decry these things from fear that their sale will injure regular practice. This is another error as they increase work for the doctor by aggravating existing trouble, as well as causing disease where there was only slight disturbance. Dr. F. E. Stewart, Ph. G., of Detroit, Mich., says in the October, 1897, _Life and Health_:-- "Taking all these facts into consideration, it is apparent that the patent, trade-mark and copyright laws should be so interpreted and administered by the court that they will secure the greatest good to the greatest number, and aid in attaining the end of government, viz., 'moral, intellectual and physical perfection.' It is not the object of these laws to create odious monopolies, to throw a mantle of protection over fraud, to enable quacks and charlatans to encroach on the domain of legitimate medical and pharmacal practice, or to support an advertising business designed to mislead the public in regard to the nature and value of medicines as curative agents. The morals of the community are injured by some of this advertising, intellectual vigor is impaired by the use of many things advertised, and physical, as well as moral, degradation frequently results. Crime is often inculcated--even the crime of murder, that the nostrum manufacturer may profit thereby. Cures for incurable diseases are promised, and guaranteed. Every scheme that human and devilish ingenuity can devise to wring money from its victim is resorted to, which can be employed without actually bringing the advertisers into court. All this wicked quackery parades under the guise of 'patent' medicines, and asks the protection of our courts. It is time for the medical and pharmaceutic professions to unite, and unmask this monster, and show the public its true nature. And this can be accomplished in no better way than through a study of the object of the laws which the secret nostrum manufacturers are now endeavoring to prostitute for their own advantage, and the teaching of the public what these laws were enacted for. "The secret nostrum business in some of its phases has assiduously found its way into the medical arts, and physicians, pharmacists, and manufacturing houses, seem to have forgotten, to a certain extent, the obligations which they owe to the public. Medicine, in all its departments, must be practiced in accord with scientific, and professional requirement, or it will sink to the level of a commercial business. _The end of medical practice is service to suffering humanity, not the acquisition of money._ Money making is a necessary part of the practice of medical arts, not, however, its chief object. This fact must be kept in view always. Once lost sight of, and trade competition substituted for competition in serving the interests of the sick, medical and pharmacal practice will become an ignoble scrabble for wealth, in which the sick become victims of avarice and greed. Better set free a pack of ravening wolves in a community than to change the end of medical practice to a commercial one, for physicians and pharmacists would soon degenerate into quacks and charlatans, and take shameful advantage of the community for gain." Where Dr. Stewart speaks of murder he probably refers to the sale of _abortofacients_. Dr. Roe Bradner, of Philadelphia, in his report upon alleged cures for drunkenness before the Society for the Study of Inebriety several years ago, said:-- "There is a certain other class of so-called remedies, prepared sometimes by physicians and pharmacists, that do a great deal of harm. I allude to the 'non-secret proprietaries' that claim to publish their formulas, _but do not_. One in particular has made thousands, and likely tens of thousands, of _chloral drunkards_, dethroned the reason of as many more, besides having killed outright very many. It is impossible for any one to estimate the mischief that is being done by such remedies, and the physicians who recommend them." Advertising is still the great hindrance in protecting the people from medical imposters. Professor E. W. Ladd, Pure Food Commissioner of North Dakota, says on this point:-- "These patent medicines, some of which are of merit, and others are only 'dopes,' or preparations intended to defraud the public, have been altogether too generally advertised and sold to the public. In many ways it seems a deplorable fact that by an unfair method of advertising the American people have come to be consumers to such an extent of a class of medicines, which, at times, are positively detrimental to health. In other instances the continued use of the product is liable to result in the formation of a drug habit which may lead to serious consequences. "It should not be understood that this department condemns the use of legitimate proprietary or patent medicines, but it insists that there is a need for wiping out of existence about half of the products now generally sold, and with regard to the others the public have a right to know what is contained in them, and not be misled by false statements, or by statements so cunningly worded as to positively mislead the unwary reader. * * * In view of the fact that about 90 per cent. of the nostrums on the market are sold by newspaper and magazine advertising and not by the customer seeing the package, it would seem advisable to amend the law so as to cover this point." There is no doubt that it is the advertising which makes the patent medicine business so tremendously profitable. One firm boasted, prior to the exposure of the fraud nature of their preparation, that they spent $5,000 a day in advertising. What must have been made on the nostrum to allow such expenditure? It is said on good authority that the cost of these nostrums does not exceed fifteen to sixteen cents a bottle, and they sell for a dollar a bottle. Such profits make it easy to buy up newspapers that are conscienceless as to the robbery of the unfortunate sick. The only effectual way of putting an end to the sale of nostrums is to make illegal the advertising of such preparations in the public press. Norway has safeguarded her people thus. The difficulty in gaining such a law in America will be the opposition of the newspapers, the large majority of which still cling to this selfish method of adding to their gains. Even the so-called religious press is not all clean yet in this respect. Once they could be excused because of lack of knowledge. Now there is no excuse. During the debate in Congress upon the patent-medicine clause of the Pure Food Bill, Senator Heyburn said:-- "I have always been aggressively against the advertisements of nostrums. Some time ago a friend of mine, a very old fellow, that I had taken a special interest in securing a pension for, had reached the age and condition of dependency. I succeeded in getting him a comfortable pension that would pay his bills for household provisions. Once, when I found he was very poor, I said to his wife, 'What are you doing with your pension?' She said, 'Don't you know, Mr. Heyburn, that it takes at least one-half of that pension for patent medicine?' Then she enumerated the patent medicines they were taking. It was being suggested to them through advertisements that they were the victims of ills that they were not troubled with, and that they could find relief through these different medicines. "I am in favor of stopping the advertisements of these nostrums in every paper in the country." It may well be asked, Would any one of these well-to-do newspaper owners entrust himself, or any of his family, in time of sickness to the cure-all imposters whose nostrums they advertise? If one of their children had anæmia would they rely on Pink Pills for a cure? If they had a genuine catarrh would they expect it to be cured by Peruna? Never! They would seek the very best medical advice obtainable. Yet, for the ignorant, credulous, sick and suffering poor they allow traps to be laid to rob of both money and such chances of recovery as might come from proper medical attendance. CHAPTER XIV. "DRUGGING." The main reason why so many people use patent medicines is the popular supposition that drugs cure disease. This is a great error. _Drugs never cure disease._ Nature alone has power to heal. There are agents, which in the hands of a trained and painstaking physician may assist nature, but the physician needs to understand something of the idiosyncrasies of his patient's system, or the use of these agents may do great harm instead of good. Those medical men who have made the most diligent study of health and disease assert as their deliberate opinion that excessive professional drugging has been decidedly destructive of human life. Dr. Jacob Bigelow, professor in the medical department of Harvard University, in a work published a few years ago stated as his belief that the unbiased opinion of most medical men of sound judgment, and long experience, is that the amount of death and disaster in the world would be less, if all diseases were left to themselves, than it now is under the multiform, reckless, and contradictory modes of practice, with which practitioners of diverse denominations carry on their differences, at the expense of the patient. Sir John Forbes, M. D., F. R. S., said:-- "Some patients get well with the aid of medicine, more without it, and still more in spite of it." Dr. Bostwick, author of _The History of Medicine_, said:-- "Every dose of medicine given is a blind experiment upon the vitality of the patient." Dr. James Johnson, editor of the _Medico-Chirurgical Review_, says:-- "I declare as my conscientious conviction founded on long experience and reflection, that if there were not a single physician, surgeon, man-midwife, chemist, apothecary, druggist nor drug on the face of the earth, there would be less sickness and less mortality than now prevail." Prof. J. W. Carson, of the New York College of Physicians and Surgeons, says:-- "We do not know whether our patients recover because we give them medicine, or because nature cures them. Perhaps bread-pills would cure as many as medicine." Prof. Alonzo Clark, of the same college, has said:-- "In their zeal to do good physicians have done much harm; they have hurried many to the grave who would have recovered if left to nature." Prof. Martin Paine, of the New York University Medical College, said:-- "Drug medicines do but cure one disease by producing another." Dr. Marshall Hall, F. R. S.:-- "Thousands are annually slaughtered in the quiet sick-room." Dr. Adam Smith:-- "The chief cause of quackery _outside_ the profession is the _real_ quackery _in_ the profession." Prof. Gilman:-- "The things that are administered for the cure of _scarlet fever_ and _measles_ kill far more than those diseases kill." Prof. Barker, of New York Medical College:-- "The drugs that are administered for the cure of _scarlet fever_ kill far more patients than the disease does." Prof. Parker:-- "As we place more confidence in nature, and less in preparations of the apothecary, mortality diminishes." The examining physician of a large insurance company in New York said to a _Mercury_ reporter:-- "The primary cause of so many cases of _la grippe_ in this and other cities is the almost universal habit of drug taking from the milder tonics to patent medicines. Whenever the average man or woman feels depressed or slightly ill, resort is made at once to medicine, more or less strong. If they would try to find out the cause of the trouble, and seek to obviate it by regulating their mode of living, the general health of the community would be better. The drug habit tends continually to lower the tone of the system. The more it is indulged in the more apparent becomes the necessity of continuing the downhill course. The majority of persons do not look beyond the fact that they seem to feel better after the use of a stimulating drug, or patent medicine. This feeling comes from a benumbing action of the drug, because it has no uplifting action. With the system in such a weakened state, the microbes of the disease find excellent ground to grow." Dr. J. H. Kellogg says in the April, 1899, _Bulletin of the A. M. T. A._:-- "Every drug capable of producing an artificial exhilaration of spirits, a pleasure which is not the result of the natural play of the vital functions, is necessarily mischievous in its tendencies, and its use is intemperance, whether its name be alcohol, tobacco, opium, cocaine, coca, kola, hashish, Siberian mushroom, caffeine, betel-nuts, maté or any other of the score or more enslaving drugs known to pharmacology. As the result of the depression which follows the unnatural elevation of sensation resulting from the use of one of these drugs, the second application finds the subject on a little lower level than the first, so that an increased dose is necessary to produce the same intensity of pleasure or the same degree of artificial felicity as the first. The larger dose is followed by still greater depression which demands a still larger dose as its antidote, and thus there is started a series of ever-increasing doses, and ever-increasing baneful after-affects, which work the ultimate ruin of the drug victim. All drugs which enslave are alike in this regard, however much they may differ otherwise in their physiological effects. Alcohol is universally recognized as only one member of a large family of intoxicating drugs, each of which is capable of producing specific functional and organic mischief, besides the vital deterioration common to the use of so-called felicity-producing drugs. "Is it not evident, then, that in combating the use of alcohol we are attacking only one member of a numerous family of enemies to human life and happiness, every one of which must be exterminated before the evil of intemperance will be up-rooted?" Among the most popular drugs for self-prescription at the present time are the coal-tar products. Of these Dr. N. S. Davis has said:-- "Only a few years since, the profession were taught to regard the degree of pyrexia, or heat, as the chief element of danger in all the acute general diseases. Consequently, to control the pyrexia became the leading object of treatment; and whatever would do this promptly, and at the same time allay pain and promote rest, found favor at the bedside of the patient. "It was soon ascertained that antipyrin, antifebrin, phenacetin and other analogous products, if given in sufficient doses, would reduce the heat, and allay the pains with great certainty and promptness, not only in continued fevers, but also in rheumatism, influenza, or la grippe, etc.; and thus their use soon became popular with both the profession and the public. No one, however, undertook to first ascertain by strictly scientific appliances the actual pathological processes causing the pyrexia in each form of disease, or even to determine whether in any given case the increased heat was the result of increased heat production, or diminished heat dissipation. Neither were any of the remedies subjected to such experimental investigation as to determine their influence on the elements of the blood, the internal distribution of oxygen, the metabolism of the tissues, or on the activity of the eliminations. Consequently their exhibition was wholly empirical, and the one that subdued the pyrexia most promptly was given the preference. Yet we all know that the pyrexia invariably returned as soon as the effects of each dose were exhausted, and in a few years the results showed that while the antipyretics served to keep down the pyrexia, and give each case the appearance of doing well, the average duration of the cases, and their mortality, were both increased. "Step by step experimental therapeutic investigations have proved that the whole class of coal-tar antipyretics reduce animal heat by impairing the capacity of the hemoglobin and corpuscular elements of the blood to receive and distribute free oxygen, and thereby reduce temperature by diminishing heat production, nerve sensibility and tissue metabolism. Therefore, while each dose temporarily reduces the fever, it retards the most important physiological processes on which the living system depends for resisting the effects of toxic agents; namely, oxidation and elimination. This not only encourages the retention of toxic agents and natural excretory materials by which specific fevers are protracted, but it greatly increases the number of cases of pneumonia that complicate the epidemic influenza, or la grippe, as it has occurred since 1888-89. "The bad work that people make in dosing themselves with patent medicines, without a physician's prescription is not unfrequently punctuated with a sudden death from overdosing with antipyrin, sulphonal, or some other coal-tar preparation." Dr. C. H. Shepard, Brooklyn, N. Y., says:-- "Quinine is a most fatal drug. Of course, it is the orthodox treatment for malarial conditions, but quinine never did nor never can cure malaria or any other disease. The action brought about by its use is simply to benumb the nervous activity and interfere with the natural action of the system to throw off the poison, which is expressed by the chill. Because of this interference with the manifestation or symptom of the disease, many imagine that the disease is being cured, but there never was a greater mistake. A drug disease is added to the original disease. This is shown by the invariable depression that follows the administration of the drug, and the length of time required to recuperate, which imperils restoration, and sometimes hastens the final results. This is ordinarily met by the use of what are called stimulants, that is, more drugs, and the last state is worst than the first; the poor patient is thus made the victim of a triple wrong, which only a most vigorous constitution can pass through and live, and even then he is crippled and made more liable to whatever disease may come along ever afterward. "Disease is not entity to be killed by a shot from a professional gun, but a condition, an effort of outraged nature to free itself from an incumbrance, and should be aided rather than hindered by the administration of any nerve irritant. There never will come a time when the laws of health can be evaded. Nor is there any vicarious atonement. The full penalty of disobedience will invariably be exacted. The hunt for a panacea is as sure to be disappointing in the future as it has been in the past." A writer in the _Brooklyn Citizen_ says:-- "Few people are aware of the extent of a peculiar kind of dissipation known as ginger-drinking. The article used is the essence of ginger, such as is put up in the several proprietary preparations known to the trade, or the alcohol extract ordinarily sold over the druggist's counter. Having once acquired a liking for it, the victim becomes as much a slave to his appetite as the opium eater or the votary of cocaine. In its effect it is much the most injurious of all such practices, for in the course of time it destroys the coating of the stomach, and dooms its victim to a slow and agonizing death. "The druggist who told me about the thing says that as ginger essence contains about one hundred per cent. alcohol, and whisky less than fifty per cent., the former is therefore twice as intoxicating. In fact, this is the reason why it is used by hardened old topers whose stomachs are no longer capable of intoxicating stimulation from whisky. They need the more powerful agency of the pure alcohol in the ginger extract. He told me that he had two regular customers, one a woman, who had ginger on several occasions for stomachic pains. The relief it afforded her was so grateful that she took it upon any recurrence of her trouble. She found, too, that the slight exhilaration of the alcohol banished mental depression. In this way she got to using it regularly, and finally to such excess that she was often grossly intoxicated. Large doses produce a quiet stupor; additional doses induce a profound lethargic slumber, which lasts in some cases for twenty-four hours. His other customer was a peddler, who came at a certain hour every morning, bought a four-ounce bottle and drank its contents by noon. The man craved the stuff so ardently that he was unable to go about his business until he set the machinery of his stomach in operation, and started the circulation of the blood by means of the fiery draught. He says that the habit is well known to the drug trade." "The morphia habit, the cocaine habit, the chloral habit, and other poison habits which are prevalent in this and other countries, are only different manifestations of a wide-spread and apparently increasing love for drugs which benumb or excite the nerves, which seems to characterize our modern civilization. Indeed, there appears to be, at the present time, almost a mania for the discovery of some new nerve-tickle, or some novel means of fuddling the senses. It is indeed high time that the medical profession raised, with one accord, its voice in solemn protest against the use of all nerve-obtunding and felicity-producing drugs, which are all, without exception, toxic agents, working mischief and only mischief in the human body."--DR. J. H. KELLOGG. Much discussion upon careless drug-taking has resulted from remarks made recently in London by Sir Frederick Treves, the King's surgeon, at the opening of a hospital. He said that the time is fast approaching when physicians will give very little medicine, but will instead teach the people right methods of living so that sickness may be avoided. Although there are some physicians who appear to enjoy the old routine of giving heroic doses of ill-tasting liquids, there are others who agree with Sir Frederick, and admit that they would often be glad to give no medicine if their patients would be satisfied without it. But the great mass of people are unwilling to take a physician's advice as to proper clothing, suitable diet, and regular habits of living. They do not seek his advice upon those points; what they want is a drug that will benumb uneasy sensations while they live as they please. Not long ago a business man of intelligence was heard to complain because he had tried several physicians and all had failed to cure his sciatica. He said they all told him he must live differently; several said he must quit smoking and lay aside wine and beer or he could not be cured. With scorn he said, "What are physicians good for if they don't know a drug that will cure as simple a thing as rheumatism?" He could not and would not believe that rheumatism might be the result of his wrong habits. Akin to him in thought is a woman, much above the average in intelligence, who a few months ago had an operation performed upon her stomach. The stomach was enlarged so that the food did not pass through the pylorus, the opening into the intestines. The operation consisted in making a new opening and connecting it with an intestine. This bright woman now complains that the operation was not a success, because she still has times of great distress with indigestion. Upon being asked what she eats, she laughed and said, "Everything, peanuts, mince-pie, sauer-kraut, frankforts; whatever is going. I have a vigorous appetite, and keep peanuts and figs in my room, for I often have to eat in the night." Until multitudes of people like that business man, and that bright woman, are educated in matters of health, it will not be easy for physicians to bring Sir Frederick's prediction to fulfilment. The popular supposition is that drugs _cure_ disease, and all that the medical adviser is for is to choose the drug that will produce the desired effect with the greatest speed. Consequently the physician is in many cases driven to prescribe drugs that simply allay pain without removing the cause of the pain. He cannot remove the cause without the patient's co-operation, and as that would require the abandonment of wrong habits few are willing to accept health at such a price. What man will abandon beer to escape rheumatism, or smoking to save his eyesight if he has weakness there? Or, what woman will cease tea-drinking if she has neuralgia? The _Journal of the American Medical Association_ for November 16, 1907, contained an editorial article in which, after reference to drugs necessary in the practice of a physician or surgeon, this is said:-- "The remark of Holmes years ago that it would be better for the patients, but worse for the fish, if most of the drugs were thrown into the sea, is probably even more true to-day. The vast majority of these drugs have not the slightest excuse for existence." Dr. T. D. Crothers, in his valuable book upon Morphinism and other drug addictions, reports a case of murder where it was shown that the assailant was delirious from large doses of quinine. He says assaults are often clearly traced to the drug taking of the assailant. A surgeon from a New York hospital, in speaking of drug habits before an audience at Chautauqua, New York, said that some of the ovarian difficulties which demand operations are the result of over-dosing with quinine. There are people who keep morphine in the house all the time lest some little pain or ache should find them unprepared. Dr. Crothers, who has perhaps made more of a study of the evil results of drug taking than any other man in America, says of this:-- "Morphine as a common remedy, taken for pains and aches, may suddenly develop into an incurable craze for its continuous use. * * * The early relief which morphine brings to the sufferer is often the beginning of an unknown journey ending in disease and death." Cases are on record where morphine given to mothers soon after the birth of children to allay pain, has resulted in the death of the infant, the morphine having poisoned the milk. Cocaine is possibly the most insidious of all drugs yet known. Few of those who become enslaved to it ever are able to lay it aside. It leads to hallucinations of sight and hearing. Many persons have become enslaved to cocaine unwittingly through its use in catarrh snuffs, asthma "cures," and other proprietary preparations, the composition of which was secret. Some states now have strict laws regulating the sale of this dangerous drug. It is not only the enslaving drugs which are injurious to the body, but even such apparently simple agents as liver pills and pills for the relief of constipation may do more harm than good if resorted to frequently. Some of the ingredients used in the pills for the relief of constipation are said to be injurious to the liver. Dr. Nathan S. Davis, late dean of the Northwestern University Medical School, Chicago, said of the coal-tar remedies, such as phenacetin and antipyrin, in the treatment of influenza and _la grippe_:--"While each dose temporarily reduces the fever it retards the most important physiological processes on which the living system depends for resisting the effects of toxic agents, namely, oxidation and elimination. This not only encourages the retention of poisonous agents by which fevers are protracted, but it greatly increases the number of cases of pneumonia that complicate _la grippe_. The bad work that people make in dosing themselves with patent medicines is not infrequently punctuated with a sudden death from overdosing with antipyrin, sulphonal, or some other coal-tar preparation." Deaths from acetanilid are becoming more and more frequent. The presence of acetanilid in headache powders "guaranteed to be harmless" and thrown upon the door-steps as samples has led many persons into grave danger, and not a few to death. Bromo-Seltzer, Orangeine, Antikamnia, Taylor's Headache Powders, and various other preparations have all contained this drug. The use of cocaine is advancing rapidly in this country.[TN: see Errata at end of text] The following article is taken from _The Banner of Gold_, of Feb., 1899:-- "Value of cocaine leaves imported at the port of New York in 1894 $14,284 Imported in 1897 54,122 Indicated value of imports for 1898 75,000 "In these simple figures are contained the elements of a warning sermon that would startle all America. We seem to be rapidly becoming a nation of cocaine fiends. If the number of those addicted to the use of the dreadful drug continues to increase at the present rate, the importation of what was originally regarded as a blessed alleviation of pain, will have to be classed with opium, and its use prohibited by law, except for medicinal purposes. "At present the cocaine fiend can purchase the drug without trouble, and the ease with which it is taken is a fatal recommendation to those who crave a nerve-deadener. No laborious cooking of pills over a lamp, cleaning of implements, or troublesome necessity for secrecy, as with the use of opium. Cocaine can be taken at any time, with scarcely any trouble, and without a soul besides the user being aware of his being in the toils. "At first, that is. It will not be long before every intimate friend will observe a change, a gradual and scarcely perceptible change, come over the appearance and general conduct of the cocaine fiend. "Begun in many cases in a legitimate way, as an anæsthetic, the surprisingly pleasant effect is sought for again by the one who has had a glimpse at the portals of the elysium. This is the beginning of the terrible habit. The effect is a sense of exhilaration followed by a quiet, dreamy state that causes the worried man to forget his troubles, and the sufferer his pain. Once this freedom from physical and mental sickness has been experienced, the cocaine fiend will rob or kill to get the drug. Enforced non-use of it will not cure the victim. Sentence him to a term of imprisonment, and he will go straight from the jail door to the nearest drug store to secure cocaine before he eats or sleeps. "From an occasional use of the drug to insatiable craving is the rational course of the cocaine fiend. From thence to the insane asylum and the grave is a swift and easy descent. "In his fall from health to physical and mental disintegration, the cocaine fiend undergoes a terrible experience. When not in the temporary heaven that the drug provides, the victim is in the lowest depths of an _inferno_. He suffers from insomnia, anorexia, and gastralgic pains, dyspepsia, chronic palpitations, and will-paresis. He is a terror both to himself and others. The life of the man is a living death. He knows it, and with this knowledge staring him in the face, he rushes for the drug, and is happy for a brief period under its influence. "It is time something was done to keep from this high-strung nation a drug so deadly. Clear-minded medical men have recommended its exclusion from the country, believing that its use medicinally should be foregone rather than that such a cursed temptation should be placed in the way of weak humanity. "What the real action of the drug is, and how to counteract its influence, are at present puzzling questions to the medical fraternity. A leading member of the profession to whom these questions were put replied after careful consideration as follows: 'Its physiological action is practically unknown. As an analgesic, it is uniform in its action, and this is due to the suspension of the physiological functions of the sensory cells which it comes in contact with. Beyond this, it is an excitant of the cerebro-spinal axis, later it has a peculiar action on the encephalon, manifest in a wide range of psychical phenomena. Beyond this a great variety of widely variable symptoms appear. In some cases all the intellectual faculties are excited to the highest degree. In others a profound lowering of the senses and functional activities occur. Morphine-takers can use large quantities of cocaine without any bad symptoms. Alcoholics are also able to bear large doses. Not unfrequently the excitement caused by cocaine goes on to convulsions, and death. Sometimes its action is localized to one part of the cerebro-spinal axis, and then to another. In some cases well-marked cerebral anæmia appears, and for a time is alarming, but soon passes away. "Small doses frequently given are more readily absorbed than large doses. Habitues always use weak solutions, the effects being more pleasing with less excitation. Morphine and alcoholic inebriates very soon acquire certain tolerance to large doses taken at once. The cocaine user takes large quantities, but in small doses frequently repeated. He becomes frightened at the effects of large doses, and when he cannot get the effects from small (to him safe) doses, he resorts to alcohol, morphine, or chloral. In many cases memories of the delusions and hallucinations are so vivid and distressing that other narcotics are used to prevent their recurrence. In other cases the recollection is very confused and vague, and strong suspicions fill the mind that the real condition is grossly exaggerated by the friends for some deterring effect. In common with opium and alcoholics, there is moral paralysis, untruthfulness, and low cunning in order to conceal and explain the condition by other than the real causes." Hoffman Drops are used considerably as a heart stimulant. They are much more intoxicating than whisky, and, used as a beverage, make the drinker crazy while under their influence. According to Dr. F. E. Jones, of Mass. Board of Health, they consist of 325 parts ether, 650 parts alcohol, and 25 parts ether oil. They are said to have a very bad effect upon the kidneys. _The Banner of Gold_ for Oct., 1898, contained a lengthy article upon the dangers of drugging, from which an extract is given here:-- "Philanthropists, when trying to stay the hand of rum, do not overlook the victims of drugs. If you will go, under the protecting ægis of an officer, to an opium den, such as are to be found in every large city, and as a visitor view for yourself the degradation of hopeless opium users, then train your batteries towards removal of the cause. Do not depend upon preaching, or the writing of essays, or the delivery of an address before some society whose mission ends in telling others what to do, but put on the armor of earnestness, go into the nursery, and demand of the mother to know why, when little lumps of human clay are placed in her keeping for the sacred purpose of moulding them into men and women, she deliberately feeds the prattling babe with soothing syrups, sleeping drops, paregoric, and opiates in various other forms, rather than with the healthful food, and simple remedies, that nature only requires. With such commercial nostrums the thoughtless mother too often paves the way for her offspring to a life of toxic-slavery by creating a systemic condition, which, in maturer years, develops an abnormal craving, or appetite, for narcotics and stimulants. Follow this little victim of nursery malpractice through the imitative age, and you will discover in him the cigarette smoker, the tippler, the self-abased youth, and later, the man whose life is shadowed with the curse of baneful appetite. "Ask the druggist, and the saloon keeper, why they dispense deadly poisons so freely to old and young, and they will tell you the law permits it; a sad commentary! "Converted men relapse into evil ways through coquetting with sin; and cured inebriates relapse to drink, and drugs, through the use of proprietary medicines, with which the domestic market is flooded. Tonics, compounds, nerve remedies, bitters, vitalizers, appetizers, balsams, pectorals and kindred nostrums contain, with few exceptions, from 7 to 50 per cent. of alcohol, or opium in varying quantities, each preponderating in kind, as the effect is designed to be stimulating, or sedative. The active principle of some of the best known catarrh remedies is cocaine, and a few manufacturers are honest enough to so announce on the labels covering their goods; more do not, and leave the victims to discover the truth after they have paid the penalty of ignorance, and developed the cocaine habit. Wholesale legislation, as well as vigorous education, is needed along these lines, and while considering means of betterment, the reputable citizen, the clergyman, and others of good moral repute, whose names are so generally used to herald the efficacy of so-called remedial inventions, should not be overlooked for ethical attention. "For the information of those of our readers, who are not familiar with the nature and use of toxic drugs, we here refer briefly to the prominent characteristics of a few most dangerously potent for evil, and seductive in kind. OPIUM AND MORPHINE:--"Gum opium, the dried milky exudate from the green capsules of the white poppy, and its product--morphine--are the most reliable drugs known for the relief of pain. The dose of gum opium in medicine is from 1/4 to 1 grain. It contains from 8 to 14 per cent. of morphine, which is its principal alkaloid. Opium is a much more stable, and stronger, sedative than morphine. The cumulative effect of repeated medicinal doses is frequently observed, and is followed by dangerous symptoms. It is both a sedative and hypnotic, and, if given in large doses, quiets the brain, and excites the spinal cord. Small doses have little perceptible effect upon the circulation, but, under the influence of large doses, the pulse is retarded, and the respiration becomes fuller, deeper, and slower. In poisonous doses the pulse may become rapid, and great depression follow, the respiratory centres are paralyzed, thus causing death. If taken in from 2 to 4 grain doses it produces deep comatose sleep, full breathing, full pulse, dry skin, and contracted pupils. If the dose is sufficiently large, the sleep will be more profound, the patient can hardly be roused, and if awakened quickly, he sinks back into slumber. The face may be swollen, and reddened, and the lips deeply tinged with blue. At this stage the breathing may be characterized as puffing. Respiration may be from 8 to 10 per minute, perhaps be reduced to 4, 2 or 1, and as the toxic effect is more marked, it becomes shallow, the pupils are contracted, and the patient is so thoroughly narcotized that nothing will arouse him, the heart ceases to beat, and he dies by respiratory failure, or paralysis of the pneumogastric nerve. "Morphine, extracted from gum opium by a slow and expensive process, is used much less in proprietary medicines than is tincture of opium, which is more easily manufactured. "A medicinal dose of sulphate of morphine is from 1/8 to 1/4 of a grain. One grain is a dangerous dose, and 2 grains are liable to prove fatal. Morphine is a true narcotic. It is a sedative, lessens tissue change, and weakens every function of the body. TINCTURE OF OPIUM, OR LAUDANUM:--"Laudanum, or the tincture of opium, is a mixture of gum opium with alcohol and water, the solution consisting of equal parts of alcohol and water. Each ounce contains 5-1/2 grains of powdered gum opium and half an ounce of alcohol, and is equal in alcoholic strength to one ounce of strong whisky. The ordinary medical dose is from 12 to 15 minims, or from 25 to 30 drops. It is much used as a domestic remedy for pain from any cause, such as ear or toothache, indigestion, insomnia, summer complaints with children or adults, and is often used in poultices over painful sores or swellings. It is also used in many medicines for throat and lung troubles, in nearly all medicines for painful chronic diseases, and in many of the well advertised spring tonics, as well as in nearly all the compounds that are offered for sale for blood troubles, or as alteratives. The opium in laudanum acts the same as morphine, or any other of the thirty preparations of opium, officially recognized by the medical profession. PAREGORIC:--"Paregoric of standard grade is half alcohol, which is as strong of alcohol as high proof whisky. It contains a little opium, some benzoic acid, oil of anise, and camphor. The dose is from 15 to 60 drops. COCAINE:--"Cocaine is an alkaloid of coca leaves, and is used in medicine in the form of hydro-chlorate. It is used locally in powder or solution to relieve pain. It is a strong local anæsthetic. The ordinary dose when used as medicine is from 1/4 to 1/2 grain, and is very unstable and treacherous in its effects. Some patients will tolerate large doses while in others small doses produce unpleasant effects. Deaths are recorded from the use of 1-7 to 1 grain. CHLOROFORM:--"Chloroform is an anæsthetic, and death is often caused by a few inhalations. The dose internally is from 3 to 20 minims. It is not much used in medicine, except to control pain, and produce sleep. It is inhaled to produce mild slumber, or complete insensibility in surgical operations. Death may come suddenly, and without warning, at any time during its administration. CHLORAL:--"Chloral, or hydrate of chloral, is an hypnotic. It is of but little value in medicine, except to control nervousness, and produce sleep. The dose is from 15 to 30 grains. It should be administered with caution, and only by the physician. It is made by passing chlorine gas through pure alcohol, and gets its name from the first syllables of the two words, chlorine and alcohol. It produces death by inhibition of the heart's action, and by paralyzing the pneumogastric nerve. BROMIDIA:--"Bromidia is the trademark of an hypnotic, the manufacturers of which give out to the public that each fluid drachm contains 15 grains of chloral hydrate, or 1 ounce to every 4 ounces of bromidia. SULPHONAL:--"Sulphonal is a coal tar preparation, and is valuable in medicine as an hypnotic only. An ordinary dose to produce sleep is from 10 to 40 grains. If it is given in these doses for several days in succession it produces great weariness, an unsteady gait, and may involve paralysis of the lower limbs, with great disturbance of digestion, and scanty secretion of urine of about the color of port wine. There are a number of cases of death reported as resulting from acute, or chronic poisoning, by sulphonal. PHENACETINE:--"Phenacetine is a product of coal tar, and an antipyretic, a drug that lessens the temperature in high fevers, and rapidly disintegrates the blood. ANTIFEBRIN:--"Antifebrin, another of the coal tar preparations, is the registered name for acetanelid. Its effects are very similar to the effects of phenacetine, and it is used in fevers for lessening the temperature, and for neuralgic pains. The medicinal dose is from 3 to 10 grains. Unpleasant effects follow its continued use, such as great exhaustion, blueness of the lips, and a slow, labored pulse. HEADACHE REMEDIES:--"The indiscriminate use of the many coal tar products and other hypnotics, such as sulphonal, phenacetine, antifebrin, chloral, bromidia, etc., under the guise of headache remedies is productive of much disaster, all being nerve paralyzants." The public owe a debt of gratitude to those physicians, and chemists, who give freely such valuable information as to the real nature and effects of dangerous drugs. While it is true that the popular belief in drugging is due to professional practice, yet it is also true that what the people know of the preservation of health, and of the danger of alcohol and other drugs is largely owing to the medical profession. There is as much difference among the members of the medical profession as there is among the members of any profession; some are careless, selfish, unprincipled, unobservant of the effects of various medicines; while others are anxious to teach the people how to avoid sickness, and gain strength. It is the latter class who warn against the self prescription of drugs, especially those of the dangerously seductive, narcotic class. Yet, with all the warnings, few pay heed. Even highly educated, intelligent people seem possessed of a blind faith in the power of drugs. Every little ache or pain must have its sedative, be the future penalty what it may. Were people to quit drugging themselves, avoid indigestible viands, eat at regular hours, chew well, stop eating when they have had enough, take a sufficiency of exercise, sleep and fresh air, with a hot bath once a week, and a cold "towel bath" each morning, laying aside all alcoholic beverages, tea and coffee, and tobacco, there would be very little sickness in the world. Over-eating leads to the drug habit for relief from uneasy sensations, so does improper food, or poorly cooked food. It should be remembered that it is not possible to violate the laws which relate to the physical well-being, and then escape the natural penalty of transgression by swallowing a few doses of medicine. Remedies may postpone the results of physical transgression, and may even seem to prevent them altogether, but careful observation will show that the escape from punishment is only apparent. Sometimes a parent escapes, while his child pays the penalty of his transgression, in a weakly nervous system, which may lead to insanity, or other trouble. CHAPTER XV. TESTIMONIES OF PHYSICIANS AGAINST ALCOHOLIC MEDICATION. "In abandoning the use of alcohol it should be clearly understood that we abandon an injurious influence, and escape from a source of disease, as we do when we get into a purer atmosphere. _There is not the slightest occasion to do anything, or to take anything to make up for the loss of a strengthening or supporting agent._ No loss has been incurred save the loss of a cause of disease and death."--DR. J. J. RIDGE, of London Temperance Hospital. Sir. B. W. Richardson, M. D., said of the London Temperance Hospital:-- "No alcohol is administered, and no substitute for it. Any drug with similar action would be bad; warmth and suitable nourishment are relied on to keep up the system. We know that people who take alcohol often feel better; this is from the narcotic action. The pain may be stilled, and the disease forgotten, but it has not been removed; its symptom has been narcotized." Another writer says:-- "I am asked for a substitute for brandy, and frankly and gladly I tell you there is no substitute, for I have no knowledge of any agent equally pleasing to the palate, and yet so destructive of life." Dr. Norman Kerr, President of the Society for the Study of Inebriety, England, says:-- "My own experience of thirty-four years in the practice of my profession has taught me that in nearly all cases and kinds of disease the medical use of alcohol is unnecessary, and in a large number of instances is prejudicial and even dangerous. Having given an intoxicant, in strictly definite and guarded doses, probably on the whole only about once in 3,000 cases (then usually when nothing else was available in an emergency), and having had most varieties of disease to contend with, my death-rate and duration of illness have been quite as low as my neighbors. The experience of the London Temperance Hospital and other similar institutions, the current reports of that hospital being now reliable scientific records, amply support this experience. "The chief peril of narcotic drugs has always appeared to me to lie in their disguising the real state of the patient from himself as well as from his doctor and his friends. If there is any serious ailment, such as cholera or fever, the sufferer may seem to be and may feel better. He is not better. He is actually worse--made worse by the alcohol, and not unseldom, after the evanescent alcoholic disguise and deceptive improvement has faded, it is found that the malady itself has been progressing, unseen and unsuspected from the delusive aspect of the alcohol, steadily toward a fatal termination, which might, in many cases, have been averted but for the true state of the patient having been completely masked. "Wherever the blame really has lain, one thing is now clear, that alcoholic intoxicants are very rarely useful as a medicine; are at the best dangerous remedies; and that, other things being equal, the less they are resorted to the better for the chances of the patient's recovery, the better for body and brain, the better for physical, intellectual and moral well-being. Alcohol does not nourish, but pulls down; does not stimulate, but depresses; does not strengthen, but excites and exhausts. Alcohol is the pathological fraud of frauds, degenerating while it claims to be reconstructing, enfeebling while it appears to be invigorating, destroying vitality while it professes to infuse new life." A medical writer in the Toledo, O., _Blade_ holds up in clear light the relation of the _materia medica_ and alcohol, and the opportunity of the physician to become a benefactor, and active temperance worker. His remarks follow:-- "One of the signs of the times in the temperance movement is the steady growth among physicians of a sentiment against the administration of liquor of any kind as a medicine. The accepted scientific view of alcohol is that it is a poison, and its administration should be as guarded as that of any other poison used as a medicine. Perhaps the hardest thing a physician finds in his effort to restore his patients to health without the use of liquors is the common, but erroneous, belief that they are 'strengthening,' and that the convalescent, by their use, reaches recovery more quickly. The error is in supposing that any alcoholic liquor is nourishing, or strengthening. They are neither. Alcohol does not nourish, but it pulls down; it does not strengthen, but excites and exhausts, for every stimulation is necessarily followed by a period of depression, and this is inevitably unfavorable to the patient. "There is a grave responsibility resting on the physician who prescribes alcoholic liquor. It may arouse in a susceptible patient a dormant, inherited tendency to drink. He may, by authorizing its use during the period of convalescence, fix a habit upon a patient of feeble will, which the latter will never be able to shake off. No physician who realizes this great moral responsibility will be willing to accept it habitually. He certainly knows that the best medical authorities agree that alcoholic intoxicants are rarely useful as a medicine; that at best they are dangerous remedies, and that the less they are resorted to, the better for both brain and body. "In point of fact the physician who does his duty to his patient teaches him the error of the prevalent belief in the virtues of liquor in restoring the sick to health. He becomes an active temperance worker in effect. And he can do a noble and useful work in the rescue of those who are under the control of the drink habit. * * * * * "Furthermore, every physician owes it to his profession to teach his patients the utter fallacy of the common belief that alcohol is an article of food value. It has no such value. The use of intoxicants in any quantity whatever, or at any time, is entirely useless and unnecessary. The continued use of them gradually induces structural degradations and functional derangements of the great bodily organs, thus leading to the gravest physical disorders." "I have demonstrated by actual experience that no form of alcoholic drink is necessary, or desirable, for internal use, either in health, or any of the varied forms of disease; but that health can be better preserved, and disease more successfully treated, without the use of such drinks.* * * * * Simple truth compels me to say that I have never yet seen a case in which the use of alcoholic drinks either increased the force of the heart's action, or strengthened the patient. But I could detail very many cases in which the administration of alcoholics was quieting the patient's restlessness, enfeebling the capillary circulation, and steadily favoring increased engorgement of the lungs and other internal viscera, and thereby hastening a fatal result, where both attending physician and friends thought they were the only agents that were keeping the patient alive. "I have found no case of disease and no emergency arising from accident, that I could not treat more successfully without any form of fermented or distilled liquors than with. It is easy to see that the anæsthetic properties of alcohol can be made available by an intelligent and skillful physician to meet a very limited number of indications in the treatment of some cases that will come before him. But the same intelligence and skill will enable him to select other remedies capable of meeting the same indications more perfectly, and, with less tendency to secondary bad effects. I have no hesitation, therefore, in stating that for the attainment of the highest degree of success in the management of all forms of disease, whether acute or chronic, we need no form of fermented, or distilled, alcoholic drinks. And whoever will boldly make the trial, will find that his patients, of every kind, will make better progress, on good air and simple nourishment, without any admixture of alcoholic liquids, than they will with such addition. In other words he will find that the supposed benefits of this class of agents in medicine, are as illusory as they are in general society, and that the words of the wise man are worthy of careful consideration when he says: 'Wine is a mocker and strong drink is raging, and whosoever is _deceived_ thereby is not wise.'"--DR. N. S. DAVIS, Chicago, Ill. "Dr. Hirschfeld, a well-known physician of Magdeburg, Germany, was recently arrested on a charge of malpractice. The specific charge was that he had refused to give alcohol to one of his patients who was supposed to need it. The doctor, like the more advanced German physicians, is discarding liquor from his practice, and made such a hot defence to the charge that the court not only discharged the physician, but assessed the cost of the defense against the prosecution."--_Bulletin of A. M. T. A._ Dr. Greene, of Boston, when addressing his brethren and sisters of the medical association in that city, upon alcohol, said in closing:-- "It needs no argument to convince you that it is upon the medical profession, to a very great extent, that the rum-seller depends to maintain the respectability of the traffic. It requires only your own experience, and observations, to convince you that it is upon the medical profession, upon their prescriptions and recommendations for its use upon many occasions, that the habitual dram-drinker depends for the seeming respectability of his drinking habits. It is upon the members of the medical profession, and the exceptional laws which it has always demanded, that the whole liquor fraternity depends, more than upon anything else, to screen it from opprobrium, and just punishment for the evils which the traffic entails upon society; and it is because the rum-seller, and the rum-drinker, hide under this cloak of seeming respectability that they are so difficult to reach either by moral suasion, or by law. Physicians generally have only to overcome the force of habit, and the prevailing fashion in medicine, to find an excellent way, when they will all look back with wonder and surprise, that they, as individuals, and members of an honored profession, should have been so far compromised." "It will be asked, _Was there no evidence of any good service rendered by the agent in the midst of so much obvious bad service?_ I answer to that question THAT THERE WAS NO SUCH EVIDENCE WHATEVER, AND IS NONE."--SIR B. W. RICHARDSON. "A prominent general practitioner expressed surprise that any one could do without alcohol in general medicine. He was persuaded to make a trial, by abandoning the internal use of spirits as medicine. A year afterward he wrote that his success in the treatment of disease had been equal to that of any year in the past, and that his cases recovered as well without alcohol as with it. In a recent medical meeting he remarked, 'I thought for many years that I could not do without spirits as medicine. I was mistaken. I am constantly treating cases of all degrees of severity without alcohol, and my success is fully equal to the average.'"--_Quarterly of A. M. T. A._ "Happily, the belief in alcohol is passing away."--DR. C. R. FRANCIS, late Professor of Medicine, Calcutta Medical College. Dr. Moor, the distinguished editor of the _Pacific Record_, says:-- "While the use of alcohol is always injudicious and injurious, it is particularly so in summer, when the system is predisposed to disturbances of the gastro-intestinal tract. "Alcohol flushes the capillaries of the mucous membranes just as it does the capillaries of the skin, and where there is already a smouldering congestion, it will take but little to light the fire of acute inflammation, which will rage with greatly increased intensity. "It is wiser to habitually avoid even the medicinal use of alcohol, as there are plenty of other stimulants which will give the desired results without entailing any disastrous after effects." "All the pleasant sensations of increased mental and physical power, which the use of alcohol produces, are deceptive and arise from the paralysis of the judgment and the momentary benumbing of the sense of fatigue which afterwards returns so imperiously with perhaps even greater intensity."--PROF. ADOLF FICK, of Wurzburg. Dr. Frank Payne, vice-president of the London Pathological Society, says:-- "Alcohol is a functional and tissue poison, and there is no proper or necessary use for it as a medicine." "When I first heard that there was going to be a total abstinence hospital, I thought it would be a complete failure. That was because I had been taught as a student to regard alcohol as absolutely necessary in the treatment of disease. Nevertheless I was an abstainer myself. When I was asked to join as physician, I did not consent without a good deal of consideration, and then only on the understanding that if I thought a person needed it, I should be allowed to administer alcohol. I remember the first case of severe typhoid fever I had. He was hovering between life and death, and I was anxiously watching to see whether it would be necessary to give alcohol, but the man made a good recovery without it. After watching many cases to whom I should have given alcohol if I had been treating them elsewhere, I came to the conclusion that I had been completely deluded. I gave it at one time to a woman in the Hospital who was in a dying condition, but it did not save her. I do not think I am likely to administer alcohol again. We have had progress and efficiency in the Hospital. It has been like an experiment for the profession, and our success shows that this giving of alcohol is certainly a matter for re-consideration for the medical profession. I believe that they are mistaken. There is no doubt that the amount of alcohol used in other hospitals has diminished greatly, compared with what was used in the past. To the outside public also this Hospital is an example. I believe that an immense number of the public have been teetotalers some time in their lives, but a great many of them have gone back to the drink in time of illness, because they have been advised to do so. This Hospital is a standing witness that disease and surgical injuries can be treated without alcoholic liquors."--DR. J. J. RIDGE, of London Temperance Hospital. "I find very little use for alcohol in the practice of medicine. Where there is one element of good in alcohol there are thousands that are bad."--DR. ALFRED MERCER, Syracuse, N. Y., Professor of Medicine in Syracuse Medical School. "Alcohol is rarely necessary. Other remedies are much more efficacious. In my department of the University of Buffalo I follow Cushny, who claims that alcohol is a poison, a depressant in direct proportion to the amount ingested, and a so-called false food."--DR. DE WITT H. SHERMAN, Adjunct Professor of Therapeutics, University of Buffalo Medical Department. "I believe that alcohol is the greatest foe to the human race to-day. I feel that it would not be a serious harm if its use as a medicine were totally discontinued."--DR. WALTER E. FERNALD, Professor in Tufts Medical School, Boston, Mass. "I rarely or never prescribe alcohol as a medicament or a food, or sanction its use as a beverage. Physiologically I look upon alcohol as a narcotic, with perhaps a primary stimulating effect, but I believe that such desired action as it is capable of producing can be equally well brought about by other agents. As a beverage the use of alcohol, particularly in excess, is attended with definite and well-known dangers."--DR. A. A. ESHNER, Professor of Clinical Medicine, Philadelphia Polyclinic and College for Graduates in Medicine. "I agree with you altogether in your agitation against the use of alcohol in any form. I believe that wine is a mocker, and belief in wine as a benefit, mockery."--DR. MATTHEW WOODS, Philadelphia, Pa. "It is extremely seldom that I ever advise the use of alcohol in any form for my patients."--ELLIOTT P. JOSLIN, M. D., Professor in Harvard Medical School, Boston, Mass. "My belief is that there is very little need of the medical use of alcohol. I almost never use it in my practice, and think that its use by practitioners generally is far less than it was a few years ago."--DR. E. G. CUTLER, Professor in Harvard Medical School, Boston, Mass. "I believe that the trend of teaching in the Harvard Medical School has been growing less favorable, of late years, to the use of alcohol in the treatment of disease, and in fact it is far less used than it was a generation ago."--DR. JAMES J. PUTNAM, Professor in Harvard Medical School. "My personal opinion in regard to the use of alcoholic drinks is very decidedly averse to such use. I have long been of the opinion that while the use of alcohol may restrain tissue metamorphosis, it cannot legitimately be considered a food."--DR. WILLIAM O. STILLMAN, Albany Medical College, Albany, N. Y. "I do not think you will meet with very many physicians who favor alcohol and its use. I believe the trend of the teaching in the Albany Medical College is that alcohol is not a food or stimulant."--DR. A. VANDER VEER, Albany, N. Y., Medical School. "I think the medical profession could get along perfectly well without the use of alcohol, except as it is needed in the manufacture of drugs. As a therapeutic agent, it has very little value. I do not suppose I have used a pint of alcohol in the last ten years. I think the tendency of the medical profession throughout the country is to give up alcohol in the treatment of disease."--DR. MATTHEW D. MANN, Dean of the Medical Department of the University of Buffalo, N. Y. "I very seldom prescribe alcohol as a medicine, and think its effects are positively harmful in the vast majority of medical cases."--DR. ALLEN A. JONES, Adjunct Professor of Medicine, Buffalo, N. Y. "At the Baptist Hospital I have not ordered alcohol for a patient in several years. At the Massachusetts General Hospital, in the out-patient department, I never prescribe it."--DR. RICHARD BADGER, of Harvard Medical School, Boston. "Alcohol is used much too freely in the treatment of the sick, especially in such conditions as mild typhoid fever, neurasthenia and early tuberculosis. It should be prescribed only when there is definite indication for it, and then in definite dose for a limited period in the same manner as any other powerful and potentially harmful drug."--DR. S. S. COHEN, Jefferson Medical College, Philadelphia. "It is seldom necessary to prescribe alcohol as a medicine."--DR. JAMES B. HERRICK, Professor of Medicine in Rush Medical College, Chicago. "As I have said but little about the use of medicine in the treatment of typhoid fever, save for one symptom, I may add, for the purpose of definiteness, that I use none except for special symptoms. The rare exceptions are stimulants such as strychnia, in less marked indications coffee. Alcohol as a routine drug I have entirely abandoned, having found that the doses formerly given before or after the bath are altogether unnecessary. Hot milk internally, or hot water bags externally, more than replace spirits according to my experience."--DR. GEORGE DOCK, New Orleans. "I have no use for alcohol, either personally, or in my practice. Yet I cannot say that I have entirely abolished it. Alcohol is used in compounding most of our tinctures, but in remedies proper my experience has been that other stimulants, such as ammonia, strychnine, caffeine, kolafra, etc., answer the same purpose without alcohol's dangerous effects. In my practice, which is confined to surgery, I find very, very little use for it. During the past year, in extreme cases, I used it in hypodermic injections, and afterwards felt that ether, or ammonia would have answered the same purpose. I think, in general practice, physicians are dispensing with alcohol more and more, but perhaps unconsciously."--D. W. B. DE GARMO, Professor of surgery in Post-Graduate Hospital, New York City. "Medicine, to-day, would be in a more satisfactory condition if the use of alcohol as a medicine had been interdicted a hundred years ago, and the interdict had remained to the present day. The benefits derived from its use are so small (even when they can be proved, which is much more rarely the case than most people imagine), and the advantages gained are so slight, that they are completely outweighed when we set against them the evil that has been wrought by the abuse of alcohol, and that has arisen out of the loose methods of prescription that have obtained, and even still obtain, in regard to this drug."--DR. G. SIMS WOODHEAD, F. R. C. P., F. R. S., Director of the Research Laboratories of the Royal College of Physicians and Surgeons, London. "The effect of continually dosing with this drug is too apparent wherever it is used, benumbing the senses, and rendering more difficult every natural function. Alcohol never sustains the powers of life. It sometimes changes the symptoms of disease, but at the expense of the vitality of the body. What is called its supporting action, is a fever induced by the poison, which finally prostrates the patient. The secret of its action is found in the laws of vitality. The man who takes alcohol to help digest his food, must first throw off the alcohol, before his stomach can act healthfully. "There is one encouraging fact to be noted in this connection, that the use of alcohol in medicine has very much diminished during the past twenty-five years, and the present tendency is constantly in that direction. Right here is an important point which I wish to make: When the physician ceases to prescribe alcohol as a medicine, the drink problem will have reached the final stage of its solution. Mankind will eventually learn that safety lies not so much in skillful doctors, or in some wonderful 'new remedy,' as in daily obedience to the laws of health. A small amount of prevention is of more worth than all the power of cure."--DR. C. H. SHEPARD, Brooklyn, N. Y. "My observation has been that there is a decided tendency among educated physicians to give less alcohol than formerly in the treatment of disease. Of late years I have given but very little alcohol in my own practice. The tendency is due, in my opinion, to the study of the physiological action of drugs, and to the better understanding of the causation of disease and pathological processes. Modern investigators now know that we have therapeutic agents that meet the requirements of disease processes with more scientific accuracy than is obtained by the exhibition of alcohol."--DR. DONNELLY, Secretary of Minnesota State Medical Society, St. Paul, Minn. "Dr. Pearce Gould recently made a speech to the National Temperance League on alcohol and the advantage of doing without it, both in health and in the treatment of disease. It takes a strong man to say the strong things which Mr. Gould said on the subject, especially if he happens to be a medical man. No doubt, as Dr. Gould says, the use of alcohol in medical practice is nothing now compared to what it was twenty years ago, much more forty years ago, when Dr. Todd's influence, and the reaction from the so-called antiphlogistic treatment were at their height. Public opinion has been enlightened by the evidence of leaders in medicine, such as Dr. Parkes, Sir William Gull, Dr. Gairdner, Dr. Sanderson, and others, and medical men have dared to treat disease without alcohol, or with only small quantities of it. There are physicians and surgeons of reputation and success, who are so strong in their convictions that alcohol is of little use in the treatment of disease, that it destroys tissues, lessens the resistance to microbes, deranges functions, spoils temper, and shortens life, that they are ready to testify to this effect in public, in company with redoubtable champions of the temperance cause like the Archbishop of Canterbury, Sir William White (chief constructor of the navy), and the Bishop of Derry, who have as much prejudice to contend against in their spheres as the medical man has in his. We recognize with pleasure the good done by such testimony as Dr. Gould's. Men whose record and authority in the profession are such as his have the courage of their opinions, and their honest testimony will be respected even by those who do not go quite so far in discarding alcohol as an element of diet, or as a medicine."--_The Lancet_, London, May 14, 1898. "The light of exact investigation has shown that the therapeutic value of alcohol rests on an insecure basis, and it is constantly being made clearer that after all alcohol is a sort of poison to be handled with the same care and circumspection as other agents capable of producing noxious and deadly effect upon the organism. It has been shown by Abbott and others that alcoholic animals are more susceptible to infections than normal animals. And Laitinen, after having studied the influence of alcohol upon infections with anthrax, tubercle and diphtheria bacilli in dogs, rabbits, guinea-pigs and pigeons, reaches the same general results with certainty and directness. Under all circumstances alcohol causes a marked increase in susceptibility no matter whether given before or after infections, no matter whether the doses were few and massive or numerous and small, and no matter whether the infection was acute or chronic. The alcoholic animals either die while the controls remain alive, or in case both die, death is earlier in the alcoholic. The facts brought out by the researches of Abbott and Laitinen and others do not furnish the slightest support for the use of alcohol in the treatment of infectious diseases in man."--_Journal American Medical Association, Editorial, September 8, 1900._ "Step by step the progress of science has nullified every theory on which the physician administers alcohol. Every position taken has been disapproved. Alcohol is not a food and does not nourish, but impairs nutrition. It is not a stimulant in the proper acceptation of the term; on the contrary it is a depressant. Hence its former universal use in cases of shock was, to say the least, a grave mistake. It has been proved by recent experiments that alcohol retards, perverts, and is destructive either in large or small doses to normal cell growth and development."--NATHAN S. DAVIS, SR., M.D., former Dean of Northwestern University Medical School, Chicago, Illinois. (Deceased.) "It seems to me that the field of usefulness of alcohol in therapeutics is extremely limited and possibly does not exist at all. Probably every supposed indication for its use can be met better and more safely by other drugs. The recent work on the so-called food value of alcohol is the subject of much misunderstanding. While it is true that under some circumstances, for example, after a person has acquired a certain degree of tolerance to its poisonous effects, alcohol seems to act as a food in the sense that fats and carbohydrates do, I believe this to be at present a matter of little more than theoretical importance."--DR. REID HUNT, Chief of the Department of Pharmacology, Public Health and Marine Hospital Service, Washington, D.C. "The physician should have blazoned before him, 'If you can do no good, do no harm.' If this rule is adhered to, in ninety-nine cases out of one hundred the physician will give no alcohol. In the medical wards of the Pennsylvania Hospital I have found that in acute as well as chronic disease we can do without alcohol. It does harm rather than good. Alcohol masks the symptoms of disease, so that we cannot know the patient's real condition."--J. H. MUSSER, M. D., Philadelphia, Pa., Ex-President American Medical Association. "It is time alcohol was banished from the medical armamentarium; whisky has killed thousands where it cured one."--J. H. MCCORMACK, M. D., Secretary Kentucky Board of Health, and Organizer for the American Medical Association. "I very rarely use alcohol in my practice. I think that its use is never essential. Physicians are using it less and less in the treatment of disease owing to the recognition that it is a narcotic, not a stimulant, and that other narcotics are usually better when a narcotic is required."--RICHARD C. CABOT, M. D., Professor of Clinical Medicine, Harvard Medical School, Boston, Mass. "My position has been that alcohol should be prescribed with as much care as to indications and circumspection as to dose and method as in the use of any other drug that in health would prove harmful, as morphine, belladonna, aconite, quinine, etc. I believe strongly that in pneumonia, typhoid fever, and tuberculosis especially, the indiscriminate use of alcohol in the past has caused an incalculable amount of distress and needless disaster to suffering humanity."--HOWARD S. ANDERS, M. D., Professor of Physical Diagnosis, Medico-Chirurgical College, Philadelphia, Pa. "I do not think alcohol of any value in the treatment of disease; formerly it was used a great deal in the hospital wards, and 'liquor slips' were daily signed. Now, I never order liquor in any quantity, and at times for weeks I have not signed a single slip ordering liquor."--HENRY JACKSON, M. D., Professor in Harvard Medical School. "In the overwhelming majority of cases I am in entire sympathy with the movement to abolish the routine use of alcoholics from medicine, and I rarely advise such in my practice."--EDWARD R. BALDWIN, M. D., Saranac Lake Sanitarium, New York. "I seldom prescribe alcohol."--GEORGE BLUMER, M. D., Yale Medical School, New Haven, Conn. "WHEREAS, The study of alcohol from a scientific standpoint has demonstrated that its action is deceptive, and that it does not have the medical properties that we once claimed for it; now, therefore, be it "_Resolved_, By the West Virginia State Medical Association, That we deplore the fact that our profession has been quoted so long as claiming for it virtues which it does not possess, and that we earnestly pledge ourselves to discourage the use of it, both in and out of the sick room."--_Resolution passed at annual meeting May, 1908._ "I have been actively engaged in the practice of medicine for nearly twenty-five years, in the early portion of which I prescribed alcoholics moderately but yet with considerable frequency. For the past ten years I have been finding professionally less place for alcoholics of any sort in my practise, and for perhaps three years I have scarcely ever prescribed them. I am satisfied that my cases of pneumonia and typhoid come through in better condition without anything alcoholic, even wines, and I no longer prescribe these at all in cases of tuberculosis. I have noted also that among my professional associates of the thinking rather than of the automatic type, the medicinal use of alcohol is rapidly lessening."--C. G. HICKEY, M. D., Lecturer on Medicine, Denver and Gross College of Medicine, Denver, Colorado. "In the thirteen years I have taught in Michigan I have not used alcohol in the treatment of disease in a routine way. Even alcoholic preparations, such as tinctures, have been used in very rare instances. I have occasion to speak on this subject every year to about two hundred students. My reasons for taking this stand are chiefly medical, though I am heartily in sympathy with the ethical and moral phases of the temperance movement."--DR. GEORGE DOCK, formerly Professor of Medicine, University of Michigan Medical College, now of Tulane University, New Orleans. "Alcohol is distinctly a poison, and the limitation of its use should be as strict as that of any other kind of poison. It is not an appetizer, and even in small quantities it hinders digestion. The use of alcohol is emphatically diminishing in hospital practise."--SIR FREDERICK TREVES, Surgeon to King Edward. "If during the last quarter of a century I have prescribed almost no alcohol in the treatment of disease, it is because I have found very little reason for its use, and it seemed to me that my patients got on better without it."--SIR JAMES BARR, Dean of the Medical School of Liverpool University. "With the increase of medical knowledge and with the increase of medical observation, it is shown every year that the value of alcohol as a drug has been enormously overestimated. It is a very poor agent, and only in common use because it is so easily obtained. The medical profession is using it less and less, because they appreciate it now at its true value. Personally I never order it, because I believe patients recover better without it."--SIR VICTOR HORSLEY, Surgeon to London Hospital. "The same care and discrimination should be given to the prescribing of alcohol as to the most deadly drug with which we have to deal. In looking at the report of Radcliffe Infirmary for the past month I see that in dealing with twenty-five cases I ordered alcohol costing exactly 1-3/4 pence."--DR. WILLIAM COLLIER, President British Medical Association, 1904. "In England at present the use of large doses of alcohol seems to have greatly gone out of hospital practise, and opinion is certainly growing that not even small doses are required. Diseases of the stomach, liver, heart, and kidneys have appeared to me, in my practise, to be much more satisfactorily treated without beer, wines, or spirits."--DR. C. R. DRYSDALE, Consulting Physician to the Metropolitan Hospital, London. "Alcohol is a functional and tissue poison, and there is no proper or necessary use for it as medicine."--DR. FRANK PAYNE, Vice-President London Pathological Society. "Of scarlet fever I have treated some 2,000 cases. I have never seen a case in which, in my opinion, alcohol was necessary; no case in which its administration was beneficial; but I have seen more than one case in which its action was directly injurious. * * * Alcohol in no case averts a fatal issue where such is impending. * * * The facts are dead against alcohol. In hospitals there has been an increase of 300 per cent. in the use of milk, and a decline of 47 per cent. in the use of alcohol. Progress in treatment of disease has gone hand in hand with disuse of alcohol. The use of alcohol formerly was the outcome of ignorance, a confession of weakness and defeat; to-day it is the expression of inability to discard the fetters of an outworn routine."--DR. C. KNOX BOND, in Medical Times. "For many years I have dispensed almost entirely with alcohol as an aid in surgical treatment. As a student I saw it used, almost as a matter of routine, for every kind of surgical malady except head injuries, and in my early years I naturally followed the practise of my teachers; but as soon as I made trial for myself of the effect of withholding alcohol, I found how entirely overrated its value was, and how gravely mistaken had been the teaching. It is commonly held, I believe, that alcoholic stimulants are of especial value in all forms of septic inflammation, such as erysipelas, pyæmia, septicæmia, and hectic fever. I believe that this belief is founded solely upon tradition unsupported by any trustworthy evidence, and untested by experiment or experience."--DR. A. PEARCE GOULD, F. R. C. S., Surgeon to the Middlesex Hospital, London. "I have not prescribed alcohol to my patients for more than ten years, and can affirm positively that they have fared well under this change of treatment. Since I formerly followed the universal practice, I am competent to make comparisons, and these speak unconditionally in favor of treatment without alcohol. As a preventive of waste I use among fever patients nothing but real foods; in addition to milk, particularly sugar, which can be administered to any fever patient in ample quantity in the form of fruit juices, stewed fruit, sweet lemonade, fruit ices, sugared tea, etc., concerning which hundreds of investigations have demonstrated positively that it prevents the waste of both albumen and fat. As a stimulant I employ, besides hydriatic methods, which at the same time abstract heat, almost nothing but camphor, and I can affirm that it is unconditionally preferable to alcohol for its prompt results and the absence of disagreeable after-effects (intoxication, benumbing). Pneumonia, especially, subsides without alcohol to perfect satisfaction, and I rejoice to agree in this respect with Aufrecht, one of the best authorities on this disease, who in his monograph in Nothnagle's manual, acknowledges himself hostile to the use of alcohol in the treatment of pneumonia, and hopes that its use may be speedily abolished. For the reasons previously specified, I should like to see that extended to all use of alcohol in therapeutics. However, that can come to pass only when all thinking physicians clearly appreciate the fact that no substance is able to undertake the double role of a food and a poison, and, also, that for alcohol no nutritive, but only toxic properties can be claimed."--MAX KASSOWITZ, M. D., Professor in the University of Vienna, Austria. "Besides its deleterious influence on the nervous system and other important parts of our body, alcohol has a harmful action on the phagocytes, the agents of natural defense against infective microbes."--PROF. METCHNIKOFF, Pasteur Institute, Paris, France. "Alcoholic liquors are, to my mind, not only not valuable, but distinctly disadvantageous, in the treatment of disease, except in rare instances, as for example in the initial chill of some acute infectious disease. However, I have almost given up the use of alcohol in the treatment of disease."--DR. D. L. EDSALL, Professor of Therapeutics in the University of Pennsylvania Medical School. "As a rule which might well be regarded as universal in the practice of medicine, alcohol in the treatment of disease is an evil. In ordinary doses and in continuous use the sum of its reactions increases exhaustion, which may terminate fatally."--DR. JOHN VAN DUYN, Professor of Medicine in Syracuse, N. Y., University Medical School. "In sixteen years of active practice I have not used alcoholics at all. I am medical director of the Scranton Sanitarium, and I have considerable trouble in trying to cure those who use alcohol, and to undo some of the work my fellow practitioners have unwittingly made."--D. WEBSTER EVANS, M. D., Scranton, Pa. "I am opposed to the use of alcoholic liquors as a beverage, and with rare exceptions, to their use in the treatment of diseases."--DR. EUGENE KERR, Physician to Phipps Dispensary, Johns Hopkins Hospital, Baltimore, Md. "In my professional work I do not advise or permit the use of alcohol as a beverage or medicine in any form whatever. No alcohol is used medicinally in my hospital wards. Beer or wine is not permitted to convalescents. Children are never given tinctures. Cases of delirium tremens receive no alcohol. The hypodermic use of alcohol is not permitted in cases of shock. There are other much more effective and less depressing diffusable stimulants. "Among my colleagues the employment of alcohol as a medicine has diminished at least seventy-five per cent. in the past fifteen years. "I have cast it out entirely."--J. P. WARBASSE, M. D., Chief Surgeon German Hospital, Brooklyn, N. Y. "The habitual use of alcohol in any disease is worse than harmful."--ROBERT B. PREBLE, M. D., Chicago, Ill. "The last few years I find I have used less and less alcohol in prescribing for my patients until at the present time I use very little. I think my typhoid cases do better without alcohol than with it."--H. H. HEALY, M. D., former Sec'y North Dakota Board of Health. "Alcohol is a poison. It is claimed by some that alcohol is a food. If so, it is a poisoned food."--FREDERICK PETERSON, M. D., Professor of Psychiatry, Columbia University, N. Y. "Few physicians now credit alcohol as a food (that is, as a tissue builder) or as having any valuable medicinal qualities. In fact, it is considered by many to have a destructive rather than a constructive quality. I believe it should never be put into the human body."--EUGENE HUBBELL, M. D., St. Paul, Minn. "The medical profession is learning that alcohol has been much abused in the treatment of the sick, and is largely discarding it. I hardly find occasion to prescribe it once a year."--W. A. PLECKER, M. D., Sec'y State Board of Health, Hampton, Va. "The use of alcohol as a beverage or therapeutically, is in either case a habit of the user. The stimulation is but temporary, the reaction leaving the nerve cells of the individual with less resisting power than before the ingestion of alcohol. * * * Never permit a verbal or written prescription of yours to give rise to the use of a habit forming drug."--_From a lecture to students in Omaha Medical College by J. M. Aiken, M. D., Clinical Instructor and Lecturer upon Nervous and Mental Diseases._ "The use of spirits as a stimulant in diseases, except in a very limited circle, is a mere empiricism for which no good reasons can be given. The teachings of medical men are no more to be followed blindly and without question. The tests of alcohol as a tonic, as a food, as a stimulant, as a retarder of waste, are all negative. There is no reliable evidence to support these claims, but a constant accumulation of facts to indicate the danger from the use of spirits. To give alcohol or any other drug without some rational theory in accord with the scientific researches of to-day is unpardonable."--DR. T. D. CROTHERS, Hartford, Conn., Editor of the Journal of Inebriety. "Many physicians prescribe alcohol only because it is the desire of the patient, and because patients refuse medicine which the physicians would rather use."--EVERETT HOOPER, M. D. Boston, Mass. "You are right in indicting alcohol for its insidious wrongs to humanity. It is an old and sly offender and very much the 'mocker' in medical practise that it has been pronounced in holy writ. It exhausts the latent energy of the organism often when that power is most needed to conserve the failing strength of the body in the battle with disease."--DR. C. H. HUGHES, St. Louis, Missouri. "The best class of thinkers, men of the best intellectual gauge, are those who are doing away with this miserable, unscientific practise of giving liquor."--DR. BOYNTON, Clifton Springs, N. Y. "I believe that in the scientific light of the present era alcohol should be classed among the anæsthetics and poisons, and that the human family would be benefited by its entire exclusion from the field of remedial agents."--DR. J. S. CAIN, Dean of the Faculty, Medical Department, University of the South, Sewanee, Tenn. "Let me cite my experience in surgery for the last three years in proof of the uselessness of alcohol, and the benefit of abstinence from its administration. During that time I have performed more than one thousand operations, a large portion upon cases of railroad injuries, one hundred for appendicitis, and in none of these was alcohol administered in any form, either before, during, or after operations. I defy any one who still adheres to alcohol to show as good results. Equally gratifying results have been obtained with my medical cases, and I fail to understand how any observing and thinking physician can still cling to so prejudicial a drug as alcohol, when he has within his reach a multitude of valuable, exact, and reliable methods for combating, governing, and controlling disease."--DR. EVAN C. KANE, Surgeon Pennsylvania Railroad, Kane, Pa. "In my neurological practice I emphatically forbid my patients the use of alcohol. This poison has a special predilection for the nervous system which it influences sometimes to an alarming extent."--ALFRED GORDON, M. D., Jefferson Medical College, Philadelphia, Pa. "Alcohol finds no place in my remedial list. It has been banished, not from sentiment, but from knowledge secured by scientific investigation."--T. ALEXANDER MACNICHOLL, M. D., New York City, one of the founders of the Red Cross Hospital, New York. "No sound, scientific argument can be offered for the medical use of alcohol, either internally or externally. It is a toxic substance which ought to be retired from the _materia medica_, and placed in the catalog of obsolete drugs along with tobacco, lobelia, and like useless but highly toxic drug substances."--DR. J. H. KELLOGG, Superintendent Battle Creek Sanitarium, Battle Creek, Michigan. "The majority of medical men, without making any searching investigation into the abundant recent literature upon the subject of alcohol, are disposed to regard it with less and less favor as the years go by, while those who have closely followed the thorough investigations into the physiological action of alcohol recently made by scientists, have repudiated it altogether. * * * It is a lack of information upon this subject--together with the fact that alcohol has been used as a therapeutic agent for hundreds of years, during which it has formed the basis of all tonic or stimulating treatment--that gives alcohol its present hold upon a part of the medical profession."--JOHN MADDEN, M. D., Portland, Oregon, formerly professor in Milwaukee Medical College. "Alcohol may fill an emergency when better means are not at hand, but, apart from this, I know of no use in the practise of medicine and surgery for which we have not better weapons at our command. There is but one reason for the continued use of alcohol--men use it because they love it." DR. W. F. WAUGH, Chicago, Editor Journal of Clinical Medicine. "If alcohol had become a candidate for recognition years ago instead of centuries ago it is safe to say that its application in medicine would have been very much more limited than we find it at the present time. Its wide therapeutic use is to be attributed in part to fallacies and misconception regarding its pharmacology, and in part to a disinclination on the part of the average practitioner of medicine to depart from old and well-beaten lines."--WINFIELD S. HALL, M. D., Professor of Physiology, Northwestern University Medical School, Chicago. "In its relation to the human system, alcohol is never constructive and always destructive."--PROF. FRANK WOODBURY, M. D., Philadelphia, Pa. "The clinicians who decide for the deleterious action of alcohol in infectious conditions have what evidence of an experimental nature we possess at the present time to support their impressions. The advocates of the continuous use of the drug have this evidence against them."--HENRY F. HEWES, M. D., Harvard Medical School, Boston, Mass. "I am very glad that you are undertaking so important a work as this in connection with the terrible problem of alcoholism. Physicians need awakening in this matter; they need reform. The evil results of alcohol are unfortunately brought to my notice each day of my life as I pursue my vocation and my public duties as Health Officer, and a reform in prescribing so as to eliminate alcohol would undoubtedly have far-reaching beneficent effects."--EDWARD VON ADELUNG, M. D., Health Officer, Oakland, Cal. "I am forwarding you a report of 303 cases of typhoid fever treated without alcohol, and my reasons for not using it. I believe the results will not suffer by comparison with those obtained in other hospitals where alcohol is used. Wishing you lasting success in your war upon the greatest evil of the times."--J. H. LANDIS, M. D., Cincinnati, O. "Only precise evidence that it (alcohol) is able to protect albumen from destruction can warrant its employment and establish its value as a food in the sick diet. And this evidence which is of determinative importance must be looked upon as having failed, according to the recent investigations of Stammreich and Miura (who both worked under von Noorden's direction), as well as by Schmidt, Schöneseiffen and Roseman. The uniform result of all these experiments, arrived at by altogether different methods, is that _alcohol does not possess albumen sparing power_; that it even brings about an undoubted breaking down of albumen, and consequently it is entirely unequal to carbohydrates and fat."--DR. JULIAN MARCUSE, a contributing editor of _Die Heilkunde_, a German medical magazine. See issue of July, 1900. "Thirty years ago the general principle of practice was stimulation. Alcohol was supposed to rouse up and support vital forces in disease. Twenty-three years ago the first practical denial was put into a permanent position in a public hospital in London, where alcohol was seldom or never used. * * * Doctor Richardson's researches showing the anæsthetic nature of alcohol have had a great influence in changing medical practice in England. * * * On the Continent a number of scientific workers have published researches confirming Doctor Richardson's conclusions, and bringing out other facts as to the action of alcohol on the brain and nervous system. These papers and the discussions which followed have been slowly working their way into the laboratory and hospital, and have been tested and found correct, materially changing current opinions, and creating great doubts of the value of alcohol. "In 1896, the prosecution of Doctor Hirschfeld, a Magdeburg physician, in the German courts, for not using alcohol in a case of septicemia, seemed to be the central point for a new demonstration of the danger of the use of alcohol in medicine. Doctor Hirschfeld was acquitted on the testimony of a large number of leading physicians from the large hospitals and universities of Europe. It was proved that alcohol was not a remedy which was specifically required in any disease; also that its value was most seriously questioned as a general remedy by many able men, and its substitution was practical and literal in most cases. Statistics were presented proving that alcohol was dangerous, and never a safe remedy, and laboratory investigations confirming and explaining its action were given. Since then a sharp reaction has been going on in Europe, and alcohol is rapidly declining and passing away as a common remedy. "Doctor Frick, an eminent teacher of medicine in Zurich, Switzerland, and Doctor von Speyer, of the University of Berne, have made statistical studies of cases treated with and without alcohol, and have analyzed the effects of spirits as medicinal agents to check and antagonize disease, and assert very positively, that alcohol is a dangerous and exceedingly doubtful remedy. Doctor Meyer, of the University of Gottenburg, Doctor Möbius, of Leipsic, and Doctor Wehberg, of Dusseldorf, are equally prominent physicians who have taken the same position, and are equally emphatic in their denunciations of the current beliefs concerning alcohol in medicine."--_Journal A. M. A._, January 6, 1900. Dr. H. D. Didama, Dean of the Medical College of Syracuse University, Syracuse, N. Y., said in January, 1898, in the _Voice_:-- "For many years after my graduation at Albany, in 1846, I prescribed alcohol, and for twenty years, while occupying the chair of professor of the science and art of medicine in the College of Medicine of Syracuse University. I followed in my lectures--often reluctantly and usually afar off, but still I followed--the almost unanimous teaching of authors, ancient and modern, and the professors in the medical schools. "Convinced that a great number of the diseases I was called to treat owed their existence or aggravation to the use, in alleged moderation, of alcoholic beverages, and that not in a few instances this use was commenced and even continued by the advice of the medical attendants; convinced also by the published experiments of many acute observers at home and abroad, and by my own observations, that almost all diseases could be managed as well if not better by the non-use of alcohol, and satisfied from the communications of some brother practitioners that the fatality in certain specified diseases was not delayed, to say the least, by the employment of increasing and enormous doses of wine, whisky and brandy, and influenced also, I must admit--overwhelmed, indeed--by what I know and what I read daily of the pauperism, domestic wretchedness, crime, insanity and incurable maladies transmitted to innocent offspring, I abandoned entirely, more than three years ago, the use of alcoholic remedies. "I have endeavored by personal example and earnest council to dissuade my patients from the use of intoxicating beverages and medicines. "The outcome of this practice, medically and morally, has been satisfactory to myself, and, I have reason to believe, to my patients also. "Whatever regrets I may feel for my former teaching and practice, I have no apology to offer for my inconsistency except that once given by Gerrit Smith:--'I know more to-day than I did yesterday; the only persons who never change their minds are God and a fool.' "Permit me to add that while there may be an honest difference of opinion regarding the efficacy of legislative enactments in overcoming or restraining the drink habit, there should be little doubt that a whole-hearted, persistent, precept-and-example effort of the medical profession exerted as individuals on their patients and the families of their patients, and as associations on the community at large, would do immeasurable good. "And the newspapers might aid materially in this beneficent work if, while they continue to spread before our households every day the details of the brawls and fights of drunken men and the horrible murders which they commit, they would discontinue advertising, without warning or dissent, side by side with the atrocities, the 'innocuous beers,' the pure malt whiskies, the genuine brandies, guaranteed to prevent and cure all manner of diseases." The following testimony from an English physician is significant:-- "Although I know beforehand that their united testimony must be in favor of the practice of total abstinence from all intoxicating drinks, being most conducive to health and longevity of their patients, but very inimical to the pocket interests of themselves, my own experience is, that my teetotal patients are seldom ill, and that they get well very soon again, if they are attacked by disease. A higher principle than that of gain must influence a medical man's mind, or he will never advocate the doctrine of total abstinence."--J. J. RITCHIE, M. R. C. S., Leek. "One of the most dangerous phases of the use of alcohol is the production of a feeling of well being in weakly, dyspeptic, irritable, nervous or anæmic patients. In consequence of the temporary relief so obtained, the patient develops a craving for alcohol, which in many cases can end only in one way, and, as I felt compelled to tell an assembly of ladies a short time ago, the very symptoms for the alleviation of which alcohol is usually taken are those, the presence of which renders it exceedingly desirable that alcohol should not be taken."--DR. G. SIMS WOODHEAD, of London. In an address upon the London Temperance Hospital delivered shortly before his death, Sir B. W. Richardson gave a brief review of the influences which led him to abandon the medical use of alcohol. The following is taken from that address as reported in the _Medical Pioneer_:-- "I was a member of the Vestry of St. Marylebone, and we had in our parish a very serious outbreak of small-pox, attended with a considerable mortality. In his report to us Dr. Whitmore stated that in his treatment of earlier cases of the confluent and hemorrhagic, and malignant forms of disease, stimulants of wine and brandy were freely administered without any apparent benefit; and, that after consultation with Mr. Cross, the resident surgeon, they resolved to substitute simple nutriments, such as milk, eggs and beef-tea, at frequent intervals, with discontinuance of stimulants altogether. The result of the change was most satisfactory, and many bad cases did well, which under the stimulant plan they believed would have terminated fatally. Again I was struck very much by a report made by Mr. Cadbury, in which that gentleman showed the course that was going on in various hospitals. The amount of alcohol in twelve hospitals in London, taken by the inpatients, varied in ounces from 37,531 in one establishment to 300,094 in another during the year 1878. I also found, from the same author, that the whole cost in St. George's Union Infirmary for the year 1878 was £8. 3s. 6d., amongst 2,496 patients, while the cost of the same number at the average of the twelve hospitals was £124. About this same time I also remarked that in many of the public institutions of England there was a reduction something similar in kind, if not to the same extent, and that the number of persons who suffered seemed to make better recoveries than those who were taking the free amount of stimulant. The effect of these observations chimed in very remarkably with the physiological experiments it had been my duty to carry out, and which tended to show in a most striking manner that the action of alcohol in the body very much differed from the ordinary opinion that had been held upon it, and thereupon, in my own practice, I abandoned the use of alcohol, and began to give instead small quantities of simple, nourishing, dietic food, a course I pursued up to the present time with the most satisfactory results, results I have never felt any occasion to regret. By these steps, learned in the first place from the study of alcohol in its action on man, I was led to become a believer that alcohol is of no more service in disease than it is in health, and a lengthened experience in this matter has really confirmed the correctness of the idea." In his last report as physician to the Temperance Hospital Dr. Richardson made some remarkable statements upon the fallacy of the general ideas of stimulation. So interesting are his views that they are incorporated here:-- "Sir B. W. Richardson, M. D., who was unable to be present, communicated (through the secretary) his annual report as physician to the hospital. After twelve months further trial of the treatment of all kinds of disease in this institution without the assistance of alcohol, either as a diet or a medicine, he (Sir B. W. Richardson) was fully sustained in the belief that the plan pursued had been attended with every possible advantage. About 500 cases had come under his observation and treatment as in previous years, and these cases had been of the most varied kind, including all patients who were not directly suffering from contagious disease. In not one instance had alcohol been administered, nor had anything like it been used in the way of a substitute, and there had not been a single case in which he could conceive that it was ever called for, while the success which had attended the treatment generally had been superior to anything he had ever seen following upon the administration of alcoholic stimulants. One great truth which had forced itself upon him had reference to the doctrine of stimulation generally. It had been one of the grand ideas in medicine that there came times when sick people were benefited by being stimulated. It was argued that they were low, and in order that they might be raised and brought nearer to the natural life they required something like alcohol to quicken the circulation, quicken the secretion, and help to preserve the vitality. But the experience which was learned here tended to show in the most distinct manner that that very old and apparently rational idea was fallacious. Such stimulation only tended ultimately to wear out the powers of the body, as well as change the physical conditions under which the body worked. True lowness meant practical over-fatigue, and when the body was spurred on, or stimulated, over-fatigue was simply intensified and increased. What, therefore, was wanted was not stimulation, but repose. The sufferer was placed in the best position to gain entire rest, and all the surroundings or environments were employed which tended to prevent waste. The air was kept at the proper temperature, the body of the patient kept warm, and the simplest and most easily digested foods were used; the patient's condition then swung round to a natural state, and he began to get well. In other cases where the sick were brought under observation suffering already from excitable condition of the senses, with congestions here and there of the circulatory or nervous systems, with imperfect condition of the brain, and with the elements of what was usually denominated inflammatory or febrile state--the stimulant was already present (was, indeed the cause of the symptoms) and did not want in any degree to be enforced further by the acts of treatment. Here, therefore, they were on the safest grounds as regarded methods of administration, for they calmed as well as they possibly could both mind and body and left nature to do the rest, which she did with the best and most tranquilizing effect. On both sides, therefore, in the treatment of disease, they did good, and that was the reason, he believed, why their returns were so satisfactory. It often happened in an institution where some particular plan was carried out that the old ideas in which they had been bred were without intention refined or suppressed. For example, he had been taught, and believed for a number of years, that some medicament of a particular kind was needful for some particular train of symptoms, be the surrounding conditions what they might. There was no doubt that this same feeling had given rise to the persistent use of alcohol; but, greatly to his own surprise, he discovered that when the surroundings were all good, the rule that applied to alcohol constantly applied to other substances that were called remedies, with the result that recovery was often just as good without the particular remedies as with them, so that a revision came quite simply with regard to stimulating agents and their properties, and also with regard to every medicine that might at earlier times have been employed. He had seen many cases in this hospital recover without any other aid than that of the environments, which cases he would have said could not possibly have gone on well, or towards complete recovery, unless some special recipe had been followed. He believed the day would come when others, learning this same truth as he had been obliged to learn it, would act on such simple principles that the books of remedies would have to be vastly curtailed. It would be seen that there was such a tendency of disease to get well of itself, or by virtue of natural processes, of which people had at present but a very poor idea, that the art of physic would pass into directions how to live rather than into dogmatic assertions that particular means must be employed in addition to the common details of life for the process of cure. If therefore they learned in this hospital by their reduced death-rates the true lesson, the institution would have performed a double duty, and become one of the test objects in medicine, and in the field of disease. They made no attempt by selection, or by any side action, to exaggerate their results. The cases were taken indiscriminately, except that they gave admission to the worst cases first; that was to say, they never caused patients to come under their treatment if they saw they were only slightly affected, and were bound to get well."--_Medical Pioneer._ Dr. Landmann, of Boppard-on-the-Rhine, Germany, says:-- "The members of the Association of Abstaining Physicians, reject the use of spirituous liquors in every form, and particularly declare the use of alcohol at the sick-bed a scientific error of the saddest kind. In order to war against this abuse, they earnestly appeal to the officers having charge of funds for the sick, henceforth, under no circumstances, any longer to permit the prescription of wine, whisky and brandy for sick members; but to resist to the utmost, according to the right given them by the laws insuring the sick, the taking of spirituous liquors, under the false pretext that they have a curative and strengthening effect." Dr. Bleuler, Rheineau, Switzerland, says:-- "The treatment of chronic diseases with alcohol is contrary to our knowledge of the physiological effects of alcohol. There is no probability that its use will be beneficial, certainly its benefits have not been established. Often an injurious result is proved. "It is not implied that there may not be some benefit in the use of alcohol in cases of sudden weakness with or without fever. But even in such cases the benefit is not demonstrated. At any rate, other remedies can with advantage be substituted for alcohol. "The essential thing in the treatment of all alcoholic diseases, delirium tremens included, is total abstinence. "The physiological effect of alcohol is that of a poison, whose use is to be limited to the utmost. Even the moderate use as now practiced is injurious. "The customary beneficial results unquestionably depend chiefly on suggestion, and by making the patient believe falsely that the momentary subjective better feeling means actual improvement. "Physicians share the blame of the present flood of alcoholism. They are, therefore, morally bound to remedy the evil. Only by means of personal abstinence can this be done." Dr. A. Frick, professor in Zurich, is a careful student and an influential writer on alcohol. His statements are weighty. This is his testimony:-- "In larger doses, alcohol is absolutely injurious in the treatment of acute fevers, especially in case of pneumonia, typhus and erysipelas. They first of all injure the general state of the patient, they cause delirium, or increase it if already existing, and, secondly, they injure most seriously the organs of digestion and interfere with proper nourishment; thus they have a weakening effect, instead of preventing weakness, which they are usually supposed to do. In case no alcohol is used, the convalescence is much more rapid. In no case has the benefit of treatment with alcohol been established. According to the view of the most eminent pharmacologists, the stimulating effect of alcohol consists simply in a local irritation of the mucous membrane of the stomach, similar to that produced by a mustard plaster." The following selection from the excellent address of Dr. Harvey, president of the Virginia State Medical Society, at a recent meeting, is a most timely caution:-- "Our prisons, asylums and homes are filled with the victims of the careless and indiscriminate use by the medical profession of those twin demons, alcohol and opium, which, save tuberculosis, are doing more to debase and destroy the human race than all the other diseases together. I most earnestly beseech you, young men, who are just starting out in life, to stay your hand in the use of these agents in your own persons, and in your daily work, and to beware of the seductive needle, and the cup that inebriates. Make it an invariable rule, never to prescribe alcohol, nor one of the solinaceus or narcotic drugs, if you can possibly avoid it. The use of alcohol and opium debases the minds and morals of habitués, predisposes especially to Bright's disease and insanity, and lays the foundation in the offspring for the majority of the neuroses and degenerations of modern civilized life. The physical fatigue of long working hours, loss of sleep, mental strain, worry and hunger, invite the tired physician, especially, to their seductive use. To totally abstain from them is always business, and very often character, and even life itself. I feel free to speak to you on this subject very earnestly, my younger brothers, for, having prescribed alcohol for over thirty years, I am familiar with its tendencies and its dangers." Dr. T. D. Crothers of Hartford, Conn., in an article upon "The Decline of Alcohol as a Medicine," says:-- "Thoughtful observers recognize that alcohol as a medicine is rapidly becoming a thing of the past. Ten years ago leading medical men and text-books spoke of stimulants as essentials of many diseases, and defended their use with warmth and positiveness. To-day this is changed. Medical men seldom refer to spirits as remedies, and when they do, express great conservatism and caution. The text-books show the same changes, although some dogmatic authors refuse to recognize the change of practice, and still cling to the idea of the food value of spirits. "Druggists who supply spirits to the profession recognize a tremendous dropping off in the demand. A distiller who, ten years ago, sold many thousand gallons of choice whiskies, almost exclusively to medical men, has lost his trade altogether, and gone out of business. Wine men, too, recognize this change, and are making every effort to have wine used in the place of spirits in the sick-room. Proprietary medicine dealers are putting all sorts of compounds of wine with iron, bark, etc., on the market with the same idea. It is doubtful if any of these will be able to secure any permanent place in therapeutics. "The fact is, alcohol is passing out of practical therapeutics because its real action is becoming known. Facts are accumulating in the laboratory, in the autopsy room, at the bedside, and in the work of experimental psychologists, which show that alcohol is a depressant and a narcotic; that it cannot build up tissue, but always acts as a degenerative power; and that its apparent effects of raising the heart's action and quickening functional activities are misleading and erroneous. "French and German specialists have denounced spirits both as a beverage and a medicine, and shown by actual demonstration that alcohol is a poison and a depressant, and that any therapeutic action it is assumed to have is open to question. "All this is not the result of agitation and wild condemnation by persons who feel deeply the sad consequences of the abuse of spirits. It is simply the outcome of the gradual accumulation of facts that have been proven within the observation of every thoughtful person. The exact or approximate facts relating to alcohol can now be tested by instruments of precision. We can weigh and measure the effects, and it is not essential to theorize or speculate; we can test and prove with reasonable certainty what was before a matter of doubt. "Medical men who doubt the value of spirits are no more considered fanatics or extremists, but as leaders along new and wider lines of research. Alcohol in medicine, except as a narcotic and anæsthetic, is rapidly falling into disfavor, and will soon be put aside and forgotten." CHAPTER XVI. RECENT RESEARCHES UPON ALCOHOL. In the year 1900 Prof. Taav Laitinen, of the University of Helsingfors, Finland, published an account of experiments made upon 342 animals--dogs, rabbits, guinea pigs, fowls and pigeons--to determine the effects of alcohol upon the resistance of the body to infectious diseases. He used as infecting agents, anthrax bacilli, tubercle bacilli, and diphtheria bacilli. The doses of alcohol given varied with the animal. For his "small dose" experiments he used the quantity of alcohol given as a food or as a medicine, or both, in a neighboring sanitorium. The alcohol employed was, as a rule, a 25 per cent. solution of ethyl alcohol in water. It was given either by esophageal catheter, or by dropping it into the mouth from a pipette. It was administered in several ways, and for varying times; sometimes in single large doses, at others in gradually increasing doses for months at a time, in order to produce here an acute, and there a chronic poisoning; in fact, he produced the conditions consequent upon steady, moderate drinking. His first conclusion from these experiments, most carefully carried out, is that alcohol, however given, induces in the animal body a markedly increased susceptibility to infectious diseases; and he maintains that his experiments indicate that the use of alcohol, at least in the treatment of anthrax, tuberculosis, and diphtheria, is not only useless but probably injurious. From a number of other experiments carried out with scrupulous care he comes to the same conclusion as Abbott, Welch, and others that the predisposing to disease of alcohol must be explained by its action in producing abnormal conditions--pathological changes in the alimentary canal, liver, kidneys, heart, and nervous system. He found that the alkalinity of the blood was slightly diminished, and the number of leucocytes somewhat decreased. He also draws attention to the fact that his experiments prove that pregnant animals and their offspring are markedly affected by the continued use of small doses of alcohol. He shows, too, that the temporary lowering of the body temperature by alcohol produces the most favorable condition for the invasion of disease germs. Since the publication of these experiments, and of others similar to them, the use of alcohol in diphtheria and tuberculosis has very largely ceased. Boards of health and charity organizations unite in warning against indulgence in alcoholic drinks as conducive to tuberculosis. At the International Congress on Alcoholism, held in London in July, 1909, Professor Laitinen delivered two lectures. The first was upon "The Influence of Alcohol on Immunity." The following is taken from this lecture:-- "Modern researches have done much to explain the extent and nature of the protective powers by which the organism endeavors to defend itself against the attacks of all kinds of injurious agencies, and especially against invasion by the germs of infective diseases. It is now a well-established fact that alcohol weakens the normal resisting power of the body against the above-named disease-producing influences. In the hope of contributing something to the explanation of the way in which alcohol weakens the organism, I have made a number of experiments bearing upon the question of the influence of alcohol on immunity. "Early in this century careful experiments went to show that alcohol certainly had some influence upon immunity. Two Americans, Abbott and Bergey, were the first to discover that this agent produces a diminution of the hæmolytic complement in the blood-serum of certain animals which were tested. They showed also that the formation of specific hæmolytic receptors (immune bodies) may be retarded by the action of alcohol. "The extent of the evil effects upon the human body resulting from the consumption of alcoholic liquors is as yet far from being fully known, and stands in need of scientific verification. Many other injurious influences such as unsanitary dwellings, bad feeding, excessive toil, and toxic agents like nicotine, etc., may produce somewhat similar morbid effects. It is therefore necessary, in the scientific study of the question, to take these possibilities into consideration. In my investigations, the results of which I am now to lay before you, I have endeavored to select as subjects for my experiments both abstainers from alcohol, and those who indulge more or less in its use, in such a way that their conditions of life and their habits in other respects should be as nearly as possible the same. All persons, for instance, suffering from any acute or chronic disease were rejected, and very few of the persons selected were smokers. The subject of this research has been human blood, and especially its two principal components, namely, red blood-corpuscles and blood-serum, both of which up to the present time have been very little studied in relation to the question under discussion. I have gone into these matters chiefly because the modern theoretical study of immunity during the last few years has, in general, attracted greater attention to the blood, and shown the important role which the different parts, properties, and capacities of the blood play in defending the organism against internal and external injurious agencies. Further, the subtle methods employed in the study of immunity (such as organic reactions, and reactions between greatly attenuated organic liquids) would also seem to be available for our purpose, as they allow of the detection of the minutest differences which alcohol may produce in any part of the organism in question. "During the course of this research, which has lasted over a period of three years, I sought to investigate the action of alcohol on the resistive power of human red blood-corpuscles. I wished to ascertain whether the resistivity of the red blood-corpuscles in a healthy man could be lowered by the consumption of alcohol. * * * "It may be well for me here to explain that in this lecture I mean by the term 'drinker' a person who has taken alcohol in any quantity whatever. Many of these 'drinkers,' therefore, were in fact most moderate consumers of alcohol. By the term 'abstainer' I mean a person who has never taken alcohol in any quantity worth mentioning. In the course of my investigations I have examined blood from two hundred and twenty-three persons. They were of different classes and ages. There were professors of medicine and other physicians, University fellows, students of both sexes, hospital nurses, school-teachers, waiters, and other men and women belonging to the working-classes." The rest of the lecture as given here is an abstract made by Professor Laitinen:-- "My studies have been directed to an investigation of the following points: "1. I sought to ascertain whether the resistance of human red blood-corpuscles against a heterogeneous normal serum, or an immune serum, can be diminished by the use of alcohol. "2. I have studied the action of alcohol in drinking and abstaining persons on the hæmolytic power of blood-serum over heterogeneous red blood-corpuscles (rabbits). I have studied not only the hæmolytic power of the human blood-serum, but also its power of precipitation in the presence of rabbit-serum, with a view to ascertain if the reaction between a known dilution of rabbit-serum and a certain dilution of serum of alcohol-users and non-drinking persons is different or not, and if the reaction is more apparent with the former or with the latter. "3. The resisting power of serum obtained both from alcohol-drinking and from non-drinking persons was further tested by human blood, with the object of discovering whether any difference in reaction existed between the same immune serum and the two kinds of human sera above mentioned. "4. I have studied the problem as to whether the hæmolytic complement in the blood-serum of alcohol-drinking and non-drinking persons is altered in any way by alcohol. "5. The bactericidal power of blood-serum from both alcohol-drinking and non-drinking persons was determined by some experiments. "The above experiments have given the following results: "1. The normal resistance of human red blood-corpuscles appears to be somewhat diminished against a heterogeneous normal serum or an immune serum by the consumption of alcohol, provided that tolerably large equal, or nearly equal, numbers of drinkers and abstainers of both sexes be examined, and the average of resistance be taken on both sides: this last-named precaution being necessary because the resistance of red blood-corpuscles from different human beings varies largely. The difference is often greater when using weaker solutions than when using stronger dilutions of lysin. "2. These experiments have shown the normal hæmolytic power of human blood-serum to be less in the case of alcohol-drinkers than in that of abstainers. "3. The precipitating reaction between a solution of 1 per cent. human blood-serum and different dilutions of immune serum was greater in the case of drinkers than in that of abstainers. "4. These experiments have also shown that the bactericidal power of blood-serum against typhoid bacteria was less in the case of drinkers than in that of abstainers. "It seems clear, therefore, that alcohol, even in comparatively small doses, exercises a prejudicial effect on the protective mechanism of the human body." The lecturer made his points clear by a carefully prepared series of charts. At its close Sir Victor Horsley, Professor Sims Woodhead, A. Pearce Gould, and several other distinguished physicians spoke in high terms of the painstaking care exhibited in the experiments. Professor Laitinen's second lecture was upon "The Influence of Alcohol Upon Human Offspring." He sent out 15,000 circulars to his countrymen, asking many questions relative to themselves and their infant children, and received 5,845 replies relative to 20,008 children. He also studied personally a large number of drinking and abstaining families. From these studies he shows by careful tables that the drinking of alcohol by parents, even in small quantities, has an injurious influence upon human offspring. His studies in former years showed the same unfavorable influence upon the offspring of animals. One of his tables gives percentages of deaths of children in the homes of abstaining parents, moderate drinkers, and harder drinkers. Children of abstainers dying in the first year, 13.45 per cent.; of moderates, 23.17 per cent.; of harder drinkers, 32.02 per cent. Other tables show that abstainers' children gain in weight more steadily in the first year than drinkers' children, and have their teeth earlier, as a rule. At the International Medical Congress of 1909, held in Budapest, Professor Laitinen lectured again upon his researches, and summarized his conclusions thus:-- "1. The importance of alcohol as an article of food is rendered very questionable by recent researches. 2. These researches prove that alcohol diminishes the natural power of the tissues to resist injury, promotes degeneration, and has a disastrous effect on future generations. 3. The questions of relation of alcoholic liquor to crime and of the manufacture and sale of such beverages deserve the serious consideration of the legislature. 4. It is the duty of medical men to direct more attention than formerly to the alcohol question, and by careful study to decide whether recent researches are justified or not in regarding alcohol and alcoholic beverages as a poison and one of the principal causes of degeneration in the human family; they ought also to consider whether it would not be advisable in medical practice, and especially in hospitals, either to banish it altogether or at least to prescribe it with the same care as other poisonous drugs. In this matter the attitude taken by medical men as representatives of public hygiene was of quite exceptional importance." Metchnikoff, the illustrious Russian scientist, who has for some years been connected with the Pasteur Institute in Paris, was the discoverer of the work assigned by nature to the white corpuscles of the blood. These blood-cells are the "guardian-cells" of the body, and their duty is to destroy disease germs which may gain an entrance. They actually devour disease germs. Metchnikoff has been studying the effect of alcohol upon these protective cells, and he asserts that alcohol, even in small doses, has a harmful action on these agents of defence against disease. Alcohol seems to paralyze them more or less so that they are unable to do their full duty in destroying the infective microbes. Thus disease germs can multiply more rapidly when alcohol is in the blood. In his book called "The New Hygiene," Metchnikoff suggests that the administration of alcoholic liquors in infectious disease appears to be attended with danger to the patient. The researches of Kraepelin, Ach, Aschaffenberg and other German scientists have become so well known through the articles by Henry Smith Williams in _McClure's Magazine_ that only brief reference need be made to them here. Kraepelin used very small doses of alcohol for some of his experiments. He found that after 1/4 to 1/2 ounce of alcohol had been taken the time occupied in making response to a signal was slightly shortened, but in a few minutes, in most cases, this quickening action passed and a slowing process began, and continued until the body was free from the influence of the alcohol, which was sometimes four or five hours. The ability to add figures was tested, and this decreased very rapidly under minute doses of alcohol. Memory tests showed that only 60 figures could be remembered from numbers written in columns after alcohol had been taken, while 100 figures could be remembered correctly when the mind was free from the alcoholic influence. Type-setters were tested, and the average number of errors they made and the amount of work they did in a given time was carefully recorded. After a small dose of alcohol none of the men could in the same time do as much work, or as accurate work. Yet every one of the men experimented upon thought he was doing better work after his drink. This proves the narcotic effect of alcohol. The economic loss to a people from beer and wine drinking is worthy of serious consideration since a bottle of wine or its equivalent in beer could diminish by ten to fifteen per cent. the amount of work done by these type-setters experimented upon by Professor Aschaffenberg. Professor Kraepelin says:-- "I must admit that my experiments, extending over more than ten years, have made me an opponent of alcohol." He says again:-- "The laborer who wins his livelihood by the working power of his arm strikes at the very foundation of his power by the use of alcohol." Professor Aschaffenberg says of moderate doses:-- "Any quantity of alcohol must be regarded as considerable which causes a disturbance, even if only transitory, of bodily and mental efficiency." Dr. Reid Hunt, chief of the Division of Pharmacology, Hygienic Laboratory, United States Public Health and Marine Hospital Service, made some very interesting experiments to determine the physiological changes upon animals which would result from the strictly moderate use of alcohol. These are described in Bulletin No. 33 of the Hygienic Laboratory, published in 1907. Mice and guinea-pigs were used. The food, usually oats, was soaked in diluted alcohol, at first of five per cent. strength, then gradually increased to forty or fifty per cent. By carefully observing the weight of the mice, and not increasing the strength of the alcohol too rapidly, it was possible to keep the animals for months on this diet without any material loss of weight. After the lapse of weeks, in some cases, and months in other cases, these alcohol fed animals were given small doses of a poison known as acetonitrile. Other mice to whom no alcohol was fed were given similar doses of this poison. In the first series the mice which had received alcohol died from about one-half the quantity of acetonitrile required to kill those which had not received alcohol. In the second series with a somewhat stronger dilution the alcohol mice succumbed to one-half to one-third the dose necessary to kill the non-alcoholized animals. In no case was enough alcohol given for any symptoms of intoxication to appear, nor was there any outward indication of any injury being done by the alcohol. In another experiment a mouse was kept for four months on a diet of oats soaked in water, then 0.5 milligram of acetonitrile per gram body weight was injected. The mouse recovered. It was then fed on oats soaked in an alcoholic solution which was gradually increased to 45 per cent. After a little more than a month of this diet 0.2 milligram acetonitrile per gram body weight proved fatal. The weight of the mouse had remained about the same throughout. Alcohol increased the susceptibility of the guinea pigs also. Dr. Hunt says on page 33 of the bulletin:-- "These experiments with alcohol and acetonitrile are of interest in another connection. The greatest advance in recent years in our knowledge of the physiological action of alcohol has been the clear demonstration that alcohol is oxidized in the body, and may replace fats and carbohydrates and to a certain extent, the proteids of an ordinary diet. So clear has been this demonstration that the view that alcohol, in moderate amounts, should be regarded as a food is almost universally accepted by physiologists, and the drift of opinion is certainly toward the view that it is in all respects strictly analogous to sugar and fats, provided always that the amount used does not exceed that easily oxidized by the body. Under these premises it would be expected that alcohol in a diet would have the same effect upon an animal's susceptibility to acetonitrile as has dextrose, for example. This is by no means the case, however; on the contrary, the action of these substances in this regard is entirely different. Mice fed upon oats soaked in a solution of dextrose or upon cakes containing considerable dextrose, or upon rice, show a very distinct increase in their resistance to acetonitrile; such mice may recover from two or three times the dose fatal to controls. (Controls are the animals fed in the ordinary way without alcohol or in this case dextrose.--Ed.) While these facts are not sufficient to justify the conclusion that in many cases alcohol has not a true food value, yet they are sufficient to indicate caution in applying, without further consideration, the brilliant and very exact results on the proteid sparing power of alcohol to practical dietaries." Various other experiments were made, but there is not room here for a record of them. In the summary Dr. Hunt says:-- "It is believed that these experiments afford clear experimental evidence for the view that extremely moderate amounts of alcohol may cause distinct changes in certain physiological functions, and that these changes may, under certain circumstances, be injurious to the body. The results also afford further evidence that in some respects the action of alcohol as a food is different from that of carbohydrates, and finally that in all probability certain physiological processes in 'moderate drinkers' are distinctly different from those in abstainers." Professor Chittenden, of Yale University, has made extensive researches upon alcohol and digestion. A full report of these may be found in the "Physiological Aspects of the Liquor Problem." In the _Medical News_, vol. 86, page 721, Professor Chittenden says of the theory that alcohol is a food similar to sugar and fats:-- "It is, I think, quite plain that while alcohol in moderate amounts can be burned in the body, thus serving as food in the sense that it may be a source of energy, it is quite misleading to attempt a classification or even comparison of alcohol with carbohydrates and fats, since, unlike the latter, alcohol has a most disturbing effect upon the metabolism or oxidation of the purin compounds of our daily food. Alcohol, therefore, presents a dangerous side wholly wanting in carbohydrates and fats. The latter are simply burned up to carbonic acid and water, or are transformed into glycogen and fat, but alcohol, though more easily oxidizable, is at all times liable to obstruct, in some measure at least, the oxidative processes of the liver, and probably of other tissues also, thereby throwing into the circulation bodies such as uric acid, which are inimical to health; a fact which at once tends to draw a distinct line of demarcation between alcohol and the two non-nitrogeneous foods--fat and carbohydrate." Dr. S. P. Beebe, now of the Cornell Medical College Laboratory, New York City, has made some very valuable experiments with alcohol. It is well known that impairment of the functions of certain organs results in the appearance in the urine of nitrogeneous compounds which do not normally occur there. In certain diseases of the liver the same quantity of nitrogen may be excreted as in health, but a portion of it is in the form of acids never found in the urine during health. Dr. Beebe, with this knowledge in mind, sought to discover the effects of alcohol upon the excretion of uric acid in man. Most of the experiments were made on the same person, a young man in good health, of regular habits, unaccustomed to the use of alcohol in any form. Absolute alcohol, diluted with water, whisky, ale, and port wine were used at different times. Dr. Beebe reported his experiments in the _American Journal of Physiology_, vol. 12, No. 1. His conclusions are given as follows:-- "After a consideration of these experiments, it hardly seems possible to doubt that alcohol, even in what is considered by the most conservative as a moderate amount, causes an increase in the excretion of uric acid, and this effect is seen almost immediately after taking the alcohol. The following points indicate that the effect is due to a toxic effect on the liver, thereby interfering with the oxidation of the uric acid derived from its precursors in the food: Alcohol taken without food causes no increase. The maximum increase occurs at the same time after a meal as it does when purin food but no alcohol is taken. Alcohol is rapidly absorbed and passes at once to the liver, the organ which has most to do with the metabolism of proteid cleavage products. "There is no evidence that the alcohol has merely hastened the excretion of urates normally present in the blood; the increased excretion means that a larger quantity has been in circulation, and although it is classed by Van Noorden among the substances easily excreted, still most physiologists would consider the presence in the blood of this larger quantity as undesirable. Certainly in pathological conditions it might be harmful. "If we accept the origin of the increased quantity of uric acid to be in the impaired oxidative powers of the liver, the results of these experiments will have greater significance than can be attributed to uric acid alone. For the impaired function would affect other processes which are normally accomplished by that organ, and the possibilities for entrance into the general circulation of toxic substances, of intestinal putrefaction, for instance, would be increased. The liver performs a large number of oxidations and syntheses designed to keep toxic substances from reaching the body tissues, and if alcohol, in the moderate quantity which caused the increase in uric acid excretion, impairs its power in this respect, the prevalent ideas regarding the harmlessness of moderate drinking need revision." Dr. Winfield S. Hall, professor of physiology at the Northwestern University Medical School, Chicago, has interpreted these researches of Beebe and Hunt in a very striking way. He says that they prove that the oxidation of alcohol in the body is a protective oxidation, the same as the oxidation of any other poisonous substance by the liver. His views have such an important bearing upon the commonly accepted theory that alcohol is in some sense a food that they are given here, somewhat abbreviated, as a fitting finish to this chapter. Dr. Hall says:-- "The fact that alcohol is oxidized in the body has been generally misunderstood. The first impression naturally was: 'Foods are Oxidized; Alcohol is Oxidized; therefore alcohol is a food.' But many difficulties appeared. A real food promotes muscular, glandular and nerve activity, and its oxidation maintains body temperature. But alcohol disturbs muscular, glandular, and nervous activity, and its oxidation does not maintain body temperature. When one eats a real food it is assimilated largely by muscle tissue and is oxidized for the purpose of liberating the life energy. When one ingests alcohol it is carried by the blood to the tissues, mostly to the liver, where it is oxidized, as any toxine would be, for the purpose of making it harmless. Its oxidation liberates heat energy but this energy cannot be utilized by the body even for the maintenance of body temperature. If a food is defined as a substance which, taken into the body, is assimilated and used either to build or repair body structure, or to be oxidized in the tissues to liberate the energy used by the tissue in its normal activity, then alcohol is not a real food. "But, if alcohol is not a real food, what is the significance of its oxidation? It has been long known that the liver produces oxidases and that it is the site of active oxidation of mid-products of katabolism of toxins and of other toxic substances. Alcohol, usually formed as an excretion of the yeast plant, is also found as a mid-product of tissue katabolism. On a priori grounds we should expect alcohol to be oxidized in the liver along with leucin, tyrosin, uric acid, xanthin bodies, and various amido bodies. There have recently appeared two most important papers based upon extended researches upon man and lower animals. These researches practically clear up this knotty question." Dr. Hall then reviews the work of Dr. Reid Hunt and Dr. S. P. Beebe, and continues:-- "The value of this work can hardly be over-estimated. In the first place the rapid oxidation of the alcohol in the liver is explained. _Alcohol itself being one of the toxic substances which reach the liver from the alimentary canal is at once attacked by the liver, and if the oncoming tide of alcohol is not too great it will practically all be oxidized._ "But the liver oxidation of other toxic substances is impaired in the meantime so that they get past the liver to the tissues, where they may do injury. Some of these toxins are excreted unoxidized by the kidneys. There are three ways of accounting for this condition: (1.) The oxidation capacity of the liver is limited. The physiological limit of alcohol ingestion is that amount which taxes the oxidation capacity of the liver to its limit. When thus taxed all other toxic substances including uric acid and the xanthin bodies pass through the liver unoxidized to appear in the urine. (2.) The presence of alcohol in the blood, through its toxic action upon the liver cells, impairs the hepatic oxidation capacity and thus permits toxic substances to pass unoxidized. (3.) A combination of these conditions may represent the real situation. It is hardly conceivable that the relation of alcohol to the liver activity is not covered in the hypotheses above formulated. "We may therefore accept it as practically demonstrated by the researches of Beebe, Hunt, and others that the oxidation of alcohol in the liver is simply one of the defensive activities of that organ, _i. e._, it is a protective oxidation and belongs strictly in the same category with the oxidation of uric acid, xanthin bodies, leucin, tyrosins, and the amido acids. "The next question which arises is, why does the liver select alcohol first and oxidize that substance to the exclusion of other toxic substances up to the oxidation capacity? The answer is probably to be found in the chemical composition of alcohol. "It oxidizes very easily, much more so than any of the other toxic substances which gain access to the liver. Its early oxidation may be due to this fact alone, or in part to an actual selection on the part of the liver. Another question of importance: Is the energy liberated in the oxidation of alcohol in the liver available for the use of the muscles, nervous system, or glands? "If this question is answered affirmatively, then alcohol is a food. If negatively then alcohol is not a food. Let us reason together. All body oxidations may be classified in two groups: (1.) _Active oxidations_ which take place in the active tissues--muscles, nervous system, or glands--and take place incident to action. It is under the perfect control of the nervous system and is proportional to normal activity. (2.) _Protective oxidations_ which take place in the liver. This class of oxidation processes is wholly independent of the usual tissue activity and is proportional to the ingestion of toxic substances and quite independent of muscle action, brain action, or gland action, other than liver action. "If the oxidation of alcohol in the liver belongs to class 1, the following consequences should be found: (1.) The ingestion of alcohol would lead to an increase in muscular power and in the working capacity of the brain or glands. (2.) The ingestion of alcohol would serve to maintain body temperature in the healthy individual subjected to low external temperature. (3.) The accession of muscle, brain, or gland activity would be proportional to the amount of alcohol ingested, but laboratory observations and general experience show that none of these things are true; _i. e._, the ingestion of alcohol decreases muscle, brain, and gland work, and depresses body temperature when external temperature is low. "In the nature of the case there can be no proportional relation. The oxidation of alcohol does not therefore belong to class 1. If the oxidation of alcohol in the liver belongs to class 2, the following consequences would be found: (1.) The ingestion of alcohol would be followed by its early oxidation in the organs in question. (2.) If the oxidation capacity of the liver is limited this capacity may be overloaded by exceeding the physiological limit of alcohol. (3.) If the oxidation capacity of the liver is taxed nearly to its limit in the oxidation of uric acid, xanthins, and other toxic substances, the introduction of alcohol may seriously interfere with this protective oxidation by overtaxing the capacity. (4.) If the oxidation capacity is overtaxed, an excess of uric acid, xanthin bodies, and other toxic substances will get by this portal and reach the active tissues or the kidneys. Now all of these things take place, so we are forced to the conclusion that the oxidation of alcohol is a protective oxidation. In the light of this presentation the significance of Dr. Hunt's work becomes very clear. The alcohol given to the animals taxed the oxidation capacity of the liver to the limit and left the organism defenseless against bacterial or other toxic substances." CHAPTER XVII. MISCELLANEOUS. ALCOHOL BATHS:--The action of alcohol upon the surface of the body is that of a refrigerant. Alcohol baths for debility, weakness, and states of exhaustion are opposed by non-alcoholic physicians. The old custom of bathing a new-born babe with whisky was simply a superstition, and a dangerous one, because the infant should not have a refrigerant applied to its body so soon after leaving the warm nest where it had been sheltered so long. Warm water is the proper liquid for a baby's bath until it becomes hardy. There is nothing of strength imparted by an alcohol rub; the 'rub' is good, but vinegar, or water, or olive oil can be used according to what is desired. Alcohol is not necessary internally nor externally. Its proper use is for mechanical purposes and to give light and heat. WILHELMINA LEMONADE:--Take four or five rough-skinned oranges (according to size) and two pounds of sugar, in big lumps. After having cleaned the oranges, rub the sugar with them, till the oranges are quite white--the sugar yellow. Place the sugar in a big earthernware pan or jar, and add three pints of _cold_ water. Then cover it up and let it stand two days, stirring it occasionally to help the melting. Now take two ounces of citric acid, dissolved in a little boiling water, and add it to the syrup, stirring the whole. Then strain the whole through a fine sieve, covered with muslin, so that it becomes perfectly clear. In well-corked bottles it will keep for more than a year. Mix one-third of the lemonade with two-thirds water. [Instead of the oranges five or six lemons may be used.] BEVERAGES FOR THE SICK:--Unfermented Grapejuice. Hot milk. Egg cream, made as follows: Beat the white and yolk separately, add milk and sugar, and stir well, flavor to suit taste. Egg lemonade--beat yolk and sugar thoroughly, add lemon and water, shake well, then add white, beaten stiff. Barley water, made by boiling pearl barley five or six hours, and straining the water from it; add milk or cream if wished. These are used in the National Temperance Hospital of Chicago. BATHS:--"If all people understood the value of water to cool, cleanse, invigorate and sustain life, and how to use it, _and would use it_, one-half of all the afflictions from disease would be removed; and the other half might be banished if all the people understood how and what to eat, how to breathe, and the necessity of daily vigorous exercise. A daily towel bath will do more to counteract disease, and restore the body to its normal health condition, than any other method or remedy yet discovered. After the bath, the body should be thoroughly rubbed with a crash or Turkish towel. Rub until a warm glow is produced. This bath is a fine tonic if taken upon rising in the morning." HOT WATER AS A MEDICINE:--"One is never," says a physician, "far from a pretty good medicine chest with hot water at hand. It is a most useful assistant to the mother of a family of small children, who is frightened often to find herself confronted by a sudden illness of one of her flock, without her usual dependence--the family doctor. If the baby has croup, fold a strip of flannel or a soft napkin lengthwise, dip into very hot water, and apply to the child's throat. Repeat and continue the application till relief is had, which will be almost at once. For toothache, or colic, or a threatened lung congestion, the hot-water treatment will be found promptly efficacious if resorted to. Nature needs only a little assistance at the first sign of trouble to rally quickly in the average healthy child, and often hot water is all that is wanted." ALCOHOL INJURIOUS TO THE INSANE:--Dr. Richard Maurice Bucke, whose valuable paper on "The Evolution of the Mind" appeared in the December number of the _Journal of Hygiene_, in a recent report of the Asylum for the Insane in London, Canada, makes the following statement concerning the use of alcohol in the institution over which he presides:-- "As we have given up the use of alcohol, we have needed and used less opium and chloral; and as we have discontinued the use of alcohol, opium and chloral, we have needed and used less seclusion and restraint. I have, during the year just closed, carefully watched the effect of the alcohol given, and the progress of cases where, in former years, it would have been given, and I am morally certain that the alcohol used during the past year did no good. With humiliation I am forced to admit that in the recent past my noble profession has been to an alarming extent, and is still too much so, guilty of producing many drunkards in the land, directly or indirectly, by the reckless and wholesale manner in which so many of its members have prescribed alcoholic stimulants in their daily practice for all the aches and pains, coughs and colds, inflammations and consumptions, fevers and chills, at the hour of birth and at the time of death, and all intermediate points of life, to induce sleep and to promote wakefulness, and for all real or imaginary ills." TOBACCO AND THE EYESIGHT:--"Prof. Craddock says that tobacco has a bad effect upon the sight, and a distinct disease of the eye is attributed to its immoderate use. Many cases in which complete loss of sight has occurred, and which were formerly regarded as hopeless, are now known to be curable by making the patient abstain from tobacco. These patients almost invariably at first have color blindness, taking red to be brown or black, and green to be light blue or orange. In nearly every case, the pupils are much contracted, in some cases to such an extent that the patient is unable to move about without assistance. One such man admitted that he had usually smoked from twenty to thirty cigars a day. He consented to give up smoking altogether, and his sight was fully restored in three and a half months. It has been found that chewing is much worse than smoking in its effects upon the eyesight, probably for the simple reason that more of the poison is thereby absorbed. The condition found in the eye in the early stages is that of extreme congestion only; but this, unless remedied at once, leads to gradually increasing disease of the optic nerve, and then, of course, blindness is absolute and beyond remedy. It is, therefore, evident that, to be of any value, the treatment of disease of the eye due to excessive smoking must be immediate, or it will probably be useless."--_Journal of Inebriety._ "Dr. Isaac Fellows was for many years a prominent physician in Los Angeles. A temperance man, he was persuaded by an old physician whom he loved to try for a year substituting alcohol in drop doses in water for such patients as demanded alcoholic stimulants. He was delighted with the result. When his patients found they could not have wine, beer or brandy under the guise of medicine, but must take it in drop doses in water, as they did their other medicines, they speedily learned to do without 'a stimulant.'"--_Pacific Ensign._ ADVERTISED "CURES" FOR DRUNKENNESS. "_Poudre Coza_, an English product, is sold at $3.00 for thirty powders. On analysis these powders were found to contain an impure form of sodium bicarbonate, together with a little aromatic vegetable matter. Gloria Tonic was examined by the Massachusetts Board of Health, and found to consist of sugar of milk and cornstarch, with a small quantity of ground leaves resembling those of senna. White Ribbon Remedy was found to be made of milk sugar and ammonium chloride. Of course such things are clearly frauds, as they can have no power to destroy a craving for liquor. The Infallible Drink Cure was 98 per cent. sugar and 2 per cent. common table salt. Another 'cure' was made of chlorate of potash and sugar. Cases of poisoning by chlorate of potash are on record. Another 'cure' contained tartar emetic, a dangerous poison. Most of the liquid 'cures' for drunkenness sold prior to the passage of the National Pure Food Law contained large quantities of cheap alcohol. It is safe to say that practically all of the secret cures for drunkenness are fraudulent, and some are dangerous. "If a man wants to quit drinking, he can be helped by a proper diet, and by frequent use of the Turkish bath, or even of the ordinary hot bath at home, with a quick cold sponge or shower bath each morning as a tonic. The hot bath is to draw out impurities from the system. The diet should consist of plenty of fruit, nuts, grains and vegetables. It is better to eat no meat. It has been fully demonstrated in Lady Henry Somerset's work with women drunkards that a vegetarian diet is a great help in allaying the alcohol crave. The Salvation Army, in England, have also found by experience that a meat-free diet is a great aid in overcoming the drink habit. "Dr. T. D. Crothers, who has for years conducted a large sanitarium for the cure of inebriety, at Hartford, Connecticut, says that a valuable remedy to break up the impulsive craze for spirits is a strong infusion of quassia given in two-ounce doses every hour. As desire for liquor abates the quassia can be given less frequently, until it is no longer needed. "Dr. Alexander Lambert, of Bellevue Hospital, New York, has been treating drunkards and other drug habitues successfully of late. A description of his treatment may be found in _Success_ for November, 1909." MEDICAL PUFFS OF WHISKY AND OTHER ALCOHOLICS:--"Every medical man knows how he is pestered with advertising circulars of so-and-so's genuine whisky, and what-do-you-call-em's extra stout, to say nothing of the tempting offers of wines and spirits on sale with special discounts to medical men. Other enterprising firms send samples or offer to send them with the implied understanding that a testimonial is to be given, or that at least the wares in question will be recommended to patients. Even our medical papers have not always been incorruptible. We have little expectation ourselves of being favored with an offer of full-page advertisements of extraordinary wines and spirits. We are not prepared to recommend them except as vermin killers. Nor are we prepared to remain silent as to their alleged virtues. The whole system of testimonials is a huge imposture. Granted that the sample is all that it is described as being, who can guarantee that what is served to the public in the face of severe competition will be up to the sample? "But there is another and a sadder view of the case. We cannot believe that all the eulogies of all the medical trumpeters of the wines and the spirits are wilfully false or even exaggerated. It is a lamentable fact that a vast number of doctors have a genuine faith in the value and virtue of these pernicious drinks. It is not simply a question of medicinal use, though even on that we should join issue. These things are vaunted as valuable for the promotion of health in spite of all the accumulating evidence to the contrary. We wish that these doctors would carefully study this evidence. The pity of it is that the very worst offenders are the least likely to study it. We suppose they must die out, and be replaced by men less prejudiced and bound by the chain of alcoholic habit. We can only regret that they should be doing so much harm in fastening the fetters of drink on other people, and hindering their emancipation from the evil customs which play havoc amongst us."--_Medical Pioneer._ ALCOHOL AND CHILDREN:--"Parents often labor under the delusion that alcoholic drinks are good for children and act as tonics. Mothers will put drops of brandy into the milk with which their children are fed, increasing the quantity with the age of the recipient. In the illness of children the same is given to meet disturbances of the stomach or to increase growth and development, without taking the advice of any medical man as to the wisdom of the practice. This is all erroneous. The excitement of the central nervous system under alcohol, excitement which seems to be a relief to weariness and to give strength, is nothing more than temporary at best, and injurious, causing in fact symptoms of alcoholic poisoning, abnormal excitement, ending, in extreme cases, in convulsions succeeded by exhaustion of body and mind, and inducing a kind of paralysis. Many cases of stomach and gastric catarrh in children followed by emaciation and debility are due to the early administration of alcoholic drinks; and impediment of growth from the same cause is thereby produced. The most serious derangement is that of the nervous system, and the development in the young, under the influence of alcohol, of what is known as nervousness, to which is added the moral paralysis with which the habit of alcoholic drinking smites its victims in the very spring-time of life."--PROF. DEMME, of Berne, Switzerland. "The action of the New York Board of Health, in recommending to tenement house parents, that on the hottest days of summer a few drops of whisky be added to the water or food of their infants, has received a strong protest and rebuke in a meeting at Prohibition Park, where the opinions of eminent physicians, collected by the _Voice_, were read, condemning such a course. A resolution of protest was also adopted."--_Sel._ "For nineteen years we lived with a physician whose success may be estimated from this one item: He had between 1,600 and 1,700 labor cases, and never once lost the mother, and only twice the child, and what seems still more remarkable never used instruments. When other physicians, as often happened, would come to him to know how he did it, he always answered, 'A woman will do anything if you only encourage her.' Nor was obstetrics his specialty--he had none. "In a fifteen years' practice in Chicago and New York, where these diseases are so very fatal, and he was much sought after to treat them, he did not lose a case of scarlet fever, diphtheria or cholera infantum which he managed himself, and saved many a one where he was called in consultation, or after some other physician. Now when such a man after an experience more than fifty years long and as wide as the continent, gives it as his unqualified opinion that wines, beers, liquors of every kind, alcohol itself, are not medicines and should never be used as such, for SCIENTIFIC reasons, not to mention moral, is not his opinion entitled to a hearing? Isn't it probable it weighs more than the doctor's you were just quoting? Is it too great a risk to act upon it?"--_Pacific Ensign._ "A lady, Mrs. A., tenderly nurtured, refined, cultured, moving in an influential position, belonged to a family in whom the tendency to intemperance existed. Realizing the danger, she, for seven years of her married life, adhered to total abstinence. Illness came, and the doctor ordered wine; and her husband, deaf to her arguments, insisted on her taking it. She fell into habits of intemperance. Her husband died, and for a time she pulled up and trained as a hospital nurse; but temptation prevailed, and she fell from bad to worse. Loving hands received her time after time, and at last placed her in an Inebriate Home. For a short time she did well, but soon became unmanageable. After another desperate period she entered a second home, but after leaving she yielded again, was twice in prison, and fell into the lowest degradation and utter ruin, surely deserving our deepest pity. Her doctor and her husband had persisted in working her fall in spite of her own strongest convictions."--_Selected._ THEY DID NOT DIE.--"Dr. Lord of Pasadena suffered from rheumatism of the heart for more than half of a long lifetime. No doctor ever felt his pulse (which intermitted) without exclaiming, 'Why, doctor, you have no business to be alive with such a pulse,'--or something similar. For nineteen years his wife never retired without having at least one medicine she could put her hand on in the dark, the ammonia bottle within reach, the electric battery ready to start like a fire-engine, and preparations for heating water in less than no time. His acute attacks usually came in the night--an uninterrupted night's sleep was something unknown to either the doctor or his wife in all these years. "They lived in sight of an open grave, and seldom a week passed when it did not seem as if death had actually occurred. If ever a case called for alcoholic stimulants this one did. But none were ever administered, none were ever kept in the house. The doctor's standing orders were: 'If all the doctors in the country order you to give me liquor, and say my life depends upon it, don't do it. Tell them I know more about it than they do. It won't save my life; it will only lessen what little chance I have.' All who knew about this case, and hundreds did, were driven to the conclusion that if these two people, one in this condition and the other feeble, could live all alone as they did, miles from a doctor, and neighbors not near, and could get along without alcoholics of any kind, everybody can do the same everywhere. And the doctor finally wore out his heart trouble and died of another disease."--_Pacific Ensign._ An English weekly journal is responsible for the following anecdote:-- "A Birmingham physician has had an amusing experience. The other day a somewhat distracted mother brought her daughter to see him. The girl was suffering from what is known among people as 'general lowness.' There was nothing much the matter with her, but she was pale and listless and did not care about eating or doing anything. The doctor, after due consultation, prescribed for her a glass of claret three times a day with her meals. The mother was somewhat deaf, but apparently heard all he said and bore off her daughter, determined to carry out the prescription to the very letter. In ten days' time they were back again, and the girl looked a different creature. She was rosy-cheeked, smiling and the picture of health. The doctor congratulated himself on his diagnosis of the case. 'I am glad to see that your daughter is so much better,' he said. 'Yes,' exclaimed the excited and grateful mother. 'Thanks to you, doctor! She has had just what you ordered. She has eaten carrots three times a day since we were here, and sometimes oftener--and once or twice uncooked--and now look at her!'" THE REST CURE:--"After all, the veneer of civilization is quite thin. Scratch most people, and very near the surface you come on the savage. This is specially true when they are sick. They at once want charms and miracles to restore them to health, and come to the doctor or 'medicine man,' as they look upon him--with this demand: 'I want something, doctor, to fix me up.' But he, unhappy man, has not wherewith to satisfy them, unless he is a quack. "He knows that in most cases all he can do is to give advice as to how best Nature may be allowed to effect a cure; for Nature is the great physician, and the doctor's main duty is to stand by and see that she gets fair play. Nature's chief cure, in a large number of the diseases to which flesh is heir, is rest. The tired man needs rest. The tired brain, the tired stomach, the tired liver and kidneys, need the same rest. "So, when the patient turns up with an overworked and exhausted organ of some sort within him--be it what it may--heart, brain or stomach--the true physician prescribes, first and chiefly, not drugs, but rest. "Now, this is generally the advice the patient doesn't want. His desire is for a bottle of something, no matter how nasty it may be, which shall 'fix him up,' and let him go on doing what he has been doing previously. Common-sense is always at a discount, and never more so than in this case. The tired brain-worker doesn't want to stop. Give him something to whip up his brain and his body, something to drive the spurs into them. 'What I want,' he says, 'is a really strong tonic'; though, if he knew that before, what was the use of coming to the doctor? Or he would like to be told to take a glass of whisky-and-water when he is tired, which is the maddest and most disastrous advice that could be given. "The man who has been ill-treating his stomach, eating too much or too well, also demands a tonic--something to give him an appetite so that he may eat more. And his poor overwrought stomach is all the time crying out for rest. "So it is all along the line. The possessor of an inflamed and swollen knee prays for a liniment to rub into it which will cure it straight away, and is highly disgusted when told that he will have to lie up for a week or two. "Again, for the tired stomach the cure is starvation. Let the person live on his own fat, and a little milk-and-water for a few days, and his stomach will take courage again and return to work with renewed zest. But it is the most difficult thing in the world to persuade the patient or his kind relatives of the truth of this. There are many diseases in which, for a short time at least, the less food the sick person has the better. But the relatives are always much wiser than the doctor. They insist 'that the strength must be kept up,' and would like to force the patient to eat more than he does when well. 'You will let his strength down, doctor,' is a common complaint, and one of the difficulties hospital authorities have to face is to prevent kind friends from smuggling in food to the inmates, who, in their opinion, are being brutally starved. "I myself have cured people by making them rest--lie in bed and starve. But the next time they were sick, _I wasn't the doctor_."--"PHYSICIAN" in _Our Federation_. "The blessings of sunlight and fresh air should be more appreciated. The sun is the godfather of us all. The source of all light, heat, electricity and energy, what wonder that it was once worshipped as the Creator. The future will recognize it not only as the best disinfectant, an all powerful preventive of disease, but also as a wonderful healer of disease. The more people can be taught to live in pure air out of doors, and bask in the rays of the sun, the less of disease there will be to prevent."--DR. C. H. SHEPARD, Brooklyn, N. Y. ALCOHOL TESTED. "Some years ago Dr. Beddoes, a physician of eminence, was very anxious to put to the test the disputed question as to the power of alcoholic liquors to give strength to the system. He discovered that those who had most calls upon their physical endurance were the smiths who were engaged in forging ship's anchors, for at one moment they would be exposed to a heat so fierce that one marveled that any human organization could endure exposure to it, and then their work would call them away to a temperature that was chilly and cold, added to which all the time their work lasted they were bathed in a profuse perspiration, the demands upon their physical energy were so great. To counteract this perpetual drain upon their system they were in the habit of drinking unlimited quantities of beer, which their masters provided for them as a matter of course, and a _sine qua non_. One day, as they were resting from their work at midday, Dr. Beddoes made his appearance amongst some of these men who were employed in a certain foundry, and submitted a formal proposition to them, to this effect, that twelve of their number, the strongest and stanchest, should be selected for an experiment, and they should work for a week, six of them drinking only water, and the other six taking their beer as usual. His proposition was laughed to scorn. The men would not hear of it. 'Look here, mate,' said their spokesman, 'do you want us to be all dead men; you don't know what our work is, and how it takes all a man's strength to weld an anchor. Why, if we did not have our beer and plenty of it, it would be all up with us in a brace of shakes.' "The doctor said: 'I should be very sorry for any harm to come to you. You know I am a doctor, and I will be constantly at hand to see if any of you are going wrong, and I promise that if I see any of you breaking down I will at once stop my experiment.' And then taking out of his pocket ten crisp five-pound notes, he displayed them to the anchor smiths. 'I will put down these notes, £50 in all; six of you shall try water for one week honestly and fairly; if you pull through without giving in, the £50 shall be yours; if not, I'll take the £50 back again. Is it a bargain?' "This clenched the matter, and very soon the doctor's offer was accepted, and a gang of six men volunteered to begin their work on the Monday without beer. The beer drinkers did their best to chaff the water drinkers, and aggravated them by taking good care to show them how very nice it was to have recourse to unlimited beer. The water drinkers kept firm, and the first day, to their astonishment, found that they could do just as much work as the rest of their mates. On Tuesday the water drinkers began to crow over the beer drinkers, for they found that, while the latter complained and grumbled at the heat, they were enabled to take the work in a philosophical kind of way. Wednesday, Thursday and Friday wore away, and the teetotal band became more and more triumphant, the laugh was all on their side, for not only did they feel more comfortable than their beer-loving companions, but the £50 came nearer and nearer, and at last, on Saturday, when the time for finishing work came, they threw down their tools and their hammers, and crowded up to the doctor to claim the prize, and to give a faithful record of their experiences; and one and all declared that they had done their hard work with more ease and comfort to themselves than ever it had been done before, and, instead of feeling tired and jaded, as they often did on the Saturday afternoon, they were quite ready to begin work again, and if the doctor had another £50 to dispose of, they would most gladly give him a chance of protracting his experiment for another week. The doctor expressed himself perfectly satisfied with the trial which had already taken place, and left the place amidst three hearty cheers, while the men proceeded to discuss the ins and outs of the matter among themselves."--_National Advocate._ BEER-DRINKING INJURES HEALTH. "I think there is no doubt that beer-drinking is deleterious to health, and personally I have never seen any case of disease where I thought it useful. I believe it is more deleterious to health than the stronger spirits, and this opinion is derived from the report of the actuaries' investigations for our insurance companies a few years ago."--DR. JOHN M. DODSON, Dean of the Medical Department of the University of Chicago. "My connection with large medical institutions for many years past has given me, I think, an excellent opportunity to observe the effect of beer-drinking and the use of other alcoholic liquors in many cases. I can say as a result of my own observation that beer-drinking has a very pernicious effect upon nearly every organ of the body. It produces disease of the stomach and digestive tract, of the heart and circulating system, of the kidneys and liver, and of the nervous system. In addition to this it lessens the vigor and vital resistance of the whole body, makes the beer drinker very much more susceptible to infection such as pneumonia, and other acute infections, and also lessens his ability to recover from illnesses of any kind. An untold amount of misery and disease would be avoided if the use of beer and other intoxicating liquors could be wiped off the face of the earth."--DR. W. H. RILEY, Battle Creek Sanitarium, Battle Creek, Mich. In the report of Bellevue Hospital, New York City, for 1904, Dr. Alexander Lambert, in speaking of delirium tremens, says: "The delirium tremens from beer does not come on so readily as that from whisky, but is slower in clearing up." Page 138 of report. "Apart from its toxic effect it is seldom realized how harmful beer may be by promoting obesity, and, in susceptible persons, favoring dilatation of the stomach."--DR. E. P. JOSLIN, Professor in Harvard Medical School. "It is not the concentrated alcoholic liquors alone that cause heart and kidney trouble but pre-eminently the continued immoderate use of beer. Nothing is more false than the belief that the progressive dislodgement of other alcoholic drinks by beer will diminish the destructive influences of alcoholism. * * * It has been conclusively established by thousandfold experiments that soldiers in all climates, in heat, cold and rain, endure best the most fatiguing marches when they are absolutely deprived of alcoholic drinks."--PROF. G. VON BUNGE, M. D., Basle, Switzerland. "Beer, wine and spirits furnish no element capable of entering into the composition of blood, muscular fibre, or anything which is the seat of vital principle. If a man drinks daily 8 or 10 quarts of the best Bavarian beer in a year he will have taken into his system as much nourishment as is contained in a five-pound loaf of bread."--_Liebig, the great German chemist._ "Beer-drinker's heart is a term well-known to the physicians of our large hospitals, and indicates a special condition of unhealthy enlargement of the heart due to dilatation, accompanied by some increase of tissue and of fat. Doctors Bauer and Bollinger found that in Munich one in every sixteen of the hospital patients died from this disorder. It is common in Germany--the land of beer-drinking--and proves incontestably that the habit of drinking even such a mild alcoholic beverage as lager-beer is one that is undesirable and unwise."--_From "Alcohol and the Human Body," by Sir Victor Horsley, M. D., London._ "Nothing is more erroneous from the physician's standpoint, than to think of diminishing the destructive effects of alcoholism by substituting beer for other alcoholic drinks, or that the victims of drink are found only in those countries where whisky helps the people of a low grade of culture to forget their poverty and misery."--PROF. STRUMPEL, Breslau, Germany. "The result of extolling beer as the mightiest enemy of whisky and brandy has been that the consumption of the distilled liquors has changed very little, while to these liquors has been added beer, the use of which has led to a great and still increasing beer alcoholism. * * * "The beer drinker who is not at all a drunkard in the popular sense, is very frequently the victim of chronic inflammation of the kidneys. * * * An enlarged and fatty condition of the liver, marked by a dull pain in the region of the organ, often follows from the habitual use of beer. The death-rate from liver diseases among brewers of beer in England is more than double that in all other occupations. * * * Beer-drinkers have a marked tendency to enlargement of the stomach, and to chronic diarrhoea. Beer causes also inflammation of the nerves. This is often announced by 'rheumatic' pains in the legs. * * * Beer alcoholism, as well as alcoholism in general, lowers the resistance of the body to all diseases by injuring most of the organs. And herein lies the chief danger in the general wide-spread use of beer. The drinker is especially open to attacks of infectious disease. * * * The brutalizing effect of beer-alcoholism is shown most clearly by the fact that in Germany crimes of personal violence, particularly dangerous bodily injuries, occur most frequently in Bavaria where there is the highest consumption of beer."--DR. HUGO HOPPE, Nerve Specialist, Konigsberg, Germany. "The life insurance companies make a business of estimating men's lives, and can only make money by making correct estimates of whatever influences life. Now they expect a man otherwise healthy, who is addicted to beer-drinking, will have his life shortened from 40 to 60 per cent. For instance if he is twenty years old and does not drink beer he may reasonably expect to live until he is 61. If he is a beer-drinker he will probably not live to be over 35. If he is 30 years old when he begins to drink beer he will probably drop off somewhere between 40 and 45 instead of living to 64 as he should. There is no sentiment, prejudice or assertion about these figures. They are simply cold-blooded business facts, derived from experience, and the companies invest their money on them just the same as a man pays so many dollars for so many feet of ground or bushels of wheat."--DR. S. S. THORN, Toledo, Ohio, in U. S. Senate Document, published in 1901. "Fatty degeneration of various organs is frequently witnessed in beer-drinkers. Diabetes mellitus is frequently due to beer-drinking, and is made much worse by its continuance. In Germany more than half of the cases in the inebriate asylums enter from beer-drinking. In Bavaria, the women are not able properly to suckle their children because of the universal consumption of their favorite national drink. Indeed, so grave are the evils caused by beer-drinking that the fight against beer should now be conducted as strenuously as that against stronger liquors."--DR. LEGRAIN, Paris, France. DRUG DRINKS. In the report of the President's Homes Commission, Senate Document 644, may be found a list of soft drinks examined by the Bureau of Chemistry. The report says:-- "Attention is directed to the danger of soft drinks containing caffeine, and extract of coca leaf, the active principle of the latter being cocaine. * * * We have seen how the opium habit may be acquired by the use of the various proprietary or secret preparations, and so the cocaine habit may be developed by the use of these much lauded soft drinks. * * * No wonder that insanity and diseases of the nervous system are on the increase." The following is a list of drinks examined by the Bureau of Chemistry. Investigation showed that these contained both caffeine and extract of coca leaf: Afri Cola, Ala Cola, Cafe Coca, Carre Cola, Celery Cola, Chan Ola, Chera Cola, Coca Beta, Coca Cola, Pilsbury's Coke, Cola Coke, Cream Cola, Dope, Four Kola, Hayo Kola, Heck's Cola, Kaye Ola, Koca Nola, Koke, Kola Ade, Kola Kola, Kola Phos, Koloko, Kos Kola, Lime Cola, Lima Ola, Mellow Nip, Nerv Ola, Revive Ola, Rocola, Rye Ola, Standard Cola, Toka Tona, Tokola, Vim-O, French Wine of Coca, Wise Ola. The manufacturers of some of those listed claim that their coca extract is prepared from a decocainized coca leaf, the refuse product discarded in the manufacture of cocaine. The Coca Cola company claims that their coca extract is now without cocaine, and most of the recent analyses show this to be true, yet the Pure Food Commissioner of North Dakota says in his report for 1907 that Coca Cola as examined by him, "Gave a reaction for cocaine." It is easy to see that so long as even refuse coca leaves are used some cocaine may at times be in the product. As cocaine is the most destructive drug known to humanity its presence in any of the so-called temperance drinks is a frightful evil calling for speedy legislation. It is practically impossible to cure a person of the cocaine habit. This drug causes insomnia, dyspepsia, chronic palpitations, and complete paralysis of will-power, with a tendency to criminal acts. When a person becomes habituated to its use he suffers torments when not under its influence. The real cocaine fiend will rob or kill to get the drug. What can be thought of men, who knowing the deadly nature of this drug, will hide it away in a drink sold as harmless to children and women who would never touch beer or wines? It is placed in the drink to form a craving for that drink and thus create a demand that will enrich the conscienceless manufacturers. The following preparations were found to contain caffeine, but there was no evidence to the effect that coca leaf in any form had been used in their manufacture: Calcycine, Celery Cocoa, Citro Cola, Deep Rock Ginger Ale, Fosko, Heck's Star Pepsin, Koke, Koke Ola, Kalafra, Kumfort, Lime Juice and Kola, Lon Kola, Meg-O, Mexicola, Pau Pau Cola, Pedro, Pepsi Cola, Speed Ball, To-Ko, Vril. The report says that the following list were not examined but from their names, and from the evidence submitted, they contain either caffeine or coca leaf extract, or both: Charcola, Cherry Kola, Cola Soda, Cola Ginger, Field's Coca, Imported French Cola, Jacob's Kola, Koko Ale, Kola Cream, Kola Pepsin Celery Wine Tonic, Kola Vena, Loco Kola, Mintola, Mate, Pikmeup, Ro-Cola, Schelhorn's Coca, Vine Cola, Viz. Dr. Harvey W. Wiley, chief of the Bureau of Chemistry, says that the sale of all such drinks should be prohibited. Caffeine is a drug much used in headache remedies. It is derived from the kola nut, and from tea and coffee. It is also made artificially from uric acid occurring in the guano or bird manure deposits of South America. This bird manure product is said to be used in some of the drinks while in others caffeine obtained from refuse tea sweepings is used. The sales-manager of the Coca Cola Company says the caffeine in their product is made from tea. It is claimed by the manufacturers of caffeine drinks that they are as harmless as tea or coffee. But physicians advise against the use of tea and coffee for children and for delicate, nervous people, and every intelligent person knows that these drinks should not be indulged in immoderately. The secret caffeine drinks at the soda-fountain are not warned against because few people know of what they are made. So it frequently happens that children whose parents do not permit them to drink tea and coffee are taking caffeine in a much more injurious form at the drug stores. Dr. Harvey W. Wiley, Chief of the Bureau of Chemistry, says: "When caffeine is separated from tea and coffee, and used as a separate drug, it exerts a much more specific action upon the system than when in natural combination. Its general effect is to induce that unhappy state described as nervousness, with deranged digestion and impaired health." Dr. H. H. Rusby, Dean of the College of Pharmacy, of Columbia University, New York City, a high authority, says: "Caffeine is a genuine poison, both acute and chronic. Taken in the form of a beverage it tends to the formation of a drug habit, quite as characteristic, though not so effective, as ordinary narcotics. Permanent disorders of the cardiac function, and of the cerebral circulation, result from its continued use." The _Druggists Circular_, for May, 1908, contained a query from a druggist as to a good formula for a kola nut soda syrup. The answer was in part as follows: "There are two kinds of druggists. One kind puts any and every kind of stuff into stock, and passes it out to his customers, young and old, ignorant or learned, foolish or wise, his only desire being to get a profit. The other kind of druggist refuses to stock some things at all. Kola drinks owe their vogue to the caffeine which they contain. Caffeine is a poison which is cumulative in its effects, and an excess of which has not infrequently caused death. We believe you would better be on record as discouraging rather than encouraging the growth of the caffeine habit, especially among young people, who constitute a large part of the soda-water trade." The _London Lancet_ of January 25, 1908, reports the results of experiments made in Paris with kola given to horses to determine its action in relieving fatigue. It apparently diminished fatigue, but the horses receiving it lost more weight than those to whom it was not given. The experimenter said this showed that kola (caffeine) like alcohol, can give the tissues a lash with a whip, but that such energy, artificially produced, is at the expense of the organism. So, when people see the alluring advertisements of caffeine drinks which "relieve fatigue," let them beware of the relief which carries with it injury to the body. Of the most widely advertised of these caffeine drinks the government report says: "The prevalence of the 'Coca Cola fiend' is becoming a matter of great importance and concern." (See volume on Social Betterment of Senate Document 644, page 268.) M. M. A. SPECIAL MEDICAL DIRECTIONS FOR WOMEN. "In the treatment of diseases of women, alcohol has been considered a very important remedy. Because it affords relief from pain, many resort to its use during painful menstruation. Each month either whisky, or some medicine containing a liberal supply of alcohol, is considered a necessity. "The alcohol habit is not infrequently formed in this way. I have in my mind several cases of inebriety which were traceable to the habit of taking something to relieve pain at these periods. A woman whose husband held a high official position, thus acquired a craving for alcohol and became a confirmed drinker. He was finally compelled to place her in an institution for treatment. "Alcohol affords relief, not by lessening the internal congestion which causes the pain, but by paralyzing or benumbing the nervous system. In fact, alcohol, instead of relieving, aggravates the internal congestion. It is a deceiver, for it makes the patient believe she is benefited when in fact the condition is made worse. The uterus has become more congested by its use, and when the paralyzing effect of the alcohol has worn off the pain will be found more severe, and the demand for alcohol increased correspondingly. The only safe and wise plan when suffering from pain due to internal congestion is to remove the cause. If uterine misplacement exists suitable treatment must be taken to correct this. Almost immediate relief from pain due to congestion of the pelvic organs may be obtained by taking a hot full bath. A hot foot or leg bath is also a good treatment since the warming of the extremities quickens the circulation in the limbs and relieves congestion in the pelvic region. "There are various forms of dysmenorrhea or painful menstruation and each form has a treatment by itself. The congestive type which is due to taking cold is better relieved by a hot sitz bath before the date expected, the temperature of the water should be 101°-103° with the feet in water a degree or two hotter. If at the time of the period the pain still continues, an enema or vaginal douche will usually give the necessary relief unless the patient should be exposed to cold by allowing the hands, arms, feet or legs to become chilled. "Many women do not dress their limbs warmly enough at any time. Just before the menstrual period the tendency is for the pelvic organs to become congested; there is a greater tendency to cold feet then, than at any other time. I would therefore advise warmer clothing on the limbs at such times. The drinking of hot pepper tea, ginger tea, etc., is a pernicious practice, for these irritants inflame the mucous membrane of the stomach and intestines. Hot lemonade or hot water will afford the same relief without leaving an inflamed surface behind to be irritated by the next meal. "There are some cases of great constriction of the uterine canal which have reflex irritability in the stomach. Those having the stomach affected cannot take food, the least thing is rejected. It is best for such to remain quiet in bed, applying heat to the stomach and abdomen and to the feet until relief is experienced. Those suffering from headache should also remain quiet in bed. Some resort to anodynes and form the habit of using codeine, morphine. All these are bad and should be avoided. I have never found it necessary to give one dose of either to relieve pain at such times. Hot applications with the enema, vaginal douche, or foot bath, has usually been all that was required. "I recall many cases of severe pain where the extremities were cold and clammy and the entire body was in a hysterical contraction that were immediately relieved by a hot vaginal douche. The muscles relaxed, the patient warmed up and recovered nicely. "For securing sleep in insomnia, a hot toddy is often used, but a quicker and better effect can be gained by a hot, or neutral bath. The latter given at 99° or 100° for twenty minutes will produce sleep and refreshment, as it equalizes the circulation by bringing the blood to the surface. "It is safer under all circumstances to do without alcohol or other dangerous drugs in treatment of these diseases."--DR. LAURETTA E. KRESS, Washington, D. C. NOTE--An experienced nurse says that prompt relief in painful menstruation may often be found by sitting upon a toilet water-jar half full or more of hot water. The steam rises and the heat relieves. TOTAL ABSTINENCE AND LIFE INSURANCE. Nothing shows more clearly and convincingly that alcoholic liquors have a tendency to shorten life than the figures published by life insurance companies. A most interesting and valuable paper upon this theme was read before the Actuarial Society of America, in 1904, by Mr. Joel G. Van Cise, actuary of the Equitable Life Assurance Society of the United States. In it he gives the experience of different life insurance companies which have separate sections for total abstainers and non-abstainers. The Mutual Life Insurance Company of New York, one of the large companies, showed after a few years' experience with the two sections a death-rate 23 per cent. higher among the drinkers than among the abstainers. The Sceptre Life for the years from 1884 to 1903, inclusive, gave the following: Expected deaths of abstainers, 1,440; actual deaths, 792, being 55 per cent. of the expected. Expected deaths of non-abstainers, 2,730; actual deaths, 1,880, or 79 per cent. of the expected. The Scottish Temperance Life from 1883 to 1902 gave the following: Abstainers, expected deaths, 936; actual deaths, 420, or 45 per cent. of the expected. Non-abstainers, expected deaths, 319; actual deaths, 225, or 71 per cent. of the expected. Mr. Van Cise goes on to show that the statistics which have been published from time to time, giving the percentages of mortality in the various occupations of life, invariably show a higher death-rate among those engaged in the liquor business than among those engaged in other lines of work, except such as are specially hazardous. He says: 'The higher death-rate among liquor dealers is so universally recognized by life assurance companies that a number of them will not issue policies, even on the lives of the richest brewers, upon any terms, and not one of the companies, to my knowledge, admits liquor dealers upon as advantageous terms as those engaged in other ordinary occupations.' He then quotes from a circular sent to the agency force of a prominent United States company, in which attention is called to a rule which forbids the taking of any risks on bartenders: 'Saloonkeepers, generally, not taken, but best of this class may be accepted on 10 or 15 year endowments only.' Others connected more remotely with the liquor business might be taken with a charge of $5.00 per thousand extra. The circular of instructions adds that the limitations of liquor dealers are made necessary 'by the very excessive rate of mortality found to exist among persons so employed.' Mr. Van Cise closed his address before the Actuaries' Society by saying: 'I contend that the facts given in this paper show conclusively that the effect of total abstinence is to lower the death-rate, and increase the average duration of human life.' The Equitable Company had a section for total abstainers for a few years which was discontinued on account of the new insurance laws which came into effect in 1907. The actuary writes in response to inquiry: 'We are very careful in our selection of risks, and only those who drink in moderation will be accepted. I think it safe to say that, other things being equal, all American life insurance companies would consider a total abstainer a more desirable risk than a moderate drinker.' The United Kingdom Temperance and General Provident Institution, of London, is a large and successful company which was organized in 1840, expressly for total abstainers, because at that time larger premiums were asked from abstainers than from drinkers, the common opinion then being that alcoholic liquors were necessary to health. In 1846, this company added a general section, in which carefully selected moderate drinkers were accepted, but each section was kept entirely separate from the other. This separation has continued to the present time, both classes paying the same premiums, but sharing in profits according to the earnings of the section to which the members belong. From 1866 to 1900, for every 100 deaths in the temperance section there were 137 deaths in the moderate drinking section, based on a corresponding number of lives at risk. The dividends for a recent five years average $20 to the temperance members, and $17 to the drinking members. The actuary of this English company, Mr. Roderick Mackenzie Moore, read a paper before the Institute of Actuaries, in 1903, in which he reviewed the work of this company during its history of sixty years' experience with abstainers and over fifty with non-abstainers. He showed that there has been no marked difference in the number of policies in force in the two sections, and the average amount of the policies in each section has been about the same, so that the comparison is as fair as could possibly be made. He gives these figures: 'Non-abstainers, male, expected deaths, 8,911; actual deaths, 8,947; per cent. of actual to expected, 100.4. Abstainers, male, expected deaths, 6,899; actual deaths, 5,124; per cent. of actual to expected, 74.3.' This shows a difference of 26.1 per cent. between the actual and expected deaths of abstainers and moderate drinkers, and the full figures show the death rate among the drinkers to be 35 per cent. higher than among the abstainers. The American Temperance Life Insurance Association was organized in 1887. It gives a lower premium rate to members of the abstainers' section than to those in the general section. The circulars sent out by this company state that the average life of moderate drinkers is thirty-five and a half years; tipplers, fifty-one years; total abstainers, sixty-four and one-fifth years. Very interesting is the result of an inquiry made of various insurance companies not long ago as to whether they consider the habitual user of intoxicating beverages as good an insurance risk as the total abstainer; 'if not, why not?' All but two out of forty-one companies answered, 'No.' The two answered, 'Depends on quantity used.' In answer to the 'Why not?' the Etna said, 'Drink diseases the system and shortens life'; Hartford Life, 'Moderate use lays foundation for disease'; Knights of the Maccabees, 'Drink tends to destroy life'; Knights Templar and Masons' Life Indemnity, 'Drink lessens ability to overcome disease'; Sun Life, 'Drink injures constitution. Habit apt to grow'; Massachusetts Mutual Life, 'Drink causes organic changes. Reduces expectation of life nearly two-thirds.' The rest of the answers are much the same as these.--_M. M. A._ INDEX Abbott, Dr. A. C., 264, 278, 280, 281, 368 Abdominal bandage, 199 Abel, Prof. J. J., 128 Abernethy, Dr., 36 Acetanilid, 180, 301, 346 Acetic acid in pharmacy, 134, 136 Acid drinks kill bacilli, 150 Adelung, Dr. Edward Von, 326, 379 Adynamic disease, 272 Aiken, Dr. J. M., 376 Alabama law and alcoholic prescriptions, 27 Albumen, 30, 60, 62, 152, 173 Alcohol, food claims, 112-114, 128 a mocker, 364, 377 a narcotic, 121, 123 a poison, 28, 29, 100, 105, 358, 371, 388 injurious to living cells, 275 advance in study of, 380 affinity for blood and tissues, 114 affinity for water, 148, 149 and foods, action contrasted, 406 and empty stomach, 100 mental work, 400 anti-spasmodic, 124 apparent benefits; deceptive warmth from evanescent, 108 anæsthetic and paralyzant, 120, 181 anæsthetic effect deceptive, 222, 262, 266 antipyretic, 127 as medicine, 96-130 as medicine, causes waste of force, 83 as medicine, diminished use, 20, 53-57 as medicine, need of popular education regarding, 297 as medicine, opposition to by W. C. T. U., 21-27 causes disease, 28-36 as sedative, 127 as tonic, 124, 126 beginning of scientific study, 11 a cause of Bright's disease, 34, 91 causes malnutrition, 284 craving, 140 delusion that it "supports", 294 depressant, 150, 178 dangerous in pneumonia, 201 difference in action from carbohydrates and fats, 403 diminishes arterial pressure, 119, 120 effect on respiration, 263, 266 experiments, 11, 15, 62, 65, 80, 93, 101, 119, 120, 149, 200, 266, 267, 268, 275, 279, 288, 392-405, 421 Alcoholic diseases ascribed to other causes, 33 drink, no danger in sudden stopping, 293 drinks, stories of life sustained on, 112 dyspepsia, 63 proprietary medicines, 299-334 Alcohol, medical use bulwark of liquor-traffic, 96, 97, 360, 361 medical use causes death, 260 medical use delays recovery, 115 medical use evidence against, 336-391 medical use result of habit and tradition, 292, 294, 295, 298, 378 medical use, Toledo Blade on, 358 medical use, mortality increased by, 247-261, 267 Ammonia, 40, 188 Anæsthesia, 119, 120 Anæmia, 141 Anders, Dr. Howard S., 370 Angina pectoris, 181, 182 Animal poison, 206-211 Anthrax, 281, 282 Alcoholism, 36, 111 Ale, 120, 142, 236 Alkalies for stomach, 174 Alum, 143, 164, 171, 215 American Association for Study of Inebriety, 329 American Druggist and Patent Medicine Agitation, 26 American Medical Association, declaration on alcohol, 14 Antikamnia, 192, 346 Anti-Tuberculosis Congress resolution, 154 Apoplexy, 31, 32, 111, 142 Appetite, loss of, 142 Aschaffenberg, Prof., 400 Association of Abstaining Physicians, Germany, 387 Asthma, 179, 345 Athletes and alcohol, 103 Atwater, Prof., 128-130 Australian Government Commission on Patent Medicines, 314 Baldwin, Dr. Edward R., 370 Barton, Miss Clara, 48 Baths, 57, 145, 146, 147, 152, 164, 193, 197, 199, 410, 431, 432 Battle Creek Sanitarium, 223-227, 255, 256 Bavaria, beer-drinking effects, 425 Beale, Dr. Lionel, 99, 286 Beaumont, Dr., 61, 293 Beddoes, Dr., 13, 421 Beebe, Dr. S. P., 404, 405 Beef-tea, 194, 197, 325 Bacteria, 150 Badger, Dr. Richard, 365 Baer, Dr., 19 Barker, Prof., 337 Barr, Sir James, 372 Beer, 31, 66, 116, 117, 124, 126, 142, 179, 239, 244-246, 247, 423-426 Bellevue Hospital, 36, 54, 309 Berkley and Friedenwald, 279 Beverages for the sick, 411 Bigelow, Dr. Jacob, 335 Billings, Dr. Frank, 155 Bitters, 176, 329 Blankmeyer, Dr. H. J., 159 Bleuler, Dr., 388 Blood, 66-75, 76, 86,106, 113, 114, 119, 393 Blood purifiers, 75 Blood vessels, 63, 75, 76, 108, 109, 120, 124, 143 Blumenau, alcohol and digestion, 173 Boils and carbuncles, 144 Bond, Dr. Knox, on fevers, 252, 373 Bostwick, Dr., 336 Bowditch, Prof. Vincent Y., 157 Boynton, Dr., 377 Bradner, Dr. Roe, 329, 332 Brain, 32, 36 Brandy, 35, 120, 143, 151, 173, 177, 183, 196, 215, 356 Brewers, 38, 425 Bright's disease, 34, 91, 94 British army, experiences with alcohol, 101, 102 British Medical Journal, 180, 247, 269, 270, 319, 324 British Medical Temperance Association, 148-151, 250 Broadbent, Dr., 274 Brodie, Dr. Benj., 105 Bromidia, 353 Bromo Seltzer, 346 Brown, Dr. Alonzo, 271-273 Brunton, Dr. Lauder, 269, 270 Bucke, Dr. R. M., alcohol and the insane, 412 Buckley, Rev. J. M., D.D., cured of consumption, 159 Bunge, Prof. G. Von, 207, 424 Bureau of Chemistry, 426, 427 Burnett, Dr. Mary Weeks, 41-44 Burt, Mrs. Mary T., 24 Bussey, Dr., 237 Butter, substitute for cod-liver oil, 314 Cabot, Dr. Richard C., 57, 370 Caffeine, 49, 135, 300, 428-430 Cain, Dr. J. S., 229, 377 Calmette, Dr., snake-bite 206-209 Camphor, 217, 374 Cancer and alcohol, 288 Carbolic acid, 138, 145 Carbon dioxide, 71-73 Carbonic acid in wine, 117 Cardiac paralysis in diphtheria, 272, 273 Carpanutrine, 313 Carpenter, Dr. Alfred, 86 Carson, Prof. J. W., 336 Casgrau, Dr., doctors who personally use alcohol less observant of its effects, 294 Catarrh, 144, 145, 345 Cells, 58-60, 68, 130, 271, 272 Chapman, Dr. C. W., 184 Charcoal, 179 Charrin, Dr., 287 Cheese, cannot be made from milk of cows fed on distillery slops, 236 Cheyne, Prof. W. W., snake-poison, 209, 210 Children, danger of alcohol for, 416 Children of beer-drinking mothers, 236, 237 Children, per cent. of deaths of those of abstaining and drinking parents, 397, 398 Chills, 146 Chittenden, Prof., 93, 403 Chloral, 127, 138, 190, 275, 332, 353 Chlorodyne, 127 Chloroform, 119, 120, 121, 270, 353 Cholera, 35, 147-152, 257, 258 infantum, 152, 153 morbus, 152 Christian Advocates, The, and patent medicines, 26 Christison, Prof., 34 Cincinnati Hospital, 254 Circulation, 76, 77, 184-186 Claret, 120, 177, 419 Clark, Dr. Alonzo, 336 Sir Andrew, 35, 101 Clinique, The, 180 Coal-tar drugs, 75, 180, 192, 339, 340 Coca wines, 319-324 Coca Cola, 427 Cocaine, 300, 319-325, 345-351, 427 Cod-liver oil, fraudulent preparations, 314 Coffee, 40, 141, 194, 236 Cohen, Dr. S. S., 365 Cold, as a heart stimulant, 184-186 as tonic, 125 pack, 186 treatment for pneumonia, 202 Colds, cause and treatment, 146 Colic, 147 Collier, Dr. Wm., 372 Collier's Weekly and nostrums, 26 Collins, Dr., 157 Coloring matter in wines arrests digestion, 176 Coma from waste retention, 115 Committee of Fifty, 19, 128, 279 on Pharmacy, 314, 315, 316 Condi, Dr., nursing mothers, 236 Constipation, 146 Consumption, 153-162, 326 Convalescence and alcohol, 292, 294 Convulsions, 147, 179 Cook County Hospital, 54, 159, 253 Cordials in dyspepsia, 176 Cough medicines, 310-312 simple remedies, 146, 147, 162 Cramps, 179 Cream, substitute for cod-liver oil, 160, 314 Crothers, Dr. T. D., 120, 131, 183, 218, 345, 390 Cures for inebriety, 329, 414 Deaths from alcohol, 28, 83, 87 from alcoholic diseases ascribed to other causes, 31-34 Death-rates, comparative, 75, 85, 247-261, 267 lowered by non-alcoholic treatment, 37, 46, 219 Debility, 171, 172 Davis, Dr. Nathan S., Sr., 11, 12, 29-31, 45, 66, 75, 80-82, 91-95, 107, 112, 117, 118, 125, 128, 178, 193, 217, 219, 244, 253, 262, 267, 289, 294, 358-360 De Garmo, Prof., 366 Deléarde, Dr., Pasteur Institute, 279, 284 Delirium tremens, 388 Depression of spirits, 172, 179 Diabetes, 88, 89 Diarrhoea, 172 Digestion, 106, 155-157 Digestive organs, injured, 389 Digitalis, 128, 135 Diphtheria, 75, 85, 272 Diseases of women, 430 non-alcohol treatment, 140, 233 Distilled liquors, composition, 117 Doan's Pills, 315 Dodson, Dr. John M., 423 Dogbite, 211 Dock, Dr. George, 365, 371 Douches, 164, 431 Drowning, 193, 194 "Drugging", 335-355 Drug habits formed by patent medicines, 301 Drugs, medical opinions of, 336-338 Druggists' resolutions against whiskey drug-stores, 27 Druggist's Circular, 8, 429 Druggists, liquor selling by, 139 Drunkards made in infancy, 311 Drunkards, 126, 350 Drysdale, Dr., 372 Dubois, experiments, 119 Dysentery, 172, 173 Dysmenorrhea, 431 Dyspepsia, 65, 127, 173-177 Edmunds, Dr., 37, 38, 183, 238-243 Edsall, Dr. David L., 374 Epilepsy, 32, 36, 178 Erysipelas, 74, 388 Eshner, Dr. A. A., 364 Exhaustion, 178 Fainting and faintness, 177, 178, 180, 181 Fatigue, 178, 320, 430 Fatty degeneration, 34-36, 82-85, 114 Fats digested in small intestines, 60 Fere, Dr., 203 Fermentation, 116, 274 Fevers, 75, 85, 249-255, 388 Fibrine, 40, 62 Fits, 238 Flatulence, 179 Flick, Dr. Lawrence, 156 Fomentations, 147, 199, 229 Food, alcohol as indirect, 112-114, 29, 98-117, 128-130 Foods, proprietary, 313 Forel, Dr. A., 36, 105 Forrest, Dr., 160, 161 Foster, Dr., 68 Franco-Prussian War, wine, 110, 111 Francis, Surgeon Gen'l, cholera, 150 Frick, Dr. A., 388, 389 Fruit, 141, 146, 374 juice, 65, 232, 374 Gairdner, Dr., fevers, 251, 252 Garber, Dr., typhoid, 230 Garfield Memorial Hospital, 55, 254 Gastric juice, 62, 65 Gastritis from beer and gin, 246 Georgia law and alcohol prescriptions, 27 Germs, 70, 115, 223, 272, 286, 287 Giddiness, 179 Gilman, Prof., treatment leads to death, 337 Gin, 61, 117, 199, 246 Ginger drinking, 341 Gloria Tonic, 414 Gluzinski and digestion, 61, 176 Glycerine in pharmacy, 134, 135, 138 Glycogen, 85, 130 Gordon, Dr. A., 377 Gould, A. Pearce, 288, 367, 373 Gout, 31, 74 Grape juice, 65 Gréhant, 288 Gruber, Prof., 128, 129 Guardian cells, see leucocytes Gull, Sir Wm., 35, 104 Gum resins, non-alcoholic preparation, 134 Hagee's Cordial of Cod-Liver Oil, 314 Hall, Dr. W. S., 379, 405-409 Hamilton, Dr. Frank H., 285, 286 Hammond, Dr. W. A., 36, 95 Hargreaves, Dr. W., 35, 85, 86, 105, 236, 237 Harley, Dr., alcohol and diabetes, 88, 89 Harrington. Dr. Chas., 313, 316 Hart, Dr. Ernest, 126, 152, 269 Harvey, Dr., counsel to young physicians, 389 Hay Fever, 145, 146 Hayes, Dr., arctic work, 110 Headaches, 179, 180 Headache remedies, 301, 354 Health, how to preserve, 355 Health Grains, 315 Healy, Dr. H. H., 375 Heart abscesses, 277, 278 and alcohol, 31, 75-85, 263 beer-drinkers, 424 disease, 181, 182 failure, 83, 85, 184, 185-188, 227, 273 force diminished, 183 stimulants, 188 weak, 182 Hemaboloids, 313 Hemapeptone, 313 Hemaglobin, 30, 67, 114, 221 Hemorrhage, 34, 180, 197 Heredity of alcoholic diseases, 33 Herrick, Dr. James B., 365 Hewes, Dr. Henry F., 379 Heyburn, Senator, nostrums, 334 Hiccough, 179 Higginbotham, 13, 140, 180 Higginson, Col. T. W., 196 Hirschfeld, Dr., 360, 380 Hiss, Dr. A. Emil, 309, 310 History of study of alcohol, 9-20 Hob-nailed liver, 87 Hoffman drops, 349 Hoff's Consumption Cure, 316 Holmes, Dr. Oliver W., on drugs, 137, 344 Hop tea, 66, 142, 176 Hoppe, Dr. Hugo, beer, 425 Horsley, Sir Victor, 129, 372, 424, 425 Hospitals, Temperance, 37-53 death-rates, 252-261 decreased use of alcoholic liquors, 53-57 Hugounencq, alcohol and pepsin, 176 Hunt, Mrs. Mary H., temperance education, 17 Hunt, Dr. Reid, 369, 402 Hydrochloric acid, 173, 177 Hydrophobia, 281-283 Internal Rev, Dep't. and Nostrums, 27, 312 International Congress on Alcoholism, London, 1909, 9, 393 Encyclopedia of Surgery, 209 Medical Congress 1876, and National W. C. T. U., 23, 82 Immunity, influence of alcohol on, 281, 282, 393-395 Indigestion and alcohol, 32 Infant feeding, 242, 243 Infection, liability to increased, 392, 393 Infectious diseases, 288, 368, 369, 425 Inflammation in wounds, 74 Influenza and drinkers, 192, 193 Iron, injurious to stomach, 315 Jackson, Dr. Henry, 370 Jaundice, alcohol prejudicial, 89 Jayne's Expectorant, 310 Johnson, Lieut., arctic work, 110 Joslin, Dr. E. P., 364, 424 Journal Amer. Med. Ass'n., 129, 204-209, 211, 368, 369 Journal of Inebriety, 131, 192, 329, 413 Kansas prohibits whiskey drug-stores 27 Kassowitz, Prof. Max, 373, 374 Kellogg, Dr. J. H., 36, 89, 95, 121, 129, 141, 152, 166, 176, 185, 195, 199, 255, 378 Kerr, Dr. Norman, 150, 357 Kidneys, 30, 89-95, 276, 425 Koch, Dr., consumption, 153 Knopf, Dr. S. A., 155 Kola, see caffeine. Kraepelin, 399, 400 Kress, Dr. Lauretta, 430-432 La grippe, 190-193, 337 Ladd, Prof., 332, 333 Ladies' Home Journal, 26 Laitinen, Prof. T., 368, 369, 392-398 Lambert, Dr. Alex., 415, 424 Lancet, The London, 191, 184, 252, 368, 429 Landis, Dr. J. H., and typhoid, 379 Laudanum, 137, 352 Laxative pills often harmful, 346 Lees, Dr. F. R., 106 Legrain, Dr., 426 Liebig, 116, 251, 424 Lemon, 146, 147, 179, 194, 411 Lesser, Dr. A. Monæ, success in treating fevers in Cuban War, 53 Leucocytes, 271, 272, 274, 275, 278, 282, 283, 284, 285 Life insurance and total abstinence, 36, 423, 426, 432-435 Life saving stations and alcohol, 193 Liniments, non-alcoholic, 134, 135 Liquid Peptones, 313 Liver, 31, 33, 85-89, 404-409, 425 Lloyd, Prof. J. U., 328 London Temperance Hospital, 37-41, 132-135, 357 Loomis, Dr. A. L., 255 Dr. Henry P., 157 Lungs, 30, 201 Lying-in-Hospital, London, 37, 38 Martin, Dr. Newell, 63, 79, 84, 85, 91, 109, 119, 158 Massage, 166, 180, 213, 214 Mass. State Board of Health, 34, 310 Massart and Bordet, leucocytes, 277 McNicholl, Dr. T. A., 48, 378 Madden, Dr. John, 378 Magnesia, 179 Malaria[D], 195, 196 [Footnote D: Of late years malaria is attributed to the bite of a certain kind of mosquito. In preparing this edition that item was overlooked.] Malt Extracts, 316-319 Manassein's Clinic, alcohol and kidneys, 93, 94 Mann, Dr. Matthew D., 365 Martin, Alexis St., 61, 293 McCormack, Dr. J. H., 370 Measles, 194 Meat extracts, valueless, 325, 326 Medical temperance department of W. C. T. U., 25-27 Menstruation, painful, 197 Mercer, Dr. Alfred, 363 Metchnikoff, 374, 398 Milk, 141, 153, 188, 236, 237, 251, 373 Miller, Dr. James Alex., 157 Mitchell, Dr. S. Weir, 207, 210 Miura, investigations, 379 Morphine, 300, 345, 351, 352 Mossop, Dr., experiments, 120 Mother Bailey's Quieting Syrup, 310 Munyon's Kidney Cure, 315 Mulford's Predigested Beef, 313 Muscles and alcohol, 33, 103, 124 Musser, Dr. John H., 369, 370 Mussey, Prof. R. D., 12 Nansen and polar expedition, 110 Narcotic drug dangers, 345, 346, 350-355, 357 Nausea, 199 Nerves, 32, 36, 76, 77, 105, 118, 185, 425 Nervous system affected by retention of waste, 115 Neuralgia, 198 New York State Board of Health, 154, 155 Newspapers and whiskey ads., 382 and patent medicine ads, 333 Nichol, Dr., experiments, 120 Nichols, Dr. Jas. R., 136, 138 Nitrite of amyl, 15, 181, 182 Non-alcoholic treatment, 37, 89, 140-233, 258-260, 360 Nurses, abstinence in cholera, 149 Nursing mothers and beer, 234, 426 Nutrition retarded by alcohol, 114 Oatmeal, 197, 235 Oils, essential, non-alcoholic preparation, 134 Opium, 127, 132, 149, 150, 172, 180, 189, 190, 300, 351, 352, 389, 412 Orangeine, 346 Osler, Dr., 158 Oxidations, 408 Oxidation checked by coal-tar drugs, 339, 340, 346 hindered by alcohol, 263 Oxidative powers of liver effected by alcohol, 404 Oxygen, 40, 67, 71, 75, 92, 113, 114, 118, 130, 187, 264 Page, Dr. C. E., on typhoid, 232 Pain after food, 203, 204 Palmer, Dr. A. B., 79, 121-123 Pepper, Cayenne, 147, 188 Pepsin, 62, 64, 173, 176 Peptonic Elixir, 313 Peruna, 312 Peterson, Dr. Frederick, 375 Phagocytes, 271, 272, 374 Pharmacy, non-alcoholic, 132-139 Phenacetine, 300, 339, 340, 346, 354 Physicians need awakening as to evils of alcohol, 379 responsibility for prescribing alcoholic liquor, 358, 359, 388 why they prescribe alcoholics, 291-298 Pneumonia, 40, 75, 85, 192, 200-203, 253, 254, 257, 280, 340, 346, 371, 388 Poheman, Dr. Julius, 200, 201 Poisons, 29, 204-211, 300, 301 Port Wine, 64, 65, 144, 172, 292 Porter, 236 Pregnancy, danger of alcohol in, 203 vomiting in, 199 Packs, hot 194, 202, 213 Panopepton, 313 Paralysis, caused by alcohol, 31, 36 Paregoric, 352 Parkes, 77-79, 100, 102 Patent medicines, 26, 27, 299-334, 350 Preble, Dr. Robert B., 375 Proprietary "Foods", 313, 314 Prostration, 179 Protoplasm and alcohol, 59, 60, 286, 287 Psychical treatment, Cabot, 57 Ptomaine poisoning, 152, 270 Puerperal fever, 229, 290 Pulse and alcohol, 79, 181 Pure Food Law, 299, 300 Putnam, Dr. J. J., 364 Quackery, cause, 337 Quinine, 128, 190, 196, 340, 345 Rattlesnakes, bite of, 210 Recent researches on alcohol, 276-284, 392-409 Reichert, alcohol and snake-bite, 207 Retina, blood-vessels and alcohol, 120, 124 Rheumatism, 211-214, 259, 260, 343 Richardson, Sir B. W., 15, 17, 31, 39, 63, 72, 105, 111, 121, 148, 153, 177, 259, 295-297, 356, 383, 385-387 Ridge, Dr. J. J., 73, 84, 124, 127, 143, 149, 180, 188, 196, 213, 216, 248, 250, 275, 286, 292, 356, 362 Riley, Dr. W. H., 223-227, 423 Ringer and Sainsbury, 80, 119 Ritchie, Dr. J. J., 383 Roberts, Sir W., 176 Robin, 264 Rusby, Dr. H. H., 429 Salicylic acid, 128 Saline injections, 187 solutions, 145 Sartoin Skin Food, 316 Scarlet fever, 91, 248, 337, 373 Schafer's physiology on alcohol, 129 Scientific temperance education, 17, 18 Sedatives, dangers of, 127 Shock, 215, 216 Sight impaired by alcohol, 120 Sleeplessness, 179 Small-pox, 247-250 Smith. Dr. E., 105, 238 Snake-bite, 207, 211 Soft drinks, dangerous, 427 Soldiers, 101, 102, 285 Soothing syrups, 310 Sore nipples, 215 Sore throat, 145 Sphygmograph, 79, 120, 122 Stammreich, investigations, 379 Starch, 116, 129, 130 Stimulant, definition, 118, 222 Stimulants, 105, 177, 179, 186, 188, 190, 194, 237, 338 Stimulation, fallacy of theory,, 385 Stockton, Dr. C. G., 158 Stomach, 32, 60, 63, 87, 293, 425 Strychnia, 222, 365 Strumpel, Prof., on beer, 425 Sudden illness, 217 Sugar, 86-88, 116, 117, 129, 130, 374 Sulphonal, 346, 353 Sunstroke, 217, 218 Switzerland and alcohol deaths, 36 Syncope, 177 Tannin, 124, 152, 164 Taylor's Headache Powders, 346 Tea, 236 Temperance hospitals, 37-53 Tonic Beef, 313 Toxins, 267-269, 406-409 Treves, Sir Frederick, 342, 372 Trudeau, Dr. Edward, 155, 161 Tuberculosis, 35, 154-158 Tetanus, 281, 282 Thompson, Sir Henry, 120 Tinctures, 131-137 Tissue changes, 113-115 waste retarded, 115 Tobacco and alcohol, 212, 343, 413 Todd, Dr. B., 250, 252 Turkish baths, 193, 208, 212, 213 Type-setters and alcohol, 400 Typhoid fever, 219-233, 251, 252, 253, 268, 365, 373, 379 Typhus, 252, 255, 388 Uric acid, 93, 404, 405 Urine and alcohol, 89, 92, 93, 267, 268 Uterine displacements, 163-171 hemorrhage, 180 Van Duyn, Dr. John, 374 Vasomotor nerves, 76, 77, 83 Vegetarian diet for drink crave, 414 Vinol, 314 Vita-Ore, 315 Vomiting, 140, 233 Water, 30, 95, 112, 128, 135, 143, 145, 150-152, 175, 177, 187, 188, 224, 225, 232, 411 Weakness in growing youth, 125, 178 W. Va. Medical Society resolutions, 371 Whisky, 28, 50, 112, 127, 155, 157, 173, 190, 193, 196, 210, 265, 370, 390 Willhite, Dr. O. C., 159 Wine, 13, 31, 64, 65, 109, 110, 117, 123, 125, 141, 176, 236, 325, 417, 424 Wampole's Cod-Liver Oil, 314 Warbasse, Dr. J. P., 375 Waste, retention invites disease, 70 Welch, Dr. W. H., 393 White, Dr. John E., 158 White Haven Sanitarium, 155 White Ribbon Remedy, 414 Wiley, Dr. H. W., 301, 428, 429 Willard, Miss Frances E., 23, 44-47 Williams, Henry Smith, 399 Pink Pills, 315 Willson, alcohol and snake-bite, 211 Winternitz, 184, 185, 225 Wolff, 176 Wollowicz, 77-79, 81 Woodhead, Dr. G. Sims, 211, 276-284, 366, 383 Woods, Dr. Matthew, 364 Wood, Dr. H. C., 119 Zwieback, 175 ERRATA Page 346, third line from bottom omitted: The use of cocaine is advancing rapidly in this [Transcriber's Note: The text was emended to include the above correction.] * * * * * TRANSCRIBER'S NOTE: Every effort has been made to replicate this text as faithfully as possible, including obsolete and variant spellings. Obvious typographical errors in punctuation (misplaced quotes and the like) have been fixed. Note that the index has _not_ been resorted alphabetically.Corrections [in brackets] in the text are noted below: page v: typo corrected Sims Woodhead on immunity--Delearde's[Deléarde's] experiments page vi: typo corrected Dr. Knox Bond on Scarlet Fever--Metchinkoff[Metchnikoff] on white blood-cells--Kassowitz describes his page vii: typo corrected to quit drinking--Dr. T. D. Crother's[Crothers'] remedy page 21: typo corrected THE WOMAN[']S CHRISTIAN TEMPERANCE UNION IN OPPOSITION TO ALCOHOL AS MEDICINE. page 48: typo corrected department of the hospital was commissoned[commissioned] to treat diseases without the use of alcoholic liquids. page 53: typo corrected treatment for seven weeks for metorrhagia[metrorrhagia], nietortes[TN: unsure what this word is] and peritonitis page 106: typo corrected who, but for its mistaken use, might have recovered from the illness affecting then[them]. page 111: typo corrected or influenced by alcoholism. If the clinical thermometor[thermometer] shows the temperature to be above page 129: typo corrected An editorial in the Journal of the Amercian[American] Medical Association said: page 158: typo corrected E. White, M. D., Medical Director Nordrach Ranch Sanatorium[Sanitorium], Colorado Springs, Colorado. page 172: typo corrected irritant of which the stomach is trying to be rid. Do not arrest it permaturely[prematurely], but assist it. page 180 is usually a symptom of trouble somewhere else, often in the alimentary canal, and[an] overloaded stomach, page 238: duplicate word removed which they soon experience in the [the] supply of milk? page 255: typo corrected Dr. A. L. Loomis, in the treatmemt[treatment] of 600 typhus fever cases on Blackwell's Island in 1864, excluded page 256: typo corrected These cases include a number of hyterectomies[hysterectomies], and many cases so desperate that those who trust in alcohol page 257: aded missing single quote be called criminal. I certainly feel that punishment would be just.[']" page 260: typo corrected there is less frequent relapse, and there is quicker recovery. In brief, the experience of treament[treatment] of rheumatic page 275: typo corrected therefore, may open the door to fever or erysipelas.' A similiar[similar] experiment of Doyen confirms this. page 301: added missing quote a habit of gaining relief which becomes an obsession and incapable of being resisted.["] page 302: added missing quote harmful only, that so many people profess to have received benefit from them?["] There are different page 313: added missing quote no fatty substances present in these products; their food value from this point of view is, therefore, _nil_."] page 314: added missing quote show any oil. Analysis revealed sugar, alcohol, and glycerine, none of which is contained in cod-liver oil.["] page 316: added missing quote ["]Hoff's Consumption Cure consists essentially of sodium cinnamate and extract of opium, a mixture at one time suggested page 319: typo corrected 5233 Philadephia[Philadelphia] Porter page 348: end of quote ambiguous questions were put replied after careful consideration as follows: '[could not find ending single quote]Its physiological action is practically unknown. page 360: typo corrected "Dr. Hirschfield[Hirschfeld], a well-known physician of Magdeburg, Germany, was recently arrested on a charge page 361: typo corrected more than upon anything else, to screen it from opprobium[opprobrium], and just punishment for the evils which the traffic entails upon page 381: added missing quote in their denunciations of the current beliefs concerning alcohol in medicine.["]--_Journal A. M. A._, January 6, 1900. page 392: typo corrected RECENT RESEARCHES UPON ALCOLOL.[ALCOHOL] page 402: typo corrected strictly analagous[analogous] to sugar and fats, provided always that the amount used does not exceed that easily oxidized page 421: added missing quote and starve. But the next time they were sick, _I wasn't the doctor_.["]--"Physician" in Our Federation_. Throughout the index, typos corrected: Berkley and Friendenwald[Friedenwald], 279 Delearde[Deléarde], Dr., Pasteur Institute, 279, 284 Fére[Fere], Dr., 203 Grehaut[Gréhant], 288 Hirschfield[Hirschfeld], Dr., 360, 380 International Congress on Alcoholism, London, 1909, 9, 393 " Encyclopædia[Encyclopedia] of Surgery, 209 Lesser, Dr. A. Monae[Monæ], success in treating fevers in Cuban War, 53 Massert[Massart] and Bordet, leucocytes, 277 Panopeptone[Panopepton], 313 Phenacetin[Phenacetine], 300, 339, 340, 346, 354 Rushy[Rusby], Dr. H. H., 429 Stamreich[Stammreich], investigations, 379 Whiskey[Whisky], 28, 50, 112, 127, 155, 157, 173, 190, 193, 196, 210, 265, 370, 390 Zweiback[Zwieback], 175 
44325	----	THE GREAT AMERICAN FRAUD By Samuel Hopkins Adams A Series of Articles on the Patent Medicine Evil, Reprinted from Collier's Weekly I-----The Great American Fraud 3 II----Peruna and the Bracers 12 III---Liquozone 23 IV----The Subtle Poisons 32 V-----Preying on the Incurables 45 VI----The Fundamental Fakes 57 ALSO THE PATENT MEDICINE CONSPIRACY AGAINST THE FREEDOM OF THE PRESS I. THE GREAT AMERICAN FRAUD. Reprinted from Collier's Weekly, Oct. 7, 1905. {003} This is the introductory article to a series which will contain a full explanation and exposure of patent-medicine methods, and the harm done to the public by this industry, founded mainly on fraud and poison. Results of the publicity given to these methods can already be seen in the steps recently taken by the National Government, some State Governments and a few of the more reputable newspapers. The object of the series is to make the situation so familiar and thoroughly understood that there will be a speedy end to the worst aspects of the evil. [IMAGE ==>] {003} Gullible America will spend this year some seventy-five millions of dollars in the purchase of patent medicines. In consideration of this sum it will swallow huge quantities of alcohol, an appalling amount of opiates and narcotics, a wide assortment of varied drugs ranging from powerful and dangerous heart depressants to insidious liver stimulants; and, far in excess of all other ingredients, undiluted fraud. For fraud, exploited by the skillfulest of advertising bunco men, is the basis of the trade. Should the newspapers, the magazines and the medical journals refuse their pages to this class of advertisements, the patent-medicine business in five years would be as scandalously historic as the South Sea Bubble, and the nation would be the richer not only in lives and money, but in drunkards and drug-fiends saved. "Don't make the mistake of lumping all proprietary medicines in one indiscriminate denunciation," came warning from all sides when this series was announced. But the honest attempt to separate the sheep from the goats develops a lamentable lack of qualified candidates for the sheepfold. External remedies there may be which are at once honest in their claims and effective for their purposes; they are not to be found among the much-advertised ointments or applications which fill the public prints. Cuticura may be a useful preparation, but in extravagance of advertising it rivals the most clamorous cure-all. Pond's Extract, one would naturally suppose, could afford to restrict itself to decent methods, but in the recent {004}epidemic scare in New York it traded on the public alarm by putting forth "display" advertisements headed, in heavy black type, "Meningitis," a disease in which witch-hazel is about as effective as molasses. This is fairly comparable to Peruna's ghoulish exploitation, for profit, of the yellow-fever scourge in New Orleans, aided by various southern newspapers of standing, which published as _news_ an "interview" with Dr. Hartman, president of the Peruna Company. Drugs That Make Victims. When one comes to the internal remedies, the proprietary medicines proper, they all belong to the tribe of Capricorn, under one of two heads, harmless frauds or deleterious drugs. For instance, the laxatives perform what they promise; if taken regularly, as thousands of people take them (and, indeed, as the advertisements urge), they become an increasingly baneful necessity. Acetanilid will undoubtedly relieve headache of certain kinds; but acetanilid, as the basis of headache powders, is prone to remove the cause of the symptoms permanently by putting a complete stop to the heart action. Invariably, when taken steadily, it produces constitutional disturbances of insidious development which result fatally if the drug be not discontinued, and often it enslaves the devotee to its use. Cocain and opium stop pain; but the narcotics are not the safest drugs to put into the hands of the ignorant, particularly when their presence is concealed in the "cough remedies," "soothing syrups," and "catarrhal powders" of which they are the basis. Few outside of the rabid temperance advocates will deny a place in medical practice to alcohol. But alcohol, fed daily and in increasing doses to women and children, makes not for health, but for drunkenness. Far better whiskey or gin unequivocally labeled than the alcohol-laden "bitters," "sarsaparillas" and "tonics" which exhilerate fatuous temperance advocates to the point of enthusiastic testimonials. None of these "cures" really does cure any serious affection, although a majority of their users recover. But a majority, and a very large majority, of the sick recover, anyway. Were it not so--were one illness out of fifty fatal--this earth would soon be depopulated. As to Testimonials. The ignorant drug-taker, returning to health from some disease which he has overcome by the natural resistant powers of his body, dips his pen in gratitude and writes his testimonial. The man who dies in spite of the patent medicine--or perhaps because of it--doesn't bear witness to what it did for him. We see recorded only the favorable results: the unfavorable lie silent. How could it be otherwise when the only avenues of publicity are controlled by the advertisers? So, while many of the printed testimonials are genuine enough, they represent not the average evidence, but the most glowing opinions which the nostrum vender can obtain, and generally they are the expression of a low order of intelligence. Read in this light, they are unconvincing enough. But the innocent public regards them as the type, not the exception. "If that cured Mrs. Smith of Oshgosh it may cure me," says the woman whose symptoms, real or imaginary, are so feelingly described under the picture. Lend ear to expert testimony from a certain prominent cure-all: "They see my advertising. They read the testimonials. They are convinced. They have faith in Peruna. It gives them a gentle stimulant and so they get well." There it is in a nutshell; the faith cure. Not the stimulant, but the faith inspired by the advertisement and encouraged by the stimulant does the work--or seems to do it. If the public drugger can convince his patron {005}that she is well, she _is_ well--for his purposes. In the case of such diseases as naturally tend to cure themselves, no greater harm is done than the parting of a fool and his money. With rheumatism, sciatica and that ilk, it means added pangs; with consumption, Bright's disease and other serious disorders, perhaps needless death. No onus of homicide is borne by the nostrum seller; probably the patient would have died anyway; there is no proof that the patent bottle was in any way responsible. Even if there were--and rare cases do occur where the responsibility can be brought home--there is no warning to others, because the newspapers are too considerate of their advertisers to publish such injurious items. The Magic "Red Clause." With a few honorable exceptions the press of the United States is at the beck and call of the patent medicines. Not only do the newspapers modify news possibly affecting these interests, but they sometimes become their active agents. F. J. Cheney, proprietor of Hall's Catarrh Cure, devised some years ago a method of making the press do his fighting against legislation compelling makers of remedies to publish their formulæ, or to print on the labels the dangerous drugs contained in the medicine--a constantly recurring bugaboo of the nostrum-dealer. This scheme he unfolded at a meeting of the Proprietary Association of America, of which he is now president. He explained that he printed in red letters on every advertising contract a clause providing that the contract should become void in the event of hostile legislation, and he boasted how he had used this as a club in a case where an Illinois legislator had, as he put it, attempted to hold him for three hundred dollars on a strike bill. "I thought I had a better plan than this," said Mr. Cheney to his associates, "so I wrote to about forty papers and merely said: 'Please look at your contract with me and take note that if this law passes you and I must stop doing business,' The next week every one of them had an article and Mr. Man had to go." So emphatically did this device recommend itself to the assemblage that many of the large firms took up the plan, and now the "red clause" is a familiar device in the trade. The reproduction printed on page 6 {p006} is a fac-simile of a contract between Mr. Cheney's firm and the Emporia _Gazette_, William Allen White's paper, which has since become one of the newspapers to abjure the patent-medicine man and all his ways. Emboldened by this easy coercion of the press, certain firms have since used the newspapers as a weapon against "price-cutting," by forcing them to refuse advertising of the stores which reduce rates on patent medicines. Tyrannical masters, these heavy purchasers of advertising space. To what length daily journalism will go at the instance of the business office was shown in the great advertising campaign of Paine's Celery Compound, some years ago. The nostrum's agent called at the office of a prominent Chicago newspaper and spread before its advertising manager a full-page advertisement, with blank spaces in the center. "We want some good, strong testimonials to fill out with," he said. "You can get all of those you want, can't you?" asked the newspaper manager. "Can _you?_" returned the other. "Show me four or five strong ones from local politicians and you get the ad." Fake Testimonials. That day reporters were assigned to secure testimonials with photographs which subsequently appeared in the full-page advertisement as promised. As for the men who permitted the use of their names for this {006}purpose, several of them afterward admitted that they had never tasted the "Compound," but that they were willing to sign the testimonials for the joy of appearing in print as "prominent citizens." Another Chicago newspaper compelled its political editor to tout for fake indorsements of a nostrum. A man with an inside knowledge of the patent-medicine business made some investigations into this phase of the matter, and he declares that such procurement of testimonials became so established as to have the force of a system, only two Chicago papers being free from it. [IMAGE ==>] {006} To-day, he adds, a similar "deal" could be made with half a dozen of that city's dailies. It is disheartening to note that in the case of one important and high-class daily, the Pittsburg _Gazette_, a trial rejection of all patent-medicine advertising received absolutely no support or encouragement from the public; so the paper reverted to its old policy. [IMAGE ==>] {007} A WINDOW EXHIBIT IN A CHICAGO DRUG STORE. {008} The control is as complete, though exercised by a class of nostrums somewhat differently exploited, but essentially the same. Only "ethical" preparations are permitted in the representative medical press, that is, articles not advertised in the lay press. Yet this distinction is not strictly adhered to. "Syrup of Figs," for instance, which makes widespread pretense in the dailies to be an extract of the fig, advertises in the medical journals for what it is, a preparation of senna. Antikamnia, an "ethical" proprietary compound, for a long time exploited itself to the profession by a campaign of ridiculous extravagance, and is to-day by the extent of its reckless _use_ on the part of ignorant laymen a public menace. Recently an article announcing a startling new drug discovery and signed by a physician was offered to a standard medical journal, which declined it on learning that the drug was a proprietary preparation. The contribution was returned to the editor with an offer of payment at advertising rates if it were printed as editorial reading matter, only to be rejected on the new basis. Subsequently it appeared simultaneously in more than twenty medical publications as reading matter. There are to-day very few medical publications which do not carry advertisements conceived in the same spirit and making much tin same exhaustive claims as the ordinary quack "ads" of the daily press, and still fewer that are free from promises to "cure" diseases which are incurable by any medicine. Thus the medical press is as strongly enmeshed by the "ethical" druggers as the lay press is by Paine, "Dr." Kilmer, Lydia Pinkham, Dr. Hartman, "Hall" of the "red clause" and the rest of the edifying band of life-savers, leaving no agency to refute the megaphone exploitation of the fraud. What opposition there is would naturally arise in the medical profession, but this is discounted by the proprietary interests. The Doctors Are Investigating. "You attack us because we cure your patients," is their charge. They assume always that the public has no grievance against them, or, rather, they calmly ignore the public in the matter. In his address at the last convention of the Proprietary Association, the retiring president, W. A. Talbot of Piso's Consumption Cure, turning his guns on the medical profession, delivered this astonishing sentiment: "No argument favoring the publication of our formulas was ever uttered which does not apply with equal force to your prescriptions. It is pardonable in you to want to know these formulas, for they are good. But you must not ask us to reveal these valuable secrets, to do what you would not do yourselves. The public and our law-makers do not want your secrets nor ours, _and it would be a damage to them to have them_." The physicians seem to have awakened, somewhat tardily, indeed, to counter-attack. The American Medical Association has organized a Council on Pharmacy and Chemistry to investigate and pass on the "ethical" preparations advertised to physicians, with a view to listing those which are found to be reputable and useful. That this is regarded as a direct assault on the proprietary interests is suggested by the protests, eloquent to the verge of frenzy in some cases, emanating from those organs which the manufacturers control. Already the council has issued some painfully frank reports on products of imposingly scientific nomenclature; and more are to follow. What One Druggist Is Doing. Largely for trade reasons a few druggists have been fighting the nostrums, but without any considerable effect. Indeed, it is surprising to see that people are so deeply impressed with the advertising claims put forth daily as to be impervious to warnings even from experts. {009} A cut-rate store, the Economical Drug Company of Chicago, started on a campaign and displayed a sign in the window reading: [IMAGE ==>] {009} PLEASE DO NOT ASK US What is ANY OLD PATENT MEDICINE Worth? For you embarrass us, as our honest answer must be that IT IS WORTHLESS If you mean to ask at what price we sell it, that is an entirely different proposition. When sick, consult a good physician. It is the only proper course. And you will find it cheaper in the end than self-medication with worthless "patent" nostrums. This was followed up by the salesmen informing all applicants for the prominent nostrums that they were wasting money. Yet with all this that store was unable to get rid of its patent-medicine trade, and to-day nostrums comprise one-third of its entire business. They comprise about two-thirds of that of the average small store. Legislation is the most obvious remedy, pending the enlightenment of the general public or the awakening of the journalistic conscience. But legislation proceeds slowly and always against opposition, which may be measured in practical terms as $250,000,000 at stake on the other side. I note in the last report of the Proprietary Association's annual meeting the significant statement that "the heaviest expenses were incurred in legislative work." Most of the legislation must be done by states, and we have seen in the case of the Hall Catarrh cure contract how readily this may be controlled. Two government agencies, at least, lend themselves to the purposes of the patent-medicine makers. The Patent Office issues to them trade-mark registration (generally speaking, the convenient term "patent medicine" is a misnomer, as very few are patented) without inquiry into the nature of the article thus safeguarded against imitation. The Post Office Department permits them the use of the mails. Except one particular line, the disgraceful "Weak Manhood" remedies, where excellent work has been done in throwing them out of the mails for fraud, the department has done nothing in the matter of patent remedies, and has no present intention of doing anything; yet I believe that such action, powerful as would be {010}the opposition developed, would be upheld by the courts on the same grounds that sustained the Post Office's position in the recent case of "Robusto." A Post-Office Report. That the advertising and circular statements circulated through the mails were materially and substantially false, with the result of cheating and defrauding those into whose hands the statements came; That, while the remedies did possess medicinal properties, these were not such as to carry out the cures promised; That the advertiser knew he was deceiving; That in the sale and distribution of his medicines the complainant made no inquiry into the specific character of the disease in any individual case, but supplied the same remedies and prescribed the same mode of treatment to all alike. Should the department apply these principles to the patent-medicine field generally, a number of conspicuous nostrums would cease to be pat-, rons of Uncle Sam's mail service. Some states have made a good start in the matter of legislation, among them Michigan, which does not, however, enforce its recent strong law. Massachusetts, which has done more, through the admirable work of its State Board of Health, than any other agency to educate the public on the patent-medicine question, is unable to get a law restricting this trade. In New Hampshire, too, the proprietary interests have proven too strong, and the Mallonee bill was destroyed by the almost united opposition of a "red-clause" press. North Dakota proved more independent. After Jan. 1, 1906, all medicines sold in that state, except on physicians' prescriptions, which contain chloral, ergot, morphin, opium, cocain, bromin, iodin or any of their compounds or derivatives, or more than 5 per cent, of alcohol, must so state on the label. When this bill became a law, the Proprietary Association of America proceeded to blight the state by resolving that its members should offer no goods for sale there. Boards of health in various parts of the country are doing valuable educational work, the North Dakota board having led in the legislation. The Massachusetts, Connecticut and North Carolina boards have been active. The New York State board has kept its hands off patent medicines, but the Board of Pharmacy has made a cautious but promising beginning by compelling all makers of powders containing cocain to put a poison label on their goods; and it proposes to extend this ruling gradually to other dangerous compositions. Health Boards and Analyses. It is somewhat surprising to find the Health Department of New York City, in many respects the foremost in the country, making no use of carefully and rather expensively acquired knowledge which would serve to protect the public. More than two years ago analyses were made by the chemists of the department which showed dangerous quantities of cocain in a number of catarrh powders. These analyses have never been printed. Even the general nature of the information has been withheld. Should any citizen of New York, going to the Health Department, have asked: "My wife is taking Birney's Catarrh Powder; is it true that it's a bad thing?" the officials, with the knowledge at hand that the drug in question is a mater of cocain fiends, would have blandly emulated the Sphinx. Outside criticism of an overworked, undermanned and generally efficient department is liable to error through ignorance of the problems involved in its administration; yet one can not but believe that some form of warning against what is wisely admittedly a public menace would have been a wiser form {011}of procedure than that which has heretofore been discovered by the formula, "policy of the department." Policies change and broaden under pressure of conditions. The Health Commissioner is now formulating a plan which, with the work of the chemists as a basis, shall check the trade in public poisons more or less concealed behind proprietary names. It is impossible, even in a series of articles, to attempt more than an exemplary treatment of the patent-medicine frauds. The most degraded and degrading, the "lost vitality" and "blood disease" cures, reeking of terrorization and blackmail, can not from their very nature be treated of in a lay journal. Many dangerous and health-destroying compounds will escape through sheer inconspicuousness. I can touch on only a few of those which may be regarded as typical: the alcohol stimulators, as represented by Peruna, Paine's Celery Compound and Duffy's Pure Malt Whiskey (advertised as an exclusively medical preparation); the catarrh powders, which breed cocain slaves, and the opium-containing soothing syrups, which stunt or kill helpless infants; the consumption cures, perhaps the most devilish of all, in that they destroy hope where hope is struggling against bitter odds for existence; the headache powders, which enslave so insidiously that the victim is ignorant of his own fate; the comparatively harmless fake as typified by that marvelous product of advertising and effrontery, Liquozone; and, finally, the system of exploitation and testimonials on which the whole vast system of bunco rests, as on a flimsy but cunningly constructed foundation. II. PERUNA AND THE BRACERS. Reprinted from Collier's Weekly, Oct. 28, 1905. {012} A distinguished public health official and medical writer once made this jocular suggestion to me: "Let us buy in large quantities the cheapest Italian vermouth, poor gin and bitters. We will mix them in the proportion of three of vermouth to two of gin, with a dash of bitters, dilute and bottle them by the short quart, label them '_Smith's Reviver ana Blood Purifier; dose, one wineglassful before each meal_'; advertise them to cure erysipelas, bunions, dyspepsia, heat rash, fever and ague, and consumption; and to prevent loss of hair, smallpox, old age, sunstroke and near-sightedness, and make our everlasting fortunes selling them to the temperance trade." "That sounds to me very much like a cocktail," said I. "So it is," he replied. "But it's just as much a medicine as Peruna and not as bad a drink." Peruna, or, as its owner, Dr. S. B. Hartman, of Columbus, Ohio (once a physician in good standing), prefers to write it, Pe-ru-na, is at present the most prominent proprietary nostrum in the country. It has taken the place once held by Greene's Nervura and by Paine's Celery Compound, and for the same reason which made them popular. The name of that reason is alcohol.* Peruna is a stimulant pure and simple, and it is the more dangerous in that it sails under the false colors of a benign purpose. * Dr. Ashbel P. Grinnell of New York City, who has made a statistical study of patent medicines, asserts as a provable fact that more alcohol is consumed in this country in patent medicines than is dispensed in a legal way by licensed liquor venders, barring the sale of ales and beer. According to an authoritative statement given out in private circulation a few years ago by its proprietors, Peruna is a compound of seven drugs with cologne spirits. This formula, they assure me, has not been materially changed. None of the seven drugs is of any great potency. Their total is less than one-half of 1 per cent, of the product. Medicinally they are too inconsiderable, in this proportion, to produce any effect. There remains to Peruna only water and cologne spirits, roughly in the proportion of three to one. Cologne spirits is the commercial term for alcohol. What Peruna Is Made Of. Any one wishing to make Peruna for home consumption may do so by mixing half a pint of cologne spirits, 190 proof, with a pint and a half of water, adding thereto a little cubebs for flavor and a little burned sugar for color. Manufactured in bulk, so a former Peruna agent estimates, its cost, including bottle and wrapper, is between fifteen and eighteen cents a bottle. Its price is $1.00. Because of this handsome margin of profit, and by way of making hay in the stolen sunshine of Peruna advertising, many imitations have sprung up to harass the proprietors of the alcohol-and-water product. Pe-ru-vi-na, P-ru-na, Purina, Anurep (an obvious inversion); these, bottled and labeled to resemble Peruna, are self-confessed imitations. From what the Peruna people tell me, I gather that they are dangerous and damnable frauds, and that they cure nothing. What does Peruna cure? Catarrh. That is the modest claim for it; nothing but catarrh. To be sure, a careful study of its literature will suggest its value as a tonic and a preventive of lassitude. But its reputation {013}rests on catarrh. What is catarrh? Whatever ails you. No matter what you've got, you will be not only enabled, but compelled, after reading Dr. Hartman's Peruna book, "The Ills of Life," to diagnose your illness as catarrh and to realize that Peruna alone will save you. Pneumonia is catarrh of the lungs; so is consumption. Dyspepsia is catarrh of the stomach. Enteritis is catarrh of the intestines. Appendicitis--surgeons, please note before operating--is catarrh of the appendix. Bright's disease is catarrh of the kidneys. Heart disease is catarrh of the heart. Canker sores are catarrh of the mouth. Measles is, perhaps, catarrh of the skin, since "a teaspoonful of Peruna thrice daily or oftener is an effectual cure" ("The Ills of Life"). Similarly, malaria, one may guess, is catarrh of the mosquito that bit you. Other diseases not specifically placed in the catarrhal class, but yielding to Peruna (in the book), are colic, mumps, convulsions, neuralgia, women's complaints and rheumatism. Yet "Peruna is not a cure-all," virtuously disclaims Dr. Hartman, and grasps at a golden opportunity by advertising his nostrum as a preventive against yellow fever! That alcohol and water, with a little coloring matter and one-half of 1 per cent, of mild drugs, will cure all or any of the ills listed above is too ridiculous to need refutation. Nor does Dr. Hartman himself personally make that claim for his product. He stated to me specifically and repeatedly that no drug or combination of drugs, with the possible exception of quinin for malaria, will cure disease. His claim is that the belief of the patient in Peruna, fostered as it is by the printed testimony, and aided by the "gentle stimulation," produces good results. It is well established that in certain classes of disease the opposite is true. A considerable proportion of tuberculosis cases show a history of the Peruna type of medicines taken in the early stages, with the result of diminishing the patient's resistant power, and much of the typhoid in the middle west is complicated by the victim's "keeping up" on this stimulus long after he should have been under a doctor's care. But it is not as a fraud on the sick alone that Peruna is baneful, but as the maker of drunkards also. "It can be used any length of time without acquiring a drug habit," declares the Peruna book, and therein, I regret to say, lies specifically and directly. The lie is ingeniously backed up by Dr. Hartman's argument that "nobody could get drunk on the prescribed doses of Peruna." Perhaps this is true, though I note three wineglassfuls in forty-five minutes as a prescription which might temporarily alter a prohibitionist's outlook on life. But what makes Peruna profitable to the maker and a curse to the community at large is the fact that the minimum dose first ceases to satisfy, then the moderate dose, and finally the maximum dose; and the unsuspecting patron, who began with it as a medicine, goes on to use it as a beverage and finally to be enslaved by it as a habit. A well-known authority on drug addictions writes me: "A number of physicians have called my attention to the use of Peruna, both preceding and following alcohol and drug addictions. Lydia Pinkham's Compound is another dangerous drug used largely by drinkers; Paine's Celery Compound also. I have in the last two years met four cases of persons who drank Peruna in large quantities to intoxication. This was given to them originally as a tonic. They were treated under my care as simple alcoholics." The Government Forbids the Sale of Peruna to Indians. Expert opinion on the non-medical side is represented in the government order to the Indian Department, reproduced on the following page, the kernel of which is this: {014} DEPARTMENT OF THE INTERIOR, OFFICE OF INDIAN AFFAIRS, Washington, D. C., _August 10, 1905._ _To Indian Agents and School Superintendents in charge of Agencies:_ The attention of the Office has been called to the fact that many licensed traders are very negligent as to the way in which their stores are kept. Some lack of order might he condoned, but it is reported that many stores are dirty even to filthiness. Such a condition of affairs need not be tolerated, and improvement in that respect must be insisted on. The Office is not so inexperienced as to suppose that traders open stores among Indians from philanthropic motive's. Nevertheless a trader has a great influence among the Indians with whom he has constant dealings and who are often dependent upon him, and there are not a few instances in which the trader has exerted this influence for the welfare of his customers as well as for his own profit. A well-kept store, tidy in appearance, where the goods, especially eatables, are handled in a cleanly way, with due regard to ordinary hygiene, and where exact business methods prevail is a civilizing influence among Indians, while disorder, slovenliness, slipshod ways, and dirt are demoralizing. You will please examine into the way in which the traders under your supervision conduct their stores, how their goods, particularly edible goods, are handled, stored, and given out, and see to it that in these respects, as well in respect of weights, prices, and account-keep-ing, the business is properly conducted. If any trader, after due notice, fails to come up to these requirements you will report him to this Office. In connection with this investigation, please give particular attention {016}to the proprietary medicines and other compounds which the traders keep in stock, with special reference to the liability of their misuse by Indians on account of the alcohol which they contain. The sale of Peruna, which is on the lists of several traders, is hereby absolutely prohibited. As a medicine, something else can be substituted; as an intoxicant, it has been found too tempting and effective. Anything of the sort under another name which is found to lead to intoxication you will please report to this Office. When a compound of that sort gets a bad name it is liable to be put on the market with some slight change of form and a new name. Jamaica ginger and flavoring extracts of vanilla, lemon, and so forth, should be kept in only small quantities and in small bottles and should not be sold to Indians, or at least only sparingly to those who it is known will use them only for legitimate purposes. Of course, you will continue to give attention to the labeling of poisonous drugs with skull and cross-bones as per Office circular of January 12, 1905. Copies of this circular letter are herewith to be furnished the traders. Yours, respectfully, C. F. LARRABEE, _Acting Commissioner._ Note, in the fifth paragraph, these sentences: "The sale of Peruna which is on the list of several traders, _is hereby absolutely prohibited._ As a medicine something else can be substituted; as an Intoxicant it has been found too tempting." Alcohol In "Medicines" And In Liquors. [IMAGE ==>] {015} These diagrams show what would be left in a bottle of patent medicine If everything was poured out except the alcohol; they also show the quantity of alcohol that would be present if the same bottle had contained whisky, champagne, claret or beer. It is apparent that a bottle of Peruna contains as much alcohol as five bottles of beer, or three bottles of claret or champagne--that is, bottles of the same size. It would take nearly nine bottles of beer to put as much alcohol into a thirsty man's system as a temperance advocate can get by drinking one bottle of Hostetter's Stomach Bitters. While the "doses" prescribed by the patent medicine manufacturers are only one to two teaspoonfuls several times a day, the opportunity to take more exists, and even small doses of alcohol, taken regularly, cause that craving which is the first step in the making of a drunkard or drag fiend. Specific evidence of what Peruna can do will be found in the following report, verified by special investigation: Pinedale, Wyo., Oct. 4.-- (Special.)--"Two men suffering from delirium tremens and one dead is the result of a Peruna intoxication which took place here a few days ago. C. E. Armstrong, of this place, and a party of three others started out on a camping trip to the Yellowstone country, taking with them several bottles of whisky and ten bottles of Peruna, which one of the members of the party was taking as a tonic. The trip lasted over a week. The whisky was exhausted and for two days the party was without liquor. At last some one suggested that they use Peruna, of which nine bottles remained. Before they stopped the whole remaining supply had been consumed and the four men were in a state of intoxication, the like of which they had never known before. Finally, one awoke with terrible cramps in his stomach and found his companions seemingly in an almost lifeless condition. Suffering terrible agony, he crawled on his hands and knees to a ranch over a mile distant, the process taking him half a day. Aid was sent to his three companions. Armstrong was dead when the rescue party arrived. The other two men, still unconscious, were brought to town in a wagon and are still in a weak and emaciated condition. Armstrong's body was almost tied in a knot and could not be straightened for burial." Here is testimony from a druggist in a Southern "no license" town: "Peruna is bought by all the druggists in this section by the gross. I have seen persons thoroughly intoxicated from taking Peruna. The common remark in this place when a drunken party is particularly obstreperous is that he is on a 'Peruna drunk,' It is a notorious fact that a great many do use Peruna to get the alcoholic effect, and they certainly do get it good and strong. Now, there are other so-called remedies used for the same purpose, namely, Gensenica, Kidney Specific, Jamaica Ginger, Hostetter's Bitters, etc." So well recognized is this use of the nostrum that a number of the Southern newspapers advertise a cure for the "Teruna habit." which is probably worse than the habit, as is usually the case with these "cures." In southern Ohio and in the mountain districts of West Virginia the "Peruna jag" is a standard form of intoxication. Two Testimonials. A testimonial-hunter in the employ of the Peruna company was referred by a Minnesota druggist to a prosperous farmer in the neighborhood. The farmer gave Peruna a most enthusiastic "send-off"; he had been using it for several months and could say, etc. Then he took the agent to his barn and showed him a heap of empty Peruna bottles. The agent counted them. There were seventy-four. The druggist added his testimonial. "That old boy has a 'still' on all the time since he discovered Peruna," said he. "He's my star customer." The druggist's testimonial was not printed. At the time when certain Chicago drug stores were fighting some of the leading patent medicines, and carrying only a small stock of them, a boy {017}called one evening at one of the downtown shops for thirty-nine bottles of Peruna. "There's the money," he said. "The old man wants to get his before it's all gone." Investigation showed that the purchaser was the night engineer of a big downtown building and that the entire working staff had "chipped in" to get a supply of their favorite stimulant. "But why should any one who wants to get drunk drink Peruna when he can get whisky?" argues the nostrum-maker. There are two reasons, one of which is that in many places the "medicine" can be obtained and the liquor can not. Maine, for instance, being a prohibition state, does a big business in patent medicines. So does Kansas. So do most of the no-license counties in the South, though a few have recently thrown out the disguised "boozes." Indiana Territory and Oklahoma, as we have seen, have done so because of Poor Lo's predilection toward curing himself of depression with these remedies, and for a time, at least, Peruna was shipped in in unlabeled boxes. United States District Attorney Mellette, of the western district of Indian Territory, writes: "Vast quantities of Peruna are shipped into this country, and I have caused a number of persons to be indicted for selling the same, and a few of them have been convicted or have entered pleas of guilty. I could give you hundreds of specific cases of 'Peruna drunk' among the Indians. It is a common beverage among them, used for the purposes of intoxication." The other reason why Peruna or some other of its class is often the agency of drunkenness instead of whisky is that the drinker of Peruna doesn't want to get drunk, at least she doesn't know that she wants to get drunk. I use the feminine pronoun advisedly, because the remedies of this class are largely supported by women. Lydia Pinkham's variety of drink depends for its popularity chiefly on its alcohol. Paine's Celery Compound relieves depression and lack of vitality on the same principle that a cocktail does, and with the same necessity for repetition. I know an estimable lady from the middle West who visited her dissipated brother in New York--dissipated from her point of view, because she was a pillar of the W. C. T. U., and he frequently took a cocktail before dinner and came back with it on his breath, whereon she would weep over him as one lost to hope. One day, in a mood of brutal exasperation, when he hadn't had his drink and was able to discern the flavor of her grief, he turned on her: "I'll tell you what's the matter with you," he said. "You're drunk--maudlin drunk!" She promptly and properly went into hysterics. The physician who attended diagnosed the case more politely, but to the same effect, and ascertained that she had consumed something like half a bottle of Kilmer's Swamp-Root that afternoon. Now, Swamp-Root is a very creditable "booze," but much weaker in alcohol than most of its class. The brother was greatly amused until he discovered, to his alarm, that his drink-abhorring sister couldn't get along without her patent medicine bottle! She was in a fair way, quite innocently, of becoming a drunkard. Another example of this "unconscious drunkenness" is recorded by the _Journal of the American Medical Association_: "A respected clergyman fell ill and the family physician was called. After examining the patient carefully the doctor asked for a private interview with the patient's adult son. "'I am sorry to tell you that your father undoubtedly is suffering from chronic alcoholism,' said the physician. "'Chronic alcoholism! Why, that's ridiculous! Father never drank a drop of liquor in his life, and we know all there is to know about his habits.' "'Well, my boy, its chronic alcoholism, nevertheless, and at this present {018}moment your father is drunk. How has his health been recently? Has he been taking any medicine?' "'Why, for some time, six months, I should say, father has often complained of feeling unusually tired. A few months ago a friend of his recommended Peruna to him, assuring him that it would build him up. Since then he has taken many bottles of it, and I am quite sure that he has taken nothing else.'" From its very name one would naturally absolve Duffy's Malt Whiskey from fraudulent pretence. But Duffy's Malt Whiskey is a fraud, for it pretends to be a medicine and to cure all kinds of lung and throat diseases. It is especially favored by temperance folk. "A dessertspoonful four to six times a day in water and a tablespoonful on going to bed" (personal prescription for consumptive), makes a fair grog allowance for an abstainer. [IMAGE ==>] {018} A SALOON WINDOW DISPLAY AT AUBURN. N. Y. This bar-room advertises Duffy's Malt Whiskey, the beverage "indorsed" by the "distinguished divines and temperance workers" pictured below, and displays it with other well-known brands of Bourbon and rye--not as a medicine, but purely as a liquor, to be served, like others, in 15-cent drinks across the bar. Medicine or Liquor? [IMAGE ==>] {019} THREE "DISTINGUISHED TEMPERANCE WORKERS" WHO ADVOCATE THE USE OF WHISKEY. Of these three "distinguished divines and temperance workers," the Rev. Dunham runs a Get-Married-Quick Matrimonial Bureau, while the "Rev." Houghton derives his income from his salary as Deputy Internal Revenue Collector, his business being to collect Uncle Sam's liquor tax. The printed portrait of Houghton is entirely Imaginary; a genuine photograph of the "temperance worker" and whiskey Indorser is shown above. The Rev. McLeod lives in Greenleaf, Mich.--a township of 893 inhabitants, in Salina County, north of Port Huron, and off the railway line. Mr. McLeod was called to trial by his presbytery for Indorsing Duffy's whiskey and was allowed to "resign" from the fellowship. {020}It has testimonials ranging from consumption to malaria, and indorsements of the clergy. On the opposite page we reproduce a Duffy advertisement showing the "portraits" of three "clergymen" who consider Duffy's Pure Malt Whiskey a gift of God, and on page 18 [IMAGE ==>] {018}a saloon-window display of this product. For the whisky has its recognized place behind the bar, being sold by the manufacturers to the wholesale liquor trade and by them to the saloons, where it may be purchased over the counter for 85 cents a quart. This is cheap, but Duffy's Pure Malt Whiskey, is not regarded as a high-class article. [IMAGE ==>] {020} REV. W. N. DUNHAM. Born in Vermont eighty-two years ago, Mr. Dunham was graduated from the Boston Medical College and practiced medicine until about thirty years ago, when he moved west. There he became a preacher. He occupied the pulpit of the South Cheyenne, Wyoming, Congregational Church for ten years. Two years ago he retired from the pulpit and established a marriage bureau for the accommodation of couples who come over from Colorado to be married. No money was paid by the Duffy's Malt Whiskey people for Dunham's testimonial; but he received about $10 "to have his picture taken." "REV." M. N. HOUGHTON. This Is the actual likeness of the "distinguished divine" with the side whiskers in the Duffy whiskey advertisement. Mr. Houghton was for a number of years pastor of the Church of Eternal Hope, of Bradford, Pa. He retired six years ago to enter politics, and is now a deputy Internal Revenue collector. Although a member of the Universalist Church, Mr. Houghton is a spiritualist and delivered orations last summer at the Lily Dale assembly, the spiritualistic "City of Light" located near Dunkirk, N. Y. Mr. Houghton owned racehorses and was a patron of the turf. Its status has been definitely settled in New York State, where Excise Commissioner Cullinane recently obtained a decision in the supreme court declaring it a liquor. The trial was in Rochester, where the nostrum is made. Eleven supposedly reputable physicians, four of them members of the Health Department, swore to their belief that the whisky contained drugs which constituted it a genuine medicine. The state was able to show conclusively that if remedial drugs were present they were in such small {021}quantities as to be indistinguishable, and, of course, utterly without value; in short, that the product was nothing more or less than sweetened whisky. Yet the United States government has long lent its sanction to the "medicine" status by exempting Duffy's Pure Malt Whiskey from the federal liquor tax. In fact, the government is primarily responsible for the formal establishment of the product as a medicine, having forced it into the patent medicine ranks at the time when the Spanish war expenses were partly raised by a special tax on nostrums. Up to that time the Duffy product, while asserting its virtues in various ills, made no direct pretence to be anything but a whisky. Transfer to the patent medicine list cost it, in war taxes, more than $40,000. By way of setting a _quid pro quo_, the company began ingeniously and with some justification to exploit its liquor as "the only whisky recognised by the government as medicine," and continues so to advertise, although the recent decision of the Internal Revenue Department, providing that all patent medicines which have no medicinal properties other than the alcohol in them must pay a rectifier's tax, relegates it to its proper place. While this decision is not a severe financial blow to the Duffys and their congeners (it means only a few hundred dollars apiece), it is important as officially establishing the "bracer" class on the same footing with whisky and gin, where they belong. Other "drugs" there are which sell largely, perhaps chiefly, over the oar, Hostetter's Bitters and Damiana Bitters being prominent in this class. When this series of articles was first projected, _Collier's_ received a warning from "Warner's Safe Cure," advising that a thorough investigation would be wise before "making any attack" on that preparation. I have no intention of "attacking" this company or any one else, and they would have escaped notice altogether, because of their present unimportance, but for their letter. The suggested investigation was not so thorough as to go deeply into the nature of the remedy, which is an alcoholic liquid, but it developed this interesting fact; Warner's Safe Cure, together with all the Warner remedies, is leased, managed and controlled by the New York and Kentucky Distilling Company, manufacturers of standard whiskies which do not pretend to remedy anything but thirst. Duffy's Malt Whiskey is an another subsidiary company of the New York and Kentucky concern. This statement is respectfully submitted to temperance users of the Malt Whiskey and the Warner remedies. Some Alcohol Percentages. Hostetter's Bitters contain, according to an official state analysis, 44 per cent, of alcohol; Lydia Pinkham appeals to suffering womanhood with 20 per cent, of alcohol; Hood's Sarsaparilla cures "that tired feeling" with 18 per cent.; Burdock's Blood Bitters, with 25 per cent.; Ayer's Sarsaparilla, with 26 per cent., and Paine's Celery Compound, with 21 per cent. The fact is that any of these remedies could be interchanged with Peruna or with each other, so far as general effect goes, though the iodid of potassium in the sarsaparilla class might have some effect (as likely to be harmful as helpful ) which would be lacking in the simpler mixtures. If this class of nostrum is so harmful, asks the attentive reader of newspaper advertising columns, how explain the indorsements of so many people of prominence and reputation? "Men of prominence and reputation" in this connection means Peruna, for Peruna has made a specialty of high government officials and people in the public eye. In a self-gratulatory dissertation the Peruna Company observes in substance that, while the leading minds of the nation have hitherto shrunk from the publicity attendant on commending any patent medicine, the transcendent virtues of Peruna have overcome this amiable modesty, and, one and all, they stand forth its avowed champions. This is followed by an ingenious document headed {022}"Fifty Members of Congress Send Letters of Indorsement to the Inventor of the Great Catarrh Remedy, Pe-ru-na," and quoting thirty-six of the letters. Analysis of these letters brings out the singular circumstance that in twenty-one of the thirty-six there is no indication that the writer has ever tasted the remedy which he so warmly praises. As a sample, and for the benefit of lovers of ingenious literature, I reprint the following from a humorous member of Congress: "My secretary has as bad a case of catarrh as I ever saw, and since he has taken one bottle of Peruna he seems like a different man. "Taylorsville, N. C. Romulus Z. Linney." The famous letter of Admiral Schley is a case in point. He wrote to the Peruna Company: "I can cheerfully say that Mrs. Schley has used Peruna, and, I believe, with good effect. [Signed] W. S. Schley." This indorsement went the rounds of the country in half-page blazonry, to the consternation of the family's friends. Admiral Schley seems to have appreciated that this use of his name was detrimental to his standing. He wrote to a Columbus religious journal the following letter: "1820 I Street, Washington, D. C., Nov. 10,1904. "_Editor Catholic Columbian_:--The advertisement of the Peruna Company, inclosed, is made without any authority or approval from me. When it was brought to my attention first I wrote the company a letter, stating that the advertisement was offensive and must be discontinued. Their representative here called on me and stated he had been directed to assure me no further publication would be allowed, as it was without my sanction. "I would say that the advertisement has been made without my knowledge or consent and is an infringement of my rights as a citizen. "If you will kindly inform me what the name and date of the paper was in which the inclosed advertisement appeared I shall feel obliged. "Very truly yours, W. S. Schley." Careful study of this document will show that this is no explicit denial of the testimonial. But who gives careful study to such a letter? On the face of it, it puts the Peruna people in the position of having forged their advertisement. Ninety-nine people out of a hundred would get that impression. Yet I have seen the testimonial, signed with Admiral Schley's name and interlined in the same handwriting as the signature, and I have seen another letter, similarly signed, stating that Admiral Schley had not understood that the letter was to be used for such advertising as the recipient based on it. If these letters are forgeries the victim has his recourse in the law. They are on file at Columbus, Ohio, and the Peruna Company would doubtless produce them in defense of a suit. What the Government Can Do. One thing that the public has a right to demand in its attitude toward the proprietary medicines containing alcohol: that the government carry out rigidly its promised policy no longer to permit liquors to disguise themselves as patent medicines, and thereby escape the tax which is put on other (and probably better) brands of intoxicants. One other demand it should make on the purveyors of the concoctions: that they label every bottle with the percentage of alcohol it contains; that they label every man who writes testimonials to Duffy, and the W. C. T. U. member who indorses Peruna, Lydia Pinkham, Warner and their compeers, will know when they imbibe their "tonics," "invigorators," "swamp roots," "bitters," "nerve-builders" or "spring medicines" that they are sipping by the tablespoon or wineglassful what the town tippler takes across the license-paying bar. III.--LIQUOZONE. Reprinted from Collier's Weekly, Nov. 18, 1905. {023} Twenty years ago the microbe was making a great stir in the land. The public mind, ever prone to exaggerate the importance and extent of any new scientific discovery, ascribed all known diseases to microbes. The infinitesimal creature with the mysterious and unpleasant attributes became the leading topic of the time. Shrewdly appreciating this golden opportunity, a quack genius named Radam invented a drug to slay the new enemy of mankind and gave it his name. Radam's Microbe Killer filled the public prints with blazonry of its lethal virtues. As it consisted of a mixture of muriatic and sulphuric acids with red wine, any microbe which took it was like to fare hard; but the ingenious Mr. Radam's method of administering it to its intended prey via the human stomach failed to commend itself to science, though enormously successful in a financial sense through flamboyant advertising. Liquozone "Cures" Thirty-seven Varieties. In time some predaceous bacillus, having eluded the "killer," carried off its inventor. His nostrum soon languished. To-day it is little heard of, but from the ashes of its glories has risen a mightier successor, Liquozone. Where twenty years ago the microbe reveled in publicity, to-day we talk of germs and bacteria; consequently Liquozone exploits itself as a germicide and bactericide. It dispenses with the red wine of the Radam concoction and relies on a weak solution of sulphuric and sulphurous acids, with an occasional trace of hydrochloric or hydrobromic acid. Mostly it is water, and this is what it "cures": "Asthma, Gallstones, Abscess--Anemia, Goiter--Gout; Bronchitis, Hay Fever--Influenza, Blood Poison, La Grippe, Bowel Troubles, Leucorrhea, Coughs--Colds, Malaria--Neuralgia, Consumption, Piles--Quinsy, Contagious Diseases, Rheumatism, Cancer--Catarrh, Scrofula, Dysentery--Diarrhea, Skin Diseases, Dyspepsia--Dandruff, Tuberculosis, Eczema--Erysipelas, Tumors--Ulcers, Fevers, Throat Troubles --all diseases that begin with fever--all inflammations--all catarrh--all contagious diseases--all the results of impure or poisoned blood. In nervous diseases Liquozone acts as a vitalizer, accomplishing what no drugs can do." These diseases it conquers by destroying, in the human body, the germs which cause (or are alleged to cause) them. Such is Liquozone's claim. Yet the Liquozone Company is not a patent medicine concern. We have their own word for it: "We wish to state at the start that we are not patent medicine men, and their methods will not be employed by us.... Liquozone is too important a product for quackery." The head and center of this non-patent medicine cure-all is Douglas Smith. {024}Mr. Smith is by profession a promoter. He is credited with a keen vision for profits. Several years ago he ran on a worthy ex-piano dealer, a Canadian by the name of Powley (we shall meet him again, trailing clouds of glory in a splendid metamorphosis), who was selling with some success a mixture known as Powley's Liquefied Ozone. This was guaranteed to kill any disease germ known to science. Mr. Smith examined into the possibilities of the product, bought out Powley, moved the business to Chicago and organized it as the Liquid Ozone Company. Liquid air was then much in the public prints. Mr. Smith, with the intuition of genius, and something more than genius' contempt for limitations, proceeded to catch the public eye with this frank assertion: "Liquozone is liquid oxygen--that is all." It is enough. That is, it would be enough if it were but true. Liquid oxygen doesn't exist above a temperature of 229 degrees below zero. One spoonful would freeze a man's tongue, teeth and throat to equal solidity before he ever had time to swallow. If he could, by any miracle, manage to get it down, the undertaker would have to put him on the stove to thaw him out sufficiently for a respectable burial. Unquestionably Liquozone, if it were liquid oxygen, would kill germs, but that wouldn't do the owner of the germs much good because he'd be dead before they had time to realize that the temperature was falling. That it would cost a good many dollars an ounce to make is, perhaps, beside the question. The object of the company was not to make money, but to succor the sick and suffering. They say so themselves in their advertising. For some reason, however, the business did not prosper as its new owner had expected. A wider appeal to the sick and suffering was needed. Claude C. Hopkins, formerly advertising manager for Dr. Shoop's Restorative (also a cure-all) and perhaps the ablest exponent of his specialty in the country, was brought into the concern and a record-breaking campaign was planned. This cost no little money, but the event proved it a good investment. President Smith's next move showed him to be the master of a silver tongue, for he persuaded the members of a very prominent law firm who were acting as the company's attorneys to take stock in the concern, and two of them to become directors. These gentlemen represent, in Chicago, something more than the high professional standing of their firm; they are prominent socially and forward in civic activities; in short, just the sort of people needed by President Smith to bulwark his dubious enterprise with assured respectability. The Men Who Back the Fake. In the Equitable scandal there has been plenty of evidence to show that directors often lend their names to enterprises of which they know practically nothing. This seems to have been the case with the lawyers. One point they brought up: was Liquozone harmful? Positively not, Douglas Smith assured them. On the contrary, it was the greatest boon to the sick in the world's history, and he produced an impressive bulk of testimonials. This apparently satisfied them; they did not investigate the testimonials, but accepted them at their face value. They did not look into the advertising methods of the company; as nearly as I can find out, they never saw an advertisement of Liquozone in the papers until long afterward. They just became stockholders and directors, that is all. They did as hundreds of other upright and well-meaning men had done in lending themselves to a business of which they knew practically nothing. While the lawyers continued to practice law, Messrs. Smith and Hopkins were running the Liquozone Company. An enormous advertising campaign was begun. Pamphlets were issued containing testimonials and claiming {025}the soundest of professional backing. Indeed, this matter of expert testimony, chemical, medical and bacteriologic, is a specialty of Liquozone. Today, despite its reforms, it is supported by an ingenious system of pseudoscientific charlatanry. In justice to Mr. Hopkins it is but fair to say that he is not responsible for the basic fraud; that the general scheme was devised, and most of the bogus or distorted medical letters arranged, before his advent. But when I came to investigate the product a few months ago I found that the principal defense against attacks consisted of scientific statements which would not bear analysis and medical letters not worth the paper they were written on. In the first place, the Liquozone people have letters from chemists asseverating that the compound is chemically scientific. Faked and Garbled Indorsements. [IMAGE ==>] {025} ANALYSIS OF LIQUOZONE. SULPHURIC ACID -- About nine-tenths of one per cent. SULPHUROUS ACID -- About three-tenths of one per cent WATER....... -- Nearly ninety-nine per cent. Sulphuric acid is oil of vitriol. Sulphurous acid is also a corrosive poison. Liquozone is the combination of these two heavily diluted. Messrs. Dickman, Mackenzie & Potter, of Chicago, furnish a statement to the effect that the product is "made up on scientific principles, contains no substance deleterious to health and is an antiseptic and germicide of the highest order." As chemists the Dickman firm stands high, but if sulphuric and sulphurous acids are not deleterious to their health there must be something peculiar about them as human beings. Mr. Deavitt of Chicago makes affidavit that the preparation is not made by compounding drugs. A St. Louis bacteriologist testifies that it will kill germs (in culture tubes), and that it has apparently brought favorable results in diarrhea, rheumatism and a finger which a guinea-pig had gnawed. These and other technical indorsements are set forth with great pomp and circumstance, but when analyzed they fail to bear out the claims of Liquozone as a medicine. Any past investigation into the nature of Liquozone has brought a flood of "indorsements" down on the investigator, many of them medical. My inquiries have been largely along medical lines, because the makers of the drug claim the private support of many physicians and medical institutions, and such testimony is the most convincing. "Liquozone has the indorsement of an overwhelming number of medical authorities," says one of the pamphlets. One of the inclosures sent to me was a letter from a young physician on the staff of the Michael Reese Hospital, Chicago, who was paid $25 to make bacteriologic tests in pure cultures. He reported: "This is to certify that the fluid Liquozone handed to me for bacteriologic examination has shown bacteriologic and germicidal properties." At the same time he {026}informed the Liquozone agent that the mixture would be worthless medicinally. He writes me as follows: "I have never used or indorsed Liquozone; furthermore, its action would be harmful when taken internally. Can report a case of gastric ulcer due probably to its use." Later in my investigations I came on this certificate again. It was quoted, in a report on Liquozone, made by the head of a prominent Chicago laboratory for a medical journal, and it was designated "Report made by the Michael Reese Hospital," without comment or investigation. This surprising garbling of the facts may have been due to carelessness, or it may have some connection with the fact that the laboratory investigation was about that time employed to do work for Mr. Douglas Smith, Liquozone's president. Another document is an enthusiastic "puff" of Liquozone, quoted as being contributed by Dr. W. H. Myers in _The New York Journal of Health_. There is not nor ever has been any such magazine as _The New York Journal of Health_. Dr. W. H. Myers, or some person masquerading under that name, got out a bogus "dummy" (for publication only, and not as guarantee of good faith) at a small charge to the Liquozone people. For convenience I list several letters quoted or sent to me, with the result of investigations. The Suffolk Hospital and Dispensary of Boston, through its president, Albert C. Smith, writes: "Our test shows it (Liquozone) to possess great remedial value." The letter I have found to be genuine. But the hospital _medical_ authorities say that they know nothing of Liquozone and never prescribe it. If President Smith is prescribing it he is liable to arrest, as he is not an M.D. A favoring letter from "Dr." Fred W. Porter of Tampa, Fla., is quoted. The Liquozone recipients of the letter forgot to mention that "Dr." Porter is not an M.D., but a veterinary surgeon, as is shown by his letter head. Dr. George E. Bliss of Maple Rapids, Mich., has used Liquozone for cancer patients. Dr. Bliss writes me, under the flaming headline of his "cancer cure," that his letter is genuine and "not solicitated." Dr. A. A. Bell of Madison, Ga., is quoted as saying: "I found Liquozone to invigorate digestion." He is _not_ quoted (although he wrote it) as saying that his own personal experience with it had shown it to be ineffective. I have seen the original letter, and the unfavorable part of it was blue-penciled. For a local indorsement of any medicine perhaps as strong a name as could be secured in Chicago is that of Dr. Frank Billings. In the offices of _Collier's_ and elsewhere Dr. Billings has been cited by the Liquozone people as one of those medical men who were prevented only by ethical considerations from publicly indorsing their nostrum, but who, nevertheless, privately avowed confidence in it. Here is what Dr. Billings has to say of this: Chicago, Ill., July 31, 1905. _To the Editor of Collier's Weekly._ _Dear Sir_:--I have never recommended Liquozone in any way to any one, nor have I expressed to any representative of the Liquozone Company, or to any other person, an opinion favorable to Liquozone. (Signed) Frank Billings, M.D. Under the heading, "Some Chicago Institutions which Constantly Employ Liquozone," are cited Hull House, the Chicago Orphan Asylum, the Home for Incurables, the Evanston Hospital and the Old People's Home. Letters to the institutions elicited the information that Hull House {027}had never used the nostrum, and had protested against the statement; that the Orphan Asylum had experimented with it only for external applications, and with such dubious results that it was soon dropped; that it had been shut out of the Home for Incurables; that a few private patients in the Old People's Home had purchased it, but on no recommendation from the physicians; and that the Evanston Hospital knew nothing of Liquozone and had never used it. Having a professional interest in the "overwhelming number of medical indorsements" claimed by Liquozone, a Chicago physician, Dr. W. H. Felton, went to the company's offices and asked to see the medical evidence. None was forthcoming; the lists, he was informed, were in the press and could not be shown. He then asked for the official book for physicians advertised by the firm, containing "a great deal of evidence from authorities whom all physicians respect." This also, they said, was "in the press." As a matter of fact, it has never come out of the press and never will; the special book project has been dropped. One more claim and I am done with the "scientific evidence." In a pamphlet issued by the company and since withdrawn occurs this sprightly sketch: "Liquozone is the discovery of Professor Pauli, the great German chemist, who worked for twenty years to learn how to liquefy oxygen. When Pauli first mentioned his purpose men laughed at him. The idea of liquefying gas--of circulating a liquid oxygen in the blood--seemed impossible. But Pauli was one of those men who set their whole hearts on a problem and follow it out either to success or to the grave. So Pauli followed out this problem though it took twenty years. He clung to it through discouragements which would have led any lesser man to abandon it. He worked on it despite poverty and ridicule," etc. Liquozone Kills a Great German Scientist. Alas for romance! The scathing blight of the legal mind descended on this touching story. The lawyer-directors would have none of "Professor Pauli, the great German chemist," and Liquozone destroyed him, as it had created him. Not totally destroyed, however, for from those rainbow wrappings, now dissipated, emerges the humble but genuine figure of our old acquaintance, Mr. Powley, the ex-piano man of Toronto. He is the prototype of the Teutonic savant. So much the Liquozone people now admit, with the defence that the change of Powley to Pauli was, at most, a harmless flight of fancy, "so long as we were not attempting to use a name famous in medicine or bacteriology in order to add prestige to the product." A plea which commends itself by its ingeniousness at least. Gone is "Professor Pauli," and with him much of his kingdom lies. In fact, I believe there is no single definite intentional misstatement in the new Liquozone propaganda. For some months there has been a cessation of all advertising, and an overhauling of materials under the censorship of the lawyer-directors, who were suddenly aroused to the real situation by a storm of protest and criticism, and, rather late in the day, began to "sit up and take notice." The company has recently sent me a copy of the new booklet on which all their future advertising is to be based. The most important of their fundamental misstatements to go by the board is "Liquozone is liquid oxygen." "Liquozone contains no free oxygen," declares the revision frankly. No testimonials are to be printed. The faked and garbled letters are to be dropped from the files. There is no claim of "overwhelming medical indorsement." Nor is the statement {028}anywhere made that Liquozone will cure any of the diseases in which it is recommended. Yet such is the ingenuity with which the advertising manager has presented his case that the new newspaper exploitation appeals to the same hopes and fears, with the same implied promises, as the old. "I'm well because of Liquozone," in huge type, is followed by the list of diseases "where it applies." And the new list is more comprehensive than the old. All Ills Look Alike to Liquozone. [IMAGE ==>] {028} Just as to Peruna all ills are catarrh, so to Liquozone every disease is a germ disease. Every statement in the new prospectus of cure "has been submitted to competent authorities, and is exactly true and correct.," declares the recently issued pamphlet, "Liquozone, and Tonic Germicide"; and the pamphlet goes on to ascribe, among other ills, asthma, gout, neuralgia, dyspepsia, goiter and "most forms of kidney, liver and heart troubles" to germs. I don't know just which of the eminent authorities who have been working for the Liquozone Company fathers this remarkable and epoch-making discovery. {029} Unfortunately, the writer of the Liquozone pamphlet, and the experts who edited it, got a little mixed on their germs in the matter of malaria. "Liquozone is deadly to vegetable natter, but helpful to animals," declares the pamphlet.... "Germs are vegetables"--and that is the reason that Liquozone kills them. But malaria, which Liquozone is supposed to cure, is positively known to be due to animal organisms in the blood, not vegetable. Therefore, if the claims are genuine, liquozone, being "helpful to animals," will aid and abet the malaria organism in his nefarious work, and the Liquozone Company, as well-intentioned men, working in the interests of health, ought to warn all sufferers of this class from use of their animal-stimulator. The old claim is repeated that nothing enters into the production of Liquozone but gases, water and a little harmless coloring matter, and that the process requires large apparatus and from eight to fourteen days' time. I have seen the apparatus, consisting of huge wooden vats, and can testify to their impressive size. And I have the assurance of several gentlemen whose word (except in print) I am willing to take, that fourteen days' time is employed in impregnating every output of liquid with gas. The result, so far as can be determined chemically or medicinally, is precisely the same as could be achieved in fourteen seconds by mixing the acids with the water. The product is still sulphurous and sulphuric acid heavily diluted, that is all. Will the compound destroy germs in the human body? This is, after all, the one overwhelmingly important point for determination; for if it will, all the petty fakers and forgery, the liquid oxygen and Professor Pauli and the mythical medical journalism may be forgiven. For more than four months now _Collier's_ has been patiently awaiting some proof of the internal germicidal qualities of Liquozone None has been forthcoming except specious generalities from scientific employés of the company--and testimonials. The value of testimonials as evidence is considered in a later article. Liquozone's are not more convincing than others. Of the chemists and bacteriologists employed by the Liquozone Company there is not one who will risk his professional reputation on the simple and essential statement that Liquozone taken internally kills germs in the human system. One experiment has been made by Mr. Schoen of Chicago, which I am asked to regard as indicating in some degree a deterrent action of Liquozone on the disease of anthrax. Of two guinea-pigs inoculated with anthrax, one which was dosed with Liquozone survived the other, not thus treated, by several hours. Bacteriologists employed by us to make a similar test failed, because of the surprising fact that the dose as prescribed by Mr. Schoen promptly killed the first guinea-pig to which it was administered. A series of guinea-pig tests was then arranged (the guinea-pig is the animal which responds to germ infection most nearly as the human organism responds), at which Dr. Gradwohl, representing the Liquozone Company, was present, and in which he took part. The report follows: {030} LEDERLE LABORATORIES. Sanitary, Chemical and Bacteriologic Investigations. 518 FIFTH AVENUE, NEW YORK CITY. October 21, 1905, Anthrax Test. Twenty-four guinea-pigs were inoculated with anthrax bacilli, under the same conditions, the same amount being given to each. The representative of the Liquozone people selected the twelve pigs for treatment. These animals were given Liquozone is 5 c.c. doses for three hours. In twenty-four hours all pigs were dead--the treated and the untreated ones. Second Anthrax Test. Eight guinea-pigs were Inoculated under the same conditions with a culture of anthrax sent by the Liquozone people. Four of these animals were treated for three hours with Liquozone as in the last experiment. These died also in from thirty-six to forty-eight hours, as did the remaining four. Diphtheria Test. Six guinea-pigs were inoculated with diphtheria bacilli and treated with Liquozone. They all died in from forty-eight to seventy-two hours. Two out of three controls (i. e., untreated guinea-pigs) remained alive after receiving the same amount of culture. Tuberculosis Test. Eight guinea-pigs were inoculated with tubercle bacilli. Four of these animals were treated for eight hours with 5 c.c. of a 20 per cent, solution of Liquozole. Four received no Liquozone. At the end of twenty-four days all the animals were killed. Fairly developed tuberculosis was present in all. To summarize, we would say that the Liquozone had absolutely no curative effect, but did, when given in pure form, lower the resistance of the animals, so that they died a little earlier than those not treated. Lederle Laboratories. By Ernst J. Lederle. Dr. Gradwohl, representing the Liquozone Company, stated that he was satisfied of the fairness of the tests. He further declared that in his opinion the tests had proved satisfactorily the total ineffectiveness of Liquozone as an internal germicide. But these experiments show more than that. They show that in so far as Liquozone has any effect, it tends to lower the resistance of the body to an invading disease. That is, in the very germ diseases for which it is advocated, _Liquozone may decrease the chances of the patient's recovery with every dose that is swallowed, but certainly would not increase them_. In its own field Liquozone is _sui generis_. On the ethical side, however, there are a few "internal germicides," and one of these comes in for mention here, not that it is in the least like Liquozone in its composition, but because by its monstrous claims it challenges comparison. Since the announcement of this article, and before, _Collier's_ has been in receipt of much virtuous indignation from a manufacturer of remedies which, he claims, Liquozone copies. Charles Marchand has been the most active enemy of the Douglas Smith product. He has attacked the makers in print, organized a society, and established a publication mainly devoted to their destruction, and circulated far and wide injurious literature (most of it true) about their product. Of the relative merits of Hydrozone, Glycozone (Marchand's products); and Liquozone, I know nothing; but I know that the Liquozone Company has never in its history put forth so shameful an advertisement as the one reproduced on page 28, [IMAGE ==>] {028} signed by Marchand, and printed in the New Orleans _States_ when the yellow-fever scare was at its height. {031} And Hydrozone is an "ethical" remedy; its advertisements are to be found in reputable medical journals. The Same Old Fake. Partly by reason of Marchand's energy, no nostrum in the country has been so widely attacked as the Chicago product. Occasional deaths, attributed (in some cases unjustly) to its use, have been made the most of, and scores of analyses have been printed, so that in all parts of the country the true nature of the nostrum is beginning to be understood. The prominence of its advertising and the reckless breadth of its claims have made it a shining mark. North Dakota has forbidden its sale. San Francisco has decreed against it; so has Lexington, Ky., and there are signs that it will have a fight tor its life soon in other cities. It is this looming danger that impelled Liquozone to an attempted reform last summer. Yet, in spite of the censorship of its legal lights, in spite of the revision of its literature by its scientific experts, in spite of its ingenious avoidance of specifically false claims in the advertising which is being scattered broadcast to-day, Liquozone is now what it was before its rehabilitation, a fraud which owes its continued existence to the laxity of our public health methods and the cynical tolerance of the national conscience. IV--THE SUBTLE POISONS. Reprinted from Collier's Weekly, Dec. 2, 1006. {032} Ignorance and credulous hope make the market for most proprietary remedies. Intelligent people are not given largely to the use of the glaringly advertised cure-alls, such as Liquozone or Peruna. Nostrums there are, however, which reach the thinking classes as well as the readily gulled. Depending, as they do, for their success on the lure of some subtle drug concealed under a trademark name, or some opiate not readily obtainable under its own label, these are the most dangerous of all quack medicines, not only in their immediate effect, but because they create enslaving appetites, sometimes obscure and difficult of treatment, most often tragically obvious. Of these concealed drugs the headache powders are the most widely used, and of the headache powders Orangeine is the most conspicuous. Orangeine prints its formula. It is, therefore, its proprietors claim, not a secret remedy. But to all intents and purposes it is secret, because to the uninformed public the vitally important word "acetanilid" in the formula means little or nothing. Worse than its secrecy is its policy of careful and dangerous deception. Orangeine, like practically all the headache powders, is simply a mixture of acetanilid with less potent drugs. Of course, there is no orange in it, except the orange hue of the boxes and wrappers which is its advertising symbol. But this is an unimportant deception. The wickedness of the fraud lies in this: that whereas the nostrum, by virtue of its acetanilid content, thins the blood, depresses the heart and finally undermines the whole system, it claims _to strengthen the heart and to produce better blood_. Thus far in the patent medicine field I have not encountered so direct and specific an inversion of the true facts. Recent years have added to the mortality records of our cities a surprising and alarming number of sudden deaths from heart failure. In the year 1902 New York City alone reported a death rate from this cause of 1.34 per thousand of population; that is about six times as great as the typhoid fever death record. It was about that time that the headache powders were being widely advertised, and there is every reason to believe that the increased mortality, which is still in evidence, is due largely to the secret weakening of the heart by acetanilid. Occasionally a death occurs so definitely traceable to this poison that there is no room for doubt, as in the following report by Dr. J. L. Miller, of Chicago, in the _Journal of the American Medical Association_, on the death of Mrs. Frances Robson: "I was first called to see the patient, a young lady, physically sound, who had been taking Orangeine powders for a number of weeks for insomnia. The rest of the family noticed that she was very blue, and for this reason I was called. When I saw the patient she complained of a sense of faintness and inability to keep warm. At this time she had taken a box of six Orangeine powders within about eight hours. She was warned of the danger of continuing the indiscriminate use of the remedy, but insisted that many of her friends had used it and claimed that it was harmless. The family promised to see that she did not obtain any more of the remedy. Three days later, however, I was called to the house and found the patient dead. The family said that she had gone to her room the evening before in her usual health. The next morning, the patient not appearing, they investigated and found her dead. The case was reported to the coroner, and the coroner's verdict was: 'Death was from the effect of an overdose of Orangeine {033}powders administered by her own hand, whether accidentally or otherwise, unknown to the jury.'" Last July an 18-year-old Philadelphia girl got a box of Orangeine powders at a drug store, having been told that they would cure headache. There was nothing on the label or in the printed matter inclosed with the preparation warning her of the dangerous character of the nostrum. Following the printed advice, she took two powders. In three hours she was dead. Coroner Dugan's verdict follows: "Mary A. Bispels came to her death from kidney and heart disease, aggravated by poisoning by acetanilid taken in Orangeine headache powders." Prescribing Without Authority. Yet this poison is being recommended every day by people who know nothing of it and nothing of the susceptibility of the friends to whom they advocate it. For example, here is a testimonial from the Orangeine booklet: "Miss A. A. Phillips, 60 Powers street, Brooklyn, writes: 'I always keep Orangeine in my desk at school, and through its frequent applications to the sick I am called both "doctor and magician."'" If the school herein referred to is a public school, the matter is one for the Board of Education; if a private school, for the Health Department or the county medical society. That a school teacher should be allowed to continue giving, however well meaning her foolhardiness may be, a harmful and possibly fatal dose to the children intrusted to her care seems rather a significant commentary on the quality of watchfulness in certain institutions. Obscurity as to the real nature of the drug, fostered by careful deception, is the safeguard of the acetanilid vender. Were its perilous quality known, the headache powder would hardly be so widely used. And were the even more important fact that the use of these powders becomes a habit, akin to the opium or cocain habits, understood by the public, the repeated sales which are the basis of Orangeine's prosperity would undoubtedly be greatly cut down. Orangeine fulfills the prime requisite of a patent medicine in being a good "repeater." Did it not foster its own demand in the form of a persistent craving, it would hardly be profitable. Its advertising invites to the formation of an addiction to the drug. "Get the habit," it might logically advertise, in imitation of a certain prominent exploitation along legitimate lines. Not only is its value as a cure for nervousness and headaches insisted on, but its prospective dupes are advised to take this powerful drug as a _bracer_. "When, as often, you reach home tired in body and mind... take an Orangeine powder, lie down for thirty minutes' nap--if possible--anyway, relax, then take another." "To induce sleep, take an Orangeine powder immediately before retiring. When wakeful, an Orangeine powder will have a normalizing, quieting effect." It is also recommended as a good thing to begin the day's work on in the morning--that is, take Orangeine night, morning and between meals! These powders pretend to cure asthma, biliousness, headaches, colds, catarrh and grip (dose: powder every four hours during the day for a week!--a pretty fair start on the Orangeine habit), diarrhea, hay fever, insomnia, influenza, neuralgia, seasickness and sciatica. Of course, they do not cure any of these; they do practically nothing but give temporary relief by depressing the heart. With the return to normal conditions of blood circulation comes a recurrence of the nervousness, {034}headache, or what not, and the incentive to more of the drug, until it becomes a necessity. In my own acquaintance I know half a dozen persons who have come to depend on one or another of these headache preparations to keep them going. One young woman whom I have in mind told me quite innocently that she had been taking five or six Orangeine powders a day for several months, having changed from Koehler's powders when some one told her that the latter were dangerous! Because of her growing paleness her husband had called in their physician, but neither of them had mentioned the little matter of the nostrum, having accepted with a childlike faith the asseverations of its beneficent qualities. Yet they were of an order of intelligence that would scoff at the idea of drinking Swamp-Root. [IMAGE ==>] {034} An Acetanilid Death Record. This list of fatalities is made up from statements published in the newspapers. In every case the person who died had taken to relieve a headache or as a bracer a patent medicine containing acetanilid, without a doctor's prescription. This list does not include the case of a dog in Altoona, Pa., which died immediately on eating some sample headache powders. The dog did not know any better. Mrs. Minnie Bishop, Louisville, Ky.; Oct. 16, 1903. Mrs. Mary Cusick and Mrs. Julia Ward, of 172 Perry Street, New York City; Nov. 27, 1903. Fred. P. Stock, Scranton, Pa.; Dec. 7, 1903. C. Frank Henderson, Toledo, 0.; Dec. 13, 1903. Jacob E. Staley, St. Paul, Mich.; Feb. 18, 1904. Charles M. Scott, New Albany, Ind.; March 15, 1904. Oscar McKinley, Pittsburg, Pa.; April 13, 1904. Otis Staines, student at Wabash College; April 13, 1904. Mrs. Florence Rumsey, Clinton, la.; April 23, 1904. Jenny McGee, Philadelphia, Pa.; May 26, 1904. Mrs. William Mabee, Leoni, Midi.; Sept. 9, 1904. Mrs. Jacob Friedman, of South Bend, Ind.; Oct. 19, 1904. Miss Libbie North, Rockdale, N. Y.; Oct. 26, 1904. Margaret Hanahan, Dayton, O.; Oct. 29, 1904. Samuel Williamson, New York City; Nov. 21, 1904. George Kublisch, St. Louis, Mo.; Nov. 24, 1904. Robert Breck, St. Louis, Mo.;'Nov. 27, 1904. Mrs. Harry Haven, Oriskany Falls, N. Y.; Jan. 17, 1905. Mrs. Jennie Whyler, Akron, 0.; April 3, 1905. Mrs. Augusta Strothmann, St. Louis, Mo.; June 20, 1905. Mrs. Mary A. Bispels, Philadelphia, Pa.; July 2, 1905. Mrs. Thos. Patterson, Huntington, W. Va.; Aug. 15, 1905. Some of these victims died from an alleged overdose; others from the prescribed dose. In almost every instance the local papers suppressed the name of the fatal remedy, {035}Peruna. That particular victim had the beginning of the typical blue skin pictured in the street-car advertisements of Orangeine (the advertisements are a little mixed, as they put the blue hue on the "before taking," whereas it should go on the "after taking"). And, by the way, I can conscientiously recommend Orangeine, Koehler's powders, Royal Pain powders and others of that class to women who wish for a complexion of a dead, pasty white, verging to a puffy blueness under the eyes and about the lips. Patient use of these drugs will even produce an interesting and picturesque, if not intrinsically beautiful, purplish-gray hue of the face and neck. [IMAGE ==>] {035} Drugs That Deprave. Another acquaintance writes me that he is unable to dissuade his wife from the constant use of both Orangeine and Bromo-Seltzer, although her {036}health is breaking down. Often it is difficult for a physician to diagnose these cases because the symptoms are those of certain diseases in which the blood deteriorates, and, moreover, the victim, as in opium and cocain slavery, will positively deny having used the drug. A case of acetanilid addiction (in "cephalgin," an ethical proprietary) is thus reported: "When the drug was withheld the patient soon began to exhibit all the traits peculiar to the confirmed morphine-maniac--moral depravity and the like. She employed every possible means to obtain the drug, attempting even to bribe the nurse, and, this failing, even members of the family." Another report of a similar case (and there are plenty of them to select from) reads: "Stomach increasingly irritable; skin a grayish or light purplish hue; palpitation and slight enlargement of the heart; great prostration, with pains in the region of the heart; blood discolored to a chocolate hue. The patient denied that she had been using acetanilid, but it was discovered that for a year she had been obtaining it in the form of a proprietary remedy and had contracted a regular 'habit.' On the discontinuance of the drug the symptoms disappeared. She was discharged from the hospital as cured, but soon returned to the use of the drug and applied for readmission, displaying the former symptoms." [IMAGE ==>] {036} NEW YORK STATE'S NEW POISON LABEL. On a cocain-laden medicine. Where I have found a renegade physician making his millions out of Peruna, or a professional promoter trading on the charlatanry of Liquozone, it has seemed superfluous to comment on the personality of the men. They are what their business connotes. With Orangeine the case is somewhat different. Its proprietors are men of standing in other and reputable spheres of activity. Charles L. Bartlett, its president, is a graduate of Yale University and a man of some prominence in its alumni affairs. Orangeine is a side issue with him. Professionally he is the western representative of Ivory Soap, one of the heaviest of legitimate advertisers, and he doubtless learned from this the value of skillful exploitation. Next to Mr. Bartlett, the largest owner of stock (unless he has recently sold out) is William Gillette, the actor, whose enthusiastic indorsement of the powders is known in a personal sense to the profession which he follows, and in print to hundreds of thousands of theater-goers who have read it in their programs. Whatever these gentlemen may think of their product (and I understand that, incredible as it may seem, both of them are constant users of it and genuine believers in it), the methods by which it is sold and the essential and mendacious concealment of its real nature illustrate the {037}level to which otherwise upright and decent men are brought by a business which can not profitably include either uprightness or decency in its methods. Orangeine is less dangerous, except in extent of use, than many other acetanilid mixtures which are much the same thing under a different name. A friend of mine with a weak heart took the printed dose of Laxative Bromo Quinin and lay at the point of death for a week. There is no word of warning on the label. In many places samples of headache powders are distributed on the doorsteps. The St. Louis Chronicle records a result: "Huntington, W. Va., Aug. 15, 1905.--While Mrs. Thomas Patterson was preparing supper last evening she was stricken with a violent headache and took a headache powder that had been thrown in at her door the day before. Immediately she was seized with spasms and in an hour she was dead." That even the lower order of animals is not safe is shown by a canine tragedy in Altoona, Pa., where a prize collie dog incautiously devoured three sample tablets and died in an hour. Yet the distributing agents of these mixtures do not hesitate to lie about them. Rochester, N. Y., has an excellent ordinance forbidding the distribution of sample medicines, except by permission of the health officer. An agent for Miniature Headache Powders called on Dr. Goler with a request for leave to distribute 25,000 samples. "What's your formula?" asked the official. "Salicylate of soda and sugar of milk," replied the traveling man. "And you pretend to cure headaches with that?" said the doctor. "I'll look into it." Analysis showed that the powders were an acetanilid mixture. The sample man didn't wait for the result. He hasn't been back to Rochester since, although Dr. Goler is hopefully awaiting him. Bromo-Seltzer is commonly sold in drug stores, both by the bottle and at soda fountains. The full dose is "a heaping teaspoonful." A heaping teaspoonful of Bromo-Seltzer means about ten grains of acetanilid. The United States Pharmacopeia dose is four grains; five grains have been known to produce fatal results. The prescribed dose of Bromo-Seltzer is dangerous and has been known to produce sudden collapse. Megrimine is a warranted headache cure that is advertised in several of the magazines. A newly arrived guest at a Long Island house party brought along several lots and distributed them as a remedy for headache and that tired feeling. It was perfectly harmless, she declared; didn't the advertisement say "leaves no unpleasant effects"? As a late dance the night before had left its impress on the feminine members of the house party, there was a general acceptance of the "bracer." That night the local physician visited the house party (on special "rush" invitation), and was well satisfied to pull all his patients through. He had never before seen acetanilid poisoning by wholesale. A Chicago druggist writes me that the wife of a prominent physician buys Megrimine of him by the half-dozen lots secretly. She has the habit. On October 9, W. H. Hawkins, superintendent of the American Detective Association, a mar of powerful physique and apparently in good health, went to a drug store in Anderson, Ind., and took a dose of Dr. Davis' Headache Powders. He then boarded a car for Marion and shortly after fell to the floor, dead. The coroner's verdict is reproduced on page 35. {035} Whether these powders are made by a Dr. W. C. Davis, of Indianapolis, who makes Anti-Headache, I am unable to state. Anti-Headache describes itself as "a compound of mild ingredients and positively contains no dangerous drugs." It is almost pure acetanilid. In the "ethical" field the harm done by this class of proprietaries is perhaps {038}as great as in the open field, for many of those which are supposed to be sold only in prescriptions are as freely distributed to the laity as Peruna. And their advertising is hardly different. Antikamnia, claiming to be an "ethical" remedy, and advertising through the medical press by methods that would, with little alteration, fit any patent painkiller on the market, is no less dangerous or fraudulent than the Orangeine class which it almost exactly parallels in composition. It was at first exploited as a "new synthetical coal-tar derivative," which it isn't and never was. It is simply half or more acetanilid (some analyses show as high as 68 per cent.) with other unimportant ingredients in varying proportions. In a booklet entitled "Light on Pain," and distributed on doorsteps, I find under an alphabetical list of diseases this invitation to form the Antikamnia habit: [IMAGE ==>] {038} "Nervousness (overwork and excesses)--Dose: One Antikamnia tablet every two or three hours. "Shoppers' or Sightseers' Headache--Dose: Two Antikamnia tablets every three hours. "Worry (nervousness, 'the blues')--Dose: One or two Antikamnia and Codein tablets every three hours." Codein is obtained from opium. The codein habit is well known to all institutions which treat drug addictions, and is recognized as being no less difficult to cure than the morphin habit. The following well-known "remedies" both "ethical" and "patent," depend for their results upon the heart-depressing action of Acetanilid: Orangeine Bromo-Seltzer Megrimine Anti-Headache Ammonol Salacetin Royal Pain Powders Dr. Davis's Headache Phenalgin Cephalgin Miniature Headache Powders Powders A typical instance of what Antikamnia will do for its users is that of a Pennsylvania merchant, 50 years old, who had declined, without apparent Antikamnia {039}cause, from 140 to 116 pounds, and was finally brought to Philadelphia in a state of stupor. His pulse was barely perceptible, his skin dusky and his blood of a deep chocolate color. On reviving he was questioned as to whether he had been taking headache powders. He had, for several years. What kind? Antikamnia; sometimes in the plain tablets, at other times Antikamnia with codein. How many? About twelve a day. He was greatly surprised to learn that this habit was responsible for his condition. "My doctor gave it to me for insomnia," he said, and it appeared that the patient had never even been warned of the dangerous character of the drug. Were it obtainable, I would print here the full name and address of that attending physician, as one unfit, either through ignorance or carelessness, to practice his profession. And there would be other physicians all over the country who would, under that description, suffer the same indictment within their own minds for starting innocent patients on a destructive and sometimes fatal course. For it is the careless or conscienceless physician who gets the customer for the "ethical" headache remedies, and the customer, once secured, pays a profit, very literally, with his own blood. Once having taken Antikamnia, the layman, unless informed as to its true nature, will often return to the drug store and purchase it with the impression that it is a specific drug, like quinin or potassium chlorate, instead of a disguised poison, exploited and sold under patent rights by a private concern. The United States Postoffice, in its broad tolerance, permits the Antikamnia company to send through the mails little sample boxes containing tablets enough to kill an ordinary man, and these samples are sent not only to physicians, as is the rule with ethical remedies, but to lawyers, business men, "brain workers" and other prospective purchasing classes. The box bears the lying statement: "No drug habit--no heart effect." Just as this is going to press the following significant case comes in from Iowa: "Farmington, Iowa, Oct. 6.-- (Special to the Constitution-Democrat.)--Mrs. Hattie Kick, one of the best and most prominent ladies of Farmington, died rather suddenly Wednesday morning at 10 o'clock from an overdose of Antikamnia, which she took for a severe headache from which she was suffering. Mrs. Kick was subject to severe headaches and was a frequent user of Antikamnia, her favorite remedy for this ailment." There is but one safeguard in the use of these remedies: to regard them as one would regard opium and to employ them only with the consent of a physician who understands their true nature. Acetanilid has its uses, but not as a generic painkiller. Pain is a symptom; you can drug it away temporarily, but it will return clamoring for more payment until the final price is hopeless enslavement. Were the skull and bones on every box of this class of poison the danger would be greatly minimized. With opium and cocain the case is different. The very words are danger signals. Legal restrictions safeguard the public, to a greater or less degree, from their indiscriminate use. Normal people do not knowingly take opium or its derivatives except with the sanction of a physician, and there is even spreading abroad a belief (surely an expression of the primal law of self-preservation) that the licensed practitioner leans too readily toward the convenient narcotics. But this perilous stuff is the ideal basis for a patent medicine because its results are immediate (though never permanent), and it is its own best advertisement in that one dose imperatively calls for another. Therefore it behooves the manufacturer of opiates to disguise the use of the drug. This he does in varying forms, and he has found his greatest success in the "cough and consumption cures" and the soothing syrup class. The former of these will be considered in another article. As to the "soothing syrups," {040}designed for the drugging of helpless infants, even the trade does not know how many have risen, made their base profit and subsided. A few survive, probably less harmful than the abandoned ones, on the average, so that by taking the conspicuous survivors as a type I am at least doing no injustice to the class. Some years ago I heard a prominent New York lawyer, asked by his office scrub woman to buy a ticket for some "association" ball, say to her: "How can you go to these affairs, Nora, when you have two young children at home?" "Sure, they're all right," she returned, blithely; "just wan teaspoonful of Winslow's an' they lay like the dead till mornin'." What eventually became of the scrub woman's children I don't know. The typical result of this practice is described by a Detroit physician who has been making a special study of Michigan's high mortality rate: "Mrs. Winslow's Soothing Syrup is extensively used among the poorer classes as a means of pacifying their babies. These children eventually come into the hands of physicians with a greater or less addiction to the opium habit. The sight of a parent drugging a helpless infant into a semi-comatose condition is not an elevating one for this civilized age, and it is a very common practice. [IMAGE ==>] {040}I can give you one illustration from my own hospital experience, which was told me by the father of the girl. A middle-aged railroad man of Kansas City had a small daughter with summer diarrhea. For this she was given a patent diarrhea medicine. It controlled the trouble, but as soon as the remedy was withdrawn the diarrhea returned. At every withdrawal the trouble began anew, and the final result was that they never succeeded in curing this daughter of the opium habit which had taken its hold on her. It was some years afterward that the parents became aware that she had contracted the habit, when the physician took away the patent medicine and gave the girl morphin, with exactly the same result which she had experienced with the patent remedy. At the time the father told me this story his daughter was 19 years of age, an only child of wealthy parents, and one who could have had every advantage in life, but who was a complete wreck in every way as a result of the opium habit. The father told me, with tears in his eyes, that he would rather she had died with the original illness than to have lived to become the creature which she then was." The proprietor of a drug store in San José, Cal., writes to _Collier's_ as follows: [IMAGE ==>] {041} "I have a good customer, a married woman with five children, all under 10 years of age. When her last baby was born, about a year ago, the first thing she did was to order a bottle of Winslow's Soothing Syrup, and every {042}week another bottle was bought at first, until now a bottle is bought every third day. Why? Because the baby has become habituated to the drug. I am not well enough acquainted with the family to be able to say that the weaned children show any present abnormality of health due to the opium contained in the drug, but the after-effects of opium have been thus described.... Another instance, quite as startling, was that of a mother who gave large quantities of soothing syrup to two of her children in infancy; then, becoming convinced of its danger, abandoned its use. These children in middle life became neurotics, spirit and drug-takers. Three children born later and not given any drugs in early life grew up strong and healthy. "I fear the children of the woman in question will all suffer for their mother's ignorance, or worse, in later life, and have tried to do my duty by sending word to the mother of the harmful nature of the stuff, but without effect. "P. S.--How many neurotics, fiends and criminals may not 'Mrs. Winslow' be sponsor for?" This query is respectfully referred to the Anglo-American Drug Company, of New York,' which makes its handsome profit from this slave trade. Recent legislation on the part of the New York State Board of Pharmacy will tend to decrease the profit, as it requires that a poison label be put on each bottle of the product, as has long been the law in England. An Omaha physician reports a case of poisoning from a compound bearing the touching name of "Kopp's Baby Friend," which has a considerable sale in the middle west and in central New York. It is made of sweetened water and morphin, about one-third grain of morphin to the ounce. "The child (after taking four drops) went into a stupor at once, the pupils were pin-pointed, skin cool and clammy, heart and respiration slow. I treated the case as one of opium poisoning, but it took twelve hours before my little patient was out of danger." As if to put a point of satirical grimness on the matter, the responsible proprietor of this particular business of drugging helpless babies is a woman, Mrs. J. A. Kopp, of York, Pa. Making cocain fiends is another profitable enterprise. Catarrh powders are the medium. A decent druggist will not sell cocain as such, steadily, to any customer, except on prescription, but most druggists find salve for their consciences in the fact that the subtle and terrible drug is in the form of somebody's sure cure. There is need to say nothing of the effects of cocain other than that it is destructive to mind and body alike, and appalling in its breaking down of all moral restraint. Yet in New York City it is distributed in "samples" at ferries and railway stations. You may see the empty boxes and the instructive labels littering the gutters of Broadway any Saturday night, when the drug-store trade is briskest. Simey's Catarrhal Powder, Dr. Cole's Catarrh Cure, Dr. Gray's Catarrh Powder and Crown Catarrh Powder are the ones most in demand. All of them are cocain; the other ingredients are unimportant--perhaps even superfluous. Whether or not the bottles are labeled with the amount of cocain makes little difference. The habitués know. In one respect, however, the labels help them by giving information as to which nostrum is the most heavily drugged. "People come in here," a New York City druggist tells me, "ask what catarrh powders we've got, read the labels and pick out the one that's got the most cocain. When I see a customer comparing labels I know she's a fiend." {043} Naturally these owners and exploiters of these mixtures claim that the small amount of cocain contained is harmless. For instance, the "Crown Cure," admitting 2% per cent., says: "Of course, this is a very small and harmless amount. Cocain is now considered to be the most valuable addition to modern medicine... it is the most perfect relief known." Birney's Catarrh Cure runs as high as 4 per cent, and can produce testimonials vouching for its harmlessness. Here is a Birney "testimonial" to the opposite effect, obtained "without solicitation or payment" (I have ventured to put it in the approved form), which no sufferer from catarrh can afford to miss. [IMAGE ==>] {043} READ what William Thompson, of Chicago, says of BIRNEY'S CATARRH CURE. "Three years ago Thompson was a strong man. Now he is without money, health, home or friends." (Chicago Tribune.) "I began taking Birney's Catarrh Cure (says Thompson) three years ago, and the longing for the drug has grown so potent that I suffer without it. "I followed the directions at first, then I increased the quantity until I bought the stuff by the dozen bottles." A famous drink and drug cure in Illinois had, as a patient, not long ago, a 14-year-old boy, who was a slave to the Birney brand of cocain. He had run his father $300 in debt, so heavy were his purchases of the poison. Chicago long ago settled this cocain matter in the only logical way. The proprietor of a large downtown drug store noticed several years ago that at noon numbers of the shop girls from a great department store purchased certain catarrh powders over his counter. He had his clerk warn them that the powders contained deleterious drugs. The girls continued to purchase in increasing numbers and quantity. He sent word to the superintendent of the store. "That accounts for the number of our girls that have gone wrong of late," was the superintendent's comment. The druggist, Mr. McConnell, had an analysis made by the Board of Health, which showed that the powder most called for was nearly 4 per cent, cocain, whereon he threw it and similar powders out of stock. The girls went elsewhere. Mr. McConnell traced them and started a general movement against this class of remedies, which resulted in an ordinance forbidding their sale. Birney's Catarrhal Powders, as I am informed, to meet the new conditions brought-out a powder without cocain, which had the briefest kind of a sale. For weeks thereafter the downtown stores were haunted by haggard young men and women, who begged for "the old powders; these new ones don't do any good." As high as $1.00 premium was paid for the 4 per cent, cocain species. To-day the Illinois druggist who sells cocain in this form is liable to arrest. Yet in New York, at the corner of Forty-second street and Broadway, I saw recently a show-window display of the Birney cure, and similar displays are not uncommon in other cities. Regarding other forms of drugs there may be honest differences of opinion as to the limits of legitimacy in the trade. If mendacious advertising were stopped, and the actual ingredients of every nostrum plainly published {044}and frankly explained, the patent medicine trade might reasonably claim to be a legitimate enterprise in many of its phases. But no label of opium or cocain, though the warning skull and cross-bones cover the bottle, will excuse the sale of products that are never safely used except by expert advice. I believe that the Chicago method of dealing with the catarrh powders is the right method in cocain- and opium-bearing nostrums. Restrict the drug by the same safeguards when sold under a lying pretence as when it flies its true colors. Then, and then only, will our laws prevent the shameful trade that stupefies helpless babies and makes criminals of our young men and harlots of our young women. V.--PREYING ON THE INCURABLES. Reprinted from Collier's Weekly, Jan. 13, 1906. {045} Incurable disease is one of the strongholds of the patent medicine business. The ideal patron, viewed in the light of profitable business, is the victim of some slow and wasting ailment in which recurrent hope inspires to repeated experiments with any "cure" that offers. In the columns of almost every newspaper you may find promises to cure consumption. Consumption is a disease absolutely incurable by any medicine, although an increasing percentage of consumptives are saved by open air, diet and methodical living. This is thoroughly and definitely understood by all medical and scientific men. Nevertheless there are in the patent medicine world a set of harpies who, for their own business interests, deliberately foster in the mind of the unfortunate sufferer from tuberculosis the belief that he can be saved by the use of some absolutely fraudulent nostrum. Many of these consumption cures contain drugs which hasten the progress of the disease, such as chloroform, opium, alcohol and hasheesh. Others are comparatively harmless in themselves, but for their fervent promises of rescue they delude the sufferer into misplacing his reliance, and forfeiting his only chance by neglecting those rigidly careful habits of life which alone can conquer the "white plague." One and all, the men who advertise medicines to cure consumption deliberately traffic in human life. [IMAGE ==>] {045} Certain members of the Proprietary Association of America (the patent medicine "combine") with whom I have talked have urged on me the claim that there are firms in the nostrum business that are above criticism, and have mentioned H. E. Bucklen & Co., of Chicago, who manufacture a certain salve. The Bucklen salve did not particularly interest me. But when I came to take up the subject of consumption cures I ran unexpectedly on an interesting trail. In the country and small city newspapers there is now being advertised lavishly "Dr. King's New Discovery for Consumption." It is proclaimed to be the "only sure cure for consumption." Further announcement is made that "it strikes terror to the doctors." As it is a morphin and chloroform mixture, "Dr. King's New Discovery for Consumption" is well calculated to strike terror to the doctors or to any other class or profession, except, perhaps, the undertakers. It is a pretty diabolical concoction to give to any one, and particularly to a consumptive. The chloroform temporarily allays the cough, thereby checking Nature's effort to throw off the dead matter from the lungs. The opium drugs the patient into a deceived cheerfulness. The combination is admirably designed to shorten the life of any consumptive who takes it steadily. Of course, there is nothing on the label of the bottle to warn the purchaser. That would be an example of legitimate advertising in the consumption field. [IMAGE ==>] {046} A TYPICAL FRAUD. Chloroform and Prussic Acid. {047} Another "cure" which, for excellent reasons of its own, does not print its formula, is "Shiloh's Consumption Cure," made at Leroy, N. Y., by S. C. Wells & Co. Were it to publish abroad the fact that it contains, among other ingredients, chloroform and prussic acid. Under our present lax system there is no warning on the bottle that the liquid contains one of the most deadly of poisons. The makers write me: "After you have taken the medicine for awhile, if you are not firmly convinced that you are very much better we want you to go to your druggist and get back all the money that you have paid for Shiloh." [IMAGE ==>] {047} [IMAGE ==>] {048} [IMAGE ==>] {049} But if I were a consumptive, after I had taken "Shiloh" for awhile I should be less interested in recovering my money than in getting back my wasted chance of life. Would S. C. Wells & Co. guarantee that? {050} Morphin is the important ingredient of Dr. Bull's Cough Syrup. Nevertheless, the United States Postoffice Department obligingly transmits me a dose of this poison through the mails from A. C. Meyer & Co., of Baltimore, the makers. The firm writes me, in response to my letter of inquiry: "We do not claim that Dr. Bull's Cough Syrup will cure an established case of consumption. If you have gotten this impression you most likely have misunderstood what we claim.... We can, however, say that Dr. Bull's Cough Syrup has cured cases said to have been consumption in its earliest stages." Quite conservative, this. But A. C. Meyer & Co. evidently don't follow their own advertising very closely, for around my sample bottle (by courtesy of the Postoffice Department) is a booklet, and from that booklet I quote: "_There is no case of hoarseness, cough, asthma, bronchitis... or consumption that can not be cured speedily by the proper use of Dr. Bull's Cough Syrup_." If this is not a claim that Dr. Bull's Cough Syrup "will cure an established case of consumption," what is it? The inference from Meyer & Co.'s cautious letter is that they realize their responsibility for a cruel and dangerous fraud and are beginning to feel an uneasiness about it, which may be shame or may be only fear. One logical effect of permitting medicines containing a dangerous quantity of poison to be sold without the poison label is shown in the coroner's verdict reproduced on page 47. [IMAGE ==>] {047} In the account of the Keck baby's death from the Dr. Bull opium mixture, which the Cincinnati papers published, there was no mention of the name of the cough syrup. Asked about this, the newspapers gave various explanations. Two of them disclosed that they had no information on the point. This is contrary to the statement of the physician in the case, and implies a reportorial, laxity which is difficult to credit. One ascribed the omission to a settled policy and one to the fear of libel. When the coroner's verdict was given out, however, the name of the nostrum got into plain print. On the whole, the Cincinnati papers showed themselves gratifyingly independent. Another case of poisoning from this same remedy occurred in Morocco, Ind., the victim being a 2-year-old child. The doctor reports: "In an hour, when first seen, symptoms of opium poisoning were present. In about twelve hours the child had several convulsions, and spasms followed for another twelve hours at intervals. It then sank into a coma and died in the seventy-two hours with cardiac failure. The case was clearly one of death from overdose of the remedy." The baby had swallowed a large amount of the "medicine" from a bottle left within its reach. Had the bottle been properly labeled with skull and cross-bones the mother would probably not have let it lie about. Caution seems to have become a suddenly acquired policy of this class of medicines, in so far as their correspondence goes. Unfortunately, it does not extend to their advertising. The result is a rather painful discrepancy. G. G. Green runs hotels in California and manufactures quack medicines in Woodbury, N. J., one of these being "Boschee's German Syrup," a "consumption cure." Mr. Green writes me (per rubber stamp): "Consumption can sometimes be cured, but not always. Some cases are beyond cure. However, we suggest that you secure a trial bottle of German Syrup for 25 cents," etc. On the bottle I read: "Certain cure for all diseases of the throat and lungs." Consumption is a disease of the lungs; sometimes of the throat. {051} If it "can sometimes be cured, but not always," then the German Syrup is not a "certain cure for all diseases of the throat and lungs," and somebody, as the ill-fated Reingelder put it, "haf lied in brint" on Mr. Green's bottle, which must be very painful to Mr. Green. Mr. Green's remedy contains morphin and some hydrocyanic acid. Therefore consumption will be much less often curable where Boschee's German Syrup is used than where it is not. Absolutely False Claims. A curious mixture of the cautious, semi-ethical method and the blatant claim-all patent medicine is offered in the Ozomulsion Company. Ozomulsion does not, like the "cures" mentioned above, contain active poisons. It is one of the numerous cod-liver oil preparations, and its advertising, in tne medical journals at first and now in the lay press, is that of a cure for consumption. I visited the offices of the Ozomulsion Company recently and found them duly furnished with a regular physician, who was employed, so he informed me, in a purely ethical capacity. There was also present during the interview the president of the Ozomulsion Company, Mr. A. Frank Richardson, former advertising agent, former deviser of the advertising of Swamp-Root, former proprietor of Kranitonic and present proprietor of Slocum's Consumption Cure, which is the "wicked partner" of Ozomulsion. For convenience I will put the conversation in court report form, and, indeed, it partook somewhat of the nature of a cross-examination: Q.--Dr. Smith, will Ozomulsion cure consumption? A.--Ozomulsion builds up the tissues, imparts vigor, aids the natural resistance of the body, etc. (Goes into a long exploitation in the manner and style made familiar by patent medicine pamphlets. ) Q.--But will it cure consumption? A.--Well, without saying that it is a specific, etc. (Passes to an instructive, entertaining and valuable disquisition on the symptoms and nature of tuberculosis. ) Q.--Yes, but will Ozomulsion cure consumption? A.--We don't claim that it will cure consumption. Q.--Does not this advertisement state that Ozomulsion will cure consumption? (SHowing advertisement.) A.--It seems to. Q.--Will Ozomulsion cure consumption? A.--In the early stages of the disease-- Q. (interrupting)--Does the advertisement make any qualifications as to the stage of tne disease? A.--Not that I find. Q.--Have you ever seen that advertisement before? A.--Not to my knowledge. Q.--Who wrote it? A. (by President Richardson)--I done that ad. myself. Q.--Mr. Richardson, will Ozomulsion cure consumption? A.--Sure; we got testimonials to prove it. Q.--Have you ever investigated any of these testimonials? Q. (to Dr. Smith)--Dr. Smith, in view of the direct statement of your advertising, do you believe that Ozomulsion will cure consumption? A.--Well, I believe in a great many cases it will. Health for Five Dollars. That is as far as Dr. Smith would go. I wonder what he would have said as to the Dr. T. A. Slocum side of the business. Dr. Slocum puts out a "Special Cure Offer" that will snatch you from the jaws of death, on the {052}blanket plan, for $6, and guarantees the cure (or more medicine) for $10. His scheme is so noble and broad-minded that I can not refrain from detailing it. For $5 you get, 1 large bottle of Psychine, 1 large bottle of Ozomulsion, 1 large bottle of Coltsfoote Expectorant, 1 large tube of Ozojell, 3 boxes of lazy Liver Pills 3 Hot X-Ray Porous Plaster, "which," says the certificate, "will in a majority of cases effect a permanent care of the malady from which the invalid is now suffering." Whatever ails you--that's what Dr. T. A. Sloram cures. For $10 you get almost twice the amount, plus the guarantee. Surely there is little left on earth, unless Dr. Slocum should issue a $15 offer, to include funeral expenses and a tombstone. The Slocum Consumption Cure proper consists of a gay-hued substance known as "Psychine." Psychine is about 16 per cent, alcohol, and has a dash of strychnin to give the patient his money's worth. Its alluring color is derived from cochineal. It is "an infallible and unfailing remedy for consumption." Ozomulsion is also a sure cure, if the literature is to be believed. To cure one's self twice of the same disease savors of reckless extravagance, but as "a perfect and permanent cure will be the inevitable consequence," perhaps it's worth the money. It would not do to charge Dr. T. A. Slocum with fraud, because he is, I suppose, as dead as Lydia E. Pinkham; but Mr. A. Frank Richardson is very much alive, and I trust it will be no surprise to him to see here stated that his Ozomulsion makes claims that it can not support, that his Psychine is considerably worse, that his special cure offer is a bit of shameful quackery, and that his whole Slocum Consumption Cure is a fake and a fraud so ludicrous that its continued insistence is a brilliant commentary on human credulousness. Since the early '60s, and perhaps before, there has constantly been in the public prints one or another benefactor of the human race who wishes to bestow on suffering mankind, free of charge, a remedy which has snatched him from the brink of the grave. Such a one is Mr. W. A. Noyes, of Rochester, N. Y. To any one who writes him he sends gratis a prescription which will surely cure consumption. But take this prescription to your druggist and you will fail to get it filled, for the simple reason that the ingenious Mr. Noyes has employed a pharmaceutical nomenclature peculiarly his own If you wish to try the "Cannabis Sativa Remedy" (which is a mixture of hasheesh and other drugs) you must purchase it direct from the advertiser at a price which assures him an abnormal profit. As Mr. Noyes writes me proposing to give special treatment for my (supposed) case, depending on a diagnosis of sixty-seven questions, I fail to see why he is not liable for practicing medicine without a license. Piso Grows Cautious. Piso's Consumption Cure, extensively advertised a year or two ago, is apparently withdrawing from the field, so far as consumption goes, and the Pino people are now more modestly promising to cure coughs and colds. Old analyses give as the contents of Piso's Cure for Consumption alcohol, chloroform, opium and cannabis indica (hasheesh). In reply to an inquiry as to whether their remedy contains morphin and cannabis indica, the Piso Company replies: "Since the year 1872 Piso's Cure has contained no morphin or anything derived from opium." The question as to cannabis indica is not answered. Analysis shows that the "cure" contains chloroform, alcohol and apparently cannabis indica. It is, therefore, another of the {053}remedies which can not possibly cure consumption, but, on the contrary, tend by their poisonous and debilitating drugs to undermine the victim's stamina. Peruna, Liquozone, Duffy's Malt Whiskey, Pierce's Golden Medical Discovery and the other "blanket" cures include tuberculosis in their lists, claiming great numbers of well-authenticated cures. From the imposing book published by the R. V. Pierce Company, of Buffalo, I took a number of testimonials for investigation; not a large number, for I found the consumption testimonial rather scarce. From fifteen letters I got results in nine cases. Seven of the letters were returned to me marked "unclaimed," of which one was marked "Name not in the dictory," another "No such postoffice in the state" and a third "Deceased." The eighth man wrote that the Golden Medical Discovery had cured his cough and blood-spitting, adding: "It is the best lung medisan I ever used for lung trubble." The last man said he took twenty-five bottles and was cured! Two out of nine seems to me a suspiciously small percentage of traceable recoveries. Much stress has been laid by the Proprietary Association of America through its press committee on the suit brought by R. V. Pierce against the Ladies' Home Journal, the implication being (although the suit has not yet been tried) that a reckless libeler of a noble and worthy business has been suitably punished. In the full appreciation of Dr. Pierce's attitude in the matter of libel, I wish to state that in so far as its claim of curing consumption is concerned his Golden Medical Discovery is an unqualified fraud. [IMAGE ==>] {053} One might suppose that the quacks would stop short of trying to deceive the medical profession in this matter, yet the "consumption cure" may be found disporting itself in the pages of the medical journals. For instance, I find this advertisement in several professional magazines: "McArthur's Syrup of Hypophosphites has proved itself, time and time again, to be positively beneficial in this condition [tuberculosis] in the hands of prominent observers, clinicians and, what is more, practicing physicians, hundreds of whom have written their admiring encomiums in {054}its behalf, and it is the enthusiastic conviction of many that _its effect is truly specific_" Which, translated into lay terms, means that the syrup will cure consumption. I find also in the medical press "a sure cure for dropsy," fortified with a picture worthy of Swamp-Root or Lydia Pinkham. Both of these are frauds in attempting to foster the idea that they will _cure_ the diseases, and they are none the less fraudulent for being advertised to the medical profession instead of to the laity. Is there, then, no legitimate advertising of preparations useful in diseases such as tuberculosis? Very little, and that little mostly in the medical journals, exploiting products which tend to build up and strengthen the patient. There has recently appeared, however, one advertisement in the lay press which seems to me a legitimate attempt to push a nostrum. It is reproduced at the beginning of this article. Notice, first, the frank statement that there is no specific for consumption; second, that there is no attempt to deceive the public into the belief that the emulsion will be helpful in all cases. Whether or not Scott's Emulsion is superior to other cod-liver oils is beside the present question. If all patent medicine "copy" were written in the same spirit of honesty as this, I should have been able to omit from this series all consideration of fraud, and devote my entire attention to the far less involved and difficult matter of poison. Unhappily, all of the Scott's Emulsion advertising is not up to this standard. In another newspaper I have seen an excerpt in which the Scott & Bowne Company come perilously near making, if they do not actually make, the claim that their emulsion is a cure, and furthermore make themselves ridiculous by challenging comparison with another emulsion, suggesting a chemical test and offering, if their nostrum comes out second best, _to give to the institution making the experiment a supply of their oil free for a year_. This is like the German druggist who invented a heart-cure and offered two cases to any one who could prove that it was injurious! Consumption is not the only incurable disease in which there are good pickings for the birds of prey. In a recent issue of the New York Sunday _American-Journal_ I find three cancer cures, one dropsy cure, one "heart-disease soon cured," three epilepsy cures and a "case of paralysis cured." Cancer yields to but one agency--the knife. Epilepsy is either the result of pressure on the brain or some obscure cerebral disease; medicine can never cure it. Heart disease is of many kinds, and a drug that may be helpful in relieving symptoms in one case might be fatal in another. The same is true of dropsy. Medical science knows no "cure" for paralysis. As space lacks to consider individually the nature of each nostrum separately, I list briefly, for the protection of those who read, a number of the more conspicuous swindles of this kind now being foisted on the public: Rupert Wells' Radiatized Fluid, for cancer. Miles' Heart Disease Cure. Miles' Grand Dropsy Cure. Dr. Tucker's Epilepsy Cure. Dr. Grant's Epilepsy Cure. W. H. May's Epilepsy Cure. Dr. Kline's Epilepsy Cure. Dr. W. 0. Bye's Cancer Cure. Mason's Cancer Cure. Dr. Williams' Pink Pills for Pale People, which are advertised to cure paralysis and are a compound of green vitriol, starch and sugar. Purchasers of these nostrums not only waste their money, but in many cases they throw away their only chance by delaying proper treatment until it is too late. {055} Properly, a "cure" known as Bioplasm belongs in this list, but so ingenious are its methods that it deserves some special attention. In some of the New York papers a brief advertisement, reading as follows, occupies a conspicuous position. "After suffering for ten years the torture that only an ataxic can know, Mr. E. P. Burnham, of Delmar, N. Y., has been relieved of all pain and restored to health and strength, and the ability to resume his usual pursuits, by an easily obtained and inexpensive treatment which any druggist can furnish. To any fellow-sufferer who mails him a self-addressed envelope Mr. Burnham sends free this prescription which cured him."--Adv. Now, people who give away something for nothing, and spend money advertising for a chance to do it, are as rare in the patent medicine business as out of it, and Delmar, N. Y., is not included in any map of Altruria that I have learned of E. P. Burnham, therefore, seemed worth writing to. The answer came back promptly, inclosing the prescription and explaining the advertiser's purpose: "My only motive in the notice which caught your attention is to help other sufferers. _You owe me nothing. I have nothing to sell_. When you are benefited, however, if you feel disposed and able to send me a contribution to assist me in making this great boon to our felow-sufferers better known it will be thankfully received and used for that purpose." I fear that Mr. Burnham doesn't make much money out of grateful correspondents who were cured of locomotor ataxia by his prescription, because locomotor ataxia is absolutely and hopelessly incurable. Where Mr. Burnham gets his reward, I fancy, is from the Bioplasm Company, of 100 William street, New York, whose patent medicine is prescribed for me. I should like to believe that his "only motive is to help other sufferers," but as I find, on investigation, that the advertising agents who handle the "Burnham" account are the Bioplasm Company's agents, I am regretfully compelled to believe that Mr. Burnham, instead of being of the tribe of the good Samaritan, is probably an immediate relative of Ananias. The Bioplasm Company also proposes to cure consumption, and is worthy of a conspicuous place in the Fraud's Gallery of Nostrums. Even the skin of the Ethiop is not exempt from the attention of the quacks. A colored correspondent writes, asking that I "give a paragraph to these frauds who cater to the vanity of those of my race who insult their Creator in attempting to change their color and hair," and inclose a typical advertisement of "Lustorene," which "straightens kinky, nappy, curly hair," and of "Lustorone Face Bleach," which "whitens the darkest skin" and will "bring the skin to any desired shade or color." Nothing could better illustrate to what ridiculous lengths the nostrum fraud will go. Of course, the Lustorone business is fraudulent. Some time since a Virginia concern, which advertised to turn negroes white, was suppressed by the Postoffice Department, which might well turn its attention to Lustorone Face Bleach. There are being exploited in this country to-day more than 100 cures, for diseases that are absolutely beyond the reach of drugs. They are owned by men who know them to be swindles, and who in private conversation will almost always evade the direct statement that their nostrums will "cure" consumption, epilepsy, heart disease and ailments of that nature. Many of them "guarantee" their remedies. They will return your money if you aren't satisfied. And they can afford to. They take the lightest of risks. The real risk is all on the other side. It is their few pennies per bottle against your life. Were the facile patter by which they lure to the bargain a menace to the pocketbook alone, one might regard them only as ordinary {056}followers of light finance, might imagine them filching their gain with the confidential, half-brazen, half-ashamed leer of the thimblerigger. But the matter goes further and deeper. Every man who trades in this market, whether he pockets the profits of the maker, the purveyor or the advertiser, takes toll of blood. He may not deceive himself here, for here the patent medicine is nakedest, most cold-hearted. Relentless greed sets the trap and death is partner in the enterprise. VI--THE FUNDAMENTAL FAKES. Reprinted from Collier's Weekly, Feb. 17, 1906. {057} Advertising and testimonials are respectively the aggressive and defensive forces of the Great American Fraud. Without the columns of the newspapers and magazines wherein to exploit themselves, a great majority of the patent medicines would peacefully and blessedly fade out of existence. Nearly all the world of publications is open to the swindler, the exceptions being the high-class magazines and a very few independent spirited newspapers. The strongholds of the fraud are dailies, great and small, the cheap weeklies and the religious press. According to the estimate of a prominent advertising firm, above 90 per cent, of the earning capacity of the prominent nostrums is represented by their advertising. And all this advertising is based on the well-proven theory of the public's pitiable ignorance and gullibility in the vitally important matter of health. Study the medicine advertising in your morning paper, and you will find yourself in a veritable goblin-realm of fakery, peopled with monstrous myths. Here is an amulet in the form of an electric belt, warranted to restore youth and vigor to the senile; yonder a magic ring or a mysterious inhaler, or a bewitched foot-plaster which will draw the pangs of rheumatism from the tortured body "or your money back"; and again some beneficent wizard in St. Louis promises with a secret philtre to charm away deadly cancer, while in the next column a firm of magi in Denver proposes confidently to exorcise the demon of incurable consumption without ever seeing the patient. Is it credible that a supposedly civilized nation should accept such stuff as gospel? Yet these exploitations cited above, while they are extreme, differ only in degree from nearly all patent-medicine advertising. Ponce de Leon, groping toward that dim fountain whence youth springs eternal, might believe that he had found his goal in the Peruna factory, the Liquozone "laboratory" or the Vitæ-Ore plant; his thousands of descendants in this century of enlightenment painfully drag themselves along poisoned trails, following a will-o'-the-wisp that dances above the open graves. Newspaper Accomplices. If there is no limit to the gullibility of the public on the one hand, there is apparently none to the cupidity of the newspapers on the other. As the Proprietary Association of America is constantly setting forth in veiled warnings, the press takes an enormous profit from patent-medicine advertising. Mr. Hearst's papers alone reap a harvest of more than half a million dollars per annum from this source. The Chicago _Tribune_, which treats nostrum advertising in a spirit of independence, and sometimes with scant courtesy, still receives more than $80,000 a year in medical patronage. Many of the lesser journals actually live on patent medicines. What wonder that they are considerate of these profitable customers! Pin a newspaper owner down to the issue of fraud in the matter, and he will take refuge in the plea that his advertisers and not himself are responsible for what appears in the advertising columns. _Caveat emptor_ is the implied superscription above this department. The more shame to those publications {058}which prostitute their news and editorial departments to their greed. Here are two samples, one from the Cleveland _Plain-Dealer_, the other from a temperance weekly, Green Goods "Cable News." The "Ascatco" advertisement, which the Plain-Dealer prints as a cablegram, without any distinguishing mark to designate it as an advertisement, of course, emanates from the office of the nostrum, and is a fraud, as the _Plain-Dealer_ well knew when it accepted payment, and became partner to the swindle by deceiving its readers. Tne Vitæ-Ore "editorial" appears by virtue of a full-page advertisement of this extraordinary fake in the same issue. Whether, because church-going people are more trusting, and therefore more easily befooled than others, or from some more obscure reason, many of the religious papers fairly reek with patent-medicine fakes. Take, for instance, the _Christian Endeavor World_, which is the undenominational organ of a large, powerful and useful organization, unselfishly working toward the betterment of society. A subscriber who recently complained of certain advertisements received the following reply from the business manager of the publication: "Dear Sir:--Your letter of the 4th comes to me for reply. Appreciating the good spirit in which you write, let me assure you that, to the best of our knowledge and belief, we are not publishing any fraudulent or unworthy medicine advertising. We decline every year thousands of dollars' worth of patent-medicine advertising that we think is either fraudulent or misleading. You would be surprised, very likely, if you could know of the people of high intelligence and good character who are benefited by these {059}medicines. We have taken a great deal of pains to make particular inquiries of our subscribers with respect to this question, and a very large percentage of them are devoted to one or more well-known patent medicines, and regard them as household remedies. Trusting that you will be able to understand that we are acting according to our best and sincerest judgment, I remain, yours very truly, "The Golden Rule Company, "George W. Coleman, Business Manager" Running through half a dozen recent issues of the _Christian Endeavor World_, I find nineteen medical advertisements of, at best, dubious nature. Assuming that the business management of the _Christian Endeavor World_ represents normal intelligence, I would like to ask whether it accepts the statement that a pair of "magic foot drafts" applied to the bottom of the feet will cure any and every kind of rheumatism in any part of the body? Further, if the advertising department is genuinely interested in declining "fraudulent or misleading" copy, I would call their attention to the ridiculous claims of Dr. Shoop's medicines, which "cure" almost every disease; to two hair removers, one an "Indian Secret," the other an "accidental discovery," both either fakes or dangerous; to the lying claims of Hall's Catarrh Cure, that it is "a positive cure for catarrh" in all its stages to "Syrup of Figs," which is not a fig syrup, but a preparation of senna; to Dr. Kilmer's Swamp Root, of which the principal medicinal constituent is alcohol; and, finally, to Dr. Bye's Oil Cure for cancer, a particularly cruel swindle on unfortunates suffering from an incurable malady. All of these, with other matter, which for the sake of decency I do not care to detail in these columns, appear in recent issues of the _Christian Endeavor World_, and are respectfully submitted to its management and its readers. Quackery and Religion. The Baptist Watchman of Oct. 12, 1905, prints an editorial defending the principle of patent medicines. It would be interesting to know whether the back page of the number has any connection with the editorial. This page is given up to an illustrated advertisement of Vito-Ore, one of the boldest fakes in the whole Frauds' Gallery. Vitæ-Ore claims to be a mineral mined from "an extinct mineral spring," and to contain free iron, free sulphur and free magnesium. It contains no free iron, no free sulphur, and no free magnesium. It announces itself as "a certain and never-failing cure" for rheumatism and Bright's disease, dropsy, blood poisoning, nervous prostration and general debility, among other maladies. Whether it is, as asserted, mined from an extinct spring or bucketed from a sewer has no bearing on its utterly fraudulent character. There is no "certain and never-failing cure" for the diseases in its list, and when the _Baptist Watchman_ sells itself to such an exploitation it becomes partner to a swindle not only on the pockets of its readers, but on their health as well. In the same issue I find "Piso's Cure for Consumption," "Bye's Cancer Cure," "Mrs. M. Summer's Female Remedy," "Winslow's Soothing Syrup," and "Juven Pills," somewhat disguised here, but in other mediums openly a sexual weakness "remedy." A correspondent sends me clippings from _The Christian Century_, leading off with an interesting editorial entitled "Our Advertisers," from which I quote in part: "We take pleasure in calling the attention of our readers to the high grade of advertising which _The Christian Century_ commands. We shall continue to advertise only such companies as we know to be thoroughly reliable. During the past year we have refused thousands of dollars' {060}worth of advertising which other religious journals are running, but which is rated 'objectionable' by the better class of periodicals. Compare our advertising columns with the columns of any other purely religious journal, and let us know what you think of the character of our advertising patrons." Whether the opinion of a non-subscriber will interest _The Christian Century_ I have no means of knowing, but I will venture it. My opinion is that a considerable proportion of its advertisements are such as any right-minded and intelligent publisher should be ashamed to print, and that if its readers accept its endorsement of the advertising columns they will have a very heavy indictment to bring against it. Three "cancer cures," a dangerous "heart cure," a charlatan eye doctor, Piso's Consumption Cure, Dr. Shoop's Rheumatism Cure and Liquozone make up a pretty fair "Frauds' Gallery" for the delectation of _The Christian Century's_ readers. [IMAGE ==>] {060} As a convincing argument, many nostrums guarantee, not a cure, as they would have the public believe, but a reimbursement if the medicine is unsatisfactory. Liquozone does this, and faithfully carries out its agreement. Electro-gen, a new "germicide," which has stolen Liquozone's advertising scheme almost word for word, also promises this. Dr. Shoop's agreement {061}is so worded that the unsatisfied customer is likely to have considerable trouble in getting his money back. Other concerns send their "remedies" free on trial, among these being the ludicrous "magic foot drafts" referred to above. At first thought it would seem that only a cure would bring profit to the makers. But the fact is that most diseases tend to cure themselves by natural means, and the delighted and deluded patient, ascribing the relief to the "remedy," which really has nothing to do with it, sends on his grateful dollar. Where the money is already paid, most people are too inert to undertake the effort of getting it back. It is the easy American way of accepting a swindle as a sort of joke, which makes for the nostrum readers ready profits. Safe Rewards. Then there is the "reward for proof" that the proprietary will not perform the wonders advertised. The Liquozone Company offer $1,000, I believe, for any germ that Liquozone will not kill. This is a pretty safe offer, because there are no restrictions as to the manner in which the unfortunate germ might be maltreated. If the matter came to an issue, the defendants might put their bacillus in the Liquozone bottle and freeze him solid. If that didn't end him, they could boil the ice and save their money, as thus far no germ has been discovered which can survive the process of being made into soup. Nearly all of the Hall Catarrh Cure advertisements offer a reward of $100 for any case of catarrh which the nostrum fails to cure. It isn't enough, though one hundred times that amount might be worth while; for who doubts that Mr. F. J. Cheney, inventor of the "red clause," would fight for his cure through every court, exhausting the prospective $100 reward of his opponent in the first round? How hollow the "guarantee" pretence is, is shown by a clever scheme devised by Radam, the quack, years ago, when Shreveport was stricken with yellow fever. Knowing that his offer could not be accepted, he proposed to the United States Government that he should eradicate the epidemic by destroying all the germs with Radam's Microbe Killer, offering to deposit $10,000 as a guarantee. Of course, the Government declined on the ground that it had no power to accept such an offer. Meantime, Radam got a lot of free advertising, and his fortune was made. No little stress is laid on "personal advice" by the patent-medicine companies. This may be, according to the statements of the firm, from their physician or from some special expert. As a matter of fact, it is almost invariably furnished by a $10-a-week typewriter, following out one of a number of "form" letters prepared in bulk for the "personal-inquiry" dupes. Such is the Lydia E. Pinkham method. The Pinkham Company writes me that it is entirely innocent of any intent to deceive people into believing that Lydia E. Pinkham is still alive, and that it has published in several cases statements regarding her demise. It is true that a number of years ago a newspaper forced the Pinkham concern into a defensive admission of Lydia E. Pinkham's death, but since then the main purpose of the Pinkham advertising has been to befool the feminine public into believing that their letters go to a woman--who died nearly twenty years ago of one of the diseases, it is said, which her remedy claims to cure. The Immortal Mrs. Pinkham. True, the newspaper appeal is always "Write to Mrs. Pinkham," and this is technically a saving clause, as there is a Mrs. Pinkham, widow of the son of Lydia E. Pinkham. What sense of shame she might be supposed to suffer in the perpetration of an obvious and public fraud is presumably {062}salved by the large profits of the business. The great majority of the gulls who "write to Mrs. Pinkham" suppose themselves to be addressing Lydia E. Pinkham, and their letters are not even answered by the present proprietor of the name, but by a corps of hurried clerks and typewriters. You get the same result when you write to Dr. Hartman, of Peruna, for personal guidance. Dr. Hartman himself told me that he took no active part now in the conduct of the Peruna Company. If he sees the letters addressed to him at all, it is by chance. "Dr. Kilmer," of Swamp-Root fame, wants you to write to him about your kidneys. There is no Dr. Kilmer in the Swamp-Root concern, and has not been for many years. Dr. T. A. Slocum, who writes you so earnestly and piously about taking care of your consumption in time, is a myth. The whole "personal medical advice" business is managed by rote, and the letter that you get "special to your case" has been printed and signed before your inquiry ever reached the shark who gets your money. An increasingly common pitfall is the letter in the newspapers from some sufferer who has been saved from disease and wants you to write and get the prescription free. A conspicuous instance of this is "A Notre Dame Lady's Appeal" to sufferers from rheumatism and also from female trouble. "Mrs. Summers," of Notre Dame, Ill., whose picture in the papers represents a fat Sister of Charity, with the wan, uneasy expression of one who feels that her dinner isn't digesting properly, may be a real lady, but I suspect she wears a full beard and talks in a bass voice, because my letter of inquiry to her was answered by the patent medicine firm of Vanderhoof & Co., who inclosed some sample tablets and wanted to sell me more. There are many others of this class. It is safe to assume that every advertising altruist who pretends to give out free prescriptions is really a quack medicine firm in disguise. One more instance of bad faith to which the nostrum patron renders himself liable: It is asserted that these letters of inquiry in the patent medicine field are regarded as private. "All correspondence held strictly private and sacredly confidential," advertises Dr. R. V. Pierce, of the Golden Medical Discovery, etc. A Chicago firm of letter brokers offers to send me 50,000 Dr. Pierce order blanks at $2 a thousand for thirty days; or I can get terms on Ozomulsion, Theodore Noel (Vitæ-Ore), Dr. Stevens' Nervous Debility Cure, Cactus Cure, women's regulators, etc. With advertisements in the medical journals the public is concerned only indirectly, it is true, but none the less vitally. Only doctors read these exploitations, but if they accept certain of them and treat their patients on the strength of the mendacious statements it is at the peril of the patients. Take, for instance, the Antikamnia advertising which appears in most of the high-class medical journals, and which includes the following statements: "Do not depress the heart. Do not produce habit. Are accurate--safe--sure." These three lines, reproduced as they occur in the medical journals, contain five distinct and separate lies--a triumph of condensed mendacity unequaled, so far as I know, in the "cure all" class. For an instructive parallel here are two claims made by Duffy's Malt Whiskey, one taken from a medical journal, and hence "ethical," the other transcribed from a daily paper and therefore to be condemned by all medical men. Puzzle: Which is the ethical and which the unethical advertisement? [IMAGE ==>] {063} "It is the only cure and preventative [sic] of consumption, pneumonia, grip, bronchitis, coughs, colds, malaria, low fevers and all wasting, weakening, diseased conditions." {064} "Cures general debility, overwork, la grippe, colds, bronchitis, consumption, malaria, dyspepsia, depression, exhaustion and weakness from whatever cause." All the high-class medical publications accept the advertising of "McArthur's Syrup of Hypophosphites," which uses the following statement: "It is the enthusiastic conviction of many (physicians) that its effect is truly specific." That looks to me suspiciously like a "consumption cure" shrewdly expressed in pseudo-ethical terms. The Germicide Family. Zymoticine, if one may believe various medical publications, "will prevent microbe proliferation in the blood streams, and acts as an efficient eliminator of those germs and their toxins which are already present." Translating this from its technical language, I am forced to the conviction that Zymoticine is half-brother to Liquozone, and if the latter is illegitimate at least both are children of Beelzebub, father of all frauds. Of the same family are the "ethicals" Acetozone and Keimol, as shown by their germicidal claims. Again, I find exploited to the medical profession, through its own organa, a "sure cure for dropsy." "Hygeia presents her latest discovery," declares the advertisement, and fortifies the statement with a picture worthy of Swamp-Root or Lydia Pinkham. Every intelligent physician knows that there is no sure cure for dropsy. The alternative implication is that the advertiser hopes to get his profit by deluding the unintelligent of the profession, and that the publications which print his advertisement are willing to hire themselves out to the swindle. In one respect some of the medical journals are far below the average of the newspapers, and on a par with the worst of the "religious" journals. They offer their reading space for sale. Here is an extract from a letter from the _Medical Mirror_ to a well-known "ethical firm": "Should you place a contract for this issue we shall publish a 300-word report in your interest in our reading columns." Many other magazines of this class print advertisements as original reading matter calculated to deceive their subscribers. Back of all patent medicine advertising stands the testimonial. Produce proofs that any nostrum can not in its nature perform the wonders that it boasts, and its retort is to wave aloft its careful horde or letters and cry: "We rest on the evidence of those we have cured." The crux of the matter lies in the last word. Are the writers of those, letters really cured? What is the value of these testimonials? Are they genuine? Are they honest? Are they, in their nature and from their source, entitled to such weight as would convince a reasonable mind? Three distinct types suggest themselves: The word of grateful acknowledgement from a private citizen, couched in such terms as to be readily available for advertising purposes; the encomium from some person in public life, and the misspelled, illiterate epistle which is from its nature so unconvincing that it never gets into print, and which outnumbers the other two classes a hundred to one. First of all, most nostrums make a point of the mass of evidence. Thousands of testimonials, they declare, {065}just as valuable for their purposes as those they print, are in their files. This is not true. I have taken for analysis, as a fair sample, the "World's Dispensary Medical Book," published by the proprietors of Pierce's Favorite Prescription, the Golden Medical Discovery, Pleasant Pellets, the Pierce Hospital, etc. As the dispensers of several nostrums, and because of their long career in the business, this firm should be able to show as large a collection of favorable letters as any proprietary concern. Overworked Testimonials. In their book, judiciously scattered, I find twenty-six letters twice printed, four letters thrice printed and two letters produced four times. Yet the compilers of the book "have to regret" (editorially) that they can "find room only for this comparatively small number in this volume." Why repeat those they have if this is true? If enthusiastic indorsements poured in on the patent medicine people, the Duffy's Malt Whiskey advertising management would hardly be driven to purchasing its letters from the very aged and from disreputable ministers of the gospel. If all the communications were as convincing as those published, the Peruna Company would not have to employ an agent to secure publishable letters, nor the Liquozone Company indorse across the face of a letter from a Mrs. Benjamin Charters: "Can change as we see fit." Many, in fact I believe I may say almost all, of the newspaper-exploited testimonials are obtained at an expense to the firm. Agents are employed to secure them. This costs money. Druggists get a discount for forwarding letters from their customers. This costs money. Persons willing to have their picture printed get a dozen photographs for themselves. This costs money. Letters of inquiry answered by givers of testimonials bring a price--25 cents per letter, usually. Here is a document sent out periodically by the Peruna Company to keep in line its "unsolicited" beneficiaries: "As you are aware, we have your testimonial to our remedy. It has been some time since we have heard from you, and so we thought best to make inquiry as to your present state of health and whether you still occasionally make use of Peruna. We also want to make sure that we have your present street address correctly, and that you are making favorable answers to such letters of inquiry which your testimonial may occasion. Remember that we allow 25 cents for each letter of inquiry. You have only to send the letter you receive, together with a copy of your reply to the same, and we will forward you 25 cents for each pair of letters. "We hope you are still a friend of Peruna and that our continued use of your testimonial will be agreeable to you. We are inclosing stamped envelope for reply. Very sincerely yours, "The Peruna Drug Manufacturing Company, "Per Carr." And here is an account of another typical method of collecting this sort of material, the writer being a young New Orleans man, who answered an advertisement in a local paper, offering profitable special work to a news paper man with spare time: "I found the advertiser to be a woman, the coarseness of whose features was only equaled by the vulgarity of her manners and speech, and whose self-assertiveness was in proportion to her bulk. She proposed that I set about securing testimonials to the excellent qualities of Peruna, which she pronounced 'Pay-Runa,' for which I was to receive a fee of $5 to $10, according to the prominence of 'the guy' from whom I obtained it. This I declined {066}flatly. She then inquired whether or not I was a member of any social organizations or clubs in the city, and receiving a positive answer she offered me $3 for a testimonial, including the statement that Pay-Runa had been used by the members of the Southern Athletic Club with good effects, and raised it to $5 before I left. "Upon my asking her what her business was before she undertook the Pay-Runa work, she became very angry. Now, when a female is both very large and very angry, the best thing for a small, thin young man to do is to leave her to her thoughts and the expression thereof. I did it." [IMAGE: ==>] {066} No Questions Desired. {067} Testimonials obtained in this way are, in a sense, genuine; that is, the nostrum firm has documentary evidence that they were given; but it is hardly necessary to state that they are not honest. Often the handling of the material is very careless, as in the case of Doan's Kidney Pills, which ran an advertisement in a Southern city embodying a letter from a resident of that city who had been dead nearly a year. Cause of death, kidney disease. In a former article I have touched on the matter of testimonials from public men. These are obtained through special agents, through hangers-on of the newspaper business who wheedle them out of congressmen or senators, and sometimes through agencies which make a specialty of that business. A certain Washington firm made a "blanket offer" to a nostrum company of a $100 joblot of testimonials, consisting of one De Wolf Hopper, one Sarah Bernhardt and six "statesmen," one of them a United States senator. Whether they had Mr. Hopper and Mme. Bernhardt under agreement or were simply dealing in futures I am unable to say, but the offer was made in business-like fashion. And the "divine Sarah" at least seems to be an easy subject for patent medicines, as her letters to them are by no means rare. Congressmen are notoriously easy to get, and senators are by no means beyond range. There are several men now in the United States Senate who have, at one time or another, prostituted their names to the uses of fraud medicines, which they do not use and of which they know nothing. Naval officers seem to be easy marks. Within a few weeks a retired admiral of our navy has besmirched himself and his service by acting as pictorial sales agent for Peruna. If one carefully considers the "testimonials" of this class it will appear that few of the writers state that they have ever tried the nostrum. We may put down the "public man's" indorsement, then, as genuine (documentarily), but not honest. Certainly it can bear no weight with an intelligent reader. Almost as eagerly sought for as this class of letter is the medical indorsement. Medical testimony exploiting any medicine advertised in the lay press withers under investigation. In the Liquozone article of this series I showed how medical evidence is itself "doctored." This was an extreme instance, for Liquozone, under its original administration, exhibited less conscience in its methods than any of its competitors that I have encountered. Where the testimony itself is not distorted, it is obtained under false pretences or it comes from men of no standing in the profession. Some time ago Duffy's Malt Whiskey sent out an agent to get testimonials from hospitals. He got them. How he got them is told in a letter from the physician in charge of a prominent Pennsylvania institution: "A very nice appearing man called here one day and sent in his card, bearing the name of Dr. Blank (I can't recall the name, but wish I could), a graduate of Vermont University. He was as smooth an article as I have ever been up against, and I have met a good many. He at once got down to business and began to talk of the hospitals he had visited, mentioning physicians whom I knew either personally or by reputation. He then brought out a lot of documents for me to peruse, all of which were bona fide affairs, from the various institutions, signed by the various physicians or resident physicians, setting forth the merits or use of 'Duffy's Malt Whiskey.' He asked if I had ever used it. I said yes, but very little, and was at the time using some, a fact, as I was sampling what he handed me. He then placed about a dozen small bottles, holding possibly two ounces, on the table, and said I should keep it, and he would send me two quarts free for use here as soon as he got back." Getting a Testimonial from a Physician. {068} "He next asked me if I would give him a testimonial regarding Duffy's Whiskey. I said I did not do such things, as it was against my principles to do so. 'But this is not for publication,' he said. I replied that I had used but little of it, and found it only the same as any other whisky. He then asked if I was satisfied with the results as far as I had used it. I replied that I was. He then asked me to state that much, and I very foolishly said I would, on condition that it was not to be used as an advertisement, and he assured me it would not be used. I then, in a few words, said that 'I (or we) have used and are using Duffy's Malt Whiskey, and are satisfied with the results,' signing my name to the same. He left here, and what was my surprise to receive later on a booklet in which was my testimonial and many others, with cuts of hospitals ranging along with people who had reached 100 years by use of the whisky, while seemingly all ailments save ringbone and spavin were being cured by this wonderful beverage. I was provoked, but was paid as I deserved, for allowing a smooth tongue to deceive me. Duffy's Malt Whiskey has never been inside this place since that day and never will be while I have any voice to prevent it. The total amount used at the time and before was less than half a gallon." This hospital is still used as a reference by the Duffy people. Many of the ordinary testimonials which come unsolicited to the extensively advertised nostrums in great numbers are both genuine and honest. What of their value as evidence? Some years ago, so goes a story familiar in the drug trade, the general agent for a large jobbing house declared that he could put out an article possessing not the slightest remedial or stimulant properties, and by advertising it skillfully so persuade people of its virtues that it would receive unlimited testimonials to the cure of any disease for which he might choose to exploit it. Challenged to a bet, he became a proprietary owner. Within a year he had won his wager with a collection of certified "cures" ranging from anemia to pneumonia. Moreover, he found his venture so profitable that he pushed it to the extent of thousands of dollars of profits. His "remedy" was nothing but sugar. I have heard "Kaskine" mentioned as the "cure" in the case. It answers the requirements, or did answer them at that time, according to an analysis by the Massachusetts State Board of Health, which shows that its purchasers had been paying $1 an ounce for pure granulated sugar. Whether "Kaskine" was indeed the subject of this picturesque bet, or whether it was some other harmless fraud, is immaterial to the point, which is that where the disease cures itself, as nearly all diseases do, the medicine gets the benefit of this _viæ medicatriæ naturæ_--the natural corrective force which makes for normal health in every human organism. Obviously, the sugar testimonials can not be regarded as very weighty evidence. Testimonials for a Magic Ring. There is being advertised now a finger ring which by the mere wearing cures any form of rheumatism. The maker of that ring has genuine letters from people who believe that they have been cured by it. Would any one other than a believer in witchcraft accept those statements? Yet they are just as "genuine" as the bulk of patent medicine letters and written in as good faith. A very small proportion of the gratuitous indorsements get into the newspapers, because, as I have said, they do not lend themselves {069}well to advertising purposes. I have looked over the originals of hundreds of such letters, and more than 90 per cent, of them--that is a very conservative estimate--are from illiterate and obviously ignorant people. Even those few that can be used are rendered suitable for publication only by careful editing. The geographical distribution is suggestive. Out of 100 specimens selected at random from the Pierce testimonial book, eighty-seven are from small, remote hamlets, whose very names are unfamiliar to the average man of intelligence. Only five are from cities of more than 50,000 inhabitants. Now, Garden City, Kas.; North Yamhill, Ore.; Theresa, Jefferson County, N. Y.; Parkland, Ky., and Forest Hill, W. Va., may produce an excellent brand of Americanism, but one does not look for a very high average of intelligence in such communities. Is it only a coincidence that the mountain districts of Kentucky, West Virginia and Tennessee, recognized as being the least civilized parts of the country, should furnish a number of testimonials, not only to Pierce, but to Peruna, Paine's Celery Compound and other brands, out of all proportion to their population? On page 65 {065} is a group of Pierce enthusiasts and a group of Peruna witnesses. Should you, on the face of this exhibit, accept their advice on a matter wholly affecting your physical welfare? This is what the advertiser is asking you to do. Secure as is the present control of the Proprietary Association over the newspapers, there is one point in which I believe almost any journal may be made to feel the force of public opinion, and that is the matter of common decency. Newspapers pride themselves on preserving a respectable moral standard in their news columns, and it would require no great pressure on the part of the reading public (which is surely immediately interested) to extend this standard to the advertising columns. I am referring now not only to the unclean sexual, venereal and abortion advertisements which deface the columns of a majority of papers, but also to the exploitation of several prominent proprietaries. Recently a prominent Chicago physician was dining _en famille_ with a friend who is the publisher of a rather important paper in a Western city. The publisher was boasting that he had so established the editorial and news policy of his paper that every line of it could be read without shame in the presence of any adult gathering. "Never anything gets in," he declared, "that I couldn't read at this table before my wife, son and daughter." The visitor, a militant member of his profession, snuffed battle from afar. "Have the morning's issue brought," he said. Turning to the second page he began on Swift's Sure Specific, which was headed in large black type with the engaging caption, "Vile, Contagious Blood Poison." Before he had gone far the 19-year-old daughter of the family, obedient to a glance from the mother, had gone to answer an opportune ring at the telephone, and the publisher had grown very red in the face. "I didn't mean the advertisements," he said. "I did," said the visitor, curtly, and passed on to one of the extremely intimate, confidential and highly corporeal letters to the ghost of Lydia E. Pinkham, which are a constant ornament of the press. The publisher's son interrupted: "I don't believe that was written for me to hear," he observed. "I'm too young--only 25, you know. Call me when you're through. I'll be out looking at the moon." Relentlessly the physician turned the sheet and began on one of the Chattanooga Medical Company's physiological editorials, entitled "What {070}Men Like in a Girl." For loathsome and gratuitous indecency, for leering appeal to their basest passions, this advertisement and the others of the Wine of Cardui series sound the depths. The hostess lasted through the second paragraph, when she fled, gasping. "Now," said the physician to his host, "what do you think of yourself?" The publisher found no answer, but thereafter his paper was put under a censorship of advertising. Many dailies refuse such "copy" as this of Wine of Cardui. And here, I believe, is an opportunity for the entering wedge. If every subscriber to a newspaper who is interested in keeping his home free from contamination would protest and keep on protesting against advertising foulness of this nature, the medical advertiser would soon be restricted to the same limits of decency which other classes of merchandise accept as a matter of course, for the average newspaper publisher is quite sensitive to criticism from his readers. A recent instance came under my own notice in the case of the _Auburn_ (N. Y.) _Citizen_, which bought out an old-established daily, taking over the contracts, among which was a large amount of low-class patent medicine advertising. The new proprietor, a man of high personal standards, assured his friends that no objectionable matter would be permitted in his columns. Shortly after the establishment of the new paper there appeared an advertisement of Juven Pills, referred to above. Protests from a number of subscribers followed. Investigation showed that a so-called "reputable" patent medicine firm had inserted this disgraceful paragraph under their contract. Further insertions of the offending matter were refused and the Hood Company meekly accepted the situation. Another central New York daily, the _Utica Press_, rejects such "copy" as seems to the manager indecent, and I have yet to hear of the paper's being sued for breach of contract. No perpetrator of unclean advertising can afford to go to court on this ground, because he knows that his matter is indefensible. Our national quality of commercial shrewdness fails us when we go into the open market to purchase relief from suffering. The average American, when he sets out to buy a horse, or a house, or a box of cigars, is a model of caution. Show him testimonials from any number of prominent citizens and he would simply scoff. He will, perhaps, take the word of his life-long friend, or of the pastor of his church, but only after mature thought, fortified by personal investigation. Now observe the same citizen seeking to buy the most precious of all possessions, sound health. Anybody's word is good enough for him here. An admiral whose puerile vanity has betrayed him into a testimonial; an obliging and conscienceless senator; a grateful idiot from some remote hamlet; a renegade doctor or a silly woman who gets a bonus of a dozen photographs for her letter--any of these are sufficient to lure the hopeful patient to the purchase. He wouldn't buy a second-hand bicycle on the affidavit of any of them, but he will give up his dollar and take his chance of poison on a mere newspaper statement which he doesn't even investigate. Every intelligent newspaper publisher knows that the testimonials which he publishes are as deceptive as the advertising claims are false. Yet he salves his conscience with the fallacy that the moral responsibility is on the advertiser and the testimonial-giver. So it is, but the newspaper shares it. When an aroused public sentiment shall make our public men ashamed to lend themselves to this charlatanry, and shall enforce on the profession of journalism those standards of decency in the field of medical advertising which apply to other advertisers, the Proprietary {071}Association of America will face a crisis more perilous than any threatened legislation. For printers' ink is the very life-blood of the noxious trade. Take from the nostrum vendors the means by which they influence the millions, and there will pass to the limbo of pricked bubbles a fraud whose flagrancy and impudence are of minor import compared to the cold-hearted greed with which it grinds out its profits from the sufferings of duped and eternally hopeful ignorance. THE PATENT MEDICINE CONSPIRACY AGAINST THE FREEDOM OF THE PRESS. Reprinted from Collier's Weekly, Nov. 4, 1905. {072} "Here shall the Press the People's rights maintain. Unawed by influence and unbribed by gain." --Joseph Story: Motto of the Salem Register. _Would any person believe that there is any one subject upon which the newspapers of the United States, acting in concert, by prearrangement, in obedience to wires all drawn by one man, will deny full and free discussion? If such a thing is possible, it is a serious matter, for we rely upon the newspapers as at once the most forbidding preventive and the swiftest and surest corrective of evil. For the haunting possibility of newspaper exposure, men who know not at all the fear of God pause, hesitate, and turn back from contemplated rascality. For fear "it might get into the papers," more men are abstaining from crime and carouse to-night than for fear of arrest. But these are trite things--only, what if the newspapers fail us? Relying so wholly on the press to undo evil, how shall we deal with that evil with which the press itself has been seduced into captivity?_ In the Lower House of the Massachusetts Legislature one day last March there was a debate which lasted one whole afternoon and engaged some twenty speakers, on a bill providing that every bottle of patent medicine sold in the state should bear a label stating the contents of the bottle. More was told concerning patent medicines that afternoon than often comes to light in a single day. The debate at times was dramatic--a member from Salem told of a young woman of his acquaintance now in an institution for inebriates as the end of an incident which began with patent medicine dosing for a harmless ill. There was humor, too, in the debate--Representative Walker held aloft a bottle of Peruna bought by him in a drug store that very day and passed it around for his fellow-members to taste and decide for themselves whether Dr. Harrington, the Secretary of the State Board of Health, was right when he told the Legislative Committee that it was merely a "cheap cocktail." The Papers did not Print One Word. In short, the debate was interesting and important--the two qualities which invariably ensure to any event big headlines in the daily newspapers. But that debate was not celebrated by big headlines, nor any headlines at all. Yet Boston is a city, and Massachusetts is a state, where the proceedings of the legislature figure very large in public interest, and where the newspapers respond to that interest by reporting the sessions with greater fullness and minuteness than in any other state. Had that debate {073}been on prison reform, on Sabbath observance, the early closing saloon law, on any other subject, there would have been, in the next day's papers, overflowing accounts of verbatim report, more columns of editorial comment, and the picturesque features of it would have ensured the attention of the cartoonist. Now why? Why was this one subject tabooed? Why were the daily accounts of legislative proceedings in the next day's papers abridged to a fraction of their usual ponderous length, and all reference to the afternoon debate on patent medicines omitted? Why was it in vain for the speakers in that patent-medicine debate to search for their speeches in the next day's newspapers? Why did the legislative reporters fail to find their work in print? Why were the staff cartoonists forbidden to exercise their talents on that most fallow and tempting opportunity--the members of the Great and General Court of Massachusetts gravely tippling Peruna and passing the bottle around to their encircled neighbors, that practical knowledge should be the basis of legislative action? I take it if any man should assert that there is one subject on which the newspapers of the United States, acting in concert and as a unit, will deny full and free discussion, he would be smiled at as an intemperate fanatic. The thing is too incredible. He would be regarded as a man with a delusion. And yet I invite you to search the files of the daily newspapers of Massachusetts for March 16, 1905, for an account of the patent-medicine debate that occurred the afternoon of March 15 in the Massachusetts Legislature. In strict accuracy it must be said that there was one exception. Any one familiar with the newspapers of the United States will already have named it--the Springfield _Republican_. That paper, on two separate occasions, gave several columns to the record of the proceedings of the legislature on the patent-medicine bill. Why the otherwise universal silence? The patent-medicine business in the United States is one of huge financial proportions. The census of 1900 placed the value of the annual product at $59,611,355. Allowing for the increase of half a decade of rapid growth, it must be to-day not less than seventy-five millions. That is the wholesale price. The retail price of all the patent medicines sold in the United States in one year may be very conservatively placed at one hundred million dollars. And of this one hundred millions which the people of the United States pay for patent medicines yearly, fully forty millions goes to the newspapers. Have patience! I have more to say than merely to point out the large revenue which newspapers receive from patent medicines, and let inference do the rest. Inference has no place in this story. There are facts a-plenty. But it is essential to point out the intimate financial relation between the newspapers and the patent medicines. I was told by the man who for many years handled the advertising of the Lydia E. Pinkham Company that their expenditure was $100,000 a month, $1,200,000 a year. Dr. Pierce and the Peruna Company both advertise more extensively than the Pinkham Company. Certainly there are at least five patent-medicine concerns in the United States who each pay out to the newspapers more than one million dollars a year. When the Dr. Greene Nervura Company of Boston went into bankruptcy, its debts to newspapers for advertising amounted to $535,000. To the Boston _Herald_ alone it owed $5,000, and to so small a paper, comparatively, as the Atlanta _Constitution_ it owed $1,500. One obscure {074}quack doctor in New York, who did merely an office business, was raided by the authorities, and among the papers seized there were contracts showing that within a year he had paid to one paper for advertising $5,856.80; to another $20,000. Dr. Humphreys, one of the best known patent-medicine makers, has said to his fellow-members of the Patent Medicine Association: "The twenty thousand newspapers of the United States make more money from advertising the proprietary medicines than do the proprietors of the medicines themselves.... Of their receipts, one-third to one-half goes for advertising." More than six years ago, Cheney, the president of the National Association of Patent Medicine Men, estimated the yearly amount paid to the newspapers by the larger patent-medicine concerns at twenty million dollars--more than one thousand dollars to each daily, weekly and monthly periodical in the United States. [IMAGE ==>] {074} Silence is the Fixed Quantity. Does this throw any light on the silence of the Massachusetts papers? {075} Naturally such large sums paid by the patent-medicine men to the newspapers suggest the thought of favor. But silence is too important a part of the patent-medicine man's business to be left to the capricious chance of favor. Silence is the most important thing in his business. The ingredients of his medicine--that is nothing. Does the price of goldenseal go up? Substitute whisky. Does the price of whisky go up? Buy the refuse wines of the California vineyards. Does the price of opium go too high, or the public fear of it make it an inexpedient thing to use? Take it out of the formula and substitute any worthless barnyard weed. But silence is the fixed quantity--silence as to the frauds he practices; silence as to the abominable stewings and brewings that enter into his nostrum; silence as to the deaths and sicknesses he causes; silence as to the drug fiends he makes, the inebriate asylums he fills. Silence he must have. So he makes silence a part of the contract. Read the significant silence of the Massachusetts newspapers in the light of the following contracts for advertising. They are the regular printed form used by Hood, Ayer and Munyon in making their advertising contracts with thousands of newspapers throughout the United States. On page 80 [IMAGE ==>] {080} is shown the contract made by the J. C. Ayer Company, makers of Ayer's Sarsaparilla. At the top is the name of the firm, "The J. C. Ayer Company, Lowell,, Mass.," and the date. Then follows a blank for the number of dollars, and then the formal contract: "We hereby agree, for the sum of............ Dollars per year,........to insert in the............. published at............... the advertisement of the J. C. Ayer Company." Then follow the conditions as to space to be used each issue, the page the advertisement is to be on and the position it is to occupy. Then these two remarkable conditions of the contract: "First--It is agreed in case any law or laws are enacted, either state or national, harmful to the interests of the T. C. Ayer Company, that this contract may be canceled by them from date of such enactment, and the insertions made paid for pro-rata with the contract price." This clause is remarkable enough. But of it more later. For the present examine the second clause: "Second--It is agreed that the J. C. Ayer Co. may cancel this contract, pro-rata, in case advertisements are published in this paper in which their products are offered, with a view to substitution or other harmful motive; also in case any matter otherwise detrimental to the J. C. Ayer Company's interest is permitted to appear in the reading columns or elsewhere in the paper." This agreement is signed in duplicate, one by the J. C. Ayer Company and the other one by the newspaper. All Muzzle-Clauses Alike. That is the contract of silence. (Notice the next one, in identically the same language, bearing the name of the C. I. Hood Company, the other great manufacturer of sarsaparilla; and then the third--again in identically the same words--for Dr. Munyon.) That is the clause which with forty million dollars, muzzles the press of the country. I wonder if the Standard Oil Company could, for forty million dollars, bind the newspapers of the United States in a contract that "no matter detrimental to the Standard Oil Company's interests be permitted to appear in the reading columns or elsewhere in this paper." Is it a mere coincidence that in each of these contracts the silence {076}clause is framed in the same words? Is the inference fair that there is an agreement among the patent-medicine men and quack doctors each to impose this contract on all the newspapers with which it deals, one reaching the newspapers which the other does not, and all combined reaching all the papers in the United States, and effecting a universal agreement among newspapers to print nothing detrimental to patent medicines? You need not take it as an inference. I shall show it later as a fact. [IMAGE ==>] {076} "In the reading columns or elsewhere in this paper." The paper must not print itself, nor must it allow any outside party, who might wish to do so, to pay the regular advertising rates and print the truth about patent medicines in the advertising columns. More than a year ago, just after Mr. Bok had printed his first article exposing patent medicines, a business man in St. Louis, a man of great wealth, conceived that it would {077}help his business greatly if he could have Mr. Bok's article printed as an advertisement in every newspaper in the United States. He gave the order to a firm of advertising agents and the firm began in Texas, intending to cover the country to Maine. But that advertisement never got beyond a few obscure country papers in Texas. The contract of silence was effective; and a few weeks later, at their annual meeting, the patent-medicine association "Resolved"--I quote the minutes--"That this Association commend the action of the great majority of the publishers of the United States who have consistently refused said false and malicious attacks in the shape of advertisements which in whole or in part libel proprietary medicines." I have said that the identity of the language of the silence clause in several patent-medicine advertising contracts suggests mutual understanding among the nostrum makers, a preconceived plan; and I have several times mentioned the patent-medicine association. It seems incongruous, almost humorous, to speak of a national organization of quack doctors and patent-medicine makers; but there is one, brought together for mutual support, for co-operation, for--but just what this organization is for, I hope to show. No other organization ever demonstrated so clearly the truth that "in union there is strength." Its official name is an innocent-seeming one--"The Proprietary Association of America." There are annual meetings, annual reports, a constitution, by-laws. And I would call special attention to Article II of those by-laws. "The objects of this association," says this article, "are: to protect the rights of its members to the respective trade-marks that they may own or control; to establish such mutual co-operation as may be required in the various branches of the trade; to reduce all burdens that may be oppressive; to facilitate and foster equitable principles in the purchase and sale of merchandise; to acquire and preserve for the use of its members such business information as may be of value to them; to adjust controversies and promote harmony among its members." That is as innocuous a statement as ever was penned of the objects of any organization. It might serve for an organization of honest cobblers. Change a few words, without altering the spirit in the least, and a body of ministers might adopt it. In this laboriously complete statement of objects, there is no such word as "lobby" or "lobbying." Indeed, so harmless a word as "legislation" is absent--strenuously absent. Where the Money Goes. But I prefer to discover the true object of the organization of the "Proprietary Association of America" in another document than Article II of the by-laws. Consider the annual report of the treasurer, say for 1904. The total of money paid out during the year was $8,516.26. Of this, one thousand dollars was for the secretary's salary, leaving $7,516.26 to be accounted for. Then there is an item of postage, one of stationery, one of printing--the little routine expenses of every organization; and finally there is this remarkable item: Legislative Committee, total expenses, $6,606.95. Truly, the Proprietary Association of America seems to have several {078}objects, as stated in its by-laws, which cost it very little, and one object--not stated in its by-laws at all--which costs it all its annual revenue aside from the routine expenses of stationery, postage and secretary. If just a few more words of comment may be permitted on this point, does it not seem odd that so large an item as $6,606.95, out of a total budget of only $8,516.26, should be put in as a lump sum, "Legislative Committee, total expenses"? And would not the annual report of the treasurer of the Proprietary Association of America be a more entertaining document if these "total expenses" of the Legislative Committee were carefully itemized? [IMAGE ==>] {078} Not that I mean to charge the direct corruption of legislatures. The Proprietary Association of America used to do that. They used to spend, according to the statement of the present president of the organization, Mr. F. J. Cheney, as much as seventy-five thousand dollars a year. But that was before Mr. Cheney himself discovered a better way. The fighting of public health legislation is the primary object and chief activity, the very raison d'etre, of the Proprietary Association. The motive back of bringing the quack doctors and patent-medicine manufacturers of the United States into a mutual organization was this: Here are some scores of men, each paying a large sum annually to the newspapers. The aggregate of these sums is forty million dollars. By organization, the full effect of this money can be got and used as a unit in preventing the passage of laws which would compel them to tell the contents of their nostrums, and in suppressing the newspaper publicity which would drive them {079}into oblivion. So it was no mean intellect which devised the scheme whereby every newspaper in America is made an active lobbyist for the patent-medicine association. The man who did it is the present president of the organization, its executive head in the work of suppressing public knowledge, stifling public opinion and warding off public health legislation, the Mr. Cheney already mentioned. He makes a catarrh cure which, according to the Massachusetts State Board of Health, contains fourteen and three-fourths per cent, of alcohol. As to his scheme for making the newspapers of America not only maintain silence, but actually lobby in behalf of the patent medicines, I am glad that I am not under the necessity of describing it in my own words. It would be easy to err in the direction that makes for incredulity. Fortunately, I need take no responsibility. I have Mr. Cheney's own words, in which he explained his scheme to his fellow-members of the Proprietary Association of America. The quotation marks alone (and the comment within the parentheses) are mine. The remainder is the language of Mr. Cheney himself: Mr. Cheney's Plan. "We have had a good deal of difficulty in the last few years with the different legislatures of the different states.... I believe I have a plan whereby we will have no difficulty whatever with these people. I have used it in my business for two years and know it is a practical thing.... I, inside of the last two years, have made contracts with between fifteen and sixteen thousand newspapers, and never had but one man refuse to sign the contract, and my saying to him that I could not sign a contract without this clause in it he readily signed it. My point is merely to shift the responsibility. We to-day have the responsibility on our shoulders. As you all know, there is hardly a year but we have had a lobbyist in the different state legislatures--one year in New York, one year in New Jersey, and so on." (Read that frank confession twice--note the bland matter-of-factness of it.) "There has been a constant fear that something would come up, so I had this clause in my contract added. This is what I have in every contract I make: 'It is hereby agreed that should your state, or the United States Government, pass any law that would interfere with or restrict the sale of proprietary medicines, this contract shall become void.'... In the state of Illinois a few years ago they wanted to assess me three hundred dollars. I thought I had a better plan than this, so I wrote to about forty papers and merely said: 'Please look at your contract with me and take note that if this law passes you and I must stop doing business, and my contracts cease.'" The next week every one of them had an article, and Mr. Man had to go.... I read this to Dr. Pierce some days ago and he was very much taken up with it. I have carried this through and know it is a success. I know the papers will accept it. Here is a thing that costs us nothing. We are guaranteed against the $75,000 loss for nothing. It throws the responsibility on the newspapers.... I have my contracts printed and I have this printed in red type, right square across the contract, so there can be absolutely no mistake, and the newspaper man can not say to me, 'I did not see it.' He did see it and knows what he is doing. It seems to me it is a point worth every man's attention.... I think this is pretty near a sure thing. [IMAGE ==>] {080} THIS IS THE FORM OF CONTRACT--SEE (A) (B) (C)--THAT MUZZLES THE PRESS OF THE UNITED STATES. The gist of the contract lies in the clause which is marked with brackets, to the effect that the agreement is voidable, In case any matter detrimental to the advertiser's interests "Is permitted to appear in the reading columns, or elsewhere, in this paper." This clause, in the same words, appears in all three of these patent-medicine advertising contracts. The documents reproduced here were gathered from three different newspapers in widely separated parts of the United States. The name of the paper in each case has been suppressed in order to shield the publisher from the displeasure of the patent-medicine combination. How much publishers are compelled to fear this displeasure is exemplified by the experience of the Cleveland _Press,_ from whose columns $18,000 worth of advertising was withdrawn within forty-eight hours. {081} I should like to ask the newspaper owners and editors of America what they think of that scheme. I believe that the newspapers, when they signed each individual contract, were not aware that they were being dragooned into an elaborately thought-out scheme to make every newspaper in the United States, from the greatest metropolitan daily to the remotest country weekly, an active, energetic, self-interested lobbyist for the patent-medicine association. If the newspapers knew how they were being used as cat's-paws, I believe they would resent it. Certainly the patent-medicine association itself feared this, and has kept this plan of Mr. Cheney's a careful secret. In this same meeting of the Proprietary Association of America, just after Mr. Cheney had made the speech quoted above, and while it was being resolved that every other patent-medicine man should put the same clause in his contract, the venerable Dr. Humphreys, oldest and wisest of the guild, arose and said: "Will it {082}not be now just as well to act on this, each and every one for himself, instead of putting this on record?... I think the idea is a good one, But really don't think it had better go in our proceedings." And another fellow nostrum-maker, seeing instantly the necessity of secrecy said: "I am heartily in accord with Dr. Humphreys. The suggestion is a good one, but when we come to put in our public proceedings, and state that we have adopted such a resolution, I want to say that the legislators are just as sharp as the newspaper men.... As a consequence, this will decrease the weight of the press comments. Some of the papers, also, who would not come in, would publish something about it in the way of getting square....." [IMAGE ==>] {082} This contract is the backbone of the scheme. The further details, the organization of the bureau to carry it into effect--that, too, has been kept carefully concealed from the generally unthinking newspapers, who are all unconsciously mere individual cogs in the patent-medicine lobbying machine. At one of the meetings of the association, Dr. R. V. Pierce of Buffalo arose and said (I quote him verbatim):... "I would move you that the report of the Committee on Legislation be made a special order to be taken up immediately... that it be considered in executive session, and that every person not a member of the organization be asked to retire, so that it may be read and considered in executive session. There are matters and suggestions in reference to our future action, and measures to be taken which are advised therein, that we would not wish to have published broadcast over the country for very good reasons." Now what were the "matters and suggestions" which Dr. Pierce "would not wish to have published broadcast over the country for very good reasons?" {083} Can Mr. Cheney Reconcile These Statements? Letter addressed to Mr. William Allen White, Editor of the Gazette, Emporia, Kan. By Frank J. Cheney. Dear Sir-- I have read with a great deal of interest, to-day, an article in Colliers illustrating therein the contract between your paper and ourselves, [see p. 18--Editor.] {018}Mr. S. Hopkins Adams endeavored very hard (as I understand) to find me, but I am sorry to say that I was not at home. I really believe that I could have explained that clause of the contract to his entire satisfaction, and thereby saved him the humiliation of making an erratic statement. This is the first intimation that I ever have had that that clause was put into the contract to control the Press in any way, or the editorial columns of the Press. I believe that if Mr. Adams was making contracts now, and making three-year contracts, the same as we are, taking into consideration the conditions of the different legislatures, he would be desirous of this same paragraph as a safety guard to protect himself, in case any State did pass a law prohibiting the sale of our goods. His argument surely falls flat when he takes into consideration the conduct of the North Dakota Legislature, because every newspaper in that State that we advertise in hid contracts containing that clause. Why we should be compelled to pay for from one to two years' advertising or more, in a State where we could not sell our goods, is more than I can understand. As before stated, it is merely a precautionary paragraph to meet conditions such as now {084}exist in North Dakota. We were compelled to withdraw from that State because we would not publish our formula, and, therefore, under this contract, we are not compelled to continue our advertising. Extract from a speech delivered before the Proprietary Association of America. By Frank J. Cheney. "We have had a good deal of difficulty in the last few years with the different legislatures of the different states.... I believe I have a plan whereby we will have no difficulty whatever with these people. I have used it in my business for two years, and I know it is a practical thing.... I, inside of the last two years, have made contracts with between fifteen and sixteen thousand newspapers, and never had but one man refuse to sign the contract, and by saying to him that I could not sign a contract without this clause in it he readily signed it. My point is merely to shift the responsibility. We to-day have the responsibility of the whole matter upon our shoulders.... "There? has been constant fear that something would come up, so I had this clause in my contract added. This is what I have in every contract I make: 'It is hereby agreed that should your State, or the United States government, pass any law that would interfere with or restrict the sale of proprietary medicines, his contract shall become void.'... In the State of Illinois a few years ago they wanted to assess me three hundred dollars. I thought I had a better plan than this, so I wrote to about forty papers, and merely said: 'Please look at your contract with me and take note that if this law passes you and I must stop doing business, and my contracts cease.' The next week every one of them had an article.... I have carried this through and know it is a success. I know the papers will accept it. Here is a thing that costs us nothing. We are guaranteed against the $75,000 loss for nothing. It throws the responsibility on the newspapers.... I have my contracts printed and I have this printed in red type, right square across the contract, so there can be absolutely no mistake, and the newspaper man can not say to me, 'I did not see it.' He did see it and knows what he is doing. It seems to me it is a point worth every man's attention.... I think this is pretty near a sure thing." To illustrate: There are 739 publications in your State--619 of these are dailies and weeklies. Out of this number we are advertising in over 500, at an annual expenditure of $8,000 per year (estimated). We make a three-year contract with all of them, and, therefore, our liabilities in your State are $24,000, providing, of course, all these contracts were made at the same date. Should these contracts all be made this fall and your State should pass a law this winter (three months later) prohibiting the sale of our goods, there would be virtually a loss to us of $24,000. Therefore, for a business precaution to guard against just such conditions, we add the red paragraph referred to in Collier's. I make this statement to you, as I am credited with being the originator of the paragraph, and I believe that I am justified in adding this paragraph to our contract, not for the purpose of controlling the Press, but, as before stated, as a business precaution which any man should take who expects to pay his bills. Will you kindly give me your version of the situation? Awaiting an early reply, I am, Sincerely yours, FRANK J. CHENEY. [IMAGE ==>] {083} [IMAGE ==>] {084} Valuable Newspaper Aid. {085} Dr. Pierce's son, Dr. V. Mott Pierce, was chairman of the Committee on Legislation. He was the author of the "matters and suggestions" which must be considered in the dark. "Never before," said he, "in the history of the Proprietary Association were there so many bills in different state legislatures that were vital to our interests. This was due, we think, to an effort on the part of different state boards of health, who have of late years held national meetings, to make an organized effort to establish what are known as 'pure food laws.'" Then the younger Pierce stated explicitly the agency responsible for the defeat of this public health legislation: "We must not forget to place the honor where due for our uniform success in defeating class legislation directed against our legitimate pursuits. The American Newspaper Publishers' Association has rendered us valued aid through their secretary's office in New York and we can hardly overestimate the power brought to bear at Washington by individual newspapers."... (On another occasion, Dr. Pierce, speaking of two bills in the Illinois Legislature, said: "Two things operated to bring these bills to the danger line. In the first place, the Chicago papers were almost wholly without influence in the Legislature.... Had it not been for the active co-operation of the state outside of Chicago there is absolute certainty that the bill would have passed.... I think that a great many members do not appreciate the power that we can bring to bear on legislation through the press.") But this power, in young Dr. Pierce's opinion, must be organized and systematized. "If it is not presumptuous on the part of your chairman," he said modestly, "to outline a policy which experience seems to dictate for the future, it would be briefly as follows"--here the younger Pierce explains the "matters and suggestions" which must not be "published broadcast over the country." The first was "the organization of a Legislative Bureau, with its offices in New York or Chicago. Second, a secretary, to be appointed by the chairman of the Committee on Legislation, who will receive a stated salary, sufficiently large to be in keeping with such person's ability, and to compensate him for the giving of all his time to this work." "The benefits of such a working bureau to the Proprietary Association," said Dr. Pierce, "can be foreseen: First, a systematic plan to acquire early knowledge of pending or threatened legislation could be taken up. In the past we have relied too much on newspaper managers to acquaint us of such bills coming up.... Another plan would be to have the regulation formula bill, for instance, introduced by some friendly legislator, and have it referred to his own committee, where he could hold it until all danger of such another bill being introduced were over, and the Legislature had adjourned." Little wonder Dr. Pierce wanted a secret session to cover up the frank {087}naïveté of his son, which he did not "wish to have published broadcast over the country, for very good reasons." [IMAGE ==>] {086} EXAMPLE OF WHAT MR. CHENEY CALLS "SHIFTING THE RESPONSIBILITY." This letter was sent by the publishers of one of the leading newspapers of Wisconsin to Senator Noble of that state. It illustrates the method adopted by the patent-medicine makers to compel the newspapers In each state to do their lobbying for them. Senator Noble introduced a bill requiring patent-medicine manufacturers to state on their labels the percentage of various poisons which every bottle might contain. Senator Noble and a few others fought valiantly for their bill throughout the whole of the last session of the Wisconsin Legislature, but were defeated by the united action of the newspaper publishers, who, as this letter shows, exerted pressure of every kind, Including threats, to compel members of the Legislature to vote against the bill. In discussing this plan for a legislative bureau, another member told what in his estimation was needed. "The trouble," said he--I quote from the minutes--"the trouble we will have in attempting to buy legislation--supposing we should attempt it--is that we will never know what we are buying until we get through. We may have paid the wrong man, and the bill is passed and we are out. It is not a safe proposition, if we consider it legitimate, which we do not." True, it is not legitimate, but the main point is, it's not safe; that's the thing to be considered. The patent-medicine man continued to elaborate on the plans proposed by Dr. Pierce: "It would not be a safe proposition at all. What this association should have... is a regularly established bureau.... We should have all possible information on tap, and we should have a list of the members of the legislature of every state. We should have a list of the most influential men that control them, or that can influence them.... For instance, if in the state of Ohio a bill comes up that is adverse to us, turn to the books, find out who are members of the legislature there, who are the publishers of the papers in the state, where they are located, which are the Republican and which the Democratic papers.... It will take money, but if the money is rightly spent, it will be the best investment ever made." The Trust's Club for Legislators. That is about as comprehensive, as frankly impudent a scheme of controlling legislation as it is possible to imagine. The plan was put in the form of a resolution, and the resolution was passed. And so the Proprietary Association of America maintains a lawyer in Chicago, and a permanent secretary, office and staff. In every state it maintains an agent whose business it is to watch during the session of the Legislature each day's batch of new bills, and whenever a bill affecting patent medicines shows its head to telegraph the bill, verbatim, to headquarters. There some scores of printed copies of the bill are made, and a copy is sent to every member of the association--to the Peruna people, to Dr. Pierce at Buffalo, to Kilmer at Birmingham, to Cheney at Toledo, to the Pinkham people at Lynn, and to all the others. Thereon each manufacturer looks up the list of papers in the threatened state with which he has the contracts described above. And to each newspaper he sends a peremptory telegram calling the publisher's attention to the obligations of his contract, and commanding him to go to work to defeat the anti-patent-medicine bill. In practice, this organization works with smooth perfection and well-oiled accuracy to defeat the public health legislation which is introduced by boards of health in over a score of states every year. To illustrate, let me describe as typical the history of the public health bills which were introduced and defeated in Massachusetts last year. I have already mentioned them as showing how the newspapers, obeying that part of their contract which requires them to print nothing harmful to patent medicines, refused to print any account of the exposures which were made by several members of the Legislature during the debate of the bill. I wish here to describe their obedience to that other clause of the {088}contract, in living up to which they printed scores of bitterly partisan editorials against the public health bill, and against its authors personally; threatened with political death those members of the Legislature who were disposed to vote in favor of it, and even, in the persons of editors and owners, went up to the State House and lobbied personally against the bill. And since I have already told of Mr. Cheney's author-ship of the scheme, I will here reproduce, as typical of all the others (all the other large patent-medicine concerns sent similar letters and telegrams), the letter which Mr. Cheney himself on the 14th day of February sent to all the newspapers in Massachusetts with which he has lobbying contracts--practically every newspaper in the state: "Toledo, Ohio, Feb. 14, 1905. "Publishers "----- Mass. "Gentlemen: "Should House bills Nos. 829, 30, 607, 724, or Senate bill No. 185 become laws, it will force us to discontinue advertising in your state. Your prompt attention regarding this bill we believe would be of mutual benefit. "We would respectfully refer you to the contract which we have with you. "Respectfully, "Cheney Medicine Company." Now here is the fruit which that letter bore: a strong editorial against the anti-patent-medicine bill, denouncing it and its author in the most vituperative language, a marked copy of which was sent to every member of the Massachusetts Legislature. But this was not all that this one zealous publisher did; he sent telegrams to a number of members, and a personal letter to the representative of his district calling on that member not only to vote, but to use his influence against the bill, on the pain of forfeiting the paper's favor. Now this seems to me a shameful thing--that a Massachusetts newspaper, of apparent dignity and outward high standing, should jump to the cracking of the whip of a nostrum-maker in Ohio; that honest and well-meaning members of the Massachusetts Legislature, whom all the money of Rockefeller could not buy, who obey only the one thing which they look on as the expression of the public opinion of their constituents, the united voice of the press of their district--that these men should unknowingly cast their votes at the dictate of a nostrum-maker in Ohio, who, if he should deliver his command personally and directly, instead of through a newspaper supine enough to let him control it for a hundred dollars a year, would be scorned and flouted. Any self-respecting newspaper must be humiliated by the attitude of the patent-medicine association. They don't ASK the newspapers to do it--they ORDER it done. Read again Mr. Cheney's account of his plan, note the half-contemptuous attitude toward the newspapers. And read again Mr. Cheney's curt letter to the Massachusetts papers; Observe the threat, just sufficiently veiled to make it more of a threat; and the formal order from a superior to a clerk: "We would respectfully refer you to the contract which we have with you." And the threat is not an empty one. The newspaper which refuses to aid the patent-medicine people is marked. Some time ago Dr. V. Mott {089}Pierce of Buffalo was chairman of what is called the "Committee on Legislation" of the Proprietary Association of America. He was giving his annual report to the association. "We are happy to say," said he, "that though over a dozen bills were before the different State Legislatures last winter and spring, yet we have succeeded in defeating all the bills which were prejudicial to proprietary interests without the use of money, and through the vigorous co-operation and aid of the publishers. January 23 your committee sent out letters to the principal publications in New York asking their aid against this measure. It is hardly necessary to state that the publishers of New York responded generously against these harmful measures. The only small exception was the _Evening Star_ of Poughkeepsie, N. Y., the publisher of which, in a very discourteous letter, refused to assist us in any way." Is it to be doubted that Dr. Pierce reported this exception to his fellow patent-medicine men, that they might make note of the offending paper, and bear it in mind when they made their contracts the following year? There are other cases which show what happens to the newspaper which offends the patent-medicine men. I am fortunate enough to be able to describe the following incident in the language of the man who wielded the club, as he told the story with much pride to his fellow patent-medicine men at their annual meeting: "Mr. Chairman and Gentlemen of the Proprietary Association," said Mr. Cooper, "I desire to present to you a situation which I think it is incumbent on manufacturers generally to pay some attention to--namely, the publication of sensational drug news which appears from time to time in the leading papers of the country.... There are, no doubt, many of you in the room, at least a dozen, who are familiar with the sensational articles that appeared in the Cleveland _Press_. Gentlemen, this is a question that appeals to you as a matter of business.... The Cleveland Press indulged in a tirade against the so-called 'drug trust.'... (the 'drug trust' is the same organization of patent-medicine men--including Pierce, Pinkham, Peruna, Kilmer and all the well-known ones--which I have referred to as the patent-medicine association. Its official name is the Proprietary Association of America.) "I sent out the following letter to fifteen manufacturers" (of patent medicines): "'Gentlemen--Inclosed we hand you a copy of matter which is appearing in the Cleveland papers. It is detrimental to the drug business to have this matter agitated in a sensational way. In behalf of the trade we would ask you to use your influence with the papers in Cleveland to discontinue this unnecessary publicity, and if you feel you can do so, we would like to have you wire the business managers of the Cleveland papers to discontinue their sensational drug articles, as it is proving very injurious to your business. Respectfully, E. R. Cooper.' "Because of that letter which we sent out, the Cleveland Press received inside of forty-eight hours telegrams from six manufacturers canceling thousands of dollars' worth of advertising and causing a consequent dearth of sensational matter along drug lines. It resulted in a loss to one paper alone of over eighteen thousand dollars in advertising. Gentlemen, when you touch a man's pocket, you touch him where he lives; that principle {090}is true of the newspaper editor or the retail druggist, and goes through all business." The Trust's Club for Newspapers. That is the account of how the patent-medicine man used his club on the newspaper head, told in the patent-medicine man's own words, as he described it to his fellows. Is it pleasant reading for self-respecting newspaper men--the exultant air of those last sentences, and the worldly wisdom: "When you touch a man's pocket you touch him where he lives; that principle is true of the newspaper editor..."? But the worst of this incident has not yet been told. There remains the account of how the offending newspaper, in the language of the bully, "ate dirt". The Cleveland _Press_ is one of a syndicate of newspapers, all under Mr. McRae's ownership--but I will use Mr. Cooper's own words: "We not only reached the Cleveland _Press_ by the movement taken up in that way, but went further, for the Cleveland _Press_ is one of a syndicate of newspapers known as the Scripps-McRae League, from whom this explanation is self-explanatory: "'Office Schipps-McRae Press Association. "'Mr. E. R. Cooper, Cleveland, Ohio: "'Mr. McRae arrived in New York the latter part of last week after a three months' trip to Egypt. I took up the matter of the recent cut-rate articles which appeared in the Cleveland _Press_ with him, and to-day received the following telegram from him from Cincinnati: 'Scripps-McRae papers will contain no more such as Cleveland _Press_ published concerning the medicine trust--M. A. McRae.' "'I am sure that in the future nothing will appear in the Cleveland Press detrimental to your interests. "'Yours truly, "'F. J. Carlisle.'" This incident was told, in the exact words above quoted, at the nineteenth annual meeting of the Proprietary Association of America. I could, if space permitted, quote many other telegrams and letters from the Kilmer's Swamp Root makers, from the Piso's Cure people, from all the large patent-medicine manufacturers. The same thing that happened in Massachusetts happened last year in New Hampshire, in Wisconsin, in Utah, in more than fifteen states. In Wisconsin the response by the newspapers to the command of the patent-medicine people was even more humiliating than in Massachusetts. Not only did individual newspapers work against the formula bill; there is a "Wisconsin Press Association," which includes the owners and editors of most of the newspapers of the state. That association held a meeting and passed resolutions, "that we are opposed to said bill... providing that hereafter all patent medicine sold in this state shall have the formula thereof printed on their labels," and "Resolved, That the association appoint a committee of five publishers to oppose the passage of the measure." And in this same state the larger dailies in the cities took it on themselves to drum up the smaller country papers and get them to write editorials opposed to the formula bill. Nor was even this the measure of their activity in response to the command of the patent medicine association. I am able to give the letter which is here reproduced [see page 86]. {086} It was sent by the publisher of one of the largest daily papers in Wisconsin to the state senator who {091}introduced the bill. In one western state, a board of health officer made a number of analyses of patent medicines, and tried to have the analyses made public, that the people of his state might be warned. "Only one newspaper in the state," he says in a personal letter, "was willing to print results of these analyses, and this paper refused them after two publications in which a list of about ten was published. In New Hampshire--but space forbids. Happily there Is a little silver in the situation. The legislature of North Dakota last year passed, and the governor signed a bill requiring that patent-medicine bottles shall have printed on their labels the percentage of alcohol or of morphin or various other poisons which the medicine contains. That was the first success in a fight which the public health authorities have waged in twenty states each year for twenty years. In North Dakota the patent-medicine people conducted the fight with their usual weapons, the ones described above. But the newspapers, be it said to their everlasting credit, refused to fall in line to the threats of the patent-medicine association. And I account for that fact in this way: North Dakota is wholly a "country" community. It has no city of over 20,000, and but one over 5,000. The press of the state, therefore, consists of very small papers, weeklies, in which the ownership and active management all lie with one man. The editorial conscience and the business manager's enterprise lie under one hat. With them the patent-medicine scheme was not so successful as with the more elaborately organized newspapers of older and more populous states. Just now is the North Dakota editor's time of trial. The law went into effect July 1. The patent-medicine association, at their annual meeting in May, voted to withdraw all their advertising from all the papers in that state. This loss of revenue, they argued self-righteously, would be a warning to the newspapers of other states. Likewise it would be a lesson to the newspapers of North Dakota. At the next session of the legislature they will seek to have the label bill repealed, and they count on the newspapers, chastened by a lean year, to help them. For the independence they have shown in the past, and for the courage they will be called on to show in the future, therefore, let the newspapers of North Dakota know that they have the respect and admiration of all decent people. "What is to be done about it?" is the question that follows exposure of organized rascality. In few cases is the remedy so plain as here. For the past, the newspapers, in spite of these plain contracts of silence, must be acquitted of any very grave complicity. The very existence of the machine that uses and directs them has been a carefully guarded secret. For the future, be it understood that any newspaper which carries a patent-medicine advertisement knows what it is doing. The obligations of the contract are now public property. And one thing more, when next a member of a state legislature arises and states, as I have so often heard: "Gentlemen, this label bill seems right to me, but I can not support it; the united press of my district is opposed to it"--when that happens, let every one understand the wires that have moved "the united press of my district." {092} The Following are Extracts and Abstracts from Various Articles in the Ladies Home Journal? A PECULIAR "ETC." A great show of frankness was recently made by a certain "patent medicine." The makers advertised that they had concluded to take the public into their confidence, and that thereafter they would print a formula of the medicine on each bottle manufactured. "There is nothing secretive about our medicine," was the cry. "We have nothing to hide. Here is the formula. Show it to your physician." Then comes the formula: This herb and that herb, this ingredient and that ingredient, and the formula winds up, "etc." All good, old-fashioned, well recognized drugs were those which were mentioned--all except the "etc." A certain Board of Pharmacy had never heard of a drug called "etc.," and so made up Its mind to find out. And the "etc." was found to be 3.76 per cent of cocain!--just the simple, death-dealing cocain!--From _The Ladies' Home Journal_, February, 1906. PATENT MEDICINE CONCERNS AND LETTER BROKERS. One of the most disgusting and disgraceful features of the patent medicine business is the marketing of letters sent by patients to patent medicine firms. Correspondence is solicited by these firms under the seal of sacred confidence. When the concern is unable to do further business with a patient it disposes of the patient's correspondence to a letter-broker, who, in turn, disposes of it to other patent medicine concerns at the rate of half a cent, for each letter. This Information was made public by Mark Sullivan in the _Ladies' Home Journal_ for January, 1906. [IMAGE ==>] {092} An advertisement showing how the names to orders sent to "Patent Medicine" concerns are offered for sale or rent to be used by others. Yet we are told how "Sacredly Confidential" these letters are regarded and held. (The advertisement is from the _Mail Order Journal_, April, 1905.) Says Mr. Sullivan: "One of these brokers assured me he could give me 'choice lots' of 'medical female letters'... Let me now give you, from the printed lists of these 'letter brokers' some idea of the way in which these {093}'sacredly confidential' letters are hawked about the country. Here are a few samples, all that are really printable: "'55,000 Female Complaint Letters' Is the sum total of one Item, and the list gives the names of the "medicine company" or the "medical institute" to whom they were addressed. Here is a barter, then, in 55,000 letters of a private nature, each one of which, the writer was told, and had a right to expect, would be regarded as sacredly confidential by the "doctor" or concern to whom she had been deluded into telling her private ailments. Yet here they are for half a cent each! "Another batch of some 47,000 letters addressed to five 'doctors' and 'institutes' is emphasized because they were all written by women! A third batch is: "'44,000 Bust Developer Letters'--letters which one man in a "patent medicine" concern told me were "the richest sort of reading you could get hold of." "A still further lot offers: '40,000 Women's Regulator Letters'--letters which in their context any woman can naturally imagine would be of the most delicate nature. Still, the fact remains, here thy are for sale." Is not this contemptible? In the same article Mr. Sullivan exposes the inhuman greed of patent medicine concerns that turn into cold cash the letters of patients afflicted with the most vital diseases. To quote Mr. Sullivan again: "All these are made the subject of public barter. Here are offered for sale, for example: 7,000 Paralysis Letters; 9,000 Narcotic Letters; 52,000 Consumption Letters; 3,000 Cancer Letters, and even 65,000 Deaf Letters. Of diseases of the most private nature one is offered here nearly one hundred thousand letters--letters the very classification of which makes a sensitive person shudder." An Appeal To The American Woman. "If the American woman would withhold her patronage from these secret nostrums the greater part of the industry would go to pieces. I do not ask any woman to take my word for this. Let me give her a personal statement direct from one of these manufacturers himself--a 'doctor' to whom thousands of women are writing to-day, and whose medicines they are buying by the hundreds of thousands of bottles each year. I quote his own statement, word for word: "'Men are "on" to the game; we don't care a damn about them. It is the women we are after. We have buncoed them now for a good many years, and so long as they remain as "easy" as they have been, and we can make them believe that they are sick, we're all right. Give us the women every time. We can make them feel more female troubles In a year than they would really have if they lived to be a hundred.' ".--From "Why 'Patent Medicines' are Dangerous," Edward Bok, Ladies' Home Journal, March, 1905. "REPEATERS." It is the "repeat" orders that make the profit. Referring to a certain patent medicine that had gone to the wall a nostrum agent said that It failed because "it wasn't a good repeater." When these men doubt whether a new medicine will be a success they say: "I'm afraid it wouldn't be a 'repeater.'" "_Cure_ rheumatism" said a veteran patent medicine man considering the exploitation of a new remedy; "good Heavens, man, you don't want a remedy that _cures_ 'em. Where would you get your 'repeats'? You want to get up a medicine that's full of dope, so the more they take of it the more they'll want."--From "The Inside Story of a Sham," _Ladies' Home Journal_, January, 1906. PATENT MEDICINES AND TESTIMONIALS. In the January, 1906, issue of the _Ladies' Home Journal_ Mark Sullivan contributes an article on the business of securing from well-known people testimonials indorsing and praising nostrums. Mr. Sullivan learned that three men, rivals in trade, make a business of securing these indorsements. They are known as "testimonlal-brokers." A representative of a patent medicine who was anxious to exploit his preparation through the press approached one of these brokers and made arrangements for the delivery of one hundred signed testimonials from members of {094}congress, governors and men high in the Army and Navy. The following is the memorandum of the agreement as drawn up by the broker: "Confirming my talk with Mr. ------, I will undertake to obtain testimonials from senators at $75 each, and from congressmen at $40, on a prearranged contract.... A contract for not less than $5,000 would meet my requirements In the testimonial line.... I can put your matter in good shape shortly after congress meets if we come to an agreement.... We can't get Roosevelt, but we can get men and women of national reputation, and we can get their statements in convincing form and language..." It was for this reason that years ago Mrs. Pinkham, at Lynn, Mass., determined to step in and help her sex. Having had considerable experience in treating female ills with her Vegetable Compound, she encouraged the women of America to write to her for advice in regard to their complaints, and being a woman, it was easy for help ailing sisters to pour into her ears every detail of their suffering. No physician in the world has had such a training, or has such an amount of information at hand to assist in the treatment of all kinds of female ills. This, therefore, is the reason why Mrs. Pinkham, in her laboratory at Lynn, Mass., Is able to do more for the ailing women, of America than the family physician.' Any woman, therefore, is responsible for her own suffering who will not take the trouble to write to Mrs. Pinkham for advice. [IMAGE ==>] {094} The way in which the testimonial is actually obtained is thus described by the broker: "The knowing how to approach each individual is my stock-in-trade. Only a man of wide acquaintance of men and things could carry it out. Often I employ women. Women know how to get around public men. For example, I know that Senator A has a poverty-stricken cousin, who works as a seamstress. I go to her and offer her twenty-five dollars to get the senator's signature to a testimonial. But most of it I do through newspaper correspondents here in Washington. Take the senator from some southern state. That senator is very dependent on the Washington correspondent of the leading newspaper in his state. By the dispatches which that correspondent sends back the senator's career is made or marred. So I go to that correspondent. I offer him $50 to get the senator's testimonial. The senator may squirm, but he'll sign all right. Then there are a number of easy-going congressmen who needn't be seen at all. I can sign their names to anything, and they'll stand for it. And there are always a lot of poverty-stricken, broken-down Army veterans hanging around Washington. For a few dollars they'll go to their old Army officers on a basis of old acquaintance sake and get testimonials." It goes without saying that such testimonials are a fraud on the purchaser of the medicine thus exploited. "Not one in a thousand of these letters ever reaches the eyes of the 'doctor' to whom they are addressed. There wouldn't be hours enough in the day to read them even if he had the desire. On the contrary, these letters from women of a private and delicate nature are opened and read by young men and girls; they go through not fewer than eight different hands before they reach a reply; each in turn reads them, and if there is anything 'spicy' you will see the heads of two or three girls get together and enjoy (!) the 'spice.' Very often these 'spicy bits' are taken home and shown to the friends and families of these girls and men! Time and again have I seen this done; time and again have I been handed over a letter by one of the young fellows with the remark: 'Read this, isn't that rich?' only to read of the recital of some trouble into which a young girl has fallen, or some mother's sacred story of her daughter's all! "Then, to cap the climax of iniquity, with some of these houses these names and addresses are sold at two, three or five cents a name to firms in other lines of business for the purpose of sending circulars. As a fact, often the trouble is not taken to copy off the names and addresses, but the letters themselves, with all their private contents, are sold! "This is the true story of the 'sacredly confidential' way in which these private letters from women are treated!"--Statement of a man who spent two years in the employ of a large patent medicine concern, as told in "How the Private Confidences of Women Are Laughed At." Edward Bok, _Ladies' Home Journal,_ November, 1904. 
48746	----	Transcriber's Note: Italic text is denoted by _underscores_. Small capital text has been replaced with all capitals. Minor typographical and punctuation errors have been corrected without note. Irregularities and inconsistencies in the text have been retained as printed. The cover for the eBook version of this book was created by the transcriber and is placed in the public domain. * * * * * ENCYCLOPEDIA OF DIET _A Treatise on the Food Question_ IN FIVE VOLUMES EXPLAINING, IN PLAIN LANGUAGE, THE CHEMISTRY OF FOOD AND THE CHEMISTRY OF THE HUMAN BODY, TOGETHER WITH THE ART OF UNITING THESE TWO BRANCHES OF SCIENCE IN THE PROCESS OF EATING SO AS TO ESTABLISH NORMAL DIGESTION AND ASSIMILATION OF FOOD AND NORMAL ELIMINATION OF WASTE, THEREBY REMOVING THE CAUSES OF STOMACH, INTESTINAL, AND ALL OTHER DIGESTIVE DISORDERS BY EUGENE CHRISTIAN, F. S. D. VOLUME II NEW YORK CITY CORRECTIVE EATING SOCIETY, INC. 1917 COPYRIGHT 1914 BY EUGENE CHRISTIAN ENTERED AT STATIONERS HALL, LONDON SEPTEMBER, 1914 BY EUGENE CHRISTIAN, F. S. D. ALL RIGHTS RESERVED PUBLISHED AUGUST, 1914 CONTENTS VOLUME II _Lesson VIII_ _Page_ FOODS OF VEGETABLE ORIGIN 287 Grains 289 Uses of Grains: (1) Grain as a Source of Energy 295 (2) Grain as a Source of Nitrogen 297 (3) Grain as a Remedial Food 298 Nuts 300 Peanuts 306 Legumes 307 Fruits 308 Classification of Fruits according to acidity 313 Vegetables 317 Classification of Vegetables 319 Sugars and Sirups 324 Beet-Sugar 325 Honey 330 Confections 332 Vegetable Oils 335 _Lesson IX_ DRUGS, STIMULANTS, AND NARCOTICS 341 Alkaloids and Narcotics 349 Opium 350 Cocain 353 Nux Vomica and Strychnin 356 Quinin 356 Acetanilid 357 Tobacco 361 Coffee 363 Tea 365 Cocoa and Chocolate 366 Alcohols and Related Compounds 367 Alcohol 367 Chloroform, Ether, and Chloral 372 Poisonous Mineral Salts and Acids 373 Mercury 373 Potassium Iodid 374 Lead and Copper 375 Purgatives and Cathartics 375 _Lesson X_ IMPORTANCE OF CORRECT DIAGNOSIS AND CORRECT TREATMENT 379 _Lesson XI_ COMMON DISORDERS--THEIR CAUSE AND CURE 403 Health and Dis-ease Defined 405 Overeating 413 Superacidity 418 The Cause 420 The Symptoms 421 The Remedy 423 Fermentation (Superacidity) 424 The Cause 425 The Symptoms 426 The Remedy 428 Gas Dilatation 431 The Symptoms 432 Importance of Water-drinking 434 Constipation 434 The Cause 434 The Remedy 436 Foods that May Be Substituted for One Another 439 Constipating and Laxative Foods 446 Constipating and Laxative Beverages 446 Gastritis 447 The Cause 449 The Symptoms 449 The Remedy 450 Nervous Indigestion 453 The Cause 454 The Symptoms 455 The Remedy 458 Subacidity 460 The Cause 461 The Symptoms 462 The Remedy 463 Biliousness 465 The Cause 466 The Symptoms 466 The Remedy 466 Cirrhosis of the Liver 467 The Cause 467 The Symptoms 468 The Treatment 469 Piles or Hemorrhoids 471 The Cause 471 The Symptoms 472 The Treatment 472 Diarrhea 474 The Cause 474 The Treatment 476 Emaciation or Underweight 477 The Cause 478 The Symptoms 481 The Remedy 482 Obesity or Overweight 491 The Cause 493 The Remedy 495 Neurasthenia 503 The Cause 505 The Symptoms 506 The Remedy 506 Malnutrition 511 Cause and Remedy 511 Locomotor Ataxia 511 The Cause 511 The Symptoms 514 The Remedy 515 Colds, Catarrh, Hay Fever, Asthma, Influenza 519 Colds--The Cause 520 The Symptoms 521 The Remedy 523 Catarrh--The Cause 527 The Symptoms 528 The Remedy 528 Hay Fever--The Cause 530 The Symptoms 531 The Remedy 531 Asthma--The Cause 533 The Symptoms 533 The Remedy 534 Influenza--The Cause 536 The Symptoms 537 The Remedy 537 Insomnia 538 The Cause 538 The Remedy 539 Rheumatism--Gout 543 Rheumatism--The Cause 544 The Symptoms 545 Gout--The Cause 546 The Symptoms 547 Rheumatism, Gout--The Remedy 547 Bright's Dis-ease 550 The Cause 551 The Symptoms 551 The Remedy 552 Diabetes 556 The Cause 556 The Symptoms 557 The Remedy 557 Consumption 560 The Treatment 564 Heart Trouble 569 The Cause 571 The Remedy 573 Dis-eases of the Skin 574 The Cause 575 The Treatment 578 Appendicitis 580 The Symptoms 582 The Treatment 583 Chronic or Severe Cases of Appendicitis 586 LESSON VIII FOODS OF VEGETABLE ORIGIN GRAINS Grains constitute the most important article of human food, not so much on account of their superior nutritive, curative or remedial value, but chiefly because of their prolific growth and abundant production in all civilized countries throughout the world. The variety of grain produced in the various countries depends largely upon the climate and the habits of the people. The predominant use of rice by the Asiatics, wheat by the Europeans, and maize by the aboriginal American, shows how people adapt themselves to the foods of prodigal growth. It also shows the effect different foods have upon the physical development of the various tribes that inhabit these remote countries. [Sidenote: Wheat] Wheat is said by some writers to be a complete food. This is not strictly true. Wheat contains a very small percentage of fat, and while fat can be made in the body from carbohydrates, it is more natural, and entails less work upon the digestive organs and the liver if the diet is balanced so as to contain the required amount of fat, and all other nutritive elements in the right or natural proportions. [Sidenote: Results of eating too much starch] A diet composed of wheat alone would contain 70 per cent of carbohydrates, chiefly in the form of starch. While this would be perfectly wholesome, it would give the body an excess of starch which would ultimately result in intestinal congestion, gout, rheumatism, hardening of the arteries, and premature old age. Wheat contains a larger quantity, and a greater variety of proteids than any other grain, but wheat proteids are more difficult to digest than the proteids of milk, eggs, or nuts. [Sidenote: Composition of wheat] Wheat varies greatly in composition, according to the soil and the climate in which it is produced. This fact is not recognized or considered by the average writer on dietetics, who eulogizes wheat as the wonderful "staff of life," because certain food tables show that wheat contains 13 per cent, while corn contains only 10 per cent of proteids. It is neither the proteid nor the carbohydrate content that determines the value of any grain as food, but rather the proportions of the different elements of nutrition it contains, that being the best which is more nearly balanced to meet the requirements of the human organism. [Sidenote: Rye] Rye may be considered in the same class as wheat. Chemically, the contents are very similar, and the effects upon the body are very much the same. It contains a larger per cent of cellulose, and less gluten than wheat, therefore as a remedial food it is superior to all other grains for exciting intestinal peristalsis, thereby removing the causes of constipation. [Sidenote: Barley] The nutritive elements of barley are similar to those of wheat and rye. It contains less cellulose fiber, and therefore a larger per cent of digestible nutrients than any one of the cereal group except rice. It has never become popular as a bread-making grain because-- 1 The nitrogenous or gluten substances are not tenacious enough to make the conventional "raised" bread 2 The flour is dark in color 3 The grain is so hard and "flinty" that it is very difficult to mill it down to the required fineness For these reasons barley has been greatly neglected as a food commodity. From a chemical standpoint it deserves a much higher place in our dietaries than it has hitherto been given. [Sidenote: Oats] The composition of oats varies somewhat from that of wheat, rye and barley. They contain a larger proportion of both fat and proteids, and form a desirable food if correctly prepared. The objection to oats as an article of diet is the hasty manner in which they are usually prepared, which converts them into a gummy mass of gelatinized starch, entangled with the peculiar gummy proteid of the oat grain. Thus prepared the oat is a most prolific source of disturbed digestion. [Sidenote: Corn] Corn is the cheapest material capable of nourishing the human body that is produced in the temperate zone. It is less digestible, and more deficient in the salts than the group of grains thus far mentioned. It is very wholesome, however, but in no way superior to other grains. In the future corn will probably play an increasing part in the problem of feeding the world, as a cheap source of carbohydrates, and for the purpose of manufacturing glucose. [Sidenote: Rice] In all tropical and semi-tropical countries rice occupies the same position that corn does in the temperate zone. It is more deficient in proteids and in fat than any other food grain, while the starch of rice is more easily digested than any other form of cereal starch. This grain, however, is almost entirely devoid of mineral constituents, and for this reason it is productive of serious nutritive derangements when indulged in too freely. This deficiency can be overcome by taking a liberal quantity of green salads, or fresh vegetables, whenever rice is eaten. [Sidenote: Buckwheat] Buckwheat is a grain whose consumption is very limited, owing to the fact that it is dark in color. It compares favorably with wheat and corn as to nutritive elements, and is now much used as a winter food by the northern people. USES OF GRAINS The use of grains as an article of food may be considered under three headings: 1 As a source of energy 2 As a source of nitrogen 3 Grain as a remedial food; that is, as a source of cellulose or roughness, for the regulation of intestinal action (1) GRAIN AS A SOURCE OF ENERGY [Sidenote: Too much grain consumed] All grains are composed largely of starch, therefore the question of energy to be derived from this source is one of assimilation and use. The use of grains in the diet deserves the most careful consideration, and the study should not be confined to any particular grain, but to the entire group, and especially to the method of preparation, and the quantity that should be consumed under the varying conditions of age, temperature of environment, and work or activity. The conventional American diet contains such an abnormal quantity of grain-starch, and the methods of preparation are so unnatural, that the Food Scientist, in practise, will find many people whose digestive organs have become so deranged that he may deem it necessary to prohibit grain-starch almost entirely. The grown person, pursuing the ordinary sedative occupation, should not eat more than three or four ounces of cereal food a day, while the manual laborer should not consume more than five or six ounces each twenty-four hours. This quantity contemplates cool, or winter weather. In summer this quantity should be reduced according to work or activity. (2) GRAIN AS A SOURCE OF NITROGEN Grain as a source of proteid has received undue consideration in hygienic works. Upon an allowance of one-fourth of a pound of grain per day, which would make four vienos, with a nitrogen factor of six, we see that 24 decigrams of nitrogen would be supplied from the grain. The variations between the proteids contained in two varieties of breakfast food is seldom more than two or three per cent. This would amount to a variation in the daily intake of nitrogen of about five decigrams, an amount too little to be worth consideration. [Sidenote: Digestibility of grain proteids] Grain proteids are not so easily digested as are the proteids of eggs, milk and nuts. The following list of grains and grain products is given in the order of the digestible nitrogen they contain: 1 Gluten or dietetic foods 2 Barley 3 Macaroni 4 White flour 5 Whole wheat--Graham flour 6 Rye 7 Oatmeal 8 Corn products 9 Buckwheat 10 Rice 11 Pure starches (3) GRAIN AS A REMEDIAL FOOD [Sidenote: Remedial value of the whole grain] [Sidenote: Wheat bran a natural remedy for constipation] Grain is constipating or laxative in effect according to the way it is prepared and eaten. Whole grain, especially wheat and rye, will normalize intestinal action, and in some cases act as a laxative, while the same grains made into flour, and milled in the usual way, are constipating. Ordinary wheat bran is one of the most effective remedies known for intestinal congestion, and it can be administered or regulated with much accuracy, according to the severity of the case. An intelligent understanding of the use of bran in treating constipation is quite necessary. The object should be to employ bran as a remedy in chronic cases, and to vary the quantity, the quality, and the cellulose content of the meals. In rare cases, bran may produce irritation; in such cases it should be cooked three or hours, and eaten only with hot water. In other cases the mechanical stimulation of the peristaltic action is not effective. The practitioner can usually determine these questions on the third or the fourth day. Bran should be administered about as follows: In cases of severe constipation, one rounding tablespoonful in water, just after rising; one-half teacupful, cooked, taken at each meal, and a heaping tablespoonful in water just before retiring. The following table gives, in the order of their laxative effects, a few of the principal grains: 1 Flaked or whole rye 2 Flaked or whole wheat 3 Flaked or whole barley 4 Flaked or whole oats NUTS [Sidenote: Nuts as heat producers] The true nut is the seed of trees and shrubs which stores the greater proportion of food material for nourishing the seedling in the form of vegetable oil. The nut is very largely a fuel food or heat producer, therefore among the primitive races, along the warmer belts of the earth's surface, the nut was not of so much importance, but in the northern or colder countries, where the body-heat meets with such powerful resistance from climatic environment, the nut is of equal, if not of more importance than fruits. There are a few miscellaneous articles of food that are classed as nuts, which do not belong primarily to this group. In the following discussion I will take up the several varieties of nuts in the order of their general value as articles of human nutrition: [Sidenote: Pine nuts] [Sidenote: Composition of the pine nut] [Sidenote: The nitrogen factor in nuts] There are several species of pine seeds from many varieties of trees, and from many different countries. The Italian pine seed or nut, called in Italy "Pignon," and in this country "Pignolia," is the refined or cleansed nut, called by the writer "protoid" nut. This is a coined word given to it because it contains the highest percentage of protein of any other food that has yet been analyzed. The "protoid" nut contains 34 per cent protein, 47 per cent oil, 9 per cent carbohydrates, 4 per cent ash, and 6 per cent water. The relative proportion of nitrogen to energy is not so great as in some other food products, such as eggs, or skimmed milk. These contain a large per cent of water, so that the protoid nut, while containing pound for pound more nitrogen than any other known food, has a lower nitrogen factor than foods which do not contain so large a percentage of fat. This same rule will apply to all nuts. They are rich in protein, but because of the large amount of fat which supplies energy in its most condensed form, the nitrogen factor, which is the relation between nitrogen and energy, is often lower in many nuts than in grain. The chief advantage of protoid nuts over other varieties is in their softness, consequently they are more digestible, and more assimilable than any other specimen of the nut family. The pine nuts which grow prodigally in the western part of the United States are not so rich in protein as the protoid nuts, but in other respects are very excellent food. The annual crop of these is about one million pounds, but is variable, a full crop being produced only about every third year. They are harvested in a very crude way, chiefly by Indians, from the remote districts of New Mexico, Utah and California. [Sidenote: Almonds] The almond is a most desirable food. It contains 17 per cent nitrogen, and 54 per cent fat. The flavor is very agreeable, and the nuts, in digestibility, rank next to protoid nuts. They may be substituted for each other in many dietaries. [Sidenote: Pecans] The pecan, which is a species of hickory-nut, contains 13 per cent protein, and 70 per cent fat. It is a very delicious article of food, though somewhat inferior to pine nuts and almonds, in digestibility, and as a source of nitrogen. [Sidenote: Brazil-nuts] Brazil-nuts contain 18 per cent protein and 66 per cent fat, and rank high as an article of body-heat and energy. [Sidenote: White walnuts] Soft-shelled or white walnuts are commonly known as "English walnuts," though they are chiefly grown in France and in California. These nuts contain 24 per cent protein, 63 per cent fat, and form one of the staple nut foods of both Europe and America. [Sidenote: Hazelnuts] Filberts or hazelnuts contain 15 per cent protein, and 65 per cent fat. They differ widely from the varieties hitherto named, and are less digestible. They should be masticated exceedingly fine, and should not be taken by one whose digestion is particularly weak. [Sidenote: Butternuts] Butternuts are a species of walnut. They contain 27 per cent protein, 61 per cent fat, and rank in the dietary along with English walnuts and Brazil-nuts. [Sidenote: Beechnuts] Beechnuts contain 22 per cent protein and 57 per cent fat. Owing to the difficulty of gathering or harvesting, these nuts have never become popular as an article of human food. They are in the grain class, therefore rank high as an energy-producing material. [Sidenote: Cocoanuts] The cocoanut is a product of the palm tree, and, while quite distinct from our nuts of the temperate climate, is a very valuable and abundant food, deserving more extended use. Cocoanut is about one-half fat, contains 6 per cent protein and 28 per cent carbohydrates. The milk of the cocoanut is an excellent article of food, and used by the natives in the tropics in many remedial and medicinal ways. PEANUTS [Sidenote: Value of pea-nuts and soy-beans] Peanuts, which are so widely used as food, are on the boundary line between nuts and legumes. They were classed as peas by some of the early botanists, and as nuts by others. The name indicates the compromise that was made between the two theories. Another legume, which is largely used in Japan and China is the soy-bean. Both the peanut and the soy-bean are better balanced, and more nutritious than common beans and peas. They are similar in composition, and contain about equal quantities of protein and fat, some peanuts yielding as much as 48 or 50 per cent oil. Neither are palatable in their natural state, but both are very delicious when their starch content is converted into dextrin by roasting. The Japanese have a method of preparing the soy-bean by a process of fermenting, which renders the proteid material very digestible. Soy-beans have not yet been introduced into this country, hence there will be little opportunity to use them, and they will, therefore, not be discussed here at length. LEGUMES Legumes are the seeds of a certain group of plants grown in pods. The term comes from a very ancient word, "legere," meaning _to gather_. Beans and peas are the most familiar types of this group. [Sidenote: Legumes rich in nitrogen] Legumes are rich in nitrogen, and some varieties are also very rich in oil. They are not equal to nuts in fuel or food value, however, because in the natural state they are hard, somewhat indigestible, and unpalatable. These qualities are due to the fact that the nitrogenous material of legumes are radically different from the nitrogen found in nuts, and belong to a class not so desirable as food. Meat may be omitted from the diet and legumes adopted as the chief source of nitrogen, but this change requires some knowledge and careful feeding in the beginning. Meat is digested wholly in the stomach and does not require mastication (only enough to be swallowed), while dried or mature legumes require much mastication, owing to the carbohydrates they contain. The best form in which legumes can be taken is in their green or immature state, owing to the fact that the immature starch they contain is readily soluble, while mature legume starch is rather difficult to digest. FRUITS The term "fruit" in a strictly botanical sense includes a very wide range of vegetable articles--the reproductive product of trees, or other plants, such as grains, legumes, nuts, berries, apples, peaches, plums, etc. In this lesson, however, I will apply the popular meaning to the term. [Sidenote: General composition of fruit] The common succulent or juicy fruits, including both tree fruits and berries, have many properties in common. The chemical composition of these typical fruits consists of from 80 to 85 per cent water, 5 to 15 per cent sugar, 1 to 5 per cent organic or fruit-acids, and small quantities of protein, cellulose, and the numerous salts, a portion of which may be combined with the fruit-acids. Some unripe fruits contain starch and various other carbohydrate substances, many of which are distasteful and unwholesome. On the other hand, when fruits become over-ripe, and decay sets in, the sugar is changed into carbon dioxid, alcohol, and acetic acid, and the fruit rapidly deteriorates in nutritive value and unwholesomeness. These changes, together with the loss of water, account for the sponginess and the tastelessness of cold storage and other long-kept fruits. All varieties of fruit are best when they have been allowed to ripen naturally on the trees, but modern commercial conditions demand that fruits for shipping purposes be picked slightly immature, and allowed to ripen in transit to the markets. [Sidenote: Dietetic value of fruits] The fruit-acids are composed of carbon, hydrogen, and oxygen, and are burned in the body the same as sugar, or fats. The actual energy-producing content of fruit is not large, and depends almost entirely upon the sugar content. The nutrient elements of fruit consist of fruit-sugar, combinations of salts, organic acids, and various flavoring or aromatic substances. These same salts, acids, etc., purchased at the drug store, and administered separately, would be of no particular value, and might produce harmful results, but in the various combinations of fruits they have very important places in the diet. [Sidenote: Fruit as an aid to digestion] One of the most important functions that fruit performs in the body is that of an artificial solvent, or an aid to digestion. To make food serve this purpose well would require some knowledge in regard to chemical harmonies, quantity, etc. To illustrate: If the stomach does not secrete a sufficient quantity of hydrochloric acid, fruit-acid should be absolutely omitted, as any acid, except hydrochloric acid itself, tends to inhibit the formation of the normal stomach acid. And this in turn tends to fermentation of the sugars and starches--causing acid fermentation and all the symptoms that accompany this condition. [Sidenote: Effect of acid fruits] So it is very important to prevent all the causes and sources of fermentation if we would prevent the development of all the various diseases that arise from acid conditions of the stomach, and autointoxication. This explains why people of rheumatic tendency cannot take acid fruit. Citrus fruits, however, and limes, lemons, oranges, grape-fruit, etc., are beneficial in rheumatism and conditions of lowered blood alkalinity, because they are changed to alkalis in the system, and reinforce the blood alkalinity. People of rheumatic tendency, therefore, should confine the diet as nearly as possible to starchless foods, omitting all but the citrus fruits. [Sidenote: Classification of fruit according to acidity] In the lesson on "Vieno System of Food Measurement" I give the energy value of various fruits, and also the nitrogen factor. These tables consider fruits in the same light with other foods; that is, as sources of energy and nitrogen. In the table which follows, the more important fruits are grouped according to their total acidity. The _figures_ represent the _volume_ of _acidity_, not strength: ACID FRUITS SUBACID FRUITS SWEET AND NON-ACID FRUITS Limes 95 Raspberries 16 Grapes 8 Lemons 78 Plums 14 Prunes 7 Grapefruit 39 Cherries 13 Raisins 6 Cranberries 37 Peaches 12 Bananas 6 Pineapples 22 Blackberries 12 Persimmons 4 Oranges 20 Apples 11 Figs 4 Apricots 18 Pears 3 Strawberries 18 Dates 3 The fruits in the above table are all reasonably wholesome, and the particular fruits to be used depend as much upon convenience as upon the nature of the food substances. The above groups, however, will be given much attention in dietetic prescriptions, and the food scientist should become thoroughly familiar with this classification. Of the acid fruits, oranges are the best and most desirable, and cranberries perhaps the least. Acid fruits are responsible for much stomach and intestinal trouble. Food was prior to life. Animal life on this globe has been fitted into, and is the net result of food; therefore, in the wonderful adaptations of Nature, it is evident that life will develop higher and better by subsisting upon the food that grows in its respective country. Acid fruits, such as lemons, limes, grapefruit, pineapples, and oranges, are grown in the tropical and semi-tropical countries, where the climate is warm, and where people subsist largely upon native vegetables. These fruits supply the acids and the fruit-sugars which the system requires in a warm climate. In the tropics the people live out of doors, the pores of the skin are kept open, and the effete matter produced by acids can be cast out of the body. [Sidenote: Evils of acid fruit in northern countries] In northern countries people live largely indoors, and are heavily clad except during a very short term in midsummer, therefore they do not eliminate freely. They subsist largely upon the heavier foods, such as flesh and grains, both of which require a large amount of hydrochloric acid for digestion, hence when the acid of fruits is added to the hydrochloric acid, of which most people have a deficiency, serious acid fermentation may result. Acid fermentation is the beginning of nearly all stomach trouble, and is the primary cause of many other ills. (See "Fermentation," p. 424.) [Sidenote: Value of subacid fruits] Practically all the fruits of the subacid group are excellent; however, on account of the mechanical irritation of the seeds, berries should not be used in cases in which the stomach and the intestines are irritated or catarrhal. In such cases the juice should be pressed from the fruit and the seeds discarded. [Sidenote: Value of non-acid fruits] Of the non-acid fruits, raisins, figs, and dates are excellent foods from the standpoint of furnishing a large amount of sugar in its very best form. _Very ripe_ bananas and _ripe_ persimmons, especially the large Japanese variety, are fruits which have a distinct nature, and are suited to a particular purpose in dietetics. These pulpy fruits are especially desirable in all cases of digestive irritations and disorders, because of the amount of nourishment contained in them, which is greater than that contained in the juicy fruits. In my practice I seldom, if ever, find a stomach so weak that it cannot digest ripe persimmons and very ripe bananas. I attribute much of my success in treating such cases to the skillful use of these products. The persimmon and the banana as remedial and nutritive articles, are the most valuable fruits grown. [Sidenote: Canned and evaporated fruits] Raisins, prunes, figs, dates, apricots and peaches are common types of fruit preserved by the process of evaporation, and when soaked in clear water may be restored to almost their original condition. Evaporated fruit should not be cooked. This is perhaps the most palatable and wholesome method of preserving fruit. Next in purity and importance are the methods of canning, as practised by the housewife. The ordinary commercial preparations of canned fruits, together with the many jams, marmalades and jellies, are generally of doubtful, if not inferior quality. The Pure Food Law has accomplished much to establish honesty in the preserving and the labeling of food, but these products are still far from ideal, and are not to be considered where fresh or evaporated fruits are obtainable. VEGETABLES In this group we may conveniently class all food products not elsewhere discussed. [Sidenote: Composition of lettuce] Beans, peas, and corn, when taken in the immature state, are classed as vegetables. The importance of this group of food products is not their great food value per pound (succulent vegetables contain anywhere from 75 to 95 per cent of water); it is the great variety of nutritive substances which they contain. Lettuce contains cellulose, proteids, active chlorophyl, pentoses, sugars and starches, representing carbohydrates in various processes of transformation; small quantities of fat, and a relatively large per cent of mineral salts, besides numerous flavoring materials. All other edible plants contain many of the same elements in different proportions. Edible vegetables may be conveniently grouped according to that portion of the plant which we consume. These groups are: a Above ground b Roots and tubers c Leafy or succulent d Cucurbita family Melons, cantaloups, and tomatoes are on the border line between vegetables and fruits. The following groups of vegetables are made up according to these classifications: VEGETABLES _(a) Above Ground_ Beans-- Dried Green Beets Brussels sprouts Cauliflower Corn Eggplant Lentils (dried) Okra Peas Dried Green _(b) Roots and Tubers_ Artichokes Asparagus Carrots Onions Potatoes-- Sweet White Parsnips Radishes Turnips _(c) Leafy or Succulent Vegetables_ Beet-tops Cabbage Celery Dandelion Kale Lettuce Parsley Romaine Radish-tops Spinach Turnip-tops Watercress _(d) Miscellaneous Vegetables (of the cucurbita family)_ Cantaloup Muskmelon Pumpkin Squash Watermelon [Sidenote: Value of succulent vegetables] Succulent vegetables are very essential in a well-rounded bill of fare, and the neglect of their use is one of the errors in dietetics. The most important function of succulent or leafy vegetables is in the supply of pure water and mineral salts. They give to the body that which cannot be obtained elsewhere. [Sidenote: Vegetable juices aid the digestion of all food] The diet of the average person is composed of too many solids, especially of the carbohydrate class. Cereal products compose a very large proportion of the civilized diet, especially in America, yet the starch of cereals is the most difficult of all starches to digest and to assimilate. The water and solvent juices in fresh vegetables and succulent plants are important factors in the digestion and the assimilation of cereal starches. The relative importance of salads and succulent plants in the diet may be graded according to the following table: 1 Spinach 2 Turnip-tops 3 Dandelion 4 Lettuce 5 Romaine 6 Endive 7 Celery 8 Cabbage 9 Kale 10 Watercress 11 Parsley 12 Beet-tops [Sidenote: The white potato] The Irish or white potato is the only true tuber that is used very extensively as an article of food. It is formed chiefly of starch and water. The starch of this tuber is very coarse and much softer, more soluble, and hence much more digestible than the starch of cereals or legumes. Baking is the best method of preparing the white potato. The skins or peeling should be eaten in order to balance the diet as to cellulose, which is a most important article in the excitation of peristalsis of both the stomach and the intestines. [Sidenote: The sweet potato] The sweet potato is a root, and differs chiefly from the Irish potato in that it contains more sugar and less starch. The sweet potato is more wholesome than the Irish variety. Measured by its chemical contents, it is one of the best foods of all the tuber group. [Sidenote: Root vegetables] The root vegetables given in the order of my preference are: Carrots, parsnips, turnips and beets. Carrots are exceedingly nutritious and palatable in an uncooked state, eaten with nuts. Tomatoes may be considered upon the border line between vegetables and fruits. They are exceedingly useful in cases of intestinal congestion and torpidity of the liver. [Sidenote: The melon] The watermelon is very wholesome. The water is rich in sugar, while the pulp is composed of a soft fiber, which is a mild stimulant to the digestive and the excretory organs. Muskmelons and cantaloups are rich in natural sugar. They are non-acid, hence in harmony with nearly every known article of food. Considering their chemical neutrality and food value, they are about the best articles of diet in the watery or juicy class. The pumpkin and the squash, which are closely related to the melon, are of the genus cucurbita, and are divided into three species: 1 Pepo or pumpkin 2 Maxima or winter squash 3 Moschata, the pear-shaped squash With a slight variation of the water content, all of these varieties contain much the same elements of nutrition. However, the pumpkin is most important to the student of dietetics--(1) because of its food value, and (2) because of its prolific and universal growth. SUGARS AND SIRUPS It will aid the student greatly in comprehending this subject if he will review the chemical composition of sugars as given in Lesson IV under "Carbohydrates," Vol. I, p. 107.) Sugar in its various forms is a very prolific food product. It is the principal substance contained in nearly all fruits, but we shall confine our discussion here to the various sugars and sirups as they appear in commerce, freed from the other materials with which they are associated in nature. BEET-SUGAR [Sidenote: Origin of beet-sugar] Contrary to common belief, the greatest proportion of the world's supply of sugar comes from the sugar-beet. Sugar, which was once manufactured solely from the maple-sap and the sugar-cane, was discovered about one hundred years ago, to be present in beets. A very interesting historical fact is that the sugar-beet industry owes its origin to the efforts of Napoleon to supply France with home-produced sugar, because of the tariff or embargo laid upon foreign commerce. As a result of this effort all of Central Europe is now a heavy sugar-producing region. The method of production and the quantity of sugar contained in the sugar-beet have been so greatly improved that the present industry is quite able to compete with the production of sugar from cane in the tropical regions. Crude sugar from sugar-beets is very unpalatable, but the refined or crystallized form of beet sugar is chemically identical with cane-sugar. [Sidenote: Cane-sugar] Sugar-cane, though not so important as formerly, is still grown very extensively in several of the Southern states--Cuba, Porto Rico, and many semi-tropical countries. The chief distinction between cane-sugar and beet-sugar is that the crude cane-sugar, before it is refined, is a very wholesome and palatable product. The brown sugar of commerce is uncrystallized, or unrefined cane-sugar, and is fully as wholesome, and to most tastes more palatable than the granulated product. It is to be regretted that fashion has decreed we should use white sugar. [Sidenote: Refined sugar] Refined sugar, whether produced from beets or cane, is sometimes slightly contaminated with sulfurous acid and indigo, which are used for bleaching purposes, and if present in any quantity are very objectionable. [Sidenote: Maple-sugar] Maple-sugar, which is made by boiling or evaporating the sap of the sugar-maple, is a product decidedly superior in natural flavor to either beet or cane-sugar. Maple-sugar contains a small proportion of glucose and levulose, but its chief distinction from other sugars is a matter of flavor. The hickory tree contains flavors somewhat similar to the maple. A cheap substitute for maple-sugar has been manufactured by flavoring common sugar with the extract of hickory bark. The other forms of dry sugar obtainable in the market are milk-sugar and crystallized glucose. The chief use of milk-sugar as an article of diet is in humanizing cow's milk for infant feeding. The dry glucose, or, as it is sometimes called, grape-sugar, is not commonly seen in the market for the reason that it is difficult to crystallize, hence it is much cheaper to market glucose in the form of sirups. [Sidenote: The manufacture, composition and uses of glucose] Commercial glucose, as was explained in Lesson IV, is made by treating starch with dilute acids, and its wholesomeness depends entirely upon the care with which this is done. Theoretically, glucose is a very good food. In practise it is somewhat risky because cheap chemicals used in its manufacture may leave harmful and poisonous substances in the finished product. The manufacture of glucose is an excellent illustration of the objections to man-made foods as compared with natural foods. When we eat grapes we know that we are taking one of the most important substances required in the life-processes in a perfectly pure, unadulterated and wholesome form. Science has taught man to manufacture the identical substance that is found in the grape from corn, which is a much cheaper product, but the temptation to economize for the sake of dividends, and to allow the commercial spirit to control in the manufacture of food products is always present. For this reason the manufactured article comes under suspicion, while the natural form we know to be "exactly as represented." The principal uses of glucose are for table sirups and confectionery. Pure glucose as an article of food lacks flavor; for this reason the usual method of manufacturing sirups is to mix glucose and some other form of sirup or molasses. [Sidenote: Sirups and molasses] The original sources of sirups, besides commercial glucose, are cane-sirup, made directly by evaporating the juice of the sugar-cane; maple-sirup, made from the pure maple-sap; sorghum-sirup, or molasses, from the juice of the sorghum-cane, which is grown extensively in the South and Central West; and last, yet perhaps most common, "New Orleans" molasses, which is the residue from the manufacture of cane-sugar. This may be very wholesome if taken from the first drippings of the crystallized sugar, but if taken from sugar refineries it contains chemicals that have been used in the refining and the bleaching processes, and is a very doubtful product. An excellent quality of sirup can be made in the home by adding to the brown sugar a certain quantity of water, and boiling down to the desired consistency. HONEY [Sidenote: Honey, man's only food from the insect world] Honey occupies a very unique place, as it is practically the only food substance which man utilizes from the insect world. Honey cannot be strictly compared with milk and eggs as a food product, as the latter are complete foods for the nourishment of young and growing animals, hence must contain all food material necessary to construct the animal body. Honey, which is a carbohydrate, is gathered and used as a food for the adult bee. Pollen, or bee-bread, a nitrogenous substance, is the food of the larvae or young bees. This illustrates a very interesting fact in physiological chemistry. The insect differs radically from higher animals in that its life is divided into three complete stages. When the adult insect, with its wings, emerges from the cocoon or pupa, its growth is complete. Some insects never take any food in the adult stage; but the adult bee takes food, which is practically pure carbohydrates, and which would not maintain the life of a young animal. Honey is composed chiefly of glucose and levulose, with perhaps 10 per cent of cane-sugar, depending upon the flowers from which it is gathered. Honey is extensively adulterated with glucose, and sometimes with cane-sugar; thus the natural flavors are impaired and the product cheapened. CONFECTIONS [Sidenote: Evil effect of confections] Under the general term of confections are included all products manufactured for the purpose of appealing chiefly to the sense of taste rather than to serve any special purpose as food. The chief products that enter into confections are the various forms of sugars, chiefly glucose, because of its cheapness; fruits, nut-kernels, flavoring extracts, and coloring materials. Many of the substances used are very wholesome, yet the habit of eating confections as a general rule should be discouraged, if not condemned, the reasons being-- 1 That the material from which they are made is usually unknown to the public, and the temptation of manufacturers to use cheap or adulterated material too often controls, therefore quality is sacrificed to profits. 2 Confections are usually eaten without regard to appetite, or the physical need of food. 3 The combination of things from which confections are made shows that they are put together not for their food value, or nutritive virtue, but wholly for the purpose of appealing to an artificial sense of taste, rather than natural appetite. This destroys the appetite for similar products in simpler forms. The following are the best forms in which sugar can be found, given in the order of their importance: 1 Sweet fruits 2 Honey 3 Sorghum 4 Maple-sugar or sirup 5 Unrefined cane-sugar 6 Refined cane-sugar Even glucose sirups are perfectly wholesome when free from adulterants. The mixing, fixing, refining and manufacturing all go to make our sugar supply more expensive and less wholesome than the plain fruit-sugars, honey and sorghum. [Sidenote: Application of the term "sweets" as herein used] In order to avoid repetition, all articles containing sugar are referred to throughout this work as _sweets_. By "sweets" I mean sugar, sirups, honey, and all foods containing sugars, such as desserts, soda-fountain drinks, and the limitless number of confections. While carbohydrates rank second in importance in the human diet, yet Nature has made no provision for sugar being taken in its concentrated form. In this form it is the most severe article of human diet, and to its use can be traced the origin of a vast number of stomach, intestinal, and other disorders. Superacidity, fermentation, intestinal gas, and the large number of sympathetic disorders that follow these conditions are caused largely by the overconsumption of sugars. It would be equally as important for the Federal Government, or the States, to regulate the manufacture and the sale of confections as to regulate the manufacture and the sale of intoxicating liquors. VEGETABLE OILS [Sidenote: Value of vegetable oils] Vegetable oils form too small a portion of the modern bill of fare. Oils of vegetable origin, whether taken in their natural form or pressed out, and used with other foods, are the most valuable nutrients known for the production of heat and energy. By this statement I mean to convey the idea that a given quantity of fat will produce more heat and energy than any other article of human nutrition, and that vegetable fats are more valuable than animal fats, because they are more adapted to the fat metabolism of the human body, and less likely to contain harmful substances. Vegetable oils contain a larger per cent of olein, which is considered the most palatable and the most valuable fat known. [Sidenote: Olives and olive-oil] The olive is a unique plant, standing along the border line between fruits and nuts. Ripe olives contain from 40 to 60 per cent oil, the best quality of which is extracted by cold pressure, the cheaper grades being pressed out at higher temperature. The superiority of olive-oil is due to the fact that it is composed almost wholly of olein; that it contains very little fatty acids and other impurities, and has a mild, sweet, and agreeable flavor. The adulteration of olive-oil has been extensively practised, but the agitation of pure food, and the demand for same are improving the quality of this excellent article of food. [Sidenote: Cottonseed-oil] Cottonseed-oil is the largest vegetable oil industry in America. It is also the cheapest of vegetable oils. The cottonseed-kernel from which the oil is taken is not an edible product. Though used as cattle feed, it contains alkaloid substances which sometimes have a poisonous effect when fed too generously. The methods of cottonseed-oil manufacture are more complex than those of olive-oil. The oil must be heated and bleached with certain chemical agents, and if designed for salad-oils, frequently a portion of the stearin is removed to make the oil more liquid. When the cottonseed-oil is carefully manufactured, it is considered to be entirely free from harmful substances. However, as the original material contains poisonous combinations, and as chemical agents are used in refining and bleaching, cottonseed-oil products are open to the same criticism as glucose and refined sirups; that is, they are wholesome when properly made, but cheap and careless production renders the product undesirable as food. Manufactured under careful Government supervision, cottonseed-oil will, no doubt, be one of the great foods of the future. I recommend the purer brands of cottonseed-oils, when pure olive-oil cannot be obtained or afforded. [Sidenote: Peanut-oil] Peanut-oil is an excellent food substance which is almost entirely neglected in this country. It contains the best portion of the peanut. Other vegetable oils, valuable as foods, and the use of which is to be recommended, are sesame-oil and sunflower-oil. These products are not produced extensively in this country. [Sidenote: Cocoa-butter] The cocoa-butter is pressed from the beans from which cocoa and chocolate are made. The butter has a flavor similar to these articles. Cocoa-butter should not be confused with cocoanut-butter. These products are very different in origin. [Sidenote: Cocoanut-butter] Cocoanut-butter is not extensively used in America as a food product, owing to the fact that the exposed fat globules oxidize very rapidly. It is extensively used in Germany, however, and with the introduction of better methods of preservation, we expect to see cocoanut-butter more generally used in this country, as the source from which it is derived is almost unlimited. [Sidenote: Palm-oil] Palm-oil comes from a different species of the palm plant than that which produces the cocoanut. It is a very inexpensive product and one which is chiefly used in the production of soap and candles, although it is perfectly wholesome as a food. Such products have not been utilized in this country as food, because our boundless prairies and corn-fields have made the production of cattle and swine cheap, and our fat supply has swung toward points of least resistance. Not all vegetable oils are edible or wholesome. Some contain, in addition to olein, stearin and palmitin, and other fats quite as undesirable. Castor-oil, for example, contains ricinolein, which is a poison, and to which its purgative action is due. Croton-oil is the most powerful laxative known to medicine, owing to the fact that Nature abhors a poison. [Sidenote: Linseed-oil] Linseed-oil contains large quantities of linolein, which is the substance that oxidizes, forming the stiff, rubbery coat on the surface of linseed-oil when exposed to the air. This makes linseed-oil valuable matter to the painter, but objectionable as a food. LESSON IX DRUGS, STIMULANTS, AND NARCOTICS With the origin and the use of drugs in the treatment of dis-ease, most people are familiar. The purpose of this lesson, however, is to give brief but accurate information concerning the various chemical elements and compounds termed drugs or medicines. Many of the medicines in common use are neutral, having no particular effect upon the body, and the effects attributed to them are largely imaginary. Out of the many thousands of chemical materials found in nature, there are, however, certain substances, groups, and compounds which have most marked and violent effect upon all forms of living protoplasm. [Sidenote: Ancient belief concerning medicine] The general theory upon which the practise of medicine rests is that certain chemical substances which are not found in the animal body, and which have no natural place therein, have mysterious and beneficial effects; that they possess certain powers, among which are the rebuilding of dis-eased cells, and the purifying of dis-eased blood. This belief arose in a very remote age, when the mind was primitive; when man was ignorant, and controlled almost wholly by superstition--when every natural phenomenon was believed to be the work or whim of some god, and every dis-ease was thought to be the work of some devil. [Sidenote: Life the result of chemical harmony] Modern science has proved all this to be untrue. We know by the selective processes through millions of years of evolution that those chemical substances which work in harmony have become associated so as to form life. We know that life is merely an assemblement of organic matter, very complex and little understood; that it is eternally undergoing chemical changes governed by the natural laws of development and decay. We know that conformity to certain natural laws will produce physical ease, and that violation of these laws will produce dis-ease. We know that ease is what we most desire, therefore the trend of thought, throughout the world, is to realize this desire by turning toward the natural. [Sidenote: The material upon which life depends] True food furnishes the foundation or constructive material upon which all life depends. Nearly all other substances which affect the human body are merely disturbing elements that interfere with the natural chemical processes of life. To illustrate more fully these general principles, we will take, for example, the chemical changes that may take place in the hemoglobin of the blood. Hemoglobin is a proteid containing iron. It is a complex chemical compound and reacts with other substances very readily. In the lungs it combines with oxygen. In the muscles, this oxyhemoglobin is again received into the original body-substances. This life-giving process is only one of the many thousands selected by evolution from the millions of chemical changes possible in nature. [Sidenote: Effect of carbon monoxid upon the hemoglobin of the blood] When carbon monoxid, which is present in illuminating gas, is breathed into the lungs, it combines with hemoglobin, producing a compound which prevents the formation of oxyhemoglobin, thus stopping the process of oxidation in the body, and death is the result. [Sidenote: Drug theory declining] In proportion as science has shown the origin of life, and the methods by which it has been sustained and developed, the use of drugs as a remedial agent has declined. This line of reasoning followed to its logical end, points with unerring certainty to the total abandonment of the drug theory of treating dis-ease except, perhaps, as anesthetics and disinfectants. [Sidenote: Treatment of dis-ease by disinfection] The means of combating dis-ease by disinfection is sometimes confused with the general system of drugging. The modern methods of preventing and of combating contagious dis-eases by disinfection are in harmony with the best known sanitary laws. These results depend, not upon the ignorant and the harmful theories on which general drug medication was founded, but upon the latest and the most scientific knowledge. [Sidenote: Patent medicines and the doctor's prescription] In the recent magazine exposures of patent medicines, the chief trend of argument was that these stock remedies were evil because the user took opium, cocain, or whisky without a doctor's prescription. This standpoint is more amusing than instructive. Just why a poison taken without a doctor's prescription should be dangerous, and its sale a crime, while the sale and the use of the same drug over a doctor's prescription should be highly recommended, is rather difficult to comprehend, and this the enterprising journals have not explained. The exposé that is most needed is not of a few poisonous patent preparations, but of the fundamental folly of interfering with Nature's work by any form of poisoning. Poison is poison whether advertised in a newspaper as a "New Discovery," or prescribed by a reputable representative of the "Ancient Order of Medicine Men." In a lesson of this kind it is impractical to classify all drugs accurately according to their chemical nature. For convenience of the student, however, the drugs commonly used in medicine will be divided into three groups, which have common representatives, and whose general effect upon the human body are well understood. These three groups are: a Alkaloids and narcotics b Alcohols and related compounds c Poisonous mineral salts and acids a ALKALOIDS AND NARCOTICS [Sidenote: Effect of alkaloids upon the body] All alkaloids are of vegetable origin. They all contain nitrogen, and in some respects resemble ammonia. Many of the alkaloid compounds are used in medicine. They affect primarily the nervous system, and may cause freedom from pain, or that abnormal state of exhilaration of which the cocain addict is a typical representative. Substances of this alkaloid group doubtless have useful functions in the plant in which they grew, but in the animal body they are disturbing factors. Among the most important alkaloids may be mentioned opium, cocain, nux vomica, and quinin. OPIUM [Sidenote: Composition of opium] Opium is the evaporated sap that flows from incisions made in the unripe capsules of certain Asiatic species of poppy. It contains a large number of chemical compounds which belong to the alkaloid group. The chief alkaloids in opium are codein, narcotin, heroin, and morphin, the most active being heroin. Other alkaloids are of similar composition. The general effects and the uses of the crude opium and the refined morphin may be considered together. The latter, being more concentrated, is used in much smaller quantities. [Sidenote: Effect of opium] The effect upon the body of either opium or of morphin is that of benumbing the nerves and producing sleep. Opium illustrates in a typical manner the progressive stages by which both the body and the mind may become enslaved to the influence of a narcotic. The last stages of the opium or of the morphin slave is probably the lowest state of depravity into which the human being can sink. [Sidenote: Origin of the morphin habit] Opium is eaten or smoked by the Chinese and by other Asiatic races to a very great extent. This habit is considered the worst form of slavery to drugs that is known except cocain. In this country the morphin habit is the more common form. Morphin is either taken internally or is injected beneath the skin by a hypodermic syringe. It is estimated that the great majority of the morphin slaves in this country begin the use of this drug under "their" doctor's prescription. [Sidenote: The several uses of morphin] The use of opium as prescribed by medical men is chiefly for the relief of either pain or of insomnia. Its employment in cases of great agony is probably justifiable, but the repeated taking of this drug until the habit is formed becomes a criminal blunder for which the doctor who prescribed it should be held responsible. Unfortunately this is only one of the uses to which opium is put by the medical profession. Prescriptions containing either opium or morphin are frequently given to relieve pain, or to produce sleep, when the primary trouble is chronic, and should be treated by removing the causes, and not alleviated by stupifying the nerves. In the majority of such cases, if the diet is balanced according to age, activity, and climate, and vigorous intestinal peristalsis created, sleep will follow, and other disorders will gradually disappear. [Sidenote: Opium in patent medicines] The dangers that lurk in the use of opium are so well known, and the habit has become so unpopular, that tricks are resorted to by manufacturers of this drug to deceive the people into believing that they are using some "harmless" substance, while it is the influence of the opium that gives the medicine its apparent good effect. Patent medicines which claim to kill pain, soothe nerves, and produce sleep, usually contain opium. The popular "Soothing Sirups" for children are nearly all opium products, and have been given to millions of babies in this country by deluded mothers, in the belief that because it soothed, their innocent child was being benefited. These are the crimes of greed passed on to innocent childhood through ignorance. COCAIN Cocain is an alkaloid, the use and the influence of which are almost as noteworthy as that of morphin. Cocain is derived from the leaves of the cocoa plant which grows in the Andes of Peru. Just as the Chinese use opium, so the Peruvian Indians use cocain. [Sidenote: Uses and effects of cocain] Owing to its hydrochloric-acid salt, the effects of cocain differ somewhat from those of opium. It produces relative freedom from pain, and is used more particularly to produce insensibility in local parts of the body, as in the case of extracting teeth. The cocain slaves, which are increasing alarmingly in this country, usually take it by snuffing, or in an atomizer. The habit is usually acquired, as in the case of morphin, by the prescription of a physician. The patient, learning from experience the freedom from pain and the sense of exhilaration that can be produced by the drug, and not being warned by "his" physician of its baneful effects, continues the habit after the doctor's treatment has ceased, and awakes to find a monster owning his body and his mind. The cocain fiend, like the opium slave, develops an insatiable desire for the drug, and suffers extreme mental and physical pain when deprived of the usual allowance. The development of untruthfulness and trickery in a person desiring his allowance of a forbidden drug, is one of the marked traits of the narcotic slave. [Sidenote: Cocain in patent medicines] There are a number of different medicines which depend for their action wholly upon the cocain they contain. A large number of catarrhal powders in the market are diluted forms of cocain, and are used extensively both by those who do not realize the nature of the drug they are using, and by those who know that they are cocain slaves, but prefer to disguise the fact in this manner. NUX VOMICA AND STRYCHNIN [Sidenote: Effect of strychnin] Nux vomica is derived from the seeds of a plant that grows in India. Strychnin is the alkaloid which exists therein. Strychnin is quite different in its effects from the above-mentioned alkaloids, for instead of benumbing the nerves, causing sleep or a pleasing sensation, the effect is a nerve stimulus which causes muscular convulsions. The medical use of strychnin is more of a stimulant than of a narcotic. It is one of the most widely used of all the drugs prescribed by the old school physicians, and is extremely dangerous in over-doses. Indeed, thousands of people have been killed by strychnin poisoning. QUININ Quinin is derived from Peruvian or cinchona-bark. This bark, like the juice of the poppy plant, contains a number of alkaloids. These alkaloids, in turn, may react with acids, forming salts. [Sidenote: The uses of quinin] Sulfate of quinin is the most common form of this drug. Its principal use is for the destruction of the malarial germ, and it is, therefore, the standard drug in all malarious countries. The germs of malaria, however, are not bacteria (microscopic plants, as many suppose), but minute forms of animal life. Aside from this particular use, the effect of quinin is to disturb the nervous system, produce insomnia, ringing of the ears--and even deafness, in a great many cases. It does not, however, produce an addiction, as do morphin, cocain, heroin, and other drugs. ACETANILID [Sidenote: Composition and effects of acetanilid] Acetanilid is one of the coal-tar poisons and is chemically related to anilin. This drug has come into use only within the past few years, and of all the coal tar group is one of the most remarkable in its physiological effects. Its influence is to produce at first a deadening effect upon the nervous system, which puts it in the "pain-killer" class. Its continued use destroys the hemoglobin of the blood and produces marked cell-destroying effects throughout the body. Its medical use is for rheumatism, headache, severe coughs, and the like. A patent medicine now being widely exploited advertises, "We print our formula." So they do, and acetanilid is one of the ingredients. The general public does not know what acetanilid is. The habitué of this "healthful drug" experiences a craving similar to that of other narcotic drug fiends. A person who has long used a medicine containing acetanilid shows a bluish-white complexion caused by the destruction of red blood-corpuscles. I merely mention this as an example to show that a knowledge of the composition of patent medicines does not protect the public unless the public is made familiar with the ingredients that compose these medicines. Acetanilid is the active principle in many popular headache powders, the formulas of which are not made public. The use of acetanilid by those claiming to cure suffering, or to relieve it, is one of the most glaring malpractises of the day. [Sidenote: Evil effects of coal-tar products] Other coal-tar products chemically related to acetanilid are antipyrin, phenacetin, and various derivatives of benzol and phenol. The general uses of this class of drugs are to reduce fevers and to allay pain. They accomplish this by stupifying the nerves and the nerve fibers, which serve as telegraph wires to inform the brain that something is wrong. This is equivalent to killing the messenger that warns us of our sins. The following are a few of the toxic remedies used by old school physicians in the treatment of nearly all forms of dis-ease: Laudanum--which is merely another name for opium Paregoric--a standard baby medicine which is a tincture of opium with camphor and other drugs Codein--an alkaloid manufactured from morphin Lyoscine--the alkaloid of henbane Atropin--an alkaloid extensively used by oculists. (It is contained with other alkaloids in BELLADONNA, which, in turn, is prepared from the plant known as the "Deadly Nightshade") Hellebore--a powerful alkaloid, is one of the old standard drugs used in the treatment of rheumatic gout TOBACCO Tobacco belongs strictly to the narcotic class of drugs. With the possible exception of opium, tobacco is by far the most detrimental narcotic used by man. [Sidenote: Effect of nicotin] The active principle of tobacco is nicotin, which resides in the leaves in combination with malic acid. Nicotin is an alkaloid, and one of the most deadly poisons known. In distilled form, nicotin, even in minute quantities, produces death almost instantaneously. The nicotin contained in a pound of tobacco is sufficient to kill several hundred men if administered in the form of pure nicotin, but in smoking and chewing tobacco only a small amount of this poison is absorbed into the body at one time, and, owing to the gradual growth of the tobacco habit, the system has time to partly adjust itself to the use of this powerful drug, enough at least to prevent acute narcotic poisoning. The violent sickness caused by the first use of tobacco evidences the poisonous effects of the nicotin upon a body not accustomed to its use. Tobacco as a narcotic is not as drastic in its effect as opium, morphin, and cocain; for this reason its use is not so generally condemned. Popular opinion, however, is now rapidly recognizing that all of these substances belong in the same general class and are deteriorating factors in human development. The rapid spread of the cigarette habit among young boys has done much to arouse popular agitation against the tobacco evil. [Sidenote: General effect of tobacco] From the standpoint of health, nothing can be said in favor of the use of tobacco in any form, as it gradually deadens the sensitiveness and control of the nervous system. It preys with great violence upon the optic nerves, and more than any other drug known dethrones sexual vitality. The tobacco heart, which is readily recognized by medical practitioners, shows the effect of this narcotic upon the nervous system. The craving for tobacco is closely related to the craving for intoxicating liquors and for highly seasoned food--three of the most potent factors in perverting the true sense of taste and arousing abnormal cravings which destroy natural hunger. Neither tobacco nor nicotin are now used by medical practitioners. Tobacco was formerly used as a purgative, and also as a poultice to relieve swellings and inflammation. COFFEE [Sidenote: Composition of coffee] Coffee is one of the most extensively used articles in the narcotic group. The alkaloid which gives coffee its characteristic properties is caffein. Coffee also contains from three to four per cent of tannic acid. Other substances in coffee, to which the pleasant odors and taste are due, are various forms of fats and carbohydrates, but these exist in such small quantities as to be negligible food elements. The effect of the caffein is that of a nervous stimulant, increasing the general nervous and mental activity. Coffee is frequently used to keep people awake. It is given as an antidote for opium poisoning because it stimulates the nervous system and prevents sleep. [Sidenote: Effects of coffee-drinking] Coffee, when used habitually, produces various forms of dyspepsia, especially hypersecretion of hydrochloric acid, tannic acid being the provoking factor. The effect of coffee upon the nervous system is that of continued stimulation or excitation. Its continued use overworks and wears out the nervous system, thus causing a deterioration of both body and mind. If caffein were taken in a highly concentrated form, it would result in a narcotic habit quite as enslaving as the use of opium or cocain. TEA [Sidenote: Composition of tea] Tea, in its chemical composition, is similar to coffee, containing even a greater percentage of the alkaloid caffein, and also a larger percentage of tannic acid. Tannic acid is present in larger quantities in green tea than in the black variety. In addition to the evil effects caused by the caffein which it contains, tea is more destructive to the normal activities of the stomach because of the tannic acid. The student may get some idea of what the stomach of the tea-user has to contend with, when it is stated that tannic acid gets its name from the essential action that this substance has in the process of tanning leather. COCOA AND CHOCOLATE The cocoa bean, which was mentioned as the source of chocolate and cocoa-butter, is also the source of the beverage known as breakfast cocoa. The cocoa bean contains caffein, though the per cent is considerably less than in coffee or tea. Cocoa is practically free from tannic acid. For these reasons, and because of its food value, it is decidedly the least harmful of the stimulant beverages. Cocoa, though being in reality more tasteful and nutritious than either coffee or tea, is less used because it lacks the stimulating effect. The various alkaloid poisons thus far discussed form but an infinitesimal part of the great group of articles used by old school physicians in the treatment of dis-ease, and by civilized people as stimulating and sedative beverages. b ALCOHOLS AND RELATED COMPOUNDS The second group of drugs which is associated with alcohol includes the ethers, chloroform, and coal-tar products. This group is also wholly of plant origin, alcohol being distilled from plant products, and coal-tar being formed from petrified plants. These drugs always contain the three elements carbon, hydrogen, and oxygen; some contain an additional element which gives them their peculiar property; for example, chloroform contains chlorin. Coal-tar is the most wonderful source of drugs known. The distillation of this substance produces coloring matter, preservatives, poisons, and "pain killers" ad infinitum. ALCOHOL The uses and the effects of alcohol will not be discussed at length in this lesson because the subject of alcohol is constantly before the public, and its evil effects universally known and acknowledged. However, I deem it well to examine a phase of the question which is not so well understood. [Sidenote: Alcohol a poison not a food] Whether or not alcohol is a food has recently been discussed by a wide range of writers. The answer of science is that alcohol is a food in the sense that it can produce heat in the body. Even if alcohol were a true food, the heat is produced, however, by the increased circulation of the blood, which is Nature's warfare against a poison, and in the reaction the vitality of the body is lowered. Thus the true effect of the poison is made manifest. Starvation is not the danger that threatens mankind, but OVERFEEDING and WRONG feeding. Were we in danger of starvation, whisky at one dollar a quart would not save us. The very fact that alcohol produces heat in the body, whether we call it a food or not, only adds another reason why it should not be used. It produces heat by stimulating heart action; rapid heart action is Nature's defense against the intruding poison. Alcohol taken in addition to food, and in connection with it, produces surplus heat, and overstimulates metabolism, which is very harmful. It also adds one more to the long list of detrimental effects traceable to intoxicating beverages. Alcohol is a food in the same sense that dynamite is a fuel. Dynamite produces heat, but it would be an unwise fireman who would use it under his boiler. [Sidenote: Correct eating the best treatment for the drink-habit] Another point regarding the use of alcohol that is worthy of consideration, is the fact that improper nutrition, together with the over-ingestion of stimulating and heating foods such as meat and condiments, invariably increase the appetite for intoxicants. The appetite for alcohol seldom, if ever, develops in a perfectly nourished body, and the best treatment known for the drink-habit is a careful course of balanced dieting and hygienic methods of living. Alcohol is purely a stimulant. It increases the heart action, the circulation, the production of heat, and the general vital activities. It is an offense to Nature, and the body calls into activity all her powers to cast out the poison. When the influence of alcohol has run its course, there is a reaction or stupor which calls for more of the same drug. This indulgence cultivates the desire through both the body-functions and the appetite, and the blighting habit dethrones the reason, thus rendering useless the lives of millions of worthy people. [Sidenote: Why alcohol is used in patent medicines] The prescribing of alcohol by physicians has chiefly descended from the ancient idea that alcohol was strengthening and beneficial to the body. The practise is being discontinued by many reputable physicians, which proves that no great benefits, in dis-ease, can be derived from its use. The regular use of alcohol in small doses gives the patient the feeling of physical exhilaration, and is therefore an excellent means of making him believe that he is being benefited. For this reason, and because of its cheapness, low grade alcohol is the chief component of many medicines. The following table gives the percentage of alcohol contained in a few patent medicines, previous to the popular exposé of the subject. (I do not vouch for the accuracy of this table at the present time, as the manufacturers under the pressure of public opinion may have changed their formulas): Peruna 28% Hostetter's Bitters 44% Lydia Pinkham's Compound 20% Hood's Sarsaparilla 18% Ayer's Sarsaparilla 26% Paine's Celery Compound 21% Within the past few years these facts have been made public, resulting in a heavy decline in the sale of these concoctions. The number of good temperance people who have been innocently under the influence of alcohol for a goodly portion of their days can only be vaguely estimated. CHLOROFORM, ETHER, AND CHLORAL [Sidenote: Uses of chloroform, ether and chloral] These drugs are chemically related to alcohol, and are typical anesthetics, which mean that they produce temporary relief from pain when the vapors are inhaled. They are chiefly used in surgical operations, which is justified providing the operation is justified. One death in three thousand occurs from the administration of chloroform, and one in thirteen thousand from the administration of ether. These products have been used to some extent in patent medicines, particularly in consumptive cures, where they have been given with the idea of relieving the cough. POISONOUS MINERAL SALTS AND ACIDS The mineral acids and salts of certain metals, especially of mercury, lead, and copper, are powerful poisons. Patent medicines are frequently labeled "Pure vegetable compounds." This statement may be true, but it is deceptive because they are equally as poisonous as the coal-tar products which have become so popular. They are life-destroying in their final effects upon the human body. MERCURY [Sidenote: Uses of mercury and mercurial salts] The metal mercury or quicksilver is used very extensively as a medicine, chiefly in compounds of mercurial salts. All salts of mercury are extremely poisonous. Calomel (mercuric chlorid) is a standard allopathic medicine. Mercuric bichlorid or corrosive sublimate is more destructive to protoplasm, and is used as a germicide or disinfectant. The poisonous action of mercurial salts is probably due to the combination of mercury with the protoplasm of the body-cells. When mercurial compounds are taken in poisonous doses, the antidote is the white of egg with which the mercury combines in the stomach, thus sparing the human protoplasm. The mercurial salts, when given in small doses, produce very remarkable physiological disturbances, sometimes even loosening of teeth. Because of their violent physiological action, these drugs are generally to be condemned. POTASSIUM IODID Potassium iodid has a very destructive effect upon the natural functions of the body, and for this reason it has been associated with mercury in the treatment of syphilis, the usual method being to alternate between potassium iodid and mercurial salts. LEAD AND COPPER The salts of lead and copper, like those of mercury, are poisonous. However, these salts are not extensively used in medicines. The mineral acids, such as sulfuric, are recognized poisons, but their destructive effects upon the living tissue are so apparent and so painful that they have never gained favor with physicians. PURGATIVES AND CATHARTICS [Sidenote: Effects of salts] The popular term "salts" includes sodium sulfate (Glauber's salt), and magnesium sulfate (Epsom salts). These salts cause a large amount of watery mucus to be excreted from the mucous membrane of the intestines, the physiological purpose of which is to wash the offending substances from the body, thus producing a laxative effect. Were the large doses usually taken of these salts absorbed into the blood, death would ensue within a few hours. The number of products that are used for the purpose of relieving constipation is almost unlimited. Many poisons which react directly upon the mucous membrane of the alimentary canal have a laxative effect. [Sidenote: Why laxatives cause loss of vitality] Laxative drugs do not act on the body--the body acts on the drug because it abhors a poison, and, in throwing out the drug, the food residues of the digestive tract are also thrown out, regardless of whether digestion is complete or not. The rapid loss of vitality and weight while taking physic is caused by this fact. [Sidenote: Object of this lesson] In this lesson I have examined only a few of the many thousand drugs in general use. I have omitted many drugs and compounds whose properties and uses would form interesting information, but the purpose of this book is to impart a knowledge of foods, not a knowledge of drugs. This lesson, however, is for the purpose of giving the reader some authentic information about the standard drugs and medicines, so that he may form his own conclusions in regard to the efficacy of drugs in curing dis-ease. If the reader will secure at a public library a copy of the "National Standard Dispensatory," the book used by practising druggists, and scan through its two thousand pages, he can form some idea of the limitless number of things, and the complex, uncertain, and unscientific methods used in the prescribing and in the dispensing of drugs. LESSON X IMPORTANCE OF CORRECT DIAGNOSIS AND CORRECT TREATMENT The word "diagnosis" is derived from two Greek words, "dia," meaning _through_, and "gnosis," meaning _knowing_. It therefore means literally "through knowledge," "to know thoroughly," or, as we now say, "thorough knowledge." The old form of the word is still retained in the very common expression "to know it through and through." [Sidenote: Diagnosis may be a source of danger] The primary purpose of diagnosis is to locate a difficulty, to find an internal disorder that is causing unpleasant symptoms. It will readily be granted that this is only desirable when, after the internal disorder has been located, we are able to do something to correct it; that otherwise it is of no more importance than to learn by post-mortem examination what caused death. Indeed, to know what the trouble is without knowing how to deal with it, is a very grave source of danger, and has caused many a death through resort to wrong methods. In a large percentage of cases Nature will heal, if her processes are not interfered with, and in all cases she is the real physician; our only proper office is to supply the right materials, and to leave her to use them as she will. [Sidenote: True diagnosis, merely an interpretation of Nature's language] Correct diagnosis is important because it is the guide--the beginning--the primary step in the treatment of dis-ease. Wrong diagnosis is usually followed by wrong methods of treatment, while correct diagnosis simplifies, and points the practitioner, with certainty, to the interpretation of Nature's language (symptoms). With an understanding of these, the remedy, in most cases, will suggest itself. [Sidenote: The human body and the linotype machine compared] The linotype machine that set the matter you are now reading is composed of several thousand parts. The keyboard is operated by the compositor, in much the same manner as that of a typewriter, and the delicate mechanism produces the metal lines of type ready to be "made up" in "forms" for the press. Where several such machines are in use, an expert machinist is usually employed to keep them in order. He can take them apart, study the mechanism at leisure, and reassemble them, yet it not infrequently happens that almost insurmountable difficulties are encountered. What would be the difficulties, then, if the machine were enclosed in a case that could not be opened, with only the keyboard exposed? What mechanical engineer in all the world could then make it work if something went wrong? One who could tell from the faulty action just what the matter was, and correct it from without, would be looked upon as a wizard. [Sidenote: Belief in the magical effect of drugs] The human body is incomparably more complex and delicate than any machine, yet it is a widespread superstition that one skilled in the art of locating disorders (diagnosis) can, almost invariably, correct them by the magical effect of drug applications. This is a superstition with no more foundation in fact than the parallel one that a man of vicious character can be made virtuous by a magical process. He may turn from vice to virtue in a moment, but he can become spiritually strong and wholesome only by growth, and by conformity to the moral law. In like manner bodily health comes not by magic, but by right living, by conformity to the laws of health. [Sidenote: Involuntary functions are perfectly performed] It is literally true that "the only perfectly performed functions of the body are the involuntary or the automatic functions." Those that are even partly under the control of the will, such as breathing, are almost invariably ill done. The infinite wisdom is strikingly exemplified in the fact that the vital functions are quite independent of our volition except for "hindrances or ruinous urgence." We may, and we do hinder them constantly, and we subject them to "ruinous urgence" almost continuously. These two facts are responsible for nearly all the bodily ills from which we suffer. [Sidenote: Nature's marvelous methods beyond our comprehension] The marvelous metabolism by which energy is translated into life, by Nature's processes, is not only beyond our control, but beyond our comprehension. We should make it an invariable rule, therefore, never to interfere in any way, but to confine our efforts to the task of supplying Nature with material with which to do her wonderful work, and to an observance of the common laws of health and life. [Sidenote: The blood-corpuscles like little workmen] The blood-corpuscles are like millions or tens of millions of little workmen in the body, each with a particular work to do; each on duty and quickly responsive to call every moment. When we recognize the fact that the body is constantly being broken down and rebuilt; that every atom of broken-down material must be floated away in the blood, and new atoms built in to keep the structure from deterioration; that all the broken-down material is poisonous, and must be eliminated from the body without delay, we realize that the internal activities are almost bewildering. When we consider that all the blood in the body passes through the heart every two or three minutes, carrying food to every cell, and at the same time carrying away the poisonous products of physical and mental activities, disposing of them by various processes; when we remember that the supply to every cell is delicately adjusted to constantly varying requirements; that all this goes on so quietly and so smoothly that we are unconscious of it--when we remember all this, we begin to have some appreciation of the Psalmist's exclamation, "I am fearfully and wonderfully made." How faithful these little workmen are! Not for an instant do they leave their tasks. Verily, they are the sentinels forever at the portals. In our work, in our pleasures, they are ever active; in our sleep, they sleep not. Not for an instant do they cease watch. Is there a wound--be it a great rent or a tiny pin-prick, they are there in force to repair it, to wall up the breach and to make it whole--swarming to the rent as the Lowlanders to a break in the dike. Has a foreign substance penetrated the structure?--instantly they set about to expel it; but if this be impossible, they seal it in a capsule of impervious integument that it may do no harm, or, the least possible injury. [Sidenote: A seeming consciousness in the automatic action of the blood] If these little workmen are not conscious as we know consciousness, at least their work shows purposeful action, and when we see an obvious purpose definitely carried out by every available agency, we may be sure there is a consciousness back of it, whether it be like ours or not. But while these workmen are faithful--while they will stand to their tasks to the end, they are limited in their power, and will break ranks under long-continued hindrances. [Sidenote: The human body a power-plant] The human body is a power-plant, a combined engine and boiler, and there is a close analogy between this conscious, self-acting power-plant and the one that furnishes the power to generate electricity, or to turn the wheels of a factory. [Sidenote: Symptoms compared with electric light] When your electric lights grow dim, and the defect is not cured by renewing the lamps, then you are convinced that the trouble is elsewhere. If the lights in every part of the house are dim, you will know (if you are a skilful electrician--a good diagnostician) that the trouble is not in the electric nervous system of the house. It may be between your house and the electric station, but before taking the trouble to examine the line, ask those of your neighbors who are on a different line, whether their lights are dim. If they are, you may go to the electric station with reasonable certainty of finding the cause. [Sidenote: The stomach and the lungs of this leviathan] Suppose we have come to the station and are commissioned to locate the difficulty. We go into the engine room and find everything in good order. The engine is a fine piece of mechanism; it has no loose joints, no leaky valves, yet it seems to lack power; is overloaded. Inquiry shows there are no more lights than formerly, while the service was satisfactory. You go at once to the boiler room. It may also be in good order so far as appearances go, but you look at the steam gage and find the pressure is low. "Yes," says the fireman, "I simply can't keep the pressure up. I shovel in coal and keep the drafts on so that I have a roaring fire, but, in spite of all, my steam pressure runs down." Look into the furnace (the stomach) of this leviathan! If the grate-bars are clean; if there is no accumulation of ashes, cinders, or clinkers to interfere with the combustion (digestion) of the black provender fed to it, you may close the furnace door and open another. Look into the fire tubes (the lungs) of the laboring monster that has shown signs of weakness! If the fire tubes are clean, free from soot and dust, the trouble is not there. [Sidenote: "Scale," like an irritated mucous lining] [Sidenote: "Scale," the cause of dim light] We have now gone almost the full course; there is but one place left to explore and that is closed. The trouble is inside the boiler. It is lined with scale deposited from the water evaporated in producing steam. This scale, which may be likened unto an irritated mucous lining of the stomach, or the intestines, forms a coating upon the lower inside of the boiler, and the upper side of the fire tubes, just as it is deposited on the bottom of a teakettle, and it shuts out the heat from the water. The heat being the source of energy, and the steam only the means of applying it, the power-plant is crippled. Seldom does it happen that so great a thickness of scale is to be found in a boiler as may be seen in almost every household teakettle, yet the effects (symptoms) are found in the dimmed lights miles away, and if the difficulty is not dealt with, it will rapidly increase until the service becomes intolerably inefficient. [Sidenote: Difficulty in dealing with the "scale"] Had we found the grate-bars choked with ashes, cinders, and clinkers, and the fire tubes (lungs) smothered with soot and dust, we should have instructed the fireman to keep them clean and free. This is not a difficult thing to do, requiring only careful daily attention, but the scale inside the boiler is not so easily dealt with. It is completely enclosed, and there is no possibility of getting at it except by extinguishing the fire and letting the boiler cool--by making the boiler "dead," or "killing" it, as firemen term it. [Sidenote: Treating the "dim light" dis-ease] Having diagnosed this case of the lighting system, starting with the symptoms of a dim light in a residence some miles away, and having located the difficulty inside of the boiler of the power-plant, we desire to treat it. The boiler can be "killed," and the scales removed by going into the boiler. It can then be revived by refilling it with water and rekindling the fire. Then, too, let us assume that there are two boilers, and that we can keep the plant alive with one; a low ebb of life, to be sure, but not dead. We will then cool one boiler at a time, go into it, and remove the scale, thus restoring the plant to full efficiency. This method can be used where the boiler may be cooled, but as this cannot be done with the human power-plant, for the sake of our analogy, let us suppose that the steam boiler, like the human body, must always be kept under pressure that it cannot be "killed" and revived. What, then, shall be done? [Sidenote: Removing the cause of the scaly deposit] It is evident that the first thing to do is to cease the use of water containing the solution of mineral, which causes the scaly deposit. This will prevent the condition from growing gradually worse, and may be accomplished by distilling the water before introducing it into the boiler, or, by using rain-water. As to the scale already in the boiler, it must be dissolved, and gradually eliminated, or remain there. There are many so-called "boiler compounds" for the purpose, and every well-informed man in charge of such a "plant" knows how important it is to avoid using a compound that may cause damage to the boiler itself. A "compound" that would attack the steel, as well as the scale, would be a desperate remedy indeed. [Sidenote: One degree of variation in temperature indicates dis-ease] [Sidenote: The marvelous economy of Nature] In the human body something happens very similar to the deposit of scale in a steam boiler. But the human body is a furnace as well as an engine. It is so intricate and so delicate that if the temperature rises or falls one degree above or below normal, the condition is one of dis-ease. As food is its fuel, how can we expect the mechanism to remain in order if we utterly disregard the body's requirements, not only as to the character of the fuel supplied, but also as to the quantity, especially if we so choke it with fuel that Nature is unable to burn it up in the vital processes, and to dispose of the resulting ashes and cinders? Nature is resourceful--full of expedients and makeshifts! If she were not, the span of life would be much shorter than it is. As previously stated, she will seal up a foreign substance that cannot be expelled, and not only will she do this with solids that have penetrated the flesh, but she will actually build "catch basins" in the body, called cysts--bags, somewhat like a bladder, in which the excess or refuse that cannot be eliminated may be impounded, and the ruin of the body postponed for months or even for years. [Sidenote: True diagnosis locates a disorder; also the causes] The true office of diagnosis is not only to find the disorder, but to discover also the conditions that lead to it, or have a bearing upon it; hence that diagnosis is faulty which comes short of this, for the reason that even if the disorder be located and overcome, it will recur if its cause persists, just as the scale in the boiler will form again if the causes that produced it are not removed. As the blood is the life, as it brings to every cell life (nourishment), and carries away death (poisonous by-products of vital activities in the form of dead matter to be eliminated from the body); as it does this by its marvelously rapid circulation through every cell, it is obvious that every part of the body will be in a state of health if the blood itself is pure, and its supply and circulation such that every cell is abundantly fed. The supreme law of health, therefore, may be expressed in two statements, one positive and one negative: 1 Feed the body correctly 2 Do not interfere with the circulation of the blood [Sidenote: Both the storing of fat and the disposing of waste are expensive processes] If the blood is not a perfect building material it is because we have not put into the digestive mill the right materials; and if it is not properly circulated, it is because the circulation is impeded by positive constrictions, or, as is more frequently the case, because the composition of the blood is not perfectly suited to the demands of the vital activities. As a result, much of the material must be rejected as unusable, thus involving a great deal of extra work in disposing of it. If the excessive material is wholesome, though not at present usable, it may be packed away for future use as fat, this being the easiest, and perhaps the only possible way of disposing of it in the rush. The builders are not only overworked, but literally overwhelmed with excessive and unsuitable materials--and why?--that we may indulge perverted appetites. [Sidenote: Corpulency considered unhealthy] Even the excessive material packed away in the wholesome form of fat may, merely by its bulk, become an impediment to the circulation. It not only reduces the efficiency of the bodily mechanism, but also is so potent a factor in shortening life that a corpulent person is likely to be rejected by an insurance company, even though his present state of health may be good. [Sidenote: Defective circulation reduces efficiency] A condition often found illustrates most forcibly the manner in which defective circulation reduces the efficiency of the human power-plant, even as the scaly deposit impairs the efficiency of the steam boiler. "That tired feeling" of which so many complain, is so called because the person thus afflicted has a sense of painful exhaustion upon slight exertion--is tired all the time. If our diagnosis shows a state of chronic exhaustion, and we endeavor to increase the body-efficiency by increasing the food, we shall make the same mistake as the fireman who shovels more coal under a scaly boiler. [Sidenote: Exhaustion, the accumulation of body-poisons] Painful exhaustion in a perfectly healthy body results from violent, or too long-continued exercise of a muscle, and if there are no intervals of rest, excruciating pain results. The cells are broken down more rapidly than the resulting waste can be carried away by the circulation, hence the body-poisons and pain. The pain is a symptom, and where the condition of which it is the index is temporary, rest soon restores the normal condition of ease. [Sidenote: Rest is imperative] There would be no sense of exhaustion if the building and the eliminating processes could be carried on with sufficient rapidity concurrently to make good all the expenditures of mental and bodily activities. Not only should we not need rest, but we should not even need sleep. The only occasion to stop, then, would be to take in more fuel (food), and if this could be taken while the body is in action, as fuel is fed to the steam boiler, there would be no necessity to stop. But apparently both the upbuilding and the elimination of waste normally lay behind the demands of even ordinary activity, so that a given muscle must have very frequent intervals of rest (every few seconds), and the organism, as a whole, must reduce activity to the minimum by sleep about one-third of the time. [Sidenote: Nature's devices to provide rest] As some of the muscles are used with practical continuity during the waking life, Nature resorts to some very cunning devices to provide the necessary rest. The tension upon the muscle of the eye is relaxed for an instant in the unconscious act of winking, but by reason of the persistence of visual sensation, this does not interfere with vision. Thus Nature has always used the principle involved in the moving picture. The heart must perform its work every instant, from the time before we are born until the end, but each muscle rests about one-third of every second--when it relaxes, and the chamber of the heart expands with the inrush of blood. [Sidenote: The body a pile of mysterious atomic masonry] Nature alone is the builder, and will do all that should be done if she only has the proper materials in proper proportions. We may well stand in awe and admiration of her mysterious atomic masonry, but let us lay no sacrilegious hand upon her work. LESSON XI COMMON DISORDERS--THEIR CAUSE AND CURE HEALTH AND DIS-EASE DEFINED Health is that condition of the human body in which the functions or activities work together in perfect harmony. Any serious interference with this condition we call dis-ease. Dis-ease, therefore, in its final analysis, is merely the expression of violated natural law. [Sidenote: Three fundamental laws of life] The harmonious working of the life-processes in the human body depends upon three things--(1) nutrition; (2) motion and (3) oxidation. Nutrition is the principal factor that controls the action of the living cells, for, if the body is kept up to its one hundred per cent of energy it will demand a certain amount of motion or exercise, and this will enforce the proper breathing (oxidation). We can see, therefore, that nutrition is the physical basis of all activities of life. By nutrition as here used I mean to include all chemical substances that may be supplied for the use of the body-cells, also the sum total of all chemical substances in solution in the circulating fluid or blood-plasma which bathes the body-cells. [Sidenote: The phenomenon of death caused by self-poisoning] The stoppage of the heart beat causes the nutritive fluids of the body to cease circulating. The cells are then no longer supplied with nutritive material, and the poisons which they are constantly throwing off accumulate, cell activity ceases, and the phenomenon we call death ensues. Suffocation acts in a very similar manner--oxygen ceases to be supplied to the blood; carbon dioxid accumulates; the vital fluids cease to flow, and death is the result. Dis-ease has been defined to be an absence of harmonious activity in the body. It may result from the inactivity of some particular function. A stomach which secretes no hydrochloric acid is abnormal or dis-eased. Again, a dis-ease may be due to an overdevelopment of some function, because the man whose stomach secretes more hydrochloric acid than digestion requires is as truly dis-eased as is the man whose stomach secretes too little. [Sidenote: Dis-ease is partial death] [Sidenote: Animals starve when fed on salt-free food] Dis-ease may also be defined as partial death, for it is the disturbance or weakening of functions whose complete failure we call death. Starvation illustrates one side of this process. When nutritive material ceases to be supplied, the cells have nothing with which to work, causing disturbance of function (dis-ease), and then partial, or complete death. The man in a desert under a hot sun will starve for water in one-tenth the time that he would starve for solid food. Animals fed on a diet from which all salts have been chemically removed will die in a shorter time than will those from which all food is withheld. This rather interesting fact is due to the rapid utilization of the salts residual in the body during the digestion and the assimilation of the salt-free foods taken. The order in which the withdrawal of nutritive substances will produce starvation is about as follows: 1 Aerial oxygen 2 Water 3 Mineral salts 4 Organic nitrogen 5 Carbohydrates [Sidenote: Examples of drug poisoning] Poisoning by drugs is an excellent illustration of dis-ease and death produced by specific starvation. When a man takes ether, this substance, passing to the brain, immediately interferes with the function of that organ. Insensibility to pain results. If ether is taken in larger quantities, the functions of the brain may be still further interfered with, and the nervous control of the heart beat will be lost, and death will ensue. When castor-oil is taken into the alimentary canal, the irritating substances therein contained inflame the cells of the mucous membrane, and excite them to abnormal secretion, thus disturbing the harmony of the body-activities, and producing dis-ease. [Sidenote: Scientific definition of dis-ease] The examples here referred to are not commonly considered dis-ease, because we know the particular or immediate cause of the physical disturbance. Modern knowledge now shows us that the most prolific cause of what is commonly known as dis-ease is but the interference with cell activities, either by the deficiency or by the excess of nutritive substances, or by the presence of irritating and disturbing poisons. This condition may be caused by an unbalanced diet containing too much of certain nutritive elements, or too little of others, causing surfeiting on the one hand and starvation on the other. [Sidenote: Man still in the childhood state of development] [Sidenote: Hunger, thirst, and taste are Nature's language] Health is the normal condition, and in spite of Ingersoll's witticism, it is more "catching than dis-ease." Were it not so, the race would long since have become extinct. With reference to body-health, however, we are still in the childhood stage of development, and the science, therefore, of building man to his highest estate--of lifting his mental, moral, and physical faculties to their highest possible attainment, is worthy the labor of the greatest minds. That person, then, who enjoys the best health, the keenest mentality and power of perception, the highest physical and emotional organism, is he who can select such articles of food as will supply all the constituent parts of the body most nearly in the right or natural proportions. The science of feeding, upon which this mainly depends, becomes possible only when food is taken in accordance with certain fixed, natural laws. These laws are not complicated--they are simple and easy to comprehend. Nature is constantly endeavoring to aid us in their solution. Hunger, thirst, taste--all the instincts and natural desires of the body are merely Nature's language. To interpret this language, and to obey the laws it lays down is man's highest duty to himself and to his race. There are very few true dis-eases. Nearly all of the abnormal physical expressions given off by the body can be traced to a few primary causes, and most of these causes can be removed by ascertaining and removing other causes that precede them. [Sidenote: Classification of dis-ease, a matter of convenience] The classification of dis-eases is merely a matter of convenience, and is of no practical importance between the food scientist and the patient. It merely enables the one who has studied these classifications to convey his knowledge or information to the lay mind. The dis-eases which will most interest the student will be those caused by a lack of nutrition, or by a surfeit of nutrition; that is to say, a form of starvation caused by a lack of certain nutritive elements, and overingestion caused by an excess of certain other nutritive elements. The only practical method of describing dis-ease is by indicating the organs afflicted and the impairment of their functions. Beginning with the stomach, in which, as previously stated, originates probably ninety-one per cent of all human disorders, I will first take up the question of the abnormal action of food caused by overeating. OVEREATING [Sidenote: The resourcefulness of Nature] Fortunately Nature does not demand exactness. She has made wonderful provision for our errors or our lack of precision. If we eat too much now and then she will cast out the excess. If, however, we habitually overeat, she will store away the surplus in the form of useless fat, or she will decompose it; that is, make an effort to volatilize it and cast it out through the pores of the skin. If our diet is unbalanced, Nature has the power to convert one chemical into another--a secret yet unknown to modern science. [Sidenote: Injurious effects of congested waste matter] While the tendency of Nature is to maintain normality by casting the debris out of the body, she demands that we obey the laws of motion and oxidation. If we do not observe these laws, the debris or matter she cannot use will accumulate, and congestion and constipation will take place. The excess of food thus actually clogs the system and generates in the intestines the poisons which cause autointoxication. THE EFFECTS OF OVEREATING The effects of overeating are so far-reaching, and so common among civilized people that a volume might be devoted to this habit and the subject not exhausted. Here, however, I will review only that which is of most importance to the student of dietetics, namely, the causes and a few of the effects of overeating. Overeating is due to three specific causes: 1 Eating several articles of food at the same meal which are incompatible 2 Taking stimulants at meals 3 Eating too many things at the same meal (1) Incompatible foods: When foods are eaten together that are incompatible they usually result in superacidity and sometimes cause a gnawing sensation in the stomach. (2) Stimulants with meals: When one takes stimulants such as beer, liquor or wine with meals, the stomach-cells secrete a deficient amount of hydrochloric acid, causing food to leave the stomach too slowly, thereby allowing fermentation to take place and acid conditions to develop. (3) Too many things at same meal: Too many things eaten at the same meal may exhaust the digestive juices and cause a condition of subacidity (lack of acid), which is true indigestion, or it may cause just the reverse, too much acid, and therefore produce the same result as in taking stimulants with meals. (See "Causes of Superacidity," item 2, p. 420). ABNORMAL APPETITE [Sidenote: The cycle of cause and effect] In nearly all cases of overeating Nature's only weapon with which to defend herself is hydrochloric acid, thus the stomach-cells become over-trained in the secretion of acid, and the constant irritation caused by acid fermentation produces abnormal appetite. The desire to satisfy this abnormal craving produces more acid, therefore the cycle of overeating and superacidity is complete. [Sidenote: Disorders originating in the stomach] Standard medical works give about sixty different disorders arising from what is termed dis-eases of nutrition. These include diabetes, gout, arthritis, rheumatism, rickets, scurvy, obesity, emaciation, adiposis dolorosa, and various disorders of the liver, heart, and the circulatory system; also constipation and dozens of disorders under the broad term of autointoxication. The first step in the practise of scientific eating should be to limit the quantity of food, or, in many cases, to take a complete fast for a brief time. In the slow stages of human development, Nature seems to have accommodated herself to man's omnivorous habits of eating. She will accept many things that are wholly unfit for food without apparent harm if the quantity is not too great. On the contrary, the results of the most scientific dieting will be injurious if a quantity be taken in excess of that which the body can use. SUPERACIDITY We will first consider superacidity because it is usually the first disorder that appears in consequence of wrong eating. It is commonly known as "sour stomach." The chief cause of superacidity is a wrong combination of foods; and particularly an excess of starchy foods and sugars. The starch and sugar breaks down under the action of fermentation, and develops lactic acid. This further inhibits--or prevents--the normal secretion of hydrochloric acid, and, as a consequence, the albumen molecule is insufficiently converted--the transformation of the protein into peptones and proteoses is incomplete. As with all acid fermentation, gases are produced in the stomach, which give rise to belching and eructations. This fermentation sometimes occasions a feeling as though there were a solid lump in the stomach. This may come on immediately after eating. And then again, it may not come on for two or three hours after the meal--depending entirely upon the activity of the enzymes that are responsible for the fermentation. HYPERCHLORHYDRIA Occasionally the hyperacidity is caused by the presence of a superabundance of hydrochloric acid in the stomach. This condition is called hyperchlorhydria, and gives rise to a boring, gnawing sensation in the pit of the stomach, together with an abnormal desire for food. SUPERACIDITY--THE CAUSE The chief causes of superacidity are-- 1 Too great a quantity of food 2 Wrong combinations and wrong proportions of food For instance, a diet consisting of an excess of acid fruits, or sweets and starches, and at the same time an insufficient quantity of other nutrients 3 By poisoning from the use of tea or coffee, liquor, tobacco, and the various stimulating and narcotic drugs used by civilized man 4 An excess of hydrochloric acid SUPERACIDITY--THE SYMPTOMS So far as the symptoms are concerned, all the above causes may be considered together, since the ultimate result is the same. The symptoms are named in the order of their various stages or the time acidity has endured: 1 [1]Irritation of the mucous lining of the stomach, expressed by a burning sometimes called "heartburn" 2 Abnormal appetite caused by the irritation of too much hydrochloric acid in the irritated cells of the stomach Many people mistake these symptoms for evidence of good health, until overeating produces nervous indigestion, and sometimes a complete breakdown. 3 Fevered mouth, and so-called fever-sores on the lips and tongue, both of which are a true mirror of the condition of the stomach 4 [1]A sour fluid rising in the throat from one to two hours after meals 5 White coating on the tongue 6 Faintness, emptiness; in the language of the layman a "hollowness and an all-gone caved-in" feeling [1] (See "Fermentation--The Symptoms," p. 426) SUPERACIDITY--THE REMEDY In all cases of superacidity all fruit, especially that of an acid character, except citrus fruits, should be omitted, and also all sweets except a very limited quantity of maple-sugar and sweet fruits--and these never in conjunction with the meal. Foods containing proteids (nitrogen, albumin and casein), together with fresh green vegetables, should form the principal part of the diet. [Sidenote: One acid will not counteract another] It has been the theory with dietitians that those afflicted with hyperchlorhydria (supersecretion of hydrochloric acid) should not take sweets, but should take acids liberally. This is one of the few instances in which medical guesswork seems to have a foundation of fact. For there is no doubt but that the giving of hydrochloric acid, the normal stomach acid, _before_ a meal, tends to retard and restrict the development of hydrochloric acid _during_ the meal. It remains true, on the other hand, that the giving of hydrochloric acid after the meal tends always to increase the supply of free and combined hydrochloric acid in the stomach during the process of stomach digestion. For list of foods to be eaten and omitted in cases of overeating, superacidity, fermentation and gas dilatation, see p. 433. For the importance of water-drinking, see p. 434. FERMENTATION Fermentation is the effort of Nature to dispose of or to dissolve things it cannot use; it is the first step in the process of decay. FERMENTATION--THE CAUSE The common causes of fermentation are the same as those of superacidity (see p. 420), the difference being that superacidity originates in the stomach, and is confined chiefly to it, while fermentation may take place throughout the entire intestinal tract. The causes are-- 1 Overeating 2 Too much acid fruit 3 An excess of sweets 4 Stimulants of the alkaloid group 5 Overeating of cereal products FERMENTATION--THE SYMPTOMS [Sidenote: Difference between superacidity and fermentation] The first evidence of fermentation is a burning sensation in the stomach, almost exactly as in superacidity, the difference being that in cases of fermentation the symptoms appear later after eating. Superacidity may appear immediately after eating, and the symptoms such as a lump in the stomach, or a sour fluid rising in the throat may also appear within an hour after meals, but fermentation, which produces the same symptoms, does not manifest itself until the acid has acted upon the food, which requires from two to four hours, governed by the time required to digest the different articles of which the meal is composed. The patient may also experience a fullness; an unpleasant and sometimes painful distention of the bowels. [Sidenote: Results of fermentation] The gas generated by fermentation sometimes passes along down the intestinal tract into the ascending colon, accumulating at the highest point, which is in the transverse colon. This causes the transverse colon to become very much distended and seriously interferes with the blood flow, both into and out of the heart and the lungs. (See "Gastritis," p. 447; also "Heart Trouble," p. 569). In considering the symptoms of fermentation, it might be well to return to the question of causes. The primary cause of nearly all conditions of fermentation, either in the stomach or in the intestinal tract, is overeating, or an unbalanced dietary. This practise indulged in from day to day causes two specific conditions: 1 Fermentation followed by various disorders, usually toxic substances, and catarrh, and ulceration of the stomach 2 Intestinal congestion and physical emaciation If the stomach and other digestive organs are capable of assimilating this superabundance of food, they force into the tissues an excess which Nature stores up in the form of fat, and if work or activity is not increased, or the food diminished, excessive fat or chronic obesity is the result. If the first warnings are not observed, and the remedy applied, Nature gives to the disobedient one more impressive signals in the form of nervousness, irritability, abnormal appetite, and sometimes mental depression, which indicates one of the most advanced stages of superacidity. FERMENTATION--THE REMEDY The remedy for fermentation is first to eat only such foods as are in chemical harmony, and second to limit the quantity to the actual needs of the body. If the patient is _under_ normal weight, all acid fruits should be eliminated, and the diet should be about as follows: BREAKFAST Three or four egg whites and one yolk, whipped five or six minutes; add a large spoonful of sugar and one of cream while whipping A baked white potato or boiled wheat A tablespoonful of wheat bran LUNCHEON One whole egg whipped five minutes; add sugar and cream to taste while whipping, mix with a glass of milk A large boiled onion A baked potato, with butter Two tablespoonfuls of bran DINNER Two fresh vegetables--choice of carrots, corn, turnips, peas, beans, or squash Spinach, or a salad of lettuce and celery The whites of two or three eggs, whipped; add sugar and cream while whipping A baked potato Wheat bran, cooked as a cereal From two to three glasses of cool water should be drunk at each meal. It will be noticed that this bill of fare is composed largely of vegetables, which is right in cases of fermentation. [Sidenote: Despondency, the result of superacidity] The foods named in the above menus will remove the primary causes of fermentation, which in turn is the most prolific cause of that abnormal mental condition called despondency. Under the most favorable social and financial conditions, when every environment is pleasant and seemingly conducive to the highest degree of pleasure and interest in life, the one afflicted with superacidity and fermentation has been known to destroy himself; all life seems gloomy, all effort useless, and the thought "Why should I desire to live?" enters the mind unbidden, until it often takes tangible shape in some rash act. Possibly within the memory of every individual one of these rash acts can be recalled. The practitioner should make it a special point to ascertain any adverse or depressed mental conditions of his patient and remove them, if possible, by encouragement, sympathetic counsel and optimistic views, all of which have a splendid psychological effect, and which, in nearly all cases of mental depression, are very important. As the supersecretion of hydrochloric acid becomes less and less, fermentation will gradually disappear; the patient will at once begin to gain weight; the mental conditions will show an immediate improvement, and every part of the anatomy will share in the general upbuilding. GAS DILATATION So closely related are gas dilatation, fermentation and superacidity that it might be said they all come from common causes, such as excessive eating, over-consumption of sweets, acid fruits, starches, and the use of tobacco, stimulating beverages and drugs. GAS DILATATION--THE SYMPTOMS The symptoms of gas dilatation are practically the same as those given for fermentation, page 426. In addition thereto, however, there is often belching, loss of appetite, a weighty or draggy feeling, and vomiting sometimes an hour or two after meals, or late at night. Scanty urine and constipation are frequently the results of gas dilatation. In severe cases the stomach drops down below its normal level, causing permanent stomach prolapsus. To the trained eye, in severe cases, the stomach may be outlined, especially when it is much distended. For remedy, see "Fermentation," page 428. See also menus for Gastritis. IN CASES OF OVEREATING, SUPERACIDITY, FERMENTATION AND GAS DILATATION OMIT EAT All acid fruits Bananas, very ripe All sweets except sweet fruits Green salads in limited quantities Liberal quantity of fresh Cane-sugar green vegetables Condiments Limited quantity of blood-less Coffee and tea meat, such as fish and white meat Cream of tender fowl Fatty foods Limited quantity of coarse cereals Gravies Limited quantity of eggs and Pastries milk--sweet and sour Stimulating and intoxicating Melons beverages Nuts Subacid fruits in extreme cases Potatoes Tobacco Sweet fruits--limited quantity White bread Wheat bran Whole wheat, thoroughly cooked Whole wheat bread--sparingly IMPORTANCE OF WATER-DRINKING The lack of body-moisture is one of the causes of supersecretion of acid, therefore water is of primary importance in removing the causes of the above disorders. It should be drunk freely immediately on rising, and just before retiring. From two to three glasses should also be drunk at each meal, especially in treating severe cases. Copious water-drinking also relieves irritation of the stomach, thus reducing abnormal appetite. Patients afflicted with superacidity never have natural thirst. CONSTIPATION THE CAUSE This disorder might be called "civilizatis," so universal has it become among civilized people. Several conditions may conspire to cause constipation-- 1 Premature stomach digestion 2 Neutralization of the bile by excessive acid 3 Eating too much starchy food 4 Flesh-eating 5 Sedentary habits or lack of proper exercise 6 A diet too refined--lacking in roughness, cellulose or "fodder" 7 The use of sedatives, stimulants, and narcotics, such as tea, coffee, liquor, tobacco, and drugs, especially of the alkaloid group While most of these are direct causes, the primary cause, however, goes back to superacidity--premature stomach-digestion. In cases of superacidity the liver is nearly always more or less inactive. Just why this is so is not definitely known, but in the opinion of the writer it is caused by the neutralization of bile by the excess of acid. Be this as it may, nearly all cases of superacidity are accompanied by intestinal congestion, commonly called constipation, or by intermittent diarrhea and constipation. CONSTIPATION--THE REMEDY [Sidenote: Laxative drugs an offense to the body] It is believed by the medical profession, and generally accepted by the public, that certain drugs act upon the alimentary tract with beneficial effect in cases of intestinal congestion. This is untrue. The facts are the intestines act upon the drug. The drug is an offense to Nature, and when it is taken into the stomach and passed on to the intestines, the body-fluids are severely drawn upon to neutralize the poison, and to cast it out. The result, therefore, of taking poisons, miscalled "laxatives," is that each time the act is repeated, the liver and the peristaltic muscles are weakened, and rendered more and more abnormal, and less and less able to perform their natural functions. [Sidenote: Suggestions for the relief of constipation] That system of treatment which has been prescribed for fermentation will, in most cases, relieve constipation. The treatment should be varied, however, according to the age and the occupation of the patient, governed by the season of the year, or the foods available at the time of treatment. If diagnosis of the patient reveals the fact that constipation has been caused primarily by overeating, the quantity of food should be reduced, and the articles changed so as to include a generous quantity of cellulose (coarse foods). The following bill of fare may be given under ordinary conditions: Immediately on rising, take two or three cups of water, the juice of one or two oranges, or half a pound of grapes, swallowing the seeds and pulp whole, masticating only the skins. Devote from eight to ten minutes to vigorous exercise, especially movements Nos. 3 and 5, as shown in "Exercise and Re-creation," Vol. V, pp. 1344 and 1345. BREAKFAST Half a cup of coarse wheat bran, cooked ten minutes; serve with thin cream Whole wheat, boiled five or six hours One or two very ripe bananas, with either nuts or thin cream LUNCHEON One or two fresh vegetables A "two-minute" egg or a very small portion of fish A heaping tablespoonful of bran DINNER Two of the following vegetables: Corn, carrots, peas, beans, parsnips, turnips, onions A baked potato Celery, lettuce, or anything green, with nuts One egg A tablespoonful of wheat bran From one to two glasses of water should be drunk at each of these meals. These menus are merely suggestive. They may be varied according to judgment, depending upon the habits and the environments of the patient. Curative feeding for constipation is one of the most important departments of this work, and will receive special consideration in the volume of Menus. FOODS THAT MAY BE SUBSTITUTED FOR ONE ANOTHER The menus may also be varied by substituting the articles herein given for other things of the same general class. EXAMPLES: {Evaporated peaches Dried fruits {Evaporated apricots {Prunes The above are all in the same general class, and may be substituted for one another. {Dates Sweet fruits {Figs --All form another class {Raisins {Eggs Dairy products {Milk and Meats {Fish {Fowl These compose the nitrogenous group, and may be substituted for one another. {Carrots Vegetables {Parsnips --Are in the same group {Turnips {Beans Legumes {Peas --Are in the same general class {Lentils {Barley Rice Cereals {Corn Rye {Oats Wheat Barley, corn, oats, rice, rye and wheat are the six great staples, which grouped are called cereals. They form the carbohydrate class of grains, and may be substituted for one another. In cases of constipation, however, whole wheat and rye are preferable, owing to the large amount of bran they contain. {Dandelion {Kale Edible succulent {Lettuce --Belong to same class Plants {Parsley {Romaine {Spinach Citrus fruits {Grapefruit {Lemons {Limes {Oranges All citrus-fruits (fruits containing citric acid), so far as their action upon the liver is concerned, have practically the same effects, and substantially the same nutritive value. [Sidenote: Milk may be laxative or constipating] Whether or not milk is constipating depends entirely upon how it is taken, and the articles with which it is combined. In small quantities, from one to two glasses at a time, milk is constipating. However, if taken at intervals of fifteen or twenty minutes, a quantity is very soon taken, greater than the hydrochloric acid of the stomach can convert into curd, therefore the surplus quantity becomes rather laxative. In many years' experience I have rarely treated a case of constipation that would not readily yield to milk and to coarse vegetables, or bran, if taken in this way; however, the milk diet should not be given longer than two or three days at one time. After this period adopt the menus herein given, varying them by selecting different articles from the several groups named. When the bowel action has become regular, the milk period should be reduced, and the breadless diet extended until the milk is entirely withdrawn. (See "Emaciation--The Remedy," p. 482) [Sidenote: Hernia due to abdominal pressure] Man undoubtedly sprang from anthropoid stock. His original position of locomotion was upon his four feet. The intestines, therefore, rested upon a flexible belly surface, but since he has risen and changed his two front paws into hands, the intestines are inclined, with every step, to sag to the bottom of the abdominal cavity, and are prevented from so doing only by small ligaments attached to the abdominal walls. Hernia or rupture is exceedingly common owing to this downward pressure in the lower part of the abdominal cavity. The position maintained while walking, therefore, is not conducive to the relief of that pressure in the abdomen, which is the direct cause of hernia, and often the cause of very stubborn intestinal congestion. [Sidenote: Remedial and counteractive exercises] It is obvious, therefore, that this condition needs remedial exercise. It will be observed that all the movements given in the lesson on "Exercise and Re-creation" bring the trunk to a horizontal position with the body leaning forward. All of these movements are designed to counteract this abdominal pressure. [Sidenote: Exercise a necessity in counteracting constipation] I go thus into detail for the purpose of showing the great necessity of these exercises, especially in cases of constipation, and of insisting that they be executed vigorously and regularly. _The most beneficial diet that could be prescribed will not relieve and cure constipation unless it is supplemented by certain remedial exercises or movements._ This is true because Nature contemplates a certain amount of motion exactly as she contemplates a certain amount of nutrition, and her laws governing motion are just as mandatory and her penalties just as certain. [Sidenote: Proper nourishment promotes natural desire for exercise] Nutrition is of more importance because it is more fundamental, and it is more fundamental because when the body is naturally nourished, there is created a surplus amount of energy which will compel a certain amount of motion, and this in turn will cause deep or full breathing. Therefore the well-fed person will take his exercise because he has an appetite for it, or because the superabundance of energy forces him to do it in obedience to the same law that produces hunger. Hence the perfectly nourished body will conform automatically to the other two great physical laws of motion and of oxidation. _Constipating Foods_ _Laxative Foods_ --------------------- --------------- All white flour products All green salads Blackberries Apples Cheese Apricots Chestnuts Beet-tops Corn-starch Celery Fine corn-meal Figs Macaroni Peaches Oatmeal Persimmons Red meat Plums Rice Prunes Spaghetti Spinach Sweet potatoes Turnips-tops White bread Wheat bran Whole wheat _Constipating Beverages_ _Laxative Beverages_ ------------------------ -------------------- All alcoholic stimulants Mineral water containing magnesia Chocolate Unsweetened fruit-juice Cocoa Water--lime-free Coffee Cream Lime-water Milk (In small quantities) Tea In cases of constipation: OMIT EAT Baked beans All fresh vegetables Chestnuts Apricots Cheese Bananas Coffee, tea, chocolate Grapes--seeds, skins and all Corn products Nuts Cream Peaches Flesh food of all kinds Plums Intoxicants Prunes Milk Succulent plants Oatmeal Tomatoes Rice Wheat bran Sweet potato Whole wheat Tobacco Rye White flour products Drink plain water with meals. GASTRITIS Gastritis is a word meant to describe a chronic and a painful condition of stomach and of intestinal irritation. When the stomach becomes much irritated from constant fermentation of food, and from the resultant presence of acid, certain articles such as milk, fruit-acids, and starchy foods will cause rapid accumulation of gas, which becomes exceedingly painful and sometimes dangerous. [Sidenote: Gas, the primary cause of heart trouble] The majority of deaths from so-called heart-failure is caused directly by the accumulation of gas from the fermenting mass of food in the stomach and in the intestines. These organs become greatly inflated, and their pressure against all the vital organs, and against the arteries leading into and out of the lungs and the heart so impair the circulation that the heart action becomes very irregular--first slow and faint; sometimes skipping a beat, and again violent and palpitating. When the congested blood spurts through into the heart it is called "arterial overflow," and the old diagnostician seems to have been content with giving this a name. It is certain they have not yet given the world a remedy, as the regular profession is still prescribing such drugs as bicarbonate of soda, bismuth subnitrate, and nux vomica, none of which can give more than temporary relief, and that is accomplished by neutralizing the acid at the tremendous expense of the cells that secrete it. GASTRITIS--THE CAUSE Gastritis is caused: 1 By the use of stimulants 2 Irritating foods, condiments, etc. 3 Overeating, especially of acid fruits, starches and sweets 4 Cirrhosis of the liver is sometimes one of the secondary causes of gastritis GASTRITIS--THE SYMPTOMS The symptoms are usually a dull pain in the region of the stomach and upper intestines, a swollen full feeling, now and then biting pains, followed by a dark vomit, especially when the attack comes late at night. Gastritis is often confused with gastric cancer, and in diagnosis it is difficult to speak with authority as to whether the case is ordinary gastritis, as above described, gastric ulcer, or gastric cancer. The diagnostician in making up his opinion must be governed largely by the time the condition has endured, and the immediate causes, giving especial care to the food and drink that has been consumed just prior to the attack. GASTRITIS--THE REMEDY In severe cases the patient should be given a glass of cool water. In fact, one of the best means of allaying the inflammation of gastritis--or as a matter of fact any other inflammation--is cool water. All food should be omitted for at least twenty-four hours, then the patient should be given vegetable juice prepared as follows: Grind spinach, carrots, squash, or turnips, any two or three of these, very fine; cook about ten minutes in enough water to make a pint of thin vegetable soup. Put through a colander; strain through a coarse cloth, discarding the pulp. Give this to the patient every two hours in quantities not more than one or two ounces, dependent upon the condition. The diet may be varied by changing vegetables, always selecting one green plant such as spinach, lettuce, beet or turnip-tops. As the patient improves more of the pulp may be used. After the second or third day a thin puree may be used, care being exercised not to overfeed. [Sidenote: Foods to be used in the treatment of gastritis] In milder cases the patient should be fed after the same methods, only more of the vegetable pulp may be used, thereby increasing the strength of the diet after four or five days; or, when the patient shows signs of substantial recovery, egg whites, baked potatoes, and the ordinary fresh vegetables may be given in moderate quantities. Inasmuch as stomach fermentation is the beginning or parent cause of gastritis, the causes, symptoms, and menus given for fermentation would apply in cases of gastritis, limiting the quantity of food according to the severity of the condition. In cases of gastritis: OMIT (In severe cases) EAT (In severe cases) Coffee Baked bananas Condiments Egg whites Flesh foods Lettuce Fruit Puree of tender beans Intoxicants Puree of tender carrots Starchy foods Puree of tender corn Sweets Puree of tender peas Tea Spinach Tobacco Squash Vegetable juices In the earlier stages of acute gastritis, all foods should be omitted except, perhaps, vegetable juices. (See recipe, p. 451.) See also Fermentation and Superacidity, pp. 424 and 418. NERVOUS INDIGESTION [Sidenote: Mental effects of nervousness] There are millions of nerve fibers leading out from the stomach and alimentary tract to every part of the anatomy, so that the nervous connection, especially between the stomach and the brain, is very direct and sensitive. The stomach seems to bear the same relation to the brain that a basket bears to a balloon so far as their nervous connection is concerned. Thus it is that the irritated stomach produces an irritable temper, insomnia, forgetfulness, and a lack of ability to concentrate the thoughts. These are the milder symptoms or first warnings. NERVOUS INDIGESTION--THE CAUSE The use of stimulants or narcotics, such as tea, coffee, liquor and tobacco are most prolific causes of nervousness. These drugs act upon the body in a dual capacity: (1) They excite or raise the nervous system above normal, only to drop it below when the reaction takes place. (2) In addition to this, they irritate the stomach and the intestines by causing superacidity. Nervousness caused by sedatives and narcotics acts both upon the mental and the physical organism, and the source of such nervousness can be easily traced by ascertaining the habits of the patient. [Sidenote: Abnormal appetite for sweets and starches] When the patient has used stimulants and narcotics long enough to cause nervousness, the mucous membrane of the stomach is usually in a state of irritation. The presence of blood, under these conditions, causes abnormal appetite, frequently followed by overeating, especially of sweets, starches, and acids, for which the patient usually has a great craving. This is followed by fermentation, and comes into or envelops superacidity and must necessarily be classed with it. Overeating and the constant use of stimulants and narcotics will, after a time, cause a chronic state of fermentation, and the stomach will seldom be free from acid, the constant presence of which will ultimately cause gastric ulcer, and perhaps stomach carcinoma. NERVOUS INDIGESTION--THE SYMPTOMS [Sidenote: Nature's final symptoms] The more advanced stages of stomach irritation which are expressed by nervousness cause melancholia and a gloomy sort of pessimism. These are among the last signals the stomach gives to the brain before final collapse, and if these signals are not heeded, the victim may expect to go down in the maelstrom of nervous prostration within twelve months from the time the first signals are given. These fits or spells of melancholia often come on suddenly. The palms of the hands become moist with a cold, clammy perspiration, and the mind is flooded with a train of thoughts such as "What's the use of living?" "Why all this struggle for mere existence?" The victim of this condition invariably believes that his mind is becoming affected; that he is becoming insane, and will soon be a public charge, and shunned by those whom he loves. While under these spells many people take their own lives rather than face what they believe to be insanity and ostracism. The patient should be made acquainted with his true condition, and shown that it is only temporary, and that all such thoughts are mere mental aberrations which will disappear when the causes of stomach irritation are removed. The above-named symptoms always point with certainty to an irritated stomach, the severity of which can be determined by the symptoms above described. [Sidenote: Difference between stomach and intestinal irritation] _Stomach irritation_ is expressed largely through the _mind_, as in irritability, nervousness and melancholia, while _intestinal irritation_ is generally expressed by some _physical symptom_, such as restlessness, twitching of the muscles and a general lack of physical tranquillity. There is another form of nervousness believed to be caused by overwork, business worries, etc. With these opinions the writer does not agree. If the body is properly fed one is not likely to overwork. Nature will demand rest, and sleep will come while at the desk, or when following the plow. [Sidenote: Acidity the cause of worry] Investigators are much divided on the question of whether worry causes superacidity, or superacidity causes worry. The experience of the writer in treating several thousand cases of stomach acidity has proved beyond a doubt that acid fermentation and stomach irritation are the primary causes, and what is commonly called "worry" is merely a symptom or result of this condition. It is quite evident, therefore, that all forms of nervousness must go back to the food question for final solution. NERVOUS INDIGESTION--THE REMEDY Nervous indigestion should be treated as follows: 1 The patient should employ his time in pleasant but useful occupation 2 As to diet, _omit_ the following: All red meats Acid fruits Bread and cereals Condiments Pickles {Such as-- {Candies Sweets {Cane or maple-sugar {Dates and figs {Desserts and pastries of all kinds {Sirups 3 The diet should consist of-- An abundance of green salads Baked potatoes (Including the skins) Egg whites Fats--limited quantity-- Such as-- Dairy butter Nut butter Olive-oil Nuts Fresh vegetables--not canned {Beans Legumes {Peas {Lentils In cases of Nervous Indigestion: OMIT EAT Acid fruits Baked potatoes Bread and cereals Fats (limited quantity) Coffee and tea Fresh vegetables Condiments Green salads Desserts and pastries Legumes Pickles Limited quantity of milk (preferably Red meats sour) Stimulants of all kinds White of eggs Sweets Tobacco The experience of the writer for many years has been that the _fewer the articles composing the diet, the better the progress could be made in treating nervous indigestion. In many instances, the mono-diet system (eating only one kind of food at a meal) has been adopted with excellent results_. SUBACIDITY Indigestion is a term used to describe the condition caused by food remaining in the stomach _over_ Nature's time-limit. In such cases there is usually a lack of hydrochloric acid. This disorder is sometimes called hyperchlorhydria. The expression of indigestion, which is a lack of acid, and the expression superacidity or hyperchlorhydria, which is too much acid, are often confusing, inasmuch as both conditions cause a feeling of heaviness or a lump in the stomach. (See "Superacidity," p. 419.) SUBACIDITY--THE CAUSE The most prolific cause of subacidity is sedentary habits or lack of activity. This is especially true of young people, while in adults, or those who have passed forty, the usual cause is incorrect eating, or an unbalanced diet. Another cause of subacidity is the overconsumption of flesh foods. Flesh requires considerable acid for dissolution; sometimes more than is normally supplied by the stomach, and consequently results in indigestion or non-dissolution. The over-consumption of either starchy foods or sweets may produce the same result. It is therefore obvious that this particular disorder is caused primarily either by overeating or by an unbalanced dietary. SUBACIDITY--THE SYMPTOMS 1 Brown coating on the tongue-- The _white_ coating on the tongue always indicates too much acid, hence predigestion; while the _brown_ coating indicates insufficient acid, hence indigestion. The _white_ coating shows the action of the acid on the stomach lining, while the _brown_ coating shows the decomposition of food matter in the stomach, usually accompanied by an offensive breath. 2 Gas in the stomach-- Gas sometimes appears in the stomach immediately after eating. This shows that food, in a state of fermentation, remains in the stomach from a previous meal. It also shows that the stomach may be prolapsed; that is, dropped down below its normal level. A sort of pocket is thus frequently formed in which a small quantity of food remains from one meal to another, causing an immediate formation of gas after eating. SUBACIDITY--THE REMEDY The logical remedy is to limit the amount of food to the actual requirements of the body, and especially to balance the daily bill of fare in conformity to the chemistry of nutrition. [Sidenote: Diet in cases of subacidity] In cases of chronic indigestion or impoverished acid secretions, it often becomes necessary to prescribe a counteractive diet, the composition of which should be determined by the cause of the disorder. If the cause be over-consumption of meat, the patient should be given a breakfast of acid fruits, and nuts and salads; while if the cause be over-consumption of starchy foods, all legumes and grain products of every kind should be omitted, and a diet of subacid fruits, an abundance of green salads, and even some flesh now and then, such as tender fish or fowl, should be prescribed. In all cases the special object should be to prescribe an amount of food for the first few days somewhat below the normal requirements of the body, and after the counteractive diet has been taken for three or four days, the menu should be balanced daily as to nutritive elements. By observance of these rules, together with a reasonable observance of the laws of exercise, fresh air and deep breathing, the most obstinate cases of indigestion or subacidity can be overcome. In cases of Subacidity: OMIT EAT Cereals All acid fruits with meals Coffee and tea Buttermilk Flesh foods Fish Liquors Fresh vegetables Sweets Potatoes Tobacco Sautern wine, sparingly White bread Succulent plants Tea Tomatoes Wheat bran Whole wheat See "Diet in cases of subacidity," p. 464. BILIOUSNESS Biliousness is the supersecretion of bile; that is to say, more of this fluid is secreted by the liver than is required for the ordinary processes of digestion, and the excess passes into the stomach. BILIOUSNESS--THE CAUSE Biliousness is caused, in a majority of cases, by the overconsumption of fats, milk, eggs, and sweets, or by taking stimulants, especially such as malted or brewed liquors. BILIOUSNESS--THE SYMPTOMS The presence of bile in the stomach interferes with the stomach-secretion, thus causing faulty digestion and severe headache, usually starting at the back of the head and ending in a severe pain over the eyes. The complexion becomes sallow and there is a general decline in strength and vitality. BILIOUSNESS--THE REMEDY The logical remedy is to remove the above causes by eliminating from the diet such articles as tea, coffee, distilled, brewed and malted liquors of every character, and sweets, selecting such foods as will give to the body all the elements of nutrition, and so combining them as to furnish these elements in the right proportions. (See menus for "Constipation," Vol. III, p. 761). In cases of Biliousness: OMIT EAT Coffee and tea Bananas Cream Coarse cereals Egg yolks Egg whites Fats Fresh vegetables Intoxicants Fruit Milk Melons Sweets Nuts Wines and liquors of all kinds Succulent plants Wheat bran CIRRHOSIS OF THE LIVER THE CAUSE Cirrhosis of the liver, or Hanot's Disease, is a condition characterized by degeneration of the liver cells, usually associated with a fatty infiltration. While there are many conditions that may cause cirrhosis, the principal one, perhaps, is excessive indulgence in alcohol. Thus the disease is frequently called "hob-nailed liver," "gin-liver," etc. Cirrhosis of the liver is a disease that is almost invariably fatal in from one to two years--although, if the process is not far advanced, and the cause is removed, the patient may recover tolerable health. It is absolutely necessary that further irritation of the liver, caused by the drinking of alcohol, be stopped. Close attention should be paid to the catarrhal condition of the stomach and bowels, which is usually associated with cirrhosis. (See chapter on Catarrh.) CIRRHOSIS OF THE LIVER--THE SYMPTOMS The symptoms are usually pain in the epigastrium; nausea and sometimes vomiting in the morning; general loss of vitality and ambition; sallow complexion. A dull aching or a throbbing pain is often experienced, followed by a heavy, sluggish feeling, especially on rising in the morning. Alternate constipation and diarrhea, and enlargement of the liver are frequent symptoms. In the atrophic variety, however, the liver shrinks in size. CIRRHOSIS OF THE LIVER--THE TREATMENT The diet should be nutritious, yet simple, so as to put as little labor as possible upon the already impaired digestion. Fats should be restricted, and starchy foods should be closely limited, so as not to set up additional fermentation. A liberal service of plain wheat bran should be taken at least twice a week in order to insure active intestinal peristalsis. All stimulants, narcotics, sweets, condiments and irritating foods of every character should be omitted. The patient should drink copiously of pure water at meals, omitting all other beverages. In cases of Cirrhosis of the Liver: OMIT EAT Acid fruits, except the All legumes citrus fruits Edible succulent plants Condiments Fresh vegetables Fats Green corn Gravies Liberal quantity of wheat Red meats bran Stimulants and narcotics Limited quantity of-- Sweets Apples Oranges White bread Bananas Peaches Grapes Pears Grape fruit Plums Lemons Nuts Potatoes Salads Whole wheat thoroughly cooked Cirrhosis of the liver is always aggravated by the overconsumption of sweets, starches, fats and intoxicating beverages. Sweet and starchy foods should be limited and intoxicants of all kinds should be entirely omitted. An abundance of pure water should be taken at meals. PILES OR HEMORRHOIDS THE CAUSE Piles or hemorrhoids are usually the result of chronic constipation; or, they may occur from violent exercise, or a shock. The straining at stool when constipated has a most potent influence in causing piles, as well as the passage of hard, dry feces. In both of these cases the rectal mucous surfaces are torn loose or detached from the supporting walls, and the cells fill with blood, thereby becoming very greatly distended. PILES OR HEMORRHOIDS--THE SYMPTOMS The first symptoms are usually itching of the mucous membrane of the anus. In the second stage a bloody discharge will appear with the feces, and in the more advanced cases the rectal mucous membrane will protrude. PILES OR HEMORRHOIDS--THE TREATMENT [Sidenote: How to relieve the strain upon the rectal lining] When it is first discovered that there is a slight protrusion of the rectal mucous membrane from the anus, great care should be taken in evacuation of the feces. The first or direct cause of this condition is usually congestion; that is, the feces in the rectal cavity forms into a hard mass. When this condition appears, just before each evacuation, inject into the rectum, with a small rectal syringe, a tablespoonful of olive-oil, followed by a pint or two of lukewarm water, taken as an ordinary enema, and retain two or three minutes. Then place the first and the middle fingers, one on each side of the anus, and press gently so as to relieve the strain upon the rectal lining. The feces, if very hard, can be worked back and forth until broken up, and evacuation made easy. By this means I have known many cases of bleeding piles or hemorrhoids to be permanently cured. It is exceedingly difficult to cure chronic cases in which the membrane has been torn from the walls for many years. However, Nature never tires of doing her work of repair, and if these suggestions are religiously observed, even chronic cases can be greatly relieved, and sometimes permanently cured. For diet, see menus for constipation and fermentation. Every night, just before retiring, take a light enema and retain it over night; also, take an enema just after rising. DIARRHEA THE CAUSE Diarrhea is in reality not a dis-ease, but a symptom behind which there are always primary causes, usually-- 1 Overeating 2 Irritating condiments 3 Wrong combinations of food at meals 4 Poisonous laxative drugs 5 Excess of acids 6 Excess of sweets 7 Sometimes nervous excitement Diarrhea caused by the last-named condition is usually of temporary duration. Sudden attacks of diarrhea are often caused by exposure, by changes of diet, or by the overconsumption of acids in the form of berries. [Sidenote: Errors in eating the cause of diarrhea] There is no abnormal condition of the alimentary tract that is more directly traceable to errors in eating and drinking than diarrhea and all forms of dysentery. This condition is most generally caused by chronic fermentation, or by the presence of some non-nutritive or foreign substance. It matters not whether this condition comes from the use of poisonous drugs called laxative remedies, or from foods containing foreign or non-nutritive substances, the result is the same. The habitual taking of drugs sufficiently poisonous to cause the intestinal machinery to exert enough action to cast them out, is a painful and slow process of self-destruction. It frequently happens that the peristaltic muscles become relaxed and give way completely from the habitual use of poisonous cathartics, and chronic diarrhea or dysentery is the result. DIARRHEA--THE TREATMENT In ordinary cases of diarrhea one can pursue his usual work provided he observes the suggestions in regard to diet, given below, but in severe cases one should avoid labor or exercise, and remain most of the time in a reclining position. Drink copiously of pure water, and eat very sparingly. OMIT EAT Acid fruits Boiled rice (thoroughly cooked) All green salads Boiled sweet milk Coarse foods, such as cabbage, Cottage cheese celery, turnips, spinach Ordinary white bread Condiments Potatoes-- Desserts, pastry, etc. Sweet (baked) Pickles and all foods preserved in White acids Puree of rice Red meat and flesh food of ever Sweet clabbered milk, including kind except very tender fish the cream and white meat of chicken and Very tender white meat of chicken, turkey or turkey, or fish Relishes Sweets Tuber vegetables except sweet and white potatoes Omit all beverages at meals except plain water, taking only about one glass. EMACIATION OR UNDERWEIGHT Underweight, or lack of adipose tissue, is a condition with which the practitioner will often have to deal, as under nearly all abnormal conditions of the body, called dis-ease, the first result or evidence is loss of weight. The tendency of a perfectly normal body, after it passes the forty-fifth year, is to become muscular, or what is termed "thin." In all countries those who have lived to a very great age have been termed emaciated. However, there is a normal body-weight that can be maintained, and which indicates normal health. [Sidenote: Effects of emaciation] Emaciation is usually followed by general anemia and a weakening of nearly all the functions of the body. The memory, sight, hearing, all become impaired, while the taste or appetite usually becomes keener or more sensitive. This is caused by irritation of the mucous membrane of the stomach and the consequent presence of too much blood therein, the same as when intoxicating liquors are taken just before meals. Overwork, loss of sleep, unbalanced diet, worry, grief, or a period of extreme emotional tension, all have a tendency to disturb and derange the processes of metabolism. Under these conditions the body is very likely to lose weight, but there is always a fundamental cause which should be discovered and removed. EMACIATION OR UNDERWEIGHT--THE CAUSE There are a number of things which usually conspire to cause emaciation. Named in the order of their generality, they are as follows: [Sidenote: Physical causes of emaciation] 1 Overeating 2 Superacidity 3 Stomach and intestinal fermentation 4 Constipation 5 Autointoxication 6 Under-drinking of pure water 7 The use of tobacco, coffee and tea All of these things tend to cause malassimilation, which is the secondary cause of emaciation. In a majority of cases the loss of weight begins while the body is surfeited with food. In fact, it is nothing uncommon for those suffering most from this condition to consume from three to four times the necessary quantity of food; overeating becomes a habit, and consequent fermentation and toxic substances, usually known as autointoxication, are the results. The causes of emaciation, according to most authorities, are impoverished blood and malnutrition. With these opinions the writer fully agrees, but the intelligent reader will naturally inquire--What are the causes of impoverished blood and malnutrition? The answer goes directly back to the food question. [Sidenote: Mental causes of emaciation] All mental influences, business, social, or financial worry, contribute their share toward physical emaciation, but when the body is perfectly nourished it is more capable of withstanding these drains because it is made fearless by perfect health. Behind all forms of business and financial trouble is the demon "fear," and fear rests on the uncertainty of our ability to provide creature comforts and necessities; therefore when we have mastered the science of feeding our bodies, and have learned how simply and cheaply this may be done, the mere possession of such knowledge does more than all else to make of us philosophers and students, eliminating fear and worry of every kind, as in health the mind is usually in a state of optimism and tranquillity. EMACIATION OR UNDERWEIGHT--THE SYMPTOMS The symptoms of emaciation, of course, are so apparent that it is only necessary to say that when the above-named errors are corrected, and the following symptoms are observed, the normal weight can nearly always be maintained. So-called cold-sores, fevered lips and canker-sores on the tongue, intestinal congestion, torpidity of the liver, slight headaches, fullness after eating, alternate constipation and diarrhea, are all symptoms that point to the causes of emaciation. EMACIATION OR UNDERWEIGHT--THE REMEDY Emaciation is sometimes caused by organic or hereditary dis-eases, but the usual causes are to be found within the field of dietetics. The remedy, therefore, is first to naturalize or normalize the diet as to quantity, selection, proportion, and combinations of food. In the majority of cases, those who come to the food scientist for treatment will be those who have tried every conceivable remedy except the natural one, therefore they come in a chronic state of emaciation, poisoned by overeating. Never having been instructed in regard to diet, exercise, breathing, bathing, or any other hygienic law, they will, in most cases, require a counteractive or remedial diet. There may be a number of supplementary causes to be considered, but the most important things for the practitioner to ascertain are: 1 Time the patient rises 2 Hour the first meal is eaten 3 Of what that meal consists 4 Time the second meal is eaten 5 Of what the second meal consists 6 Time the third meal is eaten 7 Of what this meal consists 8 All mental influences under which the patient is laboring, especially fear or worry 9 The condition of the bowels as to congestion 10 The amount of liquid taken during the day and at meals In nearly all emaciated cases it will be found that the patient is suffering from premature fermentation, intestinal and stomach gas, and a congested condition of the bowels commonly known as constipation. [Sidenote: Foods that are necessary in the treatment of emaciation] The first remedy lies in the selection and the combination of foods which are readily soluble and assimilable, and which contain the best flesh and cell-building properties. The chemical properties or elements most necessary are albumin, phosphorus, casein, proteids and carbohydrates. These elements are supplied best by milk, eggs, nuts, sweet fruits and coarse cereals, followed by a limited quantity of fresh green vegetables. [Sidenote: Value of milk and eggs in the remedial diet] The nutriment contained in the egg is all that is required for the young chick, while the nutrient contents of milk is all that is necessary for the young animal. Therefore these two articles contain the most reliable and speedy counteractive elements known to chemistry, but in dealing with the adult they should be supplemented by fresh vegetables, coarse grain, wheat bran, raisins, and the seeds and skins of grapes. [Sidenote: Constipation must be overcome in cases of emaciation] It must be remembered that milk has a constipating tendency when taken in ordinary quantities--from one to two glasses at a meal. Therefore in laying out the diet for the emaciated, it is vitally important to avoid constipation, which may be done by giving milk during the first two or three days in quantities ranging from two and one-half to three and one-half quarts a day, together with a liberal quantity of coarse cereal. (See "Constipation--The Remedy," p. 436.) These remedial methods may be repeated day by day until a substantial gain in weight is noticed, when the diet may be normalized--such articles selected as will give to the body all the required elements of nourishment in the right proportions. [Sidenote: Chronic emaciation--its cause and remedy] It sometimes happens that the body is thrown into a chronic state of emaciation on account of a catarrhal formation over the mucous membrane of the intestines, which closes the "winking valves" that take up nutriment from the alimentary tract. In such cases coarse cereal or wheat bran, the seeds and skins of fruit, especially grapes, together with milk and eggs, form the best foods known. The milk and the eggs may be forced, not only beyond the limitations of hunger, but beyond the normal needs of the body. By thus forcing them for a short period of time (twenty to thirty days) a physical "trial balance" can be reached, and the body brought to its normal weight, which can be maintained for an indefinite period of time, if the bill of fare is again balanced or leveled according to the chemical requirements governed by the three natural laws, namely, age, temperature of environment, and work. [Sidenote: Diet for extreme constipation in emaciated cases] There is another condition of chronic emaciation which, in the beginning, should sometimes be treated in exactly the opposite way. For instance, when the forcing of casein proteids, albumin and nitrogen (the principal nutrient elements in milk and eggs) produces complications, such as extreme constipation, it becomes necessary to put the patient on a diet composed of coarse cellulose articles and fruit for a period of from three to six days. This should be done in the following manner: Immediately on rising drink two or three cups of water--lime-free. BREAKFAST (One hour later) The strained juice of two or three sweet oranges, or a bunch of grapes; grapes preferred A cup of wheat bran, cooked; serve hot, with thin cream LUNCHEON Plain wheat and an equal quantity of coarse wheat bran, cooked until very soft; preferably simmered over night A salad of celery, lettuce and tomatoes, with nuts DINNER About four tablespoonfuls of boiled wheat; also one of bran A baked potato One fresh vegetable Drink copiously of water at all meals. Just before retiring, eat half a pound of grapes, when in season. After the first or second day this bill of fare may be increased in quantity, and heavier fruits added, such as pears, prunes, and very ripe bananas. After the fourth or fifth day, a salad and a few of the lighter vegetables, such as onions, romaine or cabbage, celery, carrots, or other fibrous vegetables may be included. After the first week the diet should be composed of fresh vegetables, coarse cereals, eggs, bananas, nuts, salads, and wheat bran. Those who are emaciated should drink an abundance of water immediately on rising and at meals. They should also take a sufficient quantity of plain wheat bran, or grapes if in season (Concord preferred), eating skins, seeds, and pulp, in order to keep the bowels in normal condition. In cases of extreme emaciation, loss of appetite, or fermentation, the patient should, for a time, adopt a diet of milk and eggs, alternating as follows: The first, second, and third days, drink from two and a half to four quarts of milk, in small quantities--one glass at a time. For the next three days, reduce the quantity of milk, and begin taking six eggs a day, increasing the number, until twelve eggs are taken. Alternate between the milk and the eggs, for a month or more, unless the patient responds in weight in a shorter time. When there is a perceptible gain in weight, and normal hunger has been restored, reduce the milk and the eggs, and add the solid foods already suggested. In cases of Emaciation: OMIT EAT Acid fruits Bananas Coffee Cheese Condiments Coarse cereals Tea Eggs Tobacco Fruits Wines and liquors Dates, figs, raisins Milk Sweet milk or buttermilk Nuts Vegetables, such as-- Beets Lettuce Cabbage Parsnips Carrots Potatoes Celery Spinach Cauliflower Turnips Green beans Green peas The proteid and the carbohydrate foods should predominate in the diet. OBESITY OR OVERWEIGHT [Sidenote: Diet, the governing law of body-weight] It is generally supposed that obesity is a natural result of modern civilization. This theory has no foundation in fact or physiology. Man can be genuinely modern without being obese. The law that governs the growth and graceful symmetry of the human body is based upon dietetics, and the indispensable adjuncts of diet are exercise, oxidation and elimination. A body that is filled with vitality by a perfectly balanced diet will experience the same appetite for motion or exercise that it does for food or drink. Exercise forces more blood to the lungs, and more thorough oxidation is the result. The properly fed young animal, whether brute or human, plays and exercises involuntarily, and the older animal, adequately nourished without being overfed, does not lose its youthful instincts. An observance of the above laws will prevent the accumulation of an excess of fatty tissue. The following table gives the normal weight of natural healthy adults according to height, also the weights considered thin and obese: -----------+-------------------+------------------- | MALES | FEMALES -----------+-------------------+------------------- Height | Weight | Weight -----------+-----+------+------+-----+------+------ Feet Inches| Thin| Fat |Normal| Thin| Fat |Normal -----------+-----+-----+-------+-----+------+------ 5-- -- | 95 | 126 | 110 | 93 | 122 | 111 5-- 1 | 98 | 132 | 115 | 94 | 128 | 116 5-- 2 | 100 | 138 | 120 | 96 | 134 | 118 5-- 3 | 106 | 144 | 125 | 102 | 140 | 121 5-- 4 | 110 | 149 | 130 | 105 | 145 | 126 5-- 5 | 114 | 155 | 135 | 109 | 151 | 131 5-- 6 | 116 | 158 | 138 | 112 | 154 | 134 5-- 7 | 118 | 161 | 140 | 114 | 157 | 136 5-- 8 | 121 | 164 | 143 | 117 | 160 | 140 5-- 9 | 126 | 173 | 150 | 123 | 169 | 145 5-- 10 | 131 | 178 | 155 | 126 | 173 | 150 5-- 11 | 133 | 184 | 160 | 128 | 179 | 155 6-- -- | 136 | 190 | 165 | 131 | 185 | 160 6-- 1 | 140 | 192 | 170 | 135 | 187 | 165 6-- 2 | 148 | 201 | 175 | 143 | 196 | 170 6-- 3 | 152 | 207 | 180 | 147 | 200 | 175 -----------+-----+------+------+-----+------+------ OBESITY--THE CAUSE A very exhausting treatise could be written upon the cause of obesity, but, summing it all up briefly, corpulency is invariably induced through a direct or indirect violation of the laws of nutrition, as exemplified in their wonderful processes of transforming material called food into pulsating life. A combination of commissions and omissions generally conspire to produce the obese body. They may be mentioned in the order of their importance: 1 Overingestion of fat-producing foods 2 Omission of the proper amount of motion or exercise 3 Imperfect oxidation (breathing) 4 The overconsumption of fluids [Sidenote: Obesity caused by overeating] In every case of obesity, one or more of these causes are present. If one is blessed with good digestion and good assimilation, or, in other words, if all the nutriment taken into the body is absorbed into the tissues, then the quantity must be regulated by one's work or labor, otherwise any excess of fat-producing food is stored up by provident Nature, contemplating future use; and if it is not used, by actual work, the result is a gradual accumulation of fatty tissue. Again, if a quantity of food commensurate only with the requirements of mental labor be consumed, and only ordinary body-activity indulged in, there is likely to be a gradual decrease in weight, because a considerable percentage of energy is consumed by the mere carrying on of the vital processes. [Sidenote: Obesity caused by drinking malted liquors] The worst form of obesity, however, is that caused by overconsumption of fermented wines or malted liquors. This form of enlarged tissue contributes no strength whatever to its own support. It is as much of a dead weight as a hod of mortar, and much more useless; in fact, all forms of obesity are not only useless weight, but dangerous to life. The obese body is much more liable to contagious and infectious dis-eases, and when once affected, less able to defend itself than the normal body. OBESITY--THE REMEDY The control of body-weight rests upon three distinct and separate laws, the first and most important of which is nutrition, the second exercise, and the third oxidation. [Sidenote: The storing of fat regulated by labor or activity] While at the outset body-weight may be controlled by increasing the amount of activity sufficiently to use the surplus which Nature is storing away, if however, the activity ceases and the surplus is not used, then the storing process becomes chronic, and radical remedies both in regard to dietetics and activity must be applied in order to bring the body back to normal. [Sidenote: Amount of fat required daily in different climates] A man of normal weight, say 150 pounds, doing ordinary work in a tropical country, would not need to consume more than an ounce of fat each twenty-four hours, while the same man in a northern climate, where the thermometer ranges from zero to 20 below, could use up, with similar labor, from three to four ounces of pure fat daily. Fats, however, do not produce fat in the human body unless taken largely in excess of its needs. Their primary purpose is to keep up the temperature of the body. [Sidenote: Dietetic suggestions for chronic obesity] Where the weight is only from ten to fifteen pounds above normal, a substantial reduction can be made by merely balancing the diet, but where the accumulation of adipose tissue has become chronic, and the body has taken on from twenty to fifty pounds, or more, above normal, then a diet composed largely of non-acid fruits and fresh vegetables should be adopted for a period of from twenty to thirty days. [Sidenote: Foods that produce fat] Carbohydrates, that is to say starch and sugar, are the principal fat-making nutrients, and all people inclined to take on abnormal weight, as a rule, are very fond of, and eat an excess of starchy foods. A great amount of the casein in milk and the phosphorus in eggs are converted into fat, especially if a quantity be taken in excess of the amount used in effort or work. The fat-producing staple foods are: All cereal products All legumes Bread Eggs Milk Potatoes In order, therefore, to remove the causes of obesity, one must begin with the diet. [Sidenote: Foods that reduce fat] Eliminate meat and animal fat; ascertain as nearly as possible the amount of carbohydrates necessary for each day and take none in excess of this quantity. This will stop the accumulation of fatty tissue. If the body is obese, and a reduction of weight is desired, the diet should consist of nuts, fruits, salads, fresh vegetables, and a very limited quantity of eggs, omitting starchy foods entirely. After a week or two of this diet, discontinue the use of eggs, reducing the diet entirely to nuts, fruits, fresh vegetables and salads, which in nearly every case will bring a very substantial reduction in weight, even if the patient takes but little exercise and fresh air. If, however, he can be induced to adopt the above diet, and at the same time take two hours' moderate exercise, either in gymnastics or useful labor, with a reasonable amount of exposure to fresh air, the reduction in weight will be greater, and the muscular tissue and vitality will increase. Inasmuch as fat contributes no item of strength to its own support, if the patient will take a reasonable amount of exercise and fresh air, muscular tissue will increase in the same ratio that fatty tissue decreases. [Sidenote: How menus for obesity may be varied] The menus for obesity may be varied according to the fruits and vegetables at one's command. Fish is the one article among animal food that has much to recommend it, insomuch that it contains an excellent form of proteid and phosphorus. If the taste of the patient should rebel against natural foods, fish would supply these elements better than any form of flesh. The following articles should compose the general diet for the obese under ordinary conditions: Buttermilk Eggs or fish--limited quantity Fruits Green salads Nuts { Such as-- { { Asparagus { Beans { Beets { Carrots Fresh vegetables { Celery { Parsnips { Peas { Pumpkins { Spinach { Squash { Turnips The ordinary obese person should adopt either of the following menus, varying them according to vegetables in season: MENU I MENU II BREAKFAST An orange, or grapes Choose two of the following: One or two eggs, whipped Berries, grapes, peaches, plums, pears, apples, melons, soaked evaporated apricots, peaches, or prunes LUNCHEON Choice of two fresh vegetables, One fresh vegetable cooked A small portion of fish A baked potato A baked potato One very ripe banana, with two tablespoonfuls of nuts DINNER A salad of lettuce or romaine Spanish onions Peas, beans, beets, carrots, or An egg, or a small portion turnips of fish Two tablespoonfuls of nuts Tablespoonful of nuts One egg One or two vegetables A green salad [Sidenote: Foods should be selected according to vocation] If the patient is doing manual labor, the proteid foods, such as milk, cheese, nuts, fish and eggs should be increased according to the work. If, however, the labor is sedative, such as followed by the average business man, the amounts herein prescribed are sufficient. The breakfast should be taken an hour after rising, and the luncheon early, not later than 12 noon, and the dinner not later than 6 p.m. The symptoms during the first two or three days will be that of weakness and perhaps hunger, leaving the impression of under-nourishment. This will disappear after the third or fourth day, and strength will not only return to normal, but the body will feel more energetic than before, and there will be a marked increase in the powers of endurance. If the patient can be induced to "fight it out" for a week on these lines, favorable symptoms will develop so fast that the practitioner will be aided in his work by the mental conviction of the patient, and success will be assured. In cases of Obesity: OMIT EAT Bread products Eggs--limited quantity Cereals Fish or Lobster Dried beans Fresh vegetables Flesh food Fruit Milk Melons Sweets Nuts Succulent vegetables Wheat bran Whole wheat thoroughly cooked (sparingly) Do not drink at meals. NEURASTHENIA That disorder of the nerves known as neurasthenia is expressed in general anemia, or a breaking down of the nervous vitality. This does not indicate, however, that neurasthenia is wholly a dis-ease of the nerves; it merely means that through the nerves the symptoms are given to the brain. [Sidenote: Neurasthenia a last or final warning] Neurasthenia is a signal or warning given by the united voice of all the functions of digestion, secretion, and excretion. Therefore, this disorder does not appear until the body has given fair warning in many other ways, and if proper heed had been given the preceding signals, the nerves would have performed their functions without an outcry. Every so-called dis-ease of the human body, especially of the nervous system, is in reality the voice of Nature telling us of our mistakes, and giving us the opportunity to correct them. Dis-ease, therefore, is not an enemy to the race, but a friend. It is an effort, as it were, in our behalf, of provident Nature to prevent race extinction. Nearly every seeming misfortune with which we are afflicted can be turned to our benefit. We never take a step upward until we are mentally prepared for it; we never become mentally prepared until we have passed through a certain amount and kind of experience. [Sidenote: Education defined] Education reduced to its last analysis is merely the accumulation and co-ordination of useful knowledge; useful knowledge is accumulated only by and through the art of comparison. The more experience we have, the more comparisons we can make. [Sidenote: Ability to make comparisons, measures, ability to enjoy] Country-raised people control the great industries of the city and lead in the nation's great work because they never become _blase_. They have always their homely and primitive child life to draw upon for comparisons. Every good thing, every invention, every step forward and upward, every advancement is appreciated and realized exactly according to their ability to compare these things with their opposites. If the patient should be suffering from mental disturbances called worry, he should be reminded that he is merely a floating mote in the abyss of space, and if the matter composing his form should change from organic to inorganic, from active to inactive; in other words, if he should die, the great planets would move on in their majestic courses and the cosmic scheme would in nowise be interfered with. NEURASTHENIA--THE CAUSE Neurasthenia is caused by a violation of the laws of nutrition, such as overeating, taking intoxicants, tea, coffee, tobacco, stimulating and sedative drugs; an oversupply of certain elements of nourishment and an undersupply of others; failure to eliminate waste; a lack of activity or motion, and improper oxidation. These causes removed, nervousness and all neurasthenic tendencies disappear, and Nature asserts herself and produces physical normality. NEURASTHENIA--THE SYMPTOMS Neurasthenic symptoms are excitability, irritability, mental depression, insomnia, fatigue, exhaustion, emaciation and sometimes hysteria, which very often result in other local disorders, such as extreme constipation or chronic hyperchlorhydria, with a tendency toward weakened sexuality. NEURASTHENIA--THE REMEDY In medical literature there are hundreds of alleged remedies for nervous disorders, yet not one of them attempts to ascertain the causes and to suggest their removal. Drugs only paralyze and stupify the delicate, sensitive nerve fibers that are conveying the intelligence to the brain that something is wrong, and the average man mistakes this for a remedy or a cure. [Sidenote: Unbalanced diet, a primary cause] In the opinion of the writer, neurasthenia would be almost impossible if the body were thoroughly nourished, and the daily bill of fare kept level, or, as we would say in our cash system, "balanced." But when one labors under heavy mental strains, especially that character of burden called worry, and is not properly fed and nourished, the expenditure of force on one side and the lack of supplying it on the other, are very likely to result in an abnormal physical condition called neurasthenia. It is safe to say that all cases of neurasthenia can be traced to improper nourishment on the one hand and abnormal mental tension on the other. [Sidenote: Diet more important than rest] The rest cure has been employed quite successfully for these conditions for many years, and if the proper diet, or what might be called a counteractive or remedial diet, were employed in all the rest cure establishments, they undoubtedly would meet with greater success, but unfortunately some of the best institutions in the country--those best equipped to take care of neurasthenic patients--do not attach any great importance to diet. This comes, no doubt, from the universal lack of information concerning the natural laws governing Food Chemistry, and their particular application to animal life. [Sidenote: Suggestions for the neurasthenic] Neurasthenic patients should first be given rest, which means complete or total diversion from business cares, worry, financial or social responsibility. They should be induced, if possible, to become interested in some special eleemosynary work; some "hobby" that has for its purpose the uplifting of people. The best remedy for the weary or discouraged mind, or the neurasthenic body, is the praise and esteem of people. The suggestions hitherto given for all kindred disorders will apply in most cases of neurasthenia. (See also "Nervousness--Its Cause and Cure," Vol. V, p. 1211.) The patient should be advised to spend at least from three to four hours a day in the open air and sunshine, when the weather will permit, in some quiet way, walking, driving, or in moderate exercise. Most important of all is the diet. It should be balanced according to age, labor, and temperature of the atmosphere, and should consist of-- Such foods as will cause normal action of the bowels Green corn Nuts Rich fresh milk Yolks of eggs Young beans, peas, or any legume before it hardens Immature starch composes the best form of carbohydrate food, which is exceedingly necessary in most cases of neurasthenia, unless the patient be obese, in which event it should be reduced to meet only the requirements of the body, and nitrogenous foods should predominate. A passive form of exercise is very highly recommended, such as all forms of Swedish or mechanical electrical massage. In connection with this the body should be given an olive-oil rub at least twice a week. In cases of Neurasthenia: OMIT EAT Confections All legumes Desserts Cheese Fatty foods Eggs (yolk) Hot drinks Fish--very tender Fresh milk Fresh vegetables Pastries Green corn Rich gravies Nuts Red meat Potatoes Stimulants Tea and coffee White flour products MALNUTRITION CAUSE AND REMEDY Malnutrition is caused mainly by errors in eating, sedentary habits, and lack of fresh air. The remedy, therefore, suggests itself. Level or balance the diet according to the patient's requirements, and advise from two to three hours' vigorous exercise every day, and deep breathing in the open air. All the causes as well as the cure of malnutrition were discussed under the subject of emaciation. (See "Emaciation," p. 477.) LOCOMOTOR ATAXIA THE CAUSE The principal cause of locomotor ataxia is syphilis, the treatment of which has not been sufficiently thorough. So, after lying latent--sometimes for as long a period as twenty years--the disease breaks out again, the germs (which are called _spirochaeta pallida_) assume new virulence, and attack the nervous system--usually the posterior column of the spinal cord. Not infrequently, the optic nerve is also affected, developing what is known as gray atrophy of the nerves. This causes a gradual loss of vision, and finally, relative blindness. Locomotor ataxia may occasionally be brought on by long-continued exposures to wet and cold, injuries to the spinal column, and by excesses of various kinds. But its chief origin is in syphilis--indeed, most European authorities claim that this is its only origin. LOCOMOTOR ATAXIA--THE SYMPTOMS Among the earliest symptoms of ataxia are the so-called lightning or lancinating pains--which come on in paroxyms of varying duration--lasting for hours, or even days at a time. These pains may be burning, tearing, cutting or boring in their nature--and usually affect only the upper half of the body. There is generally, also, a sense of constriction in the throat--as of a choking by the clutch of a hand--and sometimes regurgitation of food, intense pains around the heart or in the epigastrium--with flatulence, eructations, and hiccough. A very common symptom is the so-called "girdle," a sensation as though a rope or band were tightly drawn around the body at the waist. One of the earliest noticeable symptoms is the want of co-ordination--ataxia. This is most pronounced in the lower extremities, and is responsible for the unsteadiness of ataxics in walking or standing. The gait in ataxia is staggering--resembling somewhat the inco-ordination of a man under the influence of alcohol, and there is an exaggerated lifting of the feet and legs with each step. The normal "knee-jerk" reflex--that quick jerk of the foot and lower leg that follows a sharp blow struck below the knee when the leg is held free--is generally abolished. In fact, this failure of the reflexes is usually one of the earliest diagnostic symptoms. Later in the disease the sphincters of the bladder and the anus lose their power to contract, and there is incontinence of both urine and feces. THE IMPORTANCE OF DIET As with any other disease in which there are serious trophic changes, and the generation within the system of toxic products from food decay, it is absolutely indispensable in ataxia to observe the utmost care in the selection of the diet. The food should be light, but nutritious--nourishing and strengthening the system, without, at the same time, putting too great a tax upon the organs of digestion and assimilation. Particular care should be taken to insure daily movements of the bowels, and to see that the kidneys are flushed with a plentiful supply of water drunk each day. LOCOMOTOR ATAXIA--THE REMEDY The generally accepted opinion among medical men is that locomotor ataxia is an incurable disease, and that there is little or nothing that any form of treatment can accomplish that will tend to restore function--or even to arrest the course of the disease, and postpone its fatal termination. With this opinion I beg leave to differ. I am convinced that, by the proper regulation of the diet, limiting the system only to that which it requires for its complete nourishment--giving ample quantities of those foods that are rich in lecithin (or nerve-fat) and phosphorus--such as eggs, milk, whole wheat bread, fish, roe, etc.--much may be done to arrest the progress of the disease. This, in combination with the proper kind of exercise--particularly those forms of which the "Fraenkel Movement System" is an example,--will do a wonderful amount of good in re-educating such groups of nerves in the spinal column as have not yet suffered degenerative changes. The following diet is a mere suggestion, subject to change in order to meet the conditions of temperature, age, and activity. Immediately on rising, the patient should take a few spoonfuls of strained orange juice and drink a cup of hot water. He should also devote a few minutes to deep breathing, and such moderate exercises as he is able to endure. BREAKFAST The whites of four eggs and the yolks of two (If digestion is good, the whites of six eggs may be taken--one yolk to each two whites) A glass of milk A tablespoonful of nuts One very ripe banana with cream Three or four dates LUNCHEON Three or four eggs whipped eight minutes; to each egg add one teaspoonful of lemon juice, and a heaping teaspoonful of sugar; whip this mixture into a quart of milk; drink slowly DINNER Smelts, or any small fish A Spanish onion, baked in casserole dish Corn bread Buttermilk or skimmed milk One fresh vegetable, cooked plain In addition to this diet, there should be a regular daily schedule of exercise and deep breathing, which the patient should be required to carry out with rigid precision and regularity. [Sidenote: Value of exercise and massage] In nearly all cases of locomotor ataxia the body is unable to cast off the generated poisons, or used-up tissue, the result being that the new building material (food) taken in is not appropriated. This condition of atrophy must be overcome by exercise, massage, fomentation (wrapping the patient in a hot, wet blanket), or by anything that will induce excessive superficial circulation. If one afflicted with locomotor ataxia can be induced to arise from his lethargy and exert himself, following the methods herein suggested, a gradual increase in strength is very likely to be experienced inside of two or three months, and sometimes a complete arrest of the process may be expected in time. The writer had a patient, a retired ship captain, who came under his treatment after suffering for twelve years with locomotor ataxia, and after twelve months declared himself cured. The only evidence remaining of his former condition at this writing is shown when he attempts to turn around suddenly, and his control of the lumbar and motor muscles are undergoing such improvement that even this symptom, it seems, will finally disappear. In cases of Locomotor Ataxia: OMIT EAT Drugs of every character Carbohydrates--limited quantity Intoxicants Corn hominy Sex indulgence Dates, figs, honey Stimulants and narcotics {Beans {Buckwheat Foods {Cheese rich in {Eggs proteids {Fresh corn and {Fish albuminoids {Milk such as {Nuts {Peas {Potatoes {Whole wheat Rice Rye COLDS, CATARRH, HAY FEVER, ASTHMA, INFLUENZA [Sidenote: Overeating a common cause of capillary congestion] These disorders are grouped under a general heading because there are a few fundamental laws that affect them all alike. Capillary congestion is a common cause in all these disorders, and anything that will produce this condition will cause, or at least augment catarrh, hay fever, asthma, influenza, and colds. As overeating is the primary cause of congestion throughout the capillary system, it, rather than exposure, is the most common cause of all these disorders. The treatment that will remove or prevent this form of congestion will, therefore, remove a primary cause, when such remedial measures may be employed as each case demands. COLDS--THE CAUSE That condition commonly known as a cold is merely a congestion of effete matter and toxic substances in the body-cells, coming from two causes, and, so far as my experience has been able to guide me, from two causes only, namely: 1 Overeating 2 Exposure to violent atmospheric changes COLDS--THE SYMPTOMS The symptoms from both causes manifest themselves in exactly the same way, therefore it becomes very necessary to ascertain what the sufferer has been eating, both as to quantity and as to kind of foods during the previous forty-eight hours. [Sidenote: Colds caused by overeating] It often occurs that colds from overeating are cumulative, that is, the patient habitually takes too much fat, sweets, or meat, especially the two latter articles, and these may have been digested, and their nutritive elements may have passed into the circulation, but the body being unable to use them, they finally begin to decompose and are converted into alcohol and other decomposition products. An excess of this effete matter brought to the lungs is called a "cold." If one who is blessed with good digestion and assimilation should habitually take an amount of nutrition in excess of his needs, it will manifest itself first, perhaps, in the growth of adipose tissue, and later in the various disorders called autointoxication, among which are colds, catarrh, etc. [Sidenote: Colds caused by exposure] If the body be exposed to a violent draft of cold air, and sufficient motion is not exerted to keep the circulation active, or if the feet be exposed to cold and wet, Nature, in obedience to the law of self-defense, closes the pores of the skin against the intrusion, hence the poisonous and effete matter that is constantly passing off through these openings cannot escape, but it is picked up by the blood and carried to the lungs to be oxidized or burned in the process of breathing. [Sidenote: Colds from overeating and exposure, identical] If the amount of poisons thus brought to the lungs be in excess of the amount that can be consumed or burned, a form of congestion will take place (in the lungs) causing first irritation, then suppuration, which must be thrown off in the form of mucus. It matters not whether the congestion is caused by exposure or overeating, the effects are identically the same, and Nature's method of ridding the body of these poisons is the same in either case. The only difference between an ordinary cold and pneumonia is one of degree. COLDS--THE REMEDY Since colds are merely a form of congestion, first in the capillary vessels and next in the lungs, the first thing to be done is to cease eating. The misunderstanding of the old adage "stuff a cold and starve a fever" has killed thousands of ignorant but innocent people. Its real meaning is, if you stuff a cold, you will have to starve an internal fever. In the treatment of colds, I would suggest the following method of procedure: 1 (a) Omit all food except-- {Such as-- {Apples Juice of subacid fruits {Grapes {Peaches {Plums This should be continued until the congestion is relieved, whether it be one day or a week. (For list of subacid fruits, see Lesson VIII, p. 313.) (b) Drink copiously of pure, cool water 2 Select a light diet of-- Nuts Salads White of eggs Fresh watery vegetables Limited quantity of carbohydrates If the cold is severe, a Turkish bath or any treatment that will produce liberal perspiration, will aid in the elimination of body-poisons and the relief of congestion. [Sidenote: Remedial value of fresh air and exercise] Inasmuch as the blood is conveying an excessive amount of poisons to the lungs for oxidation, much depends upon the amount of pure air that is breathed and the cell capacity of the lungs for oxidation; therefore the sufferer, if unable to be out of doors, should be warmly clad and placed before an open window, or on a veranda in the sunshine, if possible, where every breath will be of fresh air. If, however, the patient is able to go out, every moment possible should be spent walking briskly in the open air. Every morning the patient should be given a vigorous "sponge" with a towel dipped in cold water, and rubbed down with a dry one. This should be done in a warm room, with the body well protected from undue exposure. The room should be thoroughly ventilated at night, and in severe cases all garments and sheets used during the day should be thoroughly aired or changed at night. The old methods of drugging and of excluding the air and sunshine, which is in reality poisoning the patient both within and without, is little less than criminal. A cool shower, or a sponge bath, together with a vigorous rub every morning immediately on rising, and a normal quantity of natural food, render the body almost entirely immune from colds, la grippe, and all forms of capillary congestion and effete and toxic (poisonous) substances. (For diet, see volume of Menus, p. 917.) In cases of Colds: OMIT EAT Confections Coarse cereals (very little) Desserts Fresh vegetables Fatty foods Fruit (See p. 524) Flesh foods Light vegetable soups Heavy starchy foods Nuts Intoxicants Wheat bran Whites of eggs CATARRH--THE CAUSE [Sidenote: Decomposition of unused food the primary cause of catarrh] The causes of catarrh are attributed by all old school writers to acute coryza and exposure to irritating dust, or cold, moist, and perhaps infectious air. These may be secondary causes and may augment catarrh after it has appeared, but experience has proved that the primary cause of catarrh is the decomposition of unused food material, and that Nature throws off the decomposition products resulting therefrom, through the nasal passage, in the form of mucus. In the support of this theory I may refer to many cases of ordinary stomach trouble, constipation, torpidity of the liver, etc., that have had my personal care. In nearly all these cases I found that, when the diet was balanced according to the age and the occupation of the patient, with the climate or time of the year, practically all catarrhal symptoms disappeared, and exposure to atmospheric changes, dust, and the usual things that had formerly brought on catarrhal conditions, did not affect the patient. CATARRH--THE SYMPTOMS The symptoms of catarrh are constant secretion of nasal mucus, which often passes off into the postnasal and nasopharyngeal spaces. This mucus is usually thin and of a light-colored watery character, varying in quantity according to exposure or activity, the quantity of food eaten, and the temperature of the atmosphere. CATARRH--THE REMEDY In the treatment of catarrh, avoid the following: All meats Heavy starchy foods (Especially white flour products) Sweets (See Lesson VIII, p. 334) The diet should consist of-- A reasonable quantity of proteid foods in the form of-- Beans Peas Eggs Sour milk Nuts Bananas Coarse cereals--twice a day; such as entire wheat and rye Fish (small quantity, occasionally) Fresh vegetables Green watery salads Non-acid fruits Wheat bran-- (Enough to keep the bowels in normal condition) [Sidenote: Nasal breathing] Deep breathing through the nostrils and vigorous exercise should be taken freely, especially just after rising and just before retiring. Special attention should be given to breathing through the nose. When the air is pure, there is nothing more healing and remedial in the treatment of catarrh than the abundant passage of air through the nasal cavities. In cases of Catarrh: OMIT EAT All meats A reasonable {Beans Heavy starchy foods (white flour quantity of {Eggs and grain products) Proteids {Nuts Stimulants and narcotics such as {Peas Sweets {Sour milk Bananas Coarse cereals--entire wheat and rye Fish, occasionally Fresh vegetables Green watery salads Non-acid fruits Take vigorous exercise, together with deep breathing through the nose. HAY FEVER Hay fever might be called autumnal catarrh. It is popularly supposed to be irritation of the nasal passages and the bronchial tubes, caused by the flying pollen from various flowers and plants. HAY FEVER--THE SYMPTOMS The symptoms of hay fever are usually a salty discharge from the eyes and the nostrils, followed by severe irritation of the mucous lining of the nasal cavity, a sense of fullness in the head, and violent sneezing. HAY FEVER--THE REMEDY It has not been the writer's opportunity to examine deeply into the actual causes of hay fever, but it has been his good fortune to cure many cases. The remedy should be confined to-- Fresh air and sunshine Close observation of the rules of diet Total abstinence from all forms of stimulants and narcotics I would suggest the following diet: Berries Eggs Fish (Limited quantity) Green and fresh vegetables Sour milk (Buttermilk) (Where this kind of milk cannot be obtained, the ordinary sweet milk will suffice) The diet must be governed, as already explained in many other cases, by the individual requirements of the patient in regard to the amount of exercise, the temperature of the atmosphere, and the age of the patient. In spring and summer is the ideal time to remove the causes of hay fever and effect its cure. (See Catarrh.) In cases of Hay Fever: OMIT EAT Coffee {Bananas Confections {Berries Condiments Abundance {Fresh Liquors and wines of {vegetables Tea {Green salads Tobacco {Sweet fruits White flour products Limited {Eggs quantity {Fish {Sour milk (buttermilk) The diet should be governed by amount of exercise, temperature, etc. ASTHMA THE CAUSE The cause of asthma is congestion in, or constriction of, the bronchial tubes. This congestion is usually caused by overeating and the excessive use of narcotics and stimulants such as tobacco, liquors, and beer. The excessive use of sugar and starches, or what is generally known as carbohydrates, will set up a form of difficult breathing, or at least augment asthmatic tendencies. This condition is more likely to occur among those whose lungs are weakened and who have a tendency toward consumption. ASTHMA--THE SYMPTOMS There are but few conditions preceding asthma that can properly be called symptoms. The attacks are usually violent and frequently come on late at night. The patient suffers with a sense of asphyxia, which causes the impression of death from suffocation. ASTHMA--THE REMEDY The causes of asthma can be removed by diet, fresh air and exercise. If the patient can take a reasonable amount of exercise, sunshine and fresh air, the cure will be more rapid, but if this cannot be done, the diet can be limited so that there will be but little waste, therefore little congestion, and the necessity for exercise and fresh air will be reduced to the minimum. In cases of asthma, the diet should be confined to-- Egg albumin Limited quantity of nuts (No more than two ounces per day) An abundance of-- Fresh and green vegetables Fruits Salads If meat be taken at all, it should be confined to fish, young and tender game, or fowl, although these articles are not recommended. If the patient be obese or above normal weight, the diet given for obesity should be rigidly observed. If of normal weight, the body should be fed somewhat below its physical requirements, even if a radical loss in weight should be experienced for the first three or four weeks. If the patient is emaciated, then the diet should consist of six or eight eggs, and about one quart of milk daily, together with sweet fruits and fresh vegetables. Milk may be given in larger quantities, up to three quarts daily, if all other food except eggs be omitted. In cases of Asthma: OMIT EAT All intoxicants About two ounces of nuts per day (no more) Coffee Condiments {Fruits Confections Abundance {Salads Red meat of {Fresh green vegetables Tobacco Egg albumin If any meat, it should be fish or tender fowl INFLUENZA THE CAUSE [Sidenote: Bacteria the result, not the cause] This disorder is popularly supposed to be of bacteriological origin, but upon this question the scientific world is much divided. In the opinion of the writer the cause of influenza cannot be traced to bacteria or any other form of germ life. Bacteria is nearly always present in decomposing animal matter. It is the opinion of the writer, therefore, that bacteria is the result and not the cause of influenza. It might be described as an acute activity of the entire system in throwing off accumulated waste or toxic substances. This process of excretion will become more difficult at certain times, during violent changes in temperature, and many people in small communities may be similarly afflicted, which no doubt gives rise to the theory that it is a disease of germ origin. INFLUENZA--THE SYMPTOMS The symptoms are headache, languor, sometimes nausea and congestion in the lungs, together with acute irritation of the nasal passages. INFLUENZA--THE REMEDY The logical remedy is normal temperature of environment, abundance of fresh air, and omission of all solid food. There are two specific forms of diet to be recommended-- 1 A liquid diet entirely, such as-- Juice of berries Orange juice Milk Very thin vegetable soups 2 Confine diet entirely to-- Nuts Fruits Fresh green vegetables 3 Eliminate fats, starches, sugars Either of the above suggestions will be sufficient to control an ordinary case of influenza if it is rigidly adhered to. In the spring and summer, the latter diet would be recommended, while in winter, when green and fresh vegetables, fruits, etc., cannot be procured, the milk diet should be given. In cases of influenza, see menus for colds, hay fever, and catarrh. Take choice, giving preference to those prescribed for hay fever. Whichever menu is chosen, it should be taken in its entirety; that is, do not select the meals from two or three menus. INSOMNIA THE CAUSE The inability to sleep is caused: 1 By intestinal congestion or sluggish intestinal peristalsis 2 By irritation of the mucous membrane of the stomach and intestines 3 By the presence of gas, superacidity, and the consequent irritation and excitation of the nerves leading out from the digestive tract 4 By the use of tobacco 5 By the consumption of stimulants and narcotics, which are so universal and so life-destroying The effects of (4) and (5) upon the stomach are much the same as those of overeating, in that they invariably cause supersecretion of acid, and, in the majority of instances, produce false appetite, thus augmenting the baneful habit of overeating. INSOMNIA--THE REMEDY The logical remedy for insomnia is first to eliminate the use of tea, coffee, tobacco, distilled and malted liquors, and drugs of every kind whatsoever, as the ultimate effect upon the stomach of all these things is the same. When this has been done, the amount of food required by the body, governed by the three laws of age, work, and temperature of environment, should be accurately laid out so that the quantity of food may be controlled and overeating avoided. [Sidenote: Cases necessitating a special remedial diet] The diet should also be balanced according to the chemical needs of the body heretofore mentioned. In a a majority of cases, when the food scientist can prevail upon his patient to confine himself to a normal quantity of food, reasonably well balanced as to nutrient elements, the stomach will perform its natural functions, and fermentation with its long train of ills will gradually disappear. This can, in many instances, be accomplished by merely standing out of Nature's way, but in some cases the stomach, liver, intestines, and nervous system have been so long abused and so impaired that they seem to have entered into a conspiracy for mutual protection, hence may not yield to the "normal quantity" or "balanced dietary" remedy. In these cases a remedial diet must be followed, such as will restore the balance by omitting altogether the elements on which the patient had been overfed, and taking an excessive quantity of the elements for the lack of which the patient had been suffering. The following menus should be adopted in the treatment of ordinary cases of Insomnia: SUMMER WINTER BREAKFAST BREAKFAST Cantaloup Hot water A baked banana Wheat bran, cooked Wheat bran, cooked Whole wheat, thoroughly cooked Thin cream LUNCHEON LUNCHEON A baked potato or fresh corn Vegetable soup DINNER DINNER Choice of one of the following: Choice of one of the following: Beans Peas Cabbage Parsnips Carrots Spinach Carrots Turnips Corn Squash Eggplant A potato--eat skins and all One two-minute egg Wheat bran A baked potato In cases of insomnia: OMIT EAT Distilled and malted liquors All fresh vegetables Drugs of every kind Coarse cereals, boiled whole Desserts Egg whites Flesh foods Leafy salads Soda-fountain drinks Nuts Tea and coffee Wheat bran, if constipated White bread Mastication should be very thorough. Eat sparingly at the evening meal. Two meals a day preferred, 9 a.m. and 5 p.m. Drink plain water. RHEUMATISM--GOUT These disorders are grouped under the same heading because they are of identical origin. [Sidenote: Why rheumatism manifests itself largely in the joints] In the average body of five feet eight inches in height, there are about 2,000 miles of tubing, classified under the various names of arteries, veins, capillaries, and nerves. Altogether this is called the circulatory system. A vast amount of this system is infinitely small. Every atom of food taken into the circulation that is not used or converted into energy passes into some of these infinitely small tubes and nerve fibers. These tubes are susceptible of considerable expansion in the fleshy part of the body, but where they pass through the joints or cartilage, there is but little expansion. There these undissolved atoms are most likely to congest, therefore the first expression of rheumatism is usually in the joints. If it takes place at the terminals (fingers or toes), it is called gout; if in the muscles, it is called muscular or inflammatory rheumatism. This congestion accounts for the stiffness and lack of elasticity in the joints. These accumulated atoms become in time almost as hard as bone. RHEUMATISM--THE CAUSE The cause of both rheumatism and gout are practically the same--that is, overeating, especially of flesh and starchy foods. _Meat_ and _bread_ are the two things that cause nearly all rheumatism, though rheumatic symptoms often appear among vegetarians, caused by the overconsumption of starchy food, especially when acid fruits are used. The ideal diet for producing rheumatism is cereals, white bread, meat, acid fruit and eggs. RHEUMATISM--THE SYMPTOMS The symptoms of rheumatism often manifest themselves a year or more before an attack comes on. The _earlier_ symptoms are-- Languor, stupidity and dulness in the morning Impaired circulation and a sense of body-heaviness The _later_ symptoms are pain in the joints or muscles, often followed by inflammation and severe soreness and stiffness. The rheumatic usually has good digestion. In fact, it is the ability of the digestive organs to force more nutrition into the circulation than is needed, that produces this dis-ease. In nearly all cases of rheumatism and gout the patient will be found to have been a large consumer of starchy food, especially of the cereal family, which is the most difficult of all starches to dissolve. GOUT--THE CAUSE [Sidenote: An excess of starch causes an excess of acid] The primary cause of gout is faulty metabolism; behind this, however, are other causes. The metabolic process is rendered faulty or incomplete by the overingestion of heavy starchy foods. This excess of starch, which the body is not able to appropriate or use, becomes acted upon by the excess of acid which is always present when too much starch is consumed. This harmful process is often augmented by the eating of fruit-acids such as grapefruit, lemons, oranges, pineapples, and other citrus-fruits. In addition to these causes the uric acid residual in meat and in the yolk of eggs is an important factor in the causation of gouty or rheumatic conditions. GOUT--THE SYMPTOMS The earlier symptoms of gout are nervousness, irritability, and sometimes insomnia. In the second stages, shooting pains through the fingers and toes are experienced, and later a swelling or a slight inflammation of these terminals. After this acute condition has existed for perhaps a year, the pain may cease and the joints may begin to swell. Knots are also often formed, especially upon the hands, and sometimes upon the feet. RHEUMATISM, GOUT--THE REMEDY The remedy for these disorders may be said to lie wholly within the realm of diet, exercise and oxidation, supplemented by a liberal superficial application of heat, such as Turkish and electric light baths. In all cases of rheumatism and gout, the following should be omitted: All acid fruits, such as, Grapefruit Lemons Limes Oranges Pineapples Eggs Red meats Starchy foods (Carbohydrate class) The diet should be confined to-- Fish and white meat of fowl Fresh vegetables Nuts Salads Sweet and non-acid fruits (See Lesson VIII, p. 313) [Sidenote: How to prevent the active principle of rheumatism] If the diet were confined wholly to green salads, fresh vegetables and white meats, it would remove the causes of these disorders, and inasmuch as Nature is always striving to create perfect health, the cause being removed, she would begin at once to apply the remedy, by removing the congested mass of undissolved calcareous matter, atom by atom. Thus the active principle of rheumatism would disappear. Where the joints have become enlarged, the best that can be done is to render them flexible. It is almost impossible to take out of them all the accumulated deposits, and to reduce them to their natural or normal size. [Sidenote: Natural perspiration vs. artificial in the treatment of rheumatism] In addition to the above-named restrictive diet, the patient should be given sufficient exercise each day to generate enough heat to cause perspiration. It is well to remember that one drop of perspiration forced out of the body by activity is worth a dozen drawn out of the body by the application of superficial heat, such as the Turkish bath. Natural perspiration should come from exercise (muscular friction). This is the method designed by Nature to throw poisonous substances to the surface in the form of sweat, thereby demolishing the old cell and making a place for the new. The Turkish bath and massage is the lazy man's method of cheating Nature, and cannot possibly bring as good results as can obedience to the natural law of motion. In cases of Rheumatism and Gout: OMIT EAT All acid fruits-- Buttermilk Grapefruit Fish and white meat of fowl Lemons Fresh vegetables Limes Nuts Oranges Potatoes Pineapples Salads (green) Coffee Sweet fruits (non-acid) Eggs Liquors, wines, beers Red meat Starchy foods Tobacco Eat rather sparingly, especially at the evening meal. BRIGHT'S DIS-EASE This disorder is confined entirely to the kidneys. In its final analysis it is nothing more than consumption or destruction of the kidneys by thrusting upon them a greater amount of waste matter than they are capable of throwing off, the result being (1) irritation; (2) ulceration; (3) suppuration or consumption. BRIGHT'S DIS-EASE--THE CAUSE The causes of Bright's dis-ease are overingestion of food, especially sweets, starches and meats; the taking of stimulants and narcotics, and the consequent failure of the body to eliminate the poisons or waste accumulating therefrom. BRIGHT'S DIS-EASE--THE SYMPTOMS The symptoms of Bright's dis-ease are scant amount of urine, heavily laden with solids and fatty granules, while leucocytes and even red blood-corpuscles are often shown, especially in advanced cases. Dull pains in the small of the back, and a general weakening in the lumbar regions are common symptoms. BRIGHT'S DIS-EASE--THE REMEDY [Sidenote: Prevention of Bright's dis-ease by correct feeding] It has been popularly supposed, and announced from many alleged sources of authority, that there is no remedy for this dis-ease, and from the standpoint of Materia Medica this probably is correct, but from the standpoint of the natural scientist there is a remedy. However, Bright's dis-ease, like all others herein discussed, can better be prevented than cured, and under a correct dietetic regimen, with plenty of exercise and fresh air, the kidneys, like every other organ of the body, will perform their normal functions. When Bright's dis-ease has made its appearance, the first thing to be ascertained is the character of the diet and the general habits of eating and drinking during the previous two or three years; secondly, the occupation or habits of exercise, especially exposure to fresh air and sunshine. BRIGHT'S DIS-EASE--THE TREATMENT A very restricted diet should be observed, consisting largely of the following: Fresh vegetables Green salads Subacid fruits The fine cereals--(Such as barley and rice) Milk and eggs--(limited quantity) All _sweets_ taken should be in the form of sweet fruits. (See Lesson VIII, p. 313). Milk is very beneficial in this condition--especially when taken in the form of buttermilk, clabbered milk, koumyss or zoolak. The lactic acid ferments in the sour milk help to destroy the germs of putrefaction in the intestines, which are always one of the aggravating causes of Bright's disease. Sometimes an exclusive acid milk diet for a while works wonders. [Sidenote: Suggestions for diet in different seasons] If the patient is under treatment in the spring and summer, as many green plants and fresh sweet fruits as possible should be taken, in connection with the milk, eliminating cereal starch entirely. In the fall and winter, the many varieties of apples and autumn vegetables may be taken in liberal quantities. GENERAL SUGGESTIONS FOR BRIGHT'S DIS-EASE In the majority of cases it is well to first put the patient on a short fast of about twenty-four hours, and then begin the diet with articles containing a liberal quantity of cellulose, such as the entire wheat, boiled; celery, cooked in casserole dish. Keep the bowels open by the use of wheat bran, or grapes, if they are in season, swallowing skins, seeds and pulp. As in all sympathetic disorders, an abundance of pure, cool water should be taken and as much time as possible should be spent in the open air and sunshine. Care should be taken to limit the diet to the minimum so that the excretory organs can easily eliminate all waste matter, and so that there may be no further poisonous accumulations. In cases of Bright's Dis-ease: OMIT EAT Drugs Abundance of nuts (Italian pine nut) Flesh of every kind Fine cereals--barley, rice Intoxicants Fresh vegetables Rich desserts Green salads Sweets Limited quantity of milk and eggs Sweets in form of fruit-sugar, such as dates, figs, raisins (limited quantity) Subacid fruits Wheat bran with evening meal The diet should be somewhat restricted. Drink an abundance of pure water. DIABETES This disorder may be described as one of malassimilation from the stomach, liver, kidneys, and intestines, but to the trained student it is better described as a condition in which the capacity of the body to burn or use grape-sugar has become chronically depressed. It is usually supplemented by a lack of physical exercise and elimination of body-poisons. DIABETES--THE CAUSE From the above explanation it will be seen that diabetes, like all other dis-eases of the digestive organs, is caused directly by errors in eating--overconsumption of carbohydrates (sweets and starches), and albuminoids. These errors are augmented by inactivity, causing lack of assimilation or utilization of nutritive elements. DIABETES--THE SYMPTOMS The symptoms of diabetes are intense thirst and appetite, copious passing of urine and the presence of excessive quantities of sugar and uric acid therein. DIABETES--THE REMEDY The selecting, proportioning and balancing of the daily menu, together with an observance of the natural laws hitherto laid out, will prevent diabetes, but after it has made its appearance the remedy lies in simple and limited feeding. The sufferer should be put upon a rigid diet of fresh vegetables, nuts, fruits, and salads. If the body has not been trained to accept these foods, the diet might consist of the following: Bloodless (white) meats Eggs Fats--reasonable quantity (Olive-oil, butter, cream) Fish Fresh vegetables Green salads--generous quantity Nuts If the patient be _overweight_, the diet should consist largely of subacid fruits and nuts. If _underweight_, a liberal quantity of sour milk should be given, especially whole soured milk in which the cream is also present. [Sidenote: Diet in extreme cases of diabetes] In extreme cases the patient should be required to subsist upon Pignolia (the pine) nuts, and green or fresh vegetables uncooked. The writer knows of a gentleman suffering from a very advanced case of diabetes, who, in utter despair, adopted a diet consisting entirely of pine nuts, merely because they appealed to his taste, while nothing else did. A noticeable change for the better was seen in a week, especially in regard to the amount of sugar passed in the urine. He adhered rigidly to this diet for nearly three months. He then added green salads and carrots, and the seventh and eighth months a few fresh cooked vegetables, and was pronounced thoroughly cured before the year had expired. This might have been due partly to the limited bill of fare, but undoubtedly it was largely due to the food elements contained in this wonderful product of the Italian pine. In cases of Diabetes: OMIT EAT Condiments All fresh vegetables, cooked-- Confections preferably in casserole dish Irritants Nuts Pastries Baked potatoes Red meats Coarse whole cereals thoroughly Stimulants and narcotics cooked--small quantity Sweets Fish White flour products Milk (sour) Very ripe subacid fruit White meat of fowl Drink an abundance of pure water. In treating diabetes, foods containing starch and sugar should not be wholly eliminated from the diet, but should be administered in limited proportions, or such quantities as the body could use. Starches and sugars contained in cereals and legumes, however, should in extreme cases be omitted because they are difficult to digest and to assimilate. If the digestion is impaired, the body is likely to cast out these valuable nutrients through the kidneys, rather than labor to digest and to assimilate them. The starches and sugars found in fresh vegetables (See table, Vol. III, p. 614), are easily digested and assimilated, therefore in cases of diabetes the body will use or appropriate them, as this entails less energy than that required to cast them out. CONSUMPTION For many centuries chemists, scientists, and medical men generally have been vainly battling with this dis-ease. It is only within the past decade that it has been understood or successfully treated. Consumption is an infection of the lungs by the bacteria called bacillus tuberculosis. The local inflammation produces lesions, and the formation of small growths (nodules) of gray, white, or yellowish tubercles. [Sidenote: Authorities differ concerning the bacillus] It is yet an open question and a matter of grave doubt in the minds of various authorities on this subject as to whether the bacilli is the real _cause_, or the _result_ of the dis-ease. The fact that a person or an animal afflicted with tuberculosis was in "susceptible condition" is much emphasized by all authorities. [Sidenote: Predisposing conditions and occupations] Such disorders as catarrh, influenza, chronic colds, etc., are all predisposing conditions. Such trades as metal grinding, spinning, weaving, cleaning grain, street sweeping, or any vocation necessitating the breathing of large quantities of dust, are termed predisposing occupations, which show very clearly that all writers are practically agreed that the real cause is undoubtedly due to imperfect oxidation or impaired use of the lungs. The above conditions may be brought on from two specific causes-- 1 By the habitual overingestion of food, and the consequent congestion of effete matter in the lungs, brought thither by the circulation in its effort to dispose of the waste-products by burning them with oxygen. 2 Through the agency of foreign substances breathed in, which gradually congest, and prevent thorough oxidation and normal activity of the excretory function of the lungs. [Sidenote: Bacilli the result, not the cause of consumption] The opinion of the writer is that the bacillus above referred to is the result and not the cause of this dis-ease, and that such living organisms (bacilli) are created in the economy of Nature to dispose of this congested matter, just as she, in her provident economy, disposes of the carcass of a dead animal. [Sidenote: Facts shown by experiments and by modern treatment of consumption] The fact that a tuberculosis culture, deposited in the lungs of another animal, reproduces the dis-ease, proves nothing, as it may have been planted in susceptible soil, well prepared for the growth and the development of the bacteria. The fact that some very healthy animals did not contract the dis-ease by this method, supports the theory that if conditions are not favorable the culture is killed by the process of oxidation. This sustains the theory that the bacillus tuberculosis is the result, and not the cause of this dread dis-ease. This theory is further supported by the results of the most modern and only successful methods of treating it. CONSUMPTION--THE TREATMENT When beginning treatment, the tubercular patient should be restricted as to diet for the purpose of giving Nature an opportunity to make use of every atom of food taken into the body, leaving nothing to go to waste. The diet should consist almost wholly of vegetable fats, sour milk, nuts, fruits, salads, and eggs, with a limited amount of readily digestible carbohydrates. The following menu is given as a fair example of selection as to quantity and combinations: BREAKFAST Cantaloup, orange, grapes, pears, or persimmons Two or three eggs, whipped five minutes, adding a teaspoonful of lemon juice, and one of sugar to each egg LUNCHEON A green salad eaten with nuts, a dash of lemon juice and olive-oil One or two fresh vegetables, including a baked potato One egg prepared as for breakfast A glass of sour milk DINNER A green salad, with nuts and oil Eggs or buttermilk One or two fresh vegetables A baked potato The above menus may be increased in quantity after the first week or ten days, at least sufficient to meet all physical requirements, and the articles may be changed according to seasons. [Sidenote: Dietetic suggestions for spring and summer in consumptive cases] In spring and summer all kinds of fruits and berries may be used, and such vegetables as squash, asparagus, spinach, beets, green peas and beans, turnips, parsnips, carrots, and green corn. All of these vegetables should be cooked in a casserole dish. The bowels should be kept free. (See treatment for "Constipation," p. 437.) Drink copiously of pure water. [Sidenote: Suggestions for the treatment of mild cases of consumption] If the patient is not far advanced, he should seek employment which affords constant exercise in the open air, preferably in the hills or mountains, and the labor should be of such a character as to cause normal activity of the liver and the bowels, and to enforce deep respiration. A spirometer or lung-measuring machine should be secured, and the patient should practise upon this night and morning, endeavoring each day to register from one to five cubic inches more than the previous day, until every air cell of the lungs is opened and the full capacity is reached, which should be about 315 cubic inches for the average man, and 250 for the woman of normal size. [Sidenote: General rules of hygiene in consumptive cases] Contrary to usual customs and theories, the patient should take a cool sponge bath every morning, in a warm room, except in very cold weather. It should be followed by a vigorous rub down and deep breathing. Wear thin cotton under-clothes. Dress as lightly as possible, except when exposed where exercise or motion cannot be taken, such as riding in an open car or vehicle. Nature's method of producing hardihood and increasing endurance is by means of exposure. The house-plant life is conducive and favorable to tuberculosis. [Sidenote: Importance of perfect oxidation] The most important thing in the treatment of this dis-ease is perfect oxidation (breathing). Every cell of the lungs should be filled at every breath. The lungs should be filled to their extreme capacity, one hundred or more times a day, with pure, fresh, dustless air. The patient should never breathe the same breath twice; especially should he not breathe the air that has been used by other people, or by pet animals in a closed room. In order to carry out this regimen, it is necessary to live out of doors day and night, winter and summer. The tubercular patient should sleep in a tent, or upon an open piazza every night, regardless of the weather or the temperature of the atmosphere. If these rules were observed the white plague would lose some of its terrors. In cases of Consumption: OMIT EAT Coffee Cheese Meat Eggs Stimulants { Preferably-- Sweets { Carrots Tea { Dried beans, Tobacco Fresh { Onions vegetables { Peas { Parsnips { Potatoes { Pumpkin { Squash Figs Milk Raisins HEART TROUBLE [Sidenote: The heart, a sentinel of the body] The heart may well be called the thermometer of the body. Under normal conditions it is never heard from, but under abnormal conditions it is the first and the most reliable sentinel of the body. It stands eternally on duty and sends its danger signals to the brain with truthful accuracy, whether the trouble be of physical, mental, or emotional origin. A word or a sound sent through the air enters the ear and is analyzed by the brain, but the heart registers accurately its effect upon the physical body. We see a face or an occurrence a block away, and through the optic nerves it is comprehended by the brain, but the heart alone registers or gives back to the brain the effect upon the body. [Sidenote: Necessity for heeding the symptoms of the heart] This little engine, but little bigger than one's fist, pumps about twenty tons of blood every day above its own level in every body of average size, besides sending the life fluids of the blood-serum with lightning speed to the parts of the remotest anatomy, carting away the effete and poisonous matter to the lungs to be burned with oxygen, and carrying new building material from cell to cell for repairs. Should we not, therefore, take good care of, and heed the warnings of so wonderful a piece of automatic mechanism? Should we not study all its symptoms told in a language sympathetic and truthful, and as unerring as the laws that govern the movement of worlds in space? [Sidenote: Some undefined technical terms] The heart gives off various symptoms indicating the different kinds of sins we commit against the natural laws of our organisms. Medical men have named some of these symptoms as follows: Dilation, hypertrophy, atrophy, aneurism, inflammation, valvular derangement, etc., but in none of their reference works are the causes of these so-called dis-eases clearly defined. Fatty degeneration is the only one that is explained, the term meaning that the heart has been deprived of room in which to do its work, owing to surrounding fatty accumulations. HEART TROUBLE--THE CAUSE The blood enters the heart through the superior venae cavae flowing to the right lobe or auricle, then it is pumped by the heart beats to the right ventricle. From here it is forced through the pulmonary artery to the lungs where it is purified and charged with the oxygen we breathe. From the lungs the blood returns through the pulmonary veins to the left auricle of the heart, and then to the left ventricle. Having passed once through the purifying plant and twice through the distributing station, it is now sent out through the large systematic artery and distributed to every capillary cell of the body. [Sidenote: Heart trouble caused by (carbon dioxid) gas] From the accumulation of gas caused by fermenting food the transverse colon becomes very much distended. This interferes with the free flow of blood into and out of the heart, causing at times a very faint heart action from a lack of inflow, and again a very heavy, rapid action when the blood spurts through. This produces dizziness and vertigo, and sometimes where the inflow is greater than the heart can discharge, there is arterial overflow; the heart ceases action, and the victim falls prostrate, and sometimes dies. (See "Fermentation--The Symptoms," p. 426.) [Sidenote: Heart trouble caused by calcareous substances] Many cases of serious heart trouble are caused by habitual overeating, especially of grain and grain products. The calcareous substances from these products are deposited in the capillary vessels and in the joints, causing rheumatism, rheumatoid arthritis, sciatica, lumbago, gout, and other evidences of our lack of knowledge. When the one thus afflicted follows a sedentary occupation, taking but little fresh air and exercise, a hardening or stiffening of the arteries is usually the result. It is safe to say that if one would eat moderately, omit stimulants and narcotics, take but a limited quantity of starchy foods, a liberal amount of fresh air, deep breathing and exercise, heart trouble would be unknown. HEART TROUBLE--THE REMEDY [Sidenote: Diet for heart trouble] For the treatment of those who are afflicted with heart trouble I would suggest a very limited diet of nuts, fruits, salads, fresh tuber and green vegetables, eggs, and a limited quantity of coarse foods, such as boiled whole wheat, wheat bran, grapes (seeds and all), and all coarse vegetables, with an abundance of mild exercise and fresh air. [Sidenote: Exercise for heart trouble] In cases of heart trouble no greater mistake can be made than to cease exercise, as is often prescribed by well-meaning doctors. This is compromising with the enemy, with absolute certainty of ultimate defeat. Exercise, above all, is the very thing that is most needed. The patient should begin moderately at first, daily increasing the time and the tensity of the work until a balance is established between the intake and the outflow of blood to the heart. For foods to be eaten and omitted in cases of heart trouble, see p. 573. Also see menus for Fermentation. DIS-EASES OF THE SKIN There are two distinct kinds of skin dis-eases, namely-- 1 Local 2 Constitutional The _local_ is that which manifests itself in the form of pimples or eruptions which come and go, and are of only a few days' duration. The second, or _constitutional_ kind, is that which manifests itself by a permanent irritation or inflammation, which is classified as eczema, psoriasis, etc. DIS-EASES OF THE SKIN--THE CAUSE [Sidenote: Local disorders] The local or temporary disorders are caused and controlled entirely by diet, usually overeating. Sometimes overingestion of some one particular food; for instance, too much acid taken in the form of berries, or citrus-fruits, will often produce an eruption or a rash within a few hours after eating. [Sidenote: Eruptions augmented by autointoxication] That form of pimples or eruptions caused by overeating is usually augmented by constipation or by some form of intestinal congestion, which has been given the impressive title of autointoxication. Autointoxication is a broad word that seems to have been invented, not for the purpose of explaining, but for the purpose of evading the necessity of explaining. The meaning of this word (self-poisoning) has been narrowed down by the profession to describe the above conditions, but in reality it should be applied to all forms of self-poisoning by overeating; eating the wrong combinations of food; the use of all stimulants and narcotics, such as tobacco, tea, coffee, liquor and wines of all kinds. In fact, self-poisoning from the last-named sources is as common as from errors in eating, and much more difficult to control. Nearly all dis-eases are traceable directly to unexcreted poisons which the body has been unable to throw off. These poisons are from two sources: 1 The natural poisons or gases that accumulate in the body under normal conditions, which, if prevented in any manner from passing off, will cause some kind of disorder which would come under the head of autointoxication. 2 The poisons that accumulate under abnormal conditions, such as hitherto described, and which are very often made manifest by eruptions of the skin. [Sidenote: Constitutional disorders] That form of skin dis-ease known as eczema has baffled the medical world for many centuries. It has hitherto been treated locally by the most skilled and learned specialists, in the belief that it was of bacteriological origin, but modern experiments in the field of food chemistry have demonstrated the fact that it can be cured by scientific feeding, therefore it is only fair to assume that its origin or primary cause is due to some form of self-poisoning, caused by errors in eating and faulty metabolism. DIS-EASES OF THE SKIN--THE TREATMENT If a rash should appear on the skin after eating acid fruit or berries, one would naturally know the remedy; namely, omit acids, limit the quantity of food at the next meal, drink copiously of pure water and breathe an abundance of fresh air. The same general remedy should be observed in all cases. [Sidenote: Preliminary treatment for dis-eases of the skin] The pimples or eruptions will gradually disappear when the causes are removed, and the same rule will apply to eczema or any chronic form of skin irritation. The patient should first be put upon a short fast of two or three days' duration, and caused to perspire freely each day for an hour or so. This can be accomplished by the aid of the Turkish bath, but preferably by exercise. On the first day the fast should be broken by taking either the juice of such fruits as plums, peaches, apples, grapes, and pears, or the juice of cantaloup and watermelon. DIET FOR DIS-EASES OF THE SKIN The diet should be gradually broadened by the addition of green salads, uncooked carrots, onions and turnips, and a limited quantity of such cooked vegetables as spinach, asparagus, squash, fresh corn, green peas or beans when in season. Later, the diet should be confined mainly to egg whites, skimmed milk, nuts, sweet fruits, salads, fresh green vegetables, including a very limited quantity of sugar and coarse cereals, two or three times a week. DIET FOR CHRONIC ECZEMA In extreme and chronic cases of eczema the diet should be confined entirely to green salads, sweet fruits, fresh vegetables, and about two ounces of olive-oil daily, feeding the body always somewhat below its normal requirements as indicated by hunger. Under this diet and regimen the patient will, of course, lose weight and possibly strength, but the body will so completely make use of all nutrition and the elimination of all waste will be made so completely, through the excretory channels, that the dis-ease will gradually disappear, owing to the removal of its primary causes. For "Sweet Fruits," see Lesson VIII, p. 313. APPENDICITIS There are three large colons in the intestinal tract which form an inverted U, the "ascending," "transverse," and "descending" colons. The descending colon is situated on the left side, its lower part opening into the rectal cavity. The ascending colon, located on the right side, connects with the small intestines, while the transverse colon goes across at a point opposite the navel, connecting the two. [Sidenote: The vermiform appendix a useful organ] To the lower part of the ascending colon is attached the vermiform appendix. Authorities are much divided as to the function of this organ. Many claim that it is a relic of anthropoid man, while others contend that it is a useful and important part of the anatomy. In the opinion of the writer it secretes a valuable digestive fluid and therefore performs a function valuable both to digestion and to alimentation. In the ascending colon is the only place in the thirty-six feet of intestinal tubing where the fecal matter must rise against the law of gravity, therefore, if there is any congestion throughout this canal, it is most likely to occur in this colon. While the bowels may seem to act normally, yet, owing to the tremendous amount of waste matter necessary to be conveyed from the body, and the peristaltic action involved in moving it along, especially at this point, some of the fecal matter often lodges under the small folds and in the flexuous surfaces of this colon, decomposing and causing an acute form of inflammation. The vermiform appendix, being attached to this inflamed colon, becomes inflamed also. In other words, this inoffensive and useful little organ suffers the penalty of being in bad company. [Sidenote: Old diagnosis correct] Thus it is seen that appendicitis, so-called, is merely a form of fevered or irritated colon; hence the old-fashioned diagnosis--"bowel inflammation"--before appendicitis became popular, and profitable, was in reality correct. Knowing the cause--the physiology of appendicitis--the remedy becomes a simple one. APPENDICITIS--THE SYMPTOMS The symptoms of appendicitis (bowel inflammation) are usually pain, at times sharp, but generally dull, in the lower abdomen on the right side. APPENDICITIS--THE TREATMENT (IN MILD CASES) If the pain is dull and intermittent, the patient should cease work, especially that vocation which necessitates being on foot, and spend at least twenty-four hours, most of the time in a sitting or reclining position. All such substances as meat, cereal and cereal products, sweets, milk, tea, coffee, cocoa, and all stimulating beverages should be omitted. [Sidenote: A natural remedy] The patient should take high enemas (knee or chest position) of lukewarm water, thus removing as much of the congested fecal matter as possible. Take from two to three tablespoonfuls of olive-oil, and two or three cups of hot water several times a day. The application of an ice-bag will sometimes afford much relief, and has a tendency to reduce the inflammatory process. Too much emphasis cannot be laid upon the fact that in any inflammatory condition of the stomach or intestines, rest for these organs is imperatively demanded. APPENDICITIS--THE DIET After the first day or two, the following diet should be adopted and continued for a few days until the pain has ceased and the bowels are restored to normal action: BREAKFAST A cup of hot water One or two exceedingly ripe bananas peeled and baked in a hot oven One egg, whipped five minutes; sugar to taste; flavor with lemon or fruit-juice A glass of water LUNCHEON A salad of anything green Liberal portion of boiled onions DINNER Spinach, or a green salad, same as at luncheon Green beans, or peas, if in season, rejecting all the fiber; or, carrots or parsnips Two whipped eggs Baked banana, with butter or oil These menus are intended as a general guide. They may be modified by selecting such articles, in the same general class, as are in season. The following list of foods may be drawn upon to compose the menus, at the various seasons of the year: ----------------+----------------+----------------+---------------- | | | SPRING | SUMMER | FALL | WINTER | | | ----------------+----------------+----------------+---------------- | | | Asparagus | Carrots | Artichokes | Carrots Beets | Cauliflower | Beets | Parsnips Cabbage | Eggplant | Brussels | Potatoes Dandelion | Lettuce | sprouts | Pumpkin Lettuce | Okra | Carrots | Squash Onions | Onions | Cauliflower | Peas | Romaine | Eggplant | Potatoes | Spinach | Okra | Spinach | Squash | Potatoes | | Tomatoes | Squash | | | Sweet potatoes | | | Tomatoes | | | | ----------------+----------------+----------------+---------------- CHRONIC OR SEVERE CASES OF APPENDICITIS The errors in diet that cause fermentation and superacidity in the stomach will also cause fermentation and inflammation in the intestines. A constipated condition in the intestines so hinders the natural flow of food-matter that in extreme cases of inflammation and suppuration the congested matter might be forced into the vermiform appendix, thus causing what is termed "appendicitis," and under these conditions the removal of the appendix might be advisable, but in the opinion of the writer more lives have been sacrificed on the operating table than the old-fashioned doctors ever lost from "bowel inflammation" before this dis-ease was named "appendicitis," and before the knife was applied as a remedy. [Sidenote: Treatment in severe cases] There should be injected into the rectum a tablespoonful of olive-oil, followed immediately by an enema of hot water at a temperature of about 115 degrees. This should be retained as long as possible. In order to aid in this process, the head might be lowered, and the feet slightly elevated so as to relieve the strain upon the rectal muscles. In very severe cases an ice pack may be placed over the lower abdomen for five minutes. The ice pack should be kept in place until the temperature is lowered and the pain relieved. THE DIET IN SEVERE CASES OF APPENDICITIS From three to four quarts of cool water should be taken the first day and all food omitted. The second day fruit-juices and olive-oil should be administered. This treatment should be continued for several days, or until the pain is relieved, when the diet for milder cases may be adopted in a reduced or limited form. DANGERS OF INTESTINAL CONGESTION [Sidenote: Causes of appendicitis] All conditions of bowel inflammation are caused primarily by congestion of fecal matter in the intestinal tract. That which will relieve congestion, therefore, will, by removing the causes, relieve inflammation. Intestinal congestion has become one of the most common disorders among civilized people, because of the fact that a large percentage of the coarse material known as cellulose fiber has been removed from their food by super-civilized methods of preparation. For instance, in modern milling methods, every trace of cellulose is removed from the grain, leaving nothing but a white mass of unbalanced food material, largely carbohydrates, and the peelings are removed from all kinds of fruits and vegetables. Thus the diet of civilized man has become woefully impoverished in cellulose and mineral salts, with the result that there is nothing left in the diet to stimulate the liver and the peristaltic activity of the intestinal tract. [Sidenote: Evils of the civilized diet] This condition is largely augmented by flesh food, all sedative drugs, and intoxicating drinks which have become so conspicuous in the diet of modern civilization. [Sidenote: Why coarse food is necessary] The intestinal (digestive and eliminative) organs of man, through the millions of years of his development, have been built up on the primitive plan. They have been shaped by the process of ages to accommodate coarse food, therefore a generous amount of non-nutritive cellulose is absolutely necessary to both the digestion of food and the elimination of waste. The liberal use of cereal bran puts back into the diet that which modern milling methods have taken out of it. [Sidenote: Remedial value of coarse food] The use of wheat bran and the seeds of grapes in the treatment of appendicitis has both a scientific and a common-sense basis. The bran and the seeds pass into the various folds, wrinkles and turns of the intestines, and sweep out the congested fecal matter which is undergoing decomposition and causing inflammation. After the bowels have been thoroughly cleansed, the patient should adopt a fresh vegetable diet selected from the list heretofore given, drinking an abundance of water both at meals and between meals. Under these conditions most symptoms of appendicitis will disappear, and if the diet is made to consist of a sufficient quantity of coarse food, all causes of bowel inflammation will be removed. 
63293	----	available by Internet Archive (https://archive.org) Note: Project Gutenberg also has an HTML version of this file which includes the original illustrations. See 63293-h.htm or 63293-h.zip: (http://www.gutenberg.org/files/63293/63293-h/63293-h.htm) or (http://www.gutenberg.org/files/63293/63293-h.zip) Images of the original pages are available through Internet Archive. See https://archive.org/details/fastingcure00sincrich THE FASTING CURE * * * * * * _BY UPTON SINCLAIR_ LOVE'S PILGRIMAGE THE FASTING CURE KING MIDAS PRINCE HAGEN THE JOURNAL OF ARTHUR STIRLING MANASSAS THE OVERMAN THE JUNGLE THE INDUSTRIAL REPUBLIC THE METROPOLIS THE MONEYCHANGERS SAMUEL THE SEEKER _at all bookshops_ * * * * * * [Illustration: _Mr. Sinclair's expression, as shown in the upper photograph, used to be called "spiritual." Systematic fasting has evolved the athletic figure pictured below._] THE FASTING CURE by UPTON SINCLAIR [Illustration: Logo] Mitchell Kennerley New York and London MCMXI Copyright, 1911 by Mitchell Kennerley The University Press, Cambridge, U. S. A. _TO BERNARR MACFADDEN_ _in cordial appreciation of his personality and teachings_ _Contents_ PAGE PREFACE 5 PERFECT HEALTH 9 A Letter to the _New York Times_ 34 SOME NOTES ON FASTING 39 Fasting and the Doctors 48 THE HUMORS OF FASTING 53 A SYMPOSIUM ON FASTING 62 Death during the Fast 68 Fasting and the Mind 74 Diet after the Fast 81 THE USE OF MEAT 86 APPENDIX Some Letters from Fasters 105 The Fruit and Nut Diet 132 The Rader Case 137 Horace Fletcher's Fast 143 PREFACE In the _Cosmopolitan Magazine_ for May, 1910, and in the _Contemporary Review_ (London) for April, 1910, I published an article dealing with my experiences in fasting. I have written a great many magazine articles, but never one which attracted so much attention as this. The first day the magazine was on the news-stands, I received a telegram from a man in Washington who had begun to fast and wanted some advice; and thereafter I received ten or twenty letters a day from people who had questions to ask or experiences to narrate. At the date of writing eight months have passed, and the flood has not yet stopped. The editors of the _Cosmopolitan_ also tell me that they have never received so many letters about an article in their experience. Still more significant was the number of reports which began to appear in the news columns of papers all over the country, telling of people who were fasting. From various sources I have received about fifty such clippings, and few but reported benefit to the faster. As a consequence of this interest, I was asked by the _Cosmopolitan_ to write another article, which appeared in the issue of February, 1911. The present volume is made up from these two articles, with the addition of some notes and comments, and some portions of articles contributed to the _Physical Culture_ magazine, of the editorial staff of which I am a member. It was my intention at first to work this matter into a connected whole, but upon rereading the articles I decided that it would be better to publish them as they stood. The journalistic style has its advantages; and repetitions may perhaps be pardoned in the case of a topic which is so new to almost every one. I have reproduced in the book several photographs of myself which appeared in the magazine articles. Ordinarily one does not print his picture in his own books; but when it comes to fasting there are many "doubting Thomases," and we are told that "seeing is believing." The two photographs of myself which appear as a frontispiece afford evidence of a really extraordinary physical recuperation; and the reader has my word for it that there was nothing in my way of life to account for it, except three fasts, of a total of thirty days. There is one other matter to be referred to. Several years ago I published a book entitled "Good Health," written in collaboration with a friend. I could not express my own views fully in that book, and on certain points where I differed with my collaborator, I have come since to differ still more. The book contains a great deal of useful information; but later experience has convinced me that its views on the all-important subject of diet are erroneous. My present opinions I have given in this book. I am not saying this to apologize for an inconsistency, but to record a growth. In those days I believed something, because other people told me; to-day I know something else, because I have tried it upon myself. My object in publishing this book is two-fold: first, to have something to which I can refer people, so that I will not have to answer half a dozen "fasting letters" every day for the rest of my life; and second, in the hope of attracting sufficient attention to the subject to interest some scientific men in making a real investigation of it. To-day we know certain facts about what is called "autointoxication"; we know them because Metchnikoff, Pawlow and others have made a thorough-going inquiry into the subject. I believe that the subject of fasting is one of just as great importance. I have stated facts in this book about myself; and I have quoted many letters which are genuine and beyond dispute. The cures which they record are altogether without precedent, I think. The reader will find in the course of the book (page 63) a tabulation of the results of 277 cases of fasting. In this number of desperate cases, there were only about half a dozen definite and unexplained failures reported. Surely it cannot be that medical men and scientists will continue for much longer to close their eyes to facts of such vital significance as this. I do not pretend to be the discoverer of the fasting cure. The subject was discussed by Dr. E. H. Dewey in books which were published thirty or forty years ago. For the reader who cares to investigate further, I mention the following books, which I have read with interest and profit. I recommend them, although, needless to say, I do not agree with everything that is in them: "Fasting for the Cure of Disease," by Dr. L. B. Hazzard; "Perfect Health," by C. C. Haskell; "Fasting, Hydrotherapy and Exercise," by Bernarr Macfadden; "Fasting, Vitality and Nutrition," by Hereward Carrington. Also I will add that Mr. C. C. Haskell, of Norwich, Conn., conducts a correspondence-school dealing with the subject of fasting, and that fasting patients are taken charge of at Bernarr Macfadden's Healthatorium, 42d Street and Grand Boulevard, Chicago, Ill., and by Dr. Linda B. Hazzard, of Seattle, Washington. THE FASTING CURE PERFECT HEALTH Perfect Health! Have you any conception of what the phrase means? Can you form any image of what would be your feeling if every organ in your body were functioning perfectly? Perhaps you can go back to some day in your youth, when you got up early in the morning and went for a walk, and the spirit of the sunrise got into your blood, and you walked faster, and took deep breaths, and laughed aloud for the sheer happiness of being alive in such a world of beauty. And now you are grown older--and what would you give for the secret of that glorious feeling? What would you say if you were told that you could bring it back and keep it, not only for mornings, but for afternoons and evenings, and not as something accidental and mysterious, but as something which you yourself have created, and of which you are completely master? This is not an introduction to a new device in patent medicine advertising. I have nothing to sell, and no process patented. It is simply that for ten years I have been studying the ill health of myself and of the men and women around me. And I have found the cause and the remedy. I have not only found good health, but perfect health; I have found a new state of being, a new potentiality of life; a sense of lightness and cleanness and joyfulness, such as I did not know could exist in the human body. "I like to meet you on the street," said a friend the other day. "You walk as if it were such fun!" I look about me in the world, and nearly everybody I know is sick. I could name one after another a hundred men and women, who are doing vital work for progress and carrying a cruel handicap of physical suffering. For instance, I am working for social justice, and I have comrades whose help is needed every hour, and they are ill! In one single week's newspapers last spring I read that one was dying of kidney trouble, that another was in hospital from nervous breakdown, and that a third was ill with ptomaine poisoning. And in my correspondence I am told that another of my dearest friends has only a year to live; that another heroic man is a nervous wreck, craving for death; and that a third is tortured by bilious headaches.[1] And there is not one of these people whom I could not cure if I had him alone for a couple of weeks; no one of them who would not in the end be walking down the street "as if it were such fun!" I propose herein to tell the story of my discovery of health, and I shall not waste much time in apologizing for the intimate nature of the narrative. It is no pleasure for me to tell over the tale of my headaches or to discuss my unruly stomach. I cannot take any case but my own, because there is no case about which I can speak with such authority. To be sure, I might write about it in the abstract, and in veiled terms. But in that case the story would lose most of its convincingness, and so of its usefulness. I might tell it without signing my name to it. But there are a great many people who have read my books and will believe what I tell them, who would not take the trouble to read an article without a name. Mr. Horace Fletcher has set us all an example in this matter. He has written several volumes about his individual digestion, with the result that literally millions of people have been helped. In the same way I propose to put my case on record. The reader will find that it is a typical case, for I made about every mistake that a man could make, and tried every remedy, old and new, that anybody had to offer me. I spent my boyhood in a well-to-do family, in which good eating was regarded as a social grace and the principal interest in life. We had a colored woman to prepare our food, and another to serve it. It was not considered fitting for children to drink liquor, but they had hot bread three times a day, and they were permitted to revel in fried chicken and rich gravies and pastries, fruit cake and candy and ice-cream. Every Sunday I would see my grandfather's table with a roast of beef at one end, and a couple of chickens at the other, and a cold ham at one side; at Christmas and Thanksgiving the energies of the whole establishment would be given up to the preparation of delicious foods. And later on, when I came to New York, I considered it necessary to have such food; even when I was a poor student, living on four dollars a week, I spent more than three of it on eatables. I was an active and fairly healthy boy; at twenty I remember saying that I had not had a day's serious sickness in fourteen years. Then I wrote my first novel, working sixteen or eighteen hours a day for several months, camping out, and living mostly out of a frying-pan. At the end I found that I was seriously troubled with dyspepsia; and it was worse the next year, after the second book. I went to see a physician, who gave me some red liquid, which magically relieved the consequences of doing hard brain-work after eating. So I went on for a year or two more, and then I found that the artificially-digested food was not being eliminated from my system with sufficient regularity. So I went to another physician, who gave my malady another name, and gave me another medicine, and put off the time of reckoning a little while longer. I have never in my life used tea or coffee, alcohol or tobacco; but for seven or eight years I worked under heavy pressure all the time, and ate very irregularly, and ate unwholesome food. So I began to have headaches once in a while, and to notice that I was abnormally sensitive to colds. I considered these maladies natural to mortals, and I would always attribute them to some specific accident. I would say, "I've been knocking about down town all day"; or, "I was out in the hot sun"; or, "I lay on the damp ground." I found that if I sat in a draught for even a minute I was certain to "catch a cold." I found also that I had sore throat and tonsilitis once or twice every winter; also, now and then, the grippe. There were times when I did not sleep well; and as all this got worse, I would have to drop all my work and try to rest. The first time I did this a week or two was sufficient; but later on a month or two was necessary, and then several months. The year I wrote "The Jungle" I had my first summer cold. It was haying time on a farm, and I thought it was a kind of hay-fever. I would sneeze for hours in perfect torment, and this lasted for a month, until I went away to the sea-shore. This happened again the next summer, and also another very painful experience; a nerve in a tooth died, and I had to wait three days for the pain to "localize," and then had the tooth drilled out, and staggered home, and was ill in bed for a week with chills and fever, and nausea and terrible headaches. I mention all these unpleasant details so that the reader may understand the state of wretchedness to which I had come. At the same time, also, I had a great deal of distressing illness in my family; my wife seldom had a week without suffering, and my little boy had pneumonia one winter, and croup the next, and whooping-cough in the summer, with the inevitable "colds" scattered in between. After the Helicon Hall fire I realized that I was in a bad way, and for the two years following I gave a good part of my time to trying to find out how to preserve my health. I went to Battle Creek, and to Bermuda, and to the Adirondacks; I read the books of all the new investigators of the subject of hygiene, and tried out their theories religiously. I had discovered Horace Fletcher a couple of years before. Mr. Fletcher's idea is, in brief, to chew your food, and chew it thoroughly; to extract from each particle of food the maximum of nutriment, and to eat only as much as your system actually needs. This was a very wonderful idea to me, and I fell upon it with the greatest enthusiasm. All the physicians I had known were men who tried to cure me when I fell sick, but here was a man who was studying how to stay well. I have to find fault with Mr. Fletcher's system, and so I must make clear at the outset how much I owe to it. It set me upon the right track--it showed me the goal, even if it did not lead me to it. It made clear to me that all my various ailments were symptoms of one great trouble, the presence in my body of the poisons produced by superfluous and unassimilated food, and that in adjusting the quantity of food to the body's exact needs lay the secret of perfect health. It was only in the working out of the theory that I fell down. Mr. Fletcher told me that "Nature" would be my guide, and that if only I masticated thoroughly, instinct would select the foods. I found that, so far as my case was concerned, my "nature" was hopelessly perverted. I invariably preferred unwholesome foods--apple pie, and toast soaked in butter, and stewed fruit with quantities of cream and sugar. Nor did "Nature" kindly tell me when to stop, as she apparently does some other "Fletcherites"; no matter how much I chewed, if I ate all I wanted I ate too much. And when I realized this, and tried to stop it, I went, in my ignorance, to the other extreme, and lost fourteen pounds in as many days. Again, Mr. Fletcher taught me to remove all the "unchewable" parts of the food--the skins of fruit, etc. The result of this is there is nothing to stimulate the intestines, and the waste remains in the body for many days. Mr. Fletcher says this does not matter, and he appears to prove that it has not mattered in his case. But I found that it mattered very seriously in my case; it was not until I became a "Fletcherite" that my headaches became hopeless and that sluggish intestines became one of my chronic complaints. I next read the books of Metchnikoff and Chittenden, who showed me just how my ailments came to be. The unassimilated food lies in the colon, and bacteria swarm in it, and the poisons they produce are absorbed into the system. I had bacteriological examinations made in my own case, and I found that when I was feeling well the number of these toxin-producing germs was about six billions to the ounce of intestinal contents; and when, a few days later, I had a headache, the number was a hundred and twenty billions. Here was my trouble under the microscope, so to speak. These tests were made at the Battle Creek Sanitarium, where I went for a long stay. I tried their system of water cure, which I found a wonderful stimulant to the eliminative organs; but I discovered that, like all other stimulants, it leaves you in the end just where you were. My health was improved at the sanitarium, but a week after I left I was down with the grippe again. I gave the next year of my life to trying to restore my health. I spent the winter in Bermuda and the summer in the Adirondacks, both of them famous health resorts, and during the entire time I lived an absolutely hygienic life. I did not work hard, and I did not worry, and I did not think about my health except when I had to. I lived in the open air all the time, and I gave most of the day to vigorous exercise--tennis, walking, boating and swimming. I mention this specifically, so that the reader may perceive that I had eliminated all other factors of ill-health, and appreciate to the full my statement that at the end of the year's time my general health was worse than ever before. I was all right so long as I played tennis all day or climbed mountains. The trouble came when I settled down to do brain-work. And from this I saw perfectly clearly that I was over-eating; there was surplus food to be burned up, and when it was not burned up it poisoned me. But how was I to stop when I was hungry? I tried giving up all the things I liked and of which I ate most; but that did no good, because I had such a complacent appetite--I would immediately take to liking the other things! I thought that I had an abnormal appetite, the result of my early training; but how was I ever to get rid of it? I must not give the impression that I was a conspicuously hearty eater. On the contrary, I ate far less than most people eat. But that was no consolation to me. I had wrecked myself by years of overwork, and so I was more sensitive. The other people were going to pieces by slow stages, I could see; but I was already in pieces. So matters stood when I chanced to meet a lady, whose radiant complexion and extraordinary health were a matter of remark to everyone. I was surprised to hear that for ten or fifteen years, and until quite recently, she had been a bed-ridden invalid. She had lived the lonely existence of a pioneer's wife, and had raised a family under conditions of shocking ill-health. She had suffered from sciatica and acute rheumatism; from a chronic intestinal trouble which the doctors called "intermittent peritonitis"; from intense nervous weakness, melancholy, and chronic catarrh, causing deafness. And this was the woman who rode on horseback with me up Mount Hamilton, in California, a distance of twenty-eight miles, in one of the most terrific rain-storms I have ever witnessed! We had two untamed young horses, and only leather bits to control them with, and we were pounded and flung about for six mortal hours, which I shall never forget if I live to be a hundred. And this woman, when she took the ride, had not eaten a particle of food for four days previously! That was the clue to her escape: she had cured herself by a fast. She had abstained from food for eight days, and all her troubles had fallen from her. Afterwards she had taken her eldest son, a senior at Stanford, and another friend of his, and fasted twelve days with them, and cured them of nervous dyspepsia. And then she had taken a woman friend, the wife of a Stanford professor, and cured her of rheumatism by a week's fast. I had heard of the fasting cure, but this was the first time I had met with it. I was too much burdened with work to try it just then, but I began to read up on the subject--the books of Dr. Dewey, Dr. Hazzard and Mr. Carrington. Coming home from California I got a sunstroke on the Gulf of Mexico, and spent a week in hospital at Key West, and that seemed to give the _coup de grace_ to my long-suffering stomach. After another spell of hard work I found myself unable to digest corn-meal mush and milk; and so I was ready for a fast. I began. The fast has become a commonplace to me now; but I will assume that it is as new and as startling to the reader as it was to myself at first, and will describe my sensations at length. I was very hungry for the first day--the unwholesome, ravening sort of hunger that all dyspeptics know. I had a little hunger the second morning, and thereafter, to my very great astonishment, no hunger whatever--no more interest in food than if I had never known the taste of it. Previous to the fast I had had a headache every day for two or three weeks. It lasted through the first day and then disappeared--never to return. I felt very weak the second day, and a little dizzy on arising. I went out of doors and lay in the sun all day, reading; and the same for the third and fourth days--intense physical lassitude, but with great clearness of mind. After the fifth day I felt stronger, and walked a good deal, and I also began some writing. No phase of the experience surprised me more than the activity of my mind: I read and wrote more than I had dared to do for years before. During the first four days I lost fifteen pounds in weight--something which, I have since learned, was a sign of the extremely poor state of my tissues. Thereafter I lost only two pounds in eight days--an equally unusual phenomenon. I slept well throughout the fast. About the middle of each day I would feel weak, but a massage and a cold shower would refresh me. Towards the end I began to find that in walking about I would grow tired in the legs, and as I did not wish to lie in bed I broke the fast after the twelfth day with some orange-juice. I took the juice of a dozen oranges during two days, and then went on the milk diet, as recommended by Bernarr Macfadden. I took a glassful of warm milk every hour the first day, every three-quarters of an hour the next day, and finally every half-hour--or eight quarts a day. This is, of course, much more than can be assimilated, but the balance serves to flush the system out. The tissues are bathed in nutriment, and an extraordinary recuperation is experienced. In my own case I gained four and a half pounds in one day--the third--and gained a total of thirty-two pounds in twenty-four days. My sensations on this milk diet were almost as interesting as on the fast. In the first place, there was an extraordinary sense of peace and calm, as if every weary nerve in the body were purring like a cat under a stove. Next there was the keenest activity of mind--I read and wrote incessantly. And, finally, there was a perfectly ravenous desire for physical work. In the old days I had walked long distances and climbed mountains, but always with reluctance and from a sense of compulsion. Now, after the cleaning-out of the fast, I would go into a gymnasium and do work which would literally have broken my back before, and I did it with intense enjoyment, and with amazing results. The muscles fairly leaped out upon my body; I suddenly discovered the possibility of becoming an athlete. I had always been lean and dyspeptic-looking, with what my friends called a "spiritual" expression; I now became as round as a butter-ball, and so brown and rosy in the face that I was a joke to all who saw me. I had not taken what is called a "complete" fast--that is, I had not waited until hunger returned. Therefore I began again. I intended only a short fast, but I found that hunger ceased again, and, much to my surprise, I had none of the former weakness. I took a cold bath and a vigorous rub twice a day; I walked four miles every morning, and did light gymnasium work, and with nothing save a slight tendency to chilliness to let me know that I was fasting. I lost nine pounds in eight days, and then went for a week longer on oranges and figs, and made up most of the weight on these. I shall always remember with amusement the anxious caution with which I now began to taste the various foods which before had caused me trouble. Bananas, acid fruits, peanut butter--I tried them one by one, and then in combination, and so realized with a thrill of exultation that every trace of my old trouble was gone. Formerly I had had to lie down for an hour or two after meals; now I could do whatever I chose. Formerly I had been dependent upon all kinds of laxative preparations; now I forgot about them. I no longer had headaches. I went bareheaded in the rain, I sat in cold draughts of air, and was apparently immune to colds. And, above all, I had that marvellous, abounding energy, so that whenever I had a spare minute or two I would begin to stand on my head, or to "chin" myself, or do some other "stunt," from sheer exuberance of animal spirits. For several months after this experience I lived upon a diet of raw foods exclusively--mainly nuts and fruits. I had been led to regard this as the natural diet for human beings; and I found that so long as I was leading an active life the results were most satisfactory. They were satisfactory also in the case of my wife, and still more so in the case of my little boy; the amount of work and bother thus saved in the household may be imagined. But when I came to settle down to a long period of hard and continuous writing, I found that I had not sufficient bodily energy to digest these raw foods. I resorted to fasting and milk alternately--and that is well enough for a time, but it proves a nervous strain in the end. Recently a friend called my attention to the late Dr. Salisbury's book, "The Relation of Alimentation to Disease." Dr. Salisbury recommends a diet of broiled beef and hot water as the solution of most of the problems of the human body; and it may be believed that I, who had been a rigid and enthusiastic vegetarian for three or four years, found this a startling idea. However, I make a specialty of keeping an open mind, and I set out to try the Salisbury system. I am sorry to have to say that it seems to be a good one; sorry, because the vegetarian way of life is so obviously the cleaner and more humane and more convenient. But it seems to me that I am able to do more work and harder work with my mind while eating beefsteaks than under any other _régime_; and while this continues to be the case there will be one less vegetarian in the world. The fast is to me the key to eternal youth, the secret of perfect and permanent health. I would not take anything in all the world for my knowledge of it. It is Nature's safety-valve, an automatic protection against disease. I do not venture to assert that I am proof against virulent diseases, such as smallpox or typhoid. I know one ardent physical culturist, a physician, who takes typhoid germs at intervals in order to prove his immunity, but I should not care to go that far; it is enough for me to know that I am proof against all the common infections which plague us, and against all the "chronic" troubles. And I shall continue so just as long as I stand by my present resolve, which is to fast at the slightest hint of any symptom of ill-being--a cold or a headache, a feeling of depression, or a coated tongue, or a scratch on the finger which does not heal quickly. Those who have made a study of the fast explain its miracles in the following way: Superfluous nutriment is taken into the system and ferments, and the body is filled with a greater quantity of poisonous matter than the organs of elimination can handle. The result is the clogging of these organs and of the blood-vessels--such is the meaning of headaches and rheumatism, arteriosclerosis, paralysis, apoplexy, Bright's disease, cirrhosis, etc. And by impairing the blood and lowering the vitality, this same condition prepares the system for infection--for "colds," or pneumonia, or tuberculosis, or any of the fevers. As soon as the fast begins, and the first hunger has been withstood, the secretions cease, and the whole assimilative system, which takes so much of the energies of the body, goes out of business. The body then begins a sort of house-cleaning, which must be helped by an enema and a bath daily, and, above all, by copious water-drinking. The tongue becomes coated, the breath and the perspiration offensive; and this continues until the diseased matter has been entirely cast out, when the tongue clears and hunger reasserts itself in unmistakable form. The loss of weight during the fast is generally about a pound a day. The fat is used first, and after that the muscular tissue; true starvation begins only when the body has been reduced to the skeleton and the viscera. Fasts of forty and fifty days are now quite common--I have met several who have taken them. Strange as it may seem, the fast is a cure for both emaciation and obesity. After a complete fast the body will come to its ideal weight. People who are very stout will not regain their weight; while people who are under weight may gain a pound or more a day for a month. There are two dangers to be feared in fasting. The first is that of fear. I do not say this as a jest. No one should begin to fast until he has read up on the subject and convinced himself that it is the thing to do; if possible he should have with him someone who has already had the experience. He should not have about him terrified aunts and cousins who will tell him that he looks like a corpse, that his pulse is below forty, and that his heart may stop beating in the night. I took a fast of three days out in California; on the third day I walked about fifteen miles, off and on, and, except that I was restless, I never felt better. And then in the evening I came home and read about the Messina earthquake, and how the relief ships arrived, and the wretched survivors crowded down to the water's edge and tore each other like wild beasts in their rage of hunger. The paper set forth, in horrified language, that some of them had been seventy-two hours without food. I, as I read, had also been seventy-two hours without food; and the difference was simply that they thought they were starving. And if at some crisis during a long fast, when you feel nervous and weak and doubting, some people with stronger wills than your own are able to arouse in you the terrors of the earthquake survivors, they can cause their most direful anticipations to be realized. The other danger is in breaking the fast. A person breaking a long fast should regard himself as if he were liable to seizures of violent insanity. I know a man who fasted fifty days, and then ate half a dozen figs, and caused intestinal abrasions from which he lost a great deal of blood. I would dwell more upon this topic were it not for my discovery of the "milk diet." When you drink a glass of milk every half-hour you have no chance to get really hungry, and so you glide, as if by magic, from a condition of extreme emaciation to one of blooming rotundity. But very frequently the milk diet disagrees with people; and these have to break the fast with very small quantities of the simplest foods--fruit juices and meat broths for the first two or three days at least. I will conclude this chapter by narrating the experiences of some other persons with the fasting cure. With the exception of one, the second case, they are all people whom I know personally, and who have told me their stories with their own lips. First, I give the case of my wife. She has always been frail, and subject to sore throats since girlhood. In the past five years she has undergone three major surgical operations and had several serious illnesses besides. Two years ago she had a severe attack of appendicitis. The physician made a wrong diagnosis, and kept her alive for about ten days with morphine. She was then too low to risk an operation, and was not expected to live. It was several months before she was able to walk again, and she had never fully recovered from the experience. When she began the fast she was suffering from serious stomach trouble, loss of weight, and neurasthenia. I did not think that she would be able to stand a fast. She had more trouble than I--some nervousness, headache and nausea. But she stood it for ten days, when her tongue cleared suddenly. She had lost twelve pounds, and she then gained twenty-two pounds in seventeen days. She then took another fast of six days with me, and with no more trouble than I experienced the second time--walking four miles every morning with me. She is now a picture of health, and is engaged in accumulating muscle with enthusiasm. Second, a man well on in life, who had always abused his health. He suffered from asthma and dropsy, and was saturated with drugs. He had not been able to lie down for several years. He weighed over 220 pounds, and his legs were "like sacks of water, leaking continually." His kidneys had refused to act, and after his doctors had tried all the drugs they knew, he was told that he was dying. His brother, who narrated the circumstances to me, persuaded him not to eat the supper that was brought in to him, and so he lived through the night. He fasted seven days, and went for four weeks longer on a very light diet, and is now chopping wood and pitching hay upon his farm in Kentucky. Third, a young physician, as a college boy a physical wreck from dissipation, now twenty-four. "A born neurastheniac." He was attacked by appendicitis twice in succession. He fasted five days after the last attack, and six days later on. Gained thirty-five pounds, and is a splendidly developed athlete; he runs five miles in 26 minutes 15 seconds, and rode a wheel 500 miles in seven days. Fourth, a young lady, who had suffered a nervous collapse caused by overwork and worry. The bones of her spine had softened; her hipbones tilted upwards three-quarters of an inch; she was "barely able to crawl on two sticks." She fasted ten days, and again eight days, and took the milk diet for six weeks. I have seen her every day for the last eight or ten weeks, and I do not think that I ever met a woman who impressed me as possessing more superabundant and radiant health. Fifth, a young man, injured in a railroad wreck; a rib broken and the outer lining of the lungs punctured. Still has an opening for drainage, caused by chafing of the membranes. Suffered in succession attacks of bronchitis, typhoid, pneumonia and pleurisy. Was reduced from 186 to 119 pounds, and had planned to take his life. Fasted six days, gained twenty-seven pounds, and plays tennis vigorously, in spite of having an opening in his chest. Recently walked 442 miles in eleven days. Sixth, a lady, married, and in middle life, a life-long sufferer from stomach trouble; had experienced six attacks of inflammatory rheumatism, resulting in valvular heart disease and the loss of the use of her limbs. Fasted four times--four, eight, twenty-eight, and fourteen days. I can best describe her present condition by saying that all this summer she arose every morning at daybreak, walked four and a half miles, went for a swim, and then walked home for breakfast. Seventh, an Episcopal clergyman, who had suffered almost all his life from indigestion; had an acute attack of gastritis, followed by nervous prostration and complete breakdown. Specialists had diagnosed his case as "prolapsed stomach and bowels, autointoxication and neurasthenia," and told him that he could not expect to get well in less than five years. He was so emaciated that he could hardly creep around, and, despite the fact that he had a wife and six children, was contemplating suicide. He fasted eleven days, and then gained thirty pounds. I am prepared to testify that he is the most hard-working, cheerful and athletic clergyman it has ever been my fortune to meet. I have taken some trouble to investigate the subject of the fast, and to meet people who have been through the experience. I could give a dozen more cases such as the above if space permitted. I know one man who reduced his weight from 365 pounds to 235. I know one little girl whose spine was bent in the shape of a letter U lying sideways, and who, by means of fasting and a diet of fruits exclusively, has come four inches nearer to straightness in a few months. She has the complexion of perfect health, and is rapidly recovering the use of arms and legs, which were paralyzed years ago. The reader may think that my enthusiasm over the fasting cure is due to my imaginative temperament; I can only say that I have never yet met a person who has given the fast a fair trial who does not describe his experience in the same way. I have never heard of any harm resulting from it, save only in cases of tuberculosis, in which I have been told by one physician that people have lost weight and not regained it. I regard the fast as Nature's own remedy for all other diseases. It is the only remedy which is based upon an understanding of the fundamental nature of disease. And I believe that when the glad tidings of its miracles have reached the people it will lead to the throwing of 90 per cent of our present _materia medica_ into the waste-basket. This may be unwelcome to those physicians who are more concerned with their own income than they are with the health of their patients; but I personally have never met any such physicians, and so I most earnestly urge it upon medical men to investigate the extraordinary and almost incredible facts about the fasting cure. * * * * * * * Shortly after the above was completed the writer had another interesting experience with the fast. He had occasion to do some work which kept him indoors for a couple of weeks, under considerable strain; and after that to spend the greater part of a week in the dentist's chair suffering a good deal of pain; and finally to spend two days and nights in a railroad train. He arrived at his destination with every symptom of what long and painful experience has taught him to recognize as a severe attack of the "grippe." (The last attack laid him up in hospital for a week, and left him so reduced that he could hardly stand.) On this occasion he fasted, and although circumstances compelled him to be up and about during the entire time, every trace of ill-feeling had left him in two days. Having started, however, he continued the fast for twelve days. During this time he planned a play, and wrote two-thirds of it, and he has reason to think that it is as good work as he has ever done. It is worth noting that on the eighth day he was strong enough to "chin" himself six times in succession, though previous to the fasting treatment he had never in his life been able to do this more than once or twice. A LETTER TO THE NEW YORK TIMES (_unfit to print_) ARDEN, DEL., May 31, 1910. EDITOR OF THE _Times_, New York City, DEAR SIR,--Some time ago your news columns contained a despatch to the effect that three young ladies in Garden City, Long Island, were undertaking a three days' fast as a result of reading a magazine article recommending this measure. In your editorial referring to this despatch, you say that the ladies are "the victims of a shallow and unscrupulous sensationalist." As I am the writer of the magazine article in question, I presume that this means me. I did not intend to make any reply to the remark, as I figure that I must have long ago lost whatever reputation could be taken from me by newspaper comments. Thinking the matter over, however, I concluded that I would venture a mild protest, not on my own account, but for the sake of the important discovery of which I told in the article in question. It is one of the privileges incidental to owning a newspaper that one can call other people names with impunity, and can always have the last word in any argument. Will, however, your sense of fair play give me the privilege of asking you to state just what you meant by the slur in question? In the magazine article I stated that I had taken several fasts of ten or twelve days' duration, with the result of a complete making over of my health. I presume that the writer of the editorial had read the article before he condemned it. Am I to understand that he got from the article the impression that I was telling lies, and that I had never really taken the fasts as I said I had taken them? Or was it his idea that I exaggerated the benefits derived therefrom, in order to make "victims" of the three young ladies in Garden City? I might say that I took the fasts in question in an institution where hundreds of people were fasting anywhere from three to fifty days; that during the entire time I was under the observation of many people; my weight was taken regularly every day, and all the symptoms which I described were observed by physicians and friends. May I also call attention to the fact that I published in the article two photographs, one of which was taken four years ago, and the other of which was taken after the fasting treatment? The contrast between these two photographs was sufficiently striking, it seems to me, to impress anyone. May I also call attention to the fact that the article was found of sufficient interest to be published in one of the most representative of the English monthlies, the _Contemporary Review_? Also that the _Contemporary Review_ appended to the article the testimony of half a dozen people whose cases I had myself observed, and whose letters I have in my possession? I fully recognize the fact that many of the things for which I stand as a writer are abhorrent to you, but surely that is no reason for condemning recklessly and blindly an important discovery concerning human health, simply because I happen to be the person who is telling about it. Setting aside all personalities, and simply in the interest of the discovery in question, I respectfully invite you to make an investigation of the claims which I have set forth in that article. Let me give you the names of some people who have fasted either under my direction or in my presence, and who will tell a representative of your paper of the results it has brought to them. I can tell you of a dozen such people. Also, perhaps by way of preliminary, you might be willing to publish as an appendix to this letter of mine the communication from another of my "victims," omitting the name of the writer unless you obtain permission to use it. Yours truly, UPTON SINCLAIR. Appended to the above was the letter which the reader will find in the Appendix, page 111. The _Times_ did not publish this letter, nor did it pay any attention to several letters of protest which followed. I leave it to the reader to judge whether the silence of the paper was one of dignity or of fear. The following despatch from the New York _World_ of May 17, 1910, records the experiences of the Garden City ladies, and makes clear how much in need of sympathy my "victims" were. All three of the young women are in rare spirits. They have gone about their usual occupations and recreations, and Mrs. Trask found time yesterday to talk about the single tax in the course of a conversation that had to do primarily with her newer interest. "We are getting the most extraordinary number of letters about this adventure of ours," Mrs. Trask said. "They began to come the first day, and to-day there were lots of them. They come from some of the most unexpected places and they contain some of the most unexpected things. "What most astonishes me is that of all those who write to tell us that they have tried just what we are doing, not one has told us of a failure. There isn't any reason why they shouldn't write to say that we are foolish and that we can't hope to gain what we want, but dozens of them have reiterated the promise that we'll never regret having made our experiment. "One New York woman told us something that we had wondered about more than once. Her husband had suffered greatly from rheumatism, and finally he tried fasting. Not dieting like ourselves, but fasting. He went without food of any kind, she said, for nineteen days. He kept on at his work, too, which was the thing we had been wondering about. "We've heard from another physician, too. He lives in Boston and has made a specialty of dietetics. He warned us not to stick too closely to milk, because we'd find that after a day or two it would quit being of the service it had been at first. People we never heard of tell us that thus and so was their experience, and when we measure our own discoveries beside theirs we find new and convincing evidence that we picked the true way to the end we hoped to reach. "I know that for myself I'll have reason to be grateful always that I took this up. We have been greatly benefited." FOOTNOTE: [1] The first two of these, Edmond Kelly and Ben Hanford, have since died. SOME NOTES ON FASTING In relation to the article, "Perfect Health," I received some six or eight hundred letters from people who either had fasted, or desired to fast and sought for further information. The letters showed a general uniformity which made clear to me that I had not been sufficiently explicit upon several important points. The question most commonly asked was how long should one fast, and how one should judge of the time to stop. I personally have never taken a "complete fast," and so I hesitate in recommending this to any one. I have fasted twelve days on two occasions. In both cases I broke my fast because I found myself feeling weak and I wanted to be about a good deal. In neither case was I hungry, although hunger quickly returned. I was told by Bernarr Macfadden, and by some of his physicians, that they got their best results from fasts of this length. I would not advise a longer fast for any of the commoner ailments, such as stomach and intestinal trouble, headaches, constipation, colds and sore throat. Longer fasts, it seems to me, are for those who have really desperate ailments, such deeply-rooted chronic diseases as Bright's disease, cirrhosis of the liver, rheumatism and cancer. Of course if a person has started on a fast and it is giving him no trouble, there is no reason why it should not be continued; but I do not in the least believe in a man's setting before himself the goal of a forty or fifty days' fast and making a "stunt" out of it. I do not think of the fast as a thing to be played with in that way. I do not believe in fasting for the fun of it, or out of curiosity. I do not advise people to fast who have nothing the matter with them, and I do not advise the fast as a periodical or habitual thing. A man who has to fast every now and then is like a person who should spend his time in sweeping rain water out of his house, instead of taking the trouble to repair his roof. If you have to fast every now and then, it is because the habits of your life are wrong, more especially because you are eating unwholesome foods. There were several people who wrote me asking about a fast, to whom my reply was that they should simply adopt a rational diet; that I believed their troubles would all disappear without the need of a fast. Several people asked me if it would not be better for them to eat very lightly instead of fasting, or to content themselves with fasts of two or three days at frequent intervals. My reply to that is that I find it very much harder to do that, because all the trouble in the fast occurs during the first two or three days. It is during those days that you are hungry, and if you begin to eat just when your hunger is ceasing, you have wasted all your efforts. In the same way, perhaps, it might be a good thing to eat very lightly of fruit, instead of taking an absolute fast--the only trouble is that I cannot do it. Again and again I have tried, but always with the same result: the light meals are just enough to keep me ravenously hungry, and inevitably I find myself eating more and more. And it does me no good to call myself names about this, I just do it, and keep on doing it; I have finally made up my mind that it is a fact of my nature. I used to try these "fruit fasts" under Dr. Kellogg's advice. I could live on nothing but fruit for several days, but I would get so weak that I could not stand up--far weaker than I have ever become on an out-and-out fast. One should drink all the water he possibly can while fasting, only not taking too much at a time. I take a glass full every hour, at least; sometimes every half hour. It is a good plan to drink a great deal of water at the outset, whenever meal time comes around, and one thinks of the other folks beginning to eat. I drink the water cold, because it is less trouble, but if there is any hot water about, I prefer that. Hot water between meals is an immensely valuable suggestion which I owe to Dr. Salisbury. One should take a bath every day while fasting. I prefer a warm bath followed by a cold shower. Also one should take a small enema. I find a pint of cool water sufficient. I received several letters from people who were greatly disturbed because of constipation during the fast. People apparently do not realize that while fasting there is very little to be eliminated from the body. (Of course, there are cases, especially of people who have suffered from long continued intestinal trouble, in which even after three or four weeks the enema continues to bring away quantities of dried and impacted fæces.) Many of the questions asked dealt with the manner of breaking the fast; I suppose because I had been particular to warn my readers that this was the one danger point in the proceeding. I told of my experience with the milk diet, and I received many inquiries about this. My answer was to refer the writers to Bernarr Macfadden's pamphlet on the milk diet, as I took this diet under his direction and have nothing to add to his instructions. I might say, however, that I was never able to take the milk diet for any length of time but once, and that after my first twelve-day fast. After my second fast it seemed to go wrong with me, and I think the reason was that I did not begin it until a week after breaking the fast, having got along on orange juice and figs in the meantime. Also I tried on many occasions to take the milk diet after a short fast of three or four days, and always the milk has disagreed with me and poisoned me. I take this to mean that, in my own case, at any rate, so much milk can only be absorbed when the tissues are greatly reduced; and I have known others who have had the same experience. While I was down in Alabama, I took a twelve-day fast, and at the end I was tempted by a delicious large Japanese persimmon, which had been eyeing me from the pantry shelf during the whole twelve days. I ate that persimmon--and I mention that it was thoroughly ripe; in spite of which fact it doubled me up with the most alarming cramp--and in consequence I do not recommend persimmons for fasters. I know a friend who had a similar experience from the juice of one orange; but he was a man with whom acid fruit has always disagreed. I know another man who broke his fast on a Hamburg steak; and this also is not to be recommended. It has been my experience that immediately after a fast the stomach is very weak, and can easily be upset; also the peristaltic muscles are practically without power. It is, therefore, important to choose foods which are readily digested, and also to continue to take the enema daily until the muscles have been sufficiently built up to make a natural movement possible. The thing to do is to take orange juice or grape juice in small quantities for two or three days, and then go gradually upon the milk diet, beginning with half a glass of warm milk at a time. If the milk does not agree with you, you may begin carefully to add baked potatoes and rice and gruels and broths, if you must; but don't forget the enema. People ask me in what diseases I recommend fasting. I recommend it for all diseases of which I have ever heard, with the exception of one in which I have heard of bad results--tuberculosis. Dr. Hazzard, in her book, reports a case of the cure of this disease, but Mr. Macfadden tells me that he has known of several cases of people who have lost their weight and have not regained it. There is one cure quoted in the appendix to this volume. The diseases for which fasting is most obviously to be recommended are all those of the stomach and intestines, which any one can see are directly caused by the presence of fermenting and putrefying food in the system. Next come all those complaints which are caused by the poisons derived from these foods in the blood and the eliminative organs: such are headaches and rheumatism, liver and kidney troubles, and of course all skin diseases. Finally, there are the fevers and infectious diseases, which are caused by the invasion of the organism by foreign bacteria, which are enabled to secure a lodgment because of the weakened and impure condition of the blood-stream. Such are the "colds" and fevers. In these latter cases nature tries to save us, for there is immediately experienced a disinclination on the part of the sick person to take any sort of food; and there is no telling how many people have been hurried out of life in a few days or hours, because ignorant relatives, nurses and physicians have gathered at their bedside and implored them to eat. I can look back upon a time in my own experience when my wife was in the hospital with a slow fever; they would bring her up three square meals a day, consisting of lamb chops, poached eggs on toast, cooked vegetables, preserves and desserts; and the physician would stand by her bedside and say, in sepulchral tones, "If you do not eat, you will die!" My friend, Mr. Arthur Brisbane, wrote me a gravely disapproving letter when he read that I was fasting. I had a long correspondence with him, at the end of which he acknowledged that there "might be something in it." "Even dogs fast when they are ill," he wrote; and I replied, "I look forward to the time when human beings may be as wise as dogs." I read the other day an amusing story of a man who made himself a reputation for curing the diseases of the pampered pets of our rich society ladies. They would bring him their overfed dogs, and he would shut them up in an old brick-kiln, with a tub of water, and leave them there to howl until they were hoarse. In addition to the water he would put in each cell a hunk of stale bread, a piece of bacon rind, and an old boot. He would go back at the end of a few days, and if the bread was eaten he would write to the fond owner that the dog's recovery was assured. He would go back in a few more days, and if the bacon rind was eaten would write that the dog was nearly well. And at the end of another week, he would go back, and if the old boot was eaten he would write to the owner that the dog was now completely restored to health. Several people wrote me who were in the last stages of some desperate disease. Of course they had always been consulting with physicians, and the physicians had told them that my article was "pure nonsense"; and they would write me that they would like to try to fast, but that they were "too weak and too far gone to stand it." There is no greater delusion than that a person needs strength to fast. The weaker you are from disease, the more certain it is that you need to fast, the more certain it is that your body has not strength enough to digest the food you are taking into it. If you fast under those circumstances, you will grow not weaker, but stronger. In fact, my experience seems to indicate that the people who have the least trouble on the fast are the people who are most in need of it. The system which has been exhausted by the efforts to digest the foods that are piled into it, simply lies down with a sigh of relief and goes to sleep. The fast is Nature's remedy for all diseases, and there are few exceptions to the rule. When you feel sick, fast. Do not wait until the next day, when you will feel stronger, nor till the next week, when you are going away into the country, but stop eating at once. Many of the people who wrote to me were victims of our system of wage slavery, who wrote me that they were ill, but could not get even a few days' release in which to fast. They wanted to know if they could fast and at the same time continue their work. Many can do this, especially if the work is of a clerical or routine sort. On my first fast I could not have done any work, because I was too weak. But on my second fast I could have done anything except very severe physical labor. I have one friend who fasted eight days for the first time, and who did all her own housework and put up several gallons of preserves on the last day. I have received letters from a couple of women who have fasted ten or twelve days, and have done all their own work. I know of one case of a young girl who fasted thirty-three days and worked all the time at a sanatorium, and on the twenty-fourth day she walked twenty miles. FASTING AND THE DOCTORS A most discouraging circumstance to me was the attitude of physicians, as revealed in the correspondence that came to me. Mostly I learned of this attitude from the letters of patients who quoted their physicians to me. From the physicians themselves I heard practically nothing. We have some one hundred and forty thousand regularly graduated "medical men" in this country, and they are all of them presumably anxious to cure disease. It would seem that an experience such as mine, narrated over my own signature, and backed by references to other cases, would have awakened the interest of a good many of these professional men. Out of the six or eight hundred letters that I have received, just two, so far as I can remember, were from physicians; and out of the hundreds of newspaper clippings which I received, not a single one was from any sort of medical journal. There was one physician, in an out-of-the-way town in Arkansas, who was really interested, and who asked me to let him print several thousand copies of the article in the form of a pamphlet, to be distributed among his patients. One single mind, among all the hundred and forty thousand, open to a new truth! In the _English Review_ for November, 1910, I find an article entitled "Bone-setting and the Profession, by Fairplay." It is a narrative of the experience of the writer and some of his friends with Osteopathy, being a defence of that method of treatment in cases of bruises and sprains. I quote the following paragraph: "Harvey's statement about the circulation of the blood was met with scorn by the doctors, who called him in derision the 'Circulator.' Simpson's discovery of the use of chloroform was scouted by them as incredible, some even declared it to be 'impious,' and a 'defiance of the will of God.' Elliotson's use of the stethoscope called forth the rage of the protected society as a body: the _Lancet_ described him as a 'pariah of the profession.' The ignorant scorn and slander broke his heart; but to-day the stethoscope is in constant use, and is recognized as one of the most important aids to a correct diagnosis." It might also be of interest to quote the note which one finds appended to this remarkable article: "The Editor was amused to find that the _Lancet_ refused the advertisement of the above article, thereby confirming what the writer alleges against the ring." Of course I realize what a difficult matter it is for a medical man to face these facts about the fast. Sometimes it seems to me that we have no right to expect their help at all, and that we never will receive it. For we are asking them to destroy themselves, economically speaking. We do not expect aid from eminent corporation lawyers when we set out to overthrow the rule of privilege in our country; and it must be equally difficult for a hard-worked and not very highly paid physician to contemplate the triumph of an idea, which would leave no place for him in civilization. In an article contributed to _Physical Culture_ magazine for January, 1910, I stated that in the course of my search for health I had paid to physicians, surgeons, druggists and sanatoriums not less than fifteen thousand dollars in the last six or eight years. In the last year, since I have learned about the fast, I have paid nothing at all; and the same thing is true, perhaps on a smaller scale, of every one who discovers the fasting cure. As one man, who wrote me a letter of enthusiastic gratitude, expresses it: "I have spent over five hundred dollars in the last ten years trying to get well on medicines. It cost me only thirty cents to use your method, and for that thirty cents I obtained relief a million-fold more beneficial than from five hundred dollars' worth of medicine." Not so very long ago I saw a report in some metropolitan newspaper to the effect that the medical profession was greatly alarmed over the decrease in its revenues--it being estimated that the income of the average physician to-day was less than half of what it had been ten years ago. All this, I think, is directly attributable to the spread of knowledge concerning natural methods in the treatment of disease--and, more important yet, of natural methods in the preservation of health. Only the other day I was talking with a friend who was a teacher in a small college in the Middle West. There was a physician regularly employed to attend the girl-students, but several of the teachers became interested in the fasting cure, and whenever they learned of any illness they would go to the girl and start her on a fast; as a result, the physician lost considerably more than half his practice. In the same way, I myself recently started several people in a small town to fasting, and every time I saw the local physician driving by in his carriage I marvelled at the courtesy and cordiality he displayed; for before I had left that place I had cured half a dozen of his permanent customers--people to whom he had been dispensing pills and powders every few weeks for a dozen years. THE HUMORS OF FASTING At the time of writing these words, it has been just six months since I published my first paper upon fasting, and I am still getting letters about it at the rate of half a dozen a day. The tent which I inhabit is rapidly becoming uninhabitable because of pasteboard boxes full of "fasting-letters"; and the store-keeper who is so good as to receive my telegrams over the 'phone, is growing quite expert at taking down the symptoms of adventurers who get started and want to know how to stop. I could make quite a postage-stamp collection from these letters--I had one from Spain and one from India and one from Argentina all in the same day. I am sure I might have kept a sanatorium for those people who have begged me to let them come and live near me while they were taking a fast. One woman writes to ask me to name my own price to take charge of a case of elephantiasis which has been given up by all the experts in Europe! Also, I could fill an article with the "humors" of these letters. One woman writes a long and anxious inquiry as to whether it is permissible to drink any _water_ while fasting; and then follows this up with a special delivery letter to say that she hopes I will not think she is crazy--she had read the article again and noted the injunction to drink as much water as she can! And then comes a letter from a man who wants to know if I really mean it all; do I truly expect him to eat nothing whatever--or would I call it fasting if he ate just nuts and fruit now and then? Quite recently I was talking with a physician--a successful and well-known physician--who refused point-blank to believe that a human being could live for more than four or five days without any sort of nutriment. There was no use talking about it--it was a physiological impossibility; and even when I offered him the names and addresses of a hundred people who had done it, he went off unconvinced. And yet that same physician professes a religion which through nearly two thousand years has recommended "fasting and prayer" as the method of the soul's achievement; and he will go to church and listen reverently to accounts of a forty-day fast in the wilderness! And he lives in a country in which there are sanatoriums where hundreds of people are fasting all the time, and where twenty or thirty-day fasts occasion no more remark than a good golf-score at a summer hotel! If you have any doubt that such fasts are taken, you can very quickly convince yourself. Less than a year ago I saw a man completing a fifty-day fast; I talked with him day by day, and I knew absolutely that it was all in good faith. The symptoms of fasting are as distinct and unmistakable as are, for instance, those of smallpox; you could no more persuade an experienced person that you are fasting when you are not fasting, than you could persuade a bacteriologist that you had sleeping-sickness when you were merely lazy. When I was a very small boy, I recall that a Dr. Tanner took a forty-day fast in a museum in New York; and I recollect well the conversation in our family--how obvious it was that the thing must be a fake, and how foolish people were to be taken in by so absurd a fake. "He gets something to eat when nobody's looking," we would say. But then what about his weight? Here is a man, going along day by day, year in and year out, weighing in the neighborhood of a hundred and fifty pounds; and now, all of a sudden, he begins to lose a pound a day, as regularly as the sun rises. How does he do it? "Well," we would say, "he must work hard and get rid of it." But how can a man do that, when he had no longer enough muscular tissue left to support his weight? And when his pulse is only thirty-five beats to the minute? Then, says the reader, perhaps he goes to a Turkish bath, and sweats it off. But ask any jockey how he'd like to take a Turkish bath every day for fifty days! And how he would stand it when his arms and thighs were so reduced that you could meet your thumb and forefinger around them, and could plainly trace the bones and the blood vessels! And then again, there is the tongue. If you take a fast and really need the fast, you will find your tongue so coated that you can scrape it with a knife-blade. And if you break your fast, your tongue will clear in twenty-four hours; nothing in the world will coat it again but several days more of fasting. How would you propose to get around that difficulty? Such ideas have to do with fasting as seen by the outsider. I recollect reading a diverting account of the fasting cure, in which the victim was portrayed as haunted by the ghost of beefsteaks and turkeys. But the person who is taking the fast knows nothing of these troubles, nor would there be much profit in fasting if he did. The fast is not an ordeal, it is a rest; and I have known people to lose interest in food as completely as if they had never tasted any in their lives. I know one lady who, to the consternation of her friends and relatives, began a fast three days before Christmas and continued it until three days after New Year's; and on both the holidays she cooked a turkey and served it for her children. On another occasion, during a week's fast, she "put up" several gallons of preserves; the only inconvenience being that she had to call in a neighbor to taste them and see if they were done. I myself took a twelve-day fast while living alone with my little boy, and three times every day I went into the pantry and set out a meal for him. I was not troubled at all by the sight of the food. The longest fast of which I had heard when my article was written was seventy-eight days; but that record has since been broken, by a man named Richard Fausel. Mr. Fausel, who keeps a hotel somewhere in North Dakota, had presumably partaken too generously of the good cheer intended for his guests, for he found himself at the inconvenient weight of three hundred and eighty-five pounds. He went to a sanatorium in Battle Creek and there fasted for forty days (if my recollection serves me), and by dint of vigorous exercise meanwhile, he got rid of one hundred and thirty pounds. I think I never saw a funnier sight than Mr. Fausel at the conclusion of this fast, wearing the same pair of trousers that he had worn at the beginning of it. But the temptations of hotel-keeping are severe, and when he went back home, he found himself going up in weight again. This time he concluded to do the job thoroughly, and went to Macfadden's place in Chicago, and set out upon a fast of ninety days. That is a new record--though I sometimes wonder if it is quite fair to call it "fasting" when a man is simply living upon an internal larder of fat. It must be a curious experience to go for three months without tasting food. It is no wonder that the stomach and all the organs of assimilation forget how to do their work. The one danger in the fasting treatment is that when you break the fast, hunger is apt to come back with a rush, while, on the other hand, the stomach is weak, and the utmost caution is needed. If you yield to your cravings, you may fill your whole system with toxins, and undo all the good of the treatment; but if you go slowly, and restrict yourself to very small quantities of the most easily assimilated foods, then in an incredibly short time the body will have regained its strength. My experience has taught me that it is well not to be too proud at such a time, but to get some one to help you. And it ought to be some one who has fasted, for a person at the end of a fast is an agitating sight to his neighbors, and their one impulse is to get a "square meal" into him as quickly as possible. Quite recently there was one of my converts camping on my trail in New York City, and he called at the home of a relative of mine, an elderly lady, who does not take much stock in my eccentricities. I shall not soon forget her description of his appearance--"I thought he was going to die right there before my eyes!" she said. And no wonder, since the poor fellow had climbed four flights of stairs to the apartment. "I know you'll get into trouble," added my relative, "if you don't stop advising people to do such things!" I was interested enough in the question of fasting to spend some time at a sanatorium where they make a specialty of it. One can see a sicker looking collection of humans in such a place than anywhere else in the world, I fancy. In the first place, people do not take the fasting cure until they are looking desperate; and when they have got into the fast they look more desperate. At the later stages they sometimes take to wheelchairs; and at all times they move with deliberation, and their faces wear serious expressions. They gather in little groups and discuss their symptoms; there is nothing so interesting in the world when you are fasting as to talk symptoms with a lot of people who are doing the same thing. There are some who are several days ahead of you, and who make you ashamed of your doubts; and others who are behind you, and to whom you have to appear as an old campaigner. So you develop an _esprit de corps_, as it were--though that sounds as if I were trying to make a pun. All this may not seem very alluring; but it is far better than a life-time of illness, such as many of these people have known before. I never knew that there was such terrible suffering in the world until I heard some of their stories; they would indeed be depressing company, were it not for the fact that now they are getting well. The reader may answer sarcastically that they _think_ they are. But every Christian Scientist knows that this comes to the same thing; and I have talked with not less than a hundred people who have fasted for three days or more, and out of these there were but two or three who did not report themselves as greatly benefited. So I am accustomed to say that I would rather spend my time in a fasting sanatorium than in an ordinary "swell" hotel. The people in the former are making themselves well and know it; while the people in the latter are making themselves ill, and don't know it. A SYMPOSIUM ON FASTING Recently I published a request that those who had tried the fast as the result of my advocacy would write to advise me of the results. I stated that I desired to hear unfavorable results as well as favorable; that I wanted to get at the facts, and would tabulate the results exactly as they came. The questions asked were as follows: 1. How many times have you fasted? 2. How many days on each occasion? 3. From what complaints did you suffer? 4. Were these complaints ever diagnosed by regular physician? If so, give the names and addresses of these physicians. 5. Do you consider that you were definitely benefited by the fasts? If so, in what way? 6. For how long did the benefit continue? 7. Do you consider that you were completely cured? 8. Do you consider that you were definitely harmed? If so, in what way? 9. Have you ever been examined by any regular physician since the cure? If so, give name and address. 10. Are you willing that your name and address should be quoted for the benefit of others? The total number of fasts taken was 277, and the average number of days was 6. There were 90 of five days or over, 51 of ten days or over, and 6 of 30 days or over. Out of the 109 persons who wrote to me, 100 reported benefit, and 17 no benefit. Of these 17 about half give wrong breaking of the fast as the reason for the failure. In cases where the cure had not proved permanent, about half mentioned that the recurrence of the trouble was caused by wrong eating, and about half of the rest made this quite evident by what they said. Also it is to be noted that in the cases of the 17 who got no benefit, nearly all were fasts of only three or four days. Following is the complete list of diseases benefited--45 of the cases having been diagnosed by physicians: indigestion (usually associated with nervousness), 27; rheumatism, 5; colds, 8; tuberculosis, 4; constipation, 14; poor circulation, 3; headaches, 5; anæmia, 3; scrofula, 1; bronchial trouble, 5; syphilis, 1; liver trouble, 5; general debility, 5; chills and fever, 1; blood poisoning, 1; ulcerated leg, 1; neurasthenia, 6; locomotor ataxia, 1; sciatica, 1; asthma, 2; excess of uric acid, 1; epilepsy, 1; pleurisy, 1; impaction of bowels, 1; eczema, 2; catarrh, 6; appendicitis, 3; valvular disease of heart, 1; insomnia, 1; gas poisoning, 1; grippe, 1; cancer, 1. There follows a brief summary of some of the most interesting cases. A number of longer letters will be found in the Appendix. Mrs. Lulu Wallace Smith, 324 W. White Oak Ave., Monrovia, Cal. Age 28. Fasted 30 days for appendicitis and peritonitis, diagnosed by four physicians. "Yes, indeed, I have definitely been benefited by fasting. My stomach is not distressed after meals, I have regular evacuations of the intestines, which I had not had since I was seventeen. I feel perfectly healthy and look the same." William N----. Syphilis, with advanced ulcers in throat. Physicians declared the case hopeless. Complete disappearance of symptoms after four day's fast, but they gradually reappeared, and longer fast intended. Dora Jordan, Connersville, Md. Indigestion, extreme nervousness, neuralgia in its worst form. Fasted thirty days; did most of cooking for a family of five, was at no time tempted to eat. "I am no longer troubled with the old diseases, and weigh more than ever before. After my fast I felt as happy and care free as a little child." C. L. Clark, Greenville, Mich. Nervous, poor digestion. Fasted nine days. "I have been wonderfully benefited, and am a rabid convert. Alas, for the poor mortal who shows the faintest spark of interest in my fast--I hand him the whole works, lock, stock and barrel! I feel a new power and new incentive in life. Whenever I see a sick person, I feel like telling him that for all he knows to the contrary, good health has been and may be only eight or ten days away and waiting for years for him to claim it." T. S. Jacks, Muskegon, Mich. Twenty days, followed by shorter fasts, for stomach trouble, diagnosed by Dr. M---- as cancer. "He advised me to be operated on. Since my fast, three years ago, I have had no trouble with my stomach. I am entirely cured, and am enjoying fine health." Gordon G. Ives, 147 Forsythe Bldg., Fresno, Cal. "Have fasted a good many times since 1899, to cure catarrh of stomach, constipation, deafness of four months' standing, neuralgia, etc. Duration, from one to sixteen days. Never failed in accomplishing a cure. Benefit continued until I had over-eaten for a long time. Complaints were never diagnosed by regular physicians, as I got on to them in 1894. Use my name if it will help the truth." Mrs. Maria L. Scott, Boring, Ariz. Reports case of husband, who fasted seven days for constipation and deafness; had been obliged to take enema daily for several months. Complete cure. Mrs. A. Wears, De Funiak Springs, Fla. "Age forty-two, subject to severe colds and sore throat all my life, chronic catarrh of head and throat, in bed two winters with bronchitis and asthma. Did not take complete fast. My catarrh is much improved. I feel perfectly well and enjoy life so much more than I did before the fast." Mrs. Mae Bramble, Alba, Pa., R. F. D. 70. One fast of thirty days, another of three days; nervous prostration the first time, appendicitis the second time. "The first complaint was diagnosed, the second was not; as I am a professional nurse, I understood the symptoms myself." Complete and permanent cure. "I have never had a return of the nervous trouble, and am well of the other complaint. It is five years since the first fast." M. E. Beard, Corning, Cal. Fasted nine days for scrofula. Had been diagnosed. Complete cure, permanent since 1908. Age forty-seven. "Five years ago I broke down. Physicians never could tell me what ailed me. I kept busy during my fast physically and mentally; worked over the cook stove and outdoors. Felt no weakness." Joseph L. Lewis, Hatfield, Ark. Fasted three days, and then four days. "During the last ten days have felt better than at any time during the last seven years." Monroe Bornn, Port of Spain, Trinidad. Fasted seven days on three occasions, for liver trouble. "I had been treated by three physicians. I consider that I was completely cured. I have been examined by regular physicians since the cure." E. B. Bayne, White Plains, N. Y. Sends record of fasts taken by two people, Mr. and Mrs. A. Mr. A. fasted for rheumatism, which had caused kidney and bladder trouble of years' standing, and iritis; fasted five days and then four days and was completely cured. Mrs. A. Neuralgia and catarrhal deafness. Completely cured. "Finds that exposure to draughts has no effect upon her whatever, heretofore she would catch cold upon the least exposure." Mrs. Charles H. Vosseller, Newark, N. J. "I don't agree with you or Bernarr Macfadden in not recommending fasting for tuberculosis. My case was diagnosed by Dr. B. G----, New Brunswick, N. J. I fasted nineteen days and was completely cured; I received no harm, and have been examined since by a physician. I weigh 114 lbs. now and before my fast weighed 100 lbs. I never felt better in my life than I do at present. Do not know that I have a pair of lungs." In connection with the above tabulation of results, it should be specified that it does not include any of the cases quoted elsewhere in the book; it includes some of the letters given in the Appendix, but not all. Thus it will appear that there are many more than 277 cases of fasting recorded in this volume. The reason that I did not summarize in the tabulation all the letters I have received is, that I wished to give only those which were sent to me in answer to my definite series of questions, so that I might be sure of getting the unfavorable as well as the favorable reports. Recently a well-known physician who edits a magazine of health came out in vehement opposition to the fasting cure, maintaining that we hear only of the cases which are successful, and do not hear of the disastrous failures. In reply to this, I wrote to him suggesting that he publish my series of questions in his magazine, thus giving his readers an opportunity to make me acquainted with the unsuccessful cases. This, however, the physician declined to do. DEATH DURING THE FAST There was much newspaper discussion of my fasting papers--most of it being sarcastic. The most biting comment that I recall came from somewhere out West, and ran about as follows: "A Seattle man fasted forty days for stomach trouble. His stomach is troubling him no longer. He is dead." I set to work to find out about this case, and I give the facts on page 137. I also saw a report from the London _Daily Telegraph_ to the effect that a man had died in South Africa as a result of trying my "cure." How many thousands of people tried it and lived, I do not know; but horrified relatives and enterprising newspaper writers would see that the public was informed about any that died. As to the possibility or probability of death during a fast, I have one or two points to note: First, a good many sick people are dying all the time. It would be an argument for fasting if it saved any of them. It is no argument against fasting that it fails to save them all. No one would think of bringing it up against his surgeon or his family physician that he occasionally lost a patient. Second, people might die very frequently, without that being an argument against the cure. It might simply be a consequence of the desperately ill class of people who were trying it. A doctor who had a new method of healing, and was permitted to use it only upon those whom all other doctors had given up, would be considered successful if he effected even an occasional cure. I would wager that of the people who read my article and set out to fast, practically all had been suffering for many years, and had given the "regular" physicians unlimited opportunity to work on them. Third, it may be set down as absolutely certain that no one ever died of starvation while fasting. The essential feature of the fast is that after the first two or three days all hunger ceases; and that any one could die of lack of food without feeling a desire for food, is absurd upon the face of it. Nature simply does not work that way. It reminds me of a young lady who once told me that she would not go to sleep with a mouse in the room, because she imagined the mouse might nibble off her ear without waking her! As to the possibility that you might starve, during those first days while you _are_ hungry--the answer is simply that you _don't_. It is perfectly true that men have died of starvation in three or four days; but the starvation existed in their minds--it was fright that killed them. That they did not truly starve is proven by my letters from several hundreds of people who have fasted over that time, and who are alive to tell of it. There are conditions in the human body which lead to death inevitably; and some of these conditions are beyond the power of the fast to remedy. When a person so afflicted sets out to fast, and dies in spite of the fast, the papers of course declare that he died because of the fast. Dr. L. B. Hazzard of Seattle has published a very useful little book, "Fasting for the Cure of Disease," in which she tells of two cases of "death from fasting," where the autopsy revealed conditions with which the fast had no connection, and which made death certain. Chances of that sort one has to take in life. You may have a blood vessel in such a state that when you run after a street car the increased pressure will cause it to burst; but you do not on that account declare that no man ought to exert himself violently. As an example of the part that mental disturbances may play in the fast, I will cite the case of a woman friend who started out to fast for a complication of chronic ailments. She was rather stout, and did not mind it at all--was going cheerfully about her daily tasks; but her husband heard about it, and came home to tell her what a fool she was making of herself; and in a few hours she was in a state of complete collapse. No doubt if there had been a physician in the neighborhood, there would have been another tale of a "victim of a shallow and unscrupulous sensationalist." Fortunately, however, business called the husband away again, and the next day the woman was all right, and completed an eight-day fast with the best results. Bear this in mind, so that if you wake up some morning and find your temperature sub-normal and your pulse at forty, and your arms too weak to lift you, and if your friends get round you and tell you that you look like a mummy out of a sarcophagus of the seventeenth dynasty, and that I am a Socialist and an undesirable citizen--you may be able to smile at them good naturedly and tell them that you will never again eat until you are hungry. I have thought over the cases of failure of the fast, where I have been able to inquire into all the circumstances, and I think I can make the statement that I do not know a case which might not be attributed either to the influence of nervous excitement, or to unwise breaking of the fast. In the last batch of letters was one with a printed account of the disastrous results of a three weeks' fast taken by a woman. It is an example of about all the blunders that I can think of. She describes herself as occupying "a responsible office position," which taxed her strength to the utmost; and she tried to do this work all the time she was fasting. She would get up and go to work when she was "scarcely able to drag one foot after another." On about the nineteenth day her mother arrived, and then I quote: "She almost dropped at sight of me, for I had not given a hint as to my condition; but despite my protests, she sent for the doctor at once. My! Didn't he scold, and tell me what was what! Mother's heart was so torn with sorrow and pity that she hadn't the heart to reproach me for my three weeks' orgy of fasting. She thought I had paid dearly for my folly." I don't think it necessary to say anything more, except that I feel sorry for the victim, and that I am glad to know this happened two years ago, so that I am not to blame for the results. By way of contrast with this case I will quote the following letter, which will show the reader the kind of experience that makes fasting enthusiasts: "My wife and I have each nearly reached our seventy-second year. I was born a physical wreck. A dozen years ago we began taking short fasts, from three to eleven days' duration, for all our ills of the flesh. But each of us had chronic troubles of forty years' standing, which seemed growing no better. And finally, two years ago last July, my wife said she was going to take a 'conquest fast' if it killed her, for she was tired of living with her present ills. I thought it a good time to try a little conquest fasting on my own hook. I had no fear of the result. I knew that nature would tell me when I had fasted long enough. So we began an absolute fast from all food except distilled water and fresh air. We lived in fresh air night and day. We took copious enemas daily, and I took a cabinet sweat, followed by a cold plunge every other day. I knew that I must have many years of filth accumulation in my bowels. And the amount of putridity that came from my bowels the first twenty-five days of the fast was amazing. "After fasting twenty-eight days I began to be hungry, and broke my fast with a little grape juice, followed the next day with tomatoes, and later with vegetable soup. My wife began to be hungry after fasting thirty-one days, and broke her fast in a similar manner to myself. "It is now two years since we took the conquest fast, and my wife has no return of her former troubles. And I am enjoying all the mental and physical pleasures which come from clean bowels. We think we have learned how to live that we will never need another fast. Soon after the fast I was examined by Dr. S----, the leading surgeon of Los Angeles and Southern California, who pronounced me as being the most wonderful person he ever met regarding softness of arteries, and suppleness of body, for my age." FASTING AND THE MIND The reader will observe that I discuss this fasting question from a materialistic view-point. I am telling what it does to the body; but besides this, of course, fasting is a religious exercise. I heard the other day from a man who was taking a forty-day fast, as a means of increasing his "spiritual power." I am not saying that for you to smile at--he has excellent authority for the procedure. The point with me is that I find life so full of interest just now that I don't have much time to think about my "soul." I get so much pleasure out of a handful of raisins, or a cold bath, or a game of tennis, that I fear it is interfering with my spiritual development. I have, however, a very dear friend who goes in for the things of the soul, and she tells me that when you are fasting, the higher faculties are in a sensitive condition, and that you can do many interesting things with your subliminal self. For instance, she had always considered herself a glutton; and so, during an eight-day fast, just before going to sleep and just after awakening, she would lie in a sort of trance and impress upon her mind the idea of restraint in eating. The result, she declared, has been that she has never since then had an impulse to over-eat. There are many such curious things, about which you may read in the books of the yogis and the theosophists--who were fasting in previous incarnations when you and I were swinging about in the tree-tops by our tails. But I ought to report upon one fasting experiment which resulted disastrously for me. Earlier in this book I told how I had been able to write the greater part of a play while fasting. Shortly afterwards I plunged into the writing of a new novel, and as usual I got so much interested in it that I wasn't hungry. I said that I would fast, and save the eating time, and the digesting time as well. So I would sit and work for sixteen hours or more a day, sometimes for six hours at a stretch without moving. After two or three days of this I would be hungry, and would eat something; but being too much excited to digest it, I would say, "Hang eating, anyhow!"--and go on for another period of work. I kept that up for some six weeks, and I turned out an appalling lot of manuscript; but I found that I had taken off twenty-five pounds of flesh, and had got to such a point that I could not digest a little warm milk. I cite this in order that the reader may understand just why I take a gross and material view of fasting. My advice is to lie round in the sun and read story-books and take care of your body, and leave the soul-exercises and the nervous efforts until the fast is over. But all the same, I know that there will be great poetry written some day, when our poets have got on to the fasting trick--and when our poets care enough about their work to be willing to feed it with their own flesh. The great thing about the fast is that it sets you a new standard of health. You have been accustomed to worrying along somehow; but now you discover your own possibilities, and thereafter you are not content until you have found some way to keep that virginal state of stomach which one possesses for a month or two after a successful fast. It must mean, of course, many changes in your life, if you really wish to keep it. It means the giving up of tobacco and alcohol, and a too sedentary life, and steam-heated rooms; above all else, it means giving up self-indulgent eating. A couple of years ago my wife and myself made the acquaintance of a young lady patient in a sanatorium, who was in a much run-down condition, anæmic and nervous. We persuaded her to take a fast of five or six days, and afterwards take the milk diet, as the result of which she went back to her home in Virginia with what she described as "smiles and dimples and curves and bright eyes." She was so enthusiastic about the cure that she proceeded to apply it to all her family and her friends; and some time afterwards she wrote my wife a most diverting account of her adventures. After some persuasion I secured her permission to quote her letter, having duly omitted all the names. It makes clear the thorny path which the fasting enthusiast has to travel in this world. I will try in a very limited space of time to tell you what keeps me a slave here at home. I got Mr. X---- down from ---- to put papa and mamma on the fasting cure--papa had a bad case of grippe--mamma had indigestion. My oldest married brother is in dreadful health, and his wife and baby are not well. I wore myself nearly out trying to get them well, and at the same time trying to pick up some threads of long neglected social duties. People were beginning to call me "stuck-up" (horrid vulgar term), so unless I wanted to make enemies of the wives and daughters of papa's and brother's business friends, I had to go to a few parties and pay some long-neglected calls. I did it all, and then decided to have Mr. X---- come to help me. I got papa and mamma and M---- and _her baby_(!) on a fast--and then woe is me--I had to get them off again! They had various and alarming symptoms due to their ignorance of the methods, and the wild interest of the town medicine-men. The family doctor gave me a "straight talk" and asked me if I was going to try _to kill my father and mother_. Papa would not give up his cigarettes, and a "toddy" now and then. M----'s baby lost four pounds while his mother was fasting. All the doctors' wives came to call, and beset me with questions--and I had the d---- of a time. But I stood by my guns. When the overfed, self-indulgent family all got to vomiting at once, my hands were full, and I nearly had nervous prostration before I got order out of the bedlam I had stirred up. Well, they got over the fast and on to the milk. Then I had to tend to the milk myself or they refused to drink it. Finally mamma got to feeling so well that she sat up, and planned big course dinners and invited people to eat them. She began to order new clothes for the kids, new furnishings for the house, and started in to live her disorderly, ungodly "Southern hospitality" life all over again. Our senator died and mamma got into politics in the new election; and Cousin J---- got drunk, and I had to go with him to the Keeley Institute, etc., etc. Surely there is a heaven for saints like me. I did not fly the roost as I was tempted to do, but I answered midnight calls of the spoiled, nauseated ones, and fixed hot-water bags, quelled riots among the meat-eating servants and hungry children--and swore I'd win! I did. Well, I got things going in fine order at last, with papa cured of his grippe and an old case of kidney trouble. Mamma is now comfortably eating boiled ham and stuffed peppers, and fruit cake and cherry pie, and green olives and what not at the same meal. She is well, though. But of course she will get sick again. Papa, the only sane member of our family, is still holding on to the milk, taking four quarts of buttermilk a day, and he is flourishing, thank heaven! M---- is still bilious, having broken her fast with hard-boiled eggs and pork chops. And I am still living, in spite of having been to Keeley, and incidentally having danced all night (with a low-neck, short-sleeved gown on!) at the ---- Club ball, sat through several dinners and bridge parties into the "wee sma' hours," and had two men propose to me with the prelude, "You are the nicest, most refined, and most lovable girl in the world if you _are_ a crank." Wasn't that a nice beginning for a proposal of marriage? I accepted them both on condition that I be allowed to remain a crank. Well, the next chapter began with an old lover who had married another woman. He came to see me and said he had a tape-worm! Ye gods--such romance! His wife had stomach and intestinal trouble. I turned Mr. X---- over to them, and them over to Mr. X----. The lady got along, but the poor man with a wild beast inside him got so sick after an eight-day fast that he wanted to have me mobbed, sent for two trained nurses and four doctors--this is no exaggeration--the doctors looked at me, and looks were as plain as words--"You little devil! You did it for pure meanness." For three days my poor friend had the doctors giving him hypodermics, and he never stopped vomiting until we were all nearly dead. Then he quieted down, got well, ate a beef-steak with a few dozen oysters and mushrooms, and took me riding in his new automobile. The grim humor in the whole thing is that if I had not gotten my roses and dimples and curves and bright eyes back by fasting, this man would never have taken me riding in his new automobile. Take a tip from me--all the good nursing and friendly efforts in behalf of the health of my friends did not endear me to them one half as much as the plump, rosy smile I wore with my new silk gown. The first day our sick friend went out in his car--alas for the ways of human nature--masculine human nature, I mean--I told him so. And he agreed with me and ended by saying, "Darn an ugly woman--I'll forgive a pretty one _anything_." DIET AFTER THE FAST Many people write me, begging me to outline for them the ideal diet. I used to do that sort of thing, but I have stopped; having come to realize that we are still at the beginning of our diet-experiments. I have done a good deal of experimenting myself, and have made some interesting discoveries. I have lived for a week on fruit only, and again on wheat only; I have lived for three weeks on nothing but milk, and again on nothing but beef-steak. I have lived for a year on raw food, and for over three years I professed the religion of vegetarianism. For the last two months I have lived on beef-steak, shredded wheat, raisins and fresh fruit; but by the time this book appears I may be trying sour milk and dates--somebody told me about that the other day, and it sounds good to me. Some of my correspondents object to my willingness to try new diets; they write me that they find it bewildering, and think it indicative of an unstable mind. They do not realize that I am exacting in my demands--I want a diet which will permit me to overwork with impunity. I haven't found it yet, but I am on the way; and meantime I make my experiments with a light heart, for I always know that if anything goes wrong, I can take a fast and start afresh. The general rules are mostly of a negative sort. There are many kinds of foods, some of them most generally favored, of which one may say that they should never be used, and that those who use them can never be as well as they would be without them. Such foods are all that contain alcohol or vinegar; all that contain cane sugar; all that contain white flour in any one of its thousand alluring forms of bread, crackers, pie, cake, and puddings; and all foods that have been fried--by which I mean cooked with grease, whether that grease be lard, or butter, or eggs or milk. It is my conviction that one should bar these things at the outset, and admit of no exceptions. I do not mean to say that healthy men and women cannot eat such things and be well; but I say that they cannot be as well as they would be without them; and that every particle of such food they eat renders them more liable to all sorts of infection, and sows in their systems the seeds of the particular chronic disease that is to lay them low sooner or later. There are a number of other things, which I do not rate as quite so bad, but which we bar in our family--simply because they are not so good. For instance, I am inclined to regard beans as being too difficult of digestion and too liable to fermentation to be eaten by any one who can get anything better. And I personally do not eat peanuts, because I have found that I do not digest them; and I do not use milk (except in the exclusive milk diet), because it is constipating, and I have a tendency in that direction. Almost everyone will discover idiosyncrasies of that sort in his own system. One person cannot digest cheese, another cannot digest bananas, another cannot stand the taste of olive oil. You may read a glowing account of some diet system by which some other person has worked miracles, and you may try it, and persist in it for a long time, and finally come to realize that it was the worst diet you could possibly have been following. I have always counted orange juice as the ideal food with which to break a fast; yet a friend whom I was advising broke his fast with the juice of half an orange, and had a violent cramp. He had been so confiding in my greater knowledge that he had omitted to tell me that any sort of acid fruit had always made him ill. Such things as this are of course not natural; but a perfectly normal and well person is, under the artificial conditions of our bringing up, a very great rarity; and so we all have to regard ourselves as more or less diseased, and work towards the ideal of soundness. We must do this with intelligence--there is no short cut, no way to save one's self the trouble of thinking. I used to think there was. I would discover this or that wonderful new diet-wrinkle, and I would go round preaching it to all my friends, and making a general nuisance of myself. And some one would try it, and it would not work; and often, to my own humiliation, I would discover that it was not working in my own case half so well as I had thought it was. By way of setting an ideal, let me give you the example of a young lady who for six or seven months has been living in our home, and giving us a chance to observe her dietetic habits. This young lady three years ago was an anæmic school-teacher, threatened with consumption, and a victim of continual colds and headaches; miserable and beaten, with an exopthalmic goitre which was slowly choking her to death. She fasted eight days, and achieved a perfect cure. She is to-day bright, alert and athletic; and she lives on about twelve hundred calories of food a day--one half what I eat, and less than a third of the old-school dietetic standards. Occasionally she will eat nut butter, or sweet potato, or some whole wheat crackers with butter, or a dish of ice-cream; but at least ninety per cent of her food has consisted of fresh fruit. Meal after meal, day after day, I have seen her eat one or two bananas and two or three peaches, or say, a slice of watermelon or canteloupe; at some meals she will eat only the peaches, and then again she will eat nothing. A dollar a week would pay for all her food; and on this diet she laughs and talks, reads and thinks, walks and swims with my wife and myself--a kind of external dietetic conscience, which we would find it hard to get along without. And tell me, Dr. Woods Hutchinson, or other scoffer at the "food-faddists," don't you think that a case like this gives us some right to ask for patient investigation of our claims? Or will you stand by your pill boxes and your carving-knives and the rest of your paraphernalia, and compel us to cure all your patients in spite of you? THE USE OF MEAT I am asked many questions as to my attitude toward the question of meat-eating. I was brought up on a diet of meat, bread and butter, potatoes, and sweet things. Four years ago when I found myself desperately run down, suffering from nervousness, insomnia, and almost incessant headaches, I came upon various articles written by vegetarians, and I began to suspect that my trouble might be due to meat. I went away on a camping-trip for several weeks, taking no meat with me, and because I found that I was a great deal better, I believed that the meat had been responsible for my trouble. I then visited the Battle Creek Sanitarium, and became familiar with all their arguments against meat, and thereafter I did not use it for three years. I called myself a vegetarian; but at the same time I realized that I differed from most vegetarians in some important particulars. For instance, I had never taken any stock in the arguments for vegetarianism upon the moral side. It has always seemed to me that human beings have a right to eat meat, if meat is necessary for their best development, either physical or mental. I have never had any sympathy with that "humanitarianism" which tells us that it is our duty to regard pigs and chickens as our brothers. I was listening the other day to one of these enthusiasts, who had been reading aloud one of the "Uncle Remus" stories, and who went on in touching language to set forth the fact that his vegetable garden constituted one place where "Bre'r Rabbit" was free to wander at will and to help himself; and he described how happy it made him to see these gentle animals hopping about among his cabbages, having lost all their fear of him. That sort of thing will work very well so long as it is confined to one farm, and so long as there is a hunting season upon all the other farms in the locality; but let the humanitarians proceed to apply their regimen in a whole state, and they will soon have so many billions of rabbits hopping about among their cabbages that they will have to choose between shooting rabbits or having no cabbages. The reader, I presume, is familiar with calculations which show the rate at which rabbits multiply, how many tens and hundreds of millions would be produced by a single pair of rabbits in ten years. It should be quite obvious that the time would come when all human beings would be spending their energies in planting gardens to support rabbits; and that if ever they stopped planting gardens, there would be a famine for the rabbits, with infinitely more suffering than is involved in the present method of keeping them down. Also, even though the humanitarians might have their way with men, the hawks and the owls and the foxes would probably remain unregenerate. I remember, when I was a small boy, being sternly rebuked by an agitated maiden lady who discovered me throwing stones at a squirrel. Not so many days afterwards, however, the lady discovered the squirrel engaged in carrying off young birds from a nest outside her window, and she found her theories about "kindness to dumb animals" rudely disturbed. The same thing, it seems to me, is still more true of domestic animals. Domestic animals survive on earth solely because of the protection of man, and for the sake of the benefits they bring to him. If it is necessary to human health and well-being to slaughter a cow rather than to wait and let her die of old age and lingering disease, it seems to me that nothing but mawkish sentimentality would protest. It is pointed out to us what places of cruelty and filth our slaughter-houses are; the reader may believe that I learned something about this in my preparations for the writing of "The Jungle." But then this is not necessarily true about slaughter-houses--any more than it is necessarily true that railroads must kill and maim a couple of hundred thousand people in this country every year. In Europe they have municipal slaughter-houses which are constructed upon scientific lines, and in which no filth is permitted to accumulate; also they have devised means for the killing of animals which are painless. In the stockyards I have seen a man standing upon a gallery, leaning over and pounding at the head of a steer with a hammer, and making half a dozen blows before he succeeded in knocking down the terrified animal. In Europe, on the other hand, they fit over the head of the animal a leathern cap, which has in it a steel spike; a single tap upon the head of this spike is sufficient to drive it into the animal's brain, causing instant insensibility. And it must be borne in mind also that the sufferings of dumb animals are entirely different from our own. They do not suffer the pains of anticipation. A cow walks into a slaughter-house without fear, and stands still and permits a leathern cap to be fitted over its head without suspicion; and while it is placidly grazing in the field, it is untroubled by any consciousness of the fact that next week it will be hanging in a butcher's shop as beef. I recall in this connection an observation of that wise philosopher, Mr. Dooley, concerning the inhumanities of vegetarianism. He said that it had always seemed to him a very cruel thing "to cut off a young tomato in its prime, or to murder a whole cradle full of baby peas in the pod." These things will convince the devotee of the religion of vegetarianism that I am a lost soul, and always have been. Perhaps so. I try to guide my conduct by scientific knowledge; what I ask to know about the question of meat-eating is the actual facts of its effect upon the human organism--the amount of energy which it develops, the diseases which it causes, or, on the contrary, the immunity to disease which it claims to confer; also, of course, its cheapness and convenience as an article of diet. Some evidence of this sort we possess; but very little, it seems to me, in proportion to the importance of the subject. Professor Fisher has conducted some thorough experiments as to the influence of meat-eating upon endurance, which seem to develop the fact that vegetarians possess a far greater amount of endurance than meat-eaters. These experiments are what we want, but they seemed to me, when I read them, to be weak in one or two important particulars. They did not tell us what the vegetarians ate, nor what the meat-eaters ate. Those who are vegetarians at the present day are very apt to be people who have given some thought to the question of diet, and have attempted to adopt sounder ways of life; while, on the other hand, meat-eaters are generally people who have given no thought to the question of health at all--they are very apt to be smokers and drinkers as well as meat-eaters. Also it is to be pointed out that endurance is not the only factor of importance to our physical well-being. There have been numerous expositions of the greater liability of meat to contamination. Dr. Kellogg, for instance, has purchased specimens of meat in the butcher-shops, and has had them examined under the microscope, and has told us how many hundreds of millions of bacteria to the gram have been discovered. This argument has a tendency to appal one; I know it had great effect upon me for a long time, and I took elaborate pains to take into my system only those kinds of food which were sterilized, or practically so. This is the health regimen which is advocated by Professor Metchnikoff; one should eat only foods which have been thoroughly boiled and sterilized. I have come, in the course of time, to the conclusion that this way of living is suicidal, and that there is no way of destroying one's health more quickly. I think that the important question is, not how many bacteria there are in the food when you swallow it, but how many bacteria there come to be in food after it gets into your alimentary canal. The digestive juices are apparently able to take care of a very great number of germs; it is after the food has passed on down, and is lodged in the large intestine, that the real fermentation and putrefaction begin--and these count for more, in the question of health, than that which goes on in the butcher-shop or the refrigerator or the pantry. Do not misunderstand what I mean by this. I am not advocating that anyone should swallow the bacteria of deadly diseases, such as typhoid and cholera; I am not advocating that anyone should use food which is in a state of decomposition--on the contrary, I have ruled out of my dietary a number of foods in common use which depend for their production upon bacterial action; for instance, beer and wine, and all alcoholic drinks, all kinds of cheeses, sauerkraut, vinegar, etc. My point is simply that the ordinary healthy person has no reason for terrifying himself about the common aërobic bacteria--which swarm in the atmosphere, and are found by hundreds of millions in all raw food, and in cooked food which has not been kept with the elaborate precautions that a surgeon uses with his instruments and linen; also that the real problem is to take into the system those foods which can be readily digested and assimilated, and which afford the body all the elements that it needs to keep itself in the best condition for the inevitable, incessant warfare with the hostile organisms which surround it. So far as meat is concerned, of course no sensible person would use meat which showed the slightest trace of being spoiled, nor any meat which had been canned, or ground up and made into messes, such as sausage. If one uses reasonably fresh meat, the bacteria which may be on the outside of it will be killed by proper cooking. And so the question is, it seems to me, what does meat do after it gets into the stomach? And that is a matter for practical experiment, which very few people have made, so far as I have any information. Innumerable people are eating meat, of course; but they are eating it in combination with all other kinds of destructive foods, and they are eating it prepared in innumerable unwholesome ways. So far as I know, no scientist has ever taken a group of normal men and kept them for a certain period upon a rational vegetarian diet, and then put them for another period upon a diet containing broiled fresh meat, and made a thoroughly scientific study of their condition, as, for instance, Professor Chittenden did for his "low proteid" experiments. For about a year previous to reading about Dr. Salisbury's "meat diet," I had been following the raw-food regimen. I had gained wonderful results from this, and I had written a good deal about it; but I had got these results while leading an active life, and not doing hard brain-work. I found continually that when I settled down to a sedentary life, and to writing which involved a great nervous strain, I began to lose weight on raw food; and if I kept on with this regimen, I would begin to have headaches, and other signs of distress from what I was eating. As an illustration of what I mean, I might say that quite recently I plunged into a novel in which I was very much absorbed, and I lost twelve pounds in sixteen days; and this, it must be understood, without changing my diet in the slightest particular. I went on with the work for about six weeks, and by that time I had lost twenty pounds. In explaining this to myself, I was divided between uncertainty as to whether I was working too hard, or whether I was eating too much. Finally I took the precaution to weigh what I was eating, and to make quite certain that I was eating no more than I had been accustomed to eat during periods when I had remained at my normal weight. I then cut the quantity of my food in half, and found that I lost much less rapidly. This served to convince me that the trouble lay in the fact that I had not sufficient nervous energy left to assimilate the food that I was taking. And I have known others to have this same experience. Bernarr Macfadden, in particular, told me that he could not get along upon the nut and fruit diet while closely confined in his office, and that he found the solution of his problem in milk. Inasmuch as there is nothing that poisons me quite so quickly as milk, I had to look farther for my solution. As a matter of fact, I had been looking for this solution for more than ten years, though it is only quite recently that I had come to understand the problem clearly. It is a problem which every brain-worker faces; and I am sure, therefore, that there will be many who will find the report of my experiments and blunders to be of interest to them. I have tried, under these circumstances, all kinds of the more digestible foods--toast, rice, baked potatoes, baked apples, milk, poached eggs, and so on; always I have found that these foods digested perfectly, but they poisoned my system because of their constipating effect; and this was a dilemma which I was never able to get around. I now read Dr. Salisbury's book, "The Relation of Alimentation to Disease." Many of his experiments I found extremely interesting. Dr. Salisbury described the consequences of the ordinary starch and sugar diet as making a "yeast-pot" of one's intestinal tract. I found in my own case many of the symptoms which he described, and I determined to see what would be the effect of the meat diet in my case. I began the experiment with reluctance. I had lost all interest in the taste of meat, and I had a prejudice against it; I hated the smell of it, and I hated the feeling of it, and I was prepared for the direst consequences, according to the prophecies of my vegetarian friends. I should not have been at all surprised if I had been made very ill by my first meal. I was prepared to allow for that, supposing that after three years I had perhaps forgotten how to digest meat. To my surprise, however, I found no difficulty at all. I soon gave up preparing the meat according to the elaborate prescription of Dr. Salisbury, and contented myself simply with eating good lean beef-steak. I continued the experiment for two weeks, living upon meat exclusively. I found that all my symptoms of stomach trouble disappeared, and I had no headaches whatever. I got quite weak upon the exclusive diet, but this was according to Dr. Salisbury's statement; just as soon as I added a little shredded wheat biscuit and dried fruit to the menu this trouble disappeared, and I gained in weight with great rapidity, and was soon back where I had been before. I did not continue the diet, owing partly to distaste for it, and partly to the inconvenience of it. I had accustomed myself to the raw food way of living, and any one who knows what this means can understand my distaste for washing plates and scraping frying-pans, and going to the bother of getting fresh meat and keeping it and cooking it. Also, of course, there was the item of expense. Upon the raw-food diet I had been able to live for ten cents a day. I am never accustomed to spending more than thirty or forty cents a day, even when indulging in abundant fresh fruit. Perhaps I ought also to specify that a good deal of the success of the diet may have been owing to the hot-water regimen which is a part of it. An hour or two before every meal one is supposed to sip at least a pint of very hot water, which has the effect of cleansing out the stomach, and stimulates peristaltic action to a remarkable degree. I had been accustomed to drink hot water while fasting, but I had never taken it systematically, as I did at this time. It is a trick well worth knowing about. I ought also to mention the fact that I suggested to several others that they try this meat diet. One of them, a friend who had been eating raw food at my suggestion, with the very best results, began the experiment and continued for three days, and the results were most disappointing. This friend, a woman in middle years, became very ill, with all the symptoms of stomach trouble, diarrhoea, and general poisoning. She wrote me that she gave up the diet at the end of three days, because she saw no use in making herself desperately ill. She added: "I followed the regimen in every smallest detail, precisely according to Dr. Salisbury's direction. You know me, and you know that when I do a thing I do it thoroughly, so there is no need to say any more about that." Which only goes to show that, as the proverb has it, "One man's meat is another man's poison." Dr. Salisbury recommends the meat diet especially in cases of tuberculosis. He finds that the predisposing cause of this disease is "vegetable fermentation." He declares that the excessive starch and sugar diet leads to the production of yeast spores and other ferments in the intestinal tract, and that these are absorbed into the circulation and ultimately clog the small capillaries in the lungs. Dr. Salisbury's theory was set forth over thirty years ago, and that was before Koch had made his discovery of the tubercle bacillus. This discovery would seem to put Dr. Salisbury's theory out of court altogether; but as we physical culturists are inclined to suspect, there are causes of disease lying behind the attack of the specific bacillus. These causes are a depleted blood supply and a weakened system; and it seems to me, from what I have observed of consumptives and their diet, that Dr. Salisbury's theories fit in very well indeed with the Koch theory. I wrote recently to Professor Chittenden to ask him what, in his opinion, would be the effects of the meat diet upon tuberculosis. He replied that he knew no reason for believing that it would be of special benefit but that the whole subject of diet in tuberculosis seemed to him to be one concerning which there was urgent need of experiment and investigation. This is unquestionably the case. I know no two physicians who seem to agree in the diets they prescribe to consumptives, and I have never met two consumptives who followed the same regimen. The general idea seems to be to stuff as much food in your system as you possibly can, especially milk and raw eggs; and it seems to me quite certain that, whatever system may be correct, this system is incorrect. This much seems to me to be clear: tuberculosis is a disease brought about by under-nourishment. It is a disease to which the poor are especially liable; and while this is undoubtedly in part due to bad air, it is also due to bad feeding. And when ignorant people wish to live cheaply, the foods they eat are the sugar and starch foods. I remember in Thoreau's "Walden" he sets forth how he lived for many months upon five or six dollars' worth of food. He does not give the amount of the food by weight, so of course we cannot tell exactly; but he gives the prices he paid, and the leading articles in his diet were flour, rice, corn-meal, molasses, sugar and lard. One is, therefore, perfectly prepared to learn that Thoreau died of consumption. And the same thing, I believe, will happen to a good many enthusiastic vegetarians of my acquaintance. They have given up meat, and they have made up for it by increasing their consumption of bread and crackers, rice and potatoes, and prepared and predigested cereals, which they eat with cream and sugar. Even when they use high proteid food, it is in some form such as beans, which contain a great deal of starch, and in a form which is difficult of digestion. As a result of this, they are thin and anæmic looking--they do not seem to be able to put on flesh by means of intellectual fervor and an optimistic philosophy. The result of my meat-diet experiment has been to convince me yet more firmly that the cooked-vegetable diet is the worst diet in the world for myself. (I am content to phrase it that way, and leave it for others to find out about their own case.) There has been some agitation in vegetarian circles since the report has gone around that I have become a backslider, and have gone back to the flesh-pots. I state the facts here for what they may be worth to others. I shall never call myself a "vegetarian" again--though I shall be a vegetarian the greater part of the time. For it should be noted, of course, that the objections which I have brought against the cooked vegetarian diet do not apply at all to the raw-food diet, which is entirely a different matter. If one lives upon nuts, whole grains boiled or shredded, salad vegetables and fruits, he does not get an excess of either starch or sugar, but a perfectly balanced dietary, every article of which is rich in natural salts--in which the starchy foods, and especially the prepared cereals, are fatally deficient. Such a diet can be followed by any person in normal health, who is leading a physically active life. I have known a number of people, old and young, to start out upon this way of life without any preliminaries, and they have noted a great gain in health and efficiency, and have had no trouble of any sort. This diet is as cheap as the bean and white flour and rice diet of the ordinary "vegetarian," and it is, by all odds, the simplest and most convenient diet in the world. I have been accustomed all my life to think of meat as a very "heavy" article of food, an article of food suited for men doing hard physical labor; it is a curious fact that the view I am setting forth here is precisely the opposite. So long as I am doing hard physical labor, whether it is walking ten miles a day, or playing tennis, or building a house, I get along perfectly upon the raw food; but when I settle down for long periods of thinking and writing--often sitting for six hours without moving from one position--I find that I need something else, and nothing has answered that purpose quite so well as beef-steak. It appears to be, so far as I am concerned, the most easily digested and most easily assimilated of foods. And because the work that I am doing seems to me to be important, I am willing to make the sacrifice of money and time and trouble which it necessitates. My diet at such times will consist of beef or chicken, shredded wheat biscuit, and a little fruit. If any one is disposed to follow my example and make this experiment, I beg to call his attention especially to the fact that I name these three kinds of food, and none others; and that I mean these three kinds and none others. The main trouble with advising anybody to eat meat is that he proceeds to eat it in the everyday world, where it means not the eating of broiled lean beef, but also of bacon and eggs, and of bread and butter, and of potatoes with cream gravy, and of rice pudding and crackers and cheese and coffee. Please do not proceed to eat these things and then hold meat-eating responsible for the consequences. I do not for a moment wish to give the impression that I believe that meat-eating is necessary to a normally active person, or that humanity will always continue to eat meat. No invention of science can ever make meat as cheap a food as nuts and fruit, and nothing can ever make it as beautiful or attractive a food, nor as clean a food, nor as easily prepared a food. I believe that children can be brought up without knowing the taste of meat, and can be trained to lead normal and active lives from the very beginning, and can live on the raw-food diet and thrive. What I am discussing here are my own experiences, and I do not regard myself as a normal specimen of humanity, because I work a great deal harder than anybody has a right to work. I do that because there are so many idle and useless people in the world at present--and some have to make martyrs of themselves, until conditions of injustice and cruelty have been done away with. APPENDIX SOME LETTERS FROM FASTERS LONDON, ONTARIO, May 2, 1910. DEAR SIR,--Your article in a recent magazine very greatly interested me. My sister, on her way home from a five-and-a-half-weeks' visit in Boston and New York, where she had been endeavoring to discover the causes of her frightful headaches, bought that number of the magazine and read your experience, with, as you can well imagine, a deep interest. In Boston she had consulted one of the two physicians supposed to head the profession (as consultants) in that city. This man told her she had Bright's disease and leakage of the heart, and he gave her ten years to live--if she was very careful. As she has five children under twelve years of age, this was a sad outlook. She weighed 122 pounds when she left--and this was the lowest weight since early girlhood--but on her return, weighed on the same scales in the same clothing, she was only 108 pounds. She looked _very_ bad, and her spirits were at zero. Your article appealed to her, and she would have unhesitatingly tried your remedy, but that she was pregnant, and thought it would probably mean the child's death. The Boston obstetrician, who was consulted, said, if the other doctor's diagnosis was correct, the child would have to be taken at eight months. After reading your experience, I said to my sister: "You cannot perhaps follow Mr. Sinclair's example, but you can approximate to it. If you go to your own doctor he will undoubtedly send you to some sanatorium where the patients are fairly stuffed. Suppose you come over to my place each noon and take dinner, having eaten only _a very light breakfast_; then rest from two to five, take a long bath when you rise, go for a walk from six to six-thirty, and then to your own home for tea, taking only a shredded wheat biscuit for that meal." My sister consented, and on Saturday was weighed. On that light diet, and in twelve days, she had gained fourteen pounds. Her color is returning, she does not tire as she did, and we are full of hope that she may recover. My object in writing was to thank you for your frank recital of ills and aches and their cure, and to get from you the names of the books to which you referred. Several of my friends have read your articles on my recommendation, and one at least is seriously considering a lengthened fast. Reading the article took me back to the "no-breakfast régime," which I followed for five years, and then, for no especial reason, abandoned. Already I feel much better. Sincerely and gratefully, M. R. T. SKOWHEGAN, MAINE, May 30, 1910. DEAR SIR,--I read your article in the _Cosmopolitan_ with deep interest, and am to-day on my seventh day's fast. My sensations thus far are exactly like yours. I shall fast until hunger returns, if it take a month. My age is forty-eight, and I have enjoyed the best of health nearly all my life. Even now my digestion is all right, but for five years or so I have been troubled with rheumatism, not the painful, swelling sort, but lame joints. I tried "Fletcherism," and for the last nine months have done my best to live up to his suggestions, but fell down, exactly as in your own case. I can't tell what to eat, or when I have eaten enough. Whether this fast of yours does me any permanent good or not, my joints certainly move better to-day than for six months, and I have every confidence in the theory. The physicians here to a man all laugh at me, likewise my friends. I had lost ten pounds in weight at the end of the sixth day; I lost three the first, two each for the next two days, and a pound a day for the next three days. You speak of an unmistakable appetite. I could eat, of course, now, though I have no appetite, and I am wondering how I shall know when a real appetite returns. Mrs. W. is as keen to try the fasting cure as I, and her condition is very like Mrs. Sinclair's, but I thought one member of the family was enough for the first try-out. Please pardon a total stranger for encroaching upon the time of a busy man, but in the hunt for health, without which life is not worth living, one will do things he would not otherwise think of. For your information I will say that I have attended to my office and business every day since my fast began, walking to my home and back at least three times daily, for the exercise; driving a touring-car nights and Sunday, for pleasure, exactly as though there had been no change in my habits. The strangest part of the experience is that I feel so well, and except for a slight faintness, feel perfectly well to-day. Say--but I was hungry for the first two days! Yours truly, HERBERT WENTWORTH. CLYDE PARK, MONT., May 17, 1910. DEAR SIR,--I was much interested in your article in the _Cosmopolitan_ on "Starving for Health's Sake." For some time before I read it I had been troubled with a coated tongue and a nasty, bitter taste in my mouth. When I read the article my complaint was probably at its worst. I consulted a doctor, who gave me some capsules to clean out my intestinal canal, so he said. I asked him what I could eat and he said, "The less you eat the better." So I ate nothing for a week. Everything connected with my fast for that week was just as you described it--a ravenous hunger on the second day and after that no hunger at all. However, the coated tongue was still there, and when I next saw the doctor I mentioned your article and said you recommended rectal injections. He said he read your article and approved of it, and said after a thorough examination that I had an impaction of the colon. He said he would give me something to work on my colon and also added that if I fasted long enough the impaction would move out of itself. He also recommended injections. On the 25th day, although the coated tongue and nasty taste were still with me, I commenced eating again, as there was so much work to do on the ranch, and I had to do it, as hired help was scarce. I drank nothing but tepid water and very thin lemonade, slightly sweetened, during my fast of twenty-four days. I dropped from 175 pounds to 143 pounds. It is a week now since I broke my fast and I am rapidly gaining weight. Yesterday I weighed 152 pounds. However, as I said, I still have the coated tongue, although not so bad as formerly, and when I regain more weight, I'm going to begin another fast. I am fifty-three years of age, and have never used tea, coffee, whisky, or tobacco. I want to read up on the subject, so that when I begin again I'll know what to do. Your article was all the literature I had on the subject, and it may have been incomplete in a great many important particulars. Respectfully yours, ROBERT AITKIN. CHICAGO, ILL., May 22, 1910. DEAR SIR,--I think you will be interested to learn the experience of my wife, who tried your fast, with the same results as your wife, over which we are very much delighted. Allow me to say that it was all done on the quiet, and no one knew of it until it was all over. And then, of course, every one thought she was raving crazy, but she has since shown her friends that it was just the thing to do. In the first place it appealed to her, and she went into it with _faith_. She fasted for eleven days, after the second day was never hungry at all, and really began to take nourishment before she was hungry. The whole thing came out exactly as in your cases and was most interesting. She had temperature the first two days and ate crushed ice. After that, hot or cold water as desired. The tongue was coated very badly and her breath very bad. The tongue cleared very slowly and was quite discouraging, but after a few days was clear again. She lost over ten pounds, all of which has been regained and more, too, and she is gaining all the time. Complexion very clear, and the picture of health. Appetite great, eats everything, no aches or pains of any kind, and, best of all, no constipation, which was what she tried the fast for. She lost no strength to speak of and didn't have to take to bed at all; in fact, did everything about the house as usual. Everything has been fine now for three weeks, and if the troubles return, she is to fast again and do it right, and will take no nourishment until the tongue clears. She took internal baths nearly every day, and was astonished at the results when nothing but water was being taken. While we don't recommend it for every one, it certainly has been a godsend in this case, and I believe because it was done right and with faith that it was just the thing for her. You certainly have one convert, and if this interests you, shall be pleased to know it. Yours very sincerely, C. D. F. KNOXVILLE, TENN., June 5, 1910. DEAR SIR,--I wish to acknowledge my indebtedness to you for a restoration to such health of body and clarity of mind as I have not known since my sixteenth year, when first I entered the high school. That was twenty years ago. I read your article, "Starving for Health's Sake," in the _Cosmopolitan_, and, as you may recollect, asked you for information as to certain books treating of the fast as a cure for disease. Instead of answering me fully, you referred my case to the Bernarr Macfadden Institution in Chicago, for which I thank you, but I did not go there because I had neither time nor money for that purpose. Through a local book-dealer I ordered a copy of "Fasting, Hydrotherapy and Exercise," but after two weeks of waiting it failed to arrive, so with your _Cosmopolitan_ article as my only guide and sum total of knowledge as to the fast, I quit eating on May 13 and did not take anything except water until the morning of May 26. Even then I was not hungry, but as I did not care to remain away from work any longer I broke the fast on the morning of the 26th. I lost thirteen pounds in weight, but was never too weak not to move around. I worked in the office for seven days, and the balance of the time remained at home, basking in the sunshine and reading constantly. My health and appetite are in such perfect condition I can eat anything without fear of ulterior consequences. As a result of the fast, I have sloughed off all my impedimenta of disease. Constipation of ten years' standing is gone as if by magic. Piles and resulting pruritis of eight years' tearing torture are nightmares of the past. Bronchitis and eczema of scalp have vanished. Asthma, due to nervous sympathy with the pneumogastric nerve, is no more. Catarrhal deafness, sore throat, intestinal catarrh, and a general neurasthenic condition have left me. Work was never so pleasant. I cannot get enough of physical exercise, it seems; my muscles seem to grow stronger as the exercise proceeds, and my weight is going upward about a pound daily. I am now three pounds heavier than I was before my fast began. Life was never so beautiful, hope and joy never so green, the future for me and humanity's great movement toward a better day and higher good of existence never seemed so reasonable and possible of every realization as now, in the full possession of physical health and mental strength which have come back to me. Heretofore my work has been wrought out in pain. I am through with drugs. I graduated from allopathy long ago, then took up homeopathy and have now discarded it. I have spent over $500 in the last ten years trying to get well on medicines. These professional quacks bled me for a living and knew not how to cure me. Your article was written in the spirit of wishing to help suffering man. It cost me only thirty cents to use your method, viz.: six feet of rubber tubing to make a siphon to take two enemas daily. For that thirty cents I obtained relief a million-fold more beneficial than from $500 worth of medicine. Nay more, from your fasting idea I got rid of $500 worth of poisoning during ten years of medical superstition. Sincerely yours, H. E. HOOVER. NORTHWEST SOCIETY ARCHAEOLOGICAL INSTITUTE OF AMERICA WASHINGTON UNIVERSITY, SEATTLE, WASH. Nov. 5, 1910. EDITOR _Cosmopolitan_ MAGAZINE. Am enclosing clipping which shows that prominent men up here in the great Northwest are not afraid to try out certain methods of fighting disease merely because they are thought to be "new" or "faddy" (tho' in truth the fast cure is as old as the Old Testament). The value of Professor Colvin's fast experience seems to be that he has given to the world the best method of breaking the fast and getting on to a solid-food diet. Upton Sinclair said the breaking of the fast is the most important part of it, and would be the most dangerous were it not for the great natural food, milk, which tides you over. But he fails to remember there are thousands with whom milk does not agree, sick or well. Shortly after interview noted in enclosed clipping from Seattle _Times_, Professor Colvin attempted to begin to break the fast with orange juices and utterly failed. He then tried milk and was made so sick that he had to fast for three more days to get into a condition to break the fast. He then started in with a very light veal broth (not soup, nor tea). He soon got so he could take a cup of it every hour and a half. To get on to solid food he tried a few crackers with the broth, but found too much soda in the crackers and abandoned their use. Finally he hit upon the very thing that fitted the condition of his body, dry whole-wheat bread toasted. This toasted whole-wheat bread he had his cook crush with a rolling pin into a powder and each day mixed more of it with the cup of broth. After this he filled the cup three-fourths full of this toast powder and only poured in as much broth as the dust would absorb, making a solid gruel, which was very appetizing and nourishing (so much so that the professor continues to use it for breakfast food though his fast is closed). Now to this gruel he added mashed baked potato from time to time (more each time) until he virtually supplanted the toast dust. From this he went to baked apple, thence to raw eggs, thence to macaroni, thence to pigeon squab, and thence to solid earth. It seems to me that his discovery of the broth-toast-gruel method is a great discovery. Especially so for those who live in the cities and cannot be sure as to the absolute purity of their milk. Even when the milk diet can be used it does not afford a solution for getting off of a liquid diet on to a solid food basis. In your July number appears a letter from Mr. Buel of New York in which he says that it would be almost criminal to permit any one advanced in years to enter upon the dangerous folly of the "fast cure." I am enclosing you a clipping from the _Oregonian_, telling of the fasting experiences of Professor Colvin's friend, Rev. J. E. Fitch. Rev. Fitch is 81 years of age and a year ago took it into his head to out-fast Moses. Holy Writ says that Moses fasted 40 days, and to prove to his congregation that one did not have to be superstitious to believe some of these Old Testament tales, Rev. J. E. Fitch, at the age of 80, fasted fifty days; and instead of losing flesh towards the last part of his fast actually gained in weight. He is as vigorous to-day as he was at 21. Your Mr. Buel spoke of fasters as cranks and faddists and intimated that your solid citizen would not thus be led astray. Professor Colvin is not a crank but one of our best citizens, being well known both in this country and Europe, and spoken of as the probable president of the Pan-American University to be located in Porto Rico. Very respectfully, THOS. F. MURPHY. 210 Merriman Ave., ASHEVILLE, N. C., 9/11/10. MR. UPTON SINCLAIR, ARDEN, DEL. DEAR SIR,--After fasting for ten days I went off for ten days. Then on for seventeen days, during which time I got rid of a long list of troubles, except a cough, for which I underwent examination by a specialist. I found I had tuberculosis. The entire upper right lobe of my lung and about half of the left upper lung being affected. Now I am up here making a very rapid recovery. I consider that the fasts I took were the best things that could have happened for me, since they eliminated a bunch of troubles that are nearly always present with tuberculosis, such as indigestion, sore throat, rheumatism, etc. All of these left me, and I never felt better in my life than since fasting. I do not believe that such a rapid recovery as I am making could be possible had I not fasted. Fasting did not cure the tuberculosis, but it gave me an excellent stomach, with which to fight it, and tuberculosis will always give way to a good stomach. I did not know I had tuberculosis when I started fasting, but I now know, since learning more about the disease, that I had the trouble in an active state more than nine months before I fasted. My cough got very tame during the fast and very nearly disappeared, but returned as I increased the amount of food I took after breaking the fast, but at no time did it get as bad as it was previous to the fast. I weighed 172 lbs. in May, when I began my fasting and dropped to 148 lbs., and now weigh 180 lbs. and never felt better in my life. Have but a slight spot of the tuberculosis affection left in my right lung. While I would not recommend others affected with tuberculosis to fast, I would ask that if you have any letters from consumptives who have fasted I would appreciate a copy. ROLAND A. WILSON. NEW ZEALAND, Sept. 10, 1910. DEAR MR. SINCLAIR,--Your article "The Truth about Fasting" in August _Physical Culture_ to hand this week has much interested me. The questions you ask at end of article will, I hope, receive many replies, and give much information regarding the fasting cure. I, personally, can supply a considerable amount of just such information as you require, but the fact that I am a druggist in business precludes the giving of such for publication until drugs and I part company. Let me explain. A little under four years ago I came upon a copy of _Physical Culture_. It interested me and I followed up the reading by subscribing, and obtaining various books--Dewey's, Hazzard's, Carrington's, Desmond's, Eales', Bell's and others. I became quite convinced that about 99 per cent of usual medical treatment was wrong, and, in fact, actually detrimental, and often death-dealing to those who were in search of health. More and more I felt that I was doing a big injustice to those who applied to me for help, and an accessory in bad practice by the dispensing of physician's prescriptions. Yet I know that, like myself, the great bulk of the doctors and chemists were acting innocently and even conscientiously when recommending drugs and practicing the accepted drug and surgical treatments. The belief that drugs cure disease is so deeply rooted in the average human mind, and the teachings in medical and druggists' colleges so universal, and even thorough, that doctors and druggists can hardly be blamed for holding to their mother-loves. However, I had an open mind, and a desire to hand out a square deal, and decided to make a practical test of the new teachings that had come my way. I started by carefully selecting my patients--those who I believed had a fair amount of intelligence, and whose ailments had supplied them with a fairly long course of pain, worry and expense. Being a druggist in business, it would have been a very foolish thing for me to have wholly condemned drugs. And that is one reason why I selected chronics for a start--I was able to use the argument that as drugs had had a long and faithful trial, and had proven valueless in curing, a fast of nine or ten days would be, at least, worth a trial. My first case was a lady about thirty-five years of age. Complaint, badly swollen, highly inflamed and ulcerated leg, extending from two inches below knee to one inch above ankle, and more than half way around. She proved a good patient. The leg had been bad with more or less severity for fourteen years, and had been treated by several doctors, druggists, and others. She started on an immediate fast. Within twenty-four hours after fast commenced, the inflammation decreased; by the end of the fourth day it had entirely subsided, and by the end of the eighth day not a vestige of the trouble remained. This fast took place over two years ago--she has held reasonably well to the simple foods I advised, and so far there has been no return of the ailment. Her general health has very considerably improved. Since then I have treated, perhaps, fifty cases by fasting, and many others by simple dieting. Many complete cures have been effected that ordinary medical methods had entirely failed to benefit. My list comprises many ailments, ranging from one to forty-five years in evidence, while the patients themselves have ranged in age from one year to eighty-five years. X. ---- HASTINGS, MICH., Sept. 11, 1910. EDITOR, THE _Cosmopolitan_. Every reader of your magazine owes you a vote of thanks for the Upton Sinclair article on fasting. Mr. Sinclair said, "There are three dangers attending the fast." In my case there were four--the danger of being sent to the Insane Asylum. All my neighbors and relations had the utmost contempt for what they termed "my craziness." But notwithstanding all this, I fasted fourteen days, and stomach trouble, heart trouble, kidney trouble, chronic catarrh, and rheumatism, which for years had made life a burden, are no more. I do not have to tell my friends, at this date, that it was a success, they know it. My family physician has since said that it was probably the best thing I ever did in my life. I consider myself greatly indebted to you for furnishing me so efficient a remedy, free of cost. Gratefully yours, MRS. E. L. RAYMOND. UPTON SINCLAIR. DEAR SIR,--Yes, you may use my name in connection with my experience. As I did not take a complete fast the first time, I began again Sept. 4th, and fasted thirteen days, when natural hunger returned. Had none of the unpleasant experiences of the first fast. Was able to be on my feet and work more than at any time in years. Chronic rheumatism had caused sinewy swelling of my knee joints, that in turn had caused numbness of the feet and lower limbs, making it impossible for me to be on my feet. What I have suffered with them from jar of people walking across the room, or brushing against them, cannot be told. The first fast removed all the pain and soreness. The last fast has brought them down to normal or nearly so. I am confident that I shall soon be able to walk any reasonable distance. You are certainly entitled to a place among the public benefactors of the age for giving to the people the knowledge you had gained by the fast. Gratefully yours, MRS. E. L. RAYMOND. 20 Bowdoin St., BOSTON, MASS. Aug. 1, 1910. DEAR SIR,--I have just read with much interest your article in _Physical Culture_ and am minded to send you a brief account of my experience, which has been in some respects more full than your own. In speaking thus, I refer to the fact that my fasts, though not of so long duration as many reported, were complete in this: that my blood and tissue had cleaned up, my mouth was sweet, tongue moist, and there were plenty of the digestive fluids and a call for good plain wholesome food, which was slowly eaten and perfectly digested, and my appetite was perfectly satisfied with a very moderate amount. I suffered severely from indigestion and rheumatism, and made up my mind to try the effect of complete abstinence from food till I was better. I was familiar with the writings of Dr. Dewey and was well convinced that he was correct in his views. I was in my office the morning of Jan. 1st, and the bookkeeper remarked as to how ill I looked. Seven days after that (the first seven days of my fast) I was in again, and he spoke of my greatly improved appearance, said I looked very much better. He did not know nor did I tell him the reason for the improvement. On the 12th day--the first after I had broken the fast--he said I looked much better, which was also true, but when I gave him an explanation of the reason, he would not believe in it at all. In none of the four fasts which I have taken have I set any time limit or taken it as a stunt at all, but only have been guided by conditions as they developed. In no instance have I failed, and in no case was food a temptation to me until natural hunger returned. It seems to me an error to attempt to gauge the length of the fast. We ought to be governed by nature's direction. A "wise dog" knows when he needs to fast, and fasts till he wants food. It seems to me when we get to that point of wisdom, to know as much as the dog, we will know enough to go by intelligent needs instead of the clock. My experience is not in accord with the view expressed in your article as regards weakness of stomach and lack of peristalsis after fasting. It is my experience that after a complete fast any plain food desired can be taken without harm. I do not favor imprudence, of course, but I do not think that there is any good reason for being compelled to take fluid foods unless one desires to. My longest fast was nineteen days. C. D. NORRIS. 39 Rue Singer, PARIS, FRANCE. DEAR SIR,--I read your article in the May _Cosmopolitan_ and was very much impressed with the ideas you advocated. I had for twenty years been troubled with constipation, which caused colds and grippe, besides making me very sluggish. Being a singer and teacher, these things were great handicaps on my work, so after reading your article I decided to try it. I was in Paris studying singing with Oscar Seagle and Jean de Reszke, and of course I needed to be at my very best all the time, but I wasn't. I couldn't keep from taking cold, which always knocked me out of a week or two of work. So when my teachers went away for their vacation, I decided to start the fast, and on July 31 I did so. Being a coffee "toper," it made it very hard for me to give up my breakfast cup of strong black coffee, but I did it and the first three or four days I nearly lost my mind. Never experienced anything in my life that required so much will power. However, I stuck to it, but I was very hungry and had a splitting headache for four days, after which it got a little better. Then about the fifth day, as my hunger began to leave me, I began to break out as if I had measles--this kept up for five or six days. To add to that, my mouth and throat became inflamed and very sore, and that didn't cure up until about the twelfth day of the fast. I was exceedingly miserable all these days, but I realized how much I needed something of the kind to get the terrible poison out of my system, so I just held on and drank much water, and walked in the sunshine all I could. My tongue had a thick coat on it and I had a terrible bilious taste in my mouth for twelve days. I believed it would take about twenty days to fix me up just right, so I was going ahead when I suddenly decided to make a hurried business trip back to Texas; so on the fourteenth day I sailed from Cherbourg without having broken my fast. I carried a dozen oranges on board with me to make sure. When I began to breathe the salt air I got hungry, so on the fifteenth day I began to eat oranges and kept it up for a day and a half and then tried to get some milk, but could get none that was good, and most of what I got was of the condensed variety. I did the best I could for four days, when my system rebelled and became clogged up and I took another cold as usual. So I decided not to eat another mouthful on that ship, and I kept the fast up until I got to Ft. Worth. Then I went at the matter according to your instructions, and the results were perfect. I took up oranges for two days, then went on the milk diet for two days, then began on the boiled wheat. The results have been highly satisfactory. Going from a cold climate like Paris into a veritable inferno like Texas in summer made it very hard on me, but the wheat diet did everything for me and gave me unusual strength and vigor even in that hot climate where vigor doesn't abound much in hot weather. All my troubles seemed to disappear. I had not sung a tone since I began the first fast in Paris, so I began to practice again, and I never realized such a change in anything. Everything went so easy and all my friends said that they never saw such improvement in a human voice. I have never even desired to taste coffee. I am living on wheat, nuts, all kinds of fruit and vegetables, and the result is everything you said it would be. I have completed my business in Texas and will start back to Paris to-day. I am preparing myself for the journey this time. I have a large "thermos" bottle which I have filled with wheat and will carry plenty of fruit and nuts. I thank you very much for your information along the line of health. You have been a great blessing to me, and I am sure you have been also to thousands of others. ANDREW HEMPHILL. OMAHA, NEB. DEAR MR. SINCLAIR,--I was so fascinated with the story of your fast that I immediately made the experiment for myself, abstaining entirely from food of any kind for five days. I had no particular ailment which seemed to need the fast cure, but felt impelled to do a little investigating on my own account. I kept a diary in which I recorded each day's experience, including loss in weight, effect of cold bath, amount of exercise taken, etc. Without going into details, I can simply say I was astonished by the results. While in one respect my experience differed from yours, in that the desire for food did not entirely cease at any time, I was surprised to find how easily it could be controlled after the first day. Since the fast I have kept on drinking large quantities of pure water--resulting in a gain in weight of twelve pounds, increased digestive powers and a wonderfully improved appetite. I am frank to say I was never so pleased with, nor so greatly benefited by anything ever previously extracted from a magazine article. R. E. WHEELER. 750 PENOBSCOT B'LD'G, DETROIT, Oct. 19, 1910. DEAR MR. SINCLAIR,--Complying with your suggestion, will hurriedly and briefly group my experiences through a fast which I took largely because of your persuasive article on that subject. I absorbed the information you gave as well as I could, and having been a great sufferer for over twenty years with stomach and bowel troubles, began a fast which I continued for nearly eleven days, adhering scrupulously to the program outlined by you, in so far as I could practically do so, except I took only one bath (tepid) daily before retiring and omitted the enemas after the fifth day. Am fifty-seven years of age, powerfully built and athletic in habit and practice. Normal weight around two hundred pounds, height six feet one and one-half inches. Various causes reduced my weight some four years ago to about one hundred and eighty-five pounds, and almost constant non-assimilation of foods prevented my regaining normal weight. Weight an hour previous to my last lunch prior to the fast, one hundred and eighty-six pounds; lost fourteen pounds during the fast, eight of which fell off me the first three days. My indigestion had for years been accompanied by distressing, persistent constipation. This did not yield until the afternoon of fourth day of fast, when my entire intestinal functions seemed to become normal, and although I had taken no food, solid or liquid, no fruit juices, coffee, tea or milk, absolutely nothing in fast except Detroit River water, hot or cold, as fancy suggested, after the fourth day the bowels inclined to movement at least twice during each twenty-four hours. Lost strength gradually throughout fast, but looked after essentials in my office from six down to three hours the last day. I had no pronounced desire for food from first to last. Tongue remained heavily furred throughout the fast, breath offensive, even to myself. I sat at table at breakfast and evening meals, serving same, but using only a cup or two of hot water as my portion. Voice lost resonancy and timbre, and I finally felt so enervated that I broke the fast--juice of an orange first evening, and of five oranges the second day; of six oranges the third day, during which I also sipped a quart of rich milk, hot. Fourth day ate six oranges, two quarts milk, slice of old bread and about three-fourths pound juicy steak, after which I soon began to eat more than the usual quantity of wholesome food. For over four months had no indigestion, bowels regular and normal. I am hoping to see my way clear to fast again soon, for am needing a brace physically.... I owe you grateful thanks for inciting me to undertake the remedy. With best wishes for your continued success, usefulness and happiness. Sincerely, M. E. HALL. In my discussion of the question of what to eat, I have referred to the meat diet, and also to the raw-food diet. By way of throwing further light upon the problem, I reprint here two letters, one by a follower of Dr. Salisbury, and the other by a man whom I was instrumental in starting upon raw food. The latter article is reprinted from _Physical Culture_, by courtesy of Mr. Bernarr Macfadden. The reader may find it difficult to understand how two people can have had such apparently contradictory experiences. I myself, however, have no doubt of the literal truth of their statements, for I know dozens of people who are thriving upon each of these diets. It is to me only a further proof of the fact that our knowledge of this subject is as yet in its infancy, and that all one can do is to experiment, and find out what system best agrees with his own organism. 504 West Second St., LOS ANGELES, CAL., July 28, 1910. DEAR SIR,--As you say in the August _Physical Culture_ that you would like to hear the experiences of fasters, I will tell you of mine. In 1889-1890 I was very sick with catarrh of the stomach and bowels, which developed into consumption of the bowels accompanied by inflammatory rheumatism. On May 1st, 1890, I went to the office of Dr. James H. Salisbury and treated with him for one year. During the first nine months I ate nothing but Salisbury steaks, beginning with one ounce per meal and increasing gradually as I could assimilate it to one pound per meal, and drank a pint of hot water an hour and a half before meals and at bedtime. Salisbury steak, as you probably know, is beef pulp,--round steak with all fat and fibres removed. I dropped weight rapidly, going from 140 pounds to 90 pounds as this loss was diseased flesh. I then gained as rapidly on beef alone and this was good hard flesh. During the next three months he allowed me a slice of toasted bread at two meals daily in addition to the meat. For the past twenty years I have eaten meat three times a day with other foods, consequently have not needed a physician in that time. I have foolish spells occasionally and indulge in fruit, vegetables and cereals, and destroy the proper ratio, viz: 2/3 of meat to 1/3 of other foods, then I begin to get out of shape and this brings me to my fasting experiences,--about eight of them in the last seventeen years and lasting from five to fifteen days according to the time it took for my tongue to clear off. I find that the more hot water I drink the quicker it clears; during the last fast three years ago I drank one quart every two hours through the day. I got my stomach so clean that the water tasted sweet--this is the test of a clean stomach. Fasts have benefited me and I recommend them, as few people will live on beef till their blood gets pure; that an exclusive diet of beef _will_ make pure blood I saw demonstrated in New York at Dr. Salisbury's by microscopic tests of my own blood and that of others. When you are in this condition you can expose yourself as much as you like without danger of taking cold. If people suffering with stomach and intestinal troubles, Bright's disease, diabetes, rheumatism, sciatica, or tuberculosis, would eat nothing but beef pulp and drink hot water before meals they would be cured in nine cases out of ten, as this was Dr. Salisbury's average of cures when they stuck to the treatment. I acknowledge that one gets rid of a lot of diseased tissue while fasting, but not more rapidly than on the beef diet, and the latter has the advantage that one is making good blood all the time. I consider that you are doing a great work in recommending the fast cure, and agree with you that _Hamburg_ steak is not the best food to break a fast with, as it contains 1/4 to 1/3 of fat and "animal fat is a lower form of organization, in fact is often a process of degeneration." I have seen several Salisbury patients have slight bilious attacks from eating over-fat beef, but they quickly recovered by eating leaner beef. Beef pulp is the best thing to eat after a fast as it is absorbed quickly into the circulation and I never saw a patient whose stomach was too weak to digest it in small quantities, well broiled. I believe in dry foods, well masticated,--no slops. Dr. Salisbury said to me "a man whose food is beef can live in a hole in the ground and be healthy." His last words to me were, "Stick to beef and hot water the rest of your life and nothing but old age will kill you barring accident." I asked him how long he had lived on this diet, he replied, "thirty years."--"Do you expect to die of old age?" "Sure." He died August 23rd, 1905, at the age of eighty-two from the result of an accident. He was a most scientific and successful practitioner; but nearly all physicians, aside from those he cured, called his treatment a farce and a delusion because his teachings if generally followed would put the majority of them out of business. One New York doctor told me while I was on the diet "unless you give up beef and hot water you will not live five years--you will wear your kidneys out." I replied, "you doctors say I am going to die anyway, so I might as well die clean." I immediately increased my hot water from one pint to one quart before each meal and have kept it up ever since. When I began drinking hot water I had a slight kidney and bladder trouble; this has disappeared; the constant flushing has strengthened these organs,--I am now sixty-four. Cold water before meals is better than none, but is not as good as hot water, as the latter does not chill the stomach or gripe one, and acts as a tonic on the internal organs; is more quickly absorbed and starts perspiration, causing the skin to share with the kidneys the work of eliminating waste matter. If a person is not very sick he can eat his round steak (after removing the fat) ground without removing the fibre. For a regular Salisbury steak leave the knife loose and clean the grinder frequently. You have a large contract in trying to force medical men to recognize the fast cure. They even told me, "while we think you are honest, you are mistaken; you did not see Dr. Salisbury perform the cures you think you saw." The Doctor considered me one of his star patients; he said I was as far gone as any man he ever saw cured by the treatment, and that he would rather have three cases of tuberculosis of the lungs than one like mine, my disease being in the last stage. You can do as you like with this letter. I write simply to strengthen you. Persist, you are on the right track at last. You are no "shallow sensationalist." I like your writings. Very sincerely, JAS. Y. ANTHONY. THE FRUIT AND NUT DIET From early childhood until January 9, 1910, or about twenty years in all, I had been a sufferer from asthma, and chronic catarrh in addition. As a child I was sick a great deal of the time, having regular attacks every few weeks, of such little troubles as bilious fevers, chills and la grippe, with pneumonia, typhoid, measles, whooping cough and the like sprinkled in at times. I have taken gallons of castor oil, and pounds of calomel and quinine, I think. I don't believe I ever had more than one cold, but I was never really free of that. The first attack of asthma came shortly after the disappearance of a severe case of eczema, and from that time on throughout the entire twenty years, I did not pass a single moderately cold night without having at least one, and more often, two and three spasms of asthma during the night. These were relieved temporarily, only after sitting up in bed and inhaling, for several minutes, the smoke from a green powder which I burned for that purpose. Frequently attacks would last continually for three and four days or a week, during which time I was not able to draw a single free breath, and would suffer so intensely that on many occasions I felt as if I was breathing my last. I mention all this for fear some Salisbury followers may doubt that mine was a real genuine case of asthma. In that case, I think I can get satisfactory evidence from our family physician and others who were with me a great deal during that time. As I grew older, and about the time I went to work for myself, I began to be interested in physical culture methods, and noticed a great improvement by exercising and cutting down my diet, and afterwards adopting the two-meal-a-day plan. However, there was one thing which is strongly emphasized in these methods that did not work with me at the time, but seemed to make the asthma worse; and that was the fresh air idea. I always had better results, and the attacks were less frequent and not so severe, when I closed the windows and doors, and filled the room with the smoke and fumes of the remedy I used. That was due mostly to the narcotic effect of the remedy when breathing the smoke and fumes continually. I mention this for fear some one may suggest that the ultimate permanent relief was brought about simply by breathing fresh air continually when I did begin to open the windows. During all this time, I ate meat with each meal, or twice daily. I began to notice that nuts and especially pecans, of which I am particularly fond, and which are quite plentiful in that part of the country in which I live, seemed to have a decidedly bad effect on my asthma, and a greater part of the time I would not touch them on this account. At that time, however, I had the impression that generally prevails among a large majority of people, that nuts or fruits were only good for eating between meals, or as a dessert at the end of a meal, and in addition to the regular food that was eaten; and that was the way I had eaten them. Mr. Upton Sinclair's first article in the _Physical Culture_ magazine on the fruit and nut diet was the first hint I ever had that fruit and nuts eaten alone as a diet had any real substantial food value. From this time on I began experimenting with short fasts of one meal or one day, and also began substituting fruit for some meals, and at the same time cut down my meat eating from twice daily to two or three times a week. I noticed a great improvement in both asthma and catarrh, although I continued having attacks of asthma almost every night, as this was during the winter and most of the nights were quite cold. After the appearance of his second article, I determined to try this diet out in my own case, hoping to lessen the attacks of asthma at least, never dreaming of the real surprise that was in store for me. I fasted the last two days of December, 1909, and started in January 1st, eating mostly acid fruits, such as lemons, oranges, grape fruit, etc. (This in order to relieve the constipation that I was then, and had been troubled with more or less for the past two or three years.) As a result of the fast, and of what might be termed a partial fast for a few days after, I lost several pounds in weight, which I did not regain until after I had been eating other fruits for several days, such as dates, figs, bananas and apples, also all kinds of nuts, including the much dreaded pecan, which seemed to cause so much trouble before. On the night of January 8, 1910, I had my last attack of asthma, and have had none since. By that time my bowels were perfectly free, and all traces of constipation gone. The night of the 9th I spent in peaceful, dreamless sleep, my head perfectly clear of any cold or catarrh, enabling me to breathe freely through my nose during sleep, which had never been possible before this. Although the temperature outside was a little above zero, and stood close around there during the greater part of January and February where I was, two windows in my room were wide open all of the time, and I slept between them; also there was no stove or other heating appliances in the room to warm me on retiring and arising. I stuck rigidly to the fruit and nuts, living on them alone until the weather began to grow warmer. I then grew so confident, that I gradually lapsed into a general raw-food diet, and later on, to a partly raw and partly cooked diet, but no meat at all, save at times, when it was necessary in order to avoid unpleasant controversies and explanations among people who knew nothing on the subject, and were therefore sceptical, and often inclined to ridicule me. With the return to cooked foods, came a return of constipation, and with it, traces of the old cold or catarrh. This is one thing I noticed in particular; that when my bowels were moving freely, then and only then was I free of catarrh or cold. I am situated at present where I am away from the influences of kind-and-well-meaning friends and members of my own family, so am living on a raw-food diet entirely, doing heavy gymnasium work every day, also quite a bit of study and other brain work besides, which in all keeps me quite busy most of the day. I am enjoying the best of health in every particular all the while. H. MITCHELL GODSEY. THE RADER CASE Mr. L. F. Rader of Olalla, Wash., died at 12.15 P. M., May 11, 1910, at 123½ Broadway North, in the forty-seventh year of his age. Mr. Rader's physical history is one of intermittent suffering. As the result of an accident in childhood in which he was internally injured, his youth and early manhood were filled with a succession of most acute attacks of painful illness. About fifteen years ago he deserted the orthodox means of treatment and turned to what is now known as the natural or drugless method, with the consequence that he experienced the first relief he had ever known. Three years ago he lay ill for three months, and after again submitting to medical treatment he turned to the fast and to me. In fourteen days he was up and about, and in a month he was able to attend to his ordinary business. Since then he had no return of acute symptoms until March 31 of this year, when, after unwonted physical exercise and a heavy meal, he was seized with severe pains in the intestines, which compelled him to take to his bed. His stomach rejected food, and within a week the taking of water brought nausea. I was then called to diagnose the case and to direct treatment. I made the statement at that time to Mrs. Rader that there seemed but little chance for his recovery, but tried the administration of fruit juices and light broths. The point was soon reached, however, when Mr. Rader refused any sustenance, since it resulted only in nausea and excruciating pain. In the meanwhile the patient came to Seattle, and went to the Hotel Outlook with every symptom showing the relief that is the logical sequence of removing food temporarily from a system struggling to right abnormal conditions. Things progressed smoothly until meddlesome outsiders interfered and caused the city health officials to take cognizance of the fact that a man was "starving" in the hotel. Without warrant Mr. Rader's rooms were entered, and he was confronted by Drs. Bourns and Davidson, who endeavored to persuade him to return to orthodoxy and to the care of the orthodox physicians. Mr. Rader's indignant repudiation is of record, as is also the result of the attempt to declare him insane. In connection with the latter, after his removal to a quiet, comfortable room in the upper part of the city, an order of the court, obtained in some manner by the health officials, sent the humane officers to the rescue, and the house was watched and guarded while the faithful nurses prevented forcible entry attempted by these servants of the people. The latter even went so far as to raise ladders to the window of Mr. Rader's room, and with display of weapons tried to force the catches in the vain effort to serve the writ which was their excuse. To prevent their seeing the patient and to save him as much as possible from the noisy disturbance, I carried him to the bath and locked the door. I then climbed from one window to another across a court into the next flat in order to call the attorney for the humane society, who took the needful steps that eventually recalled the writ. In the meanwhile Mr. Rader had suffered mentally to such an extent that his life was despaired of for many hours, and he never fully recovered from the nervous shock, which undoubtedly hastened his end. Until the coming of these officers he was able to walk from his room to the bath, but afterwards he continually begged to be protected from outsiders and to be permitted to die, if need be, in peace. When the death of a patient under my care occurs I am most anxious that no stone should be left unturned to exhibit the cause. In this, my seventh death in four years' practice in Seattle, I find my diagnosis and prognosis completely corroborated. I was assisted in the autopsy by two old-line physicians and by the deputy coroner. The results of the post-mortem examination were as follows: Mr. Rader's viscera showed the most abnormal characteristics it has been my fortune to observe in years of post-mortem work. The lungs were adherent at every point to the pleural cavity as well as to the diaphragm in places. The heart in fair condition. Stomach dilated and prolapsed. Gall bladder in three distinct pouches, any one of which was the size of the normal sac, and two of these sections were filled with 126 gall stones of one grain to half an ounce in weight; the largest was 3 inches in circumference one way and 4 inches the other way. The small intestines collapsed to the pelvis and midway intussuscepted so that a section of two measured yards occupied but five inches in length; portions of these were of infantile development. The transverse colon lay anterior to the descending colon throughout its extent, while the ascending and descending colon showed infantile size and cartilaginous structure. The sigmoid bend and rectum were of diameter not larger than the adult thumb and in advanced cartilaginous state. The kidneys fair; the liver enlarged and badly congested. The conditions exhibited were such that the wonder in any mind practised in the care of the human body lies in the thought that nature was able to preserve under these handicaps this man's life until the forty-seventh year. To me this is proof positive that "man does not live by bread alone." The facts given may easily be verified. Mr. Rader fasted because he had to fast. He could not take food in any sort or in any manner, and his death occurred because of organic disease beyond repair. He was never without water and fruit juices; vegetable broths and prepared foods were given whenever the occasion seemed to present itself, but always with painful consequences. During the month of April he was virtually fasting, although food was supplied as mentioned. It is not at all remarkable in my work to have patients abstain from food for thirty, forty, and fifty days, although by far the greater number do not require this length of time. Criticized as I have been for my methods, and realizing that the combined efforts of the old schools are aimed at what it eventually means, perhaps a definition may not prove amiss: Starvation consists in denying food, either by accident or design, to a system clamoring for sustenance. Fasting consists in intentional abstinence from food by a system non-desirous of sustenance until it is rested, cleansed, and ready for the task of digestion. Food is then supplied. The conduct of the health and humane officers in the Rader case is not the first instance of their methods of procedure that it has been my fate to experience. In the latter part of January, 1908, I had under my care Mrs. D. D. Whedon, a young married woman in a critical state of health, mother of one child and about to become the mother of another. Officious neighbors complained to the authorities that the child was being subjected to the fasting method and was slowly starving. Without warrant these creatures of authority entered the apartments of Mrs. Whedon, subjected her to a bodily examination against her will and protests, took her child from her by force, and when her husband attempted to regain possession of his daughter, they arrested him for resisting an officer and had him placed in the city jail. I also was charged at this time with practising medicine without a license, an accusation that was quashed on appeal to the superior court. I rather court an investigation of my work and its results, successful and unsuccessful. Thus far the methods pursued by those antagonistic have been the very ones that have succeeded in informing the world at large that the work is here, that it progresses, else why the furor? It is here to stay and to do what the truth eventually always does--prevail. The autopsies in each of the several deaths that have occurred in my practice in the city of Seattle have exhibited organic disease, the origin of which lay in the early years of life. In all of these bodies arrested development of one or other of the vital organs was in evidence, and in the majority the injured intestines showed cartilaginous structure and deformation that must have required either violent shock or continued functional disturbance to produce. In view of the fact that these instances cover subjects who had endeavored to follow orthodox methods until orthodoxy proved unavailing, and who then turned to the fast and its accompaniments, I feel perfectly confident in declaring that early drug treatment is responsible for later and fatal disease. Nature had endowed each of these patients with strong vitality; each of them had suffered from severe functional disorder in infancy; each had been drug-drenched. Broadly speaking, there is no drug that is not a poison, stimulating or paralyzing in result, and in infancy the latter is doubly apparent and appalling. It needs but the parallelism between the effect of an application of a glass of brandy upon an infant and an adult to emphasize this statement. Consider then the consequences of repeated dosings for fevers, colic, colds, and the varied category of infantile disease, and conceive the results upon tender, growing, human bodies. Not one of us but has these sacred relics of the days of powdered dried toads and desiccated cow manure to blame for organs arrested in development or functionally ruined. The principle embodied in the intelligent application of fasting for the cure of disease is not to be crushed by vilification. The knowledge of it, thanks to strenuous attacks by the medical profession, has been distributed gratis throughout the English-speaking world; and my own part in the work of propaganda has been made more than easy by opposition displayed. I believe that I have a cause to defend, a truth to uphold, a principle for which, if need be, I shall die fighting. LINDA BURFIELD HAZZARD. SEATTLE, WASH., May 16, 1910. HORACE FLETCHER'S FAST Dec. 11, 1910. MR. HORACE FLETCHER, Care EDITOR OF _Good Health_, BATTLE CREEK, MICH. MY DEAR MR. FLETCHER,--It must have been a year and a half ago that we had our talk on the subject of fasting; you promised me that you would investigate it. I have only just seen the copy of the November _Good Health_, and discovered that you carried out your promise. There are some things in connection with your account about which I want to ask you. You say that you have come to agree with Dr. Kellogg, that autointoxication continues during the fast; and that your reason for this is that at the end of a couple of weeks you found yourself developing weakness, bad breath, coated tongue, etc. You broke your fast because these symptoms grew worse and worse. Now surely if a person is going to give a fair trial to the claims of the fasters, he should follow their instructions, and he should not proceed in opposition to their most important advice. You say that for four days you took no water, and that after that you took only a pint or so a day. In this you violated the leading injunction of every advocate of fasting with whose writings I am acquainted; I have read the books of Bernarr Macfadden, C. C. Haskell, and Dr. L. B. Hazzard, all of whom have treated scores and hundreds of patients by means of the fast, and all of whom are strenuous on the point that one should drink as much water as possible. I myself while fasting have taken at least a glass every hour. I believe that a very great deal of your trouble may have been caused by your procedure in this respect. Another point which you do not mention is whether or not you took an enema during the fast. This is a very important point. It may very well be true that poisons are excreted into the intestinal tract, and that owing to lack of food they are re-absorbed; if we can aid nature by washing these poisons out at once, can we not overcome this difficulty? May not the reason for the non-success of your fast lie here? If it be true that the fast leads to constantly increasing autointoxication, how do you account for those phenomena which are summed up in the phrase, "the complete fast"? I personally do not advocate the complete fast; I only advocate the investigation of it. I have never taken one, but I have letters from many people who have taken them, and they are in agreement upon the point that there comes a time during the fast when the tongue clears, the breath becomes pure, and hunger manifests itself in unmistakable form. How can this possibly be true if Dr. Kellogg's explanation of the symptoms of fasting is correct? Would it not happen just to the contrary, would not the symptoms of autointoxication increase, until death through poisoning resulted? Dr. Kellogg's argument is a very plausible one; for many years it sufficed to keep me from trying the experiment of the fast. I know that it has kept many other people. His claim is, in brief, that during the fast the body is living off its own tissue; that we are therefore meat-eaters, and even cannibals, while fasting. We are living on a kind of food which is over-rich in proteid, and which generates excessive quantities of uric acid, indican, etc. This, as I say, sounds plausible, but I found by actual experiment that the facts do not work out according to the theory. I myself have taken a week's fast recently, with perfect success. During this time I had not one particle of weakness or trouble of any sort. Perhaps it may be that my body was excreting undue amounts of uric acid and indican, but I did not know it, and it did me no harm so far as I could discover. I am much less afraid of the consequences of living from my own body tissue, since I have tried for myself the experiment of living on the tissues of other animals. I am trying to get at the truth about these questions, and I know that you are trying to do it also. For three years I did myself incalculable harm by accepting blindly statements that meat was the prime cause of autointoxication, together with other high proteid food. I lived on starches and sugars, grew pale and thin and chilly, and, as I was accustomed to phrase it, was never more than fifteen minutes ahead of a headache. I can give myself a headache at any time at present by two or three days of eating rice, potatoes, white flour, and sugar. Apparently I cannot give it to myself by eating any possible quantity of broiled lean beef. So far as I can make out, beef is the one article of diet which never does me any harm, no matter how much of it I eat. The same thing is true, apparently, with my little boy. I wish you would tell me what you think about all this. I wish that I could induce you to try the experiment of fasting again with the use of the enema and the copious water drinking. Still more do I wish that you could be induced to try it with some people who need it--some people who are desperately ill, and who have not been able to get well by following the low proteid diet. Sincerely, UPTON SINCLAIR. NORWICH, CONN., U. S. A. Dec. 23, 1910. MY DEAR MR. SINCLAIR,--Your valued favor of the 14th inst. received enclosing copy of your letter to Horace Fletcher. I have read your letter to Mr. Fletcher with much interest, and I have also read Mr. Fletcher's letter to Dr. Kellogg in _Good Health_. I am so crowded with work that I cannot take the time to write you on this subject of Fasting as I would like. I have had nearly seventeen years' experience studying and practising the "no-breakfast plan and fasting for the cure of disease." I have followed the no-breakfast plan all that time without a single break, and I know it has been of exceedingly great value to me. It has also been my privilege and pleasure to advise in thousands of cases covering nearly all forms of disease, and where the Law of Fasting has been followed faithfully, there have always been splendid results. Aside from the omission of the breakfast, I have fasted a great many times from one day to four weeks, and always the results have been beneficial. This could not have been the case if Dr. Kellogg's contention is correct, that autointoxication continues and increases during a fast. If his idea is correct on this point, instead of one improving and at last overcoming the disease entirely, there would not only be a continuation of the disease but an increase, and death would naturally result. Should autointoxication continue and increase while one is fasting, the time would not come when the tongue would be clean and natural hunger manifest itself. On the contrary, there would be an increase of the coating on the tongue until death finally resulted. I think if Mr. Fletcher had continued his fast until his tongue had become clean, which certainly would be the case, he would have written a very different letter. In the case of Mrs. Tarbox, whose letter I enclose, on the thirty-seventh day of her fast, her tongue was perfectly clean and she had natural hunger, and she was well on the way to recovery from the terrible cancerous growth and condition in which I found her. Since Mrs. Tarbox' cure, I have had several other cases of cancer cured through fasting. You will note the case of Mrs. Hobson, copy of whose letter I enclose, and the case of Mr. Davis is another very interesting case as well as that of Mrs. Osborne. These persons would not have been cured if autointoxication had been going on and increasing. Dr. Dewey's contention I know to be true, that during a fast the heart, lungs, and brain are supported by the predigested food stored up in the body. These organs take the nourishment and not the poison, for during a fast the eliminating organs work to the very limit to force the poison out of every cell of the body, so that during a fast all the poison in the body is growing less every hour, and when it is all eliminated natural hunger manifests itself, the tongue is clean, and the patient is ready to build up and have a clean physical organism. The use of the enema is exceedingly important during a fast. I believe that it hastens the cure at least twenty-five per cent, and perhaps more than that. Mr. Fletcher's own letter is to my mind a refutation to Dr. Kellogg's claim as to the continuation and increase of autointoxication, for he tells the benefits that he has received during his fast of seventeen days, and those benefits would have been greatly increased if he had continued the fast until his tongue was clean. His sense of taste had become so refined by the fast that his food was more delicious than ever before, which showed that the refining process had been going on all through his body. Another benefit that he mentions is the lessening of his desire for sugar, that he is satisfied with the sugar sweet that is in the food itself, which is so much more healthful than the cane sugar. Another thing that he speaks of is the reduction in his weight, which he needed. I sincerely hope that Mr. Fletcher will fast again, and make it a complete fast, for I think he will have a very different story to tell from what he tells in this letter. CHARLES COURTNEY HASKELL. Dec. 28, 1910. DEAR MR. SINCLAIR,--I have your letter of the 14th inst. and its enclosures. To those who have carefully and scientifically undergone or advised the fast, the cause of the symptoms that Dr. Kellogg and all of the rest of us recognize as indicating self-poisoning, is readily discovered to lie in the inability of the organs of elimination to promptly convey from the body the products of food supplied in excess of digestion. It is a conclusion that cannot be escaped that, when the refuse from broken-down tissue and from food ingested beyond the needs of the body is discharged into the intestines, and when means of removal are not at hand, re-absorption at once begins and continues until the canal is cleansed. Self-poisoning, autointoxication, ensues, and all of its symptoms were emphatically shown in the fast of seventeen days that Mr. Fletcher essayed. These results are also often observed when feeding is in progress, and in this connection I refer to an article written by Dr. Kellogg for _Good Health_ in the summer of 1908. In it he says, "The writer's observations, extending over a considerable number of years, have brought him to the conclusion that the cases which are benefited by fasting are practically without exception cases of autointoxication, generally cases of intestinal autointoxication, though perhaps also including some cases of metabolic autointoxication." It seems to me that the Doctor has not made it quite clear just why, if the fast is the certain producer of the condition, he recommends it for the cure of the condition. Perhaps "similia similibus" or "the hair of the dog theory" is implanted in the Doctor's ego. As we review the situation, covering in origin thousands and thousands of years of wrong living, the facts are patent. The processes of digestion and assimilation as functions have long since lost natural expression. Drugs and heredity have created in them an inability to cope with their work without assistance, and have in many instances caused a positive cessation of normal action. Dr. Kellogg would have us accept his dictum that the cause of loss of weight during the fast is to be found in the impoverished state of the blood, and in the fact that, food being denied, no up-building of tissue can occur. Can he explain in this manner the wasting of tissue in illness when food is regularly supplied? It should be readily understood that, in either instance, the process of elimination of decomposed excess food has at last become the predominant function of the diseased system. Fasting is the voluntary act that permits rapid accomplishment of the result; and disease itself is but Nature's attempt to cleanse and purify by means of elimination. The longer this thought is dwelt upon, and the more its details are verified by experiment, the stronger becomes the conviction that we are facing the truth of the matter. When coated tongue, foul breath, and vertigo appear, whether feeding or fasting, hunger is absent. It must have disappeared many days before these signs became acute, although Nature's warnings did not fail of display. The sensation of hunger, the desire for food for the purpose of restoring cell life, is the human body's greatest natural safeguard. A sentinel of lower rank is the sense of taste, which, however, like other outposts, often becomes debauched and valueless. But hunger never can be turned from its protecting task, and it cannot be stimulated into action. Hunger is the one natural function that is incorruptible, for once abused it withdraws. Its deceptive counterpart, appetite, is the product of taste-stimulation, and, as Mr. Fletcher says, takes upon itself the guise of habit. Or, as expressed in the text of my book, "Appetite is craving; Hunger is desire. Craving is never satisfied; but Desire is relieved when Want is supplied. Eating without Hunger or pandering to Appetite at the expense of Digestion makes Disease inevitable." Had real normal hunger been present when Mr. Fletcher broke his fast, the demand for food would have been so great and so insistent that no denial would have been tolerated. Mr. Fletcher states that he did not want food until he had tasted it,--a clear case of taste-stimulation or appetite. Even this was momentary and was but the expiring flame of taste relish left after seventeen days free from the progressive accumulation of excess food. Despite his care in the selection and the mastication of his food, Mr. Fletcher must still have continually eaten without hunger, and must, as a result, have stored within his system an unusual amount of material beyond the needs of his body. Had this not been true, he would not have exhibited the coated tongue, foul breath, and vertigo. Hunger would have been ever present, and it would have been impossible for him to fast. My only comment upon the neglect of the enema that seems to have occurred in the conduct of Mr. Fletcher's fast is that it was a most vital error. The enema is absolutely necessary. The question of diet also need not be discussed, for experience shows that the feeding of the body is a matter of individual requirement. If normal physical balance be ever reached, fixed laws to govern the diet problem could be formulated. In its present state, argument resolves itself into mere utterances of individual opinion and prejudice. Faithfully yours, LINDA BURFIELD HAZZARD. +-------------------------------------------------+ |Transcriber's note: | | | |Obvious typographic errors have been corrected. | | | +-------------------------------------------------+ 
14985	----	Valere Aude (DARE TO BE HEALTHY) _or_ THE LIGHT _of_ PHYSICAL REGENERATION A vade mecum on BIOLOGY _and the_ HYGIENIC-DIETETIC METHOD _of_ HEALING By Dr. Louis Dechmann Biologist _and_ Physiological Chemist Second Edition (Compendium) 1919 SEATTLE. WASHINGTON Christmas 1918 WASHINGTON PRINTING COMPANY SEATTLE USA 1919 DEDICATION "Dispel this cloud, the light of Heaven restore; Give me to see, and Ajax asks no more!" (Pope) To you of that great voiceless multitude, "THE PEOPLE"-- You whose bewildered cry is still for light; whose silent tragedy our well beloved Longfellow could so well portray: "O suffering sad humanity! O ye afflicted ones, who lie Steeped to the lips in misery, Longing, and yet afraid to die, Patient, though sorely tried!" To you and your needs this brief epitome of a coming greater work is given as a fitting Christmas offering-- "LET THERE BE LIGHT!" It is the cry which despairing, deluded humanity, in the darkness of its frenzied ignorance, has flung back hopelessly to heaven since first the spirit of an Infinite Intelligence brooded upon the race. It is the appeal of man's immortal unity to the All-Father, from age to age, for knowledge sufficient for its hourly needs, since ever, back in the far dim ages of the earth, primeval man, beetle-browed, furtive and fashioned fearsomely, first felt the faint vibration of a Soul; and, like an awakened giant, that chief of human faculties, a Mind took form which, pressing on along the uncertain way, has scaled the giddy heights of knowledge where genius, enthroned, does battle with an envious world of shams and greed and venal prejudice. Led by the resistless pulse of power it follows still that "banner with a strange device: Excelsior!";--for, ever onward yet it wends its way where'er the devious pathway trends, whose troubled, varied course is time, whose bourne is in eternity. But where seek we, then, the answer to a cry so shrill, that smites the high face of heaven from a world in pain? Shall we seek it where false learning leads us in the quest?--Ah no. It comes, not in the crash of Sinai's thunders with the rockings of a riven sphere, as in the allegoric stories of a puerile past. Softly it falls--yes, almost fearfully--from the fervid lips of some lone world-neglected persecuted man--some patient toil-worn son of science, whom Genius loves to call her own--though, haply, to the schools, to fortune and to fame unknown. One whose transcendent, superconscious mind has dared, Prometheus-like, to snatch from heaven the fire of the immortal gods and offer it in benefits to all mankind. Thrice happy he upon the sensory surface of whose open mind such seeds of knowledge and of wisdom fall, and happy the land where one and all may dare to warm chill hands and hearts before its sacred flame; that halcyon land, the Ultima Thule of our fond imaginings, wherein true freedom reigns; wherein the legalized tyranny of the chartered libertines of a so-called learned profession shall be finally relegated, in common cause to the limbo of a sordid and degraded past. For these are they who seek to maintain a strangle-hold on science, who paralyze the arm of individual research and, even in this advancing age, still block the path of progress and of peace, of universal freedom and equality of intellect, to all beyond the narrow limits of their own elect. Thus then, to the free fraternity of the open mind I dedicate this brief resumé of the product of long years of study and of toil, steadfastly believing that therein is found the missing dimension for their urgent need, suited alike to all who hold that to maintain the health of body and of mind is a worthy object for enlightened man. To you, mothers of the land, who recognize your duty, towards God and to the State, to rear your children healthy, strong and good to look upon. To all whose keener common-sense looks upon Nature, the Creator, as logically therefore, the healing power also. To all endowed with wit to understand the obvious truth that, not by poisonous drugs is healing wrought, but by such reasonable help as man's intelligence can afford, to second nature's effort to that end; and further, that, in order to achieve success, it is useless to attack, suppress or remove the symptoms of disease by force of drugging or the knife, whilst the _cause_ of the evil is left untouched, unthought of, and, too frequently, unknown. Truth and reason alike proclaim: remove the cause and the symptom _must_ disappear. To all, then, to whom the ever blessed triad of health, hope, and happiness on earth, are dear, the sanctity of child-life and the improvement of the race; and especially to those whose clearer mental vision can grasp the stupendous fact of eternal Universal Unity--the oneness with that mighty Primal Cause, the great Life Principle, immanent and active throughout all nature; can grasp and assimilate the idea that everything that has life is, each in its separate form and degree, but a medium through which the Infinite Universal Source of Life--that vast, ineffable power which we, blindly, designate as God--or Good--seeks expression in the scheme of evolution whose aim sublime is pure perfection, as its ultimate, attainable, though far off goal. Directed and attracted by an intelligence we call divine, it is a hope, instinct with ability, implanted by that Power in the soul of man, as patent in his ceaseless struggle upward toward the light of fuller knowledge; it is a power, restricted, only in degree, by that individual sense of human limitations fostered by false prophets and grounded in the vitals of the race. To you all, this brief precis is presented, as a guide, with the author's benediction, coupled with the fervent hope that, reading the scientific deductions and precepts therein contained you, too, may see Regeneration's Light and seeing, may "_Dare to be Healthy._" LOUIS DECHMANN, _Christmas, 1918. Seattle, Wash._ "Dare to be Healthy" FORE-WORD _To the Reader_: The volume, shortly to be published, and to which the ensuing pages are designed to serve the purpose of stepping-stone or forecast, has been compiled for the purpose of placing before the public the experiences of thirty-five full years of my life as a biologist and physiological chemist, devoted to the sifting and solution of vital problems of health and eugenics and in the practice of the resultant knowledge of the laws of life discovered in the course of my research. I would beseech you, in your own vital interest, to peruse these pages thoughtfully and with an open mind. There are throughout America already, thousands of steadfast disciples who are daily reaping the benefits of the teachings contained therein; and I would that you also may be added to that goodly multitude, to enjoy together with them the best advantages emanating from systematic study along the most advanced lines of modern thought and science. The facts are correlated and simply expressed with the earnest desire to bring within the scope of the layman the good that may accrue. It is, however, not for the laymen alone that this work is undertaken, but for unprofessional and professional alike, be he medical student or practitioner or other interested person; for to each and all I present herein the best that a lifetime of research has enabled me to wring from nature's secret store for the betterment and conservation of human life and the help of human kind. In the development of my movement I have formulated a system under which all may participate in the benefits of my message, though possibly prevented by circumstances in some cases from coming within direct personal contact with myself. This system comprises the following: The "Dare to be Healthy" Club. The "Dare to be Healthy" Lecture Course. The "Dare to be Healthy" Hygienic Dietetic Course. Full particulars regarding these will appear at a subsequent point in this prospectus. LOUIS DECHMANN. INTRODUCTION "... Argentea proles, Auro deterior, fulvo pretiosior aere." (Ovid) Succeeding times a silver age behold Excelling brass, but more excelled by Gold. Hessiod, in his celebrated distribution of mankind, divides the species into three orders of intellect. "The first place," says he, "belongs to him who can, by his own powers, discern what is fit and right, and penetrate to the remoter motives of action. "The second place is claimed by him who is willing to hear instruction and can perceive right and wrong when they are shown to him by another;--but he who hath neither acuteness nor docility--who can neither find the way by himself, nor will be led by others, is a wretch without use or value." "You are seeking truth," quoth Adalbert von Chamisso, "_Remember that the world clings more firmly to superstition than to faith_,"--or, to borrow expression from an equally inspired source,--remember that perverse humanity rarely fails to favour, rather, what Shakespeare terms "_The seeming truth which cunning times put on to entrap the wisest._" Courageous, then, must be the knight who sets his lance in rest to tilt against the windmills of the world. Nevertheless, although the truth is still banned as "heterodox" by common consent--or tacit connivance--an attitude patent to commercial instincts in view of the cataclysm which must naturally ensue, with deadly results to the vested interests of orthodoxy, so soon as the long-trusted barriers of plausible and pretentious mystery and importance shall be swept away by the rising tide of popular indignation. When the masses become educated to discriminate between truth and falsehood and thus shall come into their rights, then and not till then, will the dawn of physical salvation break. Still, I maintain, there are, and have been all along the way, eminent medical men of high intelligence, who, unlike the drones of the medical hive, have dared to think for themselves and have even dared to speak their thoughts. Thus, for instance, spoke Sir William W. Gull, Physician to her late Majesty Queen Victoria: "Having passed the period of the goldheaded cane and horsehair wig, we dare hope to have also passed the days of pompous emptiness; and furthermore, _we can hope that nothing will be considered unworthy the attention of physicians which contributes to the saving of life_." Again, an authority of the first rank, Prof. Oesterlin, says in his noted work on the Materia Medica: "_The studious physician of our century will hardly expect to accomplish by force, through some strange drug or other, that which only nature can bring about when assisted by all the rational accessories of hygiene and dietetics._ _Nature alone can furnish the beneficient means, sufficient for all needs_,"--which the science of medicine never has afforded and never can. As we survey the civilization of our age and its medical science, we see, on the one hand, the crude superstitions of the masses, the subtler superstitions of the educated classes; gross materialism, bewildering Darwinism, pessimism, and degenerate political economy; on the other hand, unmitigated quackery and cupidity, with its weight of oppression on humanity,--everywhere confusion instead of harmony. Very surely,--and perhaps more speedily than we think--a reaction will come, when our present degenerate system of medical subterfuge--misnamed science--will have passed away, to be replaced by accredited methods of natural healing consistent with the dignity of an enlightened, self-respecting people. "Ignorance is the curse of God: Knowledge the wing wherewith we fly to heaven" (Shakespeare) THE HYGIENIC-DIETETIC METHOD OF HEALING Biology, the Science of life, has developed under my hand that system of natural healing which I practice, in common with some of the most successful physicians on the continents of Europe and America. Although based upon the same biological laws, their systems of therapy--or healing--differ materially from one another. My system is entirely my own, developed during the last thirty-five years to that degree of perfection it has attained today. I am, naturally, honestly proud of the success achieved during this strenuous period, yet am I still as anxiously imbued as ever with the spirit and habit of research which is now directed to the endeavour to further simplify my method of treatment, by further discoveries in the realm of that most abstruse of the sciences, _Physiological Chemistry_. In this baffling but wonderful domain I am inspired by the ambitious hope that some, at any rate, of the many unsolved problems of the Science of Life may yet give up their secrets to the demand of my persistency, exerted in the interest of the well-being of humanity. After centuries devoted by the faculty to a futile and arrogant attempt to counteract the disturbances of health, which we call diseases, in the stereotyped manner known as "orthodox;" after endless complications, infinite "specializing"--in itself a futility--and unblushing complicity with the powers that be, we find them now at length, baffled, discredited, but unashamed, cast back, discomforted, upon Mother Nature's kindly breast, their victims humbly seeking healing in simple unity from her ample store. Based upon this firm foundation, we term the new departure the "Natural Method of Healing." The greatest physicians of all time, from Hippocrates to our own day, were satisfied to be simply _natural_ physicians. They were not satisfied to merely suppress the symptoms of suffering and to quiet the sufferer by abnormal appliances. Their higher, more ambitious aim was to reach the active source of distress--and in this they succeeded. For, not only did they achieve where others failed, but, in addition to healing, they also _prevented the recurrence_ of disease, and, more noteworthy still, they established a system of Prophylactic Therapy, which is the highest function of the healing art; namely, the _prevention of disease_ by treatment _before full development_, or, in other words, the _preservation of health_. It is not the object of this brief brochure to enter into the devious details which a full explanation of this practical, successful, modern method would require. It is designed merely for those who, after experiencing disappointment and failure in other directions, have had recourse, as a last alternative, to advice and assistance, from myself. Such patients, as a rule, have heard of my method from others; have heard that it differs widely, in its frank simplicity, from the empty pomposity of the old-school "orthodox" elements, though of the principles of the old-school teaching they have really little or no conception, beyond a crude, unwholesome, fear of the unknown, consequent upon the, _very necessary_, veil of mystery with which its votaries surround themselves--a semi-superstitious sentiment inherited from a malignant past and one which does little credit to the vaunted modern civilization of today. On this point of difference they ask for enlightenment, and naturally enquire as to the nature of both, but especially of this new hope which is held out to them as a refuge in their hour of despair. This information it is equally my duty and my desire to give, and in the most convenient and simple form, shorn of all shroud of mystery; for my object is to educate and not to conceal. It is my chief desire that patients should thoroughly understand the methods and principles of the New-School of Healing and should exercise their own intelligence as to its merits as compared with the old, and, being once thoroughly convinced--not by faith, or fear, or fashion, nor yet biased by the unfair influence of the false prestige of a legalized monopoly detrimental to the interest of the people--they should forthwith honestly test the new deliverance by faithfully following my advice and instruction, to their own unfailing ultimate benefit and relief. As a labour of love towards the world in general and the people of my adopted country in particular, I have made it my duty to formulate the substance of my researches in the field of science--researches which represent the struggles of a lifetime--in a large and comprehensive work which, to the scientist as well as to the laymen, will constitute in the most detailed and complete degree a reliable guide to the conservation of health which, even now, in the immediate present, has come to be regarded not only as a scientific phase of education, but as a duty incumbent upon every citizen. Should sickness supervene, as well it may sometimes, despite all reasonable precaution, the knowledge and instructions contained therein are sufficient, if closely followed, to prevent, for the most part, the serious consequences of disease and to afford the patient the necessary enlightenment to enable him to co-operate with the hygienic-dietetic physician in the task of restoring him to health and ability. This book, entitled "_Regeneration_" or "_Dare to be Healthy_," will consist of some three thousand or more pages. It will be published shortly; and, in the common interests of human health will, I trust, find prominent place on the book-shelf of every home whose inmates either belong to the ever increasing number of the followers of my patients, or who, by careful study of my teachings therein contained, may be finding their independent way back from the dreary depths of suffering to the glad plains of health. In following up the general outline of the "New Regeneration" these pages will not lend themselves to the otherwise necessary encounter with what are now admitted to be the recognized errors of the, temporarily dominant, medical school, save in so far as it may be requisite to remove from the mind of the layman pernicious and antiquated ideas to which he has been long and persistently educated, or to protect those who have ceased to believe in them from the pitfalls to which, as an alternative, they may be exposed amongst the numberless unscientific, quasi-miraculous, healing cults, or the equally pernicious nostrums of the spectacular advertising medicine vendor, both of whom reap golden harvests among the ranks of the so justly disappointed and despairing people. * * * * * It is, nevertheless, an imperative duty to issue this necessary warning; namely, that the public should safeguard itself against the absurd, but possible mistakes of confusing the Legitimate Scientific School of the Hygienic Dietetic Method of Biological Healing with the nebulous cults aforesaid. There is no vestige of resemblance between them, either in thought or principle, and nothing could be more fatal and foreign to the truth. * * * * * There is one thing, and one only, which, like the rest of the community, we share with them in common, and this is that _growing spirit of profound distrust_ with which all classes seem daily more and more constrained to regard the Medical Fraternity and all its ways. It is the general knowledge of the existence of this sentiment which has called into being the present epidemic of curious cults and catholicons--due, it would appear, more to this insidious temptation to such _commercial enterprise_ than to any other cause--and which form so prominent a feature throughout all sections of the community--and especially in the press--throughout the length and breadth of the land. To such, in an alarming degree, the public turns, in protest, as it were, against the tyranny and turpitude of this "learned profession," with its kindred corporations and its studied callous disregard of scientific advancement in any direction which might tend to jeopardize or reduce the profitable exercise of its own obsolete methods, its system of poisonous medicaments, and dangerous operations and anti-toxins. There is no possible efficacy or help to be derived from other teachings, whatsoever they may be, except from those based absolutely upon the solid foundation of biological fact. Since Johannes Müller (1833) wrote the first book on physiology and its chemistry, more than a thousand so-called "Authorities" in that branch of science have tried to find some of the secrets of nature pertaining to physiology. A very few (about 10 or 12) may be named as great men who discovered certain laws and solved certain problems. But the majority added nothing to Müller's discoveries. Most of them became teachers or authors, one plagiarizing the work of the other, eulogy being very liberally distributed on all sides, but valuable deductions from the great masters, very few have been able to make, and even those were more or less suppressed by the "orthodox school." In less than half the time since 1833, i.e. 85 years, it was my good fortune to give more valuable deductions and practical applications to the student and the reader, than the mediocre talents of the "old school" were able to give. * * * * * I pretend to no miracles and expect none; nor do I arrogate to myself any so-called _super_-natural secrets or powers; I simply maintain that, aided by the erudition of the great scientists of the past and present, this system has finally been brought to a point which should rightly have been always the chief aim of Medical Science, namely, an _exact knowledge of human nature and the human organism, as it is_. With this vital knowledge at command I have been able to successfully formulate a system for supplying the individual organism with any of the various constituents of which it may be deficient, in a manner in which it can best receive and assimilate the same, thereby maintaining a correct balance between the constituents of the blood wherein lies hidden the sole criterion of health and the fatal secret of disease. Simple as this may sound, the way has been long and lonely until that elusive goal was reached; and, even now, in the heat of the controversy which ensues, we find ourselves sometimes in a somewhat parlous position, placed, as it were, between two fires; on the one side are those who, though not without sympathetic feeling for the well-intentioned, earnest-minded believers in the errors now being exposed, yet cast aside all scruples in the interest of humanity and truth. On the other side are those obsessed by care and compunction for these accredited practitioners who by reason of age or temperament are unable or unwilling to assimilate new ideas or to relinquish the theories of a life time in order to enter the field of competition with the men of a younger generation. Such is the impasse before which we stand. REGENERATION OF THE RACE BY THE LIGHT OF BIOLOGY AIDED BY PHYSIOLOGICAL CHEMISTRY. "For as the body is one, and hath many members, and all the members of that one body, being many, are one body:... whether one member suffer, all the members suffer with it; or one member be honoured, all the members rejoice with it." (St. Paul, I Corinthians, XII. 12 & 26.) "_DYSAEMIA, or Impure Blood is the cause and source of disorder in all constitutional diseases. So spoke the Master. Believe it who will, that, in a nutshell, is 'the burden of my song'--the Alpha and Omega of my teaching_." (From Chapter X. "Dare to be Healthy.") _The Process of Natural Healing_ is the art of curing diseases by natural methods. As natural remedies, only those may be included which stand as vital conditions in constant relation to the organism, assimilable thereby. Among these are no poisons or chemical preparations, such as were promulgated by Paracelsus and the medicasters; for these are elements abnormal to the body, and call forth its reactionary powers, and so, being useless, they are eliminated; or, after having served an improper purpose, to _suppress_ some symptom of disease, they become embedded in the tissues, there causing various forms of medicinal complication or morbid condition. Do we not produce blood poisons enough by our irrational diet and modes of living? The human body is a microcosm--a world in minature--and as such, exists in constant interchange with universal nature. A definite relationship exists between it and the solid, fluid and gaseous elements. Solid food, water and air, elements of the universe, must become elements of our bodies, if relations of universal unity are to be maintained. There must be a constant interchange of organic matter, and this inter-transmission is the cause of life, of health, and of disease; therefore, we must first of all see that the conditions of this process are uninterrupted. Food, air, water, light, exercise, must be so provided that they condition the process of nutrition and metamorphosis. Skin, lungs, kidneys, intestines, must always be in condition to eliminate the abnormal products of decomposition. If then disease be a derangement of the life process, it is self-evident that disease is not confined to one organ alone, but that the whole body is diseased. The body, thus, being in fact an indivisible unity, the treatment we employ in disease must, logically, act upon it as a united whole. The modern school of medicine in its present, bacteria ridden frame of mind or mania, looks upon the bacillus, or microbe, as the sole cause of disease. The cause, however, is not the bacillus, but rather the impure blood which prepares a fertile soil for the development of those destructive germs. He who lives strictly in accordance with the rules of hygiene need not fear the bacillus, for man is not born to sickness; he creates sickness for himself by his irrational mode of living. What does the world profit by bacteriological institutions if the people continue to live in the old sins against health and hygiene? Man may be born with a predisposition to disease, but not with disease itself. Our health depends entirely upon the conditions of our life. In cases of predisposition to disease, therefore, as well as in disease itself, according to the principles of hygiene, we must employ only the hygienic and dietetic methods of treatment. Is the medical science of the day, then, totally incompetent? You may well ask.--Have the patient studies and researches of nearly two thousand four hundred years, since the days of Hippocrates, been all in vain? The reply lies ready to your hand, from the lips of one of the brightest scientific spirits that ever illumined this dull earth of ours with knowledge and sincerity. In Goethe's Faust the following lines are found,--lines which sad memory brings back to the minds of many an unfortunate who, according to the dictates of the medical science of today, is pronounced incurable--a sufferer from one or other of the so-called chronic diseases--and in dire need of both physical and spiritual support. "I have, alas, philosophy, Medicine, jurisprudence too, And, to my cost, theology With ardent labour studied through, And here I stand with all my lore, Poor fool, no wiser than before" Like Faust, such sufferers study day and night the opinions of learned doctors and follow their prescriptions with ardent zeal. The more they study, the more doctors they consult, the more rapidly does strength fail them, until at length they realize that, in spite of all their lore, they are but "poor fools, no wiser than before." For more than two thousand years it has been, in fact, as it is to a great extent today; the physician prescribes to the best of his knowledge, medicines compounded according to certain rules dogmatically laid down in the schools. Here we have at once the fatal mistake at a glance. Instead of studying nature and the laws of nature, instead of using natural means to _heal disease_, they administer deadly poisons to _allay suffering_, poisons, which doubtless may be able to repress pain or to temporarily suppress the symptoms of disease; but can _never remove the cause_, which alone may rightly be called healing. The drugs prescribed by thousands of physicians today, with but a casual acquaintance with their action, are bound by their nature to produce evils worse than the disease itself. To cite an instance: Physicians prescribe creosote in cases of consumption to stop the expectoration of blood. Creosote will do this, and may suppress the cough, as well as the accompanying pain; but will it cure consumption or destroy or remove the cause of this deadliest of diseases? On the contrary, it inevitably produces laryngeal phthisis after a very short time. It destroys the head of the windpipe and the patient dies in consequence of the destruction of one of the most important organs of the body. In most instances the physician is either oblivious or unaware of these facts. He follows those old-standing doctrinal sophisms laid down by human "science" but discredited by nature. His courage is called "audacity" by those who have not lost all feeling for humanity. Meanwhile, those who regard medical science from a business standpoint only, are very quick to pronounce judgement upon any natural treatment of disease and to condemn the most successful natural physicians as charlatans and frauds. In order to be competent to decide upon a correct course in the treatment of disease the physician must possess a thorough chemical knowledge of all the fundamental substances of which the human organism is constructed. With the patient therefore rests the responsibility of choosing his physician, since no physician can be of any assistance who cannot define what substances are deficient in the blood, and who does not possess the requisite technical knowledge to supply this deficiency by adequate dietetic means. In my nutrition cell-food therapy for constitutional diseases, I have followed consistently upon the lines of one of the greatest masters of physiological chemistry that the world has known, who, in one of his medical colloquies spoke as follows: "In order to thoroughly understand any form of sickness or disease, so as to undertake the cure of the same, it is first of all necessary to picture before one's mental vision the ways and means of its inceptive formation, and by degrees to trace its origin, step by step, before one is enabled to decide upon adequate remedial measures conformable to the individual stages of the same." In this sense it has ever been my strenuous endeavor to fathom the secret of the inception of constitutional diseases; but the entire medical literature did not advance me further than pathological anatomy, which informs us that the original cause of disease is a change in the form of the cellular elements of different digestive organs,--in explanation of which the customary technical terms are used, such as "atrophy," "degeneration," "metamorphosis," etc. But, I reasoned with myself, this surely cannot be seriously regarded as the origin of disease! The cause of the visible changing of the cellules must be sought in the conditional interstitial substances which cause the invisible changes or shiftings of the cellular forms, and which are scientifically termed "_Changed nutritional conditions_." By the aid of physiological chemistry I was successful in finding a pathway to the centre of those mysterious occurrences of life. And this was my course of reasoning: As the cellules, which are the smallest individual elements of the human system, are only _products of the blood_, and for their composition require the different chemical substances in sufficient quantities, it is obviously necessary to fathom what those chemical elements of the cellules may be, what form they take in their mutual relation to the separate parts of the body, and in what way they enter the organism. In this manner I obtained a clear insight into the actions of the so-called _mineral material_ in the organism, and it gradually became obvious to me that everything is dependent upon the introduction of the proper _sanguifying or nutritive_ mineral salts into the blood. On this basis I founded the so-called "_organic nutritive cell-food therapy_" (called the Dech-Manna therapy). The point may be raised that the elements of the food we eat or drink are heterogeneous and that the mineral matter in them is naturally and casually acquired, according to the properties of the soil they grow in. This is the general opinion, but not the fact. Our vegetables, grain, meat and milk contain too much phosphoric acid and sal ammoniac, and this is due to the use of artificial and animal fertilizers, while the sulphurics are very often entirely missing. Von Liebig says: When we consider that the sugar refineries of Waghausel have an annual output in the market of 600,000 lbs. of potassic salt, which is taken from the soil by the turnips of the Baden fields without being replaced, and that there is cultivated in Northern Germany, year by year, with the assistance of guano, an immense amount of potatoes solely for the manufacture of spirits, and that these potato fields are consequently robbed of the essential ingredients which potatoes should contain, and as these elements are only partially replaced by the insufficient component parts of the guano, we cannot be in doubt as to the condition of these fields. The ground may be ever so rich in ingredients, but it is exhaustible. The analysis of our blood indicates that, in order to remain healthy, it must contain twice as many sulphuric as phosphoric salts. We talk glibly about a natural mode of living, a simple diet; but where in our civilized countries can we find food that really serves healthy sanguification? The crux of the question is this: Why do we propose to _heal naturally_ and not also to _nourish naturally_?--The latter is, to say the least of it, just as important as the former. But if both were practiced conjointly, a beneficial object might be more quickly and surely gained. It is true, we are taught to eat more vegetables than meat; that our bread lacks the chief nourishing qualities, and so on; but we have hitherto been in no wise informed as to the substances that are relatively harmful or beneficial to us. Why is it then that the science of the sanative power of nature, as well as medical science, is still in doubt in regard to the relation that must absolutely exist between the separate component parts of our nourishment in order to obtain normal healthy sanguification? _The reason is that the application of a real chemistry of life has never been comprehended until now._ According to my judgment it is Von Liebig and Julius Hensel who showed us the paths we are to take to the field of enquiry most important of all; for without a sound body all the coveted acquisitions of modern times are worthless to us. The solution of the question how to prevent the degeneration of mankind would be a simple and natural one, if history and proverb had not taught us that as often as a new truth appears "the very oxen butt their horns against it." They cannot help this, the "disposition" is natural; for when Pythagoras had found the Master of Arts, Mathesios, he was so overjoyed that he sacrificed one hundred oxen to the gods, and ever since that time oxen are attacked with an hereditary fright whenever a new truth appears,--the human ox is no exception. Of what use to us, for instance, are the Roentgen X-rays in diseases of the nerves when there is a generally diseased condition of the blood, which, as we now know, is also the primary cause of lung, liver, stomach and kidney troubles, cancer, scrofula, rheumatism, gout, obesity, diabetes, and the rest? In such cases _chemistry_ is necessary, in order to ascertain what ingredients are missing in the blood; they cannot be detected microscopically. What blunders are continually committed in the treatment of nerve diseases! No one considers the physiological law that _no parts of the nerves can perform their functions lastingly and naturally unless they are continually supplied with blood permeated_ with oxygen; and for this purpose iron is most necessary as an adequate ingredient. Physicians of the old-school do prescribe iron plentifully, but in inorganic form; and because it is not organized it is indigestible and is excreted. That is why the treatment of the diseases of the nerves, which are so general and widespread, has been so unsuccessful. It is not generally known that organized ammonium phosphate (Lecithin), which is the mineral foundation of the Neurogen I prescribe, will regenerate the nerve cells if consumed in the proper proportions. It is, likewise, little known that although a person with diseased lungs be placed under conditions where he may acquire an ample quantity of pure air--that is oxygen--and may consume as much as four quarts of milk daily, he will nevertheless most certainly be doomed to perish if his food does not contain the elements of iron, lime and sulphur in sufficient quantities. These simple physiological laws have been ignored and medical men have given us instead, the teachings of the school of bacteriology with its pitiful illusions and its endless train of suffering and sorrow. The testimony of many patients who have undergone treatment in the best physical culture and so-called, natural healing establishments both in Europe and America, serves to show that their success has been but partial and one-sided; that is, they have abandoned their wrong albumen theory, and their state of health has consequently improved. But, practically, the treatment has failed; for complete and final recovery--that is, full and correct nutrition and strengthening of the nerves, has not been accomplished. Such failure is due to the fact that certain essential constituents have not been supplied. These vital constituents my organic nutritive cell-food therapy is designed to provide. What is lacking in the field of practical science, as authoritatively voiced by the unprogressive faculty of today, is an absence of chemical knowledge, especially on the part of the physician and the naturalist; and, as likewise, the so-called scientific farmer upon whose assurances we so naturally rely for the wholesome production of food is woefully ignorant on matters of agricultural chemistry, the logical consequence is that in all civilized countries great mistakes have been unconsciously made and perpetuated, detrimental to the health of man and beast alike and vitally prejudicial to the healthy sustenance of the race. _Where are the most vitally necessary mineral substances_ to be found in nature? It is an established fact that the fields, on which our nutritive salts or cell-foods--our vital sustenance--are grown, were originally formed from decayed primitive rock and _this primitive earth-crust matter is composed of the same mineral substances that are found in normal blood_. Therefore, our physical welfare and our capacity to resist disease is clearly dependent upon the condition of our fields. We must always bear this in mind--the old truism--that, "AS A MAN EATS, SO IS HE." _We are thus, directly, the products of our fields._ Wrongly fertilized, our fields must produce sickly vegetation, and this in turn will produce a sickly race and disease in cattle. Primitive rock consists of granite, porphyry, gneiss and basalt, deposits which are still found upon the earth in immense quantities, and in the same condition as thousands of years ago. As a matter of fact, proposals have been made by noted scientists to utilize pulverized rock of this kind as compost to _assist_ the fields in a natural way, and so to restore them to their former producing power, which would thus enable plants, animals, and man, alike, to regain those substances indispensable to proper sanguification and general growth. The agricultural experiments performed with this stone dust fully confirm this assumption. One of the most important tasks of today is to indicate to the farmer new ways and means of promoting and increasing growth for the food supply of the nations. Why, then, I imagine I can hear it asked, if this fact be true and demonstrated, has it not been applied? This question may be answered by another. Why does not the natural system of Hygienic Dietetic Healing find general application in cases of sickness, since its success is so obviously greater than even that claimed by medical science? To this vital question upon which so much of human life and happiness depends, the weak and degrading answer must suffice; to the effect that the last vestige of public respect for the sciences would be shaken, and many wise theories would fail of their imaginary virtues and succumb, before humanity's best birthright--the quality of healthy blood, kind nature's ample gift to all,--could be wrested from the selfish hand of tyranny and mankind enabled to secure from nature's willing hand the succour that an Infinite Providence offers to disease. A physician to whom I once explained my theories, heard me for some minutes and then he said "Well, and so you want to create healthy blood in this way?" "Yes, surely," I replied. "We have no use for that," he callously exclaimed, "there would _be no business in that_." _Hence Mankind must degenerate and Disease of all kinds ride rampant_ through the land, rather than upset the firmly rooted fallacies of the past or foil the ghoul-like greed of a certain set of conscienceless practitioners. To the first of these the terse old Latin satire would apply: "Homine imperito nunquam quidquam injustius Qui, nisi quod ipse fecit, nihil rectum putat." (Terentius.) "Who is there so unreasoning as he, that learned drone, Who reckons nothing perfect save what he himself hath known." (M.B.) To the second let an outraged public reply. * * * * * But meanwhile, as the hideous holocaust proceeds, the mills of God grind slowly but mysteriously secure. The eternal law of equity is working still; and from every evil there proceeds a good. Truth may be hidden in the nether deeps, but some day the strained tension breaks, the balance reversing brings it to the light. Its spirit works for ever, like a ferment, hidden long, deep down in the Universal heart of things; for with majestic, unimpressionable tread, sublimely the silent force of human progress moves; slow and inevitably sure, the great indwelling spirit of a vast eternal energy leading man ever upward to the True and Best. Against this axiom, alas, graceless and suicidal seems the unwisdom of the world, in action against all who offer it salvation from its pain; aye, though he be Christ or Commoner. Rather be wrong in league with wealth and power than be right--and stand alone. This is now the worldly wisdom of the sage. Genius at grips with material and religious power, fares ill; as with far-famed Copernicus, or "starry Galileo and his woes"; or, in a brave woman's daring words:--"He, who dares to see a truth not recognized in creeds, must die the death." "A time of transition is a time of pain," is a truism well recognized by all, and he who would press Regeneration upon the world--weak, weary and unthinking as its people are--must run the gauntlet of the bitter antagonism of the exploiting clans on this benighted sphere, though later he may see, across the bourne that bounds life's earthly day, a stately monument, perchance, by gratitude upreared, where pious crowds pay tribute to his name. HYMN OF HEALTH (From the Greek) Health, thou most frangible of heaven's dower, With thee may what remains of life be spent; Cease not upon me, thus, thy gifts to shower, And in my soul to find a tenement. For what is there of beauty, wealth or power, Of gentle offspring, or the wiles of love, But owes its solace, sweet, in every hour, To thee, thou regent of the powers above. The spring of pleasure blooms if thou but bless, And every step upon the Autumn way Is lit by thee, parent of happiness! Without thee sadly sounds life's roundelay. (M.B.) Health is one of those intangible inestimably precious possessions, like life and liberty, to which all are entitled by natural Law. Yet are there but few who are careful to conserve this priceless heritage. It is a boon all too often unappreciated until lost, and once lost, it may not always be regained, though intense be our regrets and our endeavours exhaust the field of human resource. Again, although the possession of passable health may be ours, it is a condition rarely totally untroubled and continuous and, therefore, cannot be correctly classified as perfect health. These simple definitions may seem to the reader trite and trivial; but how many of us, let me ask, give thought to their vital vast significance. Never to need a physician; ever to be unconsciously guarded against all access of disease; to maintain the fair form and vigor of the body without effort, so that no depleting influences can find a hold; this is the health ideal by nature set, the standard to which the earliest progenitors of our race may doubtless have conformed, but upon which succeeding generations have sedulously turned their backs. Philosophers have defined this physically perfect state. Historians have immortalized it in heroic tomes. Poets have extolled it in great epic verse. Artists have depicted it in portraiture and tapestry. Sculptors have expressed it in the life-like stone. The sick have longed for it. Saints have prayed for it and, in the search for its fabled, false elixir, alchemists have sacrificed their lives. It remained for the smug, "sober judgment" of our day to pronounce it "unattainable"--unattainable! This, however, is a matter of small moment; for, as Whittier reminds us: "The falsehoods which we spurn today were the truths of long ago"--and although men part reluctantly with favorite--and lucrative--fallacies, and "Faith, fantastic Faith, once wedded fast to some dear falsehood, hugs it to the last," nevertheless this false belief, like so many other sapient pronouncements of human wisdom, must be subjected to final reversal. The ideal state of health is, truly, "unattainable" when we refuse to yield obedience to the simple laws of nature--when we continuously persist in interference with her work and embarrass her with artificial substitutes, defying her august hygienic precepts by our manner of life. Not so, however, if we yield to her inducements, fulfil her requirements, and submit ourselves freely to her unerring will. There is less of fault than of weakness in the fact that so many of us fail to give nature the opportunity to rear us as healthy men and women, to keep us more free than we are from suffering and disease. Her ways are ways of pleasantness and follow on the lines of the veriest simplicity. The preservation of health must needs, then, move along these self-same simple lines. It is ignorance, in most cases, rather than unwillingness that brings upon the race the punishment we call disease. But how can they be expected to learn who have no teacher? And how can they teach who are themselves untaught? It is incumbent upon those who have acquired knowledge to impart life-saving truths, and _there is no greater benefactor of his kind than he who reduces life's problems to their simplest terms_. "He that dwelleth in the secret place of the Most High shall abide under the shadow of the Almighty." Such is the dictum of King David, the psalmist, as expressed in the Hebrew Scriptures. All that man's intellect can conceive of the Almighty is bounded by its expression in Nature. It is neither arrogant, nor irreverent, then, to claim with reasonable confidence that the devoted service of long years of close application to research in Nature's secret dwelling-place may entitle such an one to share the guidance of the Almighty mind and inspire him to share its favours with his fellow man. * * * * * This then, the Author of this brochure, realizing vividly and with sympathy, humanity's sore need, has been constrained to formulate, for the benefit of those desirous to learn;--a means of enlightenment suitable and accessible to all. For although, to quote from Goethe, whose transcendent mind was almost omniscient in all mundane things: "Allwissend bin ich nicht; doch viel ist mir bewusst." (Omniscient am I not, though much I know.) Yet "Unity is strength," and in conjunction with associated minds, such knowledge as I have may amply suffice to save many a sad sufferer from hereditary doom. The scheme, or, to be more explicit, the Club, I purpose to inaugurate, is fully expounded in detail in the succeeding pages. THE DARE TO BE HEALTHY CLUB All other things the mandate, "must", obey, Man only has the power, "I will", to say. (After Schiller.) (M.B.) Thoughtless and imitative, men follow custom, careless where it may lead, and unconsciously imitate each other. Strong harmful habits grow, which overcome the opposing will and fickle fashion rules where common sense should reign. Such instances are common to us all. A combination opposed to such influences is the force we need and for this purpose I propose to establish a Club for the study of the ways and means of health. THE DARE TO BE HEALTHY CLUB. The Club will be comprised of those who desire to pursue a course of Health Study by correspondence. This combination will constitute the first and only Club of its kind in the world. It will unite in its membership a group of independent thinkers, representative of all parts of the American Continent. The purpose of the Club will be to teach the science of Regeneration--to teach them to "dare to be healthy" according to the laws and teachings of biology. These teachings will consist of a two years' course in _Biology_, dealing with its most important branches, in _Physiology_, _Anatomy_, _Hygiene_, _Physiological Chemistry_, _Pathology_, according to biological facts, and _Therapy_ in accordance with biological and physical laws and precepts. All methods of _natural healing_ will be explained in detail, including diet, breathing exercises, and rest. The comprehensive aim will be to inculcate the principles which govern the process of perfect metabolism--that is to say, the changes of nutritive matter within the body--as the means of bringing into being a race endowed with health and beauty and therefore predestined to happiness. The course of instruction will be based upon the literature of science, including certain fundamental teachings from the pen of the author of the present pamphlet, which comprises, moreover, extracts from the works of distinguished scholars whose theories have been tried and tested during the last thirty-five years. Its precepts will be based upon personal experience and actual practice, the outcome of careful and patient observation. The series throughout will be formulated with a view to the purpose of graduating later from among those who follow the course, a body of competent instructors capable of transmitting the knowledge they have acquired to others, privately or professionally. But remember the axiom of Cicero: "Not only is there an art in acquiring knowledge but also a rarer art in imparting it to others." The first question, then, which will naturally arise in the mind of the reader will be: _What is This Method of Regeneration?_ The reply to this question is in reality a simple one, but in order to explain and define the word "Regeneration" from a purely scientific standpoint, it will be necessary to cite the results of the author's researches and to outline his method of healing by regeneration, showing how he purposes to lead the way from a dark past and a dull present into a brighter future. Before doing so, however, it may perhaps conduce to a better understanding if I quote from the remarks of an eminent local authority on the chemical composition of the body--a subject "new," as it appears, to the general medical practitioner of the day though, for over a quarter of a century freely expatiated upon by the great Biologists of the period. The extract is taken from a recent article by Assistant Surgeon General Dr. W.C. Rucker, of the United States Public Health Service, and reads as follows: "Much of the advance of modern medicine has been accomplished through the development of physiological chemistry which is even yet a new science. "Although so new, it is assuming such importance as to make it manifest that the physiology of the future will be written largely in terms of chemistry. "We have come to realize that the body is in a literal sense of the word, a chemical laboratory. The foods we eat, the fluids we drink, the gases we breathe are complex chemical compounds which the body must take apart and put together again in such a way that the materials may be delivered in a shape that will enable the cells to store them. It is then the business of the cells to utilize these materials for TISSUE BUILDING and in the production of energy, in the form of work and heat. The body manufactures different kinds of products, some beneficial, others harmful. Thus for example, excessive muscular effort throws into the bloodstream fatigue products that are poisonous. A person utterly tired out is really suffering from acute poisoning. On the other hand, to resist invasion by infectious diseases, the body manufactures anti-poisons that kill the enemy germs--making in other words, its own medicine." The physical processes here mentioned by Dr. Rucker are fully explained in my book, "Dare to be Healthy," chapter VI, VII, VIII, and the natural principles involved have been practiced by me for over 30 years. I mention the fact simply as corroborative evidence of the authenticity and value of the work shortly to be published. "Art may err, but Nature cannot miss,"--is an aphorism attributed to the poet Dryden. It adequately supports Dr. Rucker's wise, significant and timely pronouncement and reminds me of an illustrative incident recorded in connection with the world famed physician Boerhaave of Leyden,--Holland's chief centre of learning--who lived some 250 years ago, when doctors knew less than at present of the circulation and functions of the blood. Boerhaave, it appears, conceived the idea of a sort of posthumous pleasantry, of a distinctly lucrative nature, at the expense of his medical brethren. Professional ignorance and popular superstition had alike surrounded his name with a halo of mystery and he was credited with almost miraculous powers of healing and the possession of the Secret of Disease and Health. At the sale of effects, following his death, there was a great gathering of the most celebrated physicians of the day and his books and records fetched fabulous prices. But one special tome, ponderous, silver-clasped and locked, entitled: "Macrobiotic, The True and Complete Secret of Long, Healthy Life," was the cynosure of every avaricious eye. The auctioneer shrewdly reserved it until the last. Amidst a scene of unparalleled excitement and competition the Great Book was at length knocked down to a famous London physician for no less a sum than seven thousand Gulden. When opened with eager anticipation before the disappointed bidders, its pages were found to be blank--with one exception. Upon this one was inscribed in the handwriting of Boerhaave himself, only these ten words: "_Keep the head cool, the feet warm, the bowels open._" Turning to an excited audience it was thus the great London authority spoke: "I once heard it said that the world is simple; that health is simple; that it is the folly of man that causes all complications, and that it is the delicate task of the true physician to reduce everything to its original simplicity. Heaven knows that our great Master, Boerhaave, has solved life's problem. To me this truth is well worth the 7,000 Gulden I pay to secure it; while to you, my friends, who have travelled from distant parts of the globe in search of it, receive from me the legacy of our Master and also be, likewise, content." The moral that this story teaches is the same eternal lesson of all time, as expressed through the medium of Biology: that not by art or artifice can health be cheaply snatched at will from the Infinite Sources of Life, but that by consistently following the guidance of Nature's Laws the healthy functions of the human organism may alone be correctly maintained, or, when driven by ill-treatment into decline, it is the rational scientific assistance we afford to the efforts of Nature, by which alone we may hope to re-establish that normal condition of health. For, in the worthy words of Wordsworth I may say: "So build we up the being that we are." The writer does not claim for this method so great a degree of simplicity. But he does base it upon the same truth that simplicity and a return to natural conditions are the only ways of effectively healing the diseased body. Guided by the great masters of biology and physiological chemistry, his object has been to determine the elements of which the twelve main tissues of the human body are composed and to learn in what manner these tissues suffer from the various diseases which attack them. Were I desirous of emulating the illustrious Boerhaave, I might concentrate my work into these few words: _Supply the system with the necessary constituents of its tissues and at the same time assist the organism by means of simple and natural appliances, and REGENERATION will continue until the desired physiological condition is reached._ In so doing, I fear, I should bequeath but little to the comprehension of humanity. I desire that all shall benefit by the diligent research work of my life. I desire to leave my legacy to humankind clearly and distinctly defined, in rules carefully expressed in the Course of Study I have prepared. I do not expect them to be accepted without controversy. Nor do I look for gratitude from those whom I seek to benefit. I have no delusions and the satisfaction of having delivered my message will be my sole reward. I can only trust in this more enlightened age, that history as poetized by Pope may not repeat itself: "Truths would you teach, or save a sinking land? All fear, none aid you, and few understand." My solace, even so, for the nonce would be the knowledge of life and health restored to the faithful, though, comparatively, few and the confidence that truth must, in the issue, at length prevail, convincing, victorious over all. Before proceeding further I wish it to be distinctly understood that it is no part of my scheme or intention to seek in any way to eliminate the physician. As there are, in fact, no two human organism exactly alike, so also is there divergence, more or less, in each individual case, in disease; and however apparently similar the symptoms may be, the knowledge and experience of a physician becomes necessary in order to determine correctly what the ailment is and how general principles should be applied in each particular case. On the contrary, I purpose to explain fully the secret causes of disease and their removal, in pursuance of the belief held in common with fair-minded physicians the world over, that a better knowledge of the human organism and hygiene on the part of the layman, would be of equal advantage alike to physician and patient. Drawing aside the veil from professional secrecy and allowing the patient to know the why and the wherefore of things, means positive success for my hygienic-dietetic system of healing, because it is the only system which can ultimately survive in the light of general knowledge and wisdom. No knowledge, no precautions, will always prevent disease. It is the natural incidence of the law of cause and effect that man, collectively, cannot expect to go through life unmolested by disturbances of health. From the very outset the tendency to disease is inherited; and indeed today, although we have now learned how to combat the enemy, yet opposing hosts are seen to be so vast and strongly entrenched about us that we realize to some extent the years that must elapse before mankind can be entirely set free from his hideous heritage, the harvest sown by past ignorance, deception and neglect. But, from the malignant evil of internecine strife Universal Good is rising with an awakened nation's cry--a cry for freedom and release from the ever-lengthening chains of pernicious interests and obsolete institutions. The moment of release is at hand: That pyschological moment of which James Russell Lowell sings: "Once to every man and nation Comes the moment to decide, In the strife of Truth with Falsehood, For the good or evil side." And knowing what the People know--they who have borne so long, in grimly impotent silence, under the guise of Freedom, the fortunes of the slave--can we for one moment doubt what view their lawful, reasoning demand for redress will take and whether or no it will prevail? The hundred million voices of the Union sternly answer: NO! In effecting this release, so far as the Science of Healing is concerned, my system, which I claim to be entirely original, will be found particularly efficacious, for it presents plainly and convincingly, in the light of the most recent discoveries, the truth that _all constitutional diseases are but the variations of one basal deficiency_; that the entire art of rational healing lies in a knowledge of the component parts of the body tissues, in a determination of the tissues involved in the process of degeneration in each specific instance, and in the subsequent treatment thereof by means of supplying to the blood the elements necessary to regenerate the tissues in question. From this brief explanation may be judged the importance of the hygienic dietetic physician in cases of sickness. The quack and charlatan it is who persuade people to believe that they do not need the physician, and compel them to pay for this belief in money and in health. It is the obvious duty of every one to seek aid in case of sickness from some physician who is a profound and professed advocate of the only sensible, practical method of treatment; but, at the same time I would make it possible for all to acquire sufficient knowledge to enable them to judge for themselves whether the attendant summoned responds in some measure to this requirement, the simple and logical course of which contains at least some ray of hope for all who suffer. * * * * * It may not be amiss to cite here a brief outline of the teachings of the four bright particular stars who have served as beacon lights in the history and development of medicine. Not only does the modern medical world acknowledge the doctrines of these four men as the foundation upon which the practice of healing has been raised to a science, but moreover,--_a point much more important for our consideration_,--it also admits that the least essential part of the work of Hippocrates, the "Father of Medicine;" namely, his _statement of theory_, is the part which has been accorded permanent prominence, whilst the portion of greatest value in his labours; that is to say, the _practical part_, has been neglected and ignored. The following passages are taken from the article entitled "History of Medicine" in the Encyclopedia Britannica, 11th. Edition, vol. XVIII, pages 42-51. "_Hippocrates_, called the 'Father of Medicine,' lived during the age of Pericles, (495-429 B.C.), and occupied as high a position in medicine as did the great philosophers, orators, and tragedians in their respective fields. His high conception of the duties and position of the physician and the skill with which he manipulated the materials that were at hand, constituted two important characteristics of Hippocratic medicine. Another was the recognition that disease, as well as health, is a process governed by what we call natural laws, learned by observation, and indicating the direction of recovery. These views of the 'natural history of disease' led to habits of minute observation and careful interpretation of symptoms, in which the Hippocratic school excelled and has been the model for all succeeding ages, so that even now the true method of clinical medicine may be said to be the method of Hippocrates. One of the important doctrines of Hippocrates was the healing power of nature. He did not teach that nature was sufficient to cure disease, but he recognized a natural process of the humours, at least in acute disease, being first of all _crude_, then passing through _coction_ or digestion, and finally being expelled by resolution or crisis through one of the natural channels of the body. The duty of the physician was to 'assist and not to hinder these changes, so that the sick man might conquer the disease with the help of the physician.'" "_Galen_, the man from whom the greater part of modern European medicine has flowed, lived about 131 to 201 A.D. He was equipped with all the anatomical, medical, and philosophical knowledge of his time; he had studied all kinds of natural curiosities and was in close touch with important political events; he possessed enormous industry, great practical sagacity, and unbounded literary fluency. At that time there were numerous sects in the medical profession, various dogmatic systems prevailed in medical science, and the social standing of physicians was degraded. He assumed the task of reforming the existing evils and restoring the unity of medicine as it had been understood by Hippocrates, at the same time elevating the dignity of medical practitioners. In the explanation and healing of diseases he applied the science of physiology. His theory was based upon the Hippocratic doctrine of humours, but he developed it with marvelous ingenuity. He advocated that the normal condition of the body depended upon a proper proportion of the four elements, hot, cold, wet and dry. The faulty proportions of the same gave rise, not to disease, but to the occasions for disease. He laid equal stress upon the faulty composition or dysaemia of the blood. He claimed that all diseases were due to a combination of these morbid predispositions, together with injurious external influences, and thus explained all symptoms and all diseases. He found a name for every phenomenon and a solution for every problem. And though it was precisely in this characteristic that he abandoned scientific methods and practical utility, it was also this quality that gained for him his popularity and prominence in the medical world. However, his reputation grew slowly. His opinions were in opposition to those of other physicians of his time. In the succeeding generation he won esteem as a philosopher, and it was only gradually that his system was accepted implicitly. It enjoyed great, though not exclusive predominance until the fall of Roman civilization." "_Thomas Sydenham_, (1624-1689) was well acquainted with the works of the ancient physicians and had a fair knowledge of chemistry. Whether he had any knowledge of anatomy is not definitely known. He advocated the actual study of disease in an impartial manner, discarding all hypothesis. He repeatedly referred to Hippocrates in his medical methods, and he has quite deservedly been styled the English Hippocrates. He placed great stress on the 'natural history of disease,' just as did his Greek master, and likewise attached great importance to 'epidemic constitution,' that is, the influence of weather and other natural causes on the process of disease. He believed in the healing power of nature to an even greater degree than did Hippocrates. He claimed that disease was nothing more than an effort on the part of nature to restore the health of the patient by the elimination of the morbific matter. The reform of practical medicine was effected by men who advocated the rejection of all hypothesis and the impartial study of natural processes, as shown in health and disease. Sydenham showed that these natural processes could be studied and dealt with without being explained, and, by laying stress on facts and disregarding _explanations_, he introduced a _method_ in medicine far more fruitful than any discoveries. Though the dogmatic spirit continued to live for a long time, the reign of standard authority had passed." "_Boerhaave._ In the latter part of the seventeenth century a physician arose (1668-1738) who was destined to become far more prominent in the medical world than any of the English physicians of the age of Queen Anne, though he differed but little from them in his way of thinking. This was _Hermann Boerhaave_. For many years he was professor of medicine at Leyden, and excelled in influence and reputation not only his greatest forerunners, Montanus of Padua and Sylvius of Leyden, but probably every subsequent teacher. The Hospital of Leyden became the centre of medical influence in Europe. Many of the leading English physicians of the 18th century studied there. Boerhaave's method of teaching was transplanted to Vienna through one of his pupils, Gerard Van Swieten, and thus the noted Vienna school of medicine was founded. The services of Boerhaave to the progress of medicine can hardly be overestimated. He was the organizer and almost the constructor of the modern method of clinical instruction. He followed the methods of Hippocrates and Sydenham in his teachings and in his practice. The points of his system that are best known are his doctrines of inflammation, obstruction, and 'plethora.' In the practice of medicine he aimed to make use of all the anatomical and physiological acquisitions of his age, including microscopical anatomy. In this respect he differed from Sydenham, for the latter paid but little more attention to modern medicine than to ancient dogma. In some respects he was like Galen, but again differed from him, as he did not wish to reduce his knowledge to any definite system. He spent much time in studying the medical classics, though he valued them from an historical standpoint rather than from an authoritative standpoint. It would almost seem that the great task of Boerhaave's life a combination of ancient and modern medicine, could not be of any real permanent value, and the same might be said of his Aphorisms, in which he gave a summary of the results of his long experience. And yet it is an indisputable fact that his contributions to the science of medicine form one of the necessary factors in the construction of modern medicine." * * * * * These extracts represent the principles of that bright constellation of Master Minds who have gone before us and guided our footsteps through tedious and tentative wanderings into the pathway of Truth. May their undoubting, united testimony act as a reassuring, convincing influence which will carry the reader back to the very fountain head of Medical jurisprudence, through the medium of the Encyclopedia Britannica, the highest accepted authority and criterion of authenticity in the English speaking world; for, at the same time it will also provide a positive and perfect safeguard and assurance of the solid basis and absolute authenticity of my methods and teachings besides indicating definitely the source and direction whence they are derived and establishing their classical trend and legitimate purpose. SYSTEM OF REGENERATION In order to bring the entire system of regeneration under review, I shall here endeavour to present in condensed form all the essential points in my teachings. The reader will thus be enabled to picture to himself his body, with its vital organs, clearly as in a mirror; he will become familiarized with its composition and twelve principal tissues, as well as with the sixteen elements of which they consist. Man is a unit, and the human body an accumulation of millions of separate cells, which are centres of life and which, in different groupings and combinations, form the various organs that render existence possible. This existence is the natural sequel of the existence of former human beings. They generated the life that is to be transferred by us to other living beings. The several functions of the organism combine to form a chain of activities in which there must not be a single link missing, if life is to continue. These activities are comprised within an accumulation of cells which are by no means stationary, for life means nothing more than the constant dying, of the old cells and the reconstruction of the new. It means that the human body as a whole is continually in a state of composition and decomposition. Not until the accumulation of cells we call the body is recognized as one complete correlated and inseparable entity and the absolute interdependence of the separate cells, each one upon the others, is likewise accepted as the verified fact that it is--not until then will the erroneous and obsolete idea be discarded, by which the various organs of the body have been professionally treated as separate and independent considerations, even to the extent of being dealt with, in cases of disease, as totally aloof from one another and conveniently classed as proper subjects for submission to the expert opinion of that superior class of physicians who devote their attention exclusively to special organs and are accordingly termed "Specialists." Thus the question arises: What is the cause of _disease_? The question does not apply to any one particular form of disease or class of diseases, but to disease generally, as a concrete term meaning any disorder which may manifest itself by individual disturbances in the body; for such disturbance is but a variation in quantity or quality of one general disturbance, a variation in the mechanism that controls the work of keeping the existing cells in proper condition and replacing those cells which are constantly being destroyed. It is a variation in the process of _regeneration, which we term life_. METABOLISM is the process which is constantly going on in the human system, whereby the cells that have been consumed by oxidation are removed through the excreta--the faeces, the urine, the perspiration, and the exhalations from the lungs--to be replaced by new ones. _Metabolism_, means change of matter. It signifies the course by which nutritive material, or food, is built up into living matter. This process is accomplished through the blood, which distributes the necessary material to all parts of the body where cells need to be replaced and carries away the consumed portions. In the marvelous performance of its functions, when properly supplied, it carries the elements that are essential to regeneration in the correct proportions. When not properly supplied, these proportions become incorrect and foreign formations may arise which are disturbing to the organism. In nature there is a constant tendency to counterbalance disturbances in the proper proportion and by distribution of cell building material to restore the normal condition. We may thus speak of the overwhelmingly curative tendency of nature. Metabolism is the function of the body which most constantly requires attention. So, therefore, it is always through the blood that we must assist nature in the process of counterbalancing and rectifying or healing abnormal conditions. It follows then, that, despite the apparent variety in _constitutional_ diseases, they are all practically the same. They are all disturbances of metabolism through some irregularity in the quantitative or qualitative condition of the blood. Professor Jacob Moleschott, the great physiologist, has crystallized this truth in the immortal words: "One of the principal questions to be always asked of the physician is this: How may good healthy and active blood be obtained? View the question as we may, we shall be forced to acknowledge openly and explicitly or guardedly and indirectly that our volition, our sensations, our strength, and our pro-creative powers are dependent upon our blood and our blood upon our nutrition." If such unity exists, why then the great difference in the human organs? How is it that a bone in its stonelike hardness is essentially the same as the exquisitely sensitive eye? This is owing to the adaptive property of the cells, in the course of their enormous accumulation, to different functions, which, again, depends upon the varied arrangement of the constituent elements. These elements all find lodgement in the blood, and are carried by it in necessary quantities to the points where they are needed to assist the organs in replacing consumed matter. The difficulty found in grasping this idea of _unity_ has led to the most momentous errors in modern medical science. One result has been the undue attention paid to the study of anatomy, insomuch that the different organs are regarded as wholly distinct groups of cells. This is convenient from a descriptive standpoint, but it tends too much to draw attention away from the source of life, and of health. Only by noting the common characteristics of the cell accumulations termed organs, are we enabled to supply the necessary elements that may be lacking. And thus we arrive at the subject of _the chemical analysis of the human body_ and its various organs, a subject that has been badly neglected throughout the centuries. It has been determined that the entire human body consists of a certain number of chemical elements, appearing in different aggregations in different parts. These aggregations repeating themselves in the various organs. Twelve principal aggregations of chemical elements have been established and designated by the term _tissues_. This fact led to the discovery of the truth that in the process of healing attention must be given, not to the various organs, but to the various tissues. These tissues are dependent directly upon the condition and contents of the blood, whose office it is to nourish them and which exhibits the wonderful property of conveying to each tissue its selective regenerative materials, _provided of course, that these elements are present at the time in the blood_. Sixteen definite elements have been established--and a seventeenth will probably soon be added thereto--which, in their various combinations and aggregations, form the different tissues of which the organs in the human body are composed. The prevalence of one or several of these elements in a certain tissue forms the main or governing feature of that tissue. Thus, the prevalence of potassium phosphate characterizes muscle tissue, the prevalence of ammonium phosphate (lecithin) nerve tissue. Each one of the various tissues consists of certain of these elements, and each tissue at every point where it occurs is affected by the lack of any of its elements. One of the greatest physiological chemists, Justus von Liebig, maintains that, if one of the necessary elements in a chemical composition is missing, the rest cannot fulfill their duties and the respective cells must become diseased and degenerate. This discovery, known as "the law of the minimum," has thrown additional light upon the tasks before the new school of medicine. Upon the basis of a careful diagnosis, the necessary nutritive salts or cell-foods, carefully compounded in accordance with the law of chemotaxis must be administered. This law discovered by _Engelmann_, requires that these cell-foods must be administered in digestible and assimilable forms so that the cells will be attracted by the chemical reaction, which may be of a positive or a negative character. This being so, we can easily build up the tissues, by studying their chemical composition and supplying to the system that which is necessary, in the form of food. The cell will take care of the rest. Each tissue has its specific cell-system, and each cell will be attracted only by those ingredients which are needed for the mother tissue. _To bring to a tissue through the blood the lacking constituent element or elements is the only means of regenerating and healing diseased cells._ In this connection we are considering only constitutional diseases. It has been shown that the lack of certain chemical elements from the blood signifies disease and that the variety of the disease depends on which of the elements are either lacking entirely or are present in incorrect proportion. After this lack has been determined, the course to pursue in curing the disease is to supply the lacking chemical elements in the form of concentrated cell-food in _addition_ to the regular food. This method displaces entirely the old system of filling the body with poisonous drugs in order to _counteract the effects of the disease_. Such a system may suppress the symptoms by benumbing the nerves and preventing pain, it may counteract the natural process of healing of which inflammation, fever and pain, are the outward manifestations;--_but it can never cure_. The discovery of dysaemia, or impaired blood supply, as the governing cause of disease, has destroyed another idol of modern fetish worship in medicine. Since the discovery of various species of bacilli, which accompany nearly every form of disease in some form or other, these have been commonly declared to be the causes of diseases, and the tendency is to find some poison that will kill the bacilli in order to cure the disease. The bacillus, on the contrary, is only the consequence, or symptom, of a disease. The diseased and decomposing parts furnish fertile soil suitable to the propagating of bacilli because of the lack of the normal chemical elements in the blood and tissue. But to kill them, while the underlying conditions for their reproduction remain unchanged, can, obviously, never effect a cure. So the great hopes that have attached to sero-therapy are doomed to disappointment, and the application of anti-toxins prepared from the serum of animals, are fated shortly to vanish in the wake of others of those strange temporary crazes which periodically obsess mankind for a while and pass away. The discovery that a dysaemic condition of the blood leads to certain destructive processes termed diseases, was soon followed by the apprehension that one of the principal factors in bringing about such disturbance is _predisposition_,--in many cases heredity. The term "Hereditary disease" signifies that the improper chemical composition of the blood of one or both parents is transmitted to the offspring, and that it causes in them likewise a degeneration of certain tissues and of the organs composed of those tissues. The hygienic-dietetic system of healing does not, however, regard heredity as an invincible enemy, especially since my discovery of the "Law of the Cross-Transmission of Characteristics." It is in the solution of this problem of "hereditary disease" that my system will eventually come into its own and will ere long be recognized as the most rational and effectual therapy ever applied since the beginning of the art of healing. It may be years before it is accorded the proverbially tardy acknowledgment of the "orthodox" schools, but that it will, nay _must_ be eventually adopted is virtually a foregone conclusion--that is, if it be indeed the function or policy of the physician of the future to adequately seek to succour the suffering and regenerate the races of mankind. Of the physician of the present it can at best be said in Goethe's incisive words: "Er halt die Theile in seiner Hand, Doch fehlt ihm leider das gelst' ge Band." He holds the parts within his hand, But lacks the mental grasp of all. For full explanation of the significance of my law, I must refer you to the first lecture in my book entitled "Within the Bud,"--and the lesson therein on the theory of "Pangenesis," which space forbids my repeating here. This lesson will convey conclusively to any thinking mind what heredity really means. After a brief study of this interesting subject the importance of the "Law of the Cross-Transmission of Characteristics" will become amply apparent and the intelligent reader will undoubtedly wonder why it has not been applied and acknowledged long ago. For answer, I must refer you to the schools, whose policy it has ever been to, at any rate, abstain from assisting, if not absolutely to diplomatically hinder the development of fresh scientific discoveries. But the time is fast approaching when a sharp and decisive end to this iniquity will be demanded by the will of an enlightened people; only then will the existing orthodox power be compelled to loosen its obstructive grip which the interests of humanity have, so far, been powerless to unclasp. But, to quote the stirring words of one who looked with prophetic, faithful eye into the tangled problems of futurity: "The people will come into their own at last,-- God is not mocked for ever." My Law of the Cross-Transmission of Characteristics may be simply stated as follows: Under all conditions, the matter of sex is determined in the egg-cell at the moment of fertilization. Under all conditions, the sex is determined by a struggle for the mastery in the egg-cell, between the energy of that egg-cell and the energy of the male spermatozoon. In a crisis, when the life of one of the two seeds is trembling in the balance, one of them--through the exertion of its "Latent Reserve Energy," dominates, and engenders a child of the opposite sex. This reversal of the sex is in conformity with the Law of the _Cross-Transmission of Sex_; that is, the mother is represented in the male offspring and the father in the female,--this being the normal expression of the Law of Cross-Transmission of Characteristics. The "Latent Reserve Energy" is provided by nature for the "Preservation of Species," and through this provision an impulsive, vehement energy can, at the final moment of a crisis, be called upon for the salvation of its kind. A _seeming_ exception to this is due to the "Law of the Dominant" which overrides the action of "Latent Reserve Energy," and is a provision of nature for the preservation of the "Dominant," which is the most prominent quality in nature. When the subject is properly understood, this _seeming_ exception will also become clear. In the natural course, the study of heredity leads to the understanding of _predisposition_. In other words, if you have understood heredity, it will be easy to understand predisposition; for it means that the protoplasm or seed, from whichever organism it may proceed, must contain some of the salient characteristics of its ancestors, good and bad, dominant and recessive. Not only will it contain characteristics from father and mother, but from _all_ the direct ancestors. It is impossible to know exactly which points will manifest themselves, but a good many _bad_ points _may be_ eliminated by studying the ancestral line; and the direct diseases or bad characteristics of a parent, _must be_ eliminated by applying the Law of the Cross-Transmission of Characteristics. For example: If the father has a certain disease or positive symptoms of that disease, by no means create a girl, as she will certainly be predisposed for that disease, and may pay the penalty, if "Regeneration" is not begun early. The same principle applies to the mother. If she is diseased, do not create a son, until "Regeneration" has been brought about. Furthermore, it will be possible to improve the offspring by encouraging and promoting the good points, especially after studying and applying the above law, as well as my law of the "Determination of the Sex at Will." Looking at the question from this point of view, we begin to realize the enormous significance of my discovery. This supplies the main reason for the study of the laws, for the "_Prevention of Diseases_." Only when we know that every acquired characteristic may be transmitted to the offspring will we become conscious of the _terrible responsibility_ we assume when we reproduce offspring, and realize that we may create more pain and suffering instead of eliminating it. As Nature _demands_ that we reproduce ourselves or be punished for disobeying her laws, what is to be done? Study and follow the advice given in this book, and you will awake to the fact that Nietsche's words were not "Utopian" when he commanded us to "reproduce something better than we are." Together with the predisposition to disease, the child also acquires the hereditary tendency to regeneration; and thus rational hygienic-dietetic treatment may be able to eliminate the diseases which were formerly pronounced incurable. This can only be effected by the effort to remove the cause and strengthen the weak points by means of Regeneration. The reader will now plainly understand that in order to heal, according to the hygienic-dietetic system, the blood must be supplied with the chemical elements that are missing from the tissues. There are three ways of accomplishing this; namely, by diet, by nutritive preparations, and by physical treatment. The first and most natural way is by means of proper diet. Since the chemical elements are introduced into the body through the food, the quantity and quality of the food must be regulated. The patient must receive food that will help in regenerating his blood; particularly such food as contains the elements that are lacking in the affected tissues in his body. The regular supply of food is however usually insufficient to overcome the process of destruction, and it is therefore necessary to add the missing elements in purer form and larger quantity. These nutritive preparations contain only such chemical elements as exist in the human body; they also contain them in the proper chemical proportion and are entirely free from poisonous substances. They promote a general regeneration of the blood that will eventually lead to a complete cure. Physical treatment may be made to assist the proper circulation of the blood, opening at the same time the pores of the skin for the withdrawal from the body of disease elements and the introduction of desirable material. Massage, gymnastics, ablutions, and various kinds of baths and packs constitute the most of the healing measures of this description resorted to. This is indeed the legitimate field for Osteo-Chyropractice. In order to understand the method of treatment which I apply, it is necessary to understand one of the great laws of physiological chemistry, acknowledged as such by the great masters of chemistry, such as Liebig and Hensel. This law demonstrates that _nature is a unit, its component parts a given number of elements, each of which has distinct qualities, and the combination of which produces the various manifestations of life_. These elements are classified as combining to form minerals, plants and animals. They are all closely interrelated. The plant draws the mineral elements from the soil, and after certain processes of combination, conveys them as food to the animal. The animal substances that man consumes make up the balance of the elements that are required to build up the human body. It is a matter of comparatively new discovery that the minerals are just as important a part of the human body and of its food as the other basic chemical elements. The discovery showing of what minerals the necessary ingredients of the different body tissues are composed and in what combination and quantity, in order that they may become incorporated into the organism, has made it possible to supply them to the diseased body in the purest and most effective way through nutritive preparations, while their existence in food also furnishes an indication as to the regulation of diet. I have already given, in the preceding pages, the frank expression of favourable opinion upon this vital topic generally, as voiced with unmistakable, conviction by no less an authority than Assistant Surgeon-General, Dr. W.C. Rucker of the United States Public Health Service. I will now cite, in further corroboration, the opinion of the distinguished Editor of "The Fra," as addressed to myself personally, in special relation to an advance section of the book "Dare to be Healthy," together with other similar matter, and which, coming as it does from one who is himself a leader in the van of the advancing phalanx of the followers of Truth and Enlightenment, may be safely held to constitute a just criterion of the literary and technical value of the work. It is expressed as follows: _From John T. Hoyle, Managing Editor of "The Fra."_ "From my reading of your 'Lessons,' and especially from 'Dare to be Healthy,' I can see that you have evolved a new concept in medicine, or rather 'Nature Healing,' which promises great results. I trust you will be able to put the whole into a printed book that we may all have the benefit of your discoveries. Unlike most physicians, while you treat of the most profound and vital scientific subjects, your language is so well chosen and your method of presentation is so clear, that no intelligent person would have difficulty in following your thought. You have undertaken a monumental work, and that success may attend your efforts is our heartfelt wish." _From Elbert Hubbard._ "What I have read of it is intensely interesting and shows that you have a keen insight into the philosophies of life." There are other spontaneous and unexpected testimonials of an equally encouraging and complimentary nature from men whose knowledge and attainments entitle their opinions to the tribute of respect. These might well be likewise added here, but for the necessary limitations of space. When Moses saved the hosts of Israel from starvation in the desert, by obtaining the solid and liquid food requisite for their deliverance, he called the name of that food "Manna." in like manner, both as a just tribute to the success they have achieved in the past and as an earnest of the deliverance they are destined to achieve in the future, I have designated my preparations by a similar term and called them the _"Dech-Manna" Nutritive Preparations_. Although presented in so condensed a form, the preceding outline cannot fail to inspire in the mind of the reader a vivid conception of the simple grandeur of nature's handiwork, more especially as regards her provisions in relation to health and disease--secrets revealed, through microscope and alembic, to those who, in spite of organized discouragement, have attempted to fathom the erstwhile mysteries of human suffering and to carry hope and freedom into the hostile camps of Fear, Disease and Death. To bring these considerations within the comprehension of all, and to win all, so far as possible, to the practical observance of the means and precepts of Health and Safety is the object of the projected course of study of which the following is the business proposition. THE DARE TO BE HEALTHY CLUB BUSINESS PROPOSITION The course of study in connection with the above consists of A SERIES OF ONE HUNDRED LESSONS to be issued in weekly instalments, the whole course to extend over a period of two years. Each lesson will consist, approximately, of some twenty-two to twenty-five full-sized pages (i.e. 25/28 lines of 8/12 words each) which will be mailed to every subscriber weekly prepaid. It is necessary, in view of contingent expenses that a membership of _One thousand subscribers_ should be obtained, as only when such an amount of support is guaranteed would the printing of the hundred lectures under the easy and advantageous terms offered be at all justified. If, however, it should be represented to me by those most immediately interested, that it is their desire to Confine the Club to narrower limits, I might, though with some reluctance, consider the advisability of reducing the minimum membership to _One hundred students_ provided that these should agree to contribute the sum total of the fees for the two years course in advance. With every twentieth lesson will be forwarded to the subscriber, gratis, one of five well bound volumes of superior literary attraction and interest. These five volumes are as follows: ATLAS OF HUMAN ANATOMY (profusely illustrated with coloured plates and containing folding manikin) especially compiled for the student. MANUAL OF PHYSIOLOGY, especially compiled for the student. MANUAL OF PHYSIOLOGICAL CHEMISTRY, especially compiled for the student. MANUAL OF BIOLOGICAL THERAPY, Dechmann's system, (500 pages). MEDICAL DICTIONARY (pocket edition in flexible leather with gilt edges, giving 30,000 definitions.) At the end of the course each student in good standing, will receive free of cost a Membership Diploma in the form of a beautifully artistic colour plate, the facsimile of which will appear herewith. "Within the Bud; the Procreation of a Healthy, Happy, and Beautiful Child of the Desired Sex, by L. Dechmann, Biologist." This is a book of 302 pages, the paper bound edition retailing at $3.00, the edition de luxe at $5.00, can be obtained at any book store or direct from the author. The above literature cannot be otherwise procured, and its cost actually amounts to nearly one-half the subscription for the entire course of lessons. At the close of the course a beautiful engraved cover design for binding the 100 lessons may be obtained at the price of $1.00. Separate file binders and perforators for the lessons, each cover holding some 300 pages, may be obtained at the nominal cost of about 50 cents each; one of these will be delivered free with the first lesson. CELL-FOODS. In addition to these advantages, all members of the Club will be entitled to procure any supplies they may need of the Dech-Manna Cell-Foods at special (wholesale) prices. LOUIS DECHMANN. _Biologist and Physiological Chemist._ 127 North 59th Street, Seattle, Wash., U.S.A. THE BASIS OF PROCEEDINGS _of_ THE DARE TO BE HEALTHY CLUB In the ensuing pages I shall endeavour to give the reader a necessarily brief and cursory, glance into the subjects which will form the underlying motif of the vast and manifold deliberations which will constitute the fundamental basis of the projected course of study which will be brought under the consideration of the members of the proposed association and will constitute the schedule, as it were, of the periodical dissertations of these matters of world-wide and vital individual significance to be comprised in the Series of One Hundred Lessons. I have been at some pains to avoid as far as possible the use of technical and professional phrases and terminology, for the express purpose of bringing within the scope of every faculty of understanding these subjects which are equally _a matter of life and death importance_ to every man, woman and child, in all the wide and varied range of nationalities and languages which constitute so large a part of our great Republic and upon whose health and efficiency so much of our national life depends. The great and ominous unrest, so much in evidence of late, is ample proof of a latent popular dissatisfaction with the conditions of life and it is equally significant of the prevailing nervous tension--the obvious result of malnutrition of the system--which is one of the most prominent popular features of the worry-worn denizen of today. Life, Health, Happiness--that vital interdependent triad--are surely a preoccupation strong enough and precious enough to startle the minds of the most complacent; and it is with the object of awakening all to their possibilities--in health or in disease--of protection of the one, and hope and regeneration under the other, that the course of study has been inaugurated of which the following is but a bare outline. MAN AS A UNIT.[A] The human body is an accumulation of millions of separate cells, which are the bearers of life, and which in various groups form the different organs, the combined action of which constitutes our individual existence. This existence itself is the natural issue of the existence of our predecessors, who generated the new life which will be transmitted by us and reappear in our offspring. In like manner all the functions of the body form an endless chain in which not a single link must be faulty or missing, if healthy organic life is to continue. This accumulation of cells, however, is by no means inactive. On the contrary, organic life is nothing but the constant dying of the old and the reconstruction of new cells; it means that we are in a perpetual condition of composition and consequently of decomposition throughout our entire being, its different parts and organs. As soon as we are able to recognize this accumulation of cells as one individual whole and thus arrive at the idea of their absolute interdependence, we shall get rid of the prevalent idea, that the mere structural differences between the respective organs of the body make them separate and independent things which may be treated irrespective of one another in case of disease, or dealt with by different specialists. We arrive then at the one great question: _What is the cause of disease?_ Not of one or other form of disease or class of diseases, but of disease as a whole. _There is, in fact, only one disease._ What appear to us as different disturbances of the normal condition of our body, are only variations, in quantity or in quality, of the one thing. It is the variation of the controlling element which performs the necessary work of keeping the existing cells in proper condition and replacing those which in the course of nature are destroyed. In a word, the work of _perpetual regeneration, which is life_. METABOLISM. This continuous changing of the entire human body,--the removal of the discarded cells, burned up by oxidation and expelled from the body in the urine, the perspiration and other excretions, and their replacement by new ones,--is called metabolism, that is, "change of matter." This change is brought about by means of a vital fluid in the body, which circulates from the moment in which the spermatozoon, or male seed, touches the female egg in the womb of the mother, until the time of our last breath. That fluid is _the blood_,--the carrier of nature's supplies to all parts of the body for the rebuilding of cells; the exact and equitable distributor in quantities of material which determines the quality of the cells. In its marvelous performance of this function, the blood is the bearer of the sole existing condition of health; namely the necessary elements of cell-building in the right proportions. This is health, and the lack thereof is disease. The demand of nature for upbuilding and rebuilding is the strongest instinctive impulse of our being; and this being so, a wrong proportion may cause the upbuilding of things which are different and disturbing to the normal organism. But, on the other hand, kindly nature exhibits an ever existent inclination to counterbalance any disturbance in the right proportion, and to bring back conditions to uniformity. We may thus justly speak of _the overwhelming healing tendency of nature_. Metabolism is, therefore, the one great dominant function of the body which, accordingly, must have our especial care. It is the blood, consequently, to which alone we can resort if we desire to assist nature in its process and tendency of balancing and healing. This again indicates that, notwithstanding the apparent great variety of _constitutional diseases, they are all practically one and the same disease. They are all disturbances of proper metabolism, by some irregularity of the quantitative or qualitative condition of the blood_. This governing truth the great physiologist, Prof. Jacob Moleschott, has formulated in the memorable words: "It is one of the chief questions which humanity must always ask of the physician: how to attain good, healthy and active blood. And, view the question as we may, all who give it serious thought, are forced by experience to acknowledge explicitly, or otherwise, that _our mental and physical capacity, and likewise the power of reproduction, are directly dependent upon our blood, and our blood on our nutrition_." VARIETY OF ORGANS. Why then, you may ask, if such unity exists, why this dissimilarity in the tissues of the respective bodily organs? How is it that a bone in its stonelike hardness is essentially the same as the infinitely tender tissues of the eye? This difference is due to and accounted for by the adaptation of certain portions of the immense accumulation of cells to diverse functions, which has necessitated the variable conformity of the supporting elements. But all of these elements are in the blood, which carries them in the necessary quantities to the different organs to which they belong and where they are utilized to replace used-up matter. I do not overlook the difficulty of grasping this idea of unity. The fact, that it is so difficult to realize, has led to the greatest errors in present day medical science. It seemed at first sight, so obviously necessary to study the different organs as entirely different groups, to work out a careful system of bones, of intestinal organs, of blood-vessels, of nerves, and so on; all of which is of course very valuable, in its place, but only from a descriptive standpoint. Anatomy shows us what life has produced in the construction of a human form, but it does not indicate the source of life, nor, consequently, the source of health. It is well to know the different forms of cell accumulations, which are called organs, but if we desire to keep them in good order, we must watch closely what is common to them all; for it is only from this point of view, that we are able to determine the necessary, and possibly, the lacking elements for purposes of healing. Thus, as one of the greatest achievements of modern science, we come to the one most vital thing, so sorely needed and yet so badly neglected throughout the centuries: _The chemical analysis of the human body and its different organs._ A new light has now dawned upon the subject most essential to the inauguration of a new and effective system of healing. The physiological chemist has at length discovered that the human body, and every organ of that body consists of a certain number of chemical elements, which appear in different parts in different aggregations. These aggregations, however, repeat themselves in the various parts or organs. It was thus finally discovered that there are _twelve different main aggregations of such elements_, which groups of equal elements we call _tissues_. Through this discovery we have arrived at the great truth that _it is not to the purpose, in healing, to turn attention to the various organs, but rather to the various tissues_. The influence which can be exercised on these tissues is exercised through the blood which nourishes all of them alike, and which has the wonderful capacity of carrying to each of them their necessary building and rebuilding, or regenerating materials,--_provided, of course, that these are, as they should be, present in the blood_. THE CONSTITUENT ELEMENTS. Research in physiological chemistry, has so far determined that there are sixteen definite and discernible elements--and a seventeenth is now in course of determination--which, in their various combinations and aggregations, form the different tissues of which the various organs of the human body are constructed. The preponderance of one or more of these elements in a certain tissue forms the main or governing feature, or tissue of any organ. Thus the prevalence of potassium phosphate forms the muscle tissue, the prevalence of ammonium phosphate (lecithin) forms the nerve tissue. For the purpose of general explanation it is sufficient to know that each of the various tissues consist of some of these elements, and that each of the tissues, at whatever part of the body it exists, is affected by the lack of any one of these elements. The greatest chemist of the age, Justus von Liebig, maintains that if one of the necessary elements in a chemical composition is missing, the rest cannot fulfil their duties, and the consequence of such deficiency is that the cell in question must become diseased and degenerate. This discovery, known as "the law of the minimum," has thrown an additional reassuring light upon the practice of the new school of medicine. _To bring to the tissue the lacking constituent element or elements by way of the blood is the only means of regenerating that tissue, that is, of healing its diseased cells._ DYSAEMIA THE CAUSE OF ALL CONSTITUTIONAL DISEASES. Within the limits of this abstract I do not propose to deal with the disturbances in the system caused by traumatic influences, such as wounds, etc. We are treating only of _constitutional_ diseases which, whether of acute or of chronic character, are all caused by the lack of such chemical elements as described. It has been shown that the blood supplies all the chemical substances to the different tissues, and that, consequently, it is the lack of these elements in the blood, which causes the tissues to degenerate, or, in other words, _the lack of certain chemical elements in the blood is disease_. It is, therefore, merely a question as to _which of the elements are missing or which do not exist in correct proportion_, that determines the different forms of disease. When once this fact is established, the method of healing consists mainly in supplying in the regular way, that is, _by certain additions to the regular food_, the missing chemical elements in organic form; and medical science has but _to determine which elements are wanting_, and consequently, must be supplied. _It goes without saying that in this system the old, pernicious drug method of filling the body with various poisons to counteract the effects or symptoms of disease, has no place whatever._ Certain poisonous drugs may prove effective to suppress certain symptoms by benumbing the nerves and preventing pain; they may, and do counteract the natural process by which nature exercises her power in various ways in the spontaneous effort to throw off disease, in the form of inflammations, fevers or pains; _but they can never heal, or eradicate disease_. With the discovery of dysaemia as the governing cause of disease, another idol of regular medicine has been cast down. Since the discovery of the bacillus or microbe, which in varied form accompanies nearly every variety of disease, it has become a dogma of the at present dominant school of medicine that the various bacilli are the actual causes of the different varieties of disease, and the tendency has been to find some poison that would kill the bacilli in order to heal the disease. The truth is that the bacillus is not the cause, but the effect of disease; in fact is nothing but another consequence or symptom of a specific form of disease. Bacilli grow spontaneously in the ready soil which the diseased and decomposing tissues provide, through lack of the necessary chemical elements; but to attempt to exterminate them, while the underlying conditions for their reproduction remain unchanged, can, of course, never bring about healing. And thus the high hopes and claims attached to the sero-therapy inocculation process, the injection into the blood of anti-toxins prepared with the serum of animals, have positively vanished. Hundreds of thousands of human beings have perished in the course of this delusion; but countless numbers will have cause, yet in our day, to rejoice at the exposure of the stupid and unnatural theory, so long legally enforced, that the introduction into the human system of such poisonous substances could remove or overcome the natural consequences of constitutional disease. HEREDITY. The discovery that a diseased condition of the blood leads to certain bodily disturbances which we call disease, was soon followed by the realization of the fact that one of the main conditions which bring about such disturbances is predisposition, which in many cases is hereditary. "Hereditary disease" simply means that the improper chemical composition of the blood of one or both parents has become duplicated in the offspring, and that it has similar consequences in causing the degeneration of certain tissues, and consequently of the organs composed thereof, as may have been the case in the parents. It is at least reassuring to know, however, _that to the modern hygienic-dietetic system of healing, heredity, though perhaps more tenacious, is by no means an invincible enemy_. With a predisposition to disease the child acquires also the hereditary tendency to self-protection, and thus rational hygienic-dietetic treatment may be able to eliminate, in a comparatively short time, the chain of diseases which in former years, generations have carried hopelessly to the grave. HEALING. It has been already stated that healing, under the modern hygienic-dietetic system, means supplying to the blood such chemical elements as will replace what are missing in defective tissues of the body. I will now outline the methods of carrying it into effect. In a general way there are three means of doing this: No. 1. _Diet_: The first and most natural way is by proper diet. As the normal chemical elements are introduced into the body as constituents of the regular daily food, the task which, in the first place, confronts the hygienic-dietetic physician is that of regulating the quantity, quality and description of food. Too little importance has heretofore been given to this question and, beyond prohibiting certain dishes and obviously detrimental viands, little attention was paid by the average physician to the matter of the every-day nourishment of the patient. The hygienic-dietetic physician on the other hand, employs the utmost care in giving to the patient everything that will help to regenerate his blood, laying particular stress on such foods as contain the largest proportion of the chemical elements that are missing in the affected tissues. No. 2. _Nutritive compositions_: The process of destruction, however, which has to be met, in more or less advanced stages, in nearly every case requires supply, in quantity of the pure material to compensate the deficiency of the missing elements, beyond that which could be derived in the ordinary way of digestion from every-day food. To meet this difficulty, certain condensed preparations have been devised. These nutritive compositions contain only such chemical elements in like chemical proportions as exist in the human body. They are of the purest material and contain no injurious elements whatsoever, while they foster that general regeneration of the blood which will finally bring about a complete cure. No. 3. _Physical treatments_: It is the object of these treatments to assist the proper circulation of the blood; to automatically open the pores of the skin for the external treatment of certain diseases; to withdraw elements of disease from the body, and to introduce certain material influences, through the pores. Massage, gymnastics, ablutions, various kinds of baths and "packs," constitute the chief features of the healing methods in this department. Following this general explanation of the system, I may now go a little deeper into the question of the constituent elements, the tissues formed therefrom, the degeneration of these tissues, and the species of degeneration which constitutes the various forms of disease commonly known to us. After this I will give a concise and simple general idea as to how my methods should be applied. THE UNITY OF NATURE. To fully understand the method of healing which I apply, it is necessary to understand one of the great natural laws, the discovery of which by the great chemists, Justus von Liebig and Julius Hensel, has shown us the path along which to proceed. This law demonstrates that, in the last analysis, _nature is a unit, a composition of a number of elements, each one possessing distinct qualities, the combination of which produces the various manifestations of life_. These are classified, for convenience, according to their main qualities, as minerals, plants or animals. All of them are closely interrelated and one transmits the basic elements to the other. It is the plant which draws the mineral elements from the soil, and after certain processes of composition conveys them as food to the animal, including the human being, while such animal substances as are used for human food, contribute the balance of the elements for the upbuilding of the human body. It is a matter of comparatively new discovery that minerals are thus just as important as a component part of the body and of its food as are other basic chemical elements. The discovery as to the mineral constituents of the body, their nature, proportion and in which composition and in which quantity as necessary ingredients of the different body tissues, in order that they may become a part of the organism, has made it possible to administer them to the diseased body in the purest condensed and most effective way in _nutritive compositions_, while their proportionate existence in food is also a criterion of diet, not only for the sick, but also as a preventative of disease. THE CHEMICAL PROCESS OF DISEASE. In this, my scrutiny of nature's deep designs, I did not rest content when only the composition of all the tissues of the body had been laid bare; but I delved deeper and discovered that certain electric currents and reactions of these elements were the causes of accelerating or retarding the natural processes of metamorphosis and metabolism,--provoking disturbances of the normal, which express themselves as disease. Excessive growth, and lack of growth, are thus explained, together with other phenomena which in this short chapter it is impossible to give in scientific detail. It is my object now merely to show that in their apparent simplicity the manifestations of life require special technical knowledge such as cannot be expected of the layman in any adequate degree. Notwithstanding this free and open statement of cause and cure available to the patient and to the world at large, the hygienic-dietetic physician himself can by no means be dispensed with in case of the appearance of disease, for only by his knowledge, experience, and skilled advice can the aforesaid natural system of healing be applied with effect in each individual case. And here it must always be borne in mind that, of the countless individual organisms that this world contains, no two, even, are exactly alike; and that consequently only the skilled and accustomed practitioner =will be able to regulate such hidden, internal processes as cause the visible disturbance, and thus bring about healing and regeneration, which simply means a return to the normal=. =His methods will prevent the use of the surgeon's knife, which only removes the symptom, leaving the cause untouched and inflicting useless and irreparable harm. The specialist, with his poisonous specific remedies for forms of disease, which after all are only degrees of chemical exhaustion, will also disappear, together with all similar treatment which enervates the body making it an easy prey to new attacks of the same chemical anomalies which must and will most certainly return so long as they are not rectified according to the principles of biology.= THE TWELVE TISSUES. Bearing the above principle of unity in mind, we may now proceed one step further, and study the most important details upon which the method of healing, as applied by the hygienic-dietetic physician, is based. As previously mentioned, the cells of the human body are organized into twelve distinct tissues, some of which are the component parts of the various organs as discernible by form and function. These twelve tissues are the following: 1. The plasmo tissue (blood plasma). 2. The lymphoid tissue. 3. The nerve tissue. 4. The bone tissue. 5. The muscular tissue. 6. The mucous membrane tissue. 7. The tooth and eye tissue. 8. The hair tissue. 9. The skin tissue. 10. The gelatigenous tissue. 11. The cartilage tissue. 12. The body tissue in general. 1. _The plasmo tissue_: This tissue is a liquid, the blood plasma, which is one of the important component parts of the life-giving substance, blood. It is the blood serum--blood-water and fibrogen--which harbours the white and the red corpuscles. The red corpuscles are the carriers of oxygen to the various tissues, which the body draws from the atmosphere, and of the other nutriments. They exchange it for the carbonic acid which is forming in the body, and while the blood in flowing through the system of arteries, brings the oxygen, it carries away, through the veins, the poisonous carbonic acid which is exhaled into the atmosphere. The red corpuscles, after having performed their duties, enter the liver and are used to build the gall. The proper quality of the plasma alone regulates the speed of blood circulation and ensures its entrance into the finest capillaries--the ultimate branches of the blood-vessels--hence, its capacity to carry supplies of nutriment to the tissues. The disturbance of this proper quality is among the main factors of constitutional disease. 2. _The lymphoid tissue_: The lymph is another of the life-giving liquids of the body, which through a vascular system of its own, draws certain nutritive substances from the food and carries them to certain organs which it feeds, especially the nerves. After this slow task is completed, the rest of the lymph enters the blood and is carried by it to other parts of the body where only smaller quantities of lymph are needed for nourishing purposes. The proper quality and chemical composition of the lymph, which is different from that of the blood, is of no less importance than that of the plasma for the preservation and regeneration of the organism. What the plasma is to the blood, the lymph is to the nerves. 3. _The nerve tissue_: A particular aggregation of cells forms the nerves, which, emanating from their center in the brain and spine, run as another separate system all through the body. This system, however, is not one of vessels; but the nerves may best be compared to the wires of a telephone system, establishing connection between the remotest parts of the body and its central point, from which the directions for both voluntary and involuntary movement are given and transmitted through the nerves. They are of a peculiar chemical composition in which the nerve fat (lecithin) plays a very important part, since its frequent presence in insufficient quantity is among the most common causes of a great number of nervous and other diseases. 4. _The bone tissue_: The bones consist of a special and very distinct tissue in which lime predominates. This gives them the strength and solidity which enables them to act as support to all the other organs. The bones too are fed by the blood, and it is through the blood that the necessary constituent parts for the regeneration of their tissue is conveyed to them. While naturally their power of resistance is greater than that of any other organ, they are nevertheless subject to a number of structural disturbances, other than traumatic, the causes of which are sometimes hereditary, sometimes acquired through deficient properties of the nourishing blood. Certain tissues which form the connection between the bones and the rest of the organs, and the gradual transition into other tissues, are subjects separate and distinct and will be treated separately. 5. _The muscular tissue_: As to quantity, the muscular tissue represents the maximum of any in the human body. The muscles do not only consist solely of this one tissue, but of several others, as do most of the other organs; but here, as in all other cases, the principal component element is called after the organ in which it is chiefly found. The structure of the muscular tissue varies according to its function, so that we distinguish between the striated and the unstriated or smooth muscles. This, however, has no influence on their chemical composition, a distinctive element of which is muscular fibrin, which has the particular property of contractibility. 6. _The mucous membrane tissue_: The mucous membrane forms the covering of many of the organs, and its chemical and structural composition is identical in all parts of the body. It is characterized by a viscid watery secretion from the mucous glands, which are always found in the mucous membrane. Its extremely delicate nature renders it subject to all sorts of irregularities in chemical composition. This is the cause of numerous diseases, most of which are due either to overproduction or underproduction of the secretion which regulates numerous functions of the body. 7. _The tooth and eye tissue_: While very different in external appearance, functions and physical qualities, the teeth and the eyes have nevertheless, the most important part of their chemical composition in common; namely, _the fluoric acid_, which distinguishes them from all other tissues. In the process of natural healing the replacing of any element lacking through destructive causes in either tissue will practically be the same. 8. _The hair tissue_: Certain chemical component elements are only found in the tissue which is called the hair, and which receives its nourishment like all other tissues, through the blood. While the hair may seem to be in apparently slight connection with the rest of the body, it is in reality, none the less an organic portion of the same, and dependent, like the rest upon the same central system of supply. 9. _The skin tissue_: With reference to this tissue, much the same remarks apply as already mentioned in regard to the mucous membrane. It, however, has certain chemical elements, which are characteristic to its various layers. Since the skin forms the most important intermediary between the external elements and the chemical and structural elements of the interior of the human body, it is of the greatest importance that its chemical composition should always be correct, and that it should not be subject to decomposition such as improper nourishment engenders. It should be borne in mind that the skin, like all other organs of the body, grows from the inside outward, so that any ailment concerning the skin, which is not of a traumatic nature, must be based upon wrong or insufficient nourishment, and cannot be cured in any other way than by internal regenerative means. 10. _The gelatigenous tissue_: This tissue, chemically and otherwise peculiar as it is, forms the chief component part of many of the human organs, and it may be truly said that the lack of attention which its peculiarities have received in the past is responsible for more disease and its fatal issue than almost anything else. The gelatigenous tissue contains a number of special component elements, which require special nourishment through proper diet; and in view of the fact that the gelatigenous tissue pervades so many of the various organs, its effect upon the functional abilities of a great number of them is obvious. The elasticity of most organs which work by contraction and expansion, depends entirely upon the gelatigenous, rubber-like tissue of which they are so largely composed. 11. _The cartilage tissue_: Practically the same applies to the cartilage tissue; but it is only recently that it has been found to what extent this is the case. Although entirely different in nature and chemical composition, the cartilage tissue serves to maintain certain outlines of form and feature in the human body, which are not based on the still stronger forms of supporting material, such as the bone tissue and the gelatigenous tissue. 12. _The body tissue in general_: This comprises the red blood corpuscles and all tissues which are in any way different from the distinct tissues just described, but which nevertheless cannot be classified as separately and distinctly independent. It may be justly presumed that all elements of the other tissues are to be found in these final tissues which share the unity of the organism. * * * * * By devising a specially nourishing dietary system for the body tissue in general, all component elements profit, in like degree, and such disturbances as attack practically all the tissues and organs of the body severally and conjointly; will be effectively prevented or cured in the regular course of nature, in strict accordance with biological principles. DEGENERATION OF TISSUES. Speaking biologically, if through some disturbance in the normal chemical composition of the tissues, degeneration sets in, we speak of it as disease. Such degeneration may attack one tissue or several at the same time. _To reduce the elements to their proper proportions, to force them thereby to reassume their normal functions, means to restore health, or, to heal._ As previously explained, it has been the great achievement of hygienic-dietetic science, based on the natural laws of biology, to discover that so many diseases which for centuries were considered as entirely different from each other in cause and treatment, were essentially the same. It was found that they were nothing but the natural consequence of impure or imperfect blood, the result of malnutrition of the vital fluid, the malign effect of which increases in degree and manifestation the longer the impurity passes, by process of heredity, from one generation to another. Instead of following the natural tendency to return to the normal, the blood becomes the fertile soil in which all manner of irregularities may germinate in abundance, and combine in strong attacks on the normal healthy organs, which will fast relax their natural power of resistance. The system of natural healing, while adhering closely to the principle of the unity of the body as well as of the unity of disease, has by no means ignored that such differences are due to the differences in the twelve tissues and _according to the said differences, the constitutional diseases are grouped under the accustomed titles, as follows_: 1. Degeneration of the plasmo tissue: Anaemia, Chlorosis, Pernicious Anaemia, etc. (A.) Scrofulosis. (B.) Tuberculosis. (C.) Syphilis. (D.) Cancer. 2. Degeneration of lymphoid tissue: (See I.--A. B. C. D.) 3. Degeneration of the nerve tissue: Neuralgia, Neuritis, Neurasthenia, Asthma, Epilepsy, St. Vitus's Dance, etc., etc. 4. Degeneration of the bone tissue: Rickets, Osteomalacia and similar diseases. 5. Degeneration of the muscular tissue: Muscular Rheumatism, Sciatica or Nerve Rheumatism, Atrophia, Amyloid heart, kidney and liver. 6. Degeneration of the mucous membrane tissue. (A.) Catarrh in all its forms: Bronchitis, Pleurisy, Pneumonia, Inflammation of nose, throat, bowels, stomach, bladder, etc. (B.) Hemorrhoids, Polyps, Adenoids. 7. Degeneration of the tooth and eye tissue: All tooth and eye diseases. 8. Degeneration of the hair tissue: All hair diseases. 9. Degeneration of the skin tissue: All skin diseases. 10. Degeneration of the gelatigenous tissue. (A.) Stomach and Intestinal diseases--acute forms. (B.) Stomach and Intestinal diseases--chronic form. 11. Degeneration of the cartilage tissue: Ankylosis, Gout, Arthritis deformans. 12. Degeneration of the body tissue in general. (A.) Locomotor ataxia. (B.) Basedow's disease. (Graves disease.) (C.) Diabetes mellitus. (D.) Obesity. (E.) Bright's disease. (F.) Arterio-sclerosis. THE A.B.C. OF MY SYSTEM OF HEALING. Setting aside for the time being the special groups of more complicated diseases, such as are characterized by the degeneration of several of the tissues at the same time, I will now give a short and comprehensive description of the several distinct groups of disease. In each case, as already shown, there must be a joint co-operation of these three factors: (A.) _Diet_, or the natural means of providing both healthy and degenerating tissues alike with such substances as will support and strengthen the healthy tissues, enabling them to resist the danger of disease and consequent decomposition, and will also arrest degeneration and prepare the way for the regeneration of the tissue which is already affected. (B.) _Nutritive compositions._ Such as will in each case introduce into the system in a pure and proportionate combination, the necessary quantities of the sixteen nutritive elements, the lack of which is the characteristic factor of all disease and which diet unaided could not adequately produce with the needful speed and proportion, unless supplemented in this simple and effective manner. (C.) _Physical treatment_, for the purpose of assisting the proper distribution and assimilation of these nutritive factors--(A. and B.)--and promoting the proper circulation of the blood. DIET. This is a subject of vast and vital importance. It comprises the science of alimentation, which forms one of the indispensable functions of life; it is thus, of necessity, a serious preoccupation under all conditions. I have treated this important subject in my greater work with the minute detail, which it deserves; thus, in following the advice given, therein, in chapter XVIII, the reader will be able to ascertain the foods that are best suited to various conditions, and how to prepare them in the most sensible way. At present, I can treat it only in a short and general way, giving the principal groups of diet prescribed, with more or less variation, in each case of disease as a part of the general treatment. A few words may show _why_ diet plays so important a part in this system of healing. In the body there is a laboratory which produces spontaneously everything necessary to maintain life. This laboratory has various branches which are busy day and night without interruption. Here the life blood is created. Prominent amongst these branches are: The stomach with its prolonged intestines; The liver; The kidneys; The lungs, and The skin. Each one of these branches has a distinct part, or function to perform. The stomach serves as the sorting house. Here the food is mixed with the gastric juice which aids digestion and dissolves those ingredients necessary to produce blood, flesh, fat, bones, etc. Each of the other branches receives that portion of the ingredients needed to perform its share of the work. A structure cannot be constructed without a frame upon which every part depends. In order to stand erect, the body must possess such a framework. The skeleton is the same to the body as the frame is to the building. This frame, then, or skeleton, together with the flesh, blood, etc. are all formed from the material furnished by the food. A residue of the digested food is removed from the body as useless; everything else is utilized. The portion of the food used, therefore, must contain all those ingredients which go to make up and maintain the body in perfect working order. Experience has suggested certain groups of suitable diet which for the sake of convenience I shall enumerate under the title of _Forms No. I to No. VI_. These food forms contain everything of which patients may safely partake, and from these selection, in each case, must be made. They are as follows: _Form I. Complete elimination of the stomach in the nourishing process._ To allay thirst, moisten the mouth with pure or carbonized water, melting small pieces of ice on the tongue. Small sips of water either lukewarm or cold, according to the condition of the stomach. Otherwise, only introduce water by clyster--i.e.--injection, and if the stomach cannot be disturbed for more than one or two days, introduce nourishing substances by way of the rectum. _Form II. Purely liquid nourishment, "soup diet."_ Consommé of pigeon, chicken, veal, mutton, beef, beef tea, meat jelly (which becomes liquid under the influence of the heat of the body,) strained soups or such as are prepared of the finest flour with water or bouillon, of barley, oats, rice (thick soup), green corn, rye flour, malted milk. All of these soups, with or without any additions, such as raw eggs, either whole or the yolk only, if well mixed and not coagulated, are easily digested. _Form III. Nourishment which is not purely liquid, but partly glutinous._ Milk and milk preparations (belonging to this group on account of their coagulation in the stomach): (a) Cow's milk, diluted and without cream, dilution with 1-2 to 2-3 barley water, rice water, lime water, vichy water, weak tea, or pure water. (b) Milk without cream, not diluted. (c) Unskimmed milk. (d) Cream, either diluted or undiluted. (e) All of these milk combinations with an addition of yolk of egg, well-mixed, whole egg, cocoa, also a combination of egg and cocoa. Milk mush made of flour for children, arrowroot, mondanin, cereal flour of every kind, especially oats, groat soups with tapioca or sago and potato soup. Egg,-raw, stirred, or sucked from the shell; or slightly warmed in a cup; any of these, either with or without the addition of a little sugar or salt. Biscuit and crackers, softened or well masticated and salivated, taken with milk, mush, etc. _Form IV. Diet of the lightest kind, containing meat, but still mainly glutinous._ Noodle soup, rice soup. Mashed boiled brains or sweetbread, or puree of white or red roasted meat, in soup. Brains and sweetbread boiled. Raw scraped meat (beef, ham, etc.) Lean veal sausages, boiled. Mashed potatoes prepared with milk. Rice with bouillon or with milk. Toasted rolls and toast. _Form V. Light diet, containing meat in more solid form_: Pigeon, Chicken boiled. Small fish with little fat, such as brook or lake trout, boiled. Scraped beefsteak, raw ham, boiled tongue. As delicacies: Small quantities of caviar, frogs' legs, oysters, sardelles softened in milk. Salted potatoes crushed, spinach, young peas mashed, cauliflower, asparagus-tips, mashed chestnuts, mashed turnips, fruit sauces. Groat or sago puddings. Rolls, white bread. _Form VI. Somewhat heavier meat diet. (Gradually returning to ordinary food)._ Pigeon, chicken, young deer, hare, everything roasted. Beef tenderloin, tender roast beef, roast veal. Boiled pike or carp. Young turnips. All dishes to be prepared with very little fat, butter to be used exclusively. All strong spices to be avoided. =NOTE=:--For special dietary in all diseases, see under each separate tissue degeneration in the succeeding Chapter on Therapy. FOOTNOTES: [A] In the following chapter, several important paragraphs given in the foregoing had to be repeated as the readers who were not interested in the "Club" proposition, would miss these points. NUTRITIVE COMPOSITIONS In order to convey a better understanding of these nutritive compositions, I deem it necessary to outline and explain more emphatically and in greater detail their wonderful scope and possibilities, in perhaps a more impressive manner, by giving the reader the benefit of an article entitled: "The functions of minerals in our food How they may be greatly increased" Of these I have sent some 560 copies to all our Senators and Congressmen, as well as to our chief Government Physicians, for their information and disposition, with the intention of placing my knowledge and equipment freely at the disposal of the United States Government. I have made this purely disinterested proposal at this critical and trying juncture, in the interest, first, of our war-worn soldiers; next, of our women, enervated by unaccustomed labour and restricted means; and lastly, of the children, born, and yet to be born of them--the future Citizens of the Republic--all, in short, who, under stress of injury, strain and hardship abroad, or the sometimes equally strenuous privations of war conditions at home, may, in their respective degrees, be suffering from nervous breakdown or depleted vitality and the various disorders which my proffered remedial measures are so admirably fitted to successfully overcome, bearing, as they must untold relief, comfort and renewed health to thousands. I have not spared expense in putting this matter fairly and fully before the Authorities--and indeed the initial cost of so doing has already absorbed some $300 or more. That is merely a detail. But the main point is this: That I have offered this valuable knowledge--(practically the work of a lifetime)--to the Nation, together with the prescriptions of my compositions, free of cost, as an earnest of my sympathy and goodwill; and had the Government, seen fit to accept my proposal, the immediate effect would have been that these compounds, which at present, through reduced manufacture and the consequent great scarcity of chemicals (necessarily of the finest description and purity) are very costly, would have been brought by extensive and organized production within the reach of every citizen, removing at once that paramount difficulty of my system, so far as the general public is concerned; namely, the expense. I append hereto a copy of the article referred to, together with copy of an accompanying letter. My dear Senator: The disarrangement of the habits of life of our civilian population, and the physical needs of our boys who will return from Europe wounded and crippled, prompts me to offer my services to the Government for the development of specially enriched foodstuffs to maintain the health of our people under the strain of the war, but particularly to aid in the speedy recovery of our boys who return shattered from the trenches. I have spent more than thirty years in the study of physiological chemistry and biology, and this study has been devoted to the application of scientific principles in the treatment of various diseases. Hitherto our food experts and medical men have been satisfied with a ration properly balanced as regards protein, carbohydrates and fat, but the mineral salts in our food have been given little if any serious consideration. Indeed, they have usually been dismissed as "ash." As a matter of fact, however, as the statement I am sending you under separate cover will show clearly, even to a layman, mineral salts perform an important function in keeping the body strong and healthy. I am prepared to demonstrate that the quantity of essential minerals in vegetables, small fruit and eggs can be multiplied several times by scientific fertilization and nutrition. If I can do this (and I am prepared to prove that I can) the Government should be willing to arrange for the production of such foods in connection with every military hospital and convalescent camp, both here at home and behind the lines in Europe. Moreover, given a central experimental station with proper equipment, it would be an easy matter to train men to teach this knowledge to soldiers at every reconstruction camp. The statement is made by Dr. Mae H. Cardwell, of Portland, Oregon, one of the investigators for the Federal Children's Bureau that millions of children are suffering from lack of sufficient food and from improper feeding, and she adds that not only the parents but the doctors, in many cases, need education with respect to what constitutes proper feeding for children. I think that when you have read and digested my statement of the function of the mineral salts in the human economy, you will agree with me that the need for just what I am asking the government to give me an opportunity of doing is very great indeed. I trust that I may count upon your co-operation, not only in getting this matter before the proper officials, but also in seeing that an opportunity for a fair demonstration is accorded me. The dissemination of this knowledge and the production of such foods would make America the ALMA MATER of the world in scientific nutrition, thanks to the application of physiological chemistry. As things are now done in agriculture and in aviculture, however, very little can be expected along this line. I will give you two concrete illustrations of what can be done in the way of augmenting the mineral content of food, and then I will point out the significance of that fact. We will consider eggs: ordinarily 100 grams of egg yolk contains from 10 to 20 milligrams of iron, but eggs laid by hens fed by my method yield from 30 to 80 milligrams of iron per 100 grams of dried yolk. This is an increase, as you see, of between 300 and 400 per cent. Such eggs might be justly classed as haemoglobin eggs, and they would be a godsend to our boys suffering from anaemia due to wounds or operations. At the same time, my method of handling chickens greatly enriches the lecithin, or nerve substance, in the eggs, and they are, therefore, of special value in dealing with cases of shell shock and nerve exhaustion. What is true in the case of iron and lecithin content of eggs produced by my method, is equally true with respect to their content of all the other essential mineral elements; they are all multiplied several times. This is made possible of accomplishment by the application of the principles of physiological chemistry to the breeding and feeding of the poultry. Needless to say, I am prepared to submit to the test of scientific examination of my claims. No, not merely a theoretical examination of myself, but, rather, to submit the claim I make for eggs produced under my direction to the test of chemical analysis. It is a very easy matter to determine thereby whether my claims are well founded. I cannot state my desire to serve the government in this way too strongly; as I have spent more than thirty years of my life in the study of biology and physiological chemistry, I feel that it is my duty to offer to the Government the benefits of my knowledge and experience. All that I can ask in this connection is to be given an opportunity to prove that my claims are sound and practical. I believe that you will realize the full value of such a course of action as outlined, if it can be proven practicable. The opportunity of offering proof under direction of the proper branch of government is, I repeat, all that I ask at the moment, as the results will tell their own story far more eloquently than mere words. Thanking you for giving this matter your attention, and trusting that my hope of serving in the ranks of those seeking to rebuild our boys will not prove vain, I am, Sir, Yours truly, L. DECHMANN. THE FUNCTION OF MINERALS IN OUR FOOD: HOW THEY MAY BE GREATLY INCREASED. By LOUIS DECHMANN. 1918. When physiological chemistry has isolated and classified the component elements of the various organs, tissues and fluids of the body, it must analyze and classify the vegetables, fruits and meats on which man feeds in order that we may not only know how to arrange a perfectly balanced ration for the healthy, but shall be able to add lacking elements to the diet of the diseased. This classification of foods naturally leads, if there be a deficiency of any essential element, to the analysis of the soil on which this food was raised. In the course of my studies in physiological chemistry and biology, which have extended over a period of more than thirty years, I have been led to grappel with problems in agriculture, in horticulture, and in aviculture, for the purpose of finding solutions to problems in human nutrition. Very early in my studies I learned the value of the mineral elements in our foodstuffs. I was led to attempt to augment the quantity of mineral salts in various foods, and my efforts were crowned with success. But this is not the point, however, to enter into a detailed discussion of that aspect of the subject. It may be wise for the sake of clearness to divide this statement into two parts, as follows: 1. A brief summary of the function of minerals in the human economy. 2. A short argument showing how we can and why it is imperative that we should augment the mineral content of our vegetables, small fruits and eggs. In the case of eggs, for example, I am able to increase their iron content 300 or 400 per cent. More than that, I can multiply every item in their mineral content several times, thus producing specific eggs for those suffering for lack of any mineral. In other words I am able to produce special eggs for a given tissue degeneration as, for instance, haemoglobin eggs for degenerate blood; lecithin eggs for the nerves; calcareous eggs for the bones, and kaliated eggs for the muscle. So much by way of preface. I. The following explanations are made for the purpose of showing you that I have made extensive studies along these lines, and are not, naturally, intended to be taken as a lesson to you personally. There are sixteen chemical elements absolutely essential to healthy human life, which are classified by physiological chemistry as the elements of organic life. In the composition of vital tissues we constantly find these basal elements: Carbon, oxygen, hydrogen, nitrogen, sulphur, phosphorus, chlorine, potassium, sodium, magnesium, calcium, iron, manganese, fluorine, silicon, and iodine. The function of these elements will be discussed in a moment. I would here lay stress upon the fact that the absence of the tiniest ingredient necessary to the growth and functioning of an organ will, according to the Law of the Minimum as laid down by Justus von Liebig, result in disease, improper functioning and degeneration of that organ or tissue. Although the chemical salts constitute but a small part in the composition of our bodies, and are a very small item in our daily diet, their importance cannot be too strongly emphasized. They are the main sources for the development of electro-magnetic energy in the blood and nerves, and perform other services. I am of the opinion that "vitamines" are neither more or less than these chemicals in proper proportion and relation, but whether you agree or disagree with this conclusion, you will instantly agree that the elements named above are indispensible to perfect metabolism. It goes without saying, of course, that no action in the world occurs of itself, that is without impulse, hence the body must be given impulse to growth. A series of chemical and physical facts indicate that phosphorus plays this vital part. The property of phosphoric acid of uniting with carburetted hydrogen to form carbonic acid and phosphureted hydrogen certainly is of fundamental importance, as phosphureted hydrogen readily ignites on coming into contact with oxygen. Since cerebrin consists of a combination of phosphoric acid with gelatine which contains ammonium and with oleine, it is easy to infer that the light of the soul may be due to the phosphoric acid in the nerves, and still further the potassium phosphate forming the mineral basis of the muscles. Thus we come to the conclusion that the phosphates, combinations of phosphoric acid with basic substances, possess in general the property of imparting the true impulse to growth, that is to accumulation of organic matter. Like every other structure, however, the body requires supports and props and, above all, a firm foundation on which to rest. Iron and lime, whose union is secured by their opposition to one another, bring into conjunction materials of contrary disposition for the creating of organic forms of the nature of plant and animal bodies. The sulphuric compounds are related and yet opposed to the growth determinating phosphoric compounds. All organic building material (protein) contains phosphorus and sulphur, in varying proportions, and all indications are that sulphur plays the part of a regulator in organic growth. Just as an engine requires a governor to regulate its pace, so the human body requires a controlling factor to ensure definite stability. It is interesting to observe that normal blood contains about twice as many sulphates as phosphates. When there is great scarcity of sodium sulphate in the blood, abnormal growths develop from the phosphatic nerve tissues, and they continue to develop so long as the blood and lymph are deficient in sulphur, particularly the sulphates. This is, I believe, the genesis of polyps, tumors and cancers. In the same manner that sulphuric acid controls and regulates the phosphoric acid of ammonium phosphate, so lime and magnesia act on the ammonia of this same ammonium phosphate. Phosphatic ammonium carbonate lodges in the gelatinous cartilage and stretches it, when there is a deficiency of lime and magnesia in the food, resulting in rickets. Such a growth of cartilaginous tissues is controlled by lime and magnesia, as they change the pliant cartilage into bony barriers in which small particles of magnesia combine to produce phosphate of ammonium and magnesium which checks the further deposit of cartilage. Lime and magnesia are indubitably quite as effective agents in the control of ammonia as sulphur is in the control of phosphorus. If we consider the minerals as the foundation and mortar which give stability to the vital machine, leaving out chlorine and fluorine, we find that iron, manganese, potash, soda, and silicic acid play this role. Sulphur, because it possesses the property of becoming gaseous, is able to take part directly in the formation of albumen, that variable basis of body material, whereas all of the other mineral substances except silicic acid can only be assimiliated in so-called binary compounds in the form of salts. I will give a brief review of them, beginning with iron, as thus the significance of augmentation of the mineral content of vegetables and small fruits and eggs will be made much clearer. Normal blood albumen is essentially a compound of calcium and sodium into which iron and sulphur both enter. A deficiency of calcium commonly makes itself known by dental defects, just as lack of sulphur reveals itself by the falling out and poor growth of hair. Insufficiency of iron in the blood is evidenced, apart from lack of spirit, by paleness of face and blue lips; insufficient sodium by glandular tumors and abnormal cartilaginous growths. The entire amount of iron in the blood of an adult person is, on the average under normal conditions, four grams, as much as a nickel weighs. We may well judge that this amount is not sufficient to set the motive power of our bodies in action, if we overlook that complex factor the circulation of blood. The left side of the heart has the capacity of containing about six ounces of blood, and every heart beat drives this amount through the aorta. With seventy beats to the minute, twenty-five pounds of blood is pumped from the heart every minute. What is the result? That the four grams of iron keep up such an incessant movement that they pass from the heart into the aorta sixty times an hour or 1440 times in 24 hours. It may be asserted, therefore, that in 24 hours 13 pounds of iron (that is 1440x4 grams) pass from the heart into the aorta. Can it be doubted, in view of this, that the iron serves to produce an electro-dynamic force? In respect to the generation of electricity, it matters not whether there be an entirely new supply of iron passing a given point, or whether the same iron pass that point anew each minute. Two factors work together in the circulation of the blood, namely, the active attraction of nerve tissue and the passive susceptibility of the blood contents to that attraction. Faraday has conclusively shown that blood is magnetic in character because of the iron it contains. If four grams of iron is the normal quantity in the blood, it is clear that the reduction of this amount, say by two grams, will lessen its susceptibility and slacken its circulation. The electrical nerve ends will then strain in vain for the electricity which the blood current should yield, and the result will be neuralgia. It is the magnetic iron in haemoglobin which makes every sort of nervous function possible, in the cerebral (brain) and in the sympathetic (intestinal) tracts, and since it is thus made clear that intellectual activity on the one hand and breathing and digestion and excretion on the other are dependent on the iron content of the blood, we must also recognize that, as iron attends every nerve action, the secretion of urine too takes place under the influence of haemoglobin. Insofar as haemoglobin hastens the departure of the excrementitious matter in urine out of the system, there is a daily loss of iron in the urine. This loss in the form of urohaematin may total four centigrams, or a hundredth part of our supply. This loss of iron if not replaced by eating suitable food will soon make itself felt. In the course of a day the reduction by four centigrams will diminish the energy of nervous activity about 1440 times the apparent loss, so that even a four weeks-tropical fever, during which no meat is eaten, may completely exhaust the strength of an individual. Moreover, iron conditions bodily warmth as it combines with oxygen in a higher and a lower degree. In the lungs it is highly oxidized by the respired oxygen, but in contact with the nerve ends it gives itself only to a part of the oxygen present, and burns a certain portion of the lecithin to water, carbonic acid and phosphates, thus creating body warmth to a considerable extent. In response to the chemical consumption of lecithin a new oil flows down the axis cylinders of the nerve fibrils, which are arranged like lamp wicks. The duration of the flow of this oil is, on the average, about eighteen hours. When the cerebro-spinal nerves refuse longer to perform their function, fatigue and sleep ensue, and the current of blood leaves the brain and seeks the intestines. While the cerebro-spinal system rests, the sympathetic system takes up its task of directing the renewal of tissue and supplying the nerve sheaths through the lymph vessels, which draw their material from the digestive canal, with a new supply of phosphatic oil. Thus the brain and spinal nervous system are prepared for another day's work. For the fulfillment of these processes, the magnetic blood current forms the intermediary. The presence of formic and acetic acid supplies the blood with fresh electricity to stimulate the nerves. "Under normal conditions," says Julius Hensel, "this function is assigned to the spleen. This organ takes the part of a rejuvenating influence in the body in the manner of a relay station, and does so by virtue of an invisible but significant device. In every other region of the body the hairlike terminals of the arteries which branch out from the heart merge directly in the tiny tubes (capillaries) of the veins, which lead back to the heart again: in the spleen this is not the case. Here rather the arteries end suddenly when they have diminished to a diameter of one one-hundred-and-fortieth of an inch and end in a bulb (the Malpighian bodies). Under such circumstances the sudden stoppage, particularly the impact of the magnetic blood stream against the membrane of a Malpighian body, exemplifies the physical law of the induction of electricity, in accordance with which the blood that enters the spleen is changed into plasma and exudes through the membrane of the Malpighian bodies. The event indicates some fluidity of the red blood cells, which is a change effected in the body by the impact of electric sparks, and one which electrical therapy also brings about locally to prevent increase in the solid constituents of the blood." The numerous Malpighian bodies in the spleen act as so many electrical conductors, and the product of their electrical activity is found in the formic and acetic acid of the fluid plasma which filters through the Malpighian corpuscles and supplies the acid tissue of the spleen (pulpa splenica). These acids are the electrolytic division products of lecithin. In the splenic pulp arise the capillaries of the splenic veins whose acid blood is carried directly to the liver, where certain cells formed like galvanic elements possess the property, through the electrical action of formic and acetic acid, of extracting from blood albumen the opposite of acids, namely, alkaline bile. The normal functioning of the liver, therefore, is dependent upon that of the spleen, and since the bile produced by the liver goes to aid the digestive activity of the duodenum, disturbance of digestion must result when the quality of the bile is inferior. One of the substances contained in bile, lecithin, is of wide importance. When it was referred to a moment ago, I spoke only of its individual chemical nature as a fat in combination with ammonium phosphate, as by so doing I avoided error in connection with its apparently complicated formula, which includes glycerophosphoric acid, trimethylamin, palmitic and stearic acids. As it is a fatty substance, the only question that arises, is, what does it contain besides fat? This may be answered by a process of substraction: 2 (C_{21} H_{42} O_{4}) C_{42} H_{84} O_{8} which represents tallow or stearate of glycerine. Lecithin, C_{42} H_{84} O_{9} NP, differs from this only by a larger amount of NP. The significance of this difference becomes clear when two atoms of water are added. Then ammonium phosphate, PO_{3} H_{4}, N is formed. The two atoms of water needed for the condensation of the ammonium phosphate from the stearate are obtained by separating them away from two of glycerine. The bile contains lecithin in a partially oxidized form. The chemical "remainders" are biliverdin and cholesterin. The latter when normal has, as you know, the power to neutralize snake venoms and other poisons, and thus acts as a natural anti-toxin. In addition, the bile contains combinations of stearine with gelatine and with carbonate and sulphate of sodium, which theoretical chemists believe are twin compounds of glycocholate and taurocholate. These fatty compounds depend upon stearine partly oxidized, that is deprived of a certain number of atoms of hydrogen. As the compounds of fatty acids with ammoniacal blood gelatine and sodium carbonate, the ingredients of the bile also, develop into a peculiar soap. In the economy of the body the bile acts as a soap. When it is discharged into the duodenum, it changes the fats into so fine an emulsion (chyle) that the microscopically fine drops of fat may be drawn into the orifices of the lymph canals and conveyed to the circulatory system, and the cleavage products of albumen produced by gastric digestion, the peptones (leucin and tyrosin) are carried along with them for the renewal of tissue cells consumed in respiration. If a soda soap is requisite for the purpose just stated, it follows that soda in the food is essential, as otherwise the supply of soda in the blood albumen cannot be renewed, and the bile cannot get its necessary supply of soda from blood albumen devoid of soda. Consequently, the entire nutritive process is dependent upon bile, and the bile cannot properly perform its function if denied soda. In addition to carbonates of sodium, especially the hydrocarbonate known as glycolate, the bile apparently contains ammonium sulphate combined with hydrocarbon (taurin); but this results from the transposition of sodium sulphate and gelatine. Gelatine contains six atoms of hydrocarbon joined with two of ammonium carbonate, a group which is separable by chemical action into five of carburetted hydrogen with ammonium carbonate (leucin or gelatine milk), C_{5} H_{10}, CO_{2}, NH_{3}, and into one of carburetted hydrogen with ammonium carbonate (glycin or gelatine sugar), CH_{2}, CO_{2}, NH_{3}. This latter substance, gelatine sugar, is not produced in the liver, as it exists already in the blood gelatine. In an isolated condition it has the property, in virtue of its ammoniacal acids and its carbonic acid bases and, therefore, of both combined, its salts, of producing chemical fixation. This property is conveyed to the undivided blood gelatine in which the gelatine sugar is contained intramolecularly. Since normal blood albumen is inconceivable without sulphur it is absolutely essential, in accordance with our knowledge of the constituents of the bile and their origin, that our nutriment should contain a sufficiency of sodium sulphate, if normal blood serum is to be produced. The use of pepsin for this purpose cannot serve nature's purpose, as it contains neither sodium carbonate nor sodium sulphate. Our blood must be given a fresh and sufficient supply of sodium carbonate and sodium sulphate via our food, if it is to produce normal bile and supply the requisites of normal nutrition. It is erroneously held that sodium sulphate is simply a laxative, even Borner's "Royal Medical Calendar" so classifies it. Often it discharges this function, it is true, in concentrated solution (one to five). But it is an important ingredient of healthy blood albumen (one to one thousand), and in this proportion assists in the formation of normal bile. The blood of the Caucasian race is found to contain about ten parts of salt to the thousand, and this proportion of salt denotes firm tissue material. If the quantity of salt in the blood is diminished, the bi-concave red blood cells swell to a spherical form from access of water and lose their ability to unite for the production of connective tissue. Moreover, to the extent salt in the blood cells is decreased the connective tissue and muscle and tendon substance absorb water and the tissues become spongy, especially in the kidneys, so that the thinned blood albumen seeps through (urea albumen). Phosphate of potassium is the mineral basis of muscle tissue, phosphate of lime with a small amount of magnesium phosphate the basis of bones, and phosphate of ammonium the bases of nervous tissue. There is a sufficient quantity of phosphate in all healthy foods. When the milk fed to nurslings, however, is greatly thinned with water instead of firm muscle fibers and solid lymph glands we find loose and spongy tissues. This is a scrofulous condition. In the formation of healthy bones and teeth, calcium fluoride is essential. It is insoluble in plain water, but is made soluble by the aid of the glycocoll in blood gelatine and changed into ammonium fluoride. It appears in this form in the cartilaginous matter of the eye lenses, and lack of calcium fluoride in the food results in the clouding of these lenses. Silicic acid is not only indispensible to the growth of hair, but it forms a direct connection between blood and nerve tissues. It is found in birds eggs, both in the white and the yolk. It is a conservator of heat and electricity as it is a good insulator. It also possesses eminent antiseptic qualities. Its mere presence in the intestinal canal, even its simple passage through the canal; conserves the electrical activity of the intestinal nerves and thus influences the whole sympathetic nervous system. This brief review, cursory as it is, of the function of the minerals in the renewal of substances undergoing tissue change, makes it clear that our daily food must contain a sufficient quantity of them if healthy metabolism is to be maintained. Chemically considered the human body is one individual whole, its characteristic chemical basis being gelatine. Lieut. C.E. McDonald, U.S.A. Medical Corps, recognized this when he recently wrote: "The similarity of chemical compositions explains why, when any particular region falls a prey to chemical decomposition, others quickly become affected." Oxygen gas is the medium through which chemical combustion is carried on in the body for the purpose of preparing materials to enter into its composition. The mineral salts already named not only form the solid basis of the various tissue but also serve as conductors or insulators of electricity in the body. The absence of one of them for a protracted period is sufficient to explain widespread degeneration in the system. In view of the fact that these various minerals play an indispensable part in healthy metabolism it is imperative that a sufficiency of them should be supplied in proper proportion in our daily food. It is imperative, if we desire to retain or to restore health to the body. These mineral elements are to be found in the first instance in the earth, but they are of no use to the body in that form. We cannot digest and assimilate inorganic matter no matter how finely it may be pulverized. But plants can assimilate them from the earth and organize them in such form as to make them easily assimilable by animals and man. If the soil on which our food is produced is itself deficient in some of these elements, our food must also lack them. If, moreover, we cannot for any reason add the missing elements to the soil, we must supply them to the human system in the shape of prepared nutritive salts. It is preferable, of course, that our food should contain all of the elements necessary for the proper nourishment of the body. Thus we are forced to return to consideration of the soil. It is an established fact that our fields were originally formed from decayed rock, and analysis shows that this primitive rock contains the same minerals as healthy blood. But if our agriculturists are taught that stable manure and three or four other things are all that is necessary for the fertilization of their fields, where shall the other minerals essential to human metabolism come from? What a man is, largely depends upon what he eats. Hence man is very largely a product of the fields. When the soil is denuded of any of the elements essential to plant and animal life, it must be properly fertilized. Incomplete or improper fertilization can have but one result, to-wit, it will produce sickly vegetation, and this in turn must produce unhealthy cattle, and since man is dependent upon plant and animal life for his food a sickly race of human beings is the ultimate result. Is not barrenness of the soil responsible for disease in potatoes, for San Jose scale, Phylloxera, and other similar phenomena. The fields are manured profusely, it is true, but the very chemical elements which are not only essential to the development of wholesome plant tissue but which would also enable the plant to protect itself against parasites, are not used. Every farmer has observed, for instance, that grass grown upon cow dung in pastures is not eaten by cows, oxen or sheep. The instinct of the animals is correct. In using the term incomplete fertilization, I mean supplying only potash, phosphoric acid and nitrogen, and possibly lime and sulphur, when the soil is denuded of several other elements. No matter how rich a field may be made in these things if it lacks other elements healthy vegetation cannot be grown in it. Improper fertilization is another matter. It may consist in dressing a field with nothing but stable manure, or of applying crude sulphur or brimestone instead of using calcium sulphate--plus the other lacking elements. The advocate of crude sulphur certainly does not know how truly criminal his advice is. It is not to be denied that at the outset sulphur will increase the crop yield. But in the end--what? The sulphur will dissolve all of the essential minerals in the soil, and in the course of four or five years they will all be leached out and it will be so barren that not even wild grass can be grown upon it. Improper fertilization may also consist of a dressing of carbonate of lime applied at the wrong time or in excessive quantity. The effect of this course will be equally as harmful, namely, the transformation of the nitrogenous material into free nitrogen which will ascend to heaven. Without nitrogen albumen cannot be formed, and without albumen the formation of vegetable and animal tissue is impossible. Wholesome soil may, then, be defined thus: It is such ground as contains a sufficient supply of humus and nitrogen and all of the essential mineral components of organic tissue. The problem of fertilization, therefore, consists of supplying any or all of these elements in which the soil is deficient. The aim of fertilization, as a rule, is merely to increase crop production. But this may prove to be not merely shortsighted, it may turn out to be a social crime. It is criminal, indeed, as a great many diseases are directly traceable to incomplete and improper fertilization. Let us face the effect of attempting to fertilize our fields with nothing more than stable manure, which, it is true, supplies phosphoric acid, potash and nitrogen. We know that phosphorus forms the foundation of nerves, and too much of it provokes nerve irritation in exact ratio to the deficiency of sulphur. There should be twice as many sulphuric salts as phosphoric salts in the blood, if it is to be normal and the nerves are to be steady. Foodstuffs from fields that have been fertilized in this manner must, of course, contain a superabundance of phosphoric salts and be deficient in sulphuric salts. Is it strange, then, that the present age presents a picture of restless, irritated nervous activity and thoughtless action? We must return to the primitive rock and humbly learn the lesson it has for us, and upon this rock we must rear our science of fertilization and nutrition. This rock consisted of granite, porphyry, gneiss and basalt, and these are still found upon the earth in immense quantities in practically the same condition they were thousands of years ago. Both Justus von Liebig and Julius Hensel, as a matter of fact, advocated that this rock should be finely pulverized and used as a compost to assist in restoring and maintaining the original fertility of the soil and thus aid the development of healthy plant and animal life. Indeed the instincts of both animals and human beings lead them under certain conditions right back to the rock and its lesson. Note the avidity with which hens confined in arid runs devoid of vegetation, worms, insects and small stones devour a compound of lime and ground bones and oyster shells. Observe a child whose ration is deficient in mineral elements eating egg shells, wall plaster, chalk and other earthy substances. What do these things mean? Nothing more than this: both chicken and child express a natural craving for the essential elements to build bone and form the basis for the tissue. I have discussed the important part the minerals play in both the vegetable and animal kingdoms for the purpose of laying stress upon our great need of more of them in our daily diet, and I may add that this is equally as true in the case of those we call healthy as of those who are diseased. No matter how carefully the diet may be regulated as regards the quantity of protein and carbohydrates and fats and the ratio between them, healthy metabolism is impossible without a sufficiency of the essential minerals. II. How can we perform this imperative duty to mankind? The solution of the problem of supplying these essential minerals demands that our soil shall be properly fertilized for the growing of wholesome vegetables and fruits and our cattle properly fed with a ration rich in mineral content. Thus the food which we eat will contain all of the elements necessary to the growth and maintenance of our bodies in a state of health. In the course of my effort to show why it is imperative that we pay greater heed to the mineral content of our foodstuffs, and why it is imperative that we enrich that content, I have shown basically how that end is to be attained. In conclusion I will cite the result of a series of experiments in applying the principles of physiological chemistry to poultry, and I may say that it took me twelve years to find the breed which would most readily lend itself to my purpose. I experimented with 250 varieties of hens before I found the one most amenable to my method of feeding and breeding. While living at Needham, Massachusetts, I made a thorough test of my principles with the selected variety of hens. They were not only fed a ration properly balanced for protein, carbohydrates and fat, but I gave them a liberal supply of properly prepared mineral salts. I used three different mixtures of feed, made up in 100 pound lots, in which the proportion of albumen ranged from 13.50 to 18.00 pounds; of fat from 4.00 to 5.00 pounds; of carbohydrates from 41 to 44 pounds; and actual nutritive salts from 4.50 to 5.00 pounds. The respective ratios being: 1:4, 1:3.5 and 1:3 It is not necessary to enter into discussion of the details of the feeding method and the variation in the daily handling of the hens. The result of this experiment, however, was completely satisfactory, as the eggs produced by those hens not only contained a startling increase in the quantity of mineral salts, but their fertility was far greater than that of hens handled in the usual manner. The increase of fertility in itself is, it seems to me, the best proof of the soundness of my theoretical premises. Some of the results of this experiment were published in the Reliable Poultry Journal in 1905, and Dr. Woods offered confirmatory evidence of the soundness of my conclusions two years later, after he had himself experimented along the same line. I will cite just one fact revealed by that experiment, namely, that whereas 100 grams of dried egg yolk ordinarily contains only from 10 to 20 milligram of iron the eggs of those hens yielded from 30 to 80 milligrams. And all of the minerals were increased from 10 to 25 per cent or more. The method of applying the principles of physiological chemistry to the enriching of the mineral content of our foodstuffs evolved by me is, with due recognition of the difference between the vegetable and animal kingdoms, equally applicable in the raising of all our foodstuffs with an augmented mineral content. I will adduce just one result of my work in the handling of small fruit: on the average, 100 grams of dried strawberries will yield 8.6 to 9.3 milligrams of iron, but strawberries raised by me yield from 30 to 40 milligrams per 100 grams. In view of the facts with regard to the function of these minerals, it is indisputably true that a ration is physiologically inefficient if it does not contain a sufficiency of them in proper proportion. Moreover, this is trebly true in the case of those whose constitution has been weakened by loss of blood from rounds, by shell shock and trench fever, and of those here at home whose nerve tissue has been degenerated and whose blood has been weakened by anxiety and the strain of unwonted manual labor. The last consideration applies with especial force to the multitudes of women who have entered industry as manual laborers. What kind of offspring can we expect from these people whose plasma is thus degenerated? The children are the citizens of the future, and even before they are born we must plan for their health. What could be more effective in treating the anaemic condition of wounded and crippled boys, and in treating the same condition in women industrial workers, than haemoglobin eggs? What could be more efficacious in treating conditions arising from shell shock, from bad wounds and operations thereon, and neurasthenia in general, than an abundance of lecithin (which, as you know, dear doctor, is made from the yolk of the egg)? What could be more successfully used in treating conditions arising from shattered bones and from operations for the removal of bone tissue than calcareous eggs in connection with a ration perfectly balanced as regards all of the other essential elements. For the regeneration of the blood and bone and nerve tissue of these victims of war, something more than a sufficiency of nutritive food, as that term is commonly used, is needed, and something more than medicine is needed! I am the last person in the world to deny that wonderful progress is made in surgery every day, and the last to fail to applaud its successful efforts, but you know quite as well as I do that in 90 out of 100 cases recovery involves exhaustion of the patient's reserve energy. Moreover, when the reserve energy has already been drawn upon almost to the point of exhaustion, no matter how successful the operation may be the recovery of the patient is a very doubtful quantity. The first requisite in all surgical cases, as also in all anaemic and neurasthenic cases, is to restore metabolism to its normal condition and thus help the patient to regain his reserve energy in order to prevent the collapse of the whole fabric. It is indubitably true that healthy metabolism and the restoration of reserve energy depends upon the organism being given the requisite quantity of the sixteen essential elements of organic life in easily digestible and assimilable form, and I am asking for the opportunity to demonstrate how foods extremely rich in these elements may be produced and used to aid nature. I have not entered into a full discussion of the various aspects of my method of accomplishing that, but have confined myself to consideration of the basic principles underlying it. Neither have I attempted to show how these different minerals will serve as regenerative agents in different dysaemic conditions. I am prepared to discuss the matter from both of these viewpoints, however, and, more than that, I am ready to practically demonstrate the soundness of my theories, when given an opportunity under proper conditions to do so. --Sapienti sat-- FINIS. NUTRITIVE COMPOSITIONS. The sixteen substances,--nutritive cell foods,--of which all of the tissues of the body are composed are: carbon, oxygen, hydrogen, nitrogen, potassium, soda, lime, magnesia, iron, manganese, phosphor, sulphur, silica, chlorine, fluorine and iodine. My nutritive compositions consist of these same sixteen nutritive salts, each composition mixed in the same proportion as they are found in the healthy tissue for the regeneration of which they are prescribed. Since in various diseases not only one but several tissues are affected, it must be decided individually in each case whether only one, or several, of the nutritive compositions will require to be taken, and in what proportion. In accordance with the system of the twelve tissues of the body, the twelve nutritive compositions, commonly known as "DECH-MANNA" Compositions, are the following: No. 1. Plasmogen Bloodplasma-Producer. No. 2. Lymphogen Lymph-Cell-Producer. No. 3. Neurogen Nerve-cell-Producer. No. 4. Osseogen Bone-cell-Producer. No. 5. Muscogen Muscle-cell-Producer. No. 6. Mucogen Mucous membrane-cell-Producer. No. 7. Dento-Ophthogen Tooth and Eye-cell-Producer. No. 8. Capillogen Hair-cell-Producer. No. 9. Dermogen Skin-cell-Producer. No. 10. Gelatinogen Gelatigenous-cell-Producer. No. 11. Cartilogen Cartilage-cell-Producer. No. 12. Eubiogen Healthy body-cell-Producer. In addition to these I use only a few specialities in certain cases of disease, viz.: A. Oxygenator A radium emanation for the bath. B. Eubiogen Liquid Same as No. 12, but liquid form. C. Tonogen A stimulating tonic. D. Tea. Diabetic, Dechmann E. Tea. Laxagen, after Kneipp F. Salve. Lenicet, after Dr. Reiss G. Massage Emulsion, Dechmann H. Propionic acid for steam atomizer I. Oxygen Powder, after Hensel J. Anti-Phosphate, Dechmann (These specialities are used only in certain individual cases, according to prescription). NUTRITIVE COMPOSITIONS. In discussing the various preparations of Dech-Manna-Diet, I refrain from detailed prescription and analysis. My intention is to explain them in such a way that it may become apparent to everyone that they are rational remedies for every properly diagnosed constitutional disease. If I should do more than this, it would be simply placing a premium upon unscrupulous imitations. For the present therefore, I prefer to have the remedies prepared exclusively by accredited and absolutely reliable chemists of first class local standing, in order that I may myself assume the entire responsibility. In cases of illness, however, it is always necessary to consult a biological-hygienic physician. The Dech-Manna-Diet remedies, for the time being, will always be obtainable on application to myself, to be administered in accordance with such medical directions. I trust that very shortly when official and general recognition will permit, I shall be enabled to entrust the detailed prescriptions to a wider circle of practising physicians and chemists. In order to illustrate how necessary it is to abstain from more detailed description of my remedies, I will cite but one of several incidents which happened to me in course of practice. In the year 1905, I wrote a number of articles for the "Reliable Poultry Journal" on the scientific feeding of chickens, and gave, amongst other tables, two food-formulas of the mineral contents of _chicken food rations_. (Both formulas were copyrighted). I gave the same gratis, for private personal use. A certain "Chicken Specialist" from the Orange River Colony, South Africa, first wrote a glowing article upon the wonderful success he had secured with my prescriptions. Not satisfied with this, however, he conceived a brilliant idea of great possibilities of future income to be derived therefrom. He left South Africa and came to America, the country of unlimited possibilities, and settled in Los Angeles, California, where he floated a company, which sells my copyrighted prescriptions for poultry feeding, to all and sundry as specifics for all possible and impossible ailments. This ambitious gentleman even went so far as to offer my labouriously earned discoveries to the United States Government.--But further comment is unnecessary! This is but one of numerous instances of the kind some of which are embodied in a little treatise I have published, free to my friends, entitled "A Message to the Thinker." Patients sometimes ask me what my methods have in common with "Schuessler's Tissue Remedies." I answer: Nothing--absolutely nothing, as the explanation will show. Schuessler's therapy claims that the minerals are needful to build up the system; but he only uses one trillionth part of a gram and _imagines_ that the remainder is to be found in the food. Now anybody with a fair understanding can easily figure that if a patient of middle age eventually loses through disease about 200 grams of lime, it is simply a farce to claim that the above dose of 1/100,000,000,000 of a gram (which is the homeopathic dose of Schuessler), will cure or replace the lime which was lost. There are other equally erroneous pretentions in Schuessler's therapy which are really too silly to go into in detail. Time and space are too valuable to squander on any such puerile hypothesis. DECH-MANNA-DIET. MENTOR TO PRESCRIPTIONS. It may be well to preface this summary of prescriptions with the following explanatory remarks; namely, (1) That while my compositions are usually taken in the form of powders, they may be taken in the form of capsules or tablets, in which case the dose given is always exact. They may also be mixed with Eubiogen or various kinds of food, except where this is strictly forbidden by the physician. Such mixtures cannot be harmful, since they consist of components from which our body-cells are constructed. They may be taken either singly, or as compounds. (2) As regards the matter of quantities:-- Whenever one-fourth teaspoonful is mentioned, the meaning is that one-fourth of a _heaping_ teaspoonful be taken. Whenever a _level_ one-fourth teaspoonful is meant, as in the case of plasmogen, it is because the basic remedy is heavier and, therefore, the smaller quantity renders an equal amount in weight. Every dose mentioned herein contains the exact amount of the necessary constituents, and the harmonious system of dosage which I have worked out, consists of reducing every compound dosage to one gram, which weight is equal to about one quarter teaspoonful of the regular preparation, made lighter and fluffier through trituration with milk-sugar. This trituration is a manual process and requires some three hours steady and continuous rubbing of the ingredients with pestle and mortar, for each separate composition. All my compositions should be kept in a dry and cool place. It is best to put them into wide-mouthed bottles with glass stoppers, as they are all hygroscopic, that is, sensitive to moisture. DECH-MANNA COMPOSITION No. 1. PLASMOGEN (PLASMA PRODUCER.) Plasmogen--Blood-plasma producer. (The red and white blood-corpuscles are produced by using Eubiogen, XII). (a). Blood-plasma, is the habitat of the red and white blood-corpuscles. It can be readily understood that the more sanitary a place, the better will be the condition of those who live in it. Therefore, the plasma, (blood-plasma), must first be made as perfect as possible in accordance with the teachings of science and especially of biology,--a theory which my own experience has proved to be correct. No matter how perfect the red or white corpuscles may be, if they live in diseased blood-plasma, they cannot perform their functions properly and, as a consequence, the resistant power of the system is crippled. (b). Plasmogen contains all the constituents in the proportions in which they should be contained in perfect plasma. The Law of the Minimum teaches that if one of the ingredients is lacking in the food, the cells _must_ become diseased. This the great Justus v. Liebig emphasized when he said: "If the most minute component is lacking, the rest cannot perform their functions." Taken as directed, the plasmogen is also in its natural dosage. It was only after years of ardent study that I was enabled to produce this composition in the perfect form in which it is furnished today. Since the plasmogen contains all the salts necessary to keep the blood in perfect harmony, the circulation as well as the resistant power will be maintained, the heart relieved, the fighting capacity of the white corpuscles strengthened, and therefore the power of disease very greatly reduced. (c). In all cases of constitutional disease, plasmogen is used to bring about a proper regeneration and preservation of the blood-cells. In all cases of acute, febrile diseases its purpose is to bring about a proper circulation and fluid condition of the blood-cells. The most wonderful results will accrue through the use of plasmogen in _all acute_ febrile cases, particularly in the case of children; also by using the same as directed in individual cases of constitutional diseases. It is indispensable in producing bactericide blood, which is necessary to regenerate the body-cells. Therefore, I recommend It in _all_ Regenerative Treatments. How many thousands of children may be saved by this single remedy alone only the biologist who has studied life according to the teachings of nature's laws, is able to appreciate today. It will take some time before the general medical practitioner will realize the truth of this statement, because the old-school medicine does not teach these facts. Therefore it is the duty of every thoughtful mother to prevent harm to her children resulting from the drugs they favour. All anti-febrile chemicals are rank poisons and contrary to nature's way. _Only by producing a higher temperature is nature able to throw off impurities_; but in many cases this becomes dangerous, because so very few know how to avoid an over-taxation of nature's strength. Instead of assisting nature by keeping the head cool, the feet warm and the bowels and pores open, the anxious mothers will wrap their babies up nicely, give them some patent or other obnoxious medicine, and really kill nature's efforts by means of narcotics and other poisons. Results are always fatal. The mother must learn to use correct, harmless remedies and to follow the instructions given nearly 3000 years ago by the wise Hippocrates, the "Father of Medicine," who warned every medical practitioner with these words: "Nil nocere." (Never do harm). (d). _Dose_: In acute cases, that is to say, in emergency cases where the patient, for instance a child, has developed a high temperature, and the doctor has not as yet diagnosed any special form of disease, or has been unable to do so because the time of incubation of the germ has not passed, give the patient a dose of plasmogen, that is, one gram, or as much as will lie on a ten-cent piece, or one-fourth of a level teaspoonful. Dissolve it in one-half tumbler of water, (or milk if prescribed), and let the patient drink it slowly at intervals, as seems necessary. In ordinary cases individual directions should be followed. DECH-MANNA COMPOSITION No. II. LYMPHOGEN (LYMPH CELL PRODUCER.) (a). In nearly every tissue and organ of the body there is a marvelous network of vessels, called the lymphatics. These are busily at work taking up and making over waste fluids or surplus materials derived from the blood and tissues generally. The lymphatics seem to spring from the parts in which they are found, like the rootlets of a plant in the soil. They carry a turbid, slightly yellowish fluid, called lymph, very much like blood without the red corpuscles. The lymph is carried to the lymphatic glands where it undergoes certain changes to fit it for entering the blood. It is a fact that very few doctors know, that the whole nervous system can only be fed by the lymph, whose central station is the so-called ductus thoracicus (thoracic duct), in the upper region of the chest. As there is no pulsation or magnetism connected with the same, the body must lie down and rest at night. Then and only then is the system enabled to feed all the nerve centers, especially through the influence of the sympathetic nerve system, which may be said to work in the form of a relay station, through its inherent power from the very beginning. Therefore, it becomes quite a task to regenerate a broken-down nervous system, for those practitioners who are not familiar with physiological chemistry--that is, life chemistry, which teaches the composition of the tissues. The law of chemotaxis will explain it. The lymphatic system also plays a great part in constitutional diseases of the blood. Every degeneration of the blood cells, or dysaemia, is influenced more or less by the perfect condition of the lymphatic fluid. All cachectic or morbid nutrition conditions are due to imperfect lymph. (b). Lymphogen contains all the organic minerals in the same proportion in which they are contained in perfect lymph, and if taken as directed, will always restore the lymphatic system and allow it to perform its important function. (c). The great importance of perfect lymph will be understood from the previous remarks, especially those pertaining to the feeding of the whole nervous system. If the lymphatic system is impeded by underfeeding or inanition of the nerve-cells, how can any one with common sense expect such a system to be in perfect working order and harmony? This applies particularly to those constitutional diseases where the lymphatic system and the lymph itself are degenerating through causes due to heredity, predisposition or acquisition of such conditions. (d). _Dose_: Twice daily I gram or one-fourth heaping teaspoonful or, if in tablet form, I tablet, dry or with a little water or in foodstuffs; to be taken at 10 a.m. and 4 p.m. or as specially directed. DECH-MANNA COMPOSITION No. III. NEUROGEN (NERVE CELL PRODUCER). (a). The nerves are the cord-like structures which convey impulses from one part of the body to another. The tremendous importance of their absolute health is obvious, since the co-operation of all parts of the human body depends upon it, while, on the other hand, their very delicate structure exposes them to numerous and easily acquired forms of disease. (b). This composition contains all the constituents required to generate nerve tissue. The most important and expensive is lecithin. Pure lecithin, the kind I use, is made from the yolks of fresh eggs. In this composition I supply nutritive cell-food for generating lecithin in exactly the same form in which it is found in a healthy, perfect nerve-cell. It is absolutely digestible and assimilable, and is triturated with the finest milk sugar. (c). All morbid conditions caused by imperfect nerve-cells can be regenerated through this composition as long as there is some foundation left on which to work. Under an endless variety of names--as a matter of fact, a big book would not be sufficient to describe all so-called "nervous diseases"--it can be readily seen in what a brainless way some "nerve specialists" classify patients of this kind. Not knowing the constituents of the nerve-cells, they still attempt to prescribe for neurasthenic patients. The results are in accordance with such travesty of treatment. The increase in the number of Insane Asylums gives, or should give, a true picture of existing conditions. What is needed is a little more knowledge of physiological chemistry, but as it is too much to expect of the ordinary so-called "nerve specialist" to be familiar with this science, we must per force be content with the prevailing condition, that is, a condition characterized by ignorance of the most vital laws of being. But what reasonable ground of complaint, let me ask, have the people, themselves, in this matter? Of the appalling results of the prevailing medical system, recognized as it is by the law of the land and supported and virtually endorsed by the people's own will and prejudices, they themselves, though well aware, are yet complacent. But, mark it well, not until independent medicine shall be accorded reasonable recognition, a fair field and general fair play, and the chance afforded to science outside the "orthodox" medical clique to inaugurate some drastic measures of urgently needed reform, not until then will it be possible to alter this disastrous state of affairs--not until then will matters become less unbearable to the individual and less discreditable to every one concerned. _We can cure disease only by removing its cause; this is my maxim and it is true for all time._ Much of neurasthenia is due to the degenerate times in which we are now living. Causes must be removed in every line of life, political, social, and economical, before normal physical and mental conditions can be restored. Then neurasthenia, in all its forms, will be a disease of the past, but not before--not withstanding the frequent alleged discoveries of serums and antidotes of wonder-working properties so triumphantly heralded from the "Halls of Science." (d). _Dose_: Twice daily, 1 gram or one-fourth heaping teaspoonful or, it in tablet form, 1 tablet, dry or with a little water or in foodstuffs; to be taken at 10 a.m. and 4 p.m. or as specially directed. DECH-MANNA COMPOSITION No. IV. OSSEOGEN (BONE CELL PRODUCER). (a). If I tell you that it takes seven different compositions of organic lime to make perfect bones, some people, even very learned ones, may doubt my word. But biology and physiological chemistry teach that this is so--and prove it. If this composition were lacking in a certain quantity of organic magnesia, the bones would grow hard and brittle. It is the magnesia that turns the tissue into perfect, elastic form. (b). Osseogen is the composition the constituents of which are necessary to generate perfect bone tissue. How many troubles could easily be prevented by using this cell-food in time! (c). This composition becomes an absolute essential in all cases of imperfect bone structure, such as rachitis, or rickets, constitutional disease of children, osteomalacia, tuberculosis of the bones, deformity of bone structure, such as curvature of the spine, etc. Softening of the bones, known as osteomalacia, curvature of the spine, rachitis and many other terrible conditions of disease would not be known to humanity if proper precaution were taken in time. Hundreds of patients are today cured by my method of supplying this lacking constituent in a form assimilable to even the smallest infant. Lime-water and such imaginary substitutes are pure nonsense, as must surely be apparent to even the simplest layman when they consider for a moment that it takes seven different lime compositions in order to supply the necessary lime for generating bone tissue. Is it necessary to say more to convince even a dogmatist? How indispensable osseogen becomes may be realized when people begin to know enough about themselves to realize that our bone structure must be "fireproof" in order to last for the normal span of human life! (d). _Dose_: Once or twice daily, according to the individual case. 1 gram will be sufficient for a proper dose. As stated before, one-fourth of a heaping teaspoonful is equal to a gram. It may be that in a short while I shall be able to supply all these compositions in tablet form in their respective doses. Then medication will become still more simple. This composition may also be taken in food or a little water. DECH-MANNA COMPOSITION No. V. MUSCOGEN (MUSCLE CELL PRODUCER). (a). The term muscle signifies every organ of the human body which, by contraction, produces the movements of the organism. Muscles are of the greatest variety and strength, but all consist of the same chemical elements, and can be regenerated in case of disease, like every other organ, by feeding the patient with the chemical substances which the muscle cells require. (b). Into this composition I have introduced the components necessary for muscle tissue. The basis of this form of cell-food is potassium phosphate. It will regenerate all muscular tissue when used as directed. All minerals contained therein are organized and in a perfectly digestible and assimilable form. Even an infant can easily digest it. It will prevent all decompositions of the muscular system and regenerate the cells as long as any basis for life is left. (c). As it is impossible for even the healthiest system to build up new tissue without the necessary proportion of albumen, it becomes very important to use the right proportion and form of this component. Therefore, all patients who are in need of this special tissue builder, must at the same time take the main composition, Eubiogen (life producer). Under No. XII, I will endeavor to give the reader some little idea of its properties, and describe its marvelous regenerating powers. (d). _Dose_: 1 gram, or one-fourth of a heaping teaspoonful once or twice daily will be sufficient. It may have to be taken for 3, 6, 9 or 12 months, and even longer. Everything depends upon the cause of the degeneration of the muscle tissue. DECH-MANNA COMPOSITION No. VI. MUCOGEN (MUCOUS MEMBRANE CELL PRODUCER). (a). The entire intestines, the stomach, all cavities, organs, openings of the body, the genital and urinary tracts, etc., are lined with mucous membrane, which must always be kept in a normal and healthy condition, otherwise the functions of metabolism and procreation of the organism cannot be carried on in safety and health. (b). Mucogen consists of all the constituents necessary for the building up of the peculiarly tender tissue called mucous membrane. These constituents are absolutely indispensible, and nature must be supplied with them if disease of the mucous membrane is to be healed by removing its cause. (c). The tenderness of this tissue is obvious, and experience has shown how much it is exposed to changes in its normal condition, how easily an increase or decrease in its main functions is brought about. While this increase or decrease in many instances is a natural fight of nature against the intrusion of opposing elements into the body, it frequently assumes dimensions that are most unpleasant and seriously impair the health, such as catarrhal conditions, all of which are due to poor or degenerated cells of this tissue. The frequent occurence of this form of disease shows the importance of always supplying the cells of this tissue with the substances that keep them in health, or if need be, will regenerate them. (d). _Dose_: 1 gram or one-fourth of a heaping teaspoonful once or twice daily will be found sufficient to supply the requirements. In some instances this composition, as well as others, may be mixed with the main composition Eubiogen, in order that the patient may digest it more readily, especially in the case of a child. Special directions must always be followed closely. DECH-MANNA COMPOSITION No. VII. DENTO AND OPHTHOGEN (TOOTH AND EYE CELL PRODUCER). This refers to the enamel of the teeth and the crystalline lens of the eye. (a). Two special tissues of the human body, the close connection between which has been observed and recognized but very little, contain a predominant quantity of fluoride of lime, and consequently may be placed under one heading in this system, although the basis for the fluorate of the teeth is calcium, while the basis of the crystalline lens of the eye is gelatine. (b). I have composed this cell-food, containing the necessary fluoride of lime, in this particular way in order to avoid too much specialization. From long years of practical experience I have found that the special cells of each tissue will take up only those constituents which they need for the construction of their respective tissue, as taught by the law of chemotaxis. (c). Composition No. VII will be prescribed in case of tooth and eye troubles. Any observant student of human nature will have noticed that in severe cases of degeneration (as for instance, diabetes) not only one of these two tissues mentioned above is affected, (as the decaying and falling out of the teeth), but in most cases also the other (as cataract of the eye). Some doctors of course may ask what in the world the tooth has to do with the eye. But, alas! they have yet much to learn. The two are not so distinct from each other when one understands. I fear that later on, when this method, which is the only true and natural one, comes into practice, everything will be specialized to such an extent that the real science of it will become so complicated that the proverb--"Veritatis simplex oratio est"--(The language of truth is simple)--will become entirely obsolete. It is my endeavor to state the pure unvarnished truth, and in terms as simple as possible; that is my mission. (d). _Dose_: One gram or one-fourth of a heaping teaspoonful, or one tablet in a little water or milk, once a day will be sufficient except in very severe cases of degenerated tissue. DECH-MANNA COMPOSITION No. VIII. CAPILLOGEN (HAIR CELL PRODUCER). (a). The hair is built of a number of elements not contained in other tissues of the body, and which must be supplied in order to keep the hair in good health and prevent it from falling out. (b). Capillogen contains all the necessary constituents in proper proportion required by perfect hair tissue. (c). The main disease of the hair, responsible for this falling out, may be due, to two different causes. It may be due to the quality of the hair, or to the condition of the nutritive soil of that part of the skin where hair is wont to grow. If the loss of hair is due to the first cause, its regeneration, through Dech-Manna Composition No. VIII, naturally gives rise to the hope that the lost hair may be replaced, if the process of regeneration is not begun too late, as is usually the case. My composition, however, is not a "hair restorer." As a great many of my readers may know, and some of them to their sorrow, all so-called hair restorers on the market are failures--although perhaps not so to the manufacturer or clever salesman. My composition will prevent the hair tissues from degeneration. Thus baldness, which might otherwise have occurred in a larger or smaller degree, may be prevented. In the case of the disability of the skin to retain the hair, which may occur after forms of febrile disease, such as typhoid fever, or if children show little promise of growing nice hair, the composition will prove very useful in combination with Dech-Manna Composition No. XII, Eubiogen, which restores the original strength of the whole body, while hair regenerated by the blood through capillogen has a better chance of growing and remaining in the regenerated soil. (d). _Dose_: One gram or one-fourth of a heaping teaspoonful, or one tablet in a little water or milk, once a day. It is imperative to follow directions implicitly. DECH-MANNA COMPOSITION No. IX. DERMOGEN (SKIN CELL PRODUCER). (a). The skin, like all other tissues of the body, is made up of different constituent elements. While its disease appears on the outside, it is built up, like all other parts of the human organism, from within and through the blood only. The elements necessary for regenerating the skin and keeping it in a healthy condition must, therefore, also be supplied to the body from within, in the form of nutriment, as otherwise, though we might suppress and eliminate the symptoms, the disease would still remain. (b). Dermogen, skin producer, contains all the constituent elements which a healthy skin tissue requires. (c). The skin, being exposed to all external influences, discloses the symptoms of all forms of skin disease, the names of which are legion. The skin specialist termed "dermatologist" is another production which flourishes--more or less--upon the ignorance of the public. The patient, alas, is less fortunate. He tries one after another until disgusted he sometimes resorts to special diet. Sometimes this may help, if he choose a certain kind of vegetable diet, and especially if the vegetables are such as contain a great deal of silica; for silica is the mineral basis of skin tissue. Full details of this are to be found in my analysis of foodstuffs given in the chart at the end of volume No. I of my work, "Regeneration." (d). _Dose_: One gram or one-fourth of a heaping teaspoonful of dermogen in a little water or milk once a day until regeneration of the skin is fairly started. Reduce the dose gradually until complete recovery has been accomplished. DECH-MANNA COMPOSITION No. X. GELATINOGEN (GELATIGENOUS TISSUE PRODUCER). (a). All blood and lymphatic vessels, the alveoli of the lungs, all tendons and cords in the entire system, the bowel tract, including the stomach, the bladder, and in fact every organ or tissue which has the function of expanding and contracting, must be of healthy gelatigenous (rubber-like) tissue; otherwise it cannot perform its functions in the system and must degenerate. (b). Gelatinogen contains the constituent elements of gelatine, which it carries, through the blood, to the parts of the body where it is needed to rebuild degenerated gelatigenous tissue. (c). While there are not many special forms of disease of the gelatigenous tissues, many diseased conditions are more or less connected with its degeneration. In fact, every layman should be able to judge the importance of perfect gelatigenous tissue. But how many human beings ever think of such things. Yet they know very well that a poor rubber tire on an automobile will not last very long or stand much strain; for the fact appeals to the pocket book--and that degenerates. It is well to learn the truth before too late and give, to the rising generation at least, the chance to which they are surely entitled:--A good healthy body. (d). _Dose_: Twice daily, 1 gram or one-fourth of a heaping teaspoonful, or one tablet, at 10 a.m. and 4 p.m., or as individually prescribed, in a little water, milk or other foodstuffs, to be taken for a certain length of time. DECH-MANNA COMPOSITION No. XI CARTILOGEN (CARTILAGE PRODUCER). (a). Every bone in the human system must be covered with cartilage at its ends so as to prevent self-destruction through friction, especially in the joints. (b). Cartilogen consists of all the necessary constituents of this important material, and under certain circumstances it must be introduced in this concentrated form, as for instance when the general diet is unable to counteract the influences of disease which tends to degenerate the cartilage and subjects the body to the great suffering which the absence of cartilage invariably produces. (c). Cartilage keeps all the joints in working order and must be regenerated constantly. As soon as the blood and lymph no longer contain the proper, necessary constituents for the rebuilding of cartilage tissue, the consequence is degeneration of this tissue. It is obvious then that the presence of proper cartilage constituents in the blood is of the greatest importance to the regenerating forces in the human body. Our foodstuffs, therefore, must contain the material in a digestible, assimilable form, thus to prevent inanition of the cells, otherwise degeneration of the cartilage tissue must follow. (d). _Dose_: One gram or one-fourth of a heaping teaspoonful twice a day for a certain period, depending on the condition of the patient. This may be taken in the same manner as previously described. DECH-MANNA COMPOSITION No. XII. EUBIOGEN (HEALTHY LIFE PRODUCER). (ALSO TERMED "POSITIVE COMPOSITION"). (a). While all other compositions contain _special_ elements for the rebuilding of _special_ tissues through regeneration of _special_ cells, Eubiogen contains a combination of all the important elements in the most concentrated form. I was fortunate enough, after years of experimenting with plants and animal life, to concentrate the solid constituents of the human body _ten_ fold. The full import of this achievement few can realize, but those who know what it means in time and study. The effect of this composition is felt simultaneously in all the vital tissues of the body, and since the co-operation of all these tissues is what we call "life," I feel there is no name more fitting for this product than the one I have selected, namely, "Eubiogen," or "Healthy Life Producer." I maintain that it is the most scientific composition discovered since the time of Hippocrates and the following is its analysis: It has at all times been an ideal aim of mankind to produce a species of food that would combine a minimum of quantity with a maximum of quality, and philosophers and scientists have dreamed of a time when the day's portion of foodstuffs would be concentrated in one small pill. The biologist cannot accept this theory. While Greek mythology seemed to symbolize a similar idea; namely, of one concentrated food-substance combining all nutritive elements, as represented in their "Ambrosia," the food of the Gods. Yet the gods and goddesses were permitted to partake of it only at solemn assemblies when all sat at the table of Zeus and enjoyed their food and drank its liquid counterpart, termed "nectar." This symbolism represented Ambrosia and Nectar as the highest climax of food; just as the Greek gods stood for the climax of various human qualities, in each case attributed to one single personality. The Greeks knew well that the human body requires a variety of food in order to remain healthy. It is an echo of the same thought expressed in the Bible when the Jews are given the "Manna" only in the utmost emergency. The Bible also advocates a considerable variety of food, regarding which the Old Testament lays down the most careful and explicit regulations. In praising "Ambrosia" as the climax of food-substances, Greek mythology attributed to it the power not only of regeneration, but of procreation. For the reproduction of healthy human life in its offspring, was to them just as sacred and important a preoccupation as it was natural, to ensure the survival of the race; and to secure to all the food that would assist in this, their highest and most worthy aim, seemed to them a manifest duty which, at the present day, prudish "morality" either practically ignores or modestly pretends to neglect. Healthy food, generally speaking, will do much towards ensuring healthy offspring. But the times of extreme leisure, as enjoyed by the ancient Greeks, are long past and a more exacting age makes its more strenuous demands upon the human tissues, and in innumerable cases causes them to deteriorate more rapidly than they can be regenerated and restored to their original vigor by even the healthiest food. Hence I have felt justified, in considering the best interests of the race--present and future--in devoting the crowning effort of my long scientific career to the production of modern biological remedies such as would be felt in the reproductive powers of the people--a consideration concerning which the old-time, prudish reticence is a foolish figment rapidly passing away. Now, as regards myself and my great work. Surely to boast a little is but human. The man who puts his very best efforts into an ideal, and having achieved it, has not striven to reap the fruits thereof for selfish gain, but year by year, has perfected that work until the tests have finally permitted him to cry: "Eureka"--it is accomplished beyond dispute,--that man has the right to overstep the conventional rule which forbids self-praise. While in other work accomplished I see but the links of an uncompleted chain, the synthesis of Eubiogen, I feel to be one of those so rare occasions in human life, when a tested accomplishment allows and even demands a somewhat different treatment. And so I have the courage to speak as follows in eulogy of my own production: This product is my masterpiece. I am proud of it. Nothing like it in efficiency has ever before been given to the world. In the fullest sense of the word, it is in food value the most perfect concentration that science and research have ever evolved. It is the result of the quest of 30 years and should make its finder famous. Hundreds of men of mark have each one given to mankind some noble token of their genius; but of such gifts not one possessed the concentrated virtues, the materialized knowledge of "Eubiogen." This, to unsympathetic ears, may sound like vain, exaggerated vapouring;--but it is not so. _It is the truth_. It is impossible to describe the real value of its properties within a limited space. Sufferers in their thousands will yet live to be grateful for the benefits derived from it, and the full and positive knowledge of its excellence makes it the more difficult to describe in a few weak words. An abler pen than mine would fail to do it justice. In sentimental somnolence I sometimes dream how, perhaps, in the days to come, another hand may write in glowing terms the faithful history of "Eubiogen" and say kind feeling words and fair of the hard worked lone scientist who gave its healing virtues to mankind, terming it--he too perhaps--the stereotyped "Ambrosia," the diet of the Olympian gods; but for myself, it is all I ask to know that it has served the appointed end to which my energy has aimed,--that it has proved a food instinct with healing and comfort to my kind--a staunch support and refuge for the overwrought sinews of humanity. May such be my guerdon of reward for the long years of thought and toil and--I shall rest content. (b). Eubiogen contains the best and purest ingredients science and experience can produce today. It is the most delicate and at the same time the most digestible and assimilable cell-food obtainable. Many great names since the time of Hippocrates have figured in the list of those who shared with me the ambitious hope to give mankind some wonder-working remedy--Metschnikoff, Voit, Koenig, Biedert, Rubner, Gruber, Kussmaul, Bischoff, Teschemacher, Hirschfeld, Boemer, Wintgen, Virchow, Hammarsten, Gilbert, Fournier, Heim, Lahmann, von Noorden, Epstein, Wair Mitchel, Salkowski, Kornauth and the rest, but not one of them ever dreamed of a perfect regenerator of the cells of the human body such as this composition, Eubiogen, affords. The analysis of my product, shows that it is practically impossible to improve upon in life-giving, cell-generating qualities. This fact should satisfy the student. Still I will describe the ingredients a little more minutely, so that all who use it may be convinced that they are doing the best that can be done, as known to the science of today, to improve conditions of health for themselves and for their offspring. As a basis, then, I use for the necessary trituration, the finest radio-active milk sugar produced, flavored with _pure_ vanilla extract. The high percentage of albumen contained in it is due to the use of the most highly perfected hygienic product of albumen known to chemistry. It is chemically pure and manufactured from eggs, milk and vegetables and, therefore, absolutely free from microscopical germs, harmful to the human system. The organic iron contained in it is obtained from the red-coloring matter of healthy ox blood, called haemin, examined and tested. For the nerve material, pure lecithin or nerve fat is used, obtained from the yolks of fresh eggs. These two products are enormously expensive. All the organic minerals are in the form of glycerophosphates, and the milk sugar necessary for making a perfect trituration is radio-active, as explained before. To make the whole product as digestible and assimilable as possible, I use the best material known, that is, Taka and Malt diastase. It is made palatable through the use of genuine van Houten's cocoa in chocolate form. It will remain in good condition an unlimited length of time when kept in a dry, cool place. No drugs of any kind are used. This I guarantee in the fullest sense of the word. The manufacturer is a renowned chemist of the highest type, and all the products are of the highest quality obtainable. This is capable of verification by any really capable authority on the chemistry of food. In order to bring this product within the reach of all classes, the same has been compounded in three different forms: Form aaa. contains radio-activity, haemin, lecithin, glycerophosphates and all other constituents of the highest purity. Form aa. contains haemin, lecithin, glycerophosphates and all other constituents of the highest purity. Form a. contains haemoglobin, glycerophosphates and all other constituents (chemically pure.) For the use of babies and very feeble invalids, special composition B (see appendix) may take the place of Eubiogen, since it contains nearly all of its constituent elements in a form that can be assimilated by either. It will regenerate the invalid as fast as his condition will allow, and is the salvation of weak children. (c). As to when Eubiogen should be administered, the rule is simple. Whenever any of the Dech-Manna Compositions are given, Eubiogen should be given in smaller or larger doses, as the case may require, remembering that its most important task is to rebuild and regenerate the body so that it may readily perform its fullest functions and transmit the power unimpared to posterity. (d). _Dose_: The dose may vary considerably, from 1 to 3 times a day. Generally a dose consists of 1 gram or one-fourth of a heaping teaspoonful. The composition may be combined with any kind of food, or may be given in separate form with chocolate in equal parts. There are endless ways in which my remedies may be administered, since they are merely concentrated cell-food. _It must be definitely understood at the outset that these remedies must be absolutely and entirely dissociated with the idea of so-called "medicine,"_ prescribed by the old-school doctor, which has nothing whatsoever in common with my "remedies," since these contain the real constituents of our body-cells and _not_ poisonous chemical concoctions, known as medicines, which _may_ in some cases suppress symptoms, _but never will and never can remove the constitutional cause or condition of disease_. =COMPARATIVE ANALYSIS.= =The Human Body= consists of: 83.0% Water \ 0.9% Minerals | 3.8% Albumen | Solid constituents 2.5% Fat | only 17% 9.8% Carbohydrates | ------ | 100.0% / =Eubiogen= consists of: 9.0% Minerals. (Chiefly Glycerophosphates, Haemin or Blood-Iron and organized minerals) 10 times concentrated. 33.5% Albumen. (Egg, Milk and Vegetable-Albumen) 9 " " 15.0% Fats. (Chiefly Cacao, Glycerin fats, Lecithin) 6 " " (Note.--Lecithin is made from fresh yolks of egg.) 42.5% Carbohydrates (Chiefly Malt Extract, Milk, Sugar etc.) 5 " " ------ Of the original amount 100.0% Solid Constituents. in the human body. =Note.= 1 Pound of Powdered Egg-Albumen represents the total egg-albumen contents of 116 Eggs. 1 Pound of Powdered Milk-Albumen represents the total milk-albumen of 25 pints of Milk. 1 Pound of Blood-Iron represents 250 pounds of Haemoglobin. (The cost of Haemoglobin is $4.50 per pound, the value, therefore, of 1 pound of Haemin or Blood-Iron is $1,125--) APPENDIX LIFE PRESERVERS AND ELIXIRS. In addition to the twelve Dech-Manna Compositions mentioned before, I have composed three others that are most important and are to be used practically and in various doses; the first and the third should be used in nearly every treatment of patients suffering from constitutional diseases, while the second is the remedy which takes the place of Eubiogen when the patients are babies or very weak. SPECIAL DECH-MANNA COMPOSITION. (A) OXYGENATOR. This consists of radium emanation tablets or powders and the necessary bath salts for the decarbonization of the system in all cases of what is called auto-intoxication. They have a wonderful effect on the metabolism of the human organism, and increase the oxidation of all diseased cells that poison the system. The radium tablets are officially guaranteed and the bath salts are the result of many years study in balneotherapy and hydrotherapy, and have demonstrated their effectiveness by the wonderful results that have been obtained during the last thirty years. Rheumatism, gout, arterio-sclerosis, etc., cannot exist in the system when these baths have been taken for a certain length of time. I rarely undertake a treatment for disease of this kind without them. HOW TO APPLY OXYGENATOR. For a half or partial bath fill the bath two-thirds full of water at 90° to 98°. Use one pound of bath salts. Mix and dissolve them completely in the water. As soon as dissolved, put two of the oxygenator radium tablets into the water, one at the head and one at the foot of the bath, allowing one-half to one minute for dissolving. Mix very slowly and quietly in order not to release too much of the radium emanation. Lie in the bath very quietly for 20 to 25 minutes, with cold compresses on the head. Then open the cold water faucet, begin to move about in the bath, sit up and wash face and chest with cold water. Let the cold water run into the bath until you notice some signs of "goose-flesh," then get out and rub down well with a good Turkish towel. Never remain alone while taking this kind of a bath. Stop the bath immediately if any feeling of faintness is experienced. Drink a glass of Tonogen, or other refreshment. SPECIAL DECH-MANNA COMPOSITION. (B) EUBIOGEN LIQUID. This composition is in liquid form and intended for babies and very feeble invalids. It contains nearly all the constituents of No. XII, Eubiogen, but in such a form that even the infant can safely partake of it, with rapid regenerative results. Thus the degeneration of inherited or predisposed conditions or weak tissues will be prevented. _Dose_: From one-half to three teaspoonfuls a day, pure or diluted in milk, according to the individual directions given. As a fermentative agent I know of nothing better, and through the formation of gases, acidity of the stomach will be prevented, perfect digestion assured and consequently health and normal conditions restored. SPECIAL DECH-MANNA COMPOSITION. (C) TONOGEN. As a beverage Tonogen scientifically speaking, stands at the head of all chemical achievements in drinks. Therapeutically, there is nothing that could be more beneficial to the human system. It contains the fundamental constituents of normal blood and nerve cells in such form that even the weakest and most sensitive digestion will readily respond to its influence. This compound is absolutely free from all deleterious chemicals; as a tonic it is stimulating and strengthening and as a beverage it is so palatable that few will hesitate to pronounce its taste delicious. In all cases of acute febrile diseases, also in chronic forms of these diseases, as well as in climatic fevers, it is wonderfully effective in supporting the healing process of nature. From a physiologico-chemical standpoint, it has been thus described: Tonogen is the acme of chemical perfection, both as a tonic and as a beverage. It is the captured and crystalized outcome of years of scientific observation focussed upon the true ingredients of healthy blood cells as viewed from both the theoretical and practical biological standpoint. It represents, in fact, a life study of the science of life, in a concrete form of body-cell invigorator suitable to all mankind, from earliest infancy to advancing age, and this of a nature equally digestible and assimilable to both. After but a brief experience of this seductive beverage, it may speedily be felt how, once digested and assimilated, it courses through the lymph channels and lacteal vessels and, by the familiar route of the Chyle passes into the heart, where joined with the blood of that organ, it produces a sensation of liquifaction. In its course, by way of the arteries, it gradually reaches the external glands, warms the limbs and, in a manner electrifies them. In the body, it suffuses the pancreas and other glands and the intestines, mingles with the fluids existing in the glands and with the oily salts of the bile; and whatever impurities (autotoxins), may be there it drives in the form of excrement and urine completely out of the body. Thus in its free and ample scope is all the ground of all the intricate vital processes of physiology covered in its course and the active principles of the excretions of skin, kidneys and intestines are made visible at a glance. In combination with Plasmogen, taken alternately, it is really indespensable in all the diseases mentioned above. Many a life has been saved through the use of this combination. It is one of my standard home remedies, and my own family would not think of allowing themselves to be without it for a single day, for, as they say, one never knows when it may be required. _Dose_: One teaspoonful tonogen with three teaspoonfuls of granulated sugar in a tumbler of water, to be taken slowly, once or twice daily. In cases of diabetes and arterio-sclerosis the dose should be 20 to 25 drops tonogen in a teaspoonful of milk sugar 1 to 3 times daily. Pregnancy is a contra-indication to the use of tonogen. APPENDIX II. The following compositions are also used especially in specific cases. =(D). Tea. Diabetic. _Dechmann._= Description: Compound of many herbs (powdered) found beneficial to the diabetic system. =(E). Tea. Laxagen. _Kneipp._= Description: Compound of several herbs (powdered) approved by the celebrated Kneipp in cases of chronic constipation. =(F). Salve. Lenicet. _Reiss._= Description: The most beneficial salve in case of inflamed wounds, boils or exanthematous eruptions. =(G). Massage Emulsion. _Dechmann._= Description: Consists of the finest ethereal oils and other ingredients useful and valuable, yet absolutely harmless, in case of nerve or muscular pains, applied as a liniment. =(H). Propionic acid.= Description: The product of various herbs known for their high percentage of propionic acid; applied in case of catarrh in the form of atomized steam. =(I). Oxygen Powder. _Hensel._= Description: A composition of sugar, gum tragacanth (traganth) and citric acid, used in the form of lemonade in case of high carbonic acid poisoning. =(J). Anti-Phosphate. _Dechmann._= (Otherwise termed "Negative Compound.") Description: Contains all basic salts as sulphates, thus acting as the governor of a machine; that is it prevents the accumulation of too much phosphate in the blood, which would promote the formation of all fungus growths. (See paragraph in the article, "Importance of the Mineral Constituents in our food"). * * * * * A copy of my wholesale price list as given in 1915--before we entered the war--may give you a fair idea of the price of my compositions. Since that time, most of the ingredients of these remedies have increased from four to ten times in value. The reader can easily judge therefrom of the fairness of the present values. I may say that most of the compositions are listed at only one-fourth to one-third advance, notwithstanding the high cost of chemicals. This fact will absolve me, I think, of any tendency to profiteering. PRICE-LIST DECH-MANNA COMPOSITIONS. No. Per oz. Per lb. I. Plasmogen $0.75 $ 8.00 II. Lymphogen 1.00 10.67 III. Neurogen 1.50 16.00 IV. Osseogen 1.00 10.67 V. Muscogen 1.00 10.67 VI. Mucogen 1.00 10.67 VII. Dento & Ophthogen 1.50 16.00 VIII. Capillogen 1.50 16.00 IX. Dermogen 1.50 16.00 X. Gelatinogen 1.50 16.00 XI. Cartilogen 1.50 16.00 XII. Eubiogen 2.00 21.35 Same with sacch. lact. radio 2.50 26.67 A reduction of 33-1/3% on the prices per pound will be allowed on all the above products as quoted in the second column. A. Radio emanation tablet (5,000 volts); Per tablet $ 1.50 Bath salts, original composition, lb. 1.00 B. Eubiogen Liquid (a) oz. 0.75 (b) oz. 1.00 pt. 8.00 pt. 10.67 C. Tonogen (a) oz. 0.50 (b) oz. 0.75 pt. 5.33 pt. 8.00 J. Anti-Phosphate (a) oz. 0.50 (b) oz. 0.75 lb. 5.33 lb. 8.00 Copies of the Handbook "Dare To Be Healthy" Second Edition, may be procured at 75c for the paper-bound edition and $1.50 for the leather-bound edition. PHYSICAL TREATMENT. As I have already stated, it is necessary in disease to assist the process of regulating the circulation and opening the body to the full benefit of the dietetic and nutritive salts treatment by applying a number of physical treatments, in each case, which, for convenience sake, I have divided into ten different groups, some of which may need to be applied simultaneously in certain cases. They are as follows: 23. Ablutions with vinegar and water, 1 part vinegar, 2 parts water. 24. Abdominal packs, vinegar and water, dito 25. Partial packs: (a) Vinegar and water, dito (b) Radium and salts. 26. Partial packs: (a) Arms. (b) Legs. (c) Neck. (d) Shoulder. 27. Three-quarter packs, vinegar and water, dito 28. Gymnastics. 29. Massage. 30. Breathing Exercises. 31. Oxygenator Baths. 32. Radium and Salt Baths. (a) Half. (b) Whole. NOTE--=The Vinegar= indicated to be used for these treatments, and in all similar treatments, packs, or ablutions, prescribed, is the natural, or what is known as "Apple Cider Vinegar." The manufactured or ordinary table vinegar, as made from chemicals, is not suitable for the purpose. From these groups a treatment is usually prescribed in each and every case of disease. The importance of ablutions especially packs is so great that it is necessary to give further explanations concerning them: In a general way, it is necessary to apply a bath or an ablution (See Form 23) when the test with the thermometer, usually applied under the tongue, in arm-pit or in the rectum, shows that the temperature of the patient exceeds 100 degrees. The patient grows restless, his skin feels dry and the pulse, which regularly is 70 to 80 with adults, 90 to 100 with children, and about 130 with infants, shows an increased speed. As soon as these symptoms appear, they indicate that the immediate cooling off of the body by means of a bath, an ablution or a pack is necessary. Adults will always show the desire for such instinctively. In extreme cases baths or ablutions should be administered several times every day. Healthy people perspire as soon as they become too hot. This means that they cool off through the evaporation of the perspiration. This is supplemented by the bath and its cooling effect; balancing the higher temperature of the body with the lower temperature of the water, brings this about. The blood which flows towards the skin during the bath is cooled off, and returns in this condition to the interior of the body, and is immediately followed by other quantities of blood. Since the blood circulates through the body about twice every minute, the cooling takes place from 20 to 24 times during a bath, lasting from 10 to 12 minutes. This explains the soothing and cooling effect of the bath on the waves of blood and the nerves, which are irritated by the increased temperature. At the same time the bath opens the pores which assist in the excretion of degenerated matter produced by the disease, and fosters the reception of oxygen. It is a natural function of the body that an increased flow of the warming blood flies always to any region of the body which is assailed by external cold, so that such parts may not become too cold or, in common parlance, may not "catch" cold. This explains why the hands get red and hot after throwing snow-balls, the feet burn after a cold foot bath. As soon as the body, which is hot with fever, is put into the cool bath, the first effect is that the blood-vessels of the skin contract under the cooling influence. The blood recedes. Soon, however, it streams with renewed energy to the skin to defeat the cold. The first action,--the recession of the blood,--is followed by reaction or increased activity of circulation towards the skin. This removes the pressure of the blood upon the overburdened internal organs, such as the brain, the lungs and the heart. The blood is diverted. For ablutions the water should be cool or lukewarm, the exact temperature to be determined by the strength of the patient. Some vinegar should be added to the water, taking two parts water and one part vinegar. To accustom children to the use of water and ablutions is one of the important duties of motherhood. A healthy child should be washed once every day with water at 59 degrees to 64 degrees. The best way to wash the child is to put two chairs in front of its bed. On one of them place the vessel with the necessary water, on the other place the child, after it has been disrobed in bed, in a standing position, so that it can be supported with the back of the chair. The ablution is performed by means of strong application with the hands, dipped into the water, and is repeated several times. Then the shirt is put on again, and the child is allowed to stay well covered in bed for another 15 minutes. Children must become accustomed to gargling as early as possible, and to draw water up through the nose, or to remove it from the mouth through the nose. This is very valuable and facilitates the treatment of children in case of disease. VINEGAR PACKS. It appears opportune at this juncture, and before entering upon the detailed description of the modern healing system of Vinegar Packs, included in the prescribed course of Physical Treatments which follow, to make a few rational remarks illustrative of the physical significance and scientific basis of a branch of therapy which largely amongst the laity, through ignorance, and more so amongst the regular medical fraternity, for reasons of their own, is too frequently lightly regarded by the one and diplomatically depreciated by the other. In this manner one of the most potent and logical modern factors in the healing of disease would be conveniently consigned to the back ground in company with other simple _but unremunerative_ truths, but for the timely intervention of the new and enlightened school of independent medicine of which the Biological or Hygienic Dietetic Method of Healing is the outcome. The wonderful efficacy of natural Vinegar upon the organism and its employment in the form of Vinegar Packs and compresses dates back probably to the early traditions of the healing art, but scientific analysis of its subtle operation upon the system through the vital fluid has been left for the scientific research of today to determine. To those of the public--or the profession--therefore, who are not conversant with the subject the following notes may be valuable as descriptive of the why and wherefore of the use of Vinegar. It will be admitted, I think, that one of the most prolific sources of disease, in innumerable forms, is that of congestion of blood. The greatest danger of such congestion is inflammation. Should inflammation occur in or near a vital organ and fail to be promptly reduced and its cause (coagulation) removed, the result is decomposition--and decomposition, if not arrested means death. The most valuable--I might almost say infallible--remedy known, even to the greatest accepted authorities of physiology, for the prevention of inflammation is acetic acid in diluted form, or, in a word, Vinegar, as a restorer of the fluidity of the blood. Inflammation is the result of coagulation of the blood-albumen; congestion is its sequal, inflammation and decomposition of the tissues its climax. The last is nearly always fatal. _The manifest object therefore to be achieved in all such cases is to restore the normal fluidity and circulation of the blood_ without unduly taxing any vital organ. Thus, for instance, hot packs on the feet draw the blood towards the feet, where no vital organs exist. Hot packs act as an absorbent, by suction; cold packs, on the affected place, act in inverse ratio as an expelling force. The two operating conjointly promote full circulation and extend the absorbing tendency to the whole system. Ice, on the other hand, though not infrequently prescribed, is too strong a force. It contracts the blood vessels, arrests normal circulation, and in many cases is the direct cause of death. This is attested by the teaching of physiological law which maintains that any part of the human system which is not fed by fresh oxygenous blood _must decompose_. Packs, of course, must be regulated in accordance with the vital strength of the patient, as indicated by the physician; for in the course of the excretion of morbid matter through the pores, under the influence of the packs, a certain proportion of accompanying healthy substance is necessarily exuded simultaneously, with a slightly weakening tendency. This however can be promptly and effectively replaced by proper alimentation, or food selection in accordance with the Dech-Manna Diet System already particularized. One other matter it is advisable to deal with in advance and that is the _Nature of the Vinegar to be employed for Packs_. It must be borne in mind that for this purpose an absolutely pure natural product should be obtained. I recommend, in the first place a genuine _Apple Cider Vinegar_; for apples not alone contain the pure acetic acid but also some five or six other fruit acids which are so beneficial for the purpose of keeping the blood at normal temperature and normal fluidity, and contain also a considerable amount of the essentials known under the head of vitamines. As a secondary alternative I would recommend _Wine Vinegar_ for the same purpose. The manufacturers vinegar product--_Acetic acid, should never the used_ as it contains, very frequently, harmful ingredients. It should never be forgotten that the substances used for the purpose of packs, and thus absorbed into the system, become a part of the blood and therefore cannot be too pure. The reader will doubtless observe from the foregoing demonstration that the Dechmann System of Therapy differs materially from the science of the Old-School of Medicine in that it is not based upon evanescent theories of hairsplitting philosophy but upon the solid basis of cold-blooded fact. Why then, the reader will inquire, should so wonderful and at the same time _simple, inexpensive and easily applied remedy_ be treated by "the faculty" with an affectation of indulgent toleration, ridicule or "damning with faint praise." To this riddle there are two solutions--neither of them very creditable to those concerned. On the one hand, only crass ignorance of some of the most important facts of physiology and physiological chemistry could account for it. And, it must be borne in mind that in the course of the prolific verbosity of pontificated dogma which has graced the scroll of medical science, whole libraries have been written--and ably written, too--by skillful pens for the sole purpose of covering the simple nudity of the agnostic position of science--the dreaded, confidence-shattering admission: "I don't know." Failing this solution there is, unfortunately, but one alternative and that a singularly distasteful one to entertain; namely, to attribute the unpopularity of this splendid gift of Nature to unprofessional considerations on the part of an apothecary-loving profession. The employment of vinegar is, as I have said, a royal remedy, ready to the hand of any man and at little or no expense, and it needs no "learned" interpretation. It is consequently beyond the omnivorous talons of "the trade." Would it be unkind to say: "Hinc illae lachrymae"? THE PACKS. The packs mentioned as physical treatment, under Nos. 24, 25, 26 and 27, are of the greatest importance, and in fact I never undertake the treatment of any disease whatsoever without applying them as the most effective means of restoring proper circulation of the blood and removing diseased matter from the body, which is the only way to bring about a real and definite cure. The effect of the pack is the cooling of the blood. The temperature of the pack is 50 degrees and more below the temperature of the blood. In the first place this brings about quiet after unrest. Through the action of the body, which sends a large quantity of blood to the places which are touched by the cool compresses, a certain surplus of heat is created which is transferred to the compresses and retained by them as moist warmth. Under this influence the blood-vessels of the skin extend and absorb blood more freely, which is thus diverted from the important internal organs to the skin. In all cases of fever the diseased matter is dissolved in the hot feverish blood and circulates in and with it. The evaporation of the skin is increased, and with it the diseased matter is absorbed by the compresses, which consequently diffuse an unpleasant odor when removed, and when cleansed, give to the water a muddy appearance. Thus it may be observed to what extent the pack removes diseased matter from the body. Packs must be changed as soon as they cease to give comfort to the patient, and make him too warm. Highly flushed cheeks, increasing temperature and unrest are sure signs that the pack requires to be changed, and in case of high fever this may happen after 20 to 30 minutes. For short packs, such as are prescribed in all inflammatory and feverish diseases, water at from 59 degrees to 64 degrees is used. A piece of linen cloth is folded from 4 to 8 times, wrung out, but not too much, and then covered with moderately thick folds of woollen cloth. The stronger the patient and the higher the fever, the thicker should be the pack. For infants a double linen strip is sufficient. The faster the fever and inflammation recede, the longer may the pack last, up to three hours. The convalescent will enjoy the moist warmth, under the influence of which still existing diseased material is thoroughly dissolved and completely excreted. The dissolving effect of packs of long duration is most noticeable in chronic diseases. Through the penetrating effect of the moist warmth on the body or parts thereof, deposited diseased matter is dissolved, and dislodged, existing excoriations are disintegrated, and withdrawn into the circulating blood, and thus excreted. The dissolving packs of long duration must be applied somewhat thinner than the cooling ones (from 1 to 3 folds); they must be wrung out more vigorously, and covered more closely. If a pack should be applied for the sake of prevention of disease, it may be put on in the evening and remain all night. In the beginning of fever, while it remains moderate, the patient can endure the pack for from 2 to 2-1/2 hours. Biological hygienic therapy rejects the external application of ice, for it causes severe congestion of the blood. Extensive application of the ice pouch causes more or less paralysis of the nerves, which in many cases prevents recovery and even causes chronic disease or fatal results. The biological hygienic treatment desires _to moderate inflammation only_, to the degree that it should lose its dangerous character, but it leaves to the body its power _to remove, through the process of inflammation, alien and diseased matter, and to absorb and gradually carry away the products of inflammation through the blood current_. Paralysis of the vocal cords, of the muscles of the eye, of the nerves of hearing, the exudations from the nose and eyes after diphteria, meningitis and scarlet fever, adhesions, suppurations after pneumonia and other forms of inflammatory disease, are often the _consequences of the use of ice_, because the products of inflammation are not absorbed, and the ice paralyzes the neighbouring nerves. Inflammations, which are suppressed by medicine or ice, must renew themselves; since the causes, the alien matter (auto toxins), as well as the products of inflammation remain in the body and are not thoroughly excreted. To apply water, on the contrary, quickly removes not only the inflammation, but its causes and eventual consequences. The organs which have been inflamed do not show any further inclination to renewed inflammation. In no case will a chronic ailment be the consequence of an acute disease, provided the same is dealt with in a natural way, according to the principles of biological hygienic treatment. In order to bring about the complete excretion of all autotoxins and, in case of inflammation, the complete absorption of all products thereof, it is necessary to continue the lengthy packs even during the period of convalescence, and not to stop immediately the fever and inflammation have somewhat disappeared. This is a mistake which is frequently committed, and the fault is then laid at the door of the biological hygienic system. Any relapse, or succeeding illness, will be avoided by continuing the packs for four to six weeks after the disease has been cured, applying them during the night and at first also during the day-time, from two to three hours. While most people understand the cooling effect of a pack, _the important diverting, dissolving and excreting effect is rarely understood_. Few people understand why ablutions, abdominal and leg packs are prescribed in case of inflammation of the eyes; why, in case of ulcers, besides compresses on the part affected, nightly abdominal packs and ablutions in the morning, are considered indispensable; and why, in case of inflammation of _one_ leg, the healthy leg is also subjected to a pack. And yet the explanation is very simple, rational and logical. In limiting packs, in case of inflammation, to the inflamed part only, the blood current would be directed mainly to the one place, and the excretion of autotoxins from the body would only occur in the inflamed place. The blood would carry all diseased matter principally to the diseased spot and deposit it there. The inflamed organ would thus be burdened with work which it simply would not be able to perform. The effect is far otherwise when the pressure of blood into the diseased part is moderated, if the dissolution and excretion of the matter that causes the disease, takes place, not in one spot only, but is distributed over the entire body. If the entire skin comes into action, the entire body participates in the healing process. In biological hygienic-dietetic practice it is, consequently, not sufficient to treat the one diseased organ only. In all diseases _the co-operation of the entire body in a general treatment, remains the main issue of the biological, hygienic therapy_. It regards the human body, as so often stated, purely as a unit, and knows neither specialist nor special cures. This is the key to its success. IMPORTANT GENERAL ADVICE. For use in packs take coarse, previously used and loosely woven linen, which readily absorbs water and clings closely to the body. After each pack the linen must be rinsed well and boiled and the woollen material or blanket must be thoroughly aired. From time to time the woollen covering must be washed, or chemically cleaned, if possible. Raw silk is an excellent substitute for linen. It clings well to the body, does not cause any discomfort, and has an excellent absorbing quality for water and other substances. The proper application of the pack is of course of great importance. Adults can easily apply many of the packs without assistance, but generally speaking a third person is necessary, whether in the case of children or patients. It is consequently advisable for every mother to become thoroughly familiar with the methods of applying packs, and she should always have the necessary material on hand. It should be cut to the proper size, and there should be duplicates of each piece for the necessary changes. The approximate measurements for adults are: =Width= =Length= Neck pack 5" 40" to 60" Shoulder pack 10" 40" Abdominal pack 28" 40" to 60" Breast or stomach pack 16" 52" to 60" "T" pack 16" 52" to 60" Cross piece alone 5" 24" The shawl 32" to 40" 32" to 40" Scotch pack (undivided) 16" 80" to 100" Same for children 10" to 16" 60" to 80" Calf pack 24" 26" Leg pack 24" 30" Three-quarter pack 56" 52" to 60" Whole pack 68" 80" The measurements for children are accordingly shorter and narrower. As to the application of packs, a mother can learn a great deal by experimenting on her own body. Packs at night are by no means detrimental to adults, and the application of a regular abdominal pack, a three-quarter pack, and a whole pack once a week or once every two weeks is decidedly advantageous. Three-quarter and whole packs should be occasionally tried on the body of children with dry linen so that in case of disease the mother will be a well trained nurse, at least in this respect. To go about the application of the pack quietly and without much talking is very comforting to the patient, who usually grows excited during the procedure. In case of acute feverish disease the packs and the changes must be applied very quickly, so that the patient will not catch cold. While, as a rule, the patient should not be disturbed in a quiet sleep, unconsciousness or delirium must not prevent change of the pack. Packs should be applied so as not to cause any creases which may hurt the patient. The temperature of the water used for packs should be as follows: For the cooling packs, 59 degrees to 64 degrees. For dissolving packs, 64 degrees to 71 degrees. The higher temperature is used in the treatment of infants, nervous and anaemic persons. In chronic diseases a gradual return to a lower temperature by about 2-1/2 degrees per week is advisable. No packs or compresses should be put on when parts of the body are cold. In such cases the parts in question must first be warmed. The linen should be wrung out less for short cooling compresses than for dissolving packs of longer duration. Cooling compresses must be changed as soon as the patient indicates that he feels oppressed or irritated by the heat. As a general rule, packs on the legs may be left on feverish patients twice as long as packs on the upper parts of the body. No fever being apparent, the abdominal pack may be changed after about 2-1/2 hours, the leg pack after 5 hours, and even not at all during the night. Packs should be renewed according to requirements of the individual patient, not in accordance with fixed rules. Great care must be exercised to fasten the packs well and tightly. This is usually done with good strong safety pins; these should be fastened perpendicularly, or at right angles to the length of the material. When changing the pack on feverish patients who are to receive an ablution or a bath two or three times a day, all pins must be loosened under the bedcovers so that the pack may be removed quickly. If ablutions only are to be given, the pack is removed gradually as the respective parts of the body are to be washed. When the fever is moderate, there should be ablutions morning and evening, or a bath in the morning and an ablution in the evening. When packs are applied only at night, patients require only an ablution in the morning. If the packs are not renewed, an ablution must follow the removal. This refreshes and strengthens the skin, closes the wide open pores and prevents taking cold. Dissolving packs, if annoying at night, may be removed under the bedcovers without an ablution. If the pack is changed without intervening ablution, the new pack must be ready to be applied before the old, hot one, is taken off. While in a pack, the patient should not leave his bed, not even for the purpose of urinating or for stool. GENERAL RULES. The following general rules must be applied in connection with the directions given anon for packs during different diseases. In case of inflammation, the inflamed spot is cooled off by local compresses, and diverting packs of longer duration are applied on other parts of the body. For instance, in case of inflammation of the brain or tonsils. The first step is to cool off the blood which flows to the neck and head by short-time compresses on the neck and on the cervix. At the same time an attempt must be made to divert it through lengthier packs on the abdomen, the legs and the wrists, thereby to prevent a further delivery of diseased matter to the centre of inflammation. The solution and excretion of diseased matter from other points than the inflamed spots will thereby be effected, and these will be unburdened and calmed accordingly. In case of inflammation of the organs of the breast (lungs, heart), the blood is diverted to the abdomen, legs and lower arms through long-time packs, and the upper parts of the breast are cooled with short compresses. If the inflammation has its seat in the abdomen, this must be cooled off, while the diversion with longer-time packs is made to the legs and arms. Ulcers are treated by applying extremely hot compresses, which are frequently changed, and the surrounding parts are cooled off and diversion is effected through nightly packs on the abdomen and on the legs. The hot compresses dissolve the diseased matter, so that the ulcer opens. Thereupon cool compresses of 71 degrees to 64 degrees are applied and allowed to remain for 2-1/2 to 3 hours, which will effect quick healing without the necessity of an operation. _The main rule is never to divert towards a vital organ_ of the body, such as the lungs or heart; thus, in case of inflammation of the head, diversion must be attempted, not to the breast, but to the arms and legs. ABDOMINAL PACK (24) The abdominal pack should be applied on infants and children whenever they show signs of illness in any way, and naturally, in cases of summer complaints, measles, scarlet fever, diphtheria, whooping cough, pneumonia, typhoid fever, in which cases a pack should be applied during the entire course of the illness with slight intermissions only. As in acute diseases, it is also applied in chronic ones. (See descriptions to follow). Its early application will often serve to prevent serious sickness. The abdominal pack reaches from the level of the base of the breast bone to the hips. It is made from a piece of linen crash about 12 inches in width which must cover the space from 6 inches below the arm-pits to the hips, while its length must be such that it can encircle the body, overlap upon the abdomen and be secured with tapes at the left side. A further piece of soft linen is needed to pass between the legs, to be fastened to the former, back and front, with safety-pins. The next requirement is a piece of woollen cloth, or blanket, folded double or treble as required, in breadth, about 6 inches wider than the linen crash and of equal length, with a shorter woollen strip for between the thighs, attached like the linen, back and front. For children a linen towel etc. with the accompanying woollen coverings, will be found, as a rule, sufficient; for infants, a properly folded piece of old linen. The linen as well as the woollen material must be properly folded before the pack is made, and measured, so that the patient need not be kept waiting while the pack is being placed on the body. [Illustration: No. 1] The above cut shows how to apply the abdominal pack on an adult patient. The linen is saturated in two parts of water with one part of vinegar, at 64 to 75 degrees Fahrenheit, well wrung out, and is placed on the woollen material in such a way that the latter extend about 2 to 3 inches on the upper and lower edge. The pack is now placed around the back of the patient, who sits in bed or is held in position by another. The patient's shirt is lifted and he is laid down on the moist linen, which is then quickly raised on both sides and folded over the abdomen. The same is done with the woollen material, which is then fastened tightly in the middle, the upper and lower corners with three safety pins. Then the shirt is pulled down and the patient is warmly covered. In individual cases it is advisable sometimes to divide the pack into a back and front compress of greater proportions. In such cases the woollen cloth, which is used for the abdominal pack is placed underneath the patient as before. A towel is folded 6 to 8 times, so that it will grow warm slowly and thus may remain on the body for a longer time. This is placed under the back of the patient. Then two properly folded towels, which are not wrung out very thoroughly, are put on the abdomen, and tucked down a little on both sides. The woollen cloth is thereupon fastened so as to keep the compresses in place, the arrangement being otherwise exactly as before. In such cases the back compress only needs to be changed every 2 to 3 hours, even in case of severe fever. The front towels may be changed several times in the meantime. Since this system permits the application of the pack without disturbing the patient and making him sit up too often, it is very desirable in cases of severe illness. The undivided pack is often very uncomfortable for patients suffering from respiratory complaints. It is better to treat very excitable patients with front compresses only. When the stomach pack only is prescribed, as in catarrhal and nervous, stomach or liver complaints, which pack may be worn during the night as well as the day, a long, wide mesh shawl, with a bandage, 7 to 8 inches in width at each end, is most servicable, as it will reach around the body 4 or 5 times. In order to exclude the air as much as possible, the moist compress is first applied, and then the shawl is placed around the body in such a way that each succeeding turn covers the previous one to about one-half, in bandage form. THE CROSS PACK (25) This is applied in case of men's diseases and women's diseases of the sexual organs. To the woollen material and the linen crash of the abdominal pack, another piece, about half as long and about 7 inches wide, is sewed or pinned before application, in the form of a T. [Illustration: No. 2] Before the two ends of the abdominal pack are folded over on the front of the abdomen, the narrower piece is drawn up between the legs from behind, so that the end of it can be fastened to the two sides of the abdominal part of the pack that are folded over in front. As shown above, the abdominal pack must reach down as far as possible, and if a patient is unable to stand both packs, the moist part of the abdominal pack may be omitted, and only the regular pack over the sexual organs and the woollen part over the abdomen applied. In case the cross piece is for the purpose of cooling and contracting, it must be frequently renewed. Women should accompany the ablutions mornings and evenings with injections of lukewarm water at 71 degrees to 82 degrees, and men should make ablutions of the sexual parts 5 to 6 times a day with water at 64 degrees to 71 degrees. The cross pack has the advantage of gradually putting back into normal position, the female organs, if they are in any way displaced. These packs will help to cure cases of leukorrhoea and gonorrhoea, locally too, without operations or the application of poisons, especially if applied at an early stage. LEG PACKS (26) These are applied in a similar way to the abdominal pack. A towel or linen is doubled, moistened, and placed upon the woollen cloth, so that the woollen material extends about two inches beyond the upper and lower edges of the towel. These are laid together under one of the patient's legs, covering it from the middle of the thigh to the ankle, turned up from both sides and fastened with three safety pins. The other leg is packed in the same way, each one separately. [Illustration: No. 3] In like manner partial packs of the calves or the feet are applied. In all of these cases it is more expedient and comfortable to use "knit" packs. Cotton stockings of suitable length from which the foot has been removed, should take the place of the linen or towel in the packs previously described. They are moistened and covered with woollen stockings of corresponding length. The foot parts are to be used only for foot packs in a similar way. The woollen stocking should be as loose and comfortable as possible. In case of bent legs (through gout or otherwise) the moistened linen is wrapped around the leg like a bandage, and then a woollen bandage is wound over it. In cases of severe fever the wrists are also packed, no woollen cover, however, being necessary in this case. The leg pack has, in the first place, a diverting and consequently a calming effect. It is, therefore, of the highest value, next to the abdominal, cross, neck and shoulder packs, in all feverish and especially all chronic cases of disease where congestion in the head and breast, with consequent dizziness, headache, insomnia, pains in the lungs and heart, must be removed; moreover, in chronic cases, they assist in the effects of the abdominal pack. Foot packs, that is, wet stockings, have a very favorable action upon headache, toothache and earache, and are best applied during the night. If they excite the patient too much, they may easily be taken off during the night; otherwise they should be followed by a cold ablution of the feet in the morning. Nervous patients are usually unable to stand the wet stockings, which only work well if the feet become warm quickly, which, as a rule, is not the case in feverish illnesses. Patients who suffer from cold feet should take a steam foot bath before applying cold foot packs. Since the legs and the feet develop less heat than the abdomen, leg and foot packs do not require as thick material as abdominal packs, and are changed less frequently. They are best applied when the fever is at its height, in the late afternoon and at night. In case leg packs are continued for a long while, the legs show decreasing inclination to grow sufficiently warm. Whenever this occurs, leg packs must be discontinued, or the packed legs must be warmed in an artificial manner. The diverting wrist packs are of special value, especially in all acute diseases of the lungs (inflammations, bleedings, hemorrhages) and the heart. NECK PACK (26) This is made by folding a piece of linen fourfold, long enough to reach twice around the neck. It is dipped in the vinegar-water at from 59 degrees to 64 degrees, placed around the neck and some woollen material wound over it, covering well the moist linen. The neck pack has its effect on the inside of the neck in case of tonsilitis, croup, etc. If stiffness of the neck, headache or similar pains are felt after its use, the moist linen should not be extended to the back part of the neck but only the front and sides. Where the effect is to be extended to the trachea and its branches, the bronchia and the tips of the lungs, especially in the case of cough, it is still better to apply the following: SHOULDER PACK (26) For this purpose a short towel is folded into a strip of about a hand's width, extending from one of the nipples across the opposite shoulder, around the neck, to the other nipple. [Illustration: No. 4] A woollen shawl or fabric, fastened together with a safety pin, must cover the moist towel completely. The shoulder pack is always applied together with the abdominal pack. It is put on first, and the two ends are pulled under the abdominal pack, and then fastened. [Illustration: No. 5] THE SCOTCH PACK (26) The Scotch pack is of the greatest advantage in all diseases of the trachea and the lungs, also in case of whooping cough. Two towels are sewn together lengthwise and, as a moist pack, are placed over the breast of the patient so that the seam will be in the center. The ends are crossed over the back, one end is brought forward over the left and one over the right shoulder; then the ends are crossed once more and tucked under. A woollen shawl or covering is placed over the moist towels as usual, so that it completely covers the moist pack. The ends are tucked under the pack in front. The pack is fastened with safety pins where the ends cross. THE DIVIDED SCOTCH PACK (26) This pack is, in some respects better than the last, since it is less liable to form creases, and the upper portion may be changed more frequently for the purposes of cooling, than the undivided pack. It is used together with the abdominal pack. [Illustration: No. 6] [Illustration: No. 7] Instead of using one strip 4 to 6 inches wide, folded 4 to 6 times, as for the shoulder pack, two strips are taken. One strip is passed across each shoulder, and crossed on the breast as well as on the back. The woollen strips used for covering are of course wider and of double thickness. The ends of the two strips are drawn underneath the abdominal pack, and held by it, and the two shoulder packs may be changed as often as necessary for cooling purposes without necessitating a simultaneous change of the abdominal pack. THE SHAWL (26) (This is an application similar to "Kneipp's Shawl") A large square piece of linen crash from 35 to 40 inches in width is folded into a triangle, dipped in the vinegar-water at 59 to 64 degrees, and after being wrung out, is applied diagonally round the neck. The upper part of the back, the cervix, the neck, the shoulders and the upper parts of the breast are thus covered. A woollen wrap, the ends of which are pinned together on the back, will cover the whole pack tightly. This pack must be changed if the patient becomes too hot (after 1/2 to 2 hours), otherwise it may stay on all night. In case of feverish catarrh it is used together with the three-quarter pack. Among other things the "shawl pack" causes the cooling of the blood which streams to the head. Thus its effect in case of congestion and brain trouble is explained. _Neck and shoulder packs, Scotch packs and shawl packs must always be used in connection with a diverting leg, calf or foot pack._ THE THREE-QUARTER PACK (27) Next to the abdominal pack the three-quarter pack is one of the best applications, especially for children. A piece of woollen cloth, or a single blanket, as long as the patient and sufficiently wide to reach all around him, is placed on the bed in such a way as to be level with the arm-pits of the patient. A bedspread of about the same size as the blanket is then dipped into cool vinegar-water, wrung out well, and placed on the blanket so that the upper edge of the latter protrudes. The patient is now laid on the bedspread so that it reaches to the arm-pits. The moist spread is then turned up on both sides, part of it is tucked between the legs, and the protruding lower end is laid on or between the feet. Thus the body, from the arms down, is completely wrapped in the wet spread, and the woollen blanket is covered over it as usual and fastened with safety pins. The patient's shirt is then adjusted. The head, the neck, the uppermost part of the breast and back are not packed. Another blanket is placed over the patient and well fastened on all sides. A pillow must be placed between the feet and the lower edge of the bed. To avoid cold feet the wet spread should reach only to the ankles, and the feet be covered with the woollen blanket, or a hot bottle placed near them. [Illustration: No. 8] The three-quarter pack is very valuable in feverish diseases, since it takes effect on so large an area of the skin. It is also very helpful in case of meningitis and other inflammations. It should, however, not be applied by a layman, except with the greatest caution. The inflamed parts must be covered with compresses, as in case of pneumonia and inflammation of the heart. If three-quarter packs excite children too much, they must be replaced by abdominal and leg packs. The patient should remain in the pack as long as he does not become too hot or restless. This may occur after 20 to 30 minutes, in case of severe fever; otherwise, the pack may last an hour or longer. The pack is very useful with children when indications of disease appear. In many cases it will develop and cure disease, such as measles, if it is properly applied for 2 to 2-1/2 hours, and followed by a bath at 77 degrees or an ablution at 64 degrees. When fever and inflamation begin to slacken, and also during convalescence, three-quarter or whole packs applied daily or every second day, followed by an ablution, are very useful for the purpose of solution and excretion. In such cases the moist heat should be conserved by applying additional blankets or comforters to the limit of endurance. THE HALF PACK (25) The half pack is applied like the three-quarter pack, with the exception that it reaches only from the arm-pits to the knees. It is especially necessary to close it carefully around the legs. The half pack allowing the body more freedom, it may be kept on all night. It is most effective on the thighs in cases of sciatica. It is, however, also applied in case of febrile disease. THE WHOLE PACK This is applied in nearly the same way as the three-quarter pack, but includes also the arms, breast and neck. [Illustration: No. 9] In this case the blanket must reach to above the ears. On top of the moist spread a towel is laid, which is first drawn around the abdomen. The patient's arms must be somewhat bent, so that they will not oppress the breast when packed with it. Otherwise the arms may be treated just like the legs, so that the moist spread touches them everywhere. When it is impossible to fasten the blanket at the neck with safety pins, it can be tucked firmly under both shoulders. The blanket must be drawn tightly over the shoulders and the ends tucked under the opposite shoulder. It must exceed the length of the patient by 18 inches. In case one blanket is not large enough, two must be used, one of which may be drawn down 6 inches below the other. [Illustration: No. 10] Additional blankets, pillows and comforters may be used in case of high fever. The advice already given in regard to the differences in packs, depending on their various purposes of cooling, diverting, calming or dissolving, must also determine in this case as to the extra amount of covering. The access of cold air at the neck and legs, however, must always be carefully guarded against. An ablution or bath must follow each whole pack. If properly applied, the "whole pack" will be of the greatest benefit in all febrile and chronic cases. Inflammations require partial packs, while at the same time dissolving or diverting packs of longer duration are applied to the parts of the body which are not affected. SMALL COMPRESSES Small compresses may be applied to any part of the body. They reduce ulcers and slight inflammations; they dissolve coagulation in cases of rheumatism or gout, even of long standing. A medium sized piece of linen folded six to eight times, is useful in case of toothache or earache. The compress must be covered with a woollen cloth and fastened as securely as possible. Dissolving compresses must be covered more thickly than cooling ones. Special compresses are sometimes needed on the head, on the heart and around the neck to prevent congestions. They are covered only slightly, and like all cooling compresses, are changed as soon as they become hot. GYMNASTICS, MASSAGE AND BREATHING EXERCISES (28, 29, 30) The three items under "Physical Treatment": 28. _Gymnastics_, 29. _Massage_ and 30. _Breathing_, require only a few explanatory remarks. Their common object is, by means of external mechanical aid, to stimulate the circulation of the blood which is undergoing the process of regeneration. They remove obstacles to circulation and produce movements and reactions. While, in the case of massage, this external aid must, as a rule, be given by a third person in order to be effective, gymnastics and breathing exercises depend upon the patient himself. All of them, however, have the common attribute that, in order to be useful, they must be strictly individual. The old proverb: "No one thing is good for everybody," is fittingly applied in this case. There are few things that are so much abused as this rule in regard to gymnastics. I cannot urge too strongly the importance of caution in advising such exercises. While much of what is claimed for them may be good and true, the governing question as to _what is suitable in an individual case_, can obviously not be determined by any such impersonal advice. It is the exclusive right and the duty of the attending physician to prescribe whether, and to what extent, these exercises should be applied in each case. This is true of gymnastics even when practised by reputedly healthy people. By executing certain movements, they may develop disease and weaken certain organs, through ignorance of their abnormal condition. In case gymnastics or breathing exercises are prescribed as part of a treatment they should be executed in strict accordance with the order of the attending hygienic-dietetic physician. One of the great principles never to be overlooked in gymnastics is, that in order to have the desired effect they must be carried out with the greatest regularity. As to massage, this requires knowledge of anatomy in general, and of the anatomy of the individual to be treated, in particular. Only in this way can the desired effect be produced on certain muscles and nerves, with the further consequence that their movements promote the correct and health-giving circulation of the blood. Here again the governing factor must be the prescription of the hygienic-dietetic physician who has studied the individual case and knows the effect he wishes to produce by means of massage, and how to procure the same. Books on massage and its general practice without knowledge of the particular case, will really accomplish nothing. ELECTRIC VIBRATORS In certain cases, and where it is not a question of general massage, the patient will be able to apply massage for himself according to the physician's prescription. In this connection he will find an electric vibrator of valuable assistance. It will allow him to extend the area of the self-applied massage, but again, it will be useful only to the extent that it is carried out in strict accordance with instructions. OXYGENATOR, RADIUM AND SALT BATHS (31, 32) Since the discovery of radio-activity and the many effects which the presence of radium in certain waters and minerals produces on the human body, it has been the special task of research to find means of giving humanity in general the benefit of this important discovery. The radium preparation, called "Oxygenator," possesses the quality of oxidizing about five times as quickly as any other known substance, and thus removing the degenerated and diseased cells of the human body accordingly. This material itself, as well as other combinations of radio products and salts I use and prescribe for half or whole baths, as the case may require. They are of the greatest assistance in carrying out the course of treatment in each individual case. What in former times could be effected only through expensive trips to the few famous healing springs of the world, can now be accomplished in the comfort of the home or the sanatorium. But these measures, too, should be followed only in strict accordance with the physician's orders, bearing in mind that there is such a thing as "too much" even of so valuable an energizer as this. THE DISEASES TO BE TREATED AND THE APPLICATION OF THE METHOD. Having given, in the foregoing paragraphs, a brief description of the course of healing which I advocate, I am now about to give a short explanation of the different methods to be applied in treating various forms of disease, all of which have been already explained as degenerations of the twelve tissues of the body. This will enable patients to apply the prescriptions given to their individual cases. ..._Once more, however, I warn every one not to commit the mistake of believing that a layman can cure his own disease by even the most careful study of a book such as this is._ To the patient, who has been led into the path of health, it will, as is its purpose, give such instructions as will enable him to see his condition plainly. _He will then be able the more effectively to follow the instructions of the physician, and--what is of equal importance--to inform him correctly in regard to his own observations of his condition and the changes brought about by the treatment._ There is another point that I wish to mention here at the outset. Disease, although reduced to its last analysis under this system, is never so simple that it can be determined as the degeneration of one tissue exclusively. The unity of the body, the close connection of the various tissues, and the gradual transition from one into another, make it impossible to draw the lines as sharply and distinctly as between chemical elements. For the sake of classification we make the degeneration of a certain tissue the distinguishing element between various forms of disease. Let us not forget, however, that this does not mean more than the _degeneration of the main tissue_ which is affected by this particular complaint, while the same is also characterized by simultaneous degeneration of one or more of the other tissues, only to a lesser degree. It is, therefore, not inconsistent if, in giving the more detailed description thereof, several tissues are mentioned as being degenerated, and not only the one particular tissue from which the class derives its name. I. DEGENERATION OF THE PLASMO TISSUE. _Anaemia, Chlorosis, Pernicious Anaemia. A. Scrofulosis. B. Tuberculosis. C. Syphilis. D. Cancer._ To many who are unfamiliar with the results of modern research, and even to many physicians of the old school of medicine, the family of disease forms, as enumerated above, will look somewhat formidable. It comprises the most disastrous plagues of mankind,--plagues for which cures have been so frantically sought with such an ominous lack of results. It thus constitutes one of the most practical revelations of the biological method of research to positively proclaim that the common cause of these manifestly so different constitutional diseases is one and the same. That this fact was not recognized long ago is the reason they have been pronounced incurable by so many physicians who, by poisoning symptoms, established only a semblance of cure, until biological study led to the recognition of the truth. It discovered that all of these constitutional diseases are essentially blood defects and degenerations, resulting in the destruction of the body tissue in general,--the necessary and logical consequence of an imperfect condition of the blood. So there is a ray of hope for humanity breaking through the night of despair; that is, that its worst foes can be made to disappear in due time by attack directed at their common root. Not the knife of the surgeon, not the poison of the physician of the old school, but simply harmonizing the individual life with the laws of nature, will eradicate the cause. The tremendous importance of the subject, the wide field to be covered, makes it wellnigh impossible to treat the matter within the present limits as extensively as it should be treated. A large part of my book, "Dare To Be Healthy," of which this is but an abstract, deals exhaustively with this topic. There the reader will find the most interesting details in regard to the connection between these widely divergent forms of disease. Their nature as blood-diseases carries with it the fact that they are preeminently persistent through many generations, so that today there is but a minority of human beings in whom all tendency towards them is missing. So predisposition advances with the continuity of environment, the one point at which, at least in the case of the so-called white plague, or tuberculosis, an effort against it has been made. _The development towards the eradication of these evils has been neutralised by the overwhelming importance science has given to the theory of the bacillus as the incentive element of disease, while it is only a product of the same. The serum and anti-toxin therapy, which in its fight against the bacillus, lost sight of the first task of medicine, that of fighting the disease, was the logical consequence thereof._ The blood liquid which consists of the plasma and red and white blood corpuscles, and is the carrier of the lymph to such parts of the body as are not fed directly by the lymphatic vessels, such as the nerves, must have a well defined chemical composition in order to fulfil its task. What we call deficiency of blood is, with the exception of traumatically inflicted losses, normal in quantity, to a great extent, but deficient in quality. This consists in the chemical composition and the proportion of nutritive salts in the serum, or in the relation and quality of the oxygen carriers, that is, the red and white corpuscles, whose task it is to remove foreign and disturbing elements from the blood. It is obvious that deficiency in these elements may be of infinite variety and of the most far reaching consequence for the various tissues of the body, which receive their nourishment therefrom. According to the nature of the effects which this variety in blood deficiency (dysaemia) produces, we distinguish certain groups of degenerations in the body, for which names were established at a time when the unity of these forms of disease had not yet been recognized. Thus, where dysaemia produces only general debility, we call it anaemia, which may gradually become destructive and develop into "pernicious" anaemia. When it affects girls with all kinds of disturbances in menstruation, perverting their appetite and causing a greenish color of the skin, it is called "chlorosis." If the symptoms are the destruction of the lymphatic glands, so often noticed in children said to be hereditarily affected, we speak of "Scrofulosis." When erroneous composition of the blood, produced by poor living and unsanitary environment, causes destruction of the lungs or of certain bones or tissues, the name "tuberculosis" indicates that the decaying condition of the affected tissues results in producing numerous tubercle bacilli. In the many cases in which the destruction is even more widespread, attacking the skin, bones, brain and other tissues or organs, and where the decomposing poison, if not hereditary, has entered the blood by way of sexual intercourse, the ominous word "syphilis" indicates the resulting blood disease. When the weakened tissues, which are not sufficiently fed with the elements they need for their normal existence, cannot resist the developing power of the phosphates prevalent in the blood, the much dreaded malign "cancer growths" appear. The destructions wrought by dysaemia in these various forms, cannot be fully described in this brief abstract. They can all be reduced, arrested and forced to give place to healthy regeneration by the hygienic-dietetic healing system. In each case, however, the possibility of cure will depend entirely on the degree of decomposition which has been reached. If the trouble is from hereditary tendency it is obviously harder to fight, and a long regenerative treatment may be anticipated. If attacked at an early stage, complete restoration to health is possible in a comparatively short period. The most careful and thorough investigation by the physician must precede any treatment. It is his task to prescribe accordingly, with the development of the disease and its gradual disappearance. The simultaneous direct and indirect affection of various tissues, especially of the lymphatics, will necessitate more complicated application of the various nutritive compositions. THERAPY. _Diet: I. For the Anaemic._ All that grows in the sunshine makes blood. Therefore, the food of an anaemic person should consist mainly of articles of diet which grow above the surface, such as green vegetables, fresh greens, fruit, berries. Since the blood has already grown very thin, as little fluid as possible should be taken, and for this reason the boasted milk cures are far from advisable. If all hot reasoning is avoided and little salt and sugar are used, no thirst will be felt. Coffee, tea, beer, wine and other alcoholic drinks are to be avoided because they consume oxygen, such as also do thin soups, lemonade, malt coffee, and other beverages of slight food value. _Breakfast_: In summer, a glass of cold milk, sweet or sour, and with it strawberries, huckleberries, cherries, or other fruit in season; in winter milk or cocoa, oatmeal porridge with bread (whole wheat, whole rye), or something similar. When the bowels are sluggish, take a little fruit on rising in the morning and at bedtime. _Dinner_: Cereals, rice, macaroni, dumplings and eggs, with fresh greens, spinach, fresh peas, fresh beans, cauliflower, all varieties of cabbage, cucumbers, pumpkins and squashes. Root vegetables are not excluded. Celery and parsnips alone interfere with the renewal of blood. They ought not to be eaten frequently. _Afternoon Lunch_: Fruit, milk or one cup only of weak cocoa. If the appetite is good, omit this meal. _Supper_: Every day, if possible, some fresh greens seasoned with lemon juice, particularly cresses, lettuce, endive, spinach and red cabbage, with puddings of meal or eggs. Sour milk with fruit and mild cheese, may be taken for a change. In winter, thick soup or porridge with fruit, preferably apples and huckleberries. Also an apple at bedtime. Anaemic people commonly have no wish for meat. They force themselves to eat it in the belief that only on a meat diet is it possible for them to become strong. They would do better to follow their inclination and refrain from it altogether. They regain health faster on a purely vegetable diet, one special reason being that the digestion is less burdened. Fattening, combined with rest and rational remedies, like Dech-Manna-Diet, are the best means of curing anaemia. The deficient appetite must be stimulated through tastefully prepared dishes and much variety. The patient will thus unconsciously be induced to take more food. Delicacies and dainty dishes foster pleasure in eating, and a little food between the principal meals will help to make up the necessary amount. Spinach, also egg omelettes filled with spinach, puddings, groat, oatmeal, light dishes prepared with plenty of eggs, sugar, butter and milk, also roasted meat if desired are the best articles of food for anaemic patients. Drinks that are recommended are: strong malt extracts, buttermilk, sour milk, Dech-Manna chocolate, fruit coffees, fruits, berries, honey and Dech-Manna-Diet. _I. and II. A. For Scrofulous Patients._ Two affections, rachitis and scrofula, frequently co-exist, and the same dietary is appropriate for both. Scrofulous patients often have a great longing for sulphur and for irritating compounds. Frequently they consume salt greedily, eat charcoal, onions, and other piquant substances. This indicates their need of vegetables and fresh greens full of nutritious salts and of pungent taste and smell because of the amount of sulphur they contain. Various kinds of cabbage are appropriate for the principal dinner dish, cooked or raw in the form of a salad, with horseradish to give them relish. For seasoning of vegetables and salads, onions and leeks may be used unsparingly; onion soups will be found palatable and will improve the lymph. At supper water-cress, lettuce, radishes, and sandwiches made of chives are preferable to sausage and rich cheese. Fresh, mild cheese makes a good side-dish. Meat should be eaten sparingly, because it rapidly changes into products of decomposition in the lymph, and so the harmful rather than the useful fluids of the body are increased. In connection with rachitis and scrofula a ravenous appetite is often manifested. This is a morbid symptom. It arises from exhaustion of the stomach and intestines, for no increase of bodily weight accompanies it. The greater part of the nourishment taken passes out of the system without being digested. Such persons, whether adults or children, should have their meals at regular, short intervals, for they are unable to restrain their morbid eagerness for food. After a few days of strict diet they lose their appetite, a condition that must be accepted until a natural hunger takes its place and results in a normal increase in bodily weight. It is well known that many people suffer from hives and eczema after having eaten certain dishes, such as crawfish, strawberries, oysters, honey, tomatoes or cheese. For such people to refrain from partaking of this kind of food is no protection against eczema. Only regeneration of the blood will lead to a cure. As a rule such patients should avoid sharp and spicy dishes; especially desirable is a diet of fresh, good meat, not in very large quantity, alternating with days on which no meat at all is taken. It is imperative to avoid sharp cheese, such as Roquefort, mustard, sardelles, mixed pickles and similar spicy dishes. Form VI is best for patients suffering from scrofulosis. _I. and II. B. For Tuberculosis Patients._ Patients who suffer from diseases of the lungs or other tubercular tissues do not require food of different composition than is generally recommended, provided their digestive organs are healthy. They must have albumen (medium fat beef, veal lean pork, haddie, pickled herring, eggs, brick cheese, peas) and fat in sufficient, even abundant quantity. Warmed milk is recommended especially. Variety in food should prevail. This will be the best means of overcoming the dangerous lack of appetite, which must be stimulated by delicacies and cleverly prepared dishes given between meals, sandwiches, cold fowl, jellies, piquant cold meats. The single portions should be small but frequent. Good beer rich in malt, sherry, malaga and other sweet wines, are all able to promote the appetite, unless the physician orders strict abstinence from alcohol. In case of haemorrhage of the lungs, the physician will generally prescribe liquid food exclusively, and his orders must be observed strictly. In such cases it is very advisable to take gelatine, which can be prepared in a variety of ways, or meat jellies. Care should be taken in all forms of tubercular patients, that the special tissue gets its special composition. _I. and II. C. For Syphilitic Patients._ The diet for people affected with syphilis does not vary from the one given under I and II. A. for scrofulous patients. Just as in the case of scrofulosis, a rich diet is recommended for syphilis. (Form VI). In former times starvation-cures were applied in case of syphilis, based on the hypothesis that diseased humours in the body should be reduced. In view of the noxious effect which the disease exercises on the entire body, this method has been given up. In case of the hereditary syphilis of infants, the best possible diet for the mother must always be insisted upon. (Never less than Form VI and Dech-Manna Eubiogen, with each meal). If nursing by the mother is impossible, and since a wet-nurse cannot be subjected to the danger of contamination through the child, easily digestible substitutes for mother's milk should be selected; that is, not cow's milk, but other approved nutritive foods for infants. It will be most beneficial to add Dech-Manna Eubiogen Liquid to the child's food. _I. and II. D. For Cancer Patients._ Cachectic patients should not, as some authorities recommended in former times, be starved by poor diet in addition to the losses which they already suffer when afflicted with diseases, such as cancer. Except in case of cancer of the stomach and bowels, when I would recommend Form III and, with gradual improvement, an increase up to Form VI, the latter form of diet should always be prescribed in case of cancer. Special instructions, as given under the heading, I. and II. C. For Syphilitic Patients, should also be followed in these cases. _Dech-Manna-Compositions_: (Only main compositions, specialities to Doctor's order). I. Anaemia: Plasmogen, Eubiogen. I. and II. A. Scrofulosis: Plasmogen, Lymphogen, Dermogen, Eubiogen. I. and II. B. Tuberculosis: =Plasmogen=, =Lymphogen=, Mucogen, Gelatinogen, =Eubiogen= I. and II. C. Syphilis: =Plasmogen=, =Lymphogen=, Dermogen, =Eubiogen= I. and II. D. Cancer: =Plasmogen=, =Lymphogen=, =Eubiogen.= _Physical_: I. Anaemia. Breathing Exercises. I. and II. A. Scrofulosis: Partial Packs, Oxygenator baths, Radium and Salt whole baths. I. and II. B. Tuberculosis: Ablutions, Breathing Exercises. I. and II. C. Syphilis Abdominal packs, Partial packs, Oxygenator, Radium and Salt half baths. I. and II. D. Cancer: Oxygenator, Radium and Salt whole baths. II. DEGENERATION OF THE LYMPH TISSUE. The lymph, the second life-giving fluid, is first drawn from the chyle, the milky juice, into which all food is converted after it leaves the stomach, and after having directly fed the nerves, enters the blood through the ductus thoracicus, and accompanies it in its circulation. According to its nature some degenerations of the lymph tissue are coincident with degenerations of the blood, and especially the plasma, such as Scrofulosis, Tuberculosis, Syphilis and Cancer, while other degenerations of the lymph tissue coincide with degenerations of the lymph-fed nerve tissue and are consequently treated under that heading. III. DEGENERATION OF THE NERVE TISSUE. The nerves which form the very complicated system of gelatinous cords of various sizes which emanate from the brain and the spinal cord, send thousands of branches throughout the entire body. They communicate the impressions from the outside to the brain and convey its conscious or unconscious (instinctive) mandate to the muscles of all organs. The nerves are fed by the lymphatic system and are everywhere accompanied by blood-vessles, and the oxygenous blood in the latter conveys the oxygen to the nerve substance, which it consumes and thus develops power sufficient to execute the various functions. Naturally the supply that replaces the burned nerve substance, must be adequate, and if for any reason whatsoever more nerve substance is consumed than the body is able to renew by the time it is needed, the nerve system becomes degenerated and numerous disturbances are the consequence. This is the great field of mental functions and disturbances, of moods and reactions on muscular tracts which in themselves are healthy, but are paralyzed in their work through the defective functioning of the power-conveying nerves. Again it is impossible here to give more than a general description, showing on what conditions nervous diseases are based. The manifold manifestations of this degeneration were combined into groups under the old system in which the Greek name of a system was everything, its practical explanation but little. The principal ways in which these degenerations manifest themselves are pains, mental agony and derangement, temporary cessation of functions, cramps, involuntary movements and similar disturbances. The names generally applied to them are neuralgia and neuritis,--causing pains in the nerves of certain parts of the body; neurasthenia,--consisting mainly of the complete relaxation of tension in the nervous system, causing sadness, inability for work, etc.; asthma, cramp-like cessation of certain functions of the small vessels of the lungs, alveoli, which impedes respiration; epilepsy, temporary cramp in the greater part of the body, causing loss of consciousness, involuntary movements of the limbs, etc.; St. Vitus's dance,--a similar affection, usually in children. While the complicated nature of nerve diseases requires very careful treatment of great individual variety, the general rule is that the re-enforcement of the nerves with the material of which they are built, together with regeneration of the blood, which, when in normal condition prevents such disturbances, will bring about a cure. Of course this is sometimes a slow process, especially when, as in the case of epilepsy, the nervous disease is of an hereditary character, and the resistant power of the nerves is correspondingly weak. In regard to one of the most disastrous diseases, caused by degeneration of the most important nerve i.e. the Vagus, see under "Catarrh"--section VI. THERAPY. _Diet_: If the entire nervous system is in a condition of pathological irritability, as in cases of neurasthenia and hysteria, it is the object of rational diet to keep all irritations from such a vibrating organism. To prescribe: "No coffee, no tea, no alcohol, no strong spices and no tobacco," will do no harm, and in most cases will prove beneficial. Nothing is more absurd than the attempt to strengthen nervous people by the use of alcohol. When forbidden alcohol entirely, it will very often transpire that some symptom, like headache, neuralgia, etc., was due to its use. Whenever the general conditions permit the continued use of alcohol to a certain extent, it must not be left to the patient's judgment to determine how far this may go, but definite quantities must be prescribed in each individual case, although the patient's experience may be of assistance in determining the quantity. (Moritz). Good results have been obtained by limiting the meat diet of extremely nervous patients, and prescribing for them a diet consisting principally of milk, eggs, cereals, vegetables and fruits. In this way the irritating effect of many of the meat extracts is avoided. At the same time the digestive work of the stomach, reduced by the limited meat diet, and the stimulation of stool, always promoted by a prevalence of vegetable elements in the diet, exercises a beneficial influence on the condition of the patient. Disturbances of the stomach and intestines are very closely connected with neurasthenia, loss of strength of the nerve-tissue, and hysteria, in some cases being the cause, and in other cases, which occur more frequently, the consequence of the same. Excessive and, more rarely, defective secretion of hydrochloric acid by the stomach cells, cramps, general atony or debility, of the stomach, vomiting, diarrhoea, constipation, tympanites (excessive production of gases), may all arise from nervous causes. In such cases the diet must be the same as given for nervous disease. Not only in these cases, but in most instances of nervous diseases, a diet which does not produce irritation and excludes alcohol, will have to be prescribed. The danger of alcohol in cases of peripheric neuritis, epilepsy and mental diseases, is obvious. Epileptics, like other nervous patients, should receive a diet that is mainly, but not solely, a vegetable diet, exclusive of all highly spiced food. The same principles govern in case of Basedow's disease, which is a special type of irritating disease. Absolutely necessary foodstuffs to be recommended in this case are clams, sole and water cress, because they contain more organic iodine than any other known food-stuff. As iodine is the basic mineral of the thyroid gland, and other preparations are poisonous or dangerous, the necessity of partaking of these dishes becomes obvious, in addition to the fact that if properly prepared, they are delicious. This organic iodine will regulate the secretions of the glands. A diet void of irritation is also most important for children who suffer from nervous conditions, such as St. Vitus's dance, involuntary urination during sleep, etc. Alcohol and alkaline and carbonated drinks must also be avoided in all nervous conditions that are combined with hyperaemia of the brain, as meningitis, apoplexia, tumors of the brain, etc., since they produce congestions. Special dietetic directions cannot be given for all of the innumerable varieties of the various other nervous complaints. The general principle must always govern, that sufficient food is the natural foundation, not only of the self-healing tendencies of the organism, but also of any effective therapy. In special cases where neurasthenia and hysteria or nervous dyspepsia prevail, it will be necessary to apply a special diet to be prescribed by the physician, who must understand the underlying cause, which is, 9 times out of ten, the degeneration of the Vagus nerve. See article on Influenza. DECH-MANNA-COMPOSITIONS _(Only main compositions, specialities to Doctor's order)_ Acute form, Neuralgia, Neuritis: =Neurogen=, Plasmogen, Eubiogen. Chronic form, Asthma, Epilepsy, St. Vitus's Dance: =Neurogen=, Plasmogen, Lymphogen, Eubiogen. _Physical_: Acute form: Partial packs. Chronic form: Partial packs, Massage IV. DEGENERATION OF THE BONE TISSUE. =Rickets, Osteomalacia and similar diseases.= The condition of the skeleton,--the solid structure of the osseous frame,--is of the greatest importance to the maintenance of health. Its various forms of disease,--such as deficient development of bone; osteomalacia,--softening of the bones; flat foot; caries--molecular decay or death of the bones, especially of the teeth,--are based mostly upon rachitis (rickets). Rachitis should be fought at the time the child develops in the womb, by properly feeding the mother and preparing her to give it, after birth, healthy milk, with all the elements necessary for bone structure. Rachitis is principally lack of lime in the food, which causes parts of the bones to remain soft instead of becoming rigid. It is a constitutional, often hereditary, disease caused by poor nutrition and by influences of environment, such as marshy regions and humid climates. The lack of lime in the food is often obvious when children show a tendency to eat chalk, and even to scratch walls in order to eat the lime obtained therefrom. More solid food, that gives work to the teeth and the digestive organs, is certainly advisable in such cases. The symptoms of rachitis become apparent at the pelvis and at the wide open, soft parts of the skull, the unossified fontanelles. The cartilage in the wrists and ankles becomes thick. Slow development of the teeth, swollen glands in the neck, inflammations in different parts of the body, cramps and convulsions,--among others, of the vocal cords,--are further indications. In the progressive development of the disease, the softened cartilage grows and protrudes everywhere, especially in the thorax, such as "rachitis rosary." Crooked bones and hunchbacks not infrequently develop. _Therapy._ _Diet_: Older children should receive chopped meat, eggs, zwieback or whole grain bread. Bouillon will stimulate their digestion. Uffelmann recommends a mixture of one part veal bouillon and two to three parts of milk, which children like. It is unnecessary to give calcium directly, when a rachitic diet is observed. Sufficient is contained in the Dech-Manna-Diet, given principally in milk and as a rule also in the drinking water. Quantities of amylaceous (starchy) food, candy, cakes and other sweets, coarse vegetables and potatoes must be avoided, since with children they are the cause of stomach trouble, resulting in decomposition and the formation of acids in the intestines. _Breakfast_: Milk and whole grain bread, or oatmeal porridge and fruit.--Whole grain bread signifies any variety of bread made from flour containing the entire contents of the grain, the gluten as well as the bran; among these are Graham-bread, rye-bread, pilot-bread, and Rhenish black bread. _Mid-morning Lunch_: Raw scraped carrots; for small children and for those having poor teeth, oat flakes. _Dinner_: Every other day--legumes, prepared in various ways, and fruit, vegetables or fresh greens; for example: (a) White beans boiled to the consistency of a thick soup, with apples. (b) Fresh pea soup containing rice, barley, sweet corn or oatmeal; a thick pea-porridge with parsley, served with carrots, cabbage, white turnips, red cabbage, Savoy cabbage, or various fresh greens; or simply browned. (c) Dried pea soup with similar contents; barley porridge, fresh greens, baked potatoes; or browned and eaten with any vegetables. (d) Lentils boiled in soup with the same contents as before; or as porridge, particularly with potatoes and fresh greens. Care must be taken never to eat leguminous products in large quantities, because their nutritious properties are so high. Potatoes should be used whole when added to other vegetables, and steamed not strained, because they easily lose thereby their valuable sulphuric contents. _Afternoon Lunch_: Fruit and whole grain bread, or a glass of milk and bread. _Supper_: In summer, cold or warm porridge with fruit and fresh greens, and besides these millet, buckwheat, oats, barley and Graham-bread, as especially efficient bone material. Sweet or sour milk proves a relishing addition. In winter, soup made of the above grains, or of potatoes not deprived of their mineral contents by peeling and straining. _Dech-Manna-Compositions_: =Osseogen=, Plasmogen, Cartillogen, Eubiogen. _Physical_: Gymnastics, Massage. V. DEGENERATION OF THE MUSCULAR TISSUE. =Muscular Rheumatism, Sciatica, Infantile Paralysis, Atrophy, Amyloid Organs.= The muscles, about 400 pairs, which must perform all the actual work of the body, require good nourishment through the blood, which will rapidly replace the cells that are constantly used up. Muscular degeneration is caused by disturbances in the quality and circulation of the blood. Interruption in the proper circulation of the blood, stagnation etc., cause _rheumatism_ with intense pains, and this can be removed only by restoring the undisturbed circulation of the blood, carrying all substances requisite for the proper nutrition of the muscles. If disease of the muscular tissue combines with a diseased condition of the accompanying nerves, we speak of _Sciatica_. Infantile paralysis, which often appears suddenly, muscular atrophy, which develops slowly, _progressive and chronic atrophy_ of the muscles, are also forms of muscular disease, combined with destruction of the accompanying nerve tissue. A special group of muscular diseases consists of amyloid (fatty) degeneration of vital muscle substance, as for instance of the heart, the kidneys, the liver. These are also caused by faulty composition of the blood, which does not feed the muscles with the substances required and thus causes them to degenerate by developing too much fat. The predisposition for such forms of disease is very often inherited. Amyloid degeneration is often combined with wasting diseases, such as atrophy, tuberculosis and dropsy. _Therapy._ _Diet_: Sufferers from gout must always be guided by the necessity of avoiding all food that contains large quantities of acid. In a general way it is also necessary to live moderately in every respect and so avoid all excesses. There are a number of dishes that are harmful to such patients. Among them are various meats, especially dark roast meat, also game. In general, and especially in very severe cases, it is better to refrain from white meat also. Spleen, liver, kidney, sweetbread, brains are absolutely prohibited, also sausage and smoked and canned meats, oily fish, especially eel, salmon, pike, and all smoked fish, because they may create a large amount of uric acid. The amount of meat eaten must not exceed 200 grams per day. The following must also be avoided: all sharp cheeses, cabbage, sauerkraut, and beans. Among vegetables the following are recommended: asparagus, celery and potatoes. The vegetables containing oxalic acid, such as spinach, sorrel, rhubarb and cress it is best to avoid. Butter is permitted in small quantities, also eggs. Sweet farinose dishes are unnecessary. Tea and coffee are allowed as beverages in very small amounts. The principal drinks, however, should be mineral waters, such as Vichy, Apollinaris, etc., which may be varied from time to lime. It is strongly recommended that the patients eat much fruit. Fruit-acids promote good circulation. _Breakfast_: (a) In winter, tea made from the leaves of the haw, blackberry, or strawberry, cereal coffee, weak cocoa with bread and butter. (b) In summer, sour milk, fruit juices, or fruit and bread; among fruits particularly strawberries, currants, gooseberries, huckleberries, cherries, grapes, apples. _Mid-morning Lunch_: Radishes mashed with apples, also a raw cucumber or tomato in the form of a salad. _Dinner_: No meat, no soup; fresh greens, fresh vegetables with potatoes, rice, macaroni, and a dish of corn, rice, groats, peas, beans, tomatoes or mushrooms. In addition, light custard with fruit or sweetmeats with fruit. _Afternoon Lunch_: Fruit only. _Supper_: Fresh lettuce, with macaroni, baked potatoes, pancakes, custard; or radishes with cream and potatoes, custard, mild cheese and leeks. Exclusive fruit dietaries, comprising strawberries, currants, cherries and grapes, are effective in preventing eruptions on the skin and removing their effects. From one to three-quarters of a pound of fruit should be eaten at a meal, either with a little bread or with sour milk, and at dinner as a desert. In winter, from three to seven lemons a day serve the same purpose. The juice is used without sugar and with as little water as possible, never with the meal, but a little before, or in the morning on an empty stomach. Only fresh lemons should be used for this purpose, not the prepared lemon juice which is on the market. Tomatoes may be eaten in the raw state, likewise. In mild cases of gout and rheumatism some crisp lean meat and fish may be eaten, but not every day. A diet without meat has a better curative effect upon the disease. Alcohol is to be shunned as totally inadmissible. The wines which contain no alcohol must serve as substitutes. _Special Diet: For Diseases of the Heart and Inactive Kidneys._ Patients, who are afflicted with any kind of heart or kidney disease, must be very careful never to overload the stomach. They should eat small meals, at frequent intervals, and avoid irritating food; the amount of liquids and milk must be determined by the physician. A moderate amount of salt only is allowed, and if the physician so prescribes, a diet containing little salt, must be observed. In case of acute inflammation of the kidneys, meat is absolutely prohibited; the best diet is an exclusive milk-diet, consisting of at least 1 to 1-1/2 quarts fresh milk, and in certain cases warmed milk, taken by the spoonful; the quantity to be increased, if necessary, to 3 and 4 quarts per day. Instead of milk, buttermilk, sour milk, kefir, koumiss or yoghurt may be taken. Beef broths are strictly prohibited. In their place glutenous soups, of oats, barley sago, tapioca, rice, groat, may be taken; furthermore leguminos soups, made from the preparations of the firms Knorr, Liebig, Maggi, and others. 1 to 2 spoonfuls of these preparations are put into a cupful of water, some salt is added and the mixture is then boiled. A more varied diet is allowed in lighter forms of the disease, such as milk dishes, mashed potatoes, preserved apples or pears, rolls and butter, bread, cream, cream cheese, farinaceous dishes, eggs and green vegetables, meat according to the orders of the physician. Spices and alcohol must be strictly avoided. In cases of chronic kidney diseases, greater variety should be observed in the diet. In any event, however, a certain quantity of milk should be taken, not less than 1 quart per day. The following food is to be limited: All game, including birds, sausages and smoked meat, sweetbread, brains, liver, spleen, crawfish, lobster, rich cheese especially Roquefort, Parmesan, Camembert, all sharp spices, such as pepper, paprika, mustard, cinnamon, garlic, onions; among vegetables such as radishes, horseradish, celery asparagus, mushrooms, tomatoes, sorrel; furthermore, all meat extracts, piquant sauces and soup spices. No alcohol should be served on the table of a patient with kidney disease. The exceptions must be prescribed by the physician. The same applies to all new wines and beef soups. The following dishes are permitted: Among meats, white meat (about 200 grams per day, preferably at noon). This comprises domestic fowl, fresh pork, lamb and veal, also beef, especially boiled beef. As a variety from time to time, mutton and fresh fish. The preferable way to prepare dishes for patients suffering from kidney diseases, is to boil them; the next best way is to steam them, and the third and least desirable way is frying. Strongly recommended: calf's feet and pig's feet, calf's head, especially in the form of jellies and pickled, if so ordered by the physician. Occasionally raw beef may be given, but without sharp spices. Fish: Trout, pike, carp; Saltwater fish: haddock and cod-fish, boiled blue; also frogs' legs. Eggs are permitted, soft boiled, 2 to 3 per day. Vegetables: With the exception of those mentioned, vegetables are very commendable, especially potatoes, green peas, white and yellow turnips, red beets, cauliflower, lentils, beans, the last particularly, mashed; also salad with cream and a little mild vinegar or lemon juice. Fruit-acids must not be classified with vegetable or meat-acids, as several, so-called "Food-Specialists" try to impress on patients, for they do not know, what they talk about. Fats, such as cream, butter, rich cheese, olive oil, may be given if they agree with the patient; bacon is not so good. Bread, white as well as brown, and especially Graham bread, may be eaten without restrictions. As drinks: mineral water with lemon or orange juice added. Raspberry juice is permitted, but currant and gooseberry juice must be avoided on account of the substances contained in them irritating to the kidneys. Fruit juices free from alcohol (apple cider) may be given. Every _morning_ on rising, a glass of fruit juice or some fruit. These fruit-acids promote peristaltics of the bowels, and free circulation of the blood. At _supper_: Salad of cresses or celery, or a mixed salad, radishes, asparagus, squash and cucumbers. When the urinary flows is very scanty, supper may consist of a cup of celery soup, or asparagus broth; in winter, haw tea. A few suggestions for _dinner_, omitting meat entirely: Dumplings with cabbage salad, red cabbage or Bavarian cabbage; sliced oatmeal cake with fruit.--Cucumbers with eggs and potato bread, rolled griddle cakes and fruit.--Cabbage with rice and butter, griddle cakes with fresh greens. Squash with lemon, potatoes, baked beans, fruit.--Red cabbage with macaroni, potato fritters, with fruit.--Dumplings and pears, lettuce.--White turnips with cream and potatoes, buckwheat groats, fruit.--Pea soup with sweet corn, squash and rice with fruit.--Lentils and potatoes, salad of celery or beets, fruit.--Asparagus with drawn butter and parsley sauce and bread dumplings, oat groats with fruit.--Cauliflower with macaroni, buckwheat groats and milk.--Cabbage with browned potatoes, oatmeal cake with fruit. _For Irritable Kidneys (Inflammation, Supperation, Contraction, etc.), and Diseases of the Bladder._ For patients suffering from these diseases all spiced and sharp dishes are prohibited, especially dishes with much pepper and mustard, also mixed pickles, preserves containing vinegar, salads unless seasoned with lemon juice instead of vinegar; furthermore, dishes which produce gas, such as dishes made from yeast. Fruits are permitted only in small quantities, avoiding absolutely gooseberries and preserves made from the same. Preserves from other fruits, such as apples and cherries, are permitted in smaller quantities. As drinks, the mineral waters which are recommended for people suffering from gout, are advisable here also. Kidney stones require a mixed diet, preferably vegetable; fat and carbohydrates--very little meat--no sweetbread, kidneys, brains, liver or spleen; meat, if taken at all, must be boiled. Not permitted: game, pickled fish, piquant sauces, beef broth. Dispense with meat, raw celery, radishes, pears, cucumbers, even asparagus in large amounts, at least during the state of inflammation. Eat eggs only in a raw or very soft boiled state. In place of these foods make up a diet of milk preparations, rice, groats, oats, millet, buckwheat. Currant juice and wild cherries, apple sauce, diluted lemon juice, are all of great benefit. Soups made from squash, cucumbers or celery, haw tea, buttermilk and sour milk, mild cheese, or porridge and fruit are excellent supper dishes. _For Liver Disease._ In general, fatty substances should be eliminated as much as possible from the nourishment in the case of liver disease, jaundice and gall stones. To be recommended are light farinaceous dishes with milk, vegetables, fruit and all easily digestible foods. Meat must be taken only in very small quantities, according to the advice of the physician, and with very little fat. Spices and alcohol are prohibited. Pastry and rich foods must be avoided. In case of jaundice the patient should receive liquid food only during the first few days, consisting of soups, light tea, carbonated waters; later, milk, the yolks of eggs, zwieback and light milk dishes. Patients suffering from gall stones may receive the same diet as prescribed for those suffering from liver disease, generally speaking. In case of liver disease it is necessary to adhere very strictly to the prescriptions of the physician, since they are due to various reasons, and only the physician can give the proper individual directions, after having determined the cause. Every morning on rising, a glass of unsweetened lemonade, or a wineglass of currant wine or grape juice, or some acid fruit.--The same on retiring at night. For a second breakfast, four or six radishes, or a tablespoonful of grated radish, or a teaspoonful of horseradish mixed with broth and white bread, eaten with a little toast and butter.--The same for supper. The following are a few suggestions for dinner without meat: Cabbage, potato porridge, gooseberries with egg and milk sauce.--Lentils with potatoes and fresh greens, cresses or lettuce, fruit.--Savoy cabbage with rice and tomato sauce, fruit with millet cakes.--Leeks with potatoes, macaroni and plums.--Young green beans with dried white beans and apples or other fruit, beets with cream, rolled dumplings, fruits.--White cabbage with macaroni, chopped apples or curdled milk. _Dech-Manna Compositions_: (Only main compositions, specialities to the Doctor's order.) _Rheumatism_: =Muscogen=, =Plasmogen=, Eubiogen. _Sciatica_: =Muscogen=, =Plasmogen=, Neurogen, Eubiogen. _Amyloid heart_: =Muscogen=, =Plasmogen=, Eubiogen. _Amyloid kidney or liver_: =Muscogen=, =Plasmogen=, Mucogen, Eubiogen. _Physical: Rheumatism_: Partial packs, either vinegar and water or radium and salts. Massage, if necessary, and special oxygenator baths, and radium and salt baths. _Sciatica_: Leg packs, oxygenator baths, half radium and salt baths, followed by massage. _Amyloid heart, kidney or liver_: Abdominal packs, gymnastics, oxygenator baths, whole radium and salt baths. VI. DEGENERATION OF THE MUCOUS MEMBRANE TISSUE. =Catarrh in acute and chronic forms, bronchitis, pleurisy, pneumonia, inflammation of nose, throat, bowels, stomach, bladder.= =Decomposition of mucous membrane, hemorrhoids, polyps, benign tumors, also Bright's disease in initial stages.= Catarrhal disease is amongst the most common, in varied form and degree, owing to the very tender nature of the mucous membrane. These ailments are characterized as destructions of the protective membranes which cover the serous layer of the organs, in which layer the lymph circulates. The numerous ends of blood-vessels and nerves which are thus exposed to attack, and the spreading of the disease to healthy tissues which thus become affected in the same way, make the various catarrhal troubles with their accompanying excretions particularly unpleasant. All degenerations of the mucous membrane are based on deficiencies in blood circulation and composition. A cure is effected through the restoration of the serous layer to normal conditions and the regeneration of the blood and its circulation. These various forms of catarrh affect all parts that are covered with mucous membranes, among them the female sexual organs, hence leukorrhoea or fluor albus, which, if not properly treated, constitutes the basis for all sorts of polyps, tumors, etc., and in many cases of continued attack forms the predisposition to cancer. The lymphatic system is the carrier of all germs to the various mucous membranes, and promotes the spreading of catarrh to all parts of the body. Among the more serious and dangerous forms of acute disease of this class which, lacking proper treatment, develop into chronic forms, are the catarrhal affections of the lungs and bronchia, =grippe=, =influenza=,[B] catarrh of the intestines, the bladder, the hemorrhoids and Bright's (kidney) disease. The latter especially is among the most dangerous diseases, and is considered incurable by the adherents of the old medical school. The discovery that it is essentially the same as other catarrhal diseases has, however, established the possibility of complete cure, which has been effected in many, even neglected, cases of long standing, under my present system. The many varieties of symptoms, all of which are finally reduced by proper treatment of the mucous membranes, it is impossible to cite, in this brief synopsis. More details concerning this important group will be found, together with the modern explanation of the development of serious disease from apparently unimportant catarrhal affections, in the very complete and extensive descriptions given in Chapter X, Section 6, of my greater work. _Therapy._ _Diet_: (a) Catarrh in all its acute forms. In these cases the diet is almost identical with the fever diet, as given in Forms II, III, and IV. (b) Catarrh in all its chronic forms. Diet as above, but apply Forms IV, V, VI. (c) Haemorrhoids, Polyps, Adenoids, Benign Tumors or Fungus Growths. There are no special prescriptions for these, regarding diet, except that easily digestible food must be eaten. Mashed vegetables and fruit should prevail. The indigestible tissues, such as skin, sinews and gristle, should be removed from the meat. No gas-producing dishes, such as sauerkraut, cabbage, turnips or beans, ought to be taken. _Throat and Larynx Disease._ To avoid irritation of the mucous membranes of the mouth and larynx, all sharp and spicy dishes and drinks are prohibited. In case of fever, particularly recommended are warm glutenous soups, creams, milk, steamed fruit, fruit soups and sauces, minced white meat, baked or steamed fish, no sharp spices. _Dech-Manna-Compositions_: (Only main compositions, specialities to the Doctor's order). In general: =Muscogen=. _Bronchitis, Pleurisy, Pneumonia, Inflammation of nose, throat, bowels, stomach, bladder, also benign growths in all chronic forms._ =Muscogen, Plasmogen=, Gelatinogen, Eubiogen. _Bright's disease_: (See special section XII chapt. X, "Dare to be healthy.") =Physical Treatment.= _Bronchitis, pleurisy_: Ablutions with vinegar and water; partial packs or ablutions with vinegar and water; shoulder packs. _Pneumonia_: Shoulder packs. _Inflammation of nose, throat etc._: Partial packs or radium and salt three-quarter packs. _Inflammation, of bowels, stomach and bladder_: Warm abdominal packs in addition to the above. _Catarrh in chronic forms_: Cold abdominal packs, massage. _Decomposition of mucous membrane_: Abdominal packs, partial packs, with vinegar and water, or salt and radium emanation, oxygenator and other baths, in case especially prescribed. VII. DEGENERATION OF TOOTH AND EYE TISSUES. It has been explained that this unusual method of classifying the eyes and the teeth together in one group, is based upon the biological, chemical discovery that the lens of the eye, like the enamel of the teeth, contain fluoric acid, otherwise contained also in very small quantities in the enamel of the finger-and toe-nails. Disease of the eyes and of the teeth would require lengthy description, for which space is lacking; suffice it to mention that the best way of preserving the health of the teeth and of the eyes is to keep them scrupulously clean. This simple hygienic method, regarding the teeth, will prevent decay. In all cases where eye trouble concerns the lens, as well as when there is a general disposition to caries in the teeth, the following treatment will produce a curative and preventive effect. _Therapy_ _Diet_: Since most of the disease of the teeth and eyes is merely the consequence of other disease, such as Bright's disease, diabetes, etc., the diet will be in accordance with the main disease, as described. In the treatment of both, rye bread, which contains large quantities of fluoric acid, is highly recommended. _Dech-Manna-Compositions: Teeth_: =Dento-Ophthogen=, =Plasmogen=, Osseogen, Eubiogen. _Eyes_: =Dento-Ophthogen=, =Plasmogen=, Gelatinogen, Eubiogen. _Physical_: All physical directions according to the main disease of which the tooth and eye disease, is but an accompanying symptom. VIII. DEGENERATION OF THE HAIR TISSUE. The hair, though a tissue by itself, is connected with the rest of the body and nourished by the blood, as are all the other tissues, in organic unity. In the long course of years that mark the progress of the race, it has lost much of its original significance as a body covering against the elements, but even in its present reduced capacity, it is a good and true indicator of certain deficiencies in the blood and in the functions of the body. Its principal disease manifests itself in loss, through the shrinkage of the little globular terminal, by means of which it is rooted in the skin. The hair has become an accepted criterion of youth and beauty, and its change in color or its loss are consequently regarded as the unfailing heralds of approaching age. The vast majority of people accept this fact with reluctance, and thus the hair, more than any other feature has become a centre of the nefarious activities of impostors. Its loss can be prevented to a great extent, and its quality kept in healthy condition, if it is treated in the proper hygienic-dietetic manner. _Therapy._ _Diet_: Diet in case of hair disease calls for a combination of food containing lime, silica and gelatine. It must be selected from a list of foods that possess these special nourishing qualities. _Dech-Manna-Compositions_ =Capillogen=, =Plasmogen=, Gelatinogen, Eubiogen. _Physical_: No special directions required. IX. DEGENERATION OF THE SKIN TISSUE. According to the conception of the human body as a unit, it is not difficult to understand that the skin, while not a separate organ, forms the outermost layer of the body-tissues and is nourished _from within_. By means of more than 2,500,000 small openings in the skin, called the pores, communication is established between the external and the internal parts of the body. This produces a permanent exchange of matter, and thus the skin is, in fact, a second system of respiration of the greatest importance to the health of the entire body. Naturally it is subject to traumatic accidents through its exposed position. Traumatic affections cannot now be discussed; except to give a brief idea of the constitutional diseases of the skin which, like all others, originate in deficient blood. Often they are only secondary, and indications of various, more complicated, diseases. In a few cases they affect the skin alone, but are nevertheless constitutional, especially in such cases as could not exist at all, were the disposition not established constitutionally. There is hardly another department of medicine where the "quack" reaps so great a harvest as in the treatment of skin diseases. Thus the suppression of symptoms becomes the rule; the removal of causes is invariably neglected. Many forms of skin disease, being the result of sexual infections, are allowed to develop because prudery and other motives prevent the early investigation of the cause, and hence delay its prompt treatment and healing. It is easy and natural for every one to notice the skin and see when there is anything amiss. Upon discovery immediately consult an hygienic-dietetic physician, and follow his advice closely, since skin diseases are among the most obstinate to overcome. The physician will be able to determine whether there is real constitutional trouble or merely a superficial skin disease. Thus the underlying evil, if any, can be correctly treated, in combination with such specialities as the skin tissue requires. _Every skin disease must be treated from the inside_, so as to destroy the disposition and even the chance for development. In view of the large field and the great importance of this group, it will be advisable for every one to read the many pages that have been devoted to this special subject in my work, on "Regeneration" or "Dare To Be Healthy," Chapter X, Section 9. _Therapy._ _Diet_: The general rule of abstaining from highly seasoned food should govern all patients suffering from skin diseases. Special attention should be given to a diet consisting of good, fresh meat, not too rich; it should be alternated with days on which no meat is eaten. Strong cheese (Roquefort), mustard, sardelles, mixed pickles must be avoided. See also remarks on Scrofulosis under I. A. _Dech-Manna-Compositions_: =Dermogen=, =Plasmogen=, Gelatinogen, Eubiogen. _Physical_: Partial packs, either vinegar and water, or salt and radium. Special packs by order of the Doctor. X. DEGENERATION OF THE GELATIGENOUS TISSUE. Another group of organ's of vast importance is the one which consists of gelatigenous tissue. In fact all blood and lymphatic vessels, air alveoli of the lungs, tendons and cords of the whole system, the digestive tract from the mouth to the anus, the stomach, the bladder, and indeed every organ or tissue which has the function of expansion and contraction, must be made of gelatigenous (rubber-like) tissue. Otherwise it cannot perform its duties in the organism and must needs become degenerate. While there are not many special forms of disease of the gelatigenous tissue itself, many diseased conditions occur in connection with its degeneration. This in turn is caused by the lack of gelatigenous food, which the blood must convey to this tissue wherever it exists in the body. It is obvious that any degeneration which may affect the intestinal duct, the bladder or other organs which contain gelatine in their composition will require gelatigenous regeneration. The principal forms of disease which may affect the organs in question are those which have been discussed under catarrhal diseases (Section VI). The acute and chronic forms of stomach and intestinal disease, especially, belong to this group, and have consequently received special attention. The treatment of this question in my work, "Regeneration" or "Dare To Be Healthy," Chapter X, A and B, will answer, in detail the questions of those who desire more enlightenment on this most vital and intricate subject. _Therapy._ _Diet_: These forms include all catarrhal disease mentioned under VI. A, also all inflammatory conditions of the stomach and intestines, in their acute form. As far as the latter are concerned, the suitable lists of diet will be found under Forms II, III, IV, V and VI. Regarding the same diseases in the chronic form, the special diet lists are given under Forms IV, V and VI. In addition the following suggestions will be helpful: _Diseases of the Stomach and Intestines._ These prescriptions of diet serve especially for the diseases of the stomach and intestines. In most cases a prescription for the rational preparation of food is such as only the hygienic physician is able to give. Food for persons suffering from diseases of the stomach, must be selected individually according to their idiosyncrasies. In one case the stomach must be prevented from doing too much; in another case it must be stimulated. In one case the object is to fatten; in another, to remove fat. In some cases the physician prescribes food which will retard the movement of the bowels, in other instances, the patient requires food that will promote such movement. The diet for patients with fever must be different from the diet for convalescing patients. People suffering from diabetes require a peculiar preparation of their food. Not everything that is good for an adult will be beneficial to a child. The digestibility of many foods depends upon their preparation. The value of food for patients can be judged rightly from but one standpoint, that of digestibility. The fundamental principles governing the nourishment for patients are digestibility, great variety, abolition of all strong spices, nutritive and well selected material. The temperature of drinks must be in strict accordance with the prescription of the physician. The patient must be urged to thoroughly masticate the food, so that it will be properly salivated and thus facilitate digestion. Patients seriously ill, should receive their food mashed or minced, so that they can partake of it more easily. All waste parts, such as skin, fat, sinews, bones, must be removed from the food, even for convalescents. Warmed up food and fibrous vegetables must be banished from the patient's diet. It must not be a question as to what the patient wants; the prescription of the physician only must govern. The patient's food must be prepared carefully, absolutely correctly and in a cleanly manner. In case of strong thirst, great care must be exercised in regard to drinks, depending on the physician's directions. The thirsty feeling of the patient may be alleviated by putting glyzerine on his lips and small pieces of ice on his tongue, without, however, permitting him to swallow the water as the ice melts. _Normal Diet for Stomach Diseases._ Milk, sweet and sour, buttermilk, yoghurt, kefir, albumen cacao, cereals in the form of mush, strained legumes, cooked in soup or milk, all sorts of glutinous soups, farinose dishes prepared from stale rolls, biscuits, zwieback, tender and easily, digestible meats, mashed game meat, chicken, raw beef, ham, meat jelly, young vegetables, preserved fruit. Avoid the following: all indigestible fats, meat which requires more than 4 to 5 hours for its digestion, hot salads, gas-producing vegetables, gravy, fruits which abound in cellulose, such as apricots and peaches, hard stems, xylocarp ribs of leaves, the strong smelling and sharp tasting parts of some kinds of vegetables, as for instance, new potatoes, cabbage (in the cooking of which the first water must be poured off), hot soups and spicy herbs, spices of all kinds, high game, sausages, bacon, yeast pastry, drinks too hot or too cold, strong coffee (in the place of which fruit coffee is recommended), stale raisins and almonds, nuts, too much candy, much liquid with meats, and excitement of all kinds while eating. _General Hints for a nourishing treatment._ The patient who is to gain in flesh must adhere strictly to the prescribed diet as well as to the prescribed rest, if the treatment is to take effect. The following articles are very nourishing: yolks of eggs prepared in any style, milk, cream, kefir, rich cheese, beef marrow on toast (cooked in soup), all kinds of noodles and dumplings, puddings, cocoa and chocolate, white bread, rich thick soups, gravy, potatoes and oats prepared in various ways, sweet beer, malt beer, sweet wines and puddings with preserved fruits, fruit juices, meat from well-fed animals only. All meals must be served in small portions, so as not to create distaste for food. 7 _A.M._--250 grams of fresh, boiled, unskimmed milk, or 1/4 quart cocoa prepared with milk or Knorr's oat-cocoa, or 1/8 quart cream with tea added, one roll, butter and honey. 9 _A.M._--1 cup bouillon, 20 grams hot or cold roast meat, 30 grams Graham or gluten bread, 10 grams butter. Then 1/4 quart milk, butter and Graham bread. 11 _A.M._--1/4 quart milk with the yolk of one egg. 1 _P.M._--100 grams soup (oat, barley, vegetable soup), green corn, sago soup, 100 grams potatoes, 100 grams tender vegetables, such as spinach, mashed peas, mashed carrots, mashed artichokes, asparagus tips strained, 20 grams easily digestable rice, 50 grams preserved fruit; or, no soup, but, instead meat, vegetables, apple sauce, dishes made from milk or flour, such as noodles, fruit, 1/8 quart cream. 4 _P.M._--Light tea or milk, with malt or cocoa added, two crackers, 1/2 quart milk. 6 _P.M._--20 grams meat (hot or cold roast meat), raw meat or 10 grams Graham bread, 10 grams butter, milk chocolate, Graham bread, butter, honey. 8 _P.M._--1 cup soup with 10 grams butter and one yolk, barley, oats, etc., eggs or meat, vegetables, preserved fruits, Graham bread, butter, mild cream cheese. 9.30 _P.M._--1/4 quart milk, with a spoonful of malt extract, 1/8 quart cream. As a special breakfast, for a thin patient, the following drink is recommended: To a cup of unskimmed hot milk add one yolk and one spoonful of pure bee-honey. This must be taken in the morning on an empty stomach for several weeks. _In case of Constipation._ If constipation is due to nervousness or sluggishness of the bowels, the best means to overcome the trouble is mixed coarse food, using various mineral waters, and little meat, but plenty of vegetables, especially sauerkraut, cabbage, comfrey, cauliflower, pumpkin, tomatoes, cucumbers, various salads and fruits, jellies. Among beverages sour milk, buttermilk, kefir No. I and II, yoghurt, various new wines, fruit juices, different mineral waters, such as Apollinaris, Karlsbad waters, Hunyady; coarse bread, such as Graham, avoiding fine white bread. In extremely chronic cases use my Laxagen Tea in case of emergency. _Dech-Manna-Compositions_: =Gelatinogen=, =Plasmogen=, Mucogen, Eubiogen. _Physical_: Abdominal packs, with vinegar and water. Acute--warm. Chronic--cold. XI. DEGENERATION OF THE CARTILAGINOUS TISSUE. Cartilage in the human body is the material which must cover the end of each bone so as to prevent its destruction by friction. It is the important part in all joints. It is obvious that any degeneration of this particular tissue will cause friction, which is combined with severe pains, called Ankylosis, Gout. The degeneration is usually a consequence of improper proportion of the various food ingredients consumed, omitting the material necessary for the construction of the cartilage, which, being in use, is constantly used up rapidly. Regeneration of the blood, by assisting it in its important task of feeding the cartilaginous tissues, and regulation of the diet are the only two possible remedies for this form of disease, of such frequent occurrence, the alleged cure for which attracts thousands to bathing resorts, where they derive not the slightest real benefit. The variety of gout called arthritis (deforming gout), is the most pronounced and dangerous phase of this form of disease. _Therapy._ _Diet_: The diet is exactly the same as prescribed for rheumatism and gout under V, Degeneration of the Muscular Tissue. _Dech-Manna-Compositions_: =Cartilogen=, =Plasmogen=, Gelatinogen, Eubiogen. _Physical_: Partial packs, salt and radium, massage, oxygenator bath, half bath radium and salt. In case of arthritis, also special packs according to the directions of the Doctor. It is impossible to give a diet for arthritic patients, peculiarities of this disease being largely individual. XII. DEGENERATION OF THE BODY TISSUE IN GENERAL. By "body tissue in general" is understood the body with the total sum of its cells--especially the red blood corpuscles--and their various aggregations. Consequently a special composition of nutritive salts, under the name of Eubiogen, has been composed, which is the most perfect duplication of all the chemical elements of the entire body in the correct proportion. Eubiogen, therefore, is prescribed as a secondary Dech-Manna-Composition, to be taken with all other compositions. But it also acts independently as the best means of preventing degeneration, and in this capacity should not be missing in the diet of adults as well as of children. The cost thus incurred would be recouped many times over through its prevention of disease. Eubiogen takes a leading position in reference to the following complicated forms of disease, in the treatment of which it becomes the most important factor among the nutritive compositions: Ataxia, Basedow's Disease, Diabetes Mellitus, Obesity, Bright's Disease, Arterio-Sclerosis. I am prepared to explain to patients, this curative method and the reasons for its application; but these complicated diseases, while based on the same degenerations of blood, and consequently of the tissue and organs, as all others, offer impressions which, from the point of view of the conscientious physician, cannot be presented with but a few bare words of explanation. Nor does the space at my disposal permit me to go into the matter with due thoroughness. All of these ailments have been described in my work: "Regeneration or Dare To Be Healthy." The intelligent reader will readily conceive that he who has found the secret of the degenerations constituting the various forms of disease, will not hesitate before their complications. _Ataxia, Basedow's Disease, Diabetes Mellitus, Obesity, Bright's Disease and Arterio-Sclerosis, can be cured. They can be cured by the same methods of which simpler examples have been already given. No one, who in the struggle for health has surrendered to the attack of constitutional disease, the germ of which may have been implanted in him by his forefathers, needs despair. Let him seek advice before too late, and the strong probability is that in due time he will have regained his health, and will be enabled to fulfil his duties to himself and to posterity._ _NOTE._--In reference to the foregoing tables of dietary "Regimen" the reader must clearly understand that the prescriptions are merely indications of diet appropriate to various phases of the complaints to the treatment of which they are attached; but the decision as to how and when these phases occur in individual cases should be left entirely to the discretion of the physician in charge of the case who will, of course, also pronounce upon the diet. Should there be no such authority present, the greatest care and common sense must be devoted to the selection from the said tables of a system of diet suitable to the various stages of disease. Any recommendations therein contained which may appear to be contradictory or conflicting must be ascribed to their complication on a progressive dietary system consistent with the prospective advancement of the case towards recovery. INFANTILE PARALYSIS. Amongst the forms of Degeneration of the Muscular Tissue the reader will have noticed that of Infantile Paralysis or Poliomyelitis. The startling prominence that this complaint quite recently acquired was due to its world-wide ravages in epidemic form and the absolute and confessed inability of the combined sagacity of the whole faculty of the orthodox medical profession to cope with it or to cure it--to fathom its cause and origin or to curtail its increasing rate of mortality. I am therefore constrained, so far as space permits, to give the matter special and particular consideration. The scientific name, "Poliomyelitis," is derived from the Greek words: polios, grey and myleos, marrow; for its chief feature is a softening of the grey spinal marrow. First noticed by the medical world no later than the year 1840, statistics show that in the last decade it has appeared in various parts of the world in epidemic form, notably in Sweden and Norway. In America, epidemics occurred in 1907 and 1908 and again in 1916. It was promptly and energetically dealt with by the Rockefeller Institute of New York where the proof was established of the possibility of transmission by a living virus taken from the spinal marrow of a victim; but whether this disseminator may be correctly termed a bacillus, or fungus or a germ, medical-science has been unable lo determine; neither has it succeeded with the most powerful microscope in discovering the individuality of this "carrier," whilst all experiments with re-agents have been bare of results. Thus the researches of science have merely brought us back to the starting point; namely, that there is a "something" which exerts a degenerating influence upon the cellular tissue of the spinal marrow and causes the morbid enlargement of its cells. The New York Board of Health, cites eight different forms in which the disease may appear and acknowledges a startling failure to determine either any uniform period of incubation (i.e. the time between contagion and the appearance of the symptoms,) or the period of infection (i.e. how long a sick person may be a danger to others). The New York press accepts the situation philosophically; as follows: "Infantile Paralysis cannot be cured by means of medicines. The physician must of necessity limit his ministrations to easing the pain, providing for easy movement of the bowels and so forth, but otherwise _he must let nature take its course_." Medical reference books vaguely define the disease with diverse and indefinite theories, showing that science on the subject is practically mute. But the medically "unprofessional," random remark of the New York press-man has exactly hit the mark: "Let nature take its course." The fact is that nothing very clear or absolute can be said about Infantile Paralysis; for observation shows that it is apparently a matter of racial conditions and environment and that only from the general application of the Laws of Nature, as taught by biology can we reasonably hope to solve the problem or cure the disease. As the result of careful study of many cases I simply confirmed the fact that Infantile Paralysis belongs strictly to the class in which in the foregoing chapter I have placed it, and is subject to the same rules, influences and treatment. In most of the cases treated I have not failed to discover the existence of spinal trouble in one or other of the parents. This, engendering _predisposition_ to similar complaints _in the children of the opposite sex_, which, acted upon by the irritants bred of poor or irrational nutriment and unhygienic environment in greater or lesser degree, results in attacks of this disease, in plain or epidemic form as the case may be, to which all children so predisposed are liable. Thus, incidentally, is my recently discovered "Law of the Cross-Transmission of Characteristics" amply verified. As to the cause which leads to the development of this predisposition in the children, the answer, of course, is improper nourishment; and amongst the contributory causes I would specially indicate, "Pasteurized" and "sterilized" milk which has been absolutely banned by science on the basis of Physical Chemistry, according to which it was definitely proved in a report laid before the Paris Academy of Sciences, that valuable bone-forming ingredients in the milk, (a combination of carbonic and phosphoric lime,) are lost in course of Pasteurization, since at the temperature necessary for the process they are _transmuted by heat into insoluble elements_, (phosphate and carbonate of lime) which, precipitated by chemical action, either drop to the bottom in sediment or cling to the surface coating and, in either case, are eliminated and lost to the child to an extent which constitutes a serious deterioration in its food and one likely in any case to promote rickets. Milk also contains important constituents which change into necessary food elements in the course of natural fermentation--gelatine for instance--which being, as has been shown, so vital a factor in the building up of tissue, it needs no argument to prove the disastrous consequences its depletion must engender in the child and it may be likewise safely left to the intelligence of the reader to grasp the obvious fact that for the prevention or healing of Infantile Paralysis the one and only safeguard is Regeneration through the course already indicated of Hygienic-Dietetic treatment which will, if applied beforehand, eliminate the tendency to disease or, in the event of its occurrence, will conduct it along safe and natural lines to a quick recovery. This brief sketch of the subject must suffice for the present purpose but a special article[C] with full and interesting details has been devoted to the subject, which will appear in my greater work, "Regeneration or Dare to be Healthy." "FACIAL DIAGNOSIS" AND "THE CLINICAL EYE." It is an incident common to the experience of all Natural Hygienic Physicians for the patient to exclaim in quasi protest: "But Doctor! How can you tell?" Accustomed to the pompous pantomime of the orthodox physician--the gold watch and chain trick, while pulse and tongue reveal their hidden records--and then the well known questions which call forth the personal predilection in the fashion of disease and diet, (prescriptions which are often not untinged by the physician's own proclivities), at first the patient misses the old familiar presence. If ill he _must_ be, he expects that the process should proceed from the outset on the old accustomed, "strictly respectable" lines, and something like resentment stirs him when, in place of questioning, a physician presumes to _tell him_ at a glance the substance of his malady _unasked_. But such is the method of real efficiency and such the qualification of the men who practice the new philosophy which shall save the world from shams. _Facial diagnosis_ is the determining factor of the logical and never failing science of natural therapy which is coming to the rescue of mankind, in spite of legal and commercial obstruction. _The "Clinical Eye"_ is, emphatically, _not_ the sad old "Eye of Faith" which has sent its millions to their doom, but the _sober, steady, practiced introspective hopeful eye of knowledge and experience_. The external symptoms visible to the clinical eye of a physician worthy of the name, vastly outweigh in important significance, all the objectionable detailed examination of parts and organs which from long use has become the habit of the old-school practitioner. Moreover the swift impressions gathered under the clinical eye are spontaneous and reliable whereas, as the result of questioning or the description of the patient, they possibly are not, but rather represent too often some preconceived notion of alleged heredity or devotional pessimism, sometimes original but more probably the suggestion of relatives and friends. The subject is a vitally important one and, with a view to clearing away the obstruction of old superstitions from the mind of the reader, I shall trespass upon my allotted space in order to give a brief extract of my remarks thereon as expressed in my greater work: "Regeneration or Dare to be Healthy." DIAGNOSIS, PHYSIOGNOMY AND PSYCHOLOGY. The biological healing system, based on the laws of nature and the acknowledgment of the fact that no two cases of disease are exactly alike, requires much broader knowledge and much deeper insight on the part of the physician than did the old-school of medicine with its search for symptoms of special diseases and its occult prescriptions. Since the object is to get at the root of the evil in order to regenerate the patient thoroughly, it becomes imperative to obtain, what is hardest to elicit from him perhaps, the accurate truth about himself and his ailment. And though expert in recognizing external symptoms, it is unwise to rely entirely thereon and research must continue into realms where the patient himself only can lead us and where, willing or otherwise, he is apt to mislead. Psychology teaches how to find the way into the darkness of a patient's soul. Physiognomy teaches, not only to read in the face and external appearance, the story of a life which is written there in characters which only experience may decipher, but also to realize when the patient employs physiognomical expressions to hide what we persistently seek; namely, the truth. And again, in regard to healing, psychology teaches how to influence the patient so that he may discontinue to be his own worst enemy; that he may recognize his mistakes as such and discard them, although possibly he may have grown so addicted to his tastes as to prefer to continue therein in place of daring to be healthy. In the plan of production of a regenerated and healthy humanity, every individual of this kind must be regarded as a foe who interferes with the prevention of disease both now and in futurity. To win such an one over, to make him an enthusiastic believer in the theory that health is a necessity, and, a task less easy, to prevent his relapse into his previous degenerate manner of life and health,--this is another branch of science for which psychology and physiognomy are more needful than anything else. Here again it is the true physician's principle to enlighten the layman, and not to surround his methods with a mysterious, but imposing wall of secrecy. We do not hesitate to reveal the main points of our system of diagnosis, which is much broader than the old system of scholastic medicine,--the performance with auscultation, percussion, X rays and the rest. Certain knowledge of these things will lead every one, ere long, to submit all disturbances of health to the hygienic physician while prevention is still probable and possible, instead of waiting until disease has taken firm hold. It will also enable men to realize that the old-school practitioner who pronounces them sound while they feel for themselves that there is something wrong within has yet "a something" left to learn. The realm of psychology, however, is beyond the scope of my present endeavour, save in so far as it may serve to show that we are fortified with this particular knowledge, and to the end that this book may constitute a help to the aspiring hygienic-dietetic physician, calling his attention to the necessity of acquiring as profound a knowledge of psychology as may be. I will confine myself at present, therefore, to the external symptoms which must be observed, though they are not generally considered as symptoms of disease; and yet they indicate disease or the disposition thereto, individual or hereditary, as the case may be. I shall consequently deal with the peculiarities of hands and feet, nails and hair, eyes and ears, nose and teeth, mouth, forehead, tongue, chin, cheeks, neck, chest, abdomen, legs, and general constitution. Nature has endowed us with strong discriminating faculties against certain external indications of disease. We experience a pleasant feeling when the hand is pressed by another hand that is warm and dry, but we shrink from the hand that is cold and moist and clammy. Perspiring hands and feet are a sure indication that some process of degeneration is going on within the body, the production of diseased cells being in excess of what the body, under normal conditions, is able to excrete, and therefore they seek unusual channels of leaving the body, that is, through the skin and mucous membranes. Perspiring feet are a symptom of disposition to colds and possibly tuberculosis, while perspiring hands indicate certain nervous diseases and disposition to gout; constantly cold hands and feet are usually found in people who suffer from scrofulosis or anaemia. In many cases the quality of _nails_ leads to the conclusion that there is a thorough disturbance of the process of nutrition. If they are fragile and brittle, there is no question but that there is lack of certain nutritive salts in the blood. Swollen and deformed nails indicate special disturbances in circulation, chronic heart and lung diseases. _Hair_, or rather the absence of hair, especially in early life, is sometimes another indication of faulty nutrition. Baldness or premature gray hair is usually a pathological indication, as is also the dishevelled hair of nervous people and children suffering from scrofulosis, while rich, glossy hair is always a sign of good health. The development of the hair depends upon the activity of the skin, the nerves and the composition of the blood. The blood of dark-haired people is lacking in water and fat, but richer in albuminous matter. Poor quality of hair is indicative of living in bad air, poor nutrition of the skin, hard mental work, pain and sorrow. Sexual excesses during youth are often the cause of premature baldness and thin hair. The _eyes_ present a picture that manifests the general condition of the body, whether it be healthy, disposed to disease, or suffering from disease. Protruding eyes are the sure symptom of the disease known as Basedow's disease; they indicate also short-sightedness, and hereditary epilepsy. The condition of the mucous membranes of the eyes permits certain conclusions as to the genital organs. If the eyes are abnormally small, we draw the conclusion that there is general weakness and deficiency in nutrition. They indicate retarded development, which may be seated in the central nervous system. The eyes usually recede during severe diseases. A hyperaemic condition of the eyelids, with or without inflammation, is always a symptom of a dysaemic condition of the entire system (scrofulosis). In some cases of scrofulosis there is not another visible sign on the entire body, and yet the eyelids and eyelashes, which sticks together most of the time, tell the story of an inherited condition of dysaemia. A yellowish hue of the eyes indicates disease of the liver. The color of the iris does not indicate much in itself, although the theory of Liljequist, which deserves some attention, claims that if a person deteriorates in health, the eyes, if originally light blue, darken more and more and finally change into brown or the color of the hybrid race. Liljequist's scale of healthy eyes reads: Light blue, medium blue, dark blue; then light, medium and dark brown. However, brown eyes do not represent sickness; they but indicate nervousness and sensibility. According to Liljequist, individuals belong to the hybrid race when they are born of parents one of whom has blue eyes and the other brown eyes. The weaker race transmits the brown colour of its iris to the middle part of the iris of the child, while the colour of the stronger race reappears in the outer part of the iris; not, however, as pure blue, but tinted with a delicate shade of green, in consequence of the light brownish-yellowish colour which emanates from the central part. When death is imminent, the iris displays a grayish-black, muddy gray or muddy brown colour. The pupil of the eye is irritated in cases of nervous disease and indicates this condition. In cases where only one pupil is dilated, a local disease of the optic nerve or one side of the brain is evident. If the pupils are insensible to external irritations and remain rigid, the conclusion is that the brain or the spinal cord is badly affected. It may be stated in a general way that clear, brilliant eyes, (when not caused by fever) are usually an indication of the good quality of the blood as well as of all other humours of the body, together with normal activity of all the central organs. The _mouth_ and _tongue_: Pathological indications manifested by the mouth are principally displayed by the lips, which are clear red in healthy people, while a hectic red indicates fever and pulmonary disease. Pale lips indicate anaemia and chlorosis, and lips of a bluish hue are signs of a generally weakened organism. Frequent, vivid contractions of the lips (usually thin in this case) indicate great nervousness. The color of the mucous membrane of the tongue is a very fair indication of health or sickness. If a person is in health, the tongue is rosy and not coated. But any disturbance in the intestines causes a more or less coated tongue, and consequently shows the detrimental influence these particular ailments exert upon the brain and nerves. Hence, a coated tongue affords a valuable indication in making a correct diagnosis, especially in case of chronic catarrh of the stomach, this being one of the main causes of depression, and melancholia, as stated by Piderit. The _forehead_, or rather the record traced thereon, in lines of nature's unimpeachable calligraphy, warrants certain conclusions as to mentality and character; and these may be important in determining the truthfulness of the patient's stories of suffering and other items which facilitate or impede a correct diagnosis. The interpretation of such features, however, belongs to the realm of pure psychology, this is also true of similar conclusions drawn from the outlines of the chin. Of much more importance for the purpose of diagnosis is the _nose_. Even a child understands what the red nose of the habitual drunkard signifies. A bloated nose with a tendency to become sore is an indication of a disposition to scrofulosis. Other indications of disease are displayed to the experienced physician by the condition of the nose. The _nose_ is one of the most typical of the human organs; it is also in the closest connection with the entire system with its groups of organs--the brain, intestines, breast and even the sexual organs. The infinite variety of nasal formation has attracted the intense interest of the physiognomist to this organ. The most important function of the nose lies in its action as a respiratory organ. Bad habits or faulty construction which prevent it from serving in this capacity, lead to much suffering and disease, and it is always important to determine whether the channels of the nose are clear and open and efficiently serve their purposes. The function of the nose as an olfactory organ must also rank highly in its importance. In this case, however, the nose of the physician plays the important part; not the nose of the patient. In fact, most of the famous authorities, among them Professor Jaeger of Stuttgart, Dr. Heim of Berlin and Dr. Lahmann of Dresden, have made very valuable discoveries in this respect. Dr. Heim has found methods of determining the nature of certain acute diseases from the odour emitted from the person. Dr. Lahmann distinguishes the hypochondriacal, the melancholic and the hysteric odours, which, as he says, are most characteristic. The same applies to the odour of diabetics and other people who suffer from disturbances of digestion, and patients who suffer from cancer and other diseases involving a process of putrefaction. The fact that most patients diffuse unpleasant odours is of the greatest importance to married people, as it easily produces antipathy, and especially in the case of chronic diseases, is frequently made the basis of separation and divorce. Were this defect known to be but the symptom of a curable disease, the husband or wife would probably prefer to consult the hygienic physician rather than the lawyer. Knowledge in such case would mean the preservation of domestic happiness. _The teeth_: The parents of a young man once complained to me that their son had been rejected as a cadet at West Point upon physical examination, because two of his teeth were filled. The authorities are certainly justified in their decision. The lack of perfect teeth indicates faulty digestion. Usually the teeth are ruined during youth because children breathe through the mouth instead of through the nose,--either on account of the physical condition of the nose or because the tonsils are enlarged. The lack of sufficient nutritive salts in the diet is often revealed by the condition of the teeth. From a physiological standpoint the teeth are no less important than the brain, the eyes and the hair; and the conclusion that perfect eyes, hair and teeth indicate a perfect brain is absolutely justified, while the lack of perfection in these organs shows internal deficiencies long before they appear in external manifestation in the form of disease. Since healthy blood is the basic condition of healthy teeth, the fact that people have clean white teeth, set in regular line, indicates the existence of healthy blood. On the other hand, a bad composition of the blood is manifested by short, irregularly set, yellowish teeth. The teeth of healthy people are always somewhat moist, dry teeth are accordingly a bad sign. The only advantage of yellowish teeth rests in the fact that their dentine is, as a rule, stronger. Extremely bluish white teeth often consist of a soft, porous and tender dentine. Faulty structure of the teeth indicates weak bones in general. Crippled teeth and the late appearance of teeth in infants,--that is, not before the ninth month,--are symptoms of rachitis. Healthy children have their teeth between the fifth and seventh months. The teeth of diabetics become loose without any formation of tartar, (an incrustation of phosphate of lime and saliva). Extremely yellow teeth indicate jaundice, while reddish teeth show hyperaemia of the dentine. Carious teeth are a result of disturbed circulation. The gums are also very indicative of disease. If they are of a pale pink colour, they indicate anaemia or chlorosis; if bluish red on the edge, they indicate tuberculosis. Some of the most striking indications of existing disease are demonstrated by the _neck_. By feeling the neck and carefully watching its external appearance, the experienced scientist will obtain much valuable information that will aid in his diagnosis, and give him additional knowledge as to the processes going on within the body of the patient. The significance of the formation of the _thorax_ (_chest_) is well known, even to many laymen. Flat chest, so-called chicken chest, indicates imperfect development of the lungs, and when extreme, even tuberculosis. A flabby abdomen indicates disposition to hernia and stagnation of the blood, frequently causing hemorrhoids or inflammation of the prostate gland in men, and all kinds of diseases--inflammatory or catarrhal--in women. As to the _legs_, the so-called varicose veins are indications of weak blood-vessels and intestinal hemorrhage, while inflamed nerves lead to the conclusion of gouty diathesis and the danger of paralytic strokes. The _skin_ usually affords more indications that aid in forming a correct diagnosis than is usually recognized. If examination were made of the excreta through the pores of an individual during 24 hours, some conclusion might be definitely arrived at as to any germs of disease present in the body and in course of expulsion in this way. All bacteria incident to detrimental processes proceeding within the human organism, are to be found in the perspiration. Freckles indicate a certain predisposition inherent in the blood, while some forms of eczema point to the conclusion that there are diseased processes in action within the body. It is most important under this system to determine the chemical condition of the body in each individual case. Acids or alkalines prevail. If the former, patients have bad teeth, a disposition to gout, diabetes and cancer. The normal condition is the predominance of alkalines. In such cases as the former, physiological chemistry will point to the counterbalancing of the acids to establish a correct composition of the blood, and thus to prevent the impending danger. The biological system of health which is rapidly taking the place of all others, is equipped with so searching a knowledge of the human organism that no disease, be it ever so adroitly concealed, can escape its minute attention; not excepting even the disposition to disease. The old adage is still true that "prevention is better than cure" and the intelligent person will probably recognize the wisdom of so safe and sane a course and endeavor to prevent the evils to which he may be exposed. Thus, for his own satisfaction, if he be wise he will adopt these two simple precautions: (1) Examination by an accredited hygienic-dietetic physician. (2) Regulation of his mode of living in accordance with the course prescribed. The words of the famous Moleschott ring true today, more than in the past, when he said: "One of the principal questions a patient should ask his physician is, how to make good, healthy blood." Experience shows that there is but one method to attain good blood,--that _priceless factor_ upon which our _thinking_, our _feeling_, our _power_ and our _progeny depend_, and that is by means of _correct food and nutrition_. FOOTNOTES: [B] See special article on Influenza, page 408. [C] This article is also printed in pamphlet form and may be had from the author for 50c. Postage paid. CHILDREN'S DISEASE. _"The cause of the Poor to plead on, 'twixt Deity and Demon."_ (Carlyle). _"Child of mortality whence contest thou, Why is thy countenance sad, and why are Thine eyes red with weeping?"_ (Bartauld). I have opened this chapter with somewhat startling mottos, for its pathetic theme is Children and children's disease; and it seems to me appropriate, in view of what it portends, to send forth in this form a world-thought, as a harbinger of sympathy--a foreword which may set in motion the thought-waves of pity. For of all living creatures born into this world of pompous ignorance and maudlin solicitude to struggle for precarious existence from the cradle to the grave, by reason of the unnatural conditions of our vaunted hygienic and educational systems--generously termed "civilization"--there is surely nothing quite so "poor," so woefully devoid of practical protection, and, in its exceptional helplessness, so weakly gushed over and little understood as the child of frail humanity. "The cause of the poor"--thus the legend runs--"in deity's or demon's name." For truly, of the two angels which, we are told, attend upon the birth of credulous mankind and the initial stages of development, the malign influence would seem to be ever in the ascendant, irrespective of the social status of the, more or less, pre-natally affected, innocent reproduction wherein is focused the latent follies and delinquencies of the race, as portrayed in the course of its long pangenesis. Now, incredible though it may seem and deplorable though it be, the secret which has revealed itself with absolute force and conviction to the judicial minds of unemotional scientific observers is simply this: that the children of the present generation are, as an incontestable matter of actual fact, really brought into this world alive and some attain to maturity, not through maternal intelligence, but rather, _in spite of mothers_. This is a hard saying but none the less a truth. They survive in spite of the idiosyncracies of their fondly irrational, untutored mothers rather than because of any practical, efficient effort these contribute towards the well being and survival of their offspring. This, as a general rule, is unhappily beyond question. It is a rule which has, naturally, many exceptions,--many brave and brilliant ones--these however only serve to confirm it. Comte, writing as an authority on the subject, made the assertion that there is hardly an example on record of a child of superior genius whose mother did not possess also a superior order of mind. As an example he cites: The mother of Napoleon Bonaparte, high-souled, heroic and beautiful; the mother of Julius Caesar, a singularly fine character, wise and strong; the mother of Goethe,--affectionately termed: "The delight of her children, the favourite of poets and princes--one whose splendid talents and characteristics were reproduced in her son." There are also, we know full well, unnumbered hosts of others, whose kindly light has been shed in many an humble or secluded home, whose beloved names have been called blessed by thousands though unrecorded in historic page--who have lived and loved and passed on to higher realms--to the world, to eulogy and to fame unknown. In ancient days, when Athens was the centre of culture and of learning, the Greek mothers were more prone to regard the significance of pre-natal influences than are the mothers of the present day of putative advancement. The hereditary tendencies of child-life, with all its complexities of racial and ancestral character and the qualities resulting from the dual source of parentage, were then perhaps better understood, or at least more seriously considered; also the obvious but grossly disregarded fact that the cradled infant of today may be the responsible citizen of the future, was kept more effectively in mind and its significance to the State more fully recognized. The wisdom of Solomon was never more clearly demonstrated than when he said: "Train up a child in the way he should go; and when he is old, he will not depart from it." It is a piece of world philosophy which has reigned unquestioned throughout the ages--a policy upon which human discernment, in Church and State, has relied with unfailing effect; "for the thoughts of a child are long, long thoughts"--those well-remembered words, how true; for those "long thoughts"--the mental environment of the formative period of child-life--do inevitably determine the future character of the individual, and the immediate result of neglect in these vitally important stages is painfully and promptly apparent in the aggressive and unchildlike deportment of the turbulent young neophytes of both sexes, so disproportionately in evidence in all directions throughout the community of the present, as to bring into ridicule and utter contempt existing methods of control. This dire defect in individual restraint may be largely ascribed to both physical and mental degeneracy, of hereditary origin; and when to this is added the attempts of parents to maintain the tranquility of the home by threats, bribery and fatuous promises--undue severity on the one hand and undue licence on the other--serious developments are not far to seek. It has been well said that children who are governed through their appetites in their infancy are usually governed by their appetites in maturity. Thus it is, by unwise methods of control which appeal wholly to the spirit of greed, emulation and selfishness in the child--the purely animal instincts--with perhaps the occasional degrading influence of corporal punishment, as a later development, that so many young lives are wrecked and the downward path made easy which leads through duplicity to crime. The infantile precosity of the age leaves little scope for the old-time sentimental prudery of parents who fail to discriminate between innocence and ignorance; but it has been stated by a well known American authority on the subject of child-culture, whose experience of child-life and schools is nation-wide, that only about one child in a hundred receives proper instruction early enough to protect it from vice. Then again there supervenes the evil of the competitive school system which, too frequently, forces the education of a child beyond the natural order of growth. Countless numbers of little ones are injured by enforced premature development, thereby diverting the vital forces to the development of the brain which should be devoted to the development of the body. Encompassed by such a chain of adverse circumstances as the combined result of parental egotism and pedantic, pedagogical ignorance, is it wonderful, I would ask, that the ghastly record of the hideous sacrifice of child-life is what it is, and that the young lives which do by chance escape the horrible holocaust, still reap the prevailing harvest of prolific ills of which the coming explanation will give some adequate conception. Often the fondly futile questions fall from the anxious lips of maternal foreboding: What has the future in store for me? Will my child live? Will providence grant me this long-sought blessing? A thousand such thoughts continually assail the heart in a mother's intense solicitude; but not in vain will her hopes be set, if haply, she may reverently follow the course of Mother Nature's laws and precepts, into which I will endeavor to give you some insight. Every thinking man must shudder to find it recorded in statistical tables how insane asylums and prisons are overflowing, how suicides and crimes against life and soul are but common incidents. It is not hard for each one of us to see the demon of greed and avarice in the eyes of those we meet, ready and eager to snatch away the very bread from the lips of his fellow man because he, too, is hungry and lacking life's necessities. The egotism of mankind grows constantly stronger; all are in haste to become rich, that thus they may enjoy life before its little span is spent. What has become of the youths exuberant in strength, who once were wont to set out, all jubilant with song, in their heyday of freedom, to revel in nature and bathe their lungs in its balsamic atmosphere--to return strengthened to their sleep at early evening, and who really sought to retain their health? They who were the pride of their parents, the joy of their sisters, the blissful hope of a waiting bride. Can we recognize such in the average youth of today,--the citizen of the tomorrow--these effigies of men, degraded by the demons of alcohol and nicotine, by the gambling passion, and by the company of loose women, into dissipated dissolute invalids unwholesome in themselves and a menace to the race? Let us pass on rather to the gentler sex. Where are the sprightly, modest maidens with cheeks rosy with healthy blood, graceful in figure with well developed forms--the chaste, pure spirit shining in their eyes, with witchery and common sense combined? Where are the fathers and mothers whose good fortune it is to possess such children as these? Can it be that they should deem these caricatures of fashion worthy of their fond desire?--these whose days are spent in idling, who find their pleasure in the streets, the shops, the theatres and the like they term "society?" Those men are old at forty years. Those youths too often die at twenty, dissipated wrecks, holding as a mere ceremony the marriage they expect eventually to consummate; or married, now and then produce a single child that had far better never have been born. What of those mothers who cannot nourish their own offspring, but fain would make shift with all imaginable unnatural substitutes and bring up children in whom a predisposition to disease has already been born? Oh nature! High and mighty mistress! A bitter penalty dost thou exact from these thine erring progeny. And rightly so. Cruelly plain dost thou stamp thy mark on the tiny brow of the unborn child to mark in what degree its parents have departed from thine eternal ways of truth. When a great man, recently, in his address before the body of a famous university, solemnly asserted that mankind is growing better, day by day, he must have had before his inner eye fair visions of a future race--the Future of Truth, which come it must--some day--but now lies dormant in the lap of the gods, its alluring, visionary, transcendental form depicted, for an optimistic instant, in the fervent, hopeful heart of a sincere but far-sighted reformer. But it is written: false prophets must come, deceiving in respect to all things in heaven and earth. "Mundus vult decipi, ergo decipiatur." (The world wishes to be deceived, therefore, let it be deceived.) The world elects to be deceived. It is so--often on the most paltry of pretences. And here lies the fatal and prolific cause which has ever, throughout the ages, wrought infinite harm and impeded the progress of the world: _The world's indifference to truth._ For the proper understanding and radical cure of any disease it is of primary importance to have before the mind's eye a distinct picture of its character and developments, thus tracing it back step by step to its source, so that the therapeutic, or healing measures employed may be properly adjusted to its various stages. Nature has her foes, chief amongst which are ignorance, indulgence and fear; and these foes have ever waged fierce warfare upon her from time immemorial. But today a positive spiritual revolution is being wrought among men, for Mother Nature is calling defaulting humanity back to herself with no uncertain voice. Back to Nature is now the cry. Never before were homilies on food so manifold and the ability to profit by them so diminished; never were remedies so abundant and conditions of health so bad; never were deeds of charity so numerous and the poor so discontented; never were measures of reform so prominent and their results so meagre; never was production of commodities so enormous and the cost of living so excessive; never were the resources of all the world so accessible and counterfeits so plentiful; never was enlightenment so widely diffused and sound judgment so restricted; never were the avenues of truth so open, yet never was falsehood so widespread, as in our time. Our age--well named by Dr. Rudolph Weil, the Age of Nerves--has brought to our service the most significant development of natural forces--electricity in all its forms of application, to medicine and industry and traffic; the expression of motive power in terms of machinery--railroads, ocean travel, air navigation, and endless appliances from the almost limitless scope of which, in the hands of man, the master, not even the very wild beasts escape. Meanwhile however--most strange anomaly--mankind degenerates in body and still more in mind. The race has become diseased, is suffering, cries out for a betterment of its conditions, grows constantly more embittered and renounces its faith in the powers, human and divine. Epidemics of terrific proportions sweep their recurring millions into the arms of death; diseases of stupendous mortality, such as tuberculosis, cancer, syphilis, diabetes, and the extensive array of so-called contagious diseases of children, are continually increasing, in spite of doctors, hospitals, sanatoria, hydros, hygienics, asylums, nostrums and serums, and continue to afflict humanity, taking their ghastly toll in daily thousands, despite the vaunted but theoretical advancement of Medical Science. In the field of medical science the controversy rages at full blast today. An endless succession of hypotheses, conjectures and dogmas lies widespread before us--a troubled sea of uncertainties--a complex labyrinth of doubt. The "doctors of medicine" are many but responsible physicians are few, while disease is constantly on the increase among mankind. It is really little that the people have to learn, for instinct has taught them there is little to be hoped of succour from the professional source. But the world-old habit of superstitious fear and reverence for the "Medicine Man" fetish yet holds its grip upon the race--alike in the savage or the Senate and, despite the knowledge of its fallacy, humanity, still faithful, turns to it weakly, fear-driven, in its hour of distress, knowing no self-reliance and no safer refuge. The reader will pardon this digression, since it is better that from the outset we should divest ourselves of all delusions and recognize existing conditions as they really are in order that it may help to eliminate these ignorant superstitions from the public mind and implant therein the wholesome fact that there is _no magic in medicine_ but simply _an ordinary problem of cause and effect_. Existence is movement; the whole visible world is progress, development. These are facts which, in truth, are daily becoming more generally known. But man--even modern man--is still so stubbornly unyielding in his faith that what he learns in an instant becomes immovably rooted in his mind to the utter exclusion, generally, of anything new, which even though it be a matter of demonstrated fact, it matters not if at variance with this earlier knowledge; to him it is an impossibility. How often the fallacy of such ultra-conservative principles has been demonstrated has no bearing upon the case; the fact remains--irrational, stupid though it be--that, sublimely indifferent to criticism, it survives, with all the wrong and persecution that follows in its train. But one of the most noticeable surprises of this description occurred in the year 1896, when Professor Roentgen made public his discovery of the X-rays; for through this discovery facts were disclosed such for instance, as the permeability of solid bodies by luminous rays and the possibility of photographic examination of bony tissues in living creatures--facts entirely incompatible with prevailing ideas and teachings. But these facts were not only intrinsically veracious but were capable of occular demonstration, beyond all possibility of doubt, and thus, as nothing could be changed or refuted, _science found itself compelled, for once, to honour the truth in its initial stage_--to receive them gracefully unto itself and adopt them in its teachings. This discovery of the X-rays was followed closely by that of the N-rays, by the two Curies, husband and wife. This further discovery was a still greater surprise to the scientific world than the former one; for by its aid was established nothing less than the inconstancy of matter. Hitherto science, dealing not with knowledge, but with opinions, had held the belief that the atom is the ultimate form of matter and that no chemical or physical force can divide it, a teaching held to be incontrovertible. First, the discovery of the X-rays had markedly disturbed this belief, and then, on the discovery of the N-rays, it soon became indubitably clear that a constant destruction is taking place within the atom, an uninterrupted throwing off of smaller particles. But it is not our task to show how one discovery after another was made. We are merely interested in knowing that, because of these discoveries, we find today in the atom--not in the radium atom alone, but in every atom as such--only a union of particles identical with one another, the so-called electrons, being but special forms of electro-magnetic forces. Professor Gruner writes as follows: "The atom is no longer the accepted, final unit of matter, but has given place to the electron. The atom is no longer an individual compact particle of matter, but an aggregate of thousands of tiny bodies. Furthermore, the atom is not indestructible; it can throw off successive electrons or groups of electrons from its numerous contents and so keep up a gradual, but veritable destruction." Professor Thomson, who won the "Nobel" prize for his work on natural science, makes these distinct assertions: "(1) The electron is nothing more than a form of electricity. (2) Each electron weighs 1/770th of a fluid atom. Of an atom, that is, which, hitherto had been regarded as the smallest individual particle. (3) A fluid atom consists of 770 electrons and is formed of electricity without any other material. (4) The atoms of other elements, besides radium, are also composed of electrons and of nothing else. The number of electrons varies in different elements; for instance, an atom of quicksilver is composed of 150,000 electrons. (5) Electricity is the basis of all being." Hitherto we have been taught to consider our bodies and their organs from no other standpoint than that of their elements. For if we attribute all the life of the body to the cells, these must consist only of primary matter, like the atoms of which they are formed. But we have now come to know that atoms, and, therefore, our bodies as well, are formed of electrons, or we might say, of crystalized electricity, consequently, we are compelled to recognize in the body a human machine operated entirely under the direction of electrical forces. For electrons cannot lose their electrical character, merely because they are grouped together in atoms and form our bodies. It is a well known scientific fact that atoms attract and repel each other, just as is the case with electro-magnetic forces. Our bodies, then, are not only formed of electrons, which unite into atoms, but they are absolutely filled with free electrons; for every atom is surrounded with an envelope of free electrons, or, in other words, is the centre of a molecule of electrons, and carries its envelope of electrons precisely as the earth carries its envelope of air. Thomson asserts on the basis of his latest observations that: "Every atom forms a planetary system. The 150,000 electrons of mercury, for instance, are arranged in four concentric spheres, like a system about the sun." When we arrive at a complete understanding of these facts and their bearing upon life, we shall be able to control our bodies with perfect success by regulating their electric forces and adjusting their energies. As yet the main difficulty which obstructs our comprehension comes from the seeming dissimilarity of things within and things without man's "passing strange, complex mortality." This apparent lack of co-ordination presumedly stands in direct contradiction to the similarity of electrons. But however similar electrons may be, they still have different vibrations, which cause the differences between various objects,--between colors, shapes and sounds, between positive and negative conditions. It is only by differences of vibration in this world substance, which we may now venture to term electrons, that we are able to perceive a difference in objects around us. It is a matter of primary interest that the organs of the body should differ in this way; for in them are electrons with their inherent electro-magnetic properties, upon which the whole bodily machinery depends. Within our bodies positive currents of energy flow from above downward; for manifestly the remainder of the body is governed by the head. The electrons of the head must consequently be arranged as in a magnet--the positive pole above, the negative below--and they must be always connected with their opposite pole, because the strength and the nature of a magnet depend entirely upon such connection. Thus our heads, under normal conditions, are cool, and our feet warm, so long as positive electro-magnetic force flows from above downward. In most men of the present day, on the contrary, a condition usually exists the exact opposite of that common to normal healthy individuals. A sense of well-being prevails in the body only so long as the electrons are in sympathetic contact with their opposite poles, and, because by this means they increase and extend their forces reciprocally, there exists also throughout the entire body a feeling of physical strength. Life upon the earth is dependent, as we know, upon the power of the sun. Positive electrical forces are displayed in sunlight, and we find that the electrical forces of the soil furnish their complements. Electrical power is manifested by both the earth and the sun--a fact unquestioned by those acquainted with observations made in the field of radio-activity. As a third factor, absolutely essential, I may mention the ocean, which I regard as the storage battery that distributes the power. Then mark the natural contrast between these mundane and solar forces--the one of a nature warm and vibrating quickly, the other cold and more slow of vibration. From this we may infer that we have before us an electrical opposition, a polarity; and assuredly the electrical forces of the earth are those which are negative, since they vibrate more slowly and yield to control, while those of the sun are, on the contrary, positive, since they possess the higher capacity for vibration and dominate the electrical forces of the earth. We may assert, further, that the forces of the earth are electrical, whilst those of the sun are magnetic. In support of this assertion the proof may be advanced that a magnet can raise a heavier load after lying in the sunlight; for the close affinity, between magnetism and sunlight are, in this way incontestably demonstrated. The interchange of these principles underlies all mundane activity and existence, and upon its cessation life would wholly disappear from the planet. The various organs of the body, like everything else, fall under the immediate influence of this interchange of polar forces. The same electric or electro-magnetic opposition exists therein as are elsewhere apparent in nature and, for evidence of the same we have not far to seek. The phenomena occurring in electrolysis--the science of chemical decomposition by galvanic action--are well known. When a current of electricity passes through a fluid capable of decomposition the acids gather about the positive pole and the alkalies about the negative pole. We thus detect the exercise of separate activities on the part of the positive and negative electrical forces,--their polarization,--when we notice that alkalies and acids separate upon the application of electrical forces. Similar conditions exist in our bodies. They occur in the mucous and serous membranes; for the serous secretions react acid, the mucous ones, alkaline. The contrast, in anatomical structure, between the mucous and the serous membranes is due to the fact that they line the various organs, respectively, within and without. It also indicates an opposition in their electro-magnetic forces. These membranes cover, not only the large organs, but also the small ones, to the smallest muscular fibres. In this way an electro-magnetic contrast exists in every part of the body, and it is this opposition Of forces which keeps the vital machinery of the body in working order. Electro-magnetic attraction and resistance are the agencies which control metabolism and the action of the organs, so long as bodily strength and healthy blood are maintained. All internal and external stimuli are nothing more than electro-magnetic processes. Even our bodily temperature, as we commonly think of it under such conditions, resolves itself into electro-magnetic force or its product. Electricity, magnetism, light, and heat differ only in respect to vibration, and are in the final analysis one and the same. But since our bodies are not cold like the earth or, like its electric forces, vibrate slowly, but are warm and of quick vibration, we are sufficiently assured that they contain, not only the cold electro-magnetic forces, of slow vibration, but also those that are warm and vibrate rapidly. And thus, when a correct relation exists between positive and negative forces--that is to say, between the forces of electricity and magnetism, then only have we normal temperature, _then alone are we normally healthy_. When we come to enquire into the sources from which the body obtains these forces, there is little to be said. They are well known, can easily be traced, but to the keenest mind of scholarly research their source of origin is still an unturned page. Of things in the human economy which count, however, first in importance are food and breath; for in every atom of food we eat and every breath of air we breathe there are electrons which enter the body, there to be seized by the attraction of electro-magnetic action, stored away, and applied in vital processes. A source of vital energy, commonly known and little recognized, is the free, pure air, or, ether charged with the electrons of space. Out of space, positive and negative electrons constantly pass into the human body, their effect we feel at once; when, for instance, in a cold room, we commence to feel chilly, or on removal to a warm room, or into the sunlight, a comfortable feeling of warmth pervades the body and restores its normal temperature. Weather and local conditions have no small influence upon our state of health. In dry and elevated positions or in warm weather the condition of the body is more positive; in damp, low-lying places and in raw weather the electro-magnetic forces have a negative tendency. _This is the explanation of those disturbances of health which occasionally arise and which we sometimes experience in the dire form of epidemics._ As an illustration, the difference of climatic conditions between the adjoining States of Washington and Oregon are a case in point. Among other disturbing influences which effect the electro-magnetic forces of the body are _overfeeding_ and _underfeeding, too much_ and _too little exercise_, particularly too much or too little _stimulation_, or _false stimulation_, or excitement of a physical or mental nature. Any one of these influences may produce disorder in the relations of the electro-magnetic forces of the body. The positive or negative electrons may be abnormally increased or diminished or their location disturbed. When the body contains too many negative, slowly vibrating forces, or electrons, and its aggregate of electron vibration is consequently diminished, the result follows that the feeling of strength--the vitality, that is, becomes depressed; we feel weak, tired in the limbs; we possess little warmth and easily grow cold; metabolism falls below the normal; the skin becomes pale and so causes the overplus of negative electrons stored in the mucous membrane to set up a morbid action of that structure. Catarrh sets in. In short, negative diseases are the immediate result; such, for example, as nervous debility, anaemia, diabetes, catarrh of the stomach, intestines or air passages, _influenza_, cholera and diphtheria. In these conditions the principles of physiological chemistry laid down by me may well be called into service and improvement effected by a correct adjustment of diet. When there is an excess of rapidly vibrating, positive electrical forces, or electrons, raising the vitality of the nerves and blood above the normal, the sufferer becomes easily excitable; the body is hot and inclines to inflammatory, feverish or positive diseases, which take the form of inflammation of the lungs, measles, scarlet fever, chicken-pox, typhoid fever, etc. As I have already remarked, in order to understand a disease and to undertake its cure, it is first of all necessary to form a clear mental picture of its course and origin. With this purpose in view and a medical library at command I have honestly tried to formulate from the initial stages a mental picture of scarlet fever, measles, and kindred ailments; but the entire medical literature did not advance me further than pathological anatomy, which informs us that the original cause of disease is certain changes in the form of the cellular elements of different digestive organs, in the explanation of which the customary technical terms are used, such as atrophy, degeneration and metamorphosis. By the aid of true physiological chemistry I have been enabled to trace these mysterious incidences in the life current, learning that the cellules--the smallest elements in the human system--require for their composition alternating quantities of different chemical substances. Which of the chemical elements these are, what mutual relations exist between different organs of the body, and by what means they enter the organism, it has become my intricate and absorbing task to observe. In this investigation it was gradually made clear to me that every organ and every tissue is dependent upon the introduction of proper nutritive constituents into the blood. Healthy blood formation is the one great essential requisite to the maintenance of health or the cure of disease. And such blood must be formed from a full supply of the requisite chemical factors, including all of the mineral ingredients. _Dech-Manna Diet._ This is a point commonly overlooked, and my organic nutritive cell-food termed Dech-Manna-Diet is especially designed for the purpose of its enforcement. In order to obtain a clear understanding of the various forms of disease which attack the human body, it is requisite to know more of the condition we call inflammation. To this end we may consider successively the following facts; namely, that electrons so fill the body as to bring its condition to one equivalent to that of a magnet; that electron lies ranged beside electron; and, that no alteration of location takes place. _Effect of Injury._ But now, suppose some part of the body is subjected to a morbid irritation by some injury. The affected electrons are set into increased vibration and acquire an excess of force above that of the neighbouring electrons. For, the faster a substance vibrates, the more its force increases--a fact with which we are familiar in the action of boiling water and the generation of steam. In proportion as the affected part exceeds the adjoining parts in the vibration of its electrons, it becomes more positive than they and gradually involves these adjoining electrons in the accelerated process of vibration. So, at the seat of injury a centre of positive action is brought into existence which becomes the more intense the longer it continues. Since the electrons in this locality fall out of their regular positions, in consequence of the general attraction and gravitate toward their appropriate poles, they are found to exercise a reciprocally repellent influence upon each other, by which action the vibration naturally increases still further. This causes pain; for the pronounced opposition of the electrons is attended by a feeling of considerable unpleasantness. The blood, which is an efficient conductor of electro-magnetic force, becomes involved through its ready mobility. The affected part becomes filled with blood. It swells and becomes inflamed;--quickened metabolism and greater warmth are produced by the increase in blood contents and by the more rapid vibrations of the electrons. If the inflammatory process progresses further, the tissues finally disintegrate, partly because of blood stagnation, but chiefly because of the supra-normal vibration of the electrons. Either the tissues are shattered by this motion, or melt in the resultant heat. They undergo purulent disintegration, as we may call it. _Bacteria._ Since the cells created are formed of bacteria, that is to say, of vital germs, as the body tissues are of cells, the destruction of the tissues and cells of necessity sets bacteria free; these therefore are not in reality the cause, but the result of disease. _Febrile, or Positive Diseases._ In pronounced inflammation the disturbance of the electrons, the heat, apart from the functional irregularities which occur in systemic processes, is diffused through the entire body: the sickness becomes fever. The blood is impelled with increased pressure throughout the whole body. If during this process negative electrons hold the preponderance in the body, the fever is of a feeble, adynamic type. But when there are many positive electrons in the body and extensive regions are involved in the disease process, so that pronounced cause exists for increased vibration of electrons, there arise those conditions we designate as scarlet fever, measles, and chicken-pox. For, just as in a steam engine, the increased vibration of the steam exerts a strong pressure upon the piston, so the increased vibration of the electrons in the body finally drives the blood with a similar pressure to the skin, where it produces stasis, or stagnation, sweats and other like disturbances. _Curative Process._ As to curative measures, the course to be followed is clearly self-evident and defined. It could not be other than that of regulating each vibratory body, of soothing the electrons quickened by morbid conditions, and accelerating those which have been depressed. _Law of opposites._ Since treatment can effect this end in no other way than by producing contrary conditions it is evident that a plan of opposition must be followed. And, just as day is the opposite of night, summer of winter, heat of cold, the positive of the negative, so, from the changes effected by this opposition every circumstance and every manifestation takes its rise. This is Natural Law, fixed and immutable throughout nature and for all time. Following this law consistently, our course is clear and simple: in cases of innutrition we seek to increase the nutritive faculty by means of proper food; for the overworked we prescribe rest, for those who need exercise, work; warmth for the cold and cooling for the feverish. _Action of Water._ For cooling we use pure water, the most common and most serviceable of remedies. It cools, soothes and restores equilibrium because its mineral affinities determine its vibratory action as of lower, slower grade, and because one of its constituents is oxygen, the most negative of all elements. _Action of earth or mud._ Even more opposed to inflammation than water, is earth, or mud. Mud produces a more decided cooling effect than water; necessarily so, since its nature is more pronouncedly negative, its vibrations slower. Antiphlogistine, clay acetate, or mud, would be of undoubted service in accordance with the law we have been following; But the same object may be more easily and readily attained by the use of packs. _Vinegar packs._ In employing vinegar in this connection, it should only be used with mud or water. Acids are decidedly negative in their electrical action, and therefore, have a curative effect upon inflammatory diseases. The use of vinegar in connection with clay and water in the treatment of inflammations and fevers is a common, old-time custom; but those who do so, ignorantly perhaps, from force of example or hear-say, unconsciously carry out in so doing one of the plainest scientific laws. Why so? Is it because this liquid kills bacilli or destroys morbid products? No, because it quiets the agitated electrons and equalizes their distribution. The safest plan is to take two parts water and one part of vinegar. Vinegar prevents coagulation of the blood-cells, and in consequence, stagnation and inflammation are avoided. _Cooling Drinks._ For a similar reason acid drinks, such as lemonade, raspberry vinegar, and diluted raspberry juice, are of the greatest services in inflammations and fevers. They compose the system from within outward. For, as soon as any electrical negative is brought into contact with the system, streams of electricity course through the body and reduce the inflammation. The best lemonade for this purpose is my preparation "Tonogen," because it contains all the necessary acids, besides the necessary constituents for inducing circulation and thereby preventing stagnation It is easily established that patients treated according to my method have become very much stronger and healthier than they were before the beginning of their illness. Formerly, the proportion of deaths among these who contracted typhoid fever reached twenty and thirty per cent and even higher. These deaths occurred simply because of excessive internal heat. Today, a wide experience shows that hardly any of such cases succumb. _Temperature Reduction._ The application of water in typhoid fever has secured for it a permanent place in the sickroom. Not only have we been enabled by reducing the temperature with water, to attain the very best results in the treatment of typhoid cases, inflammation of the lungs, and all positive heat diseases, but by the same measures, we are now able to forestall its development with increasing certainty. Brand kept typhoid fever away from his soldiers while it raged around them in the severest form, by the simple specific of a daily bath of an hour's duration in cold water. It is easy to understand why scarlet fever, measles and chicken-pox--all positive diseases--demand the exclusion of sunlight in their treatment. Experience has shown that the treatment of these diseases makes a more favorable progress when sunlight is excluded. This fact stands in sharp contrast to all previous observations as to the importance of sunshine in the treatment of disease. _Negative Diseases._ Now let us leave the consideration of the febrile or positive diseases and turn to those of negative character, as well as to disturbances where a reduced vibration of the electrons, a preponderance of cold negative electrical forces, and unhealthy action on the part of the mucous membranes, constitute the condition. _Curative Process._ In this instance, in order to initiate the curative process it is necessary to accelerate the vibration of the electrons in the body--to render the system positive. The principal remedy is heat, because it engenders a higher rate of vibration of the electrons. For this reason steam baths and other methods of applying heat prove highly remedial in negative diseases of the catarrhal and kindred varieties. They increase the vibration of electrons throughout the body and consequently, stimulate metabolism. The morbid activity of the mucous membranes is reduced and the blood flows actively again toward the surface, so that the internal organs experience immediate relief from abnormal pressure. _Sun baths. Light baths._ Unquestionably in this age, marked as it is by the prevalence of negative ailments, sun baths and electric light baths will celebrate triumph upon triumph over disease, for they reanimate the vibration of the electrons even more than do steam baths, and create a direct supply of rapidly vibrating positive electrons. One can easily be satisfied on this point by observing the result of the simple but conclusive experiment of lying in the sunshine when cold. Baths in electric light and in sunshine strengthen the system of one negatively sick, just as a strong current of inductive electricity gives augmented force to a machine operated by inadequate electric power. The responsive reaction need cause no surprise, for every popular sea-beach shows with what wonderful electrical results a salt water bath is attended when followed by a sun bath in the sand. _Exercise._ Equally important in the management of negative diseases is exercise. Everyone knows that exercise makes us warm, and we know now that warmth comes from a quicker vibration of ether, or rightly speaking, the electrons of ether. So, not only is the circulation of the blood improved and metabolism increased by exercise, above all, the vibration of the electrons is enlivened, thus causing their character to be changed to positivity, and the number of positive electrons in the body to be increased. Consequently, negative diseases, which result from a preponderance of negative electrons in the body, disappear before systematic exercise, as the darkness of night before the rising of the sun. _Massage._ Massage not only removes mechanical disturbances of circulation, but also increases the vibration of electrons in the body. It is, therefore, an invaluable remedy in negative diseases. In case of chronic depression, we should by no means underestimate the importance of that comfortable feeling induced by the exercise of electronal vibrations, which supervenes upon properly administered massage. _Colored Light Treatment._ A recent method of treatment is that by colored light. Sunshine, prismatically dissected, is known to vibrate at a rate of about four hundred million for red and eight hundred million for blue. The different rays of sunlight therefore must have different effects upon the world of living things, and red light must produce conditions of less violent vibration, blue light of quickened vibration. In scarlet fever, measles, and chicken-pox, as in all positive febrile diseases, we have seen that there is a morbid increase of vibration in the electrons. Here, therefore, red light is used for curative purposes because it vibrates quietly. In lupus, chronic rheumatism, anemia, and such diseases, a slow vibration of electrons takes place in the body; hence, in such cases, blue light is a medium of cure. _Internal Treatment._ These considerations of the effects of colored light bring us to the treatment of disease by so-called internal means. _Salts._ In a chemical sense the salts of the body are those compounds which consists of two elements, such as water. All salts possess the peculiarity of producing electrical excitation; consequently it is possible for them to generate electricity when coming in contact with carbohydrates. Now the entire structure of the human connective tissue is nothing more or less than a combination of carbohydrates with a salt, that is, with sulphate of lime-ammonia. In this way, natural electrical energy of a positive character exists in the connective tissue which forms the basis of the spleen, the lungs, the stomach, the intestines, the muscles, in fact of the whole body. Therefore, the nervous and arterial systems, together with the heart, are supplied, through the medium of their basis of connective tissues, with electrical energy, by the contact of the electro-negative oxygen which the blood furnishes and the positive sulphate of lime-ammonia in the walls of these organs. _Nourishment._ We now come to a consideration of nourishment. We recognize today the truth of what was asserted years ago by Jezek; namely, that food undergoes a kind of gaseous decomposition in our bodies--one in which the atoms of the elements are resolved into electrons and so become the foundation of new atomic structures. For the separation of atoms into electrons and their entrance into new and different forms--that process which is constantly taking place before our eyes in the external world of Nature--must assuredly be likewise going on in like manner in the human body. _Food._ The world is just awakening and far more inquiry will now be made in the future as to the chemical properties of food, and also as to its necessary quantity and calorific value. It will then be clearly appreciated that vegetable food has a higher value as a producer of energy than animal food, because we find in it in more available form the original elements of force which exists in all matter. For the animal kingdom lives upon the vegetable kingdom and obtains every power it has from vegetable atoms. In the vegetable kingdom the vibration of the electrons is of an electrical character; therefore, vegetable food is of value in the form of electrical force, through its nutritive salts. By maintaining vital processes through its vibrations it renders us another service of a magnetic nature. It is definitely known that quite as much force is derived from vegetable as from animal food, because the former is introduced into the system chiefly in the form of a rapidly vibrating positive magnetic force. Because of its slow vibration vegetable food manifests a lower degree of heat than animal food, and plants possess less warmth than animals. _Diet._ For this reason vegetable diet is distinctly appropriate in febrile diseases. By reason of its more moderate vibration it is also the best diet for nervous people. _Food Standard._ The usefulness of any article of diet depends upon its adaptability for entering into combinations within the system. This, in turn, depends solely upon its higher or lower standing in respect to vibrations. This is the reason why the human organism cannot subsist upon mineral food. _Heat._ We need in our vital economy a definite amount of heat, or positive magnetic force. This is lacking when the system neither produces enough to meet its needs in compensation for expended energy or is not properly supplied with food, fresh air and sunshine. _Discretion._ For this reason it is well to remember that discretion must be used, as any unauthorized, unwise or too rapid change to a strict vegetarian diet may result, in certain cases, in bringing about an underfed condition or in weakening, and even disease, so that the system may be obliged to call in the aid of digestive tonics in order to obtain all the material it needs for the formation of its body-cells. Enough, however, has been said on the subject I think, to clear the stage, as it were, of the debris of antiquated "orthodox" performances. We of the independent and rational branch of the science of healing, ignorantly termed "unorthodox," have devised a means of preventing disease and curing it, when encountered, in a natural way, with materials that regenerate and invigorate the blood, and this method is slowly but surely fighting its way into general recognition. In time we may hope to be able to make the so-called "inevitable" children's complaints a matter of the past, and to raise a generation in which the sins of the forefathers shall be extinct, so that sane and healthy offspring will be the result. But pending such time--until the final victory of the biological-hygienic system for the prevention of disease--we are now prepared and able to cope with the still existing conditions, and to heal, if proper attention is paid to our teachings. _Diet for Children in General._ For the infant child as well as for its mother, it is naturally best that it should be nursed by the mother. The infant should receive the breast every three hours approximately, and no food should be given it during the night, in order to make the feeding regular and avoid intestinal catarrh through overfeeding. A regular diet is necessary for a nursing mother. Hot spices and foods producing gas, must be avoided. Tight clothes that cause degeneration of the mammary glands, are prohibited. If the mother is unable to nurse the child, and a wet-nurse cannot be afforded, the child must be fed artificially, and this requires painstaking care and attention. The main factor is to secure good cow's milk, which is most like human milk. Milk from cows that are kept in barns, should not be used, for these animals constantly live in stables that lack fresh air, and under conditions very detrimental to the milk. The milk should be warmed carefully, thereby approximating the temperature of the mother's milk (86° to 98.6°) before it is given to the infant. The nursing bottle and the rubber caps must be kept scrupulously clean. The milk should be shaken thoroughly before being used, in order to make a perfect intermixture of milk and cream. The newly born infant is not able to digest undiluted milk, and therefore must receive: 1st to 5th day: 1 part milk to three parts water. 5th to 30th day: 1 part milk to two parts water. 30th to 60th day: Half milk, half water. 3rd to 8th month: I part milk, one-half part water. Or: 1st to 3rd month, every 2 hours; 1 part milk, two parts water, with the addition of 2 table-spoonsful milk sugar to I or 1-1/2 quarts milk. 4th to 5th month, every 3 hours: 1 part milk, 1 part water. 6th to 9th month: 2 parts milk, 1 part water. Thereafter pure milk, with the addition of very little sugar, or gruel made of oatmeal or something similar. Among the preparations that are best known are Knorr's and Nestle's. Not until the first teeth have made their appearance, should the child begin to have thin groat soup, a few soft boiled eggs, and a little more solid food. Infants fed artificially must receive food frequently. Later on, still maintaining the milk diet, light milk and flour food, vegetables and meat gravy may be given. Infants and even older children should, under no circumstances, receive miscellaneous delicacies, or highly seasoned and greasy dishes. Strong tea and coffee are poison to the nervous system of children. In case of intestinal diseases milk must be substituted for other diet, with decoctions of cereal flour. Furthermore, Dech-Manna chocolate and malt-chocolate, boiled in milk, are recommended. _Diet for School Children._ The appetite of children increases with their growth and years, and is always a sign of good health. Much exercise in the open air is of the greatest benefit to children. It is not, however, immaterial how children are fed. The theory that children should receive whatever is served on the family table, may be correct from the standpoint of discipline, but it may bring about trouble if the food that is offered does not agree with the stomach of the child. Food for children should be light and display variety. It is not correct to believe that what is eaten with aversion, has a healthy effect, and by forcing children to eat food against which their natural instinct rebels, parents have often seriously injured their children. In a general way, soup, vegetables, farinaceous food or a little meat and fruit is sufficient for the principal meal. In the morning a cup of milk, cocoa or weak coffee (fruit or malt), with a piece of bread; for anaemic children, butter and bread and honey. Prepared in various forms, plenty of milk and farinaceous food, rice, groat, oats, barley, cornmeal, fruit and cooked fruit should be eaten, which all children like and which are superior in effect, since they are so easily digested. Pure water with a little fruit-juice added occasionally; in the afternoon weak tea with milk, fruit coffee, cocoa, malt chocolate; in the summer time, cold sweet or sour milk; these should be the drinks for growing children. Bread and butter with a little marmalade is always welcome. When fruit is in season, some fresh fruit and dry bread is sufficient in the afternoon; the supper should be simple, warm or cold, but without high seasoning; potatoes with butter, soft boiled eggs, bread and ham, cold roast meat, soup or some well prepared farinaceous food one hour before bedtime. Food should not be served very hot, should be well masticated and eaten with little to drink during the meal. It is better to take a glass of water before the meal. Alcoholic drinks are strictly prohibited, since they produce nervous irritation and make study much harder. Game, when not too high and without spice is good for growing children. Dishes prepared from internal organs, such as liver, kidneys and brains, are usually repugnant to children, and should be avoided. Steamed vegetables are preferable to those cooked with sauce. Salads for children should not be highly seasoned, but should be prepared with butter, cream and lemon juice, in which form they are of great nutritive value. Avoid delicacies and mayonnaise dressing. Ice cream is the delight of most children. Permit small quantities, but eaten with crisp biscuit only, so as to avoid catarrh of the stomach. Children should have one or two meals between the regular meals. Greatest variety should prevail at dinner and supper, and the favorite dishes of the various children should be served from time to time. Taste and appetite are the means by which the intestinal organs express what they consider most suitable for the system. That which tastes good not only influences the health of the body, but also the mental condition of the child. Proper food, ample time for play and much fresh air will make the physician's visit a rare necessity. However, if a child becomes ill, medical advice should be obtained immediately and followed strictly, thus avoiding many sad experiences. Nearly all forms of children's disease are combined with fever, and even without any of the characteristic symptoms of the various forms of disease, children are often subject to more or less intense attacks of fever. Therefore, in the following pages I am giving an extensive description of fever from a biological standpoint, together with its dietetic treatment--not _cure_ for, as will be seen, _fever in itself is not a disease, but the attempt of nature to get rid of a disease_. This elaborate description of fever in all its phases will also serve as a valuable illustration of the manner in which all subjects dealt with are treated in my greater work: "Regeneration, or Dare to be Healthy." FEVER AND ITS TREATMENT, BASED ON BIOLOGY (A) GENERAL DESCRIPTION. Fever is one of the protective institutions of the body, which very often acts most advantageously in the interests of the preservation of the organism. It is a symptom, or rather a group of symptoms, consisting of an increase of temperature, acceleration of metabolism, excitement of the nerves, numbness and frequently delirium. Undoubtedly a fever of long duration and high temperature may injure the organism to the extent that death ensues. There have been, nevertheless, at all times, those who hold the opinion that fever, as such, does not under any circumstances, injure the organism of itself alone. Fever has at all times been regarded, and to a much higher degree today than formerly, as a healthy reaction against diseased matter, and indeed, as an expression of the healing tendency of nature, Hippocrates considered it an excellent remedy. Thomas Campanello recognized its qualities of removing diseased matter. This doctrine is corroborated by the findings in regard to infections. Through fever the organism is freed from micro-organisms which may have forced their way in. Fever operates like fire, destroying the contagious matter. After this is done the remnants are excreted through intense and extremely offensive perspiration. Experiments have taught us that the growth and the resisting power of many microbes decrease if the temperature of the body rises, but 1.8 to 3.6 degrees above normal. It is also a remarkable fact that in every disease where bacteria are found, there is a special type of fever, which takes its course in such strict accordance with its law, that the physician is thereby able to determine the nature of the disease. While the degree of temperature is decisive in regard to the life of micro-organisms, the height of the temperature does not, in itself, constitute a criterion of the gravity of danger. It is the duty of the physician to fight the fever, since the patient may succumb to a high temperature, as to a low one. In order to gauge the situation accurately it is necessary to regard fever, not as a disease, but as what it really is in essence: a symptom which accompanies the greatest variety of the processes of disease,--symptom of the most variable significance in various cases. It must be fought like other symptoms, such as vomiting, coughing, pains and diarrhoea; namely, in a general way--provided only that it is not a manifestation of the healing tendency of the organism. In decreasing the fever, we moderate the excitement of the nerves, remove the numbness, secure calmness, refreshment and sleep, and defend the patient against threatening manifestations of disease. Very often it is not a case of treating the fever, but of dealing with the disease which causes the fever. We must consequently not be guided by the thermometer but by the condition of the nervous system. Two conditions must be observed in treating fever according to the rules of biology. In the first place, the treatment of febrile disease must not be carried on in accordance with general principles, but individually, according to the nature of the disease in each particular case. In the second place, it is necessary that the antipyretic treatment, to reduce the fever, should not be foreign to the organism and should not be such as is not measurable in degrees as to its effects, or has any unpleasant accompanying effects or after-effects. Only the biological system of healing responds to these demands. Only cognate physical forces, in affinity with the human organism according to biological laws, can influence vital occurrences with the hope of success and without the danger of unfavorable accompanying effects and consequences. Only physical remedies and treatments permit of adequate gradations such as will appeal to the power of reaction of the organism. In the appropriate application of certain, influences of nature, especially in the diversified applications of water, we possess a mode of procedure which, assisted by an appropriate dietetic regime adapted to the principles of biological healing and to the conditions of life in health and disease, offers advantages which no other treatment affords and benefits the patient to an extent which cannot be too highly estimated. In the treatment of fever we must, in the first place, follow the impulses of instinct--harmonized, however, with the fundamental laws and methods of biological treatment--if success is to be obtained. Instinctively, in the case of a hot forehead, we turn to the application of cold compresses; for cold feet, the use of such appliances as will bring about heat. Tormenting thirst is assuaged by a mouthful of cooling water. But the instinct of impulse alone might also lead one burning with high fever to seek relief by immersion in cooling water; thus, in order to discover the rational course we must be guided by the fundamental laws of the biological system of healing. (B) TREATMENT. To these biological explanations of what fever is, it will be interesting to add some general description and explanation of its treatment, such as may serve in an emergency as an indication of the proper course to be pursued and by the most simple means, pending the attendance of an hygienic physician. I must again call special attention to the importance of not clinging too literally to the letter of the law,--of every rule laid down,--but rather to study by the light of such laws and with alert intelligence the special features of the case at issue. Of all hygienic treatments of fever, which have come under my notice in the course of many years, there is none more clearly, simply and intelligibly described than that which Dr. C. Sturm, has published in his book, "Die natur liche Heilmethode" (The Natural Method of Healing). I will, therefore, employ it in my explanations, (as translated from the German) adding to it my advanced methods, especially the hydropathic and dietetic treatments which are more in accordance with the demands of modern biological therapy. In the first place, as we know, fever is indicated by an abnormally hot skin. This heat is noticeable even by touching the patient with the palm of the hand. A precise measurement of this heat, of course, requires a thermometer. The best kind is a so-called maximum thermometer. The temperature is taken by putting the lower end of the glass into the axilla, or arm-pit, of the arm, or in the mouth or the rectum of the patient, and leaving it there for from 8 to 10 minutes. When withdrawn, the temperature of the patient can be read at a glance. The temperature of the skin, however, is not the only indication of fever. It is accompanied simultaneously by accelerated action of the pulse, up to 120 beats per minute, and even more; also by increased thirst and, as an indication of very intense affection, extreme exhaustion and lassitude. The increased excretion becomes manifest through dark and strong-smelling urine and, especially at the time when the fever begins to abate, through intense perspiration. In the beginning of fever the change alternating between chills and abnormal heat is very characteristic; frequently, and especially in severe attacks, it begins with shivers. The patient suddenly feels an intense chill, so that he commences to shake all over, his teeth chatter and he grasps whatever covering he can for warmth. Suddenly, following this, a rapid increase of temperature occurs, and the patient begins to complain of intense heat. In other cases patients complain of feeling very cold, while their skin indicates a marked degree of warmth. With higher degrees of temperature, the fever may induce a loss of consciousness. The patient becomes delirious, loses urinary and fecal control and displays the signs of total collapse. Fever, as I have already indicated, is a kind of physical revolution, a state of excitation which, differing so widely as to cause, character and degree, cannot be judged according to any fixed rule. The temperature of a patient we may read from the thermometer; but the real nature of the fever we do not learn until we consider his constitution, his innate faculties and the strength to which his various organs have attained. For this purpose we must take into consideration not only the physical attributes, but also the quality of the senses and of the mind, since these items are of the utmost importance in determining the tenacity, i.e., the power of resistance of the patient. From this point of view it will be understood that people possessing a calm and phlegmatic temperament, will not attain to high degrees of fever, except in cases of very serious complications, while nervous people may quickly reach very considerable degrees of temperature. Children and younger people are more inclined to high fever, since their organs are still immature. This explains why simple inflammations, which are not general throughout the body, or frequent indigestion, which in itself does not figure as a dangerous illness, will in the case of children appear under the gravest symptoms. It follows, therefore, how necessary it is to discriminate closely and decide accordingly between severe symptoms of fever as manifested by people of calm temperament, and similar cases when manifested by people of nervous temperament. Unfortunately fever has been treated in the past according to set and rigid rules. As soon as the temperature of a patient rose from 98.6° and 99.6° to 100.4°, it was pronounced to be fever, and preparations were made to treat it accordingly. The treatment became more energetic the higher the fever rose to 105.8° and 107.6°. It was said that under all circumstances the temperature must be lowered to normal. This idea is decidedly wrong and most dangerous for the patient. For, while a calm and phlegmatic patient may withstand this strong reduction of excitement in his internal organs, which in fact require it, the procedure necessary to bring it about, as a rule exceeds what the nervous patient can endure. The fever should only be reduced in accordance with the strength of the patient, otherwise extreme irritation must ensue, such as has caused the death of hundreds of thousands in the past. It is better, therefore, to leave a nervous patient in his fever and strengthen him by various devices, so that he may overcome it. Later he may require and, consequently, be able to withstand stronger measures. For this purpose I recommend simple ablutions, in some cases the application of abdominal packs for half an hour _using two-thirds water and one-third vinegar_, as previously prescribed. In addition, the natural vigor of the patient is to be strengthened by administering to him, at intervals of from half an hour to two hours, Dechmann's Tonogen and Dechmann's Plasmogen alternately. The treatment must be in proportion to the strength of the patient. Thus the quiet, energetic temperament can endure more extensive packs; his nature in fact requires them. His body may be completely packed or at least three-quarters, by placing the moist sheet around his entire body except the arms, while the woolen blanket is either wrapped around the whole body, including the arms, or, as before, leaves the patient free to move his arms, which are then only covered by the bed-clothes. A patient of this kind may also be treated with ablutions or put into a half bath at 75.2°, while cooler water is poured over him. Young and strong patients have endured even cooler baths as powerful stimulants. The nearer a patient approaches to a nervous, weak condition, the more caution is required to allow him hike warm baths only, or, still better, ablutions at 77°, which may be made severer by not drying the patient. It is very beneficial to weak patients to frequently wash their hands, face and neck, without drying them. A very careful treatment of the hair is also a great necessity, especially for women. Clean and well combed hair is very beneficial to a patient. Slight ablutions of the head and combing the hair while wet, are very cooling and refreshing. The stronger the nature of a patient, the safer it becomes to rely upon a single mode of procedure. Thus, cold packs may be sufficient in case of high fever if applied about every half hour or hour; or, if the temperature is not quite so high, at intervals, from one hour and a half to two hours With weaker persons more variety of procedure is imperative, but none of them must be too stringently applied. In these cases mild ablutions should be used several times during the day, and they may be alternated with packs of the whole lower part of the body or packs on the calves of the legs. Cool or cold enemas are rapidly absorbed and thus have a quieting influence on the large blood reservoir in the abdomen. Little mouthfuls of water are also taken from time to time, but too much water always weakens the patient. (C) DIET IN CASES OF FEVER. As diet in cases of fever I recommend the prescriptions of Professor Moritz, which coincide with my own experiences, so far as a fever diet is concerned; and in addition the physiologico-chemical cell-food which I have used for many years with the greatest success (Dech-Manna Diet). The importance of the latter is due to the fact that it not only _prevents_ the destruction of the cells, but has a general strengthening effect upon the system. Whatever the differences in manifestation the febrile diseases may show, the _febrile reduction of the digestive capacity of the stomach and the bowels is so characteristic_, that it should be specially noted in this connection. True, fever shows considerable _disturbance of metabolism_, since the _decomposition of the albumen is increased in an abnormal way_. This fact, however, does not demand any particular attention, in regard to diet. As far as possible during fever it is well to exercise an economizing influence on the decomposition of the albumen of the body through the introduction of _all kinds of food_ that produce energy, so that it is not necessary to _give preference to any one particular kind of food_. The injury to digestion during fever comprises not only the peptic functions, which manifest themselves clearly in a reduction of the excretion of hydrochloric acid, but all functions pertaining thereto, the motory as well as the resorptive. The danger that the patient will receive too much solid food, hard to digest, is generally speaking not very great since, during acute fever, patients as a rule show a decided lack of appetite. The other extreme is the more likely to occur; that the amount of nutrition given may be less than what is requisite and helpful; too much deference being paid to the inclinations of the patient. Formerly the general belief obtained that fever would be increased, in a degree detrimental to the patient, by allowing the consumption of any considerable amount of food, and following this doctrine, the patient was permitted to go hungry. This, however, is absolutely erroneous. _No one would feed a feverish person in a forcible manner, but it is absolutely imperative to take care that he receives food productive of energy in reasonable quantities._ As a rule hardly one-half, or at the most two-thirds of the normal quantity of nourishment necessary for the preservation of life, may be introduced into the organism in case of acute febrile disease. I have already indicated that there is no particular danger in such partial "inanition" (starvation) for a short period, but that, accordingly, the qualitative side of the nourishment becomes more important the longer the fever lasts. It has also been mentioned that the organism reduces its work of decomposition, gradually adapting itself to the unfavorable conditions of sustenance, and thus meets our efforts to maintain its material equilibrium. _It is important always to make use of any periods of remission and intermission, during which the patient has a better appetite and can digest more easily, to give him a good supply of food._ It is also well to administer _as much nourishing food as possible_ in the beginning of an illness, which is likely to be lengthy, provided the patient is not yet wholly under the effects of the febrile disease. The food must then be gradually reduced in the course of the illness. As to quality, the diet must be selected from forms II and III (as below), and will consequently consist of glutinous soups, in some cases with the addition of a nutritive preparation of egg, meat jelly, milk and possibly thin gruel and milk. The quantity of food which the patient may receive can only be given approximately, as follows: For adults--(to constitute a sustaining diet). Soup 1/2 pint, milk and milk gruel 1/3 pint, meat 3 oz., farinaceous food the same, 2 eggs, potatoes, vegetables, fruit sauces 2 to 2-1/2., pastry and bread 2 oz. These quantities must be considered as the maximum for each portion. The quantity of beverage at each meal must also be very limited, not exceeding 3 to 6 oz., so that the stomach is not overburdened unnecessarily nor its contents too much diluted. The reduced meals are harmonized with the object of sufficient general nourishment by eating more frequently, about five to six times a day. Patients with fever should have some food in small quantity every 2 to 3 hours. It is important that _the patient be fed regularly at fixed times_. This will be found advantageous both for the patient and for nursing. _Form II_ comprises _purely liquid nourishment, "soup diet."_ Consommé of pigeon, chicken, veal, mutton, beef, beef-tea, meat jelly, which becomes liquid under the influence of bodily heat, strained soups or such as are prepared of the finest flour with water or bouillon, of barley, oats, rice (glutinous soup), green corn, rye flour, malted milk. All of these soups, with or without any additions such as raw eggs, either whole or the yolk only, if well mixed and not coagulated are easily digested. (Besides albumen preparations, Dech-Manna powders, dry extract of malt, etc., may be added). _Form III_ comprises _nourishment which is not purely liquid_. Milk and milk preparations (belonging to this group on account of their coagulation in the stomach): (a)--Cow's milk, diluted and without cream, dilution with 1/2 to 2/3 barley water, rice water, lime water, vichy water, pure water, light tea. (b)--Milk without cream, not diluted. (c)--Full milk, either diluted or undiluted. (d)--Cream, either diluted or undiluted. (e)--All of these milk combinations with an addition of yolk of egg, well mixed, whole egg, cacao, also a combination of egg and cacao. Milk porridge made of flour for children, arrowroot, cereal flour of every kind, especially oats, groat soups with tapioca, or sago, and potato soup. Egg, raw, stirred, or sucked from the shell, or slightly warmed and poured into a cup; all either with or without a little sugar or salt. Biscuit and crackers, well masticated to be taken with milk, porridge, etc. As a rule fever is accompanied by an increased thirst, which may be satisfied without hesitation. It is unnecessary, and detrimental, for patients suffering from an increased excretion of water through the fever heat, to be subjected to thirst. Since the mucous membrane of the digestive channel is usually not very sensitive to weak chemical food irritations, the cooling drinks, which contain fruit acids, such as fruit juices and lemonades, are as a rule permissible. Fruit soups may also be given. It is different, of course, if an acute catarrh of the stomach or of the bowels is combined with the fever. In such cases fruit acids must be avoided. Still it is not necessary to resist the desire of the patient to take whatever may be given him, at a low temperature. Even ice cream, vanilla or fruit water ice, may be used in moderate quantity. Warning against cold drinks is necessary only in case of disease of the respiratory organs when the cold liquids would cause coughing. The use of dietetic stimulants such as Dechmann's Tonogen, Eubiogen and Plasmogen, is the same in these cases as has been mentioned in several places previously. * * * * * As soon as the patient has made sufficient progress, he may receive more solid food. The salivary digestion being improved, he may now be allowed several more substantial dishes of rice and groat, cooked partly in milk, partly in water and eaten with fruit juice. He may also have several kinds of green vegetables, like spinach, cauliflower, asparagus, comfrey, etc. With additional increase in his strength, fresh fish, well prepared, is especially refreshing to a patient with light fever. As to mental pabulum, in case of severe fever, I recommend for the patient absolute mental and physical rest; little talking, no noise, no visits, no disturbance of any kind. Within his system nature has to accomplish an enormous task to facilitate which complete quiet is essential. Just as he who has serious preoccupations needs quiet environment, so that his attention may be devoted to his thoughts, so also a patient in the throes of fever must relax all external considerations in deference to the struggle of the vital forces within. Whatever disturbance of mentality occurs has always prejudicial effects, such indeed as may in some cases cost the life all are seeking to save. SCARLET FEVER. Scarlet fever is an exanthematous form of disease distinguished by a scarlet eruption of the skin. It produces marked symptoms in three localities, the skin the throat and the kidneys. It is doubtful whether it can be conveyed from one person to another; at least nothing is known concerning the "contagium," or germ of conveyance of infection,--according to the differential diagnosis of Dr. G. Kuhnemann, whose work on the subject is held to be authoritative. It is not to be denied that the disease may be carried by articles of clothing and by intermediary persons, who themselves are not suffering from it. The incubation period--the time intervening between infection and eruption--during which the infected person is "sickening for" disease, varies from two to as much as eight days. Chills, feverishness, headache, nausea and actual vomiting are the initial symptoms, and sore throat with difficulty in swallowing soon follow. Inspection reveals the appearance of an acute throat inflammation, and the tip and sides of the tongue are red as a raspberry. A few hours later--or at most a day or two--the eruption appears; first in the throat, then on the face and chest. It begins with minute, bright red, scattered spots, steadily growing larger until they run together so that the entire skin becomes scarlet, being completely covered with them. Frequently the temperature in the evening ranges as high as from 103° to 105° Fahrenheit. Albumen is always found in the urine. After two or more days the fever mounts gradually, the throat symptoms increase, the eruption fades away, and from four to eight days later the patient's condition returns to normal. At the beginning of the second week desquamation, or scaling, begins, the skin peeling off in minute flakes. At this stage heavy sweats set in and the excretion of urine is increased. In epidemic form the type is sometimes much more malignant, even to the degree that death occurs on the first day with typhoid and inflammatory brain symptoms, unconsciousness, convulsions, delirium, excessive temperature, and rapid pulse. This may happen even without the eruption becoming fairly recognizable. In such severe epidemics the throat symptoms are apt to take on the aspect of diphtheria. The renal discharge exhibits the conditions of a catarrh of the urinary canals originating from causes we do not understand. Among the after effects of scarlet fever are inflammation of the ear with all its consequences, and inflammatory affections of the lungs, air passages, diaphragm and heart membrane. The cause, I repeat again, is _dysaemia_--impure blood. If the patient is predisposed to this form of disease and moreover, a weakling, the case is a dangerous one. Every good mother should see to it that there is healthy blood in her offspring. The task is comparatively an easy one, the method, is simple and ignorance ceases to be an excuse, for my object is to place the necessary knowledge within the reach of all. The treatment of scarlet fever varies according to which symptoms are most severe. In the first place prophylactic efforts must be constantly employed to prevent _possible_ contagion. Healthy children must be strictly seperated from the sick till the end of desquamation or scaling--a period of four to six weeks. If the course of the attack is normal, the patient should be kept in bed under a light cover with a room temperature of 60° to 65°. The sick room must be well ventilated and aired daily. The windows should be hung with transparent _red_ curtains. The diet may consist of milk, curds, barley soup, oatmeal gruel, flour gruel, with some cooked fruit and, of drinks, lemonade, soda water, and raspberry juice; but the most important drink from a scientific point is Dechmann's "Tonogen," as previously described. The linen should be changed often Sponge baths with chilled vinegar-water (1 part cider vinegar diluted with 2 parts water) are helpful when the temperature rises to 102°. If the temperature reaches 105° or over, baths must be promptly administered. The patient may be placed in a bath of 85° or 90°, and the water allowed to cool gradually down to 70° or 65°. A sick child may stay in such a bath ten or twenty minutes, while the time in a bath practically should not be more than three or five minutes. The bath must be repeated as soon as the fever again reaches 105°. When the first symptoms of measles, scarlet fever or chicken-pox are noticed, give the child a three-quarter pack. (See directions under "packs"). After each pack sponge the patient with cool vinegar-water. If the fever is high during the night, apply a sponge bath every half hour or hour. During the day give the patient 1/4 teaspoonful of Dechmann's Plasmogen, dissolved in 1/2 pint water, a little every hour. In the evening and during the night alternate this blood-salt solution with Tonogen. Blood plasm contains eight different salts in different composition, and only when the actual physiological composition is employed can there be any guarantee against the decomposition of the blood-cells. Plasmogen is such a composition. When diphtheria and Bright's disease complicate the case, they must be dealt with as under ordinary conditions and treated by a competent, Hygienic dietetic physician. If recovery is prompt and desquamation (scaling) is in progress, warm baths may be applied for a few days. When the temperature and urine continue normal for a few weeks, the child may be regarded as restored to health. MEASLES. Measles or Rubeola is an exanthematous or eruptive contagious form of children's disease. In Measles the medium of contagion is the excretion from the air passages, mucus coughed up and air exhaled; also the saliva, tears, blood and perspiration of the patient. In Measles also, as is the case with regard to scarlet fever, the "contagium," or germ of contagion, is unknown. The general susceptibility to measles is extraordinarily great the poison being of a virulent nature. If the disease attacks one of feeble constitution whose environment is unfavorable and insanitary,--dwelling in badly ventilated rooms, for instance, with little attention paid to personal cleanliness, the attack is likely to assume a malignant form. A period of from ten to fourteen days may elapse between infection and the development of the symptoms. During this period the patient may infect others. This explains how easily a whole school may become infected. During the preliminary period children feel tired, relaxed, suffer pain in the joints and headache; they have chills and are feverish at evening. Among the symptoms enumerated are catarrhal affections of the air passages, the larynx, the nose and eyes. Constant sneezing, nosebleeding, cough, watering eyes, ultra sensitiveness to strong light, are concurrent conditions. At the same time the fever becomes pronounced. These symptoms continue for four or five days and then rapidly abate and the eruption appears. First a red rash is seen, which spreads over the surface of the face. Inside the mouth and throat a similar mottled redness is seen. In the course of a day the eruption spreads over the whole body. After continuing at their height for a day or two the symptoms gradually decline, and in a little over a week the child may be pronounced well. The skin then sheds all the superfluous cuticle left by the eruption, and in three or four weeks after inception the normal condition is again reached. In the malignant form all the symptoms are of a severe type. Occasionally catarrhal affections of the air passages, croup or pulmonary inflammation supervene, and the patient succumbs. Other concurrent forms of disease are whooping cough, diphtheria, pulmonary consumption, inflammation of the eyes, ear disease, and swelling of the glands. Measles demand no distinctive treatment. The room must be well ventilated, with a temperature of about 60°, and light must be almost totally excluded. At night no lamp should be allowed. _Treatment and diet_ should be the same as in scarlet fever. GERMAN MEASLES. German Measles (Rubella or Roetheln), is an eruptive form of children's disease, much more harmless than the disturbances previously depicted. It is one which occurs in epidemics, but to which children individually are largely susceptible; the actual contagium thereof, however, is likewise unknown to science. Eight days generally intervene between the time of infection and the breaking out of the rash. During this period no acute symptom is noticeable. In the majority of cases the fever that precedes the eruption is not high; headache, cold and sorethroat accompany the appearances of the rash, which in this case breaks out at once, and not after several days, as in the case of actual measles. The spots are about the size of lentils, and are quite deep red, appearing first upon the face. After the rash has been out for one or two days, it gradually becomes paler, the fever goes down, and recovery progresses rapidly, usually without any after effects. It is not necessary for the patient to remain in bed longer than three or four days; nevertheless, the treatment should be just the same as prescribed in the case of the real measles, so as not to leave any weakness or subsequent complication. There are many other forms of disease, besides these, which are likewise accompanied by fever and a rash, which also appear in epidemics and are evidently due to a great variety of causes. As they, however, invariably run the natural course, I shall not dwell upon them here. CHICKEN-POX. Chicken-pox, or Varicella, of which the contagium also remains a mystery, is another infectious eruptive form of disease, peculiar to children. It begins with the appearance of a number of little pigmented elevations on the skin which develop into vesicles and pustules. After a certain period they become encrusted with scabs, which dry up and fall off. When the pustules are deep-seated, small scars remain There is no fever, and the illness is over in about fourteen days. The contagion passes through personal contact, or through clothing and bed linen. If symptoms are severe enough to require it, treatment should follow the directions for scarlet fever. SMALL-POX. As a matter of fact Chicken-pox is of congeneric origin with small-pox, with which, in a very much milder degree, it has various features in common. But small-pox itself is engendered of foul and insanitary conditions of life, impure blood and bad and insufficient nourishment and these, together with its risk under unscientific conditions and in times past of facial disfigurement, have made its name more repugnant to the layman than perhaps any other form of disease. All that need be said about it here, however, is that it is largely a terror of the past and that the sure preventative against it always, and the one reliable anti-toxin against contagion, under all circumstances, is good healthy blood and hygienic-dietetic living. Those readers who may desire a minute description of this form of disease will find the same in chapt: XII of my greater work "Regeneration." TYPHOID FEVER OR TYPHUS ABDOMINALIS. _(A) General Description._ This description of fever is usually termed typhus or nerve fever. It characterizes all forms of typhoid disease of which the following features constitute the prominent symptoms. To a peculiar degree, chiefly young and strong individuals of from 15 to 30 years of age are attacked by this disease, while those in early youth and of more advanced years are much less subject to the same. It is a complaint very dangerous to those who eat and drink to excess and without discretion. Strong excitement of the mind, such as a shock or great anguish, will undoubtedly favor the appearance of typhus. The seasons too have considerable influence upon it, most cases occurring during the Autumn months--from August to November. It has been previously indicated to what extent the study of the hygienic conditions of life will assist in the discovery of the real causes of so-called contagious disease. One instance may show the enormous influence of dietetic movements on the outbreak of great epidemics. It is reported in the "Journal of the Sanitary Institute," London, that the English Seaside Resort Brighton, in the period from July, 1893, to August, 1896, 238 cases of abdominal typhus were observed,--about equally divided for the different years. In 56 cases the typhus was caused by the eating of oysters (36 cases) or clams (20 cases). There was evidence that the water from which these oysters and clams were taken was badly polluted by the excrement of several thousand people, brought through sewers to the place were the shell-fish had been gathered. It was very characteristic in a number of cases that only one of a number of persons, who were otherwise living under equal conditions, fell ill with typhus, a short while after having eaten some of the shell-fish. No other points essential to the spreading of this contagious disease could be discovered. Brighton is healthily situated and built; hygienic conditions in general are favourable; much attention is paid particularly to keeping the soil clean, removing all faeces and providing good drinking water. Contamination through milk in all of the 56 cases, according to most careful investigations, was out of the question. They occurred in entirely different streets in various precincts of the town; 45 of the patients lived on 43 different streets. Besides the people attacked by typhus, many other persons fell ill from lighter disease of the intestines, after having eaten of these crustaceous bivalves, the symptoms being diarrhoea and pains in the stomach. Measures were taken to remove the noxious causes as soon as the source of infection was discovered. The same conditions were some time ago noticed in Berlin. Out of 14 people invited to a dinner, nine fell ill--5 of them very seriously--under symptoms of typhus, after having eaten oysters from Heligoland. Part of the personnel of the kitchen and some of the servants were taken ill with the same critical symptoms. _B. Essentials._ Abdominal typhus is a general illness of the whole body, and consequently all organs of the body are more or less altered in a morbid way while the disease lasts. The main change occurs in the lymphatic glands of the intestines and in the spleen. The following are its anatomical symptoms: With the beginning of the disease the lymphatic glands of the mucous membrane of the intestines begin to swell; they are constantly growing during the course of the disease and attain the size of a pea; extended over the level of the mucous membrane they feel firm, hard and tough. In favourable cases the swelling may go down at this stage, but generally the formation of matter begins through the dying of the cells, caused by insufficient nourishment. This is gradually thrown off, and a loss of substance remains--the typhoid ulcer. This varies in size and in depth. Light bleeding in no great quantity ensues. If the ulcer has gone very deep, the intestines may be perforated and then the faeces and part of the food enter the abdominal cavity. The result is purulent and ichorous peritonitis. As a rule, however, the ulcers are purified and heal by cicatrization. Usually the spleen is enormously enlarged (through a rapid increase in the number of its cells). The swelling of the spleen can easily be detected by external touch. _(C) Symptoms and Course._ During what is termed the earlier stage, which as a rule last about two weeks and precedes the breaking out of the disease proper, the patient still feels comparatively well, or only begins to complain of headache, tired feeling, prostration in all the limbs, dizziness, lack of appetite. It is thus absolutely impossible to fix a definite date for its development. In most cases the patient complains of a chill, followed by feverishness,--symptoms which confine him to bed,--although no actual shivering takes place. It is expedient, although quite arbitrary and subject to many modifications, to divide the course of the illness into three periods:-- (1) The stage of development. (2) The climax. (3) The stage of healing. During the stage of development, which usually lasts about a week, the symptoms of the disease rapidly increase. The patient gets extremely weak and faint, has severe headaches and absolutely no appetite. In consequence of the high fever, he complains of thirst; the skin is dry, the lips chapped, the tongue coated; the pulse is rapid and full; the bowels are constipated, but the abdomen is practically not inflated nor sensitive to pressure. In most cases the spleen is evidently enlarged. Before the end of the first week the climax is reached. This in the lighter cases lasts for the second week, or in more severe cases, even until the third. The fever is constantly high, even 104° and over. The body is generally benumbed, the patient becomes delirious at night or lies absolutely indifferent to all surroundings. The abdomen is now inflated, the buttocks show small, light red spots,--the so-called "roseola,"--which are characteristic of abdominal typhus. Furthermore, in most cases, bronchial catarrh of a more or less severe nature appears. Instead of obstruction of the bowels there is diarrhoea--about two to six light yellow thin stools, occur within 24 hours. During this second stage the complications appear. At the end of the second or the third week respectively, the fever slackens; in cases which take a favourable turn, the patient becomes less benumbed and less indifferent, his sleep is quieter; appetite gradually returns. The bronchial catarrh grows better, the stool once more becomes normal; in short, the patient enters the stage of convalescence. This is a short sketch of the course the illness usually takes. Of the deviations and complaints accompanying Abdominal Typhus, the following are the most important details:-- The fever takes its course in strict accordance with the described anatomical changes in the intestines. It increases gradually during the first week, and at the end of that period it reaches its maximum of about 104°. It stays at that point during the second stage, gradually sinking during the third stage. In lighter cases the second stage may be extraordinarily short. If perforation of the intestines, heavier bleeding or general collapse should ensue, attention is directed thereto through sudden and considerable decrease in the temperature of the body. Pneumonia, inflammation of the inner ear and other accompanying complications also cause sudden access of fever. Effect upon the digestive organs: The tongue is generally coated while the fever lasts; the lips are dry and chapped, and look brown from bleeding. If the patient is not carefully attended to during the extreme numbness, a fungus growth appears which forms a white coating over the tongue, the cavity of the mouth and the pharynx, and may extend into the oesophagus. Later on the tongue loses this coating and becomes red as before. Few symptoms are shown by the stomach, except occasional vomiting and lack of appetite. During convalescence there is great desire for food. The anatomical changes in the intestines have already been mentioned. While obstruction prevails during the first week, the second week is characterized by diarrhoea of a pale and thin consistency. When general improvement sets in, the stools gradually decrease in number, they grow more solid and finally reach the normal. The abdomen is not very sensitive to pressure and is usually intensely inflated with gas. In the region of the right groin a cooing sound is often heard, caused by a liquid substance in the intestines, which can be felt under pressure of the finger. Bleeding from the intestines is not infrequent and happens during the third week of the illness. It usually indicates a bad complication, since the result may be fatal. The stool assumes a tar-like appearance through the mixture of the coagulated blood with the faeces. Close attention must be given to minor hemorrhages, since they often herald others of a more intense nature. In such extreme cases of serious complications, however, a cure has nevertheless been sometimes effected. They are occasionally followed by the immediate beginning of convalescence. The perforation of the intestines, which is caused by an ulcer eating its way through the wall of the intestines, is much more dangerous. It happens most frequently during the third or the fourth week. The patient feels a sudden, most intense pain in the abdomen; he collapses rapidly, the cheeks become hollow, the nose pointed and cool. Vomiting follows, the pulse becomes weak and extremely rapid. The abdomen is enormously inflated and painful. In the severest cases death ensues, at latest, within two or three days, the cause being purulent and ichorous (or pus-laden) peritonitis. Such extreme developments as these, however, are infrequent, since the illness, by timely attention according to the methods herein prescribed, will, as a rule, respond to the treatment and take a favourable turn. _Respiratory Organs_:-- In the course of typhus, intense bleeding of the nose is not infrequent. In the severer cases this is a sign of decomposition of the blood, but in lighter cases it merely serves to alleviate the intense headache which is a feature of the case. The throat is liable to be affected; hoarseness and coughing occur; hardly any case of typhus catarrh. This sometimes extends into the air-passes without a more or less intense bronchial cells and causes catarrhal pneumonia, which--if not promptly treated according to the instructions herein detailed--may become extremely dangerous. _Organs of Circulations_:-- With the exception of a strongly accelerated action, no change is noticeable in the heart. It may, however, suddenly become paralyzed and cease entirely, owing to the general weakness of the patient and the intensity of the fever. Weakness of the heart and possible cessation occur only during the climax or convalescence. _Nervous System_:-- Disturbances of the nervous system are very frequent, hence the name "nervous fever." Consciousness is, in nearly all cases, more or less benumbed, and at times completely lost. The patient is either lying absolutely indifferent, or he is delirious, cries, rages, attempts to jump out of bed and can only be subdued by the strongest efforts. Patients lose control of urinary and faecal movements and require feeding. These disturbances disappear as soon as convalescence sets in and consciousness returns. As a rule the patient, on return to consciousness, knows nothing of what he has gone through, and has no reminiscences of the immediate past. Sometimes cramps in the masticatory muscles have been observed, which explains the grinding of teeth apparent in some instances. Convulsions in the limbs and facial muscles sometimes appear, but most of these disturbances are of short duration. _Urinary and Sexual Organs_:-- With high fever albumen appears in the urine. In some instances it may lead to inflammation of the kidneys, the symptoms of which may at times completely overshadow the symptoms of typhus. Fortunately this complication is very rare. Catarrh of the bladder occurs, because the patient retains the urine too long, while in a state of unconsciousness. Inflammation of the testicles has been observed with male patients, and pregnant women have miscarried or given birth prematurely. _Bones and Joints_:-- Inflammation of the joints is infrequent and in a few cases only, inflammation of the periosteum has been observed. _Skin_:-- At the beginning of the second week small rose-like spots of a light rose colour appear on the buttocks (roseola typhosa), which later on are also found on the upper legs, upper arms and back. They soon disappear, however, and leave no traces. Pustular eczema is so rare in cases of typhus, that as a rule its appearance is taken to indicate that the disease is not a case of abdominal typhus. Frequently, however, urticaria, (nettle-rash) perspiration and other pustules are to be noticed. The great variety of symptoms indicates that innumerable peculiarities may occur in the course of typhus. In some cases it is so light and indistinct (walking typhoid) that it is extremely difficult to diagnose it. In other cases pneumonia or unconsciousness, headache or stiff neck are indicated so overwhelmingly, that it is well-nigh impossible to recognize the underlying illness as typhus. In such cases one speaks of lung and brain typhus. _Recurrence_:-- In about 10% of all cases recurrence is observed, mostly caused through mistakes in diet, leaving bed too soon, and excitement. Usually in such relapses the fever takes the same course as the original attack, but is much less intense. Although such secondary attacks are not very dangerous as a rule, great caution should be observed, especially in regard to diet, which must be followed in the strictest way until all danger has passed. Complications and Subsequent Troubles:--are very frequent and a serious menace to life. The most important are hemorrhage of the brain, meningitis, erysipelas, gangrene of the skin and bones, wasting of the muscles, fibrinous pneumonia; pericarditis, and frequently weakness of the heart with its consequences. Purulent inflammation of the middle ear is one which deserves special attention. Loss of hair is a frequent occurrence during convalescence, owing to the ill-nourished condition of the skin; this, however, is but a temporary feature soon succeeded by renewed growth. _The prognosis_ or forecast of typhus is not altogether bad, notwithstanding the gravity of its symptoms and the dangers of its course. Statistics show that the mortality from typhus does not exceed 7% but each complication makes the result more uncertain and the outlook less hopeful. In the event of perforation of the intestines and severe internal hemorrhage supervening, the chances of saving life are slender. _D. Treatment._ The treatment of typhus requires, in the first place, a correct judgment of the physical condition of the patient in determining the fever treatment to be applied. Success in severe cases of typhus will only be secured by those who understand the correct methods of treating the skin. Robust patients, with reserve energy and resisting power, may receive the unrelaxing application of repeated whole packs or cool full baths. There is, however, a species of endurance, which may prove unable to endure the sustained and active force of these applications. In such cases milder applications and more frequent changes are recommended. Packs, interchanged with baths, clysters or enemas which subdue fever, alternated with ablutions, and similar methods. Extremely stout and nervous patients must be treated with the greatest caution. As typhus cases gradually develop, care must be exercised to prevent too violent treatment in case of serious complications. In fact the physician must not be guided by fixed rules, but must be able to individualize with prompt discretion. During the severest stage the diet must be absolutely a fever diet, prescribed in Form II, while patients suffering from lighter attacks, and convalescents, may be permitted the milder fever diet, given in Form III. _Mental Condition._ Great care and observation is necessary with regard to the patient's mental state. The observance of a quiet demeanour on the part of everyone about the sick room should help to keep the patient quiet and undisturbed and may serve to preserve his consciousness. I have treated very severe cases of typhus, with extremely high fever, during which, however, consciousness remained. Inexorable strictness in this respect is often resented and misunderstood by those surrounding the patient until they realize the far-reaching importance of the orders by comparison with other cases. Cold ablutions on the affected parts, air and water cushions, must be employed early enough to avert any danger of bed-sores. This strict treatment of the patient--physically and mentally, will in most cases be sufficient to render his condition endurable; otherwise the struggle against the irritation of complications becomes intense, rendering it imperative, in the first degree, that the brain symptoms should be carefully watched. Cold compresses on the head must be used in case such symptoms appear, but absolute undisturbed rest will conduce more than anything else to their infrequent occurrence. Collapse must be contended against with light stimulating food (light bouillon of veal or chicken with a little condensed substance). Wine with alcohol might endanger the life of the patient. If the collapse is protracted, constituting a menace to life, the addition of cold water to the lukewarm bath and similar procedure may be tried, but only by a skilled expert. Diarrhoea must be resisted by means of diet and clysters (enemas) with rice-water, if necessary; the enemas must be given _cautiously_. They are dangerous on account of possible violations and consequently rupture of the ulcerated intestines. These and other points, however, such as threatening paralysis etc., are entirely in the hands of the physician. The contest against all the complications of typhus must be directed by absolutely skilled and experienced persons only, since in this disease particularly every mistake of any importance whatsoever, may cost the life of the patient. Besides this specific form of typhus which commands general attention, the others are of merely theoretical interest. One, however, I wish to mention in passing; namely: _E. Relapsing Fever (Typhus Recurrens)._ This also begins with chills and shivering, and a general tired feeling, and is immediately followed by high fever, up to a temperature of 104°. The skin is covered with excretory perspiration. The brain symptoms are lacking. The illness reaches its climax very quickly; but suddenly the patient feels much better, after extremely free perspiration. He continues remarkably well for about a week, when a new attack of the illness, a relapse, occurs. There are frequently from three to four relapses of this kind, which severely tax the strength of the patient. The number and the intensity of these relapses determines the degree of the illness. The treatment is regulated in accordance with the principles to be applied in abdominal typhus. The relapses may be averted or at any rate reduced to a great degree, by strict observance of the methods herein prescribed, especially in regard to diet. _F. Diet in Cases of Typhus._ Typhus abdominalis is a form of disease which requires the most careful dietetic treatment, since it combines high fever, which lasts for several weeks, with a severe ulcerous process in the small and large intestines. Nutrition is seriously hampered by the long duration of the illness, usually considerable lack of appetite and the absolute necessity of nursing the ulcerous intestines in the most studiously careful way. In cases which develop to the highest degree, it naturally follows that the patient wastes away to a great extent. _In the first place, all solid food must be strictly avoided. Too great stress cannot be laid on this point_, since the patient, especially in lighter cases, frequently shows a strong desire for food--especially fruit. Any lack of firmness and caution in this respect may have the most disastrous consequences. Many a patient suffering from typhus has lost his life or experienced a bad relapse and hemorrhages of the intestines through a mistake in diet,--through taking too much or unsuitable food. The most critical period for the liability to hemorrhage, which in some cases is very profuse, is the third, and in lighter cases, the second week, when the crust of the intestinal ulcers begins to scale off. The diet list, as in cases of typhus, consists of Form II, and milk; and it should be made a rule to confine it strictly to the most simple food, bouillon, mucilaginous soups, milk, undiluted or with tea, everything prepared with a little egg. Cream will sometimes agree with the patient. The stools will indicate the digestion or otherwise of the milk. If there are many morsels of casein apparent in the same, the quantity of milk must be reduced and given in diluted form. The use of meat juice, liquid or frozen, and meat jelly, is quite permissible. Although neither of these preparations are very strong, they must be considered as important building-stones for the nourishment of the patient, and they offer a little variety, which is often most desirable. _Drinks._ For drinking, usually fresh water is used, also bread and albumen water, especially Dechmann's Plasmogen, 15 grains in one pint of water, a mouthful from time to time alternating with Dechmann's Tonogen. Great caution must be used in regard to fruit juices and lemonade on account of the danger of irritation of the intestines. Carbonated and other mineral waters must be strictly avoided, since they only add to the usually prevailing meteorism, or gas in the abdominal cavity. Albumen water, which is occasionally used in case of febrile disease and intestinal catarrh of children, is prepared by mixing the white of an egg and two to four spoonfuls of sugar in a tumbler of water. This is strained and cooled before being used. It is easily understood that by this we generate new life in the patient, so to speak, through the albumen, since it contains a large quantity of tissue building material, which in turn prevents catabolism or destruction of the organism, this as contrasted with the methods of the old regime which dooms the patient to certain death by opiates,--a course frequently resorted to by inexperienced practitioners. If, by attention and care, the treatment has succeeded in strengthening the energy of the resisting organism to a certain degree during the fever, it becomes necessary in due course to regulate the desire for food, which sometimes grows and asserts itself in a rapid and energetic manner, while the fever is receding. The cessation of fever by no means indicates that the ulcers are completely healed, and any mistake as to quantity and quality of food may cause a relapse. Liquid diet must, therefore, be given exclusively for at least, another eight days after the fever has ceased. After this, from week to week, gradually, the use of Form III, may be employed and thereafter more solid food, as given anon, under Form IV. _These cautions must be strictly heeded, especially in case of typhus recurrens._ If in the course of typhus severe complications, such as hemorrhage of the intestines or perforation thereof, should supervene, nourishment must immediately be reduced to a minimum. In such instances it is best to confine the diet to mucilaginous soup and to forbid everything else, as long as hemorrhages have not ceased, or the other dangerous peritonitic symptoms have not disappeared. Gradually, Form V and lastly, Form VI, may be followed. _Form IV. Diet of the lightest kind, containing meat, but only in scraped or shredded form._ Noodle soup, rice soup. Mashed boiled brains or sweetbread, or puree of white or red roasted meat, in soup. Brains and sweetbread boiled. Raw scraped meat (beef, ham, etc.) Lean veal sausages, boiled. Mashed potatoes prepared with milk. Rice with bouillon or with milk. Toasted rolls and toast. _Form V. Light diet, containing meat in more solid form_. Pigeon, chicken boiled. Small fish, with little oil, such as brook or lake trout, boiled. Scraped beefsteak, raw ham, boiled tongue. As delicacies: small quantities of caviar, frogs' legs, oysters, sardelle softened in milk. Potatoes mashed and salted, spinach, young peas mashed, cauliflower, asparagues tips, mashed chestnuts, mashed turnips, fruit sauces. Groat or sago puddings. Rolls, white bread. _Form VI. Somewhat heavier meat diet. (Gradually returning to ordinary food.)_ Pigeon, chicken, young deer-meat, hare, everything roasted. Beef tenderloin, tender roast beef, roast veal. Boiled pike or carp. Young turnips. All dishes to be prepared with very little fat, butter to be used exclusively. All strong spices to be avoided. Regarding drinks to be taken with these forms of diet, as a rule good drinking water takes the first place. This is allowed under all circumstances. Still less irritating are weak decoctions of cereals, such as barley and rice water. Other light nutritive non-irritating drinks are bread water and albumen water. Only natural waters, such as Vichy, Apollinaris with half milk or the like are to be used. Drinks containing fruit acid, like lemonade and fruit juices, are somewhat stimulating; however, in a general way, they may be given during fever, but not in typhus. Of alcoholic drinks the best is light wine (bordeaux), first diluted and later in its natural state. As a rule it should not be used before Form IV has been followed and Form V commenced. Occasionally, mild white wine or well fermented beer, may be permitted. Coffee is absolutely forbidden during any of the foregoing forms of diet, but light teas with milk are allowed in most cases. The main point in the different forms of diet as enumerated herein is to be found in the mechanical gradation of the substances in accordance with the progressive condition of the patient. The diet in a certain individual case of the kind will not, however, always be necessarily identical with one or any of the foregoing forms, but must depend upon the individual condition. In the first place, under each form there are easily discernible gradations, according to relative points of view which are all familiar to the physician and to which attention must be paid under similar circumstances. On the other hand, very often one of the items of a later form may be allowed while, in general, one of the previous forms is applied. Thus the transition from Form II to the first items of Form III is hardly perceptible. Of course every form comprises all previous ones, so that each consecutive form affords a greater range than the last. Occasionally other points than those I have mentioned may have to be taken into consideration. It is obviously impossible as the reader will observe, to formulate an absolutely uniform scheme applicable to every case. Next to the description and quality of food, the quantity to be introduced into the stomach at one time, is a matter of the utmost vital importance. DECH-MANNA-COMPOSITIONS. (Only main compositions, specialities to Doctor's order.) In all forms of Typhoid fever: =Neurogen=, =Plasmogen=, =Tonogen=, Eubiogen. _Physical: Partial Packs._ SO-CALLED "NEGATIVE CHILDREN'S DISEASE". In strong contrast to the conditions of "positive" disease amongst children, due, as I have explained, to over-vitality and too rapid vibrations, we have to consider the opposite condition of Negative disease, comprising all physical disturbances wherein cold negative electrical forces and reduced vibrations produce unhealthy action of the mucous membranes, resulting in degeneration of the tissues known as Catarrh in various forms. Bronchitis, Grippe, Influenza and light catarrhal inflammation of the respective organs. One of the most serious in this chapter is summer-complaint (Cholera infantum). This disease, which causes the death of so many, is due to the bringing up of infants on artificial food instead of on the mother's breast. It is one of the negative diseases caused by diminished vitality. The disease is similar to Asiatic cholera. An extensive description of the same is given in Chapter XI A of my book, "Regeneration or Dare To Be Healthy." Frequent vomiting and diarrhoea, with rapid collapse of all vitality, and severe brain disturbances manifest themselves, and death frequently occurs after 36 hours. During hot weather bacterial germs impregnating the air, frequently enter the milk, and many children succumb to the disease at the same time, until wind and rain improve the general conditions. This is the explanation of the occasional epidemic appearance of Cholera Infantum--and its established cause. _Therapy._ _Diet_: The mother's breast or the breast of a healthy wet nurse is the very best remedy for this complaint, if applied at an early stage. If this is impossible, a gruel of barley, oats or mucilaginous rice-water, a decoction of salep (1 teaspoonful to 1 pint of water), or rice water (1 teaspoonful of crushed toasted rice to 1/2 pint water) are recommended. The missing nutritive substance is best supplied by calcareous earth (calcium carbonate), giving 1/4 teaspoonful in a tablespoonful of sweetened water every 3 to 4 hours, for a day or two. It is the simplest, yet most wonderful remedy ever discovered. It is in cases like this that physiological chemistry celebrates its victory. Try it and you will be convinced. For more vigorous means the physician must be consulted, as he should be in any case of this kind, and that as quickly as possible. _Physical_: Sponging the entire body of the child with lukewarm vinegar and water, using one-half vinegar and one-half water, may prove very successful. Warm packs around the abdomen and extending down to the soles of the feet, often prove very effective. The abdomen must be kept warm. The employment of coloured light for curative purposes has been already explained in the preceding pages. The use of _blue_ curtains is, accordingly enjoined here on account of the invigorating influence of the more violent vibrations of _blue light_ upon an organism suffering under the reduced vibration of a "negative disease." =The Contagious Character of Children's Diseases.= In strict adherence to the biological standpoint, it is recommended that a child be separated from the other children in the house as soon as it becomes ill, and if it is not convenient to send the other children away to be taken care of by friends, they must at least be excluded from the sick-chamber. _Each one of these diseases develops some sort of bacillus in its first appearance, and this leaves the body and may fall on receptive soil in the body of another child._ Since all the children in one family live in the same environment and receive practically the same nourishment, and are of the same parentage, the presumption prevails that each one of them is equally susceptible to the disease with which one of the children has been affected. It is, therefore, advisable to adopt preventive and protective measures with them all, by applying abdominal packs and giving them Dechmann's Plasmogen, which will strengthen the white corpuscles of the blood in their fight against possibly intruding bacilli; also Dechmann's Tonogen, in order to give the red corpuscles and the heart the power to endure the greater efforts which the demand for increased vitality will necessitate. The application of these measures will in many cases entirely prevent an impending attack of the disease, and if not, will at least make it easier to control. _The golden rule_: Keep the head cool, the feet warm and the bowels open; that is the golden rule to be followed in the treatment of all children's diseases. All means that are applied must have but the one object, that of making the condition of the blood as good as possible, so that it will maintain a fluid form and circulate readily, richly supplied with all the necessary upbuilding substances. This, and not the use of anti-toxins, will guarantee a speedy return to normal conditions. _Diet_: The importance of the diet in all of these diseases has been indicated on several occasions. Its application is treated extensively under the fever diet; exceptions to be determined by the physician. _Dech-manna-Compositions_: The compositions to be used in case of children's diseases will, as indicated above, consist mainly of Plasmogen and Tonogen. Small doses of Eubiogen will be of great advantage in promoting the general condition of the patient. These three compositions should always be available in a family where there are children, as their application will prove very beneficial in any case, even before the arrival of the physician. _Physical_: The correct application of ablutions of vinegar and water, of partial and other packs and various baths, must be left to the prescription of the physician, depending on the nature of the individual case, and the effect on the patient, with the exception of the abdominal pack. This should always be applied immediately: cold in positive, and warm in negative diseases. THE TONSURE OF THE TONSILS. Though not strictly within the scope of my intention in the present booklet, I feel that no treatise, however brief, which purports to be a free and candid expression of the ills that child-life is heir to, could afford to ignore the burning and much debated question of the tonsils and their significance, present and future, to the well-being of the child, or could deem the task accomplished without raising a warning and protesting voice on behalf of the helpless victims, whose recurrent name is legion, against the callous and persistent violation and destruction of the functions of vital organs, the only shadow of justification of which is, on the one hand, a fashionable popular delusion on the part of parents and, on the other, interested complacency on the part of their medical advisers, accentuated by a strong and dangerous tendency towards operation and empiric surgery generally. This is a strong and sweeping indictment, perhaps. Let us therefore pause for a moment whilst we consult other sources of opinion for confirmation or refutal. And, in the wide range of American and English criteria, what corroboration do we find? We find, as regards America, the venerable Professor Alexander H. Stevens, M.D., a member of the New York College of Physicians, writing as follows: "The reason medicine has advanced so slowly is because physicians have studied the writings of their predecessors instead of nature." From England the verdict comes to this effect: Professor Evans, Fellow of the Royal College of Physicians and Surgeons, of London, says, in part: "The Medical Practice of our day is, at the best, a most uncertain and unsatisfactory system: it has neither philosophy nor common sense to recommend it to confidence." If such opinions prevail _within_ the sacred, State-protected precincts of the profession, how long, revolted confidence exclaims--how long before a credulous, deluded public awakens from its deep hypnotic trance. Against Tonsil destruction three arguments stand: (1) That the primal intention of Universal Mind--(sometimes termed the Soul of Being; the Spirit of All Good or, in simple reverence, "God")--was obviously no malign intention, but an intention for _good_, is an axiom which will be rationally accepted, I presume, as logically and conclusively assured. (2) That the functions of the tonsils are, in the present state of medical knowledge, practically still unknown is the deliberate and final statement made within the past few years by one of the greatest reputed authorities on the subject. (3) That the tonsil has some important mission to fulfill is clearly demonstrated by the fact of its frequent recrudescence, or rather, the natural renewal of the organ after surgical removal--a spontaneous physiological organic mutiny, as it were, supported by its lymphatic glandular dependents, against the reckless ignorance of medical practitioners and the perversity of the medico-cum-parental fashion of the day. For the fact that it is a fashion, and nothing more, is unhappily fully established on ample and high authority within the medical prescriptive pale. And, in fact, even as "The Tonsure" or shaving of the crown, became by fashion and mendicity a feature of priesthood and monastic piety, so has the slaughter of the Tonsils come to be regarded by fashion and mendacity as a feature of childhood and medical expediency and ineptitude. Professor John D. Mackenzie, M.D., of Baltimore, a distinguished leader of the advanced school of medical science, in the course of a brilliant and exhaustive treatise on the subject written as he says, reluctantly, in the interest of the public health and safety, quotes the deliberate opinion of an equally eminent medical friend to the effect that: "Of all the surgical insanities within his recollection this onslaught on the tonsils was the worst--not excepting the operation on the appendix." Dr. Mackenzie then proceeds to show how abysmal has been the ignorance of the functions of these organs from the earliest times, (including a distinguished English medical luminary who went to far as to say: "were I attempting the artificial construction of a man I would leave out the tonsils,") adding that the tonsil was regarded as a useless appendage and "like its little neighbour, the uvula, was sacrificed on every possible pretext or when the surgeon did not know what else to do." "Never," he says, "in the history of medicine has the lust for operation on the tonsils been as passionate as it is at the present time. It is not simply a surgical thirst, it is a mania, a madness, an obsession. It has infected not only the general profession, but also the laity." In proof of this he adds: "A leading laryngologist in one of the largest cities came to me with the humiliating confession that although holding views hostile to such operations he had been forced to perform tonsillectomy in every case in order to satisfy the popular craze and to save his practice from destruction." He cites an instance in which a mother brought her little six-year-old daughter to him, "to know whether her tonsils ought to come out;"--and in answer to the assurance: "your baby is perfectly well, why do you want her tonsils out?" the fond mother's reply was: "Because she sometimes wets the bed!" Recent universal inspection of the throats of school children has revealed the fact that nearly all children at some time of life have more or less enlarged tonsils. And the reports maintain that this, for the most part, is harmless if not actually physiologic--natural--and that their removal in these cases is not only unnecessary but injurious to the proper development of the child. Nevertheless, the reports of the special hospitals for diseases of the nose and throat show to what an appalling extent this destructive operation is perpetrated throughout the land. "Much wild and incontinent talk," Dr. Mackenzie continues, "for which their teachers are sometimes largely to blame, has poisoned the minds of the younger generation of operators and thrown the public into hysteria. They are told that with the disappearance of the tonsils in man, certain diseases will cease to exist and parents nowadays bring their perfectly sound children for tonsil removal in order to head off these affections. Summing up the writer demonstrates that the functions of the tonsils are, at present unknown and that until known nothing authoritative can be said definitely on the subject, whether they be portals for the entrance of disease or the exit for the very purpose of germs of infection; common sense must decide;--whether they protect the organism from danger or invite the presence of disease." I, for my own part, am of Dr. Mackenzie's opinion: that there is an endless flow of lymph from their interior to the free surface, which unchecked, _prevents the entrance of germs from the surface and washes out impurities from within_. That in any case, one of the functions undoubtedly is the production of leucocytes or protective white blood corpuscles and that the tonsil is not, as generally understood, a lymphatic gland; that the general ignorance of this fact has led to the useless sacrifice of thousands of tonsils, on the fallacious assumption that their functional activities may be vicariously undertaken by other lymphatic glands; and finally, that the physiologic integrity of the tonsil is of the utmost importance in infant and child life. The consensus of advanced scientific opinion is now to the effect that the activity of the tonsils as possible accessories of disease has been vastly exaggerated, that like the thousand and one successive misleading theories which in turn, from time to time, have seized upon the imagination and obsessed the minds of the medical fraternity for brief and passing periods, this pernicious craze too, has about run its course. The causes from which this peculiar lust for operation emanates would be perhaps a difficult psychological puzzle to determine; the malign impulse, as regards some special function, seems to spring, as it were, by intuition, unbidden into being from the illusive depths of some perverted intellect, to rage for a while through the medical world with a death roll deadly as the plague and as suddenly to pass into desuetude and disappear behind the impregnable ramparts of "prescriptive right" and "privilege"--terms which in plain parlance mean to the masses in cold actual fact, the absolute negation of all right--the domination of arbitrary, irresponsible and State protected wrong. Between facts and fables, the evidence with regard to the tonsils and their functions seems to establish the conclusion that they have been wrongfully and foolishly held responsible for "an iliad of ills." The region of the nose and mouth is obviously the happy hunting-ground of myriads of pathogenic bacteria. It is likewise continually the scene of innumerable surgical operations, performed necessarily without antiseptic precautions, thus extending the area of possible infection indefinitely to the entire upper air tract which medical incompetence so often fails to explore. And indeed, as Dr. Mackenzie freely remarks: "Of far graver, far-reaching and deeper significance are cases of infection in which life has doubtless been sacrificed by clinging to the lazy and stupefying delusion that the tonsil is the sole portal of poisoning." The mere size of the tonsil, it is shown, is no indication for removal except it be large enough or diseased enough to interfere with respiration, speech or deglutition--that is, swallowing; in which case only a sufficient portion should be taken away, and that without delay. The tonsil may be greatly enlarged or buried deeply in the palatine arcade and yet not interfere with the well-being of the individual. Such tonsils are the special prey of the tonsillectomist. If they are not interrupting function they are best left alone. Moreover, it occasionally happens that the resurrection of a "buried" tonsil is followed shortly by the _burial of the patient_. The practical illuminating lesson to be gleamed is this: That if in infancy and childhood, we pay more attention to the neglected nasal cavities and to the hygiene of the mouth and teeth, we will have less tonsil disease and fewer tonsil operations. "The partial enucleation of the tonsil," the writer asserts, "with even the removal of its capsule if desired, is complete enough for all necessary purposes and practically free from danger; moreover, it produces equal or better results than complete enucleation with its many accidents and complications, to say nothing of its long roll of _unrecorded death_." Another point: From the professional vocalist's point of view. The tonsils are phonatory or vocal organs and play an important part in the mechanism of speech and song. They influence the surrounding muscles and modify the resonance of the mouth. Enlarged by disease, they may cripple these functions and if so, their removal may increase the compass of the voice by one or more octaves; but it is a capital operation and a dangerous one in which a fatal result is by no means a remote possibility. The object of this interesting paper, it is pointed out, is not to assail operation for definite and legitimate cause, but to warn against the "busy internist"--the hospital surgeon--too busy for careful differential diagnosis--and his "accommodating tonsillectomist" who is "in the business for revenue only." But the onus for the existing deplorable state of affairs he lays frankly upon the shoulders of the teachers and insists that the cure of the evil is largely educational. "When," says he, "_pre-eminent authority proclaims in lecture and text book as indisputable truth the relationship between a host of diseases and the tonsils of the child and advises the removal of the glands as a routine method of procedure, what can we expect of the student whose mind is thus poisoned at the very fountainhead of his medical education by ephemeral theory that masquerades so cheerily in the garb of indestructible fact_?" "How," he exclaims, "are we to offset the irresponsibility of the responsible?" But we hear on all sides--"Look at the results." Results? Here is a partial list from the practice--not of the ignorant, but of the most experienced and skilled: Death from hemorrhage and shock, development of latent tuberculosis, laceration and other serious injuries of the palate and pharyngeal muscles, great contraction of the parts, removal of one barrier of infection, severe infection of wound, septicemia, or bacterial infection, troublesome cicatrices, suppurative otitis media and other ear affections, troubles of voice and vision, ruin of singing voice, emphysemia, or destruction of the tissues, septic infarct,--infected arterial obstruction, pneumonia, increased susceptibility to throat disease, pharyngeal quinsy and last, but not least tonsillitis! The trenchant and tragic article concludes with the expression of the hope that the day is not far distant when not only the profession but the public shall demand that this senseless slaughter be stopped. "Is not this day of medical and moral preaching and uplifting," it is asked, "a fitting one in which to lift the public out of the atmosphere into which it has been drugged, and as to the reckless tonsillectomist, a proper time to apply the remedy of the _referendum_ and _recall_. It has come to a point when it is not only a burning question to the profession, but also to the public. This senseless, ruthless destruction of the tonsil is often so far reaching and enduring in its evil results that it is becoming each day a greater menace to the public good." Such is the wisdom of these world-wide sages, They wildly yearn to learn its innermost And break the organ's wondrous works with sledges-- Though music, its sweet soul, for aye is lost; That they have reached the goal, such is their dreaming, When tissues, nerves, and veins reveal their knife-- When in the very core their steel is gleaming-- But, one thing they forget--_and that is life_! This matter of the functions of the tonsils is fully dealt with in my greater work "Regeneration or Dare to be Healthy"--Chapters VII. and VIII., in which I show on the best authority that _the tonsils have a great mission to fulfill_--so great indeed that their treatment according to the present methods of the medical faculty can, in my estimation, only be stigmatized as the equivalent of a crime. It is the conclusion arrived at scientifically by the greatest authorities that the Tonsils secrete a very potent anti-toxic fluid which is excreted whenever dangerous pathogenic bacilli attempt to enter the pharynx or larynx, constituting in fact the ever watchful sentinels of the oral and nasal portals through which an entrance into the human organism might be surprised by its ever active surreptitious enemies--the bacteria of infection and disease. PRE-NATAL CARE. It would be improper to close this section, touching child-life, without some special reference to pre-natal care. It has been well said by eminent authorities that a child's "_education should begin long before its birth_." This to many may seem mysterious or even foolish, according to their advancement on the plane of knowledge. But America has long ago awakened to the truth of it, and pre-natal clinics have been established on a large scale--notably in New York--for the scientific supervision and comfort of expectant mothers who may need it. The natural right of every child to be born in health and happiness, is at length recognized. Human magnetism, or nerve force, is beginning to be understood and utilized as a great vital, health-compelling, harmonizing factor of vast significance to the future of the race. The real and practical alliance between the physical and the psychic--between body and mind--is better realized; as for instance: You may be seized with _an idea_, or a passion, and it disturbs your _health of body_; you may take indigestible food, or suffer injury or fatigue, and it disturbs your _health of mind_. But beyond and behind all else are all those seemingly occult and sinister, pre-natal influences centered in hereditary and kindred considerations which are still more significant and difficult to locate and overcome. These problems have been thought out and solved long before the dawn of the present social awakening and the conclusions have been tabulated in the closest detail from the first moment of embryonic life, faithfully defining the paths that inevitably lead to the desired goal of Hygienic Birth, of Physical Perfection and the Mental State termed Happiness, in Infancy. All these things will be found minutely focussed in picturesque relief, in my previous work entitled: "Within the Bud." ENDEMIC AND EPIDEMIC DISEASE. Among the most deadly menaces that beset human life upon this planet are those forms of disease classed under the head of so-called Endemic and Epidemic disease and including in its baleful limits Yellow fever, Cholera, Pellagra--otherwise known as Hook-worm, Plague and so-called Spanish Influenza. Based upon Physiological Chemistry and explained from the Biological standpoint, the explanation of these covers a wide scientific area and geographically treated embraces the globe. The various problems of their cause and prevention have exercised the mind of science and research to an enormous degree and heavy premiums have been placed upon their solution, with more or less success and much expenditure has been incurred in the examination of local conditions. As far as this Continent is concerned, perhaps the most troublesome has been Climatic Fever which varies greatly in form and intensity according to temperature and location. "Yellow Fever," as it is named, has swept some Southern localities from time to time, but Science, Sanitation and Hygiene have curbed its virulence and spread, as in the case of outbreaks of epidemics such as small-pox--for the control of which, by the way, the advocates of the vile and pernicious practice of vaccination, fraudulently claim the credit, even in these advancing times, when the wiles of self interest are disclosed, the worship of the "Putrid Calf" exposed and the days of the vaccine vendor numbered. Yellow Fever occurs on the Coast of tropical countries and, as a rule, is fatal, after a rapid development of from 3 to 7 days. The explanation of the cause of the disease is comparatively simple: The air on the hot coast lands is highly charged with evaporated water. Heat and humidity have the effect of diverting from the human organism the electricity which, as already shown, constitutes its vital cohesion and the same influences likewise reduce the oxygen in the atmosphere. These are the two primary causes of Yellow Fever. Pellagra (hook-worm or Lombardy Leprosy) is, according to the tenets of the Regular School, an endemic skin and spinal disease of Southern Europe. It is said to be due to eating damaged corn but dependent also upon bad hygienic conditions, poor food and exposure to the sun. Its salient features are weakness, debility, digestive disturbance, spinal pain, convulsions, melancholia and idiocy. More recent investigation has judged it to be a deficiency disease, due to low and unvaried diet and consequent failure of metabolism. In every case these climatic disease forms are caused by a combination of hot air, lacking oxygen, and evaporated water, including Cholera which also varies in intensity according to heat conditions. Cholera and Plague originate on the coast of Bengal, India, where conditions are bad enough of themselves without the apology of the illusive bacillus as a causative agent. That Cholera is contagious cannot be doubted and it is no superstition that fear predisposes thereto. For all emotions consume electrical power in the body and thus break down its power of resistance. Infantile paralysis, Typhoid-fever, Small-pox, etc., are dealt with elsewhere and therefore need no mention here. It is impossible to deal adequately with so wide a subject within the narrow limits at my disposal; but the full details and environment of each, together with the respective methods of treatment will be found in detail in the parent work "Regeneration or Dare to be Healthy." THE SPANISH INFLUENZA. In any attempt to unravel the tangled skein of cause and circumstance which surrounds the subject of the world-sweeping pandemic which masquerades under the misleading title of the "Spanish Influenza," the first and most important initial step must be a keen and careful sifting of the facts and forces, natural and artificial, which control or dominate the situation. The debatable questions appear to be chiefly the following: (1) The fundamental causes that underlie the great-epidemics or pandemics that the world experiences from time to time--the present one in particular. (2) The fact or fallacy of the germ as a causative factor or merely an effect or product of disease conditions. (3) The alternative course, origin and medium of transmission and finally (4) The soundness and efficiency or otherwise of the preventive and curative measures with which the combined intelligence of the Medical Faculty has risen to the dire emergency of the moment for the protection of the people who have relied so confidently, as by law compelled, upon the standard of their acumen and official aid as competent guardians of public safety. The findings, as to the first question, are to the effect that it appears, from the earliest recorded annals of disease, that epidemics corresponding to the present outbreak have occurred at irregular periods all up the centuries under names and conditions peculiar to the times, and following usually in the wake of some great social cataclysm, strain or upheaval, the result of wars, persecutions, famines and distress--causes which clearly illustrate the close reactive connection between the mental and physical action of disease. The great pandemics seem to have originated largely in the Orient--the region of vast congested populations and racial struggles and starvation--the advent of their apparent influence upon the western world depending chiefly upon the rate of commercial or popular intercourse, the movements of armies or the ingress or egress of peoples. The logical establishment of direct proof of the connection between these visitations and local epidemics in distant lands is a problem as yet unsolved. The weight of evidence, at first sight, would seem to lie rather in the other direction--to indicate that such epidemics are the direct outcome of existing local conditions, mental and physical. For example: At the end of that strenuous period in England's history, between the reign of the first Charles and the fall of the Commonwealth, an epidemic broke out which, as the historian tells us, converted the country into "one vast hospital." The malady--which by the way was fatal to Cromwell--the Lord Protector himself--was then termed "the ague." The term "Influenza" was first given to the epidemic of 1743 in accordance with the Italianizing fashion of the day, but was eventually superseded by the French expression "La Grippe," usually held to represent a more modified form of the disease which appears to vary in intensity and virulence according lo its provocation and derivation. The old school hypothesis and the deductions therefrom would seem therefore, to be this: That a super-malignant contagium imported from some foreign source falls upon organisms predisposed to infection by mental stress or physical privation and over-strain or both combined; and the contagion thus generated through the medium of some unsuspected "carrier" seizes upon and sweeps through that portion of the community so predisposed, in the form of a great, general epidemic with a maximum of mortality. At later intervals the same repeats itself with less violence and reduced mortality, because a great proportion,--representing the sufferers in the original epidemic,--being now thereby immune, the onus falls upon that section of the younger generation unprotected by individual resistant force who consequently become the chief sufferers--as in the case of the present epidemic, the pandemic form of which is obviously due to the fact that equal conditions of unrest, privation and distress prevail universally throughout the entire nerve plains of the Planet. The first recorded outbreak in America occurred in the year 1647, followed by a second in 1655 and again in 1789 and 1807. In these the mortality appears to have been confined, after the first outbreak, to a few mere modest thousands whereas in the present visitation a conservative estimate places the figures of the horrible world-holocaust at no less a sum than 18 _million lives_ in all.[D] The ravages in America have been appalling including many of the medical profession. We pass on then to the second item--the question of the germ. The illusive germ has come to be regarded by the layman with reserve--nay more--with suspicion. The part of the bacteriologist has been somewhat overdone. The conditions of popular credence are not what they were. A great change has awakened the masses of the people and a new intelligence is born which now discerns that disease is one great Unity just as the body is one inseparable interdependent whole--that _the cause of disease is in the blood_ and dependent upon its nourishment and moreover, that the _physical forces of the body can be exhausted as much by mental strain,--causing the too rapid burning up of nerve fat (lecithin),--as by excessive physical exertion_. For example. Mental disturbance--grief, worry, excitement--produce immediate physical effect in headache, palpitations and the like. Physical exhaustion--privation, hunger and over-work--on the other hand produce mental depression and collapse. The inevitable law of compensation rules. Thus the germ, bacillus, or microbe, as a direct _cause_ of disease is an exploded fallacy. They are now recognized as the _result_ of disease--_not the cause_: releasing irritants perhaps and possibly carriers or transmitting mediums to other diseased or predisposed organisms. It follows accordingly that Sero-Therapy or Inoculation with specific serums derived from such germs, as a preventative of disease is simply a pernicious farce; "pernicious," since the introduction of such poisons by inocculation into the blood constitutes in itself a serious menace to life and health. This has never been more clearly demonstrated than in the present singularly futile efforts of the Regular Medical Faculty to stay the on-rush of the Influenza Epidemic or to save or safeguard its victims--a fact which compels the people in their thousands to turn to the less pretentious but more successful members of the eclectic or Irregular schools among whom both help and healing may be found. And this is the history of the Influenza germ: The bacterial criminal was located. We know it, for the discovery was officially proclaimed and vouched for by the press with all due pomp and circumstance. True, it was "so minute as to be _invisible to the most powerful microscope_;"--but it was sensed by science, none the less, and handed over captive, for "culture" to the _manufacturing chemist_. Inoculation followed freely--the people in their thousands and our gallant troops alike submitted to the mandate of the powers that be--the soldiers voiceless and under penalty. America breathless, awaited the result. There was none. Finally scare-heads in the Press astonished the land. They were these: "_Medical World is Baffled by the 'Flu'._"--"_Exhaustive Experiments Leave Doctors Mystified._"--"_Every Test a Failure._"--"_Explosion of Accepted Theories Causes Science to Grope for Light._" It appears that, through the heroism of a _hundred_ of our naval men who volunteered for the purpose at the risk of life, the Medical Authorities in desperation were enabled to try every possible method of infection with the alleged Influenza Germs, our boys submitting to inoculation and even to the repulsive ordeal of introduction into the nose and throat of diseased mucous from and close contact with coughing and spitting bed patients in the severest forms of the disease. The experiments were made simultaneously at San Francisco and Boston under the direction of Surgeons McCoy and Goldberger of the U.S. Health Department and the Naval Authorities. The astounding negative result as indicated by the press, was described as "The Sensation of the day," for the fact was revealed that _Not one, of the hundred who underwent these drastic and determined tests, developed any symptoms of Influenza._ This picture of failure was surmounted by the summing up of the situation on the part of the highest Medical Authority; to this effect: "These new experiments in the transmission of Influenza," said Surgeon General Blue, "show how difficult is the Influenza Problem." The result points clearly to a state of natural immunity enjoyed by those who, like these men of the Naval Service, lead an hygienic, contented well regulated life with the simple accessories of good and sufficient food, fresh air and regular exercise. The same principle has been recently demonstrated in England in the same connection by the annual report of one of the great public schools celebrated for hygienic methods, where amongst a total of 800 students not a single case of influenza appeared--although no preventive measures were employed beyond the simple rules of health and cleanliness. Finally, as regards serums and specifics, the judgment of Dr. Karl F. Meyer, of the Hooper Institute of Medical Research of the University of California, may be accepted as focusing the consensus of unbiased opinion on the subject. It was as follows: "Serums have not yet been introduced which produce immunity from Spanish Influenza. The serums now employed are of no use whatsoever. You have no idea how really and truly helpless we are. As an example, take the advice given us by the Public Health Department when we asked what should be done if the epidemic struck West. They said: '_Organise your hospitals and undertakers_.'" In the same statement Dr. Meyer declared that the Medical fraternity _is in total darkness as to the cause and nature of the epidemic_. Of other preventive measures resorted to--Masks, Quarantine and the veto upon public gatherings--proved equally mistaken and futile. Masks of a texture calculated to baffle the most determined attempts of the minute invisible homicide were made compulsory, and in the great cities masquerading millions became a constant feature of the streets, until an idea of the danger of masks, _as microbe preservers and carriers_, dawned upon the official mind. Thus, beyond fostering fear and depression amongst the citizens nothing was achieved in the direction desired, but rather the reverse; since it is now very generally recognized that such mental conditions with their consequently lowered vitality are a common prelude to disease. At the annual meeting of the American Public Health Association in Chicago, following a two days' discussion of preventive measures against Influenza and Pneumonia, Dr. Chas. J. Hastings, president of the organization said: "A tremendous amount of damage is done by interfering with nature, when nature would have done better had she been left alone. We have very little power over pneumonia. I am convinced that as many patients have been _killed_ by physicians as have been _cured_." The talented "Health" editor of the Los Angeles Times, commenting upon these matters, writes: "The handling of this epidemic by 'health boards' and doctors who have been running around like wet chickens--their eyes, however, fastened on the feed box--has furnished another striking evidence of the futility of what is misnamed 'Medical Science.'" All this carries one back 50 years to the memory of Sir John Forbes, Court Physician to the late Queen Victoria of England, and the eminent Editor of the British and Foreign Medical Review, who thus tersely recorded the scientific conclusions arrived at in the course of his long, professional experience, in connection with drugs, drug medication and allopathy, under the title of "Why we should not be poisoned because we are sick:" "Firstly,--that in a large proportion of cases treated by allopathic physicians, the disease is cured by nature and not by them. Secondly,--that in not a small proportion, the disease is cured by nature in spite of them. Thirdly,--that consequently, in a considerable proportion of diseases it would fare as well or better with patients if all remedies, especially drugs, were abandoned;" and he emphatically adds: "Things have come to such a pass that they must either mend or end." This, be it remembered, was in 1868,--50 years ago--and such frankness would not have been tolerated from other than "Sir John"--for, as was said by an inspired American: "He who dares to see a truth not recognized in creed must die the death." And now indeed is revealed the wisdom of Shakespeare when he said: "Ignorance is the Curse of God;" or of Bolinbroke's bitter assertion: "Plain truth will influence half a score men at most in a nation or an age, while _mystery will lead millions by the nose_." I am not prepared to endorse the cynical saying of Voltaire: "Regimen is superior to medicine--especially as from time immemorial out of every hundred physicians ninety-eight are charlatans." But this much is certain, that they have found the needs of nature too laborious--the pathway of their leader--the Great Hippocrates--of Galen, Sydenham, Boerhaave, too tame, and have listened to the lure of Paracelsus, and adopted, with its high pontificial manner and medication, the more luxurious empiricism of the medicasters of five centuries ago. But the time has come when the reign of bigotry, drugs and mystery must have an end--the chartered lien on human life must cease and the antique secret consistories so long omnipotent, must be brought to the enlightened level of the day. We have come to the parting of the ways, where it becomes the bounden duty of every earnest, fair-minded physician to cast off the manacles of professional caste and secret obligation and to advance with open mind across the wholesome confines of eternal truth. This as much in their own interest as in that of their patients. For there is disaffection in the once solid phalanx, and we find strictures such as these in the standard works of the profession: "It cannot be denied that practitioners in medicine stand too low in the scale of public estimation and, something is rotten in the State of Denmark." A series of articles appearing recently, in the English Review, from the daring and masterly pen of George Bernard Shaw, deals with the subject with an ungloved hand, taking as opportunity a vitriolic controversy recently raging between exalted lights of the medical profession in London, which raises abruptly the long-drawn curtain of mystery and exposes the secret skeleton to the view of a wondering world. Speaking of the absolute, autocratic powers of the medical monopoly and the superstitious, hopeless complacency of the public, the writer says: "The assumption is that the 'registered doctor' or surgeon knows everything that is known, and can do everything that is to be done. This means that the dogmas of omniscience, omnipotence and infallibility, and something very like the theory of the apostolic succession and kingship by anointment, have recovered in medicine the grip they have lost in theology and politics. This would not matter if the 'legally qualified doctor' was a _completely qualified healer_: but this is not the case; far from it. Dissatisfaction with the orthodox methods and technique is so widespread that the supply of technically qualified _unregistered_ practitioners is insufficient for the demand.... The reputation of the unregistered specialist is usually well founded. _He must deliver the goods._ He cannot live by the faith of his patients in a string of letters after his name." From all sides the same dissatisfaction is told showing that, with the sick and simple majority, what is termed "the attractive bed-side manner" of the polished practitioner has vastly out-weighed--in the past--the more vital advantage of superior skill on the part of practitioners of the drugless and natural systems which are winning their way to favour, in spite of the organized opposition of the orthodox profession and the powerful "vested interests" of the medicine-men. To return to the subject proper: The summing up as to the efficacy of inoculation, drugs, serums and specifics for Influenza may best be found in the supplements to the U.S. Public Health reports, and vouched for by Surgeon-General Rupert Blue and the Government experts: "Since we are uncertain of the primary cause of Influenza, no form of inoculation can be guaranteed to protect against the disease itself." "No drug has as yet been proved to have any specific influence as a _preventive_ of influenza. "No drug has as yet been proved to have any specific _curative_ effect on influenza--though many are useful in guiding its course and mitigating _is symptoms_. "In the uncertainty of our present knowledge considerable hesitation must be felt in advising vaccine treatment as a curative measure. "The chief dangers of influenza lie in its complications, and it is probable that much may be done to mitigate the severity of the affection and to diminish its mortality _by raising the resistance of the body_...." It is not my purpose in adducing these startling facts to impugn the Allopathic system or to disparage the elder branch of the Profession of Healing. They are simply assembled for the purpose of proving a case in favour of the newer or Hygieo-Dietetic System. But here in consecutive order of testimony is a truly terrible denouncement--the testimony, as it were, of two hemispheres of the terrestrial globe proclaiming the positive failure of the section of science upon which, for very existence, their inhabitants have been accustomed to rely! Now Health and Disease are dependent upon degrees of positive and negative vibrations, as is every form of life in the great Cosmic Unity of the Universe. Both are tones with endless modulation, but the integral fact, in either case, _is one_. Disease, then, is a Unit--a degenerate function of the blood--and, such being the case, the failure of any curative principle or system aspiring to remedy that degenerate functioning, in any degree, is a failure of that principle or system as a whole. The sensational admission, therefore, of the chiefs of the Profession in America and England, as herein cited, amounts in plain language to the tacit admission that drugs and serums are powerless to produce any "preventive influence" or any "curative" effect upon Influenza, (or as it rationally and logically follows, upon any other disease) although, as openly stated in this official proclamation, they may influence the "symptoms." But, finally--And here is the supreme announcement, wherein at length the Truth comes out triumphant--"The severity of the disease may be mitigated and its mortality diminished _by raising the resistance of the body_." This in one single sentence is the sum total of the teachings of the eclectic, independent and legally debarred and officially unrecognized Physiologico-Chemical, Hygieo-Dietetic School of Natural Science which I have the honor to represent. The true teaching of Hippocrates, surnamed "The Father of Medicine"--the ostensible leader, for all time, of the "regular school" of Medicine was comprised in one phrase: the _Vis Medicatrix Naturae_--The Healing Power of Nature. The teaching of our New, Independent School is identically the same--plus the physiologico-chemical discoveries of the intervening centuries. They are plain and natural precepts, surrounded by no fearsome atmosphere of mystery. They are to this effect: That the human organism, together with all its interdependent parts, organs and functions, is an inseparable whole--a Unit--subject absolutely to Natural Laws. As said St. Paul: "And whether one member suffer, all the members suffer with it." (Cor. 12-26.) That disease, therefore, is likewise a unit with a diversity of manifestations which, like all conflicting elements, develop in the individual organism along the lines of least resistance, according to the weakness--hereditary or acquired--of the individual. This we term predisposition. The cause of predisposition to disease, centres absolutely and entirely in the blood, causing obstructions to normal circulation, the obstructing materials being poisons and impurities, either hereditary or acquired through malnutrition or the introduction of unassimilable matter into the system in the form of improper food, drugs, medicines or vaccines which remain as poisons in the blood. Disease is the remedial effort of Nature to throw off such obstructions--a process of purification and regeneration--and its symptoms should be assisted and regulated rather than resisted and suppressed. "Doctors prescribe--but only Nature cures," is an ancient axiom, but it faithfully represents the "_vis medicatrix naturae_." The question has recently been publicly propounded "Is sickness criminal?" Very certainly, disease is the outcome of personal neglect, in past or present; but the nature of the question is a sign significant that the laity are awakening to the truth that the healing power of nature rests wholly in the generation and conservation of latent reserve energy. As regards the influenza controversy the Official verdict is, as we have seen, that the Regular Medical Profession as a whole, has failed in its endeavor to fathom the mystery and is at present "_really and truly helpless_." Let us therefore, seek the cause of this disastrous failure and strive to solve the problem along other lines. If so poor be the harvest, what of the soil? is the natural enquiry. And it must be generally admitted that this spectacular failure lies in the superficial teaching of the medical schools--its search for causes in the mature, and "specialized," anatomical organs in place of the fundamental physiological, chemical and embryonic causes from which, in their appointed order those various organs are evolved;--first the brain and nervous system, afterwards the tissues and the bones. Thus, unversed in the deeper phases of causation, men are hurried unprepared into ranks of a noble profession to struggle as best they may, through lack of deeper knowledge, with the serious symptoms of disease--at first by rote but later, are tempted to tamper empirically with its issues. It has been said by a great scientific authority that, in order to thoroughly comprehend and cure any form of disease it is necessary, in the first place, to mentally map out and visualize the course of its growth and to follow it backward, step by step, to its source before it is possible to formulate curative treatment adapted to its cause and phases. To commence then at the initial stage, let us bring upon the scene one of the greatest chemists of the age: Justus von Liebig, the discoverer of "The Law of the Minimum," which is this: That of the sixteen known constituents of the blood essential to the healthy growth and maintenance of the organs and tissues of the body, the absence of any proportional ingredient, however small, will cause degeneration in the organism and interfere with the proper functioning of one or more of the activities concerned. _Upon this Law is based the attested, dominant fact that all our mental and physical activities--powers of thinking, feeling, motion and every action, including the reproduction of species are equally dependent upon our blood--and our blood, in turn, depends upon proper nutrition._ The ancient aphorism: "Man is as man eats," is therefore true in theory and in fact. Human diet and human life being thus closely allied, it becomes a consideration of the first magnitude to see that all food contains in well balanced degree a correct proportion of the sixteen essentials: carbon, oxygen, hydrogen, nitrogen, iron, sulphur, phosphorus, chlorine, potassium, sodium, magnesium, calcium, manganese, fluorine, silicon and iodine. Amongst the chemical salts of such scientific nutrition may, or may not, be found the famous "Vitamines," long sought of science; but what they certainly do supply is the electro-magnetic energy, the impulse of growth and vital function, the secret of bactericide blood and its power of circulation. It is the magnetic iron in the blood which promotes nerve function in both the brain and the intestinal tract, producing on the one hand intellectual activity and on the other, breathing digestion and excretion. Similar causal action in corelation to the integral elements of food prevails throughout the organs of the body, demonstrating the vital importance of the quality of our daily food for the renewal of tissue and the maintenance of healthy metabolism. In an attempt to define the _primary cause of Influenza_, Prof. Kuhnemann, a well known authority on practical and differential diagnosis, gives a minute description of its various _symptoms_, terminating with a weak suggestion that the already discredited bacillus _may be regarded as the cause_. This is, in detail, as follows: "Fever is always present," Prof. Kuhnemann says, "but not of any certain type. At times, after short periods of Apyrexie there is a rise in temperature sometimes swelling of the spleen. There is no characteristic change in the urine; sometimes Albuminuria. There is an inclination to perspire freely; consequently Miliaria is often present; also Herpes, less frequently other Exanthema, Petechien. The mucous membranes are inclined to hemorrhage (Epistaxis, Hematemesis, Menorrhagia, Abortion). "Complications and after effects: (1) Of the respiratory system:--Croupose and Broncho-pneumonia of atypical progress (atypical fever of protracted course, relatively strong Dyspnoe, Cyanosis, feeble pulse) and high mortality; after effects serous or mattery Pleuritis, Lung abscesses, Phthisis. (2) Of the circulatory system:--Myocarditis, Endocarditis, Thrombosis. (3) Of the digestive tract:--Chronic stomach and intestinal catarrh, Dyspepsia. (4) Of the nervous system:--Any form of Neuralgia, Paralysis, Neuritis, Psychosis, etc. (5) Of the sense organs:--Otitis media; Nephritis and Muscular Rheumatism are also observed. Influenza aggravates any case of sickness, especially lung trouble." All this seems to constitute a very formidable and perplexing indictment, sparkling with learning and bristling with difficulties. But when these mellifluous mysticisms are once translated into "the vulgar tongue" they prove to be, strange to say, easily within the comprehension of the ordinary layman. For instance, "Apyrexie" means Free from fever; Albuminuria--Albumen present; Miliaria--an acute inflammation of the sweat-glands (Abnormal sweating); Herpes--an inflammatory skin disease characterized by the formation of small vesicles in clusters (Fever rash); Exanthema--Skin eruption; Petechien--Spots; Epistaxis--Nose-bleeding; Hematemesis--vomiting blood; Menorrhagia--Excessive menstruation; Croupose--resembling croup; Broncho-pneumonia--Inflammation of the lungs; Atypical fever--irregular fever; Dyspnoe--Hard breathing; Cyanosis--Blue discoloration of the skin from non-oxidation of the blood; Pleuritis--Pleurisy; Phthisis--consumption; Myocarditis and Endocarditis--Inflammations of the heart; Thrombosis--coagulation of blood; Intestinal Catarrh--Inflammation of the bowels; Dyspepsia--Indigestion; Neuritis--Nerve inflammation; Psychosis--Mental derangement; Otitis media--Inflammation of the ear; and Nephritis--Inflammation of the kidneys. "Aetiology:--The influenza bacillus (found in blood and excrement) is to be regarded as the cause. The malady is highly contagious. Period of incubation given as, from two to seven days. Runs its course in one or two weeks, recovery as a rule favorable; though convalescence is often protracted. Unfavorable results are brought on through complications, most often by Pneumonia. "Diagnosis:--Easily determined during an epidemic or marked symptoms. The catarrhal form of influenza differs from simple catarrh of the mucous membranes of the respiratory tract through the presence of nervous symptoms and a more abrupt beginning. The symptoms may be similar to those of Measles or Abdominal typhus. In each case, complications with Pneumonia must be considered. "The proof of the presence of the Influenza bacillus," he concludes, "is of little value in the diagnosis and differential diagnosis in medical practice as the bacillus cannot be distinguished with enough accuracy through the microscopic examination, which must be a very minute culture proceeding." This is the final dictum of medical Science on the subject--Science which however, adds nothing to our knowledge and leaves us still in darkness and uncertainty, while memory brings a well known couplet to the mind: He holds the threads of Wisdom's way Loosely, with palsied hand. Why lacks he now, for pity's sake, The grace to understand? M.B. (After Goethe.) But let us weigh this long list of symptoms and estimate their respective significance by the light of physiological perception. The ever present fever is due to stagnation of the blood. Swelling of the spleen is caused by catabolism of the Malpighian bodies. Albuminuria is the result of cold in the Plexus renalis; Perspiration is due to numbness in the nerve fibrils. The inclination of the mucous membranes to Hemorrhage is explained by congestion of blood in the capillaries, due to lack of vigor in the nerve fibrils. When the nerve fibrils fail to act, the capillary circulation stops and the blood overloaded with carbonic acid presses against the walls until they burst. The complications and after effects are explained in the following manner: Complications in the respiratory system are all due to failure to properly treat the acute stage of the disease, and where the resistance of the patient has been sapped they usually end fatally. Complications in the circulatory system are subject to the same explanation as fever. Digestive complications are due to impaired metabolism brought on by loss of energy in the Vagus nerve. Complications in the nervous system are consequent upon the degeneration of the whole Vagus tract. Sensory complications are due to the disease attacking the "minoris resistentia," the point of least resistance in the patient. This explanation of the real significance of the symptoms of Influenza should make it sufficiently apparent that its cause is fundamental, widespread and deeply rooted in the organism--a menace not to be lightly and tentatively treated with impunity. That the disease is not one that may be met--with any prospect of success--with febrifuges, drugs, serums and specifics--to say nothing of whisky and the like futilities, to use no harsher term, such as are said to have characterized the prescriptions of a very considerable proportion of the Regular Medical Profession and with such terribly disastrous results. What the liquor statistics show on our side of the line I am at the moment unable to say, but I see it reported in the press of an adjoining province that under nominally strict "Prohibition" the sale of liquor had increased no less than 900 per cent, largely upon doctors orders, and that the sales from the Government stores in one city, during the past month had totaled $50,000--as compared with $6,000 for the corresponding period of the previous year. The Professor's elaborate diagnosis, from a physiologico-chemical point of view seems rather to point to a meaning which he has missed--to indicate a latent, more remote possibility behind the shy bacillus, as the primary cause of the disease. Let us endeavor to read the riddle rightly. On scientific contemplation it at once becomes apparent that the symptoms as defined by Kuhnemann--and indeed all other observers--are confined to the regions traversed by the _Vagus_ (wandering) or _Pneumogastric_ nerve--a nerve of comprehensive scope and bi-functional activity, _physical and psychic_ and in operation, remarkably in accord with the manifestations of Influenza. Concisely stated, the physiological function of the _Vagus nerve_ is to regulate the process of breathing, tasting, swallowing, appetite, digestion, etc.; and the result of its failure to function would create coughing, choking, indigestion--separately or in combination. Its mental functions include the expression of shame, desire, disgust, grief, torture, depression and despair. The following is its academic description: _Vagus_ or Pneumogastric nerve (tenth cranial); function--sensation and motion; originates in the floor of the fourth ventricle (the space which represents the primitive cavity of the hind-brain; it has the pons and oblongata in front, while the cerebellum lies dorsal), and is distributed through the ear, pharynx, larynx, lungs, esophagus, and stomach; possesses the following branches--auricular, pharyngeal, superior and inferior laryngeal, cardiac, pulmonary, esophageal, gastric, hepatic, communicating, meningeal. It is interesting to compare the scope and characteristics of the Vagus, as here defined with the details of Prof. Kuhnemann's diagnosis of Influenza and to draw conclusions. In order to establish more unmistakably the symptomatic sympathetic connection between the Vagus and Influenza, it may be well to touch briefly upon the initial processes of metabolism and nerve production. An inherent impulse in the ovum (protoplasm or egg cell) serves to separate the albuminous substance into groups of an opposite nature. Water is chemically separated from one portion, which results in thickening the albumen from which it was extracted, while the liberated water aids in liquifying another portion of the albuminous matter. Thus, on one side slender threads arise, termed fibrine or filaments, and on the other lymph fluid appears, which receives the particles of salts freed from the filaments during their chemical separation. When the fibrine and lymph are organized from the protoplasm, the remaining albumen is absolutely unchanged and ready to furnish material for the growth of either. It is the function of salts to increase the electrical tension of the lymph. All salts possess the property of being electrically positive or negative. The more concentrated a saline solution, the greater its electrical energy. That the function of the lymph is to assist in the formation and nutrition of the nerves is apparent when the nature of lymph and the composition of nerve substances are compared. The contrast which exists between fibrine and lymph, and the similarity of lymph to nerve fat when taken together, justify the conclusion that the nerve substance lecithin, was formed from lymph in the first instance. The whole process of life consists of an electro-chemical combustion. This is clearly shown in the case of lecithin, which serves to control both motion and sensation. In the presence of oxygen it burns up, forming a new chemical combination, and throwing off minute quantities of carbonic acid and water in the process. _Every movement and process, both voluntary and involuntary, and every thought and emotion, depends upon oxidation, which consumes muscular tissue and nerve substance._ The greater our physical exertion the more muscular tissue must be consumed. The higher our emotional state, the more we think or agitate ourselves, the greater must be the quantity of nerve substance burned up. All of the substance burned up in labour, in worry and in thought, must be replaced or the flame will flicker out! The metabolism of muscular tissue is not in question at the moment. We are concerned here with nerve metabolism alone. This occurs in the following manner: In response to the demand for new material created by the chemical combustion of lecithin, new oil flows down the axis cylinders of the nerve fibrils, which are arranged somewhat in the manner of lamp wicks. The average duration of the flow of this oil is about eighteen hours. When the cerebro-spinal nerves refuse to perform their function any longer, because the supply of oil is running low, fatigue and sleep ensue, and the blood descends from the brain to the intestines. Thus the cerebro-spinal system is permitted to relax and rest. In the meantime the sympathetic nervous system has taken up the task of directing the renewal of worn tissues, which draw their supply of necessary materials from the digestive canal, with a new supply of phosphatic oil. For the carrying out of these processes, which prepare the brain and spinal nerve system for the demands of another day, the magnetic blood current acts as distributor of supplies. Through the fact that this supply is directly dependent upon nutrition, three possibilities inevitably present themselves: (1) That any radical change of diet may result in an insufficient supply of the various elements necessary for the production of lecithin in the requisite quantities. (2) That strenuous and unaccustomed physical and mental exertion may involve a consumption both of nerve substance and muscular tissue, greater than the outcome of the ordinary diet is able to compensate. (3) That a protracted term of emotional strain and agitation may adversely affect both appetite and digestion while rapidly consuming the substance of the nerves. In discussing the causes of disease Julius Hensel lays great stress upon the emotions. He goes so far as to say that they "_undoubtedly occupy the first place amongst the factors causing disease_, and we must not evade the consideration of them. _We shall find that their action also amounts to an electro-chemical process._" I would not for an instant be understood to contend that the emotions alone are sufficient to explain the origin of disease--not at all. There are other factors--jointly or severally dominant--diet, occupation, changes of weather, climate, or conditions. In the matter immediately under review, however, the world-wide pandemic of "Spanish Influenza," there can remain no shadow of doubt in the mind of any unbiased observer who follows the question fairly along the lines of electro-chemical biology, but that the general emotional disturbances incident upon the war conditions of the world, combined with the chaotic dietetic position with its anxieties and privations under strenuous and unwonted physical demands, do undoubtedly afford a sound and reasonable explanation of the cataclysmal outbreak which has recently fallen upon the nations. The brazen blast of war, in 1914, with all its ruthless wreck and carnage, shook the universal fabric of the sphere. Fear, fraud and famine were met together, duplicity and greed had kissed each other. Short rations and with some, starvation, were soon the order of the day. The corners of the earth were swept of stale forgotten stores and profiteers waxed fat and prices soared, whilst the vitals of the working world were vastly underfed. The ranks of labour, depleted of its men, were filled by females uninured to toil and dangerous nerve racking environments. Relentless time brings its revenges fast; but still they worked and suffered while malnutrition sapped the life-blood of the race. In the homes of the fighting men fear reigned supreme--ever the sword of Damocles suspended at the hearth. And then the death lists came and the world was wet with human tears and all the furies flew the earth--grief, hatred, revenge, love, pity and remorse, but the wail of mourning was throughout all lands in all the "sable panoply of woe" attending fast lowering vitality, bred by force of pain and hope deferred. Pliny well said: "Dolendi modus, non est timendi"--Pain has its limits, _apprehension none_--and now as in his day, the latter bore the palm. Such was the position when two years ago the world first felt the impact of the pestilence and millions withered up like blighted corn. The Vagus nerve with which we have been dealing, is concerned with the expression of emotions such as these; and being so, was burned up rapidly with fervent heat--the flames of sorrow still with fasting fed. In the majority of human lives such was the case, while the sources of nutritive reserve force were depleted by lack of things of universal use and foreign substitutes for normal food. Small wonder then the once steady nerves soon buckled with the strain; that sickness followed swiftly with disaster in its train and that the death rate rose enormously, beyond recorded precedent. And then when seeming good succeeds the storm of ills a plethora of new-born cares arose and worse, more fatal still, reaction from the strain which with relaxing energy demands its deadly share. Here in America we meet our troubles with serener front, unawed by State-fed sacerdotal superstitions; but in England how the scourge has wrung from dire depression its full toll of death. There for the first time deaths exceed the births and for the final quarter of 1918, the deaths exceed those of the former term by 127,000 of which Influenza claimed one hundred Thousand dead. Similar conditions, it would appear, have been more or less general throughout the European and indeed all other Continents and the title "Pandemic" has been richly earned; but the term which would seem to me more descriptive still would be _"Panasthenia"--the general loss of vitality_. The human organism is, as we know, electro-magnetic. The effect upon the fabric of abnormal disturbance is registered with infinite exactitude by electrons--atoms of electricity--which rise and fall in numerical vibration according to the positive or negative tone of the whole; and excessive manifestations in one direction or the other, indicate respectively, a condition of positive or negative disease. When the slowly vibrating negative electrons outnumber the rapidly vibrating positive atoms the electronic vibration of the whole body is lowered. As a result, we become depressed, weak, tired and retain little bodily warmth. Digestion is upset, metabolism falls far below normal, and the skin becomes pale, because of the morbid action set up in the mucous membrane by the excess of negative electrons. Catarrh supervenes. This is the condition in which negative disease thrives best: Influenza, nervous debility, anaemia, sleeping disease, cholera, diphtheria and the rest, in all varied forms of negative disease. The Vagus, or Wandering Nerve, permeates every vital section of the body, as the accompanying plate will show. It controls, as has been shown, all the highest functions, both mental and physical of human life--that life which depends for its well-being upon electro-chemical combustion, metabolism, and the fuel supply we designate as food. It is the first postulate of healthy vitality in the human frame that metabolism and catabolism--intake and output--shall go hand in hand--that the body must receive continually such fresh nutrition as may replace what it consumes in the process of muscular action and the exercise of mental and emotional activity, and we are consequently brought to the conclusion that such bonds of safety and provision being rudely and suddenly severed, all physical resistance must be quickly broken down, the latent reserve energy is used and disappears, psychic resolution--the immunity of mind--soon abdicates its throne and the depleted organism, robbed of all defense, falls victim to contagion when it comes to kill. _Treatment._ As regards the treatment, actual and preventive, applicable to Spanish Influenza, the methods employed under the Hygienic-Dietetic System of Healing have been already defined in a previous chapter on the subject of negative disease in general. Instruction, however, devoted to Influenza alone may be found in Chapter VI of the special pamphlet issued in that connection under the title: "Influenza, Cause and Cure,"[E] and also in my greater work: "Regeneration or Dare to be Healthy," now in course of completion. * * * * * And now, one final word in conclusion, for the purpose of drawing together, as it were, the multiplicity of threads which constitute the complex skein of causes and effects, with their remedial measures which cover the wide range of human life's vicissitudes--the interruptions of its would-be harmonies--which take the forms, all too common in these times of stress, of physical disturbance and of mental strain which come to us in the combined and threatening guise of suffering and disease. That these forms are more pronounced, more virulent today than ever before in the records of the race, is surely great Nature's manner, crude and masterful, of pressing her mandate home--right home upon the plastic film of evanescent shadows and ephemeral shades we proudly call our consciousness. How many, let me ask, how many of us, in the absorbing round of life's futilities, have paused to really recognize the sinister "hand writing on the wall?" The phase of the world's history through which we pass complacently is of no light portent, its happenings no casual concern, but, in point of crucial fact, a virtual "rending of the sphere"--a cosmic upheaval such as never yet before has racked the tense life sinews of the world, confounding the wisdom of the wise and wrecking in one fell climax of contempt the moral precepts of two thousand years. The greatest human struggle the world has ever known synchronizes strangely, yet logically with the world's greatest pestilence which has swept successive millions to their doom without exacting from the residue even the sentimental tribute of a tear. The official brains of the entire globe are leagued in self-protective unison "to make the world safe for democracy;" but Demos dies, by violence and disease, ere yet salvation comes. It appeals to its old-time standards for relief,--they are gone; to its pastors--they are mute; to its masters--they are impotent; to its doctors--they are baffled, helpless and aghast, whilst vainly searching earth and air for some frail pretext of unreal enlightenment, some fragile figment of belief. And yet in hypnotized complacency the masses stand; for meanwhile commerce reaps its costly gains and labour draws in enhanced increment the wages of the living and the dead. Less serious visitations have, in former times, left their eternal imprint on the age. They served to point the moral of widespread reform--to emphasize the practice of hygiene and sanity. For all such scourges are but signs of Nature's trust betrayed, her sacred laws defied in the wild rush for gain, oblivious of the Law of Compensation's cost, with its inevitable reckoning. Thus, to the discoverer of the lost initiative, what prospect does the future hold in store? Pandemics, such as this, repeat themselves; and other forms of dread disease are following the footsteps of mankind. Arterio sclerosis, (hardening of the arteries), with its kindred complaints, for instance, now threatens to become a standing feature of the race through ignorance of the physiological functions of the nerves, their tissue exhaustion and supply. With such impending dangers are our men distressed; and yet there seems but grudging, slight encouragement for those who seek to stay the onslaught of the foe, by scientific measures of precaution and hygiene. What the nation needs is now a practical and nation-wide awakening. Let the people realize the danger of their risk; let them rally to the call and loyally support those who thus offer them the safeguard of knowledge as a refuge from the impending storm. Then will so-called "incurable disease" be relegated to the limbo of the past and, among other prophylactic means, this, my latest great discovery--the cause of Influenza, its prevention and its cure, a discovery which must rank amongst the great scientific achievements of the day--will mitigate the force of epidemics on mankind. It should also give to the reader of this little book a fair assurance of what immunity it is possible to secure by careful study and practice of its truths and should prove to the thinker the nucleus of a lesson which can nowhere be better learned than in the teachings and the precepts of the Hygienic-Dietetic School. "But to the hero, when his sword Has won the battle for the free, Thy voice sounds like a prophet's word And in its hollow tones are heard The thanks of millions yet to be" FINIS. Wide and unlimited as the field of biology and the hygienic-dietetic method of healing is, I have in the foregoing pages tried to devise a guide that will indicate the points that are most necessary to the confidence of the patient, based upon knowledge. If I have enlightened my readers sufficiently regarding the most modern results of biological research, if I have succeeded in showing them the ray of hope, in the midst of their suffering, that will give them courage to live, and live as healthy human beings, I shall feel amply rewarded for the hard work that had necessarily to be done before the present pinnacle in the art of healing could be reached. Let me repeat: this brochure is not designed to lead any one away from the man who knows, who has gone to the sources of wisdom, to bring salvation to those who demand the right to live in health and vigor. Far otherwise; for my deliberate injunction is that the cure of disease, in any form, should not be undertaken except under the guidance of an hygienic physician who may indicate to them the path, so that they may not tread it blindly, but in the light of knowledge. The outlines of a great and wonderful science are presented. Another wall between the layman and the professional has been torn down. If, my readers, you can one day say this booklet has guided you to the right path, back to the enjoyment of life in youthful health and vigor, then join with me and others in propagating these sane and safe principles, and make others "Dare to be Healthy," as you have dared yourself. FOOTNOTES: [D] This amount is given by the Seattle Post-Intelligencer, in an editorial devoted to the terrible plague on March 16th, 1919. [E] The pamphlet, which also contains a chart of the Vagus in 2 colors, may be obtained either from the author or through any bookseller. The price is 50 cents. INDEX Dedication, 5 Foreword, 13 Introduction, 15 The Hygienic-Dietetic method of Healing, 19 Physiologico-Chemical Research, 20 The Natural Method of Healing, 20 Prophylactic Therapy or Prevention of Disease, 21 The New-School of Healing, 22 "Regeneration" or "Dare to be Healthy", 24 Distrust of the Medical Fraternity, 25-6 Johannes Müller and his followers, 26-7 The Medical Impasse, 28-9 The Regeneration of the Race, 31 Dysaemia--the cause of disease, 31 The process of Natural Healing, 31 The Human Body a Microcosm, 32 The body an indivisible Unity, 33 The Bacteria craze, 33 Predisposition, 34 The Allopathic failure, 35-36 Choosing a Physician, 37 Cell-food Therapy, 37 Medical Literature, 38 Chemical elements of the blood, 39 Dech-Manna, or "Organic Nutritive salts or cell-food Therapy", 39 "As a man eats, so is he", 46 Humanity the product of the exhausted fields, 46 The remedy, the question and the reply, 47 No "business" in healthy blood, 47 Truth versus Creeds and Capital, 49 Health: Hymn of Health, 51 The Health ideal by Nature set, 52 Ignorance the basis of disease, 54 A Means of Enlightenment, 55 The Dare to be Healthy Club, 57 The purpose of the Club, 58 The Teachings of the Club, 58 Two years' course in Biology, 58 Physiology, Anatomy, Hygiene, Physiological Chemistry, Pathology, according to Biological facts, 58 Therapy, in accordance with Biological and Physical Laws and Precepts, 58 Its comprehensive aim, 58 The Course of Instruction, 58 Its Precepts, 59 Graduates as Teachers, 59 The Method of Regeneration, 59 Dr W.C. Rucker Assistant Surgeon Gen. US Public Health Service on Physiological Chemistry, 60 The Boerhaave Incident, 62 The Secret of Disease and Health, 62 The eternal Lesson Nature Teaches, 64 Simplicity the Essence of the System, 64 A Life's Legacy, 65 The Physician, 66 Fair Minded Physicians, 66 Behind the Veil, 66 Disease the Heritage of the Ages, 67 The Moment of Release, 67 Disease a Unit, 68 The Part of the Physician, 69 The Teachings of Great Masters, 69 Hippocrates, 70 Galen, 71 Thomas Sydenham, 73 Boerhaave, 74 System of Regeneration, 77 Man as a Unit, 77 Perpetual Existence, 77 Functions, 77 Cell life, 78 Specialists, 78 Cause of Disease, 79 Metabolism, 79 Creative Matter, 79 Functions of the Blood, 79 Foreign Formations, 80 Nature's Curative Powers, 80 The Blood as Universal Medium, 80 The Oneness of Disease, 80 All Powers Dependent on Nutrition, 80 Diversity of Construction, 81 Adaptivity of Cells, 81 Medical Misconception, 81 Resultant Errors, 82 Diagnosis, 82 Chemical Analysis of Human Body, 82 The Twelve Tissues, 82 Secret of Healing, 82 Tissues Depend Upon the Blood, 82 The 16 Elements of the Blood, 83 Dominant Features, 83 Von Liebig's Law of the Mirimuin, 83 The Law of Chemotaxis, 84 Cell Attraction, 84 Process of Healing, 84 Constitutional Disease, 84 New Cell food Treatment, 85 Old System Superseded, 85 Dysarmia, 85 The Bacillus Fallacy, 85 Predisposition, 86 Hereditary Disease, 86 Heredity Not Invincible, 87 The Dechmann Law of the Cross transmission of Characteristics, 87 The Theory of Pangenesis, 88 The Dechmann Law of the Determination of Sex at Will, 89 Latent Reserve Energy, 89 Law of the Dominant, 90 Heredity and Predisposition, 90 Prevention of Disease, 91 Terrible Responsibility, 91 Alternative Betterment, 92 The "Incurable," Curable, 92 Chemical Elements Missing, 92 Three Methods of Supply, 92 Diet, 92 Nutritive Preparations, 93 Physical Treatment, 93 Nature a Unit, 94 Natural Elements, 94 Importance of Minerals, 94 Testimonials, 95 Dech-Manna Nutritive Preparations, 97 The Means of Health and Safety, 98 The Dare to be Healthy Club, 99 Business Proposition, 99 Membership, 99 Terms and Literature etc., 100 "Within the Bud", 101 Cell Foods Special Rates to Members, 102 The Basis of Proceedings, 103 Life, Health, Happiness, 104 Man as a Unit, 105 Metabolism, 106 Variety of Organs, 109 The Idea of Unity, 109 The Constituent Elements, 111 Dysaemia, the Cause of All Constitutional Diseases, 113 Heredity, 116 Healing, 117 The Unity of Nature, 119 The Chemical Process of Disease, 121 The Twelve Tissues, 123 1. The Plasmo Tissue (Blood Plasma), 124 2. The Lymphoid Tissue, 125 3. The Nerve Tissue, 125 4. The Bone Tissue, 126 5. The Muscular Tissue, 127 6. The Mucous Membrane Tissue, 128 7. The Tooth and Eye Tissue, 128 8. The Hair Tissue, 128 9. The Skin Tissue, 129 10. The Gelatigenous Tissue, 130 11. The Cartilage Tissue, 130 12. The Body Tissue in General, 131 Degeneration of Tissues, 132 The Meaning of "Healing", 132 Grouping of Constitutional Diseases, 133 The A.B.C. of My System of Healing, 135 A. Diet, 135 B. Nutritive Compositions, 135 C. Physical Treatment, 136 Diet--Its Vital Importance, 136 The Reason Why, 137 The Laboratory of the Body and Functions of Its Branches, 137 Creation of Life blood, 137 Building the Framework, 138 The Material, 138 The Refuse, 138 Diet Forms No. I to No. VI, 138 Nutritive Compositions, 143 Representations to Government, 143 Functions of Minerals in Our Food, 148 Minerals in the Human Economy, 148 Chemical Elements Essential to Life, 149 The Impulse of Growth, 150 The Genesis of Polyps, Tumors and Cancers, 151 Review of Mineral Elements, 152 Iron in the Blood, 152 Generation of Electricity, 152 Faraday, on Magnetic Blood, 152 The Motor of Nervous Function, 153 Creation of Bodily Warmth, 153 The Secret of Sleep, 153 The Function of the Spleen, 154 Rejuvenating Influence, 154 The Malpighian Bodies, 154 The Liver and the Bile, 155 Lecithin or Nerve Fat, 155 System of Cell Renewal, 156 Nutrition-Soda and the Bile, 156 Chemical Fixation, 156 Sodium Sulphate Essential, 157 Basis of Muscle Tissue, 157 Basis of Bones and Teeth, 158 Growth of the Hair, 158 Medium of Chemical Combustion, 158 Human Organism Cannot Assimilate Inorganic Matter, 159 Necessity of Prepared Nutritive Salts, 159 Incomplete Fertilization, 160 Sickly (food) vegetation, 160 Improper Fertilization Breeds Disease, 161 The Rock and Its Lesson, 161 Food Instinct, 161 An Imperative Duty to Mankind, 162 Result of Experiments (Poultry), 162 Results of Experiments (small fruit), 163 Haemoglobin Eggs for Weakened Constitutions, 164 Lecithin for Neurasthenia, 164 Physical Regeneration, 164 Reserve Energy Essentials, 165 Nutritive Compositions, 166 16 Nutritive Cell-foods, 166 12 "Dech-Manna" Compositions, 166 Specialities, A. to J., 167 Explanations, 168 Schuessler's Absurdity, 170 =Dech-Manna Compositions=-- No. 1. Plasmogen--(Plasma Producer), 172 No. 2. Lymphogen--(Lymph-cell producer), 176 No. 3. Neurogen--(Nerve-cell producer), 179 The Ignorance of "Nerve Specialists", 180 Consequent Increase of Insanity, 180 A Complacent Public, 181 Neurasthenia, 181 No. 4. Osseogen--(Bone cell Producer), 182 Deformity of Bone Structure, Curvature of the Spine, etc., 183 The Lime-water Fallacy and Others, 183 "Fire proof" Bone Structure, 183 No. 5. Muscogen--(Muscle-cell Producer), 184 Combination with Eubiogen (No XII), 185 No. 6. Mucogen--(Mucous Membrane-cell producer), 186 Pervading Importance of Membrane, 186 Catarrhal Conditions of Tissues No. 7. Dento & Ophthogen--(Tooth & Eye cell Producer), 187 Connection Between Teeth and Eye, 189 No. 8. Capillogen--(Hair-cell Producer), 189 Causes of Falling Hair, 190 Prevention of Baldness, 190 Failure of "Hair Restorers", 190 No. 9. Dermogen--(Skin-cell Producer), 191 The Fallacy of Dermatology, 192 No. 10. Gelatinogen--(Gelatigenous-tissue Producer), 193 The Functions of Expansion and Contraction, 193 No. 11. Cartilogen--(Cartilage Producer), 194 Prevention of Friction, Bones and Joints, 194 No. 12. Eubiogen--(Healthy Life Producer), 196 Positive Composition, 196 Eulogy of Eubiogen, 196 Analysis of Eubiogen, 201 3 Forms of Eubiogen, 204 Special Composition B Alternative for Infants and Feeble Invalids, 204 Comparative Analysis Human Body and Eubiogen, 206 =Appendix I=, 207 Life Preservers and Elixirs, 207 =Special Dech-Manna Compositions=, 207 A. Oxygenator (Radium Tablets), 207 Balneotherapy-directions, 208 B. Eubiogen Liquid. For babies and feeble invalids, 209 C. Tonogen--Tonic and Beverage, 210 Universal Scope and Effectiveness, 211 Combination with Plasmogen, 212 =Appendix II=, 213 =Compositions for Specific Cases=, 213 D. Tea, Diabetic, 213 E. Tea, Laxagen, 213 F. Salve, Lenicet, 213 G. Massage Emulsion, 213 H. Propionic Acid, 213 I. Oxygen Powder, 213 J. Anti phosphate or Negative Compound, 213 Price list Dech-Manna Compositions, 214 Physical Treatment, 215 Baths and Packs--Vinegar Water, 215 Massage and Exercises, 216 Importance of Ablutions, 216 The Habit of Gargling, 220 Vinegar Packs--Their Significance and Basis, 220 Effect of the Packs, 226 Temperature, 226 Construction of Packs, 227 Length of Application, 227 Danger of Ice Applications, 228 Excretion of Auto toxins, 230 Dissolving, Diverting, Excreting, 230 General Treatment of Body, 232 The Key to Success, 232 General Advice for Packs, 232 Measurements for Material, 233 Temperature of Packs, 234 Duration of Packs, 235 Changing the Packs, 236 General Rules, 237 "Diverting Packs" Important, 237 The Main Rule, 238 24. Abdominal Pack, 238 Divided Packs, 241 25. The Cross Pack, 242 26. Leg Packs, 244 Partial Packs, 245 Foot and Wrist Packs, 246 Neck Pack, 247 Shoulder Pack, 248 Scotch Pack, 249 Divided Scotch Pack, 250 Shawl Pack, 251 27. Three quarter Packs, 252 Half Pack, 255 Whole Pack, 255 Small Compresses, 257 28. Gymnastics, 258 29. Massage, 258 30. Breathing, 258 Electric Vibrators, 260 31. Oxygenator, 261 32. Radium and Salt Baths, 261 Diseases, Treatment and Method, 262 I. Degeneration of the Plasmo Tissue, 263 Anaemia, Chlorosis, Pernicious Anaemia, 263 A. Scrofulosis, 266 B. Tuberculosis, 266 C. Syphilis, 266 D. Cancer, 267 Therapy, 267 Diet I. For Anaemic Patients, 267 I. & II. A. For Scrofulous Patients, 269 I. & II. B. For Tuberculous Patients, 270 I. & II. C. For Syphilitic Patients, 271 I. & II. D. For Cancer Patients, 271 Dech-Manna Compositions, 271 Physical, 272 II. Degeneration of Lymph Tissue,272 III. Degeneration of the Nerve Tissue, 273 Neuralgia Neuritis, Neurasthenia, 274 Asthma Epilepsy St Vitus's Dance, 274 Therapy, 275 Dech-Manna Compositions, 277 Physical, 277 IV. Degeneration of the Bone Tissue, 277 Rickets Osteomalacia and Similar Diseases, 277 Therapy, 278 Diet, 278 Dech-Manna Compositions, 279 Physical, 279 V. Degeneration of the Muscular Tissue, 280 Muscular Rheumatism, Sciatica, 280 Infantile Paralysis, Atrophy, 280 Amyloid Organs, 280 Therapy, 281 Diet, 281 Special Diet For Disease of Heart and Inactive Kidneys, 282 For Irritable Kidneys and Diseases of the Bladder, 285 For Liver Disease, 286 Dech-Manna Compositions, 287 Physical, 287 VI. Degeneration of the Mucous Membrane Tissue, 288 Catarrh, Acute and Chronic, 288 Bronchitis, Pleurisy, Pneumonia, 288 Inflammation of Nose Throat, Bowels, Stomach and Bladder, 288 Decomposition of Mucous Membrane, 288 Hemorrhoids, Polyps Benign Tumors, 288 Bright's Disease, Initial Stages, 288 Therapy, 289 Diet, 290 For Throat and Larynx Disease, 290 Dech-Manna Compositions, 290 Physical, 290 VII. Degeneration of Tooth and Eye Tissue, 291 Therapy, 292 Dech-Manna Compositions, 292 Physical, 292 VIII. Degeneration of the Hair Tissue, 292 Therapy, 293 Diet, 293 Dech-Manna Compositions, 293 Physical, 293 IX. Degeneration of the Skin Tissue, 293 Therapy, 295 Diet, 295 Dech-Manna Compositions, 295 Physical, 295 X. Degeneration of the Gelatigenous Tissue, Stomach & Intestinal Disease, 295 Therapy, 296 Diet, 296 Normal Diet for Stomach Diseases, 297 General Hints for Nourishing Treatment, 298 Treatment, 298 In case of Constipation, 299 Dech-Manna Compositions, 299 Physical, 299 XI. Degeneration of the Cartilagenous Tissue, 300 Ankylosis. Gout. Arthritis, 300 Therapy, 300 Diet, 300 Dech-Manna Compositions, 300 Physical, 300 XII. Degeneration of the Body Tissue in General, 301 Infantile Paralysis, 303 Facial Diagnosis and "The Clinical Eye", 306 Diagnosis, Physiognomy and Psychology, 308 The Biological Healing System, 308 The Psychological Side, 308 Regeneration and Retrogression, 309 The True Physician's Principle, 309 External Symptoms, 310 Perspiring Hands and Feet, 310 Quality of the Nails, 311 Baldness, Gray and Dishevelled Hair, 311 The Evidence of the Eyes, 312 Prof Liljequist on the Colour of the Eyes, 312 The Shades of Death, 313 Testimony of the Mouth and Tongue, 313 Indications of the Nose, 314 Diagnosis by Odour, 315 Story of the Teeth and Gums, 316 Demonstrations of the Neck, 317 Significance of Chest Formation, 317 Signs of the Abdomen, 317 Indications of the Legs, 317 Indications of the Skin, 318 Freckles, 318 Chemical Construction, 318 Prevention and Cure, 319 Simple Precautions, 319 Children's Disease. Introduction, 319 The Cause of "the Poor", 319 The Child of Mortality, 319 Parental Egotism and Pedagogy, 323 Maternal Solicitude--and Ignorance, 320 Vital Statistics, 324 O Tempora! O Mores!, 325 The World's Indifference to Truth, 326 For the Understanding of Disease--the sine qua non, 326 Back to Nature, 326 "The Age of Nerves", 327 Medical Polemics, 327 "Existence is Movement"--Progress, 328 Man, the Sceptic, 328 The X-Rays and the Sequel, 329 The Atom and the Electron, 330 "Man's Passing Strange, Complex Mortality", 332 The Vibrations of Electrons, 332 Electro-Magnetic Control, Mundane and Solar Forces, 333 The Ocean a Storage Battery, 333 The Action of Acids and Alkalies, 334 Electro-Magnetic Processes and Metabolism, 335 Weather and Local Influences, 336 Negative and Positive Vibrations, 337 Healthy Blood Formation, 338 Dech-Manna Diet, 338 Electrons and the Effect of Injury, 339 Bacteria, 340 Febrile, or Positive Diseases, 340 Curative Process, 341 The Law of Opposites, 341 Action of Water, 341 Action of Earth on Mud, 341 Vinegar Packs, 342 Cooling Drinks, 342 Temperature Reduction, 343 Negative Diseases, 344 Curative Process, 344 Sun Baths, Light Baths, 344 Exercise, 345 Massage, 345 Coloured Light Treatment, 346 Internal Treatment, 346 The Salts of the Body, 346 Nourishment, 347 The Science of Food, 347 Diet, 348 Food Standard, 348 Heat Production, 348 Discretion in Diet, 348 Diet of Children in General, 349 Diet for School Children, 351 Fever and its Treatment Based on Biology, 354 A. General Description, 354 B. Treatment, 357 C. Diet in Cases of Fever, 362 Scarlet Fever, 367 Measles, 371 German Measles, 372 Chicken-pox, 373 Small-pox, 374 Typhoid fever or typhus abdominalis, 375 A. General Description, 375 B. Essentials, 376 C. Symptoms and Course, 377 Stage of Development, 378 The Climax, 378 Stage of Healing, 378 Respiratory Organs, 381 Organs of Circulation, 381 Nervous System, 381 Bones and Joints, 382 Urinary and Sexual Organs, 382 Skin, 382 Recurrence, 383 D. Treatment, 384 Mental condition, 385 E. Relapsing fever (Typhus Recurrens), 386 F. Diet in Cases of Typhus, 387 Dech-Manna compositions, 392 Physical Treatment, 392 Negative Children's Disease (so called), 393 Catarrh, 393 Bronchitis, 393 Grippe, 393 Influenza, 393 Catarrhal Inflammations, 393 Cholera Infantum or Summer Complaint, 393 Therapy, 393 Physical Treatment, 394 The Contagious Character of Children's Diseases, 394 The Golden Rule, 395 Diet, 395 Dech-Manna Compositions, 395 Physical Treatment, 396 The Tonsure of the Tonsils, 396 A Strong Indictment, 396 American and English Corroboration, 397 Arguments Against Tonsillotomy, 397 A Medico-cum parental craze, 398 Prof Mackenzie's Denunciation, 398 Maternal Ineptitude, 399 Wild and Incontinent Superstitions, 400 Operators and Their Teachers, 400 Facts and Fables, 401 A "Lazy and Stupifying Delusion", 402 The "Roll of Unrecorded Death", 402 A trenchant and Tragic Article, 404 The True Mission of Tonsils, 405 Pre-natal Care, 405 Pre-natal Clinics, 405 Human Magnetism, 405 Hygienic Birth, 406 Endemic and Epidemic Disease, 406 Climatic, or Yellow Fever, 407 Pellagra, or Hook worm, 407 Cholera and Plague, 408 The Spanish Influenza, 409 The World's Great Pandemics, 410 Terminological Notes, 410 Fundamental Causes, 410 Sero Therapy, or the Illusive Germ Theory, 412 The Alternative Origin, 412 The Attitude of the Public, 413 The History of the Influenza Germ, 413 Culture and the Manufacturing Chemist, 413 The Great Experiment, 413 The Dictum of Surgeon Genl. Blue, 414 Serums and Specifics, Hospitals and Undertakers, 415 Opinions of the Press, 416 The Parting of the Ways, 417 George Bernard Shaw's Views, 418 Public Health Reports, 419 Raising the Resistance of the Body, 419 The Vis Medicatrix Naturae, 421 St Paul, on the Unity of the Body, 421 The Cause of Medical Failure, 421 The Law of the Minimum, 423 The Sixteen Essentials, 423 Prof Kuhnemann, on the Influenza, 424 The Interpretation, 427 The Professor and the Shy Bacillus, 428 The Vision of the Vagus Nerve, 429 Its Vast Responsibility, 431 Three Nutritive Possibilities, 432 The Emotions as Factors of Disease, 432 "Panasthema," the General Loss of Vitality, 434 The Seat of Affection in the Vagus, 435 "The Writing on the Wall", 437 Demos Dies by Violence, 438 Nature's Trust Betrayed, 438 The Law of Compensation, 438 A Great Scientific Discovery, 440 Finis 440 ERRATA IN VALERE AUDE Page 6, line 28 from top read, Sinai's 19, line 5 from top read, continents 134, line 10 from top read, adenoids 149, line 9 from top read, haemoglobin 149, line 27 from top read, fluorine 150, line 6 from top read, a comma after 'itself' 152, line 5 from top read, tumors 152, line 20 from top read, grams 156, line 34 from top read, two of ammonium 156, line 45 from top read, ammoniacal 157, line 44 from top read, phosphate of ammonium 161, line 44 from top read, avidity 166, line 7 from top read, fluorine 182, line 9 from top read, organic lime 186, line 14 from top read, indispensible 187, line 1 from top read, dimensions 192, line 17 from top read, the patient 200, line 22 from top read, vain 201, line 16 from top read, sinews 223, line 1 from top read, oxygenous blood 244, line 22 from top read, leg 261, line 6 from top read, allow him to extend the area 276, line 27 from top read, Alcohol and alkaline 279, line 11 from top read, legumes 281, line 3 from top read, Amyloid degeneration 301, line 31 from top read, space at my disposal 315, line 20 from top read, the hypochondriacal 365, line 16 from top read, Form III comprises 409, line 34 from top read, social cataclysm. 414, line 37 from top read, consensus. 423, line 36 from top read, chlorine. 427, line 21 from top read, to numbness in the nerve. 429, line 35 from top read, more unmistakably. 430, line 31 from top read, nerve substance lecithin. 438, line 16 from top read, hypnotized complacency. 440, line 12 from top read, Hygienic-Dietetic. [Transcriber's Note: The items on the list of Errata have been corrected in the text.] 
46356	----	Issued April 4, 1912. U.S. DEPARTMENT OF AGRICULTURE, BUREAU OF CHEMISTRY--BULLETIN No. 148. H. W. WILEY, CHIEF OF BUREAU. THE TOXICITY OF CAFFEIN: AN EXPERIMENTAL STUDY ON DIFFERENT SPECIES OF ANIMALS. BY WILLIAM SALANT, _Chief Pharmacological Laboratory, Division of Drugs_, AND J. B. RIEGER, _Assistant Chemist_. [Illustration: UNITED STATES DEPARTMENT OF AGRICULTURE SEAL] WASHINGTON: GOVERNMENT PRINTING OFFICE. 1912. LETTER OF TRANSMITTAL. U. S. DEPARTMENT OF AGRICULTURE, BUREAU OF CHEMISTRY, _Washington, D. C., November 14, 1911_. Sir: I have the honor to submit for your approval a manuscript on the toxicity of caffein, which is the first of a series of reports to be made by Dr. Salant on the pharmacology of this drug; the conclusions here reported are, therefore, in some particulars to be regarded as tentative. The data obtained are primarily of use in the execution of the food and drugs act, but are capable of much broader application. Acknowledgment is made of the assistance rendered by Dr. John R. Mohler, Chief of the Pathological Division, Bureau of Animal Industry, and his assistants, in performing the autopsies recorded in this report. I recommend the publication of the manuscript as Bulletin No. 148 of the Bureau of Chemistry. Respectfully, H. W. WILEY, _Chief_. Hon. JAMES WILSON, _Secretary of Agriculture_. This publication may be procured from the Superintendent of Documents, Government Printing Office Washington, D. C., at 15 cents per copy CONTENTS. Page. Introduction 5 Historical review of the literature on the toxicity of caffein 9 Acute caffein intoxication 18 Experiments on rabbits 18 Subcutaneous injection 18 Administration by mouth 26 Injection into the peritoneal cavity 28 Intramuscular injection 33 Intravenous injection 37 Summary 42 Experiments on guinea pigs 43 Subcutaneous injection 43 Injection into the peritoneal cavity 47 Administration by mouth 49 Summary 52 Experiments on cats 53 Subcutaneous injection 53 Injection into the peritoneal cavity 56 Administration by mouth 57 Summary 59 Experiments on dogs 60 Administration by mouth 60 Subcutaneous injection 60 Experiments on puppies 61 Summary 62 Chronic caffein intoxication 63 Experiments on rabbits 63 Experiments on dogs 75 Discussion of results 91 General summary and conclusions 95 Bibliography 97 THE TOXICITY OF CAFFEIN. INTRODUCTION. Comparative physiology has established the fundamental fact that some properties are common to all forms of living matter. But the same method of inquiry has also led to the recognition of marked differences in the physiological processes of various species of animals. Among the most important investigations which contributed to the knowledge of such variation of function are the studies in comparative metabolism. It is now recognized that metabolism is in some respects quite different in herbivora and in carnivora. Some forms of oxidation are much greater in the rabbit than in cats and dogs. Nuclein metabolism presents important differences in the rabbit and in man, while the mode of neutralizing acid in the body may be cited as another variation in the metabolism of these forms. Perhaps the most striking examples of differences in the metabolism of different organisms is furnished by the results of studies on the fate of certain poisons introduced into the body. The classical experiments of Bunge and Schmiedeberg(15)[A] on the synthesis of hippuric acid are of interest in this regard. It will be recalled that in the dog the synthesis takes place in the kidney; the rabbit is able to form hippuric acid in the liver as well as in the kidney, while frogs can synthesize hippuric acid even when both of these organs have been removed or excluded from the circulation. Observations on the fate of some of the alcohols of the fatty acid series have likewise shown that these substances may be combined with glycuronic acid in some animals but not in others. According to Thierfelder and Von Mering,(84) tertiary alcohols are combined in this manner in the rabbit but not in the dog. According to Neubauer,(64) the primary and secondary alcohols are so combined in the dog as well as in the rabbit, but to a greater degree in the latter. [A] The small figures refer to the bibliography at the end of this bulletin. Pohl(73) found that amyl alcohol is largely eliminated by the lungs in the cat and in the dog. The protocols of his experiments show that 65 per cent of the alcohol given these animals was thus recovered, while he recovered only 22 per cent of this substance in the expired air of the rabbit. Examination of the urine showed the presence of glycuronic acid. Hofmeister's(37) work with tellurium in the dog is of interest in this connection. He made the important discovery that some animals possess the power of methylation as well as of demethylation. Abderhalden and Brahm's(1) experiments with pyridin show that the same is true of young dogs when on a meat diet. His experiments on rabbits with this substance were negative. The metabolism of caffein and theobromin furnish another illustration of differences in the physiological mechanism of animals. Although the substances found in the urine of man, dog, and rabbit after the administration of caffein and theobromin were the same, the quantities varied considerably. According to Krüger and Schmidt,(47) over 14 per cent of the theobromin introduced into the rabbit is eliminated as 7-methyl xanthin in the urine. The dog eliminates only about 0.67 per cent. On the other hand, the amount of tri-methyl xanthin eliminated was only 3 per cent in the dog and not quite 1 per cent in the rabbit. It appears, therefore, from studies in comparative metabolism, whether endogenous or exogenous, that well-marked physiologic and chemical differences exist in various species of animals. That pharmacological action may likewise vary in different species of animals is shown by the following investigations. According to Guinard,(31) who made an exhaustive study of morphin, the reaction to this alkaloid varies in different forms of life, both qualitatively and quantitatively. He established its narcotic effect in the dog, rabbit, guinea pig, white mice, and rats, while for the cat, horse, ox, sheep, hog, and goat it is, on the contrary, a stimulant. Moreover, there is no evidence of cerebral effect. The stimulating effect of morphin on the nervous system in some animals was also observed by Noe(65) in experiments with this substance on the hedgehog. Guinard(29), (30) has also shown that morphin has no narcotic effect in the marmot, although this animal is very sensitive to the drug. Two milligrams per kilo were found to be a surely fatal dose for this animal. His experiments on the comparative toxicity of morphin(30), (31) show a considerable range of variation in different species. Thus the fatal dose for the dog was found to be 0.65 per kilo, while 7 mg per kilo is the fatal dose for the horse. About twice the amount is fatal for the ox and 0.2 mg per kilo kills the pig. Experiments with other drugs has shown that a considerable range of variation in resistance exists in animals of different species. Noe's(65) studies on the comparative toxicity of chloral brought out the interesting fact that the rabbit is more resistant to it than the hedgehog and the latter more resistant than the guinea pig. Perhaps the most striking example of a difference in reaction of the same substance in widely different species is that furnished by apocodein, quinin, and yohimbin. According to Gunn(32) these substances have been found to cause vasodilation in warm-blooded animals, but they constrict the blood vessels of the frog. Experiments with apomorphin likewise show that the reaction to this substance varies in different species of animals. The resistance of the cat to this drug is, according to Guinard(31), ten times greater than that of the dog, and the latter is more sensitive than the rabbit to the crystalline form of apomorphin when given intravenously. According to Kobert(45) amygdalin is without effect on dogs, but it is poisonous to rabbits. Lapicque(49) found that the toxicity of curara varies in different species of frogs, the dose required to produce paralysis in _Rana esculenta_ being three times greater than in _Bufo vulgaris_. Weir Mitchell(59) pointed out long ago that turtles stand enormous doses of curara. Schmiedeberg's experiments with caffein on _Rana temporaria_ and _Rana esculenta_ (and more recently those of Jacobi and Golowinski(42) with caffein, theobromin, and theophyllin) are also of interest in this connection. These experimenters observed well-marked differences of reaction to methyl-xanthins in these closely allied forms. Experiments with quinin have shown that the action of this substance differs in some animals. It causes a fall of temperature immediately after its administration in the guinea pig, but frequently produces, at first, a rise of temperature, followed by an unimportant fall, in rabbits, dogs, and man. The numerous investigations which have been carried out on the effect of atoxyl within recent years have contributed much to the comparative pharmacology of this substance. Although the symptoms and organic changes produced by this substance in a variety of animals present no great differences, the resistance of some has been found to vary; according to Köster(46) it is more toxic for dogs than for rabbits. A number of other substances have been found by various experimenters to vary in toxicity for different species of animals. Cantharadin, phenol, atropin, and strychnin may be mentioned as illustrations. Pharmacological studies on lower forms of life have also revealed marked variations in the effect of some poisons. Observations made by Danilewski(18) with hydrochinone indicate that solutions of 1 to 100 or 200 are toxic to Celentrates, causing paralysis in these organisms. Echinoderms are killed within one or two hours in 1 to 1,000 or 2,000 solution, while in Vermes even weaker solutions cause tetanus and finally paralysis. The experiments of Drzewina(19) with potassium cyanid are also interesting in this connection. Teleosts placed in 100 cc of sea water containing twentieth-normal potassium cyanid showed signs of asphyxia and died in 10 to 20 minutes. Actinia placed in a solution of sea water containing five times as much potassium cyanid were active on the thirteenth day of the experiment. Similar results were obtained with other marine organisms. From these data it is evident that the toxicity of a substance may vary considerably in different forms of life. It has been shown also by some investigations cited by Salant(78) that the action of drugs may be modified by different conditions in the environment as well as in the subject of the experiment. The recognition of the importance of these factors in determining pharmacological action has contributed much to the elucidation of the mechanism by which drugs and other substances produce physiological effects in the body. Moreover, such knowledge has often enhanced the therapeutic value of pharmaco-dynamic agents and has frequently served to avert effects of an undesirable character in man and domestic animals. The results obtained in one species of animals under a particular condition do not admit, therefore, of universal application. Furthermore, the nature of the action of a drug can only be partly learned from the manifestation of its acute effects. Equally important, therefore, especially in studies on toxicity, are the changes produced in chronic intoxication. That the acute effects of a substance can hardly be considered a correct estimate of its toxicity is shown by the evidence obtained in experiments on tolerance and cumulative action of drugs; for the toxicity of a substance may diminish when the substance is given steadily for a long time if the body acquires tolerance for it. Arsenic, morphin, and cannabis indica may be cited as illustrations of drugs, the toxicity of which decreases with repeated doses, while digitalis and lead show a tendency to increased toxicity when similarly administered. Moreover the acute and chronic effects are sometimes qualitatively different. According to Igersheimer(41) the symptoms in acute atoxyl intoxication are nausea, vomiting, and diarrhea. These symptoms are absent in chronic intoxication, in which trophic disturbances of the skin and inflammation of the mucous membranes were the effects produced. That the acute action of atoxyl differs from the chronic effects was likewise shown by experiments on animals. The studies of von Anrep(5) on chronic atropin intoxication are of interest in this connection, as he found that after 10 to 15 injections of atropin there is no manifestation of symptoms such as is observed in acute intoxication, while the effects on the circulation are also less marked, the acceleration of the pulse being less than after the same dose in a normal subject not accustomed to its use. When the administration of atropin is continued for a longer time its usual effects on the pulse disappear altogether; there is, on the contrary a decreased frequency of the pulse. If atropin has been administered for from two to three weeks, respiration is likewise affected. HISTORICAL REVIEW OF THE LITERATURE ON THE TOXICITY OF CAFFEIN. Caffein was discovered in 1820 by Runge,(77) Pelletier,(60) and Robiquet(75) and was first analyzed by Dumas and Pelletier,(20) but its exact percentage composition was determined by Pfaff and Liebig,(71), (72) while to Herzog (13), (18) belongs the credit of having established that it is basic. Strecker(82) prepared caffein synthetically by heating theobromin silver and methyl iodid in a closed tube for 24 hours. Soon after its discovery in coffee Oudry(67) reported the presence of a substance in tea which he called "thein." Its identity with caffein was established 15 years later by Jobst(43) and also by Mulder.(62), (63) According to Brill,(13) Mulder (1838) was also the first to perform experiments with caffein on animals. After the administration of one-half grain to a pregnant rabbit he observed loss of appetite and kyphosis. The rabbit aborted but recovered from the effects of caffein. It has since been made the subject of numerous investigations which were carried out on a variety of animals. Observations with caffein were also made on the human subject. About four years after Mulder published his results, Lehmann(51) (1842) reported experiments on a number of people who were given caffein. The administration of from 2 to 10 grains of the alkaloid was followed by headache, palpitation of the heart, increased frequency and irregularity of the pulse, tinnitus aurium, photopsia, insomnia, and even delirium. Similar experiments reported by Frerichs(25) (1846) indicate that in doses of 25 grains it may induce severe symptoms about 15 minutes after its administration. He also observed circulatory as well as nervous symptoms and vomiting. According to Albers(2) (1852), 4.5 grains of caffein citrate injected subcutaneously into the thigh of a rabbit was soon followed by diminished motion and tremors of the operated thigh. Other symptoms reported were spasms of the facial muscles, increased respiratory movements, and mental confusion. Of interest in this connection are the experiments of Cogswell(17) (1852) on frogs. He concluded that in point of destructive action on the tissues, caffein is far superior to morphin and may be compared to strychnin and coniin, its action on the nervous system he believed to be principally confined to the effect on the brain and spinal cord. Lehmann(52) (1853) observed increased frequency of heart action after the administration of 4 grains, which were given with a normal diet to an adult man. When the dose was doubled the frequency of the pulse was still more increased, heart action became stronger, and tremors and confusion of thought with excitement of the imagination made their appearance. There was also an increased desire to micturate. Stuhlmann and Falck(83) (1857) were the first to make a study of the toxicity of caffein on animals of different species. The administration of 0.5 gram of caffein subcutaneously or per rectum in rabbits induced tremors, tonic and clonic convulsions, paralysis, and increased frequency of respiration at first followed by violent dyspnoea. On autopsy he noticed congestion of the organs and in two of the three rabbits experimented upon punctiform hemorrhages of the brain with congestion of the meninges were found. In the other rabbit anemia of the brain was observed. Experiments on cats were carried out by subcutaneous, intravenous, and rectal injections. The symptoms observed after the administration of 0.5 to 0.7 gram of caffein were the same as in rabbits except that the cats developed diarrhea when caffein was given and no anatomic lesions were found on autopsy. The effect of caffein on dogs indicated that in subjects of medium weight a dose of 0.5 gram given by mouth might produce restlessness and increased frequency of respiration, while the injection of the same amount intravenously into such animals may cause death. Large, full-grown dogs, however, survived an intravenous injection of 2 grams of caffein, showing symptoms of incoordination, salivation, and frequent defecation. These investigators also made observations on caffein, using pigeons and other birds; 0.5 to 0.1 gram introduced into the stomach caused vomiting, diarrhea, tonic, but more frequently clonic, convulsions, incoordination, tremors, paresis, and paralysis. In a few, but not in all of the birds, there was at first increased frequency of respiration followed by dyspnoea and circulatory disturbances. These amounts of caffein proved fatal in all of the experiments on birds. Inflammation of the intestinal mucosa and congestion of the meninges were the only changes found on autopsy. Stuhlmann and Falck also studied the effects of caffein on fishes and toads. Mitscherlich(60) (1858) fed 0.4 gram of caffein with bread to a rabbit and noticed lowered temperature, fatigue, convulsions, first increased then decreased frequency of respiration, and on autopsy congestion of all the viscera. He also reported observations on two frogs, one of which was given one-sixteenth of a grain of caffein in a pill with bread. It was administered to the other frog in aqueous solution, but the mode of administration was not published. The symptoms observed were in the main the same as in rabbits. In pigeons 0.125 gram introduced into the stomach caused severe vomiting, muscular incoordination, tonic rigidity of the limbs, and retraction of the head. Respiration was increased in frequency. Death followed within 3 hours and 15 minutes. From a series of experiments on frogs which Hoppe(38) carried out (1858) by applying one-fourth of a grain of caffein to the muscles of the back, he concluded that caffein causes paralysis of the nerves, spinal cord, and brain, sensation being paralyzed before movement. The injurious action of caffein proceeds, according to Hoppe, from the spinal cord. This was based on experiments on two frogs, _Rana esculenta_, in which the right leg was amputated, the nerve being left intact, while the nerve of the other leg was ligated. At the end of 30 minutes paralysis was more marked on the right than on the left side. In another frog of the same species he resected the femoral nerve on the right side; about 1½ hours after the administration of caffein convulsions were observed. The left leg was rigid, but the right was relaxed. Voit(85) (1860) ligated the vessels of the right lower extremity, cut the nerves of the left leg, and introduced a few drops of caffein solution into the stomach. Shortly afterwards tetanus of the right leg occurred on touching the back of the animal; the left leg was motionless. Later the entire body exhibited tetanic convulsions. From this and similar experiments Voit concluded that caffein acts first and principally on the central nervous system, and that caffein is also poisonous to nerve and muscle fibers, as they die when a solution of caffein is applied to them. The action of caffein, according to Voit, is similar in great part to that of strychnin. The effect on the blood vessels is particularly interesting, as Voit observed dilatation of the vessels, due as he thought to muscular paralysis, and also transudation and congestion of the capillaries. Kurzak(48) (1860) made a study of the comparative toxicity of caffein in frogs and rabbits and came to the conclusion that the lethal dose for frogs is about one-seventh of that for rabbits. Caffein citrate in the form of crystals was administered in both cases by mouth. The doses given to frogs were 1 to 1.5 grains. He observed convulsions and increased respiratory activity at first; after one hour respiration diminished and voluntary muscular activity disappeared. Even on the second day convulsions were sometimes noticed. Death occurred at the end of the first or second day. Experiments on only two rabbits were reported, 0.8 gram of caffein citrate causing the death of one at the end of 13 hours. The symptoms noticed were the same practically as in frogs, but it is interesting to observe that ecchymosis of the mucous membranes of the stomach near the cardia was the only lesion found on autopsy. Several experiments made on different days on the other rabbit indicated that the toxic dose exceeded 0.5 gram, while smaller doses caused but very mild symptoms. According to Gentilhomme(27) (1867), after caffein the reflexes are at first diminished and then disappear altogether. Death is produced by stiffness and immobility of all the muscles, particularly of the muscles of respiration, thus causing asphyxia. He furthermore held that caffein has no effect on cardiac or smooth muscle fiber, its action being specific on voluntary muscle fiber, contractions of which he observed under the microscope, thus differing completely from strychnin, which is a nerve poison. These observations seemed to be confirmed by Pratt(74) (1868), who reported that the isolated posterior extremities and muscle fibers of the toad placed in a solution of caffein (1 grain to a wineglassful of water) for three minutes were contracted, while controls placed in distilled water were relaxed. This experiment is, of course, defective, as normal salt solution should have been used in both cases. When the muscular fibers previously immersed in caffein solution were placed under the microscope violent contractions were observed. The same author administered from 2 to 18 grains at a dose to five healthy young men. After the administration of 12 grains he noticed mental anguish, tremors of the hands and arms, and insomnia. Doses under 5 grains had no marked effect except a diminution in the frequency of the pulse and wakefulness. About the same time Amory(4) (1868) published the results of his studies on the toxicity of caffein in cats, dogs, rabbits, and pigeons. In all cases very large doses were introduced directly into the stomach by means of a temporary gastric fistula. Ten grains given in meat to a dog caused restlessness, but no other symptoms. Doses of 30 grains and above were invariably fatal. Seventy-three grains given to a cat caused death within 20 minutes. From observations on frogs, guinea pigs, rabbits, and on one dog, Leven(53) (1868) concluded that caffein which he gave in the form of the citrate in doses of 10 mg to frogs, from 150 to 200 mg to guinea pigs, and three to four times the latter amount to rabbits, stimulates the central nervous system and the voluntary, cardiac, and smooth muscles. He found that 0.9 gram caffein was fatal for a rabbit when injected subcutaneously, while 1 gram of the citrate was not toxic for a dog of medium size. Caffein applied directly to muscle fiber causes tetanus and destroys muscular contractility, while a nerve fiber similarly treated loses its irritability. According to Johansen(44) (1869), caffein acts directly on the muscular fiber. After the subcutaneous injection of 0.02 gram of caffein into frogs, he observed contraction of the muscles at the site of injection, then contraction of the anterior extremities, and finally the posterior extremities become rigid and extended. Johansen observed muscular rigidity after caffein, even after curara was injected, or after ligating the vessels, or cutting the nerves which supply the muscles. He also observed that large doses of caffein diminish muscular irritability. When cardiac muscle was poisoned with caffein, microscopical examination showed that the striations disappeared. Johansen also states that reflexes disappear after caffein poisoning. He never observed tetanus in frogs, but reported tonic and clonic convulsions as a result of caffein poisoning in mammals. Somewhat different effects of caffein in frogs were observed by Buchheim and Eisenmenger(14) (1870). After the injection of 2 per cent of the citrate the frogs soon become inactive. He also observed muscular twitching of the extremities, which gradually increased, with rigidity of the muscles and opisthotonos, while respiration became slow and superficial, finally stopping altogether. Aubert(6) (1872) studied the toxicity of caffein in man and other animals. After the ingestion of 0.36 gram, he observed dizziness, but doses of 0.12 and 0.24 gram were without any apparent effect. On the other hand, a dose of 0.5 gram of caffein was followed by increased frequency of the pulse, which soon disappeared. After one hour he noticed dizziness and trembling of the hands, which likewise passed away soon. The injection of 0.16 gram of a 2 per cent solution of caffein into the jugular vein of a rabbit weighing 1,090 grams caused tetanus and death in two and one-half minutes, and 0.12 gram injected into a rabbit weighing 980 grams caused death in one minute. Much larger doses could be borne, however, when artificial respiration was resorted to. A dog which was given 3 grams of caffein survived when artificial respiration was performed. Aubert reports, on the other hand, a similar experiment with 0.25 gram of caffein which terminated fatally. That caffein may give rise to different effects in various species of animals was observed for the first time by Bennett.(9) He studied its action on frogs, mice, rabbits, and cats, and attempted to determine the minimum fatal dose in rabbits and cats. He also reported experiments with thein. In his first communication on the subject he states that the administration of thein to rabbits first increased and then diminished the frequency of respiration, while the pulse was decreased in frequency. Caffein, which he apparently thought was different from thein, caused increased frequency of respiration, while the pulse was markedly retarded after a preliminary acceleration. He also noticed congestion of the ears, muscular incoordination, tetanus, paralysis, diminished reflexes, and contraction of the pupils. Bennett reported the minimum fatal dose of caffein for a rabbit weighing 3.25 pounds as being 5.25-5.5 grains. The symptoms in cats after the administration of toxic doses of thein or of caffein were great excitement, paralysis alternating with convulsions, and profuse salivation. The minimum fatal dose for a cat weighing 5 pounds was, according to Bennett, 6 grains of caffein and 5.5 grains of thein. Only one experiment on a mouse is reported; the administration of 0.1 grain proved fatal. The symptoms were the same as those observed in cats and rabbits after the administration of caffein. The experiments on frogs indicate that the symptoms were about the same as those previously described in the case of warm-blooded animals except that the reflexes are almost completely lost after the subcutaneous injection of doses of one-sixteenth to one-twelfth of a grain. The latter dose was fatal for frogs. It would be of interest to know the comparative toxicity of caffein to frogs and mammals, but unfortunately the weights were not reported. Schmiedeberg(79) (1874) noticed that the administration of 20 mg of caffein to frogs weighing about 45 grams was followed, in _Rana esculenta_, in about 25 minutes, by increased reflexes, 7 minutes later by tetanus. Several attacks occurred, but tonic spasms were never observed. On the contrary, when the same amount of caffein was given to _Rana temporaria_ weighing 45 grams he noticed a marked diminution of the reflexes and tonic rigidity of the muscles after 23 minutes; the reflexes were greatly increased, however, about 24 hours later. The frogs were under observation for three days, and although symptoms were still present at the end of this time in the subjects of both species tetanus was never observed in _Rana temporaria_. Peretti's(70) (1875) studies on the effects of caffein were confined chiefly to observations on dogs. He also made observations on a few rabbits and reported an experiment on one cat to which he administered, by subcutaneous injection, 0.18 gram of caffein per kilo and noticed increased frequency in lachrymation and crying. The cat was found dead the next day. The subcutaneous injection of a rabbit in which artificial respiration was instituted with 0.36 gram of caffein per kilo proved fatal soon after the injection without any manifestation of symptoms. Small doses of caffein, 0.1 gram, given to a rabbit weighing 3,670 grams, failed to produce any visible effects. Doses under 0.1 gram per kilo likewise failed to induce any symptoms in dogs. When 0.1 gram of caffein per kilo was given by mouth or subcutaneously it was followed by restlessness, salivation, rigidity of hind legs, and vomiting. In both instances the dogs recovered. The symptoms were more severe when the dose was increased to 0.185 gram per kilo, but even in this case the dog recovered. A dose of 0.2 gram per kilo, however, proved fatal. Henneguy(36) (1875) experimented on three frogs to which he gave 0.01 gram of caffein citrate subcutaneously. He observed mild stimulation of the nervous system and of the muscles, as well as increased cardiac activity. Later, voluntary movement and respiration disappeared and sensations diminished, but convulsions of the extremities appeared. Cardiac activity was then diminished, the heart being finally arrested in systole. Since the motor nerves retained their irritability even after the reflexes disappeared, he concluded that the loss of motion was due to the action of caffein on the nerve centers. Binz(11) (1878) reported experiments on dogs and also made some observations on man with caffein. The subcutaneous injections of 0.2 gram caffein may prove fatal to dogs, although some survive such a dose. The toxic dose in man varies from 0.5 to 1.5 grams. Disturbance of the circulation, such as palpitation of the heart and fullness of pulse, restlessness, and diarrhea were the symptoms he observed. Extensive investigations on the action of caffein were carried out by Leblond(50) (1883), who studied its effect on the circulation in man and lower animals, and its toxicity in the lower animals alone. Five to twenty centigrams of caffein and 0.06 to 0.25 gram of salicylate of soda were dissolved and injected into the muscles of the thigh of young guinea pigs weighing a little over 300 grams. In the three experiments reported the death of the animals occurred after 23 minutes, 40 minutes, and 1 hour and 20 minutes. Symptoms appeared in from 10 to 15 minutes after the injection of caffein. Incoordination of movements, convulsions, both tonic and clonic, opisthotonos, tremors, increased frequency of respiration, ataxia, paralysis were the symptoms observed. It is worthy of note that the appearance of paresis preceded the convulsions. Diminished sensation was reported in one pig, but no sensory disturbances nor reflexes had been observed in the other. Two rabbits, one of which received 0.5 and the other about 0.3 gram of caffein per kilo with equal parts of salicylate of soda, were injected subcutaneously into the thigh. Diminished sensation, paresis of the posterior extremities, hyperexcitability, convulsions, opisthotonos, dilation of the veins of the ear were observed. Death followed in 1 hour and 23 minutes in one rabbit and in 3 hours and 7 minutes in the other. Filehne(22) (1886) experimented with caffein on _Rana esculenta_ and _Rana temporaria_. The subcutaneous injection of 7 mg of caffein into _Rana esculenta_ caused tetanus, while 50 mg given by mouth caused tonic spasms. He further stated that the difference between _Rana esculenta_ and _Rana temporaria_ as regards the reaction to caffein was one of degree only. Amat(3) (1889) reported experiments on three guinea pigs, in which 0.4 to 0.5 gram per kilo injected subcutaneously proved fatal within 38 and 44 minutes. One guinea pig which received 0.1 gram of caffein per kilo survived. The symptoms observed in the two fatal cases were general muscular rigidity and convulsions. Parisot(68) (1890) made a study of the toxicity of caffein on different species of animals. Unlike most of his predecessors, however, he reported, at least in some cases, the weight of the animals on which he worked. After the subcutaneous and intramuscular injections of from 5 to 20 mg of caffein into _Rana temporaria_ weighing from 14 to 16 grams, he noticed increased irritability at first; later, a loss of reflexes, inability to use the muscles, complete muscular rigidity resembling rigor mortis, and also cessation of heart action. The effect of caffein produced in the green frog was analogous to that observed in strychnin poisoning. Parisot found, however, that muscular rigidity developed, although very gradually, also in the green frog, but it set in much later than in frogs of the other species and without superseding the clonic convulsions. According to Parisot, the muscular rigidity after caffein persists after the destruction of the brain and spinal cord, thus showing that it is not of nervous origin. He further emphasized the difference in the behavior of these two species of frogs toward caffein by stating that he never observed tetanic convulsions in the red frog. His experiments also indicate that the green frog is more resistant to caffein than _Rana temporaria_, as the same doses which are fatal for the latter were only toxic for _Rana esculenta_. The number of experiments, however, is too few to justify a positive conclusion on this point. Parisot also made some experiments on turtles. The results he obtained show that caffein is at least as toxic for these animals as for the frogs he experimented upon, 0.33 gram per kilo (carapace not included in weight) having proved fatal within 24 hours. Two experiments on one pigeon were also reported by the same observer; two doses of 0.06 gram per kilo given at an interval of four hours caused mental depression and muscular rigidity, but the pigeon survived. Experiments with caffein on the human subject made by Parisot showed that man is far more susceptible to this substance than the other animals he investigated. After the ingestion of 0.3 gram of caffein symptoms of intoxication pointing to cerebral disturbance appeared, which became more marked when the size of the doses was increased. It will be noticed that the nature of the action of caffein, whether it is a nerve or a muscle poison, formed the subject of several investigations. Binz(11) (1890) brought forward additional evidence in support of the view that caffein acts primarily on the ganglion cells, and not on the muscle directly. This he has shown by injecting 0.5 gram into each of two rabbits after cutting the sciatic nerve on one side; in one case he also resected the obdurator and crural nerves on the same side. Clonic spasms developed in both subjects soon after caffein was given, but in each rabbit the side operated upon remained paralyzed. Baldi(8) (1891) studied the action of caffein on _Rana esculenta_. After injecting from 4 to 20 mg tetanus, such as observed in strychnin poisoning, was noticed. Fröhner(26) (1892) made observations on the comparative toxicity of caffein in domesticated animals. After the administration of 5 grams of caffein sodium salicylate by mouth to a dog weighing 10 kilos, he noticed salivation, restlessness, vomiting, and convulsions as in strychnin poisoning. Death occurred three hours after the drug was given. On autopsy he noticed mild inflammation of the mucous membranes of the stomach and intestines and edema of the lungs; the heart was in diastole. A dose of 2 grams of caffein sodium salicylate given to the same animal subcutaneously two days previously provoked only very slight symptoms. The subcutaneous injection of 10 grams of the same preparation into a pig weighing 30 kilos caused death in two and a half hours, with the production of symptoms of disturbance of the nervous system and of gastrointestinal irritation. The same dose per kilo of body weight given to a goat likewise caused death in two and a half hours after its administration. Examination on autopsy revealed inflammation of the gastrointestinal tract. Similar lesions were found in a horse killed by 100 grams of caffein, in which he also noticed hemorrhage of the mucosa in the fundus of the stomach. Gourewitch(28) (1907) conducted experiments with caffein on rabbits, pigeons, and white rats. It appears from his protocol that single doses of about 0.2 to 0.25 gram caffein per kilo given subcutaneously proved to be fatal. He states, however, that the resistance to caffein was markedly diminished, when its administration was repeated daily, for much smaller amounts sufficed to cause death in these animals. A dose of 120 mg of caffein per kilo proved fatal after the third injection. When the dose was increased to 170 mg per kilo, the animal succumbed to the effects of caffein after the second injection. His experiments on the other animals do not indicate the degree of resistance to caffein, since the weights for some were not given while for the others no attempt was made to determine the minimum toxic or fatal dose. Maurel(55) (1907) studied the influence of different methods of administration on the toxicity of caffein on frogs and rabbits. He determined the minimum toxic and lethal doses of caffein hydrobromid which he employed in 1 to 2 per cent solutions. He concluded from his experiments that the toxicity of caffein when given by mouth is twice as great for the frog as for the rabbit. More recently Hale(33) carried out a number of experiments on guinea pigs in which he determined the toxicity of caffein given in the form of the citrate and made into a pill with mucilage of acacia and arrow-root starch. After the pill was dried it was fed to the animal, due precaution being taken that none of it was lost during feeding. From experiments on guinea pigs which received doses of 0.3 to 0.6 gram caffein citrate, the following data have been reported: Three decigrams per kilo given to one pig was not fatal. Of three pigs which received 0.4 per kilo, one died and two survived. Exactly the same results were obtained in three others which received 0.5 per kilo. Two guinea pigs, which received 0.55 and 0.6 per kilo each, died after 15 and 7 hours, respectively, while another animal survived a dose of 0.45 per kilo. This review of the literature on the toxicity of caffein, although bearing evidence of considerable investigation and extending over three-quarters of a century, is largely qualitative in character. It appears from the experiments that the main object of the investigations was to ascertain the nature of the action of caffein, whether it is a muscle or a nerve poison. The comparative toxicity in different species of animals by the accurate determination of the toxic and fatal doses received but little attention. To fill the gap in our knowledge of the toxic effects of caffein, the present investigation was undertaken. This, it will be seen, proved to be a most laborious task, because in the large number of experiments careful observations showed that individuals of the same species varied considerably in their reaction to the drug. Numerous other factors, as will be shown, were also found to play an important part in the determination of the toxicity of caffein. ACUTE CAFFEIN INTOXICATION. The object of these experiments was to determine the resistance to caffein in various species of animals and by various methods of administration. Caffein was therefore given by mouth and injected subcutaneously into the peritoneal cavity, into the muscles, and intravenously. As far as could be judged by appearance, healthy animals were selected for the subjects of the experiments, but as it is impossible to diagnose with any degree of accuracy the condition of the animal while it is alive, post mortem examinations were resorted to in many cases in which the issue of the experiment was fatal. Since the age of the animal may modify toxicity full grown, as well as young, animals were employed for these experiments; diet, race, and season also play an important part in determining the toxicity of a drug and these factors were also taken into account in the present investigation. EXPERIMENTS ON RABBITS. Animals of different varieties were used and were given caffein by all of the methods indicated in the preceding paragraph. Some of the rabbits employed in these experiments received oats, others received a diet exclusively of carrots for several days or weeks previous to the administration of caffein. The experiments were conducted at all seasons of the year. SUBCUTANEOUS INJECTION. From a study of the literature on the toxicity of caffein it seemed that about 150 mg per kilo is probably the lethal dose for the rabbit when the drug is injected subcutaneously. Preliminary observations were therefore carried out with such a dose, but it was found, on the contrary, that this amount per kilo was hardly sufficient to induce symptoms in the great majority of cases. SERIES A. [Doses of 147 to 167 mg of caffein per kilo were employed in these experiments.] _Rabbit 332. Belgian hare, female. Weight, 1,070 grams. Diet, oats._ March 25: 8.5 cc 2 per cent caffein (158 mg per kilo) injected subcutaneously at 2.15 p. m.; 4 p. m., reflexes increased; 5.45 p. m., increases of reflexes still more marked. March 26: Rabbit looked normal; no symptoms observed. _Rabbit 331. Belgian hare, female. Weight, 1,170 grams. Diet, oats._ March 25: 2.15 p. m., 9 cc 2 per cent caffein (153 mg per kilo) injected subcutaneously; 4 p. m., reflexes increased; 5.45 p. m., condition the same. March 26: Rabbit looks normal; no symptoms observed. _Rabbit 328. Belgian hare, female. Weight, 1,200 grams. Diet, oats._ March 25: 9 cc 2 per cent caffein injected subcutaneously (150 mg per kilo); 4 p. m., reflexes increased; 5.45 p. m., reflexes increased but not markedly. March 26: No symptoms; rabbit looks normal. _Rabbit 322. White female. Weight, 1,065 grams. Diet, oats._ March 17: 8 cc 2 per cent caffein (150 mg per kilo) injected subcutaneously at 11.55 a. m.; 12.55 p. m., reflexes increased, but no tetanus nor any other symptoms. March 18: Rabbit running around in cage; condition apparently normal. March 25: Condition of rabbit good. _Rabbit 217. White. Weight, 1,355 grams. Diet, oats._ October 29: 10 cc 2 per cent caffein (147 mg per kilo) injected subcutaneously at 1.51 p. m. 5.15 p. m., rabbit alive; survived. _Rabbit 219. Maltese. Weight, 1,820 grams. Diet, oats._ October 29: 14 cc 2 per cent caffein injected subcutaneously at 1.40 p. m. (153 mg per kilo); 5.15, rabbit alive; survived. _Rabbit 194. White female. Weight, 1,490 grams. Diet, oats._ October 14: 13 cc 2 per cent caffein (174 mg per kilo) injected subcutaneously; increased reflexes and tremors were observed. October 15: Condition of rabbit good; no symptoms. _Rabbit 191. Brown male. Weight, 1,915 grams. Diet, oats._ October 14: 16 cc 2 per cent caffein (167 mg per kilo) injected subcutaneously; reflexes increased and tremors present. October 15: Condition of rabbit good. A study of this series shows that about 150 mg of caffein per kilo caused increased reflexes within one to two hours after injection. When the dose was increased, as in rabbits 194 and 191, the symptoms were more pronounced; 150 mg per kilo may be regarded as the minimum dose which produces symptoms of nervous irritability when caffein is injected subcutaneously. Experiments with larger doses were therefore carried out in order to determine the minimum fatal dose. SERIES B. Approximately 0.2 gram of caffein per kilo was employed in these experiments. Diet and race as possible factors which may influence the toxicity of caffein were made the subject of study in these experiments which were divided into two groups as shown in the table, page 25. _Rabbit 95. Gray and white male. Weight, 1,478 grams. Diet, oats._ February 27: 11.30 a. m., 15 cc 2 per cent caffein (210 mg per kilo) injected subcutaneously; 2.20 p. m., no symptoms, tremors observed when handled, but not marked, reflexes slightly increased, no muscular rigidity nor any other symptoms; 2.45 p. m., rabbit suddenly became very restless, jumped off the table, and had convulsions; 3.45 p. m., rabbit died, rigor mortis set in almost immediately after death. _Rabbit 96. Gray and white male. Weight, 1,585 grams. Diet, oats._ February 27: 16 cc 2 per cent caffein (200 mg per kilo) injected subcutaneously at 3.40 p. m.; increased reflexes observed about one hour after caffein was injected, but no other symptoms. February 28: Rabbit found dead. _Rabbit 112. Black female. Weight, 875 grams. Diet, oats._ March 18: 9 cc 2 per cent caffein (205 mg per kilo) injected subcutaneously at 3 p. m.; 3.30 p. m., rabbit became restless, reflexes were increased, tremors were observed, but no other symptoms; 4.15 p. m., rabbit had tremors, was handled but this failed to induce tetanus, 10 minutes later tetanus of short duration with recovery occurred. March 19: 9 a. m., found dead. _Rabbit 119. Yellow white female. Weight, 1,060 grams. Diet, oats._ April 17: 10 cc 2 per cent caffein (188 mg per kilo) injected subcutaneously at 2.10 p. m. April 18: Rabbit found dead. _Rabbit 195. White female. Weight, 1,300 grams. Diet, carrots, since October 7._ October 14: 13 cc 2 per cent caffein (0.2 gram per kilo) injected subcutaneously at 11.15 a. m.; 2.25 p. m., rabbit had convulsions and died. _Note_: Ulceration of rectum was noticed. _Rabbit 208. Gray. Weight, 1,068 grams. Diet, carrots, October 7-15, inclusive._ October 15: 10 cc 2 per cent caffein injected subcutaneously at 11 a. m.; 1 p. m., increased reflexes and tremors observed; 3.45 p. m., tremors were marked when rabbit was handled. October 16: Rabbit found dead. _Note_: Looked poorly nourished. _Rabbit 247. Belgian hare, female. Weight, 1,295 grams. Diet, oats last 10 days before experiment._ November 10: 11 a. m., urine obtained from the bladder was acid to litmus and did not contain sugar or albumen, 13 cc 2 per cent caffein was injected subcutaneously; 1.30 p. m., 15 cc urine obtained was markedly alkaline to litmus and reduced Fehling's solution; 2.30 p. m., reduction of urine considerable, marked tremors observed but no tetanus. November 11: 10.30 a. m., 95 cc urine collected gave moderate reduction of Fehling's solution, no symptoms, condition of rabbit seemed to be good. _Rabbit 248. Belgian hare, female. Weight, 1,305 grams. Diet, oats the last 10 days before the experiment._ November 10: 11 a. m., urine markedly acid to litmus, no albumen, no sugar; 13 cc 2 per cent caffein injected subcutaneously; 1.30 p. m., urine was slightly alkaline to litmus, no reduction of Fehling's solution; 2 p. m., reflexes increased; 2.30 p. m., 2 cc urine obtained from bladder, sugar abundant; 4.45 p. m., reflexes increased as before, but no tetanus. November 11: 10.30 a. m., urine collected showed slight reduction of Fehling's solution; otherwise condition of rabbit was good; rabbit did not show any effects of caffein. _Rabbit 337. Belgian hare. Weight, 1,040 grams. Diet, carrots, March 31 to April 6, inclusive._ April 6: 3 p. m., 11 cc 2 per cent caffein injected subcutaneously in the back (0.211 per kilo); 4.30 p. m., reflexes much exaggerated. April 7: 8.15 a. m.; condition good, no symptoms. _Rabbit 336. Belgian hare. Weight, 1,040 grams. Diet, carrots, March 31 to April 6, inclusive._ April 6: 3 p. m., 11 cc 2 per cent caffein injected subcutaneously into tissues of the back. April 7: 8.15 a. m., no symptoms, condition good. Although symptoms appeared in rabbits of Group I (see table, page 25) about the same time after the administration of caffein as in the rabbits of the preceding series all of them terminated fatally 2¼ hours to 24 hours after its administration. Two of these rabbits (Nos. 195 and 208) were fed carrots for several days before the injection of caffein, the others were fed oats. Since symptoms and death appeared in these two rabbits about the same time as in the rest of this group it may be concluded that caffein is not less toxic when carrots are fed than when oats form the exclusive diet. But since rabbit No. 208 was poorly nourished and ulceration of the rectum was observed in No. 195 it is quite possible that caffein might be less toxic in normal rabbits on this diet. This was tested in rabbits Nos. 336 and 337, both of which seemed to be free from abnormality and were well nourished. Since these rabbits survived and manifested mild symptoms only of intoxication it would seem that a carrot diet decreases the toxicity of caffein. It was suggested, however, that another factor might be the cause of the greater resistance to caffein in these two rabbits, namely, race. This was tested in rabbits 247 and 248, both Belgian hares. Since the toxicity of caffein in these two rabbits was the same as in Nos. 336 and 337, diet as a factor in acute caffein intoxication may be disregarded. The greater resistance to caffein of these four rabbits is in all probability due, therefore, to a difference of race. This suggestion gained additional support from the experiments of the next series. SERIES C. The object of these experiments was to determine the minimum fatal dose for the gray rabbit and to obtain additional evidence as to the toxicity of caffein in the several varieties of rabbits. Eight experiments were performed, in which from 236 to 252 mg per kilo were given. The white rabbits, three in number, received 250, 242, and 238 mg per kilo. All the others (which were Belgian hares) received from 236 to 252 mg per kilo. Two of the white rabbits were fed carrots for one week preceding the injection of caffein. The other was fed oats. Three of the Belgian hares were on a diet of oats, two were fed carrots the week before the experiment with caffein. _Rabbit 122. White, female. Weight, 2,060 grams. Diet, oats._ April 14: 25 cc of 2 per cent caffein (250 mg per kilo) in aqueous solution injected subcutaneously in the back at 1.35 p. m.; 4.30 p. m., tremors, reflexes increased, condition otherwise good. April 16: 9 a. m., found dead in cage. _Autopsy_: Liver deeply congested; kidneys congested in cortex and medulla; stomach showed small hemorrhagic areas, perforating ulcers in pyloric portion; small intestine petechiated on mucosa; lungs and spleen normal. _Rabbit 234. White, female. Weight, 1,650 grams. Diet, November 2-9, carrots._ November 9: 10.45 a. m., 20 cc 2 per cent caffein (242 mg per kilo) administered subcutaneously. November 10: 9 p. m., found dead. _Rabbit 335. Gray hare, female. Weight, 1,170 grams. Diet, March 31 to April 7, carrots._ April 7: 9.30 a. m., 14 cc 2 per cent caffein solution (240 mg per kilo) injected subcutaneously in the back; 10.30, reflexes much increased, rabbit is extremely sensitive. April 8: 9 a. m., found dead. _Autopsy_: Liver was congested and contained several coccidiosis nodules; stomach distended with rather dry food mass; mucosa exhibited mild catarrhal inflammation; mucosa of intestines also slightly inflamed. _Rabbit 249. Belgian hare, female. Weight, 1,185 grams. Diet, oats._ November 11: Urine, 5 cc, from bladder acid to litmus, no sugar, no albumin; 11.50 a. m., 14 cc 2 per cent caffein (236 mg per kilo) administered subcutaneously; 3.45 p. m., reflexes increased, hyperæsthesia marked, but no tetanus, even when handled; 30 cc urine collected at 4 p. m., reduction of Fehling's solution considerable. November 12: 10 a. m., 8 cc urine collected, reduction heavy, only a few cubic centimeters obtained from bladder, did not contain any sugar, general condition of rabbit good, no symptom of caffein intoxication. _Rabbit 321. Yellow, female. Weight, 1,135 grams. Diet, oats._ March 16, 1910: 11.50 a. m., 14 cc 2 per cent caffein (246 mg per kilo) injected subcutaneously in the back; 2 p. m., reflexes increased, is very sensitive, started to run when put on floor, no handling except what was required for removal and return to cage, feces soft. March 17: 9.30 a. m., condition good, rabbit put on floor, gait normal, but does not care to walk. March 18: 9 a. m., walks around when put on floor, appetite good, condition seems to be normal. March 25: 11 a. m., rabbit still alive, condition good. _Rabbit 250. Belgian hare, female. Weight, 1,435 grams. Diet, oats at least two days before the experiment._ November 11: 11 a. m., urine obtained from bladder acid to litmus, no albumin, no sugar; 11.10 a. m., 18 cc, 2 per cent caffein (252 mg per kilo); 3.45 p. m., reflexes and hyperæsthesia, no tetanus; 4 p. m., 60 cc urine, marked reduction of Fehling's solution. November 12: 10 a. m., condition of rabbit good, no symptoms of caffein intoxication, 80 cc urine collected, sugar considerable, only a few cubic centimeters of urine obtained from bladder, no reduction of Fehling's solution. _Rabbit 834. Belgian hare, female. Weight, 1,270 grams. Diet, carrots, March 31 to April 7._ April 7: 9.30 a. m., 15 cc 2 per cent caffein (240 mg per kilo) injected subcutaneously in the back; 10.30 a. m., reflexes much increased, rabbit extremely sensitive. April 8: 9 a. m., condition good, no symptoms. _Rabbit 233. White, male. Weight, 1,675 grams. Diet, carrots, November 2 to 9._ November 9: 10.50 a. m., 20 cc 2 per cent caffein (238 mg per kilo) injected subcutaneously, no symptoms observed until 5 p. m., when increased reflexes and hyperæsthesia were noticed, but no tetanus. November 10: 9 a. m., paralysis of posterior extremities; died at 1 p. m. Analysis of the results obtained in the experiments of this series and inspection of Table I, page 25, show that all four of the rabbits which survived doses of 236 to 252 mg of caffein per kilo were Belgian hares. Of the four which died one only was a Belgian hare. The other three were white rabbits. Two of these were fed oats; the other two received carrots during seven days preceding the administration of caffein. This diet does not seem to be a factor, therefore, in the toxicity of caffein. Moreover, it may be observed that rabbit No. 122, which was fed oats, died after receiving 250 mg per kilo, while rabbit No. 250 received the same diet and survived the same dose of caffein per kilo. Experiments 234 and 334 offer another illustration that the toxicity of caffein is not dependent upon diet, since both rabbits were fed carrots, but the same dose of caffein caused only symptoms in one while it proved fatal to the other. It is evident, therefore, that the difference in resistance to caffein shown in these experiments is in all probability due to race, the Belgian hare being more resistant to caffein than rabbits of other varieties. Rabbit No. 335 seems to be an exception, but the post-mortem examination showed the presence of coccidiosis of the liver. As will be shown later, wherever this condition prevailed even smaller doses of caffein proved fatal. SERIES D. To obtain additional evidence regarding the resistance of the various races of rabbits to caffein and to ascertain the smallest dose which is surely fatal to the gray rabbit or Belgian hare was the object of this series of experiments. The diet in all cases consisted of oats, which was given ad libitum excepting to rabbit No. 235, which received carrots for one week previous to the injection of caffein. The doses administered ranged from 267 to 300 mg per kilo and were administered to different varieties of adult rabbits. _Rabbit 253. Brown and black, male. Weight, 1,600 grams. Diet, oats, November 9 to 12._ November 12: 11.30 a. m., urine from bladder acid, no albumen, no sugar; 11.35 a. m., 22 cc 2 per cent caffein (275 mg per kilo) injected subcutaneously; 11.45 a. m., rabbit jumped, off the table, had convulsions, retraction of head and opisthotonos, general tremors, anterior extremities stretched out, posterior extremities almost normal, frequent twitchings; died at 12.15 p. m. _Rabbit 252. Black, female. Weight, 1,335 grams. Diet, oats, November 9 to 12._ November 12: 11.30 a. m., 18 cc 2 per cent caffein (270 mg per kilo) injected subcutaneously. Urine obtained from bladder before injection, acid, no albumen, no sugar, color normal, tremors and great excitement noticed about 12 noon; 4.30 p. m., when handled, showed unusual restlessness and excitement followed by convulsions with opisthotonos; occasional twitching, condition bad. Died 4.35 p. m. _Rabbit 327. White, female. Weight, 820 grams. Diet, oats, March 8 to 16._ March 16: 11.45 a. m., 12 cc 2 per cent caffein (292 mg per kilo) injected subcutaneously in the back; 2 p. m., found dead, but was still warm. _Autopsy_: Hemorrhagic area at point of injection into spinal muscles; subcutaneous abdominal region exhibited a large area of cheesy purulent material; liver and spleen were engorged; bladder filled; intestines normal. _Rabbit 340. White and brown male. Weight, 1,465 grams. Diet, oats._ March 30: 3.20 p. m., 20 cc of 2 per cent caffein (273 mg per kilo) injected subcutaneously in back. March 31: 9 a. m., found dead. _Rabbit 341. White and brown. Weight, 1,450 grams. Diet, oats._ March 30: 3.20 p. m., 20 cc 2 per cent caffein (270 mg per kilo) injected subcutaneously in back; 4.40 p. m., found in dying condition, had convulsions; 4.45 p. m., dead. _Rabbit 326. White, male. Weight, 1,645 grams. Diet, oats, March 8 to 16._ March 16, 1910: 12 noon, 20 cc 2 per cent caffein (243 mg per kilo) injected subcutaneously in the back; 2 p. m., tremors marked, hypersensitive, started to run when put on floor; rabbit was not handled any more than was required for his removal from and return to cage. March 17: 9.30 a. m., tremors still present and marked, otherwise general condition good; no other symptoms. March 18: 9.30 a. m., no appetite, tremors still present, general condition poor; died about 2 p. m. _Rabbit 235. Belgian hare, male. Weight, 1,870 grams. Diet, carrots, November 2 to 9._ November 10: 11.05 a. m., 25 cc 2 per cent caffein (267 mg per kilo) injected subcutaneously; reflexes increased and tremors, but no tetanus observed; found dead next morning. _Rabbit 316. Belgian hare, female. Weight, 860 grams. Diet, oats, March 8 to 16._ March 16, 1910: 11.40 a. m., 12 cc 2 per cent caffein (267 mg per kilo) injected subcutaneously in the back; 2.15 p. m., reflexes somewhat increased, but not markedly so; walked when put on floor; gait clumsy and slow; tremors of head observed; 2.35 p. m., rabbit lying in his cage, posterior extremities extended and rigid, anterior extremities flexed, head retracted; is still breathing; occasional spasms observed. Rabbit died at 3 p. m. _Autopsy_: No lesion at point of injection in dorsal spinal muscles; liver and spleen engorged; intestines injected; other organs apparently normal. _Rabbit 395. Belgian hare, male. Weight, 1,410 grams._ August 18: 1 p. m., 20 cc 2 per cent caffein (283 mg per kilo) injected subcutaneously in the back; 4 p. m., reflexes markedly increased; 5 p. m., reflexes about the same, but no tetanus. August 19, 9.15 a. m.: Reflexes increased markedly. August 21, weight, 1,215 grams. Given 275 mg per kilo of caffein; no symptoms observed. August 23, found dead. _Autopsy_: Liver greatly engorged; stomach fairly well distended and mucous membrane in a slightly inflammatory condition; contents of small intestine liquid in nature, but walls of same appeared normal; other organs normal in appearance. _Rabbit 396. Belgian hare, female. Weight, 1,475 grams. Diet, oats._ August 18: 1 p. m., 20 cc 2 per cent caffein (272 mg per kilo) injected subcutaneously in the back; 4 p. m., reflexes increased markedly; 5 p. m., reflexes increased markedly but no tetanus. August 19: 10.30 a. m., reflexes still increased very markedly; rabbit jumps when touched. August 21: Weight, 1,245 grams. Injected subcutaneously 275 mg of caffein per kilo; reflexes increased, posterior extremities stiff over hour later. August 22: 9 a. m., found dead. _Autopsy_: Thoracic organs normal in appearance; stomach distended and mucous membrane affected with a catarrhal inflammation; contents of stomach were covered with a shiny mucus; contents of small intestine liquid in nature and bile stained; liver showed a coccidial infestation; kidneys and spleen normal in appearance. _Rabbit 397. Belgian hare, male. Weight, 1,375 grams. Diet, oats._ August 19: 10.30 a. m., 20 cc 2 per cent caffein (290 mg per kilo) injected subcutaneously in the back. August 22: 9 a. m., found dead. _Autopsy_: Stomach distended with ingesta; mucous membrane exhibited a catarrhal inflammation with excessive secretions; major portion of intestines showed a condition similar to that of stomach, contents consisting mainly of a shiny mucus; liver enlarged; other organs apparently normal. _Rabbit 398, Belgian hare, female. Weight, 1,570 grams. Diet, oats._ August 19: 10.30 a. m., 23 cc 2 per cent caffein (293 mg per kilo) injected subcutaneously in the back; 4 p. m., found dead. _Autopsy_: Thoracic organs seemingly normal; mucous membrane of stomach exhibited a catarrhal inflammation generally; large intestines somewhat impacted but walls appeared normal; other organs normal. _Rabbit 399, Belgian hare, male. Weight, 1,725 grams. Diet, oats._ August 19: 10.30 a. m., 26 cc 2 per cent caffein (300 mg per kilo) injected subcutaneously in the back; found dead at 4.30 p. m. _Autopsy_: Lungs slightly congested; liver engorged and friable; gall cyst well filled; stomach exhibited catarrhal gastritis; injection of mesenteries and intestines; kidney showed marked cortical congestion. The results of the experiments of this series likewise indicate that the Belgian hare is more resistant to caffein than the rabbits of other varieties. Thus, of the four gray rabbits (Nos. 235, 316, 395, and 396), which received 267 to 283 mg of caffein per kilo, two died and two lived,[B] one of which, 396, showed the presence of coccidiosis of the liver. On the other hand it will be observed that the black and white rabbits which received from 270 to 275 mg of caffein per kilo all died from the effects of the drug; one within 1 hour and 25 minutes and another within 50 hours after the administration of the caffein, while No. 340 died in the night. Furthermore it will be noted that of the last three rabbits of this series, which were Belgian hares and received 290, 293, and 300 mg of caffein, two died six hours after the injection, while the other, No. 397, lived three days. The minimum fatal dose of caffein for Belgian hares is, therefore, about 290 to 300 mg per kilo when injected subcutaneously, which is about 50 per cent greater than for rabbits of other varieties. [B] Survived first dose. SERIES E. It was shown in series A that 0.15 caffein per kilo caused symptoms of intoxication. Before concluding, however, that this is the smallest dose which causes symptoms of poisoning, a number of experiments were performed with smaller doses. It was found that in the great majority of cases 0.1 caffein per kilo may cause diuresis, but no nervous or muscular symptoms. In some rabbits, however, even such a dose proved fatal. Post-mortem examinations in these cases showed the presence of coccidiosis of the liver, and it will be recalled that similar observations were made before. It is quite possible, therefore, that coccidiosis of the liver is an important factor in decreasing the resistance to caffein. Experiment 551 (p. 25) shows that other conditions may likewise increase the toxicity of caffein. _Rabbit 325. White, female. Weight, 1,065 grams. Diet, oats._ March 17: 11 a. m., 6 cc 2 per cent (112 mg per kilo) caffein injected subcutaneously in the back. About 5 cc of urine squeezed out from bladder before injecting caffein. March 17: 1 p. m., hind legs crossed and stretched out, front legs also extended; rabbit lying stretched out on her belly. March 17: 5.40 p. m., rabbit still alive, condition somewhat improved. March 18: 9 a. m., found dead, stiff and cold. _Autopsy_: Hemorrhagic area at point of inoculation; subcutaneous region of both thighs presented a hemorrhagic infiltration of the tissues; liver contained lesions of coccidiosis; other organs apparently normal. _Rabbit 330. Belgian hare, female. Weight, 935 grams; poorly nourished._ March 18: 3.35 p. m., 5 cc 2 per cent caffein (107 mg per kilo) injected into subcutaneous tissues in the back; 5.30 p. m., no symptoms. March 19: 9 a. m., no symptoms. March 25: Weight, 825 grams. _Rabbit 329. Belgian hare, male. Weight, 775 grams; poorly nourished. Received March 18._ March 18: 3.30 p. m., 4 cc 2 per cent caffein (103 mg per kilo) injected into subcutaneous tissues in the back; 5.30 p. m., no symptoms. March 19: 9 a. m., no symptoms. March 25: Rabbit alive in good condition; weight, 825 grams. _Rabbit 320. Black, male. Weight, 1,040 grams. Diet, oats._ March 17: 11 a. m., 6 cc 2 per cent caffein (115 mg per kilo) injected subcutaneously in the back; only a few drops of urine obtained from bladder before injecting caffein; 1 p. m., rabbit very restless; ran away when placed on floor; cried when touched with a piece of paper; no tremors observed, but rabbit became exhausted and was unable to walk; legs extended out; after running for about a minute dyspnoea was very marked, but rabbit soon raised himself on his legs; 5.40 p. m., rabbit up on his legs. March 18: 9 a. m., found dead, but still warm. _Autopsy_: Lungs studded with small grayish white nodules, adhesions to costal pleura; probably lesions of coccidiosis; liver studded with coccidiosis nodules. Hemorrhages at point of inoculation. _Rabbit, 551. Gray, female. Weight, January 26, 1,650 grams. Diet, oats; fed 20 cc of 25 per cent alcohol daily from January 26-31._ January 31: Weight, 1,450 grams; 10.20 a. m., temperature 101.6°; 10.45, a. m., temperature 101.6°; received 7 cc 2 per cent caffein subcutaneously into back; 11.15 a. m., convulsions of short duration; raised himself on posterior legs, anterior legs wide apart; 4.10 p. m., looked normal, not hypersensitive; 4.30 p. m., condition seemed to be good. February 1: 9 a. m., found dead, was alive at 5.30 p. m. of previous day. _Autopsy_: Lesions found involved thoracic cavity mainly; lungs were hepatized and a fibro plastic exudate caused them to adhere to costal pleura; liver engorged and appeared fatty; no marked lesions affecting digestive tract, a slight catarrh of stomach being the only noticeable feature; kidneys and spleen normal. TABLE 1.--_Subcutaneous injections of caffein--rabbits._ SERIES A. ----+--------+-------+-------------+--------------+-------+----------- | |Caffein| Appearance | Duration | | No.| Weight.| per | of symptoms | of life. | Diet. | Remarks. | | kilo | in-- | | | ----+--------+-------+-------------+--------------+-------+----------- |_Grams._| _Mg._ | | | | 332| 1,070 | 158 |1 hour |Survived | Oats |Gray. | | | 45 minutes| | | 331| 1,170 | 153 | do. | do. | do. | Do. 328| 1,200 | 150 | do. | do. | do. | Do. 322| 1,065 | 150 |1 hour | do. | do. |White. 217| 1,355 | 147 | | do. | do. | Do. 219| 1,820 | 153 | | do. | do. |Maltese. 194| 1,490 | 174 | | do. | do. |White. 191| 1,915 | 167 | | do. | do. |Light brown. ----+--------+-------+-------------+--------------+-------+------------ SERIES B, GROUP I. ----+--------+-------+-------------+--------------+-------+------------- 95| 1,478 | 210 |2 hours |3 hours |Oats |White. | | | 50 minutes | 10 minutes | | 96| 1,585 | 200 |1 hour |About 18 hours| do. |Gray white. 112| 875 | 205 |30 minutes | do. | do. |Black. 119| 1,060 | 188 | | do. | do. |Yellow white. 195| 1,300 | 200 | |3 hours |Carrots|White. | | | | 10 minutes | | 208| 1,068 | 188 |2 hours |About 24 hours| do. |Gray. ----+--------+-------+-------------+--------------+-------+------------- SERIES B, GROUP II. ----+--------+-------+-------------+--------------+-------+----------- 247| 1,295 | 200 |2.5 hours |Survived |Oats |Gray. 248| 1,305 | 200 |3 hours | do. | do. | Do. 337| 1,040 | 211 |1.5 hours | do. |Carrots| Do. 336| 1,045 | 211 | do. | do. | do. | Do. ----+--------+-------+-------------+--------------+-------+----------- SERIES C. ----+--------+-------+-------------+--------------+-------+------------ 122| 2,060 | 250 |2 hours |1.5 days |Oats |White. | | | 55 minutes | | | 234| 1,650 | 242 | |About 24 hours|Carrots| Do. 335| 1,170 | 240 |1 hour | do. | do. |Gray | | | | | |coccidiosis. 249| 1,185 | 236 |4 hours |Survived |Oats |Gray. 321| 1,135 | 246 |2 hours | do. | do. |Yellow. | | | 10 minutes | | | 250| 1,435 | 252 |4 hours | do. | do. |Gray. | | | 35 minutes | | | 334| 1,270 | 240 |1 hour | do. |Carrots| Do. 233| 1,675 | 238 |6 hours |26 hours | do. |White. | | | 10 minutes | | | ----+--------+-------+-------------+--------------+-------+------------ SERIES D. ----+--------+-------+-------------+--------------+-------+----------- 253| 1,600 | 275 |10 minutes |35 minutes |Oats |Brown and | | | | | | black. 252| 1,335 | 270 |30 minutes |4 hours | do. |Black. | | | | 55 minutes | | 327| 820 | 292 | |2 hours | do. |White. | | | | 15 minutes | | 340| 1,465 | 273 | |About 18 hours| do. |White and | | | | | | brown. 341| 1,450 | 270 | |1 hour | do. | Do. | | | | 25 minutes | | 326| 1,645 | 243 |2 hours |50 hours | do. |White. 235| 1,875 | 267 | |20 hours |Carrots|Gray. 316| 860 | 267 |2 hours |3 hours |Oats | Do. | | | 45 minutes | 20 minutes | | 395| 1,410 | 283 |3 hours |Survived | | Do. 395| 1,215 | 275 | do. |About 2 days |Oats | Do. 396| 1,475 | 272 | do. |Survived | do. | Do. 396| 1,245 | 275 |1 hour |About 18 hours| do. | Do. 397| 1,375 | 290 | |3 days | do. | Do. 398| 1,570 | 293 | |5.5 hours | do. | Do. 399| 1,725 | 300 | |6 hours | do. | Do. ----+--------+-------+-------------+--------------+-------+----------- SERIES E. ----+--------+-------+-------------+--------------+-------+------------ 325| 1,065 | 112 |2 hours |Less than | Oats |White female. | | | | 22 hours | | 330| 935 | 107 |None |Survived | |Gray. 329| 775 | 103 |do. | do. | |Gray male. 320| 1,040 | 115 |2 hours |46 hours | Oats |Black male. 551| 1,450 | 100 |30 minutes |Less than | do. |Gray female. | | | | 24 hours | | ----+--------+-------+-------------+--------------+-------+------------ ADMINISTRATION BY MOUTH. These experiments were carried out on two varieties of rabbits, the white and the gray. The diet consisted chiefly of oats, but in a few cases carrots formed the exclusive diet. Food and water were given ad libitum. A 2 per cent solution of caffein was administered through a stomach tube. Since the resistance to most drugs is commonly supposed to be greater when given by mouth than when administered by any other path, doses of 175 to 200 mg per kilo were fed in a series of preliminary experiments, all of which were performed on gray rabbits weighing from 865 to 1,135 grams, and which were fed carrots for several days previous to the experiment. Three of the rabbits survived, two without showing any symptoms; in the other case paralysis of the posterior extremities was observed five hours after he received caffein and he was found dead the next morning. Unfortunately no autopsy was performed. The low resistance to caffein of this animal was probably due to some abnormal condition which developed about the time of the experiment, since this rabbit received 325 mg of caffein per kilo two weeks previously and increased reflexes only were observed as a result of this treatment. Hence 200 mg of caffein per kilo can not be considered the toxic dose when fed by mouth. In the following experiments larger doses were therefore given. SERIES A. _Rabbit 248. Belgian hare. Weight, 1,170 grams. Diet, oats._ November 17: 1.20 p. m., 19.5 cc 2 per cent caffein (330 mg per kilo) administered by the mouth; 4.30 p. m., somewhat hypersensitive. November 19: No symptoms; at 9 a. m., urine collected, no reduction of Fehling's solution; rabbit survived. _Rabbit 241. White male. Weight, 1,380 grams. Diet, oats._ November 17: 1.15 p. m., 20 cc 2 per cent caffein (290 mg per kilo) administered by the mouth; 4.30 p. m., some hypersensitiveness, but no other symptoms. November 18: 9 a. m., urine collected, no reduction of Fehling's solution; no symptoms; rabbit survived. _Rabbit 249. Belgian hare. Weight, 890 grams. Diet, oats._ November 17: 1.30 p. m., 14.5 cc 2 per cent caffein (325 mg per kilo) administered; 4.30 p. m., hypersensitiveness; no other symptoms. November 18: 10 a. m., no symptoms; urine collected, no reduction; rabbit survived. SERIES B. The object of these experiments was to determine the minimum fatal dose of caffein in the two varieties of rabbits, the white and the gray. All of the animals selected were approximately of the same weight. _Rabbit 239. Belgian hare, male. Weight, 935 grams. Diet, oats._ November 19: 4 p. m., 17 cc 2 per cent caffein (363 mg per kilo) administered by mouth, followed by 10 cc of 0.9 per cent salt solution. November 20: Urine examined, no sugar found, no symptom noticed at any time after injection. _Rabbit 254. Belgian hare, female. Weight, 975 grams. Diet, oats._ November 19: 4.05 p. m., 18 cc 2 per cent caffein (369 mg per kilo) administered by mouth, followed by 10 cc of 0.9 per cent salt solution. November 20: 9 a. m., rabbit found dead. _Rabbit 267. White. Weight, 1,050 grams. Diet, oats._ November 23: 12.10 p. m., 18 cc 2 per cent caffein (342 mg per kilo) given by mouth, followed by 18 cc salt solution; 1 p. m., increased reflexes, tremors marked but no tetanus; 1.05 p. m., rabbit stretched on abdomen, posterior extremities in extended position and paralyzed, soon after clonic spasms set in, which recurred about every minute; 1.14 p. m., tetanus and death. _Autopsy_: Liver showed fatty degeneration; slight inflammation of stomach and intestines; other organs normal. _Rabbit 268. White. Weight 1,100 grams. Diet, oats._ November 23: 20 cc 2 per cent caffein (363 mg per kilo) administered by mouth, followed by 20 cc salt solution; 1.15 p. m., somewhat hypersensitive; 4.30 p. m., tremors fairly marked, no urine passed, about 2 cc of bloody looking urine obtained from bladder, which contained albumen and a considerable amount of glycogen; rabbit died. _Rabbit 419, Belgian hare, male. Weight, 1,600 grams. Diet, oats._ September 26: 10 a. m., 28 cc 2 per cent caffein (350 mg per kilo) given by mouth; reflexes increased at 4 p. m.; 6 p. m., reflexes still increased, no other symptoms. September 27: 9 a. m., found dead. _Autopsy_: Lungs, liver, and kidneys congested; other organs normal. _Rabbit 420. Belgian hare, male. Weight, 1,250 grams. Diet, oats._ September 26: 10 a. m., 22 cc 2 per cent caffein (352 mg per kilo) given by mouth; 11.35 a. m., convulsions; 12 noon, found dead. _Autopsy_: Liver showed very extensive coccidiosis; no other lesions. _Rabbit 421. Belgian hare, male. Weight, 1,485 grams. Diet, oats._ September 26: 10 a. m., 26 cc 2 per cent caffein (351 mg per kilo) administered by mouth; 4 p. m., reflexes increased; 6 p. m., reflexes as before, no tetanus observed. September 27: 9 a. m., rabbit found dead. _Autopsy_: Congestion of lungs and kidneys; liver congested and slightly fatty. _Rabbit 424. White, male. Weight, 1,295 grams. Diet, oats._ September 26: 2 p. m., 19 cc 2 per cent caffein (293 mg per kilo) administered by mouth; 4 p. m., reflexes increased, no other symptoms; 6 p. m., no change since 4 p. m. September 27: 12 noon, convulsions and death. _Autopsy_: Congestion of the lungs; no other lesions. _Rabbit 423. White, male. Weight, 1,205 grams. Diet, oats._ September 26: 2 p. m., 18 cc 2 per cent caffein administered by mouth; 4 p. m., reflexes increased, no tetanus; 6 p. m., condition unchanged since 4 p. m. September 27: 9 a. m., found dead. _Autopsy_: Lungs, liver, and kidneys congested; other organs normal. _Rabbit 422. White, male. Weight, 1,440 grams. Diet, oats._ September 26: 2 p. m., 21 cc 2 per cent caffein (291 mg per kilo) given by mouth; reflexes increased at 4 p. m. September 27: 3 p. m., alive, no symptoms; 4 p. m., convulsions with recovery, this was soon followed by a violent attack of tetanus, which lasted about one minute and was succeeded by paralysis; rabbit died at 4.30. _Autopsy_: Liver slightly congested; a small portion of the intestine showed congestion and edema; other organs normal. A study of these experiments shows also considerable variation in the toxicity of caffein when given by mouth. In some cases a dose of 300 mg per kilo, and even less, caused death, as in rabbits 423 and 424. In other rabbits, however, approximately the same doses of caffein produced increased reflexes only. The same symptoms were produced in Nos. 248 and 249 after the administration of 325-330 mg of caffein per kilo, while another rabbit (No. 239) survived a dose of 363 mg per kilo. That this is exceptional, however, appears from the result of the following experiments on rabbits Nos. 419, 420, and 421, all of which died after receiving 350 mg of caffein per kilo, and rabbits 267 and 268, to which doses of 363 and 342 mg, respectively, per kilo proved fatal. It will be observed further that the gray rabbits are more resistant to caffein than the white animals, as 350 mg per kilo was the smallest fatal dose for rabbits 419, 420, and 421, all of which were gray rabbits, while a dose of 290 mg per kilo was fatal for some of the white rabbits. Again, it will be noticed that of the two gray rabbits, Nos. 254 and 239, which received the largest doses in these experiments, namely, 369 and 363 mg, respectively, one survived. The largest doses given to the white rabbits were 363 and 342 mg caffein per kilo. Both of these died from the effects of the drug. It may be concluded, therefore, that the minimum toxic dose for the gray rabbit is about 325 mg of caffein per kilo, and the minimum fatal dose is at least 350 mg per kilo. It is to be remarked in this connection that post-mortem examination showed extensive coccidiosis in rabbit 420 and fatty liver in No. 421, while the macroscopical examination of the organs of Nos. 424 and 423 failed to show the presence of such abnormalities. Since, as was observed in the section on subcutaneous injection and elsewhere in this investigation, pathological changes are apt to decrease the resistance to caffein, it is quite possible that 350 mg per kilo is not the minimum fatal dose for the normal rabbit. Indeed, the experiment on rabbit 239 lends support to this view, thus furnishing additional evidence of difference in the resistance to caffein in the two varieties of rabbits. TABLE 2.--_Administration of caffein by mouth._ SERIES A. ------+--------+-------+-----------+--------------+-------+----------- Rabbit| |Caffein| | Duration | | No. | Weight.| per | Symptoms | of life. | Diet. |Remarks. | | kilo. | | | | ------+--------+-------+-----------+--------------+-------+----------- |_Grams._| _Mg._ | | | | 248 | 1,170 | 330 |3 hours |Survived |Oats |Gray. | | | 10 minutes| | | 241 | 1,380 | 290 |2 hours | do. | do. |White male. | | | 15 minutes| | | 249 | 890 | 325 |3 hours | do. | do. |Gray male. ------+--------+-------+-----------+--------------+-------+----------- SERIES B. ------+--------+-------+-----------+--------------+-------+----------- 239 | 935 | 363 | |Survived |Oats |Gray male. 254 | 975 | 369 | |About 2 days | do. |Gray female. 267 | 1,050 | 342 |50 minutes |1 hour | do. |White. | | | | 4 minutes | | 268 | 1,100 | 363 | |About 3 hours | do. | Do. 419 | 1,600 | 350 |6 hours |Less than | do. |Gray male. | | | | 24 hours | | 420 | 1,250 | 352 |1 hour |2 hours | do. | Do. | | | | 35 minutes | | 421 | 1,485 | 351 |6 hours |Less than | do. | Do. | | | | 24 hours | | 424 | 1,295 | 293 |2 hours |22 hours | do. | White male. 423 | 1,205 | 300 | do. |Less than | do. | Do. | | | | 19 hours | | 422 | 1,440 | 291 | do. |2½ hours | do. | Do. ------+--------+-------+-----------+--------------+-------+------------ INJECTION INTO THE PERITONEAL CAVITY. In a number of experiments caffein was introduced into the peritoneal cavity. Rabbits of different varieties receiving a diet of oats or carrots were employed for this purpose; food and water were given ad libitum. The minimum doses required to induce symptoms or cause death in these animals were determined; tests with caffein were also made on young rabbits in order to study the influence of age on the resistance to this substance. The results are shown in the following experiments: SERIES A. In this series large doses were administered, approximating 0.3 gram per kilo. _Rabbit 71. Gray female. Weight, 1,659 grams._ January 20: 2.20 p. m., 25 cc aqueous solution 2 per cent caffein (300 mg per kilo) were injected into the peritoneal cavity; 3.45 p. m., when doors of cage were opened rabbit had spasm of short duration. January 21: Rabbit found dead. _Rabbit 72. Gray and white. Weight, 1,402 grams._ January 21: 11.17 a. m., 20.2 cc (aqueous solution) of 2 per cent caffein (300 mg per kilo) injected into peritoneal cavity from burette; 11.25 a. m., paralysis; 11.30 a. m., rabbit had convulsion when picked up from the floor, followed by several spasms later; 11.35 a. m., typical tetanus; 12.30 noon, found dead. _Rabbit 61. Black female. Weight, 2,143 grams._ January 19: 40 cc 2 per cent caffein, aqueous solution (300 mg per kilo), injected into peritoneal cavity from burette; tetanus when about 30 cc were injected; when removed from holder, repeated and violent convulsions, terminating in death. SERIES B. The object of these experiments was to determine the minimum lethal dose; 0.2 to 0.15 gram of caffein per kilo was injected into the rabbits of this series. _Rabbit 69. White female. Weight, 1,714 grams._ January 20: 10.15 a. m., 6 cc 2 per cent caffein, aqueous solution, injected into peritoneal cavity. No symptoms, under observation for 45 minutes, rabbit defecated rather copiously; feces were soft; 11 a. m., 6 cc 2 per cent caffein, aqueous solution, injected into peritoneal cavity, no symptoms, under observation for 40 minutes; 11.40, 6 cc 2 per cent caffein injected into peritoneal cavity; 11.45, rabbit is restless, reflexes increased. _Rabbit 70. Gray and white female. Weight, 1,487 grams._ January 20: 1.30 p. m., 15 cc 2 per cent aqueous solution of caffein (0.2 gram per kilo) injected into the peritoneal cavity; 2.20 p. m., no symptoms. January 30: About 2 p. m. rabbit died. February 1: _Autopsy_: Cirrhosis of the liver; enteritis of small intestines; stomach and kidneys normal. _Rabbit 93. Maltese, male. Weight, 1,197 grams._ March 2: 11.30 a. m., 12 cc of 2 per cent caffein (200 mg per kilo) injected into peritoneal cavity; 11.35 a. m., while being released from holder, tetanus occurred, repeated attacks later, clonic convulsions with tonic rigidity of posterior extremities during the attacks as well as during intervals, anterior extremities were relaxed during the intervals between the attacks, opisthotonos of cervical region but kyphosis in lumbar region were observed, no salivation nor dilatation of the pupils; 2 p. m., rabbit died. _Rabbit 92. Yellow female. Weight, 1,388 grams._ February 25, 4.15 p. m., 14 cc 2 per cent caffein (0.2 gram per kilo) injected into peritoneal cavity; 4.20 p. m., restlessness and increased reflexes, rabbit found stretched out in cage, but raised himself on his legs again; 4.45, general tremor when touched. February 26: 9 a. m., rabbit found dead. _Autopsy_: Hemorrhage into abdominal muscles at site of injection; hemorrhage also in walls of stomach opposite similar spot in abdominal wall. _Rabbit 309. Belgian hare, female. Weight, 1,500 grams. Diet, oats._ March 2: 2.05 p. m., 2 per cent caffein solution (0.2 gram per kilo) injected into peritoneal cavity; 2.25 p. m., found dead, no urine found in bladder. _Rabbit 307. Belgian hare, female. Weight, 1,320 grams. Diet, oats._ March 2: 12 noon, urine obtained from bladder, clear amber colored, no albumin, no reduction; 12.06 p. m., 10 cc of 2 per cent caffein (0.151 gram per kilo) injected into peritoneal cavity; 1.30 p. m., rabbit placed on floor, runs around but anterior and posterior extremities soon extended, in tonic condition; 2.25 p. m., reflexes increased, paralysis of extremities, dyspnoea; 4.50 p. m., about 100 cc urine collected, no albumin, reduction of Fehling's solution moderate. March 3: 9.30 a. m., posterior extremities extended and rigid, anterior extremities paralyzed, respiration less frequent and deeper than normal. Rabbit died at 11.50 a. m.; urine collected since 4.50 p. m. previous day gave very heavy reduction of Fehling's solution. _Autopsy_: Animal in good condition; in the left axillary region was observed a hemorrhage into the subcutaneous and muscular tissue of that region. The ventral portion of the large colon, in contact with the ventral abdominal wall, showed a hemorrhagic area about one-half inch in length, such as might be produced by a puncture or bruise of the colon through the abdominal wall. A small portion of the small intestine adjacent to the colon was affected in a similar manner. All internal organs were apparently normal. _Rabbit 308. Belgian hare, female. Weight, 1,350 grams. Diet, oats._ March 2: 11.45 a. m., urine obtained from bladder, no albumen, no reduction; 11.50 a. m., 10 cc 2 per cent caffein (0.15 gram per kilo) injected into peritoneal cavity; 1.30 p. m., not very active, no abnormal symptoms otherwise; 3.30 p. m., rabbit looked depressed, made very little attempt to move about, remained in one position most of the time when placed on floor; 4.30 p. m., 180 cc urine collected, no albumen, reduction of Fehling's solution moderate. March 3: 9.30 a. m., rabbit looks normal, is able to walk but is easily fatigued when made to walk about or when placed on his side, followed by paralysis of anterior extremities, posterior extremities apparently normal, about 90 cc of urine collected at noon was free from albumen, did not reduce Fehling's solution. March 4: 11 a. m., lying on his side in cage, anterior extremities limp, posterior extremities extended and rigid, is in dying condition. March 5: 9 a. m., found dead. _Autopsy_: Liver engorged; spleen congested, but not enlarged; kidneys, some congestion in cortex; stomach filled, mucosa thickened and easily pulled off; petechial hemorrhages on serosa of colon. SERIES C. The experiments of this series were made to determine the minimum toxic dose. _Rabbit 295. Belgian hare, female. Weight, 1,205 grams. Diet, carrots._ March 1: 10.40 a. m., 6 cc 2 per cent caffein (0.1 gram per kilo) injected into peritoneal cavity; about 2 cc of urine obtained before injecting caffein; 2 p. m. 100 cc urine, bloody in appearance, collected, a moderate quantity of albumen present, no reduction; 3.40 p. m., no symptoms. March 4: 2 p. m., rabbit looks well. _Rabbit 293. Belgian hare, female. Weight, 1,605 grams. Diet, carrots._ March 1: Urine from bladder clear, alkaline; 11.55 a. m., 8 cc 2 per cent caffein (0.1 gram per kilo) injected into peritoneal cavity; 3 p. m., 90 cc urine normal in color collected, no albumen, no reduction; 3.40 p. m., no symptoms. March 4: 1.15 p. m., rabbit looks normal. _Rabbit 292. Belgian hare, male. Weight, 1,595 grams. Diet, carrots._ March 1: 10.10 a. m., 8 cc 2 per cent caffein (0.1 gram per kilo) solution injected into peritoneal cavity; 10.40 a. m., rabbit urinated, reflexes increased, but no other symptoms; 10.50 a. m., no urine obtained from bladder; 2 p. m., 105 cc of clear pale urine collected; no albumen, no reduction; 3.40 p. m., no symptoms. March 4: 2 p. m., rabbit looks well, urine collected, did not contain sugar. _Rabbit 298. Belgian hare, female. Weight, 1,205 grams. Diet, carrots._ March 1: 4.06 p. m., 7.5 cc 2 per cent caffein solution (0.125 gram per kilo) injected into peritoneal cavity, urine obtained from bladder immediately after injection, no albumen, no reduction; 5.30 p. m., reflexes increased, rabbit was able to run around, but became paralyzed soon; 5.40 p. m., rabbit is again able to run around. March 3: 10 a. m., anterior extremities paralyzed, is able to use posterior extremities. March 4: 1 p. m., rabbit looks normal. _Rabbit 223. Belgian hare, male. Weight, 1,165 grams. Diet, carrots._ March 1: 3.50 p. m., urine obtained from bladder clear, amber colored, no albumen, no sugar; 3.52 p. m., 7.5 cc 2 per cent caffein (125 mg per kilo) injected into peritoneal cavity; 5.40 p. m., rabbit makes little attempt to run when put on the floor, weakness of extremities marked. March 4: 1.15 p. m., rabbit normal. SERIES D. The object of the experiments of this series was to study the effect of age on the resistance to caffein. Half-grown rabbits were, therefore, used in the following experiments. _Rabbit 310. Belgian hare, female. Weight, 880 grams. Diet, oats._ March 2: 3.25 p. m., 9 cc 2 per cent caffein (0.2 gram per kilo) injected into peritoneal cavity. March 3: 9.30 a. m., no symptoms, rabbit looks normal. March 4: 11 a. m., posterior extremities abducted, walked when placed on the floor, made no attempt to change attitude when placed on its side, remained some time in this position. March 5: 9 a. m., found dead. _Autopsy_: Liver showed areas of degeneration; kidneys congestion and petechial hemorrhage on cortex; small and large intestines, inflammation marked; bladder distended. _Rabbit 75. Gray and white, female. Weight, 842 grams._ January 25: 3 p. m., 8.5 cc 2 per cent caffein solution (0.2 gram per kilo) injected into peritoneal cavity; 3.15 p. m., anterior extremities weak and reflexes increased. January 27: Rabbit paralyzed but is able to turn over when placed on back. _Rabbit 74. Gray and white, female. Weight, 692 grams._ January 25: 3 p. m., 7 cc 2 per cent caffein (0.2 gram per kilo) solution injected into peritoneal cavity; 3.15 p. m., reflexes increased and anterior extremities paralyzed. January 27: Rabbit recovered and is able to walk about in the room. _Rabbit 312, maltese, female. Weight, 740 grams. Diet, oats._ March 3: 11.47 a. m., urine obtained from bladder, appearance normal, no albumen, no reduction of Fehling's solution; 11.50 a. m., 7.5 cc 2 per cent caffein (0.2 gram per kilo) injected into peritoneal cavity; 2.30 p. m. anterior extremities paralyzed, posterior extremities rigid and extended; 5 p. m. (about), rabbit died. _Rabbit 311. Belgian hare, female. Weight, 650 grams. Diet, oats._ March 3: 11.26 a. m., urine obtained from bladder normal in appearance, albumen considerable, reduction of Fehling's solution none; 11.27 a. m., 6 cc 2 per cent caffein solution (0.2 gram per kilo) injected into peritoneal cavity; 2.30 p. m., rabbit seemed to be normal, no symptoms had developed; urine collected contained a large amount of sugar, reduction was very heavy, but no albumen was found. March 4: 11 a. m., condition good, moves about when put on floor; gait, normal. _Rabbit 78. Yellow and white. Weight 659 grams._ January 26: 1.30 p. m., 8.5 cc 2 per cent caffein (250 mg per kilo) injected into peritoneal cavity, under observation the rest of the afternoon, no symptoms. January 27: 4 p. m., no symptoms developed. _Rabbit 317. Belgian hare, female. Weight 635 grams. Diet oats._ March 15: 10.35 a. m., 8 cc 2 per cent caffein (0.252 gram per kilo) injected into peritoneal cavity; 12 noon, marked abduction of hind legs, was unable to walk after a little exertion, rabbit died between 12.30 and 12.50 p. m. _Autopsy_. Right lung hepatized and showed adhesions to costal and mediastinal pleura; liver studded with nodules of coccidiosis; spleen congested; stomach filled, mucosa normal; intestines injected; colon hemorrhagic on serosa in ventral region, near point of injection; kidneys normal. _Rabbit 323. White, female. Weight 820 grams. Diet oats._ March 15: 10.45 a. m., 10 cc 2 per cent caffein (250 mg per kilo) injected into peritoneal cavity; 12 noon, reflexes increased, hind legs abducted but is able to walk, symptoms are mild; 1.40 p. m., tremors, weakness, and abduction of head and legs much more marked than at 12 noon. March 16: Condition good. March 17: Condition good, recovery apparently complete. Since the experiments of Series A, which were intended as preliminary tests, have shown that 0.3 gram of caffein per kilo when introduced into the peritoneal cavity is rapidly absorbed and is fatal, much smaller doses were employed in subsequent trials with the drug. This is shown in series B, which may be divided into two groups. Group I, consisting of rabbits 69, 70, 92, 93, and 309, which received 0.2 gram of caffein per kilo, and Group II, Nos. 307 and 308, into which 0.15 gram of caffein per kilo was injected. Three rabbits of Group I (Nos. 92, 93, 309) died from the effects of caffein; rabbit 309 twenty minutes after injection, and rabbits Nos. 92 and 93, twenty hours and two and one-half hours, respectively, after the administration of caffein. In both of these rabbits symptoms appeared within five minutes after the injections were made. Rabbits 69 and 70, it will be noticed, survived the same amount of caffein in proportion to body weight as was given to the other members of this group. Increased peristalsis and the distribution of the dose may account for the greater resistance of rabbit No. 69. The case of rabbit No. 70 is evidently one of exceptional resistance to caffein, since both the rabbits of Group II died from the effects of a much smaller dose, namely, 0.15 gram of caffein per kilo. Moreover, macroscopical examination at the autopsy of Nos. 307 and 308 failed to show any lesions which might tend to lessen the resistance to caffein. That a dose of 0.15 gram per kilo is therefore in all probability the minimum fatal dose for the rabbit when injected into the peritoneal cavity appears from the results of the experiments in series C, in which smaller doses, 0.125 gram of caffein per kilo caused mild symptoms only, while 0.1 gram per kilo rarely induced any symptoms. It may be remarked that the rabbits of series C were fed carrots while rabbits Nos. 307 and 308 received oats. Their resistance to caffein may be different, but, as was pointed out in the earlier part of this investigation, diet does not seem to influence the toxicity of the single dose of caffein. Doses of 150 and of 100 to 125 mg per kilo, when injected into the peritoneal cavity, may be considered, respectively, as the minimum fatal and minimum toxic doses for the gray rabbit. Analysis of the experiments in series D shows much greater resistance to caffein than in the other rabbits which received it intraperitoneally. Thus, after the administration of 0.2 gram per kilo to each of five rabbits, no effect was observed in two cases (Nos. 310, 311), while in two others (Nos. 74, 75) symptoms developed, but they survived. Only one rabbit, No. 312, died from the effects of this dose; the autopsy showed the presence of degeneration of the liver and petechial hemorrhages on the cortex of the kidneys in the case of No. 310, which was probably the cause of death rather than the caffein. Two decigrams of caffein can not be considered, therefore, the fatal dose for rabbits. This is further corroborated by the results obtained in experiments with larger doses. Rabbit 78, which received 257 mg per kilo, failed to show any symptoms. The same amount in proportion to body weight in No. 323 caused mild symptoms only, while the rapid death of rabbit No. 317 after the same dose of caffein may be explained by the lesion found at autopsy, thus affording additional evidence that disease may decrease the resistance to caffein. It will be observed that all the members of this series were young rabbits and, as will be shown later, young animals of other species are likewise more resistant to caffein than adult animals. Similar results were obtained by von Anrep, who observed that atropin is less toxic in young than in full-grown animals. Observations were also made on the diuretic effect of caffein when injected into the peritoneal cavity. The results shown in the following table indicates the stimulating effect on renal secretion whether the diet consisted of oats or of carrots. The urine of some rabbits contained moderate amounts of sugar after from 0.2 to 0.15 gram of caffein per kilo was given; albumen was observed in one case, but in none of the others. In rabbit No. 311 albumin was found before the injection of caffein, but none in the urine which was collected three hours after caffein was injected. _Effect of caffein on renal secretion._ -----+--------+---------+-------+--------------------+--------- No. | Weight.| Caffein | Urine.| Time. | Diet. | |per kilo.| | | -----+--------+---------+-------+--------------------+--------- |_Grams._| _Gram._ | _cc._ | | 307 | 1,320 | 0.150 | 100 | 4.5 hours | Oats. 308 | 1,305 | .150 | 180 | do. | Do. 295 | 1,205 | .100 | 100 | 2 hours 20 minutes | Carrots. 293 | 1,605 | .100 | 90 | 3 hours | Do. 292 | 1,595 | .100 | 105 | 4 hours | Do. -----+--------+---------+-------+--------------------+--------- NOTE.--The amount of urine secreted in three hours by control rabbits, on a carrot diet, varied between 35 and 50 cc, the average weight of the animals being a little above 1,600 grams. The secretion of urine on an oat diet was much less for an equal period of time. TABLE 3.--_Intraperitoneal injections._ SERIES A. ----+--------+-------+-------------+--------------+------------------- | |Caffein| Time of | Duration | No.| Weight.| per | appearance | of life. | Remarks. | | kilo. | of symptoms.| | ----+--------+-------+-------------+--------------+------------------- |_Grams._|_Gram._| | | 71| 1,659 | 0.3 |85 minutes |24 hours |Gray. 61| 2,143 | .3 | |At the end of |Black. | | | | injection | 72| 1,402 | .3 |8 minutes |1.25 hour |Gray and white. ----+--------+-------+-------------+--------------+------------------- SERIES B, GROUP I. ----+--------+-------+-----------+--------------+--------------------- 70| 1,487 | 0.2 | |10 days |Gray and white. 93| 1,492 | .2 |5 minutes |2.5 hours |Maltese; given second | | | | | dose after 3 days, | | | | | died 2.5 hours later. 69| 1,492 | .2 |About |Survived |White. | | | 5 minutes | | 92| 1,388 | .2 |5 minutes |24 hours |Yellow. 309| 1,500 | .2 | |20 minutes |Belgian; oats. ----+--------+-------+-----------+--------------+--------------------- SERIES B, GROUP II. ----+--------+-------+-------------+--------------+------------------- 308| 1,350 | 0.15 |3 hours and |About 2.5 days|Belgian; oats. | | | 40 minutes| | 307| 1,320 | .15 |1 hour |24 hours | Do. | | | 24 minutes| | ----+--------+-------+-------------+--------------+------------------- SERIES C. ----+--------+-------+-------------+--------------+------------------- 223| 1,165 | 0.125|2 hours |Survived |Belgian; carrots. 293| 1,605 | .1 | | do. | Do. 295| 1,205 | .1 | | do. | Do. 292| 1,595 | .1 | | do. | Do. 298| 1,205 | .125|1.5 hours | do. | Do. ----+--------+-------+-------------+--------------+------------------- SERIES D. ----+--------+-------+-------------+--------------+------------------- 310| 880 | 0.2 |2 days(1) |About |Belgian; oats. | | | | 2.5 days(1)| 311| 650 | .2 | |Survived | Do. 312| 740 | .2 |40 minutes |4.5 hours |Maltese; oats. 78| 659 | .257|15 minutes |Survived |Yellow and white; | | | | | oats. 75| 842 | .2 | do. | do. |Gray and white. 74| 692 | .2 | do. | do. | 317| 635 | .252|1 hour |About 2 hours |Belgian; oats. | | | 25 minutes| | 323| 820 | .25 |1 hour |Survived |White; oats. | | | 15 minutes| | ----+--------+-------+-------------+--------------+------------------- (1) Not due to caffein. INTRAMUSCULAR INJECTION. Well-fed rabbits, which received a diet exclusively of oats, were used for these experiments. The injections were made into the lumbar or into the gluteal muscles. SERIES A. In this series the caffein was injected into the gluteal muscles. _Rabbit 284. Brown and white, female. Weight, 1,100 grams._ December 14: 2 p. m., 11 cc 2 per cent caffein injected into the gluteal muscles (0.2 gram per kilo), under observation until 5 p. m., had frequent convulsions; at 5 p. m. in a comatose condition. Rabbit was found dead the next morning. _Rabbit 286, white and black, female. Weight, 1,315 grams._ December 15: 2.30 p. m., 13 cc 2 per cent caffein injected into the gluteal muscles (0.1977 gram per kilo), tremors and increased reflexes observed during the next two hours, but no other symptoms. December 17: Rabbit alive. _Rabbit 285, yellow and white, female. Weight, 1,385 grams._ December 14: 10.15 a. m., 14 cc 2 per cent caffein injected into the gluteal muscles (0.2 gram per kilo), general tremors, but no convulsions observed. Rabbit survived. December 17: Rabbit still alive. _Rabbit 287. Belgian hare, female. Weight, 1,140 grams._ December 15: 2.15 p. m., 11 cc of 2 per cent caffein injected into the gluteal muscles; 2.30 p. m., tonic contractions of posterior limbs. Paralysis and death at 2.40 p. m. SERIES B. In series B the caffein was injected into the lumbar muscles. _Rabbit 307. Belgian hare, female. Weight, 1,175 grams._ February 16: 11.05 a. m., 8 cc 2 per cent caffein injected (0.136 gram per kilo) into the lumbar muscles; under observation until 4 p. m., no symptoms; 4 p. m., allowed to walk on the floor; after walking a short distance loss of coordination and paralysis of posterior extremities; 5.20 p. m., found dead. _Rabbit 306. Belgian hare, female. Weight, 1,860 grams._ February 16: 11 a. m., 12.5 cc 2 per cent caffein injected into the lumbar muscles; 12 noon, no symptoms; 2 p. m., walked about 10 feet, exhaustion and paralysis; 3 p. m. found dead. _Rabbit 181. Belgian hare. Weight, 1,230 grams._ (Was experimented on some time previously.) February 16: 10.55 a. m., 8 cc 2 per cent caffein injected into the lumbar muscles; (0.130 gram per kilo); 12 noon, no symptoms; 2 p. m., no symptoms; 3 p. m., put on the floor, walked about 10 feet and was exhausted, posterior extremities paralyzed; 4 p. m., found dead. SERIES C. In the fall of the same year additional experiments were carried out with doses ranging from 100 to 200 milligrams of caffein per kilo, which were injected into the lumbar muscles. The results are given in the following abbreviated protocols: _Rabbit 425. Belgian hare. Weight 1,520 grams._ September 27: 10.30 a. m., 7.5 cc 2 per cent caffein injected into the lumbar muscles; 2 p. m., reflexes increased. September 28: Rabbit normal. October 5: Weight, 1,620 grams; 2.50 p. m., 10 cc 2 per cent caffein injected into lumbar muscles; 3.05 p. m., reflexes increased. October 13: Weight, 1,520 grams; 10.30 a. m., 10 cc 2 per cent caffein (131 mg per kilo) injected; 11 a. m., no symptoms; 11.30 a. m., reflexes much increased. October 14: Alive, no symptoms. _Rabbit 426. Belgian hare, female. Weight, 1,425 grams._ September 27: 7 cc 2 per cent caffein injected into the lumbar muscles at 10.30 a. m.; 2 p. m., reflexes increased. September 28: Rabbit normal. October 5: Weight, 1,425 grams; 2.55 p. m., 9 cc 2 per cent caffein injected into lumbar muscles; 3.05 p. m., reflexes increased. October 13: Weight, 1,405 grams; 10.30 a. m., 10 cc 2 per cent caffein (142 mg per kilo) injected; 11 a. m., no symptoms; 11.30 a. m., reflexes increased. October 14: Rabbit alive, no symptoms. _Rabbit 427. Belgian hare, female. Weight, 1,780 grams._ September 27: 9 cc 2 per cent caffein injected into the lumbar muscles; 2 p. m., reflexes increased. September 28: Rabbit normal. October 5: Weight, 1,850 grams; 3 p. m., 11.5 cc 2 per cent caffein injected into lumbar muscles; 3.10 p. m., reflexes increased. October 13: Weight, 1,830 grams; 10.40 a. m., 14 cc 2 per cent caffein (153 mg per kilo) injected into lumbar muscles; 11 a. m., no symptoms; 11.30 a. m., reflexes increased. October 14: Rabbit alive, no symptoms. _Rabbit 453. Belgian hare, male. Weight, 1,160 grams._ October 12: 3.45 p. m., 11.5 cc 2 per cent caffein in aqueous solution injected into lumbar muscles; 4.15 p. m., reflexes increased; 4.30 p. m., paralyzed. October 13: 9 a. m., found dead. _Autopsy_: Gastric mucosa hemorrhagic; liver darkened; other organs normal. _Rabbit 455. Belgian hare, gray, female. Weight, 1,185 grams._ October 12: 3.30 p. m., 11.5 cc 2 per cent caffein injected into the lumbar muscles; 4 p. m., reflexes increased. October 13: Rabbit weighed 1,070 grams, no symptom of caffein poisoning, reflexes normal; 10.30 a. m., 10 cc 2 per cent caffein injected into the lumbar muscles; 11.30 a. m., jumped off the table, had attack of convulsions and died. _Autopsy_: Findings same as in No. 453. _Rabbit 428. Belgian hare, gray, male. Weight, 1,650 grams._ October 5: 4 p. m., 14.8 cc 2 per cent caffein (0.18 gram per kilo) injected into the lumbar muscles. October 6: Found dead. _Rabbit 429. Belgian hare, male. Weight, 1,340 grams._ October 5: 4 p. m., 13.5 cc 2 per cent caffein (0.2 gram per kilo) injected into lumbar muscles. October 8: Rabbit found dead. SERIES D. Further experiments making injections into both the lumbar and the gluteal muscles, were made in this series. _Rabbit 577. Gray male. Weight, 1,380 grams._ February 14: 3 p. m. 14 cc 2 per cent caffein injected into the gluteal muscles of the right side; 3.10 p. m., restless, jumped off the table and walked about, reflexes increased; 3.45 p. m., passed 30 cc clear, straw-colored urine; 4.45 p. m., allowed to walk about, ran across the room, about 20 feet, looked tired, stretched himself out on the floor, then raised himself and walked about showing no disturbance of gait. February 15: 9 a. m., found dead. _Rabbit 578. Gray, female. Weight, 1,670 grams._ February 14: 3.05 p. m., 18 cc 2 per cent caffein solution injected into the gluteal muscles of the right side; 3.15 reflexes increased, but not restless; 5 p. m., allowed to walk about, no symptoms observed. February 15: Found dead. _Rabbit 579. White and gray, male. Weight, 1,490 grams._ February 14: 3.15 p. m., 15 cc 2 per cent caffein solution injected into the gluteal muscles of the right side; put in cage; 3.30 p. m., reflexes increased; 5 p. m., taken out of cage and allowed to walk across the room, no special symptoms noticed. February 23: Still alive. _Rabbit 580. Gray male. Weight, 1,510 grams._ February 14: 3.35 p. m., 15 cc 2 per cent caffein solution injected into lumbar muscles. February 23: Still alive, in good condition. _Rabbit 581. Gray female. Weight, 1,680 grams._ February 14: 3.45 p. m., 17 cc 2 per cent caffein solution injected into the lumbar muscles of the right side; 4 p. m., reflexes increased; 4.15 p. m., jumped off the table and had wild convulsions, became very restless, walked about the laboratory; 4.25 p. m., had convulsions occasionally; 4.30 p. m., extremities extended and quite rigid; 4.35 p. m., convulsions and death. _Rabbit 582. Gray male. Weight, 1,870 grams._ February 14: 4.15 p. m., 18 cc 2 per cent caffein solution injected into the lumbar muscles of right side; 5 p. m., reflexes increased; walked about in the room, then rested; 5.15 p. m., had short spasm when handled. February 23: Alive; good condition. The data presented in these experiments show that the toxicity of caffein when injected into the muscles of the lumbar regions is the same as when injected into the gluteal muscles. The rabbits of series A received approximately 0.2 gram caffein per kilo and two died as a result of this treatment. The other two survived but symptoms of caffein intoxication were observed. In series B smaller doses proved fatal, from which it would appear that caffein is more toxic when injected into the lumbar muscles. Further observations, however, failed to corroborate the results obtained in this series. Thus, in series C, 130 to 150 mg of caffein per kilo injected into the lumbar muscles produced mild symptoms only. Experiments with larger doses showed that 0.180 gram caffein per kilo may cause death. It will be noticed, on the other hand, that rabbit No. 455 survived a dose of 0.2 gram per kilo. New experiments were therefore carried out in which the same amounts of caffein in proportion to the weight of the animals were injected into the lumbar muscles as into the gluteal muscles. As shown in the experiments of series D, one rabbit (No. 581) died shortly after caffein was injected into the lumbar muscles; two recovered. Two of the three which received injections into the gluteal muscles were found dead the next day; one recovered. Post-mortem examination failed to indicate the presence of any abnormalities. The rate of absorption of caffein from the gluteal and from the lumbar muscles seems to be, therefore, the same, or not to differ very much. The observations of Auer and Meltzer(7) are of interest in this connection. According to their investigations adrenalin is more rapidly absorbed from the lumbar than from the gluteal muscles. This is in all probability due to the greater delicacy of the test they employed (since they judged the rate of absorption by the effect of adrenalin on blood pressure) as well as to the much greater activity of the substance. TABLE 4.--_Intramuscular injections._ SERIES A. ----+--------+-------+----------+-----------+----------+-------------- | |Caffein| | | | No.| Weight.| per | Symptoms | Duration | Site of | Remarks. | | kilo | after-- | of life. |injection.| ----+--------+-------+----------+-----------+----------+-------------- |_Grams._|_Gram._| | | | 284| 1,100 | 0.200 | 3 hours |Less than | Gluteal |White and | | | | 20 hours | | brown female. 286| 1,315 | .1977| 2 hours |Survived | do. |White and | | | | | | black female. 285| 1,385 | .200 | Present | do. | do. |Yellow and | | | | | | white female. 287| 1,140 | .210 |15 minutes|25 minutes | do. |Gray female. ----+--------+-------+----------+-----------+----------+-------------- SERIES B. ----+--------+-------+----------+-----------+----------+------------- 307| 1,175 | 0.136 | 5 hours |6 hours, | Lumbar |Gray female. | | | | 20 minutes| | 306| 1,860 | .134 | 3 hours |4 hours | do. | Do. 181| 1,230 | .130 | 4 hours |5 hours | do. |Gray. ----+--------+-------+----------+-----------+----------+------------- SERIES C. ----+--------+-------+----------+-----------+----------+------------- 425| 1,520 | 0.131 | 1 hour |Survived | Lumbar |Gray. 426| 1,405 | .142 |30 minutes| do. | do. |Gray female. 427| 1,830 | .153 |50 minutes| do. | do. | Do. 453| 1,160 | .200 |30 minutes|Less than | do. |Gray male. | | | | 20 hours | | 455| 1,185 | .200 | do. |Survived | do. |Gray female. 428| 1,650 | .180 | |Less than | do. |Gray male. | | | | 20 hours | | 429| 1,340 | .200 | | do. | do. | Do. ----+--------+-------+----------+-----------+----------+------------- SERIES D. ----+--------+-------+----------+-----------+----------+------------- 577| 1,380 | 0.200 |10 minutes|Less than | Gluteal |Gray male. | | | | 18 hours | | 578| 1,670 | .210 | do. | do. | do. | Do. 579| 1,490 | .200 |15 minutes|Survived | do. |White and | | | | | | gray male. 580| 1,510 | .200 | | do. | Lumbar |Gray male. 581| 1,680 | .200 |15 minutes|50 minutes | do. | Do. 582| 1,870 | .192 |45 minutes|Survived | do. | Do. ----+--------+-------+----------+-----------+----------+------------- Examination of Table 4 shows that 14 rabbits received from 180 to 210 mg caffein per kilo. The appearance of symptoms in these rabbits varied considerably. In some increased reflexes could be noticed in 10 to 15 minutes after the injection of caffein; in others it was delayed 2 or 3 hours. It might be added that the onset of symptoms occurred in many cases very soon after the administration of the drug--on an average about 10 to 30 minutes after the drug was injected. After smaller doses were administered by injection into the lumbar muscles the appearance of symptoms was delayed several hours in some cases. The duration of life in these 14 rabbits varied considerably. Eight of them died within 1 to 20 hours; six survived. About 0.2 gram caffein per kilo may be regarded as the minimum fatal dose, while the minimum toxic dose is somewhere between 130 and 150 mg per kilo. INTRAVENOUS INJECTION. These experiments were carried out on well-fed, full-grown gray rabbits. The diet for several days preceding the experiments consisted of oats or carrots, which were given ad libitum. The injections were made into the ear veins from a burette or by means of a syringe, the temperature of the caffein solution being about 40° C. Attention was also directed to the effect of the rate of injection and of the concentration on the toxicity. The minimum toxic as well as lethal doses were determined as shown in the following experiments. SERIES A. In these experiments the rate of injection was about 1 cc of 2 per cent caffein solution per minute. _Rabbit 194. White, female. Weight, 1,310 grams._ October 19: Injected 7.5 cc 2 per cent solution caffein (115 mg per kilo) into the ear vein. Rabbit showed stiffness; paralysis of extremities appeared soon after.[C] Rabbit survived. [C] Time of injection inadvertently omitted, but was probably not slower than in the other cases of this series. _Rabbit 556. Gray, female. Weight, 1,635 grams._ January 31: 2 p. m., 11 cc 2 per cent caffein (134 mg per kilo) injected into ear vein, in about 11 minutes; 2.10 p. m., convulsions, rabbit remained lying on its side; during the rest of the hour it had convulsions occasionally; 3.20 p. m., convulsions and died. Rabbit did not urinate after the injection of caffein. _Rabbit 557. Gray, female. Weight, 1,580 grams._ January 31: 2.30 to 2.37 p. m., 7 cc 2 per cent caffein injected from the burette at the rate of 1 cc per minute; 2.37 p. m., flow of liquid ceased, veins were engorged and bled freely, injection was continued by means of a syringe; 2 cc 2 per cent caffein injected in two minutes; injections discontinued as convulsions appeared; 2.50 p. m., rabbit raised itself but fell over; 3.10 p. m., rabbit assumed normal attitude, walked about the floor without manifesting any signs of the effects of caffein; 4.30 p. m., walked about, gait normal, condition seemed to be good. February 1: 2 p. m., condition good, appetite good, total amount of caffein injected, 9 cc 2 per cent solution, or 114 mg per kilo. _Rabbit 558. Gray, female. Weight, 1,590 grams._ January 31: 3 p. m., given 8 cc 2 per cent caffein in eight minutes; 3.10 p. m., violent convulsions; 3.20 p. m., rabbit was stretched out on his abdomen, extremities extended, urinated; 4.30 p. m., looked normal; was able to walk about. February 1: 2 p. m., condition good, appetite good. _Rabbit 292. Belgian hare, male. Weight, 1,770 grams._ February 18: 4.26 to 4.39 p. m., 12.5 cc warm caffein solution (0.141 gram per kilo) injected into ear vein, convulsion followed when this quantity was injected, tonic rigidity of limbs followed soon after; 4.52 p. m., condition unchanged, rabbit on floor, limbs stretched out, and lying on abdomen. _Rabbit 294. Belgian hare, female. Weight, 1,350 grams. Carrot diet for about 10 days before the experiment._ February 19: 12.20 p. m., 5 cc 2 per cent caffein (74 mg per kilo) injected into ear vein in five minutes, edema of the ear, other ear used, 3.5 cc injected in 10 minutes, repeated convulsions; 1.25 p. m., rabbit still alive, frequent attacks of convulsions; 2.30 p. m., found dead. Total amount injected in 15 minutes, 8.5 cc, or 0.126 gram per kilo. It will be observed in the preceding experiments that symptoms of severe intoxication were present in all of the six rabbits, but only two of these (Nos. 294 and 556) died from the effects of caffein. Of those which survived, three received doses of 100 to 114 mg caffein per kilo, and another (No. 292) received 141 mg of caffein per kilo. The death of rabbits Nos. 294 and 556 may be regarded therefore as a case of exceptionally low resistance to caffein. SERIES B. Doses of 160 to 200 mg caffein per kilo were employed in these experiments. The rate of injection was 1 cc per minute, with the exception of Experiment 254, in which 10.8 cc 2 per cent caffein were introduced in 17 minutes and 25 seconds. _Rabbit 562. Gray female. Weight, 1,650 grams. Diet, oats._ February 1: Injection began at 3 p. m., injected 10 cc in 12 minutes; 3.01 p. m. to 3.09 p. m., 3 cc injected, convulsions; 3.09 p. m. to 3.14 p. m., 3 cc injected, followed by violent convulsions, marked opisthotonos; 4.30 p. m., rabbit died; total quantity injected, 16 cc. _Rabbit 561. Gray female. Weight, 1,450 grams. Diet, oats._ February 1: Injection began at 11.40 a. m.; 11.48, rabbit struggled, 7 cc 2 per cent caffein injected; 11.50, convulsions, 10 cc 2 per cent caffein total amount injected; 11.55 a. m., injections stopped; injections resumed 11.58, violent convulsions, injections discontinued, total quantity received, 14.5 cc 2 per cent caffein solution; 1.30 p. m., found dead, did not urinate, 25 cc urine found in the bladder. _Rabbit 560. Gray male. Weight, 1,620 grams. Diet, oats._ February 1: Injection began 11 a. m.; 11.10 a. m., 7 cc 2 per cent caffein injected, rabbit struggled; 1 cc was injected during the next three minutes, rabbit struggled but there were no convulsions, injection stopped; resumed at 11.15 a. m. and continued 10 minutes, 8 cc 2 per cent caffein introduced during this time; total amount caffein injected, 16 cc; reflexes markedly increased; 12 noon, tetanic convulsions off and on until 2 p. m., then remained stretched out on abdomen, extremities extended. February 2: 9 a. m., found dead. _Rabbit 559. Gray female. Weight, 1,875 grams. Diet, oats._ January 31: 4 p. m., convulsions after injection of 9 cc 2 per cent caffein in 14 minutes; 4.08 p. m., convulsions after injection of 7 cc caffein in 8 minutes; 4.10 to 4.12 p. m., injected 2 cc more, rabbit lying stretched out on abdomen, extremities extended; total amount of caffein injected, 18 cc (190 mg per kilo). February 1: 2 p. m., condition good, walked about, appetite good, passed 155 cc dark, reddish-brown urine since 5.30 p. m. previous day. _Rabbit 279. Gray and white female. Weight, 1,320 grams._ February 24: 10.09 a. m., 6 cc 2 per cent caffein passed rapidly into jugular vein; 10.15 a. m., involuntary twitching of muscles of legs, but no other symptoms; 10.23 to 10.26, 3 cc of 2 per cent caffein injected; 10.27 to 10.28, 2 cc 2 per cent caffein injected, convulsions; 10.29, convulsions stopped; 10.32, convulsions; 11 a. m., rabbit lying on its side, anterior extremities paralyzed, posterior extremities contracted, no clonic convulsions, breathed deeper and more slowly than normal; 11.10 a. m., rabbit died, had no convulsions immediately before death; amount of caffein injected, 11 cc 2 per cent solution, or 0.166 gram per kilo. _Rabbit 254. Belgian hare, female. Weight, 1,285 grams. Diet, oats._ November 12: 1.30-1/3 to 1.47¾ p. m., received 10.8 cc 2 per cent caffein from burette into ear vein, after injection of 6.2 cc dyspnoea, 6.7 cc struggling, convulsions; at 1.50½ p. m., released from holder, paralysis especially marked in the anterior extremities; 1.50 p. m., recovered, survived; total amount injected, 10.8 cc 2 per cent caffein in 17 minutes and 25 seconds, or 0.16 gram caffein per kilo. _Rabbit 255. Belgian hare, male. Weight, 1,105 grams. Diet, oats._ November 12: 2.31¾ to 2.35¼ p. m., received 3.7 cc; from 2.37-1/6 to 2.46-1/6 p. m., 5 cc injected; after injection of 6.1 cc convulsions followed by dyspnoea, then continuous struggling; when 8.3 cc were injected rabbit had another convulsion; 2.47 p. m., tonic contraction of anterior extremities; amount injected, 8.7 cc (158 mg per kilo) in 15 minutes and 35 seconds. _Rabbit 567. Gray female. Diet, oats._ February 6: Injection began at 4.11 p. m.; 4.18, convulsions after injection of 5 cc 2 per cent caffein; 4.21, convulsion after total injection of 8 cc; 4.24 p. m., injection resumed and 2 cc more introduced; 4.28 p. m., convulsions, injected 2 cc more; total caffein injected, 12 cc, or 162 mg per kilo; 4.40 p. m., rabbit paralyzed in posterior extremities; 5 p. m., found dead. In the eight experiments comprising series B rabbits Nos. 567, 254, 279, and 255, which may be designated as Group II, received doses of 162, 160, 166, and 158 mg, respectively. Nos. 562, 561, 560, and 559, which may be designated as Group I, received about 200 mg caffein per kilo. In Group II, which received the smaller doses, one (No. 254) survived. This may be regarded as exceptional, since, as was shown in the experiments of the preceding series, even smaller doses may be fatal. About 160 mg per kilo is, therefore, the smallest surely fatal dose. This might be regarded as a contradiction of the results obtained for rabbit No. 559, but it will be noticed that in this case diuresis was very marked. The results of experiments Nos. 294 and 255 are of interest in this connection, since they indicate that a moderate difference in the rate of injection is without any effect on the toxicity of caffein. The greater resistance to caffein of rabbit No. 559 is in all probability due, therefore, to increased diuresis. SERIES C. In these experiments the minimum toxic dose was determined. The conditions were the same as in the experiments of the other series. _Rabbit 293. Belgian hare, female. Weight, 1,610 grams. Diet, oats._ February 18: 3.40 to 3.43 p. m., 4 cc 2 per cent warm caffein solution injected into ear vein, convulsions when 3 cc were injected, repeated attacks; 4 p. m., raised itself on legs, but fell over immediately and lay stretched on abdomen. February 19: 9 a. m., rabbit looked normal, apparently recovered. _Rabbit 227. White male. Weight, 2,320 grams._ October 26: 3.29¼ to 3.37½ p. m., injected into ear from burette 6.7 cc 2 per cent caffein, no symptoms; experiment discontinued; survived. _Rabbit 563. Gray female. Weight, 1,650 grams. Diet, oats._ February 6: Injection began at 1.02 p. m., injected 3.5 cc 2 per cent caffein (42 mg per kilo) in four minutes, 0.6 cc more within the next two and one-half minutes, total amount injected 4.1 cc; 1.10 p. m., hypersensitive, some disturbance of muscular coordination; restlessness; 1.35. p. m., reflexes decreased, urinated and walked about, gait normal. Under observation for several days; no symptoms noted. _Rabbit 564. Gray female. Weight, 1,515 grams._ February 6: Injection began at 1.26 p. m., 3.5 cc 2 per cent caffein (46 mg per kilo) injected at the rate of 1 cc per minute; 1.30 p. m., reflexes increased; 1.34 p. m., marked paresis of the extremities, rabbit stretched out on abdomen, legs abducted and partly extended, able to hop about but gait disturbed, no untoward symptoms noticed, under observation for several days after experiment. _Rabbit 565. Gray female. Weight, 1,545 grams. Diet, oats._ February 6: Started to inject at 3.40 p. m., received 2.5 cc 2 per cent caffein intravenously in two minutes or 32 mg per kilo, under observation all afternoon, no symptoms. _Rabbit 566. Gray female. Weight, 1,900 grams. Diet oats._ February 6: Injection began at 3.05 p. m., received 3 cc 2 per cent caffein intravenously in three minutes or 31 mg per kilo, no symptoms observed. These experiments show that a dose of about 50 mg per kilo when injected intravenously produces mild symptoms, such as increased reflexes. In the four experiments with this amount of caffein these effects were observed in each case. In the experiments in which smaller quantities, 30 mg per kilo, were given intravenously there was no manifestation of symptoms. A dose not over 50 mg per kilo may, therefore, be regarded as the minimum toxic dose when injected intravenously under the conditions stated. SERIES D. A 0.5 per cent caffein solution was used in these experiments in order to test the effect of concentration on its toxicity; the rate of injection was 1 cc per minute. _Rabbit 569. Gray male. Weight, 1,475 grams. Diet, oats._ February 6: 11.50 a. m. to 12.01 p. m., injected 10 cc 0.5 per cent caffein; 12.03 to 12.12 p. m., injected 10 cc of 0.5 per cent caffein; 12.13 to 12.26 p. m., injected 10 cc of 0.5 per cent caffein, total amount injected, 30 cc; 12.20, passed 35 cc of urine; 12.30, increased reflexes, but no convulsions; 4 p. m., reflexes increased. February 11: Alive, condition good. _Rabbit 574. Gray female. Weight, 1,555 grams. Diet, oats._ February 8: 10.25 to 10.33 a. m., injected 4 cc of 0.5 per cent caffein in salt solution, injection discontinued for five minutes; 10.38 to 11.10, injected 30 cc, total amount of caffein solution received, 34 cc; 11.55 a. m., very sensitive; reflexes markedly increased. February 9: Alive, condition good. _Rabbit 571. Gray female. Weight, 1,530 grams. Diet, oats._ February 7: Injection 3.18 to 3.50 p. m., received 30 cc in 32 minutes, not hypersensitive; 3.55, restlessness and weakness of extremities; 4.10 p. m., control of anterior extremities impaired, distinctly paretic but tried to walk about, died the same afternoon. _Rabbit 568. Gray male. Weight, 1,605 grams. Diet, oats._ February 7: Injection 10.53 to 11.01 a. m., injected 10 cc 0.5 per cent caffein; 11.03, injection resumed after two minutes interval; 11.14, received 10 cc 0.5 per cent caffein intravenously in 11 minutes; 11.16, injection resumed; 11.35, received 12 cc 0.5 per cent caffein, total amount of caffein solution received, 32 cc; 12.30 p. m., urinated 14 cc of bloody urine; 12.55 p. m., convulsions and death a few minutes later. Autopsy showed congestion of viscera, but no other lesions. _Rabbit 570. Gray female. Weight, 1,225 grams. Diet, oats._ February 7: 2.06 to 2.35 p. m., injected 24.5 cc 0.5 per cent caffein, reflexes increased but no convulsions, paresis especially marked in the anterior extremities; 3 p. m., passed urine which was normal in appearance, reflexes not increased but rabbit was weak. February 9: Found dead. _Autopsy_: Liver, spleen, and kidneys congested; large intestines hemorrhagic; omentum congested and showed the presence of small caseous nodules; liver showed adhesion to diaphragm; viscera presented the appearance of intraabdominal infection. Of the five rabbits of this series three died as a result of the administration of caffein. The other two which survived showed mild symptoms only, such as increased reflexes, but no evidence of severe poisoning such as was observed after the injection of the same doses of caffein in series A when a 2 per cent solution of caffein was injected. Convulsions were noticed in one case only (No. 568); paresis in two cases (Nos. 570 and 571). The nervous symptoms even in this group, therefore, were much milder than in series A. The percentage of death, however, was greater than in series A, in which the concentration of caffein was four times as great. It is quite probable that the strain on the heart due to the sudden increase in volume of the blood and its dilution might be an important factor in increasing the toxicity of caffein. It is conceivable that doses just sufficiently large to depress the normal heart may cause paralysis of an already overstrained organ. SERIES E. In the two experiments of this series the rate of injection as a possible factor influencing the toxicity of caffein was tested. A 2 per cent caffein solution was injected at the rate of 1 cc in two and one-half to three minutes. _Rabbit 572. Gray male. Weight, 1,770 grams. Diet, oats._ February 8: Injection began at 3 p. m., discontinued at 3.37 p. m., and resumed at 3.38 p. m.; rabbit was restless; injection finished at 3.52 p. m. Total quantity received, 17.4 cc 2 per cent caffein intravenously in 52 minutes; struggled intermittently during the injection; anterior legs paralyzed. February 9: Found dead. _Rabbit 573. Gray male. Weight, 1,810 grams. Diet, oats._ February 8: Started to inject at 1.35 and discontinued at 2.27 p. m.; received 18 cc 2 per cent caffein intravenously in 52 minutes; reflexes markedly increased soon after; 2.45, passed bloody urine; 4.30 p. m. reflexes increased; no other symptoms. February 9: 9 a. m., found dead. It will be observed that some retardation of the onset of symptoms was caused by slower injection, but the final result was the same as when the injections were made more rapidly. It is quite probable, therefore, that a much slower rate of injection may lessen considerably the toxicity of caffein. From the results of the experiments by intravenous injection summarized in the table, it appears that the minimum toxic dose for rabbits of a 2 per cent caffein solution, injected at the rate of 1 cc per minute, is about 50 mg per kilo. Twice the dose induces severe symptoms and may be fatal; 160 mg per kilo are surely fatal. If the rate of injection is diminished, the toxicity of caffein is lessened, but this effect is not marked unless the injections are very slow. Dilution of the caffein solution suppresses to some extent the nervous symptoms, but the toxicity, on the contrary, seems to be increased. TABLE 5.--_Intravenous injections._ SERIES A. ----+--------+-------+-----------+-----------+-------+--------------- | |Caffein| | Duration | | No.|Weight. | per | Symptoms. | of life. | Diet. | Remarks. | | kilo.| | | | ----+--------+-------+-----------+-----------+-------+--------------- |_Grams._| _Mg._ | | | | 194| 1,310 | 114 |Present |Survived |Oats |White female. 556| 1,635 | 134 |10 minutes |20 minutes | do. |Gray female. 557| 1,580 | 114 |Present |Survived | do. | Do. 558| 1,590 | 100 | do. | do. | do. | Do. 292| 1,770 | 141 | do. | do. | do. | Do. 194| 1,350 | 126 | do. |10 minutes |Carrots| Do. ----+--------+-------+-----------+-----------+-------+--------------- SERIES B, GROUP I. ----+--------+-------+-----------+-----------+-------+--------------- 562| 1,650 | 200 | |1½ hours |Oats |Gray female. 561| 1,450 | 200 | | do. | do. | Do. 560| 1,620 | 200 |Present |Less than | do. | Do. | | | | 24 hours | | 559| 1,875 | 190 | do. |Survived | do. | Do. ----+--------+-------+-----------+-----------+-------+--------------- SERIES B, GROUP II. ----+--------+-------+-----------+-----------+-------+--------------- 279| 1,320 | 166 | |1 hour | |Gray and white | | | | | | female. 254| 1,285 | 160 | |Survived |Oats |Gray female. 567| | 162 | |About 45 | | Do. | | | | minutes | | 255| | 158 | |Died | | ----+--------+-------+-----------+-----------+-------+--------------- SERIES C. ----+--------+-------+-----------+-----------+-------+--------------- 293| 1,610 | 500 |Present |Survived |Oats |Gray female. 227| 2,320 | 570 |None | do. | |White male. 563| 1,650 | 500 |Present | do. | do. |Gray female. 564| 1,515 | 460 | do. | do. | | Do. 565| 1,545 | 320 |None | do. | do. | Do. 566| 1,900 | 310 | do. | do. | do. | Do. ----+--------+-------+-----------+-----------+-------+--------------- SERIES D. ----+--------+-------+-----------+-----------+-------+--------------- 569| 1,475 | 100 |Present |Survived |Oats |Gray male. 574| 1,555 | 112 | do. | do. | do. | Gray female. 571| 1,530 | 100 | do. |About | do. | Do. | | | | 2 hours | | 568| 1,605 | 100 | |20 minutes | do. |Gray male. 570| 1,225 | 100 | |Less than | do. | Do. | | | | 20 hours | | ----+--------+-------+-----------+-----------+-------+--------------- SERIES E. ----+--------+-------+-----------+-----------+-------+--------------- 572| 1,770 | 200 |Present |About |Oats | | | | | 24 hours | | 573| 1,810 | 200 | | do. | do. | ----+--------+-------+-----------+-----------+-------+--------------- SUMMARY. The results of the experiments on rabbits show considerable variation in the toxicity of the single dose. Individuals differed so widely in their resistance to this drug that the same experiments had to be repeated many times with each method of administration before satisfactory conclusions could be drawn. This is strikingly illustrated in the experiments by intravenous injection in which a dose of nearly 0.2 gram per kilo was not fatal. Similar instances of exceptional resistance or of sensitiveness to caffein were observed when it was given in other ways. A comparison of the toxicity of caffein administered by different methods in this investigation shows well-marked differences in its activity, although they are not quite so striking as similar experiments with other alkaloids reported by several observers. The toxicity of caffein in these experiments on the rabbit indicates that it is greatest when given by vein and least when given by mouth. The ratio of the minimum toxic doses by these two methods of introduction of caffein was about 7.1; the relation of the minimum fatal dose was about 3.1. The toxicity when given subcutaneously is about 15 to 20 per cent greater than when given by mouth. The difference between the intramuscular and subcutaneous injection is even more marked. The toxicity of caffein when injected into the muscles is about midway between that administered by the subcutaneous and intraperitoneal routes, and is about half that injected intravenously. Meltzer and Auer,(58) who experimented with a number of drugs found that the intramuscular method of administration is as effective as the intravenous, fluorescin forming the only exception according to their observations. In the experiments of Sollman and Brown(81) with ergot, the effect was quite different from those obtained by Meltzer and Auer(58) with the drugs they used. It is quite possible that the result obtained with ergot is merely illustrative of a difference in the behavior of various substances in this regard. This appears probable on account of the difference in the rate of absorption for various substances. Thus, according to Achard, Gaillard, and Ribot (Compt. rend. Soc. biol., 1907, _62_: 90), absorption from the peritoneal cavity varies with the concentration of the solution and the size of the molecule. The smaller the molecule and the greater the concentration the more rapid the absorption. That the rate of absorption from the intramuscular tissues is unequal and varies for different substances appears from the experiments of Meltzer and Auer.(58) The difference was very striking between intramuscular and subcutaneous administration of curara or adrenalin; the results were somewhat different with morphin and with fluorescin. As shown in their protocols, the onset of the symptoms after the intramuscular injection of morphin was sooner than after subcutaneous injection, but in time the difference diminishes and disappears altogether. The absorption of fluorescin is much faster when the intramuscular path is used than when given subcutaneously, but the writers state that the rate falls far behind that of the intravenous administration. The difference in toxicity we observed between feeding by mouth and subcutaneous injection, although distinct, was not very great. It was much less than Maurel(55) obtained with the hydrobromid of caffein in the rabbit. Whether this difference between his results and ours is due to the use of the pure alkaloid in our experiments and the hydrobromid employed by Maurel can not be stated at present with any degree of accuracy. It is hoped that the work in progress in the laboratory will throw some light on the subject in the near future. But Maurel's(56) experiments show that various substances behave differently in this regard. Thus the toxicity of strychnin, he states, is three times as great when given subcutaneously as when given by mouth and six times that of the minimum fatal dose by vein. It may be remarked, however, that examination of his data shows that his doses are much too large for the rabbit. In experiments with other drugs little or no difference between the two modes of administration was noticed. Thus, digitalin was but slightly more active when given subcutaneously than by mouth, while the toxicity of emetin hydrochlorid was just the same, whichever one of these methods of introducing the substance was used. Differences in the toxicity of substances have also been observed between subcutaneous and intravenous modes of administration, but here, too, the differences for various substances were unequal. EXPERIMENTS ON GUINEA PIGS. The toxicity of caffein was studied in a large number of individuals. The experiments were conducted on full-grown animals and were carried out at different seasons of the year in a variety of ways. Special attention was given to diet as a possible factor influencing resistance to caffein, and the effect of different modes of administration on toxicity. Some animals were therefore fed oats, some carrots, others received both hay and oats. Caffein was introduced subcutaneously, intraperitoneally, and by mouth. SUBCUTANEOUS INJECTION. SERIES A. Preliminary experiments carried out on three guinea pigs, which received 360, 300, and 290 mg of caffein per kilo subcutaneously have shown that such doses were rapidly fatal. Two of the animals were seized with convulsions half an hour after the introduction of caffein and died during the attack. The other had tetanus two minutes after the injection of caffein. Repeated attacks followed, which terminated in the death of the animal two and a half hours later. The fatal and toxic doses must therefore be considerably under 0.3 gram of caffein per kilo when introduced by this path and smaller doses were therefore injected. The results are shown in the experiments of the next series. SERIES B. Experiments with 2 decigrams per kilo constituted this series. _Guinea pig 20. Female. Weight, 497 grams. Diet, oats._ April 2: 5 cc 2 per cent caffein injected subcutaneously at 11.30 a. m.; 1.50 p. m., spasm of short duration. Died at 3 p. m., three and one-half hours after injection. _Guinea pig 38. Brown male. Weight, 570 grams. Diet, carrots and oats week previous to injection._ February 11: 3.50 p. m., 6 cc 2 per cent caffein injected subcutaneously in back (210 mg per kilo); 4.15, reflexes increased, had convulsion of short duration when disturbed; 4.45 p. m., on handling, repeated convulsion and paralysis; 5 p. m., guinea pig lying on his side, respiration difficult and labored. February 11: 5.05 p. m., guinea pig found dead, 2 hours and 15 minutes after injection. _Guinea pig 37. Male. Weight, 820 grams. Diet, carrots and oats during week preceding the injection of caffein._ February 11: 3.35 p. m., 8.5 cc 2 per cent caffein injected subcutaneously in the back; 5 p. m., pig very sensitive, anterior extremities paralyzed when handled, frequent spasms of posterior extremities, no symptoms noticed before 5 p. m., although watched all the time; 5.05 p. m., guinea pig on his legs and looked normal. No attack on handling. February 12: 9 a. m., found dead; died within 18 hours. _Guinea pig 13. Female. Weight, 618 grams. Diet, oats._ March 29: 2.45, 6 cc 2 per cent caffein injected subcutaneously (0.194 grams per kilo). March 30: Died at 4 p. m., 25 hours after injection. _Guinea pig 36. Male. Weight, 850 grams. Fed oats and carrots for one week previous to injection._ February 11: 3.30 p. m., 8.5 cc 2 per cent caffein injected subcutaneously into back; 5 p. m., somewhat more sensitive than normal, no other symptoms, no effect on handling; 5.05 p. m., no symptoms. February 12: 9 a. m., found dead, about 18 hours after injection. The results of these experiments, as observed in five guinea pigs, indicate that two decigrams of caffein per kilo of animal produce symptoms within a half to about two and a quarter hours after injection. Death followed in two guinea pigs 70 minutes to 1 hour after the first manifestations of symptoms. Two others died during the night, while one lived 25 hours after the injection of caffein. Even 2 decigrams caffein per kilo weight might therefore be fatal to the guinea pig. Experiments carried out later have shown, however, that the resistance to caffein is appreciably greater in some guinea pigs. This is indicated by the following experiments, in which doses of 0.2 to 0.24 gram caffein per kilo were administered by the same path. SERIES C. _Guinea pig 66. Yellow and dark brown male. Weight, 510 grams. Diet, oats._ October 4: 5 cc 2 per cent caffein (0.2 gram per kilo) injected subcutaneously in the back at 3 p. m.; 5 p. m., no symptoms. October 5: 9 a. m., alive; condition good. October 9: Found dead. _Autopsy_: Congestion of liver, kidney, and small intestine. _Guinea pig 65. White and black male. Weight, 510 grams. Diet, oats._ October 4: 5 cc 2 per cent caffein (0.2 gram per kilo) injected subcutaneously in the back at 3 p. m.; 5 p. m., no symptoms. October 5: 9 a. m., condition good. _Guinea pig 60. White and gray female. Weight, 320 grams. Diet, oats._ October 3: 2.25 p. m., 3.5 cc 2 per cent caffein (0.219 gram per kilo) injected subcutaneously in the back; 3.40 p. m., convulsion with recovery; 3.50 p. m., frequent spasms with paralysis, especially of anterior extremities; 5.30 p. m., tetanus when removed from cage and put on floor. October 4: 8.50 a. m., found dead. _Autopsy_: Congestion of small intestines, lungs, liver. _Guinea pig 57. White and gray female. Weight, 350 grams. Diet, oats._ October 3: 2.15 p. m., 3.5 cc 2 per cent caffein injected subcutaneously in the back (0.2 gram per kilo); 3.40 p. m., convulsions with recovery; 5.30 p. m., no marked symptoms. October 4: 8.50 a. m., alive, active. October 6: Found dead at 9 a. m. _Autopsy_: Congestion of lungs and liver; kidneys petechiated; severe gastro-enteritis. _Guinea pig 68. Yellow male. Weight, 785 grams. Diet, oats._ October 6: 11.35 a. m., 7.8 cc 2 per cent caffein (0.2 gram per kilo) injected subcutaneously; 12 noon, reflexes increased markedly; 4.20 p. m., reflexes the same as at 12 noon. October 7: 9 a. m., dead. _Autopsy_: Lungs congested; liver congested and fatty; spleen congested, kidney showed hemorrhagic spots; gastric mucosa necrotic; small portion of small intestine inflamed. _Guinea pig 69. White male. Weight, 585 grams. Diet, oats._ October 6: 11.40 a. m., 5.8 cc 2 per cent caffein injected subcutaneously; 12 noon, reflexes increased, but not as much as in No. 68; 4.20 p. m., guinea pig hypersensitive, reflexes increased more than at 12 noon. October 7: 9 a. m., alive. October 15: 9 a. m., found dead. _Guinea pig 61. Brown and black female. Weight, 330 grams. Diet, oats._ October 3: 4 p. m., 4 cc 2 per cent caffein (240 mg per kilo) injected subcutaneously; 5.30 p. m., reflexes increased; runs, but drags posterior extremities. October 4: 8.50 a. m., found dead. _Guinea pig 62. White, yellow, and black female. Weight, 335 grams. Diet, oats._ October 3: 4.05 p. m., 4 cc 2 per cent caffein (238 mg per kilo) injected subcutaneously in the back; 5 p. m., convulsions; 5.20 p. m., convulsions, alternating with paralysis of anterior and posterior extremities. October 4: 8.50 a. m., found dead. _Guinea pig 70. White and brown male. Weight, 545 grams. Diet, oats._ October 7: 3 p. m., 6.5 cc 2 per cent caffein (238 mg per kilo) aqueous solution injected subcutaneously; 3.50 p. m., reflexes increased. October 9: 9 a. m., found dead. _Guinea pig 71. Brown and white male. Weight, 540 grams. Diet, oats._ October 7: 3 p. m., 6.5 cc 2 per cent caffein solution (0.24 gram per kilo) injected subcutaneously; 3.45 p. m., reflexes increased, tetanus. October 9: 9 a. m., found dead. _Guinea pig 72. Brown and white male. Weight, 560 grams. Diet, oats._ October 7: 3 p. m., 6.5 cc 2 per cent caffein (0.232 gram per kilo) aqueous solution administered by subcutaneous injection; 3.35 p. m., reflexes increased. October 10: found dead. _Autopsy_: Nos. 70, 71, 72 showed congestion of organs. The reaction to caffein in the experiments of this series (C) showed considerable variation. The appearance of symptoms, as well as the final outcome of the experiments, differed markedly in a number of cases, notwithstanding the fact that the conditions were the same; thus the administration of 0.2 gram per kilo to guinea pigs, all of which received the same diet, induced no symptoms in two of the animals (Nos. 66 and 65), while marked symptoms were observed in the other four; in two of these the symptoms appeared in one hour and a quarter after injection, and in two others (Nos. 68 and 69), mild symptoms only appeared in 20 or 25 minutes. The last two were under observation for 4 hours longer, but there was no visible change in their condition. The duration of life in all of these guinea pigs, as indicated in the table, likewise varied. Two (Nos. 60 and 68) died during the night after they received caffein, one survived (No. 65), and three others (Nos. 57, 66, and 69) lived 2½, 5, and 9 days, respectively. Experiments with larger doses likewise showed differences in the behavior of these animals toward caffein, but they were not quite so marked. As shown in the table, symptoms appeared in from 35 minutes to 1.5 hours after injection. The duration of life was less than 1 day in two pigs, about twice as long in two others, and in one case between 2 and 3 days. A comparison made with results obtained in the preceding series shows a striking difference in the resistance to caffein. As 2 decigrams per kilo proved more rapidly fatal to the guinea pig than the larger doses employed in the later experiments, this difference in the resistance to caffein may be due to several factors. As pointed out in the experiments on rabbits, age might be an important factor influencing the toxicity of caffein. Unfortunately, no accurate data were available on the age of the guinea pigs, but they were all apparently full grown, although they differed in weight considerably. The difference in their ages was in all probability not very great. Moreover, it will be observed that the resistance in series B and C differed in animals of approximately the same weight. This is evident on comparing experiments Nos. 20, 38, and 13 of series B with Nos. 65, 66, and 69 of the next series. Again, further inspection and analysis of these tables show no difference in the toxicity, although there may be considerable difference in the weight, from which it may be concluded that the animals were of about the same age or that this plays no part in the resistance to caffein in the guinea pig. Diet is another factor which should be taken into consideration in this connection. The recent work of Hunt(39) indicates that this may influence the resistance of animals to some poisons. Our experiments, however, fail to show any difference in the toxicity of the caffein in guinea pigs, whether fed oats, carrots, or both, for different results were obtained on the same diet, and there seemed to be little or no difference in the toxicity of caffein when the diet was different. Other explanations suggest themselves to account for the results obtained. Seasonal changes have been assigned by a number of investigators as a cause of variation in the resistance to drugs. According to Focke,(24) frogs are more susceptible to digitalis in the spring than in the summer, while Moschkowitsch(61) and Edmunds(21) reported the very opposite results. Schmiedeberg's(80) observations on strophantin in frogs were in harmony with those of Edmunds(21) and Moschkowitsch.(61) Similar results were reported with guinea pigs. Harrington's(34) experiments indicate that stimulation of the vagus is less effective from October to January than from February to April, when they are also much more susceptible to operative procedure. Hunt found that the resistance of guinea pigs to aceto nitril is about twice as great in the summer months as it is in January and February. Race might also be thought of as an important factor in this connection. Since the guinea pigs used at different seasons of the year were of several varieties, there is no reason to suppose, however, that the varieties experimented upon in the summer were more resistant than those used in the winter and spring. It is highly probable, therefore, that the greater resistance to caffein of the guinea pigs of series C than those of series B was due to seasonal variation. Doses of 0.20 to 0.24 gram caffein per kilo weight, therefore, may be regarded as the minimum fatal dose for the guinea pig, depending upon the season. Since 0.2 gram per kilo proved to be rapidly fatal in series B, this quantity was perhaps not the minimum fatal dose for the guinea pig at the season during which the experiments were made. Additional tests with smaller doses were therefore carried out during February and March. The results are shown in series D. SERIES D. _Guinea pig 49. Male. Weight, 510 grams. Diet, oats for 1 month previous to experiment._ March 17: 3 p. m., 4 cc 2 per cent caffein (0.16 gram per kilo) were injected subcutaneously; 4.40 p. m., reflexes increased; 5.40 p. m., no symptoms. March 18: 9 a. m., found dead, died in less than 18 hours. _Autopsy_: Hemorrhage into abdominal cavity; liver and spleen unduly congested; intestines injected; hemorrhagic area at point of injection. _Guinea pig 40. Male. Weight, 630 grams. Diet, oats and carrots one week previous to injection._ February 12: 11 a. m., 5 cc 2 per cent caffein (0.158 gram per kilo) injected subcutaneously into back. February 13: 1 p. m., still alive. February 14: 9 a. m., found dead. _Guinea pig 45. Female. Weight, 435 grams. Diet, oats for about one month previous to injection._ March 17: 3 p. m., 3.5 cc of 2 per cent caffein injected subcutaneously in the back (0.160 gram per kilo); 4.35 p. m., no symptoms; 5.40 p. m., no symptoms. _Guinea pig 39. Male. Weight, 820 grams. Diet, oats and carrots._ February 12: 11 a. m., 6 cc (0.15 gram per kilo) 2 per cent caffein injected subcutaneously in back. February 14: 9 a. m., alive; seemed to be in good condition; found dead at 1 p. m. _Guinea pig 41. Weight, 660 grams. Diet, oats and carrots one week previous to injection._ February 12: 11 a. m., 5 cc (0.15 gram per kilo) 2 per cent caffein injected subcutaneously. February 14: 2 p. m., pig alive; apparently normal. February 18: Guinea pig still alive and apparently in good condition. _Guinea pig 46. Female. Weight, 470 grams. Diet, oats about one month previous to experiment._ March 17: 3.15 p. m., 4 cc (0.170 gram per kilo) 2 per cent caffein injected into back subcutaneously; 4.35 p. m., reflexes increased, tremors on handling marked; 5.40 p. m., no change, symptoms about as before. March 18: 2.30 p. m., no symptoms. The experiments of this series (D) likewise showed a considerable difference in the resistance of the individual guinea pigs. Nos. 41, 45, and 46 survived; the rest of the pigs died within 18 hours to 2 days after the administration of caffein. Since an autopsy was held on one only, it is impossible to assign a cause for the variation in the toxicity of caffein in these guinea gigs, as the diet and the other conditions under which the experiments were conducted were the same. It was found in the experiments on cats and rabbits that the presence of morbid processes tends to increase the toxicity of caffein. The observations of Ophüls(66) are of interest in this connection. He found spontaneous lesions of the kidney and liver in a large proportion of guinea pigs examined. The greater susceptibility to caffein of guinea pigs Nos. 39, 40, 49, is probably due therefore to some pathological change which increased its toxicity. About 0.2 to 0.24 gram per kilo may therefore be regarded as the minimum lethal dose for the normal guinea pig when caffein is introduced subcutaneously, the minimum toxic dose being about 150-160 mg per kilo. Experiments were also conducted to determine the largest dose which does not produce any visible effects. In a number of tests with from 100 to 120 mg caffein per kilo (series E, see Table 6, p. 51) no manifestation of nervous or muscular disturbance nor any departure from the normal in respiratory activity was observed. Such quantities may be regarded as the largest doses which are surely safe for these animals. It is quite possible, therefore, that the greater variation in the toxicity of caffein observed in these experiments is due to morbid conditions. Moreover, there is some evidence that caffein increases the toxicity of certain poisons, as shown by Hale(33) for acetanilid. Is it not possible that caffein may similarly be affected by poisons circulating within the body? Indeed the recent work of Loeb(23) makes this supposition highly probable. This investigator found that caffein and adrenalin injected together produce myocarditis in the rabbit. It is conceivable that the combined action of caffein and some preexisting poison may cause changes which terminate in the death of the animal. The delayed death of guinea pigs after the administration of caffein observed in this and other series may probably be accounted for in this way. Experiment 57 lends some support to this view. The condition of the kidneys and the presence of a severe gastro-enteritis are sufficient to account for the death of this case. Again the frequent association of gastro-enteritis and congestion of the organs in caffein intoxication found in different animals makes it highly probable that these lesions were caused by caffein. INJECTION INTO THE PERITONEAL CAVITY. The experiments were carried out with different doses. All the guinea pigs in this series were kept on a uniform diet, consisting of oats. Most of them were of average size and there were no wide variations in their weights. The experiments of series A with the smallest doses were conducted in March and April; all the other experiments it will be noticed were made in October. SERIES A. _Guinea pig 41. Weight, 700 grams. Diet, oats._ April 1: 3.30 p. m., 4.5 cc 2 per cent caffein (130 mg per kilo) injected into peritoneal cavity. 5.35 p. m., symptoms present but no tetanus. April 2: Found dead about 2 p. m., duration of life about 22 hours. _Autopsy_: Subcutaneous hemorrhage at the point of inoculation; serious exudate on visceral and parietal peritoneum with marked inflammation of peritoneum; portions of intestines showed slight enteritis. _Guinea pig 49. Male. Weight, 370 grams. Diet, oats._ April 1: 3.15 p. m., 2.5 cc 2 per cent caffein (135 mg per kilo) injected into the peritoneal cavity; 5.30 p. m., symptoms present; reflexes increased, but no tetanus. Guinea pig survived. _Guinea pig 47. Female. Weight, 550 grams. Diet, oats since about February 4._ March 17: 3.30 p. m., 3.5 cc 2 per cent caffein (127 mg per kilo) injected into peritoneal cavity; 4.35 p. m., increased irritability present, but not marked; 5.40 p. m., symptoms about the same as before. March 18: 2.30 p. m., condition good; no symptoms. Survived. _Guinea pig 50. Female. Weight, 290 grams. Diet, oats._ April 1: 3.30 p. m., 2 cc 2 per cent caffein (138 mg per kilo) injected into peritoneal cavity; 5.35 p. m., symptoms present; reflexes much increased, but no tetanus. Survived. SERIES B. _Guinea pig 51. Yellow female. Weight, 415 grams._ October 1: 9.50 a. m., 3 cc (144 mg per kilo) 2 per cent caffein injected into peritoneal cavity; 4.30 p. m., no symptoms, although under observation all day. October 3: 2 p. m., alive. _Guinea pig 52. White male. Weight, 450 grams._ October 1: 9.45 a. m., 3.5 cc, 2 per cent caffein (155 mg per kilo), injected into peritoneal cavity; 4.30 p. m., no symptoms developed since injection. October 3: 2 p. m., alive. _Guinea pig 58. Brown and white male. Weight, 490 grams._ October 1: 9.45 a. m., 4 cc, 2 per cent caffein (163 mg per kilo), injected into peritoneal cavity; 4.30 p. m., no symptoms developed since injection. October 3: 2 p. m., alive. October 8: Found dead. _Autopsy_: Congestion of lungs, spleen, liver, kidneys, and small intestines. SERIES C. _Guinea pig 59. Gray and white. Weight, 375 grams. Diet, oats._ October 3: 2 p. m., 3.75 cc (0.2 gram per kilo) injected into peritoneal cavity; 2.15 p. m., reflexes increased but not markedly; 4 p. m., reflexes still more increased; no other symptoms; 5.30 p. m., no symptoms. October 4: 8.50 a. m., guinea pig alive and active. _Guinea pig 58. Brown and white. Weight, 380 grams. Diet, oats._ October 3: 2 p. m., 3.8 cc caffein (0.2 gram per kilo), 2 per cent solution, injected into peritoneal cavity; 2.10 p. m., hind legs extended, then tetanus; attack lasted a few seconds, after which pig raised himself on his legs, but reflexes remained much exaggerated; 4 p. m. to 5.30 p. m., no symptoms of caffein intoxication. October 4: 8.50 a. m., guinea pig alive and active. _Guinea pig 56. Gray and white male. Weight, 440 grams. Diet, oats._ October 1: 11.30 a. m., received 4.6 cc of 2 per cent caffein solution (0.2 gram per kilo) into abdominal cavity; 11.45 a. m., stiffness and rigidity of posterior extremities, reflexes increased; 12.30 p. m., hind legs paralyzed, reflexes increased; 4.35 p. m., no symptoms, guinea pig in good condition. October 3: Still alive in good condition. October 14: Died. _Autopsy_: Anterior lobe of right lung hepatized. Small portion of small intestine edematous. Other organs normal. _Guinea pig 55. White and yellow male. Weight, 690 grams. Diet, oats._ October 1: 11.30 a. m., received 6.5 cc of 2 per cent solution caffein (188 mg per kilo) into peritoneal cavity; 11.40 a. m., stiffness in all extremities, reflexes markedly increased; 12.30 p. m., reflexes increased, anterior and posterior extremities paralyzed; 3 p. m., found dead. SERIES D. _Guinea pig 67. Gray and yellow male. Weight, 330 grams. Diet, oats._ October 5: 11.25 a. m., 4 cc of 2 per cent caffein injected into peritoneal cavity (240 mg per kilo); 11.30 a. m., tetanus--survived, convulsions off and on. Death at 2.55 p. m. _Autopsy_: Severe gastroenteritis; kidney petechiated; congestion of lungs and liver. _Guinea pig 63. Gray and white male. Weight, 340 grams. Diet, oats._ October 5: 11.20 a. m., 4 cc of 2 per cent caffein (235 mg per kilo) injected into peritoneal cavity. October 14: Alive and in good condition. _Guinea pig 64. Brown and black female. Weight, 305 grams._ October 5: 11.35 a. m., 3.8 cc 2 per cent solution caffein (250 mg per kilo) injected into peritoneal cavity; 11.40 a. m., tetanus--survived, convulsions off and on, died at 4.15 p. m. _Autopsy_: Findings exactly the same as in No. 67. Examination of the results of the experiments by intraperitoneal injections showed that 0.2 gram caffein per kilo was toxic in two guinea pigs (Nos. 59 and 58). Severe symptoms were observed within 15 minutes in No. 56 and within one hour in No. 55 after the administration of approximately the same dose of caffein. One of these died within three and one-half hours; the other, No. 56, made a good recovery from the acute effects. This amount of caffein may be regarded, therefore, as the minimum toxic dose for the guinea pig when injected into the peritoneal cavity. This is corroborated by the experiments of series B in which smaller doses failed to show any muscular, nervous, or respiratory symptoms, nor were there any after effects noticed, as all of them survived and were kept under observation for some time. The guinea pigs of series A, however, seem to contradict these results. It will be remarked that appreciably smaller doses induced symptoms in all of them, and one case terminated fatally. The seasonal variation, as already pointed out, is in all probability likewise responsible for the difference in the resistance between the guinea pigs of series A and B. Tests were made also to determine the minimum fatal dose. For this purpose the experiments of series D were performed. The resistance of No. 63 in this series is quite striking. We are unable to explain such a discrepancy in the results obtained under practically uniform conditions. The minimum fatal dose of caffein, when injected into the peritoneal cavity, is therefore about 240 to 250 milligrams per kilo. These amounts, it will be observed, were rapidly fatal, in striking contrast to the results obtained when such doses were injected subcutaneously. This is probably due to a better absorption from the peritoneal cavity than from the subcutaneous tissues. ADMINISTRATION BY MOUTH. All the guinea pigs in these experiments were kept on a diet of hay and oats and were of large size. The tests were made with different doses of caffein in order to determine the limits of toxicity when the drug was administered by mouth. _Guinea pig 129. White and black male. Weight, 855 grams. Diet, oats and hay._ June 6: 2.20 p. m., 12 cc of 2 per cent caffein (0.28 gram per kilo) by mouth; 3 p. m., reflexes increased; 5 p. m., reflexes still more increased; no other symptoms. June 7: 9 a. m., found dead; guinea pig passed 75 cc urine, which was almost colorless. _Autopsy_: Heart and blood vessels injected; lungs congested; small intestines congested; other organs apparently normal. _Guinea pig 130. Black and brown male. Weight, 800 grams. Diet, oats and hay._ June 6: 2.30 p. m., 12 cc of 2 per cent caffein (0.3 gram per kilo) administered by mouth; 3 p. m., reflexes increased; 5 p. m., increase of reflexes greater than at 3 p. m. June 7: 9 a. m., found dead; only a few cubic centimeters of urine passed since 4 p. m. _Autopsy_: Heart and blood vessels injected; lungs congested; small intestines congested slightly. _Guinea pig 181. White and yellow male. Weight, 860 grams. Diet, oats and hay._ June 6: 2.40 p. m., 12 cc 2 per cent caffein administered by mouth; 3 p. m., reflexes increased; 5 p. m., reflexes still more marked. June 7: 9 a. m., found dead, pig passed about 5 cc urine since 4 p. m. of previous day. _Autopsy_: Same as in No. 130. _Guinea pig 136. White and black male. Weight, 1,000 grams. Diet, oats and hay._ June 9: 4 p. m., 7.5 cc 2 per cent caffein solution injected subcutaneously into the back; 4.50 p. m., reflexes increased. June 10: 9.30 a. m., more sensitive than normal guinea pigs, but reflexes not quite so marked as at 5 p. m. previous day, about 15 cc urine passed since caffein was injected, reduction of Fehling's solution considerable, no albumin. June 13: Alive and in good condition. Appetite good. (NOTE.--Parallel test with urine from two guinea pigs which did not receive caffein failed to show reduction of Fehling's solution.) _Guinea pig 137. White and brown male. Weight, 925 grams. Diet, oats and hay._ June 9: 4 p. m., 7 cc 2 per cent solution caffein injected subcutaneously; 4.50 p. m., reflexes increased. June 10: Reflexes less marked than at 5 p. m. previous day, but is more sensitive than normal guinea pig, about 10 cc urine passed since injection of caffein, moderate amount of reduction of Fehling's solution. June 13: Guinea pig alive, appetite good, condition good. June 16: 9 a. m., found dead. _Guinea pig 135. White and black male. Weight, 955 grams. Diet, hay and oats._ June 9: 3 p. m., 7.5 cc 2 per cent caffein solution given by mouth through stomach tube; 4.50 p. m., reflexes increased. June 10: Reflexes less than on previous day and less marked than in No. 136, a few cubic centimeters dirty brown urine collected but could not be tested for reduction. June 13: Condition good, appetite good. June 16: 9 a. m., found dead. _Guinea pig 134. White and brown male. Weight, 740 grams. Diet, hay and oats._ June 9: 2.55 p. m., 6 cc warm 2 per cent caffein solution given by mouth through stomach tube; 4.50 p. m., reflexes increased. June 10: 9.30 a. m., reflexes much less than day before, increase slight, a few cubic centimeters of urine passed since injection of caffein, looked brown and dirty, could not be tested for reducing substances. June 13: Guinea pig alive, appetite good, condition good. June 14: 9 a. m., found dead. _Guinea pig 128. White and black male. Weight, 1,075 grams. Diet, hay and oats._ June 7: 10 a. m., 11 cc 2 per cent caffein by mouth through stomach tube; 11.10 a. m., no symptoms, no urine passed; 1 p. m., increased reflexes, about 15 cc (estimated) urine passed; 4 p. m., reflexes increased, still more urine passed (about 20 cc); 4.50 p. m., tetanus, frequent attacks, then paralysis and death at 4.58 p. m. _Autopsy_: Lungs congested; blood vessels of heart injected; intestines slightly congested; fatty liver. _Guinea pig 126. White and gray male. Weight, 980 grams. Diet, oats and hay._ June 7: 9.40 a. m., 9.8 cc 2 per cent caffein given by mouth through stomach tube; 10 a. m., no symptoms; 11.10 a. m., no urine passed, reflexes increased; 1 p. m., more sensitive than before; 4 p. m., increase of reflexes more marked, no urine passed; 4.45 p. m., about 15 cc urine collected; 5 p. m., no change. June 8: 9 a. m., reflexes about the same as 5 p. m. previous day, no urine passed since 4.45 p. m. previous day, considerable reduction of Fehling's solution, much more than urine of guinea pig No. 127; 11.05 a. m., convulsions; 12 noon, still alive and stretched out on abdomen; died at 1 p. m. _Autopsy_: Lungs badly congested; heart and blood vessels injected; blood vessels of kidney and of small intestines injected; liver engorged with blood; a few necrotic spots in stomach. _Guinea pig 127. White, black, and brown male. Weight, 760 grams. Diet, oats and hay._ June 7: 9.50 a. m., 7.6 cc 2 per cent caffein by mouth through stomach tube; 10 a. m., no symptoms; 11.10 a. m., reflexes increased, no urine passed; 1 p. m., very sensitive; 4 p. m., sensitiveness increased, about 20 cc urine passed; 5 p. m., no change. June 8: 9 a. m., reflexes about the same as 5 p. m. previous day; 9.30 a. m., guinea pig passed 30 cc urine since he received caffein, urine showed a moderate amount of reduction; 12 noon, convulsions; died at 2.30 p. m. _Autopsy_: Lungs congested; blood vessels of heart and of intestines injected; numerous necrotic spots in stomach; other organs apparently normal. Examination of the protocols shows that the absorption of caffein from the gastro-intestinal canal was quite rapid, symptoms having been observed as early as 20 minutes after its introduction. The duration of life, it will be remarked, varied with the size of the dose. When approximately 3 decigrams per kilo were fed, all the animals died in the night. They lived, therefore, less than 18 hours. Two decigrams per kilo were likewise fatal, but the duration of life was longer. To decide whether or not this is the smallest fatal dose, smaller amounts were fed. It seemed at first that about 150 mg per kilo was the smallest toxic dose, and about 200 mg per kilo the minimum fatal dose. Macroscopic examination of the organs, however, threw some doubt on this supposition, for well-marked lesions were noticed in all of the guinea pigs which received 0.2 gram per kilo. It is quite possible, therefore, that the minimum fatal dose may be somewhat higher, as we have reason to believe that, at least in some pathologic conditions, the susceptibility to caffein is increased. The presence of fatty changes in the liver of No. 128 and the rapid death in this case lends especial support to this view. Hence, the minimum fatal dose is probably greater than 0.2 gram per kilo for the normal guinea pig. The doses employed for the tests on guinea pigs Nos. 129, 130, and 131 may be considered therefore the minimum fatal dose for these animals. It will be also remarked that macroscopical examination of the organs of these animals failed to reveal the presence of severe lesions. That the minimum toxic dose is probably much smaller than 0.28 gram per kilo is indicated by the experiments on guinea pigs Nos. 135 and 134, in which 0.15 gram caffein per kilo induced mild symptoms in from two to three hours. Both of these, however, and also No. 137 died four to six days after the drug was fed. As already pointed out, caffein may be a factor in the delayed death of guinea pigs which received moderate doses of it. That this supposition may also be true for guinea pigs Nos. 134, 135, and 137 is indeed made probable by the observation that after moderate amounts of caffein symptoms may persist in the guinea pig for about 24 hours, and also by the fact that the secretion of urine in these animals was very scanty, as shown in the preceding record of the experiments; this means slow elimination of caffein and its products of decomposition. It is conceivable that the presence of toxic amounts of caffein in the body for a considerable length of time would induce changes that ultimately lead to the death of the animal or that morbid processes are set up by the combined action of caffein and some preexisting poison. Since some guinea pigs, however, survived the doses indicated, it is more probable that such changes would be brought about by caffein in the presence of a preexisting poison. The death of these pigs, and also of No. 137 several days later, is difficult to account for on any other theory than the one suggested. Were it not for the fact that controls, that is, animals of the same lot which had not received caffein survived all of the experimental animals, changed conditions of environment or accident might be considered the cause of death in the guinea pigs of the last series. TABLE 6.--_Subcutaneous injection of guinea pigs._ SERIES A. ------+--------+-------+----------+----------+--------+------+-------- Number| |Caffein|Appearance| Duration | | | of pig|Weight. | per | of | of | Diet. |Month.|Remarks. | | kilo. | symptoms.| life | | | ------+--------+-------+----------+----------+--------+------+-------- |_Grams._|_Gram._| | | | | 18 | 500 | 0.300 |2 minutes |2 hours |Carrots |March |Female. | | | |40 minutes| | | 15 | 548 | .290 | |30 minutes| Oats | do. | Do. 14 | 442 | 360 |15 minutes| do. | do. | do. | Do. ------+--------+-------+----------+----------+--------+------+-------- SERIES B. ------+--------+-------+----------+----------+--------+------+-------- 20 | 497 | 0.200 |2 hours |3 hours | Oats |April |Female. | | |20 minutes|30 minutes| | | 38 | 570 | .210 |25 minutes|2 hours | Carrots|Febru |Male. | | | |15 minutes| | -ary | 37 | 820 | .200 |1 hour |Less than |Carrots | do. | Do. | | |25 minutes| 18 hours |and oats| | 13 | 618 | .194 |25 hours | |Oats |March |Female. 36 | 850 | .200 | 1 hour |18 hours |Carrots |Febru |Male. | | |30 minutes| |and oats| -ary | ------+--------+-------+----------+----------+--------+------+-------- SERIES C. ------+--------+-------+----------+----------+--------+-------+------- 66 | 510 | 0.200 |None |5 days |Oats |October|Male. 65 | 510 | .200 | do. |Survived | do. | do. | Do. 60 | 320 | .219 |1 hour |Within | do. | do. |Female. | | |15 minutes| 18 hours| | | 57 | 350 | .200 | do. |About | do. | do. | Do. | | | | 2-12 days| | | 68 | 785 | .200 |25 minutes|Less than | do. | do. |Male. | | | | 22 hours| | | 69 | 585 | .200 |20 minutes|9 days | do. | do. | Do. 61 | 330 | .240 |1 hour |Less than | do. | do. |Female. | | |30 minutes| 24 hours| | | 62 | 335 | .238 |1 hour | do. | do. | do. | Do. 70 | 545 | .238 |50 minutes|About 2 | do. | do. |Male. | | | | days | | | 71 | 540 | .240 |45 minutes| do. | do. | do. | Do. 72 | 560 | .232 |35 minutes|About 3 | do. | do. | Do. | | | | days | | | ------+--------+-------+----------+----------+--------+-------+------- SERIES D. ------+--------+-------+----------+----------+--------+-------+------- 49 | 510 | 0.160 |1 hour |Less than |Oats |March |Male. | | |40 minutes| 18 hours | | | 40 | 630 | .158 | |Less than |Oats and|Febru | Do. | | | | 2 days |carrots.| -ary | 45 | 435 | .160 | None |Survived |Oats |March |Female. 39 | 820 | .150 | |2 days |Oats and|February|Male. | | | | |carrots.| | 41 | 660 | .150 | |Survived | do. | do. | 46 | 470 | .170 |1 hour | do. |Oats (?)|March |Female. | | |20 minutes| | | | ------+--------+-------+----------+----------+--------+-------+------- SERIES E. ------+--------+-------+----------+------------+--------+--------+---- 19 | 556 | 0.100 | |Survived | Oats |April | 42 | 490 | .120 | None | do. | do. |February| 43 | 430 | .116 | do. | do. | do. | do. | 44 | 535 | .112 | do. | do. | do. | do. | 97 | 330 | .100 | do. | do. | do. |November| 98 | 520 | .100 | do. |About 3 days|Carrots | do. | ------+--------+-------+----------+------------+--------+--------+---- TABLE 7.--_Injection into peritoneal cavity; guinea pigs._ SERIES A. ------+--------+-------+----------+----------+--------+------+-------- Number| |Caffein|Appearance| Duration | | | of pig|Weight. | per | of | of | Diet. |Month.|Remarks. | | kilo. | symptoms.| life | | | ------+--------+-------+----------+----------+--------+------+-------- |_Grams._|_Gram._| | | | | 41 | 700 | 0.130 |2 hours |22 hours |Oats |April |Male. 49 | 370 | .135 |2 hours |Survived | do. | do. | Do. | | |15 minutes| | | | 47 | 550 | .127 |1 hour | do. | do. |March |Female. 50 | 290 | .138 |2 hours | do. | do. |April | Do. ------+--------+-------+----------+----------+--------+------+-------- SERIES B. ------+--------+-------+----------+----------+-------+-------+------- 51 | 415 | 0.144 | None |Survived |Oats |October|Female. 52 | 450 | .155 | do. | do. | do. | do. |Male. 53 | 490 | .163 | do. | do. | do. | do. | Do. ------+--------+-------+----------+----------+-------+-------+------- SERIES C. ------+--------+-------+----------+----------+-------+-------+-------- 59 | 375 | 0.200 |15 minutes|Survived |Oats |October|Gray and | | | | | | | white. 58 | 380 | .200 |10 minutes| do. | do. | do. | 56 | 440 | .200 |15 minutes|14 days | do. | do. |Male. 55 | 690 | .188 | 1 hour |3 hours | do. | do. | Do. | | | |30 minutes| | | ------+--------+-------+----------+----------+-------+-------+-------- SERIES D. ------+--------+-------+----------+----------+-------+-------+-------- 67 | 330 | 0.240 |5 minutes |30 minutes|Oats |October|Male. 63 | 340 | .235 | |Survived | do. | do. | Do. 64 | 305 | .250 |25 minutes|4 hours | do. | do. |Female. | | | |40 minutes| | | ------+--------+-------+----------+----------+-------+-------+-------- TABLE 8.--_Caffein by mouth; guinea pigs._ SERIES J. ------+--------+-------+----------+----------+-------+-------+-------- Number| |Caffein|Appearance| Duration | | | of pig|Weight. | per | of | of | Diet. | Month.|Remarks. | | kilo. | symptoms.| life | | | ------+--------+-------+----------+----------+-------+-------+-------- |_Grams._|_Gram._| | | | | 129 | 855 | 0.280 |40 minutes|Less than |Hay and|June |Male. | | | | 8 hours| oats | | 130 | 800 | .300 |30 minutes|Less than | do. | do. | Do. | | | | 18 hours| | | 131 | 860 | .280 |20 minutes| do. | do. | do. | Do. 135 | 955 | .150 |1 hour 50 |6 days | do. | do. | Do. | | | minutes | | | | 134 | 740 | .160 |3 hours |4 days | do. | do. | Do. (1)137| 925 | .150 |50 minutes|6 days | do. | do. | Do. (1)136| 1,000 | .150 | do. |Survived | do. | do. | Do. 126| 980 | .200 |20 minutes|27 hours | do. | do. | Do. 127| 760 | .200 |1 hour |28 hours | do. | do. | Do. 128| 1,075 | .200 |3 hours |7 hours | do. | do. | Do. ------+--------+-------+----------+----------+--------+------+-------- (1) Subcutaneous injection for comparison. SUMMARY. A survey of the results obtained in experiments on guinea pigs shows that the mode of introduction of caffein exerts but little influence on its toxicity. On careful analysis it will be observed that the rate of absorption after the administration of caffein by mouth, subcutaneously, or intraperitoneally is about the same for the time of appearance of symptoms. The persistence of the symptoms of caffein intoxication observed in these experiments for 24 hours after administration points to slow elimination, which may be expected, owing to the fact that the guinea pigs passed but little urine and caffein is not diuretic for these animals. The prolonged presence of caffein in the body probably exerts a harmful influence or after effect, which may account for the delayed death of some animals many days after a single dose of caffein was given. Among the factors which undoubtedly influence toxicity, season should be considered, while the presence of a diseased condition undoubtedly tends to decrease the resistance of the guinea pig to caffein. Diet was without any influence on the toxicity of the single dose of caffein. EXPERIMENTS ON CATS. These experiments were performed on well-fed animals which were kept under observation for several days before the tests with caffein were made. The diet consisted of meat exclusively. In some cases the urine was examined for albumin and sugar before caffein was given. No tests with caffein were made if large amounts of albumin were found. It may be remarked that sugar was never found in cats before the administration of caffein, but that considerable amounts of it were found in some cases after it was given. Studies by various modes of administration were made, by subcutaneous injection, intraperitoneally, or by mouth. Attention was also directed to the resistance to caffein in young cats, several experiments on kittens being made with this object in view. SUBCUTANEOUS INJECTION. Rost stated that caffein is eliminated in the urine unchanged after its introduction into the body and that the amounts found varied with different species of animals. In the rabbit the amount eliminated was about 21 per cent; in the dog about 8 per cent; and in the cat somewhat less than 2.5 per cent. It would appear, therefore, that the cat decomposes caffein more readily than the rabbit or dog; its resistance consequently ought to be greater than that of the other animals. Moderately large doses were accordingly employed in the preliminary experiments (series A), but the results obtained, as shown in the protocols, indicated that caffein is fully as toxic for the cat as for the rabbit or dog. The doses were then decreased and experiments were performed in order to ascertain the smallest toxic as well as the smallest fatal dose. SERIES A. Three decigrams of caffein per kilo were administered in these experiments. The results are shown in the following protocols: _Cat 4. Black and white. Weight, 1,440 grams._ May 26: 10.05 a. m., 22 cc 2 per cent caffein (0.3 gram per kilo) injected subcutaneously; 11.10 a. m., copious salivation, cat irritable, muscular stiffness present, but no tetanus; 11.45 a. m., cat restless, convulsions, attacks of short duration, no paralysis observed after the convulsions, pupils dilated; 4.45 p. m., cat quiet, slight paralysis present. May 27: Cat exhausted. May 28: Found dead. _Cat 5. Black and white male. Weight, 1,396 grams._ June 3: 10 a. m. 21 cc of 2 per cent caffein (0.3 gram per kilo) injected subcutaneously; 12 noon, found dead. Although there was considerable difference in the duration of life following the injection of the same dose of caffein per kilo, the final outcome was the same, as both cats died from the effects of the drug. One died within 2 hours and the other lived more than 30 hours after its administration. Three decigrams of caffein per kilo is, therefore, surely fatal to these animals. Tests made with smaller doses are shown in the following experiments: SERIES B. In these experiments the doses employed ranged between 0.20 and 0.25 gram caffein per kilo. _Cat 3. Black and white female. Weight, 2,854 grams. Well fed._ June 4: 10.30 a. m., 35 cc 2 per cent caffein (0.25 gram per kilo) injected subcutaneously; 11 a. m., found dead. _Cat 6. Black and white. Weight, 1,645 grams._ June 3: 20 cc 2 per cent caffein (0.243 gram per kilo) injected subcutaneously at 3 p. m., cat grew very irritable in a few minutes; about 4. p. m. reflexes decidedly increased; 5 p. m., cat paralyzed. June 4: Cat found dead. _Cat 8. Weight, 1,735 grams._ October 7: 4 p. m., 22 cc 2 per cent caffein (0.25 gram per kilo) injected subcutaneously in the back; 4.30 p. m., cat irritable, salivation profuse, convulsions; died at 5.30 p. m.; no urine passed after caffein was given. _Cat 9. Weight, 1,960 grams._ October 7: 3.45 p. m., 25 cc 2 per cent caffein (0.25 gram per kilo) injected subcutaneously in the back; 4.45 p. m., cat very irritable, repeated attacks of convulsions, salivation copious; died at 5.30 p. m.; cat did not urinate after injection of caffein. _Cat 12. Striped kitten. Weight, 1,185 grams._ October 9: Urine examined, no albumin, no sugar; 1.45 p. m., 12 cc 2 per cent caffein administered; 5 p. m., cat alive, no symptoms except salivation and general irritability. October 10: 10.30 a. m., found dead. About 15 cc urine collected, but no examination made. _Cat 14. Black. Weight, 1,855 grams._ October 8: 1.40 p. m., 18.5 cc 2 per cent caffein (0.2 gram per kilo); 3 p. m., cat became restless about 10 minutes after caffein was injected; cried persistently and moved about in cage, no convulsions, cat urinated about 15 cc, cat defecated. October 9: 9 a. m., cat found dead in cage. Urine gave very heavy reduction of Fehling's solution (much more than was obtained from urine of rabbits); 20 cc urine analyzed contained 4.65 per cent sugar. _Autopsy_: Lungs deeply congested; liver marked fatty infiltration and degeneration; spleen normal; kidneys pale and anemic; intestines normal; stomach normal. _Cat 15. Striped. Weight, 2,145 grams._ October 8: 2 p. m., 22 cc (0.2 gram per kilo) 2 per cent caffein injected subcutaneously; 2.30 p. m., cat irritable, restless, trying to get out of cage, crying persistently; 2.40, convulsions lasting about two minutes, then cat raised itself and made attempts to get out of cage, no salivation, cat urinated about 10 cc and defecated. October 9: 9 a. m., cat found dead in cage, about 10 cc of urine contained enormous quantities of sugar. _Autopsy_: Lungs severely congested; liver showed marked fatty degeneration; spleen normal; kidneys slightly pale and anemic; intestines mildly congested; stomach normal. _Cat 19. White. Weight, 1,100 grams._ October 20: 13 cc of 2 per cent caffein (0.236 gram per kilo). About 15 minutes later cat became irritable, reflexes increased, persistent crying, stiffness of extremities, diarrhea present; 4.30 p. m., stiffness of muscles, coordination much disturbed, walked with great difficulty; 4.30 p. m., no new symptoms, persistent crying continued. October 21: Found dead. _Cat 20. White kitten. Weight, 790 grams._ October 20: 11.35 a. m., 10 cc 2 per cent caffein (0.25 gram per kilo) given subcutaneously; 12 noon, convulsions followed by paralysis; 1.30 p. m., still breathing, apparently in comatose condition, lay on its side, dyspnoea, profuse salivation; 4 p. m., convulsions and death. The results of the experiments of series B show that a dose of even 0.2 caffein per kilo is very toxic for the cat. Symptoms appeared in one animal 40 minutes after the injection of caffein. Some of them were found dead 18 hours after injection, which means that the duration of life was probably a great deal less since there was evidence that they had been dead for some time. Death occurred quite soon after larger doses were injected. Cat No. 3 died 30 minutes after it received caffein. The amounts employed in these experiments can not be considered therefore as the minimum fatal doses. Smaller doses were then tried, as shown in the experiments of the next series. SERIES C. Experiments were performed on five cats which received from 140 to 155 mg per kilo, as follows: _Cat 24. Striped. Weight, 1,300 grams._ October 25: 10 a. m., 50 cc urine, albumin moderate amount--no sugar; 10 cc caffein injected subcutaneously at 12 noon; 12.30, irritable, cried persistently, no appetite; 4 p. m., no convulsions, but persistent crying. October 27: Cat was still alive. _Cat 17. Weight, 2,620 grams._ October 12: 9.30 a. m., 65 cc urine collected; more than a trace of albumin present, no reduction of Fehling's solution; 3 p. m., 20 cc 2 per cent caffein (150 mg per kilo) injected subcutaneously; 3.15 p. m., irritable and restless. October 13: 9 a. m., about 15 cc urine collected, reduction of Fehling's solution marked; osazone test also positive. _Cat 23. Black and white. Weight, 1,645 grams._ October 25: 10 a. m., 140 cc urine collected (since October 23), small amount of albumin present, no sugar. October 27: 9 a. m., no albumin; no sugar in urine; 11.50 a. m., 12.5 cc caffein injected subcutaneously (0.15 gram per kilo); 1 p. m., convulsions and death. _Cat 7. Striped kitten. Weight, 1,285 grams._ October 11: Urine collected, no albumin, no sugar; 9.50 a. m., 10 cc 2 per cent caffein injected subcutaneously in the back; 10.10, violent convulsions lasting about 30 seconds; 10.20, convulsions of shorter duration; 10.30 convulsions; 10.35, convulsions lasting a few seconds; urine passed about 10.20, contained a moderate amount of albumin, but there was no reduction of Fehling's solution; 10.45, profuse salivation and paralysis; died about 10.50. _Cat 39. Yellow. Weight, 2,285 grams._ April 13: 2.40 p. m., 16 cc 2 per cent caffein (0.14 gram per kilo) injected subcutaneously in the back; 3.45 p. m., cat died. Of the five experiments of this series three died after doses of 140, 150, and 155 mg per kilo. The other two showed symptoms of toxicity, but survived a dose of 150 mg per kilo which indicated that the minimum fatal dose was probably reached. To test this supposition smaller doses were administered, as shown in the following experiments. SERIES D. Ten cats were used for this series of experiments, and the doses administered varied between 103 and 139 mg per kilo. The results shown in the appended table (p.58) indicate that about 120 to 140 mg of caffein per kilo may induce mild symptoms in some cases. The conclusion may be safely drawn therefore that 150 mg per kilo is approximately the minimum fatal dose for the cat when the drug is given subcutaneously. That smaller doses are, however, by no means to be regarded as always safe is shown in the following experiments. SERIES E. _Cat 43. Weight, 3,225 grams._[D] [D] Cat probably old; had been in the laboratory for several weeks before the experiment. Gained in weight 175 grams. September 14: 10.20 a. m., 20 cc 2 per cent caffein (0.124 gram per kilo) injected into the back; 11 a. m., tetanus and death. _Autopsy_: Lungs congested; liver congested and showed hemorrhagic spots in capsules and fatty degeneration; kidneys slightly congested; other organs normal. _Cat 48. Black female. Weight, 3,050 grams._ September 14: 18 cc 2 per cent caffein (0.118 gram per kilo) injected subcutaneously in the back; 10.30 a. m., violent convulsions and death. _Autopsy_: Lungs congested in spots showing numerous petechia; liver congested; spleen congested; other organs normal. The diminished resistance to caffein of cats Nos. 43 and 48 might be due to the pathologic changes found on autopsy, for evidence is not wanting that the toxicity of drugs might be greatly altered under pathological conditions. Hunt(40) has shown that resistance to acetonitril is considerably diminished in chronic alcoholism. This seems to be true also of other drugs under abnormal conditions. Smaller doses of atropin(78) are required in lead poisoning than under normal conditions to produce the same results. The following experiment is of interest in this connection, for in this case a much smaller dose than was given in experiments Nos. 43 and 48 produced the typical symptoms of caffein poisoning and proved to be fatal. _Cat 47, black and white male. Weight, 4,220 grams._ September 15: Received subcutaneously 18 cc 2 per cent caffein (0.084 gram per kilo); no symptoms observed for about six hours. September 16: No symptoms. September 17: Weight, 4,250 grams; injected 18 cc 2 per cent caffein (0.084 gram per kilo); tetanus and death after two hours. _Autopsy_: Severe hemorrhagic pneumonia; kidneys pale, other organs normal. Since two controls survived the same dose in proportion to the body weight of the animal without showing any symptoms, the assumption is justified that the lower resistance to caffein was due to the presence of pneumonia, thus affording additional support to the view that the toxicity of caffein may be increased in disease. INJECTION INTO THE PERITONEAL CAVITY. These experiments were carried out on full-grown and on young subjects. As in previous experiments, doses of different sizes were employed. A dose of 0.2 gram per kilo was tried first and then reduced gradually to 0.1 gram per kilo. _Cat 10. Female. Weight, 2,970 grams._ October 9, 1909: 1.30 p. m., 30 cc 2 per cent caffein (0.2 gram per kilo) injected into the peritoneal cavity; urine examined for albumin and sugar, negative; cat found dead at 2.30 p. m. No urine in the bladder. _Cat 16. Black female. Weight, 2,420 grams._ October 9, 1910: Urine examined for albumin and sugar, negative; 2.30 p. m., 22 cc 2 per cent caffein (0.183 gram per kilo) injected into the peritoneal cavity; found dead at 3 p. m. _Cat 99. Well-fed gray female. Weight, 3 kilos._ June 22, 1911: 3.40 p. m., 15 cc 2 per cent caffein injected into peritoneal cavity; salivation and marked irritability within one hour after injection. June 24: Alive, appetite good. _Cat 98. Well-fed black male. Weight, 4,100 grams._ June 22: 3.45 p. m., 20.5 cc 2 per cent caffein (0.1 gram per kilo) injected into peritoneal cavity; very irritable a few minutes after injection, no other symptoms. June 24: No symptoms, appetite good. _Cat 93. Black and white. Weight, 1,450 grams._ June 22: 3 p. m., 30 cc 2 per cent caffein (0.137 gram per kilo) injected into peritoneal cavity; salivation, no other symptoms; under observation until 6 p. m. June 23: 9 a. m., no urine, cat showed no symptoms. June 24: 9 a. m., no symptoms, took nourishment as usual. _Cat 87. Well-fed white female. Weight, 2,615 grams._ June 23: 2.45 p. m., 19 cc 2 per cent caffein (0.145 gram per kilo) injected into peritoneal cavity; became irritable and restless. June 24: 9 a. m., no symptoms, took nourishment as usual. _Cat 97. Gray. Age, 3 months. Weight, 500 grams. Diet, meat._ June 24: 2.25 p. m., 5 cc 2 per cent caffein (0.2 gram per kilo) injected into peritoneal cavity; 4 p. m., no symptoms. June 29: Died. _Cat 96. Gray and white. Age, 3 months. Weight, 575 grams. Diet, meat._ June 24: 2.20 p. m., 4 cc 2 per cent caffein (0.139 gram per kilo) injected into peritoneal cavity; 3.55 p. m., no symptoms. June 30: Died. _Cat 95. Black. Age, about 3 months. Weight, 860 grams. Diet, meat._ June 24: 10.15 a. m., 8.6 cc 2 per cent caffein injected into peritoneal cavity, salivation immediately after injection; 10.25, convulsions and paralysis; died 10.45 a. m. _Autopsy_: Macroscopical examination of the organs, negative. _Cat 94. Black and white. Weight, 790 grams. Age, about 3 months. Diet, meat._ June 24: 10 a. m., 8 cc 2 per cent caffein injected into peritoneal cavity; 4 p. m. under continual observation since injection, cat very irritable, respiration more rapid than normal, diarrhea present. Examination of the above protocols show that a dose of 2 decigrams per kilo was fatal within one hour to one cat and that a somewhat smaller dose killed another individual in 30 minutes. Amounts under 0.15 gram per kilo were just sufficient to induce mild symptoms, such as increased irritability and salivation, which disappeared within a few hours. In no case were the effects noticeable on the following day. The experiments on young kittens are especially interesting, as they proved, contrary to expectation, to be distinctly more resistant than full grown individuals. The death of Nos. 97 and 96 within five and six days, respectively, can not be ascribed to caffein, since some of the controls also died. Moreover, it will be remarked in this connection that no symptoms appeared in three of the four young kittens after the administration of a dose which was rapidly fatal to adult cats. The rapid death of No. 95 after the same dose forms an exception which can not be accounted for, as macroscopical examination at autopsy proved negative. ADMINISTRATION BY MOUTH. Two decigrams per kilo were given at first, but it was found that this amount was surely fatal. The dose was therefore reduced to 0.125 gram per kilo. In all of these experiments caffein was given by means of a soft rubber catheter slipped over the stem of a funnel which served as a stomach tube. A 2 per cent aqueous solution was used throughout these tests except in one case in which caffein was given mixed with the food. _Cat 92. Black and white female. Weight, 1,750 grams._ June 10: 12.05 p. m., 14 cc 2 per cent caffein (0.16 gram per kilo) given by mouth; cat was quiet when tied on holder, struggled only a little when tube was put into stomach; 12.30 p. m., cat vomited, no other symptoms. June 13: Condition good, appetite good. _Cat 87. White female. Weight, 2,620 grams. Diet, meat._ June 5: 2.15 p. m., 20 cc 2 per cent caffein (0.15 gram per kilo) solution administered by mouth through stomach tube; 2.30 p. m., cat irritable, but no other symptoms; 5 p. m., condition about the same, except that it was more irritable and showed some stiffness of the extremities. June 13: Alive and in good condition, appetite good, not irritable. _Cat 91. White female. Weight, 3,050 grams._ June 10: 12 noon, 23 cc (0.15 gram per kilo) of 2 per cent caffein administered by mouth, cat struggled violently; 1.30, salivation; 1.40 p. m., convulsions; died at 2 p. m. _Autopsy_: Congestion of lungs, liver, and spleen; heart vessels injected; other organs normal. _Cat 88. Black and white female. Weight, 3,260 grams. Diet, meat._ June 5: 2.20 p. m., 25 cc of 2 per cent caffein (0.15 gram per kilo) given by mouth; 2.45 p. m., cat irritable, no other symptoms (cat did not vomit after the administration of caffein); 4 p. m., cat found dead. _Autopsy_: Liver very much congested; heart contracted; body was still warm at the time of autopsy. _Cat 90. White and yellow female. Weight, 2,685 grams. Diet, meat._ June 5: 3.15 p. m., 27 cc of 2 per cent caffein (0.2 gram per kilo) given by mouth through stomach tube, about half an hour later cat became irritable and began to salivate; at 4.30 p. m. salivation became more marked, dyspnoea was well developed, and the cat was quite restless and had tremors; 5 p. m., short spasms of posterior extremities, but lay quietly in the cage most of the time; 5.20 p. m., convulsions of short duration and death, muscular relaxation followed immediately after convulsions, no vomiting, diarrhea observed after administration of caffein, and cat passed about 10 cc of urine. June 6: 9 a. m., found dead. _Cat 89. White and black female. Weight, 2,860 grams. Diet, meat._ June 5: 3.15 p. m., 28.6 cc (0.2 gram per kilo) of 2 per cent caffein given by mouth through stomach tube, no vomiting observed, nor any other symptoms; 3.30, found dead. _Autopsy_: Organs normal; liver congested. _Cat 82. Gray female. March 3, weight 2,450 grams; June 6, weight 2,750 grams. Diet, 150 grams of meat daily._ June 7: Given 0.4125 gram of caffein in 150 grams of meat, did not eat. June 8: Given 0.4125 gram of caffein in 150 grams of meat, refused to eat. June 9: Given 150 grams of meat without caffein, ate all of it. June 10: No food given. June 11: No food given. June 12: Given 0.4125 gram caffein in 150 grams of meat (150 mg per kilo), ate all of it. June 13: Found dead. _Autopsy_: Lungs congested, liver congested; other organs apparently normal. _Cat 100. Gray female. Weight, 2,740 grams. Diet, meat._ July 17: 3 p. m., 17 cc of 2 per cent caffein (124 mg per kilo) given by mouth through stomach tube at 3.20 p. m.; 5 p. m., very irritable, but no other symptoms. July 18: Under observation all day, no symptoms. _Cat 93. Black and white female. Weight, 1,640 grams._ July 17: 3.30 p. m., 10 cc (0.125 gram per kilo) of 2 per cent caffein given by mouth through stomach tube. July 18: Under observation all day, no symptoms. From the results of the experiments of this series it appears that 0.15 gram caffein per kilo may be fatal within a few hours after its administration, even if the drug is mixed with a moderate amount of meat. Experiments 87 and 92 show, however, that this amount may be borne by some individuals without any serious consequences, as the cats were under observation for some time after they received caffein, and no untoward symptoms were noticed in either of them during this time. It may be remarked that cat No. 92 vomited shortly after it received caffein. It is practically certain, therefore, that this amount of caffein in proportion to the weight of the animal will in the great majority of cases prove fatal, and perhaps in a smaller percentage of individuals it is surely toxic if it does not escape absorption. Smaller doses may cause irritability in some individuals, but symptoms referable to nervous symptoms of muscles were absent, as in experiments Nos. 93 and 100. The minimum fatal dose of caffein for the cat when given by mouth is, therefore, 0.15 gram per kilo. TABLE 9.--_Subcutaneous injection; cats._ SERIES A. -------+--------+---------+-----------------------+------------------- Number.| Weight.| Caffein | Symptoms. | Duration of life. | |per kilo.| | -------+--------+---------+-----------------------+------------------- |_Grams._| _Gram._ | | 4 | 1,440 | 0.30 | 65 minutes | Over 29 hours. 5 | 1,396 | .30 | | About 2 hours. -------+--------+---------+-----------------------+------------------- SERIES B. -------+--------+---------+-----------------------+------------------- 3 | 2,854 | 0.25 | | 30 minutes. 6 | 1,645 | .243 | Few minutes | 1 hour 30 minutes. 8 | 1,735 | .25 | 30 minutes. | 1 hour. 9 | 1,960 | .25 | 1 hour | 1 hour 45 minutes. 12 | 1,185 | .20 | 3 hours | Less than 18 hours. 14 | 1,855 | .20 | 1 hour 20 minutes | Do. 15 | 2,145 | .20 | 40 minutes. | Do. 19 | 1,100 | .236 | 15 minutes | Do. 20 | 790 | .25 | | 4 hours 30 minutes. -------+--------+---------+-----------------------+-------------------- SERIES C. -------+--------+---------+-----------------------+------------------- 24 | 1,300 | 0.153 | 1 hour | Survived. 17 | 2,620 | .15 | 15 minutes | Do. 23 | 1,645 | .15 | | 1 hour 10 minutes. 7 | 1,285 | .155 | 20 minutes | 1 hour. 9 | 2,285 | .14 | | 65 minutes. -------+--------+---------+-----------------------+------------------- SERIES D. -------+--------+---------+-----------------------+------------------- Number.|Weight. | Caffein | Symptoms. | Duration of life. | |per kilo.| | -------+--------+---------+-----------------------+------------------- |_Grams._| _Gram._ | | 13 | 730 | 0.139 | Restlessness | 21 | 1,165 | .138 | None | 25 | 965 | .103 | do. | 26 | 1,605 | .125 | do. | 27 | 1,625 | .125 | do. | 28 | 2,335 | .128 | do. | Received 2 doses: | | | | survived. 40 | 2,710 | .129 | do. | Do. 41 | 1,785 | .123 | do. | Do. 42 | 2,315 | .112 | do. | Do. 38 | 2,325 | .120 | Mild | Died after second | | | | dose. -------+--------+---------+-----------------------+------------------- SERIES E.(1) -------+--------+---------+-----------------------+------------------- 43 | 3,225 | 0.124 | | 40 minutes. 48 | 3,050 | .118 | | Died soon after. 47 | 4,220 | .084 | | Survived. (2)47 | 4,250 | .084 | | 2 hours. -------+--------+---------+-----------------------+------------------- (1) Pathological conditions. (2) Two days after first injection. TABLE 10.--_Injections into peritoneal cavity; cats._ -------+--------+---------+-----------------------+------------------- Number.|Weight. | Caffein | Symptoms. | Duration of life. | |per kilo.| | -------+--------+---------+-----------------------+------------------- |_Grams._| _Gram._ | | 99 | 3,000 | 0.100 | Mild | Survived. 98 | 4,100 | .100 | do.(1) | Do. 93 | 1,450 | .137 | Very mild | Do. 87 | 2,615 | .145 | do. | Do. 97 | 505 | .200 | None | 5 days. 96 | 575 | .139 | do. | 6 days. 95 | 860 | .200 | 15 minutes | 30 minutes. 94 | 790 | .200 | Diarrhea | Survived. 10 | 2,970 | .200 | | 1 hour. 16 | 2,420 | .183 | | 30 minutes. -------+--------+---------+-----------------------+------------------- (1) In few minutes. TABLE 11.--_Administration of caffein by mouth; cats._ -------+--------+---------+-----------------------+------------------- Number.|Weight. | Caffein | Symptoms. | Duration of life. | |per kilo.| | -------+--------+---------+-----------------------+------------------- |_Grams._| _Gram._ | | 91 | 3,050 | 0.15 | 1 hour 40 minutes | 2 hours. 88 | 3,260 | .15 | | 1 hour 40 minutes. 92 | 1,750 | .16 | 25 minutes | Survived. 87 | 2,620 | .15 | 3 hours | Do. 90 | 2,685 | .20 | 1 hour 15 minutes | Less than 18 hours. 89 | 2,860 | .20 | | 75 minutes. 82 | 2,450 | .15 | | Less than 24 hours. 100 | 2,740 | .124 | 1 hour 40 minutes | Survived. 93 | 1,640 | .125 | | Do. -------+--------+---------+-----------------------+------------------- SUMMARY. The toxicity of caffein in cats is shown to be the same when given by mouth as when injected subcutaneously, the minimum fatal doses in both cases being 0.15 gram per kilo. When introduced by the intraperitoneal route, caffein is, on the contrary, distinctly less toxic. After the administration of 0.137 and 0.145 gram caffein per kilo (Nos. 93 and 87) salivation in one cat (No. 93) and irritability and muscular stiffness in the other were the only effects noticed. These symptoms were no longer observed the next day and the cats appeared to be perfectly normal. Experiments with larger doses indicate that the minimum fatal dose by this method of administration is about 0.2 gram per kilo. EXPERIMENTS ON DOGS. The experiments were carried out on well-fed adult dogs and on puppies, kept under observation for some time before the drug was administered. Only those manifesting no signs of abnormality were used for these tests. Caffein was given by mouth mixed with 10 to 20 grams of meat, or subcutaneously in 2 per cent aqueous solution. The young animals received caffein dissolved in milk. The determination of the minimum toxic or fatal doses when the drug was fed presented considerable difficulty, as in many instances the ingestion of the drug was closely followed by vomiting. ADMINISTRATION BY MOUTH. SERIES A. The effective dose in these experiments showed considerable variation. One dog (No. 38) died after a dose of 0.12 gram caffein per kilo, while some subjects survived doses of 0.2 and 0.23 gram per kilo. In the 12 experiments given in Table 12, page 62, it will be noticed that from 0.12 to 0.152 gram per kilo proved fatal to three dogs, while three others survived the same amounts in proportion to the body weight. The results were the same with larger doses. It may be observed in this connection that in the case of the five dogs in which vomiting was noticed some time during the 24 hours following the administration of caffein, four survived, No. 38 being the exception. The greater toxicity of caffein in this case is in all probability due to some morbid process, the presence of which was indicated by the high temperature of this subject. That vomiting may avert a fatal issue after larger doses of caffein is made further probable by experiment on dog No. 48, for which, in the absence of vomiting, a dose of 0.2 gram of caffein per kilo proved fatal. On this supposition the discrepancy in the results obtained in this series may be readily explained. The smallest doses which proved fatal in these experiments were 0.145 and 0.152 gram per kilo. No. 38, which died from a dose of 0.12 gram per kilo, may be considered as an exception, as this subject was not normal. Experiments with caffein on dogs were made at various other times in this laboratory but failed to show that smaller doses of caffein, even when vomiting did not occur after its administration, were fatal, although toxic effects were observed. The conclusion is therefore justified that the minimum fatal dose of caffein for the normal dog is about 0.15 gram per kilo when given by mouth. SUBCUTANEOUS INJECTION. SERIES B. To determine the toxicity of caffein more accurately, especially for comparison with animals of other species, the subcutaneous method of administration was also used. The injections were made with a syringe of 20 cc capacity, the contents of which were introduced into contiguous areas. The results of experiments on six dogs indicate that approximately 150 to 160 mg per kilo is the minimum fatal dose, since such doses proved fatal to two out of the three animals receiving this amount, while three others which received doses of from 143 to 160 mg per kilo survived. EXPERIMENTS ON PUPPIES. SERIES C. In these experiments the resistance of young growing puppies to caffein was studied. Caffein was given by mouth to all the subjects except one, to which it was administered subcutaneously. The protocols, only a few of which are given, and the tabulated data of the experiments (p. 62) show that the age of the animal has a decided influence on the toxicity of caffein. _Dog 11. Weight, 1,260 grams._ August 2: At 10 a. m. given 12.5 cc of 2 per cent of caffein through stomach tube; 2 p. m., had convulsions, diarrhea, salivation, and stiffness of limbs. August 3: Found dead 9 a. m. _Autopsy_: Thoracic viscera apparently normal; stomach immensely distended and filled with a white, cheesy mass and some fluid; round worms plentiful in stomach and small intestine; mucosa of entire intestine congested; contents of lower intestine congested; liver pale; spleen flabby; kidney congested. _Dog 10. Weight, 1,650 grams._ July 26: 9.30 a. m., 29 cc of 2 per cent caffein added to 60 cc of milk offered, but refused, and was therefore fed by mouth through stomach tube; 10.25 a. m., no symptoms; 11.30 a. m., restlessness, extremities stiff, post. extremities spread apart, dog shows well-marked symptoms of caffein poisoning; 12.10 p. m., symptoms more severe, extremities extended and spread out, is lying flat on belly so that nose touches floor of the cage; 12.40 p. m., found dead; was alive at 12.10 p. m. _Autopsy_: Lungs showed hemorrhagic foci in all lobes; heart apparently normal; liver fatty; stomach and intestines filled with round worms; spleen and kidney apparently normal. _Dog 9. Weight, 3,000 grams._ July 25: 350 mg caffein per kilo; 5 p. m., lying down most of the time, occasionally walks about in stall; restlessness present, but not marked; 5.30 p. m., vomit which looked frothy and mucilaginous noticed on the floor of the stall; no meat particles noticed in vomit, though searched for; whines occasionally. July 26: 9 a. m., looks well; no signs of the effect of caffein given the day previous. _Dog 8. Yellow female. Weight, 3,100 grams._ July 22: 10.50 a. m., received 1.1 grams of caffein in 10 grams of meat (354 mg caffein per kilo); 3 p. m., vomited mucus; gait clumsy; refused to eat; continually drinking water; very restless; 4 p. m., convulsions set in at 3.55 p. m.; tonic rigidity of the posterior extremities; profuse salivation; convulsions were both tonic and clonic in character, and resembled those seen in rabbits in caffein intoxication; a striking feature was the duration of the spasm, which began at 3.55 p. m. and kept up for more than two hours. July 23: Found dead at 9 a. m. The data recorded in the table and in the protocols of the experiments of series C show that four out of the seven animals experimented upon died in less than 24 hours after caffein was fed; three of these received 300 to 354 mg caffein per kilo, and one received 200 mg caffein per kilo. No. 8 vomited four hours after caffein was given. No vomiting was observed in the other three dogs. From 0.300 to 0.350 gram of caffein per kilo may be regarded, therefore, as surely fatal to young growing puppies. That this is in all probability the minimum lethal dose appears from the following experiments: No. 9, which received 350 mg per kilo, vomited one hour after and survived, which indicates that some of it was probably not absorbed. The amount which entered the circulation was therefore less than 350 mg per kilo. Since No. 15, which received 250 mg caffein subcutaneously, likewise survived, the probabilities are that 300 to 350 mg per kilo were the minimum fatal doses for these animals. Moreover, No. 12, which received 200 mg caffein per kilo, survived, no vomiting having been observed. The case of No. 11, in which the same amount of caffein in proportion to body weight proved fatal, may be explained perhaps by the findings of the autopsy. The results obtained in these experiments justify the conclusion that young growing dogs can stand larger doses of caffein than full-grown and older dogs. Attention may also be called here to the difference in the symptoms produced by caffein in very young and in adult dogs. It was often noticed in these experiments that the symptoms in older subjects when given toxic doses of caffein set in rather abruptly and ended in instantaneous death. We failed to observe this phenomenon after the administration of large amounts of caffein to very young dogs, in which tonic and clonic convulsions alternating with paresis were observed. These symptoms set in rather gradually and lasted several hours (see experiment No. 8), resembling the rabbit in this regard. SUMMARY. The toxicity of caffein for adult dogs is about the same, whether given by mouth or injected subcutaneously. The resistance of puppies to caffein is much greater than that of adults. TABLE 12.--_Administration by mouth; dogs._ (_Series A._) ----+--------+-------+-----------+------------------------------------ | |Caffein| | No.| Weight.| per | Results. | Remarks. | | kilo. | | ----+--------+-------+-----------+------------------------------------ |_Kilos._|_Gram._| | 47 | 13.60 | 0.144 |Survived |Vomiting observed. 55 | 12.75 | .200 | do. |Stiffness of muscles; no other | | | | symptoms. 56 | 7.95 | .200 |Found dead | | | | next day | 52 | 13.60 | .147 |Survived | 57 | 6.50 | .230 | do. |Vomited after 1 hour; convulsions | | | | after 1 hour and 45 minutes. 39 | 23.10 | .120 | do. |Increased frequency of respiration, | | | | thirst, loss of appetite, vomited | | | | rest of day when he drank water, | | | | salivation, restlessness, passed | | | | feces frequently. 48 | 11.50 | .174 | do. |Vomiting observed. 48 | 12.00 | .200 |Found dead |No vomiting observed. Second dose | | | next day | was given 8 days after first. 54 | 13.40 | .200 |Survived |Vomiting observed. 49 | 13.15 | .152 |Found dead | | | | next day | 38 | 14.50 | .120 | do. |Symptoms after 1½ hours: Dog had | | | | a temperature of 104° F. before | | | | caffein was given; vomited 3 hours | | | | after caffein was fed. 18 | 10.80 | .145 | do. | ----+--------+-------+-----------+------------------------------------ TABLE 13.--_Subcutaneous injection; dogs._ (_Series B._) ----+--------+-------+-----------+------------------------------------ | |Caffein| | No.| Weight.| per | Results. | Remarks. | | kilo. | | ----+--------+-------+-----------+------------------------------------ |_Kilos._|_Gram._| | 62 | 9.30 | 0.161 |Survived |Restlessness and vomiting one-half | | | | hour after injection. 61A| 14.00 | .160 |Found dead | | | | next day | 63 | 12.00 | .150 |Survived |Restlessness 1 hour after injection. 64 | 14.00 | .150 | do. |Restlessness and thirst 45 minutes | | | | after injection. 59 | 7.20 | .160 |Died 1 hour|Marked restlessness, but no | | | and 20 | convulsion. | | | minutes | | | | after | | | | injection.! 61 | 14.60 | .143 |Survived |Symptoms observed in 1½ hours. ----+--------+-------+-----------+------------------------------------ TABLE 14.--_Administration by mouth to puppies._ (_Series C._) ----+--------+-------+-----------+------------------------------------ | |Caffein| | No.| Weight.| per | Results. | Remarks. | | kilo. | | ----+--------+-------+-----------+------------------------------------ |_Kilos._|_Gram._| | 8 | 3.10 | 0.354 |Found dead |Vomited in 4 hours after feeding; | | | next day | restlessness, loss of appetite, | | | | thirst, incoordination of muscles, | | | | convulsions. 9 | 3.15 | .350 |Survived |Muscular incoordination and | | | | stiffness, restlessness, vomited 1 | | | | hour after caffein was given. 10 | 1.60 | .350 |Died in |Convulsion; no vomiting. | | | 3 hours | 11 | 1.26 | .200 |Found dead |Salivation; convulsions. | | | next day | 12 | 1.28 | .200 |Survived |No symptoms. 15 | 1.20 | .250 | do. |Subcutaneous injection. 16 | 3.50 | .300 |Died in |Convulsions 45 minutes after caffein | | | 1 hour | was fed. ----+--------+-------+-----------+------------------------------------ CHRONIC CAFFEIN INTOXICATION. The object of this study was to ascertain the effect of repeated dosage when caffein was given daily or at longer intervals. The experiments were tried on rabbits and on dogs. As in the experiments on acute intoxication, the animals were under observation for some time in the laboratory before the administration of caffein was begun in order to ascertain the presence or absence of abnormality. The relation of diet to toxicity received some attention, but the question was not studied exhaustively in the present investigation. EXPERIMENTS ON RABBITS. Full-grown adult as well as young rabbits were employed. The diet consisted either of carrots or of oats; water was given ad libitum. The rabbits were kept in metal cages in a well-lighted and well-ventilated room. Unnecessary handling or any other procedure tending to fatigue or to cause discomfort to the animals was very carefully avoided, since we had found that such treatment was likely to decrease the resistance of the rabbit to caffein. The caffein was administered by feeding by mouth and through a stomach tube, or by the subcutaneous method. In a good many cases it was given daily, in some at longer intervals. SERIES A. The experiments of this series formed a preliminary study for the purpose of testing the effect of moderate doses. One decigram of caffein per kilo was given daily for several days; when administered at longer intervals the dose was increased to 150 to 200 mg per kilo. It was found that the smaller doses did not produce any symptoms; even the weights of the animals were not influenced. Doses of medium size given on two successive days were likewise without any noticeable effect (Nos. 182, 183, 123, 101). When a third dose of this size was given within 48 or 24 hours it proved fatal (Nos. 123, 182, and 183). Exceptionally, however, moderately large doses (for rabbits) may be given for three consecutive days without fatal issue, as in rabbit No. 101. When given at intervals of two to three days, larger doses, as may be seen from the protocols, can be administered without causing acute death (Nos. 173, 181, 201). The results of the tests of this series point to the absence of any accumulation and to the possible elimination of moderate doses of caffein and its products of decomposition within 24 hours or thereabouts. When the doses are larger the time of its elimination is apparently longer, as shown by the fact that repetitions of the dose the next day may be fatal, but when a longer interval is allowed it may be given without causing death. It will be observed that only one rabbit of this series survived, but it was extremely emaciated. This condition has been observed in a number of cases after caffein had been given for several days. Even when the drug was withdrawn the animals continued to lose weight. This may be explained by the condition of the gastro-intestinal canal as found at autopsy. The presence of inflammation of the mucous membrane of the stomach and intestines, with ulceration of the mucous membrane of the pylorus in one of the rabbits (No. 173) of the series, in all probability caused diminution or loss of appetite, which of itself would tend to cause loss of flesh and strength and finally death. Protocols of the experiments follow. _Rabbit 173._ _Carrots were fed from October 1 to 18 and oats for the remainder of the experiment._ ---------+---------+--------- Date. | Weight. | Caffein | |per kilo. ---------+---------+--------- | _Grams._| _Gram._ Oct. 9 | 1,980 | 0.141 Oct. 11 | 1,905 | .190 Oct. 13 | 1,930 | .207 Oct. 16 | 2,005 | 0.220 Oct. 18 | 1,845 | Oct. 20 | 1,740 | .230 ---------+---------+-------- October 21: Paralysis of posterior extremities. October 22: 9 a. m., found dead. The urine was examined before and after the administration of caffein. No symptoms were observed after the administration of caffein (5 doses in 11 days), nor was albumen or sugar found in the urine after any of the experiments on this rabbit. _Autopsy_: Pyloric mucosa exhibited several ulcers; small intestines showed slight inflammation; liver deeply congested; kidneys showed marked inflammation of cortex; other organs practically normal. _Rabbit 181._ _Diet, carrots September 29-October 17, then oats._ ---------+---------+---------- Date. | Weight. | Caffein | |per kilo. ---------+---------+---------- | _Grams._| _Gram._ Oct. 4 | 1,425 | 0.105 Oct. 5 | 1,450 | .100 Oct. 6 | 1,270 | .100 Oct. 7 | 1,210 | .100 Oct. 8 | 1,375 | .130 Oct. 9 | 1,305 | .153 Oct. 11 | 1,370 | 0.175 Oct. 13 | 1,385 | .180 Oct. 16 | 1,345 | .200 Oct. 17 | 1,030 | Oct. 18 | 1,230 | Oct. 20 | 1,215 | ---------+---------+---------- Rabbit was markedly emaciated and weak. No albumen or sugar found in the urine as a result of caffein feeding. _Rabbit 182._ _Diet of carrots from September 29._ Received caffein subcutaneously as follows: ---------+---------+----------- Date. | Weight. | Caffein | |per kilo. ---------+---------+----------- | _Grams._| _Gram._ Oct. 4 | 1,765 | 0.100 Oct. 5 | 1,880 | .100 Oct. 6 | 1,750 | .100 Oct. 7 | 1,710 | .100 Oct. 8 | 1,685 | .135 Oct. 9 | | .150 Oct. 11 | 1,605 | .174 ---------+---------+---------- October 12: 11 a. m., 23 hours after caffein was given, convulsions with recovery; rabbit died at 1.30 p. m. No sugar was found in the urine at any time after the administration of caffein. Albumen was present only in one specimen. _Rabbit 183._ _Diet of carrots from September 29._ Received caffein subcutaneously as follows: ---------+---------+---------- Date. | Weight. | Caffein | |per kilo. ---------+---------+---------- |_Grams._ | _Gram._ Oct. 4 | 1,385 | 0.100 Oct. 5 | 1,460 | .100 Oct. 6 | 1,385 | .100 Oct. 7 | 1,240 | .122 Oct. 8 | 1,310 | 0.153 Oct. 9 | 1,390 | .142 Oct. 11 | 1,390 | .187 ---------+---------+--------- October 12: 9 a. m., found dead. No albumen was found in the urine. Only one sample contained sugar. _Rabbit 123._ _White, female._ _Diet, oats._ Received caffein subcutaneously as follows: ---------+---------+--------- Date. | Weight. | Caffein | | per | | kilo. ---------+---------+--------- |_Grams._ |_Grams._ Apr. 14 | 2,350 | 42 Apr. 16 | 2,250 | 90 Apr. 17 | 2,325 | 86 Apr. 20 | 2,126 | 141 Apr. 21 | 1,965 | 152 Apr. 22 | 1,876 | 160 ---------+---------+--------- Rabbit died 30 minutes after last injection of caffein. _Autopsy_: Stomach exhibited marked inflammation of mucosa. Slight enteritis. Liver and kidneys were deeply congested and dark colored. _Rabbit No. 101, white male._ _Diet, oats._ Received caffein subcutaneously as follows: ---------+---------+--------- Date. | Weight. | Caffein | | per | | kilo. ---------+---------+--------- |_Grams._ |_Grams._ Mar. 18 | 2,025 | 0.100 Mar. 19 | 1,970 | .100 Mar. 20 | 2,009 | .100 Mar. 22 | 1,855 | .100 Mar. 23 | 1,738 | .114 Mar. 24 | 1,815 | .166 Mar. 25 | 1,830 | .185 Mar. 26 | 1,710 | .176 Mar. 29 | 1,734 | .219 Apr. 1 | 1,606 | .224 ---------+---------+--------- April 5: Found dead. _Autopsy_: Marked inflammation of gastric mucosa. Considerable enteritis affecting the whole extent of the intestines; liver congested and friable; kidneys deeply congested in cortical and medullary portions; spleen congested, but of normal size; lungs and heart normal. Four days, 0.1 per kilo; 10 doses in 14 days. _Rabbit 201._ _Diet of carrots begun October 1; October 19, oats._ Subcutaneous injections as follows: ---------+---------+--------- Date. | Weight. | Caffein | | per | | kilo. ---------+---------+--------- |_Grams._ |_Grams._ Oct. 9 | 1,000 | 0.150 Oct. 11 | 1,015 | .180 Oct. 13 | 1,065 | .187 Oct. 16 | 1,065 | .225 Oct. 18 | 850 | Oct. 20 | 890 | .111 ---------+---------+--------- Under observation six hours October 20; no symptoms. October 23: Died; was much emaciated but did not show any symptoms; emaciation set in when caffein was withdrawn; urine never contained sugar or albumen; symptoms observed after second dose only. SERIES B. The question whether caffein is cumulative in the rabbit, suggested in the preceding experiments, was the subject of further investigation in Series B. Caffein was given by mouth or subcutaneously. Carrots formed the exclusive diet, a measured amount being given. The rabbits were kept under observation for two weeks, except Nos. 370 and 373, records of which were made only for four days before the administration of caffein was begun. Caffein was given by mouth in experiments of Groups I and III. Rabbits 292, 293, and 295 received daily 20 cc water by mouth for four days previous to the administration of caffein, while in the rabbits of Group II the caffein treatment was preceded by the injection of 0.8 per cent salt solution subcutaneously. The object in both cases was to ascertain whether or not the method of the administration of caffein has any influence on the animal, but observation made from day to day failed to show any effect of such treatment. About 1 decigram of caffein per kilo was administered daily, with occasional intermissions. Later in the course of the experiment the doses were increased, 0.15 gram per kilo being the maximum dose given. Rabbit 293 died after the third dose with symptoms of typical caffein poisoning. The administration of the same dose of caffein was continued 10 days longer in Nos. 292 and 295. It was omitted on the seventh, fourteenth, and fifteenth days of the experiment. On the eighteenth day of the experiment the dose was increased to 150 mg per kilo and was repeated 2 days later. No. 295 was found dead the next day. No. 292 survived. Rabbits 313 and 315 may be considered together, as they were treated alike in every respect. The initial dose of 100 mg caffein per kilo was finally increased to 122 mg. After the twelfth dose the emaciation was well marked and the rabbits were very weak. No. 313 was found dead 2 days, and No. 315 3 days, after the last dose of caffein was given. It should be remarked in this connection that symptoms of caffein poisoning were never observed in these rabbits. Death was not due, therefore, primarily to caffein, but the rapid loss of flesh and strength observed during the last few days suggests that it was due to malnutrition apparently brought about by caffein. The results obtained by subcutaneous injection of caffein are given in the table as Group II. The initial dose of 100 mg per kilo was injected daily. No. 298 died after the second dose. Nos. 223 and 296 received this amount daily for 6 days. An intermission of 2 days followed, at the end of which the same dose was given again. The next day it was increased to 150 mg per kilo, but no effect was observed; 48 hours later this dose was repeated. No. 223 was found dead, but its mate survived. Symptoms of acute caffein intoxication were not observed in any of these rabbits. It would seem, therefore, that caffein is not cumulative. This supposition, however, appears somewhat contradictory in view of the fact that out of the eight rabbits of this series six died, nor could any cause of death be ascribed other than caffein. Also the first results of Experiments 293, 370, and 373 might be considered as indicating that cumulation, though to a moderate extent, does take place, since in these cases reflexes developed after the drug was given for some time. But this view is contradicted by the results of Experiment 371, in which 150 mg per kilo given 5 days after the daily dosage of caffein was suspended likewise caused increased reflexes. Cumulation, therefore, does not account for the effects noted in the other rabbit. It will be observed that rabbit No. 370, as well as Nos. 371 and 373, had diarrhea for several days. It is quite possible that the weakened condition rendered the rabbits more sensitive to the action of the drug. This is made highly probable by the observations recorded in the experiments on acute intoxication with caffein in which death occurred after small doses. In such cases some pathological condition was often disclosed by the autopsy. The results of this series corroborate, therefore, those of Series A, and indicate again the absence of cumulative action. The results obtained are in all probability due to malnutrition and other conditions brought about by congestion of the viscera and consequent injury to the gastro-intestinal canal. TABLE 16.--_Chronic caffein intoxication of rabbits; Series B on cumulation._ --------------+--------------------+--------------------+------------- | Group I. | Group II. | Group III. Data. +------+------+------+------+------+------+------+------ | No. | No. | No. | No. | No. | No. | No. | No. | 292. | 293. | 295. | 296. | 223. | 298. | 315. | 313. --------------+------+------+------+------+------+------+------+------ Diet (grams | | | | | | | carrots in | | | | | | | 2 days) 1,000| 1,000| 975| 930| 905| 880| 355| 300 Caffein | | | | | | | administered | | | | | | | (cc) and weight | | | | | | | (grams): | | | | | | | | | | | | | | Mar. 5 { | | | | | | | {1,410| 1,470| 1,045| 1,040| 1,070| 955| 770| 770 | | | | | | | Mar. 7 { | | | | | | | {1,415| 1,360| 1,140| 1,090| 1,095| 1,000| 715| 690 | | | | | | | Mar. 9 { | | | | | | | {1,350| 1,270| 1,070| 1,000| 1,055| 1,005| 655| 665 | | | | | | | Mar. 11 { | | | | | | | {1,505| 1,465| 1,190| 1,230| 1,285| 1,250| 755| 760 | | | | | | | Mar. 16 { | | | | | | | {1,580| 1,460| 1,230| 1,165| 1,170| 1,145| 730| 745 | | | | | | | Mar. 17 { | | | | | | | {1,515| 1,415| 1,080| 1,040| 1,115| 1,105| 720| 685 | | | | | | | Mar. 19 { | | | | | | | {1,565| 1,570| 1,280| 1,195| 1,235| 1,220| 710| 735 | | | | | | | Mar. 21 { 7| 7| 6| | | | 4| 4 {1,585| 1,530| 1,265| 1,150| 1,215| 1,260| 755| 700 | | | | | | | Mar. 22 { 7| 7| 6| (1) | (1) | (1) | 4| 4 {1,440| 1,315| 1,175| 1,100| 1,045| 1,150| 675| 635 | | | | | | | Mar. 23 { 7| 7| 6| (1) | (1) | (1) | 4| 4 {1,335| 1,140| 1,110| 1,145| 1,190| 1,230| 715| 700 | | | | | | | Mar. 24 { 7| | 6| (1) | (1) | (1) | 4| 4 {1,310| (2) | 1,090| 1,115| 1,170| 1,250| 680| 650 | | | | | | | Mar. 25 { 7| | 6| (1) | (1) | (1) | 4| 4 {1,375| | 1,035| 1,125| 1,215| 1,215| 695| 685 | | | | | | | Mar. 26 { 7| | 6| | | | 4| {1,255| | 1,095| 1,105| 1,155| 1,150| 675| 695 | | | | | | | Mar. 27 { | | | | | | | { | | | | | | | | | | | | | | Mar. 28 { 7| | 6| 5.5| 6| 6| 4| 4 {1,355| | 1,115| 1,120| 1,160| 1,155| 595| 685 | | | | | | | Mar. 29 { 7| | 6| 6| 6| 5| 4| 4 {1,385| | 1,150| 1,155| 1,165| 955| 695| 675 | | | | | | | Mar. 30 { 7| | 6| 6| 6| | 4| 4 {1,330| | 1,075| 1,035| 1,095| Dead.| 630| 610 | | | | | | | Mar. 31 { 7| | 6| 6| 6| | 4| 4 {1,325| | 1,170| 1,110| 1,140| | 690| 605 | | | | | | | Apr. 1 { 7| | 6| 6| 6| | 4| 4 {1,335| | 1,050| 1,050| 1,120| | 625| 620 | | | | | | | Apr. 2 { 7| | 6| 6| 6| | 4| 4 {1,390| | 1,125| 1,090| 1,155| | 695| 625 | | | | | | | Apr. 3 { | | | | | | | { | | | | | | 200| | | | | | | | Apr. 4 { | | | | | | | {1,300| | 1,005| 1,105| 1,080| | 585| 580 | | | | | | | Apr. 5 { 7| | 6| 6| 6| | 4| 4 {1,385| | 1,090| 1,130| 1,090| | 655| 630 | | | | | | | Apr. 6 { 9| | 7.5| 7.5| 8| | | {1,260| | 1,010| 1,050| 1,110| | 560| 530 | | | | | | | Apr. 7 { | | | | | | | { | | | | | | | (3) | | | | | | | Apr. 8 { 9| | 7.5| 7.5| 8| | | {1,260| | 1,000| 1.090| 1.965| | Dead.| | | | | | | | Apr. 9 Survived.| | Dead.|Surv. | Dead.| | | Dead. ---------------------+------+------+------+------+------+------+------ (1) On these days 5 _cc_ of salt solution was administered subcutaneously. (2) Dead Mar. 23. (3) Found dead 9 a. m. TABLE 17.--_Chronic intoxication of rabbits, series B, Group IV, on cumulation._ RABBIT, 370. ---------+---------+----------+--------+--------+----------+---------- | | | | | Caffein | Date. | Weight. | Carrots. | Water. | Urine. | by | Symptoms. | | | | | stomach. | ---------+---------+----------+--------+--------+----------+---------- | | | | |_Mg per_ | | _Grams._| _Grams._ | _cc._ | | _kilo._ | Aug. 7 | 2,155 | 450 | 50 | 280 | | Aug. 8 | 2,030 | 450 | 25 | 185 | | Aug. 9 | 2,105 | 290 | 0 | 275 | | Aug. 10 | 2,095 | 450 | 30 | 335 | | Aug. 11 | 2,105 | 450 | 65 | 360 | 50 | Aug. 12 | 2,125 | 450 | 65 | 220 | 50 | Aug. 13 | 2,120 | 350 | 25 | 265 | 50 | Aug. 14 | 2,170 | 450 | 35 | 275 | 75 | Aug. 15 | 2,175 | 350 | (?) | 200 | 75 | Aug. 16 | 2,170 | 360 | 65 | 250 | 75 | Aug. 17 | 2,175 | 310 | 35 | 170 | 100 | Aug. 18 | 2,095 | 180 | 40 | 285 | 100 | Severe | | | | | | diarrhea. Aug. 19 | 2,120 | 400 | (?) | 285 | 125 | Do. Aug. 20 | 2,120 | 400 | (?) | 310 | 125 | Better. Aug. 21 | 2,120 | 400 | 70 | 250 | 125 | Do. Aug. 22 | 2,040 | 400 | 45 | 265 | 150 | Diarrhea | | | | | | bad. Aug. 23 | 2,030 | 370 | 35 | 220 | 150 | Diarrhea | | | | | | better. Aug. 24 | 1,950 | 215 | 40 | 120 | 150 | Do. Aug. 25 | 1,885 | 195 | 35 | 60 | 200 | Reflexes. Aug. 26 | | | | | | Found | | | | | |dead at 9. ---------+---------+----------+--------+--------+----------+---------- RABBIT, 373. ---------+---------+----------+--------+--------+----------+---------- Aug. 7 | 2,240 | 450 | 50 | 230 | | Aug. 8 | 2,150 | 150 | 30 | 300 | | Aug. 9 | 2,120 | 205 | 0 | 150 | | Aug. 10 | 2,150 | 450 | 15 | 245 | | Aug. 11 | 2,195 | 450 | 5 | 285 | 50 | Aug. 12 | 2,160 | 450 | 65 | 325 | 50 | Aug. 13 | 2,120 | 300 | 45 | 190 | 50 | Aug. 14 | 2,195 | 450 | 40 | 265 | 75 | Aug. 15 | 2,215 | 350 | 35 | 200 | 75 | Aug. 16 | 2,205 | 310 | 45 | 225 | 75 | Aug. 17 | 2,240 | 400 | 40 | 265 | 100 | Aug. 18 | 2,255 | 350 | 30 | 320 | 100 | Aug. 19 | 2,115 | 185 | (?) | 170 | 125 | Severe | | | | | | diarrhea. Aug. 20 | 2,115 | 280 | 35 | 195 | 125 | Diarrhea. | | | | | | better Aug. 21 | 2,050 | 175 | 75 | 115 | 125 | Slight | | | | | | diarrhea. Aug. 22 | 2,060 | 180 | 75 | 130 | 150 | Aug. 23 | 2,005 | 200 | 75 | 125 | 150 | Reflexes. Aug. 24 | 1,990 | 200 | 75 | 150 | 150 | Slight | | | | | | diarrhea. Aug. 25 | 1,950 | 255 | 55 | 132 | 175 | Severe | | | | | | diarrhea. Aug. 26 | 1,870 | 205 | 80 | 140 | None | Do. Aug. 27 | 1,830 | 200 | 50 | 140 | do. | Do. Aug. 28 | 1,950 | 400 | 25 | 265 | do. | Slight | | | | | | diarrhea. Aug. 29 | 1,825 | 400 | 0 | 315 | do. | Very weak | | | | | | and in | | | | | | poor | | | | | | condition Aug. 30 | 1,850 | | 10 | 140 | do. | Aug. 31 | 1,835 | | | | | ---------+---------+----------+--------+--------+----------+---------- RABBIT, 371. ---------+---------+----------+--------+--------+----------+---------- Aug. 7 | 2,240 | 450 | 50 | 300 | | Aug. 8 | 2,260 | 450 | 50 | 225 | | Aug. 9 | 2,310 | 430 | (?) | 300 | | Aug. 10 | 2,295 | 450 | 50 | 305 | | Aug. 11 | 2,320 | 450 | 50 | 335 | 50 | Aug. 12 | 2,280 | 450 | 70 | 400 | 50 | Aug. 13 | 2,300 | 350 | 70 | 255 | 50 | Aug. 14 | 2,265 | 425 | 55 | 154 | 75 | Aug. 15 | 2,260 | 250 | 40 | 125 | 75 | Aug. 16 | 2,295 | 155 | 70 | Lost | 75 | Aug. 17 | 2,180 | 105 | 70 | 120 | 100 |Severe | | | | | | diarrhea. Aug. 18 | 2,150 | 125 | 70 | 100 | 100 |Diarrhea | | | | | | better. Aug. 19 | 2,075 | 210 | (?) | 192 | 100 |Diarrhea | | | | | | severe. Aug. 20 | 2,075 | 280 | 70 | 180 | 100 |Do. Aug. 21 | 2,165 | 260 | 50 | 225 | None |Diarrhea | | | | | | better. Aug. 22 | 2,105 | 400 | 50 | 275 | do. | Aug. 23 | 2,080 | 300 | 0 | 145 | do. |Diarrhea | | | | | | severe. Aug. 24 | 2,105 | 250 | 15 | 245 | do. |Do. Aug. 25 | 2,055 | 320 | 10 | 176 | 150 |Reflexes. Aug. 26 | 2,040 | 190 | 75 | 250 | 150 |Died at | | | | | | 1 p. m., | | | | | | without having | | | | | | showed any | | | | | | symptoms other | | | | | | than reflexes. ---------+---------+----------+--------+--------+----------+---------- SERIES C. The subjects used in these experiments were rabbits of medium size and were apparently young or at any rate were not very old. The series was planned for the study of the possible effect of diet on the toxicity of caffein when given for some time, and therefore oats were substituted for carrots, which had been fed in the previous work, as already stated. Caffein was given by mouth in the usual way, in 1 per cent solution, 100 mg. per kilo daily. Fourteen rabbits were used for these tests. Their weights were recorded daily and observations made at frequent intervals during the day. The only change noticed in all of the experiments of this series was progressive loss of weight which set in from 3 to 8 days after the administration of the drug was begun. The duration of life varied considerably. No. 382 died after the first dose. No. 389 lived 2 days, No. 386, 3 days, and No. 385, 5 days; No. 390 lived 7 days and No. 404 lived 20 days after the administration of caffein was begun. The duration of life in all the others was from 11 to 16 days. The findings at autopsy are interesting and suggestive as regards the possible explanation of the effects of repeated dosage of caffein. In eight of the rabbits there was involvement of the mucous membrane of the stomach or intestines or of both. Since the same condition of the gastro-intestinal canal was observed in previous experiments with caffein when injected subcutaneously, the mere passing of the tube into the stomach is obviously not the cause of this condition. The fatal outcome due is therefore, as was suggested above, to inanition brought about by the condition of the gastro-intestinal canal. Moreover parallel experiments carried out on rabbits in the same way with alcohol survived this treatment much longer. Obviously then the passing of the soft rubber catheter is not the cause of this condition of the gastro-intestinal canal nor the diet. Rabbits were fed oats exclusively for several months in this laboratory and thrived. The presence of pneumonia in the other rabbits of this series may be regarded as accidental, as it is inconceivable that one or two doses of caffein, as was the case in Nos. 382 and 389, could predispose the lungs to infection. The results of these experiments therefore are in harmony with those of the preceding two series, indicating that caffein does not accumulate in the body, and that the toxicity of caffein, whether of the single dose or of repeated doses is the same, on a diet of carrots or of oats. These results also show that caffein is much more toxic with repeated dosage. As stated in the historical part of this bulletin the same view was held by Gourewitch.(28) _Rabbit 386._ _Belgian female._ Given 1 cc of 1 per cent caffein for each 100 grams, through stomach tube. --------+--------+---------- Date. | Weight.|Treatment. --------+--------+---------- |_Grams._| _cc._ Aug. 17| 1,300 | 13.0 Aug. 18| 1,215 | 12.0 Aug. 19| (?) | (?) --------+--------+---------- August 20: Found dead 9 a. m. _Autopsy_: Lungs slightly congested; liver engorged and friable; gall cyst well filled. _Rabbit 389._ _Black male._ Given 1 cc of 1 per cent caffein for each 100 grams, through stomach tube. --------+--------+---------- Date. | Weight.|Treatment. --------+--------+---------- |_Grams._| _cc._ Aug. 17| 1,070 | 10.0 Aug. 18| 1,025 | 10.0 --------+--------+---------- August 19: Found dead 9 a. m. _Autopsy_: Lungs severely congested and partially hepatized; liver was engorged; other organs appeared normal. _Rabbit 382._ _Belgian female._ On August 17 weighed 1,035 grams; received 1 cc of 1 per cent caffein for each 100 grams; 10 cc of 1 per cent caffein given in all. August 18: Found dead 9 a. m. _Autopsy_: Lungs congested and hepatized; liver engorged; stomach showed numerous petechial hemorrhages on mucosa; kidneys slightly congested; intestines appeared normal. _Rabbit 385._ _Belgian female._ Given 1 cc of 1 per cent caffein for each 100 grams, through stomach tube. --------+--------+---------- Date. | Weight.|Treatment. --------+--------+---------- |_Grams._| _cc._ Aug. 17| 780 | 8.0 Aug. 18| 760 | 7.5 Aug. 19| 755 | 7.5 Aug. 20| 715 | 7.0 Aug. 21| 700 | 7.0 --------+--------+---------- August 22: Found dead 9 a. m. _Autopsy_: Lungs exhibited pneumonic lesions, with inflammation of adjacent pleura; a fibro-plastic exudate present around lung; liver showed a coccidial infestation; stomach distended with ingesta; mucous membrane characterized by a catarrhal inflammation; contents of small intestine liquid in nature and bile stained; large intestine somewhat impacted; liver and kidneys seemingly normal. _Rabbit 404._ _White male._ Given 1 cc 1 per cent caffein for each 100 grams. ------------+---------+------------ Date. | Weight. | Treatment. ------------+---------+------------ |_Grams._ | _cc._ Aug. 20 | 1,465 | 14.5 Aug. 21 | 1,475 | 14.5 Aug. 22(1) | | Aug. 23 | 1,475 | 14.5 Aug. 24 | 1,400 | 14.0 Aug. 25(2) | 1,405 | 14.0 Aug. 26 | 1,415 | 14.0 Aug. 27 | 1,400 | 14.0 Aug. 28(1) | | Aug. 29 | 1,310 | 13.0 Aug. 30 | 1,320 | 13.0 Aug. 31 | 1,330 | 13.5 Sept. 1 | 1,335 | 13.5 Sept. 2 | 1,315 | 13.0 Sept. 3 | 1,350 | 13.5 Sept. 4 | 1,335 | 13.5 Sept. 5 | 1,350 | 13.5 Sept. 6 | 1,380 | 14.0 Sept. 7 | 1,375 | 14.0 Sept. 8 | 1,325 | 13.0 ------------+---------+------------ (1) Not fed. (2) Reflexes. September 9: Found dead 9 a. m. _Autopsy_: Both lungs showed extensive pneumonia, with adhesions to pleura; pleuritis and pericarditis very marked; large amount of fibrous exudate in pleural cavity; pyloric end of stomach slightly congested; liver congested; other organs normal. _Rabbit 393._ _Belgian._ Given 1 cc of 1 per cent caffein to each 100 grams, through stomach tube. ------------+---------+------------ Date. | Weight. | Treatment. ------------+---------+------------ | _Grams._| _cc._ Aug. 17 | 950 | 9.5 Aug. 18 | 910 | 9.0 Aug. 19 | 895 | 9.0 Aug. 20 | 910 | 9.0 Aug. 21 | 905 | 9.0 Aug. 22(1) | | Aug. 23 | 825 | 8.0 Aug. 24 | 870 | 8.5 Aug. 25 | 835 | 8.5 Aug. 26 | 780 | 8.0 Aug. 27 | 765 | 7.5 Aug. 28(1) | | Aug. 29 | 710 | Aug. 30(2) | | Aug. 31(1) | | ------------+---------+------------ (1) Not fed. (2) Condition very poor; not fed. September 1: Found dead. _Autopsy_: Lungs congested and adhering to the pleura; extensive inflammation of pleura; liver slightly enlarged and congested; mucosa of stomach and small intestines slightly congested; other organs normal. _Rabbit 390._ _Belgian, male._ Given 1 cc of 1 per cent caffein to each 100 grams through stomach tube. ------------+---------+------------ Date. | Weight. | Treatment. ------------+---------+------------ | _Grams._| _cc._ Aug. 17 | 1,490 | 15.0 Aug. 18 | 1,370 | 14.0 Aug. 19 | 1,365 | 13.5 Aug. 20 | 1,340 | 13.5 Aug. 21 | 1,265 | 12.5 Aug. 22(1) | | Aug. 23 | 1,120 | 11.0 ------------+---------+------------ (1) Not fed. August 24: Found dead 9 a. m. _Autopsy_: Heart and lungs appeared normal; abdominal viscera showed no apparent pathologic change other than coccidial infection of the liver and fullness of the blood vessels. _Rabbit 392._ _Maltese, female._ Given 1 cc of 1 per cent caffein to each 100 grams through stomach tube. ------------+---------+----------- Date. | Weight. | Treatment. ------------+---------+----------- | _Grams._| _cc._ Aug. 17 | 1,265 | 12.5 Aug. 18 | 1,275 | 12.5 Aug. 19 | 1,240 | 12.5 Aug. 20 | 1,220 | 12.0 Aug. 21 | 1,245 | 12.5 Aug. 22(1) | | Aug. 23 | 1,180 | 12.0 Aug. 24 | 1,190 | 12.0 Aug. 25 | 1,155 | 11.5 Aug. 26 | 1,140 | 11.5 Aug. 27 | 1,140 | 11.5 Aug. 28(1) | | Aug. 29 | 1,115 | 11.0 Aug. 30 | 1,080 | 11.0 Aug. 31 | 1,020 | 10.0 Sept. 1 | 995 | 10.0 Sept. 2 | 930 | 9.0 ------------+---------+----------- (1) Not fed. Died at 3 p. m. September 2. _Autopsy_: The stomach and small intestines showed numerous small hemorrhagic spots; a thick coating of mucus surrounded the contents of the stomach; the other organs were apparently normal. _Rabbit 403._ _Black._ Given 1 cc of 1 per cent caffein for each 100 grams. ------------+---------+----------- Date. | Weight. | Treatment. ------------+---------+----------- | _Grams._| _cc._ Aug. 20 | 1,640 | 16.5 Aug. 21 | 1,640 | 16.5 Aug. 22(1) | | Aug. 23 | 1,490 | 15.0 Aug. 24 | 1,515 | 15.0 Aug. 25 | 1,475 | 15.0 Aug. 26 | 1,390 | 14.0 Aug. 27 | 1,330 | 13.5 Aug. 28(1) | | Aug. 29 | 1,130 | 11.5 Aug. 30 | 1,055 | 10.5 ------------+---------+----------- (1) Not fed. August 31: Found dead at 3 p. m. _Autopsy_: Extensive gastroenteritis; liver enlarged and congested; spleen slightly congested; peritoneum thickened and congested; other organs normal. _Rabbit 884._ _Black, female._ Given 1 cc of 1 per cent caffein for each 100 grams through stomach tube. ------------+---------+----------- Date. | Weight. | Treatment. ------------+---------+----------- | _Grams._| _cc._ Aug. 16 | 1,195 | 12.0 Aug. 17 | 1,205 | 12.0 Aug. 18 | 1,140 | 11.5 Aug. 19 | 1,180 | 12.0 Aug. 20 | 1,145 | 11.5 Aug. 21 | 1,145 | 11.5 Aug. 22(1) | | Aug. 23 | 1,005 | 10.0 Aug. 24 | 1,035 | 10.5 Aug. 25 | 990 | 10.0 Aug. 26 | 960 | 9.5 Aug. 27 | 955 | 9.5 Aug. 28(1) | | Aug. 29 | 870 | 9.0 Aug. 30(2) | 850 | 8.5 Aug. 31 | 810 | 8.0 Sept. 1 | 740 | 7.5 ------------+---------+----------- (1) Not fed. (2) Poor condition, mucus from rectum. September 2: Found dead at 9 a. m. _Autopsy_: The mucosa of stomach showed numerous hemorrhagic spots; the first portion of the small intestines was slightly congested; the other organs were apparently normal in appearance. _Rabbit 383._ _Belgian, female._ Given 1 cc of 1 per cent caffein for each 100 grams through stomach tube. -----------+---------+------------ Date. | Weight. | Treatment. -----------+---------+------------ | _Grams._| _cc._ Aug. 16 | 995 | 10.0 Aug. 17 | 1,005 | 10.0 Aug. 18 | 990 | 10.0 Aug. 19 | 895 | 9.0 Aug. 20 | 945 | 9.5 Aug. 21 | 965 | 9.5 Aug. 22(1) | | Aug. 23 | 875 | 9.0 Aug. 24 | 855 | 8.5 Aug. 25 | 850 | 8.5 Aug. 26 | 785 | 8.0 Aug. 27 | 710 | 7.0 -----------+---------+------------ (1) Not fed. August 28: Found dead at 9 a. m. _Autopsy_: Lungs, heart, and spleen apparently normal; liver infected with coccidia; stomach apparently normal; walls of small intestines injected; colon marked congestion and hemorrhagic; kidneys hemorrhagic. _Rabbit 387._ _Belgian male._ Given 1 cc of 1 per cent caffein for each 100 grams through stomach tube. -----------+---------+------------ Date. | Weight. | Treatment. -----------+---------+------------ | _Grams._| _cc._ Aug. 17 | 1,260 | 12.5 Aug. 18 | 1,340 | 13.0 Aug. 19 | 1,335 | 13.0 Aug. 20 | 1,300 | 13.0 Aug. 21 | 1,325 | 13.0 Aug. 22(1) | | Aug. 23 | 1,205 | 12.0 Aug. 24 | 1,200 | 12.0 Aug. 25 | 1,285 | 12.5 Aug. 26 | 1,185 | 12.0 Aug. 27 | 1,255 | 12.5 Aug. 28(1) | | Aug. 29 | 1,115 | 11.0 Aug. 30 | 1,135 | 11.5 Aug. 31 | 1,175 | 12.0 Sept. 1 | 1,050 | 10.5 Sept. 2 | 900 | 9.0 -----------+---------+------------ (1) Not fed. September 3, found dead. _Autopsy_: Stomach and small intestines showed numerous hemorrhagic spots; thick coating of mucus surrounded the contents of the stomach; bladder was greatly distended with urine; the other organs were apparently normal. _Rabbit 388._ _Belgian male._ Given 1 cc of 1 per cent caffein for each 100 grams, through stomach tube. -----------+---------+------------ Date. | Weight. | Treatment. -----------+---------+------------ | _Grams._| _cc._ Aug. 17 | 1,080 | 10.0 Aug. 18 | 1,115 | 11.0 Aug. 19 | 1,150 | 11.5 Aug. 20 | 1,130 | 11.5 Aug. 21 | 1,120 | 11.0 Aug. 22(1) | | Aug. 23 | 1,020 | 10.0 Aug. 24 | 985 | 10.0 Aug. 25 | 960 | 9.5 Aug. 26 | 900 | 9.0 Aug. 27 | 875 | 9.0 Aug. 28(1) | | -----------+---------+------------ (1) Not fed. August 29, found dead 9 a. m. _Autopsy_: Heart and lungs normal; liver and kidneys engorged; stomach normal; intestines showed a catarrhal inflammation, though not severe; spleen normal; walls of colon somewhat injected. _Rabbit 391._ _Belgian._ Given 1 cc of 1 per cent caffein to each 100 grams through stomach tube. -----------+--------+----------- Date. | Weight.|Treatment. -----------+--------+----------- |_Grams._| _cc._ Aug. 17 | 940 | 9.5 Aug. 18 | 950 | 9.5 Aug. 19 | 955 | 9.5 Aug. 20 | 935 | 9.5 Aug. 21 | 945 | 9.5 Aug. 22(1)| | Aug. 23 | 835 | 8.5 Aug. 24 | 805 | 8.0 Aug. 25 | 800 | 8.0 Aug. 26 | 765 | 7.5 Aug. 27(2)| 690 | 7.0 Aug. 28(1)| | Aug. 29 | 565 | 5.5 -----------+--------+----------- (1) Not fed. (2) Poor condition. August 30, found dead 9 a. m. _Autopsy_: Heart injected; lungs normal; liver affected slightly with coccidiidea; stomach normal in appearance; small intestines normal, but colon considerably inflamed; kidneys slightly engorged; other organs normal. _Rabbit 402._ _Black female._ Given 1 cc of 1 per cent caffein to each 100 grams. -----------+--------+----------- Date. | Weight.|Treatment. -----------+--------+----------- |_Grams._| _cc._ Aug. 20 | 2,030 | 20.0 Aug. 21 | 1,950 | 19.5 Aug. 22(1)| | Aug. 23 | 1,955 | 19.5 Aug. 24 | 1,905 | 19.0 Aug. 25 | 1,890 | 19.0 Aug. 26 | 1,780 | 18.0 Aug. 27 | 1,765 | 17.5 Aug. 28(1)| | Aug. 29 | 1,630 | 16.5 Aug. 30 | 1,540 | 15.5 Aug. 31 | 1,510 | 15.0 Sept. 1 | 1,425 | 14.0 -----------+--------+----------- (1) Not fed. September 2, found dead 9 a. m. _Autopsy_: The lungs were badly congested, the posterior lobe of the right lung showing hepatization; the liver was considerably enlarged and congested; the mucous membrane of the stomach and small intestines was congested and showed numerous hemorrhagic spots; the kidneys showed slight congestion; all other organs normal. SERIES D. The evidence brought forth in the preceding pages regarding cumulation of caffein naturally suggests the question whether or not the body acquires a tolerance for it. This question has already been answered in the affirmative by Gourewitch,(28) but owing to the method he used for the identification of caffein and the few experiments made his results are not conclusive. The experiments of series A, B, and C might be regarded as indicating that tolerance for caffein is not acquired by the rabbit. It was noticed, however, that the rabbit apparently does tolerate increasingly larger doses under certain conditions, as the following experiments show: _Rabbit 223._ _Belgian hare, male._ October 22: Weight, 1,520 grams; 15 cc 2 per cent caffein injected subcutaneously at 2 p. m. November 1: 10.30 a. m., weight, 1,510 grams; 17 cc 2 per cent caffein injected subcutaneously (225 mg per kilo), reflexes observed, but no tetanus. November 4: 10.30 a. m., weight 1,535 grams; 19 cc 2 per cent caffein injected subcutaneously at 2.40 p. m.; 4.40 p. m., no symptoms. November 8: Weight, 1,425 grams; 20 cc 2 per cent caffein (285 mg per kilo) injected at 11.45 p. m.; 5 p. m., no symptoms. November 17: Weight, 1,325 grams; 22 cc 2 per cent caffein injected at 2.55 p. m. (329 mg per kilo), no symptoms. November 18: Rabbit in good condition. _Rabbit 224. Belgian hare, female. Diet, carrots._ October 18: Weight, 1,935 grams; 11.20 a. m., 15 cc 2 per cent caffein (155 mg per kilo) injected. November 1: Weight, 1,780 grams; 20 cc 2 per cent caffein (224 mg per kilo) injected subcutaneously, reflexes increased, muscle tremors present, but no other symptoms. November 4: Weight, 1,710 grams; 21.5 cc 2 per cent caffein (252 mg per kilo) injected. November 8: Weight, 1,435 grams; 22.5 cc 2 per cent caffein or 314 mg per kilo injected at 11.40 p. m.; 5 a. m., no symptoms. November 17: Weight, 1,340 grams; 24 cc 2 per cent caffein (358 mg per kilo) injected subcutaneously. November 18: 9 a. m., rabbit died. _Rabbit 226. Gray male. Diet, carrots._ October 28: Weight, 1,045 grams; 10 cc 2 per cent caffein injected subcutaneously at 1.50 p. m.; 4.30 p. m., tremors observed, but no other symptoms. October 29: Rabbit in good condition. November 1: Weight, 950 grams; 10.55 a. m., 11 cc 2 per cent caffein injected subcutaneously (231 mg per kilo). November 4: Weight, 930 grams; 2.50 p. m., 12 cc 2 per cent caffein injected subcutaneously (258 mg caffein per kilo). November 6: Weight, 945 grams; 11.45 a. m., 15 cc 2 per cent caffein (313 mg per kilo) injected subcutaneously. November 17: Rabbit still alive; weight, 890 grams. The results of these experiments indicate that when sufficient time is allowed between two successive injections, susceptibility to caffein is not increased. The rabbit, on the contrary, seems to acquire a tolerance for the drug, for the fourth dose was 15 per cent larger than the minimum fatal dose of caffein. This is in all probability due to the better elimination of caffein and its products of decomposition and to recovery from the deleterious effects of each dose, made possible by long intervals between injections. The results of these experiments may be briefly summed up by stating that subminimum doses of caffein given to the rabbit daily or at intervals (not too long) do not produce any symptoms such as were observed in acute caffein intoxication, namely, increased reflexes and convulsions, or increased rate of respiration, thus showing that it is not cumulative. But evidence of undoubted summation of effect was adduced to show that if the administration of subminimum doses of caffein be continued daily for a period of 11 to 18 days the result is fatal. Tolerance, however, may be acquired, although to a limited extent only, provided sufficiently long intervals between injections are allowed to give time for repair of the injury done by the drug and to develop a mechanism for its better decomposition and elimination. Furthermore, the evidence just given indicates that the elimination of subminimum doses of caffein and its products of decomposition is probably accomplished within 24 hours or thereabouts. That the elimination of larger doses is not accomplished in this interval is made probable by the following experiment: _Gray rabbit 455. Female. Diet, oats._ October 12: Weight, 1,185 grams; 3.30 p. m., 11.5 cc 2 of per cent caffein injected into the lumbar muscles; 3 p. m., reflexes increased. October 13: 10 a. m., rabbit weighed 1,070 grams; no symptoms of caffein poisoning, reflexes normal; 10.30 a. m., 10 cc 2 per cent caffein injected into the lumbar muscles; 11.30 a. m., rabbit jumped off the table, had convulsions, and died. EXPERIMENTS ON DOGS. Having gained some information respecting the effects of repeated doses of caffein on rabbits, it was of interest to find out how carnivora reacted to the drug when similarly administered. A number of dogs were used for the purpose. Considerable variation in the mode of experimentation, as will appear later, was allowed. Since the condition of the animal, its age, environment, or diet might be factors influencing toxicity, tests were made on full-grown and on young growing dogs whose food was varied. The subjects of the experiment were kept under observation for a few days to several weeks before the administration of caffein was begun, in order to determine whether or not any morbid condition existed, as well as to ascertain whether the new environment had any effect on these animals. Caffein was given chiefly by mouth, but the subcutaneous method was also employed during a portion of the experimental period in some dogs. The initial dose, which varied for different individuals, was maintained for a variable length of time. It was then progressively increased, in most cases until the death of the animal. With larger doses the intervals between successive injections were also increased. SERIES A. Six dogs were used in this series. Caffein was administered by mouth for periods of six days to five weeks. It was given daily or at intervals of two, and sometimes of three, days. In a few instances the drug was withheld for four or even for seven days, and its administration was resumed at the end of this time. The initial dose in these experiments varied approximately between 40 and 140 mg per kilo. The doses were then increased gradually, and thus the maximum resistance of the subject to caffein was tested. The diet consisted either exclusively of meat or largely of carbohydrates with a minimum amount of meat to give flavor to the food. _Dog 11. Female._ Diet consisted of rice, 250 grams; cane sugar, 250 grams; meat, 50 grams; cracker meal, about 100 grams. Caffein was given by mouth daily or at intervals of one day, when the dose did not exceed 1.5 grams. Before the dose was increased to 2 grams, or approximately 0.213 gram caffein per kilo, an interval of two days was allowed. Symptoms were noticed the next day. An interval of two days was therefore allowed again at the end of which the same dose was repeated. It will be remarked that there were no symptoms this time, and the general condition of the dog seemed to be good. Two grams of caffein were, therefore, given daily during the next two days without any untoward effects; the dose was then increased to 2.5 grams. Even after this enormous quantity no symptoms were observed except slight tremors. When this dose was repeated 26 hours later, it proved fatal. No albumin or sugar was found in the urine, although the dog was fed on a very liberal carbohydrate diet. The following is a complete record of the experiment. April 20: Urine acid, no albumin, no sugar. April 21: Urine free from sugar. April 22: Urine free from sugar. 1 gram caffein given in the afternoon. April 23: 9 a. m., dog was very thirsty, drank a large quantity of water, urine did not reduce Fehling's solution. April 24: 2.30 p. m., 1 gram caffein, no sugar in urine. April 25: 1 gram caffein administered. April 26: Weight, 10.6 kilos, urine collected in the morning, no sugar; 4.10 p. m., 1.5 grams caffein. April 27: 1.5 grams caffein; 1.30 p. m., diet as before, no sugar in urine. April 28: Weight, 10.2 kilos, no caffein, no sugar in urine. April 30: Weight, 10.4 kilos, no sugar in urine; 4.20 p. m., 2 grams caffein. May 1: Urine examined, sugar absent, weight 10 kilos, vomited, sick, tremors observed, drank 500 cc water at one time, appetite poor. May 2: No caffein, drank 150 cc water. May 3: Urine, no sugar, moderate quantity of albumen present; 12 noon, 2 grams caffein given by mouth, weight 10.3 kilos; 2 p. m., urine, sugar negative, condition of dog good, no symptoms of caffein intoxication. May 4: 10 a. m., about 10 cc thick, dark-colored mucilaginous urine found in collecting bottle; albumin a little more than a trace, decidedly less than on May 3, no sugar, condition of dog pretty good except for slight muscular tremors; 4 p. m., 2 grams caffein by mouth (as usual). May 5: Urine not examined, no symptoms; 4 p. m., 2 grams caffein. May 6: Urine not examined; 2.30 p. m., 2.5 grams caffein given by mouth; 4 p. m., slight tremor, no other symptoms. May 7: No examination of urine, no symptoms observed; 4 p. m., 2.5 grams caffein. May 8: 9 a. m., found dead, urine collected since last dose of caffein was given did not contain any sugar or albumin, the amount of caffein fed to this dog was 18 grams in 18 days. _Autopsy_: Post-mortem examination showed marked enteritis with hemorrhagic spots on the mucosa; liver and kidneys congested and dark colored; lungs congested; thyroid gland was greatly enlarged and congested. _Dog 28_. April 30: Weight, 6.8 kilos; the diet consisted of 250 grams rice, 250 grams sugar, 100 grams cracker meal, and 100 grams of meat. On May 3 his weight was 7 kilos. He received 1 gram of caffein by mouth at 12 noon. At 2 p. m. he vomited and tremors were observed. The next day, May 4, tremors were still present though less pronounced. Examination of the urine for sugar and albumin was negative; on May 4, 1 gram caffein was given again and repeated on May 5. On this date his general condition was not good--dog had no appetite and refused to take caffein. As the dog lost 10 per cent of his weight he was put on a meat diet exclusively and the dose of caffein was reduced to 0.5 gram. He became sick after the second dose, and the administration of caffein was therefore discontinued. It was resumed after five days and the caffein was administered in increasing amounts, i. e., on May 18, 0.5 gram; May 19, 0.5; May 20, 1; May 21, 1 gram in two doses of 0.5 each, given at intervals of one hour; May 22, 1 gram. Dog became irritable, but no other symptoms were observed. The administration of caffein was omitted the next day. On the following day when the same dose of caffein was given there was again marked irritability and tremors. The experiment was therefore discontinued. _Dog 22. Male bulldog._ June 24: Dog weighed 13.7 kilos. Diet consisted of meat exclusively; 1 gram caffein was given by mouth; diarrhea developed; no caffein was given for three days. June 28: Dog weighed 13.6 kilos, 1.5 grams caffein given at 10 a. m. June 30: 1.75 grams caffein administered. July 2: Dog weighed 13.5 kilos; 2 grams caffein or 0.15 gram per kilo, caused well-marked thirst, but did not produce any other symptoms. _Dog 20. Female_. May 12: Weight, 7.7 kilos. Fed liberal carbohydrate diet, consisting of rice, 100 grams; sugar 100 grams; meat and cracker meal, a sufficient quantity to flavor the food. May 14: Weight, 7.7 kilos. Examination of urine for albumin and sugar gave negative results. Urine was acid to litmus. May 17: Weight, 7.4 kilos. Three hours after it was fed the dog received 0.5 gram caffein by mouth. The test of the urine the next day for sugar was negative, but a trace of albumin was present. It will be noticed that the doses were increased gradually and that symptoms were observed only after the fourth dose of 0.1 gram per kilo. Later meat was substituted for the carbohydrate diet and the administration of caffein was stopped for four days. At the end of this period 100 mg caffein per kilo was fed daily for five days, and the dose was then very gradually increased. Diarrhea occurred twice, but no other symptoms, the second attack having lasted a few days. The following is a complete record of the experiment: May 19: 0.5 gram caffein 11.45 a. m. May 20: 0.75 gram caffein 12.45 a. m. May 21: 0.75 gram caffein 12 noon; no sugar, no albumin in urine. May 22: 0.75 gram caffein; urine, same condition found; no symptoms. May 23: Weight, 7.5 kilos; no caffein. May 24: 0.75 gram caffein; tremors very marked. May 25: No caffein. May 26: 0.75 gram caffein. May 27: 0.75 gram caffein. May 28: 0.75 gram caffein. May 29: 1 gram caffein in two doses of 0.75 and 0.25 gram. May 30: No caffein. May 31: No caffein; meat diet exclusively. June 1: No caffein; meat diet exclusively. June 2: No caffein; no sugar, no albumin in urine. June 3: Weight, 7.6 kilos; 0.75 gram caffein; no sugar in urine. June 4: Weight, 7.3 kilos; 0.75 gram caffein; no sugar in urine. June 5: Weight, 7.5 kilos; 0.8 gram caffein; drank 500 cc water; ate 200 grams meat. June 6: Weight, 7.4 kilos; 0.8 gram caffein; 500 cc urine; drank 500 cc water; ate 200 grams meat; no symptoms. June 7: Weight, 7.7 kilos; 0.8 gram caffein 10 a. m.; 400 cc urine, 500 cc water, 200 grams meat. June 8: Weight, 7.5 kilos; 0.9 gram caffein, 450 cc urine, 1 p. m.; 200 grams meat, 500 cc water. June 9: Weight, 7.6 kilos; 0.9 gram caffein, 1 p. m.; 500 cc water, 200 grams meat and bone dust; diarrhea and restlessness all afternoon. June 10: Weight, 7.6 kilos; 1 gram caffein, 500 cc water, 200 grams meat, 480 cc urine. June 11: Weight, 8 kilos; 1 gram caffein, 470 cc urine, 500 cc water, 200 grams meat. June 12: Weight, 7.8 kilos; 1 gram caffein, 710 cc urine, 500 cc water, 200 grams meat. June 13: 450 cc urine, 500 cc water, 300 grams meat. June 14: Weight, 7.9 kilos; 1.2 grams caffein, 500 cc water, 300 grams meat, 490 cc urine. June 15: Weight 7.8 kilos, 500 cc water, 300 grams meat, 550 cc urine. June 16: Weight 8.0 kilos, 1.2 gram caffein, 500 cc water, 300 grams meat, bone dust added to check diarrhea. June 17: 500 cc water, 300 grams meat, 450 cc urine, diarrhea continues, bone dust added. June 18. Weight 7.8 kilos, 1.3 gram caffein, 300 grams meat, 500 cc water, 300 cc urine. June 19: Dog very thirsty, drank 1 liter of water and ate 350 grams of meat; 960 cc urine passed during the past 24 hour. June 21: Weight 7.5 kilos, 1.5 grams caffein given at 10 a. m. At 2 p. m. convulsions and death. This dog received a total of 21.15 grams caffein in 25 doses during a period of 35 days, which amounts to an average of 85 mg per kilo daily. _Dog 19._ _Female fox terrier._ May 13: Weight 6.4 kilos. Diet consisted of rice, 100 grams; sugar, 100 grams; and a sufficient quantity of meat and cracker meal to give flavor to the food. Examination of the urine showed a trace of albumin but no sugar. The urine was acid to litmus. Two days later the urine was alkaline to litmus. There was still a small amount of albumin but no sugar. May 17: 0.5 gram caffein was given by mouth. Examination of the urine collected the next day still showed the presence of albumin and the absence of reducing substances. The dog had tremors. Caffein was, therefore, not administered. May 19: 0.5 gram caffein was given by mouth. May 20: 0.75 gram caffein was fed at 12.45 p. m. The dog vomited during the night and tremors were observed the next morning. The urine collected was examined for albumin and sugar, but neither was found. May 21: 12 noon, 0.75 gram caffein was fed. The dog weighed 6 kilos, which therefore represented a loss of 0.4 kilo. Grew abnormally thirsty and lost appetite, but no other symptoms of caffein poisoning were observed. May 22: The dog was again given 0.75 gram caffein at 12 noon. The examination of the urine for albumin and sugar gave negative results. The dog died at 4.15 p. m. The fatal dose for this dog was therefore 0.125 gram caffein per kilo, and the total amount of caffein ingested in six days amounted to 3.25 grams, or 0.54 gram per day, which makes 90 mg per kilo. _Dog 21._ _White female bull._ This dog was kept on a diet exclusively of meat, and was given water ab libitum. From 0.5 to 0.6 gram of caffein was administered daily for seven days; the doses were then increased and were given at longer intervals. No symptoms of the effects of caffein were observed until a dose of 1.5 gram was fed, when diarrhea was noticed on the next day. In the following record the details of the experiment are given: ----------+---------+---------- Date. | Weight. | Caffein. ----------+---------+---------- | _Kilos._| _Grams._ June 7 | 12.5 | 0.5 June 8 | 12.5 | .5 June 9 | 12.5 | .5 June 10 | 12.3 | .6 June 11 | 12.3 | .6 June 12 | 12.3 | .6 June 13 | 12.3 | .6 June 14 | 12.3 | .8 June 16 | 12.7 | 0.8 June 18 | 12.9 | 1.0 June 21 | 13.4 | 1.2 June 24 | 13.3 | 1.5 June 25 | (1) | .0 June 27 | 13.5 | 1.5 June 30 | 13.5 | 1.75 ----------+---------+---------- (1) Diarrhea. July 2: 11.30 a. m., 2.0 gram caffein fed by mouth; 1.30 p. m., tetanus, dog died. The total amount of caffein fed to dog No. 21 out of the 25 days of the experiment was 14.45 grams, or an average of 578 mg per day, which amounts to about 42 to 43 mg per kilo of body weight. Notwithstanding the diversity in the method of experimentation, there was a striking uniformity in some of the results obtained. All the experiments of the series showed absence of cumulative action of caffein. The experimental evidence presented indicates that moderately large doses may be given at intervals of about 24 hours without inducing any symptoms of nervous or any other disturbance. This is illustrated in the tests on dog 11, which were preliminary in character. In this subject 100 to 150 mg of caffein per kilo were ingested daily for several days without showing any changes. Later in the course of the experiment, after larger doses were given, mild symptoms only, such as tremors, were observed. Additional evidence of the absence of cumulative action of caffein was furnished by the results of the following experiments: Dog 23 received 142 mg of caffein per kilo on three successive days. His general condition indicated that these amounts of caffein were toxic, but he survived. In another series of tests, made after he was allowed to rest a few days, he again failed to show any cumulation of the drug, as he survived this time a series of tests of longer duration than the first. A much better illustration of the absence of cumulative action of the drug is furnished by the experiments on dog No. 20. In this case 100 to 125 mg of caffein per kilo, given on 10 consecutive days, did not cause any marked effects. Diarrhea and restlessness were the only symptoms observed. These experiments therefore show that the elimination and decomposition of caffein are apparently effected by the body within twenty-four hours or thereabouts. Experiments on dog 19, however, form an exception--the third dose of 125 mg caffein per kilo having proved fatal. The very low protein content of the diet of this dog suggests itself as a possible cause of the lower resistance to caffein of this subject. But it may be observed that the same diet was furnished to dog 20, which stood such amounts of caffein much longer. The presence of a trace of albumin in the urine of dog 19 is likewise inadmissible as a cause of the difference in the toxicity of caffein in this dog, for the urine of dog 20 likewise contained a trace of albumin. The alkaline reaction of the urine, together with the fact that the first dose of only 60 mg of caffein per kilo induced symptoms of toxicity, suggests the presence of an abnormal condition which in all probability was the cause of the death of this subject under the conditions indicated. In a large number of experiments on caffein performed in this laboratory it has been observed that symptoms due to caffein often disappeared when the administration of the same dose of the drug was continued. Thus dog 19 vomited when the amount of caffein was increased to 125 mg per kilo. When this amount was repeated the next day there was no vomiting. Similar observations were made on dogs 11 and 23, also on other dogs. No. 22 developed diarrhea at first; when the administration of caffein was resumed several days later, however, there was no diarrhea. In other experiments performed in this laboratory, symptoms of nervous irritability induced by caffein disappeared on continued treatment. It was interesting, therefore, to inquire whether resistance to caffein would be increased by the continued administration of progressively larger amounts of the drug. When doses of 150 and over were fed, the intervals allowed were usually longer than 24 hours. Two and sometimes three days were permitted to elapse between two successive doses. This was done in order to allow time for recovery from possible changes induced by larger doses of caffein, and thus prevent the summation of effect. In the experiments considered, therefore, Nos. 11, 23, 20, and 19, the toxicity of caffein does not seem to be greater than in the experiments on acute caffein intoxication in the dog. It was thought, however, that the large initial doses or the quick change to large doses when the amounts used in the beginning were small, might have something to do with failure to induce a marked degree of tolerance. The experiment on dog 21 was therefore carried out by giving from 40 to 60 mg per kilo for eight days, and then increasing the dose, but tolerance could not be induced, as is shown in the protocol to the experiment. SERIES B. According to the studies of Chittenden,(16) low protein diet improves the general metabolism of the body, fatigue is diminished, and bodily vigor, therefore, correspondingly increased. The expectation is, therefore, justified that the defense of the organism against deleterious substances introduced into the body is much improved by such a diet, thus increasing its resistance to poisons. Hunt's experiment on this subject, also quoted by Chittenden, lends support to this view. He found that mice fed on carbohydrates chiefly, or on foods containing only a small amount of protein, were more resistant to acetonitril. It was interesting, therefore, to inquire whether the toxicity of caffein differs under similar conditions of diet. A fixed diet of the same calorific value was provided for all dogs of this series, but the protein content for three of the animals was approximately one-third of the amount usually fed to dogs. Caffein was at first administered subcutaneously, but all the dogs on a low protein diet developed abscesses at the site of injection, while none of those on high protein diet showed a local reaction. Feeding by mouth was then begun and continued throughout the experiment in each case. The initial dose was 50 mg per kilo, which was given daily for seven to nine days. It was then increased progressively by 25 mg per kilo; 75 mg per kilo were administered for one to two days, 100 mg for two to three days, 125 mg for one to two days, 150 mg for one to two days, and a single dose of 175 mg. It will be remarked that sometimes an interval of one day had to be allowed during which no caffein was fed. _Dog 30. Black and tan hound, male._ The dog was under observation for about eight weeks before the experiment was begun and had received a high protein diet. He was then given 50 mg caffein for nine consecutive days. On the tenth day the dose was increased to 75 mg per kilo. As no symptoms developed, this dose was increased to 100 mg per kilo, and was fed one day apart. It was then raised to 125 mg per kilo. For the first time since the drug was fed, symptoms appeared; they were noticed a few hours after feeding and persisted during the next day. Although the appetite was good, no caffein was given on this day. On the following day this dose was repeated. As the symptoms were not serious, 150 mg per kilo were given daily for the next three days, until 175 mg per kilo was reached. This dose proved fatal within six hours. Record of experiment follows: October 9: Weight, 9 kilos, on full nitrogen diet, received daily 0.724 gram nitrogen per kilo or 87 calories per kilo, received 18 grams meat per kilo, 4 grams lard per kilo, 3 grams carbohydrates per kilo, bone dust, ad libitum. November 3: Weight, 9.10 kilos. November 10: Weight, 9 kilos. November 20: Weight, 9.55 kilos. November 29: Weight, 8.70 kilos. December 6, 7, 8, and 9: Received subcutaneously 22 cc 2 per cent caffein. Condition good, site of injection normal. December 10, 11, 12, 13, and 14: Received 0.4375 gram caffein by mouth equal to 0.050 gram per kilo, no symptoms, appetite and general condition good. December 15: 11.30 a. m., received 0.6563 gram caffein by mouth, or 0.75 gram per kilo, no symptoms, appetite good, condition excellent. December 16: 11 a. m., received 0.870 gram caffein by mouth, or 0.1 gram per kilo, weight 8.70 kilos, no symptoms. December 17: No caffein given. December 18: Received 0.870 gram caffein, or 0.1 gram per kilo, no symptoms. December 20: 2.45 p. m., received 1.0875 grams caffein, or 0.125 per kilo; 4 p. m., ate food readily, seemed very uncomfortable and sick. December 21: 9 a. m., stiffness in muscles, but no other symptoms, appetite good, no caffein given. December 22: 11 a. m., received 1.0875 grams caffein, or 0.125 gram per kilo; 3 p. m., depressed in spirits and sick, but no other symptoms observed. December 23: 11.30 a. m., received 1.305 grams caffein, or 0.150 gram caffein per kilo; 1.30 p. m., apparently quite sick, but no other symptoms, had good appetite. December 24: 10 a. m., received 0.175 gram caffein per kilo; 4 p. m., when about to be fed fell over and died; no autopsy. The total amount of caffein given dog 30 was 11.3458 grams, administered for a period of eighteen days. The average daily amount per kilo was therefore 72 mg. The feces became offensive when the amounts of caffein were increased to 75 mg per kilo. It will be observed that in this dog the appetite was uniformly good until the day of his death. Whether or not this is the cause of his resistance to caffein will be discussed later. _Dog 32. White, male, young._ Although he was growing rapidly this dog's weight was constant, but he looked anemic. He received a high protein diet until December 3, when the rations were increased by one-third. This dog was under observation from October 26 to December 6 when the administration of caffein was begun. He then received 50 mg caffein per kilo daily for nine days consecutively without showing any effects, when the dose was increased to 75 mg per kilo, then to 100 mg per kilo. This dose was further increased to 150 mg per kilo without causing symptoms, which was repeated the next day. No symptoms having been observed after such amounts of caffein, 175 mg per kilo were fed. This dose, however, proved fatal within two hours. Record of experiment follows: October 26: Weight, 6.90 kilos. November 3: Weight, 6.90 kilos. November 10: Weight, 6.90 kilos. November 20: Weight, 6.90 kilos. November 29: Weight, 6.55 kilos. December 3: Put into cage, diet increased one-third. December 6, 7, 8, 9: Weight 6.30 kilos; 12.30 p. m., received 16 cc 2 per cent caffein by subcutaneous injection in back, no symptoms of any kind noticed, site of injection normal. December 10, 14: 0.05 gram caffein per kilo. December 15: Received 0.4725 gram caffein by mouth, no symptoms. December 16: Received 0.655 gram caffein, 0.100 gram per kilo. December 17: No caffein given. December 18: Received 0.655 gram caffein daily, 0.100 gram per kilo, no symptoms. December 20: Received 0.8188 gram caffein, 0.125 gram per kilo, no symptoms, appetite good. December 21: Received 0.9825 gram caffein, 0.150 gram per kilo, somewhat uncomfortable, no other symptoms. December 22: Received 0.9825 gram caffein, 0.150 gram per kilo, no symptoms except some uneasiness. December 23: 9 a. m., no symptoms, appetite good; 11.30 a. m., received 1.146 grams caffein, 0.1759 gram per kilo; 1.30 p. m., died while making an effort to get out of cage, tonic contraction of limbs observed before death. The amount of caffein received during the entire experimental period was 9.2223 grams, or an average per day approximately of 80 mg per kilo, and therefore 10 per cent more than dog No. 30 received. It will be observed that the appetite in dog No. 32 was likewise uniformly good, and that he received a very high protein diet which was also of a very high calorific value. _Autopsy (dog 32)._--Stomach presented a severe inflammation of the mucosa, especially in the fundus and pyloric portions. The gastritis was more marked in pyloric portion, and the inflammatory condition extended along the whole course of small intestines, which presented numerous hemorrhagic areas, and a thick catarrhal exudate on the mucosa. The large intestine contained quite a large number of parasites, probably round worms. The liver was enlarged and the gall cyst well filled. The spleen was also considerably engorged, kidneys appeared normal, other organs all appeared normal. _Dog 31. Black spaniel, male._ This dog had been under observation one month previous to the experiments with caffein. The usual initial dose was then administered for nine days. There were no signs of local irritation when the drug was given subcutaneously, but symptoms of toxicity were present. These disappeared, however, when the drug was administered by mouth. The dose was therefore increased to 75 mg per kilo. This, as will be seen, proved fatal within six hours. High nitrogen diet, same as No. 30. November 3: Weight 10.250 kilos. November 10: Weight, 10.25 kilos. November 20: Weight, 10.30 kilos. December 1: Put in cage. December 6, 7, 8, 9: Weight, 10.20 kilos; received 26 cc 2 per cent caffein subcutaneously, site of injection normal. December 6: Very restless and excited, whined when handled as though muscles were sore, appeared to be sick. December 10-14: Condition good, received 0.51 gram caffein by mouth daily, no noteworthy symptoms, appetite continues good, somewhat restless at intervals. December 15: 11.30 a. m., received 0.765 gram caffein per mouth (0.075 gram per kilo); 2 p. m., depressed in spirit, seemed sick and uncomfortable; 4.15 p. m., when about to feed, animal jumped up, then fell back dead. _Autopsy (dog 31)_: Lungs congested; heart filled with blood and contained small amount of blood-stained fluid in pericardial sac. Liver deeply congested, soft and friable; gall bladder distended with bile; kidneys showed inflammation of cortex; spleen pale, normal in size and consistency; stomach practically empty, the mucosa of the pyloric portion exhibited severe gastritis, with thick catarrhal exudate. This catarrhal inflammation extended through the duodenum; remaining portion of small intestine showed mild inflammation; large intestine appeared practically normal. The total amount of caffein received by dog 31 during 10 days was 5.395 mg, or a daily average of 53.9 mg per kilo. This unusually low resistance to caffein (which was practically the only case in all the experiments on dogs presented in this research) suggests the presence of some abnormal condition. The bloody exudate in the pericardial cavity indicating pericarditis, which is likely to induce secondary changes of cardiac muscle, may be considered as a possible cause of the increased toxicity of caffein in this case. _Dog 29. Male fox terrier, black._ This dog was kept on a low nitrogen diet for nearly five weeks before the feeding of caffein was begun. The administration of 50 mg of caffein per kilo was then carried on for eight days without showing any symptoms of toxicity. The usual increase of dose was then given--75 mg per kilo--which was followed by a manifestation of symptoms. Further increase, however, to 100 mg per kilo had no visible effect. Nevertheless it was considered advisable to suspend the feeding of caffein for one day. The same amounts were then repeated on two consecutive days. No symptoms having been observed, 125 mg per kilo were given. As symptoms of toxicity and especially loss of appetite were observed, the dog was not given any caffein the next day. Since his appetite had now improved, the experiment with larger doses was resumed. Death followed after the second dose of 150 mg per kilo. Protocol follows: Weight, 9.90 kilos. One-third nitrogen diet. Receives 0.269 gram nitrogen per kilo (88.269 calories per kilo). November 3: Weight, 9.85 kilos. November 10: Weight, 9.55 kilos. November 12: Weight, 9.40 kilos. November 29: Weight, 9.85 kilos. December 6: Weight, 9.90 kilos; 11.35 a. m., received 25 cc 2 per cent caffein solution by subcutaneous injection in back; 4 p. m., no symptoms, appetite good. December 7-9: Received 25 cc caffein 2 per cent solution--subcutaneous injection, no symptoms, area of injection inflamed and swollen. December 10, 13: Site of injection showed increased inflammation, received 0.495 gram caffein (50 mg per kilo) in 30 grams meat daily without showing any symptoms. December 14: 12 noon, received 0.7425 gram caffein by mouth (0.075 per kilo); 2.30 p. m., restless and uneasy. December 15: 11.30 a. m., received 0.7425 gram caffein by mouth; 2 p. m., depressed in spirits, although continues to have good appetite. December 16: Weight, 9.50 kilos; 3.15 p. m., received 0.9509 gram caffein by mouth; 4.50 p. m., no symptoms. December 17: Animal rested. December 18: Received 0.950 gram caffein by mouth, no symptoms. December 19: Received 0.9509 gram caffein by mouth, no symptoms. December 20: 2.45 p. m., received 1.1875 grams caffein (0.125 gram per kilo); 4 p. m., restless and quite sick; ate only a little food. December 21: 9 a. m., still uncomfortable, allowed to rest, no caffein given, gradually recovered appetite. December 22: 11 a. m., received 1.875 grams caffein; 3 p. m., seemed sick, but showed no other symptoms, appetite fair. December 23: 9 a. m., showed no symptoms from the day before, ate food gradually, seemed sick; 11.30 a. m., received 1.425 grams caffein (0.150 gram per kilo); 1.30 p. m., looked and behaved as if very sick, no other symptoms; 3.45 p. m., in attempting to get out of box fell over on back, had convulsions, whined, dyspnoea, died within 30 seconds. _Autopsy_: Stomach exhibited mild inflammation; small intestine inflamed and hemorrhagic areas on mucosa; liver engorged and friable; spleen normal; kidneys slightly congested; other organs appeared normal. The total amount of caffein fed to Dog 29 was 12.135 grams, which was given in 18 days. The average daily amount per kilo was therefore 67.68 mg. _Dog 28. Male fox terrier._ Low nitrogen diet was begun about four weeks before the feeding of caffein; 50 mg of caffein was then fed for seven consecutive days. Partial loss of appetite was observed after the first dose. As the experiment progressed the desire for food steadily diminished, and the feces became fetid. Symptoms of intoxication manifested themselves early in the experiment, and vomiting occurred after the fourth dose. The dog was then put on a diet exclusively of meat. After an intermission of 10 days 109 mg caffein per kilo were given. Since there were no symptoms, the following day the amount was increased to 125 mg per kilo. This dose proved fatal within 16 to 20 hours. This dog was stout and strong, weight 12.25 kilos, received daily 0.269 gram nitrogen per kilo (88.269 calories per kilo). November 3: Weight, 11.75 kilos. November 10: Weight, 11.95 kilos. November 20: Weight, 11.20 kilos. All through this period had been kept in a cold, poorly ventilated room, put in a warm room, with bedding and good ventilation. November 29: Weight, 11.95 kilos. December 1: Put in a cage; weight, 11.95 kilos. December 6: Weight, 11.95 kilos; 11.45 a. m., received 0.050 gram caffein per kilo; then received 30 cc 2 per cent caffein (0.6 gram) in practically one subcutaneous injection; 4.30 p. m., ate only part of food. December 7: 10.25 a. m., received 30 cc 2 per cent caffein by subcutaneous injection (0.6 gram, or 50 mg, per kilo); 1.45 p. m., seemed sensitive to touch, no desire for food, depressed in spirit. December 8: 11.40 a. m., received 30 cc 2 per cent caffein by subcutaneous injection (50 mg per kilo); 1 p. m., depressed in spirit, hind legs seemed somewhat stiff, no desire for regular food, site of injection inflamed. December 9: 10.50 a. m., received 30 cc 2 per cent caffein by subcutaneous injection (50 mg per kilo); 2.30 p. m., had vomited, no desire for regular food. December 10: Inflammation of site of injection, and swelling very pronounced; 2 p. m., received 0.5975 gram caffein, or 50 mg per kilo, with 30 grams of meat, refused regular food. December 11, 12: Received 0.5975 gram caffein by mouth, no symptoms except refusal of regular food, feces fetid. December 13-22: Put on meat diet exclusively, high temperature, no caffein, weight 10 kilos, appetite good, feces fetid. December 22: 12 a. m., weight 11 kilos, received 1.2 grams caffein by mouth (0.109 gram per kilo); 4 p. m., no symptoms. December 23: 11.30 a. m., received 1.375 grams caffein (0.125 gram per kilo) had vomited food of the day before, but could notice no caffein or capsules in vomit; 4.30 p. m., no symptoms, seemed in good spirits, appetite good, had no meat to feed with, so was given low nitrogen feed, of which he ate about one-fourth. December 24: 9 a. m., found dead, stiff, and cold. The most striking effect of caffein in this dog is the increased intestinal putrefaction. The feces were still fetid 10 days after the administration of caffein was stopped. _Autopsy, dog 28_: Stomach partially filled with an undigested food mass; mucosa showed severe inflammation; small intestines presented a hemorrhagic enteritis along whole extent; large intestine also exhibited mild inflammation; liver was engorged; spleen appeared normal; kidneys slightly congested in cortical portion; other organs appeared normal. _Dog 24. White and tan male_: Was put on low protein diet six weeks before experiments with caffein were begun. The initial dose of 50 mg per kilo was then administered on eight consecutive days. The only symptoms observed during this period of caffein administration were those of intestinal putrefaction. Fetid feces were noticed already after the first dose of caffein was injected. When the second dose of 75 mg of caffein was repeated, mild symptoms appeared, but none have been observed even with increased amounts of caffein. One-third nitrogen diet. Received daily 0.269 gram nitrogen per kilo (88.269 calories per kilo). October 26: Weight 11.15 kilos. Food consisted of 5 grams cracker meal per kilo; meat, 3 grams per kilo; lard, 2 grams per kilo; tapioca, 10.69 grams per kilo. Kept in a cold, damp room with poor ventilation until November 20. November 3: Weight, 11 kilos. November 10: Weight, 10.75 kilos. November 20: Weight, 10.55 kilos; changed to a warm room, with bedding and good ventilation. November 29: Weight, 10.85 kilos. December 1: Put into a cage. December 6: Weight, 10.90 kilos; 11.25 a. m., received 28 cc 2 per cent caffein subcutaneously in side, below the shoulders, area washed with alcohol and ether, approximately 50 mg per kilo administered, no symptoms. December 7: 10.15 a. m., received 28 cc 2 per cent caffein injected subcutaneously; feces soft and very fetid; 1 p. m., depressed in spirit, eyes dull. December 9: 10.45 a. m., received 25 cc 2 per cent caffein solution subcutaneously, feces still fetid, site of injection inflamed and swollen, no other symptoms. December 10: Inflammation of area of injection more pronounced; 2 p. m., given 0.5449 gram caffein and 30 grams of meat; 4 p. m., fed, no symptoms, feces fetid. December 11: 12 a. m., given 0.5459 gram caffein and 30 grams of meat, no symptoms, feces fetid. December 12, 13: Given 0.5459 gram caffein daily, without noticing any symptoms. December 14: 12 a. m., received 0.817 gram caffein (75 mg per kilo); 2.30 p. m., restless and uncomfortable, no other symptoms. December 15: 11.30 a. m., received 0.8175 gram caffein by mouth; 2 p. m., depressed in spirit, acted as though sick, no other symptoms. December 16: Weight, 11 kilos; 11 a. m., received 0.100 gram caffein per kilo (1.100 grams) by mouth, no symptoms. December 17: Rested. December 18: 2.30 p. m., received 1.100 grams caffein by mouth; 4 p. m., no symptoms. December 19: 12 noon, received 1.100 grams caffein by mouth; 4.15 p. m., no symptoms. December 20: 2.45 p. m., given 1.375 grams caffein (0.125 gram per kilo); 3.45 p. m., vomited--one of the capsules being found intact, the other broken open; 4 p. m., given regular diet, containing 1.3757 grams caffein in capsules, ate most of this during the night, whined at intervals, coordination disturbed, appeared very sick, but exhibited no other symptoms. December 21: 9 a. m., found dead, stiff, and cold. The total amount of caffein received by dog 24 was between 10.109 and 11.484 grams. As one of the capsules vomited was intact and the other broken open, the amount was probably about 10.75 grams. The fatal dose in this case was undoubtedly less than 185 mg per kilo--somewhere between 125 and 185 mg. Autopsy showed heart in diastole; posterior lobe of right lung deeply congested; liver engorged; gall cyst filled; spleen appeared normal; stomach well filled with semifluid mass; pyloric portion of stomach exhibited a severe inflammation of mucosa; mucosa of duodenum greatly inflamed and showed hemorrhagic areas and catarrhal exudate; remainder of small intestine also exhibited mild inflammation; kidneys deeply engorged, mesentery injected. A comparison of the fatal doses of caffein in the experiments on high and low protein diet does not show much difference in the resistance to caffein, since 175 mg per kilo proved fatal to Nos. 30 and 32, while No. 29 died after receiving 150 mg per kilo, and No. 24 received 125 to 185 mg per kilo. Moreover, No. 28, which was changed from low to high protein diet, succumbed when given 125 mg per kilo. Observations made during the experimental period indicate, however, greater toxicity of caffein in the subjects on low protein diet. Dog 30 showed the effects of the drug when the dose was increased to 125 mg of caffein per kilo, while in No. 32, 150 mg per kilo were received without any manifestation of symptoms. Dog 31, which was likewise on a high protein diet, is evidently an exception, and its low resistance to caffein may be accounted for by the condition found at autopsy. In other dogs on low protein diet symptoms of intoxication appeared early in the experiment. In Nos. 29 and 24 it was observed as soon as the amount of caffein was increased to 75 mg per kilo. In dog 28 the first dose of caffein 50 mg per kilo was toxic. The symptoms of gastro-intestinal disturbance were especially marked after caffein on low protein diet. This may seem to contradict the results of experiments on dogs 11 and 20, in which larger doses of caffein failed to induce symptoms of intoxication. But it should be observed that the diet, which consisted almost exclusively of carbohydrates, was given only during the administration of caffein, while in the experiments of series B the subjects received a low protein diet for several weeks before the administration of caffein was begun, and it was continued through the entire caffein period. It will be remarked that the absence of cumulative action in the experiments of the preceding series was also observed in dogs on high as well as on low protein diet. The appearance of symptoms after smaller doses of caffein in the latter experiments might suggest cumulative action, but since these symptoms disappeared on continued administration of the substance cumulation is clearly not indicated. The gastrointestinal lesions observed on post-mortem examination were, it will be recalled, also found in rabbits similarly treated. The explanation suggested probably applies also in the case of dogs. SERIES C. As already pointed out in the experiments on acute toxicity of caffein, young growing dogs are probably more resistant to caffein than adults. That this may also hold true in chronic caffein intoxication seemed indicated by the following experiments. _Dog 33. Black female puppy. Weight, 4 kilos. Had been continuously on a meat diet._ December 22: 2.30 p. m., received 0.69 gram of caffein (0.172 gram per kilo); 3.15 p. m., no symptoms except that feces were fetid. December 23: 11.30 a. m., received 0.79 gram of caffein (0.197 gram per kilo); 1.30 p. m., no symptoms. December 24: 11 a. m., received 0.87 gram of caffein (0.2009 gram per kilo); 4 p. m., no symptoms. It will be observed that the only effect produced in dog 33 by feeding caffein was increased intestinal putrefaction, although 2.37 grams of caffein were given in three days. Additional data on the effects of the age of animals on the resistance to caffein seemed desirable. The following experiments were therefore carried out. Six puppies of the same litter were weaned when 7 to 8 weeks old and put on a milk diet. Three of them received this diet throughout the experimental period. Meat was substituted in the other three a few days before the administration of caffein was begun, and was continued until the end of the experiment. Caffein was given by mouth; the initial dose, which was administered for several days and then gradually increased, being 160 to 200 mg for each dog, except one, which received only 100 mg per kilo for several days and then an increased amount. An intermission of a few days (during which no caffein was given) was allowed. This was done on account of some studies carried on at the same time on the effect of caffein on certain constituents of the urine. PUP NO. 1. ---------+---------+--------+-------------+-------------------------- | | | Treatment | Date. | Weight. | Food | (2 per cent | Symptoms. | |(milk). | caffein). | ---------+---------+--------+-------------+-------------------------- | _Grams._| _cc._ | _cc._ | Apr. 21 | 1,450 | 300 | 10.0 | No symptoms. Apr. 22 | 1,520 | 300 | 10.0 | Do. Apr. 23 | 1,450 | 250 | 10.0 | Do. Apr. 24 | 1,375 | 250 | 10.0 | Do. Apr. 25 | 1,420 | 250 | 10.0 | Do. Apr. 26 | 1,390 | 250 | None. | Apr. 27 | 1,400 | 250 | None. | Apr. 28 | 1,405 | 250 | None. | Apr. 29 | 1,420 | 250 | None. | Passed worms. Apr. 30 | 1,430 | 250 | None. | Do. May 1 | 1,450 | 250 | 10.0 | No symptoms. May 2 | 1,515 | 250 | 15.0 | Do. May 3 | 1,475 | 250 | 15.0 | Do. May 4 | 1,495 | 250 | 15.0 | Do. May 5 | 1,515 | 250 | 22.0 | Seems dull and whines. May 6 | 1,535 | 250 | 20.0 | Whines. May 7 | 1,525 | 250 | 20.0 | No symptoms. May 8 | 1,530 | 250 | 20.0 | Do. May 9 | 1,500 | 250 | 23.0 | Diarrhea; passed worms; | | | | tremor and rigidity of | | | | legs; whines. May 10 | 1,490 | 250 | None. | Completely recovered from | | | | the effects of 9th. May 11 | 1,535 | 250 | 25.0 | Can not balance itself; | | | | continually vomiting. May 12 | 1,460 | 300 | None. | Recovered from effects. May 13 | 1,475 | 350 | None. | In good condition. May 14 | 1,545 | 250 | None. | May 15 | 1,550 | 250 | None. | May 16 | 1,555 | 250 | None. | May 17 | 1,560 | 250 | 25.0 | Salivated in cage; | | | | stiffness of muscles. May 18 | 1,450 | 250 | None. | Weak and stiff; diarrhea. May 19 | 1,500 | 250 | None. | No symptoms. May 20 | 1,565 | 250 | None. | May 21 | 1,545 | 250 | None. | May 22 | (1) | 250 | None. | May 23 | 1,595 | 250 | 27.0 | Tremors; gait clumsy; in- | | | | coordination of movements. May 24 | 1,495 | 250 | 27.0 | Diarrhea; vomited; weak | | | | and stiff; found dead | | | | 9 a. m. 25th. ---------+---------+--------+-------------+-------------------------- (1) Sunday. _Autopsy_: Marked pulmonary congestion; liver very pale; heart wall injected; slight inflammation of stomach and intestines. PUP NO. 2. ---------+---------+---------+------------+--------------------- | | Food | Treatment | Date. | Weight. | (milk). |(2 per cent | Symptoms. | | | caffein). | ---------+---------+---------+------------+--------------------- | _Grams._ | _cc._ | _cc._ | Apr. 21 | 1,350 | 300 | 5.0 | No symptoms. Apr. 22 | 1,240 | 300 | 5.0 | Do. Apr. 23 | 1,250 | 200 | 7.5 | Do. Apr. 24 | 1,205 | 200 | 7.0 | Do. Apr. 25 | 1,220 | 200 | 7.0 | Do. Apr. 26 | 1,210 | 200 | None. | Apr. 27 | 1,210 | 200 | None. | Apr. 28 | 1,205 | 200 | None. | Apr. 29 | 1,200 | 200 | None. | Passed worms. Apr. 30 | 1,210 | 200 | None. | May 1 | 1,220 | 200 | 10.0 | No symptoms. May 2 | 1,220 | 200 | 10.0 | Do. May 3 | 1,235 | 200 | 10.0 | Do. May 4 | 1,235 | 200 | 10.0 | Do. May 5 | 1,235 | 200 | 17.0 | Whines. May 6 | 1,250 | 200 | 17.0 | Do. May 7 | 1,235 | 200 | 15.0 | Diarrhea | | | | and worms. May 8 | 1,250 | 200 | 15.0 | Diarrhea. May 9 | 1,165 | 200 | 18.0 | Little or | | | | no symptoms. May 10 | 1,235 | 200 | None. | No symptoms. May 11 | 1,300 | 200 | 20.0 | Salivated in cage; | | | | refused to eat; | | | | draws up hind legs. May 12 | 1,200 | 200 | None. | Recovered. May 13 | 1,215 | 200 | None. | In good condition. May 14 | 1,280 | 200 | None. | May 15 | 1,300 | 200 | None. | May 16 | 1,310 | 200 | None. | May 17 | 1,310 | 200 | 20.0 | Salivated in cage; | | | | stiff; all symptoms. May 18 | 1,250 | 200 | None. | Weak and stiff. May 19 | 1,245 | 200 | None. | No symptoms. May 20 | 1,310 | 200 | None. | May 21 | 1,325 | 200 | None. | May 22 | 1,325 | 200 | None. | May 23 | 1,325 | 200 | 22.0 | Somewhat stiff. May 24 | 1,315 | 200 | 22.0 | Restless; scratches | | | | eyes; sick. ---------+---------+---------+------------+--------------------- PUP NO. 3. ---------+---------+---------+------------+------------------------ Apr. 21 | 1,215 | 300 | None. | Apr. 22 | 1,220 | 300 | None. | Apr. 23 | 1,220 | 200 | None. | Apr. 24 | 1,200 | 200 | None. | Apr. 25 | 1,205 | 200 | None. | Apr. 26 | 1,195 | 200 | None. | Apr. 27 | 1,200 | 200 | (1) | Apr. 28 | 1,215 | 200 | None. | Apr. 29 | 1,220 | 200 | None. | Apr. 30 | 1,200 | 200 | None. | May 1 | 1,225 | 200 | 10.0 | No symptoms. May 2 | 1,230 | 200 | 10.0 | Do. May 3 | 1,235 | 200 | 10.0 | Coughs and whines. May 4 | 1,245 | 200 | 10.0 | Passed worms. May 5 | 1,270 | 200 | 17.0 | Eyes appear dim | | | | and is continually | | | | scratching them. May 6 | 1,260 | 200 | 17.0 | Appears restless and | | | | draws up hind legs | | | | when walking. May 7 | 1,240 | 200 | 15.0 | Eyes dim; passed | | | | worms; diarrhea. May 8 | 1,265 | 200 | 15.0 | Coughing continually; | | | | very restless. May 9 | 1,240 | 200 | 18.0 | 12 noon; salivated in | | | | cage; passed worms; | | | | diarrhea; foaming at | | | | mouth; can not balance | | | | himself; rigidity and | | | | tremor of hind legs. | | | | 2.15, found dead. ---------+---------+---------+------------+------------------------ (1) Urine squeezed from bladder. _Autopsy_: Severe pulmonary congestion; catarrhal gastritis; mild enteritis with small hemorrhagic areas on mucosa. PUP NO. 4. ---------+--------+----------+-----------+---------------------------- | | |Treatment | Date. | Weight.| Food. |(2 per cent| Symptoms. | | | caffein). | ---------+--------+----------+-----------+---------------------------- |_Grams._| _Milk_ | _cc._ | | | _(cc)._ | | Apr. 28 | 1,670 | 300 | | Apr. 29 | 1,670 | 300 | | Apr. 30 | 1,670 | 300 | | May 1 | 1,690 | 300 | | May 2 | 1,690 | 300 | | May 3 | | 300 | | May 4 | 1,720 | 300 | | May 5 | 1,735 | 300 | | | | | | | |_Meat_ | | | |(_grams_).| | May 6 | 1,760 | 60 | | May 7 | 1,745 | 80 | | May 8 | 1,710 | 180 | | May 9 | 1,750 | 180 | | May 10 | 1,750 | 180 | | May 11 | 1,755 | 180 | 10.0 |No symptoms. May 12 | 1,730 | 180 | None. | May 13 | 1,785 | 180 | None. | May 14 | 1,835 | 115 | 10.0 | Do. May 15 | 1,820 | 115 | 10.0 | Do. May 16 | 1,835 | 115 | 10.0 |Passed worms. May 17 | 1,860 | 115 | 10.0 |Feces soft and black. May 18 | 1,855 | 115 | 15.0 |Stiff; loss of appetite. May 19 | 1,770 | 115 | 15.0 |Loss of appetite. May 20 | 1,755 | 115 | 15.0 | Do. May 21 | 1,780 | 115 | 17.0 |Restless. May 22 | | 115 | 17.0 |Feces soft and black. May 23 | 1,785 | 115 | 17.0 |Loss of appetite. May 24 | 1,795 | 115 | |Loss of appetite; threw up | | | | worms. May 25 | 1,630 | 115 | 20.0 |Loss of appetite; worms; | | | | cough; diarrhea. May 26 | 1,600 | 115 | 23.0 |Weak; no appetite; diarrhea; | | | | cough. May 27 | | | |Found dead, 9 a. m. ---------+--------+----------+-----------+---------------------------- _Autopsy._--Lung uniformly congested; liver deeply congested; heart muscle pale with hemorrhagic areas; kidneys pale with hemorrhagic spots on surface and in cortex; slight catarrhal inflammation of stomach and the small intestines. PUP NO. 5. ---------+--------+----------+-----------+---------------------------- | | |Treatment | Date. | Weight.| Food. |(2 per cent| Symptoms. | | | caffein). | ---------+--------+----------+-----------+---------------------------- |_Grams._| _Milk_ | _cc._ | | | _(cc)._ | | Apr. 28 | 1,745 | 300 | | Apr. 29 | 1,745 | 300 | | Apr. 30 | 1,750 | 300 | | May 1 | 1,765 | 300 | | May 2 | 1,765 | 300 | | May 3 | | 300 | | May 4 | 1,490 | 300 | | May 5 | 1,805 | 300 | | | |_Meat_ | | | |(_grams_).| | | | | | May 6 | 1,815 | 60 | | May 7 | 1,825 | 80 | | May 8 | 1,770 | 180 | | May 9 | 1,795 | 180 | | May 10 | 1,805 | 180 | | May 11 | 1,800 | 180 | 10.0 |No symptoms. May 12 | 1,720 | 180 | None. | May 13 | 1,815 | 180 | None. | May 14 | 1,845 | 115 | 10.0 | Do. May 15 | 1,830 | 115 | 10.0 | Do. May 16 | 1,815 | 115 | 10.0 |Loss of weight; no other | | | | symptoms. May 17 | 1,830 | 115 | 15.0 |No symptoms. May 18 | 1,835 | 115 | 15.0 |Stiffness. May 19 | 1,825 | 115 | 15.0 |No symptoms. May 20 | 1,850 | 115 | 15.0 |A little stiff. May 21 | 1,835 | 115 | 17.0 |No symptoms. May 22 | | 115 | 17.0 | May 23 | 1,820 | 115 | 17.0 | Do. May 24 | 1,835 | 115 | 20.0 | Do. May 25 | 1,840 | 115 | 20.0 |Feces soft and black. May 26 | 1,820 | 115 | 23.0 | May 27 | 1,840 | 115 | 25.0 |A little stiff. May 28 | 1,830 | 115 | 25.0 | May 29 | | 115 | None. | May 30 | | 115 | None. | May 31 | 1,770 | 115 | None. | June 1 | 1,765 | 115 | 25.0 |Diarrhea; stiff in hind | | | | legs. June 2 | 1,750 | 115 | 27.5 |Diarrhea and worms. June 3 | 1,635 | | 27.5 |Paralyzed; vomited; | | | | died at 3 p. m. ---------+--------+----------+-----------+---------------------------- PUP NO. 6. ---------+--------+----------+-----------+---------------------------- | | |Treatment | Date. | Weight.| Food. |(2 per cent| Symptoms. | | | caffein). | ---------+--------+----------+-----------+---------------------------- |_Grams._| _Milk_ | _cc._ | | | _(cc)._ | | Apr. 28 | | 300 | | Apr. 29 | 1,280 | 300 | | Apr. 30 | 1,290 | 300 | | May 1 | 1,315 | 300 | | May 2 | 1,330 | 300 | | May 3 | | 300 | | May 4 | 1,360 | 300 | | May 5 | 1,365 | 300 | | | |_Meat_ | | | |_(grams)._| | | | | | May 6 | 1,395 | 60 | | May 7 | 1,365 | 80 | | May 8 | 1,340 | 180 | | May 9 | 1,380 | 180 | | May 10 | 1,400 | 180 | | May 11 | 1,425 | 180 | 14.5 |No symptoms. May 12 | 1,470 | 180 | None. | May 13 | 1,485 | 180 | None. | May 14 | 1,510 | 115 | 14.5 | Do. May 15 | 1,500 | 115 | 14.5 | Do. May 16 | 1,485 | 115 | 14.5 |Passed worms. May 17 | 1,480 | 115 | 14.5 | May 18 | 1,485 | 115 | 19.5 |Feces soft and black; | | | | almost diarrhea. May 19 | 1,495 | 115 | 19.5 | May 20 | 1,500 | 115 | 19.5 |Scratches her eyes and | | | | chases her tail. May 21 | 1,500 | 115 | 17.0 | May 22 | | 115 | 17.0 | May 23 | 1,470 | 115 | 17.0 | May 24 | 1,465 | 115 | 20.0 | May 25 | 1,450 | 115 | 20.0 |Feces soft and black. May 26 | 1,450 | 115 | 23.0 |Diarrhea and worms. May 27 | 1,355 | 115 | 23.0 |Refused to eat all food. May 28 | 1,270 | 115 | 23.0 |Threw up worms, stiff, and | | | | has skin over both eyes. May 29 | | | |Found dead. ---------+--------+----------+-----------+---------------------------- Highest amount of caffein given, 362 mg per kilo. No autopsy. Examination of the results obtained in the experiments of series C shows that young and growing dogs tolerate large amounts of caffein. In four subjects of this series, Nos. 1, 2, 3, and 6, no effect was observed when moderately large amounts (160 to 200 mg per kilo of caffein) were fed. Symptoms were noticed only when these amounts of caffein were increased from 50 to 60 per cent. The other two dogs, Nos. 4 and 5, of this series were less resistant, however, to caffein, as 0.16 gram of the drug per kilo induced well-marked symptoms. Since these were fed meat, while Nos. 1, 2, and 3 received milk, the difference in toxicity may be due to the diet employed, but No. 6, which likewise received a meat diet, failed to show the effects of caffein when 200 mg per kilo were fed. On the other hand, it should be noticed that No. 1 died after receiving 360 mg per kilo, No. 2 survived a dose of 334 mg, while No. 3 died after a dose of 322 mg per kilo of caffein. The fatal doses for Nos. 4, 5, and 6 were 287, 335, and 300 mg per kilo, respectively. Although the differences are too small to justify any definite conclusion regarding the effect of a milk diet or of a meat diet on the toxicity of caffein, the results nevertheless suggest a reasonable possibility that caffein is more toxic to young dogs when on an exclusively meat diet than when fed milk. It is perfectly evident, however, that the resistance to caffein in either case is very great, almost twice that of adult subjects. As shown in series A and B, 125 to 175 mg per kilo proved fatal to all but two animals in these experiments, while symptoms of toxicity appeared after much smaller doses. In other respects the behavior of young dogs toward caffein was the same as that of the adult. In neither case was cumulation nor tolerance observed under the conditions of these experiments. The findings at autopsy were likewise similar, as gastro-enteritis was the chief lesion observed on macroscopic examination. It might be mentioned, however, in this connection, that the symptoms of caffein intoxication in young dogs often presented marked differences from those observed in those of more advanced age. The resemblance of the effects of caffein in young puppies and in rabbits was very striking. In both, the tonic with clonic convulsions were observed after a sufficient quantity of caffein was administered. In the dogs which were fully grown a large dose of caffein was usually followed by tonic convulsions and almost instantaneous death. Moderately large amounts of caffein fed daily to puppies for several days--in some cases as long as 10 days--induced mild symptoms only. No cumulative effect was observed in any of the experiments of series C. There seems to be tolerance of certain functions toward caffein, but no general tolerance of the body could be obtained in these experiments. Caffein is apparently less toxic for adult dogs on high than on low protein diet. In young and growing dogs caffein is somewhat less toxic when milk, rather than meat, forms the exclusive diet. Some pathological conditions apparently increase the toxicity of caffein also in dogs. The symptoms of caffein intoxication observed in young dogs are in some respects different from those in full grown and older animals, and resemble those noticed in rabbits. DISCUSSION OF RESULTS. It was pointed out at some length in the introduction that the toxicity of some drugs may not be the same for all forms of life. This observation was also made by some investigators who experimented with caffein on different species of animals. Thus Maurel(55) stated that caffein is twice as toxic for the frog as for the rabbit when administered by mouth. Fröhner's(26) experiments, on the other hand, made on domestic animals, failed to show great differences in the toxicity of caffein. According to this observer, horses seem to be more susceptible than cattle, goats, and swine, the minimum toxic dose being the same for all of these, while the resistance of the dog to caffein is about midway between that of the horse and the other animals mentioned. It may be remarked, however, that Fröhner made only 13 experiments. That these data are inadequate for the formation of any conclusions as to the toxicity of caffein is evident since the most striking effect of caffein observed in the work herein reported was the comparatively wide range of variation in the resistance of individuals of the same species to this drug. This was found to be the case even when the conditions of experimentation were approximately uniform, and was observed whatever the mode of administration of the drug employed. The toxicity for different individuals also varied in acute as well as in chronic intoxication. It is for this reason that the number of tests employed were often quite large, for no conclusions of any value could be drawn without averaging the results of a sufficiently large number of experiments. Furthermore, it is to be borne in mind that the action of a drug may differ according to the mode of its introduction into the body and that different species of animals may vary in this regard. This is especially true of some substances when given by mouth, the range in toxicity for certain species of animals being much greater when thus administered than when injected subcutaneously or intravenously. Maurel's(56) investigations are of interest in this connection, as his work embraces a systematic study of the toxicity of a large number of substances in the rabbit, pigeon, and frog when given by mouth, subcutaneously, intravenously, or when injected into the muscles. According to this investigator the range of variation of the toxicity of a substance is widest when given by mouth. Potassium sulphocyanid, for example, is about 2.5 times as toxic for the frog as for the rabbit when given by mouth. Quinin hydrobromid is three times as toxic for the frog as for the pigeon, while for the rabbit it is twice as toxic as for the pigeon. When given by hypodermic injection the toxic dose per kilo weight is practically the same for all three species. The difference of resistance according to the mode of administration is even more marked for spartein sulphate. When given by mouth the toxicity for the rabbit is six times as great as for the frog, but when injected subcutaneously the toxic dose is about the same for the rabbit and for the frog. The relation of the mode of administration to toxicity is further shown in the following substances: For the rabbit the minimum fatal dose per kilo of quinin hydrobromid is 1.5 grams administered by mouth, 0.5 gram when injected subcutaneously, and 0.07 gram by the intravenous path, while strychnin sulphate is twice as toxic administered intravenously as subcutaneously, and six times as toxic as when administered by mouth. The mode of introduction, however, does not always affect the toxicity of a substance. This is made evident by the action of strychnin on frogs in which, according to Maurel(56), the toxic dose is the same whether given by mouth or injected into the subcutaneous tissues. This appears to hold true also for other animals as demonstrated by the experiments of Hatcher(35) on the cat, in which he observed that strychnin is as readily absorbed from a full stomach as from the subcutaneous tissues. These findings are extremely interesting, especially in view of Maurel's(57) work on the subject, according to which he finds that a substance is much less toxic when given by mouth than when administered by hypodermic injection or intravenously. That this generalization does not admit, however, of universal application is made evident by the work of various experimenters. Claude Bernard(10) observed that curara is as poisonous for the pigeon when given by mouth as when injected subcutaneously, while Zalesky(86) found that samandarin is more toxic for frogs when introduced into the stomach than by injection into the lymph sacs. Our experiments with caffein likewise show that Maurel's generalization does not always hold good, since it was found in experiments with gray rabbits that the minimum fatal dose is but moderately greater by mouth than by the subcutaneous path. Equally interesting is the observation of the writer, that in the guinea pig the difference in the toxicity between the subcutaneous and intraperitoneal injections is very slight, while in the cat the toxicity of caffein is the same whether given by mouth or injected into the subcutaneous tissues, and is markedly less when injected into the peritoneal cavity. The experiments on dogs show considerable variation of effective dose when given by mouth, but the interesting observation was made that the toxic dose by mouth may be smaller in some cases than the average dose by subcutaneous injection. If the resistance to caffein by subcutaneous injection of the different species of animals experimented upon in the present research be compared, it will be noticed that the gray rabbit or Belgian hare, which is more resistant than the other varieties employed, stands more caffein in proportion to the weight of the body than the other animals. Although the minimum fatal dose was found to be somewhat larger for the guinea pig than for the gray rabbit when caffein was injected intraperitoneally, it was on the contrary smaller by other paths of introduction, and approximated quite closely the minimum fatal dose for rabbits of the other varieties. Cats as well as dogs were found to be distinctly less resistant to caffein than the herbivora. There are a number of factors far more important than zoological differences which influence the toxicity of caffein. Some of these are age, season, and pathologic conditions. As these factors have already been dwelt upon in their appropriate places, further discussion might seem unnecessary, but owing to their importance in determining the action of a drug, emphasis is desirable. Especially is this the case with pathological conditions in relation to toxicity. While no positive proof of diminished resistance to caffein in pathological conditions was obtained by subjecting the suggestion to experimental test, it was observed in these experiments on rabbits that death occurred in some individuals after small doses which are usually not even toxic. The findings at autopsy indicate the presence of pathological conditions. The same was observed in some experiments on cats and dogs. It is extremely probable, therefore, that disease modifies the reaction of the organism to caffein as well as to other drugs.(78) That the resistance to drugs may vary according to the age of the subject has been maintained by a number of pharmacologists. According to Guinard,(30) young dogs, rabbits, and guinea pigs are very susceptible to morphin, resembling children in this regard.[E] The minimum fatal dose for these animals is about one-third less than for the adult. This is not true, however, for the young of other species. Cats under 15 days of age tolerate twice the toxic dose of morphin for the adult cat. Young beeves and goats are likewise more resistant to this alkaloid than adults. On the other hand, according to Livon,(54) young guinea pigs are more sensitive to alkaloids than adults. The toxicity of caffein, as shown in the present investigation, was found to be less in the young than in the adult. In dogs the young subjects are in some instances almost twice as resistant as adults. The difference was found to be less in cats and rabbits than in dogs, but it was quite marked. [E] A case of accidental poisoning reported recently by Wichura (Münich. Méd. Woch., 1911, No. 30, p. 1618) throws some doubt on the accepted view that the susceptibility of young children to morphin is greater than that of adults. Wichura also found that the therapeutic doses of codein preparations ordinarily recommended for children in pleuritic cough are not effective in this condition. The effect of season on the toxicity of drugs has been discussed in the section on the experiments on guinea pigs, which were more resistant to caffein in the fall than in February and March. The effect of season seems to vary with the animal, but it may also differ with the substance employed. In Noe's(65) studies on this subject cantharidin was found to be more toxic for the hedgehog in November than in July. The effect of season was different for morphin, as it was observed that the resistance of the hedgehog was greater at the end of the summer than earlier in the season. The relation of diet to toxicity of drugs has been studied by Hunt.(39) His experiments indicate that this is an important factor in the resistance to acetonitril. The studies here reported on the effect of diet on toxicity of caffein in rabbits were confined to experiments with oats and carrots and do not show any modification of the resistance to caffein. The question of diet in chronic intoxication in dogs, however, suggests that in these animals diet may affect the toxicity of caffein, although the data on this subject are far from satisfactory. There is nevertheless sufficient evidence to suggest that a high protein diet for the adult dog tends to greater resistance of the animal to caffein and similarly the growing dog tolerates larger quantities of caffein on a milk diet than on a diet of meat. This brings us to a consideration of the behavior of caffein in chronic intoxication. Although in both rabbits and dogs absence of cumulation was evident, in other respects decided differences in the resistance to caffein were observed. While the rabbit tolerates more than twice the single dose of caffein per kilo for the dog, the result is quite different in repeated dosage of the drug, the rabbit succumbing to continued administration of much smaller doses of the drug than the dog. This is probably due to lesions of the gastro-intestinal canal caused by caffein which occasions loss of appetite much more readily in the rabbit than in the dog. The abundant energy reserve in the dog makes it possible for this animal to stand inanition much longer than the rabbit and other herbivora. The difference in the behavior of the rabbit and dog toward caffein is interesting as showing complete reversal of resistance in acute and chronic intoxication. From the statement in the introduction it is evident that the size of the single toxic or lethal dose of a substance is in no wise an index of the active degree of its toxicity. The experiments with caffein here reported furnish additional evidence that this is true, at least for the rabbit. GENERAL SUMMARY AND CONCLUSIONS. The toxicity of caffein in the rabbit varies with the mode of its administration, being least when given by mouth and greatest by intravenous administration. The toxicity is from 15 to 20 per cent greater by subcutaneous injections than by mouth, but is about half of that when injected into the peritoneal cavity. No difference was observed in the toxicity of caffein whether administered into gluteal or into the lumbar muscles. When introduced by this route the toxicity was found to be less by one-third than when it is injected into the peritoneal cavity, but is about 30 per cent more toxic than the subcutaneous injections. White or black rabbits were found to be less resistant to caffein than gray rabbits. The resistance of the guinea pig to caffein, as of the rabbit, is greatest when given by mouth. The minimum fatal dose is less by intraperitoneal injections, but greater than by subcutaneous injections, thus differing from the rabbit in this regard. The adult cat is less resistant than the guinea pig or rabbit to caffein. The minimum lethal dose by mouth is the same as by subcutaneous, and is less than by intraperitoneal, injection. The minimum fatal dose for dogs was found to be the same by mouth as by subcutaneous injection and is almost the same as for the cat. The toxicity of caffein varies in the guinea pig according to season of the year. Age is likewise a factor in the toxicity of caffein, young animals being more resistant than the full-grown and older animals; this was shown in experiments on rabbits, cats, and dogs. The symptoms of caffein poisoning also were different in puppies and in full-grown dogs. Different diets, such as carrots and oats, did not influence the resistance of rabbits and guinea pigs to caffein. Low protein diet tends to decrease resistance to caffein in dogs. Young growing dogs are less resistant to caffein on a meat than on a milk diet. Caffein is not cumulative in the rabbit or dog, even if administered for a considerable length of time. Some degree of tolerance may be induced in the rabbit under certain conditions, but not in dogs under the conditions of the experiments made in this investigation. The possibility, however, that dogs may acquire tolerance for caffein is not excluded. Although the rabbit tolerates a much larger single dose of caffein than the dog, it was found, in experiments on chronic intoxication that the rabbit is less resistant to caffein than the dog. The toxicity of caffein is probably increased under pathological conditions, since comparatively smaller doses were fatal to rabbits, cats, and dogs, when marked lesions not due to caffein were found at autopsy. Glycosuria was observed in rabbits, guinea pigs, and cats when caffein was given in sufficient amounts. TABLE 18.--_Acute caffein intoxication: Table showing average minimum toxic and minimum fatal doses for adult animals._ Table headings: SC: Subcutaneously. BM: By mouth. IP: Intraperitoneally. IM: Intramuscular. IV: Intravenous. -------------+------+------------------------------------------------- |Effect| Dose per kilo (grams) Animal. |of +---------+-----------+-----------+-------+------- |dose. | SC | BM | IP | IM | IV -------------+------+---------+-----------+-----------+-------+------- Rabbit, gray |{Toxic| 0.15| 0.325| 0.100| 0.13| 0.05 | | | | -0.125 | -0.15| |{Fatal| .30| .350| .150| .20| 0.10 | | | | | | -.16 Rabbit, white|{Toxic| | | | | or black |{Fatal| .20| .290| | | | | | | | | Guinea pig |{Toxic|0.15- .16| .150| .200| | |{Fatal| .20- .24|0.280- .300| .240- .250| | | | | | | | Cat |{Toxic| .12- .14| .125| .125- .150| | |{Fatal| .15| .150| .180- .200| | | | | | | | Dog |{Toxic| | .100- .120| | | |{Fatal| .15- .16| .140- .150| | | -------------+------+---------+-----------+-----------+-------+------- NOTE.--The doses given in this table are approximate. CAFFEIN BIBLIOGRAPHY. 1. ABDERHALDEN and BRAHM. Zts. Physiol. Chem., 1909, =62=: 133. 2. ALBERS. Deut. Klin., 1852, =5=: 577. 3. AMAT. Diss. Paris, 1889. 4. AMORY. Boston Med. Surg. J., 1868, =1=: 261. 5. VON ANREP. Arch. Ges. Phys., 1880, =21=: 185. 6. AUBERT. Pflüger's Arch., 1872, =5=: 589. 7. AUER and MELTZER. J. Pharm. Exper. Ther., 1911, =2=: 402. 8. BALDI. Terapia Moderna, 1891, =5=: 617. 9. BENNETT. Brit. Med. J., 1874, =2=: 674. 10. BERNARD, CLAUDE. Leçons sur les substances toxiques, Paris, 1857, p. 292. 11. BINZ. Arch. Exper. Path. Pharm., 1878, =9=: 31. 12. ---- Ibid., 1891, =28=: 197. 13. BRILL. Diss. Marburg, 1861. 14. BUCHHEIM and EISENMENGER. Beitr. Anat. Physiol., 1870, =5=: 115. 15. BUNGE and SCHMIEDEBERG. Arch. Exper. Path. Pharm., 1876, =6=: 233. 16. CHITTENDEN. The Nutrition of Man, 1907. 17. COGSWELL. Lancet (London), 1852, =2=: 488. 18. DANILEWSKI. Arch. Exper. Path. Pharm., 1894, =35=: 105. 19. DRZEWINA. Compt. rend. Soc. biol., 1911, =70=: 772. 20. DUMAS and PELLETIER. Ann. chim. phys., 1823, =24=: 182. 21. EDMUNDS. J. Amer. Med. Assoc., 1907, =48=: 1744. 22. FILEHNE. Arch. Phys., 1886, p. 72. 23. FLEISCHER and LOEB. Archives of Internal Medicine, 1909, =3=: 78. 24. FOCKE. Arch. Pharm., 1903, =241=: 678. 25. FRERICHS. Handwörterbuch Phys., 1846, =3=: 721. 26. FRÖHNER. Monats. prakt. Tierh., 1892, =3=: 529. 27. GENTILHOMME. Bull. Soc. Med. Reims, 1867, =5=: 93. 28. GOUREWITCH. Arch. Exper. Path. Pharm., 1907, =57=: 314. 29. GUINARD. Compt. rend. Soc. biol., 1900, =2= (2d ser.): 727. 30. ----. Compt. rend., 1893, =113=: 520. 31. ----. La Morphine et l'apomorphine, Paris, 1903. 32. GUNN. Arch. Int. Pharm. Ther., 1909, =19=: 319. 33. HALE. U. S. Public Health and Marine-Hospital Service. Hyg. Lab. Bul. 53, p. 43. 34. HARRINGTON. Amer. J. Phys., 1898, =1=: 385. 35. HATCHER. J. Amer. Med. Assoc., 1910, =60=: 746. 36. HENNEGUY. Diss. Montpellier, 1875. 37. HOFMEISTER. Arch. Exper. Path. Pharm., 1894, =33=: 198. 38. HOPPE. Écho Méd. Neuchâtel, 1858. 39. HUNT. U. S. Public Health and Marine-Hospital Service. Hyg. Lab. Bul. 69, p. 51. 40. ----. Ibid., Bul. 33. 41. IGERSHEIMER and STAMI. Arch. Exper. Path. Pharm., 1909, =61=: 18. 42. JACOBI and GOLOWINSKI. Arch. Exper. Path. Pharm., Supplement Bd. 1908, p. 286. 43. JOBST. Ann. Pharm., 1838, =25=: 63. 44. JOHANSEN. Diss. Dorpat, 1869. 45. KOBERT. Lehrbuch der Intoxicationen, 1902, =1=: 24. 46. KÖSTER. Arch. Gesamt. Phys., 1910, =136=: 17. 47. KRÜGER and SCHMIDT. Ber. d. chem. Ges., 1899, =32=: 2677. 48. KURZAK. Zts. Aerzte zu Wien, 1860, n. f., =3=: 625. 49. LAPICQUE. Compt. rend. Soc. biol., 1910, =68=: 1007. 50. LEBLOND. Diss. Paris, 1883. 51. LEHMANN, C. G. Lehrbuch für physiolische Chemie, 1842, =1=: 336. 52. LEHMANN, J. Ann. chim. pharm., 1853, =87=: 205. 53. LEVEN. Arch. Phys., 1868, =1=: 180. 54. LIVON. Compt. rend. Soc. biol., 1897, =4=: 979. 55. MAUREL. Compt. rend. Soc. biol., 1907, =62=: 897. 56. -----. Ibid., 1909, =66=: 782. 57. -----. Ibid., 1910, =69=: 5. 58. MELTZER and AUER. J. Exper. Med., 1905, =7=: 59. 59. MITCHELL. J. Phys., 1862, =5=: 109. 60. MITSCHERLICH. Diss. Berlin, 1859. 61. MOSCHKOWITSCH. Arch. Pharm., 1903, =241=: 358. 62. MULDER. J. prakt. Chem., 1838, =15=: 280. 63. ----. Poggendorff's Ann. Physik Chem., 1838, =43=: 180. 64. NEUBAUER. Arch. Exper. Path. Pharm., 1901, =46=: 133. 65. NOE. Arch. Int. Pharm. Ther., 1904, =12=: 160. 66. OPHÜLS. Proc. Soc. exper. biol. med., 1911, =8=: 75. 67. OUDRY. Nouvelle Bibliothek Médicale, 1827; Geiger's Magazin Pharm., 1827, =19=: 49. 68. PARISOT. Diss. Paris, 1890. 69. PELLETIER. J. Pharm., 1826, =12=: 229; also quoted by Brill, 3. 70. PERETTI. Diss. Bonn, 1875. 71. PFAFF. Schweigger-Seidel, 1831, =1=: 87. 72. PFAFF and LIEBIG. Ann. Pharm., 1832, =1=: 17. 73. POHL. Arch. Exper. Path. Pharm., Suppl. Bd., 1908, p. 427. 74. PRATT. Boston Med. Surg. J., 1868, =2=: 82. 75. ROBIQUET. Dict. Tech., Paris, 1823, =4=: 59. 76. ROST. Diss. Heidelberg, 1895. 77. RUNGE. Neuste phyto-chem. Entdeckungen, Breslau, 1820. 78. SALANT. U. S. Dept. Agr., Bureau of Chemistry Cir. 81. 79. SCHMIEDEBERG and BUNGE. Arch. Exper. Path. Pharm., 1874, =2=: 62. 80. -----. Ibid., 1910, =62=: 296. 81. SOLLMAN and BROWN. J. Amer. Med. Assoc., 1905, =45=: 229. 82. STRECKER. Ann. Chem. Pharm., 1861, =118=: 151 83. STUHLMANN and FALCK. Arch. path. Anat. Phys., 1857, =11=: 324. 84. THIERFELDER and VON MERING. Zts. physiol. Chem., 1885, =9=: 511. 85. VOIT. Untersuch. über den Einfluss des Kochsalzes, des Kaffes München, 1860. 86. ZALESKY. Hoppe-Seyler Med. Chem. Untersuch., Berlin, 1866, 85-116. * * * * * Transcriber's Notes Obvious typographical errors have been corrected, but variations in spelling, punctuation and hyphenation have been retained. Rabbit 396. The date August 15 has been corrected to August 19. The data for Rabbit 123 is presented as printed in the original, although it is likely that the Caffein per kilo. values should be preceded by a decimal point (or that the heading should be Mg.). Standard footnotes are identied alphabetically thus [A]. Notes to the tables are placed directly under the tables and identified numerically thus (1). Numeric references within the text refer to the bibliography. The headings of Table 18 have been abbreviated for clarity on small screens. Italics are shown thus _italic_ and bold thus =bold=. 
46745	----	THE ACTION OF MEDICINES IN THE SYSTEM; OR, "ON THE MODE IN WHICH THERAPEUTIC AGENTS INTRODUCED INTO THE STOMACH PRODUCE THEIR PECULIAR EFFECTS ON THE ANIMAL ECONOMY." Being the Prize Essay TO WHICH THE MEDICAL SOCIETY OF LONDON AWARDED THE FOTHERGILLIAN GOLD MEDAL FOR MDCCCLII. BY FREDERICK WILLIAM HEADLAND, B.A., M. R. C. S., ETC. [Illustration] PHILADELPHIA: LINDSAY AND BLAKISTON. 1853. WM. S. YOUNG PRINTER TO THE PRESIDENT, OFFICERS, AND FELLOWS OF THE MEDICAL SOCIETY OF LONDON, This Essay IS RESPECTFULLY INSCRIBED, BY THEIR VERY OBLIGED FRIEND AND SERVANT, THE AUTHOR. CONTENTS. CHAPTER I. PAGE INTRODUCTORY REMARKS 13 CHAPTER II. ON SOME OF THE MORE IMPORTANT CLASSIFICATIONS OF MEDICINES, AND OPINIONS OF AUTHORS RESPECTING THEIR ACTIONS 29 CHAPTER III. ON THE GENERAL MODES OF ACTION OF THERAPEUTIC AGENTS INTRODUCED INTO THE STOMACH; TREATED OF IN TEN PROPOSITIONS 60 PROP. I. 61 That the great majority of medicines must obtain entry into the blood, or internal fluids of the body, before their action can be manifested. PROP. II. 68 That the great majority of medicines are capable of solution in the gastric or intestinal secretions, and pass without material change, by a process of absorption, through the coats of the stomach and intestines, to enter the capillaries of the Portal system of veins. PROP. III. 87 That those medicines which are completely insoluble in water, and in the gastric and intestinal juices, cannot gain entrance into the circulation. PROP. IV. 90 That some few remedial agents act locally on the mucous surface, either before absorption, or without being absorbed at all. That they are chiefly as follow:-- _a._ Irritant Emetics. _b._ Stomach Anæsthetics, _c._ Irritant Cathartics. PROP. V. 98 That the medicine, when in the blood, must permeate the mass of the circulation, so far as may be required to reach the parts on which it tends to act. That there are two possible exceptions to this rule:-- _a._ The production of sensation or pain at a distant point. _b._ The production of muscular contraction at a distant point. PROP. VI. 103 That while in the blood the medicine may undergo changes, which in some cases may, in others may not, affect its influence. That these changes may be-- _a._ Of Combination. _b._ Of Reconstruction. _c._ Of Decomposition. PROP. VII. 106 That a first class of medicines, called Hæmatics, act while in the blood, which they influence. That their action is permanent. 1. That of these some, called Restoratives, act by supplying, or causing to be supplied, a material wanting; and may remain in the blood. 2. That others, called Catalytics, act so as to counteract a morbid material or process; and must pass out of the body. PROP. VIII. 217 That a second class of medicines, called Neurotics, act by passing from the blood to the nerves or nerve-centres, which they influence. That they are transitory in action. 1. That of these some, called stimulants, act so as to exalt nervous force, in general or in particular. 2. That others called Narcotics, act so as first to exalt nervous force, and then to depress it; and have also a special influence on the intellectual part of the brain. 3. That others again, called Sedatives, act so as to depress nervous force, in general or in particular. PROP. IX. 256 That a third class of medicines, called Astringents, act by passing from the blood to muscular fibre, which they excite to contraction. PROP. X. 268 That a fourth class of medicines, called Eliminatives, act by passing out the blood through the glands, which they excite to the performance of their functions. CHAPTER IV. 309 ON THE ACTION OF SOME OF THE MORE IMPORTANT MEDICINES IN PARTICULAR A CLASSIFICATION OF MEDICINES WHICH ACT AFTER ENTERING INTO THE BLOOD, ACCORDING TO THEIR SUPPOSED MODES OF OPERATION. PAGE CLASS I. HÆMATICA 106 DIV. I. RESTAURANTIA 113 Ordo 1. Alimenta 115 Ordo 2. Acida 120 Ordo 3. Alkalia 126 Ordo 4. Tonica 129 Ordo 5. Chalybeata 145 Ordo 6. Solventia 149 DIV. II. CATALYTICA 157 Ordo 1. Antiphlogistica 185 Ordo 2. Antisyphilitica 188 Ordo 3. Antiscrofulosa 191 Ordo 4. Antiarthritica 194 Ordo 5. Antiscorbutica 205 Ordo 6. Antiperiodica 207 Ordo 7. Anticonvulsiva 211 Ordo 8. Antisquamosa 213 CLASS II. NEUROTICA 217 DIV. I. STIMULANTIA 226 Ordo 1. Stimulantia Generalia 227 Ordo 2. Stimulantia Specifica 232 DIV. II. NARCOTICA 234 Ordo 1. Inebriantia 237 Ordo 2. Somnifera 238 Ordo 3. Deliriantia 240 DIV. III. SEDANTIA 242 Ordo 1. Sedantia Generalia 244 Ordo 2. Sedantia Specifica 249 CLASS III. ASTRINGENTIA 256 Ordo 1. Astringentia Mineralia 260 Ordo 2. Astringentia Vegetabilia 265 CLASS IV. ELIMINANTIA 268 Ordo 1. Sialagoga 281 Ordo 2. Expectorantia 283 Ordo 3. Cathartica 286 Ordo 4. Cholagoga 295 Ordo 5. Diaphoretica 298 Ordo 6. Diuretica 302 ON THE ACTION OF MEDICINES IN THE SYSTEM. CHAPTER I. INTRODUCTORY REMARKS. In commencing this Essay on the Action of Medicines, I must confess that I feel at first a certain discomfort when I consider the magnitude of the task before me. Many a volume has been written to elucidate the operations of single medicines, and when the variety and complexity of such an operation is considered, the space devoted to its consideration will hardly seem too great. Thus it is not to be wondered at that, when pausing on the threshold of my subject, I should be sensible of the many difficulties with which such an inquiry is surrounded. In this introductory chapter it will be my aim, in the first place, to set forth briefly the great importance and extent of the subject, showing that it is an essential requisite in the advance and perfection of medical science. Next, I must insist on the advantage of correctness and clearness of language and argument in the treatment of such topics as this, and show in what manner I propose myself to attain to it. And in the third place, I must shortly explain the scheme or arrangement which will be followed in this Essay. If the preliminary remarks contained in this chapter are not first considered and clearly apprehended, I fear that I may be but imperfectly understood in what I shall have to say hereafter. There have been, more or less, in all ages, two systems or schools of medical treatment, of which the one prevails among ignorant men, and in rude states of society, but the other requires a higher degree of enlightenment. These are the Empirical and the Rational systems. The first is founded on simple induction. By accident or by experience it is found that a certain medicine is of use in the treatment of a certain disorder: it is henceforth administered in that disorder; and on a number of such separate data an empirical system is constructed. It naturally requires for its elaboration a comparatively small degree of knowledge. Now this observation of facts is indispensable as a beginning, but something more is required. We must not be satisfied with taking them separately, but we must proceed to compare together a large number of facts, and draw inferences from this comparison. And our plan of treatment will become rational, when on the one hand, from an accurate knowledge of the symptoms of diseases, we are better enabled to meet each by its appropriate remedy, and on the other hand, from some acquaintance with the general action of a medicine, we are fitted to wield it with more skill and effect, and to apply it even in cases where it has not yet been proved beneficial. Thus, for the proper perfection of medicine as a rational science, two things are in the main needed: the first is a right understanding of the causes and symptoms of disease; the second, a correct knowledge of the action of medicines. Should our acquaintance with these two subjects be complete, we should then be able to do all that man could by any possibility effect in the alleviation of human suffering. This sublime problem is already being unravelled at one end. Diagnosis and Nosology are making rapid strides; and perhaps we shall soon know what we have to cure. But at the other end our medical system is in a less satisfactory condition; and though some impatient men have essayed, as it were, to cut the Gordian knot, and have declared boldly on subjects of which they are ignorant, yet it must be confessed, that in the understanding of the action of medicines, and of their agency in the cure of diseases, we do not so much excel our ancestors. While other sciences are moving, and other inquiries progressing fast, this subject, so momentous in its applications, has, in spite of the earnest labours of a few talented investigators, made after all but small progress. Let but those who feel this want bestir themselves to remove it, and it will soon be done. Those doubts and difficulties, which are now slowly clearing away before the efforts of a few, will then be finally dispelled by the united energies of all; and instead of our present indecision and uncertainty on many points, we shall find ourselves eminently qualified to wage the conflict with disease, being skilled in that science whose name bespeaks its peculiar importance, the science of _Therapeutics_. The subject assigned to me as the text of this Essay concerns this problem:--"On the mode in which Therapeutic Agents introduced into the stomach produce their peculiar effects on the Animal Economy." It is naturally a subject of very great extent; and one difficulty with which I am beset is that I scarcely know how to compress what I have to say on the action of medicines into the compass required. It will be granted that it is an important subject; it is also a difficult one. This difficulty depends mainly on the variety and complexity of the proof required to establish any one point with absolute certainty.[1] A long time ago, when men knew and understood less than they do now, it was fancied that the action and choice of medicines was a thing of the utmost simplicity; that it was comparatively an easy matter to fix at once upon that remedy required most in any particular case.[2] But the light of science, which in this day burns more brightly, at the same time that it displays all objects with greater distinctness, discloses to us also many dim vast tracts in the distance, of which nothing had been seen or imagined before. In this, as in other things, the more we know the more we discover our real ignorance. It is wrong, then, to treat dogmatically of matters that we cannot comprehend; and when perfectly in the dark as to the operation of a medicine, we should rest content with declaring the result of that operation. This by itself will be of great use to us.[3] I am induced to lay stress on the difficulties surrounding an inquiry into the _modus operandi_ of medicines, because it will be some excuse for the manifest insufficiency of the sketch which I am about to draw. For this, too, I may find a further apology in the fallacies and mistakes, both of reasoning and statement, of which previous writers have been guilty. These are best shown by their discrepancies. On no question, perhaps, have scientific men differed more than on the theory of the action of medicines. Either facts essentially opposed and incompatible have been adduced by the disagreeing parties; or, which is nearly as common, the same fact has received two distinct and opposite interpretations. Many hypotheses, when tested, are seen to be grounded on bare assertions, and to be destitute of logical proof; many others are attempted to be established on ill-sustained analogies. Analogy, in such a case as this, may be used to increase a probability already evidenced; but by itself it is no proof, for we find often that medicines are capable of producing the same result in very dissimilar ways. How then are we to arrive at the truth! The best and surest way is to be extremely careful in the means which we employ in its discovery. It is, I think, impossible to overrate the importance of _exact precision of language and thought_ in scientific details, and in the deduction of conclusions from them.[4] A subject so interesting as this requires to be treated in a logical way. Facts, when ascertained, should be ranged together and compared, and exact inferences made, without ever straining a point. And when we are inclined to hazard a theory that is barely supported, we should take care to state it as a theory, and not to bring it forward as a truth. It has not been an uncommon habit among scientific authors, who should be of all men the most careful and exact, to confound assertion with fact--to mistake hypothesis for truth. In such illogical and incorrect reasoning is to be found the true source of a multitude of errors. Being sensible of this danger, I have endeavoured to keep it in view in the arrangement of this Essay. In order to obtain, if possible, this clearness and precision, or at all events, to be better understood, I have arranged the heads of my ideas on the action of medicines in a number of distinct propositions, the scope of which will be presently described. I shall attempt to prove each of them separately, as if it were a theorem in geometry, sometimes dividing it first into a number of minor propositions, which, taken together, imply the original one, and which have to be severally discussed. The great use of such an arrangement is its distinctness: so that it may in any case be easily seen whether a proposition has been established, or whether I have failed to prove it. These propositions are the foundation of the Essay; and upon them has been erected a superstructure of more or less logical consistency. In them has been stated about as much of the general principles by which medicines operate as seems to me to be capable of distinct proof: _i.e._ which may be regarded with that kind of certainty which we generally expect to attain to in scientific matters. So far, then, I have kept myself in a straight road, between two walls, diverging neither to the right nor to the left to gratify my inclination; it being, as I have said, a most obvious duty to guard against stating that for fact which is at the best uncertain. But having gone so far, I have in several instances indulged in speculations and hypotheses on certain matters, taking care to state that such explanations are only probable, and very far from determined. But it is often our duty to inquire into uncertain things; and those who do so, who officiate, in however humble a capacity, as the pioneers of knowledge, have to hazard many conjectures before they arrive at the truth. In striving after truth, we must investigate many an unknown path, and try at many a door where we have not before entered. Thus, when in some cases I have perceived before me a line of thought stretching onwards, and seeming to lead somewhere in the direction of truth, I have not, as it were, shunned it, or turned aside to tread only in more certain paths, but I have thought it my duty to follow it up, and to investigate it thoroughly, to see if by any means it might not help me on my way to that desired haven. These theories are the weak points of the Essay, but I must crave indulgence for them on the grounds alleged above. It will be observed that the original propositions are so stated, that the overthrow of any one of these extra hypotheses would not shake them, or in any way invalidate their proof. I will now sketch out the arrangement which I propose to follow in the consideration of the topics which present themselves to me. In the next chapter I shall take a brief review of the opinions of other writers on the subject of the action of medicines; knowing, indeed, that in so short a notice I shall be perfectly unable to do them justice, but wishing, in some broad points, to draw the line between what is known and what is unknown,--what is ascertained and what is debated,--what is approved and what condemned. In some cases also I may venture to object to opinions hitherto unquestioned. Now, as the best key to the main opinions of authors on this subject, we have to consider the various classifications of medicines which they have adopted. A classification of remedies presupposes a set of theories concerning either their primary action or their general results, and is, in fact, identical with them. The formation of such an arrangement depends on the necessity of considering medicines in groups, each possessed of some common character, in order that their various properties may be simplified, and admit of being compared. In a classification we do not so much consider the peculiarities of single remedies, as the points in which large numbers agree together. These points of resemblance we gene rally find to be of the most importance. I have to consider three sets of authors in the second chapter. The first set treat of the general or ultimate effect of a medicine on the system; and classify medicines accordingly. A second set of writers have arranged therapeutical agents according to the organ or part of the body to which their action is especially directed. Neither of these deal with the mode in which medicines act as the basis of classification. A third set of writers have attempted in various ways to explain the modes of operation of medicines. They have laid down general rules about these operations, and have constructed more or less plausible theories on the subject. Some few have classified remedies on this plan. Now, with these theories I am more particularly concerned, as they trench immediately on the subject of this Essay. But they are not many, and it will not take us long to review them. It is easier to find fault than to teach. After pointing out the shortcomings of some who have preceded me, I find myself necessitated in the third chapter to state my own conclusions as to the _modus operandi_ of medicines. Let us consider, as it were, the history of a remedy from the beginning to the end of its course. It is already "introduced into the stomach"--we must commence with it there. Now it does not remain there. It cannot act from the surface of the stomach through the medium of the nervous system. In the _First Proposition_ it is affirmed that it must obtain entry into the fluids of the body--pass, that is, from the intestinal canal into the system at large--before its action can begin. There are four proofs of this. It is shown that when introduced at another part of the body a medicine acts in the same way as when placed in the stomach. It is found by direct experiment that a poison will not act through the medium of nerves only, but that its passage in the blood is required. Thirdly, the course of the circulation is quick enough for the most rapid poison or medicine to pass quite round the body from the veins of the stomach before it begins to operate. The last and most conclusive argument to show that medicines pass out of the stomach into the system, is that they have actually been detected by chemists, not only in the blood, but in the secretions formed from the blood. Remedies, then, pass from the stomach into the blood and fluids. How do they do so? In the _Second Proposition_ it is laid down that all those which are soluble in water, or in the secretions of the stomach or intestines, pass through the coats of these organs into the interior of the capillary veins which surround them. It has already been shown that most medicines pass through in some way; we shall now have to learn how they pass, and what special arrangements are made for the passage of substances differing in nature. By the physical process of absorption a liquid may pass through the animal membranes, from the interior of the stomach or intestine to the interior of the small vein which lies close outside it. In examining the laws by which this process is conducted, we shall find that all the requirements are present in these parts, provided only that the substance to be absorbed shall be first in some way dissolved, and reduced to the liquid state. In the stomach there is, in contact with the substance just introduced, a thin watery secretion containing acid and a matter called pepsin: this is the gastric juice. A large number of medicines are soluble in water. They are dissolved in this fluid. Some others are soluble in dilute acid. These too are dissolved here. Albumen, and matters like it, are reduced to solution by the aid of the pepsin, which is the principle of digestion. But there are some few mineral bodies, and many vegetable substances, as fats and resins, which cannot be thus dissolved by the juice of the stomach. They are soluble, more or less, in a weak alkaline fluid; and such a fluid is the bile, which is poured out into the first portion of the intestine. They too are reduced to solution and absorbed. In this manner it is shown that a very great majority of remedial agents are capable of being reduced to solution, of being absorbed without material change, and of passing thus into the circulation.[5] Very few are quite insoluble; but some that are dissolved with difficulty may be left partly undissolved in the intestinal canal. What becomes of these? It is asserted in the _Third Proposition_ that substances which are thus insoluble cannot pass into the circulation. Arguing from a physical law, we should say at once that it was impossible; but the matter cannot be so lightly dismissed, for a foreign professor has lately asserted that insoluble matters may and do pass into the circulation. I have made experiments to satisfy myself on the point, and have come to the contrary conclusion. In the _Fourth Proposition_ it is stated that some few substances may act locally, by irritation or otherwise, on the mucous surface of the stomach or intestines. These are not many; they act without being absorbed; and they do not extend into the system at large. In some few cases, these local actions may be succeeded by changes in distant parts, on the principle of _Revulsion_. Having just shown how medicinal substances are absorbed, we have now to suppose that they are in the blood. It is next maintained, in the _Fifth Proposition_, that the medicine, being in the blood, must permeate the mass of the circulation as far as to reach the part on which it tends to act. This it can easily do. The circulating blood will conduct it any where, in a very short time. Supposing a medicine has to act on the liver, or on the brain, or on the kidney, it does not influence these organs at a distance, but it passes directly to them in the blood, and then its operation is manifested. This may be called the rule of _local access_. Its proof depends on two things: on the impossibility of the medicinal influence reaching the part in any other way, as shown in the first proposition; and on the fact of medicinal agents having been actually detected in many cases in the very organs over which they exert a special influence. But are there any exceptions to this? Can a medicine ever produce an effect without actually reaching the part? It seems that there may be two exceptions. In some cases an impression of _pain_ may be transmitted along a nerve from one part to another; and in some other few instances a muscle, when caused to contract by the influence of a medicine, may cause other muscles near it to contract by sympathy. Before we inquire into the remedial action of the medicine in the blood, we must consider whether that fluid may not first alter it in some way, so as to hinder or affect its operation. To a certain extent this is possible. In the _Sixth Proposition_ it is asserted that while in the blood the medicine may undergo change, which change may or may not affect its influence. It will have to be shown that this change may be one of _combination_, as of an acid with an alkali; of _reconstruction_, when the elements of a body are arranged in a different way, without a material change in its medical properties, as when benzoic is changed into hippuric acid; or of _decomposition_, when a substance is altogether altered or destroyed, as when the vegetable acids are oxidized into carbonic acid. Having considered these preliminary matters, we shall arrive at the main point. The medicines are now in the blood. We must consider what becomes of them; what they do next; where they go next; and how they operate in the cure of diseases. I have made a classification in which medicines are divided according to my views of their mode of operation. The classes and their subdivisions will serve for references in illustration of what I have to say. For it is not possible to speak of the general operation of medicines without adducing particular instances; nor will time and space always allow me, in doing so, to refer to individual medicines. There are four great groups of medicines, the action of each of which is well marked and distinct. The first class acts in the blood; and as a large number of diseases depends on a fault in that fluid, we may by their means be enabled to remedy that fault. They are the most important of all medicines. They are called Hæmatics, or blood-medicines. They are used chiefly in chronic and constitutional disorders. But a second class of remedies are temporary in their action. They influence the nervous system, exciting it, depressing it, or otherwise altering its tone. They are chiefly useful in the temporary emergencies of acute disorders. They can seldom effect a permanent cure, unless when the contingency in which they are administered is also of a temporary nature. They are called Neurotics, or nerve-medicines. A third set of medicines, less extensive and less important than the others, acts upon muscular fibre, which is caused by them to contract. Involuntary muscular fibre exists in the coats of small blood vessels, and in the ducts of glands. Thus Astringents, as these agents are called, are able, by contracting muscular fibre, and thus diminishing the calibre of these canals, to arrest hemorrhage in one case (when a small vessel is ruptured,) and to prevent the outpouring of a secretion in another case. The fourth class is of considerable importance. Some medicines have the power of increasing the secretions which are formed from the blood by various glands at different parts of the body. By their aid we may be enabled to eliminate from the blood a morbid material through the glands; or we may do great good by restoring a secretion when unnaturally suppressed. They are called Eliminatives. Like Hæmatics, their influence is more or less permanent. That of Neurotics and Astringents, particularly the former, is transient. The general mode of action of these four classes of therapeutic agents is laid down in the four remaining propositions, about as far as it seems to me to be capable of a positive definition. Each proposition concerns one of these classes of medicines. All I can do now is to recapitulate the chief affirmations made; as to give any idea of their proof would require me to enter into a number of details which had better be postponed to the third chapter. In the _Seventh Proposition_ it is stated of Hæmatic medicines that they act while in the blood, over which fluid they exert an influence; and that their effect, whatever it be, is of a more or less permanent character. A line of distinction is drawn between two divisions of this class of blood-medicines. Some of them are natural to the blood; they resemble or coincide with certain substances that exist in that fluid; so that, having entered it, they may remain there, and are not necessarily excreted again. These are useful when the blood is wanting in one or more of its natural constituents. This want causes a disease, and may be supplied by the medicine, which in this way tends to cure the disease. Medicines of this division are called Restoratives; for they _restore_ what is wanting. Some other blood-medicines, although they enter the blood, are not natural constituents of the vital fluid, and cannot remain there, for they are noxious and foreign to it. They must sooner or later be excreted from it by the glands. They are of use when disease depends on the presence and working in the blood of some morbid material or agency, which material or action they tend to counteract or destroy. They may be called _vital antidotes_; not strictly _specifics_, for they are not always efficacious, on account of variations in the animal poisons, or from the casual operation of disturbing causes. They are applicable in those many disorders which depend, not on the absence of a natural substance, but on the presence of an unnatural agent in the blood. These medicines are called Catalytics, from a Greek word which signifies _to break up_ or _to destroy_. Having performed this, their function, they then pass out of the blood. All this requires to be proved. In the _Eighth Proposition_ it is stated of Neurotics, or nerve-medicines, that they act by passing out of the blood to the nerves, which they influence. This is only to insist on the rule of _local access_, already laid down in Prop. V. It is further affirmed that they are transitory in action. They appear to effect molecular changes in nerve-fibre, similar to those by which the phenomena of the senses are produced, and which are by nature transitory in their results. And yet they may be very powerful, even so as to extinguish vital force. Thus, short and unenduring as is the operation of these agents, it may last long enough to cause death, and so a temporary influence produce a permanent result. There are three divisions of Neurotics. The first set are of use when there is a dangerous deficiency of vital action. These are Stimulants. They exalt nervous force, either of the whole nervous system, or only of a part of it. They vary very much in power. A second set, called Narcotics, first exalt nervous force, and then depress it. They have thus a double action; but they have also a peculiar influence over the functions of the brain, which is different from any possessed by other nerve-medicines. They control the intellectual part of the brain, as distinguished from its organic function; the powers of _mind_ more than those of _life_. Some Narcotics tend to produce inebriation; others, sleep; others, again, delirium. In the third place some Neurotics tend simply and primarily to depress nervous force. They may act on the whole nervous system, or on a part of it only. They are often very powerful; and they are of use when, from any cause, some part of the nervous system is over-excited. They are called Sedatives. Like other Neurotics, they are used in medicine as temporary agents in temporary emergencies. If a permanent action be required, the remedy must be constantly administered, that the effect may be kept up by continual repetition. In the _Ninth Proposition_ it is affirmed of Astringent medicines that they act by passing out of the blood to muscular fibre, which by their contact they excite to contraction. They do not so much influence the voluntary fibre of the muscles, which is under the direct control of the nervous system: but they chiefly manifest their action on the involuntary or unstriped muscular fibre, which is not directly controlled by the brain and nerve-centres, and for this reason more under the operation of external or irritating agents. Meeting this in the coats of the capillary vessels and of the ducts of glands, they are enabled to act as styptics, and as checkers of secretion. The action of Astringents appears to depend on a chemical cause; for we find that all of them possess the power of coagulating albumen. The _Tenth Proposition_ treats of Eliminatives. It is not said simply that these increase the secretions of a gland; or that they stimulate the glands while passing by them in the blood. But it is laid down as a rule that they act by themselves passing out of the blood through the glands, and that while so doing they excite them to the performance of their natural function. They are substances which are unnatural to the blood, and must therefore pass out of it. In so doing they tend to pass by some glands rather than by others: in these secretions they may be detected chemically; and it is on these glands that they have an especial influence. Their uses in treatment are various and manifold. In these classes are included all medicines that act after entry into the blood. On referring to the classification which precedes this chapter, it will be seen at a glance what groups of medicines are arranged as orders under each class or division.[6] In the third chapter I shall attempt at some length to prove the propositions which treat of these four classes; and I shall also attempt to explain the nature and mode of action of the orders, or small groups of remedies. In the fourth chapter some of the more important medicines will be considered separately, either as individually interesting, or as illustrative of general modes of operation previously described. I may point to some parts of the Essay as being more original than others, although not perhaps for that reason more valuable. For this purpose may be mentioned the treatment of the second proposition: the distinction attempted to be drawn between the two divisions of blood-medicines; the account given of Tonics in one of these divisions, and of Anti-arthritics in the other; the theory of the action of Eliminative medicines; and the experiments made on the action of Aconitina. CHAPTER II. ON SOME OF THE MORE IMPORTANT CLASSIFICATIONS OF MEDICINES, AND OPINIONS OF AUTHORS RESPECTING THEIR ACTIONS. I have thought it necessary, before stating at length my own conclusions, to refer to some of the more important statements of authors concerning the subject of which I have to treat; because by so doing I may to some extent indicate what points are to be regarded as determined and proved, and what as still unsettled, and point out where I can agree with other writers, and where I am disposed to differ from them. The opinions of authors on the general action of medicines are in most cases best ascertained by observing the manner in which they have arranged and classified them, grouping together those which they consider to be alike in their mode of operation. Differences of opinion respecting individual medicines will be best considered afterwards, when we come to discuss those medicines. We are now to make inquiry as to the action of classes and groups. So that, in examining classifications as a key to the opinions of writers on this matter, we are only concerned with those which are founded in some way on the effects and operations of medicines. Now there are three different points of view from which the action of a medicine may be regarded. We may ask,--1. What is the ultimate effect of its action on the system? 2. To what organ or tissue is its action directed? 3. In what way does it operate? In other words, we may speak of the _result of the action_ of a medicine, of the _direction of the action_ of a medicine, or of the _mode of operation_ of a medicine. The first of these questions is the simplest, and may be answered from experience. We know that one medicine is a purgative, because it opens the bowels. We call another an alterative, because the manifestations of vital action are somewhat different after its use from what they were before. The last question is the most difficult to answer, because it involves the exact mode in which a medicine first behaves itself, so as to bring about its recognised operation. Though the arrangements and theories of authors have generally taken into account all three of these questions, yet they have usually given greater prominence to one or other of them. And according to this their predominant idea, I will take the liberty of grouping them into three schools for the sake of convenience; considering, first, some theories and therapeutical arrangements which are based upon the ultimate effect of medicines; secondly, some that depend upon their local tendencies; and thirdly, some others that concern their mode of operation. Among those who have directed attention to their ultimate effect, regarding that as generally sufficient for practical purposes, are included the great majority of those who have classified medicines. Such arrangements are practically useful, as by their means we are enabled easily to select a medicine which shall produce a required result. A classification founded upon local tendency is such as hardly to admit of practical application, for it is too vague. It is said that the action of mercury is directed to the blood; that of a tonic, to the muscular system. It is not said how they operate, or how these parts are affected. The terms employed are too wide and indefinite. Supposing the word _Neurotic_ to signify a medicine acting on the nerves, we cannot say that any known medicine may not at some time or in some way act on the nervous system. The same term means a very different thing when found in a classification based on the mode of operation of medicines, for then it signifies a medicine acting on the nerves in a certain way which is defined, and it conveys to us an amount of information respecting that medicine and its applicability which we had not otherwise acquired. A classification of this third kind, though difficult of construction, would naturally be of great practical and scientific utility. The precise mode in which groups of medicines operate has first to be discovered and laid down, together with the results of that operation; and it has then to be proved that each remedy included in a class operates in the exact way predicated of that class. None which do not do so can be consistently included in it. Such an arrangement is precise; there may be a great deal of error, but there is very little vagueness about it. Each name and term should contain in itself and in its position an exact description of the general action of the substances included under it. Such an arrangement I have attempted to construct myself, as it is with the mode of operation of medicines that I am particularly concerned. The chief and obvious objection to such a classification consists in the insufficiency or insecurity of the data which we have to guide us. Thus the best and safest way is to select as the bases of primary subdivision those distinctions which admit of being the most readily and firmly established, and not to rest it on a number of uncertain or questionable hypotheses. I. OPINIONS CONCERNING THE ULTIMATE EFFECT OF MEDICINES, AND CLASSIFICATIONS FOUNDED ON THIS. Most authors have grouped remedies together according to the broad results of their action. They do not make inquiry as to the mode of operation or behaviour of a medicine after passage into the system; nor do they ask whether this action is especially directed to any organ or tissue; but they judge by external evidence of its ultimate effect on the body, and on the powers of life. There is commonly a tendency to describe all medicines under two heads, as either causing or diminishing vital activity. Dr. Murray indeed confounds these two effects, and adopts an idea on this subject which was originated by Mr. Brown. I shall now represent in an abridged form the classifications adopted severally by Dr. Young, Dr. Duncan, and Dr. Murray. DR. YOUNG. 1. CHEMICAL AGENTS. Caustics, etc. 2. VITAL AGENTS. A. _Supporting strength._ Nutrients. B. _Causing action._ (Partial and transitory.) Stimulants, Irritants, Astringents, Alteratives, Evacuants. (Permanent.) Tonics. C. _Diminishing action or sensation._ (Primarily.) Narcotics, Nauseants, Sedatives, Diaphoretics. (Secondarily.) Exhaurients. 3. INSENSIBLE AGENTS. Specifics. In the names of these three classes some reference is made to the _modus operandi_ of medicines, but the distinctions thus attempted to be drawn are of the slenderest possible description. Among _chemical_ agents are included some that are applied externally, and act then on the tissues in obedience to known chemical laws. But how can we affirm that some medicines passing into the stomach may not operate chemically? The term _vital_ signifies little; and the word _insensible_, applied to the third class, is a confession of absolute ignorance. It does not attach to a medicine any distinctive character to say that we know nothing of its operation. Pursuing the subdivision further, we find that the distinctions are not well maintained. Tonics support strength as well as cause action; and it can hardly be said that the action of an Alterative, such as mercury, is partial and transitory. It seems unwise to have made a separate class of Specifics. They are especially associated with Alteratives. Mercury, Iodine, and others, would fall under both groups. Of Evacuants it may be observed, that they are also Exhaurient, and thus included in two opposed classes; that their action is not always partial and transitory, as, for example, Purgatives may permanently remedy constipation; and that it seems wrong to have separated Diaphoretics from them. Thus neither the primary nor the secondary subdivisions of this arrangement can be reasonably maintained in theory, and we must fall back on the ultimate groups which are based upon common experience. From this failure we may infer that the idea that medicines differ prominently in causing or diminishing vital activity, upon which idea this and many other arrangements are founded, is in fact an erroneous one. There is no such universal distinction. A medicine which at one time raises or excites the vital forces, may at another time depress them; it may do one thing with a sick man, the other thing with a healthy man; it may have the one effect when taken for a short time in moderation, the other effect when taken for a long time or in excess. In fine, the result of the operation of a medicine does not necessarily depend upon this alternative. Although there are undoubtedly some medicines which tend to stimulate the nervous forces, and others which tend to depress them, yet as there are many remedies which may operate well without doing either the one or the other, and whose operation does not depend at all upon this, the distinction cannot be generally applied. The next arrangement, that of Dr. Duncan, appears, as far as it extends, to be correct in theory. If some additions were made to it, it would be a tolerably perfect classification of this kind. Assuming as a basis the ultimate or practical effect of medicines, we may proceed to divide them into groups in a natural way. Food and liquids are of use in the nutrition of the tissues, and will form the first class. A second set of substances act so as to expel from the body certain humours and secretions. Another class exalt the tone of the nervous system, and through it stimulate the system at large. A fourth set depress the same. And a fifth group do none of these things; but their action results in certain obvious changes in the chemical nature of the secretions. DR. DUNCAN. ALIMENTA. Diluentia, Demulcentia. EVACUANTIA. Diaphoretica, Errhina, Expectorantia, Cathartica, etc. STIMULANTIA. Topica (irritants, etc.) Generalia permanentia. Generalia transitoria. DEPRIMENTIA. Refrigerantia, Narcotica. CHEMICA. Acida, Alkalina. As far as it extends, this classification seems to be founded on correct data. The smaller divisions are natural. Thus Evacuants are grouped according to the part of the system at which the evacuation is made. General Stimulants are divided into those which are transitory in action, and those whose effect is permanent, as Tonics. Dr. Duncan is concerned only with the ultimate effect, and enters into no theory respecting the action of Tonics. I regard them as medicines acting primarily in the blood, and, applying my terms with a view to the _modus operandi_, I would restrict the term Stimulant to medicines acting on the nerves, whose effect is transitory. The great fault of this arrangement is the omission of the very important class of Alteratives. We have medicines which increase secretion; medicines which exalt or diminish the vital energy; but where are the remedies which act in the blood? Where, for example, shall we place such medicines as Mercury, Arsenic, and Iodine, which neither act by eliminating, nor by stimulating, nor by depressing, but appear to counteract in the blood the agency of certain morbid poisons? In an arrangement founded on ultimate effect, they should be grouped in a class as Alteratives, as medicines which result in _altering_ for the better the condition of the system. Both Dr. Duncan and Dr. Murray seem to have thought that no medicines could act in the fluids but such as have a well known chemical effect upon them. It cannot be that medicines should be able to affect the nerves, and to influence the glands, in divers ways, but that none should exert any action upon the blood, a most susceptible and changeable fluid, the medium of nutrition, the source of all the tissues, the "_fons et origo_" of disease. It is only very lately that authors have begun to recognise and include in their arrangements the class of blood-medicines, which seem to me to be considerably more important than any other. Having shown thus what appear to me to be the correct bases upon which an arrangement of this kind should be constructed, I shall quote as another specimen the classification of Dr. John Murray, but mentioning only its most prominent details. DR. MURRAY. GENERAL STIMULANTS. _Diffusible_ {Narcotics. {Antispasmodics. _Permanent_ {Tonics. {Astringents. LOCAL STIMULANTS. Evacuants, Irritants. CHEMICAL AGENTS. MECHANICAL AGENTS. We find in this division some reference made to the local tendencies of medicines. Evacuants are classed as Stimulants which tend to act locally on the glands. In the arrangement of Dr. A. T. Thomson, founded upon this one, still further reference is made to the local tendencies of different medicines. Dr. Paris also has adopted this arrangement, but in a very much improved form. Both Dr. Thomson and Dr. Paris take exception to the inclusion of Sedatives (under the head of Narcotics) among general Stimulants. This is the great fault of Dr. Murray's classification. The idea, as he states, was taken from Brown. It is considered that both Stimulants and Narcotics act alike; that is, that they both produce a primary stimulation followed by a secondary depression; only that, in the case of Narcotics (under which head all Sedatives are included) the stimulation is very brief, and rapidly passes away, to be followed by a great depression. Now, even if this were true, the most prominent action would be the depressing effect, and it is on the most prominent action that denominations such as these are usually based. But it is well urged by Dr. Thomson that in the case of true sedatives there is no stimulant action whatever; and it is manifestly unreasonable to suppose that the depressing effect follows as a consequence on the primary stimulation, when the latter is so inconspicuous. At any rate such an arrangement as that of Dr. Murray can be of little practical utility in its original form. A man would be considered to be indulging in the wildest and most dangerous fancies who would run through the catalogue of Narcotics when he desired to produce a general stimulant effect. To this system it might further be objected, that Alteratives are again entirely omitted; and that the class of Mechanical agents would seem to belong to the division of Irritants, included among Local Stimulants. Dr. Murray classes Refrigerants among Chemical remedies, for which, when I come to speak of Acids, I hope to show that there are good reasons. II. OPINIONS CONCERNING THE LOCAL TENDENCY OF MEDICINES, AND CLASSIFICATIONS FOUNDED UPON THIS. Here another step is made in the explanation of the action of medicines. They are said to have particular tendencies towards certain parts of the body, over which parts they exert a peculiar and special influence. It is thought that we shall make an advance in our knowledge of the subject, if we can discover what these tendencies are. An arrangement of medicines may be made accordingly. It is certainly more scientific than a merely empirical arrangement; and it will be so far of use that it will enable us, when we wish to make an impression on a certain organ or set of organs, to select those medicines which especially influence it or them. There is no doubt whatever of the existence of these local tendencies. There is no doubt that some medicines, such as Iodine, Bromine, Mercury, and Iron, tend especially to affect the blood and the blood-making organs, as the liver and spleen, rather than to act on the nervous or glandular systems. That some tend particularly towards the nerves, and prefer individually different parts of the nervous system, as Opium acts on the brain, Aconite on the superficial sensory nerves, Digitalis on the organic nerves of the heart, and Stramonium on those of the lungs. Again, it is evident that some medicines tend to act on the organs of secretion; and of these, particular sets select particular glands, as Diuretics the kidneys, Diaphoretics the glands of the skin, and Purgatives those of the bowels. There may be disagreements on minor points, but there can be no dispute as to the fact of the existence of these local partialities.[7] But, though such statements are admitted to be correct in theory, it remains still to be considered whether they form a fitting basis for a classification of medicines. Now it will be observed that no theory of action enters into such an arrangement, but merely the tendency of the action of each medicine is considered; and as each medicine has naturally many distinct tendencies, it comes therefore under many different heads. But the chief practical use of a classification seems to be, that we may quickly learn from it the general action or effect of a medicine; so that, if it is stated to have many different tendencies, and is ranged under no one particular head, we can gain from this no very distinct practical information respecting it. In an arrangement of the kind that we have last examined, the most important result is the chief point considered. Thus it is rendered useful. And in one of the third kind, where the mode of operation is the great thing taken into account, as each remedy has only one primary operation, and according to this is classified, we gain from its designation some useful information respecting it. It may sometimes come under another head in its secondary operation, but only according to the primary should it be classed, the other term being supplementary. The designations founded on local tendency are further of an indefinite character, because they do not denote the kind of action exerted. Of such a kind is the classification adopted by Dr. A. T. Thomson, founded on that of Dr. Murray. He divides what he calls _Vital remedies_ into one division that acts on the nervous system, a second that affects the secerning system, and a third that influences the muscular and sanguiferous systems. This is certainly a step in the right direction. Nerve-medicines seem to have no relation to those that act on the glands, though connected with them as Stimulants by Dr. Murray. They are thus separated. Tonics are also separated from Stimulants, and included with those which act on the muscular and sanguiferous systems. This seems to me to be a correct view of their action. I do not consider that they act primarily on the nerves, but on the blood. Dr. Thomson places Astringents beside them. Though alike in some points, as with regard to their tendency to affect the condition of muscular fibre, yet there appears to be very little agreement in the mode of operation of Tonics and Astringents. There is not altogether much similarity between Quina and Sulphuric acid. I will now transcribe the chief divisions adopted in the classification of Eberle, which seems to have been the prototype of that one since so ably elaborated by Dr. Pereira. EBERLE'S CLASSES. A. Medicines acting on the intestinal canal, or its contents. B. Medicines acting on the muscular system. C. On the uterine system. D. On the nervous system. E. On the circulating system. F. On the organs of secretion. G. On the respiratory organs. The subdivisions are founded on the kind of effect produced. As in Dr. Thomson's arrangement, Tonics and Astringents are said to act on the muscles; but no mention is made here of either of them acting on the blood. While Narcotics are placed among nerve-medicines, Stimulants are classed as acting on the circulating system. They no doubt act on the nerves, and then through them on the vessels; but so also do Narcotics, from which they are separated. If in class E are only included medicines acting on the organic nerves of the heart and arteries, why were they not placed in D, with Nerve-medicines? But if medicines acting on the contents of the vessels are meant, why were not Blood-medicines, or Alteratives, placed here? They are entirely omitted; which seems to be a fault in this system. Dr. Pereira seems to have adopted a more correct view of both of these cases. He includes Stimulants with _Neurotics_, and places among _"Hæmatics"_ those medicines which are commonly termed Alteratives. It seems to me that when a medicine acts on the blood, this action ought not to be thrown into the shade, but should rather be placed before all its other operations, as being of more importance than any of them. Dr. Pereira arranges in six classes those medicines which are given internally, having previously made three classes of external or topical agents, with which we are not now concerned. Some of the classes are again divided into large groups, these and the other subdivisions being either based on more particular local tendencies, or on the _physiological action_ of the medicine on the part to which its operation tends. DR. PEREIRA'S CLASSES. CLASS IV. Hæmatica. 1. _Spanæmica._ 2. _Hæmatinica._ CLASS V. Pneumatica. CLASS VI. Neurotica. 1. _Cerebro-spinalia._ 2. _Ganglionica._ CLASS VII. C[oe]liaca. CLASS VIII. Eccritica. CLASS IX. Genetica. These groups, though differently placed, correspond to six of Eberle's seven classes. The class acting on the muscular system is omitted. The subdivision here is more accurate and scientific. _Hæmatics_ or blood-medicines, are divided into two classes. _Spanæmics_ the first of these, are named from their tendency to impoverish the blood. _Hæmatinics_ including the compounds of Iron, tend to enrich it. In the first division are included the medicines commonly termed Alteratives, as well as Acids, Alkalies, the compounds of Lead, Silver, Copper, etc. In the selection of the above name attention is paid to the abstract physiological effect of these medicines, rather than to their therapeutical applications. The impoverishing of the blood may be the ultimate action of such a medicine as Potash or Mercury, but not exactly the primary operation for which it is used in medicine. It is produced by the remedy when taken in excess, and not when given in small doses. _Neurotics_, or medicines which act on the nerves, are divided into those which affect the brain and spinal system, and those which are supposed to influence the ganglionic system, and through it the heart and great vessels. (When we shall afterwards discuss the action of nerve-medicines, it will be seen that it is very difficult, if not impossible, to enforce this distinction.) The different kinds of Narcotics form the first division, while the second includes Stimulants and vascular Sedatives. The class of _Eccritics_ includes all medicines acting on the glands, commonly called Evacuants. The details of this arrangement, to which I shall at present venture to object, are, first, the multiplicity of classes, and secondly, the inclusion of certain medicines in the division of _Cerebro-spinals_. Three of the classes seem to be superfluous, and only tend to confuse. There is a class of _Pneumatics_, acting on the respiratory organs. But Expectorants are found elsewhere among _Eccritics_; and those medicines which influence the nerves of the lungs, among _Neurotics_. The same with _C[oe]liacs_; for Cathartics, found among _Eccritics_, are the most important medicines acting on the intestines. _Genetics_ contain medicines which control the uterine and sexual systems, which may all be reckoned among _Neurotics_. And yet this multiplicity of names is consistently employed in carrying out the principle of this classification, which is, to arrange according to the different parts of the system all substances which have any tendency to act on those parts. Dr. Pereira makes four orders of _Cerebro-spinals_; three include different kinds of Narcotics, very minutely subdivided; another is called _Cinetics_. They affect the muscular system; but it is altogether an assumption to assert that these medicines, Astringents and Tonics, do so by influencing the nerves. As to Astringents, it appears that they do not affect the nerves in any way, for which reason I shall have to make a separate class of them. For Tonics, there is great reason to suppose that in the first place they act on the blood; so that I cannot agree with Dr. Pereira, who ranks them among _Neurotics_. Emetics are classed by him among _Eccritics_; but it seems to me that their action is either external, and of an irritant nature, or when from the blood, that it is exerted upon the nerves of the stomach. The stomach is not, like most glandular organs, a simple emunctory, and it is affected by medicines in a different way. Whereas gland-medicines increase secretion, the chief action of Emetics is to cause an evacuation of the contents of the stomach by contraction of itself and of other muscles. All substances which touch the stomach cause the copious outpouring of a thin fluid by mere contact; yet we cannot for this reason call them medicines which tend to increase secretion. Emetics acting from the blood after absorption, as Tartar emetic, which generally influence at the same time either the lungs or the heart, parts supplied by the other branches of the Vagus nerve, which is distributed to the stomach, seem to me to be Specific Neurotics, probably acting on that nerve. So that in these points, as well as in some others, I am disposed to differ from Dr. Pereira. It is apparent that in none of the classifications of this second kind is any mention made of the primary action or _modus operandi_ of medicines in the cure of disease, as a necessary basis of such distinctions. III. OPINIONS CONCERNING THE MODE OF OPERATION OF MEDICINES, AND CLASSIFICATIONS FOUNDED ON THIS. In this third division are included those writers who have attempted to account for the mode in which medicines produce each their peculiar effects after entering into the blood, and some who have classified them according to their ideas on this point. It is with such theories as these that I am more immediately concerned in this Essay. Such writers have dived into a deeper subject than those who have directed attention to the general effects or tendencies of medicines rather than to the means by which such results are attained. Thus it is not to be wondered at that they have sometimes failed. Those have erred most who have allowed their imaginations to lead them astray from facts, or to guide them in matters which are naturally incomprehensible, to which our reason gives us no clue. Attempts have been made to account for the _modus operandi_ of therapeutic agents generally, in three different ways. 1. On mechanical principles. 2. On chemical principles. 3. On general or vital principles. 1. Mechanical theories of the action of medicines were greatly in vogue during the seventeenth and eighteenth centuries. There is a tendency in the human mind to explain every thing; and it was only natural for men who knew little of chemistry or of physiology to resort to the science of physics, which they could comprehend, in attempting the explanation of observed phenomena. John Locke, in his essay concerning the Human Understanding, published in 1689, gave it as his opinion, that the shapes of the minute particles of medicines were sufficient to account for their several operations. "Did we know," said he, "the mechanical affections of the particles of rhubarb, hemlock, opium, and a man, as a watchmaker does those of a watch, whereby it performs its operations, and of a file, which, by rubbing on them, will alter the figure of any of the wheels, we should be able to tell beforehand that rhubarb will purge, hemlock kill, and opium make a man sleep." This idea did not originate with the great metaphysician. The first rudiments are to be found in the doctrines of the _Methodic Sect_ among the Romans, a medical branch of the Epicurean school. They held that diseases depended either on constriction or relaxation of the tissues, and that medicines operated by mechanically affecting these conditions. The simple and philosophical statement of Locke was not improved by the various applications which were subsequently made of it. At the early part of the eighteenth century these ideas derived great support from the principles inculcated by Dr. Herman Boerhaave, the learned physician of Leyden. He likewise supposed that many diseases of the solid parts were to be attributed to a weakness or laxity of the animal fibres, and were to be cured by external or internal agents, which should act mechanically on those fibres so as to increase their tenacity. Also, that disorders of the fluids often depended on their being too viscid, and that this condition might be improved by agents which should attenuate this viscidity. Dr. Archibald Pitcairn, a Scotchman, the immediate predecessor and contemporary of Boerhaave, was elected to the Chair of Physic in Leyden in 1691, and was also an able exponent of the mathematical theories. But he applied to physiology those ideas which were employed by the other to throw light upon physic; if that may be called _light_ which was at least an improvement on the ignorance which preceded it.[8] He explained the digestive process by the mechanical trituration to which the food was subjected in the stomach; and accounted for secretion by supposing the existence in glands of vascular pores of different sizes, which intercepted certain particles of the blood; actually giving for the process a mathematical formula. He was a vehement opponent of those who based their theories on the then youthful science of chemistry, who, having scarce yet shaken off from them the dust of alchemy, only substituting Acids, Alkalies, and Fermentations, for _Salt_, _Sulphur_, and _Mercury_, fell easy victims to his satire. Dr. Charles Perry, in 1741, propounded a mechanical view of the action of Mercury and Arsenic. He thought that the particles of the former, being round and heavy, were able, when shaken about in the vessels, to break up and to annihilate those crude acrid humours which were the causes of disease; and that Arsenic acted as an irritant by the sharp and pointed nature of its atoms. He attributed the occasional poisonous effects of Mercury to the presence of Arsenic or some such substance as an impurity.[9] Dr. Mead, in 1751, states that the administration of Mercury is dangerous in cases where there is carious bone, as there is a fear that its ponderous particles may break the weak lamellæ.[10] He was the Court Physician in the reign of George II. He accounted for the poisonous nature of the venom of serpents by asserting that it consisted of pointed particles, which pierced and destroyed the globules of the blood. Dr. Perry conceived that some medicines, such as Steel and Antimony, did not act by their mere bodily presence, but by certain subtle vapours which emanated from them, and affected the vital spirits. This was a very misty notion. He stated that he borrowed this idea from a great philosopher of the German nation. This was probably Boerhaave, who lectured at Leyden in 1707. Among those who regarded with favour the mechanical hypothesis, were Fourcroy and Hecquet in France, Van Swieten and Huygens in Holland, and Bellini in Italy. Excepting perhaps the case of external irritants, these explanations of the action of medicines have been universally condemned by scientific men at the present day. Doubtless these old authors were in the wrong, both in applying one hypothesis to the action of all remedial agents alike, and still more, in carrying their theories into such minute details, where it is impossible that they should be verified. And yet we may go too far in our condemnation of all such ideas. It does not seem to me to be so impossible, or even improbable, that the operation of some medicinal agents, particularly those which act on the nerves, may depend in some way on the shapes of the atoms of these substances, as related to those of the tissues which they influence. At least, there is no other possible explanation of the power of such substances. We know that the nerves are very much under the influence of mechanical impressions, upon which depend the phenomena of two at least out of the five senses, those of hearing and touch, as probably also of the other three, if we understood them better. We know also that if we accept the Atomic theory, by which so many chemical phenomena are cleared up and explained, we must admit a certain definite and peculiar arrangement and shape to the ultimate particles of every compound body. These considerations render it possible that the ultimate particles of a stimulant medicine may be of such a nature as to irritate, or to refuse to coincide with, the ultimate molecules of the sensitive nerve with which they come in contact; and those of a sedative may, on the other hand, be so shaped and arranged as to dove-tail with those particles, and by extinguishing, as it were, their salient points, to cloak their vital sensibility. This is obviously a mere conjecture, and the only value which can attach to it is, that it appears in some sort to explain a thing which without it is inexplicable. Some modern writers have attempted to clear up the actions of certain medicines by their supposed influence on the physical process of endosmosis, as carried on through the coats of the stomach and intestines. Poissenille and Matteucci have attempted to prove that the action of saline liquids in causing purging, and that of a solution of morphia in preventing the same, may be explained by the _endosmotic_ properties of these liquids, as ascertained by experiment. It does not seem to me that these ideas can be successfully maintained. (_Vide_ Prop. II.) 2. Several attempts have been made to explain the general action of medicines on chemical principles. Perhaps the strange doctrine taught by Galen, which prevailed for so many centuries afterwards, should be mentioned under this head as the first approach to a chemical theory. He considered all medicines to be _hot_, _cold_, _moist_, or _dry_. There were four degrees of each of these properties. In the _Pharmacopæia Londinensis_ of 1702, translated by Dr. Salmon, it is stated of every herb that it possesses in a certain degree one or more of these qualities. It is amusing to find Dr. Salmon in great doubt as to whether Opium were _hot_ or _cold_, as the Ancients said one thing, and the Moderns another. Galen supposed that diseases depended on similar qualities, and were to be counteracted by medicines; that, for example, we were to meet a _hot_ disease by a _cold_ remedy. The next advance, if such it may be termed, was made by the Alchemists of the middle ages, who frequently turned their attention towards the healing art, and almost imagined that by their _Philosophers' stone_ they could purify and rekindle the perishable _base metal_ of the human body. One of their dreams was, that from Gold, the most durable of metals, or from Mercury, the most lively and volatile, they might by their magical arts be enabled to prepare a medicine that should render life perennial. A most impracticable formula for the preparation of this _Elixir Vitæ_ was given, among others, by Carolus Musitanus. Basil Valentine, who flourished in the fifteenth century, did good service by adding to the Materia Medica the preparations of Antimony, as well as the Mineral Acids. In the sixteenth lived Paracelsus and Von Helmont, the latest and most enthusiastic of the medical Alchemists. They considered the chemical principles of medicines, by virtue of which they operated, to be three in number,--viz., _Salt_, _Sulphur_, and _Mercury_. And though the seventeenth century was illumined by the philosophy of Bacon, and the discoveries of Newton and Boyle, we find that this strange doctrine survived in full vigour at the commencement of the eighteenth. It is laid down as an axiom in Dr. Salmon's Pharmacopæia in 1702.[11] About the middle of this century there arose a new sect of chemical philosophers, somewhat better informed than the last. They imagined that most diseases depended on the predominance in the blood of _acid_ or _alkalic humours_, and that each of these conditions should be counteracted by a direct chemical antidote. They supposed also that the various secretions were the products of _fermentations_ in the blood which took place in the neighbourhood of the glandular organs. (_Vide_ Eliminatives.) In some of their ideas there was much that was reasonable; but it must be confessed that they were rather imaginative than argumentative, and, knowing really but little of the principles of that science on which their system was ostensibly based, they were ill-qualified to contend with their opponents of the mathematical school, who at least understood their own position. Foremost among these new chemical philosophers was Raymond Vieussens, who was severely censured by Dr. Pitcairn for having asserted that he had found an acid in human blood.[12] Vieussens was one of the earliest of the sect, which afterwards numbered many followers. There is very little that is tangible to be discovered in these old chemical theories of the action of medicines; and it is not to be wondered at that most of them have faded away before the advance of science, and particularly before that wonderful development of the science of chemistry, which has distinguished the end of the last, and the first half of the present century. We have seen that some of the early writers made great account of the affinities of acids and alkalies. So also a chemical explanation of the action of these remedies is generally adopted by writers at the present day. It is known that they have powerful tendencies to combine with each other, and it is supposed that these affinities are manifested even in the living blood. Schultz attempts a further chemical explanation of their action in some diseases, particularly inflammations. He says that both affect the condition of the blood; but that acids tend to dissolve and destroy the corpuscles, wherefore he terms them _Hæmatolytica Physoda_; and alkalies prevent the coagulation of the fibrine of the plasma, for which reason he calls them _Hæmatolytica Plasmatoda_. Some modern writers have tried to extend a chemical theory to the operation of medicines in general. This is an error to which those who have devoted themselves particularly to the study of chemical phenomena are especially prone. Müller thinks that the agency of many remedies may be explained by their chemical affinities. He supposes that they may effect a change in the nutritive fluids, or that they may so disturb the state of combination in which the elements of an organ may be, that it becomes insensible to the action of morbid stimuli. Some chemists have accounted for the action of Alcohol by its chemical affinity for the brain substance. Liebig considers that the similarity of their composition to that of the brain may serve to explain the operation of such medicines as Quina and Morphia. Such ideas as these are at the best purely hypothetical, and even as theories they seem to me to be untenable,--for what reasons I shall have to show when I consider these remedies. Liebig has hazarded several other explanations of a similar kind, of which the following is an example:--"The frightful effects of Sulphuretted Hydrogen and Hydrocyanic Acid are explained by the well-known action of these compounds on those of Iron, when Alkalies are present, and free Alkali is never absent in the blood." (_Organic Chemistry_, p. 274.) Now in the first place it is not proved that the complete abstraction of iron from the blood would occasion sudden death, though doubtless it is a necessary constituent of that fluid. Further, Prussic Acid acts on the superficial nerves as an Anodyne when applied externally, which it can hardly do by displacing iron. Besides, by parity of reasoning, Ammonia, or Benzoic or Cinnamic Acid, should precipitate iron, if present in the blood in the soluble state, and Sulphuric or Nitric Acid should dissolve it, if in the state of peroxide; and yet none of these agents are frightful poisons. It is not to be imagined that chemical solutions and decompositions of every kind are allowed to take effect in the human system in the same way as in the laboratory of the chemist, for there are in the former many disturbing and controlling causes which suffice to hold them in check. We may altogether conclude, that though the actions of many remedies may be partly elucidated by chemical considerations, it is impossible to account for the influence of all alike in this way. For at least the actions of nerve-medicines and of gland-medicines cannot be reasonably explained on any such hypothesis. 3. The most plausible explanations of the mode of operation of medicines have been founded on _vital_ or _general_ principles. By _vital_ I mean that these theories concern actions which could only take place in the living body. They may be termed _general_ principles, because the grounds on which they are based are neither mechanical nor chemical, but something different from both. The term _dynamical_ has sometimes been applied to an ill-understood vital action of this sort. Many different ideas have been broached to account thus for the action of medicines. Some, who have constructed very ingenious and plausible systems, have explained in different ways the operations of different groups of medicines. But when others have adopted a single inflexible hypothesis to account for the action of all alike, this is found, as might be supposed, to be of a very untenable character. I will now consider very briefly several such ideas; first, for the sake of clearness, dividing them into seven sections. I shall explain my meaning as I proceed. Different writers have supposed that the general operation of remedies in the cure of disease is conducted in these various ways. _a._ By degrees of stimulation. _b._ By counter-stimulation. _c._ By opposition. _d._ By similar agencies. _e._ By elimination. _f._ By alterative actions. _g._ By various counteractions. _a._ This idea has received the title of the "Brunonian Theory," from the name of its founder. It was promulgated by the famous Dr. John Brown at the close of the last century. He considered all diseases to arise from excessive or diminished "excitement." He was of opinion that all medicinal agents were stimulants, only that some acted so powerfully as to produce "indirect debility." These latter were to be used in sthenic, the others in asthenic disorders. But it is to be urged against this idea, that many sedatives produce no appreciable degree of "primary stimulation;" that alterative medicines are neither stimulant nor depressent; and that the actions of different therapeutic agents,--as, for example, of Opium, Mercury, and Rhubarb,--differ very much in quality, and not simply in degree, as Dr. Brown supposed. The principle, then, cannot be maintained. _b._ Rasori and other Italians adopted a similar idea about the commencement of this century, only that they supposed two contrary agencies, instead of variations in the degree of the same action, like the Brunonians. Giacomini classified medicines on this plan. The two classes of medicines are termed "Hypersthenics," and "Hyposthenics,"-- _i.e._ Stimulants, and Contra-stimulants, or Sedatives. These were to be used respectively in asthenic and in sthenic disorders. But this idea did not originate with these physicians. It prevails among the modern Hindoos, and seems to have been inculcated by certain medical writers of that nation in very remote times. (_On the Hindoo System of Medicine, by Dr. Wise_, 1845, p. 213.) _c._ The last-mentioned idea supposes only one kind of opposition, and therefore only two descriptions of diseased action. But a much more plausible notion than that is, that each particular disease or symptom is to be cured by administering a remedy which is capable of producing a contrary state. By this contrary condition the disorder is to be neutralized. This was the maxim of Hippocrates--[Greek: ta enantia tôn enantiôn estin iêmata]--"contraries are the remedies of contraries." (De Flatibus, par. iii.) On this principle we give purgatives in constipation, opium in diarrh[oe]a, sedatives to relieve pain, sudorifics to combat dryness of skin, etc. etc. But the rule becomes inapplicable when the cause of disease is so complicated that we cannot tell where to find a substance that shall directly oppose its agency. Besides, it cannot in theory be universally applied, for it takes no notice of treatment by evacuation or by revulsion. _d._ I am brought now to an idea which is directly opposed to the last. The rule of the disciples of Hahnemann is, "Similia similibus curantur"--or, diseases are to be cured by remedies which shall produce effects similar to them. Now if this were the case, the majority of disorders would be hopelessly incurable. We know of no medicines that are capable of producing such affections as ague, small-pox, or phthisis; and when such remedies are known, their employment would certainly be singularly objectionable. Who would administer Strychnia in tetanus, Opium in congestion of the brain, or irritants in Gastrodynia? The arguments alleged in support of the theory are of the most fallacious kind. For example, it is said that diaphoretics cured the sweating-sickness, and purgatives are given with advantage in diarrh[oe]a, on the "Hom[oe]opathic" principle. But it should be observed that the sweating in one case, and diarrh[oe]a in the other, are the attempts of nature to get rid of the disease by eliminating a poison; and that in seconding these attempts we are availing ourselves of an agency which does not resemble the disease, but is like to the natural mode of cure. Such treatment depends, in fact, upon the principle which will have to be considered next in order. The hom[oe]opathists would work a strange revolution in the Materia Medica.[13] Charcoal, Silica, and other substances commonly supposed to be inert, appear as remedies of wonderful efficacy. It is said that Belladonna produces a state like scarlatina, and also a condition resembling hydrophobia, and thus cures both of these disorders. Of these three propositions it is almost needless to say that all are equally erroneous. Further, an experimental trial of this principle was made by Andral on a large number of patients at the Académie in Paris, with the assistance of the hom[oe]opathists themselves. The medicines were carefully and fairly administered, but in no one instance were they successful. (_Medical Gazette_, vol. xv. p. 922.) _e._ The idea that diseases are to be cured by assisting nature to eliminate from the system the morbid material, is probably as old as medicine. It was one of the doctrines of Hippocrates; but long even before his time it appears to have been inculcated by a certain sect of old medical writers among the Hindoos. These last were the very earliest advocates of the humoral pathology. (_Dr. Wise_, _op. cit._ p. 212.) Dr. Thomas Sydenham, born in 1624, the contemporary of Harvey, and the most illustrious of the early English exponents of the humoral system, was probably the first in this country who clearly elaborated this view of the action of medicines by elimination; which has been more or less approved, though not so universally applied, by all who have lived since his time. Agreeing with Stahl in his view of the advantages of the "expectant" treatment of diseases, he thought it better to rely on the "vis medicatrix naturæ," than to make rash or violent attempts at a cure. He maintained that what we call a _disease_ was in fact "no more than a vigorous effort of nature to throw off the morbific matter, and thus recover the patient."[14] He proposed, therefore, that our efforts should be directed to assist nature to procure the evacuation of a poison, promoting its elimination by acting on the various secretions--as by purgatives, diaphoretics and such medicines. For he had noticed that in fevers and febrile disorders the crisis or turning-point was generally accompanied or preceded by an increase in one or more of these secretions, and he regarded this as an indication of the treatment to be pursued in all such cases. "That," said he, "appears to be the best method of curing acute diseases, which, after nature has pitched upon a certain kind of evacuation, assists her in promoting it, and so necessarily contributes to cure the distemper."[15] He further proposed, that in the treatment of chronic diseases, when nature herself was slow in procuring this evacuation, we should seek for _specific_ medicines, by which we might assist her in doing so, and thus effectually expel the morbific matter. This theory was reasonable and natural compared to those that followed it; but it was nearly extinguished and forgotten amid the war of opinions which was subsequently kindled by the _aphorisms_ of Boerhaave. About this time we find Dr. Pitcairn mixing up this idea with his mechanical notions, in a treatise "On the Cure of Fevers by Evacuation." Huxham also, in 1729, maintained similar principles. At the present day a more enlarged view is adopted. It is admitted that we may often assist these attempts of nature at a cure, and do good by the use, when thus needed, of evacuant medicines; but at the same time we must allow that there are many other advantageous modes of treatment,--that we may sometimes cut short a disease in the blood, or relieve a disorder by controlling vascular or nervous excitement, without resorting to elimination at all. _f._ M. Broussais was one of the first who rightly maintained that many medicines were of use by means of an _alterative_ or _revulsive_ action, by producing a distinct effect which diverted the attention of the system from the disease. His followers have classed remedies under three heads,--as _Stimulants_, _Debilitants_, and _Revulsives_. He maintained also some other peculiar ideas. Blood-medicines are commonly termed _Alteratives_, from the notion that they divert or alter the original disease by setting up in the system a peculiar process of their own. The term _Revulsive_ is especially applied to medicines which produce a powerful local effect, and are supposed so to occupy the attention of the system as to tend to cure the disease which formerly engaged it. Counter-irritants externally, and emetics among internal medicines, are generally admitted as revulsives. The idea of revulsion is a prominent feature in the arrangement of medicines adopted by Dr. Schultz, of Berlin, who adds to the above, Expectorants, Purgatives, Diuretics, and Sudorifics. He divides medicines into _Biolytics_, tending to dissolve life and structure; _Anabiotics_, which tend to stimulate the same; and _Agonistics_, tending to produce a "defensive" process, and acting by revulsion. Each class is again divided into those which affect the organs and nutrition in general; those which act on the blood; and those which particularly influence the nerves. I will give examples of each. SCHULTZ'S CLASSIFICATION. A. BIOLYTICA. (_Depressents._) 1. Plastilytica. (Mercury, Alteratives.) 2. Hæmatolytica. (Acids, Alkalies.) 3. Neurolytica. (Sedatives.) B. ANABIOTICA. (_Excitants._) 1. Plastibiotica. (Astringents.) 2. Hæmatobiotica. (Diffusible stimulants.) 3. Neurobiotica. (Opium, Strychnia.) C. AGONISTICA. (_Revulsives._) 1. Plastagonistica. (Purgatives, etc.) 2. Hæmatagonistica. (Irritants.) 3. Neuragonistica. (Emetics, Expectorants.) These divisions are again subdivided with great minuteness, according to their supposed operation. And yet it will be seen that, in spite of the hard names, there is an admirable simplicity in this arrangement. So many and so various are the statements made, and so plausible the theories involved, that I cannot accord to it here a fair consideration. I must object to it, however, that there is too much generalization, and, what is more important, that many medicines may cure diseases without necessarily causing either excitation or depression or acting distinctly by revulsion. The only principles of action admitted here are these three, the same which are adopted by the disciples of Broussais. To suppose that medicines acting on the glands are only of use as revulsives, that they have no influence on the blood, and are never engaged in purging the system of peccant or morbid matter, is surely incorrect in theory. Medicines of the first class, when given in proper dose and in fit cases, are not engaged in _destroying_ organization, nor is it invariably the case that such remedies as Mercury, Acids, and Alkalies act even as depressents, when given in moderation. Further, the lines of distinction are too arbitrary, and drawn with too much precision. The variations in the actions of different medicines are too many and too great to be thus easily accounted for, and we do not know enough about many of them to be able to define their operation so exactly. And there is no explanation at all given here of the special tendencies of some remedies, by which we are enabled to cure a great number of disorders. _g._ The Hippocratic maxim was a step towards a correct solution of the therapeutical operations of remedial agents. The humoral theory of Sydenham, and the threefold action supposed by Broussais, were further advances in the right direction. But these views were all too confined. Correct as far as they extended, they did not embrace the whole range of the subject; for it is impossible to explain by any one of them the operations of all medicines. Biassed by the satisfactory observation which he had made of the _modus operandi_ of particular medicines, and misled by the insufficiency of his knowledge, each of these writers was tempted to apply the view which was applicable to a certain set to all remedies alike. Once persuaded of its sufficiency, he easily found arguments by which to fortify both himself and others against any subsequent objections. The right course lies in a combination of these various theories, embracing what is true and discarding what is erroneous in each of them, and supplying what may seem to be wanting in the whole. None of these ideas being by itself perfect, the sounder reasoners of the present day are driven to suppose that there are _various_ different ways in which medicines may _counteract_, and thus cure, different diseases. This _counteraction_ is distinct from _contrary action_; it may be direct or indirect; and it allows of any action in a medicine, tending to restore health, except an effect similar to the disease. Such a view was adopted by Dr. Cullen, the well known Nosologist, who lectured at Edinburgh towards the close of the last century. He discarded all special and confined views of the operation of medicines, believing that they acted in many and various ways, all of which tended to the same end--to counteract the influence of the disorder. This is well exemplified in his admirable directions for the treatment of fever, in which he enjoined the use of a number of different remedies, varied according to the nature of the case, and progress of the symptoms.[16] Dr. Pereira, the most learned and acute of living English writers on this subject, appears, like many others, to prefer a wide explanation of this description. On such views my own statements are based. I suppose that a disease in the blood is to be met by agents in the blood, which directly or indirectly counteract it there; that disorders, generally temporary, which depend on nervous derangement, are to be benefited by remedies which affect the nerves; and in the same way that a laxity of muscular fibre, or a failure in a secretion, should be treated by agents which especially possess the property of restoring to a right condition such parts or functions. Concluding, then, that it is impossible to account clearly for the actions of most medicines on _Mechanical_ or on _Chemical_ principles, we are led to infer that their influence must for the most part be _vital_ in its nature--that it must be such as could only be exerted in the living body. Even then we are unable to fix upon any single rule or formula which shall be capable of accounting for the actions of all at once. So it seems that the only general explanation which we can offer of the _modus operandi_ of medicines in the cure of diseases, is to say that they operate by _various counteractions_. This, then, introduces my Third Chapter. CHAPTER III. ON THE GENERAL MODES OF ACTION OF THERAPEUTIC AGENTS INTRODUCED INTO THE STOMACH. The principal affirmations which I have to make on this subject are divisible into Ten Propositions, as seen in the Table of Contents. The first four of these concern the general conduct of medicines after their introduction into the stomach, and before their passage into the blood. Some broad rules are laid down by which the course which they take must be determined. The action of some few on the mucous membrane is also defined. The remaining six propositions treat of the subsequent behaviour of those medicines which pass into the blood and fluids of the body. Of these, the fifth specifies their general course. The sixth states that they may undergo certain changes in the system. And the concluding four treat of the various modes in which these agents may operate in the cure of disease. The first proposition lays down the great fundamental rule of the action of medicines through the medium of the blood and fluids. PROP. I.--_That the great majority of medicines must obtain entry into the blood, or internal fluids of the body, before their action can be manifested._ This is to say, that the mere contact of a medicine with the stomach is not in general sufficient for the production of its peculiar action. It will be seen that the only apparent exception to this rule consists of agents having a mere local action on the mucous membrane, for which simple contact is all that is required. Even when acting on any part of the system removed from this mucous surface, as when applied to the skin, it is necessary that the medicine pass away from it to enter the blood or internal fluids. In the great majority of instances it enters the blood directly. But we know that it would be sufficient for its operation if it were to enter through the chyle, or into the serous fluid which exists in the interstices of the tissues throughout the body. For by these it might at length be conducted to distant parts. This is what is meant by _internal fluids_. We are not just now concerned with the way in which this passage into the blood and fluids is obtained. It is by the process of absorption. The question of passage by absorption is treated in the second and third propositions. What we have now to decide is, whether a medicine acts by mere contact with the stomach, its influence being propagated to distant parts by means of the nerves; or by passage thence into the system, acting through the medium of the blood and fluids. I affirm that it operates in this latter way; and this is to be proved by four considerations, which we will consider in succession. _A medicine introduced into the system elsewhere acts in the same way as when introduced into the stomach._ This proves at least that contact with the mucous surface is not an essential requisite for the operation of a remedy. We may cause a medicine to be absorbed by the skin, or inject it directly into an opened vein. The result of this latter experiment proves not only that entry into a distant part of the system is sufficient for the action of a medicine, but that it will operate when introduced into the blood. Numberless proofs of this affirmation may be adduced. Tartar Emetic injected into the veins produces vomiting. Croton Oil rubbed on the surface of the abdomen causes purging. Mercurial ointment applied by friction to the skin will produce salivation. Extract of Belladonna applied to the temples causes dilatation of the pupil of the eye; and tincture of Opium dropped on the eyeball causes the pupil to contract. Ammonia inhaled as gas into the lungs will relieve fainting in the same way as when swallowed. The breathing of Prussic acid, causing its vapour to be applied to the pulmonary surface, is sufficient to kill. Prussic acid, dropped in a concentrated state into the eye of a dog, causes speedy death. Solution of Aconitina, applied to the skin, will produce numbness, and tingling of distant parts. Injection of Nux Vomica, or any powerful poison, into the veins, is rapidly followed by symptoms of poisoning, like those which would have followed its introduction into the stomach.[17] Thus contact with the stomach is not necessary, but introduction into the system any where is sufficient. But still, may not the poison in either case act by influencing the nerves? Even when it has entered the blood, it may not travel along in it, but act in a more direct way. So in the second part of the proof we must show that a remedy cannot act by an impression conducted from the surface of the stomach by means of the nerves. _The continuity of nerve is not necessary for the propagation of such effects; but vascular connexion is necessary._ This alone, if established, would be sufficient to prove that a medicine must be introduced into the circulation, in order to act on distant parts. When confined to a surface, it can operate on the remote part only by its contact with the superficial extremities of the nerves. For vascular connexion to be established, it must first enter the vessels. Many experiments have been made which demonstrate that the vessels are the only channel by which medicinal effects can be propagated. M. Magendie introduced some Woorara poison into the limb of a dog, which was only connected with the trunk by means of quills uniting the divided ends of the main vessels. It rapidly took effect. Having divided all the nerves and lymphatics in the intestine of another dog, he introduced into it some Nux Vomica, beyond the division. It quickly acted, and must again have done so through the vessels. Sir B. Brodie cut all the nerves of the anterior extremity of a rabbit, near the axilla, and then introduced Woorara into the foot. It rapidly acted.[18] Thus we see that vascular connexion is sufficient, and that nervous connexion is not necessary. By other similar trials it is found that vascular connexion is absolutely necessary, for when it is interrupted, the action cannot be propagated along a nerve. If, on introducing poison into an extremity, a cord be tightened round the limb above it so as to intercept the flow of blood, no effect is produced. It takes effect after the ligature is relaxed. Sir B. Brodie introduced Woorara into the leg of a dog, which was connected with the trunk only by means of the principal nerve, carefully dissected out. No effect followed. M. Ehbert found that poison would not act when applied to an amputated limb connected with the trunk by a nerve only. Thus vascular connexion is necessary; whereas continuity of nerve is not necessary, neither is it sufficient by itself.[19] Woorara poison is a substance which acts with great rapidity on the nervous system; and if its action cannot be propagated by means of the nerves, _à fortiori_ would it seem that slower poisons must act through the circulation. But, granting that it has been shown that introduction into the stomach is not necessary for the action of a medicine, and that when in the stomach medicines do not act by influencing the nerves, still it may be objected that the rule cannot possibly be universal. It may be urged that some poisons and medicines, as Hydrocyanic acid and Ammonia, act with such great rapidity, that we can only suppose their influence to be transmitted directly along a nerve-fibre to the nervous centre, because the process of passage in the blood to this distant part would be far too slow. This argument requires us to prove a third thing. _The circulation of the blood is sufficiently quick to account even for the operation of those poisons which act most rapidly by influencing the nerve-centres._ There is no poison whatever which acts so quickly on distant parts that the circulation cannot previously have had time to conduct it to them. By means of an instrument invented by M. Poisseuille, Dr. Blake found that a chemical substance traversed the whole circulation of a dog in nine seconds, and of a horse in twenty seconds.[20] The results of Hering were similar. M. Volkmann, in the tenth chapter of his work on Hæmadynamics, states, as the result of several experiments, that the whole circulation in an adult man occupies exactly 65.76 seconds. Now a poison that operated by nervous connexion would probably operate directly when it touched the stomach. This is not the case even with Hydrocyanic acid. This, the most sudden of all poisons, before it takes effect, allows sufficient time to elapse for the blood to conduct it to the brain. Blake made an interesting experiment upon it. He placed some on the tongue of a dog, having first fitted a tube into the larynx, so as to prevent the vapour from passing into the lungs. The effect did not commence until sixteen seconds had elapsed, and forty-five were required for its completion. This allowed of time for absorption. Thus it is proved that poisons act when introduced into the system at any point; that vascular connexion is required for this action; and that the rapidity of the circulation is in all cases quick enough to account for it. But this last is only a proof of _possibility_, and does not by itself show that a substance may not nevertheless act through the nerves. And to the experiments on nervous connexion some may object that no conclusions on this point can be drawn from trials made on isolated and exposed nerves. So we may imagine a person to be still incredulous as to the truth of the Proposition, that medicines must pass into the blood before they can act. But a fourth consideration will suffice to bring this probability as close as possible to a certainty. _The great majority of medicines have been detected in the blood, and found in the secretions formed out of it._ Having tried to prove that they must pass into the blood, if we find that they actually do so, we shall establish a stronger case. Isolated observations on this subject have been frequently made. Thus in 1847 Mr. Allen detected Daturia in the urine of a man poisoned by Stramonium. In 1824 M. Runge had discovered in the same way the principles of Henbane and Belladonna. M. Ragsky has lately detected Chloroform in the blood. (_Journal für Prakt. Chem. 1849._) Dr. Golding Bird observes that Indigo, when given for Epilepsy, has turned the urine blue; that Logwood also passes into it, and causes it to give a dark precipitate with solutions containing iron; and that during a course of Copaiba or Cubebs, a resin may be precipitated from it on the addition of Nitric Acid. If a medicine cannot be proved to pass into the blood or secretions, we cannot so certainly affirm that it does not act through the nerves. But the experiments of Tiedemann and Gmelin, and since then of Wöhler, have definitively settled this point. The former two have found the great majority of mineral, and many vegetable substances, in the blood of animals to which they had been administered. Thus, from these four considerations, we are strictly justified in concluding that a medicine must pass from the stomach into the blood before its action can be manifested. This action cannot then be conducted from the surface of the stomach through the agency of the nerves. Some experiments made by Dr. Garrod and others on the action of animal charcoal as an antidote, furnish again an additional confirmation of this fact. He finds that if a sufficient quantity of this absorbing agent be introduced into the stomach before time has been allowed for the passage of a medicine through the mucous membrane, then even such powerful nerve-medicines as Morphia and Strychnia, in very large doses, are prevented from taking effect. Yet before the contact of the charcoal they would have had time to act through the nerves, had they been capable of any such action. In the fifth Proposition the rule here laid down will have to be further extended. It will be shown that medicines, having already passed into the blood, must travel along in it so far as to reach the part of the system on which they act. Before concluding this question, a few remarks must be made on a subject which will be again referred to in the discussion of the Fourth Proposition. The proper and peculiar action of a medicine, by which I mean that action on the system which is immediately recognised as distinct from that of any other agent, cannot be exerted on distant parts from the stomach-surface, but requires the passage of the medicine into the circulation. But can any other action on distant parts be produced by the remedy while in the stomach? This is a different question, and must be answered in the affirmative. Suppose a Cantharides plaster be applied to the surface of the chest in a case of Pericarditis, so as to redden or blister the skin, absorption of the fluid in the pericardium may follow this application. But any other irritant would have done this. It is not the proper or peculiar action of Cantharides, but an operation of the nervous system which follows the local change. Such agents are said to act by _Counter-irritation_ or _Revulsion_, because it appears that, as a consequence of their action, the attention of the nervous system may be drawn off from a morbid process going on at some other part of the body. But it is only a consequence, and not a direct operation. Such an effect is no more the action of Cantharides than the healthy functions following recovery from sickness can be ascribed to the remedy which has cured the latter. Now some few medicines have a marked local action on the mucous surface of the stomach and intestines. (_Vide_ Prop. IV.) These, and these only, may, without passing into the blood, produce on distant parts an action of this kind by counter-irritation. Thus the operation of an irritant emetic may be followed by the arrest of some incipient inflammation, _e.g._ Ophthalmia. This revulsive action, when carried to an extreme, so powerfully impresses the nervous system, that it puts a stop to all other actions, and produces Syncope or Death. This extreme action is called _Shock_. Powerful corrosive poisons may effect this by a sudden destruction of the mucous surface, operating like a surgical injury. But such actions, not being the proper and characteristic operations of medicines, but rather attributable to a change in the relations of the nervous system, following a local impression, are not to be considered as exceptions to the above rule, that medicines cannot from the surface of the stomach or intestines propagate their influence to remote parts. PROP. II.--_That the great majority of medicines are capable of solution in the gastric or intestinal secretions, and pass without material change, by a process of absorption, through the coats of the stomach and intestines, to enter the capillaries of the Portal system of veins._ It has already been shown of medicines in general, that it is necessary for them to pass away from the mucous surface into the circulation. Mention has been made of their discovery in the blood by chemical means; and as we proceed it will be shown more particularly of different sets of medicines that each of them has been found in that fluid. Now, to gain entrance there, the medicine must first pass through the soft mucous membrane lining the stomach and intestine. This passage is performed by a process to which the names of _Absorption_ and _Endosmosis_ have been applied. Immediately outside this membrane, and between the tubes and cells which are formed by its involution, is a close net-work of very small veins, having thin and delicate walls. Now the same forces, whatever they be, which conduct the medicinal solution through the mucous membrane, cause it to pass on through the fine walls of these vessels. The two membranes, lying in such juxtaposition, are to all intents the same as one. Thus the medicine passes into the blood, and this is the only direct way by which it can gain entrance into it. These small veins, or capillaries, lead at length to the Mesenteric veins, which pour into the Portal vein, by which the blood proceeding from them is conducted into the Liver. The process of Absorption is the only mode by which remedies can thus enter the blood; we have now to consider what it is, and to show in what manner and by what agents different medicines are fitted to undergo it. The subject of this Proposition divides itself naturally into three parts. We shall have to consider--1. What is the nature, and what the function, of the gastric and intestinal secretions. 2. The laws of this process of Endosmotic absorption, and how they are fulfilled in this case; and, 3. The mode in which the great majority of medicines are reduced to a state of solution, which is necessary before they can be absorbed. The process of stomach-digestion has been cleared up of late years by the decisive experiments of Spallanzani and Réaumur, of Tiedemann and Gmelin, and of Dr. Beaumont of Canada. Immediately that a substance touches the mucous surface of the stomach it causes the copious outpouring of a thin fluid, which is secreted by a glandular apparatus. This gastric juice is highly acid, and contains besides a peculiar nitrogenous substance called Pepsin. Dr. Prout thought that the reaction was due to free Hydrochloric acid. But it seems more likely that it is due to Lactic acid. Such at least is the opinion entertained both by Liebig and Lehmann. Now the result of the action of this fluid is to dissolve down the solid materials of the food, or other substances presented to it, reducing them to a thin watery pulp. This pulp is then mainly absorbed; and that which is not taken up through the coat of the stomach is absorbed in the earlier portion of the intestinal canal. I shall have to treat of Aliments as one of the orders of Restorative Hæmatics. We are now concerned with medicines in general. The same juice is poured out to receive them. Such as are dissolved by it are immediately absorbed. Some other matters may be rendered soluble by the agency of the Bile and Pancreatic juice which are poured out into the middle of the Duodenum. The former is an alkaline fluid, containing carbonate of Soda. The Pancreatic juice is also said to be alkaline. That the stomach is absorbent may be proved by the experiment of placing a ligature round the intestine of a dog, just below the pylorus. It is then found that soluble substances placed in the stomach pass rapidly from it into the circulation. It is probable that all substances which are easily dissolved pass through the coats of the stomach. That the surface of the intestines is absorbent may be proved by the disappearance of enemata thrown into them. Liebig states that a solution of common salt, in the proportion of one part to eighty of water, disappeared so completely in the rectum that an evacuation one hour afterwards was found to contain no more than the usual proportion of salt. (_Animal Chemistry_, _p._ 77.) On the mucous surface of the small intestines are a number of small projections, called Villi. Within these are the origins of the Lacteals, a peculiar set of Lymphatic vessels, which are engaged in the absorption of chyle. This chyle is a thick fluid which is formed by the meeting of the Bile and Pancreatic juice with that part of the digested food which passes into the Duodenum. It is generally white, from the presence of fat. Now these lacteal vessels are no doubt absorbent, but are they ever engaged in the absorption of medicinal solutions? It seems that they are not in ordinary cases at all concerned in this; for three chief reasons. In the first place it appears from the researches of Bernard and others that the lacteal system is a special arrangement for the absorption of fatty substances, and that other matters, such as albuminous compounds, pass generally into the veins, and thence to the liver. Besides, it seems that these lacteal absorbents are only in action during the digestion of food, when the epithelium on the surface of each villus becomes loosened, in order to allow to the chyle an easier access to the lacteal within it.[21] So that it is likely that a small portion of a fluid or soluble substance would be insufficient to rouse them to action. And, inthe third place, direct experiments of a decisive kind have been made on this point. Magendie has found that the ligature of the lacteal trunks does not prevent the occurrence of poisoning from agents introduced into the bowels. And Tiedemann and Gmelin have carefully sought in the chyle for a number of different medicines administered to animals in their food, and have been unable to detect any of them there. So that, with the exception perhaps of fats and fixed oils, we may reasonably conclude that no medicinal substances pass into the system through the lacteals, but that all are absorbed by the veins or capillary vessels.[22] It seems probable that the Bile and Pancreatic juice may be engaged in reducing to a soluble state certain medicines that are insoluble in the Gastric secretion, and may thus procure the absorption of these substances by the veins of the intestinal canal. Having briefly considered the secretions which meet the medicine on its first entrance into the system, we are next to inquire into the manner in which this medicine gains admission into the blood. In the first place, it must be in a fluid state, or it cannot be absorbed at all. It will be most convenient to consider afterwards how different remedies are to be reduced to this condition. Now the force or process by which fluids are enabled to pass and repass through an animal membrane, has been named by Dutrochet _Endosmose_ and _Exosmose_, according as the current tends inwards or outwards. There are fluids on both sides of the membrane. The circumstances which determine their passage are mainly five. 1. _The densities of the liquids:_ other things being equal, the lighter of the two tends to pass through to the heavier, more than the heavier to the lighter. 2. _Their attraction for the intervening membrane._--That one passes through most which has the greatest affinity for the membrane. 3. _The affinity of the fluids for each other._--A fluid passes through more rapidly when it is readily taken up and dissolved by that on the opposite side. By virtue of the last two laws, but contrary to the first, water passes through to alcohol more rapidly than alcohol to water. 4. _The motion of the fluid on one side_ promotes the passage through of that on the other, because it is carried off as fast as it permeates the membrane. This also will cause endosmosis in defiance of the first law. This may be proved by a simple experiment. Let a large vein, cleanly dissected, be attached at one end to the stopcock of a vessel containing pure water. Let it then pass through a basin containing a strong solution of Ferrocyanide of Potassium, and let the other end hang over a jar filled with a solution of the Sesquichloride of Iron. If the cock be now turned, and water be allowed to pass through the vein into the vessel beyond, the solution of Iron will quickly acquire the tint of Prussian blue; for the heavy solution in the central vessel has passed through to the simple water of the vein, mainly by virtue of the motion of the latter. It will be seen directly that this is a matter of considerable importance. 5. The last law is, that _any pressure on the fluid on one side of the membrane_ has a powerful influence in determining the passage of the current from that side. (_Vide Liebig's Animal Chemistry_, p. 72; _Liebig on the Motion of the Juices_; and the _Lectures of Professor Matteucci of Pisa_.) The mucous membrane and the coat of the capillary vessel beyond it are probably subject to about the same physical conditions of absorption as those which are thus found by experiment to regulate the passage of fluids through dead animal membranes. As to the first condition, it is probable that the aliment or medicine which is digested, however solid and dense, may be diluted down by the gastric juice until the solution is of less specific gravity than the serum of the blood. With the second law we are not so much concerned, as the medicine after solution has generally no repulsion for the animal membrane. So also with the third, as the serum of the blood mixes readily with all watery fluids. The fourth, viz. the condition of motion, is of great importance; for by it the motion of the contents of the capillary vessels will tend powerfully to determine the passage through of the liquid on the other side. Fifthly, the influence of pressure on endosmosis is one which is certainly exerted in the case of the stomach and intestines, which are muscular, and during the process of digestion contract on their contents with considerable force. This contraction, together with the circulation of the blood in the capillaries, would doubtless be sufficient to determine the passage of the digested matters inwards, even in opposition to the first law.[23] Under the first proposition I have shown that the majority of medicines are absorbed into the system. It is now seen where and how they are absorbed. But it still remains to be seen what particular substances or classes of medicaments are thus taken into the blood, and whether while so passing they undergo any modifications. The following, then, are the chief classes which I believe to undergo solution and absorption in the intestinal canal. They comprise the great majority of all substances used either as food or medicine:-- 1. Mineral substances soluble in water. 2. Mineral substances soluble in acids. 3. Mineral substances soluble in alkalies. 4. Vegetable products soluble in water. 5. Animal and vegetable substances rendered soluble by the gastric juice. 6. Fatty and resinous substances soluble in alkali. 1. All soluble mineral substances--acids, alkalies, salts, and soluble compounds of the earths and metals--are absorbed in the stomach and intestines. The conditions and the process of absorption have been already stated. When solid they are first dissolved, when in a dense solution diluted down by the gastric fluid before they are absorbed. Thin watery liquids are quickly taken up. Motion on one side, and pressure on the other, hasten the process. I am not inclined to make any exception to this rule. This leads me to make some remarks on _the Endosmotic theory of the action of saline purgatives_. M. Poisseuille found that the serum of the blood would pass through an animal membrane to a solution of Sulphate of Soda of greater specific gravity. He thus concluded that an ordinary saline purgative of greater specific gravity than serum (1.028) acted by causing the passage of this serum outwards into the intestine, producing a watery evacuation. The theory was taken up by Liebig and Matteucci, and by Laveran and Millon. Dr. Pereira and Dr. Golding Bird have drawn some practical inferences from it. It is said that when a saline is absorbed it produces diuresis, and no purging; that when it purges it is not absorbed; that when given to act on the kidneys, the solution should be so diluted as to contain less than five per cent. of the solid; and when administered as a purgative, the specific gravity should be considerably above 1.028. Now I do not deny that a weak solution is more likely to pass off by the kidneys, and a dense one by the bowels; but I consider this due to the fact, that the kidneys are the proper emunctories of water, and of such matters as are soluble in it. But I believe that these solutions are equally absorbed, both heavy and weak, and that the purging or diuretic effect depends mainly on the quantity of the salt, as the kidneys will not eliminate beyond a certain amount of it. I must allege, to support this view of the question, firstly, some arguments _à priori_; and secondly, some experiments which I have made to satisfy myself. To consider first the former. Analogy is certainly against this theory. Other purgatives from the vegetable kingdom produce their effect when injected into the blood, and are yet often powerfully hydragogue. What effect on the process of endosmosis can be exerted by Castor or Croton oils, or by calcined Magnesia? On turning to what we know of the theory of digestive endosmosis, we find that the solid parts of the food are diluted down so as to be absorbed, and that the influence of pressure is to be taken into calculation. It was laid down by the great Boerhaave that a necessary requisite for the formation and absorption of chyle was the contractile force of the viscera. (_Van Sweiten's Comment_, vol. i. p. 290.) This, in fact, would press the fluid into the absorbent vessels, even if against the other endosmotic forces. Further, a fundamental principle was insisted on by Dutrochet--that even when the liquids on the two sides varied in density, they would both pass through to each other, though in different proportions. The ultimate result of this would be, that a heavy saline solution would be diluted down to the specific gravity of the serum, and would then pass through. This point I have illustrated in my first experiment. Thus it seems that my view is favoured by these physical laws. But even if it were not so, I should not be inclined to admit that all the endosmotic processes in the living body were regulated by merely physical tendencies. This cannot be the case with some of the secretions. The bile is of higher specific gravity than the serum of blood. Urine in health is lower, but in diabetes often much higher. The production of these secretions, differing in density from the serum of blood, would be inconsistent with the first law of endosmosis. Lastly, we find that in many known cases the theory which I am contesting does not hold good. Seidlitz water and sea-water are both known to be purgative. In both the specific gravity is _below_ that of the serum of blood. The first, according to Bergmann, has a density of 1.006. It contains in each pint 192.8 grains of solid matter. Out of this, 180 grains consist of Sulphate of Magnesia. Sea-water has a specific gravity of 1.026, and its solid contents are about 3.5 per cent. But Dr. G. Bird says that less than five per cent. of saline matter constitutes a liquid diuretic. These, then, are strong reasons against this idea considered merely as a theory. But it can readily be put to the proof. With this purpose I have made the following experiments. As far as they are concerned, they seem to show that salines are in all cases absorbed, and that whether they are subsequently excreted through the kidneys or by the bowels depends more on the quantity administered than on the degree of dilution of the dose. EXP. 1.--A sufficient quantity of white sugar was dissolved in four ounces of water to raise its specific gravity to 1.028, that of the serum of the blood. Two drachms of sulphate of magnesia were dissolved in another ounce of water, so that the solution measured nine fluid drachms, and had a density of 1.060. This heavier solution was introduced into an open wide tube, closed completely below by a clean piece of bladder. It was introduced into a small vessel containing the solution of sugar, and arranged so that the height of the two liquids should correspond. After three days, the inner solution measured two drachms more, and the specific gravity had sunk to 1.050. The outer solution, after making up exactly the loss by evaporation, was found to have risen in density to 1.040. On adding a small quantity each of the solutions of phosphate of soda and carbonate of ammonia, a copious precipitate took place, indicating the presence of magnesia. Thus it appeared that the fluids passed both ways, some of the heavy solution of magnesia finding its way through to the lighter solution of sugar. The tendency of this process was evidently to an equalization of their densities, both by endosmose one way and by exosmose the other. Thus, apparently, would it be with a saline purgative, and with the serum of the blood. EXP. 2.--Three drachms of Sulphate of Magnesia (a very mild purgative dose) were dissolved in ten ounces of water, and thus administered to a healthy young man. It produced, after some time, slight purging, and some diuresis. The urine, when tested, contained only a very little more than the usual quantity of magnesia. The quantity in the dose was less than five per cent. of the solution, and thus, according to the endosmotic theory, should have produced no purging. EXP. 3.--Six drachms of the same salt were given in eighteen ounces of water to the same patient. After a few hours, it caused very copious and long-continued watery purging. The urine did not seem to be increased, and contained no excess of magnesia. It seemed, that in spite of the dilution, the quantity of the salt was so large, that it could not pass off by the kidneys, and so was eliminated from the blood by the bowels, in the same way as other purgative medicines. (_Vide_ Chap. IV.) EXP. 4.--This trial was the reverse of the last. Two scruples of Acetate of Potash were dissolved in three drachms of water, and thus administered. The solution then contained about twenty per cent. of the salt. According to the endosmotic theory, it should have caused only slight purging, on account of its density. It did not do so, but produced diuresis. The dose was so small, that after absorption it was easily eliminated by the kidneys. These experiments are in favour of my views, and seem, as far as they go, to cast discredit on the theory of Poisseuille. It will be very easy to multiply them, so as to place the fact beyond a doubt.[24] This point being so far settled, and there being no physical reason why any other soluble mineral substance should not be absorbed--it being, moreover, proved, by repeated experiments, that they all pass into the blood, we therefore proceed to the second class of bodies capable of absorption. 2. Mineral substances soluble in acids.--It is apparent that if any insoluble substance will admit of easy solution in the fluids of the stomach and intestines, it may be brought to the condition of a soluble one and thus absorbed. Now the gastric juice is acid. This secretion has been variously ascribed to free hydrochloric, acetic, phosphoric, and lactic acids; also to an acid phosphate or lactate of magnesia. There seems to be most reason to conclude that it is lactic acid, which would be easily formed out of the constituents of the food.[25] But we have now only to regard the gastric juice as containing a free acid. This would reduce to solution the carbonates and oxides of all the metals; less perfectly when anhydrous, more easily when in the hydrated form. In this manner are absorbed the oxides of Iron and Silver, the carbonates of Lime and Magnesia, and other medicines of the same kind. They would be slightly modified, being absorbed in combination with the (lactic) acid of the stomach. In this they would differ somewhat from the substances already soluble, which would probably be absorbed unchanged, unless we except the alkalies and their carbonates, which might be similarly decomposed. Even these, if given in solution, would probably be absorbed faster than the gastric acid could be secreted to neutralize them. Other insoluble substances, such as calomel and metallic sulphurets, would be more or less dissolved by the action of this acid. But as a great part would necessarily escape its influence, being propelled onwards by the muscular contraction of the stomach, it follows that insoluble substances of this kind are much less active as medicines than similar compounds introduced in a soluble state. It is also likely that a certain quantity would be sufficient to exhaust for a time the acid gastric secretion. We now pass on to a third class of mineral products, which, though insoluble both in water and in acid, yet, being soluble in alkalies, appear to be in this way prepared by absorption. 3. Mineral bodies insoluble in water and in acid, but soluble in alkalies.--These remain unaffected by the action of the gastric juice, but on passing on as far as the centre of the duodenum, they meet with two alkaline fluids. These are the bile and the pancreatic juice. We know that some such insoluble bodies pass into the blood. It will be shown in the proof of the next Proposition, that they cannot do so without being first dissolved. Therefore, there must be in the intestinal canal something capable of thus dissolving them. For this purpose these two alkaline secretions are well adapted. As an example of such mineral bodies, of which there are not many, I may adduce sulphur. It unquestionably passes into the blood, and is found there in combination with alkalies, as a sulphuret or sulphate. It has been detected in the urine of those who were taking it, by Dr. Ronalds and others. It is possible that iodine, bromine, and some of the hydrated metallic oxides; may enter the blood in the same way. 4. Vegetable substances soluble in water.--These would be absorbed with more or less readiness according to their degree of solubility. They would probably be taken up in great part by the stomach. Some vegetable matters--as Lignine, or woody fibre, and Resins--are insoluble in water. Starch even is comparatively insoluble, and thus comes under another division, being probably one of those vegetable substances which are rendered soluble by the aid of the pepsin of the gastric juice. These soluble vegetable matters are of several kinds. Cane-sugar and grape-sugar are readily soluble. So also are the various vegetable acids. There is another class of bodies which is highly important in a medical point of view. These are the natural salts of the vegetable alkaloids, of which are constituted so many of the active principles of plants. In pharmaceutical operations we are enabled, by the judicious employment of different menstrua, to extract from the crude and inert mass these vegetable active principles, and thus to obtain in a concentrated form the medicinal power for which each plant is esteemed. This process is also performed in the stomach. By digestion and concoction, with or without the aid of acid, it is enabled to dissolve out these soluble and potent matters from the ligneous and bulky tissues which surround them. For though the alkaloids themselves are in general almost insoluble in water, yet their natural salts which occur in the vegetable kingdom are mostly very soluble. The most important of these salts are as follow. In Cinchona bark, the Kinates of Quina and Cinchonia. In Opium, the Bimeconates of Morphia and Codeia. In Nux Vomica, the Igasaurate of Strychnia. In Aconite, the Aconitate of Aconitina. In Colchicum and Sabadilla, the Supergallates of Colchicia and Veratria. There are some neutral soluble substances, not partaking of the nature of Alkalies. Thus we find in Ipecacuanha and Ionidium, Emetine; in Tea and Coffee, Caffeine; in Willow-bark, Salicine; and the soluble active principles of Senna, Aloes, and Gentian, are probably of the same nature. Many other alkaloids are known. Atropia in Belladonna, Daturia in Stramonium, and Hyoscyamia in Hyoscyamus, occur in combination with Malic acid. Conia in Hemlock, and Nicotia in Tobacco, are peculiar volatile alkalies containing no Oxygen: thus in two respects they resemble Ammonia. They too are soluble in water. Alcoholic and Ethereal fluids may be enumerated here as soluble products of the vegetable kingdom. Alcohol mixes with water to any extent; and one part of Ether is soluble in ten parts of water. Nitric Ether and Chloroform are also sufficiently soluble. So is Creosote, 1.25 parts of which dissolve in 100 of water. But this may be absorbed in another way, as will be seen presently. Volatile Oils and Turpentine come also under this head. They are all slightly soluble in water. The former, when given in small doses, are probably absorbed in this way. Turpentine, when given in large doses, may perhaps, by undergoing a change, come under the head of vegetable substances dissolved by alkalies. Camphor may be included here: one part is soluble in 1000 parts of water. The soluble gummy matters of plants, when added to the substances enumerated above, constitute an aggregate which is called the _watery extractive_ of a vegetable product: _i.e._ that part which is capable of being dissolved out of it by pure water. But there are other active parts of vegetables, such as oily and resinous matters, and some neutral acrid principles, which, before they can be dissolved by water, require the aid of an alkali. These will be considered separately. We now arrive at a fifth class of matters which are taken up by absorption. 5. Animal and vegetable products dissolved by the gastric juice.--The most important of these are the nitrogenous and nutritive constituents of the flesh of animals and of the parts of vegetables. Albumen, Glutine, Fibrine, and Caseine, are connected together as compounds of Proteine. Animal Fibrine, and the analogous Glutine of vegetables, are quite insoluble in water. Albumen and Caseine, though soluble, are immediately precipitated by acids. This is known to be at first effected by the gastric juice on their entry into the stomach. But the action of the gastric juice which contains an acid, and a peculiar nitrogenous material called Pepsin,--together with the temperature of the body, which is about 100°,--causes at length the gradual solution of these previously insoluble matters. This is found to take place out of the body when the above conditions are imitated with an artificial gastric fluid. The result of the process is a viscid fluid, which is then absorbed. The hard Gelatine of gristle and bone is not soluble in water at this temperature, but is readily soluble in the acid gastric juice. The Pepsine seems to be an important agent in this process, for an acid by itself is found to produce an imperfect solution. The nitrogenous matters thus digested and absorbed constitute that portion of the food which is of most use in the nutriment of the system; for the starchy compounds cannot be appropriated to the more solid tissues, although in some cases they may be converted into fat, as in herbivorous animals. (Liebig's _Animal Chemistry_, p. 113.) Starch itself is one of this class. Tiedemann and Gmelin found that by the action of the gastric juice it was slowly converted into Dextrine, which afterwards changed into grape sugar. Both of these are very soluble. From the researches of Bouchardat and others, it appears that other fluids, as the Saliva, the secretion of Brunner's glands, and the Pancreatic juice, possess also this power of converting starch into a more soluble compound. So that if any of it escape the action of the stomach-secretion, it is probably reduced to solution and absorbed in the small intestine. This change of starch is the first of a series of transformations, now ascertained, the ultimate result of which is its combustion and resolution into carbonic acid. Thus the nitrogenous compounds are called the _nutritive_, and the starchy materials the _calorifacient_ elements of the food. Considered as medicines, these substances belong to the division of Aliments. 6. We have already considered some few mineral substances which are absorbed by the aid of the free alkali contained in the Biliary and Pancreatic secretions.[26] The sixth kind of absorbed matters consists of some vegetable and animal products which can only be rendered soluble by a similar agency. Fats and oils, resinous matters, and some principles resembling resins, come under this head. Fats and fixed oils consist of acids, as Stearic, Margaric, and Oleic, insoluble in water, in combination with a base, Glycerine, which, when isolated, is soluble. With a free alkali such a fat forms a soluble salt, called a soap, and the base Glycerine is set free. In Man the Bile and Pancreatic juice are discharged together into the middle of the Duodenum. The fatty matters of the food are not absorbed before they meet with these secretions. But, after they have mixed with them, a milky fluid, called chyle, is formed, which is then taken up by the lacteal absorbents. It passes thence into the Thoracic duct, meeting there with an albuminous lymph, and is discharged at length into the general circulation at the junction of the left jugular and subclavian veins. M. Bernard, in some papers laid lately before the French Academy, states, as the result of his experiments, that the function of the Pancreatic juice is to reduce the fat to the condition of a white emulsion. He states that no milky chyle is formed when the Pancreatic ducts are tied in dogs. He considers it absolutely necessary that saccharine and albuminous matters should be absorbed by the capillaries of the Portal veins, and then pass through the liver; and believes that the sole function of the lacteals is to take up fat thus emulsified. His experiments and inferences have received the high sanction of M. Magendie. M. Frerichs has since affirmed that, whatever be the function of the Pancreatic juice, the Bile, by virtue of the alkali which it contains, is an indispensable agent in the absorption of fats. But M. Bernard has also found that the Pancreatic juice is always alkaline in health. Whatever be the particular function of the Bile, it may reasonably be concluded that the alkali contained in one or both of these fluids is engaged in the saponification and solution of the emulsified fats. If it were not for this, this alkali would seem without an object; and further, it is contrary to all we know of the process of absorption to suppose that oil could pass through to a watery fluid without the intervention of an alkali to reduce it to the soluble state. Thus it would seem likely that by means of the Pancreatic juice, with or without the aid of the Bile, fatty matters are first emulsified, in order to undergo an increase of surface, and then again saponified before they can be absorbed by the lacteal villi. The principal fixed oils which are used in medicine are Castor, Olive, Almond, Croton, and Cod oils. It is certainly to be regarded as a very beautiful arrangement in the animal economy, that those substances which are not acted upon by an acid fluid should be subsequently subjected to the action of a free alkali, so that by the successive action of these solvents, together with the peculiar process of stomach digestion, the great majority of substances taken into the system are dissolved and rendered fit for absorption. There seem to be other vegetable substances which are rendered soluble by means of alkali in the way already described. Resins form an important class of remedial agents, in which are comprised many Diuretics, Diaphoretics, and Purgatives. They consist chemically of peculiar acids, which, though themselves insoluble in water, combine with alkalies to form salts which are soluble. They are certainly in most cases absorbed. They have been found in the blood, and detected when passing out in the urine. From this last they may be precipitated by an acid, indicating that they are held in solution by an alkali. In large doses they may not be absorbed, but by irritating the surface of the intestinal canal, may act externally as Cathartics, and be expelled by the peristaltic action which they excite. But in small doses they enter the circulation in solution, and affect remote organs. The only way in which they can be dissolved is by means of the alkali of the two intestinal fluids. Among resinous medicines I may mention Catechu, Kino, Benzoin, Storax, Peru and Tolu, Copaiba, Guaiacum, the fetid resins, etc. Many purgative drugs, as Jalap, Scammony, and Gamboge, owe their efficacy to resin. There are moreover certain neutral acrid principles, similar in their nature to resins, which are soluble only in alkalies, and thus come under this head. Such are Cantharidin, Piperin, Pyrethrin, Colocynthin, Elaterin, and Capsicin, obtained from Cantharides, Pepper, Pyrethrum, Colocynth, Elaterium, and Capsicum. But it should be observed that some of these are soluble in Acetic acid; and if, as some have supposed, this acid exist in the gastric juice, then they might be dissolved in the stomach. We may add here some medicines which were enumerated also in a former division. Creosote, not very soluble in water, is easily dissolved in a free alkali. This substance also, like the last, is soluble in Acetic acid. Some volatile oils, especially Turpentine, display a marked tendency to oxidize into resins; and being themselves very sparingly soluble in water, may perhaps be dissolved after having undergone this change. Thus Turpentine changes into common Resin, which consists of two isomeric acids, Pinic and Sylvic. Turpentine = C_{20}H_{16} Pinic Acid = C_{20}H_{15}O_{2} and, C_{20}H_{16} + 3O = C_{20}H_{15}O_{2} + HO. or, Oil of Turpentine, with the addition of three atoms of Oxygen, produces Pinic acid, _i.e._ Resin, and an atom of water. Now Turpentine, when given in large quantities, irritates the surface of the intestinal canal in man, and is not absorbed. But in the horse very large doses are found to pass through the system into the urine. It is not likely that a large quantity should enter in solution in water. It seems more probable that it may first in some way become oxidized, and then dissolved as a resin. The action of turpentine resembles that of some other substances which contain resin, as Copaiba and Balsam of Peru. The resins thus dissolved would pass, like other solutions, through the mucous membrane of the intestines into the Portal capillaries. But of the fats and fixed oils it cannot be said to be _proved_ that they are absorbed in a state of solution, although such a conclusion is almost forced upon us by a consideration of the laws of endosmosis. They do not pass into the veins, but are taken up by the lacteal absorbents. They are _capable of solution_, and are thus not in that sense an exception to the rule of Prop. II. But in another sense they are an exception to it; for they do not pass directly into the veins, but through the lacteal system. It seems that the sole purpose of these lacteal vessels is to absorb fats. Thus it appears that all soluble substances, whether in the food or given as medicine, and in whatever manner rendered soluble, whether by acid, by alkali, or by stomach digestion, are absorbed in the stomach and intestines. All of them, with the exception of fatty matters, pass directly into the blood, traversing the mesenteric and Portal veins, to reach the liver. From this organ they pass on into the heart through the Vena cava inferior. I have shown also that they are mostly absorbed without material change. Supposing the stomach acid to be lactic, it would be too weak to displace mineral acids. It would, however, decompose a few insoluble matters, and combine with alkalies and their carbonates, forming salts which in the blood would again change into carbonates. (_Vide_ Prop. VI.) PROP. III.--_That those medicines which are completely insoluble in water, and in the gastric and intestinal juices, cannot gain entrance into the circulation._ It may at first sight be objected to this proposition, that fatty matters may probably enter the lacteals in an undissolved state. But this is not proved; and besides, whether dissolved or not, we know that they are soluble in one at least of the intestinal juices--viz. the Bile. So that they do not come under the above definition. We have just seen that many medicines which are given in the insoluble form are capable of being dissolved in the fluids of the intestinal canal. This so much reduces the list of perfectly insoluble medicines, that it is difficult to find any that come under such a definition. But Charcoal, the simple metals, woody fibre, and Nitrate of Bismuth, will serve as examples. Sulphate of Lead is often quoted as perfectly insoluble; but this is not the case. It is soluble in a solution of acetate of ammonia. This salt is contained in the perspiration. Thus the sulphate, when substituted for the carbonate in some lead works at Paris, proved fatal to the foreman, who died of colic. M. Flandin found that it poisoned a dog when rubbed into the skin as ointment. Even some metals may possibly be brought within the influence of weak acids when in a fine state of subdivision, as Mercury in blue-pill. Gold in a very fine powder has been used successfully in syphilis. Thus the list of insoluble substances is still further reduced. But there is no doubt that many substances which are slightly soluble in the intestinal fluids may in great part escape this solution, and pass out with the fæces just as they went in. To assert that the particles of an insoluble substance cannot pass through the homogeneous wall of the capillary or absorbent vessels, is merely to state what follows from an absolute physical law, and is generally admitted by physiologists. But even this fundamental datum has been lately attacked. Professor [OE]sterlen of Dorpat has been induced to affirm the possibility of the absorption of insoluble substances, from some experiments which he has made. Finely-powdered charcoal was administered to rabbits for some days. They were then killed, and globules of charcoal, measuring from 1/6000 to 1/3000 of an inch, were found in the blood of the Portal circulation. (_Zeitschrift für Rationelle Medizin_, 1847.) To obtain these results the microscope was used, a far less certain test in such matters than chemical analysis. [OE]sterlen reasonably concludes that, if charcoal can so pass, so also can any other insoluble substance. The necessity of solution could then at once be done away with, and the blood continually liable to admixture with all kinds of heterogeneous and crude materials. [OE]sterlen asserts further that he has found minute globules of mercury under the skin after rubbing in mercurial ointment. (_Journal für Praktische Chem._, No. IX. 1850.) Now, if these things were true, there could be no need to suppose the solution of insoluble active medicines, for they would be enabled without difficulty to pass through in an undissolved state. To test for myself the accuracy of such statements, I have made some experiments, the object of which is to discover if some of the most insoluble of our known remedies, which are yet known to obtain entry somehow into the blood, could do so while yet in the insoluble state. They are as follow:-- EXP. 1.--Ten grains of calomel were given to a large dog. It was killed after three hours, allowing this time for digestion. A considerable quantity of blood was collected from the Portal vein, and submitted to analysis to determine whether it contained any compound of Mercury in an insoluble form. The blood was dried and pulverized. The result was boiled for some time in water, and the insoluble part collected. It was dissolved in a small quantity of aqua regia, and the clear acid solution placed in a test tube. A slip of zinc foil was folded round a narrow plate made of gold foil, and introduced into the solution. A galvanic current being thus set up, the minutest quantity of mercury, if present, would have been deposited on the gold, so as to tarnish it. But this did not take place, and when at last the zinc was completely dissolved, the gold remained as bright as before. Thus there was _no_ Calomel, or compound of mercury, present in the insoluble form. EXP. 2.--Ten grains of strong mercurial ointment (containing half its weight of metallic mercury, with some oxide) were given to another dog. He was killed after the same time, and the Portal blood analyzed carefully in the same way, but here also _no_ mercurial compound was present in the insoluble form. EXP. 3.--To a third dog five grains of Oxide of Silver were administered. After three hours he was killed. The Portal blood was dried in a water-bath, and reduced to powder. This was boiled for some time in water, which was separated by filtration. Aqua regia was then boiled on the insoluble part. This would convert any silver into chloride. The acid was evaporated off as much as possible, and the solid remainder heated in a small porcelain crucible to dull redness. The result was powdered, and digested in liquor ammoniæ. It was filtered, and excess of nitric acid was added. There was not any precipitate. Had chloride of silver been present, it would have been dissolved by the ammonia, and precipitated by the acid. Thus no insoluble silver compound was contained in the blood analyzed. EXP. 4.--Ten grains of sulphur were administered in the same way to a fourth dog. On killing it and opening the body, the thoracic duct was found to be full. A considerable quantity of chyle was collected from it. Now, as it is asserted by some, that fat passes undissolved into the chyle, and as I believe that sulphur is digested in the neighbourhood of the bile duct, this chyle was chosen for analysis in preference to blood, as more likely to contain any insoluble sulphur. Besides, the blood would be less satisfactory, on account of the large quantity of albumen and fibrine contained in it, both of them also containing sulphur. The insoluble part of the chyle was obtained in the same manner as with the blood. It was then boiled in a small quantity of a weak solution of caustic potash. By this any free sulphur would be converted into a soluble sulphate of Potassium. The solution was filtered, and a few drops of a solution of the Nitro-prusside of Potassium added. (This is a salt lately discovered by Dr. Playfair. It is a delicate test for soluble sulphurets, with which it strikes a deep purple colour.) No change was produced. Therefore no insoluble sulphur was present in the chyle. The results of these experiments are thus in direct opposition to those of M. [OE]sterlen, and support a view of the question which seems even _à priori_ more philosophical and reasonable than that which he has adopted. I believe that no insoluble medicine can in any way gain entry into the blood without first undergoing solution in some way or another. PROP. IV.--_That some few remedial agents act locally on the mucous surface, either before absorption, or without being absorbed at all. That they are chiefly as follow:_-- _A. Irritant Emetics._ _B. Stomach Anæsthetics._ _C. Irritant Cathartics._ It has already been shown, during the consideration of the first proposition, that medicines which act on distant parts of the body must be, and are, absorbed before they can so act. This necessity for absorption has been shown to extend even to medicines which act most rapidly on the nervous system. If any medicines could produce a distant effect by a mere contact with the coats of the stomach, such a power would be ascribed to those stimulants and sedatives which, from the suddenness of their action, are called diffusible. Such are Hydrocyanic Acid and Ammonia. Their rapidity of action is to be ascribed to their volatility, whereby they spread over a large surface, and are almost _suddenly_ absorbed and transmitted through the blood. But Hydrocyanic Acid may be absorbed from any surface. It is poisonous when inhaled into the lungs. It rapidly causes death when dropped into the eye of an animal. So also the results of the inhalation of ammoniacal gas are the same as of the ingestion of its solution. I believe that the latter, on account of its diffusibility and rapid absorption, escapes neutralization by the stomach acid, and passes into the blood as free Ammonia. In the consideration of the first Proposition, I endeavoured to point out that though the proper action of a medicine could in no case be conducted, without absorption, from the mucous surface to a distant part of the system, yet that a remote action of another kind might occur as the result of a change in the nervous system produced by a powerful local impression. I stated that the term _Counter-irritation_ was employed to express this action, the nature of it being but ill understood. A powerful impression on any surface of the body, external or internal, seems to be capable of arresting and diverting, as it were, the attention of the system, and thus, for a time, of checking a morbid process. Frictions and Sinapisms act on the skin externally on this principle. So do Blisters and Issues; but they are not simply counter-irritants, for they also drain away the serum of the blood. It is not now within my province to consider such an action on the skin, any further than for the purpose of stating that similar local impressions on the mucous surface of the stomach and intestines are capable of operating on the same principle. We have then to consider what are the local actions that medicines are capable of producing on these surfaces. And first, it must be laid down as a rule, that all medicines, when given in excess, act as irritants on the stomach and intestines. This is more especially the case with mineral salts, with the bitter and astringent principles of vegetables, and with acrid and resinous matters. By irritating the stomach locally, they cause vomiting; by causing peristaltic action of the bowels, purging. Some of them are actually employed to produce these effects, and will be presently specified. The corrosive and narcotico-acrid poisons may produce by this local action a degree of irritation sufficient to cause death. In the case of the first, some erosion of the mucous surface may occur. By both kinds violent vomiting and purging is apt to be produced, and succeeded by symptoms of collapse. These last, however, are not _therapeutic_ agents, when in such doses. Antidotes, employed to counteract these poisons, are remedies which are given to act locally in extraordinary cases. There are three chief kinds of them; Demulcents, to sheath the irritated surface, and protect it from further injury; Emetics and Purgatives, to get rid of the poison; and chemical antidotes, to neutralize it or render it insoluble while in the stomach. With this last object, acids are given in alkaline, and alkalies in acid poisoning. The soluble salts of Lead may be precipitated and rendered insoluble by sulphuric acid or sulphates. Those of Mercury, Copper, and Zinc, by albumen. Tannic acid precipitates the vegetable alkaloids. There are some other special antidotes of the same kind. Let us now consider the three kinds of remedial agents in ordinary use, which are employed for the purpose of producing a local effect on the mucous surfaces, before absorption, or without absorption. _a. Irritant emetics._--Two kinds of medicines are employed to produce Vomiting,--specific emetics, and irritant emetics. The former act from the blood; the latter, by local irritation. In the same way that irritation of the external surface of the body will sometimes cause at the same time the _direct_ contraction of a neighbouring muscle, and the _reflex_ contraction of others at a distance, so does local irritation operate on the surface of the stomach. On the one hand the muscle of the stomach itself is caused to contract, so that, the pylorus being at the same time forcibly closed, it tends to expel its contents in the wrong direction. On the other hand, a large set of distant muscles is thrown into sudden action. First, a quick deep breath is taken by means of the inspiratory muscles. Then the aperture of the glottis is spasmodically closed, so that, the lungs being full, the diaphragm cannot be pushed upwards. Then immediately the abdominal muscles contract, and being unable to act on the diaphragm, they press on the stomach, emptying it forcibly of its contents. All this is by reflex action, and follows sympathetically the contractions of the stomach, co-operating with it, and resulting, like it, from irritation of the sensitive mucous surface.[27] Such is the action of an irritant emetic. Now, Tartar Emetic and Ipecacuanha do not act in this way. When injected into the blood elsewhere, in sufficient quantity, they are found to produce vomiting. They have also special actions on the heart and lungs, which are not possessed by merely irritant emetics. They seem to me to act specifically on the Vagus Nerve, which is supplied to these organs as well as to the stomach, and to cause vomiting by deranging its functions. By this action on the Vagus while in the blood, they excite, in a special way, the same reflex contractions which are produced, in the case of an irritant emetic, by irritation of the extremity of that nerve in the mucous membrane. They are thus Neurotics, or nerve-medicines. They are not gland-medicines; or, at least, there is no proof that they are excreted by the stomach, and thus they do not come under my definition of Eliminatives. All substances which touch the surface of the stomach cause it to pour out its secretion. Specific emetics cause nausea, even without vomiting, depressing the action of the heart by their influence over the Vagus nerve. Irritant emetics scarcely cause nausea, producing only a feeling of discomfort, arising from the inverted action of the stomach. The Sulphates of Zinc and of Copper; common Salt, and among vegetables, Mustard and Horse-radish, are used as irritant emetics. They cause, by contact and irritation, a large quantity of the gastric juice to be poured out. This, together with the emetic, and any contents of the stomach, is rejected. The process is not followed by much inconvenience. Such emetics are chiefly used when we wish to unload the stomach of any irritating or poisonous matters; but not when our object is to cause nausea, depression of the heart's action, or relaxation of the muscles. The violent action which they produce may possibly act on remote parts on the principle of counter-irritation. Thus emetics of various kinds are often administered in the early stages of inflammatory disorders, and have been known sometimes to cut them short. But such an effect is much more likely to be produced by a specific emetic, which adds to this counter-irritant action the production of nausea, by which the force of the heart is powerfully depressed, and the pulse reduced. Tartar Emetic, the most powerful of these specific agents, must doubtless be absorbed to a certain extent before it can produce its effect. Thus the important difference between the modes of operation of irritant and specific emetics is, that the former do not produce vomiting when injected into the blood, but act locally; whereas the latter act from the blood on the nerves. (_Vide Prop. VIII., Specific Sedatives._) _b. Stomach-Anæsthetics._--There is a class of medicines used in Gastrodynia which seem to act locally on the sentient nerves of the stomach, in the same way that Aconite acts on the superficial nerves of the skin. Although the majority of them are subsequently absorbed, yet, in order to exert this particular action, it is not necessary that they should pass beyond the substance of the stomach itself. They do not seem to have any special or peculiar tendencies towards the stomach nerves. But if introduced into the blood elsewhere, they would not pass the nerves of the stomach in so concentrated a form as when coming directly from the mouth, and thus would not be so useful as stomach-anæsthetics. Thus this action depends upon local contact, and is so far a local action. Hydrocyanic acid, Creosote, and Nitrate (also called Tris-Nitrate) of Bismuth, are the most useful of these medicines. The first two are subsequently absorbed, and pass into the blood. The third is a very insoluble salt. It acts also as an astringent on the mucous surface of the intestine, and is probably the only astringent which is not absorbed. Being insoluble, its action is quite confined to the mucous surface. It may be given safely in very large doses, (as [dram]ss, or even [dram]j.) and it is likely that its anæsthetic action may be in some part mechanical in nature, and depend upon its affording a mechanical sheath to the irritable and painful surface of the stomach. Hydrocyanic acid and Creosote,--general sedatives,--act locally as anodynes to the nerves of the stomach. _c. Irritant Cathartics._--As there are two kinds of emetics, differing in their mode of operation, so also do there seem to be two kinds of Cathartics. But the distinction between them is not exactly the same. As with the Emetics, one kind seem to act by topical irritation, exciting an outpouring of the intestinal secretions, and causing an expulsion of the contents by exciting peristaltic contraction. But Specific Emetics, which act from the blood, seem to produce their effect by influencing the nerve of the stomach; so that they are Neurotic medicines. Specific Cathartics act differently. They are truly Eliminatives. They exert no influence over nerves, but they operate by passing out of the blood through the intestinal glands. Like Specific Emetics, they must be first absorbed. I will not now enter into the theory of Elimination, which I shall have to consider afterwards, but I wish merely to distinguish between local action on a surface, and specific action on a gland, exerted from the blood. Many substances used as purgatives are capable of absorption, and are absorbed. But it seems that they are not fit to remain in the blood; and after passing round in the circulation, they are expelled by the depurative force at a point near to that at which they previously entered by the laws of absorption, namely, the mucous surface of the bowels. They are most commonly expelled by the glands of this surface somewhere in the lower or fæcal portion of the intestinal canal, which is more engaged in secretion, but less active in absorption, than the upper part. The increased secretion which they excite causes peristaltic action, which expels both it and them, so that they cannot again be absorbed. Such a specific Cathartic would be capable of acting thus if introduced into the system at any point. Castor Oil and Croton Oil, whether received into the stomach, or injected into the veins, or introduced into the system at any part, equally produce purging. So also do Rhubarb, Aloes, and Senna. The principles of these medicines have been detected in the blood by Tiedemann, Gmelin, and others. Colocynth and Elaterium have also been proved to act specifically.[28] It is to be inferred from analogy that other resinous Cathartics, as Jalap, Scammony, and Gamboge, must also act from the blood. It has also been shown that both from actual experiment, and from a consideration of the laws of the process of absorption, we must conclude that saline Cathartics are absorbed into the blood before they cause purging. But we have now to do with Cathartics that act by topical irritation. Which are they? I believe that the same resinous Cathartics which have the power of acting specifically, may have, especially when in large doses, a double action. It has been shown that resins are difficult of absorption; and whether they be absorbed or not, we know that they must irritate the intestinal surface, from the violent griping which often attends their operation. Thus Scammony does not act so well, and does not gripe, when the bowels are lined with mucus. Gamboge and Euphorbium are irritant in an extreme degree, and are therefore too dangerous for general use. The powder of Euphorbium resin has been used as an Errhine, for, by irritating the mucous membrane of the nose, it increases its secretion. This illustrates the operation of irritant Cathartics. A great part of the fæces is secreted by the mucous membrane of the bowel. This secretion a Cathartic may increase by mere contact and irritation; or, being also a specific agent, by absorption and elimination likewise.[29] Some Cathartics employed as Vermifuges, as the hairs of _Mucuna pruriens_, metallic Mercury, and Tin powder, cannot be absorbed at all, and must act solely and altogether by irritation. These Vermifuges, or Anthelmintics, are employed for a strictly local purpose--that of killing and expelling intestinal worms. Any powerful Cathartic may be used to expel them. But such an agent should generally be conjoined with a medicine that tends directly to kill the parasite; for after that it will be more easily dislodged. For this purpose the root of Male Fern, Kousso, and the bark of the root of Pomegranate, have been used with advantage in the case of tape-worm. Ascarides are situated low down in the intestine, and may be dislodged by the use of an enema, as of Salt. Turpentine is often very efficacious in cases of this kind, being at once a poison to the worms and a powerful irritant cathartic. I have already alluded to Nitrate of Bismuth, as seeming to be an astringent to the mucous surface of the intestine, although apparently incapable of absorption. It has been used with advantage in diarrh[oe]a, and is highly recommended by Dr. Theophilus Thompson in the diarrh[oe]a of Phthisis. But all other astringents are absorbed; and when they act on the mucous glands of the intestines, it is probably from the blood. It has been supposed by M. Poisseuille and others that the action of Opium in confining the bowels is to be attributed to a power of checking the process of endosmosis, said to be possessed by a solution of Morphia. I shall afterwards state my reasons for discrediting this explanation. (_Vide Chap. IV., Art. Opium._) Thus we have concluded the list of substances which seem to act locally on the mucous surface, without passing into the blood. Having previously endeavoured to explain the various modes in which medicines are absorbed and pass into the blood, and having now defined the action of some few before absorption, the greater part of our investigation remains still to be accomplished. The actions of medicines in the blood, and their various and complicated operations in the cure of diseases, have to be traced out, and, if possible, accounted for. The remaining six Propositions concern the behaviour of medicines after their passage into the blood. The first two of them are comparatively unimportant. The Fifth is merely an extension of the First Proposition,--in which the same rule is applied to the blood which was there proved of a surface,--and indeed follows in part from the latter. The Sixth Proposition defines three kinds of changes which certain medicines are liable to undergo during their stay in the system. PROP. V.--_That the medicine, when in the blood, must permeate the mass of the circulation, so far as may be required to reach the parts on which it tends to act._ _That there are two possible exceptions to this rule:_ _a. The production of sensation or pain at a distant point._ _b. The production of muscular contraction at a distant point._ We might already have concluded that, as a general rule, it is impossible for medicines to exert their primary action on a remote part by nervous or any other agency, but that they must actually reach the part which they affect by means of the circulation. The experiments, already quoted, of Magendie, Blake, Ehbert, and others, show that even those medicines and poisons which tend most powerfully to influence the nervous centres, cannot act by nervous connexion, or without being allowed to pass on in the blood. They must actually reach the brain, before they can act upon it. The circulation of the blood is sufficiently quick to allow of this. The action of nerve-medicines when applied to a part, being similar to that which follows their absorption, would alone render it highly probable that in the latter case they reached the part in the blood. Thus Morphia, Hydrocyanic Acid, Chloroform, and Aconite, benumb the superficial nerves: Belladonna dilates the pupil; and Strychnia augments muscular irritability; whether locally applied, or administered through the stomach. Neurotic medicines have even been detected after death in the parts and organs which they influence. Thus Alcohol has been found in the brain, and Lead in the spinal cord and muscles. From these various facts we may conclude that however near these remedies may be brought to that part of the nervous system over which their power extends, whether it be centre or periphery, they do not in general affect it, unless they are allowed to reach it. And what is proved of nerve-medicines holds good still more obviously with medicines that act on the blood, and on blood disorders. Nearly all of these have been found to exist in the blood, and to pervade the whole mass of the circulation, wherever at first introduced. The glands of the body form a third case in which we require proof of actual local access. This matter will be discussed when we have to consider the subject of Eliminative medicines, when I shall attempt to show that the majority of those medicines actually pass through and are excreted by the glands which they affect. When Mercury is chemically detected in the secretions of the liver and bowels; Sulphur in that of the skin; Turpentine and Copaiba in that of the kidneys; it is evident that these substances must have reached bodily the glandular organs to which their action is directed. Astringents are medicines which from the very nature of their action--apparently a chemical one--cannot operate at all without touching the muscular fibre, which they cause to become contracted. But in laying down this rule of the necessity of local access for the production of the primary[30] effect of a medicine, we must be careful that we do not make it too absolute. In saying that no action at all can be propagated by the agency of the nervous system, we do not make proper allowance for the vital properties of nerve-fibre. The vital nature of common nerve-fibre is such that two actions can be conducted along it;--an impulse producing sensation, or an impulse producing muscular action, at a distant point. It is known that an impression on the terminal extremity of a sensory nerve is capable of producing either sensation or motion at a distance, by what is called _reflex nervous action_. Though this impression must pass through the brain or spinal cord, yet these centres are not appreciably affected by it. Now it is possible, though it does not often happen, that the action of a medicine on the extremity of a nerve may cause this distant action, without reaching the part at which it is manifested. It may be positively affirmed that in no other case can the direct action of a medicine be conducted along a nerve. Having made allowance for the physiological characters of nerve, we must also take notice of the vital properties of muscular fibre. We sometimes find, especially in the case of unstriped muscle, that when one part of a muscular organ is caused to contract, a wave of contraction is propagated along the fibres; and this action may even be extended to a neighbouring muscle, either by contact or sympathy. In one or two cases it seems that muscular contraction may occur in this way as the result of the action of a medicine. We will now consider separately the two exceptional cases. _a._ _A medicine may occasionally produce pain or sensation at a distant part, without reaching that part._ We often find that a morbid action at one part of the body is capable of producing pain or uneasiness at another distant part by a reflex nervous action. We are familiar with instances of this among the symptoms of disease. The pain in the knee which occurs in disease of the hip-joint; in the left arm, in some cases of heart disease; and in the right shoulder, in disorders of the liver; are examples. Certain impressions on the surface of the stomach may cause such a reflex pain. Swallowing a piece of ice will sometimes produce pain over the brow; and it is likely that the headache which follows over-eating, or a large dose of a tonic medicine, may result in a similar way from mere irritation of the stomach. Any irritant, as a solution of Iron, Arsenic, or Zinc, will do the same. The action of a violent purgative will cause headache while it lasts. Although we cannot deny the possibility of other actions of the same kind, yet there are so few medicines which, in ordinary and safe doses, are capable of producing pain in any way, that it becomes difficult or impossible to adduce a satisfactory example of an agent which operates on distant parts in this manner when in the blood. _b._ _A medicine may occasionally produce muscular contraction at a distant part, without reaching that part._ This may be done in two ways; either by a reflex nervous action, or by a propagation of the contraction from one muscle to another in its neighbourhood. The first of these never results from the action of a medicine while in the blood; but it may follow an impression on a surface. Thus we have already seen that the irritation of the mucous membrane of the stomach, and probably of the filaments of the Vagus nerve distributed in it, which precedes the act of vomiting, may cause the contraction of the muscles of the abdomen. The propagation of contraction from one muscular organ to another appears to take place in the case of violent purgatives, particularly some, as Aloes and Savine, which act on the lowest portion of the large intestine, exciting it to a peristaltic contraction,--whose action may thus be extended to the contiguous Uterus in the female, causing it also to contract. This renders the employment of such medicines dangerous in cases of pregnancy, as tending to produce abortion. In other cases these agents may be useful; for by the irritation and congestion which follows this action on the Uterus, they may cause the appearance of the menstrual secretion when deficient or retained. This also is the result of an action on a surface. Now, though in such cases the action of a medicine seems to be continued from the part where it is situated to a distant point, there are certainly no authenticated examples of such an action by a remedy in the blood. Yet it would not be reasonable to deny the bare possibility of such a thing. But such instances are at all events rare, and, being cases of the manifestation of their vital properties by nerve and muscle, rather than of the proper action of a medicine, must not be considered to invalidate the above proposition, which, as a general rule, is of considerable importance. PROP. VI.--_That while in the blood, the medicine may undergo change, which in some cases may, in others may not, affect its influence. That these changes may be--_ _a._ _Of Combination._ _b._ _Of Reconstruction._ _c._ _Of Decomposition._ Before advancing to the consideration of the modes in which medicines operate in the cure of disease, it is of importance to mention that some of them are liable to undergo changes in the animal organism, because in particular cases these changes may materially affect their action, and in all cases they have some bearing upon it. With a view to this point I have divided these changes, somewhat arbitrarily, into three kinds,--of which the first does not hinder the effect of a medicine--the second may alter it slightly--and the third entirely changes or neutralizes it. Some of these change have to be considered more at length in the progress of the Essay, so that here I will only give an outline of them. _Changes of Combination._--The chief, and indeed almost the only way of detecting changes in medicines, is by taking notice of their effect upon the composition of the secretions. Now in the blood we have a slight excess of alkali; in the urine, an excess of acid. Acids and alkalies are often given as medicines; and as it is not right that there should be much excess of either in the blood, both are generally soon neutralized in the system, and reduced to salts. This may sometimes occur before absorption, but perhaps more often after it. Now, it may seem strange for me to say that this neutralization does not destroy their influence. But it evidently does not; for in being neutralized they diminish in the blood, and in the system generally, the quantity of basic or of acid matter, and thus tend to alter the reaction of the secretions. Though an acid may combine in the blood with Soda, or with salts of Soda, yet by so doing it causes an excess of some other acid, probably an animal acid, which, being set free, acts on the secretion of urine much in the same way that the first acid would have done. It is easier to render the urine alkaline than to make it acid, for two reasons; first, as I shall show hereafter, an acid may pass out through other glands besides the kidneys; and secondly, an alkali is not so easily neutralized, either before or after absorption, the blood being already more or less alkaline. A large quantity of acid would easily overcome the feeble reaction of the blood, and thus, by remaining free, Sulphuric and other acids are enabled to act as astringents on certain of the glands. Other changes of combination have already been shown to take place during the process of absorption. Alkalies and their carbonates are more or less neutralized by the stomach acid. Substances soluble in alkalies are probably absorbed in such solution. Calomel, Chalk, Magnesia, and metallic oxides, as well as other insoluble medicines, are taken up in the soluble form, in which only they are capable of acting. But we are now concerned with medicines in the blood. And here I must protest against the idea that all chemical affinities have free play in that liquid. If it were so, many of our most valuable medicines would be decomposed and rendered insoluble there. All the mineral salts would be precipitated by the free Soda in that fluid. Acetate of lead would be immediately decomposed by sulphates, and Nitrate of Silver precipitated by chlorides. It is probable that the vital forces, as well as the viscidity of the plasma, exert a retarding or controlling power over such chemical tendencies. Some substances are decomposed while passing out of the body. Decomposing matters in the intestines and in the saliva, cause the formation of Sulphuret of Iron, while chaly-beates are taken, which blackens the fæces; and of Sulphuret of Lead, when lead is taken for some time, producing the well known blue line on the gums. _Changes of Reconstruction._--The elements of a body may be disturbed in the system, and combined together anew, without any material or apparent alteration of its properties. Probably many changes of this kind occur, but only some isolated instances have been verified. Thus Tannic acid, acquiring Oxygen, changes into Gallic. Benzoic and Cinnamic acids are converted into Hippuric acid, which passes out in the urine. Turpentine changes into a volatile oil, which communicates to the urine an odour of violets. Ferridcyanide of Potassium changes in the system into Ferrocyanide. Some of these changes will be afterwards considered more at length. _Changes of decomposition._--By this I mean such a disarrangement of elements as shall neutralize or reverse the action of a medicine. There is free Oxygen in the blood, and the most important change to which all organic substances are liable there is _oxidation_. This probably occurs in many cases. It always takes place with the starchy elements of the food, and with those parts of the nitrogenous tissues that have done their work, and are preparing to be excreted from the body. By this oxidation Wöhler has proved that the alkaline salts with vegetable acids are changed in the blood into alkaline carbonates. From being first neutral, they become now alkaline in their reaction, and affect the urine in the same way as free alkalies. (_Vide Hæmatics, ord. Acida, Alkalia, Tonica, Solventia._) We have now to treat of the actions of medicines in the blood. These are recited in the four remaining Propositions. The seventh treats of Hæmatics, acting primarily in the blood. The eighth treats of Neurotics, passing from the blood to the nerves. The ninth of Astringents, passing to muscular fibre. The tenth and last treats of Eliminatives, which pass out of the body through the glands. PROP. VII.--_That a first class of medicines, called_ HÆMATICS, _act while in the blood, which they influence. That their action is permanent._ 1. _That of these, some, called_ RESTORATIVES, _act by supplying, or causing to be supplied, a material wanting, and may remain in the blood._ 2. _That others, called_ CATALYTICS, _act so as to counteract a morbid material or process, and must pass out of the body._ Supposing that a medicine has fairly passed into the blood, and circulates round with it, there are now two ways in which it may behave itself. In the first place, it may have a tendency towards some tissues or parts of the body, on which to exert its powers, as the nerves, or the glands, or muscular fibre, and may use the blood only as a vehicle by which most readily and easily to attain to these. Such are Neurotics, Astringents, and Eliminatives. They may not affect the blood, but they must pass through it. But there is another and still more important class of medicines, whose action is particularly directed towards the blood itself. The blood, after their action, is different from what it was before. It may be a change for the better or for the worse; but there certainly is a change. Medical authors, with few exceptions, have been very backward to acknowledge the existence of medicines of this description. But even those who would fain have classed all medicines as stimulants or sedatives, differing only in the kind or degree of their action on the nervous system, have in many cases been obliged to confess that there is a set of remedies which they call "Alteratives," whose action, though slower, is more certain and more durable than that of the former. It is allowed that they alter the condition of the blood. To suppose that they do so by first influencing the nerves, is to adopt a circuitous and uncalled-for explanation. It is proved that they pass into the blood. It is known that when actually applied to nerves, they do not affect them. From these considerations merely, without further evidence, it would seem tolerably clear that they act by influencing the blood itself, simply and solely. But this it will be my business to prove more at length directly. Such medicines, then, I have designated Hæmatics, a simple and expressive term which has been used by others before me. It is obviously necessary that a medicine of this class should be absorbed. Now some of them tend in the end to act on the nerves or on the glands, not merely indirectly, but by bodily contact. But, whatever their subsequent action, they exert a primary and apparent influence on the blood itself. A little reflection will convince us that these remedies are more efficient than any others that can be selected out of the armory of physic. It is easy, and satisfactory for the time, to allay nervous excitement by employing a sedative, or by using a stimulant to communicate to the system a temporary strength. It is easy to knock down an inflammation, or to evacuate morbid humours, by stirring up the glands with a powerful eliminative. But these are all at the best but temporary measures. Unless the exigency be also of a temporary character, the disorder may soon return with unabated violence; again is the patient bowed down by its strong hand; again is the fatal termination seen looming in the distance but too distinctly. Then has the physician to call to his aid more potent means, remedies of more permanent and certain efficacy. The disease is in the blood--ever circulating, breeding, and destroying. It is there that it must be met; let the physician strike boldly and warily there, if he would effect a cure. These medicines, then, act in the blood. How they do so, and in what way they prove of use in the cure of disease, I shall next have to show, while attempting to prove the proposition in which I have briefly stated this mode of operation. Hæmatics are very numerous, and very important: I shall thus devote some space to their consideration. But I must first lay down a broad distinction between the two divisions of Hæmatic medicines. The diseases in which they are used appear all to originate in the blood, however they may manifest themselves. Now some of these diseases originate in a want of some principle or constituent of the blood, which want causes an aberration of the vital functions. Thus, in anæmia, there is a deficiency of the Hæmatosin of the blood corpuscles. In simple debility a want of a similar nature probably exists. In rheumatic fever and other disorders an excess of acid is formed and eliminated, possibly from a want of the alkali by which it should be neutralized. In common inflammatory fever there is an abnormal oxidation of the Proteinaceous compounds, possibly arising, as we shall see hereafter, from a failure of some principles which are the proper food of the oxygen. In diseases causing urinary deposits there is a want of those principles which should naturally retain them in solution. In typhoid fever there is said to be an excess of basic matter, and a deficiency of acid, in the blood. In pulmonary phthisis there is a deficiency of fat in the system. In the latter stage of malignant cholera there is an absence of watery particles in the blood. Some suppose that in scurvy there is a want of the salts of Potash in the blood. These diseases, then, in some of which the want is proved, in others partly hypothetical, may be treated by medicines which supply the deficient matter, and thus restore a right state of things. They may supply it to the blood directly, or else cause it to be generated there. The former of these modes of restoration seems to be the most frequent, and may possibly, when we shall know more of such matters, be found to occur in all cases. This division of Hæmatics I have named Restoratives (Restaurantia.) Their action, as we shall see, is in some cases apparent, in others more obscure. They restore the blood directly to its proper condition, if there is only a deficiency, but they do not in general seem to have the power of counteracting any morbid or active material that may exist in the blood. Nor do they, except in large doses, exert themselves any peculiar action on that fluid. In these respects they differ from the other division of Hæmatics. They also differ in another important character. Each Restorative has in healthy blood a substance analogous to, or identical with itself: it replaces this when deficient. Not so with other Hæmatics. There is in general nothing in the blood corresponding to them--or if there be in some cases, they are not introduced with the intention of supplying its wants. Thus Restoratives may remain in the system, and are intended so to do; but these may not remain. They must pass out. In so doing they come under the head of Eliminatives, or that of Astringents. This is their secondary action, distinct from their primary and most important operation. What then is the curative action of these remedies? A large class of diseases depends on the presence in the blood of a morbid material, or, what amounts to the same thing, on the constant working of a morbid process in that fluid. Some of these, as the eruptive fevers, will run a certain course, and then come to an end. These we cannot generally stop, but can only alleviate. But others, more in number, and more commonly met with, tend naturally to run on for an indefinite period, unless by any means we can arrest their progress. Some depend on a contagious virus, communicable from one person to another, as Syphilis. Some, as Ague, are dependent on atmospheric or terrestrial influences. Others are due to some derangement of the secondary assimilative processes, as Scrofula, Scurvy, Gout, and Rheumatism. Others again, to causes that are ill understood, as convulsive disorders and skin diseases. Lastly, some may be caused in many different ways, as common inflammatory fever. Now the object in the treatment of such diseases is to obtain in each case some remedy, that shall be able to counteract this process, something that shall destroy the morbid influence at work, and thus restore health. Medicines that are used with this intention form the second division of Hæmatics, which I have named Catalytics (Catalytica,) from a Greek verb signifying to destroy or to unbind. Now though I have a probable hypothesis to advance as to the action of some of these, I would not have this considered as more than hypothetical. I would not speak positively of the action of any one of them, any more than to say that each of them tends to neutralize one or more particular morbid poisons. Some have tried to give a general explanation of their action, and have talked of it as if it were easily understood by their known properties. I am not of their opinion; and when I speak of Catalytics, I shall give my reasons for disagreeing with them. Now each Catalytic has peculiarities and affinities that distinguish it from all others. I have not thought that I could arrange them more truthfully than by subdividing them according to diseases which they tend to counteract. How inadequately is the action of Mercury and of Iodine expressed by calling them special stimulants, alteratives, or absorbents! Is it not better and more correct to say at once that Mercury is useful in checking inflammation in general, and in counteracting the poison of Syphilis in particular? and that Iodine is effective in secondary forms of the latter disorder, as well as in Scrofula? These medicines, then, are specifics, in so far as they are particularly useful in certain disorders, and in those excel other remedies; but they are not, in the vulgar acceptation of that term, the only medicines which can be employed in such a disease, nor is their use to be restricted to it alone. I have already said that a Catalytic tends of itself to work out a peculiar process in the blood. For this reason their administration in health generally does harm. They have nothing in the blood corresponding to them; or if so, they are not introduced to supply its want. Thus they must eventually pass out of the body. Before doing so, some may act on the nerves. While so passing out, they may, as I have said, act either as Astringents or Eliminatives on the glands. Under these heads their secondary action will be subsequently considered. Being thus foreign to the blood, Catalytics do not remain there to supply a want; but just long enough to counteract a morbid action, and are then excreted. Such is the difference between Restorative and Catalytic medicines. Although so far as this their action is sufficiently distinct, yet some care is required in separating the remedies in one division from those in the other. Sometimes both kinds are used in the same disorder. For whenever the action of a morbid poison causes any derangement in the proportion of the normal constituents of the blood, a Restorative may become of use to supply this defect. Thus a cancerous or scrofulous condition may cause a deficiency in the red colouring matter of the blood, which may be supplied by Iron. When, as in Gout and Rheumatism, there is an excess of acid in the system, partly due to an absence of that basic matter which should be present to neutralize it, this may be restored by an alkaline remedy. In both of these cases a Restorative may be used in a disease which depends on a morbid agency. But other remedies, Catalytic in their action, are of more direct use in such disorders. They counteract the original poison, and striking at the root of the evil, instead of correcting the consequences, they are more likely to eradicate the disease. Some medicines come under both heads, acting in different ways in different cases. Thus Potash may be a Restorative in Rheumatism, but a Catalytic in Scrofula. The operation of some particular agents is rather obscure. I shall have to show how it seems to me that the vegetable acids may act as Restoratives in fevers; and also to explain why, of those medicines which are used in Intermittents, I have placed Quina among Restoratives, and Arsenic with Catalytics. It may be remarked that the fact that Catalytic medicines produce of themselves distinct actions in the blood has proved a stumbling-block to the disciples of M. Hahnemann. For in some few cases their action may, to a certain extent, simulate the disease which they tend to cure, and has thus been confounded with it by this imaginative observer. This partial resemblance is probably due to the fact that both disease and remedy produce a series of changes in the same set of particles in the blood. If it were not so, the remedy could not meet the disease. It would be out of its province, as not acting at all in the same sphere. But that the actions are essentially different is sufficiently proved by the fact that they counteract each other. The remedy, moreover, is often of equal efficacy in other different disorders. It has been shown in Chapter II., that with regard to Eliminative medicines, the Hom[oe]opathic theory is founded on a misapprehension of facts. It must not be inferred, from what has been said on the importance of blood-medicines, that I am disposed to agree with those who would account for all diseases by some fault in the humours of the body. For though we know that many cases of convulsive disorder, as of Hysteria, Chorea, and Epilepsy, may be reasonably accounted for by supposing the existence of a wrong in the blood, which has affected the nervous system,--yet there are doubtless many nervous affections which are primarily independent of the blood, which can only be treated by Neurotic medicines, and even then often without benefit. Thus far I have chiefly dealt in assertions on the subject of Hæmatic medicines, but I am now about to attempt a thing which is more difficult, that is, positive proof. I shall treat separately of Restoratives and Catalytics; each division will be divided into certain distinct orders of medicines; and of each of these orders in turn I shall attempt to prove what is laid down concisely in Proposition VII. To simplify this proof, that part of the Proposition which relates to Restoratives will be divided first into a number of minor propositions, which, taken together, imply the original one. Each must be shortly proved applicable to each order of Restoratives. The same will be subsequently done with Catalytics. Having sustained the original proposition to my own satisfaction, I shall, in some cases, venture to offer an additional hypothesis--only as hypothetical--on the action of particular medicines. Let us now proceed to the consideration of the first division of Hæmatic medicines. RESTORATIVES. The general name given to the medicines in this division is founded upon a fact relative to their action, which will be acknowledged of most that I have here included--namely, that they restore to the blood certain materials in which it is deficient.[31] I will divide them into six orders, which are all distinct and characteristic in their mode of action. RESTAURANTIA. Ord. 1. Alimenta. Ord. 2. Acida. Ord. 3. Alkalia. Ord. 4. Tonica. Ord. 5. Chalybeata. Ord. 6. Solventia. On reverting to Proposition VII., which treats of the action of the first class of medicines, it will be seen that what has been there stated with respect to the action of Restoratives resolves itself into the following simple affirmations or minor propositions. _m. p._ 1.--That they act in the blood, and that their effect is permanent. _m. p._ 2.--That there are naturally in the blood substances which resemble or coincide with them. _m. p._ 3.--That they are not of necessity excreted, but may remain in the blood. _m. p._ 4.--That they are of use when a disease depends on the want of one or more materials in the blood. It will be seen that the first minor proposition affirms them to be Hæmatic medicines, according to the definition given before. The second is required; for if there were not a necessity in the blood for substances like them, they could supply nothing. The third also is necessary, for if they were excreted in all cases, it is evident that their Restorative action could not be lasting. An exception must be made in the case of those that are used to supply something which is necessary in order that a secretion may be properly elaborated. Medicines of the Sixth Order are particularly used with this intent; as also some acids and alkalies. But these are not repugnant to the blood, like Catalytics. In the fourth place it is affirmed that being thus fitted for the blood, and allowed to remain in it, they tend to cure a disease which depends on the want of a substance similar in nature to themselves. After giving a brief account of each of the orders of Restoratives, it will be my object to prove that these affirmations are severally applicable to each of them. ORD. I. ALIMENTS. An article of food is the simplest form, and in fact the type, of all medicines of this division. Out of the materials of the food the whole blood is constantly elaborated, and all the tissues are constructed. Aliments were divided by Dr. Prout into four kinds:--(1) Aqueous; (2) Albuminous; (3) Saccharine; (4) Oleaginous. These kinds differ much in chemical conformation. The second kind alone contain Nitrogen. The last two are both called _carbonaceous_; but those of the fourth kind contain more Carbon than those of the third. The following will serve to illustrate the differences in the chemical composition of these groups. 1. Water = H O 2. Proteine = C_{40}H_{31}N_{5}O_{12} 3. Starch = C_{10}H_{10} O_{10} 4. Stearic Acid = C_{68}H_{68}O_{7} Water is useful in dissolving the other elements, and reducing them to a state of solution which is fitted for the formation of blood, and of the other fluids of the body. We have already seen in what way these various matters are dissolved and absorbed in the _primæ viæ_, and how they pass into the circulation; that Proteinaceous and Saccharine matters pass into the capillaries of the Portal vein, and thence onwards through the liver; and that fatty matters are reduced to a kind of emulsion by the intestinal juices, and pass through the lacteals into the thoracic duct, by which they are conducted into the circulation at large. What then are the chief uses for which these matters are required in the system, and what great functions do they fulfil? The nitrogenous Aliments are needed particularly to supply the growth and waste of the muscular and nervous tissues, which both contain Nitrogen; as also do all the parts of the body, excepting Fat. This waste is continually going on. It depends upon the fact that, after having lasted a certain time, the particles of all these tissues are gradually displaced, oxidized, and conveyed away out of the blood into the urine and other secretions. In the urine these waste matters are found as Urea, Uric acid, and Kreatine. The starchy and saccharine parts of the food are destined to pass through a series of changes, which ends also in their being burnt and oxidized, maintaining the animal heat, and forming Carbonic acid. Starch passes first into grape-sugar, by taking into itself two atoms of water, becoming C_{12}H_{12}O_{12}. The Ptyaline of Saliva, Pepsin of the gastric juice, and some similar principle in the Pancreatic fluid, are all capable of causing this first transformation. This sugar is more soluble than Starch. When in the blood, it undergoes a further change, the nature of which is not so clear. It is supposed to be into Lactic acid (C_{6}H_{5}O_{5}, HO_{7}) whose equivalent number is just half that of anhydrous grape-sugar, so that one atom of the latter may become two of the former. This important compound was found by Berzelius, in 1807, to exist constantly in the juice of muscle, as well as in the urine and sweat. (_Annuaire_, 1848, p. 347.) Liebig at first controverted this, but in 1847 he assented to the statement of Berzelius, which had already been further confirmed by the experiments of M. Pelouze. Many modern chemists, among whom may be mentioned Dr. Bence Jones,[32] consider that Lactic acid, or some compound nearly resembling it, is formed at this step of the process of changes connected with the function of respiration. The acid next combines with free Soda, existing in the blood; and this salt is oxidized into Carbonate of Soda and water, just as a Tartrate or a Citrate might be. (_Vide_ page 127.) This has been ascertained by Magnus and Dumas. Fatty matters are used in the production and renovation of the adipose tissues; and may also, like the last, be burnt and oxidized to support the animal heat. As a general rule, the diet of a man in health should contain a due proportion of all four kinds of food; for each one of them is essential, and has its proper function in the system. The albuminous material cannot be dispensed with; and is also the only food which will suffice by itself to sustain life. The mode in which it can adapt itself to perform the office of the other varieties of food was ill understood, until explained by the researches of M. Bernard. From some experiments detailed in a paper read before the Académie Française in 1848, he concluded that the liver was capable of actually producing sugar and fat out of Proteine compounds. For he found sugar to exist in the substance of the liver when none was to be detected in the blood of the Portal vein which proceeds to it. His results have been mainly confirmed by M. Lehmann. M. Bernard states further, that the action of the liver is in some way essential to the assimilation of saccharine matters; for he has found that when sugar is injected into the veins beyond the liver, it passes out unaltered in the urine. Thus the process of assimilation, whether of albuminous or of saccharine matters, is not so easy and so simple a thing as might at first be imagined. The study of this process is of great importance; and it appears to afford us a clue to the causation of certain disorders of the blood, of which I shall have to speak hereafter. Upon the regulation of diet, one of the most important of the duties that devolve upon the medical man, it is not my purpose to make more than a few observations. All kinds of food are less required by the system in inflammatory and febrile disorders; and should then be administered sparingly, or wholly denied, according to the severity of the case. But in Typhus fever long abstinence would be dangerous; the patient is in peril from extreme weakness and inanition, and, being often totally unconscious of his natural wants, requires to be carefully sustained by constant and small increments of animal and farinaceous food. Water may be given largely whenever we wish to increase the amount of any of the fluid secretions; as the urine, to render less likely the deposition of gravel; or the perspiration, when it is desirable to promote it in fevers or other disorders. Albuminous food is always necessary in health, and is contained not only in the flesh of animals, but in vegetable substances in their natural condition. It is recommended to restrict it in the management of gouty or plethoric patients. On the other hand, animal is more easily digested than vegetable food in many cases of dyspepsia. In Diabetes mellitus, when a large quantity of sugar is excreted in the urine, it is a common practice to confine the patient to a diet of meat and gluten bread. This latter is a tough horny material, prepared from flour from which the starch has been separated by washing. It is thought that if no starch be given, no sugar can be formed; but it is found that, though both the amount of urine and the quantity of sugar in it are diminished by this plan, yet the latter does not wholly disappear. This may be easily accounted for, if we admit that sugar may be formed from albumen. Water should be given sparingly in this disease; for the more a patient drinks, the more urine he passes, and all of the same high specific gravity. Fat may be given in Diabetes, for it is not proved that it can be converted into sugar; but as the contrary seems to be the case with albumen, and it being impossible to withhold this, the cure of the patient by mere dieting may be considered almost hopeless. We have seen that Starchy and saccharine matters form an important element of the food; and that, by combining in the blood with the Oxygen absorbed in the respiratory process, they are of use in maintaining the heat of the body. In some constitutions there is a peculiar tendency to an abnormal oxidation of these materials into Oxalic acid. It appears likely that Cane-sugar is more liable to this change than Grape-sugar, although it may occur with the latter. Thus the patient is sometimes benefited by an injunction to abstain entirely from this article of food. Fatty matters need not be given where there is organic disease of the Pancreas; as in that case they are not rightly digested. This is a rare case. They are sometimes repugnant to the stomach, from other causes. The application of oily substances to the cure of Phthisis is a matter of considerable importance. Of late years Cod-liver oil has been used with more success than any other medicine, both as a prophylactic, and as a curative agent in this disease. When this remedy is considered separately in Chap. IV., mention will be made of several theories which have been propounded to account for its mode of operation. Liebig's idea that there is in Phthisis an excess of Oxygen in the system, would, if sufficiently supported, serve to explain its action when considered simply as oil. This Oxygen would consume the Carbon and Hydrogen in the food, and prevent the accumulation of fat. (_Liebig's Animal Chemistry_, part i. p. 126.) A supply of oil might then serve to restore this fat, and afford a sufficient pabulum to the devouring element. Thus an attention to diet is of great importance in the cure and alleviation of different diseases; for by this means we are enabled, within a certain limit, to regulate and control the composition of the blood, and through it the nutrition of the body. Thus are Aliments essentially Restorative, forming and supplying the blood, and from it the several tissues, which are destined to work and to endure, until, like all organic creations, their turn is come to die. Then only are they excreted, and in a different form from that in which they entered; at that time, developing into tissues of high organization, they now decompose and retrograde into simpler bodies; at first fitted for life, they are now shaping for destruction. The disease which collectively they are intended to cure is Hunger; which is in fact a call from the blood for the renovation of its failing constituents, a demand for fresh supply from the body, which, because always changing, is always requiring nutriment. ORD. II. ACIDS. (_Mineral:_--Sulphuric, Hydrochloric, Nitric, and Phosphoric Acids. _Vegetable:_--Acetic, Citric, Tartaric, and Malic Acids.) To this list may be added the super-salts of the alkalies, which have an acid reaction. Although the mineral differ from the vegetable acids in their ultimate action, and are altogether more powerful than them, yet in their proximate effects they are similar. They are all soluble in water, and, when given as medicines, should be so diluted that they can exert no corrosive action on the mucous coat of the stomach and intestines. Dr. Pereira lays it down as an axiom that though they all act as acids in the alimentary canal, yet that they enter the blood as salts. He considers that they combine with free alkaline matters in the saliva, bile, and Pancreatic juice. (_Materia Medica_, vol. i. p. 171.) But this explanation seems to me to be calculated to communicate an erroneous idea of their action. For supposing first that they did thus combine with alkalies before entering the blood, yet as more alkaline matter would then have to be secreted to supply that which they had neutralized, they would thus immediately increase the amount of acid in that fluid. The action of acids in the blood is very different from that of their salts. Sulphuric acid does not act like the sulphates of Soda and Magnesia, nor is the action of Hydrochloric acid the same as that of common salt. Again, we must remember that the secretions mentioned are either neutral or barely alkaline in their reaction, and that the acid medicine, on passing into the stomach, would meet there with an active absorbent surface, secreting an acid, and not an alkaline fluid. So that it seems probable that the acid would enter the blood as such. Now the presence of the acid is not unnatural to the blood. The mineral acids exist there in combination, and the vegetable acids have an analogue in lactic acid. The blood is alkaline; which is due either to the presence of carbonate of Soda, or (according to Liebig) of an alkaline phosphate of that base. So that the acid, on entering into the blood, passes at once into combination with this alkali, and the result of this is a general diminution of the amount of basic matter in the system, and an increase in that of acid. Thus a free acid may act as a Restorative in cases where there is an excess of alkali in the blood. It may either remain in the blood after entering into combination, or it may pass off by the urine, supplying there the place of a natural acid, which it leaves behind it in the system. It is on such a theory as this that the action of mineral acids in typhoid and putrid fevers has been explained. I do not mean to affirm positively that there is in these cases an excess of alkali in the blood. Although likely, it is not proved. The explanation is plausible. Acids are used to correct a phosphatic deposit in the urine, caused by an alkalinity of that secretion. The alkaline urine may be secreted so, as has been observed in petechial fever by Dr. Graves and Dr. Golding Bird, and in insanity by Dr. Sutherland, and may also occur in diseases of the nervous centres; or it may be caused by a decomposition taking place in the bladder, as in chronic inflammation, or in the case of retention of urine from any cause. In the former case the acid may act as a corrective to the fluids before secretion; in the latter case, after it. But it is not always easy to cause acidity of the urine by any medicines. Mineral acids may be excreted in other ways, and vegetable acids are liable to decomposition in the system. (_Vide_ page 125.) The use of mineral acids in assisting a weak digestion admits of a simple explanation. For whatever notion we adopt as to the composition of the gastric juice, it is certain that it contains an acid in excess. Now an acid medicine would set free in the blood more of this acid which it is the business of the stomach to furnish, and thus prove useful in that kind of dyspepsia which depends on a failure of the gastric secretion. Hydrochloric acid has been particularly recommended by those who consider it to be the acid normally secreted by the stomach. When not wanted in the system, it seems probable that acids pass in all cases out of the blood in the same condition as they entered it. Thus vegetable acids act as diuretics; and mineral, as astringents to the glands generally. The latter, when given in excess, may prove hurtful by causing a lithic deposit in the urine. The addition of a mineral acid to healthy urine causes after some time a deposit of uric acid. The action of acids on the urine is neither so constant nor so certain as that of alkalies. In attempting to correct abnormal conditions of that secretion, it must be remembered that its reaction is liable to great variations in health. The whole amount passed during a day should be examined together. Dr. Bence Jones states that the urine is most alkaline just after meals, and most acid when a sufficient time has elapsed for the completion of the digestive process. (_Animal Chemistry_, p. 51.) I shall have afterwards to consider the action of the mineral acids as Astringents; and I must now add a few words on that use of the vegetable acids which has gained for them the title of Refrigerants. In febrile cases of all kinds it is often found that diluent drinks containing the free vegetable acids, or solutions of their salts with alkalies, act beneficially in lowering the pulse, and in moderating the progress of the disorder. These should both be distinguished from mineral saline drinks; for mineral salts, from their known effects on the blood, would seem to belong simply to my division of Catalytics. But the effect of these vegetable acids seems to be to restore the blood to a more natural condition, and this independently of the action of the diluent with which they are administered. Now of this effect there is no certain explanation, but a theory, which may or may not be true, may be ventured to account for it. Should it prove correct, it would seem that in such cases the free vegetable acid acts as a Restorative; and that the alkaline salt of this acid has at first the same action, but adds to it afterwards a Catalytic operation. Let us then attempt to clear up this matter. It has long been considered probable, but may now be said to have been proved by the researches of M. Becquerel, that in febrile disorders and inflammations there is excreted in the urine an excess of Urea and of Urate of Ammonia, substances which are formed by the oxidation of the Nitrogenous tissues. This extra-oxidation probably arises from a deficiency of that matter which is the proper food of oxygen in the system. This, as we have seen, being the step between grape-sugar and Carbonic acid, must either be Lactic acid, or something similar to it. It must be remembered that no food is usually taken in fever; this would at length quite cut off the usual source of this lactic acid, which is the starch and sugar of the food, and render it necessary that the animal tissues should continue to undergo oxidation, to maintain the animal heat. Now if we compare the commonly received formula of Proteine with those of Lactic acid and Tartaric acid, it will at once be seen, as was pointed out some time ago by Dr. Murray, that the latter contain more Oxygen, in proportion to their Carbon and Hydrogen, than is found in Proteine, or Albumen. Proteine = C_{40}H_{31}N_{5}O_{12}. Lactic acid = C_{6}H_{6}O_{6}. Tartaric acid = C_{8}H_{4}O_{10} + 2 HO. Thus, while for 40 equivalents of Carbon, Proteine contains only 12 of Oxygen; Lactic acid contains 40, and Tartaric 50, of that element. So it seems that Albuminous matters, containing less Oxygen, would require much more Oxygen for their combustion; this would produce more heat, augment the number of respirations, and keep up the fever. And though it has been proved by Wöhler that free vegetable acids pass out in the urine without having undergone oxidation, yet the condition of fever would probably be an exceptional case. Lactic acid, the natural fuel, being deficient, the alkali with which it should combine must be present in some excess; so it seems likely that a free vegetable acid would combine at once with this alkali as the Lactic acid would have done, and thus be burnt or oxidized instead of the latter. Its action would then be simply Restorative. Requiring less Oxygen than the Proteine would need to transform it into Carbonic acid, it would thus diminish the number of the respirations, the frequency of the pulse, the temperature of the body,--and in this way allay the fever. It would be strongly confirmatory of this idea if it were proved that the amount of Urea and Urates in the urine is actually diminished by the use of acid drinks and fruits in febrile cases. This hypothesis can only be admitted on the supposition that fever constitutes an exception to the general rule that the vegetable acids pass through the blood without undergoing change. Now, the salts of these acids, with alkalies, which are often administered in the form of effervescing draughts, might exert the same refrigerant action. But there would be this difference: the alkali of the blood would not be required, the acid being already combined with an alkali. M. Wöhler has found that these vegetable-acid salts always undergo oxidation in the system, being converted into carbonates or bicarbonates, and thus reacting on the secretions as alkalies. And so in the same way it seems that the natural lactate of soda is formed into a carbonate, the carbonic acid being afterwards freed from the base, to be excreted by the lungs. But by this natural process the quantity of alkali in the blood would not be increased, nor would it be augmented by the action of a free vegetable acid. But the change undergone by a salt of this acid would continually add to the alkaline matter already in the system. Now, alkalies have a Catalytic action on the blood, which may prove useful in some sthenic fevers; and therefore these salts have a double action, and are not simply Restorative. (_Vide Alkalies_; _Antiphlogistics_; _Antiscorbutics_.) Rheumatism and Gout differ considerably from other fevers, both in their nature, and in the remedies which they require. They are produced by special morbid poisons or agencies, which we are enabled to counteract by certain Catalytic medicines. There is in both of them an excess of free acid formed in the system. Remedies which are apparently opposed in nature have proved useful in these complaints. On the Restorative plan, alkalies are the remedies required; for they neutralize the acid. But in spite of this excess of acid, some of the free vegetable acids have been used with advantage, particularly in rheumatic cases. We shall have hereafter to consider how far this operation resembles the common refrigerant action of these remedies just now considered. (_Vide Antiarthritics._) Some obscurity rests upon the subject of the use of Citric acid in scurvy; but as it seems to partake rather of the nature of a Catalytic than of a Restorative action, I have placed Antiscorbutics in the second division. Now, though there are possibly some exceptions, yet in most cases Acids act as simple Restoratives; but Alkalies certainly operate as Catalytics in some disorders, and have thus to be included in both divisions of Hæmatic medicines. ORD. III. ALKALIES. (Potash, Soda, Ammonia, Lime, Magnesia;--their Carbonates, and neutral Acetates, Citrates, and Tartrates.) We have to consider the alkalies now as Restoratives--treating of those cases only in which they are used to restore a wanting material to the blood or fluids of the body. That they pass into the blood, is proved by their solubility, and their appearance in the secretions; and that they are natural to it we know, because they are all found in it. Wöhler has demonstrated the curious fact that the neutral salts of the alkalies with vegetable acids undergo oxidation in the blood, being transformed into carbonates. (I have just said that it seems likely that certain conditions of the system may determine this oxidation, even in the case of the free acids.) Thus it may be easily shown how the neutral (bibasic) tartrate of potash may, with the addition of ten atoms of oxygen, produce two equivalents of bicarbonate of potash, together with four of carbonic acid and four of water. 2 KO, C_{8}H_{4}O_{10} + 10 O=2 KO + 8 CO_{2} + 4 HO. ____________ =2(KO, 2 CO_{2}) + (4 CO_{2} + 4 HO.) Again, one equivalent of the neutral acetate of potash, with eight of Oxygen, will make one equivalent of the bicarbonate, two of free carbonic acid, and three of water. KO, C_{4}H_{3}O_{3} + 8 O=KO + 4 CO_{2} + 3 HO. ____________ =KO, 2 CO_{2} + (2 CO_{2} + 3 HO.) This carbonate, easily decomposed by any acid, is equivalent to a free alkali. Thus these salts fulfil a double function. They may supply the respiratory process, as has already been explained. They also act on the blood, and on the secretions, as alkalies. Alkalies are used wherever there is an excess of acid in the system, whatever that acid may be. Alkali should naturally be present to neutralize it, for it is unnatural to have a large excess of acid in the secretions, or any excess in the blood. We thus administer alkalies on the restorative principle. They are not always excreted; but whether excreted or not, they tend to render the secretions neutral and alkaline by increasing the quantity of basic matter in the system. Alkalies being more stable than acids, and being more invariably secreted by the kidneys, it is more easy to render the urine alkaline than to make it acid. Alkalies are thus of use in a tendency to lithic acid deposit. The bicarbonates are probably the best for this purpose, for they may be given in large doses, being less irritating. The celebrated Vichy water contains bicarbonate of soda. Lime-water has been used as a solvent for stone. These all act by first diminishing the acid of the blood, and subsequently influencing the secretion of the urine, which secretion, acting as a counterpoise to the condition of the blood, may be generally taken as an index to it. Dr. Pereira recommends alkalies in cases of dyspepsia and pyrosis, when there is an excess of acid secreted by the stomach. He further thinks it likely that they may aid in the digestion of fatty substances when there is a deficiency of bile. This is quite hypothetical, and depends upon a theory which has been shaken by M. Bernard. The same eminent authority states that Ammonia invariably enters the blood as a salt, and thus can exert no peculiar action beyond the coats of the stomach. I shall state my reasons for doubting this when I consider Ammonia separately in Chapter IV. Ammonia will be again enumerated as a stimulant--Potash as a catalytic--and lastly, all the alkalies as diuretics. The alkalies are useful in gout and rheumatism in diminishing the acidity both of the blood and of the secretions. It is often advantageous to apply an alkaline wash locally around an affected joint, in the fluids about which the morbid process seems especially to have fixed itself. If we may receive a certain theoretical explanation of these two kindred diseases, still more light will be thrown on the advantage attending the employment of alkaline restoratives. To this I shall recur when I consider the Catalytics which are used to counteract these same disorders, not, as here, by restoring a wanting material, but apparently by determining the process in a different direction, and thus checking it altogether. The action of Catalytics is more obscure than that of Restoratives, but there is generally a broad line between them. The most difficult case is that of the medicines used in ague and other periodic diseases; of these, for certain reasons that I shall state, I have grouped Quina and tonics among Restoratives, placing Arsenic among Catalytic medicines. It seems to me that Cinchona bears the same relation to Arsenic in the treatment of ague, as Alkalies to Colchicum in gout; the former, in each case, supplying a needful material, the latter neutralizing a morbid process. Thus, when air has been rendered impure by breathing, we may render it again respirable by adding fresh oxygen; but still more certainly, by neutralizing the carbonic acid. ORD. IV. TONICS. Under this term I intend to include only the bitter principles of vegetables. The chief medicines of this order are as follow: _Alkaloids and neutral principles._--Quina, Cinchonia, Bebeerine, Narcotine, Salicine, etc. _Bitter drugs._--Cinchona, Quassia, Cusparia, Gentian, Calumba, Chiretta, Centaurium, Menyanthes, Rhubarb, Hops, Elm and Willow barks, Tansy, Wormwood, Chamomile, Cascarilla. The power by virtue of which these medicines are enabled to act as Tonics, is due, in each case, to a vegetable alkaloid or neutral principle, having a bitter taste. All of those mentioned above, with the exception of Salicine, contain Nitrogen. The uses of Tonics are of a twofold nature. Firstly, they are of use in simple debility and in atonic dyspepsia. Here they give an appetite, increase the muscular strength and powers of digestion, and improve the general health. In the second place, they have all, more or less, a curative power in Ague and other periodic disorders, caused by Marsh miasm. Many explanations have been given of this curious and double action of vegetable bitters; and some erroneous theories have been assumed, and false analogies attempted, in the classification of these remedies. The subject is certainly a difficult one, and there are, at starting, several questions which require a distinct consideration and reply. Upon the answers given to them it must depend whether they should rightly be grouped with blood-medicines or with nerve-medicines; and, if the former, with Restoratives or with Catalytics. Do these medicines act primarily in the blood, or on the nerves? Is their action of a permanent character? Are there any substances in the blood which resemble them? May they remain in the blood, or are they always excreted? If acting in the blood, are they wont to effect a cure by supplying to it a material wanting, or by counteracting in it a morbid process? These questions require each a satisfactory reply, before it can be proved that I have done rightly in classing Tonics among Restorative medicines; for they coincide with the minor propositions in which I have defined the action of such remedial agents. Quina may be taken as the type of the whole order. It is the most powerful; and the others all more or less resemble it. Perhaps Cusparia bark comes nearest to the Cinchona alkaloids in its anti-periodic action. It is worthy of remark, that some common bitters which owe their efficacy, not to alkaloids, but to neutral principles, as Quassia, Calumba, and Gentian, possess the least control over periodic affections. There can be no doubt that these active principles are all absorbed, and pass into the blood. They may easily be dissolved out of the vegetable which contains them, if not by simple water, at all events by such an acid liquid as we find in the stomach. We possess positive proof of absorption in the case of Quina, which has been detected by Tiedemann and Gmelin in the blood of a patient to whom it was administered. Having them now in the blood, we arrive at the first question. Do Quina and other vegetable Tonics act on the blood or on the nerves? This has been answered at once by many writers, as if it were a thing of great simplicity. But it does not seem to be so. Tonics, as we know, have the power of communicating health and strength in debility produced by various causes, and also of arresting the progress of intermittent fever. Do they effect these things by bettering the condition of the blood, and, from it, that of the system at large, or do they at once, and in the first place, influence the nervous system? This is an important question, and it has been variously answered. Dr. Pereira, in his classification of medicines, ranks them among _Cinetics_ ([Greek: kineô], to move,) which are defined to be medicines exerting a power over the motor system of nerves, and through them on the muscles. But in a subsequent account of Quina, he states that its action is quite inexplicable, and that its use in Ague must be ranked with some other special and ill-understood actions, as that of Mercury in Syphilis, or of Arsenic in Lepra. Dr. Neligan, (in his work _On Medicines,_) lays it down that Tonics act as stimulants when given to a healthy man. Dr. Pereira, on the contrary, states what is more consonant with general experience, _i.e._ that a moderate dose of a tonic has little or no effect on a man in perfect health. Dr. Neligan admits that their action is permanent, and produced slowly; he also declines any explanation of the action of Quina and others in Ague, calling them specifics. Some other authors have been still more decided in classing Tonics with nerve-medicines. Dr. Guy, (in his edition of _Dr. Hooper's Physician's Vade Mecum_,) considers that Stimulants and Tonics should rightly be classed together, for that Stimulants act as Tonics to the weak, and Tonics as Stimulants to the strong. It should be observed, that the irritant action on the stomach of a large dose of a bitter medicine appears to have been the chief foundation of this frequent opinion of the stimulant action of tonics. The irritable stomachs of nervous persons are more easily affected in this way. Some too are met with who bear Tonics worse than others, on account of an idiosyncrasy or peculiarity of constitution. But this irritation, and the headache and febrile symptoms which succeed to it, do not surely constitute the proper action of a tonic medicine, which is found to operate most favourably when given in too small a dose to produce any thing like a stimulant effect. Nor do I think it proved that any true stimulants are capable of communicating a permanent tone to the system, or to any part of it. Dr. Ballard also, (in _Ballard and Garrod's Materia Medica_,) states that Tonics acts first upon the nerves, and through them on the muscular system. He opposes them to Sedatives, and ranks them with stimulants; quoting Strychnia as an example of a stimulant which gives tone to the muscular system. But, in the first place, this alkaloid is quite exceptional among stimulants; and further, the comparison with Tonics seems unnatural, inasmuch as the action of Strychnia is more or less immediate, not slow and permanent, and it evidently influences the spinal system of nerves in the first place. The results of large doses of Quina, in producing determination of blood to the head, ringing in the ears, and vomiting, seem to me to mark its action as an irritant poison, and not to be characteristic of Tonic medicines. (_Vide_ p. 91.) The action of Tonics has been more correctly defined by another able authority. "Tonics," says Dr. A. Billing, "are substances which neither immediately nor sensibly call forth actions, like stimulants, nor repress them, like sedatives, but give power to the nervous system to generate or secrete the nervous influence by which the whole frame is strengthened." This definition I would accept in a modified sense, considering that no permanent alteration in the nervous system can be produced without a primary impression on the blood. Dr. Billing further considers, that the supposed stimulant action of Tonics in some cases should either be attributed to the operation of the disease, or of some other medicine administered along with them; and that though in large doses they may sometimes produce a quick pulse with headache, and in other instances depression with nausea, yet that these effects should be ascribed merely to their irritating action on the stomach. On the whole, it seems to me that those authors who, in defining the action of Tonics, have commenced by saying that they act on the nervous system, have started with a mistaken notion; and I am more of the opinion of Dr. A. T. Thomson, who classes them as medicines which act on the muscular and sanguiferous systems. I consider, then, that Quina is not in the first instance a Neurotic medicine; and for the following reasons. The action of other nerve-medicines is distinguished by the following signs. It is quick, and very rapidly follows the administration of a substance. It is transient, and does not endure. It requires no particular state, but takes place in health: thus Alcohol stimulates and intoxicates both healthy and sickly, and Digitalis would subdue a Hercules. Most Neurotics are capable of acting without entry into the blood at large; mere contact with the nerves, as when they are applied externally, being sufficient for their action on those nerves. Again, Neurotics are chiefly used in cases in which the nervous system is unusually excited or depressed, and are of no permanent efficacy in diseases depending on blood-disorder. The action of Hæmatics is of an opposite kind. Now is the primary action of Tonics distinguished by the above signs? Are they quick and sudden in action? Is their effect transitory? Is it evidenced in health as well as in disease? Do they act on the superficial nerves, when applied to them? In each case the answer must be a negative. In all of these particulars the operation of vegetable bitters differs from that of Neurotics, and coincides with that of Hæmatic medicines. It appears that their action on the nervous and muscular systems is secondary. They could hardly in either case effect any permanent improvement without first acting on the blood, if we may argue from known analogies. For Neurotics and Astringents, which operate directly on these two systems, are alike transitory in the results of their action. Another demonstration is required, before the presumption thus established can approach to a certainty. We require proof to show that the disorders in which Tonics are used are blood-diseases. This does not seem to be difficult. The condition of Debility, whatever its proximate cause, seems always to be traceable in the first place to a want in the blood, which interferes with the due exercise of their functions by the nerves and other organs, by impairing their nutrition. It follows fevers, and accompanies chronic diseases, in both of which cases the blood has been exhausted by continual waste and excretion, without the maintenance of a proper supply. In cancerous, scrofulous, scorbutic, and dyspeptic habits, the blood may be deteriorated by a fault in the assimilative processes. When in these instances there is marked Anæmia, iron may be of most service; but when the blood is poor without any apparent deficiency of red colouring matter, then are bitter Tonics needed to improve its condition, and form a valuable adjunct to the special remedies that the case may require. They ought not, as a general rule, to be administered in high fever, or when the pulse is hard, the tongue coated, or the stomach irritable. A loss of appetite, a nervous headache, a soft compressible pulse, a quivering tongue, a flabby condition of the muscles, with general inertia and indisposition to exertion, are indications for their employment. In some cases emetics and antimonials, in others mild purgatives, are of use in preparing the system for their reception. It seems then that Debility is to be attributed generally to the state of the blood; and is to be cured by improving it. By so doing we may communicate tone to the muscular system, improve the appetite, and increase the nervous force. Ague, or Intermittent fever, is also a blood-disease. If it were only from the analogy of other fevers, we might infer this. But there are more particular proofs. This disorder is caused by the exposure of the system to a certain peculiar poison or miasm, which is generated in the ground in certain places, and subject to known laws. The result of the influence of this miasm is a process in the blood which has been compared to fermentation, and which produces regularly recurring paroxysms of a peculiar kind. There is apparently some disturbance in the great calorifacient process, in which the blood is concerned, and not the nerves. Each fit commences with shivering; there is then a hot stage; and finally sweating. The attack then goes off, seemingly as if the poison that caused it were eliminated in the perspiration. But it is not all gone. After working in the blood for a definite period, most commonly two days, it again breaks out, and the same train of symptoms recurs. Thus this strange disorder, both in its origin and in its progress, appears to be seated in the blood. So also are its results evidenced there. Continual Ague deteriorates that fluid, causing general anæmia, and producing more or less enlargement of the spleen, which could only be brought about by some faulty condition of the circulation. Against these proofs it has been urged that the nervous system has certainly an influence over this disorder, for that a sudden alarm has been known to arrest it. But this may occur also with other blood-diseases, and it does not prove that the nervous system is at all connected with their origin. It can hardly be supposed that Goitre or Scrofula is ever caused by a derangement of the nerves. And yet Baron Alibert relates an authentic case of a French lady who had a large goitre, which for a long time resisted all treatment, but which nevertheless disappeared entirely during the brief Reign of Terror in the French Revolution. In addition to these arguments it may be urged that Ague is often, if not always, connected with deranged hepatic functions, a fact that again points out that disease as a blood-disorder. Seeing then that the medicines of this order of Tonics differ in each particular of their action from those remedies which influence the nerves directly, and that the diseases in which they act beneficially are essentially blood-diseases, there are sufficient grounds for concluding them to be Hæmatics, or blood-medicines. We have now to consider the remaining minor propositions, which treat of their action as Restoratives; to ascertain whether they have been rightly allotted to this division. Are there in healthy blood any substances which resemble them? This will appear to be a question of no small difficulty, when it is considered how little information we have actually obtained respecting the chemical composition of the vital fluid. It is nevertheless desirable that we should inquire into it to the best of our ability. During the last few years, many propositions, intended to throw a light upon physiological science, have emanated from the fertile pen of M. Liebig of Giessen, who is rightly and universally ranked among the most illustrious of modern chemists. There are two which especially bear upon the present subject. In his first work on Organic Chemistry (p. 182,) he argued, that whereas the alkaloids Quina and Morphia resembled the brain substance in their chemical constitution, they were therefore enabled to exert a direct control over that organ by influencing its nutrition. But it is impossible to accept this explanation. The composition of the brain has been since more accurately investigated, and it has been shown to consist mainly of a mixture of albumen and fat. Now there is no reason why these substances should have a special affinity for albumen and fat in the brain, any more than for the same elements in other parts of the body. There is also no analogy at all between Quina and Morphia as medicines beyond their resemblance in chemical constitution. The theory seems to be altogether groundless. Another, and a more important suggestion has been made by the same chemist. He has pointed out a chemical analogy between certain vegetable compounds and a substance which exists in the bile. He has shown that for the most part the elements of the bile re-enter the blood after passing into the intestine, scarcely more than the colouring matter being finally excreted with the fæces. He has found that if an enema of bile be injected into the rectum, it becomes absorbed there, and does not afterwards pass out into the urine.[33] (_Animal Chemistry_, p. 77.) What the exact function of the bile may be, is as yet undecided. Its most important constituents are, a non-saponifiable fat, Cholesterine; a neutral substance, Taurine; and an acid called Choleic, in combination with Soda,--which latter is present in excess. Bile is bitter to the taste; and ox-gall, or the bile of an ox, has been found, when administered as a medicine, to have an action which resembles that of Tonics. It appears that both the bitterness and the tonic action reside in the Taurine. M. Liebig has pointed out an important chemical resemblance between this Taurine and the vegetable alkaloids. Of these he has singled out Caffeine, the peculiar principle of Tea and Coffee, as most analogous to the biliary product. From the analysis of these two substances he has deduced the following formulæ. Taurine = C_{4}H_{7}NO_{10}. Caffeine = C_{8}HN_{2}O_{2}. Then he shows that an atom of Caffeine, if added to 9 of water and 9 of oxygen, will form two atoms of Taurine. (_Organic Chemistry_, 1842, p. 180.) It should be remarked that a different formula for Taurine has been arrived at by M. Lehmann and others, who assert that it contains Sulphur. Choleic acid, and other constituents of this complicated fluid, certainly contain sulphur. But even if Sulphur be combined with Taurine, it is not clear that it enters with it into the blood. And the above formula for Taurine has been confirmed by the analysis of M. Löwig.[34] It seems to be sufficiently correct for our purpose. With the supposed function of Caffeine as a creator of bile, however probable or interesting, we are not now immediately concerned. We are engaged in inquiring whether there is naturally in the blood any substance which resembles the tonic alkaloids. Liebig has shown that this element of the bile is intended for re-absorption into the circulation. And without theorizing at all on the subject, it may readily be demonstrated that, with the existence in the blood of such a material as Taurine, we cannot say that we have not in that fluid an analogue to substances like Quina. Taurine is soluble in water, and crystallizable; is chemically analogous to the tonic bitter principles; and contains the same four elements as Quina. If necessary, this similarity could be exchanged for identity, and Quina could be formed into Taurine in the blood. If there be one change in the blood to which, more than to any other, the substances which enter it are liable, it is certainly the process of oxidation. Free oxygen is continually entering the blood through the air-cells of the lungs. The formula for Quina is C_{20}H_{12}NO_{2}. Adding to this 45 atoms of oxygen, we could make out of it one atom of Taurine, together with 16 of Carbonic acid, and 3 of water. C_{20}H_{12}NO_{2} + 45 O = C_{4}H_{7}NO_{10} + 16 CO_{2} + 5 HO. Thus it is conceivable that this and similar alkaloids may at the same time supply an important material to the blood, and serve as fuel to support the animal heat, by combining with oxygen and giving off Carbonic acid. I would not, of course, affirm that this actually does occur; but if it were to take place, we might gain, in this oxidation of Quina, some clue to the production of that quickening of the pulse and increase of the general temperature, which are affirmed by some to follow the ingestion of the alkaloid, even in small doses. But it is now sufficient for us if we have ascertained that there is naturally in the system, and in the blood, a substance which resembles Quina. We may be allowed to infer that the presence of the latter substance in that fluid would not be unnatural to it. Having dismissed the second of the minor propositions which relate to Tonics as Restorative medicines, we pass on to the third. Are Quina and the vegetable bitters necessarily excreted from the blood? It is not easy to answer this question with certainty, because it would be difficult to detect small quantities of this alkaloid in any of the secretions. But all that is known on the subject is in favour of a negative answer. A number of careful and elaborate experiments on the passage of medicines into the urine have been made by M. Wöhler, and in the long list of substances detected by him in that secretion, Quina is not mentioned. Neither has it been found in any other of the secretions. The same may be said of all the Tonic principles. There is no proof that they are necessarily excreted, but there is every reason to suppose that they may remain for a while in the blood. Let us then consider the last question. Can Quina, or substances like it, improve the condition of the blood when deficient in any of its natural materials. We know that it is capable of curing simple debility, ague, and remittent fevers. It appears that it has also been successfully used of late by Dr. R. Dundas, in large doses, in the treatment of typhoid or continued fever. Supposing it to be proved that this agent operates in the blood, does it remedy a disease by supplying something wanting, or by counteracting something present in that fluid? In fine, is it a Restorative or a Catalytic medicine? The probabilities which have been established, that it is not unnatural to the blood, and is not always excreted from it, are in favour _à priori_ of its being Restorative. Catalytics are generally unnatural to the blood, and are excreted because they cannot remain in it. Besides, a Catalytic has generally some peculiar action on the blood in health; but a Restorative, in moderate doses, none,--only evidencing its operation when supplying a previous want. In this also Quina and its congeners agree with Restoratives and differ from Catalytic medicines. Arsenic is of use in Ague; and Arsenic is decidedly a Catalytic in all these particulars. In other respects, too, it differs widely from Quina. The latter is employed in debility, which depends evidently on some want in the system, and not on any morbid agent. Arsenic, on the contrary, is of use in Lepra, which, like other skin diseases, must be caused by some morbid agency, though we know not what precisely. But some diseases may be cured in two ways; either by the supply of something, or by the neutralization of something else. Perhaps Ague is one of these. And it is not repugnant to what we know of Ague to suppose that there is in it a want of some natural material, which would have, when present, the effect of checking the operation of the morbid agent. The fact of having had Ague once does not, as in the case of the Eruptive fevers, protect a man from the disorder thenceforward. So in this sense all persons may be said to be liable to Ague, and none protected from its assault. But it is not the case with Ague as it is with Syphilis and Small Pox, which diseases most persons inevitably catch who are exposed to the virus for the first time in their lives. For, of a number of persons exposed to the same malarious influence, only a part take the disorder; some escape. It is generally found that those are most likely to take it who have been previously debilitated by any cause; so that we must suppose that the rest have in their blood some material which serves to prevent the working in it of the Ague-poison, which apparently must enter it. It is not unlikely then that Ague may be cured by supplying the want of this material. Coupling with this consideration those facts which have been previously stated, we may reasonably conclude that Tonics are Restorative, and not Catalytic in their action; that they supply, or cause to be supplied, a material wanting in the blood. How this material is enabled to resist the morbid influence of the miasm--whether it is by an antiseptic property, such as has been attributed to Quina--I cannot determine. Having now done my best to establish the Proposition, as applicable to Tonic medicines, I may venture to bring forward a speculation concerning their action, which I would not wish to rate higher than it is worth, and still less endeavour to demonstrate as a fact. I have already made use of Taurine, one of the principles of the Bile, for the purpose of showing that among the natural constituents of the blood there is a substance which chemically resembles a tonic alkaloid, like Quina. This similarity admits of a further and more direct application. It is ascertained that many, if not all, of the diseases in which Quina and its kindred medicines are found to be of use, are connected with a derangement of the secretory functions of the liver. One of these diseases is the debility which is consequent upon Typhoid and other fevers. In these fevers the function of the liver is always more or less interfered with, though more obviously in some cases than in others. In strumous habits, in which generally bark is of signal service,--and was very strongly recommended by Cullen, Fordyce, and others,--there is very commonly a peculiar degeneration of the liver, which has been ably described by Dr. G. Budd. This state is distinct from the fatty enlargement common in Phthisis, in the early stage of which disease Quinine is also very serviceable. Quinine is often beneficial in Gout, in which the liver is always more or less deranged. Turning to periodic diseases, we find that impaired hepatic functions are the rule, and the absence of such disorder the exception. This will be at once admitted in the case of Dysentery, and of the Remittent and Yellow fevers of the tropics. It is also true of Ague. It seems even likely that the enlarged spleen may be partly caused by an obstruction to the circulation in the liver. This affection of the spleen is not uncommon in other liver diseases. In Typhus fever both the spleen is disorganized and the liver deranged. It is observed in tropical countries that severe forms of remittent not unfrequently pass into continued fever, which seems to point to some analogy between the two. Ague even may pass into Typhoid fever. And I have already referred to the fact that Quina has of late been strongly recommended in the treatment of continued fevers in general. Dr. Watson states that in New Zealand the biliary functions suffer so much in the intermittent which occurs there, that it is known among the inhabitants by the name of the "Gall-fever." (_Lectures on the Practice of Medicine_, vol. i. p. 793.) Let us now place in conjunction with these facts the similarity which has been pointed out between the bitter vegetable principles, and one of the chief constituents of the re-absorbed bile. Quina and others resemble Taurine; they tend to cure certain diseases; and these diseases depend on deranged hepatic functions. Does not this suggest the possibility that they may be of service by actually forming the Taurine, or by supplying its place in the blood? It is possible that such bodies as Quina and Cinchonia may be able to fulfil the functions of Taurine in the blood by remaining as they are, without even changing into it. It is just possible that the presence in the blood of this bile-product, the supply of which has been cut off by the hepatic disease, might have prevented the continual action of the Ague-poison. There is another fact which gives additional probability to such an idea. Another remedy of a different kind has been used in all the diseases in which Quina is admissible, proving in some cases superior, and in other instances second only to it in its beneficial action. This is Mercury; used in remittent and yellow fevers; of the first importance in dysentery; employed by Dr. Baillie in Ague, and pronounced by him to be in some cases superior even to Quina. In small doses it is frequently of use in cases of debility and scrofula. And Mercury is a Cholagogue; _i.e._ an agent which is known to have the effect of promoting the secretory function of the liver. Thus we may conceive that Mercury, not given in excess, or to salivation, may operate in a different way to produce the same end as Quina. One explanation would suffice for both. If this connexion between Tonics and the Bile were actually established, then we should be enabled to explain a matter which would otherwise seem difficult to understand,--how it is that small doses of Mercury may sometimes act as Tonics, though we know that the ultimate action of this medicine, like that of other Catalytics, is to deteriorate the blood. Even in scrofulous and enfeebled cases, small doses of blue pill or of Calomel are often signally useful; and not prejudicial, as is sometimes stated by those who confound their application with that of Mercury given in salivating doses. Under such a course, when judiciously enforced, we may see the dilated pupil contract to its normal size, and the pale enervated countenance become rosy and lively; and feel the weak compressible pulse to become hard and firm. Perhaps Mercury in such a case may be indirectly tonic, by restoring to the blood the natural tonic principle of the bile. It will be conceded that it is a great merit in a theory, when it succeeds in explaining at the same time a number of different things in a plausible way. It seems that this hypothesis of the connexion of Tonics with Taurine, or some such element of the Bile, is capable of so doing. I am very far from asserting that it is proved, or from supposing that it is at all likely to be so in the present state of our knowledge of the subject; but I think that if not evidently true, it appears at least reasonable. And it may be observed, that even should this idea be completely overthrown, which is neither impossible nor unlikely, there would still seem to be left ample evidence to prove that Quina and other vegetable bitters act on the blood on the restorative principle,--though in what exact way is uncertain. ORD. V. CHALYBEATES. (Protoxide, Sesquioxide, and Sesquichloride of Iron. Salts of Iron:--viz., the Carbonate; Protosulphate; Persulphate; Phosphate; Pernitrate; Peracetate; Ammonio-citrate; Potassio-tartrate. Vinum Ferri. Chalybeate Waters.) Most of these substances are readily soluble in water. Steel wine contains a Tartrate. The insoluble oxides are doubtless dissolved by the aid of the acid of the stomach; and we find that both are most active when given in the form of hydrate, which is most easily soluble in such a menstruum. Thus Chalybeates are capable of being absorbed; and they no doubt are absorbed. They have been detected in the blood, and discovered in the secretions of urine and milk. Being in the blood, they act by an influence which they exert upon it; for they are wanting in all the characters which distinguish nerve-medicines. They are never sudden in their action, and the effect which they produce is lasting. Iron is found naturally in the blood; and the substance in which it is found is that which constitutes the colouring material of the red corpuscles. This is called Hæmatosin. It has been asserted by some that the red colour of Hæmatosin does not depend upon the iron which it contains. But however improbable this may be, it matters not here whether it be proved so or not; for it is sufficient that it is ascertained that Iron is essential to the chemical constitution of this red matter. Without Iron, Hæmatosin could not exist, any more than Albumen could continue to be Albumen, when deprived of nitrogen. According to the analysis of Mulder, Hæmatosin = C_{44}H_{22}O_{5}N_{3}Fe. It is a very peculiar body, and apparently an essential and most important constituent of the blood; for when it is deficient, as evidenced by the paleness of the tissues in Anæmia, the whole system suffers materially, and great and general debility is produced. The result of the administration of an Iron medicine is the restoration of this wanting colouring matter. For if the blood be analyzed before and after its employment, it is found to have undergone a remarkable change, most particularly in the quantity of Hæmatosin which it contains. A case in illustration of this is given by M. Simon, of Berlin. (_Anim. Chem._, vol. i. pp. 310, 313. _Syd. Society._) The solid constituents of the blood, in a case of Chlorosis, had increased, under the use of iron, from 128.5 to 193.5 in 1000 parts; the Globuline from 30 to 90; and the Hæmatosin from 1.48 to 4.59, in the same amount. It is probable that the increase in the Hæmatosin is the first change; that this then improves the condition of the blood corpuscles, increases their number, and through them betters the condition of the blood, and of the system generally. In a case which came under my own observation, the blood of an anæmic girl was found, before the use of Iron, to contain only 50 parts of globules in 1000, instead of 120, the normal average. The Ammonio-citrate of Iron was prescribed, in five-grain doses, three times a day. After it had been continued for a month, the blood was again analyzed, and the amount of corpuscles found to have increased to 76 parts. After another month, they had reached to upwards of 100 in 1000 parts of blood. In the mean time the appearance of the patient had improved immensely. Chalybeates have thus a most immediate and obvious effect in restoring to the blood this wanting Hæmatosin. As the exact chemical condition of the Iron in Hæmatosin has not been discovered, so also the precise changes which Chalybeate medicines have to undergo before they can supply this deficient material in a fit and proper form, are not known. All the known soluble compounds of Iron, except the Ferrocyanide and Ferridcyanide of Potassium, possess this Restorative power. In most Chalybeates the Iron acts the part of a base; but in some, as the Ammonio-citrate and Potassio-tartrate, it exists in a peculiar condition, and cannot be precipitated from their solutions by Ammonia. The water of Chalybeate springs generally contains a Carbonate of Iron, held in solution by an excess of Carbonic acid. The same salt is contained in the compound Iron mixture and pill of the Pharmacop[oe]ia, when these are rightly prepared. When the Iron has entered the system, it is not necessarily excreted again from it, because it is not unnatural to the blood. To ascertain whether Iron given in small quantities is excreted by the kidneys, I have tested the urine of a patient who had been for some time taking thirty drops of the Tincture of the Sesquichloride twice a day: but I was unable to detect in it any trace of the metal. But when given in large doses, Iron passes off by the urine and by other secretions. Some portion may be excreted by the mucous membrane of the intestines, and combine in the cavity of the bowel with Sulphuretted Hydrogen. The resulting Sulphuret communicates to the fæces a characteristic black colour. The cause of this colour was ill understood; until pointed out by Berzelius. When the salts of Iron pass through the glands, they generally prove to be more or less astringent. The Chloride and Sulphate are most so; and they will thus be mentioned again under the head of Astringent medicines. The tincture of the Sesquichloride has obtained the reputation of being diuretic. But this constitutes no exception to the rule of its being astringent; for this diuretic power is owing to a peculiar ether, formed with the spirit by an excess of hydrochloric acid used in the preparation of the tincture. I believe Iron to be simply and solely a Restorative remedy. By improving the condition of the blood, it appears similar in action to Tonics; but it is not a true Tonic, for neither in debility nor in Ague is it of any service, unless there is at the same time Anæmia. In some cases, even of Anæmia, Iron will not effect a cure. This must be because the appropriative power of the system is so weakened and degenerated, that it is incapable of consigning even this needful substance to its proper destination. Anæmia is the one disease in which Iron is of use. Purgative medicines form a valuable adjunct to the treatment in most cases. Dr. G. Owen Rees has suggested that they may be of use by removing some of the water of the blood, so that the corpuscles, being then shrivelled by exosmosis of their contents, may be in a fitter condition to absorb the "ferriferous chyle." And yet, if so, the drinking of a single glass of water would probably be sufficient to swell out the corpuscles again, and thus put a stop to the process. It is just possible that a Cathartic may be serviceable by purging away from the blood some effete matters, as Sulphuretted Hydrogen, formed by the continual decomposition of the tissues, which would have hindered the operation of the Chalybeate in the blood, by decomposing it. The use of Iron may, I think, be summed up by saying that it cures Anæmia. In this way it may benefit, and sometimes cure, other disorders, in which Anæmia is apt to be a prominent symptom. Such are Amenorrh[oe]a, Scrofula, Cancer, chronic Ague, Hysteria, Chorea, and Bright's disease of the kidney. But it seems that it can never be used advantageously in these disorders, when they are unattended with Anæmia; nor even then is it to be preferred to the other remedies specially appropriate in each case, but ought rather to be conjoined with them. Cancer, and granular kidney disease, may perhaps be alleviated, but are seldom cured. In Chorea, Arsenic or Quinine may be used, with or without Iron. Aloetic purgatives may be advantageously conjoined with Chalybeates in Amenorrh[oe]a and Hysteria. Their use may be accompanied by cold affusions, or by some antispasmodic stimulant. In Scrofula the Iodide of Iron affords us a valuable double remedy. In chronic cases of Ague, when accompanied with Anæmia, as is often the case, Iron may be prescribed with advantage. In general Anæmia, an occasional purge, a generous diet, with good air and exercise should be combined, if possible, with the Chalybeate treatment. ORD. VI. SOLVENTS. (_Antilithics._ The mineral Alkalies, their Carbonates, and neutral salts with vegetable acids. Biborate and Phosphate of Soda. Benzoic and Cinnamic acids. _Antiphosphatics._ Mineral and vegetable acids. Sour fruits.) Of all the fluid secretions, the secretion of Urine is perhaps the only important one which cannot cease to be fluid without immediate damage to the system. The deposit of solid matter from this secretion is dangerous, because tending to the formation of a solid calculus in the kidney or the bladder, in neither case easily extracted, and acting like a foreign body in these sensitive organs. This urine, naturally clear and limpid, contains in it several substances which are by their nature insoluble, but are held in solution by certain other materials. But in some morbid states these latter materials may be wanting, or else the insoluble bodies may be secreted in such quantity that the solvent material is unable to hold them in solution. In such instances, these parts of the urine may either be separated by the kidneys from the blood in a solid state, or may be deposited from the urine after excretion or on cooling. They then fall down in a crystalline or finely divided state, and constitute Urinary Deposits. Solvents are medicines which are employed to hold these insoluble substances in solution, where there is not enough of the natural solvent material in the system. They are medicines which tend, after being absorbed, to pass out of the blood into the urine. Although we are ill-informed as to the nature of the ordinary urinary solvents, yet it is evident that they must be present, because substances which are by their nature insoluble occur in healthy urine. And it is also evident that these medicines are able to supply their place; for, after one is given in a case of urinary deposit, this latter disappears, at the same time that the solvent remedy may be detected chemically in the urine. In this, the last order of Restorative Hæmatics, a number of apparently dissimilar medicines are grouped together, all of which agree in this point of their action. The deposits in which solvents are appropriate are termed respectively Lithic and Phosphatic. Among the first are comprehended Uric acid (also called Lithic,) Urate of Ammonia, and the more rarely occurring Urate of Soda. In the second set are comprised the Triple Phosphate of Ammonia and Magnesia, and the Phosphate of Lime. These deposits are each known by their peculiar form under the microscope.[35] They may easily be separated from the urine, when in any amount, and tested chemically. The Lithic deposits, (_i.e._ Uric acid and Urate of Ammonia,) are entirely dispelled by a red heat, and are soluble in alkalies. The Phosphatic deposits leave an earthy residue when heated, and are soluble in acids. When thus held in solution, the former are precipitated by an acid, the latter by an alkali, because by such a reagent that solvent is neutralized in each case. Now the circumstances which may cause these deposits are mainly of four kinds. (1.) A wrong in the diet. (2.) An error in the normal reaction of the blood, causing these matters to be deposited, _without being themselves in excess_. (3.) The suppression of another secretion. (4.) A fault of some process of assimilation or secretion, causing _an absolute excess_ of these constituents of the urine. Urinary sediments may be caused by slight variations in diet. Excessive indulgence in animal food or in wine may cause an over-secretion of Lithic acid. Sour drinks may cause a similar deposit, by rendering the urine acid; and sweet fruits, containing vegetable salts of the alkalies, may produce a phosphatic sediment, by rendering it alkaline. Such cases may be remedied by an attention to diet. Again, deposits may be caused by an excess of acid or of alkali in the blood, which excess is excreted by the kidneys, and causes a lithic or phosphatic gravel, without an excess of Lithates or of Phosphates in the urine. Whatever be the condition of Uric acid in urine, it is certain that it is held in solution by some matter of an alkaline nature.[36] When this alkaline matter is neutralized by an acid, the Uric acid precipitates. This may perhaps be caused in Rheumatic fever by an excess of Lactic acid. The Phosphates are held in solution by Phosphoric acid, or by that matter which gives to healthy urine its slight acid reaction.[37] An excess of alkali in the blood, which may probably occur in Typhoid and low fevers, will cause their precipitation. Or the alkali may be formed in the bladder by the decomposition of the urine. This may occur in inflammation of the bladder; or in retention of urine caused by paraplegic paralysis. In such cases there is no absolute excess of the deposited matter; but it is in relative excess, for the substance which should properly dissolve it is neutralized by a reagent of an opposite nature. Acids and alkalies have already been mentioned as efficacious in these instances; the former in phosphatic, the latter in lithic deposits. They directly neutralize the disturbing cause; the alkali, or the acid. They are not in such cases truly solvents; they do not themselves hold in solution the insoluble material, but they set free something else that shall be capable of doing so. (_Vide Acids; Alkalies._) A suppression of the secretion of the skin causes a lithic deposit in some cases, as in a common "cold." For the perspiration contains a free acid, probably lactic or butyric; and when it is suppressed, the secretion of this acid is thrown upon the kidneys, and the urine is rendered more acid than naturally. The obvious indication in the treatment is to restore the function of the skin, as by warm baths, diaphoretics, etc. It is in the case of urinary deposits produced in the fourth way that true solvents are appropriate. From some morbid condition of the system, it happens that these insoluble constituents of the urine are secreted in absolute excess,--in a larger quantity than in health. Now the system labours to excrete them in solution, even when in excess; and often succeeds in doing so. But frequently this cannot be done, it being impossible for a sufficient quantity of the solvent material to be formed out of the blood. There is then a deposit in the urine. We have seen that when such matters are deposited because in relative excess, the only fit mode of treatment consists in the administration of an acid or an alkali, which shall neutralize the morbid reaction of the blood. Such a case is rare; but these cases of absolute excess are much more common. There are two ways in which we may treat them; we may adopt either curative or palliative remedies. We may aim at the cause of the disease, which is generally in the blood. An absolute excess of Lithates may be caused by dyspepsia, or by a gouty disorder. This is most surely controlled by a Catalytic medicine. (_Vide Antiarthritics._) An absolute excess of Phosphates may be caused by an organic derangement of the nervous centres, when it is very difficult to cure; or it may simply be due to great nervous excitement, hard study, or melancholia. Such cases should be distinguished from a mere alkaline condition of the urine, without absolute excess of Phosphates, and may often be cured by attention to the disturbed nervous functions. Such a curative course of treatment aims at the primary cause of the deposit; but when we are unsuccessful in our attempt to control this, or when the excess of solid matter is so great as to be positively dangerous, we are then driven to have recourse to palliative remedies. These are Solvents; medicines which pass into the blood, combine there with the peccant matters, pass out with them into the urinary secretion, and hold them there securely in solution. Such an agent may often be advantageously combined with the Catalytic remedy, which tends to cure the systemic disorder. It is a blood-medicine. Its action is so far permanent, that it effects its object definitely, dissolving and carrying away a certain portion of insoluble matter. But as it also passes out itself, it requires to be frequently repeated, because the deposit continues to be formed, and requires each time a fresh portion of solvent. It obviously acts on the Restorative principle. The deposit should be excreted in a dissolved state, but is not. The remedy therefore supplies a want. Water is the simplest and most efficacious of all solvents, and should in all cases of gravel be very freely administered. Bouchardat has remarked that great water-drinkers are never afflicted with stone. All the urinary deposits are, to some extent, soluble in water, although _comparatively_ insoluble. Whenever the urine is of higher specific gravity than it should be in health, more water should be drunk. The average specific gravity of healthy urine is about 1.018.[38] Acids and Alkalies are most important as solvents. They do not now act indirectly, as in the case before mentioned, but directly dissolve the insoluble matter. Acids dissolve a phosphatic, and Alkalies or their carbonates a lithic deposit, in the body, as well as out of it. Although the natural solvent may be neither an acid nor an alkali, but something else different in nature from these, yet any thing that will rightly dissolve the deposit will be fit to supply its place. Any of the free Acids may serve to dissolve a precipitated phosphate. Hydrochloric is perhaps the best of the mineral acids, although Phosphoric has been recommended on theoretical grounds. Sulphuric is the least efficacious because it does not always pass out in the urine. (_Vide Chap. IV._) Sour fruits, as Currants or green Gooseberries, may be useful in phosphatic cases; but ripe fruits have an opposite tendency. Acidulous drinks may be recommended, as Cider, Perry, and Rhenish wines. Of the free alkalies used to dissolve a lithic sediment, Potash is preferable to Soda, because it forms a more soluble compound with Uric acid. The Bicarbonates of the fixed alkalies are best, because least irritant. Bicarbonate of Soda is contained in Vichy water. The soluble Bicarbonate of Magnesia may be given with advantage. The Carbonate of Lithia has been recommended by Mr. A. Ure; but it is comparatively insoluble. The neutral vegetable salts of the alkalies, and sweet fruits which contain them, are equivalent to the Carbonates, because converted into them in the system, as has already been shown. They may be pleasantly administered in the form of effervescing draughts, in the formation of which the Carbonic acid of an alkaline carbonate is displaced by Citric or Tartaric acid. The danger which attends the continual use of acids, or of alkalies, particularly of the latter, is that their long employment may engender a condition of an opposite nature to that which they were intended to alleviate. An acid may at length cause a lithic deposit in the urine; or, still more frequently, an alkali may produce a phosphatic sediment. Their administration should therefore be conducted with caution. There are some other remedies which may be advantageously employed as solvents for Uric acid and Urates, whose use is not attended with this danger, and whose efficacy is a proof that the occurrence of a deposit in the urine is not a mere question of the preponderance of acid or of alkali in that secretion. The most important of these is the common Phosphate of Soda, first recommended by Liebig, who discovered that Uric acid was soluble in a solution of that salt. If forty grains of dry Phosphate of Soda, seven grains of Uric acid, and fifteen of Hippuric acid, be dissolved in a pint of hot water, and to this solution two per cent. of Urea be added, a kind of artificial urine will be formed. Biborate of Soda, or Borax, has also the power of dissolving Uric acid, and has been recommended in the treatment of lithic deposits by Bouchardat and Binswanger. Mr. A. Ure has strongly recommended Benzoic acid in these cases. It passes out in the urine as Hippuric acid. (_Vide Prop. VI._) The amount of the deposit appears to decrease under the use of this remedy, but whether the formation of the Uric acid in the blood is prevented, as supposed by Mr. Ure, or whether it is not simply held in solution by means of the Hippuric acid, is not clear. Dr. Golding Bird recommends also Cinnamic acid, which is contained in Cinnamon water, and in the balsams of Peru and Tolu. It resembles Benzoic, and undergoes the same change into Hippuric acid. The salts of these acids possess a similar power. Diuretics in general are useful in all cases of urinary deposit, for they increase the quantity of the fluid part of the urine. It is observed by Dr. Prout that healthy urine is the best solvent that we are able to supply. When solvent remedies are employed for the purposes above mentioned, they not unfrequently fail altogether; and, as has been already observed, they require, even when successful, to be perpetually administered, or else the deposit will recur. For the solvent passes out along with each successive quantity of the Lithic or Phosphatic matter that is formed and excreted. A radical cure of such deposits can only be effected by a medicine that shall counteract the morbid process by which they are continually produced. This cannot be done by a Restorative, but requires a Catalytic medicine. Such remedies we must presently consider. (_Vide Antiarthritics._) Thus are concluded the six orders of restorative medicines; all of which are seen to agree together in some common characters. When a disease depends on a want of some material in the system, then it admits of being cured by a restorative, which, in the theory of its action, is the simplest of all known medicines. And when a morbid process results in a diminution of the amount in the blood of some necessary constituent, then also may a Restorative be of use in alleviating the consequences of such a disorder; or may even effect a cure, when the morbid process has ceased, and left only its results behind it. But when the _materies morbi_ is still working in the blood, a radical cure can only be effected by a Catalytic medicine, which shall be capable of meeting it there, and of counteracting its noxious influence. Some Restoratives are also included among Catalytics, from a regard to a different phase of their action. The most important of these are Alkalies, which are of use in general inflammation, and also in Scrofulous and Scorbutic diseases, acting in a way that is at present but obscurely explained. When the _modus operandi_ of a medicine is obscure, but when it is apparent that it has the power of counteracting a disease, I have preferred to place it among Catalytics, rather than to include it with Restorative medicines. But there are not many cases in which we are thus left in doubt. The diseases curable by Catalytics are all evidently produced by an active morbid agency. Those which are treated by Restoratives are just as evidently remediable by the artificial supply or substitution of some one or more of the elements of the blood. CATALYTICS. These constitute the second division of Hæmatic medicines. The above name is applied to them on the assumption that their operation in the blood results in the destruction or counteraction of certain morbid agencies. ([Greek: kataluô].) The differences in action between this and the preceding division of blood-medicines have been stated at length in the remarks on Hæmatics in general. On recurring to Prop. VII., it will be seen that it is there stated-- "That others, (medicines of the first class,) called Catalytics, act so as to counteract a morbid material or process, and must pass out of the body." The action of the remedies in this division, which are the surest and most potent of all those that are employed in the treatment of disease, is involved in a greater degree of doubt and obscurity than that of any other class. Though there may be in some cases a certain dim explanation which we may catch hold of, and strive to fix or to render definite, yet in many instances there is not even so much as this. How can we, for example, by any of the common terms which are made use of to designate the actions of Mercury, of Arsenic, and of Iodine, express the peculiarity of their influence over Syphilis, Lepra, and Scrofula, respectively? Does it not seem better to confess our ignorance, and to say that all we know for certain is that these remedies have the power of antagonizing certain diseases? Having done this, we may afterwards try, if we can, to invent for this action a theoretical explanation. Our arguments and theories will not affect the fact, nor will they lead us into danger, if we have first laid down the truth, however incomprehensible, as the only secure foundation, in such a manner that it shall be incapable of being disturbed by the flimsy superstructure. Some philosophers have erred in this; that they have first, with much pains and labour, erected an airy fabric on a basis of incontestable truth,--but subsequently, relying too much on that which they have themselves raised, they have commenced to pull up the blocks on which it was founded, and have thus brought the whole speculation tumbling to the ground in ruins. Considering then that the action of Catalytic medicines in each disorder is of a special and peculiar kind, which I think will not be denied, I have grouped them in orders which are named according to the several morbid states in which they are employed. CATALYTICA. Ord. 1. Antiphlogistica. Ord. 2. Antisyphilitica. Ord. 3. Antiscrofulosa. Ord. 4. Antiarthritica. Ord. 5. Antiscorbutica. Ord. 6. Antiperiodica. Ord. 7. Anticonvulsiva. Ord. 8. Antisquamosa. The medicines of the first order are employed in inflammatory disorders generally, and possess an influence over the process of sthenic inflammation, however first produced. The second order contains those that are used in the several forms of Syphilis. The third, those that are employed in Scrofula. The fourth, those that are found to be useful in the cure of painful affections of the joints, as Gout and Rheumatism; and also of Oxaluria, Lithiasis, Diabetes, and other disorders of secondary assimilation. The fifth order contains those that are useful in Scurvy. The sixth, those that are employed in Ague, Remittents, and other periodic disorders, on the Catalytic principle. The seventh, those used in convulsive disorders. Lastly, the eighth, those that are capable of curing Lepra, Psoriasis vulgaris, and some other skin diseases. The action of these medicines being much more obscure than that of Restoratives, I shall therefore have less to say about them individually, and shall not go so much into particulars. That part of Prop. VII. which refers to Catalytics, may be divided into the following minor propositions:-- _m. p._ 1.--That they act in the blood, and that their effect is permanent. _m. p._ 2.--That each of itself tends to work out a peculiar operation in the blood. _m. p._ 3.--That the diseases in which they are used depend on certain morbid materials or actions in the blood. _m. p._ 4.--That the result of the action of a Catalytic medicine is in some way to neutralize or counteract some one or more of these morbid processes. _m. p._ 5.--That these medicines are all unnatural to the blood, and must at length pass out of the system. It might seem at first as if the first, fourth and fifth of these minor propositions would alone suffice to include the original affirmation. But a medicine may act in the blood, and may counteract a disorder; and yet it may counteract the disorder in some other way than by acting in the blood. It is necessary further to prove the disease to be a blood disease. And the evidence of counteraction will be rendered stronger if we can prove that the medicine employed is itself capable of setting up in the blood some peculiar process--of causing in it a change of some special kind. For, were it not to do so, we could hardly understand how it could meet the requirements of one case more than of another, or how it could at all arrest an active process in that fluid over which it exerted itself no particular influence. And this thing, which is laid down in the second minor proposition, can, I think, be proved in the great majority of instances. The following is the arrangement of the subject which I have thought it best to adopt. We will, in the first place, consider some of the statements ventured by authors respecting this kind of medicines: as a comparison of these should aid us in the discovery of the truth. In the second place, it will be convenient to enumerate the medicines contained in the orders named above, and to proceed to prove the minor propositions of Catalytics taken altogether. A considerable amount of difficulty attaches to this consideration; and, as the argument which applies to one order will apply to all, much unnecessary repetition will be avoided by this plan. In the third place I must conclude by making some remarks on each of the orders in succession. To proceed now to the first of these topics. In referring to the opinions that have been advanced on the action of this group of medicines, our task is rendered comparatively easy by the fact that a great number of writers on Materia Medica have failed to recognise them collectively. It may seem strange to one who has reflected on the subject, but it is nevertheless true, that the majority of authors have taken no notice whatever of medicines acting in the blood, with the exception of Acids and Alkalies, which are grouped by some as chemical remedies. All other medicines have been generally arranged under the two great and ill-defined heads of Nerve-medicines and Eliminatives. I cannot find it possible, by either of these terms, to give any idea of the real action of the many important agents which I have included in this division. It would seem that it has been generally supposed that medicines,--bodies of active properties, and more or less peculiar construction,--are able to enter and to pass through a fluid which is still more complicated and changeable in nature than themselves, yet that while so doing they produce no impression upon it, but proceed passively to the solid tissues, or quietly pass out of the body, without ever leaving behind them any trace of their action. Certain writers have made some amends by including in their arrangements a class termed Alteratives. But even then they have not unfrequently laid it down as a rule that they produce, in the first place, an impression on the nervous system, and that this has subsequently the effect of altering the manifestations of vital force. How varied and peculiar in nature must these nervous impressions be, to account for actions which are often so widely different! The medicines thus grouped as Alteratives correspond very nearly with my division of Catalytics. The permanency of their effects, and the fact that the disorders which they cure are blood-disorders, will sufficiently stamp the character of the operation of these remedies. In many works, as in those of Dr. Duncan, of Dr. A. T. Thomson, and more lately, of Drs. Ballard and Garrod, the existence of a class of Alteratives or blood-medicines is not even recognised or alluded to. But in the learned classification of Dr. Pereira blood-medicines hold an important place. All except Chalybeates are grouped together in a sub-class, called Spanæmics, because they tend to impoverish the blood. In addition to those which I have named Catalytics, there are here the acids and alkalies. It is true that all these medicines, after long use, impoverish the blood, which, indeed, suffices to prove my first point, viz,: that they act in the blood, and that their effect is permanent. But Dr. Pereira has founded his classification on the physiological action of medicines, and not on their therapeutical uses, which form the basis of mine. Thus he takes no notice of the questions of what their ultimate destination may be, or what their primary _modus operandi_, whether they have to remain in the blood, or to pass out of it, and whether they can act by supplying a material to it, or by neutralizing a material in it. The subsequent statements which Dr. Pereira has chosen as the basis of his subdivisions, founded often on therapeutical action, seem in certain cases to be somewhat problematical. Thus he calls Acids "adipsa," or thirst-quenching, which very imperfectly expresses their action. Alkalies are grouped with Salts, Iodine, and Sulphur, under the general title of "resolventia seu liquefacientia," _i.e._ resolvents, or liquefacients, which involves an assumption that some might be inclined to dispute. The title of Spanæmics, applied to the whole, though unobjectionable in a classification which is founded upon their ultimate action in health, would be quite inappropriate in an arrangement like mine, which has to do with their influence in the cure of diseases. For our object in making use of such agents is not to impoverish the blood, but to obtain such a manifestation of their power as shall suffice to neutralize the noxious agent, and no more. Dr. A. Billing (_Principles of Medicine, 5th edit._ pp. 70-75) considers that Mercury, Arsenic, Colchicum, and all the medicines which have been called Specifics, are not in fact so, but that they are capable of subduing different kinds of inflammation by causing contraction of the dilated capillary vessels. This explanation has certainly the charm of simplicity, but not, in my opinion, the merit of truth. Dr. Billing supports his argument by instancing the number of remedies that have been used in Syphilis, and considers that they must all operate in a similar way, both in this and in other disorders. Yet are all these medicines of use or advantage in Ague, in Lepra, in Chorea, and in Scrofula? But why is it not so, if all act in the same way? Their several actions should exhibit no difference in kind, but only in degree. It is the opinion of the same able authority that Mercury and Iodine diminish morbid growths by starving them; that they cut off the supply of blood by contracting the capillaries in the same way as in other cases. But why then can we not thus remove a fatty tumour, a true exostosis, or a malignant growth? We are seldom able by such means to reduce the size of a tumour, unless it depends on a blood-disorder, as Syphilis or Scrofula. The wide distinctions and the shades of difference which exist between the operations of these several medicines are surely too many and too serious to allow us to account for them all by one explanation. But we may put aside general arguments, and appeal to facts. In the first place, it is very far from being proved that in all these disorders the capillary vessels are dilated. But let us even admit that it is so proved, and we are not then nearer to the establishment of the above hypothesis. For is the action of any medicinal agent on the capillaries constant in character? Mr. Wharton Jones, in his Astley Cooper Prize Essay, states that he has found the effects of medicinal solutions on the capillaries in the web of a frog's foot to be very various. For even a solution of Sulphate of Copper has been known to cause dilatation, and one of Atropia to produce constriction; though the former is an astringent; and the latter a paralyzer. So that the vessels are not nearly so much under the influence of such agencies as Dr. Billing would seem to imagine. In these experiments the solutions were concentrated, and applied directly. But in the cases in point we might have two or three grains of Iodide of Potassium, one-tenth of a grain of Arsenite of Potash, or one-twentieth of a grain of Bichloride of Mercury, diluted down by about twenty pounds of blood, and extended through many miles of capillary tubes! And if simple contraction of the capillaries were required, surely Astringents, which are known to effect this, should be the most useful of all these medicines. But we do not find it to be so. Further, this idea must include a virtual denial of the causation of blood disorders by special morbid agencies. Such are the grounds upon which is founded a denial of the existence of specific medicines--_i.e._ of remedies which are of particular or special use in one or more disorders. Is it reasonable to deny that Mercury is of particular use in Syphilis? that Iodide of Potassium exerts a special influence over secondary forms of the same malady? that Iodine and Potash are each peculiarly adapted to scrofulous cases? or that Colchicum will often stop a fit of the Gout when other medicines have failed to relieve it? If we cannot deny it, we must admit such actions to be in some degree specific. To adopt this term is to a certain extent to confess our ignorance, and for this reason many have objected to it; but this we cannot avoid. The word is, however, decidedly objectionable, when it is misapplied to express the idea of some particular medicine being the only one that can be used in a certain disorder. For this is an exaggeration of the truth that may lead to very serious error. Before now proceeding to the proof of the minor propositions of Catalytics taken collectively, I must enumerate the chief remedies which I intend to include in the eight separate orders into which this division of blood-medicines has been divided. _Ord. 1. Antiphlogistics._ Antimonials; Mercurials; Alkalies; Salines. _Ord. 2. Antisyphilitics._ Mercurials; Preparations of Gold; Iodide of Potassium; Sarsaparilla (?). _Ord. 3. Antiscrofulitics._ Iodine; Bromine; Chlorine; Iodides and Bromides; Potash. _Ord. 4. Antiarthritics._ Colchicum; Nitro-hydrochloric Acid; Lemon-juice. _Ord. 5. Antiscorbutics._ Citric Acid; Lemon-juice; Fresh Vegetables; Salts of Potash (?). _Ord. 6. Antiperiodics._ Arsenious Acid; Arsenite of Potash; Alum; Chloride of Sodium. _Ord. 7. Anticonvulsives._ Preparations of Arsenic, Silver, Zinc, Lead, and Copper. _Ord. 8. Antisquamics._ Preparations of Arsenic; Sulphur; Pitch. Under each head I have given the most important of those medicines which I conceive to act on the Catalytic principle. Other medicines may cure some of these disorders, or at least alleviate them; either by acting as Restoratives, as in the case of arthritic and of periodic disorders; or by influencing the nervous system, which plan may be effectual in some convulsive affections. The prefix _Anti-_ involves a principle. These medicines produce certain actions which are _contrary_ to diseased actions, inasmuch as they neutralize them, and cannot subsist with them. It is granted that in some cases the actions may appear similar in some respects. But this merely shows that they move, as it were, in the same sphere, for else one of them could not meet the other. However the operation of a medicine may sometimes seem to resemble that of a disease, it is always in effect contrary to it. The similarity is of a kind which does not concern us. An acid and an alkali are so far similar, that they may both produce heat when mixed with water, and both prove corrosive and destructive to organized tissues; but they are practically contrary, and when brought together they neutralize each other. Let us now proceed to the minor propositions. _Catalytic medicines act in the blood, and their effect is permanent._ This is simply to affirm that they belong to the class of Hæmatics, to which Restoratives also belong. Of all that I have named, there are not any, except Colchicum and Antimony, that possess in any degree the action of nerve-medicines--_i.e._ that exert a sudden and transient influence over the nervous system. I believe the sedative powers of these medicines to be quite distinct from their Catalytic influence. In the proof of the second minor proposition, I shall attempt to show that each of these remedies has a peculiar action of its own on the blood, even in health; which cannot be said of Restorative medicines. Of all these Catalytics two things are known. When they cure a disease, they do so definitely, so that it does not in general tend to return; and when they only alleviate it, the improvement effected is more or less permanent. In the second place, they are found to produce, after being long administered, a change for the worse in the blood, a diminution in the amount of Fibrine and of the red corpuscles. Thus they are blood-impoverishers, when given in excess. These considerations alone, when combined with the proof of absorption--_i.e._ that they all pass into the secretions, and may be detected there--are conclusive as to the fact of their being Hæmatic medicines. We pass on now to the third proposition, which consists in the statement of a property that is peculiar to Catalytic Hæmatics. _Each Catalytic tends of itself to work out a peculiar operation in the blood._ This peculiar process, established by their presence in the blood, forms part of the known history of each Catalytic medicine. It will suffice to demonstrate this if I condense into as few words as possible the facts that are known on this subject, with respect to each of the orders of this division of remedies. Of _Antiphlogistic_ medicines, some possess a power which stamps them at once as likely to be useful in the treatment of inflammatory disorders. Alkalies are known to have the chemical property of holding Fibrine in solution. By exerting this power in the blood, it seems that they may prevent its abnormal deposition or coagulation in inflammatory cases, and at length diminish it in quantity. On this principle they were proposed and used successfully by Mascagni in acute inflammations. Their efficacy in retarding the formation of crude deposits in scrofulous and tubercular diseases may possibly be assigned to the same operation. Potash has been extolled by Dr. Theophilus Thompson as a powerful preservative for those who are predisposed to phthisical disease. Alkalies in small doses, and in cases requiring them, may be Restoratives. Salines have been shown by Mr. Gulliver to have the effect of keeping the blood-corpuscles apart from one another. This may partly explain their action; for in inflammatory blood the corpuscles display a peculiar and abnormal tendency to aggregate together in rows. Salines also are solvents of Fibrine. The immediate action of Mercury in checking inflammation is often very apparent in the case of Iritis. This medicine in some way diminishes the plasticity of the Fibrine of the blood; and probably promotes absorption by preventing in this way a further deposit of lymph. If the blood be analyzed after the continued use of Mercury, it is found to contain less Fibrine than in health. It has also a peculiar action of its own in the blood, for it sometimes produces various eruptions, particularly Eczema, as well as a state called Mercurial fever. Antimony has various and marked medicinal properties: in large doses Neurotic; in all cases Eliminative. But we are now concerned merely with an agency in the blood. It has certainly some action of this kind. When rubbed on the skin it produces a pustular eruption; and M. Lepelletier gives a case in which it did this when administered only internally. Magendie found that when given to dogs it produced engorgement, and often inflammation of the lungs. Antimony seems to exert a blood-influence over inflammation somewhat similar to that of Mercury; but it further adds to this a powerful sedative effect. Antimony generally arrests inflammation by reducing the pulse; but Mercury reduces the pulse by arresting inflammation. Thus do Antiphlogistics exert that operation in the blood which is essential to Catalytic medicines. The divisions of Hæmatics differ in this: Restoratives act by being in the blood; Catalytics by working in the blood. All we have to prove of the latter just now is to establish this part of their action. _Antisyphilitics_ have also this action. Mention has already been made of the hæmatic effects of Mercurials. The action of the compounds of Gold is similar, though these are not now often employed. But as far back as the commencement of the eighteenth century the administration of Gold in syphilis was strongly recommended by Dr. A. Pitcairn. He employed the pure metal in a fine state of division. He also made use of a mercurial which resembled our modern blue-pill, but must have been considerably less potent, for it was given in drachm doses. Iodide of Potassium may be said to combine the actions of Iodine and of Potash. This medicine is very active in causing the absorption of syphilitic nodes. Its use is sometimes followed by a slight cutaneous eruption. Sarsaparilla is supposed by many to exert an alterative action in the blood; but this is not very clear, nor is its utility often very decided. _Antiscrofulitics_ form the third order. Iodine and its compounds have certainly an action on the blood. When given in excess, or for a long time, they may cause a train of symptoms to which the collective name of _Iodism_ has been applied. The most prominent are--coryza, itching, watering of the eyes, fever, and great constitutional depression. It powerfully promotes absorption in certain cases. Its special actions will be subsequently described in the remarks made on the second and third orders of Catalytic medicines. Potash has been already considered. Bromine and free Chlorine are very analogous to Iodine in their operation. _Antiarthritics_ exert an influence on the blood. This is least apparent in the case of Colchicum, which is a somewhat mysterious remedy. But it has been said by some to increase the amount of Urea in the urine; by others, to promote the excretion of Uric acid. (_Vide Antiarthritics, and Chap. IV._) Nitro-hydrochloric acid contains Chlorine, which is an oxidizing agent, and probably exerts in the blood an action of this kind. It is clear that it is capable of retarding the formation in the system, and deposit in the urine, of lithic acid and oxalate of lime; though its _modus operandi_ is not determined with certainty. This question is of some theoretical importance, and will soon be considered at some length. Among _Antiscorbutics_, Potash and its salts have been already shown to affect the blood. Their efficacy in scurvy is, however, a disputed point. That of Lemon-juice is established. It contains Citric acid and Potash; the former in great excess. Now either of these by itself would, in cases requiring it, and given in small doses, act as a Restorative. In large doses, Citric acid would disturb the reaction of the secretions, and Potash would impoverish the blood. When both together, the Citrate of Potash would undergo oxidation, and thus exert an operation in the blood of a refrigerant kind. Similar materials occur in most fresh vegetables. _Antiperiodics_ are medicines which are used in the cure of Ague, and of other periodic diseases, on the Catalytic principle. Tonics are used in the same diseases on the Restorative plan; but their utility extends also to other cases on the same grounds. Arsenic is the most potent of Antiperiodics. The Terchloride, and the Arsenite of Potash, are the preparations most frequently employed. Arsenic produces an evident action in the blood. When given in slight excess, it is apt to bring on [oe]dema of the face, and redness of the conjunctivæ. Besides causing various nervous disorders when in large doses, its continued use may bring on a cutaneous eruption, described by Mr. Hunt as a kind of pityriasis, together with a failure of appetite, general depression, a quick small pulse, hurried respiration, and sometimes swelling of the feet. Any kind of eruption would alone constitute sufficient proof of an operation in the blood. The metallic salts used as _Anticonvulsives_ are all capable, when taken for some time, of causing a deterioration of the blood. This is most apparent in the case of Lead, which, besides a number of nervous symptoms, tends to bring on a kind of jaundice, with general wasting of the body. Chronic poisoning by Zinc and Copper resembles that by Lead. The symptoms of what is called "Zincal intoxication" were recently described to the French Academy by M. Landouzy of Rheims, as occurring constantly among the zinc-workers. There was sometimes an [oe]dema like that produced by Arsenic. The production of all the known nervous disorders by the presence in the blood of different metallic medicines, gives a strong additional probability to the belief that these disorders, when occurring spontaneously, are in many cases due to the presence in the blood of some unknown poison. Among _Antisquamics_, the last Catalytic order, we meet with Arsenic again. Common Pitch is of almost equal utility in Lepra. It has some action in the blood, due to some one of its bituminous principles; but this action is not well made out, or understood. Sulphur, besides its use externally in Scabies, is administered internally with advantage both in this and some other skin diseases. It effects changes in the blood, inasmuch as it is found to combine there both with hydrogen and oxygen, and to carry them out of the system as sulphuretted hydrogen and sulphuric acid. Dr. Pereira and others ascribe to Sulphur a resolvent and liquefacient action. Thus it is sufficiently shown that all of these medicines work out a certain process or operation in the blood, and affect the condition of that fluid. But I am very far from believing that this known operation is in all cases the one by which they neutralize morbid poisons. This action is probably of a much more inscrutable character. Before proceeding further, I may here take the opportunity of insisting again on the differences between Catalytic and Restorative medicines. Catalytics will even in health work out their peculiar process in the blood. Restoratives exercise in that case no particular influence. The latter may remain in the blood; their office is supply or substitution. Catalytics may not remain beyond a certain time; their office is counteraction. The system then labours to excrete them. Before passing out of the body, one or two, as Colchicum, may act on the nerves. In the moment of excretion, the majority act as Eliminatives. But some, as the metals used as Anticonvulsives, are astringent, and diminish secretion generally. Mercury, Antimony, and Iodine, are among the most important Eliminatives known. They act on all glands, but on some more than on others. Antimony is also a special sedative to the Vagus nerve, and as such exerts an important influence, which enables it sometimes to cut short the process of inflammation by depressing the action of the heart. We now arrive at the third minor proposition. _The diseases in which these medicines are employed are active blood-diseases._ This consideration need not detain us long, for in most cases the correctness of the statement is universally admitted. _Inflammation_ may be produced by a variety of blood-poisons, in each of which instances it partakes of a special character. Thus there are the syphilitic, scrofulous, and rheumatic inflammations. Simple inflammation may be caused by the injury of any part or organ, external or internal. It commences in the capillary vessels, and, if extensive, affects the blood generally, and produces fever. The blood then contains an excess of Fibrine, causing it, on coagulation, to exhibit the "buffy coat." There are also found in this, according to Mulder, some peculiar hyperoxides of Proteine. The colourless corpuscles are in excess; and among the red corpuscles is observed a peculiar tendency to arrange themselves together in rows. This is doubtless in some way connected with the morbid process going on in the blood. _Syphilis_ is evidently traceable to a special poison. This is recognised by the fact of its communication from one person to another. In the system of the infected person, if left alone and uncontrolled, it breeds and increases in quantity, works out all the mischief that it is capable of effecting, and may again be propagated to others, either by inoculation into the blood, or by an equally direct transmission to a tainted offspring. _Scrofula_ is also a blood-disease. All its manifestations are explainable on such a supposition. It is transmissible from parent to child; and it holds good as a general rule that hereditary diseases are seated in the blood. It is unaffected by any of those medicines that act only on the nerves. It produces a deterioration of the blood. _Arthritic_ disorders are always accompanied by a change in the blood. In Diabetes grape-sugar is present there in large quantities, and has to be excreted by the kidneys. Similarly, in Oxaluria, oxalic acid is found there; in Lithiasis, lithic acid in excess. In Rheumatic fever there are profuse sweats, in which the natural acid of the perspiration is enormously increased in quantity. It is stated by Berzelius to be lactic acid. Either this, or some other acid like it, must be formed in excess in the blood. In Gout we have sometimes a deposit of urate of soda in the cellular tissue opposite the small joints. The same salt has been occasionally found in the urine in Gout. Lastly it has been detected in the blood in that disorder by Dr. Garrod, and since him, by Dr. Bence Jones. (_Animal Chemistry, p._ 29.) Thus, in all these disorders there is a wrong in the blood. _Scorbutic_ diseases, _i.e._, Scurvy and Purpura, are characterized by a general poorness of the blood, with a special deficiency in the amount of Fibrine and of salts. There is a general tendency to hæmorrhage and ulceration all over the body. It has been observed that these diseases seldom occur in persons who are accustomed to a natural and mixed diet. _Periodic_ disorders are known to be attributable to the entrance into the blood of a peculiar aerial poison. The mild malaria of England excites a comparatively tractable ague; that of the Maremma and of the Pontine Marshes, in Italy, brings on very fatal fevers; while the remittents that are due to the exhalations from the ground on the West coast of Africa, and in the West Indian Islands, are of a still more virulent nature. Accurate observations have shown that they are all caused by the exposure of the system to this poison, and by its working in the blood. With _Convulsive_ disorders there is more difficulty. Although these diseases are manifested either by a derangement of the nervous system in general, or by a disturbance of the functions of the brain or spinal cord in particular, yet they are very rarely accompanied with an appreciable nervous lesion. When this is the case, as in the instance of Tetanus, which may arise from a mere irritation of the end of a nerve, they are extremely intractable, and are not at all under the influence of those blood-medicines which are useful in other cases. Epilepsy, too, may sometimes be due to a bony spicula or tumour in the brain, or to the irritation produced by intestinal worms in children; but these direct nervous causes of such convulsive disorders are to be considered as the exception, and not the rule. For they are more often connected with a diseased condition of the blood. Epilepsy and Hysteria are frequently inherited. This supplies us with one argument. They are also apt to be brought on by various depressing causes which affect the system in general. The strumous diathesis, which originates in the fluids, and not in the nervous system, is affirmed by Dr. Cheyne and Dr. Watson to be a powerful predisposing cause of Epilepsy. Hysteria, too, is very often associated with Anæmia. Tetanus even depends very much on certain atmospheric conditions. There are sometimes, as it were, epidemics of Tetanus, in which the slightest abrasion will suffice to bring it on among the people residing in a particular neighbourhood. It is often rife in one district a long consecutive time. Facts like this must certainly be regarded as pointing to a condition of the blood as one, at least, of the causes of this terrible disorder. This condition of the blood may react upon the nerves, and maintain in them a particular morbid state. Chorea seems also to depend primarily on the state of the blood, and is indirectly curable by medicines which, like Iron and Quinine, improve its condition. In a weakly and strumous child it may be brought on by a sudden fright which would not affect one of a good constitution. We might conclude from these facts alone that the blood is often the seat and origin of these diseases. But there is yet a stronger reason to induce us to suppose that they are frequently produced by some poison in the blood, which acts on and disturbs the nervous organs without perceptibly altering their physical construction. Many medicinal substances present us with an artificial illustration of this action. Lead, Copper, Mercury, and Arsenic, by their presence and operation in the blood, are capable of causing severe and chronic nervous disorders, particularly Paralysis and Epilepsy. Many of the vegetable Neurotics, after their passage into the blood, bring about transient nervous symptoms which are identical with those of disease. Thus Opium produces coma; Belladonna, delirium; Aconite and Hemlock, paralysis; Hydrocyanic acid, convulsions; Indian hemp, catalepsy. When the cause of these affections is removed, the symptoms disappear; when the cause returns, the symptoms return. The same is apparently the case with those unknown animal poisons that operate so as to produce nervous symptoms, without a nervous lesion. These convulsive disorders may be treated in either or both of two ways. We may attack the supposed cause in the blood by employing one of these mineral Anticonvulsives; or we may simply apply our remedies to the nervous system, the more immediate seat of the morbid manifestations, and adopt a palliative or defensive course. _Skin diseases_ are no doubt connected with some disorder in the blood. We might almost presume this from the analogy of the known blood-poisons, by nearly all of which an eruption may be produced. The eruptive fevers, which run a certain course, depend upon contagious poisons; but they are not under the influence of Antisquamic remedies. These are serviceable in a class of disorders, of each of which a cutaneous eruption is the most apparent, or the only obvious symptom. The true squamous disorders are Lepra vulgaris and Psoriasis vulgaris. The causes of Impetigo, Porrigo, and Scabies, are probably similar to those of the true squamæ, for they are often curable by similar remedies. The actual eruption of Porrigo is accompanied by a parasitic fungus, which may sometimes be transmitted from one person to another; and a small insect or Acarus which haunts the vesicles has been alleged as the cause of Scabies; but it is not, after all, quite clear whether these attendants may not be merely the concomitants or the results of these two disorders. At all events, Lepra and Psoriasis are true blood diseases, and are often inherited. They are more obviously under the influence of Antisquamics than the other skin diseases. It has thus been shown that the diseases in which Catalytics are used are each to be accounted for by a process in the blood. The fourth minor proposition will not be so difficult to establish as the last, although it is in fact the most important of all. _The action of a Catalytic results in the neutralization or counteraction of one or more of these morbid agencies._ This has already been sufficiently proved. It is established by experience that these remedies severally counteract the diseases named. They have been shown to have an action in the blood; and the diseases have been proved to be blood-diseases. Thus it is clear, that if the former counteract the latter, and have no action on the nerves, they must do it by some agency in that fluid, over the particles of which both exert an influence. They are Catalytic Hæmatics; _i.e._, medicines which, by an operation in the blood, are enabled to counteract disorders which depend upon active morbid agencies. This is all that can be positively affirmed of their mode of operation. The fifth and last minor proposition relates to an important difference between these and Restorative medicines.--The latter may remain in the system, for if they did not do so, they could restore nothing to the blood. But Catalytics cannot restore any thing, for they are generally unnatural to the blood. They must sooner or later be excreted. _Catalytics are unnatural to the blood, and must at length pass out of the system._ Of the list of Catalytics, the only medicines that occur as constituents of healthy blood, are Alkalies, Salts of the alkalies and earths, Chlorine, and Sulphur. Of these, the Alkalies, and possibly also the others, are not unnatural to the blood when administered in small quantities, and may remain in the system and act as Restoratives, when there is a deficiency in the blood of similar materials. But even these substances, when given in large quantity, as is the case when they are used for Catalytic purposes, are unnatural to the blood, and must be excreted from it. With respect to the other Catalytics, they cannot any of them remain naturally in the blood, under any circumstances. Their very presence for awhile constitutes an artificial disease, and is only to be tolerated or recommended because it may serve to counteract a morbid action of a more serious and uncontrollable character. The kidneys generally constitute the channel by which these Catalytics are removed from the blood. Most of them, in passing out, act as diuretics. To this we must, perhaps, except the salts of lead, zinc, and copper. Doubtless some are excreted partially or entirely by the mucous membrane of the bowels, but this we cannot so readily appreciate. The circumstance that the astringents just mentioned are efficacious in diarrh[oe]a seems to point to their access to the intestinal surface from the blood. It has already been shown that these Catalytics are all soluble in some way in the intestinal canal, and that they are absorbed. (_Vide Prop. I.; Prop. II._) All of them that can be detected by chemical means, have actually been discovered in the blood. But the system will not, if it can be avoided, suffer them to remain there long. The glands are charged with the office of purging the blood of all morbid materials; and thus these substances pass out in the secretions; most particularly, as I have just said, in the secretion of urine. Every one of the medicines of this division, enumerated above,--excepting Colchicum and Pitch, which are difficult to recognise chemically,--have been detected in the urine by M. Wöhler, M. Orfila, and others. The Alkalies and Acids are combined, so as to form salts; the vegetable salts are decomposed; Sulphur has changed into Sulphuric acid; and the metallic bases are found to be variously combined; but all the fixed inorganic materials remain essentially the same, however altered in arrangement. Many of these medicines have been likewise detected in the secretions of other glands. This subject will be further discussed in the consideration of Prop. X., and does not immediately concern us now. Thus the minor propositions may be considered as proved; and all that I have ventured to affirm of this group of medicines is, that they counteract morbid agencies by an operation in the blood. Now the mode of counteraction is not defined, because it is only in a few cases that we can even guess at it. In the majority of instances it seems inexplicable. We know that Syphilis is a poison in the blood. Mercury also is a poison in the blood. But why does Mercury antagonize and annihilate Syphilis? The case is the same with Scrofula and Iodine; with Lepra and Arsenic. It is very humiliating to be baffled when we have got thus far; when, led by the hand of Science, we have been conducted almost to the end of this interesting inquiry, to find that we are perfectly unable to take the last step, and thus to conclude our adventure. When there is no disease, a Catalytic medicine may work out its own action in the blood, and produce a disease. But when there is some previous disorder, the working of the Catalytic may operate so as to counteract this already existing action, being so far similar to it, that it acts in the same department, and may thus occasionally produce by an accident like results; but being, nevertheless, as we have seen, essentially contrary to it, because it neutralizes it. Such opposite relations are met with even among natural diseases. Vaccination and Small Pox afford us an instance of the mutual counteraction of morbid processes. These poisons are alike in their operation. Dr. Fouquet, of Freiburg, has tried the effects of re-vaccination in Syphilis, on the inmates of a large military hospital, with great apparent benefit, as it is said. These poisons are unlike in their results. So are Ague and Phthisis; and persons who have had Ague are said to be less liable to Phthisis than others. Again, we find that one attack of an eruptive fever preserves the system in some way from the renewed operation of the same poison. In these morbid phenomena we find something of a parallel to the curious operation of Catalytic medicines in controlling blood-diseases; for I have shown that these remedies themselves are artificial blood-diseases. Such ideas lead us on into the uncertain regions of speculation. The idea that diseased actions may possibly be accounted for by supposing the existence of special _fermentations_ in the blood, is by no means a new one. Inscrutable as these diseased actions themselves may be, yet, we are enabled to recognise processes of a nature analogous to fermentation as going on in that fluid in health. Of such a kind probably are, the change of albumen into fibrine; the changes which take place in the starchy matters of the food before they can be oxidized into carbonic acid; and the changes that must occur in nitrogenous substances before absorption, as well as those that accompany afterwards the downward progress of the same materials, from living tissue into Urea and Uric acid, to be finally excreted from the system. It is a curious fact that nearly every known product of organic fermentation has been discovered in the human body in health or in disease. Lactic, butyric, and acetic acids, have been frequently found there. Dr. Heintz has lately added to these succinic acid, discovered in a hydatid cyst of the liver. The production of many disorders by the access of a known morbid material, the working of that material on the particles of the blood after a special fashion peculiar to itself alone, and the gradual elimination of certain products, also peculiar to this one operation, are circumstances in which diseases bear an obvious analogy to processes of fermentation. The same remark applies to the working of Catalytic medicines. It is then just possible that one of these medicines might produce in the blood a fermentation which should meet and neutralize the morbid fermentation; or that it might simply determine the latter in a different direction, and thus bring it to a desirable end. Acting in health so as to produce a morbid change, it might operate in disease by means of diverting into a right direction a change that is already going on in a wrong one. But let us leave generalities, and descend more into particulars. Are we in a position to be able to indicate the actual nature of the changes which we thus assume to be probable? The term Fermentation is used to express a change or series of changes of a special character, caused among the particles of a compound body, by the presence of a certain other body called a Ferment. There are two kinds of fermentation. In one the ferment itself is undergoing change, and impresses a similar change upon a substance which is analogous in nature to itself.[39] The process caused by a contagious disorder would probably be of this kind. Just as the changing yeast forms and increases itself out of the fermenting dough, so does the virus of such a disease renew and propagate itself out of the particles of the blood. The other kind of fermentation is simpler in action, but more incomprehensible in character. It is produced by mere contact, without any change in the ferment itself. Thus it is known to chemists that spongy platinum causes the combination of oxygen and hydrogen, and exerts generally a powerful influence over the affinities of gases and liquids, without ever itself undergoing any change. The influence of Emulsine, in causing, by mere contact, the Amygdaline in the bitter almond to resolve into Prussic acid and other compounds; and that of Pepsin or of Ptyaline, in promoting the change of Starch into Sugar, is of this kind. Considering that Catalytic medicines are not by their nature changing bodies, being mostly minerals, it is not likely that they could cause that kind of fermentation which requires that the ferment itself should be in a state of change. The influence of contact is the one which they would be most calculated to exert. I may remark that I have used the term Catalytic without any reference or allusion to this sense, in which it has been frequently employed, but merely as conveniently expressive of undoing or destroying. I would not wish, either in the terms or in the propositions which I have adopted, to assume for granted any thing which is not proved, still less an idea which is purely hypothetical. But it is not very unlikely that some of these medicines may act in a mode which is more or less analogous to an action of fermentation of the kind just described. They might then either cause change themselves, and by this means alter and destroy a morbid process somewhat similar to that which they themselves excite; or they might, by simple contact, be able to resolve this process into a natural direction. We have seen that when introduced into healthy blood, they invariably tend to produce a change in it which is productive of harm; but that when there is already an abnormal process going on there, their influence will effect the subversion or annihilation of this other process. And there are certain physiological considerations that render such an idea still more intelligible and plausible. It is to be remembered that the blood, in which we suppose such actions to go on, is not an ordinary chemical fluid, subject to common laws, and influences, such as we may meet with out of the body; but a very complicated mixture, which is ever circulating and being maintained at a high temperature, and contains a number of compound organic bodies, each of which is liable to a series of varied metamorphoses. It is not a very potent agency which is needed to disturb the chain of conditions of one of those inconstant bodies which is thus continually performing the circuit of the system. I may briefly exemplify the series of changes, simple but momentous, which an organic body is capable of undergoing, if I instance the combination of elements which constitutes Urea. By bringing Ammoniacal gas in contact with the vapour of Cyanic acid, we produce Cyanate of Ammonia, a poisonous salt. This, when exposed for some time to the air, changes into Urea, which is isomeric with it, but comparatively innocuous. Urea, when heated, gives off Ammonia, and becomes Cyanuric acid. On again heating this, hydrated Cyanic acid sublimes. This, when brought in contact with water, becomes Bicarbonate of Ammonia. Two equivalents of Cyanic acid, uniting in one compound, produce Fulminic acid. This, if combined with the oxide of Silver or of Mercury, forms a compound which is caused by the slightest friction to explode with terrific violence. If to the elements of this dangerous acid be added those of two equivalents of Ammonia, we again have Urea, a substance which is continually forming in the body by the oxidation of some of the nitrogenous tissues.--Urea with water changes lastly into Carbonate of Ammonia. These several compounds, alike or identical in their ultimate composition, are possessed of very different properties, whether regarded as medicinal or as chemical agents. A similar set of changes may be produced among the elements of Uric acid, also an animal product. Changes in some respect similar to these which are produced by the Chemist are no doubt continually going on, or capable of being set up by various influences, in the circulating blood, which is at a heat fit for such processes; in which also is a considerable quantity of free oxygen, as well as soda, ammonia, and other elements, in a state fit for combination; and to all these is superadded the agency of the vital principle, the object and effect of which is continual alteration, destruction and reproduction. By supposing the establishment of a set of changes in the blood, we may possibly gain some insight into the cause of the powerful effects of some apparently insignificant medicines belonging to this division of Hæmatics. Neurotic medicines appear to act by their mere presence, contact and excitation. This may not always be the case with Catalytics. Their power cannot in all cases be clearly accounted for by a simple and direct influence on the blood, the muscles, the nerves, or any of the tissues. It seems sometimes as if it were on the processes that their presence sets going, and on the products thus generated, that their influence and power depend. It may be observed that this idea of action by contact cannot by any means be supposed to favour the very unreasonable theory of the efficacy of infinitesimal doses of drugs. For such medicines must of necessity be present in some amount, or they cannot act at all. Their operation cannot be like that of the putrefying yeast, or of the poisons of contagious fevers, each of which can reproduce itself out of the elements of the changing or fermenting body. For Antimony, Mercury, and Iodine could never make themselves out of blood, which does not contain them. Like the Emulsine in the production of Hydrocyanic acid out of the material of the bitter almond, they must be present in certain quantity, or they are quite inoperative. Even a tenth of a grain would generally be powerless, not to mention such irrational quantities as the thousandth, millionth, or even decillionth of a grain. (_Vide_ page 54.) Experience--better even than theories and mathematics--is entirely opposed to such chimerical fancies. Having thus entered into a speculation concerning the probable action in the blood of Catalytic remedies, I must once more remark that this idea forms no part of the Proposition in which I have defined their mode of operation. In the present state of our information on the subject, we cannot certainly say more than that these remedies, by some blood-action, are able to antagonize and to annihilate certain disorders in the blood. The resolution of a disease thus effected may, in some few instances, be partly explained by certain chemical considerations, as will be particularly shown in the case of Antiarthritics. It remains for me now to add some brief remarks on the individual _modus operandi_ of the substances included in each of the eight orders of Catalytic medicines. Some of these having been partly discussed above, in arguing the Proposition, it will not be found necessary to travel over again that portion of the ground which has already been thus traversed. ORD. I. ANTIPHLOGISTICS. The inflammatory process--the chief seat of which, however it may first originate, is in the circulating blood--exerts a powerful influence over the nervous system, and may, by this influence, cause death. When fever is produced to any extent, there must be danger. We are enabled in two ways to control or to mitigate this state of things. We may produce an action on the nervous system, or we may direct our attention to the process in the blood. Of Neurotic medicines, which we shall have to consider hereafter, there are some which may be made use of at the commencement of the attack, and others which are appropriate when the process is more advanced. Of the first kind is Antimony, considered in its Neurotic action. Employing it in large doses, we may produce a powerful effect upon the nerves which supply the heart, and thus, by diminishing the impulse upon the inflamed parts, or on the vascular system generally, promote absorption and resolution. Blood-letting produces the same action, but in an inverse mode. Antimony diminishes the pressure on the vessels by weakening the force of the heart; Blood-letting weakens the force of the heart by diminishing the pressure on the vessels. Such Neurotics as Opium are employed at a more advanced stage, when the inflammation cannot be suddenly put a stop to, and our object is to counteract the effects it has produced. Besides relieving the pain and nervous irritation which are so much to be dreaded, Opium may be employed to prevent a blood-medicine from passing out through the bowels. Antimony and bleeding are appropriate in sthenic cases. Opium should not generally be employed in these instances, nor should it be given in brain disorders, or in any case where there appears to be a determination of blood to the head. Certain medicines of the class of Eliminatives, and certain Catalytic remedies belonging to the present order, are employed to counteract the inflammatory process in the blood. Of the former, the most important are Purgatives and Diaphoretics. By diminishing the amount of the serum of the blood, they not only tend to check effusions, but act indirectly on the heart, in the same way as the medicines last spoken of; and they probably also promote the passage of morbid or of peccant materials out of the system through the glands. Acid and saline drinks may act as Diaphoretics, besides exerting each a peculiar influence in the fluids. Of this Catalytic order, Antimony and Mercury are those which tend most powerfully to check the general blood-process of inflammation. The former is used in urgent and acute cases to make a sudden and powerful impression, adding to its Hæmatic action a sedative effect on the heart and circulation. Mercury exerts no such immediate influence. Diminishing the Fibrine of the blood, and having other operations of a peculiar kind in this fluid, it powerfully promotes absorption and counteracts effusion, in all inflammations. The blood-action of these remedies, though not positively slow, is slow when compared to an action on nerve. Thus when Antimony is given in large doses, as is desirable in some highly sthenic and dangerous attacks, its blood-action is lost in its immediate Neurotic operation. So that in Croup and Pneumonia, both rapid and fatal inflammations, Antimony is far preferable to Mercury. But in Pleurisy--where there is generally no immediate danger to be dreaded, but a subsequent effusion, Mercury is best, being in time to lessen or to prevent this result. From the action of both on the blood, and one on the nerves, these are very lowering remedies. In the employment of Antimony in fevers and inflammations, the production of nausea generally indicates that it has taken sufficient effect; but it may sometimes be better to give such a dose as shall cause vomiting, especially when a violent counter-irritant action is to be desired. The increase in the quantity of saliva, and slight soreness of the mouth, which result from its action, will show when the administration of a Mercurial has gone far enough. It is seldom advisable to cause copious salivation. Alkalies dissolve the Fibrine of the blood, and appear by this to lessen its deposition, and retard its formation. Thus, when given in large doses, they operate as Antiphlogistics. They have sometimes been employed with advantage in fevers of the acute or sthenic kind. Exerting an influence over the inflammatory process considered _per se_, Alkalies and Mercurials are more particularly efficacious in some special varieties of inflammation, because in such cases they further counteract the morbid agency by which the process is excited and kept up. In the Typhoid and Eruptive Fevers, when the blood is already sufficiently deteriorated, and it is not desirable that we should reduce the vital powers beyond a certain point, Salines, as Nitrate and Chlorate of Potash, supply us with a set of valuable and sufficiently mild Antiphlogistic agents. It seems that they both exercise a solvent power over Fibrine, and keep asunder the corpuscles which tend to adhere together in inflammatory blood. This latter action has been observed by Mr. Gulliver. Salts are excreted, and act on the skin, or the kidneys, or the bowels. They are not so potent as Alkalies; for salts pass out of the body as they went in; but Alkalies pass out into the secretions as salts, having first combined with acid in the system, so that they must leave behind them a certain excess of alkali in the blood, by which their action is continued for some time. (_Vide Alkalies; Prop. VIII.; Antimony and Mercury in Chap. IV._) ORD. II. ANTISYPHILITICS. These are medicines whose operation in the blood results in the counteraction or neutralization of the syphilitic poison. In primary forms of Syphilis, as the chancre, and early eruptions,--as syphilitic Lichen, Roseola and Lepra,--also in syphilitic Iritis, Mercury is the single and best remedy. Its power is universally admitted, both by English and Continental surgeons. It is often esteemed a specific. Among others, Mr. Hunt, in a treatise on Syphilitic eruptions, maintains that Syphilis has a tendency to go on without limit if left alone, but that Mercury in sufficient doses possesses the power of totally destroying the poison, and preventing its transmission. Mr. Carmichael was of opinion that Mercury was only applicable in those cases which exhibited the true Hunterian chancre, round, cup-like, and hard, followed by a leprous eruption. But it is more in accordance with common experience to say that the only contra-indications to the use of Mercury in primary Syphilis are these--a scrofulous or very debilitated state of the system; and a sloughing or irregular appearance of the primary sore. We may administer Mercury in two forms. It may be given as Calomel or Blue pill, with or without Opium, and continued until it affects the mouth. Or the Bichloride may be administered in minute doses, and may prove efficacious without producing salivation. It should be commenced as early as possible; and in most cases the action of Mercury in the blood, of whatever nature that action may be, will meet and neutralize the advance of the syphilitic virus, preventing its further manifestation in a secondary form. It is rarely necessary to push its action beyond the first symptom of salivation; for that will be evidence that the system is sufficiently saturated with it. Beneficial as it often proves when administered thus cautiously, yet, if given in excess, or to individuals that are over-susceptible of its action, it is capable of proving a poison every whit as noxious as the Syphilis which it was intended to neutralize. The mercurial cachexy is quite as deplorable, and quite as incurable as the Syphilitic cachexy. The Terchloride of Gold may be used in Syphilis in the same way as the Bichloride of Mercury; but it is much more seldom employed. There seems to be a strong medicinal as well as chemical similarity between these two metals and their compounds. Even the insoluble metal itself was used some time ago as an Antisyphilitic, apparently with success. In 1715, Dr. A. Pitcairn recommended finely-powered Gold as even more efficacious than Mercury in the treatment of Syphilis. In secondary forms of this disorder, as in Periostitis, ulceration of the mouth and throat,--or in any of the late rashes, as Rupia,--Iodide of Potassium is the best remedy. Its efficacy in such cases was discovered by the late Dr. Williams. It may sometimes fail to effect a cure; but this failure is often due to the omission of Mercury in the treatment of the primary disease. It would seem as if it were not so much the real secondary syphilis, but a certain smouldering action of a part of the poison which has escaped the operation of Mercury, but has been modified by it, which is capable of being met and controlled by Iodide of Potassium. In cases where this remedy fails, I have found that a course of the Bichloride of Mercury, combined with Sarsaparilla or some bitter tonic, proves very beneficial. But the action of the Iodide on a case of Periostitis, and the rapid absorption that follows its exhibition, are sometimes fully as remarkable as the influence of Mercury over the primary disorder. Sarsaparilla is a very doubtful member of this order. It contains a soluble principle called Smilacine. It is thought by some to purify the blood, and also to have a kind of specific influence over it in old syphilitic cases. If it were so, we should have from the vegetable kingdom a distinct analogue to one of these mysterious mineral Catalytics. But it is so rarely given without being combined with some more powerful agent, that it is difficult to judge whether or not it may have any striking virtues of its own. The Antisyphilitics, particularly the insoluble compounds of Mercury, are frequently employed as local applications to sores and eruptions. When these have a syphilitic origin, the mercurial doubtless combats the local manifestation in the same way that it can counteract the general action in the blood. In other cases the Mercury may pass into the blood of the part, and, by exerting in its antiphlogistic operation, the result of which is to diminish its plasticity, may thus promote absorption. Mercurial ointment, if rubbed into the skin, becomes in part absorbed, and may thus produce salivation. ORD. III. ANTISCROFULICS. These are medicines which have the power of counteracting the poison of Scrofula in the blood. Common and pernicious as is this disease, there are not many Catalytic remedies which exert any marked control over it. When a strumous condition is chronic, and has firmly established itself--when it has descended through many generations of the same family,--it is very intractable and difficult to cure. Palliative and indirect remedies, aimed rather at the consequences than at the source of the disorder, are often adopted with benefit. Tonics, Chalybeates, Cod-liver oil, and cold bathing, are frequently of use in improving the condition of the system, when debilitated by the long continuance of strumous disorders. But the most important and direct remedies for Scrofula are to be found in Iodine and its compounds. It is not to be wondered at that in many cases of deeply-rooted blood-disease, complicated perhaps with anæmia, structural change of organs, disordered assimilation, and various nervous symptoms, all remedies alike should prove useless. So that the experience of many practitioners, thus frequently disappointed in their hopes of a cure, has led them to question altogether the efficacy of Iodine in Scrofulous disorders. But it is generally allowed that it is more beneficial in such cases than any other medicine, and is the only remedy which is universally applicable in Scrofula. If this be true, it follows that it must have a special power over this blood-disease. Burnt sponge, and the ashes of a seaweed, the Fucus vesiculosus, both of which contain Iodine, have been used in Scrofula from very early times. But it was not until the present century that Iodine was discovered, and its efficacy in Scrofula, particularly in the cure of Goitre, pointed out by Dr. Coindet of Geneva. After this it came to be generally applied in all Scrofulous cases, and was especially recommended by M. Lugol in France, as a specific for such maladies. When given for some time, Iodine has the effect of impoverishing the blood, like Mercury and many other Catalytics, diminishing in it the amount of Fibrine. All remedies which do this favour absorption. This effect is obviously connected with the alteration in the blood, and there is no reason to suppose that any special stimulant action is exerted on the absorbent vessels. Those Catalytics which favour absorption are not all useful in the same cases, but some are most useful in one disorder, some in another. Thus they must exert a special action over morbid poisons; an action which is altogether distinct from the influence over absorption, although by this latter they may be able to cause the disappearance of effused products, and of tumours produced in various ways. In some rare cases Iodine has even been known to cause the absorption of healthy glands, as the mammæ and testicles. Iodine and Iodide of Potassium, when successful, do not merely cause the disappearance of scrofulous tumours, but further meet and neutralize the poison which is working in the system, and effect a more or less permanent cure. This could hardly be done by a remedy which had only the power of promoting absorption. It seems that some systems are able to bear with impunity very large doses of Iodide of Potassium. I once met with a medical man who denied its power altogether, because he himself had frequently taken a scruple, and sometimes a drachm at a time, without any effect. Other men are readily affected by very small quantities, and quickly experience the symptoms of Iodism. It is probable that in the former case the medicine is very quickly eliminated by the kidneys; but that in the latter it remains in the system for some time. The Iodide of Iron is a most useful medicine for scrofulous children, who commonly suffer under Anæmia, as it combines a Chalybeate with an Antiscrofulic action. Bromine and Chlorine resemble Iodine in their Antiscrofulic effects. It is said that Scrofula and Consumption are unknown among the workmen in bleaching factories, where Chlorine is being constantly inhaled. Thus it has been strongly recommended that diluted Chlorine should be constantly inhaled by consumptive patients. It is probable that part of the efficacy of sea-side air and sea-voyages in scrofulous cases may be due to the free Chlorine which is given off in small quantities from the salt water of the ocean. The powers of Iodine and Bromine are shared by their compounds; and probably Chlorine is no exception to this rule. The bad consequences which follow the omission of common salt from the food, are sufficient to show that this substance has a beneficial action on the blood. Probably large doses of this article of diet would be found advantageous in Scrofulous disorders. It is easy to recognise such an action as that of Iodine in Scrofula, but it is almost impossible to invent a satisfactory explanation for it. Potash, free or carbonated, is another remedy of considerable importance in Scrofulous diseases. It is possibly one of those Catalytics which exert a simple chemical influence. It may act by holding in solution fibrinous and fatty matters, and preventing their abnormal deposit in a crude form in the shape of tubercular matter. It may also be found useful in cases of Syphilis, when aggravated by a previously existing strumous tendency, and where a course of Mercury cannot be safely prescribed. Small doses of Mercury, as an alterative, are often efficacious in scrofulous constitutions. They appear to act simply by stimulating the torpid liver to a performance of its proper function.[40] (_Vide_ page 144.) Potash has been used as a prophylactic against Consumption. The efficacy of Cod Oil in this disease has been explained by some as depending on the Iodine which it contains in small quantities. I do not consider this explanation to be the correct one. (_Vide Cod Oil, in Chap. IV._) ORD. IV. ANTIARTHRITICS. In this order are included some blood-medicines which exert a direct influence over certain disorders which depend on some fault in the complicated processes of assimilation and nutrition. The chief of these diseases are, Diabetes; Oxaluria; Lithic deposit in the urine; and the true Arthritic disorders, _i.e._, Gout and Rheumatism. Most of those blood diseases which cannot be clearly traced to the introduction of a poison from without may be arranged under this head, and appear to be curable by the same set of remedial agents. There are certain processes always going on in the blood, whose continuance in the right direction is essential to health. When one of these processes is disturbed, it does not generally cease, but it goes on then in a wrong direction. The natural processes result, on the one hand, in the preparation of fit and proper nutriment out of the materials of the digested food, for the growth and support of the several tissues and functions; and, on the other hand, in the gradual change and conduction out of the body of the products of the waste of those tissues. But when any process goes on in a wrong direction, it results in the formation of various products different from those which are required, and which the kidneys and other glands are at length called upon to excrete from the system. The result is that the general health is more or less seriously impaired. There is also another way in which these diseases are not unfrequently caused. A natural process may stop at a certain point, and go no further. The material formed at that stage remains as it is. It is not wanted; it is morbid; and it also is excreted from the body. It is possible that these errors in the assimilative processes may sometimes arise in the first instance from a deficiency in the blood of some substance whose influence was necessary to the proper conduct or control of the natural series of changes. Some of these conducting materials may be formed by the liver; for it is found that these disorders are very commonly connected with an impairment of the function of that organ. Thus Mercury, which restores the secretion of the liver, is often useful in Arthritic disorders; as also is Quinine, which has already been shown to have a peculiar relation to liver diseases. But these disorders, however they may first originate, consist in an active morbid process of one kind or another; and the surest way of counteracting this process, or of diverting it into a right direction, is by the employment of one of the Catalytic medicines contained in this order. Some stages of these diseases are attended with a want in the blood of some of its ordinary constituents; which condition may be relieved by the supply of a Restorative remedy. Thus in this group of disorders three kinds of medicines may be employed, which tend in various ways to improve the condition of the blood. Acids and Alkalies are sometimes needed, and act on the Restorative principle. The true Antiarthritics are those medicines which are employed on the Catalytic plan, to meet and neutralize the morbid material or process in the blood. And sometimes Eliminatives are made use of, which seem, by acting on the secretions of the skin, kidneys, or bowels, to be able to rid the blood of an unnatural product. Thus Guaiacum and Salines are employed in Rheumatism, and Purgatives in Gout. These two joint affections are most characteristically under the influence of Catalytic remedies. Diabetes and Lithiasis are more under the control of Restoratives than the others. The medicines composing this fourth order of Catalytics have been already enumerated. That Colchicum tends in some way to neutralize in the blood the poison of Gout, and to a less degree that of Rheumatism also, is generally admitted, although various theories have been adopted to explain this action. (_Vide Chap. IV. Art. Colchicum._) In Oxaluria, the employment of Nitric acid as a remedy was first recommended by Dr. Prout. Dr. Golding Bird advised the substitution of Nitro-hydrochloric acid, which has proved to be a most valuable remedy, not only in this disorder, but also in some cases of lithic deposit. The Oxalate of Lime rarely occurs alone in the urine; there is generally along with it some Urate of Ammonia. The causes of the two deposits appear to be in some way connected. So also are the remedies similar. Dr. G. Bird has found Colchicum to be of signal service in cases of lithic deposit in the urine; and has proved the same medicine to be efficacious in Oxaluria. I will now attempt to show how the action of these medicines may admit, on certain grounds, of a chemical explanation. There are very few Catalytic actions in which such an explanation can be attempted, but a degree of plausibility appears to attach to the idea in this case, though it cannot of course be considered to be susceptible of more than a demonstration of probability. I have already said that in all the disorders now under consideration there are certain morbid constituents in the blood which have been recognised by chemical tests. In Diabetes there is an excess of grape-sugar formed in the blood, and excreted from it in the urine. In Rheumatism we have a painful joint affection, attended with a great development of acid in the system; and this acid, which we have many reasons for supposing to be lactic acid, is occasionally excreted by the skin. In Gout we meet with another Arthritic affection, in which there is urate of soda in the blood, and an excess of uric acid and urea in the urine. A simple excess of uric acid in this secretion constitutes Lithiasis. There is an obvious but ill-understood connexion between the last two disorders, and, indeed, between all those of which we are treating. In Oxaluria we have an abnormal formation of oxalic acid in the blood, which is excreted in combination with lime, for which base it has a great affinity. In oxalic urine there is generally an excess of urea, as I have found in many cases. Now it seems to me that all these disorders are capable of being explained by reference to the series of changes in the blood which are associated with the respiratory process. (_Vide Liebig's Anim. Chem._, part i. p. 133; _Dr. B. Jones' Anim. Chem._, pp. 20, 118.) It is the general opinion of modern chemists, that before the starch of the food can be applied to the maintenance of the animal heat, for which office it is chiefly intended, it passes through a series of chemical changes. First, assuming two equivalents of water, it becomes grape-sugar; next, this changes into lactic acid, which is isomeric with it; and this again combines with twelve atoms of oxygen, to form carbonic acid and water. This last change is a process of combustion, and thus produces heat. The oxygen needed for it is absorbed from the air by the pulmonary mucous membrane, and the carbonic acid formed passes out of the blood at the same surface. Liebig was the first to point out the connexion between these changes and the phenomena of Diabetes. It is clear that if the process were to stop at the formation of grape-sugar, the condition of blood that exists in Diabetes would result. This sugar cannot be put to any use, and is excreted as fast as formed. There is an excess of urea in the whole quantity of urine passed in the day; probably because the nitrogenous food and tissues are undergoing combustion instead of the starch. Before becoming grape-sugar, starch undergoes a transitional change into Dextrine, a gummy insipid substance which has the same composition as itself. It seems that the process may even stop as early as this, and that by this stoppage another analogous disease may be produced, _i.e._ Diabetes insipidus. The common Diabetes is called D. mellitus. (_Vide Jones' Anim. Chem._ p. 120.) If it were clearly proved that the acid of Rheumatic fever is lactic acid, then this affection might evidently be produced by a stoppage of the process at the next stage. Lactic acid has been formed; but, for some reason unknown, it is not oxidized into carbonic acid. Urea and uric acid are in excess in the urine, from the cause alleged above. But suppose some of the sugar to be oxidized prematurely, without passing first into lactic acid. By this oxalic acid would be produced, and the phenomena of Oxaluria accounted for. These things are only alleged as possible, and for the purpose of showing that, should they be true, the action of some useful remedies might be elucidated. It is not at all unlikely that the accuracy of such ideas may be completely established by fresh discoveries at no distant time. But let us continue. In Gout and Lithiasis there is an excess in the system of nitrogenous matter, and thus a tendency to an extra formation of urea. These conditions are often brought on, and always aggravated, by over-indulgence in animal food. Now if we may suppose that some of the lactic acid, instead of oxidizing directly into carbonic acid, oxidizes in combination with this urea which is in excess, then uric acid and water might result, as is shown below. The uric acid passes out into the urine in excessive quantity. Should this be the case, the great affinity existing between the course and symptoms of Gout and Rheumatism would be easily explained, there being in both disorders an impediment to the proper oxidation of lactic into carbonic acid. These things may be illustrated by a diagram, showing the results which are supposed to take place when the natural process is arrested at, or diverted from, any of its stages:-- Starch. |+ |2 |a |q |= Grape Sugar (Diabetes.) | |\ | \ | \+ O = | \ | \ | \ Oxalic acid. (_Oxaluria._) | |= Lactic acid (Rheumatism.) | |\ | \ | \+ 2 Urea + O 6 = | \ Uric acid + 10 aq. (_Gout, and Lithiasis._) |+ |O |= Carbonic acid. Thus, at each of the two transitional stages, we might have one diseased condition produced by an arrest of the process, and another by its deviation. These deviations and stoppages may result from a failure of some natural principle which is gifted with the control and direction of the series of transformations; or they may simply be traceable to a want of vital energy, or nervous force. The same ideas may be more distinctly expressed by a few chemical equations. _Natural process._ C_{12}H_{10}O_{10} + 2 HO = C_{12}H_{12}O_{12}. = 2 (C_{6}H_{5}O_{5}, HO.) C_{6}H_{6}O_{6} + O_{12} = 6 CO_{2} + 6 HO. _Oxaluria._ C_{12}H_{12}O_{12} + O_{18} = 6 C_{2}O_{3} + 12 HO. _Gout and Lithiasis._ Lactic acid + 2 Urea + O_{5} = Uric acid + 10 HO. The last equation may be thus proved at length:-- C_{6} H_{6} O_{6}. C_{10}H_{4} O_{6} N_{4}. C_{4} H_{8} O_{4} N_{4}. O_{6}. H_{10}O_{10}. ------------------------ ------------------------ C_{10}H_{14}O_{16}N_{4}. = C_{10}H_{14}O_{16}N_{4}. It is next to be inquired how far the theoretical explanation of these diseases which has thus been sketched out can be applicable to the matter in which we are more immediately interested, viz., the action of the Catalytic remedies used to cure them. For the radical cure of Diabetes there is no known remedy; though some relief may be afforded by a system of dieting. (_Vide Aliments._) It is supposed that what we have to do is to convert diabetic sugar, _i.e._ grape-sugar, into lactic acid. This acid probably exists in the gastric juice. And some such substance as Pepsin, or the decomposing Caseine in sour milk, which is capable of effecting this change out of the body, might perhaps avail us, if we could contrive to introduce it into the blood. In Oxaluria, the best treatment consists in a course of Nitro-hydrochloric acid. This remedy is prepared by adding one part of Nitric to two of Hydrochloric acid; and is diluted considerably with water when prescribed. The Nitric acid causes the oxidation of some of the Hydrogen of the other acid, and thus sets free Chlorine gas. This is stated by Mr. Brande to go on until the liquid is saturated with this gas. The result of the presence of Chlorine is, that from the affinity of this gas for Hydrogen, by which, under certain circumstances, it is enabled to set free the Oxygen of water, this compound acid becomes the most powerful oxidizing agent known. This acid has been lately used as a remedy for Gout and Rheumatism, in spite of the acid state of the fluids in those cases; and I believe it to be a very valuable medicine in both of these disorders. A simple mineral acid would do no harm in both instances. The Nitro-hydrochloric acid must operate in some special way. It is probable that its action may depend upon its oxidizing power. In Oxaluria it might cause the oxalic acid to be oxidized into carbonic acid, and thus restore health. Thus: C_{2}O_{3}+O = 2 CO_{2}. In Rheumatic fever, where we have supposed that lactic acid is formed as it should be, but then stops short, and proceeds no further, the oxidizing agent may convert this into carbonic acid. In Gout and Lithiasis, where there seems to be an excess of nitrogen in the system, and thus more oxygen is needed to restore the equilibrium, I have supposed that lactic acid and urea are changed together into uric acid. If we adopt this hypothesis, it will be evident that under the above treatment this uric acid may be oxidized back into urea and carbonic acid, and the balance of health restored. Thus: Uric acid + 6 O + 4 HO = 2 Urea + 6 CO_{2}, which may thus be proved: C_{10}H_{4}N_{4} O_{6} O_{6} C_{4} H_{8}N_{4} O_{4}. H_{4} O_{4} C_{6} O_{12}. ---------------------- ----------------------- C_{10}H_{8}N_{4}O_{16} = C_{10}H_{8}N_{4}O_{16}. Such may be the action of Nitro-hydrochloric acid. It exerts a true Catalytic or counteractive influence. But we have to explain the agency of another class of very different, and apparently opposite remedies. Alkalies are employed with benefit both in Rheumatism and in Gout; particularly in the former disease. Now I conceive these to act, in Rheumatism at least, simply on the Restorative principle; supposing lactic acid to exist in excess in Rheumatic blood. This by itself may have no more tendency to oxidize into carbonic acid, than so much vegetable acid would have. In ordinary cases a free vegetable acid passes out into the urine without undergoing any change in the system. But it has been proved by Wöhler that the same vegetable acid becomes oxidized when given in combination with an alkali. So that if we introduce into Rheumatic blood a free alkali, a lactate of potash or of soda will be formed; this may then be enabled to oxidize into a carbonate, and the natural process be completed. Such appears to be the rationale of the action of alkalies. They would be inefficacious in Oxaluria, because the oxalic acid has so great an affinity for lime, that it could not be separated from this combination by an alkali. Dr. Rees and others have found Lemon juice of great use in the treatment of acute Rheumatism. It contains Citric acid, and some Citrate of Potash; the latter being in too small amount to explain the action of the remedy. I have already shown how it seems possible that the vegetable acids may act as refrigerants in simple fever; how they may then supply the place of the natural lactic acid in the blood, and become oxidized instead of the Proteinaceous compounds. (_Vide Acids._) But Rheumatic fever is a very different case, for there is here apparently an excess of lactic acid, and an arrest of its oxidation. In considering, however, the formula for Citric acid, we perceive that not only does it contain proportionally more Oxygen than Proteins, as was proved in the former instance, but more than lactic acid contains. It is C_{12}H_{5}O_{11} + 3 HO. Thus it is possible that it may act as a carrier of oxygen to the lactic acid, and so help it on towards its transformation into carbonic acid. It appears to be decomposed in the system, for Dr. Rees has never known it in these cases to increase the acidity of the urine. The matter is obscure; but we can discern enough of it to convince us of the possibility of different medicines acting in diverse ways so as to produce very similar results. Colchicum has apparently some power in the diversion or control of these morbid processes, which we can only indicate, but cannot further comprehend. It is generally best to give it so that it shall neither produce purging, nor any great degree of general depression. Mercury and other medicines which promote the secretion of the liver, are found to be of considerable use in the treatment of all of these diseases, but more especially in Gout. They seem to act by virtue of their power in eliminating and producing Bile. And it is likely that some constituent of Bile, reabsorbed into the blood, is able to exert a beneficial influence on the conduct of such processes as those which we have just now considered. Quinine and Tonics have been strongly recommended by Dr. Todd in Gout; and they seem to be signally efficacious, both in this and in the other Arthritic disorders. This is a very interesting fact. If there should be any truth in an idea which I have explained at length in the article on Tonics (_vide_ p. 142,) it would seem that these Tonics may be of use by supplying in the blood the place of one of the wanting elements of Bile. For in all Arthritic disorders there is more or less of hepatic derangement. There seem then to be six separate and distinct explanations of the cure of these Arthritic diseases. There are six different modes of operation by which the same beneficial result may follow the employment of Nitro-hydrochloric acid, free Alkalies, Lemon juice, Colchicum, Mercury and Quinine. So that if it should be proved, which is not unlikely, that the chemical theory propounded above for the purpose of accounting for the production of these disorders in the blood is a correct view of the case, then this explanation of the action of the various remedies used in such diseases would acquire an additional probability. But at present the idea is purely hypothetical, because depending upon a number of things which, although they seem likely, are far from being proved as yet. All that we can affirm with any degree of certainty is that a number of blood-medicines are applied with advantage to the treatment of these kindred disorders, tending to counteract the morbid conditions by which they are severally produced. These Antiarthritics must operate, then, on the Catalytic principle. A number of varieties and masked forms of these disorders are grouped together under the general title of Dyspepsia. The depraved condition of the blood which tends to the production of arthritic symptoms may, when controlled and disturbed by various causes, simply manifest itself by causing acidity of the stomach, flatulence, impairment of digestive power, and general lassitude. Different Antiarthritic remedies are applicable in different cases. Colchicum or Nitro-hydrochloric acid are serviceable when this condition of the system is of long standing. Small doses of Mercury are often efficacious. Tonics, and a Purgative occasionally, may be recommended in milder forms of the disorder. ORD. V. ANTISCORBUTICS. These are remedies which are useful in the counteraction of Scurvy and Purpura. In these disorders there is a thin and poor condition of the blood, together with a deficiency in the amount of albumen, fibrine, and the solids generally; a tendency to hæmorrhages and ulcerations, consequent on this condition of the blood; and great general depression and debility. There is no doubt that these changes in the blood are due to a certain morbid action. It seems that there are some kinds of food which are able to prevent the occurrence of this morbid action, or to control it when it has been set up. The worst forms of Scurvy occur among sailors in long voyages, who have been deprived for some time of fresh vegetable food; and it is often observed that those who have been thus afflicted on land have been subjected to the same deprivation. But it does not follow as a matter of course that those who are thus deprived become invariably the victims of Scurvy. It seems that there are certain constitutions which are more disposed to it than others; and that when these systems are deprived of some articles of diet which are able to prevent or to neutralize the working of the poison in them, the latent morbid action is allowed to commence. Of all the substances of which trial has been made, Lemon or Lime juice, and Potatoes, are said to be of the greatest use in the treatment of scurvy. The former is generally employed on board ships. These both contain Citric acid and salts of potash. But the chief agent in the cure should be something which is not contained in the food eaten by those who are commonly attacked with Scurvy. The food of the sailors who are thus afflicted consists mainly of salted beef and sea-biscuit. Both contain salts of Potash; neither contain Citric acid. So that from this consideration it would seem as if the free acid must be the remedial agent. Vegetables in their fresh state generally contain a small quantity of this or some other acid; and fresh vegetable food is always the best prophylactic against Scurvy and Purpuric diseases. Various wild herbs, some of which contain Oxalic instead of Citric acid, are used among the poor for this purpose.[41] Dr. A. B. Garrod is of opinion that Scurvy is attributable to a deficiency in the system of the natural amount of the salts of Potash; he therefore treats it with salts of Potash, and apparently with success. (_Monthly Journal of Medicine_, January, 1848.) The salts of Potash, if used on such grounds, would obviously act as Restorative agents, and supply to the blood a material in which it is deficient. But Citric acid could not remain in the blood; and if it cures Scurvy, it must act on the Catalytic principle. It could not supply to the system any permanent material. Dr. Garrod concludes from analysis that the antiscorbutic articles of diet are distinguished by containing an abundance of the salts of Potash, but that the reverse is the case with the materials which form the staple food of those who are most liable to Scurvy. He gives the following as the amounts of potash obtained from one ounce of each of the articles of diet named:-- Wheaten bread .259 grains. Oatmeal .054 " Salted beef .572 " Boiled potatoes .529 " Lemon-juice .846 " Thus it appears that lemon-juice and potatoes contain more Potash than wheaten bread, and much more than oatmeal. But they do not so much excel salt beef in this particular, and that is one of the chief articles of diet among sailors. And if this deficiency of Potash were the sole cause of Scurvy, then it should be unknown in Ireland, where quantities of Potatoes are eaten, and very common in Scotland, where Oatmeal forms so important an article of diet among the peasantry. I am certainly not aware that such is the case, but believe it is rather the reverse. In spite of the very able arguments and the instances adduced on the other side, it seems to me that the probability is still in favour of the vegetable acid being the active or curative agent in these antiscorbutic vegetables. It seems to exert a purifying power over the blood in this disorder, of the exact nature of which we are not aware. It is probably not only Citric acid that is efficacious, for it appears that some other vegetable acids, and vegetables which do not contain Citric acid at all, may be used with advantage in Scorbutic diseases. ORD. VI. ANTIPERIODICS. Certain mineral medicines of the Catalytic division are employed in the treatment of periodic disorders. Arsenic is a medicine of considerable power, which, when given in too large a dose, or indeed when given at all in most cases, becomes a poison. It has already been shown to act in the blood, and to produce in it a number of effects of a particular kind. One part of this operation is that it is capable of antagonizing the poisons of intermittent disorders, as also of certain convulsive affections and skin-diseases. In health a poison, in disease it proves a remedy. But the dangerous nature of its action is such as to demand considerable care in the administration of the preparations of Arsenious acid. Dr. A. T. Thomson states that the action of Arsenic is liable to exacerbations and remissions, and sometimes even intermissions. Thus we may suppose that there is a certain degree of analogy between its operation and that of the malarious poison, by virtue of which it may perhaps exert a corrective power over the working of the latter in the blood. (_Vide_ page 166.) Such an analogy could only exist in the case of a Catalytic medicine. It is not observed of Quina, which is employed in intermittents on the Restorative plan. Arsenic is foreign to the blood, and is in every way a Catalytic medicine. In large doses Arsenical preparations act on the stomach as irritant poisons. Some of them have been used externally as Caustics, especially in Lupus. But this is a kind of action that does not concern us now. The officinal solution of Arsenite of Potash was introduced into notice by Dr. Fowler, and is the chief preparation of Arsenic employed. De Valangin's solution contains a Terchloride of Arsenic, and is of less than half the strength of the others. Both of them are used in Ague. Some recommend, in all cases where Arsenic is used, to begin with small doses, as two drops of Fowler's solution three times a day, and gradually to increase the quantity; from the idea that the system will thus be enabled to tolerate the remedy better, and that irritation of the stomach will be avoided. Mr. Hunt deprecates this practice, and recommends regular doses of three to five drops or more. It may be safely continued during the paroxysm of Ague, which is a plan that is generally considered to be unadvisable in the case of Quina. The latter may be given in a very full dose between the paroxysms; but this cannot be done with Arsenic, for the consequences would be dangerous. It is best in all cases to give the Arsenic after a meal, on a full stomach, as then it is less likely to irritate, not coming directly in contact with the coats of the stomach, and being diluted by the food during its absorption. Arsenic is useful in other intermittent disorders besides Ague, as in the various kinds of intermittent neuralgia. It has been given in some varieties of intermittent pulse, which are not due to organic disease of the heart. Dr. Darwin cured a case in which the beats of the heart intermitted regularly once in every three or four times, by the administration of four drops of a saturated solution of Arsenious acid three times a day. The preparations of Arsenic have even been used in some cases of Gastrodynia with considerable advantage. In these instances the disorder of the stomach generally assumes an intermittent form. It has been supposed by some that Arsenic in such disorders acts directly upon the nerves; but it appears to counteract all the manifestations of this intermittent poison, whether local or general, by the same action in the blood. (_Vide_ page 212.) Several attempts have been made at different times to discover a substitute for Arsenic, and a cheaper remedy than Quinine, for the treatment of Ague. Iron is employed with advantage in old chronic cases attended with Anæmia; but it is not of service by counteracting the intermittent, but by remedying the anæmic condition which co-exists with it. M. Piorry, in the course of some experiments made at the Hôpital de la Pitié at Paris, has found common salt in half-ounce doses to be very efficient. In his opinion it is more efficacious than Arsenic, and second only to Quinine, in the cure of this disorder. The suggestion is a valuable one; but the dose is very bulky, and it would be difficult to prevent it from causing vomiting in many cases. Alum is another medicine which has been recommended in Ague. It also appears to act on the Catalytic plan; but it has not been often employed. The compounds of Arsenic are found to exert a curious antiseptic influence on dead animal tissues. They particularly prevent decomposition in animal membranes, by virtue of a combination which Arsenic forms with Gelatine. Liebig has founded on these facts a theory of the medicinal action of Arsenic. (_Anim. Chem._, part i. p. 206.) He supposes that substances as Arsenic and Mercury may be able to arrest contagious and other disorders in the system in the same way that they control putrefaction out of the body. The use of Salt and Alum in Ague might seem at first sight to countenance such a hypothesis as applicable to the treatment of this disease. But we know that Arsenic does not stop all fermentations. The grain of wheat will germinate, and its starch be converted into sugar, after it has been steeped in a solution of Arsenic to protect it from vermin. And Gelatine, for which Arsenic has an affinity, has not been proved to exist in healthy blood. The compounds of Mercury, the operation of which in Syphilis is sought to be explained on these grounds, are not nearly so antiseptic as many other minerals. If this theory were correct, then all Catalytic medicines, and all antiseptic substances, should be of equal efficacy in all morbid processes. But this is far from being the case. Many substances which are distinguished for their antiseptic powers are found to have no influence whatever on the progress of these disorders. Are Acetic acid and Creosote of any use in Ague? Does Alcohol prevent the drunkard from contracting Syphilis? And if Arsenic, Alum, and common salt, acted solely by arresting fermentation, how is it that they have no control over the supposed fermentations of Syphilis and other diseases? The explanation required must needs be more specific and particular. ORD. VII. ANTICONVULSIVES. I have already sought to show that the metallic substances which are used in the treatment of spasmodic disorders act in the blood, and tend to establish in it a set of actions of a peculiar kind. I am able to add little respecting the rationale of their action to that which I have said of the operation of Catalytic medicines in general. It is certainly very mysterious; and it is perhaps mainly on this account that some have been induced altogether to deny it. But a denial so grounded is disingenuous and wrong, for we must often be content to know and to receive many things that we do not understand. Perhaps the most evident and characteristic of these agencies is that of Nitrate of Silver in the cure of Epilepsy. The Acetate of Lead, and the Ammonio-sulphate of Copper, have been used with advantage in the same disorder. Dr. Babington strongly recommends the Sulphate of Zinc, given at first in small doses, and then gradually increased, so that it may not produce vomiting. In the treatment of Chorea, Arsenic is highly esteemed and recommended by Dr. Pereira. In Hysteria these medicines are all probably more or less applicable; but on account of the obstinate and multiform nature of this disease, their use in it is less obvious than in Epilepsy and Chorea. Hysteria, too, is more under the influence of Nerve-medicines than are the other two diseases. The great objection to Silver, in whatever form given, is that its salts are liable to be reduced in the system, and it thus tends to produce a permanent discoloration of the skin, either browning it or communicating to it a dull leaden hue. This naturally constitutes a strong ground of objection with the unfortunate patient, who would often prefer to be left alone with his fits than to be turned blue for life. M. Georget supposes that the advocates for the use of Nitrate of Silver in Epilepsy employ it on the principle of counter-irritation, saying that they attempt to cure a diseased brain by cauterizing the stomach. (_Physiology of the Nerv. System_, vol. ii. p. 401.) But I am not aware that any English therapeutists have adopted this view of its mode of operation. The dose of the Nitrate of Silver, and the state of dilution in which it is given, would certainly prevent it from manifesting any such action. And we should not be warranted in supposing that any of the medicines of this or any other order of Catalytic remedies could act in so direct and so easy a way as that, even if it were thus possible. Some have supposed that Nitrate of Silver cures Epilepsy by diminishing an irritable condition of the stomach. But it is observed by Dr. Pereira that the existence of this irritability in all cases of Epilepsy is a mere assumption. The solution of this salt exerts, according to its strength, an astringent or caustic action on all mucous surfaces, and thus improves their condition when they are relaxed, inflamed, irritable, or ulcerated. The occasional benefit which follows the administration of the preparations of Silver in Gastrodynia may be referred to an action of this kind. The action of Arsenic in some intermittent varieties of this painful affection has already been mentioned, and is explained in another way. Caustic substances probably act locally in these cases; but Arsenious preparations exert an Antiperiodic influence in the blood generally. Tetanus is by far the most incurable of these convulsive disorders. Arsenic and other medicines of this order have been recommended in the treatment; but although some cases appear to be partly connected in their first origin with a certain condition of the blood, this disease is very little under the influence of blood medicines, or indeed of any medicines at all. ORD. VIII. ANTISQUAMICS. Skin diseases are both caused and cured in a variety of ways. Some are produced by external influences. They may be brought on by mere irritation, as certain kinds of Eczema and Herpes, and are then to be treated with soothing unguents or cool lotions. Or they may even be connected with some external organization, of a vegetable or animal kind, as Porrigo and Favus are traceable to a parasitic fungus, and Scabies is accompanied by the development of a species of Acarus. Others are due to some wrong in the digestive process, or to a plethoric condition of the system. Urticaria is an example of the former, Acne of the latter. They may generally be treated most effectually by the exhibition of salines and rhubarb. A third class of skin diseases are due to the existence in the blood of certain poisons or peculiar morbid conditions. The eruption may constitute one only among many symptoms of the action of this poison, or it may be the chief or only symptom. The former is the case in Syphilis and the Eruptive fevers. It is with the latter kind that we are now concerned. There are two modes by which we may get rid of the poison that causes the eruption--Elimination and Counteraction. The first may sometimes be effected by the use of Purgatives, Sudorifics, or Diuretics. But I have classed in this last order of Catalytic blood-medicines some remedies that have proved useful in counteracting the causes of these diseases. The eruptive disorders alluded to are all connected together both in their symptoms and treatment; but because the squamous diseases, Lepra and Psoriasis, are the most characteristically under the influence of these remedies, the latter have been named Antisquamics. Arsenious acid, as contained in Fowler's solution, a remedy already twice named among Catalytics, is also the most powerful of these Antisquamic agents. Mr. Hunt considers it to be a specific for all skin diseases that are not syphilitic in their origin. Besides Lepra and Psoriasis, it is found useful in Eczema, Impetigo, and Lupus. In the last disorder it has been used both externally and internally, seeming to be in both cases specific in its action. Thus we find in these skin diseases another special antagonism for this extraordinary medicine, which has already been shown to be of considerable efficacy both in periodic and convulsive disorders. Pitch or Tar is another remedy which seems to be capable of counteracting the scaly disorders. It may be either applied externally, or given internally in doses of 10 to 20 grains. It has been recommended for employment in some of the other skin diseases, but its advantage in them is not so obvious. When it is applied to the skin, some one of its principles is probably absorbed. Pitch, as a remedy for Lepra, is comparatively of recent introduction, but its efficacy has already been very widely acknowledged. Tincture of Cantharides and Acetate of Potash, both diuretics, have been employed in Lepra to eliminate the _materies morbi_ from the blood into the urine, and have sometimes appeared to succeed in so doing. But in this, as in many other cases, counteraction is both easier and more certain than elimination. The system itself naturally attempts this elimination, and when it finds it impossible, we often gain nothing by urging it. I need scarcely say that these remedies are applicable only in simple Lepra and Psoriasis, and not in the syphilitic forms of those eruptions, which are treated best by Mercury, or by other medicines of the second order of Catalytics. These Syphilitic eruptions are distinguished by a coppery or a livid-grayish colour, and by the absence of itching. Sulphur has been used with benefit in Eczema, Impetigo, and Lepra. It may be administered externally in the form of fumigation or ointment, or internally in combination with an alkali or with Iodine. In the case of Eczema and Impetigo, the fumigation and internal administration are preferable, as the ointment is apt to increase the existing irritation. In the cure of Lepra the mineral waters of Harrowgate and other places, containing Sulphuretted Hydrogen gas, have been much recommended. Thus we have in Sulphur a third Antisquamic medicine. It is more or less useful in all non-syphilitic cutaneous disorders. Dr. Burgess has found sulphur ointment and fumigations to be very useful in Psoriasis palmaris. (_On Eruptions of the Face, etc., p._ 229.) Though Sulphur seems to act specifically in the treatment of these disorders, there is another disease of a similar kind which it has been supposed to cure by a mere external agency. This is Scabies. Some have fancied that even here it acted specifically, and that this also was a blood-disease. But Scabies has long been attributed to an external cause, an insect, or, more correctly, an arachnid, which, by burrowing in the skin, is thought to produce the vesicular eruption. The Acarus Scabiei, or Itch insect, was discovered in 1179 by Abenzoar, the Arabian. In 1687 Dr. Giovanni Bonomo wrote a full account of it in a letter to Redi of Florence. It is supposed that Sulphur ointments and Sulphur fumigations have a direct external action in causing the death of this Acarus, by the bodily transmission of which from one person to another the contagious nature of the disease is accounted for. Dr. Billing considers that the confirmation of this discovery has given the death-blow to an idea which will probably last as long as medicine; viz., that certain remedies exert a special influence in the cure of particular diseases. (_Principles of Medicine_, p. 75.) But we must not deny the existence of special agents, simply because we cannot understand their operation; for it is apparent in too many instances. And from the circumstance that Sulphur has proved beneficial when given internally in Scabies, as well as the fact that this disease has often an idiopathic origin, I am still disposed to doubt the value of the inference which is drawn from the discovery of the Acarus, and inclined to believe that Sulphur may exert an action of a specific kind in this disease as well as in the others. Some other internal remedies, and many other external applications, have been used in Skin diseases; but these that I have mentioned are the only ones that appear to exert something of a special action in all cases. Arsenic is perhaps the most universal in its application. It often happens that when this remedy entirely fails, the eruption is connected with a constitutional taint of Syphilis. When there is a suspicion of this, such a remedy as Donovan's solution, containing both Arsenic and Mercury, is peculiarly applicable, because capable of acting in a double way. This medicine also contains Iodine; and either this preparation, or the Iodide of Potassium, should be prescribed when the skin disease appears to be connected with a strumous diathesis. As soon as the course of Arsenic is found to produce swelling of the face, or irritation of the conjunctivæ, symptoms which denote the saturation of the system with the remedy, its administration should be suspended for a while. We have now concluded the subject of Hæmatic medicines. I have said that this class has been very generally neglected and overlooked by writers on the subject. For this reason, and because there are some ideas respecting their action which I have thought it worth while to work out and to investigate at some length, I have devoted more space to its elaboration than I shall be able to spare for either of the remaining classes, in the consideration of which we are not likely to encounter so many interesting and debateable points. PROP. VIII.--_That a second class of medicines, called_ NEUROTICS, _act by passing from the blood to the nerves or nerve-centres, which they influence._ 1. _That of these, some, called_ STIMULANTS, _act so as to exalt nervous force in general or in particular._ 2. _That others, called_ NARCOTICS, _act so as first to exalt nervous force, and then to depress it; and have also a special influence on the intellectual part of the brain._ 3. _That others again, called_ SEDATIVES, _act so as to depress nervous force, in general or in particular._ Having investigated at some length the action of Blood-medicines, we now commence the consideration of another class of remedies, which differ very widely from the last in their mode of operation. The action of Hæmatics is slow, but more or less durable, because it is evidenced in the blood; and a change in the blood produced by this action continues for a longer or a shorter time. The action of Neurotics, or Nerve-medicines, is rapid; but it is transient, and is soon over. A Neurotic medicine does not cause any change in the blood; and it cannot remain in it, but soon passes out. It acts by contact with nerve, apparently producing no lasting change even in nerve-fibre; and as the cause of the action cannot remain, the effect also soon passes away. Whereas Hæmatics, durable agents in the blood, are used to counteract the causes of inveterate and chronic disorders; these Neurotics, which produce a transitory, but more or less forcible impression on the nervous system, are employed to rouse it when torpid, or to depress it when over-excited. Rarely of use in chronic blood-disorders, they are given mostly in the temporary emergencies of acute diseases. But it is obvious that even a temporary agent may prove of permanent efficacy by remedying a temporary emergency. It was feasible to attempt some explanation of the actions of medicines in the blood, occasionally more or less analogous to known chemical influences. But the agency of nerve-medicines is of a far more incomprehensible kind. When we consider that little or nothing is known, or can be known, about the ultimate causes of sensation, or motion, or nervous excitement, there is no need for wonder that we find ourselves at a loss to explain the operation of medicines that influence these conditions. Thus I must chiefly limit my remarks on Neurotics to defining _what_ their action is, finding it impossible to state with certainty _how_ they act. And the field of inquiry being so limited, it follows that there is much less to be said about them than had to be said of Hæmatics. Nearly all the powerful poisons that act after passage into the blood, belong to this class. Their action in most points of view is such as completely to exceed our means of comprehension. Sudden death may be produced by it. But there is no apparent cause for this. We find no erosion or perforation of the coats of the stomach or intestines; no mechanical disorganization of the tissues, or chemical change in them; no hæmorrhage, or vascular disease; no rupture of nerve-fibres. Whence, then, could death have arisen? How could the mere presence of a few atoms in the blood,--half a grain, one-twentieth, or even one-fiftieth of a grain--how could this apparently contemptible influence have produced so essential a derangement of the vital functions as to stop them altogether? It is impossible to answer. The action of such remedies in the sudden causation or alleviation of nervous symptoms, when applied in the cure of disease, is equally wonderful. How are we to account for their different actions on different nerves? How is it that Opium contracts the pupil, and Belladonna dilates it?--that Digitalis affects the heart, and Stramonium the respiration?--that Prussic acid will cause convulsions, and Hyoscyamus delirium? In what way are these various operations brought to pass? It is impossible to answer. Though it is, I say, quite impossible to frame for any one of these questions a certain or satisfactory reply, on account of the manifest insufficiency of our acquaintance with the details of such actions as these, yet I must now venture to repeat an idea which I have already referred to at the commencement of this Essay (p. 46,) and state my belief in the bare possibility of the operations of Neurotic agents being explicable upon mechanical grounds. It is generally believed among scientific men that each particle of a compound body is made up of a number of indivisible atoms, each of which is inconceivably minute in size. And as these compound bodies have each a peculiar chemical constitution, so must each of their ultimate parts be composed of a peculiar arrangement of simpler atoms, and thus have a certain shape of its own more or less different from the shape of every other compound atom. Both the substance of a nerve, and the active part of a nerve-medicine, consist of a number of definite compound atoms. And it is possible that the atom of a stimulant medicine may be of such a shape as that it shall be unable to coincide with, or to fit into, the series of atoms forming the sensitive surface of the nerve, and thus irritate this when brought into contact with it; and that the compound atoms of a sedative may so arrange with these nerve particles as to fit among and extinguish their salient points, and annihilate their natural sensibility. We learn from the phenomena of the senses that the nerves are very much under the influence of mechanical impulses of all kinds, and particularly minute and inappreciable impulses of this description. Another fact which gives additional credibility to such an idea is, that those Neurotic substances which are chemically alike are in general alike also in their influence on nerve. The particular way in which nerve-medicines affect different parts of the nervous system might perhaps be explained by supposing minute chemical differences in the composition of the atoms of which those parts are constructed, sufficient to alter their relations to the atoms of certain remedies. If we adopt the Atomic theory, we must perceive that no two chemical bodies can be precisely alike in the shapes of their particles. This various dissimilarity might throw some light upon the many shades of distinction between the operations of Neurotic medicines on different parts. Thus, as a general rule, both Morphia and Atropia are paralyzers of motor nerves. But they do not act alike on the Ciliary nerves by which the motions of the Iris are controlled. We may suppose that there is a certain chemical peculiarity in the particles of these nerves, by which they are enabled to coincide with the atoms of Atropia, and are thus blunted and paralyzed by them; but are, on the contrary, stimulated and excited by the atoms of Morphia, which have the contrary action, because unable, on account of their relative shape, to dove-tail with these atoms. This idea is, as I have said, purely conjectural and fictitious, and is indeed likely to remain so; for the thing is not by its nature susceptible of proof, nor is it even possible to inquire into it. And I have only thought it worth while to explain it at length because it is desirable that every statement which is made, however improbable and unworthy of credence it may seem, should at least be placed in as clear a light as possible. The action of a Neurotic is readily distinguished from that of Hæmatic medicines by the fact of its exerting a rapid and well marked influence of some kind on the nervous system. As it is impossible that the medicines contained in this class should remain in the blood, they therefore pass out of the blood through the glands, and in so doing generally act as Eliminatives. This, their secondary action, will be subsequently considered. It is generally of less importance than their action on nerve; with the exception of some which, as volatile oils and resins, exert a very feeble Neurotic action, but are comparatively powerful as Eliminatives. In this case the secondary action becomes the more important of the two. The most dangerous symptoms of disease are evidenced in the nervous system. Neurotics are employed to control these symptoms as they arise, but Hæmatics are used to combat the cause of the disorder. As to their relative efficacy, there is an advantage and a disadvantage on each side. On the one hand, nerve-medicines are more numerous and more powerful than blood-medicines, and thus in the control of symptoms they are wielded with more immediate certainty than the others in the counteraction of diseases. On the other hand, the symptom that is dreaded is only relieved for a time by the Neurotic remedy, while the morbid condition that caused it continues, and will perhaps cause it again; but when a disorder is remedied by the employment of Hæmatic medicines, it is more or less permanently cured and put an end to. In the above Proposition I have endeavoured to state as much as we know with certainty of the action of Neurotics. To this certainty I have already ventured to add a surmise, on which no certain reliance can be placed. But even if the theory of the action by atomic shapes should be rejected as improbable, because affording too easy an explanation of a naturally inscrutable operation, it would still seem likely that these medicines may take effect by exerting some minute and imperceptible influence on nerve-fibre, or producing in it some inappreciable disorganization or change, which has the effect of altering the natural performance of its functions. The effect of mechanical concussion or shock, which may produce death by minutely disarranging the particles of the nervous centres, presents an obvious analogy to the sudden and remarkable action of some nerve-poisons. Having offered these vague suggestions as to the ultimate _modus operandi_ of Neurotics, I will now proceed to divide the Proposition in which their more obvious action has been stated into a number of minor propositions. These apply to the whole class. The three divisions will be afterwards shortly considered separately. _m. p. 1._--That Neurotics are medicines which pass into the blood. _m. p. 2._--That their action is evidenced by a change in one or more of those functions which are attributed to the nervous system. _m. p. 3._--That it is necessary that they should pass from the blood to that part of the nervous system which is influenced by them. _m. p. 4._--That they are of use in an over-excited or depressed state of the nervous system. _m. p. 5._--That they are transitory in action, and cannot remain in the blood. Some space and labour was required in the proof of the minor propositions relating to Hæmatics, for among them were included some things that are not universally acknowledged; but the above account of the action of Neurotics concerns matters that are very generally admitted, and will not occupy us nearly so long in its discussion. In the first place it is affirmed that Neurotic medicines pass into the blood. In the consideration of Prop. II., it was shown that all of them,--whether vegetable alkaloids, volatile oils, resins, or mineral substances,--were more or less capable of being absorbed. That they do pass into the blood is proved by the fact that many of them have been detected there, as well as found in the secretions into which they must have entered from the blood. Ammonia, Hydrocyanic acid, Antimony, Assaf[oe]tida, Turpentine, Alcohol, and Camphor,--all of which are Neurotic agents,--have been chemically detected in the blood by Tiedemann and Gmelin. A still larger number have been discovered in the urine by Wöhler, particularly of volatile oils and odorous principles. The active principles of Opium, Belladonna, Stramonium, and Henbane, have been detected in the same secretion by others. Thus Neurotics pass into the blood. That they act after this absorption, and not by contact with the mucous surface, was proved in the consideration of Prop. I. The second minor proposition is borne out even by the names by which the recognised action of these medicines is distinguished. Considered as a class, they have no action on the blood, but their influence is quickly and obviously exerted on the nervous system, or on the vital functions which are universally attributed to that part of the animal frame. Stimulants are so called because they are found by experience to exalt nervous force; Sedatives, because they depress it. Thus Ammonia is given to prevent Syncope, caused by a weakness or failure in power of the nerves of the heart; and Aconite is prescribed to relieve pain caused by an over-excitement of the sensory nerves. Though in these examples Ammonia acts on the centre, and Aconite on the peripheral nerves, yet they are both capable of exalting or of depressing nervous force in general. But neither Stimulants nor Sedatives, as defined by me, exert any marked influence on the intellectual part of the brain. They do not affect the phenomena of mind, or of the four special senses which are immediately associated with it. This influence is confined to the intermediate division of Nerve-medicines, called Narcotics. Their general action is evidenced by a short or long primary stimulation,--and a subsequent depression of nervous force, which is also of variable intensity. At the same time they affect the mind in various ways; exciting it, confusing it or lulling it. Opium and Alcohol are examples of Narcotics. These distinctions are in most cases obvious and well defined.[42] The third minor proposition repeats the rule of local access, which has already been enforced in treating of the fifth proposition. It was not necessary to maintain this in the case of medicines acting on the blood; but Neurotic agents must be shown to operate locally on the various nervous organs. I have only to repeat the arguments which were urged before. It is proved that the action of nerve-medicines cannot be propagated by nervous connexion, but that passage in the circulation is necessary; that the course of the latter is sufficiently rapid to account even for the action of Hydrocyanic acid; and that, however near a medicine be introduced to a nervous organ, it does not affect it unless it be allowed to reach it. The nerves are not naturally constituted for the conduction of medicinal impressions, but only for the passage of impulses of volition, sensation, or emotion. And this evidently forms a powerful safeguard to the system against the effects of a poison. The assertion is further maintained by the fact that the action of a Neurotic, when applied topically to the part which it tends to influence, is the same as that which is exerted by it on the same part after absorption. And lastly, some nerve-medicines have actually been found after death in the substance of those nerves and centres which had been affected by them during life. The use of these medicines in the treatment of disease is defined in the fourth minor proposition. They have no influence in the blood. They are not employed in slow or long continuing diseases. Their applications depend on their known physiological tendencies, already stated. Abnormal deviations from the proper functions of the nervous system are rectified by means of the influence which they exert over the nervous organs. When the powers of life are sinking, the nervous force on which life depends may perhaps be roused by a strong Stimulant, and maintained by its repetition. Sometimes the emergency may be thus postponed, and the danger escaped. In violent inflammations and fevers, when the action of the heart is so violent, and the nerves that control it so excited, as to place life in peril, we may do good by the administration of a Sedative, such as Antimony or Digitalis, by which the nervous force may be reduced to its proper level. Narcotics are used in various cases, to cause sleep, or to quiet mental irritability. Both these and Sedatives are employed to alleviate the different kinds of pain. Neurotics are thus applied to various symptoms, and to many disorders. Their different modes of action will be detailed more at length presently. It must be remembered that all these actions, powerful though they may be, are transitory. The effect produced on the nerve is not a lasting one, and no essential change in the blood is effected by true Neurotics. They are not natural elements of this fluid, but must quickly pass out of it; and they having thus left it, their action also is over. Thus the truth of the fifth minor proposition is plain. I will now attempt to give a brief but distinct account of the three divisions into which I have divided this class of medicines. STIMULANTS. Stimulants are medicines which pass from the blood to the nerves or nerve-centres, and act on them so as to exalt nervous force, in general or in particular. That is, they may extend their operation more or less to the whole nervous system, having a general tendency to communicate nervous energy; or they may confine their action to particular departments of this system, having no manifest influence on other parts. On referring to the arrangement at the commencement of the Essay, it will be seen that Stimulants are subdivided, according to whether their action is thus extended or confined. STIMULANTIA. Ord. 1. Stimulantia generalia. Ord. 2. Stimulantia specifica. The first order includes all the medicines that are commonly understood to be Stimulants. But as the remedies of the second order obviously exalt nervous force, the term applied to the others on that ground could not consistently be withheld from them, although their action is more limited and local in its nature, being confined to a certain part of the body, and to certain nerves. The same remark may be made of the order of Special Sedatives, which will soon have to be considered. ORD. I. GENERAL STIMULANTS. (_Mineral substances._--Ammonia and its Carbonates. Phosphorus. _Animal substances._--Musk, and Castor. _Vegetables containing volatile oils._--The aromatic Labiatæ, Compositæ, and Umbelliferæ. Cloves and Nutmeg. Cinnamon, Cassia, Sassafras. Rue, Barosma. The Aurantiaceæ. Canella. Valerian. Mustard. Cajeput and Pimenta. Hops. Juniper, Turpentine. Cardamom. Onion. _Vegetables containing acrid principles._--Senega. Horseradish. Serpentary. Cascarilla. Pepper. Contrajerva. Ginger. Capsicum. Mezereon. _Resinous substances._--Guaiacum. Mastich, Olibanum, Myrrh, Elemi. Copaiba. Peru, Tolu. Assaf[oe]tida, Ammoniacum, Galbanum. Benzoin, Storax. Pine resin.) This list of General Stimulants is long, but it might even be further extended. The majority are produced by the vegetable kingdom. The acrid principles to which some owe their power are intermediate in nature between volatile oils and resins. Some of them are volatile, like the former; others fixed, like the latter. Some of the resinous products contain also a volatile oil. The principles of Capsicum and Mezereon are very similar in their chemical nature to the true resins. (_Vide_ page 85.) These remedies differ very much in power, but their influence is the same in character. They exalt nervous force in general. They seem to act on the whole nervous system; but their most obvious action is to increase the force and frequency of the pulse, and to invigorate the circulation. They are not, for the most part, very powerful medicines; and their action is seldom so violent as to be succeeded by much reaction. They improve digestion for a time, by a stimulation of the sympathetic nerves of the stomach and other viscera. In large doses they are irritants, and may impair the digestive powers, and cause headache. Though possessing no marked stimulant power over the function of mind, like that of the Inebriant Narcotics, yet they certainly exalt the activity of the brain, along with the other nervous forces. Dr. Pereira classes the majority of Stimulants among _Ganglionics_, considering that they only act on parts supplied by the sympathetic system of nerves. But this view of their operation appears to me to be too limited; for all of them seem to have a certain action on the brain. Thus Ammonia is used in Syncope, a state which no doubt depends upon a shock received by the brain. And there are several things which show that it relieves this state more by stimulating the brain than by merely rousing the heart and vascular system. It is found to be most effectual when inhaled through the nose; by which means it could easily pass at once into the cerebral circulation. Dr. Pereira thinks that when administered in the liquid form it can only pass into the blood as a salt, being neutralized by the stomach-acid. In this case it could only act before absorption. But it is probable that it is too diffusible and too rapidly absorbed to be entirely so neutralized; and besides, its operation when inhaled is the same as when ingested, which seems to point to an agency after absorption in the latter case. For when inhaled, it must be absorbed in the free state. And to suppose that it acts by stimulating the nerves of the stomach only, is to receive a thing for which we find no parallel in the action of medicines. (_Vide Prop. I._) Ammonia has been used with advantage in the prevention of Epileptic fits, being given just before their expected occurrence. It could hardly be of use in this disorder unless it affected the brain. Other General Stimulants manifest this action on the brain to a greater or less degree. Phosphorus is a Stimulant. In small doses it quickens the pulse. It somewhat heightens the mental activity. It is said also to have an aphrodisiac operation, due to its powers as a cerebral excitor. Volatile oils possess a certain influence over the functions of the brain, as well as those of the organic nerves. Cajeput oil has been used in Hysteria; employed to control various spasmodic movements; and administered in Typhoid fevers and Asiatic Cholera, to communicate nervous power. The fetid gum resins are well known as Antispasmodics. The spasms which these medicines relieve are due to a fault in the nervous polarity, commencing generally in the brain or nerve-centres,--and are more or less subdued by general stimulators of the nervous functions. Copaiba, an oleo-resin, may cause a general febrile condition, accompanied with headache,--when given in large doses. So obvious is the cerebral power of some volatile oils, that Turpentine, in large doses, has been known to produce inebriation. It is not generally used for its Neurotic powers, but as a Purgative or a Diuretic; or else it might have been classed among Inebriant Narcotics. I have enumerated it above among volatile oils. It may be regarded as transitional between true Stimulants and Narcotics. Ergot of Rye is another medicine which has a double action. It is used as a Special Stimulant to the Uterus; but it is also a Narcotic to the brain. Most General Stimulants are without any marked influence on the mind; but stimulate the organic and merely animal function of the brain, and of the Sympathetic nerve throughout the system. Concluding that General Stimulants have all more or less the power of exalting nervous force in general, we have still to consider some other questions relating to their action. It is maintained by some that Stimulants have simply the power of calling forth the nervous force which already exists in the system, and that they cannot create any more in addition to this. But if this were the case, then the reaction, or subsequent failure of nervous power, ought to be exactly equivalent to the first temporary increase of that power; assuming this increase to have been simply abstracted from the natural resources. But we do not find it to be so. The reaction from the effect of a Stimulant is always very slight, and often quite imperceptible. And there seems to be no _à priori_ reason why we should not actually cause nervous force to be generated. We know that a galvanic current, or even a mechanical cause, may induce it to be suddenly and powerfully manifested. I believe that a Stimulant is able actually to produce nervous action; perhaps by an irritative operation upon nerve-fibre. So by continually repeating the dose of a Stimulant, as Ammonia or Brandy, it is possible to maintain the circulation and nervous energy at a certain level, without the occurrence of any reaction for a considerable period. But we must take care not to confound _nervous force_ with _vital force_. The former may be very much increased, as in high inflammatory fever, without a corresponding increase of the latter. The advantage of a stimulant is regulated by this rule. When there is a failure in vital energy, no Stimulant will serve to prolong life, for it cannot communicate fresh vital power. But there may be no such failure of vital energy, and yet a sudden or accidental deficiency of nervous force may serve to peril the continuance of health, or even the tenure of life. For a certain degree of this nervous force is necessary both for life and health. When it is diminished, all the functions must suffer; when it fails entirely, the circulation must stop, and death ensues. It is in these cases that a Stimulant medicine is appropriate. It does not do good by communicating vital energy, but by remedying the want of nervous action, by which want the manifestation of the vital energy is subdued. This must always be borne in mind when the applicability of Stimulants is under consideration. Some writers have complicated the subject by classing as Stimulants all medicines which tend, directly or indirectly, to communicate vital strength; as Tonics, and remedies which counteract morbid depressing causes. This is in direct contradiction to the rule given above. True Stimulants are only of use by counteracting that failure of nervous force which hinders the manifestation of the vital strength which is stored up somewhere in the system. For I have just observed, that to exalt nervous force is not necessarily to exalt vital force, but that any thing which tends to destroy the former must at length repress and extinguish the latter. The above considerations apply to the action of these Stimulants on the powers of the system generally. But they may act locally. Thus in moderate doses they promote digestion, by acting on the nerves of the stomach and intestinal canal. They increase most of the secretions in passing through the glands in the blood. In both cases they exalt nervous force; but in the latter case their action is of a particular nature, and will be treated of when they are considered under the title of Eliminative medicines. To impress the system generally, Stimulants are used when there is a failure of nervous force on account of some sudden and acute disorder, without any material undermining of the vital energies. In long chronic cases, where there is real and manifest vital debility, Tonics or blood-medicines are required. But in such a case as Syncope, or stoppage of the heart on account of a sudden nervous shock, Stimulants are particularly appropriate; also in the latter stage of Typhoid fever, or of asthenic Pneumonia, or of Cholera, where the existence of life is endangered by a great loss of nervous power. In spasmodic diseases, as Hysteria, where the health is deteriorated on account of a derangement of the nervous functions, Stimulants may be of use. Such then appears to be the _modus operandi_, and such are the chief applications, of the remedies belonging to the order of General Stimulants. Those of the next order exert an action of the same kind, but their field of operation is on a more confined scale. ORD. II. SPECIAL STIMULANTS. (Strychnia; Brucia; Toxicodendron; Ergot of Rye; Borax; Rue.) These are medicines which pass from the blood to the nerves or nerve-centres, and act so as to exalt the energy of particular nerves or sets of nerves. They do not affect the whole nervous system, but they operate on one set of nerves in the same way that General Stimulants operate on all, though usually with greater energy. The causes of such a localized action are hid in obscurity; but it has already been hinted that they may perhaps be partly accounted for by the differences in chemical or mechanical structure existing between different parts of the nervous system. Strychnia, the alkaloid and chief active principle of Nux Vomica, acts as a Special Stimulant, chiefly to the spinal cord and the nerves that proceed from it. Its operation is mainly exerted upon the motor branches. Thus in large doses it causes a spasmodic and powerful contraction of the muscles of the trunk, and may even produce death by rendering respiration impossible. Its action is propagated from a motor nerve to a muscle, and is kept up for some time. In small doses it is useful in certain cases of paralysis. Two things are necessary in order that it may act efficiently. The muscles of the part must be whole and sound; for if destroyed by excessive atrophy or fatty degeneration, they cannot be roused by any stimulus. The nerve, too, and the centre from which it originates, must be sound, or else the medicinal impulse cannot be conducted along it. These two conditions can only concur in paralysis from disuse, _i.e._ when the incapacity to move a limb depends merely upon its having long been in a state of inactivity, but when the lesion of the centre which caused the paralysis has at length sufficiently healed, and the nerve is now in a fit state to conduct a motor impulse. Strychnia has no operation on the intellectual functions; neither does it act upon the sympathetic nerves of the heart and arteries, so as to quicken the pulse like ordinary stimulants. It exalts sensibility as well as irritability, but not so powerfully. It is a special Stimulant to the motor and sensory nerves throughout the body. Acting upon the spinal cord, it tends thus to exalt reflex action, which is derived from that centre. In small doses it appears to promote digestion, and may perhaps act upon the ganglionic nerves supplied to the stomach. Brucia, which is the other alkaloid of Nux Vomica,--and the leaves of the Rhus Toxicodendron,--resemble Strychnia in their action, but are less powerful. Ergot of Rye is a stimulant to the muscular nerves of the Uterus of the female, but to no other nerves in any marked degree. Borax and Rue possess a similar action, but are not so efficient. When labour is retarded on account of an atony or debility of the Uterine muscle, and when also there is no obstruction or danger which can result from bringing on contraction, Ergot supplies us with a ready and effectual means of doing this. It is also efficacious in cases of uterine hæmorrhage, because the open mouths of the bleeding veins in the wall of the uterus are closed by the contraction which it causes. When given in an over-dose, Ergot has a dangerous action on the brain, producing at some times narcotism, at other times syncope. But this is not the effect for which it is employed, and is altogether distinct from its operation as a Special Stimulant, which is exerted only upon the ganglionic nerves of the muscular uterus. In small doses it produces no other effect than this. Like the other medicines of this order, Ergot is not an excitor of the heart and circulation. Its stimulant action is strictly local in its nature. NARCOTICS. This, the second division of Neurotic medicines, is in one sense intermediate between the other two divisions, but in another sense different from both of them. Narcotics are defined to be medicines which pass from the blood to the nerves or nerve-centres; which act so as first to exalt nervous force, and then to depress it; and have also a special action on the intellectual part of the brain. This primary exaltation of nervous force is produced by some to a very considerable extent, but by others very slightly. Of the three orders into which I have divided Narcotics, which are named from their respective actions upon the brain, Inebriants cause most, and Deliriants least, of this primary stimulation. In the second place, Narcotics depress nervous influence. This depression is not in a direct, but in an inverse ratio to the primary stimulation. The less the one, the greater the other. Thus the depression cannot be considered as the mere re-action from the stimulation, as supposed by Dr. Brown, for then there would be a direct relation between the two effects. But we find that the exhilarating action of Alcohol may often be followed by no manifest depression; and that Belladonna, which scarcely stimulates at all, exerts a very sensible depressing influence. Regarded simply in their action on nervous force generally, the medicines of the first order of Narcotics would approach very nearly to Stimulants, and those of the third order to Sedatives. But Narcotics have all a power which is possessed by neither of the other divisions. They influence the intellectual functions, _i.e._ the mind, and the physical ties by which mind is connected with matter. These physical ties are,--the functions of volition and sensation, by which the mind is connected with the body, moving it or feeling it; and the five senses, by which the mind, through the body, is connected with external things. These intellectual properties, the centre of which is the brain, are more or less affected by Narcotic medicines. The first action of the latter is, to exalt these functions, just as they first exalt nervous force in general. The degree of this exaltation varies, as in the former case. Inebriants stimulate the mind to a considerable degree; Soporifics less; and Deliriants possess least of this primary exciting power. But it is in their secondary action on the mind that we find the most characteristic difference between them. On referring to the arrangement, it will be seen that I have divided Narcotics into the three orders to which I have already referred by name, and which are thus designated in Latin: NARCOTICA. Ord. 1. Inebriantia. Ord. 2. Somnifera. Ord. 3. Deliriantia. These Orders are named from the secondary action of these different Narcotics on the intellectual functions. In the production of inebriation these functions are impaired and deranged; in sleep they are lulled or extinguished for a time; and in delirium they are excited and led astray. The several actions of these orders will be more minutely described presently, and the individual medicines of which they are composed will be shown to agree with the general definition of Narcotics. Dr. A. Billing considers that Stimulants call forth nervous force, and Sedatives depress it; and that Narcotics do neither the one nor the other, but merely impede its communication. I do not consider this distinction to be quite correct. Narcotics exert in the first place a stimulant, and in the second place a sedative action; but these actions have no relation in degree, for one of them always exceeds the other, as we have just seen. Thus in the whole effect, either the stimulation must exceed the depression, or the depression must be greater than the stimulation. So that in one way or the other the quality of nervous influence must be altered. The medicines of the first order of Narcotics resemble Stimulants so far as this, that they tend altogether to increase the amount of nervous force. Perhaps Tobacco and Lobelia are exceptions to this. The medicines of the third order, and some of those in the second, tend on the whole to diminish the quantity of nervous force, and are thus akin to Sedatives. A correct understanding of the differences in action which exist between the groups of Neurotic medicines is, I think, very essential to a right application of these remedies in the treatment of disease. ORD. I. INEBRIANTIA. (Alcohol; Wine; Ethers; Chloroform; Camphor; Indian Hemp; Tobacco; Lobelia.) The medicines of this order, taking Alcohol as the type, approach more nearly to Stimulants than any other Narcotics. When given in small doses, their narcotic operation may hardly be perceived. They are then exhilarants; slightly quickening the pulse, and enlivening the mental faculties. When given in large doses, this stimulating action on the heart and mental powers occurs first, and is now more intense; but it is soon succeeded by disturbance and impairment of the intellectual functions. The secondary depression of the heart is comparatively feeble, except in the case of Tobacco and Lobelia, which are exceptional members of this order. The disturbance of the mind produced by these medicines is not of a partial, but of a general character, extending to all the intellectual functions. It is called Inebriation, or drunkenness, and may exist in various degrees. The mind itself is confused and bewildered; volition is impaired, so that the man staggers in his walk; and the powers of the senses are disordered or lost. This condition, when carried to an excess, results in stupefaction, coma, and death. These are the several degrees of the same action, which is a general impairment of all the intellectual functions. Alcohol and the Ethers produce the primary exhilaration in the greatest degree; Tobacco and Lobelia, in the least. Though varying in degree, yet, as far as the stage of inebriation, the effects of these medicines are similar in kind. Stupefaction constitutes the next stage of the action of Alcohol, Camphor, Indian Hemp, Ether, and Chloroform. Camphor and Indian Hemp exert at this period an anodyne influence; to which also, in the case of Indian Hemp, may be added a very curious imitation of Catalepsy. Ether and Chloroform have at this time a peculiar action in extinguishing the sense of Feeling. With this object they are commonly administered by inhalation in painful surgical operations. The stupefaction produced by the above medicines is not at all prominent in the case of Tobacco and Lobelia inflata. Instead of that they both exert a particular sedative action on the heart and circulation. This is accompanied with nausea, and with great relaxation of the muscular system, like that which is produced by Antimony. It may lead to syncope and death. Syncope has been known to be suddenly produced in some cases of the inhalation of Ether and Chloroform. These two medicines are also muscular relaxers, like Tobacco. The cases which demand the employment of these medicines, as also of the other Narcotics and Sedatives, will be considered at the close of the section treating of Neurotics, and again when some of them are separately described in the fourth chapter. ORD. II. SOPORIFICS. (Opium. Lactuca. Hops. Nutmegs.) Opium, which is the chief and only important medicine of this order, may be considered as the type of Narcotics. It causes in the first place a slight quickening of the pulse, and some excitement of the mental faculties. It is named from its peculiar secondary action on the latter. It produces drowsiness and sleep. We have seen that the term _intellectual function_ must be understood to include not only the mind itself, but also the powers of volition and sensation, by which the mind is connected with the body,--and the five senses, by which it is enabled to appreciate the external world. Inebriants affect these three in about the same ratio. Ordinarily they impair the mind, and derange the functions with which it is connected; but they do not quite extinguish either volition, sensation, or the special senses. Soporifics differ from this action in two ways. In sleep the mind may remain active; but it is left alone, dreaming, and uncontrolled by physical ties. For the functions of volition and sensation, and the special senses of Sight, Hearing, Smell, and Taste, are entirely suspended in perfect sleep. So that while Inebriants affect similarly both the mind and the natural functions with which it is connected, Soporifics may leave the first untouched, but they entirely subdue the latter. The condition of sleep differs also in another important particular from the state of inebriation,--as well as from delirium, which we shall have presently to consider. Sleep is liable to be suddenly interrupted or suspended by comparatively slight causes, as a physical shock, or a forcible impression upon one of the senses which are held in abeyance and subjection. Neither inebriation nor delirium can be suddenly put an end to in this way. Such appears to be the distinction between the operations of these two orders of medicines. Pain prevents sleep, because it enforces sensation. Thus a mere Soporific, if effectual, would prove anodyne, and relieve pain. But Opium has an important anodyne action, which is independent of its power of producing sleep, for it may occur without the latter. It is by far the best remedy for pain in the whole catalogue of medicines. It also produces relaxation of the muscular system, and is thus a powerful antispasmodic. In excessive dose it produces a marked sedative effect; causing an imperceptible or irregular pulse, and very slow breathing, with contraction of the pupil of the eye. It may kill by apn[oe]a; _i.e._ by stopping the respiration. Tobacco resembles Opium in causing contraction of the pupil, and relaxation of muscular fibre. But it is inebriant, and not soporific; and its secondary sedative action on the heart is more powerful than that of Opium. The order of Deliriants dilate the pupil. Inebriants and Deliriants act on the glands as Eliminatives, being mostly diuretic. Opium has a contrary action; it diminishes all the secretions except that of the skin, which it increases in amount. Most particularly it diminishes the secretion of the bowels, causing constipation. At the same time it impairs the appetite and digestive power, producing often nausea, and coating the tongue. It tends also to produce a determination of blood to the head. Lettuce, from which Lactucarium is prepared, resembles Opium in its action, but is neither so powerful nor so efficient. Nutmeg and Hops have proved Soporifics when given in large doses. The relief of pain, and the production of sleep, are about the commonest and the most grateful of the offices which fall to the lot of the physician; and in either case Opium, or one of its preparations, may be said to be indispensable. But a certain caution and care must be exercised, even in the administration of this most useful remedy. (_Vide Art. Opium_, Chap. IV.) ORD. III. DELIRIANTS. (Hyoscyamus; Belladonna; Stramonium.) These medicines are all produced by the natural order Solanaceæ. Of all Narcotics they approach the nearest to Sedatives. Their only stimulating action is to produce at the very first a slight and evanescent febrile condition,--a quick pulse and heat of skin,--which never lasts long, and is sometimes overlooked. They are not Soporific. Their action is soon manifested by an anodyne operation, and a sedative influence on the heart and circulation. For this double action they are employed in medicine, being used in painful disorders, fevers, and inflammations. As anodynes they are not so efficacious as Opium, but their action is not followed by constipation, or by a diminution in any of the secretions. They all dilate the pupil of the eye. Belladonna produces a peculiar dryness of the throat, and has been known to cause an erythematous eruption. Stramonium appears especially to control the respiratory nerves, and is thus used in Asthma, where there is a spasmodic circular contraction of the smaller bronchial tubes. Lobelia, a medicine of the first order, possesses a somewhat similar power. The action of the remedies of this third order of Narcotics is distinguished by the production of delirium when they are given in large doses. Let us again assume the threefold division of the mental functions, to which allusion has already been made. Inebriants impair equally the mind, volition, and the five senses. Soporifics extinguish for awhile both volition and the senses, but may leave the mind alone. In delirium these functions are not thus impaired and held in subjection, but they are excited and led astray. The mind is occupied intently upon imaginary fancies; unreal objects and hallucinations are presented to the senses. So that Deliriants, in this peculiar phase of their action, tend to excite the mind and the volition, and to delude or derange the senses. Speaking generally and rather inaccurately, we might say that the medicines of the first order of Narcotics bewilder and impair the powers of the mind; those of the second order subdue and extinguish them for awhile; and those of the third kind excite and derange them. Certain peculiar and exceptional effects are produced by some Narcotics when they are administered in repeated doses for a long time together. Taken in this way, Alcohol produces delirium tremens, and great despondency of mind; as also often a chronic inflammation of the liver. The continued smoking of Tobacco is found to exert a tranquilizing influence over the mind. And the continual use of Opium or Indian Hemp, both of which are habitually consumed in large quantities in the East, produces a curious and melancholy series of mental hallucinations and disorders. SEDATIVES. We have now to consider the third and last division of Neurotic medicines. Sedatives are medicines which directly depress nervous force. Some affect nervous force in general; others confine their action to particular nerves. They are mostly energetic and dangerous agents. For the time being they may destroy nervous power, and remove nervous control. It might already have been concluded, from what has been said of the secondary action of Narcotics, that there are two ways in which a Sedative action on nerve may be manifested. Sedatives may destroy nervous influence; or they may simply derange it. Let us suppose a special Sedative to derange the action of the Vagus nerve. It would probably cause the rhythmical contraction of the heart to be abnormally slow or irregular. It would be likely to diminish in the lungs the sensation of want of breath, and thus decrease the number of the respirations; and at the same time it would repress the irritability of the pulmonary mucous surface. Further, it would in some way derange the normal function of the stomach. All these things a Sedative to the Vagus nerve does actually effect. Given in large quantity, it may cause death, by destroying those functions which in a small dose it deranges. All the varieties in action of Sedative medicines may be accounted for by considering that they may either derange or destroy the nervous forces. In the case of each set of nerves in the body we may distinguish an action of derangement, and an action of destruction, both producible by Sedative medicines. Thus by an action on the motor nerves of the cerebro-spinal system, convulsions or paralysis may be produced. By an influence on the nerves of sensation; pain, or anæsthesia. By an affection of the organic nerves of the heart, or of the brain which controls them; palpitation, or syncope. By an action on the nerves of the lungs; cough, or apn[oe]a. By the exertion of a sedative power over those of the stomach, nausea may result, or vomiting. These various symptoms are all brought about by Sedative medicines, but in each case the first effect is referrible to a derangement, the second to a loss of nervous power. In every instance there is an impairment of natural nervous force. Narcotics act on the mind. They cause death, with stupor or delirium. Sedatives act on the organic function of the brain, which is necessary to life, but they do not affect the mind. In poisonous doses, they kill by producing syncope, which is a suspension of the action of the heart. Hydrocyanic acid causes at the same time convulsions. These convulsions appear to be caused by a derangement of the nervous polarity of the spinal cord; and not by a stimulation of this centre, as the tonic spasm of Strychnia. (_Vide_ page 232.) Sedatives are divided into two orders, according to the extent of their action; in the same way as Stimulants have been divided. SEDANTIA. Ord. 1. Sedantia Generalia. Ord. 2. Sedantia Specifica. General Sedatives have a direct action upon all the nerves and nerve-centres in the body, the result of which is a diminution of nervous force. Special Sedatives exert the same depressing action upon particular nerves only. Like the order of Special Stimulants, they are peculiar and exceptional agents. All those with which we are acquainted appear to direct their action to the branches of the Vagus nerve. It is among General Sedatives that the types or representatives of this division are to be found. The definition of this order does not admit of so great a variety in action as must be allowed to Narcotics. A Stimulant medicine simply exalts or increases nervous force; and a Sedative simply depresses the same. But a Narcotic first does one thing and then the other; and according to the degrees of these two actions, so do some Narcotics resemble Stimulants, and others approach very nearly to Sedatives. But we have seen that Narcotics have also a peculiar and mysterious action on the mind, which action is of three separate kinds. And the same three orders which are named according to their respective actions on the mind, are found to coincide with three stages of transition from the action of a Stimulant to that of a Sedative medicine. It is impossible to associate in the same prescription a Stimulant and a Sedative medicine; for their actions are directly contrary, and tend to counteract one another. But it is often desirable to prescribe an Inebriant Narcotic with a Stimulant, for their actions resemble each other so much, that they are able to work together. And Deliriants, which stand at the other end of the Narcotic scale, may often advantageously be given with Sedatives, which they very much resemble in their nervous operation. Thus, on the one head, Brandy may be given with Ammonia; on the other hand, Hyoscyamus may be prescribed with Digitalis or Hydrocyanic acid. ORD. I. GENERAL SEDATIVES. (Hydrocyanic acid. Creosote. Aconite. Conium. Colchicum. Tea and Coffee.) These are medicines which pass into the stomach, and are capable of absorption; which are absorbed, and are proved to act after passage into the blood. From the blood they pass to the nerves and nerve-centres, and on all of them alike exert a depressing influence. Some of them are much more powerful than others. They do not exert any primary stimulant effect, or any action on the intellectual part of the brain. Most of them have special actions and tendencies. Hydrocyanic acid is a powerful and dangerous medicine. In large doses it very rapidly takes effect, producing convulsions, syncope, and death. In small doses it is anodyne, and antispasmodic. It is considered especially to influence the reflex spinal system, and by this means may allay convulsive cough, and quiet spasmodic movement. It is very useful in Gastrodynia, and appears then to act locally upon the painful and irritable nerves of the stomach. Creosote stands, as a medicine, between Hydrocyanic acid and Turpentine. It has a double action; being anodyne, like the former; and a mucous stimulant, like the latter. Moreover, it is a true Astringent, which cannot be said of Turpentine. It is not powerful as a Sedative, but its peculiarity of action often renders it useful in Gastrodynia. It is particularly applicable when pain in the stomach is accompanied with a tendency to hæmorrhage, or with a probable relaxation of the mucous coat. Aconite is a powerful anæsthetic to the superficial sensory nerves. When applied in solution or ointment to the surface of the skin, it produces first some heat and tingling, which is attributable to a derangement of the nervous influence; and this is succeeded by perfect numbness. It is thus a most valuable topical remedy in true irritative Neuralgia. Other Sedatives and Narcotics have the same power as topical anodynes, but not in so marked a degree. In large doses Aconite is a General Sedative; producing tingling of the extremities, vomiting, and syncope; and affecting the brain in various ways, as will be shown by some experiments which I have made upon its action, to be detailed in the fourth chapter. An alkaloid called Aconitina, the most powerful of all known medicines, is the active principle of this drug. Conium (Hemlock) also owes its properties to the alkaloid Conia. Dr. Christison has made some experiments upon the latter. He found that it produced swiftly-spreading paralysis of the motor nerves; and he considers it to act particularly as a Sedative to the reflex spinal functions. It also paralyzes the sensory nerves, but in a less degree. Conium is certainly anodyne; and produces often a sedative action on the heart. It would thus appear to be a General Sedative. But in some recorded cases of poisoning by Hemlock, coma has been mentioned as a leading symptom. Were this to be authenticated, and shown to be the invariable result of the action of this medicine in large doses, then it ought certainly to be classed among Narcotics. Dr. Pereira considers it likely that the plant contains more than one active principle. Hemlock has a paralyzing action on the nerves of motion, which is directly the reverse of the stimulating action of Strychnia; and is thus of use in cases of convulsion and spasm. It is also often prescribed as an anodyne. Conium is further said to have a curious resolvent power over glandular enlargements, and to have thus frequently caused their absorption and disappearance. This action was first noticed and described by Dr. Fothergill. All true resolvents operate by an action in the blood, but it is difficult to conceive how such an action can be exerted by a nerve-medicine. It may possibly act indirectly by quieting the action of the heart, and controlling an irritable state of the nervous system. In the same way Opium often appears to act as a resolvent. And it is certain that Hemlock, when used for this purpose, very often fails altogether. It has been wrongfully extolled as a panacea in Phthisis; but is in fact of no greater use in that disorder than Hyoscyamus, Prussic acid, and other medicines which reduce the pulse. For the patient in this disease is devoured by a continual slow fever, and any thing which tends to lower this fever will serve to prolong his existence. But altogether it must be admitted that considerable mystery attaches to the operation of this medicine. Colchicum has many different actions. It has an agency in the blood, being Antiarthritic. It is an Eliminative, acting on the liver and bowels. And it is also a General Sedative. To the combination of an eliminative with a sedative or anodyne action, the use of Colchicum in Gout has been, I think, erroneously ascribed. For in fact it seems to act best in this disorder when it causes no purging, and scarcely any action on the nerves. When it has been long used, it causes a great depression of the spirits, like that which may be caused by some undoubted blood-medicines, as Mercury. But it does not affect the understanding, or the special senses. In poisonous doses it depresses the circulation and the nerves generally, but it causes no stupor or insensibility. It is therefore not a Narcotic; but, like other Sedatives, it kills by syncope. In the behaviour of the system towards Colchicum, Aconite, Digitalis, and other nerve-medicines, there are two peculiarities which are worthy of remark. They are called _cumulation_ and _toleration_. Some quantity of the medicine may often be given, in repeated doses for some time together, without any apparent result. It seems to remain in the blood, and to become accumulated or stored up there. But all on a sudden it breaks out, appearing to be discharged on the nerves, and may produce very dangerous symptoms. This _cumulative_ action is especially observed of Digitalis, and therefore considerable care is required in the exhibition of that medicine. This medicine is a Special Sedative, and will be presently considered as such. In other cases we find that the nervous system becomes by degrees inured to the effect of a particular medicine, and suffers less by its presence than it did at first. This is called _toleration_. It is particularly observed of Colchicum and of Antimony, and of all medicines which act on the Vagus nerve so as to cause vomiting. Tea and Coffee, common articles of diet, are slightly sedative to the nervous system generally. They lower the pulse, and, by diminishing congestion of the brain, tend to clear and tranquilize the action of the mind. This activity of thought is endangered by the cerebral congestion which exists early in the morning, on account of recent sleep,--and again towards the evening, from the full meal of the middle of the day. It is thus at these times that they are found so useful, and are so universally adopted. They are, in fact, almost indispensable to the daily existence of civilized man, with whom a continual energy of mind is a necessary of life. Infusions of these substances, or of materials similar to them in medicinal nature, are adopted as a daily beverage by all civilized nations. By diminishing congestion of the brain, Tea and Coffee have not only the effect of clearing the mind, but in large quantities they induce wakefulness. This is particularly the case with Coffee. It is not clear that Tea, as commonly drunk, is ever unwholesome. Green Tea is a more powerful sedative, and resembles Coffee. Coffee has a more potent influence over the mind and nervous system than is possessed by Tea, and is apt to disagree with many persons. Like Opium, but in a far less degree, Coffee tends to confine the bowels. By diminishing the congestion of the brain which is produced by Opium, strong Coffee is of use in cases of poisoning by the latter substance. Tea and Coffee are sometimes said to be mental exhilarants; but they only become so indirectly, by removing congestion, which is a cause of stupidity. Both Tea and Coffee contain the alkaloid Theine; but it is probable that their Neurotic action is not so much owing to this, as to a volatile oil, which exists in both in some quantity. ORD. II. SPECIAL SEDATIVES. (Antimonials. Ipecacuanha. Digitalis.) These are medicines which, like the last, depress nervous force, yet they do not exert their influence on the nervous system as a whole, but only on certain parts of it. So far they resemble Special Stimulants; but their effect is of a directly opposite nature. They have also no direct influence on any part of the brain. Antimony, Ipecacuanha, and Digitalis, have each of them a number of different actions. The first has already been included among Catalytic Hæmatics, as tending to counteract in the blood the process of inflammation. But it possesses further a Neurotic power, by which it is gifted indirectly with a more powerful control over acute inflammations than could be exerted by any slow-acting blood-medicine. It is also Eliminative. Passing out of the body through the glands of the skin, it becomes a Diaphoretic. This may be its only action when it is given in doses too small to act upon the nerves. It must not be confounded with the diaphoresis which accompanies the condition of nausea, and which is probably produced in another way. Ipecacuanha is in the first place a Neurotic, of less power than Antimony; in the second place an Eliminative, increasing expectoration, as well as Diaphoresis. Digitalis too acts first upon the nervous system; then on the kidneys, being a Diuretic. But we are now concerned with the special Neurotic actions of this group of medicines. They all exert an influence over the three functions of respiration, circulation, and digestion. They affect the heart, lungs, and stomach, parts which are supplied by the branches of the Vagus nerve, as well as by the Sympathetic. Their action is not an external action, for it is produced when they are introduced into the blood at any part. Thus Tartar Emetic or Ipecacuanha, when injected in solution into one of the veins, will cause vomiting. M. Magendie has found that in the case of dogs they also produce Pneumonia. The mere inhalation of the dust of Ipecacuanha has been found to act upon the lungs so as to cause Bronchitis. These actions, as well as the various effects which are found to follow the introduction of these medicines into the stomach, can only be explained satisfactorily by supposing that they act as Sedatives to the branches of the Vagus nerve, thereby deranging or destroying the natural influence of that nerve in the direction and regulation of the organs which it supplies. For we have already seen that the action of a Sedative medicine is of such a nature as to derange nervous force in some cases, and simply subdue it in others. These actions are obviously nervous actions; for they are quick, sudden, and transient, and confined to parts supplied by a particular nerve. They are exerted upon nervous forces, and not upon the blood. If then they are nervous operations, they must either be directed towards the Vagus, or to the Sympathetic nerve, for these are the only nerves which supply the parts influenced by these medicines. They cannot act upon the Sympathetic, for two reasons. If they did so, we might reasonably expect that the other parts of this nerve would be influenced at the same time. But this does not appear to be the case. And again, an action upon the Sympathetic nerve could not be suddenly and violently evidenced, for the natural action of this nerve is slow, chronic, and persistent. At all events, the effects for which they are used could not be produced by an affection of this nerve. We may therefore conclude that the action of these medicines is exerted upon the Vagus nerve and its branches. They affect the different parts of the Vagus nerve in variable proportion. Some apparent anomalies in their physiological influence may be explained by considering the peculiarities which attach to all sedative actions. Thus we have seen that when given in large doses to healthy persons, Hydrocyanic acid produces convulsions by deranging the reflex spinal functions; and that in convulsive affections, when the same functions are disordered, the same remedy may do good by subduing their excited condition. On similar grounds, Tartar Emetic, injected into the veins, may produce Pneumonia; and Ipecacuanha, introduced as dust into the lungs, causes Bronchitis or Asthma; and yet Tartar Emetic is advantageously employed in the cure of Pneumonia, and Ipecacuanha is a remedy for Bronchitis. When the function of the healthy nerve, or that part supplied to the lungs, is deranged to a certain degree, an inflammation of the mucous membrane or substance of the lung is a natural result. But when these tissues are already inflamed, a course of medicine, which at the same time subdues the action of the heart, and represses the irritability of the nerve supplied to the part will be likely to effect a cure. They are both sedative actions; but the first is an action of derangement, the second one of depression. This seems to me to be the correct explanation of a difficult matter. It was just now observed that these medicines affect the functions of the Vagus in different proportions. The action of Ipecacuanha, when given in repeated small doses, is particularly directed to the pulmonary organs. It allays the sensation of want of breath, and diminishes the cough, of Bronchitis. In larger doses it produces first nausea, then vomiting. Still more decided nausea is produced by Tartar Emetic. It is followed by vomiting when the dose is sufficiently large. Nausea consists in a sensation of discomfort about the præcordial region, which is due to a derangement of the stomach, with a feeling of great languor, a cold perspiration and tremor, and at the same time a striking depression of the action of the heart. This nausea may be caused without vomiting, by a regulation of the dose. On account of the depression of the heart's action, which is its chief symptom, it is often very desirable to cause nausea in acute inflammations and fevers. It is kept up by the careful administration of Tartar Emetic. It may not be so desirable to produce vomiting; for this is accompanied with great vascular excitement and active congestion of the brain. And yet it is found that the more Antimony we can get into the blood, the more potent and durable will its antiphlogistic influence be. For this medicine appears to possess a blood-action as well as an action on nerve. Experience has shown that if the dose of Tartar Emetic be gradually increased on each repetition, it may often be tolerated by the system; that is, it does not produce vomiting; and then the remedy, being absorbed, is better able to continue its antiphlogistic and nauseating action. For the act of vomiting, besides other bad consequences, causes the rejection of that part of the antimonial which has not been absorbed. By the operation of the Nauseant the violent action of the heart in high fever may be allayed. It is often of signal efficacy, most especially in Pneumonia. Digitalis given in large doses may also act on the stomach, and cause vomiting. This operation has been ascribed, erroneously, as I think, to an irritating action possessed by this drug. But in smaller doses it affects the heart and circulation powerfully, without producing the other symptoms of nausea. It depresses the action of the heart. Sometimes the rapidity of the beat is slightly increased at the first, but the pulse at the same time is weaker. It soon becomes slower and sometimes irregular. This action is characteristic of derangement of the Vagus nerve. For it was found, in some experiments on animals made by M. Weber, that when the function of this nerve was disturbed by mechanical irritation, the rate of the heart was first accelerated, its action then became slow and irregular,--and finally it stopped. There cannot be a greater mistake than an attempt to explain such a derangement by supposing this medicine to exert a primary stimulant action. Coincident with the quickening of the pulse, there is a manifest loss of power. Digitalis is especially useful in dropsies which result from an obstruction to the cardiac circulation. By subduing the action of the heart, it relieves that congestion of the vascular system which is the cause of the effusion of serum. But it is also a Diuretic; and may thus too relieve the loaded vessels by carrying off in the urine some of the water of the blood. Such is an outline of the action of Special Sedatives to the Vagus nerve. It is not clear whether they affect that nerve at its origin in the brain, or whether they act the extremities of its filaments. These Sedatives do not act directly upon the brain itself. But indirectly they may affect it, when given in large doses. For by depressing the action of the heart they cut off the natural supply of blood to the brain, and may, by so doing, produce delirium and convulsions. They tend obviously to kill by syncope. Some medicines may cause syncope by an action upon the brain. General Sedatives may do so; but it does not appear that the medicines of this order ever act in this way. Some other medicines rest very closely upon the confines of this order. Squill is the chief of these. It is not quite clear whether Squill should be regarded as a Special Sedative, or considered simply as an irritant Emetic and Eliminative. It is a valuable Expectorant. It is also a Diuretic; and from the analogy of its operation to that of Digitalis (_vide supra_,) and because it appears to be a specific Emetic, it is most probably a true Neurotic. But we must not confound with Neurotics those medicines which exert a slow operation in the blood which results at length in a nervous affection. This may take place, to a greater or less degree, with all Catalytic Hæmatics. Lead, which is anti-convulsive and astringent, approaches nearest of all to the recognised nerve-medicines. After existing for some time in the blood, it produces local palsy, particularly of the muscles about the wrist; and it sometimes affects the sensory nerves, causing sharp shooting pains in the limbs. These nervous symptoms are caused by the accumulation in the system of the poison of lead, and the deterioration of the blood which is thereby produced. In the case of the palsy, we cannot certainly say whether these causes operate first upon the motor nerves, or upon the muscles themselves. Lead certainly has some tendency to affect the brain. All kinds of brain disorders may occur in cases of chronic lead-poisoning. The metal has been found in the brain after death; but it also exists at the same time in other parts of the body. In cases of Lead-colic there is generally a paralysis of the muscular fibre of a certain portion of the intestine. The pain of the disorder is caused by an irritation of the nerves of the part. Neurotics are medicines which tend, immediately they enter the blood, to be discharged from it upon the nervous system. They therefore immediately affect the latter. Hæmatics, in small doses, pass through the blood without exerting any direct effect upon the nerves. They are never discharged upon the nervous system except after they have for some time existed in the blood in such quantity as materially to vitiate its healthy character. Corrosive poisons affect the nerves by a violent revulsive action; and are not to be considered in the same category as medicines. Thus Lead is not a true Neurotic, but a blood-medicine. (_Vide_ page 175.) We have now concluded our brief review of the action of Neurotic medicines. Some few will be again treated of in the fourth chapter. The views of their operation which I have wished to substantiate are in many cases the same as those which are generally adopted, in some cases different from them. In either instance I have attempted to base them on observation, or on simple inductive reasoning. It has already been observed that these nerve-medicines are more rapid and more evanescent in their action than those which preceded them. They are unable, as a general rule, to produce a permanent effect. When such a permanent impression is desired, an approach to it can be made by a continual repetition of the dose, by which a transitory action may be constantly renewed and kept up. In other cases a mere transitory action may produce a cure. This may be the case in a sudden and dangerous emergency, which will pass over if the system can be supported through it, but which threatens life while it lasts. Or in Neuralgia, if the irritability of the sensory nerve be continually blunted by the external application of Aconite, it may at last subside altogether, and a right condition of things be restored. The same may be said of convulsive disorders, and the stimulant antispasmodics which are used to control them. Neurotics are mostly employed in temporary emergencies. In such cases their action is often decisive and gratifying. Vital action may be restored and kept up; or excess of action allayed. Pain may be suddenly and effectually removed; delirium or convulsions subdued. Sleep may be substituted for wakefulness, or activity for torpor. By these powerful remedies we are enabled to exert an immense control over the varied manifestations of nervous force; and may often, when we wish it, substitute one condition for another which is the reverse of it. When there is a deficiency of nervous force, we make use of a Stimulant, or of one of the Inebriant Narcotics; when there is an excess of the same, we employ a Sedative, or one of the latter two Narcotic orders. But when we desire to quell a long-standing and firmly-rooted disorder, which is not displayed by violent outward manifestations, but is nevertheless working fatally within, we must then call to our aid some Hæmatic medicine, which alone can be of permanent efficacy in such a case. PROP. IX.--_That a third class of medicines, called_ ASTRINGENTS, _act by passing from the blood to muscular fibre, which they excite to contraction._ Although this class of Astringents is a small and comparatively unimportant class, yet it is necessary to separate it from all the others, because the medicines which compose it are completely distinct in their mode of operation. They do not necessarily act in the blood, although many Hæmatics are also astringent. They do not pass from the blood to the nerves. They do not always act by passing out of the body through the glands. Their operation is peculiar, but it is simple. As Neurotics act directly on nerve, so these act directly and especially on muscular fibre. They cause this to contract, whether it be striped and voluntary, or of the involuntary unstriped kind. Their action is more readily understood, because it can actually be seen. It takes place out of the body, or in the body--externally, or internally. Nearly all astringents have the power of coagulating or precipitating albumen. By virtue of this power they are enabled to constrict many dead animal matters. They affect fibrinous tissues in a similar chemical way. But they seem to possess a further dynamical influence over living tissues, which possibly depends in some way on this chemical property. This dynamical influence is, as I have said, to cause the contraction of muscular fibre. By this all their operations can be explained. Taken into the blood in a state of solution, they pass through the walls of the capillaries to the muscular tissue. By inducing the fibre of the voluntary muscles to contract, Astringents may brace the system, and simulate the action of Tonics. But as the contraction of voluntary muscle is short and brief, it requires for its maintenance a continual excitation, and unless the medicine is thus continually repeated, the tonic effect subsides. But astringents further contract involuntary muscle. This contraction is slower, and more durable and important in its results. Unstriped muscular fibres exist in the middle coat of arteries, in the walls of capillary vessels, in the lining of the ducts of glands generally, and in the substance of the heart and the coats of the stomach and intestines. Astringents are irritant and poisonous in large doses. But in small doses they constrict and stimulate to a healthy condition these tubes that contain in their coats the unstriped fibre. By diminishing the caliber of the capillary vessels generally, they promote health, and counteract a lax state of the system. By the same action on the extreme vessels, they prevent hæmorrhages. By constricting the ducts of the glands they diminish the secretion of those glands, because denying it an exit. By acting on the stomach and intestines, they are able to give them tone, to diminish their secretions when excessive, and thus to promote digestion. Having premised this general view of their action, we may now proceed to prove the Proposition in which it is stated, dividing it first into four minor propositions. _m. p. 1._--That they are medicines which pass into the blood. _m. p. 2._--That they have the power of causing the contraction of muscular fibre, living or dead. _m. p. 3._--That their operation is to diminish secretion, to repress hæmorrhage, and to give tone to the muscular system. _m. p. 4._--That these results are to be accounted for by their action on muscular fibre, to which they pass from the blood. These assertions are an extension of the major proposition, but their establishment is necessary to a correct understanding of the latter. Their proof is comparatively easy and simple. It is not supposed to be a certainty; but simply to amount to a strong probability, which is as much as we have a right to expect in such cases. Astringents constitute the third class of medicines which operate on the system after being introduced into the stomach. Their action is, however, of so simple a kind, that it may be exerted on the external surface in the same way as in the interior of the body. It will be seen by a reference to the table of medicines, that the class of Astringents is there divided into two orders. ASTRINGENTIA. Ord. 1. Astringentia Mineralia. Ord. 2. Astringentia Vegetabilia. The lists of these orders are given below. With regard to the first minor proposition, it has already been proved that most of these medicines pass into the blood. The minerals included in the first order have already been noticed as Hæmatic medicines. They are all soluble in water. They are absorbed in the stomach and intestines, and pass into the blood. Many of them pass on into the secretions. The astringent parts of the vegetables of the second order are also soluble. Tannic acid is the chief of them; it is simply an Astringent; it has been found in the blood, where it changes into Gallic acid, and in that form it passes into the secretion of urine. What then are the active properties of these medicines? They have all a certain chemical power; and a certain dynamical power. All the mineral Astringents have the power of precipitating an albuminous solution. So also do Tannic acid, Turpentine, and Creosote, coagulate albumen. Tannic acid precipitates Gelatine too. The dynamical property, which is common to all of these substances, is a power of causing the contraction of muscular fibre. It seems to depend somehow on the chemical power just mentioned; for Astringents appear to constringe fibrinous as well as albuminous tissues by a chemical action. They also coagulate fluids and discharges which contain albumen. When the solution of any Astringent is applied to a fresh fibre of dead muscle placed under the microscope, it is seen to contract. The power which they possess in causing the contraction of living blood-vessels may be witnessed in a similar way. The astringent solution may be applied to the web of a frog's foot, confined in an extended position. This web is traversed in all directions by minute ramifying capillaries; and these are found gradually to diminish in caliber. In the same way as the mechanical irritation of a small artery will act upon the unstriped muscular fibre contained in its coat, and thus cause the vessel to contract at one point; so it seems that an Astringent, by a chemical action on the same muscular tissue, is able to cause the capillary vessels seen under the microscope to contract and diminish in size. At all events we may conclude, both from actual experiment and from a comparison of their several operations, that Astringents are able to cause the contraction of muscular fibre. In the third minor proposition the chief results of their operation are stated. These have already been briefly described. They check secretion. They are thus prescribed when any secretion is excessive. The Tannic vegetables are given in diarrh[oe]a; Nitrate of Bismuth is administered in Pyrosis; Sulphuric acid in profuse perspirations; Uvæ Ursi in mucous flux from the bladder. They repress hæmorrhage. Thus Acetate of lead is employed in hæmoptysis; Creosote and Uvæ Ursi are used in hæmorrhage from the stomach or bladder; and the vegetable Astringents are prescribed in Dysentery. They give tone to the system. They do this when there exists an over-relaxation of the solid fibres on account of any depressing cause, by exciting the muscles to a more or less permanent contraction, and by constringing the capillary vessels generally. In the fourth place, it is maintained that their action in all these instances may be explained by a reference to their power in causing the contraction of muscular fibre; inasmuch as they are found to diminish the caliber of certain tubes and cavities, and these owe the contractility which they possess to the muscular fibre which is contained in their coats. It follows then from the rule of local access, that before they can influence these tissues they must pass directly to them from the blood. Such appears to be the simplest and the most rational explanation of the action of Astringent medicines. ORD. I. MINERAL ASTRINGENTS. (Sulphuric, Nitric, and Hydrochloric acids. Acetate and Diacetate of Lead; Sulphate and Sesquichloride of Iron; Alum; Sulphate of Zinc; Sulphate of Copper; Bichloride of Mercury; Nitrate of Silver.) These medicines have already been noticed among Restorative and Catalytic Hæmatics. Their Astringent action on muscle is of much less moment than their important operations in the blood. Neither is it theoretically a matter of so much difficulty; for it appears, as we have seen, to admit of a simple explanation. By their chemical action on albumen, these substances coagulate blood, and thus act in a simple way as styptics when applied to bleeding parts externally. They form peculiar insoluble compounds both with albumen and fibrine, and it is probably by virtue of their action on the latter that they are able to cause the contraction of muscular fibre, which is a fibrinous tissue. The constriction, set up chemically, is apparently continued and propagated by the vital force of the muscle. The most important only of the mineral Astringents are mentioned above. It must not be supposed, when their chemical actions are mentioned, that such actions are always allowed free play in the living and circulating blood. They are no doubt constrained by various forces from operating there, or else the consequences of such a disturbance of the condition of the elements of the blood would be dangerous in the extreme. (_Vide_ page 104.) They act, before entry into the blood, on mucous membranes and external parts; and on coming out of the blood, on the terminal capillary vessels, on the ducts of glands, and on mucous membranes again. Astringents act very much alike on external parts; only that some are more soluble than others, and some excel the rest in chemical activity. But they differ considerably in their applicability for internal use. They must be given in such quantity that, after absorption and dilution by the whole mass of the blood, they may still be capable of exerting a perceptible action on distant parts. A small portion of one of them will not suffice to repress hæmorrhage, or to diminish a super-abundant secretion. From this it follows that the mineral acids, Alum, and the salts of Iron, are the only astringents of this order which can in all cases be given internally with advantage. For being comparatively innocuous, they can be safely prescribed in the quantity required; whereas the other mineral Astringents are poisonous substances, which cannot be given in large doses without considerable danger. Of the mineral acids, Sulphuric acid is the best Astringent. Phosphoric acid is seldom or never used as an Astringent. We might indeed have supposed it to be inapplicable, from the fact that it forms soluble compounds with albumen and fibrine,--instead of coagulating these substances, like the other mineral acids. Sulphuric acid is a Restorative Hæmatic; and, when given in small doses, may remain in the blood, and not pass out through the glands. It acts first upon the mucous surface of the stomach. When there is a relaxation of this mucous membrane, as in many cases of atonic dyspepsia, with a large formation of flatus, and an over-secretion of the gastric fluid, this acid may be very serviceable. It tends to correct these evils by a topical action. In cases of Pyrosis, where there is an alkaline reaction in the vomited fluid, as sometimes occurs, Sulphuric acid is still more peculiarly applicable, because it further acts chemically in neutralizing this alkali. When given in large doses, the acid cannot remain in the system, but must be excreted from it by the glands. In passing through them it tends to act as an Astringent by corrugating and diminishing in caliber their minute ducts, and thus decreases the amount of the secretion. But it does not act on all glands alike. Dr. Bence Jones has found that it seldom passes out into the urine. It therefore does not sensibly diminish the secretion of urine. It is probably excreted partly by the skin, and partly by the bowels; for it diminishes the amount of the sweat in profuse perspiration, and of the fæces in diarrh[oe]a. Sulphuric acid is free before entrance into the blood, and after expulsion from it into the secretions. Thus at these periods it acts as an Astringent. But while in the blood it combines with the alkali contained in that fluid, and forms a salt which is not astringent. So that when it diminishes any secretion, this is nearly tantamount to a proof that it is actually excreted by the gland which forms that secretion. It acts on mucous membranes generally, being probably excreted in small quantities by those which are remote from the stomach. It is not of use in cases of hæmorrhage, except when the bleeding takes place from some mucous membrane. It is thus given with more or less advantage in Hæmatemesis, Hæmoptysis, Melæna, and chronic Dysentery--_i.e._ in hæmorrhage from the mucous surfaces of the lungs, stomach, and bowels. Alum is a universal Astringent, acting more or less on all parts of the body, and diminishing all secretions. It is a very useful remedy in all cases where Astringents are required. It does not seem to be impaired in power while in the blood, as is the case with Sulphuric acid; and is therefore applicable in all hæmorrhagic cases. It has been highly recommended in the case of lead colic, and seems to operate in this instance by stimulating to contraction the muscular fibre of a paralyzed portion of the intestine. The astringent salts of Iron are less active in this kind of influence than the medicines already referred to. They have very little action on the glands. But in cases of hæmorrhage they are particularly appropriate, for in addition to their astringent action they tend to restore the deficient red colouring matter of the blood. In many such instances the Sulphate or the Sesquichloride of Iron may be advantageously prescribed along with Sulphuric acid. Acetate of Lead is used internally as an Astringent, but being a more dangerous remedy than the medicines above mentioned, it requires greater care in its application. It should not, if possible, be used long at a time. When it has been for some time prescribed, the blue line at the edge of the gums, which is characteristic of a saturation of the system by the poison of lead, will indicate that its further administration is unadvisable. The Acetate of Lead is much esteemed as an Astringent in the case of Hæmoptysis. It is frequently combined with Opium, in spite of the chemical decomposition which follows the admixture. But it must certainly not be prescribed with Alum. The soluble salts of Silver, Zinc, and Copper, and the Bichloride of Mercury, are used with advantage as external Astringents, but can seldom be prescribed internally so as to act in this way, because they are poisonous when given in any quantity. The Sulphates of Zinc and Copper have, however, been occasionally used in diarrh[oe]a. When thus applied as Astringents externally, their solutions must be very dilute, for all the mineral Astringents are caustic and corrosive, destroying texture, when in the solid state, or in strong solutions. These solutions may be applied to any part of the surface of the skin or mucous membrane, when relaxed, inflamed, or ulcerated. Their operation is simple and obvious. When one of them is applied to an inflamed eye, or to a red ulcerated sore, that is turgid with blood and discharges an unhealthy matter, it tends to promote the contraction of the dilated vessels, and thus dispels the congestion and diminishes the discharge. Various other substances have wrongly obtained the title of Astringents, regard being had only to the result of their operation, and not to the mode in which it is produced. Thus Chalk is often of benefit in diarrh[oe]a. It acts both by mechanically absorbing irritating fluids, and protecting the surface of the bowel, and by chemically neutralizing an acid matter by which the irritation is maintained. And when applied to the surface of inflamed ulcerated parts, it does good by absorbing the discharge, and protecting from the contact of air. Thus its action in both cases is very different from that of the true Astringents. The action of some of the minerals above named, when applied externally in the solid state, as caustics, must not be confounded with their astringent power. Its efficacy depends upon the revulsive effect which follows a local destruction of tissue. ORD. II. VEGETABLE ASTRINGENTS. (Tannic Acid. Gallic Acid. Kino; Catechu; Logwood; Oak-galls; Rhatany; Bistort; Pomegranate-rind; Rose-leaves; Uvæ Ursi; Tormentil. Creosote.) Tannic Acid, Gallic Acid, and Creosote are the three chief Vegetable Astringents. To the first two the vegetable substances above enumerated appear to owe their efficacy. All contain Tannic Acid, or some modification of it; and Oak-galls contain also Gallic Acid. The relative efficacy of these active principles may be summed up in a few words. Tannic and Gallic Acids may generally be used with great advantage in all cases in which Astringents are required. When applied externally, Tannic Acid is the most powerful; but for internal administration Gallic Acid is the best. The reason of this will presently appear. Creosote, being a powerful Neurotic, cannot be employed to act on distant parts, but is appropriate in cases of hæmorrhage from the surface of the stomach. I have already said that I conceive the astringent powers of these substances to depend very much upon their chemical affinities. Tannic Acid precipitates both Albumen and Gelatine. Creosote also coagulates Albumen. But Gallic Acid does not affect either of them. Tannic Acid does not seem to be a simple substance. When boiled with acids, or with alkalies, it yields Gallic Acid and a brown matter. Tannic and Gallic Acids yield the same set of products when submitted to destructive distillation. And it appears likely, from the researches of M. Braconnot, that Tannic is a compound acid consisting of Gallic Acid in combination with the elements of grape-sugar. Three atoms of Tannic Acid are together equivalent to six atoms of Gallic Acid and one of grape-sugar. When the solution of the former acid is heated in the air, or taken into the human system, the elements of grape-sugar are oxidized into Carbonic Acid and water, and Gallic Acid is set free. (_Vide_ Chap. IV. _Art. Tannic Acid_.) It is thus Gallic Acid which passes out into the secretions, and exerts an astringent action at distant parts of the system. And as the Tannic Acid loses weight by the decomposition, it follows that a dose of Gallic Acid produces a greater effect as a medicine than an equal amount of the other. Thus one ascertained fact is cleared up by these chemical considerations, but other mysterious points remain still to be explained. Gallic Acid does not precipitate albumen, and is of little use as an Astringent when applied to external parts; but it is very efficacious when given internally. Tannic Acid, which is equivalent in composition to a combination of Gallic Acid with a saccharine matter, is a valuable external Astringent. A further chemical discovery has been made, which appears to bear upon these facts. M. Pelletier has found that a mixture of a solution of Gallic Acid with one of Gum will precipitate albumen, although neither of them will affect it separately.[43] Gum has the same composition as common sugar; and grape-sugar, or a material containing the same elements, is known to be continually forming in the blood. Thus it is likely that Gallic Acid may act along with this saccharine matter in the blood, and by this acquire chemically an astringent power, which it is not able to exert on external parts, because then isolated. But the saccharine matter is required in the system for special purposes, and thus Gallic Acid passes out into the secretions alone. It seems probable, when Tannic Acid is given, that it is not decomposed into its constituent parts until it has to be separated from the blood by the glands. These two compounds, and the vegetable substances that contain them, are used in diarrh[oe]a, and in all hæmorrhagic cases. To diminish sweating, Tannic is inferior to Sulphuric Acid; but to act as a remote Styptic, it is preferable to the other. Tannic and Gallic Acids diminish secretions generally; they are very useful in cases of hæmaturia, where Sulphuric Acid is all but useless. Creosote is a Sedative, and cannot be well given in such large doses as to act upon distant parts. In cases of hæmatemesis it acts topically on the surface of the stomach in a double way, diminishing the hæmorrhage by its astringent power over the vessels, and quieting the nervous irritation by which the vascular excitement is often maintained. In cancerous cases the bleeding can never be permanently stopped. This concludes the list of Astringent medicines. Certain stimulant Eliminatives are employed for the purpose of checking mucous fluxes, and so far simulate the action of true Astringent medicines. Thus we administer, with more or less advantage, Aromatics in diarrh[oe]a; Cubebs, Copaiba, and Turpentine, in gonorrh[oe]a; and Balsam of Peru, and other oleo-resins, in Catarrhal affections. These medicines all act upon and pass through the glands of the several mucous surfaces which they affect: while so doing, they stimulate the healthy function and secretion of the gland, and cause it to displace the morbid one. Dr. Williams thinks that they first cause dilatation of the vessels of a gland, and that this is followed by contraction. There is no apparent reason why the latter effect should succeed the former. But supposing contraction to take place in this way, then these medicines would be true Astringents. But it cannot be so, for they do not diminish any of the natural secretions, but, on the contrary, increase them. Turpentine, Cubebs, and Copaiba, are Diuretics, and it is possible that while passing out in the urine they may simply stimulate the mucous surface of the inflamed urethra, and excite it to a healthy action. These volatile oils are incapable of exerting a true astringent action. On the supposition that it is really an Astringent, Turpentine has been often prescribed as a remedy for hæmorrhages in different parts of the body. But it has very much disappointed the expectations that were entertained of its efficacy. General Stimulants may act indirectly as styptics to a mucous surface, when relaxed and bleeding on account of an atonic condition of the nerves by which the contraction of the minute vessels is maintained. Alcohol, in large quantity, coagulates albumen, and it may thus act as a true Astringent when applied externally. Some Neurotic medicines diminish secretions in a way which is not well understood. The chief of these is Opium, which particularly diminishes the secretion of the bowels. Attempts have been made to explain this by an influence possessed by Morphia on the process of Endosmosis, but they are not satisfactory. Some little light may perhaps be thrown upon the matter by a consideration of the other operations of Opium; but it is difficult to explain it decisively in any way. PROP. X.--_That a fourth class of medicines, called_ ELIMINATIVES, _act by passing out of the blood through the glands, which they excite to the performance of their functions_. In this Fourth Class are included all the medicines which tend in a direct manner to increase secretion. They have received various appellations: some authors have called them special Stimulants; others, as Dr. Duncan, have named them Evacuants; while Dr. Pereira entitles them Eccritics. The mode of operation of Eliminative medicines is a matter of considerable importance, and its consideration will require us first to make some inquiry into the character and functions of those important glandular organs which they are said to excite to action. The rational explanation of the process of elimination or secretion has been in all ages of science a favourite topic for speculators and theorists,--sound or unsound in their views, according to the light that was given to them. With regard to its essential nature, and its immediate bearing on the cure of disease, the subject has been generally understood with tolerable clearness. From the time of Hippocrates downwards, the use of Evacuants in the treatment of fevers and other disorders has been recognised, and their efficacy usually explained by supposing that they caused the passage out of the body through the glands of certain matters that were formed in the blood, but ought not to remain in it. This view was more particularly insisted on towards the close of the seventeenth century by Dr. Thomas Sydenham; and again at the commencement of the eighteenth by Dr. A. Pitcairn, in an Essay on the use of Evacuants in Fevers. These both had observed that fevers and other disorders had mostly a particular tendency to pass off with an increase in one or more of the secretions; and they drew from this, and from the results of their experience, that in stimulating and urging this secretion, the physician would be doing his best to promote a cure. (_Vide_ page 55.) More recently the same idea has been followed up by Cullen, Hamilton, and others. This theory is not in our immediate province. Though based upon reasonable grounds, it has perhaps been too universally applied. It will suffice now if we assume that remedies whose action is to increase the amount of secretion have often an important bearing on the cure of disease. We have only to inquire into their manner of action. As a preliminary step, there is one general law of secretion which it is of importance that we should clearly lay down. It is this: it is the special office of each gland, or set of glands, to secrete from the blood particular materials, and to pass them out of the body.[44] It follows from this law of selective secretion, that when any morbid substance or product,--or any thing which is in the system, but cannot naturally remain there,--has to pass out, it prefers to pass by some glands rather than by others. It must be remembered that the glands afford the only means by which a substance can make its exit from the blood. We are still much in the dark as to the _rationale_ of this force or attraction, by which particular matters are drawn towards each gland. Dr. Pitcairn, a great man for the age in which he lived,--a man of original thought and natural genius,--gives us, in his Essay on the Circulation of the Blood, a learned account of three theories on this matter which were in vogue at his time. They are of importance, as showing that the fact was then very clearly recognised, however dubious the explanation of it might be. One party supposed that there was in each gland a certain material stored up, which prevented the passage through to itself of any substance that was not like it; just as when a sheet of paper is steeped in oil, oil only will pass through it, and not water. A second party, called the Chymical party, supposed that there must be in the immediate neighbourhood of each gland a subtle fluid or ferment, whose tendency and office it was to form and separate from the blood the materials which that gland had to secrete. A third set of physicians armed themselves with mathematics and with the newly discovered principles of Newton, and actually worked out formulæ and equations wherewith to support their arguments. They had strong and perhaps reasonable ideas as to the definite shapes of atoms. They averred that each gland was to be compared to a sieve or strainer, having in it pores of a particular size and certain geometrical shape, and that each secreted atom could only pass through a pore that would exactly coincide in size and figure with itself. The first two of these theories Dr. Pitcairn disputed, and treated with high disdain. The third he accepted in a modified form. He supposed that the vessels in the glands ended in small open mouths, always circular, but differing in diameter in different glands, so that each would only admit the passage of a particle whose diameter approached a certain sum. Thus he supposed that each secretion would consist only of certain peculiar particles. Possibly Dr. Pitcairn forgot that small particles would seldom hesitate to pass through large holes. We may perhaps feel inclined to make light of these crude speculations of the philosophers of the eighteenth century; we may be disposed to smile at the idea of vessels with open mouths, and of glands which are riddled with holes like the buckets of the Naiades; but we must after all confess that if at the present day we have swept away these notions, we have certainly added nothing in their stead, nor can we explain this matter at all more clearly than our predecessors a century and a half ago. The fact, however, is plain, however vainly we may try to explain it. It is an established rule, to which there are few exceptions, that each substance which is formed in the blood and has to pass out of the body, tends to pass out through some particular glands; that it is the particular function of the kidneys to excrete water, urea, uric acid, and certain salts; that it is the especial office of the bowels to excrete certain effete matters and gases; and that it is the peculiar province of the liver to excrete fatty matters, taurine, cholesterine, and choleate of soda. Water, being the necessary solvent of the solid matters in all the fluid secretions, is secreted in greater or less quantity by all the important glands. The kidneys are the chief emunctories of water,--_i.e._ they have to separate it from the blood when it has entered in an unnatural amount. But in the excretion of water there exists a compensating relation between the skin, kidneys, and bowels,--particularly between the two former. So that when water is not properly excreted by the kidneys, it may pass out by the skin, and _vice versâ_. It is well known that this change may be determined by several circumstances, particularly by the conditions of heat and cold, or moisture and dryness. The relation between the function of the skin and kidneys applies also to other fluid and solid substances, as will be seen when we consider the medicines which act upon these glands. Now this law of selective secretion applies not only, as it seems to me, to substances which in the course of nature are formed in the blood, and have to be excreted from it, but also to other matters which have been, as it were, accidentally introduced from without, and which, being in the system, cannot properly remain there. Thus it would apply to all medicinal bodies which have passed from the stomach into the blood, and which, not being natural constituents of that fluid, must again pass out of it. So that although it is often laid down that medicines acting on the glands do so simply by passing along in the blood, and stimulating them as they go by, I regard this as a needless complication of the subject, and a thing which is wholly without proof. In fine, I am brought to the opinion which I have laid down in the Tenth Proposition, and which I have now to establish as well as my space will permit. The affirmation may be thus divided into minor propositions:-- _m. p._ 1.--That Eliminatives are medicines which pass into the blood. _m. p._ 2.--That they cannot remain there, but must pass out of the body. _m. p._ 3.--That in so doing, they tend to pass out by some glands more than by others. _m. p._ 4.--That the result of their passage through a gland is to increase its secretion. _m. p._ 5.--That they are of use when the state of the system requires that the function of a gland should be restored or promoted. What I wish to prove is, that a medicine increases secretion simply by being itself secreted; that while passing through a gland it stimulates the secreting cells, and rouses them to a proper performance of their natural function; that each eliminative medicine has a tendency towards particular glands, and increases the secretion of those glands; that thus, as far as our information on the subject extends, we find that Cathartics are excreted from the blood by the glands of the bowels, and pass out with the fæces; that Diuretics are to be discovered in the urine, Diaphoretics in the sweat, and those Expectorants which are volatile may be detected in the odour of the breath. Any material which is naturally eliminated would act as an eliminative medicine. Thus if a drachm of Urea be dissolved in water, and injected into the veins of a dog, it causes copious urination, which continues until the whole is excreted. This well illustrates the argument. Further, we find that when an eliminative medicine is diverted from the gland by which it usually passes out, it no longer augments the secretion of that gland. Dr. Ward gives an interesting case of a woman who was never purged by Castor-oil, but in whom the oil exuded from the skin, and acted as a Diaphoretic. And it is, as I have said, well known that the conditions of cold and exercise will cause a Diaphoretic, in most cases, to act on the kidneys, because it is then excreted by them. For the same reason, warmth, confinement, and rest, will induce a Diuretic medicine to act on the skin. Thus if it be shown, on the one hand, that Eliminative medicines themselves pass through the glands whose secretions they augment; and, on the other hand, that when they do not pass through them, they do not, as a general rule, augment their secretion,--it may then fairly be presumed that they operate by so passing through. I assert, then, that medicines which stimulate secretions are themselves secreted. But the converse of this--_i.e._ that all medicines which are secreted at the same time increase secretion,--though it holds good in the main, is not invariably true. There are two chief exceptions to it. These are Astringents and Hyperæmics. When an Astringent passes through a gland, it tends, by its natural force, to decrease secretion, and to cause constriction of the ducts. Thus Uvæ Ursi may decrease the amount of the urine, although it sometimes does the opposite; in which case the eliminative may be said to surmount the astringent tendency. So also Catechu, Kino, and Sulphuric Acid, decrease the secretion of the intestinal glands. But general Astringents are not always glandular Astringents. Thus the mineral acids act as Diuretics. By Hyperæmics I mean medicines which produce congestion. Powerful Eliminatives do this when given in excess, simply by exciting excessive action. Now it is a general rule that congestion, however caused, diminishes the secretion of a gland. Thus congestion of the liver produces jaundice; congestion of the kidney, ischuria. After scarlatina, when the kidneys are suddenly called upon to eliminate a morbid material from the blood, congestion of the glands may be caused: the urine is diminished, and dropsy results. Cantharides and Turpentine are Diuretics. They increase the urine when taken in moderate doses; but when in an overdose, they diminish it, and may cause painful strangury, with an almost total suppression of the secretion. The explanation of such an action is obvious. Congestion is caused by the excessive action. In the same way we find that a large dose of Mercury, naturally a Cholagogue, may produce jaundice, by causing congestion of the liver. This fact has been observed by Dr. Graves, of Dublin. In all cases, then, in which observations have been made, we find that an Eliminative medicine is secreted by the gland which is stimulated by it, and, in most cases, that a medicine which is excreted by a gland tends to increase its particular secretion. Having made this general statement of the case, I must attempt a more particular and detailed proof. I will treat in turn of the above minor propositions, as applicable to the following orders of Eliminative medicines:-- CLASS IV. ELIMINANTIA. Ord. 1. Sialagoga. Ord. 2. Expectorantia. Ord. 3. Cathartica. Ord. 4. Cholagoga. Ord. 5. Diaphoretica. Ord. 6. Diuretica. They are enumerated nearly in the order of the glands, from above downwards, in the human body. I have not enumerated Errhines, because the medicines which are used to increase the nasal mucus are merely topical irritants, and not true Eliminatives. Of Emetics I have already spoken. Some are Neurotics, acting from the blood on the nervous system; other are local irritants. They also are not true Eliminatives. Neither are Emmenagogues so; for the uterus is not a gland. Some of these too are Neurotics. Most of them act by causing a determination of blood towards the organ. Cathartics do this by their action on the contiguous mucous membrane of the intestines. (_Vide_ page 102.) These then are the six orders of Eliminative medicines. In the first minor proposition it is stated that they pass into the blood. This has already been in great part proved; for most Eliminative medicines belong also to one or more of the preceding classes, of which it has been shown that they pass into the blood. Thus Antimony, Mercury, Acids, Alkalies, Sulphur, the Salts, etc., are Hæmatics primarily. The various volatile oils and resins are more or less Stimulants. So also Alcohol and Ether, as well as Camphor and others, are found among Narcotics. Colchicum, Digitalis, Creosote, and Ipecacuanha, are Sedatives. Many Eliminatives are certainly known to pass into the blood, because they are subsequently found in the secretions, as will be presently seen. Secondly, these medicines cannot remain in the blood, but must sooner or later leave it. If they remained, they could not pass through the glandular cells. But if they pass out, they must inevitably be excreted by them. All those medicines must be secreted which have nothing in the natural blood corresponding to them. This is the case with most Eliminatives, and with all medicines except the Restorative Hæmatics. And those Restoratives which act as Eliminatives, such as Acids and Alkalies, do so because they are introduced in so large a quantity that they cannot possibly remain in healthy blood. Thus all these medicines pass out through the glands. Thirdly, we find that in so doing they tend to pass out by some particular glands rather than by others. In order to show this we may consider first the chief tendencies of the great groups of Eliminative medicines; and secondly, I shall endeavour, when considering the six orders, to show that many of the medicines included in them have actually been found in the secretions of the glands towards which they tend. The first consideration will clear the way for the second. What we have to ascertain is, that the principle of selective secretion is generally applicable to Eliminative remedies. The most important of the substances which are used to increase secretion may be divided chemically under the following six heads, of all of which it has been proved that they are capable of absorption. (Prop. II.) 1. Insoluble mineral substances. 2. Soluble minerals,--_i.e._ Acids, Alkalies, and Salts. 3. Ammonia and volatile oils. 4. Fixed acrid oils. 5. Resins and neutral acrid principles. 6. Soluble vegetable principles. 1. _Insoluble mineral substances._--The chief of these are Mercurials (Blue Pill and Calomel,) Iodine, and Sulphur. They are all more or less changed during the process of absorption, as they have to be reduced to a soluble condition. They stimulate secretion generally; but Mercury particularly tends to the liver, bowels, salivary glands, and skin; Iodine, to the kidneys, and to the salivary and mucous glands; Sulphur, to the skin. 2. _Soluble mineral substances._--Acids, Alkalies, and Salts, may pass off by any of the fluid secretions. The chief of these secretions are the sweat, the urine, and the secretion of the bowels. The sweat is only fluid when the skin is kept covered and very warm. In other cases the choice lies between the kidneys and the bowels. The kidneys are the grand purifiers of the blood, so that most of the substances which stimulate the other glands may occasionally pass off in the urine. And soluble minerals, which require some amount of water for proper solution, would tend for this reason towards the most fluid of the secretions. But there are some other things which counter-balance this tendency. The constitution of the urine is such that it cannot safely be disturbed to a very great extent. If there be much excess in it either of acid or of alkali, a deposit is occasioned. Dr. Bence Jones found that Sulphuric acid never passed out in the urine in any quantity. We find too that when a certain quantity of a saline is administered, too great to pass off readily by the kidneys, it prefers to act on the bowels. It is more likely to be diuretic if much diluted with water; but this is not the only directing cause, for a very large quantity of a saline will prove purgative even when largely diluted. (_Vide_ Prop. II.) Thus the general rule is this: soluble minerals are in small doses Diuretic, in large quantity Purgative. This applies more especially to salts; for mineral acids act as astringents on the bowels,--and mineral alkalies, being corrosive, cannot be given in large doses. 3. _Ammonia and volatile oil._--The laws of endosmosis favour the passage of soluble substances through to a liquid secretion. They are dissolved and carried away on the other side of the membrane through which they pass. In the same way it appears that volatile substances may dissolve in, and be carried away by, air. Thus they have a tendency towards the aeriform secretions. These are,--the expired air, or the secretion of the air-cells of the lungs,--and the ordinary cutaneous transpiration. While passing through the air-cells, these matters stimulate the secretion of the lining mucous membrane. They cause a morbid secretion of this surface to be replaced by a more natural one. Thus Ammonia and volatile oils are Expectorant and Diaphoretic. They may all pass out in the urine, but do not especially tend to do so, with the exception of some that are acrid, and approach to the nature of the resinous group. Turpentine, Juniper, and Copaiba, are Diuretic. 4. _Acrid fixed oils._--Such are Castor and Croton Oils; they are Purgatives, passing off by the bowels. 5. _Resinous and neutral acrid principles._--These are soluble in alkalies, and thus partly absorbed in the intestinal canal. Most of them are Cathartic, whether introduced into the stomach or injected into the veins. Such are the resins of Scammony, Jalap, and Gamboge, and the principles of Colocynth and Elaterium. Some few of them are Diaphoretic, as Guaiacum and Mezereon. Some again are Diuretic, especially those which are liquid or associated with a volatile oil, which is the case with Copaiba, Cubebs, Cantharides, and others. 6. _Vegetable principles soluble in water._--Most of these are Diuretic; as are the Vegetable Acids, and the Alkaloids of Digitalis, Tobacco, and Colchicum. So also are the principles of Broom and Sarsaparilla. The Emetine in Ipecacuanha, and the Morphia in Opium, act on the skin. Aloesin, the principle of Aloes, is purgative. So is Cathartin, the soluble acrid principle of Senna. Having thus briefly sketched out the particular tendencies in the operation of the groups of medicines which act on the glands, it remains for me to say that in very many cases these medicines have actually been proved to pass out of the body by the glands whose secretions they tend to increase. Whenever we are in a position to inquire into the facts by chemical or other means, we find that the Eliminative medicine is itself contained in the secretion which is augmented by its action, and that when the secretion upon which it usually acts is not augmented, the medicine has passed off by some other secretion instead. There are doubtless many cases in which no inquiry of the kind has been yet made; but it will be seen when we consider separately the Eliminative orders, that all that is known on the subject is in favour of the above statement. Assuming, then, the third and fourth minor propositions together, we conclude that Eliminative medicines, which must pass out of the blood, tend to pass out by some glands more than by others, and that the result of their passage through a gland is to increase its secretion. They do not exert a blood-influence, nor do they act on the nervous functions; but they operate on those obscure vital forces by which secretion is directed and controlled. The fifth minor proposition treats of the application of these agents in the treatment of disease. They are of use when it is requisite that the function of a gland should be restored or promoted. There is scarcely any disease in which some or other of them may not be of service. Their remedial applications are many and important. Eliminatives are used to restore the function of a gland when impaired. With this view, Cathartics are employed in constipation, Diaphoretics for dryness of skin, Cholagogues in torpid states of the liver. They may eliminate a poison or morbid material, and thus resolve a disease. This probably is the rational explanation of the use of Diaphoretics and Diuretics in Fevers, Gout, and Rheumatism, and of purgative medicines in a great number of disorders. We may, by an action on one gland, be enabled to replace the function of another gland. The amount of each secretion bears more or less an inverse proportion to that of other secretions. Thus when one of them is unduly copious, we may diminish it by stimulating the formation of another. In other cases the reverse condition may occur; one of the secretions may be diminished or suppressed by a cause over which we have no control, and the matters which should be contained in it may be left in the blood, causing various mischief there. Here again, by increasing one of the other secretions, we may replace the function of the diseased gland, and cause the elimination of these products from the body by another channel. Fourthly, Eliminative medicines may be of service by draining away from the blood fluid and solid matters. The first result of their action is to stimulate the proper secretion of a gland; but when it is pushed to a further extent, they may actually case the excretion of some of the natural constituents of the blood. Thus by an action on the skin or the kidneys, we may cause a copious evacuation of water, holding in solution saline matters. By increasing the secretion of the intestinal glands, we may cause the albuminous serum of the blood to be poured out into the cavity of the bowels. Thus it is that all Eliminatives are more or less antiphlogistic. Cathartics are especially so. Their influence, when carried to excess, is analogous to that of blood-letting. As evacuants, Cathartics are employed in diseases of the brain especially; and Diuretics are made use of in dropsies to diminish the amount of fluid in the blood, and in this way to promote absorption. So much having been said of the general action of Eliminatives, we proceed to make a few remarks on the individual orders of medicines which are included in this division. Those substances can alone be properly included in these groups which really act on the principle of elimination, as above defined. There are in many instances other medicines which are found to increase secretion in an indirect way. ORD I. SIALAGOGUES.[45] This name is applied to medicines which in various ways increase the quantity or promote the excretion of the saliva. They are seldom employed as remedial agents; for the excretion of saliva is constant and very rarely suppressed, and it is so small in quantity, and so great a source of inconvenience when increased to any amount, that Sialagogues can never be employed as general evacuants. There are two kinds of Sialagogues. Any solid substance which excites the mucous surface of the mouth, as the natural food,--or even the act of mastication alone,--will suffice to bring on the secretion of saliva. An irritant substance, as Ginger, or Pyrethrum, tends especially to cause this secretion when masticated. Catechu and Betelleaf are chewed for this purpose by the natives of the East. Such a stimulation of the salivary glands may be advantageously resorted to on the counter-irritant principle in obstinate cases of head-ache, ear-ache, or tooth-ache, or in neuralgic or chronic rheumatic affections of the face. When the quantity of the saliva is thus increased, it should not be rejected, but always swallowed when possible; for this secretion is apparently useful in the stomach, and in some way essential to the proper carrying on of the digestive process. The chewing of Tobacco, Betel, and other substances, is frequently found useful by sailors on long voyages, and is adopted as a preservative against the dysentery and diarrh[oe]a with which they are so often affected. This advantage is to be attributed to the increase in the salivary secretion. On the other hand, we find that the practice of constant spitting is productive of very injurious effects; and it is more than possible that the pale faces, lank figures, and dyspeptic maladies, which are so common among the American people, may be due in part to the prevalence of this habit among them. These topical irritants and masticatories are not true Eliminatives. There are also some medicines which by another topical action may occasionally produce salivation. These are Sedatives. Hydrocyanic acid, Digitalis, and nauseant medicines, may act locally so as to paralyze the muscular fibres by which the constriction of the salivary ducts is maintained, and thus allow the secretion to pour out uncontrolled into the cavity of the mouth. _True or Eliminant Sialagogues._--These are medicines which are actually excreted from the blood by the salivary glands, and which increase their natural secretion while passing through them. Mercury is the most important of these. When given to a considerable extent, it causes soreness and redness of the gums, and profuse salivation. It probably increases the amount of saliva even before this soreness is produced. It is not given for the purpose of producing salivation, but in cases where the full action of Mercury is desired this symptom is made use of as a sign that the medicine has taken full effect upon the system. If we permit it to be carried to too great an extent, sloughing of the gums and other dangerous results may be produced. In some rare cases salivation has followed the administration of Iodine. It is also not an unfrequent symptom of chronic poisoning by Lead. In cases of salivation by these Eliminative medicines, the substance which has caused the increased secretion may be, and has been, discovered in the saliva by chemical tests. They are therefore true Sialagogues. ORD. II. EXPECTORANTS. This term, when taken in its widest sense, is applied to all medicines that cause the evacuation of mucus from the secreting surface of the respiratory tubes and cavities. They help the natural process of Expectoration. Many medicines are capable of acting indirectly as Expectorants. Any thing which causes cough, as an irritant gas, will do it. So will any thing that thins the mucus when thick and viscid,--_e.g._ the inspiration of the vapour of hot water. Special Sedatives, which control the function of the Vagus nerve, are especially notable as indirect Expectorants. Such are Antimony and Ipecacuanha. By diminishing the morbid irritability of the pulmonary surface, they prevent the continued secretion of mucus. By allaying a spasm of the small bronchial tubes, and controlling the nervous sensation of want of breath, they may promote the evacuation of that which is already secreted. Opium and Stramonium, classed among Narcotics, depress the function of this nerve as well as the nervous forces generally. So do other medicines similar to them. Opium in small doses allays irritability and diminishes spasm, and is then an indirect Expectorant; but in large doses it acts so powerfully as to render respiration difficult and expectoration impossible. Its use therefore demands great caution. _True Expectorants._--The action of Antimony and Ipecacuanha upon the secretion of bronchial mucus is of so specific a character as to render it highly probable that these medicines add to their neurotic influence a true eliminative agency. We are as yet unable to decide whether or not they are ever secreted by these mucous glands, because not only is the analysis of the mucus a matter of difficulty, but hitherto no investigation of the matter has been made. Squill also is probably an Eliminative Expectorant. Many of the true Expectorants are volatile and odorous in nature. All excreted substances have to pass by an endosmotic process through a thin animal membrane. And it is necessary before they can pass, that there should be on the other side of this membrane something which is capable of dissolving them. Diuretics are soluble in water, and they pass through into a watery fluid. But these Expectorants, whether they pass through the mucous glands, or immediately through the thin wall of the lung-cell, are brought directly into contact with air. And in this air these volatile matters are soluble, and are carried away by it. This appears to be the reason why the Eliminatives which are volatile in nature tend particularly to act on the two aeriform secretions,--_i.e._ on that of the air-cells of the lungs, and on the common cutaneous transpiration. For though the glands of the mucous membrane of the lungs secrete mucus, yet the chief object of the terminal portion of that membrane is to absorb and secrete the gaseous matters of the blood. The following are the chief volatile Expectorants, the odours of which have been clearly detected in the breath of persons to whom they have been administered:--Turpentine, Camphor, Alcohol, Ether, and the volatile oils of Onions, Fennel, Asaf[oe]tida, Carraway, Cinnamon, and Anise. These medicines, and others like them, are thus excreted by the air-cells or mucous glands of the pulmonary surface, and while thus passing through they stimulate the latter to a right performance of their function. When, as in the case of Bronchitis, the secretion of mucus is increased in amount, or deteriorated into a purulent matter, they may be of service by causing the healthy secretion to replace the diseased one. Expectorants are very uncertain agents. The reason of this is, that the pulmonary glands are not naturally intended to act as emunctories, or dischargers of morbid matters from the blood, and thus are less prone to be excited by Eliminative medicines than other glands whose proper office is one of general elimination. And yet we find that the effete gases which should be excreted by the bowels are sometimes voided by the lungs in case of aggravated dyspepsia, causing tainted breath. Just so may other adventitious elements of the blood, as these volatile medicines, be sometimes excreted by the pulmonary membrane. But they may often pass off by the skin or by the urine, and would not then act upon the lungs at all. For the same reason that the lungs are not general emunctories, and cannot be made use of to produce a wholesale evacuation from the blood, Expectorants are of no use as general Antiphlogistics. In this they differ from the four remaining groups of Eliminatives. They are only employed in pulmonary disorders, where we desire to influence the amount or character of the mucous secretion, when the mucous membrane is inflamed or irritated. In old and chronic cases of Bronchitis the stimulant volatile Expectorants are the most applicable. Tartar Emetic and Ipecacuanha are appropriate in acute and inflammatory cases, because they exert a nauseating and depressing action. They are sometimes given in sufficient dose to act as Emetics; for the act of vomiting mechanically assists the expulsion of mucus from the air-cells and passages by causing straining and compression of the lungs. ORD. III. CATHARTICS. Cathartics are medicines which tend to increase the secretion from the inner surface of the bowels, and promote the natural expulsion of the contents of the intestinal tube. Of these two operations the first only is an action of elimination, and the second is an accompaniment to it. The first can hardly take place without being followed by the second; but in some few cases the second action alone may be produced. The subject of the application of Purgative medicines is so extensive, that it is impossible for us now to inquire into it at any great length. It should however be observed, that they are the most powerful and the most useful of all Eliminative medicines. The fæces consist partly of the undigested matters of the food, and partly of a secretion which is poured out by the inner surface of the bowel. (_Vide infra._) The majority of Cathartics increase this secretion. Whatever notion we may adopt as to its physiological purpose, it appears that we can act upon this intestinal function with ease and certainty in the great majority of cases. The surface of the intestine, covered as it is with a closely packed glandular apparatus, forms in the aggregate the largest secreting organ in the body. From the measurements made by Meckel, it appears that it covers a space of 1400 square inches. By the administration of a medicine of this sort, we are enabled to act upon this surface, producing simply an increase of the fæcal secretion, or causing, when the action is violent, an outpouring even of the fluid part of the blood. When this secretion is stopped, we may cause it to reappear; when another secretion is repressed, we may be enabled to replace it by this; and in the treatment of plethoric or inflammatory disorders, we find among Cathartics the simplest and readiest of antiphlogistic or evacuant medicines. For they possess these great advantages,--that they act with certainty, and produce a notable effect. All medicines which by a mere external action augment the secretion of the bowels, or promote its evacuation, must be regarded as _indirect_ Cathartics, for they do not operate on the eliminative principle. An outward irritation of the mucous membrane is sufficient to excite the peristaltic contraction of the bowel, and may even increase the secretion of that mucous surface by a reflex nervous action, in the same way that an irritation of the mucous lining of the mouth will cause the secretion of the saliva. All substances which, after being taken into the stomach, are not absorbed, which are thus pushed onwards along the inner coat of the intestine, and by their mere accumulation excite its muscular contraction, must operate more or less as indirect purgatives. Of such a nature are the ligneous fibres of vegetables,--the bulky pulp of fruits, as in Prunes, Tamarinds, and Cassia,--and the husk of wheat in brown bread,--all of which are known to act as laxatives. Very different from these in the intensity of their action are the resinous Cathartics, as Scammony and Gamboge, which, though capable of absorption, appear also to act in some cases by an external irritation of the intestinal surface. They are also true Eliminatives, for they are known to become absorbed; they may thus act in a double way, both directly and indirectly. (_Vide_ p. 96.) In small doses it is probable that they are simply Eliminatives, but when given in large doses they may add to that an irritant external action, and produce a very powerful or even dangerous effect. _True Cathartics._--These are very many in number. At whatever part of the system they are introduced, their action is the same. If one of them be injected in solution into the veins, or absorbed from the surface of the skin, it passes at length to the intestinal canal, is excreted by the glands of the mucous surface, and causes purging by augmenting their natural secretion. When given as a medicine, the Cathartic is first received into the stomach. It is capable of absorption,--whether it be soluble in water, or in acid, or be of an oily or resinous nature,--as was ascertained in the consideration of Proposition II. It is absorbed; and passes along in the circulation. But it is unnatural to the blood, and cannot remain in it; so that it is at length expelled by the eliminative force at the lower part of the intestinal canal, at a part which is more active in excretion than in absorption, though not very remote from the absorbent surface at which the remedy first entered. Cathartics may be advantageously divided into three groups:--1. Mercurials, which tend to increase all secretions; 2. Some resins, oils, and acrid principles, which tend especially to the bowels; and 3. Salines, when given in such amount that they cannot pass off by the kidneys. Mercurials, being also Cholagogues, are especially useful in bilious habits. When given to act on the bowels, a Mercurial is generally conjoined with another purgative, that it may not do damage in the system by remaining in the blood. In the second group the great majority of Cathartics are included. They vary very much in the intensity of their action. Some are mild, and may be administered in inflammations and fevers, or even in pregnancy, where a gentle action is required; others are powerful and drastic, and may cause serious congestion, or even inflammation of the bowel. All the resins and acrid principles are more or less heating, and should be administered very carefully in febrile states of the system. Of the resins, Jalap is comparatively mild, and may be given to children without risk; while Scammony, Colocynth, and Gamboge are more drastic. Of the oils, Olive-oil is merely laxative; Castor-oil may be given in all cases without danger; but Croton oil is a dangerous hydragogue Cathartic. Of the medicines which owe their efficacy to acrid principles, there are some which are mild in operation, and whose principles are soluble in Water. Such are Rhubarb, Aloes, and Senna. Senna is somewhat irritant. Aloes appears to act on the lower part of the intestine, and is therefore objectionable in cases of pregnancy or of uterine disorder. Hellebore is a more powerful acrid, but is now seldom used. Elaterium is the most potent purgative known. In cases of dropsy, when all other medicines have failed, one-twelfth of a grain of this substance has been known to produce a copious evacuation. Salines, _i.e._ salts of the alkaline and earthy metals, are all more or less purgative when given under certain conditions. Under other circumstances they may pass off from the body by the kidneys or the glands of the skin. The circumstances which determine the excretion of saline matters appear to be simple in nature. In the common condition of the body it is not possible for the secretion of the skin to be very largely increased, or rendered fluid. Suppose, then, a soluble saline, as the Sulphate of Soda or Magnesia, or Tartarized Soda, to have obtained entry into the blood, it has the choice of being excreted by the kidneys or the bowels. The alternative appears to depend mainly upon the amount of the dose. A small quantity may pass in the urine, and will not produce purging. But a large quantity cannot so pass; it is excreted by the glands of the bowels, and acts as a Purgative. It has been supposed by some that a saline solution proves Purgative or Diuretic according to the degree of its dilution only. This matter we have already considered at some length; and the reasons which have induced me to arrive at a contrary conclusion have been detailed under the head of Proposition II. Salines are hydragogue. Requiring water for their proper solution, and having further a great affinity for it, they convey a large quantity of the aqueous part of the blood with them through the glands of the bowels. When their action is very powerful, some of the albumen of the blood may be purged away along with this. This may also take place with the drastic resinous Cathartics. But the latter are much more violent in their action, producing a degree of griping and irritation which is dangerous in febrile cases. Salines, on the contrary, are cooling, and mild in their operation. They are appropriate in inflammations, not only for this reason, but because, while passing through the blood, they exert in it, as we have already seen, a mild action of an antiphlogistic nature. (_Vide_ page 188.) When the vegetable salts of the alkalies are given in diuretic doses they are decomposed into carbonates while in the system. This does not appear to be the case when they are given in such quantity as to pass off quickly by the bowels. These various Cathartic medicines are affirmed to act on the eliminative principle: it follows then that they must themselves pass out of the body along with the secretion which is augmented by their action. It is natural that the fæces should have been less examined than other secretions. The resins of Jalap, Scammony, and other such substances, are affirmed to pass out along with them. Of the passage of saline Purgatives we have an indirect proof; which is, that after their administration the amount of saline matter in the urine is not materially increased. Castor-oil is seen in the evacuations, sometimes little altered, at other times in the form of a solid fatty substance. M. Lehmann has detected Mercury in the fæces, whenever it was given as a Purgative, and whatever the colour of the evacuation. When combined with a sufficient amount of Opium, it neither acts as a Purgative, nor does it pass out by the bowels; and it has therefore in that case a better opportunity of exerting its operation in the blood. We always find that when a Cathartic passes off in some other way than by the glands of the bowels, it fails to produce purging. Thus a copious dilution with water may sometimes cause it to be excreted by the kidneys, which are the natural emunctories of water. In some persons that are wont to perspire very freely it is difficult to produce purging. The case related by Dr. Ward of a woman with whom a dose of Castor-oil was seen to pass off by the skin, and invariably failed to act on the bowels, is an extreme instance of this kind. Of what use and intention, we may now venture to ask, is this intestinal function, the continual maintenance of which in a healthy condition is found to be so essential? It was some time ago supposed that the fæces consisted simply of those parts of the food which remained unabsorbed, and that all Purgative medicines alike acted by exciting the peristaltic motion of the bowels, and causing thus the ejection of these undigested matters. Such an opinion is now rarely maintained. Although very little is known of the separate functions of the glands of the intestinal mucous membrane, yet it is generally supposed that the fæcal matters consist in great part of excrementitious substances which are separated by their means from the blood. The excretion of fæces continues when no food is taken. It is known to go on with starving men, and with patients in fever. Liebig argues for the secretion of the greater part of the fæces, on the ground that they contain nitrogenous matters, whereas all the nitrogenous parts of the food should be absorbed for the purposes of nutrition. Thus these are probably the excreted products of changes in the system, which it is the province of the bowels to separate from the blood. (_Anim. Chem._ p. 156.) The odour of these matters is partly owing to sulphuretted hydrogen, or hydrosulphate of ammonia, both of which are the products of animal decomposition. On account of their presence a black colour is communicated to the fæces by the internal administration of the salts of Iron. It seems to me to be probable that the constituents of the living as well as of the dead body are constantly subjected to the control of chemical laws, and undergoing destruction and change. Some products of these changes in an early stage are eliminated in the urine; but in great part they go on to actual putrefaction. The products of this, which are of an offensive character, are apparently discharged from the body through the follicles and glands of the intestines. We find that this decomposition is promoted and accelerated by heat, in the same way as with dead animal matter. For this reason it appears that the natives of warm climates excrete a much larger quantity of fæces than the dwellers in colder latitudes; and they are also more subject to Dysentery, Diarrh[oe]a, and Cholera, on account of the extra work thrown upon their intestines. A similar explanation may perhaps be assigned to a curious fact noticed some time ago by Mr. Curling--viz., that acute ulceration of the duodenum is a frequent consequence of severe superficial burns. A quantity of gangrenous or decomposing matter may in such a case be carried from the surface into the circulation. This blood-decomposition, which I suppose to be always going on, may be accelerated by the action of certain morbid poisons or processes. The secretion of the bowels is then increased, and by the excitement or over-work a diseased condition of the intestinal surface may be established. In this way the diarrh[oe]a and ulceration of the glands in Typhoid fever may be accounted for. The air of a dissecting-room, or the neighbourhood of a noxious sewer, is apt to bring on diarrh[oe]a by exciting a putrefaction of the blood. Severe bodily exercise, as a long walk, may cause it, by increasing the waste of tissue. We find that constipation is commonest in youth, when nutrition is most active; and diarrh[oe]a most frequent in old age, when waste and decay go on the fastest. When these decomposed matters which should be excreted, are retained in the blood, as is the case in constipation, they affect very injuriously both the brain and the system in general, causing torpidity of the one, and in the other favouring the progress and development of every description of morbid action. It is by cleaning such matters out of the blood, as well as by their antiphlogistic or evacuant action, that Cathartics become useful in so many diseases, and particularly in disorders of the brain. It would seem that the substances which would be eliminated by the bowels have, when retained in the blood, a peculiar action in the aggravation of disorders of this latter organ. Thus from very early times the exhibition of drastic purgatives, particularly Hellebore, has been strongly recommended in cases of mania. But there is scarcely any disorder in which there is not, in some way or other, a deranged condition of the intestinal function, and in which, therefore, the judicious employment of purgative medicines is not at some time necessary. Either there is constipation, in which case there is a danger of the fæcal matters being retained in the blood; or there is diarrh[oe]a, which is probably due to an over-formation of these materials in the system, and an attempt of nature at their evacuation. In each of these cases Cathartics may be necessary. The first condition is the more obstinate of the two; the second the more immediately dangerous. Some general indications for their treatment may be alluded to. In the treatment of constipated habits it is better to keep up a constant and gentle action on the bowels than to give violent doses occasionally. A condition of this sort may sometimes co-exist with comparative health, and may then often be remedied by a slight alteration in diet, and the prescription of such kinds of food as are more relaxing in their nature than those hitherto taken. Dr. Hamilton, in his work on Purgative Medicines, states that when they are given in constipation he has found that they become more and more powerful, and may be taken in smaller and smaller doses the longer they are continued. This is probably the case with such as Castor-oil, Scammony, and Jalap, which are simply cathartic in their action. But others, such as Rhubarb and Aloes, contain a bitter and astringent matter along with the purgative principle, and though they first act upon the bowels tend for this reason in the second place to confine them. Thus while the former are best in cases of constipation, the latter are preferable in diarrh[oe]a, as they supply us then with the very action which we require. There are two ways, apparently opposite and inconsistent, of treating a flux from the bowels. We may try to encourage it by Purgatives; or attempt to suppress it by Astringents. Thus we may treat a common diarrh[oe]a by Castor-oil, or by Sulphuric Acid. In dysentery we may give Calomel, or Catechu. Even in Cholera some recommend Opium, while others have employed Croton-oil. In the most obvious case, _i.e._ in simple diarrh[oe]a, it is apparent that both plans are appropriate, but at different periods of the disorder. The symptom depends upon the fact of something being formed in the blood which ought to be excreted from it. Probably it is an excess of that material which is ordinarily excreted by the bowels. Its passage out by a natural effort causes at first a simple increase of the usual evacuation. It is at this time that we should give a Purgative, to favour the natural excretion, and thus, if possible, to put an end to the disturbance. But sometimes it fails to do so. The matters to be excreted are irritating, and such an excitement may be caused in the glands by their passage out, that even after this necessary secretion an inordinate and unnatural flux may be maintained. When the symptom is thus inveterate, and refuses to yield to a brisk Cathartic, it is advisable to resort to Astringents, in order to put a speedy stop to the too copious secretion. To do this in the first instance would have been wrong, except in special instances,--as in the diarrh[oe]a which is the forerunner of cholera, when Astringents should be used from the first. In some febrile and plethoric cases it is difficult to obtain the full action of a Purgative. This is because the absorption of the medicine is prevented by the pressure on the vascular system, and without this absorption the proper action of the Purgative cannot take place, for it has no opportunity of passing out of the blood through the glands of the bowels. In such instances it is well to combine the Cathartic with a small dose of Tartar Emetic or Ipecacuanha, which by its nauseant operation may diminish the vascular pressure, and thus favour the necessary absorption. The action of a Cathartic itself favours absorption, by draining away the fluid part of the blood, and so diminishing the tenseness of the vessels. ORD. IV. CHOLAGOQUES. Medicines which are thought to stimulate the action of the liver, and to promote the excretion of bile, are called Cholagogues. There is no doubt that the function of the liver, regarded simply as a gland, is of great importance in the animal economy. We know that certain matters are excreted from the system by that organ, which, when allowed to remain in the blood, as in the case of jaundice, are found to be hurtful. Also it appears that certain other parts of the bile are secreted or formed by the same gland, for the purpose of being re-absorbed into the blood from the intestine, and that they serve some useful purpose in the processes which go on in the circulation. (_Vide_ p. 137.) A disorder of the liver by itself, _i.e._ unassociated with diseases of other organs, is comparatively uncommon. A failure in the secretion of bile is evidenced more or less by the well known icteric symptoms. Jaundice is often caused by an obstruction in the hepatic ducts. In such cases it is worse than useless to urge the liver to an extra formation of a secretion which can find no outlet. But other cases, in which the discoloration of the skin is in general incomplete, may be due to torpidity, congestion, or chronic inflammation of the organ. In such instances Cholagogues may be cautiously used; but when there is acute inflammation they may do harm; and when there is a probability of structural change in the liver, they may be useless. The great majority of intestinal diseases, as also of chronic blood-disorders, are associated with a torpidity or derangement of the function of the liver. We find this to be the case with diarrh[oe]a and constipation, with dysentery and cholera; as well as with ague and remittents,--gout, and rheumatism,--Phthisis, and scrofula. In all of these diseases it is of great importance to attend to the state of the liver. I have already stated that Quina and other Tonics are of very particular use in such cases of disorder of the hepatic functions, and have attempted to discover an explanation of this fact (p. 142.) But we are at present concerned with medicines which tend immediately to increase the secretion of bile. They are more or less applicable in all the disorders which have just been enumerated. All Cathartic medicines act as indirect Cholagogues. This is particularly the case with the drastic purgatives. There appears to be a vital connexion between the action of the intestinal canal and that of the liver, so that any process going on in the one will excite the function of the other. Thus the bile is poured out during the process of digestion; and the peristaltic motion and extra-secretion, produced in the bowel by the action of a purge, causes likewise a sympathetic formation and excretion of bile. It is supposed by some that this result is due to an irritation of the orifice of the hepatic duct in the duodenum, produced by the purgative medicine. We must either suppose the stimulus of the food, which produces the same effect, to operate in the same way,--or reject such an explanation as superfluous, which appears to me the better alternative. For it is probable that the action of a Purgative is not at all exerted in the duodenum, but that it is actually absorbed there, and works out its operation in the lower part of the small and in the large intestine. _True Cholagogues._--We are not well informed as to the exact number of medicines which pass out into the secretion of bile, and act thus on the true eliminative plan. But there is no medicine which is of such great and universal utility in all liver diseases as Mercury,--in its various forms. Mercurials increase more or less all secretions; and even if we had no direct proof of their action on the liver, we might almost have affirmed that they especially increased the secretion of bile, from the obvious way in which bilious symptoms yield to their action. But we have a direct proof of this. M. Buchheim has made some careful experiments on a dog. Having given it Mercury, he cut down upon the hepatic duct, observed and collected the secretion, and subsequently analyzed it. He found that the bile was increased, and that Mercury was contained in it. (_Vide_ p. 275.) Certain other purgative medicines are popularly, and perhaps correctly, esteemed as specific Cholagogues. These are Rhubarb and Aloes. Taraxacum is also thought to act upon the liver. But of the true eliminative action of these medicines we have no proof. It is probable that alkalies and fatty matters may act in certain cases as true Cholagogues, for they are both contained in the natural secretion of bile, and therefore likely to pass into it. In many cases of debility, and even of Scrofula, small doses of Mercury may act efficiently as tonics, by stimulating the function of the liver, which in such instances is generally deranged. ORD. V. DIAPHORETICS. These are medicines which tend to promote the secretion and exhalation from the surface of the skin. Of the matters which are given off from the surface of the body there are three kinds. Water in the state of insensible vapour, and volatile matters, are continually exhaling from the skin at all points, and pass unnoticed into the atmosphere around. The liquid sweat, which in the ordinary state of the body is only given off in sufficient amount to prevent the skin from becoming over-dry, is secreted by the sudoriferous glands, whose ducts terminate in large numbers on the surface at every part. There is in the third place an oily material, formed for a similar purpose by the sebaceous glands, which are widely distributed, but fewer in number than the last. Diaphoretics seem to increase only the first two kinds, viz., the aeriform transpiration, and the liquid sweat; and they act upon these in a varying proportion. In the consideration of this order we have not only to bear in mind the distinction between these two kinds of diaphoresis, but to note further the important relations existing between the action of these medicines and the state of the atmosphere, the condition of the body, and amount of other secretions. In all relaxed conditions of the general system, the amount of the perspiration is apt to be increased. This is especially evident in the weakness which follows a paroxysm of simple fever. The force of the heart is weakened, the tone of the capillaries impaired,--and by these conditions absorption is favoured, and the amount of fluid in the blood increased. At the same time the muscular system is relaxed, and the sudoriferous ducts being thrown open by the diminished contraction of the involuntary fibre that surrounds them, the excretion of the sweat is favoured, and the watery parts of the blood are poured out through the skin. This general relaxation precedes and follows the act of vomiting, as induced by a dose of Tartar Emetic or Ipecacuanha. Thus these medicines act indirectly as Diaphoretics, when given in emetic doses. _True Diaphoretics._--The following groups of medicines may be briefly noticed as tending to act as Eliminatives on the glands of the skin. Five divisions may be made:--1. Salines and diluents, under certain conditions; 2. Volatile substances which are soluble in air, as Ammonia, volatile oils, and Alcohol; 3. Certain acrid matters, as Guaiacum; 4. Certain Narcotics, as Opium and Camphor; 5. Antimony, Mercury, and Sulphur. These Diaphoretics are all more or less uncertain in their action, as we have seen to be the case with Expectorants. There are two causes of this uncertainty. In the first place, the secretion of sweat, like that of the lungs, cannot be considered as a common emunctory. There are hardly any solid matters in it which are not also contained in the urine, and commonly excreted by the kidneys. It is only in special cases, or when there is a fault in the normal formation of urine, that the skin is called upon to eliminate materials from the blood. In the second place, there are certain atmospheric and other conditions which promote the secretion of sweat, and certain others of an opposite nature which tend to retard it, and to divert into another channel the aqueous materials which should pass into it. With regard to the state of the atmosphere, warmth favours diaphoresis, cold repels it. Warm dry air, especially when in motion, promotes the aeriform transpiration, by favouring evaporation. Moist air, which hinders evaporation, promotes liquid sweating. Very active exercise, with the surface warmly clad, produces liquid perspiration. Moderate exercise, with a cool surface, favours diuresis. The recumbent posture, and sleep, promote diaphoresis; the erect posture and wakefulness, diuresis. Thus when it is required to produce sweating, the patient is ordered to lie in bed, to be covered warmly, and to compose himself to sleep. Any thing which keeps the surface of the skin unnaturally warm, as a hot-air or hot-vapour bath,--or thick flannel clothing, which is a non-conductor of heat,--tends powerfully to cause diaphoresis. So does friction, which stimulates and dilates the external capillaries. So far the conditions of sweating and of diuresis are nearly opposite. But this is not the case with the medicines which are used to cause them. Diluents, and salines soluble in water, form the first group of true Diaphoretics. Water promotes alike the function of the skin and of the kidneys; and it is only by a regulation of the circumstances mentioned above that it can be diverted from the latter towards the former. Diluent drinks are indispensable adjuncts to a Diaphoretic regimen. Salines also tend naturally to pass off in the urine, when in small doses; but when in large amount, by the bowels. A saline, being soluble in water, cannot pass out except into a fluid secretion; so that a saline diaphoretic should be given in a moderate dose, and to secure its action the skin should be kept covered and warm, and the patient in a recumbent posture. The medicine will then pass off into the liquid sweat, as it otherwise would have passed into the urine. Volatile Diaphoretics may increase the cutaneous transpiration, and pass off by the skin, without the production of sensible liquid sweating. For being soluble in air, and capable of being carried away by it, they therefore tend especially to the two aeriform secretions, _i.e._ those of the lungs and of the cutaneous surface. (_Vide_ pp. 278, 285.) Ammonia and its various salts are very useful as Diaphoretics. Volatile oils are less energetic, for they often pass off with such ease as not sensibly to increase the secretion of the skin. Some acrid matters, as Guaiacum, Mezereon, and Senega, appear to act specifically on the function of the skin. So also do certain Narcotics, among which Opium is conspicuous as the most certain Diaphoretic that we possess, though its other operations prevent it from being applicable in all cases. Antimony, Mercury, and Sulphur, are medicines which appear to a greater or less degree to increase all the secretions in the body. When given in the insoluble form, they are reduced by the system to a soluble state. When Tartar Emetic is given in small doses, its only apparent action is slightly to increase the perspiration. It is probable that it then passes out through the glands of the skin. When given in emetic doses, it may produce sweating indirectly, as mentioned above. Iodine, which also increases secretion generally, acts sometimes as a Diaphoretic. Many volatile oils have been detected by their odour in the perspiration, as those of Garlic, Onion, Asaf[oe]tida, Musk, and Copaiba. Mercury, Sulphur, and Iodine, have been detected chemically in it. It has happened, when a course of Mercury has followed the administration of Sulphur, that parts of the skin have turned black, from the formation of Sulphuret of Mercury. So it is proved of many of these Diaphoretics, and thus rendered highly probable of the rest, that they are true Eliminatives, being themselves excreted by the glands which they excite to action. When copious diaphoresis has been excited, care should be taken that it be allowed to subside gradually, or the consequences may be hurtful. It may be remarked that cleanliness of the surface, by which the sudoriferous ducts are kept open and healthy, is highly important to the proper function of the skin. Diaphoretics are useful in various disorders. In what is called _a cold_, when the function of the skin has been suddenly interfered with, and the vaporous transpiration is all thrown upon the lungs, producing irritation or inflammation of the respiratory mucous surface, Diaphoretics are generally required. In Fevers, and some other disorders, as Gout and Rheumatism, which are apt to improve or to pass off with an increase of perspiration, and in which it often seems likely that some morbid material may be eliminated by this channel, the same medicines are constantly necessary. When another secretion is unduly copious, an increase in the sweat may cause it to diminish. Thus in some cases of diarrh[oe]a, and still more in diabetes, Diaphoretics are appropriate. In contrary conditions, as when the formation of urine is unnaturally small, on account of granular degeneration of the kidney, it is again important to stimulate the secretion of the skin, that it may, if possible, be able to replace the other. (_Vide_ p. 280.) ORD. VI. DIURETICS. These are medicines which tend to increase the secretion of urine. By means of the kidneys a large amount of aqueous material is every day separated from the blood, and excreted. This water is in the first instance absorbed by the surface of the stomach and intestine. The causes which demand its excretion are twofold. In the first place, it is necessary that the blood should be kept down to its normal standard as regards water, and that the surplus fluid which is daily added to it should be removed. Secondly, this water is required in the urine as a vehicle, to hold in solution there certain soluble matters which are continually forming in the blood, or being received into it, but which have to be excreted from it by means of the kidneys. These matters comprehend a variety of salts,--and a number of nitrogenous substances, of which the best-known are urea and uric acid. These last are formed in the blood by the gradual decomposition or change of the animal tissues through which it flows. When retained in the circulation, on account of a failure of the function of the kidneys, they act as poisons. The kidneys are the chief emunctories of water; and mineral substances which are soluble in water tend for this reason to pass out into the urine. Many of these, as the salts of Iron, Silver, Lead, and Copper, are Astringents, and tend to diminish rather than to increase the amount of urine. But the urine is so necessary and so constant a secretion, that it is very difficult to diminish it in quantity. Saline medicines act as Diuretics under certain conditions. So also do acids and alkalies, and many vegetable substances, which will be presently spoken of. The soluble substances which thus pass off in the urine, and act as Diuretics, are many in number, but they are all uncertain in action, for several reasons. The amount of the urine depends very much on the quantity of water taken into the stomach, or absorbed from the atmosphere through the skin; so that when there is not a sufficient quantity of water in the system, it is impossible for more urine to be formed. This necessary absorption of water depends again upon the pressure of the circulation; when this is too great, it cannot go on, and the urine is diminished. A large increase in any other of the secretions, as that of the bowels,--but particularly of the skin, as in warm dry weather,--hinders diuresis. The secretion of the urine is favoured by those conditions which repress the perspiration; as by coldness of the surface, light clothing, a cold and damp condition of the atmosphere, and the erect posture. In the fourth place, the urine is diminished by causes which impede the circulation, as by congestion of the kidney or liver,--or of the whole venous system, on account of obstruction in the heart,--conditions which produce dropsy. Those medicines act as indirect Diuretics, which, by favouring the removal of one of these hindering causes, tend to allow the secretion of urine to go on as in health. The powerful action of the heart in fevers and inflammations causes such a pressure on the vessels as to retard absorption, and thus hinders diuresis. A hard bounding pulse and hot skin favour sweating more than diuresis, though they often diminish both of these secretions. Both are assisted by a relaxed state of the circulation, which favours the absorption of fluids. Thus venesection, purging, Antimony, or any thing that diminishes a febrile reaction, will help diuresis in such cases. In cases of congestion on account of cardiac disease, Digitalis, which, by powerfully weakening the force of the heart, both diminishes congestion and favours absorption, is a most efficient promoter of the natural function of the kidneys. When the portal circulation is the seat of the obstruction, a mercurial, such as blue pill, which especially acts on the liver, will be a most desirable adjunct to the other remedies employed. Tobacco and Lobelia, like Digitalis, promote diuresis by diminishing the force of the heart. _True Diuretics._--Though all true Diuretics pass into the urine, the converse of this, _i.e._ that all matters which pass into the urine are Diuretic, is not always true. Thus the astringent mineral salts pass frequently out of the system in the urine, but seldom affect its amount in either way. And for the reasons already enumerated, it is often impossible, even by the most powerful medicines of this order, to increase the urine beyond a certain amount. Diuretics may be somewhat loosely arranged in four groups:--1. Water, and soluble mineral substances, _i.e._ acids, alkalies, and salines under certain conditions; 2. Acrid matters of various kinds; 3. Alcoholic and ethereal liquids; 4. The minerals which increase all secretions. Diluents promote the secretions of the skin and kidneys. A certain quantity of water must be given with every diuretic dose, and the larger the quantity the greater will be the effect produced. In the case of a Diaphoretic, this is all that is required. But as Diuretics are generally given, as in dropsies, for the purpose of eliminating fluid out of the system, this object would be clearly defeated by the introduction of a large quantity of water into the system. This, therefore, should be avoided. The free acids, both mineral and vegetable, with the exception of Sulphuric acid (_vide_ p. 262,) pass into the urine, and act as Diuretics. So also do the mineral alkalies. But as these medicines have important agencies in the blood, and tend further, by altering the reaction of the urine, to produce in it deposits of different kinds (_vide_ p. 151,) they can seldom be safely employed for this purpose. Salines are more appropriate. They should not be given in large doses, for they will then act upon the bowels. The dose should be small, and moderately diluted with water. To prevent it from acting upon the skin, the conditions which favour diaphoresis should be, if possible, avoided. The subject of the action of saline medicines, and the effect of dilution upon this action, has been already considered. (p. 74.) The acrid Diuretics are perhaps the most powerful medicines in the order. One of them, Cantharides, is an animal product. Some contain or consist of volatile oils: as Juniper, Turpentine, Cajeput, Copaiba, Horseradish. These volatile oils may act upon the skin instead of the kidneys, under the conditions which are mentioned above as favouring diaphoresis. Others of this group contain peculiar vegetable principles; as Broom, Chimaphila, Taraxacum, Colchicum, and Squill. Alcohol, Ether, and Nitric ether, act powerfully both on the kidneys and on the skin. Wine, which further contains certain volatile oils, and sometimes a vegetable acid, acts on the kidneys when drunk in any quantity. The diuretic effect of these liquids is, as in the case of salines, greater when the surface is cold, and less when it is warm and covered. Mercury, Antimony, and Iodine, which increase more or less all the animal secretions, act, among others, upon the secretion of urine. Iodine particularly is said to be diuretic. Mercury and Antimony are most efficacious as indirect agents; the former by stimulating the function of the liver when impaired, the other by diminishing the pressure on the vessels in febrile cases. A large number of Diuretics are themselves secreted by the kidneys, and have been proved to pass out into the urine. A great many have been detected in the urine by different chemists, especially by M. Wöhler. The Carbonate, Nitrate, and Chlorate of Potash, and the Iodide of Potassium, have been found there. So also have the mineral acids--the vegetable acids--Magnesia--Mercury,[46] in combination--and Iodine, in the form of Hydriotic acid. Among vegetables, the principles of Chimaphila and Uvæ Ursi--the oils of Turpentine and Juniper, somewhat altered in nature--the oil and resin of Copaiba--and the acrid principle of Cubebs, all pass into it. Other substances, which are not diuretic, but astringent, have been found in the urine; as Alum, Lead, and the Morphia and Meconic acid of Opium. When a powerful Diuretic is given in too large a dose, it may cause a degree of action sufficient to produce congestion of the kidney, and so defeat the object for which it was intended. For congestion of a gland is invariably followed by a diminution or stoppage of its secretion. So a large dose of Turpentine or Cantharides may cause a dangerous attack of strangury, or even a total suppression of the urine for a time. (_Vide_ p. 274.) It can hardly be said that Diuretics are of very extensive application in the treatment of disease, or that they are medicines which can ever be much relied upon. For not only are the remedies themselves uncertain in action, but it happens also that the disorders in which they are most required are of a peculiarly obstinate nature. There are two chief actions for which Diuretics may be required. They may be used: (1.) to eliminate solid materials from the blood; (2.) to promote absorption, by diminishing the amount of fluid in the blood. It is easier to employ the first than to exert the second of these operations. When there is habitually a deposit in the urine, of lithates, or phosphates, or other solid matters, the simplest mode of obtaining a solution of this deposit, and thus preventing dangerous consequences, is to increase the amount of the fluid part of the secretion. Water is the best medicine for this purpose, and all Diuretics that are given with such an object should be freely diluted with water. In Gout and Rheumatism, remedies of this order may be of service by promoting the excretion from the blood of the uric or lactic acid formed there. They may also be used as Eliminatives in fevers and other disorders. In the strangury which may sometimes follow the application of a blister to the skin, copious draughts of water are often prescribed with advantage, for they serve to wash out of the blood the acrid matter which has been absorbed from the surface. It is for the second purpose, in cases of dropsy, produced by congestion of the liver, kidneys, or general circulation, that Diuretics are most urgently required, but are least efficacious. This congestion or pressure on the veins diminishes the amount of the secretion of urine, and by so doing increases itself, and aggravates the effusion and disorder. The same cause most effectually hinders the action of a Diuretic. If only we could largely increase the secretion of urine, the pressure on the venous system would be diminished, and absorption of the effused fluids might take place. In some cases of dropsy caused by renal congestion, the attempt is so hopeless that it is better to resort to Diaphoretics. In obstruction on account of heart disease, or congestion of the liver, we may sometimes gain our point by combining other Diuretics with Digitalis or Blue-pill, remedies which tend to remove the causes by which the diuretic action is hindered. (_Vide_ p. 304.) Even then we can often produce a much more copious and effectual drain of fluid from the blood by an action on the bowels, as by a dose of Jalap or Elaterium. When a Diuretic is required to eliminate fluid from the system, the dose should not be much diluted with water; this should only be done when we desire to eliminate solids from the blood. It is often advisable to combine together a number of different Diuretics, in the same prescription, so that by their joint but various agencies the causes which hinder their action may be overcome. The operation of Diaphoretics is opposed to that of Diuretics, but it is not always so with purgative medicines. The urine is often increased by the action of a hydragogue Cathartic; and a combination of Blue-pill and Squill supplies us with one of the best of known Diuretics. It is applicable in cardiac dropsy as well as in hepatic cases. Thus is concluded a brief outline of the actions and uses of the six orders of Eliminative medicines. CHAPTER IV. ON THE ACTION OF SOME OF THE MORE IMPORTANT MEDICINES IN PARTICULAR. The chief objects for which I have designed this Fourth Chapter are that I may be enabled to illustrate some general principles of the action of medicines which have been laid down in the Propositions, and show in what manner they are applicable to special cases,--and to enter into certain details respecting the more important remedies, which have not been attempted as yet. Of many of these medicines a tolerably full account has already been given; but they may again be mentioned here for the purpose of shortly summing up their several actions, and comparing them one with another. It often happens that there is more than one point of view from which the action of a medicine may be regarded. For many medicines are numbered under several distinct heads, being included in different groups on account of the several phases of their operation. There are three stages in the progress of the remedy through the system, at each of which it may exert a special action. There is a contact with the surface; a continuance in the system; and a passage out of the system. In the first place a medicine touches the mucous surface of the alimentary canal; here some few evidence their action. From this, if in any way soluble, it passes into the blood. Here it may act on the blood, being Hæmatic. Or it may employ the blood merely as a means of transit, and direct itself towards nerve or muscular fibre, being Neurotic or Astringent. But we have seen that none of these medicines, with the only exception of Restorative Hæmatics, can remain long in the system. They must pass out, and the mode of passage is through the glands. Here is a third opportunity of operation. The medicine may act now as an Eliminative, increasing the secretion of the gland; or, more rarely, as a glandular Astringent, because tending to diminish it. As a general rule, though not in all cases, the most important action of a medicine is that which it first evidences, the subsequent operations being secondary, and of less moment. Thus Mercury is, in the first place, a Catalytic Hæmatic; in the second place, an Eliminative. Creosote is firstly a general Sedative, secondly an Astringent. Antimony probably belongs to three out of the four classes, and its second operation is perhaps the most important. It is a Catalytic, a special Sedative, and also an Eliminative. COD-LIVER OIL. Class I. Div. I. Ord. I. ALIMENTA. This oil has been proved by the experience of many physicians to be a medicine of great utility in most cases in which there is a general deficiency of fat in the system. It is thought also to exert a specific action in the cure of pulmonary Phthisis, and it certainly appears to be the only medicine that possesses any marked or peculiar power over the progress of this disorder. When administered in favourable cases it seems not only to have the power of fattening the patient, but to be able also to combat and cure the disease itself, arresting or retarding the tubercular deposit. Sometimes it is unable to do this; but in all cases of consumption a trial should at least be given to it. It is of most service when the disease is only incipient, and, if given in the first stage, may often prevent its further progress; but it may even cure patients in whom the deposit has passed the stage of softening, as appears from the reports of the Brompton Hospital. It is also of use in Scrofula, in chronic Rheumatism, and in cases of emaciation generally. It may prove nutritive in Diabetes mellitus, because it is not likely to be converted into sugar in the system, whereas in that disorder all kinds of food, excepting fats and oils, are liable to this change. Cod-liver oil is assimilated to the tissues, and there seems to be something in it which not only renders it more easy to assimilate than other oils, but which further endows it with a special influence over tuberculous diseases. It does not appear that any other oils are equally effective. Though Dr. Duncan and Mr. Nunn have recommended Almond-oil instead of Cod-liver oil, yet the general experience of others is decidedly against such a substitution. It has not yet been clearly ascertained to which of the constituents of this oil its valuable properties are owing. Being itself an animal product, it is for that reason more easy of assimilation than a vegetable oil. Many have attributed its virtues to Iodine, of which, according to De Jongh, it contains 29 parts in 100,000. Dr. Theophilus Thompson has tried both Olive and Almond oils in consumptive cases, but has not found that any material benefit is derived from their use. He considers that Cod-oil produces its best effects in cases where Iodine would be inadmissible. Neither does he think its virtue to be due to the biliary matters which it contains, for a mixture of ox-gall with Almond-oil does not supply its place. Cod-oil contains 7-1/2 parts in 100,000 of Phosphorus. Dr. Thompson supposes that its efficacy may be partly owing to this. He has made trial of Phosphuretted Almond-oil, containing one grain of Phosphorus to the pint. He suggests that this Phosphorus may be of use in diverting some of the Oxygen from the tissues. This is to adopt Liebig's theory of the excess of Oxygen in Phthisis; an idea which is not very consistent with the experiments of Dr. Hutchinson on his Spirometer, from which it appears that the quantity of air inhaled at each breath by a consumptive patient is considerably less than in health, on account of a diminished capacity of the lungs. But when a continual fever has set in, an oxidation and waste of the tissues must certainly take place. (_Lancet_, October, 1851.) The Phosphorus in Cod-liver oil would soon be oxidized, and it would seem to be too small in amount to be of service in this way. If any thing were thus needed as a pabulum for Oxygen, we might suppose it to be the oil itself that was thus burnt. Possibly the utility of this medicine may depend upon a combination of several constituents and various properties. It is an oil; and thus of use as an Aliment, and as a supporter of the respiratory function. It is an animal oil; and thus peculiarly adapted for being digested, absorbed and assimilated to the adipose tissues of the human body. It contains Iodine and Bromine, which are useful as Alteratives or blood medicines, both in Phthisis and Scrofula. Their proportion will not seem so small when the large dose of the oil and its frequent repetition are taken into account. But their presence alone would not be sufficient to explain the utility of the oil. It contains also Phosphorus, a general Stimulant, which may prove of use when there is a failure of the nervous forces. Sometimes the dose of the oil excites a most distressing nausea. This may perhaps be prevented by a judicious modification of the vehicle. It may be floated on an aromatic water, on a bitter infusion, on milk, on wine, or on cold tea, to suit various tastes. In other instances the dose is swallowed without inconvenience, but the patient is not fattened, nor is his condition in the least improved by it. In such incurable conditions it is probable that there is often an organic disease of the Pancreas, or a failure in the function of that gland. For it appears that the absorption of fats is effected by means of an alkali contained in the Pancreatic fluid. When there is reason to suspect this cause of the emaciation, it is advisable to saponify the oil by shaking it with a sufficient quantity of solution of Potash or of Carbonate of Soda. The dose will then be in a state of solution, and ready for absorption. Cod-liver oil may be used with advantage as a vehicle for Iodide of Iron, in scrofulous cases. Two grains of this may be dissolved in each ounce of the oil. (_Vide_ pp. 119, 191, 229.[47]) SULPHURIC ACID. Class I. Div. I. Ord. II. ACIDA. Class III. Ord. I. ASTRINGENTIA MINERALIA. This medicine acts chemically as an acid in the blood and in the secretions. When diluted it is easily absorbed, and meeting in the stomach with an acid secretion, it passes into the circulation without being first neutralized. If in small quantity, it is neutralized by the slight excess of alkali in the blood; if in larger amount, it may exceed this alkali, and displace and set free other acids in the blood, combining with their bases on account of its strong affinities. In all cases it increases the quantity of free acid in the system, and tends to render the secretions, as the urine, more acid than they were before. (_Vide_ Dr. Bence Jones's _Animal Chemistry_, p. 49.) By this chemical action Sulphuric Acid is rendered useful in alkalinity of the blood, which may occur in fevers; or of the urine, as in Phosphaturia. It thus acts as a Restorative Hæmatic. But it is not right that there should be more than a certain quantity of this acid in the system. So that when introduced in large quantity it must be excreted. It does not appear that it is itself excreted in the urine, though it may cause an excess of other acids in that secretion. On this point Dr. Bence Jones has made some careful experiments. (_Anim. Chem._, p. 75.) He finds that Sulphuric Acid does not pass off in the urine, either free or in combination, except when given in great quantity. Now it is found that Sulphuric Acid is of great use as an Astringent in diarrh[oe]a. Placing these two facts in juxtaposition, it would seem that the acid, which is doubtless absorbed in the first place, must afterwards be eliminated from the system by the surface of the bowels. This is perhaps because the secretion of this mucous membrane is the one which is least likely to be deranged by the presence of the acid. The free acid is an Astringent, and has the power of coagulating albumen, and causing the contraction of muscular fibre. (p. 256.) Though probably neutralized and combined while in the blood, it is free before absorption, and after excretion. Before absorption it is an Astringent to the surface of the stomach; after and during excretion, to the surface of the bowels. It is useful chemically in alkaline Pyrosis. Its astringent property explains its utility in _acid_ dyspepsia, which appears at first sight incomprehensible. Lactic acid, or some similar acid, is poured out in excess by the glands of the stomach. Sulphuric acid topically constringes the muscular fibre of the ducts of these glands, and in this way diminishes their secretion. The acid, if in excess in the blood, may tend to brace the system by causing a general contraction of the fibres of the voluntary muscles. But it is chiefly on account of its anti-dyspeptic agency, and its astringent action on the secretions, that the title of Tonic has been so often applied to it. Next to that of the bowels, the acid appears to act most on the secretion of the skin. Probably there also eliminated in a free state, it is thus able to diminish excessive diaphoresis. It is applicable in cases of Hæmorrhage, when this takes place from a mucous membrane, for it probably passes off in small quantities from all the mucous surfaces. It is very useful in diarrh[oe]a. (_Vide_ p. 294.) Being a special Astringent to the intestinal mucous surface, it may possibly be useful even in malignant cholera, especially if given in the early stage of that disorder. (_Vide_ pp. 120, 154, 262.) POTASH. Class I. Div. I. Ord. III. ALKALIA. Class I. Div. II. Ord. I. ANTIPHLOGISTICA. Class I. Div. II. Ord. III. ANTISCROFULOSA. Class IV. Ord. VI. DIURETICA. Potash is one of those medicines which have several distinct actions; but its various operations are comparatively simple in nature, and easy to comprehend. In the solid state it is powerfully caustic and corrosive, having a great affinity for water, and abstracting it from the animal tissues with which it is brought in contact. When a dose of the solution, properly diluted with water, is administered internally, it passes first into the stomach, and either combines with the acid of the gastric juice, or, what is more probable, it becomes absorbed too rapidly to be neutralized by it. It passes then into the blood, and probably exists in that liquid in a free state, for the blood already contains a slight excess of alkali. However this may be, it certainly increases the amount of alkali in the system. Its hæmatic action depends in great part on its power of neutralizing acidity. It is thus useful in cases of acid dyspepsia, heartburn, or gastrodynia, when it combines with the excess of acid which exists in the gastric secretion, and probably also in the blood. For the same reason it is useful in some cutaneous diseases that are connected with disordered digestion. It is employed in Gout and Rheumatism, where there is obviously an excess of acid both in the blood and in the secretions. (p. 202.) When Potash, is administered in any quantity, it must be excreted from the blood. The secretion of alkalies is mainly performed by the kidneys, and by their agency we may render the urine neutral or alkaline, and thus counteract a tendency to lithic deposits. (_Vide_ Solvents.) For this purpose Potash is preferable to free Soda, for the lithate of Soda is comparatively an insoluble salt. The salts of Potash with vegetable acids change into carbonates while in the blood, and will render the urine alkaline. M. Wöhler, who has discovered this fact, finds that it does not occur with the super-salts. Even the neutral salts escape the oxidation when they are given in such large doses as to act on the bowels. Potash is thus a Restorative Hæmatic, and where, from any reason, alkaline matter is needed in the system, it directly supplies the want. But it has also other actions which render it Catalytic, and which are evidenced in disorders in which there is no such deficiency of alkali. By dissolving Fibrine, it tends to prevent its deposition from the blood. It thus interferes with the inflammatory process, and acts as a general Antiphlogistic. It is possibly by a similar action that it seems able to counteract the deposit of crude tubercle, and exerts a special action in the prevention and cure of strumous disorders. It is very useful in the early stage of Phthisis, and in all stages of Scrofula. In Syphilis, when occurring in scrofulous subjects, Potash has sometimes been used with greater advantage than Mercury. Potash and its salts have been used in Scurvy by Dr. Garrod, on the supposition that there is in that disorder a particular deficiency of Potash in the system. But the fact that Citric acid is at least of equal utility in the treatment of scorbutic diseases, would seem to be opposed to such an idea. When given in moderate doses, and not retained in the system, Potash and its salts pass out into the urine, and act as Diuretics. (_Vide_ pp. 126, 187, 193, 202, 206.) QUININE. Class I. Div. I. Ord. IV. TONICA. Though the utility of this important remedy is often of a sufficiently direct and obvious character, its precise mode of action is enveloped in no small degree of doubt and obscurity. This subject has been discussed at some length in the article on Tonics. It appears, from the character and results of its medicinal influence, that it is exerted primarily in the blood, and not on the nerves. It is included in the Restorative group of Hæmatics, and the general results of its action differ widely from those of a Catalytic Hæmatic. It produces no marked effect upon the system in health. Its operation consists in the cure of general debility, however produced, and in the prevention of periodic disorders in the blood. Debility depends on a want in the blood, and not on any active morbid process; and there are circumstances which render it likely that Ague may be curable by the supply of a similar want. Quinine is also serviceable in Gout, Scrofula, Dyspepsia, and other disorders; in all of which other medicines, which stimulate the secretion of the bile, are more or less applicable. Torpidity of the liver is likewise a usual accompaniment of the various forms of debility, and occurs in intermittent, remittent, typhoid, and yellow fevers; in each of which this medicine has been recommended, and used with advantage. In fact it may be said, that in all diseases in which Quinine is used there is a failure in the secretion of bile; and in all diseases in which there is a failure in the secretion of bile, Quinine is serviceable. There appears then to be some connexion between these two things. Certain of the constituents of the bile are formed by the liver out of the blood, for the purpose, apparently, of being again absorbed at some part of the surface of the intestinal canal. One of these, Taurine, has been shown to be chemically analogous to Quinine. Thus it seems to me to be not improbable that this alkaloid may be of service in these disorders by supplying the place in the blood of this biliary matter, which for some reason may be needful in the animal economy, or that it may actually become changed into the latter while in the system. Were this proved, its restorative action would be effectually cleared up. The Disulphate of Quinine (or Quina) is the preparation of the alkaloid which is most commonly used. Arsenic is used in Ague and intermittent disorders, and acts on the Catalytic principle, but it is not serviceable in the other cases in which Quinine is used. It is not a Tonic, nor does it seem to have any relation to the function of the liver. I have thought it advisable to restrict the term _Antiperiodic_ to the _Catalytics_ which are used in Ague. (_Vide_ p. 141.) Quinine and Arsenic may both be employed in all disorders which put on an intermittent or periodic type. The chief of these is Ague, or Intermittent Fever. It is perhaps easier to arrest the disorder by Quinine than by Arsenic; for Quinine may be given in large doses, which cannot be done with Arsenic. But the administration of the latter may be continued during the paroxysm, when the great febrile reaction forbids the use of the other. The dose of Quinine is apt to disagree with an irritable stomach, and to increase the fever. It is generally laid down that this remedy should not be administered when there is a quick hard pulse, or heat and dryness of the skin. Some, however, have lately ventured to prescribe it to patients in high fever. It appears that there is a particular class of patients which in such cases will bear the administration of Quinine with impunity; while others are unfavourably affected by the smallest dose. It is perhaps at all times advisable to arrange so that the medicine shall, if possible, be taken after meals, for it is less likely to irritate a full stomach. And when it is thought proper to give it to a patient in fever, a small dose of Tartar Emetic or Ipecacuanha should be conjoined with it--not, of course, sufficient to produce vomiting, but so that an increase of the febrile excitement may be prevented. Quinine is in all cases better tolerated by the stomach when the dose is considerably diluted with water. A combination of Quinine and Iron is often of great service in feeble and relaxed conditions, where there is co-existent Anæmia. (_Vide_ p. 129.) IRON. Class I. Div. I. Ord. V. CHALYBEATA. It has been shown, in the article on Chalybeates, that the action of Iron is of a distinctly Restorative nature. There is in the blood a red colouring matter, called Hæmatosin. It is found by chemical analysis that Iron is an essential part of this substance. The existence of the right amount of Hæmatosin in the blood is of vital importance. It is contained in the red globules of the blood. When it is diminished in quantity, the number of these red globules is lessened in the same proportion. This produces a paleness of all the tissues, an inactivity of the muscular fibre, an impairment of all the animal functions, and a general languor and debility of the whole frame. This is Anæmia. In all cases in which Iron is used there is a deficiency of this red colouring matter; and in all instances of Anæmia Iron is appropriate as a remedy. The blood has been analyzed before its use, and found to contain a smaller quantity of Hæmatosin and fewer red globules than in health. After its employment the blood has been analyzed again, and it is found that the amount of Hæmatosin and of red globules is increased. Iron, then, is given in Anæmia. It is also given in cases of Scrofula, Cancer, Chorea, Hysteria, and other disorders, when these are attended with Anæmia. When this last condition is wanting, it seldom proves efficacious. Iron, when given in moderate doses, remains in the system, and enters into the composition of the blood. It is then a Restorative Hæmatic. Some of the salts of Iron are also Astringent. Thus the Sulphate and Sesquichloride may, by their topical action on the stomach, be of service in cases of atonic Dyspepsia. In Anæmia produced by special causes, as by scrofulous or nervous disorder, we may often do most good by striking at the root of the evil,--employing a Catalytic medicine which shall be able to do this. In simple Anæmia, Iron is of more use than any other medicine. It should be combined with exercise, air, light, and good living. In other disorders a combination of drugs is frequently of use. In chronic Ague, and in many cases of debility, Iron and Bark may be given together. Iron and Aloetic purges may be prescribed in Chlorosis and Amenorrh[oe]a. A mild purgative should be occasionally given in all cases in which Iron is used. The Ammonio-citrate of Iron,--the compound Iron mixture, which contains the Carbonate,--and the Tincture of the Sesquichloride,--are perhaps the best of the officinal Chalybeate preparations. The first of these is the mildest, and the last the most irritant of the three. (_Vide_ pp. 145, 263.) ANTIMONY. Class I. Div. II. Ord. I. ANTIPHLOGISTICA. Class II. Div. III. Ord. II. SEDANTIA SPECIFICA. Class IV. Ord. II. EXPECTORANTIA. Class IV. Ord. V. DIAPHORETICA. The best Antimonial for general purposes, and the most characteristic in its mode of operation, is Tartar Emetic. In this medicine are exhibited three distinct varieties of action. The first of the terms which are applied to it above implies that it has a Catalytic action in the blood. As a Special Sedative, it is able to cause nausea and vomiting. And it acts upon the glands as an Eliminative; being a Diaphoretic and an Expectorant. I have found it convenient to restrict the term _Antiphlogistic_ to those medicines which counteract the inflammatory process by an action in the blood. In this sense it is applicable to Antimony; although this medicine is still better able to subdue inflammation by its powerful neurotic action. The operation in the blood is naturally slower than the action on nerve, and is therefore less marked, and less immediately applicable. Antimony deteriorates and impoverishes the blood in very much the same way as Mercury, and, if given in small and carefully regulated doses, is simply a mild Antiphlogistic and Eliminative. It tends to increase all secretions, but particularly the exhalation from the skin and lungs, independently of the production of nausea (p. 324,) a symptom which is not brought on by a small dose. It is probable that a diaphoretic dose of Tartar Emetic is actually eliminated from the skin and mucous membranes. Antimony is appropriate as a Diaphoretic in high fevers, and in cases where Opium could hardly be used. But Opium is preferable in cases where there is gastric irritation, and a weak compressible pulse. The action by virtue of which Antimony has gained its high reputation as a medicine is of a different kind. By an influence on a part of the nervous system, apparently the Vagus nerve, it produces first the state called nausea, and afterwards vomiting. The most important symptom in this nausea, and in the state of system which succeeds the vomiting, and continues for some time after it, is a depression of the action of the heart. At the same time the muscular system is relaxed, and the breathing is rendered slower. This nausea is not produced to any extent by a mere irritant Emetic, such as Sulphate of Zinc, which acts externally and takes effect immediately. The Antimonial cannot act so quickly; part of it must first be absorbed, so that it may reach the nerve. We know that it does not act by outward irritation, from the fact that if the solution be injected into the veins at any part of the body, it will equally produce nausea and vomiting. Antimony has no direct action upon the brain; it affects only a part of the nervous system. In the nausea we recognise a sedative action upon the nerves of the heart; and in the slow breathing a similar action upon the nerves of the lungs. But it may be objected that the production of vomiting is not a sedative action, for we know that the same symptom may be caused by a mere external stimulant. And yet there are several reasons which have induced me to conclude that this also is a sedative action. It would be inconsistent to suppose that Antimony could be a Sedative in producing nausea, and a Stimulant in causing vomiting. We have already noticed that a Sedative medicine may affect nervous force in either of two ways; it may derange it, or it may depress it. (p. 243.) That influence which causes the contraction of the stomach to commence at the pylorus, and to result in the expulsion of its contents upwards along the [oe]sophagus, is obviously explained by an action of derangement, for it is an exact reversal of the natural state of things. (p. 92.) But the effects of derangement are often very similar to those of excitation. Thus convulsions of the muscular system are caused by Hydrocyanic acid, a Sedative,--and by Strychnia, a Stimulant; and vomiting is producible by Tartar Emetic, a Sedative,--or by an external irritant of the mucous membrane. It is by the production of nausea that Antimony becomes so valuable an agent in the control of high fevers and acute inflammations. The force of the heart being diminished, the fever is allayed; and the active congestion of the vascular system, whether local or general, which was produced by the inflammation, and maintained by the violent action of the heart, is effectually subdued. At the same time absorption is favoured by the removal of the pressure from the capillary circulation. For its power therefore as a Special Sedative, by which it produces nausea, Antimony is used in sthenic inflammations generally, especially in those that are rapid, and in which we desire a sudden and powerful action. In such cases it is preferable to Mercury,--which is a simple Antiphlogistic, acting in the blood, and having no operation on nerve. It is thus indispensable in Croup. It is very efficacious in sthenic Pneumonia. Laennec speaks highly of its use in acute Bronchitis. In Fevers, Dr. Graves recommends that it should be combined with Opium. In inflammations of the lungs it is particularly applicable, for it exerts a sedative influence over the nerves of those organs. If a small dose be constantly repeated, and gradually increased to a large one, the system will at length be induced to tolerate the medicine, and it will not produce vomiting. Laennec recommended that it should be given in this way in inflammations. He considered the production of vomiting unadvisable; for by that act the system is temporarily excited, and a large quantity of the medicine rejected, which should have been absorbed into the blood to work out its action there. The soundness of his views on this point has been generally admitted by those who have succeeded him. Given simply as an Emetic, this medicine has been used in the early stage of acute local inflammations, as Ophthalmia and Gonorrh[oe]a. It may cut these short at their outset, by hindering the tendency of the local irritation to excite the force of the heart. When we wish simply to evacuate the stomach, as in a case of poisoning, an irritant emetic, as Mustard or Sulphate of Zinc, which acts at once without producing nausea, should be preferred, for three reasons. Its operation is more rapid. The distressing condition of nausea would be an aggravation of the existing mischief. And the production of nausea, by taking off the pressure from the vascular system, favours absorption, which is the very thing that we wish to avoid. The object of an antimonial Emetic is not so much to empty the stomach as to make a powerful impression on the system. The influence of Antimony on the glandular organs is indirectly but powerfully intensified by its nauseant action. In small doses it is a simple Expectorant; in nauseant doses, it assists expectoration by relaxing the bronchial tubes, and diminishing the number of the respirations. In a small dose it is Diaphoretic; but in large doses it may cause copious sweating, by favouring the absorption of fluid into the blood, and dilating the capillaries and pores of the sudorific glands. In inflammatory habits a small addition of Tartar Emetic forms a powerful adjunct to a purgative dose; for by it the absorption of the other medicine is assisted, and at the same time an over-tonicity of the muscular fibre of the intestine may be diminished. But in relaxed conditions of the system, where the intestine is apt to be over-dilated, and Catharsis is favoured by Tonic medicines,--Tartar Emetic would hinder it. Ipecacuanha, a vegetable substance, resembles Antimony in all its operations, excepting its blood-action. It is less potent as a Neurotic; less efficacious as a Diaphoretic; but excels it as an Expectorant. (_Vide_ pp. 93, 168, 185, 249, 283, 298.) MERCURY. Class I. Div. II. Ord. I. ANTIPHLOGISTICA. Class I. Div. II. Ord. II. ANTISYPHILITICA. Class IV. Ord. III. CATHARTICA. Class IV. Ord. IV. CHOLAGOGA. There are three principal forms in which this medicine may be exhibited. Blue pill contains the metal itself in a finely divided state, as well as a small quantity of the oxide. Calomel is an insoluble Chloride of Mercury. From the great similarity that exists between the action of these two it seems likely that they are reduced by the gastric fluid to the same condition. Both must be rendered soluble (p. 88) before they can be absorbed. Probably they are both absorbed in combination with the acid of the stomach. Bichloride of Mercury is soluble in water, and probably absorbed unchanged. It differs from the other two as a medicine, partly, but not entirely, on account of its solubility. The dose required is smaller, for it is much more powerful. It is also much more irritant, being in large doses a corrosive poison, and often producing soreness of the throat and of the urinary passages. Thirdly, it is less likely to produce salivation. It is more adapted for chronic than for acute diseases. As Hæmatic medicines, Mercurials have a double action. They counteract inflammation in general, and the poisons of Syphilis in particular. They thus belong to the first and second orders of Catalytics. Mercury deteriorates the blood, diminishing in it the amount of fibrine and corpuscles. As an anti-inflammatory agent, it may be thus compared with Antimony and Blood-letting. The immediate effect of Blood-letting is mechanical; that of Antimony, nervous; that of Mercury, hæmatic. Blood-letting weakens the force of the heart by diminishing the pressure on the vessels; Antimony diminishes the pressure on the vessels by weakening the force of the heart; and Mercury does both of these things, by impoverishing the blood. Thus all of them favour absorption, and counteract effusion; but, from its nature, the action of Mercury is slower than that of the others, and for the same reason more lasting. To produce this action on the blood, the Mercurial should be continued until some effect on the mouth is perceived, but not so as to cause copious salivation. This symptom is a sign that the blood is sufficiently saturated with the medicine. This point will be sooner reached if the Mercury be conjoined with Opium, so as to prevent it from passing out directly by the bowels. Any ill result is less likely to occur if the patient be kept warm and quiet while under the influence of the medicine. On account of the durable and effectual nature of its action, Mercury is of great use in preventing the process of effusion, and in causing the absorption of effused products. It is thus employed with advantage in Pleurisy, and in other membranous inflammations. Next to these, it is most useful in inflammations of the liver and brain. It is inferior to Antimony in fevers and rapid inflammations, because slower in operation, and without any direct action on the nervous system. In cases of primary Syphilis, Mercury is by far the best medicine with which we are acquainted. It should be used in all cases except where there is deep-rooted scrofula, or marked debility, or a sloughing and irregular condition of the primary sore. (Dr. Pereira.) It should always be given in Iritis. In Periostitis, and secondary eruptions, Iodide of Potassium is generally preferable. Mercury, being unnatural to the blood, passes at length out of the system through the glands, and acts as an Eliminative. Like Antimony it tends to increase all the secretions in the body. But whereas Antimony acts especially on the secretions of the skin and pulmonary membrane, Mercury tends particularly to excite the functions of the liver and bowels, being Cathartic and Cholagogue. Of its true eliminative action we have better proof than has yet been obtained in the case of Antimony; for Mercury has been found to pass into the alvine excretions, by M. Lehmann; and discovered in the bile of dogs to whom it had been administered, by M. Buchheim. For the purpose of acting upon the liver and bowels, Mercurials are frequently used in disordered digestion and cases of hepatic derangement. In Intermittent disorders, debility, Gout, Rheumatism, and Scrofula, small doses of Mercury are often of service. I have endeavoured to show (p. 143) that in these cases they may prove indirectly tonic, by restoring to the system some of the wanting elements of bile, which are normally secreted by the liver for the purpose of being reabsorbed into the system. In incipient and chronic cases of Scrofula, consumption, and mesenteric disease, it is possible that Mercurials may act yet in another way. They no doubt stimulate the formation of the Pancreatic secretion, which is similar in nature to the saliva. By doing so they may assist the absorption of the fatty matters of the food in the case of thin and emaciated subjects, in whom it is probable that the function of this gland is frequently impaired. (_Vide_ p. 313.) Mercury assists the operation of all other medicines which act upon the secretions. In cases of hepatic dropsy it helps the action of Diuretics, and tends to remove the cause of the congestion, by stimulating the function of the liver. The blood-operation of Mercury, by which it is enabled to counteract morbid processes, is involved in considerable obscurity. The same must be said of all Catalytic medicines (_Vide_ p. 179.) Dr. Billing (_Principles of Medicine_, p. 73) is of opinion that Mercury acts by contracting the capillary vessels. I have already stated my reasons for dissenting from this notion. (p. 163.) The same author denies the specific action of Mercury in Syphilis. But if we only admit that there is no other medicine that will cure primary Syphilis so well as Mercury, we cannot then surely deny that its action in that disorder is of a special nature. He considers it to be neither stimulant nor sedative,--but tonic. (_Op. cit._ p. 101.) No one of these terms appears to me to be strictly applicable, but perhaps the last is the best of the three. Some have, without sufficient reason, assumed Calomel to be a Sedative when given in large doses. To act in this way, very large doses have been recommended and given in fever and malignant cholera. Calomel is naturally an insoluble substance; and in these cases the function of absorption is at the very lowest ebb; so that it is probable that the large doses are often left unabsorbed, and pass out of the bowels very much as they entered, producing scarcely any more effect than so much chalk mixture. (_Vide_ pp. 88, 143, 163, 168, 185, 188, 203, 286, 295, 308.) IODINE. Class I. Div. II. Ord. II. ANTISYPHILITICA. Class I. Div. II. Ord. III. ANTISCROFULOSA. The readiest and best way of obtaining the beneficial effects of Iodine is by the use of Iodide of Potassium. This is a very soluble salt. The peculiar virtues of Iodine are not impaired, but rather improved, by its chemical combination with the alkali. And when we administer the Iodine itself, as in the tincture, there is no doubt that after entry into the blood it combines with some alkaline base. If the use of Iodine be continued for some time it has the effect of impoverishing the blood. It sometimes produces a vesicular eruption on the skin, and causes a considerable degree of irritation of the mucous membrane of the nose and eyes. The preparations of Iodine exert in the blood some special actions of a Catalytic kind, by virtue of which they are enabled to counteract the morbid actions of secondary Syphilis and of Scrofula. Iodine is not, like Mercury, a general Antiphlogistic; but it is a stimulator of the function of absorption, as are all the medicines that tend to impoverish the blood. This action in causing absorption can be no explanation of the blood-operations for which it is employed; for these are peculiar to it alone, whereas the other property is shared by other remedies. (p. 192.) Iodine is an Antisyphilitic. But this term is not applicable to it in exactly the same sense as to Mercury. Its use is confined to the later symptoms,--to Periostitis, and the late eruptions, as Rupia. Sometimes it even fails in these. This is generally when the primary disorder has not been met by Mercury. Some preparation of Mercury should then be administered for awhile; and the Iodide of Potassium may be given afterwards. Thus the disorder which is controlled by the latter medicine is so modified as to be something quite distinct from the primary Syphilis. The same medicine is an Antiscrofulic. It is applicable in all the forms of Scrofula, and in Goitre. Possibly it acts differently in such cases; but it is certain that there is often, in cases of confirmed Syphilis, a cachexy similar to that produced by Scrofula. In either disorder, when this cachexy is confirmed, Mercury is most objectionable. On the contrary, in primary Syphilis, and even in incipient Scrofula, Mercury may be used. Like all potent remedies, Iodine requires to be carefully used. It is sufficient to give it in small doses. If given in large doses, and too long continued, it causes a deterioration of the blood, followed by an emaciation of the whole frame. So vigorously was this medicine used by the Swiss practitioners after its first discovery, that serious consequences, as the absorption of the mammæ or the testes of healthy individuals, are said to have ensued in several cases. By these mishaps their faith in its utility was much shaken. But M. Magendie states that he has never known such a thing to occur; and M. Lugol, the most devoted and enthusiastic of all the advocates of Iodine, has observed that scrofulous patients frequently become fattened during its employment. The therapeutic actions of Iodine have been ascribed by Dr. Billing to a contraction of the capillary vessels; by Dr. Pereira, to a liquefaction of the blood; by others, to a direct stimulation of the absorbent system. It probably counteracts morbid operations in some way that we do not understand. It is one of those medicines which tend to increase secretion in general. It appears to act most upon the urine, but is not a powerful Eliminative. It has been chemically discovered in the blood, urine, and sweat; as also in the saliva, tears, and nasal mucus, which secretions are apt to be increased in quantity during its action. The Iodide of Potassium should be cautiously administered to excitable patients, as it sometimes acts as an irritant. When the stomach is irritable, it should be given after meals, and the dose considerably diluted with water. A bronchocele, to be benefited by Iodine, should consist of a simple enlargement of the gland, not of very long standing, nor painful to the touch. All scrofulous affections, whether of the glands, joints, liver, or other parts, are more or less benefited by the use of Iodine. Iodine has been used in simple enlargement and induration of various organs, particularly the uterus. Dr. A. T. Thomson speaks highly of its efficacy in ovarian dropsy. It is probable that Chlorine, Bromine, and their compounds, closely resemble the preparations of Iodine in their therapeutic operations. (_Vide_ pp. 169, 188, 191, 306.) COLCHICUM. Class I. Div. II. Ord IV. ANTIARTHRITICA. Class II. Div. III. Ord. I. SEDANTIA GENERALIA. Class IV. Ord. III. CATHARTICA. The majority of medicines that affect the blood permanently belong to the mineral kingdom, while most of those that powerfully impress the nerves are derived from vegetables. But to the rule that Hæmatic medicines are of mineral origin, we have already found one important exception in the case of Quinine and Tonics. Colchicum appears to be another instance of the kind. The great and obvious use of this remedy is that action in the blood which above is classed first, i.e. its influence in the counteraction of gouty disorders. We have already considered at some length (p. 200) a number of Antiarthritic medicines that seem to act in a chemical manner. Colchicum is not one of these. It is a General Sedative, and a Cathartic; in large doses, an irritant poison. It seems also to increase the amount of other secretions, particularly the urine and the bile. But it is used beneficially in Gout; and it is assumed that in the cure of this disorder it exerts an action in the blood, inasmuch as its remedial operation appears to be independent of its nervous and glandular actions. This hæmatic action must be of the Catalytic kind, and may probably consist in the exertion of a special influence over the erring assimilative processes, which tends to resolve them into a right direction. But it should be observed that at least three other explanations of the action of this remedy have been proposed, each of which is possessed of a degree of plausibility. Some have ascribed its efficacy to the union of a cathartic with a sedative effect, and have even substituted for it a combination of Opium with a drastic purgative. Those who adopt this view of its action aver that Colchicum acts best when it purges freely. But though Purgatives are often of use in gouty disorders, it is generally found that Colchicum operates most favourably when given in too small a dose to produce any purging. Colchicum stimulates the function of the liver, which is generally deranged in gouty disorders. Mercury, which also promotes the secretion of bile, is in this way useful in Gout. It seems that the formation of this secretion is in some manner essential to the integrity of those blood-processes which are disturbed in arthritic diseases. It might therefore be supposed that Colchicum too acted as a Cholagogue. But it is not clear that it increases the secretion of the bile in any very marked degree. Thirdly, it is affirmed by some that this medicine is of use in eliminating uric acid from the blood, this product being supposed to accumulate in the system before the paroxysm of Gout. It is said that under the action of Colchicum the natural amount of this substance in the urine is much increased. This would be an important fact if it were certainly proved. But it does not seem to be so; nor is it clearly shown that the observed increase in uric acid is not a symptom of the disorder, rather than of the treatment. Colchicum is more or less applicable in the gouty forms of Rheumatism, in Lithiasis, and in acid dyspepsia, but it is most efficient in the simple gouty paroxysm. There are several objections to the indiscriminate use of this remedy. Some have observed that though it cures for a time the gouty attack, it causes the next assault of the disease to recur more quickly than it would otherwise have done. The dose also certainly requires to be considerably increased on each successive occasion. Sometimes this medicine produces a great depression of the spirits. Dr. Todd believes that Colchicum has often a tendency to change the common acute form of Gout into an asthenic form which is less amenable to treatment. So that, altogether, it is perhaps a good rule to treat the patient without Colchicum as long as it can be done with safety, adopting this medicine only as a last resource, when other remedies have been tried and failed. It ought rarely to be used in Rheumatism. In the asthenic form of Gout, or in old chronic cases, when there are chalk-stones on the knuckles, Quinine, Stimulants, and Purgatives, constitute the best treatment. Alkalies and Mercurials may prove serviceable in acute cases. But it is certain that in many cases of this painful disorder Colchicum gives immense relief; and it often seems to be the only medicine that is capable of doing so. (_Vide_ pp. 194, 247.) ARSENIC. Class I. Div. II. Ord. VI. ANTIPHRIODICA. Class I. Div. II. Ord. VII. ANTICONVULSIVA. Class I. Div. II. Ord. VIII. ANTISQUAMOSA. This medicine has already been noticed at considerable length in the account of the last three orders of Catalytic medicines. It is again noticed here as one of the most remarkable of those mineral substances that are used to counteract blood-disorders. It appears to be capable of exerting no less than three kinds of action in the blood, which operations result in the counteraction of Periodic disorders, Convulsive diseases, and certain Cutaneous eruptions. That must of necessity be a various and obscure agency, which is gifted with the power of arresting and controlling so great a variety of morbid actions. It would seem that Ague and its kindred disorders are capable of being combated and cured in two different ways; by Restoratives, such as Quina, which appear to supply the blood with a certain needful material; or by Catalytics, as Arsenious acid, which operate by antagonizing a morbid action, which is either the cause or the result of the blood-disease. I have given my reasons for ranking Quina and Tonics among Restorative medicines. The following are the principal grounds for which Arsenic is included among Catalytics. It is unnatural to the blood, and is at length excreted from the system. It acts as a poison; and is able to work out in the blood a certain process of its own. It has no sudden action on the nervous system, like that which is possessed by Neurotic medicines. And it is able to counteract a number of disorders, as Lepra and Impetigo, which are assumed to depend upon morbid actions in the blood. Arsenic has been recommended in Syphilis, but it exerts no marked power over that disorder. In ague it possesses this advantage over Quina, that it may be administered with safety during the paroxysm. The ordinary precautions in the administration of the Arsenical solution (Liquor Potassæ Arsenitis) have been already enumerated, viz., that the dose should be small at first, and afterwards gradually increased; that as soon as it produces swelling of the face and eyelids, or irritation of the stomach, it should be discontinued, or the dose reduced; and that it should generally be given on a full stomach, as it is then less likely to irritate. (_Vide_ pp. 140, 165, 170, 176, 207, 211, 213.) AMMONIA. Class I. Div. I. Ord. III. ALKALIA. Class II. Div. I. Ord. I. STIMULANTIA GENERALIA. Class IV. Ord. II. EXPECTORANTIA. Class IV. Ord. V. DIAPHORETICA. This medicine may be taken as the type of simple General Stimulants. It tends to excite the nervous forces generally. The remedies of this group are not very potent in their action, Ammonia being perhaps as powerful as any of them. Alcohol, an Inebriant Narcotic, produces at first a greater stimulant effect, but its action is followed up by a depression of the nervous forces, and an affection of the powers of the mind. This influence over the intellectual functions is confined to the Narcotic division of nerve-medicines, and is not possessed by Ammonia. Ammonia is capable of acting chemically as an alkali in the system, and may be used in the various cases in which alkalies are wont to be employed; but it is inferior to Potash in such disorders, because its affinities are far less powerful than those of that alkali. It is also caustic and irritant when applied externally in any form. Administered internally in solution, it has a power of quickening the action of the heart, and exciting the circulation generally. It is therefore particularly useful in the common case of fainting, or threatened syncope. This stimulant power is possessed only by the free alkali and its carbonates. And as the secretion of the stomach is acid, Dr. Pereira supposes that the free or carbonated Ammonia becomes neutralized before absorption; that it is therefore unable to act in the blood except as a salt, and can only operate as a Stimulant while in contact with the coat of the stomach. Its influence must then be conducted by the nerves from the surface of the stomach to the heart. But though the nerves are the natural channels of various motor and sensory impressions, it is to assume an unprecedented thing to suppose that a medicinal action can be transmitted by their means to a distant part. For this and for other reasons it seems to me to be most likely that the solution of Ammonia is absorbed too fast in the stomach to be neutralized by the gastric juice. Or even if it were neutralized before absorption, it would probably be again set free on entrance into the blood, in which there is a slight excess of alkaline matter. Thus Ammonia would exist in the blood in a free state, except in those morbid conditions in which there is a general excess of acid in the system. I suppose the same to be the case with Potash, when it is given in any quantity. The great diffusibility of the free Ammonia would be an additional reason for its rapid absorption. When the gas is inhaled, as in the use of smelling-salts, and applied thus to the nasal and pulmonary mucous membranes, it must pass through to the blood in a free state, for these surfaces do not secrete an acid. And yet its effects in this case are the same as when it is taken into the stomach, which further renders it probable that in the latter instance it is absorbed free. When there is an excess of acid in the system, Ammonia may be used as a Restorative. It diminishes the acid reaction of the secretions by combining with the acid to form a salt. In ordinary conditions (_i.e._ when not required in the system) it has to be excreted from the blood. Both Ammonia and its salts act as Expectorants and Diaphoretics, being excreted on the mucous surface of the lungs, and on the skin. Free Ammonia is a better Expectorant than any of its neutral salts. The secretion of sweat contains an acid. The Ammonia which passes out on the skin combines with this acid. But on the pulmonary surface it is probably excreted free. For it is found that the careful inhalation of Ammoniacal gas has the same effect in augmenting the mucous secretion as the internal use of Ammonia. Ammonia is volatile, and soluble in air; and tends for that reason to pass off freely from those secreting surfaces which are immediately in contact with the atmosphere. (p. 278.) It is supposed by some that diffusible Stimulants act simply on the ganglionic system of nerves, being able through them to excite the functions of the heart, vessels, and glands. But Ammonia is used with advantage in some cases in which the whole nervous system is implicated in the disorder. It has been employed in cases of Typhus, of simple febrile exhaustion, of Hysteria, Epilepsy. In such affections the brain is at least involved, if not often the chief seat of the disorder. Spasms and convulsions are due to a general derangement of the nervous forces, and particularly of the brain, in which these centre and originate. Stimulants, by exalting the natural functions, counteract and control this derangement. It is thus that Ammonia and volatile oils are of use in convulsive disorders; but they are seldom of any permanent efficacy, as in most cases of Hysteria and Epilepsy there is at the bottom a blood-disease, of which the spasmodic fits are only the symptom and outbreak. (_Vide_ p. 176.) So also is there a limit to the efficiency of Stimulants in such cases as Typhus fever; there is a certain point of exhaustion beyond which they are of no avail. For I have attempted to show that though Stimulants are competent to exalt nervous force, they are unable to supply vital force. A degree of nervous force is necessary to the continuance of life; but when the powers of life themselves are ebbing away, it is impossible then to prolong any further the thread of existence by the exhibition of stimulant medicines. The action of Ammonia is directly the reverse of that of Prussic acid, which is a General Sedative, producing Convulsions and Syncope. Ammonia is thus used in cases of poisoning by that liquid. (_Vide_ pp. 126, 227, 278, 283, 301.). STRYCHNIA. Class II. Div. I. Ord. II. STIMULANTIA SPECIFICA. Strychnia is the chief alkaloid and active principle of Nux Vomica. This medicine is comparatively simple in its action. It has no claim to the title of Sedative, which is sometimes applied to it. It does not affect the nerves generally. It has no direct action on the brain, but stimulates chiefly the function of the spinal cord, and its system of nerves. Of these nerves it affects the motor considerably more than the sensory branches. Along with the spinal cord, it doubtless also acts upon that part of the brain which is immediately associated with the spinal system of nerves. But the function of reflex motion, which is thought to reside in the spinal cord, is particularly stimulated. Strychnia is thus an exciter of muscular contraction and of motion; exalting sensation in a less degree. It has also apparently some action on part of the ganglionic system of nerves, by which it is enabled to promote the function of the stomach, and becomes temporarily a tonic when given in relaxed conditions of that organ. But it does not excite the action of the heart. In cases of poisoning by Nux Vomica, the brain and the heart are unaffected. Tetanic and general convulsions are produced; and the immediate cause of death is a spasm of the muscles of respiration. Strychnia causes a contraction of the muscles by stimulating the motor centres, and originating in them an impulse which is propagated along the motor nerves. So that when these centres are diseased, or the continuity of their fibres destroyed, it is unable to exert its power. It is used as a medicine in cases of Paralysis. But when the lesion of the nervous centre is of recent occurrence, or when it has been of so serious or extensive a nature as to admit of no repair in the course of time, the remedy will be ineffectual. It is only successful in cases where the injury to the nervous centre has healed up, and where the limb continues paralyzed merely because the motor nerves have lost the power to transmit the necessary impulse, from having been so long unaccustomed to the discharge of this office. As it is able to act on the nerve itself, it is sometimes thought best to apply it to the affected part on a raw surface produced by a blister. The advantage of this plan is most obvious in the case of Lead-palsy, where the cause of the paralysis is local, residing in the nerve, and not in the centre. But in this case also it is necessary that the nerve-centre be sound. Dr. Neligan recommends Strychnia in Lead-colic, in which disorder constipation and distention of the bowel are produced by a paralysis of a portion of the large intestine. Strychnia has been used with benefit by Dr. Golding Bird in cases of Phosphaturia connected with a functional derangement of the spinal cord. (_Vide_ p. 232.) ALCOHOL Class II. Div. II. Ord. I. NARCOTICA INEBRIANTIA. Class IV. Ord. V. DIAPHORETICA. Class IV. Ord. VI. DIURETICA. We have already considered in order the peculiarities in action that distinguish Narcotics alike from Stimulant and Sedative medicines; how they tend first to exalt the nervous forces, and then to depress them, and have further a particular action on the intellectual part of the brain. We have observed that these remedies may be divided into three minor groups, which differ considerably, if only regarded in their action on the nervous forces generally. For that Inebriants approach very nearly to Stimulants, and Deliriants to Sedatives, while Soporifics occupy an intermediate place. We have seen also that though, during the stage of stimulation, these three orders tend all more or less to excite the powers of the mind, they differ characteristically in their secondary or depressing effect upon the same. That, with respect to our present purpose, the intellectual functions may be divided into three parts: the mind itself; volition and sensation, by which it is united to the body; and the special senses, by means of which it is connected with external things. And that the secondary or depressing action of Inebriants is such as to _impair_ these three in a tolerably equal degree; that of Soporifics _extinguishes_ for a time sensation, volition, and the five senses, while it may leave the mind unaffected; but that of Deliriants _excites_ and _deranges_ all the intellectual functions. If these things are borne in mind, the physiological action of Alcohol will be tolerably understood when it is said to be an Inebriant Narcotic. But it must be observed that when given in small quantities its stimulant effect may be the chief action manifested, its secondary sedative effect may hardly take place, and the production of Inebriation, or drunkenness, may be altogether avoided. So much is this the case that Alcohol is by some regarded as a Stimulant. But the same thing is remarked of Opium, though in a less degree. And the effects of a large dose of Alcohol are sufficiently obvious to indicate its place amongst Narcotics. For the state of Inebriation may even pass on into coma, and death. In small quantities, for the purpose of producing exhilaration, and of overcoming various depressing causes which are of daily occurrence, alcoholic liquors of various kinds, Beer, Wine, and Spirits, are habitually employed by a large portion of mankind. On the broad and important question of their use and abuse as articles of diet this is not the opportunity to enter. In the form of Brandy (which is more agreeable to the palate,) Alcohol is applicable as a medicine in low Fevers, in asthenic Erysipelas, in Typhoid forms of Pneumonia, and in Collapse or Syncope produced by surgical injuries or other causes. It restores the action of the heart, and enables the system to bear up against the disorder. The stimulant action may be maintained, and the secondary sedative effect prevented, by a continual repetition of the dose. Thus when once the employment of this stimulant has been determined upon, it should be steadily and unremittingly persevered in until decided symptoms of improvement have shown themselves in the patient. The tendency of the practice of the present day is towards a freer use of Stimulants, and a more sparing employment of blood-letting and antiphlogistic agents, than was some time ago prescribed. And this is probably an advance in the right direction; for in morbid actions there is altogether very little that is really sthenic; and it is, as a general rule, a wiser thing to support the system against the wearing action of a disorder, than to add to the heap of its various troubles another depressing cause. But Alcohol is a potent agent for evil as well as for good. When large quantities are taken continually for a considerable length of time, it is capable of producing a chronic injury of the brain and mind. By impairing the function of the former, it brings on the shaking paralysis of Delirium tremens. By an action on the mind, it causes the strange hallucinations and the habitual despondency which characterize that disorder. Habitual drinking may likewise cause a chronic inflammation of the liver, called Cirrhosis, which is succeeded by Dropsy. Alcohol is absorbed by the stomach; and, on passing through the Portal vein to the liver, may there produce this condition of the organ by the continual irritation which it excites. When taken in considerable quantity Alcohol passes out of the system by the skin and kidneys, and thus acts as a Diaphoretic and Diuretic. But Liebig states that when taken in small quantities it does not pass off in the secretions, but is consumed or burnt in the system into Carbonic Acid and water. He has found that persons who are accustomed to take Beer in moderation require less bread in their food. (_Animal Chemistry_, Part I., p. 96.) And as it contains more Hydrogen than starchy food, and by the combustion of this Hydrogen the animal heat is partly maintained, Vierordt has shown that during the use of alcoholic liquors the amount of Carbonic Acid exhaled by the lungs is diminished. Thus Alcohol may be regarded as one of the calorifacient articles of food. (_Vide_ pp. 234, 237, 241, 255.) CHLOROFORM. Class II. Div. II. Ord. I. NARCOTICA INEBRIANTIA. Class IV. Ord. V. DIAPHORETICA. Class IV. Ord. VI. DIURETICA. Chloroform, or Terchloride of Formyle, is a volatile liquid which is analogous to Ether and Alcohol both in nature and medicinal action, but very different in chemical construction. Ether = C_{4}H_{5}, O. Alcohol = C_{4}H_{5}, O+HO. Chloroform = C_{2}H, Cl_{3}. A solution of Chloroform in spirit, sold under the names _Terchloride of Carbon_ and _Chloric ether_, is in very general use, and is employed in very much the same cases as Nitric ether, being in the first place stimulant, and subsequently anodyne, soporific, and diaphoretic. Chloroform is physiologically an Inebriant. But it is for certain peculiar actions that are coincident with, or immediately follow, this production of inebriation, that it has been so widely and so successfully employed in medicine since its recent discovery. Its two important operations are its anæsthetic effect on sensory nerves, and its paralyzing influence on muscle. With regard first to the general selection of anæsthetic or anodyne remedies, it is to be observed that there are four distinct kinds of Pain, which differ very much in the treatment required. (1.) Firstly, there is _inflammatory_ pain, caused by an active disease. It is aggravated by pressure; and it has a local cause. For this Opium is the best Neurotic remedy, but it should not be used without an attempt being previously or at the same time made to subdue the active inflammation. (2.) _Irritative_ pain is different. It depends merely on nervous irritation. It also has a local origin; but it is relieved, instead of being aggravated, by a pressure or friction. Such is the pain produced by lead-colic, or by the passage of a gallstone or renal calculus. The pain of Neuralgia is generally of the irritative kind. So is that of Gastrodynia. So also the pain artificially inflicted by the knife in surgical operations. For irritative pain on the surface Aconite is most efficacious. Belladonna comes next to it. In Gastrodynia Hydrocyanic Acid is to be preferred. But to counteract the pain of a surgical operation we require a medicine which shall be capable of producing a powerful effect on the whole system at once. Such medicines are Ether and Chloroform. It is found most convenient to bring the patient under their influence by causing him to inhale the vapour into his lungs. Being absorbed by the pulmonary mucous surface, and passing directly into the circulation, the medicine thus takes effect rapidly. There is no time for the volatile liquid to be excreted from the blood, so that the ulterior effect of the anæsthetic cannot be escaped. The third and most important advantage of this mode of administering Chloroform is that by it we are enabled to regulate with exactness the degree of its action, which is a dangerous one, and to stop it when it has gone far enough. When introduced by inhalation into the general circulation, Chloroform acts upon the brain and sensory nerves throughout the body, so as completely to extinguish their natural sensibility. It is thus an agent of immense value where we wish to save the patient from an extreme and agonizing degree of irritative pain, whether to be caused by the edge of a cutting instrument, or by the throes of parturition. But it also acts as an anæsthetic when applied locally, as to a painful ulcer, or a hollow tooth-stump. (3.) The third kind of pain is _reflex_ in its origin; as the pain in the knee in Hip-joint disease. We should do no good if we troubled ourselves to combat the local symptom in such a case; we should rather direct our attention to that condition which is the distant cause of the pain. (4.) A fourth kind of pain may be called _eccentric_. Like the last, it does not originate in the painful part. It has its origin in the brain or nervous centres. Of such a kind are the various pains of Hysteria. Local anæsthetics are here worse than useless. The brain disorder must, if possible, be remedied. Chloroform is better adapted for inhalation than Ether, because it is considerably less irritating. It is, on the whole, very safe, when proper care is taken. And yet it cannot be denied that sudden deaths _have_ occurred from the use of Chloroform, which could not have been avoided by any known precautions. Such an admission tells little against the remedy; for supposing the proportion of deaths from inhalation to be about 1 in 10,000, it must be confessed that it is better that one out of that number should die of the Chloroform than that 100 should die of fright. Out of 9000 cases of its inhalation at St. Bartholomew's Hospital it is reported that not one died of the anæsthetic. The stages of the action of Chloroform when inhaled may be briefly stated as follows: _1st stage_: some alteration in the feelings of the patient; _2d stage_: inebriation; the mind and volition are impaired; consciousness remains; _3d stage_: unconsciousness; anæsthesia.[48] The loss of sensibility may even occur in the second stage, the patient remaining conscious. The inhalation should not be prolonged beyond the occurrence of the third stage. The pulse is still full. There may be muscular movements, or even cries. In the next stage there is stertorous breathing; the eyelids no longer contract when touched with the finger; the pulse is felt to falter. This is dangerous. To this succeed stoppage of the heart and respiration;--death. There are four rules which it is safe to follow in the administration of Chloroform; not to go on when there is stertorous breathing; not to administer it when there exists any serious disease of the heart or lungs; not to undertake under its influence an extensive operation on the mouth or jaws; and so to arrange the process as that the vapour shall be freely diluted with air. If the third rule be neglected, the blood may flow into the windpipe and cause suffocation, for the patient is deprived of the power of swallowing. The dilution with air is necessary, not only to moderate the action of the remedy, but that the necessary vital function of respiration may not be interfered with. It is also well known that it is convenient to administer Chloroform on an empty stomach, or it will be likely to produce vomiting. Though Chloroform rarely fails to annihilate pain, and thus greatly to diminish the terror of the patient, it will not prevent him from sometimes dying of the shock of a serious operation. An extensive injury to the body will suffice to produce a prejudicial effect upon the heart and nervous system, which is independent of the feeling of pain, and may occur without moral suffering. Chloroform is employed by some to relieve the pain of parturition. It is not found to interrupt the action of the uterus. But, with this exception, it is a general muscular relaxer and paralyzer, and may thus be inhaled before an attempt to reduce an old dislocation, or to restore a hernia of long standing. It is more efficient in such cases than either Opium or Tartar Emetic, and produces less distress than the latter. For the same operation it is sometimes employed in spasmodic disorders. It has even been known to arrest the paroxysm of that most incurable of all disorders, Tetanus. I have known it to do great service both in Epilepsy and in Hysteria, when ordered to be inhaled regularly twice a day. It has been highly recommended by some who have tried it in Delirium tremens. (_Vide_ p. 237.) OPIUM. Class II. Div. II. Ord. II. NARCOTICA SOMNIFERA. Class IV. Ord. V. DIAPHORETICA. Opium is the chief member of the second division of Narcotics, which consist of medicines that, in their action on the heart, are about intermediate between Stimulants and Sedatives, and in their secondary action, on the intellectual functions produce in them, the condition of sleep (p. 239.) Opium produces at first some stimulation, and exhilaration of the mind, with a full pulse, and general febrile excitement. This soon subsides, and is succeeded by drowsiness and sleep. Large doses cause slowness of the pulse, slow and difficult breathing, and coma. If a small dose of Opium be continually repeated, the stimulant action may be maintained for a time, and the Narcotic effect prevented. But whenever it is taken habitually, the dose will require to be gradually increased, or the desired effect will not be produced, for the system is induced by degrees to tolerate the remedy in larger and larger quantities. Given in moderate doses, it powerfully relieves pain, and controls nervous irritability. Though it always tends to produce sleep, its anodyne effect may take place without its soporific action. It is useful in the painful inflammations of the serous and mucous membranes. But it tends to cause congestion of the brain. It should thus be generally avoided in brain-disorders; and, on account of its primary stimulant action, it should only be very cautiously used, or altogether avoided in cases of high fever, where there is a hot dry skin, or a full and hard pulse. The system may sometimes be prepared for it by antiphlogistic treatment; or Tartar Emetic or Ipecacuanha may be conjoined with the dose of Opium. Ipecacuanha and Opium are combined in Dover's powder. Opium is a Diaphoretic; but it diminishes all the other secretions, and most especially that of the bowels. In the treatment of fevers and inflammations it is often combined with Calomel, for the purpose of preventing the latter from passing out by the bowels, and of allaying at the same time the nervous excitement and pain. Whether any precise connexion may exist between these various actions of Opium, is a difficult thing to determine. It is certain that there are other Narcotics and Sedatives which are able to relieve pain, but which neither cause constipation, nor produce cerebral congestion. Purgative medicines, which open the bowels and diminish cerebral congestion, are so far opposed to Opium. Those effete matters which it is the function of the bowels to excrete from the blood, and whose excretion is promoted by purgative medicines, have an action on the brain which in some degree resembles that of Opium. Constipation produces drowsiness, and torpor of the mental faculties. And it is worthy of remark that Opium does not seem to produce quite its proper effect when combined with a medicine which causes purging. Thus it is barely possible that the action of Opium in causing congestion of the brain may be in part referrible to the influence of those excrementitious matters which it hinders from passing out through the intestinal glands (p. 291.) But nothing conclusive is known on the subject. How, we may ask in the next place, does Opium produce constipation? It has none of the characters of a general Astringent, and yet there is no Astringent like it in its action on the bowels. An attempt has been made to explain it on mechanical grounds. Poisseuille some time ago asserted that a solution of Morphia prevented the process of endosmosis through a dead animal membrane. Matteucci and others account for the operation of Opium on this principle, supposing that by exerting this action on the living mucous membrane, it is able to prevent the transudation of fluids from the blood into the cavity of the bowel. But this view seems even at first sight unsatisfactory. If such a force is really exerted, and the passage of fluids through a membrane prevented by the action of Opium, must it not apply to the stomach as well as to the bowel? Why is Morphia absorbed at all? It should stop the digestive process altogether. And why is the secretion of the skin increased by Opium, while that of the bowels is suppressed? (_Vide_ Matteucci's _Lectures_, p. 74.) But there is reason to suppose that a serious error of observation has been made by those who first asserted that a solution of Morphia tended to arrest the process of endosmosis. Dr. Cogswell has lately made some careful experiments on the subject, and he finds that a solution of Muriate of Morphia passes readily through the bladder of an endosmometer to serum or a heavy saline solution. And when experiments are made on two other liquids of different density, the addition of Morphia to one or other of them is found to effect no alteration in the direction or rapidity of the current. Opium is a general paralyzer to muscular fibre, both of the voluntary and involuntary kind, but particularly of the latter. And the only reasonable attempt that can be made to explain the action of Opium in producing constipation, is by a reference to this its paralyzing influence on the coat of the bowel, taken in conjunction with the torpid condition of the general system, and suspension of the animal functions, produced by the secondary action of this Narcotic on the nervous forces. A considerable dose of Opium produces contraction of the pupil of the eye. A larger dose causes coma. The Deliriant Narcotics, _i.e._ Hyoscyamus, Belladonna, and Stramonium, dilate the pupil, and in large doses cause delirium. Their action is thus readily distinguished in cases of poisoning. Opium is the best internal remedy in all cases of pain and nervous irritation, except where contraindicated by great febrile excitement, by stomach irritation, or by cerebral congestion. It acts powerfully on children, and should be administered to them very cautiously, or not at all. It is given to lessen the secretion in some cases of diarrh[oe]a. It is generally unadvisable to give it when there is constipation or hepatic congestion. In wakefulness, mania, and delirium, when unattended with congestion of the brain or fever, it is highly serviceable. In spasmodic disorders, convulsions, and cough, it is more or less applicable. That the active principles of Opium are absorbed, and pass into the blood, has been proved by their detection in the urine. (p. 223.) It does not act on the system before time has been allowed for this absorption. If taken by a mother during suckling, it may act upon the infant by passing into the secretion of milk. It acts upon the nervous system, and probably on the muscles also (_see note_, p. 224,) through the medium of the blood. As a Diaphoretic in fevers and inflammations, Opium is to be preferred in cases where the skin is already moist and cool, where the pulse is soft, and the tongue not coated. But where there is febrile excitement, Antimony, or Ipecacuanha, is rather indicated. Opium may act on the glands of the skin as a true Eliminative; or it may possibly operate in the same indirect way as a nauseant dose of Tartar Emetic, relaxing the ducts of the sudorific glands by its paralyzing influence on their muscular fibre. The chemical construction of Opium is a matter of considerable interest. Morphia, the chief active principle, is an alkaloid which is almost identical with Opium in its narcotic actions but slightly more sedative. Unencumbered by inert matters, it presents us with an anodyne in a more concentrated form. But the combination of the Morphia with other principles in the crude Opium is worthy of remark. Both Morphia and Opium are liable occasionally to produce nausea, headache, loss of appetite, and depression of the spirits. There are various ways in which we may try to obviate these unpleasant symptoms. To prevent nausea, we may combine the dose with an aromatic. Dr. Copland has successfully combined Morphia with an aromatic spirit, in cases where alone it was apt to bring on hypochondriasis. And to prevent the loss of appetite in Delirium tremens, Dr. Todd recommends to combine Morphia or Opium with Quinine or some other Tonic. But it is very curious that in the construction of Opium an attempt is made by nature at the very things that we so much desire in practice. For the drug contains, in addition to Morphia, an aromatic volatile oil, and a neutral principle, wrongly called Narcotine, which has been proved by some experiments made in India to be a simple Tonic, like Quinine. So that if we could only separate from the other parts of the drug the Morphia, volatile oil, and Tonic principle, we should obtain an admirable combination made ready to our hand. But Opium contains also other matters which are mere incumbrances, but which are more or less taken up by the various liquid menstrua that we employ; as, an irritant resin; other neutral principles, as narceine, Meconine, and Papaverine,--and Meconic acid,--all of which are probably inert; and, what is worst of all, a small quantity of an alkaloid called Thebaia, said by Magendie to have an action identical with that of Strychnia. Though Morphia constitutes only about twelve per cent. of the best Opium, the dose of it required is at least one fourth of that of the latter. It seems therefore that Opium must contain some other narcotic principle. Codeia is a Narcotic, of less power than Morphia, and though it is contained in Opium, it is scarcely in sufficient quantity to explain the strength of the drug. It is likely that Opium contains more than one volatile oil, and that the odorous principle to which its peculiar smell is owing is itself narcotic in its action. A parallel case to this is verified in the instance of bitter almonds, which not only yield Hydrocyanic acid, the most powerful Sedative known, but contain a large quantity of a volatile oil, which remarkably resembles the acid in its poisonous action. (_Vide_ pp. 238, 268.) HYDROCYANIC ACID. Class II. Div. III. ORD. I. SEDANTIA GENERALIA. Hydrocyanic or prussic acid (C_{2} N, H,) a very volatile liquid, soluble in water, is one of those mysterious vegetable compounds which, containing no chemical element that is not also contained in animal structure, are yet gifted with a wonderful power over the vital forces. One drop of the pure acid is sufficient to cause death. But the officinal acid is an aqueous solution, containing only 2 per cent. of the other. It is a powerful Sedative to the nerves generally. Its action is direct, and is not preceded by any primary stimulation. Diminishing sensibility, it is therefore used as an anodyne. Controlling muscular action, it is employed as an anti-spasmodic. But it appears especially to influence the reflex nervous actions. It is therefore of especial use in the paroxysmal coughs of Hooping-cough and of Phthisis, which have a reflex origin in the irritation of the mucous membrane. It acts on nerves as well as on nerve-centres. Thus it is particularly useful in neuralgic forms of Gastrodynia; and it seems to allay the pain in the stomach by diffusing itself directly it reaches it, so passing through the mucous membrane at all points, and coming in contact every where with the irritated sensory nerves. It is sometimes useful in cases of vomiting, or pyrosis. If applied to the surface of the skin, it numbs the superficial nerves; but on account of its rapid volatility, and the dangerous results that would follow the inhalation of its vapour, it is not appropriate as an external anaesthetic. A poisonous dose produces first convulsions of the whole frame, then syncope, and death. Strychnia produces convulsions, but they are not caused in the same way as those of Hydrocyanic acid. For the two medicines are obviously opposed in their action, Strychnia being an exalter of sensation and of reflex action, and Hydrocyanic acid a depresser of the same. The convulsion caused by Strychnia is tonic; that by Hydrocyanic acid, asthenic. The one, being a special Stimulant, causes convulsions by an excitement of the spinal cord; the other, being a Sedative, does it by deranging the function of that centre. (_Vide_ pp. 245, 243.) ACONITE. Class II. Div. III. Ord. I. SEDANTIA GENERALIA. This medicine, like the last, is a powerful General Sedative, and a dangerous poison. It depresses the influence of the brain, and paralyzes all the nervous functions. It tends at length to kill by producing syncope. It acts especially on the superficial sensory nerves, and tends to extinguish feeling and pain. It is the best external anæsthetic with which we are acquainted. It is thus eminently useful in the treatment of that most painful of all disorders, Tic douloureux, or irritative Neuralgia of the face. When Quinine and all internal remedies have failed, the tincture of Aconite, or an ointment containing the alkaloid, will in most cases, if applied to the part, effectually relieve the pain. It is applicable in local irritative pain at any part of the surface, as in Sciatica, Lumbago, or a Scirrhus of the breast that has not opened. But, like the other local anæsthetics, it is of little service in cases of inflammatory pain, for this, when local, depends upon an active cause, and would be liable to be increased by the rubbing required in the application of the Aconite. When the remedy takes effect, some heat is first experienced at the part; there is then tingling; and lastly, complete numbness, and a sensation of cold, which endure for some time. No visible change is effected. Aconite subdues the action of the heart. Dr. Fleming has therefore recommended small doses internally in cases of acute rheumatism. But considerable care is required in the internal employment of the drug, on account not only of its dangerous properties, but of the great variety in strength which exists among the preparations that are usually employed. The difficulty experienced in the preparation of the alkaloid Aconitina, which is the active principle of the plant, and the very high price at which that substance is usually sold, have prevented it from being so extensively employed in practice as its medicinal properties would appear to deserve for it. On account of its cleanliness as an outward application, and the certainty and uniformity of its sedative and anæsthetic actions, the pure alkaloid is far preferable as a medicine to Aconite itself, and is adapted for all the cases in which the latter has been employed. Having some time ago been successful in an attempt to discover a mode of preparing Aconitina,[49] I have made some experiments with it on various small animals, for the purpose of ascertaining its power, and the symptoms of its action. It is a very active poison. Proceeding upwards in the animal scale, I find that 1/300th of a grain, in solution in water, suffices to kill a mouse. 1/100th kills a small bird after a few minutes; 1/50th almost instantaneously. 1/20th of a grain has killed a cat. 1/10th invariably proves fatal to the unfortunate feline in the course of twenty minutes or half an hour. Calculating as well as I can from these data, I consider that 1/10th of a grain of this alkaloid would be sufficient to cause the death of an adult man. During the action of the poison on cats the following succession of symptoms is generally observed. They will illustrate in most of its phases the action of a Sedative medicine. 1. An increased flow of the salivary secretion. (_Vide_ p. 282.) 2. Vomiting. 3. Delirium, with hallucinations. Impairment of volition; apparent loss of sensation. 4. Convulsions; paralysis. 5. Breathing difficult and gasping,--gradually ceasing. 6. Death; pupils of the eye are seen to be dilated. Aconitina has thus a powerful action on the brain, and on the nerves generally. The flow of saliva seems partly to arise from a paralysis of the fauces. The animal makes ineffectual attempts to swallow, and breathes spasmodically. By a small dose the anæsthesia would probably be produced, without the other effects. On examination of the body after death the lungs are found to be healthy, but shrunken and bloodless; the trachea contains much frothy mucus, which may possibly have flowed into it on account of the palsy of the glottis; the cavities of the heart are full; the mucous membrane of the stomach pale. It seems then that the immediate cause of death is paralytic syncope,--a loss of power in the heart. As the mucous coat of the stomach evinces no trace of congestion, it is probable that the vomiting is not caused by irritation, but by a sedative or deranging action on the function of the Vagus nerve. (_Vide_ pp. 242, 245.) DIGITALIS. Class II. Div. III. Ord. II. SEDANTIA SPECIFICA. Class IV. Ord. VI. DIURETICA. This important medicine has already been prominently noticed as one of the agents that exert a special sedative and deranging power over the functions of the Vagus nerve. It will only be necessary now to sum up shortly the details of its action. It does not depress nervous force generally. It has no action on the brain, except as connected with the Vagus nerve. Neither does it affect the spinal cord, or the nerves of sensation or motion. Its most obvious action in small doses is to depress the force of the heart. It sometimes quickens the pulse, but always weakens it, and reduces its rate in the end. It therefore supplies us with a ready means of weakening the heart, whenever we desire to do this. In cases of hypertrophy, where the heart is too strong,--or in aortic aneurism, or active hemorrhage, where a forcible beat would be dangerous,--Digitalis may be used for this purpose. But it is especially useful in dropsies; for by its action on the heart, it diminishes congestion of the venous system, and by thus removing the pressure from the veins, it favours the absorption of the fluids effused. It should, however, be avoided in cases where there is very serious cardiac obstruction, or where the heart is habitually weak, and there is a natural liability to syncope. For the tendency of the medicine is to cause death by producing syncope. Certain precautions are necessary in its administration. The patient should be generally confined to the recumbent posture; for if, while under the influence of Digitalis, he should suddenly rise, and the heart, already weakened, have further to contend with the force of gravity in the propulsion of the blood upwards, it may actually stop. The dose also should be cautiously regulated, and, if it do not operate at once, it must not be increased, or too soon repeated; for this medicine is apt sometimes to accumulate in the blood, and though several doses may perhaps be given without effect, they are afterwards liable at any time to be suddenly discharged upon the nervous system, and may then produce by their united action a dangerous result. A considerable dose of Digitalis, as of Tartar Emetic, deranges the control of the Vagus nerve over the function of the stomach, and may in this way produce nausea and vomiting. There is no reason for supposing that it irritates the coat of the stomach. (_Vide_ p. 93.) The active principle of Digitalis is secreted from the system in the urine, and probably acts as a true Eliminative Diuretic. But it tends more powerfully to promote diuresis in another indirect way. Any thing which diminishes the pressure on the vascular system, as Digitalis, by weakening the force of the heart, tends thereby to promote absorption, and to increase the secretion of urine. So that the employment of Digitalis in Dropsy is attended with a twofold advantage; by its cardiac action, it prevents a renewal of the dropsical effusion; by its diuretic power, it causes a quantity of fluid to be drained out of the system through the kidneys. That it may do this the more effectually, it is generally considered advisable to combine it with other diuretics. (_Vide_ pp. 251, 304, 308.) TANNIC ACID. Class III. Ord. II. ASTRINGENTIA VEGETABILIA. This is the chief astringent principle of vegetables. It is very soluble in water, crystallizable, and has a strong astringent taste. It is not possessed of those marked properties that are vulgarly attributed to acids; but its solution reddens litmus-paper, and it combines with bases to form salts. When received into the stomach, it is absorbed, and passes in the circulation to distant parts. Its action consists in a power of causing the contraction of muscular fibre when in contact with it; and this power appears to depend mainly upon a chemical property that it possesses of coagulating albumen and analogous compounds. Capillary vessels, and the small ducts of glands, contain in their walls certain fibres of unstriped muscle; and Tannic Acid, by causing this muscle to contract, is able to diminish the caliber of these tubes, and thus to moderate or arrest the flow of blood in the vessel, or to lessen the amount of the excretion of the gland. Thus, in all cases of hæmorrhage from the small vessels, or of inordinate secretion from any glandular organ, Tannic acid is appropriate. It is the best and safest of all Astringents for internal use, excepting only Gallic acid. I have already stated as worthy of remark the fact that Gallic acid is of little or no use as an Astringent when applied to external parts. Given internally, it is very efficacious. From this alone it would seem that there must be something in the blood which enables it to take effect. Reasons have also been alleged for supposing that Tannic acid is not a simple substance. When it is taken into the system, Gallic acid is secreted in the urine; and it appears that Tannic must actually consist of Gallic acid combined with certain other elements, or with some other definite substance; and that the astringent property which is so valuable is confined to the compound body thus produced. Gallic acid alone has not the power of precipitating albumen. What then is this other substance? It must be something which is contained in or formed in the blood, which added to Gallic, will be capable of forming Tannic acid; and which, when united to it, will enable Gallic acid to precipitate Albumen. These various requirements are fulfilled by the group of elements that constitutes grape-sugar (C_{12}H_{12}O_{12}.) This compound is continually forming in the blood during the blood-processes that are connected with respiration. It has been observed that a solution of gum (C_{12}H_{11}O_{11},) added to one of Gallic acid, will enable the latter to coagulate Albumen. And the elements of Tannic acid may be constructed out of those of Gallic acid and grape-sugar. Tannic acid = C_{18}H_{6}O_{10} + 2 aq. Gallic acid = C_{7}HO_{3} + 2 aq. Three equivalents of anhydrous Tannic acid amount to six of Gallic acid and one of grape-sugar. 3(C_{18}H_{6}O_{10}) = 6(C_{7}HO_{3}) + C_{12}H_{12}O_{12}. So that it is very probable that when Gallic acid is taken into the blood, it acts as an Astringent by co-operating or uniting with the elements of grape-sugar in that fluid. But when Tannic acid is received into the organism, and has done its work there, it is finally decomposed, Gallic acid passing out into the secretions, and the sugar being retained in the body for combustion into carbonic acid and water. (p. 116.) The principal vegetable substances that are employed as Astringents are said to contain Tannic acid in the following proportions:-- Kino 70 per cent. Krameria 43 " Catechu 40 " Uvæ Ursi 36 " Oak-galls 26 " Pomegranate-bark 19 " Tormentil 18 " Oak-bark 16 " These numbers are a tolerably fair measure of the astringent power of the substances named. But it must not be supposed that the astringent principle is in all cases strictly identical with Tannic acid, properly so called; for there appear to be various modifications of this substance contained in the different plants, many of which have peculiar chemical characters of their own, but all of which agree in possessing the power of tanning, or combining with animal gelatine, and in the medicinal property of astringency. GENERAL INDEX. Absorption, action of medicines by, 61, 68, 87. Acids, 120. Aconite, 352. Aconitina, symptoms of action of, 353. Ague, remedies used for, 129, 207. Alcohol, 339. Aliments, 115. Alkalies, 126. Aloes, absorption and action of, 80, 96, 289. Alteratives, 35, 157, 165. Alum, as an Astringent, 263. Ammonia, 334. Anæmia, treatment of, 148, 320. Anthelmintics, 97. Antidotes, action of, 92. Antimony, 321. Arsenic, 333. Astringents, 256, 358. Belladonna, 240. Benzoic acid in lithic deposits, 156. Bile, relation of remedies to the, 137. Billing, Dr., on action of medicines, 132, 163, 216. Bismuth, nitrate of, 87, 94, 97. Blood, medicinal actions in the, 103, 106, 167. Borax, actions of, 155, 232. Brodie, Sir B., his experiments, 63. Calomel, not a sedative, 328. Cantharides, its uses, 67, 214, 307. Castor oil, 291. Catechu, 358. Cathartics, 95, 286. Chalk, not astringent, 264. Charcoal, said to become absorbed, 88. Chemical theories of medicinal actions, 47. Chlorine, an Antiscrofulic, 193. Chloroform, 342. Cholagogues, 295. Cinchona, 129. Citric acid, its actions, 123, 202, 205. Cod-liver oil, 310. Colchicum, 331. Conium, its actions, 246. Copaiba, action of, 267. Copper, Sulphate of, 93, 211, 264. Counter-irritants, action of, 67, 91. Creosote, actions of, 94, 245, 265. Diabetes, treatment of, 119, 194. Diaphoretics, 298. Diarrh[oe]a, treatment of, 294. Diet, rules of, 118. Digestion of medicines, 68-86, 104. Digitalis, 364. Diuretics, 302. Duncan, Dr., his classification, 34. Dropsy, treatment of, 307, 355. Eberle, his arrangement of medicines, 39. Elaterium, its modes of action, 85, 289. Eliminatives, 268. Emetics, 92, 324. Emmenagogues, 102, 275. Endosmosis, passage of medicines by, 71. Epilepsy, remedies used in, 211, 229, 337, 345. Ergot of Rye, 233. Ether, 343. Evacuants, action of, 55, 269, 280. Expectorants, 283. Fermentations in the blood, 180. Fevers, treatment of, 124, 185, 188, 302. Gallic acid, 265, 357. Gold, its use in Syphilis, 189. Gout, treatment of, 194, 331. Grape-sugar in the blood, 116, 198. Hæmatosin, relation of to Iron, 145. Hæmorrhage, treatment of, 263. Hom[oe]opathy, fallacies of, 53, 184. Hydrocyanic acid, 351. Hyoscyamus, 240. Hysteria, remedies used in, 211, 232, 337. Inflammations, treatment of, 185, 323, 325. Iodide of Potassium, 188, 191, 328. Iodine, 328. Ipecacuanha, actions of, 249, 283, 295, 298. Iron, 145, 319. Jalap, absorption and action of, 85, 96, 289. Lactic acid in the system, 69, 116, 198. Laxatives, 287. Lead, actions of, 211, 254, 263. Lemon-juice, uses of, 202, 205. Local access, rule of, 98. Magendie, M., his experiments, 63. Masticatories, 281. Mechanical theories of medicinal actions, 43, 219. Mercury, 325. Morphia, modus operandi of, 220, 347. Murray, Dr., his classification, 36. Narcotics, 234. Nitric acid, its uses, 120, 196. Nitrohydrochloric acid in Oxaluria, 196. Nux vomica, 337. [OE]sterlen, Prof., on absorption of medicines, 88. Oils, fixed, absorption and action of, 84, 278, 288. Oils, volatile, their actions, 227, 267, 278. Opium, 346. Pain, treatment of, 342. Pereira, Dr., on action of medicines, 40, 131, 162, 228. Phosphoric acid, not astringent, 262. Phosphorus, its actions, 229, 311. Pitch, used in Lepra, 214. Potash, 315. Purgatives, 286. Quinine, 317. Refrigerants, chemical theory of, 123. Resins, absorption and action of, 83, 279, 288. Rheumatism, remedies used in, 194. Rhubarb, action of, 294. Salines, absorption and mode of action of, 74, 188, 289, 300. Salt, common, its actions, 93, 193, 210. Sarsaparilla in Syphilis, 190. Scammony, absorption and action of, 85, 96, 289. Schultz, classification of, 57. Scrofula, treatment of, 191. Scurvy, remedies used in, 205. Sedatives, 242. Senna, chemical nature and action, 279, 289. Sialagogues, 281. Silver, nitrate of, its actions, 211, 264. Skin diseases, treatment of, 213. Special Sedatives, 249. Special Stimulants, 233. Squill, its doubtful action, 253. Starch, digestion of, 82, 116, 197. Stimulants, 226. Stramonium, 240. Strychnia, 337. Sulphur, in skin diseases, 215, 301. Sulphuric acid, 313. Syphilis, treatment of, 188. Tannic acid, 356. Tartar emetic, 321. Tea, a Sedative, 248. Thomson, Dr. A. T., on action of medicines, 39. Tonics, 129. Turpentine, its modes of action, 229, 267, 305. Urinary deposits, treatment of, 149, 307. Water, its elimination, 154, 300, 307. Young, Dr., his classification, 32. Zinc, sulphate of, its actions, 93, 211, 264. FOOTNOTES: [1] "In reasoning as to the probable effects of particular remedies on the human body, the conditions and circumstances of the latter are so various in different cases, and the number of concomitants which have to be considered in addition to the more obvious facts and symptoms, is so great that the utmost exertion of human sagacity, founded upon the largest induction of particulars which any one mind is capable of embracing and retaining, can do no more than approximate to that real evidence of which the case seems by its proper nature to be susceptible."--_Glassford's Principles of Evidence._ [2] Dr. A. Pitcairn, in 1704, concluded one of his works by saying, "Thus have I succeeded in solving the noble problem, viz., to find a remedy for a given disease. _Jamque opus exegi._" [3] "In the mean time it may suffice for the physician to know the effects of a medicine when applied to the body, though he knows not the particular manner whereby it acts."--_Van Sweiten's Commentaries on Boerhaave_, vol. i. p. 394. [4] "Every branch of study which can at all claim the character of a science requires two things: 1. A correct ascertainment of the data from which we are to reason; and 2. Correctness in the process of deducing conclusions from them."--_Whateley's Elements of Logic._ [5] There is no doubt that the small veins which ramify outside the coats of the stomach and intestines are capable of taking up any matters in a state of proper solution, even fats when dissolved in alkali. But are medicines ever taken up by the lacteal absorbents? Probably seldom or never; for it seems that these vessels are only engaged after a full meal, and subsequent to the regular formation of chyle. They do not exist in the coat of the stomach, but commence in the small intestine at some distance from the pylorus. [6] It may be of some use if I adduce here a characteristic example of each of the great groups of medicines to which I have alluded above: CLASS I. _Hæmatics._ Div. 1. Restoratives. Iron, in Anæmia. Div. 2. Catalytics. Mercury, in Syphilis. CLASS II. _Neurotics._ Div. 1. Stimulants. Ammonia. Div. 2. Narcotics. Opium. Div. 3. Sedatives. Hydrocyanic Acid. CLASS III. _Astringents._ Tannic Acid. CLASS IV. _Eliminatives._ Cantharides, and Croton Oil. [7] The whimsical "_doctrine of signatures_" which prevailed in the middle ages, and had its origin from very remote times, serves at least to show that the local tendencies of medicines have always been more or less recognised. So slight an experience is sufficient to demonstrate their existence, that it could indeed hardly be otherwise. It was oddly supposed that every natural substance bore evidence in its outward form or physical peculiarities of the part of the system over which it exerted a curative power. [8] "He was one of the first who, leaving the old conjectural method of physical writers, struck into a new and more solid way of reasoning, grounded upon observations and mathematical principles."-- _Preface to Dr. Pitcairn's Works: 1715_. [9] "A Treatise of Diseases in General, wherein the true causes, natures, and essences of all the principal diseases incident to the human body, are mechanically accounted for and explained, and their respective intentions of cure assigned upon the same principles," vol. ii. p. 813, 820. [10] "Medical Precepts and Cautions," page 294. [11] "If there be any bodies--suppose gold and silver--out of which all these principles cannot be drawn, let not the artist think that it is because they are not therein contained. No! it is because that God has so firmly united them against the possibility of our separation."--P. 809. [12] Dr. Pitcairn's Works, 1715, p. 219. [13] I have omitted here to make mention of the doctrine of infinitesimal doses, not only because it is out of my province, but because it is really too unreasonable to be even discussed. When it is said that the decillionth of a grain--the ordinary dose among these practitioners--is expressed by a fraction, the denominator of which is a unit followed by sixty ciphers, this statement will be surely enough for any man who is at all acquainted with figures. I do not conceive it possible that matter is _divisible_ to any thing like this extent. [14] Sydenham's Works, translated from the Latin by Dr. Swan. 5th edition, 1769, p. 1. [15] Preface to the same, p. 22. [16] "First Lines of the Practice of Physic." Fourth edition, 1784. Vol. i. p. 126 et seq. [17] An exception should be made here of certain animal poisons, such as the venom of serpents, which, though they act on the system when introduced directly into the blood, seems to be rendered innocuous by the action of the stomach, which probably decomposes them. [18] Physiological Researches, p. 63-67. [19] It should be mentioned that Sir Benjamin Brodie, though admitting the force of the above experiments, and deriving from them very similar inferences, yet considers it likely that the action of a medicine or poison may be _partly_ propagated by means of the nervous system. _Op. cit._ p. 127. [20] _Vide_ Paper in Medical Gazette, June 18th, 1841. [21] Todd and Bowman's Physiology, vol. ii. p. 280. [22] _Vide_ Pereira's Materia Medica, vol. i. pp. 101, 106. [23] Such is the case in health, when the muscular pressure of the intestine must exceed the pressure on the vascular system on the other side. This latter pressure, when increased, tends to stop or to reverse the inward current. Thus plethora and fever, diseased conditions, counteract absorption by causing pressure on the coats of these capillary vessels. Bleeding,--a drain of fluid caused by an increased secretion,--or such agents as Tartar Emetic and Ipecacuanha,--diminish this pressure by weakening the force of the heart, and thus favour natural absorption. [24] It is stated by Dr. Carpenter, that if a ligature be applied below the pylorus of an animal, and Sulphate of Magnesia then introduced into the stomach, purging is produced. This could only be by the absorption of the salt, and its subsequent action from within on the mucous membrane of the bowel below the ligature. This experiment is unauthenticated, but if verified would certainly be most conclusive in favour of the view adopted above. [25] Hydrochloric acid would probably precipitate medicinal solutions containing silver, and thus render this substance inert when given internally. Another therapeutic argument against this, as the acid of the gastric secretion, may be drawn from the fact that the action of calomel is very different from that of bichloride of mercury,--whereas this acid would convert the former into the latter. [26] Liebig (_Animal Chemistry_, Part I. p. 76) states that the Bile contains Carbonate of Soda. The assertion that the Pancreatic juice is alkaline must be rested mainly on the authority of M. Bernard. [27] Occasionally, as in certain cases of Pyrosis, slight vomiting may take place without any straining effort of this kind, but apparently from the contraction of the stomach alone. [28] Pereira's Materia Medica, 2d edit., vol. ii. pp. 1496, 1507, and elsewhere. [29] Irritant Cathartics, like irritant emetics, may sometimes affect remote parts on the principle of counter-irritation. Some explain in this way the use of purgatives in disorders of the brain, but there are other reasons which serve to account for this still more satisfactorily. (_Vide Chap. IV., Art. Purgatives._) [30] The process of cure by _counter-irritation_ may be ascribed to the _secondary_ action of some medicines. Such an operation may take place at a distance from the part affected; but it is attributable to a peculiar affection of the nervous system, and has no necessary connexion with the primary or proper action of a medicine. _Vide_ p. 67. [31] The details of this arrangement are founded solely upon the _therapeutic operation_ of medicines, as used to cure diseases, and not in any way upon their _physiological action_ upon a healthy man. Much unnecessary confusion, in works on Materia Medica, has arisen from these two different matters being taken into account at the same time. Food is the only restoration of wanting material needful to a healthy man; neither is there in such a case any need or opportunity for the counteraction of morbid agencies. [32] Animal Chemistry, p. 20. [33] Possibly some parts of the bile, besides the colouring matter, are truly excrementitious. But part of it is needful in the animal economy, as has been proved by experiment. M. Schwann found that when the contents of the bile-duct in dogs were caused to discharge themselves externally through a fistulous opening in the wall of the abdomen, the animals quickly wasted away and died. In some cases of jaundice, the constituents of the bile appear to be vicariously excreted by the kidneys; and perhaps the great depression produced by that disorder maybe partly accounted for by the impossibility of the re-absorption into the blood of these substances, naturally formed by the liver. Having passed into the urine, there is no provision to enable them to return. [34] He states that one equivalent of binoxalate of ammonia and four of water contain together the same elements as an atom of Taurine. (_Vide Simon's Animal Chemistry_, vol. i. p. 47. _Syd. Society._) [35] A deposit of Oxalate of Lime occurs sometimes. It is seen in minute octahedra; but is rarely in sufficient quantity to be distinguished by chemical tests. It does not come within the influence of Solvent medicines. [36] Some suppose that this acid occurs in healthy urine is a free state. It is more commonly thought to exist as Urate of Ammonia. Lehmann states that it is found as Urate of Soda. Others imagine that it is held in solution by means of Phosphate of Soda. [37] This acid is ascribed by some to Urate of Ammonia, which is to a small extent soluble in water. Others consider that it is due both to this and to Phosphoric acid, which is the opinion of Dr. Prout and Dr. G. Bird. Others attribute it to Lactic acid, which is stated by Berzelius, Lehmann, and Simon, to exist in healthy urine. Some consider the acid to consist in a Super-phosphate of Soda. Liebig supposes that it is due to Uric acid, held in solution by the common Phosphate of Soda. He also considers Hippuric acid to be an invariable ingredient in healthy human urine. [38] According to Simon it is 1.0125; Becquerel makes it 1.017; Dr. Prout and Dr. Golding Bird, 1.020; Berzelius rates it still higher. [39] "The state or condition of formation or decomposition of a body, the state of change of place or motion in which its particles are, exerts an influence on the particles of many other compounds, if in contact with them. The latter are brought into the same state; their elements are separated and newly arranged in a similar way, and acquire the power of entering into combination, a power which they did not, under similar circumstances, previously possess."--_Liebig's Animal Chemistry_, vol. i. p. 194. [40] Dr. Mead, in 1751, recommended the employment in Scrofula of burnt sponge, and a pill containing "sublimed Mercury" and precipitated Sulphuret of Antimony. Plummer's pill is often prescribed in these cases at the present day. [41] Among these, Dock, Sorrel, Wood-sorrel, and Stonecrop, may be mentioned. Such herbs have been long employed, and recommended by authority. Dr. Mead, in 1751, recommended Scurvy-grass, Lettuce, and Brooklime. He also made particular mention of the _Herba Britannica_, which seems to have been the great Dock, Rumex hydrolapathum. The same physician appears to have anticipated some of the modern applications of Lemon juice. He employed it in liver-diseases generally, among which he included a number of dyspeptic and gouty disorders. He gave it in six-drachm doses; and says that he employed also in similar cases _saponaceous_ medicines, and rhubarb. These remedies, apparently heterogeneous, were recognised then, as now, to be useful in the same cases. For we have just seen that Lemon-juice, Alkalies, Cholagogues, and Tonics, are all more or less applicable in diseases of the Arthritic group. [42] I have just said that Neurotic medicines influence those functions which are attributed to the nervous system. Now there can be no reasonable doubt that they actually influence the nerves. But it is worth while to notice here the curious fact that the same agents have been found to paralyze the irritable or contractile tissues of certain vegetables. Professor Marcet of Geneva first noticed that the vapours of Chloroform and Ether affected the leaf of the sensitive plant so as to prevent it from contracting at the touch, but without at the same time perceptibly injuring its structure. I have produced the same effect on a species of Acacia, which naturally closes its leaves at the approach of night. The leaf experimented on remained open, while the others closed. After a certain time it recovered. Solutions of Morphia, Conia, and other sedatives, have been found to produce the same result. Now the existence in plants of nervous tissues is not usually admitted. How then are we to explain the analogous action of these paralyzing Neurotics on animals and vegetables? Possibly they may be capable of acting directly on contractile or irritable tissues in both cases, without necessarily influencing the nerves in order to produce paralysis. [43] Turner's Chemistry, 7th edit., p. 995. [44] I do not here mean to imply that the products of the actions of all glands are destined for excretion. It is probable that the bile and some other secretions are partly re-absorbed into the blood. But we are now concerned only with the function of glands as emunctories. [45] No lists of the Eliminative orders will be given; for as only a general outline of the mode of action of these medicines is intended, a detailed enumeration of the remedies comprised in each order would be a needless appropriation of space. [46] It has been asserted by Dr. Murray that it is impossible for Mercury to pass off in the urine, on account of the Phosphoric acid contained in that secretion, which would precipitate the metal. But Phosphoric acid is also contained in the blood; and Mercury has been discovered in the urine. [47] Reference is made at the end of each article to those parts of the Essay in which the remedy has been mentioned before. [48] See Pereira's "Materia Medica," vol. i. p. 204. [49] See account of the mode of preparation, by the Author, in the second edition of Dr. Royle's "Manual of Materia Medica." Transcriber's Note The oe ligature is represented by [oe] Subscripts are introduced by an underscore, e.g. CO_{2} Greek words have been transliterated, e.g. [Greek: kineô] The apothecaries' symbol for the dram is represented by [dram]. When followed by "j" the quantity is 1 dram; when followed by "ss" the quantity is 1/2 dram. The apothecaries' dram is 3.8879346 grams. 
33379	----	Transcriber's Note The three diagrams in the text have been rendered approximately using ASCII art. The tilde (~) symbol has been used to indicate bold text. Subscripted numbers are indicated by an underscore (_), with the subscripted item enclosed in braces ({x}). The single superscript number is indicated with a carat (^). With the large number of tables, lists and diagrams in this text, it is recommended that it is viewed using a monospaced font, such as Courier, and that the text is not rewrapped. Table 4 in the Appendix was very wide, and has been split into two pieces by page. THE MACMILLAN COMPANY NEW YORK · BOSTON · CHICAGO · DALLAS ATLANTA · SAN FRANCISCO MACMILLAN & CO., LIMITED LONDON · BOMBAY · CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, LTD. TORONTO DIETETICS FOR NURSES BY FAIRFAX T. PROUDFIT INSTRUCTOR AND CLINICAL DIETITIAN, MEMPHIS GENERAL HOSPITAL, AND ST. JOSEPH'S HOSPITAL, CONSULTING DIETITIAN, MEMPHIS ASSOCIATED CHARITIES, AND PUBLIC HEALTH NURSING ASSOCIATION, MEMPHIS, TENNESSEE SECOND EDITION Completely Revised NEW YORK THE MACMILLAN COMPANY 1923 _All rights reserved_ PRINTED IN THE UNITED STATES OF AMERICA COPYRIGHT, 1918 AND 1922, BY THE MACMILLAN COMPANY. Set up and electrotyped. Published November, 1918 Second Edition completely revised and reset Published, July, 1922 Press of J. J. Little & Ives Company New York, U. S. A. Dedicated to the Great Army of Nurses in the Service PREFACE TO SECOND REVISED EDITION The old order of things is passing. The keynote of to-day's work is prevention, rather than cure, children are taught to eat correctly that they may grow into the strong, healthy men and women which are needed to make any nation great. This instilling of good health habits must rest upon the nurse, the nutrition worker, the physician and the home-maker. Close coöperation is necessary among these workers and a definite understanding of the way to accomplish the best results, in this respect, must come from the training of those who are undertaking this all important work. The present revision of this text is the outgrowth of several years of close attention to the progress, changes and adjustments which are being made daily in this important subject of nutrition. The changes made in this revised edition are all in the line of constructive teaching. The material has been reorganized that no time may be lost in a search for the proper word to illustrate a definite point. The method of project teaching used in this edition, is not a new one, although the name may possibly be unfamiliar to some. Every good teacher recognizes the value of motivation as a means of getting an idea "across." The revision of this text was undertaken with the idea of leading the student to think for herself and to put into practice the scientific facts learned in class room and ward. The author is indebted to many of her colleagues for the encouragement and constructive criticism which enabled her to make the changes which will, it is hoped and believed, materially aid the student nurse in the study of Dietetics. She also wishes to express her appreciation for the many helpful suggestions made by her co-workers in this respect, especially to Misses L. H. Gillett and L. Willson for valuable criticism and to Miss H. Buquo for assistance in the preparation of the manuscript. F. T. P. PREFACE TO FIRST EDITION No other science has so much to do with the general welfare of mankind as the study of food and its effects in the human body. When we use the term "dietetics" as representing "the effect of the food in the human body," we do so in a very broad sense, for the subject is a big one, requiring comprehensive terms to express it. The problems of nutrition are many. Food alone is no small subject and a still greater one is the utilization of food materials in such a way that the body may gain the greatest value with the least expenditure of vital forces. These problems are discussed in this text and the methods of overcoming them are given in the simplest possible language. For this purpose the subject of nutrition has been divided into groups: (1) a comprehensive study of the sources of food, its composition and nutritive value; (2) the effect of food in the body under normal conditions, as in health; and (3) its behavior and effect when conditions in the body become abnormal, as in disease. In this way much of the non-essential material is eliminated from the course of study and only that included which it is necessary for the nurse to understand and which she will constantly use both in the hospital and later on in the practice of her profession. The simple methods of study presented in this text are given with the idea of avoiding confusion in the mind of the average pupil nurse by fitting in the course with her other studies rather than by making it stand out as a separate subject. In this way she will be able to see at a glance the connection between the body processes and the materials which are used to carry them on. Thus her study of physiology, anatomy and bacteriology go hand in hand with that of dietetics, each bearing a distinct relationship to the others. CONTENTS SECTION I FOOD AND ITS SIGNIFICANCE CHAPTER PAGE I FOOD 1 II FUEL VALUE OF FOOD 36 III FOOD REQUIREMENTS OF THE BODY 42 SECTION II LABORATORY OR DIET KITCHEN WORK IV METHODS OF FEEDING IN NORMAL AND ABNORMAL CONDITIONS 59 V FOOD MATERIALS AND THEIR PREPARATION 81 VI INFANT FOODS AND FORMULAS USED IN ABNORMAL CONDITIONS 140 SECTION III THE HUMAN MACHINE VII THE HUMAN BODY 165 SECTION IV DIETO-THERAPY VIII PREGNANCY AND LACTATION 191 IX INFANT FEEDING 199 X CARE AND FEEDING OF CHILDREN IN NORMAL AND ABNORMAL CONDITIONS AND IN INFECTIOUS DISEASES 231 XI FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL TRACT 245 XII DISEASES OF THE INTESTINAL TRACT 263 XIII FEVERS IN GENERAL 281 XIV TYPHOID FEVER 288 XV DISEASES OF THE RESPIRATORY TRACT 301 XVI DIETETIC TREATMENT BEFORE AND AFTER OPERATION 312 XVII URINALYSIS 323 XVIII ACUTE AND CHRONIC NEPHRITIS 336 XIX DISEASES OF THE HEART 365 XX DIABETES MELLITUS 372 XXI DISEASES OF THE LIVER 404 XXII GOUT, OBESITY AND EMACIATION 418 XXIII OTHER CONDITIONS AFFECTED BY DIET 451 APPENDIX Table I. Edible Organic Nutrients and Fuel Values of Foods 461 Table II. Ash Constituents of Foods in Percentage of the Edible Portion 472 Table III. Showing 100-Calorie Portions of some Common Foods, Together with Their Protein, Nitrogen, and Mineral Content 478 Table IV. Composition and Fuel Value of most of the Foods used in the Invalid Dietary 484 Table V. Vitamines in Foods 496 Heights and Weights for Children under Five Years of Age 499 Height and Weight Table for Boys 500 Height and Weight Table for Girls 501 Pelidisi Chart 502 The Nutritional Index--The "Pelidisi" 503 Index 505 SECTION I FOOD AND ITS SIGNIFICANCE PRELIMINARY COURSE OF LECTURES AND LABORATORY WORK CHAPTER I FOOD The value of a knowledge of food and its effect in the human body cannot be overestimated. In health, this knowledge leads to higher standards, since by pointing out the errors in one's mode of living, good health habits may be established, which will, undoubtedly assure the individual of a better nourished and a more vigorous body. There is no question as to the value of health either from the standpoint of comfort or of economy. And the knowledge which will enable one to spread the good work intelligently cannot but raise the standards of living throughout the entire community. In taking up the study of dietetics, the student is introduced to some of the fundamental principles governing the health and well-being of a people, since dietetics includes a study of food and its relation to the body. The relationship between right food and good health is very close; how close is being demonstrated constantly in experimental fields of scientific research. To be able to judge whether the food one eats daily is giving the best possible value from a physiological and economic standpoint, requires a definite knowledge of food, its source, composition and nutrient value, as well as its relation to the body in health and disease. No one is capable of giving constructive advice upon matters pertaining to diet, unless he has acquired this knowledge through training. A nurse should obtain this training during her course in the hospital, through the class room, the wards and the diet kitchen. The dividing line between health and disease is frequently almost imperceptible, and without a knowledge of the normal body, it is, at times, impossible to tell where the normal leaves off and the abnormal begins. For this reason a nurse must understand normal nutrition, that is, the behavior of food in the healthy body, before undertaking the task of ministering to the body attacked by disease. In a text of this kind, it is impossible to cover all phases of the subject, especially since day by day new discoveries are being made with relation to food and its uses in the body. But with careful attention to the principles set forth, a nurse should be able to carry out the dietary orders given her by the physician and dietitian in the hospital. And, when her course of training is finished, she should find herself equipped to assist in raising the standard of health through her knowledge of dietetics. With this brief summary of the aims and object of the study of dietetics, we will begin the actual work with a study of Food. ~Food Materials.~--Food is the name given to any substance which, taken into the body, is capable of performing one or more of the following functions: 1. Building and repairing tissue, maintenance, growth, and development of the muscles, bones, nerves, and the blood. 2. Furnishing the energy for the internal and external work of the body. 3. Regulating the body processes, maintaining the proper alkalinity and acidity of the various fluids throughout the body, regulating the proper degree of temperature, and determining the osmotic pressure, etc. For the convenience of study scientists have arranged the foodstuffs in groups: 1. According to type; 2. According to their chemical composition; 3. According to the function they perform in the body. All foods are composed of certain chemical elements; namely, carbon, oxygen, hydrogen, nitrogen, sulphur, phosphorus, iron, magnesium, potassium, chlorine, sodium, calcium, with traces of various others. The manner in which these elements are combined and the amounts in which they occur determine the group to which the combination belongs, and give to the foodstuff its characteristic position in human nutrition. COMPOSITION OF THE FOODSTUFFS The chemical elements are combined in food and in the body, as: (a) carbohydrates, composed of carbon, oxygen and hydrogen; (b) fats, composed of carbon, oxygen and hydrogen; (c) proteins, composed of carbon, oxygen, hydrogen, nitrogen and sulphur; (d) water, composed of hydrogen and oxygen; (e) mineral salts. The first three foodstuffs constitute the Organic Food group. The last two include the remaining chemical elements, calcium, phosphorus, sodium, potassium, chlorine, magnesium, iron and traces of others which make up the Inorganic Food group. Each of the foodstuffs belonging to the organic group is capable of being burned in the body to produce heat for: (a) the maintenance of the body temperature; (b) internal and external work. Neither water nor mineral salts alone can be burned to produce heat; nevertheless, they enter into the composition and take part in every function performed by the carbohydrates, fats and proteins; therefore one foodstuff cannot be said to be of greater importance than another, since the needs of nature are best met by a judicious combination of all. However, the wear and tear of life can be more efficiently accounted for, and the strain upon the organism reduced more nearly to a minimum when the various foodstuffs are furnished in amounts which science is proving to be necessary for the health and well-being of the organism. The sixth essential food substance, the ~Vitamines~, together with the adjustment of the five foodstuffs just mentioned--the amounts and types of each in the dietary which will assure the body of the best results--has been, and still is a subject of grave interest. Even on the most perfect adjustment of these foodstuffs, the diet would fail to give the desired results without the inclusion of the sixth, or vitamine factor, which has proved to be essential for the growth and development of the normal body, as well as for its protection against certain deficiency diseases. In order to obtain the best results from food, both from a health and an economic standpoint, it is necessary to become familiar with the foodstuffs as they are combined to make up the various common food materials. One foodstuff may be a producer of heat, but may lack certain chemical elements which are essential to the building of tissues; another may be able to accomplish both functions in the body, but will prove too expensive to use as fuel, except when it is absolutely necessary to do so. Thus, it is essential for the nurse to understand where and how both the foodstuffs and the vitamines occur in nature, in order to make use of them more advantageously. The following table gives the sources of the foodstuffs, after which a description of the individual foodstuffs and vitamine factors will serve to point the way to their use in the dietary: { Milk, cheese (especially skim milk cheese). { Eggs. { Meat (lean meat in particular). { Poultry, game. { Fish. Proteins { Cereals, corn, wheat, rye, oats, etc. { Bread and breadstuffs (crackers, pastry, macaroni, { cake). { Beans, peas, lentils. { Cotton seed. { Nuts. { Gelatin. { Wheat products (bread, cake, crackers, pastry, { macaroni, spaghetti). { Cereal grains, breakfast foods. { Corn products, corn meal, green corn. { Rice, sago, tapioca, taro. { Potatoes (white and sweet). Carbohydrates { Starchy fruits (bananas). { Sweet fruits (oranges, grapes, pineapples). { Dried fruits (prunes, dates, raisins, currants). { Sugar cane, sorghum cane. { Sugar beets, sugar maples. { Products made from sugar (candy, jellies, { preserves, marmalade). { Butter, cream, cheese. { Olive oil, cotton seed oil, peanut oil, corn oil, { almond oil. { Soy bean. { Corn meal, cotton seed meal and flour, oatmeal. Fats { Pork (bacon especially), other fat meat. { Codfish (and other fatty fish). { Eggs (yolk). { Cocoa, chocolate. { Brazil nuts, almonds, pecans, and other nuts rich { in fat. Water { All foodstuffs except those which have been put { through a drying process. { Nitrogen (in proteins, meat, eggs, milk, fish, { gluten of wheat, zein of corn meal, legumen of Mineral salts { beans, peas, and lentils). (organic form) { Phosphorus (eggs, yolk especially, cream, { vegetables, whole wheat, cereals, breadstuffs, { oatmeal, dried beans and peas). { Eggs, milk, lean meat, cereal products, whole Iron (organic and { wheat, dried beans and peas, vegetables, inorganic form) { spinach in particular, onions, mushrooms, { fruits, port wine. { Milk.[1] { Eggs. { Soft tissues and fluids of all animals, skeleton { and teeth of animals. Calcium (organic { Wheat (the entire grain), flour, oatmeal, and inorganic { polished rice. form) { Dried beans and peas. { Green vegetables (beets, carrots, parsnips, { turnips, potatoes). { Fruits (apples, bananas, oranges, pineapples, { dried prunes). { Nuts (almonds, peanuts, walnuts). { { Lean beef, eggs, milk. Sulphur (organic { { Wheat flour, entire wheat, and inorganic { The proteins { crackers, etc. form) { { Oatmeal. { { Beans, peas. { { Potatoes. { These elements are associated with the other Sodium, potassium,{ mineral salts in foods, and a diet in which magnesium, iodine,{ they are adequately supplied furnishes chlorine { sufficient magnesium, potassium, chlorine, { sodium, and iodine for the general needs of { the body. { _Fat soluble "A."_ { { Butter, cream, whole-milk. { Whole-milk powder. { Whole-milk cheese. { Cod liver oil, eggs. { Brains, kidney. { Cabbage (fresh-dried). { Carrots, chard, lettuce. { Spinach, sweet potatoes. { { _Water soluble "B."_ { { Yeast (brewers'). { Yeast cakes, yeast extract. { Whole-milk, whey. { Milk powder (whole and skimmed). Vitamines[2] { Nuts, cereals (corn embryo, wheat embryo, { wheat-kernel, rice (unpolished)). { Beans (kidney, navy, soy). { Cotton seed, peanuts, bread. { Cabbage, carrots, celery. { Cauliflower, onions. { Parsnips, potatoes. { Peas (fresh), spinach. { Rutabaga, fruit, grapefruit. { Orange, lemon, tomato, raisins. { { _Water soluble "C."_ { { Fruits: Orange, lemon, tomatoes (canned). { Tomato (fresh), grapefruit, limes, apples. { Vegetables: Spinach, lettuce, cabbage (raw). { Peas (fresh), onions, carrots, cauliflower. { Potatoes (to a less extent). { Whole-milk (to a less extent). THE INDIVIDUAL FOODSTUFFS AND VITAMINE FACTORS A study of the individual foodstuffs and vitamines will furnish the first link in the chain which constitutes our present knowledge of dietetics. CARBOHYDRATES In the ordinary mixed diet of man, the carbohydrates predominate, being not only the most abundant, but also the most economical source of energy. The term carbohydrate covers all of the simple sugars and those substances which can be converted into simple sugars by hydrolysis; the ones of special interest in this study are divided into three groups, known as, Monosaccharides (C_{6}H_{12}O_{6}); Disaccharides (C_{12}H_{22}O_{11}) and Polysaccharides (C_{6}H_{10}O_{15}). ~Monosaccharides.~--Glucose, Fructose and Galactose are substances whose monosaccharide molecules contain one sugar radical; hence they cannot be hydrolized to simpler sugars (sugars of lower molecular weight). Those constituting this group of sugars are all soluble, crystallizable and diffusible substances, which do not undergo changes from the action of the digestive enzymes, consequently these sugars will enter the blood stream in their original form, unless attacked by the bacteria which inhabit the stomach and intestinal tract. The monosaccharides are all susceptible to alcoholic fermentation. Each member of the group is utilized in the body for the production of glycogen and for the maintenance of the normal glucose of the blood. ~Disaccharides.~--Sucrose, Maltose and Lactose are substances yielding, upon hydrolysis, two molecules of simple sugar: each of these sugars is crystallizable and diffusible: all are soluble in water, and to a less degree in alcohol--sucrose and maltose are more soluble than lactose. When attacked by the digestive enzymes, these sugars are changed to monosaccharides. ~Polysaccharides.~--Starch, Dextrin, Glycogen and Cellulose are substances more complex in character than the above-mentioned groups. They are built up of many sugar molecules, which yield upon complete hydrolysis many molecules of simple sugar. The polysaccharides are insoluble in alcohol, and only soluble to a certain extent in pure water. Some members of this group swell and become gelatinous in the presence of moisture and heat; some become of a colloidal form in water, and will pass through filter paper; others remain unchanged. A brief description of the various members of these different groups of carbohydrates will assist the nurse in the ways and means of utilizing them in the dietary to the best advantage. ~Glucose~, which is abundant in the juice of plants and fruits, and to a more or less degree in the blood of all animals (usually about 0.1%) occurs free in nature. This sugar is likewise obtained from many carbohydrates, either through the action of acids, or as the result of the digestive enzymes, and as such becomes the principal form in which the animal body utilizes the carbohydrates ingested. Under normal conditions the glucose in the blood is constantly being burned and replaced; it is only when the body loses to a greater or less degree the ability to burn the glucose that it accumulates in the blood, from which it must escape by way of the urine. There are times, such as when very large quantities of carbohydrates are eaten at once, when glucose will also appear in the urine; but under such circumstances it is generally found to be merely temporary, and for this reason, the condition is known as temporary glycosuria. As a rule, however, the surplus of glucose absorbed, whether it be eaten as such, or is found as the result of enzymic action upon the other carbohydrates, is converted into glycogen and stored in the liver and to a less extent in the muscles. Glycogen is readily reconverted into glucose, which is used by the body for the production of energy. It has been estimated that over half the energy manifested in the human body is derived from glucose, and it is in this form that the tissues of the body will ultimately make use of most of the carbohydrates in food. Practically all of the fruits, and many of the vegetables, are rich in this form of carbohydrate, but grapes contain more than any of the other fruits, while sweet corn, onions, and unripe potatoes contain appreciable amounts. ~Fructose.~--The second member of the monosaccharide group is more or less associated with glucose in plant and fruit juices, and is used like that substance for the production of glycogen in the body. Eaten as such, or produced as the result of digestive action upon cane sugar, fructose is changed into glycogen, chiefly upon entering the liver, and for this reason will not be found to enter largely into the blood of the general circulation.[3] Honey is the most abundant source of fructose in nature. ~Galactose.~--This sugar, unlike the other members of this group, is not found free in nature, but it is produced as the result of hydrolysis of milk sugar, either by enzymes or by acids. Like glucose and fructose, galactose seems to promote the production of glycogen in the body. Certain substances known as galactosides, which are combinations of galactose and some substances other than carbohydrates, are found in the nerve and brain tissues of the animal body. ~Disaccharides.~--Of the second group of carbohydrates, we are probably more familiar with sucrose, or cane sugar, than with either of the other two, since it is in this form that the greater part of the sugar eaten is purchased. ~Sucrose.~--By far the greater part of the sugar entering into the average dietary is manufactured from sugar and sorghum canes, and from sugar beets; but appreciable quantities are derived from the sugar maple and sugar palms. Many of the sweet fruits are rich in this form of sugar; pineapples are said to contain at least half of their solids in sucrose; and although other fruits and vegetables do not contain so high a percentage of this sugar, oranges, peaches, apricots, dates, raisins, prunes, carrots and sweet potatoes contain goodly quantities, which are associated with glucose and fructose. Sucrose is readily hydrolized, either by acids or enzymes. The inverting enzyme (invertase) of yeast and sucrase of the intestinal juice, convert sucrose to fructose and glucose, in which forms it is absorbed into the portal blood. It is believed that when sucrose is eaten in very large quantities, it is sometimes absorbed from the stomach. In these cases it does not become available for use in the body, but acts in the same manner as when injected directly into the blood stream, being excreted unchanged by way of the kidneys. According to Herter, sucrose is much more susceptible to fermentation in the stomach than either maltose or lactose; and since it has no advantage over these sugars from a standpoint of nutrition, they are frequently substituted for sucrose in cases where the dangers arising from fermentation must be avoided. ~Maltose~ (Malt sugar) is an important constituent of germinating grains--malt and malt products being formed as the result of enzymic action (amylases) on starch. A similar action takes place in the mouth as the result of the ptyalin in the salivary juices and in the intestines from the action of the starch-splitting enzyme, amylopsin, in the pancreatic juice. The maltose thus formed is further converted into glucose by the sugar-splitting enzyme in the intestinal juice, and in this form it is chiefly absorbed. Maltose is also an intermediate product formed during the manufacture of commercial glucose as the result of the boiling of starch with dilute acids. ~Lactose~ (sugar of milk) is one of the most important constituents in the milk of all mammals. In freshly secreted human milk, lactose occurs in quantities ranging from 6 to 7%, and in the milk of cows and goats from 4 to 5%. Lactose is much less soluble than sucrose, and decidedly less sweet; hence, owing to this latter property, as well as to its lack of susceptibility to fermentation, lactose is frequently used to bring up the sugar content of infant formulas to the desired percentage, and the diets used in the abnormal conditions when additional energy material is needed. During the process of digestion, lactose is hydrolized by the lactase in the intestinal juice, yielding one molecule of glucose and one of galactose. Like maltose, little if any of this sugar is absorbed in its original form, since experiments made with injections of lactose into the blood result in the rapid and almost complete elimination by way of the kidneys. No such results are obtained when even large amounts of lactose are taken by way of the mouth. ~Polysaccharides.~--This group of carbohydrates is complex in character, built up of many sugar molecules, and upon digestion must be broken down into simple sugars before they can be utilized by the body. ~Starch~ is the form in which the plant stores her supply of carbohydrates. It is found in this form in roots and (mature) tubers, three-fourths of the bulk of which is made up of this material. From one-half to three-quarters of the solids of grains is made up of starch also. Pure starch is a fine white powder, odorless and almost tasteless. It is insoluble in cold water and alcohol, but changes from an insoluble substance to a more soluble one upon the application of heat. Upon hydrolysis starch gives first a mixture of dextrin and maltose, then glucose alone as an end-product. This hydrolysis may be the result of enzymic action, as occurs upon bringing starch in contact with the ptyalin in the saliva, or with the amylopsin in the pancreatic juice; or it may be the result of boiling starch with acid, as is seen in the manufacture of commercial glucose. ~Dextrin~, as has already been stated, is an intermediate product of the hydrolysis of starch by acid or enzymes. ~Glycogen~ is the form in which the carbohydrates are stored in the body, just as starch is the form in which they are stored in plants. It is found in all parts of the body, but is especially abundant in the liver. Here it is stored in the cell substance rather than in the nucleus. The storage of glycogen in the human body depends largely upon the mode of life and upon the diet. Active muscular work, especially out of doors, uses up the store of glycogen with great rapidity; while rest and a sedentary life promotes its storage. The body readily converts its supply of glycogen into glucose, the form in which the body uses the carbohydrates for fuel. ~Cellulose~ is a woody, fibrous material insoluble in water and to a certain extent impervious to the action of the digestive enzymes. This carbohydrate constitutes the skeleton of plants just as the bones constitute that of the animal body. It is probable that owing to the length of time required for this carbohydrate to be broken down in digestion, much of it escapes oxidation entirely. Hence, it passes down the digestive tract lending bulk to the food mass and thus promoting peristalsis throughout the whole of the digestive tract. ~Organic Acids.~--Certain of the carbohydrate foods (fruits and green vegetables) contain appreciable amounts of organic acids or their salts; oranges and lemons, for example, are rich in citric acid; grapes contain considerable quantities of potassium acid tartrate, apples and other fruits have malic acid; many of the fruits have succinic acid; a few foods contain oxalic acid, or oxalates. All of these organic acids are burned in the body to produce energy, with the possible exception of the oxalates, which seem to have little, if any, food value. According to Sherman, these organic acids have a lower fuel value, per gram, than carbohydrates, but are reckoned as such in computing a food in which they exist. The function of these acids is chiefly that of neutralizing the acids formed in the body in metabolism. Being base-forming in character, they function after absorption and oxidation in the body as potential bases--the base associated with the acid in their ash combining with carbonic acid to form carbonates, which act as above described. ~Bacterial Action upon Carbohydrates of Foods.~--The bacteria that act chiefly upon the carbohydrates belong to the fermentative type. The substances formed as a result of this activity are certain acids--lactic, butyric, formic, acetic, oxalic, and possibly alcohol. Certain forms of carbohydrates are more susceptible to bacterial fermentation than others. Herter claims that sucrose and glucose are much more so than lactose, maltose, or starch. The substances thus formed through bacterial activity are not believed to be toxic in character, but merely irritating. However, the irritation arising from excessive fermentation in the stomach may lead to gastric disturbances of a more or less serious nature; hence the amount of carbohydrate taken under certain conditions must be adjusted carefully. ~The Effect of Heat upon Carbohydrates.~--The changes wrought in the carbohydrates as a result of heat have already been discussed to a certain extent. It is seen that the sucrose (cane sugar) is soluble alike in hot and cold water; the same is true of maltose; but lactose is much more soluble in hot water than it is in water which has not been heated. So far as their digestibility is concerned, the application of heat (boiling) neither increases nor decreases the utilization of these sugars by the body. With starch it is an entirely different matter. It has been found that the application of heat, either as dry heat, or in the presence of moisture, brings about a definite change in the character of the foodstuff. Pure starch admixed with water and boiled, passes into a condition of colloidal dispersion, or semi-solution, known as starch paste (Sherman). This is graphically illustrated in the cooking of potatoes, in which the starch and water are mixed in nature; and in the cooking of cereals and like starchy foods, to which water is added in preparation for their cooking. In both cases the application of heat adds greatly to the digestibility of the raw material by reason of the change which is wrought in these substances, causing them to be more readily acted upon by enzymes in the digestive juices. This solubility of carbohydrates in hot water may be utilized in the washing of utensils in which these substances have been prepared; thus saving much time and effort on the part of the nurse in either the diet kitchen or in the home. FATS The second member of the organic food group, and one which is almost as widely distributed throughout animal and vegetable life as the carbohydrates, is found in the fats. This foodstuff, while composed of the same chemical elements that go to make up the carbohydrates, contains these elements in different proportions; that is, fats contain less oxygen and more hydrogen than carbohydrates. ~Typical Fats.~--The fats (as already shown in the Table on page 5) are derived from both animal and plant life, but, like the carbohydrates, do not always occur in the same form. Those of animal origin include: ~Adipose Tissue~ of man and animals, tallow of mutton, suet, and oleo oil of beef, lard of pork. ~Phosphorized Fats~, which include lecithin and lecithans, occur abundantly in the brain and nerve tissues and to a less extent in the cells and tissues of man, animals, and plants of which it seems an essential part. Egg yolk is the most abundant source of phosphorized fat in food material, but milk likewise furnishes an appreciable amount. ~Cholesterol~ (fat-like substances).--"The fatty secretions of the sebaceous glands of man and of the higher animals which furnish the natural oil for hair, wool and feathers," (Starling), lanoline, which is a purified wool fat, consist chiefly of cholesterol. According to Mathews, cholesterol is an essential constituent of the blood, and is found in the brain and in nearly all living tissues. It is likewise believed to be the "mother substance" from which bile acids are derived. ~Fat Soluble "A."~--The vitamine factor which occurs dissolved in certain fats, namely, milk (whole), butter, egg yolk, the organs of animals, and codfish liver. ~Definition of Fat.~--The fats are all glycerides; that is, they are substances made up of combinations of fatty acids and glycerine, which constitute a definite group of chemical compounds, certain members of which are liquid in form, while others are solid, or semi-solid. The liquid fats are known as fatty oils. The fatty acids in which we are chiefly concerned in this study are: Butyric, Stearic, Oleic, and Palmitic. Most of the common fats owe their form and flavor to the type and amount of the various fatty acids of which they are composed. For example, butter is made up of ten fatty acids; but its soft, solid form is due to the olein and palmitin (glycerides of oleic and palmitic acids) which it contains; and its characteristic flavor, as well as its name, to its butyric acid content (about 5 to 6%). It is evident that the degree of softness or hardness of a fat may be determined chiefly by the amount of oleic acid in its composition. Most of the common oils with which we are familiar in food are composed chiefly of olein. Stearin (the glyceride of stearic acid) is the hardest of the fatty acids, while palmitin, although classed with the solid fats, is not so hard as stearin. Lard and butter are higher in olein and palmitin and are consequently semi-solid, while suet and tallow, consisting chiefly of stearin, are much harder than the other food fats. ~Characteristics of Fats.~--The fats are all insoluble in water, and only partially so in cold alcohol, but they dissolve readily in ether. As a rule, the fat occurring in the animal body is more or less characteristic of the species. For example, animals that live on land have a harder fat than those living in the water; warm blooded animals, harder fats than cold blooded ones (fish); and carnivorous animals, harder fats than herbivorous species. Fats are lighter than water, hence will float in it. An emulsion is a suspension of fat in a fluid, and the fat in this case must be very finely divided and mixed with some other material which will prevent a coalescence of the fat globules. In milk, which is one of the best natural emulsions, the additional substance is protein. ~Effect of Heat upon Fat.~--When fats are brought to a high temperature, the glycerine which they contain decomposes with the production of a substance known as acrolein, which has an irritating effect upon the mucous membranes. It is possible that the over-heated fatty acids add their quota to the production of irritating fumes. As a rule, it is inadvisable to use frying as a method of preparing food for the sick or for children. Doubtless, if every cook understood the exact degree of heat to apply in frying, and knew just how moist to have the food mixture which she intended to cook in this manner, better results would be obtained; but since the average cook knows little about the scientific application of heat to fat or the changes brought about thereby, it is safer to make use of other methods of food preparation under the circumstances. ~Functions of Fat.~--This foodstuff undoubtedly serves as the most compact form of fuel available to the body for the production of energy. Weight for weight, fat furnishes twice as much heat as the carbohydrates, and in bulk the difference is even more striking; for example (about) two tablespoonfuls of sugar are required to produce 100 calories, whereas one scant tablespoonful of olive oil will produce a like number of heat units. As a source of supply for reserve energy in the body, fat is most valuable. This reserve fuel is stored in the form of adipose tissues underlying the skin and surrounding the vital organs, lending contour to the form and protecting the organs from jars and shocks. Distributed throughout the body, fat may be found as (a) cholesterol (in the cells of the muscles, organs, and nerve tissues), which acts as a protection against the destruction of the red blood cells; (b) phosphorized fat (lecithin), the universal distribution of which, according to Starling, seems to indicate that it plays an important part in the metabolic process of the cells, serving as a source of phosphorus which is required for the building up of the complex nucleoproteins of the cell nuclei. PROTEINS Upon investigation it was found that neither the fats nor carbohydrates were the chief constituents of the active tissues. It was found, in fact, that the carbohydrates occurred in very small quantities only in the muscles, and that frequently the quantity of fat was likewise limited. Other substances, containing nitrogen and sulphur in addition to carbon, oxygen, and hydrogen, which were invariably present, and which are essential constituents of all tissues and cells, both in animals and in plants, must be necessary to all known life. To these substances, believed at the time to be the fundamental constituents of all tissues, Mulder gave the name Protein, from the Greek, meaning "to take first place." Later investigations proved that, while the proteins were essential to the building and repairing of the tissues and cells in general, they were not the only factors concerned in the work; that certain mineral salts were necessary constituents of all tissues, and must be present in order for any normal growth and development to occur.[4] ~Composition of Proteins.~--The average nitrogen content of common proteins is about 16%; that is, in 100 grams of protein there will be approximately 16 grams of nitrogen, or in 6.25 grams of protein there will be 1 gram of nitrogen. To estimate the protein content of a food when the percentage of nitrogen is known, it is necessary simply to multiply the percentage of nitrogen present, by the nitrogen factor, 6.25; or, if the amount of nitrogen is desired, when the percentage of protein is given, to divide by same factor. ~Construction of Proteins.~--In plant structure the building up of the proteins is accomplished by the plants from inorganic substances existing in the soil and air; but in the animal body this is not possible, because the construction of the tissues requires the use of other proteins--the most available ones being found in food. Each animal (or species) forms the proteins characteristic of its own tissues,--while the proteins of food are similar to those found in the body, they cannot be utilized in their original form, but must be split into simpler substances from which the cells of the various tissues throughout the body may select those particularly adapted for their purpose. These transformed substances are known as amino acids, the production of which is a result of digestion in the digestive tract. There are about seventeen of these acids entering into the construction of the common proteins. One scientist has likened these units to letters of the alphabet, which, being combined, spell many proteins. When a protein contains all of the essential units, it may be said to be "complete," the best example of which may be seen in milk, eggs, and meat. When a protein lacks some of the essential elements, or letters of the protein alphabet, it is said to be incomplete. Gelatin is the best example of this type of protein, but the cereals and beans must likewise be supplemented by other substances; milk being the one most generally used for this purpose. For the purpose of building young tissues, and maintaining those already mature, it is logical to use foods containing the foodstuffs in their best form; that is, those that not only contain the complete protein, but also the requisite mineral salts and vitamines. Foods lacking in some of these respects become adequate when supplemented by these foods which can supply the missing constituents; hence, the use of such incomplete protein foods need not necessarily be abandoned, for, as in the case of cereals, the foods are both economical and palatable, and, when used in addition to milk, furnish valuable adjuncts to the dietary. ~Classification of Proteins.~--A brief description of some of the more important proteins with which we are chiefly concerned will serve to simplify the formulation of a diet. Those assuming the most important position in nutrition and food are ~globulins~, ~albumens~, ~nucleoproteins~, ~phosphoproteins~, ~hemoglobins~, and ~derived proteins~ such as proteoses and peptones. The albumens and globulins associated together occur in the tissues of both animals and plants. The albumens are richer in sulphur than the globulins and are found more abundantly in the animal fluids, such as the blood, while the globulins predominate in the more solid tissues of animals and in plants. The close association of these two proteins is particularly noticeable in the blood and cells. They have different characteristics, however. ~Albumins.~--The best examples are found in egg albumin (white of egg), lactalbumin (milk), serum albumin (blood), leucosin (wheat), legumelin (peas). Albumins are all soluble in pure water, and are coagulable by heat. Coagulation, due to the action of the ferments in the body, takes place in milk, blood, and muscle plasma. Certain albumens are particularly adapted for the building and repairing of tissues. Among those that have been used in feeding experiments to determine whether or not they were capable, when used as the sole protein in the diet, of maintaining animals in normal nutrition, and of supporting normal growth in the young animal,--may be cited lactalbumin and egg albumin. These experiments provided diets adequate in other respects, the object being to determine the value of the various proteins. It was found that the albumin from milk was more efficient in this respect than the egg albumin.[5] In the invalid dietary the solubility of the albumins in water makes them of especial value as reinforcing agents, since they may be introduced into fluids without materially altering either their flavor or their bulk. ~Globulins.~--Simple proteins, insoluble in pure water, but soluble in neutral salt solutions; examples, muscle globulin, serum globulin (blood), edestin (wheat), physelin (beans), legumin (beans and peas), tuberin (potatoes), amandin (almonds), arachin, and conarachin (peanuts). ~Alcohol-Soluble Proteins.~--Simple proteins soluble in alcohol of from 70-80% strength. Insoluble in absolute alcohol, water and other neutral solvents. Examples of these proteins may be seen in the gliadin of wheat, zein of corn, and hordein of barley. ~Albuminoids.~--These substances represent one group of incomplete proteins, inasmuch as they cannot alone support protein metabolism. However, they are classed with the proteins and may be substituted for at least a part of these compounds in the daily dietary, since they are able to do much of the work of the pure proteins. The best example of this group is seen in gelatin. This substance contains many of the structural units of meat protein but in very different relative amounts. It has not, therefore, the chemical units necessary to repair the worn-out parts of cell machinery.[6] ~Conjugated Proteins:--Nucleoproteins, Phosphoproteins and Hemoglobin.~ (a) ~Nucleoproteins.~--This type of protein is characteristic of all cell nuclei, and is particularly abundant in the highly nucleated secreting cells of the glandular organs, such as the liver, pancreas, and the thymus gland. The nucleoproteins are composed of simple proteins and nuclein. Nucleic acid is rich in phosphorus and upon decomposition yields some of the purin bases (xanthin, adenin, guanin), a carbohydrate and phosphoric acid.[7] (b) ~Phosphoproteins.~--Compounds in which the phosphorus is in organic union with the protein molecule otherwise than a nucleic acid or lecithin. Examples: caseinogin (milk), ovovitellin (egg yolk). (c) ~Hemoglobin.~--Much of the greater part of the iron existing in the body occurs as a constituent of the hemoglobin of the red blood cells. When the intake of iron is not sufficient to cover the output, there must be a consequent diminution in the hemoglobin of the blood with a corresponding development of anemia. The importance of knowing these characteristic proteins is apparent. Not only will such knowledge lead to a more intelligent use of protein foods in the normal dietary, but it will prove of the greatest assistance in the adjusting of the foodstuffs in diet for individuals suffering from certain abnormal conditions. In abnormal conditions this knowledge of the various proteins--their composition, source, and behavior in the body assumes a position of the greatest importance; since it represents the means for safeguarding a patient from the results caused by the wrong kind of food. In certain types of nephritis, for example, it is perfectly safe to give milk where the ingestion of meat and eggs might cause serious, if not fatal, results. In treating gout, when it is deemed advisable to limit the purin foods in order to control in a measure the retention of uric acid in the body, the realization that certain of the nucleoproteins, upon being broken down in the body, yield the purins, which in turn give rise to the production of uric acid, will permit the nurse to adjust the diet so as to eliminate such foods entirely (see Gout). The importance of keeping the hemoglobin content of the blood normal has already been mentioned. ~The Effect of Heat upon Proteins.~--The fact that certain proteins are most susceptible to heat has already been stated, but the application of this knowledge in the preparation of protein foods is important. In milk, for example, whole raw milk forms a large hard curd; whereas boiled milk curdles in a much finer and softer form. Pasteurized milk shows smaller curds than raw whole milk, but larger than the boiled whole milk.[8] An egg cooked by the application of a long-continued high temperature (212° F.) has a tough white; whereas an egg cooked until hard at a temperature under the boiling point shows a tenderness in the white which renders it distinctly more palatable. Soft-cooked eggs leave the stomach in less time than is required for hard cooked ones; poached (cooked in water under the boiling point), shirred eggs (cooked in hot dish), and soft-cooked eggs are among the most readily digestible forms of eggs. Raw eggs are slightly less stimulating to acid secretion in the stomach and require a longer time to leave the stomach than boiled eggs. Thus it is seen that in many cases the difference in preparation of the protein foods may make a difference in the way in which the digestive tract handles them. Necessarily, this point is emphasized more in abnormal than in normal conditions; for example, albuminized orange juice gives rise to a distinct gastric secretion, and leaves the stomach rapidly--a great advantage in certain abnormal conditions, and especially in those requiring liquid diet of high nutriment value. The knowledge of the coagulation of proteins by heat points out the advantage of using cold water over hot in the preliminary cleansing of utensils in which protein foods have been prepared. Certain members of this group are soluble in pure water, and will readily dissolve; whereas, if the water is heated, their coagulation would prevent this taking place so readily. ~Functions of Protein in the Body.~--The proteins serve two distinct uses in the body; first, that of building and repairing tissues and furnishing, in conjunction with other substances, material for growth; second, that of producing energy for the internal and external work of the body. For this latter function a large percentage of the proteins ingested is used; consequently, since the carbohydrates and fats are primarily the energy furnishing material most readily used by the organism, it is clearly demonstrated that the average individual takes more protein into the body than is necessary for its maintenance. Except during the period when an allowance for growth must be made, it is probable that a much smaller daily consumption of protein could be made without disadvantage to the organism, leaving the bulk of the work, in so far as the running of the engine is concerned, to the other organic foodstuffs. WATER Man can exist for days, even weeks, without food, but without water life soon becomes extinct. This substance is composed of hydrogen and oxygen in the proportion of two to one; that is, to each atom of oxygen there will be found two atoms of hydrogen. This is always the case no matter where it is found. When foods are put through a drying process the water is taken out and the rest of the chemical composition of the food remains unchanged. This foodstuff, unlike those belonging to the organic group, is not changed during the process of digestion, nor does the application of heat or cold affect it, save from a physical standpoint. Water boils at a temperature of 100° C. (212° F.), and freezes at a temperature of 0° C. (32° F.). ~Function of Water.~--The uses of water in the body are many, and the advantage arising from a sufficient amount of this foodstuff in the dietary cannot be overestimated. It is no longer considered an error in diet to drink a moderate amount of water with the meals, so long as it is not used as a substitute for mastication, and as a means of washing the food into the stomach. In the diet, both as a beverage and as a part of most of the food materials ingested, water serves to moisten the tissues; to furnish the fluid medium for all of the secretions and excretions of the body; to carry food materials in solution to all parts of the organism; to stimulate secretory cells producing the digestive juices, thereby aiding in the processes of digestion, absorption and excretion; to promote circulation; to furnish material for free diuresis, thus preventing to a great extent the retention of injurious substances by the body, which might otherwise take place. ~Factors Determining the Amount of Water Needed.~--In normal conditions it is probable that the kind and amount of exercise taken has more to do with the amount of water needed by the body than any other factor, since the vigorously worked body excretes more water by way of the skin than the quiescent one. With a normal amount of exercise, it is advisable to drink from six to eight glasses of water each day, increasing the amount to a certain extent when exercise causes a great loss through perspiration. It is always advisable, however, to keep in mind that an excessive amount of fluid taken into the body throws a corresponding amount of work on the organs (the stomach, kidneys and heart). In certain abnormal conditions, the body's water supply is depleted. This is particularly true in the case of hemorrhage, vomiting, and diarrhea. Under other conditions (certain types of nephritis), the body becomes overburdened through the excess of water retained, owing to the difficulty which the kidneys show in eliminating it. This retention of water by the tissues gives rise to the condition known as edema. MINERAL SALTS ~Ash.~--The eight remaining chemical elements, _i.e._, calcium, magnesium, sulphur, iron, sodium, potassium, phosphorus, chlorine, constituting the mineral salts or ash, are likewise classed as food on account of the work which they perform in the body. Some of these elements enter the body as essential constituents of the organic compounds, and are metabolized in the body as such, becoming inorganic only upon oxidation of the organic materials of which they form a part. ~Importance of the Mineral Salts.~--The way in which the mineral elements exist in the body and take part in its functions, has been graphically outlined by Sherman as follows. "(1) As bone constituents, giving rigidity and relative permanence to the skeletal tissues. (2) As essential elements of the organic compounds which are the chief solids of the soft tissues (muscles, blood cells, etc.). (3) As soluble salts (electrolytes) held in solution in the fluids of the body; giving to those fluids their characteristic influence upon the elasticity and irritability of muscle and nerve; supplying material for the acidity and alkalinity of the digestive juices and other secretions; and yet maintaining the neutrality, or slight alkalescence, of the internal fluids as well as their osmotic pressure and solvent power."[9] The above outline, showing the various ways in which the mineral constituents enter and take part in the various functions, as well as in the structure of the body, make it evident that the same close attention and study which was given to the other foodstuffs must be accorded to these substances. When the student realizes that the presence of certain salts dissolved in the blood assists in the regulation of the vital processes of the body such as the digestion, circulation and respiration; that they are responsible for the contraction and relaxation of the muscles; that they assist in controlling the nerves; that they are, in a way, instrumental in releasing the energy locked up in food--the value of these elements becomes very evident, and their importance in the dietary inestimable. Some of the mineral salts are more widely distributed in food than others, and the danger arising from their deficiency in the diet is not so great as is the case with others; hence attention is called to those found by investigators to be most often lacking or deficient in the average diet; _i.e._, calcium, phosphorus, and iron. A brief summary of the special parts played by these elements will be outlined here. ~Calcium.~--Physiology teaches that about eighty-five per cent. of the mineral matter of the bone, or at least three-quarters of the ash of the entire body, consists of calcium phosphates. It has long been known that this mineral salt is necessary for the coagulation of the blood, and science has demonstrated that "the alternate contractions and relaxations which constitute the normal beating of the heart are dependent, at least in part, upon the presence of a sufficient, but not excessive concentration of calcium salts in the fluid which bathes the heart muscles."[10] ~Phosphorus.~--According to Sherman, phosphorus compounds are as widely distributed in the body, and as strictly essential to every living cell as are proteins. Science has also proved that they are important constituents in the skeleton, in milk, in glandular tissue, in sexual elements, and in the nervous system; that these compounds take part in the functions of cell multiplication, in the activation and control of enzyme actions, in the maintenance of neutrality in the body; that they exert an influence on the osmotic pressure and surface tension of the body, and upon the processes of absorption and secretion. Like calcium, phosphorus is absolutely essential to the growth and development of the body, and, as in the case of the mineral, its presence in the dietary must be accorded strict attention, in order to avoid the results accruing from its deficiency. Casein, or caseinogen of milk and egg yolk (ovovitellin), are the substances richest in this mineral salt. The fact that the phosphorus existing in grains (cereals) may be removed largely in the process of milling, makes it advisable to consider the use of the breads made from the whole grains. ~Iron.~--The presence of iron as an essential constituent of hemoglobin has already been discussed. That which is not in the hemoglobin is chiefly found in the chromatin substances of the cells. The body does not keep a reserve store of iron on hand as is the case with calcium and phosphorus in the bone tissues, but must depend upon the daily intake in food to supply its needs. The iron content of food materials is not large, but a careful regulation of the iron bearing foods (see Table on page 5) will make it easy to cover the demands of the body with a material which has been found to do its work most efficiently. Medicinal iron has received much attention in the determination of the essential needs of the body. "Whether medicinal iron actually serves as material for the construction of hemoglobin is not positively known, but we have what appears to be a good evidence that food iron is assimilated and used for growth and for regeneration of the hemoglobin to much better advantage than are inorganic or synthetic forms, and that when medicinal iron increases the production of hemoglobin, its effect is more beneficial in proportion as food iron is more abundant--a strong indication that the medicinal iron acts by stimulation rather than as material for the construction of hemoglobin." (Sherman) The newborn infant has a store of iron already on hand, derived from the mother through the placenta before birth. After the birth, and through the nursing period, the child receives a certain amount of iron from the mother's milk. This supply is not altogether reliable, however, since any disturbance of the digestion will tend to interfere with its absorption, and consequently deprive the organism of what would otherwise be used for the building up of the blood supply. Thus it is clearly indicated that the infant's safest source of iron is from the mother during the pre-natal period. This supply must necessarily come from her diet during this time, and is made possible by regulating day by day the iron bearing foods in her dietary. After the original store of iron is reduced to that of the adult (after the child has tripled in birth-weight, generally at 12 or 13 months), and during the remainder of the growth period, it is very necessary to regulate the iron-bearing food in the diet, in order to insure the child of an adequate amount to cover the demands made by the increasing blood supply. VITAMINES Up to a few years ago it was believed a complete diet should contain an adequate amount of protein of a proper type, a sufficient amount of calcium, phosphorus and iron, and enough carbohydrates and fats to furnish the body with sufficient fuel to cover its energy expenditures. This belief was proved to be incorrect a number of years ago by Dr. Hopkins of England. In making certain feeding experiments with rats, Dr. Hopkins showed that some substance or substances present in milk, other than those already mentioned, was essential for the growth of the animal; that animals deprived of this material grew for a time, but gradually ceased to do so. Later on, Osborne, Mendel, McCollum and Davis discovered a like substance in butter fat; and still later Dr. McCollum found the same growth stimulating material, or one very like it, existing in the leaves of plants. These scientists found, upon investigation, that there were probably two substances in milk--one soluble in the fat, the other in the protein-free and fat-free whey--both of which were essential for normal growth. In 1911 Dr. Funk discovered in rice polishings a substance which he believed to be a cure and preventive of Beri-beri; to this substance, which is now believed to be identical with the second substance found in milk, he gave the name "vitamine." Dr. Funk's name "Vitamine" is now accepted to cover a number of substances essential to growth, and for the prevention and cure of certain diseases. To the first two has been added a third member of the vitamine family, which has proved to be a cure and preventive of scurvy. These substances are called--on account of the substances in which they are soluble--"Fat soluble A," "Water soluble B," and "Water soluble C." The table on page 496 shows the sources from which these factors may be obtained. The four plus system is used by Dr. Eddy to describe the abundance with which they occur.[11] ~Function of "Fat Soluble A."~--All investigators agree that the "A" vitamine is an essential factor in the growth of young tissue, and the repair of mature tissues. McCollum claims that this vitamine is likewise a factor in the prevention of the eye disease known as xerophthalmia, and other scientists also hold this opinion. Eddy states that a diet lacking in the "A" vitamine will, in the majority of cases, result in stunted growth and the development of the eye disease, and that the appearance of the latter may be taken as a sure indication of the absence or deficiency of this vitamine. The following diagram shows the effect of adding fat soluble "A" to the diet which was adequate in other respects. This chart represents the growth curve of young rats.[12] 230 +----------+----------+ | | | | | | | | | | | | | | | 190 +----------+---------/+ | | / | | | / | | | / | | | / | | | / | 150 +----------+---/------+ | | / | | With | / | | "Fat |/ | | Soluble / | | A" /| | 110 +--------/-+----------+ | / | | | / | | | / | | | / | | | / | | 70 +--/-------+----------+ | / | | |/ Without "Fat Soluble A" |----------|----------| | | | | | | 30 +----------+----------+ 0 1 2 Figure showing the effect upon growth of adding "fat soluble A" to a diet adequate in all other respects. Courtesy of Dr. E. V. McCollum. Mellanby of England believes the "A" vitamine to be a factor in the prevention of rickets. Scientists of America have recently investigated this disease, and Dr. Hess (New York) has found cod liver oil to be a remedy for it. Cod liver oil is known to be rich in "Fat soluble A," but whether the cure of rickets is due to the presence of this vitamine in the oil, or to a possible fourth vitamine, is still undetermined. ~Effect of Heat on the "A" Vitamine.~--Heat, as applied in the ordinary methods of cooking, is not believed to exert a great deal of destruction upon the "A" type of vitamine; but hydrogenation, the process used in the hardening of certain fats in the manufacture of lard substitutes, is said to destroy it completely. ~"Water Soluble B."~--The second vitamine discovered in milk and believed to be identical with the Funk vitamine is more widely distributed than the "A" vitamine. For this reason it is not so likely to be deficient in the diet as is found to be the case with the "A." A glance at the table shows that the best sources outside of yeast are the seeds of plants and the milk and eggs of animals. In beans and peas the "B" vitamine is distributed throughout the entire seed, but in the cereal grains it is found chiefly in the embryo. As a result, bread made from fine white flour or meal is much more apt to be deficient in vitamine of the "B" type than that which is made from the whole grain; the same is true of rice and other cereals. Spinach, potatoes, carrots and turnips show an appreciable amount of the vitamine, but beets are known to be extremely poor in it. Nuts too are considered a valuable source. ~Function of the "B" Vitamine.~--Like the "A" vitamine, water soluble "B" is believed to be essential to growth. Funk established its value as a preventive and cure of Beri-beri, the disease common in the Orient among people living largely upon a diet of polished rice and fish. Besides being a growth-stimulating substance and an antineuritic, the "B" vitamine is highly valued for its stimulating effect upon the appetite. To this property is probably due at least part of the credit for which certain substances work for the promotion of growth in animals. This can be utilized to good advantage for children showing a disposition to refuse food, by supplementing formulas made from milk,[13] with the expressed juice of vegetables and fruits known to be rich in the "B" vitamine. ~Effect of Heat on the "B" Vitamine.~--This vitamine also shows a resistance to heat; that is, as applied in the methods generally used in cooking, pasteurization temperatures do not materially affect the vitamine property of the formula as far as the "A" and "B" factors are concerned. ~The Effect of Alkali (Soda) upon the "B" Vitamine.~--It has been an ordinary practice to add soda to the water in which certain vegetables are cooked, for the ostensible purpose of softening the vegetables and hastening their cooking. The practice has been condemned by many scientists who are making experiments along these lines, on account of its destructive power upon the "B" vitamine. Chick and Hume in England claim that when the amount of food given contains originally just sufficient vitamines to cover the growth factor the use of soda in the cooking water does serious harm to these vitamines. This is a point well worth remembering. It is often difficult to persuade certain individuals to eat vegetables in appreciable quantities; if the vitamines were reduced though the method of preparing the food, these individuals would not obtain a sufficient quantity of the vitamines. ~"Water Soluble C."~--The third member of the vitamine family is known for its antiscorbutic property; that is, it is the best known cure and preventive of scurvy. It likewise exerts a certain amount of influence upon the growth of the animal and must be present in the diet, in order that the health and well-being of the individual may be safeguarded. The "C" vitamine, like the "B" vitamine, is soluble in water, and is present to an appreciable extent in the fresh juices of the fruits and vegetables. Some are richer in this respect than others (orange and tomato juice), while the cereals, grains, seed of plants, sugars, oils, and meats are singularly deficient. Milk (whole) does not contain a great amount of the "C" vitamine, and this amount is still further reduced under certain methods of preparation. Milk powders, made either from the whole or the skimmed milk, are found to contain only very small amounts of this essential substance. Condensed milk and cream are supposed to be free of "C," and the same is true of eggs. ~Effect of Heat on "C" Vitamine.~--All authorities agree that the "C" vitamine is much more sensitive to heat than the other two; and for this reason much of the value obtained from this vitamine in uncooked material may be lost when the food containing it is subjected to long-continued heat. Hess claims that the temperature used for pasteurizing milk for some time, is more destructive to this vitamine than boiling water temperature continued for a few minutes only.[14] There is need for care in formulating the diet for children to see that they are given fresh fruit every day; or when that is not possible, to see that they are at least given tomato juice. This substance is rich in the antiscorbutic vitamine, and according to experiments made by Sherman, LeMer and Campbell, loses fifty per cent. of its antiscorbutic power when boiled one hour. Dr. Delf at the Lister Institute experimented with raw and cooked cabbage, and found that when this material was cooked for one hour at temperatures ranging from 80° to 90° C the loss in antiscorbutic power amounted to 90% in the cooked leaves over the raw material. Dr. Delf also concluded from her experiments that it was advisable to add neither acid nor alkali in the cooking of vegetables if these substances were to give their maximum value of vitamines. From the foregoing description of these vitamine factors, it is readily seen why so many dietaries are deficient in these essential substances. The limited sources from which to obtain the "A" vitamine; the sensitiveness of the "B" vitamine to the action of alkalies; the sensitiveness of the "C" vitamine to heat, alkali and acid, moreover the limitation of its presence chiefly to the fresh fruits and plant juices,--all point to the need of special care in the selection of the food materials and of the manner in which these materials are prepared for consumption. SUMMARY In the descriptions just given of the various foodstuffs, especially in regard to their function in the body, it is readily seen that no one foodstuff is used to the exclusion of another. It is further seen that in the upkeep of the body, which includes not only the building and repairing of its tissues, but the running of the engine and maintaining of its normal temperature, the organism uses each and all of the organic food substances for the production of heat. Furthermore, while the tissues are chiefly built from protein material, and physiology teaches that protein can be built only from other protein, these tissues contain a certain amount of carbohydrate, fat, mineral salts, and water; this furnishes distinct evidence that the building of the cells and tissues of the body cannot be accomplished by means of protein alone, but by the judicious balancing of all the foodstuffs in the dietary. Science has gone even further than this, as has just been demonstrated, and has proven that without the substances known as vitamines the normal growth and development in the young would be arrested, and that the maintenance of the adult body would be impaired. It has also proven that certain diseases owe their development to deficiencies in the vitamine supply to the body. PROBLEMS (a) Outline briefly what is believed to be the essentials of an adequate dietary. (b) List the fuel foods and show their most economical source. (c) List the best sources of the complete proteins. (d) Show how the incomplete protein foods may be made adequate for growth. FOOTNOTES: [1] One quart of milk contains more calcium than a quart of clear saturated solution of lime water. [2] For complete list, see Eddy's Table, in Appendix. [3] "Chemistry of Food and Nutrition" (revised edition), by Sherman. [4] Scientists are proving the need for certain vitamine factors in the diet in order that the growth and development of young tissues and the repair of adult tissues may proceed. The part played by these substances will be discussed later. [5] "Chemistry of Food and Nutrition" (2d ed.), by Sherman. [6] "The Basis of Nutrition," by Graham Lusk. [7] "Food Products," by Henry Sherman. [8] Abstracts made from thirteen papers from the Laboratory of Physiological Chemistry, Jefferson Medical College, Philadelphia; published in the "American Journal of Physiology and Science," by Minna C. Denton. U.S. Department of Agriculture. [9] "Chemistry of Food and Nutrition" (revised), p. 333, by Henry Sherman. [10] "Chemistry of Food and Nutrition" (revised edition), by Sherman. [11] "The Vitamine Manual," p. 64, by Walter Eddy [12] Courtesy of Dr. E. V. McCollum. [13] Milk from cows whose diet has been deficient in vitamines shows a like deficiency in vitamine content--the same is true of mother's milk. [14] "The Vitamine Manual," p. 64, by Walter H. Eddy. CHAPTER II THE FUEL VALUE OF FOOD Science has proved that the human body is composed of certain chemical elements and that food materials are combinations of like elements; it has likewise proved that the body will utilize her own structure for fuel to carry on the work of her various functions unless material is supplied for this purpose from an outside source, namely, food, which in chemical composition so closely resembles that of the human body. ~Amount and Type of Food.~--The next point of investigation would logically be the amount and kind of food necessary to best accomplish this purpose. To be able to do this it was necessary to have some standard unit by which to measure the amount of heat each food was capable of producing when burned outside the body, after which it was more or less simple to calculate the heat production of each of the food combinations within the organism. An apparatus known as the "Bomb Calorimeter"[15] was devised by Berthelot, and adapted for the examination of food materials by Atwater and Blakesley. The food material to be tested was placed within the bomb, which was charged with a known amount of pure oxygen. The bomb was then sealed and immersed in a weighed amount of pure water, into which a very delicate thermometer was inserted. The food within the bomb was ignited by means of an electric fuse, and the heat given off by the burning of the material was communicated to the surrounding water and was registered upon the thermometer. It was evident that some definite name had to be devised by which these heat units might be known. Hence the name "~calorie~," which represents _the amount of heat required to raise the temperature of 1 kilogram of pure water 1 degree centigrade, or about 4 pounds of water 1 degree Fahrenheit_. ~Transformation of Foods into Available Fuel.~--A comparison has been made between the human body and steam engine, but this comparison is not adequate, since the food does not produce heat within the body originally, but energy of which heat is a by-product. Each food combination has a certain amount of dormant energy within its structure and this energy does not become active nor can it be utilized by the body until the food, of which it is a part, is changed within the organism to substances more nearly like its own. This liberated active energy is then used as a motive power to carry on the internal and external work of the body, and the heat, which is invariably the consequence of any active energy (motion), leaves the body as such. It will be seen, then, that the human body acts not as a steam engine, but rather as a ~transforming machine~ by means of which the dormant energy of the food is transformed into an active agent of which heat is a natural result. In the calorimeter it was found that the carbohydrates and fats burned to the same end products, namely, carbon dioxide and water, while the proteins, upon oxidation, produced carbon dioxide, water and nitrogen gas. In the body it was found that the carbohydrates and the fats acted in exactly the same manner as in the calorimeter, producing the same end products. But this was not the case with the proteins; the oxidation process of this chemical combination was found to be not nearly so complete within the body as in the calorimeter, and instead of the free nitrogen as produced in the apparatus there were urea and other nitrogenous substances eliminated which, while combustible, represented a less complete oxidation of the proteins. The following table represents the amount of heat produced as the result of a complete oxidation of the foodstuffs in the calorimeter. TABLE[16] ================================================== Carbohydrates 4.1 cal. per gram Fats 9.45 cal. per gram Protein (nitrogen × 6.25) 5.65 cal. per gram ================================================== The loss of potential energy due to the incomplete oxidation of the proteins in the body is approximately 1.3 calories to each gram of protein in food; consequently in calculating the fuel value of protein foods, due allowance must be made for these losses. Allowance must also be made for the incomplete digestion, or losses occurring in the digestion, of the foodstuffs. These losses, as well as the approximate amount of each constituent absorbed, are represented in the following table.[17] ===========================+===========+=============== | _Lost_ | _Absorbed_ ---------------------------+-----------+--------------- Carbohydrates |2 per cent.| 98 per cent. Fats |5 per cent.| 95 per cent. Proteins |8 per cent.| 92 per cent. ===========================+===========+=============== The physiological fuel factors of food, or the amount of heat produced as the result of combustion of 1 gram of organic food material after the above-mentioned losses have been accounted for, may be obtained as follows.[18] ================================================= Carbohydrates 4.1 × 98% = 4 cal. per gram Fats 9.45 × 95% = 9 cal. per gram Proteins 4.35 × 92% = 4 cal. per gram ================================================= EFFECT OF HEAT AND COLD UPON THE FOODSTUFFS In primeval days, when man led a more natural life, his very existence depended upon his ability to wrest from the earth his 4--9--4; these, then, constitute what are known as the "physiological fuel factors" of carbohydrates, fats, and proteins respectively. ~Determination of Fuel Value of Food.~--In determining the amount of heat produced by a given amount of food, it is first essential to reduce the amount to grams (for example, 1 lb. equals 480 grams): first, because the gram is a unit of weight commonly used in dietetic calculations; second, because the fuel factors are based on the amount of heat produced by the burning of one gram of organic foodstuffs. Knowing the composition of food, that is the number of hundredths of protein, carbohydrate and fat it contains, it is a simple matter to estimate its fuel value by multiplying the amount of each contained in one gram by its physiological fuel factor 4.4.9. Thus if the composition of a food is 3-3/10% protein, 4% fat and 5% carbohydrate, one gram would contain .033 gram of protein, .04 gram of fat and 0.5 gram of carbohydrate. Hence one gram of milk would produce .033 × 4 = .132 calorie from protein .04 × 9 = .36 calorie from fat .05 × 4 = .20 calorie from carbohydrate or .692 calorie in all But it is not necessary to estimate the fuel value of so small a quantity as one gram, and, since the value of protein, carbohydrates and fats is always the same it is more satisfactory to estimate the amount of the organic constituents contained in the entire given quantity of food, rather than stopping to figure out the fuel value of the small quantity. This is done by multiplying the entire number of grams of food given by the amount of protein, fat and carbohydrate contained in one gram, then multiplying these results by the physiological fuel factor of each. Thus 100 grams of milk would yield 100 × .033 = 3.3 × 4 = 13.2 calories from protein 100 × .04 = 4.0 × 9 = 36.0 calories from fat 100 × .05 = 5.0 × 4 = 20.0 calories from carbohydrates or a total of 69.2 calories from 100 grams of milk. ~The Standard or 100 Calorie Portion.~--Just as it has been more convenient to estimate a larger rather than a smaller quantity of food material, so it is frequently more desirable to estimate a hundred calories, rather than one calorie. This is especially useful when dietaries of high caloric (fuel) value are to be estimated, or dietaries in which foods of like composition and fuel value are to be interchangeable. In such cases it is a simple matter to select the desired number of 100 calorie portions of those foods which are to make up the dietary.[19] ~Method of Estimating the 100 Calorie Portion.~--The number of calories yielded by 100 grams of food material is taken as a basis upon which to estimate the 100 calorie portion, and X represents the number of grams required to yield this portion. The problem is one of "simple proportion," for example, take the 100 grams of milk just estimated, we found that 100 grams (or c.c.) furnished 69.2 calories of heat, then, 100:69.2 :: X:100--145; or 145 grams of milk are required to furnish 100 calories of heat. Suppose it is desirable to substitute eggs for a part of the milk in the diet, eggs have a higher fuel value per unit of weight than milk, their average composition being 13.4% protein, and 10.5% fat (no appreciable amount of carbohydrates), 100 grams of eggs would yield 100 × .134 = 13.4 × 4 = 53.6 calories from protein 100 × .105 = 10.5 × 9 = 94.5 calories from fat, or a total of 148 calories. The Standard or 100 calorie portion of eggs would be, 100:148 :: X:100 = 68 or the number of grams required to yield 100 calories. Thus it is seen that in using the fuel value of a hundred grams of food material for estimating the standard or 100 calories portion the extremes are always the same. Hence, the weight of the 100 calorie portion may always be obtained by multiplying the extremes and dividing the result by the number of calories furnished by 100 grams of food material. PROBLEMS (a) Compare the fuel value of the various common food materials. (b) How does the fuel value of a chicken salad compare with that of fruit salad? (c) Figure the fuel value of a cupful of cream of tomato soup and compare it with that furnished by the same quantity of beef broth. (d) Weigh and measure a 100-calorie portion of spinach and compare it with a 100-calorie portion of sweet potato. FOOTNOTES: [15] For full description and methods used, see "Journal of The American Chemical Society," July, 1903. [16] "Chemistry of Food and Nutrition" (revised edition), by Sherman. [17] "Chemistry of Food and Nutrition," by Sherman. [18] "Chemistry of Food and Nutrition" (revised), by Sherman. [19] See Table of Standard or 100 Calorie Portions, in Appendix. CHAPTER III THE FOOD REQUIREMENTS OF THE BODY The human body, as far as can be judged, does not use one nutrient to the exclusion of another, but science has proved that the best results are obtained from diets balanced to suit the needs of the body, providing the fuel and repair materials in the amounts which are calculated to give the maximum value with the minimum expenditure on the part of the organism. For while no two individuals are exactly alike, there are factors which govern or influence the food requirements of all, and thus make it possible to estimate the needs of the body with a fair degree of accuracy. It has been found, by means of calorimeter experiments (direct and indirect), that a certain amount of heat is produced within the body, regardless of external movement or food; that is, when a body is lying absolutely quiet with no movement save that of breathing, the internal work of the organism, which is continuous, releases so much heat, and this is produced whether there is food to replace it or whether the body structure is burned. This is known as the ~basal rate of metabolism~, and constitutes the normal ~basal requirements~. Any external movement will increase this rate; the greater the activity the higher the increase. Consequently external work calls for food in addition to that which is used to run the engine, in order to save the body from destruction. DuBois[20] finds "Basal Metabolism above normal in exophthalmic goiter, in fevers, in lymphatic leukemia, and in pernicious anemia, in severe cardiac disease, and in some cases of severe diabetes and cancer; it is lower than normal in cretinism, and in myxedema, in old age, in some wasting diseases and perhaps in some cases of obesity." This fluctuation in the Basal Rate of metabolism furnishes a factor in the diagnosis of disease, not only recognized but coming more and more in use. FACTORS DETERMINING THE FOOD REQUIREMENTS OF THE BODY ~For the Adult.~--Muscular activity, Age and Size, are most important factors influencing the food requirements. The physical condition and environment of the individual also exert a certain amount of influence upon the intake of food. ~Work.~--Muscular activity, as already stated, increases the body expenditures; consequently the more active the work the greater amount of energy food needed per unit of weight. ~Age.~--As the individual grows older, the rate of metabolism decreases until, in old age, it is not more than a third to a fifth of what it was in earlier life. This is due to a general "slowing down" of the machinery, the heart does not beat so rapidly, nor is the respiration so quick. The digestive organs, the heart, the liver, and the kidneys, cannot handle the volume of food which was required during the period of greatest physical activity. Hence, any great excess over and above that which is needed for the maintenance of the body in health will be a source of danger to the elderly person. Von Noorden claims the food requirements of individuals from 60 to 70 years of age to be reduced 10%; for people from 70 to 80 years of age to be reduced 20%; for people from 80 to 90 years of age to be reduced 30%. ~Sex.~--Science has proved, that there is little difference in the food requirements of men and women, provided they are alike in age, weight and size, and are doing the same amount and type of work. But women, as a rule, weigh less than men, hence their food requirements are approximately less. Murlin finds the food requirements of pregnant women to be some what higher than of non-pregnant ones, and the requirements of the nursing mother to be higher than either (see chapter on Pregnancy and Lactation). ~For the Child.~--The factors influencing the food requirements are different, to a certain extent, from those of the adult. The main difference lies in the fact that the adult needs food only for the maintenance and repair of the body, while the child must have food, not only to cover its maintenance requirements, but to support the growth and development which should be continuous from birth to maturity. Resistance, too, must be developed during this period in order to safeguard the child through life. The rate of metabolism in the infant is greater than at any other period of life, consequently, even if a child were one-third the weight of its parent, it would inevitably cease to grow and would become malnourished, if its food requirements were reckoned at only one-third that of the parent. ~Adjusting the Food Requirements.~--Taking these factors as guides for estimating the food requirements of man, it is evident that no hard and fast law can be laid down to cover all, that each individual must adjust the food intake according to the weight and activity of the body. Sherman has arranged the following table showing the energy expenditures per hour for the average man (154 pounds), per pound of body weight (these are approximate averages only). TABLE[21] ===================================================================== Sleeping quietly 60-70 calories per hour Awake, lying still 70-85 calories per hour Sitting at rest 100 calories per hour Standing at rest 115 calories per hour Tailoring 135 calories per hour Typewriting rapidly 140 calories per hour "Light exercise" (stationary bicycle) 170 calories per hour Shoemaking 180 calories per hour Walking slowly (about 2-1/4 miles an hour) 200 calories per hour Carpentry or metal work 240 calories per hour "Active exercise" (stationary bicycle) 290 calories per hour Walking briskly (about 3-3/4 miles an hour) 300 calories per hour Stone working 400 calories per hour Severe exercise, such as sawing wood 450 calories per hour Running (about 5-1/2 miles an hour) 500 calories per hour Very severe exercise (stationary bicycle) 600 calories per hour ===================================================================== The above table, calculated for an average man weighing 154 pounds, may seem less simple to use than one based on the energy requirements per pound of body weight per hour, of an average individual. For example, a man weighing 123 pounds and performing practically the same amount and type of work as done by the man weighing 154 pounds would require practically one-fifth less calories than the latter individual. Hence, to facilitate the estimation of the food requirements for average individuals, the following table is included.[22] ====================================================================== Sleeping 0.42 calorie per hour, per lb. of body wt. Sitting at rest 0.65 calorie per hour, per lb. of body wt. Light muscular exercise 1.10 calories per hour, per lb. of body wt. Active muscular exercise 1.90 calories per hour, per lb. of body wt. Severe muscular exercise 3.00 calories per hour, per lb. of body wt. ====================================================================== Possibly a few explanatory words, as to the terms used in the above tables, will assist the nurse in making the necessary calculation. "Sleeping quietly" makes allowance for no movement save that of respiration; any undue restlessness will call for an increase in the above allowance. "Sitting at rest" includes the time spent at meals, sitting in class room, ward office, studying or reading. It does not include much walking about the room, rising frequently, or nervous restlessness. "Light exercise" includes all light house work, running an ordinary sewing machine, walking about office or ward, (receiving ward included). It does not include washing, sweeping or scrubbing. "Active exercise" includes washing, sweeping, scrubbing, general house work, carpentry, and such sports as tennis, basket ball, and ordinary gymnasium work. "Severe exercise" includes road workers (working with pick and shovel) fast running, baseball, football, and swimming. "Very severe exercise" includes the work done by miners, handling of freight, and lumbermen, especially those working in extreme cold, where the severe cold makes extra demands on the fuel supply. By making use of the averages just mentioned it should be a simple matter to calculate the food requirements of any normal individual. It is necessary to know the weight of the person in question, and the manner in which the twenty-four hours are spent, and, in the case of elderly individuals, make the reductions believed to be necessary for health. ~Method of Using the Tables.~--Let us take a nurse in training for this purpose. Suppose the nurse weighs 110 pounds, and spends the twenty-four hours as follows, Sleeping 8 hours Sitting at meals 2 hours Studying 2 hours In class 1 hour On duty 9 hours Off duty (walking briskly) 2 hours Her daily food requirements would probably be approximately 2,235 calories. This estimate would be increased, if she were obliged to do much heavy lifting, scrubbing of beds, or other duties requiring the expenditure of much effort. It would be decreased if the hours spent in study and class room work were increased and the hours on the ward shortened. The estimation may be made as follows, Sleeping 8 hrs. 110 × 0.42 × 8 = 370 calories Sitting at meals 2 hrs. 110 × 0.65 × 2 = 143 calories Sitting in class 1 hr. 110 × 0.65 × 1 = 71.5 calories Studying, 2 hrs. 110 × 0.65 × 2 = 143 calories On duty 9 hrs. 110 × 1.10 × 9 = 1089 calories Off duty (walking briskly) 2 hrs. 110 × 1.90 × 2 = 418 calories --------------- Total for day 2234.5 calories This estimate may be made to suit any individual, the man in the office or the one working on the streets, the woman living at home or the one spending eight or ten hours scrubbing the floors of a great office building; it is simply a matter of adjusting the calories in the dietary to meet the requirements of body weight and muscular activity. ~Energy Requirements for Children.~--In estimating the energy needs of children, the above method is not satisfactory, since the storage of material for growth must be considered, as well as the activities of the body. The growth period includes the years from birth to the eighteenth year, after which time the food requirements of the body are made on a basis of weight and muscular activity, as in all adults. The table on the following page shows the food allowances made for healthy children; in the feeding of malnourished or underweight children, more food in proportion to age is given in order to overcome the handicap under which they are suffering. FOOD ALLOWANCES FOR HEALTHY CHILDREN[23] ==============+======================== AGE | CALORIES PER DAY --------------+------------+----------- _Years_ | _Boys_ | _Girls_ --------------+------------+----------- Under 2 | 900-1200 | 900-1200 2-3 | 1000-1300 | 980-1280 3-4 | 1100-1400 | 1060-1360 4-5 | 1200-1500 | 1140-1440 5-6 | 1300-1600 | 1220-1520 6-7 | 1400-1700 | 1300-1600 7-8 | 1500-1800 | 1380-1680 8-9 | 1600-1900 | 1460-1760 9-10 | 1700-2000 | 1550-1850 10-11 | 1900-2200 | 1650-1950 11-12 | 2100-2400 | 1750-2050 12-13 | 2300-2700 | 1850-2150 13-14 | 2500-2900 | 1950-2250 14-15 | 2600-3100 | 2050-2350 15-16 | 2700-3300 | 2150-2450 16-17 | 2700-3400 | 2250-2500 ==============+============+=========== CALORIES PER POUND OF BODY WEIGHT PER DAY.[24] ============================================= _Years_ |_Calories per pound, per day_ --------------+------------------------------ Under 1 year | 45 1-2 | 40-43 3-4 | 37-40 4-5 | 37-40 5-6 | 35-37 6-7 | 34-35 7-8 | 32-34 8-9 | 30-35 9-10 | 30-35 10-11 | 28-32 11-12 | 28-32 12-13 | 28-32 13-14 | 25-30 14-15 | 20-25 15-16 | 20-25 16-17 | 20-25 ==============+============================== After which time the food requirements are based on degree of muscular activity, boys and girls of seventeen years and over requiring as much food as men and women. Children, like adults, differ in degrees of activity; that is, one child may be very active, running and playing more strenuously than another. Hence a margin of safety must be allowed to cover the energy expenditures of the more active child, to safeguard it against becoming malnourished. To facilitate the computation of the food requirements of children a schedule showing the number of calories per pound of body per day is included on opposite page. The food requirements are such as to allow of a steady increase in the weight and stature of the child; the rate of gain for normal children should be as follows: AVERAGE RATE OF GAIN PER WEEK, FOR NORMAL CHILDREN =======================+================== _Age_ | _Average_ _Boys_ | _gain,_ | _Ounces_ -----------------------+------------------ First year | 3-1/2 - 4-1/2 Second year | 2-1/2 - 3 Third year | 1-3/4 - 2 Fourth to eighth year | (inclusive) | 1-1/4 - 1-1/2 Ninth to eleventh | year (inclusive) | 1-3/4 - 2 Twelfth to thirteenth | year (inclusive) | 2-3/4 - 3 Fourteenth to | sixteenth year | (inclusive) | 3 - 4 =======================+================== =======================+================== _Age_ | _Average_ _Girls_ | _gain,_ | _Ounces_ -----------------------+------------------ First year | 3-1/2 - 4-1/2 Second year | 2-1/2 - 3 Third year | 1-3/4 - 2 Fourth to eighth year | (inclusive) | 1-1/4 - 1-1/2 Ninth to twelfth | year (inclusive) | 1-3/4 - 2-1/4 Thirteenth to | fifteenth year | (inclusive) | 2-3/4 - 3-1/4 Sixteenth and | seventeenth year | (inclusive) | 1 - 2 =======================+================== The averages just given are for healthy children; those who are underweight for their age and height should show a more rapid increase in weight with an increased food allowance. It must also be remembered that a simple gain in weight is not sufficient evidence of a child's normality; a freedom from gastro-intestinal disturbances, and a resistance to disease, are equally essential. There have been tables arranged to show the proper weight for height for boys and girls of different ages (see appendix). These are valuable since, by their use, attention is called to the child who is not up to the average. Medical examination of such children frequently shows reason for their underweight, and measures may be instituted which may save the child from a lifetime of poor health. Dr. Pirquet has arranged a scale (Pelidisi Chart) showing the state of nutrition in children, based upon the sitting height (in centimeters), to weight (in kilograms). See appendix. PROTEIN REQUIREMENTS There is never a period in life in which protein is not needed. During the early years it is essential that the proteins, or at least a goodly portion of them, be obtained from animal sources, milk and eggs in particular; when cereals and legumes (beans and peas) are used to provide for the protein requirements, they must be supplemented by milk or eggs (or both), in order that the growth and development of the child may proceed at a normal rate. Adults require protein for the repair of old tissues and to furnish material for the building of new cells, and again it is believed advisable to have at least a portion of this protein from animal sources, milk, meat or eggs. MINERAL REQUIREMENTS Just as energy foods and proteins must be adjusted in the dietary to safeguard the health of the body, so the mineral salts must be adjusted for a like purpose. Studies made of the dietaries of a number of families brought to light the fact that the children more often suffered from a deficiency of calcium, phosphorus and iron in their diets than they did from too little protein,[25] proving that it is quite as essential to adjust the mineral salts in the diet as it is that of the organic constituents. According to Sherman the diet of an adult should contain each day per pound of body weight: Protein 0.5 gram or more Phosphorus 0.01 gram or more Calcium 0.005 gram or more Iron 0.0001 gram or more These averages, while covering the needs of the mature body, do not furnish the necessary amount of protein, or mineral salts to support the growth and development of the child. Hence, it has been deemed advisable to reckon the requirements of the latter per thousand calories, instead of per pound of body weight, in this way obviating some of the danger of protein and mineral deficiencies. McCollum, Simmonds and Pitz have shown that a deficiency in the inorganic content of a diet may result in a retarding or suspension of growth. This result has been overcome on the introduction of the proper mineral salts into the diet. This salt mixture is such as to make the total ash, approximate that found in the composition of milk ash. The following diagram illustrates this point. | 240 +----------+----------+----------+----------+--+ | | | | | | | | | | _| | | | | _/ | | | | _/| | | | | | _/ | 200 +----------+----------+----------+----_/----+--| W | | | | _/ | / e | | | |_/ | /| i | | | / |/ g | | | Normal_/| / | h | | | _/ | /| t 160 +----------+----------+----_/----+--------/-+--| | | | _/ | / | i | | | |_/ | / | | n | | | _/ | / | |<---Period I--->|<-/------Period II--/------> | G | | |_/ | | _/ | r 120 +----------+---_/|----+----------+_/--------+--| a | | _/ | | _/ | m | _/ | | _/ | | | s | /| | | _/ | | | / | | | _/ | | | | / | | | _/ | | 80 +------/---+-----|----+/---------+----------+--| | / | | /Effect of | | | _/ | | /|added Salt| | | | _/ | | / |Mixture | | |/ | | / | | | | X__________|_____|/ | | | 40 +----------+-----|----+----------+----------+--+ 0 1 2 3 4 Time in Months Effect upon growth of adding to a diet otherwise adequate a salt mixture of such composition as to make the composition of the total ash similar to that of milk ash; immediate resumption after entire suspension of growth. Courtesy of Dr. E. V. McCollum. The following outline will serve as a guide in making the estimates for the food requirements of children: THE DIET OF A CHILD SHOULD CONTAIN FOR EVERY 1000 CALORIES FURNISHED BY THE FOODSTUFFS, ================================== Protein 25.00 grams or more Phosphorus 0.48 gram or more Calcium 0.25 gram or more Iron 0.005 gram or more ================================== ~Vitamine Needs.~--We have seen the manner in which the energy and protein foods have been adjusted in the diet, but these can not alone assure the body, and especially the growing body of a normal maintenance and repair of its tissue, or support the growth which is essential at this time. This function is believed to belong to the vitamines, since feeding experiments have demonstrated the fact that animals soon cease to grow, develop deficiency diseases, and finally die, when deprived of the essential constituents. Gillett advises, as a safe rule, the use of one, and preferably two foods known to be rich in the fat soluble vitamine, in each day's food allowance, milk and leafy vegetables, for example. If the foods containing phosphorus, calcium, and iron are taken in sufficient quantity, the second, or "B" vitamine needs, will probably be adequately covered, but the presence of the "C" vitamine must be carefully attended to; some fresh fruit or vegetables (see table) is obligatory each day to insure the individual against the development of scurvy. ~Factors Affecting the Food Selection.~--The estimation of the energy needs of the body, and the selection of the foods to furnish the fuel for this purpose, depend largely upon the individual. The digestion of the fats, as well as the way in which the body utilizes them, makes the use of this foodstuff more or less limited according to the ability of the individual to take care of them, the minimum allowance for children being between 2 and 3 ounces per day. According to Gillett, "If boys and girls get at least this amount from butter and its substitutes, cream, bacon, fat meat and oils, additional amounts from their food will provide a margin of safety, without overtaxing the digestive system." After determining the amount of fat required in each day's food allowance, it is a simple matter to adjust the carbohydrates. It is safer from a health standpoint, to obtain the greater portion of this foodstuff from starchy foods rather than from the sugars, many foods rich in starch, likewise contain appreciable amounts of protein and fat, whereas sugar is practically one hundred per cent. carbohydrate. The ease, too, with which this substance ferments in the stomach, and the manner in which it destroys the appetite for other foods, makes the use of much of it in concentrated form unadvisable, especially in the diet of children. The amount of sugar allowed each day, should be limited to an ounce or ounce and a half (2 to 3 tablespoonfuls), and a less quantity is desirable. In order to obtain the best results, with the least deleterious effect on the body, it is advisable to give sugar in dilute form. A piece of pure candy after a meal may not harm the child; but just before, or between meals, as well as the habit of making the breakfast cocoa and cereal of syrup-like sweetness is deplorable, and should in all instances be discouraged. The American Red Cross recommends the following method for estimating the amount of sugar in the dietary: "Add one-half the weight of such foods as jellies, jams and preserves, and three-quarters the weight of such foods as candy, honey and syrup, to the weight of sugar used." The amount of sugar consumed, as such, by the adult each day, is not of such paramount importance as it is in the case of children, but even for adults an excessive amount of carbohydrate in this form is not considered advisable from a health standpoint. In order to assure each member of the family of getting all of the materials needed for the growth, repair and regulation of their bodies, as well as the necessary fuel material with which to run the engine and to maintain the proper body temperature, the following practical method is suggested for the planning of the daily dietary. THE DIET EACH DAY SHOULD CONTAIN: 1. Milk: One quart for each child under two years of age. From 1 pint to 1 quart for each child from two to five years of age. (M. S. Rose of Teachers' College advises at least a quart for every child of six years and under, at least 1 pint for children from six to sixteen, and one half of a pint thereafter.) 2. Cereals and Breadstuffs: (Activity of person determining the amount.) For children under two years of age 1-3 oz. a day For children from two to five years 2-5 oz. a day For children from five to twelve years 5-9 oz. a day For all over twelve years of age 9-16 oz. a day 3. Meat or its Substitute: For children under five years no meat is needed. (a) Meat: For children from five to ten years 1-2 oz. (no more) a day For children from ten to fourteen years 2-4 oz. (no more) a day of meat or fish. For individuals over fourteen years 2-6 oz. should be the maximum for the day. (b) Eggs: For children under two years no eggs are given.[26] For children from two to five years 3-5 eggs may be given each week, being substituted for part or all of the meat. (c) Beans, Peas, Cheese: For children it is necessary to use milk abundantly when beans or peas are substituted for the meat or egg proteins. 4. Vegetables: For children under six months[27] no vegetables need be given. For children from six to nine months 1 oz. gradually increased to 6 oz. of strained vegetable soup (see formula, page 223). For children from twelve to fifteen months 1 small baked potato may be added, and such vegetables as peas, string beans, carrots, spinach, squash, lima beans (strained). Two vegetables, one of which should be potatoes (white), should be given each day. A leafy vegetable (spinach greens, string beans, kale, lettuce) should be given from three to four times each week and oftener if possible. 5. Fruit: For children from six months on (earlier if physician approves) 1-2 tablespoons orange or prune juice a day. For children from first to second year 1-3 tablespoons twice daily. For children from two to five years 3-4 tbsp. or more, twice daily (amount governed by health of child). All children should be given fresh fruit three or four times a week; some fruit given every day. Adults may be served dried fruit most days, but some fresh fruit should be given each week. 6. Desserts: One sweet dish (custards, cereal puddings, junkets) once or twice a day, but little if any clear sugar should be given (cereals should be served with very little if any sugar). 7. Fats: For each person over five 2-3 oz. of fat (purchased as such) a day, depending upon the age and ability of the individual to digest fats. ~Suggestions for Serving Meals.~--After reckoning the number of calories needed for the day, it is well to remember that the protein must be adequate in type and amount; that there should be an abundant supply of vitamines and iron in each day's ration; that milk should always be included in order to make sure of having a sufficient amount of calcium in the diet; that there should be only one heavy protein dish at any one meal, and that it is unwise to serve a meal in which the fluids predominate on account of their deficiency in energy and proteins. If a meal is made up of the right kind of foods, in the proper proportion, and each individual eats sufficient to assure the maintenance of the normal weight, is free from gastro-intestinal disturbances, and shows a normal resistance to disease, it is more than probable that a sufficient quantity is being consumed each day. All foods should be carefully selected, and properly prepared in order to derive the maximum benefit therefrom, and the regularity and attractiveness with which the meals are served have almost as much to do with the health and happiness of the individual, as the character of the foods included in the day's dietary. PROBLEMS (a) Calculate the dietary requirements of a nurse weighing 125 pounds, who spends 8 hours sleeping, 8 hours on duty, 2 hours at meals, 2 hours brisk walking, 2 hours in the class room, and 2 hours reading or studying. (b) Calculate the diet for a child of ten years of age, weighing 65 pounds, showing the number of calories, the amount of protein, calcium, phosphorus and iron necessary to make this diet cover the requirements of the child. FOOTNOTES: [20] "Archives of Internal Medicine," Vol. XXVII (1916), p. 916. [21] "Chemistry of Food and Nutrition," (revised), p. 186, by Henry Sherman. [22] The Same. [23] Gillett, A. I. C. P. of N. Y. [24] Table compiled from material in "Feeding the Family," by Rose. [25] "The Adequacy and Economy of Some City Dietaries," by Sherman and Gillett. [26] Part of soft-cooked egg may be given at the beginning of eleventh month; this must be given at the noon meal, and should not be included in each day's meal (two or three times a week is sufficient). [27] Dr. Hess advises the use of canned tomato juice as a substitute for orange juice when the latter is unobtainable. SECTION II LABORATORY OR DIET KITCHEN WORK CHAPTER IV METHODS OF FEEDING IN NORMAL AND ABNORMAL CONDITIONS There are several methods of feeding which have been adopted to meet the needs of the individual under various conditions: Feeding by mouth, gavage or forced feeding, rectal feeding (nutrient enemata), and inunction. ~Feeding by Mouth.~--The first method is the one used in health and in the majority of abnormal conditions. In cases where there is a certain abnormal development of the mouth or throat, and in some cases of insanity or unconsciousness, where for some reason it is impossible for the individual to swallow, this method cannot be used. ~Forced Feeding.~--With very young children and babies gavage or forced feeding is found at times to be necessary. In these cases a small rubber catheter is introduced into the stomach through the nostrils and the milk or other fluid poured through the tube. In unconscious or insane patients it is often found necessary to insert a gag (a cork will serve the purpose) between the teeth to prevent the biting of the tube when it is inserted through the mouth into the stomach. ~Food Used for Forced Feeding.~--The food in these cases consists of reënforced soups, milk gruels, or nutrient beverages, not more than six or eight ounces given at one time. Finely chopped meat and vegetable purées have been given in this way when the digestion of the patient was not impaired, but when conditions rendered it necessary to resort to this method of feeding. ~Technique of Gavage.~--The apparatus used in gavage consists of a moderate sized soft rubber tube to which is attached a rubber or glass funnel and a "pinch cock." The tube should be filled with water to prevent air entering the stomach and causing pain or discomfort. In certain cases the patient refuses to swallow the tube and it will be found necessary to use some means to force the passage if the throat is shut off. By closing the nostrils the patient will be obliged to breathe through the mouth, thus opening the passage into the throat through which the tube may be quickly slipped. In certain abnormal conditions the gastric organ is so badly impaired as to render it impossible for the patient to retain food taken in by way of the mouth. It is often found that food introduced into the stomach by means of the "stomach tube" will be retained and utilized which otherwise would be rejected. It is disagreeable, however, and should only be used when it is impossible to feed otherwise. ~Rectal feeding~ is used when the other organs of digestion are impaired to such an extent as to render the need of more food obligatory. Many investigators believe that rectal feeding is absolutely useless, while others have firm faith in its efficacy. ~Technique of Rectal Feeding.~--The rectum should be cleansed by flushing with a soapsuds enema one hour before the nutrient enema is given. This should be done once a day, in the morning. The cleansing enema may be either soapsuds, a solution of bicarbonate of soda, or boric acid (1 teaspoonful to the pint), or a saline solution. When there is much mucus, or if the rectum is inflamed, the soda or boric acid solution may be more soothing than the saline or soapsuds enema. After one hour's rest the patient should be given a nutrient enema. The method of administering nourishment through the rectum is important. A nutrient enema injected only into the lower bowel not only does no good, but may actually cause a good deal of unnecessary discomfort to the patient. ~Temperature of Enema.~--Care must be taken not to have the temperature of the nutrient enema too hot or too cold or it will be promptly rejected. The patient is placed on the side with one knee flexed; the solution is poured into a fountain syringe bag or an enamel container (heat the container before pouring the solution into it or the latter will be chilled). The bag or container has attached to it a rubber tube with a cock adjusted so that only a small stream will flow in at a time. To the end of this tube a rubber rectal tube or catheter--1 cm. (about 1/2 inch)--is attached. This should be well greased (do not use glycerin as this substance is irritating to the mucous lining of the rectum). The liquid should be allowed to fill the tube before it is inserted into the rectum, to prevent any air passing in with it. The tube should be inserted with a gentle twisting movement, using very little force or the tender mucous membranes will be injured. Insert the tube twelve or more inches, since the solution is more completely absorbed if given high up in the bowel. The bag containing the solution should be held only a few inches higher than the rectum, thus allowing only a small stream to pass in and allowing an air space above the stream for the passage of gas which may be accumulated in the upper part of the rectum. The tube should be allowed to remain in the rectum for fifteen or twenty minutes, then very gently withdrawn to prevent the liquid from being rejected. A pad of gauze may be pressed against the anus to assist the patient in retaining the enema. It is well to divert the attention of the patient also, to further assist her in retaining the liquid. ~Duration of Rectal Feeding.~--Rectal feeding cannot be substituted for a great length of time, first, because the patient cannot absorb sufficient nourishment in this way to fully cover the body requirements, and, second, because the rectum becomes more or less sensitive and will reject the liquid before it has an opportunity to be absorbed. From three to four nutrient enemas a day is about the limit for the average patient. Between the nutrient enemas it is advisable to give one of saline solution. The following régime is practiced during the "Total Abstinence Period" in the treatment of gastric ulcer: 7 A.M., cleansing enema; 8 A.M., nutrient enema; 1 P.M., nutrient enema; 3 P.M., saline enema; 6 P.M., nutrient enema. One saline and one nutrient enema may be given during the night if the patient is very weak. She should not be wakened, however, to be given the enema. ~Feeding by Inunction.~--This method consists in the rubbing into the body of certain nutrient oils, such as olive oil, cocoanut oil, cocoa butter, etc. It is of little value, but is occasionally resorted to with very much emaciated and underfed infants, when digestional disorders make it impossible to introduce enough food by mouth to cover the needs of the body. SPECIAL DIETS There are a number of diets formulated to meet the various normal and abnormal conditions. In hospitals these are classified as follows, for the convenience of both nurse and doctor: ~House Diet.~--That which is served to the hospital staff, the nurses, and those patients not requiring special diets. ~Liquid or Fluid Diet.~--Consisting of milk, nutrient and other palatable beverages, broths, and thin gruels. ~Light, Semi-solid or Convalescent Diet.~--Composed of thick or cream soups, eggs, toast, cereals, custards, jellies and ice cream, and later vegetable purées, broiled birds, chicken, lamb chops, and rare beefsteak. ~Mixed Diet.~--The diet used in normal conditions and for those not affected by any special food. ~Special Diets.~--Those designed to be used for certain pathological conditions, such as scarlet fever, nephritis, etc. These diets are classified as follows: ~Milk Diet.~--A diet in which milk is the sole article of food. ~Carbohydrate-free Diet.~--One in which the sugars and starches are eliminated. ~Purin-free Diet.~--One in which the foods rich in purin bases are eliminated. This is used in gout, arteriosclerosis, etc. ~Salt-free Diet.~--Diet in which sodium chloride (salt) is as far as possible excluded. It is used in certain cases of nephritis when edema is present. ~Nephritic Diet.~--A diet used in nephritis and diseases complicated by nephritis (scarlet fever). In this diet the protein foods, meat in particular, are restricted, milk being the exception. ~Diabetic Diet.~--A diet in which the carbohydrates are restricted or eliminated. ~"Allen Treatment of Diabetes"~ consists chiefly of "starvation" for a given period and a reëducation of the organs to a toleration for carbohydrates. ~Emaciation Diets.~--Those containing a high percentage of fat-forming foods, such as milk, cream, eggs, cereals, potatoes, etc., olive oil. ~Obesity Diets.~--Those containing as few of the fat-forming foods as possible, such as cream, olive oil, potatoes, white bread, etc., pastry and desserts, candy and soda water, and containing lean meats, fish or shellfish cooked and served without butter or other fats, fresh or stewed fruit without sugar, green vegetables and salads served without oil or other fats; one egg a day two or three times a week, coffee and tea without sugar or cream, toasted gluten bread (1 slice) without butter, saccharine substituted for sugar. There are a number of other diets, but they come more or less under the above heads. THE TRAY As the patient's tray assumes an important part of the daily régime, it is necessary to give close attention to the arrangement and serving of it. There are certain definite rules to observe: (1) The linen, silver, glassware, china, and food must be absolutely clean. (2) The tray must be sufficiently large not to appear crowded. (3) The arrangement of the obligatory articles, such as salt and pepper, silver, water glass, napkin, etc., must be alike at every meal; this not only facilitates the service by making it easy for the nurse to see whether any of these necessary articles are left off, but it also enables the patient to find them without trouble. ~The Linen.~--The linen cover of the tray must be clean and uncreased. The napkin likewise must be clean and unwrinkled. The china must be free from chips and cracks. Care must be taken not to put a collection of odd pieces on the tray as it gives an untidy appearance. ~The Silver.~--The silver must be bright and in cold weather made slightly warm, as must also the china. The chill of cold silver may readily obliterate a fragile appetite, and to place hot food in cold dishes will deprive it of much of its palatability. The foods intended to be hot must be really hot, not warm, and those which are intended to be cold should be thoroughly chilled before being served to a patient. The placing of flowers on a tray is a questionable addition to it; a single flower laid across the folded napkin may add daintiness and attractiveness, but it is poor judgment to over-decorate, either with flowers or by garnishing the dishes. ~Arranging the Tray.~--If the nurse will place the necessary articles upon the tray and memorize their position so that she will be able to duplicate the same at each meal, she will be able to tell at a glance if everything needed is in its proper place, thereby saving herself unnecessary steps and the patient the worry of having to wait until they can be brought. Food should not be allowed to stand in the sickroom, and glasses or plates in which food has been served should be removed from sight as soon as the patient finishes with them. Care must be taken, however, not to create the impression of hurry or the patient will be made nervous and either will lose her appetite or have indigestion. The nurse should be careful of her topics of conversation during the meal hour. Especially must disagreeable subjects and business matters be rigidly excluded if the invalid is to obtain the full benefit of the food served her. 1. ~Setting the Tray.~--Tray should be sufficiently large not to give the appearance of being crowded, but not too large. 2. Tray cover must be spotless, and of a size to just cover the edges of tray; if too large, make a pleat down the center. 3. Place service plate directly in front of patient. 4. Knife, cutting edge in, to the right of plate; fork, tines up, to the left of plate. 5. Spoons, bowls up, next to the knife. 6. Napkin on the lower left side of tray, open edges to the lower right side. 7. Bread and butter plate on top of napkin. 8. Soup tureen in lower right corner, with cup and saucer above it. 9. Tea or coffee pot and hot water pot in upper right-hand corner of tray, with sugar bowl next to hot pot and cream pitcher next to sugar bowl. 10. Place salt and pepper next to cream pitcher (to the left). 11. Water glass in upper right corner of tray. 12. Second vegetable dish placed on the upper right side of dinner plate. 13. Place dessert to the upper left of dinner plate. ~Suggestions for Serving.~--Make tray as attractive as possible. In the cases requiring special diets, the nurse should make out the "diet sheet" for the day. In hospitals this is passed to the dietitian, who carries out the directions laid down by the physician. The nurse, however, should carefully check the tray before serving it, since mistakes sometimes occur, and to give the wrong food to a patient suffering from certain disorders may give rise to serious trouble, causing pain and discomfort and at times death. ~Contamination of Food.~--Food should always be protected from dirt and dust and from contamination and pollution from flies and other insects. Typhoid fever and certain intestinal disturbances have been known to result from flies coming in contact with raw food--milk, for example. Poisoning due to polluted water used to freshen vegetables has already been spoken of. All of these types of poisoning may be avoided by using care in the handling of the fresh foods. ~Ptomaines~, however, are not easy to prevent. Their source cannot always be traced to one particular article of diet. They may be present in cooked, raw, frozen, or canned foods. At times the evidence of extreme decomposition will be found in the foods themselves, while at other times there will be no such evidence in the food, but the result of the ptomaine will be perfectly evident whenever certain individuals partake of that food. This is a personal idiosyncrasy which it is impossible to account for. ~Food Poisoning.~--Poison caused by decomposed eggs has manifested itself in individuals who have partaken of cake in which such eggs were used. Canned meat and fish have produced the most violent types of ptomaine poisoning. As a rule in these cases the canned article has begun to decompose and while the decomposition may not have advanced sufficiently far to be discernible from the flavor or odor, it is there, and if the resistance of the individual eating this food is not great, serious danger may result. Poisoning develops in some individuals upon the eating of shellfish, strawberries, oranges, pimentos, and various other foods,--another evidence of personal idiosyncrasy against certain articles of diet. There is no way to overcome these idiosyncrasies; the only thing to do is to warn the individuals so affected to let the offending foods alone. ADULTERATION OF FOOD The adulteration of food, which formerly was practised by unscrupulous dealers to cover up inferior articles, or by manufacturers to prevent or arrest decomposition in canned goods, is regulated by law. The passage of the National Pure Food and Drug Act gave the Government authority to regulate the preservatives and coloring matter used in canned and bottled goods, forcing the manufacturers to state on the label the exact contents of each bottle or can. There are likewise stringent laws governing the adulteration of milk, butter, and other articles of food. ~Tests for Adulterants.~--Boric acid, borax, and formaldehyde are the preservatives more often found in milk. These chemicals are introduced to arrest the natural souring and decomposition which takes place after milk reaches a certain age. Occasionally salicylic acid and sodium carbonate are used. Formaldehyde may be detected by placing about 20 c.c. of milk in a small glass vessel or tube. Dilute with an equal amount of pure water, add commercial sulphuric acid, allowing it to flow gently down the inside of the tube. A purple ring will appear at the zone of contact if formaldehyde is present. "Boric acid and borax may be detected by adding a drop or two of hydrochloric acid to a few drops of milk in a white dish and then several drops of a saturated alcoholic solution of _turmeric_. The dish is then heated gently for a few minutes, and, if boric acid or borax is present, a pink or dark red color will appear. A dark blue-green should appear when the dish is cooled and a drop of ammonia added."[28] ~Canned goods~ must be carefully examined before being used. The domestic canned goods are rarely adulterated, but imperfect sterilization and defective cans may bring about a condition of fermentation and gas formation due to bacterial action. Cans should have a concave appearance on the top. If there is a bulging of the can it may be due to gas formation, and a small hole should be made in the can to note any escape of this gas. Should there be any indication of fermentation, the contents should be discarded. It is advisable to look with suspicion on cans that appear old, rusty, and soiled; they are probably left-over stock and liable to be bad. Peas which have been imperfectly sterilized produce a type of gas which is soluble in the liquid. After decomposition has occurred there will be no apparent evidence by the escape of gas, but the liquid will be found to be excessively acid, and will present a muddy appearance. Certain foreign importations of canned goods are preserved in color by the introduction of certain color preservatives. Peas--petits pois, for example--and the very small string beans which are imported are intensely green from the copper sulphate used. Its presence may be detected by adding a few drops of hydrochloric acid to some of the colored material, then dropping in a bright steel nail, knitting needle, or knife blade. There will be a deposit of copper salts (like copper plating) upon the steel if the preservative is present in the can. Canned corn is often artificially sweetened with saccharine, which may be detected by shaking several tablespoonfuls of the liquid in an equal amount of chloroform. Saccharine is soluble in chloroform, while sugar is not. Allow the mixture to stand a few minutes and remove some of the chloroform which has settled at the bottom. Place in a small dish, evaporate the chloroform by gently heating the dish; taste the residue; if sweet, saccharine is present. ~Coffee~ is adulterated more often when it is put up in ground or powdered form than when sold in the bean. Real coffee contains a small percentage of oil, and will float when thrown into a glass of water. Substitutes generally sink to the bottom. Coffee substitutes are often made up of starch-containing materials, such as cereals, beans and peas. This starch may be detected by mixing one tablespoonful of the suspected coffee in a little cold water, adding one cup of boiling water; allow it to boil two minutes, filter through cotton, and pass the liquid through charcoal to remove the color. When it is cold, add a few drops of dilute iodine solution. If starch is present, a blue color will appear. METHODS USED IN THE PREPARATION OF FOOD Food is prepared for consumption by a number of methods and the method by which the food is prepared either increases or decreases its digestibility, palatability, and general usefulness. Certain foods, as has already been stated, require a high degree of temperature to make them wholesome, but if this temperature is applied by means of heated fat, as in frying, the food is changed from a wholesome to a more or less indigestible article. In health the organs of digestion are capable of overcoming much of the harm wrought by wrong preparation, but even in the healthy, normal individual a steady diet of fried food will eventually undermine what is known as good digestion. In abnormal conditions (illness) frying is a method seldom, if ever, used. ~Preparation of Food.~--The various methods to which food is subjected in preparation for human consumption may be summed up as follows: boiling, simmering, steaming, baking, roasting, broiling, frying, sautéing. ~Boiling~ is cooking in water raised to the boiling point, 212° F. (sterilizing). This method is commonly used in the cooking of starchy vegetables and cereals, and in the cooking of green vegetables, such as spinach, carrots, beets, corn, asparagus, etc. Stewing is a form of boiling. As a rule water is used, and the vessel is left uncovered, so that as the food is cooked the surplus moisture evaporates, leaving the food tender. Dried fruits, such as prunes and apricots, are prepared by this method. ~Simmering~ is cooking in water, the temperature of which is not raised to the boiling point, but kept between 200° F. and 210° F. This method is used in the preparation of eggs and dishes in which eggs predominate, since proteins are made tough if subjected to a high degree of temperature. Coddled eggs, for example, are prepared by placing the egg in a clean vessel and pouring over it the boiling water, then covering the vessel and allowing it to stand for ten or fifteen minutes. The vessel and the cold egg reduce the temperature of the water to about 185° or 190° F. and in this way prevent a toughening of the albumen of which eggs are chiefly composed. Soups, broths, ragouts, etc., are prepared by this method. ~Steaming~ is cooking over hot water or by steam. This method may be accomplished on the top of the stove in a "double boiler" or in the oven in a deep covered pan fitted with a "rack" to hold the article to be cooked. Either method allows the vessel in which the food is placed to be surrounded by boiling water, but does not insure sufficient heat to raise the food within to the boiling point. ~Baking~ and ~roasting~ are both brought about in the oven. Bread, biscuits, pies and other pastry, potatoes, cakes, etc., are baked, while meats, roast of beef, lamb, veal, mutton, as well as chicken, turkey, duck, and large fish are roasted. The heat in the oven may be intense. The outside or cut surface of the meat is seared, the soluble albumens are coagulated, thus sealing the juices within. If the meat is placed in a pan surrounded by cold water and then placed in the oven, the juices are "drawn out" in the water. These juices contain the flavoring matter or extractives. Meat so treated is not so palatable or highly flavored as that which has first been subjected to intense heat, the water for the gravy added later. ~Frying~ and ~sautéing~ is cooking in hot fat. Food may be fried in deep fat, as is demonstrated in the cooking of croquettes, doughnuts, etc., or it may be sautéd in butter or oil in a shallow frying pan or griddle. The latter method is used in making hashed brown potatoes, for example; also in the cooking of griddle cakes, etc. ~Broiling.~--In broiling or grilling the article to be cooked is exposed to direct heat, either to the blaze or to a very hot surface. The result is the same as in roasting. The outer surface is seared, sealing the juices within. Meat to be broiled is generally cut thinner than that to be roasted. The article, whether it is meat (steak), chops, birds, or chicken, is placed about three inches away from the flames and turned frequently until the surfaces are seared, after which the article is placed in a cooler part of the stove to allow the interior to be cooked. Pan broiling is done on top of the stove. The article to be broiled is placed directly upon a very hot surface, there is no grease used and the meat must be turned frequently to prevent burning. ~Poaching.~--This term is applied chiefly to the cooking of eggs in a shallow pan of water heated just below the boiling point. To be properly poached an egg must be perfectly fresh, or the white and yolks will run together and present an unappetizing, unpalatable appearance. The following time-table should be used in the preparation of food to insure correct cooking: TIME-TABLE =================================+==========+======================= _Material_ | _Method_ | _Time_ ---------------------------------+----------+----------------------- Beef (fresh) | Boiled | 4 to 6 hours Corned beef | Boiled | 4 to 7 hours Shoulder or leg of mutton | Boiled | 3 to 5 hours Shoulder or leg of lamb | Boiled | 2 to 3 hours Fowl (4 to 5 pounds) | Boiled | 2 to 4 hours Chicken (3-lb. hen) | Boiled | 1 to 1-1/2 hours Ham | Boiled | 4 to 6 hours Lobster | Boiled | 25 to 30 minutes Salmon (whole) | Boiled | 10 to 15 minutes Vegetables: | | Asparagus | Boiled | 25 to 30 minutes String beans | Boiled | 1 to 2 hours Dried beans | Boiled | 1 to 2 hours Beets (new) | Boiled | 45 minutes to 1 hour Beets (old) | Boiled | 4 to 6 hours Beet greens | Boiled | 1 hour or more Brussels sprouts | Boiled | 15 to 20 minutes Cabbage (for creamed cabbage) | Boiled | 10 to 15 minutes Cabbage | Boiled | 30 to 80 minutes Cauliflower | Boiled | 1 to 1-1/2 hours Celery | Boiled | 2 to 2-1/2 hours Corn (green) | Boiled | 10 to 20 minutes Onions | Boiled | 45 minutes to 2 hours Oyster plant (salsify) | Boiled | 45 minutes to 1 hour Parsnips | Boiled | 30 to 45 minutes Peas | Boiled | 20 to 60 minutes Carrots | Boiled | 20 to 40 minutes Potatoes (white) | Boiled | 20 to 35 minutes Potatoes (sweet) | Boiled | 20 to 30 minutes Rice | Boiled | 20 to 30 minutes Squash | Boiled | 20 to 30 minutes Spinach | Boiled | 15 to 20 minutes Tomatoes (stewed) | Boiled | 20 to 30 minutes Turnips | Boiled | 45 to 60 minutes Coffee | Boiled | 3 to 5 minutes Beef (ribs or loin, rare) per | | pound | Roasted | 8 to 10 minutes Beef (ribs or loin, well done) | | per pound | Roasted | 12 to 15 minutes Beef (rolled, rare) per pound | Roasted | 12 to 15 minutes Beef (rolled, well done) per | | pound | Roasted | 15 to 20 minutes Leg of lamb per pound | Roasted | 10 minutes Leg of mutton per pound | Roasted | 15 minutes Mutton (stuffed, forequarter) | | per pound | Roasted | 15 to 20 minutes Lamb, well done, per pound | Roasted | 15 to 18 minutes Veal, well done, per pound | Roasted | 20 to 25 minutes Pork, well done, per pound | Roasted | 20 minutes Chicken, well done, per pound | Roasted | 15 to 20 minutes Turkey (8 to 10 pounds) | Roasted | 3 hours Ducks (domestic) | Roasted | 1 to 1-1/2 hours Ducks (wild) | Roasted | 20 to 30 minutes Small birds | Roasted | 15 to 30 minutes Large fish | Roasted | 45 minutes to 1 hour Fish steaks, stuffed | Roasted | 45 minutes to 1 hour Steak, 1 inch thick | Broiled | 6 to 12 minutes Steak, 1-1/2 inches to 2 inches | | thick | Broiled | 15 to 20 minutes Lamb chop or mutton chop | Broiled | 10 to 15 minutes Quail | Broiled | 12 to 20 minutes Squab | Broiled | 12 to 20 minutes Spring chicken (broiler) | Broiled | 20 to 40 minutes Shad | Broiled | 12 to 15 minutes Bluefish | Broiled | 12 to 15 minutes Bread (loaf) | Baked | 45 minutes to 1 hour Rolls (risen) | Baked | 20 to 25 minutes Biscuits | Baked | 10 to 12 minute Muffins | Baked | 20 to 25 minutes Sponge cake (loaf) | Baked | 45 to 60 minutes Layer cake | Baked | 20 to 25 minutes Cookies | Baked | 10 to 15 minutes Custards | Baked | 20 to 60 minutes Steamed brown bread | Steamed | 2 to 3 hours Pastry | Baked | 30 to 45 minutes Potatoes | Baked | 30 minutes to 1 hour Scalloped dishes | Baked | 20 minutes Steamed puddings | Baked | 1 to 4 hours Plum pudding | Baked | 2 hours (after | | steaming 10 hours) =================================+==========+======================= CARE OF ICE-BOX AND CONTENTS The ice-box plays an important rôle in the preservation of the health and comfort of the family, as well as that of the invalid. Therefore the first consideration is the cleanliness of it. The old-fashioned boxes were constructed without ventilation. This was clearly a mistake, since many foods absorb both the odor and flavor of the substances about them if allowed to stand for any great length of time in a closed compartment with them. The ice-boxes or refrigerators of to-day have a ventilation system which insures a circulation of air constantly throughout the interior of the box. The drain pipes require special attention, because no matter how clean the box itself is kept, the melting of the ice causes a slime to accumulate on the inside of the pipe which will clog it and become offensive unless it is flushed out often. This may be accomplished by pouring through it a solution made by dissolving one-half ounce of borax, washing soda, or ammonia in one gallon of boiling water. The adjustable part of the pipe can be removed and cleaned with a long brush made for the purpose. The pipe is then replaced and the boiling water poured through. In this way the entire drainage system of the box is completely cleaned. All loose bits of food which may drop from the containers to the floor and shelves should be carefully removed each day and the interior of the box and shelves thoroughly wiped out. Three times a week is sufficient to wash and flush the box and pipes unless milk, cream, or other food materials have been spilled, in which case it should be washed at once before it has an opportunity to sour or spoil and become offensive. Ice should always be washed off before being put in the box, and all milk and cream bottles should likewise be wiped with a clean wet cloth before being placed on the ice. Hot food must never be put in the ice-box, as the heat from the food will raise the temperature of the air in it. In some cases the sudden chilling of the food itself is undesirable, but this is not so often the case. However, the best results are obtained by first allowing the food to cool, and then placing it on ice. This is particularly the case with jellies made from gelatin. Milk and milk products, cream, butter, buttermilk, cheese, etc., meat, fish, and, at times, eggs should be kept in a refrigerator or in a cold place such as the cellar in the country, when it is impossible to procure ice. Broths of all sorts, beef juice, and meat jellies will sour and decompose unless kept close to the ice. Carbonated waters, such as Vichy, Apollinaris, White Rock, etc., as well as champagne and other sparkling wines, must be kept in a dark, cool place, lying on the side. It is better to put only one or two bottles on the ice at a time, since the wine flattens (loses its sparkle) if it is ever allowed to become warm after once being placed on ice. Koumiss and other fermented milk products must be treated in a like manner to assure having them served at their best. RULES GOVERNING SELECTION OF FOOD There are certain fundamental rules to be observed in the selection of our food materials, whether they are intended for those in health or for those suffering from pathological conditions. These rules are definite and obligatory. All food materials must be of good quality; that is, they must be of known purity and cleanliness, and adulteration should not be tolerated. In health the small amount of preservative used in certain canned and bottled foods would probably have little if any effect on the individual, but in sickness this is not always the case. With regard to milk, this point has particular significance. To obviate danger, the nurse should use discrimination in the selection of the dealer from whom the meat, milk, eggs, fruit, and vegetables are purchased, as well as the grocer who supplies the remainder of the food materials used by the patient. THE CARE OF FOODS AND UTENSILS The next point of consideration is the care of the food materials. This is quite as important as the selection, for even the best of food may be ruined by careless handling, not only in the preparation, but likewise during the period before it is prepared for the invalid's consumption. The rules governing the handling of food materials before they reach the consumer are subject to inspection by law, but the housekeeper or nurse has no such rules to guard or govern her; hence she may be wantonly careless or ignorantly unsanitary unless taught the right way to care for the food in her charge. Perishable fruits and vegetables must be kept in a cool place to preserve their freshness. ~Method of Washing Dishes.~--Cleanliness must be observed in the care of all food materials and the utensils in which they are to be prepared. If the nurse will observe the scientific rules governing the solubility of the foodstuffs, she will be able to save herself much time and trouble. For example, it is a known scientific fact that starch is insoluble in cold water and more or less soluble in boiling water, hence it would be a useless waste of time to try to wash a utensil in which a starchy food has been cooked in cold water. Fats solidify under the influence of cold and melt under the influence of heat, so that hot water should be used in conjunction with soap or an alkali to remove grease from dishes and silver and utensils. Albumens are soluble in cold water and are coagulated in hot, therefore to remove milk, egg white, and like protein substances from glasses, spoons, etc., it is advisable to soak first in cold water to wash out the food material, and then to wash thoroughly in hot soapsuds to cleanse and polish. The dishcloths used in the washing and drying of dishes and kitchen utensils should be washed after using in hot soapsuds, rinsed in clear water, then dried in the sun. When this is impossible, they should at least be hung in the fresh air to make them sweet and clean before the next using. In contagious diseases the care of the utensils and dishes used by the patient is of the utmost importance. They should be thoroughly sterilized before being placed with those used by the rest of the family, otherwise the disease may be communicated to the unaffected members. A word about the handling of glasses and spoons used in administering medicine in the sickroom: It is advisable when possible to keep these separate from those used on the tray, as many medicines have a very lasting and disagreeable taste, which is more than apt to cling to the spoons or glasses in which they are measured and in turn be communicated to the food, making it distinctly unpalatable. This has been found to be the case with asafetida, valerian, ichthyol, etc. METRIC MEASURE The metric system is a system of weights and measures expressed in the decimal scale. The principal units with which we are concerned are: The liter--L. Cubic centimeter--c.c. The gram--gm. Centigram--cgm. Milligram--mgm. These units have prefixes to show how they are divided decimally, _i.e._: deci.--0.1 centi.--0.01 milli.--0.001 UNITS OF WEIGHT 10 milligrams = 1 centigram (cgm.) 10 centigrams = 1 decigram (dgm.) 10 decigrams = 1 gram (gm.) 10 dekagrams = 1 hektogram (hgm.) 10 hektograms = 1 kilogram (kilo.) 1000 kilograms = 1 metric ton A cubic centimeter of water weighs 1 gram; 28.35 grams = 1 ounce. A liter of water weighs 1 kilogram; 1 kilogram of water = 2.2 lb. HOUSEHOLD WEIGHTS AND MEASURES 4 saltspoons = 1 tsp. 3 tsp. = 1 tbs. 4 tbs. = 1/4 cup or 1/2 gill 8 tbs. = 1/2 cup or 1 gill 16 tbs. = 1 cup or 1/2 pint = 8 oz. = 227 gm. 2 cups (c.) = 1 pint = 454 gm. 2 pints (pt.) = 1 quart (qt.) = a little less than 1 liter 4 qt. = 1 gal. 2 tbs. butter = 1 ounce (oz.) 2 cups butter (solid) = 1 pound (16 oz.) 2 cups granulated sugar = 1 pound 2-1/2 cups powdered sugar = 16 oz. = 1 lb. 4 cups flour (sifted) = 16 oz. = 1 lb. 1 pt. milk or water = 16 oz. = 1 lb. 1 pt. chopped meat = 16 oz. = 1 lb. 10 medium size eggs = 1 lb. (with shells) 8 eggs, without shells = 1 lb. 2 cups rice = 1 lb. 4 tbs. butter = 2 oz. = 1/4 cup 2 tbs. sugar = 1 oz. 4 tbs. flour (sifted) = 1 oz 4 tbs. coffee (powdered) = 1 oz. 2 tbs. powdered lime = 1 oz. 2 tbs. lemon juice = 1 oz. 2 tbs. orange juice = 1 oz. 1 glass orange juice = 8 oz. or 1/2 pint 2-2/3 cup oatmeal = 1 lb. 4-3/4 cup rolled oats = 1 lb. 28.35 grams = 2 tablespoons = 1 ounce of the following substances: arrowroot, barley flour, brandy, butter, grape juice, lemon juice, orange juice, molasses, cream, dry peptonoids, liquid peptonoids, milk (whole, skimmed), buttermilk, malted milk, rice flour, oatmeal, olive oil, wine. Materials requiring 3 tablespoons to weigh 28.35 gm. or 1 oz.:--corn meal, farina, gum gluten flour, Graham flour, white flour. Material requiring 4 tbs. to weigh 1 oz.: cocoa. The standard measuring cup holds 8 ounces or 16 tablespoonfuls. 1 ordinary glass (water) = 8 ounces 1 coffee cup = 8 ounces 1 tea cup = 6 ounces 1 wine glass = 2 ounces The following list shows the approximate weights and measures of the foods comprising dietaries: Asparagus, 8 stalks, E.P. = 2 ounces Apple (1 medium size) = 5 ounces Bread, 1 slice, home-made, 4 in. × 3-1/2 in. × 1/2 in. = 1 ounce Bread, 1 slice, baker's, 4 in. × 3-1/2 in. × 3/4 in. = 1 ounce Bread, 1 slice, whole wheat, 2-1/2 in. × 2-3/4 in. × 1/4 in. = .7 ounce Bread, 1 slice, corn, 3 in. × 3 in. × 1/2 in. = 2 ounces Bread, muffin, 1 small, or biscuit = 1/2 ounce Banana, 1 medium size = 5 ounces Chicken, 1 serving = 3 ounces Chicken (creamed) 2 tbs. = 1-1/2 ounces Cream, 2 tbs. = 1 ounce Custard (soft, 1/2 cup) = 4-1/2 ounces Custard (baked, 1/2 cup) = 4 ounces Cream (ice, 1/2 cup) = 4 ounces Custard (rice, 1/2 cup) = 3-1/2 ounces Dates (3 medium size) = 1 ounce Eggs (scrambled, 1/4 cup) = 2 ounces Eggs (poached, 1 egg) = 1-1/2 ounces Fish, medium serving, 2-1/2 in. × 3 in. = 2-1/2 to 3 ounces Honey, 4 tsp. = 1 ounce Hominy (cooked, 1/2 cup) = 4 ounces Lamb chop, E.P., 2 × 2 × 1/2 inch = 1.6 ounces Lemon or other jellies, 1/2 cup = 3.8 ounces Steak (sirloin), 3 × 1/2 × 3/4 in. = 3 ounces Vegetables: Beets, 1 medium size (4 slices) = 2 ounces Carrots, 1/3 cup diced = 2-1/2 ounces Peas (canned or drained), 1/3 cup = 3 ounces Potatoes, baked, sweet, 1 medium size = 6 ounces Potatoes, baked, white, 1 medium size = 3 ounces Spinach, cooked, 1 serving, 1/2 cup = 4 ounces Tomatoes, 1 medium size--fresh = 3 to 4 ounces Soups: Cream, 1/2 cup = 4 ounces Clear soup, 1 cup = 7-1/2 ounces PERCENTAGE CALCULATION A percentage of a number is the result obtained by taking the stated number of hundredths of it. The rate per cent. is a fraction whose denominator is 100 and whose numerator is the given number of hundredths; thus 6% of a number is 6/100 of that number. The method of figuring the per cent. of foodstuffs in a food material is simple. Milk, for example, has a percentage composition of 3% protein, 4% fat, and 5% sugar. To find the definite amounts of these foodstuffs in 1 ounce of milk it is best to reduce the ounce to grams, since the gram is the unit of measurement generally used. 1 ounce = 28.35 grams In 1 oz. there will be 28.35 × .03 = 0.85 gram protein In 1 oz. there will be 28.35 × .04 = 1.13 grams fat In 1 oz. there will be 28.35 × .05 = 1.41 grams sugar THERMOMETRY There are two scales used in thermometry, the Fahrenheit and the Centigrade. The former is generally used. However, since many of the scientific calculations are made using the Centigrade scale it is wise for the nurse to understand how to translate one to the other. Centigrade has 0° as the freezing point and 100° as the boiling point, while Fahrenheit has 32° as freezing point and 212° as boiling point. To change Fahrenheit to Centigrade it is necessary to subtract 32 from 212 in order to make the freezing points correspond. This would read 212-32 = 180° F. = 100° C; hence a degree Centigrade represents 5/9 of a degree Fahrenheit. To change Centigrade to Fahrenheit it is necessary to remember that every Fahrenheit degree is 9/5 times as large as the Centigrade and the addition of 32° must also be made. For example: Change 105° F. to Centigrade: 105°-32° × 5/9 = 41° C. Change 50° C. to Fahrenheit: 50° × 9/5 + 32° = 90° + 32° = 122° F. FOOTNOTE: [28] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot. CHAPTER V FOOD MATERIALS AND THEIR PREPARATION ~Dairy Products.~--Milk, cream, and other dairy products form such an important part of the invalid dietary that they require especial care in their selection. "Certified Milk" is the safest. This is protected by special inspection. The methods and standards governing the production and distribution of certified milk were adopted by the American Association of Medical Milk Commissions, May 1, 1912. The sanitary condition of the dairy, the cleanliness of the vessels into which the milk is placed, the health of the milkers, and a surety that no member of their family with whom they come in contact has any kind of contagious disease, are all obligatory. The feed for the cows and the purity of the water given them to drink must be inspected and made to conform to the standard laid down for certified milk. The milk of sick cows and those having tuberculosis is absolutely condemned. The composition of certified milk is standardized as follows: the fat standard shall be 4%, with a permissible range varying from 3.5% to 4.5%. The proteins shall be 3.5%, with a permissible range varying from 3% to 4%. Certified milk shall not contain more than 10,000 bacteria to the cubic centimeter when it is delivered. This inspection and standardizing necessarily raises the price of certified milk above that of milk not so rigidly cared for, and when the additional expense makes it impossible for the patient to afford certified milk, the only thing to do is to be sure of the reliability of the dealer from whom the milk is purchased and the cleanliness of the dairy from which it is procured. Buttermilk and butter are the milk products which require some attention as to selection. The former grows sour with age and the odor of advanced fermentation and decomposition is readily recognized. Sweet butter, butter without salt, is less apt to be old when purchased than the salted variety, as the flavor of rancid fat is unmistakable in butter which has not been especially treated. ~Milk.~--Milk is without a doubt the most valuable food in the invalid dietary, furnishing not only a highly nutritious beverage, but likewise acting as a carrier of additional nourishment when such is necessary. Its form, its lack of definite flavor and odor, all add to its value as a food in sickness. Milk is one of the few foods which includes in its composition all of the chemical combinations known as foodstuffs. The carbohydrates, comprising 4.88% to 5% of the solids in milk, occur as lactose or milk sugar. This sugar belongs to the disaccharide group, and is, in the majority of cases, readily digested by even the most delicate digestive apparatus. This form of sugar lends itself particularly well as a reinforcing agent, and is generally used in such cases as typhoid fever, etc. The fat in milk, comprising 4% of the solids and occurring as butter fat (cream), is made up chiefly of olein and of palmitin, with smaller amounts of stearin and from 5% to 6% of its composition in the form of butyric acid (the fatty acid to which butter owes its name and flavor) and traces of other fatty acids, as well as small quantities of cholesterin, lecithin, and a yellow coloring matter. The proteins of milk, which form the curd or larger part of the solids, according to Van Slyke[29] are in the form of casein and albumen. There are 3.6 parts casein to 1 part soluble proteins, but these figures vary somewhat at times. Casein is insoluble in pure water, but dissolves readily in water to which an alkali or calcium carbonate is added. The soluble protein in the form of lactalbumen is one of the constituents of whey. This substance contains more sulphur than does casein, but no phosphorus. ~Whey~ is the opalescent fluid which remains when the casein is precipitated, and is composed of water 93.8%, total ash 0.44% (König). ~Mineral salts~, 0.7% of milk, are made up of calcium, potassium, sodium, magnesium, iron, sulphur, phosphorus, and chlorine. Milk is so rich in calcium that it requires only 400 c.c. (or about 2-1/2 cups) to furnish 1 gram of calcium. This is the amount believed to be necessary for the welfare of man each day and this must be derived from food.[30] ~Water.~--The fluid part of milk is composed chiefly of water, constituting 87% of whole milk. Milk as a food for infants will be discussed in another chapter. As has already been said, no food has so far been discovered which could be effectually substituted for milk. There is no food, however, which requires more attention in its selection and care. It is very susceptible to both odors and flavors, absorbing them both readily, as will be found if milk be placed in the same compartment with foods of strong odor and flavor, without being properly covered and protected. This is particularly noticeable with cucumbers, melons, etc. Milk also furnishes a splendid medium for bacterial growth, and if left exposed to the air, put into unclean receptacles, or kept in a warm place, will immediately become more or less contaminated, after which it is unwise to use it. Sterilization and pasteurization will in a measure overcome the bacterial contamination, but milk purchased from a dairy which is not clean or milked under unsanitary conditions will remain dirty, hence unfit for human consumption. When the morning's milk supply is brought to the house it should be in clean, well-stoppered bottles, but before placing it in the ice-box the tops of the bottles should be carefully wiped off with a wet cloth to remove any superficial dust which may be adhering to them. Every time a portion of the milk is removed thereafter the tops should be again cleansed before the milk is poured out. This is a wise precaution, and often prevents contamination from the hands, etc. The amount of water in milk prevents its being an adequate food for adults except in certain pathological conditions. However, it furnishes a supplementary food unequaled by any other beverage known. There are fortunately only a few individuals who are unable to drink milk. There are many who fancy they cannot do so, but if the nurse has the ingenuity to utilize some of the various methods whereby milk is made more digestible, it will generally be found that the patient can take it without trouble. In cases of personal dislike, if the milk is flavored or colored or made up into soup, cocoa, chocolate, junket, custards, blanc-mange, etc., it will usually prove acceptable. ~Application of Heat.~--A word as to the changes which are brought about as the result of heat as applied to milk. These changes are demonstrated in the two methods commonly used in the preparation of milk known as "pasteurization" and "sterilization." Pasteurization is rather an indefinite term to use, unless the time and the temperature to which the milk is subjected are given. According to Morse and Talbot "the term sterilization should never be applied to the processes used in the preparation of milk for the feeding of infants, because the milk is never rendered bacteriologically sterile by them."[31] As a rule the flavor and odor of milk are not changed by heat until the temperature reaches nearly to the boiling point. A scum then forms on boiling milk, composed of casein 50.86%, fatty matter 45.42%, ash 4.72% (Rosenau). Prolonged boiling changes the color of milk from a creamy white to a yellowish brown which deepens with boiling. This is due to the caramelization of the milk sugar. Cream will not rise (or its rise will be very slow) on milk which has been subjected to a temperature of 150° F. for thirty minutes or more because the fat droplets are broken down so that they cannot hold together at that temperature and become more completely distributed throughout the fluid.[32] ~Pasteurization~ is acknowledged to be preferable to sterilization in milk used for infant feeding because the higher the temperature the greater the change in the chemical composition of the fluid. According to Morse and Talbot[33] the temperature of the pasteurization should be as low as possible. Pasteurization at 140° F. for 20 minutes is sufficient; lower temperatures are not. "At this temperature there is no change in the taste, odor, or color of the milk, no noteworthy changes in the chemical composition are produced, the ferments and bactericidal action are unaffected and bacterial toxins and non-spore-bearing microorganisms are destroyed."[34] Rosenau[35] states that the bacillus of typhoid, diphtheria, and dysentery, as well as the cholera vibrio and other pathogenic non-spore-bearing bacteria which are often found in milk, are destroyed at a temperature of 140° F. for twenty minutes, and at higher temperatures for shorter lengths of time. Sommerfield's[36] investigations prove that butyric acid bacilli are destroyed at a temperature of 212° F. for from 1 to 2 minutes. It must be understood that no matter what method is used to insure purity in milk, nothing does away with the necessity for keeping the milk both clean and cold. The receptacles in which the milk is allowed to stand, the vessels in which it is measured, and the person who handles it must be absolutely clean, and the nurse must keep in mind the fact that pasteurization does not completely destroy the bacterial growth in milk, that it merely diminishes it, and she must see that the milk which has undergone the pasteurizing process is kept cold, otherwise the microörganisms which are present, even if to a less extent than in raw milk, will undoubtedly multiply. ~Adulteration of Milk.~--There is not nearly so much adulteration of milk to-day as there was a few years ago. The stringent laws governing the care and composition of the milk make it unprofitable for the dairymen to practise it. However, there are times when such things are done and care must be taken to prevent it. Milk is, as has already been stated, very susceptible to contamination, and that which is infected with putrefactive bacteria is not fit for food even if the dealer has doctored it with formaldehyde. However, the danger to-day is not so much from drugs as from lack of care in the handling of the milk. It is well to remember, however, that water is an adulteration just the same as formaldehyde and perhaps more pernicious, since the quantities of the latter are so small in an ordinary quantity of milk as not to make a great deal of difference except in the feeding of invalids and children, while watered milk is a swindle not only to the pocketbook but to the body also, since the requisite nutritive value is lacking. ~Selection and Care of Milk.~--There are a few essential facts to keep in mind in regard to milk: (1) Be sure of the source of the milk supply, especially in the feeding of the sick and of infants. Milk for such cases should always be purchased from inspected dairies when it is possible. (2) Keep the milk cold; the best milk in the world will spoil if left in a warm place. (3) Always keep the milk bottle well covered, thus eliminating the danger of contamination, flies, etc. ALBUMINIZED MILK _135-152 calories_ 6 ounces (3/4 glass) fresh whole milk. 1-2 eggs (whites only). Have the milk thoroughly chilled. Clip egg whites with scissors and strain through cheesecloth to remove stringy parts. Now stir into the milk with a fork. If patient does not object to foam, the mixture may be placed in a milk shaker with pieces of ice and shaken until creamy, then poured over cracked ice. ALBUMINIZED MILK SHAKE _135 calories_ 6 oz. (3/4 glassful) fresh whole milk 1 egg white Place the milk on ice to become thoroughly chilled. Clip the egg white with scissors and strain through cheesecloth to free it from strings; stir into cold milk. If patient does not object to foam, the milk and egg whites may be placed in a milk shaker, and agitated for 4 or 5 minutes, then poured over cracked ice. This beverage may be flavored to suit the taste of patient. Vanilla, caramel, or coffee may be used to give variety. To add additional nourishment 1 teaspoonful of Sanatogen, or Plasmon may be added, or 1 tablespoonful of Panopepton or liquid peptonoids used instead of the casein products. MILK AND GINGER ALE (OR SARSAPARILLA) _59 calories_ 3 oz. milk 3 oz. ginger ale or sarsaparilla Pour into a milk shaker and shake with cracked ice until foamy. MILK PUNCH _298 calories_ 4 oz. rich milk 2 oz. cream 1 tbs. whisky (or sherry) 1 tbs. sugar (or less) 1 egg white (if additional nourishment is desired) A grating of nutmeg on top. Place ingredients in shaker as directed above, and shake a few minutes to thoroughly mix ingredients. Pour over cracked ice, grate nutmeg or cinnamon over the top. The milk may be peptonized if necessary, using 1/2 tube of Fairchild's peptonizing powder. PEPTONIZED MILK _314 calories_ 1 pt. of milk 1 tube of (Fairchild's) peptonizing powder Dissolve the powder in 1 gill of cold water, and place in a clean quart jar (glass). Pour in 1 pint of cold milk and stop the bottle with cotton, shake well and place the bottle in a saucepan containing water just warm enough to allow of the hand being immersed without being burned (115° F.). Keep the water at this temperature for 5 to 10 minutes or longer according to the degree of peptonization desired. Lift out of the warm water and plunge into cold, then place at once on ice. The milk may be poured from bottle into a clean saucepan and brought quickly to a boil to prevent further peptonization; this process, however, is apt to make the milk very bitter and should not be used unless it is to be flavored with fruit juice. PEPTONIZED MILK PUNCH _212 calories_ Take a goblet about one-third full of finely crushed ice, add a tablespoonful of St. Croix rum, a dash of curaçao or any liquor that is agreeable to the taste; fill the glass with "specially peptonized milk," stir well, and grate a little nutmeg on top. Add 1 tablespoon sugar. BUTTERMILK (BULGARIAN) _627 calories_ 1 qt. fresh whole milk (or skimmed if desired) 1-1/2 to 2 oz. (Bulgarian) starter, or 1 buttermilk tablet[37] If latter is used dissolve tablet in 1 gill of cold water. Stir the buttermilk starter into the cold milk and place in a one-half gallon glass jar, place the cover on loosely and allow the jar to stand for 12 hours or until the milk is well clabbered. (Insert a thin-bladed knife close to the jar so that the rest of the milk is not disturbed to see if the coagulation is complete.) When this is accomplished place the jar in the ice-box. After the milk has become thoroughly cold, beat thoroughly. The mixture is like any well-made buttermilk. If the cream is removed before adding the culture the milk will be lower nutrient value, but in many cases this is necessary since it is often the fats which cause a disturbance. COCOA _147-166 calories_ 2 tsp. cocoa 1-2 tsp. sugar 1/2 cup boiling water 2/3 cup milk Mix cocoa and sugar together and add boiling water slowly. Boil 3 to 5 minutes; heat milk in double boiler and add cocoa mixture. Beat with Dover egg beater to distribute cocoa and prevent scum forming. Serve with or without whipped cream. Cocoa may be reinforced as directed in "broths" with albumen or the whole or yolk of one egg well beaten. If the white alone is used, care must be observed that the liquid is not hot enough to coagulate the albumen. Proprietary foods and casein preparations are used in like manner. PLAIN JUNKET _161 calories_ 2/3 cup milk 1/2 junket tablet 1/4 tsp. vanilla extract or a grating of nutmeg 1 tbs. sugar Heat milk to 100° F. Add junket tablet dissolved in 1 tbs. cold water. Mix in sugar and flavoring, and pour into molds to jelly. When junket becomes firm, place in ice until needed. JUNKET ICE CREAM _428 calories_ 1/2 cup each cream and rich milk 1 junket tablet 2 tbs. sugar 1/2 tsp. vanilla Heat cream and milk to 100° F. and proceed as in junket. When mixture is jellied turn into freezer, as any ice cream. This is the most wholesome of ice creams and especially suited for children and patients who have tuberculosis complicated with gastric disturbances.[38] PLAIN VANILLA, LEMON, OR ALMOND ICE CREAM WITH OR WITHOUT EGG WHITE[39] _585-602 calories_ 1 cup thin cream 2 tbs. sugar (more if desired) 1/2 tsp. vanilla, lemon extract, or almond extract Method I. Whip cream, add sugar and flavoring, and freeze. Method II. Scald half the cream and cool. Whip the remaining half, add sugar and flavor and freeze. Method III. Make "boiled custard," as directed, add one-half the amount of cream and freeze. To reënforce ice cream:--Add 1 or 2 egg whites, beaten or unbeaten; these may be added in the beginning, or after the mixture begins to freeze. A tablespoonful of maple sirup, caramel sirup (1 tbs. sugar melted and browned and dissolved in 1 tbs. boiling water), or chocolate sirup may be poured over the ice cream to vary the flavor. Make chocolate sirup by boiling 2 tbs. water, 1 tbs. sugar, and 1 tbs. chocolate to a sirup. 143.3 calories. FROZEN CUSTARD _289-329 calories_ 1 egg (or 2 yolks) 1 tbs. sugar 1/8 tsp. salt 1 cup of milk Few drops of vanilla Prepare as soft custard, freeze. LACTONE BUTTERMILK _627 calories_ 1 qt. fresh milk 1 gill cold water 1 lactone tablet (or 1-1/2 oz. buttermilk starter) (Parke, Davis & Co.'s and Hanson & Co.'s buttermilk tablets are practically the same.) Dissolve tablet in cold water and stir into fresh milk (which may or may not be skimmed, according to the directions of the physician, but the finished product is more palatable using whole milk). Pour into a clean jar or wide-mouthed bottle; plug with cotton or close not tightly, allow to stand in room temperature 70°-75° F. 24 hours, shaking the bottle occasionally to keep the cream from rising. At the end of this time pour the milk out (if sufficiently fermented), and beat briskly for 5 to 6 minutes with egg beater or with churn; place on ice until ready to serve. MALTED MILK (1) _77-96 calories_ 1 tbs. malted milk 1-2 tsp. sugar 6 oz. boiling water 1/4 tsp. salt 3 to 5 drops vanilla Heat water to boiling and mix malted milk (Horlick's) with a little cold water. Stir into the boiling water, add sugar and salt, and serve with or without cream. MALTED MILK (2) _107-155 calories_ 1/2 to 1 tbs. malted milk 3 oz. each milk and water 1-2 tsp. sugar 1/4 tsp. salt Proceed as above. MALTED MILK CHOCOLATE OR COCOA _230-300 calories_ 1 tbs. malted milk 1 tbs. cocoa or grated chocolate 6 oz. milk 2 oz. water 1-2 tsp. sugar 4-5 drops vanilla extract Mix cocoa or chocolate with water and boil 2-3 minutes. Pour milk into a double boiler and heat, mix malted milk with a little water and stir into the hot milk, add the cocoa paste, sugar, and vanilla, mix thoroughly, beat the mixture briskly to mix ingredients thoroughly, and serve with or without cream. ~Milk or Cream Soups~ MILK OR CREAM SAUCE FOR SOUPS _599-1229 calories_ 2 tbs. flour 2 tbs. butter 1 pt. milk or thin cream 1/2 tsp. salt Cream butter and flour to a smooth paste, heat milk in double boiler on an asbestos mat over the flame; when it is scalding hot, stir in the butter and flour paste, stir until smooth and the mixture begins to thicken, cover and allow to cook without boiling for 15 minutes; strain. The sauce may be used at once or put into a glass jar in the ice-box until needed. CREAM OF ASPARAGUS (1) _213 calories_ 2/3 cup cream sauce 1/3 cup asparagus purée Heat sauce and purée in separate saucepans, and when about ready to serve, stir them together, strain carefully, season with salt, and serve with or without croutons of toast or whipped cream. If the sauce is made from the cream instead of milk, the fuel value will be much higher (302.7 calories). CREAM OF ASPARAGUS (2) _216 calories_ 8 medium stalks of asparagus 1 qt. water 1 tsp. salt 1 tbs. flour 1/2 cup cream sauce Cut off the tips of the asparagus in 1-inch pieces, and place with the rest in a saucepan, and cover with water; add salt and cook until the tips are tender; lift out and put aside to be used instead of the toast croutons. After the water in which the asparagus is cooked is of sufficiently strong flavor, strain and add the extra spoonful of flour, mixed in a tablespoonful of water; cook 15 minutes, measure 1/2 cupful, and proceed as directed above. CREAM OF POTATO _259 calories_ Boil and cream the potato. Make sauce and add potato purée; stir until well blended and serve with toast croutons. When boiling potato if a sprig of parsley is added and strained out, and a little of the potato water is used to make the purée smooth, the soup will have more character. CREAM OF SPINACH, CELERY, PEAS OR CARROTS _224-461 calories_ 3/4 cup cream sauce 1/3 cup vegetable purée Proceed as in making other cream soups. OYSTER SOUP _179 calories_ 6 oysters 1 cracker (soda) or 8 oyster crackers 3/4 cup milk 1/4 tsp. salt A dash of pepper Put oysters (and their liquor) into a saucepan, and heat gently; skim thoroughly. Heat milk in separate pan; when very hot add to oysters. Roll the cracker and add to soup just before it is served. Add salt and pepper at the same time. ~Eggs~ ~Eggs.~--The table shows eggs to have a chemical composition of water 73.7%, protein 14.8%, fat 10.5%, and mineral salts (ash) 1.0%. Fuel value per pound, 672 calories. The white of the egg, constituting 57% of the entire weight, is composed chiefly of albumen and water with a small percentage of mineral salts in the form of calcium, potassium, magnesium, sodium, phosphorus, chlorin, sulphur, and iron. Typical albumens are always rich in sulphur, and in eggs the sulphur content is much greater in the egg white than it is in the yolk. The yolk of eggs contains more protein and fat than the white, and less water. The protein of the yolk is chiefly in the form of ovovitellin, while the fats occur as palmitin, olein, and stearin. There is also 5% of coloring matter in the yolk of eggs besides lecithin, nuclein, salts of iron, potassium, magnesium, and phosphorus. The latter mineral salt comprises 1.0% in yolk, while in the white there is only .03%. Eggs have a position in the invalid dietary second only to that of milk. They are nutritious, easy of digestion, and exceedingly palatable if properly selected and correctly prepared. The albumen in the white is very susceptible to the effect of heat. At a temperature of about 135° F. the clear, pale yellowish white begins to change to an opalescent tint, and, as the temperature is gradually increased, the texture changes from a viscid, sticky substance to an opaque, jelly-like mass which solidifies with an ever increasing temperature. Hard cooked white of egg, unless it is very finely divided, is considered difficult of digestion, but if the heat is applied gradually and is not raised to the boiling point (212° F.) there is no reason why the hard cooked white of the egg should not be digested. However, it is unwise to cook eggs in this manner for invalids or children. Any of the other methods, with the exception of frying, which should never be used, is decidedly preferable. Egg albumen is soluble in water and fresh fruit juices, so that it may be used with great success as a reinforcing agent. In fact, the whole egg may be so used, but it is more difficult to disguise the yolk in a beverage than it is the white, and for this reason it is not so adaptable in many cases. Eggs may be cooked by the following methods in the invalid dietary: coddled, soft-cooked, poached, creamed, omelet, scrambled, or in custard. Uncooked eggs may be given in water, milk, wine, or fruit juices. The selection of eggs is equally as important as the selection of other foods. There are "new-laid eggs," "fresh eggs," and just "eggs." The latter are generally storage and should not be used for the sick or for infants. As a rule old eggs will not stand poaching, the whites and yolks mingle and form an unappetizing mass. It does not make any difference whether the color of the shell is white or brown; if the egg is absolutely fresh the white and yolk should be distinct and easily separated, and when they are not it is safer to discard the egg entirely. ~Fruit Beverages~ ORANGEADE _118 calories_ Juice of 1 orange 1 tbs. sugar Juice of 1/2 lemon Enough water to fill the glass Sweeten the juice of orange and lemon and pour into a glass filled with crushed ice. Fill glass with plain or carbonated water. ALBUMINIZED ORANGEADE _152 calories_ Make orangeade as directed in above recipe, without the addition of water. Break the whites of 2 eggs into a saucer and with scissors cut the albumen until free from membrane and strain, stir this into the orange juice and add several pieces of cracked ice. This is both nourishing and palatable, and the taste of the egg cannot be detected. ALBUMINIZED LEMONADE _107 calories_ Juice of 1 lemon 1 tbs. sugar Whites of 2 eggs Cut as directed for Albuminized Orangeade. Mix until sugar is dissolved. Pour over a glassful of cracked ice. Fill glass with plain or carbonated water. PINEAPPLEADE _151 calories_ 2 oz. (1/4 cup) grated pineapple 8 oz. (1 cup) cold water, or sufficient quantity carbonated water to fill glass Juice of 1 lemon 1 drop of lemon extract or a little of the peel, grated 1 tbs. sugar Mix lemon juice, water, and pineapple together; add sugar, if not sweet enough, but the less used the better, in all beverages. Add extract and pour into a shaker with a few lumps of ice. Shake well to mix ingredients and pour the pineapple over crushed ice. If this proves too much at a time, make half the recipe. Serve in tall thin glasses holding from 4 to 6 ounces after the ice is put in, or serve in punch glasses with small spoons. ALBUMINIZED GRAPE JUICE Albuminized Grape Juice is made without the addition of lemon juice unless the white grape juice is substituted for the black, in which case add one or two teaspoonfuls to relieve the flat taste and proceed as in Albuminized Orangeade, using 3 oz. of grape juice. EGG WHITE AND MINT _57 calories_ 1 egg 2 tsp. sugar 1 tsp. lemon juice Several sprigs of fresh spearmint Whip white of egg; add sugar and lemon juice. Crush lower parts of mint leaves slightly and place in glass. Pour mixture over ice in glass; stir well and serve at once. Fill glass with carbonated water, Vichy, White Rock, Apollinaris, etc. This is especially good when patient suffers from nausea. CREAM, EGG AND VICHY _232 calories_ 1 egg white 2 tsp. sugar 3 oz. (6 tbs.) cream A few drops of vanilla extract Celestine (French) Vichy to fill glass Whip egg white to stiff froth; whip cream stiff and sweeten, add vanilla; lastly, the egg. Pour over cracked ice and fill up the glass with Vichy. COFFEE 2 tbs. ground coffee 2 tsp. white of egg 1 cup boiling water 1/4 cup cold (boiled) water Mix coffee with 1 tablespoonful of cold water and egg white in small pot (after scalding pot), add boiling water; allow to boil 3 minutes; stir down and add cold water; set pot where coffee will stay hot, but not boil, for 10 to 15 minutes, serve with cream and sugar or use to flavor hot milk. PLAIN EGGNOG _267 calories_ 1 egg 2 tbs. cream 1 tbs. rum 1 tbs. whisky 1 tbs. sugar Beat yolk of egg and sugar together; add cream, rum, and whisky. Beat egg white stiff and stir into the mixture; pour into glass with or without cracked ice. Nutmeg may be grated over top for those who like it. COFFEE EGGNOG Follow recipe for plain eggnog, substituting 2 tablespoonfuls of strong coffee for the rum. PANOPEPTON OR LIQUID PEPTONOID EGGNOG _233-257 calories_ Is made as directed for plain eggnog, panopepton being substituted for the rum, using 1 ounce instead of 1 tablespoonful. This will probably more than fill a glass, but the whole amount must be made to keep the proportions correct. The whisky may be left in, if desired, or sherry wine may be substituted in its place to give flavor and additional stimulation. MALTED MILK EGGNOG _264-316 calories_ 1 egg 1 tbs. malted milk 4 oz. milk 1 tbs. sherry wine or whisky 1/2-1 tbs. sugar 1 tsp. cream Mix milk as directed above and chill thoroughly. Beat egg yolk with sugar and whisky or wine and add to the mixture. Beat egg white stiff and stir into the rest of the ingredients. Pour into shaker and shake with cracked ice until thoroughly chilled. The cream may be served on top, or beaten into the eggnog. FOAMY OMELET _130 calories_ 1 egg 1 tbs. water 1/2 tbs. butter 1/8 tsp. salt and dash of pepper Beat yolk until light colored and thick; add water, salt, and pepper. Beat white until stiff and dry. Turn the yolk over the beaten white and cut and fold the white into the yolk mixture. Have pan hot and buttered, turn in the mixture, spread evenly in pan and allow to stand about two minutes on the top of the stove at a moderate heat; then remove the pan, place in a moderate oven and cook until a knife thrust into the center comes out nearly clean. Remove from oven, cut across center at right angles with handle of pan and turn over on a hot platter. Omelets may be varied by the use of different garnishes and flavors. CODDLED EGGS _75 calories_ 1 pt. water 1 egg Allow water to boil; wash egg; drop into boiling water and place saucepan where water will keep hot, but not boil; allow to stand 7 to 8 minutes. Serve with salt. SOFT-COOKED EGGS _75 calories_ Proceed as for coddled eggs, but allow egg to remain from 10 to 15 minutes or even longer, if very soft eggs are not desired. POACHED EGGS _75 calories_ Have small, shallow saucepan half filled with boiling water or milk--if an egg poacher is at hand, use that; otherwise, lower a flat perforated spoon into water and place where the water cannot boil. Break the egg carefully into the spoon, taking care not to break the yolk; allow to stand in hot water until the white is of the consistency of jelly; lift out--slide egg on to hot toast, taking care not to break. (A broken poached egg is very unappetizing, as well as untidy in appearance.) CREAMED EGG ON TOAST _With milk 131 calories_ _With cream 170 calories_ Cut the crust from one slice of bread and cut bread in one-inch cubes; toast while preparing egg. Beat egg with egg beater until light colored; stir into it 2 tablespoonfuls of rich milk; pour into a double boiler, over hot water; add 1 teaspoonful butter, a little salt and pepper; stir until like thick boiled custard. Pour over toasted cubes of bread and serve at once. EGG NEST _204 calories_ 1 egg 1/2 tbs. butter 1 slice of bread (3/4 in. thick) Salt and pepper to taste Toast the bread on one side, butter and place on a plate (one which will not break in the oven). Beat egg white stiff, and pile roughly upon the toast, leaving a slight depression in the center. Slip the unbroken yolk into the depression (take care not to break the egg yolk or the appearance and significance of the dish will be ruined). Set plate in oven to brown the white (the oven must not be too hot or the white will brown before the yolk is sufficiently cooked to be palatable). Place the remaining butter on the yolk, dust with salt and pepper and serve at once. SOFT CUSTARD _289 to 329 calories_ 1 egg (or 2 yolks) 1 tbs. sugar 1 cup milk A few drops of vanilla Heat milk in double boiler. Beat egg and sugar together. When milk has reached the scalding point (small bubbles form around the edge of the saucepan), stir in the egg. Care must be taken not to allow the water under the saucepan to become too hot, as the custard will curdle if the egg is cooked at too high a degree of temperature. The custard must be stirred constantly in the beginning until it begins to thicken, then several times a minute until it is of the desired consistency and the raw taste is cooked out of the egg. This mixture is done when it will form a coating upon the spoon. Serve with whipped cream on top (57 calories extra with cream). BAKED CUSTARD _249 calories_ 1 egg 1 tbs. sugar 3/4 cup milk A few drops of vanilla Beat egg and sugar together, stir into the milk, grease custard cup with butter, pour in the mixture. Set cup on several layers of paper in a deep pan, surround with hot water (to about half its depth). Set pan in moderate oven and allow to cook slowly until custard is firm in the center. It may be served hot or chilled and turned out, with a tablespoonful of whipped cream on top. Care must be taken not to allow the oven to get hot, or the egg will coagulate, making a watery, unpalatable, and indigestible mixture. CARAMEL CUSTARD _306 calories_ Caramel custard is made exactly the same as baked custard, except that the cup is lined with a caramel made as follows: In a small frying pan, place 1 tablespoonful of sugar, place on the stove and stir constantly until it melts and turns a golden brown (do not allow to burn). Fold a cloth about the custard cup and pour in the caramel, moving the cup about until the sides and bottom are well coated. Pour in the custard mixture and proceed as in baked custard. FLOATING ISLAND _381 calories_ 1 egg and 1 extra yolk 1 cup milk 2 lady fingers Few drops vanilla 1 tbs. sugar Make soft custard, using the two yolks (no white). Chill custard thoroughly. Line individual ice cream cup with the lady fingers; pour the custard over. Beat the white of egg and place on top. Serve at once. The lady fingers may be dipped in sherry wine if desired, using about 2 tablespoonfuls of wine. (26 calories extra.) ~Cereals and Breadstuffs~ CORN MEAL GRUEL _101 calories_ 2 tbs. corn meal 1 cup water 1/2 tsp. salt Allow water to boil, mix corn meal with 3 or 4 teaspoonfuls of cold water. As soon as water begins to boil, stir briskly until gruel begins to thicken. Then place on a cooler part of the stove, and cook gently for 2 hours, replacing water as it evaporates. Strain through a coarse sieve if it lumps. FARINA _183 calories_ 3 tbs. (1 oz.) farina 1/2 cup rich milk 1/2 cup boiling water 1/4 cup cold water 1/4 tsp. salt Mix farina into a paste with cold water. Stir into boiling water, allow to cook for half an hour (if water boils out, add boiling water). Add milk, and place the saucepan in a hot water bath (double boiler); allow to cook half an hour longer, stirring occasionally. RICE (1) _99 calories_ 2 tbs. (1 oz.) rice 1 pt. boiling water 1/2 tsp. salt Soak rice for 1 hour in cold water. Sprinkle into the briskly boiling water, taking care not to stop the boil. Allow to cook until tender; test by pressing a grain between thumb and finger; there should be no hard center. When the rice is done, turn it into a colander and allow water from cold faucet to run over it to wash off surplus starch. Return to saucepan place on stove where moisture can be dried out of the rice without burning it. RICE (2) _2-3 servings, 316 calories_ 4 tbs. rice 1/4 tsp. salt 3/4 cup water 3/4 cup milk Wash rice and soak it in cold water for 1 hour (or overnight). Place in an earthenware baking dish, cover with the milk, water and salt. Cover and set in the oven; allow to cook until all of the moisture is absorbed (if the rice is not done by the time the moisture has evaporated, add more milk, or milk and water, and continue until the grains are tender). If the given amount of moisture is not absorbed by the time the rice is tender, drain off the surplus and return the dish to the oven for a few moments. Each grain should be separate, when the dish is prepared correctly. MILK TOAST _149 calories_ 1 slice bread, toasted 1 tsp. butter 1/4 cup milk, heated 1/6 tsp. salt Toast the bread on both sides and butter; place in a deep plate and pour over it the hot milk. CREAM TOAST _240 calories_ 1 slice bread 1/4 cup thin cream 1 tsp. flour 1 tsp. butter 1/4 tsp. salt Cream butter and flour together cold, and stir into hot milk. Stir until the mixture begins to thicken, cover the boiler and allow to cook for 15 minutes. Slice the bread and cut into cubes; toast a delicate brown, and pour over it the cream sauce. Strain the sauce if there are any lumps. WINE PANADA _185 calories_ 2 water crackers 2 tbs. sherry wine 1/2 cup hot or cold milk 1/4 tsp. grated nutmeg Sugar may be sprinkled over crackers if desired, but it is not ordinarily done. Place the crackers in a deep plate and pour over each cracker 1 tablespoonful of wine, dust with nutmeg and pour over the hot or cold milk. OATMEAL COOKIES _3333 (about) calories_ 2 cups flour 1/4 cup sugar 1/2 cup milk 1/2 cup oatmeal 2 tsp. butter, lard, or Crisco 1 cup seeded raisins 1 egg 1/2 cup shelled peanuts Mix shortening and sugar together. Mix oatmeal and peanuts (broken into small pieces) into the flour. Add milk and well-beaten eggs, then the raisins; mix into a dough, roll into a thin sheet, and cut into small cakes. Bake in quick oven. BAKED TAPIOCA _550 calories_ 1 cup milk (scalded) 2 egg yolks 3 tbs. sugar 6 dates 2 tbs. minute tapioca Beat sugar and egg together, stir in the tapioca and dates, cut into small pieces. (The dates may be omitted, if desired.) Pour mixture into custard cups and bake slowly (as rice custard) until the tapioca is clear and the custard is fairly firm in center. ORANGE TAPIOCA _570 calories_ 1/2 cup milk 1/2 cup orange juice 1/4 cup sugar 2 tbs. minute tapioca 2 egg yolks 6 drops orange extract Mix and bake as directed in plain baked tapioca custard. Any other fruit juice may be substituted for the orange, raspberry, pineapple, or grape juice. APPLE TAPIOCA _475 calories_ 1 apple (pared and cored) 1 egg 3/4 cup milk 2 tbs. sugar 1-1/2 tbs. tapioca 1/8 tsp. nutmeg Beat egg and sugar together. Heat milk in double boiler and add egg when milk is scalding hot. Stir in tapioca. Cook 20 minutes. Place apple in cup a little larger than the apple and pour the tapioca custard over the apple. Cover the cup and bake 30 minutes in a moderate oven. BROWN BETTY _470 calories_ 2 slices bread 1 large tart apple (or 1/2 cup blueberries may be substituted for the apple) 2 tbs. sugar 1 tbs. butter 1/2 tsp. nutmeg or cinnamon Toast bread and break into small pieces, line the bottom of the individual baking dish with toast bits, cover with a layer of apple or berries, sprinkle with sugar and nutmeg or cinnamon, add butter in bits over this, continue the process until the dish is filled, place bits of butter on top of the last layer of toast and set dish in oven; bake about 20 minutes in a slow oven; serve with whipped cream or hard sauce. ~Starchy Desserts~ RICE CUSTARD _309 calories_ 1 tbs. raw rice, broiled 1 egg 1 tbs. whipped cream 1/2 cup milk 1 tbs. sugar 1 doz. raisins if desired A few drops of vanilla Beat sugar and egg together. Stir into the milk, stir in the rice and flavor (add raisins if desired--29 calories). Grease custard cup and fill with the mixture. Bake slowly (in a pan of hot water) until custard is firm in center. Serve with whipped cream. ORANGE RICE CUSTARD _532 calories_ 2 oz. orange juice 2 tbs. sugar 1/2 cup milk 2 egg yolks 1/2 cup boiled rice (or 1/4 cup uncooked) Beat egg, sugar, and orange juice together. Mix milk with rice and stir the two mixtures together. Bake as directed in plain rice custard. SNOW-BALLS _356 calories_ 1/4 cup rice 1 cup milk 1/4 tsp. salt Place in a double boiler and cook without stirring until milk is absorbed and rice is tender. Then either pack in egg cups (wet first so that rice will slip out without breaking), or take a square of cheesecloth 8 inches square, dust with flour and place about 4 tablespoons of the cooked rice in center, draw the corners together and tie firmly into a ball. Set the ball in a steamer and steam 1 hour. Remove the cloth gently to prevent breaking the balls. They may be served with custard as a dessert, or as a vegetable with tomato dressing. TAPIOCA CUSTARD _503 calories_ 1 cup milk 2 tbs. tapioca (minute tapioca) 1 egg 3 tbs. sugar Flavor with vanilla or nutmeg, or 1/4 square chocolate grated. Scald milk. Boil tapioca in hot water until transparent like jelly, using one cupful of boiling water. (If tapioca does not absorb all of the water, pour off the surplus.) Beat egg and sugar together and add with the milk to the tapioca. Pour into a double boiler, and cook until the raw egg flavor has disappeared. Flavor as desired. 43 calories extra with chocolate. SPONGE PUDDING _772 calories_ 2 tbs. sugar 1/4 cup flour 2 eggs 2 tbs. butter 1 cup milk 1/4 tsp. vanilla Sift flour and sugar together and make into a thin paste with part of the milk, heat the remainder of the milk and stir in the flour paste. When the mixture is thick and smooth, stir in the butter, then the beaten yolks and last, the whites (well beaten) are folded in. The mixture is now turned into a baking dish and baked (in a pan of hot water as any other custard) until it is firm in the center and well puffed up and brown. Serve with foamy sauce. SUNSHINE CAKE _1716 calories_ 7 egg whites 5 egg yolks 1 cup flour (sifted 3 or 4 times) 1 cup sugar 1/3 tsp. cream of tartar 1/4 tsp. salt Beat whites of eggs until foamy and add cream of tartar; beat until dry and stiff, add the sugar gradually and fold in the well-beaten yolks. Sift the flour and gradually fold into the rest of the ingredients; pour into ungreased sponge cake pans and bake in a moderate oven for 30 to 40 minutes. ANGEL FOOD CAKE _721.5 calories_ 4 egg whites 1/2 cup sugar 1/2 cup flour (pastry) 1/4 tsp. cream of tartar Whip eggs until foamy and add cream of tartar, whip until stiff and dry, add sugar gradually, then fold in the flour (the flour must be sifted 4 or 5 times). Pour batter into an ungreased angel food cake pan and bake in a slow oven for 25 or 30 minutes. Care must be taken not to disturb the cake during the baking, or it will fall. CEREAL PUDDING _1470 calories_ 1/2 cup fine cereal 1 cup milk (scalded) 1/4 cup molasses 1 egg 1 tbs. butter 1/2 tsp. salt 1/2 tsp. soda 1/2 cup dates or other dried fruit Stir cereal into scalded milk and cook until mixture thickens, remove from fire, add rest of the ingredients except eggs. When mixture has cooled somewhat, add the lightly beaten eggs, turn into a buttered baking dish and steam 3 hours. This pudding may be made without steaming by cooking the cereal and milk in double boiler for 1 hour, then add rest of ingredients and bake 30 minutes. ~Sauces for Puddings~ FOAMY SAUCE _494-497 calories_ 1/2 cup powdered sugar 1/4 cup butter 1/2 one egg yolk and 1 whole egg white 1 tbs. sherry wine or 1 tbs. hot milk 1/4 tsp. vanilla Cream butter and sugar (powdered sugar must be used in this recipe). Stir in the well-beaten yolk, add sherry and pour into saucepan over hot water; stir until thick and creamy, lift from hot water and cool as quickly as possible, fold in the stiffly beaten white of egg and serve over pudding at once. WINE OR FRUIT SAUCE _381-434 calories_ 1 egg 1/2 cup powdered sugar 1 wineglass sherry wine or whisky, or 1/2 glass orange juice 1 tbs. lemon juice 1 tsp. hot milk Beat yolk and white of egg separately, add sugar to yolk and beat until creamy, add wine or fruit juice, fold in the egg white and add the hot milk last; serve at once. HARD SAUCE _231 calories_ 1 tbs. butter 2 tbs. sugar 1/2 egg white may be added if desired 1/2 tsp. vanilla, or 1/2 tsp. nutmeg Cream butter and sugar together until there are no lumps or grains in mixture. Beat the egg white stiff and fold into the sugar and butter mixture. Flavor. FOAMY SAUCE _794-797 calories_ 1/2 cup powdered sugar 1/4 cup butter 1/2 one egg yolk and 1 whole egg white 1 tbs. sherry wine or 1 tbs. hot milk 1/4 tsp. vanilla Cream butter and sugar (powdered sugar must be used in this recipe). Stir in the well-beaten yolk, add sherry and pour into saucepan over hot water; stir until thick and creamy, lift from hot water and cool as quickly as possible, fold in the stiffly beaten white of egg and serve over pudding at once. SAUCE FOR PUDDINGS _758.4 calories_ 1 egg 1/2 cup powdered sugar 1 wineglass sherry wine or whisky, or 1/2 glass orange 1 tbs. lemon juice 1 tsp. hot milk Beat yolk and white of egg separately, add sugar to yolk and beat until creamy, add wine or fruit juice, fold in the egg white and add the hot milk last; serve at once. ~Meats~ BEEF, LAMB, VEAL, POULTRY, FISH AND SHELLFISH ~Meats.~--The flesh of animals, poultry, and fish comes under the head of meat. These food materials form one of the most important sources of protein in the diet, the foodstuff being in concentrated form easily handled by the digestive apparatus and absorbed almost completely, leaving little residue in the intestinal tract. The chemical composition of different meats is very much alike, as will be seen in the table, the bulk of the weight being water, while the proteins range from 18.3% (E.P.)[40] in beef to 9.9% in bacon. The fats range from 17.9% in beef to 64.8% in smoked bacon. The mineral salts or ash, as they are found in meat: "Sodium occurs in the animal body chiefly as chlorid in the fluids and blood, and to a less extent in the other tissues." "Potassium, on the other hand, is much more abundant in the soft solid tissues, in the corpuscles of the blood and the protoplasm of the muscles and other organs." "Potassium sulphate in the blood reacts to some extent with sodium chlorid, forming potassium chlorid and sodium sulphate, both of which are rapidly eliminated by the kidneys." The greater part of the sulphur with which we are concerned in nutrition enters the body by way of the protein, the percentage in lean beef being from 0.95% to 1.00%.[41] Phosphorus in meat occurs as phosphoprotein in the nucleoproteins of cell nuclei, and lecithoproteins in the brain and to a less extent in other tissues as phosphorized fats. Meat is poor in calcium, containing only about 0.01 gram per hundred grams of substance. Meat with eggs yields a considerable amount of what is known as acids in the body. ~Quality of Meats.~--The quality of meat depends upon several factors: _age_, _sex_, care, feeding, and the length of time it is hung. Cold storage beef is much more apt to be tender than that cut from a freshly killed animal. Animals that are not allowed to run over a large area, but are kept in a small inclosure and fed on fattening foods, produce meat of a high quality. This is because the muscular tissue has not been hardened with exercise. The worked muscle is always tougher than the quiet one. For this reason the tenderloin of beef is more tender than the flank. It is situated in the part of the animal that is exercised the least. The tough parts, however, are not lacking in flavor or nourishment, but the manner in which they must be cooked to assure them of being tender deprives them of much of their original flavor. This is demonstrated in broths and soups made from the tough cuts of meat. The extractives from which meat derives its flavor and the soluble albumens are drawn out by the water, and if it is to be used as hash, croquettes, etc., needs to be seasoned, since the broth, while it has taken very little of the actual nourishment from the meat, has deprived it of practically all of its flavor. In making broth or soup, if the meat is covered with cold water instead of hot, more of the extractives will be drawn out and the broth will be more highly flavored and much more stimulating. The color, odor, and freshness of the muscular and fatty tissues of meat are all indicative of their quality. Fresh meat is firm in texture and free from offensive odor. Stale beef and that cut from an old steer exhales a pungent odor of butyric acid. The color of beef should be dark purplish when fresh cut but this changes quickly to a bright red; it should contain preservatives of no kind and must be cut from animals free from all disease. The fat should be of a yellowish white and be crumbly, and should be distributed throughout the muscular tissue and around the organs. ~Veal~, being the flesh of an immature creature, is not so highly flavored as the flesh of older animals, but the bones and cartilages are softer, and when this meat is used for broth, more of the gelatin (collagen and elastin from the bones and connective tissue) is dissolved out, giving a slightly higher percentage of nutriment in the broth. ~Selecting of Chicken and Turkey.~--In selecting chicken for the diet of invalids, use only the young birds for broiling, those a few months older for baking and roasting, and the fowls for soup and broth. To test a chicken for broiling and roasting, select one in which the cartilage at the end of the breastbone is soft and pliable; the pinions (lower part of the wings) and the feet should be soft and readily bent. The breastbone of a fowl is firmer and the wings and feet harder than those of the younger chicken. The young chicken has an abundance of pin feathers while the old fowl has not. In fact, one of the means of differentiating between the old chicken and the young, even if they are practically of the same weight, is the presence of the long hairs instead of pin feathers. The fowl selected for broth should not be very fat, as this fat will melt into the broth, causing it to be greasy and unpalatable. Turkey, even when it is young, is not quite so digestible as young chicken; the fibers are longer and the connective tissue more abundant. Goose and duck are richer in fat and not so desirable as chicken in the invalid dietary. Squab, quail, and young squirrel are all palatable and readily digested. The squirrel must, however, be young, or the flesh will be tough and more difficult of digestion. ~Fish.~--Fish should be given consideration in the dietary of the invalid since it is a valuable source of protein and readily digested in the majority of cases. As a rule fish is not so well liked as meat, but since it contains a smaller percentage of ~extractives~ and ~purin~ bases it is exceedingly valuable in certain pathological conditions. The lean varieties of fish, halibut, flounder, trout, perch, haddock, turbot, whitefish, are more readily digested than the dark fish, which contain a higher percentage of fat. To this latter class belong the bluefish, mackerel, salmon, shad, and herring. ~Shellfish.~--Of the shellfish, the oyster and the clam are exceedingly useful. The soft parts of the oyster are palatable and easily digested. They are not highly nutritious, but give a nice variety to the diet. When used in broth or for the juice, clams are particularly useful. Many cases of nausea are relieved by the taking of iced or very hot clam juice when they resist other remedies. The necessity of having both oysters and clams absolutely fresh is of the greatest importance, since a type of poison results from tainted shellfish which is exceedingly dangerous. ~Pork in the Diet.~--Fresh pork is rarely ever included in the invalid dietary save in diabetic diets. Meat from this animal must always be thoroughly cooked, not only because underdone pork is exceedingly indigestible but because there is an infectious bacterium sometimes found in pork which is only destroyed by thorough cooking of the meat. Well-cooked bacon is digestible if the surplus fat is poured off instead of allowed to soak into the cooked bacon. The most efficient method of cooking bacon is to place the strips upon a broiler under the flame. In this way the hot fat drips down into the pan beneath, leaving the bacon crisp and delicate. The meats to be used for the invalid must be selected with care. The quality of this item of food is most important. It is not always necessary to purchase the most expensive cut. If it is to be broiled or roasted then it is necessary to select parts of the animal which are tender, but for broths, soups, scraped or ground meat, or the meat to be used for the juice only, it is wasteful to buy these tender, expensive pieces when those costing less will serve the purpose equally well. The names given to the different cuts vary slightly in different parts of the country, but those in general use only will be mentioned here. The following table shows the manner in which the ~beef~ is cut and the method in which it is generally used: TABLE ============+========================+================================ _Beef_ | _Cut_ | _Method of Preparation_ ------------+------------------------+-------------------------------- Hindquarter | {more or less free |Broth, soup, beef juice, scraped |Round{ from fat | beef. | {round steak |Hamburg steak (ground meat). | |Broiled (this is a cheaper and | | less tender cut than the loin | | steaks). | | |Rump {steak |Broiled, cheaper cut steak. | {roast |Roasted, cheaper cut roast. | {lean meat |Broth, soup, beef juice. | | |Loin {3 ribs, 1st, 2d |Roasted. | { and 3d cuts | | {sirloin steak |Broiled. | {porterhouse steak |Broiled. | | | {steak |Broiled. |Tenderloin {roast |Roasted. | {fillet |Broiled or roasted, larded or | | plain. | | |Ribs (prime) |Roasted. | | |Ribs, chuck roast or |Roasted or broiled. | steak | | | Forequarter |Brisket |Corning. | |Broth, soup, scraped, meat | | juice. | |Hamburg steak. | |Salisbury steak. ------------+------------------------+-------------------------------- CUTS OF LAMB AND MUTTON ------------+------------------------+-------------------------------- Lamb |Neck |Soup, broth, etc. | | |Chuck (including | | shoulder ribs). | | Shoulder chops are not| | so tender as loin | | chops. |Broiled. | | |Flank |Soup, broth. | | |Loin (chops) |Broiled. | | |Leg |Roasted. | | Veal |Neck |Soup, broth. | | |Chuck |Soup, broth, roast, broiled. | | |Cutlets |Broiled (breaded or plain). | | |Chops (rib) |Broiled. | | |Breast |Roasted, stuffed or plain. | | |Leg |Roasted. | | |Hind shank (veal |Soup, broth. |Fore shank knuckles) | ============+========================+================================ ~Broths and Soups~ STANDARD BROTH BEEF, VEAL, MUTTON, OR CHICKEN _1 Pint, 80 calories, with rice or barley 105 calories_ Two pounds of meat (beef, mutton, veal, or chicken); 2 quarts of water; 2 pounds of bones; 1 teaspoonful of salt; 2 tablespoonfuls of rice or barley may be added if desired and parsley or celery may be used to give the additional flavor. Wipe meat with a clean wet cloth and cut into small pieces, break the bones, place all together in a deep saucepan, cover closely and allow to stand in a cool place for one hour; then place pan on the back part of the stove, or on an asbestos mat over a gas burner, and heat gently to the boiling point (broth must never do more than simmer), allow to simmer for three or four hours, skim, strain, and cool. When thoroughly cold, remove all of the fat, using blotting paper to absorb the fine particles of grease. If parsley and celery are to be used to flavor the broth they may be added during the last hour of cooking. Barley requires to be soaked overnight when it is used in broth; rice should be soaked one hour. When either are to be left in the broth it is better to cook the broth for three hours, strain, return to the fire, adding the rice or barley. Allow it to simmer for an hour or more and proceed as directed. When the broth is taken from the fire, it should be measured, and boiling water added to bring the amount up to the original quantity. This will give what is known as standard broth. Bouillon is clarified broth, most of the already small amount of nutrient material being thus strained and cleared from the broth, leaving a liquid of practically no fuel value. CLAM OR OYSTER BROTH _11.5 calories without milk; 162.5 calories with milk_ 1 doz. clams or oysters 1 tbs. whipped cream 1 pt. water or 1 cup each milk and water A dash of pepper Scrub clams and place in an iron spider and allow to heat gently until the shells open. (When oysters are used allow to heat until the edges curl.) Chop, cover with hot water, and allow to simmer 15 minutes, strain through cloth, add salt and a dash of pepper. If milk is to be used in place of part of the water, add it during the last 5 minutes of the cooking. Clam broth without milk may be served hot or cold; it will not jelly as other broths but may be frozen if desired. CLAM BROTH _Without milk, 55.6 calories; with milk, 113.4 calories_ 1/2 cup (4 oz.) clam juice 1/2 cup hot water or milk Salt and pepper to taste 1 tbs. whipped cream Mix clam juice (bottled) with water; heat, add salt and pepper, pour into cup, place whipped cream on top, and serve at once. BEEF JUICE One-fourth pound lean beef. Wipe clean with damp cloth, cut in inch pieces and sear on a hot griddle, place in a meat press and remove all juice from meat. Care must be taken not to cook the meat. The juice may be reheated by placing in a hot cup in hot water, not allowing the temperature to exceed 155° F. CHICKEN JELLY _308 calories_ _1 serving, 75.8 calories_ 1/2 small chicken 3 pt. water 1/2 cup celery 1 sprig of parsley 1 tbs. gelatin soaked in 1/4 cup cold water 1/2 tsp. salt 1/4 tsp. red pepper 1 egg white Cut the chicken in pieces, break the bones, place in a saucepan with all of the ingredients except the gelatin and egg white, cover with the water and boil until the meat falls from the bones. Press out as much of the juice as possible, strain and allow to cool, remove all of the grease, and return to the fire. Reduce to 1 pint, add the gelatin, stir in the beaten egg white, and allow to boil 5 minutes, strain again into molds and set aside to congeal. CALF'S-FOOT JELLY _376.6 calories_ 2 small calf's-feet 1/2 small fowl 1 cup of Rhine wine 1 lemon 1/2 stick of cinnamon 1 egg white (well beaten) Cut the fowl and the calf's-feet into small pieces and place them in a saucepan with 3 pints of cold water and the cinnamon. Cook until the meat falls from the bones (the quantity should be reduced to 1 pint). Strain and squeeze out as much of the juice as possible, allow to cool, and remove all of the grease. Add wine and lemon juice (and sugar if desired) and reduce the amount of broth one-half, add the egg white and allow to boil 5 minutes. Clear and strain into molds. BROILED QUAIL OR SQUAB _418-543 calories_ Split down the back and place on the broiler, cut surface uppermost. Or place upon a hot pan, cut surface next to the hot surface so that the cut side may sear quickly, thus keeping in the juices instead of having them wasted in the pan by slow cooking. The process requires about 15 to 20 minutes. Serve on toast, with butter, pepper and salt. Quail or squab cooked inside the stove is often more palatable than that cooked on a broiler. The bird is split as for broiling, and placed in a small pan just large enough to hold it; a strip of bacon pinned about the breast; add 1 tablespoonful of butter in bits, dust the cut surface first with salt and pepper, then with flour; add 1/2 cup of hot water. Turn another pan over the bird (it must fit closely to keep in the steam), place inside the oven and cook about 10 minutes; turn the bird over and cook 10 minutes longer. Lift the bird from the pan and place it where it will keep hot, add a tablespoonful more water and a teaspoonful more flour to the gravy in the pan, stir briskly to remove any lumps, remove bacon and place the bird upon a slice of nicely browned toast; pour over it the gravy, garnish with a sprig of parsley, and serve at once. BIRDS À LA BAIN-MARIE 1 small chicken, or bird 2 tbs. butter 1 tbs. parsley Salt and pepper Split birds or chicken as for broiling, place one-half in a chafing dish or double boiler (bain-marie), dot the cut surface with butter, sprinkle over it the parsley, dust with pepper and salt; place the other half of the chicken or bird on top of this, add the rest of the butter, dust with salt and pepper, cover, and place the pan over the hot water pan; allow to steam for about 1 hour, lift from hot water pan and place in oven or under the flames to brown lightly. Serve on buttered toast. CHICKEN (ONE-HALF) _355 calories_ Split small chicken (broiler) down the back, flatten the breast bone with knife before placing upon the broiler, proceed as in broiling birds, allowing from 25 to 30 minutes for the process. Chicken is very palatable and dainty if cooked after the manner described in cooking quail and squab inside the stove. The process is called smothering. Serve upon buttered toast, garnished with parsley. ROAST CHICKEN, TURKEY OR DUCK Draw the fowl and wash thoroughly inside and out. (If it is purchased from the market, it is well to wash the inside with soda water to remove any stale flavor that may be present.) Make a dressing from one-third of a small loaf of bread broken into small pieces; 1/4 cup chopped celery, 1 tablespoonful of chopped parsley, 1 tablespoonful of butter and one egg beaten lightly. Stuff the cavity with dressing, sew up the opening and place in dripping pan. Place pan under the flame for a few minutes to brown, unless a regular roasting pan (savory roaster) is used; allow to bake from 45 minutes to an hour and a half for chicken and duck according to the size, and from an hour and a half to three hours for turkey according to size. A cupful of boiling water may be poured into the pan in which the chicken, etc., is being roasted and flour may be sifted over the top; dust with salt and pepper. When an ordinary pan is used for baking, the fowl will require frequent basting to keep it moist and tender. Just as the baking is finished, more butter, flour, and seasoning may be added, with a cup or more of boiling water to make additional gravy. SWEETBREADS _209 calories_ 1/4 set of sweetbreads 1 lemon 1/2 tsp. of salt 1/4 tsp. of pepper (red) Wash sweetbreads carefully and allow to stand 1 hour in ice water, allow the water containing the lemon juice, salt and pepper to come to a boil and drop in the sweetbreads, cook for 15 to 20 minutes or until tender when pierced with fork. Remove from hot water and pour ice water over them to blanch. Serve either in cream sauce or split in half and broil upon a slightly greased broiler until light brown; season with a dash of salt and pepper. BROILED OYSTERS _174 calories_ 6 oysters 2 tsp. butter 1 slice toast Salt and pepper to taste Grease broiler or hot frying pan slightly, place oysters upon the heated surface and place under the flame or on top of the stove; cook until the edges curl (2 to 3 minutes), lift to a hot dish containing the butter, place toast upon small plate (toast and plate must be hot), dispose the oysters upon the toast, and pour over them the butter. BEEFSTEAK _267 calories_ _3 inches long by 2 inches wide by 1-1/2 inches thick_ (_weighing about 3 ounces_). Wipe steak off with a wet cloth and dry before cooking. Slightly grease the broiler and place under the flame, count ten as the clock ticks and turn the steak over, count ten again and again turn; continue this for about 3 minutes or until the steak is seared upon both sides, lift the broiler to a lower part of the oven and continue the cooking for 5 to 8 minutes; run a sharp-pointed knife between the meat and the bone (if the steak is a porterhouse or sirloin), and if the flesh is red, continue the cooking a minute or more. If it is pink, lift to a hot plate, place 1 teaspoonful of butter upon it, dust the surface with salt and pepper and serve hot. Pan broiling is done on the top of the stove in a flat frying pan. Wipe the pan with a clean wet cloth, place upon the stove and heat piping hot, and place the steak (without greasing the pan) upon the hot surface. Proceed as in broiling under the flame. After the first 3 minutes of cooking, place the pan on a cooler part of the stove to finish the cooking. LAMB OR MUTTON CHOPS _2 chops, 304 calories_ 1 to 2 inches thick will require from 10 to 15 minutes' cooking. Scrape the bone clean and wrap in paper or dough to prevent the bone from becoming charred. Proceed as in cooking beefsteak. VEAL CUTLETS _2 cutlets, 275 (about) calories_ Dip cutlets first in egg (mix one yolk with 1 tablespoonful of water) then in bread crumbs; pan broil (grease the frying pan slightly), or broil under the flame as directed in cooking beefsteak. Veal cutlets may be served plain, or with tomato sauce. Cutlets or chops may be cooked in paper bags if desired. Wrap the chop in a thin slice of bacon, grease the paper (a piece of heavy brown paper), place the chop inside and secure the ends with paper clips or pins; place in a pan and cook in the oven, or under the flame. It is wise to slip the bag containing the chop inside of another bag; in this way the meat will not taste of scorched paper if the outer bag should burn. BACON (1 SLICE) _194 calories_ Place bacon on a rack and place rack in a dripping pan, set in oven and bake until crisp and brown. Or, arrange bacon on broiler, place pan beneath to catch the drippings and prevent the fat from catching afire, broil as beefsteak. * * * * * When steak or chops are served, parsley or sliced lemon may be used as garnishes. Chops may be served garnished with green peas, and the beefsteak served with potatoes cooked in any way; all meats should be served very hot. It is best to cover with a plate. FISH Split down the back, and broil as beefsteak. Fish does not require more than from 10 to 15 minutes to broil unless very large. Serve with teaspoonful of parsley and butter. FISH STEAKS, STUFFED WITH OYSTERS _3 ounces, 168.3 calories (about)_ _Halibut, trout, or any good baking fish, 235.8 calories (about)_ 2 slices of fish 1 - 1-1/2 in. thick 1 doz. oysters 1 cup bread crumbs 4 tbs. butter Salt and pepper Lay fish for one hour in a French dressing made from 1/2 cup of oil, 1/3 cup of vinegar, salt and pepper; drain and place upon slices of bacon, placed upon a fish sheet or dripping pan. Dip oysters first in melted butter, then in bread crumbs, and place upon the slice of fish, adjust second slice above, cover top with bread crumbs, dot with butter and bake 30 to 45 minutes in moderate oven. Serve with hollandaise sauce. LOBSTER OR CRAB _1 serving lobster, 157 calories_ _1 serving crab, 154 calories_ 1 lobster 1 tbs. butter or 1 crab 2 tsp. butter 2 tbs. bread crumbs 1/4 tsp. salt 1/8 tsp. pepper Boil lobster or crab until bright red, lift from boiling water. Split lobster down the back and carefully remove cord, gall sack, and sand bag before broiling or serving. Serve with melted butter. Pick meat from shell of crab, and mix with salt, pepper and butter. Stuff into shell. Cover top with bread crumbs, and brown in the oven. HOLLANDAISE SAUCE _178 calories; 1 tablespoonful, 22 calories_ 1 egg (yolk only) 2 tbs. lemon juice 1 tbs. butter 1/4 cup boiling water Salt and pepper to please Beat egg yolk with lemon juice; add one-half the butter; place in double boiler over hot (not boiling) water. Stir until it begins to thicken and add remainder of butter; stir in boiling water, cook until of the consistency of boiled custard. ~Vegetables and Fruits~ Among the plants known as vegetables, some are seeds, some leaves, some stems or bulbs, some roots or tubers, and some are the fruit surrounding the seeds. Under the head of seeds we find peas, beans and lentils, this class of vegetables being spoken of as legumes or pulses; they are rich in protein (especially when dried) and contain an appreciable amount of carbohydrates as well, some contain fat. Green, or fresh legumes are more easily digested than the dried legumes. They are important sources of iron and phosphorus and contain a certain amount of calcium; in the body they act as neutralizing agents since the base-forming elements in these plants predominate over the acid-forming elements.[42] Among the "leafy vegetables" we find, lettuce, cabbage, spinach, beet, turnip and mustard greens, chard and parsley. These vegetables are not only prized for their mineral content but furnish a recognized source of the fat soluble vitamine, "A." Tomatoes, squash, cucumbers and pumpkin are vegetables whose "fleshy fruit" surround the seed but are eaten as vegetables instead of as fruit. Potatoes, carrots, parsnips, onions, beets and turnips are among those whose stems, roots or tubers are eaten as vegetables. More and more are we coming to see the importance of this class of foods in the dietary, they are important on account of their mineral salts, their vitamine factors and for the bulk which they lend to the food mass which facilitates its passage along the digestive tract. The majority of vegetables furnish organic acids or their salts which function in the body, as potential bases, assisting in the neutralization of the acids formed in the body as a result of the breaking down of the proteins. ~Fruits.~--Fruits have practically the same value from a dietetic standpoint as vegetables, and the same care must be given to their selection. Some fresh fruit should be given to children every day to safeguard them against scurvy. And adults should have fresh fruit several times a week, the remainder of the time dried fruits may be used. Canned fruits while good are not so valuable as fresh fruits and are more expensive than the dried fruit. The ~fruits and vegetables~ will here be considered. Some of the fruits and vegetables contain high percentages of sugar, aside from the mineral salts, for which they are especially valuable. This class includes the sugar cane, sugar beet, raisins, dates, figs, etc., while others such as the potato, taro, banana, etc., furnish an appreciable amount of starch. All of the vegetables and fruits are rich in mineral salts, which are as important to the work of the body as the proteins, carbohydrates, and fats. Hence it is essential to add the foods containing these mineral salts to the daily dietary both in health and in disease. Both fruits and vegetables should be free from blemishes. Those to be served raw, such as lettuce and other salad vegetables, must be purchased from reliable markets. Unscrupulous vendors have been known to sprinkle old wilted vegetables, to restore their freshness, with water from stagnant pools teeming with typhoid bacteria, thereby spreading infection broadcast. Vegetables which require cooking before they are eaten are, for this reason, safer. ~Canned foods~ should be avoided in the diet of the invalid whenever it is possible; but, when it is not, care should be observed that no can is used in which there is the least sign of fermentation. Beans and peas are sometimes artificially colored, but this custom is not so prevalent now as it used to be. PEAS _121 calories_ 1/2 cup fresh peas 1 pt. boiling water 1 tsp. butter 1/4 tsp. salt Add salt and peas to boiling water; allow to cook from 30 to 60 minutes, or until they are perfectly tender, drain and add butter and additional salt if necessary, or 1 tablespoonful of cream sauce. In gastro-intestinal disorders and with young children, it is best to press peas through sieve or remove the indigestible parts. STRING BEANS _94 calories_ 1 cupful of string beans (measured after the strings are removed and the beans cut into small pieces) 1 tsp. butter 1/2 tsp. salt Cover with boiling water and cook until tender, drain, and serve hot. SPINACH _90 calories_ 1/2 lb. spinach 1/2 tsp. salt 2 tsp. butter Wash thoroughly through about ten waters, until spinach is entirely free from grit, remove the tough stems, lift the spinach from water and place in a saucepan without additional water, sprinkle over with salt, cover saucepan and cook until tender (requires about 15 minutes). Cut very fine with sharp knife, or press through sieve, add butter and serve hot. CARROTS (WITH CREAM SAUCE OR BUTTER) _82-117 calories_ Carrots, about 1/2 cupful after they are cut in cubes, or 3-1/2 ounces. Serve with 2 tablespoonfuls of cream sauce, or with 2 teaspoonfuls of butter and a little salt and pepper. Scrub carrots and scrape off the skins; cut into slices or cubes, drop into slightly salted boiling water and cook until tender; drain and add butter or cream sauce. BAKED POTATO (WHITE) _140 calories_ 1 potato weighing about 3 ounces; scrub well with a brush; dry and slightly grease surface, place in moderately hot oven and bake about 45 or 50 minutes. (The potato should feel tender upon pressure.) When done, make an incision of 1 inch in the skin and gently press out the steam; cover closely with cloth and keep in a warm place until ready to serve. Put teaspoonful (about 1/6 ounce) of butter in the cut and serve very hot. CREAMED POTATO _182 calories_ 1/4 tsp. salt 1 medium size potato 2 tsp. milk 1 tsp. butter Pare and boil potato until tender when pierced with a fork; drain off the water and return the saucepan to the stove; shake the pan (to prevent burning) until the potato looks dry; mash with fork or potato ricer, add milk, butter, and salt. Beat briskly until creamy. Serve at once or brown in oven. POTATO STUFFED WITH MEAT _197.5 calories_ 1 potato (baked) 1/4 tsp. salt 1 tbs. cold chopped beef 1 tsp. butter Dash of pepper Bake potato, split in half and remove the contents, mix with the chopped meat, add salt, pepper, and butter; return to the two halves, set in oven to brown, then serve at once. SCALLOPED POTATOES _250.8 calories_ 1 potato 1/4 cup milk 2 tsp. butter Boil potato, not quite tender, and slice in moderately thin slices; arrange in layer in an individual earthenware baking dish (ramekin), add butter in bits between layers, pour the milk over; set dish in oven, cover and bake slowly for 15 minutes, until most of the milk is absorbed and the potatoes are nicely browned on top. In cases where the patient is allowed cheese, 2 teaspoonfuls may be sprinkled between the layers, giving 31 additional calories. ~Vegetable and Fruit Salads~ CUCUMBER _62.5 calories_ 1/2 cucumber (7 in. long) 1/2 tbs. vinegar 1 tsp. olive oil 1/6 tsp. salt Few grains of pepper Slice cucumber in thin slices and allow to stand thirty minutes in ice water, drain and serve with French dressing. TOMATO (NO. 1) _with mayonnaise, 61 calories_ _with French dressing, 131 calories_ Wash tomato carefully, cut in shape of flower by cutting almost through the tomato making six sections. Place on lettuce leaf and serve with dressing. 1 tsp. mayonnaise or 1 tbs. French dressing TOMATO (NO. 2) _63 calories_ Remove skin from 1 medium sized tomato, remove pulp, fill cavity with following mixture. 1/2 medium stalk celery The tomato pulp 1 tsp. mayonnaise dressing FRUIT SALAD (NO. 1) 3 grapefruit 1 cup celery (chopped) 1/4 head of lettuce 1 cupful of mayonnaise Remove skin and inner membranes from grapefruit, mix with celery and mayonnaise. Serve on lettuce. This salad may be poured into a tin (baking powder can, or mould), packed in ice and salt and frozen. Then served in slices upon lettuce. FRUIT SALAD (NO. 2) _1217 calories (about)_ 1 cup of grapefruit 1 thick slice of pineapple (chopped) 1 green pepper (1 oz.) 1 cup of celery 1 cup of mayonnaise or French dressing If mayonnaise is used the mixture may be frozen. If French dressing is used, serve on lettuce without freezing. TOMATO JELLY _77 calories_ 1 cup tomatoes (canned) 3/4 cup water 6 cloves 1/2 cup celery 1/4 cup vinegar 1 tbs. of parsley 1/2 tsp. red pepper 1 tbs. granulated gelatin soaked in 1/4 cup cold water One slice of onion may be added if there is nothing to contra-indicate it, but care must be taken in adding onion, as it is apt to disagree with many people. Boil all of the ingredients together (except the gelatin) for 20 minutes, press through a sieve, then through a cloth, return to the stove and allow to boil up; add the gelatin and boil 5 minutes; strain into wet molds. WHOLE TOMATO STUFFED WITH RICE _167 calories_ 1 medium size tomato 2 tbs. rice (uncooked) 1 tsp. butter Dash of pepper and salt Remove the center from the tomato, dust the inside with salt and a very little pepper and set aside. Boil the rice, when about half done (10 minutes) add the tomato pulp, from center of tomato. Cook 10 minutes longer, drain the water from the rice, add the butter, salt, and a little pepper. Fill the center of tomato with rice. Set the tomato upon a greased paper and bake in a moderate oven for 20 minutes. BROILED TOMATOES _353 calories_ Slice 1 tomato in three or four slices 1 tbs. butter 1 slice of bread (round preferred) 1/4 cup of cracker crumbs Salt and pepper Heat broiler or frying pan very hot, grease lightly; season crumbs with salt and pepper; dip slices of tomato in cracker crumbs, covering both sides well, and place upon the broiler; when one side is browned, turn over carefully, to prevent breaking, and allow the other side to brown. Lift the broiler to the lower half of the oven and let the tomatoes cook gently for 10 minutes. Place bits of butter upon each slice, then arrange these on the buttered toast. STEWED TOMATOES ON TOAST _171 calories_ 1/2 cup canned tomatoes 1/2 cup water 1 slice bread 2 tsp. butter 1/4 tsp. salt Pour tomatoes and water in a saucepan and allow to cook slowly for 20 minutes, add salt and a dash of pepper. Toast and butter the bread, pour the cooked tomatoes over it and serve at once. FRENCH DRESSING _131 calories_ 1 tbs. oil 1/3 tbs. vinegar, or lemon juice Dash of pepper and salt Have all ingredients cold; mix salt and pepper together; stir in the oil, add vinegar or lemon juice slowly, beating briskly to form an emulsion; use immediately or ingredients will separate. Use as little salt as possible in nephritic conditions. MAYONNAISE DRESSING _2109 calories_ 1 egg (yolk only) 2 tbs. lemon juice (or vinegar) 1/2 tsp. salt 1/2 tsp. mustard (dry) Dash red pepper 1 cup olive oil Method of Mixture: Mix dry ingredients with yolk of egg thoroughly; add all the acid (use Dover beater). Now add, one teaspoonful at a time, the olive oil; beat continually until the mixture thickens (after 8 teaspoons of oil have been added). Put in oil by tablespoonfuls until all is incorporated. This method shortens the time of making at least one-half, and the dressing rarely curdles as it often does in the old methods. Whipped cream may be added to dressing before serving. Mayonnaise will keep if placed in a cool place, and the above quantities are more easily handled than smaller amounts. ~Gelatin Jellies~ LEMON JELLY _150 calories_ 2 lemons (juice only) 1/4 cup sugar 3 tsp. granulated gelatin 1 tbs. cold water 1 egg white 1 cup boiling water ORANGE JELLY _280 calories_ 3 tsp. granulated gelatin 1 tbs. cold water 1/4 cup boiling water 6 tbs. lemon juice 3 tbs. sugar 2 drops orange extract 1/2 cup orange juice GRAPE JUICE JELLY _315 calories_ 1/4 cup boiling water 1/2 cup boiling grape juice 3 tsp. granulated gelatin 1 tbs. cold water 1 tbs. lemon juice 3 tbs. sugar _Method for Fruit Jellies._--Soak gelatin in cold water about 2 or 3 minutes, then pour over it the boiling liquid; add sugar and fruit juice; strain through cloth into wet molds. Set in cold place to stiffen; when firm, unmold. Serve with whipped cream, or pour liquid into baskets made from oranges or grapefruit hollowed out and the edges scalloped, or pour into shallow pans, and cut in 1/2-inch blocks when firm, and serve on a bed of whipped cream. WINE JELLY _127 calories_ 1/2 cup boiling water 3 tbs. sherry wine 1-inch piece of cinnamon 1 tsp. lemon juice and the yellow rind from 1/4 lemon 3 tbs. sugar _Method for Wine Jelly._--Put water, wine, lemon juice, peel, cinnamon, and sugar into a saucepan, allow to boil 5 minutes, pour over gelatin (which has been soaked in cold water). If jelly looks cloudy return to saucepan, and add 1/2 egg white beaten stiff, allow to boil 1 minute, stirring constantly, and strain into mold. Serve with whipped cream. ~Water Ices~ LEMON _276.5 calories_ 2 lemons (juice only) 1/4 cup sugar 1 egg white 1 cup water ORANGE _311 calories_ 1/2 cup orange juice 1 lemon 1/4 cup sugar 1 cup water 1/4 tsp. orange extract 1 egg white GRAPE JUICE _362.6 calories_ 1/2 cup grape juice 1 tbs. lemon juice 1/4 cup sugar 1 egg white METHOD OF MIXTURE Mix sugar and water and boil to a rich sirup (about 15 minutes), cool, and add fruit juice (and extract when it is used). Pour into freezer and surround with a mixture of 1 part salt and two parts ice. When sherbet is about half frozen, stir in the stiffly beaten egg white and continue the freezing until mixture is hard. In diseases where it is found inadvisable to give albumen, 1 teaspoonful of gelatin may be substituted. APRICOT _384 calories_ 1/2 cup apricot purée 1 cup water 1/4 cup sugar 1 tsp. granulated gelatin 1 lemon (juice only) Make sirup of water and sugar, soak gelatin in a little cold water and add to the hot sirup; press apricots through a sieve and add to the sirup as soon as it is cool; freeze as directed in other ices. STRAWBERRY AND RASPBERRY _346-393 calories_ 1 cup fruit juice 1/3 cup sugar Juice of 1 lemon and 1 egg white. Proceed as in other ices. CURRANT _526 calories_ 1 cup fresh currants 1 cup water 1/2 cup sugar 1 tbs. lemon juice Wash currants carefully and place in a saucepan on a warm but not hot part of the stove, allow to heat gently until the currants are soft, press through a cloth, and add the water and sugar; stir until dissolved (or make a sirup of the water and sugar and add the currant juice and lemon and freeze as directed in other ices). The egg white may be added if desired. LEMON CREAM, OR MILK SHERBET 3 cups (24 ounces) milk 4 lemons 1 cup cream (8 oz.) 3/4 cup of sugar Mix cream, milk and 1/4 cup of sugar and pour into freezer; freeze until half frozen (mushy). Add juice of 3 lemons and 1 whole lemon (peel and pulp) shaved into very thin slices sweetened with remainder of sugar (if not sufficiently sweet add more sugar and make allowances for same in fuel value). Continue the freezing until sherbet is of the right consistency. ~Miscellaneous Desserts~ NUT CHARLOTTE _with wine 758 calories; without wine 745 calories_ _Two servings_ 1/2 cup 40% cream 2 tbs. sugar 8 pecan or walnut meats 1/4 tsp. vanilla or 1 tbs. sherry wine Dissolve sugar in the cream and beat solid, add flavoring or sherry and nuts. ORANGE CHARLOTTE _631 calories_ 1/2 cup of orange jelly mixture (see directions for making under jellies) 1/2 cup double cream 1 tbs. sugar (the above quantity will require about 2 tsp. of granulated gelatin). Pour jelly mixture into a bowl and surround with cracked ice; when it begins to stiffen, fold in the stiffly beaten cream. Pour into molds or ice cream glasses and set aside in the ice-box to become set. SNOW PUDDING _428 calories for orange pudding_ Orange, lemon, grape juice, or pineapple may be used in preparing this pudding. 1/2 cup fruit juice 2 tsp. gelatin 1 tbs. cold water 1/4 cup sugar 1 egg white and 1/4 cup soft custard Make jelly mixture as already directed and place the bowl in a pan of cracked ice; when the mixture begins to stiffen, fold in the well-beaten egg white (beat it in with an egg beater). Pour the mixture into a mold or individual glasses and set aside on ice to become set. When ready to serve, unmold and pour on the soft cold custard. PRUNE OR PRUNE FIG WHIP _184.4 or 244.9 calories_ 6 prunes or 4 prunes and 1 fig 1 egg white 2 tbs. sugar Cook the prunes and figs in sufficient water to cover them until they are perfectly soft, press through a sieve, add sugar, chill thoroughly, and fold in the stiffly beaten egg white. The above mixture may be put in individual cups and baked in a slow oven (in a pan surrounded with hot water) until they are firm in the center and a light brown. Serve with or without whipped cream. FOOTNOTES: [29] "Archives of Pediatrics," Vol. XXII, p. 515, by Van Slyke. [30] "Chemistry of Food and Nutrition," by Henry Sherman. [31] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot. [32] Bulletin 56, Hyg. Lab., Public Health Service, 1908; Circular 153, U. S. Dept. Agric., Bureau of Animal Industry, 1910. [33] "Diseases of Nutrition and Infant Feeding," p. 173, by Morse and Talbot. [34] Quoted from "Diseases of Nutrition and Infant Feeding," p. 173, by Morse and Talbot. [35] Rosenau: Bulletin 56, Hyg. Lab., Public Health Service, 1909; Circular 153, U. S. Dept. Agric., Bureau of Animal Industry, 1910. [36] Sommerfield: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. [37] Buttermilk Tablets may be purchased from the Chas. Hanson Co. Lab., N. Y., or from Parke, Davis & Co. The Buttermilk Starter is prepared by the first mentioned firm and is ready to use, directions coming with each sample. [38] Recipes for coffee, egg, cocoa and chocolate junket will be found in junket recipes, from the Chas. Hanson Co. [39] Egg white is frequently added to increase the nutrient value of ice creams and water ices. [40] Edible Portion. [41] "Chemistry of Food and Nutrition," by Henry Sherman. [42] "Food Products," by Henry Sherman. CHAPTER VI INFANT FOODS AND FORMULAS USED IN ABNORMAL CONDITIONS ~Formulas Used In Feeding Infants~ WHEY Put one pint of skimmed milk into a clean saucepan and heat to a temperature of 100° F. (lukewarm). To this milk add 2 teaspoonfuls of liquid rennet, essence of pepsin, or 2 junket tablets, stir until well mixed, and allow to stand at room temperature (70° F.) until firmly jellied. Break up with a fork until it is finely divided, strain through thicknesses of cheesecloth; return the fluid part to the stove and raise to a temperature of 150° F. to destroy the rennet left in the whey. The whey is then cooled before it is added to the milk or cream. BARLEY WATER 3% decoction starch[43] 4 rounded tsp. barley flour 1 pt. water Mix a small amount of the water with the barley flour and put the rest of the water into a clean saucepan and allow to heat; when boiling add thin barley mixture, stir thoroughly, and allow to boil 20 minutes; remove from stove, measure, and replace with hot water that which was lost through evaporation to make up the original pint; strain through two thicknesses of cheesecloth. OAT WATER 4 rounded tsp. oat flour 1 pt. water Mix and proceed as in making barley water. ALBUMEN WATER WITH BRANDY 8 oz. water (cold) 1 egg white 1 tsp. brandy Mix egg and water and add brandy slowly to prevent coagulating egg white. BEEF JUICE Composition: 0.60% fat, 2.90% protein, and considerable extractive matter.[44] Place a piece of round steak upon a hot griddle and turn once or twice until the outside is seared and the meat is hot throughout. Remove from griddle and cut into small pieces and place in a small meat press made for the purpose. A lemon squeezer may be used when the press is not available. Salt lightly. Begin by giving one teaspoonful and increase the amount gradually to 1 ounce (6 teaspoonfuls). According to Morse and Talbot, it is never wise to give babies more than 2 ounces of beef juice even in their second year, as it is apt to disturb digestion. Also babies are often made restless or sleepless by taking beef juice. MALT SOUP _347 calories_ 1-1/2 - 2 tbs. malt soup extract (reduce if necessary) 1 level tbs. sifted flour 1 pt. milk 18 oz. water (hot and cold) Dissolve malt soup extract in 1/2 cup of hot water and measure in enough cold water to cool the mixture. With the remaining cold water mix the flour until it is free from lumps; and to the malt soup mixture, add milk. Pour all into a clean saucepan and bring slowly to the boiling point; simmer (not boil) for 20 minutes. Now increase the heat and allow the mixture to boil 5 minutes; strain and use as directed. This is a fattening mixture and the amount of malt soup and whole milk may be increased as the child is able to handle it, taking care, however, not to increase the strength of the mixture too rapidly or too much, or digestional disturbances will result. BUTTERMILK MIXTURE FOR INFANTS _544.6 calories_ 1 tbs. wheat flour, 4 tbs. dextri-maltose, 8 oz. hot water plus enough hot water to replace that which is lost through evaporation (about 6 oz.). Buttermilk, sufficient quantity to make 1 quart of mixture. Mix flour with a little cold buttermilk. Dissolve sugar (dextri-maltose) in the hot water. Stir two mixtures together and add enough buttermilk to make 1 quart. Place on stove and bring mixture quickly to a boil. Boil for 20 minutes, stirring constantly, strain, measure, and add enough boiling water to replace that which is lost in cooking. Place on ice and use as directed. The nurse will soon be able to tell how much water is lost in evaporation and add the additional amount to the mixture before beginning the boiling. EIWEISSMILCH[45] (PROTEIN OR ALBUMEN MILK) 1 quart fresh whole milk 1 pint of fresh buttermilk 4 teaspoons essence of pepsin, Heat whole milk to 100° F., add essence of pepsin and stir thoroughly. Allow to stand at same temperature until the curd is formed. Pour mass into muslin bag and drip the whey from the curd. When the mass is as dry as it is possible to have it, remove it from the bag to a fine strainer. Press curd through the strainer with a wooden spoon or potato masher (the author has found that a potato ricer with a piece of copper gauze, such as is used in a chemical laboratory, inserted, facilitates the breaking up of the curd). The mass must be passed several times through the strainer in order to make the precipitate sufficiently fine to look like milk. During the process of straining, the buttermilk is added. The composition of above formula is, according to Finkelstein and Meyer, as follows: Protein 3%, Fat 8.5%, Sugar 1.5%, Salts 0.5%. There are several prepared Eiweissmilch mixtures on the market, Beebe, Hoose and others. Larasan Roche is also a prepared mixture having a composition much like that of the original Eiweissmilch, it is easily prepared, and the results from feeding this milk have been found generally good. FORMULAS USED IN DIET FOR CONSTIPATION PRUNES AND FIGS 1/2 lb. each prunes and dried figs 1 oz. senna leaves Boil from 2 to 3 hours as directed in preparing prunes as above. Lift fruit from hot sirup, place in quart jars, strain the juice and pour over the fruit. Use as needed. CONSERVE 1/3 lb. prunes (pits removed) 1/3 lb. raisins (seeded) 1/3 lb. figs 1 oz. senna leaves Boil prunes just enough to allow of the pits being removed. Cool and pass with the senna leaves, figs and raisins through the food chopper. After passing through once return to chopper and pass through a second time. See that the senna leaves and fruit are thoroughly mixed and finely chopped. Place in a quart jar and give in doses of from 1 to 2 teaspoonfuls night and morning. BRAN GEMS (NO. 1) _560 calories_ 2 tbs. molasses 1/2 tsp. salt 1/2 cup milk 1-1/2 cup bran 1/2 tsp. soda 1 egg Mix soda into bran, add salt, stir milk and molasses together and stir into bran; add well-beaten egg. Bake in 6 well-greased gem pans. BRAN GEMS (NO. 2) _832 calories_ 1-1/2 cups bran 1 tbs. sugar 2 tbs. melted butter 1 egg 1 cup milk 2 tsp. baking powder Mix together and bake in 6 well-greased gem pans. BRAN BISCUITS _706 calories_ 1 cup of bran 1/2 cup of flour 1/2 tsp. salt 2 tbs. butter and lard mixed 1-1/2 tsp. baking powder 1/3 cup of milk Mix flour, salt, baking powder and shortening together. Add milk to make a soft dough. Mold into biscuits, and bake in a quick oven 10 to 12 minutes. BRAN COOKIES _2187.5 calories_ 1/2 cup of sugar 1/2 cup of molasses 1/4 cup of butter and lard mixed 1-1/2 cups of bran 1 cup of flour 1 tsp. cinnamon 1 tsp. ginger 1/2 tsp. cloves 1/2 tsp. nutmeg 2 eggs 1/2 cup raisins or nuts may be added, due allowance being made for the additional fuel value. Cream butter and sugar together, add molasses. Sift flour, salt and spices together. Add eggs (well beaten), to sugar mixture and stir in the remainder of ingredients. Drop from spoon on a well-greased pan, bake in moderate oven to a delicate brown. (See Protein-free cookies, p. 340.) ~Nutrient Enemas~[46] NO. 1. MILK AND EGG 6 oz. milk, 1 egg 1 tsp. pure peptone (this may be omitted) 1/2 oz. normal saline solution 1 tube peptonizing powder dissolved in 1 tbs. water Mix thoroughly and peptonize at a temperature of 110° F. for 1 hour. NO. 2 8 oz. milk 3 eggs 3 grains table salt NO. 3 8 oz. milk 2 oz. glucose (grape sugar) NO. 4. SINGER'S ENEMA 125 gm. (about 4 oz.) milk 125 gm. (about 4 oz.) wine 1 or 2 egg yolks Salt 1 tsp. Witte's peptone NO. 5. BOAS' ENEMA 250 c.c. (8 oz.) milk 2 egg yolks Small quantity of salt 1 tbs. of red wine 1 tbs. "Kraftmehl" Health Flour NO. 6 6 oz. bouillon 4 oz. red wine 1 egg yolk 1 to 2 tsp. dry peptones NO. 7. MILK AND STARCH ENEMA--VON LEUBE 250 c.c. (about 8 oz.) milk 70 grains starch MALTED MILK ENEMA Dissolve 1 oz. of malted milk in 8 oz. of hot water 1 egg and 1/2 tsp. salt or 1/2 oz. saline solution NORMAL SALINE SOLUTION 1 dram sodium chloride (common salt) 1 pt. (16 oz.) water, (boiled) ~Formulas Used in Diabetes~[47] * BRAN AGAR WAFERS Makes 30 wafers. 2-1/2 quarts washed bran (_dry_) 36 gms. agar-agar 1-1/2 tsp. salt 2 saccharin tablets (1/2 gr.) 600 c.c. of cold water Mix agar-agar, saccharin, salt and water. Boil until dissolved. Pour over dry bran. Mix thoroughly and mold into muffin tins while hot. Bake in a slow oven about 20 minutes, or until wafer is dry and will whirl in the tin. * AGAR JELLY 1 tsp. or 7 gms. agar-agar 1 cup cold water 1 tsp. mild citric acid 1/2 gr. saccharin 1/4 tsp. flavoring Coloring--as desired Dissolve agar-agar in water. Add citric acid and saccharin. Put over flame and boil. Remove from fire--add flavoring and coloring. Put in cool place to harden. This jelly has no food value. * SPINACH AND EGG SALAD 3 gms. gelatin 2 tbs. cold water, melt and swell over hot water. Add: 6 tbs. cold water 2 tbs. vinegar 50 gms. fresh cooked spinach 1 hard cooked egg Salt as desired Surround mold with slices of hard cooked egg, placing the spinach in the center. Pour over this the gelatin mixture; allow to mold and serve on lettuce. * MAYONNAISE DRESSING 2 egg yolks 360 gms. of salad oil 60 c.c. vinegar 8 gms. salt and pepper Beat egg yolks. Gradually add oil until all has been used (beating the mixture constantly). Then add the remainder of the ingredients. Put in a covered jar and keep in a cool place. The percentage composition of this dressing is Fat--83%. Protein--0.9% CELLU BRAN CRACKERS 1/2 cupful cellu flour 1 cupful dry, washed bran 1 tablespoonful India gum 1 teaspoonful baking powder 1/2 teaspoonful salt 3 tablespoonfuls mineral oil 1/2 grain saccharin Hot water Makes 12 crackers about 4 inches by 4 inches and 1/8 inch thick (resembling Graham crackers). Mix all dry ingredients. Add mineral oil and saccharin dissolved in a small amount of water. Then add sufficient hot water to make a soft dough. Spread on a baking sheet or in flat baking pans and cut into twelve wafers. Bake in a slow oven until dry. These crackers have practically no food value. * * * * * Soya Manna may be secured from Vitae Health Food Company, 364 Roy Street, Seattle, Washington. Soya Manna muffins may be substituted for hepco cakes in any of the following recipes: ** OLMSTED BRANCAKES (_Recipe 41_) 3 cupfuls bran, washed 2 eggs 2 egg yolks 1/4 teaspoonful salt 50 grams lard or crisco, melted 180 grams water 1/2 teaspoonful baking powder Mix ingredients in order given and bake in a moderate oven. This recipe makes 18 muffins. Food value of 6 muffins, 1 gram carbohydrate, 5 grams protein, 23 grams fat. ** SOYA MANNA MUFFINS (_Recipe 42_) 2 eggs 60 grams cream--20% 140 grams Soya Manna 20 grams butter 1/2 teaspoonful baking powder 100 grams water Beat eggs, add cream and then flour, beating all the time. Add water and melted butter. Mold into 12 cakes and bake. Each cake contains 6 grams protein, 6 grams fat: approximately 75 calories. ** NOODLE SOUP (_Recipe 43_) 1/2 pint broth--clear 1 egg noodle 5 grams butter Few grains salt and pepper Beat eggs until stiff and bake in 5 grams of butter as an omelet; let cool, cut into strips as noodles. Heat broth and add noodles. If desired, add vegetables, cut in cubes, using such variety and quantity as give flavor to soup adding their food value to diet. Food value 6 grams protein, 10 grains fat. ** CHICKEN SUPREME (_Recipe 44_) 50 grams chicken weighed cooked 1/2 egg 50 grams milk 25 grams celery Few grains salt and pepper Beat egg slightly, add chicken, cut in small pieces, milk salt and pepper. Put in mold, set in pan of hot water and bake in moderate oven until firm. Food value 4 grams carbohydrate, 18 grams protein, 13 grams fat. ** SALISBURY STEAK (_Recipe 45_) 75 grams steak--fat, weighed uncooked 25 grams onion, uncooked Few grains salt and pepper Grind the meat, add seasoning and make into firm balls. Sear in hot mineral oil, then cook at a lower temperature. Food value, 2 grams carbohydrate, 17 grams protein, 22 grams fat. ** VEAL BIRD (_Recipe 46_) 75 grams meat 2 Olmsted brancakes, crumbed 25 grams chopped celery Few grains salt and pepper 100 grams skim milk Have meat cut in one thin slice. Use the trimmings chopped fine in dressing of crumbs, celery and seasoning moistened with water. Spread dressing on meat, roll and tie or skewer with toothpicks. Put in casserole and bake in milk until done. Food value, 6 grams carbohydrate, 23 grams protein, 19 grams fat. ** SALMON MOLDED (_Recipe 47_) 100 grams salmon 1 egg yolk 5 grams butter 50 grams skim milk 2 tablespoonfuls vinegar Few grains salt 1/2 teaspoonful gelatin 1 tablespoonful cold water Remove the salmon from the can, weigh, separate in flakes. Add beaten yolks, melted butter, milk and vinegar and salt. Cook over boiling water, stirring constantly until mixture thickens. Soak gelatin, strain and add to salmon. Fill individual molds, chill, and serve with cucumber sauce. Food value, 3 grams carbohydrate, 26 grams protein, 23 grams fat. ** CABBAGE SOUFFLÉ (_Recipe 48_) 100 grams cabbage, cooked 15 grams lean meat, cooked, minced 35 grams sour cream--16% 1 egg 10 grams American cheese Few grains salt and pepper Chop cabbage fine, add meat, cream, beaten egg, salt and pepper. Put into mould and sprinkle grated cheese over top. Bake in a moderate oven until firm and brown. Food value, 5 grams carbohydrate, 15 grams protein, 17 grams fat. ** CELERY RAMEKINS 50 grams milk 1/2 hepco cake 25 grams celery 1 egg 5 grams butter Few grains salt and pepper Heat milk; add crumbed hepco cake, grated celery and seasonings, let come to a boil, add butter, remove from fire; add beaten egg yolk. Fold into beaten white. Put in ramekin and bake 20 or 30 minutes in slow oven until well browned. Food value, 3 grams carbohydrate, 11 grams protein, 15 grams fat. ** BAKED ONION 50 grams onion, uncooked 10 grams ground meat, lean cooked 15 grams whole milk Few grains salt and pepper Parboil the onion, scrape out the inside, leaving only shell. Weigh shell and scrapings to 50 grams. Add meat and return to shell. Put into casserole, add milk and bake until tender. Food value, 4 grams carbohydrate, 4 grams protein, 2 grams fat. ** SQUASH PIE (_Recipe 92_) 1 egg 150 grams squash cooked 50 grams cream--16% 1/2 teaspoonful cinnamon 1/4 teaspoonful nutmeg Few grains salt 1/2 grain saccharin Beat egg, add mashed squash, cream, spice, salt and saccharin dissolved in 1 teaspoonful of cold water. Bake until firm in center, using cellu flour recipe for pie crust. Food value, 12 grams carbohydrate, 10 grams protein, 14 grams fat. ** SPICE COOKIES (_Recipe 93_) 2 eggs 1/2 grain saccharin 10 grams cream--16% 1 teaspoonful spices--cinnamon, cloves, nutmeg 20 grams ground almonds Beat the yolks, add saccharin dissolved in cream, then spices and ground almonds. Add to the stiffly beaten whites. Drop from spoon on oiled pan and bake in hot oven. Food value, 4 grams carbohydrate, 16 grams protein, 25 grams fat. CREAM OF CAULIFLOWER 1/4 cup cauliflower purée 2/3 cup chicken or beef stock 1/4 tsp. onion juice (if desired) 2 tbs. 40% cream Salt and pepper Add cauliflower to stock, and allow to come to a boil, season and add cream. Serve at once. TOMATO BISQUE 1 cup creamed tomatoes 1/2 cup water 1 sprig (1 tbs. chopped) parsley 3 cloves 1/2 tsp. salt 1/8 tsp. soda 1-1/2 oz. (3 tbs.) 40% cream Cook tomatoes with cloves, parsley, and water for 20 minutes. Press through sieve and return to fire. Add soda; when effervescence ceases, add cream, and serve at once. SPINACH SOUP 30 gm. cooked spinach 15 c.c. 40% cream 1 egg yolk Cook spinach until tender and press through a sieve; add the broth; allow to cook about 5 minutes and add the well-beaten yolk and cream. Place the saucepan over hot water and cook 10 minutes. Season and serve at once. Other Cream Soups, except Tomato Bisque, are made by the same recipe. VEGETABLES The nurse must be governed in the selection of the vegetables by the physician, using those from the 5% group until otherwise ordered. These must be boiled in three separate waters to further reduce their carbohydrate content. Cream or butter is added to them when diet permits; in the beginning (after starvation) only salt or (in case the vegetable is given in form of a salad) a little lemon juice with a little salt and pepper added. Grated onion, a small quantity of celery seed, or a tiny bit of chopped green pepper may be added for additional seasoning. When some fats are allowed, butter, olive oil, and cocoanut cream may be used; the latter is prepared as follows: 1 small cocoanut grated; this is washed in cold water slightly acidulated with vinegar to remove the sugar, then washed to remove the vinegar. Over the washed cocoanut pour 1 pint of boiling water; allow to stand until cold enough to squeeze through a cloth; press as much of the water out as possible. Pour the water into a shallow dish and allow to stand until the cream rises; skim off and serve with lemon juice on salad as a dressing. BOILED CORNED BEEF WITH CABBAGE AND OTHER VEGETABLES[48] "A portion containing 50-75 grams meat and 100 grams of each vegetable makes an excellent meal." Horseradish (sauce) is recommended by Joslin as a seasoning, and some pickles made from group of 5% vegetables and without sweetening. Curry powder, tarragon, bay leaves, capers may likewise be used in moderation to vary the monotony of the diet. PARSLEY BUTTER 5 gm. butter 1 tsp. chopped parsley Salt, pepper, and 1/2 tsp. lemon juice, if desired Cream butter, add lemon juice, salt, and pepper. Stir in parsley. Serve on meat or fish. NEUFCHÂTEL CHEESE SALAD 1/3 Neufchâtel cheese 1/4 green pepper 1 tbs. cream (40%) 1 tsp. lemon juice Season with salt and paprika and dress with cream dressing. CHEESE SALAD Mash cream cheese with fork; add tablespoonful chopped pecan nuts to 1/3 Neufchâtel cheese. Season with salt and pepper and dress with French dressing. TUNA FISH SALAD 1/2 cup tuna fish 1/2 cup chopped celery Dress with French Dressing. EGG SALAD Cook 1 egg hard. Cut into rings; arrange on lettuce leaf; dress with cream dressing. TOMATO ASPIC 1 cup canned tomatoes 1/2 cup celery (hearts) 1 tsp. celery seed 1/2 small onion 1/2 cup water 1/4 cup vinegar 3-4 cloves 1/2 bay leaf 2 tsp. granulated gelatin, soaked in tbs. water Boil all ingredients (except gelatin and celery hearts) 20 minutes. Measure. Add hot water or tomato juice to make one cup; add gelatin; allow to cool; cut celery fine, place in mold; pour in the tomato aspic and allow to jelly in a cold place. ~Bread Substitutes~ BRAN BISCUITS, OR MUFFINS 1 cup washed bran 1 tsp. baking powder 1 egg 1 tbs. melted butter 2 tbs. cream 1/4 tsp. salt Tie bran in cheesecloth bag and attach to cold water faucet; allow water to pass through bran, removing starch by squeezing the water through; using dry. Beat egg separately; add cream; mix with bran, add melted butter, salt, and baking powder. Grease muffin rings and pour in the mixture. Bake in moderate oven. DIABETES MUFFINS[49] (The Equivalent of an Egg) Recipe for Hepco Cakes, so arranged that one cake is equivalent to an egg: 140 gm. Hepco flour Protein 60 Fat 29 2 eggs Protein 12 Fat 12 60 c.c. 40% cream Protein 2 Fat 24 10 gm. butter Fat 9 Make twelve cakes; each cake contains 6 grams of protein, 6 grams of fat, and approximately 75 calories. LISTER MUFFINS So arranged that each muffin is equivalent to one egg: 60 gm. Lister flour (one box) Protein 42 Fat 0 1 egg Protein 6 Fat 6 45 c.c. 40% cream Protein 2 Fat 18 30 gm. butter Fat 25 Make 17 muffins; each muffin contains 6 grams protein, 6 grams fat. BRAN BISCUITS FOR CONSTIPATION (By F. M. Allen) 60 gm. bran 1/4 tsp. salt 6 gm. powdered agar-agar 100 c.c. (1/2 glass) cold water Tie bran in cheesecloth and wash under tap until water is clear. Bring agar-agar and water (100 c.c.) to boiling point. Add washed bran and salt and agar-agar solution (hot). Mold into ten cakes; place on oiled paper and let stand 1/2 hour, then when firm and cool, bake in moderate oven 30 to 40 minutes. The bran muffins are more palatable if butter and eggs are added. This may be done, provided the patient allows for them in the diet. CASOID FLOUR AND BRAN MUFFINS 1 oz. (30 gm.) casoid flour 1 level tbs. (15 gm.) butter 1 oz. (30 c.c.) 40% cream 1/4 tsp. salt 1 egg white (whole egg may be substituted for 1 egg white) 1-1/2 tsp. baking powder 1 cup washed bran Total food value: protein, 18 grams; fat, 24 grams; carbohydrates, 1 gram; calories, 300. One muffin: protein, 3 grams; fat, 4 grams; carbohydrates, trace; and calories, 50. The flours and meals used in this recipe are prepared by Cutlard, Stewart & Walt, Ltd., London (casoid flour). Theo. Metcalf & Co., Boston (soya bean meal). Lister Brothers, Andover, Mass. (Lister diabetic flour). LISTER FLOUR AND BRAN MUFFINS, OR BISCUITS 1 cup washed bran 30 gm. Lister flour 1 tsp. baking powder 1 tbs. butter 1 egg 1/2 tsp. salt 2 tbs. 40% cream Sufficient water to make a drop batter (about 1/4 cup) Squeeze all the water from the bran, then add flour and melted butter, salt, well-beaten egg yolk and cream. Whip egg white stiff and fold into mixture. Add baking powder and enough water to make thick batter. Use less water if biscuits instead of muffins are desired, and knead into a dough. Roll out into a sheet one-half inch thick and cut with biscuit cutter. After making muffin batter, grease muffin ring with melted lard, and pour half full of above mixture. Bake in moderate oven about 20 or 30 minutes. SOYA MEAL AND BRAN MUFFINS[50] 1 oz. (30 gm.) soya meal 1 level tbs. (15 gm.) butter 1 oz. (30 c.c.) 40% cream 1/4 tsp. salt 1 cup washed bran 1 egg white (one whole egg may be substituted for one egg white) 1-1/2 tsp. baking powder Mix soya meal, salt, and baking powder. Add to washed bran; add melted butter and cream. Beat egg white and fold into mixture; add enough water to make thick drop batter. Bake in six well-greased muffin tins until golden brown from 15 to 25 minutes. Total food value: protein, 11 grams; fat, 27 grams; carbohydrates, 2 grams; calories, 304; one muffin, protein, 2 grams; fat, 4.5 grams; carbohydrates, trace; calories, 50. ALMOND BISCUITS 1 cup almond meal 1 oz. cream 1 egg 1 grain (or less) saccharin, dissolved in 1 tsp. of water 1-1/2 tsp. baking powder 3-4 drops vanilla Beat egg yolk until light, add cream and saccharin; stir this into almond meal. Fold in the stiffly beaten white. Drop on a greased paper and bake until golden brown in a moderate oven. * * * * * Almond meal or flour is prepared as follows: Blanch 1 pound of almonds; dry and pass through grinder, or pound in mortar until powdered. Place in a muslin bag and immerse in a pan of water acidulated with vinegar to remove sugar; allow to stand 15 minutes. Squeeze dry and place in a warm (not hot) oven to remove all moisture. Grind or pound once more. Almond flour does not keep well; it must be made in small quantities and kept in a glass jar in a cool place. COCOANUT FLOUR Grate cocoanut and treat as almonds to remove sugar; dry thoroughly and grind or pound to fine meal. COCOANUT BISCUITS 1 cup cocoanut 1 egg white (or whole egg if desired) 1-1/2 tsp. baking powder 1/2 grain saccharin (A biscuit may be made without saccharin for bread substitute.) SPANISH CREAM 5 tbs. coffee, or Infusion of cocoa nibs 1 tsp. gelatin 1 tbs. cold water 30 c.c. (1 oz.) 40% cream 1 egg Saccharin to sweeten Pour coffee, or cocoa infusion, into a double boiler, beat egg yolk and saccharin dissolved in 1 tsp. of water, and stir into hot coffee. Cook gently until mixture coats the spoon (raw flavor of egg has disappeared); add gelatin and mix thoroughly. Whip cream and egg white. Place on ice to set. LISTER CREAM PUFF This is made by pouring 30 grams of soft custard (diabetic) over 1 Lister biscuit. CUSTARD 1/2 cup cream 1/4 grain saccharin 1 egg 3-4 drops vanilla or almond extract Beat egg until it is well broken up, but not light; stir into the cream; dissolve saccharin in teaspoonful of water and add to mixture. If custard is to be baked, pour into molds and place upon a rack, or on a folded cloth in a pan half filled with hot water; bake in moderate oven until firm in center. If soft custard is desired, pour mixture into double boiler and cook gently until mixture coats the spoon and the raw egg flavor has disappeared. SNOW PUDDING Make 1/2 cup gelatin, as directed below. Whip in 1 egg white. When gelatin is half congealed, mold and set on ice. When ready to serve, unmold and serve with custard, or 1 tbs. whipped cream. ~Jellies~ 1 tbs. cold water to 2 tsp. granulated gelatin is used in making the following jellies: LEMON _16.6 calories_ 1/2 cup boiling water 1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water 1/2 lemon or 2 tbs. juice and 1/2 rind sliced thin IRISH MOSS PUDDING Carefully pick over and wash through several waters 1 tbs. Irish moss. Place in double boiler with 1/3 cup of water and 3 tbs. 40% cream and 1/4 grain saccharin. Cook until mixture thickens when dropped upon a cold saucer. Pour over 1 stiffly beaten egg white; add 3-4 drops of vanilla extract. Mold and set on ice. Irish moss may be used as a substitute for gelatin. The carbohydrates in this substance are not believed to be utilized for the manufacture of glucose in the human body. ORANGE _54 calories_ 1/4 cup boiling water 1/2 tbs. lemon juice 1/2 cup orange juice 1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water 2 drops orange extract WINE _40.8 calories_ 1/2 cup boiling water 3 tbs. sherry wine 1 tsp. lemon juice and the yellow rind from 1/4 lemon 1-inch piece of cinnamon 1/4 to 1/2 saccharin tablet dissolved in 1 tbs. water METHOD FOR FRUIT JELLIES Soak gelatin in cold water about 2 or 3 minutes, then pour over it the boiling liquid; add saccharin and fruit juice, strain through cloth into wet molds. Set in cold place to stiffen; when firm, unmold. Serve with whipped cream, or pour liquid into baskets made from orange or grapefruit, hollowed out and the edges scalloped, or pour into shallow pans, and cut in 1/2-inch blocks when firm and serve on a bed of whipped cream. WINE JELLY Put water, wine, lemon juice and peel, cinnamon, and saccharin into a saucepan, allow to boil 5 minutes, pour over gelatin (which has been soaked in cold water). If the jelly looks cloudy, return to saucepan, and add 1/2 egg white beaten stiff; allow to boil 1 minute, stirring constantly, and strain into mold. Serve with whipped cream. ~Ices~ LEMON _30 calories_ 1/3 cup water Fruit juice, 1 lemon 1/4 to 1/2 saccharin tablet 1 egg white ORANGE _75.5 calories_ 1/2 cup water 1 large or 2 small oranges 1/2 lemon 1/4 to 1/2 saccharin tablet 1 egg white Sweeten fruit juice with saccharin instead of sugar. Clip egg white with scissors, or beat with Dover egg beater, add mixture and freeze. ICE CREAM (1) Use recipe for soft custard, freezing after the custard has become thoroughly cold. (2) 1/3 cup cream 1 tbs. chopped nuts 1/4 grain saccharin or enough to sweeten, dissolved in 1 tsp. water 3-4 drops vanilla, orange, or almond extract Whip cream, add saccharin and nuts. Pour into a small 1/4-pound baking powder can, seal the edges of mold or can with a thin strip of buttered muslin. Pack in equal parts of salt and ice for two hours. ~Sugar-free Milk.~--A sugar-free milk has been advised by Williamson. It is made from washed cream as follows: 3 tablespoonfuls of cream are shaken in a pint of water and set aside until the cream rises, it is then skimmed off and mixed with the white of one egg and diluted with pure water. This furnishes a beverage not unlike milk in appearance and flavor. NUT CHARLOTTE 60 c.c. (2 oz.) 40% cream 30 gm. chopped walnuts Saccharin to sweeten 3-4 drops vanilla Whip cream stiff; add saccharin, nuts, and vanilla. 1 tbs. sherry wine and 1 tsp. gelatin soaked in 1 tbs. cold water and melted over hot water may be substituted for vanilla to vary the above recipe. ORANGE CHARLOTTE 75 c.c. (5 tbs.) orange juice 45 c.c. (3 tbs.) 40% cream 1/2 egg white 1 tsp. gelatin 1 tbs. cold water Saccharin to sweeten Soak gelatin in cold water; dissolve over hot water, add to orange juice; add saccharin; set aside until it begins to jelly. Whip cream and add to partially jellied orange juice; fold in the stiffly beaten egg white; mold. Serve 30 grams. FOOTNOTES: [43] When a 1.50% decoction is desired, use 2 rounded teaspoonfuls to the pint of water. "Diseases of Nutrition and Infant Feeding," p. 222, by Morse and Talbot. [44] "Beef juice is not the same as 'dish gravy,' since the latter contains a large amount of cooked fat and is often highly indigestible." Morse and Talbot's "Diseases of Nutrition and Infant Feeding." [45] Formula suggested by Finkelstein and Meyer. [46] "Diet in Disease," by Freidenwald and Ruhräh and other sources. [47] Formulas marked with one star are those used in the Presbyterian Hospital, Chicago, Ill. Courtesy of Miss R. Straka, Dietitian. Formulas marked with two stars are used in the Olmsted Hospital, Mayo Clinic, Rochester, Minn. Courtesy of Misses Foley and Ellithorpe, Dietitians. Formulas unmarked are used by the author in Memphis General and St. Joseph's Hospitals, Memphis, Tenn. [48] "Treatment of Diabetes," p. 538, by Joslin. [49] "The Treatment of Diabetes Mellitus," p. 531, by Joslin. [50] "Starvation Treatment of Diabetes," p. 43, by Hill and Eckman. SECTION III THE HUMAN MACHINE CHAPTER VII THE HUMAN BODY ~Chemical Composition of the Body.~--It has been estimated by various writers that the human body has an approximate average chemical composition[51] of-- Oxygen about 65 per cent Carbon about 18 per cent Hydrogen about 10 per cent Nitrogen about 3 per cent Calcium about 2 per cent Phosphorus about 1 per cent Potassium about 0.35 per cent Sulphur about 0.25 per cent Sodium about 0.15 per cent Chlorine about 0.15 per cent Magnesium about 0.05 per cent Iron about 0.004 per cent Iodine } Fluorine } very minute quantities Silicon } ~Dependence of the body upon Food.~--The human body, like any other piece of machinery, undergoes a constant wear and tear incidental to the work it performs, but in the human machine this is not all that must be included in its upkeep. The replacing of the dead and cast out cells with new ones, the repairing of the worn cells, the furnishing of heat, not only for the running of the engine but for the maintenance of the body temperature,--all of these must be considered and cared for if life is to continue. In man-made machinery, the renewal of the worn parts, and the replacing of those no longer useful must be accomplished by an outside agency. But in the body this work is performed by the organism; and the material used for the purpose, as well as that which is used to furnish the heat necessary for the internal and external activities of the body is food. ~Exceptions to this Rule.~--Under normal conditions the body never uses its own structure either for fuel or to replace tissue losses. In starvation the body rebuilds its important tissues, such as the nerves and glands, at the expense of the less important ones, such as the connective tissues and the skeletal muscles (Taylor). Science has proved that for the most part the body does not use the food materials in their original form, but carries them through a series of transformations into substances more easily handled by the organism. Roughly speaking, we may say that the body carries the foodstuffs through practically four processes on the pathway through the body, namely, digestion, absorption, metabolism, elimination. ~Processes Included in Digestion.~--There are several processes concerned in this transformation of the food materials. Some are purely mechanical and have to do with the movement of the food mass through the digestive tract: others are of a chemical character and bring about distinct changes in the food materials themselves. These mechanical and chemical processes with the retarding and stimulating agents that influence them are called digestion. ~Absorption.~--After the food materials have undergone digestion, or simplification into more available substances, these substances are absorbed, that is, they are passed through the membranes lining the walls of the intestinal tract, and thence to the blood. ~Metabolism.~--The utilization of the transformed food materials and their final fate in the human body is included under the term Metabolism. ~Elimination.~--After the food materials have been utilized to the extent of the body's ability to handle them, their waste products are cast out of the organism by way of the skin, the lungs, the intestines and the kidneys. A brief description of these processes seems desirable here. ~Digestion.~--Mechanical digestion begins in the mouth, where through the action of the teeth, the tongue and the muscles of the jaw, the food material is ground up and liquefied to a certain extent and made ready for the chemical action which takes place, to a limited degree only, as a result of the salivary enzyme in the mouth. The eating of food causes a flow of saliva from the three pairs of large salivary glands, and from the numerous secretory cells situated in the membranes of the mouth. As a rule the food stays for too short a time in this organ for any appreciable amount of chemical action to take place, but the liquefaction of the food mass with the salivary juices which contain the ferment (ptyalin), prepares for its passage into the gastric organ, and allows the digestion of the starch (the only foodstuff affected by salivary digestant), to continue in that part of the stomach until its action is checked by the hydrochloric acid in the gastric juice. ~Arrangement of Food in the Stomach.~--To simplify the study of the gastric organs it may be well to think of the stomach as being divided into three regions, _i.e._, "the fundus, the middle region, and the pyloric end,"[52] each of which differs slightly from the other. After being swallowed, the food enters the region situated at the cardiac end, known as the fundus. ~Motor Processes in the Stomach.~--There are no peristaltic waves in the fundus of the stomach, and the movement of the food mass is accomplished through the stretching and contraction of the muscular walls of the organ which tends to churn and further mix it with the salivary juices as it is gently pushed out into the middle region. In this region the peristaltic waves begin and travel toward the pylorus and increase in force as digestion progresses, ceasing only with the emptying of the organ. When the first stratum of food reaches the middle of the stomach it is caught by these oscillating peristaltic waves and forced forward through the pyloric region and against the pylorus, from whence it is returned back through rings of constriction. This forward and backward movement continues as long as there is food in the stomach, thus thoroughly mixing the mass with the gastric juice and allowing the enzymes existing in the juices to have an opportunity for action (chemical digestion). ~Passage of Food from Stomach.~--The material prepared in the stomach, known as ~chyme~, is passed into the duodenum through the pylorus. The opening of this sphincter is controlled, according to Cannon, to a certain extent by the liquefication of the chyme, but more especially by the presence of free acid in the stomach side of the pyloric orifice. ~Behavior of Food in the Intestines.~--The food does not pass at once along the canal, but waits in the duodenum until several portions have passed through. As the food mass is made alkaline in the presence of the intestinal juices, the pyloric valve closes, opening again as the contents nearest it on the stomach side are acidified. ~Intestinal Movements.~--The peristaltic waves in the small intestines begin in the upper part and start a course ever downward. These waves in the intestines are two-fold in character; the quick shallow wave which forces the food string forward, breaking it up into segments, and backward joining the segments together again, and the strong deep wave which carries the entire mass forward after each segmentation. This method of movement in the small intestines is the best one possible under the conditions which prevail in this region of the digestional apparatus, since it not only mixes the food material with the juices necessary for its digestion, but likewise spreads it out over a wide space, insuring a greater contact with the absorbing walls of the small intestines. ~The Effect of Muscular Constrictions.~--The muscular constrictions occurring in the intestines producing segmentation of the food string have, according to Sherman, the effect of "(1) further mixing of the food and digestive juices, (2) bringing the digested food into contact with the absorbing membrane, (3) emptying the venous and lymphatic radicles in the membrane, the material which they have absorbed being forced into the veins and lymph vessels by the compression of the intestinal walls."[53] ~Movements in the Large Intestine.~--The movements in the large intestine or colon are much like those in other parts of the digestive tract. The small and large intestine are divided by a valve known as the ileocecal valve, and any food which passes through it cannot return, since the valve is a competent one. The cells in the walls of the larger intestine secrete fluids of a lubricating character, containing no enzymes of digestion but aiding in moving the fecal matter toward the rectum. ~Distribution of Secretory Cells.~--Secretory cells are distributed in each of the three regions of the stomach, but are more numerous in the middle region than at either end. The third region includes the pyloric vestibule through which all foods must pass before they can enter the small intestine, and terminates in the pylorus, the valve which shuts off the stomach from the duodenum and the rest of the intestinal canal. ~Chemical Digestion.~--The chemical changes in the food materials, after they are eaten, are brought about through the action of certain substances known as soluble ferments or "enzymes." These enzymes exist in every tissue of the body, and their province is first to break down the food materials themselves into simpler compounds, and then to reconstruct the simpler substances into those of a more complex character, which are more available for the various uses of the organism. ~Action of the Enzymes.~--As Sherman has stated, "all fermentation is brought about either directly or indirectly by the activity of animal or vegetable organisms or cells. When the organisms or cells act directly and the chemical changes occur only in their presence, the fermentation is said to be due to an organized ferment. When the action is not brought about directly by the cell itself, but by means of a substance secreted by the cell but acting apart from it, this substance is called a soluble or unorganized ferment or 'enzyme.'" The enzymes concerned in digestion and metabolism, their source and their action, may be found in the following table: TABLE OF ENZYMES[54] SOURCE AND ACTION OF ENZYMES ==============+===================+==================+=================== | | _Where chiefly_ | | _Enzymes_ | _found_ | _Action_ --------------+-------------------+------------------+------------------- {|Ptyalin (salivary |Salivary |Converts starch {| amylase) | secretions | to maltose {|Amylopsin |Pancreatic juice |Converts starch {| (pancreatic | | to maltose {| amylase) | | {|Liver diastase |Liver |Converts glycogen {| | | to glucose {|Muscle diastase |Muscles |Converts glycogen {| | | to glucose Act upon {|Invertase (sucrase)|Intestinal juice |Converts glycogen carbohydrates{| | | to glucose {| | | and fructose {|Maltase |Intestinal juice |Converts maltose {| | | to glucose {|Lactase |Intestinal juice |Converts lactose {| | | to glucose and {| | | galactose {|Glycolytic enzymes |Muscles, etc. |Split and oxidize {| | | glucose | | | {|Lipase (steapsin) |Gastric, and |Splits fats to Acts on {| | pancreatic | fatty acids and fats {| | secretions, blood| glycerin {| | and tissues | | | | {|Pepsin |Gastric juice |Splits proteins to {| | | proteoses and {| | | peptones {|Trypsin |Pancreatic juice |Splits proteins to {| | | proteoses, {| | | peptones, Act on {| | | polypeptids and proteins {| | | amino acids {|Erepsin |Intestinal juice |Splits peptones {| | | to amino acids {| | | and ammonia {|Autolytic enzymes |Tissue generally |Split body proteins {| | | to simpler {| | | substances | | | {|Guanase |Thymus, adrenals, |Changes guanin {| | pancreas | to xanthin {|Adenase |Spleen, pancreas, |Changes adenin Act on purins{| | liver | to hypoxanthin {|Oxidases |Lungs, liver, |Changes hypoxanthin {| | muscles, etc. | to xanthin and to {| | | uric acid ==============+===================+==================+=================== ~Classification of Enzymes.~--Sherman classifies the enzymes of the body according to their effects: 1. The hydrolytic enzymes: (a) Proteolytic or protein-splitting enzymes. (b) Lipolytic or fat-splitting enzymes. (c) Amylolytic or starch-splitting enzymes. (d) Sugar-splitting enzymes. 2. The coagulating enzymes, such as thrombin or thrombase (the fibrin ferment) and rennin, which causes the clotting of milk. 3. The oxidizing enzymes or oxidases (which, if the oxidation be accompanied by a splitting off of amino groups, may be called "deaminizing" enzymes). 4. The reducing enzymes or "reductases." 5. Those which produce carbon dioxide without the use of free "deamidizing" oxygen, such as zymase of yeast. 6. Enzymes causing the breaking down of a larger into a smaller molecule of the same composition, as in the production of lactic acid from glucose. DIGESTION (CHEMICAL) ~Salivary Digestion.~--The table shows that enzymic action begins in the mouth. ~Saliva~, the characteristic secretion of this region, contains the enzyme ptyalin which exerts its influence upon the starches and dextrins. The food mass remains in the mouth for so short a time, however, that a very small percentage of the starch is changed to maltose under salivary digestion. The action of ptyalin, however, continues in the fundus of the stomach until stopped by the acid in the gastric juice. ~Gastric Digestion.~--The conditions existing in this region of the gastric organ of digestion are particularly favorable to the continuance of salivary digestion on account of the neutral character of the juices secreted by the cells there, and because there is so little movement taking place. The cells in the middle region, however, secrete a fluid rich in acid, and as the food mass is gradually pushed forward by the contraction of the stomach walls into this portion of the stomach, further conversion of starch and dextrin to maltose is checked. Gastric juice is secreted by cells situated in all parts of the stomach. The character of the secretions differs in different parts of the organ. However, that in the fundus is neutral in character or even slightly alkaline, according to Howell, while that in the middle region is highly acid. The pyloric end of the stomach exhibits strong peptonizing powers and much of the hydrolysis of protein takes place here. As the food is pushed out of the fundus it is caught by the waves of peristaltic action and swept toward the pylorus. This movement of the food mass to and from the pylorus under the influence of the muscular constriction in the stomach tends to mix it thoroughly with the juices in all parts of the stomach, and in a measure to liquefy it to the "souplike" mixture known as chyme. ~Rate of Carbohydrates, Proteins, and Fats.~--Carbohydrates, for example, do not require any acid for their digestion, hence all of the acid with which they come in contact can go toward acidifying them, while the proteins require hydrochloric acid before the enzymes can begin to exert their activities. Consequently they leave the stomach much more slowly than the carbohydrates. The fats leave more slowly than any of the other food combinations. If carbohydrates and proteins are taken together they leave the stomach more slowly than if the carbohydrates were fed alone, but more quickly than they would if the meal consisted of protein alone. When the meal consists of fats and proteins, the stomach is emptied more slowly than is the case when either is fed alone. ~Intestinal Digestion.~--Digestion proceeds in an orderly manner throughout the intestinal canal. The pancreatic juice, bile, and intestinal juice are poured upon the food mass on its entrance into the duodenum. The enzymes work simultaneously. _Trypsin_ in the pancreatic juice takes up the hydrolysis of the proteoses and peptones and those proteins which have escaped gastric digestion. The _amylopsin_ likewise in the pancreatic secretion acts upon the starch and dextrin, changing them to maltose. The lipases split the fats to fatty acids and glycerol. The _erepsin_ in the intestinal juice, "succus entericus," brings about further change in the proteins, with the production of amino acids. The bulk of the carbohydrates are converted into monosaccharids in the small intestines. The lactose, maltose, and sucrose are changed through the activity of the lactase, maltase, and invertase into glucose. Sherman states that "it is possible that the splitting of the lactose (milk sugar) may occur in the intestinal wall rather than in the food mass."[55] ~Bile.~--Human bile, the secretion most actively concerned in the digestion and absorption of the fats, contains water, bile salts, bile acids, bile pigments, cholesterin, lecithin, and a peculiar protein derived from the mucous membranes of the bile ducts and gall bladder. ~Stimulation of Intestinal Secretions.~--The flow of the intestinal juices is stimulated by a substance or _hormone_ known as "~secretin~." This hormone is the result of the action of hydrochloric acid upon some substance in the intestinal wall. Starling claims that the formation of hormones and their circulation through the blood to the reactive tissues is sufficient to account for the activity of the pancreas; he doubts if the nervous system plays any part in the activity of that organ. ~Secretion of Water in the Stomach.~--The secretion of water by the cells of the stomach is such, according to Taylor, as to produce chyme of quite constant consistency, the solid particles being held in suspension in the fluid medium. ~Factors Influencing Gastric Digestion.~--The factors influencing digestion in the stomach constitute all those mechanical, electrical, chemical, and psychical factors which stimulate or retard the action of the gastric juices. The movements in the stomach are involuntary, but their activities may be stimulated by the flow of gastric juice. Sleep retards digestion in the stomach by retarding the movements in the organ itself. ~Stimuli to Gastric Flow.~--The division and liquefaction of the food in the mouth hastens gastric digestion by making the food better fitted for the action of the enzymes in the gastric juice. The type as well as the character of the food acts as a stimulus to the gastric secretion. ~Water~ is probably the best of all the agents for stimulating the secretion of gastric juice, while ~dextrin~ (toast, zwieback) and the ~extractives of meat~ likewise exert similar powers. ~Retarding the Gastric Flow.~--The nervous system, on the other hand, at times checks or entirely inhibits a flow of these juices. Worry, excitement, anger, fatigue, chill; each plays its part in promoting poor digestion in the gastric organ. As chemical factors, water and salts are the two necessary substances for gastric digestion, since the enzymes in the juices cannot act except in their presence. ~Alkaline carbonates~ and ~fatty foods~ both check the flow of gastric juice, and retard digestion. The psychic factors which result in a stimulation of the secretory cells in the stomach are exerted through the sight, smell, and taste. One often hears the expression: "The food looked, smelled, or tasted so good that it made my mouth water." This actually occurs; hence the secretion has been named appetite juice. This appetite juice acts as a direct stimulant to the cells in the mucous lining of the stomach, causing a flow of gastric juice. It cannot be said to cause digestion, but it certainly institutes that process, thus starting the whole digestional procedure. ~Digestion in the Larger Intestine.~--Science has proved that most of the nourishing part of the food ingested is digested and absorbed before it reaches the larger intestine. The two portions of the alimentary canal known as the small and large intestine are separated by the ileocecal valve. Cannon claims "that this valve is competent, that is, under normal conditions the food mass which passes through into the colon cannot be forced back into the small intestine." The food mass sometimes contains materials which have escaped digestion, likewise some of the active enzymes which bring about their hydrolysis, in which case a certain amount of their digestion may continue in the large intestine. So far, investigators have found no enzymes in the fluids secreted by the cells in the walls of the large intestine, but they have found an alkaline fluid which assists in completing the digestion of the foods which has started in other parts of the intestinal tract. ~Absorption.~--Absorption of food occurs in all parts of the intestinal canal, but the major portion of it occurs in the small intestines, the mucous membrane lining of which seems particularly adapted for this purpose. According to Taylor there is no absorption of fats, carbohydrates, or proteins in the stomach. Other investigators believe that some of the protein is absorbed and also some glucose in concentrated solution. However, the stomach cannot be considered of great value as an absorbing organ. Physiology teaches that the absorption of the products of digestion occurs by means of the millions of small projections or villi with which the intestinal wall is lined. These villi contain numerous capillary blood vessels and spaces known as lacteals. The former converge into the portal vein, the latter into the lymphatic vessels and thence into the thoracic ducts. ~The Absorption of Fat.~--The fats, as has been described, are split into their two constituents, fatty acid and glycerol. The former is dissolved by the bile to form soap; the latter is readily soluble in water. These constituents thus dissolved pass through the walls and recombine in the form of neutral fat droplets, probably during the passage through the walls, since they appear in this form in the cells. They pass into the thoracic duct and thence into the blood stream. ~Absorption of Carbohydrates.~--The carbohydrates are chiefly absorbed in the form of monosaccharids. This has been proved by introducing cane sugar or lactose into the blood vessels and getting the greater portion of it back unchanged by way of the urine. As the monosaccharids are taken up by the capillaries lining the walls of the small intestines, they are passed on to the portal vein and carried by the portal blood into the liver, where they are stored temporarily as glycogen, and given out to the blood in the form of glucose as needed. After a meal rich in carbohydrates, the portal blood will be rich in glucose, while the blood in general circulation contains about the same amount as usual, about 0.1%. ~Absorption of Proteins.~--The absorption of the products of protein digestion occurs through the capillary blood vessels and passes on to the portal vein. The metabolism of protein is more complex than that of any of the foodstuffs. It is probable that each living cell contains enzymes which are capable of breaking down the body proteins with the production of amino acids just as the proteins of the food are broken down by enzymes of digestion, and according to Sherman "it is not improbable that protein synthesis also may be brought about by every living cell." ~The Absorption of Water.~--This does not occur in the stomach, as was formerly believed, but in the small intestines. ~The Absorption of the Mineral Salts.~--This occurs in conjunction with the other food material. Some of the mineral salts are much more soluble than others and are more readily absorbed. The function of the mineral salts in the body has already been described, and since they form a part of every tissue and fluid in the body their absorption and fate in metabolism must be studied with that of the other chemical combinations. ABSORPTION IN THE LARGE INTESTINES The digestion of the food as it is passed into the last portion of the alimentary canal has been largely completed. However, that part which has escaped digestion in the small intestine is finished and absorbed here. The important peristaltic waves occurring in this region are antiperistaltic in character and have the property of churning the food thoroughly and bringing a larger portion of it in contact with the absorbing walls. The water which is left in the food mass together with the products of the digestion of the foodstuffs is absorbed in the first part of the large intestine, leaving the remainder more solid. This residue is known as feces or fecal matter. The diagram on page 179 shows the various processes through which the foodstuffs pass after absorption.[56] ~Bacterial Action in the Alimentary Canal.~--The changes in the foods so far mentioned have been chiefly the result of the activity of the enzymes existing in the various digestive processes throughout the body. But there are other changes which occur in the foods during their sojourn in the digestive tract which are not accountable to enzymic action, but which, in fact, modify to a certain degree the changes wrought by the enzymes. These are the result of the activity of certain specific bacteria which inhabit the entire digestive tract of the individual from a few hours after birth until death. Some of these have so adapted themselves to the existing conditions that, unless present in overwhelming numbers, they are not only harmless, but they actually assist in protecting the organism from the inroads of more harmful species. Many experiments have been made to find whether or not bacteria are essential to human nutrition, and the results of these experiments prove that they are not. However, since they are so firmly established in the body it is well to study the various types and learn as much as possible of the products of their activity and the influence which they exert in human nutrition. Cells and Tissues / | \ Anabolism / | \ Catabolism Assimilation / | \ Dissimilation / | \ Foodstuff < | > End Products \ | / \ | / \ | / \ | / Combustion ~Types of Bacteria.~--It would be impossible and unnecessary to consider the action of all of the bacteria in the body in this text, but it is necessary to consider those which are prominent in bringing about decomposition of the foods in the digestive tract. Sherman holds that there are three main types having this property: "(1) the bacteria of fermentation, such, for example, as the lactic acid bacteria; (2) the putrefactive bacteria, such as the anaërobic B. aërogenes capsulatus; (3) bacteria of the B. coli type, showing the character of both the fermentative and putrefactive organisms but tending in general to antagonize the putrefactive anaërobes."[57] ~Fermentation in the Stomach.~--In the stomach, fermentation of the carbohydrates with the production of organic acids, and at times alcohol, occurs. The types of fermentation taking place in the stomach are alcoholic, lactic, butyric, acetic, formic, oxalic, and cellulose. The bacteria inhabiting the gastric organs are dependent upon air for existence, while those in the intestines are not. ~Factors Influencing Excessive Fermentation.~--The factors influencing excessive fermentation in the stomach are lack of "tone" and motility in the organ, insufficient amount or absence of free hydrochloric acid in the gastric secretion, dilatation of the stomach, and an excess of carbohydrate foods in the diet. Of the latter, sucrose and glucose are especially susceptible to the action of fermentative bacteria. Under normal conditions, that is, in health, the conditions prevailing in the stomach are very unfavorable to the development of bacteria of the putrefactive type, the gastric juice exhibiting decided germicidal properties. Then, too, the presence of air acts against their development. Much of the so-called gastric fermentation does not occur in the stomach but rather in the duodenum. ~Bacterial Action in the Intestines.~--In the lower part of the small and in the large intestines, the bacteria of the anaërobic type increase, conditions more favorable to their development existing there than farther up in the intestinal tract. However, there are a great many bacteria in the whole of the small intestine. Those producing decomposition of the unabsorbed proteins are especially prominent in the colon. Herter[58] states that "the presence in the colon of immense numbers of obligate micro-organisms of the B. coli type may be an important defense of the organism in the sense that they hinder the development of that putrefactive decomposition which, if prolonged, is so injurious to the organism as a whole. We have in this adaptation the most rational explanation of the meaning of the myriads of colon bacilli that inhabit the large intestine. This view is not inconsistent with the conception that under some conditions the colon bacilli multiply to such an extent as to prove harmful through the part they take in promoting fermentation and putrefaction." ~Effect of Bacterial Activity in the Body.~--In summarizing the effects of bacterial action in the body it is found that with the exception of oxalic acid, which is exceedingly injurious, and which, according to Herter, results from the eating of large quantities of meat and sugar, the products of fermentation are simply irritating in character, while those resulting from putrefaction are distinctly toxic. Among the substances deserving mention under this head we have indol, skatol, cresol, and phenol. These substances are very soluble and upon absorption combine with the sulphuric acid formed in the body and are excreted by way of the kidneys where they appear in the urine as "conjugated sulphates," the chief of which is indican. The amount of indican in the urine is taken as a measure of the intensity of the putrefaction taking place in the body. ~Metabolism.~--Under the term metabolism we understand the series of processes through the foodstuffs and carried (a) in the conservation of the tissues of the body and (b) in the maintenance of body temperature and physical work (Taylor). The processes concerned in metabolism are chiefly those of building up, "anabolism," and breaking down, "catabolism." In the processes of anabolism the products absorbed are built into the tissues and cells of the body. In catabolism, the worn particles from the cells, and the dead cells no longer useful are broken up and thrown out of the body. According to Taylor, "side by side with these processes are the reactions of combustion, whereby the temperature necessary for the life of the cells is maintained, and the energy needed for external work furnished." ~Behavior of Carbohydrates in Metabolism.~--As Sherman[59] has said: "At least two kinds of enzymes are believed to be involved in the combustion of glucose in the tissue cells, (1) cleavage enzymes, which split the molecule into fragments more easily oxidized, and (2) oxidizing enzymes or oxidases which stimulate the oxidation of the cleavage products. Both kinds of enzymes are widely distributed through the body and are believed to be normal constituents of all active cells." ~Production of Energy.~--It has been proved that the energy for external and internal work is produced largely from the glucose brought by the blood and oxidized in the muscles. When a surplus amount of carbohydrate food is eaten, over and above the immediate needs of the body for fuel, it is stored in the liver and muscles as glycogen, which can be readily reconverted into glucose. When the supply of carbohydrate food is greatly in excess of the body's needs, that is when the liver and muscles cease to store glycogen, it is built up into adipose tissue and furnishes a readily available source of emergency fuel. ~Fate of the Carbohydrates.~--After their oxidation the end products of carbohydrates, that is, the substances which are no longer available for use in the body, leave it in the form of carbon dioxide and water by way of the kidneys (urine), the skin, the lungs, and the intestines. ~Fate of the Fats.~--The fats upon absorption are taken up by the lymph vessels instead of the capillaries and enter the blood with the lymph. According to various investigators, the fat which causes the turbidity of the blood plasma at the height of absorption will, as a rule, disappear after a few hours, part of it being burned as fuel, producing energy for the internal and external work of the body, and at least a part of the fats eaten being rebuilt into body fat. The end-products of fat metabolism, like those of the carbohydrates, consist of carbon dioxide and water, and leave the body by the same excretory channels. When the normal oxidation of the fatty acids is interfered with or is overtaxed, a different reaction from that which usually occurs may take place, and this results in an excretion of acetone in the urine (see Chapter on Diabetes). ~Protein metabolism~ is certainly more complex than that of either of the other active organic food groups. The amino acids which are the products of protein digestion are taken up by the capillary blood vessels in the intestinal walls and are passed by them into the portal vein, soon to become available for the needs of the body. ~Fate of the Proteins.~--After utilization in the body, the proteins, like the other foods, leave certain waste products which indicate to a greater or lesser extent the completeness with which the organism has made use of the food materials. The end-products of protein metabolism are: ~urea~, ~ammonium salts~, ~purin bodies~, and ~creatinin~. These products leave the body chiefly in the urine. The chief end-product in man is urea. This substance represents from 82-88% of the total nitrogen excreted by the kidneys. However, the less highly oxidized products represent the incomplete products of protein metabolism and thus indicate the changes through which these products must pass before being changed into urea. If for any reason there is an impairment of the liver through which they must pass and where the change into urea is accomplished, there will be a rise of ammonia and a corresponding decrease in the output of urea in the urine. Thus, ammonia is formed at the expense of the urea. This occurs in fevers, diabetes, and certain structural diseases of the liver. According to Sherman:[60] "Normally about 2 to 6% of the total nitrogen eliminated is in the form of ammonium salts, the amount depending largely upon the relation between the acid-forming and base-forming elements in the food." ~Acid-forming and Base-forming Foods.~--Mendel[61] states: "There are foods which act as potential acids and others which function as bases in the organism. When burned up either in the laboratory or in the body cells, they have a preponderance of acid or base, as the case may be, in their ash." In this respect potatoes, apples, raisins, and cantaloupes, for example, are base-forming foods which depress the output of ammonia and increase the solubility of uric acid in the urine, whereas meal, cereals, and prunes (the latter with their content of benzoic acid) furnish acids in predominance. ~Purin Bases.~--These compounds are formed in the body as cleavage products of nucleoproteins or taken into the body in food. The chief of these products are ~adenin~, ~guanin~, ~hypoxanthin~, ~xanthin~, and ~uric acid~. The latter is the most highly oxidized of all the purin bases and is the form in which they are chiefly eliminated in the urine. ~Formation of Uric Acid.~--The formation of uric acid can in a measure be controlled by attention to the diet, eliminating those foods known to be purin-bearing. Normally from 1 to 3% of the nitrogen eliminated will be in the form of uric acid. The normal human being oxidizes about half of the purins eaten and excretes about half, mainly in the form of uric acid. According to Mendel, the formation of uric acid takes place throughout the body, and its partial destruction is accomplished by the kidneys, muscles, and liver. The formation of purins in the body and their elimination in the form of uric acid is especially significant in certain pathological conditions, gout, for example, in which the body has difficulty in eliminating these compounds. The purin bodies are both endogenous and exogenous--that is, they may be brought into the body in food as such, or they may be formed as a result of the metabolism of the body tissues. For this reason the damage wrought by these substances may to a certain extent be controlled by eliminating the purin-bearing foods from the diet. Flesh-foods are high in purins, especially the highly nucleated glandular organs, liver, thymus (sweetbreads), etc., kidney, beef, mutton, veal, pork, chicken, turkey, goose, sardines, anchovies, all kinds of fish except cod. Among the vegetable foods asparagus, beans, peas, and spinach are highest in purins. Boiling extracts much of the purins from food. Meat especially should be prepared by this method, if used in the diet of individuals suffering from gout. Eggs and milk are purin free, and may be used freely. Certain substances increase the difficulty of eliminating uric acid. Alcoholic beverages for example are especially deleterious. ~Creatinin.~--This end-product of protein metabolism is, like uric acid, endogenous and exogenous. It is one of the normal constituents of the urine. The quantity is fairly constant for the individual, averaging about 0.02 gram per kilogram of body weight per day. ~Mineral Metabolism.~--A study of the organic foodstuffs reveals the fact that many of the mineral salts concerned in nutrition enter the body in organic combination with those constituents. Certain of the mineral salts, however, enter, exist in and leave the body in the same organic form in which they occur in the food materials. This is true of chlorine, which for the most part, functions in and leaves the body in the form of chlorides (chiefly sodium chloride). A small part of the chlorine is used in the production of the hydrochloric acid of the gastric juice. Sulphur and iron, both enter the body as essential constituents of proteins, and their metabolism occurs with that of these foodstuffs; the sulphur being converted largely into sulphuric acid must be neutralized at once, and it leaves the body by way of the urine as inorganic sulphates. Part of the sulphates are excreted as ethereal (conjugated) sulphates; the amount excreted in this form depending largely upon the extent of purification in the intestinal tract.[62] ~Phosphorus.~--This mineral salt is found to be present as an essential constituent of certain proteins, fats and carbohydrates. It also enters the body in the form of inorganic phosphates. During the digestion and metabolism of the organic foodstuffs the phosphoric acid radical is split off and eventually nearly all of the phosphorus leaves the body in inorganic form (inorganic phosphates). ~Calcium.~--Being the chief constituent of the bones, large quantities of calcium salts are stored in the skeleton of the child both before and after birth. The functions of calcium have already been discussed. That part not stored, which has finished its work in the body is excreted through the intestinal wall and leaves the body by way of the feces, only a small part of the calcium concerned in metabolism being excreted in the urine. ~The Process of Osmosis in the Body.~--The influence exerted upon the process of osmosis in the body is one of the most important parts played by the mineral salts in metabolism. The fact that these chemical substances are indispensable to the metabolic processes makes it necessary for the nurse to know where they can be found in food and how best to use them. ~Metabolism of Body Tissues.~--The constant breaking down and building up of the tissues of the body and the evolution of heat as a by-product of the energy expended may be summed up in the term "metabolism." The metabolism of the body is normally supported by the food ingested. However, it is a known fact that were no food eaten the processes would continue just the same, the difference only being the use of the body structure instead of food materials. According to Sherman, the chemical changes and energy transformations are of course inseparable. It has become customary to speak of the metabolism of matter and the metabolism of energy, and to regard the extent of the metabolism of any material substance as measured by the amount of its end products eliminated, and the extent of the energy metabolism as measured by the amount of heat or of heat and external muscular work which the body gives off. * * * * * In summarizing the important factors in the utilization of food by the body several distinct points are made evident: 1. The composition of the body, and the composition of food, are practically the same. 2. Food must make good the losses resulting from metabolic processes and physical activity. 3. Utilization of food by the body necessitates: (a) Transformation through a series of processes: (1) Digestion. (2) Absorption. (3) Metabolism. (4) Elimination. (b) Factors influencing use of food: (1) Stimulation of secretory cells through appetite juice (stomach); hormone secretin (intestines). (2) Factors retarding use of food:--Fear, worry, anger, nervous excitement, fatty foods and alkaline carbonates (bacterial action causing fermentation and putrefaction). PROBLEMS (a) Outline the processes through which a slice of bread and butter must pass, from the time it is eaten until it reaches the blood stream. (b) Outline with a diagram the manner in which the foodstuffs are utilized in the body. (c) Show in the form of a table the effect of the enzymes on proteins, on fats, on carbohydrates. FOOTNOTES: [51] "Chemistry of Food and Nutrition," by Henry Sherman. [52] "Chemistry of Food and Nutrition," by Sherman. [53] "Chemistry of Food and Nutrition," by Henry Sherman. [54] Compiled from "Textbook of Physiology," by Howell, and "Chemistry of Food and Nutrition," by Sherman. [55] "Chemistry of Food and Nutrition," by Henry Sherman. [56] This scheme applies to the protein, fat and carbohydrates with quantitative variations only. Courtesy of Dr. A. R. Taylor, Leland Stanford University. [57] "Chemistry of Food and Nutrition," by Sherman. [58] Herter's "Bacterial Infections of the Digestive Tract" (1907). [59] "Chemistry of Food and Nutrition," by Sherman. [60] "Chemistry of Food and Nutrition," by Sherman. [61] "Newer Points of View Regarding the Part Played by Different Foodstuffs in Nutrition," by Lafayette Mendel, Ph.D. Read at the Sixty-fifth Annual Meeting of the American Medical Association, June, 1914. [62] See "Bacterial Action in the Body," p. 181. SECTION IV DIETO-THERAPY CHAPTER VIII PREGNANCY AND LACTATION There are many traditions in regard to the food requirements of the prospective mother. Many of these have been proved fallacies. As a matter of fact it is the woman more than the developing child who is likely to suffer if the diet is insufficient or badly balanced. ~Factors Affecting Diet during Pregnancy.~--In formulating a dietary for the pregnant woman, then, not only must the needs of the child be considered but those of the mother also, since the developing embryo draws from the body of the woman materials necessary for its growth, and if these needs are not covered by an increase in the diet, her body and that of the child also will show evidences of lack of nourishment. ~Phosphorus and Calcium Requirements.~--If, for example, the mother's diet is lacking in those materials which produce growth, or is deficient in those mineral salts, such as those of phosphorus and calcium, which are requisite and necessary for the growth of bones in the infant, the mother's bones and teeth will show this loss and in all probability the baby will sooner or later also show a like deficiency. However, it must be remembered that the pregnant woman is under a strain, both physical and mental. She must not be encouraged to eat beyond her needs or the digestion will be disturbed. ~Nutritional Disturbances in Early Months.~--The nutritional disturbance manifested by nausea and vomiting in the morning is due, not to the stomach or any disturbance therein, but to the fact that a mild form of poisoning occurs, resulting from the substances produced through the formation of the placenta reaching the general circulation on account of the incomplete establishment of the connection between the embryo and the mother. As soon as this connection is complete and fetal circulation is established this "morning sickness" disappears. ~Food Requirements of Prospective Mother.~--The food requirements of the prospective mother are not materially affected during the first four months of gestation, and even after this, when the infant is developing rapidly, and up to the date of its birth, the mother's requirements are only increased about 20%. The amount of food necessary to cover the body needs, for maintenance and energy of a woman living a sedentary or moderately active life, plus 20% for building materials for the growing child, will be adequate for the pregnant woman. Thus, if her needs are ordinarily from 2,000 to 2,400 calories per day, after the fourth month they will probably be increased to 2,400 or 2,800 calories a day and will rarely ever be more than 3,000 calories a day. ~Dietetic Treatment of Normal Pregnancy.~--The peculiar conditions surrounding the woman at this particular time must be taken into consideration in arranging her diet. The building foods which are necessary for the developing child must be given in the simplest form, milk and eggs being used liberally and meat sparingly to obviate any unnecessary tax being placed upon the kidneys. The use of fruit and green vegetables to supplement the milk and eggs is urged. It has been found advisable at such times to give small meals frequently rather than the regular meal three times a day. The feeling of "fullness" which often occurs during the last two or three months of gestation makes it more comfortable for the pregnant woman to eat less at a time and oftener. If, for example, she be given a glass of rich milk or a nutrient beverage, either of enforced malted milk, albumenized orange juice, buttermilk, zoolak, or koumiss, at about eleven o'clock in the morning and again about four o'clock in the afternoon, she will have taken sufficient nourishment to meet the new requirements without taxing her digestion or imposing extra work upon the kidneys. ~Abnormal Symptoms.~--The chief point to keep in mind is any abnormal symptom which may develop. The chief of these is albumen in the urine. The urine must be examined frequently and measures taken immediately to overcome albuminuria should it occur. It is wise, as has already been stated, to restrict the meat in the diet, and in cases where albumen is found in the urine even when the meats are restricted, it may be necessary to place the patient upon a milk diet for a time until the urine clears up. ~Supplementary Feeding.~--Cereals, especially the whole cereals, must be used liberally. Gruels made with milk are often found valuable additions to the dietary. The prospective mother must be urged to take a regular amount of gentle exercise, not to become over-tired, or excited, to eat sparingly at night, and to drink plenty of water. She must avoid becoming constipated by eating plenty of green vegetables and fruit. ~Sample Diet Sheets.~--The following dietary is suggested: Breakfast should consist of thoroughly cooked cereals, wheatena, cream of wheat, malt breakfast food, cracked wheat, rolled or cracked oats, served with cream or sugar or both, whole wheat bread, muffins, or biscuits, with butter, raw or stewed fruit, coffee, tea or cocoa with milk. Luncheon may consist of milk or vegetable soups, eggs in any form, boiled potatoes, sweet potatoes, string beans, greens, or any green vegetables, simple desserts such as custards, rice or tapioca puddings, bread pudding, etc., milk, tea, cocoa, buttermilk, zoolak or koumiss as beverages. For dinner, if albuminuria is not present, a small piece of meat may be taken, together with green vegetables, rice, potatoes, simple salads, and a simple dessert, milk or coffee with milk as a beverage. ~Selection of Food.~--The following foods may be used to formulate the diet sheet: Wheat, oat, or corn cereals, rice, tapioca, made into simple puddings or served as breakfast foods; fruits, oranges, prunes, apples, raisins, dates, figs, or grapefruit, stewed or raw. The fruit juices may be used instead of the whole fruit if the latter disagrees. Vegetables: peas (green or dried), beans (string beans or dried beans), spinach, greens (turnip, mustard, or beet), cabbage, onions, celery, lettuce, served as vegetables or in soups, potatoes. Meat: lightly broiled beefsteak or stewed or boiled meat or chicken served not more than once a day or three times a week. Eggs, prepared in different ways. Cheese dishes. Breakfast bacon or ham in moderate quantities, butter, olive oil (or other salad oils) in moderation, whole wheat, graham or bran bread, Boston brown bread and crackers, milk, cocoa, chocolate, buttermilk, malted milk, koumiss, or zoolak; coffee and tea in moderation. The diet, as has already been stated, may be supplemented by nutrient beverages or milk gruels. DIET IN LACTATION The diet of the nursing mother, as has been explained in a previous chapter, must not only cover her own requirements but must likewise be adequate to furnish the extra requirements imposed by the nursing infant. ~Food Requirements of Nursing Infant.~--When the baby is a month old he should be growing rapidly, and his food requirements at this period and until he is about three months old will be approximately fifty calories per pound of body weight in the twenty-four hours. As he grows older his requirements grow gradually less in proportion to his weight. This is because the rate of growth is less, so that for the next three months the requirements are from 43 to 40 calories per pound of body weight per day, and 35 calories per pound during the last three months, or by the end of the first year of life. It has been estimated, as before stated, that the average infant will take 2-1/3 to 2-1/2 ounces of mother's milk per day[63] to each pound of body weight and that every ounce of mother's milk will yield on an average 20 calories. Hence a month-old baby weighing ten pounds will be taking about 23 ounces a day, yielding 460 calories. Scientists have estimated that for every calorie produced by the milk two extra calories must be provided by food, so that for the baby requiring 460 calories per day, to cover his requirements the mother will be obliged to consume extra food to yield 920 calories, or the regular amount to meet her normal requirements plus the extra food to make sufficient food for the baby. ~Diet of Nursing Mother.~--The diet of the nursing mother need not be different from that to which she is accustomed. She should be warned against overwork or over-fatigue, nervous excitement and worry, since these factors affect the digestion of the nursing baby. She must be careful not to eat indigestible foods or foods which disagree with her, as such things will undoubtedly affect the digestion of the infant. When an article of food does cause digestional disturbances in the baby, it should be carefully omitted from the mother's diet. ~Factors Retarding and Stimulating Milk Secretion.~--Constipation in the mother reacts quickly and unfavorably upon the secretion of milk. The same has proved to be the case when she becomes excited, nervous, worried, or over-tired. The average diet for the normal woman is safe for the nursing mother. If her supply of milk is deficient, it may be at times increased or stimulated by the drinking of a glass of milk between meals or by taking a cup of hot cereal milk gruel. It was formerly believed that beer, ale, or stout acted directly upon the mammary glands, stimulating the secretion of milk, but there is little proof of this and the drinking of alcoholic beverages need not be encouraged on this account, since often more nourishing beverages fulfill the purpose more efficiently and without bad results. SUMMARY ~Gastric Disturbances.~--The nausea and vomiting so often a part of early pregnancy is not believed to be the result of a disordered stomach but primarily a mild form of poisoning resulting from the incomplete establishment of the fetal circulation. ~Adjusting the Diet.~--The adjustment of the diet to cover the needs of the prospective mother and those of the developing child is essential. The amount of food taken by the mother is not materially changed during the first three months of gestation. An average normal diet is all that is necessary. After this time a twenty per cent. increase in the woman's diet will furnish adequate means both for her maintenance and for the growth and development of the child. ~Type of Food.~--The kind of food which is necessary for the pregnant woman to take during this period is very similar to that taken ordinarily. It is necessary to furnish food materials rich in calcium and phosphorus, with an adequate supply of proteins in their simplest form in order to meet the requirement of the growing organism. Milk and eggs furnish the most efficient foods in this respect and the prospective mother should see that they form the chief items of her daily dietary. Milk furnishes calcium in its most available form for the developing skeleton of the growing infant, hence it is necessary to provide the mother with food to replace the mineral which is withdrawn from her body. ~Meat in the Diet.~--Meat should be eaten sparingly by the prospective mother, as it imposes needless work upon the already taxed kidneys and, if eaten in excess, will give rise to dangerous complications. Milk and eggs will provide ample protein for all purposes. ~Albumen in the Urine.~--Albuminuria is one of the most frequent complications in pregnant women. It should be combated and controlled as soon as possible. The allowance of meat should be cut down or entirely eliminated from the diet until the urine clears up. When albuminuria is persistent in spite of efforts to overcome it, the patient must be placed upon a strict milk diet as used in acute nephritis, to prevent dangerous complications arising. LACTATION ~Diet of Mother.~--Her dietary need not differ materially from that to which she is accustomed. She must avoid indigestible foods or any article which has been proved to disagree with either the infant or herself. ~Factors Regarding Secretion of Milk.~--Constipation, worry, nervous excitement, and over-fatigue all have an unfavorable effect upon the secretion of milk and must therefore be avoided by the nursing mother. ~The Bowels.~--Constipation of the mother reacts quickly and unfavorably upon the health and comfort of the baby, hence it should be avoided by eating coarse breads, green vegetables, and fruits, when they do not disagree with the baby, by drinking plenty of water and taking a certain amount of outdoor exercise to keep her own health in good condition. ~Stimulating the Milk Production.~--When the milk supply is deficient it will be advisable for the mother to drink a glass of milk or a bowl of cereal milk gruel between meals. Alcoholic beverages are not necessary to insure an adequate secretion of milk. The milk or milk gruels answer the purpose more efficiently and without bad results. ~Energy Requirements of Infant.~--The average baby requires fifty calories per day per pound of body weight to cover his energy growth and development needs for the first three months of life, after which the rate of growth is less and his requirements decrease from forty-three to forty, then to thirty-five calories per day per pound by the end of his first year. ~Amount of Milk Needed for Infant.~--Approximately two and one-third ounces to each pound of body weight per day covers the needs of the average baby. ~Fuel Value of Mother's Milk.~--Each ounce of milk yields twenty calories. ~The Making of Milk.~--It has been estimated that for every calorie yielded by milk, two extra calories must be provided by food. PROBLEMS (a) Formulate a dietary for a pregnant woman, allowing for a twenty per cent. increase over her normal requirements. (b) Show how the diet may be made to cover the need for additional iron, calcium and phosphorus. (c) Formulate a diet for a nursing mother with an infant two months old and weighing twelve pounds. FOOTNOTE: [63] "Feeding the Family," p. 93, by Mary Swartz Rose. CHAPTER IX INFANT FEEDING In taking up this part of our study on nutrition, there are several points to be kept in mind by the nurse: (1) that it will be difficult, if not impossible, to understand the metabolic changes taking place in abnormal conditions unless those occurring in the normal human body are understood; (2) that certain diseases are due directly to errors in diet; (3) that in other diseases, diet plays the chief part both in the bringing about and in the relieving of the conditions; (4) whereas there are certain other diseases not affected by diet, save in so far as well or poorly selected and prepared food always affects the individual, whether normal or abnormal, and that in the latter conditions the organism is more susceptible to bad influences. This being the case it behooves the nurse to examine herself to find whether or not she understands the fundamental principles underlying the nutrition of the human body, that she may efficiently deal with the changes which occur more or less when the body is attacked by disease. We include normal infant feeding in this section, because in no other age is it quite so necessary for care to be observed in formulating and carrying out a diet. Errors during this period may only appear to exert a local influence, causing disturbance which may readily be relieved, but the danger is in laying too little stress upon these disturbances, forgetting that the delicate organism of a child may be permanently injured by a constant disregard of nature's mandates. In the words of the old adage, the pitcher may go once too often to the well, and an injured digestive apparatus is even more difficult to mend than the proverbial pitcher. In this section, then, the metabolic changes due to pathological conditions and the dietetic treatment thereof will be discussed. ~Age and Weight.~--As has already been stated, there are certain points to be kept in mind in attempting to provide an adequate diet for the human machine; _First_, the _age_ and _weight_. The gain during infancy should be steady--an allowance of 40 calories per pound of body weight to cover the energy requirements and 4 protein calories per pound to cover the nitrogen needs. During the second and third years the energy requirements will be covered by 30 to 40 calories per pound and the nitrogen needs by 3 to 4 protein calories per pound. From the fifth to the eighth year the nitrogen needs continue to be covered by 3 to 4 protein calories per pound and the energy requirements by 35 to 37 calories per pound during the fifth year; 32 to 34 calories per pound during the seventh year. After the body has reached its full development its requirements will be met if sufficient protein is provided to cover its maintenance needs and if the energy calories are regulated according to the amount of exercise taken, keeping in mind that the energy requirements of a man at rest (sitting) will be about 2,000 calories per day and that exercise, especially that taken in the open air, raises the energy needs of the body. ~Daily Gain.~--In estimating the relative daily gain in body weight of children of different ages, Mendel[64] gives the following table: TABLE In the first month, about 1.00 per cent At the middle of the first year 0.30 per cent At the end of the first year 0.15 per cent At fifth year 0.03 per cent Maximum in later years for boys 0.07 per cent Maximum in later years for girls 0.04 per cent ~Retention of Nitrogen in Infancy.~--When the baby is gaining in weight and strength there is a retention of both nitrogen and salts, and when the baby is not gaining there may be a loss of both of these bodies; when one is retained in the body the other is apt to be retained.[65] NORMAL INFANT FEEDING Much has been written in the past few years on the care and feeding of infants and children. This is well, since statistics show an alarming increase in the rate of infant mortality during the early years of life, and anything which can be done to check this lamentable and often avoidable waste of valuable life should be resorted to with care and attention. ~Food for Infants.~--The natural food of all young mammals is the milk of their own mother. The rate of growth and development differs in every species; the calf, for example, doubles birth weight much more quickly than does the baby of the same age. However, the milk of the cow, which meets the needs of the calf perfectly, falls short of meeting the requirements of the infant, whose rate of growth is not nearly so rapid. For this reason if for no other, it would be advisable to give the baby its natural food rather than to attempt a substitute which is, at best, a poor one. ~Weight.~--The average infant weighs from six to seven pounds at birth. This weight should be doubled in the first five or six months of life and tripled by the end of the first year. The most important business, then, in the life of the child during the early years is growth and development. To achieve this properly the baby's habits must be adjusted to his needs. ~Regularity in Feeding.~--He must have the proper food and enough of it, and have it given at regular intervals, "by the clock," for guesswork is fatal in infant feeding. He must be given water between meals. Babies often cry from thirst when they are thought to be doing so from hunger or temper, or both. The healthy baby sleeps about twenty-two hours out of twenty-four during the early months, and even during the latter six months of the first year more time is spent in sleeping than in waking. ~The Bowels.~--The bowels should move several times a day, the stools being smooth and of a yellowish color, of the consistency of pea soup. After the first month, twice a day is about the normal number of stools for the healthy baby. The infant should be placed upon a vessel held in the lap of the nurse at regular times, preferably right before the morning bath, and in the evening. In this way regularity in evacuating the bowels is obtained, and a habit formed which will prove valuable through life. ~The Bath.~--The daily bath is likewise necessary for the health and comfort of all babies; so, too, are fresh air and sunshine. As has already been stated, breast milk is much better for babies than cow's milk or any artificial food. There is something in the mother's milk which gives strength and resistance to the baby which is absolutely lacking in any other food no matter how carefully it is selected and prepared, and for this reason young mothers must be prevailed upon to nurse their babies whenever it is possible for them to do so. When circumstances, such as having to be away all day at work, make it impossible for a mother to nurse her baby at regular intervals, she can be taught how necessary are two or three breast feedings a day to the future welfare of her child. When social reasons or lack of desire on the part of the mother make her unwilling to nurse her baby, it is the part of the nurse to lay the case before her and let her judge whether or not she is willing to accept the responsibility of bringing into the world a life for which she is unwilling to provide weapons with which to fight the good fight. ~Habits of Mother.~--The mother must be taught how to efficiently nurse her baby; she must keep in mind that upon her good health and temperate habits depend the health and comfort of her baby. It devolves upon her to provide food efficient in quality and quantity. To do this, her own diet must be simple and wholesome. The nursing mother must remember that she has to provide, not only for her own maintenance and energy requirements, but also for the infant whose fuel requirements are ever demanding more food to provide for its rapid growth. ~Food and Its Relation to Milk.~--It is believed that two calories of food extra are necessary to produce one calorie of milk, and since a month-old baby requires 2-1/3 ounces of mother's milk to every pound of his body weight, and one ounce of mother's milk will yield 20 calories, it is clearly seen that the mother will have to increase her diet to cover the requirements of the baby. For example, if the baby weighed 12 pounds, he would require 28 ounces of milk in 24 hours, or 560 calories. Thus if it requires two calories of extra food to make one calorie of milk, the mother's diet would have to provide 1,120 calories extra, or about as much food as would fulfill the needs of a laboring man, 3,000 to 3,500 calories, even if she were doing practically no actual work; while if she were actively employed and doing a certain amount of physical labor, her rations would have to approximate those of a man doing heavy muscular work (about 3,500 to 4,000 calories per day).[66] ~Breast Milk versus Cow's Milk.~--Consensus of opinion shows that breast-fed infants require less energy than the ones who must be nourished artificially. This is probably due largely to the fact that the constituents of human milk are in a more available form than those in cow's milk, the former requiring a lesser expenditure of energy on the part of the organism to become available than the latter. Very active babies, ones who kick and throw themselves about or cry violently, have a greater energy requirement than the more placid baby who sleeps more and is more quiet in movement and who cries less when awake. Breast-fed babies are generally more quiet than their less fortunate artificially fed brothers. It has been demonstrated that the artificially fed baby has a much harder fight for existence than the baby who receives his natural food; hence the necessity of using every available means to make the food digestible, and to lessen the danger arising from the additional work put upon the entire apparatus. Cow's milk contains practically the same chemical elements as are found in human milk, but these elements are combined in a slightly different manner, and are not so easily handled by the immature organs. The proteins of milk consist of casein, which is insoluble, and albumen, which is soluble. According to Van Slyke the proportion of insoluble to soluble protein in cow's milk is 3.6:1, while in human milk the proportion is only 1:1. The ash constituents in cow's milk are in excess of the needs of the infant organism, but since a great part of these salts is in an inorganic form they are not retained to the same extent as those contained in human milk, which are in an organic form. ~Rules and Regulations.~--It is not possible to lay down hard and fast laws to cover the subject of infant feeding. The food must be adapted to the individual needs of the baby in question. The nurse must see that the milk is obtained from a responsible dealer, certified milk being of course the safest. The bottles of milk should be wiped off carefully and placed directly on the ice as soon as they are received. The milk generally used in infant feeding has a fat content of 4%. That having a higher percentage of fat is technically cream. The following table showing the fat, sugar, and protein composition of whole milk, cream, skimmed milk, and whey was arranged by Morse and Talbot:[67] TABLE ==========================+============+============+============ | _Fat_ |_Milk Sugar_| _Protein_ --------------------------+------------+------------+------------ Whole milk | 4.00 | 4.50 | 3.50 7% cream | 7.00 | 4.45 | 3.40 10% cream | 10.00 | 4.40 | 2.25 16% cream | 16.00 | 4.20 | 3.05 32% cream | 32.00 | 3.40 | 2.50 Skimmed milk | 1.00 | 5.00 | 3.55 Separated milk (fat-free) | 0.25 | 5.00 | 3.65 Whey | 0.25 | 5.00 | 0.90 ==========================+============+============+============ Seven per cent. (7%) cream is obtained from the upper 16 ounces of a quart bottle of milk which has been allowed to stand undisturbed for six hours. The upper third of the bottle contains 10% fat, while the whole fat layer from the quart bottle, regardless of the number of ounces, contains about 16% of fat. ~Methods of Artificial Feeding.~--The use of whole milk, top milk, or skimmed milk, diluted with water, and either milk sugar, malt sugar, or sucrose (cane sugar) added, is the method of feeding most commonly used, and upon it are based the formulas universally advised by infant specialists. There are cases in which simple dilution is not advisable. In premature or very young infants, for example, the whey mixtures have been found to give the best results. In toxic diarrheas, where the putrefactive bacteria make the use of all but the minimum amount of protein inadvisable, the above method is contraindicated, as it is likewise in cases where vomiting of casein curd is a prominent feature.[68] ~The Use of Alkalies.~--There are many cases in which the physician deems it advisable to add an alkali to the milk mixture. The one generally selected is limewater. However, sodium citrate and sodium bicarbonate are also used. The reasons for adding alkalies to the milk mixtures are: (1) to check the coagulation of the casein, (2) to hasten the emptying of the stomach, or (3) to chemically change the formation of the curd. In certain cases it is only necessary to delay the coagulation of the casein in the stomach, in which case a certain amount of limewater is used. Its action is to swell the protein of the milk and in this way effect the precipitation of the casein. In other cases it is found advisable to prevent the formation of curd and hasten its departure from the stomach. Cannon[69] claims that milk before it coagulates leaves the stomach quickly like water in gushes. Hence, if an alkali like limewater, bicarbonate or citrate of soda is added to the milk this coagulation will be checked and the digestion be facilitated. ~Amount and Type of Alkali Used.~--The amount of alkali[70] necessary to bring about any change in the general effect of the formula must be determined by the amount of milk and cream in the mixture, since these constituents alone determine the acid content. However, it is impossible to judge exactly the amount of alkali to add, but an approximate estimate is made from the work done by the various investigators. It has been estimated that from 25 to 50% of limewater must be added to milk to change it to any marked degree. In using bicarbonate of soda, a much less quantity brings about the desired result, 1-1/2 grains of bicarbonate of soda being equal to one ounce of limewater. The action of these two alkalies is different. The soda acting upon the milk causes the curds to be more porous, and therefore more easily acted upon in digestion. Sodium citrate likewise tends to prevent the formation of tough curds. It is added in amounts of 1 to 2 grains to each ounce of milk or cream in the mixture whenever it is found necessary to use it at all. The addition of any alkali to the formula is resorted to if the symptoms indicate the need for it, but the type and quantity is entirely within the province of the physician, not the nurse. ~The Addition of Sugar.~--~Lactose~ is the form in which the carbohydrates are found in milk, and it has been a general rule to employ this sugar in making up the sugar content of a formula, using from 6 to 7% of the mixture in this form to cover the necessary energy requirements of the infant. Other sugars are used, however; and of late years malt sugar has been widely employed for this purpose. The form now generally accepted is known as ~dextri-maltose~, which is a combination of dextrin and maltose, both of which are readily acted upon by the sugar-splitting enzymes of the digestive juices. In digestion, lactose or milk sugar is split to dextrose and galactose and utilized in the body, both as a source of energy and as a food for the lactic acid bacteria which are active in the small intestine. ~Malted Foods.~--The addition of malted foods or malt sugar to the food of infants tends to bring about a more rapid gain, both in energy and in body weight, than is generally the case where other sugars are used. This sugar is used as a substitute for milk sugar in many formulas, especially in those cases in which the casein of cow's milk needs to be made more digestible in form. Malt sugar is indicated in the following conditions:[71] (1) in severe atrophies, (2) in cases of fat indigestion before the atrophic stage is reached, (3) in cases where there is slight curd indigestion, indicated by some vomiting and slow gain in weight, (4) in cases where excessive intestinal fermentation is manifested by gas and colic. ~Malt sugar~ (dextri-maltose) is contraindicated to a slight degree in cases "of simple acute diarrhea where lactose, by supplying fermentative media, more easily restores the normal bacterial balance." ~Diluents.~--Barley and oatmeal water are used as diluents to the amount of one-fourth or more of the mixture. Oatmeal water or jelly is used more during the winter months than in the hot summer months. As the fat content of the oatmeal gives it a more laxative effect, it is undesirable to use it at the season in which the summer diarrheas are prevalent. Barley water has something of a colloidal action upon the casein, causing the curds to be finer and less tough in character. Both barley and oatmeal water are used in place of plain water for babies when this colloidal effect upon the curd of the milk is desired, also where the weight of the infant shows a disposition to remain stationary, especially where there are no other symptoms to account for the lack of gain. Whey is used with babies who cannot digest the insoluble protein of cow's milk. This is often the case in premature babies and is manifested by a persistent vomiting of curd. The energy requirements are obtained by the addition of cream and lactose to the whey. ~Buttermilk Mixtures and "Eiweissmilch."~--It is often found desirable to use some other form of milk than whole, top, or even skimmed milk, and for this purpose lactic acid, milk and the albumen or "Eiweissmilch" are substituted. In the buttermilk mixtures the precipitation of the casein is brought about by lactic acid bacilli (Bulgarian culture). This prevents the coagulation of the casein into tough curds. Lactose buttermilk or lactic acid milk is used in the feeding of infants who have persistent green stools, and in cases of acute toxic diarrhea brought about through the action of gas bacillus. Buttermilk is more difficult to administer to babies than formulas made from plain milk by reason of its flavor. However, the results are remarkable in the above-mentioned conditions. ~"Eiweissmilch"~ is used in atrophic cases where there are bad green stools. ~"Homogenized Milk."~--Dr. Ladd of the Children's Hospital in Boston has presented many cases of infants who showed an intolerance for butter fat. These cases he has treated with formulas containing foreign fat, usually olive oil. This milk is subjected to a treatment which brings about a more complete emulsification of the fat than is possible in cow's milk, causing it to resemble in character the quality of the mother's milk. Homogenized milk has been used with success in cases where it was impossible to supply the infant with breast milk. The process is accomplished by the use of an apparatus known as an "homogenizer"[72]; in this machine the fat globule is crushed and so finely divided as to prevent its re-formation. The greatest drawback to the use of this process lies in the scarcity of available machines. Cod liver oil is now used in many cases where the infant shows a failure to gain or is in possible danger of developing rickets, with the homogenizer it is possible to add the oil to the formula, thus facilitating its use. ~Technique of Milk Modification.~--The absolute necessity for cleanliness has already been dwelt upon in respect to milk, and in infant feeding the vigilance which must be observed in the preparation of the food cannot be too strongly emphasized. The milk itself must be of known purity. Where there is any uncertainty about its source, it must be sterilized or pasteurized according to the doctor's orders. The bottles and nipples should be washed as soon as they are used, first with plain water to remove the milk, then with soapsuds and a bottle brush. The bottles should then be filled with boric acid or bicarbonate of soda solution until needed, when they should be emptied and placed in a deep pan filled with cold water and allowed to boil for a few minutes. They should not be taken from the water until they are to be filled with the milk mixture. The nipples are washed thoroughly and boiled once a day and dropped into a solution of boric acid or bicarbonate of soda when not in use. The plain black rubber nipples are best as they can easily be turned inside out and cleaned. If the milk drops too slowly from the bottle, the nipple may be pierced in one or two places with a darning needle. The morning is the best time in which to prepare the baby's food; the milk has not stood too long and it is easier to regulate the feedings if a fresh start is made each morning. Let the bottles and the rubber corks with which they must be stopped be boiled and cooled while the milk mixture is being prepared. ~Preparation of Diluents.~--If barley or oatmeal water is to be used as a diluent, let that be prepared first, that it may be cool before adding it to the milk. Cover the table with a clean cloth or oilcloth, upon this place the pitcher in which the milk is to be modified, have the funnel, milk dipper, and spoon which are to be used boiled with the bottles, cover the mouth of the pitcher with a clean square of gauze or cheesecloth, read the formula carefully and measure the sugar, dextri-maltose, lactose, Mellin's Food, or cane sugar as directed and place it in a clean glass; now measure the diluent, water, oatmeal water, barley water, or whey; use part of this diluent to dissolve the sugar. ~Measuring Milk according to Percentage of Fat.~--Now dip off the required layer of top milk, that is, the layer containing the desired percentage of fat and protein. Mix this thoroughly and dip out the requisite number of ounces into the pitcher. If there is not sufficient cream in one quart bottle to fill the formula, the cream must be dipped from a second bottle and mixed with that of the first before it is measured into the pitcher. The dissolved sugar and rest of the diluent, together with the correct amount of limewater, are strained into the pitcher, mixed thoroughly, and strained through the absorbent cotton lining the funnel into the bottles, allowing the correct number of ounces for each feeding in every bottle. ~Pasteurizing the Milk.~--The corks are then adjusted, the bottles placed in the pasteurizer[73] and pasteurized for the desired number of minutes. The water in the pasteurizer must be cold in the beginning and the rise of temperature recorded on the thermometer, which is adjusted at a convenient place in the pasteurizer where the scale can be read easily. If the temperature of the water is too high, add cold water and lower the flame beneath the pasteurizer. When the desired number of minutes has elapsed, lift the bottle rack above the water for a few minutes and allow a stream of cold water to flow into the pasteurizer, taking care not to chill the bottles too suddenly or they will crack. Cool the bottles as quickly as possible and place on ice until needed, warming the bottle of milk as needed in warm water. ~Amount Given at Each Feeding.~--At birth a baby will usually take from one half to one ounce at each feeding, this amount is increased at the rate of a quarter of an ounce each week until the baby is receiving eight ounces at each feeding. Or the food is measured to allow of from one ounce to an ounce and a half more than the child's age in months. For example a baby six months old would receive from seven to seven and a half ounces at each feeding. Some babies are bigger and stronger than others and require the maximum amount, while others are less vigorous and the amount of food which they can handle at a feeding may fall slightly short of the above amounts, but the quantities indicated above will serve as a guide in measuring the formula. ~Method of Calculation of Formula.~--The calculation of a formula consists in determining the amount (in grams or ounces), of the various constituents contained in the formula when the percentage of each is known. Or, in determining its percentage composition when the amount of fat, protein, carbohydrate and diluent is given. There are certain inaccuracies in all simple methods of calculation and the use of the Babcock tester to determine the fat content in the milk to be used, is advised in all milk or formula rooms. The following method of calculation has been found satisfactory, and the nurse must master it in order to intelligently carry out the directions of the pediatrist. ~Determining the Composition of Formula.~[74]--Gravity cream and skimmed milk are used in this method, the cream is estimated as containing 16% fat, and consists of the entire cream layer from a quart bottle of milk which has been allowed to stand without being disturbed for six hours or longer. The cream must be dipped off with a cream dipper, or poured off. If there is not a sufficient number of ounces in one bottle of milk, a second must be used, the entire cream layer taken, then mixed with that obtained from first bottle, before the required number of ounces are measured off. Skimmed milk is estimated as being fat-free (although this is not entirely accurate). Both gravity cream and skimmed milk are estimated as containing 3.2% protein, and 4.5% sugar. In this method, one rounded tablespoonful of milk sugar is estimated as weighing one half ounce (dextri-maltose may be estimated in the same way). With this brief explanation of the terms used we will proceed with the method itself. It is always essential before beginning the calculation of the formula, to know what percentages of fat, sugar, and protein it is to contain, and the amount to be given in twenty-four hours; it is also necessary to know how much lime water is to be added if this substance is to form a part of the formula. Suppose a thirty-two-ounce mixture is to be made containing 3% of fat, 6% of sugar, 2% of protein, and lime water sufficient to equal 25% of the cream and skimmed milk in the mixture. The fat in the food must be derived from cream, since it is the only substance containing fat to be used in the formula. If the food was composed entirely of gravity cream it would contain 16% of fat. Since it is to contain but 3% of fat it is evident that only 3/16 of the mixture must be gravity cream, 3/16 of thirty-two ounces is six ounces. Six ounces of gravity cream will, therefore, provide the 3% of fat desired in the mixture. The gravity cream contains protein as well as fat. There are six ounces of gravity cream in the thirty-two-ounce mixture. The protein content of gravity cream is 3.2%. The protein content of a thirty-two-ounce mixture containing six ounces of gravity cream is evidently 6/32 of 3.2% or 0.60%. Two per cent protein is, however, desired in the mixture. The gravity cream has provided only 0.60%. One and forty hundredths per cent of protein, the difference between the percentage of protein desired and that furnished by the gravity cream, must be obtained in some other way. It must be obtained, moreover, from some substance which does not contain fat. Skimmed milk is such a substance. Skimmed milk contains 3.2% protein. In order to get 1.40 per cent in the mixture by the use of skimmed milk, it is evident that 140/320 of the mixture must be skimmed milk. 140/320 of thirty-two ounces is fourteen ounces. Fourteen ounces of skimmed milk will, therefore, provide the additional 1.40% of protein desired. Both gravity cream and skimmed milk contain 4.50% milk sugar. Twenty ounces of gravity and skimmed milk are required to furnish the desired percentages of fat and protein. These twenty ounces in a thirty-two-ounce mixture must add 20/32 or 4.50% of sugar to the mixture. Twenty thirty-seconds of 4-1/2 or 20/32 of 9/2 = 180/64, or practically 3% of milk sugar. It is, however, desired to have 6% of milk sugar in the mixture. That is, 3% more of milk sugar is required. This additional sugar must be added in the form of dry milk sugar. Three per cent of thirty-two ounces is 3/100 of thirty-two. This will give the amount of sugar desired in ounces. The sugar is to be measured in rounded tablespoonfuls, or half ounces. If the figures given above are multiplied by two, the result will be the number of rounded tablespoonfuls needed. That is, 3/100 of 32 × 2 = 192/100 rounded tablespoonfuls, or for all practical purposes, two rounded tablespoonfuls. It is also desired to have the amount of lime water in the mixture equal to 25% of the cream and milk in the mixture. There are twenty ounces of cream and milk in the mixture. Twenty-five per cent of twenty ounces is five ounces. Five ounces of lime water must therefore be added. The total quantity of the mixture is to be thirty-two ounces. The milk sugar goes into solution and, therefore, does not add to this quantity. The difference between thirty-two and twenty-five ounces is seven ounces. Seven ounces of water must, therefore, be added to make up the quantity desired. ~Changing the Formula.~--It is often found necessary to change the formula when using artificial feeding for infants, and under these circumstances it is necessary to know the percentages of the food constituents contained in the formula already in use. For this purpose the following method, quoted from "Diseases of Nutrition and Infant Feeding,"[75] is included: ~Morse and Talbot's Method.~--Suppose that a baby is taking a food made up of-- Gravity cream 12 ounces Skimmed milk 18 ounces Limewater 6 ounces Barley water 12 ounces Milk sugar 4 rounded tablespoonfuls "The barley water is made with two teaspoonfuls of barley flour in a pint of water. The total quantity of the mixture is 48 ounces. Gravity cream contains 16% fat. Twelve ounces of gravity cream in a 48-ounce mixture will give, therefore, 12/48 of 16% of fat, or 4% fat. Both gravity cream and skimmed milk contain 3.20% protein. There are 30 ounces of gravity cream and skimmed milk in the mixture; 30 ounces in a 48-ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of protein. Both gravity cream and skimmed milk also contain 4.50% of sugar. Thirty ounces of gravity cream and skimmed milk in a 48-ounce mixture will therefore furnish 30/48 of 4-1/2 which is the same as 30/48 of 9/2 or almost 3.00% of milk sugar. Four rounded tablespoonfuls of milk sugar are equal to two ounces. Two ounces of sugar in a 48-ounce mixture is equal to 2/48 of 100% or 4%. The total percentage of sugar is, therefore, 7%. Two teaspoonfuls of barley flour in a pint of water makes a 1.50% decoction of starch. Twelve ounces of barley water of this strength in a 48-ounce mixture will give 12/48 of 1.50% or about 0.35% starch. There are six ounces of limewater in the mixture and 30 ounces of gravity cream and skimmed milk. 6/30 of 100% is 20%. The limewater is, therefore, 20% of the milk and cream. The mixture thus contains 4% fat, 7% sugar, 2% protein, and 0.35% starch, while the limewater is in the proportion of 20% of the cream and milk." If, therefore, the nurse will follow out the plan suggested by Drs. Morse and Talbot, it should be a simple matter to change the percentage of any of the food constituents in any formula. The following schemes for feeding well babies are included to facilitate the work in the home. A nurse may teach the mother the manner in which these schemes are used, keeping in mind that there can be no iron clad rule for feeding all babies. No nurse should recommend a formula without directions from a physician. And no formula should be changed without his permission. The following milk formulas are used in the Nathan Straus Pasteurized Milk Laboratories of New York: ~Formula No. 1.~--Infants from 1st to 4th week, by A. R. Green. 24 ounces of mixture divided into 8 feedings of three ounces each, fed at intervals of 2-1/2 hours: 3/4 oz. 16% cream 3 oz. full milk 19 oz. water 1-1/4 oz. limewater 1-1/2 oz. milk sugar ~Formula No. 2.~--Infants 1st to 3d month, by Dr. R. G. Freeman. 1-1/2 oz. 16% cream 3 oz. full milk 13 oz. water 1/2 oz. limewater 1 oz. milk sugar Divided into 6 feedings of 3 oz. each, fed 3 hours apart. ~Formula No. 3.~--Infants 2d to 6th month, by Dr. R. G. Freeman. 18 oz. full milk 16-1/2 oz. water 1-1/2 oz. limewater 1-1/2 oz. milk sugar Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours. ~Formula No. 4.~--Infants 3d to 7th month, by Dr. A. Jacobi. 18 oz. full milk 18 oz. barley water 1 oz. cane sugar 20 grains salt (less than 1/4 tsp.) Divided into 6 feedings of 6 ounces each, fed at intervals of 3 hours. ~Formula No. 5.~--Infants 7th to 9th month, by Dr. A. Jacobi. 2-1/2 oz. full milk 7-1/2 oz. oat or barley water 1-1/2 oz. cane sugar 30 grains (about 1/4 tsp.) table salt Divided into 5 feedings of 6 ounces each, fed at intervals of 3-1/2 hours. SCHEME FOR FEEDING NORMAL INFANTS (First Year) Scheme based on Holt and Shaw's "Save the Babies." Pub. by Am. Med. Ass'n. WHOLE MILK METHOD -----------+----------+---------------+----------+-----------+--------- | | | |_Intervals_| _Number_ _Time_ | _Milk_ | _Water_ | _Sugar_ | _of_ | _of_ | _Ounces_ | _Ounces_ | | _Feeding_ |_Feedings_ -----------+----------+---------------+----------+-----------+--------- 1st and 2d | | 1 to 3 tbs. | | | days | | every 3-4 | | | | | hours | | | | | | | | 3d and 4th | | | | | days | 3 | 7 | 2 tsp. | 3 | 7 | | | | | 5th and 7th| | | | | days | 4 | 8 | 3 tsp. | 3 | 7 | | | | | 8th day | 5 | 10 |1-1/2 tbs.| 3 | 7 | | | | | 8th day to | Increase | Increase 1/2 | Increase | 3 | 7-6 end of 3d | 1/2 oz. | oz. every | 1/2 oz. | | month | every 4 | 8 days | every 2 | | | days | | weeks | | | | | | | End of 3d | | | | | month | 16 | 16 |4-1/4 tbs.| 3 | 6 | | | | | Beginning | Increase | Reduce 1/2 | 4 | 4 | 6-5 of 4th | 1/2 oz. | oz. every 2 | | | month to | every 6 | weeks. (Cook | | | end of 6th| days | barley in | | | month | | water if food | | | | | disagrees)[76]| | | | | | | | End of 6th | | | | | month | 24 | 12 | 4 | 4 | 5 | | | | | Beginning | Increase | Reduce 1/2 | 4 | 4 | 5 of 7th | 1/2 oz. | oz. every | | | month to | every | 2 weeks | | | end of 9th| week if | | | | month | food is | | | | | well | | | | | digested | | | | | and child| | | | | seems | | | | | hungry | | | | | | | | | End of 9th | 30 | 10 oz. (in | 2 tbsp. | 4 | 5 month | | which 3 tbs. | | | | | of cereal is | | | | | cooked) | | | | | | | | Beginning | Increase | Cereal gruel | Reduce 1 | 4-5 | 5-4 of 10th | 1 oz. | as above | tbs. per | | month to | per month| | month | | end of | | | | | 12th month| | | | | -----------+----------+---------------+----------+-----------+---------- At the beginning of 7th or 8th month, or earlier if necessary, it is advisable to add orange juice, giving from 1-2 tablespoonfuls between the two morning feedings.[77] After the 4th month it is well to eliminate the night feeding between 10 P.M. and 6 A.M. At end of 11th month add 1-2 pieces of stale bread, toast or zwieback. Part of soft-cooked egg may be given every other day at noon meal by end of 11th month. The orange juice may be increased to 3 tbs. if bowels are not loose. The strained cereal should be given twice daily by the end of the first year, and the milk should be undiluted at this time unless the digestion of the infant forbids. Cooled boiled water should be given several times each day between feedings. Babies cry from thirst as well as from hunger. SCHEME 2 FOR FEEDING WELL BABIES Scheme based on Dr. Richard M. Smith's "The Baby's First Two Years." A full-term baby will usually take a formula made as follows: Cream 2 ounces Skimmed milk 2 ounces Boiled water 12 ounces Sugar of milk 6 level tsp. After 3d day increase cream and milk at the rate of 1 ounce each week, and sugar 1 tsp. every other day until at one month the baby will be receiving a formula such as-- Cream 5 ounces Skimmed milk 5 ounces Boiled water 22 ounces Sugar of milk 3-1/2 level tbs. At two months-- Cream 6 ounces Skimmed milk 6 ounces Boiled water 20 ounces Sugar of milk 4 level tbs. From this point the formula may be increased by adding 2 ounces of skimmed milk each month until the baby is eight months old. For each ounce of milk added, an equal amount of water should be omitted. The sugar in the formula should be reduced one half tbs. every three months. At six months the baby would be taking-- Cream 6 ounces Skimmed milk 14 ounces Boiled water 12 ounces Sugar of milk 3-1/2 level tbs. At eight months-- Cream 6 ounces Skimmed milk 18 ounces Boiled water 8 ounces Sugar of milk 3 level tbs. This amount will not be found sufficient in quantity for a twenty-four-hour mixture for children of this age. Increasing the amount of the last formula in the same proportion, it will be-- Cream 9 ounces Skimmed milk 27 ounces Boiled water 12 ounces Sugar of milk 4-1/2 level tbs. At this age the formula usually may be changed so as to be made from whole milk instead of cream and skimmed milk. The formula may be made as follows: Whole milk 36 ounces Boiled water 12 ounces Sugar of milk 4-1/2 level tbs. From this point on the formula may be increased by replacing the boiled water with whole milk, two ounces each month up to thirteen months. At this age the boiled water may be omitted from the formula one ounce each week. Beginning at the age of eight months the sugar may be eliminated from the formula, one tablespoonful each month. _Barley Water._--At the age of five months, or at any time thereafter, barley water may be substituted for boiled water in the formula. This should be substituted when the baby is not gaining in weight. It may be substituted in many instances when the movements are not well digested. _Lime Water._--It is frequently found to be advisable to add lime water. It is not necessary in every instance, but should be given if the baby is inclined to spit up, or in cases where the stools are too frequent in number and are slightly green in color. * * * * * ~Determining the Fuel Value of a Formula.~--The computation of the fuel value of a formula is very essential since the growth and development of the infant depends largely upon whether or not its energy expenditures are well covered. The method is simple, requiring the same methods used in the computing of other dietaries. Take the formula just calculated, its fuel value would be estimated as follows: Thirty-two ounces are equal to 960 grams. In each 100 grams there would be 3 grams of fat, 2 grams of protein and 6 grains of sugar. Hence in 9.6 one-hundred-calorie portions there would be 9.6 × 3--28.8 grams of fat, 9.6 × 2--19.2 grams of protein, and 9.6 × 6--57.6 grams of sugar, in a thirty-two-ounce mixture. To determine the fuel value of the formula, these results must be multiplied by their physiological fuel factors, 9 and 4 and 4 respectively. Thus: 29 × 9 = 261 calories from fat 19 × 4 = 76 calories from protein 58 × 4 = 232 calories from sugar, or a total of ---- 569 calories for the entire mixture. ~Scheme for Adding Solids to Infants' Diet.~-- From 9th to 15th month: 6 A.M.--Milk formula (bottle). 8 A.M.--Orange juice 1/2 ounce, or prune pulp or prune juice. 10 A.M.--Bottle, cereal (strained) and bread and butter or zwieback. 2 P.M.--Mutton, chicken, or veal soup cooked with cereal; small portion of baked potato, small portion of strained spinach or carrots; orange gelatin or cornstarch pudding. 6 P.M.--Bottle. From 15 months to 2-1/2 years: 8 A.M.--Stewed fruit or orange juice; cereal, crisp bacon, alternated with soft-cooked or poached egg; bread and butter or toast, milk or weak cocoa. 12 or 1 P.M.--Meat or vegetable soup thickened with cereal; lamb chop, scraped beef or chicken or beef juice; baked or mashed potato; strained spinach; carrots; turnips or celery; gelatin, custard, or cornstarch pudding. 3 P.M.--Crackers and milk. 6 or 7 P.M.--Bread and milk or cereal; baked apple or apple sauce. From 3 to 6 years: 8 A.M.--Stewed fruit or orange; cereal; bacon or egg (soft-cooked or poached); bread and butter; milk or cocoa. 12 or 1 P.M.--Soup; lamb chop, scraped beef, chicken, or roast meats; potato; all vegetables; celery, lettuce; light desserts: custards, gelatin, lady fingers. 3 P.M.--Milk; fruit and crackers. 6 P.M.--Milk or cocoa; stewed fruit; bread and butter; cereals; eggs. VEGETABLE SOUP 1/4 lb. beef, lamb or chicken 1 potato 1 carrot 2 stalks celery 1 tablespoonful pearl barley 2 tablespoonfuls rice 2 qts. water 1 pinch salt Finely divide the vegetables. Add the vegetables, barley and rice to 2 qts. of water. Boil down to 1 qt., cooking 3 hours. Add pinch of salt. Pass through fine sieve. Morse and Talbot advise baked potato, plain boiled macaroni, rice and wheat germ, bread and butter, baked custard, plain blanc-mange, and plain boiled tapioca to be given when the child is 1-1/2 years old. When the child is nearly two years old they add meat in the most digestible forms, such as the white meat of chicken, lamb or mutton chops, and scraped beef. The following dietary is suggested for a child two years old:[78] "Whole milk, butter, mutton broth, chicken broth, beef juice, soft-cooked eggs, dropped eggs, white meat of chicken, lamb or mutton chops, scraped beef, French bread, stale bread, toasted bread, whole wheat bread, milk toast, zwieback, plain white crackers, plain Educator crackers, barley, jelly, oatmeal, cream of wheat, wheat germ, Ralston's Farina, rice, baked potato, plain boiled macaroni, orange juice, baked apples, stewed prune pulp and juice, junket, baked custard, cornstarch pudding, plain blanc-mange, plain tapioca. It is not advisable, as a rule, to begin green vegetables until the baby is 2-1/2 years old." It will be seen in the foregoing dietaries how authorities differ in their beliefs as to the requirements of the child. The dietaries included in this text are selected from those used in different parts of the country by physicians who have successfully cared for the infants and children under their charge. THE FEEDING OF PREMATURE INFANTS The digestion of premature infants is naturally not as strong as that of infants born at term. Very little is positively known, but the consensus of opinion goes to show that in the majority of cases the tolerance for sugar is greater than that of either the proteins or fats. The loss of heat is relatively greater in proportion to its surface area in small than in large bodies. This is a well-known fact, hence the premature baby must require more food in proportion to its weight than the baby who is born at the normal time. Then, too, as the premature infant is thinner he does not keep warm like the older infant, and this must be taken into consideration in feeding him. Breast milk is of course by far the best food for such babies, not only because its constituents are in a more available form for the feeble digestive organs, but because the mother's milk furnishes a resistance which is lacking in even the most carefully modified of milk formulas. ~Energy Requirements of Premature Infants.~--Experiments made upon premature infants have proved that the caloric needs of these babies are greater than in the case of full-time babies; that is, they require more per kilogram of body weight. According to Morse,[79] "most premature babies need 120 calories per kilogram of body weight. But there are many exceptions, some thriving on as little as 70 calories per kilogram. No attempt should be made to reach 120 calories per kilogram during the first few days. Thirty calories per kilogram is as much as is wise to give in the first 24 hours of feeding. This amount should be gradually increased each day, watching carefully for symptoms of indigestion and diminishing it if these appear. One hundred and twenty calories per kilogram can be given in about 10 days."[80] ~Necessary Dilution.~--Even breast milk must be diluted with an equal amount of water or a 3% sugar solution. The amount of milk should be increased and the amount of dilution decreased until the undiluted breast milk is given in four or five days. Like older babies, the next best food for premature babies is the properly modified cow's milk, but the utmost care will have to be observed, as these babies are more easily upset than older and stronger ones. ~Premature Infant Feeding.~--The following method of feeding may be suggested, keeping in mind that it is an easy matter to increase the strength of a mixture if the baby shows the need of such an increase. The premature baby is rarely strong enough to take the breast. ~Method of Administering Milk.~--The most satisfactory method of administering the food in such cases is by means of the Brick feeder, which consists of a graduated glass tube, open at either end. On the small end is placed a small nipple like those seen on medicine droppers; this one is perforated and goes into the mouth of the baby. A large rubber finger cot is attached to the other end of the tube. The milk is forced into the mouth by pressing the finger cot. In case the infant is too feeble even for this method of feeding, the desired amount is dropped into the mouth from a medicine dropper; 5 c.c. (about 1 dram or 1 teaspoonful) of diluted milk being given at each feeding. This amount is increased gradually from day to day. ~Whey Mixtures.~--Whey mixtures have been found to meet the needs of premature infants more efficiently than ordinary mixtures. As the proteins in whey are in a more digestible form, they throw less work on the immature digestive apparatus. As a rule the casein and whey are in proportion of 1:1. The following formulas[81] show the amounts in which the food constituents are combined and are suitable for premature babies: Fat 1.00% Milk sugar 4.00% Total proteins 0.25% Lime water 25% of cream and milk mixture or Fat 1.00% Milk sugar 4.50% Total proteins 0.50% Lime water 25% of cream and milk mixture PROPRIETARY FOODS A word as to the use of Proprietary Infant Foods: These prepared foods may be classified under four heads, as follows: (1) condensed milks; (2) malted foods, those consisting chiefly of carbohydrates in the form of maltose and dextrins; (3) those consisting almost entirely of starch, and (4) those composed partly of soluble and partly of insoluble carbohydrates. (1) Condensed milk may be sweetened or unsweetened. These milks are never given undiluted, the directions calling for one part condensed milk to nine parts water, which gives a mixture containing 0.90% fat, 5.49% sugar, and 0.80% protein if "Eagle Brand" Condensed Milk is used.[82] (2) Malted Foods: Mellin's Food and malted milk are examples of this group. These foods contain the carbohydrates in soluble form and when added to milk make an acceptable addition, as they furnish the carbohydrates in the most digestible form. When fed alone, diluted only with water, they result in a mixture deficient in both fat and protein. (3) Imperial Granum is an example of this group, and there are several others with similar compositions. These foods are very much like wheat flour which has been subjected to heat, changing to a small extent the starch to dextrose and dextrin. (4) Nestlé's Food, Eskay's Albumenized Food, and Allenbury's Food are examples of this group, each containing sugar and a percentage of starch. Upon dilution with water, the amount of fat in the mixture is just a trace. ~Incomplete Foods as a Source of Danger.~--The ease with which the majority of these foods are prepared and the way in which they agree with the baby constitute the chief danger of their use. If they are added to milk, with the exception of the condensed milk, they result in a modified milk containing the carbohydrates in a more or less digested form. But they are expensive, and give no better result as a rule than a carefully modified milk containing a cereal gruel. The giving of foods like malted milk alone is dangerous because they are deficient in some of the most necessary constituents, and babies fed in this way, while growing fat, are apt to have soft or brittle bones and muscular tissue higher in fat and water than in protein, so that they do not grow and develop in a normal way, and when they are attacked by the diseases so prevalent in the early years of life, they succumb rapidly, because the resistance given by a properly modified food is lacking. Condensed milks act in a like manner. That is, in the sweetened milks the carbohydrate content is far in excess of the needs, and the proteins and fats are deficient, so that while the baby fattens he does not receive the building foods commensurate with his body requirements.[83] Many mothers adopt the use of these foods because they mean less work than in modifying the milk properly, but the nurse should point out the facts just mentioned, explaining that while these proprietary infant foods are undoubtedly valuable at times to fill a place when the milk formula has not proved satisfactory, the use of these foods as a regular custom is expensive, not only from a financial standpoint but from a standpoint of health, since their disadvantages far outweigh their advantages in the long run. SUMMARY ~Breast Milk as a Food.~--The superiority of breast milk over any other known food cannot be too strongly emphasized. ~Regularity in Feeding.~--The absolute need for regularity in feeding--"feeding by the clock" and not by guess or when the baby cries. ~Indications of Health.~--The normal growth and development to be used as guides as to the physical well-being of the infant; also as an indication of the use of the proper modification of milk for the individual needs of the child. ~Dilution.~--The amount of dilution necessary--cereal waters, whey, etc.--to increase the digestibility and nutrient values of the formula. ~The Addition of Alkali.~--The addition of alkalies to milk formulas to accomplish a like purpose. ~Milk Sugar, Malt Sugar, Cane Sugar.~--The use of the different sugars, namely, dextri-maltose, lactose, or cane sugar under various circumstances as the condition of the infant demands. ~Substitutes for Whole Milk.~--The substitution of different milk, such as lactic acid milk, Bulgarian culture buttermilk, Eiweissmilch, cream and whey mixtures, as the individual needs of the infant demand. ~Technique of Milk Modifications.~--The absolute need for the nurse to understand the technique of milk modification before attempting the care of an artificially fed infant. ~Percentage Computation.~--A knowledge of percentage, that an accurate computation of a formula may be accomplished. ~Preparation of Food.~--A sufficient knowledge of food preparation to enable the nurse to prepare any food which may be deemed necessary by the physician for the welfare of the child. ~Water.~--The importance of giving the baby water aside from that used in modifying the milk. Many babies cry from thirst when they are believed to be crying from hunger or temper. ~Increasing the Diet.~--The necessity for increasing the amount and strength of the formula with the age, growth, and development of the child by the addition of solid food as soon as the physician deems it advisable. ~Feeding Premature Infants.~--The method of feeding a premature infant differs from that employed in feeding an infant born at term: (a) because its development has not progressed so far; (b) because its digestive apparatus being more or less immature, food handled with ease by an older baby will be totally unfit for the premature one, both as to quality and quantity. ~Wet Nurse.~--The advisability of procuring a wet nurse when the mother is unable to nurse the infant, (a) on account of the more digestible character of the food constituents, especially the proteins, in mother's milk over those of cow's milk; (b) on account of the resistance furnished by the natural food which has been proved to be very much greater than that furnished by any other food, no matter how carefully the modification of the milk is made. ~Premature Infants.~--Their caloric needs are greater than in full-term babies, hence their food must be adjusted to meet these needs. In fact the nurse must have an understanding of the behavior of foods in the metabolism of infancy and the laws which govern their use in the organism of the child. PROBLEMS (a) Write a formula for a two months' old infant weighing twelve pounds, which contains 3% fat, 2% protein, and 6% sugar. (b) Change this formula so that it will contain 3% fat, 1.5% protein, and 6% sugar. (c) Write a formula for an eight months' old baby, using whole milk instead of cream and skimmed milk. (d) Write a formula for a premature baby containing 1% fat, 4% sugar, and 0.25% protein (allowing 30 calories per pound of body weight). FOOTNOTES: [64] "Childhood and Growth," p. 18, by Lafayette Mendel. [65] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot. [66] "Feeding the Family," by Mary Swartz Rose. [67] "Diseases of Nutrition and Infant Feeding," p. 218, by Morse and Talbot. [68] "Generally Accepted Methods for Artificial Feeding of Infants with Indicatives and Contra-Indicatives," by Orville R. Chadwell, M.D. Reprinted from "New England Medical Gazette," June, 1916. [69] "Mechanical Factors of Digestion," by Cannon. [70] "Diseases of Nutrition and Infant Feeding," p. 204, by Morse and Talbot. [71] "New England Medical Gazette," June, 1916. Reprint by Orville Chadwell. [72] The best substitute for the homogenizer is found in an electric mixer; a formula prepared with a fat other than cream can be made by means of this mixer to approximate very closely that of homogenized milk. [73] There are a number of pasteurizers on the market; one sold by the Walker Gordon Laboratory and one designed by Dr. R. G. Freeman of New York are both satisfactory. [74] Method suggested by Morse and Talbot, "Diseases of Nutrition and Infant Feeding," pp. 234-235. [75] "Diseases of Nutrition and Infant Feeding," pp. 225 and 226, by Morse and Talbot. [76] One-half tbs. barley flour may be cooked in the water used as diluent; it should be boiled 20 minutes, strained and cooled before adding to formula. [77] When babies are fed upon pasteurized, sterilized, or dried milk it is advisable to use orange or prune juice earlier than the seventh month. Dr. Hess suggests the use of canned tomato juice as substitute for orange juice. [78] "Diseases of Nutrition and Infant Feeding," p. 236, by Morse and Talbot. [79] Morse: "American Journal of Obstetrics," 1905. Hess: "American Journal Diseases of Children," 1911. [80] "Diseases of Nutrition and Infant Feeding," p. 238, by Morse and Talbot. [81] "Diseases of Nutrition and Infant Feeding," p. 239, by Morse and Talbot. [82] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot. [83] The proprietary foods on the market are many, but those given above as suggested by Morse and Talbot represent the best known infant foods. CHAPTER X CARE AND FEEDING OF INFANTS AND CHILDREN IN ABNORMAL CONDITIONS AND IN INFECTIOUS DISEASES ~Digestive Disturbances.~--It is a well-established fact that artificially fed infants are more subject to disturbances due to diet than breast-fed infants, the digestional disturbances of the latter yielding more readily to treatment. As a rule, with the breast-fed baby it is largely a question of adjusting the diet of the mother, of increasing the fluid in her diet, of seeing that she takes the requisite amount of exercise in the open air, and of lengthening the intervals between feedings or of giving the baby water just before putting him to the breast. With the artificially fed infant it is an entirely different proposition. ~Causes in Artificially Fed Infants.~--The digestive disturbances may arise from any one of half a dozen or more causes. The constituents in the milk may be in the wrong proportion. The amount given at a feeding may be too great or too little. The dilution may be too great or too small to meet the needs of the infant. Or the milk may contain the microörganisms which bring about fermentation or putrefaction. Any or all of these causes may assail the artificially fed baby. Consequently, all the care that can be exercised must be resorted to in the feeding of these babies, not only after digestional disturbances arise, but as a means of their prevention. In the preceding chapter the methods generally used in the feeding of normal infants were discussed. We now proceed to the feeding under abnormal or pathological conditions. ~Errors in Diet.~--The majority of the ills from which the baby suffers can be traced primarily to ~errors in diet~ and in most of these cases the treatment consists chiefly in adjusting the formula to suit the condition. As a rule, these errors may be placed under two heads: those that are brought on by under-feeding and those induced by over-feeding. The pathological conditions arising from under-feeding are due not only to a lack of food, but chiefly to the improper balancing of the different food constituents in the formula. As has already been stated, so much food is required to cover the energy expenditures, so much for maintenance, and so much for storage for the growth and development necessary during the entire period from birth to maturity. These constituents must be regulated to the individual needs of the infant. ~Over- and Under-dilution.~--If the dilution is too great, the infant, while receiving the correct amount of the mixture, may have the necessary food constituents so reduced as to have them fail completely to do their appointed work in the body. Or if the amount of diluent is too small the baby may be receiving too strong a mixture, and develop nutritional disturbances therefrom. Under the first head the child suffers from under-feeding; the appetite is satisfied before enough of the actual food is ingested to meet his various needs. However, it is probable that the artificially fed infant suffers from the results of over-, rather than of under-feeding. DISEASES DUE TO ERRORS IN DIET Gastro-intestinal disturbances, colic, enterocolitis, colitis, etc., rickets, scurvy, nephritis, and diabetes are among the diseases most apt to develop from injudicious feeding, and in these cases the dietetic treatment plays the most important part in combating the condition. The disturbances caused by food are recognized by the general symptoms: vomiting, rise of temperature, subnormal temperature, and the stools, the latter being the chief point of observation. ~Fats as Cause.~--When the fats are causing the disturbance, the rise of temperature is apt to be high, but not of long duration. The baby vomits frequently, the vomitus being acid in reaction and odor, the latter due to the presence of fatty acids, butyric acid, etc. Diarrhea often develops in a more or less acute form. In these cases there is a loss of sodium and other alkaline salts in the feces, and a consequent excess of ammonia in the urine, resulting in acidosis. Acid intoxication has been known to develop as a result of this loss of alkaline salts. The chief symptoms of this condition are rapid and deep respiration, stupor or restlessness, and cherry-red lips.[84] ~Symptoms of Excess Fat in Diets.~--The general symptoms in infants receiving an excess of fat in their food take the form of loss of appetite, with more or less loss of weight, or failure to gain. When the cases are not chronic, soft curds may often be seen, which are at times mistaken for casein curds, but may be distinguished from them by their translucent appearance and their solubility in ether. The color of the stools due to the excess of fat under the above-mentioned conditions is shiny and gray. In the majority of cases, especially of a more chronic character, the stools are apt to be large and dry, at times hard and crumbly. The fat in such stools is combined with magnesium and calcium salts, forming the characteristic "soap stools."[85] The combined loss of these salts in the feces has a definite effect on the general metabolism and nutrition, giving rise to rickets. ~Regulating the Fat.~--The treatment consists chiefly of regulating the amount of fat in the formula, and of cutting it out altogether in the beginning when the symptoms show acute acid conditions. In many cases, if the baby is given breast milk, the trouble disappears. At other times it is necessary to substitute a foreign fat such as olive oil for the butter fat. Dr. Ladd in the Children's Hospital in Boston treated many babies who manifested an intolerance for butter fat with "Homogenized Milk," which consisted of skimmed or separated milk and a certain percentage of olive oil, placed in an apparatus which brought about a more complete division of the fat, causing it to mix with the milk as an emulsion closely resembling human milk. Fat intolerance is most difficult to overcome, the baby being apt to relapse into the acute stage unless the utmost caution is observed in adding the fats to the formula. It is not safe, however, to feed the baby upon a fat-free milk for any great length of time. ~Excess Protein in Food.~--The digestional disturbances arising from too much protein in the food are as a rule readily overcome in breast-fed infants. When it is due to nervousness or worry in the mother, it disappears as soon as the mother ceases to worry or does something to remove the cause of the nervous condition. When the breast milk is high in protein, more exercise in the open air at times adjusts the percentage of protein, provided the mother does not become over-tired, in which case the percentage of protein in breast milk increases. ~Evidences of Excess Protein.~--The symptoms of excess protein in the diet of the breast-fed baby are colic and flatulence, which are often persistent and difficult to overcome. Vomiting is not so common in these babies as in those who are artificially fed. The stools are increased in number, are either brown or green, and generally loose and watery. In artificially fed infants the symptoms are much the same, except that the vomitus often contains large curds which are tough and leathery. The baby suffers from gas formation and colic. The stools are at times normal, except for the presence of large, hard curds; at other times they are increased in number, and are of a watery consistency and alkaline in reaction. ~Regulating the Protein in Formula.~--When the stools are watery and brown and musty in odor as the result of disturbed protein digestion, the treatment consists of taking out the proteins from the formula and of substituting cereal water, to which dextri-maltose or milk sugar is added, the milk being added as soon as possible to prevent too great a loss of body protein. As a rule the whey proteins do not cause the disturbances so often as the casein proteins; and at times it is possible to use whey mixtures with babies who cannot tolerate the casein at all. Buttermilk also is used in cases of protein indigestion, as is Eiweissmilch and peptonized milk. ~Regulating the Carbohydrates.~--When the disturbances are due to the carbohydrates in the formula, they may be digestional or nutritional. In this form the milk sugar is more apt to be the cause of the trouble than the dextri-maltose preparations which are at times used. In the latter, when the disturbance becomes nutritional, the cause of the trouble can usually be traced to an excess of starch. When the percentage of milk sugar is greater than can be handled by the digestive apparatus of the baby, it is manifested by frequent attacks of colic, with the passage of watery green stools, highly irritating, in character on account of their acidity. In acute cases the loss of weight is often marked, and symptoms of intoxication may develop. The outlook is grave in the very severe cases, but if the baby can survive forty-eight hours after the acute symptoms develop, he is apt to pull through the attack. ~Adjusting the Sugars.~--The treatment in these conditions consists of eliminating the milk sugar from the formula; in less severe cases dextri-maltose may be substituted. As a rule, coincident with indigestion caused by sugar there will be found to be an intolerance for much fat, so that this must be adjusted as well as the milk sugar. Skimmed milk mixtures, containing a certain amount of barley or oatmeal water, are generally found to be suitable in these cases. Dextri-maltose may be added after a few days in order to maintain the fuel needs of the body. Eiweissmilch is at times used, but whey mixtures are contraindicated on account of their high sugar content. Dextri-maltose also disagrees at times. The baby has colic and flatulence, the stools are usually loose or watery and dark brown in color. The dietetic treatment consists of an immediate withdrawal of the dextri-maltose preparation and a substitution of milk sugar after a few days. ~Evidences of Excess Starch in Formula.~--The disturbances arising from an excess of starch in the diet are, as has already been stated, more apt to be of a chronic than an acute character. Vomiting is not a common symptom under these conditions, although colic is frequent. The stools are at times loose and brown, at other times dry and small. The baby at times suffers from diarrhea and at others from constipation. When the disturbance is acute the starch must be entirely eliminated from the formula. If proprietary foods are being used containing starch, whether it is dextrinized or unchanged, they must be at once abandoned, and a formula made up of protein with sugar and fat. MODIFIED MILK FORMULAS SUGGESTED BY MORSE AND TALBOT FOR THESE CONDITIONS Fat 1.00% Fat 2.00% Milk sugar 4.00% or Milk sugar 5.00% Protein 0.75% Protein 1.25% They likewise advise whey and whey mixtures under these circumstances. ~Fermentation.~--Fermentation is often the cause of infantile indigestion. At times it is acute and may cause a decided elevation of temperature owing to the absorption of the toxic substances formed as a result of the bacterial action. In almost every case of indigestion brought on by fermentation there will be an accompanying diarrhea. As a rule the carbohydrates are more liable to the attacks of bacteria in the stomach than the other food constituents. ~Treatment.~--The treatment consists first of starvation, no food being given for at least twenty-four hours. Then water or weak tea, sweetened with saccharin, may be given, but nothing else. The medical treatment must be left to the discretion of the physician. When the condition warrants a return to food the formula must be made weaker than that which has caused the disturbance. Malt soup mixtures, buttermilk mixtures, whey and albumen water may be added as the condition of the baby improves. In older children the period of starvation may have to exceed that of infants, but a gradual return to normal diet is made. Weak tea and toast may be given after the first twenty-four hours and well skimmed meat broths, soft-cooked eggs, liquid peptonoids, and malted milk added to the diet as the condition of the child improves. ENTEROCOLITIS The dietetic treatment for enterocolitis must be adjusted according to the principal symptom. In some of these cases diarrhea is most prominent, while in others constipation is the most marked symptom. Hence the diet must be such as not only to do no harm to the child, but one that will aid in his ultimate recovery. DIARRHEA The treatment for diarrhea, whether it is from fermentation or putrefaction of food, has already been explained. The grave danger in the putrefactive diarrhea is the absorption of the toxic substances which result from bacterial action upon the unabsorbed food material in the small and large intestine. In these cases auto-intoxication may develop and the baby may die before the condition yields to treatment. The entire intestine must be cleansed as a rule. The stomach of the baby may be reached with little trouble by using a small rubber catheter attached to a glass funnel and a solution of bicarbonate of soda. The bowels may be emptied by means of a soapsuds enema. Older children may be given oil, but this of course comes under the jurisdiction of the physician. CONSTIPATION Constipation is one of the most frequent troubles visited upon people of all ages. "It is not a disease, it is a condition in which the number of stools is less or the consistency of the stools is greater than is normal for the individual at the given time."[86] It may be caused by neglect of the bowels, which should be evacuated once or twice every day during infancy and once a day after that period. If the habit of emptying the bowels every day is established in infancy it adds much to the health and comfort of the individual during the entire remainder of life. Babies are sometimes constipated as the result of the opium administered in soothing sirups. Others inherit constipation, while still others are constipated by the taking of the wrong kind of food or too little food. In any case it is decidedly bad to resort to drugs, since the habit of taking cathartics is so easily acquired and so difficult to overcome. ~Factors Inducing Constipation.~--With artificially fed babies a formula which contains too high a percentage of diluent and too low a percentage of solids will cause constipation, chiefly because the solids are so completely absorbed that they have no residue to form feces. A formula with too low a fat content in proportion to its protein and carbohydrates may cause constipation because the latter two constituents are almost entirely absorbed, and the feces, which is largely made up of the fat, is correspondingly small. Excess of fat, however, has been proved to be one of the chief causes of constipation in infants, as has also been the case with excess starch. Boiling the milk for the baby at times results in constipation. Hence sterilization is more frequently to blame for the condition than the pasteurization of milk. ~Constipation during Second Year.~--During the second year, if the child is given too much milk and too little solid food, constipation is very apt to be the result. A maximum quantity of from thirty-two to forty ounces may be given. In many diseases brought on by malnutrition, constipation is an obstinate condition to be overcome. This is especially the case in rickets and anemia. ~Use of Laxative Foods.~--After the baby is a few months old, orange juice is given between the morning feedings. Malted foods likewise exert a laxative effect. The higher the percentage of maltose, the more laxative the food. The nurse must keep this point in mind in feeding babies. With older children and adults, the question of diet for constipation is quite as important as it is for infants. Prunes or figs cooked with senna leaves and thoroughly strained furnish an excellent adjunct to the diet under such conditions. The coarse breads such as bran and Graham or wholewheat bread should be used instead of white flour breads. Care should be taken in advising a cereal diet for children, since cereals, with the exception of oats, are apt to be constipating. Fresh fruits, stewed fruits, and fresh vegetables are all good under the above-mentioned conditions. Young children require the vegetables strained or cut fine. Adults should include one coarse vegetable a day in their dietary to obviate the development of constipation. Children should be taught to drink plenty of water, and babies should not be neglected in this respect. As a rule very few adults drink as much water as is necessary for the general welfare of their bodies. SCURVY There is probably no disease of infancy which has come in for more study in the past few years than scurvy. ~Cause.~--The disease is believed to be directly due to a deficiency in the diet of the antiscorbutic vitamine, known as "Water soluble C." ~Treatment.~--For many years it was known that lime juice exerted a curative effect upon scurvy. But recently the efficiency of this fruit juice has proved to fall far short of that effected by either orange, or tomato juice. Feeding experiments have proved that animals, fed upon rations consisting of dry food without the addition of green, will develop scurvy. And that the milk of such animals will show a deficiency in the "C" vitamine which will lead to a development of the disease in infants fed upon such milk. Milk is, in fact, by no means a perfect food, so far as its vitamine content is concerned. First, because the presence of the vitamine in milk is so dependent upon the diet of the mother or the animal, second, because the pasteurization temperatures used to insure cow's milk of purity from a bacterial standpoint, destroys in it the greater part of its antiscorbutic power. Either of which makes it necessary to supplement the formula of the artificially fed infant, and, in case of the former, the mother's milk of the breast-fed baby, with orange, or canned tomato juice. The amount of either of the fruit juices which is necessary to insure the child of a freedom from scurvy, is small, ranging from one-half to one ounce of strained juice daily, this amount is increased gradually until the child is taking from one and one-half to two ounces each day. It has been found advisable to administer the fruit juice between the two morning feedings. As a rule, the fruit juices are given at the beginning of the seventh month, but they may be given at a much earlier date, the time being adjusted by the physician. RICKETS Rickets, like scurvy, is being discussed by scientists both in America and abroad. The disease is widespread, particularly in its subacute form, and its effect upon the health of the child is so serious that no amount of effort to prevent its development should be considered too great. ~Calcium Retention in Rickets.~--The disease is characterized by a failure of the bones to lay down lime salts, this failure causes a softness and flexibility in the structure of the bones which permits them to bend into deformities. Then, too, it is a well established fact that any interference with the calcium metabolism in the body, will inevitably bring about disaster. (See Mineral Metabolism, page 185.) ~Factors Inducing Rickets.~--According to Dr. Eddy, "It is impossible at present to determine whether rickets is a true avitaminose or a consequence of deficiency in a series of factors." ~Treatment.~--For breast-fed babies it is necessary to adjust the diet of the mother to include more of the vitamine bearing foods, since milk contains vitamines only in proportion to the amount eaten in food. For artificially fed children, the giving of cod liver oil has recently been adopted as the surest and safest method of curing and preventing the development of the disease. Like treatment is used with breast-fed infants if the need arises. The value of cod liver oil in this respect has only been recently recognized. Mellanby of England claims that the oil owes its curative and preventive properties to the presence of the "A" vitamine. But scientists in this country have not fully accepted this view. Eddy states, "It may be that the power of the oil is due to its 'A' vitamine content, in which it is known to be rich, or it may be due to a new vitamine, but the fact that the oil is a preventive in this respect gives the pediatrist another agent to insure normal growth." ~Sunshine as a Factor.~--It has been found that the disease rickets is more prevalent in winter than in summer; this is believed to be due to the fact that sunshine during the summer months exerts a distinctly beneficial influence over the disease. Dr. Hess's report of the good results which he has found to be derived from the use of the ultra violet rays as a substitute for sunshine in winter, would seem to confirm this view. MALNUTRITION ~Malnutrition~ is not confined to the children of the poor, though it is more common with infants of parents who have not the means to secure the best milk and give them the benefit of wholesome surroundings and plenty of sunshine. But babies of people in moderate circumstances, and even of wealthy parentage, are at times badly nourished, and require the same exacting care, the same attention to the food, the fresh air, and the sunshine that the poorer babies need in order to survive. Malnutrition may be the result of insufficient food, and it may also be due to the lack of one definite food element. Again, it may be brought on by some deformity of the mouth or stomach, which make it impossible for the baby to get all the food which he requires for his maintenance and growth. He may be born prematurely and his digestive apparatus not be sufficiently developed to care for the amount or type of food necessary for his needs, or he may have some congenital weakness which interferes with the absorption and assimilation of his food. All of these points must be considered. ~Evidences of Correct Feeding.~--If the baby shows a steady gain, both in weight and growth of stature, without digestional disturbances, the food given him is probably correct, but it must be kept in mind that nutritional disturbances, such as rickets and scurvy, are slow in developing, and do not manifest themselves with anything like the rapidity of digestional disturbances. Hence the nurse must take care as far as she is able, not only to prevent the food from causing indigestion, but also to see that it is not given in such a form as to induce those graver and more lasting nutritional disturbances which affect the entire system from infancy throughout the life of the individual. SUMMARY ~Breast Feeding versus Artificial Feeding.~--There is no doubt about the fact that the breast-fed baby suffers less from digestional disturbances and has more resistance to disease than the baby fed even upon a perfectly prepared artificial food. The majority of diseases manifested by artificially fed infants have their origin in the following errors in diet. ~Over-Feeding.~--Resulting in acute gastro-intestinal disturbances (colic, enterocolitis, colitis, constipation). ~Under-Feeding.~--Resulting in chronic, and acute deficiency diseases (scurvy, rickets, malnutrition). ~Evidences of Dietetic Errors.~--The stools, showing characteristic evidences of excessive quantities of, protein, fat, or carbohydrates in the formula. Loss of weight or failure to gain. The development of deficiency diseases (scurvy, rickets, xerophthalmia, rickets and malnutrition). ~Evidences of Correctness in Feeding.~--Normal gain, freedom from gastro-intestinal disturbances, and deficiency diseases. Rosy cheeks, bright eyes, and a vigorous body. ~Treatment in Abnormal Conditions.~--The treatment consists in adjusting the diet to meet the needs of the particular disturbance manifested. Plenty of fresh air, sunshine and sleep. ~Relapse.~--One danger which the nurse must always be on the lookout for is the relapse into the acute stage. The diet is the chief treatment. In acute gastro-intestinal disturbances rest from food is essential for at least twenty-four hours. Some infants can easily endure starvation for this short period. However, when malnutrition has already been established, it is not wise to carry out the starvation treatment over-long. A cautious return to a normal diet may be made as soon as acute symptoms disappear. ~Fevers in General.~--It requires very little deviation from the normal to raise the temperature of a child. A slight attack of indigestion, a slight soreness of the throat, will bring up the temperature of some children out of all proportion to the seriousness of the disorder. ~Diet in Fevers of Short Duration.~--As a rule, in the fevers of short duration, such as intermittent fever, malarial fever, etc., the diet is a simple matter. Milk is given when it agrees, with buttermilk, koumiss, broths, and albuminized beverages to vary the diet. ~Diet in Infectious Diseases.~--When, however, the fever is induced by specific bacteria, such as in the case of typhoid and scarlet fever, the diet is a different matter altogether. The disease may be one in which the diet is the chief item of importance; such is the case with typhoid and scarlet fever, with the former because of its long duration, the increased rate of metabolism due to both the fever and the action of the bacteria making it necessary to increase the normal amount of food to meet the new requirements of the body; and with the latter on account of the kidney complications which must be guarded against, and which can only be handled by regulating the diet. ~Infant Feeding.~--The feeding of infants under febrile conditions resolves itself into an adjustment of the milk formula to meet the existing state of affairs. The digestion is always more or less disturbed by fever, especially during the early stages. ~Restricting the Food.~--It is not always possible to diagnose the disease immediately, so that the safe thing to do is to lengthen the intervals between the feedings for the breast-fed baby and to stop food entirely for twelve to twenty-four hours for those who are artificially fed, when there is any doubt as to the cause of the rise of temperature. Some mothers find it difficult, if not impossible, to institute this period of starvation. In these cases barley water or albumen water may be given at stated intervals. Many physicians give very weak tea, slightly sweetened, under the above conditions; it does no harm to the baby and relieves the mother from the belief that her child is being starved to death. In twenty-four hours, if the fever arises from disturbed digestion, some manifestation of the condition will be observed. ~Bacterial Activity.~--In cases of intestinal putrefaction the fever is apt to rise at an alarming rate and is controlled only by removing the cause. The proteins which have escaped digestion and absorption in the intestines furnish the best medium for the growth of putrefactive bacteria. Hence this food constituent must be given in its most digestible form. ~Dietetic Treatment.~--Milk in most instances is the best form in which to give protein food, especially to young children and babies. At times, however, it will be found that milk disagrees; it must be peptonized, or one of the fermented milks, such as buttermilk (Bulgarian culture), Eiweissmilch, or koumiss must be substituted. In cases where the putrefactive bacteria make it unwise to use milk at all, for a time the proteins should be furnished in the form of cereal gruels, and the juice of an orange strained and diluted given once or twice a day between the morning and evening feedings. ~Whey~ is contraindicated in cases where the fever is brought on by putrefaction in the intestine, chiefly because it furnishes one of the best mediums known for the growth of the offending bacteria. Patience is required in handling the diet for fevers in infancy. As has already been stated, it requires a very slight cause to raise the temperature of a child, but for this very reason especial care must be observed that no enlightening symptom escapes the notice of the nurse. ~Complications.~--Tuberculosis or scurvy may be in an incipient stage, and may be overcome if recognized in time. The nurse has a better opportunity for observing changes in an infant or child under her care than the physician who comes once a day or less. The nurse should make note of these changes, that the physician may have a chance to regulate the diet accordingly. ~Fluid Diet.~--With children, as with adults, the energy output in fever is greater than in health, hence the need for plenty of fluids to help eliminate the waste products due to the increased metabolism. These fluids may consist of water, fruit beverages, cereal water, whey, and broth. It is well for the nurse to remember that when the child is confined to bed, he will not need so much food as he would if he were up and about, but that if the fever is of long duration, as in typhoid, the increased rate of metabolism must be met by an increased amount of food, as the ordinary requirement standards for a child in health cannot be applied to the diet of a child under these conditions. SCARLET FEVER Scarlet fever is an acute infectious disease, characterized by high fever, sore throat, a red rash, and a tendency to nephritis. The disease usually begins suddenly with an attack of vomiting; the temperature rises to 104° or 105° and on the first or second day a rash appears, first on the chest and neck, and spreads over the entire body. This lasts from three to seven days, desquamation begins soon after the rash disappears and lasts from two weeks to six, the palms of the hands and soles of the feet peeling last. The appearance of the tongue is very characteristic, being coated, and through this coating are seen a few bright red points, producing the well-known strawberry tongue. After a few days the coating disappears, leaving the tongue bright red. In mild cases the tonsils are enlarged and the throat very red. In severe cases there may be difficulty in distinguishing the disease from diphtheria without a culture being taken. The tendency of the child to develop nephritis during the second or third week makes the treatment largely dietetic in character. ~Dietetic Treatment.~--Milk is the chief diet for the first three weeks. If it disagrees, it should be modified or peptonized to suit the condition. Koumiss and buttermilk may be substituted when it is impossible to prepare the milk so that it will not cause digestional disturbances. This, however, is seldom found to be the case during infancy. Malted milk and even condensed milk, or some of the dextrinized and malted foods at times prove valuable when whole milk disagrees. But the nurse must remember that a baby runs a risk of developing nutritional diseases of a grave character if fresh milk is eliminated from the diet for any great length of time. Older children may have plain vanilla ice cream and plain junket, oyster or clam broth made with milk, the oysters and clams carefully strained out. Lemonade and orange juice may be given, but no meat broths or albumenized beverages or egg dishes can be admitted to the dietary. ~Development of Nephritis.~--Nephritis must be guarded against. The skin, being covered with a rash, is put out of commission as an excretory organ; in consequence all of the work of this description is placed upon the kidneys. In the first part of this text the work of the kidneys was defined; it was found that they were the chief organs for the excretion of the end-products of protein metabolism. It can be readily understood that when these organs are given not only their own work but that of the other organs to perform, unless the food requiring the greatest amount of effort on the part of the kidneys is confined to those types which can be most easily taken care of, such as milk, the kidneys stand a great chance of becoming impaired. Such is the case in nephritis. ~Convalescent Treatment.~--The return to normal diet must be made with the greatest caution. Specimens of urine must be taken often, for in this way alone can the development of nephritis be reckoned with.[87] Should nephritis develop in spite of efforts to prevent it, a farinaceous diet[88] such as is given in these conditions must be resorted to. After three weeks, if the patient shows no disposition toward nephritis, and if convalescence is progressing satisfactorily, the diet may be increased day by day, adding milk toast, cereals, cream soups, rice, baked potato, then custards and soft eggs, the soft part of oysters, broiled or baked fish, broiled breast of chicken, and, still later, rare beef and lamb chops. Meat, however, must not be given until all danger from nephritis has passed. DIPHTHERIA ~Diphtheria.~--The feeding in diphtheria follows the régime given in acute fevers. The body must be kept in good condition. At the same time it is necessary to understand the complications which make the dietetic treatment of this disease assume a place of importance. ~Complications.~--It may be complicated by broncho-pneumonia, albuminuria, carditis, endocarditis, and dilatation of the heart. Anemia must be combated, but care should be used not to push the diet to such an extent as to impose too great a tax upon the already weakened heart. ~Dietetic Treatment.~--While the fever lasts the diet must be fluid, milk, buttermilk, malted milk, and some of the proprietary infant foods such as Mellin's Food, Eskay's Food, and like preparations. Milk gruels, made with milk and some cereal such as farina, barley flour, fine cornmeal, arrowroot, strained oatmeal, etc., are at times more easily swallowed than the unthickened liquids. Liquid beef peptonoids, panopeptone, and like predigested beef preparations prove valuable in many cases. ~Convalescent Diet.~--As convalescence progresses, or in cases where the patient finds it easier to swallow a semi-solid than a liquid, soft custards, gelatin, well-cooked cereals, and ice cream may be given. Eggnog and milk punch are at times given, but only upon the advice of the physician in charge. ~Rectal Feeding.~--When the condition of the patient makes it necessary to nourish in other ways than by mouth, nutrient enemas[89] may be given. In certain cases of diphtheria, young infants can be fed more successfully through a tube inserted by way of the nose into the stomach than by feeding in the ordinary way. The formula is prepared in the same way as for bottle feeding, and is poured into a glass funnel and through the soft rubber catheter into the stomach. Care must be observed to prevent the patient struggling on account of the heart weakness which invariably complicates this disease. WHOOPING COUGH In the early months of life it is probable that whooping cough is one of, if not the most fatal of the diseases to which the infant is subjected. The period of incubation of this disease is from one to two weeks, the cough at first not appearing different from those accompanying colds of all sorts. However, in from ten days to two weeks the characteristic whoop occurs, differentiating this disease from all others. The symptoms aside from the whoop are the difficulty of taking breath and the great prostration after the paroxysm and the frequent vomiting of the food, brought on by the violent coughing. In very young infants the whoop does not always occur. But the child coughs and holds its breath until it is blue in the face. At times young babies may have convulsions. The so-called spasmodic stage, during which the child may have from a few to a great number of paroxysms of coughing a day, lasts from a month to six weeks, and in some cases even longer. As the disease declines the cough gradually disappears and the child appears to be suffering with ordinary bronchitis. The characteristic whoop may return at any time during the ensuing six months or year if the child has an attack of bronchitis and is inclined to cough. ~Complications and After-effects.~--The complications and after-effects of whooping cough give it a serious character. Hemorrhage may occur from the nose. According to Ruhräh: "Paralysis may follow from meningeal hemorrhage, broncho-pneumonia, acute emphysema, and collapse of the lung may occur. Diarrhea, convulsions, and albuminuria are also met with. Tuberculosis and chronic bronchitis may follow."[90] ~Dietetic Treatment.~--The diet plays an important part in whooping cough. The serious complications and after-effects of this disease upon children necessitate a rigid observance of dietary laws. With infants it is always best, when it is possible, to give breast milk. As this is the natural food it requires less effort on the part of the digestive apparatus to become available. It has been proved that even during the time when the baby is nursing the milk is projected in spurts into the duodenum without waiting to be attacked by digestive enzymes in the stomach, and for this reason the breast-fed infant is more apt to be efficiently nourished than the artificially fed baby, who loses his dinner by vomiting before absorption has had a chance to occur. ~Diet under Ten Years of Age.~--For children under ten years, a fluid diet is necessary, at least in the beginning of the disease while there is a fever, and later, if the vomiting is persistent. Milk, buttermilk, koumiss, broths, albuminized beverages, and cereal gruels such as barley and oatmeal gruel and arrowroot gruel can be given. Later, if the fluids are retained, cream of wheat, farina, junket, soft custards, and soft-cooked eggs may be added. Care must be taken in giving toast, unless it is softened with milk or broth, for the crumbs may bring on a paroxysm of coughing and vomiting. The best results in feeding with whooping cough are obtained by giving the food in small quantities and oftener. A few ounces given every two hours are less apt to be vomited than a larger quantity. It is also easier for the child to take the small amount after an attack of coughing and vomiting than it would be for him to attempt a larger meal. ~Use of Stimulants.~--In many cases where weakness is great, it has been found advisable to add some stimulant to the diet. With infants this is best given in albumen water, a small amount of good brandy acting better than other stimulants. With young children some of the predigested liquid beef preparations, such as liquid peptonoids, are found valuable. These foods are given alternately with the other fluid foods. ~Hygiene and Sanitation.~--Infants and children suffering with whooping cough require plenty of fresh air and sunshine. They must be kept out of doors as much as possible and sleep in well-ventilated rooms or sleeping porches. They must be protected from drafts and excitement, and never allowed to become over-tired. In this way the anemia which so often results from prolonged attacks of whooping cough is in a measure held in check. At times it is found necessary to give some kind of an iron tonic, but this comes under the jurisdiction of the physician instead of the nurse. When bad effects do occur in spite of all the care exercised during the attack of whooping cough, they must be accorded the treatment especially devised to meet the situation. MEASLES This is an acute, infectious disease characterized by a red eruption which appears on the fourth day. Measles is one of the most contagious of all the diseases of childhood. It may be acquired by direct contact with another case or by being in the room with a case. The infection may also be carried through the air and occasionally by a third person. Measles is more prevalent in the winter than in summer. In cities it often occurs in epidemics. The period of incubation is from ten days to three weeks, occurring generally at about two weeks after exposure. The attack may begin with the child showing a languid attitude, complaining of headache. Then a cough develops, with nausea and fever at times. The fever is often high, reaching 104° F. on the second day. As a rule the fever gradually falls after the second day and becomes normal in almost a week. However, the temperature varies in different cases. ~Complications.~--Measles is not considered dangerous in itself, but the after-effects sometimes prove fatal. This is especially the case in broncho-pneumonia, which frequently develops during or after the attack. The gastro-intestinal, as well as the respiratory, tract is attacked in measles, diarrhea being especially common. Very weak children have been known to develop gangrenous stomatitis; paralysis and tuberculosis[91] likewise develop in some cases as the direct result of measles. Thus it is demonstrated that measles is not to be lightly treated. Even if it is not in itself fatal, the results of the disease are so dangerous that the care of the nurse is especially necessary. The great trouble is that so often a nurse is not in attendance and the child suffers through ignorance of the mother. ~Dietetic Treatment.~--The dietetic treatment of measles is important. For infants milk is the exclusive diet, the formula for bottle-fed babies having to be weakened on account of the catarrhal condition of the gastro-intestinal tract. For older children it is necessary to confine the diet to fluids as long as the fever lasts, and at times longer if the stomach gives evidence of digestional disturbances. Milk is the chief food, with milk soups, buttermilk, and koumiss used to vary the diet. Orangeade and lemonade may be given to allay thirst. A return to normal diet must be made gradually, giving cereal gruels, milk toast, and broth before the more solid articles of diet suitable to the age of the child. When there are complications they must be treated, as in whooping cough, according to their symptoms. SUMMARY ~Gastro-intestinal Disturbances~ are responsible for much of the fever manifested during infancy and childhood. ~Infectious Diseases~ are all more or less accompanied by an elevation of temperature. ~Incipient Diseases~, especially tuberculosis and scurvy, may likewise cause a rise of temperature. The relief of either disease or the fever depends largely upon how quickly the conditions are discovered and the means instituted to overcome them. ~Metabolism in Febrile Conditions~ of children, as well as of adults, is rapidly increased, hence the energy output is greater, and for this reason the fluid intake must be augmented in order to eliminate the toxic substances produced as a result of the rapid breaking down of the body tissues. ~The Kidneys~ are more or less strained to eliminate the products of the increased metabolism and for this reason it is especially necessary to adjust the diet in order to limit, as far as possible, the foods which add to the burden already imposed upon the organs of excretion. ~The Skin~ is an organ of excretion which, under normal conditions, shares the work of the kidneys. In infectious conditions, accompanied by eruptions which more or less cover the entire surface of the body, this organ is temporarily out of commission, hence its work, as well as their own, must be accomplished by the kidneys. ~Dietetic Treatment~ in the majority of infectious diseases may be divided into three periods: Starvation, Fluid Diet, and Convalescent Diet. Starvation, during which time no food is given for twenty-four hours or longer, in order to allow the digestive apparatus to rest and to give time for any substance which may be causing the elevation of the temperature to pass from the body. This treatment is also wise because it furnishes an opportunity for the symptoms of the disease to manifest themselves; Fluid Diet, given when acute symptoms subside, and Convalescent Diet when danger from relapse is over. ~Scarlet Fever~ is treated with two main ideas in view--preventing the development of nephritis and relieving the condition should it develop. ~Dietetic Treatment~ is logically the only means of treating or relieving nephritis. For the first three weeks, during which time this complication is apt to develop, a milk diet is necessary. This may be in the form of whole milk, milk soups, malted milk, etc. At the end of this time, if there are still no symptoms of nephritis, a convalescent diet, beginning with cereals and soft toast and progressing through the simple digestible foods such as rice, baked potatoes, soft eggs, etc., may be given. This is continued until the patient is well on the road to recovery. Meat should not be added until practically all danger of nephritis is passed. ~Nephritis.~--If, during the course of the disease this complication, should develop, the treatment described for acute nephritis on page 336 should be immediately instituted. ~Diphtheria.~--Dangerous complications at times develop as a result of diphtheria, making the treatment of this disease of the utmost importance. Heart symptoms, pneumonia, albuminuria, and anemia are among the complications to be dreaded and combated. ~Dietetic Treatment~ in diphtheria is most important. It consists of a fluid diet made up of milk, malted milk, or buttermilk. At times the condition of the throat makes a slightly thickened mixture more easily swallowed than one which is distinctly fluid in character, and for this purpose farina, arrowroot, or barley flour may be used. ~Increasing the Diet.~--As convalescence advances the semi-solids, soft toast, soft custards, gelatin, and cereals may be given. Should the heart show symptoms of being affected, the intake of fluid must be restricted. ~Gavage and Rectal Feeding~ are at times necessary. Infants may be successfully fed by passing a small rubber tube through the nose into the stomach and administering the milk formula to which they are accustomed. Rectal feeding is likewise valuable in cases of extreme anemia accompanying diphtheria. Care must be observed by the nurse in giving gavage to babies, since any struggling on the part of the child may result in death from heart disease. ~Whooping Cough.~--On account of the character of the disease and the proneness of the stomach to eject the food during paroxysms of coughing, dietary measures are more or less necessary in order to enable the child to receive sufficient food to cover his daily needs. ~Complications.~--Hemorrhage, pneumonia, albuminuria, diarrhea, and convulsions may occur during the disease, while tuberculosis and chronic bronchitis may follow as after-effects. ~Dietetic Treatment.~--Breast milk is by far the best food for the baby, in this as in all conditions. In whooping cough the fact that this fluid leaves the stomach almost as soon as it enters lessens the chances of the baby losing its meal by vomiting it. ~Older children~ do well with frequent small meals, since they are not so apt to give rise to pressure which brings on the paroxysms of coughing and vomiting. When the meal is vomited, a second should be given in order to keep the child from suffering from malnutrition. ~Stimulation~ is found to be necessary in certain cases. Albumen water containing a spoonful of brandy or some of the prepared beef preparations, such as liquid peptonoids, may prove valuable under the circumstances. ~Measles.~--Complications and after-effects developing as a result of measles make the dietetic treatment of this disease important. Gastro-intestinal disturbances, especially diarrhea, are apt to occur, and tuberculosis has been known to develop as a result of measles. ~Dietetic Treatment.~--The fluid diet as used in any acute febrile condition is used as long as the temperature is elevated. Milk, buttermilk, malted milk, and milk soups constitute the chief items in the diet. Orangeade and lemonade are found valuable in relieving the thirst. PROBLEMS (a) List the evidences of errors in the diet of infants; show how they may be corrected in the formula. (b) Outline the processes in the preparation of Eiweissmilch (protein or albumen milk). What constituent is particularly low in this milk, and how was its reduction accomplished? FOOTNOTES: [84] "Diseases of Nutrition and Infant Feeding," by Morse and Talbot. [85] _Ibid._ [86] "Diseases of Nutrition and Infant Feeding," p. 307, by Morse and Talbot. [87] See chapter on Urinalysis, p. 323. [88] Consisting of cereal gruels, rice, and other starchy foods. [89] See Nutrient Enemas, p. 145. [90] "Diseases of Infants and Children," p. 326, by Ruhräh. [91] "A Manual of Diseases of Children," p. 319, by Ruhräh. CHAPTER XI THE FEEDING OF ADULTS IN DISEASES OF THE GASTRO-INTESTINAL TRACT ACUTE AND CHRONIC GASTRITIS ~Predisposing Factors.~--The majority of diseases affecting the stomach have as their predisposing factors, and owe their development to, one or all of the following conditions: (1) errors in diet; (2) disturbed secretory processes; (3) disturbed motility and tone. It is probable that in the beginning the first factor was the chief offender in the case, bringing about the development of one or both of the other conditions. The other factors to be considered in this respect are heredity, occupation, poverty, and diseases which involve to a greater or lesser degree the digestion of the stomach and intestines. A child may inherit a weakened organism through excesses or disease on the part of the parent. If this weakness is not overcome while the child is growing, the probabilities are that the digestion steadily declines until in adult life it becomes a pathological condition. Lack of fresh air, poor and dirty food, unwholesome surroundings, crowded and badly ventilated sleeping rooms, insufficient water, and overwork, all act in making the digestion bad. These must be overcome if permanent good is to result. ~Errors in Diet.~--Errors in diet arise more often through ignorance than from any other cause. A child may be allowed to eat any and all kinds of unwholesome and unsuitable food. When the stomach rebels, showing the serious danger signals of nature, medicines are given but the diet is unheeded, until the time comes when even the medicines fail to give temporary relief, and the organs of digestion are in some instances permanently impaired. ~Disturbed Secretory Processes.~--Consensus of opinion goes to show that the majority of cases of acute and chronic gastritis (catarrhal) and gastric ulceration are due primarily to a disturbance of the secretory processes, while the impaired motility and lack of tone in the stomach probably influence their development and aggravate the disease already present. ~Composition of Gastric Juice.~--In a former chapter the processes of gastric digestion were explained. The gastric juice, composed of from 0.2 to 0.3% free hydrochloric acid and several important enzymes and lipases, which act upon the proteins and emulsified fats, must be sufficient in quantity to assure good digestion, and when anything arises to interfere with the secretion of this fluid a deviation from the normal is bound to occur. ~Disturbed Motility and Tone.~--Again, it has been proved that good gastric digestion, like good intestinal digestion, depends more or less upon the way in which the food mass is mixed with the digestive juices and moved along the alimentary canal. Anything which interferes with the secretion of the juices or delays the food over its normal length of time in the stomach surely exerts unfavorable influences on the general metabolism of the food, for while, as we have already found, gastric digestion is not essential to the final utilization of the food in health, in disease it undoubtedly exerts a marked influence upon the general nutrition of the individual. HYPOCHLORHYDRIA The lack of hydrochloric acid in the gastric juice lowers the resistance to bacterial action, for this constituent exerts a decided germicidal influence in gastric digestion, preventing fermentation with the production of organic acids and probably alcohol. In conditions due to hypochlorhydria (lack of hydrochloric acid) foods which leave the stomach quickly must be given with enough of the other necessary constituents in their simplest and most easily digested form to balance the diet and prevent the occurrence of the other disorders as troublesome as the original disorder. ~Dietetic Treatment.~--The following points must be kept in mind in formulating a dietary for patients suffering from a deficiency of hydrochloric acid: (1) boil the drinking water to destroy any bacteria which may be present; (2) use carbohydrates in the form of starch rather than sugar, since starch is less liable to fermentation from bacteria than sugar; (3) limit the foods which delay the passage of the food mass from the stomach; fats pass into the duodenum more slowly than other foods and when fed with other foods delay their passage materially; (4) avoid the use of soda bicarbonate, as it tends to reduce the normal acid content of the stomach, thus preventing its germicidal action upon the fermentative bacilli; alkaline carbonates likewise inhibit the flow of gastric juices; (5) give especial attention to the attractiveness of the food served; let it be appetizing and savory, for by such means is the appetite juice and incidentally an increased flow of the gastric juices stimulated; (6) condiments and spices, meat broths high in extractives, and salt foods such as caviar and endives may be given at the discretion of the physician; it is seldom advisable to give the foods which are indigestible, even when they act as stimulants to the secretory cells of the stomach. HYPERCHLORHYDRIA (Excess secretion of acid in the stomach) ~The Effect of Excess Acid.~--An excessive flow of hydrochloric acid has been found to be the cause of much of the acute and chronic gastritis, in fact more of the cases are traceable to an excess than to a lack of hydrochloric acid. This acid is more or less irritating in character, and the tender mucous membranes lining the gastric organ being constantly bathed in a secretion composed chiefly of acid must necessarily in time suffer a certain amount of irritation and inflammation, causing the development of a pathological condition which may be temporary or permanent, that is, it may result in acute or chronic gastritis, according to the amount of acid secreted and the length of time the hypersecretion is allowed to continue. ~Determining the Acid Content of Stomach.~--The difference between the cases brought about by an excess flow of hydrochloric acid are more or less difficult to distinguish from those caused by a lack of this constituent in the gastric juice, chiefly because in the latter case the organic acids formed as the result of bacterial action upon the food exert an equally irritating effect upon the membranes of the stomach, and the only sure method of determining the cause of the disturbance is by an analysis of the stomach contents, by which means the percentage of hydrochloric acid is determined. ~Lavage.~--It has been found advisable, in some cases of acute gastritis which do not yield readily to rest and liquid diet, to wash the stomach and allow a certain period of rest before giving any food; in this way the organ is rid of all of the offending material and thus has a better chance of a quick recovery. ACUTE GASTRITIS ~Dietetic Treatment.~--The following dietetic treatment for acute gastritis is advised: As the stomach is the chief seat of disturbance, all unnecessary work must be taken from this region for a certain period: (1) That any obscure cause may manifest itself and the diagnosis may be rendered more accurately and more quickly. (2) That by resting the organ the offending materials may pass out of the body and thus prevent further trouble. ~Starvation Period.~--Twenty-four hours of total abstinence from food may seem extreme, but as a rule in acute cases of gastritis it is the only sane and safe method of instituting a diet and thus beginning to overcome the cause of the disturbance. After the period of starvation the diet is begun with caution. ~Fluid Diet.~--Fluids should be given first in the form of well-skimmed broths, which may be reënforced with egg or cereal flours when the patient is very thin or anemic. Buttermilk, made with the Bulgarian cultures, koumiss and other fermented milk foods, liquid beef preparations such as peptonoids or panopepton, albumenized orange juice, cereal gruels treated with Taka diastase when it is found necessary, and peptonized milk. These may be given in from four to six ounces at a time, every two hours on the second day. ~Increasing the Diet.~--On the third day if the attack is slight the diet may be increased by adding toast, softened with peptonized milk, an ordinary serving (3 ounces) of farina, cream of wheat or rice, reënforced meat broth with two crackers, a cup of tea and a slice of toast, and one or two soft-cooked eggs. If the acute symptoms are still present on the third day, the diet advised for the second day must be continued until they disappear. ~Convalescent Diet.~--On the fifth day, if progress is satisfactory, lightly broiled chicken or a small piece of rare broiled beefsteak may be added to the diet and the meals reduced in number from six to four. ~Relapse.~--The patient must be warned against overeating or eating any of the articles which are known to cause an acute attack in his individual case, since one attack predisposes to another, and chronic gastritis may develop as the result of the continual gastric disturbance. CHRONIC GASTRITIS The treatment in chronic gastritis is very like that in the more acute form; that is, it must be combated by removing the cause. Lack of fresh air and exercise have much to do with the development of chronic gastritis, but even they combined with a judicious amount of rest would be wasted without a proper adjustment of the diet to cover the main points of the disturbance. As has already been mentioned, the cause may be a lack of gastric juice or it may be an excess of it; it may be intensified by an ~atonic~ condition of the organ or from the food passing too quickly into the duodenum. ~Test Meals.~--As a rule it is not safe to make a snap diagnosis as to the cause of this disorder. Since in many instances the more serious disorders may be traced to a disregard for nature's danger signals, the physician as a rule advises a test meal, this meal consisting of a glass and a half of water or a cup or two of tea without cream or sugar and from one to two slices of toast or water rolls. In from three-fourths to one hour or longer this is removed from the stomach by means of a stomach pump and analyzed, the result of the chemical and bacterial analyses forming the basis for diagnosis. This meal is generally given in the morning before any other food has been eaten.[92] ~Dietetic Treatment.~--The foods constituting the diet in chronic gastritis must be of the simplest character and prepared in the simplest manner. No fried foods are permissible. Pastries, griddle cakes, rich puddings and sauces, candies, and alcoholic beverages must be omitted from the diet as well as the following articles of food: pork, veal, shellfish except oysters, sardines, canned meats and canned fish, highly seasoned and spiced dishes, twice-cooked meats, vinegar, pickles, olives, cold slaw, pickled beets, catsup, mustard, coarse fibered vegetables such as cabbage, old onions, old turnips, and cucumbers, strong tea, coffee, or chocolate, rich cream or dishes made entirely of cream. In cases of excessive acidity due to a hypersecretion of HCl the extractives of meat are contraindicated, hence all gravies and outside parts of roasted meat must be omitted or limited in the diet. GASTRIC ULCERATION Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. However, the character of this pain may be different, beginning soon after eating and radiating toward the back. This point may be affected by position. As a rule there is a tenderness over the seat of the ulcer. This is detected by palpation. Vomiting is one of the most general symptoms in gastric ulceration. This may begin from one to two hours after eating when the pain is at its height, or it may start as soon as food enters the stomach. As a rule the latter condition is found more often in very nervous women whose mental attitude affects the stomach to such an extent as to make it difficult to give them sufficient food to nourish them. ~Hemorrhage.~--Hemorrhage occurs in about half of the cases. The bleeding may be profuse and the blood bright red, or it may be less severe and the color of the blood changed by contact with the gastric juices to a dark brown like coffee grounds. ~Excess Acid.~--Hyperacidity is present in the majority of the cases, the percentage of HCl rising at times fifty per cent. or more. Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation. The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening; and the constant development of cicatricial tissue brings about an obstruction of the pylorus, which if not relieved would allow the patient to starve. ~Diet Treatment.~--There are a number of treatments used in overcoming this condition. After the test meal and the diagnosis, the patient is placed upon a diet directed to overcome the chief symptom; for example, if the ulcer developed as a result of hyperacidity, the diet would be directed toward the relieving of that symptom. Boas[93] divides the treatment into three stages: (1) hemorrhage; (2) the intermediate stage; (3) the convalescent stage. ~Starvation Treatment.~--The majority of physicians institute a total abstinence period for the first stage, allowing no food or water to be taken by mouth. If the patient is very weak and anemic from the extended course of the disease, nutrient enemas are given from four to six times a day, alternating with saline enemas. This total abstinence continues from three to six days. Some cases have been known to be fed in this way for a month or six weeks with obvious success. However, this is not the rule but the exception. The diet must be adjusted to the needs of each individual, but a few general rules may be found helpful. ~Dietetic Treatment.~--Milk is the food generally utilized in the beginning. This may require peptonizing to be digested, or it may have to be modified with limewater. Protein foods require HCl for their digestion. If these foods are fed they will absorb some of the excess acid, and in this way save the already irritated wall of the organ from additional irritation. When protein foods are given they must be in the form of soft-cooked eggs, scraped raw beef or beef juice, milk soups, and like protein foods. When there is a dilatation of the organ there is more or less danger of fermentation taking place, with the formation of organic acids. These acids are exceedingly irritating, and every care must be observed to prevent their production. The following dietetic régime may be used as a guide in many cases of gastric ulceration: ~Milk Diet.~--1/2 glass (4 ounces) of milk peptonized at 115° F. for 20 minutes, every hour for three or four days. After this the interval between feedings is lengthened to two hours and the amount of milk increased to 3/4 of a glass (6 ounces). This is continued from a week to ten days. The patient may be given a cup of well-strained meat broth, reënforced with an egg, once or twice a day, to vary the monotony of the diet. During the third week the milk may be given in the form of milk soups. These may be slightly thickened with barley, rice, or farina flour. The soups may be flavored with beef extract, but only a small quantity must be used, owing to the stimulating properties of these substances. ~Water as a Stimulus to Gastric Secretion.~--Water is exceedingly stimulating to the acid secreting cells of the stomach, hence it is advisable to limit the amount of water taken by mouth, allowing the patient just enough to wash out the mouth without swallowing any. The thirst is relieved by saline enemas. It has been found, in many cases of gastric ulceration, especially those accompanied by hemorrhage, that glucose gives better results when used in rectal alimentation, than any other substance. The strength of the solution varies from a five to a twenty-five per cent. solution. The number of glucose enemas given each day must be regulated by the physician. The method used is the same as in other rectal feedings, the enema is given "high," and the flow regulated (drip-method). ~Convalescent Diet.~--During the fourth week, if the pain and discomfort are decreasing, soft-cooked or creamed eggs may be added to the diet, together with thoroughly boiled rice, farina, cream of wheat, wheatena and other finely ground wheat foods, wine or fruit jelly, sweetened slightly, or by using a small amount of saccharin for the purpose, junket and plain vanilla ice cream. At the end of the fourth week a very small portion of meat may be given once a day. It may be scraped raw beef spread upon toast or zwieback, or very lightly broiled beefsteak, broiled lamb chop or chicken (breast only), or boiled or broiled sweetbreads or brains. Spinach or green peas pressed through a sieve are the first vegetables allowed. After these young tender carrots and string beans may be given. Tea, coffee, and chocolate are eliminated from the diet. Milk flavored with coffee or cocoa may serve as a hot drink in the morning when the desire or need for such a drink is manifested. Butter is the best form of fat to be used in cases of gastric ulceration, but this must be given with the greatest caution. In cases where this fat is used in the form of cream, the amount must be cut down or entirely abandoned when there are evidences of butyric fermentation. Buttermilk, koumiss, and other fermented milk drinks are often found very satisfactory adjuncts to the diet. These may be given between meals, or at meals they may be substituted entirely for the milk when other foods are being given. They are not sufficiently nourishing to take the place of the milk diet otherwise. Albumenized orange juice and cream, egg and vichy may be given to add variety to the diet. ~Anemia.~--When anemia is severe, as is often the case in gastric ulceration, the diet must be reënforced to overcome it. Some of the concentrated milk foods such as plasmon, encasin, sanatogen, etc., as well as the predigested meat foods, such as panopepton, liquid beef peptonoids, and like preparations, may be used to reënforce the diet. ~Bland Diet.~--In certain cases of gastric ulceration it has been found more advisable to use what is known as a bland diet. This consists of farinaceous foods such as farina, arrowroot, cream of wheat, corn meal, wheatena, malted breakfast foods cooked thoroughly and given in the form of gruels, and some of the proprietary infant foods, such as Mellin's Food, Eskay's Food, Racahout. These foods may require the addition of Taka diastase to make them more readily digested. They leave the stomach more rapidly than any of the others, and for this reason will be found to give less discomfort than the foods containing a high percentage of protein and fat. This diet, however, cannot be prolonged on account of its lack of balance. If the gruels are made with milk instead of with all water they become more evenly balanced. Samples of the stomach contents may be taken for analyses from time to time. ~Lavage.~--When lavage is necessary the patient must be allowed to rest after the process before being given food, otherwise it is apt to be vomited. ~Instructions to Nurse.~--The treatment for gastric ulceration is thus seen to be strenuous. In the beginning the patient is placed on a liquid or semi-solid diet, or is not fed at all for a time. This is done that the diseased organ may have a chance to adjust itself as far as possible and to give the physician an opportunity of studying the changes taking place in that organ. During the course of the disease the general symptoms which develop from time to time, causing more or less pain and discomfort to the patient, are nervousness, which in some individuals amounts to melancholia, extreme anemia and an utter distaste for food, all of which require patience on the part of the physician, the nurse, and the patient herself to overcome. The nurse must see that the patient is not disturbed or made unhappy by having business or home cares talked over in her presence; she must be kept as cheerful and as comfortable as her condition permits and urged to use care in her diet. After the ulcer is healed, to prevent a return of the trouble she must be warned against eating too fast or when over-tired, and she must be advised against very hot and highly seasoned foods, for, in the observance of these simple common-sense precautions only is she even in a measure saved further attacks. ~Special Diets Used for Gastric and Duodenal Ulcer.~--There are several well-known diets used in these conditions. Among those that have been found most satisfactory may be mentioned the Sippi diet, the Lenhartz diet. All of these diets require the most careful adjustment as to regulation of intervals of feeding, type of food material used, and method of preparation and administration of food. The treatment is directed toward the reduction of the free hydrochloric acid in the stomach in order that the ulcer may have an opportunity for healing. ~Sippi Diet.~--Equal quantities of heavy cream and whole milk, beginning with 1/2 ounce each every hour during the day. Alkaline powders are given with the meal and one-half hour after the meal. These consist of 15 grains each of sodium bicarbonate and bismuth subcarbonate with the feeding, and 10 grains of light oxide of magnesia and 15 grains of sodium bicarbonate between feeding. The cream and milk are increased at the rate of one-half ounce each at each feeding for two days, the powders are continued as on the first day. On the fourth day an egg is added to the diet, the milk and cream are given in quantities of one and one-half ounce each, every hour. On the fifth day two eggs are added. On the sixth day one helping of oatmeal or other soft cereal is added to the above diet. The diet is in this way increased until the patient is taking three eggs and nine ounces of cooked cereal each day in addition to the cream and milk mixture. The amount given at one time must be small, never exceeding six ounces (according to Carter, Howe and Mason). An accurate control of the acidity of the stomach should be maintained, this is accomplished by withdrawing a certain amount of the gastric contents by means of the stomach tube. ~The Lenhartz Diet.~--This diet is likewise given in hourly feedings, consisting of milk and raw eggs in the beginning, then a small portion of sugar is added, next scraped beef is added to the milk, eggs and sugar, already given, then boiled rice. Next a small quantity of zwieback (or soft toast), and continuing in this way, chicken, and butter are admitted. In the beginning the quantity of milk is 100 c.c. and the number of eggs 2, given raw. It is served iced, and with a teaspoon. When the sugar is added it is beaten up with the eggs (20 gm.). The milk and eggs are divided into separate feedings and given at hourly intervals from 7 A.M. to 7 P.M. It is rarely possible to give the amounts called for in the Lenhartz diet after the sixth day, but as much as possible should be given without risking an acute disturbance. Women, as a rule, find it more difficult to take the full amount ordered than men. The following outlines represent the diet for the first, third, sixth, seventh and tenth day: FIRST DAY 7 A.M. Egg 8 A.M. Milk, 20 c.c. 9 A.M. Egg 10 A.M. Milk, 20 c.c. 11 A.M. Egg 12 noon Milk, 15 c.c. 1 P.M. Egg 2 P.M. Milk, 15 c.c. 3 P.M. Egg 4 P.M. Milk, 15 c.c. 5 P.M. Egg 6 P.M. Milk, 15 c.c. Total: Milk, 100 c.c. Eggs (raw), 2. THIRD DAY 7 A.M. Egg; sugar, 2 gm. 8 A.M. Milk, 50 c.c. 9 A.M. Egg; sugar, 3 gm. 10 A.M. Milk, 50 c.c. 11 A.M. Egg; sugar, 3 gm. 12 noon Milk, 50 c.c. 1 P.M. Egg; sugar, 3 gm. 2 P.M. Milk, 50 c.c. 3 P.M. Egg; sugar, 3 gm. 4 P.M. Milk, 50 c.c. 5 P.M. Egg; sugar, 3 gm. 6 P.M. Milk, 50 c.c. 7 P.M. Egg; sugar, 3 gm. Total: Milk, 300 c.c. Eggs (raw), 4. Sugar, 20 gm. SIXTH DAY 7 A.M. Egg; sugar, 4 gm. 8 A.M. Milk, 100 c.c. 9 A.M. Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm. 10 A.M. Milk, 100 c.c. 11 A.M. Egg; sugar, 4-1/2 gm. 12 noon Milk, 100 c.c. 1 P.M. Egg; sugar, 4-1/2 gm.; scraped beef, 12 gm. 2 P.M. Milk, 100 c.c. 3 P.M. Egg; sugar, 4-1/2 gm. 4 P.M. Milk, 100 c.c. 5 P.M. Egg; sugar, 4 gm.; scraped beef, 12 gm. 6 P.M. Milk, 100 c.c. 7 P.M. Egg; sugar, 4-1/2 gm. Total: Eggs (raw), 7. Milk, 600 c.c. Sugar, 30 gm. Scraped beef, 36 gm. SEVENTH DAY 7 A.M. 1 soft-cooked egg 8 A.M. Milk, 100 c.c. 9 A.M. Egg; sugar, 13 gm. 10 A.M. Milk, 100 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm. 11 A.M. 1 soft-cooked egg 12 noon Milk, 125 c.c. 1 P.M. Egg; sugar, 13 gm. 2 P.M. Milk, 125 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm. 3 P.M. 1 soft-cooked egg 4 P.M. Milk, 125 c.c. 5 P.M. Egg; sugar, 14 gm. 6 P.M. Milk, 125 c.c.; scraped beef, 24 gm.; boiled rice, 34 gm. 7 P.M. 1 soft-cooked egg Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 700 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Boiled rice, 100 gm. TENTH DAY 7 A.M. 1 soft-cooked egg 8 A.M. Milk, 166 c.c. 9 A.M. Egg; sugar, 13 gm. 10 A.M. Milk, 168 c.c.; scraped beef, 23 gm.; boiled rice, 66 gm.; butter, 4 gm. 11 A.M. 1 soft-cooked egg; zwieback (or soft toast), 20 gm.; butter, 4 gm. 12 noon Milk, 166 c.c.; minced chicken, 25 gm. 1 P.M. Egg; sugar, 13 gm. 2 P.M. Milk, 166 c.c.; scraped beef, 25 gm.; boiled rice, 66 gm.; butter, 4 gm. 3 P.M. 1 soft-cooked egg; butter, 4 gm.; toast or zwieback, 20 gm. 4 P.M. Milk, 168 c.c.; minced chicken, 25 gm. 5 P.M. Egg; sugar, 14 gm. 6 P.M. Milk, 166 c.c.; scraped beef, 24 gm.; boiled rice, 67 gm.; butter, 4 gm. 7 P.M. 1 soft-cooked egg Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 1000 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Minced chicken, 50 gm. Butter, 20 gm. Boiled rice, 200 gm. Toast or zwieback, 40 gm. GASTRIC CANCER As a rule the seat of the gastric cancer is the pylorus. The patient gives evidence of chronic gastritis with continued pain, localized tenderness, vomiting of partially digested food and at times dilatation from extreme fermentation. The hemorrhages are as a rule not large, the blood having changed to a brownish color resembling coffee grounds. Vomiting, in cases where the pylorus is involved, generally occurs several hours after eating, the vomitus being in an advanced state of fermentation. Upon analysis of the stomach contents there is found to be a lack of free HCl. ~Dietetic Treatment.~--In the dietetic treatment of cancer of the stomach the most digestible forms of foods must be given, milk forming in this, as in other gastric disorders, the chief article of diet. As too much food cannot be tolerated, the meals must be small, even if given more frequently. The patient is often found to evince a distaste for meat, in which case fish may be substituted. When meat is given, it must be simple in form and preparation, such as boiled or broiled sweetbreads or brains, scraped beef or stewed chicken. Rice, farina, cornmeal mush, and other fine cereals, cooked with or without milk, are valuable additions to the diet. Well-cooked and strained spinach, green peas, cauliflower, carrots, and tender string beans and boiled or baked potatoes well mashed may be recommended. Tea, coffee, or cocoa may be used to flavor the milk. These must be given in small portions. The following diet list is recommended by Friedenwald and Ruhräh: _Calories_ 8 A.M. 100 grams of milk with tea 100.0 30 grams of milk toast 130.0 10 A.M. 100 grams of baked trout 106.0 100 grams of milk 67.0 or 30 grams panopepton (57.5) 10 grams of butter 81.0 50 grams of toast 130.0 50 grams of sherry 60.0 12 M. Bouillon with 5 grams somatose 16.0 100 grams of chicken 106.0 or 100 grams squab (100) or 100 grams of calves' sweetbreads (90) or 100 grams of calves' brains (140) 60 grams of macaroni 212.0 or 100 grams of mashed potatoes (127) or 100 grams of spinach (166) or 100 grams of asparagus (18) 25 grams of stale wheat bread 65.0 4 P.M. 20 grams of toast 130.0 20 grams of butter 162.0 40 grams of caviar 52.0 7 P.M. 130 grams of milk (100) with 5 grams somatose (16) 116.0 100 grams of rice cooked in milk 177.0 50 grams of wheat bread 130.0 9 P.M. 30 grams of panopepton 57.5 ------ 2024.5 SUMMARY FACTORS INDUCING GASTRIC DISTURBANCES 1. ~Errors in Diet.~--Over-feeding, under-feeding, improper food, unbalanced diet. 2. ~Disturbed Secretory Processes.~-- (a) Over- or under-secretion of gastric juice. (b) An excess or deficiency of hydrochloric acid in the juices. 3. ~Impaired Motility and Tone of the Gastric Organ.~--The peristaltic waves and muscular contraction of the stomach walls becoming sluggish prevent the food mass from passing into the intestines at a normal rate of speed, thus giving rise to a fermentation of the food and a consequent dilatation of the organ from the gas thus produced. ~Other Factors.~--Lack of fresh air and exercise, indoor occupation, bad hygiene, unsanitary surroundings, heredity, certain diseases which are accompanied by gastric disorders. ~Diseases of Gastric Organ.~--Acute and Chronic Gastritis, Gastric-Ulceration, Gastric Cancer. ~Treatment.~--Tests--Test meals, X-Ray examinations (pictures and Fluoroscope). Patient is given no breakfast on day of test. In X-Ray laboratory a bismuth or barium meal is given, this meal consists of a pint of fluid, either buttermilk or malted milk, into which a certain amount of bismuth or barium chloride is mixed. ~Starvation Period.~--A period of abstinence from food is instituted in most of the gastric disorders, (a) to determine the extent and character of the disease, (b) to rest the digestive tract. ~Dietetic Treatment.~--Diet adjusted to meet the needs of the individual case as determined by the medical examination. ~Instruction to Patient.~--Individual warned against overeating, drinking and constipation. PROBLEMS (a) Formulate a diet order for a patient suffering from chronic gastritis. (Individual's food requirements must be observed.) (b) Formulate a diet for gastric ulceration. List the available foods; the avoidable foods. (c) Outline a diet to be used in case of gastric cancer; show how it differs from the one used in gastric ulceration. FOOTNOTES: [92] It is also customary to give the patient a bismuth or barium meal in order that an X-ray and fluoroscopic examination may be made to determine the character and extent of the disturbance. [93] "Diseases of the Stomach," by Boas. CHAPTER XII DISEASES OF THE INTESTINAL TRACT ACUTE AND CHRONIC DIARRHEA (CATARRH), ENTEROCOLITIS, DYSENTERY, CONSTIPATION, APPENDICITIS, CHRONIC CONSTIPATION, AUTO-INTOXICATION Diarrhea, like gastritis, may be a symptom of many diseases and a result of many digestional disturbances. Enteritis, enterocolitis, dysentery, typhoid fever, and certain cases of tuberculosis and syphilis are all accompanied by an inflamed condition of the mucous lining of the intestinal walls, and in each of these pathological conditions we may find diarrhea as a resulting symptom. ~Causes.~--Diarrhea may be acute or chronic in character. It may be brought on by errors in diet, warm weather, certain drugs, ptomaines, bad hygiene, polluted water or milk, and by overeating. Idiosyncrasies against certain kinds of food have been found in both adults and children; these idiosyncrasies are manifested by pain and diarrhea whenever the offending foods have been eaten. Acute diarrhea has also been brought on in children by the drinking of cold lemonade when over-heated. ~Diarrhea in Children.~--All diarrheas in children, and especially those developing during the hot months, must be looked on with suspicion and given immediate attention before they have an opportunity to develop serious features which may terminate in death before the seriousness of the condition is realized. As a rule, almost any diarrhea in children will raise the temperature. This does not occur so often with adults unless the diarrhea results from infectious fevers, ptomaines, etc., in which case it may rise suddenly and to a considerable height. ACUTE ENTERITIS (DIARRHEA) ~The Bowels.~--The symptoms of this condition are too liquid or too frequent stools, the number varying from three to twelve or more a day. They may be greenish yellow in color and contain particles of undigested food and mucus. In prolonged diarrheal attacks the stools sometimes contain blood. The attack may be accompanied by more or less pain of a colicky nature, due to the formation of gas in the intestinal tract. In ptomaine poisoning this pain is sometimes very intense. As a rule the intestinal tract is emptied by means of salt, oil, etc., but this is generally directed by the physician. A soapsuds or salts and glycerin enema to flush the colon will often give quick relief by dispelling the gas. ~Starvation.~--The entire digestive tract requires absolute rest for a certain period; no food and very little water, the latter in the form of bits of ice only, are given for a period lasting from twelve to thirty-six hours or more, depending upon the violence of the attack and the condition of the patient. This is to allow the toxic substances which are probably causing the disturbance to pass out of the body, either in the feces or in the urine. When the acute symptoms subside, that is, when the pain and distention of the intestines have disappeared, and the bowel movements become more normal in number and character, the dietetic treatment suitable to the condition is instituted. ~Dietetic Treatment.~--The first day the patient is given a small cup of weak tea, half a glass of buttermilk or peptonized milk, or a cup of well-skimmed meat broth, every three or four hours. If the patient is weak, the nourishment may be given oftener, and in those cases it is often found advisable to give a small amount of alcohol in the form of brandy in albumen water, or panopepton or liquid peptonoids. These may be administered in tablespoonful doses every two hours. Whole milk, unless it is peptonized, and at times even then, is not advisable in diarrheal conditions on account of its liability to form curds which decompose with the production of toxic substances, known to be exceedingly irritating to the already inflamed mucous membranes lining the intestinal walls. ~Increasing the Diet.~--As the diarrhea and inflammation subside, the following foods are gradually introduced into the dietary, keeping in mind always that a return of the acute symptoms is apt to occur. Hence the patient must never be overfed. It is better to err on the side of too little than too much food during the early convalescent period. ~Diet.~--Soft-cooked eggs, toast (slightly buttered), cocoa made with water instead of milk, chicken, calf's-foot or wine jelly; later, well-cooked rice, junket, and soft custard; still later, lightly broiled beefsteak, lamb chops, chicken, squab or quail, sweetbreads or brains. Not until the patient is entirely free from all symptoms of diarrhea or intestinal disturbance may the following foods be given: cream or cream dishes such as cream toast, cream chicken, or cream soup, raw or stewed fruit, green vegetables, salt foods, spiced foods of any description; pastries, confectionery and desserts in general, unless they are simple in character and are sweetened with saccharin instead of sugar, as the latter substance is particularly susceptible to fermentation. ~Anemia as a Result.~--Anemia is one of the most common results of prolonged diarrheal attacks, especially in those toxic diarrheas resulting from infectious diseases, dysentery, etc. The blood-making tissues suffer from a lack of nourishment and are in consequence incapable of producing blood of the best quality. Hence the starvation treatment cannot be carried on over a very extended period or the resulting anemia may be more difficult to overcome than the original trouble. ~Selecting and Regulating the Diet.~--The following points must be kept in view when regulating the diets of individuals who are prone to develop diarrhea: ~Preparing the Diet.~--Only such foods as are known to agree with the individual, and these prepared in the simplest manner possible, must have a place in the dietary. ~Fermentation.~--All foods that are subject to fermentation either in the stomach or intestines must be withheld, at least until the attack is well over. Sugar is an example of such foods; saccharin may be substituted when necessary. ~Avoidable Foods.~--Pork, veal, and shellfish must be left out of the dietary, possibly for months, since they have been found frequently not only to bring about a return attack of diarrhea but also to have been the cause of the original one. Fatty foods of all sorts had best be avoided as long as there are symptoms of diarrhea; these foods are handled with difficulty by the digestive apparatus and impose extra work upon the intestine, which is already taxed by the disease. ~Restricting Fluids.~--Fluid foods should be more or less limited in the diet, since they require more effort on the part of the intestines than the more concentrated foods. ~Proprietary Foods.~--Certain proprietary infant foods[94] are at times found to be exceedingly valuable, since they furnish food in a concentrated and digestible form. Among these Mellin's Food, Racahout, and Imperial Granum may be mentioned. CHRONIC ENTERITIS ~The Stools.~--When the diarrhea is chronic in character, the character of the stools indicates the seat of the inflammation. When there is a great deal of undigested food found in them the upper part of the bowel is more affected; when the stools contain more mucus than food the lower bowel is the chief seat of the trouble. The frequency and fluidity of the stools impose a great strain upon the entire body, causing a progressive emaciation and anemia. The treatment is similar to that instituted in acute attacks. The starvation régime cannot be carried out for a long period. Efforts must be made to ascertain the cause of the trouble and to overcome it. This is, as a rule, more easily accomplished with adults than with infants and children. ~Dietetic Treatment.~--The diet is the chief point of observation and attention. The same care must be observed as is found necessary in the after-treatment of acute diarrhea. The patient must be cautioned not to eat indigestible foods or those which are known to cause trouble in this respect. She must be warned against eating when over-tired. ENTEROCOLITIS Enterocolitis is an inflammation of the lower intestines and colon. The stools contain more mucus than those occurring when the inflammation is higher up in the intestines and blood is also more frequent in these stools. The prostration is more marked and the fever apt to be higher than in ordinary diarrheal attacks. However, acute attacks of enterocolitis do not produce the marked anemia or the emaciation which are so common in the chronic cases of enteritis. Dietetic treatment the same as that used in acute diarrhea. ACUTE DYSENTERY Dysentery is a disease in which the seat of inflammation is the colon. The bowels are distended and tender, the pain at times is acute and spasmodic, and the fever moderate. The constant desire to defecate and the straining which accompanies each effort, as well as the small stools, containing both blood and mucus, furnish the characteristic symptoms of this disease. Rest in bed is absolutely necessary; the patient must be induced to use a bedpan. ~Dietetic Treatment.~--The diet consists entirely of liquids as in acute diarrhea, the same careful régime being observed as in those conditions. The soreness in the abdomen is at times relieved by spice poultices or a hot turpentine stupe. CHRONIC DYSENTERY When the above conditions become chronic, the patient loses weight and strength rapidly, becomes anemic and emaciated. The treatment, like that used in the acute disease, consists of rest and liquid diet. The medicinal treatment is left entirely in the hands of the physician. APPENDICITIS Appendicitis is an inflammation of the vermiform appendix. It may be acute or chronic in form. ~Symptoms.~--The disease is manifested by sudden pain in the right side, tenderness over the seat of the inflammation, and a localized rigidity of the right iliac fossa. The attack is as a rule accompanied by fever which may run as high as 103° or 104° F. The patient may suffer from nausea and vomiting. Constipation is generally an annoying symptom of the disease. ~Rest in Bed.~--The treatment of the acute attack consists of total abstinence from food for twelve or more hours until the most acute stage has passed and the patient either passes into the hands of the surgeon or the symptoms begin to subside in violence. It is necessary that the patient be kept in bed, not being allowed to rise for anything. The nurse must make him understand that his recovery, possibly his very life, depends upon his absolute quiet during the early stages of the disease. ~Dietetic Treatment.~--When the first acute symptoms have passed, the diet must consist of fluids, well-skimmed meat broths, buttermilk, peptonized milk, albumen water or albumenized orange juice. No solid food must be given until the acute symptoms have disappeared. When the tenderness in the right side has entirely left him and he no longer suffers the pain or nausea, a gradual return to a normal diet may be made. The patient must be cautioned against eating indigestible foods, as an attack of intestinal indigestion may readily start up an irritation in the susceptible appendix and cause a second attack of appendicitis which is often of a more serious nature than the first. ~Convalescent Diet.~--The return to solid food is made gradually as in other intestinal disorders, by giving the most digestible foods first. Soft toast, soft eggs, fine cereal gruels, well-cooked rice, well-baked white potatoes, meat, wine or fruit jellies; then lightly broiled beefsteak, lamb chop, chicken, sweetbreads, or brains given in small quantities until the intestinal tract has regained its vigor. ~Foods to Be Avoided.~--Highly seasoned foods must be avoided on account of their astringent qualities, which may cause constipation. Long, tough-fibered meats, coarse vegetables, rich foods, in fact anything which may cause intestinal indigestion, must be eliminated from the dietary. A decomposition of the foods lying in the lower part of the small intestine is dangerous to such individuals, since such products are highly toxic in character and exceedingly irritating to the already tender appendix. CHRONIC CONSTIPATION Chronic constipation is so universal a condition that it must be treated and overcome whenever it is possible. This condition is not only the cause but the result of disease. It may be induced by improper food, poor hygiene, sedentary habits, lack of exercise, the taking of drug preparations such as cough sirups which contain opium in some form, the constant taking of cathartics and enemas, or it may be an hereditary condition. ~Diet, Exercise, and Fresh Air.~--The chief means of overcoming this deplorable chronic condition is by regulating the diet and increasing the amount of exercise in the fresh air. At times it is necessary to resort to artificial stimulation of the intestinal movements; at others, on account of the disease of which it is only one of the symptoms, it is dangerous to irritate the already inflamed mucous membranes lining the intestinal wall. In these cases the physician prescribes the method of procedure. In ordinary cases, however, the following suggestions may be used as a guide in overcoming the condition. ~Available Foods.~--It must be borne in mind that the food must not be too concentrated in character or it will be so completely absorbed as to leave little or no residue for the feces, and since the waste products of metabolism, both of food and body materials, must be eliminated, a certain amount of fecal matter is necessary to assist in this work. Vegetables, such as celery, turnips, lettuce, asparagus, string beans, spinach, and beans, lentils, lima beans, and onions; fruits, such as raisins, figs, and prunes; and cereals which have not had all the bran removed, such as cut oats, cracked wheat, etc., on account of the cellulose they contain, act admirably in overcoming chronic constipation. It is found, however, that when even these are not sufficient in certain cases, bran added to the food, either alone, with the breakfast cereal, or in the form of biscuits, muffins, or cookies, will give just the necessary amount of ballast to the food mass to make it stimulate the peristaltic movements by its pressure upon the intestinal walls. ~Stimuli to Peristalsis.~--Foods yielding certain acids exert a stimulating action upon intestinal peristalsis. ~Available Foods.~--Those particularly valuable for this purpose are limes, oranges, apples, prunes, figs, raisins, and most fruit juices (with the exception of blackberries, which are constipating), tomatoes, and rhubarb. The fruit juices may be diluted with water or carbonated water (in the latter case the action is increased because of the gas contained in the water), and taken the first thing in the morning, or the fruit may be eaten at night before retiring, and in the morning on an empty stomach. Prune pulp or prune jelly may be given to children as well as to adults. The action of this fruit is augmented by the addition of senna leaves. A conserve made of prunes, figs, and raisins given in teaspoonful doses at night and before breakfast often gives splendid results in curing chronic constipation. ~Gas-forming Foods.~--The eating of foods which give rise to a slight formation of gas owing to their tendency to ferment likewise acts as a stimulus to intestinal movements. Among these may be mentioned honey, molasses, cauliflower, cabbage, spinach, and onions. If the honey and molasses are poured on bran muffins or biscuits, on breakfast food, or added as sweetening agents to cookies, they will be found particularly valuable. Care must be taken, however, not to give too much of either of these foods or they will disturb the digestion and do more harm than good. ~Use of Salt Foods.~--Foods such as herring, caviar, anchovies, ham, etc., on account of the salt they contain, exert a stimulating effect upon the movements in the small and large intestines. Graham bread, spread with brown sugar, molasses, or honey, makes an acceptable addition to the meal of the majority of children and to that of many adults. ~Fats and Mineral Oils.~--The use of fats is often recommended; olive oil may be given in tablespoonful doses before breakfast and at night or it may be served on vegetables and salads. If one or two tablespoonfuls are taken at night and before breakfast, it may act as a laxative. In many cases, however, this oil is completely absorbed in the small intestine and hence there is none left to lubricate the passage for the food mass. When vegetable oils do not prove satisfactory, mineral oils may be substituted. These oils have absolutely no fuel value and are not digested in the intestinal canal but mix with the fecal mass, softening it and stimulating its passage through the large intestine. There are certain individuals with whom the mineral oils do not act as lubricants and instead of softening the feces and lubricating the passage will slip through the intestinal canal without carrying the feces along. ~Sample Diet Sheets.~--The following menus are suggested for the use of individuals suffering with chronic constipation: BREAKFAST 7 A.M. Orange juice and water. 8 A.M. 1 bran muffin with honey and cream. 1 or 2 slices of bacon. Whole wheat biscuits. A cup of coffee, cereal coffee, or hot milk (not boiled). LUNCHEON 1 P.M. Casserole of beef made with lean beef. Turnips and potatoes. Graham bread or muffins and honey or preserves. Milk or "hot water" tea. DINNER Tomato bouillon. Roast lamb. String beans. Potatoes baked with jackets on. Celery salad, dressed with plenty of oil and lemon juice. Prune jelly with whipped cream. BREAKFAST Prunes and figs cooked together. Slice of ham with 1 soft-cooked, poached, or scrambled egg. Whole wheat or bran biscuits. Coffee with cream and sugar. LUNCHEON Vegetable soup. Pork and beans. Boston brown bread. Baked apple (skin eaten). Oatmeal wafers. DINNER Roast beef. Spinach or cauliflower served with butter sauce. Cold slaw. Pineapple jelly (pineapple left in), whipped cream, or Date and fig pudding. AUTO-INTOXICATION Auto-intoxication is a condition produced by the absorption of the decomposition products of food in the intestinal canal. ~Absorption of Toxins.~--As a rule the condition occurs in individuals suffering more or less from constipation which may be due to errors in diet or a lack of tone in the intestines, giving rise to a sluggishness in the peristaltic movements in this region of the alimentary canal. In certain individuals the liver is more or less sluggish, or in some way fails to do its regular work of detoxifying the products of metabolism brought in by the blood stream, in which case these toxins are reabsorbed into the system and induce a condition known as auto-intoxication. ~Care of Bowels.~--As a rule the patient has more or less fever, nausea and at times vomiting. The head aches and the abdomen may be distended by the formation of gas in the intestines. The treatment is like that used in the majority of intestinal disorders. The bowels are emptied by means of soapsuds or salts and glycerin enemas. Certain physicians recommend an enema made with equal quantities of milk and molasses, with enough hot water added to make a thin, warm solution. Care must be used in preparing this flatus enema on account of the danger of curdling the milk with the acid in the molasses and the hot water. If the solution should curdle it must be discarded and a fresh solution prepared. A flatus enema containing salts, glycerin, and a few drops of turpentine is also valuable in removing the gas formed by the action of the putrefactive bacteria upon the unabsorbed food mass. This enema must be given "high" so as to reach the spot in the colon where it may efficiently do its work. ~Dietetic Treatment.~--The diet may consist of fluids for the first few days, or as long as the fever continues. ~Buttermilk~ is probably the best fluid food to use under such conditions, since it not only nourishes, but likewise furnishes lactic acid bacteria which aid in the destruction of the more harmful bacteria, especially numerous under the conditions just mentioned. When whole milk is given it is best to peptonize it. Well-strained meat broths may be given occasionally to vary the diet and albumenized orange juice or orange juice in carbonated water may also be given once or twice daily during the febrile period. After this, the patient may have well-cooked cereal gruels. These may be dextrinized with vegetable diastase (Taka diastase) if necessary. A return to normal diet is made gradually to prevent a return of the trouble. The patient should be advised against overeating, and eating highly seasoned or indigestible foods. ~Convalescent Diet.~--The diets recommended for use during convalescence from other intestinal disorders may serve here, reducing, however, the allowance of meat, since meat proteins are particularly susceptible to attacks of putrefactive bacteria. ~Dietary Precautions.~--After the body has returned to its normal state, the patient must keep in mind the danger arising from constipation and intestinal putrefaction. The following menu is given as a guide to aid the individual in selecting a diet which will in a measure assist in preventing future attacks of intestinal putrefaction and auto-intoxication: 7 A.M. 1 glass of water with orange or lime juice. BREAKFAST 8 A.M. Stewed prunes or figs. Cereal and cream. Buttered toast. Crisp bacon. Coffee. LUNCHEON Vegetable or tomato soup. Green vegetables such as cauliflower, greens, or tomatoes; or Baked dishes such as macaroni and cheese, scalloped macaroni and tomatoes; or Baked potatoes, or potatoes _au gratin_, or stuffed tomatoes with rice. Stewed fruit or fruit jelly. Sponge cake with simple sauce. Junket. Toasted crackers or bread. DINNER Milk soup. Cream of spinach, celery, peas, or tomatoes. Baked eggs, cheese soufflé or nut loaf. Tender green peas, cauliflower, spinach, boiled or creamed potatoes, well-boiled rice. Fruit, vegetable, tomato, or cheese salad. Simple dessert, such as cottage pudding with simple sauce, fruit pudding, prune whip, or frozen desserts; ice cream or water ices; or Cheese and crackers. Coffee. SUMMARY DIARRHEA ~Character.~--Acute or chronic, accompanying many pathological conditions, especially in children in whom diarrhea in any form must be given immediate attention. ~Causes.~--Errors in diet, polluted water or milk, ptomaines, bad hygiene, and certain drugs. ~Bowels.~--The stools vary in number from three to twelve a day. They may be greenish yellow in color, containing mucus and particles of undigested food and, in prolonged cases, blood. ~Treatment.~--Rest in bed and total abstinence from food for from twenty-four to forty-eight hours. Salines are usually given by mouth or by rectum, but this is left to the discretion of the physician. Very little water is given by mouth during the period of total abstinence. Thirst is relieved by bits of ice, and enemas are given if necessary. ~Administration of Diet.~--When acute symptoms have disappeared and the stools are becoming more normal in character and number, a fluid diet of from four to six ounces is administered every three or four hours or oftener if patient is very weak. Brandy may likewise be given in cases in which exhaustion is marked. ~Dietetic Treatment.~--Concentrated foods of the simplest character and only those known to agree. Proprietary infant or invalid foods, except malted foods, which exert a laxative effect; among those found to be good may be mentioned Mellin's Food, Imperial Granum, and Racahout. ~Foods to Be Avoided.~--Fatty foods; pork, veal, and shellfish; all foods that are subject to fermentation in the stomach or intestinal tract (sugar). ~Foods to Be Limited.~--Fluids, soup, beverages, etc., because they impose more work on the intestines. ENTEROCOLITIS ~Seat of Inflammation.~--Lower intestine and colon. ~Differentiating Characteristics.~--More mucus and blood in stools; greater prostration; greater rise of temperature; and less anemia than in chronic enteritis. ~Dietetic Treatment.~--Practically the same as in other diarrheas. DYSENTERY ~Characteristic Symptoms.~--Acute and spasmodic pain, tenderness and distention in the bowels, moderate fever, straining and a constant desire to defecate, small stools containing blood and mucus, loss of weight and marked anemia when condition becomes chronic. ~Treatment.~--Rest in bed absolutely necessary; the use of the bedpan made obligatory; soreness relieved by hot turpentine stupes or spice poultices. ~Dietetic Treatment.~--No food for a period of from thirty-six to forty-eight hours, after which fluids and the régime recommended in acute diarrhea are advisable. In chronic dysentery the diet is practically the same. The extreme exhaustion and anemia accompanying these conditions make it necessary to increase the diet carefully but soon to offset as far as possible the devastating effects of the disease. APPENDICITIS ~Treatment.~--Confinement to bed is absolutely necessary while acute symptoms prevail. The life of the patient may depend upon the care with which this "quiet" period is carried out. No food should be given for twelve or more hours to enable the physician to make a proper diagnosis and to allow the intestinal tract and appendix complete rest from the irritating effects of food passing down the canal. ~Dietetic Treatment.~--~Acute Stage:~ Total abstinence for a period, after which fluids as given in other acute intestinal disorders. No solid food until acute symptoms have subsided; then a gradual return to normal. ~Convalescence.~--When tenderness in right side has disappeared, the return to a normal diet is made gradually. Gelatin, soft eggs, soft toast, fine cereal gruels, well-cooked rice, well-baked white potatoes, tender rare beefsteak or lamb chops, the breast of chicken, sweetbreads, and brains are recommended. ~Relapse or Recurring Appendicitis.~--The patient must be warned against eating indigestible foods or any kind of foods liable to cause constipation; also against overeating or eating when over-heated or over-tired. One attack predisposes to another, hence the above precautions are necessary to prevent the condition from becoming chronic. CHRONIC CONSTIPATION ~Causes.~--Improper foods, indoor occupations leading to a lack of fresh air and exercise, bad hygiene, certain drugs, such as cough sirups, etc., containing opium in some form, constant use of cathartics and enemas to move the bowels, heredity. ~Dietetic Treatment: Foods to Be Avoided.~--Highly spiced foods must be avoided on account of their astringent qualities, too concentrated foods because they fail to furnish the necessary bulk without which the waste matter cannot pass out of the body at a sufficient rate of speed to prevent putrefaction taking place in the intestinal tract. ~Foods Stimulating Peristalsis~ on account of their bulk: Bulky foods, such as vegetables, cabbage, turnips, cucumbers, spinach, beans, celery, lettuce, etc.; cereal foods containing a high percentage of bran, bran bread and cookies, fruits such as raisins, prunes, figs. ~Foods Acting as Stimuli to Intestinal Movements~ on account of their acid content: Limes, oranges, apples, prunes, figs, raisins, most fruit juices (blackberries excepted), rhubarb, tomatoes, cauliflower, spinach, onions, honey, and molasses; senna leaves likewise have a distinct action upon the peristaltic movement of the intestines, hence are included here. ~Precautions.~--Emphasis should be placed upon the dangers of (1) overeating any of the foods indicated in the above list and thus bringing about conditions more dangerous in result than the original disturbance; (2) the taking of drugs to move bowels on account of the ease with which the habit is acquired and the consequent inability of the bowels to move without such whips; (3) the taking of too little water, thereby allowing a too concentrated condition of the food mass and a consequent accumulation of substances which inhibit peristaltic action. ~Use of Fats and Mineral Oils.~--Olive and other vegetable oils, if not completely absorbed, are advised on account of their lubricating effects. The same can be said of the mineral oils which have no food value but in many cases furnish the lubricant necessary in certain individuals suffering from sluggish intestinal peristalsis. PROBLEMS (a) List the food used in the treatment of enterocolitis; outline the method of administering the diet. (b) Formulate a convalescent diet for diarrheal cases. (c) List the foods used in chronic constipation; list the avoidable ones. FOOTNOTE: [94] Malted foods are contraindicated, as malt exerts a very laxative effect. CHAPTER XIII FEVERS IN GENERAL Fever is an abnormal condition characterized by an elevation of body temperature, quickened respiration and circulation, and a certain amount of tissue waste. This elevation of temperature may be due to various conditions, such as local inflammation, infectious diseases, disturbed metabolism and food poisoning (ptomaine). ~Tissue Waste in Fevers.~--Fevers of short duration, such as accompany colds, tonsillitis, chicken pox and intermittent fever, remittent fever, and at times malarial fever, do not cause sufficient tissue waste to make the nutrition the important feature of the treatment. In ptomaine poisoning the tissue waste may be great, but it is the result of the poisoning, as is the fever, so that the diet needs to be adjusted only after the disturbance has abated. In the beginning, starvation is instituted and the fever disappears when the poisoning is controlled. ~Treatment of Fevers of Short Duration.~--In all fevers of short duration then, the treatment is directed with the following points in mind: (1) relieving the cause, (2) preventing gastro-intestinal disturbances, (3) saving the heart, kidneys, etc., extra strain. ~Dietetic Treatment.~--In doing this the diet is so formulated as to meet the above-mentioned conditions, and fluids seem the best form in which food can be given to bring about the desired results. The quantity of fluids should be small and the intervals between feedings short. Two-hour intervals seem best in the beginning. These intervals are lengthened as the fever decreases and the amount of food at each feeding increased. When convalescence is established, semi-solid, soft or convalescent diet may replace the fluids and the patient gradually brought back to a normal diet. ~Fluid Diet.~--The following foods constitute a fluid diet: milk, whole milk, plain, peptonized, or albumenized, buttermilk, koumiss, malted milk, milk shake, milk punch, cream, whey; fruit beverages, plain, albumenized, or mixed with whole raw egg; eggnog, milk and ginger ale, cocoa, strained gruels, broths reënforced with egg or plain. Carbonated water may be added to milk or fruit beverages. ~Schedule of Feeding.~--The following schedule may be used as a guide in fevers of short duration:[95] I 7 A.M. 6 oz. hot milk or cocoa. 9 A.M. 6 oz. broth reënforced with egg. 11 A.M. Milk shake. 1 P.M. Oatmeal gruel, 4 oz.; 2 oz. cream. 3 P.M. Albumenized orange juice, 4 oz.; 1 egg white. 5 P.M. 6 oz. broth reënforced with egg white. 7 P.M. 6 oz. cocoa. 9 P.M. 6 oz. malted milk. 12 M. 4 oz. hot milk and 2 oz. cream. and 4 A.M. The above furnishes approximately 750 calories. II 7 A.M. 6 oz. cocoa. 9 A.M. 4 oz. oatmeal gruel, 2 oz. cream. 11 A.M. Eggnog. 1 P.M. Milk broth reënforced with egg. (3 oz. milk, 3 oz. broth, 1 egg white.) 3 P.M. Cream, egg and vichy. 5 P.M. Albumenized milk, 6 oz. 7 P.M. Hot malted milk chocolate, 6 oz. 9 P.M. Milk broth reënforced with egg. 12 M. 4 oz. oatmeal gruel, 2 oz. cream. 4 A.M. 6 oz. malted milk (half water, half milk). Furnishing approximately 1500 calories. III 7 A.M. Oatmeal gruel, 4 oz., 2 oz. cream. 9 A.M. Orange eggnog. 11 A.M. Malted milk chocolate (3 oz. milk, 3 oz. water). 1 P.M. Clam broth (milk), 6 oz. 3 P.M. Milk shake, 4 oz.; 2 oz. cream. 5 P.M. Cornmeal gruel, 4 oz.; 2 oz. cream. 7 P.M. Hot cocoa, 6 oz. 9 P.M. Hot malted milk. 12 M. Hot milk, 4 oz.; 2 oz. cream. 4 A.M. Hot milk, 4 oz.; 2 oz. cream. Furnishing approximately 1460 calories. The two night feedings may be omitted if patient is asleep. These diets will be seen to be below the maintenance requirements in health, but the need for care in preventing gastro-intestinal disturbances makes it safer to have it so for a few days, especially if the elevation of temperature is great. After the temperature becomes normal the following foods may be added to the diet: ~Soft or Convalescent Diet.~--Cream soups, soft-cooked, creamed, or poached egg, soft or baked custard, junkets, egg, cocoa, or plain vanilla ice cream, soft toast, milk or cream, buttered toast, cereals, gelatin jellies, fruit, wine, or meat jellies, vegetable purées, baked white potato, apple sauce, baked apple, fruit whip, blanc-mange, broiled lamb chops, beefsteak, or chicken, sweetbreads, broiled or creamed brains. ~Sample Menus.~--The following menu is a sample convalescent dietary: BREAKFAST 7:30 A.M. Cream of wheat 3 oz., cream 1 oz. 1 soft-cooked or poached egg. 1 slice of toast buttered. 6 oz. cocoa or milk flavored with coffee. 2 tablespoonfuls of strained prune pulp with 2 oz. cream. 10:30 A.M. Albumenized orange juice. DINNER 12:30 P.M. Cream of pea soup, 6 oz. 1 baked potato with butter. 1 slice of buttered toast. 1 cup of cocoa or 1 glass of milk or buttermilk. 3:30 P.M. Ginger ale and milk, 3 oz. each. SUPPER 6 P.M. 2 slices of buttered toast moistened with 4 oz. milk and 2 oz. cream. 1 soft-cooked egg or 3 tablespoonfuls of well-cooked cereal or 2 tablespoonfuls of boiled rice. 2 tablespoonfuls of apple sauce served with 1 tablespoonful of cream. 1 cup of cocoa, malted milk, whole milk, or buttermilk. 9 P.M. 4 oz. hot milk, 2 oz. cream, or 1 cup of cocoa or malted milk. The return to normal diet is made with caution that the digestion of the patient may not be upset or the temperature raised again by over-feeding. ~Energy Requirements.~--In fevers of short duration it is not difficult to regulate the amount of food necessary for the maintenance of the patient, since the body will, as a rule, adjust itself when the cause of the fever has been removed. At times, however, it is necessary to make an effort to tempt the appetite of the patient when convalescence is established, that recovery may be made more rapid and complete. ~Care of the Mouth.~--Probably there is nothing more essential in the treatment of fevers in general and typhoid fever in particular than the care of the mouth. Well-nourished patients rarely ever show the dry, cracked tongue and lips that was formerly one of the common occurrences in typhoid fever. However, in any febrile condition the mouth is apt to acquire a disagreeable taste; this "bad taste" is so prominent in certain cases as to render it difficult for the patient to eat. This can be, to a great extent, eliminated by the use of aseptic mouth washes. When the patient is not strong enough to rinse the mouth before and after eating, the nurse must use a swab for the purpose. The food must be carefully selected and attractively served and every effort made to make food as dainty and palatable as possible. ~Thirst.~--Thirst is relieved with crushed ice, fruit beverages, and carbonated waters. In certain conditions it is necessary to limit the fluids, but in typhoid fever the giving of the requisite amount of liquids is one of the most difficult tasks confronting the nurse. It is wise to find out the beverages particularly liked by the patient and, whenever it is possible, make use of them. As a rule alcohol is not necessary in the diet of typhoid fever patients. However, in certain cases of that disease, as well as in febrile conditions induced by other causes, the use of alcoholic stimulation may be necessary; it must be left to the discretion of the physician to prescribe it. SUMMARY ~Intestinal Disturbances~ are accountable for the majority of the fevers of short duration during infancy and childhood, and in many of those cases in adults. ~Malaria~ causes an elevation of temperature which is, as a rule, of short duration. ~Contagious Diseases~, such as scarlet fever, measles, whooping cough, and mumps, are likewise accompanied by more or less elevation of temperature. ~Treatment~ consists of a period of rest in bed, with an abstinence from food, in order that the disease may manifest itself, and also that any offending food material which may cause the fever may have an opportunity to pass out of the body. ~The Heart~, in some of the diseases accompanied by an elevation of temperature, is more or less strained; this is particularly true in tonsillitis, diphtheria, etc. ~The Kidneys~ are likewise taxed in certain diseases, even when the fever is not great or lasting; this is found to be the case in scarlet fever, tonsillitis, etc. ~Dietetic Treatment~ consists in giving no food for a period lasting from twenty-four to forty-eight hours. This is followed by a liquid diet, milk and broth particularly, which is continued as long as the fever remains. ~Convalescent Diet~ is instituted as soon as the fever has disappeared and acute symptoms subside. ~Thirst~ is apt to be great with any elevation of temperature. It is relieved by water, crushed ice, and fruit beverages. ~The Mouth~ requires much care, even in fevers of short duration. A simple antiseptic wash should be used several times each day. ~Nitrogen Equilibrium~ is not sufficiently disturbed in such cases to require taking into account. Should the disease, however, develop into one causing a material breaking down of the body tissues, measures must be instituted to prevent the upsetting of the nitrogen balance in the body. PROBLEMS (a) Outline the dietetic treatment for malarial fever. (b) Outline a diet order, using liquids only. Show method of reinforcing this diet. (c) Show how the solids are added as convalescence progresses. FOOTNOTE: [95] In scarlet fever and other conditions in which the kidneys may be involved the above diet is not given unless advised by physician in charge. CHAPTER XIV TYPHOID FEVER ~Definition.~--Typhoid fever is an acute infectious disease excited by specific bacteria (Eberth). The intestines become the seat of ulcerations (Peyer's patches), which at times perforate. The chief symptoms of the disease are fever, headache, abdominal distention and tenderness, more or less diarrhea and a rose-colored abdominal rash. The source of infection is found in the intestinal contents of a typhoid fever patient, which in some way come in contact with and infect drinking water, milk, etc. ~Energy Expenditure in Febrile Conditions.~--In febrile conditions the energy expenditures increase as much as twenty-five per cent. In some cases, and when bacterial activity is added to this, as is the case in typhoid fever, the tissue waste becomes correspondingly greater; hence the nutrition assumes the chief rôle in such cases, for in no other way can the tissue waste and energy expenditure be met and overcome. ~Energy Expenditures in Typhoid.~--In typhoid fever the problem of meeting these expenditures, and at the same time protecting the heart and kidneys from the abnormal strain placed upon them in handling the toxic substances produced as the result of bacterial action in the intestines, becomes very real. It requires eternal vigilance and patience not only from the physician but especially from the nurse, with whom so much responsibility rests. The dietetic treatment necessarily is the principal point to which all efforts must be directed. By this is understood not only the type and amount of food given the patient, but the behavior of this food in the body as manifested by the symptoms, namely, the appearance of the patient, the condition of the mouth, the abdominal distention, tenderness, diarrhea, nausea, and vomiting, the hemorrhage which at times occurs in spite of all care, and perforation which sometimes results in death, and acidosis or acetonuria. All of which makes this disease one requiring the most efficient attention from a nutritional standpoint. ~Energy Requirements in Typhoid Fever.~--In a previous chapter the energy expenditures of the normal individual were dealt with; it was seen that a man at rest, that is, in bed, not rising for anything, had a normal expenditure of energy requiring from 1900 to 2200 calories per day. Now, if these expenditures were increased twenty-five per cent. by the fever and still more by the bacterial activities, it is clearly seen that the diet must be increased in proportion if the tissue waste is to be prevented and the normal body weight of the patient maintained. ~High Calorie Diet.~--Dr. Warren Coleman,[96] to whom we owe so much for his pioneer work in feeding in typhoid fever, devised the so-called "High Calorie Diet." This consists of foods of the most digestible type prepared in the simplest way. The weight of the patient is considered and the diet directed with the following points in view: (1) to cover the energy requirements of the body; (2) to make good the tissue waste which at times amounts to a loss of from 15 to 20 grams of nitrogen a day (or from 1/4 to 3/4 pound of muscle);[97] (3) to check or prevent the development of serious complications, kidney, heart, etc. In the Metabolism Ward at Bellevue Hospital, New York,[98] the best results are obtained by the giving of diets furnishing from 60 to 80 calories per kilogram per day, or from 4000 to 5500 calories. ~Fluid Diet.~--It is clearly seen that it would be practically impossible to obtain a sufficient number of calories by using milk alone or even a mixed fluid diet to supply the above requirements. Since milk alone in such a diet would probably cause such discomfort as to make it unwise to continue it, the ideal diet would seem to be one in which the fats, proteins and carbohydrates are furnished in a semi-solid or solid form, together with a sufficient amount of liquids to prevent too great concentration in the food, to relieve thirst, and to act as a carrier of reënforcing substances, such as lactose, eggs, casein products, etc. ~Absorption Food.~--The question as to whether the food is absorbed when given to typhoid fever patients has often been asked. That it is has been proved in the series of calorimeter experiments conducted in the Metabolism Ward, Bellevue Hospital.[99] Here it was demonstrated that under the high calorie diet the patient consumed large amounts of food with relish and that which was not utilized by the organism immediately was stored for future needs. ~Diarrhea and Tympanites.~--Constant attention and study of various typhoid patients taking a maximum amount of food a day has proved that the diarrhea and tympanites which at times occur in these as well as other cases are due to too much of one or another of the food constituents rather than to the general amount of the diet. Diarrhea may then be traced to an excess of cream, and the tympanites to an excess of lactose, and a reconstruction of the dietary will often obviate the trouble. ~Increasing the Diet.~--It is always advisable to "go slow" in adding new foods to the diet; milk, cream, eggs and lactose are the principal articles constituting the diet. To this are added fine cereal gruels, well-cooked rice, rice custard, tapioca custard, junket, ice cream, wine or fruit jellies, toast, eggs (soft-cooked, poached, creamed, or raw, in milk), or fruit beverages, cocoa, buttermilk, koumiss, certain proprietary infant foods such as Mellin's Food, Eskay's Food, Racahout and malted milk, with a well-baked potato, milk, cream or buttered toast added as the condition and appetite warrant. ~Milk Diet.~--The following milk diets[100] were devised by Dr. Coleman to be given in certain cases of typhoid fever during the acute stage. These formulas consist of milk, cream and lactose and furnish from 1000 to 3000 calories per day. _Calories_ 1000 calories per day-- Milk, 1000 c.c. (1 qt.) 700 Cream, 50 c.c. (1-2/3 oz.) 100 Lactose, 50 gm. (1-2/3 oz.) 200 This furnishes eight feedings, each containing Milk, 120 c.c. (4 oz.) 80 Cream, 8 gm. (2 dr.) 15 Lactose, 6 gm. (1-1/2 dr.) 24 2000 calories per day-- Milk, 1500 c.c. (1-1/2 qt.) 1000 Cream, 240 c.c. (8 oz.) 500 Lactose, 125 gm. (4 oz.) 500 This furnishes seven feedings, each containing Milk, 210 c.c. (7 oz.) 140 Cream, 30 c.c. (1 oz.) 60 Lactose, 18 gm. (4-1/2 dr.) 72 3000 calories per day-- Milk, 1500 c.c. (1-1/2 qt.) 1000 Cream, 480 c.c. (1 pt.) 2000 Lactose, 250 gm. (8 oz.) 1000 This furnishes eight feedings, each containing Milk, 180 c.c. (6 oz.) 120 Cream, 60 c.c. (2 oz.) 120 Lactose, 30 gm. (1 oz.) 120 ~Varying the Diet.~--It has been found possible, even advisable, to vary the above diets in many cases. The disease extends over such a long period that if a fluid diet is adhered to the patient would grow exceedingly tired and even disgusted if milk alone was given, hence a mixed fluid diet such as is used in the Presbyterian Hospital, New York City is suggested.[101] PRESBYTERIAN HOSPITAL DIET LIST 8 A.M. Milk and coffee, each 120 c.c. (4 oz.). 10 A.M. Milk, hot or cold, 240 c.c. (8 oz.). 12 M. Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.). 2 P.M. Junket with cane and milk sugar. 4 P.M. Oatmeal gruel, 120 c.c. (4 oz.), with milk 60 c.c. (2 oz.). 6 P.M. Junket with cane and milk sugar. 8 P.M. Hot milk, 240 c.c. (8 oz.). 10 P.M. Whey, 180 c.c. with 1 whole egg and sherry. 12 M. Oatmeal gruel, 120 c.c. (4 oz.) with milk. 2 A.M. Junket with 60 c.c. (2 oz.) can and milk sugar. 4 A.M. Milk, 240 c.c. (8 oz.). 6 A.M. Milk, 240 c.c. (8 oz.). 15 gm. (1/2 oz.) of lactose added to each of the four milk feedings. The following foods and diet lists are used with success in various hospitals: From 1 to 1-1/4 quarts of milk and 1 pint of cream and lactose, beginning with 1 tablespoonful in each milk feeding and raising the amount day by day until the patient is taking 2 oz. (4 tablespoonfuls) at each milk feeding, given in eight feedings. This may be given as milk, hot or cold, or it may be made into cocoa, soup, ice cream, junket, or on the cereal. LIQUID DIET Milk. Cream. Buttermilk. Whey. Koumiss. Zoolak. Fermillac. Albumenized fruit juices, egg, and orange juice. Milk shake. Broths (chicken, beef, mutton or clam), reënforced with lactose or egg or given plain. Proprietary infant foods. Cream soups, beef juice, liquid peptonoids, panopepton. Orangeade. Lemonade. Eggnog. Milk punch. Malted milk. Malted milk shake. Albumenized milk. Strained gruels (except oats). Cream, egg and vichy. Chocolate malted milk. Milk gruels. SOFT OR SEMI-SOLID DIETS Eggs--creamed, soft-cooked, poached, custards, baked custards. Toast--milk or cream toast. Gelatin--meat, fruit, or wine jellies. Junkets--plain, egg, or cocoa. Cereals--fine, strained cereals, except oats. Rice--boiled or in custard. Tapioca--custard. Baked or mashed potato. Cornstarch or arrowroot pudding. Ice cream. Meat is not given until convalescence is established, and then in only the most digestible form, such as rare beefsteak or lamb chop or a small piece of broiled breast of chicken. DIET LIST USED IN HIGH CALORIE DIETS FOR TYPHOID FEVER =========+============================+=================+=============== _Time_ | _Material_ | _Amount_ | _Calories_ ---------+----------------------------+-----------------+--------------- 6 A.M. |Hot milk | 4 oz. | 78 |Cream | 2 oz. | 76 |Lactose | 1/2 oz. (15 gm.)| 60 | | | 8 A.M. | {Milk | 3 oz. | 59 | {Water | 3 oz. | |Cocoa {Cocoa | 2 tsp. | 35 | {Cream | 1 oz. | 38 | {Sugar | 2 tsp. | 40 | {Lactose | 1/2 oz. (1 tbs.)| 60 |Egg | 1 | 60 |Toast | 1 slice | | |(well moistened) | 73 |Butter | 1/2 oz. | 73 | | | 10 A.M. |Buttermilk | 6 oz. | 56 | | | 12 M. |Cream of pea soup | 6 oz. | 300 |Mashed potato |20 gm. | 28 |Toast | 1 slice | 73 |Butter |20 gm. | 84 |Coffee and milk | 3 oz. each | 59 |Cream | 2 oz. | 76 |Sugar | 2 tsp. | 40 |Lactose |20 gm. | 80 | | | | {Orange juice | 3 oz. | 38 3 P.M. |Orange juice {Egg | 1 | 60 | and egg {Lactose |30 gm. | 120 | | | 5 P.M. |Farina | 3 oz. | 102 |Milk | 2 oz. | 59 |Cream | 2 oz. | 76 |Lactose |20 gm. | 80 |Egg | 1 | 60 |Apple sauce | 1 oz. | 30 |Cream | 1 oz. | 38 |Cocoa | 6 oz. | 108 | or | | |Tea and | 3 oz. | 0 |Milk | 3 oz. | 78 |Sugar | 2 tsp. | 40 |Toast | 1 slice | 73 | | | 7 P.M. |Gruel | 4 oz. | 102 |Cream | 2 oz. | 76 |Lactose |15 gm (1/2 oz.) | 60 | | | 9 P.M. |Broth | 6 oz. | 18 |Egg white | 1 | 13 | | | 12 M. |Milk | 4 oz. | 78 |Cream | 2 oz. | 76 |Lactose |20 gm. | 80 | | | 3 A.M. |Milk or | 4 oz. | 78 |Malted milk | 1 tbs. | 58 |Cream | 2 oz. | 76 |Lactose |20 gm. | 80 | | | ____ | | Total calories 3145 =========+============================+=================+=========== ~Advantages of Newer Treatment.~--A marked difference is noticed in the patients treated by the old starvation diets and those given the high calorie diet. Dr. Coleman states[102] that while the range of temperature is apparently unaffected, the total duration of the disease is shortened in some instances by months through the shortening of convalescence. He further states that certain symptoms which have hitherto been attributed to the specific action of the typhoid bacillus have been discovered to be due to faulty methods of treatment, particularly to an inadequate or improperly balanced diet. The various investigators who have made the study and treatment of this disease a lifework claim that the mortality from this disease has been tremendously reduced by the use of the high calorie diets which maintain the nutrition of the patient throughout the disease, thus eliminating the horrors of the long, tedious convalescence which tried the nerves and patience of the patient, the nurse, and the physician. There is no doubt that so far as the administering of this diet is concerned it requires more effort on the part of the nurse than the old treatment of a glass of milk every two or three hours. It is necessary for the nurse to be able to carry out the orders as expressed in the diet lists, to be able to compute the proteins (nitrogen), fats, and carbohydrates in a food or recipe. But this is readily done by studying the tables given in the first section of this text. She must likewise be able to recognize the symptoms as they arise. In hospitals, the urinalysis is made as a routine procedure. In private cases the physician will either have the analyses made or expect the nurse to be able to make the simple tests.[103] One of the greatest difficulties attending the administering of the high calorie diet is persuading the patient to take sufficient food for his needs. The fluids are often more difficult to give in quantity than the more solid foods, and it requires much tact on the part of the nurse to prevent a refusal of the necessary fluids. However, if the patient is possessed of even ordinary intelligence, an explanation of the reasons for the large amount of food will as a rule be all that is necessary. Few individuals will willingly prolong an illness attended with the discomforts generally present in typhoid fever. ~Hemorrhage~ occurs in a certain percentage of cases of typhoid regardless of the diet, whether it be a strictly milk diet or the high calorie diet just described. The measures to combat them are essentially the same. It is necessary to guard against excessive tympanites since the pressure therefrom against the ulcerated intestinal walls may cause perforation resulting in hemorrhage. Lactose at times causes an evolution of gas as do fats under certain circumstances. Hence it is necessary to follow symptoms and watch the stools in order to determine which food material is to blame for the tympanites and reduce the allowance of that food in the diet. ~Idiosyncrasies against Milk.~--Certain individuals manifest an inability to take milk. This may be real or imaginary. When it is a true idiosyncrasy, it may be found necessary to substitute some other food for the milk in the diet, but great care should be taken to determine the real character of the disagreement before eliminating so invaluable a food from the diet. When the disagreement proves merely a distaste for milk, some of the different methods used in disguising it, such as flavoring or coloring, may be practiced. Otherwise, it is well under the circumstances to use some of the pre-digestive methods in order to increase its utilization. It is well to emphasize the value of accurate data on this subject as it is exceedingly difficult to administer a high calorie diet without milk in some form. ~Essential Points.~--Thus the dietary in typhoid fever is seen to be the most important part of the treatment. A careful study of the tables will enable the nurse to do her part in nourishing the patient. It is necessary that she be able to compute the nitrogen, carbohydrates, and fats in a diet and arrange these constituents in such a way as to give the desired amount of each in the dietary and in a form acceptable to the patient. SUMMARY ~Rate of Metabolism~ is greatly increased in typhoid fever even over other febrile conditions, not only on account of the elevation and duration of the fever, but also on account of the activities of the specific bacteria in the intestinal tract which differentiate this disease from other febrile conditions. ~Energy Expenditures and Requirements~ of the body in typhoid fever, on account of the character of the disease, are much greater than those of the normal individual and must be met by an increase in the diet if the body is to be saved from destruction. ~The Bowels.~--Diarrhea develops during any period of the disease due to excess amount of fat or to a disagreement of some of the other food constituents. It is advisable to cut down the allowance of cream temporarily and to watch stools and other symptoms for evidences of dietetic errors. ~Hemorrhage~ must be guarded against by eliminating, as far as possible, all substances liable to cause an excessive gas formation in the intestines. ~Absorption of Food~ is as a rule good. The patient is usually able to handle a large quantity of food provided it is judiciously administered with a due regard to the symptoms manifested at the time. ~Simplicity of Diet~ is absolutely essential. All the materials must be selected carefully according to the physician's orders and prepared with the greatest care in order to prevent digestive disturbances. ~High Calorie Diet~ is one in which the fuel value of the food ingested meets or exceeds the energy expenditures of the patient. Foods composing the diet are, milk and eggs for the proteins, with carbohydrates and fats in their simplest and most digestible form to balance the diet. ~Administering a High Calorie Diet~ is accomplished successfully provided the nurse exercises care with regard to the symptoms arising from time to time. These must be carefully noted and reported to the physician, for in this way only is it possible to give a sufficient quantity of food to cover the excessive breaking down of the body due to the disease. ~Fluid Diet~ is at times necessary since certain patients cannot tolerate a high calorie diet, but this is a point decided by the physician. A fluid diet consists of fluids alone, milk in particular, with broths and fruit beverages as ordered. The milk is given in definite amounts and at stated intervals. ~Milk Diet~ is one consisting solely of milk or in which the bulk of the nourishment is furnished by milk. It may be reënforced or not as desired. Lactose is the substance commonly used as a reënforcing agent. It is impossible to cover the energy expenditures of typhoid fever with a milk diet even if it is perfectly administered, but certain complications make it, at times, the only rational method of feeding. ~The Advantages of High Calorie Diet~ over other diets are distinctly noticeable in typhoid fever patients. Those treated by this method are more comfortable during the course of the disease and are saved a long, tedious convalescence which has made the starvation treatment a thing of horror in the past. The return to health is attended by a much better physical condition when the patients are well nourished than is possible when they are kept on practically a starvation ration. The mortality from the disease has been materially lessened by the administration of the high calorie diet. ~Acidosis~ may develop in typhoid fever patients and must be guarded against. The behavior of the fat in the body should be carefully watched and the amount reduced at the first evidence of acidosis. At the same time an increase in the carbohydrates may assist in overcoming the condition. This adjusting of the diet, however, is entirely in the hands of the physician. ~The Kidneys~ in typhoid fever patients are under a great strain, chiefly on account of the increased rate of metabolism. Great care must be exercised in the dietetic treatment to prevent these organs from being overworked with a consequent development of nephritic conditions. ~Care of the Mouth~ in any febrile condition is important, but especially so in typhoid fever, where the disease itself causes a most unpleasant taste in the mouth. This prevents the taking of nourishment with any degree of comfort, hence the mouth should be cleansed before and after each feeding. Any of the aseptic mouth washes may be used. ~Thirst~ may be relieved by plain or carbonated waters, fruit beverages, and crushed ice. When in certain complications the fluids in the diet are in a measure restricted, ice is used and water is given in spoonful doses. This, however, is the exceptional, rather than the ordinary state of affairs. ~Increasing the Diet~ after a fluid diet must be made with great care in order to prevent a relapse. Following the high calorie diet the increase is simple. The patient passes from the prescribed foods to meat with apparently no effort. The increase should not be made, however, until convalescence is firmly established. ~Reënforcing the Diet.~--On account of the great increase in the rate of metabolism and because of the difficulty of furnishing the requisite number of calories in the diet, reënforcing agents such as lactose, eggs, some forms of casein, or beef preparations are used. ~Idiosyncrasies~ against certain foods are, at times, manifested by patients. Efforts must be made to determine whether they are real or imaginary before eliminating any food which may be of importance to their future welfare. PROBLEMS (a) Give a sample diet order, using liquids only. Raise the fuel value of the diet from 2000 to 3000 calories. (b) Formulate a diet order, using the high calorie diet, fuel value 3500 calories. FOOTNOTES: [96] Warren Coleman, University and Bellevue Hospital Medical College, Visiting Physician, Bellevue Hospital, New York City. [97] "Diet in Typhoid Fever," by Warren Coleman, "Journal of American Medical Association," Oct. 9, 1909, Vol. LIII. [98] "Diet in Typhoid Fever," by Warren Coleman, reprint from "Journal of American Medical Association," June 9, 1909. [99] Determined by calorimeter observation from the Russell Sage Institute of Pathology in affiliation with the Medical Division of Bellevue Hospital, under Warren Coleman and Eugene DuBois. [100] "American Journal of Medical Sciences," January, 1912, by Warren Coleman. [101] F. P. Kinnicut, "Diets Used in the Presbyterian Hospital," New York City. [102] "Journal of American Medical Association," Aug. 4, 1917. [103] See urinalysis, p. 323. CHAPTER XV DISEASES OF THE RESPIRATORY TRACT TUBERCULOSIS, PNEUMONIA, AND TONSILLITIS TUBERCULOSIS The dietetic treatment for tuberculosis must, as in any other pathological condition, depend largely upon the general condition of the patient, and the symptoms manifested at the time. ~Character of Disease.~--The disease may have reached an acute stage in which the rise of temperature is marked and the progress of the tuberculous symptoms rapid, or it may be found to be an old chronic condition in which the progress is slow. Again, the patient may be found to be suffering from a tuberculosis which is neither acute nor very slow. Each of these stages requires slightly different treatment which, however, for the main part is much the same. Individuals having an incipient form of tuberculosis have been known to develop an acute form of the disease upon being subjected to a strenuous treatment for some other and entirely different condition. This has been especially noticeable in certain individuals to whom the starvation treatment is given. ~Dietetic Treatment in Acute Stage.~--The dietetic treatment of the acute tuberculosis under such circumstances must necessarily be adapted to that of the original disease for which starvation was believed to be necessary. The forbidden foods must still be omitted from the dietary, but in these cases it is found advisable not to prolong the starvation treatment but to substitute foods which will do the least harm under the circumstances. This is necessary to cover the energy requirements of the body and to make good the tissue wasted through the development of the specific disease. ~Dietetic Treatment in Chronic Stage.~--The diet for tuberculosis has been so widely discussed and so universally used that a few words only seem necessary here. One of the chief points to be emphasized is the danger arising from gastro-intestinal disturbances. The digestive apparatus of the tuberculous individual is more apt to be impaired, so that any undue exertion required to digest a meal is likely to bring about disturbances more or less serious in character. ~Method of Administering Diet.~--For this reason it is no longer the custom to stuff the patient in an effort to overcome the inevitable tissue waste, since such treatment in many cases defeats the end for which it was intended, bringing on acute indigestion, or at times diarrhea, which might readily cause a greater loss of body weight than could possibly be produced by the surplus food given. ~Adjusting the Diet.~--More and more is it coming to be understood that the diet must be adjusted to suit the individual. Three wholesome meals a day are insisted upon, with lunches given between the morning and midday meal and during the course of the afternoon. Many patients are found to sleep better after they have partaken of a light lunch, consisting of hot milk, malted milk, or like beverages and crackers, so that this third meal is added to the other five. In this way the individual suffering with tuberculosis is assured of an efficient diet to meet the needs of the body without overburdening the digestive apparatus or overtaxing the excretory organs. The increased metabolism taking place in such patients, due both to the specific bacteria and to the febrile condition, is, as far as possible, provided for. ~Schedule of Diets.~--The following dietary régime may be useful in formulating menus for tubercular patients: BREAKFAST Fruits. 5 oz. cereals with cream. 1 or 2 eggs, simply prepared to prevent indigestion. 2 slices of bacon, ham; fish cake or chop. 2 slices of toast or crusty rolls with butter. Coffee, tea, or cocoa, with or without cream.[104] LUNCH Vegetable or cream soups. Cold meat, lamb chops, oysters, or fish. Baked white or sweet potato. 1 green vegetable,--greens, cabbage, spinach, or string beans. Stewed fruit or baked apple. Rice or tapioca pudding. Tea. Bread and butter. At the end of the meal one glass containing two-thirds milk and one-third cream. If the latter disturbs the digestion reduce the amount temporarily, or add one-half the contents of a tube of peptonizing powder, or one-quarter of a glass of limewater. DINNER Meat, lamb, mutton, chicken, duck, game, or fish. Mashed or creamed potatoes. 1 or 2 green vegetables. Simple salads. Simple desserts consisting of puddings, custards, wine or fruit jellies, ices or ice cream, sponge cake or angel food cake. The milk and cream is taken at the end of the meal as directed above. LUNCHES 11 A.M., 4 P.M., 9 P.M., consisting of milk, malted milk, junket, buttermilk, albumenized broth, albumenized fruit juices, cream, egg, and vichy, eggnogs, served with crackers or sponge cake; cereal gruels and raw eggs taken with water, milk, or sherry may likewise form a part of this diet, since the nourishment in them is both concentrated and palatable. ~Use of Eggs.~--The old method of forcing the patient to eat a dozen or more raw eggs a day is no longer used, but three or four a day will be of undoubted value to the patient, provided they agree. There are patients, however, with whom eggs act almost as a poison, and in these cases it is decidedly unwise to force them. ~Use of Milk.~--Milk is to be used abundantly. If it should disagree, it may be peptonized or modified with limewater. At any rate, every effort should be made to enable the patient to drink at least one quart a day, and more, if possible. If it fails to agree even when so treated, it should be abandoned, since the discomfort caused under the circumstances is more detrimental to the welfare of the individual than any benefit which he may gain by the small amount which may be absorbed. ~High Calorie Diet.~--As long as the patient is in bed the diet cannot be as full as it is made when he is up and about, as the body is then using more material to provide for the extra exertion and needs more food to replace that which has been utilized. Consequently the high calorie diet[105] will be found as a rule sufficient. As soon as the patient is able to receive more food without incurring digestional disturbances, it should be supplied, keeping ever in mind the danger of its upsetting his digestion. ~Advice to Patients.~--The patient must be impressed with the necessity for living a simple, wholesome life, free from excesses of all kinds. The need for a regular régime in the beginning must be strongly emphasized. Too strenuous exercise and the consequent over-fatigue at times completely overcome all the good which has been accomplished in weeks or even months of studied effort, so that rest is an essential part of the tuberculous régime. The patient should sleep from eight to ten hours out of every twenty-four, and if this sleep is taken in the open, that is, in a tent or on a sleeping porch, the benefits derived therefrom are inestimable. ~The Bowels.~--The bowels should move every day, even if some gentle laxative or an enema has to be used to bring about the desired result. In a majority of cases, mineral oil or bran muffins, prunes, raisins, and figs prepared with senna will be entirely sufficient, however, and these substances are much less harmful than drugs, for the habit of taking purgatives becomes a fixed one in a short time, and is especially liable to become so when the patient is forced, by reason of the sedentary life, to depend on some such measures. ~Massage.~--Massage has been found beneficial in many cases, giving the needed exercise to the body, which it is otherwise unable to obtain. CHRONIC TUBERCULOSIS In chronic tuberculosis, the patient should be instructed in the care necessary for his protection. He should be advised to report to the physician any symptoms occurring during the course of the disease, especially any hemorrhage. He must be reassured of the chances of recovery, even after hemorrhage has occurred. It is not well to encourage the habit of taking the temperature or weighing daily, since the knowledge of the fluctuations which inevitably occur in these conditions may worry the patient to such an extent as to interfere with his final recovery. ~Rest, Sleep, and Fresh Air.~--Moderation in physical exertion, wholesome food at regular intervals, plenty of rest and sleep, preferably in the open, and an effort made to look forward to a complete recovery will go far toward bringing about the desired result. The tuberculous patient who sets his mind on recovery, refusing to be discouraged by the numerous setbacks which may from time to time occur, has a much greater chance of living a long and useful life than the patient who makes no effort in this direction. ~Reënforcing the Diet.~--The following reënforced foods have been found valuable in the diet for tuberculosis, especially in those cases which are confined to bed and in which the effort to eat causes more or less gastric distress: Milk, whole milk, milk and cream, milk diluted with Apollinaris water, peptonized, modified milk, reënforced with egg or egg white or reënforced with one to four tablespoonfuls of lactose, malted milk, buttermilk, cream, egg, and vichy, milk shake, milk punch, malted milk shake, chocolate or cocoa malted milk, albumenized fruit juices, egg and orange, egg and wine, reënforced, if desired, with lactose, albumenized broths, proprietary infant foods, such as Eskay's Food, Nestlé's Food, Mellin's Food, Racahout, cream soups reënforced with lactose or egg, junkets, and ice cream. PNEUMONIA The diet in pneumonia is of considerable importance, since in this condition the strength of the patient is taxed by reason of the character of the disease, and the only means of attaining endurance to carry him through this trying period is by providing proper nourishment. ~Dietetic Treatment.~--The same general outline of diet is used as in acute infectious fevers, milk forming the basis of the diet. The patient is given an abundance of water and other beverages in addition to the other fluid foods to relieve the thirst which is so often a common symptom in this disease. It is sometimes found advisable, however, on account of the vomiting which may occur, to give a more concentrated form of nourishment, in which case liquid peptonoids, trophonine, and panopepton furnish a form of nourishment which is both strengthening and stimulating in character, and for these reasons particularly desirable. Freidenwald and Ruhräh advise against the use of starches and sugars in most cases of pneumonia. ~Daily Diet Schedule.~--The same fluid diets used in acute fevers and administered at two-hour intervals are advisable here. The following régime is used in pneumonia: 6 A.M. 6 oz. malted milk. 8 A.M. 6 oz. cocoa. 10 A.M. 4 oz. oatmeal or cornmeal gruel with 2 oz. cream. 12 M. 6 oz. chicken broth reënforced with 1 egg white. 2 P.M. 6 oz. malted milk chocolate. 4 P.M. 6 oz. albumenized orange juice. 6 P.M. 6 oz. chicken or beef broth, reënforced with egg white. 8 P.M. 6 oz. hot milk. Night feeding consisting of milk, malted milk, or reënforced broth may be given at 12 M. and 4 A.M. if patient is awake. The above diet may be varied by adding some of the beverages mentioned in the diet for tuberculosis or fevers. ~Convalescent Diet Schedule.~--As the acute symptoms subside and convalescence advances, the following diet may be instituted: I Breakfast 3 to 4 oz. cereal gruel with 2 oz. cream. 1 soft-cooked egg. 10:30 A.M. 6 oz. chicken broth, reënforced with egg, or 6 oz. albumenized orange or grape juice. 1 P.M. 6 oz. oyster soup with rolled crackers. 1/4 cup wine jelly with 1 tbs. cream. 1 glass (6 oz.) milk--2 parts milk, 1 part cream. 3 P.M. Milk shake (4 oz. milk, 1 egg white). Supper 4 oz. farina with 1 oz. cream. 6 oz. cocoa. 9 P.M. 6 oz. malted milk. Hot milk, broth, or malted milk may be given during the night at 12 or 4 A.M. if patient is awake. II Breakfast 4 oz. orange juice on cracked ice. 3 or 4 oz. strained oatmeal with cream or butter. 1 slice soft toast. 6 oz. cocoa. 10 A.M. 1 soft-cooked egg on toast. 6 oz. milk. Dinner 6 oz. cream of celery soup. 2 oz. rice. 4 oz. custard (soft or baked). 6 oz. milk or cocoa. 3 P.M. 5 oz. cream, egg, and vichy. Supper 1 soft-cooked egg. 1 small baked potato. 6 oz. cocoa or malted milk. III Breakfast Stewed prunes. 3 or 4 oz. cream of wheat with 1 oz. cream. 1 soft-cooked egg. 1 slice of toast with butter. 6 oz. cocoa or milk. 10:30 A.M. Eggnog (1 egg, 4 oz. milk, 2 oz. cream, 1 tbs. whisky or sherry wine). Dinner Cream of spinach soup. 2 oz. mashed potatoes. 2 oz. green peas. 1 slice toast with butter. 2 oz. rice or tapioca custard. 3 P.M. 6 oz. albumenized fruit juice. Supper 1 slice toast. 1 poached egg. 6 oz. cocoa or hot milk. 2 or 3 oz. stewed fruit or prune whip. The diet may be reënforced with lactose and meat added only when convalescence is well established. ~Tuberculosis Nursing.~--The nurse must keep in mind that the lungs are in a condition more or less out of commission, and their work of excretion is forced upon the kidneys. For this reason, as well as on account of the increased strain upon the heart, it is necessary to keep the diet light and avoid all foods which may in any way exert an unfavorable influence upon either the kidneys or the heart. ~Milk Diet.~--A strict milk diet has been found necessary in certain cases of pneumonia, but this is used only while the febrile condition lasts, after which the diet is gradually increased, as in the case of acute nephritis and in diseases of the heart, to meet the needs of the individual. TONSILLITIS ~Dietetic Treatment.~--The diet in this condition is much the same as that used in other acute febrile conditions, that is, a fluid diet, the basis of which is, as a rule, milk. The development of nephritis and certain cardiac symptoms at times follow attacks of tonsillitis, and for this reason the urine must be examined frequently and the diet carefully adjusted to avert, if possible, this danger. When acute nephritis does follow the attack of tonsillitis, the diet must necessarily be adjusted to meet that condition rather than that of the original disease. ~Special Diets.~--The Mosenthal diet, and at times the Karell Cure, is used with more or less success. This, however, is adjusted by the physician. It remains for the nurse to report any unfavorable symptoms as soon as they occur, and to carry out the line of dietetic treatment deemed advisable by the physician. SUMMARY TUBERCULOSIS ~Form.~--Acute and chronic in character. The chief aim of the treatment in the former is to prevent its development into a chronic form. ~Rest.~--~Sleep~, preferably in the open air, in a tent or on a sleeping porch. ~Proper Surroundings~ should be striven for. The patient should be kept tranquil in mind and body, free from disturbing worries and assured of the possibility of recovery with proper care. ~Diet~ should be adequate without being too abundant; stuffing the patient is no longer considered necessary, in fact it is believed that forcing the eating of large quantities of eggs, etc., defeats its own ends, upsetting the digestion and causing a disgust for food almost impossible to overcome. ~Gastro-intestinal Disturbances~ are apt to develop as the disease progresses. These are treated as in other conditions so complicated, except that the period of starvation must necessarily be limited on account of the metabolic waste already taking place from the disease itself. PNEUMONIA ~The Lungs~, as in pulmonary tuberculosis, are the seat of infection and are temporarily hampered in their work of excretion. ~The Kidneys~ bear the brunt of the extra work caused by the impairment of the lungs, consequently all unnecessary work must be spared these organs if they are to be prevented from being overtaxed. ~Nephritis~ is one of the complications apt to develop when the kidneys are not sufficiently strong to carry on their own work and that generally done by the lungs. ~The Heart.~--Cardiac symptoms are also likely to develop during attacks of pneumonia and make the disease one to be dreaded and guarded against. ~The Diet.~--The dietetic treatment in pneumonia is like that used in acute infectious diseases, fevers in general, fluids constituting the form of diet and milk the chief food, as long as there is an elevation of temperature. TONSILLITIS ~The Heart.~--As in pneumonia, the development of cardiac symptoms must be guarded against. These symptoms may not develop at once but show later during or after convalescence. ~The Kidneys.~--Nephritis also develops in some patients and the treatment is directed as far as possible to prevent its developing into a chronic form. ~Dietetic Treatment~ is the same as used in acute infectious conditions, fevers of short duration, taking care to institute the diet for acute nephritis should the patient show evidences of this disease. PROBLEM Write a diet order for a tuberculous patient weighing 135 pounds, allowing 3000 calories and fifty per cent. of the protein to be derived from animal sources. FOOTNOTES: [104] The addition of cream to coffee produces acute indigestion in certain individuals, hence the nurse must be governed by this point in formulating the diet. [105] See "High Calorie Diet for Typhoid Fever," Chapter XIV. CHAPTER XVI DIETETIC TREATMENT BEFORE AND AFTER OPERATION PREOPERATIVE FEEDING The dietetic treatment which is essential before and after operations is deserving of attention here, since it constitutes one of the points so frequently overlooked or slighted. As a rule the treatment depends (1) upon the character of the disease for which surgical intervention is necessary, and (2) upon the general health and physical condition of the patient in question. ~Preparatory Treatment.~--In many cases it is found to be advisable to build up the patient before subjecting her to the shock of an operation, and the more serious the operation the more necessary this "building-up" process. The character of the disease also has much to do with the preliminary diet. In certain pathological conditions involving the gastro-intestinal tract, for example, the patient comes to the surgeon after medical treatment has failed to give relief and surgical intervention is necessary to save life. The body is found to be in a condition bordering on starvation, anemic and exhausted from insufficient nourishment. The functions of the blood-making organs have become out of gear, as it were, and the blood consequently is deficient in one or more of its essential elements. For such patients it is wise to attempt to reënforce and strengthen their bodies before operation, that they may have more endurance to withstand the shock which is more or less unavoidable. ~Adjusting the Diet.~--In any case where preliminary diet is prescribed the condition for which the operation is necessary determines the nature of the diet; for example, if the operation is to be upon the kidney, the diet beforehand would naturally be in the nature of a nephritic one to save the diseased organ unnecessary work. If the stomach or intestinal tract required surgical care, the diet would necessarily be formulated to meet the particular needs of the organ in question, an analysis of the stomach content furnishing the keynote of the diet. In any case the food must be simple in character and well prepared. All food in any way liable to bring about indigestion should be studiously avoided. ~Habits.~--The habits of the patient must be regulated so that she may not "overdo"; at the same time, gentle exercise may be the very thing needed to give an impetus to the appetite and thus assist in the adding of strength for the approaching ordeal. Many patients respond readily to a change of air and scene and frequent small meals instead of a few large ones,--a lunch in the mid-morning and mid-afternoon hours, consisting of a glass of milk and a cracker or malted milk chocolate or reënforced fruit juices. A cup of warm milk before retiring induces the much-needed sleep, hence is advisable under the circumstances. ~The Bowels.~--The bowels must be kept open. Coarse bread such as that made from bran or graham flour is advisable. Prunes and figs cooked with senna leaves are likewise simple laxatives which are both palatable and effective. For stubborn cases of constipation it is often found that a teaspoonful of a conserve made with a third of a pound each of raisins, prunes, and figs ground fine, with an ounce of senna leaves added, taken at bedtime and before breakfast, will overcome the condition and make the patient more comfortable and the general health better. ~Preliminary Light Diet.~--The day before the operation the diet must be light; the intestinal tract must not be filled with a food mass which is difficult to get rid of. On the morning of the operation the patient is given no food if the operation is to be performed at an early hour, otherwise a cup of tea, coffee, weak cocoa, or broth with a cracker is given. Some physicians give a glass of milk at this time, while others do not. It is the physician who must decide the question if there is any doubt about it. The stomach must be empty before administering the anesthetic. In certain emergency operations when it has been impossible to prepare the patient ahead, the difficulties attending the administering of the ether are sometimes greatly increased. The cleansing of the stomach and intestinal tract oftentimes eliminates or materially decreases the nausea and vomiting which so often forms one of the most dreaded sequences of the operation. For this reason many surgeons require the patient to be given lavage before leaving the operating room. ~Total Abstinence.~--No food is given for twenty-four hours following the operation (1) on account of the nausea and vomiting which so often follows the giving of an anesthetic--ether particularly--and (2) because the entire organism is better for a complete rest. ~Routine Treatment.~--The routine treatment in uncomplicated cases is rest, then water, very hot or iced, or carbonated, or vichy in spoonful doses, then albumen water, broth, etc., then milk, buttermilk, koumiss, etc., after which the semi-solids, etc., until a normal diet is reached. After a week or more the character of the operation certainly determines the dietetic treatment. To quote Dr. Thomas S. Brown,[106] "To give the same diet after pyloroplasty, gastro-enterostomy, gall bladder operation, or gastric resection as we would after operations for fracture of the thigh or cancer of the breast shows a basic ignorance of the pathologic physiology of the former group of cases." "We should remember that hyperacidity remains long after the underlying cause has been removed and it is tempting providence, to say the least, to ply these patients with tomato soup, salad dressing, and coarse food in the early stages of their convalescence." ~Character of Diet.~--It must be kept in mind that the character of the diet is of vital importance, especially in the after-treatment of operations upon the stomach. In gastro-enterostomy, for example, the food mass passes from the stomach directly into the upper part of the small intestine through the new opening. Thus the semi-liquid food highly acid in character comes in direct contact with the delicate intestinal walls which are accustomed, not to the acid, but to a neutral or alkaline medium. ~Adjusting Diet to Disease.~--Thus it is demonstrated that unless care is used in selecting the diet this portion of the intestinal tract will be injured; hence the nurse must understand which foods are liable to stimulate an excess flow of acid in the stomach and avoid them. She must also keep in mind that the foods given must be in a semi-liquid or very finely divided condition, since the mechanical efforts made by the musculature of the gastric organ act as a direct stimulant to the secretory cells of that organ. * * * * * Much of the responsibility thus rests upon the nurse whose business it is to administer the diet. The efforts of the best surgeon in the world may be entirely overcome by a careless, thoughtless, or ignorant nurse. ~Rectal Feeding.~--In some cases it is found necessary to nourish the patient more than is possible by mouth. This is especially so with emaciated and very weak patients and for those who have undergone operations upon the mouth or throat and in some of the above-mentioned stomach cases when the passage of any food over the newly-operated-upon surfaces is inadvisable. In these cases rectal feeding is resorted to and from two to three nutrient enemas[107] alternated with saline enemas are given daily. Under ordinary conditions when the patient has not been operated upon for gastro-intestinal disorders, gall bladder or kidney diseases, the dietetic régime is as follows: ~Postoperative Feeding.~--First day: starvation, a little hot or cold water or carbonated water may be given if there is no nausea or vomiting. If nausea or vomiting persists, a few spoonfuls of champagne or clam broth or juice will often check or relieve it entirely. Fluids alone must be given during the first forty-eight hours after the operation. When stimulation is necessary, albumen water or coffee containing a spoonful of brandy[108] will be found useful. When nausea entirely disappears, well-skimmed broth milk, clam or oyster broth, buttermilk, koumiss, malted milk, may be given. A gradual return to the normal diet is made, adding soft toast, soft-cooked eggs, junket, ice cream, meat, wine, or fruit jellies before solid food is introduced into the dietary. ~After-care in Feeding.~--Care must be observed to prevent indigestion after almost any operation, but especially after abdominal operations there is a great tendency to form gas, hence anything which in any way increases the tendency may bring about a condition of extreme discomfort and even acute pain to the patient. For this reason it is unwise to follow too closely the desires of the patient as to the food to be eaten; for example, corned beef and cabbage may be the thing of all others desired by the patient, but it would be the height of folly to risk such a meal until all danger of digestional disturbances is at an end. It is wiser to avoid such disturbances than to trust to relieving them after they occur. The digestion of even a perfectly normal individual is at a disadvantage when that individual is deprived of outdoor exercise. How much more so will it be when the entire organism is taxed by the ordeal through which it has just passed. Convalescence is never hastened by imprudent eating, and a condition as bad as the original may be brought on by lack of care on the part of the one whose business it is to feed the patient. CONDITIONS REQUIRING SPECIAL DIETS ~Diet After Appendicitis.~--After a simple operation for appendicitis the same régime is carried out as in stomach and intestinal operations: fluids on the second day, soft diet on the third, and solid food of the simplest character and prepared in the simplest way may be given on the fifth and sixth days. When, however, the operation has been of a more serious character, for example, when there was pus formation or a gangrenous appendix, the feeding by mouth must not be instituted for five days or more, nutrient enemas being used instead. Patients have been known to die from exhaustion after operations upon the stomach and intestines, not on account of the operation but on account of the lack of reserve power and endurance to carry them through the ordeal without a sustaining diet to overcome it. Under the circumstances Dr. F. Ehrlich[109] advises the following routine method: "So soon as the nausea from the anesthetic has worn off the patient gets tea, red wine, and gruel; on the day after the operation he is given sweetbreads in bouillon even if it nauseates him; if the nausea is persistent, his stomach is washed. On the second day finely chopped cooked squab, chicken, or veal, is added; on the third day, beef, potato purée and cakes; on the fourth, chopped (raw) ham, soft zwieback, and soft-boiled eggs. On the fifth, white bread and spinach. After the seventh day the meat is not chopped, and the patient returns gradually to normal diet. The bowels are regulated by oil enemas." ~Diet After Operation upon Gall Bladder or Liver.~--The dietetic treatment in these cases is like that of any other abdominal operation except for the character of the food. Fats are not well handled by the body of such individuals and should be eliminated as far as possible from the diet. Broths must be skimmed carefully to remove fat, and milk when given should be skimmed or given in the form of buttermilk or koumiss. ~Diet After Operations upon the Kidneys.~--The diet administered after operations upon these organs is logically one in which those foods which are entirely dependent upon the kidneys for their elimination are restricted. In a former chapter the fate of the foods in metabolism was explained; the protein foods were seen to be the ones leaving the body chiefly by way of the kidneys and for this reason in the diet after operations upon these organs, as well as in that administered in disturbances affecting their functioning powers, this food constituent, the protein of meat in particular, must necessarily be restricted. The upsetting of the nitrogen equilibrium is for so short a period after kidney operations that this feature need not be considered here. The diet under the circumstances is essentially the same as that given during acute attacks of nephritis. SUMMARY ~Factors Affecting Diet~ before and after operations must be considered under two heads, namely, the character of the disease for which the operation is considered necessary and the general physical condition of the patient at the time. ~Emaciation and Anemia~ are often encountered in patients having certain gastro-intestinal disturbances for which surgical intervention was found to be necessary. At times a preliminary up-building treatment is required before it is considered wise to submit the patient to the shock of so serious an operation. ~Adjusting the Diet~ according to the character of the disease for which the operation is to be performed is most important. It is not always possible to build up the body beforehand, but in many cases it is necessary to make the effort. At times the reënforcing of the diet and a certain amount of gentle massage will enable the patient to pass through the trying ordeal more comfortably than would otherwise be possible. ~Selecting the Diet~ to conform to the character of the disease is as important a factor in the recovery of the patient as food itself. This selection is left largely to the nurse, consequently it is necessary that she should understand just which foods are indicated or contraindicated under the circumstances, and adjust the diet after the abstinence period accordingly. For example, the diet fulfilling all the needs of a patient who has just undergone an operation for a broken leg might be highly injurious for a patient just operated upon for some disturbance of the liver or kidneys. The diet given after must be essentially like that given just before the operation, in order that the affected organ may have an opportunity to heal and return to its normal functioning power. ~Gastro-intestinal Disturbances~ must be avoided, both before and after the operation. In the preliminary treatment, when every effort is being made to increase the strength and endurance of the patient, such disturbances do away with any gain brought about by judicious dieting. After the operation, attacks of indigestion not only cause pain and discomfort as a result of the gas formation, but may cause symptoms far-reaching and even dangerous in their effects. The diet, then, must be composed of the simplest food and prepared in the most careful manner, the amount of food given at a time must be small--it is wiser to feed the patient oftener than to run the risk of indigestion by giving more than can be readily handled by the already taxed digestive apparatus. ~The Bowels~ must be kept open in the majority of cases. Peristalsis is stimulated by the giving of water and fruit beverages as soon as it is advisable to give anything by mouth. ~Reënforcing the Diet~ is at times necessary in order that the patient's strength may be kept up. In such cases lactose, eggs and some of the predigested casein or beef preparations are found to be valuable. ~Before the Operation~ the patient must be made ready to take the anesthetic. This is done by preventing an accumulation of food in the intestinal tract. The day before the operation, then, it is necessary to limit the diet materially by giving food in small amounts. The light diets prescribed in acute conditions are as a rule suitable, unless otherwise indicated. ~The Day of the Operation~ a cup of tea, coffee, or broth may usually be given, with a cracker, unless the operation is to be performed early in the morning, in which case the patient is given no food at all. Some physicians allow a glass of milk on the day of the operation, but this is left entirely to the physician in charge. ~After Operation~ a period of total abstinence from both food and water is necessary in order not to increase or induce nausea and vomiting. As soon as these symptoms subside, unless otherwise indicated, a certain amount of hot, cold, or carbonated water may be given. After this, albumen water may form the first nutrient administered. Milk, broth and fruit beverages follow the giving of albumen water, after which the semi-solids, such as soft eggs, gelatin and milk soups, constitute the convalescent diet. ~The Character of the Diet~ after the operation depends wholly upon the nature of the disease for which the operation was deemed necessary. ~Diet After Gastro-enterostomy~ must be adjusted in order not to increase the acid content of the gastric organ, otherwise the delicate mucous linings of the intestines would be subjected to direct contact with materials which are irritating in character, owing to the fact that the mass passes through the new opening and has thus been deprived of the neutralizing agents found in the upper part of the intestinal tract. Under the circumstances milk, albumen water and fine cereal gruels are the best foods from which to formulate the diet after the necessary period of abstinence and fluid diet. ~After Appendicitis~, as a rule, no food is given for five days in cases where there has been a pus formation and the appendix gangrenous. Otherwise the routine treatment diet is given--water, then albumen water, followed by broth, milk and fruit beverages, fine cereal gruels, etc. ~After Liver and Gall bladder Operations~ the character of the food must be considered. The fats are not well handled in such conditions and must be avoided as far as possible. Broths must be well skimmed and the milk fat free. Buttermilk and koumiss are probably the most suitable forms in which to give milk in these cases. ~After Kidney Operations~ the work of elimination through kidney must be limited as far as possible in such cases. While it is impossible to rest the organ entirely, the giving of a proper diet under the circumstances will do much toward relieving the strain placed upon it. The protein foods, with the exception of milk, must be excluded from the diet. The régime practiced in acute nephritis gives the most satisfactory results. PROBLEMS (a) Write a diet order for patient operated upon for gastric ulcer. (b) Formulate diet to be used after a gall bladder operation. (c) Outline diet used after operation upon the kidney. FOOTNOTES: [106] "Some Gastro-intestinal Notes," "The Medical Clinics of North America," Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns Hopkins Hospital. [107] See Formulas for Nutrient Enemas, p. 145. [108] See Albumen Water with Brandy, p. 141. [109] "Diet in Health and Disease," p. 555, by Friedenwald and Ruhräh. CHAPTER XVII URINALYSIS The importance of the kidney functions has been clearly demonstrated. Urine, which is the fluid secreted by these organs, is one of the most important sources of information, not only as to the manner in which the body utilizes food in health, but as an index to certain pathological conditions, the processes of which are more or less indicated by the products excreted in the urine. ~Function of the Kidneys.~--The kidneys, as has already been stated, furnish a means by which the greater part of the waste products of the body are eliminated and in addition to this function they adjust the salts in the body. In an early chapter the function of the salts in food was explained. A certain amount of these substances, we know, is absolutely necessary to carry on the work in the body, but harm comes when a surplus is retained in excess of that which can be used in performing the various processes. Consequently the function of the kidneys to adjust the salts balance is by no means their least important one. ~Elimination of the Toxins.~--The toxic substances manufactured in the body and those resulting from bacterial action upon unabsorbed proteins are likewise eliminated in the urine. Thus it can be readily understood how necessary it is to keep these organs in good repair, that they may continue their work in an efficient manner. It is necessary from a pathological standpoint for the nurse to understand the making of some of the simpler tests, that she may simplify her own work and that of the physician. ~Excretion of Carbon Dioxide and Water.~--We have already spoken of the combinations of carbon and hydrogen compounds. These substances being oxidized, the carbon dioxide produced is eliminated by way of the lungs and the water is excreted partly by way of the lungs and skin, but chiefly by way of the kidneys. ~Oxidation and Excretion of Nitrogenous Substances.~--When the nitrogenous substances are oxidized, the used-up oxygen products are eliminated by the kidneys in the form of urea and more or less highly oxidized substances, such as ammonia and other salts, purin bases, and creatinin. ~Uric Acid~, the chief of the oxidation products of nucleoproteins, is produced in the body and from food, and is always in the urine, being one of its normal constituents. It is only when this substance is in excess in the urine that a pathological condition is indicated. ~Examination of the Urine~, then, is made for several different purposes: (1) to ascertain whether the kidneys are doing their work properly; (2) to find if the kidneys, or any part of the urinary tract, are either temporarily or permanently diseased; (3) to be able to judge from the various substances in the urine whether there is any abnormal process taking place in the body. ~Tests.~--In the examination of the urine for the above purposes, certain definite tests are made. These tests differentiate between the abnormal and the normal. (1) Color. (2) Amount in twenty-four hours. (3) Odor. (4) Specific gravity. (5) Reaction, acid or alkaline. (6) Albumen, indican, acetone bodies. (7) Sugar. (8) Microscopic examination for casts, cells, bacteria, etc. ~The Color~ of normal urine varies, especially with the amount voided. The variations in color range from the pale straw color of individuals who are voiding large quantities to the deep lemon or amber of those who void much less. Pathological conditions are indicated to a certain extent by the color of the urine. Fevers heighten the color, small quantities of blood cause a smoky appearance, while bile changes the color of the urine to a greenish yellow. ~Precipitates in the Urine.~--When the urine has been allowed to stand for a time there is sometimes a brick-red deposit due to the precipitate of urates. This disappears upon heating and is not an evidence of any diseased condition. ~Turbidity of Urine.~--The turbidity of fresh urine then is the only kind which need be considered, since standing in the cold often brings about this condition, due to the growth of bacteria and deposits of both phosphates and urates. ~Requirements in Testing Urine.~--Urine to be tested should be fresh, and when it is not possible to make the examination at once it should be preserved with chloroform, or some other harmless preservative, until ready to use. ~Bacteria in Urine.~--The changes due to bacterial growth in the urine are manifested not only by the turbid character of the urine but also by the odor of ammonia. ~The Amount of Urine.~--The amount of urine voided in twenty-four hours varies with the individual in health as well as in disease. Many individuals void a great quantity during the twenty-four hours, chiefly because they drink a great quantity of water and other beverages. The average amount of urine passed in twenty-four hours by an adult, or a child over eight years, is from 1000 to 2000 c.c. It represents from 60% to 70% of the amount of water ingested. ~Collecting the Urine for Testing.~--In measuring the urine it is necessary to begin collecting it after the bladder has been emptied the first thing in the morning. The patient should void just before the end of the twenty-four-hour period to be sure that the amount formed by the kidneys during this time is accounted for. ~Diseases in Which Urine Is Diminished.~--In certain diseases the amount of urine passed is diminished. This is found to be true in diarrhea and dysentery, when water is lost in the feces, in hemorrhage from any part of the body and from vomiting. It is likewise at times the case after abdominal operations and in nervous conditions, such as hysteria. The urine is diminished when there is an organic obstruction in the urinary tract and certain obstructive diseases of the heart, the lungs and the liver. In these latter cases, there is seen to be a retention or suppression of urine. In both acute and chronic nephritis and in certain fevers, the bladder at times must be emptied by means of a catheter. At other times, the condition is relieved as far as possible by limiting certain articles of food in the diet. At any rate, these points must be kept in mind when examining the urine. ~Effect of Food upon the Urine.~--The odor of normal urine is changed after eating certain foods, such as onions and asparagus. In disease, the odor of urine has a distinct value as a means of diagnosis; cystitis gives a foul odor, certain bacteria bringing about a decomposition in the urine and giving rise to an odor of putrefaction. In cases where there is a fistula connecting the bladder and rectum, the urine has a fecal odor. ~Specific Gravity of Normal Urine.~--The density or specific gravity of urine means the weight of any volume of urine as compared with that of equal volume of distilled water. The specific gravity of normal urine varies from 1012 to 1024, that is, in a thousand cubic centimeters of urine there are found from 11 to 18 grams of solid material. In health it is necessary to know the amount of urine passed in twenty-four hours, to be able to judge whether the amount of solids is too high or too low. ~Specific Gravity of Diabetic Urine.~--In conditions like diabetes mellitus, where there is a wastage of sugar taking place in the body--that is, instead of being oxidized to carbon dioxide and water and glucose, the sugar is passing into the urine without completing its oxidation--the specific gravity rises in these cases to 1030 and over, showing distinctly that a greater amount of solid material is in the urine than is present normally. In chronic Bright's disease and diabetes insipidus, the specific gravity is low. ~Method of Determining Specific Gravity.~--The specific gravity is determined by the use of an instrument known as a urinometer. The urine is poured into a tube and the urinometer is dropped into it. The different figures are marked upon the stem of the instrument and it is a simple matter to read off the figures of the level to which the stem sinks. ~Reaction to Litmus.~--In a former chapter it was stated that normal urine was, as a rule, acid, that is, it turns blue litmus red. Certain diseases render the urine alkaline. A like result is brought about upon the ingestion of sodium citrate or bicarbonate of soda. Urine which stands and becomes decomposed is alkaline in reaction, due to the bacterial action, with the production of ammonia. ~Albumen in the Urine.~--The presence of albumen in the urine is important, since normal urine does not contain this material in quantities sufficient to be recognized by ordinary tests. Hence in disease its presence is an indication of pathological processes taking place either in the kidney or the urinary passages. The chief abnormal condition indicated by the presence of albumen in the urine is nephritis. Traces of albumen may occur in patients with fever or a heart weakness. Blood and pus in the urine likewise indicate albumen. When the nephritic condition is chronic, the kidneys themselves are diseased and the presence of albumen may be in traces only, while during the acute attack large quantities may be passed, but the urine will clear up after a time. ~Benedict's Qualitative Sugar Test.~--Boil 5 c.c. of Benedict's solution; add 8 drops of urine to be examined; hold the tube over the flame and allow to boil vigorously for 3 minutes and set aside to cool of itself. In the presence of sugar the entire solution will be filled with a precipitate which may be greenish, yellow, or red, according to the amount of sugar present. When the percentage of sugar is low (under 0.3%) the precipitate will form only upon the cooling of the solution. If there is no sugar present, the solution will either remain clear or show a slight turbidity, due to the precipitation of urates. The nurse must remember that to be useful the test must be made accurately. There must never be more than 10 drops of urine and 8 drops is the usual quantity. The boiling must be vigorous and the solution allowed to cool spontaneously. ~Fehling's Test for Sugar.~--Fehling's alkaline solution and Fehling's copper solution must be kept in separate bottles until ready for use. Then about 2 c.c. of Fehling's alkaline solution is poured into a test tube and 2 c.c. of Fehling's copper solution is added. This is diluted with hydrant water to 8 c.c. Half of this quantity is sufficient for the test. The upper half of the solution is boiled over flame (gently agitated while heating), and while still boiling a few drops of urine are added. If no change appears, it is boiled again and a few drops more of urine are added. If a reddish precipitate appears, sugar is present. The chemical reaction taking place is the reduction of copper sulphate to cuprous oxide. Sometimes a partial reduction occurs when urates are in excess, but once having seen the real reduction, a partial one cannot mislead the examiner. ~Haines's Test.~--Pour 1 teaspoonful of Haines's solution into a test tube and boil gently over a Bunsen burner; add 6 or 8 drops of urine and again heat to boiling. A yellow or red precipitate will indicate the presence of glucose. QUANTITATIVE TEST FOR SUGAR ~Benedict's Test.~[110]--The simple quantitative test for sugar is the one devised by Benedict. This is simpler than the polariscopic examination and better suited for ordinary use. Place 5 c.c. of Benedict's quantitative solution in a small dish, add a little less than one-fourth of a teaspoonful of sodium carbonate and one-eighth of a teaspoonful of talcum and add 10 c.c. of water. Dilute urine (1 part urine to 9 parts water) except where the qualitative test showed a low percentage of sugar, that is, when the precipitate turns green instead of yellow, in which case it will be unnecessary to dilute the urine. Place dish over burner and bring the contents to a boil. Pour the urine into a graduated pipette. Now add the urine drop by drop to the contents in the dish until the blue color entirely disappears. This test should be done over several times to assure an accurate calculation. The calculation is made as follows: 5 c.c. of Benedict's quantitative copper solution are reduced by 0.01 gram of glucose, consequently the quantity of undiluted urine required to reduce 5 c.c. Benedict's solution contains 0.01 gram of glucose. 0.01 ------ × 100 = per cent. _x_ = c.c. of undiluted urine. _x_ Example; 1500 c.c. urine in 24 hours. 5 c.c. used to reduce (decolorized) Benedict's solution. 0.01 ------ × 100 = 0.2 per cent. 5 1500 × 0.002 (0.2 per cent.) = 3 grams of sugar in 24 hours. Example: If the urine had been diluted with 9 parts water, in other words, 10 times, the calculation would be 5 c.c. diluted urine = 0.5 c.c. actual urine. 0.01 ------ × 100 = 2 per cent. 0.5 1500 × 0.02 (2 per cent.) = 30 grams of sugar in 24 hours. Hill and Eckman perform the Benedict's quantitative test as follows:[111] Measure with a pipette 25 c.c. Benedict's solution into a porcelain dish, add 5 or 10 grams approximately of solid sodic carbonate, heat to boiling, and while boiling, run in urine until a white precipitate forms, then add urine more slowly until the last trace of blue disappears. The urine should be diluted so that not less than 10 c.c. will be required to amount of sugar which 25 c.c. of reagent is capable of oxidizing. Calculation: 5 divided by number of cubic centimeters of urine run in equals per cent. of sugar. ~Fermentation Test for Quantity of Sugar in Urine.~--If the urine is 70° F. (room) temperature when the specific gravity is taken at both the beginning and end of the test, it will assure accuracy. To 100 c.c. of urine of known specific gravity, add one-fourth of fresh yeast cake thoroughly broken up. Mix thoroughly and set aside at a temperature between 85° and 95° F. for twenty-four hours, after which time test with Benedict's or Fehling's solutions. If reduction is obtained, it will be necessary to allow the fermentation to continue until it is complete. When no further reduction is obtained, the specific gravity is taken after the urine has reached a temperature of 76°. The difference in the specific gravity at the beginning and end of the test multiplied by 0.23 gives the percentage of sugar in the urine. The following formulas represent the various solutions used in the above test: BENEDICT'S QUALITATIVE SOLUTION _Gm. or c.c._ Copper sulphate (pure crystals) 17.3 Sodium or potassium citrate 173.0 Sodium carbonate (anhydrous) 100.0 Distilled water to make 1000.0 FEHLING'S SOLUTION (1) Copper Sulphate Solution: 34.65 grams copper sulphate dissolved in water and sufficient water added to make 500 c.c. (2) Alkaline Solution: 125 grams potassium hydroxide. 173 grams Rochelle salts dissolved in water q.s. to make 500 c.c. Keep solution in separate bottles and mix in equal quantities when ready to use. HAINES'S SOLUTION Copper sulphate (pure) 30 grams (dissolved in 1/2 oz. (15 c.c.) distilled water) Add 1/2 oz. pure glycerin, mix thoroughly, and add 5 oz. liquor potassæ. BENEDICT'S (QUANTITATIVE) SOLUTION Copper sulphate (pure crystals) 18 grams Sodium carbonate (crystallized) (or 100 grams of anhydrous salt) 200 grams Sodium or potassium citrate 200 grams Potassium sulphocyanide 125 grams 5% solution of potassium ferrocyanide 5 c.c. Distilled water to make total volume of 1000 c.c. Dissolve the carbonate, citrate, and sulphocyanide with the aid of heat and enough water to make 800 c.c. of mixture. (Filter, if necessary.) Weigh exactly the copper sulphate crystals and dissolve in 100 c.c. of water, now add it to the first solution; stirring constantly. Add the ferrocyanide solution; cool and dilute to exactly 1 liter. 50 mg. (0.050 gm.) of sugar will reduce 25 c.c. of the above solution. ~Gerhardt's Ferric Chloride Reaction for Diacetic Acid.~--To 10 c.c. of fresh urine, add carefully a few drops at a time of undiluted aqueous solution of ferric chloride U.S.P. A precipitate of ferric phosphates first forms, but upon the addition of a few more drops of the same solution it is dissolved. A Burgundy red (red wine) color is obtained in the presence of diacetic acid. The depth of this color is indicative of the quantity of acid present. Joslin[112] records the intensity of the reaction as follows, +, ++, +++, or ++++. According to Joslin, it must be remembered that similar reaction is obtained in the urine of individuals taking salicylates, antipyrin, cyanates, or acetates, but it is a simple process to differentiate between the color produced as a result of diacetic acid and that produced by the above-mentioned drugs. If the solution is boiled for two minutes, the color from diacetic acid will disappear, owing to the unstableness of that substance, while that from the drugs will remain unchanged. ~Test for Acetone.~--Pour 5 c.c. of urine to be tested into a test tube, add a crystal of sodium nitroprusside, acidify with glacial acetic acid, shake well, and then make alkaline with ammonium hydrate. The presence of acetone is indicated by a purple color. TESTS FOR ALBUMEN The heat test[113] is the simplest. This consists of first filtering the urine through filter paper, then pouring some of the clear urine into a test tube, holding the test tube in a flame so that only the upper layer boils, then adding a few drops of 2% solution of acetic acid and boiling again. If there is albumen present, a very faint, or a heavy cloudiness (precipitate of coagulated albumen) forms on boiling and persists or becomes heavier on the addition of a few drops of dilute acetic acid (2%) and boiling again. If a precipitate occurs at the first boiling, but clears up again entirely on adding acetic acid, it is not albumen but harmless phosphates or carbonates. HELLER'S TEST FOR ALBUMEN Into a test tube pour a few drops of nitric acid, filter the urine and allow a small quantity of it to trickle from a pipette down the side of a test tube until it comes in contact with the acid. If albumen is present a distinctly formed white ring is seen at the zone of contact. TEST FOR INDICAN This material is found in cases of obstinate constipation and in other intestinal disturbances where the passage of the food mass in the small intestines is delayed and the putrefactive bacteria exert their activities upon the unabsorbed protein. ~Test.~--Mix equal quantities of urine and fresh hydrochloric acid and add drop by drop fresh concentrated solution of chloride of lime (5 to 1,000). Indican is indicated by the appearance of a blue color. SUMMARY ~Urinalysis~ represents one of the most important means for determining the health of an individual, since it is the urine that shows those substances produced in the body as a result of the breaking down of the body tissues and protein foods. ~Composition of Normal Urine~ must be familiar to the nurse in order that she may recognize any change taking place in the urine of her patient which may indicate pathological conditions in the body. ~The Specific Gravity~ of urine is one of the points by means of which the presence of certain substances more or less abnormal in character is determined. ~Other Points~, such as color, odor, quantity, reaction, and chemical composition, likewise show any deviation from the normal in the individual. ~Urine Tests~ are necessary to determine the composition of the secretion. The character of these tests and the methods used in making them form an essential part in the training of the nurse. ~Tests~ for the presence of albumen, sugar, and possibly indican in the urine, should be made by the nurse. The latter substance represents the extent of putrefaction taking place in the body and for this reason should be included in the urine tests. ~Collecting the Urine~ for testing is important. The amount includes all that has been voided throughout the entire twenty-four hours beginning after the bladder has been emptied on the first morning and ending after the first specimen has been voided on the morning of the second day. ~Preserving the Urine~ for testing is usually necessary, especially during the warm weather. The specimens should be collected in a wide-mouthed sterile glass jar. This should be kept in a cold place. Some harmless preservative such as chloroform should be added to assure its keeping. PROBLEMS (a) Outline tests used in urinalysis; state when they are used. (b) List the equipment needed for making the simple tests. (c) Make tests in laboratory and list results in note-book. FOOTNOTES: [110] "Treatment of Diabetes Mellitus," pp. 182-183, by Joslin. [111] "Starvation (Allen) Treatment for Diabetes Mellitus," by Hill and Eckman. [112] "Treatment of Diabetes Mellitus," p. 186, by Joslin. [113] "Chemistry for Nurses," by Reuben Ottenburg. CHAPTER XVIII ACUTE AND CHRONIC NEPHRITIS Nephritis is a disease of the kidneys, in which changes occur in the tissues of the organs themselves; these changes may be caused by inflammation of the kidneys and renal passages brought on as results of the retention of certain poisonous substances in the blood, or from the action of specific bacteria. The disease may be acute or chronic in form and develop as a result of prolonged exposure to cold and wet, of tonsillitis, scarlet fever, typhoid fever, and to a less extent of malaria, syphilis, pregnancy, and tuberculosis, as well as from the effects of certain irritating drugs, such as cantharides and turpentine. ~Directing the Treatment.~--In any case the treatment must be directed toward the relief of the acute symptoms in the beginning and followed up by a general treatment which will tend to strengthen and relieve the overtaxed organs and to increase their power to functionate normally. ~Causes and Effects.~--In acute nephritis, the chief symptoms are uremia, and edema; the urine is materially diminished in quantity and at times suppressed; it is often found to be rich in albumen and containing hyaline and blood casts, red and white blood cells, and various pigments. In chronic nephritis, which may be the result of an acute attack, or as a sequel of other diseases already mentioned, there is seen to be a progressive loss of flesh and strength, marked anemia, gastro-intestinal disturbances, increased blood tension and edema, the latter especially in the face on arising in the morning. Uremia may develop at any time. ~Limiting the Work of the Kidneys.~--In both acute and chronic nephritis, great effort must be put forth to relieve the tax upon the kidneys and to stimulate their functioning power. In other diseases, in which definite organs are involved, the treatment consists chiefly of resting the affected parts (1) by starvation, (2) by deflecting the work to other organs when it is possible, chiefly by changing the diet until the disturbance is overcome. This is generally effectual in most cases, as has been specially demonstrated in the treatment of gastro-intestinal diseases. ~Problems to Be Considered.~--But in nephritis, there are other problems to consider, which make it impossible to institute such a treatment as will effect a perfect rest of the renal organs. The kidneys represent the chief source whereby the waste products of the body are eliminated. This waste consists not only of the end-products of the nitrogenous foods ingested, but also the end-products of tissue metabolism, which is the inevitable result of the wear and tear of life. Hence, when the functions of the kidneys are disturbed, these products, often toxic in character, are retained instead of excreted. Thus instead of forming normal constituents of the urine they find their way into the general circulation, exerting a damaging effect upon the tissues, especially of the kidneys with which they are brought into such direct contact. ~Substances Difficult of Excretion.~--It has been proved that the kidneys in nephritis find it difficult to excrete certain substances, namely, urea, water, salts, and the purin bodies. Many authorities claim that the uremia manifested in acute nephritis is the result of the retention of end-products of the protein metabolism already mentioned and that the edema is due to a like retention of water and salts. The greatly diminished quantity of urine voided during the acute attack would seem to prove this theory. Martin Fisher,[114] however, claims the condition to be due to an acidulation of the tissues with a consequent osmosis of water, and directs his treatment to overcome this condition, not by restricting the quantity of water and salt, as is generally practised, but by injecting a saline solution into the body in large quantities with the effect of increasing the flow of urine by concentrating the salt content of the blood and therefore its osmotic power. The fluids are withdrawn from the tissues, thus adding fluidity to the blood stream, which in turn flushes the kidneys, ridding them of the poisons which interfere with their normal functioning. ~Adjusting the Diet.~--The uremia and edema must be relieved. Since it is an undisputed fact, in the majority of cases, that good results from the regulating of the diet so as to minimize as far as possible the work of the kidneys, the various diet cures will be included here. ~Milk Cure.~--Milk, as a rule, forms a basis of most of the nephritic diets chiefly because of its low salt and protein content and on account of its non-toxic end-products. The percentage of water in milk is likewise known and for this reason the fluid content of a milk diet can be easily calculated. However, it is also true that the greatest drawback to a diet consisting solely of milk is the large amount of water therein compared with its nutrient value. ~Resting the Kidneys.~--During the acute stage of nephritis the kidneys are given as much rest as possible by eliminating all food and restricting the amount of water entering the body. The thirst is relieved by small sips of plain or carbonated water or by ice pellets held in the mouth, or, as is sometimes necessary, by injections of water into the rectum. ~Adjusting the Fluids.~--The amount of fluid, however, must be adjusted to meet the condition of the patient, taking into consideration the amount of urine voided and the uremic symptoms manifested. If the urine is not suppressed the amount of water taken may be slightly in excess of the urine voided, thus promoting diuresis. In many cases an excellent diuretic drink consisting of one pint of water and one teaspoonful of cream of tartar with a half a lemon and perhaps a little sugar, serves the purpose of relieving the thirst, which is at times acute during this period. The extent of the starvation treatment must depend upon the patient himself. As a rule, however, it is not carried out longer than two days, after which milk may be substituted, allowing from twenty to thirty ounces per day, which is as much fluid as an ordinary nephritic patient can handle. The regulation nephritic diet, which is bland in character, contains nothing that will tend to increase the irritation and inflammation of the kidneys, and furnishes a certain amount of nourishment when the symptoms of the disease warrant the giving of any food other than milk. The following diets used in cases of high urea or severe hypertension: LOW PROTEIN DIET[115] -------------------------------+---------+---------------+---------- |_Protein_|_Carbohydrates_| _Fats_ | _Grams_ | _Grams_ | _Grams_ -------------------------------+---------+---------------+---------- Breakfast: | 6.7 | 160 | 51 Cooked Farina (100 grams)| Total calories for day, 1192 Butter ( 20 grams)| | | Fruit (100 grams)| | | Lactose ( 30 grams)| | | | 200 grams of fruit juice | served between meals | | | Dinner: | | | Asparagus (100 grams)| | | Butter ( 20 grams)| | | Fruit (100 grams)| | | Lactose ( 30 grams)| | | | | | Supper: | | | Carrots (100 grams)| | | Fruit (100 grams)| | | Butter ( 20 grams)| | | Lactose ( 30 grams)| | | -------------------------------+---------+---------------+---------- PROTEIN FREE DIET -------------------------------+---------+---------------+---------- |_Protein_|_Carbohydrates_| _Fats_ | _Grams_ | _Grams_ | _Grams_ -------------------------------+---------+---------------+---------- Breakfast: | | | Protein-free cookies[116] (5)| | | Fruit juice (100 grams)| 0 | 166.5 | 39 Lactose ( 15 grams)| | | | | | | | | Dinner: | | | Protein-free cookies (5)| Total calories, 1045 Fruit juice (100 grams)| | | Lactose ( 15 grams)| | | | | | Supper: | Each cookie weighs 10 grams Protein-free cookies (5)| | | Fruit juice (100 grams)| | | Lactose ( 15 grams)| | | -------------------------------+---------+---------------+---------- Doctors Chase and Rose advise farina used more frequently than oatmeal, and the plain cream soup, rice or potato, more often than soups made of celery or asparagus (the latter used to break the monotony). They also advise the more frequent use of green string beans and asparagus in preference to other vegetables. ~Elimination of Salt.~--In many cases of nephritis, especially those belonging to the parenchymatous type, the kidneys manifest a difficulty in eliminating salt, and instead of excreting the normal quantity, find it impossible to eliminate more than two or three grams or less a day. The retained salts pass into the fluids of the tissues, giving rise to or increasing the already existing edema. Tests[117] have been devised to find the extent of the kidney function to excrete salt. The following diets are among those commonly used:[118] 3 liters of milk (this contains 5 gm. sodium chloride and 100 gm. protein) or Strauss Diet, consisting of 3/4 liter milk, 4 eggs, 150 gm. bread, and enough fruit and fruit juice, tea and sugar to make it palatable. (This diet contains about 3 gm. of salt.) If the kidneys are able to excrete the amount of salt contained in these diets, salt may be added in quantities of from 5 to 10 grams. ~Salt-poor Diets.~--When the kidneys are unable to eliminate the normal amount of salt, some of the salt-poor diets should be advised. Coleman claims,[119] however, that these diets have not fulfilled the promises held out by them. Coleman groups the salt-poor diets under three headings: (1) ~The strict salt-poor diet~, of which Widal's diet is an example. (2) ~The medium strict salt-poor diet~, allowing from 2.5 to 5 grams of salt a day. Under this heading the milk diet was placed, in which 2 to 3 grams of salt is served a day at table. (3) ~The moderate salt-poor diet~, in which from 5 to 10 grams of salt are allowed each day. In using this diet it is not necessary to prepare a special menu for the patient, but take precautions to leave the salt shaker off the tray and exclude bacon, ham, and other salty foods from the dietary. ~Limiting the Amount of Food.~--It must be kept in mind that the nephritic condition makes it imperative to fall below rather than exceed the food requirements of the individual. WIDAL'S DIET[120] Salt-free bread 200 gm. Meat (beef, chicken, or mutton) 200 gm. Vegetables (beans or rice), salt-free 250 gm. Butter, salt-free 50 gm. Sugar 40 gm. Contains 60 grams of protein, 1 to 2 grams of NaCl, and furnishes approximately 1500 calories. Strouse and Perry arranged a dietary from the above diet as follows: 8 A.M. Bread, 60 grams; lamb chop, 50 grams; butter, 10 grams; rice, 100 grams; sugar, 40 grams. 12 M. Bread, 60 grams; roast beef, 100 grams; butter, 20 grams; beans, 150 grams. 5 P.M. Bread, 80 grams; butter, 20 grams; chicken, 50 grams. HALPIN'S SALT-FREE NEPHRITIC DIET Milk, 1500 to 2000 c.c., white salt-free bread, 400 to 500 grams; salt-free butter, 40 grams; eggs, 4 to 6. This diet contains from 5 to 6 grams of salt. KARELL CURE Karell has devised the milk cure, which is used possibly more than any other diet. It not only furnishes a dietary régime, which is used in nephritis, but it is likewise advocated in organic diseases of the heart and blood vessels. ~Methods of Administering the Karell Cure.~--The cure is begun by giving from 3 to 6 ounces of milk three or four times a day. Karell makes a point of using small quantities to begin with and having the milk skimmed. The milk is given at regular intervals, is warmed in winter and given at room temperature in the summer. It may be given plain or diluted with limewater. After a week if the stools remain solid, the daily allowance of milk is increased to two quarts. Constipation is an indication of the agreement of this diet and the patient's utilization of the milk. If, however, he manifests gastro-intestinal disturbances, resulting in diarrhea, the amount must be temporarily reduced. Karell advocates boiling the milk and relieving the constipation with enemas or mild laxatives. The addition of small quantities of coffee to the morning portion of milk, or of stewed prunes or a baked apple to the afternoon feeding, also tends to overcome the condition. ~Thirst.~--The extreme thirst may be relieved by adding plain water, limewater, or seltzer to the feedings. If during the second or third week of the cure the hunger becomes too great for the patient to endure, a small piece of herring or stale bread may be given. Once a day a milk soup thickened with a cereal may be given. The above diet is carried out from five to six weeks, after which the patient is gradually returned to a normal diet. Milk, however, should still constitute an important part of the diet. The Karell cure is modified more or less to meet the condition of the patient, the amount of milk administered in some cases being more and in others considerably less than mentioned in the above régime. ~Limiting the Proteins.~--The extent of the damage caused by the end-products of protein metabolism cannot be easily estimated, but it is wise not to err on the side of an over-supply, since the retaining of these materials in the body gives rise to a certain type of intoxication (uremic poisoning). ~Relative Toxicity of the Animal Proteins.~--The difference between the various animal proteins as to their relative toxicity has been the subject of much discussion. As far as their nutrient value is concerned, they are practically the same, that is, the protein of beef and the protein of chicken show very similar analyses. The beef contains, however, more extractives, which we know are high in purins. These substances have proven detrimental to the welfare of a nephritic patient. ~Selection and Preparation of Foods.~--For this reason the so-called red meat is sometimes boiled instead of roasted, as the latter mode of preparation increases the formation of purins on the brown outer surfaces of the meat. Chicken and fish contain less purin bases and for this reason are often included in the diet when beefsteak and lamb chops are excluded. Meat soups and broths contain little nutrient value, consisting as they do chiefly of water, salt, and extractives, all of which are looked upon with disfavor, and classed with the offending articles of food in the nephritic diet. Cream soups, except bean or pea soup,[121] may be given in moderation. They are non-toxic in character and of high nutrient value, furnishing a valuable addition to the diet when the gastro-intestinal symptoms permit of such addition. CONVALESCENT NEPHRITIC DIET[122] ~Advisable Foods.~--The following foods are used in the formation of diet for an advanced convalescent nephritic patient when not otherwise contraindicated: Cereals, potatoes, rice, green vegetables and salads, fruits, fresh and stewed, ham, bacon, or beef once or twice a week, chicken, lamb, or mutton[123] several times a week, simple desserts, such as junket, prune or fig whip, orange, lemon, grape, pineapple or apricot gelatin, bread, rice or tapioca pudding, plain vanilla ice cream.[124] ~Foods to Be Avoided.~--The following foods are avoided except the meats, which must be given not more than once to three times a week, as directed by physician: Meat broths, especially those made from commercial meat extracts, bouillon cubes, etc. Strong tea or coffee. Alcoholic beverages, unless especially prescribed by the physician. Liver, kidney, sweetbreads.[125] Meat croquettes and other made dishes. Rich sauces or gravies. Condiments and spices of all sorts. Rich pastries. The salt must be limited and water and other fluids restricted. ~Sample Diet Sheets.~--The following menus[126] formulated from the above diet list are suggested: ~No. 1.~--8 A.M. Sliced oranges, cream of wheat with cream, buttered toast, cocoa. 10:30 A.M. 6 ounces of milk with crackers. 12:30 P.M. Cream of spinach soup, rice, string beans, orange gelatin, bread and butter. 3 P.M. 6 ounces of buttermilk with crackers. 6 P.M. Cereal and cream, baked potato, apple sauce, cocoa, bread and butter. ~No. 2.~--8 A.M. Stewed prunes, wheatena and cream, milk or dry toast with butter, cocoa. 10:30 A.M. 6 ounces of malted milk with crackers or 1 slice of zwieback. 12:30 P.M. Cream of corn soup, mashed potatoes, beet tops or mustard greens, lettuce salad, dressing made with lemon juice and olive oil, rice pudding. 3 P.M. 6 ounces of orange or grape juice with crackers. 6 P.M. Cream toast, sliced peaches, cocoa. ~No. 3.~--8 A.M. Half a grapefruit, farina and cream, toast and butter, cocoa. 10:30 A.M. 6 ounces of buttermilk with crackers. 12:30 P.M. Cream of tomato soup, creamed potatoes, buttered beets, celery salad, apple tapioca pudding, bread and butter. 3 P.M. 6 ounces of milk with crackers. 6 P.M. Ralston's Health Food with cream, baked potato, tomato salad, toast and butter, cocoa. ~No. 4.~--8 A.M. Stewed prunes, grits and cream, toast and butter, cocoa. 10:30 A.M. 6 ounces of malted milk with crackers. 12:30 P.M. Cream of asparagus soup, creamed cauliflower, boiled rice, lettuce salad, bread and butter, pineapple gelatin. 3 P.M. 6 ounces of orange juice with crackers or zwieback. 6 P.M. Creamed toast, escalloped potatoes, fruit salad, toast, cocoa, and cocoa junket. CHRONIC NEPHRITIS (BRIGHT'S DISEASE) Chronic nephritis may develop as a sequel to an acute attack, and an individual suffering from chronic nephritis may at any time develop acute symptoms. In any case the dietetic treatment would necessarily have to be made to cover the existing symptoms. ~Dietetic Treatment.~--In cases where the patient has entirely recovered from uremia but still manifests symptoms of water and salt retention, the diet would be naturally directed to cover the latter, at the same time taking care not to strain the weakened functions by giving more food than could be readily handled. The water and salts still have to be restricted, but a certain amount of fat and carbohydrate with small additions of nitrogenous food materials may be added from time to time as the kidneys show improvement. It must be borne in mind, however, that at this time it is very easy to overtax the renal organs and it is safer to err on the side of under rather than over feeding. The logical treatment, therefore, consists of utilizing the improved functions while those still failing to react are getting further rest. ~Adjusting the Proteins in Diet.~--If the individual shows a definite anemia, as is often the case after acute attacks, either as a result of the disease itself or the necessarily low diet, which the acute symptoms of uremia and edema made necessary, other measures are necessary to bring the body back to a normal condition. It has been found that in these cases where there has been no permanent damage to the renal organs, but merely a temporary impairment of the functioning power, the treatment must be, first, a rest to the affected parts; second, the temporary restriction of all articles of food which impose a tax on the kidneys to eliminate; the third, the gradual return to normal diet as the acute symptoms decrease and the function of the kidneys no longer shows impairment. Such a case is cited by Strouse and Perry[127] as occurring in the Michael Reese Hospital. Mr. X. recovered from the acute stage of nephritis and all signs of edema and uremia disappeared; the man was kept on a low salt and low protein diet for a long time. His urine was clearing up, but he did not feel up to standard and remained anemic. Thinking in all probability that his symptoms were due to a low protein diet, meat was slowly added to his dietary until he was receiving 60 grams of protein a day. There was an immediate general improvement in his condition with no increased renal disturbance. It is an obvious fact that chronic nephritis, like any other chronic condition, requires a different method of treatment from that practised to relieve the acute stage. The very fact that it is chronic proves that the strenuous methods are neither necessary nor wise. ~Testing the Kidney Functions.~--The authorities of to-day endeavor to ascertain the extent of the damage to the renal organ by testing its functioning power. These renal function tests have been the subject of much interest and investigation. Probably the ones most commonly employed are those devised by Hedinger and Schlayer[128] and adapted for use in the Johns Hopkins Hospital by Mosenthal. ~Diets Used in Tests.~--The diet employed in making these tests consists of different amounts of certain substances known to be diuretic in character. This diet is rigidly adhered to and a careful analysis of the urine passed, the total quantity and specific gravity of each specimen made and in this way the various functions of the kidneys and the impairment thereof are tested. Thus an intelligent adjustment of the diet may be made. ~Renal Functional Tests.~--The following schedule is used by Mosenthal, of the Johns Hopkins Hospital, in making what is known as the "Two-Hour Test for Renal Function": HEDINGER-SCHLAYER-MOSENTHAL DIET[129] For _________________ Date _________________ All foods to be salt-free from the diet kitchen, salt for each meal will be furnished in weighed amounts.[130] All foods or fluids not taken must be weighed or measured after each meal and charted in spaces below. Allow no food or fluid at any time except at meal times. Note any mishaps or irregularities that occur in giving the diet or collecting the specimens. Breakfast 8 A.M. Boiled oatmeal 100 grams Sugar 1 to 2 teaspoonfuls Milk 30 c.c. 2 slices of bread 30 grams each Butter 20 grams Coffee 160 c.c. } Sugar 1 teaspoonful } 200 c.c. Milk 40 c.c. } Dinner--Noon Meat soup 180 c.c. Beefsteak 100 grams Potatoes, boiled, mashed or baked 130 grams Green vegetables as desired 2 slices bread--each 30 grams Butter 20 grams Tea, 180 c.c. } Sugar, 1 tsp. } 200 c.c. Milk, 20 c.c. } Water 250 c.c. Pudding, tapioca or rice 110 grams Supper 5 P.M. 2 eggs cooked any style 2 slices of toast 30 grams each Butter 20 grams Tea, 180 c.c. } Sugar, 1 tsp. } 200 c.c. Milk, 20 c.c. } Fruit, stewed or fresh 1 portion Water 300 c.c. 8 A.M. No food or fluid is to be given during the night or until 8 o'clock next morning (after voiding) when the regular diet is resumed. Patient is to empty bladder at 8 A.M. and at the end of each period as indicated below. The specimens are to be collected for the following periods in properly labeled bottles: 8 A.M. to 10 A.M.; 10 A.M. to 12 Noon; 12 Noon to 2 P.M.; 2 P.M. to 4 P.M.; 4 P.M. to 6 P.M.; 6 P.M. to 8 P.M.; 8 P.M. to 8 A.M. ~Chart Used in Johns Hopkins Hospital.~--The following chart is inserted here to show the method used in the Johns Hopkins Hospital for carrying out the Two-hour Renal Test: ===============+==================+==================+================== | _Urine_ | _NaCl_ | _Nitrogen_ _Time of Day_ +-------+----------+----------+-------+----------+------- | |_Specific_| | | | |_C.C._ |_Gravity_ |_Per cent_|_Grams_|_Per cent_|_Grams_ ---------------+-------+----------+----------+-------+----------+------- | | | | | | 8 A.M.-10 A.M.| | | | | | 10 A.M.-12 Noon| | | | | | 12 Noon-2 P.M. | | | | | | 2 P.M.-4 P.M. | | | | | | 4 P.M.-6 P.M. | | | | | | 6 P.M.-8 P.M. | | | | | | 8 P.M.-8 A.M. | | | | | | Total day | | | | | | Night, 8 P.M. | | | | | | to 8 A.M. | | | | | | Total 24 hours | | | | | | Intake of fluid| | | | | | NaCl | | | | | | ===============+=======+==========+==========+=======+==========+====== Urine to be collected punctually every two hours and kept in the ice-box, every specimen having twenty drops of tutuol added to insure preservation. Another ~modification of the Hedinger-Schlayer diet~ is used in the ~Peter Bent Brigham Hospital~,[131] Boston, Massachusetts, as follows: 7 A.M. Coffee, milk, sugar, toast, and butter. 10 A.M. Milk, toast, and butter. 12:30 P.M. Bouillon, broiled steak, butter, mashed potatoes, toast, coffee, milk, sugar. 4 P.M. Tea, milk, sugar, crackers. 7 P.M. Soft egg, blanc-mange (1 egg, sugar, cornstarch, and milk) and cream. Amounts sufficient to give 2500 calories, 1500 c.c. fluid, 76 grams of protein, 127 grams of fat, 245 grams of carbohydrate, and from 5 to 8 grams of sodium chloride. On two days previous to the test the patient usually had a diet containing 2000 calories, 75 grams of protein, 4 grams of sodium chloride. The test diet is a mixed diet containing known amounts of water, nitrogen, and chloride, together with the food diuretics (purins, salt, and water), as can be seen. The diet is divided into unequal portions containing known but varying amounts of fluid, nitrogen, and salt. Two-hour specimens are collected from 7 A.M. to 9 P.M., and one night specimen is obtained containing all the urine passed between 9 P.M. and 7 A.M. Each specimen is analyzed for volume, specific gravity, total nitrogen, nitrogen concentration, total chloride, and chloride concentration. ~Purpose of Tests.~--The purpose of the test is to find out to what extent and in what manner the diseased kidney under stimulation by the various diuretics taken in the food reacts in putting out the varying amounts of salt. Dr. O'Hara likewise describes another test known as ~The Added Urea and Salt Test~, which was first described by von Monakow and also carried out in the Peter Bent Brigham Hospital. The method used was as follows: ADDED UREA AND SALT TEST Patient is given 75 grams of protein, 4 grams of sodium chloride, and 1500 c.c. of water, with a caloric value of from 2000 to 2200 calories. After the output of fluid, salt and nitrogen reaches an equilibrium on this diet on one day 10 grams of additional salt is given and several days later the patient receives 20 grams of urea. This order may be reversed. The daily output of urine, salt, and nitrogen is determined and charted. After the salt and nitrogen is added to the diet in normal individuals, their excretion after forty-eight hours returns to its previous level. In diseased kidneys this may not be the case. ~Value of Tests.~--Thus it is seen that in these tests for kidney functions, an effort is made to determine the extent of damage wrought by the disease upon the renal organs and the manner in which they react under definite circumstances. However, it is not so simple as it would seem to formulate a dietary based on the findings resulting from the renal tests. Notwithstanding this, these tests are coming more and more into use, both in hospitals and private practice, and a nurse must understand just how they are carried out, and must realize that unless her part is performed with absolute accuracy the entire value of the test will be obliterated. Too much stress cannot be laid upon this phase of the test, if it is to be of any value whatsoever in determining the condition of a diseased kidney. CHRONIC INTERSTITIAL NEPHRITIS This form of nephritis is more insidious in character, developing more slowly and manifesting different characteristics, than those seen in some of the other types already mentioned. The condition is, as a rule, associated with heart symptoms and high blood pressure. The blood shows an increase in urea and other end-products of protein metabolism, whereas there is no manifest change in the metabolism of salt or water. The great increase in volume of urine voided would show an inability on the part of the kidneys to eliminate a highly concentrated urine. This hypothesis is further demonstrated in the urine tests. ~Urinalysis.~--Upon analysis the urine in these cases shows less albumen and fewer casts than found in other types of nephritis. The disease is manifested by slight headache, gastric disturbances, and a frequent desire to urinate. ~Dietetic Treatment.~--The treatment here depends upon the extent of the impairment of the functions of the kidney. If the damage is not extensive and the diagnosis has been sufficiently early to insure prompt improvement upon treatment, the diet is so directed as to prevent the occurrence of any of the acute symptoms. The patient is warned against overeating and drinking, over-exercise and nervous excitement. When it is possible, a change to a warm, dry climate is advisable with more rest and sleep and less work and worry. He is advised to eat less at meals and if hungry to eat a light lunch of milk or buttermilk with crackers in the mid-morning. The same dietary precautions must be taken in these disturbances as in other nephritic conditions, keeping always in mind the fact that the kidneys are the chief organs of excretion in the body, and through them must pass the majority of all end-products of nitrogen metabolism. ~Limiting the Nitrogen.~--The nitrogenous foods cannot be eliminated entirely, especially if, as is often the case, the individual suffers from chronic nephritis and is up and about attending to business; but they can be judiciously regulated in the diet. All such foods as fried foods, rich pastries, rich sauces and gravy, spices of all kinds, tea and coffee, celery and asparagus, must be avoided. ~Limiting the Fluids.~--von Noorden limits the amount of fluid to 1-1/4 liters per day. This does not include the water content of the various foodstuffs. He advises a period of observation to determine the amount best suited to the condition of the patient and reducing this amount from 250 to 150 c.c. a day until the desired quantity is reached. He advises a drinking day once a week, allowing the patient to drink as much water as he likes. ~Development of Uremia.~--Whenever evidences of uremia appear the treatment must be changed to meet the condition. It is necessarily more strenuous than that used ordinarily in the chronic nephritis. If the uremia becomes positive, then the treatment laid down for acute nephritis already described must be at once instituted. The patient must be put to bed at once and every effort made to assist the body in getting rid of the causes. In certain cases of nephritis, in which uremic poisoning is due to the retention of the end-products of nitrogen metabolism, or to the toxins formed as a result of the tissue changes due to the disease, the water then instead of being restricted in the dietary is greatly increased to encourage a free diuresis with a consequent washing out of the accumulated poison. Certain authorities recommend a strict milk and water diet, as has already been described in the beginning of the chapter. A light or soft diet is advised until the condition improves, resting the renal organs as far as possible. This diet may consist of fruit juices, strained cereals with cream, cocoa, milk, buttermilk, toast, butter, strained apple sauce, cream soups, except those made with beans or peas. The above diet is gradually increased by adding a mashed or baked potato, well-cooked green vegetables, stewed or raw fruit, rice and tapioca pudding, and chocolate blanc-mange. ~Selection and Preparation of Food.~--The preparation of foods for the nephritic differs in certain particulars from that used in other pathological conditions, namely, the restriction of certain food constituents; dishes made with meat and eggs are cut out of the diet, and salt is used as sparingly as possible, when it is used at all. The nurse must weigh or measure out the maximum quantity allowed and divide this in portions for each feeding, measuring carefully any that is not used and charting it. In this way it is possible to increase or decrease the amount according to the symptoms of the individual. The water content of the various foods comprising the diet is, as a rule, not considered, but it is necessary to adhere strictly to the orders of the physician and to curtail the beverages, water, tea, coffee, etc., until the amount conforms to that laid down in the dietary. The nitrogenous foods, with the exception of milk, are as a rule eliminated from the nephritic diet. The nurse must study the tables and learn which food materials come under this head. It may seem difficult to prepare diet for the sick without eggs, but it is possible and at times obligatory. ~Combating Anemia.~--In chronic (ambulatory) nephritis the anemia must be reckoned with. It is not safe to upset the nitrogen equilibrium of the body, but it has been proved that this may be maintained on as little as 30 or 40 grams of protein a day. This will be seen not to be difficult to obtain when milk forms an important part of the diet. The wheat and oat cereals, as well as the bread, contain protein, and a judicious use of these foods will enable the nurse to give her patient the necessary quantity to offset, in a measure, the anemia which is at times most troublesome. ~Advice to Patient.~--One important point must be observed by the nurse and impressed upon the patient when he leaves her care. This is moderation in the amount of food eaten. The kidneys must never be overtaxed, even with foods which in themselves seem harmless. As danger lies in overindulgence, this point cannot be too strongly emphasized. ~Advice to the Nurse.~--The use of the formulas included in this text is left to the discretion of the nurse. In those calling for seasoning, such as pepper, mustard, etc., the condiments must be omitted. A small amount of celery salt may be substituted in certain instances if the dish is unpalatable without something of the kind. In cases where the salt is restricted the dishes are prepared as directed, with the exception of the salt. The recipes calling for eggs and meat are not to be used unless directed by the physician. Cornstarch, sago, and tapioca may be used instead of gelatin. The following menus may be used as guides in selecting foods to prepare for the nephritic patient after the rigid régime is to a certain extent relaxed: FULL NEPHRITIC DIET (NITROGENOUS FOODS RESTRICTED) BREAKFAST Grapefruit, orange, prunes, pears, peaches, or strawberries. Cereals: cream of wheat, farina, Pettijohn's, Ralston's, hominy, grits, and oatmeal with cream. Toast, buttered or creamed. Cocoa, tea, or coffee, as directed by the physician. DINNER Milk or cream soup, well-cooked green vegetables with butter or cream sauce. Potatoes, white or sweet, baked, mashed, or boiled, with butter, bread or rolls. Stewed tomatoes, rice. Salads: lettuce, tomato, romaine, chicory, or fruit salad, with a dressing of oil and lemon, or cream and lemon. Simple desserts: junkets, cornstarch, sago or tapioca pudding, baked bananas, rice pudding, apple tapioca, orange tapioca, and ice cream. Beverages: cocoa or tea, as directed by the physician. SUPPER Cereals and cream. Baked or escalloped potatoes. Baked or stewed apples. Salads, excepting those made with meat or eggs. Junket, raw or stewed fruit. Toast or rolls with butter. Cocoa. Meat, fish or poultry once a day.[132] BREAKFAST Stewed or fresh fruit. Cereals with cream. Toast with butter. Cocoa, milk, or tea. DINNER Cream soups. Boiled chicken or fish. Potatoes, white or sweet. Green vegetables. Salads, except with meat or eggs. Simple desserts. Rolls or bread and butter. Milk or buttermilk. SUPPER Cereals or rice with cream or butter. Baked or escalloped potatoes. Stewed or escalloped carrots. Salads, except those made with meat or eggs. Fresh or canned pears, cherries, or pineapple. Bread pudding, junkets, or cornstarch blanc-mange. Bread, rolls, or toast, with butter. Cocoa, milk, tea, or buttermilk. TABLE SALT CONTENT OF FOOD[133] According to Leva Analysis marked thus: * from Atwater & Bryant. ==================================================== _Per Cent. of Sodium_ _Chloride in_ _Raw Material_ _Meats_ Mutton 0.17 Veal 0.13 Calf's brains 0.20 Calf's kidney 0.32 Calf's liver 0.14 Beef (lean) 0.11 Pork (lean) 0.10 _Fish_ Trout 0.12 Halibut 0.30 Herring 0.27 Cod 0.16 Carp 0.086 Salmon 0.061 Mackerel 0.28 Haddock 0.39 _Poultry_ Duck 0.14 Goose 0.20 Chicken 0.14 Pigeon 0.15 Turkey 0.17 Venison 0.11 Oysters (washed) 0.52 Oysters (with sea water) 1.14 _Prepared Foods_ Plasmon 0.21 Roborat 0.0051 Sanatogen 0.42 Somatose 0.66 Bovril's preparations 0.26-14.1 Valentine's meat juice 0.08-1.20 Egg (white and yolk) 0.21 Egg (white alone) 0.21 Egg (yolk alone) 0.039 Caviar 3.00 Milk (whole) 0.16 Cream 0.13 Buttermilk 0.16 Whey 0.11-0.15 Condensed milk 0.40 Butter (unsalted) 0.02-0.21 Butter (salted) 1.00-3.00 Peanut butter 4.10 Oleomargarine 2.15 Palmin 0.0016 Fructin 0.10 _Smoked and Salted Foods_ Ham (raw) 4.15-5.86 Ham (boiled) 1.85-5.35 Salmon (smoked) 7.50 Bacon (smoked) (German) 1.01 Bacon (smoked) (American) 11.61 Corned beef (German) 2.04 Corned beef (American) 11.52 Cod (salt)* 23.50 Cod (salt, boneless)* 10.00 Herring (smoked) 11.70 Mackerel (salt dressed) 10.40 Salmon (salted, smoked) 10.37 Sardines (French in oil) 1.34 Cod liver oil 0.17 Gelatine (dry) 0.75 Beef marrow 0.11 Sausages (Frankfurters) 2.20 Sausages (various kinds) 2.90-8.10 Anchovy paste (Cross & Blackwell's) 40.10 _Meat Extracts_ Liebig's 2.60 Kemmerich's 1.40 Various bouillon capsules, extracts, etc. 9.40-22.0 _Foods Prepared for Table_ Bouillon 0.5-1.0 Thick soups 0.54 Roast beef 0.98 Roast pork 1.54 Chops 0.97 Roast chicken 0.39 Sauces 0.7-1.5 Spinach 0.91 Cauliflower 0.49 Stewed pears 0.019 Macaroni (à la Napolitaine) 1.04 Scrambled eggs (salted) 1.10 Carrots 0.46 Apple sauce 0.41 Tapioca pudding (unsalted) 0.026 Rice, with apples 0.18 _Vegetables_ Potatoes 0.016-0.078 Beets 0.053 Beans 0.09 Peas 0.058 Lentils 0.13-0.19 Lentils (dried) 0.155 Artichokes 0.036 Cauliflower 0.05-0.15 Cucumber (fresh) 0.06-0.08 Horseradish 0.02-0.06 Radish 0.075 Celery, stalks 0.25-0.49 Celery, roots 0.089 Asparagus 0.04-0.06 Spinach 0.084-0.21 Tomatoes 0.094 Cabbage 0.11-0.44 Onions 0.016-0.09 _Canned Vegetables_ Green corn* 0.40 Green peas* 0.70 Tomatoes 0.10 Mushrooms 0.04-0.06 _Cheese_ Parmesan 1.93 Swiss 2.00 American (pale) 0.82 Pineapple cheese 2.13 Edam 3.30 English cream cheese 0.70-1.15 _Infant Foods_ Nestlé's Food 0.29 Rademan's 0.03 Robinson's patent groats Trace _Bread, etc._ Graham bread 0.61 Pumpernickel 0.46 White bread 0.18-0.20 Zwieback 0.38 Macaroni 0.067 _Cereals, etc._ Barley 0.037 Oats 0.046 Rye 0.014 Wheat 0.013 Rice 0.039 Corn (maize) 0.019 Wheat flour 0.002-0.008 Oatmeal (American) 0.29 Oatmeal (German) 0.28 Quaker oats 0.082 Sago 0.19 _Fruits_ Pineapple 0.071 Orange 0.057-0.055 Apricot 0.0047 Lemon 0.0045 Strawberry 0.010-0.020 Chestnuts 0.045-0.010 Cherry 0.013 Cocoanut juice 0.035 Olives 0.008-0.210 Plums 0.0046 Gooseberry 0.021 Watermelon juice 0.011 Grape 0.024 Almonds, dry 0.010 Walnuts, dry 0.019 Cane sugar 0.110 Lump sugar 0.049 Chocolate (Lindt) 0.073 _Spices_ Capers (preserved in salt) 2.10 Capers (preserved in vinegar) 0.20 Pepper, black 0.51 Pepper, white 0.019 Mustard 2.66 Vanilla 0.055 Cinnamon 0.061 Cocoa beans 0.05-0.095 Coffee, roasted 0.045 Tea 0.15 _Drinks_ Ground water 0.0012-0.0060 Spring water 0.00055-0.0046 Ale 0.0017 Beer, German 0.016 Beer, English 0.10 Champagne (Moet & Chandon) 0.0045 Apollinaris 0.043 Fachinger 0.039 Giesshuble (Mattoni) 0.0021 Vichy 0.053 =============================================== SUMMARY ~The kidneys~ find difficulty in eliminating certain substances, namely, the end-products of protein metabolism--urea, water, salts, and purin bodies. ~The Urine~ constitutes the chief point of investigation. Analysis shows the presence of albumen, casts, blood cells, and pigments, with a corresponding deficiency in the normal constituents, water, urea, and salts. ~Volume of Urine.~--The volume of urine is reduced, and at times suppressed, owing to the difficulty with which the kidneys eliminate water in nephritic conditions. ~The Blood~ shows the presence of the toxic substances on account of the inability of the kidneys to eliminate them properly. ~Edema~ is a common symptom and is probably due to the retention of salts and water by the tissues of the body. It is treated and at times relieved by limiting the intake of fluids and reducing the amount of sodium chloride in the diet. ~Uremia~ is the most dreaded symptom and develops as a result of the retained toxins in the blood. Its development is prevented, if possible, by reducing the amount of fluid and food, even of milk, in the diet. ~Uremic Poisoning~ is an acute intoxication due to the abnormal retention of these poisons and the inability of the kidneys to eliminate them. It is combated by instituting a starvation treatment which is followed by the above-mentioned restricted diet. ~Gastro-intestinal Disturbances~, especially diarrhea, are apt to develop in chronic nephritis. Care must be taken to keep the meals small in size, simple in proportion, and constituted only from the allowed foods. ~Anemia~ follows the acute attack and is especially noticeable in those cases in which a rigid starvation régime has been found necessary. It may likewise be the result of a long-continued diet in which the proteins have been reduced to the lowest possible amount. The simple proteins in the diet must, at times, be increased and the patient advised to take plenty of fresh air and sunshine, in order to overcome this progressive anemia. ~Restrictions~ in the diet are essential. These consist of limiting the amount of food and fluids as well as the type of food ingested. ~Restricting the Proteins.~--Proteins are restricted on account of the difficulty with which the end-products are eliminated by the kidneys, also on account of the toxic character of these substances. ~Restricting the Fluids.~--It is necessary, on account of their difficulty of elimination and because they impose an excessive tax upon the circulatory organs. ~Treatment~ is largely dietetic in character by reason of the advantages just mentioned. ~Starvation Treatment~ is instituted in order that the work of the kidneys may be lessened. This treatment consists of abstinence from food with a definite reduction in the fluid intake. It is found to be necessary during the acute stage of the disease. ~Extreme Thirst~, which is apt to be an annoying symptom at this time, is relieved, as far as possible, with small sips of water or ice pellets held in the mouth. ~Nephritic Cures~ are devised, as far as possible, to relieve the acute symptoms and to prevent the disease from developing into a chronic condition. Milk is the basis of most of these cures. It is given in definite amounts at stated intervals; the quantity and frequency with which it is given being adjusted to the state of the disease and the condition of the patient. ~The Karell Cure~ is one of the best known diet cures used in the relief of acute nephritis. It consists of the giving of skimmed milk three or four times a day in doses ranging from three to six ounces for one week, at the end of which time, provided the stools remain solid, an increase to two quarts a day is made. ~Constipation~ under the circumstances is a favorable symptom, indicating as it does the agreement of the milk. ~Diarrhea~ as a result of gastro-intestinal disturbances has directly the opposite indication. In these cases the milk must be reduced. Karell advises the boiling of milk and relieving the constipation by means of mild laxatives or enemas. ~Duration of the Karell Cure~ is from four to six weeks, after which a gradual return to a normal diet is made. ~Hunger~ is apt to be prominent at this stage of the treatment and is relieved during the second or third week by giving a small piece of dry bread and milk, soup thickened with a cereal, once a day. ~Functional Kidney Tests~ are made to determine the character and extent of the impairment of the functions of the kidneys. The diets used in these tests contain definite amounts of certain diuretic substances, and the analysis of the urine voided during the twenty-four-hour period required by the test shows the nature of the impairment and furnishes, in a measure, a means of determining the amount of food and fluid which is safe for the patient to take. It likewise shows the extent to which the restrictions in the salt and proteins are necessary. ~Salt-free, or Salt-poor Diets~ are necessary in some cases. While restriction in the amount of salt used in the preparation of food for the nephritic patient is always advisable, if there is a tendency to edema, the salt shaker should be left off the tray, and when there is a definite amount of salt prescribed, it should be weighed or measured for the day rather than for the meal, and the amount consumed recorded after each feeding. ~Special Points~ for the nurse to remember are the necessity for an early recognition of unfavorable symptoms--of instructing the patient upon leaving her care in the need for keeping the size of the meals small;--of the danger of indulging in alcoholic or other stimulating beverages;--of eating highly spiced foods, or of eating anything which may cause gastro-intestinal disorders. She should emphasize the need for regular examination of the urine and the value of rest and freedom from nervous excitement, and the need of living in the sunshine as much as possible. The nurse should study the diet list and become familiar with the foods allowed and those to be avoided. The tables show the foods which are rich in salts and proteins. She should likewise understand and be able to make the simple test for albumen in the urine and the method of collecting the urine for the test made in the laboratory. PROBLEMS (a) Outline a salt-poor diet for patient in which the fluids are limited to 1500 c.c. per day. (b) Formulate a diet for child of ten years with nephritis following scarlet fever. (c) Write a diet order, using a salt-free diet. FOOTNOTES: [114] Fisher's Solution. Sodium carbonate (pure crystals) 14 Sodium chloride 10 Water 1000 [115] The above diets used in the Olmstead Hospital, Rochester, Minn. Courtesy of M. Foley and D. Ellithorpe, Mayo Clinic. [116] See Section of Recipes, p. 145. [117] For more extensive lists see Table of "Ash Constituents of Common Food," pp. 472 to 477. [118] "Journal of Internal Medicine," Vol. XIV, 1914. [119] _Ibid._ [120] "Food for the Sick," p. 108, by Strouse and Perry. [121] Beans and peas belong to the class of foods known as legumes, which are high in protein and must be treated as any other protein food. [122] Author's list and diet sheets. [123] Meats of all sorts should be boiled, or only the inside portions allowed. [124] Some physicians exclude ice cream from the diet, while others permit a small portion, provided it is not so rich as to cause digestional disturbances. [125] Boiled sweetbreads are sometimes allowed, but should never be given without the advice of a physician. [126] The preparation of the menus requires care and attention; meal must be small and all fried foods avoided. [127] "Food for the Sick," p. 112, by Strouse and Perry. [128] "Medical Clinics of Chicago," Vol. II, No. 5, 1917. [129] Copied from "Medical Clinic of Chicago," Vol. II, No. 5, 1917. [130] NaCl, 2 to 3 grams in a capsule accompanying each meal. Any salt unused is returned to the diet kitchen, where it is weighed and the amount used is indicated on the chart. [131] Carried out by Dr. Henry Christian and described by James O'Hara in the "Archives of Internal Medicine," Vol. XVII. [132] The outside parts of roast meat must be avoided, even when meat is allowed once a day. Meat is only added after the condition materially improves. [133] Coleman, in Forchheimer's "Therapeusis of Internal Diseases," Vol. I, p. 642. CHAPTER XIX DISEASES OF THE HEART The dietetic treatment in diseases of the heart has been the subject of much study, especially during the past few years. ~The Diet.~--In this pathological condition, as in many other diseases in which one or more of the functions of the body have become impaired, there can be no hard and fast rule covering the treatment or diet for all cases, but, as in nephritis, the condition of the individual, his symptoms, and the progress and extent of the disease must be taken into consideration in order to formulate a diet calculated to adequately nourish the body, while at the same time imposing the smallest amount of work with the least expenditure of labor upon the part of the diseased organ. ~Division of Treatment.~--The treatment of the disease then may be said to be divided into three stages: first, the stage of compensation; second, that of moderate compensation; third, that of decompensation. The diet is directed, first, toward relieving as far as possible the strain which is imposed more or less by all the food eaten; and second, keeping up the general nutrition of the body. ~Dietetic Treatment.~--No matter what has caused the impairment of the heart functions, the treatment must necessarily remain the same as far as diet is concerned. The patient is no longer able to handle a full and unrestricted diet. As long as compensation is good, the restrictions are scarcely noticeable; alcoholic beverages and possibly tobacco may have to be, to a certain extent, curtailed, and in some cases avoided altogether. However, if the individual desires to live and be comfortable while so doing, he must lead a wholesome, simple life, since he cannot with safety indulge in any excesses, either in diet or in any other particular. ~Diet in Second Stage.~--When the second stage sets in, that is, when the heart muscle is unable to perform its normal function, attention must be directed toward two main points; first, the work of the heart; second, the pressure upon that organ from other sources, namely, the stomach and intestines. As long as the food does not disagree, that is, so long as there is no fermentation or putrefaction of the food material in the stomach and intestines the flatulence arising from the evolution of gas in those organs is slight and the pressure upward upon the heart inconsiderable. ~Restricting the Fluids.~--The heart must be spared all unnecessary work. This can only be accomplished by limiting the amount of food and fluids ingested. The latter imposes an extra burden upon the impaired organ to eliminate. Consequently, the amount of fluid should be limited to 1500 c.c. a day at most, and in many cases considerably less than that quantity. ~Regulating the Meals.~--The meals should be small and the intervals of feeding regular. It has been found best to give the fluids between meals rather than with the food. In many cases of heart disease, as in certain nephritic conditions, edema is a prominent symptom, so that it is necessary to direct our efforts toward overcoming that particular condition. The Karell Cure[134] and the salt-poor diet are used with excellent results. The latter is not so low as the former, and in many cases will accomplish all that is required. A modified Karell diet is used in the Michael Reese Hospital[135] in Chicago as follows: "MODIFIED KARELL TREATMENT (Salt-free) "Milk 200 c.c. at 8 A.M., 12 M., 4 P.M., and 8 P.M., for five to seven days. Eighth day--Milk same as above. 10 A.M. one soft egg; 6 P.M. 2 slices of dry toast. Ninth day--Milk as above. 10 A.M. one soft egg and 2 slices of toast. Tenth to twelfth day--Milk as above. 12 M. chopped meat, rice boiled in milk, easily digested vegetables. 6 P.M. one soft-boiled egg. The diet is gradually increased until a full tray is reached. All meats and vegetables should be chopped or scraped at first, and the heavier foods should be given only when the heart is practically compensated." ~Rules and Regulations.~--There are a few general rules which it has been found advisable to impress upon individuals suffering from a disease in which the muscles of the heart have become weakened. The compensation of the organ may improve, but there is still a danger of a reoccurrence or a further development more or less serious, and at times fatal. So for this reason, certain rules must be observed throughout life: First: the necessity for keeping the meals small, simple, and digestible. Death at times occurs with symptoms of gastric disturbance, which is, after all, due to the heart. Consequently it is not wise to invite such disaster by overeating, or by the partaking of any food which is liable to bring about indigestion, either in the stomach or in the intestines. Most authorities advise four or five meals a day rather than the regulation three, and limit the fluids at meal time to a few ounces only, when any are allowed, and to a maximum amount of 1500 c.c. during the day, chiefly between meals. Second: the need for limiting the amount and type of exercise taken, especially after eating, since the work of digestion requires all the power and strain of which the heart is capable, and since an additional tax placed upon it by muscular exertion might readily be just the final straw, the added fraction which weighs down the balance on the scale of life. Third: the advisability of abstaining from alcoholic beverages, unless specially prescribed by the physician in charge. Certain elderly people suffer from a condition known as senile heart, which is more or less associated with arteriosclerosis and high blood pressure. These individuals should be prevailed upon to take the precaution of regulating their habits of life, avoiding excesses of all kinds, not only on account of the weakened condition of the heart, but also on account of the condition of the arteries. They should avoid excitement and worry, since the very fact that they are worrying increases the blood pressure. Simple foods in limited quantities, five meals a day instead of three, and an avoidance of too much fluid, should be the keynote of their daily régime. Tact on the part of the nurse is necessary in all cases, both young and old. It is often more difficult to instill good dietary habits in heart patients, after acute symptoms have subsided, than to carry them out during the acute attack, when the life itself depends upon a rigid adherence to the diet prescribed. But as these rules and regulations are essential to the future welfare of the patient, he must be taught with care, and in such a way that he will not be alarmed to an extent when more harm than good will come of the teaching. The diet should consist chiefly of milk, eggs, rare meat in moderation (mutton, chicken, fish, and oysters), well-baked bread, well-cooked cereals, potatoes and green vegetables, and simple desserts. All foods which in any way cause gastric or intestinal disturbances must be avoided. If these disturbances arise during the course of the disease, the patient should be promptly returned to the strict milk diet. When edema is prominent, it is treated as already described in the treatment for the like condition in nephritis by the Karell or salt-free diet. The dietetic treatment given here is merely a guide to be used under certain conditions. The physician formulates the diet, and the nurse must understand what to expect and how to apply the treatment as the symptoms arise. SUMMARY ~Dietetic Treatment~, adjusted to relieve the weakened heart muscles and to save the organ from all possible strain. ~Three Stages~, during which the treatment changes according to the extent and progress made by the disease. First Stage: The diet is practically normal. Compensation is good, consequently no dietary measures save the limiting of alcoholic beverages are necessary. Second Stage: The compensation is only moderate and the heart cannot perform its normal functions, hence the diet must be directed toward relieving any pressure upon the organs from other organs and toward lessening the work of the heart itself. Third Stage: In which the compensation is decidedly impaired and for this reason the dietetic treatment undergoes a decided change. ~Digestional Disturbances~ in which there is an evolution of gas in the stomach or intestines may cause a pressure against the heart which is distinctly bad for it. ~Limiting the Fluids~ in the diet in heart disease is necessary when the compensation is only moderate, as they impose an extra burden upon the organ to eliminate them. ~Amount of Food~ must also be limited. The meals must be small and taken without fluid. The latter should be taken between meals. ~Edema~ occurs in a number of cases and must be treated as in nephritic conditions by limiting the fluids and by confining the diet to "salt-poor" foods.[136] ~Karell Cure~ or modification thereof has been used with good results in many cases of heart disease. ~Exercise~ must be limited in amount and confined to types which will not impose a tax upon the weakened heart muscles. Exercise after eating is especially to be discouraged, as this, together with the efforts required for the digestion of food, might readily prove too much for the heart to accomplish. ~Elderly Patients~ must be warned against exercises of all kinds, not only on account of the condition of the heart, but also on account of the condition of the arterial walls. These harden with age and break down under undue pressure. ~The Nurse~ should instruct the patient on the points necessary for the saving of the heart. She should teach the necessity for keeping the meals small and having them more frequently if necessary; of limiting the fluids at meals to a few ounces or leaving them out altogether at this time. She should know how necessary is the reduction of the fluid. She should also warn against the taking of alcoholic beverages except with the permission and advice of a physician. ~Excitement and Worry~ increase the blood pressure, hence must be avoided by individuals suffering with any form of heart disease. PROBLEMS (a) Write a diet order for an elderly patient with severe cardiac disturbance. (b) Outline the method of administering the Karell diet. FOOTNOTES: [134] See Karell Cure, p. 342. [135] "Food for the Sick," p. 150, by Strouse and Perry. [136] See Salt-poor Diets, p. 341. CHAPTER XX DIABETES MELLITUS ~Definition.~--Diabetes is a disease which is characterized by an inability on the part of the body to utilize the carbohydrates, in consequence of which there is abnormal excretion of glucose in the urine. ~Sugar in the Urine.~--The appearance of sugar in the urine may not necessarily signify diabetes, it may be merely a temporary glycosuria due to certain pathological conditions, such as infectious diseases, diseases or trauma which affect the pancreas, and which disappear upon the recovery from the disease. But any appearance of sugar in the urine should be looked upon with suspicion, since the future welfare of the patient depends largely upon an early diagnosis in any form of diabetes. ~True Diabetes.~--Allen claims that true diabetes may always be distinguished from nervous glycosuria by the application of the laws governing these conditions (Allen's Paradoxical Law[137]), which is "whereas in normal individuals the more sugar given the more is utilized, the reverse is true in diabetes." ~Manufacture of Sugar from Other Foods.~--If the carbohydrate foods alone caused all the trouble in diabetes, the disease might be more easily controlled. This, we found, however, not to be true, since in certain conditions the body utilizes the protein foods for the manufacture of glucose also. Consequently in diabetes if the absolute sugar output of the body is to be controlled, the intake of nitrogenous foods must be likewise adjusted. ~Functions of Carbohydrates.~--In the chapter describing the functions of the carbohydrates in the human body it was demonstrated that their energy-producing properties did not cover the extent of their usefulness. It has been proved that this food constituent normally acts as neutralizing agent for the toxic acids produced within the organism as a result of the breaking down of the _fats_. Hence, when this function of the carbohydrates becomes impaired, these acids, Oxybutyric acid, Diacetic acid and Acetone, fail to be neutralized and are consequently absorbed into the blood stream, giving rise to a form of intoxication known as acidosis. When acidosis becomes extreme, the diabetic patient is apt at any time to succumb to the dreaded diabetic coma. ~Keeping Urine Sugar Free.~--Thus it is seen that the treatment of diabetes mellitus consists not alone of freeing the urine from sugar and keeping it free, but of controlling the acidosis which may at any time develop. ~Diabetic Cures.~--Numberless so-called diabetic cures have been brought forward and more or less tested for years, but whether they have really accomplished cures has not been satisfactorily proved. Not until Dr. Allen instituted what is known as the Allen's Starvation Treatment has the disease been so universally treated, at least by one method or modification of one method. Dr. Joslin, who has used this treatment most successfully, does not claim to have accomplished a cure, but states that he is watching the results of the treatment in his patients with interest. ~Starvation Treatment.~--The Allen Starvation Treatment consists of first a period of about forty-eight hours in which the patient is given an ordinary diet, during which time the daily weight is taken and the urine examined and recorded. ~Acidosis.~--It has been found in some cases, such as with elderly patients or those in whom there is an evident acidosis, advisable to precede the period of starvation by a preliminary treatment. ~Method of Treatment.~--Joslin[138] suggests the following method of procedure: "Without otherwise changing the diet omit fat. After two days, omit protein, then halve the carbohydrates daily until the patient is taking only ten grams, then fast." In the Michael Reese Hospital, the following series of test diets are given to determine the severity of the diabetes: DIABETIC TEST DIETS[139] BREAKFAST Grapefruit 1/2 Eggs 2 Bacon 20 grams Bread 25 grams Butter 10 grams Cream 15 c.c. Coffee 1 cup DINNER Cream soup 3 oz. Roast beef 75 grams Spinach 100 grams Kohl-rabi 100 grams Lettuce salad 50 grams Ripe olives 15 grams Bread 25 grams Butter 20 grams Wine gelatin 4 oz. Coffee Cream 15 c.c. SUPPER Lamb chop 1 Asparagus tips 50 grams Eggplant 50 grams Tomato salad 50 grams Custard (diabetic) Coffee Cream 15 c.c. Butter 20 grams Bread 25 grams ~Diet in Mild Cases.~--This diet contains approximately 70 grams of protein, 100 grams of fat, and 70 grams of carbohydrates, and the patient is kept on it for at least two days; then the carbohydrates are cut down by taking away 25 grams of bread every day. DIABETIC DIETS[140] KEY A Carbohydrate B Protein C Fat D Calories E 5% Vegetable F Orange G Oatmeal H Shredded Wheat I Uneeda J Potato K Bread L Egg M Cream 20% Fat N Bacon O Butter P Meat Q Fish R Skimmed Milk S _Name of Diet_ T _Maintenance Diets_ ========+==============+===============================================+== Diets | _Diet in_ | | with | _Grams_ | _Test Diets_ | which to+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+ become | | | | | | | | | | | | | | | | | | | Sugar | | | | | | | | | | | | | | | | | | | free | A |B |C | D | E | F |G | H |I| J |K |L| M |N |O | P | Q | R |S --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- T. D.1 |189|89|15|1247|300|300| | 1 | |240|90| | | | | 90|120|480| 1 T. D.2 |102|58| 0| 640|300|300| | 1 | |120| | | | | | |180|300| 2 T. D.3 | 64|33| 0| 388|300|300| | | | 60| | | | | | | 90|240| 3 T. D.4 | 36|27| 0| 252|300|200| | | | | | | | | | | 90|120| 4 T. D.5 | 15| 5| 0| 80|300| 50| | | | | | | | | | | | | 5 --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- | | _Carbohydrate_ | _Protein and Fat_ | T | | (_C_) | (_PF_) | --------+---+--+--+----+---+---+--+---+-+---+--+-+---+--+--+---+---+---+-- C1 +PF1 | 10|11| 6| 138|300| | | | | | |1| | | | | | | 1 C2 +PF2 | 22|13|18| 302|300|100| | | | | |1| 60| | | | | | 2 C3 +PF3 | 32|24|24| 440|600|100| | | | | |2| 60| | | | | | 3 C4 +PF4 | 42|29|39| 635|600|200| | | | | |2| 60|30| | | | | 4 C5 +PF5 | 52|32|53| 813|600|200|15| | | | |2| 60|30|15| | | | 5 C6 +PF6 | 63|43|65|1009|600|200|30| | | | |2| 90|30|15| 30| | | 6 C7 +PF7 | 73|51|70|1126|600|300|30| | | | |2| 90|30|15| 60| | | 7 C8 +PF8 | 83|59|87|1351|600|300|30| |2| | |2| 90|30|30| 90| | | 8 C9 +PF9 | 96|62|93|1469|600|300|30|1/2|2| | |2|120|30|30| 90| | | 9 C10+PF10|107|63|93|1517|600|300|30| 1 |2| | |2|120|30|30| 90| | |10 C11+PF11|131|75|98|1706|600|300|30| 1 |2|120| |2|120|30|30|120| | |11 C12+PF12|155|79|98|1818|600|300|30| 1 |2|240| |2|120|30|30|120| | |12 ========+===+==+==+====+===+===+==+===+=+===+==+=+===+==+==+===+===+===+== _Weight in_ _Approximate_ _Food_ _grams_ _equivalent_ Orange 300 One and one-half (large size) 5 per cent vegetables 300 Three moderate portions Skimmed milk 480 One pint (16 ounces) Fish 120 Two small portions Potato 240 Two medium sized potatoes Meat 90 One moderate portion Bread 90 Three small slices Oatmeal (dry wgt.) 30 One large saucerful Cream 60 Four tablespoonfuls Bacon 30 Four crisp strips Butter 30 Three medium portions The Test Diets are designed for the period during which the patient becomes gradually sugar free. On successive days advances can be made from Test Diet 1 to Test Diet 5, and if on the fifth day the patient is not sugar free, fasting can be employed for one or more days. The Maintenance Diets are for use so soon as the urine of the patient is free from sugar. If this occurs as a result of Test Diet 5 the patient begins with Maintenance Diet C1PF1. The actual articles of food representing the carbohydrate in the diet for the first day are given under the heading of carbohydrate, for convenience described C1, 2, 3, etc. The articles referred to under protein and fat are under that heading, which for the same reason is described as PF1, 2, 3, etc. Certain cases of diabetes can proceed steadily day by day from C1PF1 to C12PF12, without showing sugar. If sugar does appear in the urine, drop back two days in the carbohydrate group, wait till sugar free, then advance in the protein and fat group until sufficient calories are obtained. Thus, if sugar shows on C7PF7 the diet prescribed would be that included in C5PF7 and thereafter progression could be made in the PF group until twenty-five to thirty calories per kilogram body weight were furnished the patient. Occasionally the patient becomes sugar free on Test Diet 2, 3, or 4. It is then unnecessary to begin with Maintenance Diet C1PF1, but instead with a maintenance diet which contains a value for carbohydrate similar to that of the test diet upon which the patient became sugar free. If the protein and fat are too high for the individual on a given day it is easy to advance the carbohydrate and decrease to an earlier day on protein and fat. The plan is arbitrary and the majority of cases will demand some modification. It is arranged to enable patient or nurse to see in advance the general plan of treatment. (Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.) If the case is a mild one, this may be sufficient to free the urine from sugar, but the diet is given primarily to enable the physician to find out by means of urinalysis just how great is the functional impairment. In some cases, which are mild in character, the urine is made free of both sugar and acetone without further dietetic measures. However, when a severe diabetes is manifested and a high percentage of glucose and in some cases acetone bodies are found in the urine a more rigid treatment will be found necessary. ~Preliminary Diet.~--Many physicians find it advisable, as has already been stated, to cut down the food allowance before stopping it entirely. In the Michael Reese Hospital this is done by first giving a practically fat-free diet, followed by one or two days in which three or four eggs, 250 to 300 grams (8 or 10 ounces) of 5% vegetables are given, after which it is found safe to institute the starvation treatment. ~Sample Menus.~--The following menus are given to illustrate the dietetic treatment which it is deemed advisable to institute in cases where the starvation treatment cannot be given at once: After the test diet of forty-eight hours, the following régime is instituted: THIRD DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 1 egg | 5.3 | 4.1 | | 59 1 slice bread 30 gm. | 2.6 | .3 | 15 | 73 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 7.9 | 4.4 | 20 | 152 Dinner: | | | | Broth 180 c.c. | 3.7 | .17 | .34 | 18 Chicken (breast) 90 gm. | 18.2 | 2.1 | | 92 Spinach 100 gm. | 2.0 | | 3.0 | 20 Potato (1 medium) 90 gm. | 1.8 | .09 | 15.6 | 70 Lemon jelly 90 gm. | 4.2 | | 2.7 | 27 +---------+-------+--------------+---------- Total for meal | 29.9 | 2.3 | 21.6 | 227 Supper: | | | | Lamb chop 50 gm. | 9.3 | 14.1 | | 126 Asparagus 100 gm. | 1.5 | | 3 | 18 Bread 20 gm. | 1.6 | .2 | 10 | 48 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 12.4 | 14.3 | 13 | 192 Total for day | 40.2 | 21 | 54.6 | 571 =============================+=========+=======+==============+========== FOURTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 1 egg | 5.3 | 4.1 | | 59 1 slice bread 20 gm. | 1.6 | .2 | 10 | 48 Coffee or tea | | | | +---------+-------+--------------+---------- Total for meal | 6.9 | 4.3 | 15 | 107 Dinner: | | | | Tomato bouillon 180 gm. | 2.2 | .23 | 2.5 | 15 Whitefish 90 gm. | 2 | | 5 | 28 Boiled onions 100 gm. | 1.5 | .3 | 7.5 | 40 Bran muffin (1) | 5 | 7 | 4.5 | 101 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 25.7 | 16.2 | 20.5 | 322 Supper: | | | | 1 egg | 5.2 | 4.1 | | 59 Tomato (baked) 100 gm. | .6 | | 2 | 10 Bran muffin (1) | 1 | 5 | 7 | 101 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 6.8 | 9.1 | 9 | 170 Total for day | 38.4 | 29.6 | 44 | 513 =============================+=========+=======+==============+========== FIFTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | 1/2 grapefruit | | | 5 | 20 Broiled tomato 100 gm. | 1.5 | | 3 | 18 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 1.5 | | 8 | 38 Dinner: | | | | Broth 120 c.c. | 3 | | | 12 Lettuce 50 gm. | .5 | | 1.5 | 8 Cauliflower 90 gm. | 1.5 | .4 | 3.9 | 25 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 5 | .4 | 5.4 | 45 Supper: | | | | 1 egg | 5.35 | 4.16 | | 59 String beans 100 gm. | 2 | | 5 | 28 Celery 50 gm. | .5 | | 1.5 | 8 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 7.85 | 4.16 | 6.5 | 85 Total for day | 14.3 | 12.5 | 19.9 | 168 =============================+=========+=======+==============+========== SIXTH DAY =============================+=========+=======+==============+========== |_Protein_| _Fat_ |_Carbohydrate_| | _Gm._ | _Gm._ | _Gm._ |_Calories_ -----------------------------+---------+-------+--------------+---------- Breakfast: | | | | Asparagus tips 60 gm. | 1.5 | | 3 | 18 Spinach 60 gm. | 1.1 | 1.8 | 1.8 | 32 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 2.68 | 1.8 | 5.8 | 50 Dinner: | | | | Stewed celery 100 gm. | 1 | .10 | 2.1 | 15 String beans 50 gm. | 1.5 | | 2.5 | 16 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 2.5 | .1 | 5.6 | 31 Supper: | | | | Beet tops 75 gm. | 1.5 | | 2.5 | 16 Onions (boiled) 75 gm. | 1.5 | .3 | 7.5 | 44 Tea or coffee | | | | +---------+-------+--------------+---------- Total for meal | 3 | .3 | 10 | 60 Total for day | 11.2 | 2.2 | 21.4 | 141 =============================+=========+=======+==============+========== FAST ~Method of Administering Treatment.~--In many cases the patient is first put to bed during the starvation treatment, but recently Dr. Allen has emphasized the value of exercise, claiming that it assists in utilizing the sugar. In any case, the starvation régime remains the same. The patient is given only coffee or clear broth with or without whisky (one ounce every two hours) and the treatment continued from one to four days, or until the urine becomes sugar free.[141] It has rarely been found necessary to continue the fast longer than four days, since in most cases the sugar decreases rapidly upon the discontinuance of food. ~Loss of Weight.~--The slight loss of weight, which may be noticeable as the result of starvation, is not undesirable, especially in those cases where obesity is a prominent feature. In fact care must be exercised in the follow-up treatment to prevent the taking on of weight by the diabetic individual, since, according to Allen, it is often found that even moderately obese patients (180 lb.) continue to excrete a small amount of sugar so long as they hold this weight, even upon a low carbohydrate diet, whereas those same patients show no difficulty in becoming sugar free if the weight is reduced by ten or fifteen pounds. SCHEDULE FOR TREATMENT AND METHODS OF DETERMINING FOOD TOLERANCES A number of schedules have been devised to enable the nurse successfully to carry out the Allen Treatment. In following out this treatment and reëducating the organs afterward to tolerate foods which they have been unable to handle on account of the impairment of the sugar-making organs, it is necessary to make a series of tests whereby the diet is gradually increased in its various constituents until the diabetic patient is able to handle a reasonable amount of carbohydrates as well as other foods which have given more or less trouble in the past. The following schedule, after Joslin,[142] is included, and a careful study of it is advised in order that the nurse may intelligently carry out the Allen Treatment. ~Schedule.~--Fasting in many cases begins at once and the patient experiences no ill effects from it. However, in severe, long-standing cases many patients do better if the fats are omitted at once and the rest of the diet left unchanged for two days. Then the proteins in the diet are omitted and the carbohydrates cut in half. This halving of the carbohydrates is continued daily until only 10 grams remain, after which they too are omitted. The fast is thus made complete and remains so until the urine is entirely free from sugar. ~Carbohydrate Tolerance~ is determined by giving, as soon as the urine has been sugar-free for twenty-four hours, 150 grams of 5% vegetables. This is equivalent to from 8 to 10 grams of carbohydrates. After this 5 grams of carbohydrates, or 75 grams of 5% vegetables, are added daily to the diet until the patient is taking 20 grams. Then the addition of 5 grams of carbohydrates is made every other day, using the fruits and vegetables belonging to the 10% and 15% carbohydrate group, until potatoes and oatmeal and finally bread can be tolerated unless sugar appears in the urine before this or the tolerance reaches 3 grams to each kilogram of body weight or, in other words, until a man weighing 150 pounds is consuming 225 grams of carbohydrates per day. ~Protein Tolerance.~--In making the test for the protein tolerance it is necessary to wait until the urine has been sugar free for forty-eight hours; 20 grams of protein is then given. This is equivalent to 3 eggs, and daily additions of 5 grams protein are made, usually in the form of meat, until the patient is receiving 1 gram of protein to every kilogram of his body weight per day unless his carbohydrate tolerance is zero, in which case it is wise to add only three-fourths of a gram of protein per day. ~Fat Tolerance.~--A determination of the fat tolerance is made coincidently with that of the protein. No additional fat is allowed until the protein tolerance reaches 1 gram per kilogram of body weight, unless the patient's tolerance for protein is less than that. After which 25 grams of fat per day are added until there is no further loss of weight, taking care never to allow more than 40 calories per kilogram of body weight. ~Reappearance of Sugar.~--Should the urine again show the presence of sugar, another period of fasting lasting for twenty-four hours, or until the urine is again sugar free, must be instituted. After the second fast the increase in the diet may be twice as rapid as used after the first fast. However, it is not advisable to increase the amount of carbohydrates to more than half of that determined by the former tolerance for a period of two weeks, during which time the urine has been entirely sugar free, then the increase is made more slowly and the amount given should not exceed 5 grams a week. ~Weekly Fast Days.~--One day in seven should be set aside by the diabetic patient for fasting, when the carbohydrate tolerance is less than 20 grams. When, however, the tolerance is between 20 and 50 grams of carbohydrates, the patient may take one-half of his daily allowance of protein and fat and a certain amount of 5% vegetables as well upon the weekly fast day. When the tolerance reaches between 50 and 100 grams per day, vegetables of a higher carbohydrate content may also be included. If the carbohydrate tolerance should exceed 100 grams per day, the carbohydrates upon the fast day may be simply half of the amount allowed upon other days. ~The Giving of Alkalies.~--If acidosis is evident, as may be indicated by an excretion of diacetic acid, oxybutyric acid, or acetone in the urine, alkalies may be given. Bicarbonate of soda may be given in doses of 2 grams every 3 hours, as suggested by Hill and Eckman,[143] but this is not as a rule necessary, for, as Jacobi aptly remarks: "Prevention is the treatment of acidosis in children, and those susceptible to acidosis should not have fat." What he has said for children holds good for adults. However, it is likewise true that fat must constitute a large part of a diabetic diet and the only way to prevent it poisoning, is to raise the fat in the diet gradually until the tolerance is determined. ~Determining the Extent of Acidosis.~--It will be remembered that in an earlier chapter it was found that the excretion of ammonia in the urine to a certain extent indicated the extent of the acidosis in the body, that is, if the ammonia output exceeds three or four grams a day (twenty-four hours), the extent of the acidosis is considerable, while if it falls below that amount it is not alarming. More exact methods, however, for the determining of the severity of the acidosis will be found in another part of this text, where the test for sugar and the acetone bodies will be explained in detail. ~Dietetic Treatment.~--The patient is placed upon a vegetable diet consisting of vegetables containing not more than five per cent. carbohydrate.[144] These vegetables have their carbohydrate content still further reduced by changing the water in which they are cooked three times. In many cases this will reduce their content as much as one-half. A small amount of fat usually in the form of butter is allowed with these vegetables. The amount of 5% vegetables given must be carefully adjusted since the patient might readily take too much if allowed to follow the dictates of his appetite. The carbohydrate intake during the first one or two days must be limited to 15 grams. This allows about 10 grams of protein, 7 grams of fat, and 15 grams of carbohydrates. Tea or coffee, without sugar or cream, may be given at each of the three meals. The following table is included, showing the various foods arranged according to their carbohydrate content: TABLE[145] STRICT DIET Meats, fish, broths, gelatin, eggs, butter, olive oil, coffee, tea, and cracked cocoa. Foods arranged approximately according to per cent of carbohydrates ======================+==============+================+=============== 5% | 10% | 15% | 20% ----+-----------------+--------------+----------------+--------------- |Lettuce |Pumpkin |Greens |Potatoes |Cucumbers |Turnip |Peas |Shell beans |Spinach |Kohl-rabi |Artichokes |Baked beans |Asparagus |Squash |Parsnips |Green corn |Rhubarb |Beets |Lima beans |Boiled rice F |Endive |Carrots | (canned) |Boiled macaroni r |Marrow |Onions | |Prunes V e |Sorrel |Mushrooms | | e s |Sauerkraut | | | g h |Beet greens | | | e |Dandelion | | | t o |Swiss chard | | | a r |Celery | | | b |Brussels sprouts | | | l C |Water cress | | | e a |Sea kale | | | s n |Okra | | | , n |Cauliflower | | | e |Eggplant | | | d |Cabbage | | | |Radishes | | | |Leeks | | | |String beans | | | |Broccoli | | | |Tomatoes | | | ----+-----------------+--------------+----------------+--------------- |Ripe olives |Lemons |Apples |Plums F | (20% fat) |Oranges |Pears |Bananas r |Grapefruit |Cranberries |Apricots | u | |Blackberries |Blueberries | i | |Gooseberries |Cherries | t | |Peaches |Currants | s | |Pineapple |Raspberries | | |Watermelon |Huckleberries | ----+-----------------+--------------+----------------+--------------- |Butternuts |Brazil nuts |Almonds |Peanuts 40% N |Pignolias |Black walnuts |English walnuts |Chestnuts u | |Hickory |Beechnuts | t | |Pecans |Pistachios | s | |Filberts |Pine nuts | ====+=================+==============+================+=============== M | Unsweetened and unspiced Reckon available carbohydrates i | pickle, clams, oysters, in vegetables of 5% group as 3%, s | scallops, liver, fish of 10% group as 6%. c | roe. . | ====+================================================================= 30 grams (1 oz.) contains approximately: ==============================+=========+=====+==============+========== |_Protein_|_Fat_|_Carbohydrate_| | _Gm._ |_Gm._| _Gm._ |_Calories_ ------------------------------+---------+-----+--------------+---------- Oatmeal, dry weight | 5 | 2 | 20 | 110 Meat (uncooked ham) | 6 | 3 | 0 | 50 Meat (cooked ham) | 8 | 5 | 0 | 75 Broth | 0.7 | 0 | 0 | 3 Potato | 1 | 0 | 6 | 25 Bacon | 5 | 15 | 0 | 155 Cream, 40% | 1 | 12 | 1 | 120 Cream, 20% | 1 | 6 | 1 | 60 Milk | 1 | 1 | 1.5 | 20 Bread | 3 | 0 | 18 | 90 Butter | 0 | 25 | 0 | 240 Egg (one) | 6 | 6 | 0 | 75 Brazil nuts | 5 | 20 | 2 | 210 Orange or grapefruit (one) | 0 | 0 | 10 | 40 Vegetables, 5% and 10% groups | 0.5 | 0 | 1 or 2 | 6 or 10 Oysters | 6 | 1 | 4 | 50 ------------------------------+---------+-----+--------------+---------- TABLE[146] Carbohydrate equivalent of 1 slice of white bread (1 oz. or 30 gm.) containing approximately 15 gm. of starch ==============+==============+=====+===============+==============+====== _Uncooked_ |_Household_ | | _Cooked_ | _Household_ | _Flours, etc._|_Measure_[147]|_Gm._| _Vegetables_ | _Measure_ | _Gm._ --------------+--------------+-----+---------------+--------------+------ Barley | 1 h. tbs. | 21 |Artichokes | 1 medium | 320 Buckwheat | 1 h. tbs. | 19 |Beans (baked | | Corn meal | 1 h. tbs. | 20 | canned) | 2 h. tbs. | 75 Farina | 1 h. tbs. | 20 |Beans, lima | 1-1/4 tbs. | 50 Hominy | 1 h. tbs. | 18 |Beets | 6 tbs. | 200 Macaroni | 1 h. tbs. | 20 |Carrots | 13 tbs. | 446 Noodles |1-1/2 h. tbs. | 20 |Okra | 4 tbs. | 200 Oatmeal | 1 h. tbs. | 22 |Onions | 3 tbs. | 300 Rice | 1 h. tbs. | 18 |Parsnips | 4 slices | 120 Rye flour | 1 h. tbs. | 18 |Peas, green | 3 h. tbs. | 100 Spaghetti |1-1/2 tbs. | 20 |Potatoes | | Vermicelli |1-1/2 tbs. | 21 | (baked) | 1/2 medium | 60 Wheat flour | 1 tbs. | 20 |Potatoes | | | | | (boiled) | 1/2 medium | 70 | | |Potatoes | | | | | (mashed) | 1-1/2 h. tbs.| 80 | | |Potatoes, sweet| | | | | (boiled) | 1/3 medium | 35 | | |Squash | 2 h. tbs. | 100 | | |Turnips | 3 | 210 | | | | | _Bread and_ | | |_Cooked Cereal_| | _Crackers_ | | |Force | 5 h. tbs. | 18 Bread | 1 slice | 30 |Farina | 2-1/2 h. tbs.| 125 Breakfast | | |Grape-Nuts | 1-1/2 h. tbs.| 20 biscuit, | | |Hominy | 1-1/2 h. tbs.| 90 Huntley | | |Macaroni | 2 h. tbs. | 100 and Palmer | 3 | 18 |Oatmeal | 2-1/2 h. tbs.| 130 Corn bread | 1 slice | 32 |Rice | 1/2 h. tbs. | 60 Roll, Vienna | 3 | 18 |Shredded wheat | | Zwieback | 1-1/3 | 20 | biscuit | 3/4 | 22 | | | | | _Fruits_ | | | | | Apple | 1 medium | 120 | | | Apricots | 2 large | 120 |_Dried Fruit_ | | Banana | | |Apples | 3 small | 22 (without skin)|1/2 medium | 75 |Apricots | 3 large | 24 Cherries | | 90 |Currants | 1-1/2 h. tbs.| 20 Currants | 5 h. tbs. | 120 |Dates | 3 | 19 Grapefruit | 1/2 small | 150 |Figs | 1 large | 12 Huckleberries | 3-1/2 tbs. | 90 |Prunes | 2 large | 24 Lemons | 2 medium | 210 |Raisins |10 large | 23 Muskmelon | 1/3 | 300 | | | Nectarine | 1 | 100 |_Milk and_ | _Household_ | Olives (green)| 20 | 180 | _Cream_ | _Measure_ |_C.C._ Orange | 1/2 large | 150 |Buttermilk |1-1/2 tumbler | 300 Peaches | 1-1/2 medium | 150 |Cream, 16% |1-1/2 tumbler | 300 Pear | 1 small | 100 |Cream, 40% |1-1/2 tumbler | 300 Pineapple | 3 slices | 150 |Koumiss |1-1/2 tumbler | 300 Plums | 3 medium | 75 |Whole milk |1-1/2 tumbler | 300 Raspberries | 4-1/2 h. tbs.| 120 | | | Strawberries | 8 h. tbs. | 200 | _Nuts_ | | _Gm._ Watermelon | large slice | 300 |Almonds | 60 | 90 | | |Brazil | 30 | 180 | | |Chestnuts | | | | | (roasted) | 15 | 40 | | |Cocoanut | 1 slice | | | | | (3 × 2 in.) | 50 | | |Filberts | 100 | 110 | | |Peanuts | 40 | 80 | | |Pecans | 35 | 110 | | |Pistachios | 190 | 95 | | |Walnuts | 30 | 125 ==============+==============+=====+===============+==============+====== TABLE[148] Caloric equivalent of 10 gm. steak in carbohydrate-free meat or fish =================+============+============+============+=========== _Food_ | _Gm._ | _Fat_ | _Protein_ | _Calories_ | | _Gm._ | _Gm._ | -----------------+------------+------------+------------+----------- Steak | 10 | 1.0 | 2.4 | 19 Roast beef | 5 | 1.4 | 1.1 | 18 Tongue | 7 | 1.4 | 1.6 | 20 Lamb chop | 5 | 1.5 | 1.1 | 18 Roast lamb | 8 | 1.3 | 1.6 | 20 Sweetbreads | 11 | 0.1 | 4.4 | 19 Boiled ham | 7 | 1.4 | 1.5 | 19 Fried ham | 5 | 1.7 | 1.1 | 20 Roast pork | 9 | 0.9 | 2.6 | 19 Bacon | 9 | 1.7 | 0.9 | 20 Chicken | 10 | 1.0 | 2.4 | 19 Duck | 9 | 1.3 | 1.8 | 19 Guinea hen | 12 | 0.8 | 2.8 | 19 Squab | 9 | 1.1 | 2.1 | 19 Turkey | 7 | 1.3 | 2.0 | 20 Bluefish | 13 | 0.6 | 3.5 | 20 Halibut | 16 | 0.7 | 3.3 | 20 Mackerel | 15 | 1.0 | 2.5 | 20 Sardines in oil | 7 | 1.4 | 1.6 | 20 =================+============+============+============+=========== Approximate equivalent in 30 c.c. (1 oz.) of whisky in liquors containing 2 per cent or less of carbohydrates ==============================+==============+=============== | | _Household_ | _C.C._ | _Measure_ ------------------------------+--------------+--------------- Gin, rum, brandy | 30 | 2 tbs. Claret, Burgundy Hock, Rhine | | and Moselle wines | 130-160 | 3/4 tumbler ==============================+==============+=============== CARBOHYDRATE-FREE MENUS The following menus are suggested as meeting the carbohydrate-free diet requirements with a nutrient value of from 200 to 500 calories: Breakfast--Black coffee (cream, 20 c.c.) } Bacon, 2 slices (1 oz.) } 30 grams Egg--1 Dinner--Broth, 6 ounces 180 grams Steak, 1 small piece, 1-1/3 oz. 40 grams Stewed tomatoes, 3-1/3 oz. 100 grams Lettuce (lemon juice and olive oil) 25 grams Supper--Broth 180 grams Whitefish 40 grams Spinach 100 grams Cabbage salad 100 grams Coffee Breakfast--1/2 grapefruit 1 egg Bacon 40 grams Coffee 50 grams Cream 20 c.c. Dinner--Broth 180 c.c. Kohl-rabi 100 grams Lettuce 25 grams Cheese salad 50 grams Roast beef 40 grams Coffee Butter 5 grams Supper--Cold chicken 25 grams Baked tomatoes 100 grams Water cress 50 grams Coffee Cream 20 c.c. Butter 5 grams TABLE KEY: A _Protein Gm._ B _Fat Gm._ C _Carbohydrate Gm._ D _Calories_ ===================+========================+=====+======+=====+======== | | | | | _Material_ | _Measure_ | A | B | C | D -------------------+------------------------+-----+------+-----+-------- Apple | 1 medium (150 gm.) | .5| .5 | 16 | 70 Almonds[149] | 10 small (10 gm.) | 2 | 5 | 2 | 63 Apricots (dried) | 1 oz. (30 gm.) | 1.5| .28| 17.5| 78 Asparagus | 6 large stalks | 1.3| .14| 2.5| 16 | (74 gm.) | | | | Bacon (raw)[149] | 4 slices, 6 in. long, | 10 | 64 | | 636 | 2 in. wide | | | | Bacon (cooked)[149]| 4 slices, 6 in. long, | 10 | 32 to| | 388 to | 2 in. wide | | 46 | | 468 Beef juice[150] | 100 gm. | 4.9| .6 | | 25 Beef roast[149] | 1-1/2 in. × 1/8 in. | 6 | 7 | | 89 Cheese[149] | | | | | (Neufchâtel) | 1 cheese 2-1/4 in. × | 16 | 23 | 1 | 284 | 1-1/2 in. × 1-1/4 in. | | | | Cream, gravity 16% | 1 glass (7 oz.) | 5 | 32 | 10 | 359 Cream, 40% | 30 c.c. (2 tbs.) | .6| 12 | 1 | 114 Cracker (Uneeda | 1 biscuit | 1 | .5 | 1 | 16 biscuit) | | | | | Dry peptonoids[150]| 1 tbs. | 6 | | 8 | 57 Egg | 1 medium (45 to | 54 | 4.2 | | 60 | 50 gm.) | | | | Fowl | 3-1/2 oz. (100 gm.) | 19.3| 16.3 | | 224 Grapefruit | 1/2 | | | 5 | 20 Ham (lean) | 50 gm. | 12.4| 7.1 | | 113 Lemon juice[151] | 3 tbs. (43 gm.) | | | 4.2| 19 Lemon Jelly[152] | 3 oz. (90 gm.) | 2.6 | | 1.4| 16 Milk (whole) | 1 glass (8 oz.) | 7.9 | 9.6 | 10 | 158 | 240 c.c. | | | | Oatmeal[153] | 1 tbs. (50 gm.) | 1 | | 6 | 33 Oatmeal | 1/2 cup (3.6 oz.) | 2.1| .1 | 8.2| 50 Potato[153] (size | | | | | large egg) | 1 (100 gm.) | 2 | | .8| 83 5% vegetable[153] | | | | | uncooked | 1 tbs. | | | 2.5| 10 5% vegetable | | | | | (boiled once) | 1 tbs. | | | 1.7| 7 5% vegetable | | | | | (boiled thrice) | 1 tbs. | | | 1 | 4 Orange | 1 large | 1.7| .2 | 22.7| 100 Orange[153] | 1 medium | 1 | | 13 | 57 -------------------+------------------------+-----+------+-----+-------- ~Increasing the Diet.~--The following menus show the manner in which the diet is increased after the starvation treatment: ~First Day~ Approximately 150 grams of vegetables with tea or coffee; value: protein 2, fat trace, carbohydrate 4. Breakfast--String beans 20 grams Celery hearts 20 grams Lunch--Spinach 25 grams Lettuce 25 grams Supper--Tomatoes 25 grams Cucumbers 25 grams ~Second Day~ Three eggs, 150 grams of 5% vegetables, tea or coffee; value approximately: protein 18, fat 12, carbohydrate, 4, calories 198. Breakfast--1 poached egg Spinach or beet tops 50 grams Coffee or tea Dinner--1 hard-cooked egg String beans 25 grams Lettuce 25 grams Tea Supper--1 soft-cooked egg Asparagus tips 25 grams Tomatoes 25 grams ~Third Day~ Approximately 19 grams protein, 15 grams fat, 5 grams carbohydrate, 230 calories. Breakfast--1 egg String beans 50 grams Tomatoes 25 grams Coffee Dinner--Cauliflower 50 grams Celery 50 grams Tea Supper--Asparagus 75 grams Lettuce 50 grams ~Fourth Day~ Approximately 26 grams protein, 15 grams fat, 10 grams carbohydrate, 279 calories. Breakfast--1 egg String beans 75 grams Coffee with cream 15 c.c. Dinner--Tomato bouillon 6 oz. (180 c.c.) 1 egg Asparagus 75 grams Lettuce 25 grams Tea Supper--1 egg Celery 50 grams Cauliflower 100 grams ~Fifth Day~ Approximately 20 grams protein, 46 grams fat, 15 grams carbohydrate. Breakfast--Egg omelet (1 egg) Butter 10 grams Vegetable hash 100 grams Coffee or tea Cream 15 grams Dinner--Chicken broth 180 c.c. 1 poached egg Tomatoes 100 grams Tea Supper--1 soft-cooked egg Spinach 100 grams Cucumbers 50 grams Tea or Coffee Cream 15 grams ~Sixth Day~ Approximately 33 grams protein, 35 grams fat, 12 grams carbohydrate, 495 calories. Breakfast--1/2 grapefruit 1 egg Butter 5 grams Spinach 50 grams Coffee Cream 15 grams Dinner--Broth 180 grams Fish 50 grams String beans 100 grams Lettuce 50 grams Asparagus 50 grams Supper--2 eggs Tomato, baked (1 medium) 75 grams Cabbage salad 75 grams Tea Cream 15 grams ~Seventh Day~ Approximately 38 grams protein, 45 grams fat, 17 grams carbohydrate, 625 calories. Breakfast--1/2 grapefruit 2 eggs Butter 10 grams Coffee Cream 15 grams Dinner--Beef broth 180 grams 1 lamb chop 50 grams Cauliflower 100 grams Tomato 150 grams Lettuce 50 grams Butter 10 grams Supper--1 egg Tuna salad 50 grams String beans 100 grams Butter 5 grams Tea ~Eighth Day~ Approximately 32 grams protein, 16 grams fat, 20 grams carbohydrate, 625 calories. Breakfast--1 egg String beans 100 grams Raw tomatoes 100 grams Coffee Cream 15 grams Dinner--Chicken 50 grams Cabbage 100 grams Asparagus 100 grams Water-cress salad 50 grams Tea Supper--1 egg Greens 100 grams Celery salad 50 grams Tea Cream 15 grams The following menus are used after the diet has been more or less increased: ~First Day~ Breakfast--1 soft-cooked egg 2 slices of bacon 1 bran muffin, 5 gm. butter Coffee with 15 c.c. of 40% cream Lunch--6 oz. tomato bouillon 2 oz. (60 gm.) roast lamb 60 gm. string beans 50 gm. lettuce and celery salad 25 gm. lemon jelly with 15 gm. cream Dinner--60 gm. chicken 75 gm. asparagus 4 olives 50 gm. cauliflower 30 gm. ice cream 1 Lister roll, 5 gm. butter Black coffee ~Second Day~ Breakfast--1/2 grapefruit 1 scrambled egg 1 Lister roll, 8 gm. butter Coffee with 15 gm. cream Lunch--60 gm. baked halibut with 10 gm. parsley butter 70 gm. cauliflower 50 gm. lettuce 1 Lister roll, 8 gm. butter Tea Dinner--6 oz. chicken broth 60 gm. roast beef 75 gm. cabbage 75 gm. string beans 30 gm. coffee jelly with 15 gm. cream Black coffee ~Third Day~ Breakfast--1 soft-cooked egg 2 slices bacon 1 Casoid flour and bran muffin with 5 gm. butter Coffee with 15 gm. cream Lunch--100 gm. cabbage 40 gm. corned beef 50 gm. tomato salad 1 soya meal muffin, 8 gm. butter Tea Dinner--60 gm. beefsteak 75 gm. asparagus 75 gm. spinach 30 gm. tomato aspic 30 gm. soft (diabetic) custard Black coffee ~Fourth Day~ Breakfast--1 scrambled egg with 20 gm. chipped beef 1 Casoid flour muffin with 8 gm. butter Coffee with 30 gm. or less cream Lunch--6 oz. tomato bisque 60 gm. tuna fish salad 75 gm. vegetable hash 1 Lister roll, 8 gm butter Tea Dinner--60 gm. broiled chicken 75 gm. string beans 75 gm. cauliflower 30 gm. tomato and celery salad 30 gm. wine jelly, with 15 gm. whipped cream Black coffee ~Fifth Day~ Breakfast--1/2 grapefruit 1 soft-cooked egg 1 bran muffin with 8 gm. butter Coffee, 15 gm. cream Lunch--40 gm. broiled beefsteak 75 gm. spinach 75 gm. boiled onion 1 soya meal muffin with 8 gm. butter Tea Dinner--6 oz. tomato bouillon 80 gm. baked fish with parsley sauce 75 gm. Brussels sprouts with 5 gm. butter 1 Lister roll with 5 gm. butter Coffee jelly, 30 gm., with 15 gm. whipped cream ~Sixth Day~ Breakfast--1 poached egg 2 slices bacon 1 bran and Casoid muffin with 5 gm. butter Coffee with 15 gm. cream Lunch--Ham omelet (1 egg, 1 tbs. cream, 15 gm. minced ham) 75 gm. spinach 1 soya meal muffin with 8 gm. butter Tea A departure from the now almost universally used "Allen-Joslin Starvation Diet," is seen in the "Newburg-Marsh High Fat Diet." The use of a high fat diet in the treatment of diabetes is based primarily on one fact--namely, that if the food eaten is not sufficient for the needs of metabolism, the body itself supplies the deficiency. Fat is used as long as it lasts, body protein being drawn upon for fuel when this is exhausted. It is of distinct advantage to the patient to have a diet of sufficient fuel value to run his body machine and permit him a moderate degree of exercise. For by this means he is not obliged to use his own body substance to carry on metabolic processes. We thereby avoid the condition of extreme emaciation (though it is to be emphasized that gain in weight is to be carefully guarded against) with its constant lowering of the general health. The system of feeding consists of a series of four diets, examples and standards of which are given below. The diet is made up of protein on the basis of approximately 2/3 of a gram per kilogram of body weight at the time the patient leaves the hospital, a quantity of carbohydrate known to be well tolerated and the balance of the calories in fat.[154] DIABETIC DIET NO. 1 ======================================================================= 18-22 Proteins 12-15 Carbohydrates 800-1000 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Fish | 50 | 8.9 | 5.1| | 82 with Butter | 10 | .1 | 8.5| | 77 Cabbage | 50 | .8 | .1| 2.8 | 16 with mayonnaise | | .7 | 38.2| | 353 Tomatoes | 100 | 1.2 | .2| 4.0 | 23 Broth--Tea | | | | | | | | | | Supper: | | | | | String beans | 80 | 1.8 | .2| 5.9 | 33 with bacon | 10 | 1.0 | 6.5| | 62 Spinach soup-- | | | | | Spinach | 10 | .2 | | .3 | 2 Cream | 10 | .2 | 4.0| .3 | 38 Broth to fill bowl | | | | | Celery | 20 | .2 | | .7 | 4 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Omelet-- | | | | | 1 egg | | 6.7 | 5.2| | 74 with butter | 10 | .1 | 8.5| | 77 Coffee | | | | | -------------------------+--------+---------+-----+---------+---------- | | 21.9 | 76.5| 14.0 | 842 =========================+========+=========+=====+=========+========== DIABETIC DIET NO. 2 ======================================================================= 25-30 Proteins 18-22 Carbohydrates 1200-1600 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Pork chops | 60 | 10.0 | 18.0| | 202 Cabbage | 100 | .2 | .3| 5.6 | 32 (Use pork drippings) | | | | | Spinach | 100 | 2.1 | .3| 3.2 | 24 with butter | 20 | .2 | 17.0| | 154 Broth--Tea | | | | | | | | | | Supper: | | | | | Asparagus salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 Asparagus | 80 | 1.2 | .1| 2.1 | 13 Mayonnaise | 50 | .7 | 38.8| | 338 Tomatoes | 100 | 1.2 | .2| 4.0 | 23 with butter | 10 | .1 | 8.5| | 77 Nut charlotte-- | | | | | Walnuts, chopped | 10 | 1.8 | 6.4| 1.3 | 70 Cream | 50 | 1.1 | 20.0| 1.5 | 190 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Bacon | 20 | 2.1 | 13.0| | 125 with 1 egg | | 6.7 | 5.2| | 74 Coffee with cream | 30 | .7 | 12.0| .9 | 114 -------------------------+--------+---------+-----+---------+---------- | | 28.2 |139.8| 18.9 | 1438 =========================+========+=========+=====+=========+========== DIABETIC DIET NO. 3 ======================================================================= 30-35 Proteins 25-30 Carbohydrates 1600-2000 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Beef tenderloins | 80 | 13.0 | 19.5| | 227 with butter | 10 | .1 | 8.5| | 77 Asparagus | 100 | 1.5 | .1| 2.8 | 18 with butter | 10 | .1 | 8.5| | 77 Squash | 100 | 1.4 | .5| 9.0 | 46 with butter | 10 | .1 | 8.5| | 77 Broth--Tea | | | | | | | | | | Supper: | | | | | String bean salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 String beans | 50 | 1.1 | .1| 3.7 | 26 Pimento | 10 | .2 | | .4 | 2 Onion | 10 | .2 | | 1.0 | 5 Mayonnaise | 30 | .5 | 23.3| | 228 Tomatoes | 120 | 1.4 | .2| 4.8 | 28 with butter | 20 | .2 | 17.0| | 154 Chocolate pudding-- | | | | | Cream | 100 | 2.2 | 40.0| 3.0 | 381 Cocoa, 1/2 tsp | 1 | .2 | .3| .4 | 5 Broth--Tea | | | | | | | | | | Breakfast: | | | | | Bacon | 30 | 3.2 | 19.4| | 187 with 1 egg | | 6.7 | 5.3| | 74 Coffee with cream | 30 | .7 | 12.0| .9 | 114 -------------------------+--------+---------+-----+---------+---------- | | 32.9 |163.2| 26.3 | 1728 =========================+========+=========+=====+=========+========== DIABETIC DIET NO. 4 ======================================================================= 50-60 Proteins 30-40 Carbohydrates 2000-2500 calories -------------------------+--------+---------+-----+---------+---------- |_Weight_|_Protein_|_Fat_|_Carbo-_ | _Food_ | _Gm._ | _Gm._ |_Gm._|_hydrate_|_Calories_ | | | | _Gm._ | -------------------------+--------+---------+-----+---------+---------- Dinner: | | | | | Veal steak (roast) | 100 | 19.9 | 10.8| | 177 Onions | 126 | 1.9 | .4| 11.9 | 49 with cream | 50 | 1.1 | 20.0| 1.5 | 190 Tomatoes | 150 | 1.8 | .3| 6.0 | 35 with butter | 30 | .3 | 25.5| | 231 Fruit salad-- | | | | | Lettuce | 10 | .1 | | .3 | 2 Celery | 50 | .6 | | 1.6 | 9 Grapefruit | 80 | .6 | .2| 8.1 | 37 Whipped cream | 30 | .7 | 12.0| .9 | 114 Tea--Broth | | | | | | | | | | Supper: | | | | | Cream of celery | | | | | soup-- | | | | | Celery | 50 | .6 | | 1.6 | 9 Cream | 75 | 1.6 | 30.0| 2.2 | 285 Broth to fill bowl | | | | | Boiled ham | 30 | 6.1 | 6.7| | 85 Custard-- | | | | | 2 egg yolks | | 4.7 | 10.0| | 109 Cream | 90 | 2.0 | 36.0| 2.7 | 343 Tea | | | | | | | | | | Breakfast: | | | | | Eggs (2) | | 13.4 | 10.5| | 148 with butter | 30 | .3 | 25.5| | 231 Coffee with cream | 20 | .4 | 8.0| .6 | 76 Broth | | | | | -------------------------+--------+---------+-----+---------+---------- | | 56.1 |195.9| 37.4 | 2130 =========================+========+=========+=====+=========+========== ~Nurse's Directions for Collecting and Testing the Urine in Diabetes Mellitus.~--The first urine voided in the morning at 7 A.M. should be thrown away, after which the entire quantity during the ensuing twenty-four hours, including that at 7 A.M. the following morning, should be collected in a thoroughly clean, wide-mouth bottle sufficiently large to contain the entire quantity. This should be kept in a cool place to prevent decomposition. After the urine has been measured, four or five ounces are removed for testing purposes. There is no necessity for having an elaborately equipped laboratory for making the simple tests of the diabetic urine. The nurse is only required to make the simple tests, leaving the more elaborate one for the physician. The articles necessary for these tests must be kept perfectly clean in order to make the tests accurate. The bottle in which the urine is collected must be washed and sterilized daily before the collection begins. One small three-inch white enameled or porcelain dish, one 10 c.c. graduated pipette, 6 test tubes, 1 small alcohol lamp or Bunsen burner, 1 box of sodium carbonate, 1 box talcum, and the reagents necessary for making the test, namely, Benedict's solution, Fehling's solution, and Haines's solution. SUMMARY ~Diabetes Mellitus~ is a disease in which the body becomes more or less unable to utilize the sugars and starches, consequently there is an abnormal amount of glucose in the urine. ~Manufacture of Sugar~ in the body from other food constituents besides carbohydrates has been proved with regard to proteins, hence the intake of nitrogenous substances must be restricted in diabetes--to a less extent, however, than the sugars and starches. ~Acetone Bodies.~--Diacetic acid, oxybutyric acid, and acetone develop in diabetes as a result of the breaking down of the fats and the lack of certain neutralizing agents found chiefly in carbohydrate foods. ~Acidosis~ is a form of intoxication due to the retention of these toxic acids in the body. If not combated and overcome, it will result in the diabetic coma which is fatal in so many cases. ~Diet Treatments.~--The best known treatments are those devised and used by Drs. Allen and Joslin "The Starvation Treatment for Diabetes Mellitus," and the "High Fat Diet" formulated by Drs. Newburg and Marsh. All cases cannot be handled alike and it is for the physician to determine the treatment calculated to give the best results in the definite case. ~Training for Diabetic Nursing.~--So much depends upon the administration of the treatment in this pathological condition that in many hospitals special training is being given to the nurses in the care of diabetic patients that they may be able intelligently to carry out the necessary régime, both in the hospital and in private practice. ~Symptoms.~--She must be able to recognize symptoms both from the findings resulting from the urinalysis and from those manifested otherwise by the patient. ~The Record.~--She must keep an absolute record of all that occurs during the course of treatment and instantly report any unusual happening. ~Urine Tests.~--It is advisable to make the tests in the morning; those for sugar and diacetic acid should be made every day or, in some cases, every other day, as directed by the physician, and those for ammonia and albumen about once a week. ~Weighing the Patient.~--Patient should be weighed each day before breakfast, and the weight of the clothes also carefully recorded separately. ~The Bowels~ must move daily, even if it is necessary to resort to mild laxatives or an enema. ~Formulating and Calculating the Dietary.~--The menus of the day must be formulated and the chemical composition and nutrient value of the foods calculated. The vegetables belonging to the five per cent. group should be in readiness and the amount to be used weighed after they have been boiled in clean, separate water to reduce their carbohydrate content still further. ~Commercial Diabetic Foods.~--It may be well to mention the danger of putting faith in the so-called diabetic foods so widely advertised. Some of these foods are of undoubted worth, but it is never safe for the nurse or the patient to judge of the merits of the various diabetic foods without first knowing their chemical composition, and not even then without the definite directions from the physician. ~Diabetic Flours.~--The diabetic flours used in the recipes included in this text have been approved by some of the leading specialists in diabetes in this country, but the nurse should not include them in the diet for her patient unless they are prescribed by the physician in charge. PROBLEMS (a) Outline test diets for determining the severity of the disturbance. (b) Give examples of diets used in testing for tolerance of carbohydrates, fats, proteins. (c) Give an example of a diet order showing the use of the high fat method of feeding. Why is it used? FOOTNOTES: [137] Allen's Paradoxical Law, quoted from "Treatment of Diabetes Mellitus," p. 18, by Joslin. [138] "Treatment of Diabetes Mellitus," p. 305, Joslin. [139] "Food for the Sick," by Strouse and Perry. [140] Courtesy of Dr. Joslin and Thomas Groom & Co., Boston. [141] The giving of coffee or clear broth, with or without whisky, does not materially affect the starvation and serves to make the patient more comfortable during this trying period. [142] Dr. Joslin has given a very complete schedule in his "Treatment of Diabetes Mellitus," from which the above schedule is taken. [143] Hill and Eckman's "Starvation (Allen) Treatment of Diabetes." [144] See 5% vegetable, p. 383. [145] Table used by Dr. Joslin in his treatment of diabetes mellitus. It is convenient, and many changes in the diet may be made by substituting one food for another of like carbohydrate content. This table can be purchased on cards from Thomas Groom & Co., Boston, Mass. [146] Table devised by H. O. Mosenthal showing accessory diets rich in carbohydrates. "Medical Clinics of North America," July, 1917. [147] "h" represents household measure. [148] Mosenthal: "Medical Clinics of North America," July, 1917. [149] "Starvation Treatment of Diabetes," by Hill and Eckman. [150] "Practical Dietetics," by Alidia Pattee. [151] "Food for the Sick," p. 62, by Strouse and Perry. [152] Sweetened with saccharin. [153] "Starvation Treatment of Diabetes," by Hill and Eckman. [154] Courtesy of R. Eckman and D. M. Stewart, University of Michigan Hospital, Ann Arbor, Michigan. CHAPTER XXI DISEASES OF THE LIVER Much of the so-called biliousness from which the human family is so prone to suffer is nothing more or less than one of Nature's danger signals by means of which man may understand that some part of the delicate organism called the human body is being overworked. Close investigation of these conditions has proved that it is the liver which has been overtaxed, in many cases to such an extent that in a measure it slows down, as any overtaxed machine will do, and has become clogged with material which, owing to its condition, it is not able to prepare properly and send out on time. ~Work of the Liver.~--When one considers the vast amount of work performed by this organ, one marvels that so little trouble is manifested. In another part of this text the functions of the liver were defined. It was found to be the largest secretory organ in the body, producing a constant supply of bile by means of which the fats were dissolved and the digestion and absorption of the other food materials facilitated. We likewise found that the greater part of the fuel foods was transformed within this organ into available energy, either for immediate or future use. ~As a Detoxifying Agent.~--To the liver must also be credited the detoxifying of the various poisons produced within the body during the process of metabolism or brought in by way of food. Too much cannot be said as to the value of the liver in this respect, the importance of which is made known as soon as anything happens to the organ to put it even temporarily out of commission. ~Causes of Liver Disorders.~--Is it any wonder, then, that with such abuses as overeating and drinking, especially of those foods rich in fats and carbohydrates which depend upon the liver for their availability in the body, Nature cries aloud for help and for the comparative rest of this, her largest organ? The taking of alcohol in excess has been found to bring about tissue changes in the liver. Hence it must be avoided by individuals with a tendency to biliousness or to any disease in which the liver is involved. ~The Bowels.~--The bowels are as a rule constipated, and one of the first means of relief is the overcoming of this condition. The method of doing this depends upon the individual, and the treatment must be decided on by the physician. ~Dietetic Treatment.~--The dietetic treatment consists in abstaining from food or reducing the amount to a minimum while the attack lasts and while the intestines are being thoroughly emptied. All stagnant material which has clogged the bowels and which has been subjected to the activities of putrefactive bacteria must be gotten rid of. The diet must be especially low in fat. Oyster or clam broth, soft-cooked eggs, toast, cereal, or rice, with a little milk instead of cream and very little sugar, tea, and baked apple or stewed prunes are given. ~Convalescent Diet.~--After the attack the diet may be gradually increased until it is again normal. Moderation must be observed in the amount of food eaten; no highly seasoned or spiced foods, pickles, or condiments, such as peppers, mustard, or horseradish, should be taken. Salads should be dressed without oil. Lean beef, lamb chops, fish, chicken, sweetbreads, quail, squab, eggs (except fried or hard cooked), green vegetables (except radishes, onions, water-cress, and celery) in abundance, a small amount of potato, rice, or tapioca, fresh and cooked fruit with little, if any sugar, junket, custards, fruit jellies, weak tea and coffee should constitute the diet. Certain individuals find that milk increases the tendency to constipation; this is probably due to the small amount taken; large quantities do not as a rule produce this effect. Buttermilk, koumiss, and modified milk are advised in severe cases. ~Diet for Constipation.~--Individuals inclined to biliousness should endeavor to overcome the constipation which is one of the most prominent features. This is done by proper diet more successfully than by drugs (cathartics): bran bread, vegetable soup, fresh fruit, stewed fruit, fruit beverages, plenty of water. The following menus are suggested: Breakfast--Stewed prunes Oatmeal with milk (no sugar) Weak tea or coffee Toast (milk toast or dry toast) Lunch--Tomato soup 1 small baked potato 1 lean lamb chop (broiled) or a poached egg on toast Cup of weak tea Dinner--Vegetable soup 1 slice of lean, rare beef (cut from the inside of the roast) Spinach Rice Lettuce and tomato salad Lemon jelly Breakfast--Grapefruit Hominy with milk Poached egg on toast Weak coffee (milk and little sugar) Lunch--Cream of green pea soup Tomato jelly Broiled sweetbreads Weak tea Toast Dinner--Small portion of lean lamb or chicken Boiled or mashed potatoes String beans Sliced tomatoes Prune whip ~Advice to Patient.~--The above menus are merely suggested. The diet may be selected from the list of foods already mentioned. The patient must be warned against overeating and drinking. Pastry, rich cakes and puddings, confectionery, gravies, etc., must be avoided. In certain individuals beer will induce a bilious attack. By them it should be avoided. CIRRHOSIS OF THE LIVER The cause of this disease and the stage in which it exists must determine the treatment necessary. However, it matters not what produced the disease, whether it is the result of alcoholism, syphilis, etc., the diet plays an important rôle in its cure. ~The Diet.~--The diet in this disease, as in any other, must be determined by the condition of the patient. Unfortunately, many patients do not know of their condition until the disease is well advanced and symptoms of obstruction are prominent. A study of these must be made before the diet can be formulated. When the symptoms are mainly those arising from disturbed digestion of the stomach and intestines, without kidney or heart complication, the diet for chronic gastritis is used. ~Restricting the Fluids.~--When the heart is involved, it is sometimes found necessary to restrict the fluids (dry diet) to 1 quart (about 1000 c.c.) per day. The Karell Cure has been used advantageously in many of these cases. In cases where the kidneys are involved, the diet will depend upon the condition of these organs. ~Restricting the Diet.~--The diet in any case must be restricted. Individuals with a tendency to cirrhosis and those coming of a family in which liver diseases are frequent should be especially warned about the dangers of overeating and drinking. Alcohol should be avoided especially by such individuals. They should keep their diet simple in character and moderate in amounts. ~Avoidable Foods.~--All foods, such as condiments and spices, meat extracts, the outside browned portions of roasted meat, alcoholic beverages, which exert a stimulating or irritating effect upon the liver, should be studiously avoided and the fats and carbohydrates restricted, since, as it has already been demonstrated, it is upon the liver that the body depends for the preparation of these substances for their utilization. When, for example, the flow of bile is lessened, an incomplete emulsification of the fats exists and the fatty acids which are highly acid in character cannot be efficiently dissolved or neutralized, or when the liver is diseased and for this reason the conversion of glycogen into glucose is interfered with, the utilization of the carbohydrate foods is thus impaired. GALLSTONES ~Factors Influencing Their Formation.~--According to Friedenwald and Ruhräh[155] the two factors that in all probability exert the most influence on the formation of gallstones are the stasis of bile and the inflammation of the bile passages and gall bladder. ~Dietary Rules.~--There are certain dietary rules which should be observed by all persons who have had gallstone attacks. These are (1) to prevent stasis of bile, (2) to avoid fats. Everything should be done to prevent the formation of the stones, and this can only be accomplished by observing these rules. The flow of bile must be free; this is encouraged by keeping the intestinal tract in good condition. ~Stimulating Peristalsis.~--Peristalsis must not be allowed to become sluggish, for it is only during the process of digestion when the food mass passes along the intestinal canal that there is an ejection of bile into the intestines. When the passage is abnormally slow the bile is in a measure dammed back with a formation of gallstones as a result. The restriction of the fats has already been discussed in another part of the chapter. It has been demonstrated that these substances have a chemical influence upon the formation of gallstones as well as upon the intestinal stasis which leads to their formation. ~Dietetic Treatment.~--Hence the diet should be so directed as to (1) increase the flow of bile, and (2) to avoid all foods that are liable to cause indigestion which may bring about putrefaction in the intestinal tract and a consequent irritation and inflammation of the bile passages and gall bladder. The meals should be regular and an abundant diet advised to increase the flow of bile and stimulate peristalsis in the intestines. ~Exercise.~--Exercise is especially recommended. Horseback riding, swimming, rowing, golf, and tennis are especially valuable in forcing the bile from the gall bladder and liver. ~The Clothing.~--The clothing should be loose enough to be perfectly comfortable. Certain cases of gallstone attacks in women have been said to have been traced to tight lacing, which interfered with the normal flow of the bile. ~The Bowels.~--Constipation should be avoided, and the diet should be directed with this point in view. The meals must be frequent, ranging from four to six a day. In this way only is the flow of bile encouraged. The breakfast should be ample in order to utilize the bile secreted in the night season. With all this, care must be observed not to give more food than can be adequately handled by the digestive apparatus, since food which is not digested becomes a prey to the actions of the putrefactive bacteria which infest it, and the toxic substance thus formed produces the very result which all of our efforts are directed to prevent. ~Available Foods.~--The following foods low in fats may be used in formulating the diet: Soups: Meat broth (made from lean meat) from which all the fat has been removed. Meats: Lean beef, lamb, chicken, squab, quail, lean fish (in small quantities and not too frequently). Green vegetables: Except peas and carrots; beets and turnips may be taken sparingly. Fruits: Oranges, lemons, grapefruit, and unsweetened stewed fruit. Cereals: Wheat cereals, oatmeal, rice, and tapioca in moderation. Bread: Whole wheat, white, rye, and graham bread, toast, and crackers. Fluids: Weak tea and coffee (without cream, and a little sugar), orange and lemonade, mineral waters, water, skimmed milk, whey. Eggs: (except hard-cooked or fried). Desserts: Fruit gelatin, fruit whips, raw or stewed fruit. Avoid the following foods: Fats, oils, mutton, liver, brains, sardines, and caviar, oily fish, rich gravies and sauces, sweet fruit, peas, carrots, condiments and spices, pastry and confectionery, pickles, alcoholic beverages. Restrict carbohydrates, yolks of eggs, milk (cream must be skimmed off if too rich). DAILY DIET SHEETS I Breakfast--Baked apple with milk Cream of wheat with milk Weak coffee or tea Dry toast 11:30 A.M.--6 oz. orange juice, 1 egg white Dinner--Beef broth (well skimmed) with crackers Rice Stewed pears Weak tea Toast or rolls 3:30 P.M.--Albumenized fruit juice with crackers Supper--Wheatena with milk Milk toast Stewed prunes Toast and tea 9 P.M.--Well-skimmed chicken broth with crackers II Breakfast--Stewed apples with milk Milk toast Coffee without cream 10:30 A.M.--Well-skimmed broth with crackers Dinner--Tomato bouillon with crackers Baked potato--1 small potato Purée of spinach Orange gelatin Toast 3 P.M.--Albumenized lemonade Supper--Oatmeal or cream of wheat with milk Toast Tea Stewed fruit 9 P.M.--Well-skimmed broth with crackers III Breakfast--Grapefruit Oatmeal with milk Toast Weak coffee 10:30 A.M.--Orangeade with graham crackers Dinner--Cream of spinach soup (skimmed milk) Small piece of the breast of chicken Mashed or boiled potatoes Asparagus on toast Sliced oranges 3:30 P.M.--Well-skimmed broth with crackers Supper--Farina or cream of wheat or wheatena, with milk Baked potato Baked apple with milk Toast and tea 9 P.M.--Albumenized orange juice IV Breakfast--Sliced oranges Oatmeal Toast Coffee 10:30 A.M.--Beef gruel, 6 oz. Dinner--Cream of asparagus soup, skimmed milk Thin slice of roast beef or whitefish Rice or potatoes Tender string beans Fruit Toast Buttermilk 3:30 P.M.--Orangeade Supper--Stewed fruit with puffed wheat or rice Milk toast Tea 9 P.M.--Broth SUMMARY ~Functions of Liver.~--To transform fuel foods into available energy; to detoxify those poisonous substances produced as the result of metabolism of body tissue or brought in in food, and to select those available for use; to secrete bile. ~Factors Influencing Disorder of Liver.~--Errors in diet: (a) overeating; (b) excessive drinking; and (c) unbalanced diet, especially as regards the amount of fats and carbohydrates in the diet. ~The Bowels~, in most of the disturbances affecting the liver, become constipated, thus causing much additional work on the part of the liver in handling the products produced as the result of putrefactive bacteria upon the accumulated mass in the colon. ~Tissue Changes~ in the liver have been caused by the taking of alcohol, which should therefore be avoided by all individuals having any disease involving the liver and by those with a predisposition to liver disturbances. ~Exercise and Lack of Exercise~ are potent factors in the treatment of conditions involving the liver. First, because the liver requires exercise to enable it to empty itself more completely and assure a free flow of bile; second, because exercise directly affects the energy output of the body, causing an increased rate of metabolism and a better utilization of the food ingested. Lack of exercise acts in exactly the opposite direction, and it has been found that with the majority of patients suffering from diseases of the liver too little exercise and too much food are at the bottom of the trouble. ~Dietetic Treatment~ in the majority of diseases affecting the liver is much the same. The keynote in each is a balanced diet. Constant overeating and excessive drinking have proved the foundation of the majority of such diseases, especially of the bilious type, while an excess of fat and carbohydrates in the diet lead to the more serious disorders. ~Biliousness~ requires abstinence from food for a short period and a cleansing of the entire gastro-intestinal tract, the measures being directed by the physician. After the bilious symptoms have subsided, a simple, well-regulated diet should be established, in which no rich foods of any sort are allowed. All condiments and spices which have an astringent effect upon the bowels are strictly prohibited, and alcoholic beverages had best be eliminated from the diet. ~Cirrhosis~ of the liver is apt to be insidious in its development, taking a firm hold before the character of the disorder is discovered. Dietetic treatment of this disturbance is most important and should be directed toward overcoming not only the liver symptoms but other symptoms as well. ~Gastro-intestinal Disturbances~, manifested in cirrhosis of the liver, are treated by the diet used in chronic gastritis (see p. 250). ~Heart Symptoms~ sometimes occur during the course of the disease and require especial attention to the diet. The fluids at times must be restricted, in which case a modification of the Karell Cure will prove valuable (see p. 342). ~Kidney Complications~ develop in a certain percentage of cases, and it then becomes necessary to institute one of the various diets devised to meet the needs of those special conditions (see Chapter XVIII). ~Restricting the Diet~ will be found to be necessary for those individuals showing a tendency to cirrhosis, also for those in whose family diseases of the liver are of frequent occurrence. Such individuals should be warned of the dangers arising from overindulgence in food or alcoholic beverages. ~Prohibited Foods~ are those which by reason of their astringent qualities favor the development of constipation, such as condiments and spices; those foods which exert a stimulating and irritating effect upon the liver and bile passages, such as alcohol, malt extractives, etc.; and fats and carbohydrates in excessive quantities, on account of the extra amount of work required of the liver in order to make them available in the body. ~Gallstones~ develop as the result of inflammation or clogging of the bile passages. ~Treatment~ is dietetic in character and is directed toward relieving or preventing inflammation in the bile passages, also in stimulating the flow of bile in order that it may not become sluggish and thus give rise to the development of the gallstones. ~The Fats~, therefore must be restricted in the diet, as they, more than any of the other food constituents, favor the above conditions. ~Peristalsis~ in the intestinal tract must be stimulated to facilitate a free flow of bile, which will not occur where the movements are sluggish. Stasis of the bile must be prevented or stones will be apt to form. ~Dietetic Treatment~ for gallstones is therefore directed to increase the flow of bile and to avoid the inflammation of the gall bladder and bile passages which may result from the product of intestinal putrefaction. ~The Diet~ consists of foods simple in character, low in fats, but abundant in quantity, in order to prevent constipation. It must be selected carefully that digestional disturbances may not develop. ~The Meals~ should be frequent, from four to six a day, in order to encourage a free flow of bile. ~Breakfast~ should be ample in order that the bile secreted and accumulated during the night may be utilized as soon as possible. ~Constipation~ must be avoided, and the foods particularly adapted to prevent or overcome this condition should have a prominent place in the diet. Any accumulation of unabsorbed food in the lower intestines becomes a breeding ground for putrefactive bacteria, the product of whose activity imposes a serious tax upon an already overworked organ. PROBLEMS (a) Formulate a diet for a patient suffering from gallstones. Outline method of administration. (b) List available foods for diets used in disturbances of the liver. List the foods to be avoided in such cases. FOOTNOTE: [155] "Diet in Health and Disease," p. 399, by Friedenwald and Ruhräh. CHAPTER XXII GOUT, OBESITY, EMACIATION Gout is a constitutional disease characterized by an inflammatory condition of the joints. It is caused by or associated with a retention of uric acid in the blood. Gout is also characterized by the deposit of uric acid or sodium salts which occurs in different parts of the body, the joints, the lobe of the ear, the knee and the elbow being common points where the deposit of these salts ordinarily occurs. The amount of uric acid is lessened in the urine in cases of true gout, except in acute attacks, and in this way it is distinguished from the so-called goutiness in which a urinalysis shows an excess of uric acid. According to Strouse, this excess of uric acid in the urine "means a physical-chemical change in the urine and is quite different from the small amount usually excreted."[156] ~Source of Uric Acid.~--In man the uric acid which is eliminated in the urine is derived from two sources. It may be taken with the body as purins in food, in which case it is spoken of as being an "exogenous" product, or it may be formed in the body from the breaking down of the nucleoproteins (the highly nucleated cells of the glandular organs particularly). When the uric acid is formed in this manner as the result of the metabolism of the body tissues, it is known as "endogenous." In the normal body approximately one-half of the uric acid formed is oxidized, while the remaining half is eliminated from the body by way of the urine. ~Elimination of Uric Acid.~--In gout such is not the case, the body loses to a certain extent the ability to eliminate the uric acid, hence it is retained within the body, causing an excess in the blood stream, and it is this excess uric acid in the blood which causes the acute attacks and general pain and discomfort which inevitably occur in chronic gout. ~Purin-bearing Foods as Sources of Uric Acid.~--Formerly no difference was made in food; all were supposed to cause uric acid formation, but with the exhaustive investigation of food materials this sweeping condemnation has been to a great extent removed or narrowed down to a few foods, those rich in purins being the chief offenders. ~Chief Causes of Gout.~--Without a doubt, overeating, overindulgence in alcoholic stimulation, lack of exercise, etc., are chiefly to blame for the large percentage of the cases, but upon investigation it will be seen that those individuals are as a rule large protein eaters and that their mode of living is not such as to assist the body in throwing off the poisons which form as the result of their self-indulgence. ~Rules to Combat Gout.~--To successfully combat the retention of a large percentage of uric acid in the blood there are certain definite rules to be observed: (1) The general diet must be reduced not only in amount but also in purin-bearing foods; (2) All foods which are liable to cause digestional disturbances, with the attending evils of intestinal putrefaction and constipation, must be avoided. ~Alcohol in Gout.~--If the patient is accustomed to alcoholic stimulants and has been in the habit of taking them constantly for years, the amount of alcohol consumed daily must be radically reduced and only the amount prescribed by the physician taken. Alcohol without a doubt assists in the retention and increases the difficulty of uric acid elimination by the body. In view of the present knowledge of the cause and effect of uric acid in the body, the treatment of gout is directed with the object of relieving the condition (1) by facilitating the elimination of uric acid from the body, and (2) by so regulating the diet as to exclude as far as possible those purin-bearing foods which, by reason of their chemical composition, augment the general amount of uric acid formed within the organism. In gout, as in other abnormal conditions, no set rule can be laid down to cover the treatment of every case. The individual must be taken into consideration, his daily habits studied and the extent and character of the disease known before it is possible to prescribe a treatment or formulate a diet which would adequately meet his needs under the existing conditions. ~Obesity and Glycosuria.~--Gouty individuals often become obese and show evidences of glycosuria. Consequently it is important to regulate the carbohydrates as well as the purin-bearing foods in the diet. Only the simplest foods are permissible. In acute attacks it has been found that milk and alcohol cause less disturbance than meat and alcohol. While the acute symptoms exist all meat should be avoided and the daily allowance of alcohol cut down. Tea and coffee both contain purins and should be avoided while the acute stage of the disease continues. Cereal coffee, hot water tea, hot milk or buttermilk may be substituted. ~Purin-free Diet.~--A purin-free diet is advisable during the acute attack. The following is a sample menu of such a diet: Breakfast--Banana, apple, grapefruit, orange or peach, etc. Cereals: farina, hominy, or cream of wheat with cream and sugar 1 egg, soft-cooked Buttered toast Cereal, coffee with sugar and cream or hot water tea (milk and hot water) with cream and sugar Lunch or Dinner--Poached egg on toast, 1 large baked potato with butter, 1 mold of fruit jelly with cream Supper--Rice and butter, bread or toast with hot milk Apple sauce with cream _Purin Per Cent._ Cocoa contains 1.00 per pint Tea " 1.20 per pint Coffee " 1.70 per pint Purins are soluble in water, hence those foods that are boiled contain less than those prepared by other methods of cookery. ~Foods More or Less Condemned.~--Salt has a tendency to bring about a deposit of sodium urates in the body, and for this reason should be sparingly used in the preparation of the diet. Alkaline waters are inclined to produce a like result, consequently should be avoided by the gouty individual. Condiments and spices are conducive to constipation, a condition to be avoided if possible under the circumstances. Certain physicians prohibit the use of oranges in the diet of gout, while others do not. Strawberries are likewise condemned and should be eliminated from the diet for both chronic and acute gout. ~Diet in Chronic Gout.~--In chronic gout it is necessary to maintain the general health of the patient by a well-balanced diet. This is not difficult even if the dietary is so regulated as to be well within the limits of his energy requirements. It is necessary to limit the purin-bearing foods. Meats are used sparingly and these should be boiled rather than roasted or broiled. Eggs and cheese and milk should be substituted for at least part of the regular allowance of meat. ~Exercise and Massage.~--The patient should be recommended to take a certain amount of mild exercise in the open air, or massage if he is accustomed to living an indoor life or is confined to office work. He must be warned against overindulgences of all kinds, especially of overeating and drinking. A glass or two of hot water before breakfast is recommended. ~Treatment of Obesity.~--The treatment of obesity when occurring in gouty patients is much like that used in other conditions. Ebstein regards obesity under such circumstances as an unfavorable symptom. He advises a reduction in the carbohydrates to the smallest possible amount and allows meat and fats in the diet. ~Allowable Foods.~--The following foods are practically purin-free and may be used in the diet of gout:[157] Milk, cheese, butter, eggs, nuts, gelatin, fruits, sugar, breads made with white flour, cereals, cream of wheat, farina, rice, hominy, tapioca, cornstarch, potatoes and other root vegetables, green vegetables, except asparagus, spinach, and all fats. ~Avoidable Foods.~--The following foods are rich in purins and should be avoided in the diet for gout: Sweetbreads, liver, kidneys, beef, mutton, veal, pork, turkey, chicken, goose, rabbit, duck and other game, fish, with the exception of cod, sardines, and anchovies, tea, coffee, and cocoa. The following list shows the purin content of some of the above-mentioned foods. The purins are computed by Hall as follows: 1 kilogram contains, _Grams Purin_ Milk Butter Eggs Cheese Farina Rice Hominy Potato 0.02 Flour Bread Cauliflower Eggplant Cabbage Lettuce Sugar Peas 0.39 Asparagus 0.21 Lentils 0.38 Halibut 1.00 Cod .05 Salmon 1.00 Mutton 0.96 Beef 1.10-2.00 Veal 1.10 Ham 1.10 Pork 1.20 Oatmeal 0.53 Beans 0.63 Chicken 1.20 Sherry Claret Whisky Brandy Beer 0.12 Porter 0.14 Ale 0.14 Chocolate per pint 0.70 To keep the body in good condition and to help rid it of accumulated poisons, the following diet lists are recommended: ~Daily Dietaries:~ 7 A.M.--Hot water, 8 oz. 8 A.M. Breakfast--Stewed prunes, wheatena and cream 2 eggs 2 slices of buttered toast 1 cup of milk flavored with cocoa or coffee or 1 cup of cereal coffee with cream Dinner--Cream of pea soup Boiled codfish with cream sauce Mashed potatoes Cauliflower Rice pudding Supper--Cream toast Baked potatoes Egg nest Apple sauce Hot milk flavored with coffee, cocoa, or 1 cup of cereal coffee 7 A.M.--Hot water, 8 oz. 8 A.M. Breakfast--Grapefruit Cereal and cream Soft scrambled eggs Cereal coffee, or milk and coffee Buttered toast 12:30 Lunch--Cream of tomato soup Cottage cheese and cream Baked potato Baked apple Bread and butter 6 P.M. Dinner--Chicken, small piece, no gravy or rich dressing Candied sweet potatoes Baked eggplant Lettuce salad (lemon juice instead of vinegar) Bread and butter Orange or wine jelly Milk Breakfast--Cereal and cream Baked apple with cream 1 slice of bacon 1 soft-cooked egg Toast--butter Cereal coffee, or milk flavored with coffee Lunch--Vegetable soup Scalloped potatoes Cream cheese Bread, butter Stewed pears Dinner--Halibut steak Creamed potatoes String beans Fruit salad Sponge cake, orange sauce Small coffee OBESITY Probably no one problem affecting the human family is more widely discussed than that of obesity. There are numberless "cures" suggested, most of which contain some good, but they are as a rule more strenuous than the average fat person cares to attempt, or, if attempted, persist in. ~Causes of Obesity.~--It is stated that at least fifty per cent. of the obesity is of hereditary origin, while the rest may be due to overeating and drinking, unbalanced diets, metabolic changes due to the approach of menopause in women, and diseases such as gout in which there is a certain amount of disturbance in the blood and excretory organs and in which the diet or the disease may be accountable for the gain of surplus adipose tissue. Women approaching menopause may not change their diet in the least and there may still be the noticeable increase of fat. ~Obesity Cures.~--A great number of the "cures" are undertaken not from a health standpoint but from the esthetic point entirely. It makes no difference what reason is brought forward for instituting the treatment, it is the results which count. Of the cures undertaken which are in themselves good, but which are too strenuous for the average "fat person" to stick to may be mentioned some of the early cures instituted and recommended by Banting, Oertel, and Ebstein. Obesity, then, may be said to be due to (1) heredity, (2) overeating and drinking, (3) lack of exercise (sedentary life), (4) a combination of the above causes. Whether the obesity is due to the lack of exercise or the lack of exercise is due to the accumulation of fat which causes a disinclination to move on the part of the individual, can only be judged when a thorough examination into the life and habits of the patient is made. ~Comparison of Food Intake and Energy Output.~--Many fat people who claim to be small eaters in reality constantly consume more food than their age, weight, or mode of living would necessitate. If such patients could be prevailed upon to keep a correct chart of their daily intake of food and the amount of exercise taken, they would be astounded to find how much greater was the intake in comparison to the output of energy, in other words, how much more food they ate than they required to keep them in health. A glance at the first tables in this text will show which foods are utilized by the body chiefly as a source of energy. ~Uses of Food in Body.~--Physiological chemistry proves that when more food is taken than is needed for the internal and external work of the body, the surplus is stored for future use, first, in the liver and muscles as glycogen for the general expenditures, and, second, as adipose tissue for future use. Thus it is seen that when the intake is constantly greater than the energy expenditure there must necessarily be some way in which the body can store up the surplus fuel, and so long as the digestion remains good and the amount of exercise limited there is no reason why there should not be a constant and steady accumulation of surplus fat which inevitably terminates in obesity. ~Water as a Fat Maker.~--That water is in itself fattening is of course untrue. A chemical analysis of this fluid shows that it is inorganic in character and cannot alone either produce energy or build tissue. However, this food constituent plays a most important part in all the functions of the body. In the first place the body cannot utilize food unless it is in solution; water is also one of the best known stimuli to the flow of gastric juice, and for this reason is an important factor in the preparation of the food for its absorption and utilization; since water forms the bulk of the blood, it acts as a distributor or carrier of food to the different parts of the body. ~Limiting the Fluids in Obesity.~--Thus it is seen that when the intake of fluids is limited, the body will call upon that surplus which is stored in every nerve, tissue, and fluid throughout the entire organism to assist in the necessary work of the organs, thus reducing the body weight just that much. ~Exercise.~--The athlete who is overweight, due to adipose tissue, increases his exercise at times, even adding to the weight of his clothing, causing an increased energy output, profuse perspiration, etc., all of which causes the body to use its surplus fuel in the form of the stored fat. Exercise does not break down a muscle, it builds it up. Thus many individuals who increase the strenuousness of their exercise complain that their weight is increased even when they observe a noticeable improvement in their general feelings and appearance. ~The Appetite.~--The great trouble with most women who undertake an obesity cure which calls for an increased amount of energy is that they will develop an increased appetite thereby which they appease with food instead of forcing the body to use the store in hand, thus entirely doing away with any good the treatment might have accomplished. No amount of exercise without a proper regulation of the diet will prove satisfactory as far as the reduction of fat is concerned. The following methods recommended by Banting, Oertel, and Ebstein are included here. OBESITY DIETS AND CURES ~Banting Method.~--This method is said to be unsuited to those with weak digestions. Following its use such individuals have been known to develop renal colic or gallstones; constipation may be present and the entire system may become so deranged as to render the patient liable to disease.[158] ~Banting Diet for Obesity.~--Breakfast at 9 A.M., consisting of 5-6 ounces of animal food, meat or boiled fish (except pork or veal), 1 small biscuit or 1 ounce dry toast. Total solids, 5-6 ounces. Coffee or tea (without milk or sugar), 9 ounces. 2 P.M.--Dinner: Fish or meat (salmon, eels, herring, pork, and veal excepted), poultry or game; any vegetable except potatoes, parsnips, carrots, turnips, or beet roots; dry toast, 1 ounce; fruit cooked and unsweetened; good claret, sherry, or Madeira, 10 ounces. Total solids, 10-12 ounces. 6 P.M.--Tea: 2-3 ounces cooked fruit; 1-2 ounces rusks; 2-4 ounces solids; 9 ounces tea, without milk or sugar. 7 P.M.--Supper: Meat or fish as at dinner; claret or sherry and water, 7 ounces. Total daily solids, 21-27 ounces. Total fluids, 35 ounces. * * * * * Oertel pointed out the great benefits which might be derived by those individuals suffering from certain types of heart disease which are accompanied by obesity. He made it distinctly understood that while the treatment in no way affected the heart lesion,--that is, in so far as altering the character of the disease,--it greatly reduced the work imposed upon the circulatory organ and permitted a more complete oxidation of the blood.[159] ~Oertel's Method.~--Oertel bases his dietetic treatment of obesity upon the heart changes and those which naturally follow in the circulation. He makes the following suggestions, taking always into consideration the condition of the patient, whether he is anemic or plethoric. "(a) Where there is an abnormally increased amount of fat in plethoric patients with unimpaired or only beginning changes in the heart action, the diet should aim at: (1) An increased supply of protein. (2) A decrease in the fat-forming substances. (3) Little or no diminution in the supply of liquids below the physiologic amount (1500 c.c.--3 pt.) (b) Where there is obesity in anemic patients, viz. serious plethora, the diet should aim at: (1) An increase in the quantity of proteins. (2) A diminution in amount of fat-forming substances and eventually (3) a decrease in the amount of fluid. (c) Where there is obesity in adults with anemic symptoms in whom not only the amount of protein but also the abnormally increased amount of fat is slowly wasting away, they require: (1) An increase in the amount of protein taken. (2) A sufficient amount of fat and carbohydrates or even an increase of same to prevent the falling off of fat. (3) A diminution in the amount of fluid taken." Oertel claims that the simplest method of reducing the fat-forming elements in a diet is to decrease the amount of fat and allow a certain amount of carbohydrates, regulating the diet according to the individual. The following table is given by him as showing the minimum and maximum amount of the different food constituents constituting the obesity diet: ==========++=========+========+==============+=========== ||_Protein_| _Fat_ |_Carbohydrate_|_Calories_ || _Gm._ | _Gm._ | _Gm._ | ----------++---------+--------+--------------+----------- Minimum || 156 | 25 | 75 | 1180 Maximum || 170 | 45 | 120 | 1608 ==========++=========+========+==============+=========== In instituting a treatment for obesity Oertel insists upon a certain amount of exercise daily in the open air, the amount to be regulated by the physician according to the individual case. He suggests that five or six small meals a day be given rather than a few large meals. He eliminates soups, tea, and coffee while the cure is being given. ~Ebstein~ suggests a diet in which the carbohydrates and fluids are reduced but in which the fats are allowed to a considerable extent. The diet consists of meat, eggs, fish, vegetables (green) and fruits. The following menu demonstrates his dietary régime: Breakfast: Large cup of tea (no milk or sugar); 2 oz. bread with plenty of butter. Dinner: Soup 4-1/2 to 5-1/2 oz.; meat with fat sauce; green vegetables; fresh fruit; 2-3 glasses light wine. Afternoon: Tea as at breakfast. Supper: Tea, 1 egg, fat roast meat or ham, smoked fish; about 1 oz. bread with plenty of butter; a little cheese and fresh fruit; potatoes, sweets and sugars forbidden. ~Dietetic Treatment.~--The following menus are suggested by the author: The carbohydrates and fats are restricted and the fluids reduced to a minimum. The meals as far as possible are kept "dry"; soups, milk, cocoa are avoided; water is not permitted at meals; alcoholic beverages, white bread, butter, potatoes, sugar, candy, pastry, cakes, puddings, gravies, sauces, bread dressings, griddle cakes, sirups, molasses, honey, ice cream, cereals, pork of all sorts, ham, bacon pork chops, etc., olive oil, spaghetti, macaroni, and noodles are prohibited. ~Allowable Foods.~--The following foods are allowed: Black coffee or tea, small cup twice daily without milk, cream, or sugar--saccharin may be used to sweeten if desired; fresh or stewed fruit with the exception of bananas, raisins, and dates, served without sugar; all green vegetables cooked or served without butter or fat of any description; salads, except potato or banana, served with a special dressing (no oil or sugar); water ices; watermelon and other melons served without sugar; 1 egg a day; gluten toast, no butter; brown bread or muffins made with gluten flour and prepared bran. ~The following menus~ may be used as guides in the treatment of obesity: Breakfast--1 sliced orange (no sugar) 1 small cup coffee or tea without cream, milk, or sugar (sweeten with saccharin if desired) 1 poached egg on 1 slice of gluten toast (no butter) Lunch--Cottage cheese and lettuce salad with special dressing 2 broiled lamb chops 1 slice gluten bread; 3 ounces (1 serving) apple sauce (sweetened if necessary with saccharin) Dinner--Roast beef Spinach or greens (cooked without fat meat) Green peas Tomato and lettuce salad with special dressing Orange or wine jelly (sweetened with saccharin) 1 slice of gluten bread or toast 7 A.M. or 1 hour before breakfast--1 cup of water containing juice of 1/2 lemon Breakfast--1/2 grapefruit without sugar 1 small cup black coffee or tea Beefsteak broiled and served without butter (lean) 1 slice of gluten toast Lunch--Tuna fish salad (no olive oil in dressing) 1 bran muffin or 1 slice (1 oz.) gluten toast 1 baked apple (without cream or sugar) Dinner--Roast or boiled chicken (no gravy or bread dressing) Green vegetables (peas, string beans, cabbage,[160] turnips, artichokes (without butter)) Fruit salad (special dressing) Lemon ice ~Amount of Food.~--The amount of food is limited to a certain extent. Green vegetables may be eaten in abundance, but the protein foods such as meat, fish and eggs must be limited.[161] The bread (even gluten and bran breads) must be limited to 1-2 slices at each meal. All meals are eaten without fluids except breakfast, when one small cup of coffee or tea without milk, cream, or sugar is allowed. If fruit juice is to be served instead of fruit, it must be prepared with little if any water and no sugar. The juice may be poured over cracked ice, if desired. The following reducing diet is suggested by Dr. Rose for the use of over-fat women: REDUCING DIET FOR OBESE WOMEN[7] _Fuel value 1052 calories--ordinary requirements 2200 calories_ ========================+===============+========+==========+========== | _Measure_ |_Weight_|_Protein_ | _Total_ | | _Oz._ |_Calories_|_Calories_ ------------------------+---------------+--------+----------+---------- Breakfast: | | | | Apple | 1 medium | 4.9 | 2 | 65 Egg | 1 egg | 2.4 | 27 | 75 Toast | 1 slice | 0.5 | 7 | 50 Coffee[162] | 1 cup | | | Skim milk | 1-1/2 tbs. | 1.0 | 3 | 10 | | | | 10:30 A.M. | | | | Bouillon | 1/2 cup | 4.0 | 10 | 12 Water cracker | 1 cracker | 0.1 | 1 | 10 | | | | Luncheon: | | | | Lean cold roast beef | Medium serving| 3.5 | 97 | 150 Rye bread | 2 thin slices | 0.7 | 7 | 50 Lettuce and cottage | | | | cheese salad: | | | | Lettuce | Ad libitum | | 40 | 85 Cheese | 2-1/2 tbs. | | | | | | | 4:30 P.M. | | | | Tea with lemon[163] | 1 cup | | | Water cracker | 1 cracker | 0.1 | 1 | 10 | | | | Dinner: | | | | Boiled cod with lemon | Large serving | 8.2 | 209 | 225 Boiled potato | 1/2 medium | 1.8 | 6 | 50 Cauliflower (plain) | Large serving | 3.0 | 6 | 25 Butter | 1 tsp. (scant)| 0.1 | | 30 Water-cress and egg | | | | salad: | | | | Water-cress | Ad libitum | | | Egg | 1 egg | | 27 | 110 French dressing | 1/2 tbs. | | | Orange | 1/2 large | 4.7 | 3 | 50 Black coffee | Demi-tasse | | | | | | | 10:30 P.M. | | | | Hot skim milk | 1/2 cup | 4.3 | 16 | 45 | | | | ______ Total calories | | | | 1052 ========================+===============+========+==========+========== AUTHOR'S REDUCING DIET _Approximate fuel value 965.5 calories_ =====================+==============+=========+=========+======+========== | | | _Carbo-_| | _Material_ | _Amount_ |_Protein_|_hydrate_| _Fat_|_Calories_ | | _Gm._ | _Gm._ | _Gm._| ---------------------+--------------+---------+---------+------+---------- Breakfast: | | | | | Orange | 1 medium | 1.5 | 17.4 | 0.3 | 78.3 Poached egg | 1 egg | 5.3 | | 4.6 | 62.6 on | | | | | Toast (gluten) | 1 slice (1 | | | | | oz.) | 8.4 | 8.5 | 0.3 | 70.3 Coffee (black) | 1 cup | | | |__________ | | | | | 211.2 | | | | | Luncheon: | | | | | Lettuce and cottage| | | | | cheese salad: | | | | | Lettuce | Ad libitum | | | | Cheese | 2 tbs. | 5.9 | 1.2 | 0.2 | 30.2 Dressing | 1 tbs. | 1.5 | | 3.4 | 36.6 Lamb chop | 1 chop | 9.2 | | 12.7 | 151.3 Gluten bread or | | | | | toast | 1 slice | 8.9 | 8.5 | 0.3 | 70.3 Apple sauce | 1 serving, | | | | | about 1/8 | | | | | cup | 0.6 | 22.5 | 0.7 | 97.5 | | | | |__________ | | | | | 385.9 | | | | | Dinner: | | | | | Roast beef | 2 thin slices| | | | | (2 oz.) | 11.4 | | 4.8 | 88.8 Spinach | 1/2 cup | 2.3 | 3.6 | 0.3 | 26.3 Green peas | 1/2 cup | 4.8 | 11.1 | 0.2 | 65.4 Lettuce | Ad libitum | | | | Tomato | 1 medium | 0.4 | 3.1 | 0.2 | 15.8 Dressing | 1 tbs. | 1.5 | | 3.4 | 36.6 Orange jelly: | | | | | Orange juice | 1/2 cup (8 | | | | | tbs.) | | 14.2 | | 56.8 Lemon juice | 1 tbs. | | | | Gelatin | 1 tsp. | 2.1 | | | 8.4 Water | 1 tbs. | | | | Saccharin | 1 tablet or | | | | | less | | | | Bread (gluten) | 1 slice | 8.4 | 8.5 | 0.3 | 70.3 | | | | |__________ Total grams | | 72.2 | 98.6 | 31.7 | 368.4 | | | | |========== Total calories | | | | | 965.5 =====================+==============+=========+=========+======+========== _Approximate fuel value 930.5 calories_ =====================+==============+=========+=========+======+========== | | |_Carbo-_ | | _Material_ | _Amount_ |_Protein_|_hydrate_|_Fat_ |_Calories_ | | _Gm._ | _Gm._ |_Gm._ | ---------------------+--------------+---------+---------+------+---------- Breakfast: | | | | | Fruit | 1 orange | 0.85 | 12.05 | 0.15 | 53.0 Gluten toast | 2 slices | 17.8 | 17.0 | 0.6 | 140.0 Egg (poached or | | | | | soft-cooked) | 1 egg | 5.3 | | 4.6 | 60.0 Coffee (black) | 1 cup | | | |__________ | | | | | 253.0 | | | | | Luncheon: | | | | | Oyster cocktail | 6 oysters | 3.5 | 4.20 | 0.68 | 37.0 Cold roast beef | 1 slice (1 | | | | | oz.) | 5.7 | | 2.4 | 44.0 Cold slaw: | 1/2 cup | | | | Cabbage | 1/2 cup | 0.002 | 0.001 | 0.034| 4.5 Dressing | 1 tbs. | 1.5 | | 3.4 | 36.0 Gluten toast | 2 slices | 17.8 | 17.0 | 0.6 | 140.0 | | | | |__________ | | | | | 261.5 Dinner: | | | | | Chicken (without | 3 oz. one | | | | stuffing) | serving | 18.2 | | 2.1 | 92.0 Broiled mushrooms | 6 medium | | | | | size | 1.5 | 3.0 | 0.18 | 19.0 String beans | 3 oz. one | | | | | serving | 1.95 | 6.29 | 2.29 | 34.4 Pineapple salad: | | | | | Lettuce | Ad libitum | | | | Pineapple | 1 slice | 4.0 | 31.0 | 0.6 | 129.5 Dressing | 1 tbs. | 1.5 | | 2.4 | 37.0 Apple float: | | | | | 1 apple | 1 apple | 0.6 | 22.2 | 0.77 | 98.1 1/2 egg white | 1/2 egg white| 1.5 | 0.02 | | 6.0 Saccharin to | | | | | sweeten | | | | | | | | | |__________ Total grams | | | | | 416.0 | | | | |========== Total calories | | | | | 930.5 =====================+==============+=========+=========+======+========== ~Rules and Regulations.~--The following directions and menus are given to be used when a reduction in weight is necessary. Care must be taken not to allow large amounts of even the non-fat-forming foods in the dietary, since under certain conditions the body will manufacture adipose tissue of any surplus organic material ingested. Breakfast must be limited as demonstrated in the tabulated diet sheet. ~Keeping the Weight Down.~--After the individual has been reduced to approximately the desired weight the diet may be made a trifle more liberal, keeping in mind, however, that moderation is the keynote in the obesity régime and will have to be practised to a certain extent always. It is wise to continue the dry meals and to limit the amount of butter, cream, and other "fatty foods," to a certain extent. Pork, with the exception of crisp bacon several times a week at breakfast, had best be avoided, and alcoholic beverages should be omitted entirely except when prescribed by the physician. The outdoor exercise should be continued and only the amount of sleep requisite to health indulged in. If the individual will faithfully carry out these directions, there is no reason why the weight should continue to be a burden. It must be remembered that it is never safe to diet indiscriminately and without the advice of a physician, since much harm may come of so doing. ~Value of Massage.~--Massage is an advisable accompaniment to an obesity diet and will help to prevent a sagging of the tissues which have been deprived of the supporting fat. The tissues of the face, neck, and breast are especially apt to wrinkle unless given the exercise and stimulation from massage. ~Cold baths~ are likewise advisable, since they stimulate the body to burn up the fat. OBESITY MENUS Lunch--Tuna fish salad Cauliflower Baked apple Dinner--Soft-shell crabs Roast lamb Spinach Tomato jelly Grapefruit Lunch--Corned beef and cabbage Stewed pears Dinner--Clam cocktail Roast chicken Asparagus Fruit salad Lunch--Broiled oysters; cold lamb Boiled turnips Water-cress salad Dinner--Roast beef Stewed tomatoes String beans Lettuce and tomato salad Sliced peaches Lunch--Broiled calves' liver Greens (mustard, turnip, beet tops, or dandelion) Orange jelly Dinner--Crab-flake cocktail Broiled squab Artichokes Stewed celery Lettuce, Russian dressing Lunch--Kippered herring Veal croquettes (baked instead of fried, with tomato sauce; this dressing is made by adding 1 teaspoonful of chili sauce to the regular dressing used in obesity diets) Asparagus Apple sauce Dinner--Baked halibut steak, stuffed with oysters Boiled onions Boiled carrots Pineapple and grapefruit salad Lunch--Broiled calves' brains Vegetable salad Melon Dinner--Broiled chicken Boiled beets String beans Cucumber and young onion salad Raspberry ice Lunch--Stuffed eggs Sliced tongue with spinach or greens Carrots or beets Fruit Dinner--Roast turkey, cranberry sauce Cauliflower Tomatoes stuffed with celery, green peppers and onion dressing Peach whip Lunch--Hashed beef Boiled onions Stewed prunes Dinner--Oysters Baked rabbit Eggplant (baked) Spinach Fruit jelly EMACIATION Emaciation as a rule is a symptom of an abnormal condition rather than a disease in itself. Certain individuals are said to be "constitutionally thin" and upon investigation it is often found that this thinness extends back in many cases for generations, many members of a family being thin no matter what measures are taken to overcome the condition. However, constitutional emaciation is not so prevalent as constitutional obesity and, as has already been stated, is more often a symptom of some metabolic disturbance or pathological condition. ~Causes of Emaciation.~--~Errors in diet~--insufficient or improper food--are accountable for most of the cases seen in infants and children. ~Over-exercise~, that is, when the amount of exercise taken is not commensurate with the intake of food, is accountable for other cases. This type of emaciation is found especially in growing children. ~Disease as a Cause.~--Wasting diseases, such as tuberculosis and anemia, bring about a loss of weight, while in fevers in general and typhoid fever especially not only the febrile condition hastens the metabolic processes but also the activities of the bacteria act together and break down the tissues of the body, causing a falling off from the normal body weight. Loss of sleep, unhygienic or unsanitary surroundings, and capricious appetites probably cause some of the cases of excessive thinness. ~Thinness in Children.~--Parents are to blame for much of the thinness seen in children, especially the nervous high-strung children whose energies outweigh their desire for food or, as is more often the case, their willingness to eat the proper foods. It is a mistaken kindness to cater to the whims and fancies of a child's appetite, and much harm is wrought by allowing the "trash" to overbalance the necessary building or repair food in the dietary. Not that sugar is not necessary, for it is particularly so at the age when the metabolic processes are faster than later in life, but it must be remembered that the body is being built up both in height and breadth. ~The Need for Building Foods.~--The skeleton and the muscular tissues cannot be constructed from sugar, hence the diet which consists chiefly of this food constituent is unbalanced and will sooner or later bring about disturbances which are very apt to result in emaciation. ~The causes of emaciation~ may be summarized as follows: (1) Those cases which are due to pathological conditions such as tuberculosis, anemia, typhoid fever, etc.; (2) Those induced by errors in diet and bad habits such as insufficient or improper food, loss of sleep, over-exercise, lack of ventilation in the sleeping apartment, which destroys the appetite; (3) Malformation or deformities of mouth, throat, or stomach which make it impossible for the individual to partake of sufficient food to cover the needs of the body; (4) Heredity ("constitutional thinness"). ~Regulating the Diet.~--As has been stated in a former chapter, any persistent loss of weight or failure to gain on the part of an infant whose chief business in life should be to grow, should be given immediate and careful attention. As a rule the diet is to blame; it is either improperly balanced, insufficient in amount, or poorly prepared, any of which might readily cause a disturbance to the delicate apparatus of the child. ~Diet and Habits.~--In adults, the diet and habits of life are in many cases to blame for the excessive thinness seen in many individuals. If the trouble can be traced to some abnormal condition, it can only be removed by relieving or checking the disease which induced it. The older methods of treating typhoid fever, for example, did nothing to prevent the progressive emaciation which was the result not only of the accelerated metabolism from the fever but also from the invasion of the intestinal tract by the specific bacteria which brought about a like result. In tuberculosis a similar breaking down of the tissues occurs, as is likewise the case in anemia and other diseases in which the functions of the blood-making organs are interfered with. Any of the above diseases may cause emaciation, and the treatment in most of the cases resolves itself in removing the cause as far as possible and in adjusting the diet. ~Selection of Food.~--The dietetic treatment for emaciation is practically the only one which will materially change the weight of the individual, since by food alone is the body built. Certain foods are more capable of being readily converted into adipose tissue than others, and these must have a prominent place in the dietary. ~Rules and Regulations.~--In obesity it was found that it was necessary to curtail the sleep and rest, increase the amount of exercise and decrease the amount of food. In emaciation practically an opposite régime is adopted. The patient is urged to eat plenteously, drink copiously of water and nutrient beverages, soup, etc., avoid worry and excitement, over-exertion and indigestion, to take one or two naps every day, to retire early, to avoid hot baths and take a warm cleansing bath followed by a cold shower or sponge bath. Exercise must be of a mild character; the patient must be warned against becoming exhausted, since this condition precludes a gain in weight. ~Dietetic Treatment.~--The meals must be carefully selected, well prepared and daintily served, that all of the psychical benefits from such efforts may be attained. A nutrient beverage such as cream, egg, and vichy, reënforced fruit beverages, malted milk, with egg and chocolate, cereal and milk gruels, etc., may be given between breakfast and lunch, lunch and dinner and before retiring. The meals must consist of the simplest foods that the digestion may not be overtaxed by the quantity ingested. ~Allowable Foods.~--The following foods may be used in the treatment of emaciation: All dairy products, milk, cream, butter and cheese, eggs cooked in various ways, soups of all kinds, meats in moderation, vegetables, especially potatoes, olive oil, and the various salad oils, cereals, tapioca, macaroni, spaghetti, noodles, rice, bread of every description, fruit including bananas, grapes, dates, raisins, prunes, etc., ice creams, farinaceous puddings, sauces, except those containing vinegar, grape juice and other fruit juices sweetened with sugar, cocoa and chocolate, malted milk and proprietary infant foods, honey, molasses and sirups, cakes, cookies and pastry in moderation. It is advisable to make milk the chief fluid food; to this is added cream, malted milk, lactose, eggs, and other reënforcing agents. ~Milk Cure.~--Certain physicians advise milk alone, giving from one to two gallons a day for three weeks or longer. Many individuals complain that "milk makes them bilious" but, as a rule, this is because the amount taken is small and the solids insufficient to lend the necessary bulk to the feces, consequently the peristaltic action becomes sluggish and the passage of the food mass delayed in the intestinal tract, furnishing a medium for bacterial growth and activity. When larger quantities are ingested such is not the case and the fluid so high in nutrient qualities is utilized by the body for the building up of the depleted tissues. When the emaciation is the result of disease the diet is necessarily adjusted to meet the condition. At times it is most difficult to overcome the anemia and accompanying emaciation on account of the disease precluding the giving of the foods especially designed by nature to produce flesh. This is especially the case in the progressive emaciation in diabetes. However, in this case the Allen starvation treatment, with the reëducation of the organs to a toleration for carbohydrates, has gone far toward overcoming this distressing condition. ~Readjusting the Habits.~--When the loss of weight is found to be the result of close application to work, lack of fresh air and sleep, or from errors in diet, a change of climate and occupation should be made, together with a readjustment of the daily habits, such as substituting a cool bath for the regular hot one, and sleeping out of doors or on a sleeping porch instead of in a poorly ventilated bedroom. The patient must be urged to eat, regardless of appetite, for in this way only can the body weight be increased. The dietary must be made up largely of the fat-forming foods, but not to such an extent as to upset the nitrogen equilibrium. The following diet sheet is given to be used as a guide in the treatment of emaciation. Other foods of a similar composition and fuel value may be substituted for those given here, to vary the diet. EMACIATION DIET SHEET _Approximately 5106 calories_ KEY A _Protein Gm._ B _Carbohydrate Gm._ C _Fat Gm._ D _Total Calories_ ==================+================+=======+=======+=======+======== _Material_ | _Amount_ | A | B | C | D ------------------+----------------+-------+-------+-------+-------- Breakfast: | | | | | Stewed prunes |6 prunes | 1.02 | 35.26 | | 145. Sugar |1 tbs. | | 14.7 | | 56.6 Oatmeal |1 tbs. (dry) }| | | | with cream and |2 tbs. cream }| 3.2 | 25.0 | 6.6 | 172.2 sugar |1 tbs. sugar }| | | | Poached egg |1 egg | 5.35 | | 4.16 | 58.8 Toast |3 slices }| | | | Butter |1 tbs. }| 7.9 | 44.7 | 13.0 | 328. Coffee |1 cup | | | | with cream and |1 tbs. cream | .40 | .40 | 2.8 | 53.9 sugar |2 tsp. | | 9.45 | | Milk and cream |2/3 cup milk }| | | | |1/3 cup cream }| | | | 389. | | | | | 11 A.M. | | | | | Cereal milk gruel | 8 oz. (1 cup) }| | | | with cream | 1 ounce }| | | | 248. | | | | | Lunch, 1 P.M. | | | | | Cream of pea soup | 8 oz. (1 cup) | 6. | 17.65 | 7.66 | 185.9 Potato salad | 3.5 oz. (1 | | | | | serving) | 1.75 | 15.5 | 15.33 | 210. Bread | 3 slices | 7.8 | 44.7 | 1.04}| Butter | 1 tbs. | .8 | 1.4 | 5.6 }| 328. Cocoa made with | }| | | | milk | 1 cup }| | | | Sugar | 2 tsp. }| 27. | 27.6 | 41.4 | 661. Milk | 2/3 cup }| | | | Cream | 1/3 cup }| | | | 329. | | | | | 3:30 P.M. | | | | | Cream, egg, vichy | 8 oz. | 4.9 | 12.4 | 36. | 393. | | | | | Dinner: | | | | | Tomato bouillon | 1 cup | | | | 38. with whipped | | | | | cream | 1 tbs. | .30 | .42 | 5.67 | 53.9 Beefsteak | 1 serving (3 | | | | | oz.) | 18.6 | | 17.34 | 230.5 Mashed potatoes | 1/3 cup | 1.16 | 7.5 | 3.5 | 66.5 Cauliflower | 1 serving | 1.53 | 2.99 | .42 | 21.8 Asparagus salad | 6 stalks | 2.00 | 3.72 | .24}| with | 2 tsp. | .01 | 1.45 | 9.00}| 111.8 mayonnaise | | | | | Bread | 2 slices | 5.2 | 29.8 | .68}| Butter | 2 tbs. | .28 | | 24.09}| 419. Charlotte russe | 1 serving | 2.3 | 11.1 | 22.6 | 257. Milk | 2/3 cup }| | | | and cream | 1/3 cup }| | | | 389. Black coffee if | | | | | desired | 1/2 cup | | | | | | | | | At bed time: | | | | | Malted milk | 1 cup }| | | | made with milk | }| | | | and reënforced | }| 8.4 | 41. | 10.2 | 288.5 with lactose | 1 ounce }| | | | ==================+================+=======+=======+=======+======== ~Methods of Increasing the Diet.~--The above diet furnishes three times as much food as is needed to maintain the body living a sedentary life, or about as much as would be needed to maintain a lumberman at hard outdoor labor in the Maine woods. It would be impossible for an ordinary individual to handle such an abundant diet without making the increase in the diet gradually. This is best done by adding the milk and cream at the end of each meal and a glass of milk between meals and at bedtime, then gradually adding the fattening foods already mentioned until the diet approximates the diet sheet here computed. SUMMARY GOUT Gout is a constitutional disease characterized by an inflammatory condition of the joints. ~The Joints~ are the seat of chalky deposits of uric acid or sodium salts. ~Metabolism~ in gout is disturbed, with a consequent retention instead of elimination of uric acid by the body. ~The Blood~ contains an excess of uric acid which increases greatly during an acute attack. ~The Urine~ in true gout does not contain an excess of uric acid except during an acute attack, whereas in the so-called goutiness there is a constant excess of this acid. ~Uric Acid~ is produced as the result of the metabolism in the human body of the nucleoproteins and in food of the purin bodies. ~Alcohol~ undoubtedly assists in the retention and increases the difficulty of uric acid elimination by the body. ~Chief Causes of Gout.~--Overeating, excessive alcoholism, and too little exercise, especially in the open air. ~Treatment~ consists in regulating the diet both as to the quantity and type of food eaten; reducing or eliminating the alcohol in the dietary, and increasing the amount of outdoor exercise. ~Dietetic Treatment.~--The best results are obtained by reducing the size of the meals and avoiding the purin-bearing foods as far as possible. Eggs are purin-free and may be substituted for much of the meat in the diet. In chronic gout it is impossible to eliminate meat entirely from the diet, but the quantity can be materially reduced and that which is eaten may be rendered less harmful if it is boiled instead of roasted or broiled, as in this way much of the purin is dissolved out. Highly spiced and seasoned foods, rich gravies, etc., are apt to cause an acute attack and should be omitted. Excesses of all kinds must be avoided to enable the patient to live a fairly comfortable life, free from frequent painful attacks of gout. OBESITY ~Causes.~--Heredity, overeating, unbalanced diet, chronic alcoholism, and disturbed metabolism, as manifested in gout and other pathological conditions. ~Cures~ are more or less of a risk, except when undertaken upon the advice and under the care of a competent physician. As a rule they are too strenuous to be carried out alone and are of no good unless persisted in. Among the best known obesity cures may be mentioned those formulated by Banting, Oertel and Ebstein. Most physicians have their own methods of treating obesity, but all are based primarily on diet and exercise. ~Food~ is the chief cause of obesity and since some foods are more readily converted into adipose tissue than others, it is necessary to understand the behavior and functions of the various food combinations in the body before it is possible to say which are the offending articles of diet. ~Water~ has no fattening properties of its own. This is proved by a glance at its chemical composition, but as it acts as a distributor and carrier of food to the various parts of the body and since the bulk of all the secretions is composed of water and every tissue in the body stores this fluid, thus adding to the weight, a consideration of the intake of water for obesity patients is most essential. ~Appetite~ requires attention. The majority of obese patients eat more than their energy output calls for, consequently it is necessary to curb the appetite and increase the energy output in order to utilize the material on hand in the form of adipose tissue. ~Exercise~ is absolutely essential in order to force the body to burn up its surplus fat as fuel. The best form of exercise is that which is taken out of doors. The well-worked muscle is heavier than one which is unaccustomed to exercise. The latter is infiltrated with fat and weighs less than muscular tissue, but a muscular body can endure more than one which is covered with adipose tissue. ~The Heart~ of obese patients becomes more or less affected as obesity advances and it becomes absolutely necessary in many cases to get rid of some of the surplus fat in order that the patient may live. This is best accomplished by dietetic treatment. ~Circulatory Changes~ likewise occur as the heart becomes affected, making it necessary to institute some dietary measures at once. ~Glycosuria~ in obese patients suffering from gout is not at all unusual and to relieve this condition the carbohydrates in the diet must be at once reduced. ~Dietetic Treatment~ is most important. It constitutes the only rational method of ridding the body of its surplus fat. To do this it is necessary to regulate the diet both as to quantity and type. Fat-forming foods are those which the body utilizes most easily for the production and storage of fat. Any food, no matter whether it is fat-forming or not, if taken greatly in excess of the needs of the body, will be stored as adipose tissue. ~Chief Points~ to be remembered in formulating a diet and instituting an obesity treatment are the necessity for _small meals_ and _dry meals_, no fluid given at all during the meal except perhaps one or two small cups of coffee per day, without sugar or cream, the avoidance of fat-forming foods, sugars and starches in all forms, milk, cream, butter and oil, potatoes, bananas, fat meats of all descriptions, especially pork, soups of every description and alcoholic or malted beverages. It is necessary to limit the amount of sleep, prohibiting naps during the day, and to increase the amount of outdoor exercise. ~Massage~ is advisable, especially in those patients who are unable, on account of their excessive weight or heart symptoms, to take the requisite amount of exercise necessary for their future welfare. Massage likewise makes the muscles firmer, often preventing the disfiguring sagging of the skin caused by depriving it of its padding of fat. EMACIATION ~Causes.~--Errors in diet, overwork, over-exercise, heredity, nervousness, worry, malformation of the mouth, throat, or stomach, heredity and certain pathological conditions, such as typhoid fever, tuberculosis, anemia, dysentery, etc., in which the breaking down of the tissues occurs more rapidly than they can be rebuilt. ~Children~ are often emaciated on account of their unbalanced diet. They receive an insufficient amount of building food to cover their growth and development requirements. Parents are often to blame for allowing the child to overeat of some of the food constituents at the expense of others. Sugar, for example, is very necessary in the diet of a growing active child, but all sugar and very little milk and eggs will lead to an unbalanced diet which may bring about a condition of extreme thinness later on. In ~Adults~ the constant eating of the wrong foods, overworking and persistent worrying, all contribute to the breaking down of the tissues which ends in emaciation. ~Weight~ is an index to health. Any persistent loss of weight on the part of an adult or loss or even failure to gain in a growing child, are indications that all is not right and immediate measures must be taken to locate and relieve the trouble. ~Loss of Weight~ due to pathological conditions can only be relieved by removing the cause, after which the diet may be adjusted to suit the condition. ~Dietetic Treatment~ is practically the only means of combating and overcoming emaciation, since it is by food alone that the body is built. Fat-forming foods, which in obesity were prohibited, have a prominent place in the diet for emaciation. Padding the nerves and organs with a layer or covering of fat protects them from the jars and shocks incidental to daily life, besides lending grace and contour to the body. ~Foods Which Produce Fat~ are nutrient beverages of all sorts; milk, malted milk and cream are especially valuable; water, because of its particular properties and functions in the body; and fruit beverages, which are made chiefly of water and sugar, are always included in the dietary. Milk and cream, soups and milk gruels, as well as all dishes made with milk or cream, add materially to the fat-forming quality of the diet. Butter, olive and other salad oils, as well as cereals, potatoes, bread and simple desserts are advised. The diet must be bountiful, the meals frequent, and lunches consisting of milk or cream with crackers will hasten the gain in weight. ~Rest~, preferably lying down, is absolutely essential. A period of relaxation covering from fifteen to thirty minutes should be taken before or after each meal. The body derives the use of the food for the storage of fat which would otherwise be required to cover its energy expenditures. ~Sleep~ is essential to gain, consequently the patient should retire early and take one or two naps during the day. ~Baths~ should be warm, not hot, followed by a cold shower or sponge. ~Exercise~ must be mild in character; over-exertion precludes a gain in weight and exhaustion undermines the forces which make it possible for the body to store fat as adipose tissue. ~Nervous Excitement and Worry~ must be avoided. ~Gastro-intestinal Disturbances~ should be guarded against, since all the pounds gained through months of treatment may be quickly lost during one acute attack of diarrhea or auto-intoxication. ~Massage~ is advised. The kneading and gentle manipulation of the muscles stimulates them to utilize more food material, besides enabling the patient to eat more by reason of an increased appetite. ~The Milk Cure~ has been used extensively in overcoming extreme emaciation. It consists in the taking of large quantities, ranging from one to two gallons per day. It is given every hour or oftener for a period of one month to six weeks. ~Reënforcing the Diet~ with eggs and lactose is often found of great value in increasing the weight quickly, as is the giving of one-third of a glass of cream and two-thirds of a glass of milk after each meal and at bedtime. The whole scheme of putting on pounds resolves itself into the giving of proper food in larger quantities than are ordinarily given, but dividing it up into frequent meals in order not to upset the digestion and do away with the good already accomplished. PROBLEMS (a) Formulate a diet order for a patient with gout in which the purin foods are eliminated. (b) Formulate a diet order for an obese patient whose heart is more or less affected. (c) List the foods of special value in the diet for emaciation. Write a diet order for day suitable for a patient (woman) weighing 110 pounds, whose normal weight is 135 pounds. FOOTNOTES: [156] "Food for the Sick," p. 97, by Strouse and Perry. [157] The amount of food must be limited, since overeating will precipitate an acute attack. It is best to limit the amount to about a maintenance allowance or a little more, temporarily. [158] "Diet in Health and Disease," by Freidenwald and Ruhräh. [159] _Ibid._, p. 544. [160] Boiled vegetable dinners must be prepared without fat meat and potatoes. [161] Scientific investigation has proved that both carbohydrates and fats may be formed in the body from protein. Hence any excess above that required to keep the body in nitrogen equilibrium is utilized by the organism for fuel or stored as fat. [162] "Feeding the Family," p. 84, by Mary Swartz Rose. [163] Saccharin may be used to sweeten. CHAPTER XXIII OTHER CONDITIONS MORE OR LESS AFFECTED BY DIET PTOMAINE POISONING, ACIDOSIS AND PELLAGRA PTOMAINE POISONING The poisoning due to ptomaine is very similar to that brought about by overeating and other dietetic errors. However, it is not so easy to avoid being poisoned by ptomaines as it is to observe moderation in the quantity of food eaten. ~Origin.~--These substances are believed to be of an infective bacterial origin and may be present in foods which are otherwise seemingly fresh and good. The fact that they cannot be detected in food without an analysis makes them more of a menace than they would otherwise be, for any substance which is not discernible to our senses, the taste, sight, or smell, and which exerts a baleful influence, such as ptomaine, cannot be anything but a menace to humanity. ~Infected Food Materials.~--We may congratulate ourselves in the knowledge that these substances are not present in many foods, and if we avoid eating nitrogenous materials, which may have become polluted, either through imperfect canning or by standing in unclean vessels, we may avoid much of the poisoning which may otherwise be due to the action of ptomaines. ~Chicken Salad and Ice Cream Poisoning.~--Certain violent attacks of so-called ptomaine poisoning may be traced to chicken salad which has been allowed to stand overnight in tin receptacles or to ice cream which has melted and been re-frozen. In any case the treatment remains the same. ~Treatment.~--The patient is put to bed and the intestinal tract cleansed by means of enemas and in many cases purgatives (salts, castor oil, etc.) as directed by physician. The symptoms usually present in those suffering from ptomaine poisoning are nausea, vomiting, dizziness, pain more or less violent in character, and prostration which is at times alarming. ~Dietetic Treatment.~--The treatment instituted under the circumstances is very much the same as that used in other forms of acute poisoning. All food is withheld for a period; the duration of this starvation must necessarily depend upon the condition of the patient, the violence of the poison and the extent of the prostration. ~Rectal Feeding.~--When the prostration is great, it is sometimes necessary to give saline enemas and even rectal alimentation to prevent collapse. ~Fluid Diet.~--After the violent attack subsides, the patient is placed upon a fluid diet similar to that used in auto-intoxication and practically the same as the diet for acute infectious diseases. The diet must be gradually increased until it becomes normal and the nurse must remember that the patient is in a condition to suffer a relapse with the least indiscretion. It is advisable to have a thorough investigation made to ascertain the source of the original attack, that the patient may be able to avoid future trouble from partaking of the same food. ~Personal Idiosyncrasies.~--It may be that there is a personal idiosyncrasy against one particular food, and in this case it becomes more or less of a simple matter to prevent future attacks. Certain individuals are, for example, invariably poisoned by eating shellfish, others manifest a similar idiosyncrasy against strawberries. Thus is the old proverb demonstrated: "What is one man's meat is another man's poison." And he who wantonly flies in the face of the danger signals Nature provides for his guidance must necessarily suffer the consequences of his folly. It has been proved with certain individuals that the foods that at one time cause an attack of poison at another time may be eaten with impunity. Thus it would seem to remain a question not so much of the type of poison, ptomaines, etc., as the amount of resistance manifested at the time by the individual partaking of the infected food. ACIDOSIS ~Metabolism of Fats.~--Acidosis is a condition believed to be due primarily to some impairment in the metabolism of fat in the body, in consequence of which there is an accumulation of substances more or less irritating and at times toxic in character in the blood. These substances, known as acetone bodies, are especially apt to appear in the urine of individuals suffering from diabetes, likewise in those undergoing starvation, whether as a result of treatment to overcome a definite pathological condition, as in diabetes, or as the result of disease itself. ~Malnutrition as a Source.~--Certain individuals, children especially, develop symptoms of acidosis under many different circumstances; for example, in many cases of malnutrition the evidences of acidosis are almost invariable. The treatment in these cases must be, of course, prompt in order that the condition may not assume a serious aspect. ~Dietetic Treatment.~--The diet is adjusted in order to neutralize the effect of the acid in the blood. This is done in two ways: first, by reducing the fat, and second, by increasing the amount of base-forming foods in the diet. The following table[164] illustrates the foods in which the acid-forming elements and base-forming elements predominate: FOODS IN WHICH ACID-FORMING ELEMENTS PREDOMINATE _Estimated Excess Acid-forming Elements Equivalent to C.C. Normal Acid per 100 Calories_ Beef, free from visible fat 10 Eggs .9 Round steak 6.7 Oatmeal 3.2 Wheat flour 2.7 Wheat, entire grain 2.6 Rice 2.4 Bacon 1 Corn, entire grain (high protein) .1 FOODS IN WHICH BASE-FORMING ELEMENTS PREDOMINATE _Estimated Excess Base-forming Elements Equivalent to C.C. Normal Alkali per 100 Calories_ Celery 40 Cabbage 10-13.6 Potatoes 9-12 Prunes 7.9 Turnips 6.6-12.5 Apples 5 Milk 3.3 Beans 2.9-6.8 Peas 1.9 Corn, entire grain (low protein) .8 The fruits likewise show a predominance of base-forming elements over acid-forming elements and for this reason may be used to balance the diet. ~Diabetic Acidosis.~--The acidosis during diabetes has been already discussed in the chapter devoted to that disease. It has been found advisable in the majority of cases of acidosis to restrict the fat in the diet of all patients who, during the course of a disease, have given evidence of this condition; at the same time it is well to remember that fat is one of the essential food constituents and absolutely necessary to the welfare of the individual, consequently it is impossible to eliminate it from the diet entirely. The only feasible method, then, to pursue under the circumstances is to restrict the fats in the diet so long as there are symptoms of acidosis and to add them gradually and in very small amounts until the individual's tolerance for fats is determined. ~Balancing the Diet.~--In many cases of acidosis due to starvation, no matter what the cause, the diet must be necessarily regulated and properly balanced. It would be decidedly unwise to attempt to build up the body by giving building foods alone, without due consideration to the foods containing the agents provided by Nature to neutralize the acid formed during the process of their metabolism. It is readily seen in the table just given that meat and eggs show a marked excess of acid-forming elements, whereas vegetables and fruits yield an excess of base-forming elements. With these data, it becomes more simple to balance the diet and to avoid the acidosis which may arise from impairment of the fat metabolism of the body. PELLAGRA The enormous increase in the number of cases of pellagra in America during the last twenty years makes it necessary for something to be done to arrest its progress. The cause of this disease is still under discussion, but much has been done to find out definitely the reason for the tremendous increase in the number of cases, especially in the Southern States, where the increase has been most noticeable. ~Cause.~--This disease has been the subject of much study and discussion in this country in recent years. Voegtlin, in an article published in a Report of the United States Public Health Service (Reprint 597 of Public Health Report), summarizes the current findings on pellagra as follows: "1. The hypothesis that there is a causal relation between pellagra and a restricted vegetable diet has been substantiated by direct proof to this effect and has led to results of considerable practical and scientific value. "2. The metabolism in pellagra shows certain definite changes from the normal, which point to decreased gastric secretion and increased intestinal putrefaction. "3. In the treatment and prevention of pellagra, diet is the essential factor. The disease can be prevented by an appropriate change in the diet without changing other sanitary conditions. "4. A diet of the composition used by the pellagrins prior to their attack by the disease leads to malnutrition and certain pathological changes in animals, resembling those found in pellagra. A typical pellagrous dermatitis has not been observed in animals. Pellagrous symptoms have been produced in man by the continued consumption of a restricted vegetable diet. "5. The nature of the dietary effect has not been discovered, although certain observations point to a combined deficiency in some of the recognized dietary factors as the cause of the pellagrous syndrome." ~Dietetic Treatment.~--The diet in pellagra is one which is well balanced in all its particulars, and one in which the proteins are carefully adjusted as to type. The best results have been observed on diets in which the complete proteins (milk, meat and eggs) have a prominent place. As a rule, in the diet of an adult suffering from pellagra, at least forty grams (about 60 per cent) of the necessary proteins should be in this form. The diet for pellagra must necessarily be such as to overcome as far as possible the progressive emaciation which is an important symptom. However, it must be kept in mind that gastro-intestinal disturbances are likewise prominent and that diarrhea is often most difficult to overcome. For these reasons it is essential to formulate a diet which will not interfere with the treatment for the disease, and which will be at the same time one on which the patient can gradually be built up, and in this way benefit, as far as possible, under the circumstances. The diet used in the treatment of anemia seems to be the one best suited to meet the requirements of the patient suffering with pellagra; changes may be made in this diet, however, by the physician, who will be able to judge the need of the individual under his care. Whether pellagra can be cured by dietetic treatment is very uncertain, but the condition of the patient can undoubtedly be materially improved, provided the treatment is begun sufficiently early; that is, before the disease has progressed to such an extent that neither diet nor anything else can bring about a cure. The above dietetic treatment is not claimed to be infallible. It is merely given as a suggestion to be used at the discretion of the physician. In all probability the treatment of pellagra will undergo a definite change in the near future, but at present our best results accrue from the giving of an adequate, well-balanced diet. The extent of the relief of such dietetic measures depends, as has already been stated, upon taking the disease in its early stage. SUMMARY ~Food Poisoning~ is more or less common, being induced by polluted water, milk, or other foods, bad sanitation, and imperfect canning, as well as by certain obscure substances known as ptomaines. ~Shellfish~ have often been found to cause poisoning in certain individuals. Stale fish may cause the most violent type of poisoning in any individual. ~Chicken Salad~ which has been kept overnight in tin receptacles has been known to cause violent attacks of poisoning. ~Ice Cream~ which is melted and re-frozen is likewise a source of a number of the cases reported. ~Symptoms.~--Very like those of auto-intoxication, and violent intestinal disturbances are manifested. ~Prostration~ may be great, according to the violence and duration of the attack. ~Anemia~ follows many cases of poisoning as a result not only of the impairment and lack of nutrition of the blood-making organs, but also on account of the other symptoms, especially diarrhea occurring in the disease. ACIDOSIS This condition is more or less common, especially in the disturbances manifested by children. ~Cause~ of acidosis is believed to be an impairment of metabolism, especially in regard to the fats. ~Starvation or Malnutrition~ is believed to produce many cases of acidosis in childhood and adults suffering from diseases in which certain foods have been limited. ~Dietetic Treatment~ like that used in acute gastro-intestinal disturbances begins with a starvation period and is followed by a simple fluid diet until violent symptoms subside. Examination of the stools and the material vomited will, at times, furnish an insight as to the source of the poison. ~Convalescent Diet~ is begun after the violent symptoms have subsided, but care must be taken not to increase the diet too rapidly, owing to the danger from relapse. ~Method of Administering Diet.~--First: a period of total abstinence from food. Second: fluid diet consisting of broth, buttermilk, or some of the predigested liquid beef preparations which furnish both food and stimulation necessary in such cases. ~Rectal Feeding~ may be found necessary when the prostration is great. ~Personal Idiosyncrasies~ should be taken into account and effort made to find whether or not the attack is caused by any one food material or by bad sanitation or unclean food. The patient should be warned against the danger of taking a food which has caused a previous attack of poisoning, especially in cases where a personal idiosyncrasy against a food has been manifested. PELLAGRA The cause and cure for this disease are still a matter of discussion. Whether it is due to the presence or absence of certain substances in the food materials, is as yet to be determined. ~Diet in Pellagra~ is most important. It is impossible to say that pellagra is a nutritional disease, but it is certain that in balancing the diet much has been done toward relieving the condition. ~Diarrhea~ is one of the chief symptoms of the disease and great care is needed in formulating the dietary in order not to increase this condition. ~Conclusion.~--The diet is thus shown to be directed toward overcoming the emaciation and anemia and relieving or preventing the gastro-intestinal disturbances which are so apt to occur. It must be remembered that even a well-balanced diet will not materially relieve the condition unless it is instituted sufficiently early. PROBLEMS (a) Formulate a diet for an adult in which the base-forming elements predominate. (b) Formulate a diet for child suffering from acidosis. (c) Arrange a well balanced diet for pellagra in which forty grams of protein shall come from milk, meat or eggs. FOOTNOTE: [164] "Chemistry of Food and Nutrition" (revised), by Henry Sherman. APPENDIX TABLE I[165] EDIBLE ORGANIC NUTRIENTS AND FUEL VALUES OF FOODS[166] E.P. signifies edible portion; A.P. signifies as purchased. KEY: A _Protein (N × 6.25) Per Cent_ B _Fat Per Cent_ C _Carbohydrate Per Cent_ D _Fuel Value per Pound Calories_ E _100 Calorie Portion Grams_ ============================+======+=======+=======+======+======= _Food_ | A | B | C | D | E ----------------------------+------+-------+-------+------+------- Almonds E.P. | 21.0 | 54.9 | 17.3 | 2940 | 15 A.P. | 11.5 | 30.2 | 9.5 | 1615 | 28 Apples E.P. | .4 | .5 | 14.2 | 285 | 159 A.P. | .3 | .3 | 10.8 | 214 | 212 Apricots E.P. | 1.1 | -- | 13.4 | 263 | 174 A.P. | 1.0 | -- | 12.6 | 247 | 184 Artichoke, French E.P. | 3.4 | .5 | 12.0 | 300 | 151 A.P. | 1.7 | .3 | 6.0 | 150 | 302 Asparagus, fresh E.P. | 1.8 | .2 | 3.3 | 100 | 450 cooked A.P. | 2.1 | 3.3 | 2.2 | 213 | 213 Avocado E.P. | 2.1 | 20.1 | 7.4 | 993 | 46 A.P. | 1.4 | 13.2 | 4.8 | 652 | 70 Bacon, smoked E.P. | 10.5 | 64.8 | -- | 2840 | 16 A.P. | 9.5 | 59.4 | -- | 2372 | 19 Bananas E.P. | 1.3 | .6 | 22.0 | 447 | 101 A.P. | .8 | .4 | 14.3 | 290 | 156 Barley, pearled | 8.5 | 1.1 | 77.8 | 1615 | 28 Beans, dried | 22.5 | 1.8 | 59.6 | 1565 | 29 Lima, dried | 18.1 | 1.5 | 65.9 | 1586 | 29 Lima, fresh E.P. | 7.1 | .7 | 22.0 | 557 | 82 A.P. | 3.2 | .3 | 9.9 | 250 | 182 string, fresh E.P. | 2.3 | 3. | 7.4 | 184 | 241 A.P. | 2.1 | 3. | 6.9 | 176 | 259 baked, canned A.P. | 6.9 | 2.5 | 19.6 | 583 | 78 red kidney, canned | 7.0 | .2 | 18.5 | 471 | 96 Beef, brisket, | | | | | medium fat E.P. | 15.8 | 28.5 | -- | 1449 | 31 A.P. | 12.0 | 22.3 | -- | 1130 | 40 chuck, average E.P. | 19.2 | 15.4 | -- | 978 | 46 A.P. | 15.8 | 12.5 | -- | 797 | 58 corned, average E.P. | 15.6 | 26.2 | -- | 1353 | 34 A.P. | 14.3 | 23.8 | -- | 1230 | 37 cross ribs, | | | | | average E.P. | 15.9 | 28.2 | -- | 1440 | 32 A.P. | 13.8 | 24.8 | -- | 1262 | 36 dried, salted, | | | | | and smoked E.P. | 30.0 | 6.5 | .4 | 817 | 56 A.P. | 26.4 | 6.9 | -- | 760 | 60 flank, lean E.P. | 20.8 | 11.3 | -- | 838 | 54 A.P. | 20.5 | 11.0 | -- | 821 | 55 fore quarter, | | | | | lean E.P. | 18.9 | 12.2 | -- | 842 | 54 A.P. | 14.7 | 9.5 | -- | 655 | 69 fore shank, | | | | | lean E.P. | 22.0 | 6.1 | -- | 647 | 70 A.P. | 14.0 | 3.9 | -- | 414 | 110 heart E.P. | 16.0 | 20.4 | 1.0 | 1140 | 40 A.P. | 14.8 | 24.7 | .9 | 1292 | 35 hind quarter, | | | | | lean E.P. | 20.0 | 13.4 | -- | 907 | 50 A.P. | 16.7 | 11.2 | -- | 757 | 60 hind shank, lean E.P. | 21.9 | 5.4 | -- | 617 | 75 A.P. | 9.1 | 2.2 | -- | 255 | 179 hind shank, fat E.P. | 20.4 | 18.8 | -- | 1171 | 40 A.P. | 9.9 | 9.1 | -- | 552 | 83 liver E.P. | 20.4 | 4.5 | 1.7 | 584 | 78 A.P. | 20.2 | 3.1 | 2.5 | 537 | 85 loin E.P. | 19.7 | 12.7 | -- | 877 | 52 A.P. | 17.1 | 11.1 | -- | 764 | 60 neck, lean E.P. | 21.4 | 8.4 | -- | 732 | 62 A.P. | 15.1 | 5.9 | -- | 493 | 93 neck, medium fat E.P. | 20.1 | 16.5 | -- | 1040 | 44 A.P. | 14.5 | 11.9 | -- | 749 | 61 plate, lean E.P. | 15.6 | 18.8 | -- | 1051 | 43 A.P. | 13.0 | 15.5 | -- | 867 | 52 Porterhouse | | | | | steak E.P. | 21.9 | 20.4 | -- | 1230 | 37 A.P. | 19.1 | 17.9 | -- | 1077 | 42 rib rolls, lean A.P. | 20.2 | 10.5 | -- | 795 | 57 ribs, lean E.P. | 19.6 | 12.0 | -- | 845 | 54 A.P. | 15.2 | 9.3 | -- | 654 | 69 ribs, fat E.P. | 15.0 | 35.6 | -- | 1721 | 26 A.P. | 12.7 | 30.6 | -- | 1480 | 31 round, lean E.P. | 21.3 | 7.9 | -- | 709 | 64 A.P. | 19.5 | 7.3 | -- | 649 | 70 round, free from | | | | | visible fat | 23.2 | 2.5 | -- | 512 | 87 rump, lean E.P. | 20.9 | 13.7 | -- | 940 | 49 A.P. | 19.1 | 11.0 | -- | 796 | 57 rump, fat E.P. | 16.8 | 35.7 | -- | 1763 | 26 A.P. | 12.9 | 27.6 | -- | 1361 | 33 sides, lean E.P. | 19.3 | 13.2 | -- | 890 | 51 A.P. | 15.5 | 10.6 | -- | 715 | 64 sirloin steak E.P. | 18.9 | 18.5 | -- | 1099 | 41 A.P. | 16.5 | 16.1 | -- | 960 | 48 sweetbreads A.P. | 16.8 | 12.1 | -- | 799 | 57 tenderloin A.P. | 16.2 | 24.4 | -- | 1290 | 35 tongue E.P. | 18.9 | 9.2 | -- | 717 | 63 A.P. | 14.1 | 6.7 | -- | 529 | 86 Beets, cooked E.P. | 2.3 | .1 | 7.4 | 180 | 252 fresh E.P. | 1.6 | .1 | 9.7 | 209 | 217 A.P. | 1.3 | .1 | 7.7 | 167 | 271 Blackberries A.P. | 1.3 | 1.0 | 10.9 | 262 | 173 Blackfish E.P. | 18.7 | 1.3 | -- | 393 | 116 A.P. | 7.4 | .7 | -- | 163 | 279 Bluefish E.P. | 19.4 | 1.2 | -- | 402 | 113 A.P. | 10.0 | .6 | -- | 206 | 220 Boston crackers | 11.0 | 8.5 | 71.1 | 1835 | 25 Brazil nuts E.P. | 17.0 | 66.8 | 7.0 | 3162 | 14 A.P. | 8.6 | 33.7 | 3.5 | 1591 | 28 Bread, Boston brown | 6.0 | 6.3 | 54.0 | 1345 | 34 graham | 8.9 | 1.8 | 52.1 | 1189 | 38 rolls, water | 9.0 | 3.0 | 54.2 | 1268 | 36 toasted | 11.5 | 1.6 | 61.2 | 1385 | 33 white, home made | 9.1 | 1.6 | 53.3 | 1199 | 38 milk | 9.6 | 1.4 | 51.1 | 1158 | 39 Vienna | 9.4 | 1.2 | 54.1 | 1199 | 38 average white | 9.2 | 1.3 | 53.1 | 1182 | 38 whole wheat | 9.7 | .9 | 49.7 | 1113 | 41 Buckwheat flour | 6.4 | 1.2 | 77.9 | 1580 | 29 Butter | 1.0 | 85.0 | -- | 3491 | 13 Buttermilk | 3.0 | .5 | 4.8 | 162 | 280 Butternuts E.P. | 27.9 | 61.2 | 3.5 | 3065 | 15 A.P. | 3.8 | 8.3 | .5 | 417 | 109 Cabbage E.P. | 1.6 | .3 | 5.6 | 143 | 317 A.P. | 1.4 | .2 | 4.8 | 121 | 376 Calf's-foot jelly | 4.3 | -- | 17.4 | 394 | 115 Carrots, fresh E.P. | 1.1 | .4 | 9.3 | 204 | 221 A.P. | .9 | .2 | 7.4 | 158 | 286 Cauliflower A.P. | 1.8 | .5 | 4.7 | 139 | 328 Celery E.P. | 1.1 | .1 | 3.3 | 84 | 542 A.P. | .9 | .1 | 2.6 | 68 | 672 Celery soup, canned | 2.1 | 2.8 | 5.0 | 243 | 187 Cerealine | 9.6 | 1.1 | 78.3 | 1640 | 28 Chard E.P. | 3.2 | .6 | 5.0 | 173 | 262 Cheese, American pale | 28.8 | 35.9 | .3 | 1990 | 23 American red | 29.6 | 38.3 | -- | 2102 | 22 Cheddar | 27.7 | 36.8 | 4.1 | 2080 | 22 cottage | 20.9 | 1.0 | 4.3 | 499 | 91 full cream | 25.9 | 33.7 | 2.4 | 1890 | 24 Fromage de Brie | 15.9 | 21.0 | 1.4 | 1170 | 39 Neufchâtel | 18.7 | 27.4 | 1.5 | 1484 | 31 pineapple | 29.9 | 38.9 | 2.6 | 2180 | 21 Roquefort | 22.6 | 29.5 | 1.8 | 1645 | 28 Swiss | 27.6 | 34.9 | 1.3 | 1945 | 23 Cherries, fresh E.P. | 1.0 | .8 | 16.7 | 354 | 128 A.P. | .9 | .8 | 15.9 | 337 | 134 canned A.P. | 1.1 | .1 | 21.1 | 407 | 112 Chestnuts, fresh E.P. | 6.2 | 5.4 | 42.1 | 1098 | 41 A.P. | 5.2 | 4.5 | 35.4 | 920 | 49 Chicken, broilers E.P. | 21.5 | 2.5 | -- | 493 | 92 A.P. | 12.8 | 1.4 | -- | 289 | 157 Chocolate | 12.9 | 48.7 | 30.3 | 2768 | 16 Cocoa | 21.6 | 28.9 | 37.7 | 2258 | 20 Cod, dressed A.P. | 11.1 | .2 | -- | 209 | 217 salt E.P. | 25.4 | .3 | -- | 473 | 96 A.P. | 19.0 | .4 | -- | 361 | 126 Consommé, canned A.P. | 2.5 | -- | .4 | 53 | 862 Corn, | | | | | green, canned | 2.8 | 1.2 | 19.0 | 455 | 102 sweet, fresh E.P. | 3.1 | 1.1 | 19.7 | 459 | 99 A.P. | 1.2 | .4 | 7.7 | 178 | 255 Corn meal | 9.2 | 1.9 | 75.4 | 1620 | 28 Cowpeas, dried | 21.4 | 1.4 | 60.8 | 1550 | 29 green E.P. | 9.4 | .6 | 22.7 | 603 | 76 Crackers, butter A.P. | 9.6 | 10.1 | 71.6 | 1887 | 23 cream A.P. | 9.7 | 12.1 | 69.7 | 1938 | 23 graham A.P. | 10.0 | 9.4 | 73.8 | 1905 | 24 soda A.P. | 9.8 | 9.1 | 73.1 | 1875 | 24 water A.P. | 10.7 | 8.8 | 71.9 | 1855 | 24 Cranberries A.P. | .4 | .6 | 9.9 | 212 | 212 Cream | 2.5 | 18.5 | 4.5 | 883 | 50 Cucumbers E.P. | .8 | .2 | 3.1 | 79 | 575 A.P. | .7 | .2 | 2.6 | 68 | 666 Currants, fresh | 1.5 | -- | 12.8 | 259 | 175 dried Zante | 2.4 | 1.7 | 74.2 | 1455 | 31 Dandelion greens | 2.4 | 1.0 | 10.6 | 277 | 164 Dates, dried E.P. | 2.1 | 2.8 | 78.4 | 1575 | 29 A.P. | 1.9 | 2.5 | 70.6 | 1416 | 32 Doughnuts | 6.7 | 21.0 | 53.1 | 1941 | 23 Eggplant E.P. | 1.2 | .3 | 5.1 | 126 | 349 Eggs, uncooked E.P. | 13.4 | 10.5 | -- | 672 | 68 A.P. | 11.9 | 9.3 | -- | 594 | 76 Farina | 11.0 | 1.4 | 76.3 | 1640 | 28 Figs, dried | 4.3 | .3 | 74.2 | 1437 | 32 Flounder A.P. | 5.4 | .3 | -- | 110 | 412 E.P. | 14.2 | .6 | -- | 282 | 161 Flour, rye | 6.8 | .9 | 78.7 | 1590 | 29 wheat, California fine | 7.9 | 1.4 | 76.4 | 1585 | 29 wheat, entire | 13.8 | 1.9 | 71.9 | 1630 | 28 wheat, graham | 13.3 | 2.2 | 71.4 | 1628 | 28 wheat, patent | | | | | baker's grade | 13.3 | 1.5 | 72.7 | 1623 | 28 wheat, straight grade | 10.8 | 1.1 | 74.8 | 1608 | 28 wheat, average | | | | | high and medium | 11.4 | 1.0 | 75.1 | 1610 | 28 wheat, average | | | | | low grade | 14.0 | 1.9 | 71.2 | 1625 | 28 Fowls E.P. | 19.3 | 16.3 | -- | 1017 | 45 A.P. | 13.7 | 12.3 | -- | 752 | 60 Gelatin | 91.4 | .1 | -- | 1660 | 27 Grape butter | 1.2 | .1 | 58.5 | 1088 | 42 Grapes E.P. | 1.3 | 1.6 | 19.2 | 437 | 104 A.P. | 1.0 | 1.2 | 14.4 | 328 | 138 Grapefruit E.P. | .6 | .1 | 12.2 | 235 | 193 A.P. | .4 | .1 | 8.9 | 172 | 264 Haddock E.P. | 17.2 | .3 | -- | 324 | 140 A.P. | 8.4 | .2 | -- | 160 | 283 Halibut steaks E.P. | 18.6 | 5.2 | -- | 550 | 83 A.P. | 15.3 | 4.4 | -- | 457 | 100 Ham, fresh lean E.P. | 25.0 | 14.4 | -- | 1042 | 44 A.P. | 24.8 | 14.2 | -- | 1030 | 44 fresh, medium E.P. | 15.3 | 28.9 | -- | 1458 | 31 A.P. | 13.5 | 25.9 | -- | 1303 | 35 smoked, lean E.P. | 19.8 | 20.8 | -- | 1209 | 38 A.P. | 17.5 | 18.5 | -- | 1073 | 42 Herring, whole E.P. | 19.5 | 7.1 | -- | 644 | 70 A.P. | 11.2 | 3.9 | -- | 362 | 125 smoked E.P. | 36.9 | 15.8 | -- | 1315 | 35 A.P. | 20.5 | 8.8 | -- | 731 | 62 Hominy | 8.3 | .6 | 79.0 | 1609 | 28 Honey | .4 | -- | 81.2 | 1481 | 31 Huckleberries | .6 | .6 | 16.6 | 336 | 135 Kohl-rabi E.P. | 2.0 | .1 | 5.5 | 140 | 324 Koumiss | 2.8 | 2.1 | 5.4 | 234 | 194 Lamb, breast E.P. | 19.1 | 23.6 | -- | 1311 | 35 A.P. | 15.4 | 19.1 | -- | 1058 | 43 chops, broiled E.P. | 21.7 | 29.9 | -- | 1614 | 28 fore quarter E.P. | 18.3 | 25.8 | -- | 1385 | 33 A.P. | 14.9 | 21.0 | -- | 1127 | 40 hind quarter E.P. | 19.6 | 19.1 | -- | 1149 | 40 A.P. | 16.5 | 16.1 | -- | 953 | 48 leg roast | 19.7 | 12.7 | -- | 876 | 52 side E.P. | 17.6 | 23.1 | -- | 1263 | 36 A.P. | 14.1 | 18.7 | -- | 1015 | 45 Lard, refined | -- | 100.0 | -- | 4080 | 11 Lemon juice | -- | -- | 9.8 | 178 | 255 Lemons E.P. | 1.0 | .7 | 8.5 | 201 | 226 A.P. | .7 | .5 | 5.9 | 140 | 323 Lettuce E.P. | 1.2 | .3 | 2.9 | 87 | 525 A.P. | 1.0 | .2 | 2.5 | 72 | 633 Liver, beef E.P. | 20.4 | 4.5 | 1.7 | 583 | 78 A.P. | 20.2 | 3.1 | 2.5 | 538 | 84 veal E.P. | 19.0 | 5.3 | -- | 562 | 81 Lobster, whole E.P. | 16.4 | 1.8 | .4 | 379 | 120 A.P. | 5.9 | .7 | .2 | 139 | 326 canned A.P. | 18.1 | 1.1 | .5 | 382 | 119 Macaroni | 13.4 | .9 | 74.1 | 1625 | 28 Macaroons | 6.5 | 15.2 | 65.2 | 1922 | 24 Mackerel E.P. | 18.7 | 7.1 | -- | 629 | 72 A.P. | 10.2 | 4.2 | -- | 356 | 127 salt E.P. | 21.1 | 22.6 | -- | 1305 | 35 A.P. | 16.3 | 17.4 | -- | 1005 | 45 Marmalade, orange | .6 | .1 | 84.5 | 1548 | 29 Milk, condensed, | | | | | sweetened | 8.8 | 8.3 | 54.1 | 1480 | 31 skimmed | 3.4 | .3 | 5.1 | 167 | 273 whole | 3.3 | 4.0 | 5.0 | 314 | 145 Mince meat, commercial | 6.7 | 1.4 | 60.2 | 1280 | 36 home made | 4.8 | 6.7 | 32.1 | 942 | 48 Molasses, cane | 2.4 | -- | 69.3 | 1302 | 35 Mushrooms A.P. | 3.5 | .4 | 6.8 | 204 | 223 Muskmelons E.P. | .6 | -- | 9.3 | 180 | 252 A.P. | .3 | -- | 4.6 | 89 | 510 Mutton, fore | | | | | quarter E.P. | 15.6 | 30.9 | -- | 1543 | 29 A.P. | 12.3 | 24.5 | -- | 1223 | 37 hind quarter E.P. | 16.7 | 28.1 | -- | 1450 | 31 A.P. | 13.8 | 23.2 | -- | 1197 | 38 leg E.P. | 19.8 | 12.4 | -- | 863 | 52 A.P. | 16.5 | 10.3 | -- | 718 | 63 side A.P. | 13.0 | 24.0 | -- | 1215 | 37 E.P. | 16.2 | 29.8 | -- | 1512 | 30 Nectarines E.P. | .6 | -- | 15.9 | 299 | 152 A.P. | .6 | -- | 14.8 | 280 | 162 Oatmeal | 16.1 | 7.2 | 67.5 | 1811 | 25 Okra E.P. | 1.6 | .2 | 7.4 | 172 | 264 A.P. | 1.4 | .2 | 6.5 | 152 | 300 Olives, green E.P. | 1.1 | 27.6 | 11.6 | 1357 | 33 A.P. | .8 | 20.2 | 8.5 | 995 | 46 ripe E.P. | 1.7 | 25.0 | 4.3 | 1130 | 40 A.P. | 1.4 | 21.0 | 3.5 | 947 | 48 Onions, fresh E.P. | 1.6 | .3 | 9.9 | 220 | 206 A.P. | 1.4 | .3 | 8.9 | 199 | 228 Oranges E.P. | .8 | .2 | 11.6 | 233 | 195 A.P. | .6 | .1 | 8.5 | 169 | 268 Oxtail soup, | | | | | canned A.P. | 3.8 | .5 | 4.2 | 166 | 274 Oysters E.P. | 6.2 | 1.2 | 3.7 | 228 | 199 in shell A.P. | 1.2 | .2 | .7 | 43 | 1065 canned A.P. | 8.8 | 2.4 | 3.9 | 328 | 138 Parsnips E.P. | 1.6 | .5 | 13.5 | 294 | 154 A.P. | 1.3 | .4 | 10.8 | 236 | 192 Pea soup, canned A.P. | 3.6 | .7 | 7.6 | 232 | 196 Peaches, canned A.P. | .7 | .1 | 10.8 | 213 | 213 fresh E.P. | .7 | .1 | 9.4 | 188 | 242 A.P. | .5 | .1 | 7.7 | 153 | 297 Peanuts E.P. | 25.8 | 38.6 | 24.4 | 2490 | 18 A.P. | 19.5 | 29.1 | 18.5 | 1877 | 24 Pears, fresh E.P. | .6 | .5 | 14.1 | 288 | 158 A.P. | .5 | .4 | 12.7 | 256 | 177 Peas, canned A.P. | 3.6 | .2 | 9.8 | 252 | 180 dried | 24.6 | 1.0 | 62.0 | 1611 | 28 green E.P. | 7.0 | .5 | 16.9 | 454 | 100 A.P. | 3.6 | .2 | 9.8 | 252 | 180 Peppers, green E.P. | 1.1 | .1 | 4.6 | 109 | 417 Persimmons E.P. | .8 | .7 | 31.5 | 615 | 74 Pies, apple | 3.1 | 0.8 | 42.8 | 1233 | 37 custard | 4.2 | 6.3 | 26.1 | 806 | 56 lemon | 3.6 | 10.1 | 37.4 | 1156 | 39 mince | 5.8 | 12.3 | 38.1 | 1300 | 35 squash | 4.4 | 8.4 | 21.7 | 817 | 56 Pineapples, fresh E.P. | .4 | .3 | 9.7 | 196 | 232 canned A.P. | .4 | .7 | 36.4 | 695 | 65 Pine nuts | | | | | (pignolias) | 33.9 | 49.4 | 6.9 | 2757 | 16 Pistachios, shelled | 22.3 | 54.0 | 16.3 | 2900 | 16 Plums E.P. | 1.0 | -- | 20.1 | 383 | 118 A.P. | .9 | -- | 19.1 | 363 | 125 Pomegranates E.P. | 1.5 | 1.6 | 19.5 | 447 | 102 Pork chops, | | | | | medium E.P. | 16.6 | 30.1 | -- | 1530 | 30 A.P. | 13.4 | 24.2 | -- | 1230 | 37 chuck ribs and | | | | | shoulder E.P. | 17.3 | 31.1 | -- | 1585 | 29 A.P. | 14.1 | 25.5 | -- | 1298 | 35 fat, salt A.P. | 1.9 | 86.2 | -- | 3555 | 13 sausage A.P. | 13.0 | 44.2 | 1.1 | 2030 | 22 side E.P. | 9.1 | 55.3 | -- | 2423 | 19 A.P. | 8.0 | 49.0 | -- | 2145 | 21 tenderloin A.P. | 18.9 | 13.0 | -- | 875 | 52 Potato chips A.P. | 6.8 | 39.8 | 46.7 | 2598 | 17 Potatoes, white, | | | | | raw E.P. | 2.2 | .1 | 18.4 | 378 | 120 A.P. | 1.8 | .1 | 14.7 | 302 | 149 sweet, raw E.P. | 1.8 | .7 | 27.4 | 558 | 81 A.P. | 1.4 | .6 | 21.9 | 447 | 102 Prunes, dried E.P. | 2.1 | -- | 73.3 | 1368 | 33 A.P. | 1.8 | -- | 62.2 | 1160 | 39 Pumpkins E.P. | 1.0 | .1 | 5.2 | 117 | 389 A.P. | .5 | .1 | 2.6 | 60 | 753 Radishes E.P. | 1.3 | .1 | 5.8 | 133 | 341 A.P. | .9 | .1 | 4.0 | 91 | 488 Raisins E.P. | 2.6 | 3.3 | 76.1 | 1562 | 29 A.P. | 2.3 | 3.0 | 68.5 | 1407 | 32 Raspberries, red | 1.0 | -- | 12.6 | 247 | 184 black | 1.7 | 1.0 | 12.6 | 300 | 151 Rhubarb E.P. | .6 | .7 | 3.6 | 105 | 433 A.P. | .4 | .4 | 2.2 | 63 | 714 Rice | 8.0 | .3 | 79.0 | 1591 | 29 Salmon, dressed A.P. | 13.8 | 8.1 | -- | 582 | 78 whole E.P. | 22.0 | 12.8 | -- | 923 | 49 A.P. | 15.3 | 8.9 | -- | 642 | 71 Sausage, Bologna E.P. | 18.7 | 17.6 | .3 | 1061 | 43 A.P. | 18.2 | 19.7 | -- | 1135 | 40 farmer E.P. | 29.0 | 42.0 | -- | 2240 | 20 A.P. | 27.9 | 40.4 | -- | 2156 | 21 Shad, whole E.P. | 18.8 | 9.5 | -- | 727 | 61 A.P. | 9.4 | 4.8 | -- | 367 | 124 roe | 20.9 | 3.8 | 2.6 | 582 | 78 Shredded wheat | 10.5 | 1.4 | 77.9 | 1660 | 27 Spinach, fresh A.P. | 2.1 | .3 | 3.2 | 109 | 417 Squash E.P. | 1.4 | .5 | 9.0 | 209 | 217 A.P. | .7 | .2 | 4.5 | 103 | 443 Strawberries | 1.0 | .6 | 7.4 | 169 | 269 Succotash, canned | 3.6 | 1.0 | 18.6 | 444 | 102 Sugar | -- | -- | 100.0 | 1815 | 25 Tomatoes, fresh A.P. | .9 | .4 | 3.9 | 104 | 438 canned A.P. | 1.2 | .2 | 4.0 | 103 | 443 Tuna (tunny fish) E.P. | 26.6 | 11.4 | -- | 946 | 48 Turkey E.P. | 21.1 | 22.9 | -- | 1320 | 34 A.P. | 16.1 | 18.4 | -- | 1042 | 43 sandwich, canned | 20.7 | 29.2 | -- | 1568 | 29 Turnips E.P. | 1.3 | .2 | 8.1 | 178 | 256 A.P. | .9 | .1 | 5.7 | 124 | 367 Veal, breast E.P. | 20.3 | 11.0 | -- | 817 | 56 A.P. | 15.3 | 8.6 | -- | 629 | 72 cutlet E.P. | 20.3 | 7.7 | -- | 683 | 66 A.P. | 20.1 | 7.5 | -- | 670 | 68 fore quarter E.P. | 20.0 | 8.0 | -- | 690 | 66 A.P. | 15.1 | 6.0 | -- | 517 | 88 hind quarter E.P. | 20.7 | 8.3 | -- | 715 | 64 A.P. | 16.2 | 6.6 | -- | 534 | 85 side E.P. | 20.2 | 8.1 | -- | 697 | 65 A.P. | 15.6 | 6.3 | -- | 539 | 84 Vegetable soup, | | | | | canned | 2.9 | -- | .5 | 62 | 735 Walnuts, California | | | | | or English E.P. | 18.4 | 64.4 | 13.0 | 3199 | 14 A.P. | 4.9 | 17.3 | 3.5 | 859 | 53 black E.P. | 27.6 | 56.3 | 11.7 | 3011 | 15 A.P. | 7.2 | 14.6 | 3.0 | 780 | 59 Watermelons E.P. | .4 | .2 | 6.7 | 136 | 332 A.P. | .2 | .1 | 2.7 | 57 | 800 Wheat, cracked | 11.1 | 1.7 | 75.5 | 1635 | 28 Whitefish E.P. | 22.9 | 6.5 | -- | 680 | 67 A.P. | 10.6 | 3.0 | -- | 315 | 144 Zwieback | 9.8 | 9.9 | 73.5 | 1915 | 24 ============================+======+=======+=======+======+======= FOOTNOTES: [165] Courtesy of Dr. Henry Sherman. [166] The percentages of nutrients are taken from Bull. 28, Office of Experiment Stations, U. S. Department of Agriculture. The fuel values are calculated from these percentages by the use of the factors explained in Chapter II, viz.--protein, 4 calories; fat, 9 calories; carbohydrate, 4 calories per gram. TABLE II[167] ASH CONSTITUENTS OF FOODS IN PERCENTAGE OF THE EDIBLE PORTION (Compiled from various sources) KEY: A Calcium (Ca) B Magnesium (Mg) C Potassium (K) D Sodium (Na) E Phosphorus (P) F Chlorine (Cl) G Sulphur (S) H Iron (Fe) ===============+======+======+=======+======+======+=======+======+======= _Food_ | A | B | C | D | E | F | G | H ---------------+------+------+-------+------+------+-------+------+------- Almonds | .239 | .251 | .741 | .019 | .465 | .037 | .160 | .0039 Apples | .007 | .008 | .127 | .011 | .012 | .005 | .006 | .0003 dried | .032 | .037 | (.623)|(.050)| .048 | (.025)| ? |(.0015) Apricots | .014 | .010 | .248 | .038 | .025 | .002 | .010 |(.0003) dried |(.066)|(.047)|(1.157)|(.177)|(.117)| (.009)| ? |(.0014) Asparagus | .025 | .011 | .196 | .007 | .039 | .039 | .041 | .0010 Bacon (See | | | | | | | | Meat) | | | | | | | | Bananas | .009 | .028 | .401 | .034 | .031 | .125 | .010 | .0006 Barley, entire | .043 | .141 | .477 | .076 | .400 | .016 | .153 | .0041 pearled | .020 |(.070)| (.241)|(.037)| .181 | (.016)|(.120)|(.0020) Beans, dried | .160 | .156 | 1.229 | .097 | .471 | .032 | .215 | .0070 kidney, dry | .132 | .139 | 1.144 | .041 | .475 | .041 | .227 | .0072 Lima, dry | .071 | .188 | 1.741 | .249 | .338 | .026 | .161 | .0070 Lima, fresh | .028 |(.070)| (.613)|(.088)| .133 | (.009)|(.057)| .0020 string, fresh| .046 | .025 | .24 | .019 | .052 | .024 | .030 | .0011 Beef (See Meat)| | | | | | | | Beer | .004 | .008 | .058 | .013 | .028 | .006 | .015 | .0001 Beets | .029 | .021 | .353 | .093 | .039 | .058 | .016 | .0006 Blackberries | .017 | .021 | .169 |(.007)| .034 | (.010)| .020 | .0006 Blood (avg.) | .008 | .004 | .075 | .261 | .031 | .280 | .137 | .0526 Blueberries | .020 | .007 | .051 | .016 | .008 | .008 | .011 | .0009 Bluefish (See | | | | | | | | Fish) | | | | | | | | Bread, | | | | | | | | Boston brown | .129 | .078 | (.232)|(.394)| .185 | (.607)| .201 |(.0030) entire wheat |(.05) |(.05) | (.208)|(.394)|(.175)| (.607)|(.120)|(.0016) graham |(.05) |(.05) | (.291)|(.394)|(.218)| (.607)| .150 |(.0025) rye | .024 | .039 | .151 | .701 | .148 | 1.025 | .104 |(.0016) white | .027 | .023 | .108 |(.394)| .093 | (.607)| .105 | .0009 Breadfruit | .084 | .007 | .235 | .027 | .068 | .100 | .049 | Brussels | | | | | | | | sprouts | .027 | .040 | .375 | .004 | .120 | .040 | .194 |(.0011) Buckwheat flour| .039 | .048 | .130 | .027 | .226 | .012 | .071 | .0012 Butter | .015 | .001 | .014 |(.788)| .017 |(1.212)|(.010)| .0002 Buttermilk | .105 | .016 | .151 | .064 | .097 | .099 | .026 | .00025 Cabbage | .045 | .015 | .247 | .027 | .029 | .024 | .066 | .0011 Cabbage greens | .106 | .030 | .512 | .025 | .099 | .068 | .173 | .0018 Cantaloupe | .017 | .012 | .235 | .061 | .015 | .041 | .014 | .0003 Capers | .122 | .022 | .209 | .051 | .062 | -- | -- | -- Carp (See Fish)| | | | | | | | Carrots | .056 | .021 | .287 | .101 | .046 | .036 | .022 | .0006 Cauliflower | .123 | .014 | .222 | .068 | .061 | .050 | .086 | .0006 Caviar | .137 | .022 | .422 | .874 | .176 | 1.819 | -- | -- Celery | .078 | .014 | .316 | .084 | .037 | .156 | .022 | .0005 Chard | .150 | .071 | .318 | .086 | .040 | .039 | .124 |(.0025) Cheese | .931 | .037 | .089 | .606 | .683 | .880 | .263 | .0013 Cherries | .019 | .016 | .213 | .023 | .031 | .014 | .011 | .0004 Cherry juice | .017 | .011 | .200 | .013 | .018 | .003 | .006 |(.0003) Chestnuts | .034 | .051 | .560 | .065 | .093 | .006 | .068 | .0007 Chicken (See | | | | | | | | Meat) | | | | | | | | Chocolate | .092 |(.293)| (.563)| .012 | .455 | (.051)| .085 |(.0027) Cider | .008 | .011 | .095 | .020 | .009 | .006 | .006 |(.0002) Citron | .121 | .018 | .210 | .011 | .033 | .003 | .020 | -- Clams, round | .106 | .098 | .131 | .705 | .046 | 1.220 | .224 | -- soft, long | .124 | .079 | .212 | .500 | .122 | .910 | .213 | -- Cocoa | .112 | .420 | .900 | .059 | .709 | .051 | .203 | .0027 Coconut, dried | .059 | .059 | .597 | .073 | .155 | .239 |(.056)| -- fresh | .024 | .020 | .300 | .036 | .074 | .120 | .028 | -- Coconut milk | .020 | .009 | .144 | -- | .010 | -- | .008 | -- Cod (See Fish) | | | | | | | | Corn (maize), | | | | | | | | mature | .020 | .121 | .339 | .036 | .283 | .045 | .151 | .0029 meal | .018 | .084 | .213 | .039 | .190 | .146 | .111 | .0009 sweet | .006 | .033 | .113 | .040 | .103 | .014 | .046 | .0008 sweet, dried | .021 | .121 | .414 | .146 | .376 | .050 | .167 | .0029 Cotton seed | | | | | | | | meal | .265 | .462 | 1.390 | .234 |1.193 | .037 | .485 | -- Cowpeas | .100 | .208 | 1.402 | .161 | .456 | .040 | .240 | -- Crackers | .022 | .011 | .100 |(.594)| .102 | (.910)| .125 | .0015 Cranberries | .018 | .007 | .077 | .010 | .013 | .009 | .007 | .0006 Cream | .086 | .010 | .126 | .035 | .067 | .080 | .030 | .00022 Cucumbers | .016 | .009 | .140 | .010 | .033 | .030 | .020 | .0002 Currants, | | | | | | | | dried | .082 | .044 | .873 | .081 | .195 | .060 | .044 |(.0025) fresh | .026 | .017 | .211 | .007 | .038 | .006 | .014 | .0005 Currant juice | .021 | .010 | .185 |(.006)| .018 | .004 | .005 | -- Dandelion | .105 | .036 | .461 | .168 | .072 | .099 | .017 | .0027 Dates | .065 | .069 | .611 | .055 | .056 | .228 | .070 | .0030 Duck (See | | | | | | | | Meat) | | | | | | | | Eggplant | .011 | .015 | (.140)|(.010)| .034 | .024 | .016 | .0005 Eggs | .067 | .011 | .140 | .143 | .180 | .106 | .195 | .0030 Egg white | .015 | .010 | .160 | .156 | .014 | .155 | .216 | .0001 Egg yolk | .137 | .016 | .115 | .075 | .524 | .094 | .166 | .0086 Endive | .104 | .013 | .380 | .109 | .038 | .167 | .035 | -- Farina | .021 | .025 | .120 | .065 | .125 | .076 | .155 | .0008 Figs, dried | .162 | .071 | .964 | .046 | .116 | .043 | .056 | .0030 fresh | .053 | .022 | .303 | .012 | .036 | .014 | .010 | -- Fish[168] | | | | | | | | Flaxseed | .204 | .252 | .901 | .050 | .627 | .022 | .170 | -- Flour, | | | | | | | | buckwheat | .010 | .048 | .130 | .027 | .176 | .012 | .071 | .0012 entire wheat | .031 |(.090)| (.274)|(.037)| .238 | (.070)|(.180)| .0025 graham | .039 |(.133)| (.457)|(.037)| .364 | (.070)| .183 | .0037 white | .020 | .018 | .115 | .060 | .092 | .074 | .177 | .0010 rye | .018 | .081 | .463 | .019 | .289 | .055 | .123 | .0013 Fowl (See Meat)| | | | | | | | Gluten feed | .247 | .221 | .250 | .420 | .542 | .090 | .558 | -- Goose (See | | | | | | | | Meat) | | | | | | | | Gooseberries | .035 | .014 | .197 | .038 | .031 | -- | .011 | .0005 Grapefruit | .021 | .009 | .161 | .004 | .020 | .005 | .010 | .0003 Grape juice | .011 | .009 | .106 | .005 | .011 | .002 | .009 | .0003 Grapes | .019 | .010 | .197 | .015 | .031 | .005 | .024 | .0003 Guava | .014 | .008 | .384 | -- | .030 | .045 | -- | -- Haddock (See | | | | | | | | Fish) | | | | | | | | Halibut (See | | | | | | | | Fish) | | | | | | | | Ham (See Meat) | | | | | | | | Hazelnuts | .287 | .140 | .618 | .019 | .354 | .067 | .198 | .0041 Herring (See | | | | | | | | Fish) | | | | | | | | Hominy | .011 | .058 | .174 | .020 | .144 | .046 |(.136)|(.0009) Honey | .004 | .018 | .386 | .001 | .019 | .029 | .001 | .0007 Horseradish | .096 | .039 | .468 | .062 | .076 | .016 | .190 | -- Huckleberries | .020 | .007 | .051 | .016 | .008 | .008 | .011 | .0009 Huckleberry | | | | | | | | wine | .009 | .004 | .042 | .006 | .004 | .001 | .006 | -- Jam[169] | | | | | | | | Jelly | .014 |(.010)| (.100)|(.013)| .008 | (.004)|(.007)|(.0003) Kohl-rabi | .077 | .033 | .370 | .050 | .071 | .053 | .057 | .0006 Lamb (See | | | | | | | | Meat) | | | | | | | | Leeks | .058 | .014 | .199 | .081 | .006 | .024 | .072 | -- Lemons | .036 | .007 | .175 | .004 | .022 | .002 | .011 | .0006 Lemon juice | .024 | .010 | .127 | .009 | .010 | .003 | .006 | -- Lemon, sweet | .030 | .006 | .442 | -- | .042 | .013 | .016 | -- Lentils, dry | .107 | .101 | .877 | .062 | .438 | .050 | .277 | .0086 Lettuce | .043 | .017 | .339 | .027 | .042 | .074 | .014 | .0007 Limes | .055 | .014 | .350 | .062 | .036 | .039 | .011 | -- Lime juice | -- | -- | -- | -- | -- | -- | .003 | -- Linseed meal | .413 | .432 | 1.083 | .251 | .741 | .085 | .396 | -- Lupins, dry | .191 | .191 | .840 | .073 | .520 | .034 | -- | -- fresh | .053 | .022 | .303 | .012 | .036 | .014 | .010 | -- Macaroni | .022 | .037 | .130 | .008 | .144 | .073 | .172 | .0012 Mackerel (See | | | | | | | | Fish) | | | | | | | | Mamey | .009 | .012 | .345 | -- | .028 | .140 | -- | -- Mango | .021 | .007 | .235 | -- | .017 | .019 | .013 | -- Mangolds | .026 | .030 | .334 | .071 | .038 | .082 | .026 | -- Maple syrup | .107 | .034 | .208 | .010 | .013 | (.010)|(.005)|(.003) Meat[170] | | | | | | | | Meat extract, | | | | | | | | solid | .085 | .363 | 7.347 |2.394 |2.800 | 3.117 | -- | -- Meat peptone | .025 | .124 | 2.440 | .641 |1.130 | .561 | .222 | -- Milk (cow's), | | | | | | | | whole | .120 | .012 | .143 | .051 | .093 | .106 | .034 | .00024 skimmed |(.122)|(.012)| (.149)|(.052)|(.096)| (.110)|(.035)| .00025 condensed |(.300)|(.032)| (.374)|(.134)| .235 | (.280)|(.090)| .0006 buffalo | .203 | .016 | .099 | .038 | .125 | .062 | -- | -- camel's | .143 | .021 | .114 | .019 | .098 | .105 | -- | -- goat's | .128 | .013 | .145 | .079 | .103 | .014 | .037 | -- human | .034 | .005 | .047 | .010 | .015 | .035 | -- | -- mare's | .083 | .007 | .081 | .010 | .054 | .029 | -- | -- sheep's | .207 | .008 | .187 | .030 | .123 | .071 | -- | -- Millet | .014 | .167 | .290 | .085 | .327 | .019 | -- | -- Molasses | .211 | .068 | 1.349 | .019 | .044 | .317 | .129 | .0073 Mushrooms | .017 | .016 | .384 | .027 | .108 | .021 | .051 | -- Muskmelon | .017 | .012 | .235 | .061 | .015 | .041 | .014 | .0003 Mustard | .492 | .260 | .761 | .056 | .755 | .016 |1.230 | -- Mutton (See | | | | | | | | Meat) | | | | | | | | Oatmeal | .069 | .110 | .344 | .062 | .392 | .069 | .202 | .0038 Okra | .071 | .010 | .035 | .043 | .019 | -- | -- | -- Olives | .122 | .002 | 1.526 | .128 | .014 | .004 | .027 | .0029 Onions | .034 | .016 | .178 | .016 | .045 | .021 | .070 | .0006 Oranges | .045 | .012 | .177 | .012 | .021 | .006 | .011 | .0002 Orange juice | .029 | .011 | .182 | .008 | .016 | .003 | .009 | .0002 Oysters | .052 | .037 | .091 | .459 | .155 | .590 | .187 | .0045 Paprika | .229 | .164 | 2.075 | .178 | .341 | .155 | -- | -- Parsnips | .059 | .034 | .518 | .004 | .076 | .030 | .036 | .0006 Peaches | .016 | .010 | .214 | .022 | .024 | .004 | .009 | .0003 dried | .034 | .056 | (.830)| .082 | .146 | -- | .212 |(.0012) Peanuts | .071 | .180 | .654 | .050 | .399 | .056 | .224 | .0020 Pears | .015 | .011 | .132 | .016 | .026 | .011 | .010 | .0003 Pear juice | .009 | .008 | 1.40 | -- | .011 | -- | .009 | -- Peas, dried | .084 | .149 | .903 | .104 | .400 | .035 | .219 | .0057 fresh | .028 | .038 | .285 | .013 | .127 | .024 | .063 | .0017 Pecan nuts | .089 | .152 | (.332)| -- | .335 | .050 | .113 | .0026 Pepper, green, | | | | | | | | fresh | .006 | .010 | (.139)| -- | .026 | .013 | .014 | .0004 Pepper, black, | | | | | | | | dry | .440 | .156 | 1.140 | .131 | .188 | .312 | -- | -- Pepper, white, | | | | | | | | dry | .425 | .113 | -- | -- | .233 | .029 | -- | -- Perch (See | | | | | | | | Fish) | | | | | | | | Persimmons | .022 | .009 | .292 | .011 | .021 | .002 | .005 | -- Pineapple | .018 | .011 | .321 | .016 | .028 | .051 | .009 | .0005 Plums | .020 | .011 | .203 | .019 | .032 | .002 | .009 | .0005 Pomegranate | .011 | .005 | .063 | .085 | .105 | .003 | -- | .0004 Pork (See | | | | | | | | Meat) | | | | | | | | Potatoes | .014 | .028 | .429 | .021 | .058 | .038 | .030 | .0013 sweet | .019 | .028 | .397 | .039 | .045 | .094 | .024 | .0005 Prunes, dried | .054 | .055 | 1.030 | .069 | .105 | .017 | .037 | .0030 Pumpkin | .023 | .008 | (.320)| .065 | .059 | -- | .021 |(.0008) Radishes | .021 | .012 | .218 | .069 | .029 | .054 | .041 | .0006 Raisins | .064 | .083 | .820 | .133 | .132 | .082 | .051 | .0021 Raspberries | .049 | .024 | .173 | -- | .052 | -- | .017 | .0006 Raspberry juice| .021 | .016 | .134 | .005 | .012 | -- | .009 | -- Rhubarb | .044 | .017 | .325 | .025 | .031 | .036 | .013 | .0010 Rice, brown | -- | -- | -- | -- | .207 | -- | -- | .0020 white | .009 | .033 | .070 | .025 | .096 | .054 | .117 | .0009 Romaine | | | | | | | | (salad) | .045 | .032 | .306 | .016 | .053 | .073 | .019 | -- Rutabagas | .074 | .018 | .399 | .083 | .056 | .058 | .083 | -- Rye, entire | .055 | .130 | .453 | .035 | .385 | .025 | .170 | .0039 (See also | | | | | | | | Bread and | | | | | | | | Flour) | | | | | | | | Salmon (See | | | | | | | | Fish) | | | | | | | | Sapota | .026 | .008 | .179 | -- | .006 | .087 | -- | -- Shredded | | | | | | | | wheat | .041 | .144 | -- | -- | .324 | -- | -- | .0045 Shrimp | .096 | -- | -- | -- | -- | -- | -- | -- Soup, canned | .036 | -- | .033 | -- | .030 | -- | -- | -- canned | | | | | | | | vegetable | .025 | .013 | .101 | -- | .038 | -- | .025 | -- Spinach | .067 | .037 | .774 | .125 | .068 | .074 | .038 | .0036 Squash, summer,| | | | | | | | seeds removed| .018 | .008 | .150 | .002 | -- | -- | -- |(.0006) with seeds | .024 | .012 | .180 | .004 | -- | -- | -- |(.0006) Squash, winter | .019 | .011 | .320 | .004 | -- | -- | -- |(.0006) Strawberries | .041 | .019 | .147 | .050 | .028 | .006 | .014 | .0008 Tamarind | .007 | .021 | -- | -- | .072 | .007 | .009 | -- Tapioca | .023 | -- | -- | -- | .090 | .018 | .029 | .0016 Tomatoes | .011 | .010 | .275 | .010 | .026 | .034 | .014 | .0004 Tomato juice | .006 | .010 | .310 | .015 | .015 | .055 | -- | -- Truffles | .024 | .018 | .404 | .077 | .062 | .039 | -- | -- Turnips | .064 | .017 | .338 | .056 | .046 | .041 | .065 | .0005 Turnip tops | .347 | .028 | .307 | .082 | .049 | .168 | .069 | -- Veal (See Meat)| | | | | | | | Vinegar (cider)| .016 | .008 | .165 | -- | .013 | -- | .017 |(.0003) Walnuts | .089 | .134 | (.332)| -- | .358 | .040 | .172 | .0021 Water cress | .187?| .034 | .287 | .099 | .005 | .061 | .167 | .0019 Watermelon | .011 | .003 | .073 | .008 | .003 | .008 | .007 | -- Wheat, entire | .045 | .133 | .473 | .039 | .423 | .068 | .181 | .0050 (See also | | | | | | | | Bread and | | | | | | | | Flour) | | | | | | | | Wheat bran | .120 | .511 | 1.217 | .154 |1.215 | .090 | .247 | .0078 Wheat germ | .071 | .342 | .296 | .722 |1.050 | .070 | .325 | -- Wheat gluten | .078 | .045 | .007 | .028 |2.00 | .050 | .920 | -- Whey | .044 | .008 | .157 | .038 | .035 | .119 | .009 | ? Whortleberries,| | | | | | | entire | .031 | .021 | .261 | .021 | .042 | -- | -- | -- flesh only | .020 | .011 | .087 | -- | .018 | -- | -- | -- Wine (avg.) | .009 | .010 | .104 | .008 | .015 | .011 | .015 |(.0003) ===============+======+======+=======+======+======+=======+======+======= FOOTNOTES: [167] From Sherman's "Chemistry of Food and Nutrition," by courtesy of the author. [168] Average fish is estimated to contain _per 100 grams of protein_ as follows: 0.109 gram Ca; 0.133 gram Mg; 1.671 grams K; 0.373 gram Na; 1.148 grams P; 0.528 gram Cl; 1.119 grams S; 0.0055 gram Fe. [169] The percentages of the ash constituents in jams are believed to average about two thirds those of the corresponding fruits. [170] Average meat is estimated to contain _per 100 grams protein_ as follows: 0.058 gram Ca; 0.118 gram Mg; 1.694 grams K; 0.421 gram Na; 1.078 grams P; 0.378 gram Cl; 1.146 grams S; 0.0150 gram Fe. TABLE III Showing 100-Calorie Portions of Some Common Foods--Together with Their Protein, Nitrogen, and Mineral Content[171] KEY A _Protein Calories_ B _Protein Grams_ C _Nitrogen Grams_ D _Calcium Grams_ E _Phosphorus Grams_ F _Iron Grams_ ==================+===================+=====+=====+=====+====+=====+====== _Material_ | _Measure_ | A | B | C | D | E | F | _Portion_ | | | | | | ------------------+-------------------+-----+-----+-----+----+-----+------ Almonds |12 - 15 nuts |12.9 | 3.2 | .051|.037| .072|.0006 Apples, dried |1/2 cup, 1.2 oz. | 2.5 | .6 |0.10 |.108| .163|.0005 Apples, fresh |1 large apple, | | | | | | | 7.5 oz. | 2.4 | 0.6 | .096|.012| .020|.0005 Apricots, dried |9 halves, 1.3 oz. | 7.6 | 1.9 |0.30 |.123| .044|.0005 Asparagus, fresh |20 stalks, 8 in. | | | | | | | long, 15.9 oz. |32.4 | 8.1 |1.29 |.122| .177|.0045 | | | | | | | Bacon, fried |4 - 5 small | | | | | | | slices, 5 oz. | 6.8 | 1.7 | .27 |.001| .018|.0003 Bananas |1 large, 5.5 oz. | 5.3 | 1.3 | .02 |.009| .031|.0006 Beans, Lima, dried|2 tbs., 1 oz. |23.2 | 5.8 | .92 |.020| .096|.00200 Beans, Lima, fresh|1/2 cup, 2.9 oz. |23 | 5.7 | .92 |.001| .007|.00011 Beans, string |2-1/2 cups, cut in | | | | | | | pieces, 8.5 oz. |22.4 | 5.6 | .89 |.110| .126|.0027 Beans, white, | | | | | | | dried |2 tbs., 1 oz. |26.0 | 6.5 |1.4 |.047| .137|.0020 Beets |4 beets, 2 in. | | | | | | | diam., 7 oz. |14.0 | 3.5 |0.56 |.064| .084|.0013 Beef, round, lean |1 slice, | | | | | | | 3 × 3 × 1-1/2 | | | | | | | in., 2 oz. |48.0 |12.0 |1.92 |.007| .129|.0018 Beef feet |slice, | | | | | | | 5 × 2-1/2 × 1/4 | | | | | | | in., 1.6 oz. |30.0 | 7.5 |1.6 |.004| .081|.0011 Butter |1 (scant) tbs., | | | | | | | 0.5 oz. | 1.6 | 0.4 | .064|.002| .002|.00003 Cabbage |5 cups, sliced, | | | | | | | 11.2 oz. |20.4 | 5.1 |0.89 |.143| .092|.0035 Carrots |4 - 5 young car., | | | | | | | 10.5 oz. | 9.6 | 2.4 |0.384|.124| .101|.0013 Cauliflower |1 small head, | | | | | | | 11.5 oz. |23.6 | 5.9 |0.944|.403| .200|.0020 Celery |4 cups, in 1-in. | | | | | | | pieces | 5.2 | 1.3 |0.20 |.421| .201|.0027 Clams |6 clams, 1/2 cup, | | | | | | | 7.6 oz. |79.2 |19.8 |3.16 |.285| .282|.0097 Cheese, American |1-1/8 in. cube | | | | | | | (0.8 oz.) |24.4 | 6.1 |0.97 |.211| .156|.0003 Cherries (stoned) |1 cup, 4.5 oz. | 4.8 | 1.2 |0.19 |.025| .039|.0005 Chicken, lean | | | | | | | meat, roasted |2-1/2 oz. |79.6 |19.9 |3.19 |.006| .075|.0029 Crackers, soda |4 crackers | 9.6 | 2.4 |0.38 |.006| .025|.0004 Cornmeal |3 tbs., 1 oz. |10.4 | 2.6 |0.41 |.005| .053|.0003 Corn |1/3 cup, 3.6 oz. |12.4 | 3.1 |0.49 |.006| .102|.0008 Chocolate, | | | | | | | unsweetened |3/4 × 1/4 × 7/8 in.| | | | | | | piece | 8.4 | 2.1 |0.33 |.015| .075|.0004 Cocoa |3-1/2 tbs., 0.7 oz.|17.6 | 4.4 |0.49 |.023| .143|.0005 Cream, 18% (thin) |1/4 cup, 1.8 oz. | 5.2 | 1.3 |9.20 |.050| .044|.0001 Cream, 40% (thick)|1-1/3 tbs., 0.9 oz.| 2.4 | 0.6 |0.096|.020| .020|.00005 | | | | | | | Dates |4-1/2 dates, | | | | | | | 1.1 oz. | 2.4 | 0.6 |0.096|.019| .016|.0009 | | | | | | | Eggs |1-1/3 eggs |36.4 | 9.1 |1.45 |.045| .122|.0021 Egg whites |7 whites, 6.9 oz. |96.48|24.12|3.85 |.020| .022|.00020 Egg yolks |2 yolks, 1 oz. |17.28| 4.32| .691|.036| .118|.00230 Farina |3 tbs., 1 oz. |12.4 | 3.1 | .496|.006| .035|.0002 Fish, lean |piece, | | | | | | | 3 × 3 × 1/2 in., | | | | | | | 2.4 oz. |90.4 |22.6 |3.61 |.025| .259|.0012 Fish, oily | |53.2 |13.3 |2.12 |.015| .153|.0007 Figs |1-1/2 large figs, | | | | | | | 1.1 oz. | 5.6 | 1.4 | .224|.051| .037|.0010 Flour, entire | | | | | | | wheat |3 tbs., 1 oz. |15.6 | 3.9 | .624|.009| .066|.0007 graham |3 tbs., 1 oz. |14.8 | 3.7 | .592|.011| .101|.0010 rye |3 tbs., 1 oz. | 8.0 | 2.0 | .32 |.005| .082|.0004 white |4 tbs., 1 oz. |12.8 | 3.2 | .572|.006| .026|.0002 | | | | | | | Gelatin |27 grams |98.8 |24.9 |3.98 | | | Grapefruit |2-3/4 tbs. | 5.00| 1.25| |.040| .036|.00058 Grapes (Concord) |1 large bunch, | | | | | | | 5 oz. | 5.6 | 1.4 |0.2 |.019| .032|.0003 Grape juice |1/2 cup, 3.6 oz. | 1.40| 0.35| .05 |.011| .011|.0003 | | | | | | | Hominy |3-1/2 tbs., 1 oz. | 9.6 | 2.4 |0.35 |.002| .027|.0003 Honey |1 tbs., 1.1 oz. | .4 | 0.1 | |.002| .006|.0003 | | | | | | | Lamb |1 slice, | | | | | | | 3-1/2 × 4-1/2 | | | | | | | × 1/3 in., | | | | | | | 1.8 oz. |25.6 | 6.4 | 1.02|.004| .069|.0010 Lemons |3 large, 11.4 oz. | 9.2 | 2.3 | 0.36|.081| .049|.0014 Lettuce |2 large heads, | | | | | | | 18.5 oz. |25.2 | 6.3 |1.0 |.224| .224|.0079 Lentils (dried) |2-1/2 tbs., 1 oz. |29.6 | 7.4 |1.18 |.031|1.26 |.0025 | | | | | | | Macaroni |1 cup |14.8 | 3.7 |0.59 |.006| .040|.0003 Milk, whole |3/8 cup, 5.1 oz. |19.2 | 4.8 |0.76 |.174| .134|.0009 skimmed |3/8 cup |37.2 | 9.3 |1.48 |.331| .262|.0007 unsweetened, | | | | | | | canned |3-3/4 tbs., 2.1 oz.|23.2 | 5.8 |0.92 |.188| .146|.0004 sweet, canned |1-1/2 tbs., 1.1 oz.|10.4 | 2.6 |0.41 |.096| .072|.0002 buttermilk |1-1/8 cup, 10.0 oz.|33.6 | 8.4 |1.34 |.294| .271|.0007 Milk powder[172] |1 oz. | | | | | | malted | | | | | | | (Horlick's)[173]|1-1/2 tbs., 1.2 oz.| | | | | | Molasses | | | | | | | Mutton |1 slice, 3 × 3-1/4 | | | | | | | × 1/8 inch |24.8 | 6.2 |0.99 |.004| .067|.0009 | | | | | | | Oatmeal |1/3 cup, 1 oz. |16.8 | 4.2 |0.67 |.017| .099|.0010 Onions |3 - 4 med., | | | | | | | 7.2 oz. |13.2 | 3.3 |0.52 |.069| .093|.0010 Orange |1 large, 9.5 oz. | 6.4 | 1.6 |0.25 |.088| .040|.0004 Oysters (raw) |6 - 12 oys., 2/3 | | | | | | | cup, 7.2 oz. |49.2 |12.3 |1.06 |.106| .306|.0089 | | | | | | | Parsnip |2 medium, 7.0 oz. |10.0 | 2.5 |0.40 |.091| .117|.0009 Peas, fresh |3/4 cup, 3.5 oz. |26.0 | 6.5 |1.04 |.026| .120|.0017 Peaches, fresh |3 medium, 60.5 oz. | 3.8 | 1.7 |0.27 |.038| .057|.0007 Pears |1 large, 6.3 oz. | 4.0 | 1.0 |0.16 |.024| .041|.0005 Peanuts |20 - 24 single, | | | | | | | 0.6 oz. |18.8 | 4.7 |0.75 |.013| .073|.00049 Pecans |12 single, 0.51 oz.| 5.2 | 1.3 |0.2 |.012| .045|.0004 Pepper (green) | |18.0 | 4.5 |0.72 |.034| .145|.0022 Pineapple |2 slices 1 in. | | | | | | | thick, 8.2 oz. | 3.6 | 0.9 | |.041| .064|.0012 Plums |3 - 4 large, | | | | | | | 4.4 oz. | 4.8 | 1.2 |0.19 |.024| .038|.0006 Potatoes (sweet) |1/2 medium, 3.6 oz.| 6.0 | 1.5 |0.24 |.016| .037|.0004 Potatoes (white) |1 medium, 5.3 oz. |10.8 | 2.7 |0.43 |.016| .069|.0016 Prunes |4 medium, 1.4 oz. | 2.8 | 0.7 | .11 |.018| .035|.0010 | | | | | | | Radishes |36 small, 12 oz. |17.6 | 4.4 |0.7 |.073| .098|.0021 Rhubarb |4 cups, cut in | | | | | | | small pieces, | | | | | | | 15.3 oz. |10.4 | 2.6 |0.41 |.189| .134|.0043 Rice |3 tbs., 1 oz. | 9.2 | 2.3 |0.36 |.004| .027|.0003 | | | | | | | Shredded wheat |1 biscuit, 0.9 oz. |14.0 | 3.5 |0.55 |.011| .089|.0012 Spinach |3 cups, 14.7 oz. |35.2 | 8.8 |1.40 |.281| .285|.0150 Squash, summer | |12.4 | 3.1 |0.49 |.039| .035|.0013 winter | |12.4 | 3.1 | |.038| .069|.0013 Strawberries |1-1/3 cups, 9.0 oz.|10.24| 2.56|0.40 |.104| .072|.0021 Tapioca |3 tbs., 1.0 oz. | 0.44| 0.11|0.017|.004|.025 |.0005 Tomatoes, fresh |2 - 3 medium, | | | | | | | 15.5 oz. |16.0 | 4.0 |0.64 |.050|.113 |.0018 canned |1-3/4 cup, 15.6 oz.| | | | | | Turnips |2 cups, cut in | | | | | | | cubes, 13.0 oz. |13.2 | 3.3 |0.52 |.161|.117 |.0013 | | | | | | | Veal |slice, 2 × 2-3/4 | | | | | | | inches, 2.3 oz. |58.0 |14.5 |2.32 |.008|.156 |.0022 | | | | | | | Walnuts, English |16 - 18 nuts, | | 0.5 oz. |10.4 | 2.6 |0.41 |.013|.015 |.0003 Watermelon |11.7 oz. | 5.2 | 1.3 |0.20 |.038|.010 |.0010 (edible portion)| | | | | | | ==================+===================+=====+=====+=====+====+=====+====== FOOTNOTES: [171] Table compiled from "Chemistry of Food and Nutrition," Sherman.--"A Laboratory Handbook for Dietetics," and "Feeding the Family," Rose--and other sources. [172] Milk powders now on market are made from skimmed or partially skimmed milk. [173] Horlick's malted milk. Analysis made in Horlick's Laboratories. TABLE IV COMPOSITION AND FUEL VALUE OF MOST OF THE FOODS USED IN THE INVALID DIETARY All determinations allow 28.35 grams to the ounce. All calculations are made using the factor 4 calories for protein, 4 calories for carbohydrates, and 9 calories for fats. The materials are measured in standard 8-ounce measuring cups, or tablespoons. The measures are exactly level unless otherwise stated. In calculating beverages containing alcohol, it is necessary to know the percentage of alcohol contained therein. Alcohol has a fuel value of 7 calories per gram. (Whether this heat is available for the needs of the body is still a question.) KEY A _Nitrogen Gm._ B1 _Proteins Per Cent_ B2 _Proteins Gm._ C1 _Fats Per cent_ C2 _Fats Gm._ D1 _Carbohydrates Per Cent_ D2 _Carbohydrates Gm._ E _Fuel Value_ =======================+===========+===========================+======= Material | Weight | Measure | A -----------------------+-----------+---------------------------+------- Almonds | 1/2 oz. | 6 | .48 Apples | 5.5 oz. | 1 medium | .09 Apricots | | 9 halves | -- Arrowroot | 1 oz. | 8 tablespoonfuls | -- Artichoke, French | 1 oz. | | .15 Asparagus, fresh | 4 oz. | 6 stalks | .33 Asparagus, canned | 4 oz. | 1/2 cup | .28 | | | Bacon | 1 oz. | 2 slices | .35 Bananas, E.P.[174] | 3-1/2 oz. | 1 medium | .20 Barley, pearled | 1 oz. | 3 tablespoonfuls | .39 Barley flour | 1/2 oz. | 1 tablespoonful | .16 Bass | 3 oz. | 1 serving | 2.53 Beans, string | 3 oz. | 1 serving | .31 Beans, butter | 3 oz. | 1 serving | 1.26 Beans, Lima, dried | 1 oz. | | .81 Beans, baked, canned | 1 oz. | | .31 Beef broth | 1 oz. | 2 tablespoonfuls | 0.1 Beef broth | 6 oz. | 1 cup | 0.3 Beef soup[175] | 6 oz. | 1 cup | 1.18 Beef juice | 1 oz. | 2 tablespoonfuls | .22 Beef marrow | 1/2 oz. | 1 tablespoonful | .05 Beefsteak, porterhouse | 3 oz. | 1 serving | 2.99 Beefsteak, sirloin | 3 oz. | 1 serving | 2.57 Top of round | 3 oz. | 1 serving | 2.65 Roast beef, second cut | 2 oz. | 1 slice | 1.84 Roast beef, second cut | 1 oz. | 1 thin slice | .91 Beets, cooked | 1 oz. | | .10 Bluefish | 3 oz. | 1 serving | 2.65 Brandy | 1/2 oz. | 1 tablespoonful | -- Bran | 2-1/2 oz. | 1 cup | 1.25 Bread | 1 oz. | 1 slice, 3/4 in. thick | .42 Boston brown | 1 oz. | 1 slice | .27 Rolls | 1 oz. | | .41 Whole wheat | 1 oz. | | .44 -----------------------+-----------+---------------------------+------- ==============+==================+==================+======== B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+-------- 21.0 | 2.97 | 54.9 | 7.78 | 17.3 | 2.45 | 92. 0.4 | .6 | 0.5 | .78 | 14.2 | 22. | 97.4 5.1 | 1.9 | 0.1 | .4 | 61. | 22.5 | 100. -- | -- | -- | -- | 69.2 | 19.6 | 78. 3.4 | .96 | 0.5 | .14 | 12. | 3.4 | 18.7 1.8 | 2.04 | 0.2 | .23 | 3.3 | 3.74 | 25. 1.5 | 1.7 | 0.1 | .11 | 2.8 | 3.17 | 21. | | | | | | 9. | 2.5 | 58. | 16. | -- | -- | 144. 1.3 | 1.29 | 0.6 | .6 | 22.0 | 21.83 | 98. 8.5 | 2.41 | 1.1 | .31 | 77. | 22. | 100. 10.4 | .98 | 2.2 | .21 | 72.6 | 7. | 33. 18.6 | 15.8 | 2.8 | 2.37 | -- | -- | 84. 2.3 | 1.95 | .26 | .22 | 5.1 | 4.35 | 27. 9.3 | 7.9 | 0.6 | .51 | 29.2 | 24.8 | 135. 18. | 5.1 | 1.5 | .42 | 65.9 | 18.7 | 99. 6.9 | 1.96 | 2.5 | .71 | 19.6 | 5.5 | 36. 1.8 | .5 | 0.1 | .3 | -- | -- | 4.7 1.8 | 3. | 0.1 | 1.8 | -- | -- | 28. 4.3 | 7.4 | 3.6 | 6.1 | 1.1 | 1.8 | 92. 4.9 | 1.39 | .6 | .17 | -- | -- | 6. 2.2 | .31 | 92. | 13. | -- | -- | 118. 22.0 | 18.69 | 20.4 | 17.35 | -- | -- | 240. 19.0 | 16.08 | 18.5 | 15.72 | -- | -- | 205.8 19.5 | 16.58 | 7.3 | 6.21 | -- | -- | 106.2 20.2 | 11.5 | 8.4 | 4.8 | -- | -- | 89. 20.1 | 5.7 | 8.5 | 2.4 | -- | -- | 44. 2.3 | .65 | .1 | .03 | 7.4 | 2.1 | 11.3 19.6 | 16.6 | 1.2 | 1. | -- | -- | 75. -- | -- | -- | -- | -- | -- | 42. 11.0 | 7.8 | 2.1 | 1.5 | 61. | 43. | 217. 9.2 | 2.6 | 1.3 | .37 | 53. | 15. | 73.7 6. | 1.7 | 6.3 | 1.79 | 54. | 15.3 | 84.1 9. | 2.55 | 3. | .85 | 54.2 | 15.4 | 79.5 9.7 | 2.75 | .9 | .26 | 49.7 | 14.1 | 69.7 ------+-------+--------+---------+--------+---------+--------- =======================+===========+===========================+======= Material |Weight |Measure | A -----------------------+-----------+---------------------------+------- Bread crumbs | 5 oz. | 1 cup | 2.08 Bread, graham | 1 oz. | 1 slice | .40 Bread, gluten[176] | 1 oz. | 1 slice, 1/2 in. thick | 1.34 Maryland biscuit | | | (Southern beaten | | | biscuit) | 1 oz. | 2 small biscuits | .38 Butter | 1 oz. | 2 tablespoonfuls | .04 Butter | 1 lb. | 2 cups | .72 | | | Cabbage | 1 oz. | | .07 Carrots | 3 oz. | 1 medium | .15 Carrots | 1 oz. | | .05 Cauliflower | 3 oz. | 1 serving | .24 Cauliflower | 1 oz. | | .08 Celery | 1 oz. | 1 stalk, medium sized | .05 Chard | 1 oz. | | .15 Cherries, fresh | 1 oz. | | .04 Chestnuts | 1 oz. | | .28 Clam bouillon | 1 oz. | 2 tablespoonfuls | .01 Clam bouillon | 6 oz. | 2/3 cup | .01 Cheese, American | 1 oz. | 2 tablespoonfuls, grated | 1.31 Cottage cheese (curds) | 1 oz. | 2 tablespoonfuls | .95 Cream cheese | | | (Neufchâtel) | 1 oz. | 1/2 block | .85 Chicken, broiler, E.P. | 1 oz. | | .97 Chicken, broiler, E.P. | 3 oz. | 1 serving | 2.92 Chocolate, unsweetened | 1 oz. | 1 square | .58 Cocoa | 1 oz. | 4 tablespoonfuls | .98 Cocoa | 1/8 oz. | 2 teaspoonfuls (1 serving)| .12 Cod, dressed | 1 oz. | | .50 Condensed milk, | | | sweetened | | | (Eagle Brand) | 1 oz. | 2 tablespoonfuls | .40 Condensed milk, or | | | evaporated, | | | unsweetened | 1/8 oz. | 1 teaspoonful | .07 Consommé | 6 oz. | 2/3 cup | 1.06 Corn, canned | 1 oz. | 2 tablespoonfuls | .13 Corn, green, E.P. | 1 oz. | 2 tablespoonfuls | .14 Cornmeal, granular | 1 oz. | 2 tablespoonfuls | .42 Cornflakes, toasted | 1 oz. | | .25 Cornstarch | 1 oz. | 3 tablespoonfuls | -- Crackers, graham | 1/3 oz. | 1 cracker | .15 Crackers, water | 1/3 oz. | 1 cracker | .19 Crackers, oyster | 1 oz. | | .51 Cracker crumbs | 2-1/2 oz. | 1/2 cup | 1.32 -----------------------+-----------+---------------------------+------- ==============+==================+==================+========= B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+--------- 9.3 | 13.0 | 1.2 | 1.7 | 53. | 75. | 367. 8.8 | 2.5 | 1.8 | .51 | 52. | 14.7 | 73.5 29.5 | 8.4 | 1.1 | .3 | 30. | 8.5 | 70. | | | | | | | | | | | | 8.4 | 2.38 | 5.6 | 1.5 | 60. | 17. | 91.7 1.0 | .28 | 85. | 24.09 | -- | -- | 218. 1.0 | 4.53 | 85. | 385.5 | -- | -- | 3488. | | | | | | 1.6 | .45 | 00.3 | .09 | 5.6 | 1.59 | 9. 1.1 | .93 | 00.4 | .34 | 9.3 | 7.91 | 37.5 1.1 | .31 | 00.4 | .11 | 9.3 | 2.63 | 12.5 1.8 | 1.53 | 00.5 | .42 | 4.7 | 3.99 | 25.8 1.8 | .51 | 00.5 | .14 | 4.7 | 1.33 | 8.6 1.1 | .31 | 00.1 | .03 | 3.3 | .93 | 5.2 3.2 | .91 | 00.6 | .17 | 5. | 1.41 | 10.8 1. | .28 | 00.8 | .23 | 16.7 | 4.73 | 22. 6.2 | 1.76 | 5.4 | 1.53 | 42.1 | 11.94 | 68.6 0.2 | .057| -- | -- | 0.2 | .057 | .45 0.2 | .342| -- | -- | 0.2 | .342 | 3. 28.8 | 8.16 | 35.9 | 10.18 | 0.3 | .09 | 124.6 20.9 | 5.92 | 1.0 | .28 | 4.3 | 1.22 | 31. | | | | | | 18.7 | 5.24 | 27.4 | 7.77 | 1.5 | .42 | 93. 20.7 | 5.8 | 8.3 | 2.35 | -- | -- | 44.35 20.7 | 17.4 | 8.3 | 7.05 | -- | -- | 133. 12.9 | 3.65 | 48.7 | 13.8 | 30.3 | 8.59 | 173. 21.6 | 6.12 | 28.9 | 8.19 | 37.7 | 10.69 | 141. 21.6 | .76 | 28.9 | 1.02 | 37.7 | 1.33 | 17.6 11. | 3.12 | 0.2 | .06 | -- | -- | 13. | | | | | | | | | | | | 8.8 | 2.49 | 8.3 | 2.35 | 53.9 | 15.3 | 92. | | | | | | | | | | | | 7.5 | .27 | 8.3 | .29 | 9.7 | .34 | 5. 2.5 | 4.25 | -- | -- | 0.4 | .68 | 19.7 2.8 | .79 | 1.2 | .34 | 19. | 5.39 | 28. 3.1 | .88 | 1.1 | .31 | 19.7 | 5.58 | 28.6 9.3 | 2.63 | 1.9 | .54 | 75.5 | 21.4 | 101. 5.5 | 1.56 | 1.5 | .43 | 81.2 | 23. | 102.1 -- | -- | -- | -- | 89.1 | 25.25 | 101. 10. | .94 | 9.3 | .88 | 73.8 | 6.97 | 39.5 11.7 | .77 | 5. | .47 | 75.7 | 7. | 35.3 11.3 | 3.2 | 10.5 | 2.98 | 70.5 | 19.98 | 119.5 11.6 | 7.8 | 6. | 4.3 | 72.9 | 51.7 | 276.7 ------+-------+--------+---------+--------+---------+--------- =======================+===========+===========================+======= Material |Weight |Measure | A -----------------------+-----------+---------------------------+------- Cranberries | 1 oz. |2 tablespoonfuls | .02 Cream, 18% (single X) | 1 oz. |2 tablespoonfuls | .13 Cream, 40% (double X) | 1 oz. |2 tablespoonfuls | .10 Cucumber, E.P. | 1 oz. | | .04 Currants, dried | 1 oz. |2 tablespoonfuls | .11 | | | Dates, dried | 1.1 oz. |4-1/2 | .09 Dry peptonoids | 1 oz. |2 tablespoonfuls | .96 | | | Eggs, whole, without | 1.8 oz. or| | shell | 5 gms. |1 medium sized | 1. Egg white | 1.2 oz. |1 white (34 gm. wt.) | .67 Egg yolk | .6 oz. |1 yolk (17 gm. wt.) | .43 Eggplant | 1 oz. | | .05 | | | Farina | 1 oz. |3 tablespoonfuls | .50 Figs, dried | 1 oz. |1 fig | .19 Fish | 1 oz. | | .84 Flour, barley | 1 oz. |2 tablespoonfuls | .46 Flour, gum gluten | 1 oz. |3 tablespoonfuls | 1.65 Flour, graham | 1 oz. |3 tablespoonfuls | .60 Flour, wheat | 1 oz. |3 tablespoonfuls | .51 Flour, wheat | 1/3 oz. |1 tablespoonful | .17 Flour, entire wheat | 1 oz. |3 tablespoonfuls | .63 Fowl, E.P. | 1 oz. | | .88 Fowl, E.P. | 3-1/2 oz. |1 serving | 3.09 | | | Gelatin, granulated | 1 oz. | | 4.15 Gelatin, granulated | 1/4 oz. |1 tablespoonful | 1.04 Gum gluten bread | 1 oz. |1 slice | 1.34 Gum gluten biscuit | 1/4 oz. |1 biscuit | .47 Greens (A.P.), | | | beet tops | 4 oz. | | .38 Greens, cooked | 4 oz. |1 serving | .37 Grapes, malaga | 2 oz. |about 12 grapes | .12 Grapes, malaga | 1 lb. | | .95 Grapefruit | 1 oz. | | -- Grape juice | 1 oz. |2 tablespoonfuls | -- Grape juice | 4 oz. |1/2 cupful | -- | | | Halibut (E.P.) steak | 3 oz. |1 serving | 2.53 Ham, lean, smoked, | | | E.P. | 1-1/2 oz. |1 serving (1 slice) | 1.35 Ham, medium fat, | | | smoked | 1 oz. |1 slice | .74 Hominy | 1 oz. |2 tablespoonfuls | .38 Hickory nuts, shelled | 1 oz. |2 tablespoonfuls | .70 Honey | 1 oz. |2 tablespoonfuls | .02 -----------------------+-----------+---------------------------+------- ==============+==================+==================+========= B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+--------- 0.4 | .11 | 0.6 | .17 | 10.0 | 2.8 | 13. 3. | .8 | 19.7 | 5.6 | 4.9 | 1.4 | 59. 2.2 | .62 | 40. | 11.34 | 3. | .85 | 108. 0.8 | .23 | 0.2 | .06 | 3.1 | .88 | 5. 2.4 | .68 | 1.7 | .48 | 74.2 | 21.04 | 91. | | | | | | 2.0 | .57 | 2.8 | .79 | 78.4 | 22.2 | 7.5 21.1 | 6. | -- | -- | 28.2 | 8. | 56. | | | | | | | | | | | | 13.4 | 6.8 | 10.5 | 5.36 | -- | -- | 75. 12.3 | 4.18 | .2 | 0.07 | -- | -- | 17. 15.7 | 2.67 | 31.0 | 5.27 | -- | -- | 58. 1.2 | .34 | .3 | .09 | 5.1 | 1.45 | 8. | | | | | | 11.0 | 3.11 | 1.4 | .39 | 76.4 | 21.65 | 103. 4.3 | 1.21 | 0.3 | .09 | 74.1 | 21. | 89.6 18. | 5.24 | 1.4 | .4 | -- | -- | 24.6 10.2 | 2.9 | 2.2 | .62 | 72.7 | 20.6 | 99.7 36.3 | 10.3 | 1.3 | .36 | 36.9 | 10.44 | 86.2 13.3 | 3.77 | 2.2 | .62 | 71.4 | 20.24 | 101.6 11.2 | 3.18 | 1.0 | .28 | 75.2 | 21.31 | 100.5 11.2 | 1.06 | 1.0 | .09 | 75.2 | 7.1 | 33.5 13.8 | 3.91 | 1.9 | .53 | 71.9 | 20.38 | 102. 19.3 | 5.47 | 16.3 | 4.65 | -- | -- | 63.5 19.3 | 19. | 16.3 | 16.3 | -- | -- | 222. | | | | | | 91.4 | 25.91 | 0.1 | .028 | -- | -- | 103.8 91.4 | 6.47 | 0.1 | .007 | -- | -- | 25.9 29.7 | 8.4 | 1.1 | .30 | 30.0 | 8.5 | 70.3 41.9 | 2.9 | 1.8 | .13 | 44.4 | 3.15 | 25.4 | | | | | | 2.1 | 2.4 | 3.3 | 3.7 | 3.2 | 3.6 | 57. 2.0 | 2.3 | 0.3 | .3 | 3.2 | 3.6 | 26.3 1.3 | .74 | 1.6 | .9 | 19.2 | 10.88 | 54.5 1.3 | 5.9 | 1.6 | 7.2 | 19.2 | 87.04 | 436. .6 | .17 | .1 | .03 | 12.2 | 3.46 | 14.8 -- | -- | -- | -- | 25.0 | 7.09 | 28.3 -- | -- | -- | -- | 25.0 | 28.36 | 113.4 | | | | | | 18.6 | 15.81 | 5.2 | 4.42 | -- | -- | 103. | | | | | | 19.8 | 8.41 | 21.0 | 8.93 | -- | -- | 114. | | | | | | 16.3 | 4.62 | 38.8 | 11. | -- | -- | 117.5 8.3 | 2.35 | 0.6 | .17 | 79.0 | 22.39 | 100.5 15.4 | 4.36 | 67.1 | 19. | 11.4 | 3.23 | 201.3 0.4 | .11 | -- | -- | 81.3 | 23.04 | 92.6 ------+-------+--------+---------+--------+---------+--------- =======================+===========+===========================+======= Material |Weight |Measure | A -----------------------+-----------+---------------------------+------- Jell-O | 3.5 oz. | 1 box | 1.79 Jell-O | .6 oz. | 1 serving | .30 | | | Kohl-rabi | 1 oz. | | .09 Koumiss | 1 litre | 1000 c.c. | 4.01 Koumiss | 4 oz. | 1/2 glassful | .51 | | | Lactose (sugar of milk)| | | 100% carbohydrates | 1 oz. | 2 tablespoonfuls | -- Lady fingers | 1/2 oz. | 3 lady fingers | .20 Lamb chops, broiled | 3 oz. | 2 chops, medium size | 2.95 Lamb, leg, roasted | 1 oz. | 1 serving (small) | -- Lard | 1 oz. | 2 tablespoonfuls | -- Lemon juice (1 lemon) | 1-1/2 oz. | 3 tablespoonfuls | -- Lemon juice | 1 oz. | 2 tablespoonfuls | -- Lettuce | 8 oz. | 1 head | .44 Lettuce | 2 oz. | 1 serving (1/4 head) | .11 Liver | 1 oz. | | -- Liquid peptonoids | 1 oz. | 2 tablespoonfuls | .26 Lentils | 1 oz. | 2 tablespoonfuls | 1.17 Lobster | 2 oz. | 1 serving | 1.75 | | | Macaroni | 4 oz. | 1/2 cupful | 2.43 Mackerel, fresh, E.P. | 3 oz. | 1 serving | 2.54 Mackerel, salt | | | dressed, E.P. | 2 oz. | 1 serving (small) | 1.57 Malted milk (Horlick's)| 1/2 oz. | 1 tablespoonful | .37 Milk (whole) | 1 oz. | 2 tablespoonfuls | .15 Milk (whole) | 8 oz. | 1 glassful | 1.20 Milk (skimmed) | 1 oz. | 2 tablespoonfuls | .15 Milk, dried (whole) | 1 oz. | 2 tablespoonfuls | 1.1 Milk, dried (skim) | 1 oz. | 2 tablespoonfuls | 1.5 Molasses, cane | 1 oz. | 2 tablespoonfuls | .11 Mushrooms | 1 oz. | | -- Muskmelons | 8 oz. | 1/2 small melon | .22 | | | Noodles (gluten) | 2 oz. | 3/4 cupful | 2.05 | | | Oatmeal | 1/2 oz. | 1 tablespoonful | .38 Oatmeal gruel | 4 oz. | 1/2 cupful | .21 Oats, rolled | 1 oz. | | .76 Okra | 1 oz. | | .07 Olives | 1/2 oz. | 3 medium sized | .02 Olive oil | 1 oz. | 2 tablespoonfuls | -- -----------------------+-----------+---------------------------+------- ==============+==================+==================+========= B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+--------- 11.2 | 11. | -- | -- | 86.4 | 86. | 388. 11.2 | 1.9 | -- | -- | 86.4 | 14.7 | 66. | | | | | | 2. | .56 | .1 | .03 | 5.5 | 1.56 | 8.8 2.8 | 25.4 | 2.1 | 19.5 | 5.4 | 48.9 | 473. 2.8 | 3.17 | 2.1 | 2.38 | 5.4 | 6.12 | 58.5 | | | | | | | | | | | | -- | -- | -- | -- | 100.0 | 28.35 | 113.4 8.7 | 1.23 | 5. | .70 | 70.5 | 10. | 51.2 21.8 | 18.54 | 30. | 25.51 | -- | -- | 303.7 19.7 | 5.58 | 12.7 | 3.6 | -- | -- | 54.7 -- | -- | 100.0 | 28.35 | -- | -- | 255.1 -- | -- | -- | -- | 9.7 | 4.12 | 16.4 -- | -- | -- | -- | 9.8 | 2.77 | 11. 1.2 | 2.72 | 0.3 | .68 | 2.9 | 4.52 | 35. 1.2 | .68 | 0.3 | .17 | 2.0 | 1.13 | 8.77 20.4 | 5.78 | 4.5 | 1.28 | 1.7 | .48 | 36.5 5.6 | 1.6 | -- | -- | 14.8 | 4.2 | 23. 25.7 | 7.29 | 1.0 | .28 | 59.2 | 16.78 | 98.8 18.1 | 10.26 | 1.1 | .62 | 0.5 | .28 | 48. | | | | | | 13.4 | 15.20 | 0.9 | 1.0 | 74.1 | 84. | 406. 18.7 | 15.90 | 7.1 | 6.03 | -- | -- | 117.8 | | | | | | 17.3 | 9.8 | 26.3 | 14.85 | -- | -- | 173. 16.2 | 2.3 | 8.5 | 1.2 | 67. | 9.5 | 58. 3.3 | .94 | 4.0 | 1.13 | 5.0 | 1.41 | 19.6 3.3 | 7.52 | 4.0 | 9.04 | 5.0 | 11.28 | 156.8 3.4 | .96 | 0.3 | .09 | 5.1 | 1.45 | 10.4 24.3 | 6.89 | 28.5 | 8.08 | 36.8 | 10.43 | 142. 33.9 | 9.6 | 1. | .28 | 55. | 15.6 | 103.3 2.4 | .68 | -- | -- | 69.3 | 19.65 | 81.3 3.5 | .99 | .4 | .11 | 6.8 | 1.93 | 12.7 0.6 | 1.36 | -- | -- | 9.3 | 21. | 89.44 | | | | | | 45. | 25.5 | 4.1 | 2.3 | 32.5 | 18.4 | 196.4 | | | | | | 16.1 | 2.3 | 7.2 | 1. | 67.5 | 9.5 | 56.4 1.1 | 1.3 | 0.4 | .45 | 0.6 | 7.3 | 38.4 16.7 | 4.73 | 7.3 | 2.07 | 66.2 | 18.77 | 112.6 1.6 | .45 | .2 | .06 | 7.4 | 2.1 | 10.74 1.1 | .15 | 27.6 | 3.91 | 11.6 | 1.64 | 42.4 -- | -- | 100. | 28.35 | -- | -- | 255.1 ------+-------+--------+---------+--------+---------+--------- =======================+===========+===========================+======= Material |Weight |Measure | A -----------------------+-----------+---------------------------+------- Onion | 2 oz. | 1 medium sized | .07 Orange | 5 oz. | 1 medium sized | .17 Orange (juice) | 1 oz. | 2 tablespoonfuls | -- Oysters | 1 oz. | 3 small | .28 | | | Panopepton | 1 oz. | 2 tablespoonfuls | .32 Parsnips | 1 oz. | 1 medium size | -- Peaches, E.P. (fresh) | 3 oz. | 1 medium size | .10 Peaches, canned | 3 oz. | 1 serving | .10 Peanut butter | 1 oz. | 2 tablespoonfuls | 1.33 Peanuts, shelled | 2-1/2 oz. | 1/2 cupful | 3.32 Pears, fresh | 3 oz. | 1 medium size | .08 Pears, canned | 3 oz. | 1 serving | .04 Peas, green, fresh, | | | E.P. | 3 oz. | 1 serving, about 1/2 cup | .95 Peas, canned | 4 oz. | 1/2 cup | .65 Peas (dried, split | | | peas) | 1 oz. | 3 tablespoonfuls | 1.12 Peppers, green | 1 oz. | | .05 Pineapple (canned) | 3 oz. | 1 thick slice | .07 Pineapple (fresh, | | | E.P.) | 3 oz. | 1 serving | .05 Pecans, shelled | 2-1/2 oz. | 1/2 cup | .58 Plums | 1 oz. | | .04 Port wine (10% alcohol)| 1/2 oz. | 1 tablespoonful | -- Potatoes, white, raw | 3 oz. | 1 medium size | .30 Potatoes, sweet, raw | 4 oz. | 1 medium size | .30 Prunes, A.P. | 1 oz. | 3 prunes | .08 Prunes, E.P. | 4 oz. | 1 cupful | .38 | | | Quail | 3-1/2 oz. | 1/2 quail, 1 serving | 1.00 | | | Raisins | 1 oz. | 3 dozen | .12 Raspberries, black, | | | fresh | 1 oz. | 3 tablespoonfuls | .08 Raspberry juice, fresh | 4 oz. | 1/2 cup | -- Rhubarb, fresh, E.P. | 1 oz. | | .03 Rice | 1 oz. | 2 tablespoonfuls, 1 | | | serving | .36 Rum | 1 oz. | 2 tablespoonfuls | -- | | | Salmon, canned | 1 oz. | | .99 Salmon, canned | 1 lb. | 1 can | 15.82 Saltines (crackers) | 1 oz. | | .48 Saltines (crackers) | 1 lb. | 1 box | 7.68 Sardines, canned | 1 oz. | 1 small serving | 1.08 -----------------------+-----------+---------------------------+------- ==============+==================+==================+========= B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+--------- 1.6 | .9 | 0.3 | .17 | 9.9 | 5.6 | 27.5 0.6 | .85 | 0.1 | .14 | 8.5 | 12.05 | 53. -- | -- | -- | -- | 11.3 | 3.2 | 12.8 6.2 | 1.75 | 1.2 | .34 | 3.7 | 1.04 | 14.2 | | | | | | 7.1 | 2. | -- | -- | 17.3 | 5. | 28. 0.1 | .03 | .5 | .14 | 13.5 | 3.83 | 16.70 0.7 | .60 | 0.1 | .09 | 9.4 | 7.99 | 35.1 0.7 | .60 | 0.1 | .09 | 10.8 | 9.18 | 39.9 29.3 | 8.31 | 46.6 | 13.20 | 17.1 | 4.85 | 151.4 29.3 | 20.77 | 46.5 | 33. | 5.8 | 4.12 | 396.5 0.6 | .51 | 0.5 | .42 | 14.1 | 12. | 53.8 0.3 | .26 | 0.3 | .26 | 18.1 | 12.4 | 53. | | | | | | 7. | 5.95 | .5 | .42 | 16.9 | 14.37 | 85. 3.6 | 4.08 | 0.2 | .23 | 9.8 | 11.11 | 62.8 | | | | | | 24.6 | 6.97 | 1.0 | .28 | 62.0 | 17.57 | 100.7 1.1 | .31 | 0.1 | .03 | 4.6 | 1.3 | 6.71 0.5 | .4 | 0.7 | .6 | 36.4 | 31. | 131. | | | | | | 0.4 | .34 | 0.3 | .26 | 9.7 | 8.25 | 36.7 9.6 | 6.8 | 70.5 | 50.0 | 15. | 10.6 | 519.6 1. | .28 | -- | -- | 20.1 | 5.7 | 23.9 -- | -- | -- | -- | -- | -- | 10. 2.2 | 1.87 | 0.1 | .09 | 18.4 | 15.65 | 70.9 1.8 | 2.04 | 0.7 | .79 | 27.4 | 31.07 | 139.6 1.8 | .51 | -- | -- | 62.2 | 17.63 | 72.6 2.1 | 2.38 | -- | -- | 73.3 | 83.12 | 342. | | | | | | 21. | 20.3 | 8. | 7.9 | -- | -- | 152.3 | | | | | | 2.6 | .74 | 3.3 | .94 | 76.1 | 21.57 | 97.7 | | | | | | 1.7 | .48 | 1.0 | .28 | 12.6 | 3.57 | 18.7 -- | -- | -- | -- | 10.0 | 11.3 | 45.2 0.6 | .17 | 0.7 | .20 | 3.6 | 1.02 | 6.6 | | | | | | 7.9 | 2.26 | 0.3 | .09 | 79.0 | 22.39 | 99.35 -- | -- | -- | -- | -- | -- | 76. | | | | | | 22. | 6.24 | 12.8 | 3.63 | -- | -- | 57.6 22. | 99.8 | 12.8 | 57.6 | -- | -- | 922. 10.6 | 3. | 12.7 | 3.6 | 68.5 | 19.42 | 123. 10.6 | 48. | 12.7 | 57.6 | 68.5 | 310.7 | 1968. 23. | 6.72 | 19.7 | 5.58 | -- | -- | 77. ------+-------+--------+---------+--------+---------+--------- =======================+===========+===========================+======= Material |Weight |Measure | A -----------------------+-----------+---------------------------+------- Shad | 3 oz. | 1 serving | 1.96 Shad roe | 1 oz. | 1 small serving | .95 Sherry wine | 1 oz. | 2 tablespoonfuls | -- Spinach | 4 oz. | 1/2 cup | .38 Squab | 2-1/2 oz. | 1/2 squab | 1.86 Squash | 3 oz. | 1 serving | .10 Strawberries | 3 oz. | 1 serving, about 1/2 cup | .13 Strawberry juice | 4 oz. | 1/2 cup | -- Suet | 1 oz. | 2 tablespoonfuls | .21 Sugar (granulated) | 1 oz. | 2 tablespoonfuls | -- Sugar (loaf) | 1/2 oz. | 1 lump | -- Sugar (powdered) | 1/3 oz. | 1 tablespoonful | -- Sweetbreads | 3-1/2 oz. | 1 serving | 2.28 Sweetbreads | 8 oz. | 1 set | 6.08 | | | Tapioca | 1 oz. | 2 tablespoonfuls | .02 Tapioca (minute) | 1 oz. | 2 tablespoonfuls | .02 Toast | 1 oz. | 1 thick slice | .52 Tomatoes (fresh) | 5 oz. | 1 whole tomato | .07 Tomatoes (canned) | 1 oz. | 2 tablespoonfuls | .05 Trout | 3 oz. | 1 serving | 2.46 Trout | 1 oz. | | .82 Turnips (fresh) | 3 oz. | 1 serving | .18 Turkey | 2-1/2 oz. | 1 serving (2 slices) | 2.39 Turkey | 1 oz. | | .96 | | | Veal cutlet | 1 oz. | | -- | | | Walnuts | 1 oz. | | .84 Walnuts | 5-1/2 oz. | 1 cupful | 4.59 Watermelon, E.P. | 1 oz. | | .02 Wheat (shredded) | 1 oz. | 1 biscuit | .55 Wheat flakes | 1 oz. | 1 cupful (about) | .61 Whey | 6 oz. | 1 cup (scant) | .27 Whitefish, E.P. | 1 oz. | 1/3 serving | 1.04 | | | Zwieback | 1 oz. | 3 small slices | .44 -----------------------+-----------+---------------------------+------- ==============+==================+==================+========= B1 | B2 | C1 | C2 | D1 | D2 | E ------+-------+--------+---------+--------+---------+--------- 18.8 | 11. | 9.5 | 8.07 | -- | -- | 116.6 20.9 | 5.92 | 3.8 | 1.08 | 2.6 | .73 | 36.3 -- | -- | -- | -- | -- | -- | 28. 2.1 | 2.38 | .3 | .34 | 3.2 | 3.63 | 27. 16.3 | 11.5 | 36.2 | 25.65 | -- | -- | 277. 0.7 | .60 | 0.2 | .17 | 4.5 | 3.83 | 18.3 1.0 | .85 | 0.6 | .51 | 7.4 | 6.29 | 33. -- | -- | -- | -- | 4.8 | 5.4 | 22. 4.7 | 1.33 | 82. | 23.19 | -- | -- | 215. -- | -- | -- | -- | 100.0 | 28.35 | 113.4 -- | -- | -- | -- | 100.0 | 7.1 | 28.4 -- | -- | -- | -- | 100.0 | 9.45 | 37.8 16.7 | 16.45 | 12.1 | 12. | -- | -- | 173.8 16.7 | 38. | 12.1 | 27.4 | -- | -- | 398.6 | | | | | | 0.4 | .11 | 0.1 | .03 | 88. | 24.95 | 100.5 0.4 | .11 | 0.1 | .03 | 88. | 24.95 | 100.5 11.5 | 3.26 | 1.6 | .45 | 61.2 | 17.35 | 86.5 0.9 | 1.27 | 0.4 | .57 | 3.9 | 5.5 | 32. 1.2 | .34 | 0.2 | .06 | 4. | 1.13 | 6.4 18. | 15.3 | 10.3 | 8.76 | -- | -- | 140. 18. | 5.1 | 10.3 | 2.92 | -- | -- | 46.7 1.3 | 1.11 | 0.2 | .17 | 8.1 | 6.9 | 33.6 21.1 | 14.94 | 22.9 | 16.22 | -- | -- | 206. 21.1 | 5.98 | 22.9 | 6.49 | -- | -- | 82.4 | | | | | | 20.3 | 5.75 | 7.7 | 2.18 | -- | -- | 42.6 | | | | | | 18.4 | 5.22 | 64.4 | 18.26 | 13.0 | 3.79 | 200. 18.4 | 28.71 | 64.4 | 100.43 | 13.0 | 20.84 | 1100. .4 | .11 | .2 | .06 | 6.7 | 1.9 | 8.58 10.5 | 2.98 | 1.4 | .4 | 78. | 22. | 103.5 13.4 | 3.8 | 1.4 | .39 | 74.3 | 21.06 | 103. 1.0 | 1.70 | 0.3 | .51 | 5. | 8.5 | 45.4 22.9 | 6.5 | 6.5 | 1.84 | -- | -- | 42.56 | | | | | | 9.8 | 2.77 | 1.0 | 2.80 | 73.5 | 20.83 | 119.6 ------+-------+--------+---------+--------+---------+--------- FOOTNOTES: [174] Edible portion. [175] Beef soup is not so thoroughly strained or so well skimmed as broth. [176] Gum gluten has a smaller percentage of starch than ordinary gluten flour. TABLE V[177] VITAMINES IN FOODS ============================+==========+==========+========== _Foodstuff_ | "_A_" | "_B_" | "_C_" ----------------------------+----------+----------+---------- Meats: | | | Beef heart | + | + | ? Brains | + + | + + + | + ? Codfish | + | + | ? Cod testes | + | | Fish roe | + | + + | ? Herring | + + | + + | ? Horse meat | + | + | Kidney | + + | + + | Lean muscle | 0 | 0 | + ? Liver | + | + | + ? Pancreas | 0 | + + + | Pig heart | + | + | ? Placenta | | + | Thymus (sweetbreads) | 0 | 0 | 0 Vegetables: | | | Beetroot | + | + | + + Beet root juice | ? | Little | + + + Cabbage, dried | + + + | + + + | + Cabbage, fresh | + + + | + + + | + + + + Carrots | + + + | + + + | + + Cauliflower | + + | + + + | + + Celery | ? | + + + | ? Chard | + + + | + + | ? Dasheens | + | + + | ? Lettuce | + + | + + | + + + + Mangels | + + | + + | ? Onions | ? | + + + | + + + Parsnips | + + | + + + | Peas (fresh) | + | + + | + + + Potatoes | 0 | + + + | + + Potatoes (sweet) | + + + | + + | ? Rutabaga | | + + + | Spinach | + + + | + + + | + + + Cereals: | | | Barley | + | + + + | ? Bread (white) | | + ? | Bread (whole meal) | + | + + + | ? Maize {+ In yellow} + + + | ? {0 In white } | Oats | + | + + + | 0 Rice (polished) | 0 | 0 | 0 Rice (whole grain) | + | + + + | 0 Rye | + | + + + | 0 Corn embryo | | + + + | Corn (kaffir) | | + + + | Corn (see maize) | | | Corn pollen | | + + | Malt extract | 0 | 0 | 0 Wheat bran | 0 | + | 0 Wheat embryo | + + | + + + | 0 Wheat endosperm | 0 | 0 | 0 Wheat kernel | + | + + + | 0 Other seeds: | | | Beans, kidney | | + + + | Beans, navy | | + + + | 0 Beans, soy | + | + + + | 0 Cotton seed | + + | + + + | Flaxseed | + + | + + + | Hemp seed | + + | + + + | Millet seed | + + | + + + | Peanuts | + | + + | Peas (dry) | + ? | + + | 0 Sunflower seeds | + | | Fruits: | | | Apples | | + + | + + Bananas | ? | + | + + Grapefruit | | + + + | + + + Grape juice | | + | + Grapes | 0 | + | + Lemons | | + + + | + + + + Limes | | + + | + + Oranges | | + + + | + + + + Pears | | + + | + + Raisins | | + | + Tomatoes | + + | + + + | + + + + Oils and fats: | | | Almond oil | 0 | 0 | Beef fat | + | 0 | 0 Butter | + + + + | 0 | 0 Cocoanut oil | 0 | 0 | 0 Cod liver oil | + + + + | 0 | 0 Corn oil | 0 | 0 | 0 Cotton seed oil | 0 ? | 0 | 0 Egg yolk fat | + + + + | 0 | 0 Fish oils | + + | 0 | 0 Lard | 0 ? | 0 | 0 Oleo, animal | + | 0 | 0 Oleo, vegetable | 0 | 0 | 0 Olive oil | 0 | 0 | 0 Pork fat | 0 ? | 0 | Tallow | 0 | 0 | 0 Vegetable oils | 0 ? | 0 | 0 Nuts: | | | Almonds | + | + + + | Brazil nut | | + + + | Chestnut | | + + + | Cocoanut | + + | + + + | English walnuts | | + + + | Filbert | | + + + | Hickory | + | + | + Pine | + | + | + Dairy products: | | | Butter | + + + + | 0 | 0 Cheese | + + | + | ? Condensed milk | + + | + | 0 Cream | + + + | + | ? Eggs | + + + + | + + | 0 Milk powder (skim) | + | + + + | + ? Milk powder (whole) | + + + | + + + | + ? Milk whole | + + + | + + + | + + Whey | + | + + + | + Miscellaneous: | | | Alfalfa | + + + | + + + | ? Blood | Varies with source Clover | + + + | + + + + | ? Honey | | + + | 0 Malt extract | 0 | 0 | 0 Nectar | 0 | 0 | 0 Timothy | + + | + + + | Yeast, brewers' | 0 | + + + + | 0 Yeast cakes | 0 | + + | 0 Yeast extract | 0 | + + + | 0 ============================+==========+==========+========== Table V taken from "The Vitamine Manual," by Walter S. Eddy, published by Williams & Wilkins Co., Baltimore, Md. FOOTNOTE: [177] Courtesy of Dr. Walter S. Eddy. HEIGHTS AND WEIGHTS FOR CHILDREN UNDER FIVE YEARS OF AGE (Based on Data Published by the Children's Bureau, U. S. Department of Labor) ==========+=====================++===================== | BOYS || GIRLS _Age_ |----------+----------++----------+---------- | _Height_ | _Weight_ || _Height_ | _Weight_ | _Inches_ | _Pounds_ || _Inches_ | _Pounds_ ----------+----------+----------++----------+---------- Birth | 20.6 | 7.6 || 20.5 | 7.2 3 mo. | 23.5 | 13.0 || -- | -- 6 mo. | 26.5 | 18.0 || 25.9 | 16.8 9 mo. | 28.1 | 20.4 || 26.6 | 19.1 12 mo. | 29.4 | 21.9 || 28.9 | 20.8 15 mo. | 30.8 | 23.6 || 30.1 | 21.9 18 mo. | 31.8 | 24.6 || 31.1 | 23.4 21 mo. | 32.9 | 25.8 || 32.3 | 24.8 24 mo. | 33.8 | 27.1 || 33.4 | 26.4 27 mo. | 34.8 | 29.0 || 33.9 | 27.3 30 mo. | 35.4 | 29.5 || 34.9 | 28.3 33 mo. | 36.1 | 30.6 || 35.6 | 29.1 36 mo. | 37.1 | 32.3 || 36.8 | 30.5 39 mo. | 37.9 | 33.1 || 37.3 | 31.6 42 mo. | 38.6 | 33.8 || 38.0 | 32.5 45 mo. | 39.0 | 34.5 || 38.5 | 33.3 48 mo. | 39.5 | 35.9 || 39.0 | 33.8 5 years | 41.6 | 41.4 || 41.3 | 39.7 ==========+==========+==========++==========+========== HEIGHT AND WEIGHT TABLE FOR BOYS ===+====+====+====+====+====+====+====+====+====+====+====+====+====+==== H I| 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 e n| | | | | | | | | | | | | | i c| Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y g h| r | r | r | r | r | r | r | r | r | r | r | r | r | r h e| s | s | s | s | s | s | s | s | s | s | s | s | s | s t s| . | . | . | . | . | . | . | . | . | . | . | . | . | . ---+----+----+----+----+----+----+----+----+----+----+----+----+----+---- 39 | 35 | 36 | 37 | | | | | | | | | | | 40 | 37 | 38 | 39 | | | | | | | | | | | 41 | 39 | 40 | 41 | | | | | | | | | | | 42 | 41 | 42 | 43 | 44 | | | | | | | | | | 43 | 43 | 44 | 45 | 46 | | | | | | | | | | 44 | 45 | 46 | 46 | 47 | | | | | | | | | | 45 | 47 | 47 | 48 | 48 | 49 | | | | | | | | | 46 | 48 | 49 | 50 | 50 | 51 | | | | | | | | | 47 | | 51 | 52 | 52 | 53 | 54 | | | | | | | | 48 | | 53 | 54 | 55 | 55 | 56 | 57 | | | | | | | 49 | | 55 | 56 | 57 | 58 | 58 | 59 | | | | | | | 50 | | | 58 | 59 | 60 | 60 | 61 | 62 | | | | | | 51 | | | 60 | 61 | 62 | 63 | 64 | 65 | | | | | | 52 | | | 62 | 63 | 64 | 65 | 67 | 68 | | | | | | 53 | | | | 66 | 67 | 68 | 69 | 70 | 71 | | | | | 54 | | | | 69 | 70 | 71 | 72 | 73 | 74 | | | | | 55 | | | | | 73 | 74 | 75 | 76 | 77 | 78 | | | | 56 | | | | | 77 | 78 | 79 | 80 | 81 | 82 | | | | 57 | | | | | | 81 | 82 | 83 | 84 | 85 | 86 | | | 58 | | | | | | 84 | 85 | 86 | 87 | 88 | 90 | 91 | | 59 | | | | | | 87 | 88 | 89 | 90 | 92 | 94 | 96 | 97 | 60 | | | | | | 91 | 92 | 93 | 94 | 97 | 99 |101 |102 | 61 | | | | | | | 95 | 97 | 99 |102 |104 |106 |108 |110 62 | | | | | | |100 |102 |104 |106 |109 |111 |113 |116 63 | | | | | | |105 |107 |109 |111 |114 |115 |117 |119 64 | | | | | | | |113 |115 |117 |118 |119 |120 |122 65 | | | | | | | | |120 |122 |123 |124 |125 |126 66 | | | | | | | | |125 |126 |127 |128 |129 |130 67 | | | | | | | | |130 |130 |132 |133 |134 |135 68 | | | | | | | | |134 |135 |136 |137 |138 |139 69 | | | | | | | | |138 |139 |140 |141 |142 |143 70 | | | | | | | | | |142 |144 |145 |146 |147 71 | | | | | | | | | |147 |149 |150 |151 |152 72 | | | | | | | | | |152 |154 |155 |156 |157 73 | | | | | | | | | |157 |159 |160 |161 |162 74 | | | | | | | | | |162 |164 |165 |166 |167 75 | | | | | | | | | | |169 |170 |171 |172 76 | | | | | | | | | | |174 |175 |176 |177 ===+====+====+====+====+====+====+====+====+====+====+====+====+====+==== Prepared by Dr. Thomas D. Wood ABOUT WHAT A BOY SHOULD GAIN EACH MONTH _Age_ 5 to 8 6 oz. 8 to 12 8 oz. 12 to 16 16 oz. 16 to 18 8 oz. Weight and measures should be taken without shoes, and in only the usual indoor clothes. _Courtesy of Child Health Organization of America_ HEIGHT AND WEIGHT TABLE FOR GIRLS ===+====+====+====+====+====+====+====+====+====+====+====+====+====+==== H I| 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 e n| | | | | | | | | | | | | | i c| Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y g h| r | r | r | r | r | r | r | r | r | r | r | r | r | r h e| s | s | s | s | s | s | s | s | s | s | s | s | s | s t s| . | . | . | . | . | . | . | . | . | . | . | . | . | . ---+----+----+----+----+----+----+----+----+----+----+----+----+----+---- 39 | 34 | 35 | 36 | | | | | | | | | | | 40 | 36 | 37 | 38 | | | | | | | | | | | 41 | 38 | 39 | 40 | | | | | | | | | | | 42 | 40 | 41 | 42 | 43 | | | | | | | | | | 43 | 42 | 42 | 43 | 44 | | | | | | | | | | 44 | 44 | 45 | 45 | 46 | | | | | | | | | | 45 | 46 | 47 | 47 | 48 | 49 | | | | | | | | | 46 | 48 | 48 | 49 | 50 | 51 | | | | | | | | | 47 | | 49 | 50 | 51 | 52 | 53 | | | | | | | | 48 | | 51 | 52 | 53 | 54 | 55 | 56 | | | | | | | 49 | | 53 | 54 | 55 | 56 | 57 | 58 | | | | | | | 50 | | | 56 | 57 | 58 | 59 | 60 | 61 | | | | | | 51 | | | 59 | 60 | 61 | 62 | 63 | 64 | | | | | | 52 | | | 62 | 63 | 64 | 65 | 66 | 67 | | | | | | 53 | | | | 66 | 67 | 68 | 68 | 69 | 70 | | | | | 54 | | | | 68 | 69 | 70 | 71 | 72 | 73 | | | | | 55 | | | | | 72 | 73 | 74 | 75 | 76 | 77 | | | | 56 | | | | | 76 | 77 | 78 | 79 | 80 | 81 | | | | 57 | | | | | | 81 | 82 | 83 | 84 | 85 | 86 | | | 58 | | | | | | 85 | 86 | 87 | 88 | 89 | 90 | 91 | | 59 | | | | | | 89 | 90 | 91 | 93 | 94 | 95 | 96 | 98 | 60 | | | | | | | 94 | 95 | 97 | 99 |100 |102 |104 |106 61 | | | | | | | 99 |101 |102 |104 |106 |108 |109 |111 62 | | | | | | |104 |106 |107 |109 |111 |113 |114 |115 63 | | | | | | |109 |111 |112 |113 |115 |117 |118 |119 64 | | | | | | | |115 |117 |118 |119 |120 |121 |122 65 | | | | | | | |117 |119 |120 |122 |123 |124 |125 66 | | | | | | | |119 |121 |122 |124 |126 |127 |128 67 | | | | | | | | |124 |126 |127 |128 |129 |130 68 | | | | | | | | |126 |128 |130 |132 |133 |134 69 | | | | | | | | |129 |131 |133 |135 |136 |137 70 | | | | | | | | | |134 |136 |138 |139 |140 71 | | | | | | | | | |138 |140 |142 |143 |144 72 | | | | | | | | | | |145 |147 |148 |149 ===+====+====+====+====+====+====+====+====+====+====+====+====+====+==== Prepared by Dr. Thomas D. Wood ABOUT WHAT A GIRL SHOULD GAIN EACH MONTH _Age_ 5 to 8 6 oz. 8 to 11 8 oz. 11 to 14 12 oz. 14 to 16 8 oz. 16 to 18 4 oz. _Courtesy of Child Health Organization of America_ SCALE FOR JUDGING THE STATE OF NUTRITION IN CHILDREN, PREPARED BY PROFESSOR PIRQUET[178] PELIDISI CHART (FOR SCHOOL CHILDREN) ==================================================================== Sitting Height _Percentage (Pelidisi)_ in Cm. ___________________________________________________________ ~85 86 87 88 89 90 91 92 93 94 95 96~ ~55~ 10.0 10.4 10.7 11.1 11.5 11.9 12.3 12.7 13.1 13.6 14.0 14.4 ~56~ 10.6 10.9 11.4 11.7 12.2 12.6 13.0 13.4 13.9 14.3 14.8 15.3 ~57~ 11.1 11.5 11.9 12.4 12.8 13.2 13.7 14.2 13.6 15.1 15.6 16.1 ~58~ 11.7 12.1 12.6 13.0 13.5 13.9 14.4 14.9 15.4 15.9 16.4 16.9 ~59~ 12.4 12.8 13.2 13.7 14.2 14.7 15.2 15.7 16.2 16.7 17.3 17.8 ~60~ 13.0 13.4 13.9 14.4 14.9 15.4 15.9 16.5 17.1 17.6 18.2 18.8 ~61~ 13.7 14.1 14.6 15.2 15.7 16.2 16.8 17.3 17.9 18.5 19.1 19.7 ~62~ 14.3 14.8 15.4 15.9 16.5 17.1 17.6 18.2 18.8 19.4 20.0 20.7 ~63~ 15.0 15.6 16.1 16.7 17.3 17.9 18.5 19.1 19.7 20.4 21.0 21.7 ~64~ 15.8 16.3 16.9 17.5 18.1 18.8 19.4 20.0 20.7 21.4 22.1 22.8 ~65~ 16.5 17.1 17.7 18.3 19.0 19.7 20.3 21.0 21.7 22.4 23.1 23.9 ~66~ 17.3 17.9 18.5 19.2 19.9 20.6 21.2 21.9 22.7 23.4 24.2 25.0 ~67~ 18.7 18.7 19.4 20.1 20.8 21.5 22.2 23.0 23.7 24.5 25.3 26.1 ~68~ 18.9 19.6 20.3 21.0 21.7 22.5 23.2 24.0 24.8 25.6 26.4 27.3 ~69~ 19.8 20.5 21.2 22.0 22.7 23.5 24.2 25.0 25.9 26.7 27.6 28.5 ~70~ 20.6 21.4 22.1 22.9 23.7 24.5 25.3 26.2 27.0 27.9 28.8 29.8 ~71~ 21.5 22.3 23.1 23.9 24.7 25.6 26.4 27.3 28.2 29.1 30.1 31.3 ~72~ 22.4 23.2 24.1 25.0 25.8 26.6 27.6 28.5 29.4 30.4 31.4 32.4 ~73~ 23.4 24.3 25.1 26.0 26.9 27.8 28.8 29.8 30.7 31.7 32.8 33.8 ~74~ 24.4 25.3 26.2 27.1 28.0 29.0 30.0 31.0 32.0 33.0 34.0 35.2 ~75~ 25.4 26.3 27.2 28.2 29.2 30.2 31.2 32.3 33.2 34.3 35.5 36.6 ~76~ 26.4 27.4 28.4 29.4 30.3 31.3 32.7 33.5 34.6 35.7 36.9 38.2 ~77~ 27.5 28.4 29.5 30.6 31.6 32.6 33.8 34.8 36.0 37.2 38.4 39.6 ~78~ 28.6 29.6 30.7 31.8 32.8 33.9 35.0 36.2 37.4 38.6 40.0 41.1 ~79~ 29.7 30.8 31.8 33.0 34.0 35.2 36.4 37.7 38.8 40.1 41.5 42.8 ~80~ 30.8 31.9 33.1 34.2 35.4 36.6 37.9 39.0 40.4 41.7 43.0 44.5 ~81~ 32.0 33.2 34.3 35.5 36.7 38.0 39.3 40.5 41.9 43.3 44.7 46.1 ~82~ 33.2 34.4 35.6 36.8 38.1 39.4 40.8 42.0 43.5 45.0 46.4 47.9 ~83~ 34.4 35.7 36.9 38.2 39.6 40.8 42.3 43.7 45.1 46.6 48.0 49.6 ~84~ 35.7 37.0 38.2 39.6 41.0 42.3 43.8 45.3 46.8 48.3 49.9 51.5 ~85~ 37.0 38.2 39.6 41.0 42.4 43.9 46.4 46.9 48.5 50.0 51.6 53.4 ~86~ 38.3 39.6 41.0 42.5 44.0 45.5 47.0 48.7 50.2 51.9 53.7 55.4 ~87~ 39.6 41.0 42.5 44.0 45.5 47.1 48.7 50.3 52.0 53.8 55.5 57.2 ~88~ 41.0 42.5 44.0 45.5 47.2 48.7 50.4 52.0 58.8 55.5 57.5 59.3 ~89~ 42.5 44.0 45.5 47.1 48.8 50.5 52.2 53.9 55.7 57.5 59.6 61.2 ~90~ 44.0 45.4 47.0 48.7 50.4 52.2 54.0 55.8 57.5 59.5 61.5 63.4 ____________________________________________________________________ ====================================================================== Sitting Height _Percentage (Pelidisi)_ in Cm. ______________________________________________________________ ~97 98 99 100 101 102 103 104 105 106 107 108~ ~55~ 14.9 15.4 15.8 16.4 16.9 17.4 17.9 18.4 19.0 19.6 20.1 20.7 ~56~ 15.7 16.2 16.8 17.3 17.9 18.4 18.9 19.5 20.1 20.6 21.2 21.8 ~57~ 16.6 17.1 17.7 18.2 18.8 19.4 20.0 20.6 21.2 21.8 22.4 23.0 ~58~ 17.5 18.0 18.6 19.2 19.8 20.4 21.0 21.6 22.3 22.9 23.6 24.2 ~59~ 18.4 19.0 19.6 20.2 20.9 21.5 22.2 22.8 23.5 24.1 24.8 25.6 ~60~ 19.3 20.0 20.6 21.2 22.0 22.6 23.3 24.0 24.6 25.4 26.1 26.8 ~61~ 20.3 21.0 21.7 22.4 23.1 23.7 24.4 25.2 25.9 26.6 27.4 28.2 ~62~ 21.4 22.1 22.8 23.4 24.2 24.9 25.7 26.4 27.2 28.0 28.8 29.6 ~63~ 22.4 23.2 23.8 24.6 25.4 26.2 27.0 27.8 28.6 29.4 30.2 31.1 ~64~ 23.5 24.3 25.0 25.8 26.8 27.4 28.2 29.1 30.0 30.8 31.6 32.6 ~65~ 24.6 25.5 26.2 27.0 27.9 28.8 29.6 30.5 31.4 32.2 33.2 34.2 ~66~ 25.7 26.6 27.4 28.2 29.2 30.0 31.0 31.9 32.8 33.8 34.8 35.8 ~67~ 26.9 27.8 28.6 29.5 30.6 31.4 32.4 33.4 34.3 35.4 36.3 37.4 ~68~ 28.2 29.1 30.0 30.9 32.0 32.9 33.8 34.9 35.9 36.9 38.0 39.1 ~69~ 29.7 30.4 31.3 32.3 33.4 34.4 35.4 36.4 37.5 38.6 39.7 40.9 ~70~ 30.7 31.6 32.7 33.8 34.8 35.8 37.0 38.1 39.1 40.3 41.5 42.6 ~71~ 32.1 33.1 34.1 35.2 36.4 37.4 38.6 39.7 40.9 42.0 43.2 44.5 ~72~ 33.5 34.5 35.6 36.7 38.0 39.0 40.3 41.5 42.6 43.9 45.1 46.8 ~73~ 34.9 36.0 37.0 38.2 39.5 40.7 42.0 43.2 44.5 45.7 47.1 48.4 ~74~ 36.3 37.4 38.6 39.8 41.1 42.4 43.7 45.0 46.4 47.6 49.0 50.4 ~75~ 37.8 39.0 40.1 41.4 42.8 44.1 45.4 46.9 48.3 49.5 50.9 52.5 ~76~ 39.3 40.5 41.7 43.1 44.5 45.9 47.3 48.7 50.3 51.5 53.0 54.5 ~77~ 40.9 42.7 43.5 44.8 46.4 47.7 49.2 50.7 52.3 53.6 55.2 56.8 ~78~ 42.5 43.9 45.2 46.6 48.2 49.6 51.0 52.6 54.3 55.7 57.3 58.9 ~79~ 44.1 45.5 46.9 48.4 50.0 51.5 53.1 54.7 56.5 58.0 59.6 61.3 ~80~ 45.9 47.3 48.7 50.2 52.0 53.6 55.1 56.9 58.6 60.1 61.8 63.7 ~81~ 47.6 49.1 50.6 52.1 54.0 55.5 57.3 59.0 60.8 62.5 64.3 66.0 ~82~ 49.9 51.0 52.5 54.1 56.0 57.6 59.5 61.3 63.0 67.9 66.7 68.5 ~83~ 51.2 52.9 54.5 56.1 58.1 59.7 61.7 63.5 65.3 67.2 69.1 71.0 ~84~ 53.0 54.8 56.5 58.2 60.2 62.0 64.0 65.8 67.7 69.7 71.6 73.6 ~85~ 55.0 56.8 58.5 60.4 62.4 64.3 66.3 68.2 70.0 72.1 74.2 76.3 ~86~ 57.1 58.9 60.7 62.6 64.6 66.5 68.5 70.5 72.7 74.8 76.9 79.0 ~87~ 59.1 60.9 62.9 64.7 66.9 69.0 71.0 73.0 75.2 77.5 79.6 81.8 ~88~ 61.2 63.0 65.0 67.0 69.3 71.4 73.5 75.5 77.8 80.0 82.4 84.7 ~89~ 63.3 65.3 67.3 69.4 71.6 73.6 76.0 78.1 80.5 82.9 85.2 87.5 ~90~ 65.4 67.5 69.5 71.5 74.0 76.4 78.6 80.9 83.4 85.7 88.1 90.5 ___________________________________________________________________ Instructions for use: To determine the "pelidisi," locate in the left-hand column the child's sitting height in centimeters. With a ruler follow the weights in kilograms to the right until the proper figure is reached. Trace upward in that column to the heavy figure at the top, which indicates the pelidisi. FOOTNOTE: [178] This material was published in the American Medical Journal, Vol. 77, No. 20, Nov. 12, 1921, by Dr. William E. Carter, Dept. Pediatrics, University of California Medical School, San Francisco, Calif. THE NUTRITIONAL INDEX--THE "PELIDISI" Pirquet believes that the sitting height is a basis for the more accurate estimation of the nutritional state than is the standing height. It was demonstrated that the cube of the sitting height in centimeters is approximately ten times the weight in grams of the normal person. With this formula in mind, it becomes easy to compute the nutritional state in percentages, when the sitting height and the weight are known. The formula would read: 10 times the weight ------------------- = 100 per cent. Sitting height^{3} or ____________________ 3 / v 10 times the weight ----------------------- = 100 per cent. Sitting height ADDENDA TO INDEX Diet, in fevers, 244 in infectious diseases, 244, 244j Diphtheria, 244d, 244k complications of, 244d, 244k convalescent diet in, 244e, 244k dietetic treatment of, 244e, 244k gavage in, 244k rectal feeding in, 244e, 244k Fevers, diet in, 244 Infant feeding, in infectious diseases, 244 Infectious diseases, diet in, 244, 244j infant feeding in, 244 restricting diet in, 244a Measles, 244h, 244l complications of, 244h, 244l dietetic treatment of, 244i, 244l Nephritis in scarlet fever, 244c, 244j Scarlet fever, 244b, 244j convalescent treatment in, 244d dietetic treatment of, 244c, 244j nephritis in, 244c, 244j Whooping cough, 244e, 244k after-effects of, 244f complications of, 244f, 244k dietetic treatment of, 244f, 244k hygiene and sanitation in, 244g INDEX Absorption, 166, 176 defined, 166 in large intestine, 178 of carbohydrate, 177 of fat, 177 of mineral salts, 178 of proteins, 177 of water, 177 Acetone bodies, in diabetes, 401 Acetone in urine, test for, 333 Acid, uric, _see_ Uric acid Acid content of stomach, determining of, 248 Acid-forming foods, 184, 454 Acidosis, 453, 454, 458 dietetic treatment in, 453, 458 fat metabolism in, 453 in diabetes mellitus, 372, 382, 401, 454 in typhoid fever, 299 Acids, amino, 19 organic, 13 Added urea and salt test, 351 Adenase, 171 Adenin, 184 Adipose tissue, 15 Adult, factors influencing food requirement of, 43 Agar jelly, preparation of, 147 Age, influence of on food requirements, 43 Albumen, in urine, 333 tests for, 333 Albumen milk, preparation of, 142 Albumen water, with brandy, preparation of, 141 Albumenized grape juice, preparation of, 97 lemonade, preparation of, 97 milk, preparation of, 87 milk shake, preparation of, 87 orangeade, preparation of, 96 Albumins, 20 Albuminoids, 21 Albuminuria, 333 of pregnancy, diet in, 197 Alcohol in gout, 418 Alfalfa, vitamines in, 498 Alkalies, effect of on vitamine B, 32 in diabetes mellitus, 382 in infant feeding, 205, 206 Alkaline carbonates, effect of on gastric secretion, 175 Allen's Paradoxical Law, 371 starvation treatment in diabetes, 63, 372 Almond biscuits, preparation of, 157 Almond flour, preparation of, 158 Almond ice cream, preparation of, 91 Almond meal, preparation of, 158 Almonds, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 Amino acids, 19 Ammonium salts, 183 Amylopsin, 171, 174 Anabolism, 181 Anemia, in gastric ulceration, 255 Angel food cake, preparation of, 110 Appendicitis, 268, 278 convalescent diet in, 269, 278 dietetic treatment in, 269, 278 after operation, 317, 321 food to be avoided in, 269 recurring, 278 relapse in, 278 Apples, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 vitamines in, 497 Apple tapioca pudding, preparation of, 107 Apricot ice, preparation of, 137 Apricots, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 Arrowroot, composition of, 484 fuel value of, 484 Artificial feeding of infants, 205 Artificially fed infants, digestive disturbances in, 231 Artichoke, composition of, 484 fuel value of, 461, 484 nutrient value of, 481 Ash, 25 Ash constituents of foods, 472, 473, 474, 475, 476, 477 Asparagus, ash constituent of, 484 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 Auto-intoxication, 273 absorption of toxins in, 273 care of bowels in, 273 convalescent diet in, 275 dietetic treatment of, 273 Autolytic enzymes, 171 Avocado, fuel value of, 461 nutrient value of, 461 Bacon, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 Bacteria, action of in alimentary canal, 178 types of, 180 Bacterial action, in body, 180 upon carbohydrates, 13 Bacterial activity, 181 Baked custard, preparation of, 102 Baked onion, preparation of, 151 Baked potato, preparation of, 130 Baked tapioca, preparation of, 106 Baking, 71 Bananas, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 vitamines in, 497 Banting's method for obesity, 426, 427 Barley, ash constituent of, 472 composition of, 484 fuel value of, 461, 484 nutrient value of, 461 vitamines in, 496 Barley water, 220 preparation of, 140 Basal metabolism, 42 Basal requirements, 42 Bass, composition of, 484 fuel value of, 484 Beans, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 461, 484 nutrient value of, 461 standard portion of, 478 vitamines in, 497 Beef, and _see_ Meats ash constituents of, 472 cuts of, 117 food content of, 473 fuel value of, 462, 463, 484 composition of, 484 methods of preparing, 117 nutrient value of, 462, 463 standard portion of, 478 vitamines in, 496 Beef broth, preparation of, 118 Beef juice, preparation of, 119, 141 Beef steak, preparation of, 123 Beer, ash constituents of, 472 Beets, ash constituent of, 472 composition of, 484 food content of, 478 fuel value of, 463, 484 nutrient value of, 463 standard portion of, 478 vitamines in, 496 Benedict's solution, 331, 332 Benedict's test for sugar in urine, 328, 329, 331, 332 Bile, 174 Biliousness, 404, 414 Birds à la bain-marie, preparation of, 121 Blackberries, ash constituent of, 472 fuel value of, 463 nutrient value of, 463 Blackfish, fuel value of, 463 nutrient value of, 463 Blood, ash constituent of, 472 vitamines in, 498 Bluefish, ash constituent of, 472 composition of, 484 fuel value of, 463, 484 nutrient value of, 463 Body, 165 chemical composition of, 165 food requirements of, 42, 50, 165 metabolism of tissues of, 187 Boas' enema, preparation of, 146 Boiled corn beef with cabbage and other vegetables, preparation of, 153 Boiling, 70 Bomb calorimeter, 36 Borax, test for, 68 Boric acid, test for, 68 Boston crackers, fuel value of, 463 nutrient value of, 463 Bowels, of nursing mother, 197 Boys, height and weight of, 500 Brains, vitamines in, 496 Bran, composition of, 484 fuel value of, 484 Bran agar wafers, preparation of, 146 Bran biscuits, preparation of, 149, 155, 156 for constipation, 156 Bran cookies, preparation of, 145 Bran gems, preparation of, 144 Bran muffins, preparation of, 155 Brandy, composition of, 484 fuel value of, 484 Brazil nuts, fuel value of, 463 nutrient value of, 463 Bread, ash constituent of, 472 composition of, 484, 486 fuel value of, 463, 464, 484, 486 nutrient value of, 463, 464 vitamines in, 496 Breadfruit, ash constituent of, 472 Breadstuffs, preparation of, 103 Bread substitutes, preparation of, 155 Breast feeding _versus_ artificial feeding, 243 Breast milk, as a food, 228 _versus_ cow's milk, 203 Brick feeder, 225 Bright's disease, _see_ Nephritis Broiled oysters, preparation of, 123 Broiled quail, preparation of, 121 Broiled squab, preparation of, 121 Broiled tomatoes, preparation of, 133 Broiling, 71 Broths, preparation of, 118 standard, 118 Brown betty, preparation of, 107 Brussels sprouts, ash constituent of, 472 Buckwheat flour, ash constituent of, 472 fuel value of, 464 nutrient value of, 464 Bulgarian buttermilk, preparation of, 89 Butter, ash constituent of, 472 composition of, 486 food content of, 478 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 478 vitamines in, 497, 498 Buttermilk, ash constituent of, 472 fuel value of, 464 nutrient value of, 464 Buttermilk, Bulgarian, preparation of, 89 Buttermilk mixtures, 208 for infants, 142 Butternuts, fuel value of, 464 nutrient value of, 464 Cabbage, ash constituent of, 472 composition of, 486 food content of, 478 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 478 vitamines in, 496 Cabbage soufflé, preparation of, 150 Calcium, 27, 186 requirements in pregnancy and lactation, 191 retention in rickets, 241 source of, in food, 6 Calculating formulas for infant feeding, 212 Calf's-foot jelly, fuel value of, 464 nutrient value of, 464 preparation of, 120 Calorie, defined, 37 Calorie allowance for children, 48 Calorie portion, 40, 478 Calories, in carbohydrates, 38 in fats, 38 in proteins, 38 Calorimeter, 36 Cancer, gastric, dietetic treatment of, 260 Canned goods, 68, 128 adulteration of, 68 Cane sugar, in infant feeding, 228 Cantaloupe, ash constituent of, 472 Capers, ash constituent of, 472 Caramel custard, preparation of, 103 Carbohydrates, 7 absorption of, 177 bacterial action upon, 13 calories in, 38 composition of, 7 effect of heat upon, 14 enzymes acting upon, 171 fate of, 182 function of, 372 metabolism of, 182 rate of digestion of, 173 regulation of, 235 source of, 5 tolerance of in diabetes, 380 Carbohydrate-free diet, 63 Carbohydrate-free meat and fish, calorie equivalent of, 386 Carbon dioxide, excretion of, 324 Carbonates, alkaline, effect of on digestion, 175 Carp, _see_ Fish Carrots, ash constituent of, 472 composition of, 486 food content of, 478 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 478 vitamines in, 496 with cream sauce or butter, preparation of, 129 Casoid flour and bran muffins, preparation of, 156 Catabolism, 181 Cauliflower, ash constituent of, 472 composition of, 486 food content of, 478 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 478 vitamines in, 496 Caviar, ash content of, 472 Celery, ash constituent of, 473 composition of, 486 food content of, 479 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 479 vitamines in, 496 Celery ramekins, preparation of, 151 Celery soup, fuel value of, 464 nutrient value of, 464 Cellu bran crackers, preparation of, 148 Cellulose, 12 Centigrade scale, 80 Cereal pudding, preparation of, 110 Cerealine, fuel value of, 464 nutrient value of, 464 Cereals, preparation of, 103 vitamines in, 496, 497 Certified milk, 81 Chard, ash constituent of, 473 composition of, 486 fuel value of, 464, 486 nutrient value of, 464 vitamines in, 496 Cheese, ash constituent of, 473 composition of, 486 food content of, 479 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 479 vitamines in, 498 Cheese salad, preparation of, 154 Chemical digestion, 169, 172 Cherries, ash constituent of, 473 composition of, 486 food content of, 479 fuel value of, 464, 486 nutrient value of, 464 standard portion of, 479 Cherry juice, ash constituent of, 473 Chestnuts, ash constituents of, 473 composition of, 486 fuel value of, 464, 486 nutrient value of, 464 vitamines in, 498 Chicken, and _see_ Meat composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 preparation of, 122 selection of, 114 standard portion of, 479 Chicken à la bain-marie, preparation of, 121 Chicken broth, preparation of, 118 Chicken jelly, preparation of, 120 Chicken salad, poisoning by, 451 Chicken supreme, preparation of, 149 Children, care of in abnormal conditions, 231 diarrhea in, 263, 276 energy requirements of, 47 errors in diet in, 232, 243 feeding of, in abnormal conditions, 231 food allowance for, 48 food requirements of, 44, 52 gain in weight in, 49 heights and weights for, 499 malnutrition in, 242 nutrition in, 502 over-feeding, 243 under-feeding, 243 Chlorine, source of in food, 6 Chocolate, ash constituent of, 473 composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 standard portion of, 479 Cholesterol, 15 Cider, ash constituents of, 473 Citron, ash constituents of, 473 Clams, ash constituents of, 473 composition of, 486 food content of, 479 fuel value of, 486 standard portion of, 479 Clam broth, preparation of, 119 Clover, vitamines in, 498 Cocoa, ash constituents of, 473 composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 preparation of, 89 standard portion of, 479 Cocoanut, ash constituents of, 473 vitamines in, 498 Cocoanut biscuits, preparation of, 158 Cocoanut flour, preparation of, 158 Coddled eggs, preparation of, 100 Codfish, and _see_ Fish composition of, 486 fuel value of, 465, 486 nutrient value of, 465 vitamines in, 496 Coffee, adulteration of, 69 preparation of, 98 Coffee eggnog, preparation of, 99 Coleman's high calorie diet in typhoid fever, 289, 291, 294, 295, 298, 299 Condensed milk, composition of, 486 for infants, 226, 227 fuel value of, 486 vitamines in, 498 Conserve, preparation of, 143 Consommé, composition of, 486 fuel value of, 465, 486 nutrient value of, 465 Constipation, 238, 270, 279 Constipation, bran biscuits for, 156 dietetic treatment of, 271, 279 diet for, 143, 239, 271, 272, 279, 406 in nursing women, 197 Convalescent diet, 62 Cookies, protein-free, 340 Cooking, time-table for, 72 Copper, test for, 68 Corn, ash constituents of, 473 composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 standard portion of, 479 vitamines in, 497 Cornflakes, composition of, 486 fuel value of, 486 Corn meal, composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 standard portion of, 479 Cornstarch, composition of, 486 fuel value of, 486 Cotton seed, ash constituents of, 473 vitamines in, 497 Cowpeas, ash constituents of, 473 fuel value of, 465 nutrient value of, 465 Crab, preparation of, 126 Crackers, ash constituents of, 473 composition of, 486 food content of, 479 fuel value of, 465, 486 nutrient value of, 465 standard portion of, 479 Cranberries, ash constituents of, 473 composition of, 488 fuel value of, 465, 488 nutrient value of, 465 Cream, ash constituents of, 473 composition of, 488 food content of, 479 fuel value of, 465, 488 nutrient value of, 465 standard portion of, 479 vitamines in, 498 Cream egg and vichy, preparation of, 98 Cream of asparagus, preparation of, 93 of carrots, preparation of, 94 of cauliflower, preparation of, 152 of celery, preparation of, 94 of peas, preparation of, 94 of potato, preparation of, 94 of spinach, preparation of, 94 Cream sauce for soups, preparation of, 93 Cream soups, preparation of, 93 Cream toast, preparation of, 105 Creamed egg on toast, preparation of, 101 Creamed potatoes, preparation of, 130 Creatinin, 185 Cucumber, ash constituents of, 473 composition of, 488 fuel value of, 465, 488 nutrient value of, 465 Cucumber salad, preparation of, 131 Currant ice, preparation of, 137 Currant juice, ash constituents of, 473 Currants, ash constituents of, 473 composition of, 488 fuel value of, 465, 488 nutrient value of, 465 Custard, preparation of, 102, 159 Dairy products, 81 vitamines in, 498 Dandelion greens, ash constituents of, 473 fuel value of, 465 nutrient value of, 465 Dasheens, vitamines in, 496 Dates, ash constituents of, 473 composition of, 488 food content of, 479 fuel values of, 465, 488 nutrient value of, 465 standard portion of, 479 Desserts, preparation of, 138 Dextri-maltose, 236 in infant feeding, 207 Dextrin, 12 Diabetes mellitus, 371 acetone bodies in, 401 acidosis in, 372, 382, 401, 454 alkalies in, 382 Allen's starvation treatment in, 372 carbohydrate-free diets in, 387, 389 carbohydrate tolerance in, 380 determination of food tolerance in, 379 dietetic treatment in, 382 diets in, 374, 382 in mild cases, 373 fast days in, 381 fasting in, 379 Diabetes mellitus, fat tolerance in, 381 formulas used in, 146 Joslin's diet in, 383 menus for, 376, 377, 383, 389, 397 protein tolerance in, 381 schedule of treatment for, 380 starvation treatment of, 372 test diets in, 374 urine in, 328, 329, 330, 371, 401, 402 Diabetic acidosis, 454 Diabetic cures, 372 Diabetic diet, 63, 374 Diabetic flours, 403 Diabetic foods, commercial, 403 Diabetic muffins, preparation of, 155 Diacetic acid in urine, Gerhardt's test for, 332 Diarrhea, 263, 276, and _see_ Enteritis causes of, 263, 276 dietetic treatment of, 264 in children, 263 dietetic treatment of, 237 Diastase, 171 Diet, or Diets, and _see_ under the various diseases carbohydrate-free, 63 convalescent, 62 diabetic, 63 emaciation, 63 fluid, 63 house, 62 light, 62 liquid, 62 milk, 63 mixed, 63 nephritic, 63, and _see_ Nephritis obesity, 63, and _see_ Obesity protein-free, 340 purin-free, 63 salt-free, 63 semi-solid, 62 special, 62, 63 Dietary, for child, 221, 223 sample, 54 Dieto-therapy, 189 Digestion, 167 chemical, 169, 172 gastric, 172 intestinal, 173, 176 processes included in, 166 salivary, 172 Digestive disturbances in infants and children, 231 Diluents, in infant feeding, 208 preparation of, 210 Dilution for premature infants, 225 Disaccharides, 8, 10 Dish gravy, 141 Dishes, washing, 76 Doughnuts, fuel value of, 465 nutrient value of, 465 Dry peptonoids, composition of, 488 fuel value of, 488 Duck, _see_ Meat Dysentery, dietetic treatment of, 268, 278 Ebstein's method for obesity, 429 Egg, or Eggs, 95 ash constituents of, 473 composition of, 488 coddled, 100 food content of, 479 fuel value of, 465, 488 nutrient value of, 465 standard portion of, 479 vitamines in, 497, 498 Egg nest, preparation of, 101 Eggnog, preparation of, 99 Eggplant, ash constituents of, 473 composition of, 488 fuel value of, 465, 488 nutrient value of, 465 Egg salad, preparation of, 154 Eggwhite and mint, preparation of, 98 Eiweissmilch, 142, 208, 209 Elimination, 167 Emaciation, 438 allowable foods in, 441 dietetic treatment in, 440 diet in, 63, 439 diet sheets, 442, 443 in children, 438 method of increasing diet in, 444 milk cure in, 441 need for building foods in, 439 regulating diet in, 439 selection of foods in, 440 Endive, ash constituents of, 473 Enema, or Enemas, malted milk, 146 milk and egg, 145 milk and starch, 146 nutrient, 145 temperature of, 61 Energy output compared with food intake, 425 production of, 182 Enteritis, acute, 264, and _see_ Diarrhea Enteritis, acute, dietetic treatment of, 264, 265, 266, 276, 277 foods to be avoided in, 266, 277 Enteritis, chronic, 267 dietetic treatment in, 267 Enterocolitis, 267, 277 dietetic treatment of, in infants, 237 Enzymes, 170, 171 acting, on carbohydrates, 171 on fats, 171 on proteins, 171 on purins, 171 action of, 170, 171 amylolytic, 172 autolytic, 171 classification of, 172 coagulating, 172 deaminizing, 172 glycolytic, 171 hydrolytic, 172 lipolytic, 172 oxidizing, 172 proteolytic, 172 reducing, 172 source of, 171 sugar-splitting, 172 table of, 171 Erepsin, 171, 174 Errors in diet, in infants and children, 232, 243 Fahrenheit scale, 80 Farina, ash constituents of, 473 composition of, 488 food content of, 479 fuel value of, 465, 488 nutrient value of, 465 preparation of, 104 standard portion of, 479 Fast days, in treatment of diabetes, 381 Fat, or Fats, 14, 15 absorption of, 177 calories in, 38 cause of gastro-intestinal disturbances in children, 233 effect of heat upon, 16 enzymes acting on, 171 excess of, in diet of infants and children, 233 fate of, 182 functions of, 17 metabolism of, in acidosis, 453 phosphorized, 15 rate of digestion of, 173 regulation of, in diet, 233 source of, 5, 448 tolerance of, in diabetes, 381 vitamines in, 497, 498 Fat soluble A, 15 effect of heat upon, 31 function of, 30 foods containing, 6, 496, 497, 498 Fatty foods, effect of, upon gastric secretion, 175 Feeding, by inunction, 62 by mouth, 59 correct, evidences of, 243 forced, 59 in diseases of gastro-intestinal tract, 245 infant, _see_ Infant feeding methods of, 59 post-operative, 316, 319, 320 pre-operative, 312, 318, 320 rectal, 60, 61 Fehling's solution, 331 Fehling's test for sugar in urine, 328 Fermentation, and _see_ Enzymes cause of infantile disorders, 236, 237 in stomach, 180 Fermentation test for sugar in urine, 330 Fever, or Fevers, 281 care of mouth in, 285 convalescent diet in, 283 dietetic treatment in, 281 energy expenditure in, 288 energy requirements in, 285 fluid diet in, 282 nitrogen equilibrium in, 286 sample menus for, 284 schedule of feeding in, 282 soft diet in, 283 thirst in, 285 tissue waste in, 281 typhoid, _see_ Typhoid fever Figs, ash constituents of, 473 composition of, 488 food content of, 479 fuel value of, 465, 488 nutrient value of, 465 standard portion of, 479 Fish, 115 ash constituents of, 473 composition of, 488 food content of, 479 fuel value of, 488 standard portion of, 479 Fish roe, vitamines in, 496 Fish steaks stuffed with oysters, preparation of, 125 Flaxseed, ash constituents of, 474 vitamines in, 497 Floating island, preparation of, 103 Flounder, fuel value of, 465 nutrient value of, 465 Flour, ash constituents of, 474 composition of, 488 food content of, 479 fuel value of, 465, 488 nutrient value of, 465 standard portion of, 479 Flours, diabetic, 403 Fluid diet, 62 in fevers, 282 Foamy omelet, preparation of, 100 Foamy sauce, preparation of, 111, 112 Food, or Foods, 1, and _see_ Foodstuffs acid-forming, 184, 454 adulteration of, 67 allowance for children, 48 arrangement of, in stomach, 167 as fuel, 24, 36, 39 ash constituents of, 472, 473, 474, 475, 476, 477 base-forming, 184, 454 care of, 76 chemical composition of, 3, and 484 to 495 contamination of, 66 defined, 2 diabetic, 403 effect of cold upon, 39 effect of heat upon, 39 fuel value of, 36, 39, 221, 461 to 471, and 484 to 495 functions of, 2 idiosyncrasies to, 452 incomplete, as source of danger, 227 intake of, compared with output of energy, 425 materials, 2 mineral matter in, 25 nutrient value of, 461 to 471 passage of, from stomach, 168 preparation of, 69, 70 purin content of, 421 relation of, to mother's milk, 203 requirements of body, 42, 43, 51, 52 factors influencing, 43, 44 salt content of, 358, 359, 360 selection of, 52, 75 sources of, 2, 3, 4 transformation of into fuel, 37 uses of, 2, 425 vitamines in, 496, 497, 498 which produce fat, 448 Food materials, 2 Food poisoning, 66, 451 Foodstuffs, heat produced by oxidation of, 38 Forced feeding, 59 Formaldehyde, test for, 67 Formulas, determining fuel value of, 221 for constipation, 143 for feeding infants, 140, 212 Fowls, and _see_ Meat composition of, 488 fuel value of, 466, 488 nutrient value of, 466 French dressing, preparation of, 134 Frozen custard, preparation of, 91 Fructose, 9 Fruit, preparation of, 126, 127, 128 vitamines in, 497 Fruit beverages, preparation of, 96 Fruit jellies, method for, 135 preparation of, 160 Fruit salads, preparation of, 131, 132 Fruit sauce, preparation of, 111 Frying, 71 Fuel value of food, 36 to compute, 39, 221 Galactose, 9 Gall bladder, diet after operations on, 318, 321 Gallstones, 408 available foods, 410 dietetic treatment for, 408, 409 diet sheets for, 411, 412, 413 Gastric, and _see_ Stomach Gastric cancer, 260 dietetic treatment in, 260 Gastric digestion, 172 factors influencing, 175 Gastric, disturbances, factors inducing, 261, 262 Gastric hemorrhage, 251 Gastric juice, composition of, 246 retardation of, 175 stimulation of, 175 Gastric secretion, effect of alkaline carbonates on, 175 effect of fatty foods upon, 175 water as a stimulant, 253 Gastric ulcer, 251 bland diet in, 255 convalescent diet in, 254 dietetic treatment in, 252, 256 lavage in, 255 Lenhartz diet in, 257 starvation treatment of, 252 Gastritis, acute, 248 dietetic treatment in, 248, 249 Gastritis, chronic, 250 dietetic treatment of, 250 Gastro-enterostomy, diet after, 321 Gastro-intestinal disturbances, relapses in, 244 Gastro-intestinal tract, feeding in diseases of, 245 Gavage, 60 Gelatin, composition of, 488 food content of, 480 fuel value of, 466, 488 nutrient value of, 466 standard portion of, 480 Gelatin jellies, preparation of, 135 Gerhardt's test for diacetic acid, 332 Girls, heights and weights for, 501 Globulins, 20 Glucose, 8 Gluten food, ash constituents of, 474 Glycogen, 12 Glycolytic enzymes, 171 Goose, _see_ Meat Gooseberries, ash constituents of, 474 Gout, 417 alcohol in, 412 allowable foods in, 420 avoidable foods in, 420, 421 dietaries in, 422 dietetic treatment in, 420, 445 foods to be condemned in, 420 glycosuria in, 419 obesity in, 419 purin-free diet in, 410 Grape butter, fuel value of, 466 nutrient value of, 466 Grapefruit, ash constituents of, 474 composition of, 488 food content of, 480 fuel value of, 466, 488 nutrient value of, 466 standard portion of, 480 vitamines in, 497 Grape juice, ash constituents of, 474 composition of, 488 food content of, 480 fuel value of, 488 standard portion of, 480 vitamines in, 497 Grape juice ice, preparation of, 136, 137 Grape juice jelly, preparation of, 135 Grapes, ash constituents of, 474 composition of, 488 food content of, 480 fuel value of, 466, 488 nutrient value of, 466 standard portion of, 480 vitamines in, 497 Greens, composition of, 488 fuel value of, 488 Guanase, 171 Guava, ash constituents of, 474 Gum gluten, composition of, 488 fuel value of, 488 Haddock, and _see_ Fish fuel value of, 466 nutrient value of, 466 Haines' solution, 331 Haines' test for sugar in urine, 329 Halibut, and _see_ Fish composition of, 488 fuel value of, 466, 488 nutrient value of, 466, 488 Halpin's salt-free nephritic diet, 342 Ham, and _see_ Meat composition of, 488 fuel value of, 466, 488 nutrient value of, 466 Hard sauce, preparation of, 111 Hazel nuts, ash constituents of, 474 Heat, application of to milk, 84 effect of on carbohydrates, 14 effect of on fats, 16 effect of on proteins, 22 effect of on vitamine A, 31 effect of on vitamine B, 32 effect of on vitamine C, 33 produced by oxidation of foodstuffs, 38 Hedinger-Schlayer-Mosenthal diet, 348, 350 Heights and weights for children, 499, 500, 501 Heller's test for albumen in urine, 333 Hemoglobin, 22 Hemorrhages, gastric, 251 Hempseed, vitamines in, 497 Herring, and _see_ Fish fuel value of, 466 nutrient value of, 466 vitamines in, 496 Hickory nuts, composition of, 488 fuel value of, 488 High calorie diet, in tuberculosis, 304 in typhoid fever, 289, 291, 294, 295, 298, 299 Hollandaise sauce, preparation of, 126 Hominy, ash constituents of, 474 composition of, 488 food content of, 480 fuel value of, 466, 488 nutrient value of, 466 standard portion of, 480 Homogenized milk, 209 Homogenizer, 209 Honey, ash constituents of, 474 composition of, 488 food content of, 480 fuel value of, 466, 488 nutrient value of, 466 standard portion of, 480 vitamines in, 498 Horse meat, vitamines in, 496 Horseradish, ash constituents of, 474 House diet, 62 Household weights and measures, 78 Huckleberries, ash constituents of, 474 fuel value of, 466 nutrient value of, 466 Huckleberry wine, ash constituents of, 474 Hydrochloric acid, in gastric juice, 246 Hyperchlorhydria, 247 Hypochlorhydria, 246 Ice-box, care of, 73 Ice cream, poisoning by, 451 preparation of, 161 to reënforce, 91 Ices, preparation of, 161 Idiosyncrasies, to milk, 296 to foods, 452 Ileocecal valve, 176 Indican, test for in urine, 334 Infancy, retention of nitrogen in, 201 Infant, or Infants, and _see_ Children bath for, 202 bowels of, 202 care of in abnormal conditions, 231 daily gain in weight, 200 danger of incomplete foods, 227 digestive disturbances in, 231 energy requirements of, 198 enterocolitis in, 237 errors of diet in, 232, 243 feeding, _see_ Infant feeding food for, 201 foods, _see_ Infant foods over-feeding, 243 premature, _see_ Premature infants proprietary foods for, 226 quantity of milk needed for, 198 under-feeding, 243 weight of, 201 Infant feeding, 199 alkalies used in, 205, 206 amount given at each meal, 211 artificial, 205 breast versus artificial, 243 cane sugar in, 228 diluents in, 208, 228 formulas for, 140, 212, 229 in abnormal conditions, 231 lime water in, 206, 221 malt sugar in, 228 method of calculating formulas for, 212 milk sugar in, 228 Morse and Talbot's method in, 215 normal, 201 over-dilution in, 232 regularity in, 201, 228 rules and regulations for, 204 scheme for, 217, 219 sugar in, 207 under-dilution in, 232 water in, 229 Infant foods, 140 addition of alkali to, 228 dilution of, 208, 228 increasing, 229 percentage, computation of, 229 preparation of, 229 scheme for adding solids to, 221 Infected food materials, 451 Intestinal digestion, 173 Intestinal secretions, stimulation of, 174 Intestinal tract, diseases of, 263 Intestines, behavior of foods in, 168 movements of, 168, 169 muscular contractions in, 169 Inunction, feeding by, 62 Invertase, 171 Iodine, source of in food, 6 Irish moss pudding, preparation of, 160 Iron, 28 sources of in food, 5 Jam, ash constituents of, 474 Jellies, ash constituents of, 474 preparation of, 159 Jello, composition of, 490 fuel value of, 490 Joslin's treatment in diabetes, 383 Junket, preparation of, 90 Junket ice cream, preparation of, 90 Kidneys, function of, 323 functional tests for, 347, 348, 349, 351 limiting work of, 337 operations on, diet after, 318, 321 resting of, in nephritis, 338 vitamines in, 496 Kohl-rabi, ash constituents of, 474 composition of, 490 fuel value of, 466, 490 nutrient value of, 466 Koumiss, composition of, 490 fuel value of, 466, 490 nutrient value of, 466 Lactase, 171 Lactation, diet in, 191, 194, 197 Lactone buttermilk, preparation of, 91 Lactose, 8, 11 composition of, 490 fuel value of, 490 in infant feeding, 207 Lady fingers, composition of, 490 fuel value of, 490 Lamb, 112, and _see_ Meats composition of, 480 cuts of, 117 food content of, 480 fuel value of, 467, 490 nutrient value of, 467 standard portion of, 480 Lamb chops, preparation of, 124 Lard, composition of, 490 fuel value of, 467, 490 nutrient value of, 467 vitamines in, 497, 498 Lavage, 248 in gastric ulceration, 255 Leeks, ash constituents of, 474 Lemon, ash constituents of, 474 food content of, 480 fuel value of, 467 nutrient value of, 467 standard portion of, 480 vitamines in, 497 Lemonade, albumenized, preparation of, 97 Lemon cream, preparation of, 138 Lemon ice, preparation of, 136, 137, 161 Lemon ice cream, preparation of, 91 Lemon jelly, preparation of, 135, 159 Lemon juice, ash constituents of, 474 composition of, 490 fuel value of, 467, 490 nutrient value of, 467 Lenhartz diet, in gastric ulceration, 257 Lentils, ash constituents of, 474 composition of, 490 food content of, 480 fuel value of, 490 standard portion of, 480 Lettuce, ash constituents of, 474 composition of, 490 food content of, 480 fuel value of, 467, 490 nutrient value of, 467 standard portion of, 480 vitamines in, 496 von Leube's enema, preparation of, 146 Limes, ash constituents of, 474 vitamines in, 497 Lime juice, ash constituents of, 474 Lime water, in infant feeding, 206, 221 Linen, 64 Linseed meal, ash constituents of, 474 Lipase, 171 Liquid diet, 62 Liquid peptonoid eggnog, preparation of, 99 Liquid peptonoids, composition of, 490 fuel value of, 490 Lister cream puff, preparation of, 159 Lister flour and bran muffins or biscuits, preparation of, 156 Lister muffins, preparation of, 155 Liver, cirrhosis of, 407 avoidable foods for, 408 dietetic treatment in, 407 composition of, 490 diseases of, 404 convalescence, diet in, 405 dietetic treatment in, 405, 414 fuel value of, 467, 490 functions of, 413 nutrient value of, 467 operations on, diet after, 318, 321 vitamines in, 496 work of, 404 Lobster, composition of, 490 fuel value of, 467, 490 nutrient value of, 467 preparation of, 126 Lupins, ash constituents of, 474 Macaroni, ash constituents of, 480 composition of, 490 food content of, 480 fuel value of, 467, 490 nutrient value of, 467 standard portion of, 480 Macaroons, fuel value of, 467 nutrient value of, 467 Mackerel, and _see_ Fish composition of, 490 fuel value of, 467, 490 nutrient value of, 467 Magnesium, source of in foods, 6 Maize, vitamines in, 496 Malnutrition, 242 Maltase, 171 Malt extract, vitamines in, 497, 498 Malt soup, preparation of, 141 Malt sugar, in infant feeding, 207, 208 Malted foods, for infant feeding, 207, 226, 227 Malted milk, composition of, 490 fuel value of, 490 preparation of, 92 Malted milk chocolate, preparation of, 92 Malted milk cocoa, preparation of, 92 Malted milk eggnog, preparation of, 99 Malted milk enema, 146 Maltose, 8, 10 Mamey, ash constituents of, 475 Mango, ash constituents of, 475 Mangolds, ash constituents of, 475 vitamines in, 496 Maple syrup, ash constituents of, 475 Marmalade, fuel value of, 467 nutrient value of, 467 Mayonnaise, preparation of, 475 Meals, serving suggestions for, 56, 66 Measures and weights, 77 household, 78 Meat extract, ash constituents of, 475 Meat peptone, ash constituents of, 475 Meats, 112 ash constituents of, 475 carbohydrate-free, calorie equivalent of, 386 cuts of, 117 quality of, 113 selection of, 116 vitamines in, 496 Metabolism, 166, 181 basal, 42 mineral, 185 of body tissues, 187 of carbohydrates, 182 of proteins, 183 Metric system, 77 Milk, 82 adulteration of, 86 application of heat to, 84 ash constituents of, 475 breast versus cows', 203 care of, 86 certified, 81 composition of, 205, 490 condensed, _see_ Condensed milk diet, 63 fats in, measuring according to, 210 food content of, 480 formulas, 212, 214, 216, 217 fuel value of, 467, 490 homogenized, 209 idiosyncrasies against, 296 method of administering to premature infants, 225 modification of, technique of, 209, 228 nutrient value of, 467 pasteurization of, 85, 211 quantity of needed for infant, 198 relation of food to, 203 secretion of, factors retarding, 195, 197 factors stimulating, 195, 197 selection of, 86 standard portion of, 480 sterilization of, 84 substitutes for whole, 228 sugar-free, 162 use of in nephritis, 162 vitamines in, 498 Milk and egg enemas, preparation of, 145 Milk and starch enemas, preparation of, 146 Milk cure in nephritis, 338 Milk powder, food content of, 480 standard portion of, 480 vitamines in, 498 Milk punch, preparation of, 88 Milk sauce, preparation of, 93 Milk shake, preparation of, 87 Milk sherbet, preparation of, 138 Milk soups, preparation of, 93 Milk sugar, in infant feeding, 228 Milk toast, preparation of, 105 Millet, ash constituents of, 475 Millet seed, vitamines in, 497 Mince meat, fuel value of, 467 nutrient value of, 467 Mineral metabolism, 185 Mineral oils, use of in constipation, 279 Mineral requirements of body, 50 Mineral salts, 25, 26 absorption of, 178 sources of in foods, 5 Mixed diet, 63 Molasses, ash constituents of, 475 composition of, 490 food content of, 480 fuel value of, 467, 490 nutrient value of, 467 standard portion of, 480 Monosaccharides, 7 Morse and Talbot's method of infant feeding, 215 Mother's milk, fuel value of, 198 making of, 198 Mouth, care of in typhoid, 299 Muffins, diabetic, preparation of, 155 Mushrooms, ash constituents of, 475 composition of, 490 fuel value of, 467, 490 nutrient value of, 467 Muskmelon, ash constituents of, 475 composition of, 490 fuel value of, 467, 490 nutrient value of, 467 Mustard, ash constituents of, 475 Mutton, and _see_ Meat cuts of, 117 food content of, 480 fuel value of, 468 nutrient value of, 468 standard portion of, 480 Mutton broth, preparation of, 118 Mutton chops, preparation of, 124 Nectar, vitamines in, 498 Nectarines, fuel value of, 468 nutrient value of, 468 Nephritic diet, 63 Nephritis, 336 acute, 336 adjusting diet in, 338 adjusting fluids in, 338 advisable foods in, 344 causes of, 336 Chase and Rose's diet in, 340 chronic, 336, 346 dietetic treatment in, 346 functional tests in, 347, 348, 351 protein diet in, 346 chronic interstitial, 352 dietetic treatment in, 352 limiting fluid in, 353 limiting nitrogen in, 353 selection and preparation of food in, 354 convalescent diet in, 344 diet in, 339, 345, 356 effects of, 336 elimination of salt in, 340 foods to be avoided in, 344 Halpin's diet in, 342 Karell cure in, 342 limiting the amount of food in, 341 milk cure in, 338 preparation of food in, 343 problems to be considered in, 337 proteins in, 343 resting the kidneys in, 338 selection of foods in, 343 thirst in, 343 Widal's diet in, 341 Neufchâtel cheese salad, preparation of, 154 Nitrogen, retention of in infancy, 201 source of in foods, 5 Nitrogenous substances, oxidation and excretion of, 324 Noodles, composition of, 490 fuel value of, 490 Noodle soup, preparation of, 149 Normal saline solution, preparation of, 146 Nucleoproteins, 21 Nursing infant, food requirements of, 194 Nursing mother, constipation in, 197 diet of, 195 habits of, 203 Nuts, vitamines in, 498 Nut charlotte, preparation of, 138, 162 Nutrient enemas, 145 Nutrition in children, 502 Nutritional index, 503 Oatmeal, ash constituents of, 475 composition of, 490 food content of, 481 fuel value of, 468, 490 nutrient value of, 468 standard portion of, 481 Oatmeal cookies, preparation of, 106 Oats, composition of, 490 fuel value of, 490 vitamines in, 496 Oat water, preparation of, 141 Obese women, Rose's reducing diet for, 431, 432 Obesity, 424 allowable foods in, 429 amount of food to be taken in, 431 Banting's method in, 426, 427 cures for, 425, 426 dietetic treatment of, 426, 429, 446 diets for, 63, 426 Ebstein's method in, 429 exercise in, 426 in gout, 419 limiting fluids in, 426 massage in, 425 menus for, 430, 435, 436, 437 Oertel's method for, 427 Proudfit's menu for, 429, 433, 434 Rose's diet for, 431, 432 Oertel's method in obesity, 427 Oils, vitamines in, 497, 498 Okra, ash constituents of, 475 composition of, 490 fuel value of, 468, 490 nutrient value of, 468 Oleo, vitamines in, 497, 498 Olives, ash constituents of, 475 composition of, 490 fuel value of, 468, 490 nutrient value of, 468 Olive oil, composition of, 490 fuel value of, 490 Olmstead bran cakes, preparation of, 148 Onion, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 496 Operations, diet in relation to, 312 Orange, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 497 Orangeade, preparation of, 96 Orange charlotte, preparation of, 138, 162 Orange ice, preparation of, 136, 137, 161 Orange jelly, preparation of, 135, 160 Orange rice custard, preparation of, 108 Orange tapioca, preparation of, 106 Organic acids, 13 Over-dilution of infant's food, 232 Over-feeding of infants and children, 243 Oxidases, 171 Oxtail soup, fuel value of, 468 nutrient value of, 468 Oyster broth, preparation of, 119 Oyster soup, preparation of, 94 Oysters, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 Pancreas, vitamines in, 496 Panopepton, composition of, 492 fuel value of, 492 Panopepton eggnog, preparation of, 99 Paprika, ash constituents of, 475 Parsley butter, preparation of, 154 Parsnips, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 496 Pasteurization, 85, 211 Pea soup, fuel value of, 468 nutrient value of, 468 Peaches, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 Peanut butter, composition of, 492 fuel value of, 492 Peanuts, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 497 Pears, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 497 Pear juice, ash constituents of, 475 Peas, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 468, 492 nutrient value of, 468 standard portion of, 481 vitamines in, 496, 497 Pecans, ash constituents of, 475 composition of, 492 food content of, 481 fuel value of, 492 standard portion of, 481 "Pelidisi," the, 503 Pelidisi chart, 502 Pellagra, dietetic treatment in, 455, 456, 459 Peppers, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 469, 492 nutrient value of, 469 Pepsin, 171 Peptonized milk, preparation of, 88 Peptonized milk punch, preparation of, 89 Peptonoids, dry, composition of, 488 fuel value of, 488 liquid, composition of, 490 fuel value of, 490 Percentage calculations, 79, 229 Perch, _see_ Fish Persimmons, ash constituents of, 476 fuel value of, 469 nutrient value of, 469 Phosphoproteins, 21 Phosphorized fats, 15 Phosphorus, 27, 186 requirements in pregnancy and lactation, 191 sources of in food, 5 Pies, fuel value of, 469 nutrient value of, 469 Pig heart, vitamines in, 496 Pineapple, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 469, 492 nutrient value of, 469 standard portion of, 481 Pineappleade, preparation of, 97 Pine nuts, fuel value of, 469 nutrient value of, 469 Pistachios, fuel value of, 469 nutrient value of, 469 Placenta, vitamines in, 496 Plums, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 469, 492 nutrient value of, 469 standard portion of, 481 Pneumonia, 306, 311 convalescent diet in, 307 diet schedules for, 307 dietetic treatment in, 306, 307, 311 Poached eggs, preparation of, 101 Poaching, 71 Poisoning, food, 66, 451 Polysaccharides, 8, 11 Pomegranates, ash constituents of, 476 fuel value of, 469 nutrient value of, 469 Pork, 116, and _see_ Meat fuel value of, 469 nutrient value of, 469 vitamines in, 498 Port wine, composition of, 492 fuel value of, 492 Postoperative feeding, 316, 319, 320 Potassium, sources of in food, 6 Potato chips, fuel value of, 469 nutrient value of, 469 Potatoes, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 469, 492 nutrient value of, 469 standard portion of, 481 vitamines in, 496 Potatoes stuffed with meat, preparation of, 130 Poultry, 112, and _see_ Meats Pregnancy, 191 albuminuria in, 197 diet in, 192, 193, 194, 196, 197 nutritional disturbances in, 191 Premature infants, dilution of food for, 225 energy requirements of, 224 feeding of, 224, 225, 229 Pre-operative feeding, 312, 318, 320 Presbyterian Hospital diet list in typhoid fever, 292 Protein milk, preparation of, 142 Proteins, 17 alcohol-soluble, 21 calories in, 38 classification of, 19 composition of, 18 conjugated, 21 construction of, 19 effect of heat upon, 22, enzymes acting upon, 171 excess of in infant's and children's food, 234 fate of, 183 function of in body, 23 metabolism, 183 in nephritis, 343 rate of digestion of, 173 requirements in body, 50 sources of, 4 tolerance of in diabetes, 381 Proudfit's menu for obesity, 429 reducing diet for obesity, 433, 434 Prune fig whip, preparation of, 139 Prunes, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 469, 492 nutrient value of, 469 standard portion of, 481 Prunes and figs, preparation of, 143 Prune whip, preparation of, 139 Ptomaines, 66 poisoning by, 451 dietetic treatment for, 451, 452 Ptyalin, 171 Pumpkins, ash constituents of, 476 fuel value of, 469 nutrient value of, 469 Punch, milk, preparation of, 88 Purin bases, 184 content of food, 421 Purin-free diet, 63 in gout, 419 Purins, enzymes acting upon, 171 Quail, composition of, 492 fuel value of, 492 Radishes, ash constituents of, 476 food content of, 481 fuel value of, 469 nutrient value of, 469 standard portion of, 481 Raisins, ash constituents of, 476 composition of, 492 fuel value of, 469, 476 nutrient value of, 469 vitamines in, 497 Raspberries, ash constituents of, 476 composition of, 492 fuel value of, 470, 492 nutrient value of, 470 Rectal feeding, 60, 61, 315 Respiratory tract, diseases of, 301 Requirements, basal, 42 Rhubarb, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 470, 492 nutrient value of, 470 standard portion of, 481 Rice, ash constituents of, 476 composition of, 492 food content of, 481 fuel value of, 470, 492 nutrient value of, 470 preparation of, 104 standard portion of, 481 vitamines in, 496 Rice custard, preparation of, 108 Rickets, 241 calcium retention in, 241 dietetic treatment of, 241 Roast chicken, preparation of, 122 Roast duck, preparation of, 122 Roast turkey, preparation of, 122 Roasting, 71 Romaine, ash constituents of, 476 Rose's reducing diet for obese women, 431, 432 Rum, composition of, 492 fuel value of, 492 Rutabaga, ash constituents of, 476 vitamines in, 496 Rye, and _see_ Bread, and Flour ash constituents of, 476 vitamines in, 497 Saccharine, test for, 69 Salad, egg, preparation of, 154 Salads, fruit, preparation of, 131 vegetable, preparation of, 131 Saline solution, normal, 146 Saliva, 172 Salivary digestion, 172 Salisbury steak, preparation of, 149 Salmon, and _see_ Fish composition of, 492 fuel value of, 470, 492 nutrient value of, 470 Salmon, molded, preparation of, 150 Salt, elimination of in nephritis, 340 Salt content of foods, 358, 359, 360 Salt-free diet, 63 Salt-poor diet for nephritis, 341 Saltines, composition of, 492 fuel value of, 492 Sapota, ash constituents of, 476 Sardines, composition of, 492 fuel value of, 492 Sauce for puddings, preparation of, 111, 112 Sausage, fuel value of, 470 nutrient value of, 470 Sautéing, 71 Scalloped potatoes, preparation of, 131 Scurvy, 240 treatment of, 240 Secretin, 174 Secretory cells, distribution of, 169 Secretory processes disturbed in diseases of stomach, 246 Seeds, vitamines in, 497 Semi-solid diet, 62 Serving meals, suggestions for, 56, 66 Shad, composition of, 494 fuel value of, 470, 494 nutrient value of, 470 Shellfish, 112, and _see_ Meats Sherry wine, composition of, 494 fuel value of, 494 Shredded wheat, ash constituents of, 476 food content of, 481 fuel value of, 470 nutrient value of, 470 standard portion of, 481 Shrimp, ash constituents of, 476 Silver, 64 Simmering, 70 Singer's enema, preparation of, 146 Sippi diet, in gastric ulceration, 256 Snow-balls, preparation of, 108 Snow pudding, preparation of, 139, 159 Soap stools, 233 Sodium, sources of in food, 6 Soft-cooked eggs, 100 Soft custard, preparation of, 102 Soups, ash constituents of, 476 preparation of, 118 Soya manna muffins, preparation of, 148 Soya meal and bran muffins, preparation of, 157 Spanish cream, preparation of, 158 Special diets, 62, 63 Spice cookies, preparation of, 152 Spinach, ash constituents of, 476 composition of, 494 fuel value of, 470, 494 nutrient value of, 470 vitamines in, 496 Spinach and egg salad, preparation of, 147 Spinach soup, preparation of, 152 Sponge pudding, preparation of, 109 Squab, composition of, 494 fuel value of, 494 Squab pie, preparation of, 151 Squash, ash constituents of, 476 composition of, 494 food content of, 481 fuel value of, 470, 494 nutrient value of, 470 standard portion of, 481 Standard broth, preparation of, 118 Standard portion of foods, 40, 478 Starch, excess of in food formulas, 236 Starchy desserts, preparation of, 108 Starvation, in treatment of diabetes, 372 Steaming, 70 Steapsin, 171 Sterilization, 84 Stewed tomatoes on toast, preparation of, 134 Stomach, and _see_ Gastric acid content of, determining, 248 arrangement of food in, 167 diseases of, predisposing factors in, 245 disturbance of motility and tone of, 246 disturbance of secretory processes in, 246 fermentation in, 180 passage of food from, 168 secretion of water in, 174 Strawberries, ash constituents of, 476 composition of, 494 food content of, 481 fuel value of, 470, 494 nutrient value of, 470 standard portion of, 481 Strawberry ice, preparation of, 137 Strawberry juice, composition of, 494 fuel value of, 494 String beans, and _see_ Beans preparation of, 129 Succotash, fuel value of, 470 nutrient value of, 470 Sucrase, 171 Sucrose, 8, 10 Suet, composition of, 494 fuel value of, 494 Sugar, adjusting of, in food formulas, 235 composition of, 494 fuel value of, 470, 494 in infant feeding, 207 in urine, in diabetes, 371 tests for, 328, 330, 331 nutrient value of, 470 Sugar-free milk, 162 Sugar-splitting enzymes, 171 Sulphur, sources of in food, 6 Sunflower seeds, vitamines in, 497 Sunshine cake, preparation of, 110 Sweetbreads, composition of, 494 fuel value of, 494 preparation of, 123 vitamines in, 496 Tallow, vitamines in, 498 Tamarind, ash constituents of, 476 Tapioca, ash constituents of, 477 composition of, 494 food content of, 482 fuel value of, 494 standard portion of, 482 Tapioca custard, preparation of, 109 Test meals, 250 Thermometry, 80 Thirst, in nephritis, 343 in typhoid fever, 299 Thymus, vitamines in, 496 Timothy, vitamines in, 498 Toast, composition of, 494 fuel value of, 494 preparation of, 105 Tomatoes, ash constituents of, 477 composition of, 494 food content of, 482 fuel value of, 470, 494 nutrient value of, 470 standard portion of, 482 vitamines in, 497 Tomato aspic, preparation of, 154 Tomato bisque, preparation of, 152 Tomato jelly, preparation of, 132 Tomato juice, ash constituents of, 477 Tomato salad, preparation of, 131, 132 Tomato stuffed with rice, preparation of, 133 Tonsillitis, dietetic treatment of, 309, 310 Toxins, elimination of, 323 Tray, 64 arranging, 65 Trout, composition of, 494 fuel value of, 494 Truffles, ash constituents of, 477 Trypsin, 171, 174 Tuberculosis, 301, 305 dietetic treatment in, 302 high calorie diet in, 304 reënforcing the diet in, 306 schedule of diets in, 307 Tuna, fuel value of, 470 nutrient value of, 470 Tuna fish salad, preparation of, 154 Turkey, composition of, 494 fuel value of, 470, 494 nutrient value of, 470 selection of, 114 Turnips, ash constituents of, 477 composition of, 494 food content of, 482 fuel value of, 470, 494 nutrient value of, 470 standard portion of, 482 Turnip tops, ash constituents of, 477 Typhoid fever, 288, 297 absorption of food in, 290, 297 acidosis in, 299 care of mouth in, 299 Coleman's high calorie diet in, 289, 291, 294, 295, 298, 299 energy expenditures in, 288, 297 energy requirements in, 289, 297 essential points in dietary, 297 hemorrhage in, 296, 298 high calorie diet in, 289, 291, 294, 295, 298, 299 idiosyncrasies in, 300 increasing diet in, 290, 300 liquid diet in, 290, 293 milk diet in, 291, 298 Presbyterian Hospital diet list for, 292 rate of metabolism in, 297 reënforcing diet in, 300 semi-solid diet in, 293 soft diet in, 293 thirst in, 299 tympanites in, 290 varying diet in, 292 Under-dilution of infants' foods, troubles due to, 232 Under-feeding in infants and children, 243 Urea and salt test, 351 Uremia, 353, 361 Uremic poisoning, 361 Uric acid, 324 elimination of, 417 formation of, 184 source of, 417 Urinalysis, 323 Urine, acetone in, test for, 333 albumin in, tests for, 333 analysis of, 323, 324 collection of, 326, 334 diacetic acid in, test for, 332 diseases in which it is diminished, 326 effect of food upon, 326 examination of, 323, 324 in diabetes, 328, 329, 330, 371, 401, 402 indican in, test for, 334 preserving, 335 sugar in, tests for, 328, 329, 330, 331 Utensils, care of, 76 Vanilla ice cream, preparation of, 91 Veal, 112, 114, and _see_ Meats composition of, 494 cuts of, 117 food content of, 482 fuel value of, 470, 494 method of preparation, 117 nutrient value of, 470 standard portion of, 482 Veal bird, preparation of, 150 Veal broth, preparation of, 118 Veal cutlets, preparation of, 124 Vegetable oils, vitamines in, 498 Vegetable salads, preparation of, 131 Vegetable soups, fuel value of, 471 nutrient value of, 471 preparation of, 223 Vegetables, preparation of, 126, 128, 153 vitamines in, 496 Vinegar, ash constituents of, 477 Vitamines, 29 fat soluble A, 15 in foods, 496, 497, 498 functions of, 30, 31 in foods, 496, 497, 498 requirements of in body, 52 source of in foods, 6, 7 water soluble B, 31 in foods, 496, 497, 498 water soluble C, 33 in foods, 496, 497, 498 Walnuts, ash constituents of, 477 composition of, 494 food content of, 482 fuel value of, 471, 494 nutrient value of, 471 standard portion of, 482 vitamines in, 498 Water, 24 absorption of, 177 administration of to infants, 229 as a fat maker, 425 as a stimulant to gastric secretion, 253 excretion of, 324 factors determining amount needed, 25 function of, 24 sources of in foods, 5 Water soluble B, 31 effect of alkalies upon, 32 effect of heat upon, 32 functions of, 31 in foods, 6, 496, 497, 498 Water soluble C, 33 effect of heat upon, 33 in foods, 7, 496, 497, 498 Water-cress, ash constituents of, 477 Water ices, preparation of, 136 Watermelon, ash constituents of, 477 composition of, 494 food contents of, 482 fuel value of, 471, 494 nutrient value of, 471 standard portion of, 482 Weights and measures, 77 household, 78 metric, 77 Weights and heights of children, 49, 499, 500, 501 Wet nurses, 229 Wheat, ash constituents of, 477 composition of, 494 fuel value of, 471, 494 nutrient value of, 471 vitamines in, 497 Whey, 83 ash constituents of, 477 composition of, 494 fuel value of, 494 vitamines in, 498 Whey mixtures, 226 Whitefish, composition of, 494 fuel value of, 471, 494 nutrient value of, 471 Whortleberries, ash constituents of, 477 Widal's diet in nephritis, 341 Wine, ash constituents of, 477 Wine jelly, preparation of, 136, 160, 161 Wine panada, preparation of, 105 Wine sauce, preparation of, 111 Work, influence of upon food requirements, 43 Yeast, vitamines in, 498 Zwieback, composition of, 494 fuel value of, 471, 494 nutrient value of, 471 Transcriber's Note Minor punctuation errors have been repaired. Hyphenation and accent usage has been made consistent. There are some errors in calculation in places; these have been preserved as printed. For example, addition errors in the table on pp. 377-8. Variable spelling is preserved as printed (e.g. sirup and syrup). 12 M. has been used inconsistently, to indicate either 12 Midnight or 12 Midday. It has been preserved as printed in all cases. Calorie count or separate ingredients lists are omitted from some recipes; these are left as printed. The 'Eggs' section, starting on page 95, has no recipes included. However, the following 'Fruit Beverages' section has a large number of egg recipes included in it. Whether this was an error or intentional is unclear, so the sections and ordering of recipes have been preserved as they appeared in the original publication. The recipe for Foamy Sauce appears twice, once each on page 111 and 112. There is no apparent difference apart from the calorie amount. Both versions have been left in place. The recipe for Sauce for Puddings (page 112) appears identical to the recipe for Wine or Fruit Sauce (page 111), except for the recipe name and calorie amounts. Both versions have been left in place. The table heading on page 117 refers to cuts of lamb and mutton, while the table itself refers to lamb and veal. This has been left as printed. There are two instances of a recipe called Beef Juice, on pages 119 and 141. Both have been left in place as printed. The following amendments have been made: Page 30--Mellanbly amended to Mellanby--"Mellanby of England believes the "A" vitamine to be a factor ..." Page 31--or amended to of--"Effect of Heat on the "A" Vitamine." Page 77--the first reference to centigram has been amended from c. to cgm. Page 80--in amended to is--"... that every Fahrenheit degree is 9/5 times as large ..." Page 92--erroneous 'or' removed from second malted milk recipe (original called for either milk and water or salt). Page 111--omitted word 'juice' added to ingredients list in Wine or Fruit Sauce recipe. Page 125--omitted subheading for Fish added. Page 128--repeated heading 'Vegetables and Fruits' removed. Page 131--omitted 'or' added to dressing options in Tomato (No. 1) recipe. Page 134--in the ingredients for French Dressing, paprika amended to salt, to follow the recipe. Page 145--superfluous 'and' deleted between paragraph starting "1/2 cup raisins ..." and paragraph starting "Cream butter and sugar ..." Page 146--chlorid amended to chloride--"1 dram sodium chloride (common salt)" Page 146, footnote--Ellithorp amended to Ellithorpe-- "Courtesy of Misses Foley and Ellithorpe, Dieticians." Page 147--agar gar amended to agar-agar--"1 tsp. or 7 gms. agar-agar" Page 156--superfluous 'grams' removed following calorie count in Casoid Flour and Bran Muffins recipe. Page 156--omitted ', trace;' added to carbohydrate quantity for one muffin in the Casoid Flour and Bran Muffins recipe. Page 157--omitted 'protein,' added to 2 grams quantity for one muffin in the Soya Meal and Bran Muffins recipe. Page 172--dioxid amended to dioxide--"Those which produce carbon dioxide without the use ..." Page 194--grapefuit amended to grapefruit--"... dates, figs, or grapefruit, stewed or raw." Page 213--proced amended to proceed--"... we will proceed with the method itself." Page 219--zweiback amended to zwieback--"... pieces of stale bread, toast or zwieback." Page 241--Mellenby amended to Mellanby--"Mellanby of England claims that the oil owes its curative ..." Page 244f--empysema amended to emphysema--"... broncho-pneumonia, acute emphysema and collapse of the lung ..." Page 259--"Soft-cooked egg (1)" has been amended to "1 soft-cooked egg" in the 11 A.M. section of the Seventh Day diet, for consistency with other entries. Page 272--omitted heading 'BREAKFAST' added. Page 281--tonsilitis amended to tonsillitis--"... as accompany colds, tonsillitis, chicken pox ..." Page 337--omitted 'of' added--"... the end-products of the nitrogenous foods ingested, ..." Page 349--grams amended to c.c.--"Supper 5 P.M. ... 200 c.c. ..." Page 385--Huntly amended to Huntley (Breakfast biscuit entry on table). Page 407--bilous amended to bilious--"In certain individuals beer will induce a bilious attack." Page 435--supportting amended to supporting--"... which have been deprived of the supporting fat." Page 476--Sapato amended to Sapota (in table). Page 481--Horlick amended to Horlick's (milk powder entry in table). Page 519--The index entry for Organic acids originally followed Over-feeding of infants and children. It has been moved to the correct place. Page 523--The index entry for Utensils originally followed Under-feeding in infants and children. It has been moved to the correct place. 
36450	----	[Transcriber's Notes] This book is derived from a copy on the Internet Archive: psychotherapy00walsgoog/psychotherapy00walsgoog_djvu.txt> A publication contemporary to this book is "Mother's Remedies" by Thomas Jefferson Ritter. It contains hundreds of suggestions that hindsight shows to be purely "mental" in their effect. http://www.gutenberg.org/ebooks/17439 One of the author's favorite terms is "over-solicitous". The patient literally "worrys themselves sick" over trivial symptoms and makes serious cases worse than necessary. Most of his use of psychotherapy consists of informing, diverting and cheering the patient so that worry and its consequences are not piled on top of real or imagined disease. This book illustrates the general state of medicine in 1910. Psychotherapy was more important to medical care because so little was known of the complex physical mechanisms of the body. I particularly reacted to the discussion of hay fever because it plagued me for thirty years until experimental desensitization therapy successfully cured my case. Nonetheless, much of value has been lost with the decline of psychotherapy by the family physician. A personal relationship with the physician is often replaced with expensive impersonal technology that mostly tells what is not wrong. Many paragraphs have bold or italic titles. These are rendered by a extra blank line--a total of two blank lines. Obvious spelling or typographical errors have been corrected. Inconsistent spelling of names and inventive and alternative spelling is left as printed. The outline format of the book uses these conventions: Major Topics, [Upper Case title] Sections, [Upper Case, italic title] Chapters, Minor topics, denoted by bold face and an em-dash Topic subheads denoted by italics and and em-dash for example: SPECIAL PSYCHOTHERAPY SECTION VII. _Cardiotherapy_ Chapter III. Cardiac Neuroses Varieties.-- [Bold] _Palpitation_.-- [italic] During the transcription of this book Dr. Michael Stewart of the Mayo Clinic, Jacksonville, FL., diagnosed me with a retinal condition that had deprived me of the ability to read with my left eye. His skilled surgery corrected the condition. I dedicate this transcription to Dr. Stewart and the skilled and thoughtful staff of Mayo. [End Transcriber's Notes] PSYCHOTHERAPY PSYCHOTHERAPY INCLUDING THE HISTORY OF THE USE OF MENTAL INFLUENCE, DIRECTLY AND INDIRECTLY, IN HEALING AND THE PRINCIPLES FOR THE APPLICATION OF ENERGIES DERIVED FROM THE MIND TO THE TREATMENT OF DISEASE. BY JAMES J. WALSH, M.D.. Ph.D. DEAN AND PROFESSOR OF FUNCTIONAL NERVOUS DISEASE AND OF THE HISTORY OF MEDICINE AT FORDHAM UNIVERSITY SCHOOL OF MEDICINE, AND OF PHYSIOLOGICAL PSYCHOLOGY AT CATHEDRAL COLLEGE, NEW YORK; FELLOW OF NEW YORK ACADEMY OF MEDICINE; MEMBER A.M.A., A.A.A.S., NEW YORK STATE MEDICAL SOCIETY, GERMAN SOCIETY FOR THE HISTORY OF MEDICINE AND THE PHYSICAL SCIENCES, NEW ORLEANS PARISH MEDICAL SOCIETY, ST. LOUIS MEDICAL HISTORY CLUB, ETC. NEW YORK AND LONDON D. APPLETON AND COMPANY 1912 COPYRIGHT, 1912, BY D. APPLETON AND COMPANY Printed in New York, U. S. A. TO THE JESUITS TO WHOM THE AUTHOR OWES A HAPPY INTRODUCTION TO THE INTELLECTUAL LIFE AND CONSTANTLY RENEWED INSPIRATION IN HIS WORK THIS BOOK IS RESPECTFULLY AND AFFECTIONATELY DEDICATED {vii} PREFACE "Prefaces are a great waste of time," said Francis Bacon, "and, though they seem to proceed of modesty, they are bravery." In spite of this deterring expression of the Lord Chancellor, the author ventures to write a short _apologia pro libro suo_. Five years ago he began at Fordham University School of Medicine a series of lectures on Psychotherapy. This book consists of material gathered for these lectures. It will be found in many ways to partake more of the nature of a course of lectures than a true text-book. In this it follows French rather than English or American precedent. Its relation to lectures makes it more diffuse than the author would have wished, but this is offered as an explanation, not an excuse. Addressed to medical students and not specialists the language employed is as untechnical as possible, and, indeed, was meant as a rule to be such as young physicians might use to their patients for suggestion purposes. The historical portion is probably longer than some may deem necessary. The place of psychotherapy in the past seemed so important, however, and psychotherapeutics masqueraded under so many forms that an historical résumé of its many phases appeared the best kind of an introduction to a book which pleads for more extensive and more deliberate use of psychotherapy in our time. The historical portion was developed for the lectures on the history of medicine at Fordham and perhaps that fact helps to account for the space allotted to this section of the book. So far as the author knows, this is the first time in the history of medicine that an attempt has been made to write a text-book of the whole subject of psychotherapy. We have had many applications of psychotherapeutics to functional and organic nervous and mental disease and also indirectly to nutritional diseases; but no one apparently has attempted to systematize the application of psychotherapeutic principles, not only to functional diseases, but specifically to all the organic diseases. A chapter on the use of mental influence in anesthesia was, during the course of the preparation of this volume, written for Dr. Taylor Gwathmey's text-book on Anesthesia, which is to appear shortly (Appletons). No one knows better than the author how difficult is the subject and how liable to misunderstanding and abuse. He appreciates well, too, how almost hopeless it would be to make a perfectly satisfactory text-book of so large a subject at the first attempt. The present volume is founded, however, on considerable experience, on wide reading in the subject, and on much reflection on its problems. It is offered to those who are interested in the old new department of psychotherapy until a better one is available. The author's principal idea in the book has been to help students and practitioners of {viii} medicine to care for (_curare_) suffering men and women and not cases, to treat individual human beings, not compounds in which various chemical, physical and biological qualities have been observed, diligently enough and with noteworthy success, but incompletely as yet, and quite without the satisfying adequacy which it is to be hoped will result from future investigations. James J. Walsh. 110 West Seventy-fourth Street, New York City. {ix} CONTENTS PAGE Introduction 1 HISTORY OF PSYCHOTHERAPEUTICS SECTION I _Psychotherapy in the History of Medicine_ I. Great Physicians in Psychotherapy 7 II. Unconscious Psychotherapeutics 19 III. Genuine Remedies and Suggestive Exaggeration 25 IV. Signatures And Psychotherapy 35 V. Pseudo-science and Mental Healing 38 VI. Quackery and Mind Cures 46 VII. Nostrums and the Healing Power of Suggestion 53 VIII. Amulets, Talismans, Charms 60 IX. Deterrent Therapeutics 63 X. Influence of the Personality in Therapeutics 69 XI. Faith Cures 77 GENERAL PSYCHOTHERAPEUTICS SECTION II _General Considerations_ I. Influence of Mind on Body 84 II. Unfavorable Mental Influence 93 III. The Influence of Body on Mind 100 IV. The Mechanism of the Influence of Mind on Body 108 V. Brain Cells and Mental Operations 124 VI. Unconscious Cerebration 134 VII. Distant Mental Influence 140 VIII. Secondary Personality 147 IX. Hypnotism 151 SECTION III _The Individual Patient_ I. Psychotherapy and the Individual Patient 163 II. The Morning Hours 165 III. The Day's Work 171 IV. The Middle of the Day 179 V. The Leisure Hours 181 {x} SECTION IV _General Psychotherapeutics_ I. General Principles of Psychotherapy 186 SECTION V _Adjuvants and Disturbing Factors_ I. Suggestion 194 II. Exercise 198 III. Position 207 IV. Training 213 V. Occupation of Mind 218 VI. Diversion of Mind--Hobbies 224 VII. Habit 229 VIII. Pain 235 SPECIAL PSYCHOTHERAPY SECTION VI _The Digestive Tract_ I. Influence of Mind on Food Digestion 242 II. Indigestion and Unfavorable States of Mind 250 III. Psychic Treatment of Digestive Conditions 254 IV. Appetite 262 V. Constipation 268 VI. Neurotic Intestinal Affections 278 VII. Muco-Membranous Colitis 286 VIII. Obesity 290 IX. Weight and Good Feeling 297 X. Vague Abdominal Discomforts--Loose Kidney 302 SECTION VII _Cardiotherapy_ I. The Heart and Mental Influence 310 II. Diagnosis and Prognosis in Heart Disease 316 III. Cardiac Neuroses 321 IV. Cardiac Palpitation and Gastro-Intestinal Disturbance 328 V. Angina Pectoris 335 VI. Tachycardia 340 VII. Bradycardia 342 SECTION VIII _Respiratory Diseases_ I. Coughs and Colds 345 II. Tuberculosis 350 III. Neurotic Asthma and Cognate Conditions 364 IV. Dust Asthma--Seasonal Catarrh, Hay Fever 368 V. Dyspnea--Cat and Horse Asthma 373 {xi} CONTENTS xi SECTION IX _Psychotherapy in the Joint and Muscular System_ I. Painful Joint Conditions--Pseudo-Rheumatism 379 II. Old Injuries and So-called Rheumatism 387 III. Muscular Pains and Aches 389 IV. Occupation Muscle and Joint Pains 395 V. Painful Arm and Trunk Conditions 400 VI. Lumbago and Sciatica 402 VII. Painful Knee Conditions 409 VIII. Foot Troubles 413 IX. Arthritis Deformans 421 X. Coccygodynia 428 SECTION X _Gynecological Psychotherapy_ I. Mental Healing in Gynecology 430 II. Psychic States in Menstruation 434 III. Amenorrhea 437 IV. Dysmenorrhea 440 V. Menorrhagia 447 VI. The Menopause 450 SECTION XI _Psychotherapy in Obstetrics_ I. Suggestion in Obstetrics 453 II. Maternal Impressions 461 SECTION XII _Genito-Urinary Diseases_ I. Prostatism 468 II. Sexual Neuroses 472 III. Sexual Habits 482 SECTION XIII _Skin Diseases_ I. Psychotherapy in Skin Diseases 491 SECTION XIV _Diseases of Ductless Glands_ I. Diabetes 496 II. Graves' Disease 500 {xii} xii CONTENTS SECTION XV _Organic Nervous Diseases_ I. Psychotherapy of Organic Nervous Diseases 508 II. Cerebral Apoplexy 513 III. Locomotor Ataxia 524 IV. Paresis 530 V. Epilepsy and Pseudo-Epilepsy 534 VI. Paralysis Agitans 542 VII. Headache 546 SECTION XVI _Neuroses_ I. Nervous Weakness (Neurasthenia) 555 II. Chorea 561 III. Tics 564 IV. Stuttering, Ataxia in Talking, Walking, Writing, Etc. 570 V. Tremors 580 DISORDERS OF THE PSYCHE SECTION XVII _Psycho-Neuroses_ I. Psycho-Neuroses (Hysteria) 585 SECTION XVIII _Disorders of Mind_ I. Mental Incapacity (Psychasthenia) 597 II. Hallucinations 603 III. Dreads 612 IV. Heredity 627 V. Premonitions 634 VI. Periodical Depression 641 VII. Insomnia 651 VIII. Some Troubles of Sleep 663 IX. Dreams 669 X. Disorders of Memory 678 XI. Psychic Contagion 688 SECTION XIX _Disorders of Will_ I. Alcoholism 694 II. Drug Addictions 707 III. Suicide 713 IV. Grief 727 V. Doubting 732 VI. Responsibility and Will Power 738 {xiii} SECTION XX _Psychotherapy in Surgery_ I. Psychotherapy in Old-Time Surgery 746 II. Mental Influence Before Operation 749 III. Mental Influence and Anesthesia 753 IV. Mental Influence After Operation 759 APPENDICES I. Illusions 766 II. Religion and Psychotherapy 776 INDEX 781 {xiv} {xv} LIST OF ILLUSTRATIONS FIG. PAGE The Temple of Epidaurus as a health resort Facing page 9 1.--Expressions of the mouth 102 2.--Cortex of human brain illustrating complexity of the systems and plexuses of nerve fibers 109 3.--Small and medium-sized pyramidal cells of the visual cortex of a child twenty days old 110 4.--Series of sections showing the fine nerve endings and branchings of the first and second layer of the visual cortex of a child fifteen days old. 111 5.--First, second and third layer of the anterior central convolution of the brain of a child one month old 112 6.--Layers of the posterior central or ascending parietal convolution of a new-born child 112 7.--Diagram of cells of cerebral cortex 113 8.--Scheme of lower motor neuron 114 9.--Scheme of the visual conduction paths 115 10.--Schematic frontal section through the occipital lobe illustrating manifold connections in a single lobe 116 11.--Isolated cell from human spinal cord 117 12.--Neuron from the optic lobe of the embryo chick 118 13.--Deep layer of giant pyramidal cells of the posterior central or ascending parietal convolution of a child thirty days old 119 14.--Pyramidal cell of cerebral cortex of mouse 119 15.--Neuroglia cells of the fascia dentata, in the new-born rabbit 121 16.--Neuroglia cell from the subcortical layer of the cerebrum from which two processes go to a blood vessel 122 17.--Neuroglia cells from the spinal cord 122 18.--An artery from the cerebral cortex 125 19.--Neuroglia cells of the superficial layers of the brain from an infant aged two months 126 20.--Complexity of cell of the central nervous system 131 21.--Section through the cortex of the gyrus occipitalis superior 132 22.--Motor cell of ventral horn of spinal cord from the human fetus 133 23.--Normal diaphragm curve in normal breathing 577 24.--Curve in diaphragm before and during talking by a stutterer 577 25.--Illusion of dual vision 615 26.--Illusion of dual vision 767 27.--Binocular vision 767 28.--Binocular vision 767 29.--The Müller-Lyer lines 768 30.--Illusions of size 769 31.--Illusion of filled space (interrupted vision) 769 32.--Illusions of size and linear continuity 770 33.--Poggendorf's displacement of oblique lines 771 34.--Zöllner's distortion of parallel lines 772 {1} PSYCHOTHERAPY INTRODUCTION To physicians who are students not alone of the manifestations of disease but also of the workings of human nature, there are few chapters in the history of medicine more interesting than those which record the welcome by each generation of the supposed advances in the treatment of disease. Each generation announced its cures for diseases, provided its remedies to relieve symptoms, and invented methods of treatment that seemed to put off the inevitable tendency toward dissolution. Yet few of these inventions and discoveries maintain their early reputations, and succeeding generations invariably abandon most of this supposed medical progress in favor of ideas of their own, which later suffer a like fate. Plausible theories have not been lacking to support the successive remedies and methods of treatment, but the general acceptance of them was always founded far less upon theory than upon actual observation of their supposed efficacy. Certain remedies were given and the patients began to improve. Patients who did not have the remedies continued to suffer, and sometimes the course of their disease led to a fatal termination. Even with the best remedies death sometimes took place, but that was easily accounted for on the ground that the disease had secured so firm a hold that it could not be dislodged, even by a good remedy. The connection of cause and effect between the administration of the remedy and the improvement and eventual cure of the patient seemed to be demonstrated. The archives of old-time medicine disprove the notion that clinical learning and teaching--that is, observation and demonstration at the bedside--were not part of medical education until quite modern times. The medical books of the thirteenth, fourteenth and fifteenth centuries are full of descriptions of actual cases, while, over a millenium before, one of Martial's epigrams tells of a patient who dreaded the coming of his physician because he brought with him so many students, whose cold hands gave chills to the poor victim. Coincidence and Consequence.--In spite of the opportunities for careful observation thus afforded and the facilities for training clinical observers in medicine, many remedies came into vogue, were enthusiastically applied, and then, after a time, went out of use and were heard of no more. Sometimes they were subsequently revived and had even a greater vogue than when originally brought out. But most of these remedies eventually went forever into the lumber room of disused treatments. Of the many thousands of remedies which had the approval and the praise of past generations, two score at most hold a place in the pharmacopeia of to-day. There are many reasons for this initial success and eventual failure; but the most important explanation lies not so much in reason as in coincidence. In the majority of human ills there is a definite tendency to get better, and almost anything that is given to the patient will be followed by relief and {2} improvement. The recovery is not, however, on account of the remedy, but occurs only after a definite succession of events that would have taken place either with or without the remedy. Mental Influence.--What the old physicians did not, as a rule, appreciate, or at least failed to value at its true significance, was the effect upon the patient's mind of the taking of a remedy. Because of the confidence with which it was given, the patient, having full faith in the physician who gave it, became impressed with the idea that now he must get well. The very presence of the physician and his assurance that the illness was not serious and that many symptoms that were sources of dread to the patient were only concomitant conditions of the ailment, naturally to be expected under the circumstances, relieved the patient from worry, and so gave his nervous energy a chance to exert itself in bringing about improvement. In other words, the suggestive elements of the presence of the physician and the taking of his remedy were important therapeutic factors which enabled what was an absolutely inefficient remedy, as the event proved when closer observations of it had been made, to relieve even serious symptoms, or helped a weak remedy to accomplish good results by strengthening the patient's resistive vitality. In recent years we have come to study much more closely this suggestive element and to appreciate better its true value. Suggestion has always been an important factor in therapeutics, but has been used indeliberately and indirectly rather than with careful forethought. Not that the great thinkers in medicine have not known its value and have not used it deliberately on appropriate occasions, but that the profession generally has been so much occupied with the merely material means of curing that practitioners have not realized the influence for good of the psychotherapeutic factors they were unconsciously employing. The history of the phases of psychotherapy brings out clearly how much it has always meant in the curing of human ills. Constancy of Psychotherapy in Medicine.--Though we are prone to think of it as coming to attention in our time, psychotherapy has played an important role in every phase of the history of medicine. It has always been at work, though usually under other names, and has been effectively used without conscious direction. Germs and their pernicious activity were not recognized before our time, yet many definite precautions against them, such as cooking of food and the keeping of perishable goods on ice, which now seem to be the direct result of our knowledge of bacteriology, were commonly practiced. The influence of the mind on the body exerted itself quite apart from man's recognition of its place or appreciation of its power. When employed unconsciously it was in many ways even more effective than it will be when a consciousness of the means by which it is applied becomes more general. For most people are unwilling to confess that their minds exercise as much influence as now proves to be the case, and that over-solicitude means so much in inhibiting the curative powers of nature, and that it is this which is favorably affected by psychotherapy. The great physicians employed psychotherapy very commonly, and on that account many of their disciples were inclined to think that they were neglectful of medication and other remedial measures. At all times physicians have had to be large-minded and have had to recognize the limitations of medicine in {3} their own time, to turn to other agents and to appreciate how much their own influence on the patient and that of the patient on himself meant for the relief of symptoms and the increase of resistive vitality. Some of the phases of indeliberate psychotherapy, however, are even more interesting than this chapter of the history of genuine and deliberate psycho-therapeutics. Not a few of the remedies recommended, even by distinguished physicians, were utterly inert, yet accomplished good through their effect upon the patient's mind. If we were to omit all reference to certain favorite prescriptions that passed down from generation to generation, sometimes for centuries, yet eventually proved to be quite inefficient for the purpose for which they were employed, what a large lacuna would be left in the history of medical treatment! Galen's _theriac_ is a typical example of this. Still more strikingly the role of psychotherapy is seen in the many remedies that were recommended at various times for such self-limited diseases as erysipelas, ordinary coughs and colds, pneumonia and typhoid fever. Anything that was administered just before the change for the better came in these diseases, or that was persistently taken until that change came, was proclaimed as curative. An even more interesting chapter in the positive history of psychotherapy is that which shows how the value of genuine remedies was exaggerated by suggestion, and how these remedies became therapeutic fads, and sometimes almost seemed to be cure-alls. What a large place antimony holds in medical history, though it is now entirely discredited! How beneficent has venesection seemed, though it is now frankly confessed that it has but a narrow usefulness for a very circumscribed set of ills! Calomel in large doses has a history very like that of antimony. Alcohol in various forms, now so strikingly losing its hold in therapeutics, must also be placed in this category. Psychotherapy has perhaps had its most fruitful field of potency in connection with discoveries in the physical sciences. Whenever a discovery has been made in any science, an application of it to medicine has been mooted by some fertile mind, though as a rule it eventually proved to have no place in medicine. One might ordinarily expect that the suggestion would be latent only when the discovery was in one of the sciences allied to medicine, but this relation has not been necessary. Discoveries in astronomy even, in light, in electricity, in every department of physical science, have each been given their opportunity to affect patients' minds favorably, and have succeeded. Irregular Phases of Psychotherapy.--The quack has always been a psycho-therapeutist _par excellence_. His main stock in trade has been his knowledge of men and his power to convince them that he was able to do them good, so that he could tap all the sources of energy that were in the patient, some of them quite latent, yet of great efficiency. Often what the quack and the nostrum vender did for their patients was calculated to do harm rather than good, yet the mental energy aroused by the appeal to the patients' minds was sufficient not only to neutralize the evil, but to release curative powers that otherwise would not have been called out. The advertisements of the nostrum maker have proved especially effective, and printer's ink, properly administered, has been a most potent remedy. Drug Therapeutics.--Many of the newer phases of mental healing pretend to do away with drugs. Nothing is farther from my purpose than to condemn drugs: I am simply pointing out how much supposed drug efficacy has been {4} due to the mental influence on the patient of the suggestion that went with the drugs. There has been no thought at all of pushing drugs out of the extremely valuable place they occupy in medicine, for I yield to no one in my thorough conviction of their usefulness. But the efficacious element in the administration of many drugs has been entirely the confidence of the physician in them, which confidence was communicated to the patient's mind. Undoubtedly many highly recommended drugs have in themselves tended to do harm rather than good, and have been useful only because of this psycho-therapeutic element. Dr. Oliver Wendell Holmes' famous expression, that if all the drugs that had ever been used had been thrown into the sea instead of put into patients' bodies the human race might have been the better for it, should not be taken to mean that a great many drugs are not efficacious. Above all, it leaves out the most important consideration, that patients, while taking drugs that are either inert or at times even slightly harmful, have had their mental attitude towards themselves and their ills so favorably modified by the repeated suggestion that the result has been distinctly beneficial. There are probably two score of drugs that are simply invaluable--magnificent auxiliaries in times of physical and mental distress. To realize and appreciate the place of these drugs, their limitations, how they should be administered, and what they can do under varying circumstances, has taken us centuries. When to these drugs there is intelligently attached the influence that psychotherapy has over the patient, their efficacy is probably doubled. Without that influence nature often works against the drug and lowers its efficiency. That is the reason why physicians, when themselves patients, do not respond well to drugs. Familiarity has bred contempt for some of the old-fashioned remedies, but the contempt that comes from familiarity is often quite undeserved, and many of the things that we thus undervalue because of accustomedness have a power that should be respected. People in a dynamite factory become so familiar with danger as to despise it at times, but that does not lessen the energy of the dynamite when occasion arises. When the physician himself is ill he is likely to remember his failures with drugs rather than his successes. That is, however, only the tendency of human nature to a certain pessimistic outlook where we ourselves are concerned. There is another class in whom familiarity with drugs has become a serious matter. They are the patients who have made the rounds of physicians, have learned to read prescriptions, have looked up the significance of the various remedies that they have seen prescribed, have heard doctors talk about them, and remember only what is depreciatory, and who critically examine a prescription and conclude that the remedies recommended are not likely to do them good. Every physician knows the hopeless condition such patients are in. Mental attitude will greatly help drugs, and it can utterly undo the effect of all drugs except those which have certain drastic mechanical effects. Drug failure in these cases is another illustration of how much psychotherapy means in connection with drug treatment. Not only is there no intent, then, to lessen respect for drugs in this textbook of psychotherapeutics, but the one thing that the author would like to emphasize is the necessity for giving drugs in sufficient doses. Recommendations in text-books of medicine are often vague in their indications as to dosage, and surprisingly small doses are, in consequence, sometimes prescribed. {5} Practically the only remedial element of such small doses is the mental effect on the patient, whereas a combination of pharmaceutic and psychotherapeutic factors would be much more efficacious. It is not unusual to find that the patient who is supposed to be taking nux vomica as an appetizer or a muscle tonic, or in order to produce heart equilibrium in the cardiac neuroses, is getting five drops, two and a half minims, three times a day, when he should be getting at least twenty drops with the same frequency. I have known a physician to prescribe ten grains of bromid where thirty to sixty grains should have been prescribed, and such valuable pharmaceutic materials as bismuth and pepsin are often given in doses so small that they preclude all possibility of benefit except by mental influence. With therapeutic nihilism or skepticism of the power of drugs I have no sympathy. As a teacher of medicine I have for years emphasized the necessity of the use not of conventional doses of drugs for every patient, but of doses proportioned to the body weight. It seems to me quite absurd to give the same amount of a drug to a woman who weighs a hundred pounds and to a man who weighs two hundred and fifty pounds of solid muscular tissue. I believe in using drugs well up to their physiological effects if the drugs are really indicated. With regard to other modes of treatment the same thing is true. Where they are indicated, balneo-therapy, hydro-therapy, mechano-therapy, electro-therapy, massage, and all the forms of external treatment, should be used rationally and not merely conventionally. The individual and not his affection must be treated. In all of these methods there is a psychotherapeutic element, and for the benefit of the patient this, too, must be recognized and used to its fullest extent. Supposed Novelties in Mind Healing.--We hear much of mental healing, of absent treatment, of various phases of suggestion, and of the marvelous therapeutic efficiency of complete denial of the existence of evil, and sometimes we wonder whether all these things are not offshoots of our recent growth in the knowledge of psychology. It is possible, however, to find, masquerading under the head of the efficacy of nostrums in the past, the equivalents for all the activities of mental healing of the present. It all depends on what is the scientific fad of the hour. If it is electricity, then some mode of electrical treatment serves the purpose of suggesting cure, and relief of symptoms follows. If drug treatment of any particular kind is attracting much attention, then the suggestion is most effective that is founded on this basis. Perkins' tractors or the Leyden jar are effective at one time, radium or the X-rays at another, sarsaparilla or dilute alcohol at another, while a generation that is much interested in psychology may find, as ours does to a noteworthy degree, quite sufficient favorable suggestion for the cure of many ills in purely psychic influences, either direct or indirect, deliberate or unconscious. Men and women do not change, their ills are about the same, and except for certain definite scientific remedies it is only the superficial mode of treatment that differs very much. Psychotherapy has always been an important element in most of the therapeutics of history. With so much accomplished in the past by indirection, there can be no doubt but that important advances in psychotherapeutics must result from the extension of its deliberate use. We have not yet reached a point in our knowledge of the mode of the {6} influence of the mind on the body that will enable us to treat this large subject in a scientific manner. What has been written is set down rather as suggestive than conclusive. There is almost nothing that the human mind cannot do, its power ranging from the ability to delay death for hours or even days to causing sudden or unlooked for death under strong emotional strain. But we are as yet without definite data as to the possibilities of the immense power for good, and also for ill, that lie unrevealed in this domain. Anything that makes for observations by a large body of trained observers in a large number of cases will almost surely serve to bring about a development of this subject of valuable practical application. Psychotherapy is open to large abuse. It will happen that men who are not trained in diagnosis will occasionally try to use psychotherapeutic means when what is needed is the knife, the actual cautery, a good purge, some strong drug, or other efficient remedy whose value has been demonstrated and which any trained physician can use. It will also happen that men who lack tact will occasionally disturb patients' minds still further by what they say to them in a mistaken attempt at psychotherapy, and will sometimes suggest other symptoms and make sufferers worse by their clumsy attempts to remove symptoms that are already present. Every good thing, however, is open to the same objection. Even good food is abused. The use of drugs has been so abused that the abuse has done much to discredit medicine at many periods. There is a Latin proverb which says: "From the abuse of a thing no argument against its use can be drawn." We cannot prevent liability to abuse, and psychotherapy is sure to meet that fate. It has been abused in the past, and is abused now, and always will be abused, but formal study of psychotherapy and its deliberate employment will do more than anything else to limit the inevitable abuse. If its place in history and in medicine is definitely set forth, its problems squarely faced and their solutions definitely suggested, it is much less likely to be misused. At least, then, the whole subject is open for free and frank discussion and for such additions and subtractions as may make this department of therapeutics as important, or at least in a measure as valuable, as climato-therapy or balneo-therapy or mechano-therapy or electro-therapy. The development of each of these subjects has proved helpful. It is true that each specialist has, in the eyes of his colleagues in general practice, exaggerated the significance of his own department. This is true in all specialties, however, and psychotherapy deserves quite as much as any of the subjects we have mentioned to have a place among the text-books of medicine; and so this one is committed to the judgment of clinical observers. Long ago Horace said: Si quid novisti rectius his candidus imperti Si non his utere mecum. {7} HISTORY OF PSYCHOTHERAPEUTICS SECTION I _PSYCHOTHERAPY IN THE HISTORY OP MEDICINE_ CHAPTER I GREAT PHYSICIANS IN PSYCHOTHERAPY "The real physician is the one who cures: the observation which does not touch the art of healing is not that of a physician, it is that of a naturalist." Psychotherapy is as old as the history of medicine and may be traced to the earliest ages. The great physicians of all time have recognized its value, have used it themselves and commended its use to their disciples, though realizing its mysterious side and appreciating its limitations. FIRST PHYSICIAN The first physician of whom we have any record was I-em-Hetep, who lived in the reign of King Tcsher of the third dynasty of Egypt, probably before 4000 B. C. Among his titles, besides that of Master of Secrets, was Bringer of Peace. He was looked up to as one who, when not able to cure physical ailments, did succeed in consoling and reassuring patients so as to make their condition much more bearable. Like others of the great early physicians, he was after his death worshiped as a god, a tribute which probably signifies that those who had been benefited by his ministrations felt that he must have been more than mortal. The extent of the Egyptians' admiration for him will be appreciated from the fact that the step pyramid at Sakkara is said to have been built in his honor, though, as a rule, pyramids were erected only to honor kings or the very highest nobility. The extant statue of I-em-Hetep shows a placid-looking man with an air of beneficent wisdom, seated with a scroll on his knees. It produces the distinct impression, as may be seen from the illustration, that his patients must have trusted him thoroughly, since this is the memory of his personality that was transmitted to posterity. While he came to be looked upon as the medical divinity of the Egyptians, he was never represented with a beard, which is the token of the gods, or of mortals who have been really apotheosized. Evidently his devotees felt that it was the divine in his humanity which was the most prominent feature that they wished to honor. Among the Greeks AEsculapius, who had been merely a successful physician, came to be honored as a deity. When we recall the condition of therapeutics at that {8} time, it is evident that man's appreciation of his power to console, even though he might not be able to heal, of his influence over men's minds in the midst of their sufferings, and the confidence that his presence inspired, were the real sources of their grateful recognition. PSYCHOTHERAPY IN EGYPT Among the Egyptians the first great development of medicine came among the priests. The two professions, the medical and priesthood, were one, and the temples were the hospitals of the time. We have stories of people traveling long distances to certain temples in the early days of Egypt and also of Greece. Often the sick slept in the temples and dreamed of ways by which they would be cured. The stories make one feel that somehow the sleep which came over them was not entirely natural and spontaneous, but must have been something like hypnotic sleep. As for the dreams, the suggestions of modern time given in the hypnotic condition seem to be the best indication that we have of what happened in those old days. Certain it is that the persuasion of the patient that he would get better, the influence of the diversion of mind consequent upon his journey and the regulation of life under new circumstances in the temple, with the repeated suggestions of the priests and of their various remedial measures, as well as those due to the fact that other patients around him were improving, all plainly show the place of psychotherapy at this time. Much of the old-time therapy was in association with dreams supposed to have been in some way inspired. This was true at Epidaurus, at Kos, at Rome, at Lebene, at Athens, and at every place we know of where cures were worked in the olden times. To the modern mind it seems impossible that dreams should come so apropos unless they were in some way directed. The only explanation seems to be the use of suggestion, with the probable production of sleep resembling our modern hypnotic trance. Apparently the patient's attention was little directed to the origin of the suggestions received, but he remembered and benefited by them. The most explicit testimony that we have to the antiquity of psychotherapeutics and to the employment of the influence of the minds of patients over their ailments in the olden time is in Pinel's "Nosographie philosophique" and in his "Traité médico-philosophique sur l'alienation mentale." Pinel himself will be remembered as the great French psychiatrist who, confident that he could control most of them by mental influence, first dared to strike the chains from the insane in the asylums of Paris, at the end of the eighteenth century, when for more than a century they had been treated more barbarously than ever before in history. The passage makes clear that the writer himself, over a hundred years ago, was persuaded of the significance of the patient's mental attitude and of the value of mental treatment for many nervous and mental diseases: An intimate acquaintance with human nature and with the character in general of melancholics must always point out the urgent necessity of forcibly agitating the system, of interrupting the chain of their gloomy ideas, and of engaging their interest by powerful and continuous impressions on their external senses. Wise regulations of this nature are considered as having constituted in part the celebrity and utility of the priesthood of ancient Egypt. Efforts of industry and of art, scenes of magnificence and of grandeur, the varied pleasures of sense, and {9} the imposing influences of a pompous and mysterious superstition, were perhaps never devoted to a more laudable purpose. At both extremities of ancient Egypt, a country which was at that time exceedingly populous and flourishing, were temples dedicated to Saturn, whither melancholics resorted in crowds in quest of relief. The priests, taking advantage of their credulous confidence, ascribed to miraculous powers the effects of natural means exclusively. Games and recreations of all kinds were instituted in these temples. Beautiful paintings and images were everywhere exposed to public view. The most enchanting songs, and sounds the most melodious "took prisoner the captive sense." Flowery gardens and groves, disposed with taste and art, invited them to refreshment and salubrious exercise. Gaily decorated boats sometimes transported them to breathe, amidst rural concerts, the pure breezes of the Nile. Sometimes they were conveyed to its verdant Isles, where, under the symbols of some guardian deity, new and ingeniously contrived entertainments were prepared for their reception. Every moment was devoted to some pleasurable occupation, or rather a system of diversified amusements, enhanced and sanctioned by superstition. An appropriate and scrupulously observed regimen, repeated excursions to the holy places, preconcerted fêtes at different stages to excite and keep up their interest on the road, with every other advantage of a similar nature that the experienced priesthood could invent or command, were, in no small degree, calculated to suspend the influence of pain, to calm the inquietudes of a morbid mind, and to operate salutary changes in the various functions of the system. [Illustration: The Temple at Epidaurus as a Health Resort] This gives some slight idea of the magnificent arrangement of this famous health resort of the Greeks in which every possible care was taken to influence the mind of the patient favorably and bring about his cure. The buildings of the Hieron or medical institution of Epidaurus were beautifully situated about six miles from the town of Epidaurus in picturesque scenery and the most healthful surroundings. There were a series of bathing houses for hydropathy. The abatons, lofty and airy sleeping chambers with their southern sides and open colonnade, are singularly like the open balconies of our tuberculosis sanatoria. Every occupation of mind was provided. There was a theatre that would seat over 10,000 people. Here the great classic Greek plays were given with fullest effect. There was a stadium seating about 12,000 people in which athletic events were witnessed, finally there was a hippodrome for alt sorts of amusements in which animals shared. Then there were the walks through the country, sheltered paths around the grounds for inclement weather, even tunnels for passage from one building to another and all the influence of religion, of suggestion, of contact with cultured priests thoroughly accustomed to dealing with all manner of patients. No wonder the place was popular and many cures effected. A, South Propylaea; B, Gymnasium; C, Temple of Esculapius; DD, East and West Abatons (temple enclosures); E, Pholos; F, Temple of Artemis; G, Grove; H, Small Altar; I, Large Alter; J, South Boundary; K, Square (building); L, Baths of Esculapius; M, Gymnasium and Hostel; N, Four Quadrangles (for promenade and exercise); O, Roman Building; P, Roman Bath; Q, Portico of Cotys; R, Northeastern Colonnade; S, Northeastern Quadrangle; T, Temple of Aphrodite (?); U, Northern Propylaea, on the Road to Epidaurus; V, Roman Building; W, Northern Boundary; X, Stadium; Y, Goal or Starting Line; Z, Tunnel between Temple and Stadium. (Caton.) [End Illustration] There are other phases of Egyptian medicine which serve to show us how early many of the psychological ideas that we now are trying to adopt and adapt in medicine had come to the thinkers in medicine of long ago. There is, for instance, now in the Berlin museum an interesting papyrus of the Middle Kingdom, the date of which is about 2500 B. C, in which there are many modern ideas. It is a dialogue which attempts the justification of suicide. The principal speaker, a man weary of life, has made up his mind to suicide, but is hesitant. The others who speak in the dialogue are his _secondary personalities_. The Egyptians considered that there were several of these interior persons with whom the man himself might have communication. A man could play draughts with his _ba_ somewhat as we play solitaire. He could talk to and exchange gifts with his _ka_. He could argue and remain at variance, but more often come to an agreement, with his _khou_. This last was his luminous immortal _ego_, which, according to the then generally received Egyptian conception, formed a complete and independent personality. The whole scene thus outlined is typically modern in certain phases of its psychology, and presents the only known treatment for the tendency to suicide. While we have but this instance, there seems no doubt that the same system of persuasion must have been employed for the cure of other mental conditions than that which predisposes to suicide. What is described in our quotation from Pinel as the most ancient form of psychotherapy has all down the centuries been the rule of life for patients at institutions similar to those of Egypt. We know more of Greece than of other countries; there the shrines of AEsculapius were in many ways what we now call sanatoria. They were spacious buildings pleasantly situated, the hours of rising and of rest were definitely regulated, the patients' minds were occupied with the details of the cure, they met pleasant companions from distant places, they had all the advantages of diversion of mind, simple diet, long hours in the open air and abundance of rest away from the ordinary worries of life. Besides, there had usually been some weeks or months of {10} preparation during a lengthy journey and all the diversion of mind which that implies. No wonder that these institutions acquired a reputation for cures of symptoms which the physician had been unable to accomplish while the patient was at home in the midst of his daily cares and worries of life. The temples in Egypt, in Assyria, in Greece, were much like the health institutions--"cure houses," as the expressive German phrase calls them--of our day. Pictures of the temple of AEsculapius at Epidaurus show a magnificent building with beautiful grounds, ample bathing facilities, and evidently many opportunities for a quiet, easy life far from the worries and bustle of the world and with everything that would suggest to the patient that he must get well. This phase of psychotherapy in the olden time is not only interesting in itself, but furnishes a valuable commentary on corresponding modern institutions, since it shows that it is not so much the physical influences, which have differed markedly at different periods, as the mental attitude so constantly influenced at these institutions which was the real therapeutic factor. Now our sanatoria are nearly all founded on some special principle of therapeutics. Some of them have dietetic fads and no food out of which the life has been cooked is eaten. Some of them are absolutely vegetarian. Some of them depend on wonderful springs in their neighborhoods, others on certain forms of exercise, still others give the rest cure. All succeed in relieving many symptoms. No one who has analyzed the cures effected will think for a moment that it is the special therapeutic fad of the institution that accomplishes all the good done for patients suffering from so many different complaints. Similar ills often are affected quite differently, and, while some are relieved, others are not. Those who fail to be cured at one will, however, often be relieved at another. It depends on how much influence of mind is secured over the patient and how much diversion from thoughts of self is provided. MIND HEALING IN GREECE When Greece awoke to the great literary and scientific discussion of human thought that gave us such philosophic and scientific thinkers as Hippocrates, Plato and Aristotle, then psychotherapy, in the formal sense of caring for the mind of the patient as well as for his body, came to be explicitly recognized as having therapeutic value. Hippocrates insisted that medicine was an art rather than a science, that personality had much to do with it, and that the patient must be optimistically influenced in every way. The first of his aphorisms is well known, but few realize all of its significance. Hippocrates declares that "life is short and art long, the occasion fleeting, experience fallacious and judgment difficult. The physician must not only be prepared to do what is right himself, _but also to make the patient, the attendants and externals coöperate."_ No one emphasized more than he the necessity for differentiating the individual patient, and to him we owe, in foundation at least, the aphorism that it is more important to know what sort of an individual has a disease than what sort of a disease the individual has, for the chances of cure greatly depend on favorable individuality. Perhaps Hippocrates' most striking direct contribution to psychotherapy is his aphorism with regard to pain. He said: "Of two pains occurring together in different parts of the body, the stronger weakens the other." When {11} the attention is distracted from pain, then it is lessened. Of two pains, then, only the one that attracts the most attention is much felt, and, if a slight pain is succeeded by a severe pain in another part of the body, the lesser pain will apparently become trivial, or, indeed, not be felt at all. In Plato we find the direct philosophic expression of the value of psychotherapy. There had been during the preceding century a great increase in information with regard to the facts of physical nature, and especially the sciences relating to the human body, and so men had come, as they are prone to at such eras--our own, for instance--to think too much of the body and too little of the mind that rules it. Accordingly, we have from Plato a deliberate, emphatic assertion of this great truth under circumstances which make us realize how keenly he appreciated its significance for the art of medicine and for humanity. Professor Osier, in his address, "Physic and Physicians as Depicted in Plato," [Footnote 1] tells a story which shows clearly how much the great Greek philosopher appreciated the place of psychotherapy. [Footnote 1: "AEquanimitas and Other Addresses."] Charmides had been complaining of a headache, and Critias had asked Socrates to make believe that he could cure him of it. Socrates said that he had a charm which he had learnt, when serving with the army, of one of the physicians of the Thracian king. Zamolxis. This physician had told Socrates that the cure of a part should not be attempted without treatment of the whole, and, also, that no attempt should be made to cure the body without the soul, "and, therefore, if the head and body are to be well, you must begin by curing the mind; that is the first thing. And he who taught me the cure and the charm added a special direction. 'Let no one,' he said, 'persuade you to cure the head until he has first given you his soul to be cured. _For this,'_ he said, _'is the great error of our day in the treatment of the human body, that physicians separate the soul from the body._'" Because it anticipates so much that is thought to be recent in the treatment of certain affections this paragraph is interesting from many standpoints. Headache is typically one of the ills that in the modern time has often been cured by suggestion. Critias knew how much confidence Charmides had in Socrates, whom he looked upon as his master, and that, therefore, Socrates' declaration of his power to cure would probably be sufficient to relieve his disciple. Critias shrewdly suggests, however, that Socrates possessed a charm which he had learned from a distinguished royal physician. Cures in the modern time of any kind are likely to be much more effective if they come from a distance and, above all, if they have some connection with royalty, or have been tried with favorable results upon distinguished personages. ALEXANDRIAN PSYCHOTHERAPY When the center of interest in Greek medicine was transferred from Greece itself to Egypt, and the Alexandrian school represented what was best in medical thinking and investigation, we find evidence once more of wise physicians realizing the influence of the mind on the body and of what seemed to physicians of lesser experience the cure of physical ills by mental means. One of the most distinguished physicians of all time is Erasistratos, who, with Herophilus, made the fame of the great medical school at Alexandria, {12} the first university medical school in the world's history. Both practiced dissection with assiduity, and, while it is Herophilus' name that is associated with the _torcular_ within the skull, and it was he who gave the name _calamus scriptorius_ to certain appearances in the fourth ventricle, and otherwise stamped his personality on the study of the brain, it is to Erasistratos that we have to turn for a typical example of the mental physician. Erasistratos, about 300 B. C, recognized the valves of the heart, gave them the names tricuspid and sigmoid, and, like his great colleague, studied particularly the nervous system. He seems to have distinguished the nerves of motion from those of sensation, recognized their different functions and the different directions in which they carried impulses, and thought the brain the most important organ in the body. The story is told that he was summoned in consultation to see the son of Seleukos, surnamed Nikator, the Macedonian general of Alexander the Great, who became ruler of Babylonia. The illness of this son, Antiochos, had baffled the skill of the court physicians. While Erasistratos was feeling his patient's pulse, the stepmother of the young prince entered the room. She, the second wife of his father, was young and handsome, and Erasistratos noted that there was great perturbation of the pulse as soon as the stepmother came in. He correctly surmised that the young man was in love with the lady and that his illness had been occasioned by the feeling that his love was hopeless. The very sharing of his secret seems to have started the young man's cure, and Erasistratos' wisdom and medical skill became a proverb throughout the East. PSYCHOTHERAPY AT ROME Galen.--Galen, whom we are prone to think of as a Latin because so much of his work was done at Rome, but whose works have come to us in Greek, and who was a disciple of the Greek school of medicine, brought up under Greek influence in his native town of Pergamos, re-echoed Hippocrates' expressions as to the necessity for securing the patient's confidence and setting his mind at ease. The story in the "Arabian Nights" of his experience with the quack, which is known to most people, shows clearly how the place of mental influence in the relief of human ills must have been brought home to him. For nearly fifteen centuries his works continued to be the most read of medical documents. Nine tenths of all the physicians of education and influence, confidently looking to him as their master, kept copies of his works constantly near them, and turned to them for medical guidance as they would to the Bible for spiritual aid. The book of Galen which is usually placed first among his collected works shows how much more important is the mind than the body for human happiness, and insists on mental interests as making life worth while. In it he describes the good physician, and says that to be a good physician a man must also be a good philosopher. When he comes to talk of the different sects in medicine--for even in his time there were groups of men who founded their medical practice on very different principles--he points out that the members of the different medical sects, while all employing practically the same remedies, do so on quite different principles, and yet get about the same {13} results. This concept comes as near to being a conscious reflection as to the place that the patient's mental reaction had in therapeutics as might well be expected at that early date. Alexander of Tralles.--After Galen, medicine suffered an eclipse because the Romans became too devoted to luxury to permit of its development, and later the descent of the barbarians from the North disturbed silence and culture. In spite of the disturbance, however, there is evidence during the succeeding centuries of the deliberate use of mental influence and even of direct suggestion in the cure of disease. Alexander of Tralles (sixth century A. D.) was not judiciously critical in his selection of remedies. Often he has quite ridiculous therapeutic suggestions, and yet we have at least two stories with regard to him which clearly indicate his employment of mental influence. One of his patients is said to have been suffering from the delusion that his head had been cut off by order of the tyrant, but he was cured as soon as the doctor hit on the interesting expedient of making him wear a leaden hat, which eradicated his delusion and made him think his head had been restored. It is also in Alexander Trallianus, as he is sometimes called, that we have the original of the story which has been often told, many writers giving it as an experience of their own. A woman was sure that she had swallowed a snake, and that it continued to exist in her stomach, devouring much of her food and causing acute pain whenever large quantities of food were not provided for it. All sorts of remedies had been tried without result. At last Alexander gave her an emetic and then slipped into the basin into which she was vomiting a snake resembling as closely as possible that which she thought she had swallowed. The ruse effected a complete cure. Usually in latter-day variants of this story the cure is only temporary, for the patient after a time has the same symptoms as before and then is sure that during the time of its residence in the stomach the snake has given birth to young. Paul of AEgina.--In the seventh century Paul of AEgina collected all that had been written on insanity by physicians of olden times, and many of his directions and prescriptions for treatment show that he appreciated the value of mental influence. He recommends that those who are suffering from mental disease should be placed in a quiet institution, should be given baths, and that an important portion of the treatment should consist of mental recreations. ARABIAN MENTAL MEDICINE The Arabian physicians who succeeded to the traditions of Greek medicine preserved also those relating to psychotherapy. Rhazes, the first of the great Arabian physicians, has a number of aphorisms that show his interest in and recognition of the value of mental healing. He insisted that "doctors ought to console their patients even though the signs of death are impending. For the bodies of men follow their spirits." He believed that the most important function of the physician was "to strengthen the natural vitality for, if you add to that you will remove a great many ills, but if you lessen it by the drugs which you employ you add to the patient's danger." "Truth in medicine," he said, "is a goal which cannot be absolutely reached, and the art of {14} healing, as it is described in books, is far beneath the practical experience of a skillful, thoughtful physician." Manifestly he realized the importance of the influence of the physician over the individual patient. His greatest successor among the Arab physicians, Avicenna (eleventh century), "the Hippocrates and the Galen of the Arabians," as Whewell called him, has some striking tributes to what he recognized as the influence of the mind on the body. He appreciated that not only might the mind heal or injure its own body, but that it might influence other bodies, through their minds, for weal or woe. He says: "The imagination of man can act not only on his own body, but even on other and very distinct bodies. It can fascinate and modify them, make them ill or restore them to health." In this, of course, he is yielding to the dominant mystical belief that man can work harm to others, which subsequently, under the name of witchcraft, came to occupy so prominent a place for ill in European history. But at the same time it is evident that his opinions are founded on his knowledge of the influence of mind on body, as he had seen its action in medicine. From him we have the expression: "At times the confidence of the patient in the physician has more influence over the disease than the medicine given for it." MEDIEVAL MIND-HEALING During the Middle Ages faith was one of the things most frequently appealed to, and even the physicians made use of religious belief to secure a favorable attitude of the patient's mind toward the remedies. One of the men who particularly realized the importance of this was Mondeville, the great French surgeon. Pagel has called attention to Mondeville's insistence on preparing the patient's mind properly for venesection. The patient should be made to feel that this procedure was sure to do him good, and various reasons should be given him why the removal of a certain amount of blood carried with it poisons from the body, and so gave a better opportunity to nature to conquer the disease. If the patients were unfavorably disposed towards venesection, Mondeville thought that it should not be performed, as it was not likely to do good. It was not that he felt that the mental influence was the more important of the two therapeutic factors, but that a combination of the remedial force of blood-letting with a favorable state of the patient's mind meant so much more than could be accomplished by venesection alone that it was worth while to take pains to have the combination of the two. We in modern times realize that in most cases blood-letting rather did physical harm than good. It continued to hold a place in medicine because patients were so much impressed by it that they were given renewed vigor after its use. MENTAL HEALING IN THE RENAISSANCE What is exemplified in medieval medicine in this matter remains true during the Renaissance. In the fifteenth century Petrus Pomponatius, well known as a thinker and writer on borderland subjects related to medicine, came to the conclusion that men might very well be cured of certain ailments {15} by influence from the minds of others, and that such treatment, undertaken by physicians appropriately endowed, produced wonderful effects. He said: Some men are specially endowed with eminently curative faculties; the effects produced by their touch are wonderful: but even touch is not always necessary; their glances, their mere intention of doing good are efficient for the restoration of health. The results, however, are due to natural causes. PSYCHOTHERAPY AND MODERN MEDICINE Paracelsus.--Paracelsus, the great physician of the first half of the sixteenth century, who may well be considered the father of modern pharmaceutics, had no illusions with regard to the exclusive power of drugs over disease. He recognized that mental influence was extremely important, and often lent a power not otherwise possessed to many remedies. He said: Imagination and faith can cause and remove diseases. Confidence in the virtue of amulets is the whole secret of their efficacy. It is from faith that imagination draws its power. Anyone who believes in the secret resources of Nature receives from Nature according to his own faith; let the object of your faith be real or imaginary, you will in an equal degree obtain the same results. Personal magnetism, in the sense in which we now use it, a transference of the idea from the science of magnetics as related to the phenomena of the magnet, seems to have originated with Paracelsus. He was sure that the influence exerted over certain patients by certain physicians was due to a force very like that exerted by the magnet over iron. He was even inclined to think that magnets themselves might exert a strong potency over diseased conditions, and he found them to be useful in epilepsy. Doubtless in many cases of supposed epilepsy successfully treated the ailment was really of an hysterical nature. In these cases the strong suggestion which the use of the magnets gave for many centuries acted favorably. Agrippa.--The writings of Cornelius Agrippa, a contemporary of Paracelsus, and, like him, a student of alchemy and of the secrets of nature, contain corresponding passages which serve to show how much of interest there was in mental influence during the Renaissance. All of these men were, of course, a little outside of the ordinary medical tradition, intent on getting to realities, not being satisfied either with words or assumptions, refusing to accept many thing that the physicians of their time completely credited. Agrippa in a characteristic passage said: Our mind doth effect divers things by faith (which is a firm adhesion, a fixed intention, and a vehement application of the worker or receiver) in him that coöperates in anything, and gives power to the work which we intend to do. So that there is made in us, as it were, the image of the virtue to be received, and the thing to be done in us, or by us. We must, therefore, in every work and application of things, affect vehemently, imagine, hope and believe strongly, for that will be a great help. Van Helmont.--At the end of the sixteenth century Van Helmont, who carried on the work in pharmaceutics begun by Paracelsus, and to whom we owe the discovery of a number of substances commonly used, as well as the invention of the word "gas," was a thorough believer in the influence of mind over body and, indeed, in the existence in human beings of storehouses {16} of latent energy ordinarily unemployed, but that might under special circumstances be tapped to produce wonderful effects. Indeed, some passages remind us of Prof. James' expressions in his discussion of the law of human energy. Van Helmont said: All magical power lies dormant in man, and requires to be excited. (Compare Prof. James's "Law of Mental Energy" in the chapter on Mental Influence). This (need for excitation) is particularly the case if the subject upon whom we wish to operate is not in the most favorable disposition; if his internal imagination does not abandon itself entirely to the impression we wish to make upon him; or if he towards whom the action is directed possesses more energy than he who operates. But when the patient is well disposed or weak, he readily yields to the magnetic influence of him who operates upon him through the medium of his imagination. In order to operate powerfully, it is necessary to employ some medium; but this medium is nothing unless accompanied by internal action. Sydenham.--In the more modern period the deliberate use of the influence of the mind on the body is quite as clear. Undoubtedly the greatest of modern physicians, who well deserves the name of the English Hippocrates, is Sydenham. How much Sydenham realized that many of his patients' ailments could only be cured by occupying their minds with other things is seen in his writings. There is a characteristic story told by Dr. Paris in his "Pharmacologia" which illustrates this well and is a striking anticipation of what we are prone to think of as very modern views in these matters: This great physician, Sydenham, having long attended a gentleman of fortune with little or no advantage, frankly avowed his inability to render him any further service, at the same time adding, that there was a physician of the name of Robertson, at Inverness, who had distinguished himself by the performance of many remarkable cures of the same complaint as that under which his patient labored, and expressing a conviction that, if he applied to him, he would come back cured. This was too encouraging a proposal to be rejected; the gentleman received from Sydenham a statement of his case, with the necessary letter of introduction, and proceeded without delay to the place in question. On arriving at Inverness, and anxiously inquiring for the residence of Dr. Robertson, he found, to his utter dismay and disappointment, that there was no physician of that name, nor ever had been in the memory of any person there. The gentleman returned, vowing eternal hostility to the peace of Sydenham, and on his arrival, at home indignantly expressed his indignation at having been sent on a journey of so many hundred miles for no purpose. "Well," replied Sydenham, "are you better in health?" "Yes, I am now quite well; but no thanks to you." "No," says Sydenham, "but you may thank Dr. Robertson for curing you. I wished to send you on a journey with some object of interest in view; I knew it would be of service to you: in going, you had Dr. Robertson and his wonderful cures in contemplation; and in returning, you were equally engaged in thinking of scolding me." Morgagni.--In the century following Sydenham we have a number of examples cited by Morgagni, the father of pathology, in which his recognition of the value of the mind as a curative agent and of the harm that may be done by over-occupation of the mind is set forth at its proper value. Benjamin Ward Richardson in his "Disciples of AEsculapius" [Footnote 2] tells of two incidents in which this phase of Morgagni's very practical application of knowledge to medical practice is exemplified: [Footnote 2: London, 1901] {17} In other examples, where the symptoms are due to mental oppression, he pursued a course of treatment that was of soothing nature. A distinguished professor of physic at Bologna happened to discover that his pulse was intermittent, and being extremely anxious about it was incessantly feeling his pulse, to discover that the evil was daily increasing. Morgagni's advice to his patient was to take his finger off his wrist and not to inquire too anxiously about his condition. The advice was followed, and the result was a complete removal of the disturbance. It is a very singular truth that in describing the action of the nervous system on the circulation Morgagni shows that he was cognizant of the fact that the circulation may be disturbed by two sets of nervous irritations, one inflicted through the pneumogastrics, the other "through those nerves which are subservient to the arteries"--the vaso-motor system which is readily disturbed by the mind. In one patient he observed great perturbations of the pulse in both wrists as the result of mental anxiety. But a day or two later the pulse derangement was confined to the left side altogether. The pulse of the right arm was quite regular, while that of the left arm still showed the inequality. When the mental distress was relieved, this pulse also became equal. Morgagni cites Sydenham's contemporary, Lancisi, the great Italian physician, as recognizing the influence of the emotions on the heart. Examples of similar convictions as to mental influence in medicine are also found in the works of Morgagni's great contemporaries, Boerhaave and Van Swieten, and the great physicians of the seventeenth and eighteenth centuries were closely imitated in their recognition of the value of the influence of mind over body in medicine by their successors in the profession. John Hunter.--Wise old John Hunter recognized the influence of the mind on the body very clearly. He said, for instance, "There is not a natural action in the body, whether voluntary or involuntary, that may not be influenced by the peculiar state of mind at the time." He lays it down as a law that "every part of the body sympathizes with the mind, for whatever affects the mind, the body is affected in proportion." He said further, "as a state of the mind is capable of producing a disease, another state of it may affect a cure." He called attention to the fact that the touch of a corpse produced wonderful effects upon the minds of patients. He said, "Even tumors have yielded to the stroke of a dead man's hand." He observes that "while we should naturally expect that diseases connected with the nerves--and those in which their alteration is in the action of parts not in their structure--would be most affected by the imagination, we find that there are other diseases in which they appear to have little connection that are much affected by the state of mind." German Mind Healing.--In his monograph on "Psychotherapy in Its Scientific Aspects" [Footnote 3] Dr. Berthold Kern calls attention to a forgotten book of the German physician Scheidemantel, published in 1787. Its title was "The Emotions as Remedies." It seems to be very rare since even our Surgeon General's Library has no copy of it. The author treated psychotherapy systematically. He insisted that man was a unit in which body and soul mutually influenced each other. Scheidemantel blamed the moralists for considering the soul exclusively and the physicians for thinking only of the body. He thought that this was a serious mistake for both sides and he seems to have anticipated much of our recent discussion on the influence of the body and {18} of things physical generally in what is called crime and various divagations from law. On the other hand, he thought that the influence of the mind on the body was one of the most important elements in therapeutics. [Footnote 3: "Die Psychische Krankenbehandlung im Ihren Wissenschaftlichen Grundlagen." Berlin 1910.] Reil, after whom the Island of Reil is named, and who taught us much with regard to brain anatomy, was also interested in the influence of mind on body. He was the professor of anatomy at Berlin in the early part of the nineteenth century and had great influence over the medical science of the time. He insisted on the recognition and development of psychotherapy and hoped to give it a place beside the medical and surgical treatment of human ills. He did much to create a current of thought in German medicine which culminated in Johann Müller's very definite expressions with regard to the power of the mind over the body. Very probably the most striking expression of the influence of mind upon body is in that wonderful old book, Johann Müller's text-book of physiology, issued in an English edition (London, 1842) under the title "Elements of Physiology." The subject, a favorite study, is set forth very clearly, and evidently from personal knowledge. He recognized that the mind might influence every organ and function of the body. The influence of expectancy he emphasized particularly: The influence of ideas upon the body gives rise to a very great variety of phenomena which border on the marvelous. It may be stated as a general fact that any state of the body, which is conceived to be approaching and which is expected with perfect confidence and certainty of its occurrence, will be very prone to ensue as the mere result of that idea, if it do not lie without the bounds of possibility. The case mentioned by Pictet, in his observations on nitrous oxide, may be adduced as an illustration of such phenomena. A young lady, Miss B., wished to inspire this intoxicating gas; but in order to test the power of the imagination, common atmospheric air was given to her, instead of the nitrous oxide. She had scarcely taken two or three inspirations of it, when she fell into a state of syncope, which she had never suffered previously; she soon recovered. The influence of the ideas, when they are combined with a state of emotion, generally extends in all directions, affecting the senses, motions and secretions. But even simple ideas, unattended with a disturbed state of the passions, produce most marked organic effects in the body. With regard to the influence of the mind over the body in the matter of fatigue Müller is especially emphatic. He states just as clearly two generations ago the Law of Reserve Energy as James stated it in recent years. Of course, Müller was far beyond his time in everything, but then men who really think always are, and even Müller's accurate expression only represents what had been in the minds of thinking men in many previous generations. He says: The idea of our own strength gives added strength to our movements. A person who is confident of effecting anything by muscular efforts, will do it more easily than one not so confident in his own power. The idea that a change is certainly about to take place in the actions of the nervous system, may produce such a change in the nervous energy, that exertions hitherto impossible become possible. This is still more likely to be the case, if the individual is at the time in a state of mental emotion. Even this necessarily fragmentary and rather disjointed sketch of the main features of psychotherapeutics, as we see them recognized by the great {19} physicians of the past, serve to show that mental influence has always been appreciated as an important element in the care of the individual patient. The times when special attention has been paid to psychotherapy have certain special characteristics. Usually the periods have come just after a signal advance in medicine made through devotion to physical science. Great attention is given to the advances and for a time the individual patient is forgotten in the hope that at last physical science is going to solve the problems of the physical man. With the disappointment that always follows there is a reversion of feeling and men realize once more how important is the mental state of the patient, even in physical diseases. Then there comes an emphatic expression of the value of psychotherapy. We are at present in the midst of one of these periods, hence the widespread interest in the subject. CHAPTER II UNCONSCIOUS PSYCHOTHERAPEUTICS The great authorities in medicine, the men whose thought counted for most in the development of not only the science but the art of medicine, the men to whom we look back as having been great practicing physicians, have always used this remedial measure deliberately and have suggested to others that it should be so used. But the smaller minds have been satisfied to think that their drugs, their external remedies and applications, have been the sole sources of the benefit that accrued to the patient. Such smaller men are prone to think that they have specifics for disease, while the larger men hesitate and recognize that coincidence plays a large role and that the suggestive factors in therapeutics often deceive us as to the real efficacy of drugs and remedies. All physicians have at all times used, though often unconsciously, the suggestive factor in therapeutics, and mental influence has had everywhere a large role in the treatment of disease. Only in recent years have we come to appreciate how many diseases are self-limited. In the treatment of these self-limited diseases all sorts of drugs and therapeutic methods achieved a reputation. Some of them were looked upon by generations as specifics, though we know now that they are almost, if not completely, useless so far as any direct influence upon the disease is concerned. Indeed, at times they were, _per se_, harmful rather than beneficial, and the patient literally got well in spite of the treatment, though the repeated suggestion of betterment often more than overcame the ill effect and helped in recovery. REMEDIES PLUS SUGGESTION Prof. Richet, the head of the department of physiology, University of Paris, quotes the expression of a French critic of medicine: "Hurry up and take the new remedy while it still cures. After a time it will lose its power." The power that is lost as remedies grow familiar is the suggestive element that accompanied them at the beginning. They were announced with a flourish of trumpets as a discovery in therapeutics, a number of cases treated with them {20} were much benefited (because of the feeling that they must do good), and it was only after a great many cases had been treated, many of them under circumstances where patients knew nothing of the claims made for the remedies, and where physicians had little or no previous confidence in them, that their true place in therapeutics was revealed. Every physician of experience has seen the popularity of remedies wax and wane as a consequence of the attention called to them. We have new therapeutic discoveries every week. Enthusiastic articles are written about them, many of them in perfect good faith, and then after a time no more is heard of them, or they sink back into the long list of dubious remedies that may be tried when others have failed, but have no special claim upon us, in spite of the fact that some physicians continue to think them wonder-working. "Time is short and art is long, the occasion is fleeting, experience fallacious and judgment difficult," as Hippocrates bemoaned 2400 years ago, and conditions in medicine continue the same. With suggestions and coincidence ever at work, it is still practically impossible to determine the intrinsic value of any remedy until after a prolonged trial. In the olden time it was still more difficult because there had been no such accumulation of experience as we have to guide us, and so it is not surprising to find striking examples of even great physicians recommending remedies whose main therapeutic influence must have been the element of suggestion. Galen's Theriac.--Perhaps the most striking instance of suggestive therapeutics is Galen's famous _theriac_, various prescriptions for which have come down to us, some of them much more complex than others, so Galen is probably not responsible for all its absurdities. This remedy contained a host of ingredients, some of which neutralized others, and all of which taken together could have had but little effect save by a strong suggestion to the patient that as he was taking so many drugs he surely must be benefited. Bernard's Theriac.--Almost in our own time another _theriac_ came prominently before the public. In his younger years Claude Bernard, the French physiologist, worked in a little drug store in a country place not far from the farm on which he was born. There he found that the most called for remedy was a _theriac_. It was good for most of the ills that flesh is heir to and was bought in quantities by the old women of the neighborhood, who administered it on every occasion. The remedy was made in large quantities, but the secret of its composition in this particular pharmacy was what interested Bernard. Whenever any compound was for any reason spoiled in the drug store, the rule was, "Put that aside for the _theriac_." This much sold remedy then consisted of the most heterogeneous drugs. It was so diluted that it could do no harm, though it had quite sufficient taste and odor to make every one who took it realize that without doubt they were taking a strong medicine. The effect of the knowledge of the composition of this wonderful remedy on Claude Bernard was the best that could have been anticipated. He resolved to study the physiological effects of drugs so that they could be given scientifically, and not in the hit or miss fashion that made possible the success of the _theriac_. The custom of Bernard's country drug store, however, was not different from that of most country drug stores of the time. Unconscious psychotherapeutics we may well call it, because the main therapeutic factor was {21} suggestion, renewed as often as the mixture was taken, that the patient ought to feel better, until finally whatever symptoms were due to over-attention and to concentration of mind on feelings of discomfort were diverted. Just as soon as the inhibition exercised by this over-attention ceased its hampering effect nature completed the cure. Suggestion in Colds.--Many remedies acquired a reputation for breaking up coughs and colds. It is, however, extremely doubtful whether any one has ever aborted a cold, or any other infection, that had gained a hold on the patient. We now know that this common affliction is not due to cold but to absorption of infectious material. Nansen spent two winters near the North Pole without catching any cold, and his men were as healthy as himself. He had been back in civilization scarcely a week before he and his men were confined to bed with a grippy cold. In the far north, and high on mountains where the temperature is low, colds are not as common as they are in crowded cities and especially among those who are much in crowds. Cold weather only predisposes to the infection, and after it has occurred it is sure to run its course. That course may be longer or shorter. The cold is usually preceded by chilly feelings. Every one knows it is possible to have chilly feelings that seem to portend a cold, yet be well the next day. If in the meantime any remedy is taken, credit will be given to the remedy. When a cold was supposed to be merely a disturbance of circulation or a congestion, one might expect to break it up. Now that we know that it is a microbic infection, and know further that microbic diseases are usually cured by a definite reaction on the part of the body, we are not so likely to think of breaking them up. There are still physicians who think they can abort a threatened pneumonia or abbreviate typhoid fever, but they are not those who know most about the science of medicine. We have the story, then, of a series of remedies used with great confidence in coughs and colds, some of them physically beneficial, many of them, especially those containing opium, often physically harmful, yet taken with such confidence that undoubtedly the patient was helped through his mind if not otherwise. What is thus true for this class of diseases can also be said of other minor affections. Many internal remedies have been used for boils and styes and other external infections and have often had wide vogue. The reason for their acceptance as remedies has been that the giving of anything produces a more hopeful attitude in the mind of the patient and this, by bettering the general health, sometimes overcomes the tendency that may exist to a repetition of such infectious processes. Erysipelas.--The medical history of erysipelas is just a succession of remedies recommended, each claimed to be almost infallible, yet abandoned after a time for another for which like exaggerated claims were made. The doctrine of signatures played a large rôle in the treatment of erysipelas, and, strange as it may seem, still survives. According to the doctrine of signatures, erysipelas, being a disease involving intense redness of the skin, red things in nature would be likely to do it good. Red pepper, for instance, was suggested for it over and over again, both internally and externally. Various red remedies have been favorites at different times in history. At present, in many country places, a poultice made of cranberries is supposed to be most efficacious. For many years I lived in a small town where one of the grocers {22} put in a large stock of cranberries each fall, though the people of the neighborhood used them but little on the table, because during the winter there were many calls for them for the making of poultices for erysipelas. People who have had erysipelas, especially if it has occurred on unexposed portions of the body, are supposed to be protected against its recurrence--for there is a distinct liability to its recurrence--by the wearing of red flannels! There is scarcely any drug that has not at some time been recommended as almost a specific for erysipelas. Anything that was given on the third or fourth day, and it was only at this time as a rule that patients came to physicians to be treated, seemed to bring about the alleviation of symptoms that occurred on the fifth or sixth day. Erysipelas, because of the sudden irruption of fever which accompanies it, the intense redness which characterizes it, and the discomfort which is often present, is an affection that disturbs patients very much. For them, then, the presence of the physician and his assurance that their affection is not likely to be severe, and his prompt relief of certain conditions, all act by suggestion on the patient's mind and strengthen the natural curative reaction. In country places where physicians were not near, erysipelas was one of the affections that continued almost down to our own day to be treated by incantations. I have known in a little American country town of a woman making a "charm," as it was called, for erysipelas. Pneumonia.--Pneumonia is another of these sharply self-limited diseases that give opportunity to many remedies for the acquisition of a reputation as cures. Croupous pneumonia is so disturbing in its onset, so rapid in its progress, yet so strictly self-limited in the previously strong and healthy, that in the old days there were many remedies that were supposed to bring about the crisis. The old text-books contain so many cures that it is surprising pneumonia should have continued to be the fatal disease it has been at all times. Almost any remedy that is used for three or four days in pneumonia will be followed by the crisis with, in most cases, a favorable termination. The crisis takes place some time from the seventh to the tenth or eleventh day, and often we do not see a pneumonia patient until the second or third day of the disease. Just before the crisis the patient runs into a series of acute and more or less alarming symptoms. Often there is much restlessness, difficulty of breathing with complaint of heaviness, and perhaps prostration. The pulse and temperature are high, the skin hot and dry. Then in the midst of this the patient sleeps, there is a critical sweat, the temperature drops, the patient wakes up feeling quite well, there is little difficulty in breathing, and he feels that recovery is sure to come. The change is so great that it is natural that it should have been attributed to all sorts of remedies which had been used immediately preceding the crisis. I once heard an old physician declare at a meeting of a large and important medical society that calomel in divided doses was practically a specific for pneumonia. He said he waited forty-eight hours to be sure that the affection was pneumonia, and also that it had reached that diffusion in the lungs beyond which it was not likely to go, then he gave the calomel. He said that, almost as a rule, during the next forty-eight hours the crisis came--and he attributed it to the calomel. We have had other remedies just as curious as this recommended and taken quite seriously. Some years ago a {23} Russian physician, who had been treating soldiers in the Russian army for the pneumonia which occurs so commonly after exposure on the Steppes, announced that he had found in digitalis almost a specific. He pushed the tincture up to twenty drops three times a day, beginning it just as soon as the pneumonia was detected, and the rate of mortality among his patients was about one per cent. According to his theory, it was the failure of the heart in pneumonia that made the disease fatal. Apparently the character of the patients in whom his pneumonias occurred was forgotten. They were absolutely the most favorable cases that could be selected. Most of them were young men between twenty and twenty-five. At this age no one who is given a reasonable amount of fresh air should die of pneumonia. If the patient had a serious heart lesion, or a crippled kidney from nephritis after scarlet fever, or crippled lungs because of a previous attack of tuberculosis, then the pneumonia might be fatal--indeed, almost inevitably would be, or, in the last-mentioned case, would end by lysis and not crisis. It really matters little what remedy is given to young, otherwise healthy, adults; they will get better, barring serious complications. The use of digitalis lessened the chances of recovery by stimulating too early in the case the heart that later had to bear one of the most serious strains that the organ can stand. But doubtless this harm was more than overcome by the patient's knowledge that he was taking a new and powerful remedy, supposed to be particularly calculated to cure him. Moreover, the special interest of the physician in these cases, and his administration of a remedy with confidence which inspired the patient, undoubtedly did much good. Pneumonia is one of those diseases in which the patient is likely to be greatly depressed unless he is surrounded by favorable mental influences, and is encouraged to believe that he is going to get well. Every physician has probably had cases in which patients died, not because of the severity of the disease, but because they gave up the struggle in fright. If several of a man's friends have died of pneumonia during the year or two before he gets it, he is likely to conclude, especially if he is of the worrying kind, that his doom is sealed as soon as the diagnosis of pneumonia is made. If this thought persists hardly anything will save him. He must be assured that pneumonia is not necessarily serious, that there are remedies that influence it, and that his own case is particularly likely to respond favorably to them. We now realize that nursing is the most important element in the treatment of pneumonia. Such attention to the patient as will treat symptoms so as to prevent them from disturbing him, will secure him against discouragement, will arouse his resistive vitality by assuring him of a favorable termination. This will above all prevent the patient from feeling that he is attacked by a fatal disease. The presence of the doctor and his general directions make the patient realize how thoroughly the course of the disease is understood and therefore how likely it is that a favorable termination will be brought about. We know how much the mind may interfere with the breathing if allowed to dwell on it, and therefore if the patient becomes over-solicitous about the condition of his lungs he seriously hampers his recovery. In pneumonia the physician has always brought relief, and he has usually attributed his success to his drugs, though he has felt, too, that the confidence inspired {24} by him meant much for his patient. It would have been better had he exaggerated the mental influence rather than the drug power. Typhoid Fever.--Typhoid fever is another affection for which we have many therapeutic suggestions, with wide vogue, that are nevertheless almost directly opposed to what we know about the pathology and etiology of the disease. Typhoid fever runs its course in from between twenty to thirty days. The majority of people who take the affection and who give in to it early enough, so as not to wear themselves out, come through successfully. Complications may carry them off, but we expect uncomplicated cases to recover. The longer course of typhoid has made the action of drugs appear less striking than in pneumonia and erysipelas, but a number of remedies have been proclaimed to shorten its course, to make it less dangerous, to cure, and sometimes actually to abort it. So often have these come and gone that the physician who knows the history of therapeutics is likely to be suspicious of them. Even at present there are certain remedies supposed to have this effect, but one does not find them used in hospitals where large numbers of cases are seen and where there are opportunities for comparative observation. They are used only by physicians who see a few cases every year, and to whom coincidences may mean much more than they are likely to when extensive statistics of the disease are made. As a rule, these remedies are founded on some real or supposed scientific principle. The antiseptic treatment of typhoid, for instance, was based on the supposition that if one can kill the microbes in the intestine the disease will run a shorter course. The principle apparently fails to note that any remedy likely to kill microbes is still more likely to kill cells of other kinds, and above all human cells lessened in their resistive vitality by disease. The advocates of this remedy also forget that typhoid is now recognized as a general disease with only a local manifestation in the intestines, and that the treatment of this local manifestation is no more likely to affect the course of the disease than the treatment of the symptoms of typhoid would be likely to do. But the giving of remedies with the thoroughgoing confidence that awakens trust is in itself an excellent therapeutic agent, and patients thus treated are sure to be benefited in so far as they share the physician's confidence. Just the same effect, however, can be produced by careful nursing and by making the patient realize that even though typhoid fever runs a definite course, which we cannot abbreviate nor probably influence, we can by nursing so prevent complications as to make a fatal termination almost impossible. Whooping Cough.--Perhaps none of the common affections illustrate the influence of psychotherapy better than it is exemplified in the history of the therapeutics of whooping cough. We have had all sorts of remedies suggested for it, and most of them have been introduced by those who had found them of great service in shortening the course of the disease, and in making the "whoop" disappear much sooner than would otherwise be the case. There have been internal and external remedies, inhalations and inunctions, as well as many less likely methods of treatment. Practically none has maintained itself. Whooping cough is likely to run a rather long course. We know now that as a consequence of the strain upon the lungs tuberculosis not infrequently develops. Whenever this is true the tendency to cough is likely to be {25} prolonged far beyond the natural period, and from habit ingrained upon the nervous system the "whoop" is likely to continue, though there is no necessity for it. It is this secondary period of the affection that the remedies have succeeded in shortening either apparently or in fact. Practically anything that is done for children is likely to instil the persuasion that the "whoop" should disappear. Anything impressive will arouse this favorable attitude of mind toward the affection, and hence the remedies have obtained a reputation. In the interior of many countries draughts of sea water are a popular remedy for whooping cough. Sea water, it is said, loses its efficacy if carried long distances from the shore, so the children must be brought to the seaside. In mining regions children are taken down into the mines. The experience is enough of itself, especially when talked over a good deal in the family, and when the occasion is often the first outing that the child has had for months, to bring with it such improvement in health as will enable it to suppress the whoop. If the exposure to the mine air does not bring improvement, it is said to be either because the child was not taken deep enough, or because there was no gas in the air, or the wrong sort of mine was chosen, or some other plausible excuse is advanced. The development of scientific medicine, or at least what we are pleased to think of as more scientific therapeutics than they had in the past, has not kept us from having many and varied remedies for whooping cough, which, after being introduced on apparently good authority and apparently accomplishing many good results, have eventually been allowed to drop into innocuous desuetude. Whenever the administration of any such remedy was accompanied by strong suggestion--when the internal remedies were particularly distasteful, or the inhalations rather trying or at least sure to attract the attention of the sufferers--then good results followed. But the cures were due to the mental influences at work. In recent years various serums, including diphtheria serum, have been tried with reported good results. The giving of the injection is one of those little operations that is likely to impress itself forcibly upon the child's mind, and when given in connection with the promise, implied or explicit, of improvement it is easy to understand that there will be a tendency to lessening the frequency of the whoop, at least during the secondary periods of the disease. CHAPTER III GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION The story of the suggestive use of drugs shows us many suggestions employed even by distinguished physicians, men whose work is eminently rational and has lived long after their time. In fact, very few, even of the most distinguished physicians, have failed to extol remedies which later proved to be quite ineffectual. Hippocrates felt quite sure that an external application of snake skin was a cure for all forms of that chronic skin manifestation, lichen. Pythagoras declared that anise seed held in the hand was an excellent remedy for epilepsy. These are only examples which serve to show how much suggestion has been used unconsciously by the medical profession. The sensation {26} produced by the touch of the viper's skin was sufficient in some patients to bring about a change in the circulation in the skin, or perhaps a distinct modification of the nerve impulses on which trophic conditions in the skin depend, and this may have produced some cures on which Hippocrates founded his recommendation. We know that the skin can be unfavorably affected directly through the nervous system, and there is no good reason for thinking that it may not also be affected favorably. In our own day we have seen the suggestive influence of an operation act as a remedy in epilepsy and have lauded it for a time. It is, therefore, not surprising that Pythagoras saw, as he thought, the strong scent of the anise seed act favorably. Both of these conclusions as to the causative agency at work were wrong, because it was suggestion and not the operation in most cases, nor the anise in any case, which caused the improvement. THERAPEUTIC PERSUASION It is not only in the distant past, however, but also in quite modern times that these therapeutic persuasions have existed among physicians, and as a result physicians have frequently recommended and employed remedies that we now know not only to have been quite useless, but sometimes even harmful. A typical example of this is the use of antimony, originally discovered and studied by Basil Valentine, an alchemist who had busied himself much with the nature of substances, vegetable and mineral, and with their action as remedies for disease. Sir Michael Foster hailed him as the first of pharmacologists, and said: "The old monk did not care for the problem of the body; all he sought to understand was how the constituents of the soil and of plants might be treated so as to be available for healing the sick and how they produced their effect." Suggestion and Antimony.--This was an eminently scientific research. It brought the father of pharmacology to certain supposed discoveries which continued to occupy men's minds for centuries, yet ultimately proved to be utter misunderstandings of drug action, because suggestion played so large a role that it vitiated all the conclusions. The best known of Basil Valentine's books is the "Triumphal Chariot of Antimony," which contains many interesting scientific observations that were probably new at the time and which show their author's investigating spirit and his interest in scientific research. In spite of his scientific advances, however, Valentine was wholly mistaken with regard to antimony. He used it in various diseases, and, of course, it always produced very definite effects on the bowels. These effects the physician could easily foretell. It was for the patient a proof that the physician knew much, both about his disease and his remedies, since he could prophesy the results. After the antimony had exerted its influence the patient was much more ready to think that he must get better, and the influence of this suggestion worked strongly in all cases where the affection was not serious, and undoubtedly helped the patient's resistive vitality to throw off disease. In weak patients its physical effect was lamentable. It still further reduced vitality, and when used by thoughtless physicians must have done great harm. In spite of this, however, antimony continued to be used for centuries. Shortly {27} after the middle of the seventeenth century, when it was beginning to be neglected, antimony received a new lease of life as a consequence of its employment in a lingering illness of Louis XIV. The French king was attacked by what has since been recognized as typhoid fever. Many remedies were tried, but all in vain; the fever continued. When the fever had nearly run its course and the physicians were on the point of acknowledging that they could do nothing, and when a fatal termination seemed near, it was decided at a consultation to follow the advice of an old practitioner and use the old-fashioned remedy, antimony. Almost immediately the king began to get better. His improvement was quite naturally attributed to the last drug that he had taken, and antimony regained and held its remedial reputation for the next two centuries. Such stories have always worked wonders in producing popular faith and even professional confidence in drugs. When great personages seem to be cured by certain remedies, ordinary logic ceases to act, and the strong power of suggestion comes in to strengthen whatever remedial influence there may be. Calomel and Suggestion.--Such mistaken notions as to therapeutic efficiency are not confined to centuries before our own. During much of the nineteenth century calomel was employed as extensively as antimony had been in preceding centuries. Calomel was often given in doses which produced effects resembling those of antimony. Even in the small doses we now employ, it is apt to be a thorough purgative. In the twenty and forty grain doses, commonly administered by the country doctors of two generations ago at the beginning of practically every ailment, it was purgative--and worse. Its effects could, of course, be very strikingly seen, and what patients wanted were just such visible results of the doctor's prescription. Undoubtedly, then, the calomel did good, but not by its effect upon the patients' bodies, but upon their minds. Calomel is still used in ways that partake more of the old-fashioned ideas than we care to confess. Some of its supposed effects in stimulating the flow of bile have been placed in doubt by modern investigation, but we still use it empirically, and undoubtedly its effectiveness is partly due to the fact that many patients see the results in the purgation in dark coloration of the stools and are confident that improvement must follow--and it does. Perhaps at a subsequent operation we find the bile ducts effectively blocked and then learn for certain that the stool coloration observed was not biliary but due to a chemical reaction of the calomel itself. Venesection and Its Suggestiveness.--Between the periods of antimony and calomel popularity venesection was the favorite remedy of physicians. It is hard to understand now the extent to which this practice was carried by the medical profession. People were bled for nearly every combination of symptoms. In severe cases the amount of bleeding practiced was almost incredible. Mirabeau, the great French orator, suffering from angina pectoris, was bled some eighty ounces in the course of forty-eight hours. In spite of this heroic treatment, which his physicians thought ought to have cured him, he died. We find it hard to understand how he lived so long. This, of course, was an exceptional case at the very height of the venesection furor, but it helps us to realize how convinced physicians were of the curative power of the practice. {28} Thoughtful physicians like Morgagni did not accredit it, or at least refused to allow it to be practiced on themselves, but its acceptance was practically universal. Probably no remedial measure ever generally used was calculated to be so effective as bleeding in producing a strong mental influence. The rather sacrificial preparations for it, the sight and the prick of the lancet, then the sight of the blood, the languor that followed, the reaction on nature's part to reproduce the lost material, all united to impress the patient's mind so deeply that it is easy to understand that all the reserve of mental force was now directed toward helping nature in the cure of whatever disease was present. Venesection itself in nine out of ten cases probably did more physical harm than good, but all the good came from its suggestion. We are now apt to think of venesection as consisting only in the removal of some blood from a favorably situated vein, but we must not forget that in the olden time they bled from many veins, and that a particular vein was picked out because it was supposed to be connected in some way with the seat of the special trouble under treatment, and as a result there was a particular appeal to mental influence. A vein on the forehead was opened for the treatment of migraine and diseases of the eyes, on the nose in case of discharge from the eyes, back of the ears in chronic headache and in stuporous conditions, or beneath the chin when there was pain in the eyes, or in the nose, or in the jaws. The cephalic vein was opened for headache and for certain affections of the eyes and ears. Altogether there were thirty different veins opened for as many maladies. It was thought extremely important in the drawing of blood from the arm that that arm should be chosen which, for some anatomical or other reason, was supposed to be the more intimately connected with the affected part of the trunk or head. The psychotherapeutic factors at work in these cases are easy to understand, and their beneficial effects gave the practice a firm foothold in medicine. Quinine and Suggestion.--Whenever any drug has secured a reputation its use has always been extended to many other diseases besides that for which it was definitely indicated. Quinine is a typical example. It is a specific for malaria and, properly administered in suitable doses, breaks up the fever--not because of any action upon the febrile condition itself, but because it kills the _Plasmodium malariae_ whose reproduction in the blood brings about the paroxysms of fever. It was argued, however, that since quinine was good for one kind of fever it would probably be good in others, and all sorts of theories were invented and supported by supposed observations of the effect of quinine on various organs and tissues, even on the white blood cells, by which its efficacy in fever was supposed to be explained. Quinine was used in all sorts and conditions of fever, and acquired a reputation as a remedy that had the power even to abort conditions leading to all fevers. It was used in large doses for such conditions as cold, incipient pneumonia, or indeed any disease with a chill at the beginning, and was supposed to be a powerful prophylactic. Now it is settled that while quinine in small doses is an excellent tonic, it has no effect at all upon fevers in themselves nor upon fever-producing conditions. Yet it is still administered by many who have not quite abandoned the old teachings as if it were a general febrifuge. In the meantime, the use of quinine as a prophylactic of colds and other minor febrile conditions has {29} spread so that many people make themselves very uncomfortable by taking a large dose of quinine and whiskey whenever they fear they are going to have a cold. As a consequence they feel dull and heavy the next day, but assume that they would have been much worse than they are had they not taken the potent remedy the night before. Undoubtedly some of them are enabled by the suggestive value of the remedy and the continued suggestion of its unpleasant effects to throw off the lassitude that comes from some minor infection and are encouraged to get out into the air, when they might otherwise have stayed in the house. This enables them to get rid of their colds sooner than would be the case if they allowed themselves to be confined. Most of them, however, are harmed rather than benefited, and the cold runs its course, unaffected except that the patient is more miserable and depressed for the first day or two than he would otherwise have been. There are physicians who still use quinine as a febrifuge in typhoid and other essential fevers, and doubtless its bitter taste helps their patients because of the suggestive value of an unpleasant medicine. St. John Long's Liniment.--An interesting exemplification of the power of mystery in adding to the curative value of a commonplace remedy is found in the story of the famous St. John Long liniment. St. John Long was a well-known quack in London in the early part of the nineteenth century. Like all quacks at all times, his specialty was chronic diseases. He claimed to be able by means of external applications to cure the pains and aches to which the old are so likely to be subject. St. John soon acquired an immense reputation. He gave a liniment with a secret formula that was literally a miracle worker. People who used it found after a few times that they were free from, or at least greatly relieved of, aches that had bothered them for years. It was good for sprains and for internal pains of all kinds, as well as for the so-called chronic rheumatisms, which have as their principal symptom pains and aches around joints. So great a reputation, indeed, was acquired by the remedy that an agitation was begun to have Parliament buy the secret from its inventor in order to present it to the British nation. The proposition was actually carried through the legislative chambers and a considerable amount of money, still larger in those days because of the comparatively greater value of money, was voted to St. John Long. His liniment had a place in the British Pharmacopeia under his name for many years afterwards. It proved to be only a simple old-fashioned remedy, the basis of which was turpentine, and one of the principal ingredients was the white of egg. Just as soon as the secret was known the power of the remedy began to decline. So long as it remained mysterious and unknown, discovered by a man who supposedly had made a special study for many years of these conditions, and had finally worked out the external applications necessary for them, it accomplished wonders. Just as soon as it was known to be a combination of familiar turpentine and egg it lost its power. The remedy is, of course, an excellent counter-irritant, and the gentle rubbing undoubtedly did much good. The most important element, however, was the mental influence, the feeling that now things must be better, which thought distracted attention from the aches and pains and caused the unfavorable influence of over-concentration of mind on the part to cease, for the vaso-motor system is particularly under mental influence. Every now and then since that time some {30} liniment or oil containing nearly the same ingredients as that of St. John Long's acquires a reputation as a consequence of a campaign of advertising. It is the printers ink that counts, however, and just as soon as the advertising ceases to attract attention the remedy fails in efficiency. Alcohol Plus Suggestion.--Alcohol has been employed in medicine with the persuasion that it is a remedy for many states of exhaustion, though we have gradually gotten away from its use to a great extent, because we realize that subsequent physical ill consequences outweigh, in most cases, the physical good it may do. Its use was undoubtedly due to the confidence of physicians communicated to patients, and the sense of good feeling which it gives and which proves a further strong suggestion to the patient. This sense of well-being is illusory, for it is sure to be followed by a longer period of dejection, which more than counteracts it unless the dose of alcohol can be maintained for some time. A generation ago few physicians would have cared to treat exhausting diseases, the continued fevers for instance, without liberal doses of alcohol. Practically the only treatment for pyemia and septicemia on which any stress was laid, and in which there was any general confidence, was the administration of alcohol in large quantities. In the septicemia consequent upon puerperal infection it was the common teaching to give alcohol by the tablespoonful or more every hour, or oftener, until its effects began to be noticed, and ordinarily large quantities were required, so that sometimes nearly a quart was taken in the twenty-four hours. Undoubtedly these septic conditions were accompanied by great mental prostration, and this was emphasized by the knowledge that they are often fatal. So patients were usually depressed into a state of mind in which their resistive vitality was much lowered. Alcohol, then, by producing a sense of well-being as well as by stimulating hope in other ways and suggesting possibilities of recovery, undoubtedly exerted a powerful and favorable influence on the mind. Its use in these cases nearly always did good, in spite of its inevitable depressive reaction, for the course of these infections was rapid and the dosage of alcohol could be maintained until there was a change for the better or the fatal termination was in sight. Alcohol was frequently used in many other conditions of a similar nature, and above all in the septic conditions so common in hospitals before the days of antisepsis and asepsis. When it is recalled that amputations yielded a mortality from sepsis of at least one in four, the extensive use of alcohol in hospital practice two generations ago will be readily understood. We have changed that, however, and Sir Frederick Treves, at a meeting of the British Medical Association at Toronto, five years ago, called particular attention to the statistics of the use of alcohol in British hospitals. During the last forty years milk and alcohol have exactly changed places in the London hospitals. Between 1860 and 1870 about four times as much was spent for alcohol as for milk in these hospitals; during the last decade about four times as much was spent for milk as for alcohol. A corresponding change has taken place in many other phases of treatment in which alcohol was commonly used. The physician of fifty years ago would have thought that one of his most efficient remedies had been taken from him if he could not use alcohol freely in tuberculosis. There are practically no well-known specialists in tuberculosis now who recommend the use {31} of alcohol. On the contrary, most of them point out the dangers from its use and consider that the depression which follows even a moderate dose is likely to do much more harm than the temporary and fleeting stimulation which it gives can do good. In the treatment of phthisis in recent years milk has done much more than take the place of alcohol: it has displaced it entirely. The medical profession realizes now that what the consumptive needs is not more stimulation--for more of that than is good for him is forced upon him by the toxins of the disease--but more nutrition to enable him to resist the progress of the disease and raise his resistive vitality against its toxemia. The one stimulant that is of service in the affection is oxygen, and even that should be given in nature's dosage rather than by artificial means. _Alcohol in Pneumonia_.--A corresponding change has taken place in the professional attitude towards the use of alcohol in pneumonia. There was a time not so very long ago when alcohol was considered the sheet anchor of our therapeutics for pneumonic conditions, especially those in which from the beginning a fatal termination seemed inevitable, because of the age of the patient or some complication. There were physicians who said that if they had to choose between all the drugs of the pharmacopeia on the one hand without whiskey and whiskey without all drugs whatsoever, for the treatment of pneumonia, they would make the latter choice. We are not as yet entirely away from the point of view that attributes a certain value to alcohol in pneumonia, though even those who still employ alcohol are less emphatic in their advocacy of it. Any one who has seen the result of the fresh air for pneumonia patients will think less and less of alcohol. One well-known clinical authority declares that the very best place to treat pneumonia in our cities would be beneath the trees in the parks. Our patients are being treated at the ends of wards with the windows up, on the balconies, and on the roofs, and the death rate is much reduced and the necessity for any other than oxygen stimulation seems much less. _Alcohol in Vague Affections_.--The suggestive influence of the effect of alcohol is unconsciously obtained in a number of vague and rather chronic affections. Among these the most noteworthy are women's diseases. Various alcoholic home remedies, gin and whiskey, usually disguised by some bitter, used to be popular. But the known presence of alcohol in these discredited them. Then the nostrum vendors proceeded to supply something just as good. They were, in fact, the same things under another name. Many of the much-advertised remedies that are supposed to cure the ills the weaker sex is liable to, have been found to be little more than dilute whiskey, for in alcoholic strength they were about equal to whiskey diluted once with water, and the other substances were added only to disguise the taste and the odor of this principal ingredient. Many of these remedies have elicited innumerable flattering testimonials and not all of these were fraudulent or obtained by questionable means, but many of them were given because of results secured through the remedies. The alcohol gave the well-known sense of well-being, and the suggestive influence of this increased the appetite, tempted the patient to move around more, and to get more into the air than before, and the consequence was an improvement in the general health, in the midst of which many symptoms that seemed to the excited imaginations of run-down individuals to be serious were relieved. In a great many cases, however, the result was the {32} formation of a whiskey habit; hence the crusade which has discredited these remedies. Other patent medicines, and, indeed, some of the proprietary preparations, commonly recommended as nutrients and the like, and supposed to be ethical, are found to owe whatever efficiency they have to their alcoholic content. Here once more the suggestive elements were the more important, and enabled substances of little physical efficiency to produce effects that seemed to indicate the presence of powerful energizing materials. _Whiskey in Snake-Bites_.--A typical example of a remedy which owes its efficacy to mental influence over the patient is the use of whiskey for snake-bites. It is generally recognized that whiskey is not only of no special beneficial effect for snake-bite, but that when taken in the large quantities usual in such cases it probably produces an ill effect by disturbing the patient's general condition and lowering his resistive vitality. I have no doubt, however, that its use in considerable quantities has in these cases proved of value because of the mental effect upon the patient. Ordinarily a snake-bite is followed by a sense of extreme terror and prostration that lowers the resistive vitality. This is overcome by the temporary stimulation of the alcohol. The generally accepted idea that whiskey is almost a specific remedy for snake-bite takes away from most people this dread and consequent depression, and does this especially at a time when the acuter symptoms of the venom are making themselves felt. Only about one in six even of those bitten by large rattlesnakes are likely to die. Many circumstances are in their favor. The bite is not likely to be fatal unless the full contents of the poison sac is injected--which will not be done if the sac has been emptied in the preceding twenty-four hours--and if there are any obstacles, such as clothing or even hair, on the part struck by the snake. Most people, however, would almost die from fright, and such a thing is quite possible, if they thought there was no remedy. The fact that they understand that alcohol is an almost infallible remedy gives them courage, and as soon as they receive some whiskey and it begins to take effect this intense depression is relieved. It would be better if the knowledge we now have as to snake-bites were more generally used, and if people understood that only rarely is such an accident fatal. In this way there would be no necessity for an appeal to mental influence through whiskey. It is probable, however, that alcohol will still be used for many years, at least in the country districts, because the supposed knowledge is too widely diffused for a correction to come soon, and then other modes of treatment have not that persuasive mental influence which whiskey has as the result of the long tradition. There are many other popular remedies for snake-bite not quite so inefficient as whiskey, but that will continue to enjoy a reputation and really have a certain efficacious result as a consequence of the expectant attitude evoked by the fact that for as long as the patient has heard anything about these things this particular remedy has been mentioned always as the one thing sure to do good. Other Cures.--Fontana, toward the end of the eighteenth century, was sure that he had discovered in caustic potash an absolute specific for snake poisoning. He had had a series of cases, and felt that he had actually observed this substance following the snake poison into the system and neutralizing it. Its active effect on the external tissues proved eminently suggestive for {33} the patient and good results followed. We have had many specifics since, and yet we are not quite sure how much any of them avail unless recent biological remedies prove lasting in their effects and are really of therapeutic efficiency. Antidotes and Suggestion.--For many other poisons beside snake venom there have been announced supposed antidotes of all kinds. The literature of the antidotes used for opium is extremely interesting and even in recent times contains many disillusions. Twenty years ago our medical journals contained any number of cases in which a solution of potassium permanganate seemed to have proved effective in neutralizing not only opium itself but its alkaloids and derivatives. Not only was it efficacious, then, if taken while the opium was still in the stomach but, just as with Fontana's caustic potash and the snake venom, it followed the opium into the tissues and at least blunted its action. Numbers of cases were reported in which potassium permanganate was supposed to have had this desirable effect. The effect of alcohol in neutralizing carbolic acid attracted as much attention as did potassium permanganate for opium. Here there was no doubt that alcohol immediately after the external application of carbolic acid did prevent its corrosive action. It was supposed to do the same thing in the stomach and even, as some enthusiastic observers thought, followed the carbolic acid into the tissues. Here once more the claim is not proven and it is evident that the influence on patients' minds when small doses of carbolic acid were taken, was the real therapeutic factor at work. Poultices in Suggestive Therapeutics.--Poultices represent another phase of the value of suggestion in medicine and surgery, though for many centuries those who used them were sure that the reasons for their employment were entirely physical and not psychic. All sorts of poultices have been used and each was supposed to do specific curative work. New forms of poultice material have been introduced, and physicians and patients have been certain that each worked wonders of its own. The drawing power of the poultice was extolled until patients dwelt on the idea that this external application was literally engaged in extracting from them, even from distant portions of their anatomy, virulent material that would do harm if allowed to remain in them. Poultices in suitable cases, because they represent moist heat, do good by counter irritation, by bringing about the expulsion of gas, by diverting internal hyperemia to external tissues, but most of their supposed efficacy has been really due to the bother required to prepare and apply them, the discomfort of having them on, and the feeling that now something had been done and the aches and pains must get better. They are still used, but to a much less degree than before. Now the ordinary teaching is that a hot water bag wrapped in dry flannel, if dry heat is the agent desired, and in moist flannel, if moist heat is the desideratum, is much more efficient. It takes but a few minutes for a poultice, no matter how hot when applied--and occasionally in the olden time they were applied so warm as to burn or scald--to decrease in temperature to that of the body. After that they represent only a moist compress. It is easy to understand that the suggestive influence of poultices might serve for an age that knew less about the realities of the efficacy of external applications than ours. As a matter of fact, we have, nevertheless, shown ourselves to be quite as credulous and ready to receive analogous remedies as the past generation. With the waning of the popularity of the poultice, not {34} only among the profession, but also among the people generally, there came into use various plasters which were supposed to have even more wonderful efficacy than the poultice of the olden time. These required a good deal of trouble to apply and once applied remained on for hours, and so continued to produce a definite curative effect on patients' minds. When first introduced, exaggerated claims were made for their therapeutic value and a regular crusade to diffuse correct information regarding them had to be made, in order to set them in their proper place as mere wet compresses, without any therapeutic efficiency beyond that of cloths wrung out in water and kept in touch with the skin. _Poultices and the Doctrine of Signatures_.--There was a general impression in the past that the indication of the ailment for which substances are medically useful has been set on them by nature, either through the color, or the form of the plant, or other qualities. In general, the law of similars is supposed to hold in the doctrine of signatures--like cures like. Hence the cornmeal poultice for light jaundice, the flax-seed meal poultice for darker jaundiced conditions and for tendencies to gangrene. The charcoal poultice was employed for this same purpose with no better reason, though some of its efficacy may have been due to oxygen present in the pores of the charcoal. I have already spoken of the appeal to the patient's mind in the use of the cranberry for erysipelas, and various other berries were used in like manner on the doctrine of signatures. _Deterrent Materials and Suggestion_.--Another basic principle in the making of poultices was the use of deterrent, repulsive materials, because these were more effective on the patient's mind. All the ordures were so employed. Goose and chicken excrement was supposed to be particularly efficacious for many of the purposes for which we now use iodine. It was applied over sprains and bruises on the unbroken skin. Cow-dung was employed as a poultice for sprains of the larger joints, especially on the feet and legs, but to be efficacious it had to be applied fresh. I have known, within twenty years, of physicians in two so supposedly cultured parts of the country as Pennsylvania and Maryland, to employ such ordure poultices for the cure of sprains and dislocations, and these physicians had a great reputation among the people of their countryside. They were known especially as good bone doctors, and their use of such deterrent materials instead of decreasing their practices rather added to them. Ointments.--In the Middle Ages ointments made of the most far-fetched materials were employed even by distinguished surgeons. That, indeed, is the one serious flaw in the surgery of the thirteenth and fourteenth centuries, when they did everything else so well. These ointments contained all manner of materials that were likely to impress patients and make them feel that something wonderful was being done for them. Crushed insects of all kinds were employed for external lesions. Here the doctrine of similars seems once more to have been in play. Insects gave creepy feelings, and whenever such feelings, or the paresthesiae generally, were complained of, a poultice or ointment made of insects seemed to be the natural remedy. The more repellent the materials, the more efficient they were likely to be. Many of the paresthesiae are due to neurotic conditions and it is not surprising that when an ointment of crushed lice--these insects being collected from barnyard {35} fowls or from hogs--was used, the suggestive influence was strong. Another important ingredient in ointments were portions of dead bodies. A bit of a mummy from the East was supposed to be particularly efficacious. Portions of the bodies of men who had been hanged, or of the moss that grew on the skulls of malefactors whose bodies had been long exposed in chains to the air, were also favorite ingredients. Plants and shrubs gathered in graveyards, especially in the dark of the moon, because on account of the terror of the place they were then harder to get, also had a great reputation. CHAPTER IV SIGNATURES AND PSYCHOTHERAPY _Similia similibus curantur_, like is cured by like, is a very old idea. According to the doctrine of signatures nature had put an external natural marking or a symbolical appearance or characteristic upon a plant, mineral or other object, to indicate its special usefulness for the treatment of certain diseases or for affections of certain organs. Sir Robert Boyle, sometimes spoken of as the father of chemistry, said, "Chymists observe in the book of nature that those simples that wear the figure or resemblance, by them termed signature, of a distempered part, are medicinal for that part or that infirmity whose signature they bear." On this principle yellow flowered plants were good for jaundice, because they resembled it in color. The blood stone was good for hemorrhage, and plants of certain forms were good for the organs or parts of man which they resembled. Certain plants were named with this idea. Kidneywort, liverwort, are typical examples. Scorpion grass, our familiar forget-me-not of the _genus myosotis_, was so-called because its spike resembled a scorpion's tail and was, therefore, good against the scorpion's sting, or against pains similar to that produced by such a sting. Some of the resemblances were extremely far-fetched, but in spite of the defect of nature's signature on them, they seem to have been effective in therapeutics. The plant, sometimes called Jew's ear, which can by an effort of the imagination be made to bear resemblance to the human ear, was, for instance, supposed to be a successful cure for diseases of that organ. We know now that there is no significance in this doctrine of signatures. It represented one phase of pseudo-science. But the idea of itself was enough to help people to throw off many symptoms, to relieve discouragement, to encourage them with the thought that they ought to get better; accordingly they took new heart, ate better, went out more, and as a result naturally slept better, and then nature did the rest. Signatures are an exquisite example of pure psychotherapy, as the initial agent and natural curative methods accomplishing the cure. Signature Details.--Some of the details of the doctrine of signatures are amusing. For a considerable period nuts were supposed to be a good brain food, and some traces of this idea are still extant, although there does not seem to be any better reason for it than the fact that many nuts have an arrangement of their lobes which resembles the conformation of the brain. On the same principle the Chinese use ginseng-root as a general tonic. The extract is not {36} of any special significance in medicine, though it has come to be much advertised in recent years, and the Chinese continue to pay high prices for it. The reason is that the root of the ginseng plant often resembles the human body. The more nearly this resemblance can be traced, the more virtue there is for the Chinese in the particular specimen of ginseng. The signature is on the roots. It is good for man because it looks like man, just as the nuts are good for the brain because they look like the brain. In modern times we are likely to think that we are far away from any such self-deception. But our deceptions have a more appealing pseudo scientific element in them. Fish was for some time considered a good brain food because fish has phosphorus in it and so has the brain. The two reasons have as much connection as that between nuts and the brain; or ginseng and man. Astrological ideas came in to help out ignorance and foster supposed knowledge. The sun and the stars were favorable planets and the moon unfavorable. If anything about a plant reminded the gatherer of the sun or the stars, then that plant was sure to be beneficial, especially in chronic diseases. If anything reminded him of the moon, however, then it could be expected to be maleficent in influence. Though childish, this had yet its power to help. The use of nitrate of silver, which in the old days was called lunar caustic, because it had, in a fresh state, a silvery, moon-like sheen, was largely a matter of signatures. The signature went both by similitude and by contrary. Since the lunar caustic supposedly had a moon quantity, therefore it would be good for moon-struck people--the lunatics of the old time and of our own time. As a consequence nitrate of silver was used in many obscure nervous and mental diseases. In epilepsy it was commonly employed. Even in our own times, entirely on empiric grounds, it was used for such severe organic nervous diseases as locomotor ataxia and sometimes to such an extent as to produce argyria. Undoubtedly, its use, with confidence on the part of the physician and suggestion and persuasion on the part of the patient, did much to relieve sufferers from discouragement and from such psychic disturbance of their general health as would have made their condition seem worse. Wines as Remedies.--How much suggestibility means in the choice of remedies that of themselves are more or less indifferent, may be well judged from the recommendations with regard to various wines that have been made by physicians. At one time and place it is red wine, at another it is white wine that is particularly effective. For certain nations the stronger wines, as Port or some of the Hungarian wines, have appeared to exercise specific effects. Except for the tastiness of these various brands or for other trivial accessories, it is probable that the therapeutic efficacy of the wine depends entirely on the alcohol and the effect of this upon the patient. In his "Memories of My Life," Francis Galton relates that Robert Frere, one of his fellow pupils with Prof. Partridge, who became through marriage in later years a managing partner in a very old and eminent firm of wine merchants, told him that the books of the firm for one hundred and fifty years showed that every class of wine had in its turn been favored by the doctors. In prescribing wine the doctrine of signatures probably had more to do with the special choice than anything else. Red wines were recommended for anemic people, because somehow the coloring was supposed to affect the {37} patient in such a way as to make up for the lack of coloring in the blood. On the other hand, the light, and especially the straw-colored wines, were recommended for liver troubles, because of their relation in color to the yellow of bile. Light wines were best for people who had more color than normal. Some wines are much stronger than others, and the alcohol, as in so many of our patent medicines, had a stimulating tonic effect, but in olden times this was supposed to constitute only the smallest portion of the efficiency of the wine, while the ingredients that made its color and taste were extremely important. The taking of red wine by anemic patients often proved suggestively valuable, and the alcoholic stimulation led them to eat more freely and look at things more hopefully and, consequently, to improve in health more rapidly than would have been the case had they not had the feeling that somehow they were actually consuming elements that would make their blood red. Precious Stones.--The doctrine of signatures applied particularly to precious stones, and many of the popular medical superstitions with regard to precious stones were founded on it. The blood stone was said to be efficient as a tonic: it stimulated people: it made the anemic stronger and ruddier if it were worn on the fingers. The torquise turned pale when its owner was in poor health. It was the stone that was an index of what has been called "the blues" or what one modern writer has dignified by the title "splanchnic neurasthenia." Dr. Donne wrote of: A compassionate turquoise that doth tell By looking pale, the owner is not well. It is probable that the pallor of the patient's hands as the background to the stone made the difference in its appearance thus noted. It became deeper in hue, as it were, when people were in ruddy health. The suggestive influence of such beliefs is easy to understand. It is even possible that the wearing of an amethyst did help to keep people from indulging in liquor to excess, for that is the traditional effect of the wearing of this stone, though its virtue seems to be founded on nothing better than the supposed derivation of the name from the Greek _a_ privative and _methuo_, "I get drunk," suggesting strongly to the wearer that he should not get drunk. The jacinth superinduced sleep and doubtless the strong suggestion of this supposed influence helped many sufferers from so-called insomnia to get sleep. The single fixed idea that now they must get to sleep would greatly help them. Pillows in the olden time were occasionally set with bits of jacinth, and there is even the record of bed-linen embroidered with it. This would probably be quite as effective as are hop-pillows in the modern time, for their main influence, as is also true of pine pillows, seems to be through suggestion. Some other traditions with regard to precious stones are harder to understand, yet may be explained. The owner of a diamond was supposed to be invincible. Diamonds represented money and money meant power. It is harder to explain the tradition that the possession of an agate made a man able and eloquent. The wide acceptance of the doctrine of signatures, and of allied ideas, as to the effect of precious stones and metal and jewelry upon disease, makes {38} it clear that the acceptance of a mental persuasion with the changes in habits that follow, may serve as the basis of a successful system of therapeutics. The materials associated with the idea had absolutely no more physical influence than does the carrying of a horse chestnut or a potato in the pocket serve to keep off rheumatism. CHAPTER V PSEUDO-SCIENCE AND MENTAL HEALING An interesting phase of psychotherapy is found in the history of the applications of new scientific discoveries to medicine. The development of every physical science has been followed by an attempt to apply its new principles and discoveries to the treatment of disease. Such applications have nearly always been followed by excellent results at the beginning. But almost without exception, the medical significance of these discoveries has, after a time, been found to be _nil_. When these discoveries were made they became the center of public attention. The announcement of their application to medicine then seemed natural and produced a feeling that another great therapeutic principle had been discovered. Sometimes wonderful therapeutic effects were noted. The chronic diseases particularly were helped for some time, at least, and practically all the affections that have mainly subjective symptoms were greatly relieved, or actually cured. After a time, however, when the novelty of the discovery wore off, its suggestive power was lessened and then the remedy lost its therapeutic power. ASTROLOGY Astrology is the typical example of pseudo-science in medicine. The stars, and particularly the planets and the moon, were supposed to have great influence on human destiny, human health, and human constitutions. Astrology was an organized body of knowledge over 3,000 years ago. Mr. Campbell Thompson has recently translated a series of 300 inscriptions from the cuneiform tablets in the British Museum, and Professor Südhoff of Leipzig has compiled all the references to medicine in these. The latter's studies show the extent which star influence was supposed to have over human health. A halo round the moon, an obscuration of the constellation of Cancer, the pallor of a planet in opposition to the moon, the conjunction of Mars and Jupiter, and other movements and phenomena of heavenly bodies were supposed to foretell the approach of disease for man and beast. As a consequence of this application of astrological knowledge to medicine, operations were performed only on certain favorable days or under favorable conjunctions of planets. An ailment that occurred at an unfavorable time, because of an unpropitious state of the heavens, would not be relieved until the motions of the stars brought a more benign conjunction. Observations seemed clearly to indicate that the stars actually had such influences. Even Hippocrates, though he insisted that "the medical art requires no basis of vain presumption, such as the existence of distant and doubtful factors, the {39} discussion of which, if it should be attempted, necessitates a hypothetic science of supra-terrestrial of subterrestrial belief," could not entirely get away from astrology. In his treatise on "Air, Water and Locality" he writes: "Attention must be paid to the rise of the stars, especially to that of Sirus as well as the rise of Arcturus, and after these to the setting of the Pleiades, for most diseases in which crises occur develop during these periods." In the second chapter he writes: "If anyone would be of the opinion that these questions belong solely in the realm of astrology, he will soon change his opinion as he learns that astrology is not of slight, but of very essential importance in medical art." (Personally I doubt the Hippocratean authorship of these passages, but they are surely very old.) The influence of the suggestions derived from astrology on human patients continued until almost the nineteenth century. There were many protests, especially from the Doctors of the Church, that the applications of astrology to medicine were false, but the practice continued. Both Kepler and Galileo drew horoscopes for patrons, and while Kepler doubted their value, he felt that in making them he was justified by custom. Galileo drew up the horoscope of the Grand Duke of Tuscany during an illness, and declared that the stars foretold a long life, but the Duke died two weeks later. But incidents of this kind did not disturb either popular faith or medical confidence in astrology as helpful, in prognosis, at least, if not also in diagnosis. Even so late as 1766 Mesmer was graduated at the University of Vienna, when it was doing the best medical work in Europe, with a thesis on "The Influence of the Stars on Human Constitutions." Later Astrology.--Few now realize that the curious figure printed at the beginning of most of our almanacs down to the present day is a relic of the time when physicians believed in the influence of the constellations over the various portions of the body. Even yet this idea has not entirely gone out of the popular mind, and hence its retention as something more than a symbol in our little weather books. Man was considered as a little world, a microcosm, and the universe, as men knew it--the sun, the moon and the planets together--constituted a macrocosm. It was observed that the bodies constituting the universe were circumscribed in their movements and never went out of a particular zone in the heavens which was called the zodiac. This zodiac was divided into twelve equal parts called signs or constellations. Similarly man's body was divided into twelve parts, of which each one was governed by a sign of the zodiac or by the corresponding constellation. The ram governed the head; the bull the neck; the twins the paired portions, shoulders, arms and hands; the crab the chest; the lion the stomach, and so on. The old surgical rule, as quoted by Nicaise in his edition of Guy de Chauliac's "Grande Chururgie," was that the surgeon ought not make an incision, or even a cauterization, of a part of the body governed by a particular sign or constellation on the day when the moon was in that particular portion of the heavens, for the moon was supposed to be the bringer of ill-luck and to have untoward influences. The incision should not be made at these unfavorable periods for fear of too great effusion of blood which might then ensue. Neither should an incision be made when the sun was in the constellation governing a particular member, because of the danger and peril that might be occasioned thereby. {40} Such rules were supposed to be founded on observation. Patients were influenced by them mainly because they were assured that the surgical treatment was undertaken under the most favorable influence of the stars and that all unfavorable influences had been carefully observed and eliminated. It is hard for us to understand how such ideas could have been maintained for so long in the minds of men whose other attainments clearly show how thorough they were in observing and how profoundly intelligent in reaching conclusions. We should, however, have very little censure for them, since from some other standpoint we find every generation, down to and including our own, jumping at conclusions just as absurd and just as inconsequential. And the practice of astrology was not without its value, for the reassurance given patients by the consciousness that the stars were favorable did much to relieve their anxiety as to the consequences of surgery, lessened shocks, hastened convalescence, and favored recovery. HERBAL MEDICINE What is thus exemplified in astronomy and astrology can be found in the story of every other science. After the knowledge of the stars, the next organized branch of information that might deserve the name of science related to plants. This, too, was introduced into medicine, and with more justification than astrology. Most of what was accomplished by early herbal medicine was, however, due to the influence produced on the mind rather than to any physical influence tending to correct pathological conditions. The shape and color of plants, their form, the appearance of their leaves, were all supposed to indicate medical applications for human ailments. The reason for their acceptance was entirely the ideas associated with the plants and not any definite therapeutic effect. Whatever good nine-tenths of all the herbal medication accomplished certainly was by means of the influence on the mind. We have abandoned the use of most herbal remedies in recent years, even many that are still retained in the pharmacopeia, because we have realized their physical incapacity for good. ALCHEMY When chemistry, under the old name of alchemy, began to develop, its first study was of minerals, and just as soon as a body of knowledge was acquired chemistry was applied to medicine. All the investigators were engaged in searching for the philosopher's stone, the substance by means of which it was hoped to change base metals into precious. It was generally believed that when this substance was found, it would have wonderful applications to human diseases and would transmute diseased tissues into healthy tissues in the same way that it transformed metals. It was felt that the philosopher's stone would be an elixir of life as well as a master of secrets for wealth. This would seem amusingly childish to us were it not for the fact that in radium we, too, seem to have discovered a philosopher's stone--a substance that transmutes elements. For some years after its discovery {41} we were inclined to think that it must have some wonderful application in medicine and in surgery, and we actually secured many good results until its suggestive value wore off. The fact that much had been learned about chemicals persuaded men that they must be beneficial to human beings. Thus they were taken with confidence and produced good results. When our modern chemistry developed out of alchemy a great variety of drugs began to be used, and long, complex, many-ingrediented prescriptions were written. Polypharmacy became such an abuse that the time was ripe for Hahnemann, whose principles, if carried to their legitimate conclusions, would require his disciples to give practically nothing to patients and treat them entirely by suggestion. MATHEMATICAL MEDICINE When mathematics developed, applications of that science were made to physiology and to medicine. Under the influence of Borelli, the school of Iatro-Mathematical medicine developed and it flourished long after him. Foster, in his "History of Physiology," says: Borelli was so successful in his mechanical solutions of physiological problems that many coming after him readily rushed to the conclusion that all such problems could be solved by the same methods. Some of his disciples proposed to explain all physiological phenomena by mathematical formulas and hypotheses concerning forces and the shapes and sizes of particles. MAGNETISM Magnetism occupied a large place in the minds of the great thinkers of the sixteenth and seventeenth centuries. There is no doubt that Paracelsus accepted, quite literally, what we embody in figurative expressions with regard to magnetism. To him the attraction of sex was magnetic. People had personal magnetism because they possessed physical powers by which they attracted others. He considered that these powers of attraction were expressions in human beings of the power of the magnet in the physical world, and that the two were literally equivalents. Kepler, one of the deepest thinkers of his time, evidently entertained the idea that the magnet represented the soul of the physical world, and that the planets were held in connection with the sun and their satellites with the planets, by magnetic attraction. We now call it the attraction of gravitation. We understand the force no better than before, but have changed the terms. Descartes theorized much along magnetic lines, and felt that by the use of certain expressions he was adding to knowledge, though he was really only multiplying terms. Human Magnetism.--How seriously the question of human magnetism was taken will perhaps be best appreciated from one old fallacy. For a long period it was supposed that human beings were so highly magnetic that if a man were exposed in an open boat, in perfectly calm weather, in the open sea, where no currents would disturb him, his face would turn to the north, under the same magnetic influences as caused the needle to point to the north! Many studies of magnetism were made at this time, so that the subject {42} attracted widespread attention. Columbus had made some rather startling observations on his voyage to America with regard to the declination of the magnetic needle, and, during the century following, Norman and Gilbert made interesting studies in the same subject. Father Kircher wrote two books on magnetism and there were a number of others written by university professors. Advantage was taken of this thoroughly scientific interest in magnetism to erect a whole body of pseudo-scientific medicine supposed to be founded on magnetic principles. The same theories were also applied to supposed explanations of various psychological phenomena. During the sixteenth and seventeenth centuries the application of magnets was a favorite treatment for a great many diseases. Especially were they useful in the treatment of muscular pains and aches and the chronic diseases which so disturbed men's minds. Many of the joint troubles of the aged, the muscular pains and aches that develop from the wrong use of muscles, and the vague internal discomforts which often disturb men so seriously, were cured by the application of magnets. Perkins' success with his tractors shows how much can be accomplished in this way. ELECTROTHERAPY The great development of pseudo-science in medicine remained for the era following the scientific investigation of electricity. With the discovery of the Leyden jar and its startling spark, a new and marvelous healing agent seemed to be at hand. It is quite amusing to read the accounts of the influence of the spark of the Leyden jar on the well and on the ailing. In my "Catholic Churchmen in Science" (Dolphin Press, Phila., 1909) I summed up the situation. Winckler of Leipzig said that the first time he tried the jar, he found great convulsions by it in his body; it put his blood into great agitation; he was afraid of an ardent fever, and was obliged to use refrigerating medicines. He felt a heaviness in his head as if a stone lay upon it. Twice it gave him a bleeding at the nose. After the second shock his wife could scarcely walk, and, though a week later, her curiosity stronger than her fears, she tried it once more, it caused her to bleed at the nose after taking it only once. Many men were terrified by it, and even serious professors describe entirely imaginary symptoms. The jar was taken around Europe for exhibition purposes, and did more to awaken popular interest than all the publications of the learned with regard to electricity, in all the preceding centuries. The extent to which the curative power of electric sparks from the Leyden jar was supposed to go is best appreciated from a list of the affections that one distinguished electro-therapeutist claimed could be not only benefited, but absolutely cured by its employment. It included pulmonic fever, under which title practically all the more or less acute diseases of the chest were included, and some at least of the sub acute; dropsy, by which was meant every effusion into the abdominal cavity no matter what its cause; dysentery, under which was included at that time not only the specific dysenteries but many of the summer complaints and some typhoid fevers; diarrhea, including all the intestinal diseases not already grouped under dysentery; putrid and bilious fever, under which category were assembled the worst cases of typhoid; typhus {43} fever, and all the other continued fevers, and any febrile condition reasonably severe for which no other term could be used; epidemic diseases, pest, anthrax, small-pox, cancer, gravel, diseases of the bladder and of the brain and spinal cord. The Leyden jar had no real effect on any of these affections, but doubtless the mental effect of this new remedy was quite sufficient to be of distinct therapeutic value in the milder forms of many of them. With Galvani's discovery of the twitching of the muscles of the frog there came a new impetus to the exploitation of electricity in medicine. Many felt that now it was beyond doubt that electrical energy bore some definite relation to vital energy--that one might be made to replace the other if indeed they were not more or less the same thing. This led to many applications of electricity in medicine. Students of physiology were convinced that they were getting close to the solution of the mystery of life, and their persuasion was readily carried over to the people of the time, so that electricity literally worked wonders on them. When the various electrical machines were invented and their use popularized, pseudo-science proceeded to exploit them, and succeeded, because the mechanical shock of the electric current proved a suggestive therapeutic stimulant. Gordon in the eighteenth century made the first practical frictional electrical machine, and soon some men were observing wonderful effects with it, though the charge was so small that it could actually accomplish little. Just after the invention of the voltaic pile in 1800 it came to be used in medicine with wonderful results. We are prone to think that electrotherapy is modern, but when electrical machines were quite crude, current strength small and potential low, old-time electro-therapeutists were recording their wonderful results and were getting just as marvelous effects as are reported now by enthusiasts. Considerable electro-medical literature existed a century ago when next to nothing was known of electricity. When, later, high potency currents came in and the Wimshurst and other powerful machines were invented, there was revealed at each novel invention a new horizon in electro-therapy and wondrous cures were reported. These continue to occur in the practice of a few favored individuals, though the general profession secures only some ordinary mechanico-muscular effects, which demand much time for real good to be accomplished and have nothing at all of the marvelous about them. The power of the pseudo-scientific aspect of electricity to influence patients, far from being lost in our time, has rather been increased. Our newspapers make their readers eminently suggestible because they constantly furnish suggestions, and nothing so strengthens a function of any kind as exercise of it. All sorts of electrical contrivances and apparatuses are advertised to cure various pains and aches. Many of them actually seem to relieve long-standing discomfort, though it is not through any electrical power that they do so, but entirely through their influence on the patient's mind. A museum of the electrical contrivances of various kinds for which absurdly high prices are paid at the present time and which people recommend to others because of having been benefited by them would be interesting. There are belts of many kinds, and rings, and medallions, and plates to be worn on the back and on the chest, and curiously shaped poles or "polar plates" resembling various organs, and pendants and armlets and anklets and insoles of many, many kinds, usually {44} going in pairs, one made in zinc and the other in copper, and worth exactly as much as the weight of copper and zinc in them, yet curing chronic ailments by suggestion, or at least bringing relief from many pains and aches complained of. LIGHT AND PSYCHOTHERAPY Just as electricity has always been therapeutically abused by those who have taken advantage of the suggestive influence of its marvelous energy, so each new discovery in light has been the source of pseudo-scientific applications to medicine. When the explanation of photography was first made, shortly after the middle of the nineteenth century, and it was demonstrated that it was the blue light, or at least that end of the spectrum, and even some of the rays beyond the visible violet, which were the most active in this regard, applications of this fact to popular medicine became the order of the day. We had a wave of "blue light therapy" that wandered over this country and sold tons of blue glass. People simply sat beneath the blue glass as the sun shone through it and were supposed to absorb the actinic rays and acquire new life. According to many who had tried them, the ultra-violet rays were quite equal in their power to heal and restore new vigor to old frames to the fabled elixir of life of the olden time. "Rheumatism (that universal ill of the unthinking) in all its hydra-headed forms disappeared," as one enthusiast declared, "before the blue light, like the mists of the morning before the sun." All this, though it is said that the movement had no more serious foundation than the desire of a manager of a glass factory, who found himself stocked up with blue glass through a mistake, to dispose of his surplus stock. He not only did so, but many other manufacturers turned special attention to the new product because of the demand for it. The newspaper advertising was through the reading columns. The results were heard of on every side. THE X-RAY That happened two generations ago, and it might be supposed that in the meantime there had been so much advance in popular education, and particularly in the diffusion of scientific knowledge, that such a self-deception on the part of scientists, and blind following by the people, could not take place in our time. Just as soon as Roentgen discovered the X-ray, however, we began to have applications of that wonderful agent to curative purposes. About 1900, scarcely five years after Roentgen's discovery, there was hardly an ailment that some one did not claim to have seen treated successfully by the X-rays. Especially was this true for the chronic and hitherto supposedly incurable diseases. All the forms of malignant disease were treated by the new agent, and some supposedly marvelous cures were reported. Everything chronic was favorably affected--lupus, rodent ulcer, eczema, acne rosacea, even tuberculosis of the lungs. At the time I was on the staff of a medical journal, and the favorable reports came in so thick and fast that it really looked for a time as though the surgery of the future was to be much simplified. It took but a year or two to show us how little of lasting therapeutic benefit there was {45} in the X-ray, in spite of the fact that it is a marvelous agent in its action upon living tissues. At the present moment it is used comparatively little, and its use is gradually diminishing, except for very special limited affections. RADIUM AND RADIO-ACTIVITY When radium was discovered, though it came so soon after the discovery of the X-ray and our disappointment with it, the old story of another pseudo-scientific medical application was told. For a time it looked as though radium might accomplish all that had been promised for the X-ray, though that promise had been so lamentably broken. Then, besides radium, we had brought home to us the whole class of radio-active substances, and their possibilities. The internal administration of radio-active liquids was one of the hopes of therapeutics. We had found it difficult to explain how many of the mineral waters produced the beneficial action credited to them when taken at the spring. We knew that artificially made waters of exactly the same chemical composition, so far as we could determine, did not have the same effect, nor even the waters themselves when taken at a distance from the spring. With the discovery of the radio-active principle there came the suggestion that possibly the main virtue of mineral waters at the spring was due to radio-activity. This would not be present in artificial water and would disappear from the natural water during shipment. This new idea was alluring, and it captured many. Radium seemed to be the new panacea. But we are discovering its limitations. It is of little avail in surgery; it is probably of less avail in medicine. As yet, however, we cannot say absolutely and must wait until results are determined. In the mean time many zealous advocates of the marvelous power of radio-activity to cure are exploiting it, apparently getting results and certainly making money. In the case of the mineral waters, also, the most important therapeutic element is probably the mental influence, which is strongest at the spring itself, where the suggestion of efficiency is repeated many times a day, and where the very atmosphere breathes confidence in the results to be obtained. SUGGESTION AND PSEUDO-SCIENCE These applications of science, or rather of supposed science, illustrate the influence of suggestion. The succession of events in each case is about as follows: The definite attitude of mental expectancy is created in the popular mind. As a consequence, with the application of the new scientific principle, patients cease inhibiting the recovery that would have come spontaneously before, only that they were self-centered and had their nervous energies short-circuited. Some are benefited by the habits of life that are established as a consequence of the belief that they are about to be cured, while before this they had been largely confining themselves to their houses, and had been refusing to take recreation or get diversion because of the conviction that they were ill. Finally, many of them had no real physical ills, but were suffering from mental ailments brought on by dreads and by a concentration {46} of attention on certain portions of the body which interfered with the normal physiologic action of those parts. Whenever strong mental impressions are produced, from any cause, results will surely follow, some of them marvelous. The supposed causes of these results will seem quite absurd to those who study them afterwards, but they were living realities to the sufferers. Nothing is more calculated to produce a strong mental impression than a newly discovered scientific fact with some supposedly wonderful application to humanity. The subsequent history of the application of scientific discoveries to medicine has been as invariably the same as the primary enthusiasm over each new therapeutic agent. After a time some people were not benefited. Physicians lost confidence in the power of the new remedial measure, whatever it might be. Patients were no longer impressed by the assurance that they would be benefited, and then the new application has either completely disappeared from our list of remedies, or has remained only to be used by a few, who still report good results from it. In spite of the constancy of this succession of events, we are still quite ready to take up with enthusiasm new discoveries in science and their applications to medicine. We have not yet lost the feeling, common in earlier centuries, that all science was meant for man and that every new scientific development must have some special reference to him. CHAPTER VI QUACKERY AND MIND CURES Not less interesting than the therapeutic results obtained by men who in good faith were using inert remedies that they thought effective, are the cures obtained by men who had good reason to know that the therapeutic methods they were using were quite inefficient. Their good results, often loudly proclaimed by healed patients, are obtained entirely through the patients' minds. Usually these men are supposed to possess some wonderful therapeutic secret, which they have obtained by a fortunate discovery, or by long years of study, though usually their discovery is a myth and their long years of study a fable. So long as people can be brought to believe in their powers many cures are sure to follow their ministrations. The real secret is their knowledge of human nature. They induce people to tap new sources of vital energy in themselves, and somehow they succeed in bringing to their aid this law of reserve energy. Besides, in many cases the real reasons why patients continue to have certain symptoms once they have been initiated, is that their worry about themselves inhibits their natural curative power. This inhibition is prevented or obliterated by the change of mind produced by the quack, and then the _vis medicatrix naturae_ brings about a cure. Probably the oldest story that we have of a quack in our modern sense of the word is found in the Arabian Nights, some of the stories of which were old even in the time of Herodotus. One day Galen, famous for his work at Rome in the second century after Christ, found a wandering healer pursuing his avocation in his front yard. He found also that this man succeeded in relieving certain patients for whom he had been unable to do anything. He {47} found that the medicines prescribed were likely to do harm rather than good, yet many of the patients were benefited. Galen succeeded in winning the man's confidence, who told him his story. He had been a weaver, but his wife thought he was not making money enough to support her properly, so she had advised him to become a leech. After taking lessons from a wandering quack, he set up for himself. When Galen inquired as to his method of making a diagnosis, he found that he did it entirely by his knowledge of human nature. He was even able to tell what was the matter with patients at a distance when friends came to demand medicine for them. We think that such ready deception was possible only in earlier times, when education was not widely diffused and when belief in superstitions was fostered. Any such idea completely ignores the modern status of the quack and the success that he meets among even the more intelligent members of the community. Indeed, with the diffusion of information in modern times the quack has secured a wider audience. Superficial ideas of science are disseminated by the newspapers and by the magazines, people think that they understand all about it, and then these ideas are turned to their own advantage by the irregular practitioners of medicine. We have quacks by the score in all the centers of population, making a livelihood by exploiting the ailing, and serving to no small extent to create a feeling of popular discontent towards the physician, because that serves the purpose of quackery. Indeed, it is during the past century or a little more that some of the most striking examples of quackery have occurred. Cagliostro.--Cagliostro, whose story is told in Dumas' "Memoirs of a Physician," and an excellent account of whose life may be found in Carlyle's "Miscellanies," is one of the great quacks and humbugs of history. He began his supposed medical work at Strasburg by the modest claim that during his travels in the East he had found a series of remedies which made old people young. In proof of his power to do this he exhibited his wife. She was a handsome young woman of very shady reputation whom he had married on his travels. She professed to be sixty years of age, though she was really under thirty and looked it, but she claimed that she had a son who had served for many years in the Dutch army. This imposition was so effective that in Strasburg, and subsequently in Paris, the charming pair collected large sums from wealthy old persons, especially from women on whom the marks of time had begun to show, and who expected, as the result of the treatment, to be shortly as young and as handsome-looking as Madame Cagliostro herself. We might think that it is quite impossible for any such a deception as this supposed renewal of youth to be practiced in our more enlightened day when popular education is so widely diffused. We must not forget, however, that the newspapers bring us evidence every month of some old person who is quite sure that something that was being done for him was, if not renewing his youth, at least giving him back much of his pristine vigor, healing his aches and pains, and enabling him to take up his work once more. In treating the ravages of old age, which would seem to be altogether beyond any influence of psychotherapy, some of the most striking results are obtained. New therapeutic methods for the old come into vogue every year. As they grow older, {48} people become discouraged and so do not exert even the natural energy that they have for the maintenance of health and the keeping up of strength. Their discouragement keeps them from exercising enough, and this decreases appetite and sleep, and as a consequence there are many disturbances of function. All of this disappears as soon as they feel encouraged. Brown Sequard and his extract of testicular tissues is a typical example of how strong suggestion may influence the old and make them think that they are renewing their vigor and strength, and even their youth. Perkins, Prince of Quacks.--Shortly after Cagliostro an American succeeded in using a very simple idea to gain world fame and at the same time to make an immense amount of money. He was a Connecticut Yankee with the typical name, Elisha Perkins. Dr. Perkins must have been born under a lucky star; at least he lived in fortunate circumstances for his purposes. Galvani's discovery of the twitchings that occur in the frog's legs when a nerve-muscle preparation or its equivalent was touched by metals in contact, had aroused world-wide discussion as to the place of electricity and magnetism in biology. Volta's brilliant experiments, which led to the invention of the Voltaic Pile, still further increased men's interest in this subject. It was then that Dr. Perkins came to exploit these electrical and magnetic ideas in medicine by means of a very simple invention. It was indeed the simplicity of his apparatus that made its appeal even more wide than would otherwise have been the case, and, be it said, left a larger measure of profit for the inventor. Oliver Wendell Holmes in his "Medical Essays" [Footnote 4] has told the story of what may be called the rise and fall of tractoration. Any physician who wants to appreciate the real significance of cured cases should read Holmes' essay. We quote: [Footnote 4: Houghton, Mifflin Co., Boston.] Dr. Elisha Perkins was born at Norwich, Connecticut, in the year 1740. He had practiced his profession with a good local reputation for many years, when he fell upon a course of experiments, as it is related, which led to his great discovery. He conceived the idea that metallic substances might have the effect of removing diseases, if applied in a certain manner; a notion probably suggested by the then recent experiments of Galvani, in which muscular contractions were found to be produced by the contact of two metals with the living fiber. It was in 1796 that Perkins' discovery was promulgated in the shape of the Metallic Tractors, two pieces of metal, one apparently iron and the other brass, about three inches long, blunt at one end and pointed at the other. These instruments were applied for the cure of different complaints, such as rheumatism, local pains, inflammations, and even tumors, by drawing them over the affected parts very lightly for about twenty minutes. Dr. Perkins took out a patent for his discovery, and traveled about the country to diffuse the new practice. [Footnote 5: (Transcriber: This footnote is not numbered in the text but appears to refer to the preceding paragraph.): In one of Plautus' plays there is a curiously interesting expression that is recalled by this subject. The dramatist described one of his characters, Sosia, as thrown into a sleep by the manipulations of Mercury. These manipulations are described as _tractim tangere_--that is, to touch strokingly. It would remind one very much of Perkins' Tractors, and in this regard the fact that Mercury was to the Romans, besides being the messenger of the gods, the divinity of thieves, seems not without interest.] Just what the tractors were composed of may be found in the description of them filed with an application for a patent in the Rolls Chapel Office in London. They were not simply two different metals, but a combination of many metals, with even a little of the precious metals in them, partly because {49} of the appeal that this would make to the multitude, as chloride of gold did to our own generation, but doubtless mainly because the claim of precious metals entering into the composition enabled the inventor to sell his tractors at a better price. Dr. Holmes continues: Perkins soon found numerous advocates of his discovery, many of them of high standing and influence. In 1798 the tractors had crossed the Atlantic, and were publicly employed in the Royal Hospital at Copenhagen. About the same time the son of the inventor, Mr. Benjamin Douglass Perkins, carried them to London where they soon attracted attention. The Danish physicians published an account of their cases in a respectable octavo volume, containing numerous instances of alleged success. In 1804 an establishment, honored with the name of the Perkinean Institution, was founded in London. The transactions of this institution were published in pamphlets, the Perkinean Society had public dinners at the Crown and Anchor, and a poet celebrated their medical triumphs. [Footnote 6] [Footnote 6: "See pointed metals, blest with power t' appease The ruthless rage of merciless disease, O'er the frail part a subtle fluid pour, Drenched with the invisible galvanic shower, Till the arthritic staff and crutch forego And leap exulting like the bounding roe!"] Miss Watterson [Footnote 7] tells how he attracted attention. Like all successful quacks, he had an inborn genius for advertising. [Footnote 7: "Mesmer and Perkins's Tractors," _International Clinics_, Vol. III, Series 19. 1909.] He lived in the house once occupied by John Hunter [how characteristic this is--the first quack we mentioned in this chapter, took up his work in Galen's front yard], and in 1804 the Perkinean Institute was opened, but by the end of 1802, 5,000 cases had already been treated. Lord Rivers was president. Sir William Barker, Vice-President [Prominent legislators, lawyers, bankers always lend their names.] Twenty-one physicians, nineteen surgeons, and the leading veterinaries succumbed to the influence of the magic tractors. One "eminent physician" who had had 30 guineas from a country patient and had done him no good was very angry when the sick man took to Perkinism. "Why, I could have cured you in the same way with my old brick-bat or tobacco pipe, or even my fingers." "Then why, sir," answered the patient in a stern voice (Perkins quotes this), "did you dishonorably pick my pocket when you had the means of restoring me to health?" In some 176 pages young Perkins gives us the pick of 2,000 cases who had, of course, been foolish enough at first to put faith in the ordinary physician and his drugs. In Bath, particularly, where aristocratic London went, as they do to-day, to repair the damage wrought by a season in town, the Tractor Cure was the talk of the place. But an enemy dwelt there, a Dr. Haygarth, an unbeliever. He, with a certain Dr. Falconer, fabricated a pair of false tractors. Five cases of gout and rheumatism were operated on by the conspirators, who discussed in a light tone the wonders of magnetism as they described circles, squares and triangles with the sham tractors. "We were almost afraid to look each other in the face lest an involuntary smile should remove the mask from our faces," says Haygarth, but the two assistant doctors, unaware of what was being done, were almost converted to Perkinism when they saw the five patients slowly mending under the treatment. One man experienced such burning pain that he begged to wait till the next day. [Footnote 8] [Footnote 8: Compare the first effects of the Leyden Jar, related in the chapter on Pseudo-Science.] So rapid, and so many were the hospital cures wrought by these two doctors, that patients crowded to them and they could hardly spare five minutes to eat. They amused themselves inventing other instruments made of common nails and sealing wax, and effected with them cures, while they sent a pair of false tractors {50} to Sir William Watson in London and Dr. Moncriffe in Bristol, who operated with them with wonderful results. It must not, however, be thought that the uneducated, or the unskilled, or even merely unoccupied, were the only ones taken in by the supposed power of Perkins' Tractors. As we have seen, many physicians did not hesitate to avow themselves publicly as believers in this new and marvelous application of magnetism to human healing. It is true that the only thing we know about the men who became advocates of this new instrumental therapeusis, is their connection with it. The attention of the scientific world was rather cleverly managed. Dr. Perkins presented a pair of his tractors and the book that he had written about their use to the Royal Society. The custom of that learned body was to accept such presentations by a formal letter of thanks and place the objects and books on their shelves. No formal investigation of the claims to scientific consideration of such presentations was made. All possible advantage was taken of the fact that the Royal Society had accepted the new invention and had publicly thanked the discoverer for it. How characteristically recent this old story is; it is renewed on every possible occasion and wears all the familiar aspect of modern devices for securing recognition and obtaining the apparent approbation or recommendation of some scientific society or institution. We had an example of it a few years ago when a nostrum exploiter signed the register of an International Congress immediately after a great medical investigator and then used a photograph of the names for advertising purposes. How did the tractors secure the vogue they enjoyed? Those who believed in them did so not because of the scientific theory that animal magnetism or magnetic influence was behind them, nor because of the plausible ways of the Connecticut Yankee, but because of the unquestioned and unquestionable facts of actual healing that they saw in connection with the use of the tractors. Every one of these applications of science to medicine that has proved to be pseudo-scientific after enthusiasm subsides has made its appeal through the cures effected by it. Cures are what Eddyism advances to support its claims, cured patients are presented as their most effective argument by the osteopaths, cured symptoms are the proofs for Hahnemannism, but none of these systems of treatment ever cured as many cases in a corresponding time as did Perkins' tractors. They cured all sorts of physical ills, but their only effect was exerted through the mind. Holmes wrote: Let us now look at the general tenor of the arguments addressed by believers to sceptics and opponents. Foremost of all, blazoned at the head of every column, loudest shouted by every triumphant disputant, held up as paramount to all other considerations, stretched like an impenetrable shield to protect the weakest advocate of the great cause against the weapons of the adversary, was that omnipotent monosyllable which has been the patrimony of cheats and the currency of dupes from time Immemorial--Facts! Facts! FACTS! First came the published cases of the American clergymen, brigadier-generals, almshouse governors, representatives, attorneys and esquires. Then came the published cases of the surgeons of Copenhagen. Then followed reports of about one hundred and fifty cases, published in England, "demonstrating the efficacy of the metallic practice" in a variety of complaints, both upon the human body and on horses, etc. But the progress of facts in Great Britain did not stop here. Let those who rely upon the numbers {51} of their testimonials, as being alone sufficient to prove the soundness and stability of a medical novelty digest the following from the report of the Perkinistic Committee. "The cases published (in Great Britain) amounted, in March last, the date of Mr. Perkins' last publication, to about five thousand. Supposing that not more than one cure in three hundred, which the tractors have performed, has been published, and the proportion is probably much greater, it will be seen that the number, to March last, will have exceeded one million five hundred thousand!" It is not surprising that with such "facts" behind them the tractors attracted deep and wide attention. A contemporary tells of it and the fate of the inventor: A gentleman in Virginia sold a plantation and took the pay for it in tractors. Nothing was more common than to sell horses and carriages to buy them. But the worst (or the best) of it was, yellow fever was raging in New York, and Perkins thought he could cure the fever with the tractors and fell a victim to the fever himself. Success of Quackery.--Always in the history of quackery and, indeed, in the history of all therapeutics, the appeal is to the cures that have been effected. This is the only evidence, of course, that can be adduced for the development of therapeutics, and yet the history of medicine makes it clear how carefully supposed cures must be analyzed if they are really to mean anything. Mesmer could adduce thousands of cured cases. Perkins could do the same. Every quack in history, from Galen's weaver, who became a leech, down to the last street corner nostrum vendor, does the same thing. When on the strength of supposed cures, then, a new system of therapeutics is introduced, it is much more likely than not that there is no foundation for the claims made. We have had ever so many more experiences of disappointment after the introduction of remedies which cured at the beginning of their history, than we have had of remedies that maintain themselves after prolonged experience. It is the attitude of scepticism and suspended judgment until after a remedy or method of treatment has been tried on many different kinds of cases in varying circumstances that constitutes the only efficient safeguard against repeating the unfortunate errors of old times in the matter of drugs and remedial measures. If the public could be made to realize this, they would be much less easily taken in. What the quacks cure are not always imaginary ills, but often ills that are very real, at least to the patients, and the symptoms of which are relieved by the confidence aroused in the new remedy and the representations of the supposed discoverer, who, in spite of the exaggerated claims which he makes, somehow succeeds in catching the trust of patients. Very often this process initiated by the quack is really only the beginning of the cure. In most people a vicious circle of pathological subsidiary causes is formed when anything becomes the matter. Patients are persuaded that a serious illness is ahead of them. This keeps them from exercising as much as before. Becoming overcareful of their diet, they reduce it below the normal limit for healthy activity. This causes them to have less energy for work and disturbs their sleep. Then a host of minor symptoms, supposed to be due to the disease, whatever it is or they think it is, but really consequent upon the unhealthy habits that have formed, begin to develop. Just as soon as confidence in their power to regain health is restored to these people, a virtuous circle, {52} to use the Latin word virtue in its etymological sense, of strength and courage, is formed. Everything conspires to stimulate the patients; they live more naturally, the subsidiary symptoms consequent upon their bad habits disappear and the disappearance of each one of them means for the patients a new assurance of triumph over disease. They attribute every improvement to the remedy they happen to be taking, though most of them are due to the changes in their habits, their diversion of mind, and the new energy released by their sense of encouragement. An excellent example of how some of these mental persuasions in quackery act, and of how the cure is often really due to the physician who previously treated the case, though it is credited to the quack, may be found in the story that Hilton tells in his "Rest and Pain": When this patient was first seen by a surgeon, he was thought to be laboring under some disease of the bladder and kidneys, for he had severe lumbago, pain over the bladder, and offensive urine. There had been no suspicion of anything wrong as regards the spine. He was a master painter and a house decorator, and was monstrously conceited, thinking himself right and everybody else wrong. When I explained to him, after careful examination, that the spine was the cause of the symptoms, he was not satisfied with my opinion and without my knowledge consulted Sir Benjamin Brodie, who also assured him that his spine was diseased and told him that he must rest it by lying down. To this he then assented. As he could not be controlled in his own house, I persuaded him to go to Guy's Hospital, where he had got nearly well; but he was very impatient, and would not remain long enough under my care to be quite cured. He returned home, gradually improved, and was getting quite well when some pseudo friend advised hydropathy and homeopathy--it did not matter which of the two--as "the thing" to cure him. After a few months he was perfectly restored, not by either hydropathy or homeopathy, but, no doubt, by nature. The man, however, feels convinced that hydropathy and homeopathy cured him. It so happens, gentlemen, that sometimes we do not get the degree of credit which perhaps belongs to us. To Mr. Hilton's reflections one is tempted to add that many of these patients, after having been seriously ill, cannot bring themselves to think that they will gradually get well by the forces of nature. Even after they have improved very much they are still inclined to think that that improvement is illusory or will relapse because they have not been "cured," that is, actively treated, in some way so that a "cure" should result. When they are nearly well, because of properly directed rest and nursing, someone recommends some irregular form of treatment. They take it up and this gives them confidence that they are being cured. This state of mind makes the ultimate steps of their recovery more rapid than it otherwise would be. As a consequence, the irregular gets the credit. Immediately after this case Mr. Hilton tells the story of another case in which a "rubber" got all the credit for the cure. It is evident that the modern osteopath has only somewhat systematized what had been in existence generations ago. All this tendency of human nature to respond to anything that is done for it, provided the promise of cure goes with it, is taken advantage of by the quack, sometimes unconsciously, for his own purposes. Results, as a rule, are secured, in spite of the remedies that he suggests, which in most cases do harm rather than good. Of the thousands of remedies that have been introduced by quacks, not one now remains, though every one of them produced {53} wonderful cures on a great many patients at some time or other. It is the duty of the physician to secure just as good results honestly. He must influence the patient's mind favorably so as to bring about a modification of habits and a hopeful outlook on life, in spite of whatever ailment there may be. If he can do so he will have in his hands the best therapeutic measure that has been employed in all the history of medicine. It is the most universally applicable. It will cure, that is help, all forms of disease. It will relieve many of the symptoms of even incurable diseases. It will occasionally arouse the resistive vitality of the patient to such an extent that even apparently incurable diseases will be overcome. This is the lesson that the modern student of medicine must draw from the history of quackery. CHAPTER VII NOSTRUMS AND THE HEALING POWER OF SUGGESTION A striking illustration of the power of the mind to bring about the cure of ailments and symptoms of every sort is found in the history of the many nostrums and remedies that have worked wonders for a time and later proved to be inert or even harmful. The ordinary definition of a nostrum includes the idea of secrecy. At all times in the world's history fortunes have been made out of such remedies. They appeal not only to the uneducated, but also to those who are supposed to be well informed, and this in spite of the fact that generally the remedies are claimed to do good for nearly every form of disease, and it must be evident to anyone, after a moment's serious thought, that the one idea of their inventor is not to benefit patients, but to make money. With the multiplication of newspapers and magazines, there has been a great increase in these secret remedies and of their users. Apparently all that is needed for many people who are ailing, or think they are ailing, is to be told in a more or less impressive way that some remedy will cure, and then it proceeds to do them good. There is a general impression abroad that some of these remedies represent great discoveries in medicine, and the feeling of most of those who take them is that the inventor has found a new and wonderful remedy. During all the centuries such secret remedies have come and gone, and not one of them has proved to be of lasting value. Just as soon as its composition is no longer a secret it begins to fail. It is, therefore, evident that its effect was entirely due to influence on the mind and not at all to any influence on the body. The stories of the origin of these remedies bear a striking similarity. There are two variants on the theme: either the inventor is supposed to be an earnest student of science, devoting himself to profound research for many years and finally finding some wonderful secret of nature hitherto hidden from men; or else the remedy has been discovered by happy accident, and some chronic sufferer pronounced by the most eminent physicians to be hopelessly incurable has in despair turned to the now method, caring little really, so discouraged is he, whether it does good or ill, and wakes up to find that he is on the high road to recovery, apparently having been directed by Providence in the use of the remedy in question. Overflowing with gratitude, he {54} wants to share the heaven-sent blessing with all mankind--for a valuable consideration. The Weapon Ointment.--Among the most famous nostrums, and a striking example of the great rôle played in therapeutics by mental influence and coincidence, is the Unguentum Armariam or Weapon Ointment. This famous remedy would cure any wound made by a weapon, if it could only be employed before the fatal effects were absolutely manifest. There was an abundance of evidence that it stopped the pain, checked the bleeding and initiated the restoration of the patient to health. We know the remedy not from traditions of its use among the uneducated, but from descriptions that we have by men who were among the best educated of their time, and that by no means an era of dullards. The story of this infallible remedy is all the more surprising because it was not applied to the wound itself, nor indeed to the sufferer at all, but _to the weapon which inflicted the wound_. Nay, it was well authenticated that, where the weapon could not be secured for inunction, if the ointment were applied to a wooden model of the weapon, the cure followed with almost, though, it was confessed by some, not quite so much assurance as in the fortunate case of the weapon being available. The story has been so well told by Oliver Wendell Holmes in his "Medical Essays" [Footnote 9] that it seems best to retell it in abstracts from his "Homeopathy and Its Kindred Delusions." He says: [Footnote 9: Houghton Mifflin Co., Boston.] Fabricius Hildanus, whose name is familiar to every surgical scholar, and Lord Bacon, who frequently dipped a little into medicine, are my principal authorities for the few circumstances I shall mention regarding it. The Weapon Ointment was a preparation used for the healing of wounds, but instead of its being applied to them, the injured part was washed and bandaged, and the weapon with which the wound was inflicted was carefully anointed with the unguent. Empirics, ignorant barbers, and men of that sort are said to have especially employed it. _Still there was not wanting some among the more respectable members of the medical profession who supported its claims_. [Italics ours.] The composition of this ointment was complicated, in the different formulas given by different authorities; but some substances addressed to the imagination, rather than the wound or weapon, entered into all. Such were portions of mummy, of human blood and of moss from the skull of a thief hung in chains. Hildanus was a wise and learned man, one of the best surgeons of his time. He was fully aware that a part of the real secret of the Unguentum Armarium consisted in the washing and bandaging the wound and then letting it alone. But he could not resist the solemn assertions respecting its efficacy; he gave way before the outcry of facts (!), and therefore, instead of denying all their pretensions, he admitted and tried to account for them upon supernatural grounds. Holmes says further: Lord Bacon speaks of the weapon ointment, in his Natural History, as having in its favor the testimony of men of credit, though, in his own language, he himself "as yet is not fully inclined to believe it." His remarks upon the asserted facts respecting it show a mixture of wise suspicion and partial belief. He does not like the precise directions given as to the circumstances under which the animals from which some of the materials were obtained were to be killed, for he thought it looked like a provision for an excuse in case of failure, by laying the fault to the omission of some of these circumstances. But he likes well that "they do not observe the confecting of the Ointment under any certain constellation; which is commonly the excuse of magical medicines, when they fail, that they {55} were not made under a fit figure of heaven." It was pretended that if the offending weapon should not he had, it would serve the purpose to anoint a wooden one made like it. "This," says Lord Bacon, "I should doubt to be a device to keep this strange form of cure in request and use, because many times you cannot come by the weapon itself." And in closing his remarks on the statements of the advocates of the ointment, he says, "Lastly, it will cure a beast as well as a man, which I like best of all the rest, because it subjecteth the matter to an easy trial." It is worth remembering that more than 200 years ago, when an absurd and fantastic remedy was asserted to possess wonderful power, and when sensible persons ascribe its pretended influence to imagination, it was boldly answered that the cure took place when the wounded party did not know of the application made to the weapon, and even when the brute animal was the subject of the experiment, and that this assertion, lie as we all know it was, came in such a shape as to shake the incredulity of the keenest thinker of his time. It is interesting to follow up some of the controversies among scientific men with regard to the weapon ointment, for they serve to show how the remedy came to maintain its prominence for so long. Podmore, in his "Mesmerism and Christian Science" (London, 1909), tells the story of the controversy between Goclenius, a professor of medicine at the University of Marburg, who published as the Inaugural Thesis for his professorship, a treatise on the "Weapon Salve," and Father Roberti, a Jesuit scientist and philosopher, whose final treatise in the controversy was entitled after the lengthy fashion of titles in that day, "Goclenius Corrected Out of His Own Mouth; or, The Downfall of the Magnetic Cure and the Weapon Salve." The decision of the controversy was eventually referred to the great physician of the time. Van Helmont, who decided that both disputants were partly wrong, the Jesuit erring most, but that above all Goclenius should distinguish between the cases when the weapon had blood on it and when it had not. When there is blood on the weapon, he held, then the salve is always effective; when there is not, then much stronger remedies were required. In both cases, of course, the salve or ointment was applied to the weapon. In the midst of this discussion of the points at issue, it is interesting to note Van Helmont's opinion with regard to many curious things used in medicine at that time. He insists that Goclenius makes a mistake in attributing therapeutic power alone to the moss taken from the skull of a condemned criminal who had been hung in chains. This material, under the name of _usnea_, was apparently quite popular in prescriptions for various chronic ills, and especially those that we now recognize as prolonged neurotic affections. Van Helmont emphasizes the fact that the experience of all physicians shows that material taken from the heads of condemned criminals executed in other ways, as, for instance, those broken on the wheel, may be just as effective. Van Helmont conceived of the magnetic and sympathetic feeling as a natural process. All the force of the stars might be concentrated in objects that had been beneath their beams for a long time, and this might be communicated in some wonderful way to patients so as to supply defects of vitality. Such defects of vitality Van Helmont's prescriptions actually were compensating, but the source was in the patients themselves--that reservoir of surplus energy which remains unused unless some strong suggestion brings it out. Sympathetic Powder.--After the weapon ointment, the best known of the nostrums of older times is probably Sir Kenelm Digby's famous Sympathetic {56} Powder, which Dr. Holmes talks of as even better known than its great therapeutic predecessor. This, too, was a wonderworker. Unlike the Unguentum Armarium, however, its composition was simple. It was nothing else than copper sulphate which had been allowed to deliquesce to a white powder. This powder would cure any injury as infallibly as the weapon ointment. It, too, was not applied to the wound, but to the _bloodstained_ garments (Van Helmont's distinctions between the bloody and the bright weapon should be recalled) of the wounded person. The patient did not need to be present at the time the application was made. He might be far away and yet its efficacy was, according to many very intelligent and highly educated persons, quite assured. For the sympathetic powder we have one of the stories of far-fetched discovery that have since become so familiar. A missionary, traveling in the East, was said to have brought the recipe to Europe about the middle of the seventeenth century. The Grand Duke of Tuscany, in whose dominions the missionary took up his residence, heard of the cures performed by him and tried by offers of money and favor to obtain the missionary's secret, but without success. Sir Kenelm Digby, however, who was traveling in Italy, happened by good fortune to do a favor for the missionary, and put him under such deep obligations that he felt the only way he could properly repay his benefactor was to confide to him the composition of this wonderful remedy. Sir Kenelm Digby was at this time one of the best known of English scholars. After having reached distinction in the English navy, he had devoted himself to literature, to philosophy, and to politics. He had devoted much time to the old books of alchemy. Therefore, the offer of this precious piece of information especially appealed to him. On his return to England he proceeded to use it for the benefit of his friends, and it created a sensation. The French dictionary of the Medical Sciences tells the story of the application of the powder for the first time in England and of the subsequent use of it, especially on the nobility of England: An opportunity soon presented itself to try the powers of the famous powder. A certain Mr. Howell, having been wounded in endeavoring to part two of his friends who were fighting a duel, submitted himself to a trial of the sympathetic powder. Four days after he received his wounds, Sir Kenelm dipped one of Mr. Howell's garters in a solution of the powder, and immediately, it is said, the wounds, which were very painful, grew easy, although the patient, who was conversing in a corner of the chamber, had not the least idea of what was doing with his garter. He then returned home leaving his garter in the hands of Sir Kenelm, who had hung it up to dry, when Mr. Howell sent his servant in a great hurry to tell him that his wounds were paining him horribly; the garter was therefore replaced in the solution of the Powder, and the patient got well after five or six days of its continued immersion. King James I, his son, afterwards Charles I, the Duke of Buckingham, then Prime Minister, and all the principal personages of the time were cognizant of this fact; and James himself, being curious to know the secret of this remedy, asked it of Sir Kenelm, who revealed it to him, and his majesty had the opportunity of making several trials of its efficacy, _which all succeeded in a surprising manner_. Tar Water and Therapeutic Faith.--One further story of an old nostrum deserves to be told because of the distinction of its chief promoter, who did not, however, as do most of the nostrum promoters, make a fortune by it. {57} This is the incident of Bishop Berkeley and his tar water. Berkeley was one of the leaders of thought of the eighteenth century. At one time he came to America with the idea of enlightening the ignorance of the colonists and of founding a school of philosophy. Besides being one of the most learned men of his time, he was one of the best. He was known for his gentleness, his unselfishness, and his lack of pretension. Yet all of these virtues were unable to save him from falling a victim to a medical delusion. One of his essays is on the value of tar water in medicine, and is entitled "Siris, a Chain of Philosophical Reflections and Inquiries Concerning the Virtues of Tar Water," etc. Tar water was prepared by stirring a gallon of water with a quart of tar, letting it stand for several days, and then pouring off the clear water. It, in fact, retained scarcely more of the tar than the odor. According to the great philosopher, this not only cured, but prevented diseases. The list is, indeed, so long that it is hard to understand how the claims for it could have received any credence. They did, however, and Berkeley himself, and many of his friends, were cured of many and various ills, and were protected from many more by its frequent use. The odor was the factor that proved of suggestive value and set free the springs of vital energy. Sarsaparilla.--It might be thought that such deception of self and others as has been illustrated in the weapon salve and sympathetic powder would be impossible in our enlightened day. Anyone who thinks so forgets certain incidents of recent times. The story of sarsaparilla is a striking illustration. Few drugs have been more popular in the last half century, and it is even yet popularly supposed to be a wonderful tonic, a cure for many diseases. During the first half of the nineteenth century, when the humoral theory of the causation of diseases was generally accepted, certain German physicians thought they observed that a decoction of sarsaparilla was a sovereign remedy for various ailments having their origin in the blood. The blood was at that time supposed to become impure for many reasons, and the possibility of neutralizing such impurity by medical measures was seriously attempted. As Virchow used to insist, the humoral pathology still holds its ground in popular estimation, and so blood purifiers are favorite remedies, and will doubtless continue to be for at least another generation, until cellular pathology secures a hold on the popular mind. Sarsaparilla came in, then, as a great blood purifier, and was used for ten years by many of the physicians of the world, confident that they were obtaining excellent results from its use. After a time, however, further study of the drug showed that it was inert. Gradually the employment of sarsaparilla as a remedial agent ceased, though it continued to be used as an elegant vehicle in the prescription of nauseating remedies. Only after it had been thus abandoned by the regular profession, was it taken up extensively by others who advertised its virtues widely and secured a great clientele for it. Probably more money has been spent on sarsaparilla during the last fifty years than on any other single drug. Many millions were every year appropriated by rival concerns to advertise its virtues. It has been possible at any time during the last half century to secure any number of people who were willing and ready to declare--and most of them convinced of the truth of what they said--that various preparations of {58} sarsaparilla had cured them of long-standing ills, and that they considered it a life-saving remedy. The efficient ingredient in the sarsaparilla, so far as any of its various preparations have seemed to do good, has not been anything that was in the bottle, but the printer's ink that was absorbed from the outside of it. People were persuaded that they would get better, and, as far as most of them were concerned, this was of itself quite sufficient to turn the scale in favor of improvement that led to the obliteration of symptoms. So long as these symptoms were a source of worry and trouble to them, they continued to be quite incurable. Just as soon as the inhibition of nervous energy, due to worry and over-attention to their sensations, stopped, then the natural force of the body was sufficient to remove the sources of complaint. Psychology, Old and New, of Remedies.--Men have always known how to take advantage of the possibility of influencing patients' minds by wondrous claims for remedies. Anyone is sadly deceived who thinks that it is only in recent times that men have learned to make their advertisements of nostrums suggestive by the promises made or that we have developed the psychology of advertising to such a degree as to appeal to the ailing more forcibly and surely than was done in the past. Here is the announcement that went with a remedy in old Irish medicine more than 1,000 years ago. It was, according to its inventor, "a preservative from death, a restorative for the want of sinews (strength), for the tongue-tied, a cure for swelling in the head, and of wounds from iron and of burning by fire, and of the bite of the hound; it preventeth the lassitude of old age, cures the decline, the rupture of the blood vessels, takes away the virulence of the festering sore, the fever of the blood, the poignancy of grief--he to whom it shall be applied shall be made whole." The announcement ended up with the panegyric "extolled be the elixir of life bequeathed by Diancecht to his people; by which everything to which it is applied is made whole." When it is noted that, besides death and loss of muscle power and aphasia and wounds and burns and bites, it also cures old age and consumption (for that is what is meant by decline) and hemorrhages, and probably aneurysms, and fevers and also grief, there are not many modern panaceas that exceed it in power. Always, as in this Irish announcement of the olden time, the climax of the advertisement is a note of exultant praise for the inventor who has brought such a magnificent blessing to mankind. The ways of the nostrum vender are ever the same. Roman Nostrums.--How old are all these methods, and how little human nature has changed through all the centuries! The patent medicine men of Rome in the early Christian eras made use of just the same methods that are employed to-day. Friedländer, in his "Roman Life and Manners Under the Early Roman Empire," tells the story well. Many remedies were known by special arbitrary names, instead of descriptive names recalling the ingredients. Sometimes they were named after famous physicians who had used them, or were said to have done so; again, the preparations were named after persons of distinction who actually, or supposedly, were cured thereby, much as, in our own day, cigars are named after poets, statesmen and pugilists. The titles of some of these preparations, for instance, were "Ointment for Gout, Made for Patroculus, Imperial Freedman--Safe Cure"; "Ointment for {59} Aburnius Valens" (probably the famous jurist) called the "Expensive Ointment"; "Eye Salve with Which Florus Cured Antonia, the Wife of Drusus (the Emperor's son) After the Other Doctors had Nearly Blinded Her." Many of these remedies were labeled "instantaneous," "safe," "sure cure," "Harmless remedy," and the like. Frequently euphonious names, sometimes from the Greek, were chosen: Ambrosia, Anicetum, Nectarium, for the promoters evidently knew the satisfying effect, on both patient and physician, of a mystifying foreign name. _Proprietary Remedies_.--A corresponding abuse very like that of our own time was with reference to proprietary medicines. Physicians, instead of compounding their own, accepted those made by others with the exaggerated claims for them, used them on patients, transferring their own confidence in them to the patients, thus producing cures which, after a time, proved to be due entirely to the influence on the patient's mind. Pliny, the elder, complains that physicians of his time (the first century after Christ) often bought their remedies so as to avoid the trouble of preparation. He evidently refers to compounds supposed to be curative for various affections; for Friedländer says that "often the physicians did not know the exact ingredients of the compounds that they used and should they desire to make up written prescriptions, would be cheated by the salesmen." Both Galen and Pliny complain that physicians used ready-made medicines, instead of original prescriptions carefully prepared by or under the supervision of the physicians themselves. It is evident that the proprietary remedy had come into existence thus early, and that various drug manufacturers made specialties which physicians, following the line of least resistance, found it easy to prescribe, though men like Pliny and Galen realized that this was an abdication of one of the most important functions of their profession, which was bound to work harm in the end both to themselves and to their patients. How curious it is to find exactly the same state of affairs recurring in our time, with absolutely similar results. Simple remedies that are well known combinations of ordinary drugs receive high-sounding names, usually derivatives from the Greek or the like, and are claimed to work just as many wonders as the old-fashioned nostrums. Even imitations of the old-fashioned poultices, when thus exploited, give a new lease of life to the exploded idea of the drawing-out power of external applications. Common Ailments and Nostrums.--Certain ailments are particularly the subject of exploitation by the manufacturers of remedies. Rheumatism is one of these, neuralgia is another, catarrh is a third, and headache a fourth. Then there are various forms of indigestion and all the pains and aches associated with it. All of these ailments are rather vague and are in some cases at least, due to the insistent dwelling of the patient's mind on some symptom of very little significance. Others are real pains and aches, relieved by some simple anodyne drugs, doubly efficient when taken with the suggestion that they represent a wonderful discovery, which came only after long years of study and investigation, and are said to represent a new departure in medicine. Another favorite field for the nostrum vender is the series of pains and aches associated with the menstrual condition. Many of these nostrums are used by hundreds of thousands, and yet an analysis shows that probably the only active substance in them is the alcohol in which certain of the drug {60} principles are dissolved. This makes the patient feel better by the exaltation that comes from the dose of alcohol and the rest is merely suggestion, though there is no doubt that symptoms which have failed to be cured by physicians are sometimes relieved by these remedies. It is a cure by faith, not by medicine. Cured Cases as Evidence.--As all of the nostrums, and indeed all the therapeutic movements supposedly medical or physical or religious, secure their vogue on the strength of reported cures, this would seem to be the best possible evidence for the efficacy of a remedy. But unless the cases supposed to be cured are critically examined and analyzed, and above all, followed for some time afterwards, such evidence is open to all sorts of errors. Is it any wonder, then, that the physician, familiar with the history of medicine in this regard, asks for the careful study and analysis of these cases. We know that it was on the strength of cures effected by it, that the weapon ointment became possible throughout Europe. We know that portions of the body of executed criminals and the touch of the hanged cured as many cases as, let us say, osteopathy or Eddyism. The sympathetic powder and its advocates appealed to the many cures that followed its use. Every other nostrum from the beginning of time has made this same appeal. CHAPTER VIII AMULETS, TALISMANS, CHARMS Amulets, talismans, charms--these words are commonly used with something of the same significance, and for our purpose all three may be treated in common. Prophylactic Objects.--From the earliest ages men have worn amulets, that is, objects often resembling jewelry, though sometimes the remains of animals or even of men, [Footnote 10] with the idea that they would ward off illness, or cure it when present. Rings of many sorts, brooches, various objects suspended around the neck, ear-rings, head-bands, belts for the waist, and rings for the wrists and the ankles, ornamented bracelets and anklets, have at all times had a medicinal power attached to them in some minds. Earrings are still worn by many with the idea that they are helpful in affections of the eyes. I have known children's ears to be pierced and earrings inserted because the little ones were suffering from headache. Precious stones were supposed to have this power when worn. The amethyst protected its wearer from drunkenness; the bloodstone cured anemia; while the opal was supposed to portend evil. Occasionally such gems were ground up and used as internal or external remedies, because of the power supposed to be attached to them. Their influence upon the mind, at least, can be readily understood. The earliest prescription we have in America is at the Metropolitan Museum, New York, among the curiosities from Egypt (about 1500 B.C.). It calls for the use of ground up precious stones in fumigations, probably for an hysterical person. [Footnote 10: A king of Italy of the later nineteenth century used to send the parings of his toe-nails to friends to be worn in rings for luck and protection against disease.] The precious metals were used also as powerful cures. Chaucer says, "for {61} gold in physick is a cordial." Some think that our own use of chloride of gold a few years ago for many chronic ills had little more reason than the preciousness of gold impressing itself on patients. Inscriptions were made on the metals, and these were supposed to add to their healing or preservative quality. Famous among these was the abracadabra. It had to be written in a particular triangular form, and was then very powerful. Here the amulet invades the sphere of the charm. Prayers were written on parchment, or on paper, or on papyrus, in the old time in Egypt, Babylon and Assyria, and when worn about the body were supposed to do great good. It is surprising to us now how many physicians and scientists placed confidence in these things because they thought that they had seen good results. Alexander of Tralles recommends a number of them. Robert Boyle, the father of chemistry, says that he was cured of a severe ague, that the doctors could not benefit, by the application of an amulet to his wrists. Burton, in the "Anatomy of Melancholy," has a series of references that show how much he, himself, and the educated men of his time, believed in the power of amulets to help in illnesses and Boyle, particularly, has a number of references to precious stones and their curative virtue. Rings in Therapy.--Under Faith Cures I mention the cramp rings blest by the Queen of England and effective against abdominal pains. Other kinds of therapeutic rings were used rather commonly. All through the Middle Ages iron rings were worn, which were good for colic and biliousness and also for rheumatic pains. There are literally thousands of such rings worn now, here in the United States, and by quite intelligent people. Personally, I know of more than a dozen cases where they have been worn for years. The wearers faithfully take them off each day, rub off the rust which collects on the inside, call their own and others' attention to the fact that all this material has been drawn out of the body through the supposed electrical power of the ring, and then they replace them. Here is pseudo science obtruding itself. Usually these rings are of polished steel and look a little like silver. They may, however, be obtained in gold plate, and then are supposed to be quite as efficacious. The iron or steel rings cost two dollars each; gold-plated rings cost five to ten dollars, according to the ability of the patient to pay, for metallotherapy has as one of its effects the lessening of congestion of the purse. Those who wear them would not part with them, because they feel the benefits derived. These rings are supposed to be particularly good for vague, painful conditions in the joints, especially the so-called rheumatic pains. In old times these rings were sometimes engraved with a legend that was itself a strong suggestive element. The rings of the Middle Ages that were supposed to be a cure for biliousness were engraved with a command to the bile to go and take possession of a bird. Occasionally rings were supposed to be valuable because of their origin. Epileptic fits, for instance, were rendered much less frequent and less severe if a ring made of money that had been given in the church were worn. The condition was that the sufferer should stand at the church door asking a penny from every unmarried man who passed in or out. After sufficient alms had been thus collected the money was exchanged for silver money that had been contributed to the church, and from this the ring was made. It was to have a cross and sometimes a verselet from Scripture, or an exorcism, or a prayer, engraved on it. It is {62} easy to understand that all of this represents strong suggestive influence and that the standing at the church door begging alms might well represent an enforced prolonged opportunity to get rest and air, for many unmarried men do not go to church, and so there were also physical factors at work in the cure noted. Precious Stones as Preservatives.--Pettigrew, in his "Superstitions Connected with Medicine and Surgery," mentions a number of the precious stones and their power to heal. Garnet hung about the neck relieves sorrow and refreshes the heart; chrysolite is the wisdom stone, the enemy of folly; heliotrope staunches blood and acts as an antidote; sapphire is good for ague and gout, and also gives its wearer courage; it also stops bleeding at the nose and was an antidote; the topaz was good for lunatics; the carnelian cured bloody fluxes and also fluxes of anger and passion. Jasper, hematite and similar stones had certain general powers of doing good. The Bezoar stone had a great reputation against melancholy; the smaragdum was infallible against epilepsy; the onyx was good for sleep; the sardonyx prevented bad dreams. The most wonderful stone, however, was the agate; taken in liquid it was good for any disease. It made the skin healthy. It preserved against snakebite, and against all poisons, and it prevented the devil from injuring one who wore it or drank it, and also preserved him from being struck by lightning. Considering how common agates were and how readily they could be obtained, it is rather surprising that we should have so many stories of illness and deaths by lightning and from poison and from venomous serpents in the old days when its curative value was rated so high. Amulets.--The coin given by the kings of England when they healed the scrofulus or epileptic came to be, in one sense, an amulet. The sight and the touch of this acted as an ever recurrent suggestion tending to make these patients better, and undoubtedly the coin was of great service by its renewal of the mental influence of the touch of the king. There are traditions, also, that these coins healed others who touched them, and sometimes for generations they were kept in families as representing a fountain of healing and of preservation of health. Any object that thus became invested with reverence produced healing effects. Virchow, in the introduction to Schliemann's "Troas," tells of going to a long distance for water, during the time when he was present at the excavations, in order to be sure that the water would be absolutely pure. The natives had heard that he was a great physician from the West. They concluded that the reason why he went to this particular distant spring for water, in spite of the trouble involved, was that it must have some wonderful healing virtues. Accordingly a tradition of healing grew up around it, and people came from long distances, drank from it and were cured. There are still people who carry horse chestnuts for rheumatism, and occasionally a farmer carries a potato for the same purpose. The feeling is, if they do no good, at least they can do no harm. Doubtless in the Middle Ages the same feeling prevailed as to other favorite objects. At present, among the better informed classes, various pendants supposed to have some connection with electricity are popular. I have seen a medal made of alternate discs of copper and zinc, and confidently believed to be strongly electrical, worn even by an otherwise sensible merchant in a country town. Electric belts still are {63} extremely common--and expensive. Supposed electric insoles, one made of copper, the other of zinc, are sold in great numbers and at good prices, though, quite needless to say, they are absolutely inert electrically. Various electric contrivances, small batteries, and the like, really are of the nature of amulets. People have a faith in them that is not justified by anything in science, but that faith helps them in their ills. Most of the supposed medicinal plasters are in the same class. As a rule, sufficient curative material cannot be incorporated in a plaster to be of any service, and most of them, though widely advertised, are scarcely more than rubber adhesive plaster. They do good partly by their mechanical effect, because they actually support muscles, but mainly because of faith in their efficacy. Whenever a particular discomfort occurs the feeling that a plaster is covering the spot gives the patient assurance that he or she must soon be better. In all of these effects there is no manifestation of any physical or marvelous supernormal power, but simply and solely of the influence of the mind on the body. CHAPTER IX DETERRENT THERAPEUTICS In the history of therapy a peculiar phase was the use of all sorts of materials, intensely repugnant to human nature and deterrent to all the finer feelings, but which, nevertheless, proved curative of many ills. We know now that there was absolutely nothing remedial in these substances or methods of treatment, but only the effect produced upon the patient's mind. If the patient makes sufficient effort to overcome the intense repugnance, that enables him to release hitherto latent vital energies, or to correct hampering inhibitions which have prevented curative reactions. The more the patient had to conquer himself, or herself, the more surely did the remedy produce a good effect. It was effective, however, not only among the poor and the uneducated, but often also among the better informed, provided the patients became persuaded of its efficiency. Persuasion in these matters is usually best secured by the reports of cured cases. It is easy to obtain "cures" from almost anything. They are set up as confident proofs of the remedial virtue of methods of treatment. They have been, in the history of medicine, more often the indexes of action upon mind than upon body. Real remedies help patients to get better. Supposed remedies, that afterwards prove quite inert, _cure_. Portions of Corpses.--One of the ingredients of the famous Unguentum Armarium (see chapter on Nostrums) was, as has been said, moss scraped from the skull of a man who had been hanged. It was declared to be particularly efficacious against so-called dead members, such as the blanched fingers of Raynaud's disease, or the hysterical palsies, and other functional paralytic conditions of the limbs. The real therapeutic factor was not the gruesome material itself, but the potent suggestions awakened by it. It is probable that the quacks and witch doctors who gave out the formula of their remedies as containing such material often did not take the trouble to collect them, and that their salves and ointments were really quite inoffensive preparations. {64} Touch of the Hanged.--Some of the traditions which gather round the effect of contact with the body of a hanged person are curiously interesting from the standpoint of psychotherapy. This form of execution seems to have had a much more potent influence in producing therapeutic elements in the bodies of the victims than any other. We do not hear much of the touch of a beheaded person's body nor of any place in medicine for portions of the victims of execution by shooting, though Van Helmont claims curative properties for these in lesser degree. All sorts of ailments were, however, supposed to be cured by the touch of a hanged person. Thomas Hardy in his "Wessex Tales" tells of a young woman in his time suffering from a paralyzed arm, apparently a form of paralysis due to a functional nervous condition, who was recommended by an old "conjure" doctor to touch her bared arm, as soon after the execution as possible, to the purple mark of the rope around the neck of a man who had been hanged. The doctor assured her this was the only means by which she could be cured. We would not be surprised to hear of her cure under such circumstances. Hardy has carefully collected his material regarding the traditions of the southern part of England, and he makes the hangman say, when the woman applies to him for permission to touch the body of the victim, that such a request had not been made for some years, but that there used to be many applicants when he was a younger man. He adds, moreover, that it was the custom to apply to the governor of the prison and that usually this application was made by the physician of the patient who accompanied him or her on the visit to the corpse. There is no doubt that physicians did, in many cases, have recourse to such methods, and that the reasons for their belief in the efficacy of the touch of the dead was that they had seen the cure in this way of many puzzling diseased conditions, which their skill in wortcraft and herbal medicines had not enabled them to relieve. The touch of the corpse was supposed to bring about a "turning of the blood," and this produced the good effects. Occasionally the patients fainted from terror, yet afterwards were found to be able to use limbs that had been quite beyond their control before. The story is typical of what happened in country districts all over Europe for centuries. Mummies.--How little distant we are from the use of such material for therapeutic purposes will be appreciated from the fact that mummy was used in medicine down nearly to the end of the eighteenth century. The first edition of the "Encyclopedia Brittanica" (1768) said: We have two different substances preserved for medicinal use under the name of mummy, though both in some degree of the same origin. The one is the dried and preserved flesh of human bodies, embalmed with myrrh and spices; the other is the liquor running from such mummies, when newly prepared, or when affected by great heat or damps. The latter is sometimes in a liquid, sometimes of a solid form, as it is preserved in vials well stopped, or suffered to dry and harden in the air. The first kind of mummy is brought to us in large pieces, of a lax and friable texture, light and spongy, of a blackish brown color, and often damp and clammy on the surface: it is of a strong but disagreeable smell. The second kind of mummy, in its liquid state, is a thick, opaque, and viscous fluid, of a blackish color, but not disagreeable smell. In its indurated state, it is a dry solid substance, of a fine shining black color, and close texture, easily broken, and of a good smell; very inflammable, and yielding a scent of myrrh and aromatic ingredients while burning. This, if we cannot be content without medicines from our own bodies, ought {65} to be the mummy used in the shops; but it is very scarce and dear; while the other is so cheap, that it will always be most in use. All these kinds of mummy are brought from Egypt. But we are not to imagine, that anybody breaks up the real Egyptian mummies, to sell them in pieces to the druggists, as they may make a much better market of them in Europe whole, when they can contrive to get them. What our druggists are supplied with, is the flesh of executed criminals, or of any other bodies the Jews can get, who fill them with the common bitumen so plentiful in that part of the world; and adding a little aloes, and two or three other cheap ingredients, send them to be baked in an oven, till the juices are exhaled, and the embalming matter has penetrated so thoroughly that the flesh will keep and bear transportation into Europe. Mummy has been esteemed resolvent and balsamic: but whatever virtues have been attributed to it, seem to be such as depend more upon the ingredients used in preparing the flesh, than in the flesh itself; and it would surely be better to give those ingredients without so shocking an addition. Serpents in Therapeutics.--Snakes and portions of snakes have been prominent features of deterrent therapeutics at all times. Headaches were cured by wrapping a dead snake around the head, or by the touch of a snake's skin, and sore throat by wearing a snake's skin around the throat at night. This seems one degree better than the custom, still common, of wrapping the stocking, that has been worn during the day, around the neck. In the chapter on Graves Disease, the use of the touch of a snake, or of a snake's skin worn around the neck, is mentioned. Girdles made of snake's skin or snakes themselves, were supposed to be good for colic and for various internal troubles, and were sometimes, among barbarous peoples, a sovereign remedy for the ills of pregnancy and assured the woman a safe delivery and an easy labor. Undoubtedly they lessened dreads by suggestion and the effort necessary to overcome repugnance. Some of the symptoms of the menopause have been cured in the same way. Rattlesnake oil has had a special reputation among mountainous people, where the snakes abounded, for the pains and aches of the old, and the vague joint discomfort, sometimes spoken of as rheumatic, but really due to various individual conditions. It is probable that in most cases the oil thus employed was not extracted from the rattlesnake, but was some ordinary oil palmed off under that name, and having its special effectiveness because of the thought associated with it. Various portions of serpents are still in use, sometimes in the hands of physicians, though usually in popular medicine. I knew a physician in a small inland city who had a great local reputation for curing external eye troubles, and who owed not a little of it to the fact that the people in his neighborhood thought that he used rattlesnake oil as one of the ingredients for his strongest prescriptions. He was supposed to be able to dissolve even cataract by his remedies, and there is no doubt that in many cases of chronic indolent ulcer of the eye he was able to bring about a cure sooner, and have it last longer, than those of the regular profession who had not the advantage of this popular faith. He was careful to buy rattlesnakes from certain of the mountain people, who killed and brought them to him and who advertised the fact that they had such commissions from him. The stories were made all the more interesting by the fact that the doctor would not purchase dead rattlesnakes. They must be brought to him alive, since the therapeutic virtues can only be extracted immediately after death. A mountaineer with a couple of live rattlesnakes with him is always an interesting object and a fine {66} advertisement. One would like to know what the doctor did with the snakes--that is, how he disposed of them without suspicion. Homeopathic physicians still have lachesis-viper venom in their pharmacopeia. Their remedies, however, if they really follow the dilution principle of their founder, can have an effect only on the mind, so that the use of lachesis is not surprising. Repugnant Remedial Measures.--Quite in keeping with the use of deterrent remedies of various kinds are the recommendations to do certain things that involve great self-control, and the overcoming of repugnance, or fright, or the like. A favorite mode of preparing remedies in the Middle Ages was to gather the particular herbs for the prescription in a graveyard in the dark of the moon. The patient himself was supposed to gather them and to be alone when doing so, if they were to be effective. How much occupation of mind and diversion of thought would be afforded for timid people by the effort to overcome themselves to this extent! The occupation of mind alone and the concentration of thought necessary for the ordeal would be quite sufficient to divert many people from the centralization of attention on themselves, which is responsible for so many of their symptoms, or for that exaggeration of symptoms that aggravates the ailment. _Ordures as Remedies_.--Among all primitive peoples we have the story of the use, as remedies, of ordures of various kinds, of repugnant portions of animals, of ground insects, of animal excrement and urine, and even of human excretions, of the blood of serpents, or eels, or carrion feeding birds, and the like. Ground lice and insects of various kinds are very common as prescriptions in the history of primitive medicine. They turn up here and there through the Middle Ages, and they are said to be still used in China. The more one knows about side-tracks in medicine, the more does one find of far-fetched repugnant materials vaunted as wonderful cures. Some of the substances employed are so disgusting that one does not care to mention, much less discuss, them. I have had a man tell me that, in a severe epidemic of diphtheria, he saved his children's lives when they were attacked by the disease, and the children of others were dying all around him, by blowing the dried excrement of dog down their throats. There are certain popular medical practices that are related to these old traditions of deterrent therapeutics. In many manufacturing establishments, in spite of progress with regard to sepsis and antisepsis and the diffusion of information as to first aid to the injured, it is still the custom to put spittle on wounds. I am sure that every doctor has seen quids of tobacco used in this way. Even native-born Americans, who are not illiterate, are sometimes found using some deterrent material. I have known such a man use his own urine as an eye-wash for sore eyes, and the use of children's urine for such purposes is much commoner than might be thought. After all, it is only a generation since physicians used to taste urine in order to determine whether it contained sugar or not, and I have seen a country doctor even take between his finger and his thumb a little of the excrement of a child and apply his tongue to it, pretending of course that he obtained very valuable information this way. _Excretions and Secretions_.--All the human excretions have formed the basis of vaunted remedies. Tears, on the principle that like cures like, were used for melancholia; nasal secretion to lessen respiratory difficulty through {67} the nose; sputum for various mouth affections, but also as an application to external abrasions, and to the eyes, the ears, and the like. Undoubtedly patients were helped by many of these, not because of any physical effect, but because they felt easier as a consequence of the satisfaction of having something done for them, and the consequent freedom from solicitude which allowed nature to produce her curative reaction without interference. The greater the effort he has to make, apparently the more efficiently does he control this disturbing state of mind. This is the secret of many cures now as well as in the olden time. Whatever good effect is produced in such cases comes, of course, from the persuasion that these substances will do good, and there must be a strong suggestion to that effect before the repugnance can be overcome. While we are prone to think the older peoples who used such materials commonly are to be condemned for ignorance and superstition, it is well to recall that human nature has not changed, and is still ready to be influenced in the same way. Brown Sequard's extract of testicular substance came in this category. We had a wave of organotherapy a few years ago, and we know now that whatever benefits patients derived from taking heart substance for heart troubles, and brain substance for brain troubles, and kidney for renal diseases, was entirely due to mental influence. The cannibal who eats the heart of his enemy, thinking that the vigor and courage of the other will pass into him, undoubtedly has for a time a power of accomplishment greater than before. Nothing acts so powerfully as suggestion of this kind to give renewed vigor and to enable us to tap sources of energy that we were not aware of in ourselves, and that enable us to accomplish what before seemed quite impossible, and even to bring about curative reactions. Diseases Benefited.--Observe the classes of disease that were particularly relieved by deterrent therapeutics. Headache was one of these. All sorts of things were cures for headaches--the touch of the hangman's rope, or of an executed criminal, or some herb gathered in the graveyard in the dark of the moon, or pills made of the excrement of various animals. The forms of headache thus relieved would be those in which over-attention to self, rather than real headache, produced queer feelings in the head, though concentration of attention might exaggerate this into an ache. Foot troubles were cured by deterrent therapeutics. To wear the shoes of a dead person, especially of a murderer who had been hanged, would cure them. Colic was cured by pills of excrementitious materials, and by all sorts of other deterrent remedies. For instance, one well-known remedy was to wash the feet and drink the wash-water. The wash-water of little babies was a favorite remedy for the vague abdominal pains of old maids, and for the symptoms due to the menopause. Deterrent Pain.--A striking illustration of a strong mental influence helping out a slight amount of therapeutic efficiency is found in the use of the actual cautery for medical affections. At a number of times in history most of the chronic pains and aches, the arthritises, the so-called gouty tendencies when localized, the rheumatic affections and especially the chronic rheumatisms, have been treated by means of the cautery. All of the neuralgias, many of the neuroses, all of the neuritises and a certain number of so-called palsies and paralyses, were treated successfully by this means. It is a very suggestive remedy producing a deep impression that now relief must be in sight. It {68} became popular over and over again, though after a time it always lost its influence, and ceased to have the beneficial effects that it had at the beginning of its reintroduction. During the second half of the eighteenth and the beginning of the nineteenth century the cautery became very popular. It was applied particularly in the form of the moxa. A cylinder of cotton was employed for this purpose, being set on fire and allowed to burn on the skin of the patient, producing a deep wound. The mental effect of this can be readily understood. Baron Larrey, one of the most eminent surgeons of the time, thought the moxa one of the best aids that he had in the treatment of many affections where the knife was not indicated. There were large groups of diseases in which it was almost a specific. Larrey employed it in affections of vision, of smell, of taste, of hearing and of speech. In many paralytic affections of the muscular system, in all chronic affections of the head, among which he enumerates non-traumatic affections, hydrocephalus, chronic headaches and many other affections supposed to be seated in the cranium. In asthma he was particularly successful with the moxa. Old catarrhal affections yielded to it. Consumption was frequently benefited by it. Most of the chronic affections of the uterus were benefited, as were also similar affections of the stomach. He considered that the moxa must be admitted, without contradiction, to be the remedy _par excellence_ against rachitis. In Pott's disease, which he called dorsal consumption, it worked wonders. In sacrocoxalgia, in cocygodynia and femero-coxalgia he had excellent results with the moxa. A glance at this list shows exactly the class of cases in which suggestion has always played a large role, and for which there has been, at various times, a series of specific remedies, medicinal, manipulative and surgical. Others extended the value of the moxa beyond these affections. Ponto found it valuable in gout, and in the various chronic affections which are sometimes grouped under the name chronic rheumatism. He insisted that the moxa could be placed on almost any part of the body, though the contra indications he suggests show how far the men of his time went with its use. Only these portions named might not have a moxa applied to them. It must not be used on the skull, on the eyelids, on the ears, on the mamme, on the larynx and on the genitals, though it might be applied to the perineum or the perineal body. Deterrent Taste and Smell.--The disturbing effects produced by other senses besides those of sight have been used in the same way for the production of definite therapeutic suggestive effects. A number of the ill-tasting, almost nauseating drugs of the olden time prove to have very little real therapeutic efficiency in the light of modern clinical careful observation. This is particularly true of the herbs and simples. Many a disgusting preparation apparently owed all of its' good effects on the patient to the effort that was required to swallow it, producing such a favorable influence upon the mind, by _contrecoup_ as it were, that the patient got better. A little girl said that cough medicines were nasty things they gave you in order to keep you from catching cold again. The sense of smell has been used in the same way. Valerian is probably an efficient drug in certain respects, but undoubtedly its efficiency is materially increased by its intensely repulsive odor. For many of the psycho-neuroses and neurotic conditions generally the ammonium valerianate is likely to be much more efficient than the strychnin valerianate, though probably the {69} latter should be considered as more physically efficacious in its tonic properties. Asafetida, musk and some preparations of the genital organs of animals that used to be in the pharmacopeia, owed most, if not all, of their power, whatever it was, to the mental effect of their odor and the feeling of deterrence that had to be overcome before they were taken. There is a precious therapeutic secret in this use of deterrent, repugnant, frightful materials which patients use to advantage under certain circumstances. It illustrates the influence of the mind over the body, and emphasizes the fact that such influence can be exerted in the full only when a deep impression is produced upon the patient. Whether this can be imitated without deceit, and without the use of undignified methods, must depend on the physician himself and his personality. There can be no doubt that there is a wonderful power here to be employed. It must be the physician's business to find out in each individual case, according to his own personal equation, just how he may be able to use at least some of it. It is well worth studying and striving for, because nothing is more potent for psychoneurotic conditions, and for neuroses on the borderland of the physical, than which no ailments are more obstinate to treatment. CHAPTER X INFLUENCE OF THE PERSONALITY IN THERAPEUTICS Though it has seldom been fully realized and has probably never been appreciated as in our time, one of the most important factors in therapeutics, in every period of the history of medicine, has been the personal influence of the physician. Therapeutic fashions have come and gone, new drugs have been introduced, have had their day and then been relegated to the limbo of worn-out ideas. At all times, however, physicians have succeeded in doing good, or at least using, with apparent success, the therapeutic means of their own time, however crude and inadequate these afterwards proved to be. They have succeeded in shortening the progress of disease as well as increasing the patient's resistive vitality and thus enabled him not infrequently to survive where otherwise a fatal termination might have occurred. All unsuspected during most of the time, it was the personal influence of the physician that counted for most in all of the historical vicissitudes of therapeusis. It mattered not that the means he employed might seem absurd to the second succeeding generation, as was so often, indeed almost invariably, the case, his personal influence has at all times overshadowed his available therapeutic auxiliaries. In spite of all our advance in scientific medicine, to a considerable degree this remains true even at the present time, and to fail properly to use this important auxiliary is to cripple medical practice. Place of Personal Influence.--When the antitoxins and directly curative serums seemed about to make for themselves a place in therapeusis, it looked for a time as though this personal element might be entirely superseded. It seemed that all other therapeutic factors must give way to definitely accurate doses of antitoxic principles, directly opposed to the toxins of disease and {70} capable of conquering it. With the success of diphtheria serum, the prospects for scientific therapeutics from the biological standpoint became very promising. Unfortunately, our further experience with antitoxins and therapeutic sera of various kinds has not been satisfactory, and now the medical world is looking elsewhere for progress in therapeutics. This throws us back once more on the old-time therapeutics, and we have to learn to use all their elements. One of the most important of these, if not, as we have suggested, absolutely the most important, the one that in all the many variations of therapeusis has maintained itself, is the personal influence of the physician by which he is able to soothe the patient's fears, allay his anxieties, make him face the situation calmly so that he may not use up any of his vital force in useless worry, but on the contrary employ all his available psychic energy in helping nature to overcome whatever disturbance there is within the organism. This personal influence was for several centuries spoken of as personal magnetism, not merely in the figurative sense in which we now employ that term, but in a literal sense. The implication was that some men possessed within themselves a reservoir of superfluous energy, vital in character, but thought to be related to the force exhibited by the magnet, when it attracted bodies to itself, and made metals for a time magnetic like itself, and which actually passed over from the physician to his patient. We have gotten away from the idea of any physical force flowing from physician to patient, but we know very well that certain physicians are much more capable than others of arousing the vital energies of the patient, sometimes to the extent of making him feel, after treatment, that he has more force than before. The patient feels that something must have been added to his natural powers, though he has only been brought into a state of mind where he can better use his own powers. It is the men whose presence created this impression in patients, an impression that is justified by the fact that somehow he enabled them to vitalize themselves better than before, who have been most successful in the treatment of patients. In all ages the men of reputation for healing have had this. A careful study of their lives shows that this counted for more in many of the experiences of their healing than the drugs and remedies which they employed. The men who have been the most sought by patients have not as a rule left us great therapeutic secrets; on the contrary, they have only employed the conventional remedies of their times with reasonable common-sense and have added to them their own personal influences. On the other hand, the men who have made discoveries in therapeutics, and in medicine, have not always been popular as physicians. They have known too much of their own lack of knowledge to be quite confident in their use of remedies, and this has hurt something of their personal influence over patients. IMPRESSIVE PERSONALITY As a matter of fact, it is easy to comprehend, even from the comparatively scanty details that we have of habits and methods of the great physicians, that their effect upon their patients was always largely a matter of impressive personality. Any one who, from a pharmaceutical standpoint, knows how {71} inefficient were many of the remedies that great physicians depended on, yet how effective they seemed to be to their patients, and even to themselves, will appreciate the factor of personal magnetism that entered into their employment. It is not alone in the olden time that great physicians have been almost worshiped. For their patients they have at all times been men of exalted knowledge, masters of secrets and comforters of the afflicted, just as was the first great physician of whom we have any account, I-em-Hetep, in Egypt nearly six thousand years ago. Such men as Hippocrates, as Galen, as Sydenham and Boerhaave, and Van Swieten, accomplished curative results far beyond the therapeutics of their time. The loving admiration of patients and of their disciples shows how strong were their personalities and gives us, almost better than the writings they have left to us, the secret of their successes as practitioners of medicine. A Great Modern Physician's Influence.--It is interesting to study in the lives of great physicians the details which illustrate their personal influence, their consciousness of it and how deliberately they used it. A typical example very close to us, whose reputation was still fresh while I was at the University of Paris, was Professor Charcot. He had made great discoveries in nervous pathology. To a great extent he had revolutionized our knowledge of nervous diseases and added many new chapters to this rather obscure department of medicine. Far from making the treatment of nervous diseases easier than before, or giving more assurance to the physician who dealt with them, his discoveries, however, had just the opposite effect. His work emphasized that practically all of the so-called nervous diseases were due to degenerations in the central nervous system, which no medicine could be expected to relieve in any way, and which nothing short of the impossible re-creation of damaged parts could ever cure. His studies included organic degenerations of other organs, and in his treatise on "Diseases of the Old" it is made clear that many of the symptoms of old age are due to organic lesions for which no cure can ever be expected. This would seem to discourage treatment, yet somehow Charcot became a great practicing physician as well as a medical scientist and pathologist. His success was due to his personal influence over his patients. In spite of the unfavorable prognosis that he had to give in so many cases, he was able by suggestion to help many patients with regard to their course of life, and to reassure them, so that many adventitious neurotic symptoms not due to their underlying nervous disease, but to their solicitude about themselves, disappeared. Very few people who came to him went away without feeling that his advice had been very valuable to them and without experiencing, as a rule, after they had followed his advice, that they were much better than they had been before. It was for the neurotic conditions associated with nervous affections that Charcot's personal influence over patients was of the greatest therapeutic significance. He himself recognized this and did not hesitate to use it to its fullest extent. Towards the end of his life, the method by which his patients were presented to him was calculated to make their relation to him, above all, a very personal one, and to give his influence the fullest weight. Nervous patients who came to see him, were each in his turn invited from the general waiting-room into a small ante-room just outside of Charcot's office and {72} there, in silence and dim light, asked to await the summons of the physician himself. When the time came for him to call them in, the folding doors between the rooms opened and he stood in a blaze of light inviting them to enter. Many a neurotic patient despairing of relief for symptoms that had lasted long in spite of the treatment of many other physicians, felt at once that here, in this kindly, gentle-voiced man standing so prominently in the light, was surely the long looked-for physician who would heal whatever ills there were. They came fully impressed with his power to heal, and all the valuable influence of auto-suggestion was enlisted on the side of their physician. What is true in the regular practice of medicine can be seen much more clearly in the history of those who were not physicians, but who, nevertheless, by personal magnetism, succeeded in curing various ills, or at least in lifting up patients so that they used their own natural powers of recovery to much better advantage than would have been possible if left unaided. Every successful healer has had this same personal influence, personal magnetism, call it what we will, which his patients have thought helpful to them through some direct communication, but which he himself, if he seriously studied it, and which every other thorough student of the question must realize, was due only to his power to call out the latent vitality of his patients. The mystery is not one of teledynamics, a transfer of energy from the operator, but one of awakening dormant faculties in the subject. Just why they should be dormant, since the patient so much wants to use them if he only could, is hard to understand. They do, however, lie dormant until the call of another strong personality wakens them to activity. Many people are so constituted that they cannot do effective work except under the direction of others. They lack initiative, though they may fill secondary places very well, indeed, much better often than the man of initiative who so frequently lacks capacity for details. In the same way many people are not able to bring out to the full all their own energies, even for their own bodily needs, unless under the guidance and influence of others; hence the stories of the healers that we have all down the centuries, and who have a definite place in the history of humanity and of medicine. A Modern Healer.--A typical instance of the really marvelous power of mental influence over the minds of sufferers from many kinds of ills, is found in the career of the well-known Father Kneipp. For more than twenty-five years he had attracted the attention of Europe, and had made the little town of Woerishofen well known all over the world because of the cures effected there by him. The exactly proper phrase is effected _by him_ because it is clear to anyone who has studied the therapeutic methods he employed, that it was not these, or at least not these alone, that enabled him to cure so many ailments which had resisted the efforts of some of the best physicians in Europe. It was his magnetic personality which won patients to the persuasion that they must get better because he said so, and then to the following out of certain very simple natural rules of life, and certain quite as simple remedial measures, which acted as alteratives and enabled patients to tap reservoirs of vitality, of which they themselves were unconscious, but which, supplying energies to overcome tendencies to various symptomatic conditions, brought about cures. {73} Pfarrer Kneipp had himself suffered from consumption, had been practically given up and then, as is the case of many another, had taken himself in hand, had secured much more outdoor air than before, and more abundant nutrition, until gradually his ailment was overcome. It is true that he used various hydrotherapeutic measures, some of them, as he confessed afterwards, to an excess, both as regards the temperature of water and the length of the application of it, that might have seriously hurt him if he had been less robust, but it was not so much his hydrotherapy as his own determination to get better and to live a little closer to nature that led to his cure. Then he became the apostle of cold water and of many natural remedial measures, and as a consequence, healer of all forms of ills in the many thousands who flocked to consult him in the little South German town. He made his patients get up early in the morning, get out in the air shortly after rising, the excuse, or, as he declared it, the reason being that they were to walk with bare feet in the dewy grass. After this he had them eat heartily of simple food, of such variety and in such quantity as relieved them of constipation, made them use water, internally and externally, in abundance, and after a time, sent most of them on their way rejoicing that they had been cured from chronic ills. Some of the highest in Europe came to him; the Empress of Austria was his patient, and he was asked to prescribe for the Pope; reigning princes and all the lesser order of the nobility were included among his patients. Several of the Rothschild family went to him and where they went, of course, others flocked. Very few failed to be benefited. People less educated, and less rich in the world's goods than these, came also, and went away relieved. After a time Kneipp societies were founded all over Europe and even spread through America. These consisted of organizations of men and women who encouraged each other to keep up the Kneipp practices. With his death there has come a decline in interest in Kneipp methods. He, himself, was sure that his remedies and recommendations were the important curative factors. Now it has become clear that it was mainly his forceful personality, his power to lift patients above their ills, and enable them to use mental resources or vital forces that they could not use until encouraged by him with the thought that they would surely get better. In the atmosphere he thus created, they seemed to borrow something of his overmastering personality. It can not be too often repeated that this is the secret of the success of the great world healers. They do not transfer force to others, but they enable others to use their _own_ forces more successfully. An Ancient Healer.--Let us compare some of the details of the career of Father Kneipp with the story we have of one Aristides, who, as the result of dreams that came to him while practicing the cult of AEsculapius and the injunctions contained in these dreams, was cured of many ills, and afterward delivered a series of sacred orations. Aristides is one of the first of the large group of literary men, much interested in their own health and their own ills, whose writings have been preserved for us. He was intensely proud of the number and variety of his ills, and he was perhaps conceited about the curious ways in which some of them had been cured. Traveling in the winter time he caught a chill; then he suffered from earache and in the midst of a storm developed fever, asthma and toothache. Arrived in Rome, he had severe internal sufferings, shivering fits and want of breath. Treatment by the Roman {74} doctor only aggravated his sufferings. A stormy voyage home made him worse. When, at last, he arrived in Smyrna, the doctors gathered round him, and were astonished at the manifold nature of the disease. They could do nothing for him. Suffering from all these ills (which remind one of a modern literary man who has got his mind on his stomach and his body on his mind), Aristides went to a number of the old temple hospitals and received suggestions in sleep from AEsculapius. These he has described in what are called his sacred orations. In them we have every phase of modern therapy that has the strong element of suggestion in it. Like Pfarrer Kneipp, he tried very cold baths and was benefited by them. Walking in the dewy grass in his bare feet was another recommendation that had come to him in a dream. Occasionally he would run rapidly for a considerable distance, and then when heated plunge into a cold bath. We have many complaints of his fever and stomach troubles. Mud-baths were also recommended to him and, of course, tried with benefit for a time. Sand baths later proved to be beneficial. For rheumatism a cold bath, after running almost naked in the cold north wind, proved successful when other remedies failed. Aristides wrote out his experiences, and his writings had great influence over generations of patients and maintained the influence of the old Greek temples as cure houses long after the general acceptance of Christianity. As the result of his writings, no matter how bizarre a dream might be, some interpretation of a therapeutic nature was found from it. Constancy of the Law of Personal Influence.--Indeed, there has apparently never been a time when some strong character, full of religious enthusiasm and of high purpose, strong in the confidence of men, has not succeeded in accomplishing wonderful curative results by the reassurance that comes from a renewal of faith in the goodness of Providence. There are, for instance, a number of stories which show John Wesley's power to help men to tap the reservoir of surplus energy that all of us have within us, but that somehow we do not succeed in making use of, unless some strong mental influence is brought to bear on us. Practically every religious man who has had the love and the veneration and the respect of those around him has succeeded in accomplishing the cures that many people in recent years have been prone to regard as rather novel phenomena in the history of psychology. Men like St. Philip Neri, St. Francis Xavier, and St. Francis of Assisi, and St. Bernard, have many stories told of them which show how much they were able to help fellow mortals by enabling them to make use, even in a physical way, of their own highest and best powers. Their lives show how much more they did. Nor is this power confined to men. In nearly every century we have the story, also, of wonderfully strong women, leaders of their time, who inspired the profound confidence and veneration of those around them, and who were enabled, by their own strength of character, to help people physically as well as morally. The Life of St. Catherine of Siena is full of such instances. She spent her life mainly in caring for the sick and the distressed at the hospital in Siena, and the beautiful hospital there was completed largely as a monument to her. During her lifetime marvelous cures occurred that in many cases were evidently due to her power over the minds of people. The {75} life of St. Teresa has a number of similar examples, and Joan of Arc, in her lifetime, lifted many a dispirited man into vigorous strength because of her own abounding personality and the physical reaction which contact with her enthusiasm brought. Modern Examples.--Nor did such occurrences come only in older and less sophisticated centuries than ours. John Wesley is close enough to our time to negative any such impression, but there are many other examples. There is Pastor Gassner, whose cures remind Prof. Münsterberg of the Emanuel movement at the present time, but there are also a number of strong, religious characters whose influence was exercised in the alleviation of physical ills during the nineteenth century. The name of Father Matthew, the Irish "Apostle of Temperance," as he was called, is mainly connected with wonderful cures of the worst forms of alcoholic addiction. Physicians know how difficult such cases are to cure, yet there are many thousands of what were apparently hopeless cases to Father Matthew's credit. It may be remarked that this is one of the ills that modern mental treatment claims most success with. Besides these morbid habits there are, however, other cases, told in detail, in which Father Matthew's influence enabled people to shake off headaches, to get rid of illusions, to overcome hysteria, and even to relieve other and much more physical affections. Animal magnetism was the subject of much thought in his lifetime (nineteenth century), so that it is not surprising that Mr. John Francis McGuire, a member of the English Parliament, who wrote Father Matthew's life in 1864, declared that "Father Matthew possessed in a large degree the power of animal magnetism, and great relief was afforded by him to people suffering from various affections; and in some cases I was satisfied that permanent good was effected by his administrations." Another strong man of this same kind was Prince Alexander of Hohenlohe. Though a prince he had become a clergyman and spent his life in the service of the poor. Shortly after he became a priest he went through a great epidemic, fearlessly caring for his poor people, and as a consequence inspired them with so much confidence that ever after they came to him with all their ills. He was able to help, not only the poor, but also many of the nobility. Some of the things reported as accomplished through his influence show extraordinary power. His usual method was to endeavor to inspire in the people who came to him a faith in their cure, and then after a time the cure was actually accomplished. During the recent troubles in Russia, attention was called to the fact that the famous Father John of Cronstadt, the hero of Bloody Sunday, was looked up to with so much respect and veneration that many people found themselves helped physically by contact with him. There are a number of interesting stories of cures of ills of various kinds, some of them exclusively mental, but many of them fundamentally physical, which took place as a consequence of the new spirit of hope infused into people because of their confidence in Father John. His subsequent history seems to indicate that this was evidently due to the forceful personality of the man rather than to any special religious influence. His influence was not limited to the ignorant masses in Russia, for some of the cures reported occurred in families of the better class, thoroughly capable of judging the character of the man apart from his religion. {76} SUCCESS IN HEALING We have any number of examples, then, of this power of the healer in history. Over and over again we find that it was the personality of the man and the suggestive value of the means that he employed that enabled patients to cure themselves, that is, to use all the vital force which they had for curative purposes. This force had hitherto been inhibited by their own doubts of themselves and their doubts of the value of all ordinary means of cure which had been previously employed in their cases. This is the secret of the success of the healer, and this secret is much more valuable for therapeusis than any remedy which has come down to us from the olden time. It has, unfortunately, been neglected, and thus an important benefit to humanity has been lost. Now that we are able to review frankly and deliberately the conditions that obtained in the past, it is time to set about making use of this oldest secret in medicine, now no longer a secret, as a strong factor in the treatment not of disease but of patients. Healers are at all times strong characters who are helpful to others because of their own superabundant strength. The world is made up of two classes of people, lifters and leaners, and the leaners constitute by far the larger class. Most men and women are the subjects of doubts and dreads and difficulties with regard to their health, and the more time they have for introspection, the more are they likely to suffer. Unable to overcome them by themselves, they need the help of others. What they need, above all, is the reassurance that a trained strong mind can give them. The exercise of this mental influence over them, is only what corresponds to leadership in all the affairs of life. Most people need to be led and to be guided. The place of the physician is that of guide and director. The family physician of the olden time had a precious amount of influence that accrued to him from his character, and it was used to magnificent purpose. Most of his drug treatment would be looked upon as quite absurd at the present time, yet he did a great good work by lifting people up to their own highest possibilities of resistive vitality. That means more for the conquest of disease, even now, in most cases, than any remedies we possess. Often men do not realize how much their personal influence counts for. They think it is their method of treatment, or some new discovery in drugs or remedial measures, or some new phase of psychology they have hit upon, that is producing results. This makes it difficult to determine, in given cases, just what are the actual influences at work. Many men supposing themselves to be discoverers of some novel force, are merely exploiting that old-time influence of one mind over another that can be observed all down the centuries. It is interesting to study the careers of men who thought they were employing on their patients some new psychological method, when all they were exploiting was the old-fashioned influence of suggestion from a stronger personality to a weaker. A dozen times in history hypnotism has been announced as a wonderful curative agent. At present no one thinks it so, but, on the contrary, if used frequently, we think that it is much more likely to do harm than good. We went through a phase of interest in hypnotism a quarter of {77} a century ago and there are now signs of the possibility of its return in another form. In recent years we have heard much of psycho-analysis, of dominant ideas, of the auto-suggestion that comes from this, and how much benefit can be conferred on the patient by removing such ideas or revealing their unfavorable influence and so neutralizing them. The patients that come for treatment and to whom psychotherapy is of special benefit, are not, as a rule, those suffering from acute diseases or injuries, though even in these cases the attitude of mind is always an important therapeutic factor. The patients are mainly those suffering from chronic ailments, and from minor affections which, while they do not confine them to bed, often prove the source of such serious disturbance as makes them very miserable. The suffering in the world is out of all proportion to the actual disease. Many people who have little disease suffer a great deal, partly from over-sensitiveness, partly from concentration of mind on their ailments, and partly from such ignorance of whatever pathological condition is present that they grow discouraged and morbid over it. The rôle of psychotherapy is particularly to help patients of this kind. This does not mean that its main purpose is to treat imaginary disease, or disease which exists only in the mind of patients, for in nearly all of these cases there is a definite physical element in the affection. Even where the disease is quite imaginary, though that term has been so sadly abused that it is perhaps better to speak of affections as purely mental in origin, psychotherapy is important. As has been well said, a patient not having something physical the matter who thinks that there is something the matter, is in a worse state than one who really has something the matter. There are a great many such cases. If the principles of psychotherapy can relieve them and cure many of them, then it has a large place in human life. In order that the individual patient may be benefited, a thorough understanding must be established between physician and patient. This must take on the character of a personal relationship. The patient must feel that the physician has a personal interest in him--that there are certain individual features in his ailment which make his case mean something much more than ordinary to his physician. Some physicians have the power to make their patients feel this personal relationship to a marked degree. They are the eminently successful practitioners of medicine. Their patients sound their praises, and even though they may not be distinguished scientists, they acquire a large practice. Some of them are thoroughly scientific men. All of us know them and, while we may not be able to understand just how it is done, we recognize their power. CHAPTER XI FAITH CURES The series of phenomena that may be grouped under the term "faith cures" represent the oldest, the most frequent, universal, and constantly recurring examples of the influence of the mind over the body for the healing of ills. Whenever men have believed deeply and with conviction that some other being {78} was able to help them, many of their ills, or at least the conditions from which they suffered severely, have dropped from them and their complaints, real or imaginary have disappeared. This was true whether it was the touch of another human being supposed to have some wonderful power that was the agent, or some persuasion of the interference of the supernatural that appealed to them. Religions of all kinds have always had their cures, and one of the main reasons why men have accepted the various religions has nearly always been because of the weight of these healing phenomena. Apparently it does not matter how debased the form of religion may be, whether it is exercised by the medicine man of a savage tribe with methods that appeal only to barbarous instincts, or by a highly cultured priest of a form of religion appealing to the loftiest feeling and the profoundest intellectuality, cures take place whenever devotees have complete and absolute faith in the possibility of divine or supernatural interference in their behalf. The very earliest history that we have tells us of such cures, and the daily papers bring us reports of them from all quarters among the high and the low, the educated and the uneducated. The phenomenon is universal and we come logically to the belief that the Supreme Being intended that confidence in Him, and above all recognition of the fact that somehow the world with all its ills has a meaning for good, should be rewarded. The argument that religion is a natural revelation should then apparently be extended to include also the thought of a healing power in connection with it. Many of the founders of religions that have meant much for uplift to mankind, have made healing a principal portion of their message to man--the proof of their missions. Indeed, there actually seems to be an extension of power, above what is natural, to those who in profound confidence in Divinity, turn to this source of strength for relief from the ills that flesh is heir to. In any of these cases, definite inquiry as to the significance of the particular incident is needed, and not any general principle of either acceptance or rejection. Faith healing is a fact, its meaning is of the greatest importance for psychotherapy and its phenomena deserve that specific study which alone can give any certainty in the matter. Accessories of Faith Cures.--From the earliest dawn of history we have definite records of faith cures. It is true that they were usually associated with certain physical factors besides the mere act of the mind. In ancient Egypt the physicians were also priests, and while they administered various remedies, these had the added advantage of being supposed to be the result of divine inspiration, or suggestion, or to be in some way connected with religion. Among these men there were many strong personalities, contact with whom brought healing. Dreams and premonitions and hallucinations all had a definite place in their therapeutics because of their supposed connection with religion, or at least with the beings of another world. Spiritualism, itself a form of religion, is very old, and communications from spirits, real or supposed, were easily thought to have therapeutic significance. Miracles.--In most cases of faith healing, faith acts through the definite conviction that there is to be a direct interference with the ordinary course of nature in the patient's behalf. Some of the evidence for such direct interference on the part of Providence is so strong as to carry conviction even to serious and judicious and judicial minds. When the circumstances are such {79} that an exception to the laws of nature would not involve an absurdity, there is no good reason why its occurrence should be absolutely put out of the question. It may well be urged that we know so little about the laws of nature that we cannot determine absolutely what are and what are not exceptions to those laws. There is in itself, however, no absurdity in what is called a miracle, and unless one is ready to reject Christianity entirely, or to declare it absolutely impossible that the God who made the universe should have any personal care for it, or above all any interest in particular individuals in it, their possibility must be admitted. The attitude of utter negation and incredulity often assumed at the present day is only a reflection of a certain ignorance of philosophy, and too great dependence on a superficial knowledge of physical science, so characteristic of narrowly trained minds. After a visit to Lourdes and careful study of _"La clinique de Lourdes,"_ I am convinced that miracles happen there. There is more than natural power manifest. In a great many cases it is easy to see that the agents involved in the faith cures, and the circumstances surrounding them, are quite unworthy of any supposition that the Deity should have interfered. Where there is anything irrational, or sordid, or eminently selfish about the faith-healing, then any appeal to a supposed interference from on high is absurd. Horace said in another matter, but it will bear application here: "Nec deus intersit nisi dignus vindice nodus." Do not let a god intervene unless there is a set of circumstances worthy of him. In many of the faith-healing phenomena claimed to be connected with religion there are a number of absurdities. It may be suggested that any one person must not set himself up as the judge of such absurdity. When it is evident, however, that the ailing are being exploited for the benefit of one or of a few persons, or when there are certain manifestly irrational conditions in the circumstances of healing, then it is fair to conclude that what we have to do with are only examples of healing by means of strong mental influence. But it would be quite wrong on account of these abuses to dismiss the whole subject of miracle healing as all imposture or merely mental influence. The Royal Touch.--Probably the most interesting chapter in the history of faith cures is that of the touch of the King of England for scrofula, or, as it was known, the King's Evil. His touch was also supposed to be efficacious in epilepsy. English historians usually trace the origin of the custom to Edward the Confessor. Aubrey remarks that "the curing of the King's Evil by the touch of the King does much puzzle our philosophers, for whether our Kings were of the house of York or Lancaster, it did the cure for the most part." Even the change of religion in the time of Henry VIII and Elizabeth made no difference. Some people who hesitated about submitting to Elizabeth as queen lost their hesitancy when they heard that the queen's touch was successful in curing. James I wanted to drop it, but was warned not to, as it was a prerogative of the crown with which he had no right to interfere. Charles I was particularly successful. Charles II, whose licentious life apparently would quite unfit him for the exercise of any such power, was perhaps the English king who devoted most time to healing. While he was in exile in the Netherlands, many people crossed over to the Low Countries in order to be touched by him, and they returned cured of many different diseases. {80} This effectively prepared the minds of many for his return. Under scrofula were included most of the wasting diseases, and under epilepsy many neurotic conditions as well as many organic disturbances. It is easy to understand how great was the room for the successful employment here of mental influence. Queen Anne continued the practice, and many cures were reported in her time as late as the eighteenth century. William of Orange, when he ascended the throne with Mary, refused to believe that there was any special power for good in his touch. On one occasion he touched a person who came to him, saying as he did so: "God give you better health and more sense." In spite of this skeptical attitude his touch is said to have healed that particular person. In the next reign, however. Queen Anne resumed the practice, and Dr. Samuel Johnson, as a boy of five, was touched by her with some hundreds of others in 1712. No cure was effected in his case, but as the gruff old doctor lived to a round age in rather sturdy health, doubtless some would raise the question as to whether, if he had early scrofula, it was not greatly modified for the better. The circumstances connected with the royal touch were all calculated to be curative of the affections for which this practice had a therapeutic reputation. There were certain times in the year, particularly in the spring after Easter, when the king touched people for their ills. Ordinarily preparations would be made for some time before, and the patients would have all the benefit of expectancy. Then there came the journey to London to the king's presence, and as it was usually known that these ailing folks were on their way to the king, they received particular care from the people of the towns through which they passed. Then came the day of the touch itself, and the presentation of a coin, the so-called coin of the king's touch, which the patient was supposed to preserve. On the way home they were once more subjects of solicitude, and they had the royal coin to assure them every now and then that they had been touched by the king's hand, and that they ought to get well--for had not many others been thus cured? All this favorable suggestion, with the outing and the better food, was eminently calculated to cure the so-called scrofular conditions, under which term was grouped many vague forms of malnutrition and the milder epilepsies and pseudo epilepsies, for the cure of which the touch was famous. Cramp Rings.--Scarcely less famous than the king's touch for nutritional and neurotic conditions were the "cramp rings," which were blessed by the Queens of England and were supposed to cure all sorts of cramps. The power attached to them for this form of ailment was similar to that which the king's touch had for scrofula or the king's evil. Cramps seemed to be the "queen's evil." Whenever a queen died there was a great demand for these rings, because no more could be obtained until a new queen was crowned. The efficiency of these and the cures which they performed can be readily understood. Many of the hysterical conditions within the abdomen are cramplike in character. Hysteria will imitate nearly every form of cramp, including even those due to gallstone and kidney calculus. Any strong mental influence will do more for hysterical pain than our strongest medicines. On the other hand, many of the cramplike conditions within the abdomen may be relieved by concentration of mind on some distracting thought, and feelings of discomfort in the intestines may thus be relieved. {81} Mental Healers.--When the king was absent from England during Cromwell's time, the touching for the king's evil was sadly missed. If Cromwell himself had announced that he would touch for the diseases that used to come to the king, a number of cures would undoubtedly have been reported. As it was, Greatrakes, the Irish soldier adventurer, dreamt that he was commissioned from on high to touch for the same diseases as formerly had gone to the king, and, having begun it, cures followed until probably many more came to him every year than usually went to the sovereign in the olden times. He worked at least as great a proportion of cures. Greatrakes had many imitators, some of them doubtless quite sincere, but they were people of more or less deranged intellect, the kind who easily get the idea that they are commissioned for some purpose that sets them above the common people. Indeed, the story of the mental healers is probably, more than anything else, a chapter in the history of insanity, and the power of those with delusions to lead others to share their delusions. This is not a slur upon human nature, and especially upon some of the inspirations and aspirations that lift it up to do great things, but a literal statement of the view of these phenomena that seems forced upon us by modern advances in the knowledge of the psychology of mental influence and of psychic contagion. Most of the influence that was acquired by men who in the course of history claimed to have a heavenly mission has been due, as with healers heretofore referred to, to reputed cures made by them. Trace the story of this among the Eastern nations in the old time. The pseudo-Messiahs of the Jews always advanced as one evidence their healing power, but so did the founders of religions among all the other nations of antiquity. It must be borne in mind, however, that many of the queer religions of after times were founded by men who claimed to have a Messiahship, and put forth, as the evidence of a divine commission, their power to cure the afflicted. Sometimes the men who made these claims were good men. In many cases they were apparently self-deceived. Very often, however, they had no claim to goodness in the commonly accepted meaning of that term, for they counseled the violation of moral precepts, made exceptions, for their own benefit, to general laws, and exploited their followers for selfish reasons. Provided their followers had confidence in them, however, they continued to work cures, so that even reasonable people were likely to be led to the thought that there must be something supernatural about their activities. In every century there have been two or three men who have thus secured a following, and apparently healed many diseases. The phenomena of faith-healing as the result of belief in the heavenly mission of special men, are as common now as at any time. Dr. Cutten in his "Three Thousand Years of Mental Healing" (_Scribners_, 1911) has a chapter on "Healers of the Nineteenth Century," which shows how many phenomena of faith-healing can be studied in recent generations. Some of the men and the women who are mentioned secured wide reputations throughout our own country. These faith-healing movements have particularly affected the New England portion of our population, and many of our most prominent healers have been born in the New England States. Wherever the new cults flourished, it is usually found that some of the most prominent members are descendants of {82} the old New Englanders. It has been suggested that this is due to the gradual loss of belief in great religious truths by New Englanders, and a definite tendency toward reaction against this loss of the religious sense, which, as is usual with reactions, easily becomes exaggerated. From lack of belief they jump to excess of belief. Men without trust in Providence find the trials of life hard to bear, and they dread the development of physical ill so much that they exaggerate their feelings, or even create symptoms. Men are happier with the feeling that the supernatural powers surrounding them are interested in them directly and personally, and that somehow things, even in an incomprehensible world, are arranged, if not for the best, at least for such good as makes ills stepping-stones to new benefits. Whenever they are led far away from that thought, there is likely to be an exaggerated reaction back to it. The stronger minded apparently can get on without religion, but to the great mass of men a strong religious sense is needed to enable them to overcome the lack of self-confidence that is the root of dreads, doubts, difficulties of many kinds, and which is also the source of many symptoms as well as the cause of the exaggeration of many ailments. As a rule, modern healers have been founders of new religions, or at least they have broken away from old-established sects, and have formed congregations for themselves. They have sprung up in every part of the country. East, North, South, West, and among all the differing nationalities of our population. We cannot console ourselves with the idea that they affect especially the foreigners, for the native-born people have proved to be quite as susceptible to them. These healers have, as a rule, abused the medical profession and the use of drugs, and have taught that disease, if it really existed at all, was from the devil: that what one needed, in order to secure relief from pains and ills, was faith in God--but always through _them_. Many of these men and women have probably been serious and earnest and have deceived themselves first. Most of them have undoubtedly been more or less disequilibrated, though they have practically all exhibited the power to accumulate large amounts of money from their followers. The people who have gone to them have not been the ignorant among our population, but particularly those who read the newspapers, and who look upon themselves as well informed. The intelligence of the disciples of these healers, as we ordinarily estimate intelligence, has been a little above the average, rather than below it. _Schlatter and Dowie._--Probably the most disillusioning phenomena with regard to the complacent idea that the diffusion of information prevents manifestations of superstition are stories of the healers Schlatter and Dowie. At the end of the nineteenth century both of them attracted widespread attention. Schlatter was probably not quite sane. He wandered through the deserted portions of the Southwest, hatless, unkempt, with clothing torn and without shoes. In July, 1895, he first attracted attention as a public healer in New Mexico. After a reputed forty-day fast he went to Denver, where people flocked from all parts of the country to him. Files of people formed--sometimes five or six thousand--to be touched, and healed, by him. His reputation was due to the cures that were reported. Dowie was another of these healers. Just at the beginning of the twentieth century he organized a great new church of his own, and announced himself as Elijah, the prophet, returned to life. {83} Nearly 20,000 persons are claimed to have been healed during the first ten years of his healing career. Toward the end of his life he declared that he treated, and cured, over 50,000 a year. An abundance of crutches, canes and every form of surgical appliance for the ailing hung on the walls of his church at Zion City, Chicago, left by people who, having been healed, had no further use for them. {84} GENERAL PSYCHOTHERAPEUTICS SECTION II _GENERAL CONSIDERATIONS_ CHAPTER I INFLUENCE OF MIND ON BODY The power of mind over body for the relief of symptoms has been recognized, not only by physicians, but by the generality of men at all times. Every one has had experiences of aches, or actual pains, or discomfort quite annoying while one is alone, but that disappear while in pleasant company or occupied in some absorbing occupation. Many a headache that was painful enough to disturb us seriously while we tried to apply ourselves to something of little interest, and became almost unbearable if we tried to do something disagreeable, and actually intolerable if the occupation of the moment was a drudgery, disappeared, at least for the time, when we turned to a pleasant game of cards or indulged in some other favorite pastime. Our relief was not, however, from an imaginary ill, for the symptoms usually reasserted themselves when we got through with the pleasant occupation, showing that they have been there all the time and that we have only turned our mind away from them, and hence have ceased to feel them. This is so familiar it seems almost too commonplace to repeat, yet it constitutes the special phenomenon that lies at the base of psychotherapeutics, or the mental healing of physical ills. It is not alone the slighter, more or less negligible aches or pains, nor the vague discomforts that thus disappear when our attention is occupied, but even quite severe and otherwise unbearable pain may be modified to a great extent. A toothache that is bearable, though it nags at us constantly and never lets us forget its presence while we are occupied with many other things during the evening, may become a positive torture when we get to bed. This is not only because of physical conditions modifying the pain, for there seems no doubt that the warmth induced by the preliminaries for sleep and the bed-covering have a tendency to increase congestion, but it is mainly because as we doze off we are able, less and less, to inhibit our attention, or divert it from the pain that is present, and so this is emphasized until we have to do something for it or lose hours of sleep. This lack of inhibition, which characterizes the dozing hours, represents the state of mind in which people are who have no interest in their occupations, and who have ceased to find recreation in the ordinary pleasures of life, when pain of any kind comes to them. Cabanis, at the beginning of the nineteenth century, under the title of {85} "The Influence of the Moral on the Physical," discusses what we would now call mental influence on the body. He says: The great influence of what one may call the moral or mental on what may be called the physical is an incontestible fact. Examples without end confirm it every day. Every man capable of making observations finds proofs of it thousands of times in himself. Many physiologists and psychologists as well as moralists, have collected the evidence that brings out clearly this power of the intellectual operations and emotions on the different organs and the diverse functions of the living body. All of us could add new illustrations to these collections. Men who are rude and credulous talk of the effect of the imagination, and if they are not themselves its playthings and its victims, at least they know how to observe its effects In others. As a matter of fact, the action of our organs can be in turn excited, suspended, or totally inhibited, according to the state of mind, the change of ideas, the affections and the emotions. A vigorous, healthy man has just made a good meal. In the midst of the feeling of satisfaction which diffuses itself over all his body, his food is digested with energy and without any bother. The digestive juices perform their work steadily and without causing any annoyance. But let such a man receive some bad news; let some sudden emotion come to excite him, and especially to shock him into profound sadness, and at once his stomach and intestines cease to act upon the food which they inclose, or they at best perform their functions badly. The digestive juices, by which the food materials were gradually being dissolved, are suddenly stricken with inactivity. What might seem to be a stupor comes over the digestive tract, and while the nervous influence which determines digestion ceases entirely, that which tends to bring about the expulsion of material from the digestive tract may become more active and all the material contained in the digestive viscera may, in a short time, be expelled. Relief in Severe Injuries.--Even extremely severe injuries, which inflict serious organic lesions that ordinarily would produce shock and collapse, quite apart from the pain induced, may at moments of excitement pass unnoticed. A soldier often does not know that he is wounded until the flow of blood calls his attention to it, or perhaps a friend points it out to him, or loss of blood causes him to faint. The prostrating effects of even fatal wounds may thus be overcome for a considerable time in the excitement of battle, or because of a supreme occupation by a surpassing sense of duty. There is the well-known story of the young corporal detailed to make a report to Napoleon at a very important crisis of one of his great battles, who made the report with such minute accuracy that it called forth a compliment from Bonaparte, for it involved a very special exercise of memory for details, yet who was actually on the verge of death when he delivered the message. As his duty was accomplished the Emperor, noticing his extreme pallor, said: "But you are wounded, my lad." The young soldier replied, as if, now that duty was done, the consciousness of his wound had just come to him, "No, Sire, I am killed," dropping dead at the Emperor's feet as he uttered the words. In all of the great theater fires examples of this kind are recorded. A woman who barely escaped with her life from a theater fire some years ago had an ear torn off, very probably by some one grasping it in the crowd. She knew nothing of this until it was called to her attention after she got out of the theater, and then she promptly fainted from the pain and shock. Under such circumstances men walk with broken legs or limp even with dislocations, utterly unconscious that anything serious has happened to them. Men have been known to be unaware of a broken bone or even more serious conditions, {86} ordinarily quite painful and disabling, while laboring to help others in an accident. Suppression of Reaction.--This side of the influence of the mind on the body is so interesting that its effects have often been noted and studied. While we do not quite understand the mechanism by which it accomplishes its marvels of anesthesia and even of motility under apparently impossible conditions, there is no doubt that severe pain may utterly fail to reach the consciousness, though the nervous system is uninterruptedly carrying the messages just as it did before. The lack of attention suppresses the ordinary effect upon the personality. Evidently the messages originate and are carried to the nerve centers, but find no attention available for them, and so pass unnoticed. The study of phases of this phenomenon of suppression of reaction forms a good basis for the use of mental influence, and shows its marvelous power to overcome disturbing physical factors. Amputation Stump Aches.--An interesting example of the influence of mind over body, when circumstances favor its exercise or emphasize it, and at the same time a striking illustration of the potency of suggestion in the cure of discomfort, is found in the stories that are so common of cases of pains in amputation stumps. Any number of weird tales are told of men who complain of feeling cramps in the toes of an amputated limb after this portion of their body had been buried. The discomfort is common enough. In the special stories, however, the limbs have been dug up, the toes straightened out--according to the story, they were always found cramped in some way--and then the patient is at once restored to ease. In the good old times they probably believed in some direct connection between the straightening out of the toes of the amputated member and subsequent relief of pain. For us it is but an example of the power of suggestion. It is not the sort of suggestion that one likes to think of employing, though it has a certain dramatic quality which adds efficiency to suggestion. The Mind and Motility.--We have spoken thus far almost exclusively of painful conditions as relieved by suggestion or mental influence, but disturbance of motor function may also be favorably affected. There are any number of cases on record in which patients who had been utterly unable to walk were restored to motility by a shock. Many such patients have, in the midst of the excitement of a fire, or the scare caused by the presence of a burglar, got up and walked quite as well as ever, though sometimes they have been for years previously confined to bed. The San Francisco earthquake is said to have exerted such an effect on a number of patients, and, while such unusual disturbances cannot often be provided for the cure of these ailments, there can be no doubt at all of the power of a shock to the mind to overcome functional incapacity that has resisted every possible form of treatment. Ailments of this kind, which involve inability of the will to control, or rather to initiate, movements of the body, receive their best explanation on the neuron or neuroglia theory. (See the chapter on the Mechanism of Suggestion.) The central neurons become either quite separated from certain of the peripheral neurons, or at least the connections are not made with that nice adjustment necessary for the proper passage of nerve impulses. The shock communicated to the nervous system by fright is sufficient, however, to restore these connections, and consequently to enable the patient once more to exercise motor functions that have been in abeyance for some time. {87} _Astasia-abasia._--Any one who has had to deal with the cases for which the French have invented the rather impressive Greek name of astasia-abasia--how much better it would be to call the condition simply what we know it to be, nervous inability to stand or walk!--appreciates how almost a miracle is needed to improve them. The incapacity for station or movement to which the disease owes its name is so complete in many cases, and the patients' lack of confidence in self so absolute, that no ordinary remedial measure is capable of doing any good. These cases are usually a severe trial to the patients' friends. Indeed, the patients themselves maintain their nutrition so well and, as a rule, enjoy such good health, or, as has been said, enjoy their bad health so well, that it is for their attendants the physician feels most commiseration. Yet generally he is quite unable to do anything. It is certain, however, that with care and authoritative suggestion there would not need to be an earthquake, or a fire, or even a burglary, as a therapeutic measure in these cases. As a matter of fact, their cure when it occurs is always brought about by some strong mental influence. Mental Influence on Organs.--_The Heart_.--The influence of mind can be noted on practically every organ of the body in a concrete way. It might be thought that the heart, the first living thing in the animal being, the pulsations of which begin before there is any sign of the nervous system, might be free from this influence. On the contrary, the heart is so readily affected by mental states that, taking effect for cause, the old popular, and even scientific idea with regard to it, was that it was the organ of the emotions. The heart is stimulated more by favoring circumstances, and suffers more from depression, than almost any other organ. In the melancholic states it usually beats less frequently and is sluggish. When individuals are tired out and the heart has become weakened in its action, new courage will first be noted as having its effect upon the heart action. As the whole muscular system is much influenced by the mental state and, as the control of the arterial system depends on the muscles in the arteries, it is easy to understand how much the general bodily condition may by mental influence be modified for good and ill. _Digestive Tract_.--The stomach and intestines, though their functions might be presumed to be dependent entirely on physical conditions, are almost completely under the control of the mental state. At moments of depression, just after bad news has been received, the appetite is absent, or is very slight and digestion itself proceeds slowly and unsatisfactorily. On the other hand, when there is mental good feeling appetite is vigorous and digestion is usually quite capable of disposing of all that is eaten. If after a period of rejoicing in the midst of which food is taken abundantly bad news is brought, the mental influence on digestion can be seen very well. It is not alone that depression interferes with digestive processes, but apparently some favorable factors for digestion consequent upon the previous state of mind are withdrawn, and now what would have been a proper amount of food proves to be an excess and the digestive organs find it difficult to deal with it.. Nervous Inhibition.--The mind can actually inhibit certain of the involuntary processes of the body by thinking about them, and, above all, by dwelling on the thought that they are going wrong. This becomes easier to understand when we recall how, in the same way, we may disturb many habitual and more or less unconscious actions that we have grown accustomed to. There {88} are any number of actions requiring careful attention to details which become so habitual that we do not have to think of them at all. Not infrequently it happens when we try to explain to others how we do them, we disturb the facility of performance and have to repeat the acts several times before we succeed in performing successfully what a moment before we did without any thought. The story of the centipede who was asked how he walked with all his hundred legs, and who tried to describe how easy it was and got so mixed up that he was unable to move at all, is a whimsical symbol of conscious attention disturbing actions which go on quite well of themselves if only we do not allow ourselves to think consciously of each and every phase of them. How much the mind may influence the body under certain conditions when trance-like states either assert themselves or are brought on, has often been noted. Lombroso in his book "After Death What?" [Footnote 11] says of Eusapia Paladino the "medium," that "when she is about to enter the trance state the frequency of the respiratory movements is lessened just as is the case with the Indian fakirs. Before the trance she will have been breathing eighteen to twenty times a minute; as the trance begins the number of respirations is gradually reduced to fifteen; when the trance is fully developed she breathes twelve times a minute or less. On the other hand, at the same time the heart beats increase. Normally her pulse is about seventy, but during the early trance stage it rises to ninety, while during the course of a deep trance, it may go as high even as one hundred and twenty. The passing from a more or less rigid state to that of active somnambulism is marked by yawns and sobs and spontaneous perspiration on the forehead." The observation of these phenomena is, of course, entirely apart from any theory one may hold with regard to mediumistic manifestations, and it provides evidence of mental influence that is very striking. [Footnote 11: Small, Maynard & Co.. Boston, 1909.] Imaginary Drug Effects.--Drug effects may be produced through the imagination. Physicians know that when patients are persuaded that certain effects are to be expected from a particular medicine, the effects may follow all the same in sensitive, imaginative people, if that medicine is replaced by some inert compound. Many a physician who has used bread pills or other placebos to replace a drug that he did not want the patient to acquire a habit for, has thus been able to allow good effects to go on without interruption, where the stoppage of medicine had previously interfered with the continuance of the good habit that had been formed. Very few physicians have not seen the effect of a hypodermic of pure water when a hypodermic of morphine is demanded, and when the patient would not sleep without having the hypodermic injection. Sleeping powders of various kinds can sometimes with distinct advantage be replaced by inert materials, because the patient's mind is fixed upon the idea of sleep coming after a certain time and they, in consequence, compose themselves to rest. The Nerves and Tissues.--Cases occur where disturbances of vitality are noted as a consequence of nervous affections, though no gross lesion of the nervous system is demonstrated. Certain nervous people suffer from ulcerative conditions of their hands, and it is evident that in some the nervous impulses {89} that would ordinarily keep the skin surface in good, healthy condition are insufficient. Some people who use a typewriter have no difficulty at all with the ends of their fingers, while others are subject even to loss of skin or ulcerative conditions that make it almost impossible for them to go on with their work. In some this is true in the winter, in others in the summer. There are a number of skin conditions which are due to nervous factors and these evidently point to the influence of the central nervous system in keeping the forces of our body in such health, and resistive vitality, as will enable us to carry on whatever work we may wish to. This is, of course, a very individual matter. Some people chap very easily, some suffer from chilblains, or are frost-bitten even on slight exposure, and these peculiarities are evidently dependent on the intensity of the nervous impulses as well as the tone of the circulation, which itself depends on the nerves to a great extent. It is evident that some of these disturbances are not enduring, but are only temporary and therefore are due to functional disturbances of the nervous system. Physicians often see hysterical patients suffering from intense pain that requires an injection of morphine, yet after a series of such incidents, the physician is able to give an injection of plain water and produce just as good an anodyne effect. In these cases some influence of the will is enough to correct the painful disturbances. Occasionally a single member loses sensation, or motion, or both, yet the fact that its nutrition does not suffer shows that there is only disturbance in the motor connections between it and the central nervous system and not in the sensory nor trophic tracts, and that this functional defect may be restored by some favorable influence. _Nerve Supply and Health_.--We know now that when a part of the body is cut off from its connections with the central nervous system, it begins at once to be lowered in vitality and gradually tends to dissolution. This will be true in spite of the fact that the circulation continues as actively as before. It is not necessary, indeed, that the nerve trunk to a part should be cut, if it is sufficiently compressed its function is stopped and various disturbances begin to appear in the vitality of the part which it supplies. A typical example is to be seen in certain fractures of the clavicle, where a fragment presses on one of the nerves leading to the arm. After a time pains develop in the arm, a burning feeling is noticed in the skin, which becomes shiny and cold and of distinctly lowered vitality. Even a slight injury to the arm will now produce a serious ulcerative condition. There are evidently important influences for life that flow down through the nerves from the central nervous system, quite as important in their way as the nutritional elements which flow through the blood. How these influences of the mind on the body are accomplished is a portion of that larger mystery of the influence of mind, or soul, or principle of life, on the material elements of which our body is composed. Why a man receives a shock of lightning or a charge of electricity at high voltage, and without a mark on his body or a change in any cell that we can make out, be dead, though he was living an instant before, is another of these mysteries too familiar for discussion. There is no change in the weight of the body, nothing physical has happened, but what was living matter with the power to accomplish the functions of living things is now simply dead material, unable to resist the invasion of saprophytic micro-organisms which will at once, {90} unhampered, proceed to tear it down, though the preceding moment resistive vitality was completely victorious. The mystery remains, but the mechanism of the influence can now at least be studied with much more satisfaction than was the case a few years ago. Death and the Mind.--The extent to which the mind can be made to influence the body is apparently without limit. While the doctor is frequently disturbed by the fact that death occurs when there is no adequate physical reason for it, just because the patient has looked forward to it with complete preoccupation of mind, there is no doubt that occasionally death may be put off in the same way. We talk about people living on their wills. This is a literal expression of what actually occurs in certain cases. On the other hand, without the will to live, it is sometimes extremely difficult to keep alive patients who are in a run down condition. If one of an old married couple dies when the other is ill, we conceal the sad news very carefully from the survivor. This is done not alone to put off the shock and sorrow for a time, but because often, under such circumstances, there will be no will to live. When the vital forces have run down to such a degree that it seems impossible, so far as ordinary medical reason goes, to look for anything but dissolution, patients still cling to life if there is some reason why they want to live until a definite time. It does not happen so much with the acute diseases but is quite common in chronic cases. Patients will live on expectant of seeing a friend who is known to be hurrying to them, or for some other purpose on which they very strongly set their minds. In the life of Professor William Stokes, the Irish physician, to whom we owe the introduction of the stethoscope to the English medical world, and many other important contributions to medicine, there is a striking story that illustrates this power of the will to maintain life until a definite moment. An old pensioner, a patient of Stokes' in the Meath Hospital whose life was despaired of, and whose death was hourly expected, was one morning distressed and disappointed at observing that Stokes, who believing that the man was unconscious at the time, and that it was useless to attempt anything further as his condition was hopeless, was passing by his bed. The patient cried out: "Don't pass me by, your honor, you must keep me alive for four days." "We will keep you as long as we can, my poor fellow," answered Stokes; "but why for four days particularly?" "Because," said the other, "my pension will be due then, and I want the money for my wife and children; don't give me anything to sleep for if I sleep I'll die." On the third day after this, to the amazement of Stokes and all the class, the patient was still breathing. On the morning of the fourth day he was found still breathing and quite conscious, and on Stokes' coming into the ward, he saw the patient holding the certificate which required the physician's signature in his hand. On Stokes approaching him, the dying man gasped out. "Sign, sign!" This was done, the man sank back exhausted, and in a few minutes after crossed both hands over his breast and said, "The Lord have mercy on my soul," and then passed quietly away. _Dread and Death_.--Dr. Laurent in his little book, "La Médecine des Âmes," [Footnote 12] has a story of similar kind but from a very different motive: [Footnote 12: Paris, Maloine, 1804.] They brought to the prison infirmary one day an old burglar, an incorrigible offender, who was undergoing a long sentence. He was suffering from cancer of the stomach, and was already in a very advanced stage of the affection. The poor devil seemed to realize his condition very well, and felt that it was only a question of a short time until he should die. He had made up his mind to that with the {91} resignation which so often characterizes people of this kind. Only one thing put him out very much, and that was the fear of dying in prison. "I know well that I have to pass in my checks," he said over and over again; "but I do not want to die here. I do not want to be cut up after I am dead." He still had two months of his sentence to undergo. Every day the disease made notable progress. His cachexia became more profound. Life was passing from him drop by drop. At the end of five weeks he was scarcely more than a living skeleton. Every morning we expected to find him dead, or at least in his last agony. Nevertheless, every morning, by an effort, he was able to recognize me and a little life shone out of his sharp, small eyes that seemed like those of a bird of prey. One morning he said to me: "Oh! you need not watch me. You shall not have my carcass. I do not want to die in prison. I shall not die here." He lived on till the end of his sentence. The morning of his freedom he said to me, "I told you that I did not want to die here, and that I would not die here." By an effort of his will he aroused himself enough so that his friends were able to take him out of the prison. It was the last bit of energy he had, however. His will power was at an end. A few hours after his arrival in the house of his son he went off into a profound depression, and would not talk even to his own. Then his death agony came on, and he died that same evening. The strange and surprising struggle of this man against death, the marvelous force of physiological resistance which the fear of autopsy, if he died, gave him, struck me vividly at the time. What intimate and mysterious bond connects mind and matter that the one is able to react in so much energy upon the other. How wonderful to think that the fear, lest his abandoned body should be cut up, should actually keep body and mind together until after the danger of that dreaded event was passed. _Suggestion and Death._--On the other hand, there are many stories that show us how the giving up of hope of life seems to even hasten death. We have many stories of the death on the same day of husband and wife, or of brothers and sisters who thought very much of each other. Some of these are mere coincidences, but there are too many to be all explained on the score of coincidence. It seems clear that the living one, on hearing of the death of the other, feels that now there is nothing more to live for, and gives up the struggle. Hence the important rule in medical practice that a seriously ill patient should not be told of an accident, and, above all, of the death of a near relative. On the other hand, strong expectation of death at a definite time, especially if accompanied by suggestions with some physical signs, may bring about actual dissolution. We have a number of well authenticated stories to illustrate this. _Renewal of Hope._--How much energy even the slightest hope may furnish, when apparently all power of effort is exhausted, is well illustrated by what happens to men who are lost at sea or in a desert. After the lapse of a certain length of time human nature seems utterly incapable of further effort and they sink down exhausted. The appearance of a light at a distance, a hail, any communication that gives them even the slightest hope will renew their energy and enable them to draw on unsuspected stores of vitality after the end seemed inevitable. It may be said that the exhaustion in these cases is more apparent than real, that discouragement prevents the release of even the energy that is present, and might be used under more favorable circumstances, but that is exactly the argument which favors the deliberate employment of psychotherapeutic motives to enable patients to use the energies which they possess. In the midst of disease, or the struggle for life, when vitality is {92} being sapped, hope is lost or obscured, just as it is when a man is alone in the desert or struggling far from help on the ocean. If we can prevent this discouragement from sapping his powers there will always be a prolongation of life, and often this will be sufficient to enable vital resistance to overcome exhausting disease. Law of Reserve Energy.--Prof. William James [Footnote 13] called particular attention to the law of reserve energy which recent studies in psychology have emphasized. This law of reserve energy is a conclusion from certain facts which are very familiar to men and have been observed as long as the memory of man runs, yet the full significance of which has never been read quite aright. Applied to a very limited range of actions, it has been applied only half-heartedly in ordinary life, and to its full extent only under the pressure of absolute necessity. This law holds out the best promise to psychotherapy. It shows that there are reservoirs of surplus energy in man which, if they can be successfully tapped, present possibilities of resistance to fatigue--and fatigue in many more ways than we used to think resembles disease. Besides, this law represents a very wonderful capacity for withstanding pains and aches and conquering disinclination that would otherwise seem impossible. If it can be made to apply to ordinary life as well as it does to extraordinary events, then the conscious deliberate use of psychotherapy or mental suggestion should prove to have wonderful remedial power. Prof. James said: [Footnote 13: _American Magazine_, Sept., 1908.] Everyone knows what it is to start a piece of work, either intellectual or muscular, feeling stale--or "cold," as an Adirondack guide once put it to me. And everybody knows what it is to warm up to his job. The process of warming up gets particularly striking in the phenomena known as second wind. On usual occasions we make a practice of stopping an occupation as soon as we meet the first effective layer (so to call it) of fatigue. We have then walked, played, or worked enough, so we desist. That amount of fatigue is an efficacious obstruction on this side of which our usual life is cast. But if an unusual necessity forces us to press onward, a surprising thing occurs. The fatigue gets worse up to a certain critical point, when gradually it passes away, and we are fresher than before. We have evidently tapped a level of new energy, masked until then by the fatigue obstacle usually obeyed. There may be layer after layer of this experience. A third and fourth wind may supervene. Mental activity shows the phenomenon as well as physical, and in exceptional cases we may find, beyond the very extremity of fatigue distress, amounts of ease and power that we never dreamed ourselves to own--sources of strength habitually not taxed at all, because habitually we never push through the obstruction, never pass those early critical points. He then states what has come to be called the law of reserve energy. _It is evident that our organism has stored up reserves of energy that are ordinarily not called upon, but that may be called upon; deeper and deeper strata of combustion or explosible material, discontinuously arranged, but ready for use for any one who probes so deep, and repairing themselves by rest as well as do the superficial strata_. There is, then, a marvelous reserve power in men and women which can be used in emergencies and in times of severe strain, to enable men and women to accomplish what looks impossible and which has often contradicted the prognosis of the physician. History is full of applications of this law which, however, does not come into action, unless especially called. Men and women {93} may die simply because they give up the struggle. Men and women who _will not give up_ seem able to overcome severe illness that would take away ordinary people. It has often been said that tuberculosis takes only the quitters and that men of character constitute the typically favorable patients for tuberculosis sanatoria. Psychology is now getting at the explanation of many events that were formerly quite inexplicable. The science has come to recognize the reservoir of reserve energy in human nature which may be tapped under special favoring circumstances. The physicians of the past have often succeeded in tapping it deliberately as well as unconsciously. There is large room, however, for the further development of medicine along this line, to the great advantage of therapeutics and probably the most promising field at the present time in view in therapy lies in this direction. Hence the necessity for more deliberate conscious use of it in every possible suitable form. CHAPTER II UNFAVORABLE MENTAL INFLUENCE Much as may be accomplished by psychotherapeutics through favorable mental influence--the modifying of the mental attitude towards disease, diversions of mind from aches and pains, concentration of attention on subjects apart from ailments--much more may be done by removing any unfavorable mental influence. This of itself produces symptoms either by interfering with normal processes through surveillance of them, or by so exaggerating, through attention to them, slight symptoms that may be present that patients are made quite miserable, though there is no adequate physical cause for their condition. Perhaps the most striking example that we have of unfavorable mental influence as productive of the persuasion that disease is present, is familiar to every physician who is close to medical students when they are first introduced to the symptoms of disease. It is almost a rule that certain members of the class immediately conclude that they are suffering from one or more of the symptoms which they are studying, and that, therefore, they must have the diseases with which the symptoms are associated. If at this time they walk on the shady side of a street on an autumn day and have a little shivery feeling, or when they get into the sun they feel a glow, these two very normal feelings are exaggerated into chilliness and fever, and the student has to go to his professor to have his mental malaria or typhoid treated. To the student, his symptoms are for the moment very real, and unless someone in whom he has confidence reassures him, his discomfort will probably continue for some time. Pathological Suggestion.--In a word, suggestions of disease are much easier to take than is usually imagined, and if people read or hear much about diseases they are likely to jump to the conclusion that they are sufferers. Under present conditions there are many more such sinister suggestions put before people than used to be the case. The newspapers are constantly reporting curious cases and rare diseases, and usually those of absolutely unfavorable prognosis and inevitably fatal termination are particularly dilated on. Pathology has become a source of many sensations, until the community {94} generally has come to eke out the thrills of the day's news by reading about fatal diseases and fatal injuries, whenever murder and suicide sensations fail. As a consequence, many become persuaded that they are suffering from forms of disease of which they have not a symptom, and, not infrequently, the wonderful cures that are reported in the newspapers consist of nothing more than recoveries from these imaginary ills into which people have suggested themselves as the result of reading about morbid states. A typical illustration of the power of the mind to influence the body unfavorably is recognized in many of the comic stories that have had a vogue in recent years. Their underlying thought is that if a man is only told often enough, and by a number of different people, that he does not look well, or if he is even asked a little solicitously as to whether he feels well or not, he will almost invariably begin to persuade himself that there must be something the matter with him. After a time, under the influence of this unfavorable suggestion, he begins to feel tired and is likely to think that he cannot go on with his work. When meal time comes his appetite fails him. A victim has been even known to go home and send for the doctor, persuaded that there is something the matter, simply because a series of friends, for a joke, or sometimes through a mistake, have insisted on asking him questions that called attention to his state of health. Few men are strong enough to stand the influence of unfavorable suggestion of this kind, if it is frequently repeated. More direct forms of suggestion of disease have, of course, even greater effects. Many a man goes to a quack only feeling a little out of sorts and wanting to reassure himself, but easily becomes persuaded that there is something serious the matter with him. Unfavorable Suggestion in Ancient Times.--This unfavorable influence of the mind on the body, even to the extent of the production of disease by means of suggestion, was recognized by the ancients. They knew and wrote of hypochondriasis and, indeed, they invented the term. In many of these cases the seat of auto-suggestion is supposed to be the digestive organs and the localization of the discomfort is in the hypochondria, that is, in the upper abdominal region. The Grecian writers seemed to recognize clearly that the symptoms were the result of thinking over much about self and concentration of attention upon unfavorable suggestions. Plato, in the "Republic," says: In former days the guild of Asclepius did not practice our present system of medicine, which may be said, he declares, to educate diseases. He cites the example of Herodicus who, "being a trainer (of gymnasts) and himself of a sickly constitution, by a happy combination of training and doctoring, came to the invention of lingering death; for he had a mortal disease, which he perpetually tended, and, as recovery was out of question, he passed his entire life as a valetudinarian." Plato, finishing the description, makes us recognize the hypochondriac when he says: "He could do nothing but attend upon himself, and he was in constant torment whenever he departed in anything from his usual regimen, and so dying hard, by the help of science he struggled on to old age." The picture of the neurasthenic, or hypochondriac, who has educated himself, as Plato says, into disease, is an interesting parallel to modern conditions in this matter. Nowhere more than in this matter of knowledge of disease, can weight {95} be attached to Pope's dictum that a little knowledge is a dangerous thing, and that one must drink deep or touch not the Pierian Spring of medical information. The teaching of pathology under the guise of physiology, now so common in our schools, is likely to do more harm than good. Various pathological conditions, such as those produced by alcohol and tobacco, have been emphasized to such an extent as to produce unfavorable suggestions in the pupils' minds with regard to the untoward events that may happen in their insides, and the serious lasting pathological changes that may occur, though all unconsciously, to the sufferer as the result of indiscretions. The study of the morbid changes produced in the mucous membranes of the digestive tract by the use of stimulants, impresses ideas on the mind that are readily transferred to other abuses in eating or drinking. The rather vivid pictures and descriptions of the pathological conditions that may develop, become a portion of the acquired consciousness as to internal conditions, and this consciousness acts as an unfavorable suggestive factor whenever there are any digestive symptoms. Bacteriphobia.--The development of bacteriology has had a similar effect, especially because periodicals and newspapers like to take up only the sensational side of biological discoveries. Most physicians who have had anything to do with nervous diseases have seen cases of misophobia, the fear of dirt, which in our day has taken on the special character of fear of microbes. Those who are sensitive to the possibility of contamination learn of the almost sacrificial precautions that surgeons take to avoid wound infection, and conclude that practically everything they handle must fairly reek with microbes. They hesitate about touching the door knob or latch, and invent all sorts of excuses to wait for a moment outside the door in order to have someone else open it. Especially are they timorous about touching the door knobs of a physician's residence, or the chairs in his waiting room, or even to shake hands with him. Hospital walls and doors become an abomination to them. These cases emphasize how much of unfavorable suggestion there has been in the present spread of popular knowledge with regard to microbes. A writer on popular science once said that every time we spread a piece of bread of the size of the hand with butter, we scatter over its surface as many microbes as there are inhabitants in the United States. The expression has gone the rounds, producing its effect on sensitive people, occasionally causing even a disgust for so important an article of diet as butter, more often giving rise to an extreme sensitiveness with regard to any special savor that butter may have, and it may have many according to the prevailing food of the cow. There has been much emphasis laid on the potentialities for harm of the microbes, and very little on the important part which they play in the production of many forms of food materials. Most people know and dread the fact that microbes produce disease. Very few seem to realize that while we know many thousands of different kinds of microbes, scarcely more than a score of them are known to be seriously pathogenic, while all the others are either indifferent or, as we know of very many, are actually benefactors of mankind. People have heard much of the flora of the digestive tract, until they have come to think with anxiety of the almost infinite number and multitudinous variety of the minute plant life that finds a habitat in the human intestine. Most people think that all of these are, in tendency at least, {96} harmful, and are only kept from being positively dangerous by the overwhelming vital activity of the mucous membrane and the secretions which keep them from exerting their malign activity. Very few appreciate the fact that the intestinal flora, far from being a disturbing factor, are often an aid to digestion, and that the equilibrium established among them favors many biological and chemical processes which help in the preparation of food and in the breaking up of waste products that might be dangerous if reabsorbed during their stay in the intestinal tract. Microbes we have always with us and always will have, and men have lived to round old age, not only in spite of them, but very probably partially because of them. They are part of that beneficent mystery of nature of which as yet, in spite of scientific progress, we know comparatively little. _Opposing Favorable Suggestion_,--A recent striking change of sentiment with regard to one form of food material furnishes a good example of how little we know about the real effect of bacterial life within the digestive tract. There was a time, not so long since, when sour milk was supposed to be especially harmful, or at least only likely to do good to those of particularly strong digestive vitality. Metchnikoff's work on the influence of sour milk on the digestive tract, however, has brought a complete reversal of opinion in this matter. Now most physicians are convinced that the bacillus of sour milk, acts in the intestinal tract to inhibit the reproduction and growth of other, and possibly more disturbing, bacterial agents. Sour milk is looked upon as one of the things that, by neutralizing certain unfortunate bacterial processes in the digestive tract, lead to longevity. There seems no doubt at all, that those who consume a great deal of it, live longer lives than the average, and many old men have taken to its use with a consequent amelioration of digestive annoyances. The popularization of bacteriology, then, has been one of those moments of unfavorable suggestion that have affected a large number of people. Such influences do not mean much for people of phlegmatic temperament. For others, however, they have a weighty significance and make every symptom, or more properly every sensation, that is at all unusual in the digestive tract, seem of ominous import. Certain sensations inevitably accompany digestion. The peristaltic movements are usually said to be unfelt, but even a slight exaggeration brings them into the sphere of sensation. Where attention is given to the abdominal region and its contents, feelings that ordinarily are not noticed at all come to be perceived. With the unfavorable suggestion derived from the unfortunate diffusion of a superficial knowledge of pathology and of bacteriology instead of hygiene and the science of beneficent microbiology, these feelings produce a bad effect upon the individual. Familiar Examples of Unfavorable Suggestion.--There are many familiar examples of the discomfort that may be produced by the mental persuasion that something will disagree with us, or that certain feelings have a significance quite beyond that which ought to be attributed to them. Everyone knows how qualmy may be the feeling produced by being told that something eaten with a relish contained some unusual material, or was cooked under unclean conditions. Food that agrees quite well with people, so long as they do not know too much about it, often fails to be beneficial after they see how it has been prepared. It is often said that people would not relish the food {97} placed before them if they were aware how lacking in cleanliness was the place of its preparation, and how negligent those who had charge of it. Occasionally a peep at the kitchen of a boarding house effectually takes away appetite, or disturbs the equanimity with which food must be taken, if there is to be that undisturbed digestion which makes for healthy nutrition. It is, indeed, with regard to digestion that the influence of the mind on the body, favorable as well as unfavorable is, perhaps, most effectively exercised. Unfortunately the unfavorable influence is even more pronounced than its opposite. Some people are much more sensitive than others in this respect, and even the thought of certain defects in the preparation of their food seriously disturbs them. Everyone has had the experience of seeing sensitive persons leave the table because some one insisted on telling a nauseating tale. Anyone who has seen the effect of talking of blood sausage or fried brains with black butter sauce at a table on shipboard, when some practical joker was exercising his supposed wit, knows how much the imagination can disturb, not only appetite but digestion. The attitude of mind means much, and especially are such unfavorable suggestions likely to produce serious effects in inhibiting digestion. _Suggestion and Seasickness_.--Seasickness illustrates the place of unfavorable suggestion in digestion. The nausea, consequent upon the movement of a vessel at sea, is due to a disturbance of the circulation within the skull, and particularly of the circulation in the semi-circular canals. The organ of direction of the body is disturbed by the over-function demanded of it, consequent upon the continuous movement of the vessel. This is, however, only a predisposing element. A strong additional factor is the firm persuasion many people have that they will suffer from nausea and seasickness, and the unfavorable expectancy thus aroused. Most people have to give their dole to Neptune. Those who for weeks before have been expecting and dreading it usually pay a heavy tribute. Probably the best remedy for seasickness is the suggestion that there is no necessity for losing more than a meal or two, if even that much, provided there is simplicity of diet and proper predisposition of body by gentle opening of the bowels, and lack of the over-feeding that sometimes comes from dinners given before departure. I have known many people who, after suffering severely not in one but in many voyages, have, by means as simple as this, been saved from days of seasickness even in rough weather. Most of the cures for seasickness that have been suggested have depended principally on the suggestive element. For instance, there is no doubt that many people are relieved by wearing dark glasses, and this remedy does good for train sickness and other afflictions of a similar kind. There is, however, no good physical reason why wearing dark glasses should help except through their constant physical suggestion. A simple remedy that has helped many through seasickness is the wearing of a sheet of glazed paper, usually some heavy writing-paper, immediately over the skin of the abdominal region. This of itself has no physical effect, but the sensation of its presence constantly obtrudes itself, and by making people feel that they must be better because a great many other people have declared that they were bettered by this remedy, they actually suffer less from nausea and vomiting. Many of the internal remedies employed for seasickness are directed to the stomach and intestines. {98} As the seat of the difficulty is not here but within the skull, the reputation which these remedies have acquired has been due largely to the suggestive effect of taking them rather than to any physical qualities they possessed, though of course they have served to set at rest stomachs disturbed by unfavorable expectancy. Disease Groups and Suggestion.--Labeling groups of ailments with a single term gives rise to many unfortunate conclusions and dreads with regard to what a particular condition really is. The word "indigestion" is commonly used for any stomach discomfort or disturbance, especially that occurring after eating, from the slight distress because too much has been eaten, or the uncomfortable feeling of fullness because too much liquid has been taken, or the discomfort due to an unsuitable mixture of food materials, to such serious conditions as develop when there is motor insufficiency of the stomach, followed by dilatation, with delay of the food for long periods and with consequent fermentation, distress and bad breath. Whenever the word "indigestion" is mentioned, the patient may think of the worst cases that he has seen or heard of with this label, and concludes that while his ailment may not be very serious just now, it is only a question of time until it becomes so, and that unless he can get rid of his uncomfortable feeling he is destined to have one of the forms of "indigestion" that are productive of such serious discomfort, with probably ever increasing torment, until some fatal complication develops. The initial symptoms of gastric ulcer and cancer have been labeled indigestion, and people, often recalling the serious consequences that followed in such cases, fear for themselves. _Fearing the Worst_.--This looseness of terms is noted with regard to many other forms of disease. Rheumatism calls up the picture of advanced arthritis deformans, with the awful deformed joints and bed-riddenness, which should not bear the term rheumatism at all, but which the patient has heard called so. Catarrh is the simplest of inflammatory processes, meaning merely an increase of secretion, functional in character and without any serious disturbance of an organic character beneath it, but many people have heard the foul-smelling ozena called catarrh, at least popularly, and so the mental picture of such a repulsive progressive process as beginning in them is suggested. It is important, therefore, when using words that have such wide connotation as these, to explain exactly what is meant, and perhaps, better still, not to use the words, but to employ some more specific term that does not carry a cloud of dreads with it. Indigestion can be a very simple passing set of symptoms, but once certain people get the notion that they are troubled with indigestion, their minds dwell on it to such an extent that they are likely to limit their eating more than they should, and to disturb digestive processes by thinking about them and using up in worry nervous energy that should be allowed to flow down to actuate digestion. So-called Incurability.--Patients are likely to hear entirely too much of the incurability of disease. To the doctor and patient this word, incurability, often has an entirely different meaning. The doctor means only that the diseased tissues cannot be restored to their previous condition by any of our known remedies, and that the effects of the deterioration are likely to be felt to some degree for the rest of the patient's life. To the patient it means, as a rule, not only that the doctor can do nothing for him, which is usually {99} quite untrue, for much can be done for his symptoms even though the underlying disease may be intractable, but also that the symptoms are to grow constantly worse. This is often quite without foundation, for nature's compensatory powers are very wonderful and seldom fail to afford relief. In a great many cases fatal termination comes, not from the original affection, but through intercurrent disease. Above all, incurable means to many patients that finally the victim is to become more and more subject to the pains and ills of his "incurable" ailment until he becomes perhaps a pitiable object. Incurability, when we recall that patients are so likely to mistranslate this term in the way indicated, must be a word little used. Etymologically it is never true, for _cura_ means care, and we can always care for and relieve the patient. In every chronic case there is room for hope of much relief through accustomedness, various remedies, nature's compensatory methods, and, above all, the modification of the state of mind. There is probably no incurable disease that is ever quite as serious as it is pictured by its victim when he first hears this word pronounced. When we recall the chances of life, and that in any given case, almost as a rule, the patient will live to hear of the deaths of men and women who were in perfect good health when his ailment was pronounced incurable, there is much of consolation to be derived from conditions as they are. It seldom happens that a physician sees a sufferer from tuberculosis, whose affection is running a somewhat chronic course, without being able to find out that since the first symptoms of the disease manifested itself, one or more of the patient's near relatives have died because of exposure incident to their abounding health. Pneumonia, appendicitis, typhoid fever, accidents of various kinds, take off the healthy relatives, while the tuberculous patient, constantly obliged to care for his health, lives on, and often is able to accomplish a good deal of work. It is important to impress facts of this kind upon these "incurable" cases, for they represent the light in the desert, or the shout, or the whistle at sea, that give renewed energy when nature seems about to give up the struggle. Thinking Health.--Hudson in "The Law of Mental Medicine" [Footnote 14] suggests that we should think health and talk health on all suitable occasions, remembering that under the law of suggestion health, as well as disease, may be made contagious. This expression probably represents an important element for the prophylaxis of disease under all conditions. Under present conditions people talk entirely too much about disease and have too many suggestions of pathological possibilities constantly thrown around them by our newspapers, our magazines and by popular lecturers as well as by our free public libraries. People have learned to think and talk disease rather than health. This predisposes them to exaggerate the significance of their feelings, if it does not actually, on occasion, lower their resistive vitality because of solicitude. The medical student torments himself with the thought that he is suffering from the diseases that he studies, and we cannot expect that the general public will be even as sensible as he is in this matter. On the contrary, people generally are much more liable to exaggerate the significance of their feelings, hence the necessity for healthy suggestions rather than innuendoes of disease. [Footnote 14: McClurg, Chicago, 1903.] In recent years, to paraphrase Plato's expression, people are much more {100} inclined to educate themselves in disease than in health. The result has been a storehouse of unfavorable suggestion, from which ideas are constantly being taken to make whatever symptoms that may be present seem unduly important. Consequently people look for the worst, and suggest themselves into conditions where not only are they exaggerating their symptoms, but they are absolutely preventing the flowing down of such nervous impulses as will enable them to overcome affections that are present. Whenever anything turns up that lessens their tendency to unfavorable auto-suggestion, their health improves. Hence the taking, with confidence, of any quack medicine, no matter what its constituents, cures them; hence the success of the numerous and very varied forms of mental treatment. New Thought, Eddyism, osteopathy, and the like, attain most of their successes because of the removal of unfavorable suggestions, and the setting up in their stead of favorable suggestion. In psychotherapy the first duty of the physician is to undo all the unfavorable suggestion at work, and, if successful in that, great therapeutic triumphs are possible. CHAPTER III THE INFLUENCE OF BODY ON MIND While trying to take advantage of the influence of the mind on the body for therapeutics, it is important to remember that the body has a great influence on the mind. There are many states of mind that are dependent on states of body, and that can be modified only by first modifying the body. Body changes can at least greatly help. In order to use the mind in the therapeutics of conditions in which it would help in the awakening of such vitality as is necessary for the cure, particularly of many of the chronic affections, it is necessary first to dispose the body so that it will not constantly be adding to, or at least emphasizing, an unfavorable state of mind. For this purpose it is important to study definitely and practically the influence that various attitudes, expressions and external manifestations may have in changing the internal feelings. This factor seems trivial when viewed from the standpoint of health, but it is one of the trifles that are very helpful in the predisposition of the patient to get better. Alteratives in medicine, while we have not been able to say just what their effect was, have done much for us, and the influence of body on mind is just such an alterative. Even those who have insisted most strenuously on the independence of mind from body have always recognized not only the influence of the mind on the body, but also of the body on the mind. Perhaps the most familiar example of this is the well-known liability to dream after eating things that disturb digestion and seem to interfere, probably by congestive tendencies, with the circulation of the brain during sleep. It has always been recognized that mental operations are sluggish for some time after eating, and that a period of depression is likely to follow any excess. The Romans feared the consequences of indigestion so much that, occasionally after they had surfeited themselves with rich food, they took such direct mechanical means as a feather or a finger in the throat to relieve their overloaded stomach, in order that they {101} might not suffer the after consequences, but especially the depression and irritability of mind. Disposition and Digestion.--The relation of the body to the mind in many other besides the purely animal digestive functions has always been realized. It has always been felt that the disposition of an individual depended to a great extent on his nutrition. Men were not usually approached for favors before their meals, and especially after a long fast, but, as far as possible, requests were made shortly after meals. It has always been recognized that the best time for men to get together in council is, at least so far as amiability goes, shortly after meals. Tiredness was also felt to be an important element in affecting the mind. The tired man, even though he may be hungry, can only eat a hearty meal at the risk of serious disturbance of digestion, for, as a consequence of the fatigue of the body being communicated to the mind, the mental influence which predisposes to good digestion is lacking, and it is easy for serious digestive disturbances to be set up. In a word, body and mind are inextricably involved in all that concerns not only health but good feeling, and these two terms are practically convertible. Feeling and Expression.--In nothing is the influence of the body on the mind more clear than in the influence of expression upon the disposition. Actors know that if they want to well express a certain feeling, they must arouse that feeling deeply, and the easiest, surest and most direct method of doing so is to fix the features in the expressions that would ordinarily indicate the presence within of these feelings. If we insist on putting our features into the shape which ordinarily expresses sadness, that will be reflected internally, and we shall become as sad as our expression. On the other hand, if the features are drawn, even by force of will, into the state that ordinarily expresses joy or lightness of heart, we shall be tempted more and more to feel that way, until at last even internal melancholy may be dissipated. In the oldest book in the world, "The Instruction of Ptah Hotep," written about 3,000 years before Christ, the old father giving advice to his sons says: "Let thy face be bright what time thou livest," and the literature of every time since then emphasizes the same idea. This influence of the expression on the mind is an extremely important element in psychotherapy. Men and women must be taught to shake off inner sadness, and over-occupation of mind, by training their facial muscles of expression as far as possible to occupy positions expressive of good feeling, but above all not to let them be fixed in positions indicative of ill feeling. It makes a great difference for the mental state whether a man has the corners of his mouth drawn down or up, or whether they are pulled straight across the face to give the severe, austere expression that some people seem to cultivate. If the corners of the mouth are allowed to droop the glumness and depression is likely to grow deeper. If the lips are curled upward and smile, even though it may be a forced smile, the inner feeling will soon yield to it. Actors are able to counterfeit the reality, but much more than this, as we have said, they realize that, by imitating the externals of the feeling, they awaken the feeling itself within them. This is true for anger and loathing, and for many of the more serious dispositions as well as for those that might be thought more superficial, and hence more controlled by the external muscles. {102} _The Mouth_.--It is interesting to realize how different are the expressions of the face as a consequence merely of control of the sphincter of the mouth and its associated muscles. Physiological psychologists have often called attention to the fact that only a few lines are necessary to picture the characteristic human expressions of sadness, joy and severity. If a little droop is given to the line that represents the lips, melancholy is at once expressed, while the upward curve expresses joy, and the straight line severity. These types of human expression are easy to control, and the internal effect of each is soon felt where there is deliberate, or indeliberate, perseverance in its maintenance. [Illustration: Fig. 1. Three abstract faces.] _The Eyes_.--A typical example of the influence of the mind on the body is to be found in the use of the eye muscles, especially the oblique muscles. Of definite and important use for many purposes, they are especially employed to attract attention by means of the eyes. Coquetry has used them to express various phases of sex attraction. We all know the picture of the young woman who "makes eyes." It is interesting, however, to set solemn people imitating these exercises of the oblique eye muscles. For most people it is practically impossible to use these muscles without a corresponding quasi-demure setting of the features, commonly associated with those who use them most. There is even likely to be a certain attitude of mind aroused corresponding to the setting of the features in a particular way. While this is true for almost any other expressive state of the countenance, it is not so easy to demonstrate as is this. The use of the superior recti muscles has also a definite effect upon the disposition. One of the pleasures of walking in a well-kept forest where the trees meet high overhead, is that the eyes are inevitably attracted upward to range among them, and there is a corresponding elevation of feeling. Bernard Shaw once said that it was impossible to enter a Gothic church without an elevation of the spirit, because the eyes were surely attracted upward by the height of the nave, and a corresponding uplift of feeling ensued. During a period of glumness it is apparently impossible to keep the eyes raised. People who are depressed and "cast down," as the expression is, invariably keep their eyes downward, and just as soon as a man "looks up and not down" there is a lifting of the depression. Even such apparently trivial muscular actions as this may influence the mind, and thus react upon the physical system generally. _Wrinkles_.--Many influences of the body on the mind group themselves in the muscles of expression around the eyes. Wrinkles, for instance, are originally a habit of mind, and then the emphasis of this, in the muscles of the face, is reflected back to deepen still further the dejection or nervous unrest that originally causes them. It is surprising to see what an influence it has on patients who go round much with wrinkled foreheads, to have them give over the practice and discipline themselves to appear with uncorrugated superciliary muscles. St. Ignatius Loyola, the founder of the Jesuits, and one of {103} the wisest managers of men that ever lived, has emphasized in one of his rules that "wrinkles on the forehead and still more on the nose" are a sign of interior disquiet and must not be seen. He realized that the interior feelings could be influenced by suggestion at least, by having those who indulged in wrinkles keep their foreheads and noses smooth. Most of the expression of the face is concerned with the eyebrows and neighboring regions, and people should occasionally be asked to look at themselves in the glass, so as to rid themselves of habits of expression indicative of a disturbed mind, for this will do much to help to relieve the mental disturbance. Attitudes and the Mind.--With regard to the influence of the body on the mind, and the stimulating mental reaction that follows even a pose of well-being and good feeling, perhaps nothing affords more striking evidence than the effect of assuming the expressions and attitudes usually associated with various states of mind and then noting the results. If a man throws his shoulders back, and takes in long breaths of air, expanding his chest and stimulating his circulation, his whole body as well as his mind feels the effect. A slow walk with bowed shoulders and head, while one moodily turns over all the possibilities for ill in the life around, does very little good, while a brisk walk with head thrown back, shoulders erect, brings a man home with mind and body both ready to throw off temporary obstacles of all kinds, and in addition to the fact that the mental depression has disappeared, to some extent at least, all the physical functions will be accomplished better than before. Tears and Feeling.--Some of the usual translations of the meaning of external expressions are not justified by what we know of their actual purpose and effects. For instance, tears are supposed to be a sign of deep grief. Except in the very young they are not, as a rule, to be thus understood. As we grow older they are much more frequently a sign of deep feeling that is usually quite pleasurable. It is almost impossible for a human being to be touched deeply without a glistening of the eyes that readily runs over into tears. A mother who is proud of something that her children have done is quite sure to have tears in her eyes. If she is present at a successful musical or dramatic performance given by a son or a daughter, especially where there is something of a triumph for them, she is sure to have tears in her eyes. There are few mothers who fail to be moved in this way when their children take prizes, or when some one writes to tell them how well their children are doing. Tears, indeed, far from being a sign of sadness, usually in adults indicate profound joy. Tears, then, instead of being discouraged, should rather be encouraged, unless when indulged in to excess. We realize how trying to health and strength is the stony grief that does not melt into tears. The mother who faints over the sudden death of her child, and who wakes to silent consciousness, is in a dangerous condition until the solace of tears comes to her. Until there are tears, we fear for the effect upon her mind of the grief. The sufferer from melancholia is sad, but a good outburst of tears will, indeed, often mean the end of a prolonged period of melancholia. In the trials of life tears are a consolation rather than an addition to sorrow. In the olden times men wept as well as women, and Homer's heroes thought it not at all beneath their dignity to be seen in tears. Over and over again, the physician learns that while people have been going to "shows" that were supposed to make them {104} laugh and so divert their minds, the best possible effect is derived not from trivial laughter, but from a serious play that touches the heart deeply and makes all who go to it melt a little. Many nervous patients never feel better than after they have had a good quiet cry. The influence of the serious things of life in producing favorable states of mind is not sufficiently appreciated, or at least has come to be neglected in our day. There is a seeking far and wide for pleasure and diversion that should be obtained near home, through the simple joys of domestic life or intimate contact with others who need us in some way. As has been well said, it is not far-fetched pleasure, but simple joys that are more needed in our time. Nothing so enables the patient to get his, and above all her, mind off self as care for others. This must be expressed, however, in external acts accomplished by ourselves for others to have any deep effect. Doing things for other people deepens the feeling of sympathy, and so makes the mind much more ready to respond to increase of these feelings so profoundly as to displace selfish considerations. Exercise is valuable, but exercise undertaken for a worthy motive, constantly before the mind during the time it is taken, means ever so much more in awakening all the sources of energy that there are in men and women to make life worth living for themselves and others. Application of Principles.--The best possible source of relief from that combination of mental despondency, and the lack of bodily vitality which so often accompanies it, and which, if not interrupted, may lead to a serious breakdown of mental health, is the discipline of work; above all, work for the benefit, of others, to which one forces one's self gradually but persistently, not with, long intervals, but day after day. The discipline of the asylum and the sanatorium is probably the most efficient curative agent when these cases are at their worst. When the symptoms are beginning, a discipline of a milder character, yet resembling that of the institution, but appealing to higher motives and leading to frequently repeated actions for the benefit of others, will undoubtedly do much to prevent worse developments or make the future condition of the patient less serious than it would otherwise be. Undoubtedly some of the old monastic regulations were efficient in preventing the more serious developments of despondency when the danger to himself and others of the melancholic was not so well recognized as at present. _Laughing Cures_.--Every now and then the newspapers announce that some physician has invented a laughing cure, or a smiling cure, or something of the kind. Sometimes these reports are founded on actual occurrences; oftener, perhaps, they are the invention of a reporter suffering from a dearth of news. There is, however, no doubt that a smiling cure will do much to make people, even those who have serious reasons to be depressed, feel better. Every physician knows that if melancholic patients of the milder type can be amused quietly, their depression is modified for the better. Accordingly, we advise them to see farces or lively comedy, and we try to pick out cheerful nurses for them. The depression consequent upon some serious illness can be better relieved in this way than by any tonics or stimulants. For the depression, for instance, that so often follows a stroke of apoplexy, the employment of a nurse with a good human sense of humor and a large sympathy with the humorous side of things in life will do more to arouse a man from the lethargy into which he settles than almost anything else. {105} With regard to laughing, there is, of course, another element that must be remembered. A hearty laugh moves the diaphragm up and down vigorously, empties and ventilates the lungs, stimulates the heart mechanically by its action upon the intra-thoracic viscera, and is one of the best tonics that we have for the circulation in the abdominal cavity, and probably also for the important nervous mechanisms centered there. Its action upon the lungs is readily recognized. Its influence upon the heart is usually not so much thought of, but deserves even a more prominent place. It is now well known that when patients have gone into coma or the apneic condition that sometimes follows shock, or the administration of an anesthetic, when the heart ceases to beat, the only effectual means of resuscitation is by directly irritating the organ. It has been suggested that if the abdominal cavity is open the surgeon's hands should be passed up and should squeeze the heart through the diaphragm. It has even been proclaimed that tapping on the chest vigorously over the precordium may arouse a heart that has for the moment stopped beating. It is easy to understand, then, that a hearty laugh, by stirring up all the intra-thoracic viscera, stimulates the heart mechanically and sets it beating more vigorously than before. This is one of the reasons why people feel so well after a hearty laugh. Even slight swallows of water act as a distinct heart stimulant. When people have fainted, a succession of swallows of water, each of them acting as a heart tonic, is one of the best methods that we have of stimulating the heart's action. It is usually said that this action is a consequence of the reflex from the terminal filaments of the vagus nerve running back and reflected down again to the heart. To me it has always seemed that the swallowing action had a direct mechanical effect upon the heart, because the esophagus passes so close to it in the thoracic cavity. Man is the only animal that laughs, and, as the old philosophers point out, he might very well be defined as _animal risibile_ with just as much truth as by the words _animal rationale_. It requires reason in order to have a sense of humor. The higher the reason, the more the humor. Peasants and the uneducated have, as a rule, a very undeveloped sense of humor. It is the highly educated man of deep intellectual powers who catches all the humor of a situation, and, though his expression of it may not be loud, it is deep and helpful at moments of depression. Humor is, of course, very different from wit, which is biting and which seems almost to be shared by the animals, if we can judge from the fact that they appear, occasionally, to play practical jokes upon one another. It seems almost absurd that a physician should tell patients that it will do them good to practice smiling, to take every possible opportunity to laugh, and even to take frequent glances into a looking glass, to see that they are not pulling long faces. The difference between a feeling of melancholy and one of gladness consists mainly in the position of the outer angles of the mouth. The putting into practice of the maxim, not to let the sad lines dominate the countenance, but to insist on keeping the others there as far as possible, means much for the correction of internal feelings of depression and discouragement that may be badly interfering with the flow of nerve impulses from the brain to the body. Mouth Breathing.--Since Meyer's discovery of the overgrowth of the {106} lymphoid tissue in the pharynx, we have learned to appreciate how important is mouth breathing, even for the intellectual life. We all knew before, and indeed from time immemorial it was well understood, that, as a rule, people who went around with their mouths open were of low grade intelligence. All sorts of methods were used to teach these young people to keep their mouths shut. They were reminded of it at home, they were told about it at school, and, if they married, their wives tried to keep them from this apparent manifestation of lack of intelligence. Of course, they were not, as a rule, able to carry out the well-meant intentions of their friends and advisors. The mouths were kept open because they could not breathe normally through their noses, and so respiration had to be accomplished by the only other available avenue. As a consequence of the open mouth, the lips were inclined to roll out somewhat, and certain indications of the human physiognomy were supposed to be associated with these thick lips. Now we know the real meaning of the condition. Mouth breathing is possible, but it is inadequate. Insufficient respiration leads to insufficient oxidation of tissues, and to lowered vitality in all structures, and this is particularly notable in the brain, as well as in certain other higher structures. It is not because the individuals are lacking in intelligence that their mouths are open, but because the same reason that compels the open mouth also affects their intellectual activity. The blocking of nasal respiration lowers vital activity of all kinds. Hence the lowered intellectual vitality. The thick lips, which are supposed to be characteristic of a certain passionateness of nature, and which usually are associated with a lack of thorough control over animal inclinations, probably owe their significance to the fact that this special peculiarity of feature usually accompanies mouth breathing, and that the individual who labors under this deficient respiration, is likely to lack control to at least some degree. There is even a question whether the deficient oxidation is not likely to be much more notable in its effect upon the higher faculties than on the lower, and as a consequence the latter develop somewhat to the detriment of the former. These studies in physiognomy may, indeed, be correlated in many ways with distinct physical conditions instead of as formerly with the general constitution of the individual. For instance, large protruding eyes used to be said to be characteristic of nervous, timid, sensitive individuals, easily scared, and not well able to take up the harder parts of the battle of life. Now we know that this feature is usually associated with an excess of secretion of the thyroid gland, and that the nervousness is not a matter of character so much as it is due to the disturbance of internal metabolism consequent upon this interference with the proper function of an important organ. It might well be called a slight thyroid intoxication. In large amounts it produces all the symptoms of Graves' disease. Bodily Conditions and Stupidity.--We have many illustrations of the influence of the body on the mind, when purely physical causes work rather serious results on disposition and character and energy. A typical example was the so-called tropical anemia which existed in Porto Rico when the Americans took possession of the island. There were so many cases of it that out of about 25,000 deaths reported in 1903, nearly 6,000 were from so-called anemia. Investigation of the conditions soon revealed the real cause. It had been {107} thought to be due to a combination of the climate, malaria and the lack of nutrition on the part of the country people. The people were absolutely without ambition, they had no energy, they seemed scarcely able to keep body and soul together, and they cared for nothing except to get just enough to supply them with a meager sustenance. Of incentive to lift themselves up, there was none. This was largely attributed by the first Americans who went to the island to the conditions which had existed under Spanish rule, as the Spaniards had not encouraged manufactures or industries in the island, and had left the people without any incentives to the awakening of enterprise or initiative. _Hook-Worm Disease_.--Before long it was found that the real reason for the anemia of the Porto Ricans was the presence in their intestines in large numbers of the so-called hook-worm. These worms exhausted the vitality of the sufferers and left them without surplus energy and, indeed, with scarcely enough life to care whether or not life itself continued. It was not a moral condition, but a very definite physical cause that was at work. Shortly afterwards it was found that the same disease existed in our Southern states among the so-called "poor whites." Before this, these people had been supposed to be a characterless, unambitious, lazy people, who cared not to get on, who had sunk to about the lowest depths possible for civilized people, and who were quite satisfied to remain there. The discovery of hook-worm disease among them, however, soon made it clear that their laziness was the result of the drain upon their systems due to the presence of thousands of hook-worms. When these were removed, if nature was not already exhausted, the "poor whites" became normal human beings once more with ambition and initiative. This story of pathology influencing racial qualities is not new in the history of the world. It is not improbable that even certain periods of decadence in Egyptian history which have ordinarily been attributed to the so-called running out of particular ruling races or families, or to the degeneration of the people consequent upon luxury, were really the result of the spread of the hook-worm disease through certain portions of Egypt. Dr. Sandwith, who has studied the disease very carefully in Egypt, is sure that it has existed there for at least four thousand years, and that the descriptions of certain affections which occurred in Egypt in historic times were really due to the same cause as now is known to produce the so-called Egyptian chlorosis, the name that was used for hook-worm disease in Egypt. Workers in soil, and in mines and in tunnels, are especially likely to be affected by it, and whenever it is neglected it spreads rather widely, as is seen in the mines of Germany and Hungary at the present time. As the cause was unrecognized in the olden time, it is possible that periods of supposed lassitude among the people were really due to infection by this parasite. _Malaria and Degeneration_.--In recent years it has come to be generally recognized that the decadence of Greece, for instance, was not due to moral causes so much, perhaps, as to physical reasons. During the classic periods in Greece there are no traces of malaria. After the invasion of Sicily, the expedition against Syracuse and other attempts on the part of the cities of Greece to spread their dominion, malaria seems to have been introduced among her people, and as the _anopheles_ mosquito was already there, the malaria spread widely, and in the course of a century affected so many of the people that their energy and ambition and initiative were to a great extent destroyed. {108} It is well known that these effects often occur as a consequence of malaria, and as generation after generation is affected by the disease, are emphasized more and more. The relaxing effect of tropical climates, of which we have heard so much, and which is supposed after a time to bring about the inevitable production of a race eminently lazy and careless of the future, is probably much more due to certain affections, such as malaria and those consequent upon animal parasites, than to any constitutional change that has taken place in the body, or any profound corresponding change in the mind. It is a case of the body influencing the mind and producing an apparently different race from that which existed before, though all this may be changed for the better by some even slight amelioration of bodily conditions. In any attempt, then, to influence the human mind in order to use its power and its reserve energy for therapeutic purposes, the place of the body and its influence upon the mind must always be remembered. It is quite impossible to lift people up to enable them to use their mental reserve force if they are living in discouraging physical conditions, which use up so much of energy as to make it impossible to have any to spare. Many of the phases of mental discouragement and lack of initiative which are reflected in what we call lowered resistive vitality and lack of immunity to infection, are really consequent upon physical states representing a drain upon the system that can be removed, or at least greatly improved, if they are discovered and properly treated. Victims of chronic malaria and of hook-worm disease cannot be lifted up by psychotherapy. Neither can sufferers from other forms of chronic physical debility. After the removal of the debilitating cause, however, mental influence may be brought to bear to encourage them to rise to their opportunities, to literally take on new life, and gradually accumulate reserve energy that will enable them to accomplish, not only the average work of mankind, but even better, in the reaction that comes with the new feeling of physical energy. And what is thus true in these extreme cases is even more true of minor ailments and conditions. CHAPTER IV THE MECHANISM OF THE INFLUENCE OF MIND ON BODY The question as to how mind influences body, and body mind, has always proved a riddle to all but those with a special theory in the matter. The facts of the mutual influence of mind on body are so obtruded on observation that they could never be missed, but it is quite another thing to reach a satisfactory explanation of them. How the will initiates motion continues in spite of all our advance in psychology, to be as much a mystery as ever. Just how sensation is transformed into ideas is a parallel mystery. Since the mind is able to influence motion, it is not surprising that it should be capable of modifying secretion or inhibiting other kinds of functions. Any of these various activities is scarcely more mysterious than the other. Since the transformation of sensation into thought takes place, it is comparatively easy to conclude that the mental processes are able to exclude, or to some extent inhibit, sensation. All these activities have actually been observed. How does this mutual influence of mind on body take place? What principles underlie it? {109} At present, it would be futile to hope to outline the absolute principles on which the mechanism of mental influence or suggestion depends, but we can discuss recent explanations that have been offered, and this will help us to understand, not the mystery itself, but just where the mystery lies and what the physical mechanism connected with it is. [Illustration: Fig. 2.--CORTEX OF HUMAN BRAIN ILLUSTRATING COMPLEXITY OF THE SYSTEMS AND PLEXUSES OF NERVE FIBERS (Combination of the methods of Weigert and Golgi--after Andriezen). _c, z.,_ clear zone free from nerve fibers; _M.P.,_ Exner's plexus in the molecular layer; _A. str.,_ ambiguous cell stratum; _Subm, P.,_ sub-molecular plexus; _Gt. P. P.,_ great pyramidal plexus; _Pol. P.,_ polymorphic plexus; _W.,_ white matter. (Barker.) ] {110} These explanations are as yet only theoretic, but theories have often helped students in science to make their thoughts more concrete and their investigations more practical. It would be a mistake to conclude that because some of the theories advanced are very plausible, we have, therefore, reached definite truth with regard to the mechanics of the brain that underlie suggestion and mental influence. Brain Complexity.--The most interesting feature of the discoveries in brain anatomy during the past generation, has been that the central nervous system is of even greater complexity than had been thought. Because of this, these new discoveries, instead of solving the biological mystery they subtend, or even helping very much to solve it, have made it still harder to understand just how we succeed in controlling and directing this immensely complex machine, of whose details we are utterly unconscious, yet which we learn to use with such discriminating nicety of adjustment and accomplishment. The discoveries of Golgi and of Ramon y Cajal show us that the brain consists of nerve cells with a number of ramifying fibers connecting each cell and each group of cells with other simple and compound elements of the brain, and sending down connecting fibers to every organ and every part of the body. Dr. Ford Robertson calculates that in an average human brain there are at least three billions of cells. Without knowing anything of their existence, much less anything of the infinite detail of their structure and mode of operation, we have learned to use these for many purposes. [Illustration: FIG. 3.--SMALL AND MEDIUM-SIZED PYRAMIDAL CELLS OF THE VISUAL CORTEX OF A CHILD TWENTY DAYS OLD. Section taken from the neighborhood of the calcarine fissure. A. plexiform layer; B, layer of the little pyramid; C, layer of the medium-sized pyramid; a, descending axis cylinders; b, ascending or centripetal collaterals; c, stems of the giant pyramidal cells. (Ramon y Cajal.) (This and the next three illustrations illustrate the complexity of the central nervous system as observed in the very young child where the development does not as yet obscure the interesting details of dentritic branching. They serve to emphasize the much more pronounced condition which develops in the adult.)] Nerve Impulses.--We do not know even how nerve impulses travel. Probably they do so by a mode of vibration, just as heat and light and electricity are transmitted as modes of motion. The similarity that used to be thought to exist between the transmission of nerve impulses and of electrical energy is now known definitely to be only an analogy, and not to represent anything closer. Waves of nervous energy travel at a different rate of speed from electrical waves, and there are other notable differences. Such phases as molecular action, or motion, or vibration are only cloaks for our ignorance, A generation ago Huxley declared that "the forces exerted by living matter are either identical with those existing in the inorganic world or are convertible into them." He instanced nervous energy as the most recondite of all, and {111} yet as being in some way or other associated with the electrical processes of living beings. As Prof, Forel said in his "Hygiene of the Nerves," "the neurokym cannot be a simple physical wave, such as electricity, light or sound; if it were its exceedingly fine weak waves would soon exhaust themselves without causing the tremendous discharges which they actually call forth in the brain." Law of Avalanche.--How great is the power of the nervous system or the energy of it that may be set loose by some very simple reflex, as suggested by Forel, is illustrated by what Ramon y Cajal calls the Law of Avalanche. A single peripheral nerve ending is represented in many different portions of the brain. An ocular nerve ending, for instance, probably has direct connection with four or more portions of each hemisphere. Each of these portions of the brain has association fibers connecting it with other parts and so the stirring of a single nerve ending may disturb many thousands, perhaps hundreds of thousands, of brain cells; at least it affects them in some way or other. The older psychologists used to insist on the similarity, or analogy, between the cosmos ol the universe and the microcosmos that man is. The English poet of the nineteenth century told us that there is no moving of a flower without the stirring of a star, so intimately connected by the laws of gravitation is the universe. In the microcosm something of this same thing is true and a titillation of even the most trivial nerve ending may produce, in Ramon y Cajal's phrase, "an avalanche" of cell disturbances in the central nervous system which may seriously disturb the whole system. What is thus true for the brain is true, also, for the cord, and the complexity of spinal cells needs to be seen to be properly realized. [Illustration: Fig. 4.--SERIES OF SECTIONS SHOWING THE FINE NERVE ENDINGS AND BRANCHINGS OF THE FIRST AND SECOND LAYER OF THE VISUAL CORTEX OF A CHILD FIFTEEN DAYS OLD. A and B, very thick nerve plexus of the layer in which the little pyramids are contained; C, a plexus containing a series of branches that is less thick and intricate; D, small cells whose ascending axis-cylinders have resolved themselves into a set of similar branches; E, arachnoid star cells whose axis cylinders produce a thick plexus in the first layer; F and G, small cells with short axis cylinders that have very few branches. (Ramon y Cajal.)] Psychic States.--There are a number of human states representing extremes of sensory and intellectual conditions in man, that have always attracted attention, and in recent years have been special objects of investigation by physiologists. Natural sleep is one of these; the unconsciousness of narcotism or anesthesia is another. Hypnotism is allied to both of these, and would seem to lie on a plane between them. Then there are various states of exaltation in which sensations fail to produce their usual effect. Those {112} escaping from a fire, or passing through a severe panic of any kind may sustain all manner of injuries without being aware of them. Martyrs, for all manner of causes, are able to withstand suffering with such equanimity, and sometimes even joy, that it is evident that they cannot feel, as would people under ordinary conditions, the pain that is being inflicted on them. [Illustration: Fig. 5.--FIRST, SECOND AND THIRD LAYER OF THE ANTERIOR CENTRAL CONVOLUTION (THAT IS, OF THE ASCENDING FRONTAL CONVOLUTION) OF THE BRAIN OF A CHILD ONE MONTH OLD. A, B, and C, little pyramids; D and E, medium-sized pyramids; F, cells with two sets of tufts; their axis cylinders resolved into end tufts; G, protoplasmic layer that comes from one of the large pyramids of the fourth layer; H and I, fine dentrites of the cells of the sixth and seventh layer; J, small cells with two end tufts; K, spindle cells with long axis cylinder. (Raymon y Cajal.)] [Illustration: FIG. 6.--LAYERS OF THE POSTERIOR CENTRAL OR ASCENDING PARIETAL CONVOLUTION OF A NEWBORN CHILD. 1. plexiform layer; 2. small pyramids; 3. medium-sized pyramids; 4. external large pyramids; 5. small pyramids and star shaped cells; 6, deep layer of large pyramids; 7, spindle and triangular shaped cells. (Raymon y Cajal.)] In the midst of intense mental preoccupation one may hold so cramped a position as would be quite impossible for the same length of time with the faculties normally engaged. There are pathological conditions, like hysteria, in which the pain and fatigue sense may, for a time at least, be quite in abeyance. {113} [Illustration: FIG. 7.--DIAGRAM OF CELLS OF CEREBRAL CORTEX (after Starr, Strong and Leaming). I, superficial layer; a, fusiform; b, triangular; c, polygonal cells of Ramon y Cajal; II, layer of small pyramids; d, smallest; e, small; f, medium-sized pyramidal cells with axones descending to the white matter and giving off collaterals in their course; III, layer of large pyramidal cells; g, largest (giant) pyramidal cells; k, large pyramidal cells with very numerous dendrites; all pyramidal cells are seen to send long apical dendrites up to I; m, Martinotti cell with descending dendrites and ascending axone; n, polygonal cells; IV, deep layer; p, fusiform cell; q, polygonal cell; V, the white matter containing the axones from the pyramidal cells, d, e, f, g, and from a cell of the deep layer q; r, neuroglia fibers. (Barker.)] {114} [Illustration: Fig. 8.--SCHEME OF LOWER MOTOR NEURON. The motor-cell body, with protoplasmic processes, axis cylinder, side fibrils or collaterals, and end ramifications, represents parts of a neuron. a. h., axon hillock devoid of Nissl bodies, showing fibrillation; ax., axon. This process near the cell body becomes surrounded by myelin, m., and a cellular sheath, the neurilemma (not an integral part of the neuron); c, cytoplasm showing Nissl bodies and lighter ground substance; d, protoplasmic processes (dendrites) containing Nissl bodies; n., nucleus; n., nucleolus: n. r., node of Ranvier; s. f., side fibril; n. of n., nucleus of neurilemma; tel., motor end plate or telodendrion; m., striped muscle fiber; s. l., segmentation of Lautermann. (Barker.)] Neurons.--With the advance in our knowledge of brain anatomy, various explanations for these curious conditions have been suggested. The discovery that the central nervous system is composed of a large number of separate units, and not of a feltwork of continuous fibers with cells here and there, revolutionized all previous attempts at explanation of these conditions. We know now that it is not fibers but cells that are the most important components of the brain and spinal-cord substance, and that, indeed, the fibers are only prolongations of cells. The central nervous system is made up of nerve cells with various appendages, and each one of these cells and its appendages is called a neuron. These appendages are of two kinds, one the axon, the long conducting fiber which transmits the nerve force of the cell, the other the dendrons or connecting elements by which the cell is linked with the axon of another cell. The contact of the axon of one neuron with the dendrons of another is called a synapse. Each neuron does not extend to and from the brain and the periphery, but series of neurons connect the surface of the body with the brain. There is usually a group of neurons in the path from the surface to the brain cortex. The peripheral neuron for sensation runs from the surface of the body to the spinal cord, while for motion it runs in the opposite direction. There is a secondary neuron in each chain that runs up or down the spinal cord to and from the base of the brain. A third--sometimes, perhaps, a fourth--neuron connects in the two directions, afferent and efferent, the cortex and the base of the brain. _Neuronic Movement_.--Duval, the French anatomist and histologist, suggested the possibility of voluntary and involuntary movement in the neurons or nerve cells themselves, thus making and breaking connections. {115} [Illustration: FIG. 9.--SCHEME OF THE VISUAL CONDUCTION PATHS (after C. von Monakow). a, rods and cones; b, rods; c, nuclei of rods; d, bipolar cells for the cones; e, bipolar cells for the rods; f, large multipolar ganglion cells giving rise to the axons of the N. opticus; g, centrifugal axon of a neuron, the cell body of which is situated in the collieulus superior, its telodendron being situated in the retina; h, Golgi cell of Type II, or dendraxon in the corpus geniculatum laterale; i, neuron connecting the corpus geniculatum laterale with the lobus occipitalis, its axon running in the radiato occipito-thalamica (Gratioleti). The visual impulses are indicated by the arrow. (Barker)] {116} [Illustration: FIG. 10.--SCHEMATIC FRONTAL SECTION THROUGH THE OCCIPITAL LOBE ILLUSTRATING MANIFOLD CONNECTIONS IN A SINGLE LOBE (after H. Sachs), v, cornu posterius ventriculi lateralis; f. c, fissura calcarina; b, upper division: i, lower division; coll, sulcus collateralis; s. o. I, sulcus occipitalis superior (fissura interparietalis); s. o. II, sulcus occipitalis medius; s. o. III, sulcus occipitalis inferior; c. a., calcar avis; g. l., gyrus lingualis; g. f., gyrus fusiformis; g. o. s., gyrus occipitalis superior; g. o. m., gyrus occipitalis medius; g. o. i.. gyrus occipitalis inferior; c, cuneus; 1-10, forceps; 11-14, stratum sagittale internum: 15, stratum sagittale externum; 16, stratum calcarinum; 17, stratum cunei transversum; 18, stratum proprium cunei; 19, stratum proprium s. o. I; 20, stratum proprium s. o. II; 21, stratum proprium. s. o. III; 22, stratum proprium, s. coll.; 23, stratum profundum convexitatis. (Barker.)] According to his suggestion, sleep would be due to a separation of the neurons that run from the surface of the body to the brain cortex, because the various neurons had become too tired for further function. As a consequence of fatigue, their terminal filaments would fall away from one another, external sensations would no longer be communicated to the brain, because the peripheral neuron was not connected with the next in the chain. As a further result, the brain, undisturbed by sensations, would be left at rest so far as the body was concerned. Within the brain certain connections through which flow thoughts that would keep us awake, are also supposed on this theory to be broken, and consequently all the nerve cells have a chance to rest, except, of course, those concerned with such very vital functions as heart movement, respiration and peristalsis. {117} [Illustration: FIG. 11.--ISOLATED CELL FROM HUMAN SPINAL CORD (Obersteiner).] Somehow, these vital neurons obtain their rest in the intervals between the impulses which they send down, just as cardiac cells do between heart beats. _Neurons in Psychic States_.--This same explanation would serve for narcosis, that is, for anesthesia, due to chloroform or ether, or any other drug. As a consequence of the effect of the narcotic upon the central neuron, they are brought into a condition resembling fatigue, at least to the extent of breaking their connections with other neurons so long as they are under the influence of the drug. While sensory nerves at the periphery, then, are being stimulated by the cutting of tissues to which they are attached, the message from them does not reach the brain because of a disturbance of the connections in the chain of neurons. Drunkenness illustrates the same phenomenon in a less degree. The effect of the intoxicant upon the central neurons disturbs sensation because it makes the connection much less complete than before, and so it is easy to understand the familiar occurrence of even severe injuries to drunken men without their being aware of them, or at least without their suffering nearly so much as would be the case if they were not intoxicated. _Hypnotism_.--The same theory would also hold for the phenomena observed in hypnotism. After all, the best explanation of hypnotism that we have is that there is a turning inward of the patient's attention, so that only those sensations are allowed to reach the brain to which mental attention has already been called by suggestion. Hypnotism usually begins with a certain fatigue of peripheral neurons until these do not act normally, and then the cerebral neurons become, as it were, short-circuited on themselves with a consequent internal concentration of attention. The anesthesia so often noted in hypnotic or hysterical states is explained by the same theory. For the time being, at least, the connection between the peripheral neurons and the central neurons is broken or but imperfectly made, and conduction does not take place, or is hampered. There may be loss of motion as well as of sensation, or of motion without sensation. In all these cases, the discontinuity of the nervous system enables us to understand more readily the mechanism by which these curious phenomena occur. Exaltation or intense interest or profound preoccupation may so concentrate nervous energy within the nerve centers themselves as to inhibit the flow of sensory impulses from without and thus enable {118} people to stand pain and fatigue that would otherwise seem quite unbearable. _Unconsciousness_.--The unconsciousness due to apoplexy, or to a blow on the head, would be comparatively easy of explanation on the same theory. The hemorrhage would actually push certain neurons apart within the skull, or the intracranial pressure produced by it would keep them from making proper connections. A blow on the head may readily be supposed to jar neuronic terminal filaments so severely that it would be some time before connections could be made, and the injury might be serious enough to prevent certain cells from ever again coming in contact in such a way as to allow the passage of nerve impulses from one to the other. Concussion of the brain would, on this theory, mean that neurons were so shaken apart as to produce some confusion in their terminal filaments and consequent serious disturbances of consciousness, if not its complete loss, and corresponding disturbance of the power to move. In a word, this theory would seem to afford a reasonably satisfactory explanation for most of the extraordinary phenomena of mental life and, therefore, might also be expected to be applicable to the ordinary phenomena, though these are so elusive that it is difficult to satisfactorily apply theories to them. [Illustration: FIG. 12.--NEURON FROM THE OPTIC LOBE OF THE EMBRYO CHICK (after Kölliker). The axon n runs toward the center, giving off in its course several collaterals. One of these, c, is much branched. (Barker.) ] _Tired States_.--When fatigued, it becomes extremely difficult for us to follow a train of thought, especially if it is somewhat intricate. It becomes easy to forget things, even such as under ordinary circumstances would be readily remembered. Names are much more likely to be forgotten. Facts and, above all, dates, refuse to come as they do under normal conditions. Efforts in the direction of recalling details are eminently unsatisfactory. The command goes forth, but there is {119} evidently hesitation about obedience. Other thoughts intrude themselves. Ideas come unbidden. The connection of thought is readily broken, and is hard to get at again. There may have been very little mental work, but somehow the fatigue of the general physical system is reflected through our central nervous system on the mind as well as the body. The early morning hours are the best for mental work, not, it seems, because the mind is fresher after its rest, but rather because the physical factors that are important for mental action are in good condition. Later they become disturbed by the fatigues of the day. The delicate cells of the brain become fatigued by sympathy with the somatic cells and it is harder to secure those nervous connections necessary for thought. [Illustration: FIG. 13.--DEEP LAYER OF GIANT PYRAMIDAL CELLS OF THE POSTERIOR CENTRAL OR ASCENDING PARIETAL, CONVOLUTION OF A CHILD THIRTY DAYS OLD. a, axis-cylinder; c, collateral branch; d, long basilar dendrites; e, end tuft. (Ramon y Cajal.)] [Illustration: FIG. 14--PYRAMIDAL CELL OF CEREBRAL CORTEX OF MOUSE (after Ramon y Cajal).] _Voluntary Neuron Motion_.--This theory of Duval's supposes that to some extent the neurons or nerve cells are possessed of voluntary movement. At least during certain states of the mind, they are moved and seem to have an inherent, if not quite voluntary, power {120} of motion. There are many objections urged against the theory because of this neuronic motion. It has been said that the movement of neurons has been observed in certain of the _Medusae_. The observation has been doubted and it lacks confirmation. In higher animals, of course, the observation is impossible because an investigation of the nervous system for this purpose would necessarily bring about the death of the animal and the cessation of spontaneous mobility. Whether it occurs or not, therefore, is a theoretic problem. So many objections tell against Duval's theory that it is now only discussed because of its subjective value. Neuroglia Theory.--Ramon y Cajal elaborated a second theory of explanation for the mechanism of the nervous system that has seemed to many authorities in brain physiology much more satisfactory than Duval's theory of the actual motion of the neurons themselves. The Spanish nervous histologist had made a special study of the neuroglia or connective tissue cells in the central nervous system. These are very small in size but very numerous. Ramon y Cajal suggested that it was because the terminal filaments of these neuroglia cells inserted themselves between the neuronic filaments, thus insulating one from another, somewhat as if an insulating plug were inserted between two portions of an electric circuit, that the interruption of nervous currents took place. This explanation is free from many of the objections urged against Duval's theory. The small size of the neuroglia cells makes it easy to understand how movement may take place in them sufficient to bring about separation of neurons. It would not be surprising if they should be more or less actively contractile. Whenever they contract, neuronic filaments which they have been holding apart, come together so as to permit the passage of nervous impulses, if any are flowing at the time. When the neuroglia cells become fatigued or seriously disturbed, they refuse any longer to obey the will in any way, or at least gradually get beyond control, and in their relaxation becoming prolonged, push neurons apart. When a man is very tired it gradually becomes impossible for him to keep awake. This is partly because poisons, produced in the course of fatigue, exhaust the vitality of the neuroglia cells and also of the neurons, so that less energy is required to push these latter apart. It is easy to understand that the neuroglia cells might well become affected by the various narcotics and intoxicants in such a way as to produce the phenomena of anesthesia and drunkenness. The rapid recovery from anesthetics seems to indicate that it is not neurons, or essential nerve cells, that are so deeply affected, but some extraneous, and less important, mechanism within the brain. The neuroglia theory explains this very well and does away with the difficulty. Certain curious phenomena of hysteria are easily explained on this theory. When there is anesthesia in a member because of hysteria, this anesthesia does not follow the distribution of certain nerves, but is limited by a line in the shape of a cuff drawn round the limb. This indicates that the trouble is not peripheral but central, and that owing to psychic disturbance, all the neurons that receive sensory impulses from a particular portion of the body are so affected by a psychic condition that they are no longer capable of receiving impulses from the periphery. The neuroglia cells in a particular area have passed from the control of the will and, relaxing themselves, have {121} inserted their processes between the terminal filaments of neurons, thus preventing conduction. [Illustration: FIG. 15.--NEUROGLIA CELLS OR THE FASCIA DENTATA; IN THE NEW-BORN RABBIT (method of Golgi). A, molecular layer; B, granular layer; C, layer of polymorphis cells; D. horn of ammon; a. neuroglia cell furnished with a descending appendage; b, another neuroglia cell; piroform; c. a cell more deeply situated; d, spider cell; e, fusiform neuroglia cell. (Ramon y Cajal.)] _Varieties of Neuroglia_.--The connective tissue cells are of many kinds, each probably exercising a special function. Ramon y Cajal has described and pictured a special kind of neuroglia cells for the gray and another for the white matter. In his description of these cells he has pointed out many interesting diversities of form, and probably also of function. He has also described particularly a special form of neuroglia cells which lie close to the blood vessels. These he calls perivascular cells, and they seem to have an important function in regulating the amount of blood that goes to a particular part of the brain. He has written so clearly and yet so concisely with regard to these that it seems better to cite his own words: [Footnote 15] [Footnote 15: This article is a translation made by the author shortly after a visit to Ramon y Cajal in Madrid, in 1900. See _International Clinics_, Phila., Vol. II Series Eleventh.] Under the term neuroglia are included at least three kinds of cells,--those of the white brain substance, those of the gray substance, and the perivascular cells, which have been described by Golgi. The neuroglia cells of the white brain material are easily recognizable, being large and with rather prominent, smooth, and sharply outlined processes. As my brother seems to have shown, their object appears to be to furnish an insulating, or, at least, a badly conducting, substance to serve as an interrupter of nerve-currents. They certainly do not represent interstices of true nerve substance through which lymphatic fluid can conveniently find its way. The neuroglia cells of the gray matter present a very special and highly characteristic appearance. They are of manifold form,--at times star-shaped, at times {122} like a comet drawn out in length. These are the tall cells of von Retzius. They have very numerous prolongations, with a large number of short branched collaterals which give the whole cell the appearance of having feathers projecting from its periphery. These cells have been observed in two different conditions. One is that of relaxation, and the picture is that given above. The other is that of contraction, during which the cell body has more protoplasm in it, and the processes become shorter and thicker, and some of the secondary branches disappear entirely. These cells resemble, in certain ways at least, the pigment cells which occur in the skin of some animals. By means of their contractility, these pigment cells can stretch out their processes while in a state of contraction. It must be remembered that this form of neuroglia cells is most abundantly present in those parts of the brain in which it might be expected that a number of nerve currents would frequently come together. They occur, for example, with special frequency in the molecular layer of the cerebral cortex, where the bundle of pyramidal fibers, with their immense number of terminal nerve-endings, come in contact with one another. [Illustration: FIG. 16.--NEUROGLIA CELL FROM THE SUBCORTICAL LAYER OF THE CEREBRUM FROM WHICH TWO PROCESSES GO TO A BLOOD VESSEL (Obersteiner).] [Illustration: FIG. 17.--NEUROGLIA CELLS FROM THE SPINAL CORD. Longitudinal section (Obersteiner). ] The third form of neuroglia cells consists of those known as the perivascular cells. They are found only in the neighborhood of the capillaries of the gray matter and they send one or more firm prolongations to the outer surface of the endothelium of the blood vessels. These processes are inserted in the walls of the blood vessels. Every capillary has thousands of these little pseudopod prolongations, and from the vessel the cell reaches out in a number of directions. The object of these cells undoubtedly is by contraction of the prolongations to bring about local dilatation of the blood vessels. This dilatation of the blood vessels causes greater or less intensity of the psychical processes in certain parts of the brain, because of the greater or less congestion of the circulation in a part which it produces. With the exception of these last cells the object of the neuroglia cells is to insulate nerve fibrils and cells from one another. When the cells are relaxed, the passage of a nerve current is either entirely prevented or rendered much less easy than before. It is in this way that the true nature of intellectual rest is explained. Sleep--not only natural sleep, but also artificial narcosis, such as is produced by narcotics, hypnotics or hypnotization--is evidently the result of the same conditions. During the state of contraction the pseudopod of the neuroglia cells are drawn in; that is to say, the protoplasm of the cells absorbs the processes, and so the true nerve cells and nerve fibrils which were separated from each other by the interposition of neuroglia come into contact. By this mechanism the brain passes from the condition of rest into one of activity. These neuroglia contractions may, particularly in certain parts of the brain, occur automatically. Often, however, they are produced by the action of the will, which, in this manner is able to influence {123} the definite groups of neuroglia cells. As the result of this influence of the will the association of intellectual operations can be guided in various directions. The unusual course that the association of ideas sometimes takes, the flow of words and of thoughts at certain moments, the passing difficulty of speech, the recurrence of tormenting thoughts, the disappearance of expressions or ideas from the memory, even the increase of mental activity and of every kind of motor reaction as well as many other phenomena of intellection, can be satisfactorily explained on this hypothesis. It is only necessary to suppose that in certain parts of the brain the neuroglia cells are at rest, while at other parts they are in a condition of active contraction. To put it all in a few words, the neuroglia cells of the gray substance of the brain represent an insulating and switching apparatus for nerve currents. They are an insulation apparatus when in a state of contraction, a switching and insulating apparatus when in a state of rest. It is to be remarked, then, that according to this theory the contraction of brain cells does not take place, as in Duval's theory, during intellectual rest, but, on the contrary, during the state of activity of the cerebral cortex. It is much more probable that the action of cells coincides with the active stage of intellection than that brain cellular activity--that is, contraction--should correspond with psychic rest. The application of some of these theories enables us to understand just how short-circuiting may come about, how many of the curious phenomena of memory happen, and what are the effects, as well as the causes, of attention and distraction of attention and of diversion of mind. It is particularly the latter portion of Ramon y Cajal's theory, with regard to attention and the more or less voluntary though unconscious and usually indeliberate control of blood supply to various portions of the brain, that is of special interest. If the neuroglia cells, whose end plates are attached to blood-vessel walls, become over-contracted or lose their power of relaxation or of contraction, many of the curious phenomena of over-tiredness in neurotic conditions, and the lack of the power of concentration, and sufficient attention to things, can be readily understood. In a word, the theory enables us to translate many expressions that are vague and indefinite, from terms of mind into terms of the physical basis of mind--the anatomy and physiology of the brain. While I have dwelt on Ramon y Cajal's theory, because for years it has been familiar, of course I must reëcho his own warning that it is, after all, only a theory. It presupposes an active interposition of the glia cells between the axon of one neuron and the dendrons of another. This cannot be demonstrated. A third theory of mental operations, then, has been suggested, and the English school, so ably led by Sherrington ("Integrative Action of the Nervous System," London, 1903) and McDougal ("Synapse Theory of Fatigue," _Brain_, 1910) has deservedly attracted wide attention. They contend that all the phenomena can be more simply explained without postulating the movement required for the Duval Theory or the glial activity of Ramon y Cajal's hypothesis. They consider that each nerve cell has, as it were, a certain potential energy which it sends forth in nerve impulses. These are transferred from neuron to neuron through the synapse. If what we might call, to borrow a figure from electricity, the voltage of the cell impulse be sufficient to overcome the resistance at the synapse, the impulse passes from neuron to neuron. In fatigue the potential energy of the cell is gradually dissipated. The impulses become feebler till they cease to pass. This occurs in the state we usually experience as tiredness and in analogous states such as sleep, unconsciousness, narcosis and the like. Obviously this {124} theory can be elaborated and applied parallel with the neuroglia theory except that here we are substituting synapse resistance for the hypothetical, undemonstrated action of the glial cells. But, as the latter seems a simpler process upon which to explain the various phenomena, especially to those not familiar with very recent developments in nervous histology and studies in nervous mechanism, and as it merely involves a question of the nature of the resistance and not of its site, I have used it for explanatory purposes without advocating either theory in the present state of our knowledge. CHAPTER V BRAIN CELLS AND MENTAL OPERATIONS While the theories of neuronic action we have discussed do not represent absolute knowledge, they are at least suggestive and helpful in psychotherapy. Whenever there are disturbances of mental operations, patients are likely to become very solicitous, lest these represent organic and incurable changes. The application of Ramon y Cajal's neuroglia theory serves to bring out the fact that most of them can be very well explained as merely functional, due to passing disturbances of activity, and not necessarily to tissue changes. When patients become possessed of the fear that certain nervous symptoms portend definite injuries to the nervous system, this unfavorable suggestion keeps them from using, to its proper and full extent for repair and convalescence, the nervous energy which they possess. This disturbing influence can be counteracted by a straightforward exposition of Ramon y Cajal's or the newer English theory of brain mechanism. Patients become very much disturbed if they observe a failure of certain faculties in themselves, and are prone to think that such a failure means serious exhaustion or enduring change. The power of attention is one of the faculties often disturbed in neurotic cases and causes patients needless solicitude. Disturbances of memory are the next most alarming elements in these cases. There are then many forms of mental distraction, absorption and preoccupation that sometimes frighten neurotic individuals who have become solicitous about themselves. Though only passing incidents, due to overattention to themselves and their ills, real or fancied, and the consequent lack of concentration of mind on a particular subject, the patients fear serious deterioration of their mental condition, or at least of mental control. The neuroglia theory of mental action throws a light on all these phases of mentality that serves to lessen the solicitude of patients and enable them to understand that, in spite of their fears, there is nothing but functional disturbance. The condition can be readily explained and it admits of complete restoration to health. ATTENTION Even more important, perhaps, than any other of the functions attributed to the neuroglia cells, is the rôle they may play in enabling the individual to concentrate attention on a particular subject, or at least to use a particular {125} portion of his brain, by bringing about a more active circulation in that portion than in any other, Ramon y Cajal attributes this power to the perivascular neuroglia cells. Every capillary in the brain has thousands of these little pseudopod prolongations. When the cells in a particular region contract, the blood vessels of the part are pulled wide open and a larger supply of blood flows more freely, stimulating the nerve cells by which it passes and supplying them with nutrition for the expenditure of energy that they may have to make. This is the physical process that underlies attention. When too much, that is, too long-continued attention is paid to any subject, without diversion of mind, the capillaries may easily acquire the habit of being open, and cells the custom of contraction, so that relaxation does not readily take place. Something of this kind is the most important element in the etiology of many functional nervous disorders. [Illustration: FIG. 18.--AN ARTERY FROM THE CEREBRAL CORTEX.--One can see numerous fine fibers passing over to the brain substance (Obersteiner).] Ease and Pleasure in Mental Operations.--On the other hand this same set of ideas explains many things otherwise difficult of understanding. For instance, we all know that habit enables us to apply ourselves to a particular subject with ever growing ease. What was extremely difficult for us at the beginning, may after a time become comparatively easy, and later even positively pleasant. Study, that is application of mind, is, at the beginning, for most people, not agreeable. If persisted in, it almost inevitably becomes a pleasure. Hard exercise of any kind is, at the beginning, sure to require great energy of purpose, and requires some subsidiary motive of approbation or reward to make us persist in it. But what was a distinct labor at the beginning becomes pleasant after a while. This may be applied to the neuroglia cells apparently as well as to the muscle fibers. On this theory, the reason for the gradual acquirement of an intense pleasure in the intellectual life becomes easy to understand. Dangers of Over-attention.--The danger of concentration of mind on one's self, quite as much as on any other subject, becomes clearer when this theory is accepted as explaining the physical basis of the mental operations involved in attention. If people allow thoughts of themselves and of their physical processes constantly to occupy their minds, gradually that portion of the brain ruling over these becomes over-fatigued and fails to respond to the calls for relaxation. Insomnia may develop readily as a consequence of continued solicitude and prove to be, as the worst forms of insomnia so often are, quite unamenable to direct drug treatment, because, even during the enforced sleep that comes from drugs, dreams with regard to self and the supposed ills may still occupy the overworked portion of the brain. Nervous people are, most occupied with those parts of the brain which have something to do with the omission and transmission of trophic influence to particular parts of the body. As a consequence of the persistent hyperemia, too many trophic impulses are sent down. These cause an exaggeration of physiological function, in the stomach, the heart, or some other important organ. Hence these organs may become oversensitive. For all these reasons, this theory of attention, of the great Spanish {126} investigator, deserves to be well known by those who hope to treat neurotic affections, especially functional diseases of the brain, and therefore I prefer once more to give it in his own words. [Footnote 16] [Footnote 16: _International Clinics_, Vol II, Series 11.] Ramon y Cajal's Theory of Attention.--Under usual conditions, the motor apparatus of the gray matter suffices for the explanation or the varied course of association of ideas and of the reaction produced by voluntary motion. But as soon as attention is concentrated upon an idea, or a small number of associated ideas, there enters into the problem, besides the active retraction of the neuroglia of the corresponding part of the brain, a new factor--the active congestion of the capillaries of the over-excited region. As a consequence of this, the energy of emotion reaches a maximum. The heat and metabolism of the hyperemic parts is increased, which, of course, makes these parts capable of more work. [Illustration: FIG. 19.--NEUROGLIA CELLS OF THE SUPERFICIAL LAYERS OF THE BRAIN FROM AN INFANT AGED TWO MONTHS (method of Golgi). A, B, C, D, neuroglia cells of the plexiform layer; E, F, G, H, K, R, neuroglia cells of the second and third layers; I, J, neuroglia cells with vascular pedicles; V, blood-vessel. (Ramon j Cajal.)] This congestion of various parts of the brain has been experimentally observed {127} by a number of physiologists. It can be best explained by considering that the will has an influence upon the nerves which produce a dilatation of the blood-vessels in different parts of the cerebral cortex. The process of attention, however, by which intellectual activity is concentrated upon a limited number of ideas, seems to be but very little under the control of the sympathetic nerve endings. As a matter of fact, the capillaries of the brain are wanting in nerves and smooth muscle fibers. Hence they are not under the control of the sympathetic system. Only the relatively large arteries of the pia mater, which possesses a tunica muscularis are under a certain limited control of the sympathetic, which is able to produce in them an incomplete and not very well limited congestion. One of the difficulties of the problem of the activity of the sympathetic is best realized when we recall that vasomotor activity is usually involuntary. The process of attention, however, is entirely conscious and voluntary. In the hypothesis that we have given, most of the difficulties disappear. Under the influence of the will, the pseudopod branches of the neuroglia cells, which end in the walls of the capillaries, contract. As the result of this, the bloodvessels, all of which are surrounded by lymph spaces, dilate, and this dilatation may proceed to such an extent that the vessels occupy the whole of the lymph spaces. Thus we can easily understand how the very limited congestions which are necessary for the concentration of thought upon a single idea may be brought about. The perivascular lymph spaces which exist in the brain seem to be for the purpose of making these limited hyperemias easier. At the same time they serve a very useful purpose in preventing pressure or concussion, such as might be caused upon the neighboring nerve cells by too great dilatation of the blood vessels of a part. It is needless to add that we do not consider the hypothesis that we have advanced to be absolutely without objection. On the contrary we believe that, owing to the difficulty of the problem and our, as yet, extremely slight knowledge of the anatomy and physiology of the nerve protoplasm, any theory as to the special mechanism of psychic processes is sure to be faulty. Rational hypotheses, however, which are supported by well-known facts, are not only justified, but are often fruitful of suggestive ideas. A scientific hypothesis often gives a new direction, suggests an untried method of observation, or hints at new ways of experiment, and, though it may not lead directly to truth, always brings us closer to methods of investigation and of criticism that are invaluable. Even though our further investigations should not confirm our hypothesis, the result will not be less positive. Negative conclusions lessen the number of possible hypotheses and therefore diminish the possibility of error in future investigations. MEMORY It is evident that some of the physical mechanisms that are employed for the lower grade mental processes at least can be explained on the neuroglia theory. Memory we share to a great extent with the animals, and for this the physical processes can be rather interestingly studied. We have all had the experience of being unable to recall a word when we wanted it. Commonly the word is a proper name with which there are not many direct connecting ideas, so that, somehow, we seem unable to trace the word to its depository in the brain. Occasionally we are sure that we know the first letter of the word. Sometimes we are able to name this letter, and, if we do so, the rest of the word will usually turn up a moment later. At times, however, the word fails to come and we grope for it. Then if we stop deliberately seeking it, the word will often after a longer or shorter time, come up spontaneously. This experience is familiar to everyone. It is especially frequent with public speakers. Certain words have a habit of slipping away just when we {128} want them. At times by beginning a sentence confidently, even though there is a feeling that there is a missing word ahead, the word will turn up in time. Often it will not, and then a weak circumlocution must be indulged in. If it is a proper name, a description may have to be substituted, sometimes a confession may have to be made that the name will not come and the audience, unless it is very young, will sympathize with the speaker. If we accept the idea that the memory has a definite location in the brain, the process is easily understood. Just how we cannot say, but somehow brain cells serve as the media by which our memory processes revert to knowledge that has been previously stored up. If now we assume that the repetition of things known is accomplished by bringing brain cells into connection with one another, and with the organs of speech, it is easy to understand that somehow the connection with a particular cell or set of cells cannot be secured at a given moment. This delay prevents us from being able to repeat things that we know, and know that we know, though we cannot somehow get at them. The will fails to reach the proper insulating plug of a neuroglia cell, which, if acted upon, would put a cell or group of cells in communication with others. As a result the message from it cannot flow down. We feel that we have it on the tip of our tongue, as we say, that a little effort may bring it to us and sometimes that effort succeeds. If there is any disturbance of consciousness by secondary motives, however, as by the excitement of public speaking or the flustering that comes to some people when they try to introduce even old-time friends and forget their names, then we cannot control the brain processes and memory fails. We do not for a moment think of attributing this failure of memory to the faculty of memory itself. We have the feeling that there is some mechanical obstacle. Ramon y Cajal's theory enables us to understand this obstacle better, perhaps, than any other. An interesting phase of this lapse in memory helping us to a revelation of something of the physical process which underlies the faculty, is the fact that it implies a very intricate machine. Recalling has become such an obvious incident that we do not think of the complexity of action involved. Many things are brought together, and relations of all kinds serve to recall various facts and names and dates. Some of these relations are most bizarre. Particular names recall a definite series of facts. A color will bring up a scene or the memory of an individual. An odor will recall scenes long since apparently forgotten and will set trains of thought at work that are quite unexpected. Sometimes we wake in the morning with a name or a fact on our lips that we have been looking for for several days. UNCONSCIOUS CEREBRATION Some people actually learn to depend on unconscious cerebration. A man, for instance, who has to make an address on a particular subject or to write an article, will record that fact on a tablet and after gathering a few basic thoughts in connection with the subject proposed, will put it aside for the time being. He is confident that various illustrations and thoughts in connection with the subject will occur to him at intervals during the next few days, and that he will thus without direct labor accumulate an amount of {129} material for use. In the early morning hours he may find that thoughts on it come to him unbidden. Sometimes he will find these thoughts precious germs, that will develop during the course of the following days, and will be of great help to him. If he is worried and preoccupied with other things very much, this may not happen, but under ordinary circumstances he can continue routine occupations which demand practically all of his time, yet continue to develop the subject selected for his paper or address. The more he has occupied his mind with the subject at the beginning, the more will this unconscious cerebration continue. ABSTRACTION OF MIND Features of the mechanism of mental operations are brought out in certain phenomena of abstraction of mind, which show how the attention can be so short-circuited that sensations from the periphery utterly fail to penetrate to the consciousness. Most men have had the experience of taking out their watches, looking at them, and then putting them back. Presently somebody asks what time it is. Unable to recollect what it was that they saw, they have to look again. There is no doubt that they meant to observe the time. The same thing is true for practically all the senses. A pickpocket takes advantage of our being occupied with many other feelings in the midst of the jostling in a crowd on a car, or before a show window, or he has a confederate add to the sensations already streaming up to us, calling attention particularly to the other side of the body, and then inserts his hand into our pocket and extracts what he finds. Sometimes we have a faint memory of something having happened to that pocket, but our attention was occupied elsewhere. In hearing we have the same experience. When thoroughly occupied with a book, a person may talk to us or ask us a question and we have no idea of what was said, sometimes utterly failing to hear the voice; sometimes we hear the sound of the voice, but do not comprehend the meaning of the words. When we are unprepared for a question we nearly always have to have it repeated to us. Sitting in a railroad train, if the person behind us, whom we did not expect to talk to us, asks a question, it is very probable that on the first asking we shall not notice it at all, considering that it is addressed to someone else. On its repetition, it may appeal to us as addressed to ourselves, but even then we readily lose its significance because our attention has not been called to the wording of it soon enough to enable us to comprehend it thoroughly. These experiences, so familiar that we have probably all had them at some time or other, indicate how universal is the power of the mind to concentrate itself upon itself to the extent of neglecting sensations from the outer world, even though they may pass the periphery of the organism and manifestly affect the first neuron of the chain that leads up to our brain and consequently to consciousness. They do not reach the center with sufficient intensity to be understood, and a conscious act of attention must be made before we comprehend their meaning. {130} PREOCCUPATION OF MIND This is true, not only for ordinary sensations, but even for such as would ordinarily be presumed to be so insistent in their call that they could not be neglected. The concentration of mind necessary for this is not common to all mankind; it is possessed only by a few individuals whose intellect represents the larger portion of their personality. Certain of the great investigating scientific geniuses have had the faculty of so concentrating their attention upon the questions with which their intellects were engaged, that even the call of appetite did not make itself felt. Newton was one of these. Over and over again, he was known to neglect to take his meals, even though they were brought to him, and, occasionally, he would entirely forget whether he had taken a meal or not. But Newton is not an extreme exception. Most of the great mathematicians have had experiences of this kind and, indeed, mathematics seems to be that special branch of intellectual work which most readily brings about a preoccupation of mind sufficient to completely shut out the outer world for the time being. Archimedes, the great ancient mathematician, lost his life because of preoccupation with mathematical problems that kept him from telling the Roman soldiers, who had strict orders to spare him, who he was. Complete absorption of mind to the exclusion of all external sensations is not, however, confined to the mathematicians. Mommsen, the historian, was famous for his fits of mental abstraction. Once he patted a school-boy on the head and asked whose boy he was, to be told rather startlingly, "Yours." Lombroso, the criminal psychologist, was subject to abstraction in almost as great a degree. Men have become so preoccupied in study as not to appreciate the significance of warnings, indicating that a serious accident was about to happen, such as a fire or the fall of some object that they should have avoided, or some other danger to themselves. The tendency to such abstraction is responsible for many accidents on busy city streets. When so preoccupied, painters walk off scaffolds, and such preoccupation of mind is extremely dangerous, not only for the man himself, but for those who are working with him. Everyone knows that a slight headache frequently disappears in pleasant company. There is sometimes the suspicion, though it is quite unjustified, that because a person has a headache which can be cured by engaging in a favorite occupation, the headache is more imaginary than real. The common experience with toothache shows the falsity of this opinion. There is no imagination in regard to toothache, yet it, too, except in very severe cases, will be so modified as to be quite negligible if the victim has some mental occupation that is very absorbing. Pains of other kinds that are just as real, may be modified in the same way. I have known a boy to suffer enough from the presence of an unsuspected kidney stone to give up play and come into the house, yet he could be made entirely to forget his discomfort by a game of checkers. On account of the ease with which the pain was thus dispelled, the suspicion was harbored that his ache was more imaginary than real. The ache continued and at the end of about a year there was an acute exacerbation which justified an operation, and the stone was removed. In all these instances there is evidently a question of the unmaking, or at {131} least imperfect making, of connections between the peripheral and central neurons, because of the existence of connections between different portions of the brain itself which take up the attention. This attention to mental things may become exaggerated, and must be guarded against, but it represents a valuable psychotherapeutic remedy. Whenever the peripheral connections are unmade, external sensation is unfelt. Even though the peripheral neuron may be suffering to some extent, this is true. It is this law of attention that must be taken advantage of for psychotherapeutics. People who are liable to be too much concerned with their sensations, must be taught to occupy themselves with interests that will absorb the attention. Central neurons can, except under very serious circumstances, be made to connect with one another so intimately as to bring about the neglect of many bothersome external sensations. [Illustration: FIG. 20.--COMPLEXITY OF CELL OF THE CENTRAL NERVOUS SYSTEM. A Golgi cell after Andriezen. (Barker.)] On the other hand, when the connections with the periphery are well made, external sensations flow in on us to the exclusion of thought and then even simple sensations may be exaggerated so as to become painful. Anything that attracts our attention so much that we cannot think quietly about it, is likely to be a disturbance rather than a pleasure. Music is distinctly pleasant, yet very loud music becomes painful. The reason is that the peripheral neuron is so much disturbed that these excessive vibrations are communicated to other neurons connected with it and they are unable to occupy themselves with anything except this over-strenuous sensation. A very bright light has something of the same effect, and the same thing is true for all the other senses. A pleasant odor, if over strong, becomes disgusting. A very sweet taste is cloying. This over excitation of neurons may come from without, or may come from within. If the central neuron is so much occupied with itself, and the sensation that is flowing into it, that it is prevented from making such connections as would communicate and distribute the sensations properly, then the sensory phenomenon becomes painful, though it may not be exaggerated in the peripheral neuron. VITAL ENERGY BEHIND BRAIN CELLS In all of these phenomena there is something more than brain cells at work. Brain cells are guided, co-ordinated, controlled, and even overseen, in their labors. The same conclusion becomes inevitable with regard to the action of the cells of the body generally. A generation or two ago it was the custom to attempt to explain all the processes in the body by chemical and physical principles. Respiration, for instance, and absorption of gases into the blood in the lungs and the expiration of gases that have been generated within the body during vital processes, were supposed to be entirely explicable on the principle of the diffusion of gases. The absorption of various substances into the body proper from the intestinal tract, and the excretion {132} of various substances from within the body into the excretory organs, as well as the process of secretion, were supposed to be nothing more than varying phenomena of osmosis and exosmosis. There has since been a general recognition of the fact that these principles do not explain many of the incidents within the body in its relations to its surroundings, and that vital processes are something much more than merely manifestations of physics and chemistry. The lungs are not mere laboratories in which refinements of the laws of the diffusion of gases may be studied, for under varying pressures from without that would vitiate the ordinary laws of diffusion, inspiration and expiration continues. Fishes live at depths where the pressure is so great that expiration would seem to be impossible, yet they succeed in eliminating harmful gaseous material. Prof. Haldane of Cambridge has called attention to many of these processes. Animal stomachs are not test-tubes. Animal excretion, and above all, secretion, is carried on sometimes in accordance with but, almost more often, in defiance of chemical and physical principles. The individual, even in the lower animals, counts for much more than the chemical constituents of the tissues and the physical principles involved. Besides, all the parts of the organism are co-ordinated, and there are wonderful checks and counterchecks which show that animals are much more than colonies of cells fortuitously growing together and habituated to such common life by many generations of heredity and environment and training. In a word, the old vitalistic principle has become popular once more and even great physiologists have insisted that there is a principle of life which guides and controls and co-ordinates the different portions of the body. Especially does this seem to be true of the brain. We have here an intensely complex machine, composed literally of billions of parts which work together, and in doing so accomplish wonderful results. Of the existence of this machine, much more of the great intricacy of its parts and mechanism, we are quite unconscious. We learn to use it in very early years with an assurance and a perfection that is amazing, considering how complex it is. The less we think about it and its workings, the better does it work and the less disturbance of function is there in its accomplishment. [Illustration: Fig. 21.--SECTION THROUGH THE CORTEX OF THE GYRUS OCCIPITALIS SUPERIOR. (Hammarberg. Barker.)] If a vitalistic principle were needed to enable us to understand the workings of the ordinary body cells, how much more is it required for the workings of brain cells. There is something behind that guides and rules the brain, and through which it accomplishes its work. It is this that brings about an unconscious cerebration accomplishing intellectual results for us even when the brain machine itself is at rest as when asleep, or fails, for some reason, to be in readiness to take up the work that we demand of it. It is this vital principle that coordinates the movements of brain cells which represent {133} the physical processes underlying memory and the nervous elements of the sensitive and motor phenomena of the organism. Reflection on the physical mechanism underlying mental operations of various kinds, demands the vitalistic explanation much more than the physiological phenomena which have converted physiologists to the old way of thinking in our time. Our individuality is probably largely due to the physical basis of our mentality, but there is something more than that required for any theory of mental operations that would satisfy all the questions that come to us. There is, then, actual proof of the existence of a force that is part of us, that constitutes a bit of the essence of our personalities, yet is capable of accomplishing results that we cannot understand, and of managing a machine that transcends any physical powers that we can think of. [Illustration: FIG. 22--MOTOR CELL OF VENTRAL HORN OF SPINAL CORD FROM THE HUMAN FETUS, THIRTY CENTIMETERS LONG (method of Golgi; after von Lenhossek. Barker.)] This vital force behind the nervous system contains stores of energy that can be called on for therapeutic purposes. It is the directing, co-ordinating and energizing force which controls the central nervous system, and enables it to accomplish its purposes. It is the disappearance of this force at death which leaves the body without vital activity, though no physical difference between the dead and the living body can be demonstrated. Changes in the body _follow_ death; they are not simultaneous. This vital force supplies the energy that we call the will, and underlies the process called "living on the will" which so often serves to maintain existence when there is every reason to think that a fatal termination is due. The amount of energy thus available is limited, {134} but is much more powerful than has been thought. It is of the greatest possible service in preserving health and eliminating disease. Its existence, demonstrated by the complex nervous system which we employ with such confidence, though we know nothing of it, furnishes the best possible basis for confident attempts at rousing the patient to use the vital energy he possesses for the strengthening of weakness, the correction of deficiency and the control of evil tendencies. CHAPTER VI UNCONSCIOUS CEREBRATION Many of the exhausting neurotic and psycho-neurotic affections so common in recent years are largely due to the failure of patients to secure such mental relaxation as will permit complete repair of nervous waste. We are proud of being a generation of specialists. Some men never get completely away from the set of thoughts with which they are occupied in their particular specialty. Waking or sleeping these thoughts are with them. It is almost impossible, then, for cells of the central nervous system to secure such rest as they need. Cells must be put at absolute rest so that nutritional processes may go on entirely undisturbed, and every portion of the cell be renewed in vigor. Re-creation, in its original meaning, is exactly what must be provided for nerve cells. The trouble is not alone that men occupy a very narrow set of brain cells with their special interest, and make all their energy pass through that set, but among men who are lacking in a certain insulation in the nervous system, this particular set of cells continues to be active, even at times when they think they are resting or diverting themselves. Unconscious cerebration (the occupation of the mind with subjects when we are not deliberately giving our attention to them) is a common phenomenon in human psychology. With the rise of extreme specialization, it has become even more dangerous than before. In the past unconscious cerebration might mean any occupation, with any one of a number of interests. At the present it is likely to mean concentration of thought on a particular subject with which the brain is prone to be occupied more than is good for it, even during the hours of ordinary labor. It seems worth while to discuss at some length, then, the subject of unconscious cerebration, because it constitutes the pathological physiology of many nervous states that we see in modern life. Frequency of Unconscious Cerebration.--The mind, having been set to work over a given thought, continues at it sub-consciously, even while apparently completely occupied with something else. Most people who devote themselves to the intellectual life have experienced phenomena more striking and going much farther in unconscious cerebration than this. Most writers have a common experience: if they arrange their thoughts on a given subject and then turn aside to something else, they find, when they go over the same subject next day, much more material than came the day before. The thoughts for an article will often gradually accumulate by unconscious cerebration after the process has been consciously started. {135} At intervals during the next few days succeeding the determination to write a certain article (at moments when no conscious thought is being given to it), ideas crop up that help to fill out the original scheme of thought, and if these are jotted down, a good deal of intellectual work is accomplished without the necessity for that labor over a desk that most of us scheme to avoid. The more familiar literary work becomes, the more frequent are these experiences, and one occasionally wakes up with a thought that opens up a new vista and adds valuable material to what has already been accumulated. If the subject is a large one, as for a book, then most writers will probably confess that some of their best thoughts have come in this "hit and miss" fashion rather than at the times when they were seriously applying themselves to elaborating their theme. Inspiration.--Some of the great literary writers have felt that their brain work was so independent of themselves that the word inspiration properly suited what they were accomplishing. Thackeray destroyed sheet after sheet of manuscript, utterly dissatisfied with it until, as the result of keeping at it, inspiration would come. Then he would be able to fill up rapidly many pages with work so finished that it needed little correction or polish. George Eliot, at times, became so absorbed in her writing that it almost appeared to her that some other personality than her own was wielding the pen. Her imaginary characters became real to her, and it was while under the stimulus of this impression of living in an imaginative world with them that she succeeded in accomplishing her best work. Many other authors were, of course, very different. Some of them ridiculed the idea of waiting for inspiration. Most of them, however, found it difficult to begin their task at certain times, yet if they forced themselves to it, and once got their minds going, the line of thought ran on easily and, at the close of the task, they looked back with pleasure and wonder that they were able to accomplish so much. _Illustrations_.--This is true not only of literary work, whose main purpose is the arrangement of details of information of various kinds with personal opinions concerning it, but also of original thought of any kind. Many stories of poets are told illustrating this. They wander round with pencils and jot down thoughts that come here and there at what are called moments of inspiration. The poets dream over their subjects, catch fleeting thoughts that, vague at first, sing themselves into musical expression. Music seems to be on the same plane with poetry, for there is the well-known story of the distinguished German musician who, walking with his wife in the park, found himself without paper at the moment when he had an inspiration. He used his own cuffs to write upon, and then finally impressed those of his wife into the service of carrying home the precious musical motifs that he was afraid might not come again if he allowed the favorable moment to pass without recording them. There are stories of Tennyson finding some of his most perfect lines in the fields, after hours of seclusion and effort in his study had failed to round them out to his satisfaction, or dreaming them into shape, or waking to find one ready made to be written down. The letters of Wordsworth tell how often such incidents happened in his life. {136} SLEEP COMMUNICATIONS Any one who has been thinking much for several days about a problem is likely to wake up with the thought that he has dreamed a solution of it, though unfortunately the solution has not remained in his memory. It seems as if a communication has been made to him during sleep. I have discussed dream life with many men engaged in serious work, and practically all of them confess to such experiences. Preoccupation of mind with a subject during the waking hours leads to at least some occupation of mind with the same subject during sleep. This unconscious occupation must often require rather strenuous attention, exhausting nutrition, using up nerve force and hampering the rest that is so important for tired human nature. [Footnote 17] [Footnote 17: A number of poetic products of dreams are in our literature, some of them interesting for more than their curious origin. Dr. S. Weir Mitchell, in his latest volume of poems, "The Comfort of the Hills," made an interesting contribution to the psychology of dreams by publishing two poems which were composed by him while asleep. The little poem, "Which?" has all the curious alliterativeness and frequent rhyme that is so likely to be noted in expressions that come during sleep, or just as we awake. The other is more like a somnambulistic effort. What we might suggest here is that the habit of poetizing during sleep would surely be dangerous to any one less eminently sane than their author. We give them as curious examples that will interest patients who complain that their dreams are too vivid. APRIL FIRST Come, let us be the willing fools Of April's earliest day. And dream we own all pleasant things The years have reft away. 'Tis but to take the poet's wand, A touch or here or there, And I have lost that ancient stoop, And you are young and fair. Ah, no! The years that gave and took Have left with you and me The wisdom of the widening stream; Trust we the larger sea. WHICH? Birth-day or Earth-day, Which the true mirth-day? Earth-day or birth-day, Which the well-worth day? For further details on this subject, see the chapter on Dreams.] Art in Dreams.--Many a painter testifies that as he slept interesting details have been added to his scheme for a picture. Mr. Huntington, who was for so long president of the National Academy, once told me that some of the arrangements of his famous picture, "Mercy's Dream" in the Corcoran Art Gallery at Washington, had come to him during sleep. Giovanni Dupré, the French sculptor, confessed that the ideas for his beautiful _pieta_ had practically all come to him in a dream. He had been thinking for a long time how he should arrange it, without allowing any of the ideas of sculptors whose treatment of the subject was well known to influence him too much, and had almost felt that it would be impossible to make anything individual. While deeply occupied with it one day he fell asleep, and when he awoke the whole scheme was clear. Mathematical Dreams.--Such phenomena of unconscious cerebration are not uncommon in the exact sciences. Some of the best examples of these {137} curious phenomena that we have are to be found in the history of them. We all know the stories of mathematicians who, occupied deeply with a problem which they have been unable to solve, have gone to bed still thinking about it, have slept deeply and, as they thought, dreamlessly, and yet they have waked in the morning to find by the bedside the problem all worked out in their own penciling--all accomplished during a somnambulistic state. Missing factors have been found in dreams; mistakes in the working out of problems have been clearly pointed out in dreams, so that, on awaking, the calculator could at once correct his calculations, and even serious errors have been thus corrected. Agassiz's Experience.--Some examples of these experiences in other sciences are striking. One that is likely to be impressive because it occurred in the experience of Professor Louis Agassiz, seems worth reporting. [Footnote 18] [Footnote 18: "Louis Agassiz, His Life and Correspondence," edited by Elizabeth Cary Agassiz, Houghton, Mifflin and Co., 1885.] It is interesting both as psychological fact and as showing how, sleeping and waking, his work was ever present with him. He had been for two weeks striving to decipher the somewhat obscure impression of a fossil fish on the stone slab in which it was preserved. Weary and perplexed he put his work aside at last, and tried to dismiss it from his mind. Shortly after, he waked one night persuaded that while asleep he had seen his fish with all the missing features perfectly restored. But when he tried to hold and make fast the image it escaped him. Nevertheless he went early to the Jardin des Plantes, thinking that on looking anew at the impression he should see something that would put him on the track of his vision. In vain--the blurred record was as blank as ever. The next night he saw the fish again, but with no more satisfactory result. When he woke it disappeared from his memory as before. Hoping that the same experience might be repeated, on the third night he placed a pencil and paper beside his bed before going to sleep. Accordingly toward morning the fish reappeared in his dream, confusedly at first, but at last with such distinctness that he had no longer any doubt as to its zoological characters. Still half dreaming, in perfect darkness, he traced these characters on the sheet of paper at the bedside. In the morning he was surprised to see in his nocturnal sketch features which he thought it impossible the fossil itself should reveal. He hastened to the Jardin des Plantes, and, with his drawing as a guide, succeeded in chiseling away the surface of the stone under which the portions of the fish proved to be hidden. When wholly exposed, it corresponded with his drawing, and his dream, and he succeeded in classifying it with ease. He often spoke of this as a good illustration of the well-known fact that when the body is at rest the tired brain will do the work it refused before. Hilprecht's Sleep Vision.--Quite as surprising a dream was that of Prof. Hilprecht, of the University of Pennsylvania. He had been trying for some time to decipher certain characters on ancient cylinders from the Orient. In spite of much hard mental labor he had been utterly unable to reach definite conclusions. In the midst of work on the subject he dreamt one night that a priest of the olden time appeared to him and read off the inscription that he had in vain been trying to decipher. Immediately after waking he told his wife of his dream and wrote down the interpretation that had thus been given. It was quite different from anything that he himself had obtained any hint of in his previous studies. When he got back to the inscription he found that this interpretation would satisfy the conditions better than any other, and there seemed no doubt that it represented the missing solution. {138} Somnambulism.--These curiously vivid dreams are occasionally associated with somnambulistic phenomena. Sometimes very definite purposes, requiring careful adaptation of means to ends, are accomplished in the somnambulistic state, and yet the actions are completely forgotten. I have recently been consulted about a case in which a young woman, on a visit to a family, had been shown some pretty though not expensive jewels. Evidently the guest envied their possession, for she got up during sleep and took the jewels and hid them. There seems no reason to doubt her statement that she remembered nothing at all about the incident. The taking was not attributed to her. There had been previous experiences of the same kind with things belonging to this young woman's sister. Somnambulism represents a degree of unconscious cerebration that may have serious results. Combinations of intellectual work with somnambulism are not infrequent, though many of the stories that are told are exaggerated. Some of them are authenticated. Ribot has a typical example of intellectual accomplishment, in a somnambulistic condition, that shows how far this may go: A clear case of somnambulism was that of a clergyman, whom his wife saw rise from bed in his sleep, go to a writing table, and write rapidly for some minutes. This done he returned to bed, and slept on until morning. On awaking, he told her that in a dream he had worked out an argument for a sermon, of which he now retained no recollection whatever. She led him to the writing table, and showed him the written sheet upon which he found his argument worked out in the most satisfactory manner. PATHOLOGICAL SIGNIFICANCE Unconscious cerebration is not, then, a trivial matter, and not an unusual experience. It probably occurs in every individual to a much greater extent than he thinks, unless he is engaged in analyzing his mental processes and their ways rather carefully. This constitutes one of the dangers of the intellectual life, which must also be guarded against in business life or in any absorbing occupation. When the mind has become intensely occupied with a subject, it is not easy to relinquish it. Even when we turn to something else, mental activity in the old groove continues to some extent, and so will prevent the rest that is necessary for the repair of tissue. Under these conditions the _re-creation_ that is so important does not take place quite as well as it should, and even sleep does not relieve us from the burden of mental work. Mental exhaustion will result as a consequence of constant occupation, and so mental relaxation must be secured. Deliberate means and methods must be employed in order that we may not deceive ourselves into thinking we are securing mental recreation, though all the time certain exhausting mental processes continue to be active. Dual Mental Occupation.--Many are inclined to think that reading, especially the reading of newspapers and magazines, which has become so popular in our time, furnishes an occupation of mind that enables one, for a time at least, to get away from cares and worries. This is probably true when the news is of special interest, or there is some form of excitement, or at the beginning of such reading before one grows accustomed to the usual {139} formula of the magazine stories; but as years go on and cares increase, such reading does not afford an occupation of mind that enables one to throw them off. It helps to pass the time, but the cares and worries keep insistently presenting themselves, and the effort to inhibit them, and at the same time pay some attention to what we are reading, makes a double task. Such reading, then, far from being restful, rather adds to the burden of care and to the labor of the mind, for besides the conscious cerebration, there is the undercurrent of subconscious cerebration disturbing the rest of cells that should be free from labor. The constant renewal of effort to keep one train of thought from interfering with another is itself a waste of nervous energy. This whole matter of reading is coming to occupy a new place in the minds of educators, especially of those who are trying to realize the scientific significance of various phases of education. In his address as the President of the British Association for the Advancement of Science, at the Winnipeg meeting in 1909, Prof. J. J. Thompson, the British physicist, sums up the value of reading as an intellectual exercise in a way that would not be gratifying to those who, in recent years, have apparently accepted the doctrine that in much reading there is much information and, therefore, much education. He says: It is possible to read books to pass examinations without the higher qualities of the mind being called into play. Indeed, I doubt if there is any process in which the mind is more quiescent than in reading without interest. I might appeal to the widespread habit of reading in bed as a prevention of insomnia as a proof of this. Social Duties.--So-called social duties are, in this respect, very like reading. When we meet new people who are interesting, we get diversion of mind in their company. When the people with whom we are, however, already familiar, and perhaps most of them a little tiresome, then what is presumed to be a social diversion becomes merely a bore, all the problems of the day obtrude themselves, of real rest there is none, and re-creation can scarcely be possible. Nearly the same thing is true of the present-day theater, after we have become used to its offerings. A serious play, well constructed and with life's problems touched deeply, may grip us and take us out of ourselves, constituting a complete and magnificent diversion. For a limited number of people music accomplishes this purpose. Unfortunately, the number is very limited, and for those for whom music is the greatest diversion, it sometimes constitutes in itself a poignant source of mental exhaustion. Music may be a very trying thing, especially for women, and for those who have souls extremely sensitive to its manifold effects. Upon these considerations, the importance of unconscious cerebration is brought home to the physician. It is impossible for a great many people to keep their minds inactive, and this is particularly true of two classes of people: those who have superabundant mental energy and those who lack self-control. To both of these classes of men and women, the physician must point out the dangers of unconscious cerebration--the occupation of mind with some subject, even at times while they imagine they are occupied with something else, or even during sleep. Such continuous occupation with a single subject is dangerous. Physicians must emphasize that many supposed {140} mental occupations are really so superficial that they allow other more exhausting processes to continue below them in the sphere of consciousness. As a consequence, the mind, instead of being relaxed, is really more tense than before, because occupied with two sets of thoughts. Very often it would be better for such people to continue with the more serious problem until its solution came, or until they realized that they must divert themselves. MENTAL RELAXATION What is important for mental relaxation, apparently, is not that a man shall try to set his mind at absolute rest, for that seems to be impossible, if a man really has a mind; nor that he shall occupy it with trivial things (because his interest will not be caught by them and will revert to the last serious thing that he was doing), but that he shall have an outlet for mental activity in entirely another direction from that to which he usually devotes himself. In other words, it is important that a man shall have a hobby, and that he shall ride that hobby whenever his ordinary business, whatever that may be, will permit him, and the more interesting the hobby, the better. REMEDIAL MEASURES The most important general remedy for over-prolonged mental occupation with a single subject, is some outdoor sport or form of exercise that requires all the attention. Horseback exercise is particularly valuable; boating, especially where the man has charge of the boat himself and where he has to have his wits about him, and the various sports. It is particularly important that men should not be alone during the taking of their exercise and diversion of mind. Above all, human interests take a man outside of himself and keep him from disturbing his mental equipoise by too much devotion to a single subject. CHAPTER VII DISTANT MENTAL INFLUENCE There is a very general impression that it is possible, at least under certain circumstances, for one human mind to influence another at a distance without any of the ordinary known means of communication. Many people have had the experience of thinking about a friend whom they have not seen for a long while, and shortly after meeting him. Sometimes it is found that the friend was making up his mind to bring about the meeting just about the time that the thought of him came. Many have had the experience of writing a letter and having it cross in the mails with another from their correspondent, evidently written within a few hours, though there had perhaps been no communication for weeks or months before. There are people who insist that they can, by concentrating the mind and fixing their eyes on the head of a {141} person some distance in front of them in a theater, or a railway car, cause the person to turn around. There are others who say that by thinking strongly of some person in a distant part of a large room, that person can be made to think of them. In general, there are many persons who are quite sure that there is evidence enough to indicate the possibility of distant mental influence, or, as it has come to be called learnedly, telepathy. Telepathy, from the two Greek words, _tele_, at a distance, and _pathos_, feeling, has been much discussed in recent years. Many people who use the word glibly are inclined to think they know much about it. A long word, however, is not an explanation, and, just here, George Eliot's expression "we map out our ignorance in long Greek names" is worth recalling. There are a number of phenomena that seem to require some such theory as that of telepathy, but the phenomena are still under discussion and their significance is by no means clear. As we understand it, telepathy may mean either thought transference or mind reading, that is, either the active process by which we communicate our thought to someone at a distance, or the passive process by which we receive communications from others. These thoughts include the idea of mental influence at a distance; that is, we can by willing influence the wills, or at least the motives to action, of people at a distance and they may, in turn, influence ours. The further thought has come, that since the mind largely influences the body in matters of health, so mental influence from a distance by affecting mind, may either improve or injure health. Some sensitive people are disturbed by the thought that they may be influenced from a distance by others, or at least that suggestions that come to them, may be due to telepathic influence. Investigation would probably show that there are at least as many persons disturbed by real or supposed telepathic influences as there are of those who have hallucinations. Sometimes it is said that such persons are not quite sane, but the more experience a physician has with them, the more he dismisses the thought of insanity and proceeds to use contrary suggestion and frank discussion, in order to counteract the mental influences. Insane persons think they are being influenced from a distance just as they hear voices and see visions, but such hallucinations may occur to the sane, as apparent telepathic experiences may also. Witchcraft.--It used to be a common belief that people could be influenced, even at a distance, by the mere evil wishes or intentions of others. After all, the old beliefs in witchcraft that were so common in Europe and in America until well into the eighteenth century represent the conviction of mankind that at least certain people might, from a distance, seriously influence them for evil. Always the fear of malign influence was uppermost in people's minds and literally hundreds of thousands of witches were prosecuted, and many thousands of them put to death, because of this belief in the possibility of their working evil to others at a distance, merely by willing it. Occasionally some such material auxiliary to malign purpose as an image in wax of the one to whom the evil was to be done was used. Into this the ill wisher stuck pins according to the part that he or she would want to be affected in the enemy, but as a rule the will, and nothing more, was used. Absent Treatment.--In our own time a system of healing, that has attracted many followers, has taken up the idea of beneficent mental influence at a distance. "Absent treatment" has now become a familiar expression. {142} That those who believe in such favorable influence at a distance should also believe in unfavorable influence seems inevitable. As a matter of fact, we know that the founder of this special sect always insisted on the power for evil over herself and her followers of those who want to exert the injurious influence of animal magnetism--malicious animal magnetism as it is called. A very definite attempt was made to bring a case of this kind before the courts, the subject matter of which exactly resembled some of the old witchcraft trials in New England! And in spite of the insistence and emphatic assertion that no such thing is intended, from the principles that are accepted the necessary logical conclusion is a return to the belief in witchcraft. Malignant Magnetism.--As a number of persons are likely to fear such evil influence of others upon them, the question of the possibility of it must come up for discussion in order that its status may be clear in the physician's mind, for by just as much as he can make certain to the patient that modern psychology refuses to accept distant influence, will he be able to reassure his patient. Of course, the patients who come with such complaints have usually some element of mental trouble. The alienist sees any number of people who are sure that enemies at a distance are working spells upon them, some by electrical, some by magnetic means, and some by telepathic absent treatment, or absent ill-wishing. Such notions are the delusions of the disequilibrated and these persons often cannot be reasoned with. Yet very often a distinct delusion may be reasoned out of even a subrational person, if it is taken seriously, and some striking expression of its irrationality and of its total disagreement with scientific views can be shown to the patient. Action Without a Medium.--The medieval scholastic philosophers quoted as an absolutely accepted principle the Latin axiom, _"actio in distans repugnat."_ Literally translated this means action at a distance is repugnant to reason. Expressed less technically, the principle declares that any action of one body on another, where there is no medium connecting them, no link that in some way places them in contact with one another, is absurd. The expression _in distans_ means that the two bodies are separated from one another and stand in two places having no connection of any kind. This principle would ordinarily seem to preclude the possibility of one person acting on another, unless there is some mode of communication. Crookes' Theory.--Sir William Crookes, at a meeting of the British Association for the Advancement of Science about ten years ago, in discussing telepathy, directed attention to the fact that there exists by scientific hypothesis, generally accepted, a definite medium of communication by which minds at a distance might influence one another. The medium is the ether which, according to physical theories, besides carrying light, also carries heat and electrical waves, and in recent years is recognized as transmitting the impulses of wireless telegraphy. It is possible that when the cells of certain human minds are stimulated to a particular phase of vibration, they may, even at long distances, affect the cells of other individuals that resemble them, or are attuned to them, that is, have the same moment of vibration. This is the principle which underlies wireless telegraphy. Whether the vibrations of living nerve cells can be made thus to radiate out over the ether and arouse in any way other cells, especially to the extent of communicating ideas, is a matter still open for investigation. The possibility of this occurring {143} cannot be denied. We are, however, still in the presence of a condition and not a theory. The question is whether minds are thus influenced at a distance--whether we have data enough to establish the occurrence of telepathy or mental communications of any kind at a distance. No Practical Thought Transfer.--At the beginning, it is of the greatest importance to recall that, while many people think there must be something in telepathy and presume that the investigations of recent years have shown not only the possibility of the communication of ideas from mind to mind and of the mental influence of one person over another, even at long distances, but also its actual occurrence, yet all our ordinary life is founded on the absolute negation of any such phenomenon. For instance, our courts of law are conducted in direct contradiction of the possibility of anything like telepathy. Juries are summoned of twelve good men and true who, as far as possible, know nothing about the prisoner and as little as may be about the case. They are supposed to get all their information in the court room. We do not believe that any of them by any wonderful process might be able to know what was going on in the prisoner's mind in spite of his plea. Nor do we think for a moment that they can know what is going on, apart from what he communicates in evidence, in the mind of any witness. Neither is there the slightest presumption that the judge or any of our lawyers can know anything about what is in the minds of any of the persons present, except as they reveal it by outward signs. A lawyer who could employ telepathy with success would be simply invaluable. Before a month had passed, he would have all the business of the criminal courts in his hands. Mental Retention.--In answer to this it may be said that these represent conditions in which determined effort is made to keep all possible information that may be in the minds of all concerned from passing to others. Everyone concedes the power of such absolute self retention of our thoughts, when we deliberately wish to keep them from being known to others. When people wish to communicate their thoughts to others, then it may be different. In that case the sending and receiving minds are both active and the conditions for interaction, if it were at all possible, would be favorable. Just this condition obtains in the court room every day. An innocent prisoner wants with all his heart and soul to communicate the idea of his innocence to the judge and jury. Of course, he does not succeed by telepathic means in transferring to them any inkling of the truth. On the contrary, his very nervousness and anxiety to set himself right before them will sometimes actually cause prejudice. The rule that has thus been exemplified in our courts of law holds for all business transactions. The ordinary customs of business presume that the buyer does not know what the seller paid for the particular article that is being exchanged, and it is on the strength of this that profit becomes possible. A few telepathic merchants or customers would work serious havoc in business life. What thus holds for important affairs in life is just as strikingly exemplified in the trivial round of social existence and in our intercourse with friends. Suppose one woman knew what another woman thought of her! That charming, old-fashioned institution "courting" would go entirely by {144} the board, if there were any such thing as real telepathy. In general, social life in all its features would become very, very different to what it is. How Much Slight External Expression Conveys.--Mrs. Coventry Patmore, the English poet's wife, once told a little story of some people who lived in a distant island where the inhabitants possessed tails. These tails were, as they are on the animals, organs of expression, but of involuntary and quite unconscious expression. It was utterly impossible for the people there to say nice things to one another when they had quite other things in mind, because if they did not like the person their tails hung down behind; if they did like them they wagged rather vigorously, no matter what their owner might be saying. This simple revelation of feelings, so much less than even the slightest degree of telepathy would occasion, was quite enough to work a revolution in the social affairs of this romantic island. It made the people truthful and candid in their relations with one another. Negation of Telepathy.--There is, perhaps, some evidence of the occurring of telepathy in special cases, but all of our present-day life is organized on a firm basis of complete negation of the existence or occurrence of telepathy to even the slightest degree. Every-day experiences teach us that husbands and wives, even those who have the greatest love and confidence toward each other, do not really know their life partners, for it frequently happens that something turns up which reveals an unsuspected side of character even after many years of intimate union. We human beings are "infinitely repellent particles," to use the phrase, of Matthew Arnold. We never get close enough to one another to have a real glimpse into the depths of other minds. The information that is supposed to pass by telepathy from one person to another is so often just the kind that we would most sedulously conceal. There is extreme unlikelihood then that any such passage of information takes place. The cases cited, as proof of this transference of thought, are much more likely to be coincidences than any evidence of true telepathy. Supposed Examples of Telepathy.--In the first place, though there are opportunities for the exhibition of the phenomena of telepathy every day and every hour of existence, the cases in which it is supposed to occur are extremely rare and are distant from one another, both in time and place. Even the people who claim to have had the phenomena of telepathy happen to them once or twice, do not pretend that it is at all a common occurrence with them, and as for the supposed exhibitions of telepathy upon the stage, these have been exposed over and over again as the simplest fakes. As to the cases of telepathy that have been reported, with careful collection of evidence, to the psychic research societies, and which are few in number, though some of them are very difficult to explain, there is no reason why they should not be striking coincidences rather than startling examples of telepathy. An example will illustrate what I mean: A few years ago what seemed to be a complete case of telepathy was reported in connection with a railroad accident. A Western man about to take an express train for the East was the object of a good deal of solicitude. There had previously been a series of accidents to this very fast train which he was to take. This fact had been discussed in the family, and did not tend to allay the fears of those who remained at home. During the night the {145} train actually left the track, and the car in which the subject of the story was asleep rolled down the bank. At the moment his train went down the bank the thought of his wife and daughter came very vividly to his mind. For a moment the awful position in which they would be placed if anything serious happened to him occupied his mind to the exclusion of all other thoughts. As soon as he could, he telegraphed home that he was unhurt, with the understanding that the telegram should not be delivered before the following morning. During the night mother and daughter sleeping in adjoining rooms were wakened at the same moment, and very seriously disturbed, by something, they knew not quite what. They rose at once to go to each other and met at the door. They felt vaguely that father was in some way connected with their awakening and disturbance of mind. After they received his telegram they were sure that what disturbed them during the night was the telepathic communication of father's danger. Each had, however, deliberately kept from speaking of her impression. When they found that he had passed through the danger unhurt, they were sure that it was a call from him that each had heard. This bears most of the ear-marks of a genuine case of telepathy. Here are minds whose cells by custom and inheritance are finely attuned to those of a distant mind that is suddenly very much disturbed. If the perturbations of that first mind were carried through the ether by a sort of wireless telegraphy, it would apparently not be very surprising. So carried, they woke the receptive cells of similar minds at a long distance, and mother and daughter felt the thrill at the same instant. Vague though it was, there was a telepathic message. But there were other passengers in this train who had near and dear relatives, yet none of them received communications. There have been literally hundreds of thousands of other accidents in the past fifty years of railroading in which passengers who have been put in very serious danger, have thought intensely of their loved ones, and yet, there has been at most only a dozen or so examples of vague telepathy of this class. Similar cases to this are extremely rare, though accidents in America are very frequent. At most, then, we are in the presence of a very exceptional case. Such cases would mean nothing as evidence for a scientific law, since they occur so rarely as to aptly exemplify the old adage that the exception proves the rule. The rule evidently is that there is no communication at a distance, hence the surprise when there seems to be some reason for thinking that a communication has actually taken place. Instead of proving that telepathy occurs, such cases make it clear, to the limit of demonstration, that telepathy does not occur unless some extremely special conditions intervene to make it possible. How much more easy it is to explain such a case on the score of coincidence! Of course, mother and daughter, with father absent, and absent in the midst of what they thought was danger, would go to bed anxiously thinking of him. They would sleep lightly because of the worry. Any slight unusual noise would wake them, and at once the thought of father and his danger would occur to them. If the noise was sudden, and not repeated, and therefore inexplicable to one awakened out of sleep, they would probably be so disturbed that it is easy to understand that they would arise at once and seek each other's company. Their meeting, therefore, in the doorway between their rooms would be readily explicable. Neither would say much {146} about the subject uppermost in her thoughts in order to shield the other. The telegram in the morning would throw a glow of retrospective light on the events and seem to give an entirely new significance to their thoughts. The whole affair, though only a coincidence, would seem to be a demonstration of telepathy. Even more marvelous instances of coincidence, in which there was no question of anything more than coincidence, have been related. The English Psychical Research Society reported the case of a young man sent to find some trace of his brother who had disappeared mysteriously from a steamer sailing from Plymouth to Lisbon. On board the steamer late at night he stood by the rail thinking of his lost brother and wondering what could possibly have become of him. Suddenly as he looked down into the ocean a body came bobbing up out of the waves almost directly under his gaze. He reported it to the officers of the vessel and it was grappled for and lifted aboard. It proved to be the body of his brother. Is this an example of telepathy, that is, of the mental influence of the perturbed spirit of the live brother upon the dead brother's body floating below the surface? No one would stretch supposed telepathy to that extent. The steamer disturbed the body which had been floating below the surface, as bodies do, gradually developing within themselves the gases of decomposition. After a time any slight disturbance, as, for instance, the booming of a cannon or the passage of even a small boat, will bring a body up. It so happened that the brother was on the spot, and actually thinking of the body, but that was the merest coincidence. There was no connection of cause and effect. Most of the cases of so-called telepathy can be explained in this way. As we have said, no source of error is so copious as that of concluding that because one thing happens after another therefore the second is caused by the first. People who are so inclined will still continue to accept such a notion of connection of cause and effect, however, and we shall have many cases of supposed telepathy exploited for us on no better grounds than this. Twins and Telepathy.--There is a definite popular impression that twins are gifted with the power of telepathic communication much more than others. Accepting Sir Wm. Crookes' theory, the possibility of mental reciprocal influence, even at a distance, is greater for them, since their brain cells must be considered as having corresponding moments of vibration. Twins of the same sex, especially those who resemble one another closely, are usually born from a single ovum. The intimate relations of two such beings to each other can be readily understood, so that we have many stories of mental communication at long distances and curious warnings, forebodings and communications of danger, and especially of sickness and death. Especially does one find stories of wraith-like appearances of one to the other of such persons at the moment of death. A series of these stories, apparently well authenticated, is published by the Psychic Research Society. There are also a number of tales, seemingly well attested, of cloud-like shapes of other persons at the moment of death. As a consequence, there has been developed an idea that there is some evidence of the distinct possibility of such appearances when the soul leaves the body. It, however, seems very doubtful whether these are anything more than a very striking coincidence. Twins are likely to be almost constantly in one another's minds, so there is abundant {147} room for coincidences. But any number of twins have died at a distance from each other without there being any such warning. Occasionally such startling appearances occur in connection with people who are so slightly related, or whose existence bears such slight importance to each other, that it is hard to understand why the appearance may have come. Whether they are anything more than the figment of an excited imagination remains to be seen, for, while we have a little positive evidence, this only emphasizes the possibility of coincidental day-dreaming in nervous persons. Negative Tests.--We hear much of the possibility of reading minds at a distance, or of getting definite information from sealed documents and the like, but it must not be forgotten that whenever definite conditions have been set down, so that all the actions of the supposed clairvoyant could be controlled, then telepathy has always failed to be manifested. Sir James Simpson, for instance, publicly offered to give a five-hundred-pound note, which he had placed in a safe deposit vault, to anyone who could read its number which he had carefully impressed on his own mind. Needless to say, no one got it. In the days when Bishop, the exhibiting mind reader, was creating such a furore in New York and London by supposedly reading people's minds, Labouchère, the editor of London _Truth_, offered a similar opportunity to Bishop, but advantage of it was not taken. Bishop's power was entirely due to muscle reading. People make involuntary movements of muscles that are very slight, but sufficient for a trained observer to notice, especially if his hand is on the individual experiencing the emotions, and the consequent muscle reflexes. [Footnote 19] About the middle of the last century, the French Academy made a labored investigation of telepathy and found that whatever there seemed to be in it, when control was not properly kept, it at once was demonstrated to be impossible when conditions were planned so as to prevent deception. [Footnote 19: The story of Hans, the calculating horse, shows that even animals usually thought rather dull-witted may catch muscle movements so slight as to be scarcely visible to any but one looking particularly for them.] If patients are worried over disturbing influences from others or the reading of their thoughts or telepathic suggestions, a calm review with them of the practical side of this subject, as we have come to know it in the modern time from actual investigation, will do more than anything else to relieve their apprehensions. Most of these patients are unfortunately insane, but the reasoning will help even some of these. There are some quite rational believers in such manifestations who will be greatly benefitted. CHAPTER VIII SECONDARY PERSONALITY So much attention has recently been directed to the subject of secondary personality by the startling phenomena described in numerous books and articles on the subject, that a certain class of "nervous" patients have permitted themselves to be influenced by the auto-suggestion, flattering the vanity, that they, too, have a secondary personality. They even do not hesitate to hint that this condition is responsible for many of the failures on {148} their part to do what they ought to do, or at least what they think they would like to do; but self-control and self-discipline require such constant attention and effort that they fail. Even when these patients have not quite reached the persuasion of a complete secondary personality, they at least think that the subconscious (or their subliminal self) plays a large role in their conduct. As a consequence, they assert, it is more or less beyond their power to control themselves, and their responsibility for certain acts is surely somewhat impaired. This is a rather satisfying doctrine for those who do not feel quite equal to the effort of conquering vicious or unfortunate tendencies. Those who like to have some excuse for self-indulgence take refuge in this supposedly scientific explanation to absolve them from blame, and from the necessity of self-control. The drug habitué, the inebriate, the victim of other habits, sometimes hug this flattering invention to their souls, especially when they are of the class who delight in the study of the abnormal. Reform becomes well-nigh impossible as long as such an auto-suggestion of inherent weakness and lack of will-power is at work. The Other Self.--From the beginning of written history, man has always been inclined to find some scapegoat for his failings. The story of Adam blaming the first fault on the woman and the woman blaming it on the serpent, is a lively symbol of what their descendants have been doing ever since. The less personal the blame is, the better, and the more it can be foisted over on some inevitable condition of human nature, the more generally satisfying it is. A secondary personality can scarcely resent being blamed for its acts by the primary personality to which it is attached, and so the field of auto-suggestion as to the blameless inevitability of certain acts is likely to widen if it is given a quasi-scientific basis. Long ago St. Paul spoke of the law in his members opposed to the higher authority, and declared that the things he would do he did not, while what he would not do he sometimes did. There is no doubt that there are two natures in the curious personality of man. Everyone at times has the uncanny feeling that there is something within almost apart from himself, leading him in ways that he does not quite understand. Usually the leading is away from what is considered best in us. But those who have dwelt much on the better side of man and have tried to climb above mere selfish aims, have realized that there is also a power within them leading to higher paths. Indeed, some of the greatest thoughts that men think, and the resolves that lift them up to heroic heights, are apparently so far beyond ordinary human powers, that the hero and the poet and even the more ordinary literary man, is quite ready to proclaim inspiration as the source of his best ideas--as if they were breathed into him from without and above. Personal Responsibility.--For ordinary normal individuals, this question of secondary personality has scant interest. Normal persons go about their work realizing that what they want to do, they may do, and what they do not want to do they can keep from doing, unless some contrary _physical_ force intervenes. There are many metaphysical arguments for free will, but none of them is so convincing as the observation that every sane man, with regard to his own actions, has the power to choose between two things that attract him. He may be much drawn to one thing, yet choose another. He may allow himself to be ruled by baser motives; he may sternly follow the {149} dictates of reason, or he may do neither and hold himself inactive. In any case, he realizes his power to choose. While this power may be impaired by many external conditions, his consciousness of its actuality makes him appreciate his responsibility. He realizes that punishment for wrong done is not only a part of the law, but it is also a proper vindication of that consciousness of free will which all men have, and which does not deceive them. The question has been obscured by much talk, but the reality is there, and the common-sense of mankind has proclaimed its truth. All our laws are founded on it. Without it punishment as meted out is an awful injustice and crime is a misnomer. Hysterical Phenomena.--Most of the cases of secondary personality that have been discussed at greatest length have been in persons who were as desirous of attracting attention, and as pleased over being the subject of special study as were the hysterical patients who used to delight in investigation two generations ago. That most of the phenomena of so-called dual personalities are mainly hysterical seems now to be clear. In a few cases, where the patient has found that the existence of a double personality was of special interest, a definite tendency to the formation of further personalities has been noted. Some triple personalities have been discussed and, in a few cases, a group of personalities, even up to five or more, began to assert themselves. This _reductio ad absurdum_, of the hypothesis of supernumerary personality has revealed the real hysteric character of the phenomena. The whole story of secondary personality in recent years vividly recalls commonplaces in the older medical literature that gathered around the study of hysteria, and that afford a striking confirmation of the conclusion as to the relation of the conditions ascribed to hysteria. Physicians of a generation or two ago who found their hysterical patients interesting, because of certain marvelous symptoms which they presented, were usually astonished to learn that their patients could, under suggestion, develop still further and more surprising symptoms. Each new visit, especially when other physicians were brought to see the patient, showed the existence of still further symptoms and revealed new depths of interesting disease. Indeed, the soil was found to be inexhaustible in its power to produce ever new and interesting crops of symptoms. When the real significance of hysteria as a mental condition in which patients devoted themselves to the task of furnishing new symptoms for the physician began to be realized, one of the most potent objections against this explanation was that it would have been impossible for the patients to have studied out their symptoms enough to furnish the new material for study which physicians found so interesting. The patients were supposed to be mentally incapable of fooling the physicians. When, however, a person devotes entire attention to the one subject of making phenomena in themselves appear interesting to others, some very startling results are usually produced. After having attracted the sensational attention so common with any novel observation and having been exaggerated out of all proportion to its due significance, the phenomenon is now settling down to its proper place--a rather obscure neurotic phenomenon of memory in hysteric individuals. _Other Neurotic Symptoms_.--Janet's studies at the Salpetriêre seem to show that the alterations of memory which bring about what we call {150} secondary personality (the forgetting of certain phases of existence and the maintenance for a time of a small portion of consciousness and memory quite apart from the rest) correspond with alterations in the physical basis of memory, that is, in the circulation to certain portions of the brain, and probably also in the modes of association of brain cells. They occur, particularly, in connection with certain phenomena of hystero-epilepsy so-called, or with the deeper forms of epilepsy in which there are various paresthesias, hyperesthesias and anesthesias as a consequence of a disturbance of the circulation in the central nervous system; and probably also of the connections made by neurons and the movements of neuroglia cells in making and breaking these connections. These alterations of memory are represented physically by such cases as those in which patients so lose their consciousness of sensation that they are unable to tell even where their feet are. As they themselves say, "they have lost their legs." In these cases, patients are often very deaf or have a limited auditory power, and their fields of vision are extremely narrowed. In most of these cases, recovery of the original personality takes place after hypnosis. This probably represents a relaxation of that short-circuiting, within the nervous system, which brought about the curious phenomenon studied as secondary personality. Dual Dispositions.--The studies of secondary personality that we have had seem to show us persons under the influence of some strong suggestion, in what is practically a hypnotic condition. There are many similarities between the actions and the mentality of hypnotics and of those in secondary-personality conditions. The individuals are, for the moment, unable to recall what happened in other states. They may be very different in disposition, gentle and tractable in one state, but morose and difficult to get along with in another. Such differences are, however, only exaggerations of the variations of normal personality. There are times when, under the stress of circumstances, even the mildest of men and women become querulous and difficult. It is often noted that people are much more gentle and careful in their relations with some people than with others. Men who are known in their business relations to be quiet, easy to get along with, are at times bears in their homes. This is a matter of the exercise of inhibition for certain mental qualities, and this inhibition is neglected for some places and persons. An American humorist said not long since that a young girl passing a weekend at the house of a friend, should remember that she is expected to be unselfish, thoughtful for others, and ready to help her hostess to make it pleasant for others, so that the party may be successful. He adds that, of course, as soon as she returns home she should be perfectly natural again. At least in a limited sense, all of us have buried in us secondary personalities that are due to a lack of control of ourselves, or occasionally to a lack of such initiative as makes possible the best that is in us. The secondary personality of some people, that side of their characters that their friends see only rarely, is the best side of them. Many people, under the demand of some great purpose, rise up to be really heroic in quality, yet in the commonplace relations of life they are quite ordinary. The secondary personality in either of these cases is not something abnormal. It is due to a tapping of deeper levels in personality than most people realize that they possess. When taken in connection with hypnotism and the power of suggestion over {151} susceptible individuals, these adumbrations of the deeper problem of secondary personality as the psychologists have discussed it, furnish the best data for its fuller explanation. Excuses for actions founded on secondary personality must either rest ultimately on insanity, or else on that lack of inhibition which constitutes the source of so many of our actions that we regret. People who are susceptible to hypnotism may remember absolutely nothing of what occurs to them in the hypnotic condition, though they will recall it without any difficulty if during hypnosis it is suggested to them that they should remember it. This represents the most prominent feature of secondary personality; the individuals who are affected by it do not recall in one state of personality what happens to them in the other. In the two states they are very different in character. These differences have been much emphasized with regard to a few cases that are especially abnormal and have not attracted much attention in cases where the differences are slight. Indeed, in a number of the cases where secondary personality asserted itself, the differences in the character of the individual in the two states were practically nil. The only difference was a lapse of memory for certain important events. Considerations such as these help in the understanding and psychotherapy of what are sometimes puzzling cases of apparent dualism of disposition. What we have to do with here are the suggestions of secondary personality which neurotic patients have been inclined to make to themselves as a consequence of the interest in the subject in recent years. The investigations of Head and of Gordon Holmes have undoubtedly shown, however, that there are true pathological conditions associated with certain definite and very marked manifestations of dualism of disposition consequent upon lesions in the optic thalamus. These cases so far as can be judged at the present time, at least, are quite rare and at most would account for duality and not for the plurality of personality that has come to be discussed by certain enthusiastic neurologists in recent years. The magnificent work done on this shows how much may yet be accomplished in the elucidation of nervous diseases by faithful study and investigation of selected cases. CHAPTER IX HYPNOTISM Hypnotism is popularly supposed to be a mysterious psychological process by which susceptible subjects are brought under the influence of a person possessing some marvelous power over others' minds and wills. According to this supposition, during the periods in which the subjects are under this influence, they either have some new source of energy transferred to them from the operator's strong personality, or else they share to some extent in the will power possessed by him. In the midst of the sub-consciousness which characterizes the hypnotic condition, then, they are in some way endowed with new strength, which enables them to overcome obstacles to physical or mental health, some of which seemed at least quite insurmountable under their normal condition. {152} As a matter of fact, hypnotism is much simpler than this, consisting merely of a state of mental absorption in which all distracting thoughts are for the moment warded off, and only such thoughts as are suggested by the hypnotist reach the consciousness of the patient. The essence of hypnotism is the concentration of mind on one idea or only a few ideas dictated by the hypnotist. This mental concentration produces the effect of greater strength, whether apparent or real, to carry out the purposes connected with those thoughts. It is usually considered that hypnotism involves sleep, and in some cases it does. This is often undesirable. True, therapeutic hypnosis leaves at least certain senses of the subject open to perceive such things as are presented by the hypnotist's suggestion though these senses may be, and usually are, quite closed to all other perceptions. In a great many cases, though there is a real hypnotic condition, a state resembling true sleep does not occur. There is only a more or less complete concentration of attention on the suggestions of the operator, and a complete cessation of all spontaneous thought, or of all suggestions that might come in ordinary ways from the subject's own senses. Effects of Hypnotism.--Most people have a very erroneous notion with regard to the effects of hypnotism. Some expect that the hypnotic sleep will work miracles. Nothing is more common in the experience of one who is known to employ hypnotism, even occasionally, than to have a patient who is addicted to some habit, alcoholic, drug, or sexual, ask, "Do you hypnotize?" If an affirmative answer is given, the patient proceeds to say that he has heard that one can be hypnotized, and then all the tendency to fall back into the old habit is immediately lost, and he has no further bother from it. This supposed miraculous effect of hypnotism in supplanting the necessity for using the human will has been cultivated very sedulously in the public mind by quacks and charlatans of various kinds and even exploiters of hypnotism who belong to the medical profession. But there is nothing in it. Hypnotism will not change character unless it be for the worse, since the habit of it sometimes leads to dependence on suggestion rather than spontaneous motives. Hypnotism cannot be substituted for weakness of will. The suggestions given in the hypnotic state are practically no stronger than those given in the waking state, if the patient would only equally concentrate his mind to receive them, and would be as ready in response. It is the readiness of response which comes in cumulative fashion, in the midst of the utter abstraction from other thoughts, that characterizes the hypnotic condition. This is, of course, quite a different valuation of hypnotism from the very strong expressions, with regard to the power of hypnotists to influence the human will, which have at various times been made. These exaggerated claims have been no stronger than those often made for remedies of various kinds that have been long since discredited. I have heard a serious though young professor of psychology declare that he was not sure whether he was justified in using all the power that he possessed by hypnotism to influence men's wills to keep them from indulging in liquor to excess, because after all men had a right to their free will, even in a matter of this kind, and it would be wrong to take it away from them. He added very philosophically that no human being had the right to play the role of Providence in directing others' actions even for good, unless they themselves were perfectly satisfied. {153} If there was any such force in hypnotism as is thus suggested, the reformation of the world, or still more its deformation, at the hands of some of the strong-minded practicers of hypnotism, would be a comparatively easy process. As a matter of fact, however, the hypnotizer has, except as regards abnormally suggestible people, only as much influence over the person hypnotized as the subject permits, and the subject retains all his personality as an individual with all his weaknesses. After he has been helped away from his weaknesses by hypnotism, he is just as likely as ever to yield to them again, unless, during the interval of conquest, he has succeeded in bracing up his will to resist them. FORMER METHODS OF HYPNOTIZATION All the methods of hypnotizing, then, are directed to securing this state of concentration of the patient's mind. The hypnotic state is brought about in different ways by different operators, and even the same operator must employ quite different methods to secure hypnotic influence over different subjects. In the old times, mysterious passes and strokings and rubbings of various kinds, and instruments that flashed light, or that made special sounds, were employed. Among the pioneers, each worker invented methods of his own. A review of these will bring out the fact that none of them represents essentials, and that they are only auxiliaries to secure concentration of the patient's mind. The methods of hypnotism practiced by those most noted in the history of the art were very different from one another, but not more different than are the methods in vogue to-day among individual hypnotizers. Indeed, the practices of the past have come down as a heritage to our own time. Stroking and touching, of which we have hints in the oldest times in Egypt and Babylonia and Greece, have always been prominent features. Valentine Greatrakes dreamt that he heard a voice in his dream telling him that his right hand should be dead and that stroking it with his left should cause it to recover its power once more. After this had happened three times in succession he began to apply this method to the ills of others. Greatrakes seems really to have come in to replace the touching by the king for the King's Evil at a time when there was no king in England, Pastor Gassner, the next worker who attracted attention by hypnotic procedures, used words of command after attracting the profound attention of his patients. Father Hell employed the touch of magnets. Mesmer used music to predispose the mind, but had many of the methods of modern hypnotists. Mesmer.--While Mesmer undoubtedly attracted attention to certain phases of hypnotism that were to prove valuable, he was by no means the first to do so, and what he did had such a tincture of charlatanism it is no wonder that he was discredited. There was a little truth, but there was a deal of mere pretense in his work. While he undoubtedly obtained results, he did so mainly because of certain mentally impressive methods that he employed in connection with whatever of hypnotism he used. Binet and Feré, who have given us some details of his work, describe his methods in such a way as to make it clear that they smacked largely of quackery: {154} Mesmer, wearing a coat of lilac silk, walked up and down amid his agitated throng, accompanied by Dezlon and his associates, whom he chose for their youth and comeliness. Mesmer carried a long iron wand with which he touched the bodies of the patients and especially the diseased parts. Often laying aside the wand, he magnetized the patients with his eyes, fixing his gaze on theirs, or applying his hand to the hypochondriac region and to the abdomen. This application was often applied for hours, and at other times the master made use of passes. He began by placing himself "en rapport" with his subject. Seated opposite to him, foot against foot, knee against knee, Mesmer laid his fingers upon the hypochondriac region and moved them to and fro, lightly touching the ribs. Magnetism, with strong electric currents, was substituted for these manipulations when more energetic results were to be produced. The master, raising his fingers in a pyramidal form, passed his hands all over the patient's body, beginning with the head, and going downward over the shoulders to the feet. He then returned to the head, both back and front, then the belly and the back, and renewed the process again and again until the magnetized person was saturated with the healing fluid and transported with pain or pleasure, both sensations being equally salutary. Young women were so much gratified by the crisis that they wished to be thrown into it anew. They followed Mesmer through the halls and confessed that it was impossible not to be warmly attached to the person of the magnetizer. De Puysegur and His Successors.--De Puysegur has some definite instructions for hypnotizers, whom he called magnetizers. It is instructive even now to read these, for they emphasize the most important element in all hypnotism, the confidence of the operator in his own power, for this, communicated to the subject, produces the beneficial results: You are to consider yourself as a magnet; your arms, and particularly your hands, being its poles; and when you touch a patient by laying one of your hands on his back, and the other in direct opposition upon his stomach, you are to imagine that the magnetic fluid has a tendency to circulate from one hand to the other through the body of the patient. You may vary this position by placing one hand on the head and the other on the stomach, still with the same intention, the same desire of doing good. The circulation from one hand to the other will continue, the head and stomach being the parts of the body where the greatest number of nerves converge; these are, therefore, the two centres to which your action ought to be mostly directed. Friction is quite unnecessary; it is sufficient to touch with great attention. Some of these methods continued to be employed by the successors of Mesmer and De Puysegur, the sense of touch being the principal adjuvant, though Mesmer employed also the sense of hearing. Braid seems to have been the first to realize that the sense of sight could be used effectively, or perhaps that the tiring of the muscle sense might well serve as a point for the concentration of attention. He used the flash of a light from some bright object or tired the eye muscles by having the patient look upward at some object brought near so as to require convergence of vision. His methods were imitated by most of the hypnotizers of the nineteenth century. Liebault and Bernheim, at Nancy, employed them regularly, and they were used in the investigations at the Salpêtrière. It was found, however, that after a patient had been once hypnotized, all that was needed was a word of command or a definite suggestion, and the hypnotic state recurred. Further experience showed also that the original hypnotic phenomena might, in most cases, be secured very simply by word-suggestion to the patient, though some individuals required persistent efforts in the application of several methods {155} to secure the concentration of mind on a single idea or set of ideas that is the essence of hypnotism. By most serious hypnotists, especially those who use hypnotism for therapeutic purposes, all the rubbings and manipulations are now either completely eliminated, or are used only under special circumstances. The important element of the operator's influence consists in obtaining the complete confidence of the subject in the operator's power to control his intelligence for the time being; getting the subject to resign himself completely, with absolute assurance that his trust will be for his good, and can by no means result in harm. Without this attitude of mind on the part of the subject, anything like real hypnotism is impossible. Even with this, only a slight degree of the hypnotic condition may be secured in certain people, but the majority have a distinct susceptibility to it. PRESENT DAY METHODS OF HYPNOTIZATION Though various methods of producing the hypnotic sleep are in use, the rule is now that, in the course of a hypnotizer's experience, less and less external auxiliaries of any kind are needed, and more and more dependence is placed on the bringing about of mental _rapport_ between the active and passive agencies in hypnotism by persuasion and command. If the hypnotic sleep has once been obtained, usually all that is necessary is a few gentle words, and then the command to sleep. It is at the initial attempts to hypnotize a particular person somewhat refractory to the condition that auxiliaries are needed. In these cases it is often well to tire the eyes of the patient. This is done by directing them to the fingers of the operator held well above the patient's head. After a minute or two of effort the distinct fatigue which occurs may induce forgetfulness of everything else and cause absorption in the single idea of attending only to the hypnotizer's suggestions. This constitutes the beginning of hypnotism. Occasionally the flash of a bright object, or a revolving mirror, may be used, but these are only adjuncts and may be dispensed with entirely if the operator has the patience and the time to give to the subject. Accessories.--Some operators use a mirror on which a ray of light is cast for the purpose of concentrating the attention and bringing about tiredness of the eye muscles. In so far as it has a more universal application, sight is certainly the best sense to act upon. Other senses may be appealed to, as I suggest later. Instead of a mirror, a polished match-box or pencil-case may be used, but as a rule the less artificiality enters into it and the simpler the procedure, the better. One of the inconveniences of using the flash of a bright object is that occasionally patients who are very susceptible may, after they have had a number of hypnotic experiences, be thrown into a hypnotic condition by the flash of a light in the street, or by the reflection of light from a mirror in their own homes. These conditions of facile auto-hypnotism constitute one of the serious dangers of the practice on susceptible subjects. Whatever good may be accomplished by hypnotism will probably be reached during the first half dozen seances. To proceed with the treatment beyond this, if it is employed at regular and short intervals, is almost sure to result in harm rather than good. {156} Sensations.--Besides sight, sounds have sometimes been used for the purpose of inducing hypnotism. The ticks of a watch, for instance, placed at a little distance and listened to very intently, have been known to assist in securing the hypnotic state. Sometimes the sound of a gong, or an imitation of a cathedral chime, have been used in the same way. Soft music has also been used by operators with decided advantage. It is necessary that the sounds should be of a kind that do not disturb, but only attract attention to one sensation, and then, as concentration on this is secured, the hypnotic condition results. Practically any other sensation may be used in the same way. Touch is often employed. Mesmer stroked his patients gently, and others have used the same process with advantage. Some of the French workers in hypnotism have claimed that there were special portions of the body the stroking of which was likely to produce this favorable effect. They have called these regions zones hypnogenes--areas that give rise to hypnotic conditions. Strokings of the forehead, of the cheeks, of the hands, are favorite locations for these auxiliary touches. In this, as with regard to sound, the main thing is to concentrate attention on some one sensation without producing disturbing thoughts. Stroking.--Stroking seems to affect many people and to easily induce a sort of hypnoidal condition. It is done very naturally to a child when one wants to console or encourage or admonish slightly but kindly. In older people it is a familiar gesture among those who think much of one another, and represents a very natural tendency. Even in the midst of physical discomfort its effect is quite soothing, and it is evident that something resembling hypnotism is at work. Evidently, what really happens is a concentration of attention on the sensation thus produced, which concentration prevents distracting thoughts from making themselves felt and permits the words of the one who does the stroking to produce a deeper effect on the mind than would ordinarily be possible. This seems to be nature's method of making suggestion more effective. It has been adopted, quite spontaneously, by many of the pioneers in hypnotism as the result of their observations upon its efficacy. Lloyd Tuckey calls attention to an illustration of this practice, which makes clear its effectiveness and at the same time shows how naturally it suggests itself as a mode of using mental influence. He says: Among the medical men who have come to watch some of my cases was a gentleman who seemed much struck at seeing the method I adopted with a rather refractory subject. I held his hand and stroked his forehead while at the same time suggesting the symptoms of sleep. The gentleman told me afterward the reason why he was so interested. It appears that he had a few months previously been in attendance on a very severe and protracted case of delirium tremens. The patient could get no sleep, and the doctor was afraid of death from exhaustion. On the third evening he resolved to make a strong effort to produce sleep, and, if necessary, to sit up all night with the patient. He told the man that he would not leave him until he slept, and sitting down by the bedside, he took his hand in one of his own, and with the other gently stroked the forehead. At the same time he talked quietly and reassuringly to him. In less than half an hour he was rewarded by seeing the restlessness entirely cease and the man drop off into a quiet sleep. That sleep, the doctor told me, lasted fourteen hours, and the patient awoke out of it weak, but cured. Manipulation about the head has in many persons a most soporific effect, and several persons have told me that they always become drowsy under their barber's hands. {157} Drugs.--A number of drugs and related substances have been used as aids to hypnosis, but in nearly all of these cases it is doubtful whether it is true hypnotism that results and whether the suggestions in these states have much therapeutic value. One of the drugs most frequently administered by hypnotists is _cannabis indica_, which has long been used in the East for a similar purpose. After this, chloroform is most popular. Schrenck-Notzing even ventured to employ alcohol as an aid in hypnosis, and claims that he has succeeded at times in making intoxication pass into the true hypnotic condition. Bernheim and many others of the French school have used chloral and morphine. These substances are, however, liable to great abuse. Whenever they have to be employed it means that the patient is but little susceptible to hypnotic influence. These aids are employed only because hypnotists do not want to confess that a very considerable portion of humanity is not directly susceptible to the hypnotic influence. Serious harm may be done by the employment of these drugs. A physician, who hoped that he would be able to overcome a drug addiction that had been the bane of his existence for a long while, went to a well-known hypnotist physician with the idea that perhaps the miracle of hypnotism would be worked in his case. He was one of these flighty mortals whom it is extremely difficult to have fix their minds upon any one idea for a definite time. As it was impossible to bring him into anything like a hypnotic condition by ordinary means, a large dose of chloral was administered. He already had an idea that his heart had been affected by his previous drug-taking habit, but the chloral was administered to him before he realized what it was. When he came out of the sleep it induced, he was in an agony of solicitude and anxiety lest his heart should have been further hurt by the chloral. He went back for no more doses of that kind of hypnotism. The use of drugs seems to be a confession of failure to secure true hypnotism, so that it is doubtful whether their employment is justified. Suggestions received while in the more or less comatose state induced by drugs, instead of having a strengthening effect on the patient's will, rather tend to produce the idea of the impossibility of effectively using his own will, or even exercising his will when helped, as he supposes, by the will of the operator. The real value of hypnotism consists in the concentration of mind upon a particular idea without any distractions, which enables the subject to make firm resolutions and then to have his mind help his body as much as possible by directing his energy to the accomplishment of one end. When drugs are employed, they have a diffusive rather than a concentrating influence, so that the real purpose of hypnotism is entirely missed. PRACTICE OF HYPNOTISM In the ordinary practice of hypnotism now, the patient is placed sitting on a comfortable chair and the operator on one side facing prepares the mind of the subject by proper assurances. The patient must be brought into a thoroughly assured and comfortable state of mind and must be quite ready to submit to hypnotism. Then in most people, if the finger is held rather close to the patient and well above the line of sight, requiring special effort {158} on the part of the superior recti muscles as well as of the power of convergence, a tired feeling will come over the subject with a tendency of the lids to droop. When this happens the subject is asked to allow the lids to drop and to quietly concentrate the attention on the idea of sleep so as to permit the drowsy feeling gradually to increase. On a first seance this may take ten minutes, subsequently much less time will be needed, and, as a rule, in five minutes the subject is quite predisposed to sleep. In more difficult cases a much longer time may be needed, and repeated efforts may have to be made. Great patience is required. The operator soon learns to adjust himself to certain peculiarities of individuals in predisposing them to the hypnotic condition. Hypnotism Simple, Natural, Not Mysterious.--The most important thing to know about hypnotism is the fact that any one who wishes can hypnotize. There may be need for favoring circumstances, but there is no need for any special faculty in the operator. If he has confidence in himself so as to take up the question of hypnotizing seriously, if the subjects are reasonably susceptible and if they are persuaded that they may be hypnotized, or even if they are not, so long as they take the operator seriously a hypnotic state will result. Nothing is more surprising to the operator himself, the first time he succeeds, than his success. This at once gives him renewed confidence, and future hypnosis becomes a comparatively simple matter. To have this idea widely diffused would do much good, since it would at once strip the charlatans, who abuse hypnotism, of most of the mystery that surrounds them. The general diffusion of such knowledge would also do good in another way. It would expose the supposed wonderful power that some people are presumed to possess. Hypnotism works no wonders; it is a mere natural manifestation not unlike sleep, and probably not a whit more mysterious. Stages.--A number of divisions of the hypnotic state have been suggested, but probably the simple division into three stages is the best for ordinary teaching purposes, and helps to the understanding both of the conditions themselves and of many things that are written about hypnotism. The first stage consists of a subdued, dreamy condition, in which the patient is not asleep and yet not thoroughly awake to all that is going on around him. He has his mind so concentrated on certain thoughts that he is preoccupied, and suggestions are much more efficient than under ordinary circumstances. This is really only a state of intense attention to the suggestions that are being made, with the banishment of all distracting thoughts. It is rather difficult for any one to keep from being distracted, and whenever this is accomplished, the ideas that then enter the mind penetrate more deeply and, above all, seem to affect the will more forcibly than when they are merely superficially considered. This first stage of hypnotism would not be considered hypnotic by most people who associate the idea of sleep with hypnotism. In recent years it has been found that most of the good that is accomplished, especially for nervous people, by hypnotic suggestion, can be attained almost, if not quite as well, in this first stage, and without the hypnotic trance. The first stage is much less liable to the dangers of hypnotism in many ways, and it represents one of the most interesting phases of psychotherapy. {159} The second stage of hypnotism is the hypnotic sleep. The patient loses consciousness of his surroundings, though his senses are still open to suggestion from the operator. Practically all that happens in the room apart from what is brought to the subject through the operator's direction remains unnoticed. If the sleep is very deep, even the suggestions of the operator do not penetrate after a time, so it may be quite difficult to awaken the subject. It may be even some hours before the person hypnotized will come out of the lethargy which has been induced in these cases. Under these circumstances, this second stage partakes somewhat of the nature of the deeper trance condition that characterizes the third stage. The third stage of hypnotism consists of a profound trance-like condition in which there is catalepsy--that is, firm contracture of muscles all over the body--and as the extensors are stronger than the flexors, this contracture takes place in the extended position. The cataleptic condition is really a nervous spasmodic seizure rather than a true stage of hypnotism. It is probably always harmful for the patient to have it induced. Its occurrence as one manifestation of hysteria, apart from hypnotism, shows its real character. It is with this stage of hypnotism that professional hypnotists, who give exhibitions, make their demonstrations--that is, of course, when their demonstrations are really hypnotic and are not merely, as is often the case, performances by actors trained for the purpose. Catalepsy is entirely pathological; experiment with it then is eminently undesirable, and certainly should not be undertaken except under the most careful precautions and by a physician. One of its dangers was very clearly pointed out by the death of a young man, who in a cataleptic condition was subjected to certain strains upon his thorax which brought about the rupture of an aortic aneurism. Catalepsy never permits of suggestion in such a way as to be helpful to the patient. It always leads to further functional deterioration of the nervous system, and yet it has unfortunately come to mean for many people the most essential characteristic of hypnotism. Its production is supposed to represent the acme of skill in the hypnotist. Nothing could possibly be less true nor be more likely to do harm. Susceptibility.--As to the number of people who are susceptible to hypnotism, there are great differences of opinion. Liebault declared that practically every one is susceptible in the hands of a patient operator. In a carefully made series of cases his failures were less than three per cent. Van Rentergehem and Van Eeden, in a series of over 1,000 persons, failed only with fifty-eight, or little more than five per cent. Schrenk-Notzing's statistics, collected from many countries, seem to show that only about six per cent. were uninfluenced. Bernheim, at Nancy, was not nearly so successful as Liebault, his master, and his failures amounted to twenty-five per cent. at the beginning and at least twenty per cent. later. I remember that when I was at the Saltpêtrière fifteen years ago, they were inclined to discount the enthusiasm of the Nancy school with regard to the value and significance of hypnotism. They insisted that probably not more than one out of two of the persons presenting themselves at a nervous clinic could be hypnotized to the extent that is ordinarily associated with the word--could be brought beyond the drowsy stage. There are other workers in the subject who have insisted that not more than one out of three ordinary individuals can be so {160} deeply hypnotized as to exhibit the ordinary symptoms. These symptoms consist of complete neglect of surroundings and absolute absorption in the suggestions of the operator. Some people can be hypnotized to the extent of being thrown into sleep and yet walk and talk under the absolute control of the operator. These are so-called somnambules, the class of persons who are exhibited by professional hypnotizers who want to attract popular attention, and, indeed, the class usually exhibited by physicians before medical societies, and even by professors before their classes. This extreme susceptibility is, however, quite rare. Even the most ardent advocates of hypnotism and of the susceptibility of humanity to it do not claim that more than one in ten of average individuals can be influenced to this degree. There are milder degrees of hypnotism than this, until we reach a state in which all the patients feel is a certain dreamy sense of well-being and a heaviness of the eyes, with a readiness to respond to suggestions. Most people who think of the somnambulistic stage as representing hypnotism would not consider these latter to have been at all subjected to the hypnotic state. _Repeated Efforts_.--As to this question of susceptibility, much depends on how often the operator has tried to hypnotize the particular subject, for susceptibility develops with repeated trials, not only where there is a manifest impression at first, but also where there is not. It is not uncommon to find that a patient who cannot be brought at all under the influence of hypnotism in the first or second or third trial, will, at the fifth or sixth trial, yield to the suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts may be followed by the development of a very satisfactory hypnosis. Those who have practiced hypnotism much tell of having tried a score or even two score of times before finally bringing on a hypnotic condition. Dr. J. Milne Bramwell, one of the English authorities on hypnotism, tells the story [Footnote 20] of having tried sixty or more times to hypnotize patients before finally succeeding. It is this persistence that enables successful hypnotic operators to accomplish results where less confident physicians fail. It is also the frequency of trial that makes all the difference in the statistics as to the susceptibility of patients to hypnotism in the hands of different individuals. There must be the confidence of the patient in the physician's power to hypnotize, but, above all, there must be the physician's own confidence in his power to bring on the hypnotic sleep so that he tries and tries again, even to seventy times. [Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M. Bramwell, 2nd edn. London, The De la More Press, 1906.] ANIMAL HYPNOTISM The hypnotization of animals shows that only a very low grade intelligence is needed for the production of this state. The famous experiment of Father Kircher with the hen, which any one may repeat at any time, is a good illustration. The fascination exerted upon birds by snakes is another familiar example. The bird is paralyzed with terror at the sight of the snake, and so cannot escape from its enemy, fairly glueing its eyes on the terrifying object, and thus loses power to control its wings. Stories of snake {161} fascination are usually told as if the eye of the snake attracted the bird, who thereupon proceeded to approach the snake. These are, however, doubtful stories. The paralysis of motion seems to be the main effect. The rabbit is affected in nearly the same way. There is a tremor of horror in anticipation, and then the animal stands perfectly quiet, though ordinarily he would be quite able to escape, while its enemy approaches. The underlying mechanism is evidently a concentration of attention, which completely precludes the possibility of the exertion of any spontaneous energy except that involved in the one act of watching the awful object. DANGERS OF HYPNOTISM There are many and various opinions of the dangers of hypnotism. Some of those who have given it a fair trial have insisted on its dangers. Some of those who have had very large experience have declared emphatically that there is no danger at all. Occasionally it has seemed that such a declaration must be considered as having been dictated by such intensity of interest as sometimes leads men to overlook the darker side of things with which they are much occupied. Certain moral aspects of hypnotism are at least dubious, and, it must be admitted, present opportunities for abuse. There are certain dangers connected with its effect upon nervous patients, and especially with its influence upon character, that have become more and more clear in recent years. Dr. John K. Mitchell, in his "Self Help for Nervous Women," a series of familiar talks on economy in nervous expenditure, [Footnote 21] has dwelt on certain of these dangers of hypnotism for nervous patients in a passage that deserves to be recalled. As a representative of a school of thought that is worthy of special regard from American physicians his expressions must carry weight: [Footnote 21: Philadelphia, Lippincott, 1909.] The greatest danger of all is the use of hypnotism in any form or degree, a two-edged sword, capable indeed of usefulness, but more capable of harm. After years of study, beginning with too easy an approval of it, hypnotism, whether called by that name or by the unsuitable one of suggestion, has been laid aside by the medical profession as a means too dangerous for ordinary use, involving great risk of deterioration of character in the subject if often repeated, and putting a terribly tempting tool in the hands of the user, fascinating in the ease with which it can produce superficial and temporary good results and equally capable of being used for harmful ones. A susceptible person, once hypnotized, is more and more easily thrown into the hypnotic state until even the slightest hint suffices to bring about the condition. It is not necessary for the hypnotization to go so far as deep sleep; this more advanced stage is indeed seldom required, and to say that persons are not hypnotized because they are not put into a sleep or a trance shows ignorance of the subject. I am not asserting that very slight degrees of the hypnotic condition are as dangerous as the deeper, but I do say that all degrees of it are dangerous to the integrity and healthy action of the subject's nervous system. The danger of harm increases with every repetition of the hypnotization. In suggestible, that is, over-susceptible, individuals, who are almost universally neurotic persons, to fix the eyes on a small point, especially a bright one, sometimes even to fix the mind on the one idea of going into the hypnotic state (mild or deep), is enough without further intervention from any one to put them into that state. {162} In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of Zurich, twenty years ago, while frankly admitting that hypnotism is by no means a panacea for all nervous affections and unfortunate habits, found it to be an extremely valuable help in the treatment of many forms of functional nervous disease. He suggests that some of its many dangers are due to the fact that hypnotism is practiced by men who are too distrustful of it, and this distrust, unconsciously communicated to the patients, produces an unfortunate effect. On the other hand, fear and distrust on the part of the subjects seriously disturbs the process of hypnotization, interferes with its effect and sometimes leads to unfortunate results. In some cases it seems that the state of dependence on some one else, at least by suggestion, that had been created during the hypnotic experience, resulted in a diminution of will power and caused a less hopeful state on the patient's part than before. I found personally that suggestion in the waking state might in most cases be used quite as efficiently as hypnosis itself, and that when improvement came under these circumstances, the patient always felt more confidence in himself and less in the operator. Anything that restores self-confidence and gives patients the feeling that they can conquer inclinations, tendencies, even habits, if they only will, merely by firmly resolving to do so, is the best possible mental influence for them. The hypnotic relief is always easier, but nothing that is easy is likely to be of lasting value. The enduring effect of gradual cure by suggestion means much more than the hypnotic miracle that these patients are so prone to crave. At present there is a very general feeling among those who have had considerable experience with hypnotism, that in spite of the claims of certain votaries for it, there is no justification for its frequent or habitual use. It has a definite place in diagnosis, in certain difficult cases, and at the beginning of the treatment of certain forms of the psycho-neuroses. When repeated frequently it is not therapeutic, but is likely to produce serious results in a certain lack of self-control and tendencies to auto-hypnotization with deterioration of character. There is very seldom need of a repetition of deep hypnosis, and, as a rule, all the diagnostic benefit can be secured in one or two seances. Its continued use only illustrates the tendency noted at all times, in the history of medicine, for the unthinking or unprofessional to persist in the application of supposed remedial measures after they have been shown to be useless or even harmful. The subject well deserves further study, but investigations should be carefully made by men who realize the dangers, and who are not likely to be tempted to exploit patients and curious psychological phenomena for the sake of sensational reputation. The use of hypnotism for exhibition purposes, by men who are not physicians, is an unmixed evil, producing entirely wrong impressions on the public, and doing untold evil to the subjects employed. {163} SECTION III _THE INDIVIDUAL PATIENT_ CHAPTER I PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT The most important element in Psychotherapy is the individual patient. Old Dr. Parry of Bath said a century ago, "It is much more important to know what sort of a patient has a disease, than what sort of a disease a patient has." Mental influence is not of the slightest avail against pneumonia or typhoid fever, nor constipation nor rheumatism as such; mental influence may be, and often is, of the greatest possible help to the patient suffering from any of these diseases. We recognize frankly now that for most diseases we can do nothing to counteract the disease directly or to cure it specifically. The idea of specifics in medicine has to a large extent disappeared. Two or three of them possibly we have, but even with regard to these, there are certain doubts as to the essential modes of their activity. We have learned, however, to help the patient to overcome disease. We know how to conserve his forces, to increase his vital reaction, to maintain his nutrition without disturbing his general condition, and to secure elimination in such a way as to prevent nature from being interfered with in her curative purposes. To this, psychotherapy would enable us to add such encouragement of the patient as would tap new sources of energy in him according to the law of reserve energy, and would prevent discouragement and the inhibition of favorable nerve impulses that so often follow. The outcome of any disease depends on two factors. One is the condition of the patient at the time the infection was acquired, the other is the virulence of the infection. We can do nothing to modify this latter element, once the disease manifests itself. We can, however, do much to enable the patient to throw off the disease and, above all, by securing a favorable attitude of mind, we can enable him to use his forces to the best advantage. Anyone who has noted the difference between the patient's state just before and just after his physician has called, though absolutely no physical remedy has been employed, is able to realize very well how much psychotherapy is able to accomplish. One who did not know, would be sure to assume that some potent remedy had been administered--and there has been. This potent remedy is psychotherapy. Whether the personal magnetism necessary to produce therapeutic effects of this kind can be learned or not depends on the individuality of the physician. Undoubtedly, however, everyone can add to whatever of personal influence he has by definitely recognizing its place, by {164} making every effort to employ it, and then by regular systematic effort in securing as much personal information as possible with regard to the patient. This personal relationship of physician and patient makes instruction easier and suggestion more effective. The securing of personal information is of the utmost importance in determining the affections that psychotherapy will relieve, because very often details of life and habits are discovered that can be so modified by instruction as to bring about a disappearance of unfavorable physical influences. It is indeed surprising to find how many unreasonable things people do from habit, from unfortunate persuasion, or from lack of knowledge. In many of the minor chronic ailments that are the source of so much mental discomfort to patients, the physician finds that a change in the patients' habits, not necessarily of marked degree, may make all the difference between cheerful health and rather despondent low-spirited feeling. Now that epidemic disease has become rarer, a physician's practice, especially among the better classes, is much more taken up with these minor ailments than with the typical classical diseases. The ordinary history of their ailments, as patients commonly present them, especially when there are neurotic elements, is likely to be meager in what is objective, but consists mostly of the subjective. Such patients have much to say of their sensations, their feelings, their dreads, their surmises, their conclusions as to their particular condition, and especially the hereditary elements in it, but comparatively little of the objective realities of their ills and of their environment. What the physician needs to know about them is their habits of life, their daily routine of existence, just as minutely as it is possible to obtain the information. There is just one way to get the latter details, and that is to inquire particularly with regard to actual happenings. In chronic conditions of many kinds, it is so helpful that it will always be worth the physician's while to get at these details, especially in supposedly puzzling cases for which various forms of treatment have been already tried. In spite of every precaution in this matter, the physician sometimes finds, after a series of consultations, that some point which when brought to light he considers to be of great importance, has been thought so trivial by the patient that it was never mentioned, in spite of the most careful questioning. In all medical practice the rule is that mistakes of diagnosis are much more due to neglect in eliciting necessary information than either to lack of expertness in diagnosis, or lack of knowledge of the significance of symptoms. In the affections that can be relieved by psychotherapeutics, the most important element for diagnosis, besides a minute knowledge of the patient's habits, is just as detailed information as possible with regard to his ways and modes of thought as to his ills. Practically every motive, as well as every action of the day, must be scrutinized, and often it will be found that little things mean much for the individual. "Trifles make perfection, but perfection is no trifle," as said by Michelangelo, might well be changed for the physician to, "Trifles make all the difference between health and discomfort, though health is no trifle." {165} CHAPTER II THE MORNING HOURS In getting the history of patients for diagnostic purposes the safest way is to begin with the getting up in the morning and then to follow out the various actions of the day. The hour and mode of rising should be inquired into. Practically all nervous people, and nearly all those beyond middle life, feel less fit in the morning hours than at any other time in the day. Apparently as a consequence of their will having been allowed to lose its hold during sleep, it does not secure thorough command over the organism for some time. Nervous people, as a rule, wake up with a tired feeling, a dread of the day, wondering whether life is worth living. They dread--for it is a real dread--to get up and tackle the daily round of life once more. If they have nothing very definite to do, then slight tired feelings or discomfort, even of very minor degree, may lead them to think that they cannot get up. Any yielding in this matter is almost sure to do harm. When there are no objective signs, that is, when there is no fever recognizable by the thermometer and there has been no diarrhea or any physical weakness, nervous patients should get up promptly at a particular hour every morning, because, as a rule, within a half hour after getting up they feel better, and by the time they are washed and have had their breakfast, life has grown not only quite possible but even plausible, and the day's work does not seem such a nightmare as it was at first. It is not advisable to tell people all this as soon as they confess their habit of dawdling in the morning, for they must be gradually brought to discipline themselves. The detail emphasizes the necessity of knowing how they get up as well as when. Mode of Awaking.--It is often valuable to know how patients awake. Sometimes it will be found that they are anxious and solicitous to be at work at a particular hour, or to catch a train at a particular time, and that as a consequence their sleep is disturbed in the early morning hours. At best it may be fitful and when they awake they fear to go to sleep again lest they oversleep. An alarm clock will sometimes remedy this state of affairs. Better still is an arrangement by which someone, who can be depended on, will wake them at a particular time. Occasionally patients cannot content themselves in spite of the assurance that they will be waked. They dread that the alarm clock may not go off, or that the awakener may make a mistake, and so they go to bed with a dominant idea, which is more or less constantly present in their mind during all their sleeping hours, disturbing sleep and preventing complete rest. It may be necessary to insist on a change of occupation for such persons, or a change of residence that will do away with the necessity for early rising. When this is done, many a neurotic condition that has before proved intractable will disappear. Amount of Sleep.--It is of cardinal importance to know how long patients sleep. In our large cities most people have too little sleep. A comparison of the hours when they get to bed with those when they get up will often show that at least three or four nights in the week some patients who are complaining of nervous symptoms, especially nervous indigestion, are {166} sleeping less than seven hours. There are but few men, and still fewer women, who will retain their health under such conditions. Some men have been able to do it, but they are comparatively rare. King Alfred's rule of dividing the day into three eight-hour periods--one for sleep, one for work, and the third for bodily necessities and recreation, still remains the best for human nature. Whenever people try to live the strenuous life and get along on less than eight hours of sleep, they are almost sure, sooner or later, to render themselves uncomfortable, to make themselves liable to all sorts of neurotic symptoms and, above all, to detract from their efficiency for whatever work they are engaged in. Whether they sleep or not, they should be in bed for nearly eight hours. Bathing.--_Morning Bath_.--In our larger cities at least, many of the inhabitants begin the day with a bath. In this matter one finds all sorts of harmful fads that need to be corrected. Many men take a cold bath, and unless they are particularly strong and vigorous, this is rather an exhausting experience for the beginning of the day, when the last nutrition the body absorbed is twelve hours before. On the other hand, large, athletic men who manufacture a great deal of heat, their muscles--the heat-making organs--being well developed, will be benefited by having a cold bath because of the abstraction of heat that it involves. It is not, however, infrequent to find that the man for whom it will be good is not taking it, while the thin, neurotic individual, already exhausting more of his vitality by worry and dieting and in various fads with regard to his health than is good for him, is regularly taking his cold plunge or douche. Unless especially asked about it, few men give particulars in this matter, yet they are extremely important. Women, on the other hand, are likely to take hot baths more frequently than is good for them. Especially when they have maids to assist in dressing and undressing, it is not unusual to find that women take two, and sometimes even three, hot baths in a day. They take them in the early morning when they first get up, and in the evening before dressing for dinner. I have known cases where some took a third hot bath before going to bed and sometimes even put in a fourth before luncheon in case they had had any exercise in the morning hours--tennis, or horseback riding, or the like--that made them perspire. These are details which the physician will learn only if he asks particularly about them. Until he has actually had the experience of finding that they play an important role in some ailment he is almost sure not to think of it. It is probable that even two hot baths a day are too many. I have known women to begin at once to get better of neurotic symptoms that before had proved quite intractable, when their hot baths were limited or when they were changed for a single warm bath with a cold rub after it in the morning, or sometimes just before dinner. Bathing is more liable to abuse than is usually thought to be possible. While the habits of modern life call for it often, and many people are quite sure that they would not be healthy without it, the people who live longest, and who have had the best health far beyond three score years and ten, have usually not been noted for bathing proclivities. The human body is composed of nearly seven-eighths water, and so our cells are constantly bathed in it, but the making of the whole organism a marine animal once more, as seems to be the definite tendency of some people, is not nearly so hygienic as {167} it is often thought to be. Enough bathing for thorough cleanliness, but not for luxury, must be the rule for people who have active work and want to retain their health. _Bathing Fads_.--While such mistakes are usually made only by the wealthy and leisure classes, the physician will sometimes be surprised to find that women who have no maids for personal service are indulging themselves in these over-frequent bathing practices. They have heard that it softens the skin and renews youth, or they have heard that the Japanese take hot baths and are revivified when they are very fatigued, and so they go to great lengths in bathing. Often this is the main reason for the relaxation of muscle tissue and the sense of prostration that has come over them. Neurotic people are constantly going to extremes. Even delicate women will sometimes be found to take very cold baths which are surely doing them harm. Over frequent washings of hands and face are sometimes responsible for skin lesions, especially if the soap used is one of the varieties so scented that the manufacturer is enabled to conceal the impurities in its ingredients. Some women easily run into what is really a misophobia, an exaggerated morbid fear of dirt, and need to be restrained from washing themselves over frequently. Many a chapped hand would be saved by avoiding unnecessary washings, and especially in warm water just before one goes out, for it leaves the skin without its proper oily protection. Clothing.--Then comes the question of clothing. It is curious how irrationally many people clothe themselves. People complain of cold hands and feet when they are wearing thin cotton undergarments, and who need only to have these changed for wool for their feelings to be at once improved. In the meantime they have been persuaded that they have a defective circulation. The usual excuse for not wearing wool is that it produces hyperemia of the skin with itchy discomfort, but this, as a rule, is only passing and is due to unaccustomedness. The coarser wools should not be worn by the sensitive. A thin cotton garment may, if absolutely necessary, be worn next the skin. There is too little variety in the underclothing that people wear. Some change from light to heavy weight and only that, but there should be a medium weight worn, and occasionally, when there is a spell of mild weather in the winter time, even during the season when heavy weight is usually worn, medium weight should be substituted for comfort's sake. It is even more common to find that neurotic individuals, who fear to catch cold, wear too much clothing, especially around the chest. Very often they alternate from this during the day to next to nothing in the evening, and by so doing subject themselves to special risks of internal congestions. When the skin is covered with too much clothing it loses the habit of reacting, and the warmth and the irritation of wool keep up an artificial hyperemia which gradually lowers the tone of the peripheral vessels. Many people wear "chest protectors," as is evident from the prominent display of these abominations in the drug-store windows. By leaving certain portions of the chest unprotected while other parts are kept over-warm, these add greatly to the risk of such disturbances of circulatory equilibrium as predispose to the infections grouped under the term "taking cold." It is not heavy clothing that keeps people warm so much as the layers of non-conducting air between the skin and the outer air. It is better, therefore, to wear three thin {168} garments than two heavy ones because of the additional layers of air that are thus confined. A paper vest, if one is driving in the wind, will probably protect better than the heaviest woolen garment worn. The wearing of chamois garments is not, as a rule, advisable because chamois does not permit free access of air and it hampers transpiration. Before Breakfast.--After dressing comes breakfast, with regard to which it may be advisable to ask many questions. It is well to begin with a query as to whether liquids are taken before breakfast. Many people have taken to the fad of drinking a large quantity of warm water, sometimes as much as a pint, before breakfast. Surely this never does any good and, in most cases, just as surely does harm. Plain water will not dissolve mucus that may have collected in the stomach, and warm water merely dilates that organ, relaxes its fibers, and renders the whole gastric digestive system atonic. If cold water can be borne, it will often be found that a glass of cold water the first thing in the morning stimulates peristalsis, and serves to lessen the necessity for laxatives. Many people complain that cold water is too much of a shock. Usually, if they are reminded that when we want to warm our hands we rub them vigorously with cold water and that the reaction after this gives a healthy glow, the effect of the supposed shock, which was merely an unfavorable suggestion, will disappear. Sometimes delicate people cannot drink cold water. If there is any reason to suspect an accumulation of mucus in the stomach, a small bouillon cup of _very hot water_, just as hot as it can be borne, in which a pinch of salt and a pinch of bi-carbonate of soda have been dissolved will prove an excellent aperitive for the day. This is physiological and appropriately chemical, as well as naturally stimulating. Mucus does not dissolve in ordinary water but dissolves readily in an alkaline salt solution, and this is just what is thus recommended. This drink is quite grateful to the palate. Indeed, it tastes very much like clear soup, and, if the eyes are closed, cannot, as a rule, be distinguished from some of the bouillon commonly served. I have known this cup of hot water to stimulate an appetite when drug tonics had failed. It is better to take the glass of cold water from fifteen to twenty minutes before the morning meal--say immediately on rising. If, instead, the small cup of hot water is chosen, it should come immediately before eating, and will usually prove an appetizer. Breakfast.--The exact details of the amount of breakfast taken and how it is eaten should be known. Nervous people eat little breakfast. When ordered to eat, they find it difficult at first, but the habit is easily formed, and then they want their breakfast like anyone else. It is surprising how often physicians will find that nervous persons, who are under weight, are not taking enough breakfast. They will ordinarily say that they are eating breakfast about as other people do and will, perhaps, mention eggs and rolls, but it will be found that their ordinary breakfast consists of a roll and piece of toast and coffee, and only occasionally do they have any of the other things mentioned. Breakfast is ordinarily the meal which those who work are likely to eat too hurriedly. Those who are neurotically inclined are especially victims of the habit. They lie abed until there is only a few minutes left to get the train so as to reach their place of occupation in time, and thus their breakfast is {169} skimped. Their oatmeal or other soft cereal is fairly shovelled in, coffee is gulped, toast is unchewed, the coffee softening it; if they have creamed potatoes they are swallowed in such large pieces that, as every physician knows, if for some reason they vomit they are surprised, beyond all measure, at the large portions they have been able to pass down into their stomachs. A breakfast thus eaten makes a bad beginning for a nervous man's day, and the more that is so eaten the worse for the victim. With a habit like this, it will be utterly impossible by means of drugs or directions as to diet to relieve the discomfort of neurotic indigestion, or to keep the patient from suffering that stomach discomfort so often complained of in the morning. Working Women.--Working women are even more prone than are men to take a hurried breakfast, and having, as a rule, less appetite than men, their meal is likely to be deficient. It is not unusual to find that a young woman who is under weight and who needs three meals a day, is taking so little for the first meal that even she hesitates to regard it as a meal. Very often her last previous meal has been taken before seven o'clock the night before, so that she goes out ill prepared for her day's work. Much more than men, women are annoyed in the morning by our transportation systems, and by worry as to whether they will get to the office on time. Suggestions as to the modification of this unfortunate routine, the taking of an earlier train, the using of a quiet local instead of a crowded express, a short walk at least before taking the train, will often help in producing a marked change in the general health. Home Keeping Women.--For those who really have homes, the morning duties are usually sufficient to rouse their activities and make them begin the day well. For those who live in apartment-hotels, however, and for those who have the luxury of many servants, the morning hours are often a serious problem. Madame does not get up, or if she does, it is only to lie around in dressing gown for most of the morning. Breakfast is easily neglected or may be eaten hurriedly because the head of the house is rushing to business. The lack of an incentive requiring them to rise, and get outside for a time every morning, is probably at the root of more feminine symptoms among leisure class patients than anything else. As we grow older all of us are likely to note the lowered physiological cycle of the morning hours, so that unless there is some sharp reason to compel action, we are rather prone to persuade ourselves that it is better to lie abed, or at least to loll around. This leads to a concentration of attention on self and on one's feelings that easily gives rise to neurotic conditions. Interest in life.--In my special clientéle I have often found that going to church in the early morning hours was an excellent remedy for many of these patients. It gives them a definite reason for rising promptly, the service provides motives to rouse them to activity, they are likely to think during it of how they shall make their life a little bit more livable for others as the result of their trying to be better, and so the apathy that is so fruitful of ill feeling is shaken off. This can only serve for those who have faith in the service. For others, the old-fashioned going out to market, or the making of appointments at morning hours that will tempt them to regular activity early in the day, is of special significance. It is always ominous for health when a woman can look forward to a whole long day without any particular duties {170} in it until the late afternoon or evening hours. This has become so frequently the case for the women of our large cities, particularly those who live in apartment hotels, it is no wonder that neuroses and psychoneuroses of various kinds have grown in frequency. The best prophylaxis for them is occupation of mind. The cure for them is the securing of many interests and such diversion of mind as will prevent concentration of attention on self. Mail Before Breakfast.--Many people receive their most important mail in the early morning, and personal mail, in cities especially, is likely to be placed beside the breakfast plate. Not infrequently, letters contain serious matters that are likely to disturb people, and occasionally even important business finds its way to the side of the plate at breakfast time. Authors often find their rejected manuscripts sent back in the morning's mail. Occasionally bad news of other kinds comes in this way, and, as a rule, it is the very worst time for its reception. The human system--it cannot be too often repeated--is at its lowest physiological term in the morning, the temperature is lower than during the rest of the day, all the nervous vitality is below the normal. Half an hour after breakfast the reception of bad news, or the coming of important matters requiring decision, would not make so much difference. Hence, the necessity for knowing whether the mail is ordinarily read in the early morning, in order to know something about people, and about the consumption and digestion of their breakfast. Company at Breakfast.--Pleasant company during meals is an important factor that makes for good digestion. At the other meals there is much more likelihood of having such pleasant company, while the morning meal is often a solitary, and quite as often as not, a rather glum quarter of an hour, preoccupied with the business cares of the day. As may be readily understood from our discussion of this problem of mental preoccupation during digestion, this may seriously hamper digestive processes. Often men take refuge in their paper. The thoughts aroused by reading the modern newspaper are not the pleasantest in the world and consist, very often, of the following out of details of hideous crimes and scandals. When, as is sometimes the case, these scandals concern relatives, friends or acquaintances in whom we are interested, and with regard to whom we feel poignantly because of the publicity involved, nearly the same effect is produced as when bad news is received in letters, or when business worries are thus brought to the breakfast table. The best conditions for the eating of breakfast are those in which it becomes like the other meals, a family matter. When father, mother and children eat their breakfast together, nearly always family interests and especially the enlivening effect of the joyousness with which children face a new day is the best possible tonic for a business man in whom a solitary breakfast starts a day of digestive disturbance. Sociability and sufficient time must be insisted on, whether at home or in a boarding house, at breakfast as well as the other meals, and it will often be surprising to find how much difference this makes both as regards the quantity eaten and the digestion of the food. Morbid Habits.--In matters of diet, it is important to ask for details, for it is surprising what unexpected things may be discovered after weeks of treatment. That was illustrated for me once by a case of persistent acne in a young girl, which all the ordinary remedies failed to cure. I felt sure that {171} I had given her such explicit directions with regard to diet that I knew exactly what she was taking and that nothing could be hoped for from any change. As a last resort, I asked once more with regard to all that she ate and only then discovered that before breakfast every day she ate a baked banana. It had been recommended to her by a friend as a sure cure for constipation, she had formed the habit of taking it as a medicine, and so had not spoken of it. Baked bananas agree with many people well, but just as soon as this was eliminated from her diet her acne began to improve and before long had disappeared almost entirely. The taking of large amounts of warm water, already spoken of, is another of these morbid habits. Then many people take a glass of salt water, or laxative water, and some have curious habits with regard to the eating to excess of salt on cereal or on fruit, or sometimes they eat too great a variety of fruit. All this should be known, but often will not be ascertained unless particularly inquired about. CHAPTER III THE DAY'S WORK Probably even more important than details with regard to the early hours of the day, is detailed information as to the day's work, the kind and character of the occupation and the length of time spent at it, the interruptions that may occur, the habits with regard to luncheon, and, above all, the state of mind in which the occupation is pursued. The physician will only learn these details when he sets before himself a definite schedule of what he wants to know, and then proceeds to secure information with regard to it. With this sufficient can be learned in a short time to ascertain the source of the affection or the symptoms complained of. In some cases it is, however, only when the whole day's occupation is reviewed that proper suggestions can be made. Getting to Work.--Many a man, especially if he has been accustomed to much exercise in younger years, craves muscular exercise, feels much better whenever he has the opportunity to take it, yet rides down to business every morning and back every evening. On his vacation in the summer time, he gets up early for the sake of a morning walk, but he scarcely has time to take his breakfast and ride to business at other times, though the main reason for his better feeling during his vacation is his exercise. There is usually the story of crowded cars in the busy hours, often with annoying thoughts pestering him that he may not be in time and with a constant call on nervous energy while he stands up in the train, jolted, pushed, crowded, or unable to read his paper with satisfaction, even if he has a seat. The discomfort experienced during a ride in crowded cars to business is about as bad a way to begin a day for a nervous person as could be imagined. As a rule, it will take more than half an hour to get to business in this way. If an extra twenty minutes were taken, it would be possible to walk the distance. On at least two out of every three days in the year this would give a magnificent opportunity for exercise of the best kind, for fresh air, {172} for diversion of mind, for the route could be frequently changed, and, during the spring and fall, if there are parks on the way, these would provide occasion for pleasant thoughts to replace the annoyances which too intimate contact with over-strenuous humanity in overcrowded cars is likely to occasion. This seems almost too trivial for a doctor to talk about, but it is on the care of trivialities that good health often depends. It is easy to assume that this amounts to little for health but tempt a dissatisfied patient, whose digestion and sleep are disturbed, to do it, especially in the spring and in the fall, and see what a difference it makes in all his physical functions. If he is not used to walking, he will have to begin by walking only a mile or two, but after a time he will do his four-mile walk in about an hour, with no waste of business time, and with a renewal of energy that will seem little short of marvelous. Details of the Day's Work.--If patients are to be benefited through mental influence it is extremely important that details as to occupation be completely secured. This must include, especially in cases where there are objective but obscure symptoms, minute information that may seem trivial, and yet which often proves to be of great importance. In recent years there has been profound study of the dangers of trades and occupations. Anyone who wants to treat nervous patients, must know much about these occupations, for otherwise symptoms may be ascribed to old infections, to obscure rheumatic conditions, to intestinal auto-intoxication, or to nervous weakness or exhaustion, when they are really the result of occupation-conditions. The various poisons must be carefully looked for, or affections will be wrongly treated. I have had a series of cases of lead poisoning [Footnote 22] under most unexpected conditions which have taught me much as to the possibilities of obscure plumbism. Lead poisoning from new lead pipes--with no one else in the household suffering from it, lead poisoning from frequent drinking of carbonated waters, the bottles of which had the old-fashioned lead stoppers, lead poisoning from the painting of a flat by a settlement worker who could not get a painter to do it, show how carefully such things must be looked for. [Footnote 22: "Curiosities of Lead Poisoning," _International Clinics_, Eighth Series, Vol. II.] _Dust and Respiratory Affections_.--Mechanical conditions connected with trades are especially important. Workers in dusty trades are almost sure to suffer severely from bronchitis at times, and to have the affection oftener than others, to have it "hang on longer," as they say, and eventually to have tuberculosis develop. There are some of the polishing trades in the metal industries in which it is impossible to maintain the ordinary death benefit fund that workmen have in other trades, because the men die so frequently and at such an early age from consumption that the drain on the treasury makes it impossible to maintain the fund. Practically all of the dusty occupations have this same tendency. This is true often in occupations where dust is sometimes not supposed to be much of a factor. Railroad trainmen suffer more frequently from colds than do those in other trades because of the dust to which they are exposed, and a trainman with incipient consumption will be greatly benefited by getting out of the dust during the summer months. Sweepers in large buildings, janitors and janitresses have colds that are often untractable because of the dust in their occupations. It is to be hoped that {173} the new vacuum cleaning system now becoming so popular will obviate these dangers, though like all improvements, it will probably bring its own dangers with it. _Lack of Light_.--People who work at occupations that keep them from the light are likely to suffer from lung symptoms and to have quite intractable colds which will not clear up until they get more sunlight. Workers in theaters and like places who do their sweeping where sunlight does not penetrate, are in more danger than others from respiratory disease. Those who work in gloomy lower stories, especially in narrow but busy and dusty streets, suffer the same way. Attendants at moving picture shows who work much in the dark where the frequently changing crowd brings in dust which cannot be well removed, and in quarters where the sun does not penetrate, are almost sure to have persistent repeated respiratory troubles. _Habitual Movements_.--After the question of dust comes the mode of the occupation. Many occupations demand certain habitual and repeated movements. When people come complaining of pains in muscles in and around joints, or of achy conditions in the limbs, it is important to know every detail of their occupation movements, if the physician is to appreciate just what pathological causes are at work. It is not enough, for instance, to know that a man is a clerk, or a bookkeeper, but it should be asked whether he stands much at his occupation, or walks considerably, or whether he sits practically all the day. If he stands much, we can expect that he will have various painful conditions in his feet and legs, unless he takes care to change his position frequently, to wear the most comfortable shoes obtainable and, above all, to provide against any yielding of the arch of the foot. Often it will be found that people who complain of discomfort in the feet stand much on a cold, and sometimes damp and draughty floor, and this needs to be corrected or their symptoms, often carelessly called rheumatic, will not disappear. If he sits down always during his occupation, he will need exercise and air or he will suffer from many vague discomforts, over sensitiveness and irritability of nerves, as well as from physical conditions. Most patients prefer to think that they are suffering from some constitutional condition, rather than from a merely local manifestation due to their occupations. Those who have to stand much can often make such arrangements as will permit their sitting down from time to time. They may, if they are standing at a desk, have a high stool; they may during their hour of lunch sit down restfully, or even to recline for a time, so as to restore the circulation in the legs. For many people who suffer from the achy discomfort connected with varicose veins in the leg, a rest of half an hour in the middle of the day with the feet a little higher than the head, will do more than anything else to make them comfortable. This same thing is true for people with flat-foot, and there are many occupations with regard to which advice of this kind will be appreciated. The well known tendency of many men to sit with their feet higher than their head is not a mere caprice, but is due to the fact that this is an extremely restful posture and thoroughly hygienic for those who have been standing much. Unfortunately, it is not so easy to secure such relief for working women, but occasionally the advice to lie down during the middle of the day on the couches of the retiring rooms may be the best medical prescription that can {174} be given. This will carry young women over trying periods of the month when everything seems to be going wrong. In women particularly, if there are complaints of the pains in the lower limbs, footwear must be investigated. When the heels are too high those who have to stand much are thrown forward and there is a strain of the muscles of the thighs and on the muscles of the back. Many young women suffer from backache supposed to be due to internal conditions usually of gynecological character, when it is only due to high heels or a combination of high heels and constipation. On the other hand, heels that are too low are not comfortable and women's shoes, in spite of the outcry against them, have been better adapted than men's to prevent them from developing flat foot. Fewer women than men suffer from this affection. Shoes that are too loose are almost as bad, sometimes it would seem worse, than those that are too tight. _Habitual Motions and So-Called Rheumatism_.--The habitual movements of various trades are extremely important for the diagnosis of conditions that develop in the muscular system. Much of the so-called rheumatism of the working people is really due to the muscular over-activity demanded by their trades. This affects all kinds of working people. Men who have to work foot-lathes, or women who have to work sewing machines, or men or women who have to use their arms much in repeated vigorous movements, are likely to suffer from achy discomfort. The strong and healthy ones do not suffer, but the delicate do. The suffering is much more prevalent in rainy, damp weather; it is worse during the spring and fall than at other times. It is particularly noticeable whenever the patient is run down physically, is worrying about many things, or, above all, is getting insufficient nutrition. The discomfort is particularly likely to recur in those who do not know how to use their muscles properly, who are naturally awkward, and who perhaps have from nature an insufficient control over opposing and coödinating muscles, so that they do not accomplish movements quite as readily as would be the case if they were normal. The personal element enters largely into these affections. Many patients, however, can be trained to do their habitual movements under the best possible mechanical conditions, whereas very often they are found accomplishing them under the worst possible mechanical conditions. Men who have to do much writing may have to be taught the application of Gowers' rule, that the forearm should so move as a whole during writing that if a pen were fastened to the elbow it would execute exactly all the movements of a pen held in the hand. The writing must all be done from the shoulder. People who do typewriting may have to be instructed not to allow the machine to be too much above them, nor on the other hand, too much below them when they sit down. Young people particularly who, from long hours of practice on the piano, suffer from neurotic conditions, may have to be instructed to do this under good mechanical conditions. Men who do much filing of metal will often suffer from painful conditions in the arms. These will be much worse in case the filing is done at a table or workbench so high that pressure has to be brought to bear upon the file by the arms instead of through the weight of the body. This same thing is true for women who iron much. If the ironing board is so high that the additional pressure applied is made by the arms, then painful conditions will {175} almost inevitably develop if the work is long continued. These details are discussed in the chapters on joint and muscular affections. Night Work.--In a large city there are many workmen who are on night duty. They will be disturbed in many ways in health, unless they make special arrangements to live under conditions that enable them to have full eight hours of sleep every day and, above all, to have their meals regularly. When they come home in the morning they usually have a rather hearty meal. Most of them can sleep very well with this, but very few of them sleep the full eight hours, and all need this amount. Usually they have another full meal about five in the evening. Very often it will be found that the third meal of the day consists of a sandwich, with a glass of milk or a glass of beer, and some cake or some crackers and cheese, or the inevitable pie. Every workman should have three full meals, and a man who is suffering from almost any symptoms will be improved at once if the third good meal is insisted upon. At one time I had occasion to see a number of men whose work began not later than seven in the evening and did not finish until six or seven in the morning. They were sufferers from all sorts of complaints. Most of them were under weight. Not a few were constipated. Some were suffering from severe headaches that came rather frequently, and a few from a headache that was severe but came only every two or four weeks. These patients alternated night and day work, and it was the week after they had been on day work, and first went on to night work, that they suffered from headache. In every one of these cases instructions with regard to eating and sleeping proved to be the best remedy. Nearly all of them were not eating enough, and were skimping the third meal. Three of them were taking only between four and five hours of sleep. They stayed up after breakfast to read the paper, went to bed about nine and got up about two o'clock. Just as soon as two or three hours was added to their sleep, they began to feel better, and various symptoms, digestive, rheumatic and nervous, of which they complained, began to disappear. Nearly always night workers are more prone than the ordinary run of workmen to some indulgence in spirituous liquors. Cold and shivery on the way home from work in the early morning, they take a nip of whiskey to brace them up. Alcoholic cirrhosis of the liver is a little more common among sea captains, policemen, printers and night workmen on the railroads than among the average of the population. The reason for it seems to be that undilute whiskey is thrown into the circulation by being taken into the stomach at a time when that viscus is empty and all the cells are craving food and drink. It is carried directly to the liver, and there either produces or predisposes to the bad effects upon liver cells which we know as cirrhosis. It is usually useless to treat such men for the indigestion and other symptoms that are likely to develop as a consequence of their habits, without getting at their story completely. It is easy, as a rule, to relieve them of certain of their symptoms by ordinary drug therapeutics. Unless their habits are changed, this relief, however, is only temporary. It must not be forgotten that in recent years women have come to do a good deal of work at night that was not usual to them before. In the telephone service of certain cities, as cashiers in restaurants, as ticket sellers in various places of entertainment, {176} as office help at busy seasons of the year, women may be kept occupied either all night or at least until quite late. Not infrequently during times when rehearsals are on, chorus girls are kept until the wee small hours. They are particularly likely to suffer from such variations in normal habits, and no treatment is so effective with them as pointing out how they must live, if they want to preserve their appearance and continue in such exacting occupations. A healthy young woman can burn the candle of life at both ends with less protest from nature at the beginning than man, but she suffers more for it and the suffering begins sooner. Positions During Occupations.--The question of position during occupation, especially as regards its influence upon digestive processes, has always seemed to me much more important than most people think. Our idea of digestion has been so largely one of digestive secretions, to the neglect of the motor side of the gastric and intestinal functions, that we have missed some important points. If a person leans over a desk shortly after a meal, there is no doubt that the crowding of the abdominal viscera hinders peristalsis, at least to some degree, not of course in the robust and healthy, but in those who already have some irregularity or sluggishness in this region. The old high desks at which many clerks used to stand, at which even proprietors did not hesitate to take their position, had a reason in common sense that has been forgotten in the modern times, and the variation of position thus permitted seems to have been good for the workers. A good deal of comfort may be obtained by having a suitable desk and chair for business hours. Not infrequently it happens that a desk is too high for comfortable writing. Any discomfort that is continuous and makes itself felt intrusively during occupation with other things, will have an unfortunate effect. Such things seem trivial by contrast with serious disease and may seem safely negligible. Trivial they are, but little things count both in themselves and as to the attitude of mind which they occasion. It is the attitude of mind that we try to modify by psychotherapy, and even the removal of little sources of annoyance help a patient materially to get through life more happily and through work more efficiently and without any more discomfort than is absolutely unavoidable. _Positions After Meals_.--While we have talked thus of business people, what is said refers, also, to the positions assumed out of business hours, as, for instance, at home after dinner. A Morris chair that permits of a somewhat reclining position, or a rocking chair that temps one to sit back, pretty well distending the abdomen and giving all due play to the internal viscera, will be found not only much more comfortable than a straight-back chair which tempts a man to lean forward, but also there will be less interference with gastric motility, the most important digestive function of the stomach. Arm-chairs which really support the arms, and therefore tend to keep the shoulders up, have something of the same effect. We naturally assume these positions, though occasionally social usage forbids them. The tendency, for instance, for elbows to be put on the table, especially toward the end of a meal, represents a natural instinct to lift up the shoulders and keep the weight of the upper part of the trunk off the abdominal organs. Children's instincts often curiously guide their postures--as is illustrated by the story of the little boy who, when asked by his grandmother if he could manage {177} another tart, said that he thought he could if he stood up. (See chapter on Position.) Mental Conditions of Occupations.--While the details of manual occupations have to be learned with great care if we are to modify the conditions so as to prevent certain unfortunate effects, just as much care has to be exercised, with those not employed manually, in finding out details as to mental worries, and the various disturbances consequent upon business conditions. Many a man has not brain enough to run his business and his liver. This is the old English expression, and the liver, as the largest of the abdominal organs, is taken for the physical life generally. Many people have not vital energy enough to waste any of it on worries and then be able to complete their digestion and other physiological functions with success. The preceding mental condition is a predisposing cause of many a purely physical ailment. It used to be said that during a cabinet crisis in England, or rather just after it was over, attacks of gout were most frequent among prominent politicians. Mental influence usually kept the attacks off until the very end of the crisis. Merchants come down with pneumonia or digestive disturbances more frequently during periods of acute business depression. Physicians are attacked by pneumonia, or influenza in bad form, after they have been wearing themselves out in an epidemic and worrying about patients. Just after a mother has nursed a child through a severe ailment she herself is prone to suffer from some acute infection. Such common-place infections as boils, styes, abscesses and even the more serious osteomyelitis are likely to come at these times. It is important, then, to know as much as possible about a business man's affairs. Any one who has had a series of tuberculous patients (who were getting along quite well in spite of latent or even active lesions) disturbed by anxieties of one kind or another, knows how much worries may mean. Men will lose weight and appetite and weaken in their general condition as a consequence of some serious business incident, while all the time physical conditions are the same as they were when they were improving. And it must not be forgotten that even in those who do no physical labor, there may be physical conditions of their occupation that are important. Many a business man does his work cooped up in a small office, with insufficient ventilation, and sometimes, especially where his business is on the ground floor of a large building, with so little sunlight that his environment is quite unhygienic. The great air purifier is sunlight. Unless sunlight is admitted for hours every day to the rooms in which people live, the dust that is inevitably breathed will contain living germs, active and noxious, though had they been exposed to sunlight these germs would be harmless. Especially then for people with respiratory defects of any kind, whether these be tuberculous or of chronic bronchitic character, the conditions surrounding the occupation should be carefully inquired into. Once the family physician knew such things as a matter of course. Now he is likely to know very little. The lack of such information may not be important for the more serious conditions that he has to treat at patients' homes, but they usually mean much for the submorbid conditions, so to say, the discomforts and chronic conditions, which come for office treatment. They mean much for comfort in life, and for the conservation of health and strength. They {178} represent that newer medicine which people are asking of us now so much more than before, which shall keep them in good health and prevent them, as much as possible, from suffering even from minor ills. Business Habits.--The modern idea of having a flat-top business desk, instead of a roll-top desk, and having it thoroughly cleared off every evening, so that each day's work does not accumulate, is an important psychic factor in the strenuous life, which in recent years many corporations have been taking advantage of. It is well for those who are their own masters to realize the value of this principle. Nothing so disturbs the efficiency of work, nor adds so much to the incubus that work may become, as having a number of unfinished things which keep intruding themselves. It is not always possible to dispose of problems, but discipline is necessary to keep us from pushing business matters aside. Then they have to be done in a rush, very often at a moment when other things are also pressing. The result is poor work, but, above all, a waste of nerve force and energy that leads up to nervous symptoms and eventually nervous exhaustion. The orderly man, who has learned to settle things as they come up, or at definite times, can accomplish an immense amount of work. Some men are born orderly, but any one who wants to do much work must have order grafted on his makeup--a habit which can be made a second nature. It may seem that a physician is unwarranted in intruding on a man's business affairs thus to inquire about the ways he does things, but this is the difference between psychotherapy and the regulation of life as compared with cures by more material but less effective means. Personal Hygiene.--Expert Advice.--For many men who are much occupied with business, the best possible safeguard for health, as well as the best guarantee against nervous or physical breakdown, would be a detailed consultation once a year with a physician regarding their habits of life and their business in relation to their health, present and future. In recent years many a business firm has found it not only expedient but profitable to turn to an expert accountant or auditing company and ask advice with regard to the management of its business. It is often found that certain business customs are causing serious drains, and that there are newer ways of doing things that save time and money. Sometimes a reorganization of the accounting system, or of the method of dealing with credits and debits, or the receiving or shipping department, proves advantageous to the business. Sometimes it is found that the capital invested will not justify the extension of business that is proposed, and not infrequently it is shown that a proposed extension adds to business movement but does not add to profits. Sometimes there are departments that can be dropped to advantage, though they seem to be adding to both business and profit. All of this may well be transferred to the question of health in its relation to business. Not infrequently it is found that the capital of strength of the business man is not sufficient to justify the extension that he is planning or has already attempted. Sometimes suggestions can be made with regard to the mode of doing business, the hours employed and the hours of relaxation, that will make business less of a drain on the system. Occasionally arrangements for sleep and exercise, as well as for afternoons or special times of diversion, may save a man from that concentration of attention on one thing {179} which frequently leads to nervous breakdown. Not infrequently business men who are of neurotic habit have customs of doing business which add to their nervous irritability, and these might be modified so as to lessen the call on nervous energy. There is need that the physician be looked to as an expert in personal health and its relation to business, just as the expert accountant or auditing firm is looked to for advice with regard to business methods. CHAPTER IV THE MIDDLE OP THE DAY Information regarding the mid-day meal will be of value to the physician in many cases. In cities, luncheon, likely to be rather an apology for a meal, is taken rapidly, and immediately there is a return to work. As a medical student in Vienna, I was much interested in the mid-day meal of the bankers and merchants of the old Austrian capital. At that time--I hope they have not changed the good custom since--the banks closed at 12 o'clock and did not open again until 3 o'clock. This gave time for taking the mid-day meal in comfort, and for a proper interval for digestion. In all the southern countries of Europe, for seven or eight months in the year at least, little is done during the two or three hours in the middle of the day. The people get up earlier and rest at mid-day as a break between the afternoon and morning. It is quite beyond expectation that anything like this will ever again be possible in the great commercial cities. The fact that this was the custom of our European forefathers, however, shows how business has obtruded itself on the habits that man would naturally form for himself. Business men hurry to luncheon, or if they take any time over it, it is because they have invited some one to lunch with them with whom they wish to talk over important matters. This means of saving time recalls the well-known expression of James Jeffrey Roche: "Time is money. Every second saved from your dinner now is a sequin in your doctor's pocket later on in life!" Hurried Lunch.--The seeds of our frequent American dyspepsia are sown partly at the hurried breakfast and then at the hurried mid-day lunch. When a physician finds this to be the case, then the patient's habits must be reformed. Otherwise there is little prospect of relief from neurotic digestive symptoms, or from those uncomfortable feelings so often supposed to refer to the heart, or other important organ, when digestion is interfered with. There should be pleasant company at luncheon if possible; it should be preceded by fifteen or twenty minutes in the open air, with, as far as possible, complete seclusion from business thoughts so as to allow the stomach to secure its share of blood, and it should be followed by at least half an hour of pleasant occupation that does not call for serious mental work. This may not be possible for every one, and many will complain that this is asking too much in our busy time. We physicians are not here to make the nice customs of medicine courtesy to great kings of finance or to the busy tyrants of the professions, but to tell them what we think should be {180} done in order that nature may not be abused. Men should be advised to take their luncheon in some building different from that in which their offices are located, or, if they eat in the same building, to go out on the street for a while before the meal. In the old days men used to call on one another in order to transact business, and these little trips were often made just before or after luncheons. Now the telephone and the messenger boy have done away with this, with a great saving of time, but with an increase of intensity of labor that makes for nervous exhaustion. Luncheon clubs are excellent things when men do not talk shop, but they have one fatal defect. Almost invariably they lack simplicity of menu, and, because of the variety supplied and the example of others, there is a tendency to eat to excess. A game of billiards after eating is often excellent, because, when standing, digestion is accomplished with more comfort than when seated. A walk after the lighter midday meal is a good thing, though the old saw said "after dinner sit a while," but that was in reference to the largest meal of the day, and may still hold good for the evening meal, which is likely to be the heaviest one. Women's Lunch.--Women are very likely to take their mid-day meal, when it is their luncheon, very irregularly. If they have to get it for themselves they are likely to be satisfied with almost anything. If they get it outside the house they are likely to take it rather late, so that if they have breakfast before eight o'clock, this putting off of the next meal causes some disturbance of the economy. When the stomach gets to be empty, either there is a tendency to swallow air, or there is a rumbling sense of fullness that disturbs the appetite, or the appetite itself is capricious, and a headache develops. How many headaches are due to missed meals it would be hard to say, but this is one of the most fruitful causes of the ordinary passing headache. Delicate women, and especially those who work, are likely not to eat enough luncheon. All the details with regard to this meal must be known or the physician will find it hard to get rid of many neurotic symptoms, particularly in working women. The same thing is true for the so-called society woman, since she is likely to have a late breakfast and then skip her mid-day meal. This is permissible if she is so stout as to be able to spare it, but it is all wrong if she is thin and needs every ounce of weight. Nature of the Noon Meal.--During the last two generations fashion, custom and the increasing demands of business have pushed the hour of taking the principal meal farther and farther away from mid-day. There are, however, cases in which it seems better that the principal meal should be taken in accordance with the old custom, about noon time. For tuberculous patients this is especially important. They often have fever in the afternoon that seriously disturbs appetite. They may eat with comfort and relish a couple of hours before the fever is due. For delicate persons, especially those who have not much appetite for breakfast and who can not be persuaded to eat a sufficient amount early in the morning, a hearty meal at noon is almost a necessity. They should be shown how low their nutrition is during working hours. Their principal meal of the day before was taken between six and seven o'clock. They have had a light breakfast, a meager lunch, and naturally have little reserve force during the afternoon hours. As a consequence they become overtired, this lessens the appetite, they do not eat properly, and, {181} above all, they do not digest as well as they would if their last good meal were not so far away. They are suffering from inanition, and, as is well known, starving people cannot be allowed to eat heartily, because their stomachs have not enough vitality to digest well. It is often difficult to change the hour of taking the principal meal, but in special cases this can be done with decided advantage. I have seen such a change make all the difference between slow recuperation from bad colds, and have seen it of the greatest possible importance in tuberculosis. The very changing of the hour will sometimes suggestively react to make the patient eat more heartily than usual, the day is broken up better, the reaction against the morning discouragement comes earlier, and the patient's general condition improves. Many people rest better at night if their principal meal is taken at the middle of the day. CHAPTER V THE LEISURE HOURS. Then comes the return from business. Here once more the ordinary method of getting on a crowded train, standing up to be pushed and jammed, to have all sorts of unpleasant things happen, to have the pessimism of one's nature stirred to its depths by the utter disregard for women, the heedless rush of men, the roughness of railroad employees, and the general lack of humanity that characterizes the evening rush from business in a large city, is eminently unsuitable as a preparation for dinner; while a calm walk of three to five miles is ideal. To walk home will probably take twenty minutes or half an hour longer, but not more than this--and it avoids the undesirable features of the usual method. Gymnastics.--Occasionally one finds that men rush through the last hour of business in order to spend an hour in a gymnasium. Often this is quite undesirable. Exercise within doors, taken in a routine manner and merely for the sake of exercise, with no diversion of mind, is eminently unsuitable for the busy man. What he needs is air much more than exercise. Walking out of doors is the very best thing for him. If he walks at a rapid pace, swinging his arms a little freely and carrying a cane in one hand and perhaps a book in the other, because this exercises his fingers and keeps him from having any unpleasant congestion of the hands when they hang down, then the exercise is almost ideal. Owing to the novelty of it, and the interest that a new occupation arouses, great benefit will at first be derived from the gymnasium. Very often, too, the cold plunge after the exercise does more good than the exercise itself. The plunge is real fun, especially when taken with many others, but the exercise itself is likely to degenerate into the sorriest kind of a task. If the man who walks home will take a bath before dinner, the temperature of the water being made suitable to him and the reaction that comes to his particular nature, there is no need of anything else, and there is nothing better that he could do. The walk must be varied. The course must not always be through the same streets. Occasionally it {182} should even lead one to see some monument or new building, or to go out of the way with a friend, so that variety is introduced. Work at Home.--There are men who in busy times take some of their work home with them. This is a mistake. And though it is the custom to tell the doctor that they cannot do otherwise, it is practically always a bit of self-deception. When the case is properly put before them, they realize, if they already have any neurotic symptoms, that to continue home work will be a serious risk. Most men who carry business home with them, easily get into the habit of pushing certain details away from them during the day with the idea that they will have more time for that in the evening. They do a certain amount of dawdling over their work. If they really resolved to finish work during business hours they could do it, and do it better than during the evening at home. Six hours of work is about all that a man ought to do with his intellect at high pressure. This should be pretty well divided into two periods of three hours each, with an interval of an hour to an hour and a half between. The nearer a man can come to this arrangement the better for him, and the better, also, for his affairs. If he has assumed obligations that require more of his time and attention than this, he is trying to do too much. After-Dinner Hours.--The evening hours and their proper occupation are important for the business man, or for anyone who is much occupied during the day. The temptation to let the work of the day run over into the evening must be overcome at all costs, or it will prove serious for the health of most men. It is important as far as possible to get something completely different for men to do at night. Many men settle down to the reading of a newspaper or of a magazine or novel. While this does very well under some circumstances, reading does not provide diversion whenever there is serious worry or solicitude over business matters. A man may think that he is occupying himself with the newspaper, but we all know very well that business cares intrude, that business troubles are often doubled by reading about others. The reading of novels does well for a while, but the serious-minded man tires of them and then, while they may occupy a couple of hours, they have exactly the same objection as the newspaper. A genuine diversion should give the physical basis of mind an opportunity literally to remake itself by storing up new energies. _Amusements_.--The fact of the matter is that a man must have, if possible, some other serious interest in life besides his business. He must have a hobby. We have discussed this in the chapter on Diversion of Mind and refer to it here only to indicate the importance of knowing something about a man's recreation as well as his work. It is not a casual occupation but a real interest that he should have. This need not necessarily be a useful employment and, indeed, it may be absolutely useless provided it is absorbing. Card playing is an excellent diversion for many people. When joined with gambling, new worries and feverish excitement usually make it harmful for neurotic persons. Chess is hard work, but of a different kind from that of the day and, therefore, often makes an excellent recreation. Any games are good. Bowling, for instance, is excellent, and billiards, if a man has an interest in it, is a fine sport for evening hours. It has the added advantage of physical exercise. A man does not sit down during billiards, crowding his {183} already well-distended abdominal viscera, but walks around and gives his viscera a better chance for their work and aids rather than retards peristalsis. _Encroachment on Sleep_.--There is just one defect about some of the more absorbing recreations--they keep a man up too late. Whenever a so-called recreation takes up such time that a man has less than eight full hours in bed, then a mistake, almost sure to be serious sooner or later, is being made. When the physician tries to limit a man's recreation by suggesting an earlier hour for retirement, he may be told that his patient must have some time for diversion and recreation. But the physician must insist that no form of recreation is as good as sleep, and any other form must be limited in order that sleep may be obtained. A man may easily regulate his affairs so that he shall have eight hours of sleep, and it is only negligence of such regulation that gives him the idea that recreation cannot be obtained except after eleven o'clock at night. Little suppers after the theater are often fine diversions, but whenever they interfere with sleep they must not be allowed except at long intervals. Other diversions that keep a man out of bed after midnight are sure not to do good in the long run, though an occasional lapse in this matter may prove a stimulant rather than a depressant. It is custom that must be regulated; an occasional variant from it is rather good than otherwise. Leisure of the Working Woman.--A woman's occupation, unlike a man's, holds out little future for her. Her occupation does not arouse her ambition. Daily work is a monotonous grind that must be endured for the sake of the wages that it brings. For a time this serves to occupy attention. After some years, when the prospects of matrimony grow less, and further advance is out of the question, women often need to have some special interest that will grip them. The working woman may then need to be tempted to some occupation of mind, especially with the companionship of others, that will give her renewed interests in life. Clubs, charities in which they are active, friends, serious intellectual interests, must all be appealed to, in different cases, in order to secure diversion. Women must have something to look forward to each week. They must know on Monday that before the following Sunday there is going to be a theater party, a lecture, a visit to friends, something to break the deadliness of weekly routine, which is anticipated with pleasure and then pleasantly remembered. This may seem to be only a slight matter, but it is of importance in many cases. Feminine Occupations.--The occupations of women who stay at home are even more important than those of women who go out to work. In our time the root of much nervousness, as it is called, neurotic symptoms of various kinds and of many symptoms apparently quite distant from real nervousness, is really a lack of occupation. Many women who live in apartment hotels have almost nothing with which to occupy their minds. They are not obliged to get up in the morning if they do not want to, or, at least, any excuse, however slight, serves to keep them in bed. Very often there are either no children or the mother has nothing to do with her children early in the morning. After the age of three, they go off to kindergarten; later on they go to school. Breakfast is sent up, there may be a nap of an hour or two after the meal, and often a magazine is glanced over lying in bed, and perhaps it will be twelve o'clock before madame gets up. Anyone in a position to do this, and who allows the habit to grow, is sure to be profoundly {184} miserable. Without any real occupation of mind, the mind occupies itself with the body and emphasizes every sensation, evokes new pains and aches, and the consequence is likely to be a highly neurotic state. Such women have nothing serious to think about in the afternoon. At best it is a luncheon engagement with a friend, or attendance at the matinee, or a lecture, or a meeting of a club. For a while, and for a certain few, these things are satisfying, but after they have been indulged in for a time, they pall so completely on most people as to leave them almost helplessly at the mercy of their feelings. These persons may have some favorite charities that occupy part of their time. They may have other interests, but most of these interests are quite amateurish. They create no obligations; they arouse no sense of duty; they are abandoned at a moment for anything else that turns up, and consequently they lack that absorbing power that a real interest gives. It is quite impossible that these people should be either happy or healthy. These ladies of leisure sometimes have fads for physical exercise that keep them from becoming absolutely sluggish, but except in a few cases, these fads pall after a time, and in a few years women of the leisure classes are generally without any interest that will save them from themselves. The root of many a case of nervousness that wanders from physician to physician and then from quack to quack, and from charlatan of one kind to charlatan of another kind, that takes up now this remedy and now that, and advertises each new method of healing--mental, hypnotic, mechanical--is due to nothing more serious than lack of proper occupation of mind. The Ambition to Have Nothing to Do.--It seems to be the ambition of everyone to reach a place in life so that he can give up work and do nothing. Men and women often envy those whose material situation is such that they are not compelled to work. It is from the leisure classes, however, that our neurotic invalids are mainly recruited. The symptoms these people give will sometimes make one wonder whether they may not be suffering from some serious ailment, but just as soon as the details of their daily occupation are gone into, the real cause for their complaints can be readily seen. Nothing will do them any lasting good until they get interested enough in life to be distracted from themselves. Such men and women are invalids by profession. They are profoundly to be pitied, for they are much more the victims of present-day social conditions than of any special fault of their own. They go from one health resort to another seeking relief and now and again finding it, not because of any special effect of the remedies that they take, but just in proportion to the amount of diversion and occupation of mind they are able to secure in their wanderings. After a time they relapse, then, the old cures having lost novelty, the physician who succeeds in occupying their minds does them good; his brother physician, who does not, fails; but anyone else, however absurd his quackery, who can in any way catch their attention, will benefit them at least for the time being. Business Anxieties.--The physician should know all that concerns such sources of excitement, worry and anxiety, as are suggested by the words speculation, investment, going on bonds and securities, especially when the person bonded gets into trouble. Fortunately most of these latter sources of worry have been eliminated by the bonding companies of recent years. Details {185} of this kind were given to the old family physician as a matter of course. With the going out of the family physician there has often been no one to replace him in hearing such stories, and it has been harder for some to bear the consequences in solitude. The very telling of many cares lessens the burden of them. The warnings of a medical friend may be more effective in keeping a man from serious loss than those of financial friends. Everyone realizes that the physician's advice is quite unselfish and that what he objects to, even more than the danger and loss of money, is worry and anxiety which may lead to loss of health. For ordinary therapeutic purposes, the physician may be content to know only the physical signs and symptoms of his patient's affection. For psychotherapeutics, he must, if he would be successful, know every possible source of worry and annoyance and, as nearly as may be ascertained, every slight phase of physical fatigue that may be a disturbing factor in his patient's life. It is surprising how many things the physician will find to correct when he carefully goes over all the actions of the day and ascertains all the possible sources of worry and anxiety his patient may have. It may happen that in many cases he will be unable immediately to remove these sources of worry. But there is relief in telling them, and then, even when they cannot be completely eradicated, they can often be modified. Every improvement of this kind, however slight, is a fountain of favorable suggestion which makes the patient look on the brighter side of life. From every amelioration, however trivial, there is a reaction on the feelings that gives more and more confidence. {186} SECTION IV _GENERAL PSYCHOTHERAPEUTICS_ CHAPTER I GENERAL PRINCIPLES OF PSYCHOTHERAPY In formal, deliberate psychotherapeutics the first and most important principle is the treatment of the individual patient, and not of his disease. It is much more important to know the kind of an individual who has pneumonia, as a rule, than to be able to tell the amount of pulmonary involvement. If heart, kidneys or lungs are affected when the disease declares itself, the outlook is extremely unfavorable. Similar conditions are true of the patient's mind. If he is of the worrying kind, the outlook is serious. If, on the contrary, he faces it bravely, and without after-thought except that of responding to medical treatment, he will probably get well. Pneumonia is only one example of the part the individual plays in therapeutics. In the popular mind it is supposed that for each disease there is a definite remedy, and that when the physician gives that remedy the patient gets well. This idea of specific remedies has come to the people from the physician, but only the quack now pretends to cure disease, the physician helps the patient to overcome the affection from which he is suffering. No Incurable Patients.--There are many incurable diseases, but there are no patients to whom a doctor should say with truth, "I can do nothing for you." We may be unable to do anything for the underlying disease. That may be absolutely incurable. In spite of this, there are practically always symptoms for which the patient can be afforded so much relief that he feels better than before. This is the most important attitude of mind for the physician who would use psychotherapy. He can always do something. Prof. Richet said not long since, "Physicians can seldom cure, but they can nearly always relieve and they can always console," and it is the physician's duty to lift up and console the mind as well as to heal the body. Unfavorable Suggestions.--Patients often have many opinions and conclusions with regard to their ailments which are not confided to their medical attendants, and which constitute the basis of many annoying symptoms. They have mental convictions with regard to the incurableness of their ailments, the supposed progressive character of the disease, and the development of symptoms which will still further annoy them, that are often more serious and harder to bear than the symptoms from which they are actually suffering. Unless the physician has their complete confidence, these patients may suffer much in silence, though the revelation of their state of mind would {187} often be sufficient to afford a good measure of relief, and the correction of false notions would do nearly all the rest. Psychotherapy confers its benefits mainly by securing the most complete _rapport_ between the mind of patient and physician. Good advice is often more important than any medicine. The correction of wrong notions will do more to relieve the patient, and make whatever symptoms he has bearable, than most of the anodyne drugs. The stimulation of hope means more than almost anything else in arousing the latent forces of nature and predisposing to recovery. The removal of unfavorable suggestions is but little less efficient. _Study of the Individual_.--The great differences in the relations between physicians and their patients is well recognized. To some physicians a patient will present only conventional symptoms, while a follow practitioner will discover the elements of an interesting case. Above all, the painstaking physician, interested in psychology, will find mental and other personal manifestations in his patient that distinctly modify the course of the disease. We must know all that is possible about the patient's attitude of mind toward his malady, and all the ideas that he has acquired with regard to it, either from previous relations with physicians or from what he may have read or heard from others. The removal of many false notions that are thus working harm will reward the medical practitioner who gets at his patient's ideas. The old rule in therapeutics is _non nocere_--to be sure to do no harm. The special rule in psychotherapy is to be sure to remove all the ideas that are doing harm to the patient and making his symptoms mean more to him than they really signify. _Neutralizing Contrary Suggestion_.--In the application of psychotherapy, then, the first principle is the neutralization of unfavorable mental influence. In our day men have such a smattering of knowledge about disease, especially about the worst forms of it, that they are likely to be in a frame of mind with regard to many affections that is quite unfavorable. Many patients think disease and not health. Disease means discomfort, and consequent loss of vital energy and disturbance of the resistive vitality that would enable the patient to throw off the affection. Sometimes the physician does not realize what a large part unfavorable suggestions are playing in the affection. Sometimes patients conceal their state of mind lest the doctor should confirm their worst fears. The preliminary to all successful treatment is to remove unfavorable suggestion. Favorable Suggestion.--The next thing is to set certain favorable suggestions at work. It is possible always to do this. Even in certain of the acute diseases favorable suggestion has its place, and for all chronic cases this form of therapeutics is extremely important. The very presence of the physician, especially if he is thoroughly in control of himself, placid, imperturbed, evidently ready to use all his powers without any excitement, is of itself the strongest kind of favorable suggestion. From the very beginning of medical history the presence of the physician has in most cases meant even more than his medicines. Münsterberg, in his recent book on Psychotherapy, has emphasized this in a way that deserves to be recalled: There is one more feature of general treatment which seems almost a matter of course, and yet which is perhaps the most difficult to apply because it cannot {188} simply be prescribed: the sympathy of the psychotherapist. The feelings with which an operation is performed or drugs given do not determine success, but when we build up a mental life, the feelings are a decisive factor. To be sure, we must not forget that we have to deal here with a causal and not with a purposive point of view. Our sympathy is therefore not in question in its moral value, but only as a cause of a desired effect. It is therefore not really our sympathy which counts but the appearance of sympathy, the impression which secures the belief of the patient that sympathy for him exists. The physician who, although full of real sympathy, does not understand how to express it and make it felt will thus be less successful than his colleague who may at heart remain entirely indifferent but has a skillful routine of going through the symptoms of sympathy. The sympathetic vibration of the voice and skillful words and suggestive movements may be all that is needed, but without some power of awakening this feeling of personal relation, almost of intimacy, the wisest psychotherapeutic treatment may remain ineffective. That reaches its extreme in those frequent cases in which social conditions have brought about an emotional isolation of the patient and have filled him with an instinctive longing to break his mental loneliness, or in the still more frequent cases where the patient's psychical sufferings are misunderstood or ridiculed as mere fancies, or misjudged as merely imaginary evils. Again everything depends upon the experience and tact of the physician. His sympathy may easily overdo the intention and further reinforce the patient's feeling of misery, or make him an hypochondriac. It ought to be sympathy with authority and sympathy which always at the same time shows the way to discipline. Under special conditions, it is even advisable to group patients with similar diseases together, and to give them strength through the natural mutual sympathy; yet this too can be in question only where this community becomes a starting point for common action and common effort, not for mere common depression. In this way a certain psychical value may be acknowledged for the social classes of tuberculosis as they have recently been instituted. Favorable Environment--After the removal of unfavorable suggestion and the implanting of favorable suggestion, the next point must be the persistent occupation of the patient's mind with thoughts favorable to his condition. A nurse who is inclined to be pessimistic must be taken out of the sick room, and there must be only cheerful faces and cheery people around him. Hence the modern trained nurse, and especially the picked nurse, who does not allow herself to be disturbed, who is not fussy, who is not forcibly cheerful but quietly placid and confident and cheery, means much for the patient's recovery. Relatives are almost sure to exert strong unfavorable suggestions, though time was when the devoted wife or mother might be depended upon to cover up all her personal feelings and give the best possible service for the mental uplift of the patient. When she can thus conceal her own solicitude, a near relative may be the best possible auxiliary in psychotherapeutics. Natural Relief.--The fourth step in the application of psychotherapeutics is that all the natural modes for the relief of symptoms, the making of patients comfortable in body as well as in mind, must be employed. In acute rheumatism, for instance, a number of small pillows must be at the disposition of the patient so that his limbs can be fixed in those positions in which there is the least discomfort. Every physician should frequently read Hilton's classical volume on "Rest and Pain" because of its unpretentious significance for psychotherapy, as well as its enduring value in the treatment of painful conditions. Just as soon as a patient finds that simple procedures relieve his pain and add to his comfort, his fear of the seriousness of his ailment is lessened, {189} and he begins to get bettor. Cold water in fevers, cold fresh air in pneumonia, all the natural modes of treating disease, thus become active factors in the application of psychotherapy. When fevers were treated by the administration of hot drinks the effect upon the patient's mind must have been quite serious. Freedom to use cold water, just as one wants it and whenever it is craved for, is of itself an excellent suggestion. Neuroses in Organic Disease.--Fifth, psychotherapy, by suggestion, may alleviate or even completely eradicate neurotic symptoms that develop in connection with organic diseases. Such neurotic symptoms may prove even more bothersome to the patient than the symptoms due to his underlying affection, and may, by interfering with nutrition, hamper recovery. The appetite of a patient who is worrying about a chronic disease will be disturbed, and, as a consequence of insufficient food, constipation and a whole train of attendant evils may ensue. Headache, sleeplessness, worry at slight irritation and exaggerated complaints from slight pain may all be due to this worry and not to the underlying disease. All these, the result of over-solicitude, are attributed by the patient to his chronic ailment. They can be relieved by simple measures after he is saved from his own worry. Until the patient is made to rouse himself and look hopefully at the situation, eating more, getting out more, and relaxing his mind from its constant attention to himself, he cannot get better. Application of Principles.--It should be pointed out to the patient that there is a constant tendency to exaggerate the significance of disease. This is true in acute as well as in chronic disease, but in acute diseases the necessity for removing unfavorable influences directly is not so urgent, since usually the presence of the physician, with his simple declaration of the meaning of symptoms, is sufficient to neutralize the effect of previous exaggerations. Secondly, the action of unfavorable suggestions due to imperfect knowledge (everything unknown is magnified, as Cicero said), or to previous medical opinions which the case does not justify, must be stopped. The natural dread which comes to all men in the presence of symptoms of disease must be as far as possible removed. Thirdly, the favorable elements in the case should be emphasized. This needs to be thoroughly done in order to secure the patient's co-operation, even though the serious possibilities of his ailment may be pointed out to his friends. These friends, however, must be persons who can be absolutely depended on not to reveal by word, or, what is much more important, by their looks or actions, the possible worse prognosis of the case. Unfortunately, people expect a doctor to tell them the worst, rather than the best. Many physicians seem to have formed the habit of representing the condition of patients as grave as possible, in order, apparently, that they may have more credit when the patient recovers. Not a little of the tendency of ills to hang on in neurotic persons is due to this habit. Over-cautiousness leads some physicians to reveal a case in its worst aspect, lest, by any chance, something unexpected should happen, and the friends of the patient might think that the physician was incompetent because he had not anticipated it. Some of the serious accidents of disease are quite beyond anticipation; but they occur only rarely. For the sake of safeguarding the possible reflection on the physician because of them, it is quite unjustifiable to make bad {190} prognosis habitually, for this acts deterrently on the vital resistance and delays recovery. _Symptoms of Organic Disease_.--It is usually considered that psychotherapy is beneficial only in nervous cases; yet we know that all sorts of affections with tissue changes in the skin, in the circulation, and very probably also in the internal organs, may be produced in hysterical affections--ailments dependent on loss of control over the vaso-motor nervous system. Just as ills can be produced, so they may also be cured. As a matter of fact, analysis of the statistics of disease cured by mental influence, shows that it has been more strikingly manifest in organic than in so-called nervous or functional diseases. Neurotic patients often make extremely unsuitable subjects for the exercise of mental influence, because their very nervousness is a manifestation of lack of power properly to control the mind. Cures by mental influence have oftenest been reported in non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence of the Mind on the Body" as long ago as 1884, it is in such cases as rheumatism, gout and dropsy that benefit was most frequently reported by mental means. Tuberculosis, certain digestive and intestinal ailments that evidently are associated with tissue changes, have in recent years come particularly into this category of ailments affected by psychotherapy. Dr. Hack Tuke's declaration, made nearly thirty years ago, seems conservative even at the present day: "The only inference which we are justified in drawing from the statistics of the affections cured by mental means is that the beneficial influence of psychotherapeutics is by no means confined to nervous disorders." Many physicians are likely to hold that when cures take place the so-called organic diseases were not actual, but were only _supposed_ to exist because of certain obscure symptoms that apparently could not otherwise be explained. But many of the cases have had external symptoms, striking and unmistakable. To assume that physicians of experience and authority were in error in diagnosing them is simply to beg the question. It is more probable that mental influence acted curatively even over tissue changes as it so often does, directly under our observation, in the production of such changes in the skin. _Tissue Changes From Nerves_.--Until one recalls how many physical changes may be brought about by mental influences or emotional disturbances, it is not always clear just how mental influence can affect disease favorably or unfavorably. Prof. Forel, of Zurich, in his "Hygiene der Nerven und des Geistes im Gesunden und Kranken Zusande," Zurich, 1905, English translation 1907, brings together into a single paragraph most of these physical and physiological influences of the mind upon the central nervous system: Through the brain and spinal cord, thoughts can lead to a paralysing or stimulation of the sympathetic ganglion nodes, and consequently to blushing or blanching of certain peripheral parts. Through disturbance of this mechanism, many nervous disorders arise, such as chilblains, sweats, bleeding of the nose, chills and congestions, various disturbances of the reproductive organs, and, if it lasts long enough, nutritional disturbances in the part of the body supplied by the blood vessels affected. In the same way there are peripheral ganglionic mechanisms which superintend glandular secretion, the action of the intestinal muscles, etc. These likewise can be influenced through the brain by ideas and emotions. Thus we can explain how constipation and a vast number of other disturbances of digestion and of menstruation can be produced through the brain, without having their cause in {191} the place in which they appear. It is for the same reason that such disturbances can be cured by hypnotic suggestion. _Health and the Central Nervous System_.--Nature has so constituted and ordered the human economy that its health depends to a great extent on conditions in the central nervous system. We discuss elsewhere the return of vitalism in physiology--that is, the reassertion of a principle of life behind the chemical and physical forces of the human organism regulating it, supplying energy, occasionally enabling it to transcend the ordinary laws of osmosis, or the diffusion of gases. The main seat of this principle of life is in the central nervous system and especially in the cerebral cortex. The importance of this portion of the human anatomy can scarcely be exaggerated. In his inaugural address to the Royal Medical Society, [Footnote 23] delivered at Edinburgh in 1896, Prof. T. S. Clouston, the distinguished English psychiatrist, has a passage on this subject that deserves to be recalled: [Footnote 23: _British Medical Journal_, January 18, 1896.] I would desire this evening to lay down and to enforce a principle that is, I think, not sufficiently, and often not at all, considered in practical medicine and surgery. It is founded on a physiological basis, and it is of the highest practical importance. The principle is that the brain cortex, and especially the mental cortex, has such a position in the economy that it has to be reckoned with more or less as a factor for good or evil in all diseases of every organ, in all operations and in all injuries. Physiologically, the cortex is the great regulator of all functions, the ever active controller of every organ and the ultimate court of appeal in every organic disturbance. _Psychotherapy in Its Relation to Patient and Physician_.--In spite of the present-day fad for psychotherapy, I have no illusions with regard to its popularity among patients, unless practiced with due regard to individuals and with proper tact. Psychotherapy has been most effective in the past when it was cloaked beneath the personality of the physician; when it was felt that there was in him a power to do good that must help the patient. This personal influence has to be maintained if the patient's mind is to be influenced favorably. Very few people are willing to think, and still less to welcome the thought, that they themselves are either bringing about a continuance of their symptoms or are hindering their own recovery. They are quick to conclude that this would be a confession that their ills are imaginary. "Imaginary" has no place in medicine. There are physical ills and mental ills. Mental ills are just as real as physical ills. There are no fancied ills. A person may be ailing because he persuades himself that he is ailing, but in that case his mind is so affecting his body that he is actually ailing physically, though the etiology of the trouble is mental. It is the duty of the physician to get at these mental causes of physical ills and remove them by persuasion, by reassurance, by changing the mental attitude, by making people understand just how mind influences body, but this must be done tactfully. From the beginning of time we have written our prescriptions in such a way that ninety-nine out of one hundred patients have not been able to understand them. It has often been said that we should change this method of prescription writing, and write directions for the compounding of our medicines in plain vernacular. Besides the many {192} scientific reasons against this, it is better for patients not to know exactly the details of their treatment. Physicians, because of their real or supposed knowledge, are usually the worst patients. If, when a physician is ill, a drug is administered in which he has lost confidence, he will really oppose its action by contrary suggestion, and perhaps neutralize it. Confidence added to the action of the drug itself, makes it much more potent and much more direct. Hence the suggestive value of a prescription the ingredients of which are unknown. Every physician knows of patients who have declared that a drug has been tried on them without avail, when it has only been used in such small quantities as to be quite nugatory in its effect. Such use was enough to prejudice them against it so that when given in physiological doses it failed to work properly. Opium given to a trusting patient, in gradually reduced doses until practically there is nothing but the flavor of the drug in the compound that he takes, will continue to have its effect. But to a patient prejudiced against the drug, even large doses of opium will prove unavailing, because the lack of confidence disturbs the mind, directs attention to whatever discomfort may be present, emphasizes the ill and prevents sleep by preoccupying the mind with the thought that neither the drug nor the dose can accomplish its purpose. In a word, medicine plus mental influence is extremely valuable. Medicine minus mental influence is valuable but sometimes ineffective. Medicine, with mental influence opposed to it, is often without effect because of the strong power the mind has over bodily functions. Most people would rather be cured by some supposedly wonderful discovery, which presumedly made it clear that they had been suffering from a severe and quite unusual ailment, than by ordinary simple methods. The recent growth of interest in psychotherapy and psychology has, however, somewhat prepared people to accept mental influence as an important factor in therapeutics. The direct and frank use of psychotherapy will be of benefit to these people. But in most cases mental influence will have to be exerted in such a way as to conceal from patients that it is their own energy we want to tap to help them cure themselves. This would be for them quite an unsatisfactory method of being cured. In practically all cases such a combination of methods is needed that the place of mental influence is not over-emphasized. As a rule, mental influence must not be used alone. Its place is that of an adjunct, a precious auxiliary, to other methods of treatment. Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient. We have to find out by experience just how to use hydrotherapy for each individual. Varying currents of electricity and varying forms of electrical action are needed for different individuals. Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with. To learn the place of mental influence in healing, so that we shall not be attributing to other therapeutic factors what is really due to the mind, will be a great advance in therapeutics. This is the mistake that we have been making in the past. In brief, the applications of the general principles of psychotherapy {193} include all means, apart from the physical, of influencing patients. Drugs will always have a large place in rational therapy. Many physical remedial measures, hydrotherapy, electrotherapy, climatotherapy and others, must be important adjuncts. To these is now added psychotherapy. It has been used before, as have most of the other forms of therapy, but in our day we are trying to systematize therapeutic modes so as to secure the greatest possible information with regard to their exact application. This is what must be done with regard to psychotherapy also. Just now its importance is being exaggerated by ardent advocates. In every department of therapy this has always been done by enthusiasts. The business of the practicing physician must be to select what is best, and above all what is sure and harmless, from the many suggestions offered, so as to build up a practical body of applied truth. {194} SECTION V _ADJUVANTS AND DISTURBING FACTORS_ CHAPTER I SUGGESTION Under the head of Adjuvants and Disturbing Factors in the psychic treatment of patients come the various phases of life which make for and against such a favorable state of mind as predisposes to the continuance of good health, minimizes inhibition, and adds to favorable suggestion. By modifying the modes of life, an ever renewed set of suggestions is initiated. By definite instruction and advice with regard to exercise, position, training, habit, pain, occupation of mind and diversion of mind, patients may be profoundly influenced, and gradually made to take on an entirely new attitude of mind towards themselves. These chapters, then, while apparently much more concerned with physiotherapy than psychotherapy, are really directions for the use of such physical methods as by frequent repetition make the most valuable suggestions. There is probably nothing more valuable in the ordinary application of psychotherapy than these various auxiliaries, with their power to remove disturbing factors, while, on the other hand, nothing aids more in bringing relief for many conditions than the removal of certain disturbing factors. There is now a general recognition of the fact that suggestion in the waking state can in most cases be as therapeutically efficient as hypnotism, and is probably even more enduring in its effects when successful, without the dangers and sequelae connected with hypnosis. _Every idea tends to act itself out_. When we crave something, when there are active ideas of desire, there usually are movements of our flexor muscles. These affect the hands especially. At moments of hatred, detestation or abhorrence our extensor muscles are affected, as if we would wave these things away from us. There may even be an involuntary turning of the trunk muscles, as if we would no longer face what is abhorrent, though the repulsive thing may be present only to the mind. It is not far-fetched to argue that, since the voluntary function of muscles is thus influenced, other functions are also touched by emotions, ideas, trains of thought, especially when the mind is much concentrated on them. Bishop, the so-called mind-reader, whose exhibitions attracted much attention in London and New York some years ago, confessed that his feats were accomplished mainly through muscle reading. He would permit a committee to select a book in a library in a certain house, and even a particular page of {195} that book, and then, blindfolded, sitting with the committee in a carriage with his hand on the forehead and the arm of one of the committee, he would direct just where the carriage should be driven and would, while always continuing his contact with the member of the committee, go to the particular house and room, select the special book, and eventually find the page. There was no opportunity for collusion in some of these feats. The most startling things were often accomplished by the system of forcing a choice which prestidigitateurs use in order to compel the taking of the particular card by suggestion (though all the time they seemed to be leaving absolute liberty of selection to the person), but there was much, besides this, required to accomplish what he did. He said that there were always involuntary muscle movements, little starts and tremors that guided him in his work. Other exhibitors have been able to use this to a considerable extent, though not with Bishop's success. That our thoughts can be read in our muscle system is interesting and valuable confirmation of the unconscious tendency of ideas to affect the body. When a single idea occupies the consciousness it will, some psychologists insist, necessarily act itself out unless some distracting thought prevents it. We know how difficult it is to stand at the edge of a height, say at the brink of a waterfall or on the cornice of a high building, or to look down a mine or elevator shaft, because the thought comes to us, how dreadful it would be to plunge over. As a consequence of this insistent idea taking possession of our consciousness, we have the sense of falling, we become tremulous and have to withdraw, or we would actually fall, or find in ourselves a tendency to throw ourselves over. There are persons who cannot even sit in the front row of a balcony because of the constant effort required to neutralize the suggestion that they may fall or throw themselves over its railing. Curious sensations become associated with this idea--a feeling of numbness and tingling in the back, sometimes a girdle feeling, sometimes a sense of suffocation. All of these are due to the concentration of attention on a single idea and its suggestions. Very few men, shaving themselves with an old-fashioned razor, have not, at moments of worry and nervousness, sometimes had the thought of how easy it would be to end existence by drawing the edge of the razor through the important structures in the neck. Some are so affected by this thought that they have to give up shaving themselves. It is a surprise usually to find how otherwise sensible, according to all our ordinary standards, are the individuals who confess to having had annoyance from such thoughts. This illustrates how strongly suggestive the concentration of attention may make an idea, and how much a single idea, when it alone occupies the center of consciousness, tends to work itself out in act, though there is no reason at all for willing in that direction. It is not improbable that in some inexplicable cases of suicide the tendency has actually worked itself out. The expression, "he is a man of one idea," enshrines in popular language the conclusion of psychologists that if a single idea is present in the mind it will surely work itself out. We all know how much men of one idea accomplish. All their powers, physical and mental, are brought to bear on its development. Obstacles that deter other men, conditions that prevent others from daring even to think of doing the thing, seem as nothing to the man {196} of one idea, and in spite of discouragement, and even apparent failure, he often succeeds, notwithstanding obstacles that seemed insurmountable. What is thus true in the practical world is paralleled, for both good and ill, in the microcosm of the human body. A man who has one idea to urge him on is capable of accomplishing things in spite of pains and aches and all sorts of disturbances of function. On the other hand, if the one idea is unfavorable, then, in spite of a heritage of good physical and mental powers, his efficiency is inhibited. If a man gets an idea that there is something the matter with any organ, and concentrates attention on it, he will surely disturb the function of that organ. Just the opposite, however, will happen in case, even with physical defect, he believes that there is nothing the matter, or only something that can be overcome. This is the power of faith as illustrated in the various forms of faith healing, from mental science to Eddyism and the rest. This is the power that the physician must learn to use. In _The Lancet_ for November, 1905, Dr. J. W. Springthorpe, writing on the "Position, Use and Abuse of Mental Therapeutics," said: Few indeed are the medical practitioners who daily prescribe suggestion as well as diet, hygiene and drugs. Yet the physician who makes even a minimum effort in this direction often does more for his patient than his more highly qualified confrère, who makes none. To some, and they naturally the most successful, this endeavor comes without conscious search, and improves with experience, but in some measure it may be acquired by all and no one who has become familiar with its powers will henceforward be content to remain without its constant aid. This power is thoroughly exploited by the irregular practitioner, and the regular practitioner is bound in duty to learn to use it just as thoroughly. What is true for the lesser faculties is eminently true for our most important faculty, the intellect. We all know how intellectual training enables us to accomplish without difficulty what at first seemed almost impossible. Not only that, but we acquire the power to devote ourselves to a subject that was at first irksome, if not actually forbidding. There are educators who insist that this discipline of mind, by which the power to devote ourselves to what we do not care for is gained, is the principal fruit of genuine education. It has been lost, or at least impaired to a great degree, by educational experiments, especially those related to the elective system which pushed interest, instead of discipline, into the foreground of education. In the same way the power of self-control, and the faculty of self-denial, so precious to the human race, have been lessened by the methods of training which omitted the consideration of these and emphasized the idea of personal comfort. Much can be done to make the unpleasant things that are inevitable in life not only tolerable, but actually to give a satisfaction surpassing selfish pleasure. It is this discipline that is needed in psychotherapy at the present time and the physician must endeavor to encourage it by every means in his power. The one purpose of the use of suggestion in therapeutics, then, is to secure as far as possible concentration of mind on a single idea. This is what is done in hypnosis, but frequently in such a way as to leave the idea {197} to work out unfavorably associated suggestions. If there could, in the conscious state, be the same absolute concentration of mind on an idea, a great force for good, without accompaniment of ill, would be secured. Experience has shown that with patient effort and definite methods such concentration of attention on a single idea can be secured, at least to such an extent as to make it efficiently therapeutic. Ordinarily, suggestion accompanies the material remedies that the doctor prescribes. He must emphasize just when and how the medicine is to be taken, and it is well to emphasize the effects that are expected and just about how they will come. If he is prescribing a tonic, he does not merely say before meals. He specifies from ten to twenty minutes before meals, according as he wishes it taken, with a definite amount of water, stating that the taste of it will excite appetite and that only food in reasonably liberal quantities will satisfy the craving produced by it. If he is prescribing a laxative, he states just when it should be taken and when its effects may be expected. The arousing of expectancy does much to relax inhibition and to permit the flow of nervous impulses that may be helpful. If a sleeping potion is given, the patient is directed to compose himself for sleep immediately after it is taken, or to take it just a definite time before he gets into bed, and then to expect its action in the course of twenty minutes or a half hour, designating rather definitely just when it shall have its climax of effect. Two or three things done together, as, for instance, a gentle rubbing with cool water over the body to produce a glow, a warm foot-bath, and then a sleeping potion, will combine to produce a climax of physical and psychical effect. In many conditions that come for treatment to the modern physician, the physical remedies are much less important than the psychical. This is particularly true for the affections known as psychoneuroses, in which some slight nervous disturbance is exaggerated into an extremely painful condition or a disturbing paralytic state; in the so-called hysteria of the older times; in the drug habits; in the sex habits; in the over-eating and under-eating habits, and then with regard to dreads and other psychic disturbances connected with dreams, premonitions and the like. In all these cases it is important to secure concentration of the patient's mind on a neutralizing suggestion. This must be done deliberately and in such a way as to secure thorough concentration of attention. It is often a time-taking process, but nearly everything worth while requires time, and the results justify the expenditure. Methods mean much in the attainment of this. They must be impressive, the patient must be convinced of the power of the physician to help him, and he must have trust in the efficacy of the mode of treatment. The patient should be put into a comfortable position, preferably in a large, easy arm-chair, should be asked to compose himself in such a way as to bring about thorough relaxation of muscles, and then to give his whole attention to the subjects in hand. Occasionally the arms should be lifted and allowed to fall, to see whether relaxation is complete, and the knee jerks may be tested, to show the patient that he is not yet allowing himself fully to relax. There should be no lines in the face: the muscles around the mouth, and especially those in the forehead, should relax. It is surprising how {198} much can be done, sometimes by slight touches on the forehead, to secure this. The patient should then be made to feel that the tension in which he has been holding himself, and which makes it so difficult for him to relax, has really been consuming energy that he can use to overcome the tendencies to sensory or motor disturbance, or to supply the lack of will which makes him a victim of a drug or other habit, or takes away from him that mental control that would enable him to at once throw off dreads and doubts and questionings and bothersome premonitions which now, because of the short circuiting on himself through worry and nervousness, he cannot do. Two or three séances usually show a patient how much better control over himself even a short period of relaxation will give. He comes out of a ten-minute session of relaxation, during which he has been talked to quietly, soothingly, encouragingly, with a new sense of power. Often he feels that there will be no difficulty in overcoming his habit. This may pass, of course, but he has received a new idea of his own resources of energy and self-control. In most cases it is well, after securing relaxation, to ask the patient to close his eyes gently and to keep them closed till all his muscles are relaxed. Then suggestions may be made to him with regard to his power to control cravings, and to put away doubts and questionings, because, after all, as he sees them himself, they are quite irrational and entirely due to habitual tendencies that he has allowed to grow on him. A concentration of attention on the idea, not only of conquering but of being able to conquer, will be secured. Unless this complete attention can be had, suggestion in the waking state may not prove efficient. There are nervous, excitable people for whom, at the beginning, it will be quite impossible to secure such relaxation and peaceful quiet as will be helpful to them. For these a number of séances may be necessary, but on each occasion a little more of quieting influence is secured. In recent years, this quiet, peaceful condition, with eyes closed, thorough relaxation and absolute attention, has sometimes been spoken of as the hypnoidal state. If it be recalled that hypnos in Greek means sleep, and that this is a state resembling sleep with the restfulness that sleep gives, the term is valuable in its suggestions. If, however, the word is connected with hypnotism, then there may be an unfortunate connotation. This state is entirely free from the dangers of hypnotism, and instead of making a patient dependent on his physician, teaches him to depend on his own will. It is not a new invention as this term hypnoidal might seem to indicate, but is as old as our history at least. CHAPTER II EXERCISE In recent years a great change has come over the popular mind regarding exercise, especially in the open air. It is well to emphasize at the very beginning the subject of too much exercise, because there is no doubt in the minds of many who study the question, that many Americans, and indeed people of the northern nations generally, take a certain amount of voluntary {199} exercise that is not good for them, though they take it at the cost of considerable effort and sacrifice of time and are firmly persuaded that it is of great benefit. Sufficient Exercise.--There is a much larger number of persons who do not take sufficient exercise. The amount to be taken is eminently an individual matter. Neurotic patients exaggerate everything in either direction, so that perhaps the state of affairs that exists is not so surprising as it might otherwise seem. Instead of the uncertainty that prompts now to too much exercise, and again to too little, for health's sake there must, as far as possible, be a definite settlement of the needs. National Customs.--There is a curious difference in the attitude of mind of the various nations towards exercise. Most of the southern nations of Europe do not as a rule take any violent exercise. As is well known, however, they are not for this reason any less healthy than their northern contemporaries, though perhaps they are less strong and muscular. But muscularity and health are not convertible terms, though many people seem to think they are. An excess of any tissue is not good. Our economy should be taxed to maintain only what is useful to it. Nature evidently intended, in cold climates at least, that men should maintain a certain blanket of fat to help them retain their natural heat, but any excess of fat lessens their resistive vitality by lowering oxidation processes. Fat in cold climates can be used to advantage as a retainer of heat. In the warmer climate it would be a decided disadvantage. Muscular tissue is a manufacturer of heat and this is a decided advantage in the colder climates, but in the temperate zone, where the summers are very warm, muscle in over-abundance, unless its energy is consumed by actual physical exercise, may be quite as much of a burden as fat. Muscular people do not stand heat well. They demand exercise to keep muscle energy from being converted into heat, and they require frequent cold baths, and other forms of heat dissipation, in order to be reasonably comfortable. Exercise in Early Years.--The question of the amount of exercise that is to be taken must be decided at an early age for individuals. Most of the young people of the Celtic and Anglo-Saxon races are tempted by traditions and by social usage to develop considerable muscle during their growing years. In this respect, the difference between the German and the English schoolboy is very striking. The English schoolboy is likely to be as "hard as nails," as the expression is, as a consequence of violent exercise in his various sports, taken often to the uttermost limit of fatigue. The German schoolboy has his walk to and from school, and some other simple methodical exercises, with some mild amusements that make little demand on muscle, but of games in the open he has very few, and of the violent sports he has none at all. A comparison of the health of the two nations will not show that the English boy, who receives a public school and a university education, with all their temptations to exercise, enjoys any better health, and, above all, reaches an average longer life than the German youth, who has gone through a similar educational career in his own country, but without the athletic training that the English schoolboy has had. As a consequence of the absence of athletics and its diverting interest, the German is apt to have learned more than his English colleague, but a {200} comparison of mortality and morbidity tables would show that his resistive vitality, his power to overcome disease and recover from accident is not lower than that of his colleague from across the North Sea. The German is less strong muscularly, and in a contest of physical effort would as a rule come out second best, but then we have gotten beyond the period when it is important for a man to be able to defend himself by physical force, except in emergencies that may never come. Surely the English time and effort devoted to athletics is not justified by this. _Preparation for a Sedentary Life_.--Certainly if a young man is going to live a sedentary life in his after years, it does not seem advisable for him deliberately to devote much time to muscular exercise during his growing years. This only provides him with a set of muscles for which he has no use. Ordinarily it is assumed that muscles are organs for the single purpose of evolving energy. This is not true, since they are important organs for the disposition of certain food materials and for the manufacture of heat for the body. Nature in her economy probably never makes an organ for one function alone, but usually arranges so that each set of organs accomplishes two or three functions, thus saving space and utilizing nutrition to the full. The man with a well-developed muscular system, which he is not using, will have to feed it, and besides will have constantly to exert a controlling power over the heat that it manufactures whenever it is not dissipated by actual exercise. For these reasons he will be constantly nagged by it into taking more exercise than his occupation in life demands, and if he does not do this, his developed musculature is likely to deteriorate so as to be a serious impediment, or to degenerate by fatty metamorphosis into a lower order of tissue that is a clog and not a help to life. The Germans are more sensible. As students, they live quite sedentary lives, develop their muscles just enough to keep them in reasonably good health, and then, when it comes to living an indoor life, as will be almost inevitable in their chosen professions or occupations, they do not meet with the difficulties that confront the Anglo-Saxon with his burdensome, over-developed muscular system. German professors, as a class, do not find themselves under the necessity of taking systematic daily exercise. They are quite content and quite healthy with an hour or two of sitting in the open air, and a quiet walk from the home to the university or the school. With the ideas that some people have with regard to the value of exercise for health, it might be expected that the German professors would be less healthy than their Anglo-Saxon colleagues. This is notoriously untrue, for the Germans live longer lives on the average, and most of them accomplish much more, and above all are much more content in the accomplishment, than their physically strenuous Anglo-Saxon colleagues. They are not oppressed by the demands of a muscular system that insists on having its functions exercised, since it has been called into being in the formative period. These German professors live to a magnificent old age, requiring very little sleep and often doing a really enormous amount of work. The man with a developed muscular system generally requires prolonged sleep, particularly after exercise, but even without it very seldom is it possible for him to do with less than seven hours, while the Germans often are content and healthy with five hours, or less. {201} Our muscular system is our principal heat-making apparatus. It is easy to understand. If we have larger heat-making organs than are necessary for the maintenance of the temperature of the body, and if we have no mode of dissipating our heat by muscular energy, as through exercise, then there will be a constant tendency for our temperature to rise, which must be overcome, at considerable expense of energy, by the heat-regulating mechanism of the body. This heat-regulating mechanism is extremely delicate, yet does not seem to be easily disturbed. With the external temperature at 120° F. or--10°, human temperature is constant. With a heating apparatus entirely too large for its purpose, it is no wonder that irritability of the nervous system ensues because of the constant over-exercise of a function called for from it. It is this state of affairs which seems to me to account for the marked tendency to nervous unrest, and to the presence of many heart and digestive symptoms that often characterize athletes who develop a magnificent muscular system when they are young, and later have no use for it. They must learn the lesson and keep up the practice of using their muscles sufficiently to dissipate surplus heat, so as to prevent this energy from being used up in various ways within the body, with a resulting disturbance of many delicate nervous mechanisms. Useless Muscles.--Whatever a human being has to carry round as useless can only be expressed by the telling Roman word for the baggage of an army, _impedimenta_. Prof. James, in his "Principles of Psychology," sums up the law very well: The great thing in all education is to make our nervous system our ally instead of our enemy. It is to fund and capitalize our acquisitions and live at ease upon the interest of the fund. For this we must make automatic and habitual as early as possible as many useful actions as can be and guard against the growing into ways that may be disadvantageous to us as we should guard against the plague. An over-developed muscular system, with its tendency to manufacture heat and its craving to be used, and the consciousness it is so apt to produce of ability to stand various dangerous efforts, is a disadvantage rather than an advantage. Useless Fat.--This reminds us very much of the attitude with regard to children in the acquisition of fat. Chubby babies with rolls of fat all over them and deep creases near their joints are considered to be "perfectly lovely." Mothers are proud to exhibit them. They are supposed to be typical examples of abounding good health. Neighborly mothers come in to coo over them and, in general, the main aim of existence for children in their early years would seem to be to make them as fat as possible. Such children, as is brought out in the discussion of the subject in the chapter on obesity, are not healthy in the true sense of the word, are well known to be of lower resistive vitality than thinner infants, and easily succumb to diseases. Resistive Vitality.--One reason for the early deaths of many athletes is the fact that, confident of their strength, they allow themselves to become so overwhelmed by an infection, before they confess that they are sick and take to bed, that often the cure of their affection is hopeless. Ordinarily neither pneumonia nor typhoid are likely to be fatal diseases for men between twenty and fifty. If a man's heart and kidneys are in good condition during this {202} period, an attack of either of these diseases, while a serious incident, is likely to be only a passing loss of time. Rather frequently, however, strong and healthy men without any organic defect that may be considered responsible for the fatal termination, succumb to these diseases. The reason for the fatality is that they are not willing to admit that they are ill enough to be in bed, they have a large reserve force of strength on which they call and which enables them, for a good while, to resist the weakening influence of disease. Doctors know and dread these cases. A young man in the flower of youth, with magnificent muscular development, comes into the office breathing very rapidly and with a laboring pulse. Almost exhausted, he sinks into a chair, confesses that he is nearly "all in," and wonders what is the matter. At times the physician will find practically a whole lung solidified by pneumonia, and at times both lungs are seriously affected. The wonder is how the young man succeeded in holding out so long. Sometimes the doctor is summoned to see him because he has fainted in his home, or in his office, and his friends are alarmed. These cases are almost invariably fatal. Any one who continues to be up and around until the third or fourth day of pneumonia will have so exhausted his vitality, no matter how great that may be, that he will have no reserve force for the life-struggle that must come before the crisis is reached. Nearly the same thing is true for typhoid fever in the same class of persons. A young athlete, who considers it babyish to confess to illness, complains of feeling out of sorts but nothing more, until some morning he is literally unable to leave his bed, or has a fainting fit after going up-stairs. He is found by the physician with a temperature of 104°, or near it, and with evident signs of being in the middle of the second week of typhoid fever. The termination of such a case is generally fatal. The ordinary man knows his limitations better; he recognizes the fact that he may be ill, and gives in quietly and rests, so that nature may employ all her energies in conquering the infection. Most of the long-lived people of history have been rather delicate and have learned young the precious lesson of caring for themselves. This care has not been exaggerated, but it has consisted in avoiding danger, in resting when tired, in not overdoing things, and above all in yielding to the symptoms of disease before these become serious. Regulation of Exercise.--Each man must be a law unto himself as to the amount of exercise that is necessary for him. He must take enough to use up the energy supplied by the food he eats, just as, on the other hand, he must eat enough food to make up for whatever waste there is in his body. There are many men who eat over-heartily and then have to take exercise to use up this material or else suffer for it. This is one of the compensations that the hearty eater must pay: he overfeeds and becomes obese, or, if he succeeds in keeping down his weight to the normal, it is only by the expenditure of time in securing such muscular action as will use up surplus energy. Many men find it difficult to control their appetites, and prefer to take exercise rather than to deny the appetite which they created during their days of indulgence in athletics. It is for such men to decide just what seems preferable. If the fuel is supplied to the heat engine, which all human beings are, it must be used for the production of energy or else it will exert {203} itself in accumulating certain waste in the tissues, just as over-abundant fuel serves merely to clog up the fire-box of an engine without doing any work. Air and Exercise.--It is easy to deceive one's self in the matter of exercise. With regard to air such a mistake is almost impossible. As a rule, it is air rather than exercise that people need when they have the restlessness and nervousness which comes from over-abundant nutrition. Fresh, pure air enables the individual to burn up nutritive material to the best advantage by the encouragement of oxidation. It is a surprise to those who are not accustomed to it, to see how tuberculosis patients who come to sanatoria with very little appetite, soon acquire an appetite and are able to consume large quantities of food, to sleep well and become restful--all as the result of living constantly in the open air during the day, and also having an abundance of fresh air at night. This is particularly true if the air in which they live is rather cold, and, above all, if it has a large difference of temperature every day, so that there is an upward and downward swing of the thermometer of from thirty to forty degrees. This varying temperature seems to use up nutritive material, and keeps all the natural processes going. Gymnastics.--The very opposite to this plan of open air life is that followed by those who take gymnastic exercises for health's sake, with the idea that the use of certain muscles is necessary to keep the bodily economy in equilibrium. Such gymnastics are usually undertaken indoors, sometimes in stuffy quarters, and the movements are commonly repeated with such continued routine that absolutely all interest is lost. That there are many who advocate this form of exercise, it has nearly always seemed to commonsense physicians an entirely wrong solution of the important question of the encouragement of oxidation. It is like running an engine, not for the purpose of having it do something, but simply in order to have it oil itself, and consume the fuel that has been put into its boiler and that must be used up because more will be put in to-morrow. It would be much better, either to limit the amount of fuel or to give the muscular exercise some useful purpose, above all connect it with some interest that furnishes diversion of mind at the same time that the muscles are used. This last is the most important consideration, for, after a time, gymnastics pall in spite of artificial incentive. Dr. Saleeby, in "Health, Strength and Happiness," has expressed very forcibly what has come to be the feeling of many physicians with regard to gymnastics, especially indoor gymnastics: The natural spontaneous exercise having been forbidden, and the bad consequences of no exercise having become conspicuous, there has been adopted a system of factitious exercise--gymnastics. That this is better than nothing, we admit; but that it is an adequate substitute for play we deny. . . . The common assumption that, so long as the amount of bodily action is the same, it matters not whether it be pleasurable or otherwise, is a grave mistake. . . . The truth is that happiness is the most powerful of tonics. . . Hence the intrinsic superiority of play to gymnastics. The extreme interest felt by children in their games and the riotous glee with which they carry on their rougher frolics, are of as much importance as the accompanying exertion. And as not supplying these mental stimuli, gymnastics must be radically defective. Granting, then, as we do, that formal exercises of the limbs are better than nothing--granting further that they may be used with advantage as supplementary aids, we yet contend that they can never serve in place of the exercises prompted by nature. For girls, as well as boys, the sportive activities to which the instincts {204} impel, are essential to bodily welfare. Whoever forbids them, forbids the divinely appointed means to physical development. Play and Exercise.--There has been a distinct tendency in modern times to think that gymnastic exercise can be a substitute for play for growing young folks. When certain of the instruments and methods of the modern systems of gymnastics which have been introduced into schools, and are supposed to be so wonderfully beneficial, are put to the test of the psychology of exercise, the conclusions are likely to be very different from the theories under which they were introduced. Dr. Saleeby has expressed these differences rather strikingly: Anyone who will consider for a moment the natural constitution of man and the principles of natural education, must agree that the deplorable thing called a dumb-bell offers an exquisite parody of what exercise should really be. The cat, as she exercises her kittens along the lines of their natural proclivities and needs, never telling them that this is exercise for the sake of exercise, and certainly prepared, if she could, to turn up her nose at any artificial implement we might offer her--should be our model in this respect. It may be imagined that some unfortunate girl, brought up on early Victorian lines, having never been permitted to wear comfortable garments, or to stretch her arms, would welcome and enjoy the dumb-bells when first introduced to them. But any one who has had a natural childhood and who has been taught to play, and who has taken his or her exercise naturally, or incidentally in the course of pursuing some mental interest--any such person may be excused for saying that a pair of dumb-bells should be deposited in our museums as indications of what was understood by exercise even as late as the earlier years of the twentieth century. All exercise for the sake of exercise is a mistake--or, at any rate, a second best. You may do your mind--and body, too--more harm by sheer boredom than you may gain good from the exercise you go through. The dumb-bell symbolizes the fact that the most elementary and obvious truths of psychology are still unrecognized, though the play and games of every natural child--if you object to be instructed by kittens--should be perfectly sufficient to teach us what indeed nature taught us ages ago, if only we would listen to her. Indoor Sport.--Indoor sport is another thing. In wintry weather it is impossible to play outside conveniently, and indoor games have their place. Unfortunately they are usually associated with dust, and when played before crowds of spectators, the participants suffer also from the disadvantage of rebreathed air containing, too, the emanations of those who are looking on. It must not be forgotten that these two factors are the most prominent predisposing causes of tuberculosis. Those who have any tendency to tuberculosis, by which is meant specifically all those who are associating with tuberculosis patients, whether those patients are related to them or not, or who are more than 20 per cent. under the weight that they should have for their height, should not be allowed to take part in indoor sports where these drawbacks are sure to be encountered. Sport, because of the diversion of mind involved, is an ideal form of exercise. An exercise that becomes a mere routine and that can be eventually gone through with so mechanically as to leave abundant room for thoughts of business or study or worries of other kinds, loses sight of one of the principal purposes of exercise as nature demands it. Horseback Biding.--It is because of the complete diversion of mind that is necessarily involved in it, that horseback riding makes such a magnificent exercise for the busy man. The old expression "the outside of a horse is the {205} best thing for the inside of a man" is founded even more on the mental influence of horseback riding than its physical quality. The same amount of exercise in the open air, taken otherwise, often does not accomplish so much good, because a man's thoughts may continue to run on his business or be occupied with his worries, or he may not be able to divert his thoughts from himself and his digestion or his ills. A horseback rider must pay attention to the other animal, rather than himself, and that represents the complete diversion of mind so necessary for the health of most people. Just as soon as man rides an old favorite animal on whose back he can throw down the reins, allowing it to saunter on as it will, while he occupies himself with other things, then horseback riding loses its efficacy and falls back into the class of bicycle riding or carriage riding or walking in the open air unless there is diversion of mind in the scenes, or the necessity for care at street crossings, to banish preoccupation of mind. Unless business troubles and worries are necessarily excluded by its conditions, or are deliberately eliminated from the mind during the course of any exercise, it may even become a renewed source of worrisome thoughts, rather than a renewal of energy, mental and physical. It is doubtful whether horseback riding should ever be recommended for those who have not been accustomed to it from their youth. To ask a man past forty to learn to ride horseback for the sake of exercise is nearly always a mistake. It becomes a trial rather than a recreation, and may thus do harm rather than good. On the other hand, horseback riding is one of the things that may be, and indeed often is, much abused. The old English fox-hunting squire would never have lived out his life even as long as he did, consuming the amount of proteid material that was his custom, and drinking his three or more quarts of port at dinner every day, but that the excessive drain upon his system by long days of hard riding in the hunting field made calls upon his nutrition which kept even this amount of food and stimulant from doing immediate harm. Just as soon, however, as long spells of severe exercise become excuses for the consumption of big dinners, and exercise is used as a factor to enable one to overeat with more comfort than would otherwise be the case, a vicious circle is formed, and one serious abuse is counterbalanced by another. What many well-to-do people of leisure need is not so much more exercise as less eating. Walking.--Perhaps the best and most readily available form of exercise for most people is walking. It has one disadvantage. As soon as the walk becomes too much of a routine, and the ground gone over has lost its interest, or is even of such a nature as to permit or, indeed, tempt introspection and occupation with other things, rather than with the surroundings, then walking loses most of its efficacy as a form of exercise. Walking in the country, for instance, becomes monotonous, though at first it is a great source of pleasure. Walking in a large city, however, has little of this objection and as large city life has grown more and more strenuous in recent years, the good effect of walking to and from the office or walking in the busy parts of the city has been increased. Between the trolley and the automobile, and the hustling commercial traffic of the streets, it is impossible for a man to walk through the busier portions of any large American city without keeping his wits thoroughly intent on what he is doing, nor without requiring all of his {206} attention for his transportation. An abstracted man will in the course of a half hour have so many narrow escapes from being run down in a busy quarter that he will either eschew walking in that particular neighborhood, or give up his habits of mental abstraction, or else he will come to himself some day in a hospital. Besides, the passing show in city life is itself of surpassing interest. It is not things but men that interest us most. There are so many phases of human life to be seen on busy city streets, so many things happen in the course of even a short walk to bring out prominently traits of human nature that, if a man is at all sympathetic, he finds much to occupy his attention, to distract him from his own worries and take him away from his business cares. The long walk to and from the office may thus become an efficacious source of thoughts that are different and of profound pleasure. All depends on the man and his mood. Men who try it whole-heartedly soon find a renewed interest in life. An hour of daily walking in the open air with the distractions of city life all around, provided the walking is done briskly and faithfully, is of infinitely more hygienic value than an hour of gymnasium work. There is only one thing that hampers this form of exercise--there are so many excuses to tempt one not to keep it up. If one gets to a gymnasium there is an instructor or director who keeps tabs on one's hours and so helps a weak human will, and excuses are easier made to one's self than to others. Massage as Exercise.--This curious tendency of men to take their exercise far more regularly, provided some other is concerned in their taking it so that it cannot be neglected without explanation, is illustrated in many of the experiences of the doctor in modern life. A number of forms of massage have come into vogue as wonderful cure-alls. It is comparatively easy for some men, and above all for many women, to take their exercise by means of massage rather than in some more vigorous way that requires their own initiative. A man who is working hard, and who feels the need of exercise, will not take the easy natural way of getting up half an hour earlier, having his breakfast half an hour sooner and then walking down to his office four or five miles, but he hears of someone who gives vigorous massage and he engages him to come every morning and exercise him for half an hour or an hour. In order to do so, he has to get up an hour earlier, but the fact that he has the engagement with someone else, rather than with himself, makes it more difficult for him to make excuses, and so morning after morning, in spite of the fact that he may have been up late the night before, perhaps to a big dinner, he gets up to be given his exercise. If he is a heavy eater he will, of course, at the end of a week or ten days feel ever so much better for he has been using up material that was clogging his circulation and irritating his nervous system. At the end of a month he will probably feel so much better that he will conclude that he has found the root of all evil in life, or of all disease, in a failure of circulation that can be removed by means of massage, manipulation and passive movements. When he gets well enough to give it up, he drops straight back into his old troubles, because what he needs is a radical change of life that will adapt his eating to the amount of exercise that he takes, and his exercise to the amount that he eats. If this fails to come, he has had only a temporary benefit that has probably tempted him rather to increase {207} the amount that he eats normally than otherwise and will probably do him harm in the end. This massage brings about a distinct reduction in the weight of women, and as most of them are very desirous of this, the remedy becomes even more precious to them than to men. Here, too, however, it is only a temporary expedient. They are tempted to eat more than before, or at least not to reduce their diet, and the good that is accomplished is only for the moment, while no habits, either of restraint of eating, or of more exercise in the open air which so many of them need, have been formed. Passive Movements.--The success of osteopathy has been largely founded on this curious peculiarity of human nature. People are not satisfied to regulate their eating and exercise in a sensible way. They prefer to submit to various methods of exercise, manipulations and passive movements which make up for the muscular exertion that should help the circulation within the body, but do not accomplish the purpose nearly so well as the voluntary exercise of muscles. It requires little exercise of will to submit to this treatment, while for many people it requires considerable exertion of will power to exercise their muscles for themselves. The old particularly, who are likely to suffer from achy conditions around joints, always worse on rainy days, which would be expelled by enough exercise to stimulate the circulation in these structures, find the new remedial measures of vicarious exercise of great service to them and consequently osteopathy has gained many votaries. Old members of many a state legislature who have been accustomed to ride for so long that exercise is almost an unknown quantity in their lives, are treated by the osteopath and lose so many vague pains and aches and discomforts of various kinds that it has not been difficult to persuade them that it is a great new discovery in medicine, and so in many of the states the osteopaths have secured legal recognition. Summary.--Exercise, as exercise, often does harm rather than good. Thin people seldom need exercise, stout people seldom take enough of it. No one should be encouraged to exercise merely that he may be able to use up material that he has eaten, when it is evident that he is eating more than is required for his ordinary occupation. The question can never be settled without taking into consideration all these individual peculiarities of each case. Properly used, exercise is one of the most important therapeutic aids. But it is liable to as many abuses as are drugs, and the patient's attitude of mind toward any particular exercise is always an extremely important factor. If the exercise produces fatigue and disgust, then it will do no good, in spite of all that is hoped from it. If it creates true diversion of mind, it will surely be precious, even though it may, for other reasons, seem unsuitable. CHAPTER III POSITION There are many changes of position that relieve pain, lessen discomfort, aid in excretion, and in the evacuation of material from the body, yet it is often found that very little advantage is taken of this natural method of therapeutic aid. Traditions and habit often rule to such an extent that {208} certain quite unfavorable positions are assumed, modifications of which frequently bring about distinct amelioration of symptoms. Very often patients learn this alone. There are many mechanical principles that can be applied in the treatment of pathological conditions which patients will not use unless definite suggestions are made. Often the physician has to suggest that they should try first one position and then another, in order to determine whether a certain amount of relief may not be afforded by position alterations, and perhaps function encouraged, or at least certain inhibiting factors modified for the better. Favoring Return Circulation.--For people who have to stand much during the day, position in their resting hours is often extremely important. The caricature of the old-time American exhibited him with his feet on the mantlepiece, or somewhere as high as his head. For thin individuals there is no doubt that the placing the feet about as high as the head often makes a very comfortable position for a time. To those who have been standing much it is particularly restful. This may be easily accomplished lying down, though it must not be forgotten that the tendency to place the feet on a neighboring chair, or over the arm of the chair, so often seen in young folks, is in response to a physiological stimulus that brings relief to the heart by encouraging by means of gravity the return circulation in the veins from dependent portions of the body distant from the heart. For people who have not much exercise, and who have to stand all day, a brisk walk or leg exercises that thoroughly empty their muscles of blood by bringing about active contraction of them is important as a factor in their hours of rest. It makes all the difference in the world between the feeling of intense tiredness due to the sluggish circulation, and a return of vigor in the muscles. Varicose Veins.--For patients suffering from varicose veins, position is particularly important. When they have to stand much, their limbs get painfully tired. The ache in the sense of fatigue is reflected over the body with the resultant depression. Active exercise, for a time, is not so good for them, and yet it is helpful. The ideal relief from their achy condition is afforded by gentle massage upwards of the limbs. That empties the dilated veins of blood and restores vigor to the circulation. It must not be forgotten, that when the circulation in the lower limbs is rendered sluggish by varicosity, the heart is also affected because it is so much more difficult to secure the return of blood through the tortuous dilated veins. This accounts for the intense general sense of fatigue that many of these patients have. Varicosities have a definite tendency to develop in those who are occupied in standing occupations, waiters, footmen, clerks, and the like, and often they have to continue at these occupations in spite of the varicose condition. It is particularly important for them to have an hour of lying down during the middle of the day so as to break their day's work in two. With a little insistence it can be secured in a great many cases and will afford more relief to the patient than anything else that can be done, even the wearing of rubber stockings, bandages and the like. I have known waiters massage each other at the time they had their period of rest with excellent results. For the rupture of a varicose vein, position may be one of the most important auxiliaries to prevent serious hemorrhage. I remember as an ambulance surgeon once being called to see a case in which a great deal of blood {209} had been lost because efforts had been used to stop the bleeding by the application of a tourniquet. This shut off the superficial arteries, but not the deep ones and effectually prevented the return of any venous blood into the trunk, while all the time the ruptured varicose veins continued to bleed profusely. Local applications of styptics failed, of course, because the varicose vein itself had nearly the diameter of the little finger. Pressure over the wound did good for the time, but the bleeding was renewed whenever it was let up, and the two physicians in charge, alarmed at the loss of blood, were beginning to lose their heads. The ambulance was summoned to take the patient to the hospital and when it was suggested that if the tourniquet were removed and her foot was elevated the bleeding would probably stop without more ado, the suggestion seemed too simple to be true, but the event showed that that was all that was necessary. Relief for Flat Foot.--For the achy discomfort of flat-foot, which is usually felt much more in the calf and the knee than in the ankle, some vigorous exercise for the foot, and especially for the calf muscles, at times during the day is likely to give great relief. Ten minutes of vigorous movement of the calf muscles followed by half an hour lying down will save most of them from the intense tiredness that is very discouraging in the late afternoon in many of the standing occupations. This relief removes from patients' minds the common idea that there must be something serious the matter with them. A good many of those who are cured of rheumatism by osteopathy, and of kidney trouble by the advertising specialists, and of various nervous diseases by new thought and irregular mental healing, are only sufferers from conditions such as can be relieved in this way. When flat-footed people sit down they should be advised to cross their feet (not their legs), because this emphasizes the arch of the foot somewhat and helps to strengthen and preserve it. Abdominal Relaxation.--Many of the discomforts within the abdomen of which patients complain, especially whenever their attention is concentrated on them, can be benefited by suggestions as to position. Many a man who feels very uncomfortable after a hearty meal when sitting curled up beneath a lamp to read the evening paper, does not notice it at all when he stretches out on an easy Morris chair and with head back talks to friends. Many a man who thinks that his discomfort after dinner must mean serious dyspepsia, finds that a game of billiards after dinner will often dissipate almost completely his ill-feeling, unless, of course, it is due to overeating. After meals generally, positions that crowd the abdominal organs should be avoided. It must not be forgotten either that when lying down a full stomach may very well interfere with the heart action and produce marked palpitation. There are many men who cannot lie down within two hours of having eaten a hearty meal without decided heart irregularity, though while they are sitting up or standing quietly, or even moving, there will be no sign of this. Many of the vague discomforts within the abdomen, those due to movable kidney, or even chronic conditions in the biliary or urinary tracts, are only manifest when there is crowding of the organs within the abdomen. How much the mechanical element may mean in kidney and biliary conditions is well illustrated by the relief often afforded by changes of position when calculi in these organs are giving trouble. Both renal and biliary calculi, which perhaps have been lying quite harmlessly in their positions {210} for years, are especially likely to become productive of discomfort by a jolting ride, or the jar of a fall, or by the influence of changes of position produced by gymnastic efforts of an acrobatic kind, or by a loop-the-loop experience, or something of the kind. In spite of this, only rarely does the physician try to use changes of position for their relief. I have seen a man suffering from excruciating biliary colic get almost immediate relief when put standing on his head alongside of a lounge. He looked upon it as magic. It was only that the stone, in the midst of the relaxation of all abdominal muscles produced by the unusual position, was able to drop back into the gall bladder, where it had been for months perhaps years before without giving any trouble. Similar relief is often afforded from the pain of kidney stones before they become definitely engaged in the ureter. Raising the Head.--Patients suffering from respiratory difficulties usually learn to accommodate themselves to such changes of position as will afford them the greatest relief. The difficulty of breathing leads to such tossing about that the position easiest for the patient is almost inevitably found. When respiratory difficulties first declare themselves patients may not realize how much relief will be afforded by raising the head, or by the assumption of a sitting position. Often such patients prefer to sit in a chair. It should be borne in mind that, wherever this is compulsory, dispositions can be made so that the chair shall be as comfortable as possible, that its seat edge shall not press upon the underportion of the legs so as to impede blood circulation, nor press upon nerves, and that comfortable arrangements shall be made for the arms. When the patient's head has to be raised in the bed, it is much better to raise the mattress by placing some large properly-shaped object underneath it, so as to secure a gradual slant rather than have the patient's head and upper portion of the thorax bent by pillows. In default of something better, a chair placed so that the mattress lies along its back will be a handy aid. This is a matter of nursing rather than strictly of medical attendance, but unless the physician pays attention to it, it will be neglected, or at least in many cases not used to the best advantage. Whenever there is difficulty of expectoration, especially when expectoration is abundant as in certain of the chronic bronchitises, and above all in dilatation of the bronchi, the advantage of position should be taken to aid in the expectoration. Patients who have to cough up large amounts in dilatation of the bronchi and who have long severe fits of coughing in the early morning, will often obtain a great measure of relief by leaning out of bed with one hand on the floor, doing their coughing in that position. Gravity helps in the emptying of the pockets of the bronchi and in five minutes they succeed in getting up satisfactorily as much material as would come up, only after severe convulsive efforts for an hour, when gravity was in opposition to their efforts. Children in whooping cough naturally bend over in order to cough. They will cough easiest if placed on a bed with a pillow beneath their chest so as to lift the face from the mattress, or in the case of older children, with the head projecting beyond the edge of the bed. This is only a trifle, but it will often save children severe convulsive efforts. Tuberculous patients who have to cough much, should be encouraged to find for themselves by trial whether certain positions, leaning out of bed, may not be of great service to them. There is often in advanced cases an accumulation of material during {211} the night that must be expectorated, and the patients are severely shaken up by their efforts to bring it up. I have known cases where a considerable measure of relief was afforded by leaning out of bed with the elbow on a pillow, a chair or foot-stool somewhat lower than the level of the bed. The mechanical help of gravity is particularly important where cavities exist and a considerable amount of material has to be emptied out of them. In modern surgical times one does not often see the emptying of a purulent pleurisy through the bronchi, but I once had an opportunity to see the termination of one of these cases in a very favorable way. When I saw her the patient had already coughed up a cup full of purulent fluid and, altogether, about a quart of pus was thus evacuated. The patient had been so ill that the effort was considerable, but the evacuation was greatly helped by having her lean out of bed whenever material was to be expectorated. The patient is still alive and in good health--fifteen years after the event. Heart Cases.--Position is also often of very great importance for the relief of the symptoms of patients suffering from heart affections. For organic heart affections, rest in bed is often advised. It must not be forgotten that this does not necessarily mean in a recumbent position. Whenever there is difficulty of breathing in connection with an affection of the heart, the recumbent position is extremely uncomfortable. This is nature's safeguard against the accumulation of fluid in the dependent parts of the lungs at the terminal capillaries of the pulmonary circulation. Most of the natural demands have a definite reason and are prophylactic rather than merely a symptom of aimless discomfort. Patients with heart disease often want to sit up in a chair. Their wish should, as a rule, be yielded to. There is no need of their sitting in a narrow uncomfortable armchair, nor of being incommoded by the position they have to assume. The end of a large lounge, especially one that curves over towards the floor on which pillows can be piled so as to make the patient comfortable, and yet afford many changes of position, is the best. In general, the arrangements should be such that changes of position can be secured without much difficulty. These prevent hypostatic pneumonia and guard the patient against serious accumulations in the lung tissue because of sluggish circulation. Changes of position can be used as valuable suggestions. Often the main portion of the patient's symptoms consists of the intense fatigue due to one position. This can be relieved and the patient made to feel that, after all, the ailment to which he is suffering must not be so serious since relief can be afforded so simply. Besides, when patients complain, something must be done for them. Medicine cannot be given for every symptom and yet some remedial measure there must be to satisfy them. This satisfaction will often be secured by changes of position, by slight local treatment, by the adjustment of pillows so as to relieve fatigue of particular muscles and parts of the body, and by the movements of the limbs and the head into other positions than those in which they have become fatigued. The experienced nurse is of the greatest possible value in these cases. Restlessness.--Usually restlessness is considered to be an unfavorable symptom of disease, just as are pain and tenderness. Like these, however, it is really conservative rather than in any sense destructive. Pain prevents serious changes from taking place without our attention being effectively {212} called to them. Restlessness induces the patient to change position frequently and often leads to the discovery of some position in which there is much more comfort than the one that had been assumed. Restlessness, in the recumbent position, is usually nature's protest against the maintenance of a posture in which, owing to failure of circulation, there may be leakage of serum into the lung tissues with dangerous results. Restlessness, in abdominal pain, often leads to such a change of position as affords the best condition for the relief of the discomfort as far as that may be brought about by position of muscles. The man with colic very soon discovers that lying on his stomach may relieve his pain. The drawing up of the knees in peritoneal conditions is the result of a similar reaction. The physician must learn to imitate nature, and recognize what mechanical conditions are likely to be of help. As soon as these afford relief, they act as a strong favorable suggestion, on the patient, and relieve dreads with regard to his affection. Joint Affections.--In painful joint conditions, position may help much to bring relief or at least considerable mitigation of symptoms. In rheumatism, for instance, of the acute articular type, a number of small pillows can be disposed in various ways, underneath the patient's limbs, between them and in other positions, so as to give as much comfort as possible and will often be of great value. There should be at least half a dozen pillows at the disposal of the patient, besides three or four for the head. In certain relaxed positions of the joints, there is more room within the capsule than others and, almost unconsciously, the patients assume such positions when there is pain from effusion. Occasionally, however, in the midst of fever, or because of apathy, patients may not do this, and then care should be taken to bring them some measure of relief. Generally patients suffering from fever, with delirium of typhoid condition, that is, when there is considerable apathy, should have their positions changed gently from time to time to prevent discomfort developing, and as a prophylactic against skin disturbances from pressure. In children, this is particularly important. Bladder Evacuation.--In emptying the bladder position may mean much. After childbirth, especially the first, many women are quite unable to empty their bladders while lying down, though if they are allowed to assume the usual position there is little or no difficulty. In certain sensitive men whose power over their bladder is disturbed by self-consciousness, the presence of anyone in the room or near them, makes it impossible for them to urinate, and this is particularly true if they are lying down. In the milder forms of prostatism position occasionally seems to have some influence in helping to empty the bladder. When there is a prostatic bladder pouch behind the prostate, it is quite impossible to empty this in the standing position. It may be emptied in the prone position, that is, lying face downwards, particularly if the pelvis is elevated above the rest of the trunk. Undoubtedly some of the cures reported after operation, when the operation itself effected no reduction in the size of the prostate (as the removal of the testicles or vasectomy), the improvement was brought about partly by the more favorable position in which, for weeks after the operation, the patient emptied his bladder, and also by the greater control gained over it, by the persuasion that the operation would do him good. The same suggestion can be made in connection with the new position for urination with just as good effect. {213} Intra-abdominal Conditions.--There are many intra-abdominal conditions in which position is of great importance for the relief of pain. Appendicitis cases are found with the right knee drawn up because this relieves the tension of the abdominal muscles, and probably also of the large muscles that go to the thigh and lie behind the peritoneal cavity. In most cases of intra-abdominal pain flexing of the knees on the abdomen means much in affording relief, and patients usually discover this for themselves. There are certain apathetic patients, however, who need to be helped by suggestions. In certain of the painful conditions, due to intra-pelvic conditions, relaxation of muscles by flexion lessens the pain. Pressure upon the abdomen, as by lying on a pillow, often does this also. Apparently one reason why children with flatulent colic stop crying almost at once, when laid on their stomachs, is because the pressure thus produced tends to bring about a movement of the gas that, collected at one or two places, was causing painful distention. Importance to the Physician.--There are many other suggestions with regard to position that will occur to thoughtful physicians in particular cases. The one idea is to secure such an alteration of the posture as is likely to bring about mechanically relief of pain. If relief is afforded in this way, as has already been emphasized, a very favorable influence is produced on the patient's mind. Above all, he realizes that his physician not only understands his general condition, but his experience with many patients suffering from the same ailment has given him the power to direct even such slight changes of position as will give comfort. Nothing that I know adds more to the confidence that a patient has in his physician than the realization of this sort of knowledge. Therefore, the necessity for such consideration of each individual case as will enable the physician to recommend such modifications of position to patients. At the same time the patient's mind can be influenced very favorably by attaching definite significance to these alterations, and having them, as it were, repeat their favorable suggestions every time that he thinks about them, and be pleased as to the relief they have afforded. This is the sort of psychotherapy that is particularly likely to be successful, and it needs careful cultivation and development. CHAPTER IV TRAINING One of the most important factors for therapeusis in the sense of the amelioration of defective motor conditions, the relief of disturbing sensory affections and the restoration of or compensation for defective functions of various kinds is training. By this is meant the training of the power of attention and its concentration in such a way that defects are overcome. There are many examples of almost marvelous improvement of function brought about in this way that are familiar, but it is well to recall some of them here in order to illustrate the uses to which this therapeutic mode may be applied. A blind man is able to read by means of his finger tips, and to recognize raised letters that seem quite beyond the possibility of tactile recognition by {214} ordinary individuals gifted with all their senses. The peculiar skill is simply due to the individual being able by concentration of attention upon slight variations in touch sensation to recognize even minute differences readily and so read raised letters with comparative ease and rapidity. Over and over again it has been shown that neither the congenitally blind nor those whose vision has become defective have any better sense of touch than the average person. With an esthesiometer, their power to recognize the distance between the points of a calipers is shown to be no better than that of an ordinarily sensitive individual. This is illustrated in other ways. Certain blind persons, even those born blind, are known to be able to distinguish colors more or less accurately, that is, at least the three primary colors. Their power to do this is consequent upon a faculty of recognizing differences in heat absorption. The ordinary seeing person going into a room in the dark recognizes at once the difference between a pencil and a piece of metal of the same shape and size by its weight and the greater tendency of the metal to feel colder. When we are not sure whether a pillar in a structure is of stone or an imitation, we determine this by touch, and the fact that stone absorbs heat rapidly while wood and other imitations of stone do not. It is the same faculty for distinguishing specific heat that enables certain blind people to recognize colors. If pieces of cloth of different colors are put over snow when the sun is shining on them, it will be found that black absorbs much more heat than the colored cloths, or white, and consequently that the snow melts faster beneath the black. After black comes red, then green, then blue. It is this difference in the power to absorb heat that the blind recognize and thus distinguish colors after long patient training of themselves. Obstacle Sense.--An example of the value of training is the so-called obstacle sense which has been rather carefully studied in recent years. By means of it blind people are able to avoid larger obstacles and to know when they are passing an open door or window on a corridor or a building alongside a street. Blind children have been known to play in a garden where there were trees and other obstacles and carefully avoid them even while moving rather rapidly. This sense is disturbed whenever there is loud noise in the vicinity. It is not very active and yet it is of considerable value to the blind. Its disturbance by noise would seem to indicate that it is due to some sense faculty in the tympanum, or ear drum. It exists in everybody, but remains quite undeveloped except in those who need it and therefore learn to make use of it. Touch and Sight.--The triumph of training is to be seen in the cases of those who are born blind and deaf and who yet are taught to understand through lip and throat reading by the tips of the fingers and taught to talk by being shown patiently the method by which others accomplish it, though the only avenue to their brain is the dull sense of touch which means so little for the ordinary individual. The cases of Laura Bridgeman and of Helen Keller illustrate how a sense that is usually quite neglected can be made to supply the place of both the eyes and the ears by patient, persistent training. Lip reading by sight is, of course, a very interesting example of the same principle that can be learned by anyone who has good sight in a comparatively short time. There are compensations of this kind and powers of development latent in every sense and function of the body that can be {215} employed to make life interesting and to restore usefulness after nearly every form of lesion or defect. Practically all of this compensatory power is mental, hence its place in psychotherapy. We do not increase the power of the sense but by concentration of attention the mind is rendered capable of obtaining definite information from sensory stimuli that are present in every person but that are ordinarily neglected. Hearing.--One of the most surprising instances of the value of training for cases in which favorable results seemed quite out of the question, is Urbantschitsch's method of training the deaf to hear. After investigating it personally I reported it in the _International Clinics_. [Footnote 24] Patients who could hear but very little, indeed, only the loudest noises, were trained by means of loud shouting and the hearing of loud notes gradually to catch sounds more and more easily until not infrequently they could hear rather well. Sometimes even those who were thought to be absolutely deaf to sound were found to be able to hear very loud sounds and then it was invariably discovered that by practice they could be made to hear much more. The secret of the success consisted not in any increase in the power to hear, but entirely in training the attention to recognize and differentiate sounds so that what seemed at first a confused murmur gradually became intelligible. It is exactly the same process as that by which a man learns to read with his fingers. He is not able to differentiate the letters but after a time it is possible to do so without difficulty. [Footnote 24: Lippincott & Co., Phila., Vol. IV, 8th series, 1899.] Equilibrium.--There are typical examples of almost as striking increase of muscle sensation, or rather of ability to distinguish minute differences in muscular sensation, noted in those who train this faculty carefully. Acrobats succeed in developing wonderful control over muscles and marvelous response to slight disturbance of equilibrium. The ordinary individual has comparatively small balancing powers, but the slack-rope performer seems almost to defy the laws of gravity, because he has learned so to coordinate all muscular action as to enable him to maintain his balance. He has trained himself to distinguish every variety of message from his semicircular canals. Of itself neither of these senses gives us very much information, indeed, only as much as we ask for from it, but when we pay careful attention to the minute details of the information that it imparts, we are able to use it to great advantage. Muscle Training.--It is this power of training to enable us to appreciate minute sensations that forms the basis of the Frenkel treatment of tabes. For the proper guidance of the muscles the muscular sense is all-important, though ordinarily we are quite unconscious of the information it conveys. This is seriously disturbed by the degeneration in tabes. The patient can, however, be taught to use even the slight amount of it that remains to great advantage or else to avail himself of some other compensatory sensations which will enable him to guide his muscles in various motions much better than before. This same faculty can probably be employed in many other conditions. Frenkel has shown that it is applicable in paralysis agitans and markedly relieves the rigidity that is so annoying a symptom. It gives these patients something to occupy their minds, too, which means a great deal for their {216} general condition, for occupation of attention saves them from neurotic disturbance of themselves. Sufferers from infantile paralysis can be taught to do many things with their weakened muscles that seem to be quite impossible to them. It requires patience to get results, but they mean so much that the efforts are well worth while. After cerebral incidents, sometimes actual apoplexies, sometimes injuries, occasionally serious effusions due to kidney diseases, there may be disturbance of motor functions. It is surprising how often training will enable the sufferer to use his muscles much better in these cases than at first seemed possible. I have seen a man who had lost most of his power for writing after a cerebral incident regain it as a consequence of being taught to write from his shoulder, instead of from the forearm as had been his custom. Heart Training.--In recent years we have learned that training is not only good for the external muscles and enables them to do more work without discomfort, but that it is particularly beneficial to the heart muscle whenever that organ can respond to it favorably. At all of the heart cures in recent years, exercise of some kind or another is one of the important features and the failure of physicians generally to secure as good results while pursuing all the other methods followed at these cures, seems to show that exercise was probably the most important factor. Nauheim is the typical heart cure and there, besides the resisted movements in the bath, there is the graduated exercise of the walks around the town, all of which, owing to the situation, lead up hill. Walking up hill, even though it be a gradual ascent, might seem to be the worst possible exercise for heart patients, yet it proves eminently beneficial. Respiratory Training.--Shortness of breath is often a bothersome symptom, especially for stout people, and prevents them from taking necessary exercise. When it cannot be traced directly to some affection of the heart or of the circulatory apparatus, it is usually due to lack of exercise. Much can be done for it by deliberate training. In the modern time, with elevators so common, people seldom have to walk up-stairs, and consequently one of the modes of exercise that was particularly likely to furnish some training in deep breathing is absent. Any one who has seen the shallow breathing of many of the patients who come to Nauheim and how much it has improved by the gradually increased walks up the hills around the valley, will appreciate how much training in deep breathing means. This exercise of the diaphragm will often give benefit besides in making the bowels more regular, and in getting rid of the accumulation of fat in the abdomen, which is one of the mechanical causes of the interference with the diaphragm and consequent shortness of breath. Training the Appetite.--Just as training may be used for the sensory and motor systems that are external, so it may also be used for many internal functions analogous to these. There are a great many people who eat too little. They are the nervous, irritable persons with no fund of reserve energy to draw on when anything happens, and who are in their years before middle life likely to be the victims of infectious disease. They suffer much from lack of proper covering in the winter time and from a certain protection that is afforded to the nervous system generally by being up to weight. Often their under-weight is a life-story, and occasionally it is a family matter. When {217} they suffer from neurotic symptoms a gain in weight nearly always does them good. They complain that when they increase their diet they have uncomfortable feelings. This is only what is to be expected, since the muscularis of their stomach--much more important than its secretory function--has not been accustomed to as much exercise as is now being demanded of it. On the other hand, for those who are over-weight, training in eating less is the one important therapeutic factor. If their diet is cut down suddenly, they soon become discouraged. If there is a gradual reduction of food quantities, variety being allowed, so that they may eat practically everything they have been eating before, the system gradually accommodates itself to less and less food. This is the only sensible way of bringing about reduction in weight. It requires constant attention over a long period, but it can be done with excellent success. In the same way the bowels may be trained to perform their work regularly. Habit means probably more with them than any other factor. Our digestive tract, however, is largely dependent on habit. We get hungry three times a day or twice a day, according to the custom that we have established. Countries differ radically in the matter, and nearly always, when a man goes from one country to another in early years, he changes to the habits of the new country, though if he comes after middle age he usually clings to those that he is used to. Training to Stand Pain.--There are many painful conditions, especially involving the muscles in the neighborhood of joints, that are worse on rainy days and are spoken of as rheumatism, that can be very much improved by training in the use of muscles. As men grow older and gain in weight, the lack of exercise in their sedentary lives incapacitates their muscles for activities of many kinds. The consequence is that where most strain is put upon them, in the neighborhood of joints, they readily become tender and painful. It is this class of cases particularly that is benefited by irregular practitioners of all kinds. Mental healing, osteopathy, Eddyism, the many liniments, rubbings and manipulations prove beneficial. What is needed is training in the use of muscles so as to enable them to do the work that is required of them without discomforting reaction. This is particularly true for the leg and foot muscles. Exercises that strengthen the muscles of the calf and of the thigh, and particularly such as require free movement of the foot, are almost sure to relieve these patients of many annoying symptoms. Pains around the ankles and in the knee and hip, worse in rainy weather, disappear as a consequence of such gradually increased use of these muscles as gives them increased nutrition and power. This subject is discussed more fully under Foot Troubles and Painful Conditions of the Knee. There may be a training in bearing discomfort which is of great value to over-sensitive patients. Some nervous patients seem to suffer merely from their ordinary physiological functions. These are the patients who abuse the drugs that are supposed to bring relief. There is just one mode of treatment that is successful with them: they must be told to bear their discomfort for a while without seeking drug relief, but always securing freedom from discomfort by means of attention to other things, until gradually they have succeeded in diverting their minds from the concentration of attention on their functions which is causing their disturbance. The whole programme {218} need not be outlined to them or they will perhaps have a revulsion of feeling against it that will make its accomplishment impossible. They can, however, be made to stand their discomforts for a time with the promise that it is for the best, since there will be eventually an improvement. Intellectual Faculties.--Nearly every one of our faculties can be trained to do much better work than we have any idea of if we only are willing to take the trouble and give the attention. I have often shown people who came complaining of loss of memory that if they wanted to train themselves to remember they could do so. The memory probably cannot be bettered any more than can the sense of touch in the blind man, but by attention to minute details, in the concentration of the mind on certain subjects, it can accomplish results that seemed quite impossible before. All systems of improving the memory are founded on this method of concentrating attention on what one wishes to remember and connecting it with other things that we know by experience are readily remembered. CHAPTER V OCCUPATION OF MIND Two classes of patients frequently apply to physicians for relief from various discomforts. They are, first, people who have no regular occupation and who often are in what is supposed to be the happy position of being able to do just what they please. The second class consists of those who take their occupations too seriously, so that they never get away from them and, as a consequence, disturb their physical functions. The feelings that these two classes complain of--for, when analyzed, their symptoms prove really to be uncomfortable feelings--can usually be "bothered" away and, if not entirely forgotten, made to disappear when the patients become deeply interested in something other than their usual occupation. The first class of patients needs occupation of mind; the second needs diversion of mind, and that subject will be taken up in another chapter. Uncomfortable Sensations, Their Location and Causes.--These pains and aches, as patients call them, though it is well to remember that they are only discomforts, senses of unequal pressure, of constriction, or perhaps only unusual feelings, or consciousness of sensation, may occur in every part of the body. Perhaps they are most commonly complained of in the head. Many of the so-called headaches that are more or less continuous consist of these senses of pressure or of constriction over a particular part of the skull. Sometimes there may be a sense of pressure at the back of the eyes. Very often there is a feeling of heaviness at the back of the head that makes the patient feel as if relief would come if the head were allowed to drop forward and if sleep could be thus obtained. Every other portion of the head, however, even within the cavities, may have some of these uncomfortable sensations. In some persons, there is a tightness in the throat. In others, there is a feeling of fullness of one cheek and the dread that they may not be able to use it properly in talking. Sometimes the uncomfortable feeling is within the nose. Not infrequently the discomfort is in the ear. {219} All of these may be due to local conditions which need to be corrected, but in most cases nothing is found locally, or at most there is some functional disturbance so slight that, though it is shared by a great many people in our climate, others do not complain of it at all. It seems evident, therefore, that the discomfort must result from the sensitiveness of the individual emphasizing the significance of some slight disturbance. Every portion of the body may suffer from these discomforts. The upper part of the back, especially below the base of the neck, is a favorite location in men, and particularly in those who bend over a desk. The lower part of the back is affected in such men as tailors and cutters who stoop incessantly at their work. In women, the lower part of the back is likely to suffer, and this is usually attributed to genital conditions, but constipation may play quite as large a role as the genital organs. Some of the stooping occupations of women, at the sewing machine or dressmaking, or even harder occupations, as sweeping, washing, and the like, may also be responsible. The commonest source of discomfort is, perhaps, the upper left-hand quadrant of the abdomen. This seems to be due to the distention of the stomach, either by gas or by liquid. Vague discomforts may occur around the umbilicus, often due to the presence of gas, with or without borborygmi. Generally the local condition is only an occasion, and the real cause of the complaint is the lack of occupation of mind and consequent concentration of attention on any organ whose function happens to be disturbed sufficiently to make one conscious of its action. _Lack of Occupation_.--For all of these cases the most important therapeutic factor is occupation of mind and diversion of attention. In our time, social conditions allow a large number of people to have very little occupation. For instance, many women of the well-to-do classes have absolutely nothing that they must do. Various phases of this are discussed in previous sections. As a rule, it is useless to try to relieve these discomforts by anodynes. Many an opium habit has been formed by a turning to opium in such cases. The coal tar products are greatly abused here, for they do not bring relief to queer feelings nor to a sense of pressure or discomfort; they rather add to depression. What they are efficacious for is acute pain. The coal tar products relieve even toothache or neuralgia, as well as a real headache, but I have had patients tell me over and over again that the continuous headaches from which they suffered were not relieved in the slightest degree by phenacetin or acetanilid. Occasionally one hears of hyoscine or hyoscyamus suggested for these conditions, but they are quite as useless and as much contraindicated as opium or the coal tar products. As a rule, these headaches are relieved by lying down; they disappear during sleep. The real indication for treatment, however, is found in the fact that all of these vague discomforts are much better or even disappear when the patient is intensely occupied, or at least pleasurably engaged. What these people need is occupation that really catches their interest and takes attention from themselves. One of the most striking expressions of this truth that we have comes from the poor, sad, mad poet, Cowper: Absence of occupation is not rest; A mind quite vacant is a mind distressed. {220} And surely poor Cowper, himself the victim of depression, saved from himself only by the suggestion that he should put into poetic form the thoughts that came so abundantly to him, could well understand the depth of wisdom in his couplet. The story of Cowper's life is enough of itself to encourage physician and patient to persevere in the effort to lift depression by occupation, since the fruits of that occupation may prove so valuable. _Mental Short-Circuit_.--The minds of these people must do something, and since there is nothing really occupying for them to do, in a very expressive modern phrase, they are doing their possessors. As we suggest elsewhere, the nearest simile is that of the short-circuiting of a dynamo. Mental energy is exerted harmfully within the machine instead of in doing work. See what happens in these cases when by some chance the women, or the men, who complain almost constantly are suddenly deprived of the means which enabled them to live an aimless life. The physician often has patients who have been in affluence but after a financial panic are in straitened circumstances. It is interesting to note what an excellent tonic effect, in younger people always, in older people very often, the change of life has on these chronic valetudinarians. Sometimes this is attributed to the simpler life which they lead when poorer, occasionally to the lack of responsibility, or other similar reason. Nearly always it is easy to see that the real cause of the improvement in health is the occupation of mind with serious interests outside of self. Regulation of Life.--In the matter of occupation, and especially occupation of mind, the formation of habits and the training of the will are extremely important. In his book on "The Education of the Will," which was so popular that it went through over thirty editions in France, M. Jules Payot [Footnote 25] emphasizes the necessity for deliberately arranging the details of life so that time shall not hang heavily on the hands, he reverts to certain rules of life of the old religious orders, and to the habits advised by spiritual directors. He counsels that every one should make an examination of the day's happenings at the end of it, in order to see just where the failures lay and in what accomplishment was made. At the end of this old-fashioned examination of conscience, he counsels that a set of resolutions for the next day be made and an arrangement of work for various times, so that even more may be accomplished. [Footnote 25: English translation by Dr. Smith Ely Jelliffe. New York, 1909.] M. Payot further suggests that a certain time be given up to reflection, or as he calls it, meditation, on the significance of life and on the consideration whether something valuable is being made of it. Without this he insists that it is easy to let one's self slip into habits of life in which absolutely nothing is accomplished for self or others. If there is no real accomplishment, then pleasure soon palls, because pleasure has a place only as an interval in the midst of labor and as a relief from effort. These reversions to the old modes of life and thought of the monastic communities show how little of real advance there is in life, and what excellent conclusions serious men came to even in the distant past. Certainly for many of the leisure class in modern times only the use of periods of reflection and the examination of {221} results obtained will serve to prevent that utter waste of time which leads to the intense dissatisfaction that is often reflected in the general health. Thought for Others.--After forgetfulness of self, the most important factor in psychotherapeutics is thoughtfulness for others. Ordinary diversions are quite insufficient to occupy most people. One must have a serious occupation that appeals deeply, and then diversions of mind will be useful for purposes of recreation. Pleasure, so-called, if pursued not as an interruption from work but for its own sake and without serious occupation, palls, and after a time its votaries find life is scarcely worth living. The pursuit of pleasure as the sole interest of life is one of the most fruitful resources of depression, discouragement and neurotic symptoms with which modern physicians are brought in contact. The only way to be sure of having compelling interests is to be so much occupied with other people that one forgets self. Yet mere flippant excitement and superficial entertainment is nothing but a cheap counterfeit of what is needed. Voluntary effort is needed, and this is the field where the psychotherapist must put in his most intelligent effort. There is no one for whom there is not a chance for work in our social fabric. The prescription of work has not only to be adjusted to the abilities, the knowledge, and social conditions, but has to be chosen in such a way that it is full of associations and ultimately of joyful emotions. Useless work can never confer the greatest benefits; mere physical exercises are therefore psychophysically not as valuable as real sport, while physically, of course, the regulated exercises may be far superior to the haphazard work in sport. To solve picture puzzles, even if they absorb the attention for a week, can never have the same effect as a real interest in a human puzzle. There is a chance for social work for every woman and every man, work which can well be chosen in full adjustment to the personal preference and likings. Not everybody is fit for charity work, and those who are may be entirely unfitted for work in the interest of the beautification of the town. Only it has to be work; mere automobiling to charity places or talking in meetings on problems which have not been studied will, of course, be merely another form of the disorganizing superficiality. The hysterical lady on Fifth Avenue and the psychasthenic old maid in the New England country town both simply have to learn to do useful work with a concentrated effort and a high purpose. From a long experience I have to confess that I have seen that this unsentimental remedy is the safest and most important prescription in the prescription book of the psychotherapist. _Care of Children_.--Probably the most important therapeutic factor in the cure of the ills which come to unoccupied women is the finding of some occupation that will absorb their hearts as well as their intellects, that is, satisfy their feelings as well as appeal to their intelligence. That very acute observer and kenner of her sex, Mrs. St. Leger Harrison, who is Charles Kingsley's daughter and writes under the pseudonym of "Lucas Malet," said in "Sir Richard Calmady": "Feed their hearts and the rest of the mechanism runs easy. I have known disease to develop in a perfectly healthy woman simply because the heart was starved." For most women the only thing that will entirely satisfy the heart or keep it from hunger is children. Fortunately an interest in other people's children can, under certain circumstances, be almost as satisfying as in one's own. _Interest in Others_.--Probably the best possible occupation that a childless woman can have is the care of others. Charity in one form or another satisfies the emotions as well as creates interest and gives varied occupations. Even the frequent disillusions that are encountered in charity work only add variety {222} to the experience, and do not discourage those who have the real charity instinct. For women particularly, as we have said, some charity that brings them much in contact with children is the surest preventive of over-occupation with themselves and over-emphasis on their feelings and sufferings. Many a woman in our large cities owes her freedom from the neurotic symptoms to which her sisters are subject, to her interest in tuberculous children. There is just enough of suffering to arouse all the pity of the visitor, without so much of anguish as would deter the more delicate from being interested in the work. _Touch with Real Suffering_,--For patients who think they have much to suffer, yet whose complaints are all of subjective feelings of oppression and depression, there is no better remedy than to come in touch with real suffering. I have known not a few neurotic young women, who were preparing for themselves years of suffering by over-attention to little pains and aches, saved to a life of usefulness and even happiness by having to nurse near relatives through the last stages of fatal cancer. When these neurotic persons are brought intimately in touch with real suffering, have their sympathies aroused, and see how well human nature can bear pain when it has to, and yet not be impatient, nor wish to end it all, then a renewed life comes over them and they cease to be preoccupied with themselves. _Sympathy as a Remedy_.--In former days, when hospitals were not so well provided and trained nurses non-existent, all forms of suffering had a wider appeal and aroused more active sympathy than at present. It is true that patients, in both hospitals and homes, suffered from the lack of trained nursing, and that was an even greater disadvantage. But it is, nevertheless, too bad that more actual touch with suffering does not come to people now, for nothing is so sure to make little ills disappear as the sympathy aroused by the sight of real suffering. Certainly, our cancer cases might well be a strong therapeutic factor for many of the neurotic ills of the world. They are, of course, deterrent to many people. It would seem to add needlessly to human suffering for some of the delicate to have to be in contact with what is one of the most awful afflictions that flesh is heir to. If death and suffering were not inevitable, we might try to save people from the suffering which sympathy entails. But there is no avoiding them; soon or late they are sure to come to everyone. The upbuilding of character, consequent upon intimacy with them, is of great value, and really brings so much of contentment to people who are over-worried about little things that it is worth while to recall how valuable this sympathy for suffering is in psychotherapy. I have spoken of this phase of occupation as if it referred only to women. There are many men of whom one may well say that they need more human sympathy in their lives and that if they had it their supposed ills would drop from them, or seem so slight as to be quite negligible. Over and over again, I have seen men who had become too occupied with themselves lose their pains and aches in an interest in some real charity. Charity, however, not philanthropy, is the secret. The sitting on a board of trustees of a charitable institution may mean little though even this usually has its good effect; but close contact with the poor, intimate personal relations with other human beings who are in suffering, are quite as necessary for men over-occupied with themselves as for women. {223} _Care of the Incurable_.--Mother Lathrop (Hawthorne's daughter) in her cancer work prefers not to take patients suffering from incurable cancer into the homes that she has for them, if they can in any way be cared for reasonably at their own home. Of course, the main reason is because there is so much of cancer in the community (one in thirty of the population now die of it), that it is impossible to take care of all the cases that apply for admission. Another excellent reason is that it would be too bad to take out of a home the opportunity for self-discipline that is afforded by the care of one of these patients, when it does not inflict an intolerable burden on someone already overworked. As a rule, the effect of attendance on such a patient does so much for character upbuilding, and for a proper realization of values in life, that trivial things fall into their right places. Anyone who has seen the development of character, And the growth in amenity of disposition of those who bear such a burden with patience, will realize just what is meant by the expressions used. Finding Mental Occupation.--For many of his patients the physician simply must find occupation of mind. Not a little racking of brain is needed for this, until experience helps. One form of occupation of mind that seemed quite unpromising at first, but that has in a number of cases proved of value, is the committing to memory of passages in verse. A generation ago it was quite common for people to have their memories stored with fine passages from authors which they could repeat literally. Latin verse particularly was learned by the school boys of fifty years ago. Frenchmen know their classical poets, and some of the Italians also know theirs with wonderful fidelity. It is said that, even in his advanced years, Pope Leo XIII could repeat long passages of Dante and often found a relief from pressing cares of state in the ponderings of the great thoughts recalled by the verses. I have known half a dozen Italian clergymen who could from memory follow up a line of Dante, taken anywhere in the poet's writings, with the rest of the passage. Such well-stored memories furnished much more abundant food for thought to their possessors than do those of the modern time. Our modern system of education has done away, to a great extent, with learning by heart, but as one of those educated under the older system and who is still able to recall many passages from Pope, or Goldsmith's "Deserted Village," or "The Traveler," or from Virgil or Horace, I feel sure that this is a serious mistake. In some cases I have deliberately tried to make up for it by having people, even well on in years, settle down to memory lessons again. Under disorders of memory I suggest the use of this practice as a valuable training which serves first to dispel the idea that memory is failing when it is only lack of attention and of concentration of mind that is at fault, and secondly, because after a time there can be observed an actual improvement of the memory faculty. Here I would insist on its value as an occupation of mind for those who lack some serious interests. I have found it to be ever so much better as a diversion than reading or the theater. If the interest in it can be awakened, it represents a valuable adjunct in the treatment of some rather difficult cases of mental short-circuiting. Lord Chesterfield, in one of his letters, suggested to his son that even very brief periods during the day--those that are ordinarily used for the fulfillment of bodily necessities--might be employed to store the memory with valuable quotations, great thoughts {224} greatly expressed, and this should be recalled. After a little practice not near so much time is required for memory work as might be imagined, and the effects are excellent. Much of this may seem too trivial for the physician to occupy himself with and quite apart from his duties as a practitioner of medical science. But it must not be forgotten that medical science is as yet quite imperfect and the practice of medicine is an art. What we have to do, is to treat individual patients rather than cure cases, for that is why medicine is a profession. Each affected individual who comes to us is quite different from any other. In spite of our grouping them under certain heads, the diseases of the race are as distinct from one another as the features of the individuals affected. CHAPTER VI DIVERSION OF MIND--HOBBIES There are two classes for whom diversion is of the utmost value. The first are over-occupied with themselves; and the second group are so occupied with some one interest in life, or with one narrow set of interests, that it becomes an obsession, never leaving them. Constancy of mental occupation with one set of thoughts proves seriously disturbing after a time, especially if the only amusements available are so superficial that they do not really act as a diversion. Many of the so-called neurasthenic or psychasthenic states (I would prefer to call them conditions of nervous weakness and of psychic impotency, because the simpler names carry with them no suggestion of a definite ailment) are really the consequence of this lack of any true diversion. The patients do not get any genuine rest. The typical example of such lack of diversion is the business man who, contrary to the wisdom of the ages, takes his business home with him. If we accept Ramon y Cajal's theory of attention, by which whenever a particular portion of the brain is occupied with a subject the capillary blood vessels in that particular part are pulled wide open by the contraction of the neuroglia cells, certain of the brain tissues in these cases are constantly in a state of congestion. It is not surprising that such men suffer from insomnia. It is scarcely less to be wondered at if their digestion suffers, since that function is so important that it requires most of the nervous energy that a man can provide at certain times. Besides his brain cells are never really resting. If a man goes to sleep with a thought and wakes with it, even though he may not be quite conscious of the fact, his mind has been occupied with it. Brain cells need definite periods of rest. These cells are not getting such rest--hence the development of many pathological conditions. I have described the extreme case, but it is not exaggerated. Writers, editors, scientific investigators and generally those whose work does not bring them much in contact with others, are likely to thus suffer. Contact with others, even on business matters, seems to have a relaxing effect. Social amenities and personal interests prevent absolute concentration of mind over long periods. In some people even milder degrees of preoccupation with a {225} single subject may work harm. Some people are able to stand concentration of mind for many hours a day for years. Others cannot. We have come to recognize that more than eight hours a day is a mistake, but there are many people who cannot work more than a four-hour day. The sooner this is recognized and diversion of mind provided, the better for them. This is one of the most important benefits that psychotherapy can confer on many of the so-called neurasthenics. Possibility of Diversion of Attention from Ills.--The necessity for diversion of attention from one's ills is best realized by considering what happens in the opposite direction. Headache, toothache, and many other uncomfortable feelings, especially discomfort associated with abdominal disturbances, can be entirely banished from the mind by pleasant association with friends, by an interesting play, by a game of cards, or, indeed, by almost anything that takes up the attention completely. It is well understood that the severer forms of pains can not be thus banished, but discomforts that make life miserable for the patient may be entirely relieved for the time being. If this power of mind to divert attention from the ills of the body means so much, it is not hard to understand that if this mental influence be directed in the other way, that is, to emphasize the ailment by attention to it, it will not be long before symptoms become quite unbearable. Hobbies.--A hobby is the physical salvation for a man who wants to work hard, yet not become so absorbed in his work that it becomes an obsession. Unfortunately, it is not possible to create a hobby for a man or a woman in a short time. It must be a growth for many years until it has become a portion of one's life. It must, as far as possible, be something to which one turns with as much interest as to one's regular occupation, so that the time taken from it, even for the necessary vocation of life, is more or less resented. If a man has two occupations that are intensely interesting, then he gets the best possible rest. Otherwise it will be necessary in many cases for the physician to help him in the choice of another interest in life. It is not enough that there should be a vacation once a year, or a conventional day off on Sunday. There must be much more than this, deliberately planned and faithfully carried out. _Gladstone_.--Men with hobbies have done some of the best of the world's work; busy for many hours every day, they have yet lived to be eighty and even ninety years of age, and have been industrious to the end. A typical example in our generation was Gladstone, the great English statesman. Few men had their minds occupied with more serious problems than he for nearly forty years of a busy existence. In spite of this, he found time to make a study of Greek literature and of ecclesiastical writers; He acquired even more authority perhaps in these subjects than in political science, doing the work of several men, yet he lived to be an extremely old man. He welcomed the opportunity to get away from one kind of work in order to devote himself to another, but this occupation of an entirely different set of brain cells gave those that had been previously at work opportunity for complete rest. Very probably, except at times of special crisis or stress of anxiety, his political problems did not disturb his studies of Greek literature, not because he insisted on keeping them away, but because this other interest was so absorbing that it required no special effort to occupy his mind completely with it. {226} _Virchow_.--For more than a year I lived close to the great German pathologist, Virchow, and found that his varied interests were probably the secret of his power to devote himself to work for many hours a day, take only a small amount of sleep and yet live healthily and happily for over eighty years. Frequently he did not leave the Prussian legislature until 1 a. m., or even later, and yet he seldom failed to be at his laboratory before 7:30 o'clock in the morning, though it was several miles from his home and took over half an hour to get there. Besides pathology, he was deeply interested in anthropology and in most of the biological sciences, and his favorite hobby was the practical care of the health of the city of Berlin. From the time when Berlin, just after the Franco-Prussian war, began to grow out of the half-million provincial town that it was, into the great world capital that it became, a transformation that took less than twenty years, Virchow had charge of the health of the men engaged on the sewer farms of the city. Berlin, unlike other great capitals, is not situated on a large stream that will carry off its excreta, and consequently a new problem in sewage disposal had to be met. The sewage was spread over fields outside the city and proved, as might be expected, a magnificent fertilizer. The whole cost of sewage disposal was recouped from the sale of the farm products. Prophecies of dire disaster of many kinds were made when this system was first proposed. It was said that the men engaged on the farms would suffer from all sorts of disease, especially respiratory and intestinal diseases, that the farm products would be insanitary, and the whole plant would be such a disease producer for the city as to become a nuisance. Virchow was put in charge of the sanitary side of the project, and how well he fulfilled his obligations is shown by the statistics. The people who worked on the farms were healthier than the average inhabitants of Berlin, and were especially free from intestinal disease. Every phase of disease that occurred among the workers on the farms, and there were many thousands of them with their families, was reported to Virchow. Every night, the last thing before he went to bed, he looked over this report and if there were any suspicious cases, made arrangements for the prevention of the spread of disease. This of itself might seem work enough for one man, but it was only a diversion for Virchow, turning his mind away from his other intellectual work completely during certain hours of the day. His visits to the farms, his planning for the prevention of the spread of disease, his deep interest in the reports and the constant improvement of conditions, instead of hampering his other intellectual activity by wasting brain force, probably proved restful by diverting the blood stream away to the cells that occupied themselves with this other and very different problem, and so proved a benefit, not an evil. Perhaps other men might not have had the store of nervous energy to enable them to carry on work in this way, but for those who have, this is the ideal arrangement. There are many others whose names might be mentioned here. John Bigelow and Pope Leo XIII are typical recent examples. Great workers are usually long livers, barring accident, and all of them have had variety of occupation. Necessity for Diversity of Occupation.--Even for those of lesser intellectual capacity, it is advisable to have, in a lower order of intellectual occupation, two very different things in which there is intense interest. The blasé {227} attitude in which the individual finds no interest in anything and nothing worth doing, makes it impossible to secure such relaxation as will give relief from worry. So long as nothing happens to call for special resistive vitality, such people may go on nursing their unhappiness. It is from this class, however, that the suicides come. The mind becomes occupied with the worries that it cannot get away from, sleep is interfered with; the worries become an obsession, and brain exhaustion results. It is usually said that suicides are insane, and to this extent certainly the expression is true. Certain brain cells have so long been occupied with a particular subject, because the mind has no other interest to divert attention and blood supply to other portions, that these cells are overborne and become utterly beyond the control of reason and will. Intervals in Work.--The old university rule of long ago was that no one should do more than two hours of intellectual work continuously at the same subject. Certain of the monastic orders required scholars and students to take a break from an intellectual occupation for a measured interval at least every two hours. The modern business man, and even the literary man or reporter, would think this preposterous. The rule is, however, founded on good common sense, for it relieves the tension and keeps conditions of strain from inveterating themselves in such a way as to do harm. As a matter of fact, better work is accomplished if it is done in two-hour intervals, with a break of fifteen minutes to a half-hour between, than if the attempt is made to work longer. This may not be true for certain forms of creative literary work, where, when the mood is on, it is easier to finish things than if a break occurs, but these are exceptional cases, and even here there may be serious abuse. Many of the men who work late at night eventually get into habits that seriously impair their sleep. This system of rest prevents such a strain from being put upon the physical organs underlying attention as will prevent them from promptly relaxing when the call upon them has ceased. There are, of course, men for whom no such rules as these seem to be needed, because they apparently thrive on work. These are exceptions, however, that prove the rule. They will usually be found on investigation to have been men who lived very simply and permitted themselves very little excitement. There is great danger in imitating them because most of them had a superabundant vitality which expressed itself in longevity as well as in a noteworthy capacity for work. They had superabundant brain power to run their business (even though it was deeply intellectual), but then, too, these men were careful not to throw extra burdens upon their digestive organs, nor to abuse stimulants, nor to permit a regular routine of work to be disturbed. When symptoms of nerve weakness begin to show themselves, even the exceptional men must be warned of the danger. The causes of the exhaustion of nervous vitality should be pointed out, and an improvement of habits insisted upon. Amusement and the Mind.--The theater, as it is at the present time, affords very little opportunity for mental relaxation. Most of our theatricals are mere show that occupies the eye but does not seriously catch the attention, especially after a certain number of types of these performances have been attended. The humor of the comedians of our musical comedy may, for {228} a certain number of people, mean something as a diversion of mind, but it does not last. Unfortunately, practically all their humor runs along the same line, most of it is extremely superficial, much of it is borrowed and wears signs of its origin, not a little of it is mere horse-play, which may divert children but not grown men, and so the theater as a mental relaxation has lost nearly all of its effect. Other diversions are sometimes more hopeful. For baseball enthusiasts, attendance at a game may be such a complete occupation of mind as to furnish thorough relaxation. The kind of work that provides mental relaxation for others often proves exhausting to those who do it. Humorists, especially those who have to grind out paragraphs or columns of humor every day or every week, are usually melancholy men. The story of Grimaldi illustrates how serious may be the effect of work that seems mere play if pursued too singly. This humorist on one occasion consulted a specialist in mental diseases, for certain symptoms of nervous breakdown and depression that were causing him much annoyance and even more solicitude. The specialist believed in diversion of mind, and, having been to see Grimaldi the night before and enjoyed him hugely, though he did not recognize him off the stage, counseled him to go and see that humorist and have his "blue devils" banished for good. "If Grimaldi won't cure you of your depression," he added, "I don't know anything that will." "My God!" the humorist said, "then don't leave me in despair. Man, I am Grimaldi!" Sports.--Unfortunately in our modern life we have to a great extent lost the idea of sport. The conventional make-shifts of life in a camp that is really a luxurious country house, or on a luxurious yacht, do not replace the complete diversions that came with real camping, hunting, fishing, sailing and the like. People now go to the country, but take the city with them. They live in country hotels and make five changes of clothing in the day, if not more. If men are interested in hunting and fishing and can go into the forest (unfortunately even the Adirondacks can scarcely be so designated now and we have to go into the Canadian wilderness to get away from the pall of regular life and civilization), complete recreation is secured. This makes a real vacation which does not mean absolute freedom of mind, but freedom from other cares so that one may with complete absorption apply himself to something different. During the year sports for grown-ups are difficult to obtain. Some men continue well on in middle life to play tennis, hand-ball, and certain other games, _O fortunati nimium_, that make the best kind of diversion. Fortunately, in recent years golf has become a favorite and for many makes a genuine diversion. Children's Diversions.--In recent years we have so interfered with the normal natural development of the child that there is need to emphasize certain details in this matter. The modern child is apt to be precociously occupied with books and adult interests, because he is brought so much into the foreground of family interests. True play for some city-bred children is almost an anomaly. Exercise and air they get. They are conducted solemnly to the park by a nursemaid, who is instructed to see that they do not play with other children unless quite as well dressed as they are themselves, and their dress is often so elaborate that it is quite impossible for them to think of any real play. There is absolutely no recreation for the child in this procedure: on {229} the contrary, a new effort of will is required to walk with the stately propriety that is expected of it. Then the child is preoccupied with the thought of its clothes. Relaxation of mind is often quite out of the question, and yet we wonder why children are nervous and do not sleep well, why they have night terrors and do not digest their food properly, while all the time they are living unnatural lives that give no proper outlet for their energies and little diversion for their mind. Games are important, but their true spirit has gone out in recent years. There are still a few young people who play for the sake of the sport, but everything now seems to be a preparation for some sort of contest. Only those are engaged in these contests and the preparation for them whose muscular development is such as to suggest that they will help to win. Winning, and not sport, has become the purpose of our games. This makes the participants worry about the games and associate them with dread of errors and ill chances. It is true that the interest for the contestants during the game is sufficient to make up for this and make the game valuable as relaxation; but those who need such relaxation most--the boys and girls who are underdeveloped muscularly--must sit and watch the contests, and this, after one has become accustomed to it, like newspaper reading and the theater, constitutes a poor apology for the complete relaxation of mind and diversion of brain-cell energy that used to come with sports when they were freely indulged, for the sake of the sport and not for the sake of winning. CHAPTER VII HABIT Few people realize how powerful a factor for physical, as well as moral, good and evil is habit. The old expression that habit is second nature is amply illustrated in the most familiar experiences. The child, unable at the beginning to make any but the most ill-directed movements, learns during its first two years to make the most complex co-ordinated movements--first with difficulty, then with ease, and finally with such facility that there is no need for it to pay any but the most perfunctory attention to their execution. Walking requires the co-ordination of a large number of muscles so that the absolute position of every muscle in both the legs and in the trunk, at least as far as the shoulders, must be definitely known and their activity properly directed. Perhaps nothing brings out more clearly the difficulty of walking, though it depends on only one factor, the co-ordination of the two sides of the body, than the story of the Italian Tozzi twins. They were born with two heads and shoulders and with only one pair of legs. It was found that each head ruled the leg on its own side of the body. It was impossible for the creatures to walk. They lived to adolescent life, yet never succeeded in walking. The intimate association of the lower parts of their trunk and the long years of companionship of their brains, did not enable them to accomplish what seems to us so commonplace a co-ordination of movement as walking. Formation of Habits.--The co-ordination of the two limbs is after all only a small portion of walking. The body must be held erect, the curve of {230} the spine must be managed so that the center of gravity is kept well within the base, and gluteal and femoral and calf muscles must all be co-ordinated with one another. In a few months a child learns to do all this, and in a couple of years it executes all the co-ordinate motions with such certainty that walking becomes not only an easy matter but an absolutely unconscious accomplishment that can be carried on while the mind is occupied with something else or while it becomes so abstracted that surrounding objects are not noticed. A far more difficult co-ordination is required for talking. It is only when we analyze how nicely adjusted must be every movement, in order to pronounce consonants and vowels properly and to combine them in various ways, that we realize how complex is the mechanism of talking. A difference of a hundredth of an inch in the movement of the tongue, or less than that in the movements of various muscles of the larynx, makes all the differences between clear articulation and a defect of speech. In the course of the years up to seven, the child learns this wonderful co-ordination apparently without difficulty, but really at the cost of constant well-directed effort. There is no time in human existence when the child really learns so much as during the first four years of its existence, even if it learns nothing else except to walk and to talk. The foolishness of obtruding other things, information and study of various kinds, on the child's attention at this time should be manifest. _Unconscious Regulation of Muscles_.--What is thus prefigured in early life invades every activity in later years. The boy who learns to ride a bicycle must at first devote all his attention to it, but after a while rides it quite unconsciously, his muscles having learned by habit to accommodate themselves automatically to all the varying positions of his machine. Anything well learned by habit is never forgotten. How hard it is to learn to swim, yet, after years away from the practice of it, the art comes back at once. The same is true of skating, and of the nice adjustments of muscles required in various games. Such is the influence of habit in forming a second nature. It is no wonder that Reid, the Scotch philosopher, should have written: As without instinct the infant could not live to become a man, so without habit man would remain an infant through life, and would be as helpless, as unhandy, as speechless, and as much a child in understanding at threescore as at three. Commenting on this Prof. J. P. Gordy, in his "New Psychology," [Footnote 26] says: [Footnote 26: "New Psychology," by J. P. Gordy, New York, 1898.] Strong as this statement seems, it is probably an understatement of the truth. Without habit, we should rather say, a man would be as helpless, as speechless, as unhandy at three-score as at birth. Habit is the architect that builds the feeble rudimentary powers of the child into the strong, developed powers of the full-grown man. If a child's vague, purposeless movements give place to definite movements performed for definite purposes, if his sensations become more definite, if his perceptions become clearer, if his memory becomes more accurate, if he reasons more and more correctly and logically, it is because of habit. Law of Habit.--The law of habit is that every time we perform any action, mental or physical, or allow ourselves to be affected in any way, we have more proneness to, and greater facility in the performance of that action or in {231} experiencing that affection under similar circumstances, than we had before. In the chapter on Tics, I call attention to the fact that all the curious gestures by which we are individualized, are due to the law of habit. It is infinitely amusing to watch a group of people and note the endlessly different habits of which they have become the victims. There are tricks of speech and tricks of gesture eminently characteristic and often quite laughably individualistic. We imitate, especially those of whom we think much. Sometimes it is only when a father's attention is called to them in his sons that he realizes the ludicrousness, or at least laughableness, of some of the things he does, and he proceeds to correct both generations of their faults. PHYSICAL HABITS Habit and Food.--Most of our likes and dislikes for food are neither physical nor physiological, but simply habitual. We have become accustomed to certain things, and so we like them. We are unaccustomed to them, and do not care for them. It is amusing when people put forward these lacks of habituation as if they were physiological idiosyncracies. Many thin people do not like butter and milk. The real reason for this is not any peculiarity of digestion, or any gastric incompatibility, at least in 99 cases out of every 100, but the mere fact that they are not habituated to their use. That is one of the reasons why they are thin. Our tastes for curious foreign foods are nearly all deliberately acquired. Not one in ten ordinary Americans likes olives or caviar when first tasted. Nearly every curious article of food is "caviar to the general" at first trial. Later it becomes impossible to understand how we could have had any objection to them. At times, even an actual craving for them asserts itself as a consequence of the habitual use, and then deprivation means positive discomfort. Slow Eating.--One of the most valuable habits that a man can cultivate, but one of the most difficult to acquire in our time, is that of eating slowly. Most Americans bolt their food to a degree that would be quite appalling to them if they realized what they were doing. Pieces of potatoe as large as the end of the thumb are swallowed. Bread and milk may be eaten so hurriedly as to be as potent a source of digestive disturbance as fried onions. There seems no doubt from what we know of Fletcher's experience and Chittendan and Follin's studies that a man derives more nutrition from food that is masticated properly, that he can get along and do his work on less material and that, above all, there is not the same tendency for him to put on weight that is so common among people after reaching middle age. Sir Andrew Clarke used to have his patients chew a definite number ol times on each bite--say thirty times. Even so great a man as Gladstone submitted to this rule and gradually learned to accustom himself to eating very slowly. Fletcher's system of chewing the food until it passes down the esophagus of itself without any swallowing effort is a better rule. It is a surprise to most people how unconsciously swallowing can be accomplished in this way and how little liquid is needed in order to prepare food to be swallowed. The formation of the habit, however, is not an easy one. Persistence and frequent reminders are needed, or else the beginnings of the habit are soon dissipated and old bolting habits reassert themselves. {232} Water Drinking.--In drinking, habit is as supreme as in eating. The majority of people who work outside and perform muscular labor crave and take an abundance of water. Many of those who live indoors, especially in steam-heated houses, may need it quite as much if not more, but get out of the habit of drinking water. As we need about three quarts of water per day for use in our economy, this no water habit often becomes a serious factor in the production of physiological disturbances. We have replaced water drinking and the milk drinking of the olden times by tea and coffee, and as these are stimulants, habits form very readily with regard to them. I have known people who were sure they would be miserable without their half-dozen cups of tea or coffee each day, and who actually would be miserable for a few days, when deprived of it. They were seriously impairing the efficiency of their nervous system by so much stimulation. Unfortunately, it is just those whose nervous systems have least stability, and are already the subjects of more stimulation by conscious introspection than is good for them, that are most likely to form the tea and coffee habits, and who are most harmed by them, though they find it hard to understand the reason therefor. Air and Exercise Habits.--Habits with regard to exercise and fresh air are particularly important. In this matter it is only habit that can be really helpful. To work at high pressure indoors for several days, and then, when one is quite on edge, to take a lot of severe physical exercise is not good. Every human being should go out between meals. I am not one of those who believe much in exercise for exercise's sake--what is needed is fresh air. Our sanatorium patients who sit out-doors all day have fine appetites. The advice to a busy man that he must form the habit of being out between every two meals for from half an hour to an hour would usually evoke a strenuous protest, but all he needs to do is to get up half an hour earlier and walk down to his office, and if he will walk back in the evening he will have plenty of air and exercise between his meals. Change of Habits.--Patients do not want to change their habits. They come to a doctor to be treated. They want some medicine that will, without further inconvenience, rid them of certain discomforting symptoms. At the beginning, at least, patients resent interference with their habits. They are quite satisfied, and to modify them requires an effort that must be continued for some time. The changing of old habits and the formation of new habits are most important for the ordinary ills to which mankind is prone. Modifications of habit constitute real hygiene and are not mere corrections of symptoms, permitting the habits that have led up to them to go on. Patients may conclude that it is too much trouble to change their habits. We all know persons who feel that they can not give up their coffee. As to whether or not the modification of a habit is worth the trouble it involves, the patient must be the judge after the case is put properly before him. It is possible that he may learn to endure the inconvenience given him by his symptoms rather than to stand the inconvenience of changing a nicely settled habit, and forming a new one. The reward should be put very plainly before him, however, and besides, the consequences of his habit in the future should be suggested so that he may realize just what it will lead to. {233} MENTAL HABITS It is evident from the foregoing that physical habits have much to do with making life easier and saving expenditure of nervous energy, but just this same thing holds good for mental states. With care, a proper habit of mind and of the mental attitude towards difficulties in life, can be so cultivated as to ward off many of the discouragements, and most of the causes of depression that weigh heavily on some people. The natural disposition can not be entirely overcome, but habit, as a second nature, can modify the personality so as to make conditions much better than before. With this wonderful power in habit, it is too bad that its force for good is not used. It is especially important that its force for evil shall not allowed to dominate human actions so as to make them harder of accomplishment. Many people, who are greatly troubled by the inconveniences and discomforts necessarily associated with human life, worry over it to such a degree as to make themselves sick. The expression I have quoted elsewhere of the old man who said, "I have had many troubles but most of them never happened," is a typical example of what the habit of looking at things from a wrong standpoint means to many people. They are confirmed pessimists. Their one consolation, when a small evil happens to them, is that perhaps this may be sufficient to ward off the greater evil that fate surely has in store. Pessimism.--Pessimism has been defined as sticking one's nose in a dungheap and then asking, "How is it that it smells bad around here?" Some people are always nursing a grievance. No matter how many times they may happen to have been undeceived, still the next time the opportunity occurs they are sure that fate or friends or someone has it in for them and that the worst may happen at any time. In the expressive words of a recent slang phrase, they have a "perennial grouch." This state of mind toward the environment not only prevents the physical and mental good that cheerfulness brings with it, but it unfavorably influences physical conditions within the body. People suffering from indigestion are usually morbid, petulant, and hard to get along with. Many a dyspeptic makes this an excuse for his bad temper. Anyone who has had to study these cases much soon comes to the conclusion that the beginning of the digestive disturbance was the gloomy outlook on life, which flowed inward to disturb the digestion and all the other animal functions. Depression of Mind and Body.--Patients suffering from melancholia nearly always lose in weight. As a result of their lowered vitality, there is a suppression of the nervous impulses which rule over nutrition, with a consequent loss of weight. In cases where there are only tendencies to depression and gloom, the effect upon the digestive system is not so marked but there is no doubt that there is some effect, and that the indigestion in these cases is more often than not a result of the depressed state of mind, rather than the depression of mind the result of the indigestion. Moodiness.--The habit of looking at the gloomy side of things is easily formed and, once acquired, it becomes very forceful. Many a man who was quite cheerful when young, becomes moody as he grows older. Nearly everyone permits moods more than is good for him. The attitude of mind that should be cultivated is one in which it is realized that, though there may be {234} many sources of evil in the world there is a preponderance of good even in the worst environment, and that opportunities for making the best of things will be found by any cheerful disposition. _Mrs. Wiggs of the Cabbage Patch_ is a typical example in fiction of the optimism that counts. Miss Helen Keller in real life is a typical example of how the most untoward circumstances can not crush the spirit of man if he only wishes to be cheerful--if he only tries to lift himself above his surroundings, no matter how discouraging they may seem to be. No one is without discouragement and causes for unhappiness. "Happy he who has least," the Greek dramatist said. The difference between the optimistic and the pessimistic point of view is much more a matter of habit than is usually thought to be the case. Indeed, there is good reason for assuming that it is so largely a matter of habit, that other factors count for little. We all know individuals who, after having, been cheery, bright, hopeful and helpful, have had some incident sour them and then they have been just the opposite. This did not come all at once; it was a growth. They felt hurt and aggrieved, and then began to look at things through dark glasses, and after a time could see nothing on its brighter side. Not infrequently, as doctors well know, the growth of such a moody disposition has been the signal for the development of a series of complaints, if not of actual symptoms, and men and women who have not been in the doctor's hands before now become valetudinarians. This new physical condition is often attributed by their friends, by themselves, and even by complacent physicians, to the effect upon them of the trial or disappointment that struck them. Only too often it is wholly due to the cultivation of a habit of pessimism consequent upon a shock that for the moment pushed their cheerfulness into the background. Strong characters will not be thus easily affected, but weaker characters need not suffer such a change of disposition and with it a deterioration of health or well-being unless they so will it. MANNERS AND DISPOSITION Habit can modify nature so much as to make what is practically another man. We all know how the dancing master can transform a country gawk into a refined, courteous society man (not gentleman, for that is something else) of graceful carriage and even handsome bearing. He cannot do this for all the pupils that come to him, for it is impossible to make a silk purse out of a sow's ear, but for anyone that comes with good will the revolution in manners is often a revelation to those who have known the man before. When the exterior can be changed so much, the interior attitude toward other people certainly can be greatly modified. Persons of a melancholic disposition may be surprisingly cheerful, and even gay, with comparative strangers when they make the effort to be so. For many people, meeting with strangers is an excellent remedial measure. It stirs them up to present the best side, and it occupies attention to the exclusion of themselves in a way that is extremely beneficial. If people would only form the habit of being as courteous to their own folks as they are to others, the disposition involved in this would often save them from certain symptoms, and save their physicians from many complaints. {235} Happiness is the basis of good health. The phrase is often put the other way: Good health is the basis of happiness. Without health there is no happiness. But every physician knows that many a patient suffering from real organic ills, and having much physical pain to bear, still has many hours of happiness in working for others. This happiness reflected back upon his physical life is not able to cure his ailments, but does so lessen the significance of the symptoms as to make the ailment more bearable. THERAPEUTIC IMPORTANCE OF HABIT The most important therapeutic element in the formation of good habits, mental and physical, is that habit does away with the necessity for conscious regulation of many details of life. Without habits of doing things, we have to make numerous decisions and keep on making them under conditions that require special effort and waste of energy. When habit asserts itself, there is little or no difficulty. Habits of living in airy rooms, of taking exercise, of food regulation as to quantity and quality, of methods of taking food as regards mastication, the quantity of fluid ingested, the hours of meals and the like, can all be formed and then followed without effort. Just inasmuch as life can be ruled by habit, nerve force is conserved. This is as true for our attitude towards life, our disposition and consequently our satisfaction with life, as for anything else that we do. Habitual cheerfulness, habitual readiness to make allowance for others and to be helpful to them, habitual self-control--all of these things can be cultivated. Properly cultivated, they save much of the wear and tear of life, and make for contentment and happiness much more than many of the things for which men strive so anxiously because they seem to promise happiness. CHAPTER VIII PAIN Pain, while always a dreaded symptom of disease, seems, with the increase of comfort and the gradual abolition that has come in our time of many of the trials of existence, to have had its terrors increased. Even a slight pain or ache is dreaded, and if continuous or frequently repeated, becomes for many people a trial that is almost impossible to bear. This is all the more to be deplored because ability to stand a certain amount of pain, with reasonable equanimity, is almost a necessary condition of rapid recovery from disease or injury. Placidity of mind favors the flow of nerve impulses for reconstructive purposes, while over-reaction to pain inhibits the natural processes of repair. According to Shakespeare's heroine: "There was never yet philosopher that could endure the toothache patiently." Pain is usually supposed to be an essentially physical phenomena for which mental influence can be of little, if any, benefit. As a matter of fact, however, the mental attitude towards pain modifies it to a considerable degree. I have quoted Hippocrates' declaration that a greater pain drives out a lesser pain. Any strong preoccupation of mind will greatly lessen pain at any time. {236} Pain is not, after all, in the nerves, nor in the central nervous system, but in the consciousness. Just as there is no sound unless the waves in the air arouse recognition in the consciousness, so there is no pain unless the disturbance of nerves finds its way above the threshold of consciousness. Nerves may be racked, yet no sensation may be felt. There may be pain in the mind apart from the nerves, and slight nervous affections may produce severe pains. The whole question of the treatment of pain involves the individual much more than it does the affliction which causes the pain. What seems unbearable pain to many may be little more than a passing annoyance to others. What would be, under ordinary circumstances, intolerable torture, especially to sensitive people, may, because of intense preoccupation of mind, remain absolutely unnoticed. Maniacal patients sometimes inflict what would normally be extremely severe pain on themselves by burning or mutilation without any manifestation of pain. In the excitement of a panic men may suffer what would, under other circumstances, be excruciating agony, and yet not know that they are hurt. To a mind that is without serious interest, even slight pain, if continuous, soon becomes unbearable. The course of pain, where there is no diversion of mind, is an interesting study. While suffering, we seem always able to bear the pain of the present moment, and it is only the cumulative effect of the pain that is past and the anticipation of the discomfort to come, that make the pain unbearable. Nearly, always it is much more the dread of what the pain may mean, and the lack of power to endure which gradually develops as a consequence of suffering, that constitute the worst features of pain. At the beginning of a period of pain we stand it well, as a rule, but its continual nagging debilitates us and heightens our susceptibility until we cannot nerve ourselves to further endurance. If our power of endurance were not thus gradually lessened the pain would not seem severe. There are many neurotic people whose susceptibility to pain has been so much increased by their lack of self-control and their tendency to react easily to pain, that even slight pain becomes a torment. Psychotherapy should gradually train these people to a power of endurance. Pain from Over-Attention.--Much of what is called pain is really due to such concentration of mind on a particular portion of the body that the ordinary sensations of that part, usually accomplished quite unconsciously, become first a source of uneasy discomfort and then an ache or pain. There may be some slight physical disturbance which calls attention to the part, but there is no really serious pathological condition. While such pains are spoken of as imaginary it must be remembered that this does not mean that they are non-existent. On the contrary they may be much more real to the patient than physical ailments. A pain in the mind is a much more serious condition than having it in the body. While pain may be thus created by concentration of attention, it must not be forgotten that what the mind can do in increasing pain is even more important than in originating it. Slight discomforts by concentration of attention on them may be made insupportable. It is this element in pain, above all, that the physician requires skill to alleviate. Habits of introspection and the lack of serious occupation of mind of many people leave them the victims of over attention to themselves. In trying to relieve their pain it may be {237} comparatively easy to alleviate their physical condition, but the mental condition, once aroused, may remain, and may easily tempt to the use of habit-forming drugs or others that may do serious harm. The story of the evil effects of headache powders in recent years, and of the opium habits formed in olden times, are a significant commentary on this fact. It is probable that in most of these cases, the discomfort for which remedies were frequently taken was of a kind that should have been treated only partly, if at all, by drugs. It is more important to lessen susceptibility than to try to cure the pain. The relation of the mind to what is often considered severe physical pain, has come to be generally recognized in recent years. Neuralgias, for instance, have often been reported as recurring after fright, or strong emotion, or worry. It is at moments when patients are much run down in health that pains are particularly likely to be unrelievable, and during periods of emotional strain that anodyne drugs are most called for and are most likely to be abused. Rest and Pain.--In any study of pain and its relief, one must always recur to that classical contribution to medicine, now in the fiftieth year of its publication and still as important as when it was written, Hilton's "Rest and Pain." He calls attention to the fact that what he wrote was only a development of what many practical physicians had thought long before his time. He quotes a prize essay of the French surgeon, David, written in 1778. Hilton's development of the idea that pain is usually a signal on the part of nature for rest, and that rest will usually enable her to overcome the pathological condition and so relieve the pain without recourse to drugs, is, and ever must be, the basic element in the therapeutics of pain. How many forms rest may take can only be judged by a careful reading of Hilton's book. The oftener one reads it, the better one realizes how much of precious common sense and acute clinical observation there is in it. It is essentially a book of psychotherapy. It treats the patient's mind first and then through that changes his habits, persuades him of the need of rest, directs how that rest should be taken and so leads up to his natural cure. Every treatment of pain must include rest of mind as well as body. Hilton has particularly dwelt on the rest of body. Rest of mind is just as important. Many pains could be easily borne were it not for the worry that accompanies them. A slight pain becomes greatly annoying because the patient's general condition makes it impossible to stand discomfort with equanimity, and there has been no training in self-control. In spite of all our advance in medicine, we are not likely ever to make life so free from pain that people can go through it without needing self-control. Training in self-control is an important psychotherapeutic prophylactic. If, with a certain amount of capacity to bear discomfort, there goes such rest of mind as does not exaggerate or emphasize the condition, then many of the pains of life lose their power to annoy, all of them are distinctly lessened and the relief of them by accessory physical methods becomes easier. Pain in Its Relation to Life.--There is an unfortunate tendency to exaggerate the significance of pain. We have cultivated irritability in the physical sense, rather than the power of endurance. Patients should, as far as possible, be lifted out of this condition of over-delicate sensitiveness and put into a state where the idea of pain is not so serious. Only in this way can {238} the more or less inevitable discomforts of life be borne without such reactions as seriously interfere with health. It may be said to be other than the physician's business to secure this magnanimity, but as magnanimity is needed in our patients, and there is no one else to respond, physicians must start its cultivation. The necessity for learning to bear minor discomforts, at least without exaggerated reaction, need not be presented to the patient directly, but can be gradually made a part of the system of treatment. By absorption in other interests, the consciousness of these discomforts disappears without the necessity for recourse to drugs. Self-Denial.--Many thoughtful people are sure that what is needed to make a large number of our generation more happy, or at least less miserable, is training in self-denial and in self-control. The word self-denial has come to have a very distant sound for most of our generation. From early childhood anything that is unpleasant is shunned and anything that is difficult is likely to be shirked. The head-master of Eton College has recently insisted that too much is being done to please young folks and too little to stimulate them to activity. He declares that, as a rule, any undertaking begins to be useful just where it ceases to be simply pleasant. Unpleasantness is avoided to such a degree that the habit of thinking that it has no part in life comes to be a second nature. As a consequence, the reaction to any continued unpleasantness is likely to be exaggerated and make the subject very miserable, and sometimes disturbs and discourages, whereas it should have the effect of stimulating to reactive efforts, to bring out the best that is in us. Hinton emphasizes the fact that an ingredient of pain is necessary to all health or pleasure. The fatigue and the hardship associated with mountain climbing is a portion of the essence of the pleasure in it. All healthy, pleasant exercise has an accompaniment of fatigue and some aches and pains. What is needed, then, in our time is the training to do things for the sake of doing them. We should be neglectful of the discomfort that may be associated with them, or we should even consciously rejoice in the fact that this very discomfort is of itself a sign that functions are being used to such an extent, that their limits are being expanded, their limitations overcome. It may well be said that it is not the physician who, as a rule, should do this; it should be accomplished in the early years by the teachers and trainers of the young. True enough. But physicians can at least help in reforming the tradition in this matter so as to neutralize the present state of mind which seems to look upon pain as an evil. Pain is always either a conservative sensation or an actual stimulus to function. Besides, many of the present generation who come to us, having had no training in the precious qualities of self-denial and self-control under difficulties and discomforts, must have this knowledge supplied for them as far as possible by suggestions of various kinds. It is more difficult to accomplish much in this matter for the adult, but even in apparently hopeless cases of over-attention to self and incapacity to bear discomfort, much can be accomplished by patience and persistence. The common dread of suffering is quite unwarranted by what we know about the effect of pain. There are many motives that may be adduced to make it seem less terrifying than it now is to many people. The effect of pain upon character is always excellent. The difference between two brothers, as we have said, one of whom has had the discipline of pain or suffering and {239} the development of sympathy that comes with it, and the other who has not had the advantage of this great human experience, is likely to be marked. In the one there is a depth of human nature that enables him to appreciate and even to express the meaning of life better than his apparently more fortunate brother. Practically all the men who have ever got close to the heart of the mystery of life, and expressed it in poetry or other form of literature or art, have gone through suffering as a portion of their training. Even the suffering that comes from ill health is never wasted. Men have gone through it who have thought that the ecstasy of relief following it made the experience worth while. Men are not deterred from action by the prospect of even severe pain. Probably no greater physical suffering can possibly be invited than is sure to come to those who go on Arctic expeditions, or who undertake prospecting in Alaska. Of course, many of the prospectors find themselves in the bitter cold of the North without having realized what they would have to stand. But Arctic explorers, as a rule, know exactly what they have to expect. Most of of them have been through it all before, yet they deliberately choose to go again for rewards that, to an average man's eyes, seem trivial. The memory of past pain is rather pleasant. Virgil's "Perhaps it will be pleasant to recall these trials at some future time" is not poetic exaggeration. _The Discipline of Pain_.--There is only one way to learn how to bear pain, and that is by practice in it. There might be no necessity for this in case life were arranged differently. But all men must die, and death inevitably involves a painful process. Suffering is practically unavoidable for the majority of men. Even in the midst of every possible material comfort, cancer may come with all its hideous connotations. It is important, then, that everyone should be prepared to stand some pain. Certain suggestions help in bearing special pains. Pain Diffusion.--Pain along one nerve may readily become diffused. This diffusion will sometimes cause discomfort, and even tenderness, at a distance from the original seat of the pain. Such diffusion tends to produce in the patient's mind the idea that the underlying pathological condition is spreading, though it is only a sign that the nervous system is becoming irritable and easily responding to sensory disturbance. Dr. Head's investigations ("Brain," 1893), should be known to physicians, and the conclusions that flow from them should be presented to patients who are sometimes suffering quite as much from their apprehension of the spread of pain, and its significance, as from the discomfort itself. Dr. Head says: If I have an aching tooth, the pain is at first localized to the tooth affected. The longer the toothache continues the more I become worn out, and the pain is rapidly accentuated by a "neuralgia," that is, a pain in the face. The neuralgia is soon accompanied by distinct cutaneous tenderness over a definite area on the face corresponding to the tooth affected. If I am anemic, or if the pain remains untreated until my bodily health is affected, I no longer have a localized area of tenderness, but the pain, and with it the tenderness, spreads until the whole of one-half of the head and even the neck may be intensely tender. Thus at last the pain of an aching tooth has produced tenderness over areas which bear no relation to the affected organ. As pain can be suppressed by diversion of mind, or concentration of thought on something that creates great preoccupation, it must not be {240} forgotten that pain may almost be created by concentration of attention on certain areas of the body, or certain nerve tracts. Over-attention will actually make sensations intolerable that are at first quite indifferent, or at least very easy to bear. Sensitive people, in the ordinary meaning of that term, are those who are much given to paying attention to their sensations, and who therefore have much to complain of them. There is much in modern life that has the tendency to produce this sybaritic condition in which even slight discomforts become the sources of almost unbearable annoyance. Even where there is no good physical reason for the occurrence of pain, thinking may produce discomfort. The one thing that Freud's work has made clear is that in neurotic persons the memory of a mental shock or strain may be transferred to some portion of the body related in some way to the shock, and then prove to be the source of hysterical pains and also of hysterical palsy. The case told by him in which the young woman massaging her father's limbs allows them always to rest on her own lap during the process, and after his death suffers from an hysterical, painful condition in this region, is a typical illustration. Her sympathy for her father, accentuated by his subsequent death, and her sorrow at a time when her nursing efforts made her particularly susceptible, led to an explosion of nervous energy along those nerves which had always felt the impress of his legs. The hysterical condition resulted. This is an extreme case. In milder forms it would be possible to explain many otherwise inexplicable pains and aches in sensitive young people along these same lines. More than once I have seen young women, who had been asked to rub father or mother with liniment, complain of tingling pains in their fingers which were followed by some redness so that one would be tempted to think of Weir Mitchell's disease, though evidently the pathological cause at work was the slight disturbance of the vasomotor system due to the liniment and the rubbing, emphasized by the sympathetic feelings, and by the over-attention which this brought about. Whenever women have, for a prolonged period, to nurse others in whom they are deeply interested, and have to perform some habitual action that is somewhat fatiguing for them, after the death of the patient there will not infrequently be the development of hysterical or neurotic over-sensitiveness in the parts employed. This may give rise even to an hysterical joint, or to severe neurotic pains. Once these cases are recognized, the attention can be diverted from themselves and they can be made to understand that their grief and sympathy are being concentrated on the part and by transfer are producing physical manifestations. The pain is not imaginary, but the condition will improve as soon as the mind is diverted from it. Neurotic and Organic Pain.--The distinction between pain due to a neurosis and to a definite lesion is often difficult to make. If there is a definite localization of pain, it is almost surely not neurotic, but organic. If there are certain positions in which pain is felt while it disappears in others, there is some local inflammatory or congestive condition and not mere hypersensitiveness of nerves at the bottom of it. These positions of maximum pain are important. When pain radiates a great deal, even though there may be complaint of a particular region, it is usually neurotic. If patients are asked to tell exactly where their pain is, and they indicate its location by a wave of the hand, it is probable that the condition is neurotic. When there is a definite {241} localized point of tenderness with the pain, even though there may be radiations, usually the condition is based upon some organic trouble. It must not be forgotten, however, that slight local troubles may by concentration of mind on them, become exaggerated and that, in spite of the fact that there is or was at the beginning a definite localization of pain with some tenderness, the neurotic elements may, after a time, become manifest and prove to be much more important than the others. Pain that is definitely influenced by motion, as by the jarring effect of walking, or by bending and stooping, is practically always organic. The best differential diagnosis between neurotic abdominal conditions and organic trouble can be made by the help of information obtained in this way. If the appendix is inflamed, or the gall bladder infected, or contains a calculus, or if the kidney has a calculus, these are all made worse by movements, by jarring, by stooping as in tying the shoes, by riding on rough roads, and the like. If patients who suffer from obscure abdominal conditions associated with pain of which they complain much, can, at certain times, indulge with impunity in these exercises and motions, it is probable that their attacks are neurotic in character. Especially is this true if the indulgence in these rides and motions is without effect when they are in pleasant, agreeable company, though there may be some complaints when they have to ride alone, or under conditions that are less pleasant. If a hint of this distinction by which the physician differentiates one form of pain from another is given a neurotic patient, the suggestion will serve the purpose of producing complaints whenever the opportunity presents itself. Such patients take such suggestions, as a rule, without wishing to deceive, but they become persuaded that their sufferings are of the character asked for. {242} SPECIAL PSYCHOTHERAPY SECTION VI _THE DIGESTIVE TRACT_ CHAPTER I INFLUENCE OF MIND ON FOOD DIGESTION With the progress of biological chemistry, digestion came to be considered a purely chemical process. Now we realize that even more important than the chemical factors of digestion is the individual liking for particular kinds of food, and the mental attitude of the patient toward digestion. Not only may mental factors interrupt or hamper digestive processes generally but, as the investigations of Pawlow at the Imperial Institute of St. Petersburg show, they may modify very materially the chemical processes within the stomach. If, for investigation purposes, a stomach pouch be experimentally segregated in a dog from the rest of the stomach, and the dog be fed food that he has a particular liking for, the gastric juice manufactured will be especially strong and effective. If the food given be less to the dog's liking, the gastric juice is not nearly so efficient in its activity. Finally, if food be consumed for which the dog does not care, but which he takes because hunger compels him, the gastric juice manufactured for its digestion is quite weak and the process of digestion is slow. If this is true for an animal like the dog, whose psyche is comparatively of much less importance than that of human beings, the corresponding influences in men and women will be even more emphasized. This is only what common experience has always shown us. The human stomach is not a test-tube in which mere chemical processes are carried on, but its vital activity is of great importance. That vital activity depends to a large extent on the state of mind, on the relish with which food is eaten, on the individual likes and dislikes, and on the emotional condition during digestion. Prejudices and Digestion.--Perfectly good food materials may become difficult or impossible of digestion as the result of learning something about their mode of preparation. In the country this is often noted, with regard to butter, milk, and even eggs. The story of the farmer's wife who wanted to trade her own butter for an equivalent amount made by someone else illustrates the influence of mind over relish for food. She was candid enough to say that the reason she wanted to exchange the butter was that a mouse had been seen in the cream, and her children could not, therefore, eat it. She took {243} back home with her exactly the same butter in another crock, and there was no further difficulty, though before this the children would have been actually sick if compelled to eat the butter. I once saw a family of three women who had vomited because they heard that the dishes had been washed in a slop pan, though this proved to be a mistake. Such occurrences emphasize the necessity for properly predisposing the mind, and for removing unfavorable suggestion, if digestion is to proceed properly. Mental States and the Stomach.--The typical example of the influence of the mind on the digestive tract is to be found in the experiences of Flaubert, the French novelist, while writing "Madame Bovary." When he was writing the scene in which he describes the effects of the arsenic which Madame Bovary takes, he himself suffered from practically all the symptoms due to the drug. In order to describe it faithfully he had studied it carefully. He had the pains, the vomiting, the burning feeling and even the garlicky, metallic taste in his mouth. Such an incident is extremely exceptional, yet its possibility is recognized, and it illustrates how sensitive some people are to the action of mental states upon the body, and how large a role a strongly excited imagination can play in producing definite physical symptoms. There are many more such realistic imaginations than we have, perhaps, been inclined to suspect. It is over these particularly that the psychotherapeutist can exert his influence by helping to modify the cause of their symptoms, the mental attitude which exists, rather than by trying to change the symptoms which are only effects, for diseases must, as far as possible, be treated in their causes. _Disgust and Disturbance of Digestion_.--Max Müller's story, told in his book on "Language," to show how language might have been a human invention from imitation of natural sounds, illustrates the influence of an unfavorable state of mind in disturbing digestion. An Englishman, traveling in China, fearful lest he should not be able to obtain food that he cared for, because of his lack of knowledge of the language of the country, was rather surprised on his first day's journey into the interior, to be served with a stew made of some kind of dark meat that tasted very well indeed and with which he was so much pleased that he asked for a second helping. Just as he was about to eat the second portion, he thought it well to ask the waiter what sort of meat it was, as he wished to be able to obtain the same kind at other places. Calling the waiter to him, he said, pointing to the dish of meat with a questioning tone, "Quack, quack?" The waiter at once shook his head and said, "Ugh! bow wow!" The Englishman pushed the second portion away and got up from the table. Tinder the same circumstances nearly everybody would feel the same qualmishness--at least all who had been brought up according to our Western notions. Reason has little or nothing to do with it. It is a question of feeling. The dog is much more cleanly in its habits than the hog, but we in the West are used to the idea of eating hog-meat just as they in the East are used to eating dog-meat. The objection, of course, might be urged that the difference between the hog and the dog is that we do not eat carnivorous but only herbivorous animals. But the slop-fed hogs from the neighborhood of our large cities, constituting a goodly portion of those brought to market, eat meat quite ravenously. They certainly are not exclusively herbivorous. There is no {244} principle behind our objection to dog meal then--only the unfamiliarity of the idea of eating it. The treatment of patients with digestive disturbances requires a careful analysis of the conditions of mind towards foods. If prejudice exists with regard to certain foods, there will be no relish for them, and unless these prejudices can be removed, the foods either will not be taken, though they represent important nutritional elements, or else they must be taken in such small quantities and digested with so much consciousness of their presence and such difficulty as to be a disturbing factor for health. Persuasion, the custom of the country, habit, training, mean much for this modification of mental attitude. _Custom and Food_.--In recent years many parts of animals, not generally eaten before, have come to be consumed with a relish because of the removal of prejudices against them. It might be thought that organs like the kidney, the essential function of which is excretory, and through which so much of the offensive waste products of the body pass, could not be a relished article of food. But it has become quite a dainty. The liver, owing to the peculiar nature of its function, its very special flavor, and the staining with bile, might be expected to be objectionable. It is not, but, strange to say, a third organ of the abdominal cavity, the spleen, which has none of the external objectionable features of kidney or liver, is not yet eaten, and most people would probably find it rather difficult to eat it. This difficulty would result, not because of anything in the organic substance itself, but because of the lack of accustomedness to it. There are a number of people who now have trained themselves to eat it. Such apparently impossible portions of the animal as the intestines, even those of the hog, are eaten with relish by a great many people, though there are others who have never been able to get used to them. The dainties of some peoples are utterly repulsive to others. The French like brains and other special portions of animals that are not much eaten by Anglo-Saxons. Fried brains in black butter sauce are enough to turn the stomach of some people by the very thought of it, though it is a highly prized dish in the south of France. In Italy most visitors eat snail soup with relish before they know what it is. It seems to be a special kind of gumbo soup. Down at Marseilles, gourmets occasionally eat angle-worms and find them to be a very appetizing dish. In all of these things the question of relish and peaceful, happy digestion depends entirely on the attitude of mind. The first men who ate eels must have been looked upon with considerable suspicion by their neighbors as viper eaters, and probably they themselves were not comfortable over the feat. It has been said that the first man who ever swallowed an oyster performed as great a feat as any of our important inventors or discoverers. _Gastric Antipathies_.--To the great majority of mankind the idea of eating horseflesh is repulsive. Numbers of people in various parts of Europe have found, however, that after the initial repugnance is conquered, it is quite as pleasant to eat as cow's meat. To my taste, at least, it is much more palatable than venison or bear meat. At the beginning, its sweetish taste has a curious reflex effect. Taken in connection with the thought that this is horse meat, the taste is apt to produce a sensation of nausea. This is readily overcome, though the first time it is necessary to keep constantly inhibiting {245} the mind from acting unfavorably upon the stomach during the course of eating and digestion. Custom, I learned from many, soon made it quite as savory as beef. _Food Varieties and the Mind_.--How easy it may be to overcome many prejudices in the matter of food digestion under the stress of necessity and the influence of example, was well illustrated during the siege of Paris. The Parisians, though a most delicate people in the matter of eating, were able to accommodate themselves to the conditions, and practically every kind of animal was eaten with a relish. Before the siege, to most of them it would have seemed quite impossible, that they should sit down with complacency to the dishes which afterwards were so appetizing. At the beginning there was a definite attempt to conceal the eating of rats, mice, cats and dogs under various names, and by various modes of preparation. But it was not long before there was an end of this pretense. The animals in the zoological garden proved a veritable life-saving store of meat. Every one of them was eaten, people were glad to get them, and paid high prices for them. Camel steaks, elephant cutlets, lion and tiger stews, appeared under their own names, even at the banquets of the wealthy. What is true of the mental attitude for meats influencing not only the relish for them, but their digestion, is also true for many vegetables. There are unfavorable suggestions in the minds of many with regard to the supposed indigestibility of potatoes, turnips, carrots, beans and occasionally with regard to tomatoes, lettuce, or the like. A few definite physiological idiosyncrasies against these vegetables, or certain of them, do actually exist. The attitude of mind, however, is largely responsible for the discomfort that occurs after the consumption of most of them. Patients who ought to consume more starchy substances, or whose bowels need the residual materials that are contained in these vegetables, for the sake of their effect upon peristalsis, should be persuaded to take these vegetables, first in small quantities and then in gradually increasing amounts. Many of them can thus be brought to a diet at once more nutritious and more likely to help out intestinal function. Their objection to them is usually but a fancy. Genuine Food Idiosyncrasies.--There are certain genuine idiosyncrasies with a physiological basis which prevent the taking of certain kinds of food, or cause disturbance if they are taken, but these are rare. Their presence should never be considered as demonstrated by subjective signs alone for these are eminently fallacious. In certain cases, however, so rare as to be almost always curiosities in medical practice, there are definite objective symptoms of the idiosyncrasy. These consist of urticarial rashes, tendencies to vomiting, or diarrhea, or both. Sometimes these result from the most bland and nutritious of foods. I have notes of the cases of two children--whose father could not eat eggs without vomiting--and to whom fresh eggs fed at the age of two and three years, always produced this same effect. Even small portions of egg would cause it. It mattered not how the egg was prepared, nor even whether it was carefully concealed in custard or in cake provided there was a certain amount of it, the food eaten with it would be vomited. There are many such idiosyncrasies for shell fish, cheese, and such fruits as strawberries, pineapples, pomegranates and the like, but they are demonstrated by objective signs. But by far the greater number of food dislikes are entirely {246} subjective and the subjective feelings can probably always be overcome by habit and training. Food Dislikes.--_Milk_.--Nothing makes more clear the absolute dominion of the mind over the stomach than the likes and dislikes of people for various kinds of milk. Most Americans can take cow's milk with good relish, though there are a few to whom it is distasteful. In this country we have not had much experience with the milk of other animals. Even goat's milk is not commonly used. The very thought of taking it disturbs many people, and to take it with other food would almost surely produce disturbance of digestion. I have seen people while traveling quite upset over the discovery that goat's milk had been put into their tea or coffee. Mare's milk is commonly used in some parts of Europe and in many parts of Asia, but it would be quite impossible to most of our people. Sheep's milk is used in some places. Ass's milk is commonly used in parts of Asia and may be obtained in Spain and is said to be less likely to disagree with children in summer than cow's milk. Most American mothers would rather not hear of it. The same thing is true of the milk products. Some people find certain kinds of cheese quite out of the question though other people relish them. It requires special training, not of stomach but of mind, to enable one to eat certain cheese, though once the habit has been acquired such articles are delicious. It is only in recent years that some forms of cheese with greenish tints have become popular in America. To serve them at a dinner a generation ago disgusted many people. Now a dinner does not seem complete without them. The beverages of various countries illustrate this same principle. The wines the Spaniards care for are not palatable to the Italians, and _vice versa_. Beer, as the result of familiarity, is now drunk everywhere in Europe, but when it was first introduced into Italy from Germany, it was considered impossible to understand how anybody could take it and pretend that its taste was pleasant. The question is said to have been once asked of one of the Congregations at Rome whether it was permissible to take beer on fast days. The Cardinals who tasted it declared that not only did it seem to them permissible but that it was a mortification to drink it and therefore it was proper Lenten exercise. _Eggs_.--Many people have a supposed natural repugnance for eggs which they are sure indicates that these are not good for them. As a result, the physician gets all sorts of stories with regard to the supposed effects of eggs. One person tells you that more than two eggs a day makes him bilious. Another will tell you that they are too heavy for him. A third will tell you that they are distinctly constipating. A fourth will tell you that they produce a tendency to diarrhea. Here, as with regard to milk, the experience of the tuberculosis sanatoria has shown that there are but few people who cannot, when properly persuaded and when eggs are given in various forms, take from four to six eggs in the day without injury, and even without inconvenience. In these cases, it is largely a matter of mental attitude towards the food. In many instances, it will be found that the disinclination began in some experience in childhood when an egg was not very good, or when it was served insufficiently cooked, or when, perhaps, eggs always cooked one way were made a staple of the diet for a considerable period. There are over one hundred {247} ways of cooking eggs and this variety of preparation will often make them palatable, and nearly always digestible. Over and over again I have seen people who had thought that eggs made them bilious, and who accordingly had for long refused to eat them, put in circumstances (from tuberculosis, diabetes, or obesity) where eggs had to form a considerable portion of the diet. Then there was no difficulty about eating and digesting eggs. In three cases in my experience patients with an objection they thought constitutional, developed glycosuria, and then nearly all their desserts were custards, and eggs became a standing dish in their daily diet. In every case not only was there no trouble, but they got to like the eggs and wondered why they should ever have had any prejudice against them. Two of the patients were women, the third a man who had not touched eggs for many years. His wife's comment was: "Eggs always made him bilious when he did not take them, but now that he is taking them freely they no longer make him bilious." Mental Changes and Digestion.--The change that has come over the public mind with regard to sour milk is a typical illustration of how much a difference in the mental attitude towards a food product may mean for its satisfactory consumption by many people. Sour milk, though many farmers and working people thought it a pleasant acid beverage, was for long looked upon as a product fit at most to be fed to the pigs, if, indeed, there might not be question even of the advisability of this. Only the very poor who craved the nutritious value there was in it, continued to take it to any extent. Even if the milk still tasted sweet, but broke when it went into the tea, that was enough to make it quite impossible for many sensitive stomachs. _Lactic Acid as a Bactericide_.--Then came Metchnikoff's announcement that his studies showed sour milk to be an extremely valuable food material, but much more than that, an important auxiliary for the lessening of microbic life in the intestines. He seemed to be able to demonstrate that a great many bacteria, whose products, absorbed from the intestines, hastened that process of deterioration in the tissues that we call old age, were inhibited when sour milk or lactic acid bacteria were present. The general health of the person who took sour milk was, as a consequence, much better. Not only this, but processes of deterioration being lessened, prolonged life and even old age could be promised to those who drank sour milk in sufficient quantities. Metchnikoff had been brought to the study of this question by what he had seen on the Steppes of Russia. Among the nomad tribes a principal part of whose diet consists of soured mare's milk, he found a large proportion of very old people. In looking for the reason for this disproportionate longevity, he came to the conclusion that the sour milk had something to do with it. Then laboratory observations and experiments as to the influence of the bacillus, that causes the souring of the milk, on the growth of other bacteria, and especially such bacteria as are usually found in the human digestive tract, seemed to show that the lactic bacteria had a strong inhibitory effect on nearly all the pathologic flora of the intestines. As the result of these studies, all the world is now quite willing to take its share of sour milk. We no longer hear the complaint that uncomfortable feelings in the digestive tract are the result of taking milk that was a little sour. {248} Since this doctrine of Metchnikoff's has come to be popularly known, fewer patients have insisted that they could not take milk in such quantities as the physician thought desirable for them. Before that, a persuasion with regard to the ease with which milk becomes contaminated with microbes, and the dread that it might thus be a source of disease, or at least of disturbance of digestion, made it very difficult of digestion for many people. Now that they have a good authority who insists that, even if it should become somewhat soured in the ordinary way, this, far from making it a pathological article of diet, rather adds to its value from a therapeutic standpoint, has changed the attitude of mind of these people. We need a similar feeling with regard to eggs in order that they may be eaten by many people who now refuse them because they fear the possible evil results of taking even a slightly tainted egg. Our recent pure food investigations have shown that the bakers in our large cities have been for many years using canned eggs, and that these would be quite impossible of consumption except disguised as they are in the midst of baker's products. Sometimes these eggs have been kept for several months before being canned. All the cold storage eggs that cannot be disposed of otherwise are thus treated. In spite of the common use of these canned eggs by a large proportion of the city population no serious results have come from them. The change that comes over eggs in time does not apparently spoil their nutritive quality, but only disturbs their taste. The main element in the change is the production of hydrogen sulphide. This gas has a very unpleasing odor, but its presence is not of pathological significance. This gas is a common ingredient in those mineral waters that are known as sulphur waters, and that have a reputation for curing many forms of digestive disturbance, especially chronic cases of nervous indigestion. What is true of sour milk, then, would seem to be true of eggs that have been, to some degree, spoiled, and at least no serious results may be expected from them. If serious results were to be expected, we should have had many evil reports of them in recent years. Whether considerations of this kind will help patients, who need to get over qualminess with regard to eggs, because they are always suspicious lest they should not be fresh, will depend a good deal on the suggestive value of such information as presented by the physician. _Another Organic Acid_.--Sauerkraut has shared the fate of sour milk, and because of its acid bacteria has been accepted by Metchnikoff as an ally. Yet sauerkraut used to be thought quite out of the question for invalids, especially those suffering from digestive disturbances. I recall the case of an old German shoemaker who had lived very much on sauerkraut when he was a young man and then, having made money in the manufacture of shoes, had not had much of it for thirty years, pleading with me, when he was old and it was rather hard to get anything to stay on his stomach, that he should be allowed to have sauerkraut. On the principle that what a man craves is usually what does him good, I allowed it. The physician with whom I was in consultation was perfectly sure there would be trouble, and the family were confident that his physicians evidently had given up all hope and were quite ready to yield to his caprices and let him take anything that he cared for. He not only took the sauerkraut without any trouble, though I must confess to some misgivings myself (for I am of those who unfortunately do not care for it and, therefore, {249} was prejudiced), but after having eaten a large plateful of sauerkraut twice a day for several days, he began to crave other things that would not stay down before, retained them well, digested them without difficulty, and got over that attack of indigestion and lived for several years afterwards. His own mental attitude was a better index than our supposed knowledge, though science has now come to confirm his state of mind. _Bacon and a Change in Suggestion_,--Another food material with regard to which there has been a complete change of view in recent years, is bacon and hog products generally. Pork in all forms used to be considered quite indigestible, and was one of the first things that people suffering from indigestion--or the fear of it--eliminated from their diet. Now we know how valuable a food product it is, especially for those inclined to suffer from constipation, or who are under weight. Many people still look surprised when advised to eat it regularly. Here we have a typical example of the change in the mental attitude toward a particular article of food bringing about a corresponding difference as regards not only the appetite for it, but also its digestibility. Many persons, who used to have no appetite for breakfast, now find that after eating a crisp piece or two of bacon, they develop an appetite for other foods. Bacon has become a fetish for some people and is considered a help, not a detriment to digestion. I recall a case in which I had very nearly the same experience with bacon as I related with regard to sauerkraut. The patient was an elderly woman, probably nearly ninety years of age, who, because of a crippling deformity, had not been able to get outside of the house for many years. She sat in a wheel chair, transported herself from one end of an apartment to another, spent most of her time by the window, but was very helpful in many little things about the house and occupied her hands with knitting and sewing. In spite of her condition, she was cheerful, pleasant, happy, and all her life had had a good digestion, her only trouble being a tendency to asthma as she grew old. I came back to the city after a summer vacation to find that she was not expected to live because nothing would stay on her stomach. She was sinking, and the end seemed not far off. I was asked to see her more because I had been her regular physician for some years, and it was thought that it would console her to see me than with any real hope of betterment. It had been extremely hot weather and this seemed to be an unfortunate circumstance. At my visit, I asked her if there was anything that she cared for. She shook her head and yet there seemed a hesitancy. I urged her to tell me if there was anything that she wanted, but only after considerable urging did she venture to say that there was something, only that she knew that she could not have it. Putting her thumb on the top of her little finger, she said, "Oh, I would like so much to have just a teenie-weenie bit of bacon." I said that she should certainly have it. Then taking courage, she asked if she could not have a little cabbage with it. I said, "Certainly." Her friends thought that it was just a yielding to one of the last wishes of an invalid with the idea that nothing could much harm her, since she was so near the end. She had eaten cabbage and bacon all her life; she ate it again with a relish, and in spite of the heat kept it down and digested it well. She had bacon and cabbage next day, and for several days; she gradually got strong and lived several more years of her happy contented life. {250} CHAPTER II INDIGESTION AND UNFAVORABLE STATES OF MIND Indigestion is the characteristic disease of our time. There are few men or women over thirty who have not suffered from it. The working classes are spared the most, but with the frequent suggestions in the newspapers and the introspection which has become so common, indigestion is often complained of even among them. Sedentary occupations, involving mental work and little physical effort, seem especially to predispose to some form of indigestion. Few of those who live what is called the intellectual life escape suffering from some of its symptoms. Not infrequently men have been hale and hearty specimens of muscular manhood when they took up some profession which compels them to be indoors, yet before long, they begin to complain of discomfort after eating, of tendencies to constipation, of headaches, of depression, of incapacity for mental effort after meals, and all these symptoms are attributed to the almost universal disease, indigestion. It is possible for the general attitude of mind to have a great effect on digestive processes, and the symptom-complex which is called indigestion, or dyspepsia, is probably much more dependent on the mind than on any other factor. In many cases it is primarily due to over-concentration of attention on digestion. In others it is due to over-occupation with business, worry, or serious thought at times when the digestive processes need all the energy. In many cases so-called dyspepsia is due to an unfavorable state of mind toward digestive processes in general, because of unfavorable auto-suggestion. Normally, stomachic sensations reach our consciousness only under special circumstances. When, however, much attention is paid to them, even the slight sensations that occur with normal digestion may rise above the threshold of consciousness and become subjects of solicitude. If they do so, then the increased attention likely to be paid to them surely interferes with function and changes what may be merely physiological into pathological processes. Disease Suggestions.--An unfortunate state of the public mind with regard to indigestion in general has been cultivated by many publications on the subject. People dread its occurrence, and fear that the first sign of discomfort in their gastric region is a signal of the beginning of a progressive affection. They fear the worst, and the consequence is a reaction quite out of proportion to the gravity of the ailment. So much has been said particularly of mistakes in diet that just as soon as they feel, or often rather think they feel, the first symptom of beginning dyspepsia they begin to study how to modify their diet so as to prevent its progress. They begin to eliminate various supposedly indigestible foods. Usually among the first things that are greatly reduced in quantity, or are entirely eliminated, are the fats and certain of the starchy vegetables. Because of expressions heard and read as to its harmfulness, the fearful ones also are usually timorous about taking fluid at meal times. As this is about the only time when they are likely to take fluid, unless it be summer, they soon suffer for lack of it. Eating only food that {251} leaves little residue and taking insufficient fluid leads to constipation. This reacts still further to disturb digestion, and to interfere with appetite. This leads to further reduction in the amount and variety of food, with the consequence that insufficient nutrition to supply energy for bodily needs is taken. The digestive system gives up to the body as much as it possibly can, not only of the food materials to be consumed, but of its own substance. Thus it weakens its own vitality, with a lessening of appetite and of digestive power. Hence, a vicious circle of change is instituted, the consequences of which are easy to see. After a time the patient is taking only the blandest foods, constipation has become an important element in the case, and the mind is constantly occupied with solicitude over the digestion and the choice of materials at meals. Contrary Suggestion and Digestion.--Hudson, in "The Law of Mental Medicine," insisted on the necessity for not suggesting to children the possibility of indigestion of various substances, for that is almost sure to disturb digestive functions. Children sometimes hear the remark that father or mother cannot take a certain article of food because it disagrees with them. The imitative faculty of the child is sure to be aroused, with the consequence that this particular food is not eaten with relish nor given a fair show for digestion, and will be the source of some stomach disturbance. Not infrequently substances thus spoken of are among those that are especially likely to do children good, such as milk or eggs, or occasionally butter. The harm done by the remark may, therefore, even be serious, for these foods should constitute a large proportion of the child's diet. Indeed, an excellent prophylactic in the matter of indigestion is to prevent as far as possible all conversation at table about the indigestibility of food. Unfortunately, this has, in late years particularly, become a favorite subject of table conversation. Transferred Feelings.--Professor Cohnheim called attention to the fact that many uncomfortable feelings are likely to be mistranslated because they are referred to organs with which there is nothing wrong. Whenever this function is hampered in any way, there are many uncomfortable feelings associated with the digestion of food. The custom has been to refer the origin of all these to the stomach. Cohnheim thinks that it is much more likely that they really originate in the intestines, though the rule has been to take the patient's feelings as an indication and to treat the stomach. It is not an unreasonable thing for patients to be deceived as to the exact location of discomfort. Even in so acute a process as toothache it is possible to mistake the particular tooth that is giving trouble, and, as dentists know, a perfectly quiescent tooth is sometimes blamed for pain that is coming from another. Fillings have been removed, teeth have been treated, good teeth have been extracted, because patients insisted on the significance of their feelings in such cases. The stomach must not always be blamed. Sometimes the only source of supposed gastric discomfort is the constipation present which is usually easy to relieve. _Gastric Reflexes_.--While the mind may serve to disturb digestion and produce gastric discomfort by over-attention, there are many reflexes that center in the digestive tract, the origin of which may be in distant organs. Fright often produces a sensation as of cold at the pit of the stomach. Looking down from a height has the same effect in some persons. Discordant noises {252} have the same effect on people of sensitive hearing and certain reactions to touch may be similarly reflected. There are a number of affections which produce uncomfortable reflex sensations in the gastric region. This is the hypochondrium of the olden time. Whenever feelings were complained of, for which there was no actual basis in the hypochondriac region, it came to be spoken of as hypochondriasis, a word that has an innuendo of imaginativeness about it. Dr. Head's studies with regard to the transfer of sensations from one portion of the body to the other, show us that there is a good physical reason in reflexes for many of these complaints. An explanation of this to patients will often relieve their minds greatly and make their discomfort seem much less serious. Dr. Head said: With orchitis or prostatitis, we also occasionally find that the patient complains of a pain at the epigastrium, representing the stomach area. This is put down to hypochondriasis and if it occurs in a woman as a consequence of ovaritis, she is said to be hysterical. But this phenomena is no more "hysterical," whatever that may mean, than is the reference of the pain and the tenderness of an aching tooth to the back of the head or the shoulder. [Transfers which have been observed actually to take place.] This is the phenomenon I have been accustomed to call "generalization" of visceral pain and tenderness, and is of such common occurrence as to form a very important factor in the clinical picture of many diseases. The order in which generalization takes place, leads one to speak of the relative "specific resistance" of the centers for the sensory impulses from various organs. No very definite rule can be laid down to govern every case, but each case must be considered on its merits. However, the area which appears most easily on a woman, as a secondary affection, is the tenth dorsal; then, perhaps the sixth dorsal, or inframammary, and then the various gastric areas, beginning first with the ensiform or seventh dorsal. In a man the tenth dorsal appears rather less readily while the ensiform appears with great ease. Affections of other organs within the abdomen may produce like reflexes. A chronic appendicitis, for instance, will often be reflected in the stomach area. So will the presence of gallstones, or of disturbances of the biliary mucosa. Loose kidney often produces stomach reflexes. Any disturbance of the intestinal function will produce gastric irritation and inhibition of digestion. Most of the other primary conditions are more serious. Often the patient is aware of their existence, and it is a relief to him to find that the stomach symptoms are not the index of further pathological development, but only reflex conditions. This of itself does much to make the condition more bearable. Patients who are suffering from symptoms of indigestion often have areas of their skin surface that are at least very sensitive, if not actually tender. They feel the pressure of their clothing over a particular portion of the body, usually on the left side of the abdomen somewhat above, though at times also below the umbilicus. Though not painful, as a rule, it is decidedly uncomfortable and produces a constant desire to loosen the clothing, or lift it from the part. Mere loosening, it is soon found, does no good, because the clothing continues to touch the skin and it is not the constriction or pressure but the contact that produces the discomfort. Sometimes there is a distinct lesion of the stomach. This cutaneous hyperasthesia may, indeed, rise to the height of extreme tenderness in cases of gastric ulcer, or the like. But there is no {253} doubt that a certain amount of this sensation is present with all functional disturbances of the stomach and that the reflex sensitiveness of superficial nerves is only what might be expected from what we now know of this subject. _Discomfort and Digestion_.--Just as certain food materials disagree because of the state of mind, so certain feelings in the gastric region, even in the skin surface, sometimes disturb digestion and lead to changes of the diet unwarranted by the condition. Patients conclude that, if the skin is so tender, then the underlying organs, the disturbance of which causes this tenderness, must be in a serious condition. For these patients the explanation of the present state of our knowledge as to reflex disturbance of sensory nerves will be of therapeutic value. They must be taught that pain is reflected from one nerve branch to another, and is not communicated by continuity of tissue, or by sympathetic affection from the stomach mucous membrane through the stomach wall, and then from the abdominal wall to the skin surface. This knowledge will prove reassuring. Division of Energy.--After this mental occupation with digestion itself, which by consuming nervous energy lessens the amount available for digestive purposes, probably the most common factor in the production of indigestion is the concentration of mind on serious subjects, while digestion is proceeding. An old English maxim is that some people have not enough brains to run their liver and their business. The liver in old-time pathology was considered the most important of the abdominal organs and was taken by metathesis for them all. Most of us have only a limited amount of vital energy and, usually, we can accomplish only one thing well at a time. If we try to do intellectual work while digestion is going on, both the intellectual work and the digestion suffer. If we persist in attempting to do both, we will surely disturb the digestive organs and we may bring about grave neurotic disturbances in the central nervous system. We may be able for a time to accomplish the two things at the same time, but it will not be long before evil results will be seen. Nervous, high-strung people should be reminded of Lincoln's anecdote of the little steamboat on the Mississippi which had not steam enough to blow its whistle and run its paddle wheels at the same time, so that whenever the engineer wanted to blow the whistle he stopped the boat. Indeed, much of the indigestion that we see is due to this dissipation of energy through the attempt to do two things at the same time. Those who live the intellectual life are the most frequent sufferers. Worries and anxieties that are allowed to trouble the mind during digestion time are sure to disturb digestion eventually because they use up energy that is needed for physical purposes. A change of environment that takes us away from the ordinary cares of life, is often sufficient to make all the difference between ease of digestion and extremely uncomfortable dyspepsia. By worry the mind apparently becomes short-circuited on itself and uses up a large amount of the available energy in nervous impulses that do not find their way outside the central nervous system at all, but are used in disturbing associated nerve cells. Just as soon as a change of scene and occupation calls for a different set of thoughts and other feelings, energy is released for work outside the central nervous system itself, digestion begins to improve, and in a comparatively short time what seemed to be a serious gastric disturbance, disappears almost completely. {254} _Lack of Sleep Repair_.--In my own experience one of the most characteristic stigmata of these cases of indigestion which are due to exhaustion through other channels of vital energy, is that they feel much better in the evening than in the morning. They are, therefore, tempted to stay up late and so do not get the necessary rest. Their excuse for late hours is that they need recreation. To that excuse I have no objection. They do need more recreation; they need more hours during which their minds are absolutely free from business cares; but these hours must not be taken from their sleep, for they need rest even more than recreation. _Worries and Irritations During Meals_.--The presence of worries or irritation during meals or shortly after, as well as unfavorable states of mind towards digestion itself, and occupation of mind with serious affairs during digestion, are likely to be sources of serious disturbance of digestion. A fright, a fit of anger, nagging, irritation, or any disturbing emotions, may hamper digestion. An experiment that is sometimes performed in the physiological laboratory on the cat nicely illustrates this. If the laboratory cat is fed some dainty that it likes, mixed with bismuth in order that its stomach and intestines may be made opaque to the x-rays, and then be examined by means of the fluoroscope, the peristaltic processes of digestion by which food is mixed in the stomach, passed out into the intestines, and by which intestinal digestion is stimulated, may be seen to go on very interestingly. If, now, the cat is made to arch its back, and manifest the usual signs of extreme irritation, the process of digestion is interrupted, and will not be resumed till some time after the cat quiets down. The lesson is obvious. CHAPTER III PSYCHIC TREATMENT OF DIGESTIVE CONDITIONS If discouragement and solicitude make a healthy stomach digest imperfectly, the same mental factors will play an even more serious role with a diseased stomach. Certainly without the mind's aid, there can be little hope of such a reactive vital resistance as will enable the organ to recover from the organic ailment. So many cases of indigestion are due to mental persuasion alone, that after a time there is danger that the physician may be over-confident in his diagnosis, and may occasionally overlook serious organic lesions. Before attempting psychotherapy in these cases, the physician must assure himself that no organic lesion is present. This is particularly true for cancer in the middle-aged and ulcer in young women. At times these lesions are latent except for certain vague digestive symptoms. After careful consideration it is generally possible to make a definite decision, and then the indications are clear. Even when an organic lesion is present, a modification of the mental attitude will often be of great service to the patient. Suggestion will even make a cancer patient gain in weight, though one must be careful of that very fact because the apparent improvement may occasion delay until the case becomes inoperable. Once the presence of these serious organic lesions of the stomach can be {255} excluded, the bringing of influence to bear on the patient's mind for the improvement of his digestion is indicated. It is true that there are certain reflex disturbances of the digestive tract consequent upon affections of other abdominal organs. Chronic lesions of the appendix may produce stomach symptoms as will also pathological conditions of the biliary tract. A floating kidney, various affections of the pelvic organs, especially in women, and of the urinary organs in men are sometimes said to produce seriously depressing effects upon the stomach. Where this occurs, the first indications undoubtedly are to put the patient into as good condition as possible before making any decision. Where a lesion of the stomach itself exists suggestions with regard to the increase of diet may do harm. They will not do harm in the reflex conditions, and so patients can be brought into better physical condition. As a consequence of this, their symptoms in other organs will often disappear. In case the symptoms do not disappear the patients are in better condition to stand and react from operative intervention. Before concluding as to the character of the stomach symptoms we must make sure that other important organs are not affected. Most cases of tuberculosis begin with stomach symptoms, which often make their appearance before there is cough or any definite localizing symptom of the disease. Often there is only a disturbance of pulse, and perhaps a slightly increased range of temperature. If the patient has been exposed to tuberculosis, a careful investigation of the lungs should be made. Any disturbance of the liver or pancreas (especially cancer) will almost surely give rise to stomach symptoms. Latent cancer in any part of the body, however, will, by its depressing toxemia, produce loss of appetite, consequent loss of weight, and a number of symptoms that are sure to be referred to the stomach. I have seen cancer of the prostate, without disturbing urination, produce such symptoms for months before it was recognized. I have seen cancer of the rectum in a comparatively young woman treated as piles, without an examination, the development of the piles being attributed to the gastro-intestinal symptoms which were consequent upon the presence of the cancer. MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION It is often said that this teaching as to the effect of the mind on digestion and its eminent usefulness for the treatment of dyspeptic conditions, is due to the attention that has been attracted to this subject as a consequence of the prominence of Eddyism, New Thought, Mental Healing, and the like. There are absolutely no good grounds for any such assertion. Here in America, more than twenty-five years ago, before there was any question of the modern mental healing movements, our greatest medical clinician, Dr. Austin Flint, expressed himself very emphatically with regard to mental influence over digestion, and to solicitude of mind as one of the most frequent etiological factors in dyspepsia. Dr. Flint was thoroughly scientific in his medical observations, was no seeker after notoriety, and he was reading his paper before the older physicians of the period, and all of those who took part in that first meeting of the New York Medical Association strove to make their papers of scientific value. His words, then, must carry great weight: {256} Dyspepsia formerly prevailed chiefly among those who adopted, to a greater or less extent, the foregoing maxims [the finicky rules of dyspeptics which he deprecates and corrects as quoted later in this chapter]. It was comparatively rare among those who did not live in accordance with dietetic rules. The affection is much less prevalent now than heretofore, because these maxims are much less in vogue. The dyspeptics of the present day are chiefly those who undertake to exemplify more or less of these maxims. It seems to me, therefore, a fair inference, that dyspepsia may result from an attempt to regulate diet by rules which have for their object the prevention of the affection which they actually produce. It is to be added that an important causative element involved in the practical adoption of these rules is the attention thereby given to digestion. It is by introspection and constant watchfulness of the functions of the stomach, that the mind exerts a direct influence in the causation of this affection. Dietetic Rules of a Former Day.--In order to make definite just what were the views of the olden times which he deprecates, he stated them briefly and forcibly: The views generally entertained, at the time to which I have referred, largely by physicians and almost universally by non-medical sanitarians, may be summed up in a few maxims as follows: Eat only at stated periods, twice or thrice daily, and never between meals, no matter how great may be the desire for food. Never eat late in the evening or shortly before bedtime. In the choice of articles of diet, carefully select those which reason and personal experience have shown to be best digested; and never yield to the weakness of eating any article of food simply because it is acceptable to the palate. In order to avoid the temptation of overeating, let the articles of food be coarse rather than attractive, and eschew all the devices of the cuisine. Always leave the table hungry. Study personal idiosyncrasies, and never indulge in kinds of food which, although wholesome for most persons, are injurious to a few who are peculiarly organized. With reference to this last maxim, bear in mind that "what is one man's meat is another man's poison." In order to secure, as effectually as possible, a proper restriction in the quantity of food, it was recommended by some physicians and to some extent practiced, that every article be carefully weighed at meal times, and that a certain quantity by weight be never exceeded. Vegetarianism or Grahamism was advocated and practiced by many. Total abstinence from drink was considered by a few as a good sanitary measure, compelling the body to derive the needed fluids exclusively from fruits, vegetables, and other solid articles of diet. Restriction in the amount of drink, as far as practicable with regard to the power of endurance, was very generally deemed important, so as not to dilute the gastric juice. When to his question, "Do you regulate your diet," the patient answered promptly and often emphatically in the affirmative, Dr. Flint insisted always: "This is a good reason for your having dyspepsia; I never knew a dyspeptic get well who undertook to regulate his diet." When the patient asks then, "How am I to be guided," the reply is, "Not by theoretical views of alimentation and indigestion, no matter how much they appear to be in accord with physiological and pathological doctrines, but by the appetite, the palate and common sense." He then goes on to answer certain other objections that patients are wont to urge, and says: But the patient will be likely to say, "Am I not to be guided by my own experience and avoid articles of food which I have found to disagree with my digestion?" The answer is, that personal experience in dietetics is extremely fallacious. An article of diet which may cause inconvenience of indigestion to-day may be followed by a sense of comfort and will be readily digested to-morrow. A variety of circumstances may render the digestion of any article of food taken at a {257} particular meal labored or imperfect. As a rule articles which agree with most persons do not disagree with any, except from casual or accidental circumstances, and from the expectation, in the mind of the patient, that they will disagree. Without denying that there are dietetic idiosyncrasies, they are vastly fewer than is generally supposed; and, in general, it is fair to regard supposed idiosyncrasies as purely fanciful. Patients not infrequently cherish supposed idiosyncrasies with gratification. The idea is gratifying to egotism, as evidence that Providence has distinguished them from the common herd by certain peculiarities of constitution. Dietetic Instructions.--Finally Dr. Flint has a series of instructions for those suffering from indigestion: Do not adopt the rule of eating only at stated periods, twice or thrice daily. Be governed in this respect by appetite; and eat whenever there is a desire for food. Eat in the evenings or at bedtime, if food be desired. _Insomnia is often attributable to hunger_ [italics ours]. In the choice of articles of diet, be distrustful of past personal experience, and consider it to be a trustworthy rule that those articles will be most likely to be digested without inconvenience which are most acceptable to the palate. As far as practicable, let the articles of diet be made acceptable by good cooking. As a rule, the better articles of food are cooked, the greater the comfort during digestion. Never leave the table with an unsatisfied appetite. Be in no haste to suppose that you are separated from the rest of mankind by dietetic idiosyncrasies, and be distrustful of the dogma that another man's meat is a poison to you. Do not undertake to estimate the amount of food which you take. In this respect different persons differ very widely, and there is no fixed standard of quantity, which is not to be exceeded. Take animal and vegetable articles of diet in relative proportions as indicated by instinct. In the quantity of drink, follow nature's indication; namely, thirst. Experience shows abundantly that, with a view of comfortable digestion, there need be no restriction in the ingestion of liquids. Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no subject that they occupy themselves with more seriously than their digestion, and they thus divert blood needed for digestive purposes as well as nervous energy that would help in it from the stomach to the brain, in order to exercise surveillance over the process. As has been well said, "Probably much more than half of the indigestion is really above the neck." This does not mean that there are not cases that need definite stomachic treatment, or even that patients who have succeeded in functionally disturbing their digestion by thinking over much about it, will not need gastric remedies. The explanation of the many fads and remedies that _cure_ indigestion, real or supposed, is exactly this tendency of the suggestive influence of such remedial measures to lessen the patient's solicitude about digestion. Any change in diet that carries with it the persuasion that for any reason digestion ought to be better, will, because of this, make digestion better. Any habit of taking warm or cold water before meals, or of chewing in a particular way, or of taking a particular kind of food different from what is usually taken--exclusively cereal, uncooked, largely fruit, vegetarian, etc.--will lift the concentration of attention on the digestive process, and so give the stomach a chance to do its work without interference from the brain. Du Bois has quoted some striking testimony in this matter from Baras, who wrote on the "Gastralgias and Nervous Affections of the Stomach and the Intestines" as early as 1820. Baras had himself been a sufferer from {258} gastric discomfort, fullness after eating, eructations of gas, constipation, and general depression. He consulted most of the distinguished medical practitioners of his time. With one exception they were convinced that he was a sufferer from chronic gastro-enteritis. They added more and more to his concern about his stomach, and furnished him with numerous sources of autosuggestion. In spite of all that they did for him, his condition grew worse and worse, he lost in weight, and was sure that his case was hopeless. He was cured in a single day. His daughter was attacked with consumption, and "in the moment my attention," says Baras, "was centered entirely upon my child, I thought no more of myself, and I was cured." Brain Workers and Indigestion.--Perhaps the best proof of how necessary it is that people should not continue to occupy their intellect seriously during the time when digestion is going on, is to be found in the frequency with which complaints of indigestion occur in literary folk. The complaints are heard most from literary folk because they are more likely to tell their stories. They have their work, and thoughts of it, always with them. So there is a constant call for nervous and mental activity and for much blood in the brain tissues. This subtracts from the nervous energy necessary for digestion, and makes it impossible to conduct it with that perfection which comes naturally to people who banish all other thoughts and keep their minds free for the pleasures of the table and social intercourse at meal time. Nervous indigestion is so common among literary folk, teachers and scientific workers, that various causes have been suggested for it. Dr. George Gould, in his "Biographic Clinics," calls attention to it and suggests that the cause is probably the need of properly fitted spectacles. In our own time, when we are much more careful in the matter of eyeglasses, and when most writers and professors wear scientifically adapted glasses, the complaints still continue. The reason is evidently something associated with the almost continuous work that they do. Such people, too, are much more self-conscious than others. They think more about their digestion and what they eat. They often think that they differ from other people and have special idiosyncrasies for food. These thoughts are sure to culminate in nervous indigestion. Food Faddists.--Literary folk and people who live the intellectual life are very prone to take up with fads of various kinds and find surcease from their sorrows in all sorts of out of the way dietaries, modes of eating, food limitations and specializations. They constitute a majority of the food faddists. Some of them--sure that they should not eat meat--are strenuous vegetarians. Others confine themselves entirely to food the life of which has not been completely destroyed by cooking. They are fruit faddists, nut faddists, milk-product faddists, and the like. Some of them try to persuade the world that it eats too much; others that it eats too frequently. Some of them take but a single real meal a day and have apologies for the other meals. All want to lead people to their particular mode of life, as if all the world had been wrong until they came to set it right. Some want the rest of the world to chew seventy-times-seven before they swallow and to adopt other exaggerations of attention to eating that are quite contrary to instinct, the most precious guide that we have in the matter of food choice and food consumption. These intellectuals are always improved by their fads, no matter what they {259} may be. The reason is apparent. Their original digestive disturbance was due to over-occupation with intellectual work. Then they began to worry about their digestion and feared that nearly everything they ate would disagree with them. This fear and solicitude still further interfered with digestion. Next they acquired the new fad. They became persuaded that they could eat certain things in certain ways. They no longer disturb their digestion by anxiety about it, but, on the contrary, help it by favorable suggestion. Now under the new regime everything will surely go on well. Besides, they usually learn the lesson of not doing intellectual work close to their meals, and of spacing their work better. They learn to do a daily stint of work and no more. One of the fads that goes with most food fashions is abundant outdoor air. This always does good. Between the favorable mental influence, the lessened work, especially just after meals, and the increased outdoor air they get better and then they attribute it all to their special fad about food. The _"cure"_ is due to psychotherapy and common sense, and not in any way to the special fad. Worry.--Worry of any kind will have the same effect as the over-attention of the literary man or teacher to his work. Anyone who brings his business home with him is likely to suffer and, unless he has a superabundant supply of energy, will impair his digestive function as a consequence of attempting to do business after dinner, perhaps also stealing some of it in before and during breakfast. PREVENTION AND CORRECTION The important rule with regard to the mental attitude of the patient toward uncomfortable feelings due to digestion must be, first to correct all other possible sources of the trouble, and only after these have been proved not to be factors in the case, should there be any question of modification of diet. This is just the opposite rule from that which obtains, and by which patients begin to meddle with their diet at the slightest symptom, or supposed symptom, of indigestion. My custom is to tell patients at once that there is probably something else besides their diet at fault. It is not that they eat too much, nor too great a variety, but that perhaps they eat too rapidly. Without reducing their diet, and above all without eliminating supposedly indigestible things from it, there should be formed a habit of eating more slowly. This will usually result in the reduction of the quantity eaten, but the variety of food should be the same, and the patient should not be permitted to limit his diet to a few supposedly bland, unirritating materials. In that event, constipation will assert itself, particularly if there is limitation of the amount of fluid taken. Longevity of Dyspeptics.--There is one consolation that may be given to nervous dyspeptics, though in the midst of their worst symptoms they may not be sure whether it is a genuine consolation or not. It has been noted that many of those who live to extreme age tell the story of having suffered from nervous dyspepsia in middle-life. Their solicitude about themselves makes them safe against over-indulgences of many kinds in food or drink that might prove hurtful to them. Much of their discomfort is indeed due to the fact that they do not eat quite enough. If they succeed in avoiding the {260} pitfalls of the infectious diseases, and especially tuberculosis during their earlier years, and most of them are likely to because of the great care they take of themselves, they often live to old age. Certainly of two men, one of whom eats very heartily and the other very sparingly, the latter is much the more likely to attain old age. There are those who declare that the valetudinarian life, "half dead and alive," which even Plato satirized nearly 2,500 years ago, ever renews the question as to whether life is worth living or not. It is particularly dyspeptics who seriously discuss this question--yet with all their complaints, they actually do live longer lives. Pharmaceutic Remedies.--This insistence on the importance of mind in the treatment of indigestion does not imply that tonic remedies, and especially such substances as strychnin, which stimulate appetite and add tone to the muscles of the stomach, should not be used when duly indicated. They are always helpful. Alone, these remedies give but temporary relief and after a short time the system becomes accustomed to them. If prescribed in connection with changes in the patient's habits, and especially such as divert his attention from his digestive tract, and from wrong persuasions as to food taking, the good they accomplish will be lasting. Nervous people usually have an increase of acidity. They are liable to overdo everything, and even the stomach overdoes its acid forming function. For this, alkaline remedies such as rhubarb and soda will do good. But, just as with strychnin, the benefit is but temporary unless the patient's habits and attitude of mind are modified so as to eliminate their solicitude as a constantly disturbing factor. Circumstantial Suggestions.--There are many changes of habits that are of great value in the treatment of nervous and allied forms of indigestion. These changes often make a great difference in the general health of the patient and thus help to improve digestion. Besides their influence as alteratives, they are valuable from the mental influence which they exercise. It requires a definite exertion of will many times, perhaps, each day to bring about the omission or performance of certain actions, and this act of the will is accompanied by the repeated suggestion that this will cause improvement in the digestion. Many of the cures effected by special diet. Habits of exercise, health resort regimes and the like, owe their efficacy to this accompanying repeated suggestion of acts for the formation of new habits or the breaking of old ones. Physiological Measures.--There are, of course, certain details with regard to digestion in which the patient's mental attitude needs to be changed by instruction rather than persuasion, by knowledge of physiology rather than by psychology. In the taking of food itself, chewing is, of course, the most important consideration after its good preparation by the cook. If patients are told to chew their food carefully, however, without further directions than this, it will usually be found that they begin to chew their meat a great deal and their vegetables scarcely more than before. It is, however, vegetables that must be chewed particularly. The meat-eating animals bolt their food. They have only cutting and tearing teeth. Their instinct is correct, for the saliva has nothing to do with the digestion of meat, and therefore no chewing is necessary. On the other hand, the vegetable-eating, and especially the grain-eating animals, chew carefully. Most of them are ruminants, that is, after a preliminary thorough chewing of their food, they swallow it, and then {261} afterwards at their leisure bring it up once more into the mouth and chew it again. _Mastication and the Stomach_.--If food is not chewed well, and occurs in large masses in the stomach, not only is it not dissolved easily, but the work of passing it out to the intestine is delayed. The reflex which brings about the opening of the stomach and the ejection of food into the intestine is best brought about by the liquefaction of the stomach contents. During the mixing process all the food, as far as possible, becomes fluid and then is passed on. Large pieces of any kind are delayed, however, hamper the emptying of the stomach and interfere with stomach motility. The stomach is only a thin-walled membranous viscus which finds difficulty in dealing with food in lumps. It is different from the stomach of the hen, which, having no teeth, swallows grains of all kinds without chewing, but also by instinct swallows small stones which, in its thick-walled, muscular gizzard, are used for grinding up the food. _Exercise_.--The taking of exercise is an important habit that needs to be changed in the case of dyspeptics. Many of those who live a sedentary life, and are much occupied with intellectual or business matters, are almost sure to take little or no exercise. If earlier in life they were accustomed to take much, the lack of it leads to serious disturbances of nutrition. They have formed certain habits as to the amount of food they eat, and these continue, so that they consume more heat-making material than they can use. In the process of dissipating it, there is likely to be much nervous energy wasted, usually to the discomfort of the patient. This is likely to be eventually reflected back to the stomach, with disturbance of appetite and digestion. We now know that the motor function of the stomach is much more important than its secretory function. Its main purpose is to mix the food and pass it on in small quantities, at intervals, to the intestines. When patients have a sense of uncomfortable fullness in the gastric region after a hearty meal, or of discomfort after the taking of food, especially if much liquid is taken with it, they are prone to attribute these feelings to imperfect secretion not completing digestion as it should, and permitting fermentation with a production of gas and consequent stomach distention. The real reason for their discomfort is not secretory, but motor. It is due to a delay in passing on the food and to stomach distention because the gastric muscle is not in good tone. People who have been used to taking exercises have their muscular system in good tonic condition. This includes the involuntary muscles, as well as the voluntary, and if they are neglecting air and exercise, the whole muscular system becomes flabby. Hence the uncomfortable sense of distention, because the stomach walls do not contract readily for the expulsion of food. A second important factor is also present--the muscles of the abdomen. Ordinarily they support the abdominal organs without any sense of effort. If by lack of exercise they have diminished in tone, however, when a hearty meal is eaten, the abdominal muscles have to support this additional weight since the stomach itself sags, and the consequence is a feeling of pressure on the left side of the abdomen about the level of the umbilicus. To relieve this feeling the tendency of the patient is almost always to lessen the amount eaten. If he is not distinctly overweight this will do harm rather than good. Instead he {262} needs to take sufficient exercise to tone abdominal muscles and reflexly also tone even involuntary muscles, and with them the gastric muscularis. _Air_.--Almost more important than exercise is an abundance of fresh air, and without this muscles soon fail to respond to voluntary or involuntary impulses. If people do not spend two or three hours in the air every day, they are likely to develop an over-sensitive condition in which all nervous sensations are exaggerated. The reason men and women differ so markedly in their reaction to pains, aches and discomforts, is mainly that their habits of being out in the air differ correspondingly. Men are out much and, as a rule, stand discomfort better. Women are out little and are more sensitive to pains and aches. The more a man is out, the less is he likely to notice discomforts and aches that he would otherwise complain about. _Sleep_.--Another important factor is the amount of sleep. Over and over again I have found that patients who were beginning to complain of discomfort, which they associated with the word indigestion, were taking too little sleep, and as soon as I persuaded them to add an hour or more to their sleep their gastric symptoms began to improve. It is easy in our large cities to acquire the habit of shortening the hours of rest. This is sometimes done so gradually that the individual scarcely realizes how much he has cut into his sleeping period. Some people who have to get up at seven or half-past seven in the morning go to bed about twelve, but really do not get settled for sleep until nearly one o'clock. Sometimes people read interesting books just before going to bed, or while in bed, and it is nearly two o'clock when they get to sleep. Many people have the habit of reading themselves to sleep. This may be an excellent way to get rid of bothersome thoughts, provided the reading selected is not of too absorbing a character, and provided also as soon as sleepiness comes its call is heeded. Some write letters late at night. Writing always keeps one awake, though reading may be helpful for sleep. If this abbreviation of sleep becomes habitual, the first organs in the body to set up an objection is the digestive tract. It is one of the hardest worked systems in the body, having to dispose of its quantum of food three times every day, and if the organism does not receive due rest, the digestive tract suffers first. People who get insufficient sleep often have no appetite in the morning, and suffer from uncomfortable feelings in the gastric region. What they are too prone to do is to meddle with their diet, and this practice always does harm. CHAPTER IV APPETITE Two classes of patients come to the physician complaining of lack of appetite. The first and more important class consists of those who are eating too little, who are consequently under weight, and who must be made to eat more. The other class consists of those who eat enough but complain that they do not relish their food. Careful questioning usually elicits sufficient information to enable one to decide that most of these latter are eating too {263} much, or unsuitable food, and at too frequent intervals. They are usually overweight, and there is need to reduce the amount they eat. In both of these classes the physician is tempted to conclude that medicines should form the principal part of the treatment. We have a number of tonics and stimulants that undoubtedly initiate a desire for food, or at least so increase the circulation in the stomach that patients feel much more inclined to eat than they otherwise would. There are a number of remedies, also, the so-called anti-fat group, which produce a disinclination for food. Power of Mind Over Appetite.--Appetite, whether in deficiency or in excess, is best regulated through the patient's mind. Patients frequently state that they cannot eat more than they do, that they have no inclination for food, and yet, after a little persuasion, they can be made to increase the amount they have been eating, and then that can be gradually raised until they are taking what is for them a normal quantity. There are many things that we swallow without caring for them. Most medicines we not only do not like, but positively dislike. We put them down, they accomplish their purpose, and food will act nearly in the same way. There are few cases where food is positively rejected. Patients can be persuaded to eat more, and after a time will be surprised to find that their desire for food increases with the habit of taking it. On the other hand, patients can be made to see that they are taking too much food really to enjoy its consumption. Their appetites are perpetually cloyed, and to them food has none of the pleasant flavor that exists when it is taken in moderation. _The Will to Eat_.--In various parts of this book there is emphasized the necessity for the exercise of the human will in order to aid in the accomplishment of even physical functions. The basis of many nervous symptoms is a lack of sufficient nutrition to steady the nervous system. Some people not only lack will power, but also judgment in the matter of eating; they prefer to err on the side of insufficiency lest they should over-eat. For these people the important remedial measure is to dictate the amount that they shall eat, and gradually to increase it until they are eating enough for their nutritional purposes. When this advice is given to patients, they are willing to agree that a gain in weight would be good for them, but they cannot understand how they can eat more since they are now eating all they can, or certainly all they care to. Appetite grows by what it feeds on, and increase in appetite is a function of the habit of eating. But some patients, after having tried the prescription of eating more, are still in the same condition, and find that they cannot put on weight. What is needed in such cases is an inquiry into all the conditions of the daily life, their habits of eating and the amount of time that they take for their meals. They are probably eating one good meal a day, their dinner in the evening--but they confess that the other meals are not satisfactory. If their habits are rearranged, the will to eat does the rest. Sometimes they complain of uncomfortable feelings after eating and this makes them eat less at the next meal. There are various mental elements that disturb the efficacy of the will to eat, consequently these patients do not get on. What they need is emphatic insistence on the necessity for persistent effort in regular eating day after day, meal after meal, and it is not long before improvement comes not {264} only in weight, but also in appetite. I have known patients to gain five or six pounds a week after having tried weeks in vain to gain a single pound. _Sitophobia_.--Many people read much of the possibilities of evil in overeating, and they conclude that a limitation of diet would be better for them. After a time some of these people of nervous constitution acquire an actual dread of over-eating and develop what has been called sitophobia, or dread of food. Before anything can be done with them, this dread must be removed. The problem is discussed more fully in the chapter on Weight and Good Feeling, but here it seems necessary to emphasize that it is often quite impossible by ordinary medical means to produce an appetite in these patients. Their mental persuasion with regard to food must first be removed. If it cannot be removed, improvement is usually out of the question. No medicines are sufficiently powerful to overcome a fixed unfavorable idea with regard to food. The same is true as to sleep, or any other natural function--it comes and must go through the mind. Disturbance of Mind and Its Influence on Appetite.--The basis of the psychotherapy of the digestive tract is the fact that appetite is a function of the state of mind rather than of the state of body. We all know how easy it is to lose the appetite by emotional disturbance. We may come into the house after a brisk walk, when we know that dinner is going to be better than usual, quite ready to anticipate the pleasure we are to have in eating it and with appetite craving that dinner shall not be delayed, we find a telegram announcing the death of a friend or the illness of a relative or some other bad news, and in an instant our appetite has disappeared. It makes no difference to us for hours whether we eat or not. What we eat gives us no satisfaction. It will be taken entirely from a sense of duty and without pleasure and will digest slowly, even if it does not produce discomfort. _Feelings and Appetite_.--There is no need for a serious stomach condition to develop, to diminish, or eliminate appetite. The sight of an accident on the street, especially if blood is shed, will entirely take away the appetite of many persons. Now that suicide beneath the wheels of subway trains has become a rather frequent way of going out of life, physicians note that nervous patients who happen to see these sad affairs have no appetite, not alone for the next meal, but sometimes for several days. Some people have no appetite at all if there is a dead body in the house where they live. I have known people who felt it almost a desecration to eat under such circumstances. Even much less than this may serve to diminish appetite. An offensive odor of almost any kind is quite sufficient to take away the appetite of many people. For some the odor of cooking food, if they have been in it for some time, is almost sure to cloy any desire for food. Cooks suffer from loss of appetite for this reason. The sight of a disagreeable stain on a tablecloth, or of a waiter's thumb in the soup, or of some unpleasant characteristic of the waiter, may be quite enough seriously to disturb the appetite of sensitive people. We know all this very well, and yet we are prone to think of appetite as something regulated by instinct, and representing the real needs of the organism in its cravings and the limitations of the necessity of food by its satisfaction. In our sophisticated modern life instinct will often fail entirely to fulfill these purposes. Appetite for those who live much indoors is a question of {265} habit and regulation rather than of instinct. It has to be voluntary to a large extent, not only as regards the quality but also the quantity of food. We eat the things that we care for, but how much of them we shall eat is another matter. That depends on how we happen to be disposed at the moment, and whether there is any good reason for eating more or less at the given time. Appetizers.--There is a whole group of substances recommended as appetizers, most of which are effective, but their effect is likely to be temporary, and to fail particularly in those cases where an appetite is most needed. Anything that will increase the circulation in the stomach will usually add to appetite; consequently warm drinks, alcoholic liquors and spices of various kinds have this effect. In vigorous people, a dash of cold on any portion of the body, is followed by a strong reaction of the circulation. Cold drinks, therefore, will sometimes serve as an appetizer, especially in hot weather. Almost anything that has a certain peculiarity of taste, and that is taken with the definite suggestion that it will produce an appetite, will almost surely have that effect. All sorts of articles of diet have in various countries acquired a reputation as appetizers. Fermented mare's milk is effective in central Europe; a glass of buttermilk in Ireland; some very hot soup with one of the strong spiced sauces in it in England; and various curious combinations of fruit and other materials in the shape of what are called cocktails, in America. Anything that stimulates the stomach a little unusually, and is accompanied by the idea that it is likely to increase the taste for food, almost surely adds to appetite. This question of appetizers is as yet a mystery to us. It is eminently individual and yet much depends on racial customs, the habits, the environments and the family training. It is surprising what curious materials serve to excite the appetite. Caviar, in spite of the distaste of "the general," is undoubtedly a good appetizer for many people. Bismarck herring, or kippered herring, acts in the same way. In the old days men used to take what were called red herrings and undoubtedly found in the eating of them a renewal of desire for food, when there had been absence of appetite. There are some people in whom a little taste of cheese serves the same purpose. Bitter tastes usually increase appetite. Salt under certain circumstances has a similar effect. Acid fruits sometimes stimulate a jaded desire for food. Nearly always the effect of these various appetizers is increased by the attitude of expectancy. They have the reputation of being appetizers and so, though often at first somewhat disagreeable, they eventually prove to be helpful stimulants. Appetite and Habit.--For those who live an indoor life, and have that nervous disposition that disturbs instinct, the only safeguard for nutrition is a definite formula for eating which must be followed strictly, especially by those who are below the normal in nutrition. In the chapter on Weight and Good Feeling I discuss the failure of appetite following a diminution of the amount of food. The stomach may be described as unselfish, and in times of scarcity it gives up to other organs more of the nutrition that comes to it than it should. As a consequence, it is not so well able to fulfill its functions of digestion and of craving for food, which is part of its function, as it would otherwise be. It is the people who are eating a proper amount and have been eating it, whose digestive tracts are in a condition to crave the proper {266} amount of food. Those whose habits have unfortunately led them into eating amounts too small, also suffer in not having the proper desire for food. Nervous people particularly are likely to lack appetite in the early morning. Those who are under weight will almost invariably confess that they take little breakfast. Their reason for so doing is that they have no appetite. For most of them what is really true is that in the early hours of the day their will has not yet taken properly hold of their economies and everything is in a depressed state. These patients usually confess that they wake feeling not rested but tired, fearing the day, and wondering now they will be able to get through it. Only toward the middle of the day do they feel like themselves, while towards evening they wonder how they could have been so depressed in the morning. What these people need is the rousing into activity of their functions. Occasionally, especially in summer, a cold sponge on rising in a room into which an abundance of air is admitted will do much for them. Often a walk of even ten minutes before breakfast will make all the difference between appetite and lack of it. Above all, however, they should be made to feel that if they want to eat they can eat--if they want to they can reestablish the habit of taking breakfast, and then it will be a pleasure instead of a burden. _Food and Caprice_.--Those complaining of lack of appetite should learn not to let caprice rule them in the matter of eating. There are people who by habit eat too much. What they must do, as pointed out in the chapter on Obesity, is to unlearn the habit of overeating, and that is almost as hard to break as the habit of taking stimulants. Most nervous people undereat, but they must take themselves in hand, eat three meals a day, and reestablish the habit of taking as much at these meals as they ought. What each one should consume is eminently individual, depending altogether on the sort of heat engine that each one is. Family traits mean much in this. Some must eat much more than others to keep up their weight and strength, because they are wasteful heat engines. As a rule, tall, thin people must eat more in proportion to their weight than shorter individuals of stout build. They expose more surface for heat dissipation. In this each person must learn for himself his own necessities. When there is a question of regulating eating by reason, the rule must be remembered that there is a tendency in people living indoors to take too little rather than too much. _Appetite and Food Preparation_.--There are many curious things with regard to the formation of the habit of eating that show how easily the appetite or instinct is vitiated. Women, for instance, are nearly always prone not to eat enough if they have to prepare their own meals. When a mother and daughter or two sisters live together, they usually prepare one good meal, but the other two meals are likely to be picked up any way. The presence of a man in the household makes all the difference in the world. Meals are prepared regularly for men. Even for a boy of five to fifteen, meals are regularly prepared, and, as a rule, the presence of a child makes for regularity in eating. _Habit of Overeating_.--On the other hand, it is easy to form habits of eating that go quite beyond appetite and vitiate the desire for food quite as seriously in the opposite direction. Many stout people take snacks between meals; women, already too heavy, indulge in the afternoon tea habit with a surprising amount of substantial food taken with the tea; many a stout man {267} takes a glass of beer occasionally and never fails to take something to eat at the same time, mainly with the idea, as he says to himself, that by taking something to eat the beer will be less likely to do him harm. Stout children are likely to form the habit of eating too frequently. When they come home from school they have a piece of something; before they go to bed they have a glass of milk, and a piece of cake, and sometimes are encouraged in these bad habits by their parents. Any child who is more than ten per cent. above weight, should be kept strictly to its regular meal times, and should not be allowed to put on additional weight, for this will be very hard to get off in adult life. To carry more than ten per cent. of over-weight is a burden, and not a benefit. Frequent Eating as an Appetizer.--Thin people should be encouraged to indulge in some of these between-meal privileges. Very often a thin person who has been accustomed to take comparatively small amounts at meal times, will find it easier to gain in weight by indulging in luncheons between meals than by increasing the amount of each meal. Large meals on stomachs unaccustomed to them, and somewhat less vigorous than they ought to be because of lack of nutrition, may be the cause of considerable discomfort if abundant meals are taken where small ones have been habitual. In this case, multiple feeding at shorter intervals will gradually increase tissue strength. After the patient has come up to normal weight, regular intervals between meals may be determined and sufficient quantities taken at each meal. Nearly all thin people sleep better, and are more comfortable if they take something shortly before going to bed. Most people will eat their breakfast better after such an indulgence than if fourteen hours elapse between the evening and the morning meal. Nervous Loss of Appetite.--Nervous patients often say they have no appetite, that, even though they eat, their food has no taste. Such people have often lost their eating instinct to a certain degree. They eat merely from routine, or because food is placed before them. They would usually just as soon not eat and they have no instinctive directions as to quantity. If a number of courses are presented to them, they eat such as they care for and take a conventional amount of each kind of food presented, but they have no particular feeling to guide them in the matter of quantity. There are moods in which these patients care to eat. There are others in which eating seems a hard task. If they are in reasonably poor circumstances and have not to prepare a meal for others they are likely to neglect the preparation of one for themselves, take almost anything that happens to be at hand, and then consider that they have eaten. Instinct and Natural Life.--If one expects the natural guidance of one's instincts then one must give these instincts a proper opportunity. Instinct is a part of our animal nature, and unless other portions of our animal nature are given rather free play, or at least the opportunities for their natural life, we cannot depend on any single one of the instincts to be a safe guide. Man was meant to live much outside. He was meant to take considerable exercise and to have to get his food by severe exertion. We have changed this. We live indoors to a great extent in an equable temperature, we very seldom tire ourselves by exercise, and it is not to be wondered at if we have not that craving for food that comes to the man who lives a more animal existence. The {268} Scotch surgeon, Abernethy, once said that the best possible tonic for the appetite was "to live on a shilling a day and earn it"--of course, he meant by manual labor. He talked at a time when the English workmen got but three shillings a day for fourteen hours of work. Application of Principles.--What is needed for the mental treatment of patients with defective appetite, is that they should be made to realize that appetite is a function of habit, rather than of absolute natural craving in the conditions in which men and women live at the present time. The most important physical factor for appetite is not exercise, as has often been thought, because this, by consuming material, is naturally supposed to increase the craving for material to renew the tissue, but air, for it is oxidation processes that stimulate metabolism and make the call for a fresh supply of tissue-building material. People without an appetite must be made to understand that they should spend a considerable portion of the time between meals in the open air. Sitting in the open air is often even more effective than exercise under similar conditions, especially in weak people. The reason is exercise exhausts energy, and sometimes does not leave enough vitality for digestion, or even for the craving for food. Exercise is, of course, excellent for those of stronger constitution, and especially those who have been accustomed to it. Those who need to eat more, must keep constantly before their minds the suggestion that if they want to eat they can, and that if they actually do eat more, satisfaction with eating grows, and appetite is restored to its normal place of influence. This is as true for those who are convalescing from some ailment, or who are in the midst of some progressive disease such as tuberculosis, as it is for the merely nervous persons whose lack of will and inefficiency of judgment have disturbed their eating habits. The will to eat is the most important appetizer that we have. The old Scotch physician's rule that if food stayed down it would do good, and that if the residue of it passed through the intestinal tract there was nothing very serious the matter with the patient, applies to the majority of patients who come to be treated for obscure ailments, especially of a chronic character, whenever they are associated with or developed on a basis of lack of normal weight. CHAPTER V CONSTIPATION To judge by the frequency of advertisements for laxatives of various kinds, constipation must be an extremely common affection. At least one out of every three city dwellers suffers, it is said, from constipation. Proper regard for the taking of food calculated to help this important function, the formation of appropriate habits, and the proper disposition of the mind so as to relieve worry and anxiety, will cure the majority of these patients. There are some who need additional treatment, pharmacal or mechanical, but these are few. Undoubtedly the mind plays the most important role in the therapeutics of the affection. It is influenced partly through instruction, {269} partly by the modification of unfortunate auto-suggestion, and partly through auxiliary favorable suggestions of one kind or another. Prophylaxis.--What is needed in most cases is such instruction as will lead to a better observance of certain common-sense laws of health, rather than the addition of remedies which eventually only complicate conditions. Many people believe that unless they have an ample movement of the bowels every day all sorts of serious results are likely to follow. If they do not have the expected movement before noon, they suffer during the afternoon from headache that is probably due more to worry than to any physical cause. Ordinarily it is quite out of the question that the retention of the contents of the lower bowel for a few hours should produce any such serious effects as these patients immediately begin to feel. Especially is this true when on the day previous there has been, as is often the case, a sufficient movement of the bowels, due to the use of medicine. Some people have become so anxious in the matter that they foster the development of feelings of discomfort both in their abdominal and intracranial regions. This over-anxiety is all the more important because recent observations have made it clear that over-occupation of mind actually hampers peristaltic movements of the intestines, and thus prevents the muscular action which would gradually pass the excrementitious material on to the lower bowel, to be evacuated in the normal way. _It cannot be too often repeated that nature resents too close surveillance of her functions and operations_. Just as soon as the over-anxiety is relieved, and patients are made to appreciate that if they do not have a movement to-day they may wait without serious solicitude till they have one to-morrow, the amount of medicine required to bring about movements of the bowels is at once reduced. The Mind and Peristalsis.--Analogous to Pawlow's ingenious experiments, with regard to digestive secretion in the stomach, are Kronecker's experiments at Berne upon the motor function of the intestinal tract. Pawlow showed that the appetite depended, not on physical conditions so much as on the mental state of the animal and its desire for a particular kind of food. Kronecker, by isolating a loop of intestine in which a metal ball was placed, showed that it was possible to modify peristalsis very materially by affecting the psychic condition of the animal. There was a distinct difference in the movements of the intestine, in the passage of a metal ball, when the animal was called and expected to go for a walk with its master, than when it was threatened with punishment or rendered depressed for some other reason. In animals, the psyche plays a very subordinate role in inhibition and stimulation compared to that exercised by man's higher nervous system, since in him this portion of the organism is so much better developed than in the animal. The condition of the human mind in its possibilities of unfavorable influence over the intestinal function, is, therefore, extremely important. The more one knows about the curious power of the mind even over so material a function as intestinal peristalsis and movement, the more is one convinced of the necessity for a properly disposed mind toward intestinal function, if it is to be accomplished with regularity and without disturbance. Many persons thoroughly under hypnotic influence, who are told that they will have a movement of the bowels at a certain hour the next day will have it. Indeed, this constitutes one way of treating certain forms of constipation in nervous, {270} preoccupied people. There are many stories that illustrate the influence of auto-suggestion upon the bowels. We have already mentioned Flaubert's suffering as a consequence of realistic absorption in "Madame Bovary's" poisoning by arsenic when he was writing that scene in the book. Boris Sidis has told the story of a man who used to have a disturbance of the bowels at every new moon, as the result of his memory, acting unconsciously, reminding him of his mother's habit of giving him a purgative about that time. These may be and doubtless are exceptional cases, yet they illustrate the influence of mind and show how much it must be the effort of the physician to use this effective adjuvant just as much as possible in this very common and often obstinate affection in which drugs so often fail, or are unsatisfactory. So-called Intestinal Auto-intoxication.--Those who are anxiously interested in the subject are likely to have read so much of intestinal auto-intoxications, of which a great deal has been written in recent years, that they will be quite sure the slightest delay in intestinal evacuation may be serious, or at least may profoundly disturb their economy. As a consequence, just as soon as the hour at which they should have a movement passes, they begin to worry about it. In a couple of hours they feel tingly all over, and they know that there most be poisonous substances in their circulation. After two or three more hours, they begin to have a headache. Then they have to give up work, and still more devote themselves to concentration of attention on the disturbed condition. Their sleep will be disturbed, perhaps will be delayed; they wake unrested and fearful of the awful effects of intestinal auto-intoxication. In most people this state of feeling is entirely due to suggestion. So much has been said in recent medical literature of the influence of absorption of poisonous substances from the intestinal tract--the so-called intestinal auto-intoxication--that it is a surprise to learn how little we know, definitely and absolutely, about this subject, and how many theories have come and gone. Arthur Hertz, in his "Constipation and Allied Intestinal Disorders" (Oxford Medical Publications, 1909), reviews the whole subject very interestingly but shows that we are entirely without any definite conclusive evidence for what has been talked about so much. The idea had often occurred, and been expressed vaguely, in medical literature in the old time, but began to have its great vogue when the high-sounding Greek term copremia (literally "excrementitious-substances-in-the-blood") was invented, toward the end of the first quarter of the nineteenth century. Naturally this had a strong suggestive effect. Bouchard took it up a generation later, and then intestinal auto-intoxication, another mouth-filling term, came to occupy much attention as an explanation for various vague conditions, and especially nervous discomforts of many kinds. Bouchard's method of proving his theory by showing how much toxic material was reabsorbed from the intestines, using the urine for injection into animals, was open to many objections. Now it has been quite discredited. Bouchard's disciples exaggerated and theorized even beyond their master, until intestinal auto-intoxication became the same sort of a refuge for the puzzled physicians of our time--like rheumatism or the uric acid diathesis, for those of a score of years ago. Various methods of demonstrating the toxicity of substances absorbed had a vogue for a time, but they have now lost their significance. There are only a limited number of people who seem to suffer {271} from the symptoms attributed to such reabsorption. Some people who are quite constipated have none of the symptoms at all, while a delay of an hour or two in the evacuation seems to affect other people very much. These latter are especially nervous persons. It now seems very clear that the liver acts as a safeguard against the absorption of poisonous materials from the intestinal tract, and that neither degenerate proteid materials, nor bacterial toxins, are allowed to affect the system to any serious degree. After all our study, as Dr. Hertz insists, we have as yet no evidence that poisons are absorbed. Reassurance as an Element in Treatment.--The most important element in the rational treatment of constipation is to make patients understand that under ordinary circumstances the symptoms of auto-intoxication, of which so much is said, do not develop until there has been long-continued accumulation of excrementitious material and under conditions favoring absorption. Even then nature learns to protect herself against untoward conditions. We have some very striking examples of good health in spite of even very rare movements of the bowels. _Examples of Intestinal Tolerance_.--There is the famous case of the French army officer who, from his earliest years, did not have regular movements of the bowels, but secured evacuations of them by artificial aid once every two months or more. He lived to the age of past fifty, and then died from an intercurrent disease not connected with his intestinal condition, having in the meantime enjoyed good health. He was able to accomplish his duties as an officer without any special allowances, and he was on the sick list much less than many brother officers whose intestinal condition left nothing to be desired. This remarkable man succeeded in doing his life work without his condition being known by others to any extent, and it was only inconvenience, and not serious illness, that he suffered from. After his death, it was found that certain folds of the lower bowel were so large as to meet across the lumen of the bowel, making shelves and pouches in which fecal material gathered, preventing the movement of all material above. In the Orient, it is said that many people, especially of the better class, do not expect to have movements of their bowels every day. Some of them, indeed, do not encourage intestinal evacuations oftener than once a week, sometimes even more seldom. As their diet is more largely vegetable than ours, this is all the more surprising. This custom does not contribute to their good odor, but this they compensate for by using various Eastern perfumes. The average length of life of such people is not much below the Occidentals and the difference is probably accounted for to a great extent by other unhygienic practices, rather than this failure to have regular movements of their bowels. In the meantime, they do not suffer any particular inconvenience, and live life quite as free from the ordinary pains and aches as do the people of the West. Of course, in such cases the custom has been established early, and nature has grown accustomed to it. Nature seems to be able to stand almost anything, if she can only survive it long enough to neutralize its effects by some of her marvelous means of compensation. A case under my observation some years ago deeply impressed upon me how thoroughly the human system can learn to get along in spite of extremely unfavorable conditions in the matter of intestinal evacuation. The case was that of a young woman suffering from some internal trouble and there was {272} a possibility of the growth of a tumor. Some charitable people had been interested in her case, and the question had arisen whether the tumor might not be physiological. Her story was a very curious one. She and her sister worked in a mill. They came from a family that had been reduced in circumstances, and were much more sensitive, as regards the decencies of life, than were their fellow workers. In order to get to the toilet, the working girls had to pass a window of an office where a number of men were at work. The other girls did not seem to mind it, but these two girls were so sensitive that they preferred not to use the toilet room at the factory. They had to leave home shortly after six o'clock in the morning. They did not get home until nearly seven. For a time, they succeeded in accomplishing their intestinal functions during the hours of their stay at home. Gradually, however, this habit was broken, and at first they went two or three days without an evacuation, then four or five days, and finally a week. It then became their custom to take a large dose of epsom salts on Saturday night and spend most of the day on Sunday getting rid of the accumulated excrementitious material of the whole week. They taught Sunday School in the afternoons, and as the elimination of the accumulation of week-long material interfered with this, they gradually acquired the habit of doing their Sunday School work on alternate Sundays, each taking the other Sunday for evacuation purposes. It might be expected that this serious abuse of function would soon lead delicate girls, compelled to work full eleven hours a day, into rapid serious breakdown. But it did not. This state of affairs continued for more than a year. Then finally one Sunday, the more delicate of the two girls found it impossible to open her bowels at the end of two weeks, and though she stayed at home the next Sunday found it likewise impossible. Had not the directress of the Sunday School, who had become interested in them, succeeded in gaining their confidence, it is possible that they would not have consulted physicians even for some time longer, though about three weeks had passed without an evacuation. Probably every physician in active practice has women patients who have been constipated for successive periods of three or four days at a time, for several months, without much disturbance of the general condition. While, then, there are many nervous persons who are quite sure that they begin to notice definite symptoms within a few hours from the failure to have a motion of the bowels at the time when they had been expecting it, it seems certain that this is generally rather the result of anxiety and nervous worry than consequent upon any actual absorption of toxic materials--intestinal auto-intoxication--as these patients, with a naïve liking for nice long names, find such satisfaction in describing their condition. A simple explanation of the complete lack of inconvenience that is found in so many cases of constipation, will neutralize the unfavorable auto-suggestion that exists, and make these people much less likely to suffer. _Individual Variation_.--Another suggestive item of information that should be given those who are over-sensitive and anxious in the matter, is that different individuals vary very much in the need for intestinal evacuation. Perfectly healthy people have lived long and happy lives, having an intestinal evacuation only once every two days. Whether it may not in exceptional cases be rarer than this without serious injury, immediate or remote, {273} experience has not definitely settled. Many of these people with infrequent intestinal movements, have gone on utterly unconscious of the frequency or infrequency of the calls of nature, paying no attention at all to the matter until by some chance remark or a newspaper health item, it is brought forcibly to their notice. They have not had a symptom before of any kind, but now they begin to note all sorts of symptoms because they try to order their lives after the supposed rule that they have heard or read. _Anatomical Peculiarities_.--On the other hand, some people normally have two evacuations a day, and seem to require them if they are to remain in the best physical condition. While daily evacuation is to be considered normal, individual departures from it in either direction must be respected as quite within the bounds of good health. Sometimes there are anatomical reasons, as the capacity of the large intestine. Sometimes there are physiological factors, as the amount of food taken, or the fullness or rapidity of function in the digestive tract. Amount of Food as a Causative Factor.--Frequency, or infrequency, of bowel movements seems to depend to a great degree on the amount eaten. It is well known that two men of the same weight and doing the same work often seem to require quite different amounts of food to enable them to accomplish their tasks. This is what might be expected, since it holds true also for the consumption of fuel in heat machines. Engines built in exactly the same way often require quite different amounts of fuel in order to release the same amount of energy. Where men are large eaters, the amount of excrementitious material left will usually provoke, if not actually demand, more frequent evacuation than where the amount eaten is small. Variety of food also has an important bearing. Men who live largely on beef, milk, eggs and food materials that do not leave much residue, do not require, indeed they cannot have, frequent evacuations. Those who live almost exclusively on vegetables, with large amounts of residue, will require more frequent evacuation of the bowels. Certain other dietetic habits, as the amount of fluid taken with the meal, or whether food is eaten in the solid state or cooked into purees, stews and the like, make a decided difference, the reasons for which are obvious. Habit in Treatment.--For the regulation of the bowels and the proper treatment of constipation in nearly all cases, more weight must be given to the directions laid down for the patient's attitude of mind and habits of life than to drug treatment. The patient must be made to realize that the directions given to him are much more important for the effective relief of his condition, than is the medicine prescribed. As a rule, medicine is meant only to afford relief from immediate inconvenience, in the hope that after a short time new habits will be formed which will remove the habitual constipation by correcting certain hampering conditions that have unfortunately become established. _Habitual Evacuations_.--By far the most important element in the treatment is to make the patient realize that habit plays the largest role in the regular evacuation of the bowels. A child, even under two years, can, by tempting it at certain times to evacuate its bowels, be gradually brought to establish a habit that will save much inconvenience for nurses and the family. This has actually been done for most human beings now alive, and this same thing can be done at all stages of life. If a particular time be chosen, and the {274} individual habitually goes to the toilet at that time, results may be confidently expected. It is rather important that the time chosen be one when there is not much hurry nor anxiety, and when it is reasonably certain that the same time can be taken every day. It is surprising how much so simple a bit of advice as this will do for many people who have considered that they have been suffering great discomfort from habitual constipation. Between the persuasion that an occasional failure to have a movement is not serious and the definite habit of journeying to the toilet room at a particular time, whether the desire is felt or not, many cases of habitual constipation will disappear with, perhaps, only the necessity for the administration of such drugs as will prove laxative to a slight degree during the first two or three weeks. Ingestion of Fluids an Important Influence.--After the suggestion of a habit and its extremely efficient influence, the most important idea that a patient suffering from constipation must be made to grasp, is the necessity for fluids. That there shall be easy movement of excrementitious material in the digestive tract, there must be fluid enough ingested to keep the residue, after digestion, thoroughly moist, so as not to allow it to become dry and compact. To secure this, a reasonable amount of liquids must be taken. So much has been said in recent years about the actual and possible harm of taking much fluid with meals, because of the danger of diluting the gastric juice, dilating the stomach and the like, that many persons who eat under the control of their reasons rather than their instincts, have very materially lessened the amount of liquids taken at meal time. This is undoubtedly one of the reasons why constipation has become more common in the last half century. In the olden time considerable quantities of fluid were taken at meals. With people in our time deliberately diminishing the quantity, there is often not enough fluid ingested to keep the human economy in proper working order. Prof. Hawk's work shows how utterly wrong was this limitation. The ordinary excretion of water through the kidneys should be at least three pints, another pint is exhaled from the lungs--the quantity is even more than this in steam-heated houses where no provision for moistening inhaled air is made--and probably still another pint is needed for other purposes, perspiration, nasal and ocular secretion, and the like. Two quarts and a half to three quarts of liquid must be daily ingested then, and unless special care is taken to see that this amount is consumed the system may have to get on with much less, but as can readily be understood, not without difficulty. The ordinary glass of water does not contain half a pint; the ordinary tea cup probably holds not more than from four to six ounces. A glass of water and a cup of tea or coffee is about the limit of consumption of fluids at meals for ordinary people, and some take even less. Except in hot weather, comparatively few regularly take any fluids between meals. At the most, then, three or four pints of liquid is taken, instead of five or six, and the consequence is that the intestinal contents are deprived of their fluids by the call of the system for more liquids. Peristalsis has, therefore, to overcome the sluggish movement of the excrementitious material, which usually does not contain as much liquid as would make its movement easy and normal. Residual Material.--The next most important consideration after the amount of fluid in the intestines, is the amount of the residuum which the lower bowel has to move. Evacuation of the intestines is to a great degree {275} a mechanical arrangement. When sufficient material is contained in the lower bowel, it pushes on ahead of it the matter that has been gathered there during the immediately preceding time, and so leads to an accumulation in the rectum that brings about reflex evacuation. It is only indigestible material that is thus excreted. If sufficient indigestible material is not taken with the food, there will not be sufficient residue left after digestion to call for the exercise of the evacuant function of the intestines, and the consequence will be sluggishness and failure to bring about daily movements. Originally nature provided food materials so arranged that the amount of indigestible material was sufficient for the exercise of peristaltic function; or rather perhaps, the regularity of peristaltic movement is of itself a development from the habits that were gradually formed in moving the residue that is normally left from food materials in the state in which they are produced by nature. Food materials are no longer taken to any great extent in the form in which they are provided by nature. We have learned to eliminate the coarser indigestible portions. Bread used to be made of the whole wheat, and of rather coarse flour, leaving a large residue for peristalsis to exercise itself on. Now only fine white flour is used, leaving a minimum undigested. Vegetables used to be taken with much more waste material attached to them than is the case now. After being baked, potatoes were often eaten with the skins on, apples and other fruits were eaten unpared and many of the coarser vegetables, turnips, carrots, beets, and greens of various kinds that leave large proportions of waste were much more commonly used. Movements of the bowels depend on this residue. If it is not present the bowel movements will not take place with the regularity observed when food with more residue is consumed. Diet--Prof. Otto Cohnheim, in his lecture before The Harvey Society in New York, December, 1909, emphasized the necessity for a mixed diet. The less vegetables are taken, the less cellulose remains undigested to stimulate peristalsis. Liquids find their way through the intestines by a system of percolation, and do not excite peristaltic movements. Meat, if well digested, is almost entirely dissolved in the stomach and becomes a fluid. Vegetables are passed on to the intestines as a rather thick paste. Occasionally, in the midst of this paste there are portions of food of good size. Those excite peristalsis; hence the necessity for vegetables in the diet, if peristaltic movements and regular evacuations are to take place. This physiological law is poorly understood. Patients have heard so much about the indigestibility of starches, that whenever they have any uncomfortable feelings in their abdominal region, supposed to be due to indigestion, they commonly eliminate vegetables from their dietary with the consequence that their disturbed condition is likely to be emphasized rather than improved. _Limitation of Diet_.--Just as soon as a patient's attention is attracted forcibly to any tendency to constipation, he is almost sure to conclude that this is a symptom of indigestion and he proceeds to put into practice all the rules which he has heard and read for the treatment of indigestion. The first of these is elimination from the diet of all indigestible food products, including most of the vegetables. The result is a vicious circle of cause and effect by which constipation is rendered worse than before. This needs {276} to be explained to intelligent patients in order to make them understand that some of the new habits which they have been forming and which they are prone to think highly hygienic, of cutting off all food containing indigestible material, are really important factors in the causation of further intestinal disturbance. It will often be found that the real reason for patients' inability to have daily evacuations of the bowels, is that they have become persuaded that various forms of food are either indigestible on general principles, or else are indigestible for them. For this reason they have eliminated from their diet most of nature's ordinary and quite natural provocations to intestinal evacuation, only to have to substitute artificial means to the same end in the form of the various laxatives. It is important to talk this matter over with patients; otherwise the true cause of their constipation may be missed. For instance, from the very beginning of human life an excess of fat acts as a lubricant of the intestine, and as a material by means of which other and more concentrated objectionable matter that needs to be eliminated is carried out with as little friction as possible. Mother's milk contains from one-fourth to one-third more fat than the baby can use in its economy. This is meant to furnish a lubricant for the large intestine. It is a residue that will aid in securing movements of the bowels at regular intervals. _Fats_.--Many people who come to their physicians complaining of habitual constipation have been told, or have read, that fat is rather indigestible, and, as a consequence, they have eliminated from their dietary all fatty materials. Even butter they use but sparingly, and they exchange the cream in their tea or coffee for plain milk; they carefully remove as much as possible of the fat of meat and they abstain from all sauces in which fat is employed. Such practices make normal, natural, regular evacuations of the bowels extremely difficult. _Sugars_.--Another food material that is a valuable aid to nature for the stimulation of peristalsis is sugar. In its digestion, a certain amount of fermentation takes place, and the gas from this stimulates peristalsis. Of course, there may be excessive fermentation, and then harm rather than good, is done. Ordinarily a certain amount of sugar is demanded by nature and practically all the food materials, even the meats, contain it. All the starches from vegetables have, as the end products of their digestion, various forms of sugary material. These are just the classes of foods that many nervous persons, suffering from constipation and anxious about their digestion, eliminate from their diet under the mistaken notion that they are indigestible, or are productive of undesirable fermentations. When they do so, it is not surprising that their constipation should be emphasized and that they should have to ingest other irritant materials, laxatives, to replace the sugars. It is probable that where constipation exists in the bottle-fed infant, the addition of a little brown sugar to the water with which the milk is diluted, is the safest and most natural way of correcting the sluggishness of the intestines. _Supposed Idiosyncrasies_.--The physician will in many cases meet with the objection that some of these materials that he is recommending disagree with his patient. Most of the presumed idiosyncrasies in the matter of food are founded on extremely insufficient evidence. Not infrequently young persons who are thin and inclined to be {277} constipated, and who need to take fats plentifully, do not care at all for butter. Sometimes this is founded on nothing more than the fact that at some time or other the butter provided for them was rather poor, and they got out of the habit of eating it. Now they assume that their disinclination is physiological. In this regard, as with milk, a little careful persistence will usually convince the person that there is no natural obstacle and no good reason why they should not partake, in moderate quantities at least, of this extremely valuable article of food. Often the supposed idiosyncrasy against a food is due to no better reason than that on a single occasion it disagreed, owing to its preparation, the circumstances under which it was eaten, or the materials with which it was associated. An aversion, for instance, to so nutritious and so valuable a food-stuff as hog-meat will be acquired for no better reason than that fried ham or bacon disagreed with the patient on one or more occasions. Such people when told that ham, boiled so thoroughly that it crumbles in the fingers, is a favorite mode of giving meat to convalescents in European hospitals and that it agrees very well with them, will often be tempted to try it. Then they find they have been harboring an illusion as to their supposed idiosyncrasy for hog-meat. Nearly the same thing is true of bacon. A trial or two of crisp bacon, with the fat so thoroughly cooked out of it that it may be eaten out of the fingers without soiling them, will often convince those who doubt of their ability to eat it, how tasty a nutriment it is. Bacon is one of the most precious dietetic adjuvants in the treatment of constipation. Exercise.--There is always a serious difficulty in the treatment of constipation in stout people. To counsel fats and starches and liquids in the quantities necessary to bring about regular natural movements of the bowels, through the mechanical presence of a sufficient amount of residue, will often add greatly to their weight. For them, exercises are needed. Not exercise in general, for many a man who takes abundant exercise may be constipated. I have patients with this complaint who are letter carriers, expressmen, even stevedores, and the like. The mere absence of a sedentary occupation will not guarantee against constipation. Motormen and conductors not infrequently suffer from it. What is needed particularly is exercise directed to the strengthening of the abdominal muscles, and the increase of peristalsis. For this certain leg exercises that can be readily and easily done in less than five minutes each day will be found useful. A patient may be directed to lie on his back, lift up the leg as high as possible in the extended position, and do that with each leg an increasing number of times every day. At the end of a month he is able to lift each leg up forty or fifty times at each trial. This exercise twice a day, morning and evening, just before and after sleep, will usually relieve the constipation. The bringing up of the thigh on the abdomen as far as possible, not only acts as a sort of massage upon the abdomen itself, but the bellying of the large muscles within the pelvic and abdominal regions mechanically helps the movement of the intestinal contents. If, in addition to this, the patient gradually accustoms himself to rise to a sitting from a lying position, the constipation will almost invariably yield. In stout people, the presence of fat in the abdominal wall seems to weaken the muscles so that the intestines are not compressed as they should be in ordinary conditions, and peristalsis seems to be thus interfered with. {278} A heavy wooden (bowling) ball rolled on the surface of the abdomen, beginning low down in the right lower quadrant up towards the liver, across just above the umbilicus, and then down on the left is often advised. It is a good remedy but not better than the simple exercises of the leg and abdominal muscles suggested. The use of the ball has the advantage of novelty, and of distinctly adding to the suggestive value of the exercise treatment. It is particularly valuable for women. All of these exercises have a distinct value from their suggestive side. If thus twice a day for three minutes people are made to recall while doing the exercises the necessity for taking an abundance of fluid, forming a habit with regard to movements of the bowels and eating so as to encourage peristalsis, a definite good effect will be produced. In the treatment of stout people particularly, it is important to remember that the use of sufficient salt, and then of certain of the natural salts, as Carlsbad or Hunyadi Janos, may be of distinct advantage for their obesity. If taken regularly in small amounts, that is, just enough to help to a movement of the bowels, and if varied from time to time and occasionally interrupted while some other form of laxative is taken, much good may be done. It is as well to take simple irritants of this kind as some of the irritant foods that will have a tendency to add to their accumulation of fat, though they may increase peristalsis. Influence of Position.--Little things may mean much in the matter of the regular movements of the bowels. In my student days in France, our little hotel in the Quartier had the old-fashioned water-closets consisting of a hole in the floor in one corner, and a place to put one's feet properly beside it, thus reverting to the old-fashioned natural method of bowel evacuation. Some of the American students found it an uncomfortable proceeding at the beginning, but, on the other hand, some of them who had suffered from constipation in America were no longer troubled that way. I have found in quite a few cases of younger men that the suggestion to revert to this natural mode of evacuation helped in the formation of the habit of having bowel movements at a regular time. How much of the effect was physical and how much was mental seemed hard to decide. The suggestion was particularly valuable in my experience with patients of the better educated classes. CHAPTER VI NEUROTIC INTESTINAL AFFECTIONS There is a whole series of intestinal affections dependent on nerve influence that get worse and better under stress of emotion or relief from it. Probably the commonest of these is constipation, which is dealt with in a separate chapter. Often these nervous intestinal conditions are associated with other neurotic manifestations. On the other hand, patients are seen who are absolutely without any other sign of the neurotic habit, and have nothing like hysteria, yet who suffer severely and rather frequently from intestinal neuroses. Most of the people who react symptomatically to the eating of strawberries, or of shellfish, or of pork in any form, or cheese or other milk products, also have a definite tendency to certain skin neuroses and to suffer from intestinal troubles as a consequence of emotional states. It is hard to trace {279} real causation in many of these cases, because it is so easy to accept the patient's expressions that they must have taken cold, or they must have eaten something that disagreed with them. Neurotic Diarrhea.--But it must not be forgotten that nervousness alone, without any additional factor, may produce a disturbance of the functions of the intestines, and may even increase peristalsis and bring about severe diarrhea. Anyone who has observed students going to examinations has surely seen many examples of this. There are some individuals--fortunately they are rather rare--who always suffer from diarrhea when they have to take a serious examination. Some of these cases are pitiable because the effects are quite beyond control, and make it almost impossible for them to do justice to themselves. _Fright and Loss of Bowel Control_.--Severe disturbance, such as fright, may bring on this paralysis of proper regulation of peristalsis, with consequent imperative intestinal evacuation. A classical case in history is that of James II, for whom the Irish soldiers invented a special name because of the tradition that he suffered from an intestinal accident in one of the battles with William of Orange. The imputation of cowardice on the last of the unfortunate Stuarts has been completely wiped out by the investigation of recent historians, and James' character for bravery has been thoroughly vindicated. The fact that the story should have gained credence shows that there is a general persuasion and popular tradition that such intestinal incidents do occur from fright. An incident told of the Franco-German War illustrates this, though I do not vouch for the facts. Wishing to test the bravery of some soldiers whom he was to send on a very dangerous expedition, and above all to try how they would bear up even before the threat of instant death, an officer of the French troops is said to have asked that half a dozen brave men be sent to him. Without a word, he announced that there had been treason in the ranks, and that the army needed an example. They were condemned to be shot. A platoon of soldiers was drawn up, the men were placed with their backs to a wall and they were asked whether they wished to be blindfolded. They refused though they protested that they did not know why they were being put to death. Then the word fire was given. All of the men, excepting one, fell down, though the guns of the firing party had been loaded with blank cartridges. The one who remained standing was told that he was the man who would be selected to go on the expedition, which, though perilous, was also of great glory for himself and profit for his country. He said that he was ready to go, but he asked permission to be allowed to change his clothing, as he had not been able to keep as good control over his intestinal muscles, as he had over his muscles of station. Fright often has this effect in children. These stories and traditions illustrate the influence of the mind and of deep emotions over the intestines, and while only profound mental disturbance will produce the most serious effects, there seems no doubt that lesser emotions do interfere with normal function. This phase of the subject serves to strengthen the contention that over-attention to the bowels may bring about constipation by causing increased inhibition of peristalsis, just as severe emotional disturbance may paralyze inhibition and so bring about increased peristalsis with consequent diarrheal symptoms. {280} Habitual Diarrhea.--There are certain forms of chronic diarrhea, usually considered most intractable, that owe their origin and continuance to neurotic conditions of the intestine, rather than to any gross organic lesion. In these cases the bowels acquire the habit of emptying themselves two or three or more times a day, and the stools are seldom formed. All sorts of physical treatment are employed for these conditions, usually without avail, but whenever the patient's mind can be set at rest, and his attention distracted from his bowels by thorough occupation with some interesting work, the intestinal disturbance gradually becomes less annoying. Ordinarily, when stools have been frequent for a prolonged period, the case is considered more or less unamenable to treatment. So far as ordinary drug remedies go, this is true. What is needed is attention to the patient's mind, to his habits of life, and to his worries, and the way that he takes them. The illustrations given of the influence of the mind over the bowels should make it clear that this therapeutic principle can be of far-reaching significance and must be applied deliberately and with confidence in the results. _Worry as a Factor_.--Very often it will be found that the diarrhea is particularly bothersome on days when the patient is worried. In a clergyman friend and patient who was building a church, the approach of days on which bills and notes became due, was always the signal for a diminished control over his bowels, and there were frequently three or four stools in the day. On his vacations, when eating unusual things, drinking unaccustomed water, exposed to changes of temperature, all the factors that give many people diarrhea, he was perfectly regular because the worries had been lifted from his mind. In another case, where for fifteen or twenty years a writer living much indoors had had tendencies to diarrhea, always made worse by worries, self-discipline and the refusal to let troubles occupy him by always turning to something else, did him so much good that he considered himself cured. In his case the return of a manuscript from a magazine would always affect his bowels unfavorably. If, as sometimes happened, he found that the manuscript had been returned only for some corrections, there would be an immediate relief of his condition. Change of Mode of life and Intestinal Control.--An interesting phase of the neurotic or mechanical disturbance of peristalsis is found in the interference with regular movements of the bowels when persons are aboard trains for long distances, or for more than twenty-four hours. There are very few people who are not bothered in some way by such a journey. Those of a nervous temperament are likely to suffer from diarrhea. This is usually attributed to catching cold because of drafts, but in recent years, when well guarded Pullmans eliminate drafts to a great extent, the bowel disturbance continues. For the majority of people, however, constipation results. The cause of it seems to be due to a disturbance of peristalsis in the line of inhibition because of the vibration and jolting of the train. The more or less conscious assumption of definite positions of the muscles of the abdominal region in order to save the body from the action of the unsteady movement of the train, seems to be reflected in the sphere of peristalsis with consequent constipation. There are other features, such as a lessened consumption of food and water and absence of exercise, that seem also to have an influence. If the journey is for several days patients should be advised to walk out during the longer stops. {281} Mental Influence and Indifferent Remedies.--The best evidence that we have of the influence of mind upon the intestinal tract, and the importance of employing that factor for therapeutic purposes, is found in the number of cases of various intestinal disturbances, often apparently chronic in character, which have been cured by the administration of quite indifferent remedies. Dr. Hack Tuke in his "Influence of the Mind on the Body" reports a number of cases in which bread pills were used with good effect. _Pillulae micarum panis_ were not an infrequent prescription in preceding generations. They are usually supposed to have been effective only against the curious symptoms that develop in hysterical women, but it must not be forgotten that neurotic manifestations connected with the abdominal region may occur very freely in men, and that treatment by suggestion in connection with some remedy, real or supposed, is the most efficient cure. The "British and Foreign Medical Review" for January, 1847, has a series of cases among naval officers which were reported by a surgeon of long standing and wide experience. These cases include painful intestinal psycho-neuroses, occasionally accompanied by diarrhea, and sometimes by constipation and sometimes even by dysenteric movements, all cured by bread pills when these were administered in certain definite ways, and the patient's attention concentrated on their expected effects. Bismuth lost its effect in one case of repeated colic, opium was beginning to lose its effect. The patient was then told that on the next attack he would be put under a medicine which was generally believed to be most effective, but which was rarely used on account of its dangerous qualities, and that would not be used unless he gave his consent. At the first sign of his next attack, a powder containing four grains of ground biscuit was administered every seven minutes while within the hearing of the patient the greatest anxiety was expressed lest too much should be given. The fourth dose caused an entire cessation of pain. On four other occasions, the same remedy was employed with equal success for the same sort of attack. In a seaman who was suffering from obstinate constipation which resisted even the strongest purgatives, including Croton oil, pills consisting of two grains of bread were administered every seven minutes, and the patient watched with very apparent anxiety lest an overdose should be given. Within two hours he began to have nausea at his stomach, which had been foretold as one of the symptoms to be expected, and his bowels were freely open almost immediately after. Apparently the administration of the bread pills eventually cured his constipation. Skin and Intestinal Sympathy.--Curious intestinal conditions are, as I have said, often associated with neurotic manifestations of other kinds. Attacks of hives and other neurotic skin disturbances are common in association with nervous diarrhea. Sometimes the attack of hives precedes the intestinal disturbance; sometimes it accompanies it. Soon after eating the offending material, the skin manifestations may begin and other symptoms follow. Only a few minutes elapse, even when the patient does not know that the offending material has been eaten, because it is concealed in some combination, yet the reaction takes place evidently not from digestive absorption, but from intestinal reflex. Very often there is vomiting, as well as diarrhea. It is not hard to understand that in these cases there is produced an irritation of the intestinal mucosa, corresponding to that seen in the skin. Whenever {282} this occurs, it is not surprising that there should be evacuation of the contents of the digestive tract in every way that nature has provided for removing irritating material. The simple nervous diarrhea is often spoken of as an "intestinal blush," as the neurotic disturbance of the bladder which causes frequent urination is spoken of as a "vesical blush." Blushing is certainly the external manifestation that corresponds most closely to the disturbance that is probably the basis of these curious manifestations. _Urticaria and Diarrhea_.--Patients who suffer from urticaria readily are almost sure to have other neurotic disturbances, and their intestines seldom escape. On the other hand, those who have an idiosyncrasy for certain kinds of food are almost sure to have other nervous neurotic disturbances, which emphasize the fact that these curious idiosyncrasies are of reflex nervous origin, rather than due to any chemical irritation. Some of these lesions of the intestinal tract related to urticaria may affect, either primarily or secondarily, the biliary structures. Under these circumstances there may be symptoms resembling true biliary colic with some jaundice and pain that radiates toward the right shoulder. Whether these bile symptoms are due to the occurrence of actual urticarial lesions in the bile duct, or so close to the papilla of entrance of the gall passages into the intestine as to occlude it, is doubtful. Practically all the symptoms of the presence of biliary calculus may be thus simulated. The differential diagnosis can only be made by the rapid clearing up of the symptoms, and by the history of the case. As a rule, where there is the story of repeated attacks of neurotic intestinal disturbance, the physician and especially the surgeon, should be slow to conclude as to the presence of a serious pathological condition anywhere in the intestinal tract, unless the symptoms are absolute. This is all the more necessary because now, in patients' minds, the words appendicitis or biliary calculus are associated with the thought of operation. This thought sometimes gives rise to so much dread as to seriously disturb the appetite and still further predispose the patient to the repetition of neurotic intestinal trouble. In the chapter on Abdominal Discomfort, the necessity for absolute assurance of some definite lesion before there is any question of operation, is insisted on. Here the disturbing mental influence of suggestion, with regard to certain serious abdominal conditions, may be emphasized. Many painful conditions in the abdomen are either primarily or secondarily due to appendicitis. Most of these are quite acute, and practically all amenable to definite diagnosis. There is, however, a tendency to exaggerate the place that this organ holds in the pathology of chronic cases. Many women who suffer from nothing more than hysterical abdominal conditions are told by someone that they have recurrent attacks of appendicitis, though there is nothing except their suggestive complaints of pain on which to found such a diagnosis, and then it becomes extremely difficult to remove this idea from their minds, and contrary suggestion applied over a long period is the only therapeutics that favorably affects them. Intestinal Idiosyncrasies.--I have had the opportunity to see a series of cases of intestinal idiosyncrasy in a family that has been an interesting study for many years. One of the members has the most exquisite case of susceptibility to various articles of food that I think I have ever seen or heard of. {283} Even the eating of a little unrecognized pork in sausage will give rise to a diarrhea so intense that there is no peace for hours, and slight movements take place every few minutes. Towards the end of the attack, there is always considerable blood in the stools. Often the attack is preceded by vomiting. While in most people the idiosyncrasy is limited to one article of food, this patient has it for all of the articles that are usually the subjects of idiosyncrasy. Besides pork, shell-fish will produce vomiting and diarrhea within a few minutes, strawberries act detrimentally at once, and cheese produces an almost immediate reaction. The most interesting feature of this case is that occasionally an attack of diarrhea that is extremely severe, will occur merely as a consequence of a strong emotional stress. Any great anxiety will have this effect. The knowledge that someone has a telegram for her whose contents she can not ascertain for a time, will act as a cathartic. She also has other neurotic manifestations, especially of an urticarial character, that are equally interesting. On a number of occasions, when she has particularly prepared for some special event such as a wedding or reception, for which a new gown has been provided and preparations made with considerable solicitude to the end that she shall appear at her best, she has suffered from a severe attack of angio-neurotic edema affecting either her lips or her eye-lids so that it was absolutely impossible for her to be present at the social engagement. This has happened to her over and over again. On the first two occasions, one eye was closed completely by the edema. In each case she attributed it to the sting of an insect. There was no sign of any sting, there was no itching or inflammation, the condition presented all the signs of angio-neurotic edema, had come without warning, and disappeared in from 36 to 48 hours without leaving any mark or trace of its origin. There is absolutely not a sign of hysteria in this individual, nor is there any tendency to what would be called an emotional neurotic condition. On the contrary, she is lively and sensible, the life of her friends when they are ill, their consolation when they are in trouble, and she herself has shown the power to bear trials and difficulties. It is only the peripheral circulation in the intestinal mucosa, and in the skin, that passes from under her control. She neither laughs nor cries without reason and she has no other exaggerated nerve reactions. Even more interesting is the fact that the angio-neurotic condition can be traced in the preceding generation, while the tendency to an intestinal neurosis complicated by diarrhea exists in a sister in this generation. Examinations are always a source of grave distress to the sister. Although she is a bright intelligent woman she does not do justice to herself because of her nervousness. Usually she has a vomiting spell in the morning before the examination, and rather serious intestinal disturbance during the day. That this is entirely neurotic is clear from its constant disappearance immediately afterwards, and its constant reappearance whenever there is this form of emotional stress. In certain of these cases of supposed neurotic, intestinal troubles, one cause of the condition sometimes fails of recognition. Many of these people are found on inquiry to be taking much more salt than usual. It is hard to understand how this occurs, but I have seen it in a number of cases, sometimes in men, but much more frequently in women. Some sort of a vicious {284} circle has been formed: probably their original tendency to diarrhea led to a craving for salt, because of the excessive serous evacuations. Somehow, then, the habit of taking more salt was formed and its presence reacted to produce irritative conditions in the patient, which, combined with neurotic tendencies, produced the intestinal disturbance. I have seen chronic diarrhea, mucous diarrhea, and even mucous colitis, associated with the over-free taking of salt. When salt was eliminated from the diet the cases at once improved. We now realize the value of a salt-free diet for many conditions disturbing osmosis, and the presence of serum where it should not be. It is probable that most people take more salt than is good for them. Intestinal Troubles Due to Air.--One of the most annoying intestinal troubles due to a neurosis is the passage of air from the intestines, or in some people a rumbling through them, which is distinctly of neurotic origin. It is increased under emotional stress or whenever there is anxiety with regard to it. This is much more common in the old than in the young, as if relaxation of tissues had much to do with it. Old men seldom complain of it to their physicians, but for obvious conventional reasons, we are rather often asked to control it in older women, and are occasionally asked to treat poignant cases of it in young women. The older women are often stout, of flabby constitution, and one has almost to accept the conclusion that the real trouble is such a relaxation of the intestinal walls that the empty intestines do not fall together as they used to, but rather tend to lie apart from one another with the production of spaces into which gases, perhaps by diffusion from the blood, find their way and are expelled. Usually these patients were stouter than they now are. Often after these patients have walked outside for some time, especially if they have become quite tired, and then sit down inside and become warm, the expansion of the air in the intestines leads to some rumbling and the production of flatus. This experience is so common with elderly people, when they come in in cold weather, that they do not feel quite right unless it actually happens. The odor of the flatus is seldom offensive. _Air Swallowing_.--There seems to be no doubt that a certain amount of air is swallowed, that it finds its way along the intestines, and then, with the change of temperature on coming into the house, expansion takes place and the air finds its way out. In certain patients the habit of swallowing air may grow, and the necessity for its evacuation, either by eructation or flatus, may be a source of great discomfort. The latter form of relief may be impossible owing to conditions, though it is quite as natural as other forms of the evacuation of the bowels, and it must not be considered pathological unless it becomes too frequent. People of other civilizations than ours are not so sensitive in this matter. A late distinguished Chinese Ambassador to this country relieved himself of an accumulation of gas in his lower bowel quite as indifferently as he would have of gas in his stomach--but without so much as "by your leave" and evidently without a thought of anything unseemly in the act--apparently to his own great satisfaction, though sometimes to the consternation of the bystanders. Utterly failing to understand why he should not permit himself this satisfaction, he peremptorily refused to conform to our Western refinements in this matter. In many of these cases habit may add to the necessity for relief of this {285} kind, and habit may require considerable self-discipline and training of organs to overcome it. To attempt to control this form of intestinal trouble by ordinary intestinal remedies, and especially by carminatives, is almost sure to increase it rather than do any good. It is the patient's mental attitude toward the affection that must be modified, and the intestinal bad habit must be brought under control. _Intestinal Uneasiness_.--In young women the cases are much more serious, for the presence of gas in the intestines sometimes leads to such dread of physical events over which they fear they may have no control, that it makes it impossible for them to carry on their ordinary occupations, hinders their conformance with social usages, or even their association with any but very near friends. The cases are not frequent, but are poignant when they occur. Many young women suffer from rumblings in the intestines whenever more than four hours have passed since their last meal. This phenomenon is not likely to manifest itself unless they are nervous, excited and worried over something, but is particularly likely to be troublesome when they are with persons whom they are most solicitous to impress favorably. The manifestation is undoubtedly associated with emptiness of the intestines and relief will usually be afforded by taking something to eat, even something so simple as a glass of milk and some crackers, shortly before the time when the rumblings are usually heard. Dread of this annoyance plays a large role in it, and it is due to an exaggeration of peristalsis with the consequent crowding into larger masses of small quantities of air that ordinarily would find their way much more slowly along the intestinal tract. Milk of bismuth will do more than anything else, though the presence of a certain quantity of food is probably the best prophylactic and remedy. Besides these cases, there are some that are even more annoying. These occur in young women who have all the symptoms of an approaching intestinal evacuation, and then find when they have excused themselves that there is nothing but gas to be passed. This gas is nearly always quite inoffensive, and is evidently air that has been present in the intestines for some time, and has in the midst of the excitement of peristalsis been forced on into the rectum and gives the sensation of an approaching stool. These cases are coming into notice much more commonly since young women have taken up business occupations. The symptoms are worse in those who are constipated, though sometimes in these cases there are recurring attacks of diarrhea showing that the normal function of the intestine is disturbed. It is more annoying just before and during menstruation than at any other time. _Physical Basis_.--Whenever the patients are run down in weight there is a distinct exaggeration of the condition. Whether the loss of weight, by removing fat from within the abdomen, does not tend to make the intestines more ready to take up air and to produce these manifestations is a question worth considering. The most annoying cases that I have seen were in people who had lost considerable weight and though there had been some tendency to the condition before they lost weight, it was doubtful whether the symptoms were greater than those often seen and which are not productive of special annoyance except in very sensitive people. In three of these cases that have been under my observation in recent years, improvement came promptly when weight was put on. The presence of an abundance of fat in {286} the abdominal cavity seemed properly to balance the intestines and to dampen peristalsis. Reassurance, absence of worry, occupation of mind with interests that keep it from putting such surveillance on the intestinal tract as will surely be resented, must be the chief care of the physician. Without these any relief afforded will be only temporary. With psychotherapy relapses will occur, for these individuals are in a state of unstable intestinal equilibrium, but practically all the successful remedies of the past have been founded on it and its effect may be renewed over and over again under various forms. CHAPTER VII MUCO-MEMBRANOUS COLITIS Probably the severest, certainly the most interesting of the neurotic conditions of the intestines, is muco-membranous colitis. The only lesions discovered are those which point to a functionally increased secretion of tenacious mucus from the lower bowel. No definite pathological changes are known. The colic seems to be due to nothing more than the effort of the large intestine to push off the thick mucus which has been secreted, and which in many cases clings to the bowel walls. This may be of such consistency that it is passed from the bowel in the shape of tubular casts. These casts have often been seen in place in the lower bowel. While the word membranous used in connection with the disease has produced the impression that this might be a form of diphtheritic affection, it is now known that it is only due to an abnormally increased function, and not to any structural pathological condition or infection of the lower bowel. The membranous material is often gelatinous, and so the casts may hang together in long pieces. Neurotic Etiology.--It might be thought that such a cast could not be formed, remain in situ in the lower bowel for a considerable period, and then be passed as a whole, or in quite long portions, without causing serious tissue disturbance in the mucous membrane. As Sir William Osier says, in spite of the apparent improbability, the separation may and usually does take place without any lesion even of the surface of the mucous membrane. The epithelium seems to be left intact. Owing to the curious nature of the stools, the disease has been recognized for a long time and the descriptions of this disease by the older authors are very interesting. Muco-membranous colitis occurs mainly in nervous individuals, and is much more frequent in women than in men, but it is not limited to women. Some of the severest cases have occurred in men, and Woodward, in the second volume of "The Medical and Surgical Reports of the Civil War," has an exhaustive description of the disease as it occurred among soldiers. It is particularly those who are worried and run down from overwork and excitement who are likely to suffer from it, but it occurs typically in people who, _faute de mieux_, worry about themselves. Most of its victims are self-centered, though not hysterical. Recent Increase in Number of Cases.--According to all the authorities, there has been a considerable increase in the number of cases in recent years. {287} At one watering place in France, Plombiêres, which has acquired the reputation for relieving, or even curing the disease, about 400 cases had been under treatment during the course of about two years. This increase was attributed by Boas of Berlin to two causes. First the struggle for life has become much more intense in our day, and the nervous conditions which are practically always the basis of muco-membranous colitis, have as a consequence become more frequent. Not only this, but mild cases that were not called to the attention of physicians in the past, have become so emphasized by the nervous worries of the strenuous life that now they seldom escape the physician's attention. Besides our generation is getting away from the old-fashioned idea of patiently standing many pains and aches, and refusing to call in a physician unless the condition persists or seems to be producing serious results. There are more cases of the disease, but physicians also see more of the cases than formerly because patients come for treatment for slighter causes. Dr. Boas considered that, besides the strenuous life, there was another prominent factor in the increase of the disease. This is the abuse of laxatives and purgatives. Many of these have their principal effect on the lower bowel. In consequence the nervous mechanism of this structure has been irritated to a point where occasionally explosions of nerve force take place. This causes an increase of the secretion, and a tendency to cramp-like contractions. While there is undoubtedly much of truth in this, there is no doubt that the most important factor in the disease is the patient's nervous condition. Only those who are inclined to be introspective, to worry much about themselves, and who are constantly examining their stools for the presence of mucus, suffer severely from the affection. Very few cases have been seen among the working classes. Most of the cases have hypochondriacal symptoms that sometimes go to the extent of real melancholia and the full persuasion that they have an incurable disease, a visitation on them for some real or fancied lapse from the laws of health in earlier years. The affection usually lasts a long time, or has been in existence for some years when the physician is asked to see it, and patients are made most miserable by it. Unfavorable Suggestion and Over-attention.--The pathological physiology of this disease, for, as has been said, it has no pathology in the proper sense of the word, is in many cases a problem of mental influence. For some reason, the patient gets his or her lower bowel on his or her mind. There is so much talk of constipation and its evil effects in the newspapers, in advertisements and by suggestion from bill-boards and in the magazines as well as, sad to relate, in parlors, drawing-rooms and even dining-rooms, that it is easy for those who are introspective and nervous about themselves, and who have some little tendency to constipation already, to become much worried about it. If, then, as was suggested by Boas, they take laxatives in profusion, the irritation set up further fixes the attention on this portion of the body. After a while, in these people, a goodly portion of the waking hours are spent in thoughts with regard to the lower bowel. The morning thought is the possibility of a stool to-day, followed by conjecture as to its character. After the stool has taken place, if there seems anything abnormal about it, comes a morbid dread of the consequences of having such stools. {288} This constant attention sends down a lot of impulses to the lower bowel. Anyone who has studied the psychology of attention knows how much influence can be exerted on the skin, or on the mucous surface by mental influence. Hyperemia is produced, and this leads to over-action of the glands of the large intestine. These glands secrete a glairy mucus which is necessary to protect the bowel from the offensive material that is always present, and from the hardened material that is so often there when there is a tendency to constipation. This mucus is secreted in large quantities, while at the same time a hyperemia of the colon tends to interfere with peristalsis and consequently to delay the passage of contents and to keep the mucus in place. An accumulation goes on for some time, until irritation is set up by the presence of such a large quantity of material in the intestine, and then colicky efforts for its removal are occasioned. All of this process is accompanied by suggestive reactions upon the mind that further complicate the case. This story of the affection points out the indications for treatment. Unless the patient's mind can be diverted from its constant attention to the lower bowel, the possibility of cure is distant, and even after such diversion any return of attention is likely to bring on a relapse. Treatment.--The treatment of this affection emphasizes its neurotic origin. We have had any number of cures for it and each one has actually relieved many patients. The more trouble the cure involves, and the greater the impression produced on the patient's mind the more likely is there to be a relief of symptoms. All sorts of drugs have been employed. Many of them have for a time been heralded as more or less specific. The important thing, however, was that the patients should come predisposed to believe that they were going to be improved, and then that suggestion should be made at frequent intervals--a combination of auto-suggestion through the administration at regular intervals for a long period of simple remedies with the confident suggestion of the physician that the patient will get better. Local treatment of various kinds has been reported to bring about improvement. The more difficult this is, and the longer it takes, as well as the more bother it involves for the patient and the attendant, the better the response to it is likely to be. Long rectal tubes were found beneficial in many cases, though they failed in many others, and most physicians have seen relapses occur in spite of the continuance of the treatment that at first did much good. High injections of water containing various drugs, and of olive oil sometimes bring improvement though they afford no guarantee against a relapse. Mineral waters do good only in the suggestive environment of the spring. _Surgery and Suggestion_.--The symptoms have sometimes been so severe and the complaints of the patients have been so great that even surgery of serious character has been recommended and tried in some of these cases. The making of an artificial anus in the right inguinal region, so that for a time the feces are not allowed to pass over the colon mucous membrane has been tried. This gives decided relief from the symptoms, but when the artificial anus is allowed to close, recurrences often take place. It has been suggested, therefore, that the artificial anus should be allowed to stay open for months, but even this seems to afford no guarantee against a relapse. In recent years the appendix has been taken out through the opening in the right inguinal region, and a portion of it allowed to remain through which, when {289} fastened to the abdominal wall, injections might be made into the colon. In these cases ice-water has been found probably of more effect than any drug solutions. This rather serious surgical procedure is, however, as yet on trial, and we do not know enough about the after-course of the cases to be sure that it has any permanent effect. A strong suggestion is involved in the removal of the appendix, and the use of the stump of it as an irrigating tube. When the treatment consists of something that is so strongly excitant of feeling as ice-water, applied directly to the colon, it is easy to understand that suggestion reaches the limit of its possibilities. No wonder these cases improve, though we are not sure as yet what happens after the appendix opening is allowed to close, or is deliberately sutured. I should expect a recurrence of symptoms, if ever a time came when the patient was run down in weight and worried by external conditions, introspection, and above all by concentration of attention on the intestines. _Direct Suggestion_.--The question is whether suggestion can be used to advantage in these cases without employing any of the radical measures that have been suggested. There is no doubt that at certain watering places where a specialty is made of this disease, and to which patients go, sure that they are going to be much better than before, and where they see patients all round them who are improving, they often get complete relief. This is only what might be expected. Whether a similar effect can be produced by simple suggestion when the patient is thoroughly convinced that the physician understands the case, and that if they will respond he can cure it, remains to be seen. I know that mild cases improve rapidly under simple hygienic measures, with a renewal of confidence in the possibility of relief, and with the diversion of the patient's mind from the intestinal difficulty. This is the most important factor in the treatment, as it is the most important factor in pathology. If the patient's nerve centers can be kept from sending down impulses causing exaggerated action of the glands, then there is some hope of relief. A habit has been formed in the matter, and a habit can only be broken by a series of acts, just as it was formed. It is not effort for a few days nor a week that counts in these cases, but diversion of mind for long periods, until normal function is restored. It is usually quite impossible to keep up this improvement constantly in nervous patients. There are setbacks, but then this is true in every form of nervous affection. It is, then, that the renewed suggestion of the physician is needed. _Resort Cures and Suggestion_.--Physicians often tell patients that muco-membranous colitis is incurable, or at least emphasize strongly that it is very refractory to treatment, and that it is prone to relapse even after improvement. After a certain number of physicians have insisted on these points, it is inevitable that patients should not respond readily to treatment, and that they should be solicitous about themselves, even when improvement does come. It is most important then to bring about the neutralization of these unfavorable suggestions. This is what is particularly accomplished at the health resorts where muco-membranous colitis is successfully treated. At these the patients see other sufferers from the disease who proclaim how much better they are and some at least who are entirely cured. The waters {290} used at these health resorts are not nearly so efficient when used at a distance because of this lack of additional suggestion. The most efficacious treatment of muco-membranous colitis then is to bring the patient up to normal weight, for they are often thin people, quiet their solicitude about themselves, give them a bland and irritating diet and get them away from worries or anxieties about themselves or others. I know cases in physicians where the effect of worry of any kind can be traced very clearly in the increased symptoms of their colitis and the greater frequency of attacks. It is particularly important not to give habit-forming drugs in these cases for they always do harm. Where the pain is much complained of the coal-tar anodynes are useful, but ice in the rectum or even suppositories of gluten, or of cocoa butter without any medication often prove useful. Most of these patients watch prescriptions that are given them rather carefully and make up their mind beforehand whether they are likely to do them good or not and the event usually follows their premonition. They often have habits of self-drugging which must be stopped and always carefully inquired into for they will sometimes continue to take things for themselves in spite of being under the doctor's care. If they have heard of surgical treatment for their affection they are likely to think that they will have to come to it eventually and this prevents a favorable attitude of mind towards their affection. Unless this is secured no treatment will prove efficient. With it almost anything that keeps up the suggestion will greatly relieve and often will actually cure the condition. CHAPTER VIII OBESITY Obesity, popularly considered to be an over-accumulation of fat, is sometimes thought to exist only when there is the large development of abdomen which is more properly designated corpulency. In its strictly scientific sense it represents excessive over-weight, that is, above twenty per cent. more of weight than is normal for the height of the particular individual. (See table of weight for height in chapter Weight and Good Feeling.) The Latin derivation of the word gives also its etiology. Ob-ese means having eaten too much. It is a question of failure of due proportion between the taking of nutrition and the oxidation processes within the body. More food being taken than is needed, there is an accumulation of it in the form of fat, and this is deposited by natural preference in certain places, such as the abdomen, the breasts and in the _panniculus adiposus_ beneath the skin. The fats and starches are most readily converted into this fat, but under certain circumstances proteid material may be turned into fat, and then a true pathological condition develops resembling diabetes in certain ways. The metabolism of fat is rather simple, but this may be disturbed by bad habits. When such large quantities of sugar-making materials are taken that they are beyond the power of the normal metabolism to dispose of, they are excreted in the urine with the production of what is known as physiological {291} glycosuria. In the same way, the eating of a superabundance of fat-forming food leads to the deposition of fat in the tissues where, when in excess, it is just as much wasted as if it were excreted. Physiological glycosuria is, however, usually considered to be dangerous, inasmuch as its frequent occurrence may disturb the normal metabolism of sugar, and lead to diabetes. In the same way, the over-consumption of fat-forming materials may disturb the fatty metabolism, and lead even to the changing of proteid materials into fat. This represents a real disease requiring careful management, while ordinary obesity needs only the exercise of the patient's will to secure such proportion between the amount of food taken, and the amount of exercise and fresh air, as will not only prevent accumulation of fat but will lead to the reduction of any accumulation that may, through neglect of this care, already have taken place. Over-eating.--The putting on of weight depends on the individual's craving for food, and his satisfaction of his appetite. While it is not ordinarily looked at from this standpoint, this craving for food and the habit of satisfying it which is developed, is not very different from the craving for stimulants and the habit that forms with regard to them. People insist that they can not eat less--that their appetite simply requires them to eat. We have all heard this story over and over again from the man who craves alcoholic stimulation. Usually the obese can be persuaded more easily than the inebriate to break off their habit, but they relapse into it even more easily than he does. It is comparatively easy to limit the appetite, or rather to forego the satisfaction of eating abundantly, for a week or two weeks or even a month, but the effort finally becomes appalling and the consequence is a relapse. If the patient really wants to lose weight, in nine cases out of ten it is a comparatively simple matter. The trouble is that they want to lose in weight without giving up the satisfaction of eating. Under Exercise.--The second factor in obesity--lack of sufficient exercise, is even more important than the habit of over-eating. This is illustrated very well by the cases of certain animals who, without any tendency to fat accumulation by nature, but rather the contrary, acquire fat to a marked degree, owing to the habits that are forced on them by their relations to human beings. A typical example is the pet dog. Dogs living their natural active lives, have little tendency to put on superfluous flesh. Kept in the house in cities, they practically always put on weight until, after some years, many of them are quite incapable of moving except in an awkward waddle, often comically symbolizing their mistresses in this respect. Besides the inactivity, the dog is subject to the influence of the other cause of obesity, the over-eating of fat producing material. Another typical example, and one that provides evidence of the pathological tendency to fat accumulation, is found in the Strasburg geese from whom the fatty goose livers for _pates de foie gras_ are obtained. Geese are placed in a warm underground room, in a mass of cement that gradually hardens round their feet keeping them almost completely inactive, and then they are fed abundantly with fat-forming materials. The absence of light and air, and the immobility, leads to the production of the fatty changes, eventually producing the enlarged fatty livers, which delight the gourmet's palate. What is true of the dog and the goose is exemplified in the lives of all other {292} animals. The fattening process is well understood by butchers--keep the animal inactive and supply an abundance of fattening food. The inactivity is even more important than the food. Prophylaxsis.--Of course, if obesity is to be successfully treated, cases must be seen early and before there has been a large accumulation of fat. When people are more than 10 per cent. over weight they are in the danger zone, and with 20 per cent. above the normal, decrease must come or the condition becomes inveterate. It is between these two points and not when they are forty or fifty pounds over weight that they need the advice of a physician and the careful institution of regular life to prevent further fat accumulation. After the body has carried thirty or forty pounds over weight for some time, it has acquired the habit of accumulating fat, rather than using it, and this, once acquired, is hard to break. Every additional pound tempts to the formation of lazy or sluggish habits because of the additional weight that has to be carried around. Everyone knows how hard it is to walk a few blocks a little briskly carrying a suit case that weighs thirty pounds. Even twenty pounds soon proves to be a burden. Fat in the tissues, though it seems to be a portion of the individual, is really quite outside of him and consists of extra food material that the body is carrying round, having accumulated it for the purpose, apparently, of using it at some time when it should be necessary. While carrying this burden, people have little inclination to an active life. Inactivity lowers oxidation processes and leaves them with an additional tendency to fat accumulation because of lack of oxidation. In a word, a vicious circle of cause and effect is formed. Accumulation of fat prevents the taking of proper exercise, and lack of exercise leads to further accumulation of fat! Not only should the treatment of obesity begin early in a particular case, but, in families where there is a recognized tendency to take on fat, it should begin early in life. Children should not be so fed that they become mere specimens, illustrative of how early fat accumulation may occur, and to what a degree it may go. Just as soon as baby shows signs of an accumulation of fat above its normal weight for age and size, there should be just such a regulation of its diet as would be considered necessary if it were an older person, and showed the same unfortunate tendency. This is particularly important if the parental relatives on either or both sides of the house show tendencies to fat accumulation. We are sure that in diabetes the over-eating of starchy and sugary substances produces what is, at the beginning, an alimentary or so-called physiological glycosuria, though it is doubtful whether any glycosuria is ever absolutely physiological. This may lead to a pathological glycosuria and the production of a true diabetes. So, also, the tendency to accumulation of fat, as the result of what might be called alimentary obesity, may lead eventually to the production of an essential obesity in which even the proteid materials of the food may be changed into fats, just as in the case of diabetes they are changed to sugar. This fat is then stored up in the tissues though there is no need at all for such an accumulation, and the food stuff is wasted quite as much as in diabetes. The Will in Treatment.--The important element in the treatment of obesity is the readiness of the patient to follow directions. Nine out of every {293} ten stout people are thoroughly able to control the accumulation of fat and even to bring themselves down to about normal weight, if only they _will_ to do so. This is no easy matter. It is not an affair of a few weeks, or even a few months. Just as in the case of over-indulgence in alcohol, it will probably be a life struggle. It is well worth the while, however, for life is longer and is larger without the accumulation of fat, which is not only so uncosmetic, but is so preventive of real enjoyment of life. Unfortunately, the cosmetic side of it, that is, the absurdity of going round among one's friends with a very prominent abdomen, or with noticeable protuberances, is the particular motive that appeals to most people. While women may be quite ready to stand many discomforts for cosmetic effect when dictated by fashion, they are not ordinarily persistent enough in their efforts to prevent fat accumulation to be successful in this much more important purpose. Such patients make the rounds from physician to physician, and from quack to quack, and go from patent medicine to patent medicine, to find something that will enable them to lose weight without the necessity for their taking any trouble. It is the old, old story that the nerve specialist who is known occasionally to treat his patients by hypnotism has so often presented to him. Patients who are sufferers from alcoholism, or drug addiction, or some other vicious habit, present themselves and ask if they cannot be hypnotized and then lose their tendency to fall back into the old habit. There is no possibility of this. If they are willing to cooperate, all of these habits may be overcome, but a constant effort will be required and, even after the habit is broken, there always remains a distinct danger of relapse. Patients suffering from obesity want to transfer the burden of working it off to someone else's shoulders, or they want some specific remedy that will bring about reduction in weight yet permit them to indulge in all the pleasures of their artificially excited appetite. They follow directions for a few weeks, often half-heartedly, and then give up the struggle. _Food Temptations_.--With obesity, as with indulgence in alcohol, the main difficulty is the occasion. Most of these fat people are placed in circumstances in which tempting food passes them three times a day, and it is hard to refuse it. If a hot punch or a fragrant cocktail were several times every day passed under the nose of a man with a tendency to inebriety it would be beyond the bounds of reason to hope that he should withstand his craving. Just as soon as those who want to reduce in weight are put in conditions in which only simple food, though there may be a reasonably good variety of it, is presented to them, the difficulty of limiting the amount they eat is comparatively easy. This necessitates, as a rule, refusing invitations to dinner at friends' houses, especially at the beginning of a reduction cure, avoiding hotel _menus_ and giving up various social functions. It may even involve changing home customs from those of luxury back to simplicity. The question is whether this is worth while or not. When a husband is likely to indulge over much in alcoholic liquors a wife is apt to consider it easy to deny herself the privilege of such liquors on her table and of avoiding places where he is likely to be tempted. The rest of the family are usually quite satisfied to stand some self-denial so that unfortunate results may not follow. Where father or mother are suffering from obesity this same thing may be necessary with regard to rich and highly seasoned foods. This would be a {294} hardship to inflict on the family were it not for the fact that the health of all the members will be distinctly benefited and a return to simple food, nutritious and with a variety that makes it eminently wholesome, will be good for them as a prophylactic measure. _Motives for Self-Control_.--The task of keeping the weight down is so difficult that very few people with a tendency to over-weight are equal to it. They need the help of every motive possible for encouragement. It is well to make these persons realize that over-weight, according to the statistics carefully gathered and collated by the large insurance companies in recent years, is a serious bar to great expectancy of life. In a large series of cases it was found that not a single individual recorded as being more than twenty per cent. over the normal weight that he should have for height, died of old age. Furthermore no one of over-weight attained the age of eighty years, though 44 under-weights passed this age, and two of them even reached the age of ninety. Death from nearly every known cause is more frequent among the over-weights than in the normal population, except in the single instance of tuberculosis. What was thus demonstrated from statistics, carefully gathered in modern times, has been a commonplace in medicine since the earliest days. Hippocrates summed up Greek experience in the aphorism "persons who are naturally very fat are apt to die earlier than those who are slender." Practically all the commentators since his time have agreed with him. In early years thinness may be quite as dangerous. If there were no other reason but the greater frequency of _diabetes_ among the obese, this of itself would be sufficient to act as a strong deterrent motive. It may well be used as such, especially in families where a tendency to diabetes has been manifest. Diabetes figures as a cause of death in life insurance statistics five times more frequently among those who are over-weight than in the general population. Those who are under-weight suffer from the disease in fatal form less than one-half as frequently as the average. Hence, obesity and diabetes are evidently closely related. As we have suggested, the disturbance of metabolism due to the failure to use sugar properly in the system and to its consequent elimination, corresponds in some, as yet not well understood, way to the other metabolic disturbance by which unnecessary fat is accumulated in the system. It is probable that the over-eating of starchy foods and fats which leads to obesity, causes in some people a breakdown of metabolism in the matter of the proper disposal of sugar, and this initiates diabetes which becomes a pathological condition, after a time quite beyond control. Sleep and Exercise.--After the reduction of diet, the most important feature of any successful treatment of obesity must consist of an increase in the amount of exercise. Both of these can be accomplished only through the patient's will, and by frequently repeated suggestion, and auto-suggestion, of the necessity for constant surveillance in both these matters. Any form of exercise that is pursued faithfully is beneficial. Exercise in the open air, because it encourages oxidation, is preferable to gymnastic exercises, but the care of a trained instructor, the influence of example, the habit of taking it at regular hours, make gymnastic exercise of value in this condition. A regular walk every day is invaluable if it can be secured. Women can be tempted {295} to walk even three or four miles, if the habit is gradually formed, and if they realize the necessity for it. It is important that too much sleep should not be indulged in. One of the difficulties with pet animals is that they sleep so much more in domesticity than in the state of nature. Sleep must be absolutely regulated for the obese. The old monastic rule "seven hours for a man, eight hours for a woman and nine hours for a hog" must be emphasized. Heredity.--There always remains in these cases the influence of heredity. Many people are sure that because they come from families with the tendency to obesity, it is impossible for them to overcome this assumed heredity, and that the only thing for them is to bear the affliction with equanimity. They usually do this while indulging their taste for the luxuries of the table rather freely. This question of heredity, however, has come in recent years to occupy a very different position in the minds of biologists from that which it held a generation ago. We know now that the evidence for acquired characters being transmitted is so trivial as to be quite negligible. The children of stout parents are likely to acquire their parents' habits as to the consumption of food, in such quantity and quality as will almost inevitably put fat on them. It is this habit much more than any hereditary element, which is the underlying cause of the obesity. There may be some influence of heredity, but it is much less than has been thought, and even where it exists, it is not so inevitable as has been considered. There are cases in every physician's experience where the children of stout parents who, for some reason, have been brought to habits of spare eating, have been thin all their lives. On the other hand, anyone who has seen the change that has come over the sons of spare, lanky farmers, in whom both father and mother were of the thin type, yet who in the midst of the luxury of city life have taken on weight, will be convinced that personal habits mean much more than any influence of heredity in the production of obesity. Where there is normal occupation of mind and body with strict regulation of the hours of sleep, and simple though abundant food, there is little tendency for people to become obese, even though there may seem to be hereditary tendencies. In a considerable experience with religious communities I have often noted that the member of a family who enters a religious order often goes but slightly above normal weight, even though other members of the family may become distinctly fat. This is not because of rigid self-denial in the matter of food, that is to such an extent as to take less food than is necessary, for most members of the religious communities work too hard for this to be possible, but because they live the regular active life and have the simple food of the community. This is true in spite of the fact that their indoor life would seem to predispose them to the accumulation of fat. After fifty most of them put on weight because this is the physiological accompaniment of that period of life, but it is not this form of fat accumulation that the physician is called upon to treat as a rule, but that in people between the ages of twenty and forty. If the prevention of over-weight is taken up in time, if habits are broken before they become tyrannous, if proper self-control is cultivated early in life, there are very few people that need fear the oncoming of obesity. There are some pathologically obese families in which this will not be true, but they are as rare as diabetic families. The most important element in any {296} treatment is the rousing of the patient's mind and his will to take up seriously the task of unlearning habits of overeating and not allowing sluggishness of life to gain control. This can be done best, not by removing all sorts of articles for which there is special taste from the diet, but by a general reduction in the quantity of food eaten, by the introduction of food material that does not put on weight yet satisfies the craving, by the replacing of many of the starchy vegetables by greens of various kinds, by replacing many of the desserts by gelatine products and cheese, and by additions to the exercise. But there must be no extremes in the reduction of food or the taking up of exercise. Patients should not be permitted to lose five pounds a week--at most two or three pounds--and they should be made to understand that it is a life work and the formation of lasting habits that they have before them. They should be made to understand, also, after a time the satisfaction that comes from a more active life will give them even more pleasure than the satisfaction of their appetite did before. Principles of Treatment.--Many systems of treatment of obesity have been invented. All of them are supported by cured cases. Some of them are founded on a reduction in the amount of fluids, some on a reduction of the amount of vegetables eaten, in some cases going to the extreme of an almost exclusively meat diet. Most of them modify the diet very extensively. It is doubtful, however, whether any of these systems, when successful, have owed their success so much to the physical effect as to the suggestive influence exercised on the patient's mind, that he must at the same time limit his eating and increase his exercise. In the matter of fluids particularly, some of the systems are absolutely contradictory of one another, yet success follows their application. There is one serious difficulty in the application of these systems. After a time the patient becomes very tired of the monotony of diet suggested, and growing discouraged, relapse into old habits. If suggestion can be used with as much force without such extreme modifications of diet, the results are as good, and are always more lasting. The important factor is a reduction in the amount eaten, without necessarily denying any but the very rich foods. In this way patients can very soon be induced to take half portions of what they have been previously eating and thus secure a prompt reduction in weight. It is important that the bowels of obese patients be kept freely open. Tendencies to constipation seem to disturb metabolism in the direction of fat deposition, and even fatty degeneration. Many of the cures at watering places include the taking of laxative salts, or waters of various kinds, and undoubtedly this is helpful at the beginning. But the continuance of such treatment may seriously disturb peristalsis so that it is important to have intervals of rest for the bowels, during which, while there is a regular daily evacuation, there are no tendencies to diarrhea. The suggestive influence of the taking of salts has meant much for a great many so-called obesity cures. They should be employed carefully, but must not be abused. For fat already accumulated, only exercise will serve as a sure remedy. For fat within the abdomen, the various leg exercises which may be gone through in bed, and the trunk movements, especially those of sitting up from a lying position, when frequently repeated, will soon serve to dissipate accumulated fat. They will also encourage the taking of outdoor exercises, as {297} well as relieve the patient from many muscular discomforts, difficulties of breathing and heart palpitation, which were not only annoying before, but discouraged the taking of exercise. CHAPTER IX WEIGHT AND GOOD FEELING Probably the most important single condition for the maintenance of good health and _good feeling_ is the carrying of weight normal for the height and age of the individual, or slightly in excess of normal. Popular expressions contain many proofs of this. The proverb "laugh and grow fat" is undoubtedly due to the recognition by all the world that stout people are nearly always laughers, and as a consequence, perhaps placing the effect for the cause, laughing has been regarded as a factor in putting on flesh. [Footnote 27] There is no doubt that the exercise for the diaphragm afforded by hearty laughing, with the stimulation of the intra-abdominal circulation consequent upon vigorous diaphragmatic movements, is an important element in producing a healthy state of the important organs of the human economy contained within the abdominal cavity. Dr. Abrams in his book, "The Blues, Causes and Cure," attributes this disturbing condition of depression so familiar to those who have much to do with nervous patients, to a disordered blood and nerve circulation in the splanchnic area, and calls it scientifically, splanchnic neurasthenia. This undoubtedly sums up one important element in the causation of a great many depressive conditions. Most of them are banished by frequent hearty laughter which, with its exercise of the diaphragm, tends to stimulate splanchnic blood vessels and nerves. [Footnote 27: Those who are interested in fossil words will find many curious confirmations of the connection between weight and good health and good humor. A typical illustration is the word _buxom_, derived from the German _biegsam_, which means "ready to obey," from the original significance of being ready to bend, that is bendsome. In our day it has come to have quite a material rather than an ethical significance. A buxom woman is one who is round and full of form and while she usually also is cheerful and tractable, the two ideas are not necessarily connected. It is curious that what was originally the obedient wife should now have become the stout and healthy wife, as if stoutness and healthiness were somehow inseparably connected with the preceding idea so that gradually one portion of the meaning was lost sight of and now only the physical significance remains.] Thinness and Discontent.--In general, it is well understood that thin people are likely to be more gloomy and discontented than those of stouter build. The pessimists of the world have usually been lank and lean. Shakespeare, in "Julius Caesar," has the great Roman declare that he likes not "the lean and hungry Cassius," and that "discontent is bred in such bodies." The issue shows his prophetic power. Discontent with life is much more likely in thin people than in stout. Most suicides are under-weight. Where nutrition is under the normal, digestion is sure to be poor because the digestive organs themselves suffer even more than others from lack of food, apparently giving up some of their own substance at the call of other tissues; sleep is nearly always disturbed, constipation is almost the rule, and muscular action becomes distasteful. While in our day we hear much of people overeating, the nervous specialist finds that many of his patients are undereating. {298} These patients grow out of many discomforts, dreads, and symptoms that often seem, even to the physician, to be due to organic change, when they take on enough weight to relieve them from the incessant calls for more nutrition to which insufficient food has made them subject. Physical Disadvantages of Thinness.--There are many dangers that go with thinness besides the tendency to that irritability of the nervous system which we have come to associate with neurotic symptoms. It has long been known that a person who is under weight is much more likely to contract tuberculosis than a normal individual. From carefully selected statistics, the large insurance companies have determined, that it is far more dangerous to insure a man who is twenty pounds under weight and who has no family heredity of tuberculosis than to insure a man with a family history of tuberculosis on both sides of the house, provided he is well up to or above the normal weight, and is not living in special conditions of danger from contagion. It is contagion and not heredity that plays the most important role in tuberculosis, and the element that is still more important is that of vital resistance. Every adult of thirty years or over has probably at some time had tuberculosis, for traces of its presence are found in the bodies of all adults who come to autopsy. Seven-eighths of the human race are, however, able to resist, and among these seven-eighths by far the greater proportion are those who are above normal weight. Of course, this matter of the relation of normal weight to good health did not escape the acute observation of the old physicians. Hippocrates, to take the first and greatest of them, realized that while excessive eating and drinking was serious, there were many people who suffered from not eating enough. One of his aphorisms runs, "A slender and restricted diet is generally more dangerous [manifestly he means to both the well and the ill] than one a little more liberal." He appreciated, too, the fact that while the old may restrict their diet with more or less impunity, this practice may be, and indeed is likely to be, more serious in young people. He has marshaled the ages and stated the effects of a low diet on them very definitely: Old persons endure fasting most easily, next adults; young persons not nearly so well, and infants least of all, especially those who are of a particularly lively disposition. _Discomfort Due to Lack of Fat_.--Many of the vague discomforts of the internal organs seem to be due to a lack of fat cushions round them, and fat blankets to keep them from being too much subjected to the vicissitudes of external temperature. Anyone who has noted in a series of cases the difference between the condition of patients suffering from a slightly movable kidney when they are well up to weight, and when, on the other hand, they are considerably reduced in weight, will have the significance of the first of these conditions brought home very clearly. Most of the people who suffer much from cold in winter are greatly benefited, as might be expected, by a blanket of fat. It is rather easy to grow accustomed to carrying ten additional pounds of fat when ten additional pounds of clothes would be an insupportable burden. Some fat people are prone to complain of the cold. These are not the plethoric but the anemic. This latter class often have a sluggish circulation, besides a lack of hemoglobin. As a consequence of this their {299} oxidation processes are slow and imperfect, and this is one of the reasons for the over-accumulation of fat. The healthy individual with normal heart and normal blood-making apparatus will always be ever so much more comfortable with a reasonable panniculus adiposus and fat cushions and coverings for the internal organs. _Muscular Weakness and Discomfort_.--There are a number of pains and aches occurring in lean persons that are due to nothing else than the weakness of muscle consequent upon the poor nutrition of their muscular tissues. Muscles which do not receive as much nourishment as they should, must necessarily be weak, and if asked to do much work they will resent it. Ordinarily it is not realized how much work is required even for such common muscular efforts as those that are needed to hold the body erect, or to keep it in a stooping position at a definite angle, or to move around on the feet. I have seen patients lose their aches and pains, and become quite capable of standing weather changes and ordinary hard muscular labor without discomfort, simply as the result of a decided gain in weight. All that was needed was the persuasion to eat more, and especially to eat a full breakfast, the meal likely to be neglected. In some persons, appetite will only return after the correction of constipation and insistence on a certain amount of outdoor air every day, not necessarily exercise--for bus riding or the open cars are excellent appetizers. Eating Enough.--It is very difficult to persuade some people to eat enough! They have all sorts of excuses. They rather pride themselves on the fact that they do not eat much. Persons who are twenty pounds under weight will calmly tell you that they do not need more than they eat. They are actually in debt to that extent to their tissues, yet they are persuaded that they are paying nature's claims in full. Sometimes the excuse is that they have heard, or read, of how much harm is done by overeating; they have taken to heart the phrase that people are digging their graves with their teeth, and so they are actually cultivating the habit of undereating instead of allowing their instinct for food to manifest itself. Many are found to be following the good old saw of getting up from the table hungry. The inventor of it is not known, but quite unlike the inventor of sleep, it would have been a great blessing if he had kept it to himself by patent right. After a time habit for these people becomes second nature, and it is hard to get them to eat enough. When people undereat it is the digestive organs that, in my experience, always suffer the most. As a consequence, the appetite decreases because of gradually acquired lack of vitality in the digestive system, its nutrition having been lowered by drafts upon it from other portions of the body. Quite contrary to what is told in the old fable, the stomach apparently is not selfish and does not keep the lion's share for itself. The decrease in the amount of food brings on a decrease in digestive power. Weight for Height.--The physician who wants to help patients by suggestion must keep before him weight tables for height, as they have been determined by statistics. When people are under weight, it matters not what they may be suffering from, improvement will come if they are made to gain in weight. To be able to show them that they are considerably below the normal and to point out what this probably means in lack of surplus energy, suffices of itself to make many people understand the necessity for {300} effort in the matter and to give them a strong suggestion as to probable relief of their symptoms. The following tables are the best-known averages for men and women: ADJUSTED TABLE OF WEIGHTS FOR INSURED WOMEN, BASED ON 58,855 ACCEPTED LIVES 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 Combined Ages 4' 11" 111 113 115 117 119 119 122 125 128 126 118 5' 0" 113 114 117 119 122 122 125 128 130 129 120 5' 1" 115 116 118 121 124 124 128 131 133 132 122 5' 2" 117 118 120 123 127 127 132 134 137 136 125 5' 3" 120 122 124 127 131 131 135 138 141 140 128 5' 4" 123 125 127 130 134 134 138 142 145 144 131 5' 5" 125 128 131 135 139 139 143 147 149 148 135 5' 6" 128 132 135 139 143 143 146 151 153 152 139 5' 7" 132 135 139 143 147 147 150 154 157 155 143 5' 8" 136 140 143 147 151 151 155 158 161 160 147 5' 9" 140 144 147 151 155 155 159 163 166 165 151 5' 10" 144 147 151 155 159 159 163 167 170 169 155 Combined 123 126 129 132 136 136 139 142 145 142 133 Heights The average shoes of the average woman will raise her about 1-1/2 to 1-3/4 inches. DR. SHEPHERD'S TABLE OF HEIGHT AND WEIGHT FOR MEN AT DIFFERENT AGES 15-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 5' 0' 120 125 128 131 133 134 134 134 131 5' 1' 122 126 129 131 134 136 136 136 134 5' 2' 124 128 131 133 136 138 138 138 137 5' 3' 127 131 134 136 139 141 141 141 140 140 5' 4' 131 135 138 140 143 144 145 145 144 143 5' 5' 134 138 141 143 146 147 149 149 148 147 5' 6' 138 142 145 147 150 151 153 153 153 151 5' 7' 142 147 150 152 155 156 158 158 158 156 5' 8' 146 151 154 157 160 161 163 163 163 162 5' 9' 150 155 159 162 165 166 167 168 168 168 5' 10' 154 159 164 167 170 171 172 173 174 174 5' 11' 159 164 169 173 175 177 177 178 180 180 6' 0' 165 170 175 179 180 183 182 183 185 185 6' 1' 170 177 181 185 186 189 188 189 189 189 6' 2' 176 184 188 192 194 196 194 194 192 192 6' 3' 181 190 195 200 203 204 201 198 Correction of Underweight.--Underweight is undesirable for many reasons, and gain in weight is often the solution of many problems in ill feeling. It is well to bear in mind that most patients who are under weight can be made to gain in weight by an appeal to their reason and by proper directions and care in seeing that those directions are carried out. Patients have told me that they could not eat more and yet I have been able to persuade them that they must eat more, and they have done so. Anyone who has much to do with tuberculous patients knows that utter repugnance for food can be overcome by will-power, when it is once made clear to the patient that they {301} must eat if they want to live. The most interesting event in the process is that with the increase in the amount of food taken, instead of the appetite becoming more and more satiated, as patients are likely to anticipate, and instead of the repugnance for food growing, the appetite grows stronger, and the repugnance gradually disappears. There is only one way to gain in weight; that is by eating more than one has been accustomed to eat. Persons who are twenty pounds under weight ought easily to gain three pounds a week, half a pound a day, if seriously intent on doing so, but in order to do this they will probably have to increase the amount they eat by double this quantity. That means that a solid additional pound of food, quite apart from the watery elements of the food, must be taken every day. In the correction of under-weight details are all-important. Patients must be given specific directions as to what and how much of the various foods they should take. With regard to supposed idiosyncrasies against such nutritious substances as eggs, milk and butter, enough is said elsewhere to make it clear that, as a rule, these are merely pet notions, beginning in some unfortunate incident and cherished until they have become a mental persuasion strong enough to disturb the digestion of these substances. What is true for quality of food is true also for quantity. People must be made to understand that the amount of food is to be increased. The results attained by this method are well worth the efforts required for it. Of course, the bitter tonics, especially strychnin and cinchona, will do much to help. Just as soon as patients begin to gain in weight many of their neurotic symptoms leave them. Their tired feelings are no longer complained of and when they are up to normal weight they are quite other individuals, both in good humor and efficiency. If for years patients have been eating less than they should, then they will have discomfort when they begin to eat more. They will have no more discomfort, however, than would be occasioned if they took more exercise than they had been accustomed to. The stomach and intestines must be gradually accustomed to the new task of disposing of more food. Unfortunately, the usual impression among these patients is that discomfort in the abdominal region, by which they mean any sense of fullness, proceeds from indigestion, and indigestion signifies developing dyspepsia with all the horrors that are supposed to go with it. In reality the slight discomfort which comes from increased eating is usually not manifest whenever the patients are occupied with something reasonably interesting. After a time the organs will become accustomed to it, and then the discomfort will cease. _Nervous Patients_.--One of the strongest suggestions that we have in our power for thin nervous patients, suffering from many and various ills, is to have them gain in weight. Many of them will be found to be distinctly under weight for their height. They insist that they cannot eat more, that they are eating as much as they care to, and that they have no appetite, that when they eat more they have discomfort, etc. It must be made clear to them that their one easy road to health is to gain in weight. If they are under weight this makes a very definite purpose to put before their minds. The objection so often urged, that they come from a thin family, must not be listened to. The unalterable purpose to make them gain in weight must be insisted upon. If they can be made to eat more than they have been {302} eating before, they will surely gain in weight. To see themselves gaining in weight is a daily renewal of the suggestion that they will be better when they get up to their normal weight. It is much better than electricity or the rest cure, or anything else that I know; it is perfectly natural and, above all, because it may be made an auto-suggestion, it does not leave the patient after a time dependent on anyone else. CHAPTER X VAGUE ABDOMINAL DISCOMFORTS--LOOSE KIDNEY After the vague pains around joints so commonly called rheumatic, and which occur so frequently that probably there is no one over forty who is quite ready to confess that he has not had rheumatism, the most important source of vague discomfort is the abdominal region. This occurs particularly in people who are engaged in a sedentary occupation which prevents much exercise, keeps them indoors, and gives them abundant opportunity as a rule for introspection and dwelling upon their sensations. There are few people who live the intellectual life who have not suffered from some of this abdominal discomfort, which they presumed must mean some definite lesion, or portend some serious development, and yet, as a rule, they have lived for years afterward without any of their fears proving true. Physicians are not spared from this source of worry and discomfort. They suffer from it even a little more than others. Their knowledge of the possibilities of serious pathological developments within the abdomen, especially after the age of forty, makes them a little more concerned as to the significance of these vague discomforts. At least half a dozen times a year, for the last ten years, I have heard physicians say that they were sure that some organ or other within was not performing its function properly, and that there was probably some organic lesion. The thought has usually been in their minds for months, sometimes for years, and they have come to be thoroughly examined. Sometimes they rather expect to be told that they should go to a surgeon. They are usually half concealing a question as to how soon they should set about putting their affairs to rights and how serious the outlook is. As a rule, I am able to dismiss them without any further treatment than the injunction not to think so persistently about certain obscure feelings which they are allowing to occupy their consciousness. Sometimes I know they take the advice--even oftener, perhaps, I know they do not. Once it has got hold of us, it is hard to get away from morbid introspection, and I sometimes hear of them consulting others. All of these patients are improved for a time after their consultation by the reassurance that so long as they have a good appetite--which is the case with all of them--and their bowels are regular--which unfortunately is not the case with most of them--and so long as they sleep well and have no acute pain, there is little likelihood of any serious latent abdominal condition. Such reassurance cannot be given until the abdominal region is carefully palpated, and especially the right side explored as thoroughly as possible. {303} Here lies the appendix, the head of the colon, which is sometimes the seat of trouble not necessarily originating in the appendix. Just above them one may find a loose kidney, for the right kidney is more likely to be movable than the left, because of the overhanging liver, and finally the gall-bladder, and the bile passages, so likely to be the seat of serious trouble. If none of these organs are tender on deep palpation, if the kidney does not come down when the patient is examined in the standing position, if there are no serious derangements of digestion, except such as can be attributed to nervous indigestion, and if there is no dilatation of the stomach, and no enlargement of the spleen, there is no reason why one should do anything but try to get the patient's mind off himself. There is always the danger of overlooking an abdominal cancer, in these eases, though with the care in diagnosis I have suggested this is minimal. The best therapeutic test that I know to determine this, if there should be any doubt, is to put the patient on an increased diet and watch the scales. If he is able to digest the added food well, and without trouble, and if he proceeds promptly to gain in weight, there is much less than one chance in a hundred that he is the subject of latent cancer in the abdominal region. The old farmer's maxim is: "A sick hog don't get fat." When human beings properly respond to increased feeding, it is probable, not only that there is nothing serious the matter with them, but that the symptoms of which they complained before may very likely have been due to lack of nutrition. The digestive organs not having enough to occupy them, were tempted to digest themselves, or at least to have their function disturbed by the short circuiting of nervous energy looking for something to do. I have seen a number of these cases that had been operated on for vague discomfort--some whose appendices had been removed, some whose kidneys had been fastened up because they were slightly movable, some whose gall passages had been examined for adhesions that were supposed to exist, or perhaps for a stone that it was thought might be found there, and except where some actual organic lesion was found and relieved, none of them was materially improved when seen several years after operation. I have heard reports of cures of these cases by surgeons who felt that the removal of an appendix presumed to show a catarrhal process, or a hyperemia, or an adhesion at its tip, had meant the cure of vague abdominal discomfort which had continued for many years and made the patient profoundly miserable. But these reports were founded on the patient's condition at the end of convalescence after the operation, and not on the condition that established itself some months, or perhaps a year, later. Operations on the abdomen, except for very definite indications, have, in my experience, always done more harm than good, and I have seen serious conditions--hernia, displacement of organs and disturbance of the peristalsis of the intestines--develop subsequent to them. I have in mind two typical cases. One was a physician whom I had seen on a number of occasions, and who complained of vague discomfort, mainly in the right side of the abdomen, though never acute, never accompanied by fever, nor even by any disturbance of pulse when he was not in an excitable mood. His bowels were not always regular, and he had had some disturbance of circulation as the result of thrombosis of veins on that side after an {304} attack of typhoid fever. My opinion was that his discomfort was entirely due to the disturbance of circulation. There was probably some interference with the normal full circulation to the large intestine, in its ascending portion, that gave him a feeling of uneasiness, or of consciousness of its function. Eventually he became convinced that he was suffering from a chronic form of appendicitis. After considerable persuasion he convinced a surgeon friend that his appendix should be removed, and the operation was done. I saw his appendix afterwards. It was supposed to be thickened, but considering the normal limits of size of the appendix, I could not think that it was beyond them in any marked way. At most there was but a slight catarrhal inflammation. For a time after operation he was much improved. He felt confident that all his trouble has disappeared, and he took some pains to impress me with the supposed fact that in these vague cases of discomfort there was always some underlying organic lesion that needed surgical treatment. During convalescence he had gained in weight, and was looking very well. When I met him a year and a half later he said that some of his discomfort had returned. He had grown thinner and was feeling discouraged. Six months later he was about to submit to another operation, this time for the breaking up of adhesions in the neighborhood of his gall-bladder. He had become convinced that this must be the seat of the difficulty. After this operation he was sure, beyond peradventure, that his trouble was gone never to return. Two years later I found him preparing to have his right kidney sewed up. I had known that his right kidney was slightly movable, but it did not move sufficiently to cause any disturbance of kidney function, and certainly not enough to justify serious surgical intervention. After this operation I met him once casually and he assured me that now everything was surely all right. I have since heard that he submitted to an operation either for the breaking up of some adhesions around his stomach or in order to tuck up that organ for ptosis. It had not been quite decided whether an adhesion caused a slight hour-glass constriction of the stomach, with some dilatation of the splenic end of the fundus, or whether there had been some actual sagging. I am sure that after this operation, as after preceding ones, with the strong suggestion that he ought to be better and an increase of weight during convalescence, he lost his vague abdominal discomfort for a time, though I have no doubt that it either has or will return. When he gets something to so occupy his mind that he does not dwell too much on his discomfort, he will not increase it to the extent that makes it intolerable. Then he will remember that most people have some discomfort, and he will learn to distract his mind, rather than allow it to dwell on the thought of his particular ailment until it becomes intolerable. It has taken twelve years or more to develop this case to the point where it is as instructive as it now is, and it is a typical example of what may happen even to a physician. There are other cases in my notes that are quite as instructive, two of them occurring in thoroughly educated men, clergymen who were of good intellectual capacity, but who became too much occupied with themselves. One of these had more operations done on him than my friend the physician. He first had his appendix removed, and was better for a time. Then his kidney was fastened up, and improvement once more took place. After this he lost in weight considerably and suffered so much {305} from headaches that a friendly surgeon suggested that there must be adhesions between his dura and his brain. Accordingly a trephining was done, and these adhesions, real or supposed, were broken up. For a time he seemed to be better. Then he had some urinary trouble. A long prepuce, though one that was never tight or adherent, and only required a little attention to cleanliness to keep it from giving bother, was removed. Some disturbance of his appetite led him to limit his eating for a time, and then he suffered from constipation. This was diagnosed by a specialist in rectal troubles as due to abnormally developed valves in his rectum, and these were cut. He still complained very much of abdominal discomfort at times. This was diagnosed as ptosis of his organs, and an operation was done to tuck these up. After this he developed a large ventral hernia, which had to be relieved by a subsequent operation. I had followed the case carefully during many years, seeing him at times, and I was always opposed to the idea of operation and fully confident that none of the operations were really needed. He could not be persuaded that what his case needed most was occupation of mind with something besides his condition. Whenever I could persuade him of this I had seen him gain in weight, get into much better spirits and be almost able to take up his work again. Then he would become discouraged, and before long I would hear of another operation that was planned, or was about to be performed. During the course of one of his many progressive losses in weight as a consequence of depression of mind, he developed tuberculosis. He resisted this very well, but eventually died rather suddenly of an empyema. A careful autopsy showed nothing but the traces of former operations, and no reason why they should have been done. Another case: A friend, also a clergyman, had three operations done, one of them circumcision, the second an appendectomy and the third on a supposed floating kidney. None were indicated, so far as I could see, by any definite symptoms, or justified by his condition. He had vague abdominal discomfort, and this continued to bother him in spite of treatment by various specialists, and his mind became so much occupied with it that he was ready to submit to anything in order to be rid of his burden of discomfort. At no time was it an ache, nor did he ever speak of it as a pain. He had some tendency to dilatation of the stomach and at times, when much occupied with indoor work and neglecting muscular exercise, there was probably some delay of digestion. His appetite was good whenever he would let it be; his bowels were regular whenever he was eating sufficient to stimulate them to normal function; he slept well, except when unnerved by something, but the presence of this abdominal discomfort disturbed most of his waking hours. He could stand it so far as it had gone, but he was sure that it would become so much worse in the future that it would be unbearable. He dreaded that cancer or some other awful development would come after a time. As a matter of fact, the main portion of the discomfort in these cases is the dread of what may happen. It is a dread, just as misophobia or claustrophobia or acrophobia or any of the other dreads that we discuss in the chapter on that subject. The constant occupation with this dread apparently inhibits to some degree the flow of nerve impulses to the abdominal organs, and digestion, already disturbed, is still more impaired. Indeed, the whole {306} of the discomfort seems to be a consciousness of stomach and intestinal function rather than anything more serious. The stomach will take two or three pounds or even more of mingled liquids and solids at a meal and pass them on to the intestines without forcing itself into the field of our consciousness. Anyone who is aware what a thin-walled membranous bag the human stomach is--what it most nearly resembles is perhaps the familiar bladder of the cow--may well be surprised that, though it is supplied with many sensitive nerves, it gives so little sign of the load that is often placed in it. It may, however, be brought rather poignantly into the sphere of consciousness by concentration of attention on it. The intestines function usually with the same lack of reflex. They proceed to pass on this quantity of food, store up two or three days' rations, digest what is nutritious and eliminate what must be rejected, without rising into consciousness. If either stomach or intestines once begin to attract attention, then it will be difficult, unless care is exercised to distract the mind from them, to replace and keep them back in the sphere of the unconscious once more. Peristaltic movements are constantly taking place in the digestive tract. Various things may interfere with peristalsis, and the disturbance of it will almost surely cause some sensation. It may not be serious, and digestive processes may continue, yet there may be discomfort. If there is delay in the passage of food, gas accumulates in the stomach, presses up against the diaphragm and interferes with the heart action. This will give rise to many bothersome sensations, some of which are felt in the heart region itself; others much lower down on the left side, where it is rather hard to recognize just what the real seat of them may be. A good deal of the abdominal discomfort of which people complain, is due to such functional disturbances, emphasized by the fact that digestive action has come into the sphere of consciousness and now attention is being concentrated on it, to the detriment of digestion itself, as well as to the increase of the annoyance which the discomfort may occasion. Operations for abdominal discomfort are quite contra-indicated, unless there are very definite localizing symptoms of some pathological lesion that can surely be relieved by operative intervention. To operate on general principles is sure to emphasize the patient's concentration of attention on his abdominal discomfort, if it does not relieve it, and in most of these cases it utterly fails. The strong suggestion of an operation will relieve for the time being, just as operations for epilepsy seemed to relieve when that procedure was first introduced, though now, unless there are definite localizing signs, there is no question of such an operation. Toxic Factors.--_Tea_.--A very interesting phase of abdominal discomfort seems to be associated with the taking of nerve stimulants. I have frequently found that patients who complained of vague abdominal uneasiness, sometimes rising particularly at night to the height of colicky feelings but always on the left side, were indulging to excess in tea or coffee. In one case, a woman was taking, she thought, about a dozen cups of tea a day. Just how much more than this she actually was taking I do not know, for it is almost incredible the amount of tea that middle-aged women who are alone may take. I once found by actual count made for me, that a woman was taking almost a score of cups of tea in each twenty-four hours. {307} Just as soon as there is a reduction in the amount of tea taken in these cases, relief is afforded the patient. This relief will not, however, be absolutely satisfactory because the craving for the tea stimulation makes the patients irritable, and it takes but very little to cause them to complain that they still have their old discomfort. In the course of three or four days they realize that the root of the trouble has been reached. If the discomfort has continued for a good while, a sort of habit seems to be formed, and the attention of the mind gives a sense of uneasiness, if not discomfort, in the left abdominal region. Usually it is in the upper left quadrant and seems to be stomachic in origin. The discomfort is apparently due to the presence of air, or gas, which is not properly expelled because of some lack of co-ordination of muscles, and then the warmth of a room or of the bed at night, or the presence of some slightly irritant substance makes the discomfort more noticeable. In the patient's over-stimulated condition, there is inability to withstand it patiently. In none of these cases is there a fever, though in all there is some disturbance of the pulse as if the heart's action were interfered with and the organ resented it. _Coffee_.--In some cases the same vague abdominal discomfort occurs as a consequence of taking too much coffee. This is seen in men more than in women. The tea topers are nearly all women, though my attention was first called to this vague discomfort, that made life miserable for a tea tester, who spent most of his day tasting tea, though drinking very little of it. With regard to coffee, individual idiosyncrasy is an extremely important matter. Some men seem to be able to take five, six or even more cups of coffee in the day without inconvenience; some cannot take even a small cup of coffee after six o'clock at night without being kept awake for several hours; others cannot take a large cup of coffee in the morning without having considerable discomfort, which is usually attributed to indigestion. I have known large, strong men, who were much better for not taking any coffee, or at the most a tablespoonful of it in a cup of milk in the morning to satisfy the taste. Loose Kidney.--Movable kidney is responsible for many of these cases of abdominal discomfort. Where it exists to a marked degree it may be relieved by operation. It occurs much more frequently in women than in men because, for physiological reasons, the kidneys are normally more movable in women and this is particularly true of the right kidney, which would otherwise perhaps be injured by pressure between the pregnant uterus and the liver. It is probable that many of the cases of the kidney of pregnancy are really due to an abnormal fixity of the kidney to a particular place, so that the growing uterus interferes by pressure with its circulation and its function. Slight movability of the kidney, then, should not be considered pathological. I have seen a number of these cases. They seem to occur particularly in women who have lost weight. The fat around the kidney is somewhat absorbed during the course of loss in weight, and this leaves this organ more movable and also less protected and consequently more liable to irritation. One sees it rather frequently in many unmarried women who have some strenuous occupation. Many of these young women come back from their vacation at the end of the summer having gained fifteen or twenty pounds in weight. If there has been any kidney sensitiveness or movability before, {308} both have usually disappeared. The kidney is well held in place because there is much more fat within the abdomen, all the organs are better cushioned, yet without any interference with their function. During the course of the year these patients, school-teachers, stenographers, and daily workers of various kinds, lose in weight. When they have lost ten pounds the kidney begins to be sensitive again and somewhat movable. By the time they have lost fifteen to twenty pounds there is serious complaint in the right upper quadrant of their abdomen extending at times over toward the navel, and the kidney becomes quite movable. At this time the treatment must consist in holding the kidney as firmly in place as possible, for dragging downward will be followed by reflex symptoms in the stomach and intestines. Disinclination to food, loss of appetite, and even the occurrence of some nausea, as well as some constipation, are easily traced to kidney reflexes. During the night there is no trouble, because while the patient is lying down the kidney falls into its proper position. On arising in the morning the kidney drops down out of place. If a corset is put on at this time the kidney may be forced still further out of place, giving rise, after a couple of hours, to considerable discomfort. New shoes can be borne at first, but after a time the pressure they produce shuts off circulation and causes intolerable discomfort. To a less degree this happens to the kidney if thus compressed and this explains the course of symptoms in many cases. _Mechanical Treatment_.--If the corset is adjusted before the patient rises, and fits reasonably snugly, but not too tight, the contents of the abdomen will all be kept in place, and the kidney will maintain its normal position. When the corset is not sufficient to retain the kidney in place, a simple pad, a towel or a napkin or, if there is much sensitiveness, something more elaborate, especially adapted to conditions, can be placed over the kidney, and when held firmly by the corset will keep the kidney in its place. At first the kidney is usually sensitive to this on account of having been pressed upon during the preceding weeks or months. The patient must bear some little inconvenience at first, must get accustomed to the new conditions in which the kidney is kept in place, and must not expect complete relief at once. Any improvement must be considered a step forward, and further amelioration can be confidently promised. As in all other cases of the use of apparatus or mechanical aids--spectacles, false teeth or crutches--the patient must be content to grow used to the new order of things, before expecting satisfying relief. This is the palliative treatment. The natural treatment of many of these cases is to have the patient maintain such weight as will hold the kidney in place, because of the fat within the abdomen, without any necessity for external aids. This can be done more readily than is often thought to be possible. These patients insist that they lose their appetite when they settle down to work, but what they really lose is the habit of eating a definite amount at stated intervals. Very often it will be found that breakfast, which they took abundant time to eat during vacation, is rushed. The luncheon suffers in the same way and is small in quantity. They take only one good meal, and one good meal is not sufficient to maintain normal weight. _Question of Operation_.--When a kidney is so movable as to deserve the adjective "floating," so that it moves considerably from its place and, perhaps, even sags and may be felt in the subumbilical region, it should be fastened up {309} by surgical means. There is a choice between two evils. The fastening of the kidney in the loin does not restore the normal condition, but puts it in an artificial condition. The kidney supports are of such a kind that it was evidently meant to be slightly movable. When it is fastened firmly in the loin, it is likely to feel every jar, and certain post-operative cases that I have seen, in which firm adhesions had supposedly taken place, complained considerably of the discomfort occasioned by this. In a certain number of cases, even after the operation, the kidney is still somewhat movable, because the adhesions yield and some of the old distress returns. All this must be realized before there is any question of an operation. There must be not merely a little discomfort, but enough of actual ache and of reflex disturbance that can be traced directly to the kidney to warrant the operation. No floating kidney should be operated upon in a patient who has lost much in weight and has developed a sensitiveness of the kidney since the reduction of weight. Definite efforts should first be made to bring about increase in weight, so as to see whether this will not restore the previous condition of reasonable comfort. At times it is said that the disturbance of the stomach, that is reflex to such a floating kidney, prevents the patient from taking and assimilating enough food to restore normal weight. This will be true if attention has been called to the condition very seriously, and if the patient is persuaded that this is the reason why there is no appetite and poor digestion. Ordinary palliative measures, such as a binder, or a specially made corset, will be sufficient to prevent the kidney from producing reflex disturbance of the stomach, and will exert a strong suggestion to this effect under the influence of which the patient will usually gain in weight. _Intermittent Discomfort_.--The discomfort that comes with a loose kidney may be quite intermittent. I have known patients to be bothered by it for months, and then quite free from it for several years, only to have their discomfort renewed so that they become quite worried. Some definite local or mechanical condition can generally be found for these variations in feeling. In thin people a jolting ride over a rough road or stepping off a car will occasionally be the beginning of the trouble, and as this also is likely to cause a stone in the kidney to give its first manifestations, there may be serious suspicion of a more grave pathological condition than is really present. If this discomfort continues only the X-ray can absolutely decide the question. Once the mechanical conditions which cause the discomfort are understood by the patient, the actual ache becomes much more easy to bear. Apprehension makes it almost intolerable. Attention exaggerates it, and makes diversion of mind difficult. Understanding helps all the conditions and lessens the pain, not actually but mentally, until after a time very little attention is paid to it. {310} SECTION VII _CARDIOTHERAPY_ CHAPTER I THE HEART AND MENTAL INFLUENCE The heart is an organ so vitally important that we might expect it to be carefully protected by nature from any interference with its action through mental influence, emotional conditions, or voluntary or involuntary feelings. As a matter of fact, it is extremely susceptible to mental influence, stimulant or depressive, and to emotions of all kinds. Psychotherapy, that is, the removal of inhibiting influences originating in the mind, and the suggestion of favorable mental influences, is probably more important for the heart than for any other organ in the body. The law of reserve energy has its most noteworthy applications with regard to it. When we are apparently so completely fatigued that we cannot do anything more, a purely mental stimulus may so enliven the heart as to give the body a new supply of strength and energy. A man wandering through a desert, or swimming for his life at sea, may be so exhausted as to be quite ready to give up entirely, and be brought to the conviction that he has absolutely no strength left for further effort, when a flash in the distance, or a sound that indicates that help is near, or some other mental incitement, will give renewed energy. It is probably through the heart that there comes to us most of our power to accomplish things when we are already so tired as to seem exhausted. On the other hand, it is the failure of circulation in muscles, because of a slacking heart, that produces the sense of exhaustion. Muscular work is easy or even pleasant when we are in good spirits, while, whenever exertion is undertaken in the midst of discouragement, we cannot accomplish nearly so much as when conditions are so framed as to give stimulus and encouragement. If a perfectly normal heart can be so affected by mental conditions and emotions as to be seriously disturbed in its work on the one hand, or greatly stimulated into new activity on the other, it is to be expected that a heart affected by disease will be similarly affected and probably even to a greater degree. It is clear, then, that our cardiac patients have to be guarded against unfavorable mental conditions, and have to have all their reserve energy called out for them by encouragement and by the best possible prognosis for their reflection. This is especially true as regards the removal of the many unfavorable suggestions which, because of ignorance, have in the past gathered round most forms of heart disease. {311} Emotion and the Heart.--The mental and emotional influence over the heart's action was the truth that lay at the basis of the old fallacy with regard to the physiology of the heart. The literature of all countries testifies that the heart was long supposed to be the seat and origin of the emotions. Every one has experienced how the heart jumps when something unexpected happens. People have fainted from excess of joy as well as of grief. The physical side of emotion is so generally associated with some modification of the heart beat that it is no wonder that emotions were directly connected with the organ. When people are in depressed states the heart is apt to beat more slowly than usual, while when in states of exhilaration, even those dependent merely on mental factors, the pulse is more rapid. Melancholic states have occasionally been attributed to the slowness of the pulse, but the slow pulse seems to be a symptom connected with the mental condition rather than a causative factor. In the maniacal conditions, the rapidity of the pulse, which is sometimes quite marked, must probably be explained in the same way, as due to the mental excitement under which the patient is laboring. The Heart and the Nervous System.--Prof. Von Leyden ten years ago recalled attention to the fact that the heart is literally the _primum movens_ in man, and that before the central nervous system is laid down, or there is any possible question of impulses flowing from center to periphery, the heart, or at least its embryonic representative, is beating as constantly, regularly, rhythmically, as it is to do during all the subsequent life of the individual. Oliver Wendell Holmes has expressed it poetically by stating that the angel of life sets this heart pendulum going and only the angel of death can break into the case and stop it. _Primitive Heart Action_.--The original beating of the heart is entirely automatic, and quite apart from any nervous initiative or stimulus. The original bend in the primal blood vessel, which is to represent the heart in the course of development, begins to pulsate very early in the chick and evidently does the same thing in all other living things. Notwithstanding this fact that the heart is thus easily demonstrated to be the _primum movens_, the first exhibitor of vitality, and might thus seem to be one of the organs or indeed the one which should be safe from any nervous interference, later on powerful connections with the nervous system are made, and heart acceleration and inhibition become familiar phenomena. Every emotion, as we have said, has its influence on the heart and even a certain amount of voluntary control may be acquired. Indian fakirs are said to be able to cause the heart to slow and almost to stop. The curious phenomenon of suspended animation which they sometimes exhibit is said to be due to this. Certain of the well-developed muscular subjects who exhibit themselves at medical clinics are able to cause their hearts to miss a beat, but this is said to be rather a result of will-power over other muscles compressing the thorax, and interfering with the heart, than direct influence upon the heart itself. Mental Influence over Diseased Hearts.--Worry produces much more serious symptoms in heart patients than in others. Anxiety about the heart itself is often a source of serious detriment to a heart patient. Most people have such a terror of having anything the matter with their hearts that the haunting thought of such calamity is likely to have a definite influence in preventing the development of such compensation as will enable the heart to {312} do its work to the best advantage. It used to be the custom to refrain from telling patients suffering from tuberculosis that they had the disease. On the other hand, people with heart disease were usually informed of that fact. The reason given for the latter course was that heart disease may in many cases be the forerunner of sudden death, and the warning knowledge was supposed to enable a man to get his affairs in order. No worse policy for either disease could well have been imagined. The pulmonary patient should be told at once, the heart patient should, as far as possible, be saved the depressing knowledge of his condition. Dr. MacKenzie, whose practically illuminating studies of heart disease give him a right to express opinions with regard to it (and when those opinions concern the influence of the mind they are doubly valuable because of the absolute objectivity of his studies), has some rather strong expressions with regard to the importance of modifying the mental state in heart cases. He says: The consciousness of heart trouble has often a depressing effect on people, whether the trouble be slight or serious. When such people become convinced that the trouble is curable or not serious, their condition at once becomes greatly improved. Cures by faith, whether in drugs, baths, elaborate methods or religion, act by playing upon the mental condition. But our employment of this element in treatment should not be the outcome of blind unreasoning faith in some rite or ceremony, bath or drug, but in the intelligent perception of the nature of the symptoms. The reassurance of the patient of the harmless nature of the complaint goes a great way in curing him. The reassurance that with reasonable care no danger need be feared is extremely helpful. Even in serious cases when there is reasonable hope of recovery or a certain degree of recovery, the encouragement of the patient may and does help forward his improvement. Heart Remedies and Suggestion.--Probably the best evidence we have for the influence of the mind over the heart in diseased conditions, that is, when there is definite organic change in the heart valves or muscle, is to be found in the history of the many remedies that have come and gone in heart therapeutics during the past generation. Strophanthus, for instance, was very popular a quarter of a century ago, and it seems as though in many cases it not only replaced, but was more efficient than digitalis. How few there are who use it now with confidence, and how general is the impression that it does not affect the heart to any extent! The confidence with which the remedy was given by the physician was conveyed to the patient and he "took heart," as the expression is, and proceeded to get better. Even more striking is the evidence afforded by other remedies. For a while it seemed that cactus provided a heart stimulant and regulator of value. Convalaria also gained a reputation as a heart remedy. Both are now practically abandoned. Here, once more, the real remedy, when these substances were employed, was, undoubtedly, the suggestion to the patient in connection with the regulation of his habits of life, so that his heart got a chance to catch up with its work. There are other remedies with which we had similar experiences. Even digitalis has had phases of confidence and distrust in it, that are interesting to study in the light of what we now know with regard to the influence of the psyche on the heart. One hears at medical society meetings reports of the favorable action of digitalis within a few hours of its administration. These are not examples of digitalis action, but of mental influence. {313} Any heart patient after the first visit of a physician in whom he has confidence is sure to brighten up at once, heart action is ever so much better and symptoms of mental depression, and even of circulatory disturbance, disappear. It is this that has made the study of even the efficiency of digitalis so difficult. There were times when most physicians employed it in rather large quantities for all forms of heart disease. In some heart cases it is absolutely contra-indicated. Fortunately many of the preparations of digitalis used in the past were quite inert, and so no harm was done. The results obtained were psychotherapeutic. Cardiac Inhibition.--The importance of the role of the nervous system and of the mental influences which control it in all functions is well illustrated by what we have learned during the last half century with regard to inhibition in the animal organism. We used to think that while the nervous system sent down positive impulses--that is, nervous stimuli which brought about the accomplishment of certain activities--it had nothing to do with the stoppage of those activities. Such interference was supposed always to be due to external influences of various kinds, potent for the time, in the organism. We have learned, however, that inhibition is one of the important functions of the nervous system. The idea has now become so familiar that sometimes we are apt to forget how great is its significance. Lauder Brunton, in his article on "Inhibition," set forth its role as we have come to know it. The recognition of the part inhibition plays in vital phenomena is undoubtedly one of the most important discoveries which have been made in physiology since Harvey discovered the circulation of the blood. It throws light upon an immense number of phenomena previously inexplicable and enables us to form theories of a satisfactory nature about many vital problems. It offers an explanation of the nature of hypnotic states, which is at least as satisfactory as that we have of the action of many drugs. The nervous mechanism of the heart affords the best and most commonly cited example of inhibitory action, and here it was first studied by Weber and Claude Bernard in 1848. The cardiac ganglia derived from the sympathetic preside over the movements of the organ, and in response to the stimulus of the intra-ventricular blood-pressure cause rhythmical contraction of the cavities. Their action is, however, controlled by the pneumogastric nerve, through which impulses of an inhibitory nature are constantly traveling and acting as a restraining force. As noted by Lauder Brunton, the late Professor Czermak had a small glandular tumor in close contact with the right pneumogastric nerve and he was able by pressure on this to compress the nerve to any extent he wished, and either "to completely stop the heart or simply retard it." He often performed this experiment so that it is not nearly so dangerous as might be thought. We have some instances, apparently too well authenticated to be doubted, in which the power of the human will to inhibit heart action has been as strikingly manifested as this mechanical disturbance of Professor Czermak. Sometimes these stories of cardiac inhibition through the will are dismissed as unworthy of credence, and doubtless many of them are mere fiction, or have been exaggerated for sensational purposes, but some of them are very suggestive examples of the power of the will over the heart. If only a modicum of such power were to be employed, it would seriously hamper heart action, and it must be the aim of psychotherapy to prevent such inhibition. {314} At least one instance of voluntary heart inhibition was observed by thoroughly trained and properly accredited scientists. A report of it has been published. As a bit of documentary evidence, on a subject that is usually considered so vague as to be scarcely worth considering, Dr. Cheyne's description of the remarkable power of Colonel Tonshend over his heart should be in the hands of those who wish to influence hearts through minds and wills. He could die or expire when he pleased, and yet by an effort, or somehow, he could come to life again. . . . We all three felt his pulse first: it was distinct, though small and thready, and his heart had its usual beating. He composed himself upon his back and lay in a still posture for some time. While I held his right hand. Dr. Baynard laid his hand upon his heart, and Mr. Skrine held a clean looking-glass to his mouth. I found his pulse sink gradually till at last I could not feel any, by the most exact and nice touch; Dr. Baynard could not feel the least motion in the heart, nor Mr. Skrine discern the least soil of breath on the bright mirror. Then each of us by turns examined his arm, heart and breath, but could not by the nicest scrutiny, discover the least symptom of life in him. We reasoned a long time about this odd appearance, and finding he still continued in that position, we began to conclude that he had indeed carried the experiment too far; and at last we were satisfied that he was already dead, and were just ready to leave him. This continued about half an hour. . . . As we were going away we perceived some motion about the body, and, upon examination, found his pulse and the motion of his heart gradually returning; he began to breathe heavily and speak softly. Nor must it be thought that the inhibitory faculty can act only in slowing the heart. Normally a certain amount of inhibition is exercised over the heart's action. If by any chance this should be decreased then acceleration of cardiac activity may take place. Lauder Brunton called attention to that in discussing another phase of pneumogastric function. He said: Paralysis of the pneumogastric, of course, does away with its action. And hence we have among other symptoms of this condition increased rapidity of the contractions of the heart from withdrawal of the inhibitory influence. If slowing of the heart action can be produced through the mind by this mechanism of inhibition, so also under other circumstances may acceleration occur. Shock and the Heart--How large a role emotion plays in disturbing the action of a heart that is already diseased, is illustrated by the story told in serious histories, on what seems good authority, of the dwarf of the French king, who was frightened to death by what he thought were the arrangements for his execution. While we take great pains as a rule to impress upon sufferers from organic heart disease the necessity for their avoiding every kind of over-exertion, or sudden movement of any kind, we do not always impress upon them the even greater necessity for the avoidance of shock and fright, and profound emotions. It must not be thought that emotional shocks have a deleterious effect only in advanced cases of heart trouble. Almost any physician will readily recall examples where emotion had much to do with the break in compensation which indicates that the heart has for a time been overworked. A case in my own experience illustrates this: The patient, a student, had suffered from severe so-called growing pains, undoubtedly rheumatic, when he was about fourteen, and probably had acquired a heart lesion at that time. {315} It did not, however, disturb him in the slightest degree. The patient had never noticed any fatigue on running up stairs; he had no shortness of breath; there were no symptoms pointing to his heart. One summer while his family were in the country he came into town for the day, and missing the last train out, he went to the family home to sleep, though it had been closed up for the summer. He let himself in without difficulty and was preparing to go to bed when he resolved to get a glass of water. There being no tumbler nearer than the dining-room, he went there. As he entered the dining-room he struck a match. With the flash of the light he found himself looking into the barrel of a revolver and a hoarse voice said, "Hands up!" His hands went up. The next minute he was in the hands of two "plain clothes" policemen who had been watching the neighborhood because of recent burglaries. Noticing the light upstairs, they had made their way in for the purpose of catching what they thought a burglar at work. The young fellow, who had never before fainted, collapsed almost at once, and was unconscious for some minutes. The next day he was rather prostrated and tired on movement. By resting a good deal for the next week this passed off to a considerable degree, but then his physician found that he was suffering from a serious heart lesion, with a decided break in compensation. I saw him several months later. His heart had never regained its old power, and his mitral valve was quite unable to fulfill its function. Just what the mechanism of the almost sudden break in compensation was after he had been for so long quite immune from any effects of the rheumatism, is hard to say, but the lesson of the case is easy to understand. Place of Psychotherapy in Treatment.--The role of psychotherapy, then, in heart cases consists in the recognition of the part that the mind, the will and the emotions play in their influence over this important organ. These psychic factors may produce disturbed conditions of various kinds. The more experience the physician has with cardiac cases of all kinds, organic as well as functional, the more powerful does he recognize the influence of the mind over the heart to be. The expression that a man is living on his will is no mere figure of speech. Some cases we have cited seem to show that a favorable attitude of mind keeps up heart action, where an unfavorable attitude would almost surely allow the heart to fail. It is this very potent influence then that must be used to as great advantage as possible in the psychotherapy of cardiac patients. Undoubtedly the most important phase of it is in prophylaxis. As far as possible we must save our heart patients from emotions. The effect of emotion on the heart is known. When that organ is already crippled, emotion may produce a serious strain on it. It is as important to save heart patients from joyful emotions as from those of contrary nature. Many a son who, after years of absence, thought to surprise a dear old mother by suddenly presenting himself to her, has learned to his cost that an old heart may break from joy, almost as easily as from sorrow, and may be as unfavorably affected by the glad emotions as by terror or fright. We must also save heart patients from the unfavorable influence of a bad prognosis, and of too serious a diagnosis, both of which may be quite unjustified, for the rule is that the longer a man has been studying the heart, the less likely is he to be confident in his diagnosis, or unfavorable in his prognosis. {316} The curative place of psychotherapy is in the obtaining, as far as possible, of placid easy lives for these patients. This does not mean that they are to give up their occupations, for very often the internal emotional life, which develops when they have nothing to do but think about themselves, will be more serious in its effect upon the heart than the ordinary vocation. Exciting incidents in life work must, however, be avoided. If men are in occupations that require exposure to excitement, then it may be advisable to change their occupations. Brokers, speculators, actors, sometimes public speakers, on whom appearances in public in spite of apparent placidity are often a severe strain, may have to be guided into quieter paths of life. In general, in every attempt to treat heart disease, and the neurotic symptoms which develop in connection with it, the patient's mind must be considered as one of the most important therapeutic factors. CHAPTER II DIAGNOSIS AND PROGNOSIS IN HEART DISEASE The more carefully heart disease, and particularly individual patients affected by various heart lesions, have been studied in recent years the more it has come to be appreciated that the most important element in the treatment of organic heart disease is the definite recognition of the difficulty of exact diagnosis of most cardiac conditions and the unfortunate tendency to make the prognosis worse than it really is. Many heart affections are quite compatible with long life. In the past both of these problems of diagnosis and prognosis have been only too often solved unfavorably to the patient, to the serious detriment of his power of physical reaction against the ailment. Many a patient has been seriously disturbed and even his power of compensation lessened by having a diagnosis of an organic affection of the heart made with the usual prognosis, or at least strong suggestion of early death that goes with it, when there was no justification for such an unfavorable opinion. Mental Attitude of Patient.--We do not pretend to cure tuberculosis, but we do relieve its symptoms and bring about a remission in the progress with a shutting in of the lesions. In heart disease something of the same kind can very often be accomplished. This does not mean that in advanced cases of heart disease much good can be accomplished any more than in advanced cases of tuberculosis, though in both a change of the mental attitude may lift the patient from what seems almost a death-bed into renewed activity for a prolonged period. Probably heart disease is more serious in its prognosis than tuberculosis, yet undoubtedly the lives of many patients could be prolonged nearly as much as in the pulmonary affection and a large amount of suffering saved through mental influence. We do not hesitate to change the occupation and the place of abode of the patient suffering from tuberculosis. There is even greater reason for doing this same thing when it seems advisable with patients suffering from heart disease. With regard to heart disease, the best authorities are now agreed that it is better, as a rule, not to tell the patient himself unless it is absolutely {317} necessary to do so in order to get him to take the precautions that will prevent further deterioration of his cardiac condition. The depression incident to the knowledge that one has a serious heart lesion is not reacted against, and especially not during a threatening break in compensation, and a more favorable time must be waited for to reveal his condition to him. The danger of sudden death in valvular heart disease is much less than is popularly supposed. Only sufferers from aortic heart disease are likely to die without warning, and this form of the disease is comparatively rare. The death of the patient suffering from mitral disease is likely to be lingering. Mitral disease is the commonest form of heart disease, and the prognosis of it in ordinary cases is by no means so grave as is usually supposed. I have seen a patient still alive with a mitral murmur who told the story of having had his affection originally diagnosed as mitral regurgitation by Skoda, the distinguished Vienna diagnostician, over forty years before. This patient at the time I saw him was nearly seventy years of age, still had the mitral murmur, but his apex beat was scarcely if at all displaced and there was neither enlargement of the ventricle nor apparently any degeneration of the auricle. The Apex Beat and Heart Murmurs.--In this regard an expression of Prof. Carl Gerhardt of Berlin deserves to be recalled. That distinguished clinician used to say that if the apex beat was not displaced there was no good reason for thinking that any heart affection which might be present was serious enough to require active treatment. Heart murmurs have been made entirely of too much significance and any man of considerable experience is likely to have seen a number of patients who, because they had a heart murmur, had been seriously and needlessly disturbed by having a physician tell them that they had heart disease, with an air of finality that seemed to the patients to say that they might prepare for the worst very soon. Patients suffering from diseased hearts have to care specially for themselves, but not to the extent of living such maimed lives as is likely to be the case if they are depressed by an unfortunate exaggeration of the seriousness of their condition. Our best authorities in* heart disease have at all times proclaimed their uncertainty as to the diagnosis of heart conditions from murmurs, while mediocre men of comparatively slight experience have not hesitated to declare their certainty in this difficult matter. It is not an unusual thing to hear of a supposed expert having declared upon the witness stand and under oath that he could tell whether a man had heart disease by _listening_ to his heart, and some have even gone the length of making their decisions in this matter while listening for a few moments sometimes even above the clothing of the patient! Needless to say, this is quite unjustifiable in our present knowledge of the status of heart affections and only men of small experience and over-confidence in themselves make any such declarations. The more experience a physician has had in heart disease, the more careful he is not to make positive declarations. One or two examinations may very easily be deceptive unless there are signs quite apart from those in the heart itself. Indeed, it is much more the state of the individual than the state of the heart itself, or anything that can be found out about it, except after a prolonged and repeated study, that enables us to make definite decisions. Probably no one during the nineteenth century had studied hearts more carefully than Prof. William Stokes, whose books on the subject were so widely read. He wrote: {318} We read that a murmur with a first sound, under certain circumstances, indicates lesion of the mitral valves. And again, that a murmur with the second sound has this or that value. All this may be very true, but is it always easy to determine which of the sounds is the first, and which is the second? Every candid observer must answer this question in the negative. In certain cases of weakened hearts acting rapidly and irregularly, it is often scarcely possible to determine the point. Again, even where the pulsations of the heart are not much increased in rapidity, it sometimes, when a loud murmur exists, becomes difficult to say with which sound the murmur is associated. The murmur may mask not only the sound with which it is properly synchronous, but also that with which it has no connection, so that in some cases even of regularly acting hearts, with a distinct systolic pulse, and the back stroke with the second sound, nothing is to be heard but one loud murmur. So great is the difficulty in some cases, that we cannot resist altering our opinions from day to day as to which is the first and which the second sound. To the inexperienced the detailed descriptions of such phenomena as the intensification of the sounds of the pulmonary valves; of constrictive murmurs as distinguished from non-constrictive; of associations of different murmurs at the opposite sides of the heart; of pre-systolic and post-systolic, pre-diastolic and post-diastolic murmurs, act injuriously--first, by conveying the idea that the separate existence of these phenomena is certain, and that their diagnostic value is established; and secondly, by diverting attention from the great object, which--it cannot be too often repeated--is to ascertain if the murmur proceeds from an organic cause; and again, to determine the vital and physical state of the cavities of the heart. . . . There are too many cases in which murmurs have no such serious significance as was often attributed to them when first studied, and yet it used to be almost a universal custom among physicians, and the custom still obtains with many, to tell a patient rather emphatically whenever a heart murmur was present, that he had heart disease. Above all, too much significance has been ascribed to murmurs in initial cases of heart disease and these are just the cases that should not be disturbed by unfavorable suggestion. The louder the murmur the less likelihood there is of there being heart disease in the ordinarily accepted sense of the term, that is, that the heart is so affected as to be incapable of doing its work properly, for where loud murmurs are present this is almost never the case. A murmur that may be heard a foot distant is usually associated with perfect compensation. If this were remembered by those who examine hearts generally, there would be much less disturbance of heart action by unfavorable mental influence. A great many more who are suffering from certain symptomatic conditions of the heart not surely or necessarily dependent on organic lesions, are plunged into depression by unfortunate, premature or exaggerated expressions on the part of their physicians. It is almost a rule to have men and even women patients say that it makes no difference to them, that they should be told the exact truth as to what their condition is. The future has been mercifully hidden from us in most things and there is no doubt that this plan is the better for human comfort and accomplishment generally. The truth is not easy to find and oftener in these cases lies on the side of favorable prognosis and refusal to think the worst than the opposite. In this there has been a great difference between the German and the Irish schools of medicine. The three great Irish physicians, Graves, Stokes and Corrigan, insisted on the place of the individual and upon how much depends upon the general conditions in pulmonary and cardiac disease. Our teaching in {319} America in this matter has come not from the conservative British schools of medicine, but from the German school, and that has had a notable tendency to exaggerate the significance of heart signs over the general condition. What a great distinction there is between this mode of looking at these diseases and the German method was pointed out by Prof. Lindwurm of Munich, when he translated Prof. Stokes' work on the heart into German. Prof. Lindwurm said: Thus our modern German works are to a greater or lesser extent only treatises on the physical diagnosis of organic affections of the heart. Stokes, on the contrary, resists this one-sided tendency which bases the diagnosis solely on physical signs and disregards the all-important vital phenomena; he lays less weight on the differential diagnosis of lesions on the several valves and on the situation of a sound than on the condition of the heart in general, and especially on the question as to whether a murmur is organic or inorganic, and whether the disease itself is organic or functional. Broadbent on Cardiac Diagnosis.--What Stokes taught the English-speaking world so emphatically in the first half of the nineteenth century Sir William Broadbent was just as insistent about in the latter half. It is evident, then, that clinical experience has not changed its viewpoint in these matters in spite of all our study of the heart in the interval. In his paper on "The Conduct of the Heart in the Face of Difficulties" he has many suggestions that will prevent the physician of less experience from taking too pessimistic a view of heart symptoms. He said: Moreover, the heart has very special relations with the nervous system; it reflects every emotion, beats high with courage, is palsied by fear, throbs rapidly and violently with excitement, and acts feebly under nervous depression; but it is not only through the cerebro-spinal system that the heart is influenced, it is in immediate relation with the vasomotor nervous apparatus, and in a scarcely less degree with the sympathetic system generally. Normally, afferent impulses are constantly flowing from the viscera to the central nervous system and by this reflex process their blood supply is regulated, and their functional activity is governed. These afferent impulses when perverted by functional derangement or disease may become serious disturbing influences. The nervous system in a large and increasing proportion of people is unduly sensitive and excessively mobile, and the reactions to influences of every kind are exaggerated. In some a little emotional excitement gives rise to palpitation, and a piece of bad news or the bang of a door seems to stop the heart altogether. _There is in such subjects no form or degree of cardiac disease which may not he simulated_. [Italics ours.] Add a touch of hysteria on the lookout for symptoms and for someone to give ear to the narration of the unparalleled agonies of the sufferer, and the difficulties of the heart, and it may be added of dealing with them, are complete. Typical Case.--We are prone to think that after the age of seventy the existence of definite heart murmurs with some tendency to blueness of the lips and of the fingers, with coldness of the hands, surely indicates the presence of a serious heart lesion. It is in old people, however, that such symptoms may be most deceptive. The outcome may prove that physical signs ordinarily presumed to be surely indicative of organic disease may be only signs of functional disorder, or at most may represent certain organic affections for which even the old heart is thoroughly capable of compensation. One such instance in my own experience is so striking that I venture to give it in detail. {320} This was the case of an old physician friend of some eighty years of age. His son had a summer lodge in the Adirondacks. Though for some sixty years the father had been living at the sea level in New York almost constantly, he went up to visit the son and be with his grandchildren at an elevation of nearly 2,500 feet. His heart began to bother him almost at once and he could not go up or down stairs or take any exercise without considerable discomfort, marked shortness of breath and a tendency to palpitation that was almost alarming. He continued his stay for several months in the hope that he would get used to the altitude, though there were always difficulties of circulation manifested by blue lips and finger nails. He returned to New York and placed himself under the care of a heart specialist who found what appeared to be evident signs of heart deterioration of muscular character complicated by valvular lesions. He consoled, the old gentleman by the reflection that a heart that had served his purposes so well for eighty years could not really be complained of if now it should show some signs of deterioration. He also insisted that any mental work would be almost sure to be injurious because of the calls upon the circulation that it would make. The old gentleman was ordered South for the following winter with an absolute prohibition of any mental work. He had planned to revise an historical work on which he had been engaged for many years and which had served to keep him in good health perhaps more than anything else. This was put away entirely and he proceeded to try to get well doing nothing. Almost needless to say with nothing to do he did not get well. He had been an extremely busy man all his life, had worked at least twelve to fourteen hours a day for most of the preceding fifty years, and for him to do nothing would be quite as impossible as for a child to be kept in utter physical inactivity. His heart palpitation continued and grew worse. He was waked up at night by starts that seriously disturbed him and usually kept him from sleep for hours. As he said himself, after he had read the morning paper and gone to stool, there was nothing else for him to do all day except eat and sleep, and these incidents had never occupied any of his attention in the past. In spite of the doctor's orders he had his manuscript sent to him and proceeded to work. At once he began to grow better. At the end of three months he was feeling better than he had felt for several years. When I saw him, about his eighty-first birthday, he was looking better than he had for some time. As he said himself in describing his case, his own experience had taught him that the more fuss a heart made the less likelihood was there of its having anything serious the matter with it, at least of such a character as would terminate life suddenly or unexpectedly. The serious heart lesions are those which give no symptoms, or but very slight ones, and the sudden deaths in heart disease usually come from the development of insidious symptoms that do not betray themselves to the patient until the fatal termination is on them. The more the patient himself has been disturbed by his heart, the less likelihood is there of its giving out suddenly. The subjective symptoms are usually due to the fact that the heart is actively overcoming external interference, or resenting over-attention to it in its work. Certain it is, that the neglect of it, so far as that is consonant with reasonably regular life, is the very best thing and the most important part of any prescription given for symptomatic heart disease, whether organic or functional, is to forget it just as far as possible. {321} Heart Symptoms in the Young.--In young people particularly it is important not to suggest the possibility of heart disease until there are definite signs in the circulation apart from the heart which place the diagnosis beyond all doubt. The psychotherapeutics of organic heart disease that is most important is that of prophylaxis. Patients' minds must be guarded as far as possible against disturbance from the thought that they have heart disease, for this of itself adds a new factor which tends to disturb compensation and adds to the heart's labor because worry interferes with the vasomotor mechanism. In this matter it seems advisable to repeat once more that there must be a complete reversal of the customs that have existed until now with regard to tuberculosis and heart disease. Consumptives have from the very nature of their disease a tendency to hopefulness which soon brings about a favorable reaction against the bad news, but heart patients derive no advantage from the announcement and, indeed, if they are of the nervous, worrying kind, the effect of it is likely to be cumulative. A week after being told the worst a consumptive has reacted vigorously and hopefully, and if he has a fair share of immunity, the scare will do good by making him take the precautions necessary to increase his resistive vitality. At the end of the same time a heart patient will be just realizing all the significance of the unfavorable diagnosis and prognosis of his case. It may be urged that heart patients by knowing their condition will be preserved better from injuring themselves by over-exertion, but what we have said elsewhere about the value of exercise in the treatment of heart cases shows how much patients may be injured by having their exercise too much reduced and their activity inhibited by the dread consequent upon the announcement made to them. It is perfectly easy to insist with them that they shall not do sudden things, or take violent exercise, or overdo activity, without disturbing them by the dread words "heart disease." CHAPTER III CARDIAC NEUROSES If, as all the authorities recognize, the attitude of mind toward organic heart disease is extremely important and when favorable is a most helpful therapeutic factor, it is easy to understand that in neurotic conditions of the heart this is of even more significance. The term "heart disease" is bound up with so many unfortunate and persistently unfavorable suggestions that it seems advisable not to use it with regard to non-organic conditions, even though it may be associated with the epithets functional or neurotic. For these the term cardiac neuroses, which avoids the implication of heart disease in the ordinary sense, seems preferable. Many of the cardiac neuroses are quite trifling. Many of them endure for years without producing any serious effect or disturbance of the general health. Many functional disturbances of the heart action which are extremely annoying may disappear entirely with judicious regulation of life. The one important condition in all of these cases is to be sure that the patient does not worry over the condition, for that {322} hampers heart activity and leads to functional disturbances of other organs which make the heart's work harder. Varieties.--There are many forms of cardiac neuroses. Indeed, functional heart affections are so individual that it is hard to classify them. In every case it is extremely important to study the individual and recognize just what are the special factors bringing about the disturbance of heart action. _Palpitation_.--In a certain number of the cases it will be found, indeed, that there is no real disturbance, but that in some way the heart action has been brought above the threshold of consciousness and has become noticeable to the patient. It must not be forgotten that the heart is an intensely active organ. Several gallons of blood are pumped through it every minute and yet it accomplishes its work, as a rule, with such noiseless, frictionless regularity that most people know nothing about it. When the action of the heart becomes conscious, it is usually spoken of as palpitation. Patients are sure to think that this must mean serious over-action, though, as a rule, no sign of over-action or at most a slight exaggeration of the muscular sounds of the heart will be found. _Missed Beats_.--A further stage of this cardiac neurosis is the missing of beats. This occurs particularly in those whose attention has been directed for some time to their heart action by the presence of palpitation. It may be due to nothing more than this over-concentration of attention. It may be due, however, to mechanical disturbances, an over-distended stomach, constipation, or certain nervous factors. _Arrhythmia_.--A third stage of cardiac neuroses consists of irregularity of the heart action, in which not only are the beats missed occasionally, but there may be certain heart sounds much less vigorous than others and the spaces between the sounds may be very unequal. This condition is usually said to be due to some serious condition of the heart muscles, and undoubtedly it often is. There is no doubt, however, that great irregularity of the heart may occur entirely as a neurotic condition without any organic affection and from factors quite extraneous to the heart itself. Etiology.--There are three causative conditions for cardiac neuroses that deserve careful study and that can be very much modified by changing the attitude of the patient's mind toward his condition. The first of these is an over-attention to self such as is particularly induced by a life without much exercise and devoted to things intellectual. The direct causation is probably intimately connected with the second etiological factor in the production of cardiac neuroses. This consists of an absence of sufficient exercise for the heart itself, when it actually seems to disturb its own activity because adequate calls for exertion are not made on it to use up accumulated energy. Cardiac neuroses are seen particularly in those who having had considerable exercise in earlier years, have settled down to a sedentary life in which there are few calls made upon their muscular system. The third etiological factor is the most important. It is due to cardiac disturbance from the stomach and intestinal tract; this will be discussed in a separate chapter. Prognosis.--The prognosis in cardiac neuroses is always worse in the patient's mind than it ought to be. If then the physician shows that he is uncertain as to the real significance of the affection, some hint of this uncertainty will be communicated to the patient with resultant unfavorable suggestion. The {323} more carefully neurotic heart affections have been studied, the better the prognosis becomes. Morgagni in the olden time, Stokes and Corrigan in the early nineteenth century, Broadbent and MacKenzie in our time, have all emphasized the necessity for favorable prognosis. Even extreme irregularity is quite compatible with long life without any symptoms of serious circulatory disturbance. MacKenzie has, in his very careful studies of heart action, shown that extra systoles may cause marked irregularity in many forms without warranting unfavorable prognosis. Arrhythmia may begin in comparatively early life, persist in spite of treatment, and yet continue up to old age. Sir William Osler tells of the case of the late Chancellor Ferrier of McGill University who died at the age of eighty-seven after having exhibited an extremely irregular heart action for the last fifty years of his life. He has seen several other patients who have had heart irregularity for many years without the slightest disturbance of their general health. His experience is not uncommon, and probably every physician who sees many cases of heart disease can recall a few of them. Ten years ago I saw a man past seventy suffering from distinctly irregular heart action, though he gave the history of having had cardiac irregularity for some years at least, and he is still alive, past eighty, and with his heart irregularity still present. I have a patient over seventy whom I know to have had irregular heart action for fifteen years, and he himself is sure that it has been present since he was about forty, at least. It is cases of this kind, together with MacKenzie's recent studies of the subject, that must be before the physician's mind when he makes his prognosis for these patients. There must be no hesitancy about his declaration. Patients think that physicians are prone to deny the significance of heart trouble so as to avoid disturbing their patients. The slightest hesitation, then, will be surely looked upon as of ominous import. The Intellectual Life and Cardiac Palpitation.--It is curious how many people who give themselves to intellectual work and live an almost exclusively indoor life have subjective symptoms relating to their hearts. Many of the English literary men and women of the last century had complaints of this kind. Sir Walter Scott described very vividly his sensations as if his heart did not have room to accomplish its functions, and said that he used to feel within his chest a fluttering as if there were a bird there beating its wings against a cage too small for it. Other literary people have told of this sense of overfullness in the chest, as if somehow there were not room for all the organs. This discomfort is mainly referred to the precordial region. In oversensitive, nervous people it may be described as painful, though analysis of what they mean by the word pain will show that they have only a persistent feeling of pressure which is uncomfortable and gives a sense of crowdedness in that region rather than any genuine ache. Where the feeling is much dwelt on, however, it may be exaggerated into pain, as, indeed, will any sensation, however trivial, if attention is concentrated on it. On the other hand, in practically all of these cases, just as soon as the mind is strongly diverted by any pleasant occupation, the sense of discomfort disappears not to reappear again until the patient has time to think about himself. Heart Surveillance.--Prof. Oppenheim of Berlin has in his usual direct way expressed the power of the mind to influence the heart beat, and he does {324} not hesitate to say that certain nervous people who have been watching their hearts overmuch, and continually thinking about them, are capable of playing all sorts of tricks on themselves and sometimes even on their physicians, by this concentration of mind upon their heart and its action. Prof. Oppenheim in his "Letters to Nervous Patients," writing to a patient complaining of irregular heart action, says: Whenever you succeed in controlling the action of your heart by means of introspection, there flows from your brain to your heart a current of innervation which disturbs the automatic movement of the organ. You now know what you have to thank for the irregularity in the action of your heart. I have frequently proved this to myself in your case: if I succeeded in feeling your pulse without your becoming aware of it, holding your attention by a conversation which interested you, the action of your heart was always absolutely regular. If, however, I tried it under your control, while your attention was anxiously directed to your heart, its action at once became irregular, and you experienced the very unpleasant sensation of palpitation. Irritable Heart of Athletes.--A curiously interesting form of heart neuroses has appealed to me very much because I have suffered somewhat from it myself and owing to circumstances I think I have seen a larger number of patients suffering from it than usually come to a single individual. I refer to the tendency to irritability of the heart which is so marked in men who have been athletes when they were younger, and have taken a large amount of exercise during the years between fifteen and twenty-five. If these men later settle down to a sedentary life they almost inevitably suffer from a marked sense of discomfort in the precordial region because of palpitation, and are apparently much more liable than other people to have an intermittent pulse. Just what these symptoms are due to is not always easy to discover, and in different individuals there seem to be different accessory causes at work. I have seen it particularly in professional men who while at college have been on the teams and have played such hard games as handball, hockey on the ice, and the like. I do not refer only to those who have played an occasional game, but who every day of the college year have had some severe muscular exercise. Whether this irregularity of heart action has not at least been predisposed to by over-exertion remains to be determined. Strenuous athletics produce curious heart symptoms. Missed heart beats and irregular heart action and even leakages at the valves are not unusual even in the best of hearts after severe exertion. A careful examination of the hearts of those who took part in a Marathon run at Harvard some years ago showed that immediately after the race many of them were irregular and some of them had leakages at the mitral valve which lasted from one to twenty-four hours. These were probably due to irregularity in the action of the papillary muscles as a consequence of the fatigue. I had occasion to examine the hearts of some theatrical dancers a few years ago, immediately after they came off the stage. One of them is one of the most successful of modern dancers and is able to occupy the better part of an hour in the severest kind of exertion before an audience. Her heart was not only very rapid immediately after she left the stage, but there were missed beats and a distinct disturbance at the mitral valve. It was hard to determine absolutely, but the sounds at all the valves were impure and there {325} seemed to be imperfect closure or irregularity of action. In another case there was a regular missed beat at every sixth or seventh pulsation. This seemed to be due to an abortive systole. Usually within an hour regularity of heart action is restored and the valve sounds become normal. At times when the patient is run down for any reason, the cardiac disturbance may persist for many hours, or even until after long hours of sleep. The patients I have mentioned seem to have developed their muscles to a noteworthy degree and have enlarged and strengthened their hearts by this exercise. Later on their occupation in life prevents them from taking any severe exercise, or at least furnishes no opportunity for it, and they often settle down to existence that, beyond a short, quiet walk perhaps once a day, affords no exercise at all. Under these circumstances the muscular development that they secured as young men and which kept them in such magnificent health during their adolescent years seems to prove a positive detriment to good health, or at least to good feeling. The muscular system seems to crave to be kept up. Occasionally I have been sure that the intermittent heart action so often seen in these cases was due to the fact that the appetite, or as I should rather put it, the habit of eating, which they formed while they were accustomed to taking vigorous exercise, remains with them during their sedentary life and as a consequence they overeat, particularly of proteid food materials. The large consumption of these materials gives rise to the presence of substances in the blood which make all the muscles more irritable than usual, and this seems to add particularly to the irritability of the heart. _Dietetic Regulation_.--For many of these people a regulation of diet seems to be the best possible remedy. They must be made to eat less substantially, since they do not need the same amount of proteid material to make up for muscle waste, now that there is no longer the old use of muscles. Some of them become very heavy. These, however, are mainly individuals who, besides eating abundantly of proteids, also consume carbohydrates in large quantities. In these there is a distinct disturbance of digestion and a tendency to dilatation of the stomach with gas which interferes with the heart action and brings on the intermittent pulse so often seen in them. In a certain number, however, there are no accessory symptoms of indigestion, but the heart symptoms are most prominent. _Exercise_.--For these people the only real relief is afforded by a certain amount of exercise every day. They become ever so much more comfortable just as soon as their physician insists that they shall have an hour's walk at least every morning and every afternoon and that this walk shall be brisk and always have some definite purpose in it, so that there is no mere sauntering or delaying on the way. Most business men to whom this prescription of an hour's walk is given will reply that it is impossible. Most clergymen will say that their duties are such that they cannot arrange their hours for this purpose. As a rule, it is not difficult to show the business man, however, that if instead of riding to his business, he should walk every day, and this will probably only take twenty minutes to a half-hour longer than if he goes by trolley or even by automobile, this walk will provide him with a full hour of brisk exercise in the open air. The walk back from business will provide the other hour, whenever golf or some other diversion cannot be provided instead. In most cities men live from three to five miles away from their {326} business, and it is not too much to ask them to take this walk. The muscular clergyman must be made to understand that there shall be no trolley cars for his ordinary clerical calls, or at least that none are to be taken unless he has had his full two hours of brisk walk. There is always the fear in the patient's mind that exercise, by calling for heart exertion, is almost sure to make the condition worse. This fear of itself further hampers heart action. When exercise is first increased in those who have been living sedentary lives the heart action for a time is brought more and more into the sphere of consciousness and any irregularity that is present is likely to be emphasized. A little persistence, however, soon shows that what the heart actually was craving was the opportunity to expend some of its energy and it was this pent-up force that was disturbing its action. There is often the fear in physicians' minds lest the advising of exercise should really do harm to the patient. They fear the presence of perhaps a fatty condition, or of some obscure muscular condition, or of some other heart lesion not easy to detect, yet likely to produce serious symptoms. Stokes, who probably knew fatty heart disease better than anyone else in the nineteenth century, outlined his views of the therapy of it as follows: In the present state of our knowledge the adoption of the following principles in the management of a case of incipient fatty heart disease seems justifiable: We must train the patient gradually but steadily to the giving up of all luxurious habits. He must adopt early hours, and pursue a system of graduated muscular exercises; and it will often happen that, after perseverance in this system, the patient will be enabled to take an amount of exercise with pleasure and advantage, which at first was totally impossible, owing to the difficulty of breathing which followed exertion. This treatment by muscular exercise is obviously more proper in younger persons than in those advanced in life. The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, such as Switzerland or the Highlands of Scotland or Ireland. We may often observe in such persons the occurrence of what is commonly known as "getting the second wind," that is to say, during the first period of the day, the patient suffers from dyspnea and palpitation to an extreme degree, but by persevering, without over-exertion, or after a short rest, he can finish his day's work and even ascend high mountains with facility. In those advanced in life, however, as has been remarked, the frequent complications with atheromatous disease of the aorta, and affections of the liver and lungs must make us more cautious in recommending the course now specified. Perhaps the most important therapeutic suggestion which Sir William Broadbent has to make with regard to the cardiac conditions that have come to occupy much of the patient's attention is of a negative character. He says that "patients suffering from these functional derangements of the heart usually make them a pretext for avoiding exercise and often for taking stimulants or drugs, whereas exercise and fresh air are what they need. The best way to prevent the expenditure of superfluous energy on the part of the heart in the form of palpitation is to give it a fair amount of legitimate physiological work to do." Personally I have found that most of the cardiac tonics seem to do harm, in the sense of increasing the subjective symptoms, except in cases where the patient is run down in general health because of failure to take sufficient food, when strychnin seems to be of avail and in the shape of nux vomica acts as an appetizer as well as a heart tonic. Sir William Broadbent has warned particularly with regard to the use of alcohol in these cases. {327} Most patients find that for the moment palpitation is lessened by alcoholic stimulation. They pay for it afterwards, however, by an increased sense of discomfort that sometimes lasts for 24 hours or more. As Sir William Broadbent declared, "To relieve one attack of palpitation or fainting by alcohol is to invite another, while the terrible danger of dropping into alcoholism is incurred." Lest it should be thought that even Broadbent is a little old-fashioned and not quite to be trusted in the light of our present-day knowledge, and above all lest it might be feared that these older men made a better prognosis or emphasized the value of exercise more than is compatible with our recent discoveries in the physiology and pathology of the heart, it seems well to give MacKenzie's opinion of these cases in full. This is all the more important because, as I have said, the influence of German teaching has led to the formation of rather different opinions in America, especially among our younger physicians. Prof. Martius in this country in his lecture for the Harvey Society gave quite a serious prognosis for practically all heart irregularity. He almost went so far as to lay it down as a rule of diagnosis that whenever a heart beats irregularly there is something the matter with the heart muscle or good reason to suspect a myocardial lesion of some kind. MacKenzie's view is very different to this and he warns particularly against permitting the influence of an unfavorable attitude of mind on the part of these patients. He says: The most serious thing about these cases is that the consciousness of having an irregularity sometimes makes a patient introspective and depressed. He keeps feeling his pulse, and communicates his doleful tale whenever he find a sympathetic ear. As the process which gives rise to it in elderly people is the same as that which produces the tortuous temporal arteries, no more significance should be attached to the one symptom than to the other. I have followed cases for many years, and watched them pass through seasons of sickness and of stress, and have seen no reason to attach any serious import to this symptom. In rare instances the heart, from being occasionally irregular, has after many years become continuously irregular for short or long periods, and in a few the permanent establishment of the nodal rhythm has been the means of hastening the end. But this is infrequent, and in cases of cardio-sclerosis has only happened in advanced life, and the patient should on no account be frightened by being warned of the possible occurrence of this unlikely contingency. In younger and neurotic people I have never seen it lead to any bad results. It may appear in serious affections of the heart, as in febrile complaints, but it does not of itself add to the gravity of the condition, though I am not sure that when due to an acute infection of the heart, as in pneumonia and rheumatic fever, it may not be a sign of invasion of the myocardium by the diseased process. If the patient is aware of the irregularity, he should be assured that there is no cause for alarm. It is useless to attempt to treat the irregularity itself. If in other respects the patient is well, then there is no need of any special treatment. If the patient be suffering from conditions which seem to promote irregularity, such as worry, fatigue, dyspepsia, the treatment should be devoted to the removal of the predisposing cause. In people with temporary high blood pressure, who show extra systoles, I find plenty of healthy exercise in the open air specially beneficial, though until they get trained, the extra systoles may at times become more frequent by the exertion. This last remark of MacKenzie's is particularly important, for at the beginning of an attempt to relieve the symptoms by insisting on more {328} exercise, the patient is almost sure to be disturbed by this symptom of which he will often be conscious, and it takes a good deal of experience on the part of the physician to reassure him that because of the increased subjective symptoms at the beginning of the treatment by increased exertion, he may not be doing harm rather than good. As a rule, however, it is not long before the good results of the exercise treatment of these cases begin to make themselves felt and the patient is reassured. Regulated exercise of body and occupation of mind are the two important factors even in the treatment of organic heart disease. They are extremely important even in the cases with alarming heart symptoms that occur in the very old, once the acute symptoms have subsided. In all the functional heart affections exercise is the most important therapeutic resource we have. It would seem that in the course of muscular exercise some heart tonic was manufactured, which in all but the cases of absolutely failing hearts is the best possible therapeutic resource for the stimulation and steadying of the heart action. Such an internal secretion would not be surprising in the light of all that we have learned of the physiological nexus of organs in recent years. Many so-called cures for heart disease probably depend for their good effect much more on the graduated exercise that goes with them than on many of the other remedial measures, though it is these latter that are usually vaunted most highly. We all now recognize how little value there is in the Nauheim bath treatment for heart disease away from Nauheim itself. The reason is because the resisted movements of the early part of the cure and, above all, the graduated exercise of walking up the hills around Nauheim, which are such important parts of the treatment there, cannot be so well given with the baths at a distance. CHAPTER IV CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE Morgagni, whom Virchow greeted as the Father of Modern Pathology, made a careful study of the pulse and especially of its irregularities. He had learned from the most careful pathological studies that marked intermission and even more decided irregularity of the heart may be present in life, though there may be absolutely no organic affection of the heart itself, either of the valves or of the muscle, discoverable at autopsy. In his opinion the most frequent cause for such irregularity is flatulency and disturbance of digestion generally. He went still farther, however, and seems to have understood very well that constipation was often one of the most important links in the chain of causes leading up to such heart disturbance, itself either a cause or an effect of other digestive symptoms. This idea deserves to be borne in mind when there is question of the significance of heart symptoms. What Morgagni thus determined by precise studies in pathological anatomy had been clinically observed by many of the distinguished old-time practitioners of medicine, who knew the fatal tendencies of organic heart symptoms, yet recognized that many cardiac cases associated with gastric symptoms did not have an unfavorable prognosis. {329} In spite of the recognition of these conditions by old-time medical investigators, there has always been a tendency to fear that heart symptoms in these cases might be due to a cardiac affection. This has invariably been true for patients themselves to whom the heart disturbance became conscious, but has often made physicians hesitate as to the diagnosis and rendered their prognosis more unfavorable than is justified by actual knowledge. Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal cardiac neuroses usually run a typical course. As a rule, with young folks, the beginning of cardiac unrest is found in some stomachic symptoms. The distention of the stomach with gas is said to be a mechanical reason for interference with the heart action. Whether this is really gas that has formed within the stomach, or whether it is to a great extent, at least, gas which has been diffused from the vessels of the stomach walls in a disordered viscus, or in some cases at least, air which has been swallowed because of certain gaspy habits of neurotic individuals, is hard to determine. In many cases the absence of all odor of decomposition, or of any disagreeable taste, makes for serious doubt whether the substance is really due to fermentation. Certainly the changes that take place in food in the stomach during the course of an hour or two of digestion are not sufficient to account for the volume of gas that exerts pressure upon the gastric walls and is eructated in large mouthfuls. Fermentative processes are slow gas producers, as anyone with experience in the chemical laboratory knows. _Mechanical Cardiac Interference_.--Every physician has seen the young man who is sure that he has heart trouble when he is really suffering from indigestion. Many of the feelings of discomfort accompanied by palpitation and irregularity are really phenomena connected rather with the stomach than the heart itself. The reason for this is not always clear. In many cases there seems to be a mechanical interference with the heart's action. This is due to the presence of gas in the stomach pressing against the diaphragm. In many cases the distention of the stomach by a heavy meal, especially if the heart has been rendered sensitive by the taking of stimulants, will have the same effect. This is particularly noticeable if the patients lie down shortly after the meal, when there is distinct discomfort in the cardiac region and noticeable irregularity of the pulse. The most frequent phenomenon is a missed beat, or often simply a sense of discomfort in connection with the heart action that makes its beating very noticeable. This palpitation, as it is called, is usually entirely subjective. There is nothing abnormal in the sensation produced on the hand when the heart is palpated, nothing the most delicate finger can detect in the apex beat and nothing uniform in the change in the heart sounds produced in these cases. There is usually a somewhat over-excited action of the heart, but this is not characteristically revealed by either palpation or auscultation. The rhythm is interfered with, but the arrythmia affects only an occasional beat, usually rather regularly spaced, and does not interfere with the heart's rate nor with its action in any way. This represents the most familiar form of cardiac neurosis and may, of course, be due to such substances as tobacco, or coffee, or tea, where these are taken in excess. Excess is always a matter of individual idiosyncrasy. {330} _Cardiac Reflexes_.--It is thought by some that this heart irregularity and palpitation is a reflex action due to irritation of the gastric terminal filaments of the vagus nerve reflected back along this nerve and affecting the heart. The doctrine of reflexes is not as popular, however, as it was, but there can be no doubt of the fact that the vagus nerve has terminal filaments in all the large organs, yet is so extremely important to the heart that it has a definite physiological meaning and doubtless is meant to act in such a way as to stimulate the heart when these important organs are overloaded or are laboring in their functions, and, on the other hand, to depress it or at least to inhibit it somewhat, whenever there is a tendency to send too much blood to these parts. In any case, whether the positive factor in the production of the heart trouble be mechanical, as it surely often is, or whether it be reflex and due to the action upon the vagus, it must not be forgotten that in all cases where heart symptoms occur with considerable intervals of absolute freedom from them and with large subjective elements in the case, the relation of the stomach or the digestive organs in general to the heart may serve as their best explanation. _Gastric Dilatation_.--In dilatation of the stomach there is likely to be an associated tendency to a cardiac neurosis. Unfortunately, enough of these cases have not been followed up so as to be sure what the outcome is and whether there may not really have been some affection of the myocardium with a premature breakdown of the heart. As a consequence of the excessive irritation of the terminal filaments of the vagus nerve in the stomach wall, or because of the mechanical interference with the heart's action as a consequence of the dilated stomach pulling upon the esophagus and probably somewhat interfering with the action of the diaphragm, an irregularity of the heart action is established and a sense of discomfort in the precordia develops that is often very marked. These patients sometimes suffer from pseudo-angina and still more frequently from cardiac irregularity. This cardiac irregularity is sometimes quite marked, and yet in 24 hours, as a consequence of the emptying of the stomach, will disappear, so that only slight intermittency remains, which eventually subsides. I have known a heart affected thus to be pronounced absolutely without any lesion when examined by a competent heart specialist within a month after it had been so irregular as to be quite alarming to both patient and physician. _Upward Distention_.--There is sometimes a tendency for the stomach to distend upward rather than to dilate downward and toward the left. Perhaps this is due to the fact that in certain individuals the gastric ligaments are much stronger and more unyielding than they are in others. One thing is sure--that there are great individual differences in these cases. In some that are without any demonstrable gastric dilatation, except that gastric tympany extends higher than usual, there is marked interference with the heart action. The physician needs to see these cases when they are so irregular that there would seem to be absolutely no doubt of the existence of a myocardial lesion and then to examine them some months afterwards when the stomach had been restored to good conditions, before he is able to realize how much interference with heart action is consonant with complete return in a comparatively short time to the normal, at least so far as heart function goes. This is a very different opinion from that held by many heart specialists and {331} especially certain German authorities, who insist that any irregularity of the heart must be considered as probably representing a muscular lesion; but the evidence of careful observers may be adduced in support of it, and it is an opinion that very much reassures the patients. Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always seemed to me wise to recur to the opinions of some of the old-time clinicians who noted symptoms very carefully and studied out particularly the connection of symptoms with prognosis. _Morgagni_.--Morgagni, for instance, whose clinical remarks are always precious, said: Now that mention is made of the intermission of the pulse which approaches more nearly to the nature of an asphyxia than even its slenderness or weakness (for what else is the intermission of the pulse but a very short asphyxia, or what is an asphyxia but an intermission which lasts very long?) the causes of this disorder in the pulse are not to be passed over without examination in this place, as the greater part of physicians are very greatly terrified thereby, often with good reason, yet frequently without any; as when there is some cause of it in the stomach or intestines, which may even vanish away of itself, or be easily removed by the physician. For in what manner a palpitation of the heart may sometimes be brought on by flatus distending these parts, and again carried off by the dissipation of such flatus, I have already said; and in the same manner, or one not very dissimilar, it is also evident, that an intermission of the pulse has sometimes generated, and gone off of itself, in many whom I have known. At another time, in these very same viscera, there is a matter which produces the same effect, by irritating their nerves, with which you know how easily the nerves of the heart consent. And this matter is sometimes of such a nature that it may readily be prevented from harboring itself there. Thus I remember, when I attended to the cure of a young girl who had a fever, and an intermission of the pulse was added to the other symptoms contrary to my expectations, I was not at all deterred from giving such a medicine as I had before determined upon, that the stomach and intestines might be well cleansed; and even that I gave it so much the more boldly; and that on the same day after these parts had been deterged, the pulse returned to its former standard. But you will read even in the _Sepulchretum_ that Ballonius had not only seen this disorder of the pulse, but also that of a languid and small stroke, removed in the same manner. "According to the degrees to which the purging was carried," says he, "the pulse was restored." And, indeed, there is an intermission of the pulse, that is of a far longer continuance as that with which Lancisi says he had been troubled "for the space of six years"; yet if this intermission should be, as it was in him, "from a consent with the hypochondria," it may be entirely and perfectly taken away, by perfectly restoring those parts. _Lancisi_.--Lancisi was another distinguished clinical observer who made special studies in neurotic heart disturbance. These studies are all the more interesting because he himself was a sufferer from this affection for many years. He was inclined to think that his heart intermittency was due to disturbance in his digestive organs and especially those lying in the upper part of the abdomen. He attributes it himself to sympathy with these and said that it came _ex hypochondriorum consensu_, as it were a reflex from his hypochondriac regions. As Lancisi lived to a pretty good age in spite of noting this symptom in early middle life, the significance of it will be well understood. It would be perfectly possible to gather a series of such cases from among the distinguished physicians of history, and as for our contemporaries and colleagues, at least one out of four of them will tell you that at some time he has suffered from an affection of this kind and has been much worried {332} about it, yet has recovered without incident and without any serious development. English Opinion.--The role of the stomach in disturbing the heart is only less important than that of the nervous system itself. Of course, individual peculiarities, as I have said, are extremely important. Some people seem to suffer very little cardiac disturbance from a distended stomach, while in others all sorts of heart affections may be simulated as the result of the mechanical interference with the heart action by the pushing up of the diaphragm. Sir William Broadbent in the article on "The Conduct of the Heart in the Face of Difficulties," already quoted from, does not hesitate to say that heart symptoms secondary to gastric disturbance probably cause more suffering than does actual heart disease. Expressions of this kind need to be borne in mind when we reassure patients who have all sorts of queer, uncomfortable, often even painful, conditions in their cardiac region, "Heart disease" has been, perhaps, mentioned casually to them and as a consequence worry is adding a nervous element to hamper a heart already seriously disturbed by gastric distention. Sir William Broadbent's own words are given because they carry so much weight in this matter: The difficulties arising out of flatulent distention of the stomach or colon or intestinal canal generally, will require some attention, since they are the cause of most of the functional derangements to which the heart is subject, and give rise to the heart complaints which occasion in the aggregate perhaps more suffering than does actual heart disease. The heart often tolerates a considerable degree of upward pressure of the diaphragm, and it is not uncommon to meet with stomach resonance as high as the fifth space, and to find the apex beat displaced upwards and outwards to the fourth space and outside the nipple line, without conspicuous symptoms. But the heart behaves very differently in different subjects in the presence of flatulent distention of the stomach. It partakes of the general constitutional condition of the individual; in the strong, therefore, it is vigorous; in the weak it cannot be anything but weak. Prognosis.--Nothing sends a young person sooner to a physician than this cardiac unrest and functional disturbance. He comes all a-tremble, as if to hear the worst. Even in middle age and in those whose education might be expected to steady them somewhat in the matter, even in physicians of long experience, there is a tendency so to exaggerate the condition and its possibilities of fatality as a consequence of emotion that inhibitory action on the heart becomes noticeable. It is a rule with very few exceptions that in these cases when the heart is complained of by young persons who have no history of rheumatism, the causative condition will be found in the stomach, or at least in the digestive tract. I know a number of physicians who have suffered in this way and who have been badly frightened about themselves, yet who have had no serious difficulty once they took reasonable care of their diet, and paid attention above all to regularity of meals and slowness in eating. Indeed, it is rare to find a physician of a nervous temperament who has not had some trouble of this kind, and the demands made on a busy professional man foster this. Some of them are sure that if their cardiac uneasiness does not signify an actual heart lesion, valvular or muscular, at least it portends a premature wearing out of the heart. There are many evidences to show that this is {333} not so. I have had a distinguished physician, now well past his seventy-fifth year, tell me of distinct irregularity in his heart action as a young man which had rather alarmed him, and as this had been preceded by an attack of acute articular rheumatism there seemed to be every reason to think that he was a sufferer not from functional but from organic heart disease; yet he has lived well beyond the span of life usually allotted to man, has accomplished an immense amount of work and is now in excellent general health almost at the age of eighty. The case is all the more striking because, while rest and care of the health and regular life and conservation of energy are usually supposed to be essential for these cases, this colleague is noted for having made serious inroads on the hours which should have been devoted to sleep in order to accomplish certain medical literary work while devoting himself to the care of a most exacting practice. That the good prognosis of these cases which I suggest is not forced and is not over-favorable nor the result of the wish to soothe patients may be judged from recent studies of the heart as well as from the older ones. In discussing extra-systole, MacKenzie in his "Diseases of the Heart," [Footnote 28] says: [Footnote 28: "Diseases of the Heart," by James MacKenzie, M. D., 1910, Oxford Medical Publications.] Dyspeptic and neurotic people are often liable [to suffer from them]. That other conditions give rise to extra-systoles, is also evident from the fact that they may occur in young people in whom there is no rheumatic history and no cardiosclerosis and whose after-history reveals no sign of heart trouble. It is well to note the frequency of such annoying symptoms in those who have gone through rheumatic fever, and where patients have a history of this it is well to be cautious, but even in these cases he says that the trouble is often entirely neurotic and the one important preliminary to any successful treatment is to get the patient's mind off his condition, improve his general nervous state, and above all relieve as far as possible the gastric symptoms that may be present. He says further: Some patients are conscious of a quiet transient fluttering in the chest when an extra-systole occurs; others are aware of the long pause, "as if their hearts had stopped"; while others are conscious of the big beat that frequently follows the long pause. So violent is the effect of this after-beat, that in neurotic persons it may cause a shock, followed by a sense of great exhaustion. Most patients are unconscious of the irregularity due to the extra-systole until their attention is called to it by the medical attendant. Both being ignorant of its origin, and its being characteristic of human nature to associate the unknown with evil, patient and doctor are too often unnecessarily alarmed. Cardiac Stomach Disturbance.--On the other hand, as a word of warning, it seems necessary to say here that later in life acute conditions manifesting themselves through the stomach are often of cardiac origin. Most physicians have been called to see some old man who had partaken of a favorite dish which did not, however, always agree with him and who suffered as a consequence from what at first was thought to be acute gastritis. The severity of the symptoms and the almost immediate collapse without any question of ptomaine poisoning, however, usually make it clear that some other organ is at {334} fault besides the stomach itself. The real etiological train seems to be that a weakened heart sometimes without any valve lesion but with a muscular or vascular degeneration hampering its activity is further seriously disturbed by the overloading of the stomach. The result is a failure for the moment of circulation in the digestive organs with consequent rejection of the contents of the tract, nature's method of relieving herself of substances that cannot be properly prepared for absorption. Unfortunately, the condition sometimes proves so severe a shock to the weakened heart that it stops beating, and the physician is brought face to face with a death from "heart failure." In these cases it is important to remember that the gastric disturbance may so mask the heart symptoms as completely to deceive the physician. The prognosis of these cases, however, is most serious. It seems worth while to give a warning with regard to these cases, because anything that we may have to say as to the relations of the stomach and the heart and the possibility of lessening the cardiac depression due to unfavorable mental influence when palpitation occurs as a consequence of gastric distention, has nothing to do with these acute cases in older patients where the condition is serious and the prognosis by no means favorable. Treatment.--The rôle of psychotherapy in this form of cardiac disturbance associated with gastro-intestinal affections is, after the differentiation of neurotic from serious organic conditions, to give the patient such reassurance as is justified by his condition. It is surprising how many people are worrying about their hearts because their stomachic and intestinal conditions give rise to heart palpitation, that is to such action of the heart as brings it into the sphere of their consciousness, sometimes with the complication of intermittency or even more marked irregularity. The less the experience of the physician the more serious is he likely to consider these conditions and the more likely he is to disturb the patient by his diagnosis and prognosis. Until there is some sign of failing circulation, or of beginning disturbance of compensation, the attachment of a serious significance to these conditions always makes patients worse and removes one of the most helpful forms of therapeusis, that of the favorable influence of the mind on the heart. On the other hand, unless the patients' own unfavorable auto-suggestions as regards the significance of their heart symptoms are corrected, these people not only suffer subjectively, but bring about such disturbance of their physical condition as makes many symptoms objective. While there are serious affections in which heart and stomach are closely associated, these are quite rare and usually manifest themselves in acute conditions and in old people. In the chapter on Angina Pectoris attention is called to the fact that there are may forms of pseudo-angina due to cardiac neuroses consequent upon gastric disturbance and without heart lesion. Broadbent has not hesitated to say that these forms of angina cause more suffering or at least produce more reaction on the part of the patient and are always the source of more complaint than the paroxysms due to serious cardiac conditions which present the constant possibility of a fatal termination. Where the stomach is the cause of the cardiac neuroses psychotherapy is an extremely important element in the treatment. The continuance and exaggeration of their symptoms is often due to a disturbance of mind consequent upon the feeling that they have some serious form of heart disease. Without {335} definite reassurance in this matter all the experts in heart disease insist that it is extremely difficult to bring about relief of symptoms in these patients. Whenever the general health of the individual has not suffered from his heart affection, it is quite safe to assume that no organic disease of the heart is present, no matter what the symptoms, for, as Broadbent and many other authorities emphasize, gastric cardiac neuroses can simulate every form of heart disturbance. The older physicians insisted that what they called sympathy with the hypochondriac organs might produce all sorts of heart symptoms. The patient must be told this confidently. The slightest exaggeration of the significance of his symptoms can do no possible good and will always do positive harm. After reassurance, the most important thing is, of course, regulation of the diet and of the digestive functions generally. Unfortunately, regulation of the diet to many patients and even to many physicians seems to mean the limitation of diet. I have seen sufferers from cardiac symptoms have these increased by excessive limitation of diet. If they are lower than they ought to be in weight they must be made to regain it. Above all, there must be no limitation of meat-eating except in the robust. Very often the heart seems to crave particularly that form of nutrition that comes through meat. It is especially important that the bowels should be regular. Fast eating is very harmful. Occupation with serious business immediately after eating is almost the rule in these cases. All of these elements of the case need special study in each individual patient. The needed suggestions can then be made. Above all, the patient is made to realize that his case is understood and that it is only the question of a gradual acquirement of certain habits, including proper exercise, that is needed for the restoration of his heart to normal. CHAPTER V ANGINA PECTORIS The two forms of this affection, known commonly as true and false angina, are characterized by pain or anguish in the precordial region with reflected pains in other portions of the body. It used to be said that whenever the precordial pain was accompanied by reflected pains in the neck, or down the arm, or, as they may be occasionally, in the jaw, in the ovary, in the testicle, sometimes apparently in the left loin, this was true angina and the patient was in serious danger of death. We know now that false angina may be accompanied by various reflex pains and that, indeed, a detailed description of the anguish and its many points of manifestation is more likely to be given by a neurotic patient suffering from pseudo-angina than by one suffering from true angina. True angina occurs in most cases as a consequence of hardening of the arteries of the heart or of some valvular lesion that interferes in some way with cardiac nutrition. The definite sign of differentiation is that in practically all cases of true angina, there are signs of arterial degeneration in various parts of the body. Without these, the "breast pang," as the English {336} call it, is likely to be neurotic and is of little significance as regards future health or its effect upon the individual's length of life. Besides the physical pain that accompanies this affection there is, as was pointed out by Latham, a profound sense of impending death. It used to be said that this was characteristic of the organic lesions causing true angina pectoris. It is now well known, however, that the same feeling or such a good imitation of it that it is practically impossible to recognize the true from the false, occurs in pseudo-angina. It is this special element in these cases that needs most to be treated by psychotherapy and which, indeed, can only be reached in this way. Where there are no signs of arterial degeneration and no significant murmurs in the heart, it should be made clear to these patients that they are not suffering from a fatal disease, but only from a bothersome nervous manifestation. Especially can this reassurance be given if the angina occurs in connection with distention of the stomach or in association with gastric symptoms of any kind. In young patients who are run down in health and above all in young women, the subjective symptoms of angina--the physical anguish and the sense of impending death--are all without serious significance. Differential Diagnosis of True and False Angina.--In the diagnosis of angina pectoris the main difficulty, of course, lies in the differentiation between the true and false forms, that is, those dependent on an organic affection of the heart muscle or blood vessels and those resulting from a neurosis. The neurotic form is not uncommon in young people and is often due to a toxic condition. Coffee is probably one of the most frequent causes of spurious angina, though the discomfort it produces is likely to be mild compared with the genuine heart pang. It must not be forgotten, however, that neurotic patients exaggerate their pains and describe their distress in the heart region as extremely severe and as producing a sense of impending death, when all they mean is that, because the pain is near their heart it produces an extreme solicitude and that a dread of death comes over them because of this anxiety. Coffee and tea, especially when taken strong and in the quantities in which they are sometimes indulged in, may be sources of similar distress. Tobacco will do the same thing in susceptible individuals, or where there is a family idiosyncrasy, and especially in young persons. For the differentiation of true and spurious angina Huchard's table as given by Osler is valuable: TRUE ANGINA Most common between the ages of forty and fifty years. More common in men. Attacks brought on by exertion. Attacks rarely periodical or nocturnal. Not associated with other symptoms. Vaso-motor form rare. Agonizing pain and sensation of compression by a vice. Pain of short duration. Attitude: silence, immobility. Lesions. Sclerosis of coronary artery. Prognosis: grave, often fatal. Arterial medication. NEUROTIC FORM At every age, even six years. More common in women. Attacks spontaneous. Often periodical and nocturnal. Associated with nervous symptoms. Vaso-motor form common. Pain less severe; sensation of distention. Pain lasts one or two hours. Agitation and activity. Neuralgia of nerves and cardioplexus. Never fatal. Antineuralgic medication. {337} True Angina and Psychotherapy.--One of the most frequent occasions for the development of true angina is vehement emotion. The place of psychotherapy then in the affection will at once be recognized. A classical example of the influence of the mind and the emotions in the production of attacks of angina pectoris in those who are predisposed to them by a pre-existing pathological condition, is the case of the famous John Hunter. He was attacked by a fatal paroxysm of the affection in the board room of St. Thomas' Hospital, London, when he was about to begin an angry reply with regard to some matter concerning the medical regulation of the hospital. He had previously recognized how amenable he was to attacks of the disease as a consequence of emotion or excitement, and had even stated to friends that he was at the mercy of any scoundrel who threw him into an attack of anger. Some of the deaths from fright or sorrow at a sudden announcement of the death of a relative, or even the deaths from joy are due to angina pectoris precipitated by the serious strain put upon the heart by the flood of terror or emotion. Men who are sufferers from what seems to be true angina pectoris must be made to understand without disturbing them any more than is absolutely necessary that strong emotions of any kind--worry, anger, exhibitions of temper, and, above all, family quarrels, must be avoided. Not a few of the serious attacks of angina pectoris which physicians see come as a consequence of family jars, owing to the persistence of a son or daughter in a course offensive to the parent. A part of the prophylaxis, then, consists in impressing this fact on members of the family and making them understand the danger. The disposition that causes the family friction is, however, often hereditary and will, therefore, prove difficult of control. It is one of the typical cases of inheritance of defeats. _Solicitude and Prognosis_.--The distinguished French neurologist, Charcot, had several attacks of what seemed to be true angina pectoris. His friends were much disturbed by it. Physicians who saw him during the attack feared that he was suffering from an incurable heart lesion. He himself, as his son, Dr. Charcot, told me, refused to accept this diagnosis, and preferred to believe that what he was suffering from was a cardiac neurosis--and, of course, he had seen many of them. He was unwilling to have a heart specialist examine him very carefully for he did not wish to be persuaded of the worst aspects of his condition. What he said in effect was, "This is either a neurotic condition, as I think it is, or it is an organic condition. If it is organic, my physicians would be apt to tell me that I must stop working so hard, and I am sure that if I should do that I would do myself more harm than good by having unoccupied {338} time on my hands. I want to go on doing my work. If I am wrong some time I shall be carried off in one of these attacks. That will not be such a serious thing, for after all I must die some time and my expectancy of life cannot normally be very long. I prefer, then, to go on with my work and think the best, for it does not seem that I could do anything that would put off the inevitably fatal issue if I am to die a cardiac death." He was found dead one morning, but he had passed into the valley of death without being seriously disturbed and without any of the neurotic symptoms that so often develop in discouraged patients. Curiously enough, one of our most distinguished heart specialists in this country went through almost the same experience and preferred to live "the brief active life of the salmon rather than the long slow life of the tortoise." The best possible factor in therapy is secured if patients can be brought to the state of mind of these distinguished physicians who calmly faced the future, refusing to disturb themselves or their work, because they feared that the worry that would come down upon them in inactivity would aggravate their disease. Where men are occupied with some not too exacting occupation, that takes most of their attention and at which they have been for years, it is best to leave them at it, though the harder demands of it must be modified. If they can be brought to persuade themselves, as did the two physicians--though probably only half-heartedly--that their affections may possibly be merely neurotic and not true angina, it will always be better for them. Death may come, and commonly will, suddenly, but, after one has lived a reasonably full life, that is rather a blessing (and not in disguise) than the terror which it is sometimes supposed to be. Pseudo-Angina.--The neurotic form of angina is quite compatible, not only with continued good health but with long life, and even after a long series of attacks, some of them very disturbing in their apparent severity, there may be complete relief for years, or for the rest of life. Exaggeration of feeling due to concentration of attention plays a large role in these cases, and it is evident that the dread of something the matter with the heart connected with even a slight sense of discomfort may readily become so emphasized as to seem severe pain, though many people have similar feelings without making any complaint. In spite of reassurances attacks of pseudo-angina are likely to worry both patient and physician. The only working rule is that in younger people discomfort in the heart region, even though it may be accompanied by some sympathetic pain in the arm or in the left side of the neck, is usually spurious angina. Broadbent goes so far as to say that this is true also in many older persons. His method of making the differentiation is interesting because so easy and practical that it deserves to be condensed here. The earlier attacks of true angina are practically always provoked by exertion, while spurious angina is especially liable to come on during repose. Any cardiac symptom or pain that can be walked off may be set down as functional and due to some outside disturbing influence, or to nervous irritability. When palpitation or irregular action of the heart, or intermission of the pulse, or pain in the cardiac region, or a sense of oppression follows certain meals at a given interval, or comes on at a certain hour during the night, there need be little hesitation in attributing the disturbance, whatever it may be, to indigestion in {339} some of its forms. Nightmare from indigestion, Broadbent thought, is not a bad imitation of true angina. In Broadbent's mind acute consciousness of any heart disturbance lays it in general under the suspicion of being neurotic in origin. He was talking to some of the best clinical practitioners in the world and some of the most careful observers of our generation, when, before the London Medical Society, he said: "The intermission of the pulse of which the patient is conscious and the irregularity of the heart's action--though this can be said with less confidence--which the patient feels very much, is usually temporary and not the effect of organic heart disease." This is particularly true, of course, in people of a neurotic character, and Broadbent went on to say that "speaking generally, angina pectoris in a woman is always spurious, and the more minute and protracted and eloquent the description of the pain, the more certain may one be of the conclusion." I had the opportunity to follow the case of a young woman who had a series of attacks of angina pectoris some twenty years ago, so severe that a bad prognosis seemed surely justified, and though at times the attacks were rather alarming to herself and friends, nothing serious developed and for the past ten years, since she has gained considerably in weight, they have not bothered her at all. She used to be rather thin and delicate, trying to do a large amount of work and living largely on her nervous energy. At times of stress she was likely to suffer from pain in the precordia running down the left arm and accompanied by an intense sense of the possibility of fatal termination. With reasonably large doses of nux vomica, an increase in appetite came and a steadying of her heart that soon did away with these recurrent attacks. These came back later several times when she neglected her general condition, but there never were any objective symptoms that pointed to an organic lesion. After twenty years she is in excellent health, except for occasional attacks of a curious neurotic indigestion that sometimes produces cardiac disturbances. Of course, such cases are not uncommon in the experience of those who see many cardiac and nervous patients. For the treatment of pseudo-angina, mental influence is all important. Of course, the conditions which predispose to the mechanical interference with heart action that occasions the discomfort, must be relieved as far as possible. The severity of the symptoms, however, are much more dependent on the patient's solicitude with regard to them, they are much more emphasized by worry about them, than by the physical factors which occasion them. Reassurance is the first step towards cure. After relief has been afforded from the severer attacks, the patient's solicitude as to the future must be allayed and the fact emphasized that there are many cases in which a number of attacks of cardiac discomfort simulating angina pectoris have been followed by complete relief and then by many years of undisturbed life. It is important to make patients understand that, in spite of the fact that their attacks occur during the course of digestion, as is not infrequently the case, this constitutes no reason for lessening the amount of food taken. Nearly always these attacks occur with special frequency among those who are under weight, and disappear rather promptly when there is a gain in weight. Solicitude with regard to the heart must be relieved wherever possible and then with the regaining of general health the heart attacks will disappear. {340} CHAPTER VI TACHYCARDIA Etymologically tachycardia means rapid heart. There are two forms of rapid heart, that which is constant and that which occurs in periodical attacks. It is for this latter that the term tachycardia has been more particularly used, though occasionally the adjective paroxysmal is attached to it to indicate the intermittent character of the affection. With regard to the persistent type of rapid heart something deserves to be said, however, because patients' minds are often seriously disturbed by them. Often it has existed for years, sometimes is known to be a family trait and probably has existed from childhood, yet the discovery of it may be delayed until some pathological condition develops, calling for the attendance of a physician who may be needlessly alarmed and in turn alarm his patient by his recognition of it. The cause for this persistent rapid pulse is not well known and is difficult to determine. Heredity, as has been suggested, sometimes plays an important role in it. Certain families have one or more members in each generation with rapid hearts. Whenever persistent rapid heart is a family trait the patient can be assured, as a rule, without hesitation, that the general prognosis of the case is that of the lives of the rest of the family. Usually the symptom seems to mean nothing as regards early mortality or any special tendency to morbidity. Favorable Prognosis.--While a rapid pulse often and indeed usually has some serious significance, it must not be forgotten that it may be an individual peculiarity and be quite compatible with long life and hard work. One of the first patients that I saw as a physician had a pulse between ninety-six and one hundred. As there was a slight tendency to irregular heart action also, I was inclined to think that there must be some cardiac muscle trouble. There was apparently no valve lesion. He told me that a physician ten years before had noted his rapid pulse and had made many inquiries about it which rather seriously disturbed him. He had been an extremely healthy man during his fifty-five years of life and there seemed no reason to conclude, since his rapid pulse had been in existence for ten years, that it meant anything serious. He has now lived well beyond the age of seventy and still has a pulse always above ninety. Contrary to what might be thought, he is an extremely placid, unexcitable individual, who, under ordinary circumstances, will probably live for many years to come. He has no family history of tachycardia, though there is a history of rather nervous irritable hearts in other members for two generations. An interesting case of this kind came under my observation about fifteen years ago in a clergyman whose pulse was never below ninety, and who on slight excitement, or after a rapid walk, or after a heavy meal, would have a pulse of 120. He knew that it was a family trait, his father having had it yet living to be past seventy. He gave a history of its having been recognized in his own person more than twenty years before. His general health, however, was excellent. He took long walks and, indeed, pedestrian excursions {341} were his favorite exercise. He was able to go up flights of stairs rather rapidly without discomfort. He was the pastor in a tenement house district so he had plenty of opportunity for such exertion. Infections of any kind, colds and the like, disturbed his pulse very much, if the ordinary standard was taken, but it was not irregular and the increase in rapidity was probably only proportionate to the original height of the pulse in his case. After all, as the normal pulse of sixty to seventy rises to between ninety and one hundred even in a slight fever, it is not surprising if a pulse normally above ninety should rise fifty per cent. to one hundred and thirty-five under similar conditions. He is now well past sixty, after over thirty-five known years--and probably longer--of a pulse above ninety, yet he is in excellent general health and promises, barring accident, to live beyond seventy. Some ten years ago I first saw another of these cases of fast heart, with a family history of the affection in a preceding generation. He was a man who had not taken good care of himself and had been especially over-indulgent in alcohol. This indulgence consisted not in rare sprees but in the persistent daily taking of large quantities of straight whiskey. In spite of warnings, he has not given up this habit; yet at the age of sixty-five he is apparently in good health and is able to fulfill the duties of a rather exacting occupation. Persistent rapid pulse often occurs in connection with some disturbance of the thyroid gland. The larval forms of Graves' disease occur particularly in young persons, though they are sometimes seen in those beyond middle life. They seem to be due to a lack of development of the thyroid in consonance with the rest of the tissues, though occasionally, especially after the menopause, they seem to be connected with some degenerative process out of harmony for the moment with other forms of degeneration. When they occur in young persons they may, of course, represent the beginning of incipient Graves' disease, but they are often only functional and the symptoms may pass away entirely. The rapid heart action may come and go, though usually the attacks last for some days and oftener for a week or more at a time. Paroxysmal Tachycardia.--A rapid heart may not only exist continuously in an individual for many years without any impairment of general health or shortening of life, but there may be spasmodic attacks of this condition with the pulse running up so high as to deserve the name of paroxysmal tachycardia; yet the patient may live for many years and die from some affection not connected with his heart. Perhaps the most remarkable case of this kind on record is that reported by Prof. H. C. Wood of Philadelphia. The patient was a physician in his later eighties when he came under Dr. Wood's observation. His first attack of paroxysmal tachycardia came in his thirty-seventh year. These attacks had apparently always been similar to those he then suffered and were abrupt in onset and the pulse would rise rapidly to 200 a minute. The original prognosis had been, of course, very unfavorable. The physician had outlived all the prophets of evil in his case, however. When large numbers of these cases were studied, it was found that they always last more than ten years, and, while heart failure in such cases is reported, it is doubtful if this occurs with more frequency in these patients as the result of strong reflexes than in the general run of patients, for it must not be forgotten that there is a certain average number of deaths from so-called heart failure in people supposed to be in good health. {342} In connection with these attacks of paroxysmal tachycardia, there often come intense feelings of depression and even local disturbances of circulation. It is probable that in many cases there is a serious factor at work. MacKenzie has suggested that they are due to nodal rhythm of the heart in which the heart beat does not start at the root of the sinus as is usual, but in some other portion of the musculature and as a consequence there is serious interference with the regular rhythmic action. In a number of cases of heart failure, tachycardia becomes a prominent feature and it is probably due to some such disturbance as this. Such cases often look very serious for a time, yet frequently recover completely after a brief interval. This must not disguise the fact, however, that many of these cases, especially where acute dilatation of the heart can be demonstrated, are extremely dangerous and may end in a sudden fatal termination. The patient seems so much prostrated that occasionally the physician may doubt whether it is worth while to put him to the bother necessary in order to diagnose the acute dilatation of the heart. It always is, however. If it were nothing else but the occupation of the patient's attention with the doctor's manipulations, as far as that is possible, the effect would be good, besides whatever irritation may be caused to the heart muscle itself by percussion of the heart area will probably do mechanical good. The most important element evidently is that the patient shall not be allowed to lose courage or to think that nothing can be done for him. Something must be done, and a combination of swallowing movements and deep breathing, as far as that is possible, with counter-irritation through the chest wall should be carried out. Drugs also should be employed and the aroma of strong coffee with the irritating effect of ammonia upon the nostrils should be employed. These act upon the vagus so as to stimulate the heart, but above all they act upon the mind, and nothing so stimulates the heart as reawakened hope. CHAPTER VII BRADYCARDIA Bradycardia, or persistent slow pulse, is much rarer than the persistent rapid pulse discussed at the beginning of the chapter on tachycardia. Cases are, indeed, sufficiently rare to be medical curiosities. Prof. Clifford Allbutt has called attention to the fact that the status of bradycardia or brachycardia, as Osler (following Riegel because of the analogue tachycardia) prefers to call it, is very different from that of tachycardia. In the latter, especially, in the specific sense of the term, the symptoms occur paroxysmically, endure for a definite length of time and then there is a return to the normal pulse rate. For this, or at least for the condition known as essential tachycardia, there is no well-defined cause and no definite pathological lesion. Bradycardia or brachycardia, however, is usually present as the result of some known physiologic or pathologic condition; it endures as long as the cause continues to act and then ceases, usually not to return unless the same cause gives rise to it again. {343} There are some cases, however, of slow pulse that cannot be traced to any definite lesion and in which the pulse is much slower at certain times than at others, though without its being possible to trace any definite immediate cause. These cases seem to be physiological analogues of tachycardia. In tachycardia there is an irritation of the accelerator nerves to the heart, in brachycardia of the inhibitory nerves. Depressed Mental States.--Occasionally the reason for this can be found, though it is rather vague. In depressed mental states, for instance, a pulse between fifty and sixty is common. In people who suffer from periodic fits of depression it is not unusual to find that in the early morning the pulse is not more than fifty-five. I have seen patients who were worrying about their hearts present records of early morning pulse before they got up that were always below sixty. This is probably in a certain number of people quite normal. I remember a series of observations made on the attendants in the Charite Hospital in Berlin in which it was clear that the normal German morning temperature at seven a.m. was below 97 F., while the pulses were always below sixty. A reassurance of this kind is helpful to patients who have acquired the bad habit of taking their own pulse and have been disturbed by finding it so much below what they consider normal. Illustrative Case.--A number of cases of persistent slow pulse seem to be congenital or produced by some definite pathological lesion, yet do not prove serious for the patient. Some years ago I described one of these cases in a paper read before the Section on Medicine of the New York Academy of Medicine [Footnote 29] and I have had the opportunity to follow it for about fifteen years. Though the patient's pulse is usually below forty and even after a rapid walk does not rise above fifty, she is in reasonably good health and during those years has buried two husbands. When I saw her she was compelled to go up and down stairs frequently and yet did not experience much difficulty. While patients suffering from palpitation would find it impossible, because of the discomfort produced, to make the journeys up and down stairs that she did, she felt only about as much respiratory discomfort as would come to a woman of her size. Her respirations were somewhat hurried--22 to 24 to the minute--but her general health was very good. Her urine was normal, her liver not enlarged, her ordinary organic functions were not disturbed and there was no sign of arterial degeneration. [Footnote 29: _The Medical News_, November 10, 1900.] With the pulse rate as low as this one might expect to find the patient phlegmatic, slow of movement and not readily moved to emotion. On the contrary, she has always been rather nervous and high-strung and inclined to be excitable. Her cardiac condition was first noted just after the first grip epidemic in this country, though her attention was not called to it during the course of the grip. It seems probable that the heart condition was acquired as a consequence of some irritative lesion affecting the inhibitory nerves to the heart that developed at that time. After her heart condition had been discovered she was for a time a skirt dancer and frequently danced for the amusement of her friends. She was always lively and active and after her first husband's death, when it became necessary for her to earn her own living, she was on the stage for a time and danced without any embarrassment of either {344} heart or respiration. As a consequence of running down in weight and general health, owing to conditions since her husband's death, she noticed that dancing proved exhausting to her and she gave it up. In general, she considered herself quite as capable as any of her friends for the ordinary duties and amusements of life. When I first saw her her digestion had been somewhat disturbed by worries and unsuitable nutrition taken at irregular intervals and this, I think, accounted much more than her heart for her complaint of tiredness on exertion. Later, after her second marriage, when she was in better circumstances, all her symptoms disappeared and even her heart rate rose so that it was seldom below forty, and after exertion always went to fifty. What was needed in her case more than anything was a change of environment, the satisfaction of mind that comes with freedom from worries and the cares of making her own living, and the improvement in digestion due to regular meals of good, simple, nutritious food. Compatibility with Health and Activity.--The above case is interesting as illustrating mental influence upon such a serious condition as bradycardia. Most people who suffer from it are likely to be over-depressed and this reacts to disturb digestion and also further to disturb the heart itself. What these patients need above all, then, is reassurance with regard to their condition. There are some striking examples in history and in medical literature of bradycardia or persistent slow pulse in persons who are able to accomplish a large amount of work and whose general health and capacity for accomplishment were not at all disturbed by this physical condition. Above all, they were not depressed and did not lack initiative. Napoleon I, whose pulse is said normally to have been about forty, rising during the excitement of battle to fifty, is a typical example. Medical literature records a number of patients with congenital slow pulse without any discernible heart lesion who lived long and successful lives. One of these was a very successful English athlete. The prognosis of these cases is not as bad as it might seem to be and the mental state of the patient is more important than anything else in the treatment. {345} SECTION VIII _RESPIRATORY DISEASES_ CHAPTER I COUGHS AND COLDS Cough under most conditions is so completely a natural reflex due to irritation from material which demands expectoration that to talk of the application of psychotherapeutics to its treatment would seem almost an abuse of words. This is true if we think of the curing of an ordinary catarrhal or bronchitic cough by suggestion. We know now, however, that, as a rule, we do not cure diseases, we only relieve their symptoms and thus enable nature to overcome the affection. The ordinary cough remedies do two things: they cause more liquid to exude into the lung tissues and thus soften and liquefy thick mucous material so as to make it easier to expectorate, or they lessen irritation and soothe the cough by making the nervous system less reactive. This second function of our remedial measures directed against cough can at least be assisted very materially by psychotherapeutics. Direct suggestion may be of great help, while the first function, that of softening the cough by liquefying the sputum, can be materially aided by certain suggestions to the patient of natural means and ways by which his cough may be relieved, its secondary symptoms modified, and its course abbreviated. Cough and Suggestion.--Much of the coughing indulged in is quite unnecessary and might well be dispensed with. At many of the German sanatoria for consumption there is a rule that patients must not cough at dinner, and no coughing is heard in the refectory. Without such a rule the midday meal, if taken in common by the large number of consumptives present, would be a pandemonium of coughing. Cough is largely influenced by suggestion. Most of the respiratory reflexes follow this same rule. To see another yawn tempts us to yawn; to hear another cough tempts us to cough. In church or in a theater after an interval of interest one cough will be followed by a battery of coughs. People who have colds think they have a right to cough, and so they often cough much more than is at all necessary. Of course, when material accumulates in the lungs it must be coughed up, but not a little of the coughing might easily be dispensed with--it is unproductive coughing. A distinguished German medical authority who is accustomed to talk very plainly once said that it is quite as impolite and injustifiable to cough unproductively as to scratch the head unproductively. Only results justify either procedure. Dry coughing, when persistent, is greatly a matter of habit acquired by yielding to slight irritation. When children scratch their heads we train them {346} not to, and the same thing should be done with regard to yielding to reactions from slight irritations of their lungs. Even when material has to be expectorated there is often much more fuss and effort made over it than is needed. Most men a generation ago insisted on their right to expectorate in public because it was better for them to rid themselves of offensive material than to retain it. The difference between men and women in this respect has always been distinctive. Women practically never expectorate in public, men do it frequently, or rather, let us hopefully say, used to. It seems to be thought the exercise of a manly privilege to spit and the boy learns the habit. It seemed almost a necessity in the past, yet now we have come to a point where, by legal regulation, we prohibit spitting in public and it seems likely future generations, not far off, will hold it as a rule that instead of the sexes being essentially different by nature in this respect, the habits formed by the enforcement of recent legal regulations will show their essential similarity and we shall have no "expectorating sex." Unnecessary Coughing Harmful.--Coughing, unless it is necessary, always does harm. It irritates the mucous membrane, already rendered somewhat hyperemic and tender by the inflammatory process at work, to have the breath pass over it in such an expulsive way. This is one case where nature's indications are not to be followed. It is like itchiness in eczema: it needs to be restrained. The cold will get better sooner, the inflammatory process will run its course with less disturbance and in briefer time than if it was not disturbed in this way or disturbed only as little as possible. This is a point that is not often explained to patients and most sufferers from colds are inclined to think that the more they cough the better, even though the cough, like the scratching in eczema, evidently produces a roughening and sensitizing of inflamed tissue. Of course, this principle of the limitation of cough may be carried to excess and indeed sometimes is when opium is administered to quell coughing. This is not the idea, however, of the suggestion made here, which is only to restrain the cough within the limits necessary for the removal of material that should be evacuated. The history of most of the tuberculous patients who suffer from hemorrhage for the first time shows that they had been coughing unproductively, and then, after coughing in this way rather severely, there came the flow of blood due to the rupture of a minute artery. In these cases the tuberculosis process has been at work for some time and has prepared the tissue for this arterial rupture, but there is no doubt, however, that the coughing itself, far from doing good, rather helped in the destruction of lung tissue, or at least made it more difficult for natural processes in the lungs to wall off the bacilli and prevent further damage. Practically every adult is in some danger of lighting up an acute tuberculous process in his lungs if he racks them by coughing. There are many similar examples in nosology of this possibility of some habit predisposing to or favoring the development of disease. After measles and whooping cough tuberculosis is especially likely to develop. In both of these diseases, but especially in the latter, coughing is an element of the affection that probably predisposes to the implantation of the tubercle bacillus so commonly present in the air of our cities. The lesions produced in the extreme expulsive efforts of the paroxysm form favorable niduses for the micro-organism. Children particularly, if at all encouraged, are likely {347} to cough more than is good for them. On the slightest irritation they cough. It is almost impossible to restrain them from scratching when they are suffering from eczema, yet we take rather elaborate means to do so, and quite as much must be done to prevent them from coughing when there is no special reason for it. This does not refer to cases in which material is being abundantly expectorated. Elimination can only be secured by a proper expulsive effort. Very often, however, children notice how much solicitude their little dry cough arouses. They like to be the objects of attention. They are dosed with various cough remedies, more or less pleasant, whenever they cough. Instead of being told that they should restrain their cough except when it is necessary, they are rather encouraged to cough whenever there seems to be the slightest occasion. Reflex Coughs.--There are a number of coughs that are said to be reflex because they are not induced by any lesion of the lungs or of the larynx, or, indeed, of any of the air passages. In these cases some pathological condition is often found in another organ or set of organs, usually one of those connected with the vagus nerves. The wide distribution of these pharyngo-laryngo-esophago-pulmano-cardio-gastric nerves gives ample opportunity for reflexes. We hear much of reflex cough. There is a stomach cough and an intestinal cough, a uterine cough, an ear cough, etc. These coughs are always dry, though often very irritating to patients, and especially may be a source of dread and disturbance of mind and health because they seem to signify some serious pathological condition. As a rule, these coughs can be restrained to a great degree and frequently suppressed entirely by suggestion and discipline. In many cases there is some temptation to cough consequent upon irritation of nerve endings communicated through some devious paths to the nerve supply of the respiratory tract, but this tendency is not very strong and can be easily overcome. It may be said that this is asking too much of human nature, and that, just as sneezing carries with it a certain satisfaction and so is apparently worth the trouble of indulging in, coughing should be permitted, at least, if not encouraged, but the reasoning is fallacious. Habit Coughs.--An interesting cough that comes to the physician is that in which there is absolutely no pathological reason to account for it. There is an irritation of the mucous membrane somewhere along the respiratory tract but it is very slight and somehow the habit has been acquired of yielding to the reflex that it occasions. I have seen these coughs in children in cases where I was sure that they were nothing but tics. I have seen so-called hacking coughs in girls of twelve to sixteen that were explained as ovarian, or sometimes as puberty coughs, that were really nothing more than habits. A slight hyperemia of the mucous membrane in the upper respiratory tract due to an ordinary cold began in a very slight degree the irritation, and then the habit of coughing was not given up. Of course, I know the danger of treating such cough as habit coughs. Tuberculosis in its initial stage may exist for a prolonged period before it produces any increase of secretion and at a time when none of the ordinary physical diagnostic signs are present, except possibly a little prolongation of expiration over the affected area. At this stage tuberculosis will sometimes produce gastric disturbance, and, as I have already said, these are spoken of as stomach coughs when there really is something much more serious than them at work. When there has been no running down in {348} weight, and, above all, no special opportunity for contagion, then, if there are no physical signs in the lungs, these coughs will be best treated as habits and gradually be made to stop by suggestion. The limitation of coughing will do good in any case. Coughs as Tics.--Some coughs are not really due to any difficulty in the respiratory tract, but are caused by nervous irritability. There are certain habits in the matter of clearing the throat that sometimes become pronounced and apparently impossible to stop. As I have said, these are tics rather than true coughs. Many of these neurotic coughs very seriously alarm patients and also their friends. They are dry, as a rule, rather harsh and inclined to be brassy. Occasionally they are only what is known as "hacks," as if the patient were trying to clear the throat of some offending material. Of course, at no time must the significance of cough be made light of unless a careful investigation of the patient's condition has been made. Diagnosis.--Names for these coughs should not be too readily accepted which, by satisfying legitimate curiosity and lessening proper apprehension with regard to them, will stop further investigations. Besides stomach coughs, one often hears of intestinal and even uterine or ovarian coughs. In many cases the real condition is one of an incipient tuberculous condition and there may be no sign of this except a disturbance of the pulse and perhaps a slight variation of the temperature range for the day (two degrees or more Fahrenheit in the twenty-four hours). Such coughs should always be carefully investigated for the possibility of incipient tuberculosis. At once the patient should be warned about coughing without necessity, since this only tends to disseminate the tuberculous process and may help to break down nature's wall of protective lymph. Where there is no disturbance of pulse or temperature and the patient is not under weight and there are no signs in the lungs, then the cough is merely a habit and partakes of the nature of a tic. Sometimes these habits are rather difficult to break; always, however, much can be done by suggestion, by a habit of self-control, by self-discipline, and by thorough persuasion of the patient. Drugs are likely to inveterate the condition if not allied with suggestion. Removing Unfavorable Suggestions.--For the ordinary coughs and colds of the winter time there are many unfavorable suggestions that deserve to be eliminated. For instance, most people are sure that exposure to the air will inevitably make their cold and cough worse. This is a relic of the olden time when the confinement of patients to their rooms was supposed to be the best remedial measure for all respiratory diseases. Tuberculosis patients were kept in and died without any chance. Now these patients, even while running a temperature, or suffering from pleurisy, or the intercostal painful conditions that are often serious complications because of the irritability and discomfort produced, and which are so often supposed to be due to drafts, are put out on the porch, or on the roof of a hospital, or allowed calmly to lie in bed between two open windows, without the slightest hesitation. They begin to improve under such treatment much sooner than if they were confined, and indeed the whole prognosis of tuberculosis has been completely changed by the modification of the old-time habit of confinement to that of perfectly free access of outer air and even cold air that has taken its place. This principle of treatment must be applied for coughs and colds. While {349} patients are running a temperature they must not take exercise, they must not be allowed to work, above all they must not be allowed to get in crowds nor tire themselves in any way. The room in which they are, however, must be thoroughly aired, the window must be open all night and, if possible, they must sit in the sun for several hours a day. This will cure a cough or a cold quicker than anything else. Many coughs that hang on when treated by remedies of various kinds, yield at once if the patient is given an abundance of fluid diet and gets freely into the air. There is no danger of catching another cold, because a cold is not due to a low outdoor temperature, but to dust and microbes, and is a real infection. Irrational Remedies.--There are an innumerable number of supposed remedies for colds. Scarcely any one who has reached the age of forty apparently feels that he or she is doing the whole duty to humanity unless they have some remedy for colds to recommend. Most of the popular remedies that are employed probably do as much harm as good and many of those that are very popular and are sometimes recommended even by physicians have no rational standing in present-day therapeutics. Perhaps the most popular is a combination of quinin and whisky. The effect of this is to give patients, who are unaccustomed to whisky and who are susceptible to quinin, about as uncomfortable a twenty-four hours the day after they take the remedies as can be imagined. Quinin now has no possible specific therapeutic significance in the cure of the series of infections called colds. In the days when we did not understand malaria and considered it in some way as an essential fever due to the absorption of miasmatic material, quinin seemed to have a specific influence upon several conditions. Accordingly it was employed in all sorts of fevers and, because it is comparatively harmless, also in that short infectious fever which we call a common cold. No physician now employs it (except in small doses as a general tonic) for febrile conditions, unless in malaria. There we know that it acts by killing the plasmodium and is a real specific. We do not think of it any more, however, as a general febrifuge and there is no justification for its use in the slight infective conditions we know as colds. As for the whisky, if taken in stiff doses as it often is, the reaction is likely to make the patient quite miserable the next day. It seems to be the rule for him to think that if, notwithstanding the taking of the quinin and whisky, he feels thus ill, he would have been ever so much worse without it. Colds, however, when left untreated so far as drugs go but managed by natural means often run a mild course. Some of the reputation of quinin and whisky is due to the fact that not infrequently persons suffer from chilly feelings that seem to portend a cold and take quinin and whisky and the cold does not develop. The remedies are then supposed to have aborted or to have inhibited the development of the cold. Anyone who has seen a number of these cases treated expectantly, however, knows how often it happens that the chilly feelings that seem to announce the cold pass off without incident after a good night's rest. Rational Treatment.--The old rule of getting the emunctories at work must be the basis of any rational therapy of colds. A mild opening of the bowels, especially if there is some constipation, a hot drink on going to bed so that there is some sweating and perhaps the use of a mild diuretic will almost surely affect these cases favorably. Patients have to be careful, {350} however, next morning to stimulate the circulation in their skin to activity so that the cutaneous muscles shall react upon the capillaries and the capillaries themselves tonically contract in order that there may not be too much blood near the surface of the body, or the patient may easily be chilled in cold weather. This chilling of the blood when much of it is near the surface seems to lower its vitality and the patient easily reinfects himself or, if he goes into dusty or crowded places, catches a fresh dose of infectious material. This is the process which is called catching a fresh cold. The removing of the unfavorable suggestions of remedies that do harm rather than good and the giving of favorable suggestions founded on our present-day knowledge of what a cold is and just what we need to do in order to benefit it, is the most important element in the treatment. Above all, however, the patient must sleep in an airy room and must be sure that he is neither breathing his own expired air nor that of anyone else. With thorough ventilation, however, and the stimulating effect of the cold air and the confidence due to proper directions, colds rapidly get better. There can be only one reason for keeping patients indoors who are suffering from cold. That is, if they are suffering from fever, the being out involves exertion. In that case, of course, patients must rest and must avoid exertion, but there is no reason why they should not have all possible fresh air. The unfavorable state of mind towards fresh air and especially night air in these patients was cultivated by the profession up to a generation or two ago, but is quite unjustified by our present knowledge. Night air is probably a little better than day air because it is freer from dust. It is because of malaria that night air was supposed to be detrimental, but we have found that the only good reason for this was that the mosquito travels at night. There are no other constituents of night air that produce any serious effect. As a rule, patients suffering from colds need more sleep than other people and above all need more sleep than they ordinarily take, for this will increase their resistive vitality and enable them to throw off the infection. A good rule is to add two hours of sleep to the usual quota. The unfortunate habit of keeping people indoors and of keeping fresh outdoor air away from them, because it is feared they will catch a fresh cold, often seriously disturbs sleep and delays recovery. In a word, many a cold that hangs on does so mainly because of unfortunate suggestions of one kind or another that have come to occupy a place in the supposed therapeutics of the condition. The removal of these and the insistence on just as much recourse as possible to the therapeutic means at nature's command constitute the basis of successful therapy of these very common infections, which probably are the source of more morbidity in the community because of their wide diffusion and frequent recurrence than all the other infectious diseases put together. CHAPTER II TUBERCULOSIS Tuberculosis, in spite of all our efforts against it, remains in Defoe's striking phrase the "captain of the men of death." Pneumonia has preempted its {351} place in the statistics of mortality, but this is to a considerable extent because tuberculosis at the end masquerades as an acute pneumonic exacerbation. Not less than one in eight, probably more, of all those who die, die from tuberculosis. It is the most serious of diseases. In spite of its eminently physical character it probably affords the best possible illustration of the place of mental influence in therapeutics. We have had any number of new cures for tuberculosis, introduced by serious physicians who were sure from the results they had secured that they had found an important new remedy. After a few years each of these cures in succession has been relegated to the limbo of unused remedies because found inefficient. At the beginning they produced a beneficial influence because of the suggestion of therapeutic efficiency that went with them. When this suggestion failed because the physician who administered the remedy lacked confidence, the real place of the supposed specific as merely another mind cure was recognized. Indeed, many of the remedies that have been introduced have not been merely harmless drugs, but not a few of them have probably had rather a detrimental physical effect than a beneficial influence. In spite of this, the influence on the patient's mind has been sufficient to neutralize whatever of harmfulness there might have been and to arouse new courage and new energy. The consequence of this has always been that the patient was tempted to live more in the open air and to eat more. _These_ are the two efficient remedies for tuberculosis. With the additional life in the open air and increase of food his appetite grew, for nothing so adds to appetite as the exercise of it, and with the gain in weight there was a cessation of cough, a reduction of fever, a disappearance of night sweats and a definite increase in resistive vitality which gradually helped to overcome the disease. Manifestly, then, the use of mental influence in tuberculosis is very significant. PROGNOSIS AND SUGGESTION The most important element in any treatment of tuberculosis must be the neutralization of unfavorable suggestions which are weighing upon the patient and preventing him from using even the vital forces that he has for resistance against the disease. The popular impression of tuberculosis, happily waning, is that it is an intensely fatal disease. Though this is true in general, tuberculosis is by no means a necessarily mortal disease in individual cases, and, indeed, a great many more patients recover from tuberculosis than die from it. Papers read at the International Congress on Tuberculosis, in Washington, in 1908, showed from careful autopsy records that practically all adults either actually had had at the moment of death, or had suffered previously from tuberculosis. If there are not active lesions then there are always healed lesions of tuberculosis in the body of almost every human being who has passed the age of thirty. Most people have quite enough resistive vitality to enable them to recover from the disease. It is only those who are placed in very unfavorable circumstances during the initial stage of the disease, or who have some serious drawback against them, who succumb to it. The fact that the bacillus finds a lodgment in so many individual tissues shows that it is not insusceptibility that makes the difference {352} between people, since we are all susceptible, but it is the lack of resistive vitality, and that most of us have, under ordinary circumstances, and all of us can have under favorable conditions, quite sufficient immunizing power to prevent serious developments. Even in advanced cases it is perfectly possible for the progress of the disease to be stopped and for many years of useful life to be gained. Probably patients who have gone beyond the incipient stage, in whom there has once been a breaking down of pulmonary tissue never are entirely cured, but they may be so much improved that all their symptoms disappear and they are able to follow an ordinary occupation for many years. There is no disease in which the unfavorable prognoses of physicians have been more frequently disappointed than in tuberculosis. In any city hospital dispensary one finds many cases of tuberculosis turning up as relapses of previous conditions, with the story that when they were seriously ill before, some prominent physician, since dead, said they had only a few months to live. The fact that the physician who made the unfavorable prognosis has since died himself adds greatly to the zest with which patients tell their story. Neither the severity of the symptoms nor the amount of lung tissue attacked is quite sufficient to justify an absolutely unfavorable prognosis in the majority of cases of pulmonary tuberculosis. No Incurable Cases.--Above all, it cannot be insisted on too emphatically that there is never a time in the course of the tuberculosis when a physician is justified in saying to a patient suffering from any form of tuberculosis that his case is hopeless. One is never justified in saying "You are incurable." Practically every town of any size in this country has a number of cases in which patients were told by physicians that there was no hope, and yet they have recovered to chronicle as often as they get the chance the fact that they have outlived their physician. To say that no case of tuberculosis can be confidently declared incurable will seem to many an exaggeration. There are patients in whom the prognosis is so unfavorable as to be almost hopeless. There are never cases of which it should be said there is no hope. When patients are told, as they so often are, that they are incurable, absolutely no good is done and harm is inevitable. Heredity of Resistance.--When the disease has developed very rapidly in patients in whom there is no previous history of tuberculosis, and in whom there is no history of previous cases in the family, the outlook is always serious. These cases come as near being incurable as any the physician sees. But the most apparently hopeless of these will sometimes recover, contrary to all anticipation. In spite of the opposite impression so commonly accepted, the most helpful element in these cases is the presence of a trace of tuberculosis in the family history. This always means the existence of some immunity against the disease and there may be a turn for the better even when the case looks absolutely hopeless and when it seems to just be verging on its fatal termination. Probably the most discouraging are the cases in which miliary tuberculosis is at work and conditions are about as unfavorable as possible. There are cases of this kind on record, however, with the most startling contradiction of anticipation, in which undoubted miliary tuberculosis produced high fever for weeks and even months, then gave rise to pleurisy, to peritonitis, to various cutaneous abscesses and to abscesses of bone, in which patients lost one-third of {353} their weight or even more, and yet after the external lesions began to discharge freely, recovery occurred. Slow Cases.--As for slow-running cases in which there is a distinct history of tuberculosis in the family, not even the most experienced physician can state with any certainty that a fatal termination is inevitable and that recovery cannot occur. Some of the most expert diagnosticians have been deceived in these cases. After half a dozen physicians have given a man up, some gleam of hope has buoyed his feelings and a turn for the better has come. Men with cavities in three lobes, even in four lobes and occasionally it is said in all five lobes, have survived acute stages, have recuperated to a considerable degree and have been able to return to work or at least to take up some useful occupation for a time. Where the lung lesion progresses slowly it is surprising how small an amount of healthy lung tissue is needed to support life. Only those familiar with many autopsies on the tuberculous can appreciate this. Ordinarily we are apt to think that when more than half the pulmonary tissue is involved so as to be of little or no use for respiratory purposes, death must be inevitable. On the contrary, one-fourth the ordinary lung capacity will serve and all of one lung may be quite out of commission and only a portion of a single lower lobe be available, yet the patient may survive for a prolonged period. The Specter of Heredity.--The most serious contrary suggestion that patients suffering from tuberculosis are likely to have is that their affection is hereditary and that, therefore, there is little hope of its cure. It is in the family strain and cannot be obliterated. This idea, fortunately, does not carry the weight it used to. It should, however, have no unfavorable influence at all and this needs to be emphasized. We discuss the subject more fully in the chapter on Heredity. We know very definitely now that the hereditary element in tuberculosis is so small that it is quite negligible. There are good authorities who do not hesitate to say that heredity plays no role in the causation of tuberculosis and does not even produce a predisposition. Some remnant of the old superstition (for superstition, from the Latin, superstare, means a survival from a previous state of thinking, the reasons for which have disappeared) always remains, and predisposition is the last rule of outworn opinion. We know now that contagion is the important element. The possibilities for contagion vitiate all proofs of the predisposition idea. Especially is this true when we recall that thirty years ago practically no one took proper precautions to prevent the dissemination of tuberculosis, and very few took them even fifteen years ago. Even at the present time many tuberculosis patients cough around the house with open mouth, spreading tubercle bacilli all around them. We are caring for the sputum, but many other avenues for the diffusion of the disease are open. Children acquire the infection, overcome it, but retain the seeds of it in them and then in some crisis in life, as after puberty, or when they are over-working and over-worrying, or during the first pregnancy, an opportunity is given to still living tubercle bacilli to find their way out of sclerotic confinement. Other forms of contagion count in the absence of a case in the immediate family. We can trace the contagion only too easily, even if there is no consumptive member of the home circle. Scrub-women, laundresses, those who are careless in their attendance upon the tuberculous, workers in dusty places or in factories, where there are others who cough, all {354} these get the disease. Predisposition counts for so little that it is a vanishing factor. Patients can be assured at once then that they need not worry that the hereditary factor will make their affection less curable. On the contrary, our recent careful studies in tuberculosis show just the opposite of the old false impressions. The children of parents who had tuberculosis are much more likely to possess resistive vitality to the disease than those whose parents never had it. As we emphasize in the chapter on Heredity, the nations that have had the disease the longest among them are the most resistant to it. When the affection is newly introduced into a tribe or race it carries off a great many victims. This immunity, however, is not a function of heredity or of the increase of resistive vitality by the inheritance of an acquired character from the preceding generation, but tuberculosis takes the non-resistant, weeds out all those who have not some immunity against it, and consequently those that are left possess some immunizing power. Tubercular heredity, then, instead of being a source of discouragement should rather be a source of hope. It is surprising to note what a relief to many patients' minds is the explanation of this newer view of heredity in tuberculosis; it lifts a burden from many and makes them eat and sleep better for days. ANNOUNCING THE DIAGNOSIS Friends and especially near relatives sometimes come to a physician when there is suspicion that a young person is suffering from tuberculosis and ask that, if there is a ground for a positive diagnosis, it shall not be communicated to the patient. They usually urge that they fear the discouragement will kill the patient. The young are not so easily killed and the reaction on being told the truth and the facing of it bravely is such a magnificent help in therapeutics that the physician should always refuse for the patient's sake alone, quite apart from any ethical obligations in the matter, to enter into any such arrangement. The assurance may be given that the patient's condition will be so stated that, far from the patient being discouraged after due consideration, he or she will look forward with confidence to overcoming the affection. EARLY DIAGNOSIS Mental treatment is most valuable in the very early stage of incipient cases of tuberculosis. The time is past when the diagnosis of tuberculosis was made only after the recognition of definite physical signs in the lungs and a considerable loss in weight. In the _Medical News_ for April 9, 1904, I called attention to the question of "Early Diagnosis of Tuberculosis" from the pulse and the temperature in these cases, and pointed out that a disturbance of temperature need not necessarily be a febrile temperature of over 100 degrees, but that any increase of the normal daily variation of temperature, usually considered to be about a degree and a half, should suffice to arouse serious suspicion at least. If the morning and evening temperatures differ by two degrees, this would indicate the presence of some pathological condition, usually tuberculosis. If in addition to this and the pulse disturbance there is any localized area of prolongation of {355} expiration, then tuberculosis is almost certainly present, even though there may be no other physical signs, no cough, no tubercle bacilli in the sputum, nor any other signs of an active process. It is in these cases particularly that patients can be benefited. Very often they have a slight hacking cough, frequently repeated, with some disturbance of appetite and of digestion and sometimes some loss in weight. Indigestion is recognized now as one of the early stages of tuberculosis. The cough in these cases, as has been said, is often spoken of as a stomach cough and is supposed to be due to the nervous reflex from the pneumogastric nerve carrying irritative impulses from the stomach to the lungs. It is much more likely to be due directly to irritation of the terminal filaments of this same nerve in the lungs themselves. FAVORABLE MENTAL ATTITUDE The most important element in any cure or successful treatment of the disease is a favorable attitude of the patient's mind. He must be told at once that consumption takes away only the "quitters." People who give up the battle or who, though still hoping, do not hope actively--that is, do not make the exertion necessary to get out into the open air and to eat heartily--inevitably succumb to the disease. Eating.--Eating is often more a question of exertion than appetite or anything else for consumptive patients. They have no active appetite and they simply must force themselves to chew and swallow. Their fatigue from chewing is, indeed, likely to be so disturbing that it is advisable to furnish patients as far as possible with such food as requires no chewing. Milk and eggs and the thin cereal foods, like gruel, and rather thin puddings are the best for this purpose. Patients must be persuaded that they must take these whether they care for them or not. Occasionally they may cough after a meal and vomit it up. The rule in the German sanatoria for consumptives is that whenever this happens they must, after a short interval, repeat the whole meal. Only rarely does it happen that a tuberculous patient vomits without some such mechanical cause as coughing. They must be made to understand that any food that stays down does them good no matter how they may feel toward it. The actual state of affairs as regards their future must be put before them. It is a question of eating or of death. They face these two alternatives. Eating is objectionable but, as a rule, death is more so. The kinds of food they do not care for, if they are good for them, must be insisted on. Most people who think that they cannot take milk can do so, if it is only presented to them insistently, with at first such slight modifications of taste as may be produced by a little coffee, or tea, or vanilla, or by some other flavoring extract, which modifies its taste. Butter and the meat fats will be taken quite readily if it is only once made perfectly clear to patients that they must take these or else lose in the conflict with the disease. It deserves to be repeated here that in many of these cases the disinclination to eat is due to the fact that patients find it almost intolerably wearying to make the effort necessary for mastication. This is particularly true if they are asked to eat meat frequently, and especially if asked to eat underdone beef, {356} which usually requires vigorous chewing. Such meat is excellent for them once a day, but it may be made much easier to take by chopping or scraping so that practically no exertion is required. Besides, it is by no means necessary that these patients should eat much meat nor that they should have to chew laboriously at their food. Raw eggs may be the basis of the diet, especially eggs beaten up, and these will be found not only to be very tasty, but eminently digestible. Their vegetables may be taken in purees, so that they require very little chewing effort, though patients must be warned to mix starchy substances well with saliva so as to facilitate their digestion. Their bread may be taken in the shape of milk toast, or in some other soft form--bread pudding for instance. All this helps, without demanding too much effort, to prevent loss of weight and to regain it when it has been lost. Air and Comfort.--Next to food, the most important adjuvant is fresh air. Often patients find many objections to this. It is too cold for them; they are shivery and become depressed. Most patients need to be dressed much more warmly than is the custom at present, and hands and feet should be covered with woolen gloves and socks and even a woolen hood worn around the head if necessary. There is usually too much covering worn on the chest and too little on the extremities. With fleecy wool garments next the body and sufficient clothing, properly distributed, many a patient who complains of the cold will at once be more comfortable. They must be made to understand that fresh air is absolutely essential. Every extra hour they spend in the air is that much gained; every hour they spend inside is just that much lost in the curative process. If they are uncomfortable, however, they become discouraged, and a discouraged tuberculous patient never resists the progress of his affection. Not only does he not improve, but he inevitably retrogresses. It must not be forgotten, however, that the thin anemic patients who complain bitterly of the cold, when they first take up the habit of living outside, will grow used to it after a time and then will from habit and the accumulation of a ten-pound blanket of fat be able to stand the cold much better than many healthy persons. Stimulating Examples.--Tuberculous patients need to have their courage kept up. It is true that the toxin of the tubercle bacillus has the definite effect of stimulating its victims so that they are likely to be hopeful, but very often this hopefulness is vague and does not tempt them to eat and to live in the open air, the two things that make their continued resistance to the disease possible. I find that the knowledge of how bravely and how successfully other sufferers from the disease resisted its invasion and succeeded in doing a good life's work is the very best tonic that sufferers from tuberculosis can have. Needless to say, there are any number of examples of heroes of tuberculosis who put to shame perfectly healthy people in the amount of work they succeeded in accomplishing in spite of the drawbacks of their disease. The unfavorable suggestion of the number of deaths from the disease must be overcome by the contrary suggestion of the brave, busy lives lived by those who suffered even the very severe form of the disease and often accomplished the full term of existence in spite of their handicaps from tuberculosis. _Robert Louis Stevenson_.--The best example in recent years is undoubtedly Robert Louis Stevenson. In spite of tuberculosis in severe form which prevented his living in the ordinary climates for the last twenty years of his life, he succeeded in doing an amount of work that is simply marvelous and in {357} influencing his generation more widely than most of the perfectly healthy writers who lived in his time. There are over, 2,000,000 published words to the credit of Stevenson, and, when we recall that most of this, owing to his critical care, had been written over and over many times, some idea of the vast amount of work he accomplished will be realized. Perhaps the climax of his cheerful nature, the utter lack of discouragement in the face of what is usually the most depressing possible incident, is to be found in his famous letter to a friend telling him, as he lies in bed, that he cannot write at any great length now but that he will write a long letter next week if "bluidy Jock," his playful name for hemorrhage from the lungs, would only let him. One of the most striking illustrations of his insatiable appetite for work and his complete refusal to admit that he was being conquered by the disease has been recently told with regard to his unfinished novel, "St. Ives." He had been suffering from certain severe symptoms and had been forbidden to do anything at all, even to dictate brief notes, or anything else that would make any extra work for his respiratory organs. The ideas for chapters of "St. Ives" were in his head and would work themselves out in spite of the doctor's prohibitions. He would not let the thought of his disease overcome him, and so he dictated these chapters to a secretary in the sign language, which he had learned so as to be able to communicate under such conditions. I know nothing that is more likely to make people realize how a brave spirit can overcome every discouragement of body, and how much such a spirit is its own reward, since it secures for its possessor a prolongation of the life of the body that would surely be worn out by depression, by discouragement, and by worry. Undoubtedly Stevenson's interest in his work literally gave him new life. It did use up some nervous energy, but if his mind had been occupied by thoughts of his disease, and its probably fatal consequences, much more of his precious store of nervous energy would have been exhausted in anxiety and worry. _J. Addington Symonds_.--After Stevenson probably the most striking example among modern literary men is John Addington Symonds. Comparatively early in life he found that he could not live in England owing to the inevitable advance of tuberculosis when he tried to do so. He took up his residence then at St. Moritz and other places of rather high altitude in Italy and continued his literary work. When we see the row of books that we owe to Symonds' literary activity it is surprising to think that he, too, like Stevenson, had to watch his temperature, that every now and then there were discouraging developments and incidents in his tuberculosis, and that a return to the ordinary habitations of men away from the friendly altitudes of the Italian Alps was always followed by a recrudescence of his symptoms. Symonds' work was not merely literary, but his books are valuable historical monographs on many subjects requiring much reading and diligent study and consultation of authorities. There are few men in perfect health and with abundant leisure who have succeeded in accomplishing as much as did this hero of tuberculosis. _Thoreau_.--There are other distinguished literary men of the nineteenth and twentieth centuries the stories of whose tuberculosis has a special interest and tonic quality. One of these is our own Thoreau, another is Francis Thompson, the English poet, whose recent death has brought him even more publicity than did his great poems while he was alive. Both of them are typical examples of another phase of tuberculosis that is interesting to realize. {358} It is probable that if Thoreau had lived the ordinary, practical, everyday life, which those who lived around him thought he should, he would have died of tuberculosis before he was thirty. He had no use for money beyond his present needs and when he had made enough to keep himself very simply he refused to earn any more. He had not time, as he said, to make money. He wanted to live his life for itself and for the interests higher than the material that there can be in it. Accordingly, he set himself to learn all about the birds and beasts and the trees and plants and the waters and their inhabitants around his country home. He introduced the modern taste for nature study in its most beautiful way. He spent most of his time out of doors. Undoubtedly this out-of-doors life prolonged existence for many years beyond what would have been his term. His biographers say that probably his being out of doors in all sorts of weather laid the foundations of "the cold which settled on his lungs" and eventually carried him off. Those of us who know anything about tuberculosis, as it has been studied in recent years in the tuberculosis sanatoria, are not likely to agree with such an opinion. Our patients in the Adirondacks live outside ten or twelve hours a day and then sleep with their windows open with the temperature sometimes down to zero during the severest winter weather. Rain and dampness are not allowed to interfere with the open air program. Colds that "settle on the chest" so that people die from consumption are not due to exposure to cold but to the bacillus of tuberculosis. Where this once gains a foothold the one hope of prolongation of life is out-door air and the more cold and stimulating that out-door air is, provided he can stand it without discouragement, the better for the patient. Thoreau is an example of a man whose life was prolonged by his out-door habits and by his refusal to live the humdrum, practical existence of other men, just to be like those other men and measure his supposed success by their standards. CHARACTER AS A THERAPEUTIC ASSET Recent interest in tuberculosis has taught us that the best possible asset for a tuberculous patient is character. Resistive vitality in the physical order and character in the moral order seem to be co-ordinate factors. If a man will not give in in the fight, if he insists on struggling on in spite of difficulties, discouragement and an outlook that seems hopeless, then he will almost without exception get over his tuberculosis, if there is any favorable factor in his environment. We talk much of immunity inborn and acquired to the disease, but it seems to go hand in hand with a certain capacity to stand the debilitating symptoms of the disease without allowing one's mind to become depressed or one's disposition rendered despondent by them. Courage and Constancy.--The career of Dr. Trudeau to whom we owe so much of our knowledge of tuberculosis is a striking example of the power of character to enable even an apparently delicate organization to withstand the ravages of the disease. This is all the more striking because he was an advanced case when he finally reached an environment in which he could make head against the disease. The story of his own personal struggle for life at Saranac, in which he both learned himself and taught others what the modern {359} treatment of tuberculosis should be, is one of the best therapeutic documents of modern times. Under circumstances that were quite apt to be discouraging to anyone of less character than he, with the bitter cold of the Adirondacks around him and quite inadequate heating facilities, so that even old-fashioned lamps were in requisition for heating purposes, he yet succeeded in winning back his own way to health and showing others how it could be done. The struggle had to be kept up for long, it had to be renewed again and again, our greatest American authority on tuberculosis had to learn in his own person all the clinical details of the disease, but in the midst of it all he succeeded in accomplishing a life work that will stand beside that of any man of his generation and will probably mean more in the history of American medicine than that of any of his supposedly more distinguished colleagues in our large cities and large teaching institutions. This is the sort of man whom tuberculosis does not take in spite of every advantage that the disease may seem to have. Two others of our American authorities on tuberculosis had almost the same experience. Persistence.--Recently I have been in correspondence with a young man who illustrates the same power quite as strikingly. He went to Florida and soon found that the unfortunate fear of tuberculosis that has so unwarrantably come into many minds in recent years made it extremely difficult--indeed, almost impossible--for him to live under such circumstances as he hoped for when he went there. In any boarding-house he went to just as soon as there was question of his having tuberculosis the landlady would either insist on his leaving at once or else plead with him to take his departure, lest her other boarders should desert her. He was coughing, he had some fever, his disease was advancing in the midst of all this disturbance, physical and mental, and the outlook seemed hopeless. His picture of this selfishness of humanity, scared about nothing (for there is practically no danger if tuberculous patients take reasonable precautions, as even nurses in sanatoria do not acquire the disease, though living in the midst of it), constitutes one of the most poignant indictments of human nature in its worst aspect that I have ever had presented to me. Finally he made up his mind that there was nothing for him to do but to tent out and live by himself. Fortunately he was able to do that and just as soon as he was settled under circumstances where human nature did not bother him, nature began to do him good. He feared that he would die during the first month in the tent, for he was having fever up to 102-1/2 and sometimes more every afternoon; but he laid in a store of provisions which with the milk and eggs delivered to him every day enabled him to stay in bed for a week, opening up the flap of the tent in the middle of the day. Then he went out and got another stock of provisions and stayed in bed for another week. His thoughts were gloomy enough, he had only some old illustrated newspapers to give him a few fresh thoughts every day, he had no one to visit him, but he hung on and kept up his habit of rest and forced feeding in spite of disinclination. At the end of two weeks he had no temperature in the afternoon. At the end of the third week he made for himself a reclining chair and sat in the sun outside of his tent wrapped in a blanket. At the end of four weeks he had gained five pounds in weight. From that on all was plain sailing. It was his character that conquered his tuberculosis. {360} SUGGESTION AS TO SYMPTOMS Besides the value of suggestion for the general condition in tuberculosis many of its symptoms can be treated best by changing the mental attitude of the patient towards them and giving him a proper appreciation of their significance. Most symptoms are likely to produce exaggerated reactions, especially in patients who are over-solicitous about themselves. Not a few of the symptoms are really nature's attempts at compensation, or the result of conditions which show a natural disposition to bring about a cure. Fever, for instance, produces lassitude and great fatigue on exertion, and patients are prone to think that this means weakness or exhaustion. It is really only an indication of the necessity for rest, and is brought about by nature's refusal to supply all the demands of the muscles for nutrition, at a time when the febrile condition is burning up a lot of extra material. Far from being a disadvantage, weakness is a decided advantage in this condition. Hemorrhage.--Probably no symptom that occurs in connection with tuberculosis is more influenced by the mental attitude than hemorrhage. It is a most disturbing incident. Even in quite small amounts it upsets the patient seriously and, of course, in large amounts it is a source of profound disturbance even to the most placid of patients. Excitement always adds to it. Probably no physical means that we have at command can be depended on to control it. Ergot used to be popular, but such physiological action as it exerts, so far as we know the drug, would seem to be likely to do as much harm as good. Other remedies have gradually lost favor in the hands of those who have had most experience with the symptom and gallic acid and supra-renal extract, the older and newer remedy, are now little depended on. Two things are important--to secure lower blood pressure and lessened pulmonary activity. For these opium in some form is undoubtedly the best drug; and then a placid state of mind on the part of the patient must be secured as far as possible. The scare in these cases, in so far as it is relaxing, is rather favorable than unfavorable for the patient. In addition, it is necessary to insist on absolute quiet and silence and then to allay all reactionary excitement. It is important to make patients realize that while hemorrhage is a serious complication, it is by no means so serious as is usually thought. Many cases of tuberculosis that eventually run a slow course are ushered in by hemorrhage, or have it as a very early manifestation. It is surprising how many people have had hemorrhage as a symptom and live to tell of it thirty or forty years later. This was not due to any mistake of diagnosis, for a generation ago tuberculosis was more likely to be missed when actually present than to be diagnosed when absent. Indeed, this tendency for the cases in which hemorrhage occurred to run not so fatal a course as others was a fact that seemed to an older generation of physicians to require explanation. They suggested that possibly the hemorrhage swept out with it some of the virulent elements from the lungs and so lessoned the infection. From what we now know this is a doubtful explanation, but it seems not unlikely that a frank hemorrhage might reduce the amount of toxins in the circulation and so in an early stage of the disease give nature a fresh start in resistive vitality. {361} What is much more likely, however, is that the occurrence of early hemorrhage made it easier for the patients to appreciate the seriousness of the affection and brought them to accept advice as to proper precautions. Under ordinary circumstances it is difficult and used to be even more so in the past to make the patient understand at the beginning of the affection the necessity for giving up indoor occupations and living the outdoor life with the care for nutrition that is so important if the case is to be improved. Hemorrhage scared them into submission. In the old days it was the first positive symptom of consumption. Now we have many others, and instead of following the advice of over-solicitous relatives that we should not tell patients what is the matter with them, we tell them frankly and secure such care of the health as will bring about improvement. Probably nothing illustrates so well the necessity for thus influencing the patients' minds into caring for themselves as the fact that the hemorrhagic cases, as a rule, do better than the others. All of this can be used to make the minds of patients much less disturbed than they would otherwise be by this alarming symptom. Cough.--In the chapter on Coughs and Colds we have outlined how much coughing may depend on suggestion, or habit, or on the tendency to yield to slight bronchial irritation when there is no real necessity for it. Most tuberculous patients cough much more than is necessary. This is always somewhat dangerous for them since it disturbs their lungs, has a tendency to distribute tubercle bacilli in their lungs, or in the air around them, and may by efforts at expulsion lacerate affected blood vessels and produce hemorrhage. Whenever cough is productive it should be indulged in, for it removes material that should not be allowed to accumulate. Unproductive coughing, however, can usually be controlled by training. It is particularly at the beginning of phthisis that the control of coughing by suggestion is important. There are many little coughs, "hacks" as they are sometimes called, frequently repeated by those in a very early stage of pulmonary tuberculosis and which are consequent upon irritation either of pulmonary nerves or of pulmonary tissues, but that are quite unnecessary, as a rule, if a little attention is paid to suppressing them. As a warning sign they are excellent, but the patient should be taught not to indulge in them. Coughing tends to prevent nature's curative reaction and the contraction of pulmonary tissues which may take place around a lesion. In beginning consumption, even where there is but slight infiltration, we know from the observation of the movements of the diaphragm either by the X-ray or directly by Litton's method that its excursions on the affected side are shortened. Coughing is in direct opposition to this setting of the lung at rest and therefore should be controlled; however, as our drug remedies are likely to disturb the stomach, whose healthy function is so important in these cases, the use of the mind in the control of the cough is of the greatest value. Thoracic Discomfort.--Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the {362} well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon--the excursions of the diaphragm--nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles. Altitude.--There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down. Suggestion and Treatment.--There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite. Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various {363} kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration. Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it. _Negative Suggestions_.--Some suggestions are valuable for the prophylaxis of complications. For instance, tuberculous patients must be warned not to indulge in breathing exercises without the express consent of the physician. So much is said in popular literature as to the value of breathing exercises that many a patient suffering from tuberculosis thinks that, not only may they be indulged in with impunity, but that they will surely do good and can do no possible harm. Nothing could be more erroneous. Many localized lesions have been diffused in this way and there is always danger that the strain will cause hemorrhage. Patients must be warned also to avoid any possible condition in which they might have to over-exert themselves. Because of the dust inevitably breathed during automobile riding, this pleasure must be denied to tuberculous patients as a rule, but even when they have recovered sufficiently so that this may be permitted they must be warned not to take long rides into the country lest the breaking down of the machine should place them under the necessity of walking a long distance. This idea should also be emphasized for rowing excursions, or trips by motor boat, for occasionally they lead to serious and exhausting exposure. One negative suggestion should be given at the very initial stage to every patient in whom the presence of pulmonary tuberculosis has been recognized. This should be a warning to exercise the greatest care against permitting the development of constipation. Tuberculous patients must never strain at stool. Almost necessarily a certain number of tubercle bacilli are swallowed every day whenever pulmonary tuberculosis is at all active and they are constantly present in the digestive tract. If tuberculous patients then strain at stool, little abrasions of the mucous membrane of the rectum are caused in which tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are common among the tuberculous and rectal fistulas often give much bother. When a tuberculous patient develops such a condition, a period of depression and discouragement will follow, for there is a curious tendency to depression associated with all lesions of the rectum. A pulmonary patient who has been doing well will often fail to make progress for months after the development of even a small ischio-rectal abscess. {364} CHAPTER III NEUROTIC ASTHMA AND COGNATE CONDITIONS For the consideration of its psychotherapy asthma may be divided into two forms--symptomatic and essential, or neurotic, asthma. Symptomatic asthma is a difficulty of breathing, the result of some interference with the circulation, as by heart disease, or with the oxidizing power of the blood, as by kidney disease, or various blood conditions, or from direct interference with respiration from some pulmonary affection. Essential asthma is not dependent on any organic condition, but is an interference with breathing without any distinct pathological condition in the lungs themselves or in the general circulation. There may be some emphysema, but not enough to account for the respiratory difficulty. It is spoken of as neurotic asthma, and the most careful investigations made of individuals who have died during a seizure has failed to give any sure pathological basis for the affection. Certain accompanying phenomena are worthy of note. The most interesting of these are Curschmann's spirals, which usually occur in the form of translucent pellets very characteristically described by Laennec as pearls. They are evidently formed in the finer bronchioles and show that the affection extends to the terminal portions of the bronchial system. In connection with these the so-called asthma crystals first described by Charcot and Von Leyden and sometimes called by their combined names are often found. Besides, there are a large number of eosinophiles in the sputum itself entangled within the filaments of the spirals and an eosinophila of the blood. Etiology.--Not only are we ignorant of the reasons for these phenomena but there is even some doubt as regards the mechanism of the respiratory spasm itself. There is a general impression that the paroxysm is due to incapacity to inspire because of a paroxysmal spasm of the respiratory muscles. Gee in his "Medical Lectures and Aphorisms" [Footnote 30] rather leans towards the explanation that suffering is due not to any inability to fill the lungs but to incapacity to empty them when they have become over-distended with air. He tells the story related by Dean Swift of the old man whose barrel-shaped chest was fixed in spasm so full of air that the patient could not find room for the slightest additional breath. "If I ever get this air that is in me out," the patient declared to the Dean, "I will never take another breath." [Footnote 30: Frowde, Oxford Univ. Press. 1908.] It is important to differentiate symptomatic from neurotic or essential asthma. In symptomatic asthma the only assured treatment of the condition must come through amelioration of the organic condition causing the symptoms. Cardiac and renal asthma respond promptly to remedies which relieve critical conditions that may be present in the heart or kidneys. It must not be forgotten, however, that respiration is readily disturbed by mental influences. Where cardiac or renal disease causes interference with respiration this is much emphasized by the patient's unfavorable mental attitude toward it, or much relieved by keeping him from worrying over his condition. Even symptomatic asthma, then, has a definite place in psychotherapeutics, though {365} it would be serious not to recognize the underlying conditions and treat them. If the patient's attitude of mind is one of discouragement, the respiratory difficulties will continue to be a marked symptom of the case, even though the proper remedies for the relief of cardiac or renal conditions are administered. Symptomatic Picture.--What is likely to be one of the most disturbing experiences of the young physician early in practice, especially if he has not before seen a typical case, is to be called to a patient suffering from a severe attack of asthma. Often the sufferer is sitting up in bed so as to get all the air possible, and, though the windows are wide open, he is gasping for breath, usually pleading for more air with a tense, anxious expression, starting eyes, and the sweat pouring from his forehead, while the accessory muscles of respiration, deeply engaged in moving his thorax to move air enough to keep him from stifling, emphasize his dyspnea. Occasionally a degree of cyanosis develops that is quite startling for the untrained observer. Most of those who see the symptomatic picture for the first time think that death is impending, and the patient himself, if he has not had a series of attacks, will fear a fatal termination. It appears impossible to believe that the next morning, within six or seven hours of this, the patient will, as a rule, be quite well and walking round in the enjoyment of apparent good health. As a rule, the worse these cases seem in their intensity and the more the patient is anxious, the more surely are they merely of functional nervous origin; above all, the more complaints of lack of air and of fear of impending death that are made, the more likely is the patient to be all right within a few hours. Asthma looks as though it must be due to some serious organic condition. Of course, in many cases of difficult breathing, even with asthma-like attacks, there are underlying serious conditions of heart and kidneys that are extremely dangerous. As a rule, however, these do not produce the woeful pictures of purely neurotic asthma. Even when the basis of the asthma is an emphysema, which of itself is not dangerous and is quite compatible with long life, the attacks, though frequent and severe, are usually not so serious looking as those in which absolutely no pathological condition of the lungs, or heart, or kidneys can be found, and, indeed, in which there is absolutely no organic change to account for the extremely uncomfortable and even terrifying symptoms. Mental Influence.--In the medical literature of asthma there are abundant proofs that the attitude of mind of the patient towards his affection means very much. There is the story, thoroughly vouched for, of the two friends stopping at a little country hotel late at night. One of them was a neurotic subject, who, whenever he remained for some time in a stuffy atmosphere, was likely to have a severe asthmatic attack. The quarters assigned to them proved to be one of the cramped little rooms with a single small window that occasionally are found in the attics of country inns in England. During the night the patient of asthmatic tendencies had one of his attacks and begged his friend to open the window. The friend, suddenly roused from sleep, did not remember the position of the window and, the night being very dark, he felt for it and finally found it. He could not raise the sash and he could not move it either inward or outward and there seemed no way of getting it open. His friend was insistently clamoring for air with that tone of despair and {366} dread of impending death so characteristic of the young, inexperienced asthma sufferer. Unable to get the window open, the sympathetic companion finally took his shoe and smashed the glass. The relief was immediate. Scarcely had the crash of the broken glass been heard before the patient gave an audible sigh of relief. When his friend went over to him he felt so much better that it was rather easy for the sufferer to persuade him that nothing more would be needed and that he should go back to bed. In the morning, when the friend awoke, his first glance, directed by the sunlight that came streaming into the window, was toward the broken panes of the night before. To his surprise it was not broken. Wondering what had happened, he looked round the room to find that he had smashed two panes in an old bookcase set into the wall, and that it was the breaking of the glass with the suggestion of free ingress of air that it involved and not any real provision of fresh air that had cured his friend's asthma so promptly. _Suggestion_.--When much-vaunted cures for asthma are analyzed, many of them are found to depend more on suggestion than on any other element. Various forms of cigarettes are used, comparatively innocuous in themselves, and certainly of no strong therapeutic action, yet they work marvels in loosening the spasm that comes over the lungs in asthmatic attacks. Any sort of a cigarette will do at the beginning. I have seen dried grape-vine stems work very well in the country, especially in young women to whom the idea of smoking anything was strongly suggestive. Cubebs cigarettes have the same effect on older people. Doubtless there is some relaxing action in the smoke. This is not enough, however, to account for the effect produced without mental influence. After cubebs have been tried for a period and begin to lose their efficacy, then other materials that produce a pungent smoke or have a certain sensory action, as stramonium leaves, may be used, and will also have the marvelous power of cubebs. After a time, however, they, too, lose their efficacy, and, as a rule, each successive cigarette that is tried has less power than the first to control the difficulty of breathing. The more one hears of cures for asthma, and the longer one has experience with these cases, the clearer does it become that there is a large suggestive element in every successful treatment. If a piece of ordinary blotting paper be dipped in a strong solution of saltpeter and allowed to dry, it will, if touched by a lighted match, burn slowly without flame, but with the production of heavy, thick smoke. The therapeutic elements in this are not very strong, but the suggestive element, when a room gets full of it, is intense and is cumulative. Very probably the thick smoke, rich in nitrites, has some tendency to relax the spasm in the lungs which causes the asthmatic seizure, but after a time the remedy fails and something else has to be tried. In many cases, when first used, it almost works a miracle. This is the simplest type of suggestive treatment for asthma. _Mental Shock_.--Any strong mental influence, especially if accompanied by the suggestion of assured relief, is likely to do much for asthma of essentially neurotic character, and indeed is more powerful in dispelling the symptoms of the seizure than almost any other means that we have. Sometimes even things absolutely indifferent which produce a profound mental impression, prove curative. There are many stories of men in the midst of a severe asthmatic seizure being suddenly roused by the cry of fire, or an alarm of some {367} kind near them, having the spasmodic conditions disappear as if by magic. Occasionally where attacks of asthma recurred regularly on successive nights for a considerable period, travel on a railroad train or anything else which occupied the attention much, prolonged the interval between seizures and sometimes put an end to the series of attacks. The more one knows of asthma the more one realizes how much its occurrence depends on mental influences of many kinds in association with various reflex irritations, some of them very distant from the respiratory tract and comparatively trivial in their effects on other people. _Loss of Control_.--Occasionally in elderly neurotic people over-fatigue induces an attack of asthma about the time that sleep becomes deep. This usually occurs after the first hour or two of sleep. The inhibitory power of the nervous system over spasmodic contraction of the lung tissues seems lost in deep sleep and then the asthmatic condition develops. The greater the effort to breathe the more intense does the contraction become, until the antispasmodic effect of the presence of a lessened amount of oxygen and an abnormal quantity of carbon dioxide in the blood makes itself felt. In many cases these patients will be relieved of the tendency to such spasm by taking a cup of coffee. This stimulates the general circulation and minimizes the reflex tendency which centers in their respiratory tracts. Such patients after taking an amount of coffee that would keep ordinary people awake all night, sink in the course of half an hour into a quiet, restful sleep and awake quite refreshed. This is not entirely suggestive, but suggestion plays an added role in the relief of all the symptoms. Treatment.--_Varied Cures_.--We do not mean to say that asthma is entirely amenable to suggestive treatment, but we emphasize the mental influences in its production and its cure. A new and almost infallible cure is announced nearly every year for asthma, as for tuberculosis. Sometimes this is some new treatment for the nose, occasionally it is a novel method of treating the throat, but reflexes from a great many other organs not at all in touch with the respiratory system have also been supposed to be productive of asthma, and their treatment has been followed by relief from this trying condition. Washing out the stomach, for instance, has been followed by prolonged cessation of asthmatic attacks. In children it is claimed that occasionally the correction of eye-strain by the proper glasses has cured neurotic asthma. There are those who have had cases where the relief of long-continued constipation had a like therapeutic result and there are other and even more curious claims for curative effect in this affection. _Negative and Positive Suggestion_.--Any condition in the human body that sets nerves in tension and requires constant inhibition may lead to such a cumulative effect of repression that reaction follows and explosion takes place. In particularly susceptible individuals, irritable respiratory centers may be affected with consequent asthmatic seizures. The direct treatment of the respiratory tract to secure ease of respiration often does away with the liability to asthma by direct prevention. If patients, especially young patients, are mouth-breathers the clearing out of the throat and nose so as to insure normal breathing can naturally be expected to lessen any tendency to asthma. In the same way treatment of irritative or degenerative conditions in the throat and larynx, as well as in the nose, may be considered directly curative. On {368} the other hand, there is no doubt that many of the slight ameliorations of intranasal conditions suggested by enthusiastic specialists as curing asthma do not have any direct therapeutic influence but owe their efficacy to the strong suggestion of the operator's assurance on the patient's mind that this treatment has cured asthma in many cases and will surely cure him. _Drugs and Suggestion_.--The medicines that are especially effective in asthma of neurotic origin are those which also have a large suggestive influence because of their taste or their effects upon the system. Hoffman's anodyne is an efficient antispasmodic and is wonderfully effective in relieving the tendency to asthma. I have always felt, however, though I have given it freely, that a large element in its effectiveness was its particularly disagreeable taste and odor and then its excretion through the lungs with a certain sense of well-being allied somewhat to the intoxication that comes from the inhalation of ether. I have seen asthmatic tendencies in young women greatly relieved by the use of valerian. Undoubtedly this remedy, like the compound spirits of ether, is antispasmodic in action, yet to a much less degree than Hoffman's mixture, and over and over again I have noted that in pill form, though given in large doses, it was not as effective as if given in liquid form when its nauseating smell added distinctly to its suggestive influence. The drug itself does good but it is distinctly helped by the influence upon the patient's mind of its taste and, above all, of its aroma. The elixir of ammonium valerianate being particularly unpleasant is likely to be more beneficial to these patients. _Climatotherapy and Suggestion_.--The climatic treatment of asthma has received much attention. Change of scene and environment nearly always does good. Different patients, however, require very different conditions. Of two cases of neurotic asthma in which no diagnostic differences can be found, one will improve at the seashore or on a sea voyage, while the other will be made worse by such a change though probably the asthma will be improved in the mountains or in some dry climate. Even moving from one part of a city to another has brought great improvement in asthma. Sometimes there were good reasons for this, as, for instance, when an investigation showed that the patient had previously been living above a bakery from which there came a good deal of hot air and flour dust. Some people are actually improved by close contact with human beings in rather crowded quarters. I have known a settlement worker to experience great relief from asthma when living in the slums. Where there is intense occupation of mind, especially if combined with the suggestion that now the asthma ought to be better, seizures will be less frequent and less severe. All sorts of places in the mountains and by the seashore have acquired reputations as relieving asthma which were justified by many cured cases and yet they have lost this reputation. Whenever there are many sufferers together, the expectancy of relief seems to do great good. CHAPTER IV DUST ASTHMA, SEASONAL CATARRH, HAY FEVER Grouped under the term "hay fever" there are probably as many different affections as there are under the term "chronic rheumatism." There are {369} people who, in the springtime, as soon as the weather gets warm, suffer from what is popularly called hay fever. This is often called "spring catarrh" or "rose cold" and seems often to be associated with the pollen of flowers. Then there are people whose hay fever, as it is called, develops about the first of June and continues to be bothersome until the middle of July, when there is a remission of symptoms, though in dry prolonged hot periods after that the affection may recur. It seems as if, at the beginning of the heated term, the warm, dry dusty air irritates their nostrils very much, while after some weeks they gradually become used to this and the reaction is not so violent. Then there are the regular hay-fever patients whose affection occurs principally in haying time, during August and September, though most of them have not been near hay pollen, and the disease is an affection of dwellers in cities rather than in the country, of indoor livers more than of farming people, who might be expected to suffer most from the supposed cause, hay pollen. Even where pollen is directly concerned in its causation it is probably oftener the pollen of the rag weed rather than that of hay that is responsible for it. There are two elements in the disease apparently of equal importance. One of these is a strictly local condition interfering with respiration in some way, or with the circulation to the mucous membrane of the nose and the lachrymal ducts. The other is an individual over-sensitiveness so that there is an exaggerated reaction to irritation. Some of this is mental, that is, is due to expectancy, or to the persuasion that this reaction is sure to occur under certain circumstances. As a consequence, attacks of hay fever are reported even after a distant view of a hayfield, or of rose cold due to the sight of an artificial rose, and of other recurrences that show the power of the mind to bring about at least a beginning of symptoms. While the first or physical element in the etiology of dust catarrh can be treated successfully by various means, it is important to get the mind of the individual in a favorable state so as to enable him to obtain better control over his vaso-motor system which is so much influenced by emotions and thoughts. It is this latter element in the causation of the disease that has been successfully treated by the many remedies that for a time have had reported success in the cure of hay fever yet afterwards proved to be of no benefit because they had lost their influence over the patients' minds. In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on Rose Cold," Dr. J. N. MacKenzie [Footnote 31] has some paragraphs on hay fever which, though written twenty-five years ago, are worth recalling for a proper understanding of the disease. He preferred to call the disease rhinitis sympathetica or coryza vaso-motoria periodica, names which are much better descriptive terms and have no unsubstantiated suggestions of etiology in them. [Footnote 31: _American Journal of Medical Sciences_, 1886.] According to our conception, the so-called nasal reflex neuroses, whether taken singly or collectively, as the cause of the _ensemble_ of phenomena known as "hay fever," may be regarded as the protean manifestation of a morbid condition to which we have given the name rhinitis sympathetica, and which is characterized by a hyperesthetic condition of the vaso-motor nerve centers linked to a peculiar excitability of the nasal cavernous tissue. For, if we inquire what condition or conditions is common to them all, and what morbid process is capable of producing them, either singly or in combination; how phenomena apparently {370} so widely different in character and anatomical sphere of operation may be traced to a solitary source, we find the answer in certain more or less clearly defined changes in the nasal apparatus and in a certain exalted state of the sympathetic nervous system, to which latter we instinctively turn as the organ most conspicuously concerned in the evolution of purely reflex acts. In whatever relation the local nasal affection and the condition of the sympathetic stand to each other in the matter of cause and effect, they must both be regarded as inseparable factors in the production of the phenomena under consideration. It matters not to what hypothesis the path of speculation may lead. Of this we can be reasonably sure, that in the production of the characteristic symptoms of this disease, a certain excitability of the nasal passages is necessary, plus an exalted state of the central nervous system. Dr. MacKenzie calls attention particularly to the erectile character of the tissues mainly involved in all these forms of dust catarrh and dwells on the rôle that mental influence always plays in the phenomena noted in such tissues. This with the vaso-motor elements in the affection which are so largely also under the control of the emotional nature make it clear that the pathology of the affection must be considered from this standpoint and, therefore, its therapy also. Dr. MacKenzie continues: From our present knowledge of the disease, it seems difficult to escape the conclusion that its pathology is intimately interwoven with a morbid condition of the vaso-motor sympathetic, and probably a hypersensitive state of the nerve centers themselves. When we recall the fact that in the famous section of the sympathetic in the neck by Claude Bernard, symptoms similar to, or closely allied to, the phenomena of hay fever were produced; when we reflect upon the results reached by Prevost in his experiments on the spheno-palatine ganglion, is there not a clue to lead us through the labyrinth of our difficulties to a rational solution of the question? . . . . . .In the human body, wherever erectile tissue is found, it is intimately related to reflex or sympathetic acts; there seems to be connected with it a certain receptivity to reflex producing impressions, a certain power of reflex excitability dependent upon its structure and functions. It is thus peculiarly a tissue of sympathy in which we may most satisfactorily study the mechanism of purely reflex or sympathetic acts. Now it seems to us that, as the nasal corpora cavernosa belong to this class of sympathetic tissues, there will be little difficulty in explaining the rôle which they play in the paroxysms of an affection which is probably connected with, if not dependent upon, an excitation of the sympathetic nerve centers, and in more clearly defining the intimate relation which its erection bears to the reflex manifestations of the disease under review. These considerations explain the heredity of the affection in many cases, since it is dependent on defects that may be family traits, yet they also enable us to understand how slight lesions of the nasal mucous membrane may be the center from which radiate the underlying pathological conditions of the disease. Railroad Asthma.--There is a form of dust asthma which deserves special attention here because it is due to modern conditions and helps to an understanding of the etiology. It occurs in sensitive persons when they travel on railroad trains in warm weather, particularly if it has been dry for several days and dust is abundant. It has been called railroad asthma or railroad catarrh by the English and the Germans, but the condition has no necessary connection with the railroad. It occurs as a consequence of the infiltration into railroad cars of fine dust during the passage of the train. {371} I have seen it in those who had made long trips over dusty roads in automobiles, though the dust of the railroad seems finer and more penetrating. It develops just as much at the end of a long train as if the passenger spent most of the journey in the car next the engine and apparently it makes no difference whether the engine burns hard or soft coal. They use soft coal almost exclusively in England and Germany, but one sees cases of it here after travel on roads that burn hard coal and are especially cleanly in this respect. Soft coal adds somewhat to the amount of dust and therefore this increases the irritation, but there is nothing specific about coal dust. It is surprising how severe the symptoms may be. I have seen a patient who had traveled continuously for four days across the continent who had so much photophobia when he alighted from the train, that he was almost unable to open his eyes, and it was not until twelve hours had passed that he could open his eyes with any comfort, yet at the end of two days practically all the symptoms had passed off. Prof. Fraenkel, professor of laryngology and rhinology at the University of Berlin, who was one of the first to classify the condition among the affections related to "hay fever," described certain features of it very well in a clinical lecture reported in _International Clinics_, Vol. II, Ninth Series, 1899. As a rhinologist he insists on the nasal conditions that underlie the affection yet suggests that the nasal hyperemia may be due to reflexes of one kind or another. The basis of these is undoubtedly very often an emotional condition of the patient, a dread of dust, an expectancy of symptoms and a consequent exaggerated reaction. Unorganized dust produces asthma, but organic materials bring more severe and lasting effects, partly because of the mental effect of odors and other sensory conditions in connection with them. The Personal Element and Power of Suggestion.--The history of these asthmas and other symptoms produced by odors and dust make it clear that the more that is known about the disease the surer it becomes that there is a large personal element, usually dependent on a certain frame of mind, in the cases. Some people are affected by one form of irritant, some by another, some by pollen, others by animal emanations, and not a few by a persuasion of the likelihood of suffering from these things, since occasionally the sight of an artificial product produces a like result. Certain classes suffer much more than others. Those who are much confined to the house and who are especially prone to reflection upon themselves and their feelings form the great majority of the patients. In old days the monks were favorite victims, in modern times literary folk, students, and those who have the time and the inclination for reading and introspection are particularly likely to suffer. How much the mental element may account for in these cases is not clear, but it stands for much more than has been thought and there seems no doubt that more relief of symptoms is afforded by diversion of mind and change of dwelling quite apart from external conditions than in any other way. It is important to remember that no specific dust but almost any kind of dust produces these conditions in sensitive persons. Dr. MacKenzie describes an interesting case in which all the symptoms were produced by the presence of an artificial rose. The story is so striking and he has told it so well that I prefer to tell it in his own words. I may say, however, that the clinical history of the case was typical. About the end of {372} May or the beginning of June every year the patient suffered from a coryza preceded for a few days by an indefinite sense of general depression with a disagreeable feeling of heaviness in the head. Sometimes there were chilly feelings and general malaise. The catarrhal stage commenced with profuse watery discharge from the nostrils, copious flow of tears with redness of the conjunctiva, itching of the puncta lacrymalia and photophobia. The exterior of the nose, especially at the tip, became intensely red and toward the close of the attack the cuticle desquamated. There was a short, dry, hacking cough relieved by sneezing, an intense tickling sensation in the throat, the voice became husky, the pharynx dry, the ears stopped up and tinnitus occurred. Her attacks continued most of the summer and were always brought on by the pollen of any plant and above all by the smell of a rose. It was, indeed, an example and of the most aggravated form. She was brought to Dr. MacKenzie in consultation and I leave him to tell the rest of the story. Decidedly skeptical as to the power of pollen to produce a paroxysm in her particular case, I practiced the following deception upon her, which still further confirmed me in that belief. For the purpose of the experiment I obtained an artificial rose of such exquisite workmanship that it presented a perfect counterfeit of the original. To exclude every possible error, each leaf was carefully wiped, so that not a single particle of foreign matter was secreted within the convolutions of the artificial flower. When the patient entered my consultation room, she expressed herself as feeling unusually well. The evening before she attempted to wear some roses, but had been obliged to remove them from her dress, as they had produced a great deal of discomfort. Apart from this incident she had been perfectly comfortable for several days and nights. Her conjunctivae were normal, the nasal passages free, and there was nothing to indicate the presence of her trouble. She conversed with me for some time about her case and on general topics, speaking in the most encouraging manner concerning the progress she was apparently making toward recovery. I proceeded to remove the slight slough from the cautery operation, which lay loose in the nostril, and made an application to the mucous membrane, and all without exciting the slightest tendency to reflex movements. After I felt sure that such tendency was absent, I produced the artificial rose from behind a screen, where it had been secreted, and, sitting before her, held it in my hand, at the same time continuing the conversation. In the course of a minute she said she must sneeze. This sensation was followed almost immediately by a tickling and intense itching in the back of the throat and at the end of the nose. The nasal passages at the same time became suddenly obstructed, and the voice assumed a hoarse nasal tone. In less than two minutes the puncta lacrymalia began to itch violently, the right and afterward the left conjunctiva became intensely hyperemic and photophobia and increased lacrymation supervened. To these symptoms were added, almost immediately, itching in the auditory meatuses and the secretion of a thin fluid in the previously dry nasal passages. In a few minutes the feeling of oppression in the chest began with slight embarrassment of respiration. In other words, in the space of five minutes she was suffering from a severe coryza, the counterpart of that which the presence of natural roses invariably produced in her case. An examination of the throat and nasal passages was then made. The right nostril was completely obstructed by the swollen, reddened, irritable, turbinated structures; the left was only slightly pervious to the air current; both were filled with a serous-looking fluid. The mucous membrane of the throat was also injected, but did not exhibit the same amount of redness and irritability found in the nasal passages. As the discomfort was rapidly increasing, and as I considered the result of the experiment sufficiently satisfactory. I removed the rose and placed it in a distant part of the room. When told that the rose was an artificial one, her amazement was great, and her incredulity on the subject was only removed upon personal examination of the counterfeit {373} flower. She left my office with a severe coryza, but also with the assurance that her disease was not altogether irremediable. A few days later she called to see me again, and on that occasion she buried her nostrils in a large, fragrant specimen of the genuine article and inhaled its pollen without the slightest tendency to the production of reflex acts. There is but one conclusion that can be drawn from this: that suggestion plays a large rôle in the relief of the symptoms of the disease. If patients once become persuaded that something will do them good, then it surely does. It is true that this good effect will usually not persist, but that is because after a time conditions conspire to make the suggestion fail of its purpose. This does not at all imply that hay fever, or just catarrh as I prefer to call it, is imaginary. The relief of our most serious and fatal diseases with profound pathological lesions, such as tuberculosis, may well be brought about by suggestion. After all, just the same story is told about consumption and its many remedies as of hay fever and its many "cures." However, the most important therapeutic element so far discovered for the treatment of hay fever is evidently suggestion. If the patient's mind can only be brought to a favorable attitude in which the discouragement incident to imperfect oxidation can be greatly lessened, then relief of many of the symptoms will be afforded and under favorable conditions the patient will deem himself cured. Undoubtedly the large amount of attention given to hay fever, the gathering of these patients in particular localities, the repetition of the story of their symptoms to each other, the body of literature that has gathered around hay fever and is read with such avidity by those who are pleased to call themselves its victims, adds to the unfavorable suggestions and inveterates the symptoms, exaggerates the nasal hyperemia and makes the general condition worse. I am the more positive about the influence of suggestion, favorable and unfavorable, in the affection after having carefully noted the conditions in certain patients from year to year for a number of years. I became interested in it because it is a family affection and several sisters as well as myself are sufferers from it. At the beginning, when the real nature of the trouble is not recognized, there is a year or two of considerable general discomfort, though not much local disturbance. Then comes the realization of what the recurrent affection is and a period of distinct depression during its continuance. Eventually it begins to be appreciated that a number of local applications will lessen the symptoms from day to day and that there need be no apprehension of serious sleep disturbance, or of any lasting effect upon the general health, the affection becomes quite bearable and, while still annoying, is no longer the object of particular solicitude. CHAPTER V DYSPNEA--CAT AND HORSE ASTHMA There is a class of cases of difficulty of breathing allied to asthma and often called by that name, the study of which throws light on the origin and the relief of neurotic asthma. These cases are usually accompanied by such a sense of oppression on the chest that breathing becomes labored and, to some {374} extent at least, the accessory muscles of respiration have to be called into play. The most typical cases are connected with the mental influence produced by the presence of some particular animal, the cat being the most frequent and the horse not rare, or with emanations from these animals, when there seems to be some physical nexus between the animal and the symptoms. Cat Asthma.--The symptoms associated with cats are rather common, and they occur at the sight or touch of the animal, but may be the result only of its presence which in some way the patient is able to recognize without sight of him. Shakespeare's expressions in a number of places, such as "I could endure anything before but a cat" and "some that are mad if they behold but a cat," shows that the affection was commonly recognized at that time and that the reason for it was considered unknowable, for Shakespeare says, "There is no firm reason to be rendered why he cannot abide ... a harmless necessary cat." Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an interesting paragraph with regard to these curious asthmatic conditions which develop in the presence of animals of various kinds. He sums up many of the curious features of this affection as reported by various good observers. Many more people than we would be apt to think are affected by it. He says: In some persons the smell of a horse or of a cat produces an attack of asthma. Some years ago I repeatedly saw a young gentleman who invariably had an attack of asthma if he went near a stable or a horse. He was so susceptible that he was unable to drive in a cab or a carriage; when traveling from place to place, while sending his traps from the station to the hotel in a cab, he himself was obliged to walk. Dr. Goodhart mentions a similar instance which occurred in the practice of Prof. Clifford Allbutt. Dr. Goodhart also mentions a remarkable case of "cat asthma": I have known of two cases of cat asthma. In one of them the existence of cats is the bane of life, for before accepting an invitation she is obliged first to ask, "Is there a cat?" [Footnote 32] An attack of urticaria and coryza followed by asthma has been noticed to come on within ten minutes of having stroked a cat. At other times, sitting in a room in which there was a cat, without any actual contact with it, was sufficient to produce a bad attack, beginning within ten minutes of entering the room. [Footnote 32: A case of this kind came under observation as this book was nearly ready for the press. The patient, a young woman in an office, had to refuse a vacation with a wealthy friend in Florida, because she knew that friend could not be separated from her pet cats, five in number, and the patient would have been intensely miserable were she near them, so that even the joys of Florida in the winter did not make up for the constant, intolerable discomfort they would have caused her.] There are two forms of this intolerance of a cat. One of them takes on the character of a dread and is discussed in the chapter on Dreads. The other is accompanied by dyspnea or asthma with a sense of discomfort and tightness of the chest that cannot be overcome. It is not merely an imagination, for sometimes even when they cannot see the cat, or at times when friends have been careful to exclude cats from the room, these people become impressed with the idea that a cat is near and a search usually shows that their impression is true, though just what was the means through which they came to know it is difficult to understand. {375} Dr. Weir Mitchell's review of the subject of "Cat Asthma and Allied Conditions" in a paper read before the Association of American Physicians brought out many curious details. There is no doubt about the power to recognize the presence of the unseen cat. Besides the respiratory oppression, some patients develop urticarial lesions and occasionally even conjunctivitis and a catarrhal condition of the nasal mucous membrane. These seem to be due to the direct irritant effect of animal emanations. As the symptoms of rose cold or hay fever have sometimes developed after the sight of an artificial rose, or even, it it said, the picture of a hay field, so, in some of these cases, the sight of a picture of a cat has produced at least some of these symptoms. Probably the most interesting feature of the affection is that the large cats, the tiger and the lion, do not have any effect on the patient. There seems to be no doubt, then, that the mind plays an important role in the matter and that relief must be secured through mental influence. In some of these cases a careful searching of the past of the patient will show that there has been some terrifying incident connected with the cat. In one case in my own experience the patient's earliest recollection, and the first time that death was brought home to her, was when a favorite bird was killed by a cat. Ever after that she had a horror of the animals, the family cat had to be disposed of, and her family never had another. She used to suffer from a severe dyspnea at the sight of a cat and was sure that she could recognize its presence without having seen it. She mentioned a number of occasions on which that had been true. The very idea of living where a cat could come near her was appalling. She was sure that she was even waked by the mere propinquity of a cat if by any chance one got into her room at night, though without any noise. A change in her material circumstances compelled her to teach in private families. Under these circumstances her cat detestation made difficulties for her. I suggested, since she had had no feeling toward cats before the bird incident, that probably her symptoms were due to suggestion and an acquired habit of mind and that she might by discipline overcome them. She was sure that would be impossible. With determined effort, however, and practice in withstanding her feelings in the presence of cats she finally learned to overcome practically all of her feelings so that though it still requires an effort she can even pick up a cat and stroke it. I have had several other patients with less marked forms of the affection who have by self-discipline overcome their feelings to a great degree. It is always well to search the past of these patients in order to find out whether there may not be a dominant idea derived from some unfortunate experience, which acts as an auto-suggestion in the production of their symptoms of constriction of the chest and sometimes even the recurrence of the swelling of the mucous membrane of the nose that produces difficulty of breathing. Whenever this can be found, contrary suggestion can be given and the patients can be persuaded to try, by frequently repeated auto-suggestion, to relieve themselves of the trouble. Occasionally these curious manifestations of a catarrhal or asthmatic character in the presence of cats occur in people who like cats. Dr. Taylor in his "Types of Habit Neuro-Psychoses" published in the _Proceedings of the Massachusetts Medical Society_, 1896-98, tells the story of a young woman in whom he saw conjunctivitis developing while she was fondling a cat. In many cases {376} besides the hyperemia of the nose and of the respiratory mucous membrane generally there is marked injections of the ocular conjunctiva. It is rather difficult to understand the phenomena of asthmatic attacks in connection with cats and other animals in terms of a habit formed, because at some time asthmatic or hyperemic manifestations occurred in association with the handling of these animals and that then, somehow, suggestion works to reproduce the same symptoms in the presence of the animals later; but this is undoubtedly the only rational explanation that we have for many of these cases. It represents the most helpful explanation, so far as treatment is concerned, for by means of suggestion either in the waking state or in the first stage of hypnosis, in many cases relief can be brought to these patients. Repeated profound hypnotism is a vaunted remedy for these conditions in the hands of professional hypnotists, but serious physicians who have tried hypnotism do not recommend it. It helps for a time but relapse follows. Only continued suggestion and a carefully cultivated habit of self-discipline and control succeed. Horse Asthma.--The cases of dyspnea in connection with horses are not less interesting. Occasionally, even when all aversion is absent, emanations from horses are capable of producing a curious effect on certain individuals. How much of this is psychic is not clear. I was once consulted with regard to a patient who suffered from asthma whenever she went to a dance. It mattered not how careful she was in not exposing herself to night air, or in wrapping herself up warmly; invariably a few hours after her return home, she was wakened from sound sleep by an attack of difficult breathing that required the opening of windows and the use of the accessory muscles of respiration in order to satisfy her air hunger, and even then her symptoms were quite alarming to herself and her friends. At first, her asthma was thought to be due to sudden changes of temperature in going out into the air after the dancing, and various devices were tried to lessen the shock of the cold to the respiratory mucous membrane. None of them had any effect. Then it was thought that the dust of the ball-room made the difference and so she was forbidden to dance. After a time it was found, however, that if she went out in the evenings to social functions, whether she danced or not, or though she avoided completely being in dusty rooms or where many people were moving, she still had the attacks a few hours after she returned home. Finally it was noted that these attacks of asthma also occurred on several occasions after she had been out riding during the day in a carriage. Then one evening after a rather long intermission free from attacks, in spite of directions and her fears, she went to a ball, but owing to circumstances went and returned by trolley instead of, as usual, in the family carriage. That night she had no attack of asthma. Experiments were made then and it was found that whenever she rode behind horses she suffered from an attack of asthma during the following night. The attack was evidently not due to suggestion. The story illustrates the necessity for carefully analyzing all the circumstances of an asthma patient and making sure that some one of these curious and unusual conditions are not at work, for if they are, the only possible curative treatment is by influencing the patient's mind, first by demonstrating the cause of the affection and then by training in self-control to reduce the reaction. {377} Recently I have been consulted with regard to a physician who has developed in a rather curious manner a sensitiveness to the presence of horses. As an interne at a hospital during an epidemic of diphtheria he took a dose of diphtheria antitoxin for immunizing purposes. The amount injected was 750 units, the remainder of the dose of 1,500 units contained in the phial being given to the nurse who had charge of the cases. She suffered absolutely no ill effects, so that the manifestations in his case were entirely due to idiosyncrasy and not to anything in the serum itself. Within fifteen minutes after taking the injection the mucous membrane of his nose became so congested as to make it impossible for him to breathe through his nostrils and the mucous membrane of his soft palate was seriously disturbed in the same way. His face became much swollen, the edema affecting particularly his eyelids and his lips and hundreds of wheals appeared all over the body. Fortunately the edema did not affect the larynx, or the issue might have been fatal, or would surely have required intubation. His pulse became extremely rapid and weak, there was marked dyspnea, and whenever the patient sat up there was fainting or a distinct tendency to it. Under active stimulation and elimination the symptoms rapidly passed off so that the only noticeable edema the next morning was in the eyelids and lips, which, however, also disappeared within twenty-four hours. Up to this time the physician had never been bothered by any tendency to hay fever or to asthma and there is no history of either of these affections in his family. Thereafter, however, though quite without his anticipating it, and, indeed, the first symptoms were incomprehensible, he became extremely sensitive to emanations from horses. When he rides behind a horse for some distance his conjunctivae become injected, the nostrils become congested and difficulty of breathing sets in with a sense of constriction of the chest. These subside as soon as he gets away from the presence of the horse and has washed himself thoroughly. He suggests that he has become sensitized to horse serum and, as it did not exist before his experience with diphtheria serum, he, of course, connects that incident with the present tendency. It is easy for such a case to have its real significance entirely missed and, of course, treatment by prophylaxis, the most efficient form, would then be out of the question. Other Forms.--Apparently at times human emanations or some peculiarity of odor seems to influence asthmatic conditions. I have been told by a good observer--a physician--of two brothers who had an attack of asthma whenever they visited each other. At first this was attributed to something in the air or some other condition of the visit. After a time it was found to occur under varying circumstances, but that the one essential was the association with each other. Treatment.--The more one knows about asthmatic conditions the more does it become clear that special study of individual cases is extremely important for any definite knowledge of the causation in a particular case. Without a knowledge of the cause the treatment is very unsatisfactory and in the meantime the unfavorable suggestion of the recurrence of the attacks acting upon the patient sometimes disturbs the general health. To remove this unfavorable influence must be the first care of the physician and then if the real cause can be found, favorable suggestion and modifications of the mode of life, with self-discipline and control of the mental attitude and of the {378} nervous system, may greatly aid in the reduction not only of the number of attacks and of the severity of the symptoms, but finally lead to complete eradication of the affection. Mental control to some degree can be obtained and it has even been suggested that if the emanations from an animal cause physical symptoms, gradually increased dosage of them, beginning with very small amounts, that is, short periods of association with the animals in question, may gradually lead to the production of an immunity to them as it does even to the much more serious results of snake poison. Certainly some patients seem to have succeeded in bringing relief to themselves by this means and it is worth while remembering in the therapy of the affection, if for no other reason than the strong suggestion that goes with it. {379} SECTION IX _PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM_ CHAPTER I PAINFUL JOINT CONDITIONS--PSEUDO-RHEUMATISM. [Footnote 33] [Footnote 33: The position here taken, that acute articular rheumatism never leaves a mark after it, is entirely due to the observation that whenever cases were seen in which sequelae were noted, there always seems to the writer to be question of something else besides simple acute articular rheumatism--a complication. Subsequent pathological investigation may show that occasionally acute articular rheumatism does to some extent disorganize joint tissues. Personally, however, I have the feeling that there are a number of different kinds of acute arthritis, probably three or four, and that most of them leave no pathological condition in the tissues. Perhaps we shall be able to differentiate the severer forms and recognize them from the beginning, as we have already done with regard to scarlatinal, gonorrheal, influenzal and other so-called rheumatisms. For practical purposes it certainly seems better to emphasize the fact that chronic rheumatism following an attack of simple acute arthritis is so rare as to be negligible.] Many painful conditions in connection with joints give rise to more or less continuous or frequently repeated discomfort, which often leads patients to think that there are serious pathological factors at work, or that some progressive disease condition has obtained a hold of them. Many of these painful conditions are due entirely to local causes: to over-exertion, to the wrong use of muscles, to the exercise of joints under unfortunate mechanical conditions and the like. Just so long as people are assured that an ailment is local, is not likely to be followed by serious impairment of function, that the discomfort of it is only temporary, and, above all, just as soon as they get rid of the notion of a progressive constitutional malady, they are content to bear even annoying pain without much complaint, and, what is more important, without such discouragement and worry as may impair the general health. Unfortunately, it is the custom to call most of these vague painful conditions "rheumatism," unless there is some other patent cause for them. Especially is this done if the symptoms happen to be worse in rainy weather, or in damp seasons. Rheumatism is always thought of as a progressive constitutional disease, and the very idea of it produces an unfortunate sense of depression. Exaggeration of Significance.--Toothache, for instance, unless it is allowed to nag for a long time, awakens no dreads and consequently fails to produce the corresponding depression and discouragement, seen so often in connections with conditions much less painful, but associated with the thought of the possibility of serious developments. _"Omne ignotum pro magnifico,"_ what is not well understood is always exaggerated, was Cicero's summing up of the tendency of the human mind to make the significance of misunderstood things greater than they really are. It is particularly true of painful {380} conditions of the body, and the tendency must be combated if patients are to be relieved. This must be done not alone because along this way lies relief of suffering, since not a little of the discomfort is due to the mental concentration consequent upon the dread, but because, also, the discouraged state of mind interferes with the trophic influences that go down from the central nervous system to the periphery to keep it in good health and to restore function when there is anything out of order. In a word, the exaggeration of significance so likely to influence such patients for ill must, as far as possible, be removed for their immediate relief as well as ultimate cure. Rheumatism, Gout, Catarrh.--There are three words in popular medical language which can be made to include more diseases and explain more symptoms than any others. Their meaning has become so indefinite that they now convey very little information, though they are much used--and abused. They are: rheumatism, gout and catarrh. Curiously enough all three of them when their etymology is studied mean the same thing as far as their derivation goes. Catarrh from [Greek text] the Greek word to flow down and rheumatism from [Greek text] the Greek verb to flow are terms that correspond exactly in etymology to gout, which is probably derived from _gutta_, the Latin word for drop--referring to the excess of secretion that is supposed to occur in the disease. All of these have for their basic idea, in etymology at least, an increase of secretion. A generation or two ago, the word rheumatism included a host of disparate painful affections, and was even more sadly abused than now, though its abuse has not ceased. The word catarrh is now at its acme of abuse. Gout has been pushed somewhat into the background by the other two. Any one of these three terms carries with it, in the popular mind, a connotation of progressive constitutional involvement which is not justified by anything that physicians know with regard to these diseases. The Uric Acid Diathesis.--The usual supposedly scientific explanation of a decade ago for many of these vague pains and aches classed as chronic rheumatism was that they developed on the basis of an excess of uric acid in the system. Advance in chemistry has completely obliterated the significance of the observation on which the theory of a uric acid diathesis, as it was so learnedly called, as an explanation for these conditions was founded. After uric acid there came for a time the theory of an excess of lithic acid, the so-called lithemia or American disease of a few years ago. These are, however, merely pseudo-scientific hypotheses and the more physicians know of chemistry the less they talk about them. Many practitioners, however, continue to accept this universal explanation which makes diagnosis so easy and which is supposed to be so suggestive for treatment. There are various remedies that are claimed to reduce the uric acid content of the blood or the system, and then there are various changes of diet that are supposed to do the same thing. These two systems of treatment and the combination of them have constituted the main therapeutic resource of many physicians for these so-called rheumatic cases, though their success has been anything but what they hoped for. Diet Tinkering.--Tinkering with diet has been particularly harmful in these cases. Over and over again I have seen patients who had lost considerably in weight because they had had all the supposed acid-forming elements removed from their diet. In many physicians' minds this seems to include most of the starches, as well as the fruits and many meats. Without any {381} potatoes, with only a limited amount of bread, with a warning as to red meats, and occasionally even some distrustful remarks with regard to butter, it is not surprising that the patients lost weight, that muscles became weaker, that painful conditions became severer, and that, above all, the patients' minds became less capable of bearing whatever discomfort is present. Besides, constipation intervenes with its train of consequences and patients become miserable, lose sleep often because of insufficient nutrition and actual clamoring on the part of their gastrointestinal tract for food. I have seen a man who was not much over normal weight to begin with lose twenty-five pounds, nearly one-sixth of his weight, while being dieted for vague pains (worse on rainy days) that were really due to his occupation, but that had been diagnosed as "rheumatic," consequent upon the uric acid diathesis, for which coal tar products were prescribed over a long period and his diet strenuously regulated. This has become as much of an abuse as the old-time purgings and bleedings. Irregular Treatment.--As we have said, this group of cases constitutes the most frequent and abundant source of profit for quacks and charlatans and irregular practitioners generally. The naturapath, the osteopath, whom we have already mentioned, for to these cases he owes most of his success in appealing to legislatures for recognition, the irregular electropath, many supposed diet specialists, and even the special shoemaker, have reaped a rich harvest from these patients. The reason why they have done so is that, as a rule, they have at once reassured the patients that their condition was not seriously progressive and have promised them certain relief from their ailment. Usually various local measures, such as St. John Long's liniment of one hundred years ago and many of its successors, or the mechanotherapy and the massage and the manipulation of the osteopaths of the present day, have been employed with consequent restoration of circulatory disturbances to normal conditions and, in general, the setting up of better mechanical employment of muscles than was possible before. If so-called chronic rheumatism is to be treated successfully and this opprobrium of medicine, as it has been called, is to be removed, it can only be done by a careful analysis of the ills of each individual patient and a definite determination as to just what local pathological condition is at work and not by a slip-shod diagnosis of rheumatism with immediate recourse to a supposed or assumed theoretic diathesis for the explanation of its etiology. Differentiation of Joint Conditions.--The local conditions that give rise to painful conditions of joints are most diverse in character. There was a time when all of the infectious joint affections had the term rheumatism applied to them. Even at present it is not unusual to hear of scarlatinal or gonorrheal or influenzal rheumatism. What is meant, of course, is that the microbes of these specific diseases have for some reason found a lowered resistive vitality in one of the joints, or perhaps several of them, and have set up an inflammatory disturbance. These specific arthritises are now definitely separated from the rheumatism group and it seems clear that in the near future we shall have rheumatism itself divided up into a series of diseases. By this I mean that even where there is the redness, the swelling and the fever of true inflammation of joints, it is not always due to one microbe, but to various microbic agents, and so we shall have various forms of rheumatism. At present we are prone to speak of many of the neuritises as rheumatic, but it is probable that {382} here a series of varying microbic infections will be found, some of them much more serious than others, most of them capable of complete cure, though some of them will tend to leave pathological conditions in nerves that are more or less crippling. Painful Joint Affections.--These pains and aches occur particularly in the old and those who have been hard muscle workers, in those who have been exposed much to the elements and especially in the subjects of old injuries. All of these conditions, one way or another, have left their mark upon tissues so that the nerves do not receive proper nutrition, especially when there is considerable exertion or in rainy weather. There are a number of reasons why rainy weather produces this effect. The humidity of the atmosphere lessens evaporation. This disturbs heat conditions in the tissues, for evaporation is the most important element in heat dissipation. This leads to the accumulation of heat in the parts and conduces to congestion. Any tissue of lowered vitality will be affected by this and nerves become oversensitive. Besides, it seems probable that the fall in the barometer with the lessened pressure from without makes a difference in the circulation. There is a general feeling of depression in wet weather and apparently the circulation is not so active. It is particularly slow at the surface of the body and in the terminal portions, so that the hands and feet are likely to be cold. Just as soon as the barometer goes up somewhat these conditions cease to be active and there is restoration of the circulation to its previous condition. Besides, it seems not unlikely that dampness produces some relaxation of muscles, so that it is more difficult to make them contract, and consequently they are used at a greater mechanical disadvantage and painful tiredness more readily ensues. All sensitive tissues become more sensitive in rainy weather, though in the case of toothache or neuralgia, for instance, we do not think of connecting this with the word rheumatism. _Classes of Sufferers_.--In persons who are over-thin or over-stout complaints of joint discomfort are not uncommon. In the first case they are due to the fact that muscles working around joints are not strong enough to accomplish their normal purposes. In the other cases, owing to the weight of the body, the muscles are overstrained. In a number of stout people the muscles do not increase proportionately to the size of the frame, much of the extra weight being in the shape of adipose tissue that constitutes a grievous burden. In people who run rapidly to either of these conditions of disturbed nutrition--thinness or stoutness--complaints are particularly likely to be heard. Familiar examples are often seen in the tuberculous who have lost weight rapidly or in convalescents from typhoid fever who are much thinner than they were before they took to their beds. On the other hand, those who gain in weight rapidly after typhoid fever or some other such pathological incident, or who, as the result of careful sanatorium treatment, put on twenty pounds in the initial stage of tuberculosis, may have similar discomforts to complain of in and around their joints. Heredity of Rheumatism.--The strongest unfavorable suggestion which most patients have is that their ailment, whatever it is, is hereditary and therefore not amenable to treatment. Nothing is more amusing to one who knows the present-day status of opinion in biology with regard to heredity than the frequent declaration that rheumatism is hereditary. Probably {383} nothing is commoner than to have a patient who is suffering from some vague, painful condition in muscles or joints, especially if that condition is worse on rainy days, declare that it must be rheumatism because father or mother suffered from rheumatism. I took the trouble to analyze in more than a dozen cases the rheumatism that was supposed to exist in the preceding generation, and found that it consisted of everything from pains due to old injuries and especially dislocations or fractures, through the various deformities connected with flatfoot, up to and including the worst manifestations of arthritis deformans. The condition in the parents supposed to be hereditary is never genuinely rheumatic. There is just as much sense in talking of hereditary pneumonia as of hereditary rheumatism. Perhaps there is an hereditary lack of resistance in the pulmonary tissues of some people that predisposes them to pneumonia. It must not be forgotten that a century ago, or even less, it was not uncommon to hear that certain people had hereditary tendencies to lung fever. We know now that these were tendencies to tuberculosis and not to true pneumonia. We know, besides, that tuberculosis itself is not hereditary and that probably even the predisposition to it is not specifically hereditary. As can be readily understood, the question of heredity in rheumatism is extremely important for psychotherapy, since the persuasion that their affection is inherited always produces an unfavorable effect upon patients' minds. In the old days, when tuberculosis was universally considered to be hereditary, a patient was likely to think himself the victim of an hereditary condition which could not be cured and which inevitably led to a fatal termination. Something of the same idea, though the immediate outlook is not so gloomy, is likely to follow the persuasion that rheumatism is hereditary. The question of heredity, of course, is bound up with that of rheumatism being a constitutional disease dependent on hyperacidity or some other pathological condition of the blood. Acute rheumatism, that is, acute arthritis, is an acute, infectious disease due to a microbe. This ought to dispose of any question of heredity in it. Chronic rheumatism is supposed to be related to acute rheumatism and to represent, as it were, a low-grade enduring condition such as in sudden accessions gives rise to acute rheumatism. So-called Chronic Rheumatism.--In these cases it is always a question whether the condition which causes the pain and discomfort is genuine chronic rheumatism or not. I am one of those who doubt whether we have any genuine, definite symptom-complex that should be termed chronic rheumatism. I have seen many ailments called chronic rheumatism. Any painful condition in the neighborhood of the joint that is worse on rainy days is likely to be labeled rheumatism and, because the salicylates are supposed to be a specific for rheumatism, treated with large doses of these drugs. These relieve the pain, as do any other coal tar products, but it is hard to understand how they are ever supposed to do any good for the underlying pathological conditions. The most noteworthy characteristic of acute rheumatic arthritis is that it leaves no mark upon the joints that were affected by it. These get completely better and the patient has no disability, no deformity, and there usually remains not even the slightest sign of there having been a serious inflammatory condition within the joints. In this it resembles pneumonia rather strikingly. True lobar pneumonia {384} clears up completely and the man has no symptoms once he has come through the convalescence. There are certain diseases affecting the joints, especially the arthritises in connection with various infectious diseases and the arthritis which accompanies acute arthritis deformans, in which there are serious sequelae and sometimes even complete disorganization of the joint. It is by these after-effects alone that we are sometimes able to differentiate genuine rheumatic arthritis from these other very different affections which resemble it so closely. Just the same thing is true of pneumonia. There are pneumonias that run a course at the beginning strikingly like true lobar pneumonia but which do not have a frank crisis and in which the lungs are seriously affected afterwards. We know now that in these cases it is not an uncomplicated pneumococcus pneumonia that has been at work, but either some other infection or else true pneumonia with a complication. Very often a dormant tuberculosis causes true pneumonia to run a different course from that which it ordinarily follows, and this, as a complication, leaves its serious mark upon the lungs. _Recurrence_.--In some cases there seems to be a tendency for the "rheumatic" disease to recur. This also is true of pneumonia. This does not so much indicate, however, any loss of special tissue vitality as a certain loss of vital resistance to a particular microbe. Certainly this tendency is not sufficient to make us think of chronic rheumatism or use that term any more than we would, under similar conditions, talk of chronic pneumonia or of chronic diphtheria, though both of these affections have a tendency to leave a lack of resistive vitality. In a number of cases, subacute rheumatism runs a course that is very bothersome and annoying and that is quite intractable, with relapses and sequelae, but even this is entirely different from the ordinary idea of chronic rheumatism. It is probable that these cases, like the pneumonias that do not end by crises, are complicated by some other condition in the joint that leads to reinfection. Unclassified Forms.--It is possible that in a certain number of cases for which as yet we have no name but rheumatism, there is a virulence of the microbic factor that brings about some joint disorganization. This, however--and the cases are very rare--is probably an affection to which the name of rheumatic arthritis will not be given when we know more of the disease and its cause. There are probably many forms of acute rheumatic arthritis due to varying microbes which will eventually be divided into groups, as we have made groups in the typhoid series of diseases and in the scarlet fever group and hope to do with other diseases. The Individual Case and Reassurance.--The main role of psychotherapy in these affections is to set patients' minds at rest as far as possible, by pointing out exactly what is the matter with them and keeping them from worry, discomfort, and even interference with their physical condition by over-solicitude. It is important to know every detail of the patient's occupation, of his habits, of his environment, of his exercise, and, above all, of his individual peculiarities of structure in the neighborhood of joints, so as to decide exactly what is the matter with him, and not be satisfied with the easy but unscientific diagnosis of rheumatism, which may mean much but usually means nothing. Unless such reassurance is given, and especially if the ordinary drug treatment for so-called chronic rheumatism is persisted in, after a time these {385} patients, unimproved by salicylate treatment, wander off to all sorts of irregular practitioners and form the greater part of the lucrative clientele of quacks and advertising specialists in the cure of chronic diseases. More probably than any other class of cases do they support the irregulars. Osteopathy has particularly appealed to a great many of these patients. It has done it in two ways. The first and most important probably by its effect upon the mind of the patients. Osteopaths immediately proceed to reassure the sufferers that their affection is not rheumatism, but some local condition dependent upon either a subluxation of the vertebra which, according to the founder of osteopathy, constitutes the basis of ninety-five per cent. of all the ills to which human nature is heir or upon some joint or muscle condition which can be corrected by manipulation or massage. These patients have, as a rule, been suffering a good deal before this from the thought that they were afflicted with a progressive constitutional condition which would almost inevitably cripple them. Often they have seen patients who were suffering from arthritis deformans in its worst forms and advanced stages; they have heard this called rheumatism and they have concluded that it was only a question of time when they would be in the same condition. There is no good reason to speak of such conditions as rheumatic. They are entirely local, the hope of relief between attacks is by properly applied massage and passive movements which facilitate the blood supply in the neighborhood, and the best applications at the time of discomfort are the various rubefacients which stimulate the circulation in the parts, call the blood to the surface, and prevent that congestion in the neighborhood of small nerves which is the cause of the aches or pains. These affections take on a much more serious character in the minds of patients as soon as the word rheumatism is mentioned. To tell them that the condition is entirely local, has no tendency to spread, has nothing to do with any constitutional condition, and can be relieved by local measures and the improvement of the general health, will often bring the patient a good measure of relief. SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS How much the treatment of these so-called chronic rheumatisms depends on suggestion, in spite of the apparent improbability of anything so materially discomforting being under the influence of the mind, is best appreciated from a consideration of the many inert materials that have been used for the cure of rheumatism. There is, of course, no more virtue in red flannel than in any other colored flannel, but many people suffer from rheumatism or rheumatic discomfort whenever they do not wear red flannel and are sure that it means much for them. Then there are all sorts of supposed electrical contrivances that do not generate an ion of electricity. They are effective only through the appeal they make to the mind. Some men wear electric belts and attribute their freedom from rheumatic pains to them. Others wear so-called electric medals or electric shields or electric insoles. Any number of people in this country wear electric rings on the little finger of one hand and get marvelous relief from it for their chronic rheumatism. Some have noted good results from even less likely objects. There are thousands in this country who carry horsechestnuts as a preventive against rheumatism, and some of {386} them, intelligent men and women, are persuaded it lessens their pains and aches. In another place I have told the story of the woman who was a sufferer from rheumatism and who found great relief from carrying a horsechestnut. As her husband was also a sufferer, she wanted him to carry one, too, and when he would not, she carried one for him. It is to be hoped that her conjugal tenderness in this matter had as good an effect on him as she was sure the propinquity of the horsechestnut had on her. The patients' occupations must be regulated by proper advice and detailed directions, and distractions of various kinds must be provided to keep their minds from becoming concentrated on certain portions of their body, emphasizing whatever discomfort is present and preventing nature's curative processes. Finally, local treatment of various kinds must be employed suitable to each individual case, that will remove all mechanical difficulties, disperse congestions, relieve fatigue and over-tiredness, and make conditions favorable for the healthy, normal use of joints and muscles. Many painful affections of joints, sometimes complicated by immovability, are really psycho-neuroses. Sir Benjamin Brodie once said that four-fifths of the joint troubles that he saw among the better classes were hysterical. Sir James Paget thought this an exaggeration, but confessed that he saw many of them and among all classes of people. One-fifth of those that he saw in hospital and in private practice were entirely neurotic. He emphasized the fact that they must be looked for not only among women but that they are often found in men and that they are by no means confined to those who are nervously inclined, the silly young women or the foolish old women, but that they may be found in special circumstances among the most sensible people. They are often initiated by an injury which makes it quite difficult to differentiate them from real joint affections. Usually, however, there is no redness, nor swelling nor heat with them, though sometimes one of these symptoms at least may occur with the redness. The connection between the trivial accident and the large reaction is usually hard to find and causes a suspicion as to the real process at work. Often, too, there is a delay of several days or sometimes weeks after the accident before the neurosis declares itself. In the meantime it has been getting on the patient's mind. In general, it must be remembered the patient's attitude of mind in these cases of pain around joints and in muscles is extremely important. They have furnished a goodly proportion of the patients on which quacks and charlatans have fattened. Greatrakes in the seventeenth century, Mesmer and Perkins, St. John Long, the early electrotherapeutists, the blue glass faddists, all the various liniment makers, many of the manufacturers of blood purifiers, and Eddyism and mental healing besides osteopathy in our day have all benefited these sufferers for a time and the patients have often been men and women of education and influence in their communities and have exerted their influence for the benefit of their supposed benefactors. The methods of treatment come and go. The promise of the physician or the healer and the confidence of the patient are the only factors that are common to all the supposed "cures." If people stay at home without the air and exercise they should have, if they nurse their ills and consider that they are sure to get worse, because they labor under hereditary or constitutional ailments, nothing will benefit them. {387} If they are convinced that their disease is only local and begin to go out to see their friends once more, a change comes over the whole aspect of their disease. CHAPTER II OLD INJURIES AND SO-CALLED RHEUMATISM As people advance in years, it is a common experience that tissues injured years before are the source of no little discomfort and are particularly prone to be bothersome during changeable seasons and in rainy weather. A bone broken when the patient was young may twenty or thirty years later continue to give warnings of the approach of change in the weather and be a source of annoyance. A dislocation, especially if complicated in any way by considerable laceration of the tissues in the neighborhood of the luxated joint, is sure to be a source of discomfort of this kind. These painful conditions are generally more noticeable when patients are run down, or when they have been recently affected by exhausting disease of any kind, during convalescence from severe ailments or injuries, or when they are undergoing a special mental strain. These conditions, like nearly all others worse in damp weather, are sometimes grouped under the term rheumatism and have been treated by internal medication. Almost needless to say, such treatment is sure to fail or to be of only temporary anodyne benefit. As rheumatic remedies are usually coal-tar products they may even be distinctly harmful, especially for old patients. It has been shown that the salicylates, for instance, are much less rapidly eliminated in the elderly than in the young, in those with defective circulation or kidney insufficiency than in the well. Their accumulation in the system causes anemic tendencies and disturbs nervous control. Just what is the underlying pathological condition in these cases is not easy to say. In the case of luxations with laceration of tissues there has undoubtedly been such a disturbance of venous and lymphatic circulation by the break in continuity of tissues and the resultant scar tissue, that lymphatic if not also venous congestion occurs whenever there is any circulatory disturbance. For the maintenance of normal nutrition of nerve endings a constant flow of blood past them and a proper action of the lymphatic channels to carry off waste products is essential. It is easy to understand how much these may be disturbed in the injuries under consideration. When a bone is broken there is usually laceration of the surrounding tissues. Owing to the fixation required to procure proper bony union, the circulation to the part is much more defective than usual and so the repair of torn lymph and venous vessels is not as complete as would otherwise be the case. This seems to explain why such injuries are especially called to the attention of the patients in damp weather. It is not so much during a rain storm as some hours before it, about the time when the barometer begins to drop, that these old injuries become sensitive. Indeed, it is often said that old persons who have suffered one of these injuries earlier in life carry a barometer around with them. Not a few of the lesions called sprains, especially those of the ankles and {388} wrists, though also of other joints, are often really breaks of small bones, or at least laceration of ligaments and other structures. These may long afterward prove a source of pain and discomfort, worse always in unsettled weather, or after the feet have been wet, and may seem to be due to some constitutional condition, though they are merely local. These occur more commonly in women than in men and the condition needs careful investigation and must not be put under the vague diagnosis of rheumatism, or the patient will probably not be improved by the treatment suggested. In all these cases the general condition must be looked to, and it must not be forgotten that fat may not mean health, and that increased weight may be a prominent factor in the production of symptoms in these cases, especially when individuals live a sedentary life. There is an important therapeutic method for the prophylaxis of these conditions that has been attracting attention and yet probably not all the attention it deserves in recent years. Prof. Lucas-Championnière of the University of Paris has pointed out that when fractures and dislocations are treated by the open method with easily removable apparatus and the employment of massage within a few days after the fracture, the subsequent discomfort of these lesions is much lessened. It seems worth while to emphasize this treatment by manipulations and massage, because it represents a psychotherapeutic factor in the treatment of these injuries. The hiding away of a limb or a joint for days and perhaps weeks, while they wonder whether it is getting better or not is most discouraging to patients. To have the physician see it, to have him declare that it is getting on well, to have the evidence of their own senses that conditions are gradually improving, is of itself a valuable factor for that satisfaction of mind which conduces to the regular functioning of tissues. Repair undoubtedly goes on better under such circumstances. Besides, the lack of constriction or at least its rather frequent periodic relaxation, the airing of the skin, the regulation of the circulation by massage and manipulation, all react upon the mind and prevent it from inhibiting trophic impulses and encourage it to stimulate them in every way. As to the after-effects of fractures and dislocations as with regard to all this series of vague pains and aches, the patient's attitude of mind is of great importance. As they get older their aches and pains grow worse, partly because circulation is more defective and partly because they are prone to be much more in the house and the nerves of patients who are much within doors are always more sensitive than those of people who are much in the open. If their attention becomes concentrated on their pains and aches, because of lack of diversion of mind, then the condition may become a source of serious annoyance. When these painful conditions develop patients are almost sure to keep much to themselves and to nurse their ills, and consequently to increase their discomfort. The circulation to the affected parts must be stimulated by local treatment, by rubbings, by the milder liniments, by massage and manipulations, and by local hydrotherapy. Douches, as hot as can be borne, on the limb followed by cold, especially if patients are otherwise in good health, will do much to relieve the stagnant circulation. Active and vigorous movement while the affected part is supported at _skin pressure_ (there must be no constriction) is even more valuable than {389} massage, liniments or douches in the treatment of all these painful conditions of joints in which there is any scar-tissue. Wonderful results may be obtained in an old sprain of the wrist, knee and ankle by covering in the part completely (taking care to surround the limb) with strips of adhesive strapping simply laid on at skin pressure, but following exactly every fold or angle of the part, and then with the part completely covered in this way to urge immediate and constant exercise. The maintained pressure prevents any tendency to venous congestion or exudation and favors absorption of fibrous tissue, and exercise, which should be immediate, is now possible through the support furnished by the strapping. The re-assumption of normal active movement molds the old scars, strengthens the muscles and ligaments and improves the patient's general condition. The relief afforded _is immediate_, and the cause of relief, a simple mechanical device, is apparent. Rheumatism is forgotten as the old crutch is discarded and the patient is able to use the limb with confidence. Recent sprains or bruises treated in this way recover perfectly and do not leave old scar tissue to be a future seat of pain. CHAPTER III MUSCULAR PAINS AND ACHES Whenever exposure to cold causes a period of discomfort in almost any organ, except the teeth and certain definite nerves (for neuralgia has been taken out of the rheumatism group in recent years) we are sure to hear the word rheumatism employed in connection with it. To add to the confusion, the various "specialists" have taken to assuring their patients that local manifestations in the eyes, in the ears, and in the nose, for which they can find no good reason, especially if they are worse in damp weather, are signs of the rheumatic diathesis. Unfortunately, our supposed knowledge of the uric acid diathesis became widely diffused, and it is not surprising in the light of the widespread acceptance of this theory, that muscular pains of all kinds should have the word rheumatic attached to them, and that patients are sure that the discomfort is only one manifestation of a severe constitutional disease, which they cannot but infer will probably make still more serious trouble for them in years to come, since it seems to be dependent on conditions beyond their control, such as heredity and general constitutional traits and their special mode of nutrition, rather than on local or passing conditions. Local and Constitutional Conditions.--It cannot be repeated too often that it is this persuasion as to the constitutional character of the disease that has in recent years proved a very unfavorable suggestive element in these cases. Patients think themselves the victims of a serious diathesis, a deep-seated pathological condition, and attribute a host of feelings to it that are sometimes rather seriously disturbing but are really only sensory manifestations of various kinds in the organs and in the skin and muscles, which would be attributed to simple local causes--fatigue, faulty mechanical conditions, etc.--but for the concentration of attention on them. {390} _Individual Cases_.--The careful study of these cases is thus extremely important. They are eminently individual and not to be grouped together. The exact diagnosis of the various conditions from which each patient is suffering is of itself a precious factor in psychotherapeutics. The precise recognition of the condition present is of immediate avail in helping him to dismiss many of his symptoms, or at least to keep him from thinking as much of them as he did before or inevitably will if the older ideas as to the constitutional nature of his affection are allowed to remain. Nearly every large group of muscles in the body may be the subject of these painful conditions. In recent years, perhaps, the muscles most affected in this way are those that pass around the ankle and give so much discomfort in cases of flatfoot, or beginning flatfoot (euphemistically called weak foot), when the plantar arch is yielding. The manifestations are not only in and around the ankle, but occur in the calf muscles and even above the knee. These painful conditions always develop unless the arch is supported. Until recent years it was rare to discover a bad case of flatfoot in which the patient had not taken many rheumatic remedies and had not come to the conclusion that he was the subject of an incurable and probably hereditary constitutional disease. Flatfoot is likely to cause considerable deformity in the old, the toes becoming bent and twisted up, and the subjects of it complain very much of their feet. Flatfoot runs in families. When the father and mother have complained of what they called rheumatism in their feet which got worse every year, then the son and daughter, when they have their first manifestation, conclude that they are inevitably bound by the stern laws of heredity. Occupation Aches.--Flatfoot is taken, however, only as an extreme and therefore striking illustration. Whenever a particular group of muscles has to do an excessive amount of work, practically always there is a development of an uncomfortable condition worse on rainy days and therefore likely to be called rheumatic. Over-use of the arm at any occupation, in writing, in the use of a file, at an ironing-board, in sewing, or at anything requiring repeated movements, will produce it almost inevitably. Especially is this true if the occupation is carried on without such careful attention to muscular action as enables the muscles to do their work to the best advantage. These painful conditions are much more likely to occur in run-down individuals of nervous temperament, above all if they have been or are subject to worry. Men who have lost money and now have to do hard physical work, after previously having lived sedentary lives, and women whose previous source of support has been withdrawn and who have to work for a daily wage after former gentle conditions of living, are especially likely to suffer in this way. The conditions develop on a neurotic basis or an exhausted nervous system. Other groups of muscles may also be the subject of these painful conditions. The large group in the loins, called the lumbar muscles, which are so important for stooping, for the erect posture and for lifting, are so commonly the subject of discomfort that a special name has been applied to their affection--lumbago. In the leg the large group of muscles supplied by the sciatic nerve are likely to be affected, and this affection is so common in men who have to bend the knee and flex the hip at their work that it, too, has received a special name--sciatica. Besides the arm muscles the groups of muscles around the shoulder girdle are often unfavorably affected and though we have not invented {391} a name to cover their conditions, it is so common that we think of it as a separate entity almost in the same manner as we think of lumbago and sciatica. In the neck the group of muscles that rule the movements of the head, especially those at the side may be affected and the special name of torticollis has been given. Practically all of these affections are thought of at times as rheumatic and the ordinary rheumatic treatment is given for them. There is no doubt that the salicylates will relieve the pain almost at once, but so will any other coal-tar product and phenacetin, acetanilid or even antipyrin may be used with good effect. There is no evidence, however, that these drugs make the underlying condition better and, indeed, after patients have tried them for a while, unless the affection is merely passing, they try some other physician and perhaps are treated the same way with a different form of the drug. These are the cases that make their way around to a number of regular practitioners of medicine and then eventually go to some irregular or quack and sometimes obtain relief where the regulars have failed. When the irregular succeeds it is always because he has done three things. First he has persuaded the patient that it is not rheumatism, with all the unfavorable suggestion that goes with that word, that is, the matter with him; secondly, he has treated the local condition; and, thirdly, he has diverted the patient's mind. Local treatment is often the real secret of his success, though the psychotherapeutic element is not without distinct benefit. Mode of Occurrence.--These muscular conditions present themselves under two forms, acute and chronic. The acute condition occurs almost suddenly and is accompanied by spasmodic pain and acute discomfort. Muscles go into spasm to avoid the movement that would necessarily bring pain with it. A typical example is found in torticollis in which the patient wakes up some morning to find a stiffness in the muscles of his neck with limitation of movement much more pronounced on one side, and this usually gets worse as movements are attempted during the day. This spasmodic painful condition usually lasts for some days and suggests all sorts of topical applications and often requires anodyne drugs. A similar acute condition may be observed in some cases of lumbago. In this the pain in the loins comes on suddenly, usually during movement, often in the midst of lifting something that one has been able to lift without difficulty before. This pain is so sudden, so unexpected, usually comes entirely without warning and seems so mysterious in its origin, that it is no wonder the Germans speak of it as _Hexenschuss_--"witches' shot"--a remnant of the superstition that a witch, by means of the evil eye or some other maleficent power, or by sticking pins in a wax image of a victim that had previously been devoted to the devil, might produce effects upon the person at the part where the thought was directed or the pin inserted. These painful conditions, especially when acute, are, as a rule the consequence of exposure to dampness, or to a draft blowing directly on the part, usually in damp and changeable weather, and often when the patient has been sweating just before. The train of events that brings about the painful condition is not difficult to understand. There is a disturbance of the normal smooth-running, indeed almost frictionless, mechanism by which muscles glide over one another. There are practically a series of joints in all muscular groups so as to permit just as free a play as possible of muscles over one another. Each muscle is covered with a glistening membrane so familiar {392} from our dissecting room days, which secretes a substance resembling a synovial fluid, to enable muscles to move upon each other without friction. When, because of exposure to drafts or the evaporation of moisture on the surface, there is a disturbance of the circulation in these intermuscular planes, the secretion which prevents the friction of muscle movements is disturbed. The blood is driven from the surface and some congestion and consequent heat accumulation occurs in the muscles, affecting particularly their contiguous layers. As a result, the muscle surfaces are no longer smooth and the muscles now have not as free play over one another as before. It is not surprising that, owing to this, sensitiveness occurs and some spasm develops. This, however, is thoroughly conservative in character since nature's idea is to set the part at rest so as to allow the normal condition to be restored. This is the pathological condition that underlies these so-called muscular rheumatisms which develop suddenly. It is important to note, however, that these conditions develop nearly always in people who have been over-using or wrongly using the groups of muscles which become thus affected. The history of a torticollis patient will usually show that there is some contortion of the muscles of the neck familiarly practiced by him. Sometimes it will be found that the patient has the habit of sitting on a particular easy chair in a special relation to the light and that in order to accommodate himself to his chair and the light in his reading, the head has to be placed in such position that the neck muscles are constrained. It is this that predisposes the patient to the development of the condition which seems to be so acute and yet is really only an exacerbation of a chronic condition. Lumbago will develop in men who have been stooping much, especially for heavy lifting, or in women who scrub or have to stoop much while cleaning, dusting and the like. Some interesting muscle pains occur as a consequence of the jostling movements of various modes of transit. They are particularly noticeable if an uncomfortable position has been maintained for a number of hours. People who travel on railroad trains often come with the story that they _must_ have caught cold on the trip for they have been sore and achy in many of their muscles since. I have known people who went on a crowded excursion and had to stand for several hours confident that, standing in the drafty aisle of the car on their way home, they had acquired rheumatism. All that had happened was over-tiredness of muscles on the jolting train which required constant balancing and unaccustomed muscular exertion. On board sea-going vessels people often suffer from pains in the loins and in various trunk muscles, due to the roll of the vessel, especially while they are asleep. These, too, are likely to be attributed to drafts, or to some form of rheumatism, or at least to the catching of cold. I have even seen people sure, because of pains in their loins, that they must be developing some kidney trouble. After a time they get used to the swinging motion of the vessel and then their achy muscle tiredness is relieved. One now sees affections of the same kind in connection with the automobile. People who ride for many hours, especially if the riding is rapid and over a rough road and they are not used to it, are likely to develop pains and aches which they may attribute to the catching of cold or to rheumatism or to something of that kind. The muscles of the trunk are especially likely to {393} suffer. The abdominal muscles may be quite sore and then later the lumbar muscles develop aches. The arms suffer if they are held in unusual positions because of the jolting. The discomfort may be relieved by any of the coal-tar products, though gentle rubbing with a stimulant such as soap liniment, always in the direction of the return circulation in the muscle, will help to relieve the painful condition. The salicylates are often given for these conditions and relieve the discomfort but because of their value as anodynes, which they share with the coal-tar products, and not because of any genuine antirheumatic effect. Treatment.--Counter-irritation of various kinds, especially the milder forms, always seems to do good. The underlying therapeutic principle seems to be that the attraction of blood to the surface lessens the hyperemia or at least diverts the circulation and permits the restoration of function and encourages the reintegration of normal conditions. Rubbings are especially helpful if accompanied by rather deep pressure from the periphery of the circulation towards the center. The leg muscles must be rubbed upward, the arm muscles upward, the neck muscles downward, the trunk muscles generally in the direction of their return circulation. This would seem to indicate, as might be expected, that it is the venous circulation especially that is disturbed in the tired condition of the muscles, that a venous congestion with interference with the nutrition of nerves accounts for the aches; hence, a mechanical helping of the circulation is of benefit. There are some whose opinion is not to be put aside lightly, who think that the rubbing alone is the most important part of these external treatments and that the liniments and counter-irritants are only of secondary importance. Indeed, some consider that the tingling of the surface is mainly beneficial in making the patient feel that now that part of the body at least _ought_ to be better. Liniments for these conditions, however, though introduced on merely empirical grounds, are very old and have the testimony of many generations as to their therapeutic efficiency. Whenever that is the case, it is a serious question to doubt the conclusions that have been arrived at. The experience of a single generation, and, above all, of a small group or school of men, no matter how learned or how scientific they may be, is often fallacious. The experience of many generations, however, even though no good reason for the benefit derived from the treatment they suggest can be found, is almost inevitably correct. After all, though it is usually forgotten, the use of mercury, of iron, of quinin and of most of the tonics depends on nothing better than empiricism. In our day the liniments have been neglected, more perhaps than was proper, considering how many generations of physicians found them beneficial. Where it is a neurosis rather than a real disturbance of the circulation, however, that is involved, the use of a counter-irritant, by attracting attention more and more to the part, may really do more harm than good. In nervous people it must be remembered that local neurosis may occur almost anywhere in the body and that subjective discomfort alone in these cases must not be taken to signify a pathological condition, unless the localization is such as to indicate that a particular group of muscles is affected. The differential distinction between a pure neurosis and a discomfort due to a true pathological condition in the intermuscular planes is, that in the one case a group of muscles is affected, while in the other a locality is complained of, and {394} while local tenderness is likely to be a marked source of complaint in the neurosis it is comparatively slight as a rule in the muscular condition. For the more chronic soreness and discomfort of muscle groups, manipulations with massage are of great importance. Undoubtedly the discomfort and soreness is due in most cases to a disturbance of the venous or lymphatic circulation of the parts. This interferes with the nutrition of nerves and leads to nerve sensitiveness from lack of nutrition, or actual nerve irritation from pressure upon sensitive nerve endings while in a state of congestion. These conditions may be relieved by gentle manipulation and by massage, provided always these measures are not painful. These encourage the circulation and very soon tend to restore functions. Just as soon as the pain of these remedial measures or of any mechano-therapy becomes noticeable, it is not likely that they are doing any good. Pain, of course, must be judged from conditions and not from the patient's complaints, which may be due to fear lest pain should be inflicted. The main point is that local treatment, gentle, simple, yet directed with the proper therapeutic purpose so as to create a favorable expectancy in the patient's mind, will do much for these conditions, which have in many ways been the opprobrium of modern medicine. The rule has almost been to call them rheumatism, because they were worse in rainy weather. The word rheumatic instinctively calls up in most physicians' minds some cut-and-dried formula of internal medication. So these patients go the rounds of the regular practitioners in medicine taking a series of these formulae in succession and, as a rule, not getting any better. Then they go to an osteopath or to a naturapath, or some other kind of path, have some local massage and manipulations performed, which restores the circulation of the part, to some degree at least, and as a consequence they are encouraged to look for further relief. Not a few of them find the relief they look for, and it is these cured patients that in many parts of the country have insisted on securing for the osteopaths legislative recognition and actually obtained it for them in many cases, just because the regular physicians have neglected methods of cure ready to hand, but not made use of, because drugs are allowed to occupy their attention too exclusively. Disuse, Atrophy and Pain.--I have seen a striking example of atrophy and pain due entirely to disuse in the upper part of the leg as the consequence of a fall. No bone was broken, the man was laid up for nearly a month from the wrench, and then continued to be somewhat halt for many years. After nearly twenty years his attention became concentrated on this limb and then he spared it more and more in his walking, tilting his pelvis and merely swinging that leg, until there was a difference of nearly two inches between the size of the thighs. Of course, under these circumstances any use of the limb brought fatigue and pain with it. To walk was painful, and he had some twitchings at night. There was no disturbance of sensation, however, anywhere and no reaction of degeneration. His knee jerk was slighter than on the other side, but it was present and the weakness was due to the loss of power in the muscles. It was only weak in proportion to the atrophy of the muscles. This atrophy was not trophic in the sense of any failure of nerve impulses from the central nervous system, but was due to disuse, that is, it did not come from any nervous lesion, central or peripheral, nor from any disturbance of circulation, but from the dwindling of muscles that inevitably {395} comes when they are not employed for their proper purpose. Power to use depends on continuance of function. All sorts of remedies had been employed in his case, but he did not improve until he was made to understand that there was no bone lesion, no lesion of nerves or muscles, and that what he needed to do was to re-exercise his muscles gently but persistently and confidently back to their normal strength. This was accomplished by exercise and resisted motion, with care never to fatigue the muscles, but at the first sign of tiredness to stop, taking up the exercises at first twice, and then three and four times a day. As can be readily understood, these curious atrophic muscular conditions from disuse occur more frequently in the legs than in the arms. They may, however, occur in the upper extremities and are noted sometimes in the trunk. After all, certain of the stooping postures of men as they get old are due to lack of use of the large muscles at the back with consequent atrophy of them to the extent that makes standing up straight an effort very fatiguing and even painful. To attempt to straighten an old man by means of braces will lead to the development of painful conditions of tiredness if the correction is emphasized. In the arms the atrophic conditions are not so noticeable because the arms may be used without having to do the hard work required of the trunk and leg muscles in holding the man erect. It is the fear of the strain put upon them by this weight that makes the disuse continue, since there has come into the mind the thought that the muscles cannot be used to bear the weight and the burden is thrown on other muscles with unfortunate results. Many of these atrophies from disuse are cured by mental influence of one kind or another. They are the best sources of profit and reputation of the "healers." Once the patients become persuaded that they can use a group of muscles if they will, they begin to improve, and it is only a question of six or eight weeks until they are so much better that they persuade themselves that they are as well as ever. It is easy to understand that if a person who has been lame for five to fifteen years, vainly going to physicians of all kinds, is cured by some new form of treatment, all the non-medical world is perfectly sure that there must be much in the new method of treatment. CHAPTER IV OCCUPATION MUSCLE AND JOINT PAINS There is one variety of painful conditions of muscles and joints, often spoken of as muscular rheumatism or as chronic rheumatism and frequently the source of so much discomfort that patients feel that occupations must be given up, even at a great sacrifice. These deserve a special chapter. They occur in persons who have some occupation which requires them to use a particular group of muscles a great number of times during the day. They are most frequent in the arms, but they may be seen in the muscles of the neck, they occur very often in the legs and are not at all infrequent in the muscles of the trunk. Whenever a patient comes complaining of a painful condition in a particular group of muscles, careful inquiry must be made as to his {396} occupation, with details of the movements required. These pains are, of course, as are all human discomforts, worse on rainy days and in damp seasons, so that this has come to be known as rheumatic weather. It is easy to assume without further inquiry that they are rheumatic and this has been done frequently in the past. There is scarcely any occupation involving frequent and habitual use of muscles which may not be the source of discomfort if the actions necessary for it are done in such a way as not to use the muscles to the best mechanical advantage. In other words, there are a whole group of occupation fatigues which may take on a character of painful discomfort if the individual has not been properly trained in the use of his muscles. This refers not only to the use of muscles in the accomplishment of rather difficult tasks, but especially for those that require nice co-ordination for their accomplishment, though they may not demand the exertion of much muscular energy. In other words, what we have to deal with are rather painful occupation-neuroses than muscular fatigue in its proper sense. Writers' Ache.--Perhaps the most typical example of these is the painful conditions that may develop in connection with writing. Writers' cramp is well known and consists in a contraction of muscles which makes it increasingly difficult to hold the pen properly for writing and may eventually make it impossible to do so. This is accompanied by a certain amount of distress, but the writer's discomfort that is much more common than writers' cramp does not occur in the fingers, but in the large group of muscles just below the elbow and may extend even to the shoulder. The pain is of a vague achy character and as it is worse on rainy days and in damp weather, the temptation to think of it as rheumatism is very great. It occurs in people who write very much and rapidly, but especially those who write in a bad position. Now that the typewriter has come in much less is heard of it than before among reporters, but it used to be common with them. There is very little hint that it is due to writing, unless one makes careful inquiries. _Gowers' Rule_.--Its occurrence can be lessened to a great extent by following Sir Wm. Gowers' directions as to writing. Gowers was a parliamentary reporter before becoming a physician and he learned the difficulties of much writing and studied out the causes of the discomfort as well as of the cramp and of the best methods to avoid it. His rule is to sit on a rather high chair before a rather low table so that the elbow swings free of the table and the writing is what is called free-hand. The extent to which Gowers demands this freedom of the elbow carried may be best appreciated from his direction that the writing must be done in such a way that if a second pen were fastened to the elbow, it would write exactly the same thing that is written by the pen held in the hand. There must not be any movements of the fingers nor of the muscles of the forearm. All the movements required from writing must be accomplished from the shoulder. Just as soon as sufferers from vague aches and discomforts from much writing learn this method of writing, their aches disappear to a great extent. My own experience in the matter, when, as a medical reporter, I often wrote ten thousand words a day, taught me the value of the suggestion. During one winter I suffered so much from discomfort in the shoulder that I was sure that I had a progressive rheumatic affection. Just as soon as I learned to write properly the trouble was minimized to such {397} a degree that I realized that it was merely a question of faulty writing. I have noted over and over again, as is true in my own case, that if there has previously been any injury in the arm, this discomfort is much more likely to develop than otherwise. Occupation Pains and Habitual Muscle Movements.--What is true for writing is true for any habitual movement of groups of muscles requiring careful co-ordination. I have seen it in marked form in the makers of cigars and the strippers of tobacco. I have seen it in men who do much filing and whose working bench is so high, that pressure direct from their shoulders cannot be brought into play to supply any force that is needed in carrying on the filing process. If such a series of movements as filing is to be accomplished with comfort, then the arms must be held straight, the force being applied from the shoulders and not by the exertion of the muscles of the forearm, which are meant only to guide and not to supply the needed pressure. The Sloyd methods of working at benches are particularly important for workmen if they are not to develop these curious painful conditions which are due to habitual wrong use of muscles, and not to any diathesis. Any and every form of work must be looked at from this standpoint. Women often iron at a table or ironing board placed too high for them, and as a result apply the pressure necessary through their forearm muscles. If they are at all of nervous constitution they will suffer rather serious discomfort from this after a time and this will always be worse in damp weather. I have known women ready to give up because of the discomfort thus occasioned, who found that they could work without muscle discomfort for much longer periods, if the ironing board was placed low enough. _Arm and Shoulder_.--The occupation aches and discomforts in the arm and shoulder are very frequent and their variety presents an interesting study in the individual and his history. I remember once having three cases present themselves at a dispensary service of the Polyclinic Hospital on the same day, all presumably suffering from rheumatism. One of them was a motorman suffering from the occupation pains that so often come to those who use their arms overmuch, and the pains seen so frequently, for instance, in baseball pitchers. These pains are always worse on rainy days and in damp weather. There is of course a large individual element as the basis of these. Why can one man pitch nearly every day all season and not suffer with his arm while another man cannot? We can no more tell the reason for this difference than we can tell why one man is right-handed and another left-handed. One individual has a store of nervous energy that serves him very well. Another has a store of nervous energy that serves him well enough for his left hand but not for his right hand. The mystery would seem to be the original endowment of nerve force according to the individual's constitution. The motorman who suffers severely from putting on the brake of a heavy car will probably never be able to continue his occupation with comfort to himself unless his sore arm is due to some temporary condition, easily recognizable. A second of my patients with rheumatism complained of his shoulder. He had been first easily fatigued, then it was painful when he moved much, most so on rainy days, and finally he had practically lost power in it entirely. His occupation was that of finisher in a molding works. He lifted a heavy hammer many hundreds of times a day with his right arm, striking quick short {398} blows and using mainly his deltoid muscle in the lifting process. It was just his deltoid that was affected and the nerve supply had evidently given out. The third man complained not of his right hand, but of his left and of his forearm, not his shoulder, having lost power especially on the ulnar side of his hand. He was a stonecutter, who held a chisel firmly in his left hand, grasping it mainly with the under or ulnar side of his hand, and consequently overusing the group of muscles supplied by his ulnar nerve, leaving that structure open to pathological conditions. There was just one feature in the history of all three that was the same. They did not drink alcohol to excess often, but they did take some whiskey straight every day. The easiest explanation seemed to be that there was a neuritis set up in the nerves, which their occupations caused them to use so much, and that, as a consequence, the low grade neuritis finally developed to such a condition as to make further use of the muscle supplied by the affected nerves practically impossible. Just why alcohol will select certain nerves and not others upon which to exercise its deteriorating influence and why lead usually affects an entirely different set we do not know. In the ordinary man of sedentary occupation who walks occasionally, as his only exercise, his most used nerve is his anterior peroneal. Those of us who are not used to walking much, know how soon this nerve complains of fatigue when we take some forced ambulatory effort. It is this nerve then that with most people is affected by alcohol. But any nerve that is overused will apparently be affected the same way, and as many outdoor workers take some whiskey straight pretty regularly, it is not surprising to find that some of them have an idiosyncrasy and develop a low grade alcoholic neuritis. Alcohol, however, is not the only substance that acts thus insidiously. I was once asked to treat a painter who was suffering from intense tired feelings in his right forearm. They were always worse on rainy days, and he had been treated for rheumatism without avail. He had no signs at all of wrist-drop, there were no suspicious signs on his gums and he had never suffered from constipation or anything like lead colic. It seemed far-fetched, then, to say that his muscles were fatigued mainly because of the irritating presence of lead in the nerves supplying his right forearm. He slipped on the ice, however, and sprained his wrist, and the next day turned up with a typical lead wrist-drop. This fact of having lead poison develop shortly after an accident is not unusual, just as a sprained ankle may sometimes be the signal for an outbreak of alcoholic neuritis in the lower leg which has been preparing for some time, the accident itself being at least partially accounted for in many cases by the awkwardness of muscles with disturbed nerve supply. _Leg Occupation Pains_.--What is true of the arm is also true of the leg. If a man uses his leg muscles very much and especially at any mechanical disadvantage, he usually suffers painful discomfort that is always worse on rainy days. Before the invention of the electric dental engine, dentists used to suffer from this and the profession talked about the "dentist's limp." This was also more painful in damp weather and many of them were treated for rheumatic conditions, though it was really only over-fatigue. Neurosis and Neuritis.--There are many cases of painful conditions in the limbs where it becomes difficult to diagnose between a neurosis and a neuritis. The usual differential characteristic of tender points along the course of the {399} nerve cannot be used in many patients with confidence, because they are prone constantly to respond to the question "is that tender" in the affirmative. Besides in a neurosis there always seems to be a hypersensitiveness of the nerves involved that may simulate the tenderness of neuritis. In a number of obscure cases I have felt that the condition was a real neuritis when the development of a corresponding condition on the other side, or relief on one side followed by development on the other, has led to the diagnosis of neurosis. Of course, a double neuritis may well occur in the same nerve on both sides of the body under certain toxic conditions. Double sciatica nearly always indicates glycosuria. Diabetes may cause double neuritis in any other much used pair of nerves. Alcoholic neuritis may manifest itself on both sides. Ordinarily, however, the transference of symptoms or their spread to the other side of the body means a neurotic condition. In some of these cases where it has been difficult to distinguish between neuritis and neurosis, a change of occupation or some strong diversion of mind for a considerable period or a change of residence has proved the beginning of a cure. I have seen what was considered by experienced physicians to be a chronic low-grade neuritis of quite intractable form clear up completely as the result of the young woman being compelled to take up a wage-earning occupation, when it had always seemed before as though life was going to be smooth and there was no necessity for her to labor. I know of cases of so-called neuritis that had been very obstinate to treatment that were cured by Eddyite treatment. What really happened in these cases was that a group of muscles used considerably more than usual had produced a painful tired condition referred to a particular nerve. Just as soon as the mind's inhibitory action was taken off them by the persuasion that there was nothing the matter with them the patient proceeded to get well, gradually progressive use bringing back the normal trophic condition. Discomforts of Bursae.--In any consideration of painful conditions in and around joints, especially in connection with occupations, the question of the formation and of the inflammation of bursae must be insisted upon because many of these inflammatory incidents are confused with joint affections and not infrequently treated as if they were due to constitutional disturbance. Practically everybody is familiar with housemaid's knee. Most people know that bunions are inflammations of the bursae which form over the metacarpo-phalangeal joint of the big toe whenever there is pressure and irritation of it. Very few realize, however, that frequently repeated irritations, when pressure is exerted over other joints and bony projections, will produce a bursa, and then, if the irritation continues and an opportunity for infection occurs, there is bursitis. Some of these are mistaken for other conditions and often have been thought by the patient to be serious developments of one kind or another with regard to which there has been much solicitude. An interesting case of this kind in my experience was that of an Italian organ-grinder who suffered from the occupation bursa which so often forms over the anterior superior spine of the ilium because of the frequently repeated rubbing of the hand and arm as it passes this region while turning the handle of his instrument. It had finally become inflamed, and the Italian was much disturbed and he feared that it was appendicitis. Other bursae are not commonly seen in America. I have seen bursae over {400} the elbows of miners, and in one case saw one of these inflamed so that miner's elbow became a concrete entity. This case had been taken for an acute inflammatory arthritis with the suspicion of tuberculosis. CHAPTER V PAINFUL ARM AND TRUNK CONDITIONS Cervical Ribs.--Some interesting cases with painful conditions of the arms develop as a consequence of the presence of cervical ribs. It would be more or less naturally expected that trouble of this kind would occur early in life, but, as a matter of fact, many of the patients are well on toward thirty or even beyond middle life when the painful symptoms develop. Cases are practically always at the beginning diagnosed as rheumatism because the first symptom is likely to be pain followed by weakness. Even when this quite fruitless diagnosis is not made, the affection is often declared to be rheumatic neuritis, though it is really a traumatic neuritis and entirely a local condition, as are so many of the painful conditions spoken of as rheumatism. Usually the pain is referred to the inside of the arm and is described as resembling slight toothache at first and even severe toothache after a time. It will often be many months or even several years after the first symptoms before wasting of muscles occurs, but this practically always follows after a time and even at this stage some physicians still talk of rheumatic neuritis as affecting the trophic nerve fibers and causing the muscles to waste. Almost a differential diagnostic sign in the case of cervical ribs is that raising the arms above the head nearly always relieves the pain. Patients usually learn this for themselves because they have been tempted to place their arms in many positions in order to get relief. The reason for it is easy to understand as the elevation of the arms changes the relative position of tissues in the neck and so relieves pressure. The direct reason for the late development of the disease is probably the ossification of the cervical rib and the pressure of this hard, bony substance upon the roots of the brachial plexus. When the disease occurs as early as the age of 30 there is likely, for some reason, to have been a preceding loss of weight. Patients are run down and then, either because there is a precocious calcification as a consequence of deterioration of tissue, or because the loss of substance in the muscles in the neighborhood makes the nerves more likely to be pressed upon, the first symptoms develop. There is only one way definitely to decide the diagnosis. That is to have a careful skiagraph, or, in case of negative results, several of them taken, in order to determine the presence or absence of cervical ribs. Not all the cases of cervical ribs give symptoms and in one recently published series of 26 cases just one-half presented symptoms and the other half did not, but all these vague cases of pain in the arm, especially if any tendency to atrophy manifests itself, should be examined from this standpoint. _Local Conditions_.--The subjective symptoms in these cases often include {401} much more than pain. There may be numbness and the hands often feel cold, though they do not become blue. As a rule, indeed, the arms are more affected than the hands, though not infrequently one of the hands becomes more sensitive to injuries than the other and, as a rule, both hands do not heal well after injury. Even scratches take a long time to heal and slight abrasions cause skin lesions that are more or less indolent for some time before healing. Any fresh injury, even of slight degree, puts back healing much more than would ordinarily be the case. In fact, most of the so-called tendency not to heal is local rather than constitutional. When a patient complains that though his or her tissues used to heal rapidly now they are very slow to heal, it is well to think of nephritis or diabetes but it is especially important to know the local conditions. Pleural Adhesions.--Another interesting cause of pains in the arms is the possible contraction of adhesions of the pleura and surrounding tissues at the apices of the lungs and the spreading by continuity of a low-grade inflammation even to the lower roots of the brachial plexus. A certain number of cases of this kind have been reported in which there seems to be no doubt of the diagnosis. In these, the early symptoms were pains or aches in the arm followed by some weakness of muscles and even some trophic disturbances. Ordinarily the condition has been very acute as, for instance, a pneumonia when the first symptoms were noticed. In the course of the exudation and the contraction of the inflammatory exudate the brachial plexus is interfered with. This, like the cases referred to the presence of a cervical rib, emphasizes the necessity for thoroughly studying local conditions in order to understand the meaning of painful conditions in the arms. It is easy to say the word rheumatism, while it requires time and careful investigation to find the real pathological factor at work; but the difference in the value of the two diagnoses for both patient and physician can be readily understood. Other Conditions.--Besides these, there are the various conditions discussed in other chapters of this section--old injuries, breaks and dislocations, so-called sprains with laceration of tissues, and any serious pathological condition that has affected the tissues deeply. An old periostitis, for instance, will leave an arm rather easily liable to the development of various painful conditions. Of course, a tuberculous process anywhere in the arm will produce a like effect. An arm that has had a lead neuritis will often be uncomfortable in rainy weather for long after and a crutch palsy may, in the same way, leave the arm sensitive. The musculo-spiral palsies that occur from lying on the arm when drunk, or that are seen sometimes in coachmen who wrap the reins around their arms--a Russian custom--or the nerve conditions seen in patients who have suffered from an anesthetic nerve-pressure disturbance, may all be at the bottom of subsequent painful conditions, worse in rainy weather. The only sure rule is to individualize the cases and make an exact diagnosis. The etiology will probably suggest itself if the history is carefully taken. In these cases the most important treatment is to disabuse the patient's mind of the idea that there is rheumatism, or any other constitutional ailment present, and to make him realize that the trouble is entirely local. After this, the strengthening of the affected muscles must, as far as possible, be secured by local measures and exercises. {402} CHAPTER VI LUMBAGO AND SCIATICA Any affection involving discomfort, pain, ache, or disability of the large muscles in the lumbar regions is likely to be called lumbago, not only by patients but by physicians. Any condition that makes it painful to use the upper part of the lower limb and especially the group of large posterior leg muscles just below the nates is called sciatica. These are commonly supposed to be typical "chronic rheumatisms." Anything in this region that is the source of discomfort on rainy days and comes especially to the working man who has been exposed to the elements, or that follows a wetting or the wearing of damp clothes, is confidently classified as a chronic rheumatic condition. Almost needless to say any such conclusion as to the heterogeneous groups of symptoms that occur in these regions, far from adding to our knowledge, rather confuses the situation. There is an assumption that we know something about them when we call these conditions either lumbago or sciatica, but unless each individual case is carefully investigated and its conditions studied so as to get at their true etiology, it is almost impossible to treat them successfully. While the general practitioner of medicine of the regular school often fails in his treatment of them, these affections are among the most fruitful sources of revenue for the irregular practitioners. It was particularly for pains and aches in the back that St. John Long's liniment proved so efficacious about a century ago. So-called lumbago and sciatica patients were among the most frequent callers on Perkins in the days of the famous tractors and many of them received great relief. In our own time these constitute a class of patients who go from physician to physician and who finally are cured or relieved by some irregular practice which we know contains nothing especially remedial, but the advocates of which somehow succeed in persuading these patients that they must be better than before. Most old people have some aches and pains in either the lumbar muscles or the large muscles at the back of the thigh. Many of them are relieved by massage, but still more of them find relief in the rubbings and manipulations of the osteopaths, and they are great advertisers of the relief that has been afforded them and they have helped much in securing such state recognition as has come to the systems they thought curative in their cases. Eddyism has been helpful to a certain number of them. Fads of various kinds catch still others. Evidently these intractable cases deserve to be studied from the standpoint of what mental influence can do for them. Conditions Mistaken for Sciatica or Lumbago.--Needless to say, a large number of conditions occur which may be called sciatica or lumbago, but which are due to the most varied causes. An affection of any of the joints in this neighborhood will produce pain to which is often added tenderness and occasionally swelling, and nearly always disability. Disease of the lower part of the lumbar spine due to tuberculosis is often in its earlier stages called lumbago. Indeed, without careful investigation showing that there is a special point of tenderness, some irregular fever and that the muscles are in spasm {403} to protect the underlying joints from use, it is difficult to decide just what is the affection in a particular case. I have seen three physicians diagnose a one-sided tenderness and pain in muscles with disability as lumbago, when the course of the disease proved that it was tuberculosis of the sacro-iliac joint. Any of the bones or joints in this neighborhood may give rise to pain, tenderness and spasm of muscles and it is important not to make the facile diagnosis of lumbago, unless careful investigation has eliminated all underlying organic conditions. There are other conditions not infrequently mistaken for lumbago or sciatica which are interesting. Needless to say unless they are definitely recognized there will be no relief afforded for any discomfort of a permanent character, though the coal-tar products will give temporary surcease of pain. Occasionally internal hemorrhoids produce an achy discomfort in the lower part of the back that is described as lumbago, and unless the physician is careful to investigate he may tentatively accept that diagnosis. Proper regulation of the bowels and the use of gluten suppositories will often practically cure the condition, though there will be relapses whenever constipation returns. Chronic posterior urethritis sometimes simulates painful conditions very low down in the back or in one hip or the other. Usually in that case there is a chronic inflammatory condition in the seminal vesicle on the side to which the symptoms are referred. Occasionally over-distention of the seminal vesicles, as seen in widowers who have been accustomed for many years to regular evacuation of them, may cause so much pain and disability in the region of the hip on one side as to be mistaken first for lumbago and then even for tuberculous hip joint disease. Artificial emptying of the seminal vesicle by milking through the rectum will usually afford relief. In all of these cases as soon as the exact diagnosis is made, the patient's mind is relieved of a serious burden of anxiety and it is usually not difficult to bring a great measure of relief. _Old Injuries and Discomfort_.--Many of the painful conditions described as lumbago are due to old injuries, to wrenches and sprains in this region due especially to heavy lifting and to the laceration of ligaments from over-exertion. _Typhoid Spine_.--Protracted cases of typhoid are sometimes followed by pain in the lumbar or sacral regions, developing usually after a slight jar or shock, sometimes after a fall or even following a severe injury, which are really the result of the physical condition of the patient. Stiffness, aching discomfort on movement and sometimes tenderness on pressure are present. Often there are associated neurotic symptoms of various kinds. This used very commonly to be considered rheumatism and occasionally one still sees cases so labeled. On the other hand, much more serious conditions, as Pott's disease, abscess of the liver, or some form of spondylitis, may be suspected. Absence of temperature is almost the rule and usually is the pathognomic differential against these. The whole condition is usually a neurosis though there may be some perispondylitis. The treatment is to increase the patient's nutrition, which has usually suffered to a marked degree, and get the mind off the condition in the back. Concentration of attention on it will make it very uncomfortable, so that even heavy doses of opiates will scarcely relieve the discomfort, and this emphasis of attention will further disturb the mind and develop neurotic {404} symptoms. Diversion of attention, gentle movements, plenty of air, and regulation of the functions of the body will bring about a cure. Stooping Occupations.--Occupations are especially important in lumbago and people who have to stoop much, above all those who do hard work in a stooping position--lifting, pushing, sawing, planing, and the like--are particularly prone to suffer. Miners working where the height of the vein does not permit them to stand up are commonly subject to it. Any one who has to assume, or has the habit of assuming, a stooping posture for long hours may suffer from lumbago. Constrained position predisposes more than hard work. Tailors, though in a sedentary occupation, often suffer from it. SCIATICA Etiology.--What has been said of lumbago applies to a great extent also to sciatica. There are a number of different affections which have come to be grouped under the term sciatica. Here, much more frequently than in the lumbar region, the cause of the pain is a true neuritis. This may be of many forms. Occasionally it is syphilitic in origin; whenever the sciatica is double it commonly develops on a basis of diabetes, while in many cases it is of an infectious nature. There is no special reason to think that there is a rheumatic infection of the nerve, though inasmuch as rheumatic arthritis is probably due to infections by many different kinds of microbes, it may well be that some of these play a role in sciatica. There is no good reason, however, why the word rheumatism or the term chronic rheumatism should be applied either to lumbago or to sciatica. Certainly there is no reason in any definitely known etiology of the affections. Each individual case must be studied carefully. Always these are local and not constitutional conditions, and usually something in the patient's occupation, or in his habits of life, helps us to understand the development of sciatica or lumbago and gives the most valuable hints for treatment. Men who shovel much and who bend one knee as they stoop in shoveling will often suffer, though more frequently in the leg which they do not bend than in the other. The same thing is true for men who use one foot to run a lathe or a small printing press, or anything of that kind. They must be taught to alternate in the use of their limbs. _Pressure_.--Occasionally direct pressure upon the nerve is the cause of the disturbance. I once was asked to see in consultation an elderly lady who had complained very much, first of discomfort and then numbness in her legs, until finally she lost all power in them below the knees. The affection was considered to be some sort of creeping paralysis. I found that her favorite chair, an old-fashioned cushioned easy chair, allowed her to sink down so that the edge of the wood seat frame pressed upon her just where the sciatic nerve comes closest to the surface. As soon as the habit of sitting on this chair was changed her numbness and inability to use her limbs began to disappear. _Alcoholic Neuritis_.--In both lumbago and sciatica one underlying factor is often present. This is the consumption of undiluted whiskey in considerable quantities. Outdoor workers are prone to take an occasional glass of whiskey, especially in the winter time, and a copious quantity of malt liquors in the summer. Both of these predispose to the development of a low-grade {405} neuritis in susceptible individuals. Alcohol is said to have an idiosyncrasy for the anterior tibial nerves. That only means, as a rule, however, that these nerves are more frequently affected by alcoholic neuritis than others in the body. The reason for this special location of the affection is that in people who stand and walk much, this constituting their main form of exercise, these nerves are much used. They are probably in such people (that is, if the intensity of impulses that pass through them be taken into account) the most used nerves in the body. It is this that makes them most susceptible to alcohol. In people who stoop much or who have to work hard in stooping postures, the nerves in the lumbar region and those that make up the sciatic trunk are over-used. This makes them more susceptible to pathological influences than others, hence the tendency for neuritis to develop in them. _Intrapelvic Causes_.--Sciatica may be due to various pathological conditions within the pelvis. Women with fibroid tumors are particularly likely to suffer from it. Their removal by operation does not always assure against the occurrence of sciatic troubles. I once saw an obstinate case of sciatica in which there was a story of a fibroid having been removed years before and, though there were no signs of any recurrence of the growth of another, there were some adhesions in the region, and there was an obstinate constipation particularly likely to have as one symptom an accumulation of fecal material in the rectum until it was very hard. The keeping of the bowels open meant more than anything else for the relief of the sciatica. This patient subsequently died from what was diagnosed by a well-known French surgeon as rupture of the bowels. This was probably due to the adhesions that occurred after the old operation, done without any regard to the possible development of such a sequela, some twenty years ago. The sciatica was undoubtedly connected with the group of disturbed conditions within the pelvis. _Position at Work_.--In this case, as in others that I have seen, the position assumed while at work seemed to have been an appreciable factor in the production of the pain in the limb. The lady made her living by writing and often wrote on a board resting on her knee--a feminine, not a masculine habit. This brought pressure to bear upon the right limb a little more than the other and then, when she crossed her knees in order to put the writing board on top of the knee, this side seemed to be used more than the other. This question of the position in occupation, even though sedentary, is very important. I have seen a strikingly typical case of the so-called _neuralgia paresthetica_, the achy condition of the outside of the thigh with some anesthesia and paresthesia, occur in an old lady who still retained the girlish habit of sitting on her foot while she did crocheting. I have often seen achiness of muscles of the trunk develop in persons who read much in a cramped position because of the reading light being too low or otherwise wrongly placed for group reading. Whenever a patient has to stand much on one foot while doing something, it is important to remember that there should be alternation in the use of the limbs; otherwise sciatica and lumbar pains will often develop, usually on the side corresponding to the limb that is kept rigid. Treatment.--_Mental Persuasion_.--The patient must be made to realize that his affection is not rheumatism, but is due to local conditions. Just as soon as a patient's mind is relieved by being made to appreciate that certain habits in his occupation, or certain local conditions that can be corrected, {406} are responsible for much of his discomfort, then that discomfort is much easier to bear. Even in cases where actual neuritis has developed, or where there have been changes in the intermuscular planes bringing considerable disability, the aches caused by these will be much more bearable if the patient's mind is set at rest as to the real significance of the condition. No condition should be called rheumatic unless at some time in the history of it there was an acute inflammatory condition with Galen's classical symptoms--_tumor, color, rubor_ and _dolor_. Pain alone is never sufficient to justify the diagnosis. Painful disability is usually due to local causes. _Treatment of Acute Symptoms_.--For acute symptoms, the coal tar products may be used and usually afford distinct relief. They include all the old-fashioned salicylates as well as certain more recent compounds, such as aspirin. Phenacetin, however, though usually not thought of in this connection, is an excellent remedy for the discomfort. These drugs should be used freely so as to give relief from the painful condition. The fact that they afford relief, however, should not be taken as an argument that the condition is rheumatic. Rheumatism, as we know it, is an acute infectious disease and there is no reason in the world for saying that the salicylates or cognate drugs are specifics in this affection. They relieve the pain, but just in the same way they would relieve the pain of toothache or of any other painful condition. After the acute symptoms are removed, the condition that remains may be treated in various ways, by massage, by local applications, and by such manipulations as will restore the normal circulation of the part. Care must be taken, however, to distract the patient's mind from the local condition after a time, or mental influence, by interfering with the capillary circulation, may inveterate the symptoms. It is not good to keep patients at rest, though rest, of course, is always indicated if there is much discomfort. Sometimes, however, the discomfort is really due to the fact that muscles have not been used for some time and so are easily fatigued and may ache even under ordinary use. In this case, a gradual restoration of the muscles to normal strength by progressively increased exercise is important. _Counter-Irritation and Its Suggestive Value_.--Personally, I have found the use of turpentine particularly efficacious in connection with suggestion. The old-fashioned system of ironing seems to do more good than any ordinary application of turpentine. For this a piece of flannel wrung out in warm water has some turpentine scattered over it and then is placed on the affected loins or back of the thigh and covered by another piece of flannel, and a hot flat-iron is rubbed over it. The physical effect is a considerable hyperemia, but the effect upon the patient's mind is especially interesting, the unusualness of the mode of application adding decidedly to the effect. It must not be forgotten, however, that there are some people who are over-susceptible to the influence of turpentine, and its use is followed by a rash. _Lumbar and Sciatic Psychoneuroses_.--Many cases of lumbago and sciatica are really psychoneuroses. They develop exactly as psychoneurotic conditions do in the abdomen or in joints. Not infrequently there is some accident or injury, some sprain or strain, or exposure to dampness or draft, that serves as the occasion. The Germans group all these occasions together under the word "insult." The "insult" produces little physical effect but after some days or sometimes weeks, the slight discomfort present secures the center of {407} attention and then the patient suffers from what seems to be severe pain and often inability to move or use muscles. Even when there is true sciatica or lumbago, that is, a genuine low-grade neuritis of the lumbar or sciatic nerves, most of the symptoms may come from the associated psychoneurosis. This is proved to be so by the fact that such patients are often cured, for the time being at least, by some shock or fright or sudden excitement, that makes them move, forgetful of the pain and inability from which they suffered just before. Besides, such cases are often cured by inert remedies of many kinds, by local applications that have no specific effect, and by various methods of treatment which cannot be responsible for the recovery. The amelioration of the condition is due to the mental influence accompanying the methods of treatment and the reassurance of the patient's mind. _Diversion of Attention_.--Almost anything that produces a continuous succession of sensations on the surface of the affected area that attract and hold the attention of the patient may prove a valuable therapeutic suggestion and even eventual relief from symptoms that have proved obstinate to more rational treatment. Liebault, the well-known founder of the Nancy school of hypnotic therapeutics, tells in his "Thérapeutique Suggestive," that he has frequently cured lumbago by the simple recommendation of a rather stiff piece of paper to be applied over the patient's loins. The rationale of this treatment seems to be that the patient's attention is attracted to the skin surface by the sensations constantly produced by it and attention is distracted from other feelings deeper in the muscles. It often happens that after an acute lumbago has run its course, there is left a chronic achiness only partly physical and largely psychoneurotic. Some of it is undoubtedly due to the habit, formed during the acute period, of keeping the muscles quiet, in order to avoid the spasmodic pain that occurs on movement. Patients cannot, as it were, let go of their muscles, and their discomfort is largely due to holding them in a cramped position. The sensation produced by the paper on the cutaneous nerves distracts the attention and brings about relaxation of the muscles with decrease of discomfort and gradual relief of all symptoms. The paper acts as a constant source of suggestion for the cure of the psychoneuroses when the affection is purely psychoneurotic. The mind has become concentrated on the idea of pain and discomfort in this region and needs another thought to occupy itself with so as to neutralize this. Wearing the paper with the assurance, for instance, that because of its impermeability to air it keeps the part more thoroughly protected from variations of temperature and from such possibilities of transudation as have before been possible, serves to lift patients out of themselves and affords relief. Whenever the sensation produced by the paper is noted, there is a renewal of the suggestion and its curative effects. There are many plasters that have obtained the reputation for curing lumbago. It is doubtful whether any of these have sufficient medicaments on them to be of any serious pharmaceutic significance. They are mostly rubber plaster. The presence of this and the consciousness of the sensation produced by it acts as favorably as does Liebault's sheet of paper. _Mechanical Agents_.--It must not be forgotten, however, that a large sheet of adhesive plaster firmly applied may act as a mechanical therapeutic agent, somewhat in the same way that strips of adhesive plaster relieve the pain of pleurisy, or are helpful in a sprained ankle or a knee. The muscles may be {408} held rather firmly together and so there is no necessity for constant attention to prevent spasmodic pain. Undoubtedly some of the newer large-sized adhesive plasters produce an excellent effect in this way. If, besides, the patient has the feeling that they must be doing him good because of materials in their composition, the psychoneurotic elements are more readily relieved. The old idea was that such plasters drew out the pathological elements to the surface whence they were dissipated. There is no truth underlying this thought. In the old days blisters were applied rather freely to these regions and the actual cautery was often employed. Both of these therapeutic processes are likely to do good in chronic cases, but much more from their psychic than their physical effects. The actual cautery is not used nearly so much as it ought to be in chronic muscular and neurotic conditions, for the mental effect of its application and the distraction of attention to the skin surface while the cauterized areas are healing are excellent remedies. There are other counter-irritant procedures of the same kind that have been used with reported successes in many cases. Hot needles, for instance, if pushed deeply into the muscles, often have an excellent effect. Some years ago a distinguished surgeon insisted that both lumbago and sciatica might be cured in many cases by the insertion of needles deeply into the muscles. He argued that what happened was that these needles brought about an equilibrium of electricity in the muscular structures which had somehow been disturbed. Deep injections of water into the muscles also do good. Stretching of nerves has been applied with reported success. After a time all of these measures fail, however, because somehow after the novelty of the treatment wears off for the physician, the patient's mind is not sufficiently impressed and then the former results are not secured. Where there are actual neuritic processes present they will almost surely fail. So many of these cases are almost pure psychoneuroses, however, that it is little wonder that anything which produces a strong impression on the mind and leaves after it some condition that attracts attention and so furnishes favorable suggestion will almost surely cure even chronic conditions for which all sorts of physical remedies, employed on rational grounds, have failed. Anything that modifies the circulation, even to a slight degree, or by causing a reaction in the local vaso-motor state, alters previous conditions, tends to enable the patient to control the affected part. These psychoneurotic conditions in large muscles help us to understand what happens in organic diseases. There is a physical element that must be modified, but unless a strong influence is brought to bear upon the mind so as to arouse all its capacity for control, the cure will not come. Anyone of a dozen things, however, may be used in this way and often when one fails another will succeed. In obstinate cases of lumbago and sciatica if necessary a number of these forms of treatment should be used successively. _Hypnotism_.--How much pure psychotherapy may mean for many of these obstinate cases of lumbago and sciatica can be appreciated from the many reports of cures by hypnotism or by suggestion in a light hypnoidal state, or occasionally, under favorable circumstances, even in the waking state. One of these cases, indeed, is responsible to some extent for the French interest in hypnotism which attracted so much attention in the last quarter of the {409} nineteenth century. Prof. Bernheim of the University of Nancy had seen a case of sciatica in which every therapeutic means at his command had failed. As the result of disuse the leg was emaciated and possessed little muscular power. It looked as though the man would never be able to regain the use of it properly. Dr. Liebault succeeded in curing the patient by light hypnotic sleep, in which the suggestion that he would be better was given while the physician stroked the limb. After the first seance the patient was able to use the leg better and the discomfort was greatly decreased. Further seances with Dr. Liebault brought further improvement until finally the condition was cured. Prof. Bernheim, who knew how intractable these cases are, had the case called particularly to his attention and naturally wanted to learn more about the method by which it had been brought about. Liebault's methods had been quite contemned by the regular faculty before. After a series of experiences under Dr. Liebault's direction Prof. Bernheim became enthusiastic over the use of hypnotism as a curative agent and this led to the publication of his well-known work "De la Suggestion et ses Applications dans la Thérapeutique." [Footnote 34] It was the interest aroused at Nancy that led Charcot to take up hypnotism, and while he came to very different conclusions, there is no doubt that the work at Nancy meant much for our knowledge of suggestion in both waking and hypnotic state in therapeutics. [Footnote 34: On Suggestion and its Applications in Therapeutics.] CHAPTER VII PAINFUL KNEE CONDITIONS Most of the painful knee conditions of which patients complain are not directly due to true pathological conditions either of the knee joint itself or of its neighboring structures, but rather to affections of other portions of the leg that set a special strain upon the knee and, above all, to various kinds of foot disturbances. The erect position is maintained principally by a nice balance of nervous and muscular energy in the knee joint and its surrounding structures. Any irregular sensory or motor impulses to the knee-joint or to the muscles of the thigh will disturb the absolute equilibrium of the flexors and extensors and will make standing painful or even impossible. Whenever a morbid condition requires a different use of the muscles and tendons around the knee from that to which they are accustomed, fatigue readily ensues, and aches and even tenderness in muscles and tendons develop as the result of the over-exertion. These collateral conditions must not be overlooked in the diagnosis and treatment of painful knee conditions. Etiological Factors.--Even a slight sore on one foot will give rise to considerable achy fatigue of the knee of the opposite leg, because, consciously or unconsciously, we stand much more on that leg, use it more in walking, and spare the other because of the pain induced by use of the foot. Above all, throwing more weight on the other leg causes us to use muscles a little abnormally with consequent soreness. This painful fatigue is most likely to be felt around the knee, though it may extend to the hip and even the lumbar {410} region of the well side if the foot continues to be spared for a number of days. Particularly will this be true if there is anything the matter with the big toe, on which so much of the use of the foot depends. An ingrowing toenail will not infrequently give so much discomfort to the well knee and hip as to make the patient sure that there must be some rheumatic or other condition at work in these joints. The serious affection of the joint which the patient apprehends is found to be no more than a sympathetic fatigue induced by having to use his feet, or one of them, a little differently from usual, perhaps because of some condition that leads him to spare them. To call the patient's attention to this is of itself therapeutic. _Inequality of Legs_.--The effort required for standing and the accurate balance of the muscles involved in it is such that any mechanical disturbance of the feet or legs or even a trivial pathological condition causes painful fatigue. It must not be forgotten, for instance, that the presumption that human limbs are of exactly the same length is not confirmed by accurate measurements. There is an average difference of probably half an inch in length between the limbs of normal persons, and there may be even a difference of more than an inch before deformity is said to be present. The longer limbs are likely to do more work and are, therefore, more subject to fatigue and consequent complaint. One of the reasons why we can distinguish persons by their gait even at a distance is that the difference in the length of their limbs makes noteworthy characteristics in their walk. _High Heels_.--People who are used to walking in a natural manner and who don a pair of high-heeled shoes for the first time are sure to complain of pain in the calf and knee, because the high heels require them to hold the knee more rigid and in a somewhat different position from that required when the persons stand under ordinary circumstances. It is the unusual in muscular effort that gives rise to the extreme fatigue which becomes positive pain if it is allowed to continue. It is curious how small a raising of the heel will cause discomfort. Over and over again I have known the careless putting on of rubber heels to be responsible for pains around the knee, which in damp weather were the source of so much discomfort that it was hard to persuade the patient that he was not suffering from rheumatism or some serious incipient pathological condition. _Unusual Occupations_.--Joint pains often develop after the patient has been doing something quite unusual and putting an unaccustomed strain upon his muscles. I have often seen dispensary patients whose knee pains began after there had been a family moving. In the course of the removal of household goods, both men and women are likely to help in hanging pictures, in taking them down, in moving heavy furniture and other occupations of this kind which make them extremely tired. If there is any tendency to relaxation of joint structures the tiredness may manifest itself as a sense of painful discomfort. The knees are particularly likely to suffer if there is a relaxed condition anywhere in the leg. It must be remembered that the laxity of tissue which predisposes a patient to weak or flat feet will have a tendency to produce some looseness of fiber, at least, also in the tissues around the knee. The patient may not have a wabbling knee, nor may he be able to overextend the limb, but still there will usually be some noticeable relaxation of the tissues which will help in the production of the painful condition by {411} making exaggerated calls upon the muscles in order to keep the joint in proper position in spite of the over motion in it. The disturbance is most frequent in waiters, store clerks, tailors' cutters and fitters, bench men in the trades, and in all those who have to spend much time on their feet. I have seen many such ready to give up their occupations, though they had no other resource and the future looked very blank, indeed, away from their work. It was difficult at first to persuade them that a slight yielding of the arch had so changed mechanical conditions in the use of the muscles of the leg as to produce such pains. But as soon as they were put in a condition where their arch was not allowed to sink, they were at once relieved of their discomfort to a great extent. The question of treatment is discussed more fully in the chapter which follows on Foot Troubles. An interesting set of painful conditions around the knee develops in a class of people in whom it might least be suspected of being due to over-exertion connected with their occupations. These are lecturers, clergymen, teachers, and others who, for several hours each day, are on their feet in a position from which, as a rule, they do not move, but stand almost perfectly quiet. A distinguished laryngologist has pointed out that not infrequently men who come to be treated for the chronic laryngitis, which is known as clergymen's sore throat, but which is seen so frequently in those who have to talk in the open air, auctioneers, cart-tail orators about election time, and in lecturers to large audiences who do not know how to use the voice, also complain of grievous discomfort from painful knee conditions which often makes the ascent or descent of stairs a painful task. He attributes the simultaneous occurrence of these conditions to some blood dyscrasia, uric acid, or the like, affecting the two most used sets of muscles and organs, the legs and the vocal cords. Whenever I have seen this condition--and circumstances have brought me into intimate personal relations with many clergymen and lecturers--the trouble at the knee has been due to some yielding of the plantar arch, while the laryngeal condition, if present, was due to an erroneous mode of using the voice consequent upon lack of proper training. Sufferers of this kind must be warned not to stand absolutely immovable while addressing an audience. Some men stand without moving during a whole hour's lecture. This is unfortunate, for it obstructs the return circulation through the tense muscles, for the venous circulation was intended to be helped by muscular contraction. Many a man finds, as he comes down from pulpit or platform, that his knees are stiff and sore, though a moment before he knew nothing about it. The failure to notice any discomfort before is of itself an example of the influence of the mind over the body for the relief of pain. Associated Lumbar Discomfort.--The painful condition around the knee which develops when high heels are worn is almost sure to be accompanied by pains, or at least a tired feeling, in the back. If we convince the patient that the trouble is due merely to a derangement of the mechanism involved in maintaining the erect posture we shall have scant need of medicine or even of local treatment. But as the pain is much worse on rainy days, owing to the relaxation of the muscles, we must be careful to remove the patient's suspicion that the pain must have a rheumatic origin. The restoration of normal mechanical conditions with the removal of the cause will prevent the {412} recurrence of the affection, and if some discomfort remains, the patient will not worry, and the muscles will gradually grow accustomed to the strain upon them. Of course, these conditions of discomfort are more common in those who are not naturally strong, who are run down, who are under-weight, or whose neurotic tendency will make any irritation seem worse than it is. Heavy and Light Patients.--Two classes are likely to suffer more than others from these conditions. They are the people who are overweight and the people who are underweight. Those who are overweight exert much more effort to maintain the erect posture than ordinary people, and, besides, in most adipose persons the distribution of weight is such that a disproportionate amount of it is carried forward of the normal center of gravity. High heels cause a further tilting forward that has to be counter-balanced, and that, at least at the beginning, gives rise to muscular discomfort. In people who are underweight the nutrition of the muscles has suffered, and, as a consequence, they are not able to support the frame as well as before. In them the additional effort necessitated by the tilting tendency of high heels is particularly felt because such people are nearly always among the neurotically inclined. Muscle Disuse.--Sometimes treatment of these conditions seems to lead up to the disuse of certain muscles and the over-use of others. I followed for several years an interesting case of this kind in which the course of the affection was so typical as to deserve to be recalled. A fuller account of the case occurs in my paper on "Rheumatism versus Muscular and Joint Pains" in _The American Journal of the Medical Sciences,_ August, 1903. In that case the joint symptoms caused by the pinching of a loose cartilage within the joint occurred suddenly on two or three occasions, so that a surgeon deemed it wise to put the knee in plaster. As a consequence, some atrophy of the muscles of the leg occurred, and a halt became habitual in the gait. Through this halting gait, the muscles of the back on the same side were also spared and thus became somewhat atrophied. Painful conditions developed in the muscles of the other side of the back from the over-use necessary to compensate for the condition on the less-used side. All of the muscles on the affected side became painful, apparently because of the atrophic condition to which they were reduced. The young man, though with the best of good will, was utterly unable to conquer the tendency to halt in his gait, and so the muscles remained under-exercised and were used at a mechanical disadvantage, with the usual painful result. He went to at least two prominent orthopedic surgeons, who assured him that all he needed was confidence in himself to walk straight, and that then the normal condition of the muscles and absence of pain would result. But their directions were absolutely without result. He went through the hands of masseurs, of osteopaths, of rubbing quacks of all kinds, and suffered at least two attacks of artificial eczema as a consequence of the use of turpentine liniments, but he remained after it all in what he considered to be an intensely miserable condition. These cases are practically always cured by definite exercise of the muscles of the affected limb so as to bring them back to their normal tone. It requires special attention for this purpose, however, and the patient's mind must be brought to understand that at first the unaccustomed use of muscles will cause discomfort, but that this will disappear after a time. These patients are persuaded that they must be "cured" to get well. {413} CHAPTER VIII FOOT TROUBLES The more physicians see of affections of the feet and of painful conditions of the legs due to foot troubles the more they realize that the human faculty of the erect position becomes the source of many discomforts unless care is taken of the muscular apparatus of the legs. There are few people engaged in standing occupations who do not suffer from their feet. These achy sensations are especially bothersome if the patient is run down in health, or is in the midst of worry or irritation from physical or mental stress. Even under favorable conditions there are few who reach old age without serious foot troubles or without, at least, some deformity of the feet, which, by preventing or limiting exercise, have an important influence upon the general health. Careful analysis of the conditions that develop will convince an observer that yielding of the joints of the foot has much to do with the deformities and that the wearing of unsuitable shoes rather than any internal pathological condition is responsible for the foot troubles that are so common. Foot Deformities in All Classes.--An Englishman who visited this country, and who had ample opportunity to observe our people, declared after seeing the bathers at Newport, that there were two interesting peculiarities of American masculine anatomy--the deformity in their feet and the appearance of having swallowed a watermelon whole and retained it within them. The latter condition has doubtless much to do with the causation of the former. Inactive lives, overeating, and the overweighting of flaccid limbs that are not capable of bearing even their normal burden, complicated by tight and ill-fitting shoes, give rise to the deformities of the toes that are so common--hammer toes, over-riding toes, bunched toes, twisted toes, bent toes. Examples of most of these are sure to be seen wherever we observe our men and women bathing. The Englishman's observation was of our so-called better class--at least, our leisure class. Ordinarily, it is assumed that clerks, waiters, and others, who have to stand upon their feet are the principal sufferers from foot deformities. They are, but they are not alone, and a goodly proportion of the population suffers in this way. Mechanical Factors.--The most important deformity in these cases is a yielding of the arch of the foot with consequent flattening of the instep and lengthening of the foot. This overstretches especially the flexer tendons which run underneath the arch, produces bunions, and gives occasion for the development of corns. The pull upon the flexor longus hallucis which runs along the inside border of the foot, gives rise to the bunion by pulling the big toe outward--in the direction of least resistance. The pressure upon the tendons of the flexor longus digitorum pedis causes the smaller toes to bend somewhat, and this gives rise to projecting angular points on which corns readily form. Besides, the imperfect action of the muscles of the foot consequent upon the fall of the arch gives rise to plantar corns and callouses that are often painful. The living cushion of muscle which is the best protection against injury, while walking or running, has its vitality interfered with by {414} the fall of the arch and the consequent blocking of the return circulation through the thin walled veins. This gives rise to cold feet and, in those who stand much, to the tender feet that are now so much complained of and for which so many foot powders and appliances are advertised. Confusion of Rheumatism and Foot Troubles.--Most foot troubles are reflected up the leg because muscles have to be overused or used at a serious mechanical disadvantage. This combined discomfort of foot and leg is readily referred to rheumatism. Some of the pains produced by yielding of the arch are in the ankle, some are in the calf, some in the tissues around the knee, and some even in the muscles and tendons above the knee. It is much easier to say "rheumatism" than to investigate carefully and differentiate the conditions that may be present. Out of forty successive patients who came to the dispensary of the Polyclinic Hospital of New York complaining of rheumatism, eighteen were suffering from flatfoot. Out of twenty-four who thought they had rheumatism in the feet or legs eighteen proved to be cases of flatfoot. Of the others, one was suffering from that rare disease meralgia paresthetica, two were suffering from sciatic neuritis, one was suffering with sub-acute joint trouble consequent upon pinching of a cartilage within the knee joint, and one had a painful condition consequent upon an old dislocation of the ankle due to a fall, accompanied by considerable laceration of the soft tissues. Analyses of the cases left no room for the so-called chronic rheumatism which had so easily covered all the cases at the beginning. It was not unusual to see patients who had consulted many physicians and taken all sorts of internal and external remedies for the rheumatism that they supposed was causing their discomfort, yet who had nothing more than flatfoot. Their condition had become so bad that some of them had actually given up occupations that required them to stand. Merely following the advice to wear flatfoot braces in their shoes relieved these patients almost as if by magic. There was no need to measure them particularly; all they needed was an ordinary set of flatfoot braces. Some of them needed only a pair of good shoes, but the metal braces were advised to make sure that there would be a firm support for the arch of the foot. No wonder the "magic shoe-maker" had such success in New York a few years ago. Nearly always the shoes worn by dispensary patients are of the worst kind, considering the condition. The patients' feet are often cold, and they think this is nature's demand for heavy shoes, so they buy heavy shoes and large sizes so as to be sure they will not hurt their feet. This clumsy footgear allows the arch to drop still further because no proper support is furnished, and the foot-trouble becomes more poignant. Then working people nearly always wear older shoes on rainy days, and this makes two elements for discomfort instead of one. The yielding arch is already a source of discomfort which is more noticeable in rainy weather because any affection around a joint is more bothersome at such times. The support that a new pair of shoes affords to the arch is lacking when what are so aptly termed "sloppy weather shoes" are worn, and the consequence is that the patient is particularly miserable in damp weather. Unfavorable Disease Suggestions.--Of the cases in my experience of so-called rheumatism in the legs, over one-half are due either to flatfoot or to the incipient yielding of the arch which is called weak foot. Rheumatism is {415} most commonly held accountable for the condition, though gout comes in for its share of blame with quite as little justification. Occasionally some even more serious pathological condition is appealed to. I have seen the tendency to passive congestion in the feet with slight swelling around the ankle consequent upon the yielding of the arch called kidney trouble in spite of the fact that there was nothing in the urine to justify any such diagnosis. I have even known the coldness of the feet, which is likely to be a symptom of the disturbed circulation consequent upon the yielding of the arch, attributed to heart disease. As we shall see, most of the curious deformities of the old that make locomotion so difficult and so painful are due to a breaking down of the arch just after middle life and then to a progressive deformity of the foot. The mechanics of the support of the body are sadly interfered with when the arch yields, for bones are pushed out of place and ligaments and tendons are lengthened in order that the foot may accommodate itself to the new conditions. In nearly all these cases the patients are prone to say that they are sufferers from rheumatism. This diffuses and inveterates the notion which is a source of many unfavorable suggestions, that rheumatism is a curious progressive crippling disease which begins insidiously but advances remorselessly and eventually leaves its victim a prey to deformity. Gout and Flatfoot.--Bunions consist originally of an enlargement of a bursa over the proximal end and the inner side of the big toe in order to protect the bone and joint from friction. If the irritation is continued, the proximal end of the first phalanx may enlarge, though usually this is preceded by a series of attacks of more or less acute inflammation of the bursa, when the bunion is said to "become sensitive." I have seen these attacks called gout so often that I feel sure that much of the gout reported in this country is nothing more than bunions. There is true gout, and it is probably almost as frequent with us as it is in England, but many of the so-called cases are really flatfoot associated with development of the bunion that so commonly occurs as the arch yields. I was once asked to see a physician's wife who was thought to be a sufferer from gout. Long ago Oliver Wendell Holmes said that, as the shoemaker's children are likely to wear the worst shoes of the village, so the doctor's family is likely to take the least medicine, that is, be subjected to the least formal medication. The physician had seen the more or less acutely swollen and red enlargement of the base of the big toe, and heard his wife complain of the severe pain associated with it, and had suggested the possibility of gout. After rest in bed and the administration of salicylates and colchicum, the pain subsided and the redness and much of the swelling disappeared. This was a typical illustration of one event following another without causal relation. The succession of events was taken as a therapeutic test of the diagnosis of gout, and the patient was advised to regulate her diet so as to prevent the further accumulation of urates or uric acid in her blood. She was warned about eating red meat, about taking acid fruits, and about the acid fermentation of starchy vegetables. The main result of eating only white meat is apt to be simply a limitation in the amount of meat eaten, because white meat is less savory and after a time palls on the appetite. In the same way fruit was largely eliminated and sweets were taken out of the diet and vegetables were limited. {416} As she did not escape recurrent attacks of soreness in her bunion, while at the same time there were achy feelings in her foot, she took up the careful study of the dietary for gouty patients which she found in the books in her husband's library. So many things have seemed possibly deleterious for gouty people that it is not surprising that after a time nearly everything worth eating except a few cereals and milk and eggs had to be eliminated and she began to suffer from inanition. Then, after a time, came constipation, due to the insufficient amount of residue in her intestines, and this, partly by physical action but largely by mental suggestion, still further diminished the appetite for food, and a loss of over twenty pounds in weight was the result. The weakening of the general muscular system consequent upon this loss emphasized the trouble with the foot and the painful condition at the base of the big toe became more marked. The supposed necessity for more exercise in the open air led her to walk long distances and in order to prevent her feet from hurting her, as she thought, she wore roomy shoes, distinctly too large. This is one of the common mistakes of people whose feet bother them, and it is just the wrong thing to do, since a snug, well-fitting shoe provides both support and protection. It is not surprising that the attacks of sub-acute bursitis became more frequent and more painful. It was then that I saw her, and, as I feared to disturb the family harmony by suggesting that the whole trouble was a bunion and flatfoot, I compromised by saying that, while there might be some gout, there was undoubtedly flatfoot, and if she would wear the proper sort of shoe and stop limiting her diet so strenuously, and cease suggesting to herself that she had a progressive gouty affection that would lead to deformity and decrepitude, she would soon be much better. It required tact to make her look favorably on this advice, after all that she had gone through during months of limited diet and enforced exercise. Though not quite convinced, she was ready to try the new method. She began to be better as soon as she was fitted with a pair of shoes that supported her arch and as soon as her increased nutrition began to make itself felt. At the end of two weeks she was able to give up the remedies for constipation that she had been using for nearly a year, while at the end of four weeks she had regained ten pounds of weight and felt much better. Several years have passed since I saw her professionally and occasionally I hear from her only to be told what a great measure of relief it afforded her and how much better she has been as a consequence of a few simple directions with regard to her feet. I have seen at least a dozen of cases of so-called gout in educated people which followed almost exactly the same course and yielded promptly to the same treatment. The hardest symptom about these cases to cure is the cherished mental conviction that they are the victims of constitutional disease, either gout or rheumatism, to which all their symptoms are attributed. They are cases for psychotherapy more than any other form of therapeutics and need for a considerable period to have repeated assurances of the entirely local character of their affection. Bunions and Flatfoot.--The etiology and preventive treatment of a bunion has always seemed to me to bear a closer relation to a flat foot than to anything else. The flatfooted man has nearly always a tendency to bunions. The {417} explanation of this is not difficult if one traces the relation between the tendons that run around the arch to the big toe. The usual etiological explanation, however, is that in youth short shoes were worn which initiated a tendency to divert the big toe inward toward the other toes. But there are many reasons against this explanation. Anyone who tries will find that it is practically impossible to wear shoes that are so short that the big toe is crowded back. Women are more apt to shorten their shoes than men, yet women suffer both from flat feet and from bunions much less than men. The reason for this seems to be that the forward position with the elevation of the heel of the shoe supports the arch and gives the shoe a shape more fitted to the normal foot than is found in the masculine flat-heeled shoe. Besides, this form of shoe maintains its shape better, and then, too, women are not so prone to wear old so-called comfortable shoes as are men. The mechanism of the formation of the bunion in many cases seems to be, that the large toe, instead of lying straight along the inner edge of the foot, is pushed or pulled toward the other toes. If this process began from the wearing of pointed shoes, especially if such shoes did not have a straight line on the inside, conditions within the foot would soon tend to emphasize it. If the adductor hallicis once gets the habit of contracting rather strongly, as it is likely to do through the irritation set up by the yielding of the arch, it will be hard for its opposing muscles to counteract it. More important than this, however, is the fact that the tendon of the flexor longus hallucis runs along the inner border of the foot and is particularly affected by the yielding of the arch. For it works at a decided mechanical disadvantage under the new conditions and is stretched in such a way as to pull forcibly and constantly upon the big toe, necessarily turning it more and more outward as the arch continues to yield. The dropping of the arch makes the distance from the heel to the toe longer than before and the tendon pulls the toe as far outward as possible to compensate for this, as the distance to its insertion is thus made somewhat shorter. The yielding of the arch lengthens the foot and puts the tendons of all the flexors on the stretch. All of them have a tendency to bend the toes, and as this action is constant, gradually the tendons of the extensors become over-stretched and these muscles are not capable of exerting their full force in overcoming the action of the flexors. The flexor longus digitorum has a tendency to cause a bending of the small toes, and as it also runs across the foot it pulls the toes somewhat inward, that is, toward the big toe. This crowding leads to hammer toes and over-riding. The big toe, however, is maintained in a state of extension by its firm, full contact with the sole of the shoe and with the floor when walking barefoot. The one direction in which it can yield rather readily is outward toward the other toes because this shortens the distance between the end of the toe and the heel. The pressure put upon the flexor longus hallucis will have a tendency to cause this, for it is over-stretched by the yielding of the arch and keeps constantly pulling on the big toe until that member has a distinct flexion outwards. This makes the metacarpo-phalangeal joint prominent and then nature proceeds to protect it by a water cushion, a special bursa due to the formation between layers of connective tissue of a pocket in which some serum is constantly present. One can scarcely admire enough this provision of nature by {418} which she protects prominent bony points whenever they are subject to much irritation or to such use as would cause injury to important structures below. If continued pressure continues to be irritating, however, the water cushion proves unavailing and an inflammation of the overlying skin occurs with occasionally a spreading of infectious agents from the surface into the serum pocket below. This serum is such a good culture medium that an acute abscess is likely to form--the acute bursitis of the surgeons. Rarer Foot Troubles.--Besides bunions, a number of other deformities of the feet occur as a consequence of the yielding of the arch. All the toes are likely to bend rather acutely, and the points of them are pressed against the shoe, while the knuckles, so to speak, are made prominent and are more likely to be subject to corns than would otherwise be the case. Besides, the displacement of the big toe toward the little toes leads to a crowding of the toes together, and this gives rise to soft interdigital corns and to a lowered resistive vitality which may be the predisposing factor to slight infections of various kinds that will make the patients miserable. Such affections may appear negligible, a matter for the chiropodist, and not deserving the physician's attention; but they mean so much for the comfort of the patient and the prevention of exercise through sore feet reacts so deleteriously on the general health that these minor ailments become important and merit careful attention. Dr. Emmet tells the story of the old family servant, always grumpy and complaining, who, when he had the many blessings of life pointed out to him, confessed that the Lord had been very good to him, but said, "The Lord knows He takes it out of me in soft corns." _Hammer Toes--Clam Toes_.--Nature has provided a wonderful mechanism in the arch of the foot and the anatomical relations of the toes to support the weight of the body firmly, gracefully, and comfortably; yet any yielding of any part of it leads to a disturbance of its delicate mechanical relations and, consequently, to ever-increasing deformity. Hammer toes are typical examples of what such a disturbance may lead to. One of the toes becomes pressed downward between two others. This over-stretches the extensor muscles and tempts the unbalanced flexors to contract. As the extensor muscles become, after a time, unable to work in the constantly bent toes, they atrophy to some extent and then the flexor muscles pull the toe farther and farther down until there is no possibility of its being straightened at all. Now, if the flexor tendons are cut and the toe straightened the atrophic extensor muscles will not hold it in that position, and when the flexors grow together the old condition will reassert itself. In the meantime, muscle changes in the neighboring toes have also taken place. With no resistance on one side of them, they become bent sidewise over the hammer toe, and so their muscles on one side are overstretched and on the other side become contracted. After a time it is impossible to correct this series of deformities which are being constantly increased and emphasized by the weight of the body above. Present-day Shoes.--In recent years we have heard much more than heretofore about foot troubles. As the old-fashioned shoes were carefully made by skilled shoemakers to fit the feet of one individual and not to conform to some supposed ideal pedal extremity, they supported the feet much better than do the modern cheap machine-made shoes. These custom shoes lasted a long time, and, after they were once molded to the foot, the wearer was not {419} disturbed for many months by the process of having to become accustomed to another shoe. The many advertisements in quite recent times of foot powders and other artificial relief for the foot show that people are suffering much more than before, or, at least, are less able to bear the discomfort. These powders, however, are not likely to do good in the long run, since they tempt the wearers to stand the discomfort against which they do furnish a certain amount of soothing. It is much better, however, for the sufferer to find the cause of the discomfort and to remove it if possible, for otherwise it will lead to constantly growing displacement of bones and muscles and may eventually even bring on actual and ever-increasing deformity. [Footnote 35] [Footnote 35: How much deterioration of the tissues of the foot may be brought about by improper footwear and, above all, by sedentary life and the substitution of the trolley car for the exercise of walking, is well illustrated by the functions that are lost. The child can use its adductor and abductor muscles for the toes quite as well as for the fingers. Those who go barefooted retain those muscular powers. Some time we will be able to influence young folks' minds enough to keep them from sacrificing all the more delicate muscular powers of their feet to the fashion of small or curiously shaped shoes. Armless men learn to use their feet almost as hands, they write, pick up small articles, oven play musical instruments. Some people have special muscular faculties, as, for instance, the power to displace certain tendons and bring them back with a snap which makes a distinct sound. The Fox sisters, to whom we owe the origin of modern spiritism, confessed that this was the way they produced their spirit rapping. Some mediums can, it is said, dislocate the tendon of the flexor longus hallucis onto the edge of its grove and then bring it back with a snap. Others can produce partial toe dislocations which by muscular power are suddenly reduced with a dull noise like the sound of a gloved hand rapping beneath the table.] Prophylaxis.--The most important means of prophylaxis in these cases is to have patients who must assume the standing position for some hours each day, exercise their legs rather vigorously. If teachers, lecturers, and the like, have to stand for a long time, it is important that on the way to and from their occupations they should not have to stand up in cars nor assume cramped and uncomfortable positions. It would be better for them to walk rapidly for several miles rather than ride in a standing or a constrained position. If they are convinced of the necessity for exercise, there is much less likelihood of the development of the severer discomfort that is sometimes very discouraging. It is particularly difficult to make women understand this; yet, once they have found how much relief is afforded by vigorous exercise, they are likely to overdo it and thus run the risk of incurring ills quite as serious as those consequent upon not taking enough. In nervous people the nagging discomfort of a yielding arch will sometimes (just as eye strain does) produce reflex headaches, constipation, lack of appetite, and apparently predispose to the frequent recurrence of migrainous headaches. I have, in not a few cases, seen these conditions relieved by rational treatment of the foot condition. Circulatory Disturbances Due to Flatfoot.--An interesting direct consequence of flatfoot is the disturbance of the venous circulation, which is likely to bring about some swelling of the feet and nearly always considerable coldness and numbness, particularly in the winter and, above all, on damp days during cold weather. The swelling of the feet makes the patient think--sometimes at the suggestion of his physician--of kidney trouble or heart trouble, and sometimes it is hard to persuade him that there is nothing serious the matter with these important organs. The disturbance of the circulation further leads to numbness, to some anesthesia, and to paresthesia. Corns and especially callouses grow more readily between the toes, and patients who are prone to read about such ailments may conclude that they are suffering from hypesthesia {420} and hyperesthesia due to some serious progressive organic nervous disease. I once had a woman patient discourse learnedly to me about these things who was sure that she had the beginning of some incurable spinal disease. Locomotor ataxia was the least she might expect from her description of her feelings. What I found was flatfoot. Raising her arch cured her. The cold feet and the numbness, to call them by simple Saxon names which will not disturb patients, may sometimes keep them awake. In the chapter on Insomnia we suggest that the best thing for this is to secure a return of the circulation either by exercises, or by wearing a flatfoot brace during the day, or by putting the feet in water as hot as can be comfortably borne and keeping them there for a quarter of an hour. Of these means exercise is the best. Raising up on the toes after the shoes are off and coming down on the outside of the foot strengthens the muscles, pulls the bones of the arch firmly together and encourages the circulation. For beginning flatfoot this is a curative measure and it is the natural mode of treatment for the coldness and numbness of the feet. Rubbing, also, is good for the feet in order to restore the circulation, but patients are inclined to rub downwards while they should rub upwards in order to help the hampered venous circulation. The thin-walled veins are more likely to be compressed by any disturbance of tissues than are the firm-walled arteries, and it is to help the veins that our remedial measures must be directed. Secondary Consequences.--The secondary consequences of flatfoot are interesting. It is surprising how many people who frequently suffer from sprains of the ankle have some yielding of the arch as a predisposing factor to that condition. Two classes seem to suffer frequently from sprained ankle--those with yielding arches and those with high insteps. Apparently there is weakness in the excess in both directions. Very flatfooted people apparently do not suffer so frequently from sprained ankles as those in whom there is only an incipient yielding of the arch. They seem to have learned to walk more circumspectly. Perhaps, too, their well-known tendency to toe outward lessens their liability to turning on their ankle. The effects of sprains of the ankle in people with weak foot last, as a rule, longer and leave more weakness after them than they do in ordinary cases. This, of course, might be expected, but it is surprising how often the significance of beginning flatfoot fails to be noticed even by the physician. I have seen rather frequently cases of so-called chronic rheumatism in which there is a series of stories of sprained ankle because of the assumed weakness of the ankle from supposed rheumatism, when the whole case can be summed up in a yielding arch. Exercises.--If the arch has not yielded much, it is often unnecessary to prescribe flatfoot braces or arch supports of any kind, unless perhaps at first. After the first soreness has passed off, exercises may be employed to strengthen the muscles. As we have said, the patient should rise on his toes and then come down slowly on the outside of his feet. He may be instructed to sit with his feet--not his legs--crossed, the feet resting on their outer edges. He may be shown how even various slight movements of his toes, almost without moving his shoes at all, will strengthen the muscles that pass around the arch, which, thus strengthened, will hold the bones of the arch firmly together and prevent further yielding. There is, at the present day, a tendency to recommend too freely the wearing of flatfoot braces or arches. After all, these are {421} only crutches and should not be worn unless absolutely necessary. If the arch can be strengthened--as it can be in many cases--so as to bear the body weight without discomfort, then this is much the better treatment. If the arch is restored the feet are in a more natural condition, while artificial support leaves the muscles without that exercise which will preserve their functions. Flatfoot braces may be necessary, but only if absolutely necessary should they be advised, and palliative measures, such as exercise, manipulations, and rubbings, should be given a fair trial after the unfavorable suggestions as to his foot condition have been removed from the patient's mind. Significance of Foot Troubles.--We have devoted much space to foot troubles--more, perhaps, than will seem justified to the minds of many physicians. We have done so, however, because of the firm conviction that the feet are the source of more discouragement and depression of mind than any other part of the body. Life very often takes on another aspect when foot troubles are relieved. In the old, progressive deformities of the feet consequent upon mechanical disturbance are probably the source of more discomfort, and by their interference with exercise and outing, the cause of more ill-feeling and even disturbance of health than any other single factor. Even life may be shortened by the confinement or limitation of movement consequent upon bad feet. Above all, the idea that any constitutional trouble, or hereditary disease, is at the bottom of their affliction must be removed, and then these patients are encouraged to live their lives more fully and with more happiness for themselves and others. Hence this long chapter. CHAPTER IX ARTHRITIS DEFORMANS Arthritis deformans has unfortunately been called by several names besides the descriptive term which, in the present state of our knowledge, is the most suitable for it. We do not know its cause. We do not well understand even the predisposing factors in its causation. Hence, the term arthritis deformans, which declares simply that it is an inflammatory condition of the joints producing deformities, exactly fits it. It has often been spoken of by such names as "rheumatic arthritis," or "rheumatoid arthritis," and, above all, by the unfortunate term "rheumatic gout." Many of the worst suggestions that attach to the word rheumatism are founded on these ill-chosen designations. Arthritis deformans was supposed to be connected with rheumatism or with gout, or perhaps to be due to a combination of the two. In a majority of the cases there is no history of either true gout or rheumatism to be obtained from the patient, and where a rheumatic or gouty history does occur, it is either quite indefinite or it is clear that arthritis deformans developed in a gouty or rheumatic subject, that is, following genuine gout or rheumatism, just as it might develop in any other individual without any causal connection between it and the other affections. Supposed under the old theory to be a constitutional, probably a blood disease, patients who saw the ugly, crippling deformities produced by it and {422} then heard the word rheumatism used in connection with it were prone to think of this as the terminal stage of all the severe rheumatic conditions. As a matter of fact no evidence that we have shows that the disease has any connection with chemical modifications of nutrition or metabolism; nor, above all, has the so-called uric acid diathesis or any other superacidity of the blood any etiological connection with it. It has always seemed to me to be clearly a nervous arthropathy, as the lesions are almost without exception more or less symmetrically distributed. The joints that suffer are commonly the smaller ones in corresponding positions on opposite sides of the body, and they run a definite atrophic course sometimes with the preceding phase of hypertrophy that is so characteristic of the trophic lesions of an affection produced by a disease or defect of the nervous system. This symmetrical distribution constitutes the best possible evidence that arthritis deformans is not a nutritional disease and, above all, is not due to chemical changes in the blood. The affection exists in at least three forms and there is a growing persuasion that there are even more varieties of it that will have to be separated by clinical observation. There is a good study of the three types of the disease in _Guy's Hospital Reports_, Vols. 56-57, London, 1902. The article is entitled "Acute Rheumatoid Arthritis," but there seems no reason for applying the word rheumatoid to the group, especially since there is no proved connection with rheumatism and no similarity, except in the case of acute deforming arthritis in which at the beginning it may be difficult to differentiate the two affections. HEBERDEN'S NODES The most familiar form is named Heberden's nodes, from the great English physician who first made a special study of it. The affection is characterized by an enlargement of the sides of the distal phalanges with small, hard nodules, "little hard knobs", as Heberden called them, developing at these points. They are more frequent in women than in men. Evidently neither hard work nor exposure nor excesses in eating or drinking occasions them. They occur in all classes, the poor and rich, manual workers as well as professionals. It is rare to find them on one hand alone, though it is not at all rare to find them affecting solely the little fingers of each hand. I have seen several cases where surgical intervention had been attempted on one little finger because of the deformity produced when the node originally appeared. When I asked if there was not some trace of a similar condition on the other hand I was told there was not, yet I have been able to show that the first signs, at least, of a corresponding growth already existed on the little finger of the other hand. In the two cases in which my attention was called to a slight enlargement on one side before anything developed on the other, my tentative prophecy that corresponding nodosities would grow on the other side was fulfilled during the following years. While this form of the disease is a true arthritis deformans it seems to be entirely separate from the progressive forms which we shall speak of later. The nodes increase in size and occasionally develop on all of the fingers, but usually never spread beyond the phalangeal joints. There is a tradition in the {423} medical profession of England, where this affection has been observed with care for some two hundred years, that sufferers from these nodes commonly live to long life. This is not founded on any theory, but is an actual observation. There is also a tradition, though I cannot vouch for its truth, that the people who are thus affected have some sort of immunity to tuberculosis, or at least good resistive vitality against a rapidly running tuberculous process. I have had at least a score of Heberden's nodes cases under observation for more than ten years and some of them for nearly twenty years, and have been surprised at the slowness with which the process develops. A year often makes no change in the size of the nodes, and I have seen cases where after five years the photograph showed no difference. The lesions are often exquisitely symmetrical so that the question of the origin of the affection in the spinal cord constantly crops up, for that is the symmetrical influence in the body. There are, however, no other symptoms that point to involvement of the cord in any way. Most of these patients have suffered more from worry about it than from their affection. It is another case of "having many troubles most of which never happen." Some of my patients are physicians, and all of them have consulted other, some many other, physicians. As a consequence, many of them have taken to various diets, especially eliminating certain foods and liquids with the idea that this might stop the progress of the disease. I have never known any change of diet or any abstinence from liquids or solids that seemed to make the slightest difference, though I have seen a number of cases that were considerably worse than they would have been if the diet had not been tinkered with to such an extent as seriously to disturb nutrition. The main disturbing feature of the affection is the dread of the development of serious crippling conditions in the hands or in the large joints. As a rule, after a time the nodes cease to grow, and then a period of remission sets in that lasts for many years and there may be no recrudescence of the affection. This remission is delayed if the patients allow themselves to run down in general health. It is apparently hastened by getting the patients up to normal weight and removing any factors that disturb their general health. If the patients' minds are properly disposed, the neurotic symptoms that sometimes develop as the result of over-solicitude about their condition are done away with, the patients are more comfortable, and even the progress of the disease is inhibited. ACUTE PROGRESSIVE ARTHRITIS The second variety of the affection is a general progressive arthritis which usually begins with fever, redness, and swelling, involving especially the smaller joints. The diagnosis of the disease can almost be made on the fact that its favorite locations are the jaw and the joints of the spine. It is a much more serious affection than Heberden's nodes. In its beginning it often simulates acute rheumatism. It occurs particularly in people who are run down for any reason, in young women who have recently come to the country and are working as domestics, in young men who have recently changed their occupation from indoors to outdoors and are not used to the inclemencies of the weather. On the other hand, it occurs rather often in young persons of {424} both sexes used to living and working out of doors who take up an occupation in a damp interior. The fever usually runs a lower course than that of genuine acute articular rheumatism, the pain is not favorably affected by salicylates, and the duration of the disease is generally longer. This affection always leaves its marks on the joints and there are always recurrences. It is, indeed, the confusion of this quite distinct disease with acute articular rheumatism that has given the latter affection the bad name it has in many minds as a producer of deformities. Arthritis deformans or general progressive arthritis is always a crippling disease; acute articular rheumatism has for its surest diagnostic sign, when the complete history of the case is known, the fact that it leaves no mark after it except, unfortunately, that so often seen in the heart. CHRONIC ARTHRITIS DEFORMANS The third type of arthritis deformans is the chronic slow running type which involves many joints before the process is complete. One form of this, commonly seen in old men, called osteoarthritis, is often confined to the hip joint, and often produces considerable deformity. Another form is more common in women. It begins in middle life by deformities in the terminal joints of the fingers and the carpo-metacarpal joints of the thumbs. Bony outgrowth takes place until the joints become almost or quite useless. It spreads from the joints primarily affected to the elbows, the knees and occasionally involves other joints. The disease has no favorable course, but is progressive, and there is great discomfort, marked disability, aches and pains particularly in rainy weather and, finally, the patient may become quite helpless. Preliminary Stage.--An early symptom associated with arthritis deformans of chronic character is likely to be a distinct loss of muscle power, which may be the first symptom in cases that have no acute beginning. The patient notices that he is unable to hold a satchel as he did before, or that quite unaccountably it drops from him. There may be a loss of control over muscles and especially small muscles that attracts the patient's attention. He finds that he cannot hold a book as he used to, or that it is difficult to pick up small objects. He finds it hard to turn a door handle or to pull a cork, although the pulling action may be perfect, but the ability to insert the corkscrew is lacking. These symptoms are prone to be intermittent. They are most noticeable when the patient is tired, or after a damp day, or a succession of damp days, when he is not feeling well. It will usually be found that a joint, the affection of which is missed unless it is carefully looked for, that between the radius and ulna has become affected, and as a consequence there is a difficulty in supination. The lesions are different from those which occur in lead poisoning but at the beginning the symptom complexes may easily be confused. This form of arthritis deformans, in its earlier and its later stages, is a source of unfavorable suggestion as regards other affections. Its first symptoms may be thought neurasthenic, and if it is so called, those who hear the diagnosis and see the later developments will conclude that neurotic symptoms {425} can lead to serious sequelae. On the other hand, the painful tiredness that is always worse in damp weather may be termed rheumatism and be a correspondingly unfavorable suggestion. Patients who develop aches and pains as a consequence of occupations, or through the relaxation of joint tissues, are most uneasy because of the confusion of the later stages of this disease with rheumatism. This must be recalled by the physician if he would be successful in treating such pains and aches; for not a little of the discomfort is due to an exaggerated mental impression of their significance. This of itself often proves sufficient to keep the patients from the exercise that would relieve many of their secondary symptoms, at least, and serve to make their discomfort more bearable. Course of Chronic Arthritis.--The course of chronic arthritis deformans is always interesting. It is never as serious as the prognosis at the beginning seems to indicate, and it always has intermissions which, in most cases, become favorable remissions with such improvement that the patients feel encouraged, though they never get entirely well. Six rather typical cases have been under my eyes for from five to fifteen years. In all of them the course was slow and the progress of the disease vague at the beginning; and it was difficult to say how the affection began, or what was its cause, and apparently nothing would stop its advance. After a time all of them became discouraged and began to go the rounds. Almost without exception the physicians told them that they were incurable, and nearly all of them received unfavorable prognoses either directly from the physician or from hints sometimes dropped to friends, or from the attitude of the physician toward them. Much of this discouragement proved unjustified by the actual progress of the disease for many years. While they got but scant encouragement from regular physicians, nearly all of them received hopeful suggestions from irregulars and were, as a rule, for the time being, somewhat bettered by the treatments suggested by these, no matter what they were. Every one of these six cases, as was to be expected under the circumstances, went through a period of intense discouragement, with loss of appetite, partly from confinement to the house, partly from thinking so much about themselves, partly from lack of exercise and, in general, from their morbid mental condition. As a consequence of the loss of appetite, or, at least, of failure to eat in the midst of discouragement, severe constipation developed in five of the six cases and this further complicated the situation. They ran down very much in weight, and this emphasized the apparent size of the hypertrophic nodosities in their joints and weakened their muscles to such an extent that even under good conditions they found it difficult to move. After a time, usually many months, sometimes a couple of years, something happened to make them realize that while they were crippled and were going to be deformed, they still might find much in life that was not to be despised. Then they began to pick up in weight, their muscles got firmer, their nodosities seemed to disappear because the soft tissues around them filled out, though in most cases some of the material previously laid down actually was or seemed to be reabsorbed, perhaps as a consequence of the patient's better metabolism. Neurotic Additions.--All of these patients are now in much better physical and, above all, in much better dispositional states than they were during the first year or two at the beginning of their disease. While they allowed {426} themselves to run down in weight they were supremely miserable, with many neurotic pains and aches that were extremely hard to relieve, they had tendernesses and sorenesses on rainy days, usually attributed to their rheumatic conditions but really due to intense depression of the nervous system, with a constant tendency to exaggerate slight pains and aches into torments, and in general were invalids, a burden to themselves and others. They have improved to a noteworthy extent so as to become cheerful, reasonably happy in their power to help others, interested in many things and, in at least two of the cases, accomplishing more actual good for those around them than they probably would if their lives had continued to be the conventional existences that they had been before their arthritis came to them. This reminds one of Dean Stanley's famous expression that life looks different when viewed from a horizontal position. He used the expression with reference to fatal illness, but it might well be applied to any ailment that makes people think seriously and keeps them from occupations only with frivolous things. One of these patients is a source of consolation to many friends, who are much better in health than she is, who bring their troubles to her, and who marvel at her power to make the best of things. The prognosis for cure is extremely unfavorable, but the prognosis for a reasonable amount of happiness and a large amount of usefulness is, in my experience, excellent and though, of course, new habits will have to be formed and new ways of looking at life assumed, if this can be quietly and persuasively made clear to the patient early in the case, much of the more or less inevitable suffering that the patient will have to endure may be lessened. The older the patient, as a rule, the better the prognosis in these cases. As with regard to diabetes, tuberculosis and many another affection, every year after fifty adds to the prospect that the patient's ordinary span of life will not be much shortened and that the symptoms will not be severe. Occasionally the disease develops in patients who have been extremely healthy until they were well past sixty. I have in mind particularly a patient who did not begin seriously to suffer from the disease until she was sixty-eight. Then for two or three years she was very miserable, mainly because she had been very active and she feared that the disease would cripple her. It did bring about a considerable limitation of her activity. Ten years have passed, however, and she is still able to be about, and, though now well on the way to eighty, in good weather she still attends to various duties that take her outside of her home and occupies herself with many interests. I was never able to tell her that she would be better. I assured her from the beginning, however, that she would never be so much worse as she imagined, and that she would never be actually crippled. During the early stages of the disease, her discouragement and, above all, the diminution of activity, the lack of exercise and occupation of mind and the over-occupation with herself, made her not only mentally miserable but seriously interfered with many bodily functions. TREATMENT In the treatment of arthritis deformans the most important object is the general health of the patient. Owing to the confinement, the pains, which {427} are often worse at night, cause disturbance of sleep which reacts upon the general health. As a result of depression and discouragement, patients are prone to loss of appetite. This is sometimes looked upon as a symptom of the disease, but it is not a direct symptom except during the acute stage when there is fever, and is due rather to the changed conditions in which the patients live and the mental influences that surround them. If the patient loses in weight, as is so often the case, the effects are likely to be more serious, for the remission is delayed and is less complete in its consequences. Above all, it is important not to disturb the diet of the patient in such a way as to interfere with nutrition. Owing to the supposed rheumatic element, meat, or at least red meat, is occasionally taken out of the diet by the recommendation of the physician. Whenever this is done, harm results. There is a definite tendency to anemia, which will be emphasized by an exclusively vegetable diet, especially in those accustomed to eat meat freely. As a rule, there is much more need to encourage the patient to eat than to limit the diet in any way. Patients must rather be advised to take a generous mixed diet and to consume about as much meat and the same varieties as before. Tinkering with the diet has never been known to do any good for arthritis deformans and often does harm. The drinking of large quantities of water seems to do more than almost anything else to help these patients into a better frame of body and mind. Their neurotic symptoms are, as a rule, even more important than their joint symptoms, and if the neurotic symptoms can be cured, as they usually can without much difficulty, the patients feel much better. Systematic Exercises.--As soon as the acute stage has passed patients should be encouraged to take some systematic exercise in spite of the discomfort that is associated with it. Unless muscles are moved regularly deformities in bad position will result and there will be crippling which can be avoided in most cases. It is sometimes difficult to secure exercises for the small muscles that are involved and definite occupations are better than artificial exercises. For the fingers, for instance, I find that the best thing is knitting. By this I mean using the old-fashioned knitting needles for the making of stockings, wristlets, jackets, and the like. Crocheting is also of some use, but it does not give employment to as many of the small muscles as knitting. If the knitting is done with old-fashioned yarn from which the lanolin has not all been extracted, some of this substance comes off on the fingers during the movements associated with knitting. This seems to do good by rendering the joints more supple and the muscles more easy of movement. At least the suggestion is very helpful to the patients. Electricity and Mechano-therapy.--Electricity has been much praised, but whatever good it accomplished has always seemed to me to be confined to the exercise afforded the muscles. Its use, however, serves to keep up the patient's hope. Mechano-therapy often does good and some of the Zander machines are likely to be useful. Pulleys and weights for the shoulders and arms have their place and resisted movements serve to restore muscles to function which they had lost during the time when the joints were worst. Their use helps to bring the joint into the most available conditions. Something that has distinct hope in it must always be done for these patients. For this local treatment means more than anything else. Unfavorable {428} suggestions keep flowing in upon him from the failure of medicine, and serve to concentrate his attention on his condition and make him think that nothing can benefit him. Often the physician finds that his patient has been to someone else, who did some simple thing that brought relief of symptoms, at least for a time, and restored his confidence to such a degree that he felt much better for a time at least. These ailments are emphasized by advancing years and, though we cannot prevent decay of tissue, we can keep the patient's mind from inhibiting still further the functions of the impaired tissue. General Condition.--The patient's general condition must be made as good as possible. For this outdoor air is the most important factor. It increases impaired appetite, makes sleep more restful and easy, and gives one of the best occupations of mind that can be obtained. Of course, changes in the weather will bring discomfort. Where it is possible, such patients must be sent to climates as equable as possible. Such a change of climate during December, January and February will often make them very comfortable, and the distraction of mind, with the possibility of getting out in the mild climate, will diminish their sensitiveness and be more powerful factors in the dissipation of their aches and pains than the climate itself. Where people cannot be sent away from home, the securing of corresponding distractions means a great deal. The one thing necessary for the physician is to keep the patient from brooding upon himself and his ills and to find other occupations of mind for him. CHAPTER X COCCYGODYNIA Coccygodynia, or, as it is sometimes called, coccydynia, is a painful affection of the coccyx or bony end of the spinal column. It usually results from trauma, as a fall on the buttocks on an icy pavement, or particularly a fall in coming down stairs in which the main portion of the impact is on the seat. Occasionally it follows horseback riding. It is said to be on the increase among women who ride astride. Occasionally it is reported after severe labor, particularly when the head of the child was very large, or after first labor when the coccyx has been beforehand bent inward somewhat abnormally and is pushed out by the oncoming head. It seems to develop with special frequency in nervous people who have to sit much, particularly if they sit on unsuitable chairs. The chair seat with the ridge in the center which has been introduced in recent years is sometimes blamed. Occasionally, on the other hand, it is said to come from sitting on heavily cushioned chairs, particularly leather chairs which do not allow of much transpiration and cause a feeling of uncomfortable heat. There are, indeed, so many different causes suggested, sometimes of quite opposite or even contradictory effects, that it seems evident that the main element in the disease is some predisposition to sensitiveness in this region which is exaggerated and emphasized by the cause that is blamed. It occurs particularly in women, though it is occasionally seen in delicate or neurotic men. Sufferers from it sometimes find it impossible to sit for any length of time. {429} Even lying down, especially if they lie on their backs, becomes a source of pain. Various operations, such as the reposition in place of the bent coccyx, or even the removal of the tip of the coccyx, have been suggested. Some reported cures are to be found in the literature. These are mainly surgical cures, however, that is to say, the patient recovered from the operation, was seen for a month or two afterwards, and was then on a fair way to complete recovery. Some of us who have had to treat these cases afterwards for painful conditions apparently due to the scar of the operation, or to a neurotic condition closely corresponding to the old coccygodynia, are not so confident of the value of an operation, though probably in purely traumatic cases surgical intervention is of value. In most cases the sufferers are women who have little to do, who have much time on their hands to think about themselves, and who usually receive abundant sympathy from friends and relatives. In one case under my observation the death of a husband and the discovery that his estate was much less than had been anticipated, so that his widow had to take up a wage-earning occupation, did more in a short time than all the treatment that had been employed before to relieve her discomfort. She had been quite unable to move around at times, especially in rainy weather, and was something of an invalid during all the winter, but now she was able to go out to work every day and had very little trouble. Her affection originally dated from a fall on an icy sidewalk and her fear to go out in the winter seemed to be dependent on the dread of another fall. She realizes now that practically all her former trouble was due to over-attention to a discomfort which is still present, but which she is now able to forget, except at times when she is alone after there have been worries and troubles that have reduced her power to control her nerves. In young girls an injury to the coccyx by a fall on the buttocks will often leave tenderness for months or even years, but if attention is distracted from this and the patient is not allowed to concentrate her mind on it and does not hear of the awful possibilities of coccygodynia--a mouth-filling Greek name in which we map out our ignorance, and which seems to carry with it such a weight of pathology--she will probably recover completely. Coccygodynia often resembles hysterical coxalgia or the hysterical arthritises, and seems sometimes to be due to the fact that there is a natural or traumatic abnormal mobility of the coccygeal vertebrae which, owing to concentration of attention, has developed into a neurosis analogous to the corresponding condition in a joint. There are undoubtedly cases in which a real pathological lesion exists, but these are comparatively few. In this, as in other joint and bone affections with vague pains likely to be worse on rainy days, the word rheumatism is often mentioned, but it has no proper place. Treatment that will put the patients into good general condition--never local unless there is objective indication--outdoor air and exercise with reassurance of mind and distraction of the attention are the important therapeutic agents. Patients with much time on their hands do not readily get well, while those who are busily occupied seldom suffer for long. {430} SECTION X _GYNECOLOGICAL PSYCHOTHERAPY_ CHAPTER I MENTAL HEALING IN GYNECOLOGY All physicians are convinced of the good that has been done by the extension of the application of surgery to women's diseases during the pest generation. On the other hand, there are probably very few, except the ultra-specialists, who are not quite sure that there has been too much surgery in gynecology, and that many a woman has been operated on without sufficient reason and without definite indications. In suitable cases surgery is sometimes life-saving and is often the only means of relief for suffering that is seriously disturbing the general conditions and is making life unbearable. Its very possibilities of good, however, have led to abuses. From the abuse of a thing, the old Latins used to say, no argument against its proper use can be derived, and this is eminently true of gynecological surgery. It will not belittle the great benefit that operative work has been to state how much of auxiliary good may be accomplished by the use of psychotherapy in gynecology. Many a woman who is operated on is benefited only for the time being, and her old symptoms return after a time. Dr. Goodell, one of our first great gynecologists, used to warn his students insistently that women had many organs outside of the pelvis. The individuality in gynecology is extremely important. Some women suffer what they describe as excruciating pain or unbearable torture from pathological conditions that other women do not notice at all. Very often these women either have no real interest in life and are so self-centered that they emphasize their feelings by dwelling on them, or else their attention has been attracted to some sensation not necessarily pathologic and then by concentration of mind on it they so disturb vasomotor conditions and the nutrition of nerves that the condition does become a veritable torture and apparently demands surgical intervention. It is possible to cause a hyperemia in the skin by thinking about certain portions of it, and the genital organs are particularly prone to be influenced by mental states. If for any reason a woman gets her mind on her genital tract and becomes persuaded that there is a pathological condition in it, symptoms will develop until an operation seems inevitable. But the operation will bring relief only for a while, and then her mind will find something else to dwell on and produce similar symptoms. {431} Place of Psychotherapy.--To fail to try to sway the mind by all the methods and auxiliaries outlined in the earlier chapters of this work before suggesting an operation to a woman is to neglect a most important means for relief in many gynecological cases. There is scarcely any pathological condition from which women may suffer that does not become worse as the result of the depressing influence of much thinking about it, and that is not made better by a change in their mind that makes them realize the possibility of being well again. The most important preliminary to operation is the promise of complete relief through surgery. The acme of suggestion is reached in the preparation for operation with its constant encouragement and then the congratulations after the operation. Then come the weeks of convalescence during which the same strong suggestion is constantly at work making the patient sure that she must be better. All this serves to add tone to the system, invigorates the appetite and puts patients in the best possible mental attitude to bring about a favorable result. Indeed, the ten or fifteen pounds in weight that such patients gain during their convalescence, especially when they have been under weight before, is often the most beneficial result of their hospital experience. If the same patients had been given the same promise that they would surely be cured, and then had been removed from depressing home influences and bothersome trials and labors, and been told that what they needed for complete recovery was to gain in weight; if they had then been visited by friends who congratulated them on the fact that now at least they were going to be better and their symptoms were going to disappear, and if they had gained the fifteen pounds that came in convalescence after their operation, most of them would have recovered quite as completely as by the operation from many of their vague gynecological difficulties. This is, of course, true only of cases where there are not very definite indications for surgical intervention. But in a certain number the symptoms are so vague that operation is decided upon rather with the hope than the assurance of benefit; and it is particularly in these that psychotherapy is useful and must be given a thorough trial. _Pain Relief_ .--It is often set down as a maxim of gynecologic practice, that pain which cannot be relieved except by recourse to dangerous or habit-forming drugs is an indication for operation. Pain, however, is a relative matter and, as we have shown in the chapter on Pain, its intensity depends not a little on the patient's attitude of mind towards it. When there is discouragement and depression, pain becomes insufferable, and what was borne quite well at the beginning may now prove intolerable. Whenever occupation of mind can be secured, however, pain is diminished in intensity. Reputed Remedies and Suggestion.--Probably the most striking indirect testimony to the value of mental influence and especially of frequently repeated suggestion in gynecology is found in the recent history of various much-advertised remedies that have been sold in enormous quantities for all the ills of women. The composition of these remedies is not, as is popularly supposed, a great mystery. They have all been analyzed and their ingredients are well known. As a rule, they contain only simple tonic drugs that have absolutely no specific effect on the genital organs, but that are stimulating to the general system. There has been much surprise at the definite evidence {432} furnished by expert investigators, that the principal ingredient in most of them--certainly their most active element--is the alcohol they contain, which, until the passage of the pure food and drug law, was in such considerable quantities that practically each tablespoonful of these favorite remedies for women was equal to half an ounce of whisky. No wonder that this gave an immediate sense of well-being which rose in most of those unused to alcohol to a feeling of exaltation. The patient was sure beyond contradiction that she could feel the effects of the medicine! Of the after effects, the less said the better, but there is no doubt that many women acquired the alcohol habit through indulgence in these nostrums. Illusory as was this sense of well-being, it sufficed in many cases to relieve women of discomfort that had become so serious, to their minds at least, that they feared an operation would be necessary. Undoubtedly many of the testimonials given to such remedies are founded on actual experiences of this kind in which patients were sure that they were cured of serious ills. Where alcohol is not the chief ingredient of these remedies, some other tonic stimulant is employed, and it has proved sufficient to make the patients feel, or at least suggest to themselves, that they must be better. This has given them courage to take more exercise and get more out into the air, and consequently relieves them of many physical symptoms that had developed because they thought they were the subjects of some serious ailment and must be solicitously careful of their health. The idea of care for the health in many persons' minds seems to be to do as little as possible of external, useful work and to occupy themselves principally with their internal concerns. They stay in the house too much and in so doing disturb nearly every physical function. Perfectly well people, if confined with nothing to interest them, become short-circuited on themselves and develop all sorts of symptoms, physical and mental. The Mind as a Factor in Gynecological Affections.--A gynecologic incident of any kind may become to many women such a center of attention that it is impossible for them to distract their minds from it, and every symptom or feeling that can by any stretch of thought be connected with the genital system becomes greatly exaggerated. Young women, whose menstruation has been perfectly regular, may have it disturbed by fright, grief, a change of environment, getting the feet wet, or something of that kind. At immediately succeeding periods their fear of bad effects will of itself influence unfavorably the conditions in their genital system. They have always had more or less discomfort, but now this discomfort becomes difficult to bear because of the fear that there may be further serious consequences of the disturbing incident in their menstrual life. It occupies all their attention; instead of deliberately trying to disregard it, they fear that, if they should do so, they would be allowing some progressive condition to gain a hold on them which would lead to serious results. One is apt to see this condition in young married women who have had a miscarriage in their first pregnancy and who fear that there will be serious results from it. If they have been much disturbed by the miscarriage, they may lose in weight, and then a number of subjective symptoms in their genital life will appear. Though their menstruation appears regularly, lasts the usual time, and is neither more scanty nor more profuse than before, and {433} though their physical conditions are normal as ever, they suffer from bearing down pains and feelings and backache just before menstruation begins; their ovarian regions become sensitive and, if they are constipated, their right ovarian region is likely to become tender, and they develop a set of symptoms that seems to call for surgical interference. If, however, they are put in conditions where they have some other occupation besides themselves and their ills, it is surprising how the case will clear up. They gain in weight, their subjective symptoms disappear and especially they lose the persuasion, so common among them, that any betterment of their symptoms is due to their getting used to the pathological condition present and not to any real improvement of it. Treatment.--In the treatment of gynecological conditions such as are not necessarily indications for operation, the most important consideration is to reassure the patient's mind and secure the discipline of self-control. If patients are under weight this condition must be corrected. If they are in an unfortunate environment it must be modified, as far as possible. If they are without occupation this must be provided for them. Dominant ideas and morbid auto-suggestion must be overcome--not always an easy task, yet always possible if patience, tact, and skill are exercised. They must be made to realize that the women of the past, before the development of modern gynecology, not only lived useful lives without any of the modern gynecological operations, but that most of them were quite happy in so doing. Even though many of them had physical symptoms, the lack of unfavorable suggestion as to the significance of these prevented mental exaggeration, and morbid dwelling on them was not allowed to produce such a deterioration of the physical condition as to emphasize the pathological conditions. This does not mean that women may not have to be operated on, and, when that is necessary, the operation should be determined on and performed with no more delay than is proper to put the patients into suitable physical condition. But many operations that are undertaken without definite indications merely because the women complain, and it is hoped that an operation will somehow prove of relief, would be replaced with much more final satisfaction and relief by properly directed psychotherapy. There are many minor pathological conditions such as slight cystic enlargements, hyperemias with tenderness, slight displacements of the ovary, slight dislocations of the uterus or twistings of it that can often be successfully treated the same way. After all, what is considered the normal condition of the feminine internal organs is only an average reached from observation and many deviations from this average cannot be considered abnormal. Many a woman living practically without symptoms, or certainly without such symptoms as to justify an operation, has pathological conditions of her internal organs worse than those for which operations are sometimes suggested because over-sensitive women complain of their symptoms. The rule must be first to relieve the over-sensitiveness and then to determine whether an operation is necessary or not. Pain alone, unless it is of a disabling character or reacts upon the physical health, is not a sufficient indication for operation. {434} CHAPTER II PSYCHIC STATES IN MENSTRUATION One does not need to be a physician to be familiar with the curious psychic states which develop or are accentuated during the menstrual period. Practically all the peculiarities of the individual are emphasized at this time and if there are any special neurotic conditions or psychic anomalies these become quite marked. All the dreads, for instance, are more noticeable at this time. Women who at all times feel uncomfortable on looking down from a height are likely at this time to be quite overcome by fear and be unable to approach any position from which they might look down for a distance. Women who are afraid of horses, yet conquer their dread sufficiently to ride behind them, cannot do so, or only with great difficulty, during the menstrual period, and the same is true of the dread of cats or other animals. Misophobia, the dread of dirt, may be particularly emphasized at this time and servants are puzzled as to what has come over a woman who was not so punctilious in the matter a short time before. Irritability.--Dr. Charcot, the famous French nerve specialist, used to say that for a day or two before menstruation and during the first day or two of their period many women were not quite responsible. This is not merely an exaggeration of French contempt for women, for Möbius, the distinguished German neurologist, insisted that there is a certain physiological mental disturbance with distinct hampering of the faculty of judgment (Schwachsinn) normally associated with menstruation. Few physiologists or gynecologists agree with these extreme views, but there is no doubt that many of the troubles which business men experience with women in their employ begin with hasty words spoken at these periods when the real reason for the irritability is not known. The consciousness of this on the part of some women saves them from much undesirable friction by making them more careful at these periods. Many a domestic misunderstanding begins at these times and is unfortunately allowed to continue because the real reason for it--the instability of disposition due to menstruation--is not recognized. Lack of Inhibition.--There is no doubt that, except in women of the most stable physical and psychic character, a notable lack of inhibition characterizes all their actions at this time. To think that this is universal, however, would be a mistake. Healthy women deeply occupied with something they like often pass through menstruation absolutely undisturbed, and this is particularly true of the mothers of families. In spite of its exaggeration, it is well to keep the great French specialist's expression in mind, for it helps to explain many things that produce much suffering in the world. This is particularly true now that women are working more and more out of their homes at occupations which often make strenuous calls on them just at periods of the month when they should have more rest than usual. The consequence often is the development of a highly neurotic condition in which psychic {435} symptoms are likely to be prominent as well as a tendency to exaggerate the significance of their feelings which is disturbing to the patient and may even disturb the physician. Exaggeration of Sensitiveness.--The most striking feature of this is the tendency to exaggerate the meaning of physical symptoms which they have often borne with for a good while without much inconvenience, but which now appeal to them as of serious significance. Any uncomfortable feeling is likely to be dwelt on to such an extent as to be called an unbearable ache or even an excruciating pain, and the patient is prone to connect it with some serious pathological process in the region in which it is felt. If a woman has been reading about some special ailment, or, above all, has been listening to the tale, usually neither plain nor unvarnished, of a friend's medical woes, she is almost sure to think that there must be something seriously wrong with herself. Many a supposed chronic indigestion had its origin in nothing more than the uncomfortable feelings in the stomach region during menstruation, which call attention to that organ and then, by morbid introspection, lead to the exaggeration of various sensations that have always been present but have hitherto been disregarded. It is a good rule to neglect symptoms that develop during the menstrual period and not to treat them directly until it is plainly seen that they persist afterwards; for symptomatic treatment at this time will cause an over-attention to the condition. And we should be careful not to suggest to a woman at this time that her symptoms may be due to some pathological condition in an important organ. Such a suggestion will almost surely be accepted seriously and dwelt on so much as to become an auto-suggestion that may lead to the disturbance of the function of the organ in question because of the surveillance over it. The diagnosis must be put off until menstruation is over in order that the exaggeration of this period may be eliminated. If this were more commonly done and if women were advised to counteract their feelings at this time as far as possible by occupations of interest to them, there would be much less need of medication. As between rest and strenuous work during the menstrual period, work is probably always the better. Rest with nothing to do emphasizes morbid introspection to such a degree as to make even ordinary feelings unbearable. _Symptomatic Conditions_.--It is interesting to note how often affections that are always present give symptoms only during the menstrual period or just before it. Many women, however, suffer considerably about the time of the menstrual period from an extremely tired, painful condition of the leg below the knee which is really due to flatfoot. At other times it gives them little annoyance. Old dislocations and sprains are particularly likely to give bother at this time. All the occupation pains and aches are emphasized. Tiredness becomes a torment. This extreme over-sensitiveness extends to physical ills of all kinds, even those that are trivial. For instance, corns and bunions become almost unbearable, especially if there is any change of the weather with moisture in the air about the time of menstruation. Teeth become sensitive and often will ache when there is little that the dentist can find the matter with them. Women are often suffering from teeth that are supposed to be quite intractable because of over-sensitiveness, while in reality it is only at these certain times that the over-sensitiveness is present. {436} Over-reactions.--Even habitual actions which are accomplished without much difficulty at other times are likely to be a source of annoyance about this period. If a young woman has to call out figures or read off lists of names, she soon becomes hoarse, her voice becomes husky and it requires more effort to accomplish her work than at other times. Complaint of sore throat is common about this time, and if there have been any recent changes in the weather this is almost sure to be a premonitory symptom of menstruation. Singers and elocutionists are likely to find their occupations particularly trying at this time and actresses are seldom without considerable physical discomfort that makes playing difficult and unsatisfactory. This happens in all occupations requiring frequently repeated use of particular muscles. Piano-players and typewriters find that their fingers become sensitive at this time. This sensitiveness of the ends of the fingers may become so marked as to prevent these usual occupations, or at least may require their limitation. Physical Basis of Psychic States.--The physical basis of these troubles is probably more responsible for them than has been thought, though the mental state renders the individual more susceptible to annoyances of any and every kind. Careful weighing seems to show that there is a gain in weight amounting sometimes to three to five pounds toward the end of the menstrual month. This is accompanied by a sense of fullness that is perhaps an actual plethora, as if nature were manufacturing a superabundance of blood in anticipation of the loss. This produces a systemic hyperemia. It is well known that hyperemic areas are more sensitive than tissues in ordinary condition and this seems to be the case in menstrual life. This renders the nervous system more active and irritable and the nerve endings more sensitive. With the menstrual loss this physical condition is relieved and then there is a return to normal with a loss of weight only partly due to the actual blood loss and somewhat to increased excretion in perspiration, in transpiration through the lungs and through all the emunctories. Treatment--To know that these psychic disturbances are likely to occur at the time of menstruation is to be prepared for them so as to lessen their effect upon one's self and others. They are much relieved by this frank recognition and the patient understands that with the betterment of the psychic condition by such reassurance the physical symptoms are lessened. Many a woman gives up her occupation at such times who would be much better if she bravely clung to it and resisted the temptation to be moodily occupied with her condition. Above all, she needs to be in the air. Oxidizing processes within the body are slower and while much exercise is not beneficial and may be often harmful, riding in the air, sitting in the air, above all, sleeping where there is an abundance of fresh air is all-important. Every form of exertion will be reflected in increased irritability. Shopping, balls and parties will disturb the woman's mental equilibrium and make it more difficult for her to stand whatever physical discomforts she may have, and also make it hard for her to pursue her ordinary occupation if this is somewhat exacting. Even these, however, must not be given up if the sacrifice involves the throwing of the patient back on self and increases introspection. Diversion of mind and temporizing with symptoms are the basis of therapy at the menstrual period. {437} CHAPTER III AMENORRHEA No feature of menstrual difficulty shows so clearly the influence of the mind over bodily function, and especially over those genital functions that are supposed to be involuntary and spontaneous, as amenorrhea. Almost any kind of mental trouble may produce a cessation of the menstrual functions. Profound grief or a severe fright nearly always does. Every physician of large experience has seen cases of women who have missed their period because they were disturbed by a fire, or a runaway, or an automobile or railroad accident within a short time before their menstruation should normally occur. Even slighter shocks may have a similar effect, and a profound shock of any kind will seriously disturb menstruation. The most frequent effect is to inhibit it, but it may be anticipated or delayed, and where there is a tendency to too profuse a flow, it may produce menorrhagia. Every physician knows that much less serious mental influences than a profound shock or fright may somewhat disturb menstruation and, in young women at least, this disturbance is nearly always in the direction of lessened flow and amenorrhea. Home-sickness, for instance, will often have this effect. Many of the foreign-born domestics who come to this country have serious disturbances of their menstrual flow, usually a diminution, during the first three or four months after they arrive in America. This may, of course, be due in part to change of climate, change of food and change of habits of life. These girls while in their European homes have often been accustomed to be much more out of doors and to have more exercise in the open air than they have here. That the mental state has much to do with menstruation may be appreciated from the fact that serious changes of her state of life may be accompanied by amenorrheal symptoms even when the patient stays in the same climate and under conditions not different physically from those under which she has lived. Country girls who come to the city often suffer from such symptoms. Young women who enter convents sometimes have these symptoms for some months, and this is so well recognized as to be expected in a certain number of cases. Indeed, there is danger that it should be attributed too much to the change of mental state, and that other factors, such as incipient tuberculosis, or disease of the ductless glands, or anemic states, which are responsible for it, may fail to be appreciated because of the ready explanation afforded by the mental factor. General experience shows that the attitude of mind of a patient toward menstruation, the expectancy of it at a particular time, and a good general physical condition that predisposes to it, are quite as important for its regularity as the specific physiological conditions which naturally bring it about. Fright and Amenorrhea.--Fright particularly may disturb menstruation in many ways. Occasionally the disturbance of menstruation consequent upon shock lasts for months or even years. At times when a woman between thirty-five and forty is seriously frightened, especially by terror that endures {438} intensely for some hours, the sort that is said to blanch the hair in a single night--and there are well-authenticated instances--menstruation never recurs or if it does recur it is vicariously from some other portion of the body than the genital tract. Among my notes is a case of a woman frightened by a revolver which a maniac had flourished for hours at her while she dared not make a move nor a sign. Her menstruation stopped completely for a time and then came back irregularly and usually from the ear. The bleeding was from the pierce in the lobule which had been made for earrings, and before it started a large swelling of this would come on in the course of an hour, often not subsiding for days. In another case a woman who was frightened during menstruation by an insane person flourishing a knife near her had for several years after an extremely irregular menstruation, and usually only the molimina in the genital tract, while the bleeding was from the nose. Deep emotion can very seriously affect menstruation. Pseudocyesis.--The mind may bring about a cessation of menstruation in another way without any other factor interfering and in spite of the fact that physiological conditions would all seem to be favorable to its regular occurrence. We have many cases in medical literature in which married women anxious to have children have concluded that they were pregnant, and have had complete cessation of their menstruation for months with all the symptoms of beginning pregnancy, so as to deceive even careful physicians. The best known historical instance is that of Queen Mary, the eldest daughter of Henry VIII of England, who, nearly forty when she married Philip II of Spain, was very anxious to have children. Not long after her marriage menstruation stopped and all the ordinary symptoms of beginning pregnancy developed. Her condition was widely heralded throughout the kingdom; then, after a time, to the intense disappointment of the Queen and her friends, it proved that she was not pregnant but that her mental attitude had produced the series of symptoms that proved so deceptive. These cases of pseudocyesis are so likely to occur that a physician in dealing with a woman, who being rather well on in years when she marries is anxious to have children, must be on his guard and he must always take into account the possibility of a pseudo-pregnancy and must be careful not to be deceived by symptoms that would ordinarily indicate beyond doubt the beginning of pregnancy. Even experts have been deceived in such cases, and it is in them that accurate rules for the certain detection of pregnancy are most needed. These symptoms have reference not only to the uterus, but also at times to other organs. They are not merely subjective, but sometimes become so objective as almost to demonstrate the diagnosis of pregnancy, and yet a mental condition is the only source of the changes. For instance, cases of false pregnancy have been reported in which, besides the gradual enlarging of the abdomen with many of the signs of pregnancy accompanying that phenomenon, there has been an enlargement of the breasts and even the secretion of milk. In a few cases the enlargement of the abdomen has been accompanied by pigmentation and the areola of the nipple has also become pigmented. This is not surprising, since corresponding changes take place in connection with fibroid tumors, and the deposit of pigment is not a symptom of pregnancy, but only a result of the congestion which takes place in these structures during their enlargement. {439} Amenorrhea from Dread.--In some cases all the symptoms of pregnancy develop, or at least there is complete cessation of menstruation, as a consequence of nervousness and dread of the occurrence of pregnancy. Unmarried women who fear that they may have become pregnant by indiscretion, sometimes become so worried over their condition that, without any physiological reason, they miss one or more periods and thus add to their nervous state and further inhibit menstruation, though usually two months is the limit of such amenorrhea and the menstrual flow commonly makes its reappearance shortly before or after the time of the third period. Occasionally, however, in the case of anxiously expectant married women further symptoms of pregnancy may appear and the case becomes more complicated. Every physician of considerable experience has seen such patients, and doubtless much of the harvest which advertisers reap from drugs that are supposed to produce abortion comes from nervous young women who are not really pregnant, but have inhibited their menstruation by worry, and who take these medicines with confidence and have the menstrual flow restored by trust in their efficacy. Ductless Gland Disease.--Of course, in many cases of amenorrhea there are serious underlying constitutional conditions which may or may not be amenable to treatment, but the possibilities of which must always be thought of. One case of amenorrhea I saw in recent years proved to be due to a beginning acromegaly. There was no sign of enlargement of the hands, though there had been a coarsening of the face which was attributed to growth and to the fact that the girl was taking much horseback exercise in all weathers. She had a headache for which no remedy seemed to be of any avail, and when the amenorrhea developed it was naturally thought that the headache must be due to gynecologic conditions. Nothing was found on investigation, however, and eventually the gradual development of the symptoms of acromegaly showed what was really the basic cause. Occasionally diseases of other ductless glands, as the thyroid, may have amenorrhea as one of the first symptoms. It is seldom that any serious thyroid condition develops without disturbance of menstruation, but this is less frequently in the direction of diminution than toward profusion and prolongation. In some cases, however, one or more periods is missed in the early development of the disease. In this, however, others of the characteristic tripod of symptoms--rapid heart, tremor, exophthalmes--are sure to be present even though the enlargement of the thyroid is not noticeable. Tuberculosis.--But more important than these causes of amenorrhea is the early development of tuberculosis. In some cases, even before there is any cough that calls attention to the condition, or when the cough has been considered to be one of those myths now fortunately passing, "a cold that hangs on," the cessation of menstruation may depend entirely on the weakness and anemia due to the growth of tubercle bacilli in the lungs. Inanition Amenorrhea.--Sometimes indigestion, or what is supposed to be indigestion, may be at the root of the amenorrhea. In many cases it really is not true indigestion that is present, but a disinclination for food which has increased to such a degree as to bring about a lowered state of nutrition. In nervous young women and, above all, in nervous spinsters beyond forty, disturbances of menstruation consequent upon lack of nutrition are not infrequent. Often their indigestion is considered to be a reflex from their genital {440} organs, when, on the contrary, whatever disturbance of their genital organs is present is due to the inanition which has developed because they have not been eating enough. Many of these women literally starve themselves, and they, must be persuaded to eat once more and taught what to eat, and their weight must be watched until it gets up to what is normal for their height. Psychotherapy and Treatment.--The treatment of amenorrhea on psychotherapeutic principles will be readily understood from the fact that there is a distinct psychic element in practically all the cases touched on in this chapter. This psychic element is generally appreciated and admitted. If a woman is accustomed to connect certain physical incidents with disturbances of menstruation, then those disturbances are almost sure to recur. As a rule, many an incident said to be disturbing to the function would probably have no influence upon it but for the dread connected with it and the anticipation of some interference. In all cases of amenorrhea, then, the patient's mind must be put into a favorable state and suggestions must be made that will lead to the expectancy of menstruation at the next regular period. If the mind can cause menstruation to cease, as is clear from experience, any inhibition from this source must be removed and its power set to bring relief to these patients. Drugs should not be neglected, and general physical conditions must be improved, but if the patient's mind continues to be unfavorably affected towards her menstruation, its satisfactory return will be delayed until somehow mind as well as body are co-ordinates for the resumption of the function. The best testimony to the value of psychotherapy in amenorrhea is found in the success of many of the remedies used for the condition, which, in the successive phases of medical development, have included all sorts of home treatments, many types of quack medicines, and innumerable proprietary combinations. Many of these have acquired a reputation for efficacy not justified by any direct pharmaceutic effects which we now know them to possess. From the familiar gin and hot water, through the various combinations of aloes and the tonic remedies of a later time, only the most general and obvious effects could have been produced by the medicines, yet apparently specific reactions have followed them in the menstrual cycle. But this was because the mind of the patient was prepared by the taking of the remedies and unfavorable suggestions as to menstruation were removed. Above all, with amelioration of the general health, constipation being relieved, the appetite restored and the whole tone of the system improved, nature became capable of taking up once more the menstrual function. What was accomplished by indirect psychotherapy in the past can now be done much better by direct mental suggestion, when at the same time various remedial measures in other therapeutic departments are employed as auxiliaries. But the physician must be sure that the mind of the patient is properly disposed or remedies may fail and symptoms continue. CHAPTER IV DYSMENORRHEA Practically every woman of menstrual age has more or less discomfort during menstruation. In most cases this does not rise beyond a heavy depressed {441} feeling shortly before menstruation begins, followed by a sense of weight and discomfort in the back and then some sensations more or less acutely uncomfortable due to congestion in the pelvis, which begin to be relieved with the commencement of the flow and then gradually disappear. Even in otherwise healthy women, various achy feelings of distention are often felt in the neighborhood of the ovaries, but these would scarcely be described as pain, unless the patient is over-sensitive. The effect upon the disposition is more marked and more universal. Some women are inclined to be irritable and hard to get along with for a few days before their menstruation and sometimes during the whole of its course. The frank recognition of this fact by them and a consultation of the calendar when they find that everything seems to be going against them and that everybody is lacking in sympathy, usually leads to an appreciation of the fact that the trouble is in themselves rather than in those around them, and their condition becomes more bearable. It is curious, however, to note how often this is forgotten, with consequent give-and-take of irritation in their environment that makes the nervous and mental condition worse and emphasizes the physical symptoms. The term dysmenorrhea, from the Greek, means difficult menstruation and is usually associated with painful conditions in connection with the menstrual flow. It may be applied, however, to various uncomfortable feelings, to superirritability, to fatigue, to lack of energy, or even to more vague discomforts at this period. The discomforts are usually spoken of as pains, especially after the patient has been dwelling on them for some time and has been reading patent medicine advertisements that tell of how women suffer in silence, but analysis often shows that they are sensations of pressure, of compression, of achy distress at most, and sometimes only of unusual feelings--paresthesiae--that having got over the threshold of consciousness, through concentration of attention upon them, are occupying the center of the stage of mental activity to the exclusion of all serious interests. The serious difficulties of menstruation are due to definite pathological conditions such as displacements of the uterus, affections of the uterine mucosa and of the ovaries. There are, however, many cases where the trouble is merely functional, dependent on conditions that can be easily corrected without serious surgical or even lengthy medical treatment, and where the patient's attitude of mind towards the trouble is the most important factor in the medical aspect of the case. As a matter of fact, many of the discomforts and even serious pains complained of in connection with menstruation are due rather to the patient's incapacity to bear even slight discomfort with reasonable patience and without exaggerated reaction than to the actual pain inflicted by whatever disturbance of function and tissue may be present. People differ very much in their power to stand discomfort and what seems quite trivial to one becomes unbearable torture to another. With this in mind it is possible to relieve many women who suffer from dysmenorrhea from their discomforts so that they shall only have to bear what is every woman's heritage in the matter. Successful management of these cases will save them from the supposed necessity of being operated on, which is likely to be constantly suggested to them in an age when women so often talk of their operations. The amount of pain suffered from any cause is dependent on two factors, the pathological condition and the power of the individual to withstand {442} discomfort. When we are irritated, when we are very tired, when we have fever, when we suffer from want of food or lack of sleep or any other condition that exhausts vitality, even slight pains become hard to bear. In relieving pain it is as important to remember this lessened capacity to stand discomfort as it is to get at the cause of the discomfort itself. This habit of standing discomfort with reasonable patience is one of the best remedies for lessening suffering, especially when it is known that the discomfort is only temporary and the end of it is in sight. Physical Condition.--In the treatment of suffering incident to the menstrual period, then, the correction of all conditions that may increase nervous irritability and make patients less capable of standing pain should be the first care. Young women who are thin and anemic, especially if they are more than ten per cent. under weight, are likely to suffer much at their menstrual periods for two reasons--through their lack of power to withstand discomfort and owing to the fact that their ovaries and the uterus itself are especially sensitive, probably through lack of nutrition consequent upon their general condition. In these cases local treatment is not as necessary as improvement of the patient's general condition and the raising of her general bodily tone. The bowels must, of course, be regulated, partly for the sake of the general condition and the fact that it is very hard to have a regular appetite unless there is a daily evacuation, and partly also because the presence of an accumulation of fecal material in the lower bowel is likely to produce congestion in the pelvic region. This added to the normal congestion due to the menstrual function may cause undue pressure upon sensitive nerves in the ovaries and uterus. Indeed a regulation of the function of the bowels is immediately followed by a lessening of the menstrual discomfort as well as by a general improvement. Many women find that the taking of a gentle purge a day or two before the menstrual period serves to make that period a source of less discomfort than it would otherwise be, and undoubtedly the suggestive value of such a remedy persuades many women that their discomfort should be lessened. Professor Goodell's reminder that women have many organs outside of their pelvis is important in dysmenorrhea. Almost any ailment that drains a woman's strength and brings a series of irritations to bear upon her nervous system will be reflected in her genito-urinary system and will cause discomfort during the menstrual period. Over and over again the physician finds that the true source of the menstrual discomfort is not in the essentially feminine organs, but in the digestive organs or occasionally even in such distant organs as the lungs, and that proper attention to these brings relief during the menstrual period. Just as soon as they realize that this is not a new affection but only a reflex from their other ailment, whatever it may be, they stand it with much better spirit and their complaints diminish. Anyone who has seen the difference between the reaction to menstrual moliminia when patients are in good condition and when they are otherwise run down will realize how much a matter of over-reaction to symptoms dysmenorrhea may be. Teachers who begin the school year, invigorated by their vacations, scarcely notice their periods, but at the end of the course, when run down by months of hard teaching work and especially by the confinement of the winter, they find the strain extremely hard to bear. In many of these cases an examination by a specialist seems to reveal something that might be {443} benefited by operation. There may be various uterine displacements, sensitive ovaries, perhaps slightly enlarged yet often not distinctly pathological, but just as soon as the physical condition is made normal, the symptoms given by these conditions completely disappear. Women who have nothing particular to do, who talk much about themselves and their ills, who have had friends operated on and heard much talk about the subject, are soon convinced that only an operation will do them good. Once _that_ suggestion is implanted in their minds, the hypnotic dread of the operation and the morbid attraction of being a center of interest and commiseration will make them exaggerate their symptoms to such a degree that operation becomes almost inevitable. Moral Fiber.--It is often said that modern women, as the result of civilization, refinement, and city life, are of laxer physical fiber and therefore cannot stand the ills that their grandmothers bore with equanimity and considered as nothing more than what was to be expected in this imperfect existence. Most physicians must feel, however, that the increased laxity is not so much of the physical as of the moral fiber. We have not weaker bodies than our forefathers, but weaker wills. This is especially so with those who have much time to think about themselves, and, therefore, is more true, of women than of men, though in our generation men also have become very introspective. I have seen--and I am sure that my experience is a common one among physicians--delicate women who seemed unable to stand any trial or hardship successfully, placed by unfortunate conditions--such as the sudden death of a husband, or his failure in business--in circumstances that were extremely hard to stand up bravely against. Not only did they stand it, but they had better health, they had less complaint of pains of all kinds, particularly in this matter of dysmenorrhea, than they had before. Pain and Occupation of Mind.--The more claims a woman has on her attention the less likely is she to be bothered at her monthly periods. If she does not _have_ to get up in the morning because there are no insistent obligations upon her, she is likely to lie in bed and worry about herself and by concentrating her attention on her ills will make them worse than they are. But if she has to be up and doing, if household cares cannot be put off, if she has to earn her living by working every day, she not only succeeds in doing it, but often also forgets her ills to a great extent in her occupation. Of course, there are pathological conditions that cannot be put off in this way, and if there are serious uterine changes, or if an infection has spread along the tubes to the ovaries, there will be symptoms that cannot be distracted away. Even where there are minor pathological conditions, however, occupation of mind will make pain less annoying and even make it quite negligible. We know our own experience with toothache. This is a real pain and with a real pathological condition of the most material kind. The congestion of the sensitive dentine or the irritation of an exposed nerve filament causes about as severe pain as it is given to mortals to bear. Even with toothache, however, we can by occupying ourselves with friends, or with a pleasant book, or a game of cards, or the theater, so diminish the annoyance consequent upon the pain as to be comparatively comfortable. If anything completely occupies our attention as, for instance, a fire or an accident, or bad news from a friend, then it may be hours afterwards before we realize that we were suffering from a toothache. Since this will happen with a dental nerve, why should it not {444} happen to branches of the genital nerve? There is no reason why one should be more sensitive than the other, and whatever reason there is is rather in favor of the dental nerve giving more bother, since it is nearer the center of the nervous system and these nerves are usually said to be more sensitive. Working Women.--With regard to painful menstruation, the habits of many country people, and of the European peasantry generally, furnish valuable indications of the power of work to dissipate discomfort. During my medical student days in Vienna I had the opportunity to know rather well a group of women who were engaged in working on a building. They carried up the bricks and mortar for the men and worked the windlasses by which heavy materials were carried to the different stories, and they mixed the mortar and prepared the building materials generally. These women, living constantly in the air and working very hard, had almost no symptoms of menstrual difficulty. They never laid off at this time except in a few cases in which subinvolution after pregnancies and genital infections had left conditions that made it hard to understand how they worked at all. I learned in addition from them, for most of them came from the country, that the women who work so commonly in the fields in central Europe have little difficulty with menstruation and practically do not know that it is coming on them until the show indicates its presence. I had known before how true this was for the Irish peasant women. This seems to be the normal healthy condition, and the state of mind of these women aids this satisfactory state of affairs. They rather look down upon women who complain at this time as being of such inferior health as to be despised. Doubtless if they were persuaded, as so many seem to be, that a woman must expect to have a serious time, or at least a great deal of discomfort about this period, they would have it, too. Of course, they have some difference of feeling at this time. They feel more tired in the evenings, and they awake in the morning less rested, but that is no more than the changes in the weather bring to men. On the coast of Brittany and Normandy many of the women rake for shellfish. Their custom is to wade into the water and, standing with the water often above the knee and waves sometimes washing as high as the waist, to rake all day for the shellfish that they are seeking. They do not lay off from this occupation, as a rule, when their menstruation is on them, but continue as if nothing were the matter, and there are very few complaints of menstrual troubles among them. Such occupation would seem to be positively counter-indicated, but long years of experience have shown them that there is no need of interruptions in their work and as they need every centime that they can obtain in this way for the support of their families, they continue even in very cold weather, when it would seem inevitable that this must produce serious results. It is not uncommon for a young woman, who, while her family was in good circumstances, was a severe trial to everyone for a week more or less, every month, to become quite free from trouble for herself and others when, owing to a change in the family circumstances, she has had to take up some occupation for a living. I have notes of cases of this kind in which the pain was so severe that, after several years of medication and external applications, it was decided to dilate the cervix uteri in the hope of affording relief. The relief thus afforded, however, was only temporary. A little later in life, {445} however, the necessity of earning a living has in some cases quite freed these young women from the torments that sent them so frequently to their physicians. We need the report of many more of such gynecological conditions which get better as a consequence of occupation of mind without any other treatment. We have any number of reports of benefits derived from operation, but not infrequently these reports refer only to a few months after the operation, when the strong mental suggestion of the performance of the operation and the general betterment of health consequent upon care during convalescence are still acting upon the patient, and she has the benefit of the gain in weight and strength that usually follows because of hope, appetite, exercise in the air, etc. Not infrequently in these cases there are, later on, sad relapses into painful conditions quite as severe as before, while, on the other hand, some change in the circumstances of the individual, or some intense preoccupation of mind a few years after, brings lasting cure, thus showing that it was the mental state which was at the root of the condition rather than any bodily affection. Spasmodic Dysmenorrhea.--There are two forms of dysmenorrhea that have been the subject of much study. One of them consists of cramp-like pains which occur some time before menstruation, are relieved if the flow is copious, but continue if it is scanty. This affection has often been attributed to mechanical obstruction. Nearly twenty years ago Dr. Champneys in his Harveian Lectures on Painful Menstruation discussed this subject, and showed that the mechanical explanation while very simple and popular was probably not correct. His conclusion was that the dysmenorrhea was more frequently due to conditions outside of the uterus than in that organ. He recommended plenty of healthy exercise between the periods and especially riding if the patient were not a working woman, regular activity of the bowels with epsom salts as probably the most valuable single remedy, and then a number of drugs such as guiacum and sulphur that are not specifics but have a general effect. In his experience castoreum, a strongly suggestive remedy, gave more relief than anything else. He advised against local treatment unless there was a very definite reason for it and frankly expressed the opinion that the complaints were often due more to an incapacity to stand the slight discomfort that is more or less inevitably associated with the congestive state that precedes menstruation than to any pathological lesion. Membranous Dysmenorrhea.--This affection like membranous colitis remains one of the mysteries of pathology and etiology. There is no doubt, however, that there are large nervous elements in its production and that it is worse at times of worry, while mental factors of many kinds influence its occurrence and also its relief. In his Harveian Lectures Dr. Champneys discussed the questions connected with it very well and his monograph is a classic on the subject. Many drugs have seemed successful and then have failed. Castoreum has done good in this as in spasmodic dysmenorrhea. A number of gynecological methods of treatment have been successful when first applied, when physician and patient were both confident of their value, and then later has failed. Probably nothing does more good than getting the patient's mind off her condition, securing such occupation as will not permit of introspection to any extent, though of course treating surgically whatever requires operation. It must not be forgotten that while many of those suffering from the disease {446} complain of pain, not a few sufferers from it have no symptoms of this kind and their condition is discovered more or less by accident. After this there is likely to be much more discomfort from it. All this must be borne in mind in its treatment. Minor Ovarian Lesions.--In many cases there is vague discomfort in the ovarian region about the time of menstruation, and the ovary is found to be somewhat enlarged or perhaps dislocated. In these cases if there is continued complaint of pain, operation will almost surely be advised and frequently cysts are found. This is considered to be justification enough for the removal of the ovaries or at least for their resection. It is doubtful, however, whether ovarian cysts in the majority of cases are really a pathological condition. Those who are engaged in spaying cattle think it almost if not quite normal for cysts to exist in the ovaries. Whether this is not also true of women we have not the data to determine. In a number of the patients who are operated upon for this condition there is a relapse of symptoms, and there seems to be no doubt but that whatever good is accomplished comes from the expectation of relief followed by the weeks of rest and quiet in bed and very often the gain in weight which succeeds the operation. Whether something of this kind would not follow from the simpler procedure of improving the general health is an open question. It is sometimes insisted that the general health will not improve in gynecological cases unless the offending pathological condition is removed. This is true if the patient is persuaded that there is some pathological condition present which must be corrected or else she will not be better, and if favorable suggestion cannot be used to advantage. If, however, these patients understand from the beginning that probably the local condition, which gives the symptoms, is due rather to their general health than to a definite lesion, there is more probability of improvement. It is surprising how many of these cases are relieved by an improvement of the general health, by the relief of constipation, by the decrease of congestion by laxatives, and by the persuasion that there is nothing which will go on to serious developments (this is the most disturbing of dreads) but only a condition that will probably get no worse and the symptoms from which may yield to general treatment. The popularity of many so-called remedies for women's diseases is due to their success in lifting the veil of discouragement and, by alcoholic and other tonic stimulation, helping the women into a better general condition and a more favorable frame of mind. The Individual.--In all cases of dysmenorrhea, then, it is important not to be influenced too much by the complaints (for here, as Broadbent insists with regard to angina pectoris, the more complaint we have the less serious the condition will often be), but to investigate the patient's condition and, where there is not some definite and serious pathological lesion, to analyze the beginning and the development of the individual case and eliminate the neurotic elements. Often the menstrual difficulty is due to suggestion, as the patient has been in contact with others who were sufferers and caught her complaint from them by psychic contagion. Special investigation is needed as to her occupation of mind. This must be provided for her. Nothing else will save her from herself. Travel may do it, exercise may be helpful, but an occupation in which she is deeply interested, especially if it involves {447} association with other people, is the best basis of psychic treatment. Improvement of the general health and the relief of various symptoms are auxiliaries. Unfavorable Suggestion.--After consulting with many women physicians, with many women who have lived active lives, with many superiors of religious orders in consultation about their religious women, I cannot but conclude that painful menstruation is ever so much oftener a result of mental and nervous states than of organic disturbances. Unfortunately a tradition has now been established that women suffer much at this time, so many of them give in to their feelings, exaggerate their discomfort, dwell on their sensations, affect the blood supply to the genital organs through the sympathetic nervous system, actually produce functionally pathological hyperemia where only physiological was present (the simile of the blush makes this easy to understand), and finally set up a condition that is actually painful, though there was only some discomforting sense of compression and congestion before. We have been educating young girls in disease, not in health. Plato pleaded for the opposite. After these 2,400 years we might take it up seriously. CHAPTER V MENORRHAGIA While the influence of the mind in producing painful menstruation and a much diminished menstrual flow is well recognized, the connection between the mind and an increased menstrual flow is not so generally appreciated. Usually profuse menstruation (especially when it reaches a height where it would properly be called menorrhagia) is considered to be due to some serious pathological condition. Its most frequent cause is undoubtedly subinvolution of the uterus after pregnancy, or an overgrowth of the uterine mucosa because of some pathological condition--usually an infection. While menorrhagia is often attributed to colds or to getting the feet wet (and undoubtedly the disturbance of the circulation consequent upon wet feet is an active factor in the production of an increased menstrual flow) there is no doubt that in most cases there is some more distinctly local cause at work. Another important cause of profuse menstruation is the presence of a fibroid tumor or other neoplasm which brings an increased blood supply to the uterus and a consequent greater elimination at the menstrual epoch. In most cases of subinvolution a curettage, at least, will have to be done. Often the use of extremely hot douches, that is, just as hot as can be borne, may accomplish much. Such quantities as a quart or two are useless; several gallons should be taken, and that not in the awkward cramped postures in which douching is sometimes done and in which it cannot be expected to accomplish its purpose, but in the reclining position and to be followed by an hour or two of rest with the hips elevated. This treatment will be more effective if women do not get the idea that an operation will surely have to be done on them. Operations are now so much spoken about that some women apparently do not feel that they have had quite all the experience that is coming to them in life unless they have at least one to their credit. If they can be made to realize that, in the past before the days of operative gynecology, most such cases recovered of themselves and that now if courage is {448} resumed, appetite strengthened through the will, constipation relieved, an abundance of outdoor air secured (exercise is not so necessary), recovery will probably be more complete than after an operation, there would be much less need of operations than at present. The material conditions based upon pathological changes which usually produce menorrhagia hardly seem amenable to influence by the patient's state of mind, yet experience demonstrates that much can be done for these patients by setting their minds at rest, by improving their general condition, by soothing their worry as to what the profuse flow means. Many nervous patients have quite normal menstruation, as regards the length and quantity of flow, until some serious disturbance occurs in their mental state. I have had patients who for months would have a perfectly normal menstrual flow of three to five days to whom a serious mental disturbance always brings a profuse menstruation. The arrest of a woman by mistake just before or at the beginning of her menstrual period will often cause a greatly increased flow and great weakness will follow. Women approaching the menopause already have a tendency to an increased flow though not beyond the bounds of what might be considered normal, and at this time almost any shock will produce profuse menstruation and lead to prostration. If the secondary anemia from this is not overcome during the interval profuse menstruations may succeed each other for many months. The necessity for reassuring these women, therefore, becomes evident. Most of us have seen women who were worried at having a slightly increased menstruation, and who had been told that they had a fibroid tumor which was producing the increased menstruation, and which would have to be removed if it continued to bring on this serious condition. Such a suggestion inevitably leads to a series of more profuse menstruations during the following months. Such women worry over their state and dread an operation. They do not eat well and, even though they do not lose much in weight, they often become distinctly anemic. This anemia adds to the tendency to a freer flow and as a consequence the menstrual period is lengthened in time and increased in amount. This soon brings them to operation, though very often there has been no increase in size of the fibroid tumor and there is no more reason for operation than there was when they were first examined. I have had under observation during the last two years a patient in whom the diagnosis of a fibroid brought this unfortunate result. Her menstruation had been profuse and prolonged before but now it became still longer and lasted nearly fifteen days each month. As she lost much in weight, was run down in strength, became self-centered, stayed more at home, and took less exercise, the resultant depression in her general condition emphasized the menorrhagia. As soon as it was made clear to her that her case had but one indication for operation--the loss of blood and that the fibroid was so small that it might well be allowed to remain until after her menopause, when involution would probably prevent further unfavorable action, she took heart, began to exercise, ate more heartily, her marked constipation was relieved, she slept better and in three months her menstruation was almost normal. For many months she had no menorrhagia. I have seen other cases in which amelioration of symptoms came just as soon as the patient learned that, by improvement in the general health, there {449} was a possibility of lessening the tendency to hemorrhage and thus of putting off the necessity for operation for a time at least, if not until such natural changes occurred in the system as to lessen the danger from the growing tumor. I have in mind the wife of a physician whose menopause was delayed for some ten years as a consequence of a good-sized fibroid growth. She had it when she first came to me, and I watched the case for some seven years, and she absolutely refused to entertain the idea of operation. I set her mind at rest as to the seriousness of the growth provided the bleeding was not injurious and no infective conditions occurred through the intestinal walls to complicate the condition and cause adhesions. Whenever she worked hard, or whenever she was much worried, she would have alarming flooding. Under ordinary circumstances, however, when things did not go awry, she had a menstruation somewhat more profuse than normal and of five or six days in length. This continued from her fiftieth to her fifty-fifth year, and then gradually subsided. She is still alive at the age of sixty and, though she has had many trials and hardships at the end of her life, she is healthy and considers herself much better off than if she had had an operation. I doubt whether this is true, that is, if the operation had been done twenty years ago. But, after watching such a case and realizing that operations on fibroids are more often fatal than any other of the gynecologic operations that do not involve serious conditions, a physician is justified in tiding women over the time to their menopause and then letting nature dispose. Infective incidents pointing to the formation of adhesions are a contraindication to this policy, however. The sufferer in this case was one of the most patient of women. She had had to suffer much in mind and in body as the result of being left almost destitute after a life of luxury, yet she seldom complained. One might almost think her indifferent to hardship if one did not know her well. She was not at all a stoic but she never allowed her imagination to run away with her, she bore the ills of the day without thinking of what was going to come next week and she worried as little as possible under the circumstances. The ordinary woman, nervous and excitable, would have broken down under the strain that was placed upon her but she promises to live to a good age and her trials have not hurt her vitality nor spoiled her disposition and she looks the world in the face with surprising cheerfulness. This state of mind modifies even fibroid menorrhagia favorably. Fibroids have been reported "cured" by so many different remedies--local applications, acupuncture, hot needles, electricity in various forms, even internal treatment, which afterwards proved quite unavailing--that it is manifest that the mind plays a large rôle in controlling the symptoms. Before operation it is important to put the minds of these patients into an attitude of confidence, for operators who make it a point to secure the confidence of their patients, or who for some reason have their full faith, have better results in these cases than others of equal surgical skill. In unmarried women the development of a small fibroid with its reflex disturbances is sure to be followed by excessive reaction in many ways. Nervous symptoms are likely to be marked and the increase in menstruation is usually much more profuse as a consequence of the solicitude than because of the fibroid. Some of these tumors which, though of small size, are so situated with regard to the nervous and circulatory systems of the uterus as to produce {450} profuse menstruation even in women of phlegmatic disposition. In these patients operations will be necessary whenever the loss of blood makes it clear that the drain on the system is producing serious effects. There are cases, however, in which the menorrhagia is not due directly to the fibroid, but rather to its effect upon the general system and this may be lessened very much by reassurance, by regulation of the general health, by resumption of exercise and toning up of appetite and, above all, by relief of the constipation which so often complicates these cases. Fibroids may or may not continue to grow. The removal of one is no guarantee that others will not form, nor that others are not present in very small form which will develop later. As a rule, there can be no question of the removal of the uterus unless conditions are serious. If in spite of general treatment and the calming of the patient as far as possible profuse menstruation continues, it is an indication for surgical intervention. Psychotherapy may readily be abused in these cases, but it has a distinct use, and its application is more frequently successful than has been thought; but it must be deliberately employed. When, however, menorrhagia is a symptom of some serious progressive condition, psychotherapy will do harm rather than good. I have known women whose menstruation was stopped and then recurred and even became profuse reassured that this was only a symptom of the menopause when it was the first symptom of a cancer. In such cases there must be no temporizing or reassurance, but a careful determination of the actual condition must be made and immediate operation done if it seems necessary. Psychotherapy may have a place in incurable cancer, but in other cases it has none at all except to calm the patient for operation where surgery may be of service. CHAPTER VI THE MENOPAUSE While the phase of feminine sexual life which involves the cessation of menstruation is physiological and not morbid, it is so commonly associated with physical and mental symptoms difficult to bear that, practically always, it sends the woman to a physician. This is as true of the artificial menopause induced by removal of ovaries as it is of the normal process by which, in the course of time, ovarian function comes to an end and changes are brought about in the system consequent upon the absence of ovarian secretion. The ovaries, like many other organs, have two functions. One, that of ovulation, is so prominent that the other, the internal secretion, has been too much neglected. How important this is, however, may be judged from the change that comes over feminine nature after its cessation. Much of the emotionality of woman disappears, not a few of her special sex qualities are modified and even masculine physical peculiarities may assert themselves. The physical effects of the ovarian internal secretion may be inferred from the definite tendency to grow stout which results from its suppression by the menopause. Certain changes in the organism are inevitable then, and the only hope of therapy is to keep them from disturbing life processes. Neutralizing Unfavorable Mental Attitude.--Psychotherapy can do more {451} for the troubles of the menopause than any other treatment. The symptoms of the change of life in the long ago, if we can trust traditions, were not so troublesome as they are now. Only rarely did women suffer from it as they are supposed to suffer at the present time. Women are so persuaded that there is to be much suffering, or at least prolonged physical discomfort, as to make it difficult for them to be quite themselves. They are prone to think that their physical symptoms are noted, and that their condition is a subject of remark. This adds to the difficulty of bearing in patience whatever symptoms are present. The introspective attitude of our time has reacted upon such affections as occur in the menopause, and, by creating an abnormal susceptibility of mind, has added much not only to its possibility but also to its actuality of suffering. Drugs or other remedial measures will modify the conditions only partially and temporarily. The mental prophylaxis of suggestion must alter the state of mind both before and during the progress of the condition. Favorable Suggestion.--After the menopause women are less disturbed by emotional strains and troubles of any kind than before. They settle down into more placid, easy-going lives. They are not subjected to the monthly interruption of their routine of work or amusement, everything comes a little easier to them, and they are not, to use the word in its physiological sense, so irritable--that is, so responsive in reaction. They are not so likely to respond to slight irritations, and are often physically and mentally more content with life. This must be insisted upon, for, at the present time, unfavorable suggestion with regard to the menopause is the universal rule. Women look for the worst from it, and their expectation makes conditions less tolerable than they really are. Most women dread it as if it were the beginning of the end of life, the first descent into old age, while it is often the dawn of a larger and broader life free from sexual and other irritations, and with better possibilities of accomplishment. Definite Prescriptions.--These patients are best reassured by being told that every woman who has lived to the age of fifty has gone through a similar experience and that they have all, with rare exceptions, revived with health of both body and mind. It is more important to insist on the patients cultivating a certain gaiety of disposition, to plan for regular diversions two or three times a week, to see that they are not too much alone and that they find abundant occupation of mind and body, than to try to combat their manifold symptoms by drugs or local measures. Of course, their physical functions must be kept normal. It is surprising, however, how much improvement can be brought about in the menopause symptoms by definite prescriptions as to the time to be spent in the open air--at least two or three hours a day--with regard to having a definite diversion of some kind in mind two or three days ahead to which they look forward with pleasure, and by convincing them that whenever they allow themselves to dwell much on their condition, their symptoms of discomfort will become so severe as to be intolerable, while when they are occupied with other things they will find them quite easy to bear. As a rule, mothers of families with many cares and diversions of mind, with little time to think of themselves, do not suffer much at this period, or at least not nearly so much as do those who are without these diversions. The more time a woman has to think about herself at this period, the worse for {452} her. Her irritability of mind will be reflected upon her physical condition and make it worse. In the olden time mothers of families went through it and no one knew about it, or even noticed that there was anything the matter with them except possibly a little increased irritability at certain periods. Neither menstruation nor the menopause is necessarily connected with more than passing discomfort, if the patient is in good health. This is perfectly true if symptoms are not brooded over, if there is not too much expectancy of evils, and the feelings and manifestations which do not deserve the name of symptoms are taken as a matter of course. Best of all, let the woman keep her mind well occupied with many duties--with care for others, the helpless, the ailing, around her, instead of with herself and her passing ills. Dread of Insanity.--There are few women who go through this period without the hideous thought that possibly they may go crazy. This is especially likely if, as a consequence of the exaggerated desire for seclusion that many women have at this time, they do not get out into the air nor exercise as much as they should. As a consequence, they suffer from constipation, from lack of appetite, and capriciousness of taste for food, and they may have a series of symptoms that, when dwelt on during the hours of solitude, very seriously disturb the good feeling that is so important for the normal accomplishment of physiological functions. Diversion of Mind.--This tendency to withdraw from social relations with their friends and from the occupations that take them out of doors and which are often a helpful diversion of mind is one of the worst symptoms of this time and must be strenuously combated. It superinduces a series of physical symptoms which are attributed to the menopause but are really due to lack of air, to inactivity, to absence of interest and the consequent opportunity provided for unfortunate auto-suggestion and introspection. These superadded physical symptoms can be readily relieved by directions for rational living and then the genuine menopause symptoms may be so diminished as to be scarcely noticeable. It is impossible for the ordinary human being to stay much in the house, to lie down a large part of the time, eat irregularly and let the bowels become sluggish without having many symptoms of depression. Summary of Treatment.--The treatment, not of the menopause but of the patients passing through the menopause, then, must consist, first, in putting them in as good physical condition as possible and keeping them in it; second, in maintaining such normal natural habits of life as will enable them to keep up this physical condition without disturbance; thirdly, in putting off solicitude with regard to the menopause and realizing that it is a normal natural process with a definite place in human life and not at all representing a terminal stage of human existence. Nature meant that the mature woman, formed by precious experience, with sympathies broadened by years, should be able to devote herself without sexual irritation to the many things that naturally come to her at this period. There is a place in life for the grandmother and even for the grandaunt, though a French visitor recently declared that he thought there must be no grandmothers in America since all the women seemed to dress in the fashion of the young girl. If this submission to natural conditions is recognized and accepted there are long years of happiness and helpfulness in store for the woman of middle age and the menopause may be welcomed as an important step towards a larger development of life. {453} SECTION XI _PSYCHOTHERAPY IN OBSTETRICS_ CHAPTER I SUGGESTION IN OBSTETRICS In no department of medicine is favorable or unfavorable mental influence more important than in obstetrics. Unfortunately, unfavorable suggestion has here played a serious rôle and must be controlled, modified, neutralized. Suggestion is valuable in its every phase, during the course of pregnancy, in labor itself, in _post-partum_ convalescence, and with regard to nursing. Many women in our time are prone to persuade themselves that labor is a more serious incident than it usually proves to be and the consequence is an unfortunate suggestion of pain to come that so exaggerates sensitiveness as to make the actual suffering seem more than it really is. Sympathy expressed for women in pregnancy and in anticipation of their labor is sure to do more harm than good. Pain instead of being lessened by sympathy is increased and capacity to bear it is diminished. Anything that calls attention more particularly to the pain removes distracting conditions that might modify it favorably. Animals have the admirable instinct of withdrawing to some quiet corner when they are in pain, preferring to be alone. In this they follow nature and imitation of them is worthy of consideration, at least so far as the avoidance of opportunities for the expression of sympathy is concerned. PREGNANCY Maintenance of Health.--Women must keep up their normal health and strength during pregnancy. By not taking sufficient exercise and by being too much indoors, many women develop a morbid mental state in which every discomfort is less bearable than it was before. Lack of air and of exercise, furthermore, makes them prone to constipation, makes their sleep less restful, and reduces the appetite. For the sake of the being within them, they force themselves to eat, but this often serves only to make them obese, without improving their general health. If a woman in her ordinary condition, who was accustomed to going out-of-doors several hours every day and having reasonable diversion of mind and exercise of body, were to adopt the habits of life that many pregnant women form, she, too, would become morbidly introspective, fearful of the future, irritable over little things, restless at night, and even have certain physical symptoms, such as constipation, tired feelings, loss of {454} appetite, etc. Many of the discomforts and symptoms of which women complain during pregnancy are really due to unfortunate habits and to their mental attitude toward their conditions, rather than to any specific influence of pregnancy on the general health. As a rule, women who live naturally are in somewhat better physical health during pregnancy that at other times. Obesity and Pregnancy.--It is important that women should not become obese during pregnancy. The woman who is taking too much fat in her diet and accumulating fat is likely to have a fat baby, and with these there is more difficulty in labor itself, and the infants have less resistive vitality than if they were unencumbered with useless adipose tissue. Her will must overcome the tendency to lassitude and the proneness to inactivity that comes over her, and she must feel that labor and her condition after it are dependent on normal, healthy life at this time. Delayed Labor and Suggestion.--One phase of maternal impressions or of suggestion for the mother's mind that I have always been interested in has been that of the possibility of preventing delay in parturition by frequent suggestion of the time that delivery should be expected. There seems to be no doubt that expectation has some influence on the time of delivery. We do not know just why, after the uterus has tolerated the presence of the fetus for nine calendar months, it should then refuse to do so any longer and contract and expel it. Any number of theories have been suggested and even now our best obstetricians are not agreed as to the reason for this action on the part of the uterus. In some cases this contraction does not take place normally. The due term of labor is past and as a consequence fetuses grow too large within the uterus, greatly increasing the difficulties of parturition and adding to the risk of both mother and child. It is the custom to announce with pride the birth of twelve- and fifteen-pound babies, but it is doubtful whether nature intended that growth to this extent should take place before birth. There is in this, as in other phases of pride with regard to children, a curiously perverted feeling. Many obstetricians feel that the babies who weigh much more than the average of seven pounds have probably been delayed in the uterus for a lunar month beyond the time when they should, or at least could have been normally born. It is a question whether this delay would have occurred if the mother's expectation of the birth had been directed to a date a month ahead of that on which her mind became fixed as the time of labor. Parturition usually takes place about the period of the recurrence of the menstrual molimina, or at least of that monthly cyclic feeling which many women experience, though there is no flow. It is not always easy to say at which of two monthly periods the birth should be expected. While physicians have warned patients of the possibility of the child being born at the first of the two possible periods, they have been inclined to dwell on the fact that it will probably be delayed until the later term. Women themselves are more prone to take the later than the earlier termination of their pregnancy. Both physician and patient are timorous of the ridicule that may follow if they make premature announcements. Whether we have not in this way created a tradition tending to delay parturition by a lunar month in many cases, is a problem that requires careful study. The suggestion of as early a period as is compatible with the data provided, so as to create a definite expectancy in the mother's mind, seems well worth {455} deliberate attention. This is a role that psychotherapy has to play in lessening the dangers and the difficulties of parturition. With most healthy women, as indeed with most sensible normal women in life as regards all things, no suggestion is needed and nature will take her course promptly and properly. It is the nervous women, over-anxious about themselves, often of lax physical fiber because of their nervous condition, that need this phase of psychotherapy. It is in them that the unfavorable or mistaken suggestion may be emphasized to such a degree as to delay labor for a lunar month or even more. Vomiting of Pregnancy.--One of the dreaded complications of pregnancy is serious prolonged vomiting. We know now that this is of two kinds, toxic and neurotic. The toxic variety may be associated with kidney changes, but is more commonly the consequence of certain rare forms of degeneration of the liver. The pathological picture after death is not unlike that of phosphorus poisoning. These cases are due to some serious disturbance of metabolism or to the absorption of some little understood poison. They are probably always fatal. The cases of neurotic vomiting are rather common. They are exaggerations, of the ordinary familiar vomiting of pregnancy which is exhibited by nearly all women at the recurrence of the menstrual times in the early portion of pregnancy. In some of these cases, however, the vomiting is so persistent and so prolonged that the patient's nutrition suffers severely, and there seems to be danger of a fatal termination. The condition has received the unfortunate name of "pernicious vomiting." In these cases there is sometimes question of the advisability of terminating the pregnancy lest the woman should die. Unfortunately this question has been so commonly discussed that most prospective mothers are likely to know something about it, so that when vomiting begins they are fearful lest they should have to lose their child. This becomes an obsession in some minds and an unfavorable suggestion that helps to maintain the vomiting. A number of remedies have been highly recommended for this at various times. Nearly every alterative drug has had its period of popularity. In the older time nitrate of silver was said to be efficacious. Small doses of ipecac were highly recommended at one time. Small doses of cocain were suggested, and the painting of the back of the throat with cocain. Small doses of morphin had a vogue; codein had its turn after its introduction, and heroin also had a time of popularity. Oxalate of cerium was highly recommended. Any obstetrician of experience will remember many other remedies that have been supposed to be efficacious. Various gynecological procedures have been suggested: the touching of the _cervix uteri_ with a mild caustic, with iodin or with nitrate of silver, slight dilatation of the cervix, sometimes the application of a tampon with just enough glycerin to produce a reaction, but not enough to terminate the pregnancy. Occasionally local applications over the stomach region, a mustard leaf, or certain plasters, or finally even a piece of sized paper bound on over this region have been known to be followed by the cessation of the vomiting. When as many different remedies are recommended and seem for a time to be successful and then later prove to be inefficacious, it is reasonably clear that it is not the remedies but the effect produced by these on the mind that is the important therapeutic factor. Many obstetricians of wide experience now teach that most of these cases of vomiting in pregnancy are merely neurotic and are to be treated entirely {456} as if they were hysterical. The patient's mind is to be distracted from her condition; she is to be assured that even severe vomiting is quite common in pregnancy, that it is annoying, but never serious in its consequences, that it always ends without unfortunate incident for mother or child, and that there need be no solicitude. Above all, no hint of the possibility of the necessity for the termination of the pregnancy, if vomiting continues, should be given. Some physicians are entirely too solicitous in the matter and have by their anxiety made the neurotic condition of their patients worse. Some men see what they call a "pernicious vomiting" in every hundred labors. A well-known obstetrician in New York has had 3,000 births without seeing a single case. He is known for his placidity and lack of over-anxiety. In the great obstetrical clinics in Europe vomiting to the extent that will put mother or child in danger is extremely rare. The greatest obstetrician of the later nineteenth century reports 100,000 obstetrical cases with only one artificial labor. In foreign obstetrical clinics these cases in recent years have been treated expectantly, without any active interference, especially with pregnancy, and the results have been much more satisfactory than any other method of treatment. There are a number of cases on record now in which pregnant women have lost from twenty to forty pounds as the result of vomiting for weeks, yet after a time the attack has passed and they have carried the child to full term. Where vomiting has occurred and relief has once been afforded by the termination of pregnancy, it is very unlikely that succeeding pregnancies will pass without corresponding conditions in which no remedy will prove effective, except the dreaded obstetrical intervention for the termination of the pregnancy. It is extremely important then that these cases should be treated conservatively and that from the very beginning there should be nothing to arouse the patient's solicitude with regard to herself or above all to give her any hint of the possibility of obstetrical intervention being necessary in her case. For some women the knowledge that a consultation has been held to discuss such a possibility will of itself prove a persistent unfavorable suggestion, that will surely prolong the vomiting. This may seem a rather strong opinion from one who is not in practical touch with obstetrics. It has been the growing opinion, however, among the great German obstetricians for the last generation. Ahlfeld, in the _Archiv für Gynaekologie_ (Band 18 Heft 2 page 310) said that he had seen [in a very large obstetrical practice] three cases of so-called pernicious vomiting (_unstillbaren Erbrechen_) in all of which the patients wanted an abortion because they had previously learned the success of this method of treatment, but all of them recovered without incident and carried their children to term. Kronig, ten years ago, in his monograph on "The Significance of Functional Nervous Diseases for Diagnosis and Treatment in Gynaecology" [Footnote 36] said: "The excessive vomiting of pregnant patients has for a long time seemed to be a genital reflex neurosis. We thought that the growing uterus irritates certain nerve tracts which are connected with the mucous membrane of the stomach. We owe it to Kaltenbach that this opinion was overturned and _hyperemesis gravidarum_ set down as the result of a functional neurosis, hysterical in character. A large number of gynaecologists have accepted this opinion in recent {457} years (men of all nations) among others Calderini, Charpentier, Schaeffer, Klein, and Graefe." [Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten für die Diagnostik und Therapie in der Gynakologie von Dr. B. Kronig. Leipzig, 1902.] Winkel and the leading obstetricians of Germany, especially the directors of obstetrical clinics in the large cities, must be quoted as of the same opinion, since Winkel has collected the statistics of 100,000 pregnancies in the large German clinics in which 6,555 obstetrical operations were performed and in only one case was artificial abortion produced. German opinion is rather strong in the assertion that a number of cases of abortion in the practice of an obstetrician indicates over-hastiness in coming to conclusions as to danger, or leaves him open to the suspicion of yielding too readily to the wishes of mothers who would prefer not to carry their children to term. The suggestion of the possible necessity for abortion has done much to make the hysterical vomiting of these patients continue until this remedy is employed. Insistence from the very beginning that vomiting, though it may injure both mother and child, never necessitates abortion--one out of 100,000 cases is practically never--would be the best possible contrasuggestion. Kronig thinks that the vomiting of pregnancy is an especially favorable subject for suggestive treatment. He inclines to the opinion that the remedies that have been reported to do good and so many of which have subsequently proved unavailing have really owed whatever success they have had to the suggestion that went with them. Bumm, in his text-book of obstetrics (Grundriss zum Studium der Geburtshülfe von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and Ahfeld's conclusions and thinks that the consideration of _hyperemesis_ as an hysterical neurosis is well supported by the success and failure of our therapeutics. All sorts of remedies, any number of drugs, all manner of gynecological procedures short of abortion, though also including abortion, have been reported as doing good. All of them even including abortion have failed in a certain number of cases. Evidently suggestion plays a large role. Hypnosis often proves an excellent remedy. Excessive Salivary Secretion.--Bumm considers that the excess of secretion of saliva which is so often noticed in pregnancy is of the same nature and should be treated rather by suggestion than by any particular remedy, though remedies should be tried because of certain helpful physical effects, and then the psychic element that goes with them. The less importance given to the symptom, the less attention it attracts, the more its passing trivial character is emphasized, the sooner it will subside. Solicitude causes it to persist and even increase. LABOR Suggestion in Labor.--When the subjects are normal, expectancy has much to do with the severity of labor pains. In recent years so much fuss has been made and so much said and written about woman's burden and travail in the pains of childbirth, that preliminary dread and anxious attention have wrought young women up to such a poignancy of expectation as to make these pains worse than they really are. In the old days child-bearing was as much a matter of course as the husband going out to his daily work, and the taking of the dangers and fatigues of it was a simple matter of duty. Labor was then {458} comparatively easy and, while never pleasant, was also never an over-uncomfortable process. The effect of unfortunate suggestion has been to make it seem ever so much worse than it really is. Multiparae furnish the best proof of this. A healthy woman who has already had more than one child does not dread labor pains very much, or only to a slight degree, because the previous maternities have lessened the physical pain to be experienced, though a healthy woman's tissues are so thoroughly resilient that nature is able to bring about a return to normal conditions so complete that it is not always easy to decide whether a woman has given birth to a child or not. Of course, there are many cases in which tears reveal the former labor, but there are others in which it is not so, and the renewal of the birth process must, therefore, be nearly if not quite as painful as before, especially if it is recalled that succeeding children are usually larger. In spite of this in multiparae, labor has lost most of its terrors because real knowledge of its comparative ease has replaced the previous unfavorable suggestion, and instead there has come a proper appreciation of what will have to be borne, and of the positive pleasure of the relief when it has been borne successfully. Healthy women of the lower classes have so little difficulty in labor that they are quite frank to confess that it means scarcely more than a few severe muscular pains during an hour or so. Some of them mind it so little that up to within half an hour of the birth of the baby they occupy themselves with other things and succeed effectually in distracting their pains away. In their article on "Hypnotism and Suggestion in Obstetrics" Drs. Auvard and Secheron [Footnote 37] suggest that hypnotism can be employed with advantage during labor, but it is more difficult to produce it then than in the normal condition. Its only advantage is anesthesia, and this can be obtained during the preliminary pains in many cases. It is frequently impossible to produce complete anesthesia, however. To replace hypnotism they advise that suggestion in the waking state be used and they even suggest the employment of pseudo-choloroform or other like means. This method they consider more advisable than hypnotism, for there are no inconveniences and many real advantages. The nervous condition of the patient after hypnotism during labor is sometimes far from satisfactory. [Footnote 37: "L'Hypnotisme et la Suggestion en Obstétrique," Paris, 1888.] Nature's Methods.--In obstetrics and labor we have been finding in recent years that we have not trusted nature enough, have not looked sufficiently to the woman herself for assistance in its difficulties, and have made her too much a passive rather than an active factor. Practically all of the dangers that have accrued to the woman in childbirth, certainly many times more than have come from any other factor, have been due to well-meant but unfortunate attempts to help her while preventing her from helping herself. Before the middle of the nineteenth century most of the puerperal fever was due to infection from over-zealous but unclean attendants. Now men are proudly reporting hundreds of cases of delivery without even a vaginal examination. Above all, we have failed to take advantage of the occupation of mind that could be used to save women much of the anxiety and suffering of labor. If the parturient woman were allowed to change her position, as she does so naturally and frequently in a state of unsophistication, and to help actively, as she can {459} in many postures, in the delivery of her child, it would mean much in diverting her mind from pain which is emphasized by inactivity. The rule of having the woman lie on her back has been unfortunate in many ways and has required much more external interference than if other positions were adopted, while the pains have been more unbearable because that is actually the position in which the woman suffers most and in which she can do least to lessen them. I was once told by an Irish grandmother the story of nearly one hundred deliveries without accident of any kind, in which the only rule had been not to touch the woman, but to allow her to change her position and, above all, to facilitate her in getting on her knees in a stooping bent-over posture so as to help herself. The upper mattress was doubled over completely and the woman was encouraged to kneel on the lower straw mattress, which was so arranged that it could be changed completely, or destroyed immediately after labor. This seemed old-fashioned and unscientific twenty years ago, when I heard the story, but I have been interested recently in reading Professor King's address on "The Significance of Posture in Obstetrics." [Footnote 38] [Footnote 38: _Bulletin of the Lying-in Hospital_, Vol. V, No. IV.] Professor King is sure that there are many advantages in following certain natural inclinations of the mother to change her position and that this helps her in many ways. Above all, as the psychotherapist sees at once, it will occupy her mind, keep down anxiety and lessen pain in many natural ways, besides encouraging concentration of attention on muscular effort instead of on painful sensation. The whole article is well worth reading, for in it he suggests that certain obstetrical operations, even version, would not be so often necessary, if the woman were sometimes allowed to assume the squatting position in the course of birth. His illustrations make very clear the help that changes of position are in the mechanics of many difficulties of labor. The pressure of the patient's thigh on the abdomen, when she was allowed to assume a squatting position, enabled him, in a case in which the woman had been in labor twenty-eight hours, in which ergot had been given by the midwife, in which the waters had been discharged and the uterus was tetanically contracted around its contents, to deliver the child without instrumentation and without further delay. In five minutes the arm (for it was an arm presentation) began to recede, and in twenty minutes the child was delivered, head first, and mother and infant both did well. Other cases with similar results have been reported by obstetricians quite as distinguished as Professor King. Many other experienced obstetrical teachers have expressed themselves to the same purpose in recent years. Postures after Labor.--Allowing changes of position after labor also has its advantages. There is often retention of urine and this can be relieved by allowing the woman to assume the usual position. It may be impossible owing to the swelling and hyperemia in the neighborhood of her urethra for the woman to pass water, and yet if she is allowed to sit in the usual position upon a commode, she will in most cases pass her water in a few minutes without difficulty and the risks attending catheterization will be obviated. The power to urinate is due in these cases partly to the pressure of the thighs upon the abdomen which helps the bladder to contract and undoubtedly also to the suggestive influence that the position has. {460} NURSING The attitude of mind of a woman toward her milk supply is important, as the flow of milk is closely subject to mental influence. The presence of the child and the consequent exercise of maternal instinct does more to bring about the prompt, healthy flow of milk than anything else. Sometimes women in the later months of their first pregnancy upon seeing a mother nursing her child have felt the flow of milk to their breasts not rarely with such painful overdistention of the milk ducts as to require artificial relief. On the other hand, a fright may stop the flow of milk or make it scanty and a mother's aversion to a child may prevent her being able to nurse it. The sight of the father of the child in a state of intoxication may have a similar result. How much milk supply may be dependent on the state of mind, or at least the state of the nervous system, can be realized from the animals from which we obtain milk. Any serious disturbance is likely to interfere with the milk supply. When a cow's calf is taken away the animal will often refuse for a time to give milk. If a cow is scared, as by the attack of a wild animal, or by being hit though only slightly injured by an engine, it will often not have milk for several days or even longer. There is an impression prevalent among farmers that if a cow takes a dislike to a particular person they are not likely to "give down" as much milk as would otherwise be the case. This may be only a curious farmer tradition, that has no basis in fact, although it is supported by so many observations reported from many different countries that it is apparently to be taken as of scientific value. In modern times many fashionable women do not nurse their children because they have not the proper supply of milk. It is easy to see how this can be brought about through suggestion from many sources and the sight of others neglecting their duty in this matter. Most fashionable women would rather not nurse their children, and yet many of them feel a bounden duty in the matter. Some of these, however, having heard that many mothers of the better class are not capable of nursing their children, easily persuade themselves that they come in this category, and so their whole attitude of mind toward nursing is one of extreme doubt. Knowing as we do how the mental state influences nursing we are not surprised when these women prove not to have sufficient milk in the early days of the nursing. If they are to have it they must look forward with confidence to nursing their children and they must be ready and willing to take such food and secure such fresh air as will put them in the best possible condition for this function, always with the thought that nothing can be better for a child than to be nursed by its own mother. Nature has made exactly the form of food suited for the particular child, and it matters not how healthy a wet nurse may be, her milk is not likely to be so suitable. Much depends on the nutrition of the child during this early susceptible period of its life and there is more that passes over with the milk than merely the food elements. It is well recognized now that the reason why nurslings are protected from most of the so-called children's diseases and the contagious diseases generally, is that, as a rule, their mothers {461} have had these diseases, have acquired an immunity to them and this immunity is transferred to the child so long as the nursing process is continued. This has been shown to be true over and over again in animals and holds good for human beings. Professor Von Leyden, the distinguished professor of medicine at the University of Berlin, points out that we are not quite sure as yet just what may happen to the human race from the very general refusal of mothers to nurse their children and the almost universal substitution of the bovine mother; whether in times to come certain bovine traits, at least as regards susceptibility to disease, may not be stamped upon the human race, cannot be determined until this experiment in ethnology, now being conducted on so large a scale, has been carried to some definite conclusion. Perhaps this view is groundless, but there is no doubt that milk is more than merely a food and that during the period after birth when the child's nervous system is being formed, the perfectly adapted mother's milk is more likely to be the proper food than anything that human ingenuity can elaborate. We have heard much in recent years of the tendency of education and civilization to lower the birth-rate and to make women less fitted for maternity and for such maternal duties as nursing, but stronger than any deterioration of the physical constitution by the mental development is the unfortunate unfavorable effect of mental suggestion upon such functions, by which the preparation of the organism for their fulfillment is greatly influenced. It is in this respect that the women of to-day differ from the woman of the past much more than in mere physical development. CHAPTER II MATERNAL IMPRESSIONS "Maternal impression" is accepted as a specific designation to signify the real or supposed influence of emotion and especially serious trouble, which may affect the mother's mind during pregnancy and be transferred to the child _in utero_, with the production of deformities or mother's marks. There used to be an almost superstitious belief in the power of the maternal impressions to influence unfavorably the child _in utero_. With the newer developments as to the influence of the subconscious and subliminal there might well occur in some minds an exaggeration of these ideas with the production of much mental suffering at least, if not of more serious results. Maternal Impressions in Old Literature.--The belief in the influence of maternal impression on the child _in utero_ is so strongly fixed that to most people it will seem paradoxical to question the whole subject. The evidence for it, however, is quite trivial, and none of it rises above the grade of what may be explained by coincidence. But there are many apparently insuperable difficulties, from the standpoint of our modern scientific knowledge, with regard to the whole subject. If we take up the medical books and the popular science, or rather pseudo-science, and the folk stories of a century ago we find overwhelming evidence for the belief in maternal impressions. More recent {462} literature has but few examples, and the more the details are studied the less is the evidence of any kind that the mother's mind influences her unborn child. There is really no more reason why a child should he marked within its mother's womb than that it should be marked while nursing at the breast if something should happen to the mother at that time. This latter effect strikes one at once as absurd; the former, as we shall see, is exactly of the same nature. Many of the older stories of maternal impressions are reported on no better grounds than the vomiting of snakes and the like, even live mice, which used to be found in old-time medical literature. It is true that there was usually no such morbidity about the stories of maternal impressions, but men wanted to find some explanation for the problem of the occurrence of deformities and markings and the maternal impression idea seemed satisfactory and inviting by its very mystery. The belief that animals could live for some time in human stomachs is now relegated to the limbo of old-time credulous traditions. Maternal impressions are on the same path and in twenty-five years they will be as great curiosities in serious medical literature as the gastric fauna of two generations ago. Under these circumstances prospective mothers who are anxious over possibilities and who have dreads of all kinds about their unborn children should be reassured and informed as to the scientific status of this important question. Mother and Child Distinct Beings.--There is no direct connection between the mother and her unborn babe. No nerves run in the cord and none pass from the uterine tissues to the placenta. It is easy to understand the influence of mind on body under ordinary circumstances, at least the mystery has a rational explanation. The central nervous system rules the nutrition of the body. To cut off the nerve supply has as serious an effect as to cut off the blood supply. Owing to the existence of a chain of neurons, that is, a succession of nervous elements, instead of one continuous nerve fiber from center to periphery, it is possible for one of the neurons of the chain to be so disturbed that the conducting apparatus is interrupted and impulses do not flow. Hence, if a strong impression is produced on the mind with regard to a particular part of the body the neurons leading to it may be so disturbed that trophic nerve impulses do not flow down, the blood supply of the part may be disturbed through the vaso-motor system and consequent changes may take place. _Absence of Circulatory Connection_.--Since no nerves pass, as we have said, from mother to babe, disturbances acting on the mother's mind can at most only influence the blood supply to the baby. Most people think that there is a direct blood supply from mother to child and that the mother's blood literally flows in the baby's veins. This is not true. The baby's blood is an entirely independent structure, originating in the child's own body, and always maintaining a distinct and quite different composition from that of the mother. The baby's blood has a higher specific gravity, and it has, in normal condition, nearly double as many red corpuscles to the cubic millimeter as the mother's blood. If the blood supply is disturbed by mental influences, then it is not the baby's blood nor its circulation that is disturbed, but only the circulation through the maternal part of the placenta where an exchange of gases and nutrient elements between mother's and baby's blood takes place. It is {463} impossible to conceive that during this passage through a membrane of nutrient elements, soluble proteids, gases, etc., mental influences should also pass over. Supposed Examples of Maternal Impression.--The stories that are told would lead us to believe that somehow definite changes in the mother are reproduced in the babe. One case, which in a circle of friends that I knew very well made many a convert to the idea of maternal impressions, was that of a young woman at whom, during an early stage of her first pregnancy, her husband playfully threw a tiny frog. He did not know that she had a mortal dread of frogs. She was seriously frightened and put up her hand to ward off the animal, and as the clammy thing struck her palm she felt a shiver go through her. When her baby was born a curious growth that had some pigment in it and that, by a stretch of the imagination, might be considered to resemble a frog was in the baby's hand--the same hand, by the way, as that which the mother used to ward off the animal. The lack of any nervous connection and of any direct blood connection between mother and child makes the story simply absurd as an illustration of maternal impression. In recent years such stories have come from more and more distant parts of the country. Kansas was the principal source of them until a generation of great editors arose there. Texas was then their favorite location, but Texas has in recent years become so progressive and so closely connected with the rest of the world that, in spite of its size, it does not produce so many of these wonders. A generation ago the announcement of the birth of six children at once in Austria, or somewhere else in Central Europe, would usually be followed by a report from Texas announcing seven at a birth. Maternal impression stories grew luxuriantly for the benefit of the news-gatherer in dull seasons. A standing type of them is that of the farmer cutting hay on his farm who puts his fingers too far into the hay cutter and has them taken off. His wife binds up the bleeding stump. She is pregnant at the time. When her baby is born--usually two or three months later--just the same fingers are missing on the same hand of the child. Now the mechanism by which such maternal impression could be transferred to the child is incomprehensible. There is no connection between the two, and the old metaphysical axiom (_actio in distans repugnat_) that all action between bodies at a distance from one another, that is without some connecting link between them, is absurd, holds as good in modern times as it did in the Middle Ages. Surely a tendency-to-amputation is not carried over from mother's blood to baby's blood through the membrane in the placenta just as are the gases for respiration and the nutrient elements for food. If it is, we have a greater mystery than ever to solve. Period of Occurrence.--The infant in the uterus is fully formed before the tenth week of pregnancy and at a time when women are usually almost unconscious of the fact that they are pregnant. Such impressional changes as we have referred to, if produced after this, must be in the nature of backward growth or an inversion of trophic influences or a great perversion of embryonic life. They have nothing to do with the formation of the child, since that is completed. They are as much accidents as if the child should fall after it was born. We know how fetal limbs are amputated through the formation of amniotic bands, but that maternal impressions should influence the formation of these bands is of itself ridiculously absurd. That it should {464} influence them in a directive and selective way so that certain limbs may be amputated at a certain point reaches a climax of absurdity. A distinguished physician of our generation once said that one might as well hope to absorb a pencil case in one's vest pocket by medicine as to try to bring about absorption of fully formed connective tissue by drugs. We cannot think of any mental influence bringing about such absorption, yet to credit maternal impressions with the production of fetal amputations not only supposes the directive formation of connective tissue within the uterus, quite beyond the domain of the influence of the mother's nervous system, but also assumes the direction of the anomalous action of that connective tissue in its mutilating procedures in a very exact and definite way. Some curious things have been explained on the score of maternal impressions and it is this very exaggeration that is perhaps the best proof of how coincidence, imitation, and other factors play a role that has exaggerated the idea of maternal impressions into a causative factor. A typical illustration is the case cited years ago, half in joke, perhaps, half in earnest, by a distinguished professor of obstetrics. It occurred in the days when the elder Sothern was playing Lord Dundreary to crowded houses and when Dundrearyisms were the current witticisms and Dundreary ties and Dundreary clothes and Dundreary whiskers were all the rage. A young woman who was recently married became much taken with the actor and went to see him over and over again, secured an introduction to him, and showed the liveliest interest in him and the performance. Their acquaintance, however, remained merely that of chance friends. Some months after it began, not more than five or six at the most, a boy was born to her. According to the story this boy, when he began to walk some years later, developed that little skip in his gait which proved so taking to those who crowded the theaters to see Sothern as Lord Dundreary. By this time the play had lost something of its vogue and most people did not recognize the curious halt in the gait, but it was very clear to the mother and her friends. It was set down as due to a maternal mental impression. Mental transfer seems ludicrous in this case. It is much more likely that the mother was hysterical, and, wishing in a morbid way to attract attention to herself and her child, taught the boy the little skip, or perhaps some curious little skip once taken by the child attracted the mother's attention because of her memory of Sothern, and her surprise at the act impressed the peculiar action upon the boy's mind, who proceeded to attract further attention by repeating it. It is cases like this with their _reductio ad absurdum_ of the whole process that have quite discredited the belief in maternal impressions. Some Figures and Coincidences.--The occurrence of mothers' marks in connection with various external incidents of pregnancy are only coincidences. Most young mothers dread lest something should happen to their children. About once in a thousand times an infant is marked in some way. Nine hundred mothers rejoice over the fact that their baby is not marked in spite of the fact that they feared it might be, ninety-nine of them never gave the matter any thought and one of them finds to her sorrow that her foreboding has come true. Occasionally a mother who has not dreaded such a result finds that her offspring is marked. Then she recalls all the happenings of her pregnancy and picks out something to which she thinks she may attribute the accident. {465} There must be some reason for it and she finds it. Sometimes she begins by saying that it must be because she was frightened at such a time, or fell down at such a place, or saw such a thing, and then a week later she tells the story with circumstantial additions which make it very clear to her friends that she knows exactly the reason and that she had thought about it before and feared it might be so, though the whole matter was hazy until it had been talked over a number of times. Coincidences have been the most serious detriment in drawing scientific conclusions in every department of medicine. Most of our diseases are self-limited and any medicine that was given being followed by recovery seemed to be the cause of that recovery and the more strictly self-limited a disease the greater the number of remedies. When stories of maternal impressions are analyzed it is found that a great many mothers have had forebodings as to their children being marked and their dreads have not come true. A few have feared and have realized their worst fears. Many women whose children are marked can recall no event in the course of their pregnancy which could have marked their child and they ask the doctor what he thinks must have been the reason. But unintelligent mothers can always find some cause by searching out unpleasant details of their experience during pregnancy. Intrauterine Nutrition and Nursing.--To explain the occurrence of a frog-like appearance or a mousey patch on a baby as due to its mother having been frightened by one of these little animals while nursing would be the height of absurdity. But it is no more absurd than the supposition that mental impressions in the late months of pregnancy can have the effects that are popularly ascribed to them. If a mother suffers from severe fright, or even if she has a fit of intense anger or other profound mental disturbance, her milk may disagree with her infant. Every physician has seen nursing infants made sick by the change in the milk superinduced by strong mental emotions in the mother. This, however, could have nothing to do with the production of a special lasting physical mark on the outside of the body. Maternal Solicitude and Superstition.--The wonderful stories that are told are nearly all in the older literature and are much more reasonably explained on the score of coincidence than on that of any possible direct connection of cause and effect. Mothers, then, may be reassured and made to understand that the better their own health, the less they worry about their condition, the more likely is their pregnancy to terminate favorably with a perfectly healthy offspring. This is the source of so much concern in the little world of child-bearing that it is worth while taking it seriously and making mothers understand that the old notions in this matter are but superstitions. Superstitions are not always nor exclusively religious, they are survivals from a previous state of knowledge, the reasons for which are now known to be false. Maternal impression, that is, the belief in the power of the mother's mind over the unborn child, is a superstition that we must now dismiss. Favorable Maternal Influences.--Every now and then a sensational newspaper has an article on how mothers will tend to make their children physically handsomer by gazing at beautiful works of art, beautiful scenes in nature, and seeing only handsome (one feels like inserting well-dressed in the category, also) people during pregnancy. The reading of good books {466} containing moral lessons of the highest quality are supposed to have something of the same influence on the child's character. There is no doubt at all that the more carefully and simply and beautifully and healthily the mother lives, and the more her mind possesses itself in peace and happiness, the better will be her own nutrition and consequently that of her offspring, and, all things considered, this will contribute to the perfection of the infant's body and so give the best instrument for the expression of its soul. That these supposed favorable influences have any more direct power than this over the state of the infant that is to be is doubtful. It is worth trying for, but if the indefinite influence for good emphasizes, as it apparently does in many minds, the presumed direct and definite influence for evil, then it is not worth dwelling on. Etiology of Deformities.--But if these curious deformities and markings are not due to maternal impressions, what, then, is their cause? To the question for many of the minor marks and slight deformities--naevi vascular and pigmentary, extra fingers, slight overgrowths, special peculiarities of bone and soft tissues--no satisfactory answer can be given. We must simply say that as yet we do not know. It is a good thing to say we do not know. Long ago Roger Bacon declared that the principal reason why man did not advance in knowledge more in spite of the amount of their work was that they were afraid to say "I do not know," and accepted inadequate reasons and insufficient authority in order to avoid this humiliating expression. On the other hand, there are many deformities and markings, the reasons for which have been found, and the more important they are the more we know about them, as a rule. Besides, with the advance of our knowledge of embryology we are getting to know more and more about these difficult problems and many things that were mysteries before are now clear. In addition to observation we have experiment and this is making observation more thoroughly scientific. The more we know of the intricacies of the development of animals and human beings, the greater is our surprise that deformities do not occur even more commonly than they do. All the openings of the human as of the animal body gradually close in with the production of the finished form. The slightest interference with growth in the neighborhood of these openings, which involve nearly all of the front of the body, leaves various deformities. Nature has surrounded the developing embryo with fluid so that it is saved from jars of all kinds and from contact with other tissues that would disturb growth. Cell is laid on cell as brick is laid on brick in the building of a house, and the predetermined plan in the immense majority of cases is followed without accident to the minutest detail. That more mishaps do not occur, considering the delicacy of the process and the perfection of the finished structure, is hard to understand. There are many factors likely to intrude in every pregnancy that may lead to the production of unfortunate results. Literally millions of cells are growing with apparent freedom from constraint in many portions of the fetus, yet all are directed with definite purpose corresponding to other cells and are destined to meet in due course of time. Each one of them or at least each group seems to be independent in its growth. Each growing cell doubles by dividing every few hours, yet all are co-ordinated to a definite end. We admire the men who begin at the two ends of a tunnel far distant from one another and work without any communication except through the engineer's plans {467} made long before, and yet make two bores that can be depended on to meet with but a few inches of divergence. The bridges of tissue that are built across the openings of the body jut out to meet one another in this way and in more than ninety-nine out of every one hundred cases there is not the slightest divergence. Many things may occur to disturb conditions--not connected with mental influences, but with distinctly physical factors--missteps, trips, jars on stairs or getting off and on cars, on the sidewalk, etc. These, and not the mythical factors that make up so-called maternal impressions, are the causes of deformities and mothers' marks. {468} SECTION XII _GENITO-URINARY DISEASES_ CHAPTER I PROSTATISM It may seem impossible to include prostatic hypertrophy, or the train of symptoms connected with it, among those affections likely to be benefited by mental treatment. The history of this affection, however, and especially of its treatment in recent years since it has come to be the subject of special study, has furnished many examples of the value of suggestion in the relief of many of its symptoms. Many forms of treatment have been exploited for a time, attracting attention because of the cures attributed to them, and have then been relegated to the limbo of unsuccessful remedial measures. A striking example of the place of suggestion came with the development of organo-therapy some fifteen years ago. The succession of events illustrated well how much persuasion and a favorable attitude of mind might mean even in so purely physical an affection as interference with urination by enlargement of the prostate. It was at a time when thyroid medication for myxedema having proved successful the medical journals were full of reports of other successful phases of organo-therapy. The spleen and the bone marrow were being used in the anemias, the ductless glands in various nutritional diseases and even extract of heart for heart disease. Just on what general principle it was assumed by some German investigator that possibly extract of prostate from animals might be of benefit in the treatment of prostatic hypertrophy is hard to understand. The German physician, however, gave an order to the butcher to send him prostates and as furnished they were administered to the patients. A number of patients began at once to improve on the treatment. They were able to empty their bladders much better than before, the residual urine was decreased, the tendency to fermentation was diminished and, above all, the patients' general symptoms were much improved. The success was so marked that the German investigator published his cases and, with the public mind interested in organotherapy, they attracted wide-spread attention. He was asked how to obtain the material and only then did he take the trouble to investigate just what the butcher had been sending him. The description furnished the butcher by the doctor was that he wanted an organ lying below and somewhat in front of the bladder of the bull. It was found on careful inquiry that the abattoir attendants following these directions had supplied not prostates but seminal vesicles. As soon as this was found out some of the therapeutic suggestions failed. A number of cases, {469} however, continued to improve. German medical journals made fun of the whole proceeding and most people will consider the ridicule deserved. Shortly before this time, however, we had had a very similar experience with another pair of organs. In spite of the fact that whatever we know about Graves' disease would seem to indicate that that affection is due to an increased thyroid secretion in the system, at the time of the organo-therapeutic fads, thyroid extract was reported as having been used successfully in the treatment of this affection. The name signed to the report was that of a trustworthy English clinical observer. A few practitioners of medicine got similar results, but most of them failed entirely to get his successes and some of them were sure that their patients were rather harmed than helped by the new medication. An investigation of just what material was being employed in the English cases showed that the butcher was supplying thymus and not thyroid glands. Suggestion did the rest, for thymus has proved to be quite ineffective, and the treatment was entirely expectant but acted on a favorable state of mind. Anyone who has had much experience with Graves' disease knows how amenable to suggestion the patients are. It would seem evident from the foregoing story of organo-therapy for prostatic hypertrophy that sufferers from prostatism are probably as prone to suggestion as patients with Graves' disease. This is all the more surprising as the two affections are so different in their etiology. Graves' disease being undoubtedly a ductless gland disease, while prostatism is due entirely to mechanical obstruction. We have abundant additional evidence of the role of psychotherapy in prostatism. Some years ago a well-known American surgeon suggested that removal of the testicles would reduce the enlarged prostates. And much improvement was seen after castration in those who previously suffered from prostatism. The subject was carefully studied. Experiments were made on animals and the results seemed to prove that castration in them constantly produced prostatic atrophy. The fallacy probably came from the fact that at the time so little was known about the prostate in comparative anatomy and, above all, with regard to the prostate in dogs, that it was impossible to come to any sure conclusion as to reduction in weight and size after removal of the testicles. A number of prostatic cases were treated by different surgeons and with excellent results. Then after a time the number of supposed successes dwindled or proved to be failures and now no one does the operation. The only explanation that is at all satisfactory in these cases, is that the rest in the hospital, the favorable suggestion of reported cures and of an experimental demonstration on animals led many patients, some of them even physicians, to secure a better control over their bladders. It took a good deal of persuasion as a rule to bring men, even men well beyond seventy, to consent to the sacrifice of their testicles, but once they did, the sacrifice brought a favorable suggestion to work and so it was not long before they were able to make their bladder act much more efficiently against the obstacles presented to its contraction. Some could be persuaded more easily to sacrifice a single testicle, but in these cases the mental influence was less and the reported cures fewer. After a time the operation of vasectomy was suggested as a substitute for the removal of the testicles. For a time even this in the hands of certain operators gave excellent results. Almost any other operation in the genito-urinary tract performed with the definite persuasion {470} on the part of the patient that he would be better after it would probably have acted just as favorably. The whole story of these series of incidents in the surgery of the last decade of the nineteenth century ought to be a clear demonstration of how valuable for therapeutic purposes is mental influence oven in prostatism, and how much we should try to secure its favorable effects. Unfavorable Suggestion.--Since enlargement of the prostate has become a familiar subject of discussion and men know and hear much about it every now and then, one has to reassure a man but little beyond fifty that he is not suffering from this affection. Just as soon as a man begins to urinate frequently during the day and to have to got up once at night he begins to wonder how soon he will be likely to suffer from further symptoms of enlarged prostate. If he is of the nervous kind his worrying will soon give him additional symptoms that will confirm his suspicions. Probably one of the most familiar of phenomena, even to the non-medical man, is the ease with which worry and excitement causes frequent urination. Probably no system of organs in the body is so likely to be disturbed by the mind as the urinary system with the exception, of course, of the allied tract, the genital system, but the two are so one in union and sympathy that they cannot be separated in practice. The prostate is rather a genital than a urinary organ. _Urinary Worries_.--When a man begins to worry about the possibility of bother from enlarged prostate and recalls that frequent urination is one of the symptoms of it, it will not be long before this symptom develops. Occasionally his first wakings to urinate at night or in the early morning are only due to passing conditions, either he drank freely shortly before bedtime or perhaps he did not drink enough. In the one case the bladder is rather full; in the other a concentrated urine, especially with the patient lying on his back, makes itself felt over the sensitive area at the base of the bladder, waking him up. The rest of the symptoms may develop as a consequence of solicitude over a few such incidents. Practically all men who reach sixty have some tendency to more frequent urination than before. Their bladder does not hold as much fluid with comfort and they are likely to have to get up in the early morning. This does not necessarily mean any enlargement of the prostate nor any pathological change. The physiological change that takes place seems to be rather conservative than otherwise. Old muscles are less capable of extension and thorough reaction than they were earlier in life and in order that the bladder may not be over-distended nature makes it more sensitive than before. _Emptying the Bladder_.--In the study of these cases individual peculiarities in the emptying of the bladder must be remembered. There are some men who cannot urinate if anyone is near them, and who even have to step into a closed toilet if they are to succeed in emptying their bladders when others are in the room. Some who find no difficulty in the presence of others in open urinals find it difficult or impossible to urinate when it is expected of them. Under worry and excitement urination may become urgent or imperative, but on the other hand some men find it very difficult to empty their bladders under an emotional strain. Now that much more is written publicly with regard to symptoms from enlarged prostate and much more is heard of the affection, many old men got worried and lose some of the power that they had over their bladder before, not so much because of their enlarged prostate as from the {471} psychic loss of control over their bladder. The viscus consists of a series of muscles, the fibres of which must be rather nicely coordinated and controlled in order to secure that complete contraction necessary for thorough emptying. A certain amount of residual urine occurs occasionally at least in many other persons besides those who have prostatic obstruction. _The Question of Operation_.--In recent years there has been a tendency to suggest operation even on comparatively small prostates when symptoms referable to them are noted. Operations on the prostate have become much more easy and successful, and there has been the same sort of feeling about them among surgeons as there was when operations for affections, real or supposed, of the ovaries came into general vogue twenty years ago. I have seen patients in whom an operation for the removal of the prostate had been suggested, though the only symptoms were somewhat increased frequency of urination during the day and the necessity for rising two or three times at night. Such a suggestion, by calling the patient's attention strongly to his condition, emphasizes the irritability of the vesical tissues and is almost sure to bring about a considerable increase in the symptoms. The first principle of any treatment of irritability of the bladder should be the setting of the patient's mind as free as possible from solicitude. Any over-attention is sure to lead to reflexes and often to what seems to be even imperative urination, though with a little care and discipline much can be done for the relief of such symptoms. The necessity for operation must be judged entirely from the symptoms of the individual patient and not from any hard and fast rule with regard to the size of the prostate. Prostates are eminently individual organs, at least as individual as the human nose, and their projection into the rectum is dependent on the relations of other tissues in the neighborhood as well as on mere size. Men have been known to live with comparatively few or no symptoms for many years, though at autopsy they proved to have what would ordinarily be considered a pathologically enlarged prostate. Operations upon the prostate are valuable and indeed often afford the only avenue of relief from an intolerable condition. The results are not so encouraging in all cases, however, as to make recourse to operation advisable until a thorough trial of palliative measures has been made. It is surprising how often the confident suggestion of assured relief when accompanied by the same amount of rest in bed and the special care that is required for an operation, brings about a disappearance of symptoms that seemed inevitably to demand surgical intervention. There may be much residual urine, there may even be, as a consequence of this, some fermentation with cystitis, and yet a course of rather simple remedial measures may serve to bring about a period of prolonged freedom from vesical symptoms. If these patients, however, have heard much of the trials and sufferings of a catheter life, the solicitude aroused with regard to their condition is sufficient of itself to disturb their urination to a marked degree. Unfavorable suggestion is particularly serious in its effects in these cases, while favorable suggestion frequently repeated will enable the patient very often to regain bladder control when the developments present might seem to put that almost out of the question. Position Suggestions.--An important suggestion for treatment in prostatism with residual urine seems to be to teach the patient to urinate lying down, {472} especially with the hips somewhat elevated. This seems to be the element that proved capable of making many different operations, castration, the removal of one testicle, vasectomy, and other suggestions appear curative. My own experience is too limited to make my opinion of much weight; but I have seen certain patients greatly relieved of prostatic symptoms and their residual urine much diminished by the advice to urinate leaning well out of bed, lying prone with the head lower than the body. A small stool is brought to the side of the bed, a pillow placed on it and the patient leans over face down on this with the shoulders considerably lower than the pelvis. This allows gravity to assist rather than hamper the emptying of the bladder and after men have become a little used to it they are quite satisfied to take the trouble. Personally I feel sure that more generally applied this would put off the necessity for using a catheter a good deal and even save some cases from operation that now seem to need it. The principle is exactly the same as that by which patients suffering from bronchiectasis avail themselves of the help of gravity and get rid of the nocturnal accumulation of material in their dilated bronchi. They can thus be saved much trouble and exhausting effort. So much, as we have said, is written in recent years with regard to prostatic symptoms that a body of unfavorable suggestion has been created. This must be neutralized as far as possible by calling the attention of patients who have initial symptoms of vesical disturbance to the ease with which mental influences act upon the urinary functions. Solicitude and anxiety will add to symptoms and may even bring about their continuance when the original, local and passing condition which has caused them has ceased. Very often if the patient's mind can be properly disposed a marked relief of symptoms will follow, especially if, at the same time, remedial measures of other kinds are employed to lessen the irritation that is being set up. While prostatism seems to be due to such purely mechanical difficulties that mental influences can mean very little, the history of the therapeutics of the condition for the last twenty years shows us clearly that if strong mental influences are aroused they bring so much relief that many patients consider themselves cured. This psychotherapy will not do away with the necessity for operation in many cases, but it will cure many of the sufferers from milder symptoms and will in not a few cases bring such relief as will prepare the patients to undergo operation, if it should be necessary, with more assurance of favorable results. CHAPTER II SEXUAL NEUROSES Anything that disturbs the sexual sphere in either sex, no matter how trivial it may be, becomes a source of worry and depression quite beyond its real importance. It is not unusual for men and women to become so worried over some trifling affection of their sexual organs that they become convinced that serious pathological conditions are developing and that there is little hope of anything like a complete cure. This is particularly true of young patients, but holds also for those of older years. Slight discomforts are exaggerated into nagging aches and pains which produce extreme depression of spirits. {473} It is important, then, for the physician to recognize this and to treat the patient's mind by reassurance while conducting whatever other therapeutics may be required. There is danger always in these cases of either making too little or too much of the affection. If too much is made of it, an unfavorable influence is produced in the patient's mind and the discouragement leads to so much inhibition or even actual physical disturbance that the affection will not improve. If too little is made of it, patients get discouraged and are prone to think that the physician does not understand their cases. Then they go to the advertising specialist in men's diseases who works upon their fears and makes them feel much worse than before, though in the end he may lift the cloud of anxiety from their minds and pretend to have cured them. He always leaves them, however, with the impression that something serious has been the matter, and this acts as a nightmare and a source of dread in after time. In men the unfavorable suggestions occur particularly as a consequence of affections of the external organs. In women the same suggestions are likely to make themselves felt with regard to the internal genital organs. We all recognize the exaggeration of feeling and even physical reaction that takes place with regard to slight sexual ailments in the male, because it is easy to recognize just exactly what pathological conditions are present and how trivial they may be and yet produce serious depression and all kinds of symptoms, reflexly referred to many other organs. There is a tendency to listen to the complaints from women more seriously because the actual pathological condition cannot be determined and there is always the fear that some serious affection may be at work. It must not be forgotten, however, that the complaints of pains and aches, the disturbance of sleep, of digestion and of the intestinal function, the mental and physical lassitude and the over-reaction to irritation which occur in both sexes as a consequence of sexual affections may be due entirely to mental solicitude and not to any real pathological change. Trivial Afflictions--Varicocele.--It is curious what a little thing will sometimes set off the explosion of a train of sexual symptoms. Every physician has probably had some young man come to him with the look and the tone that there was something the matter that he knew was serious and would affect all his after life. The patient then goes on to say that he wants to know all and is brave enough to face it, and, though he has lost sleep for two or three nights and is not looking well for the present moment because his health has been disturbed by the loss of sleep, still he has the strength to know the worst and it is to be told him and he will bravely battle on in spite of the suffering that must come. Or he will submit to a serious operation if it is necessary for his relief. With a prelude like this, the inexperienced physician might expect strangulated hernia or some preliminary symptoms of brain tumor, but what he usually finds is a varicocele, and a small one at that. By chance the patient has discovered it and slept none the following night, went round in an agony of dread next day meaning to go to a physician, but too fearful to be told the worst, losing another night's sleep and then finally coming to a friend to be told all the ill that is in store for him. There is no need for alarm in these cases; they merely illustrate the role of the mind disturbing the body. Nearly one-fourth of the male world carries its {474} varicocele around with it and never bothers about it. A few sensitive individuals are annoyed by a sense of weight and a feeling of distention from congestion in connection with it. In a few, because of special pathological conditions or congenital defects, the varicocele becomes so large that it has to be supported by a special bandage. In people who ride horseback, in athletes, and those who indulge in severe exercise, this sort of a bandage may be necessary or at least may make the wearer more comfortable even in slighter forms of the affection. Severe cases may be much relieved by it. On first discovery of his varicocele nearly every young man, because of concentration of attention on it, is so much annoyed that he thinks he must wear a bandage. After a time, however, he often finds that the bandage itself is a source of more annoyance than the varicocele, and then he learns to forget it and its feelings--and that is all about it. I have dwelt on this succession of events that takes place so often with regard to varicocele, because it is typical of the effect that an affection of the sexual organs has upon the mind. It exerts an unfavorable influence entirely disproportionate to the physical cause that is at work. If, as sometimes happens, a young man hesitates to confide in some one capable of undeceiving him with regard to the supposed significance of his affection, he may work himself into a decided nervous condition and lose much weight before he discovers his mistake. This physical running down confirms his exaggerated notion of the significance of the affection. He is sure that it constitutes the reason why he is losing weight and declining in health and he rather congratulates himself on the fact that he discovered the cause so shortly before the serious effects began. If under these conditions he places himself in the hands of any of the men who advertise themselves as curing "men's diseases," or as relieving the "awful" symptoms that are likely to follow varicocele, instead of being reassured he will be told that he has come just in time and that while his cure will require a long time and will cost a great deal of money, yet it can surely be effected. In nothing can men or women be more easily imposed upon than with regard to affections involving their sex organs. They lose their power of judgment and their control over their feelings and so plunge sometimes into profound depression. Every year we have a number of suicides among young men, the most important element in whose depression is due to unrelieved occupation of mind with the thought that they are suffering from some incurable sexual disease which will unsex them, and that even death is to be preferred to the alternative of being recognized generally--as they are sure they will be--as sexual defectives. As a rule, these young men are suffering from only some slight ailment that could be easily cured if they were frank about their state of mind and described their symptoms to a reputable physician. Oftener than not their supposed ailment is something so common as to be of no significance, so far as any serious results may possibly be anticipated, and their only real ailment is the mental condition which has developed because of concentration of mind on this one phase of organic life and the consequent inevitable exaggeration of symptoms and feelings. It is sometimes not easy to disabuse them of their unfortunate notions, but there is probably no set of cases in medicine where psychotherapeutics means more than it does with regard to the curious {475} neurotic and psychic conditions which develop in those who are suffering from any sexual ailment, real or imaginary. Long Prepuce.--Much has been said in recent years about the influence of a long prepuce in the male in producing various reflexes the effects of which may be seen in serious disturbance of even distant organs. The kidneys are sometimes said to be thus reflexly affected, and occasionally the digestion and the bowels--even, sometimes, mental processes are said to be influenced unfavorably by the diffusion of reflexes from the irritation consequent upon this sensitive structure being too long. A whole system of nosology exists in some minds due to an over-long prepuce. There are, of course, cases in which circumcision should be performed. There is a larger number of others, however, in which the redundant prepuce is neither adherent nor constricted and is only slightly longer than it should be. Occasionally something arouses the attention of the possessor of the redundant tissue and he gets the idea that it is the source of reflex irritation even for distant parts of his organism. It is an interesting study in suggestion to see how symptoms develop in various organs as a consequence of the cultivation of this thought. Urination becomes frequent, the patient even wakes at night to urinate and the urine, as in many neuroses, becomes more abundant and of lower specific gravity--the typical nervous urine of the hysterical, and there may be much worry and emotional disturbance. These symptoms, however, are not effects of the long prepuce, but are results of the neurotic influence of concentration of mind on it. It will often be advisable, in young men particularly, to have circumcision performed, but in most cases this is unnecessary, and if the patient can be made to understand how the symptoms have developed he will learn a precious lesson in not interfering with his functions by over-attention to them. Of course, there are many surgeons who will continue to hold, as they seem to now, that nature was quite at fault in the production of this organ and that it should be removed in nearly every human being. The majority of men, however, have lived their lives quite well and happily without such intervention and there are certain inconveniences attached to the condition which remains after operation that may in their way be quite as bothersome as the symptoms due to the long foreskin. Psychic Impotence.--An important sexual neurosis, at least in the eyes of sufferers from it, is what physicians have come to know as psychic impotence. Young married men, because of over-anxiety with regard to themselves for a number of reasons, but without any physical factor to disturb them, find it impossible to complete the sexual act. Naturally this creates a serious disturbance of mind. The patient will either hurry to a physician at some place on his wedding tour, or his wedding tour will be shortened and he will return to consult a friend. He presents a lively picture of despair. He has not been sleeping, his appetite is disturbed, he feels lassitude and weakness, and if he has a lively imagination he is inclined to think that the fatal termination of some serious nervous disease of which he has heard, and which is accompanied by the symptom of sexual impotence, is impending over him. His condition is quite pitiable, though largely imaginary. _Reassurance_.--The treatment of the condition is not so difficult as it might seem if the patient has a reasonable confidence in his physician. If he {476} goes to an advertising "specialist," as occasionally happens, because he concludes that the ordinary physician cannot know all the details of these intricately complex nervous diseases, he is sure to suffer severely in general health before cure is obtained. His morbid ideas will be fostered because he is ready to pay any amount of money in order to stop the progress of the presumed serious disease. An investigation of these "specialists" in New York, made a few years ago by a committee of the New York County Medical Society, showed to what an extent the terrors of these unfortunate patients are exploited for monetary reasons. A physician of even a little experience in these matters, however, recognizes at once the entirely neurotic character of the case and by reassurance soon enables the young man to dispel many of his worst terrors. His general health can be regulated, his constipation, which so frequently exists, is relieved, and he can be told, what is very true, that the excitement consequent upon the preparations for his wedding and the exhaustion due to the overwork so frequently necessary in order to enable him to take the time off for his wedding journey, have made him so nervously irritable that the ordinary mechanism of the sexual act, which is extremely delicate and requires nice co-ordination for proper function, has been disturbed. Just as soon as this fatigue and the over-excitement of mind consequent upon the unfortunate experience are mitigated his potency will return. This assurance can be given almost at once. His fears, however, will delay his recovery. His dread of incapacity will become an obsession. Probably the most effective means of treating this is to forbid him to attempt the sexual act for a definite length of time, say two or three weeks. This must be impressed upon him. There is a good reason for insisting that he shall not irritate his already excited sexual system by such attempts. Usually at the end of a week or ten days he will come back with a smiling look of confidence in himself and his physician, to confess that he has violated the injunction, but that he was not disappointed as before. _Subconscious Obsession_.--In most of these cases the young men have been victims of sex habits of some kind or of drug addictions, and they have heard that occasionally individuals who have had such experiences may suffer from sexual impotence later in life. This is a strong suggestion to them and in some cases becomes a haunting obsession, and produces the unfavorable effect upon the organism. It is necessary to remove this obsession before a cure can be effected. The patient's confidence must be obtained and the physician's personality and persuasive powers used to change his point of view. Occasionally I have seen cases in which the patients themselves seem to be scarcely aware of this strong suggestion or obsession at work in them. It seemed to be more or less subconscious. An idea with regard to the evil effects of the old habit had been implanted and remained in their minds, occasionally making itself felt but more often apparently lying dormant. In these cases it is important that the physician should make this underlying factor clear to the patient. In some of these cases hypnosis is necessary. Usually the hypnoidal condition, with suggestions in the waking state, is all that is necessary and ordinary suggestions will often effect the purpose completely. Organic Impotence.--Certain forms of sexual impotence are really preliminary signs of serious organic nervous disease. Sometimes it is the first {477} symptom of paresis or of locomotor ataxia. Oftener it is a very early symptom of syphilitic spinal myelitis. In practically all of these cases, however, there is a history of syphilis and the presence of this should always be a warning not to think of functional or psychic impotence until the possible influence of the syphilis itself or of some of the parasyphilitic diseases is thoroughly excluded. Unfortunately, not a few people who have had syphilis are nervous and anxious about themselves and by their very anticipation of possible developments may auto-suggest themselves into a state in which these symptoms will develop. It is cases of neurasthenia that develop after secondary syphilis in persons who have been studying syphilis and its possible effects, which present the most difficult problems in diagnosis that come to the nerve specialist. Many simulated symptoms are unconsciously developed and this makes differential diagnosis extremely hard. As a rule, the psychic impotence is merely functional and patients need reassurance more than anything else. Nocturnal Emissions.--One of the sexual neuroses that gives rise to a high degree of solicitude centers around the question of involuntary seminal emissions. Young men who are living normal healthy lives and who are in robust health with no indulgence of sexuality are likely to experience more or less regular involuntary emissions. If for any reason they become nervous or anxious about their sexual functions, especially at times when they are under much mental strain, these phenomena of emptying the seminal vesicles may occur rather frequently. If they have been reading some of the literature, or hearing some of the exaggerated notions that are often expressed with regard to the evil effects that may come from this, they are likely to suffer much mental anxiety over it. Occasionally they lose sleep, frequently they feel so wearied and worried the day after the occurrence as to be disturbed at their work, sometimes they are sure they are so tired that they are unable to fulfill their ordinary duties, and I suppose every physician has known young men who were even sure that the loss of the seminal fluid was seriously interfering with health, hampering many physical functions and bringing them to an untimely grave. They had no appetite and in consequence of not eating enough they were constipated and then a whole round of physical troubles, headache, lassitude, over-fatigue, to which they are almost sure to add loss or disturbance of memory, began to annoy them. In those cases it is not the physical effect of any loss of seminal fluid that is the disturbing factor of their health, but their worry over the losses. Just as soon as their minds can be taken off the subject, the supposed physical effects begin to disappear. So long as the solicitude continues the emissions themselves increase in number and the condition is made worse. These patients must be taught that in every normal healthy man in whom there is no regular occasion for the emptying of the seminal vesicles, nature provides for an evacuation about every ten days or two weeks. In some it is more frequent than this. In those who are much indoors and in whom oxidation processes are low this emptying takes place more frequently. In those who lead a sedentary life with the consumption of much proteid food the same thing seems to be true. Any anxiety about it is sure to cause frequent repetition of the evacuation processes. Over-solicitude about the bladder will have just the same effect. If the patient will take his mind off the subject, will eat normally, will get out in the air more than before, tiring himself thoroughly {478} if he is young and vigorous, and will not allow the sexual side of his being to be excited by stories or pictures, plays or voluntary thoughts, his affliction will soon disappear. _Prophylaxis_.--Certain directions are helpful and by occupying the patient's mind will overcome certain physical factors that underlie the affection. It is important that the bladder should not be allowed to be full, above all, not to be over-distended at night. Some care should be exercised in not taking too much to drink shortly before going to bed and the bladder should be faithfully emptied before retiring. The weight of a large amount of urine in the bladder pressing down upon the seminal vesicles situated below and behind it causes them to contract rather easily. This is particularly true if the patient sleeps on his back and occasionally in certain over-irritable patients for a time at least an arrangement may have to be made by means of small pillows that will prevent him from sleeping on his back. On the other hand, it must not be forgotten that too great abstinence from fluid will cause the urine to be more concentrated and this will irritate the bladder and either wake the patient up at night, which of itself is undesirable, or else will cause congestion in the prostatic region which will irritate the seminal vesicles to the point of evacuation. While five or six glasses of water a day should be taken besides the ordinary fluid taken at meals, the only regulation necessary is of the amount of fluid taken in the evening after the last meal, that is, if more than three hours intervene before retiring for the night. Besides the physical conditions in the bladder, an accumulation of fecal material in the rectum may cause irritation of the seminal vesicles. It is important, moreover, to remember that thoroughly free movements of the bowels, by preventing to a great extent the reabsorption of material from the intestines which may prove irritant when excreted through the kidneys and when present in the bladder, is of itself an excellent therapeutic measure in cases of irritability of the genital organs. The setting of the patient's mind to thinking about his rectum, his bowels, and his bladder instead of his genital tract is an excellent psychotherapeutic measure that will soon bear fruit. The consumption of various foods, condiments and drinks enters into the underlying condition which produces frequent emissions. We have already suggested that the use of a large amount of proteid materials, especially in people who live a sedentary life, often predisposes to this condition. An abundance of the carbohydrates, however, by supplying more heat than is necessary may have a like effect. Certain spices seem to predispose to irritability of the sexual system. Red pepper has always seemed to those who saw much of these cases to be particularly at fault. Mustard, curries, peppers generally, however, and even other spices seem to have a corresponding effect. As a rule, young folks suffering from this disturbance or from the tendency to eroticism in other ways should be warned about this irritation of spices. In neurotic individuals tea and especially coffee has the same effect. Probably this is only an indirect influence of tea upon the nerve centers, making them more irritable, but coffee, by raising the blood pressure, seems to have a direct unfavorable effect. All alcoholic drinks are contraindicated in these cases and must be forbidden. Certain of them seem to be more harmful than others. According to French tradition warm wine or mulled ale as it is used in England is {479} especially likely to excite sexuality. Warm alcoholic drinks of any kind are absorbed more rapidly than are cool drinks, which is the main reason in modern times for having these liquids cooled so that they will not be absorbed too rapidly and disturb the equilibrium. Champagne also has, by tradition, a special effect, sometimes said to be due to the increased hyperemia of the stomach induced by the carbonic acid gas and the consequent more rapid absorption. The prohibition of spices and alcoholic drinks has a good effect in itself. It acts constantly as a suggestion to the necessity for care and guard over one's self. Besides the exercise of self-denial necessary to keep away from the use of such substances, especially under present social conditions, is of itself a good training that strengthens the will against certain tendencies to indulgence in sexual thoughts which predispose to the frequent emptying of the seminal vesicles. _Erotic Dreams_.--Very often these nocturnal seminal emissions are associated with erotic dreams. Patients are inclined to attribute the occurrence of these dreams to some fault of their own or to consider that they are at least in some way responsible for them. This thought often becomes a source of serious worry, making their condition worse. A study of this question has convinced me that in most cases there is practically no responsibility in the matter. Pressure on the seminal vesicles by an over-full bladder, or a distended rectum, leads to the production of nervous stimuli around which the erotic dream-ideas gather. A straightforward explanation of this will relieve many patients' minds, and keep them from bothering about the subject in such a way as to make their genital tract even more sensitive than it is because of their concentration of attention on it. Sexual Mental Troubles.--In our generation sex occupies a great deal of attention. Sexual tendencies are emphasized by suggestive reading of all kinds and by forced attention to sex matters. Most of the successful novels deal with the so-called sex problem, our plays are to a great extent sex problem plays and our newspapers are full of sex crimes and sexual divagations of many kinds. This acts as a strong incitement to sexuality and represents exactly the opposite of what nature intended in the matter. As a consequence, all the tendencies to over-solicitude with regard to sexual affections and all that instability of mind and over-reaction to all forms of irritation that comes in the midst of sexual excitation are noted. This seriously disturbs the minds of many patients and makes their health as well as their morals worse than they should be. The neurotic conditions seen in those who occupy their leisure with erotic subjects are fostered by this unfortunate over-attention to sexual matters. For general prophylaxis the physician needs to throw all the weight of his influence toward the correction of unfortunate tendencies in our present-day life and healthier subjects of thought should be encouraged. We often hear it said in our time that the great fact of life is sex. Indeed, this has been insisted on _ad nauseam_ in recent years. There is no doubt that without the sex element the race would not continue under the present dispensation. If sexual feelings did not mean so much to the generality of men and women it is doubtful whether marriage would be the success that it is, though so much is said nowadays about its failure. The analogy with all the beings lower in the scale than man shows how imperative and prominent {480} in life this instinct is and how much it signifies. Those who insist so much, however, on sex as the one great fact of life seem to forget that there are many other natural functions of quite as much importance to the individual at least, if not to the race. Without eating neither the individual nor the race could go on. Neither would the race go on without eliminating waste products. If there is one thing that our consideration of the problems of psychotherapy has made clear it is that whenever any of these animal facts of life is made much of and occupies attention to the exclusion of higher ideas, there is sure to be trouble. It matters not how apparently automatic and completely spontaneous a function may be, if exaggerated attention is given to it, it is sure to be disturbed in its functions and cause serious troubles in the organism. There is no need further to illustrate this with regard to such physiological necessities as feeding and excretion. At present the world is much occupied with sex problems because, unfortunately, its attention has been focused on this subject. Physicians, particularly if they are paying attention to nervous patients, are likely to know many individuals who have food problems, diet problems, digestion problems, bowel problems, and many others of similar nature because they have been focusing their attention on these functions of their being. The most distinguished psychiatrist of our generation, certainly the man whose works have done most to open up new vistas for us in mental diseases and who has added not only new knowledge but new possibilities of development, visited this country not long since and said, "Oh! here in America you are sex mad." He added, "I knew that we were madly following sex problems in Europe, but I thought that in this country, with so many other things to occupy the minds of men and women, you were not bothered so much with sex problems." What he said represents the impression of nearly every thoughtful foreigner who is surprised to find that wealth and luxury have brought to us this same degenerate interest in things sexual that occupies the so-called upper classes and their imitators in Europe. Livy, the Roman historian, said long ago, "Whenever women become ashamed of the things they should not be ashamed of, it will not be long before they will begin not to be ashamed of the things they should be ashamed of." Whenever in history men and women have occupied themselves, not with the rearing of families, but with the suppression of families to as great an extent as possible, sex problems have always become emphasized. The woman who is a mother, and especially many times a mother, usually has no trouble at all about sex problems and no tendency to have "affinities." With her there is usually no question of sex as the central factor of life nor of any other of the curious nonsense that has been talked about this matter as the result of giving sex a place of importance that it does not deserve. Until there is a reform in this matter we can look for many "neurotic, erotic and tommy-rotic" tendencies, as they have been called, due to over-attention to one set of organs. Any organic system in the body would be disturbed by such attention, but the sexual system is particularly susceptible to suggestion. The state of affairs thus emphasized is the result of interfering with an animal instinct. It will make itself felt properly and secure the due exercises of function if allowed to pursue the even tenor of its way under reasonable {481} control, but if it is fostered, thought about, discussed, excited in various ways, pampered by indulgence and perversion, it runs away with nature. The gourmet who constantly thinks about food, plans new modes of exciting the appetite, studies savors and odors in order to satisfy a palate that has been artificially stimulated, gets a certain animal enjoyment out of his food that other people do not; but he usually overeats, loses his appetite, and with it any real satisfaction in eating, and suffers from indigestion as a consequence of indulgence, so that the suffering much more than compensates for any slight additional pleasure that he has enjoyed. Besides, man is an essentially intellectual being, and occupation with the things of sense, that will manage themselves very well if let alone, takes up just so much of the precious time that should be devoted to other things to attain that satisfaction that makes life well worth living. Sexuality cultivated with the degree of attention that certain people devote to feeding, becomes a pest, ruins intellectual effort, hurts initiative, leads to the most serious disappointments in life and is the most fruitful cause of despondency and suicide that we have besides being the origin of many social evils that still further complicate life. One great modern nation has debauched its literature to such an extent that probably the major portion of its books treat of sex and sex problems. Practically all of its esthetic expression has been seriously hurt by the same fault. Its painting, its sculpture, its dramatics, its art of all kinds, have all gone the same road. The result is seen in the lowered moral fiber of its people. A recent census report showed that the nation has reduced some 20,000 in numbers and that this was only the beginning of the race suicide. They have been thinking, talking, writing, painting, chiseling, acting sex problems, but in the only phase of life in which sex really counts it has been so pushed into the background or perverted that there it is failing utterly to accomplish its one legitimate purpose. The younger generation as they grow up are given the idea that they are missing the most wonderful thing in life unless they have memorable sex experiences. These experiences must be varied in order to satisfy the artificial appetite that has been created. As a consequence, family life and the real meaning of love and the affection of man for woman rooted in the depths of their nature is spoiled by mere animal passion and its passing expression. Nature's own attitude with regard to over-attention to sex matters must not be forgotten. The purely sexual organs have been pushed into the background to as great an extent as possible and are intimately associated in both sexes with one of the two ugly excretory functions, urination, and placed in close relationship with the structures which subtend the other--defecation. Evidently nature intended that they should be the subject of as little attention as possible. Unfortunately, the paying of attention to them to any great extent lessens somewhat of the disgust naturally aroused by the excretory functions with which they are associated. Nature has provided as far as possible for deterrence from over-interest. One might expect that cleanliness and the cultivation of the feelings of refinement would serve as auxiliaries in the repression of sex indulgence. The lessons of history are that usually the great bathing nations have been most sexually divagant. Among the Greeks and the Romans the ugliest sex habits and proclivities found a place--among peoples who devoted themselves to the cleanliness of the body. The classes {482} who bathe most are often those with the strongest tendency to sexuality. Refinement instead of lessening the tendency to sexual indulgence rather increases it. Education and the development of intellectuality, far from being a barrier to sexual divagations, seem to predispose to the exaggeration of the significance of sex in life, unless the individual has a well-balanced character or has been thoroughly grounded in ethical principles. The ugly stories of Greek love at a time when the Greeks were at the climax of culture, as well as what we know about the relations of the freedmen to their masters among the Romans during the classical period, is all confirmed by the revelations of corresponding tendencies in recent generations among the intellectual classes even at the universities. Development of mind apparently does not neutralize to any extent these sexual tendencies. Evidently the rule of life for health's sake must be to push sexuality as much into the background of the mind as nature has put the sex organs in the human body. Reason does not protect knowledge but increases suggestion. Only absorbing occupation of mind with other subjects that will bring about neglect of these functions, as of all other physiological functions, leaving them to nature, serves to keep them in their proper place and condition. CHAPTER III SEXUAL HABITS As was emphasized in the preceding chapter, sexual symptoms are usually the subject of so much worry and disturbance of mind and become the center of so much unfavorable suggestion, that the only way to ameliorate the conditions which develop is by securing relaxation of the attention and diversion of mind. Mental influence is much more important than any other remedies that we have at our command in these cases, not only for their relief but for their ultimate cure. A state of depression of mind similar to that which develops in patients frightened by seminal emissions is often seen in those who have for some time indulged in the habit of self-abuse. Rather frequently a physician, especially if he is known to be interested in nervous diseases, has to listen to the story of a patient who is sure that his health is completely undermined and that his future is the darkest possible, because of this habit in younger days. Usually the patient is a young man who has been reading some of the literature of the advertising "specialists" who distribute reading matter which pictures appalling and almost irretrievable effects from such sexual habits. The consequence is that the patient is in highly nervous condition, has lost his appetite, is not sleeping well, is avoiding society, because he fears that some one may recognize his condition and its cause, and he is really in a pitiable state. Such patients are usually sure that little can be done for them. Sometimes they have already been through the hands of several "specialists," particularly of the mail-order variety, and the literature provided for them and the letters written to them have all helped to make them worse and much more solicitous about themselves. {483} Unfortunately some of the exaggerated notions with regard to the effect of these habits that are so widely diffused by the exploiters of the young have been adopted by moralists with the idea that they can thus deter youth from certain practices and scare the victims of such habits out of them. It is extremely doubtful, however, whether self abuse of itself, unless practiced in very early years or indulged in to a degree that is possible only in those of unbalanced mind, ever works anything like the serious harm that is claimed. Certainly physicians who are most familiar with its results are not ready to confirm the opinions usually advanced as to the awful harmfulness of the practice. Personally, I have had a number of patients confess to me that they had indulged in the habit to some extent for twenty years and longer and yet had never suffered anything more than passing physical discomfort. It is unfortunate, then, that the exaggerations of the quack should by receiving the approval of the well-intentioned moralists, be emphasized so as to add to the neurotic disturbance of mind which makes these patients so miserable and for a time may seriously interfere with their health. Occasionally even suicides are reported in which the underlying motive seems to have been the dread on the part of a young man that a sexual habit has so undermined his health that cure is impossible and that physical and mental deterioration to a marked degree is inevitable. The opinions of conservative physicians tend to show that there is no good reason for thinking that in normal healthy persons such habits ever have the serious effects thus set forth. Patients can be assured that whatever evil effects follow the practice will not remain after it has been given up. There are no serious enduring sequelae, with one or two exceptions in very special cases, that perhaps should be noticed. Most men of considerable experience in the matter are now decidedly of the opinion that self-abuse does not produce any more serious consequences than the same amount of ordinary sexual intercourse. It is possible for sexual intercourse indulged in excessively, as it sometimes is in early marital life, to produce the same feelings of exhaustion, lack of control over the vasomotor system and disturbance of the gastro-intestinal tract which are noted in self-abuse. In both cases the symptoms promptly disappear upon proper regulation of life. This is a very different opinion from that which used to be expressed in this matter and it is given only after due deliberation and consultation of many authorities both in writing and orally. Its expression, far from taking away one of the best deterrent motives against the practice, rather forces an appeal to the manliness of the individual. The motive of fear never accomplishes much, while a frank statement of the real condition may be greatly helpful. While the habit of self-abuse as indulged in by the ordinary individual practically never has the awful consequences that have been sometimes pictured as resulting from it even long after its cessation, there is no doubt that it is productive of many physical symptoms during the time of its indulgence. There is almost sure to be a discouraging lassitude and a tendency to exhaustion after even comparatively small efforts. While this is true for ordinary muscular efforts it is also true for other bodily functions that involve muscular activity. In recent years we have learned that of the stomach functions the motor is more important than the chemical. In the bowels the motor function is extremely important. There are likely to be disturbances, then, in the gastro-intestinal tract as a consequence of the muscular condition that {484} develops in those patients. Probably more important even than the physical, however, are the psychic results of the habit. The patient feels discouraged and cast down at his inability to conquer himself and is likely to avoid such exercise and diversion of mind as would make normal healthy function possible. Mental Disturbances.--It is the custom to say that mental deterioration almost surely follows the habit. Those familiar with mental cases often see self-abuse practiced with serious results by young folks whose mentality is deteriorated. In these cases the practice was indulged in with great frequency and with direct physical consequences, such as loss of sleep, of appetite and the like. It is not the habit, however, that has caused the mental deterioration. The young patients are going crazy, but not because of self-abuse. Their habit of self-abuse had originated and become exaggerated because they were already mentally unbalanced. Their extreme indulgence in it is especially due to their lack of control over themselves, because they are not possessed of strong will power with regard to any thing. A vicious circle is formed and the insane young man gradually deepens his insanity by hurting his physical condition through over-indulgence in the habit and all this further lessens his self-control; but were it not for the original mental weakness the habit would not have been indulged in to so great an extent. Effect on Prostate.--There is one phase of the ill effects of self-abuse that it is well to recall as having the confirmation of men of large experience and conservative views. There is a definite impression among specialists in genito-urinary diseases that enlargement of the prostate in some cases is due to the frequently repeated irritation and the prolongation of that irritation of the prostate during the practice of self-abuse. When such men as Bangs and Keyes are agreed on a subject of this kind, then even though in a certain number of cases the changes in the prostate leading to its enlargement are evidently inflammatory, it is well to consider that the functional over-activity of the gland superinduced by the practice may lead at least to an enlargement of the glandular elements with the consequent interference with urination which so frequently comes in old age. Physical Factors.--Besides mental elements that predispose to the formation of sexual habits there are physical factors that are important in these cases. They must be particularly looked for and treated carefully if found, or there can be little hope of relief for the conditions. The most prominent of these is the existence of a long foreskin, especially if its opening is small, thus leading to the retention of urine, the deposition of urinary salts with the formation of preputial concretions or so-called calculi. These are intensely irritant, cause frequent itching and thus predispose to these sexual habits. Even where the preputial opening is free and allows egress of urine without residue, the accumulation of smegma often causes considerable irritation and if the most scrupulous cleanliness with cleansing at least once a day is not maintained, irritative conditions arise, especially in hot weather, that may give occasions for sex habits. Under these conditions the habit is sometimes seen in extremely early years. The youngest case I ever saw occurred in a child not quite nineteen months old whose mother said that for several months she had noticed certain curious actions that she could scarcely understand until finally the truth dawned on her. Then she was morbidly sensitive about it, sure that the habit was due {485} to a fault of her own and it was some time before she consulted a physician. This was her fourth child and, strange as it may seem, it was only at the conception of this child that she first knew what sexual pleasure was. She feared that her feeling had been in some way sinful and that as a consequence of her sin this curious habit had developed in such early years in her baby boy. As is usually the case in these instances, I found that the prepuce was very tight indeed, having scarcely more than a pinhole opening in it. During urination this ballooned and there remained in the pouch-like process at the end of the penis a certain amount of residual urine after every urination. From this urinary salts had been precipitated and had formed scaly concretions which remained in the preputial pouch and were extremely irritant. As a consequence of this irritation the baby had been very itchy and it was in the endeavor to relieve the itching by the natural process of scratching that the pleasure of the sensations aroused had been discovered and the sexual habit had been formed. Not infrequently in young men a condition resembling this to some degree at least is found and then, of course, the question of its removal must be taken up at once. It is surprising how often in youths in their late teens concretions are seen. The constant irritation makes it practically impossible for the patient to keep his hands from the parts, and so circumcision is absolutely necessary. Not infrequently when the preputial condition is not nearly so bad this operation may also be at least advisable if not necessary. The matter of cleanliness must be attended to, preferably after getting up in the morning and not before going to bed at night, for the reaction after cold water may cause congestion of the organ. After a time the frequent use of cold water seems to make the parts much less reactive to irritation of any kind. Physical Effects.--The super-excitation of nerves consequent upon the more or less general erethism that is induced, lessens resistive vitality. Victims of the habit are more liable to colds, to various infectious diseases, and are subject to fatigue and lassitude, with incapacity to work to their full power. They lose control over their vasomotor system to some extent as a result of this systemic erethism. They blush easily, they perspire easily, there is a tendency in many of them to flash as if of heat and cold, they become pale under excitement or anger more than formerly, they are likely to suffer from cold hands and feet, and the surface of the body is inclined to be cold and as a consequence patients are tremulous. This represents a waste of nervous energy and as a consequence sleep may be disturbed and digestion interfered with. It is important, therefore, to consider these cases as really needing medical care. For their treatment the most important consideration is prophylaxis, not alone of the habit itself, but of each of the acts. Prophylaxis of the habit is an ethical question that we can scarcely do justice to here. Prophylaxis of the acts requires consideration of the physical and moral factors that predispose to their commission. While the habit may have secured such deep control that the patient almost despairs of relief from it, when care is taken to remove physical and moral predispositions the conquest of the habit becomes comparatively easy. Over and over again I have seen cases that have lasted for years in which the patients were surprised at the ease with which they were able {486} to drop the habit just as soon as they took the measures necessary to prevent predisposing conditions. Breaking the Habit.--Once physical factors predisposing to it are removed, the habit is not so hard to break as it would seem to be from the suggestions to that effect made in sensational literature. It is neither so deleterious in its physical effects nor so deteriorating as regards character as is usually stated. Anyone with a reasonable amount of firmness can break it off if he really resolves to. Over and over again I have seen patients quite surprised at the ease with which they were able to avoid the practice for weeks once they made up their minds in the matter. Indeed this is one of the unfortunate features in completely conquering the habit. It is comparatively so easy to break it off when the mind is made up that there comes the feeling that now it must be absolutely facile to keep away from it. This is, however, never true. Relapses are extremely easy. If the patient allows himself to read vicious books, or suggestive literature of any kind, or permits himself an indulgence in the reading of several columns of the account of a sex murder trial, or goes to see a sex problem play with its suggestions, or exposes himself to sexually exciting conditions of any kind, he will be almost sure to lapse into the old habit. Relapses are almost inevitable. But it is easier to break the habit the second time than it was the first and it becomes increasingly easy if the patient keeps up the effort of regulating his life so as to avoid the occasions of the habit. Relapses are quite as sure to occur as with regard to alcoholism if occasions for the taking of liquor are not sedulously avoided. The patient always seems to need a confidant--someone to whom he can go for help and who assures him of the ability that he has to overcome himself if he only will. The practice of confession in the Roman Catholic Church makes it comparatively easy for serious people of that faith to overcome the habit. The physician must be taken into confidence in the same way and for a time, at least once a week, the patient may have to be perfectly frank with regard to his condition in order to have the help afforded by such confidences. The physician can often, particularly at the beginning, make the physical conditions such as to help in the breaking of the habit. Bromides taken to the extent of a dram or more a day are almost a specific for superirritability of the nervous system, and if taken for two or three weeks the patient will usually have little or no difficulty in overcoming the habit. They are not of much avail after this time unless the patient's character has been aroused to determined helpfulness in the matter. In obstinate cases it may be necessary to have a patient come every day, or at least every second day, for some time and give an account of how he has succeeded in resisting his habit in the interval. At least he must be asked to report whenever there is a lapse. It is surprising how much the anticipation of having to tell someone else of a drop back into the habit means in helping the patient eventually to overcome it. Very slight motives serve to cause relapses, but almost any external personal aid, if pursued with confidence, will avail effectually to break it. I talk from an experience of many cases and know how much can be accomplished even though patients insist that they have tried all the resources of their will power and of prayer without avail. They have really not tried, they have not willed in reality; sometimes they {487} have reached a point where they cannot will without the moral support of another personality. This can be readily supplied to them by a firm, sympathetic physician whom they respect. It will take time to overcome the tendency to relapse whenever the will is relapsed, but the habit itself can be broken without much difficulty in a few days. Certain times are particularly dangerous for relapses into the habit. These are just before going to sleep at night and before getting out of bed in the morning. At these times the mind must be occupied or else the patient will almost surely find his habit recurring. Often the habit of reading in bed, properly supported by pillows and with abundant light at an angle that makes reading easy, seems to be good for these patients, because they may read until their eyelids get heavy, then pull the chain of their light to extinguish it and turn over to sleep. In the morning prompt rising after waking is important. Bed clothes that are too heavy and too great warmth of clothing predispose to sexual excitation and must be avoided. The room should be cool rather than warm and the mattress rather hard. The more tired the patient is the less liability will there be to difficulty in these matters. But air is even more important than exercise in giving the tiredness which superinduces deep sleep. A lessening of the normal amount of oxygen seems to relax the inhibitory power of the higher centers over the sexual centers in the cord. People who are drowned, those who are hanged, and those whose supply of oxygen is shut off by the inhalation of the heavier gases are likely to have involuntary seminal emissions. These are probably consequent upon the shutting off of the air. The important element in the treatment is to make the patient feel that, if he really wants to, he can conquer in this matter. The old motives of fear, and especially fear of physical consequences, were quite unworthy, and inasmuch as they had any effect rather produced a deterioration of character than a strengthening of it. The patient must understand that if he is a man he can overcome it. Religious motives will help much. I do not know that I have ever seen a case where religious motives were not the most important element in the cure, but that may be due to the conditions in which I have been placed. I have seen a number of these cases in men and women because clergymen have sent them to me in order that they might be helped in the work of reform, and while there are many relapses and some had apparently given up the effort in despair of their power to overcome themselves, nine out of every ten of those who have seriously faced the problem have succeeded in overcoming themselves, and as a result have a better knowledge of their own characters and more respect for themselves. They are better men in every way than if their improvement had come about through selfish fear of physical consequences. After Cure.--After the habit of self-abuse has been conquered the seminal vesicles will have a tendency to evacuate themselves rather more frequently than before and as a consequence they will nag at certain sexual nerve endings. They are used to having their contents emptied and distention is followed by rather ready evacuation. During the course of this evacuation sexual thoughts are awakened in dreams and this may lead to dream states in which there seem to be lapses into the old habit. This constitutes a serious difficulty in getting rid of the habit entirely in young and vigorous men. They may even become disheartened by it. It should be explained to them that they must let {488} contrary habits form gradually and permit nature to accommodate herself to the new state of affairs. The bromides are a useful adjunct for body and mind. _Supposed After-effects_.--At times a patient suffering from some exhausting or serious disease, consumption, heart disease or the various forms of Bright's disease, will be discouraged by remembrance of the fact that in earlier years he allowed himself for some time to fall into the habit of self-abuse. If he has read, and very few men have not, some of the literature issued by the advertising "specialists" and has heard the unfortunately exaggerated ideas commonly entertained with regard to the influence on health of this habit, he will become more or less disheartened by the idea that he thus undermined his constitution and that one reason why he is not able to react better against his affection is that he seriously diminished his resistive vitality. This idea must, of course, be overcome or it will act as a constant source of unfavorable suggestion, lessening appetite, tending to disturb sleep, banishing peace of mind to some extent and thus inhibiting the patient from releasing such stores of vital energy for his recovery as would surely be in his power under favorable conditions. Female Habits.--The habit is more rare in women than in men, but when it occurs is a little harder to break. In men it usually develops in youth, but oftenest in women who are past thirty-five and unmarried. In these cases it is much harder for the patient to regain self-control, because the class of women patients who acquire such a habit have less character, as a rule, than the men who fall into the same condition. In all sex matters, once passion is aroused or habit formed, the woman is likely to lose control of herself more than is the man. Even in women, however, it is not only possible, but under favorable circumstances, quite easy to secure a break in the habit, though relapses are more frequent than in men. Certain occupations seem particularly to favor the development of the habit. These are mainly sedentary occupations that can be followed without the necessity for such attention as to prevent the mind from wandering off into thoughts that may prove provocative of sexual sensation. Dressmakers seem particularly likely to suffer from the affection, and those who run sewing-machines are predisposed by the movements involved in their occupation to the development or, at least, to the persistence of the habit. For women even more than men religion and the motives it supplies are the most efficient factors for the ultimate cure of the habit. In general, the greater difficulty of overcoming it in them is due in no small degree to the fact that they live indoors much more than men, often have sedentary occupations, and are more frequently alone. These afford opportunities for introspection and for the harboring of thoughts that lead to relapses into the habit. Besides, women are more prone to read novels and stories relating to sex problems and the details of sex murder trials and the like which constitute ever-recurring sources of mental erethism. If their habits can be modified, especially if they can be made to realize the necessity for being out in the air as much as possible, and for keeping their windows open at night, as well as for thorough cleanliness--for every gynecologist notes the necessity for this and how frequently it happens that neglect of it leads to irritability of the external organs that is of itself a serious factor--then it would be no more difficult for women to overcome the habit and get beyond the relapses than it is for men. {489} Sometimes we have to overcome a morbid dread of touching themselves even for cleansing purposes which allows the accumulation of irritant material and predisposes to relapse. Sexual Perversion.--Sexual perversions are sometimes considered as different from sexual neuroses, but such they really are. They are oftener due to habit than to anything deeper. Much has been said about the unfortunate natural inclination of some people to indulge in sexual perversion, but such talk partakes of the nature of similar remarks with regard to habits of other kinds. The alcohol habit, for instance, is formed by many men as the result of their environment and a weakness of character, with lack of resolution to support themselves in self-denial when they are tempted to drink. In recent years it has been only too often the custom to excuse or to justify many of these cases. There are a few persons in whom, owing to weakness of character, alcoholism is more or less inevitable if occasions for indulgence occur. And in the same way there has been much maudlin sentimentality wasted on sexual perverts, as if most of these men could not avoid the actions that the rest of humanity abominates. There are, perhaps, a few individuals who because of a failure on the part of nature to define sex in them properly--as if she had not quite made up her mind which sex they should belong to--are more to be pitied than held to account for their delinquencies in this matter. Compared to the whole number of sexual perverts, however, these are very few. Under the protection of the pity awakened for these, a large number of others find quasi-justification for their acts. Anyone who knows much about these patients realizes that their story is, as a rule, very different from what it would be if they were inevitably impelled to the commission of the acts in question. Many of them had the greatest abhorrence for it at the beginning, were attracted to it out of curiosity and morbid sexualism, because they had allowed themselves to think and read and dream about sex matters overmuch. They are usually idle people who do not take life seriously and who have an inordinate curiosity about sex subjects. At the beginning the commission of the perverted sexual act was associated with an intensely deterrent rather than an attractive feeling, but gradually this was overcome and a contrary habit has been formed. It is difficult to break this habit and to get away from the morbid sexual ideas that have been allowed to develop and grow strong in connection with it. This opinion is somewhat different from that held by many men who are recognized as authorities on this subject and who find many excuses in the nature of their patients for these perversions. If it is recalled, however, that whenever wealth has brought luxury to a people and luxury has brought over-refinement, such sex perversions have been particularly noted, it will be realized that not nature, but the ways of men are responsible for their development. Whenever men pay much attention to their bodies, exercise for the sake of their muscles, bathe not for cleanliness but for luxury, sex perversions become common in history. The story of Greek love is well known. Corresponding conditions developed at Rome under similar circumstances. According to good authorities, the English universities became tainted with it a generation ago. Our athletic clubs in this country have rightly or wrongly fallen under suspicion in this matter, though the tendency to exaggeration with regard to such things, and popular credulity in such matters must be recalled. {490} Some confirmatory evidence undoubtedly there was. Sexual perversions then would seem to be due in most cases to definite conditions and our knowledge suggests readily what should be the prophylaxis. In the course of some studies with Professor Magnan at L'Asile Ste Anne in Paris I saw a number of these curious cases of sexual divagations, exhibitionism, sex perversions and similar conditions. Some of his cases were clearly curious examples of natural tendency, at least, to mental hermaphroditism. Occasionally men of normal development otherwise have a woman's waist and woman's torso above the waist, and many womanly coquettish ways that point to this curious mixture of sexes. Occasionally women are lacking in all the sex characteristics of the upper portion of the body, have no breasts and have the hirsute characteristics of men on the face and even on the chest. In such cases one may be tempted to let one's pity override one's better judgment and feel that resistance to the temptations to indulge in perverted sexual feelings may be so difficult for these people as to be almost impossible. Even in such cases, however, under Magnan's gentle tutelage, under his faithful care and sympathy, men and women lost most of the tendency to commit unnatural acts and certainly found it easier to live normal lives than before. For the majority of these sexual perverts, however, it is as with regard to drug addictions, alcoholism, and obesity, just a question of willing not to indulge in certain appetites that serves to help them. There is no doubt that it is a difficult matter to break a habit that has become a second nature, and it is almost impossible that it should be accomplished without a number of relapses. If the patient really wishes to correct the evil habit, however, this is perfectly possible. The talk of a third sex with homo-sexual inclinations is quite beside the mark. Certain of this class have a weakness of intellect and of will that is at the root of their trouble, but not a few of them pride themselves on their intellect and will power in most other things and must not be permitted to deceive themselves as to their weakness and its significance. It is not nature but self that is at fault and the disease can be completely eradicated. {491} SECTION XIII _SKIN DISEASES_ CHAPTER I PSYCHOTHERAPY IN SKIN DISEASES The place of mental influence in the treatment of skin diseases will be best realized from the role that we know the mind plays in the production of various skin manifestations. There is a whole series of skin affections which depend to a considerable extent on mental conditions, worries, anxieties, shocks, frights and the like, and a number of skin affections that have been labeled hysterical which occur in nervous persons, due to over-attention to self and their conditions. It has been well said that it is possible to make the feet warm by thinking about them. Certainly attention to any part of the skin surface causes a tingling and hyperemia may follow. Blushing is an illustration of mental influence on the skin, and anything that would tend to make this endure for some time would give rise to erythematous conditions. We know the creepy, uncomfortable, hot feelings that come over us in times of suppressed excitement when we are waiting for something to happen; and, on the other hand, there is a pallor and tremor that accompanies fright or fear, which points to mental influences over the vasomotor system in the skin. Urticarias.--Certain skin diseases, especially those allied to the urticaria group, are prone to occur in connection with excitement and worry. In the chapter on Neurotic Intestinal Affections attention is called to the fact that many patients who suffer from intestinal idiosyncrasies and have excessive reactions to special kinds of food, as cheese, strawberries, or the like, sometimes also suffer from skin lesions and intestinal disturbance through worry or excitement. While preparing for examinations or undergoing some physical trial or suffering from worry or anxiety such persons may have urticaria or even wheals on the skin. There may be some dietary disturbance to account for them, but they would not occur, or at least would not be so serious and annoying, but for the disturbed mental condition. Under these circumstances dermatographia is a common manifestation. It used to be considered a symptom of many physical conditions, but will occur in almost any nervous person during the course of an examination by a strange physician or when some important medical decision is pending. Eczema.--Not only these passing conditions of the skin, however, but more lasting affections have been connected with mental disturbance. Probably every skin specialist has noted in a number of his cases that a first attack of eczema came after a period of worry or excitement, or sometimes followed directly on a fright. When relief from the condition has been brought about {492} by treatment, relapses occur during periods of business worry or family anxiety or mental stresses of one kind or another. Cabinet crises in England are found to be likely to be followed by the recurrence of eczematous conditions in older members of the Cabinet or by first attacks in some of those whose skin has been irritated by some internal condition. Unless business worries can be removed or family anxieties allayed the cure of eczema becomes a difficult matter. Men or women who worry about their eczematous condition apparently prolong it. This is particularly true if they have little to do and are likely to be much occupied with themselves and their condition. Herpes.--Herpetic conditions resemble urticaria in their response to mental conditions. Herpes preputialis and herpes progenitalis occur particularly in people who worry over the possibility of some infection of the genitals. The lesions are likely to be indolent until the state of mind with regard to them is relieved by reassurance as to their comparatively innocuous character. Even herpes zoster is prone to come on after a period of worry and anxiety. It is due to infection, but the infection becomes more possible after a lowering of resistive vitality in the nervous system. This is particularly true as regards herpes facialis. It has been noted again and again that facial neuralgia is most likely to occur after fright, deep emotion, or prolonged anxiety. Treatment of these cases will only be successful if the mental state is set right. This is particularly true with regard to Bell's palsy. Patients who worry much about it and who fear that it may have lasting results are likely to prolong its course and to put off complete cure for a good while. Vasomotor Disturbance.--There is a series of skin affections connected directly with the vasomotor system of the skin which are largely under the influence of emotional or mental factors. These represent particularly the milder forms of Raynaud's disease and the parallel forms of Weir Mitchell's disease. In the one case there is a spasm of the arterioles causing what the French call "dead fingers," and in the other paralysis of the vasomotor system with venous congestion in the parts. They are seen particularly in persons of highly nervous organization and especially after periods of emotional strain or stress. There is a series of affections related to these, characterized by numbness, paresthesiae, going to sleep of the fingers or members, tingling, and even milder forms of itchiness--sometimes dignified as pruritus--which are largely due to mental factors. Some physical condition will need to be corrected, but they will only disappear if the mind is set at rest and if the patient is kept from occupying his attention much with them. Concentration of attention will make them chronic. Scurvy.--Scurvy is not usually thought of as a skin disease, though it has many local manifestations on the skin and mucous membrane. It is a deep nutritional disturbance of such nature that it would seem the mind could have but little influence over it. When scurvy was common, however, it was often noticed that any change of attitude of mind in affected persons brought amelioration or deterioration of condition. Scurvy develops with special virulence during discouragement; it gets better with the dawn of hope. It has been known to be much improved by the prospect of a naval engagement when all the sick men wanted to get into the fighting. The famous case of the Siege of Breda in 1625 is often quoted. The city was about to capitulate because so many of the soldiers were suffering from the disease. The Prince of Orange, {493} however, sent word that a new and powerful remedy had been discovered that was sure to cure the affection, and that he had secured some of it and it would not be long before they would all be well. What he sent was a remedy that had been used with indifferent success for scurvy when taken in large doses. He could send only enough to give a few drops to each patient. This small dose was wonder-working in its effect and proved to have the healing virtue of a gallon of the liquor. Most of the patients got better and surrender was put off. Warts.--A striking evidence of the influence of the mind upon the skin is given by what we know of warts. All sorts of charms have been not alone suggested for them but found to work in certain cases. Lord Bacon in his "Natural History" tells the story of the charming away of warts and exemplifies it by his own experience. When he was about sixteen a number of warts--at least 100--came out upon his hands. One of these had been there from childhood. The manner of their cure he details as follows: The English Ambassador's lady, who was a woman far from superstition, told me one day she would help me away with my warts; whereupon she got a piece of lard with the skin on, and rubbed the warts all over with the fat side; and amongst the rest that wart which I had from my childhood. Then she nailed the piece of lard, with the fat towards the sun, upon a post of her chamber window, which was to the south. The success was that within five weeks' space all the warts went away, and that wart which I had so long endured for company. But at the rest I did not marvel, because they came in a short time, and might go away in a short time again; but the going away of that which had stayed so long doth yet stick with me. Lucian, the Greek satirist, tells that warts were cured by magic in his time. Carpenter in his "Human Physiology," page 984, says: "The charming away of warts by spells of the most vulgar kind belonged to those cases which are real facts, however they may be explained." Dr. Hack Tuke in his "Influence of the Mind Upon the Body" says: "In visiting a county asylum some years ago my attention was directed to several of the patients who were pestered with warts and I solemnly charmed them away within a specified period. I had quite forgotten the circumstance until on revisiting the institution a few months afterwards I found that my practice had been followed by the desired effect and that I was regarded as a real benefactor." This feature of the method of removing warts, setting a date before which they shall disappear, is noted in most of the successful charms. Dr. Tuke tells of a case in which a gentleman on shaking hands with a young lady noticed that she had many warts. He asked her how many she had; she replied about a dozen, she thought. "Count them, will you," said the caller; and taking out a piece of paper he solemnly took down her counting, remarking: "You will not be troubled with your warts after next Sunday." Now it is fact that by the day named the warts had disappeared and did not return. Neurotic Pigmentation.--Pigmentation occurs very commonly as the result of neurotic conditions. Dr. Champneys, in his article on "Pigmentation of the Face and Other Parts, Especially in Women," in St. Bartholomew's Hospital Reports, Volume XV, has illustrated this very thoroughly. The pigmentations of women during the phases of genital life, menstruation, pregnancy, the menopause and the fact that eunuchs are usually fair and fat, while deep pigmentation in the white race is usually associated with sexual irritability, all make interesting studies in this subject. From comparative {494} anatomy and physiology the influence of the nervous system over pigmentation has been very well illustrated. Brücke in 1851 established the influence of the nerves on the color of the chameleon and of the frog, and there have been many confirmations of his work. Pouchet, in 1876, in the _Journal de l'Anatomie et de Physiologie_ proved that fish gained the power of changing color by practice and lost it by disuse. The influence in most cases, animal and human, which produces pigmentation is exerted by the nervous system through the vascular supply. The duskiness that sometimes comes with emotion, the pallor that accompanies strong mental disturbance, as well as the blushing states, show that the vasomotor system can be influenced in every part. Pigmentation often seems only a consequence of local continuance of such disturbance. Many of the feminine patients in whom even deep discolorations around the eyes occur in connection with menstruation are typical neurotic individuals. It is worry in combination with the physical disturbance that produces the pigmentation. There are some cases on record where emotional states have caused loss of pigment in the negro or other colored races, or in the hair, as when, in well-substantiated cases, people's hair has become white in a single night. In every case of pigmentary disturbance, then, the individual must be carefully studied and as far as possible all emotional disturbance must be eliminated. Without this other treatment usually fails. Pruritus.--Pruritus in the old is often a bothersome symptom. All sorts of remedies, internal and external, are recommended for it and successes are reported with them. Whenever there are many remedies for a symptom complex, it usually means that the suggestive element in all of them is large. For pruritus the influence of the patient's mind is extremely important. Often it will be found that these old patients are getting out scarcely at all, but are living in close confinement in their rooms, the air of which is scarcely ever changed. I have known even the keyholes to be stuffed and arrangements made by which the cracks between the door and the frame were rendered impervious to air. In these cases the most important feature of any treatment is to secure a proper amount of air. Sir Henry Thompson, the great English surgeon, in his advice how to grow old successfully, written when he himself was over 80, suggested that the cells of the skin needed an air bath every day. He advised that men should make all their toilet arrangements for the day without any garments on. Washing, the preparation of clothing, shaving, and whatever else was done in the early morning was to be accomplished after the night clothes were taken off and before other clothes were put on. He lived to be well above eighty and was sure that this practice had been of help to him. Stimulating rubbings, if done gently and without the production of too much reaction, will always benefit these people. If old people have no interest, nothing that attracts their attention, and if they once develop pruritus their mind gets concentrated on their cutaneous sensations and it will be impossible to relieve them by any treatment until their minds get occupied with something else. Anyone who wants to sit in a chair for a few minutes and think about his cutaneous sensations will soon realize how vividly these can be brought to mind and how annoying they can become. To sit and think of a portion of the body is to want to scratch it before long. Scratching produces a flow of blood to the surface that adds to the itchy feeling. The only way to get away from it is to get the mind {495} occupied with something else. Of course, where circulation is weak because of failing heart or disturbed because of arteriosclerosis, treatment directed to these conditions should be employed, but the influence of the mind on blushing and skin feeling must not be forgotten. When pruritus develops in the old in connection with phases of arterial degeneration--its most intractable form--it is important to remember that diversion of mind is the most important therapeutic agent that we have. The old have few diversions. They have given up their ordinary occupations, they are often no longer interested in reading, friends whom they used to know have died, and they are left a great deal to themselves. Under these circumstances anything the matter with them brings about a concentration of attention. This is even more true if they have been very well in earlier life and have had practically no experience with sickness. Hysterical Cutaneous Conditions.--There are certain cracks of the skin with ulcerative lesions which occur in hysterical patients in the neighborhood of the knuckles that represent a phase of unfavorable influence of the mind. When these patients begin to worry or be anxious they know that these skin lesions will follow. Expectancy seems to make it certain that the lesions will come and attention adds to their chronicity. It has been noted that "chapped hands," especially when accompanied by deep cracks in cold weather, are made worse by anxiety or worry. In many neurotic patients it is impossible to treat such conditions satisfactorily unless the patient's mind can be put at ease. It is surprising how intractable these conditions can be, but that is usually because all the physician's attention is devoted to the skin instead of a considerable portion of it being given also to the patient's mental and nervous condition. Artefact Skin Lesions.--Of course artefact skin lesions produced by the application of carbolic acid or nitric acid or ammonia or some other chemical irritant, or by rubbing with pumice stone, or with the thumb as schoolboys make what in my schooldays were called "fox bites," are skin lesions connected with a special state of mind and so deserve a mention here. The physician finds them under the most unexpected circumstances at times and in patients apparently above all suspicion of their self-infliction. They can only be prevented by changing the patient's state of mind, though this is scarcely what is ordinarily thought of in psychotherapy. Where skin lesions are atypical it is well to bear in mind the possibility of this curious condition. The Mind in Dermatotherapy.--I have had old dermatologists assure me that they felt that the mind influenced materially the course of many forms of skin disease. Younger dermatologists are prone to be localists; as they get older the treatment of the patient's general condition is felt to be more important; after twenty years of experience they realize the place of psychotherapy in the treatment of their cases. What is said here is only meant to be suggestive, but certainly sufficient data are supplied to make it quite sure that the mind greatly influences skin conditions and must always be treated if success, especially in chronic cases, is to be secured. I have seen confidence in a particular physician or remedy do much for even the most sloughing and obstinate psoriases. Eczema follows the same law. If psychotherapy can help in the treatment of conditions that are so often intractable, it must surely not be neglected in other cases. {496} SECTION XIV _DISEASES OF DUCTLESS GLANDS_ CHAPTER I DIABETES Diabetes is an affection of metabolism definitely recognized as due to serious organic changes, though existing in several forms. We are not as yet absolutely sure whether there may not be quite different organic diseases in the various forms. Of one thing clinical experience has given us assurance, that the condition of the patient's nervous system is extremely important. While certain forms of diabetes are due to pancreatic changes and others perhaps to changes in the liver or other abdominal organs, the nervous system itself can affect the consumption and excretion of sugar within the body. Certain injuries, especially, as pointed out by animal experiments, irritation of the floor of the fourth ventricle may produce passing diabetes. The symptom may also occur in connection with states of the nervous system. Glycosuria, or the passage of sugar in the urine, may occur simply as alimentary glycosuria; and while this is usually due to an excess of sugar in the diet, the glycosuria itself is predisposed to by neurotic conditions in the patient. Diabetic patients are made worse by worry of any kind and particularly by solicitude about themselves and their ailment. Hence, the place that psychotherapy has in the treatment of the disease. Unfavorable Suggestion.--In most cases of diabetes, however, probably the most important factor in the production of symptoms is the serious disturbance of mind. The patient has an incurable disease and is frankly told so. For the physician the word "incurable" means only that his remedies are as yet inefficient in preventing certain nutritional or metabolic disturbances, and that these will be likely to continue in spite of all he can do. For the patient "incurable" means that he has a disease for which the doctor confesses that he can do nothing--which is not true--and that it is almost surely progressive, while the many reports of death from diabetes of which he hears only confirm the impression that he has not long to live and that most of the time remaining will have to be spent in irksome care of himself and almost superhuman self-denial. As a consequence of this train of unfavorable suggestions, the history of practically every case of the milder form of diabetes in older people contains a period in which, shortly after the discovery that they had the disease, they suffered more severely from it than at any other time. As a rule, the discovery was accidental. The occurrence of a succession of boils, the development of a {497} carbuncle, occasionally an intractable eczema or a great itchiness of the skin, or an irritation of the external urinary organs, the occurrence of cramps at night, or neuralgia pains, have led to an examination of the urine and the finding of a considerable quantity of sugar. As a rule, the patients are at once put on a diet containing little starch and no sugar, and after a short time most of the bothersome symptoms of the diabetes have ceased. Their own worry, however, the strictness of the regimen, the craving for starches, the decrease in weight from the limitation of diet, have made them profoundly miserable. Their feelings have been translated into the definite conclusion that the disease must still be making progress since they feel so miserable, and they have suffered more from their mental state than from their diabetes. This is as true of physicians themselves when they are sufferers from diabetes as of ordinary patients. Indeed, it seems that physicians make themselves more profoundly miserable because of their supposed knowledge of the disease than other people do. I have had the confidences of more than a dozen physicians who were sufferers from diabetes, and all of them admitted that they had suffered more from their scare over the disease and from trying to maintain a sugar-free diet than from the effects of their ailment. The lowering of nutrition reacts upon the nervous system, already laboring under the strain of the persuasion that an incurable disease is present, and the consequence is a whole series of nervous and often mental symptoms, especially of the depressive kind, that still further disturbs digestion, interferes with peristalsis, causes constipation or alternate constipation and diarrhea, leads to wakefulness at night, inability to concentrate attention and a constant state of worry. All this reacts upon the system and further increases the diabetes, that is, the inability to use sugar properly, and adds to its elimination through the urine. Favorable Suggestion.--Just as soon as these patients realize that people have often had considerable quantities of sugar--two per cent. or more--in their urine for years without serious consequences and that most diabetics die, not from the affection itself, but from intercurrent disease, the reassurance of mind which ensues makes their nervous system cease to be a factor in the further disturbance of metabolism and they are able to consume more starch and sugar without increasing the amount of sugar in their urine. This is not true, of course, for the severe diabetes that attacks young people. These run a rather rapid course and usually end in from one to two years in diabetic coma or some complication connected directly with the diabetes. Danger of Over-treatment.--To strive to keep the urine of diabetic patients free or nearly free from sugar is practically always sure to produce a serious effect upon general nutrition and to disturb the patient's mind and nervous system. Very often, however, an attempt of this kind is made. Doctors who suffer from diabetes are too prone to watch their urine carefully from day to day and this only emphasizes their solicitude about themselves, impairs their digestion, and produces such preoccupation of mind that all their functions are sure to be disturbed. After a time they learn that their general condition is a more important question than the amount of sugar in their urine. If they can maintain their weight with reasonable freedom from the secondary symptoms of diabetes, then the primary symptom--the amount of sugar in the urine--may be almost or quite neglected. {498} Interval Treatment.--Van Norden has pointed out that if diabetic patients are occasionally made to observe for a couple of weeks at a time an absolute diet, these intervals seem to form a new starting-point for metabolism and enable the patient to increase his power of utilizing sugar and consequently to diminish his pathological elimination of it. Patients look forward with interest to these periods, provided that in the intervals they are allowed a certain amount of starch; and each one of them seems a landmark on the road to recovery. There is a strong element of suggestion in this that acts very favorably and greatly influences the actual power of such intermissions to help nature recover her lost metabolic faculties. This is certainly a better method of treatment than the attempt to keep up an absolute diet which so easily produces the other evil of nervousness that adds to the diabetes, so that there is question of choosing between two evils, and the lesser evil includes particularly the reassurance of the patient. The Individual in Diabetes.--While diabetes is a question of glycosuria and usually of hyperglykemia, and the consumption of any form of cane sugar or of starch convertible into it, will usually increase the diabetic tendency, not all the forms of starch which may change into cane sugar have the same effect in all individuals or undergo the same modifications. Some patients, for instance, stand milk better than others and may take large quantities of it so that there is less craving for starchy foods. Most patients can take potatoes better than bread even when there is the same equivalent of starch in each. Those who have been accustomed to potatoes from their early years sometimes stand them well and may be able to take them almost with impunity. I have noted in several cases that the Irish and Scotch, accustomed to oatmeal from their early years, seem to be able to take notable quantities of this food when suffering from diabetes without having a marked increase of sugar in the urine. There are forms of sugar that satisfy the craving of patients for sweets and may be taken in considerable quantities without seriously disturbing metabolism. Honey is one of these, its sugar occurring in the form of mannite, and there are other substances related to it that probably can be employed to advantage. It must not be forgotten that what seems to be sugar in the urine of certain patients, that is, grape sugar, has proved on more careful investigation to be one of the other chemical forms of sugar. We have a number of cases of pentosuria on record in which patients were excreting penatomic sugar, but had not glycosuria, though their urine responded to the ordinary tests for this. It seems well not only to be sure of the diagnosis in these cases, but to use what we have learned to make patients feel that their condition though not curable is by no means hopeless. Care must be exercised to take advantage of every possible individual peculiarity for reassurance, for the extension of the diet in any possible way, and for the satisfaction of the cravings which are so likely to come to these patients. Some of their craving is really due to the suggestion that they cannot have a particular article of diet. Whenever any human being knows that he cannot have a thing, the liking for it grows by suggestion and then it may become an obsession. To be allowed even small quantities of it is often enough to enable patients to overcome this and at least put them in a better state of mind. Physical Condition.--The most important element in the treatment of {499} the less severe cases of diabetes is exercise in the open air. Whatever the ultimate solution of the mystery of diabetes may be, there is no doubt but that the muscles are an important factor in our disposal of sugar within the body. The material which is burned up in the muscles during movement is a form of sugar derived directly from the starch and sugar ingested. When diabetics exercise freely much more of their sugar is consumed within the body and much less of it eliminated through the kidneys than when very little or no exercise is taken. It is interesting to note the difference in the amount of sugar in the urine when patients are taking abundant exercise and when they are taking practically none. Even on a much more liberal diet the percentage of sugar is likely to be less in the exercising patient. One of the results of the diabetic scare is likely to be almost a cessation of muscular exercise. This is partly due to the fact that one of the results of diabetes in many cases is a sense of fatigue in the muscles on comparatively little exertion. Indeed, this is sometimes the first symptom that is noted and that calls the attention of the patient to the fact that there is something seriously wrong with him. This occurs when there is a serious disturbance of sugar metabolism so that the patient who consumes large amounts of starch and sugar is excreting most of it. Just as soon as the diet is made a little more rigid and the sugar metabolism improves, then exercise can be taken and will benefit the patient. This is particularly true of women suffering from diabetes whose depression on being told that they are suffering from an incurable disease tempts them to remain within doors; the frequent tendency to urination further adds to their disinclination to go out. Under these circumstances they lose their appetites, do not sleep well, and become highly nervous, thus increasing their diabetic tendency. If they are required to go out and take exercise in the open air and rather long riding or walking periods every day, their general health will at once improve and the diabetes will become more manageable. I have seen this happen without exception even in patients well beyond middle age, and I am convinced that it is the diversion of mind as well as the salutary tiredness and thorough oxidation consequent upon outdoor exercise that is the best possible remedial measure for these cases. Solicitude.--It is important that diabetic patients should not be bothered by frequent reports upon their urine. Their improvement and the reduction of the amount of sugar excreted is at best but slow, and is subject to many variations. While improvements, especially at the beginning, are sources of great encouragement, the deteriorations that are likely to be rather more frequent are prone to overweigh the good effects and eventual discouragement results. It is not from the urine but from the general condition that the improvement in the diabetic condition is to be judged. So long as the patient feels strong, gains in weight (when they do not belong to the obesity type of diabetes), the diabetes itself is almost sure to be improving, even though there may be discouraging periods as regards the amount of sugar eliminated. Dangers of Rigid Diet--There are more dangers in a rigid diet than in a certain amount of liberty in the consumption of starches and sugars. The craving for these becomes so strong as to make life intolerable to many people unless a certain amount of these substances is allowed. It is rather easy to manage limitation while it is almost impossible to be sure that {500} patients will practice absolute denial. Besides, the almost complete absence of starches and sugars, even though their place is supplied by the fats, always seems to predispose patients to the development of the acid intoxication which results in the coma often so serious an incident of diabetes. It is for this reason particularly that mild diet regulations are clinically more judicious than the absolute denial which on chemical and physiological grounds seems to be the scientific ideal. A rather good therapeutic method is to have the patients maintain a rigid diet for some ten, fifteen or twenty days and then leave them practically without restrictions for the rest of the month. Continuous restriction of diet becomes appalling. Looking forward to a period when they can eat as other people do relieves the tedium, and makes it much easier to keep the restrictions. The mental influence of this moderate treatment is very favorable and encourages the patients in the thought that after all their disease is not so serious. This is the most important element in psychotherapy. CHAPTER II GRAVES' DISEASE Graves' disease, sometimes called Basedow's disease, though the Irish physician has a right to the name by priority, is often called exophthalmic goitre, because this term is descriptive of the two most marked symptoms. It must not be forgotten, however, that there are cases in which there is no exophthalmos and even no goitre, at least no enlargement of the thyroid gland that can be demonstrated externally. It is said that in these cases there must be an enlargement of the thyroid bound down by fascia and concealed by other structures of the neck so that it does not appear externally. It is probable, however, that there are cases of true Graves' disease without enlargement of the thyroid yet with the characteristic tremor, rapid heart and the mental symptoms of the affection. Etiology.--The symptoms of the affection often develop after a period of excitement or worry, or at critical times in life, if sorrow or misfortune proves a burden. Responsibility sometimes has a like effect. I have seen a woman patient on several occasions in the last fifteen years develop marked symptoms of Graves' disease when she was placed in a position of responsibility involving worry, while in the intervals when pursuing a simple ordinary life without trouble of mind no symptoms were present. Occasionally a fright seems to be at least a predisposing cause for the development of the symptoms. Emotional strains, mental stresses, play a large part in occasioning Graves' disease, though the cause of it is probably deeper in some structural defect. In recent years nearly all the medical attention has become concentrated on the idea that the disease is primarily due to hyperthyroidization. More detailed study, however, has shown that other ductless glands are probably also concerned in the etiology. The adrenals particularly seem to be associated closely with the thyroid and Graves' disease may be due to some disturbance of the co-ordination between these glandular systems. The thymus gland is usually {501} persistent in these cases and this must represent something in the affection and at one time the use of thymus substance for therapeutic purposes seemed to confirm this idea. The parathyroids have also been called into question and their use in therapeusis seems to justify this to some extent, though probably we know too little about them to be able to say anything definite in the matter. Even though the affection may be due directly to hypersecretion of the thyroid, it is possible that the mental and nervous state may be closely concerned in the etiology. Some patients have had an enlarged thyroid for years, without any symptoms of Graves' disease. Then during a time of stress and worry or anxiety and responsibility symptoms of the affection develop. The circulation of the thyroid is under the control of the cervical sympathetic. It is possible that this may be affected by states of mind to such an extent as to cause an increase of the circulation in the thyroid and as a consequence more of the thyroid secretion may get into the blood stream and produce its effect. Under these circumstances anything that would allay the excited mental condition and thus neutralize the unfavorable effect of the cervical sympathetic would cure or at least relieve Graves' disease. The affection is about five times as frequent among women as it is among men. This has sometimes been attributed to the fact that there seems to be some more or less direct correlation between the sex organs in women and the ductless gland systems. It has often been pointed out that the thyroid is likely to be engorged at the time of menstruation and, indeed, there are those who have attributed some of the symptoms of tremulousness, irritability, and tiredness at this time to over-functioning of the gland. In women who have borne a child the thyroid is usually somewhat enlarged. Good authorities in obstetrics have insisted that they could pick out of a group of women in evening dress, those who had borne children, from the appearance of their necks. Probably this is an exaggeration, but there is no doubt that the thyroid is intimately related to the genital functions in women. It has been said that a direct connection could be traced between disappointments in love or in sexual matters and the development of Graves' disease. To put much stress on this would easily lead to mistaken conclusions, though it represents a principle that should be recalled in certain cases of the affection. The frequency with which slighter disturbances of the thyroid occur in connection with the common genital incidents of female life and their comparative insignificance for health or strength, should make for the holding of a not too serious prognosis in the affection. Symptomatology.--There are four cardinal symptoms of the disease: rapid heart action, tremor, enlargement of the thyroid, and exophthalmos. At least two of these are largely dependent on mental influences. There are certain accompanying symptoms that are of importance and supposed to be connected directly with the disease, though oftener they can be traced to the influence of the state of the patient's mind upon the organism. Emaciation is common. It is due to the fact that the appetite is likely to be seriously disturbed by anxiety and solicitude. Anemia develops as a consequence and there may be slight fever which is sometimes inanition fever. Attacks of vomiting and diarrhea occur intermittently and sometimes there is constipation. The disturbance of eating consequent upon the affections seems largely {502} responsible for these. The disturbance of the vascular system gives rise to flashes of heat and cold and often to profuse perspiration. Certain of the symptoms of the menopause can be compared rather strikingly with those of Graves' disease and have been attributed to the disturbance of the external secretion of the ovaries which are now known to act as ductless glands as well as genital organs. With the exception of the enlargement of the thyroid and the exophthalmos, all of the symptoms of Graves' disease are of a kind that can be produced in states of excitement with nothing more present than a functional neurotic condition. It is true that the tremor is characteristic and differs from that of hysterical patients, being finer and at the rate of a little more than eight to the second. The rapid heart action, however, and the disturbance of the general circulation which causes flushing and pruritus and the sense of nervousness, as if the patients were in a constant state of fright, are always characteristically neurotic. The changes in disposition, often in the line of irritability, sometimes with severe mental depression, seem in many cases to be only a mental reaction to the patient's solicitude. The weakness of the limbs which sometimes amounts to a giving away of the legs, is connected with the tremor, but seems to be neurotic rather than of any more serious character. In spite of all our study of the affection its place among the neuroses must still be reserved for it, at least as regards many cases, and its treatment must be conducted with that idea in mind. Diagnosis.--The disease is easy to recognize when fully developed. At the beginning of cases, however, and in certain abortive types of the affection which the French have called _formes frustes_, the diagnosis may be difficult. Usually the first symptom is tremor and this of itself will often serve, especially in association with general symptoms of nervousness, to make the diagnosis. Tremor with tachycardia puts the case beyond doubt, as a rule, though of course it must not be forgotten that hysteria may simulate rather closely this much of the disease. The abortive types of the affection are important because they masquerade as forms of psychoneurosis, hysteria, and the like, though the patients are not suggestible, have very definite, not variable, symptoms and get better and worse according to the variations in the underlying affection. Occasionally they seem to be associated with certain other forms of neurotic conditions, especially those with vascular disturbances. There may be tinglings in the ends of the fingers, occasionally with suffusion, erythromelalgia--Weir Mitchell's disease--and even a tendency to the white "dead fingers" as the French call them, of Raynaud's disease. It seems not unlikely that further study will show that many of these affections involving disturbances of the vasomotor system are connected in some special way. Prognosis in Young Patients.--Some of the cases, especially in young people, are likely to seem quite discouraging and apparently to justify even a serious operation. I have in mind a young woman seen some fifteen years ago when she was about seventeen. The prominence of the eyes, the enlargement of the thyroid, the tremor and the rapid heart were all marked. The symptoms had been growing worse for over a year and the outlook was serious. Ten years later I saw her in another city in perfectly normal health, married and happy and the mother of two healthy children. The only trace {503} apparently of the disturbance of the thyroid to be noted in the family was that her children got their teeth very late, her first child, a boy, not cutting his first tooth until after he was fifteen months old. In every other way, however, the boy was perfectly well, rugged and strong, having passed through his summers without any serious disturbance and not being a particularly nervous or excitable child. Such complete relief from symptoms after the condition had been so grave would ordinarily have seemed quite out of the question. It emphasizes the fact that for Graves' disease as it occurs among young growing people, where perhaps the thyroid does not grow in proper proportion to the rest of the body, but for some reason overgrows, the prognosis of the case may seem to be much worse than it really is. Treatment.--The story of the various methods of treatment that have been reported as successful for Graves' disease serve to show very well how much the affection must depend upon psychic and neurotic conditions, for most of them have been positive in action at the beginning when their suggestive influence was strong, and quite inert after they had lost their novelty and their power to influence the mind. Sometimes even slight operations as on the nose, the removal of polyps, or of a spur on the septum, or an enlarged turbinate, have been found to bring relief of the symptoms of Graves' disease even in marked cases. Operations upon the tonsils have had a like effect and even shortening of the uvula has been reported as curative. A generation ago applications of iodin to the goiter were reported to have good effects. In lancing the goiter, sometimes evidently a cyst was punctured, but sometimes the lance was only followed by a slight issue of blood, yet the affection was favorably modified. More serious operations have followed by complete relief of symptoms for a time, though relapses are not infrequent and occasionally the patient was not relieved, though apparently all the conditions present were similar to those of other patients in whom the operation produced excellent results. The medical treatment of Graves' disease demonstrates interestingly the power of suggestion. About fifteen years ago a distinguished English observer announced that he was getting good results in the treatment of Graves' disease by the administration of thyroid substance. At that time our present theories with regard to hyperthyroidization as the etiology of the affection had not been formulated, though some vague connection between the thyroid secretion and the symptoms had been accepted. A number of patients were improved by taking thyroid. Other observers found, however, that not only were their patients not improved, but they seemed to be worse as the result of the thyroid feeding. The English physician therefore was asked to say exactly how he obtained his material and prepared it for his patients. Organo-therapy was then new and it was found that the orders given to the butcher for thyroid had been filled by him according to the directions by furnishing portions of a large gland situated in the neck of the calf. This was the thymus, and not the thyroid. Thymus was then deliberately used for a while and there were some reported good successes while the treatment was new and strongly suggestive. After a time it proved to be of no avail. A number of biological remedies were tried after this. Personally, after having made some studies of the parathyroids while in Virchow's laboratory, I resolved to try material from those glands. The first two patients to whom {504} the material was given, with a careful explanation of the theory on which it was administered, proceeded to obtain relief from their symptoms and an intermission in their disease. Just as soon as I purposely omitted to explain to patients how much might be expected from this new remedy and failed to make suggestions founded on the parathyroids, no improvement was noted. In the first two cases this had been more or less necessary in order to determine whether the patients could stand the doses suggested, which began very low and were gradually increased. The material seemed to have no ill effects, however, and a definite dosage could be used without the necessity of taking patients into one's confidence. A number of serums of one kind or another were reported as beneficial for Graves' disease. It was admitted that they did not benefit all the cases, but that in certain cases they did much good. Practically all of these were strikingly more efficient in their discoverers' hands than when used by anyone else. Thyroids were removed from animals and after some time serum from these animals, supposed to be of lower thyroid content, was injected into human beings with the idea of reducing the hyperthyroidization or perhaps neutralizing it by some substance present in the serum. One very interesting observation on most of these cases deserves remark. The animals deprived of their thyroids, such as goats and sheep, lived on absolutely unhurt by the operation, and as one experimenter expressly noted, sold for more money after being kept for a year under observation than they had cost him before dethyroidization. Most of our biological remedies for Graves' disease then are strongly reminiscent of the therapy of the affection in older times. It was particularly for Graves' disease, or at least for nervous symptoms closely resembling Graves' disease--those of fright, nervousness, irritability and tremor--that various more or less terrifying procedures and particularly deterrent substances were employed in medicine. These patients, for instance, were cured by the touch of a hanged criminal, and particularly by the touch of their goiter to the mark on his neck. It was especially for them that _Usnea_, the moss gathered from the skull of a criminal who had been hanged, was of benefit when administered internally. Mummy as a remedial substance remained in common use until well on into the latter half of the eighteenth century in England. In older times a dead snake wrapped around the neck was said to be an excellent remedy for goiter and especially those cases of goiter that caused symptoms of fright and nervousness. Evidently anything that produces a strong effect upon the patient's mind may prove helpful. Perhaps the suggestion enables the mind to control the cervical sympathetic and by that means the circulation in the thyroid gland, thus lessening the amount of blood that flows through and therefore the amount of secretion that is carried out. There is no doubt but that the sympathetic is largely under the influence of the emotions and that through it very important effects may be worked out in various structures. There seems no other possible explanation for the uniformly reported success of remedies when their suggestive power is strong and their failure quite as invariably later even in the same cases. _Operations_.--In recent years operations for the removal of portions of the enlarged thyroid have become popular and some very successful results have been reported. Those of us who know how easy it is to influence the minds of {505} patients in Graves' disease favorably hesitate as yet to pronounce definitely with regard to the indication for operation except under such conditions of pressure in the neck or projection of the eyeballs as may lead to serious symptoms. Not all the operators have been as successful as some who made a specialty of the affection. I have personal information which shows a number of unsuccessful cases after operation and the records of conservative surgeons as published indicate this. Unfortunately, a great many cases have been reported within a few months as cured; if they were comparatively without symptoms, surgical intervention is considered to have been eminently successful. For, be it noted, very few are entirely without symptoms, even after operation. Dr. William H. Thompson in his book on "Graves' Disease" points out that even so good an operator and so thoroughly conservative a surgeon as Kocher reports cases of Graves' disease as cured, which are still exhibiting symptoms that would make the medical clinician hesitate to agree with him and, indeed, rather lead him to expect that under the stress of worry and excitement there may be redevelopment of the symptoms. As the number of cases operated upon has increased there has been a growing feeling that relapses might be expected in certain cases even after removal of large portions of the thyroid gland. The fact of the matter is that we do not understand as yet what is the underlying pathological significance of the symptoms grouped under the term Graves' disease. When there are severe symptoms, as extreme exophthalmos, greatly enlarged thyroid pressing upon the important neck structures, or serious disturbance of nutrition, an operation is always needed; but as yet we cannot be sure that it will produce even complete or lasting relief. Many patients have been greatly benefited by operation, some of them perhaps permanently, but we need more of the after-history of these patients covering a long period of time, to be sure that the results flow entirely from the operation. There was a time when operations were reported as doing quite as much good for epilepsy as they are now for Graves' disease. As we have pointed out, a number of operative procedures that had nothing to do with the underlying basic pathology of the disease have proved the occasion for considerable improvement or sometimes what might be called a cure for a prolonged period. We can be sure, as a rule, that patients will be benefited immediately after operations. The rest, with care, the strong suggestion, the aroused feeling of expectancy, the confidence in the surgeon, all this would do much of itself. It remains to be seen how much more than this the operation does. _General Condition_.--The treatment of patients suffering from Graves' disease consists largely in having them take up some occupation that, while reasonably absorbing, does not make too great a demand upon them. Often when they complain most of their symptoms they are below normal weight and the first indication is to have them brought back to it. I have seen such cases over and over again almost entirely without symptoms when they were up to normal weight and with a good many symptoms when they were below normal. It would be easy to theorize as to why this is so, but the observation is the most important consideration for practical purposes, and we are not yet in possession of enough scientific knowledge with regard to the thyroid or {506} its possible connection with other organs that have an internal secretion, to be able to say anything definite about it. After weight and nutrition the most important indication is sleep. It is impossible for patients to get along with less than eight or nine hours of sleep. Most of them are much better if they have nine or ten every night. Late hours are particularly prejudicial to them. They are tired if they have been on their feet all day and they should be encouraged to take more sleep than others. Sleep is one of the most important considerations for sufferers from the abortive forms of Graves' disease and they must be encouraged to take it in the quantity that they need. This can only be decided by their feeling. _Diversion of Mind_.--Much more than other nervous people these patients need encouragement and require diversion of mind. They are prone to be discouraged, rather tired, and easily tempt themselves into a routine in which there is little recreation and no diversion. For them more than for most other patients it is necessary to prescribe that twice every week they shall have some engagement different from their ordinary routine to which they look forward for several days. This looking forward to a break in the routine does much to make life more livable for them and must be encouraged in every way. As to what the diversion is to be must depend entirely on the character of the individual. Some find complete diversion of mind in the theater or even in vaudeville. Others are bored by this after a while and need other recreations. I have known people who were bored by the theater find an evening a week spent in helping a poor person or an afternoon devoted to a visit to a hospital ward or to an ailing friend an excellent diversion. Some of those who do not care for the theater like music and are helped by it. As a rule, however, one must be careful about the indulgence of music for neurotic people since it seems to exert a serious emotional strain on many of them and as the phrase goes "takes a good deal out of them." This is particularly true for younger people who have a passion for music. Older people may be trusted more in this matter and the attendance on concert and opera, which is looked upon as a social duty by some, giving them an opportunity to greet friends and to display their gowns and jewels, is a harmless diversion of mind. _Mental Treatment_.--Graves' disease is, then, as we have said, especially likely to be influenced by the patient's state of mind. Nothing disturbs patients more than the declaration sometimes made by physicians that their condition is incurable or that they will have to doctor for it for many years. This must be avoided because our present knowledge does not justify any such positive declarations. Most cases of Graves' disease, while not particularly amenable to treatment by specific drugs, are very much improved if the patient's general health is brought up to the best standard and if all sources of worry and emotion are eliminated, as far as possible. Nothing is more serious for them, however, than the suggestion that they will not get well. Probably no one has ever seen a mild case of Graves' disease that did not improve so much as to be practically well after the lapse of some time. Recurrences take place, but if all sources of worry and irritation of the digestive tract and over-tiredness are removed, then patients will stay free from their symptoms for surprisingly long periods. Old people do not have these {507} favorable remissions so much as the young, but under twenty there can be, as a rule, definite promise of decided improvement and sometimes of results that seem like complete cure. For patients under thirty there is every reason to think that if they are in a run-down condition when the disease is first noted remissions of symptoms can be looked for lasting for long periods, during which they will be comparatively well. _Diet Suggestions_.--The changes in diet necessary to bring improvement in Graves' disease are different for individual patients. Prof. Mendel, in Berlin, found in his extensive experience that meat does not seem to be disposed of well by these patients and acts somewhat as an irritant. He reduces the meat taken and usually allows it at but one meal. If patients get on well as vegetarians, meat is gradually eliminated from their diet. On the other hand, there are patients who seem to develop Graves' disease during a vegetarian diet. Very often it will be found that there is an intermittent constipation and diarrhea in these cases, and that the bowels will act much better if a certain amount of meat is given, and then the symptoms of Graves' disease remit, as a rule. As in most of the major neuroses, as is known so well in epilepsy, any irritative condition of the digestive tract will surely revive neurotic manifestations and make many of the major neuroses much worse than they were before. {508} SECTION XV _ORGANIC NERVOUS DISEASES_ CHAPTER I PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES Since we know that the basis of many nervous diseases is an obliteration of certain cells of the brain or of the spinal cord, or certain tracts of the central nervous system through which impulses must pass if they are to be effective as motion, sensation or function in some other form, we realize that we cannot recreate these portions of highly organized tissue and that therefore organic nervous diseases are beyond the action of any remedies we now know or may even hope to discover. The development of pathology has shown us that once there has been serious nephritis or cirrhosis of the liver certain portions of the glands are destroyed and therefore there cannot be any question of cure. There is no possibility of redintegration of destroyed tissues when they are of highly organized character, and so the patient will always be maimed. One might as well talk of causing an amputated finger to grow again as talk of curing diseases that involve destruction of specialized cells. When this first dawned on modern medicine as the result of the careful study of pathology a period of therapeutic nihilism developed during which physicians trained in the pathological schools were prone to distrust drugs entirely, or at least to a very great degree. The effect of this wave of nihilism has not entirely disappeared in our time, though we have learned that even where serious damage to an organ has been done by disease we may still hope to compensate for defect of tissue by stimulation of other organs and to replace its function by certain physiological remedies or biological products; and if we can do nothing more, we can at least alleviate the symptoms which develop as a consequence of the organic affection. Nature's Compensation.--Physicians are prone to forget nature's wonderful powers of compensation. Apparently even some regeneration may take place in diseased organs of highly organized type if the patient's general condition is kept up to its highest point of nutritive efficiency. How far this may go we do not know, but observations show some marvelous examples of unexpected regeneration. These counteracting processes can be stimulated sometimes by drugs, but oftener they can be best brought into play by keeping the patient in just as good condition of body and favorable condition of mind as possible for a prolonged period, so that nature accustoms herself to the defect and her powers of compensation have full play. {509} Unfavorable Suggestion.--What is true of organic diseases of all kinds is especially true of organic nervous diseases, and in spite of the fact that most of these are essentially incurable, so much can be done for patients that their condition is made more tolerable and indeed some of them improved to such an extent that they consider themselves quite relieved of their organic affection. One of the most serious burdens that the patient laboring under an organic nervous disease has to suffer is the consciousness drummed into him by successive physicians, by his reading, and by every possible means of suggestion, that his malady is incurable. This makes every symptom as severe in its effects as it can possibly be. Hope does not buoy up and discouragement weighs down every effort of the organism to compensate for the serious defect under which it is laboring. Nothing can be done for the disease itself, but much can be done for the patient. Many of the symptoms from which the patient suffers most are really due to his own discouragement, to that sluggish condition which develops in his body as a consequence of his lack of hope, to the absence of exercise and of air and of diversion of mind consequent upon the gloom that settles over him when he is told that his condition is incurable. _Adventitious Symptoms_.--If the adventitious symptoms that are always present in cases of organic nervous disease are eliminated, if the conditions which develop from the unhygienic condition in which the patient lives because of his discouragement and retirement are removed, as a rule he feels so much better that it is hard to persuade him that some change has not come in his underlying nervous disease and that a process of cure is not at work. It is because of this that irregular practitioners so often succeed in apparently doing much more for these patients than the regular physician. The irregular does not insist on the incurability of the disease, but, on the contrary, he promises a cure. He then proceeds to relieve many bothersome symptoms that are quite extraneous to the underlying disease, but thus makes the patient ever so much more comfortable than before, gives a cheerful air to his life for a time, makes him sleep better as a consequence and it is not surprising that the patient thinks that his disease has been bettered, if not cured. Suggestive Prophylaxis.--While we are optimistic just as far as possible since genuine nervous disease has declared itself, it must not be forgotten that we can by suggestion and warning often prevent or delay the development of nervous degenerations. This, too, is psychotherapy and must be employed wherever it seems advisable. Post-syphilitic nervous conditions of so many kinds are likely to develop that it is important to warn the patients who are sufferers from this disease from taking up the more strenuous forms of existence. This may seem an exaggerated view of the condition, but it is amply justified by the results of the opposite rule of life in almost any physician's experience in city practice. A man who has had syphilis must be warned of the danger, one may almost say likelihood, if he takes up any of the professions in which there is much mental strain and nervous worry, that he will almost surely not live out the normal span of life without some serious nervous incident. Locomotor ataxia, and, above all, general paralysis develop, as a rule, in men who, having had syphilis, have some occupation in life that calls for considerable mental strenuosity, and involves excitement and worry. Actors, brokers, soldiers and sailors, speculators of all kinds, race-track gamblers, these are the classes from {510} which victims of paresis and locomotor ataxia are particularly recruited. People who have suffered from syphilis and who live the ordinary unemotional life of a teacher, or a merchant, or a writer, do not, as a rule, develop the postsyphilitic and parasyphilitic conditions. Precocious apoplexy is especially likely to occur in patients who have had syphilis and who have then spent themselves at very hard work. I doubt if hard work alone, without some such antecedent condition, ever produces this result. Of course, it is not alone syphilis, but other serious conditions which affect the nervous system that ought to be guarded against in this same way. If there has ever been any affection of the kidneys, as a complication, for instance, of scarlet fever, then it has always seemed to me to be the duty of the family physician to warn such patients that their kidneys are more prone than those who have not suffered from such an incident to break down under any severe strain that may be put upon them by worry, especially worry following a period of strenuous work. In these cases the affection of the kidneys nearly always makes itself felt in the nervous system, and especially in the brain, and so this warning has a proper place here. Where there has been severe cerebro-spinal meningitis this warning seems also to be needful, though here our records have not been kept with sufficient care to enable us to speak positively of the necessity for the warning. Treatment.--It is important to remember that as physicians we do not treat disease but patients. We _care_ for patients, that is the real etymological significance of the Latin _curare_, we do not cure diseases in the modern sense that has come to be given to that term, of completely removing the _materies morbi_ and setting the patient on his feet once more just as well as he was before his illness. _Relieving Incurable Disease_.--A new cure for locomotor ataxia, for instance, is announced every now and then, and the evidence for its beneficial action is the testimony of patients who have been relieved of many symptoms that they thought connected directly with their spinal affection. All sorts of remedies have been employed with announced success. One man builds a particular kind of shoe for them and has a number of witnesses to his skill in curing them. Another does some slight operation on their nose or their throat or their urethra and straightway the patient feels so much better that he talks confidently about being cured. All the characteristic symptoms of the affection remain. Their knee-jerks are gone, their pupils do not react normally, they have some incoordination in their walk, but a number of other symptoms have disappeared and their walk is probably much improved because of their confidence and a certain amount of practice that they have gone through. The new hope born of confident assurance that they could be relieved gives them an appetite, makes their digestion better. This lessens the sluggishness of their bowels, gives them confidence to get out and see their friends, life takes on a new hope, they sleep better and it is no wonder they talk of having been helped or even cured. There is a definite relation between the nervous affection in these cases and many visceral symptoms. There is no doubt, for instance, that certain cases of intractable dyspepsia are associated with tabes and that in nearly the same way obstinate constipation frequently develops. Notwithstanding the connection of these symptoms with an incurable condition of the spinal cord {511} that is no reason for thinking that they cannot be relieved even though no improvement of the spinal-cord lesions is expected. Frequently, indeed, gastric dyspepsia is due more to worry over discomfort somewhere in the stomach region than to any real disturbance of the digestive functions. It may then be considerably ameliorated simply by the assurance that the trouble is local and is localized outside of the stomach itself, though there may be some sympathetic irritation of the gastric nerve supply. Probably Dr. Head and those who have studied reflexes so enthusiastically would not agree with this explanation of the relief of the gastric symptoms in some of the cases they have described, as due rather to suggestion than to the local treatment, and, as a matter of fact, we are not quite sure which factor may be the more important. Counter-irritation probably plays quite an important role in the relief of discomfort, but I am sure that the suggestive influence of acute sensory feelings at the surface produced by counter-irritation serves to divert the mind from the duller ache or the functional disturbance below. However, Dr. Head's paragraph should be given in his own words, for it furnishes a scientific basis for one aspect of these cases. Throughout the study of cases of nervous diseases, evidence of the relation between pathological condition of certain viscera and sensory disturbances in the superficial structures of the body is constantly manifested. For instance, a man with caries of the spine suffered from a girdle sensation round the area of the eighth dorsal segment. At the same time he was greatly troubled by flatulent dyspepsia which was untouched by drugs. It was, however, greatly relieved by counter-irritation applied to the maximum tender point of the eighth dorsal area in the eighth space and mid-axillary line. _Optimistic Suggestions_.--Our most prominent neurologists have in recent years insisted on the necessity for encouraging patients and for not permitting them to brood upon the worst side of what is to be expected from their ailment. Patients are entirely too prone to read up about their disease and the worst symptoms of the extreme cases impress their minds and are constantly recurring as suggestions of possible ills to come. Prof. Oppenheim in his "Letters to Nervous Patients" states in a striking way the optimistic view that it always seems advisable to give a patient in the initial stages of a serious, incurable or even progressive nervous disease. That letter is worth quoting: I cannot conceal from you the fact, which you have already ascertained from other sources, that you show the premonitory symptoms of a disease of the spinal cord. This admission is not, however, as you fear, synonymous with the sentence "the beginning of the end." There is no reason for you to despair. We doctors regard and welcome it as a marked advance in our scientific knowledge that we are now in a position to diagnose a nervous disease of this kind in its first commencement. This is undoubtedly a great gain for the patient, as on account of this knowledge a judicious, experienced physician may, at least in many cases, by the timely regulation of the mode of life and the prescription of certain remedies, arrest the progress of the disease or retard its development. This advice may, however, and should as a general rule, be given without the patient himself being made aware of the diagnosis, for the ideas as to the nature of this disease which prevail in lay circles, and indeed among many doctors of the old school, arise from the knowledge of the disease in its advanced and fully established form, since it was only in this completely developed stage that it was recognized. Then, indeed, its very noticeable symptoms were obvious even to the uninitiated. This picture, sad enough indeed in itself, was rendered still gloomier by {512} the misery and despair which popular fancy has associated with the conception of locomotor ataxia. _Arteriosclerosis_.--Even with regard to so serious a disease and, of course, absolutely fatal in its progress as arteriosclerosis, it must not be forgotten that much can be done for the patients and especially for the nervous symptoms that develop in connection with the condition. For the progressive hardening of the arteries on which the nerve symptoms depend absolutely nothing can be done. A man is as old as his arteries, and we cannot bring back the years even though the patient has become prematurely old. For the symptoms so frequently seen in connection with arteriosclerosis, the paresthesia, the burnings, the numbness, the pruritus, the pains around joints and the difficulties in connection with them, even for the intermittent claudication which develops, much can be done. Above all, the patient must not be allowed to cherish the notion that his disease is not only incurable, but that nothing can be done for it. It is inevitable and progressive, but then according to one definition, life is a progressive disease and every day brings us nearer death. "Life is a dangerous thing at best," as an American humorist once said, "and very few of us get out of it alive." These patients can be relieved of many physical symptoms, they can be encouraged, their attention can be diverted from their symptoms, and it is concentration of mind on them that often makes them intolerable, while occupation with something, especially if it is interesting, will often prove an efficient remedy for the discomforts complained of. Old people who have no interests, who have retired from business, who did not have the opportunity when young to acquire tastes in art and literature, above all, those who have no interests in children, no grandchildren nor close relatives near them, are likely to become centered on their ills in the midst of their arteriosclerosis, and this more than the advancing degeneration of arteries itself is at the root of their symptoms. The ideal old age is that which is passed in the midst of younger people, with an occasional happy hour during the day with children in whom one is deeply interested. This is the best psychotherapeutic factor that we have. Prof. Oppenheim has given the optimistic side of arteriosclerosis so suggestively that most patients suffering in this way should have the opportunity to read it. It occurs in his "Letters to Nervous Patients": An eminent physician for whom I have much esteem has told you that your troubles, especially your vertigo, are caused by calcification of the arteries. You, sir, heard in this your death sentence, and since then the encyclopedia has revealed to you all the sufferings and terrors with which you may expect to be overtaken. I would, however, explain to you, as the result of the most careful examination and the most absolute conviction on my part, that your anxiety is unfounded. Since you have a certain amount of information and scientific knowledge, I may speak to you upon this matter almost as a colleague. One is certainly justified, when a man of your age complains of vertigo, in suspecting calcification of the arteries to be the cause of the trouble, since it constitutes the common senile change, and vertigo forms one of its most frequent symptoms. But--apart from the fact that in senile calcification of the vessels this vertigo is frequently a temporary and not always a serious sign--one is by no means justified in assuming that the appearance of this symptom in later life is in itself, and without further evidence, the sign of such a cause. This is an error which in my experience is {513} far too frequently made, to the detriment of the patient. It is first of all essential to closely examine and analyze the symptom in itself. . . . Two years ago, after having overloaded your stomach, you had a real attack of vertigo, which was repeated several times during the day, until, by vomiting and diarrhea, the contents of your stomach were evacuated. Since that time the fear of vertigo has overpowered you. In my experience it is neither new nor uncommon to find that a man who has shown his intrepidity and his contempt of death on many a battlefield, who is a hero in war, may be overcome by some dread of illness, by some anxiety, or even by some pain, and may be distressed by it in a way that is in sharp contrast to his whole personality. Your remembrance of that vertigo is so lively that the mere idea of it suffices to reawaken the symptom, or at least an imitation of it which very nearly approaches the reality. That this idea is present in your case is quite certain from the consideration of your symptoms. You admit that you almost never have vertigo at home, but as soon as you leave the house, and especially if you find yourself alone in the street far from home, the remembrance of the vertigo comes over you, puts you into a state of anxiety, and is followed by a sensation of tottering and swaying, so that you have to stand still; and at last it has gone so far that you no longer venture to go out alone. And so the hero of X sits like a timid woman in his arm chair, making life bitter for himself and for those around him. Even were I to find that signs of arterial calcification were present, I should still be satisfied that your vertigo is not due to this cause, but that it is a vertigo of recollection and of fear. CHAPTER II CEREBRAL APOPLEXY Cerebral apoplexy is an extremely serious organic disease that seems surely to be an affection for which psychotherapeutics can mean little or nothing. When an artery has burst in the brain and blood is either actually flowing out or has flowed out in damaging quantities into the delicate brain tissues, seriously injuring and perhaps destroying some of them forever, no amount of mental assurance will do any good for the organic lesions that have been produced. All that can be hoped is that the hemorrhage will not prove fatal and that the powers of nature will be sufficient to deal with it, and though not able to cure it in the sense of restoring tissues to former conditions, will compensate for the lesion in some way and dispose of its products so effectually that but little interference will result with nerve functions within the skull. There is no pretence that by psychotherapy or any appeal to mental powers anything can be done for the underlying pathological process. And it may be frankly said that no remedy of any kind, physical or mental, will avail much, while some of those that have been suggested are just as likely to do harm as good. Position, with the head elevated and quiet of mind and body are the only remedial measures that promise definite help. Excitement greatly increases the danger. Reassurance does more than anything else to lessen blood pressure and lessen also the danger of a hemorrhage producing fatal effects. In nervous, excitable people the first stroke is often fatal. Occasionally the phlegmatic have three or more ruptures of brain arteries before death supervenes. Psychotherapy, then, has a definite role even at the time of the apoplexy. {514} The Mind Before and After.--Much can be accomplished for the patient by proper attention to his state of mind both before and after cerebral hemorrhage. There are many symptoms which point to the possible occurrence of the rupture of a cerebral artery, and older people are likely to know something about these and to dread them so much that to some extent they may by worrying precipitate the evil they fear. Many people, having read vaguely about apoplexy, having seen a case or two of it perhaps, and having heard of others, develop a dread of its occurrence in themselves that makes them miserable. Finally, the shock of a cerebral hemorrhage is very great and its after-effects likely to be very disturbing. It affects the whole personality and often makes a strong, vigorous, healthy man a decided hypochondriac. All of these associated mental states may be greatly benefitted by psychotherapy. A number of neurotic symptoms are always added to whatever manifestations of mind and the somatic system may develop as a consequence of the cerebral apoplexy, and these are treated more effectually by mental reassurance than in any other way. Besides, apoplexy confines people to the house who have often been vigorous and active before, and this confinement with deprivation of exercise and air and consequent disturbance of appetite and digestive functions, acts as a serious factor in the production of neurotic symptoms. Tears and hysterical manifestation are not uncommon, and for these psychotherapy is the most important remedial measure. In the period preceding true apoplexy there may be such symptoms as persistent headache with peculiar sensations in one hand. These sensations are variously described as creepy feelings or as of "pins and needles," and occasionally as if the fingers and sometimes the arm were asleep. The group of symptoms known as paresthesia are rather common as premonitory symptoms of cerebral apoplexy. When these are combined with headache patients often become seriously disturbed and begin to dread the occurrence of apoplexy. While these are premonitory symptoms of cerebral hemorrhage in those whose arteries are degenerated, patients must be made to understand that just because the fingers or hand or arm go to sleep occasionally, even though there may be complaint of headache, these are not indications of impending apoplexy unless other objective symptoms are present. Subjective symptoms alone can never mean much as regards organic disease. It is particularly neurotic individuals who are likely to exaggerate the significance of their subjective sensations, who are also prone to be so solicitous about apoplexy that they work themselves into a state of fear with regard to it. Even children have their hands go to sleep rather frequently, and at all ages if the arms or legs are placed in certain positions or under certain conditions of pressure, they are likely to develop that numbness which ends in the prickly "pins and needles" feeling that is spoken of as "going to sleep." Diagnosing Arterial Sclerosis.--Unless, then, some of the arteries at the periphery of the body show signs of such degeneration as to indicate advanced arteriosclerosis, any subjective symptoms, no matter how bothersome, must not be allowed to depress the patient. Usually they mean nothing at all, and would pass quite unnoticed but for the patients' nervousness about themselves. If the temporal arteries are not prominent and visibly thickened and tortuous, and this may be seen at a glance, the patient may be assured almost without more ado. If his radial arteries on careful observation show no signs {515} of degeneration, then it is extremely doubtful if there is sufficient arterial change in the brain to justify a fear of arterial rupture. In examining the radial artery it must not be forgotten that the pulse of nervous people, especially such as have exerted considerable mental control over themselves in order to come and see a physician about what they think is a serious condition, is likely to be of high tension. When the artery is rolled under the finger, then it may seem that there is some thickening in its walls, though it is only heightened blood pressure from emotion that causes the feeling. This high blood pressure may, of course, of itself be an indication of danger whenever there is heart or kidney disease, but it often occurs as a passing event in nervous patients whose vasomotor control is so capricious that arterial tension and blood pressure may change at very short intervals as the result of excitement. It may not be easy to obliterate the pulse in the usual way in many of these cases and as a consequence the illusion of a thickened artery may remain even when the vessel is quite normal. The important rule is to ascertain whether the artery is tortuous. Whenever there is thickening of the arterial wall the artery is lengthened as well as thickened. If the artery is not lengthened the degenerative changes in it are so slight, as a rule, as to be negligible. Indeed, the very beginning of arteriosclerosis may thus be diagnosed. When this cannot be found, patients may be completely reassured that their suggestive symptoms have no significance as regards any possibility of cerebral hemorrhage from the ordinary causes of advancing years and arterial degeneration. _Differentiation_.--Occasionally such paresthesiae as have been described especially when associated with headache, point to an intracranial growth, or to a developing syphilitic brain lesion, and these must be carefully eliminated, but they constitute quite separate problems which always present other accompanying symptoms that make diagnosis possible once a suspicion as to the nature of the lesion is aroused. Above all, these occur in much younger patients than are, as a rule, the subjects of cerebral apoplexy. Symptoms.--_Dreads--Dizziness_.--There are other symptoms of which people have heard as preliminary signs of brain hemorrhage which occasionally disturb them to a great degree and set up a set of dreads that may be difficult to banish. Probably the one that is spoken oftenest of is dizziness. There is no doubt that under certain circumstances this may be a symptom of impending cerebral hemorrhage, especially if it is accompanied by headache and by objective signs in the arteries, but dizziness by itself is not enough to justify any anxiety in even elderly people. If, when a man stoops over and then straightens up rapidly everything becomes black before him and he must immediately take hold of something to keep himself from falling, it is probable that a pathological condition of his cerebral arteries is present. This interferes with brain circulation and may have seriously impaired the elasticity of the arteries which is so necessary to overcome the rapid variations of the influence of gravity on the blood current when there are sudden changes of position. Fits of dizziness that come on immediately on rising in the morning, or that attack the patient when he sits up suddenly in bed may have the same serious significance. None of these signs are significant, however, unless there are, as we have said, objective signs in the arteries. {516} But dizziness may come from many other causes besides degeneration of arteries. A very common cause of it is the presence of gas in the stomach which interferes with the heart action mechanically and so disturbs the circulation. The column of blood to the head is more easily affected than the rest of the circulation because it must be pumped up directly against gravity when we are in a standing position, and so any, even a slight, interference with the heart action is felt at once in this portion of the body. Besides, the brain is extremely sensitive to changes of circulation and even a slight disturbance of the blood supply to it may cause dizziness. There occurs also undoubtedly a feeling of dizziness that is entirely subjective. The patient for some reason loses confidence in himself and has a feeling of dismay, as if he could not support himself. Such a patient may complain that when he comes down stairs, at the first step or two, particularly of a high stairs, he has the dread that he may pitch forward. Such people have never actually fallen, but they have to grasp the railing and they have a dread of some accident of this kind. This is, however, rather a form of akrophobia than a true dizziness. Prof. Oppenheim has dwelt on vertigo as a dread (see preceding chapter). _Vertigo_.--Besides, there are pathological conditions that cause dizziness yet have no connection at all with the dizziness that is a premonitory symptom of apoplexy. Menière's disease, for instance, even in its milder forms, causes at times a vertigo that is extremely annoying and that frequently gives rise to the fear that a serious brain lesion is either actually occurring or is impending. I have seen even comparatively young patients suffer so much from this dread that life became miserable to them and they were unable to do their work properly. A few words of explanation and reassurance literally work wonders for such patients. In one case the young woman assured me over and over again that my explanation meant a new lease of life for her. She still has occasional dizziness, but now she knows that it is due to her accompanying ear trouble and it does not worry her. _Motor Symptoms and Over-solicitude_.--Besides dizziness, there are other symptoms of which patients complain and which may indicate that an apoplexy is impending or may mean only that a patient is occupying himself too much with himself and his symptoms. Not infrequently when there is degeneration of arteries in the brain there will be slight weaknesses of the limbs or awkwardness in the use of them. Occasionally women will complain of the fact that they do not button dresses as they used to. Sometimes men will complain that they do not button their collar or their suspenders at the back with facility, or that they are awkward and grow fatigued easily in such strained positions. These symptoms may be indicative of some disturbance in the motor areas of the brain, but it must not be forgotten that all of these may be simulated by nervousness, especially if the person knows the meaning that is attached by doctors to these symptoms. In this matter particularly a little knowledge is a dangerous thing. We are only just getting a generation of trained nurses to the age when they are likely to suffer from dread of apoplexy and some of them are over-anxious patients because of their knowledge without the balance of complete practical experience with the meaning of such symptoms. Doctors themselves are prone to be disturbed by such thinking more than {517} almost anyone else. The delusion of thinking apoplexy is not at all uncommon in elderly physicians. In men it is important to insist that objective symptoms are the only details of real value and that subjective feelings are utterly illusory. If this cannot be brought home to them they make themselves extremely miserable and may even help to precipitate through worry the fatal complications they dread. Prophylaxis.--There is no doubt but that heredity plays an important rôle in apoplexy. In certain families most of the members terminate existence by rupture of an artery in the brain, sometimes at comparatively early ages. Apparently the resistive vitality of their arteries is only sufficient to enable them to maintain themselves for a limited length of time against blood pressure. They are destined to have arterial degeneration that will predispose to arterial rupture sometime before they are sixty. Father, grandfather and great-grandfather had their apoplexies from fifty-five to sixty-five and the son must realize that he probably will go the same way. Even the delay of a year or two is important. Anything that will save the wear and tear of existence may bring about such a delay and it is not by drugs, nor even by dietetic precautions, so much as by attention to the patient's state of mind that this decided benefit can be best secured. _Over-indulgence_.--People with such an unfortunate heritage should be made to understand reasonably early in life that they must save themselves from as much arterial wear and tear as possible. There are certain occupations involving intense emotion and excitement that are barred to them if they want to live out their lives, even to the extent usual in the family. There are three causes that weaken arterial walls. When the question of causation of aneurism is discussed it is usually said that it is especially the devotees of three pagan deities--Venus, Bacchus and Vulcan--who suffer from this form of arterial trouble. Just this same class suffer particularly from the tendency to early arterial rupture in the brain. Under the head of devotees of Vulcan, the hard workers, must now also be placed the advocates and exemplifiers of the strenuous life, who are perpetually doing, though often it is hard to see what they accomplish; the money-getters, who are really overworking as much as the forced laborers of olden time. People with an apoplectic heredity should not take up such professions as that of the actor, the broker, the speculator of any kind, the lawyer absorbed by the strain of trial work, perhaps not even that of the surgeon. Physicians generally are not long lived because of the irregularity of their hours of eating and sleeping and the responsibility of their professional life. Many men will not be guided by such considerations and insist on living their lives in their own way in spite of the possibility of the family inheritance shortening their career in the late fifties. More than one has said that he would prefer to have the life of the salmon rather than that of the turtle. The strenuous life alone appeals to them. "Better fifty years of Europe than a cycle of Cathay." This would be an admirable response if what these men accomplished during their lives amounted to anything. Most of these who run out their existences in the midst of excitement, however, only do harm by adding to the swarm of speculators in life, or accomplish very little because of the intense {518} excitement under which they labor. It is the quiet lives, doing a few things and doing them well, outside of the strenuous current of the bustle of existence, that accomplish most for mankind. The others may attract attention for the moment, but they soon pass out, often having done rather harm than good. _Life-direction_.--It is perfectly possible for the physician to make this clear to a young man with a dangerous heredity and perhaps change the current of life so as to make it effective in simplicity and serious patient work. The young man will usually be quite impatient to think that anything thirty years ahead should be expected to influence his decision as to how or what he shall do with life, yet this motive added to others may help to get at least some of this and the next generation from wasting their lives in an over-strenuous existence that at most merely accumulates money, often accumulates it only in order to lose it, with consequent disappointment and worry, and frequently leaves no real accomplishment but only the problem of the disposal of accumulated wealth for future generations. Where large wealth is left to the succeeding generation there is usually little use to give any advice with regard to the possibility of early apoplexy, because excitements of other kinds than those of business, of the heart rather than the mind, are likely to wear out existence even before the time when the family life of arteries ordinarily, though precociously, runs itself out. Certain people have what is called the _apoplectic habitus_, that is, they are short in stature, rather stout, with short necks and florid complexions. It seems not unlikely that the mechanical arrangement within their bodies by which the distance from their heart to their brain is so much shorter than in ordinary persons is responsible for the tradition so generally accepted that there is a definite tendency in such people for apoplexy to occur at a comparatively early age. Such people should be warned gently but firmly of the danger that they incur if they subject themselves to a life of excitement or emotional stress or permit themselves to get into circumstances in which they will worry much. It may seem as though a warning of this kind would precipitate the worry of mind that it is meant to ameliorate, but in present-day publicity such people are likely to have heard of the meaning of their particular constitution of body and consequently worry about it, but usually after it is too late to do any good. In this matter, as in heart disease, the warning must come before there are any symptoms, or else must not be used at all. _Certain Abuses_.--In most of these cases definite warnings with regard to habits of life and indulgence in stimulants and narcotics should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin insist that for patients in whom there is any likelihood of the development of early apoplexy indulgence in alcoholic liquors is almost sure to be serious, but in addition to this generally accepted warning, both of them also insist that smoking has a tendency to produce serious, premature degeneration of arteries, especially in people who already have tendencies in that direction. Overeating and high living in general without moderate exercise causes a plethora of the circulation that must be avoided. On the other hand, violent exercise, running especially to catch trains or cars, haste in the ascent of stairs or hills, heavy lifting, straining at stool, and the like, are particularly prone to have serious consequences for such people. This warning is all the more needed because many a short, {519} stout man acquires the idea that gymnastic work and various exercises indoors may help him to reduce his weight and restore the activity of his earlier years. This is practically always a delusion and indoor gymnastic work is always of dubious value. What these people need is not more muscle and the wearing off of fat but more air and the burning of it off by increased oxidation. Such patients must be taught to lead tranquil lives without any of the excitement and strenuosity that, after all, accomplishes so little. The sacrifice when first suggested, appears too great a one to make, but after a few years patients instead of feeling that it was a sacrifice at all pronounce it to be a blessing in disguise and are proportionately grateful to their physician. Life for many of these people may be prolonged not for a few years of hustle-bustle, but for many years of good work in quiet and peace, without hurting others by competition, but helping many because there is time in their considerate lives to see something of the sorrow and suffering around them and to relieve it. _Change of Occupation_.--In the matter of prophylaxis it is particularly important to insist on the fact that when men have worked at hard manual labor when they are young and then, about middle life, have turned to intense intellectual labor, such as the management and administration of important affairs, they are a little more liable than are the general average of humanity to have an apoplectic seizure at sixty or a little later. Apparently inurement to a particular kind of labor when young makes for the capacity to stand it longer than would otherwise be the case. In this matter, however, the most important factor is heredity. Men who come from long-lived families are likely to live long--indeed far beyond the ordinary term of human life. Even in them, however, certain of these directions are helpful in securing the full measure of life. After the Stroke.--After a stroke of apoplexy when it becomes clear that nature is about to reassert her control over the circulation in the brain and dispose of the remains of the old hemorrhage, psychotherapeutics is more important than anything else that we have for the treatment of these patients. As a rule, they have been active, vigorous men who are stricken and who suffer more from doing nothing and waiting to get better than from any pain they have to undergo. They know that another stroke may come at any time. It is no wonder that introspection plays its part, that every feeling that they have becomes exaggerated in significance, that their appetite fails them, that their bowels become sluggish, that they do not sleep, or that after having fallen asleep they wake up and then for hours lie awake thinking. _Lack of Air and Exercise_.--As they usually have no exercise of any kind, do not get out into the air, and have very little diversion of mind, it is easy to understand that neurotic or hysterical symptoms develop, that they lose all confidence of recovery and make themselves even worse than they are by dwelling on their condition. The only way that this group of symptoms can be treated is by favorable suggestion, by encouragement, by mental reassurance and by occupation of mind. I have always felt that the condition of affairs which developed in a family immediately after the occurrence of an apoplexy usually makes a very unfavorable environment for the treatment of these cases. It is practically impossible for those who come to visit the patient or for the members of the {520} family for some time to wear anything but the resigned air that indicates that they fear the worst. _Sympathetic Care_.--After the stroke at once when survival is assured comes the question of the management of the patient. A devoted daughter seems to be able to do more for an apoplectic father than anyone else. Somehow her youth appeals to him sympathetically, and he has not that feeling of sadness mixed with a little envy that comes so readily to all men when they find themselves slipping out of life while their contemporaries and friends and relatives are left behind. It is as if the idea of his daughter being young and strong, even though he has lost vitality, docs not touch him poignantly because he has always expected that she should have health and strength after he was gone. On the other hand, a daughter is not always a good nurse for a mother. Just why, is hard to say. A hired nurse must take, as a rule, the place close to the mother which, in the case of the father, so naturally falls to the daughter. These ideas may be founded on too few cases to generalize very much about, but I have discussed them with many physicians, including some women physicians, and they agree with them, in general principle at least. _Trained Attendance_.--As a rule, then, the first thing that has to be done for a patient who has had apoplexy and who is beginning to recover, is to have trained attendants near him who talk professionally to him and reassure him and do not make him feel constantly the possibility of an approaching end. If his improvement has begun his family must not be allowed to bother him, his affairs should not be talked over and, as far as possible, some occupation of mind should be secured for him. He needs new interests at once. These must be gradually awakened and he must be made to feel as early as possible that though he may be more helpless than before and most of his ordinary occupation in life may be cut off, there are still many interests in life which he may thoroughly enjoy. I shall never forget hearing Thomas Dunn English, the dear old poet to whom in his earlier years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the University of Pennsylvania that he used to think that all the good things of life were somehow contained in its first eighty years, but that now since he had past his eightieth birthday (he was at the time in his eighty-third year) he was beginning to agree with Bismarck, who declared under similar circumstances that he had found many interests in the second eighty years of life. At the time English was quite blind, was almost completely deaf, had been seriously ill for several months, and had suffered a rather severe stroke some years before; and yet he made the best speech at the dinner that evening and had the youngest heart of us all--joyous, uplifting, encouraging, optimistic. _Outlook_.--Men who have been great workers are prone to think that a stroke of apoplexy means the end of all serious work. Of course, it means nothing of the kind for the majority of patients. Many men find not only enjoyment in life after their recovery from even a serious stroke, but also possibilities of accomplishment sometimes better than they had done before. It has even been known that men who had been occupying themselves with things scarcely worth while, with the mere accumulation of money without any purpose, were awakened to a sense of their responsibilities to life and to their fellowmen by a stroke and planned in the after years institutions or aids to {521} existing institutions that did much to make life more livable for others. Nothing makes a man face life in a better mood to do really effective service for mankind than the prospect of possibly soon having to go out of life. _Encouraging Examples_.--On the other hand, many men have been able in spite even of a severe stroke to go on after a time with the work they had been at before and, though feeling its effects, accomplish the best achievements of their lives. A typical example is the case of Pasteur, the great French bacteriologist, to whom we owe most of our modern preventive medicine and to whom Lord Lister frankly attributes the germ idea of the antiseptic theory. When little past fifty, Pasteur after years of hard work and worry suffered from a severe stroke of apoplexy followed by several of slighter character. It seemed absolutely the end of his labors. For more than a year he was able to do nothing. For all his after life he was seriously lame as a consequence of his stroke. In spite of this, which would seem to preclude the possibility of great intellectual work, Pasteur's most important discoveries were developed after this time and he continued for over twenty years to be the leader of biological science. Had he died at the age of fifty or given up his work we would scarcely know him for the great scientist that he afterwards proved. It is worth while to be able to tell the stories of such lives as examples to patients who are dispirited and downhearted after a stroke. Of course, men must be prevented from doing hard work or from worrying during the time immediately following the hemorrhage of the brain, and, indeed, for some months. Work and worry, though worry much more than work, might easily hasten a recurrence of the seizure. It has always seemed to me, however, that it is impossible to keep the human mind utterly unoccupied. Men must think about something during their waking hours, and if they have not some interests close at heart they worry about themselves. Of the two things, worry is much harder on the tissues, raises blood pressure more, disturbs the circulation of the brain to a greater degree than does work. Anything that a man will interest himself in, then, should be allowed to him, provided, of course, that he is kept from getting into the state of mind which precipitated the rupture of the artery in his brain. It is a change of mental occupation above all that is needed and this is secured by deliberate attempts to interest his mind in various ways and keep him from dwelling on himself and his ills. This injunction cannot be repeated too often. _Change of Mental Interest_.--I have already insisted in the chapter on Diversion of Mind that so far as we know at the present time different portions of the brain are occupied with different subjects in which we may interest ourselves. When a man by business worries, occupation with financial affairs, or with political troubles, has apparently worn out one portion of his brain, he may still use other portions to decided advantage. Hence the necessity for finding new interests for the apoplectic after their attack. The best interests for them are those associated in some way with their fellows, because these are accompanied by feelings of consolation, of encouragement, of desire to live and do good to others. These do more to take men out of their moodiness, their morbid introspection, and their self-centeredness, than anything else. With the help of a good nurse, herself of broad interests, this must become the main purpose of the physician's treatment. {522} _Misplaced Sympathy_.--After the first few days, when the shock is over, a strong, healthy man who has been suddenly taken down with apoplexy, then rendered helpless as a consequence of the lesion in his brain, rather resents the sympathy and, above all, the frequent expression of the feelings of his friends towards him. Time is needed for him to recover, there is no way of hastening it, he is already impatient at the delay and words of sympathy do him very little good and often add to his impatience. He is to be taken absolutely with professional calm, made to understand that time is the most important element in his cure, provided he will not worry and will have patience to wait and to help as far as he can. I nearly always feel that it is better for these patients to be away from home as soon as they can be moved with safety. This enables them to avoid without much difficulty what they are apt to consider the intrusive and obtrusive sympathy of friends. Especially is this true of business friends, themselves in good health, who come to offer their condolences. Their hysterical condition is largely influenced by the fact that they are indoors and have so little diversion of mind. Just as soon as possible they must get out of doors. Over and over again I have found that patients did not care to expose themselves to the inquisitive gaze of neighbors and preferred to stay in the house, though the outing would be of much benefit to them. Hence the necessity for getting them away from home, among people whom they can observe without attracting too much attention themselves and, above all, without being the subjects of such obtrusive pity as will disturb them. None of us likes to be pitied and least of all the strong, vigorous man who often has had nothing the matter with him all his life and is now suddenly stricken. It requires years of experience to enable one to take sympathy properly and without resenting it. _Outings and Human Interests_.--When patients care for carriage riding I have found that the city park is an excellent place for patients suffering from the effects of apoplexy, who require outdoor air and diversion of mind, yet without exercise or much exertion. The children in the park, if they play around, serve as a better diversion of mind than almost anything else for elderly people thus stricken, for they seem to renew their youth at the sight of the little ones. Grandchildren make the best possible consolers even when they seem to probe deep into old wounds by asking questions and by talking about death. The talk of death from young lips has not the same disturbing effect as from older people. The games of children interest the old once more, and if there is occasional music and the chance to see the passing throng of carriages and motor cars and the pleasure boats and all the rest there is refreshment and reinvigoration in it all that soon brings back to the patient deep, satisfactory, even dreamless uninterrupted sleep at night, and appetite and strength. At first there will usually be some objection to being thus treated as an invalid, but only a few days of experience are needed to convert even the most morbid to the idea that this outing will do them good. As a rule, friends must be warned not to spoil the effect of it by fearing lest the patient should be lonely and so go to the park to entertain him. If the drive, the lake and the children, as well as the passers-by, do not suffice to give the patient sufficient diversion of mind, the visits of friends will not have any favorable effect. As a rule, it is better for them to see the {523} patient at home and even that not too often unless they are of his immediate family. Where people are able to go away and, above all, where they can have some pleasant companionship, a seaside resort is an ideal place for those recovering from apoplexy. The long ride in a wheel-chair on the boardwalk at least several hours in the morning and afternoon soon acts marvelously. There is constant diversion of mind at any season of the year, for there are lots of people to be seen in all sorts of costumes and the shops and the shows and the passing throng all have their interests. Then the sea air is bracing and tempts to sleepfulness and just as soon as sleep improves courage comes back. I have known patients so hysterical that they were crying every day and that seemed to have given up all hope, improve so much in two weeks at Atlantic City that it seemed little short of marvelous. What is needed, however, is not a stay of a few weeks but of several months. Prognosis of Strokes.--While, of course, any single stroke may be fatal and no one can tell anything about the prognosis of a rupture of a brain artery, there are many favorable things that can be said to patients, and they are so prone to think of all the unfavorable things that this better side should be presented to them at once. The physician is tempted to present the worst side of the case lest it should be thought that he did not realize how serious the condition was. All the seriousness of it may be impressed upon friends, but the patient must be told all the possibilities of good. I have always felt that the tonic quality of hope was worth more in preventing further damage and in encouraging the beginning of repair than any drug that we have. If patients have been unconscious, just as soon as unconsciousness disappears, they should be told that very probably this is the beginning of recovery and that the great majority of people who have a stroke recover. The more rapidly the symptoms disappear the better is the ultimate prognosis. Many a man who has had a stroke has done years of good work afterwards and very few men who recover fail to accomplish something that is of supreme satisfaction to them. They have a new outlook on life as a consequence of the near vision of death. Those who have had one stroke usually die in a subsequent one, though, of course, some intermittent disease such as pneumonia or some organic complication may anticipate the second stroke. Those who have had two strokes and survive are often much worried by the old tradition that a third stroke is always fatal. I am reasonably sure that many old men have not survived their third stroke when they felt its premonitory symptoms and knew just what was coming from their previous experience, because they had given up hope on account of this old tradition. Ignorant people or those of the lower classes who have not heard this axiom often survive their third stroke and I have seen a man who had suffered from seven apoplectic seizures. Complications.--Occasionally a patient, especially if of the educated classes, may be much worried by the fact that while one side is distinctly lamed after his stroke, yet there is also a pronounced weakness on the other side of the body. This sometimes gives rise to the rather appalling thought that there was perhaps a simultaneous rupture on both sides of the brain. It needs to be explained to such patients that this slight weakness, sometimes quite distinct, however, on the side opposite that which is most affected is extremely {524} common. Ordinarily the rupture of an artery on one side of the brain causes a paralysis on the other side of the body. This paralysis or loss of control over muscular action is due to disturbance of the motor tracts of nerves through which muscular action is controlled and directed by the brain, and these normally cross to the other side on the way to the periphery. In nearly everyone the tracts remain uncrossed to some slight extent. In some so much of the pyramidal tract remains uncrossed that there may be decided weakness on the same side as the lesion in the brain. CHAPTER III LOCOMOTOR ATAXIA How much can be done for organic nervous disease by attention to the individual patient and by favorable suggestion is illustrated in locomotor ataxia. This is, of course, an absolutely incurable disease. We know definitely that certain tracts of nerves in the spinal cord are entirely obliterated and their functions can never be restored. Occasionally the disease gives rise to severe localized pains called crises, for which even our strongest anodyne remedies are of little avail. As a rule, the patient grows more and more helpless and though he may live for twenty or thirty years after the beginning of the disease, and usually dies from some intercurrent affection rather than from any direct effect of his disease, the condition is burdensome and the outlook is most unfavorable and depressing. It is for locomotor ataxia, however, that the irregular practitioners have succeeded, apparently, in working wonders. Some of them, indeed, have made quite a reputation for the cure of the disease. This was not because they did the impossible and cured genuine cases, but because individual patients can, in many cases, be so much improved by attention to particular symptoms, and so much can be done to make life more livable for them, that it is no wonder that so many of them are ready to proclaim that they have been cured, though only certain symptoms, are bettered and their underlying disease remains in essence unchanged. One thing that constantly happens in the progress of locomotor ataxia is a yielding of joint capsules and attachments so that there is more motion permitted in joints than is possible in the normal individual. As a consequence of this relaxation of tissues around the hip joint the leg may be stretched up along the trunk when the patient is lying down, the foot being placed over the shoulder almost as a gun is placed at carry-arms. Patients often walk with a distinct "back knee" because of the yielding of the tissues around the knee-joint. The ankle nearly always yields and a specially severe form of flat foot develops. This causes muscles to act at a disadvantage and produces great fatigue and even a painful muscular condition when the patient stands much on the feet. This form of flat foot is hopeless so far as cure is concerned, but it can be greatly relieved by the wearing of flat-foot braces or even, to a greater degree, by the wearing of specially fitted shoes. This does not seem much to do for a patient suffering from the serious organic nervous disease of locomotor ataxia, and yet a lot of patients for whom properly fitting shoes {525} were made, thought themselves so much improved and relieved by this simple measure that they allowed themselves to be persuaded that their locomotor ataxia was cured. In some cases, where the brunt of the disease was borne by the feet, this relief really did so much to afford the patients freedom from most symptoms of their affection that they thought themselves on the road to recovery. Value of Favorable Suggestion.--If once the idea of the awful hopelessness of their cases is removed from locomotor ataxia patients they will suggest their own betterment so powerfully that they easily persuade themselves that their affection is considerably improved. It is evident, then, that the regular physician must take advantage of this wonderful power for the relief of human suffering and depression that proves so helpful to the irregular. We cannot cure the tabes of the spinal cord. We cannot re-create the nerve tracts that have been obliterated. We realize that there is no use trying to do so any more than there would be in trying to make an amputated finger grow to its full size again. We can treat the patient, however. We can remove many symptoms that sometimes bother him more than those necessarily connected with his spinal affection. We can relieve annoyances of all kinds that add to his misery and as a consequence we can give him hope, keep him from brooding about himself and thus perform the proper function of a physician. We shall not forget that we can only rarely cure, but we can almost always relieve pain and we can always help the patient in some way. The ataxic patient needs consolation, and this can be given without in any way deceiving him. The loss of sight seems an irreparable ill to those who see, yet the blind are quite happy, are much more cheerful than many seeing people, and have learned to stand their affliction not only with equanimity but really without much depression. In the olden times, before proper care was taken of the blind, they had little occupation, they had nothing to do with their hands, the future was blank and they suffered severely from depression. As a rule, they did not go out enough and their bodily health suffered and the disturbance of their functions still further heightened their depression. All of this happens now with the ataxic patient. A host of symptoms not at all necessarily connected with his spinal affection develop and prove sources of annoyance. Many of them can be removed entirely, all of them can be ameliorated. If, while doing this, we succeed in impressing a discouraged patient's mind with our power to benefit in spite of an underlying incurable disease, we have another triumph of psychotherapy. Removing Unfavorable Suggestions.--The general experience with those suffering from locomotor ataxia has been that the depression consequent upon the announcement that they have the disease and the stigma that is supposed to attach to it in our day leads them to a great extent to avoid going out into the air. This adds woefully to their depressed condition. Take a healthy man, let him stay inside a great part of the time without any exercise, seeing no new faces, without any interests in life, and at the end of three months he will have a set of neurotic symptoms on a basis of depression that will make him supremely miserable. This will be true even though he has not the threat of an incurable disease hanging over his head. He must be made to realize that every neglect of any law of health in his condition is even more serious in its effect upon him than it would be were he in good health. Above {526} all, it must be made clear to him that while his neglect of hygiene may perhaps not shorten his life, it will greatly add to the mental suffering, much more unbearable in its way than the physical suffering which he will have to endure during the progress of his disease. Treating Accessory Symptoms.--Nearly every ataxic patient who is not directly and almost constantly under the care of a physician, is a sufferer from two conditions that are so constantly present that they are sometimes thought to be consequences of the primary affection. These are loss of appetite with consequent loss of weight and constipation. Almost without exception neither of these symptoms or syndromes are at all connected with the locomotor ataxia. They are the result of the unhygienic life that the patient is living and of the depressed state of his mind and lack of diversion. They are mutually connected, for a man who does not eat enough will not have regular movements of his bowels, and constipation reacts to produce further depression. A vicious circle in pathogeny is formed and the patient is likely to get into a very debilitated and depressed condition. Both of these troublesome symptoms may be corrected to the manifest improvement of the patient by proper advice and ordinary care for his well being. Appetite is largely a function, as the mathematicians say of something that depends on something else, not of exercise, as is often thought, but of fresh air. In the tuberculosis sanatoria patients with fever are not permitted to take exercise, yet if they are out in the air most of the day and if their rooms are well aired at night, they can eat heartily and digest their food well. Of course, appetite is largely a psychic matter and the thoroughly discouraged man will have no care for food in spite of abundance of air. A little persuasion, however, of the necessity for making the best of a bad job will usually arouse even a locomotor ataxia patient in the early stages of his disease to the necessity for eating a reasonable amount. If he has suffered from gastric crises and fears that eating normally may precipitate these, he must be persuaded that this is not the case, that the presence of food, or its amount, or quality, has nothing to do with the initiation of these painful attacks so far as we know, and that even though at the beginning of his affection before his locomotor ataxia was recognized, his gastralgia may have been declared by his physicians, as is so often the case, to be connected with some form of gastritis or indigestion, that idea may now be given up and he may eat plentifully with confidence that it will not increase his pains. On the contrary, limitation of food seems to have a distinctly unfavorable effect in increasing the number and severity of these attacks. The same thing must be made clear to him as to intestinal and rectal crises. It seems likely that tendencies to constipation by irritating peripheral nerve endings may have some effect in bringing about the explosion in sensory nerves which have been called intestinal or rectal crises. In general, however, these are dependent on spinal and not peripheral conditions, and no thought of any connection must be allowed to disturb the consumption of a proper amount and variety of food. It seems clear that when patients are much run down, have lost considerable in weight and are in a generally depressed condition, their nervous system is much more irritable than it would otherwise be and they are likely to suffer more frequently from crises of various kinds. Once a patient is made to understand that his general {527} nutrition may affect not only the course but the occurrence of symptoms in the disease, as a rule it is not difficult to get him to eat enough and to do so with the definite feeling that it is going to do him good. Even though it should be necessary to use tonics, and often they will have to be prescribed, it is clear that this treatment of the patient's general condition is the physician's first duty, though it does not and cannot affect the specific disease. Neurotic Complications.--There can, of course, be no doubt that the crises of locomotor ataxia represents extremely poignant attacks of pain. But on the other hand, anyone who has seen many of them is prone to think that not a few of them are really attacks of pain resembling those which occasionally develop in hysterical subjects. The pain of a gastric neurosis may, indeed, so simulate the gastric crises of locomotor ataxia as to make what is only a case of hysteria seem beyond doubt one of locomotor ataxic. Locomotor ataxia patients are prone to think much about themselves and to fear the recurrence of these painful crises once they have had experience with them. As a consequence they sometimes suffer from what are pseudo-crises, that is, from neurotic painful conditions which simulate genuine crises mainly in the amount of reaction they produce in the patient. True tabetic crises yield more readily to ordinary anodyne drugs than do these pseudo-crises. Nearly always the true crises are associated with and exaggerated by neurotic symptoms due to the depression of the patient, the yielding to his feelings, the conclusion that his pain is inevitable and is going to be worse each time, while successive crises are, as a matter of fact, often milder until they disappear for good, and this element in the case must always be borne in mind. Much can be done for the relief by psychotherapy, that is, by making the patient see the realities of his condition, suggesting to him that succeeding crises are less painful and that if his general condition is as good as it should be he becomes better able to stand the pain of his crises and the shock of them is not so disturbing to his system. Mental Attitude.--Prof. Oppenheim, in one of his "Letters to Nervous Patients," advising a patient suffering from an incurable organic nervous disease, evidently locomotor ataxia, though that is not explicitly stated, outlines emphatically the favorable side of that disease. This is absolutely needed. Ever so many unfavorable suggestions with regard to his affection find their way to the patient. The very fact that it is pronounced absolutely incurable is disheartening. Prof. Oppenheim's words, then, may be a precious help and to have them repeated from time to time renews the suggestion: Now, however, we neurologists know that that disease frequently runs a very mild course, that a man showing certain early symptoms of such a disease may for ten to twenty-five years and even longer retain his capacity for work and enjoyment. This for a man of thirty to forty years is almost tantamount to the expectation of a whole normal lifetime. But on the other hand, what danger to the peace of mind, what destruction of happiness in life may be caused if the knowledge that such a disease has begun to develop is imparted to the patient without being combined with the consoling information as to the nature and course of the benign forms of this trouble! In unceasing anxiety and fear, in daily expectancy of some fresh symptoms, of some increase or aggravation of his troubles, does the poor man waste his life; and I have frequently found that this wretched apprehension and excitement cause a nervousness and mental depression which in their effects are much more momentous than is the commencing spinal disease. From this miserable condition I desire to protect you, and I would ask you to {528} take this advice deeply to heart: do not bear yourself as one who is condemned; as one who, affected by a progressive, incurable disease, will soon fall a victim to paralysis. On the strength of my own experience I give you the assurance that your condition of health will not necessarily in ten years' time be essentially different from what it is at present. But I would also strenuously exhort you to observe all the precautionary rules laid down for you, to avoid all unaccustomed strain or indulgence such as can only be undertaken with impunity by a man in full vigor and absolute soundness of health. I would advise you also to be thoroughly examined once a year by an experienced physician. But apart from these restrictions, you should as far as possible feel yourself and bear yourself like a healthy man, remaining attached to your work, and not withdrawing yourself from the pleasures of social intercourse. Relearning Muscular Movements.--Perhaps the most interesting evidence of how much may be done for organic nervous disease in spite of the fact that the underlying lesion is absolutely incurable, may be obtained from what is accomplished by Frenkel's method of treating locomotor ataxia. As is well known, by reteaching the movements necessary for walking, ataxic patients regain control of the movements of their limbs to a marked extent. As a consequence, bed-ridden patients are enabled to walk once more even though they may have to carry a cane and be supported, and patients who have had to use two canes get along with only one, or may even eventually be able to walk without any artificial support. Just how the improvement is brought about we are not quite sure. It seems probable that the eyes become trained to replace the muscle sense to a noteworthy degree, but there is in addition apparently a re-education of the muscle-sense. Perhaps there is also a transfer of the function of certain degenerated nerves to other tracts than those in which muscle impulses originally traveled. The improvement in muscular control originally obtained is a striking illustration of how much nature is able to compensate for even organic lesions and is a lesson in the necessity for never ceasing to try to do something even when the case seems hopeless. Certainly locomotor ataxic patients would seem the least likely to be benefited by training in movement and yet this movement therapy for tabes has had some wonderful results. The story of how this mode of treatment came into existence is interesting and instructive as an illustration of how happy chance in our time, as so often with regard to drugs in the past, came to assist the rational development of therapeutics. A German professor wished to demonstrate to his class the varying inco-ordination of a series of tabetic patients. Some of them had their main inco-ordination in the legs, others in their hands. He went over the cases in his wards so as to arrange the demonstration for the next day. He told each patient that he would ask him to perform a particular set of movements before the class which would illustrate strikingly a particular phase of muscular inco-ordination. His patients were interested in the announced demonstrations and during the afternoon they went over the movements that they were expected to perform. They practiced them as assiduously as their condition permitted for the exhibition. As a consequence the most striking features of their inco-ordination disappeared. After having practiced the movement for a certain length of time they could do it ever so much better than before. The special feature of the professor's demonstration was spoiled, but a great contribution to our knowledge of nature's compensatory powers {529} was made and fortunately the hint of its significance for treatment was taken and developed. Effect of Favorable Suggestion.--How much can be accomplished for the relief of the general symptoms of locomotor ataxia and for the placing of patients in an attitude of mind that makes most of their symptoms of vanishing importance, can be judged from some recent experiences with a new cure for the disease. This consisted only of some rather conventional treatment of the urethra by applications and dilatation, yet patients were relieved so much of the symptoms of locomotor ataxia, or at least persuaded themselves that they were, that both in this country and in Europe the discoverer of the new "cure" soon had scores of patients. The active therapeutic agent undoubtedly was the fact that patients who had been told that their disease was incurable and who had settled down in a state of discouragement and apathy in which their power over their muscles, their general health and their strength and vitality were at the lowest ebb, and their tendencies to discomfort emphasized and made poignant by the supposed hopelessness of their situation, became aroused to new vitality by the promise of cure and then, under the repeated suggestion of a treatment said to be sure to cure them and that had cured others, became so much better, that is, released so much latent energy, that they felt better, ate better, walked better, got out more and had their general health improved, and all to such a degree that their disease seemed cured. Another interesting illustration of what would seem to be the power of suggestion over the symptoms of tabes occurs in a recent article in the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of Madrid [Footnote 39] on the improvement of tabes dorsalis by antidiphtheritic serum. It is quite impossible that the serum should affect favorably any of the underlying lesions of the disease any more than that these should be ameliorated by the wearing of shoes of special character or operations on the urethra. The patient in this case, however, was distinctly improved in many ways _after_ the antidiphtheritic serum was injected. There were some interesting sensory manifestations, pains in the arms and legs after the injection, but these were removed by santonin or methylene blue. Both of these drugs are eminently suggestive in their action, so that one would be prone to think the pains rather neurotic than actual. After a dozen injections had been given, the patient's sensations improved, his power to pick up small things was better, and the sense of walking on carpet had disappeared to a marked extent and he was able to walk much better than before and without support. Probably any attention given to him to the same degree would have produced like results. [Footnote 39: Tomo 1 No. 7, July, 1910.] We have had previous examples of this kind in the history of the treatment of locomotor ataxia. Certain drugs when given in the past with the definite promise of cure and pursued for a good while with frequently repeated favorable suggestions, have often seemed to benefit patients, though subsequent experience has shown their total lack of value to modify the disease. Nitrate of silver was one of these in the old days and many locomotor ataxia patients acquired an argyria as a consequence of the amount of silver absorbed and deposited in the skin. Arsenic was another and some of the aluminum {530} compounds were also used. When we recall the suspension treatment and its reported good effects--and failure, the over-extension treatment with the same history and many others in the past, the real place of the mental in the therapeutics of tabies is revealed. Once this is practically realized, we find that we have ready to hand and easy to use, the one really efficient factor in all these treatments--that is, the influence on the patient's mind. It is for the physician to devise thoroughly professional ways and means of using that in each particular case so that his patients may be benefited as much as possible. Certainly it would be foolish for us to leave to the irregular practitioner the use of this extremely valuable remedial measure, when we may do so much good with it, for the relief of symptoms at least. CHAPTER IV PARESIS Paresis would seem to be one of the affections so inevitable in its course, so positively helpless as regards any medication, and so hopeless in its absolutely sure termination in idiocy and death, that nothing can possibly be done for it through the patient's mind, yet it is probably one of the diseases for which most can be accomplished by psychotherapy. Mental treatment for it naturally divides itself into three periods: that of prophylaxis, that of the early stage and that of the severer stage with remissions. Prophylaxis is much more important than is usually thought. It is very generally known at present that paresis is usually a parasyphilitic disease, that is, an affection not due directly to syphilis, but which develops by preference and perhaps exclusively in a soil prepared for it by an attack of syphilis. As a consequence of the diffusion of this knowledge men who have suffered from syphilis sometimes become supremely fatalistic as regards the development of locomotor ataxia or paresis in their cases. Worry is a prominent feature in the causation of paresis, and it is, therefore, extremely important to neutralize this. I have had university graduates tell me their histories and ask whether I thought they had suffered from syphilis, and when I replied affirmatively have seen a look of despair come into their faces. One of them, a graduate of a large eastern university, said, after hearing my opinion, though it was given with every assurance that my experience with Fournier in Paris taught me the absolute curability of the disease, "Well, there are three men of my class who have already developed paresis, and I suppose I will go the same way." With a persuasion like this haunting him night and day, exhausting nervous energy and making his central nervous system less and less resistive, it would be almost a miracle if paresis did not develop. It is particularly in those who have had nervously exhaustive occupations--brokers, speculators, actors, and the like--that paresis does develop. The strain upon their nervous systems seem to be so great that the syphilitic virus still remaining in their system has a peculiarly degenerative effect upon nervous tissue. A man may be in the least worrisome of occupations, however, and if he is constantly brooding over the possibility of the coming of the hideous specter of paresis, {531} he puts himself in the condition most likely to encourage the development of the pathological changes that underlie the disease. Prophylaxis.--As a rule patients who have had syphilis and who dread the development of paresis should be warned with regard to their occupations in life. After a patient has had tuberculosis which developed in particular surroundings, if it is at all possible, we no longer permit him to go back into the surroundings in which his disease developed. We are coming, more and more, to apply the principles of preventive medicine and this is as important in paresis as in anything else. Even though there may be many monetary or economic reasons in favor of certain occupations, the danger may overweigh these. Those who have had syphilis should be warned of the risk they run if they continue in occupations that require much mental excitement or the strain of anxiety and the speculative factor of uncertainty with the inevitable occurrence of disappointments. It is unjustifiable to permit a patient whose central nervous system is subjected to the deteriorating influence of the virus of syphilis, still in his body even after ten years, to submit to the nerve-racking irritation of occupations which require all the vigor of a healthy, undisturbed organism to survive their wear and tear. _Sources of Worry_.--One of the symptoms which neurotic patients are sure must be a preliminary sign of paresis is a disturbance of memory. Patients have heard that paresis causes memory disturbances and fearing the development of the disease, they disturb themselves very much by finding real or supposed defects of memory. Most of them have had only a very vague idea of the sort of memory they possess and cannot tell whether it is worse than before, but finding a certain difficulty in recalling things they conclude that it is deteriorating. Occasionally their supposed defect of memory is founded on nothing more serious than the fact that they are paying so much attention to themselves, that they cannot concentrate their attention enough on what they wish to remember so as really to impress it on their memories. It is curious how persistent some patients are in making themselves believe they have serious lacunae in their memory when there are only certain conventional disturbances of it. The paretic has defects of memory, but he is, as a rule, quite unconscious of them. He has to have them pointed out to him. Patients who are supremely conscious of their supposed defects, by that very fact show their possession of good intellectual faculties. Tremor is another symptom that may develop in the midst of the solicitude of those who dread paresis. The power to hold the limbs in a given position is due to a very nice balancing of flexor and extensor muscles. There are many people, especially those a little awkward in the use of their muscles, who lack this power to some extent. To stand without swaying is rather a difficult task in one who is nervous or anxious about himself. Patients who are worrying about paresis and its possible development will almost surely disturb their power over their muscles and cause at least a slight tremor or swaying. In other words, in all of these cases a series of dreads, or mental obsessions which interfere with various functions which may cause tremor, or some stuttering, or at least some apparent difficulties of speech and which will surely revive any old-time difficulties of this kind, may develop in nervous persons and must not be allowed to pass as signs of developing paresis. The {532} diagnostic tests, of course, consist in the knee-jerks, the pupillary reactions, the difference in disposition, the delusions of grandeur, and, in general, the characteristic symptoms of a physical degeneration running parallel with a mental deterioration. _Prophylactic Reassurance_.--The first point in psychotherapy, then, is to give just as much reassurance as can be given. Probably not one out of a thousand of those who have suffered from syphilis afterwards develops paresis. Nearly always there is something in the history besides syphilis that seems to be an essential etiological factor. A great many of the people who develop this disease have some hereditary taint of mental incapacity at least, if not of actual insanity. Very often there is a personal or family history that indicates some mental unevenness or at least some lack of intellectual vigor. When people are sanely intellectual and have no unfortunate hereditary tendencies they can be almost completely assured as to the possibility of the development of paresis, provided they take reasonable care of themselves. _Alcohol_.--It is still an unsettled question whether alcoholism has anything to do, even in a subsidiary capacity, with the etiology of paresis. Probably it helps to predispose nerve tissues to degeneration by lowering their resistive vitality to the direct pathogenic action of the virus of syphilis. It seems clear, besides, that men who have acquired syphilis sometimes take to over-indulgence in alcohol, at least to a greater degree than would otherwise be the case, because of the discouraging dread that develops as a result of their worry over this constitutional taint. A warning in this matter of indulgence in intoxicants is important because there are many nerve specialists who insist that alcoholism is probably one of the prime factors in paresis. Unconclusive Diagnosis.--When the first symptoms of paresis have developed so that the physician is almost certain that the disease is present--the cumulative experience of recent mistakes on the part of the most careful experts seems to show that he can never be entirely certain--then it is important not to announce the worst to the patient, but to let him learn the reality of his condition gradually, so that all the awfulness of it does not overwhelm him. What have seemed typical cases of paresis, so diagnosed by excellent authorities, have occasionally proved to be something else, or, at least, to be wayward and very irregular forms of that disease with a long course and marked remissions. There are forms of paranoia in the middle-aged which sometimes exhibit symptoms so strongly simulant of paresis as to deceive even the expert. There are forms of nervous weakness--neurasthenia--some of which are really cases of mental exhaustion or incapacity--the modern psychasthenia--which often lead even experienced physicians to think of and sometimes to diagnose paresis. There are cases of dementia praecox that only time can differentiate. Prognosis.--_Seeing the Worst_.--There is a tendency in most physicians to see the worst side of the story rather than the better. This is not because of any desire to be a harbinger of evil tidings, nor, as is sometimes said, to show the patient, should he get better, from what a depth of affliction he has been rescued, but it is rather due to the very natural tendency existing in most of us to look on the worst side of things. Besides, we have found by experience that if patients are to be aroused to the necessity of care for themselves they must be scared a little, and so we have formed the habit, not of consciously {533} and deliberately telling the worst, but of stating the unfavorable possibilities of a group of symptoms, in order that a patient may take due precautions and that he may realize, if the worst does happen, that we were not ignorant of it. If he gets better he is correspondingly grateful for this. If the unfavorable happens and we had not warned him, he is more or less justifiably resentful. _Consoling Hesitancy of Final Judgment_.--Patients suspected of suffering from paresis can then without any violation of truth be reassured that their cases may not be incurable until the epileptiform incidents of the disease bring on that happy obscuration of mentality, that either takes away all the terror of the disease or lessens so much its awful significance that the patient is spared the worst. There are cases of reported cures in the literature even after what seemed to be characteristic epileptiform attacks had occurred. We cannot be sure, in any case, of the future course of an affection exhibiting symptoms resembling paresis. The patient can always be given the advantage of this doubt then and the awful word incurable or even the diagnosis paresis need not be mentioned to him. It is perfectly possible, as a rule, to take other means to prevent unfortunate incidents from tendencies to violence or serious loss from foolishness, without overwhelming the patient with an absolutely unfavorable prognosis, and the diagnosis of paresis, involving as it does, now that so much more is popularly known of the disease than before, the dread of inevitable idiocy. In this way much of the depression that constitutes so large a part of the really sane period of the early stage of paresis and which inevitably hastens the course of the disease may be avoided. On the other hand, failure to announce absolutely the diagnosis of paresis until there can be no particle of doubt, can do no harm and will do good to the patients themselves, as well as save their anxious friends from the trial of having to think of the awful possibilities of the disease. A single sensible member of the family may be selected as the confidant and the situation saved. Rôle of Psychotherapy.--While it is important that someone closely connected with the patient should know the doctor's suspicions, he should be bound to absolute secrecy as regards the patient himself and especially as regards women friends and relatives. The attitude of mind assumed by women relatives, and especially those nearest and dearest, is sure to be communicated to the patient, if not directly at least indirectly and inadvertently, and makes for anything but relief from the depression that is sure to be his if he has any gleam of understanding of his condition. Indeed, so much of pain and suffering is needlessly inflicted on relatives of paretic patients in the early stages of the disease by a premature announcement of the diagnosis that it is especially important to insist on care in this matter. The family will usually clamor to know just what is the matter, but it is the physician's duty to care for his patient and save the sufferings of the patient's family, regardless of their unwitting insistence. Once the disease has developed and the patient's mind becomes affected it may be thought that psychotherapy is no longer of value. As a matter of fact, these patients as a rule become more childlike and are much more affected by suggestion than in their normal states. All this is worthy of careful attention on the part of the physician who feels that it is his duty to treat patients and not merely their disease. The psychic care of the patient is the most important element in any {534} scheme of therapeutics during the longer remissions of paresis, which are sometimes so complete that it is difficult to understand that the patient, who is now as sensible as he ever was, only a few months before was doing the most foolish things under the influence of his delusions of grandeur and probably within a few months will be quite as insane as before and perhaps hopelessly demented. The brevity of these remissions in most cases seems to depend directly on how much the patient is persuaded that his disease will return without fail and run its inevitable course. It is well worth while to lengthen these remissions by setting the patient's mind just as much at rest as possible. Instead of the attitude which is so often assumed of absolute assurance on the part of the physician that the old condition will inevitably return, it is advisable always to give the opinion that the previous mental derangement was paranoiac rather than paretic, or was perhaps only a passing syphilitic condition and that the ultimate outlook is not as hopeless as might be thought. This opinion is thoroughly justified by certain surprising results in a number of recently reported cases. Some patients whose symptoms have been diagnosed as paresis by excellent diagnosticians, have, after a time, experienced a cessation of their symptoms which looked very much like a remission occurring in the midst of the inevitably progressive paretic degeneration and then to the surprise of their physicians have not exhibited any further symptoms of the affection. Syphilis of the nervous system sometimes simulates paresis to such an extent as to deceive the most expert, and proper antisyphilitic treatment will sometimes produce results that are little short of marvelous. It is beyond all question, then, for the good of the patient suspected of paresis that his physician should give him the benefit of every doubt. CHAPTER V EPILEPSY AND PSEUDO-EPILEPSY EPILEPSY With regard to the major neuroses generally, very much more therapeutic benefit can be secured than in any other way that we know by reassuring the patient's mind, by careful regulation of his life and by such modifications of his occupation as will take him out of a strenuous existence, so likely to be harmful to a nervous system laboring under these serious handicaps. In recent years we have come to realize that epilepsy, for instance, is more favorably influenced by a simple outdoor life in the country without worries and cares, with carefully regulated exercise in the open air and special attention to the digestive tract, than by any formal remedial measures or drug treatment. The fewer the emotional storms the less likelihood of repetitions of attacks of epilepsy. No medicine is so effective in prolonging the intervals between attacks as this placing of the patient in favorable conditions of mind and body. Our experience with the colony system has emphasized the fact that drug treatment is quite a subsidiary factor in this general care for the patient. The most important element in this treatment is the effect on the {535} patient's mind and the consequent gain in poise and in resistive vitality against emotional explosions which are so often the immediate occasion of attacks. This lessens their number and it is well known that frequent repetition is likely to be associated with that deterioration of the physical nature and mental condition which is most to be dreaded. Mental Influences.--When living a quiet placid life without worry about himself or his concerns, the number of the epileptic attacks goes down in a noteworthy degree and the intervals between them become longer and longer. After years of quiet country living epileptics who had two or three attacks a week have scarcely more than one a month, if, indeed, that often, and their general condition is greatly improved. We have had many remedies for the affection, only a few of which have proved to be really therapeutic. The remainder have had their effect through the mental influence that went with them, the assurance of relief and the confidence that it aroused. First attacks of epilepsy are not infrequently the result of an immediately preceding fright or sudden emotion of some kind or other. Gowers tells the story of a sentinel posted near a graveyard who was very much disturbed by his proximity to the dead and who, during the night, saw a white goat run past him, jump over a low wall and disappear. He was sure it was a ghost. He had his first attack of epilepsy shortly after. Children not infrequently have their first attack after a scare from a dog or a rough-looking stranger who has come near them. After the affection has established itself attacks of epilepsy follow vehement mental disturbances of any kind. Sometimes after a long interval of freedom from attacks a sudden strong emotion is followed by a fit and then the epileptic habit is reestablished. In order to be as free as possible from the affection patients must be protected from emotional storms. Power of Suggestion.---A strong proof of the favorable influence of suggestion upon epilepsy was given when operations for epilepsy became common about twenty years ago. A number of patients were operated on by trephining, even though almost nothing else was done except to open the dura and examine the brain, for often no definite pathological condition to justify surgical intervention was found. But these patients did not suffer from attacks of epilepsy for months and sometimes years afterwards. Many surgeons reported these cases as cured, as they apparently were when discharged from the hospitals, for no attacks had recurred; but physicians had to treat them later when their epilepsy redeveloped. The surgical procedure, as indeed might have been expected from the findings, had given only temporary betterment. The real therapeutic factor at work had probably been not any definite change within the skull, but the suggestive influence of the operation, the period of rest with favorable suggestion constantly renewed, and the confidence of recovery inspired during convalescence. Even in cases where adhesions were found between the dura and calvarium and these were broken up, the relief afforded was usually but temporary. The succession of events, the relief afforded and subsequent relapse, probably represented the same influence of suggestion as in the preceding cases with perhaps a slight physical betterment in addition. An important factor in the psychotherapeutics of epilepsy is to relieve the patient as far as possible from the haunting dread of insanity, which, especially if he has read much of the disease, is so likely to hang over him as {536} a pall because of the absolutely bad prognosis which often occupies so prominent a place in older text-books and articles on epilepsy. There is no doubt that in a great many cases epilepsy is a progressive degenerative disease and that a state of lowered mentality will eventually develop. There are many cases, however, in which epilepsy is only a series of incidents which does not seem to affect the intellectual life and which is quite compatible not only with prolonged existence, but with mental achievements of a high order and, above all, with a personality that may be commanding in its power over others. This knowledge, which unfortunately is not usually given in text-books because they are studies in the pathology rather than in the psychology of epilepsy, is extremely important for the epileptic. This view is of special significance for those sufferers from the disease who are well educated and in whom mentality means so much. The Individual in Epilepsy.--In epilepsy, indeed, the individual counts much more than his ailment, and even in severe cases of epilepsy there are individuals to whom the recurring convulsions are only annoying occurrences of life, somewhat dangerous because of the risks encountered during unconsciousness, but without any ulterior significance for degeneration of character or intellectual power. As a matter of fact, there are many men in history who were epileptics and who yet succeeded in great work of many kinds, even purely intellectual, unhampered by this condition, and some of them have proved to be leaders in achievement. In his paper read before the National Association for the Study of Epilepsy and the Care and Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew Woods discussed what certain famous epileptics had accomplished in spite of epilepsy. He takes three typical examples--Julius Caesar, Mohammed and Lord Byron--the founders, respectively, of an empire, a religion and a school of poetry--with regard to whom there is convincing evidence that they were epileptics. A fourth name, that of Napoleon, might easily have been added. Greater accomplishments than these epileptics made in their various departments are not to be found in the history of the race. Many other names of epileptics distinguished for achievement might well have been added to the list. The argument that would be founded on their lives is not that epileptics are necessarily or even usually of high intelligence, but that some of them, at least, retain in spite of the major neurosis, or even serious brain disorder, whichever it may be, all their intellectual qualities undisturbed. Lombroso, arguing from the other standpoint, has pointed out that there is a close relation between genius and insanity, and he sets down epilepsy as one of the forms of insanity (mental un-health) often associated with extraordinary mental qualities. A study of this subject is extremely reassuring to the epileptic who is prone to think from traditions with regard to the disease that his fate is almost sure to be a gradual lapse into imbecility. No epileptic is likely to be at all worried over the suggestion that epilepsy and genius are allied, for since he has the one he is quite willing that the other shall follow. Treatment.--Reassurance is especially important when patients develop epilepsy in adult life. There is an unfortunate social stigma attached to the disease which adds to the unfavorable suggestions that are likely to run with it. This probably cannot be overcome, for it is a heritage, not alone of many {537} generations, but of many centuries. Our better knowledge of epilepsy, however, should gradually take the disease out of the sphere of suspected mystery in which it has been popularly placed and set it among the diseases to which human nature is liable, but which is surely as physical in its character as any other. If a favorable attitude of mind on the patient's part can be secured there is less necessity for many of the disturbing drugs that are used and there seems to be no doubt that even in producing the effect of these, such as it is, suggestion of a favorable character plays a large role. Over and over again in the history of the affection we have had remedies introduced which have seemed to be quite efficient in producing longer intervals between attacks, making the patient less nervous and putting him in better physical health. After a time, however, these have proved to be quite useless, or at most of but very slight value. It was suggestion that gave them their apparent value, and this suggestion must be used without the drugs whenever possible. The bromides have done good in the treatment of epilepsy, but they are the only drugs that maintain the reputation they first had. All the others accomplished whatever benefit they conferred on the patient, and some of them for a time seemed to excellent authorities of large experience to give marvelous results, through their influence over the patient's mind. Nothing can produce more confidence in the physician who is using suggestion for epilepsy than this fact. Even the bromides, unless used carefully, easily do more harm than good and they have often worked mischief. Favorable suggestion cannot do harm. At the present time those of largest experience in the treatment of epileptics, the directors of farm colonies, as Dr. Shanahan of Craig Colony, insist that diet, hygiene, especially hydrotherapy, are of much more importance than drugs, but that the patient's attitude of mind towards himself and his malady and the future of it is even more important. He must have occupation of mind so as not to worry about himself. He must have recreation so as to relieve the gloom so likely to come in the disease. He must have outdoor air and proper exercise, which these patients are so prone to neglect. Those who have studied the subject most in recent years agree that the great majority of cases of epilepsy are not primarily due to acquired causes, but to some congenital defect, so that there is an inherent instability of the nervous system. This makes the patient liable to explosions of nerve force, figuratively represented as boilings over of nervous energy, when not properly inhibited. Once such a paroxysm occurs it is likely to happen again, and very often it brings on gradual degeneration of the nervous system and of mentality. In many cases, however, this degeneration can be delayed or even completely kept off by putting the patient under favorable conditions. These patients need, above all, to realize that they cannot live the strenuous life nor even the ordinary busy life of most people. They are as cripples compelled to limit the sphere of their activities. If they will but take this to heart, however, and not attempt too busy occupations, they may live quite happy lives for many years, and if mentally content and without worrying anxieties they will have so few attacks as to incur only to a slight degree the dangers inevitably associated with fits of unconsciousness. To get the epileptic's mind into a condition of satisfaction with his condition must be the main portion of the treatment. {538} PSEUDO-EPILEPSY There is a large and important field of psychotherapeutics in a class of cases so closely related to epilepsy that it is often extremely difficult to make the differential diagnosis between the two varieties of seizure. Fifteen years ago, while I was at the Salpêtrière, there was much discussion of a variety of attack called hystero-epilepsy, in which the patients' symptoms were such that it was difficult if not practically impossible to decide whether the case was true epilepsy or merely hysteria. Personally I do not think there is any third, intermediate variety deserving a separate term. The attacks are either hysterical, or, to use a less objectionable name, neurotic, or they are genuinely epileptic, that is, due to some as yet not well-defined change in the brain, and therefore not likely ever to be completely relieved. To decide whether a given case is neurotic or epileptic, however, is sometimes quite out of the question until long and careful study of it has been made. It is true that such signs as full loss of consciousness, biting of the tongue, the so-called epileptic cry, involuntary urination, dangerous falls and the like in the midst of an attack, have often been declared to be signs of true epilepsy, but there are cases in which one or other of these signs has been present, yet the subsequent course of the affection has shown them to be functional and not organic in origin. Neurotic Simulation of Epilepsy.--Nearly every physician who has reasonably large experience with neurotic patients has seen cases in which there were recurrent attacks of loss of consciousness that came on sometimes at most inopportune moments, that rendered the patient quite incapable of caring for himself for the moment, yet lacked many of the signs of true epilepsy. Teachers sometimes complain of a complete lapse of memory that begins without warning and then recurs at intervals, making their work very difficult. Preachers sometimes bring the story of having lost the thread of their discourse and forgetting absolutely what they were talking about, there being a complete blank for some seconds at least. Occasionally such lapses are associated with falls that resemble fainting spells and seem to be accompanied by complete loss of consciousness. Usually after them there is a distinct tired feeling and an inclination to sleep, though, as a rule, there is a more marked tendency to want to get away from observation. Some of the cases are much more severe than those described and the conclusion that they are true epilepsy seems inevitable, yet they recover so completely that this conclusion is negatived. Occasionally such attacks occur only when the patient has been strenuously exerting mind or body for a much longer period than usual. In teachers it is likely to occur toward the end of the year or in the midst of the hard work about examination time. In students this same period is likely to be a favorite starting point for the attacks and they recur oftener at this time than at others. Very often there is a story of some digestive disturbance in connection with the attacks. At times it seems possible to trace them to some interference with the cerebral circulation through a distended stomach pressing upward through the diaphragm and interfering with the heart action. In such cases stomach resonance will sometimes be found as high as the fifth rib {539} and the apex beat may be pushed out to the nipple line or beyond it. This may be true though there are no signs of valvular lesions and no symptoms or physical signs of dilatation or hypertrophy of the heart. _The Suggestive Element_.--Analysis shows the real course of the trouble in these cases. The sufferer is usually following a sedentary occupation, not getting much exercise or diversion and prone to introspection. Many symptoms of themselves of no importance have been emphasized by concentration of attention on them. Especially is this true of any heart irregularity. The patient has dreaded for some time lest the feeling of pressure in the precordia and of discomfort in the heart might not sometime interfere with him in the midst of his teaching or preaching duties. Some day when he is feeling much worse than usual, in the midst of his work, there comes over him the feeling that now his intellect is going to stop action because there is something the matter with him. The sudden concentration of his attention on this with the fear of the consequences and the uncomfortable feeling that he will not be able to go on with his flow of ideas, cuts off the thread of what he is thinking about and puts but one single object before him--this possibility of failure of mental action. Usually the first attack is only such an interruption as is thus indicated. The fear of subsequent attacks, the worry over what has happened, the dread that some serious mental affection or nervous disease is at work emphasizes introspection and subsequent attacks are even more likely to be serious, and especially to last longer than the first. The more the cases are studied the more the conclusion comes that in many of these instances it is nothing more than auto-suggestion that is responsible for the mental lapse. It is true that some physical condition may be the occasion, though the mental state is the active immediate cause. Suddenly concentrated attention on the dread of mental interruption inhibits mental action and what was dreaded follows almost necessarily. It is a sort of auto-hypnotism in which the patient's train of thought is interrupted by a momentary or longer hypnotic state the causes of which can be traced. Even when there is a real organic lesion of the heart, the lapses of memory and even of reasoning power that occasionally occur, have often seemed to me to be due rather to the patient's dread than to any real physical condition. I cannot think that there is a sufficient interruption of the cerebral circulation, even though only for a moment, to cause such a lapse. It is a question of nerve interferences rather than of blood supply. If the blood were diverted, even though only for a moment, or if there was a stoppage, the consequences would be more serious and more lasting than they are. What evidently happens is some disturbance of neurotic connections within the brain brought on by sudden dread or emotion. The will has lost control or has seriously disturbed the conducting apparatus. The best proof that this is what happens and that it is not the result of organic change is found in the fact that when the physical occasion, that is, the digestive disturbance or the heart palpitation which is the initial factor in these states, is relieved, the attacks do not take place. Patients in whom they have occurred even for years cease to have them. This improvement does not begin, however, until their solicitude over their condition has been lessened by a confident declaration to them that they are suffering from merely functional and local reflex conditions apart from the brain itself. Usually it needs to be made clear {540} to them, too, that their anxiety in the matter means much more for the continuance of the attacks than any physical condition. Almost invariably patients somewhat resent this suggestion. Their response to this explanation of their ailment usually is that the attacks come on them when they are not particularly expecting them and that there is first some physical symptom which might readily be taken for a sort of aura to a genuine epileptic attack and then the attack itself comes on. It is this preceding symptom, pain or discomfort, or whatever else it may be, that provokes the suggestive element and brings about the state of quasi-hypnosis, which is the main part of their attack. Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are very mild, though if the word epilepsy has been mentioned there naturally arises a feeling of dread in patient and friends with consequent unfavorable suggestion. A type not infrequently seen has for its main symptom a period, usually of but short duration, in which there is an intense tired feeling so that even the eyelids droop and require effort to lift them. During such attacks the respirations may slow down to fifteen or below, though usually the pulse is inclined to be rapid. The feeling of fatigue is almost entirely subjective, in the sense that, if patients are required to do something, they are able to accomplish it by a little urging, though a moment before they were sure that they could not. Such attacks are invariably functional, have no organic basis and do not deserve the name of epilepsy. If called hysterics this will cause the patient, who is often a woman, to rouse herself and so gradually overcome them. They are really a loss of confidence in one's power to do things and a passing astasia-abasia. The use of the word hysterics may cause the patient to lose the sympathy of her friends, though she may need it; for often there is an underlying pathological condition not in the nervous but in the somatic system. Sometimes the patients are anemic, sometimes they have an abortive form of Graves' disease, and sometimes they are low in nutrition. These conditions give the indication for treatment. What is needed is, of course, improvement of the general condition, but, above all, a restoration of the patient's confidence in herself. Once it is made clear to her that the attacks are largely subjective, that is, are due to a feeling of prostration because of the fear that she is unable to do something, then the intervals between the attacks will gradually grow longer. It is important that long hours of sleep should be advised with plenty of fresh air, and that whatever disturbances of the digestive system are present should be carefully treated. Pseudo-Epilepsy and the Menopause.--A number of these cases of pseudo-epilepsy occur at the menopause. They seem particularly likely to occur in women who have not much to occupy themselves with. Childless women who have no cares and enjoy every luxury sometimes seem to have these pseudo-epileptic attacks as equivalents for the flushings of the ordinary menopause. During "a rush of blood to the head" they lose control of themselves. Occasionally mothers who have two or three daughters and who get their menopause late in life, that is, well after fifty, are especially likely to suffer in the same way. The solicitude of those near them seems to eliminate some of their power of inhibition and makes them think overmuch of themselves. If then they keep much at home, as women at this time are prone to do, have few {541} diversions of mind, little fresh air and exercise, there is an accumulation of unused nervous energy which dissipates itself in explosive attacks very like epilepsy. It is with regard to these that the term hystero-epilepsy almost seems justified. Just as soon as occupation and diversion of mind and relaxation of the solicitude of friends for them is secured they begin to get better. The differential diagnosis of these cases is made from the absence of certain of the pathognomic signs of true epilepsy. The tongue is not bitten, involuntary urination does not take place, and when the patient falls she does not hurt herself as a rule, though occasionally the fall may result in accidental abrasions or bruises, but these are quite trivial. If stress is laid upon the fact before these patients that they do not present any or all of the symptoms of epilepsy, some of them are likely to occur a little later. Slight abrasions on the tongue will be noted and the sputum will become a little bloody. Even very cleanly women will sometimes wet themselves. It is not a deliberate attempt at deception, but their curious psycho-neurotic condition causes suggestion to act upon them. Their attacks are really auto-hypnotic and during these the remarks made by the physician occur as suggestions and then are accomplished. If the suggestions in this matter have been carelessly made by previous physicians the attacks will so closely simulate true epilepsy that it will often be almost impossible to differentiate them with assurance. In the preliminary diagnosis of these cases, as well as of all other cases of pseudo-epilepsy, we must, as far as possible, avoid the use of the word epilepsy, even of hystero-epilepsy. The unfavorable suggestion attached to such terms will have the worst possible effect. There is no need to fear that the patient will be any less taken care of, if the disease is called by some other name, for instance, neurotic paroxysms or nervous attacks. Cure by Suggestion.--Such patients are often cured by remedial measures of one kind or another that are administered with the confident declaration that they will get well. A number of cases of epilepsy which were really of this character have been reported cured by Eddyism. A number also have been very favorably influenced by osteopathic treatment. Needless to say, the reports of such cured cases have not been diminished in significance by the publicity bureaus of these various cults. Mental healing has relieved a number more. Usually this relief has been afforded these cases after they had tried regular physicians who had treated them in the ordinary way with bromides, without doing anything more than causing them to miss a few attacks for a temporary period of relief, if even that, giving them bromism and further increasing their solicitude about themselves by unconsciously emphasizing their ideas as to how serious epilepsy can be. The cures of these cases are not due to the various treatments to which the patients proclaim their debt of gratitude, but to the confident assurance given them that their condition is not serious, and will be cured. After analysis of their attacks has shown them to be neurotic and not genuinely epileptic, the regular medical practitioner can readily do as much and even more; for psychotherapy has much more to do in affording relief in these cases than any other form of treatment. It must be applied with confidence and the results are often most favorable. {542} CHAPTER VI PARALYSIS AGITANS This is a chronic affection of the nervous system having for its most characteristic symptom a tremor, but with marked muscular rigidity and weakness. It is much more common in men than in women, in almost the reverse proportion of Graves' disease. It is usually a disease of the old, but may occur in early middle life and has been known to develop even early in the twenties. In the old days when malaria was a common diagnosis for many different conditions, paralysis agitans apparently followed malaria so often that there was thought to be some connection between the two diseases. The more we have learned of malaria the less likely this seems to be. Continuous exposure to cold for long periods and to dampness during the daily occupation for years, or repeated severe wettings, have been considered as causative elements. None of these physical factors, however, has been as directly connected with the occurrence of the affection as various emotional conditions, and the thought is suggested that even in cases of severe exposure the worry and fright and solicitude incident to the fear in an elderly person that this exposure will have serious consequences, is an important etiological element. Psychic Factors.--_Fright_.--Practically all the authorities agree that mental conditions are prominent factors in the production of the disease. Serious business cares and worries and anxieties have often long preceded its development. Fright is mentioned by nearly all those who write on the subject as at least an occasion for the development of paralysis agitans if not a cause. One of my own most interesting cases occurred in the sheriff of a county of the Southwest who had earned for himself the deep enmity of an Indian by arresting him. Not long afterwards one Sunday morning when the sheriff quite unarmed came round a corner he found the Indian just in front of him wildly drunk and armed with a rifle. At once the rifle went to the Indian's shoulder, but he did not want to kill his man without having his revenge by torturing him, so he did not pull the trigger, but announced to him in vigorous though broken English that he had him now and was going to kill him. The sheriff tried to parley and for a moment the Indian permitted him to do so, apparently in order to prolong the agony. They were not more than two yards apart at the beginning, and the sheriff took his only chance and jumped and knocked the gun up. It went off just as he did so, the bullet singeing his hair. He succeeded in arresting the Indian and throwing him into jail, but the next day a tremor developed in the arm which had grasped the rifle. This spread and finally became typical of paralysis agitans. He was a man only slightly past fifty and there had been no preliminary symptoms. Mental Control of Symptoms.--Many similar cases following fright or vehement emotion have been reported, so that it is easy to understand the feeling that the affection has a large psychic element in it, though evidently from its persistency and its continued development, there is some underlying pathological condition. The tremor may be controlled in voluntary {543} movements, while emotion exaggerates it. There is no doubt, however, that concentration of will and the definite effort to control the symptoms enables the patient to rid himself of them to a great degree for a time at least. It has been noted frequently that when a consultant physician is called the patient will be better for the day of the consultation than he had been for months before. The visits of particular friends will often arouse a sufferer to such efforts as greatly lessen his rigidity, decrease his tremor and make him capable of getting around better than before. The state of mental depression that commonly develops in these cases exaggerates the symptoms, adds neurotic and even physical conditions that develop from lack of exercise and air, and makes the patient's general state much worse than it would otherwise be. Pathology.--Our scanty but growing knowledge of the pathology of paralysis agitans makes it clear that the disease is, in typical cases, probably due to an overgrowth of connective tissue, the neuroglia cells, in the central nervous system. Just what causes this overgrowth of connective tissue is not clear. It is an exaggeration of a normal senile process. Apparently one of the processes of age in man is a decadence of the vitality of important higher tissues with a corresponding increase of vitality in the lower or connective tissues. When Flourens declared at a meeting of the French Academy of Sciences that such an overgrowth of connective tissue was natural with advancing years, he added that this probably accounted for the slowness with which older men come to conclusions. The old members of the Academy did not accept this new-fangled doctrine with equanimity. They were inclined to think that their conservatism and deliberateness were due to greater poise of intellect. There seems to be no doubt that at least a comparative overgrowth of connective tissue is characteristic of the brain in advancing years. In some people this occurs to a greater extent and is more precocious than in others. Just what causes are responsible for individual differences we do not know. Paralysis agitans is seen often in those who have worked hard most of their lives, but, on the other hand, may occur in those who have lived sedentary lives, and in people of all occupations. Over-indulgence in alcohol, though this is often thought to predispose to the disappearance of the parenchyma of organs and to the overgrowth of connective tissue, does not seem to have any place in the etiology of this affection. Its occurrence is a part of that mystery by which the equilibrium of different kinds of cells in the body is maintained or diminished. In a mild way paralysis agitans represents such a change in the central nervous system. Mental Influences.--With an overgrowth of connective tissue as the pathology of the disease there would seem to be no question of any relief of its symptoms or any benefit to be derived from psychotherapy. Anyone who has much to do with cases of paralysis agitans, however, knows that they are extremely susceptible to mental influences. Whenever there is anything that interests them, any business that they feel they must do, any special event that they look forward to, they will for days at a time be so much improved in general symptoms as to be greatly encouraged themselves and make their friends feel hopeful with regard to them. When they give in to their condition, however, and make no special effort at self-control and stimulation their symptoms increase very much. Their rigidity particularly increases, their {544} tremor becomes more marked and various inconveniences associated with these two cardinal symptoms are emphasized. Methods of Treatment.--_The Vibrating Chair_.--It is interesting to recall some of the forms of treatment which have been reported as beneficial in paralysis agitans, because they illustrate how much the influence of the patient's mind has over his bodily condition and how much the interest aroused in any new and particularly in any unusual form of treatment has in mitigating symptoms and how often it seems to bring about remissions in the progress of the disease. Twenty years ago Charcot suggested the use of a mechanically vibrating arm-chair. He had noticed that patients who travelled by rail seemed to have their symptoms improved for the time at least by the shaking up in the train. This treatment undoubtedly made patients much less rigid and much less tremulous. The improvement lasted sometimes for hours and sometimes for days. It was tried rather extensively and everywhere with reported good results, when first tried at least. After a time it was found that it failed to have the desired effect. Apparently whatever therapeutic value it had was due to the interest aroused in the patient's mind and the consequent effort that was made to control his muscles. _The Suspension Treatment_.--When the method of treatment by suspension became popular for cases of locomotor ataxia, the idea came to try the same thing for paralysis agitans. Accordingly suspension apparatuses of many kinds were used with reported good results. Patients were suspended by the neck for some minutes and some of them got used to the treatment and could stand it for a prolonged period. The effect was always a distinct mitigation of symptoms. The rigidity particularly became much less marked, but the tremor also was lessened and besides certain secondary symptoms were bettered. Constipation was improved, partly because patients were more cheerful, ate more heartily and, above all, were willing to make some effort in order to get out regularly into the air. There was a variety in life, different from the solitary sitting at home into which these patients so often drift. Sleep was better at night and the subjective sensations of heat and cold were lessened. Patients were encouraged to think of improvement and used all their available nervous energy. In the same way when overstretching of the spinal cord by forcibly bending of the body at the hips was tried with reported success in tabes it was also applied to paralysis agitans with similar improvement of symptoms. Both methods of treatment have gone out for both these affections and evidently their observed therapeutic efficiency at first was entirely due to their effect upon the mind. _Psychic Elements and Other Remedies_.--When organo-therapeutics became the fad paralysis agitans was treated also by this method. Some cases were treated with reported good results by thyroid. Later when the parathyroids attracted attention they were administered with reported good success in even very severe cases. I think that there is a report of some cases of paralysis agitans being improved by injections of diphtheria serum. In other words, anything that was given to a patient with the promise that he would be better after it and that produced a definite effect upon his mind was likely to do him temporary good. If the remedy had some special theory behind it, if there was a story of some new scientific significance for the material employed or the method of giving it, then this improvement was sure to take place. {545} In the drug treatment of the disease the same principles applied. Earlier, when nitrate of silver was the main recourse for organic nervous diseases, cases were reported improved by its administration. When the alterative properties of arsenic became a therapeutic fad this produced good effects. Atropin had for some time a reputation of relieving patient's symptoms. After a time all of them ceased to be used to any extent. _The Frenkel Method_.--In recent years the application of the Frenkel directed movement method, modified somewhat from its application in tabes, has attracted attention in the therapeutics of paralysis agitans. It is interesting to note how often a mode of treatment that has been applied successfully to one of these diseases has also proved successful with the other. The two diseases are, of course, very different in etiology and pathology; but have one thing in common. The control over muscles has been lost to some degree in both cases in the progress of the disease, and a special effort of attention is required on the part of the patient in order to regulate movement. Anything that will arouse the patient to make this special effort will relieve the symptoms for a while and in tabes may bring about a lasting improvement, because the habit becomes easier after a time, though apparently this does not occur in paralysis agitans, except perhaps in the younger patients. It might very well be expected, then, that Frenkel's method in many cases would do good in paralysis agitans and it has proved to be another adjunct in the treatment of the affection. It must be used with great care not to exhaust the patient, but this is true also in tabes. The real source of its therapeutic quality seems to be the patient's interest in it and if this cannot be aroused it usually fails to do good. The success of these various mechanical methods makes it easy to understand why these patients often improve for a time under osteopathic treatment. _Psychotherapy_.--It is clear, then, that the most important aid for these cases is the arousing of mental interest in some form of treatment that promises to be of benefit to them. New forms of treatment cannot always be invented and mental occupation must be secured by interest in other things. Patients suffering from paralysis agitans are prone to allow themselves to give up efforts to do things in which their interest would be aroused. They must be encouraged to do many things. Carriage riding, automobiling, train excursions, because of the effort required to resist vibration, are all helpful. They must not be allowed to drift into vacuous habits in which they make no effort for themselves. They can thus be made much more comfortable and most of their symptoms can be relieved to a marked degree. This requires constant attention and ever-renewed efforts to arouse the patient's mind and to have him make such efforts as will overcome rigidity and control the tremor to some extent; but with care an amelioration of the condition can always be brought about and can be maintained, at least to the extent of making the patient much more comfortable than would otherwise be the case. {546} CHAPTER VII HEADACHE In spite of the improvement in the general health of the community, due to more hygienic living, more healthy food and better ventilation, headache, instead of decreasing, has increased to a great degree. Any number of headache cures are advertised in the daily papers, in the street cars, on the signboards, even in medical journals, and besides these nearly every druggist has his own special preparation for headache, so it would seem as though literally many millions of doses of these headache cures must be taken every week. It would seem as though there must be some special unhygienic factor at work to produce headaches at a time when all other pathological conditions are being reduced in number and severity. A study of the patients who are especially affected by headache seems to furnish evidence as to the special factor that has led to the increase of the affection. It occurs much more frequently in women than in men. It is complained of particularly by those who have less regular occupation, and the notable increase has come with the opportunity for leisure on the part of large numbers of the community due to the growth of wealth. A feeling of discomfort in the head to which much attention is paid will become such a painful condition as to deserve the name of ache, if it develops in those who have no serious occupation in life and no interests that demand peremptory attention. With the noise of many children around them in the olden times women suffered comparatively little from headaches. Most of our grandmothers scarcely knew what it was to have a headache. Now most business men are likely to say the same thing. Very rarely do they suffer from headache. When they do, there is some specific reason and when this is removed the headache disappears. There are many women of leisure who have regular headaches for which they must have some remedy at hand or the pain becomes intolerable, but there are few women strenuously occupied with business affairs or with interests in which their attention is absorbed who find themselves under any such necessity. It is evident that certain conditions predispose to headache. The principal of these is having sufficient time to advert to certain uncomfortable feelings in or around the head. Few people who stop to think of what their head feelings are but will find there is some unusual sensation somewhere in or outside the head which if dwelt upon becomes emphasized into an ache. If the mind can be diverted it disappears. If there has been some injury of the head or some pathological conditions set up by congestion or anemia, the feelings may become emphasized and occupy the center of attention, and even after the injury has disappeared or the pathological condition been ameliorated some sensations remain which with advertence produce achy feelings of discomfort. This is the history of a great deal of the increase of headache in our time. There are, of course, real headaches due to definite pathological conditions, but the great majority of headaches complained of {547} are the result of over-attention to certain sensations, some of them normal, some of them only slightly abnormal, which are emphasized by concentration of attention on them until they become a torment. Two main classes of headaches come to the physician for treatment. One class is seen in patients who suffer from real and even acute pain that cannot be distracted by diversion of mind, that is usually worse when they try to sleep, as toothache is, and is evidently due to definite physical disturbance. In the second class are the many queer feelings about the head called headaches, though the patient suffers rather from annoyance than from pain. It is said that the Chinese in olden times put criminals to a lingering death by fastening them in such a way that a drop of water fell every minute on their heads. It was impossible to avoid the falling drop, and its constant recurrence became an awful torture. Any feeling that engrosses consciousness will be followed by the same sense of torment. The constant exercise of function of any nerve without rest is of itself physically disturbing to a serious degree. This must be realized with regard to many forms of headache which, though trivial in origin, are the source of bitter complaint. Attention Headaches.--Professor Oppenheim, in his "Letters to Nervous Patients," has a paragraph with regard to headache that is worth recalling for the benefit of patients who suffer from low-grade headaches. Doubtless these were at the beginning real aches due to some local condition. They are now due merely to exaggeration of more or less normal feelings within the head which have come into the realm of the conscious because of the attention attracted to them when the intracranial affection was first noted. Professor Oppenheim says: Your headache also I ascribe to this source. Originally it may have been a real headache, the result of your nervous shock. There is no one who has not at some time had a transient feeling of pain in the head or in some other part of the body, quite apart from those caused by injuries or painful diseases. Out of a thousand various kinds of causes I will mention only an extremely common one: the pains which result from straining muscles or nerves. Every sudden awkward movement may in this way cause pain in different parts of the body, but very specially so in nervous persons, in whom the mechanical excitability of the nerves--that is, their sensitiveness to pressure and strain--is usually exaggerated. As a rule, however, this pain is quite transient. But here again the law of which I have been already speaking comes into force: under the stimulating influence of introspection the tiny, perishable seed-grain of pain grows into the firm, strong, enduring tree of neuralgia or psychalgia. The first condition for the successful treatment of headache, then, must include the recognition of the possibility of some rather simple pathological condition being exaggerated by over-attention to a disturbing affection, or of some affection, now past, having produced a suggestion that, in a mind given to introspection, continues to have influence even to the inveteration of sensations for which there is no longer a physical cause. These patients insist that their medical status is that of real pain. Hysterical patients describe a sensation as if a nail were being driven into the forehead--the so-called clavus hystericus. In nervous people the sense of pressure increases from one of mere discomfort to a positive pain, as a consequence of attention to it. In most cases of headache, however, what is most needed is a distraction of the attention from the ailment. Over and over {548} again I have found that when all remedies failed the deliberate search for an occupation of mind that would interest the patient during many hours of the day was the only thing that promised relief and in many cases the relief afforded was so complete that patients were effusive in their gratitude. _Power of Distraction_.--The proof that these so-called headaches are really not aches is found in the comparative ease with which many of them may be suppressed. Almost any interesting occupation will make the sufferer forget them entirely and they will not return immediately after the occupation ceases, but usually only when the patient is alone and attention is once more directed to this symptom. These queer feelings about the head that are often raised to the dignity of headaches by attention and auto-suggestion may be distracted away completely. That they are not pain is shown by the fact that the ordinary remedies which ease pain so promptly often fail to relieve these or soon cease to have any effect on them. _Lack of Distractions_.--The apartment hotel system has multiplied the victims of headaches. When a woman has nothing in the world to do except get her clothes fitted and attend to what she calls her "social duties," it is no wonder that her head bothers her. Blood is constantly going to the brain and interchange of nutritive elements is taking place, yet there is no real function of cells and no consumption of material, or at least function is so slight that consumption of material must be trivial. There is no reason why these women should get up in the morning. Their breakfast is brought to their rooms, and some of them do not get around until eleven o'clock. Women used to have a morning occupation in going out to market or else in planning the household day with housekeepers, but of course there is no more of that. In olden times, too, many of them had religious practices. Now women are likely to be unemployed until the afternoon, which must be occupied at most with so-called social duties that may be done if one wishes to do them, but that may be put off for many reasons and there are constantly recurring reasons for not making any special exertion. Also, the rooms these women live in must be kept at a high temperature because the poorer the air that we breathe the higher must be its temperature for comfort, while stimulating fresh air may be quite low in temperature and yet produce only a brisk reaction instead of chilly feelings. Children used to be the best possible remedy for these non-occupation headaches, but either there are no children any more or there are but one or two and these are largely cared for by _bonnes_ at home and by various schools once they have reached the age of three. The old idea that children should not leave home until six put upon the mother the burden of their early education, but since the coming of the kindergarten she is relieved of responsibility of this and the mother of one or two children might now almost as well be childless as far as any serious occupation from care of her children is concerned. If patients are told all this bluntly there will be a vigorous protest from most of them, for to them their pains are very real. It must not be forgotten that a pain in the mind is often worse than in the body. Some of these women save themselves from having their unused mental faculties disturb them from very lack of something to do, by becoming interested in charities, in clubs, in social movements of various kinds, in art and in literature. It is {549} not to these that I refer. On the contrary, if women have nothing else to do I would insist that they find some cause or movement in which they may become deeply interested. Their interest will save them from self-annoyance, though it may not exactly add to the gayety of nations in its effect upon other people. As a physician, however, I am only interested for the moment in the good of particular patients. Source of Pain.--I would not be understood as saying that all headaches are not real aches nor pains in the most literal sense of the word, for some of them are agonizing tortures. With regard to all headaches, however, even the most genuine variety, there are certain considerations that are of value from the standpoint of psychotherapeutics. The most important of these is assurance as to the source or location of the pain. Most people think that it is the brain itself that is suffering pain and not a little of their suffering is due to the fact that they dread the effect of such pain upon the cerebral tissues and its possible consequences upon their mental state. These people will be much relieved to be told at once that the brain tissue itself is not sensitive, that when exposed it may be touched with impunity without causing any pain. It is the structures surrounding the brain that are sensitive. As a rule the lesion that causes pain is not progressive and all dreads with regard to serious after effects may be put aside. Pressure Headaches.--It is important to insist on the fact that, as a rule, headaches and pains in the head are not due to the brain, but to extraneous structures within the skull. It is true that brain tumors, gliomatous and cystic and, above all, the overgrowth of the pituitary body in acromegaly give rise to agonizing pains. The cause of these headaches is undoubtedly pressure. It is not the pressure upon the brain tissue itself, however, that is the underlying cause of the pain, but pressure upon the sensitive structures connected with the brain. The same thing is true with regard to congestive headaches. Pain is produced not because vascular congestion presses on sensitive brain tissues, for we have no reason to think that any such exist, but because the congested brain exerts pressure upon sensitive filaments in its integuments. Neuralgia may be unbearable and yet it is borne with more equanimity, and less dread of results, because it is felt to be in a comparatively unimportant structure. One of the most serious elements in severe headache is the fear of lasting results in the brain tissues, that may lead to disturbance of mentality or to injury affecting mental processes. Patients find their pain much more bearable as soon as they are assured that headaches do not lead to mental disturbances and that, as a rule, even the growth of a tumor does not disturb mentality. In the relation of the brain to the intellectual faculties that are so closely associated with it, we must remember that direct connection between the two has not been demonstrated and that the relations of the brain and the mind are almost as mysterious as they ever were. There are some who still think that the frontal convolutions are especially concerned in carrying out mental operations. All that we know about them in pathology, however, is that they are the silent convolutions. When a lesion occurs in other portions of the brain we see the effect of it practically always without delay, in some way, either in the sensory or motor functions of the body. Large lesions in the frontal region, however, often give no sign. Large tumors have been found {550} pushing frontal convolutions from their ordinary positions without any noticeable effect upon the individual. Hard Study and Headache.--It is worth while to impart this knowledge to patients who suffer from headaches, because it at once improves their outlook on life. I have known hard students--men who had spent twenty or thirty years in work at a special subject--live in constant dread that sometime their minds would give way because they frequently suffered from headaches, or at least from some uncomfortable sensations in their heads, which they feared as a portent of ultimate mental breakdown. The assurance that such a thing is utterly unlikely and quite apart from the physician's ordinary experience, not only relieved their anxiety and made their headaches more bearable, but in a dozen of cases in my note-books the headache has gradually disappeared as certain habits of life were corrected and modified, as their habits of eating were varied, as bodily functions were controlled and as diversions of mind were introduced into lives that had before been too unvaried for healthy functions. I do not think that I have ever seen a case, and I have been closely in touch with hard students for over twenty years, where I felt that the cause of a headache was mental overwork. I have known men who at the age of seventy or over have taken but four or five hours of sleep and who have worked at their favorite subjects for the better part of half a century. They never complained of headaches. Of course, there are others whose physical and mental power is less and who cannot be expected to stand a strain that for large-minded men is only the normal exercise of function. It has not been the mental work that they were doing, however, that was the source of whatever central nervous disturbance was to be found in lesser minds, but worry and anxiety and dread over what they were doing, anxiety as to what they were going to do that constituted the real pathological agents at work. _Local Conditions_.--A striking case that impresses patients much more than the physician's declaration and is more likely to be remembered and is therefore of psychotherapeutic value, is that of Von Bülow, the German musician. He suffered for many years from excruciating headaches. They were so severe as almost to drive him crazy. His only relief was morphine and he and his friends lived in the midst of no little dread that sometime or other either the pain or the process which caused it would bring about a deterioration of mentality. After his death an autopsy was made. It was found to be a small nerve fiber pinched by a scar in the dura as a consequence of an injury received when Von Bülow was very young. Many other stories of this kind have been told. It must not be forgotten that in many cases the pain is not within the skull itself or at least its cause is not and other sources should be carefully looked for. The connection of the eyes with headache has been so well worked out, owing to the initiative of S. Weir Mitchell, that nothing more need be said of it. One feature perhaps deserves to be mentioned. While strain of accommodation is a frequent source of headache and is at once looked for by ophthalmologists, there seems no doubt that some headaches, much fewer than accommodation cephalalgias, are due to muscle difficulties, that is, a lack of balance among the external muscles of the eye, whose full pathological significance has perhaps not yet been worked out. Headaches are {551} frequently due to sinus troubles, especially to disturbances in the frontal sinus and to intranasal difficulties. These must be eliminated before the patient can be helped. Sometimes these nasal and sinus difficulties are signs of a deeper constitutional disturbance, due to lack of fresh air and exercise and are relieved promptly by the establishment of hygienic habits. Congestion Headaches.--Some headaches require changes of habit and persuasion of the necessity for arranging the day's work so as to give proper intervals for relaxation. Much experience with persons whose absorption in their work causes them to miss a meal or delay taking it for seven or eight hours from the last time of eating has shown me that this disturbance of the routine of vegetative life is particularly likely to be followed by headache. This headache is not a mere dull ache and is much more than a sense of discomfort; it is often an excruciatingly painful condition that usually does not come on until toward the end of the day and then may seriously disturb sleep. An interesting thing about this class of headaches is that nearly always they are increased by lying down. Often only a faint preliminary symptom of it is apparent when the patients go to bed, though they may be wakened after two or three hours of disturbed slumber by a headache that prevents further sleep, and pass the remainder of the night in painful wakefulness. Usually it becomes impossible to continue lying down. The head must be raised and much relief is afforded by sitting up. The headache does not disappear at once but it will gradually pass away and sleep may be resumed after a half an hour of sitting up, though the sleeper will have to be in a sitting posture. Older people get up and sit in an arm-chair. I have found that placing a chair with a rather long back beneath the mattress, the mattress slanting along the chair back at an angle of about forty-five degrees and then an arrangement of three or four pillows above that, will enable these patients to get to sleep better than anything else. The ordinary remedies for headache afford some relief, but even very large doses of the coal-tar products will not relieve the pain entirely unless some arrangement is made for keeping the head quite high and immovable. The headache is evidently due to congestion. The reason for it is perhaps the failure of the blood to be recalled from the brain to do its usual physiological work at the digestive tract, with a consequent distention of arterioles in the brain so that a little later they do not react to prevent congestion. Usually with the headache there is some digestive disturbance, a feeling of unrest, flatulency with perhaps acid eructations. Accordingly the headache is often attributed to digestive disturbance. But both would rather seem to be effects of the same cause--the failure to supply the digestive apparatus with the proper amount of material to work on at the time when it expects it, while the mental absorption naturally attracts blood to the head. We know from delicate experiments made in physiological laboratories that at times of mental work there is an appreciably larger amount of blood in the head. A proof of the connection between the lack of a meal and the headache seems to be the fact that with most people even a glass of milk and a cracker, taken at the time when the meal is normally eaten, is sufficient to prevent the otherwise inevitable headache. Whenever some such simple explanation as this for a headache is found and the patient made to realize its truth on his own observation, the {552} significance of the headache at once dwindles and it becomes much easier to bear it. Before the very real pains of it were emphasized by the dread of the consequences that would result from it. If it was really a brain ache patients would find it hard to understand how under its influence even serious changes might not take place in the brain. This is only a rational suggestion, but it is mental healing of the best kind. Many of the aches which are spoken of as headaches are really forms of tenderness associated with the integuments of the skull. Certain of the muscles particularly are likely to suffer from achy feelings which are spoken of as headaches. This is true of certain feelings of discomfort in the frontal region and also of those that occur on the occipital region. External applications of many kinds relieve headaches in these regions, particularly in the frontal region. It is easy to understand that such applications do not affect the contents of the skull. Some Occipital Aches.--Occasionally I have found that people who complained of a sense of weight at the back of the head, with some muscular tenderness, were sleeping on pillows that were too high. They were over-exerting these muscles and this gave a sense of fatigue, which when much attention was paid to it, became such an ache or at least discomfort as is often found in the occupation neuroses. I have seen schemata according to which headache complained of at the top of the head meant digestive disturbance, headache in the anterior portion of the head was referred to the eyes or the brain, and headache at the back of the head spinal exhaustion or severe neurasthenia, but these are at most very uncertain and I do not think that the tabulation of cases justifies any such diagram of absolute causes and effect. Usually there is some local condition that calls particular attention to a special part of the head and then the attention being concentrated complaint is made of that part. Local Head Discomfort.--Usually a headache, accompanied by a localized sense of pressure or weight or constriction, occurs in highly neurotic people or those inclined to think much of themselves and whose attention becomes concentrated on some part. At all times we have sensations streaming up to our consciousness from every portion of the body and anyone who wants to think about them, or a particular set of them, can make them sources of considerable discomfort by concentration of attention. Sometimes there are special conditions that predispose to these localized sensory disturbances. I have known tight hats to produce such effects. It is sometimes surprising how tightly hats are worn. Nervous people are prone to overdo everything, and they overdo the pulling down of their hats. At times the wearing of a heavy hat will be the root of the trouble. I have known nervous men accustomed to wearing high hats all their lives who began to complain of headache when they were in the midst of busy worries and troubles of late life, find considerable relief by abandoning their high hats. Toxic Headaches.--There are headaches that are due to the taking of stimulants, as is well known from common experience. The mistake is often made, however, of thinking that only alcoholic stimulation will cause a severe headache. Tea and coffee headaches may be quite as severe. Whenever people complain much of headache it is important to revise their dietary as to the consumption of tea and coffee. Of course, the headaches following {553} alcoholic stimulation are usually recognized as such, though occasionally a man accustomed to taking much alcohol without any such after effects is surprised in the midst of the worry incident to business stresses to find that he is having headaches. These are due to the combination of stimulants and congestion consequent upon an excess of alcohol with the increased brain work that is demanded, or even with the same amount of brain work from a tired brain. Gradually stopping the alcohol will do more to relieve these headaches than anything else. To advise the sudden stoppage of regular quantities of spirits that have been taken for some time, will sometimes produce an anemic headache and defeat the purpose of the advice. When for some other reason tea or coffee or alcoholic stimulants are suddenly omitted after they have been taken to excess for some time, patients' complain of a headache. Some of this is probably imaginary, or at least is due to the idea that their craving for the stimulant, whatever it may be, must have a local manifestation, and the head sensation is exaggerated as a consequence. Tea and coffee cravings may here give more trouble than the longing for alcohol. Sometimes there may be a real disturbance of the circulation from the lack of the heart stimulant to which the system is accustomed and therefore an uncomfortable feeling in the head from brain anemia. This can be overcome by not cutting off the stimulant, whatever it may be, all at once, but by bringing about its gradual cessation. These patients, however, are very prone, even with the best of good will in the matter, to deceive themselves and find an excuse for not having their favorite tipple, be it tea or coffee or alcohol, taken from them, so that they readily create symptoms by auto-suggestion. Direct Mental Treatment.--For both congestive and anemic headaches mental treatment is important. For those suffering from the congestive kind the physicians's business is not so much the cure of any one attack of headache (for this can be accomplished by various now rather familiar anodyne drugs as a rule), but the discovery and removal of the cause for the recurring attacks. These will be found in some habit of the patient which must be corrected. Drugs are seldom needed for the underlying condition which occasions the headache, for when it is due to such organic affections as brain tumors or other intracranial lesions, drugs can accomplish very little. In less serious conditions benefit may be obtained by having the patient change his attitude towards certain important details of his life, such as eating, sleeping, attention to business or to study and the like, so as to prevent the mistakes of daily habit that predispose to headache. With regard to anemic headaches, especially those which occur in persons who are very much run down in weight, the most important element of treatment is to bring about an increase in weight. This can be accomplished much better through the mind than in any other way. Appetite is a function of the will, and patients should have an increase of diet dictated to them and then be persuaded to follow that. I have seen many a headache disappear among teachers, and religious workers particularly simply as the result of this measure. As regards headaches for which no definite cause can be found mental treatment is the only efficient remedy. Practically nothing but a change of mental attitude towards the affection and its underlying causes, whether these {554} be neurotic or psychic, will bring about relief, and each patient is a problem quite distinct from any other. There is no pretense that this use of mental healing for headache is new or even modern. Many stories show that in olden times headaches were often relieved by this means, and that suggestion was looked upon as an important element in the treatment for their relief. In the chapter on Great Physicians in Psychotherapy the quotation from Plato with regard to Socrates curing the headache of his young friend Charmides illustrates this very well. In the old stories of Greek medicine there are a number of references to headaches cured by suggestion or at least by mental influence. Miss Hamilton, in her book on "Incubation," [Footnote 40] tells the story of Agestratos and his headaches and how they were cured at Epidaurus. Agestratos had a combination of headache and insomnia, the description of the ailments having a strangely modern air. Just as soon as he came to the Temple at Epidaurus he fell asleep and had a dream. The God of Medicine, AEsculapius, whose cult was practiced assiduously at Epidaurus, came to him in his sleep and promised him the cure of his headache and at the same time taught him wrestling and advised its practice. When day came he departed cured, and continued to practice wrestling. Not long after he competed at the Nemean Games and was victor in the racing. The suggestion that his headache would get better had come to him and at the same time he had been given a suggestion that provided him with occupation of mind and body. Many of the people who suffer from persistent headaches need this advice more than anything else. Probably every physician has had the experience of headaches being cured by some interesting exercise, especially if taken in the open air. The important factor is the change of mental attitude, though changes in exercise, diet, amount of sleep and the like are helpful auxiliaries. [Footnote 40: London, 1906.] {555} SECTION XVI _NEUROSES_ CHAPTER I NERVOUS WEAKNESS (NEURASTHENIA) Neurasthenia, from the Greek roots, _neur_, meaning nerve, and _sthenos_, strength, joined by the negative particle _a_, turning strength into weakness, means nothing more than nervous weakness. To tell a patient that he or she is nervously weak, or is suffering from nervous weakness is usually not satisfactory, but it may be absolutely true and may represent the limit of our knowledge with regard to the particular case. To tell them that they are sufferers from neurasthenia is satisfying as a rule, because then they have a nice, long, and imposing word with which to talk to their friends about their ailment. To discuss with friends one's own nervous weakness is just a little absurd; to talk over neurasthenia and its symptoms, however, adds importance to those symptoms and makes them seem manifestations of some interesting underlying condition. The discussion of symptoms always does harm, but the internal complacency with its constant auto-suggestion of the underlying nervous disease is still more harmful. Neurasthenia seems to most people to signify a new and serious disease of the nervous system which has developed as the result of our high-pressure civilization and the modern strenuous life, and, therefore, has a special interest and an exaggerated importance. All of this makes for an unfavorable attitude of mind towards the affection and encourages the intensification of symptoms by attention to them. The opposite state of mind in which symptoms would be given their proper value by the term nervous weakness would act as a constant source of favorable suggestion. I believe that if the word neurasthenia must be used, it should be translated for the patient and the absolutely functional character of the affection insisted on in order to neutralize its suggestive influence. Probably the most serious objection to the use of the word neurasthenia comes from the number of organic affections having vague nervous symptoms, including especially tiredness, a certain incapacity to do what was readily done before with tired feelings and a general feeling of unfitness, that have come to be grouped under this head. In this it resembles the word rheumatism rather strikingly. The diagnostic general principles seem to be: tired feelings equal neurasthenia; achy feelings (especially if worse on rainy days) equal rheumatism. So whenever either word is used, patients are apt to think of cases they have known which were labeled by one of these two terms, {556} rheumatism or neurasthenia and ended by developing some serious condition. The unfavorable suggestion consequent upon this has made many patients miserable and has prevented them from using their nervous energy to relieve their condition. The use of the word neurasthenia has another decided disadvantage in that the facile recourse to it often keeps the physician from examining his patient sufficiently to detect an underlying pathological condition. The term can be made to cover so much that it has done great harm in this way. I feel, therefore, that in the discussion of what can be done for patients suffering from nervous weakness we should first of all describe and set aside a number of forms of disease that have sometimes masqueraded as "neurasthenia" and that have given the affection stronger unfavorable suggestiveness. Sir William Gowers, whom no one would suspect of either minimizing the significance of the word or of the affections that have come to be grouped under it, nor of wishing to attract attention by differing from others, has in one of his recent smaller medical works [Footnote 41] emphasized both of these unfortunate connotations of the word. Because his expressions as applied to other medical terms that are too general in their significance, will help physicians to get at the real meaning of them I venture to quote his opinion at some length: [Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy and Other Lectures," Philadelphia, 1904.] The history of the word "neurasthenia" is noteworthy. ... I have to confess to the authorship of two words. One, "myotatic," was always a puny infant, and I doubt whether it still maintains an independent existence. The other, "knee-jerk," instantly attained universal use, and indeed, I think has seemed to most persons to have sprung spontaneously from the thing itself, without suggestion--perhaps the greatest compliment a word can pay its author. But the general use at once achieved by "neurasthenia" was in spite of a strong objection to it which was felt by many. The Royal College of Physicians of London could not include it in their "Nomenclature of Disease," and yet it is now one of the most common of medical words in every language. It would be instructive in more than one way to have a careful study of the forces which have influenced its career, but that I cannot attempt. We must, I think, admit that not only is it a satisfying word to those who suffer, but it has a certain convenience which has also compelled many to employ it who at first objected. If I may be pardoned for a partial paradox, its convenience is not the less real because this rests on features that are illusory. Remember that the word is a name which should have little meaning, even to those who use it. You may employ it to collect the symptoms of the case under a general designation, but do not let it cover them as a cloak. Neurasthenia and Melancholia.--A serious mistake of diagnosis, though it is often not a mistake of knowledge but of medical judgment, is the confusion, apparent or real, of neurasthenia with melancholia. The word melancholia has come to have a definite serious significance, as it should, in the minds of many persons and as a consequence physicians sometimes hesitate to use it, and employ instead the all-embracing term neurasthenia, or neurasthenic depression. It is popularly well known that melancholies are likely to commit suicide if their condition is serious, while neurasthenia is not at all connected with the idea of suicide. As a consequence, patients are often not guarded as they otherwise would be and so we have suicides every {557} month of so-called neurasthenics who were really sufferers from melancholia. This sad state of affairs reflects in two ways to the detriment of medicine. First, it leaves melancholies without due protection. Second, it leads many of the neurotic patients whose ailments have been labeled neurasthenia and who read the stories of these supposed neurasthenics, to think that they, too, are tending toward suicide and so they are less capable of reacting against their neurotic condition and in general are much worse for the unfortunate dread of some such fatal termination. Neurasthenia Simulation by Organic Disease.--Neurasthenia is especially a dangerous term since, like other words of this kind with wide connotation, many quite disconnected diseases may in early stages simulate it and give rise to the thought that there is only a functional nervous disease present, when the symptoms are really a manifestation of an underlying organic disease, heightened somewhat by a nervous organization or by worry on the patient's part. So-called neurasthenia in the old must always be looked upon with suspicion. Neurasthenia in the young may be a purely functional nervous disease, though it is probable that in most cases the nervous system is congenitally defective, or at least is unable to perform the functions which have been assumed by the patient. If a nervous organization has stood the strain of the trials of early and middle life, which are usually severe enough to try out individuals from the physical side, if they are in moderate circumstances, or from the mental side if they are wealthy, it will not, as a rule, be overborne by the burdens put upon it by age unless some organic disease has come to seriously disturb it. _Neurasthenia and Arteriosclerosis_.--There are many serious conditions that masquerade as neurasthenia. Perhaps the most important is precocious arteriosclerosis. That a man is as old as his arteries is now recognized as an absolutely sure maxim of internal medicine. In many people the arteries wear out before their time and in all there is an inevitable wearing out in the course of years. With the beginning of degeneration of the arteries there are likely to be many symptoms that closely resemble neurasthenia. In the elderly these are nearly always symptoms of defective circulation because of lack of elasticity in the arteries and their failure to accommodate themselves to the variations of pressure in the circulation as the consequence of changes of position, variations in the barometer, heat and cold, and the like. In these cases a study of the blood pressure will give the differential diagnosis when the actual thickening of the arteries cannot be felt, but it must not be forgotten that nervous excitement may greatly heighten blood pressure on occasions so that a number of observations have to be made. _Neurasthenia and Bright' s Disease_.--Other general diseases almost inevitably produce nervous symptoms. It is curious how often a severe exacerbation of Bright's disease, which has been in existence for some time but has given no specific indication, is preceded by a series of neurotic symptoms thought to be due to nothing more than neurasthenia. Men of thirty-five to forty-five, the favorite time for the occurrence of the severe forms of Bright's disease, begin to complain of tiredness, especially on waking in the morning, of inordinate fatigue in the evening, of some stomach symptoms and occasionally a tendency to diarrhea. All of these are ascribed to a neurasthenic condition. Early in these cases an examination of the urine should be made {558} as a routine practice, because if there is nothing in it the patient will be just that much more reassured, while if it contains any pathological elements he need know no more about it than his physician deems proper, yet the real nature of the case and its indications will be appreciated. Without this a physician will often find himself suddenly confronted by serious symptoms in a patient when nothing of the kind was anticipated because the condition was thought to be entirely functional. Occasionally the symptoms of Bright's disease seem to develop suddenly, as it were a storm in the organism out of a clear sky. As a matter of fact, however, there have been for some time before more or less indefinite symptoms pointing to some serious process at work, which if valued at their proper worth might have led to a much earlier diagnosis of the impending nephritis. Such patients are labeled as neurasthenics for months and at times even years before the serious conditions develop which make the recognition of their ailment comparatively easy. One case of this kind has come under my observation that is interesting in its lessons. A medical student had during the first year of his course exhibited every now and then what seemed to be neurotic symptoms. He was inclined to complain of headache for what seemed very slight reasons, and of pains and aches whenever there was a change in the weather and especially a fall in the barometer. He often had stomach symptoms and was anxious about his heart; in general he was looked upon as one of the nervous, complaining kind. During the course of a lesson in clinical pathology in his fourth year, he was asked to furnish a sample of urine which it was supposed would be normal, for comparison with an abnormal sample that was being investigated in the laboratory. To the surprise of the professor and to his own consternation, his urine was loaded with albumin. Up to that time there had been absolutely no objective symptoms and only the vague indefinite subjective symptoms mentioned. The next day his feet swelled. Even this for a time was considered to be rather an index of the neurotic tendency in him to react to very slight causes. It was hoped that the albuminuria was functional, as the examination was made in the full tide of digestion, and that it would pass off. Subsequent examinations, however, showed not only albumin but also casts. There was a slight intermission of symptoms and then an exacerbation. Within a month after the chance examination of his urine and its unexpected result he had a convulsion. Two weeks later, altogether six weeks after the albumin was first discovered, he died in nephritic coma. Such cases are not so rare as they are thought, though they are seldom so fulminant. There is a story told of a professor at one of our American medical schools who, some twenty years ago, took a sample of his own urine in order to demonstrate the normal characteristics of healthy urine, and to his utter surprise he found albumin and casts in it. Within six months he was dead from Bright's disease. _Nervous Diarrhea and Organic Disease_.--Other internal conditions may be called neurotic when they are really due to definite pathological entities. For instance, in three cases I have seen what had been pronounced by several physicians to be chronic diarrhea of nervous origin, proved to be due to quite other and serious pathological conditions of internal organs. In one of them a chronic diarrhea of several years' standing finally culminated in death in {559} early middle age from nephritis. After the event, there seemed to be no doubt but that the diarrhea, which no ordinary means of treatment had succeeded in benefiting more than temporarily, was really due to the effort of the intestinal mucosa to supplement the defective work of the kidneys. In this case apparently one of the strongest evidences that the affection was of nervous origin was the fact that whenever the patient was away from home, eating rather plentifully of a varied diet, his intestinal condition was better than when he was eating much more simple and unvaried food at home. The change of scene and surroundings proved a tonic to his kidneys and perhaps also to his skin, thus saving his intestines some of the extra work they had assumed. _Neurasthenia and Diabetes_.--Another serious disease that may in its earlier stages be mistaken for neurasthenia is diabetes. There is no doubt that some patients have been passing sugar for a long time before any sure symptom can be noted in their general health, or, indeed, before there is anything to call attention to the possibility of glycosuria. In many of these cases, however, there is a feeling of muscular tiredness and a sense of inadequacy for occupations which were before easy, that may be attributed to neurasthenia. When this muscle tiredness changes to crampy feelings that should be enough to lead to an examination of the urine. Undoubtedly one of the reasons why neurasthenia is sometimes called the American disease and is thought to be more frequent among us than it is in Europe is this confusion with the beginnings of serious organic disease because of failure to examine patients carefully in order to detect underlying organic conditions. In recent years this neglect has become rarer and the consequence has been a reduction in the numbers of so-called neurasthenia cases. Our morbidity statistics of twenty years ago, for instance, seemed to show that we had only half as much diabetes to the population as they had in Europe. One of the reasons for this was undoubtedly the ease with which the diagnosis of neurasthenia might be made at the beginning of diabetes, and that the terminal stages of the affection were often masked by the development of the tuberculosis so frequent in diabetic conditions or of albuminuria with symptoms pointing to Bright's disease. Even at the present time it would be quite possible to reduce the number of neurasthenia cases by more careful attention to diagnosis. Simulated Neurasthenia Due to Over-attention.--While there is danger of confusing neurasthenia on the one hand with more serious disease there is a distinct liability on the other hand to exaggerate the significance of certain minor symptoms by employing the word when it is only over-attention of mind to certain portions of the body that constitutes the disease in its literal sense. If something has particularly attracted a patient's attention to some part of his anatomy and if his attention is concentrated on it and allowed to dwell long on it, his feelings may be so exaggerated as to tempt him to think that they are connected with some definite pathological condition and he may even translate them into serious portents of organic disease. If a patient once begins to waste nervous energy on himself because of solicitude with regard to these symptoms then it will not be long before feelings of tiredness, incapacity for work, at times insomnia and certain disturbances of memory are likely to be noted. Then the neurasthenic picture seems to be {560} complete. This is the process so picturesquely called "short-circuiting" by which nervous energy exhausts itself upon the individual himself instead of in the accomplishment of external work. Many of the worse cases of so-called neurasthenia have their origin in this process. It is true that this set of events is much more likely to occur among people of lowered nervous vitality, but under certain conditions it may develop in those who are otherwise in good health up to the moment when the attention happened to be particularly called to certain feelings. The physician can start these patients off anew after improving their physical condition, if he can only bring them to see how much their concentration of mind upon themselves is the cause of their symptoms. It has been well said, though to some it will doubtless seem an exaggeration, that we human beings are a regular boiler factory of sensations which, fortunately for our sanity, mental and physical, we have learned to neglect to a great extent. Wherever our clothing touches us, wherever the air touches us, wherever shoes or belts constrict us, there are definite sensations. These continue, but attract no attention unless they exceed a certain limit to which we are accustomed. Habit in this matter is very different in different individuals. After men and women have grown used to tight shoes or tight corsets these no longer produce disturbance. The chance visitor in a boiler factory or loom room of a cotton mill thinks he could not live in such din. But after a time people get so used to the din that silence and quiet may even become oppressive to them. City dwellers from the slums, especially children, find the peace of the country disturbing when they are first taken for vacations. Over-attention to sensations, often scarcely abnormal, is indeed the real source of many of the symptoms that can so readily be exaggerated into pathological portents when attention is directed to them. Every portion of our body is connected with the central nervous system. Every square inch of surface touched either by clothing or the movement of the air producers a sensation at every moment of our waking life. Ordinarily we pay no attention at all to these sensations. We can recognize their presence by turning our attention for the moment to any portion of the body and recognizing at once that there are sensations coming from it, though the moment before we did not notice them. If we think of the point of our big toe on the right foot we find, though we were totally unaware of it a moment before, that a certain pressure is being exerted in it. If we continue to think of it queer feelings develop in it. We may get a sense of numbness that proceeds up along the tendons that lead to it. We can follow them up to the insertion of the muscles in the shin. If we dwell on the subject we have curious prickly sensations and numb feelings, all of which were there and were neglected a minute before but now are acutely felt. This same thing is true of all the manifold sensations that come streaming into the brain. We learn almost to enjoy them though we are paying no attention to them. To be without them would mean very often a fright lest there should be something the matter. Usually we think of the outside of our body as the main source of sensation. It must not be forgotten, however, that our viscera have also certain sensitive nerves and while these are not as closely distributed as those on the surface they are there and their presence is often a source of pleasure or at least of satisfaction, but may be the source {561} of poignant discomfort. We are constantly disregarding ordinary messages from these, too. Something may easily call our attention to these sensations, however, and then we may translate them into pathological terms though they are really only physiological. Ordinarily man may put a couple of pounds of food and drink into his stomach and not feel it at all. If anything particularly calls attention to our stomachs, however, and we dwell on it, then this weighty feeling may seem to indicate serious indigestion because of the discomfort that is produced. This is what nervously weak persons, the so-called neurasthenics, are constantly doing. It is this habit that by suggestion and training they must be taught to break. There is a tendency to the substitution of one neurotic symptom for another whenever by psychotherapy and mental discipline one condition is overcome. Often the substitution is of something just as bad or even worse. I have known cases where people when properly persuaded gave over paying too much attention to their stomachs and then proceeded to pay too much attention to their sleep with the result that insomnia developed. On the other hand, I have known patients to get over insomnia and then develop a series of complaints of queer feelings in their head which they usually spoke of as headache, though when asked to describe them carefully they confessed that they were at most a sense of pressure or of unusual feeling in some part of the head. These curious substitutions take place particularly if for any reason special attention is called to another part of the body, either by accident or by some therapeutic manipulation or remedial measure. I have known a patient who complained of headache and was advised to take up exercise in the open air, do much stooping and lifting while cleaning snow from the sidewalk, develop a tired condition in the lumbar muscles and straightway this was thought to be rheumatic. Liniment was employed and the counter-irritation which developed attracted the patient's attention to that portion of the body for a week. The headache was no longer complained of, but lumbago was considered to have developed. I have known a person who suffered from headache develop what seemed to be a retention of urine for which unfortunately the doctor thought it necessary to use a catheter and after this there was no complaint of the headache, but the patient became almost unable to hold any amount of urine in her bladder and could not go out for social or other duties because of the fear of imperative urination. CHAPTER II CHOREA This twitching affection, so familiar that it need not be described particularly, is sometimes classed as a pure neurosis, sometimes as a nervous disease with perhaps some organic basis and sometimes is placed among the ailments related to rheumatism and attributed to some pathological condition of the circulation. Etiology.--Two elements must be considered in the problem of the etiology {562} of the disease--the predisposition and the direct occasion. The affection occurs particularly in nervous children who are made to occupy their intellects too much while their muscular systems are kept quiet for long hours. Often a preceding running down in weight is noticed, though sometimes the child only fails to increase in weight as it should in proportion to its growth. It occurs quite frequently among chlorotic girls just before or about the time of puberty. Anemia generally seems to predispose to it, but the affection may occur among children who seem to be in excellent physical health, though usually a distinct nervous heredity is found. _Immediate Causation_.--Fright is one of the most frequent immediate causes or occasions of the development of chorea. Mental worry of any kind may have the same effect. Scolding has produced it; a sudden grief has seemed to be the occasion; a slight injury, and still more, a severe injury, or a surgical operation, even a slight one, may be the forerunner of it. Pathology.--No definite lesions have been found to which the disease can be attributed, though a careful search has been made for them. Endocarditis is an extremely common accompaniment. It is probably present in three-fourths of the cases that have come to autopsy. Osler found it in sixty-two out of seventy-three cases in the literature. The association of the affection with rheumatism is insisted on by the French and English particularly, and certainly in a considerable number of cases there is a history of preceding or coincident rheumatism, that is, an acute rheumatic arthritis. Often these attacks are concealed under such names as "growing pains" or "colds in the joints" but it is not hard to elicit a history of a red and swollen joint with some fever. In children mild cases may occur of genuine acute rheumatism with the involvement of but a single joint and that not severely. These mild forms are often found in the history of cases of chorea. It seems likely that the heart affection is often responsible for the symptoms and it is probably through the endocarditis that whatever connection there is between chorea and rheumatism exists. All the elements in the disease point to the influence of the mind over it. The predisposition is caused by over-use of the mind at a time when many claims are being made on the nervous system because of the growth of muscles. There must, as a rule, be a pathological basis, natural or acquired, that is, something that tends to produce a defect in the circulation, but even without this certain children suffer from the affection. If the patient is an object of solicitude or of curiosity at home or at school, the symptoms rapidly become worse. At any time the consciousness of observation makes them worse. The symptoms do not occur during sleep, or at times when the patient's mind is much occupied with some absorbing interest. They lessen just to the degree that the patient's own attention is not called to them or the consciousness not allowed to be concentrated on them. Chorea often occurs in bright, intelligent children and always seems worse in them. Treatment.--The story of the therapeutics of chorea in recent years strongly confirms the idea of the place of mental influence in the cure of the disease. We have had a whole series of remedies, introduced with a promise of cure by distinguished authorities, used for a time with apparent success by many physicians, and then gradually falling into innocuous desuetude. It was recognized that any remedy would have to be used over a rather {563} prolonged period, at least from five to ten weeks. It was appreciated, also, that the patient must be kept quiet, both in mind and body, emotional disturbances especially being avoided, that all physical functions have to be set right and that the nutrition particularly must be corrected if in anything it is abnormal. Where all this is done patients recover without any remedy quite as promptly in most cases as with any of the supposed specifics. Expectant treatment, supplemented by symptomatic treatment, has proved in many institutions to give excellent results without the necessity of troubling the patients with more or less dubious drugs. It was important that the patient should be given certain medicine and impressed with the idea that this medicine was expected to do them good, a suggestion automatically emphasized at every dose, but it is probable that few men of considerable clinical experience now hold the notion that we have any genuinely curative remedy for chorea, though we have certain tonic, alterative remedies which, in conjunction with the setting of the mind at rest, help to put the patient in a condition where the affection is gradually overcome. The most important object in the treatment of chorea must be its prevention or its early recognition, and its immediate treatment; then there is little likelihood of relapses and, above all, the condition does not last long. Children who have had an attack of acute articular rheumatism or who have suffered from growing pains or any other of the rheumatic simulants of childhood should be watched carefully during their growing period and at certain critical times in early life. They should be especially regarded immediately after being sent to school. The first sign of involuntary twitchings should be taken to mean that the children are overborne and a period of rest from anxiety and study and over-exercise should be afforded them. Of course, all this watchful care must be exercised without attracting the little patient's attention, or the very purpose of the care will be defeated and the mind disturbed. Rest does not mean that patients should be kept absolutely in bed even after chorea has frankly developed, but that there should be hygienic rest. Long hours of sleep, interesting occupations without much exercise, a period of lying down in the afternoon, but, above all, such occupation of mind with simple pleasant things as keeps their attention from themselves. Visitors should not be allowed to see them; above all, they should not be conscious objects of over-solicitous care on the part of father and mother or the relief of symptoms will be delayed and the condition will be made worse. As a rule, children do not worry about themselves nor their physical ailments, but they can be made to do so by seeing the over-anxiety of others. A good nurse of sympathetic nature with power to interest the child, is better than its mother for a constant companion, though family life, the playing with brothers and sisters and the regular routine of home is the best possible mental solace and occupation. Grandmothers are useful adjuvants in the treatment late in the affection. At the beginning their over-solicitude nearly always does harm. Habit Following Chorea.--In certain nervous children after the chorea itself has subsided there remains a habit of twitching that often is almost more intractable than the chorea itself. This is particularly likely to be manifest in children who have an unfortunate nervous heredity or in those whose {564} nervous systems have been impaired by preceding infections disease as anterior polio-myelitis, syphilis or one of the forms of meningitis. Occasionally it is seen in children without nervous heredity, but they are usually children surrounded by solicitous relatives, made the centre of pathological interest and constantly fussed about. The habit is not surprising and would remind the observant physician of the whoop that by habit sometimes clings to children in any cough that they may have for months after they have had whooping cough. Often it will be found that these children are capricious eaters, that they take tea and coffee, that their diet instead of being the simple nutritious food that they should have consists of many things that their mothers obtain to tempt their appetites and that the children can really have anything they crave for and get it much oftener than is good for them. To continue any form of presumedly specific treatment in these cases does no good. If arsenic is used over long periods, or any of the salicylates because of the supposed connection of chorea and an underlying rheumatic diathesis they will certainly do harm. The patients' diet can be regulated, nerve stimulants of all kinds must be denied them, and their appetites must be brought into order by the proper care of a nurse who will not yield too readily to their caprices, and then the solicitous environment must be changed. These cases represent a good many of the so-called prolonged choreas and are really habits or tics due to concentration of mind and a certain hysterical tendency to continue to attract attention which may be noted. CHAPTER III TICS Without any good reason in the etymology or the history of the word, the term "tics" has now been generally accepted to signify certain involuntary movements, frequently recurrent, of which, by habit, certain persons usually of diminished nervous control, become the victims. For the psychotherapeutist, however, they have an interest quite beyond that which they have for the ordinary student of nervous diseases. They represent the possibility of the formation of habits in the nervous system, originally quite under the control of the will, but which eventually become tyrannously powerful and quite beyond management by the individual. They deserve to be studied with particular care because it is probable that they represent objectively what occurs also on the sensory side of the system, but which not being manifest externally, is spoken of as entirely subjective. If nerve explosions of motor character can, through habit, get beyond the control of the patient, it is not unlikely that sensations, primarily of little significance, may, in persons of low nervous control, become by habit so likely to be repeated as to make the patient miserable. Hence the study of tics as here presented. As a result of the studies of Gilles de la Tourette, we realize that there is an essential distinction between involuntary movements of various kinds, and that spasms and tics must be separated from one another. Tics consist of various movements of the voluntary muscles. Probably the most familiar {565} is that of winking. Everybody winks both eyes a number of times a minute quite unconsciously, though the unconscious movement accomplishes the definite and necessary purpose of keeping the conjunctiva free from irritant particles. When this same movement is done more frequently than is necessary, or is limited more to one eye than to the other, or is repeated exaggeratedly in both eyes, then it is a tic. There are many other facial tics. Most of them represent movements of the lips or of the nose or of the skin of the forehead and all of them are identical with movements that are occasionally performed quite voluntarily. There are movements of the lips as in sucking, or smacking sounds may be made, or such movements of the features as are associated with sensations of taste or smell. Sometimes changes of facial expression may be tics and without any reason there may be recurring expressions of emotion, of joy, or grief, or fright, or even pain. Sometimes the tics affect structures that are internal, as various motions of the larynx accompanied by the production of grunting or sighing sounds or sometimes even of particular words. In children the tendency is prone to manifest itself in the utterance of forbidden words, usually vulgar, sometimes indecent. Besides these facial and throat tics any of the voluntary muscles of the body may be affected. There may be the gestures that accompany certain mental states, or there may be twisting or turning movements as if the patient were in an awkward position and wanted to get out of it, or as if the clothes were hampering movement and there was an effort to relieve some discomfort. The head may be lifted and lowered, or may be twisted from one side to the other and, indeed, various nodding tics are extremely common. Almost any ordinary movement may, in nervous people, come to be repeated so frequently as to be a tic. Practically all of the convulsive or quasi-convulsive movements associated with respiration are likely to become the subject of tics. Yawning, for instance, involuntary to some degree, usually a reflex with a physical cause, but so readily the subject of imitation, may become so frequent as to be repeated a couple of times a minute and this repetition kept up for many days. Sneezing may also become a tic, though it is usually a definite reflex due to palpable physical causes. Hiccoughs may easily become the subject of a tic. The occurrence of a persistent hiccough is in popular medicine a sign of unfavorable prognosis in serious diseases, especially such as involve the abdominal region. In connection with neurotic affections of the abdomen, however, hiccoughs are not uncommon and are of no serious significance. Varieties of Tics.--There are many more tics than are ordinarily supposed. Indeed, there are few of us who escape them entirely. Nearly all the curious phrases that people interlard so frequently into their conversation, usually quite unconscious of them, or of the ridiculous significance they often have, must be placed under the tics. Some men cannot say a dozen words without interpolating "don't you know." Others use some such expression as "in that way." I once knew a distinguished professor of elocution who by actual count used this phrase forty times in an hour. Some say "hum" or "hem" every sentence or so. Whenever there is a bit of obscurity in their thought these voluntary but unconscious expressions are sure to pop out. No one who has had much experience in public speaking ever succeeds in keeping entirely out of such bad habits. It is curious how phrases will insist on repeating {566} themselves. One year one set of words, or a pet phrase, or mode of expression, creeps unconsciously here and there into an address. Then either because the speaker has been reading dictated copy, or because some good friend has the courage to tell him of it, he finds out the bad habit and suppresses it. Word formulas senselessly repeated are only one of many forms of tics that public speakers are prone to indulge in. Gesture which begins as an artificial adornment of speech, very appropriate in itself, after a while may settle down into certain forms that not only often lack elegance but that are really disturbing to an audience. Of these gestures and movements men are often quite unconscious. They have become habitual and in the absorption of mind with the thought and the words, they are reproduced quite involuntarily though they are all originally voluntary movements. Nearly every public speaker needs a mentor to correct him of such faults. It is rather difficult to break some of these habits and it requires no little concentration of effort and attention to be successful in eradicating them. It can be done, however, provided the habit is not too inveterate, and this is the best evidence that tics of other kinds can also be eradicated if the patient really takes the matter in hand and is not of a weakened will. _Teachers' Habits_.--Indeed it is almost impossible for public speakers and teachers not to acquire certain habits irritating to their auditors at first but amusing as they grow used to them, and students particularly learn to look kindly at the ridiculous side of many of them. I remember an old professor of literature who used to lecture at some length on each of the important contributors to English prose and poetry. We soon observed that whenever he came to their deaths he took out his handkerchief and blew his nose. This was as inevitable and as invariable a rule as the laws of the Medes and the Persians. It was, as it were, his tribute of sympathetic condolence with humanity for the loss of a brilliant contributor to English literature. Occasionally the effort to break up these habits will seriously interfere with modes of thought and habits of expression, for the time being at least. A professor at a certain university had a habit every now and then of plucking at a button on his coat. His students could tell when his hand was going to find this object of its occupation and knew from experience that he would twist it a certain number of times. He was not what would ordinarily be called a nervous person. One day he happened to take off his coat shortly before a lecture and one of the students surreptitiously removed the button. At the end of the first few minutes of his lecture his hand went up to find the button as usual but failed. For the moment there was a hesitancy in his speech; then he tried again. A little later his hand went up unconsciously and was disappointed; then he stammered and lost the thread of his discourse. The last half hour of that lecture was seriously impaired because of the absence of that button. _Tricks of Speech_.--There are many other curious tricks of speech that are really tics. Women often indulge in them and sometimes even pretty women spoil their appearance by bad habits. All of us know the pretty woman who talks very fast, but who every now and then projects her tongue a little beyond her teeth. Occasionally there is a tendency to wrinkle the nose or the forehead. Most of us have seen the woman who sets her face into a definite smile of a particular kind whenever her company manners are in {567} use, though there is a vacancy behind the smile that is rather disturbing. Some people have habitual movements of the fingers that are really tics, and even positions assumed on sitting down that are very ungraceful, or that are very noticeable, sometimes partake of this character. _Fussiness_.--A very common form of tic that is quite difficult to control is that tendency to be doing something with some of their muscles which characterizes many men. They must handle a pencil or a knife, or they must swing on their chair or tilt back on it, or keep one of their limbs swinging over the other, or twirl their moustaches or stroke their beards, or rumple their hair, and they cannot find it quite possible to sit still. The difference between men and women in this regard is remarkable. Women are conceded to be much more nervous than men, but men are ever so much more fidgety than women. The author of "The Life of a Prig" in his book "The Platitudes of a Pessimist" has some striking paragraphs with regard to this subject. He says: To look nearer home, the British bar affords splendid examples of nervous fidget. Observe barristers pleading a cause. How they torture a piece of red-tape, how they twirl their eye-glasses or spectacles, and how they hitch at their garments, as if they momentarily expected them to desert their finely proportioned figures. But worse than the Queen's Counsellors, and even worse than the domestic peripatetic, is the villain who is abandoned to a performance vulgarly known as "the devil's tattoo"--drumming with the fingers. _Writers' Tics_.--Writers, and above all writers for the daily press and such as have to do their writing in a rush and therefore get nervous and anxious about it, are especially prone to develop tics, though others who write leisurely may do so. Some of these are curious and others are only expressions of nervousness common to all people. Many of them chew their nails, some of them bite at their fingers round the nails and make them sore, many of them chew the ends of their pens and find it practically impossible to keep a pen with a long handle to it. Some of them run their hands through their hair until it is in a greatly rumpled condition, some of them pluck at their eyebrows. I have one patient who when he is going through a particular nervous strain plucks out the middle portion of his right eyebrow so that he has a distinct bald spot at this point. The tradition in newspaper offices is that these curious expressions of the tendency of the body to occupy itself with something while the mind is occupied are more or less inevitable in nervous people. They continue for many, many years. They are only habits, however, that it would have been rather easy to break in the beginning, though they become extremely difficult to modify after they have once secured a firm hold. Occasionally I have fastened a piece of adhesive plaster over a much battered eyebrow, but that made it difficult for the man to go on with his work. His hand would go up involuntarily time after time and while plucking at his eyebrow would not disturb in the slightest his train of thought, just as soon as his fingers touched the unusual object a serious distraction occurred and work was not only slower, but much more difficult. _In Games_.--The tendency to the formation of curious habits of associated movements can be seen very well in most games where skill is combined {568} to a certain degree with chance. It is most noticeable, perhaps, in bowling. Few men are able to restrain themselves from making some special movement just as the ball strikes the pin. This is sometimes a motion of the head, oftener it is a jerk of the trunk, sometimes it is an associated movement of the arms, occasionally it is a kick or a stamp. In billiards the same movements are noticeable if a man is much interested in making a difficult shot. Usually there is some movement of the body or of the hands or of the head that would indicate his desire to move the ball in a particular direction. Women who play these games do not usually have these associated movements to such a marked degree and this may be due either to their better restraint to movement in general, for as we have said men do not acquire the habit of self-restraint in small matters of deportment as women do, or to the fact that such associated movements might disarrange their clothes. Perhaps, also, they are not as much interested in the games as a rule as are the men. Of course, similar associated movements may be seen in outdoor sports that require skill yet have an element of chance in them. For it is, as it were, to overcome this that the additional movement is made. _Children's Tics_.--Some tics consist of some very curious habits. Occasionally children hear some obscene or vulgar expression and repeat it. The repetition of it produces such a look of shock to propriety on the part of some of the other little ones who happen to be present that they repeat it in the spirit of bravado and then continue to utter it until it becomes a habit that is hard for them to break. After all, the use of blasphemy later on in life is really a tic, a habit of uttering words no longer expressive of any particular feeling, as a rule, unless in exceptional circumstances but just the result of a tendency for the speech organs to repeat certain words. They tell a good story of the Rev. Sydney Smith who, wishing to break an acquaintance of the habit of indulging in expletives, interlarded his speech with "fire tongs and sugar tongs" every ten words or so and when his auditor protested that that added nothing to the significance of what he said the Rev. Sidney suggested that that was also true of various blasphemous expressions that his acquaintance was accustomed to use. At the Salpêtrière they tell the story of a little boy who had the habit of saying the French word which the corporal in Victor Hugo's "Les Miserables" made use of when anyone told him that it was because Wellington was a greater general than Napoleon that the French Emperor was defeated at Waterloo. Nothing seemed to be able to break the boy of the habit of interjecting this word into conversations sometimes in which he had no part and sometimes toward which he was expected to take only a respectful and childlike attitude of silence. He was sent to the Salpêtrière. The ordinary remedies had failed entirely. One day he was allowed to go outside of the hospital, or rather stole out of the gate and played marbles with some street gamins in front of it. During the game he used the word in question and they proceeded to give him a good thrashing. It is Charcot who tells that this broke him effectually of the habit. One of the childish customs that sometimes disturbs parents very much because it seems to be such an unaccountable lapse into barbarism, though it is really nothing more than a tic in the strict sense of the word, is the habit that some children acquire of removing portions of hardened material {569} from their nose and then putting it into their month. Refined parents are apt to be so seriously disturbed by this that they fear for the child's mentality. Really the habit is not nearly so rare as is usually thought by some grown-ups who have forgotten about their own and others' childhood. In country places the habit is very common. It is not alone the dull children who do it but some very bright ones. Indeed, the tendency to the habit is so common that one wonders whether there is not something in nature that tempts to it. Parents who are fearful lest their children may be seriously hurt in health by the awfully insanitary habit may be reassured that after all a certain amount of the drainage of the nose is normally carried off through the posterior nares to the stomach and that no danger to health seems ever to have resulted from the practice. As a rule, the habit can be broken rather easily by a little judicious care and insistence, though I know of cases where relapses occurred and the habit continued surreptitiously. _Motor Tics_.--Motor tics frequently develop as a consequence of some injury to a nerve or some intense overuse of it. Winking habits follow an herpetic involvement of the superior branch of the fifth nerve. Bell's palsy is sometimes followed in the face by a tendency to twitching on the unaffected side that makes the patient quite uncomfortable. Herpes zoster is sometimes followed by a catching of the breath, probably due to a little spasm in the muscles supplied by the nerve thus affected. Some of the yawning tics have this origin. Any neuritis may in the course of its betterment be followed by this curious tendency to explosion along the nerve that has been affected, as if the pathological process had more seriously interfered with inhibition than with the actual function of the nerve. Examples of over-exertion followed by twitchings are not rare. A scrubwoman who has seen better days and now has to carry a heavy bucket and use her right hand much with the brush may develop a twitching of the right arm. A janitor's wife who sweeps much may have a tendency to twitchings of the fingers as a consequence of the unusual exertion of holding the broom. Twitchings in the limbs of men who work at a foot lathe or other machine requiring foot power are not unusual though they are more often seen in the leg on which the workman habitually stands than in the other one and it seems to be oftener a strain on muscles than actual over-exercise that precedes the development of these tics. Heredity.--Heredity plays as large a role in tics as it does in stuttering and other functional nervous disturbances. Occasionally the direct inheritance of some habit will be found, though there is nearly always more than a suspicion that a trick of speech or of act, which constitutes the tic, was learned by imitation rather than transferred directly. Besides, it is a case of a similarly constituted nervous system reacting in the same way to a similar environment, rather than any definite tendency existing by heredity in the nervous system. It is surprising what close observers children are and how easily they learn to imitate any habitual action of father or mother or, for that matter, of nurses or those who are close to them. Mental Treatment.--The most important element in the psychotherapy of tics is their prophylaxis. They run in families, not by any inevitable hereditary influence, but as a consequence partly of imitation and of corresponding tendencies resulting from certain weaknesses in the family. Wherever they are known to be likely to occur, parents should be warned of the {570} possibility and the first symptom of any motor habit should be considered the beginning of a tic. As we have said, they are likely to begin in muscles that have been overstrained for any reason, especially when patients are run down. They are often seen after herpes and certain facial neuralgias. There is probably no tic, no matter how long or how serious, that can not be eradicated, or greatly modified, if the patient will take the trouble and if the treatment is conducted so as gradually to get rid of it. Peculiar movements cannot be done away with at once. They can be lessened in intensity and in frequency and then gradually the patient will be encouraged by their becoming less noticeable than before to make renewed efforts. The habit must be gradually undone and this will take as long as it did to form it originally. The exercise of contrary muscular movements carefully carried out, and of gentle repression with definite times of exercise during the day, gradually increasing the length of the intervals of repression, in the end proves successful. Only a determined struggle will effect a cure. It depends on the patient's will. Like a drug addiction, or a tendency to overeat, or a craving for alcohol, it must be gradually overcome and then care must be exercised to prevent relapses; for when the condition is somewhat better, to relax vigilance and give up effort will allow the old condition to reassert itself with startling rapidity. People suffering from severe tics will often give up. Without the patient's hearty co-operation cure is impossible. With good will its gradual diminution gives the patient a confidence in self and an uplift in character that is extremely valuable, not only for physical but for mental conditions. CHAPTER IV STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC. The difficulty of speech called stuttering has usually been considered rather as an unfortunate lack of control over the organs of articulation, somewhat corresponding to muscular awkwardness of any other kind, than as a pathological condition deserving the physician's attention. If anything was done for it formally, the first effort of the parents or the teacher was to correct the supposed bad habits and this failing the affection was relegated to someone who claimed to produce wonderful results by some special method. Perhaps, even oftener, stuttering was considered one of those affections, fortunately decreasing in number, that the child may be expected to outgrow. Often there was noted an hereditary element which was supposed to indicate incurability. Stuttering deserves special treatment in a work on psychotherapy because it illustrates very strikingly one phase at least of mental influence over bodily function. While in the study of the etiology of the disease much has been made of anatomical features, nerves and muscles and anatomical anomalies of the speech organs and the respiratory tract, the sufferers from stuttering are certainly quite up to the average both in the physiology and anatomy of these regions. They are of all ranks and conditions of life, of all sizes and build, and it is evident that the trouble is not physical, but mental. They {571} pay too much attention to their speech and to the co-ordination of the many muscles engaged in speech production and the consequence is that they impair their power to use these organs. Practically all the cures recommended contain some element which distracts the attention from the speech to something else and so permits the function of the speech organs to proceed undisturbed. A number of conditions develop in nervous individuals that resemble stuttering. There are disturbances of swallowing, disturbances of walking (astasia abasia), neurotic disturbances of writing, and of other uses of the hands and of the legs. State of Mind.--It is perfectly clear to anyone who has closely observed the ways of stutterers that the state of mind is extremely important in these cases and indeed probably constitutes the underlying factor in the speech disturbance. Stuttering and all speech defects are much worse when the patient is laboring under excitement. This is so amusingly true that the impotence of a stutterer to say a word when he wants very much to say it is a commonplace in the cheap drama and never fails to raise a laugh. In ordinary conversation with friends the stutterer may have little difficulty. As soon, however, as he begins to talk with those with whom he is unfamiliar his speech defect becomes noticeable. When the others present are entire strangers and, above all, strangers whom he wishes to impress favorably, then his stuttering becomes pronounced. The mental element is the most important factor. Just as soon as consciousness of the task supervenes his power of co-ordination fails and stuttering begins. Stuttering in Complex Activities.--There are many actions that become habitual and people are thus saved from the necessity of constantly performing them under the control of the will and the consciousness. Walking is a typical illustration of this and is seldom disturbed by consciousness, but there may be a stuttering in the gait of sensitive persons if they become overconscious when passing people who are watching them. Talking is even a more striking example of elaborate co-ordination without conscious effort. We have to bring into play more than a score of muscles whose movements are nicely and accurately co-ordinated, or else the effort at articulate speech is a failure. We have to change the positions of most of these muscles many times every minute, yet we do it without a thought of how it is done and most of us accomplish it with ease and perfection. _Stuttering Walk_.--Stuttering, after all, comes most naturally under the head of dreads in the classification of the psychoses. Stuttering is not a physical difficulty so much as a nervous apprehension, and there may be a stuttering in any co-ordination as in speech. I have a patient under observation who, if people are looking at her, finds so much difficulty in walking because of a trembling that comes over her that she fears she may not be able to keep from falling. Boys at school whistle a certain air that requires a little halt in the gait to keep time with it, as their schoolgirl friends go by, and it is impossible for these not to drop into the peculiar gait indicated by the time of the tune. _Stuttering Writing_.--There are many men who become so nervous about writing their signatures that they cannot sign while anyone is present. There are others whose penmanship becomes very irregular, or at least exhibits many signs of nervousness, whenever they think someone is watching them. Most of {572} the difficulties seen in speech may, indeed, be exhibited in writing. The same difficulty in beginning, the same elision of letters under stress of excitement, may occur. Writer's cramp is, after all, much more of the nature of a stuttering in writing than a real cramp. Over-action, added motions, and, finally, incomplete power to act as desired are seen in both cases. It might be expected that this would not affect so simple and familiar a set of motions as those required for a personal signature, but it does, as many cases illustrate. A typical example was the treasurer of a large trust company who had to sign a number of bonds, some thirty thousand. At the rate of 200 an hour, over three a minute, as he did the first day with others making it easy for him, it looked as though he could complete the task, huge as it was, in a month. At the end of a week, however, the rate had fallen to 120 an hour and, toward the end of the second week, one a minute on the average was all that could be accomplished. At the end of the month his signature, while retaining certain of its original characteristics, had become very different from what it was at the beginning and signing had become an extremely difficult matter. He had to take a rest from business for several weeks after accomplishing this apparently mechanical procedure. Emotional Ataxia.--Dr. S. Weir Mitchell in his article on "Motor Ataxia from Emotion" in the May number (1910) of _The Journal of Nervous and Mental Disease_, discusses some cases in which inability to write even a signature came as a consequence of nervousness and emotional disturbance. In one of Dr. Mitchell's patients, other manifestations of ataxia occurred as the result of the consciousness that people were watching the patient. At times he is compelled to leave a dinner table, since with strangers it is almost impossible for him to eat. If there are two or three at the table with him, however, and especially if he is worried about himself, he may become almost helpless, requiring both hands to get a cup of coffee or a glass of water to his mouth. A patient of mine with like symptoms has described to me equivalents of various kinds to his own difficulties in his sisters. One of them cannot play the piano before strangers, though an excellent musician. The other cannot crochet with any success if any but intimate friends are present. How much of this family trait is due to suggestion or psychic contagion would be hard to say. The state that comes over amateur actors and which makes them forget their lines, stammer in their speech, walk awkwardly, and trip easily, are really manifestations of this same incapacity to control even familiar sets of actions when there is great self-consciousness and over-attention. Mental Influence.--The correction of these conditions comes through soothing the mind of the patient and getting him or her not to be so self-conscious as to disturb action by thought about it. It is easy to say this and extremely difficult to do it. In certain nervous organizations it is quite impossible to overcome the tendency to this ataxia or inco-ordination of voluntary movements. Much can be accomplished, however, by proper training and discipline in all cases, and, while the patient can never be completely cured, great improvement may be brought about by patient habituation under favorable circumstances. In Dr. Mitchell's cases the taking of a glass of whiskey or of wine sometimes stimulated the patient so that co-ordination became possible where it was impossible before. In nearly all cases of writer's cramp {573} and writing difficulties the power to write is restored for a time by such stimulation. Strong coffee will sometimes serve the purpose as well as alcohol. It is easy to understand, however, how dangerous is the resort to such stimulation. _Practice in Self-Control_.--The excitement and nervousness incident to appearance before an audience which make thought and speech so difficult and action so awkward and so exaggerated gradually disappear as the individual becomes habituated to appearing in public. In most people there is never a complete loss of self-consciousness with entire freedom from nervousness, but the conditions are much improved so that there is no noticeable interference with ordinary actions and speech. Whenever there is some reason for additional excitement, however, as when a new play is being put on, or when some special audience is being entertained, there is a reappearance of many of the old symptoms due to a self-consciousness. Stuttering in the Young.--The prognosis of stuttering when it develops at a certain period is much better than at others. The stuttering of the very young can usually be overcome by a little careful training, if it is taken early and treated patiently by a competent teacher. Not infrequently a certain amount of stuttering develops at puberty when the voice changes, partly due to the inability of muscles and nerves to co-ordinate so easily as before upon the rapidly-enlarging vocal chords and larynx, and partly to that greatly increased self-consciousness amounting almost to painful bashfulness which develops in boys about this time. Breathing exercises and especially slow expiration is an excellent thing in these cases and distracts their attention from themselves and their speech. The chest has usually developed rather rapidly at this time and the muscles have to some extent lost control over it, and it will be found on careful observation that the breathing is particularly superficial, that the descent of the diaphragm is quite limited and that the use of this important muscle of respiration requires practice in order that it may be controlled properly. In Women.--Perhaps the most interesting thing about stuttering is that it is ever so much rarer in women than it is in men. Something less than one-fourth as many women suffer from it as men and this is true for all periods of life. Women are usually more bashful and self-conscious than men, but this rarely goes to the extent of disturbing their speech faculties. Ungallant observers have suggested that the sex quality of ready speech is too profoundly seated in nature to be disturbed by mere bashfulness, but there seems to be no doubt that the breathing of women has much to do with the difference between them and men in the matter of speech defects. When stuttering occurs in women the defect is much less tractable and is usually dependent on a more serious disturbance of the psyche or of the central nervous system. The prognosis of cases of stuttering in women is not so good as in men, but remarkable cures are sometimes effected by mental treatment of the self-consciousness which causes the speech defect. Correction of Respiratory Defects.--This last point, the correction of all pathological conditions in the respiratory tract, is especially important. Many stutterers are for one reason or another mouth breathers. If they are mouth breathers because they have adenoids, these must be removed. This must {574} be done early in life, certainly not later than the third or fourth year, or else there will come a serious deformation of the chest and that chicken-breastedness, which is not undesirable in itself, but which hampers to some extent the action of the diaphragm because that muscle cannot act as well in the deformed as in the natural chest. Not all who are chicken-breasted have any defect of speech, nor any tendency to stutter, but when there is a natural tendency to a lack of inco-ordination because of sub-normal nervous ability the presence of such a deformity makes the prospect of cure much less favorable than would otherwise be the case. If the mouth-breathing is due to stoppage of the nostrils, this must be relieved. Realization of Allied Conditions.--A helpful suggestion for stutterers is found in the recognition of the fact that there are so many conditions allied to stuttering and so many people afflicted with them. Under the heading Neurotic Esophageal Stricture stuttering in swallowing is treated of. In the chapters on urinary symptoms stuttering in urination is discussed. Any set of muscles requiring careful co-ordination may thus be disturbed. The stutterer is apt to look upon his affliction as a very special individual annoyance. When he learns that in practically every set of muscles requiring nice adjustment for function like difficulties may occur, that in every action requiring careful co-ordination of muscles there may be a similar disturbance, and yet that in most of them careful mental discipline, especially training in self-control, proves a source of relief, he takes new courage to face the struggle necessary to overcome the self-consciousness which is the root of most of these troubles. A striking form of inability to co-ordinate muscles so as to enable them to perform their ordinary function is aphonia, or mutism, sometimes spoken of as hysterical mutism. After some sudden emotion or fright or accident a neurotic person proves to be quite unable to talk. He cannot utter a sound. In Prof. Raymond's clinic at the Salpêtrière I once saw the classical case described by Charcot and presented at his clinics several times. It was a man whose wife had run away from him and been taken back three times. Each time on her disappearance he had an attack of aphonia, inability to utter a sound of any kind. It lasted for from several weeks to a few days. The cases are much commoner in women. After a disappointment in love or a scare the patients become unable to speak. Sometimes they can whisper but cannot phonate. The affection is entirely functional or neurotic, and if the patient's mind is properly predisposed speech returns without difficulty or delay. A little massage of the muscles of the throat or of the tongue by means of a tongue depressor or the use of Politzer's bag in the nose with the assurance that after proper swallowing movements the ability to speak will return, have proved successful. Occasionally hypnotism is recommended for these cases, but many of them are too highly neurotic to be readily susceptible to hypnotism and, besides, suggestion in the waking state proves just as effective. After several days of speechlessness it seems little short of marvelous to make a patient talk readily after a little massage of the throat. It is all dependent, however, upon confident assurance and the suggestion to talk. The physician himself must possess absolute confidence in his power to bring this about, for the slightest sign of doubt or hesitation will make it impossible {575} to influence the patient and will completely destroy his psychotherapeutic efficiency. _Neurotic Esophageal Stricture_.--A rare but interesting form of neurosis, which should be studied in connection with stuttering because of the light shed on both by their relations to each other, is that seen in the sufferers from so-called neurotic esophageal stricture. These patients are unable to swallow solids except after determined deliberate effort and occasionally the discomfort caused by this effort leads them to eat much less than is sufficient for their nutrition. The physician is sometimes tempted to overcome the spasmodic closure or partial closure of the esophagus by bougies and dilators, and these the patients learn to pass by themselves. I have never known any of these cases to be benefited more than temporarily by this treatment and I have seen two that were made distinctly worse. Forcible dilatation by concentrating attention on the affected parts hampers the proper flow of nervous impulses and the ordinary reaction to these which should occur. To appreciate how closely related to stuttering this spasmodic closure of the esophagus is, it is necessary to see these patients swallow when they do not know that they are under observation. For when they are on exhibition for the physician, when their condition is intensified by the excitement of the occasion and by the definite purpose to make the doctor appreciate how serious is their case, they swallow with more difficulty. Nearly always they have more difficulty in eating in public than with friends, and it is only with those with whom the patient is on a footing of perfect familiarity that the best swallowing power is obtained. In sufferers from esophageal stricture of the neurotic type the muscles by an unfortunate perversion of nerve force contract in front of the bolus instead of behind it. This contraction may be so complete as to prevent even the swallowing of liquids. Usually, however, liquids can be swallowed without much difficulty. Such patients, then, if they become much run down in weight, must be fed on milk and eggs and ice cream and the gruels and soups until they gain in weight. While they are much under weight their condition is distinctly worse and their power of co-ordination much less. It is, however, not hard to make them gain in weight. This gain in weight acts as a strong suggestion which persuades them that they are getting better and this of itself soon helps them to control their muscles. Local treatment does harm rather than good. Ice in small pieces swallowed shortly before a meal seems in some patients to have the effect of making the muscles less prone to follow the inco-ordinate nervous action and thus renders swallowing much easier. In some, and especially in nervous people, warm liquids have the same effect, while ice produces further irritation. Acids nearly always increase the spasmodic condition. Sucking a piece of hard candy for some time before a meal, especially if it is not too sweet nor flavored with acid, helps some people. Nearly all of them when carefully questioned prove to have special foods that are more difficult of deglutition than others. Not infrequently these idiosyncrasies for food are found to follow ideas with regard to their digestibility. If the patient is hurrying for any reason and suddenly becomes conscious that he is not masticating sufficiently, swallowing at once becomes much more difficult. {576} The main element in the treatment, however, must be as far as possible to get the patient's mind off his condition. The more attention he gives to it the worse it will be. No treatment that we have will cure it any more than stuttering can be cured, though a deliberate effort to form a habit for the control of the swallowing muscles will often do much to lessen the discomfort and the inability to swallow. It is important in all these cases to be sure that there has been no incident in childhood which might have caused the production of scar tissue in the esophagus with a consequent stricture. Sometimes it is many years before this manifests itself and, as in the case of the urethra, even ten to twenty years may pass before serious trouble comes. When the first symptoms are noticed, the actual stricture may be so slight as scarcely to be possible of diagnosis by the bougie. Occasionally the first symptom of a cancer of the esophagus is an inability to swallow, and cancers of the esophagus have been known to occur in quite young people, especially young men. I remember seeing a case at autopsy in Vienna where the first symptom had been the difficulty of swallowing and the man, at the recommendation of friends, swallowed a glass of beer with some black peppers in it and these stuck in his esophagus and produced death. Such cases are exceptional but must not be forgotten. Neurotic esophageal stricture is entirely benignant and its prognosis altogether favorable. Treatment.--The treatment of stuttering presents the best example that we have of the influence of the mind over neurotic difficulties of any and every kind. Many forms of treatment have been announced as successful, most frequently in the hands of men who have themselves been stutterers and who have helped themselves by them. This would seem to make it clear beyond all doubt that discoveries in direct therapeutics had been found. As a matter of fact, however, when a review of all the methods is made, they are seen to be so different from one another and founded on such essentially diverse principles that the only common connecting link to be found is in the occupation of mind with something else besides speech which all these methods recommend. We have had successful cures announced by surgery, by discipline, by making speech more difficult by obstacles of various kinds, by special positions of the tongue--up against the palate or down against the floor of the mouth--by associated movements, by rhythmic speech, by special control of the muscles of respiration, and of many other structures much less related to speech. The interesting phase of all this is the uniform success claimed by different specialists using many different methods. From the beginning of history cures have been suggested. That idea, still held among the non-medical, that the sufferer from a difficulty of speech is tongue-tied and needs to have the frenum cut, is as old as the history of medicine. Galen suggested cauterization of the tongue. Aetius, the first prominent Christian physician of whom we have any record, divided the frenum of the tongue. So did Paul of AEgina. Of course, in the Renaissance, when the old medical classics were revived, this became a favorite method of treatment. Hildanus is sure that it accomplishes great things. This idea has never been entirely given up, and recurs from time to time in the practice of those who do not reason much, but who look for some ready explanation and, above all, some direct method of treatment. Much more {577} serious surgical intervention has been suggested from time to time, however. Velpeau advised division of the extensor muscles of the tongue. Of course a number of surgeons have quite properly insisted on the removal of the tonsils, uvula, polyps in the nose and other obstructions of respiration. _Singing in Treatment_.--A number of the stuttering cures employ singing as a method of training in forthright utterance. Few people stutter when they sing. Most people can be given confidence in themselves and their power to talk right on by being shown that as soon as they try to follow a set of notes there is little or no difficulty in utterance. The teaching of singing, then, is of distinct value in many cases. Taking advantage of this a number of those who correct stuttering endeavor to introduce a certain rhythm into speech. So long as the rhythm can be maintained stuttering does not occur. As Kussmaul has pointed out the rhythmus acts as an efficient will-regulator, so that nerve impulses go down regularly and are not interrupted by consciousness and by the sudden starts and stoppages due to fear and tremor and mental uneasiness. Undoubtedly the lesson of this method of teaching is extremely important as an index of how stuttering may be relieved. _Regulation of Respiration_.--A number of systems to correct stuttering depend on the regulation of breathing. It has been shown over and over again, and notably by Prof. Gutzman of Berlin, [Footnote 42] that one of the most important differences between stutterers and those who talk naturally is that the normal individual talks during expiration as may be seen in Fig. 23, while the stutterer begins at the end of inspiration or at least where normally on the respiratory curve expiration is just about to begin, but instead of permitting his diaphragm to go up as in ordinary expiration, the stutterer makes it sink lower and lower in a forced inspiration. [Footnote 42: See my translation of one of his clinical lectures In _The International Clinic_ for July, 1899.] [Illustration: Fig. 23.--Normal Diaphragm Curve in Normal Breathing. Expiration as we Talk Normally.] [Illustration: Fig. 24.--Curve in Diaphragm Before and During Talking by a Stutterer.] _Attention to Something Besides Speech_.--The attention must be centered on something besides speech itself. This is the important element in any method of treating stuttering. If it is allowed to occupy itself with that {578} nothing will save the individual from getting tangled in the efforts that he makes to co-ordinate the complex movements necessary, though if he would only allow them to proceed automatically, as do the rest of mankind, there would be no difficulty at all. Washington Irving, so ready with the pen, could not utter two successive sentences at a banquet without having to sit down, with expression absolutely inhibited from excitement. Expression, thought, utterance--all may be inhibited by overconscious attention, which may also disturb all other complex activities. The most interesting methods of treatment for stuttering are those which involve the use of various hindrances to speech and which would seem to be least likely to make it possible for a person already laboring under speech difficulties to talk with more ease. The secret is, of course, that the added impediments so distract the attention of the patient that he is unconscious of the co-ordination necessary for speech and so accomplishes it without difficulty. It is because of over-attention to himself that the disturbance occurs. These methods developed very early in history. We all know the tradition of Demosthenes overcoming his impediment by placing pebbles in his mouth. One of the most earnest advocates of a similar method, who had himself suffered very seriously from stuttering was the Rev. Charles Kingsley, one of the most distinguished of English literary men. He cured himself, or at least greatly relieved his symptoms, by keeping a cork fast between his back teeth. There have been many other curious suggestions for the cure of stuttering. What was known as the American method had great vogue in the early part of the nineteenth century. It was probably invented by Yeats of New York, though it came to be known as the Leigh method. Yeats, himself a physician, seemed to fear that he might fall into professional disrepute if he advertised the method in any way, so he had his daughter's governess, a Mrs. Leigh, open an institute for the cure of stuttering in which this method was practiced and it proved to be very successful. The entire secret of it was to have the patient raise the tip of the tongue to the palate and hold it there while speaking. Another mode of treatment that attracted considerable attention consisted mainly of just exactly the opposite maneuver, that is, keeping the tongue as far as possible firmly placed on the floor of the mouth during speech. It is evident that neither of these suggestions does anything more than occupy the patient's attention with an additional activity, so that his speech function may be allowed to proceed automatically of itself, as it will if not disturbed by attention to it and by conscious attempts to regulate the various activities of it. Instruments were invented to help the patients to secure various positions of the tongue. Itard, for instance, during the second decade of the nineteenth century invented a golden or ivory fork to be placed beneath the tongue, so as to support it. After the various methods of managing the tongue, the most popular curative maneuver has been that of regulating the breathing. During the nineteenth century there were at least a dozen different methods, all of which had a number of reported successes, of treating stuttering by means of breathing exercises. Very simple methods of diverting the attention from speech are quite {579} sufficient in many cases to bring improvement. For instance, the insertion of extra letters that are themselves easy to say between words or preceding consonants that are hard to utter has been a favorite method among the specialists in stuttering. Johann Müller, as I said, suggested an e. Others have suggested an n. Occasionally stutterers themselves form the habit of using an m or a to and find that it aids their facility in uttering difficult sounds over which they would otherwise halt and stutter. A combination of these methods, as, for instance, an e between all words and the placing of an easy n before the most difficult sounds, has been repeatedly revived as an infallible method of treatment. All this serves to show that in patients whose functions are being interfered with by over-attention diversion of mind must be the main remedy. If this can be secured, the function they are disturbing will be allowed to proceed unhampered. What will prove effective for one patient will fail with another, however. After the patient gets used to a particular form of diversion another must be tried. Simple methods are sometimes sufficient to secure good results. The one thing is not to be discouraged and to proceed from one effort to another, satisfied even if relief is obtained for a while, for after relapse another method of treatment may always be tried. _Suggestion for Stuttering_.--There are many systems to train people out of the spasmodic inco-ordination that constitutes stuttering. All of these systems have their successes, but, as is well known, all of them have their failures. When the patient has confidence in the teacher and his method there is practically always quite a remarkable improvement, at the beginning. This improvement is more noticeable during the first month than at any other time. Not infrequently after this there is a tendency for patients to drop back into old habits, apparently discouraged, as a consequence of loss of confidence. It is the mental element that means more than anything else. It is the old, old story that we have to repeat with regard to every chronic ailment. _Distraction of Mind_.--Each inventor is sure that his method is the best and his "cured cases" support his claim. Others who try his method, however, never succeed as well as he does and those who are interested invent methods of their own. I have on my desk, as I write, six different, infallible--to their authors--methods of treating stuttering. I am sure that none of them succeed absolutely, that is, none of them will cure every case and most of them will not succeed beyond a moderate degree, except where the enthusiasm and the confidence of the inventor or an immediate disciple of his is behind them to make them efficient. There are all sorts of elements in these cures, but most of them depend on their power to distract the patient from his over-attention to himself and what he is doing when he talks, so as to permit without hindrance the automatic movements which are so necessary for the complex function we call speech. Those who have spent most time in treating stutterers confess that the effect produced upon the patient's mind is an extremely important part of the treatment and that, if this cannot be secured, failure is almost certain. If the patient has no confidence that he can be cured and by this particular method, failure is inevitable from the very beginning and just as soon as a patient loses confidence improvement ceases. {580} CHAPTER V TREMORS Two types of tremors come to us for treatment: those that are quite involuntary and occur when muscles are at rest, and those that are associated with voluntary movements. The most common type of involuntary tremor is that seen in paralysis agitans to which a special chapter is devoted. After this, though coming for treatment much less frequently, is senile tremor which may, however, also be increased by voluntary movement. The tremors associated with voluntary movements are spoken of as intentional tremors. They may occur as the result of organic disease of the nervous system and the most characteristic type is that seen in multiple sclerosis. They are more frequent, however, with functional diseases of the nervous system and with emotional disturbances of various kinds. They are especially frequent as the result of dreads. Usually the idea of tremor is associated only with the head and the hands. Tremors may occur in other parts of the body, however, and tremors of the legs are particularly important. A familiar type is the tremor and unsteadiness of the legs which occur as a consequence of the dread of heights when a person unused to such situation attempts to walk across a narrow path a great distance above the ground. Senile Tremor.--The most common of the involuntary tremors is that associated with old age. It develops in practically all very old people, but it comes to some who are comparatively young. Its occurrence at the age of fifty-five usually gives the sufferer a severe shock which is emphasized by the attitude of mind of friends toward the affection. They seem to be always sure that it is the index of rapidly advancing age and that it is practically a signal of approaching dissolution. As a matter of fact, when unassociated with gross pathological lesions, the senile tremor has no such significance. When associated with definite lesions it is the prognosis of the special condition and not any supposed significance of this particular symptom of tremor that expresses the genuine outlook in the case. Many people who live to a very old age develop tremor before they are threescore. Most of those who live to be eighty or more have some tremor that develops about or just after the age of seventy. _Significance_.--Senile tremor is supposed to be due to, and in most cases probably is the result of, an overgrowth of connective tissue in the central nervous system which disturbs the ordinary conduction of nerve impulses, rendering them wavering and uncertain. This seems to indicate that it will not be long before the advancement of this sclerotic process will make serious inroads on the vigor of the individual. As a matter of repeated observation, however, the ordinary involuntary tremor of old people may last twenty years. _Reassurance_.--The main principle in the treatment of tremors of the old is to make the patients realize that the symptom has no such bad prognosis as is usually attributed to it. Of course, they will find this out for themselves after a few years, but what they need is assurance at the beginning lest during the period of depression consequent upon the conclusion that the end is not far {581} off, which seems to be forced on them by their fears and the foolish sympathy of friends, their resistive vitality should be so lowered as to permit the invasion of some serious disease. In spite of apprehensions on the part of themselves and friends, tremor is rather a good sign than a bad one. It indicates the formation of connective tissue in the central nervous system, but this is always a slow process and is usually quite benign. As a matter of fact, most sclerotic processes are so chronic as to be compensatory in their action for many other degenerations. Those in whom tremor develops early often seem to be better protected against rupture of cerebral arteries, as if the growth of connective tissue was a conservative process here also. Information of this kind helps patients not to borrow trouble because of their condition. Intention Tremors.--The tremors that occur in association with voluntary movements are often very troublesome and may be difficult to manage. The worst cases are entirely functional. They are typical neuroses and often develop as a consequence of some serious crisis through which the nervous system has passed. In older people they sometimes pass over into paralysis agitans or a close simulant of that affection. The incident of the Texas sheriff and the Indian related in the chapter on Paralysis Agitans illustrates how these tremors may be induced. _Tremors from Fright_.--Frequently the tremors have no direct connection with any action, though they may be the result of fright. A little girl bitten by a dog and much shocked may, for some time afterwards, be quite unable to stand when she sees a dog on the street, so disturbing is the tremor that comes over her. Tremors of the same kind have been connected with horses after the patient had been run down in the street, and, in one case that I saw even when the patient was only thrown out of a carriage during a runaway. Occasionally fright by a burglar may cause a distinct tremulousness that supervenes whenever the patient thereafter is wakened suddenly at night. Influence of Dread.--Tremors of all kinds can be made worse by the dread of them. In the chapter on Dreads we discuss the disturbance of function by dreads and especially the tendency to exaggeration of pathological conditions of any kind when the patient's mind becomes concentrated on it. Steadiness in any position is due to a nice balancing of extensor and flexor muscles requiring the sending down of a continuous stream of impulses. The equilibrium is attained and maintained in spite of the fact that, as a rule, the flexor muscles are stronger than the extensors and better situated to exert their mechanical force. If anything happens to disturb this balance even to a slight degree, the mind becomes attracted to it and there is a corresponding result as in stuttering, or other complex function when surveillance is too great. It is important to remember this at the beginning of all cases of tremor, for the patient nearly always exaggerates his tremor by attention to it and can be made so much better by reassurance and diversion of mind that he is much encouraged and his general health usually improves, making him feel, even though his affection is organic, that he is being cured. Tremors may occur in connection with almost any set of actions requiring special co-ordination of muscles, but they are especially likely to occur when a feeling of dread disturbs the control over muscles. A typical example of this is noted in shaving. There are many men who cannot shave without trembling so as to cut themselves. The feeling that they have a sharp instrument in their {582} hand with which they may cut themselves sets up the tremor. There are others who cannot shave because they dread that while using the instrument over the important organs of the neck, and especially the blood vessels, they may be tempted to cut their throats. This is, of course, purely a dread and not a tremor. Some men find both the dread and the tremor much worse at times when they are tired and worried, and can shave very well at other times. Some men can shave very well when they are not under observation, but if anyone is looking at them they tremble and cut themselves. The safety razor usually does away with these troubles, large or small, but if it should happen that by particularly inexpert use they cut themselves even with a safety razor, especially in the throat region, the old dread and tremor reassert themselves and shaving becomes almost as difficult as before. Self-consciousness.--Almost any position or action in which a man feels himself under observation may cause one of these tremors. As a consequence this particular set of actions may become the source of so much discomfort as to produce an intense sense of fatigue. It may, indeed, become quite impossible of accomplishment. Some teachers cannot do demonstrating work on a blackboard before a large unfamiliar class, at least not without serious efforts to control themselves, though they may be facile demonstrators before a small class. I have known men, however, who practically could not do blackboard work at all because of nervousness. Their writing went all askew and very often their thoughts would not follow one another in such order as to make demonstrations possible. Sometimes they were good talkers, so long as they did not turn their backs to the class and feel the eyes of all on them. The same thing is true of such religious services as Mass in the Catholic Church, where some of the clergymen have this feeling. I know of priests who have not said Mass publicly for years and others who can only say it in a small chapel before a few people because of the intense discomfort of the fatigue caused by this state of mind. _Stage Fright_.--It is not alone the hands and the arms that tremors are likely to affect, for they may also occur in the legs. A typical and familiar case is the tremor that occurs upon the first appearance before large audiences of orators or actors or clergymen. Owing to excitement, they are unable to make flexor and extensor muscles exactly balance each other and the consequence is a tremulous movement that may be complicated by some swaying. Some people never lose this in spite of long experience in public appearance. Young people may have it upon being introduced to persons of whom they think a great deal. This passes off with years, as a rule, but in some it persists, and any excitement causes tremor of the legs and swaying movements. The effort to control this is often severe and causes intense fatigue. Any set of movements requiring even slight co-ordination of muscles may be the subject of disturbance by a tremor. Since the writing of the book on Pastoral Medicine, a text-book of medical information meant to be of assistance to clergymen, [Footnote 43] I have had some rather interesting tremors associated with the performance of clerical duties brought to my attention. One of these is a trembling of the legs which makes standing at a high altar almost impossible. Another troublesome tremor is that associated with the giving of communion. {583} Most priests find no difficulty in the performance of the rite. Some of them are much worried and anxious about it, however, and develop a slight tremor. Others become so nervous in performing the ceremony that they cannot succeed in placing the Host on the tongue of the communicant without certain false movements. These may cause them to touch the lips or the cheeks of the recipient and after this has happened a few times the giving of communion becomes practically impossible for them. Occasionally the men thus affected have no other nervous symptoms and often they are very intelligent, strong-minded men. [Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.] The General Health.--Tremor patients always complain more of this symptom when they are in a run-down condition. One of them is a wealthy merchant who, when he can be persuaded to take a vacation, comes back with nearly all the manifestations of his tremor latent or, at least, well under control. Another is a broker who at the end of a long winter of excitement and worry is at his worst, but who after a vacation in the North Woods is quite well again. Slight symptoms of this kind are not unusual in teachers, especially women, though I have seen them also in men, and are much more complained of at the end of the year when the individuals are in poorer general condition than at any other time. The symptom itself is annoying because of the notice that it attracts, but their dread that it may have some serious significance, indicating the development of a progressive lesion of the central nervous system, constitutes the worst part of their ailment. When the intentional tremor is intermittent and occurs only at times of excitement, or when the patients are under observation, they can be reassured that it is merely neurotic and that no ulterior development is to be anticipated. Treatment.--The treatment of these conditions consists first in bringing the patient's health up to its normal condition as far as that is possible. Many of the sufferers from tremors are under weight. Whenever they are, a definite, determined effort must be made to bring them up to it. This must be done even though they insist that they have never been heavier and that to be rather underweight is a family trait. In many cases it will be found that this family trait, instead of being due to some inevitable hereditary tendency, is only the result of family habits in the matter of eating. Many of these people do not eat substantial breakfasts. Their tremor, too, is likely to be worse in the early morning than at any other time during the day, unless, of course, they have become overtired during the day, when the tremor will reassert itself with vigor. Most of them are much less disturbed in the afternoon than before. The drug treatment of the affection consists mainly in the use of nux vomica, but, not in the small doses of five or ten drops so often employed, but, according to the size of the individual, beginning with fifteen or twenty minims, thirty or forty drops, and gradually increased to physiological tolerance, when the dose should be set somewhat below that. _Mental Control_.--The main treatment must consist, however, in enabling the patient to secure psychic control over himself and his muscles. This is not an easy matter. Most of them are quite discouraged, but their attitude of mind must be changed and the real significance of their affection made clear to them. As a rule, they have either heard or read or been told by a physician that their intentional tremor is significant of a serious pathological lesion of the central nervous system. Some of them have heard of multiple sclerosis {584} and are much disturbed. They must be reassured and it must be made clear to them that their disease is really due to over-consciousness and consequent lack of control. A good deal of reassurance can be given by telling them of patients who suffer from ailments not unlike theirs, showing how multiform the affection is. A man who has trouble with his signature may be told about the man who finds it difficult to drink when under observation, then, as a rule, he will better realize the neurotic character of his affection. With hysterical women this method must be used with care or the story of another patient will act as a suggestion and the physician will subsequently be treated to an exhibition of the symptoms which he has described. _Self-Discipline_.--Persistent quiet discipline is the one thing that eventually does any good. When patients are first told of this and are persuaded to attempt it, they make such a determined effort to overcome the affection that they make themselves more conscious of it than before with the result that their tremor and spasmodic movements are emphasized. It is the old story of the man trying to stand so straight that he falls backwards. It must be made clear to them that discipline, to be of any value, must be carried out as much as possible without consciousness of it and with all available artificial aids. The man who has trouble with his signature may be shown that he can overcome much of the tendency to tremor and spasm of the forearm muscles that are at the root of his difficulty by sitting at a higher chair, so that his arm swings free of the table and so that, in Gowers' phrase, if a pen were attached to his elbow it would write the same thing as the pen in his hand. The man who trembles as he drinks may be taught for a time to raise a cup to his lips while resting his elbow on the table and bringing his head well down. Nearly always methods of performing particular actions that require less effort can be found, until the habit of over-consciousness and loss of control is overcome. _Hypnotism and Waking Suggestion_.--Occasionally hypnotism is effective in these cases, but there is likely to be a relapse unless there is some discipline before and after its use. Suggestion in the waking state is often very effective. Patients need to be talked to and even though intelligent they need to be reminded at regular intervals for some time that their ailment is merely functional and not organic. Nearly always it will be found that they trace its beginning to some pathological event: occasionally there has been a severe accident, but sometimes only a slight accident seems to them a sufficient explanation. Sometimes it follows an attack of pneumonia, oftener still typhoid fever. In these cases the patients become convinced that this is one of the marks left after the accident or disease and so it is rather hard to persuade them that they can be cured. All such impressions, which act as auto-suggestions for the continuance of their tremor and lack of control, must be combated, otherwise there is very little hope of improvement. The preceding disease is not the direct cause, though the weakness consequent upon it may predispose to the tremor. Overhaste in attempting to resume their occupations before their strength has returned is often the real cause. It is the patient's mind more than his body that needs to be set in order, but this will not be possible unless the physical condition is normal and thorough reassurance can be given. {585} DISORDERS OF THE PSYCHE SECTION XVII _PSYCHO-NEUROSES_ CHAPTER I PSYCHO-NEUROSES (HYSTERIA) As the derivation of the name indicates, psycho-neuroses are functional nervous affections dependent on states of mind. They are not necessarily originated by the mind, though they may be. Their spontaneous occurrence as pure psychic phenomena, however, is rather rare. There is practically always some slight physical cause. This may be severe, for all diseases have neurotic accompaniments that disturb the nerves involved and exaggerate the original symptoms. In most cases the patient has no serious interest to divert his or her mind from this occupation with self, and as a consequence the particular feeling fills up the whole of consciousness, and as it is painful to begin with, the pain, following Cajal's law of avalanche, may become almost intolerable. It is of primary importance to remember, however, that there is practically always a physical basis for these curiously interesting affections which are so difficult to treat and which have so often proved the despair of physicians. While the attitude of mind must be changed, the physical state itself must be corrected. These two things must be secured at the same time, however, for attention to the physical state without correction of mental attitude will usually only emphasize the condition by calling further attention to the symptoms. This is especially true of local treatment. The mind must, above all, be treated and diversion of attention secured. Psycho-neuroses may occur in connection with sensory or motor nerves. The patient may either complain of intense pain in some part of the body for which there is but a very slight basis, or may be unable to move certain muscles, or there may be a combination of sensory and motor symptoms with complaint of pain on movement. The painful conditions are most important because they prove a source of worry and anxiety to the patient's friends, as well as often of such annoyance at unsuitable hours as deprives those near them of rest to a degree that may undermine health. {586} FORMS OF NEUROTIC SIMULATION Every possible painful condition is simulated by these psycho-neurotic conditions. They occur probably with more frequency in the abdomen than elsewhere; they may be thought to be colicky in nature and, as a rule, some accumulation of gas will be found. This gas is sometimes swallowed air and sometimes gaseous products that have been diffused apparently from the blood in the intestinal walls. This always produces discomfort but nothing like the discomfort that the patient complains of. The condition if treated by carminatives will nearly always be emphasized rather than relieved. Local treatment by heat will help oftener, but may exacerbate it. When chronic constipation is present, calomel in divided doses is suggestive as well as medicinal. There may be gastric crises that recall those of tabes, and there may be vesical and rectal crises of a similar nature. I have seen a patient complain of every symptom of stone in the kidney. At the beginning the pains were vague, but after she had been to several physicians and had been asked certain questions intended to elicit pathognomonic signs of stone these questions were answered in the affirmative. Her attacks became strikingly like renal colic. After a consultation, at which two physicians and a surgeon were present, she was operated upon for stone in the left kidney. No trace of it was found. But after this she was well nearly a year. Then she had another crisis of pain in the early morning hours, a time when her painful condition always came on, apparently because it attracted more attention and caused more disturbance at this time, and now all the symptoms pointed to the right kidney. She was treated on the principle that it was a neurosis, was made to gain some fifteen pounds in weight, has since then had no attacks, has not passed any stones, and there seems no doubt but that the whole case was merely neurotic. During her attacks instead of having suppression of urine, she had a free flow of urine and no blood. It is not unlikely that the physical basis of the attacks was that condition of the kidney which allows urine to flow through very freely during neurotic conditions and which somehow got into the sphere of her consciousness and being over-attended to became extremely painful. Secretory Neuroses.--Lying between the pain and motor neuroses and dependent on psychic elements to some extent at least, there is a series of neuroses that have as their principal symptoms an increase or decrease of secretion. Occasionally, of course, they are complicated by motor neuroses, especially in connection with the viscera. There are various stomach affections, represented by an increase or decrease in stomach secretion, and accompanied by pain, discomfort, and decrease or increase of peristalsis. There are biliary neuroses accompanied by increase or inhibition of biliary secretions. There are gastric neuroses associated with vomiting, often very intractable, in which there seems to be sometimes a hypersecretion of gastric juice and sometimes a lessened secretion. All of these occur, as is said, spontaneously, but there will usually be found a history of some exhaustive work or worry during the weeks or months just before. Apparently nervous control is lost and then the secretory neurosis manifests itself sometimes in conjunction with painful or motor affections. Neurotic Vomiting.--Persistent vomiting occurs in these cases but is not {587} so serious as it seems and patients do not lose weight, as might be expected. There is sometimes even a probability that some of the food ingested finds its way through the pylorus and is used for nutrition, though the vomiting may come on not long after ingestion. Practically always nature asserts herself and stops the vomiting when serious conditions seem about to develop. The solicitude of relatives may be calmed by this assurance, and just as soon, as a rule, as they show less anxiety about the patient, the first symptoms of improvement will be noted. The fasting girls exploited in the newspapers, in connection with these neurotic conditions are often frauds and investigation has shown on a number of occasions that they were obtaining food surreptitiously. It must not be forgotten, however, that, even though these cases have been discredited, we have a number of cases on record of men and women who have taken absolutely nothing nutritious and only water for from ten to forty or even fifty days. Until at least ten days have passed in one of these gastric neuroses, then, there is no need for urgent solicitude, and this of itself, when properly explained, makes an excellent favorable suggestion for these patients, and, above all, for their friends. Simulant Appendicitis.--Some of these abdominal psycho-neuroses may simulate serious pathological conditions that, in recent years, have come to be looked upon as surgical. I have seen a number of cases, especially in women who have been constipated for some time, in which there was considerable discomfort in the right lower abdominal segment and occasionally surgeons thought that an operation should be performed. Usually in these cases there is no localized tenderness and no mass of any kind to be felt in this region. Sometimes tenderness is complained of, though when the patient's attention is diverted even deep pressure may be made without their wincing. Whenever there is no history of an acute attack, no temperature and no increase in pulse rate, unless there are very definitely localized symptoms, the question of operation is always to be answered in the negative. Disturbances of the pulse may mean little. The history must guide. I have seen these cases operated on, improved for a while, but relapse afterwards just as soon as there was a resumption of their constipation. As a rule, when the appendix has been removed, either because its function has something to do with the inhibition of putrefactive processes in the lower bowel, or because as the result of the operation and consequent adhesions, the colon was not so active in its peristalsis, the constipation seemed to be worse than before, unless special care was exercised. If there is relapse after an operation the patients' attacks are almost sure to be more frequent than before and their discomfort likely to be more pronounced. Lest it be thought that such cases are mainly confined to women or that the most striking cases occur only in women, I may say that the most interesting case of this kind I ever saw was in a young, vigorous German soldier. He was admitted to Koenig's clinic in Berlin with a story of abdominal tenderness and pain, the tenderness being located in the right iliac region. There seemed even to be some distention of the abdomen after a time and the development of greatly increased diffuse tenderness. The pulse was considerably disturbed, but there was only a slight rise in temperature, and for a time it was thought that this might be a case of appendicitis without fever. A surprising feature of the case was the presence in the right iliac region of {588} a scar which, on careful investigation, proved to be double. Apparently the patient had been opened twice before in this region. His history was carefully investigated. He had had a fall from a horse about two years before and afterwards had considerable abdominal discomfort. He was quite sure that something serious had happened within his abdominal cavity as the result of the fall and his attention was concentrated on his right iliac region. At the time of the accident his symptoms were considered to be a psycho-neurosis or perhaps an exaggeration of symptoms with malingering tendencies. Shortly after his term of service expired, however, some acute symptoms developed and there was swelling, or at least tympanitic distention of the abdomen with disturbance of the pulse, and he was operated on in the hospital and his appendix removed. There proved to be nothing the matter with it and no pathological condition was found within his abdomen. He seemed to recover completely. After six months he was admitted to another hospital with the same symptoms. He seemed to have the habit of swallowing air which found its way beyond his pylorus, or else gas leaked from the blood vessels in the walls of his intestines, producing a symptom-complex not unlike the tympanitic distention consequent upon general peritonitis. Once more this was taken to mean very probably a ruptured appendix and another operation was done. This operator went through the old scar, but to his surprise found no appendix and found everything within the abdomen normal. The third time the patient came to Koenig's clinic and, owing to his military record, his hospital experience was available and a third operation was not done. Instead, according to the story current at the time, the patient was tattooed with the legend "no appendix here." The case is interesting as an example of the extent to which an abdominal psycho-neurosis may simulate a ruptured appendix. Pseudo Biliary Colic.--A similar state of affairs to that with regard to the appendix has developed in all that concerns the gall bladder and the biliary tract generally. Any complaint of discomfort in the right upper quadrant of the abdomen, if persisted in, is almost sure sooner or later to be diagnosed as due to a calculus. Now that operations for gallstones are more common than they used to be, it is probable that almost as many gall bladders are found without pathological conditions as appendices without justifiably operative lesions. In treating individuals who have a history of recurrent symptoms of intestinal reaction to various foods complicated by urticaria, it is important to remember that there may probably be lesions corresponding to those in the skin in portions of the intestinal tract which may functionally involve either the appendix or the biliary passages. Some of these cases are extremely difficult to handle because often there is pain, definite tenderness and some fever with the attacks, and very localized symptoms. The history, however, will be helpful. Operation will not relieve the patient from liability to recurrence. There are, however, other cases where the discomfort is much more vague, where there is no tenderness, no disturbance after jolting rides and where there has never been any severe pain. These should not be set down as biliary calculi without further developments. The possibility of a stone being present should not be hinted to the patient until some definite pathognomonic sign is discovered. Other Simulated Conditions.--There are many painful conditions of the {589} head that are psycho-neurotic. Many forms of headache are due to sensations of pressure or tension or constriction, usually in the external integuments of the skull, which are dwelt on and then become painful achy conditions. This is particularly true of so-called headaches in the back of the head. As we emphasize in the chapter on Headache, probably most of the headaches of patients who have not much to occupy themselves with, are due rather to queer feelings in the head emphasized by the concentration of attention on them than to real pains. Earache may occur in the same way. Nearly always when one has been out in the wind, there is likely to be an uncomfortable sensation in the ear. By attention to it this may readily be exaggerated into an earache. Occasionally the physical basis of an ache in the region of the ear seems to be an unconscious performance of Valsalva's experiment while blowing the nose when catarrhal conditions are present. All sorts of painful conditions of the arms and legs may develop in the same way. Unusual tiredness, or some special exertion of the muscles, may produce a sense of fatigue readily exaggerated by attention to it, into severe pain. This condition is not a voluntary simulation, but is due to lack of diversion and a certain inborn tendency in these people to pay attention to anything that is the matter with them. Very seldom does the physical condition need much treatment, though nearly always something can be done for it with advantage, but the mental state needs alteration and, above all, the patient needs to be diverted from over-concentration of mind. Motor Neuroses.--As has been said, beside painful conditions, various forms of motor trouble may develop. These usually consist of inability to move certain groups of muscles. They have sometimes been spoken of as hysterical palsies or paralyses. The word hysterical, by its derivation connected with the Greek word for womb, apparently indicates that these conditions are limited to women. It is well known now that they are extremely common among men and especially among young men and have absolutely nothing to do with the genital system. As with painful psycho-neurotic conditions, there is practically always a physical basis. This sometimes requires careful questioning to locate exactly. There is some injury of the muscles of a particular region, or some over-use of them, or some employment of them under bad mechanical conditions with over-fatigue, and then attention to this leads to incapacity to use the muscles or inability to co-ordinate them properly. Neurotic palsies, to use a term that carries much less unfavorable suggestion with it than the word paralysis or the word hysterical, may occur in any limb or group of muscles. They may occur in the legs with the production of complete paraplegia. One well-known form, astasia-abasia, inability to stand or to walk, affects the muscles of the trunk as well as of the lower limbs. These conditions often remain for long periods in spite of treatment, frequently recur, are often called by all sorts of names and continue to be a source of annoyance to the patient, until a definite successful effort is made to change the patient's mental state to one of less attention to the particular part. There is, it seems to me, an unfortunate tendency to think that our observations upon these cases are comparatively recent. Sir Benjamin Brodie, nearly a century ago, insisted that at least four-fifths of the female patients among the higher classes of society supposed to suffer from diseased joints were really sufferers from neurotic conditions, or, as they called them then, {590} hysteria. Sir James Paget, in his Clinical Lectures and Essays, thinks that Brodie has exaggerated the proportion, for in his own practice, though, of course, he includes his hospital cases and the poor as well as the rich, he found less than one-fifth suffering from neurotic joints. The hip and the knee, which are the most frequent seats of genuine pathological conditions, are also most frequently the subject of neuroses. Next in order, but much more rarely, the metatarsal and metacarpal joints are affected and then the elbow and shoulder. In Sir James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a number of cases which show how clearly psycho-neurotic affections were recognized in his time. He tells the story of a young man who had been overworking for examinations and who "after a three-hours' mathematical cram, fainted and when he rallied set up a very close mimicry of paraplegia which lasted many weeks." He insists that "such mimicry is found not only or chiefly in the silly selfish girls among whom it is commonly supposed that hysteria is rife, but even among the wise and accomplished, both men and women." DIFFERENTIAL DIAGNOSIS For the differential diagnosis of psycho-neuroses from definite organic conditions, the most important element is the patient's previous history and a knowledge of the condition of the nervous system. Where this is known the diagnosis is comparatively easy, but when the patient is seen for the first time it may often be extremely difficult. It is, above all, important not to jump to conclusions, for every nervous specialist knows of cases in which the diagnosis was considered to be surely a neurosis, yet a fatal termination showed that a serious organic condition was at work. It must not be forgotten either that neurotic patients may develop serious organic disease in the midst of their neurotic symptoms and care must be taken not to miss the significance of special symptoms. When the patient is not well known, the presence of certain stigmata, as they have been called, enable the physician to recognize the probability that a neurotic condition is present. Patients who are subject to neuroses are likely to have certain areas of the skin surface and of the palpable mucous membranes more or less sensitive than normal. There are likely to be spots of hyperesthesia or hypesthesia or even complete anesthesia somewhere on the skin. These should be carefully looked for and in serious cases an examination of the whole skin surface should be made. Not infrequently anesthesia or a decided lack of sensitiveness to irritation will be found in the throat or in the nose. Occasionally the conjunctiva is much less sensitive than usual. These used to be called hysterical stigmata. The word hysteria carries an innuendo of imaginativeness or occasionally of affection of the sexual organs that is unfortunate. It would be better, therefore, not to use the term in any way. The presence of these areas of hyperesthesia, hypesthesia and anesthesia indicates that association fibers are abnormally connected in the brain for the moment at least, and that as a consequence there is over-attention to certain portions of the body with lack of ordinary attention to others. This will account very readily for the occurrence of painful conditions in certain cases and palsies in others. When over-attention is paid, there may be a {591} hyperesthesia corresponding to that seen in the skin in any organ of the body. When, for any reason, there is a disturbance in a particular part, there may be a lack of motility due to nervous influences, just as there is a lack of sensation. In all of these cases the one essential element is to correct the nervous state through the mind as far as possible. Experience has shown that this can be done in nearly all cases. It must be the principal effort of the physician. TREATMENT Strong Mental Impression.--In the treatment of these affections two periods are to be considered, one during, the other after the attacks. During the attack a strong impression must be made upon the patient's mind so as to divert the concentrated attention. We have well authenticated stories of the various expedients resorted to by physicians who were confident of their diagnosis in order to secure such a strong mental impression. I once knew an old physician who was summoned to a childless wife whose adoring husband was in manifest agonies of solicitude over her and whose mother and mother-in-law had been caring for her for days with all anxiety, walk into the room of the patient, take one of her hands in his, slap her on the cheek, tell her to get up and walk and she would have no more of that supposed inability to walk which had caused the family so much anxiety. He succeeded. It can be imagined what would have happened had he not succeeded. We know of cases where an alarm of fire or a burglar scare or some sudden emotion has produced a like result. We cannot prescribe these things, however, and at the most, after one or two successes in a particular patient, they would fail. The only thing that we can do as a routine practice is to relieve by direct treatment the slight physical condition that is usually present and then try and influence the patient's mind. If a thorough examination is made in the course of which the physician is able to show the patient that he understands the condition and that he can demonstrate for himself and them that there is nothing serious the matter with important organs, he can make them feel that their pain or disability is entirely due to concentration of attention on a particular nerve or set of nerves. With many patients this will succeed, not at once, but after two or three seances of positive suggestion, even in the waking state. If the patients are bothering their relatives very much it may be necessary to give some opium as an adjuvant. As a rule, the needle had better not be used, but a suppository given. This is not nearly so attractive to the patient's mind as the use of the needle and is not likely to be called for so often. Every physician has had the experience that after giving opium two or three times, either per rectum or hypodermically, almost anything can be given, provided the patient is persuaded that the drug is being given again. A reasonably large dose may be used the first time, but certainly after the second or third time a much smaller dose will produce the same effect and often a simple gluten suppository, provided it looks like the other, will work just as well as an opium suppository. After Treatment.--The after treatment of these cases is directed mainly to such alterations of the mental attitude and physical condition as shall prevent {592} recurrences. The general condition of the patient must be improved in every case where there is indication for this. Many of these patients are under weight for their height. They must put on weight. Weir Mitchell's success with the "rest cure" consisted to a great extent in his power to cause these patients to put on weight. This supplies reserve energy, but, above all, replaces discouragement by hope and buoyancy. Gain in weight can be accomplished mainly by two methods. First, by seeing that the patient gets an abundance of air and, secondly, by dictating how much shall be eaten. In this matter details are important and it may be necessary to suggest the actual diet for each meal. This must be liberal and must consist of simple but particularly nutritious materials. Patients' dislikes need not be taken into much account, their likes are often helpful. When there is insistence on lack of appetite and decided objection to chewing, eggs and milk should be given in increasing quantities, until five or six eggs and some twelve glasses of milk are taken every day. Besides this, a good portion of meat should be eaten at one meal with some vegetables. By firm insistence, day after day, it will not be hard to get patients whose appetites are seriously inhibited to take this amount of food. To secure this, a good, firm, sensible nurse is invaluable. Appetite, as we have emphasized in the chapter on Appetite, is largely a matter of will, and anything that is eaten, provided it stays down, will do good unless there is organic disease. A certain amount of exercise is important in these cases, but not nearly so important as an abundance of fresh air. Patients must not be allowed to overtire themselves. Riding in an open carriage or on the top of a bus, especially where there are distracting scenes and many human interests, is particularly beneficial. Automobiling is often likely to be more tiresome than is good for these patients when they are run down, though it is one of the best of therapeutic measures for those who are physically capable, that is, up to weight, even though they may complain of feeling weak. _Diversion of Mind_.--It is in these cases particularly that diversion of mind is of prime importance. Many of these patients have either no serious interest or at most certain interests with which they may occupy themselves if they wish, but that are not engrossing and attention to which may be put off whenever they care to. Duties that are inevitable and that call for the occupation of so much time that the patient has little opportunity to think of herself are often the salvation of these patients. As I mention in the chapters on Occupation and Diversion of Mind, I have seen a number of cases and I am sure that every physician of reasonable large experience has seen similar cases, where women, particularly, who in the midst of prosperity have been constantly suffering from some form of psycho-neurosis, great or small, have, after some sudden turn of fortune, been completely relieved from their nervous symptoms by having to devote themselves seriously to some occupation for a livelihood. Occupation, particularly with children, with the weak and the ailing, with the poor and those who are unable to help themselves, is specially likely to be helpful to such patients when they are women. Such interests affect them deeply and by the sympathy they arouse through contact with real physical suffering, they prevent over-attention to themselves. I have seen the care of a cancer patient, and especially of a relative affected by cancer, do more for {593} a psycho-neurotic sufferer than all that doctors had been able to accomplish in years. It is often difficult to find occupation and diversion of mind for these patients, but this is the therapeutic problem the physician must solve if he is going to secure relief from present conditions and prophylaxis against further attacks. Oldtime Cures.--Many of the remedies for obscure abdominal conditions show how well the real character of the affection was duly recognized and appreciated in the past. It is in these cases particularly that the pillulae micarumpanis, the bread pills, of the olden times, were so commonly used with good effect. We have quoted examples in other chapters. Many of the drugs that are employed with reported success for these affections have a strong suggestive element in them. Valerian probably is a good tonic and yet there is no doubt that the suggestive quality of its nauseating smell and the almost inevitable eructations that occur after to emphasize it, are helpful in curing certain internal psycho-neuroses. Another drug that has been much used in the same way is asafetida, whose disgusting taste and odor have been excellent auxiliaries. Fresh pills of quinine and red pepper uncoated and therefore producing definite effects on the taste before swallowing and on the mucous membrane of the stomach after swallowing, often prove the best remedy for persistent vomiting or for enduring nausea. A drop of nux vomica, taken every half hour with the definite warning that the patient must by no means take more, and that the bottle must be carefully protected lest anyone else should be poisoned, is often very efficient. These remedies have a slight physiological action and a large psychic action, but that exactly corresponds with the etiology of the affection for whose treatment they are employed. Dominant Ideas.--During the attack it is often possible to find either from the patient or from friends that there is some dominant idea which is bringing about the mental short-circuiting that leads to the concentration of attention. From the oldest times it has been recognized that in young women a disappointment in love may prove to be the occasion for a psycho-neurotic or, as they used to call it, hysterical attack. This is, however, not a specific cause. It is the disappointment much more than the sex element in the case, as a rule, that produces the unfavorable effect. It was easy to conclude that the sex factor was extremely important in older times when women's sphere of activity was largely limited to the home, and marriage was the one legitimate object of their ambition. Now that we have had more experience with the business woman, we know that serious disappointments of any kind have a tendency to initiate psycho-neurotic conditions in susceptible and especially suggestive individuals. A failure to secure promotion in a store, or to secure some position that is eagerly sought for, a loss of money in business, etc., especially when they have been preceded by weeks or months of solicitude and worry over the event that now happens, may lead to the development of a psycho-neurosis. This is particularly notable with regard to educational interests of various kinds. Young women readily overdo application to study, or, rather, anxiety over it, and as a result get into a state of mind in which a failure to pass an examination, or to secure promotion, or even the failure to win a prize, may give rise to a highly nervous condition in which tears and laughter come unbidden and in {594} which further developments may bring on a typical psycho-neurotic attack. All sorts of pains and aches and motor incapacities may occur in these states. The supreme occupation with the single idea present in their minds at all times, waking and sleeping, while they try to study, or when they read or even when they are supposed to be diverting themselves, finally precipitates a nervous explosion along nerves that have been irritated for some reason, though the pathological condition present may be quite insufficient of itself to explain the affection that ensues. These are the popular nervous breakdowns, not difficult to treat once their real character is diagnosed. Sorrows of various kinds may produce a like effect. Worry or anxiety about the serious illness of a near relative, especially an inevitably fatal illness, such as cancer or tuberculosis or the disturbing mental affections, may have a similar result, but usually not in those who are occupied with the actual care of the patients. The mental states constitute the psychic elements underlying the neurotic condition that develops. Almost needless to say, successful treatment must include a faithful attempt to lessen the significance of the mental state that is so important in the case. Usually the mere obtaining of the patient's confidence is enough to lessen greatly the irritation produced by the mental condition. A sorrow shared is halved. It is, above all, secretive individuals who become depressed over their sorrows. While the patient who insists on constantly sharing them with everyone becomes a nuisance, it is always a little dangerous not to have a confidant to whom worries and anxieties are entrusted. If they are kept to one's self they are nearly always exaggerated--they are seen out of proper perspective and have a much more depressing influence. Calm, judicious reasoning with the patient over the significance of the condition as presented, is often of great help. Often these ideas, so potent for mental and bodily disturbance, are almost entirely unconscious or exist in the patient's subconsciousness and are recalled only under such special conditions as remove the bonds of the patient's occupation with himself or herself at the present time and allow memories to come back without interference. There are many curious stories of such cases. A child is frightened or very much disturbed by having a cat kill a favorite bird. The cat becomes a deterrent object. Gradually this deterrence grows. As a consequence, there may develop one of those intense dreads of cats which makes life miserable if near that animal. There may even be physical effects produced by the continued presence of a cat in the same room. Often in these cases the beginning of this mental attitude, or at least its occasion in the incident of the killing of the bird is forgotten, or at least not consciously referred to as an etiological element in the dread. Patients have been known to develop states of mind which made them object to certain figures or names because of earlier associations with them that were unpleasant. There is the story of a man who would never take a car with an odd number though this was sometimes a source of annoyance and delay and who could not explain to himself or his physician how this objection had developed, until his memory was searched and it was found that, years before, he had witnessed the death of a child under the wheels of a car with an odd number. He had completely lost the sense of the direct influence of this, but it existed in subconscious memory and proved the source of much {595} annoyance to him, for if with a friend he were not able to avoid taking an odd numbered car he would feel quite miserable during the ride. Frights of various kinds may produce this same effect. I have in my notes the case of a man who is unable to sleep at night without a light in his room, because of a fright. Once while asleep in the dark, he awoke conscious that someone was in the room and sat up and demanded who was there. The answer was a revolver shot and a bullet, passing not far away from him, pierced the head of the bed. As he sank back the burglar leaped from the window and escaped. He realized that this was the cause of his fear of the dark, but lesser incidents might easily become subconscious yet continue their influence. Psycho-Analysis.--In recent years Freud has suggested that in many puzzling cases of psycho-neurosis, where, so far as is known, there seems to be no dominant idea bringing about the concentration of attention, careful analysis of the patients' memories will bring out the fact that there is a subconscious idea as the underlying substratum of these affections. Freud has developed what is called the process of psycho-analysis in order to bring out these ideas which are sometimes exerting their influence unconsciously to the patient. The subconscious is one of the fads of the hour, so that Freud's announcement attracted much attention. Psycho-analysis, however, is not advanced so confidently even by its inventor as a positively curative measure, as it was at the beginning. It has been found that after the dominant idea in the subconsciousness has been found and neutralized with a consequent amelioration of the psycho-neurotic symptoms, there may be a relapse, when another dominant idea will have to be found, and that there seems to be the possibility, in some cases at least, of an almost endless succession of such ideas to account for further and further relapses. Undoubtedly psycho-analysis has its place in psychotherapy and is of great value in certain cases. There is no doubt, however, in my mind that in most of these cases reported as cured after psycho-analytic methods had been employed, what really happened is that the patient's mind became diverted to another idea--that of marvelous cure through mind searching which relieved the previous concentration of mind underlying the psycho-neurosis. These are the cases that used to be cured by hypnotism. Before hypnotism was developed they were cured by mesmerism. Before mesmerism they were cured by magnets or by the Leyden jar, and during the past century they have been cured by electrical methods or by osteopathy or by Eddyism. Many of the cures were effected by stroking and touches, the use of Perkins' tractors, or Greatrakes' methods, or anything else that attracted attention very strongly. They were given a new idea which occupied them very much and so saved them from that preoccupation with themselves and their feelings and whatever slight ailment might be present that was the physical occasion for psycho-neurotic symptoms. This happened with psycho-analysis. When it was absolutely new and the operator had great confidence in it, this confidence was imparted to the patients, with the consequent cure or decided amelioration of their psycho-neurosis, just as that used to be brought about by our previous method of treating such cases by some strong suggestion. As I emphasize in the chapter on Dreams, the examination of the dreams in order to get a hint of the dominant idea, is particularly interesting, because it represents a return to the oldest methods of suggestion of which we have record. {596} The fact that sexual ideas seem to represent a great many of the dominant ideas in these cases is of interest for a similar reason. It represents the tendency constantly recurring to refer most nervous ailments, as indeed most other ailments, to something pathological in the sexual or genital sphere. The old idea embodied in the word hysterical exemplifies this very well. The "vapors" or "tantrums" or fits which were supposed to be due, to some extent at least, to suppressed sexuality by medical writers of three or four generations ago, have come back to us under another form and with other terms. Psycho-analysis gives occasion for instruction in so far as it helps the patient to get rid of old persuasions and exploded ideas as to disease and diet and the various functions of the body and the mind that have often almost unconsciously been acquired and secured a dominance. It is surprising how often it will be found that people are taking too much or too little water at meals, too many or too few vegetables, too much or too little of salt or of other condiments as the result of habits and notions acquired when they were young and under influences that they may now forget. In the same way habits of life with regard to bathing, clothing and the like may be the source of unfavorable conditions in mind and body that need only to be discovered to be corrected. Their correction will often bring about the relief of symptomatic conditions that have proved quite obstinate to treatment. We have emphasized this in the chapters on the Individual Patient and the necessity for acquiring just as much knowledge as possible about both his occupations and his mental attitude in order to be able successfully to treat chronic disease. {597} SECTION XVIII _DISORDERS OF MIND_ CHAPTER I MENTAL INCAPACITY (PSYCHASTHENIA) In recent years we have come to realize that many of the so-called nervous diseases, or if they do not deserve the serious name of disease, nervous symptom-complexes, are really due to a deficiency of vital energy. Some people have a store of energy that enables them to accomplish many different things successfully. Some become exhausted from a few trivial occupations. What is noteworthy in the cases to be discussed in this chapter is that they show always certain symptoms of mental tiredness or, at least, of lack of capacity for affairs. Patients complain, for instance, that they cannot make up their minds so as to reach decisions because they doubt so much whether the decision they come to will be right or wrong. Others dread the outcome of any and every act and feel that something is hanging over them. Slight sources of irritation become so exaggerated by thinking about them and dwelling on their possibilities that they may even disturb sleep and appetite and, as a consequence, the general health. Fears come over patients lest various things should happen and they dread microbes, or infections, or dirt in general, or the approach of insanity, and all to such a degree as to incapacitate them for their ordinary occupations. Many of these patients become quite incapable of willing effectively. They not only lose initiative, the power to undertake new enterprises, but they find it difficult to make up their minds as to details of the ordinary affairs of life. As we have stated elsewhere in Professor Grasset's expressive formula, these patients say that they cannot do things, their friends say "they will not," and the physician, taking the middle course, which, as usual in human affairs, has much more of truth than either of the extremes, says "they cannot will." For these states Janet of Paris suggested the word psychasthenia. It is formed on the model of the word neurasthenia and unless it is used with discretion will have all the objections that attach to that other term. Above all, it shares the tendency pointed out by Sir William Gowers with regard to neurasthenia of being "too satisfying. Men are apt to rest on it as they would not on its English equivalent. Physicians, if they do not actually think that they have found the malady from which the patient is suffering, have an influence exerted on them of which they are often unconscious, which lessens the tendency to go farther in the search for the whole mental state." Much more can be said in defence of psychasthenia, however, than of neurasthenia, for the substitution for it of the translation of the Greek words of {598} which it is composed--"mind weakness" would be alarming. While it is important, then, to realize that the term may easily be made too general and prove, as such words as rheumatism has done in our time and malaria did in the past, a cloak for ignorance and an excuse for incomplete investigation for diagnostic purposes, it represents a satisfactory answer to the patient's question as to what is the matter without committing the physician to such definitely detailed opinions as to the patient's condition as would surely prove unfavorably suggestive. Psychasthenia, Natural and Acquired.--There are two forms of the mental incapacity that underlies many of the curious symptom-complexes that have been studied under the term psychasthenia. One is natural, that is, inherent in the special character of the individual, and the other acquired through disease or exhausting labor, worry, or anxiety. Some people are born without sufficient mental energy to do the work they attempt to accomplish. This is true, also, in the physical order. It is often pitiable to see young men who have not the physical strength necessary for athletic exercises, or the dexterity required for them, faithfully trying to accomplish by effort what others do with ease. When there is some natural defect in the way they will usually fail, no matter how much they strive. Just in the same way some persons are not able to accomplish certain more serious purposes requiring special mental ability or power which they attempt. Their brothers, their friends, their schoolmates, may have the ability, and they cannot understand why they should not have it, but the fact remains that they are not possessed of it and if they try to make up for this defect by overwork they simply break down. Differential Diagnosis.--Each of the two forms of mental incapacity, congenital and acquired, must be carefully differentiated and treated from a special standpoint. With regard to congenital lack of mental control, all that the doctor can do is to counsel against the assumption of duties and responsibilities that are too heavy for the patient. Some people have not enough nervous energy to run a business with many details, and some even find it difficult to try to do things involving much less responsibility. There is no use for a man five feet in height, weighing one hundred pounds, to try to be a stevedore. There is no use for men of delicate muscular build to try to make their living at heavy manual labor; they simply wear themselves out in a very short time. This inadaptability is recognized at once. Just the same thing is true with regard to many nervous systems, but the recognition is not so easy or immediate. Some cannot stand the strain of intricate business details or the burden of responsibility in important transactions. They must be taught to be satisfied, then, with quiet simple lives without what is for them, excessive responsibility and without strenuous business worries. A country life with regular hours, plenty of open air and as little responsibility as possible, is the ideal for them. The most difficult problem in this matter is the question of diagnosis. As a rule, the history is the most helpful for this. The patient tells of having found difficulty all his life whenever anything of special significance was placed on his shoulders. He is one of those who were born tired and remain so all their lives. It has been the custom to blame these people; they are rather to be pitied. If they are born in circumstances that allow of their {599} living quietly in the country, they accomplish a certain amount of work quite successfully and live happy, contented lives. If they are born in the city where the hurry and bustle around them and the insistence of friends that they must take up responsibilities becomes poignant, they get discouraged and even despondent. It is from this class of patients that the "ne'er-do-wells" of modern life are recruited. They form the under-stratum of trampdom, the scions of good families with the wanderlust, the willing but incapable. Certain of them become vicious and criminal, either because they do not want to work or because their mentality is perverted in some way. Such patients cannot be treated with any hope of their becoming successful exemplars of the strenuous life, but they may be directed into the less exacting occupations of country life and so live quiet, useful and happy lives. For the congenital class we can do little except to prevent them from trying to do things that are beyond their mental capacity and helping them to see just what their limitations are. _Mental Exhaustion_.--Many disturbances of mental energy are acquired. These may be either functional or organic. For the organic variety we cannot do much, since it is dependent on changes in organs that are permanent. We can, however, usually predispose the patient's mind to the recognition of the fact that he should no longer try to devote himself to occupations that constitute a special drain on his nervous energy. The man, for instance, who is already suffering from arterio-sclerosis must be warned that worry and work will surely hasten the process and that his nervous symptoms cannot be cured, but must be palliated. He must be advised to lessen his mental strain and to take up something which, while occupying his mind, does not make insistent calls on his vitality. In this matter it must be remembered that when a man over fifty develops nervous symptoms, as a rule there is no question of functional trouble but of organic change and usually heart or arteries or kidneys are at fault. In recent years we have come to realize that typhoid fever often makes serious inroads upon a patient's vitality which can only be retrieved by care, not alone for some months but, if possible, even for some years, not to put an overstrain on the vital energy. Certain other diseases produce an even more lasting effect. A sufferer from well-developed tuberculosis will probably never be able to go back to the strenuous city life. If he attempts to do so, not only is there danger of a recurrence of his tuberculosis, but there may even be a development of neurotic symptoms. Syphilis is another disease that leaves patients in a condition in which it is dangerous for them to assume the serious responsibilities of an exacting occupation and especially anything that involves excitement and worry. Syphilitic patients should be warned of the danger of pursuing vocations that make such demands upon them. It is the actor, the broker, the speculator, and the strenuous business man generally, who is likely to suffer from parasyphilitic conditions, tabes, paresis and the like, much more than those who follow occupations that make less demands on them. Functional Mental Incapacity.--In a large number of cases the incapacity to do things because of lack of mental energy is due to functional disturbances of the nervous system. These are the most important for the psycho-therapeutist because much can be accomplished for them. Nearly always the patient can be benefited by advice and suggestion, and very often some {600} unfavorable factor at work, using up his mental energy to no purpose, will be discovered. In order to do good, however, careful study of the individual patient is the most important element. The most frequent functional disturbance of the nervous system, leading to exhaustion of mental energy, is over-attention to one's self and to one's occupations. Men can do many complicated things quite naturally and easily, but when they carefully watch themselves doing them, accomplishment is not so ready and the task is double. They tire much easier, for, as a rule, what they are doing could be accomplished automatically and they are using up energy attending to it. This is probably one of the commonest causes for the rather frequent development of that state called nervous exhaustion in our time. People watch themselves too closely and by so doing they not only use up energy unnecessarily in the surveillance, but also they hamper their powers to do things and so consume additional energy in overcoming this inhibition. Morbidly introspective people watch almost ceaselessly everything they do. They not only watch themselves work and worry about it, but they watch themselves play and grow solicitous that it will do them good; they watch themselves divert themselves to see if it is giving them real recreation and so spoil the diversion; they watch themselves eat and disturb their appetite, and watch themselves digest and hamper digestion; they even try at least to watch themselves sleep and so interfere with sleep. Many of the cases of insomnia are really due to this over-attention. They fear they will not sleep, they worry about it, they keep themselves awake hoping that they will sleep, and in the more serious cases even during sleep itself they are so solicitous that their dreams become very vivid and a form of unconscious cerebration goes on with surveillance of themselves. They do not rest even in sleep. They wake feeling not rested, they get up with a consciousness that they are beginning a long day without being properly refreshed and they exhaust enough energy to complete a good part of the day's work in wondering whether they will be able to go on with their occupation for the day, whatever it may be. _Inhibitory Surveillance_.--People become afraid that they cannot or that they may not do things well and set a guard over themselves. This is illustrated very well in the doubts about accomplishment because of which they keep going back to see what they have done and how it was done, though usually it was accomplished quite well without any conscious attention. Dreads form another phase of this attitude of mind. For those who are affected with them they make a thing hard to do before it is begun, and harder to accomplish after it has been entered upon because of the suggestion that it may lead to some serious results, or they even inhibit their activities to a marked extent by their solicitude with regard to them. They worry about things before the event and thus consume energy uselessly. Worry has been defined as anxious solicitude about what we have to do next week at the same time that we occupy ourselves with what we are doing now and have to do in the next hour or two. The solicitude about next week is quite useless, as a rule, until the time comes, and it merely disturbs what we are doing now, making it harder to do and making errors in it almost inevitable, and so preparing ourselves for discouragement because of mistakes that have been made and still further adding to the difficulty of accomplishment. {601} _Inhibition of Automatism_.--These introspective people disturb themselves by over-attention to things that need no attention, that are accomplished automatically, and that are not done nearly so well if they are attended to. Not only is it true that it is harder to do work that ought to be accomplished automatically if much attention is given to it, but also nature resents the surveillance. Not only the brain does not work so well if watched to see whether perhaps it is working too much, or whether there are too many feelings in our head while we are doing things, but even the stomach resents being watched and does not do its work as well. The same thing is probably true for every one of our organic functions. In the chapters on the heart we call attention to the fact that surveillance makes a perfectly healthy though nervous heart miss beats. There is a dual waste of nervous energy then. We are employing our attention watching things done that need not be watched, and by that fact we are inhibiting natural processes and requiring that more energy shall be put into them for their accomplishment, and even then accomplishing them with discouraging imperfection. _Mental Short-Circuit_.--The reflex mental process that particularly affects many individuals in our time and makes it hard for them to do their work, has been well described under the figure of a short-circuit in an electrical dynamo. The short-circuit diverts the current so that instead of acting outside the dynamo and performing useful work, it is discharged within the machine, brings about deterioration of its elements and soon leads to a reduction in the amount of electrical energy that that particular dynamo can develop. Association Fibers Diversion.--Prof. Michael Foster in the Wilde Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote 44] has many valuable suggestions with regard to the mechanism of mental operations on the neuron theory. He has particularly dwelt on the function of the association fibers in connection with mental operations, or with the raising of sensation to the plane of mentality. A portion of the brain that is originating impulses, instead of sending them down to the periphery, through the projection fibers, to lead to the accomplishment of external work, may have its messages diverted through the association fibers to other portions of the brain and thus do harm rather than good. [Footnote 44: _Proceedings of Manchester Literary and Philosophical Association_, 1898.] Occurrence of Psychasthenia.--It must not be thought that these curiously interesting conditions occur only among people of low intellectual caliber, or in those of narrow intellectual interests, mere specialists who may have acquired a reputation for doing one thing well. They are frequent among the most intellectual classes. Brain workers of all kinds, unless they are careful to vary the interests of life, unless, as suggested in the chapters on Occupation of Mind and Diversion of Mind, they have a hobby besides their usual occupations, are likely to suffer in this way. As a matter of fact, many intellectual people have had what are called nervous breakdowns of this kind. A biographical dictionary shows any number of them. Dr. Gould's Biographic Clinics furnish many documents for the study of these conditions. A typical instance, told by the sufferer himself, the distinguished Sir Francis Galton, is of special significance for the psychotherapeutist. I {602} quote because it illustrates the fact that such breakdowns do not portend a short or subsequently listless life, for Sir Francis, a most successful scientific investigator, lived well beyond fourscore years in the full possession of health of mind and body. It was during my third year at Cambridge that I broke down entirely in health and had to lose a term and go home. I suffered from intermittent pulse and a variety of brain symptoms of an alarming kind. A mill seemed to be working inside my head; I could not banish obsessing ideas; at times I could hardly read a book, and found it painful to look at even a printed page. Fortunately I did not suffer from sleeplessness, and my digestion failed but little. Even a brief interval of mental rest did me good, and it seemed as if a long dose of it might wholly restore me. It would have been madness to continue the kind of studious life that I had been leading. I had been much too zealous, had worked too irregularly and in too many directions, and had done myself serious harm. It was as though I had tried to make a steam-engine perform more work than it was constructed for, by tampering with its safety-valve and thereby straining its mechanism. Happily the human body may sometimes repair itself, which the steam-engine cannot. The physician with experience in such cases would be much more apt to say, "Happily we can learn to control our mental energy and not let it go to waste by foolish persistence at one set of ideas constantly, nor be dissipated in surveillance of functions that work automatically if left to themselves." Etiological Factors.--This form of mental incapacity develops particularly in people after they have gone through a prolonged period of hard work and then have come to a time when they are much freer than they were before. They are prone to think that they exhausted their nerve force during the preceding period of labor and that now they are paying for it. Almost invariably what is really happening is that they now have much more time to occupy themselves with themselves and about themselves and to worry over their ills, real and imaginary. This is the typical nervous breakdown, as it used to be called, of elderly retired merchants or bankers. They have looked forward all their lives to a time when they could enjoy themselves doing nothing. They retire from business and then their troubles begin. It is no wonder that the old proverb, "A machine rusts out much sooner than it wears out" should have been so often quoted with regard to this condition. A man who has been working busily at something all his life cannot stop all at once and do nothing. He cannot learn to occupy himself with trivial things. Commonly, he has few, if any, interests apart from his business and he very soon wears the novelty off these and then introspection comes to make him exaggerate the significance of every feeling that he has, every stiffness that occurs, every muscle twinge due to change in the weather, until he becomes supremely miserable. As a rule, these patients are simple, practical, common-sense, business men, and it is hard for the physician to think that there is nothing more than a functional neurosis present. It is even more difficult for the patient to be made to appreciate that his ills are mainly due to his own over-attention to himself in this idleness that he has looked forward to with so much pleasure. Ordinary medicines fail to relieve and the regular professional man seldom succeeds in doing these patients much good. They constitute the richest material for the quack and the charlatan. Much occupied with their ills they tell their friends all about them. Whenever a strong impression is produced {603} on their mind by a promise to cure them with some new wonderful remedy they are favorably influenced, often get better and then are walking advertisements for the particular quack who has happened to benefit them. It is this class of people that has given more trouble to legislative committees of medical societies than any other. Some of them appeal to legislators whenever a bill for the admission of some new form of practitioners of medicine comes up with the story of how much benefit they derived from the treatment. Since they have been successful business men their word carries weight. It is curious how little the making of money, though often presumed to be so, is a test of real intelligence. It is often the man of one idea with no intellectual breadth who is the best money-getter. These conditions develop almost entirely in predisposed individuals who, for some reason, are trying to overdo the energy they possess, and who, as a consequence, have lost a certain control over themselves. At times, of course, they occur in persons who have so little occupation of mind that thoughts of various kinds along these lines become insistently suggestive and cannot be thrown off because the patients' interests are not sufficiently deep or sufficiently varied to occupy their attention. The rational treatment of them, then, must be founded on a careful study of individual cases, the recognition of the special cause, and also the occasions at work in each case, a neutralization of unfavorable suggestion and a provision of such favorable suggestions and occupation of mind as will enable the patient to rid himself of the annoyance occasioned by these and the physical symptoms that so often develop as a consequence. In a certain number of cases a history of corresponding or equivalent affections in preceding generations will be found. In many patients, however, there is no such history, though there is usually the story of symptomatic mental conditions of one or other of the types mentioned, earlier in life. When in good health physically the patient has very little bother from them. When run down in weight or when worried or anxious about business or from the stress of important responsibilities these symptoms may become bothersome mentally and physically. Often it will be impossible to obliterate them entirely, but always they can be greatly improved and the patient can be made to realize that they are not seriously significant, that in mild form they are rather common and that, above all, they are not so peculiar to the individual as he is likely to think, with consequent increase of the unfavorable suggestion. CHAPTER II HALLUCINATIONS Hallucinations Differentiated from Illusions and Delusions.--Hallucinations are vivid impressions on the consciousness which appeal to their subject as strongly as if they were really the result of sensory impressions, though those who experience them know, either at the moment, or on investigation afterwards, that they had no objective reality, that is, were not due to any external physical cause. Illusions are deceptions of the senses, due to the imperfection of the senses or the conditions in which the perception occurs. {604} Delusions are mental states in which ideas are accepted, or conclusions drawn, or information assumed to be gained, though the whole process is mental and has no relation to reality. (For illustrations of illusions see chapter with that title in the Appendix.) Hallucinations lie in between illusions and delusions as a mode of deception. They are mental occurrences, but they seem to come from the senses and probably the best explanation for them is that a previous sensory impression is vaguely aroused and then finds its way into the consciousness as if it were coming through the senses. It has been suggested that they might be due to a reversal of the nervous process by which a sensation reaches the brain. The external object produces the sensation, this travels along a nerve causing a perception, this perception is stored in the memory, and then, when very vividly reawakened, causes impulses to travel backward along the nerve to the periphery with the production of a feeling very like sensation. Frequency.--While hallucinations are often supposed to be only incidents in the life of the insane, or at least of those who are in the danger zone near mental disequilibration, carefully collected recent observations show that many perfectly sane people have experienced them, and some of them have been much disturbed by them for fear they portended loss of mental control or some developing pathological condition. A certain number of men and women have seen things that either had no existence or existed only for them and for the moment, and that evidently were due to some state of mind rather than to their senses. They have heard things that were not said or that were not audible to others, or that were only reproductions of their memory of previous sounds and quite naturally such mysterious manifestations disquiet them. It was the rule in the past to dismiss such phenomena without serious consideration, or at most to consider that they were only subjective manifestations not worth discussing, or to go to the opposite extreme and say that they were due to mental disturbances. Of course, as a rule, hallucinations are an index of mental disturbance. No matter how apparently sane the patient, this must be the first thought and must be carefully excluded before proceeding with the case. The subject of hallucinations is larger than that, however, and it is a mistake to brush it aside in every case as if it were either very serious or of no importance and that in either case nothing can be done to relieve solicitude about it. Physicians can often do much, first to prevent hallucinations by getting at the physical causes of them; second, to prevent them from disturbing patients seriously by showing them how common are such experiences and by indicating their possible physical significance; third, by securing such mental discipline and control as will render their recurrence much less frequent; and, fourth, they can make the almost inevitable unfavorable effect upon the mind of the patient and then reflexly upon his body, much less than it would otherwise be, by sympathetically discussing and entering into the details of them enough, at least, to explain their significance or throw some light on their origin in physical conditions. Hallucinations of vision, the seeing of things and persons that have no real existence at the time and place they are seen, are usually considered to be rather uncommon and to occur only in those whose mentality is seriously disturbed. Careful studies of the subject, however, show that at least one in ten {605} of educated people consulted have had some hallucinations of vision. Either they have wakened up, or they have dreamt that they waked in the early morning, and have seen some one whom they knew, but knew to be at the moment at a distance, standing near them. Such visions have gradually faded away or suddenly disappeared. Occasionally these persons have in full light had some appearance, wraithlike or otherwise, some manifestation that appeals to vision, yet that they knew at the time or learned afterwards was non-existent. Many people are backward about confessing that they have had such experiences, for they fear that it will make them ridiculous or even cause them to be suspected of disturbed mentality. Just as soon as it is made clear to them that their admissions will be taken as evidence for a phenomenon to be discussed seriously, many more than would otherwise be thought confess to such hallucinations. Most of these, it may be said at once, are quite sensible people, a great many of them belong to the educated classes; all of them are trustworthy witnesses as far as good will goes, and the circumstances of their hallucinations are such in many cases that there cannot be a mere mistake, or error of judgment. The frequency with which hallucinations occur may be appreciated from the investigation made some years ago at the instance of the Congress of Experimental Psychology. The following question was put to 17,000 persons, mostly residents of Great Britain, and answers received: "Have you ever, when believing yourself to be completely awake, had a vivid impression of seeing or being touched by living beings or inanimate objects, or of hearing a voice, which impression, so far as you could discover, was not due to any external physical cause?" The answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women had experienced a sensory hallucination at some time in their lives. Some of them had had a number of them. That is, one out of ten in the educated classes has had some hallucination, and nearly one out of every eight women. An analysis of the statistics, however, brings out some interesting suggestions. There were nearly twice as many hallucinations related as having occurred during the year before the question was asked as in the preceding years. There was a definite reduction in the number that had occurred in all the preceding years, except the fifth and tenth, and these were evidently due to uncertainties of memory, so that five- and ten-year periods seemed about the length of time that had passed since the event. It is evident then that in spite of the fact that an hallucination would seem to be very important and surely startling enough to be well remembered, it is yet easily forgotten, since even a year's interval made so much difference in the number that were remembered. The committee, after considering this easy forgetfulness in the matter, considered that to arrive at the actual total of visual hallucinations experienced by this group of 17,000 persons during the ten-year period in question, the numbers in the table should be multiplied by four. That means that probably very nearly one in three people have had an hallucination of some kind within ten years. The great majority of the visual hallucinations consist of apparitions of human figures. Other forms that are seen are so few, as Mr. Podmore has insisted in his "Telepathic Hallucinations, The New View of Ghosts," [Footnote 45] that they are almost negligible. A frank {606} discussion of these details with a person who is much disturbed by having experienced an hallucination is the best possible remedy for the physical and mental disturbance that may result. [Footnote 45: The Twentieth Century Science Series, New York, 1910.] Sir Francis Galton, well known for his investigation of many subjects and who may well be called the father of biometrics or statistical biology, in his "Memories of My Life" [Footnote 46] tells of his own investigations of the visions of sane persons. The fact that he delivered a lecture on this subject at the Royal Institution of London shows how seriously his studies were made and how much value scientists placed on them. Galton's well-recognized training in the careful weighing of evidence and his ability to strip phenomena of everything that might divert their significance from what they really were, add to the worth of his conclusions. Those who care to study the subject further will find his discussion in the _Proceedings of the Royal Institution_ (London, 1882). [Footnote 46: New York, 1909.] There are few people beyond middle age who have not had one or more curious experiences in the matter of visions or appearances. Mostly these have been vague and have not proved a disturbing element in the minds of the subjects. Many more than are thought, however, have seen visions vividly and with a detail that makes it almost impossible for them to believe that what they saw was merely an externation of ideas already in their mind. In this matter it must not be forgotten that the dreams of many people, especially nervous people, often present themselves with marvelous vividness of detail. They see people or places in their dreams and reason about them quite rationally. Occasionally a dream will bring back details that have been forgotten. The dreaming state seems in some people to have wonderful power over the subconscious. Things that are not remembered at all in the waking state sometimes come back in dreams, and only then are recalled by the individual as representing past events in his life. He is apt to wonder where the details could possibly come from, since he had before no conscious memory of them. This same thing holds for the day-dreams or sudden visual appearances that come when the attention has been wrapped in something else. A typical example of such visual hallucinations is the following incident told by a prominent London physician of himself: One afternoon at tea time, before a meeting of the Royal Society, Sir Risdon Bennett (1809-1891, a well-known physician. President of the College of Physicians in 1876, and a fellow of the Royal Society), drew me apart and told me of a strange experience he had had very recently. He was writing in his study separated by a thin wall from the passage, when he heard the well-known postman's knock, followed by the entrance into his study of a man dressed in a fantastic medieval costume, perfectly distinct in every particular, buttons and all, who, after a brief time, faded and disappeared. Sir Risdon says that he felt in perfect health; his pulse and breathing were normal and so forth, and he was naturally alarmed at the prospect of some impending brain disorder. Nothing, however, of the sort had followed. The same appearance recurred; he thought the postman's knock somehow originated the hallucination. ... I heard the story at length, very shortly after the event, told me with painstaking and scientific exactness and in tones that clearly indicated the narrator's earnest desire to be minutely correct. Those who are especially interested in this subject will find any number of similar stories, some apparently rich with meaning, most of them quite {607} meaningless, in the volumes of transactions of the English Psychic Research Society, in F. W. H. Myers' "Human Personality," in Podmore's "Naturalizing the Supernatural," in Flammarion's "The Unknown," or many other books published in recent years. It is quite easy to get sufficient material to bring reassurance to any patient that visual hallucinations, at least, mean nothing serious for the mind or body of the individual having the experience. Hallucinations in the Past.--It must not be thought, however, that this subject of hallucinations is new. Literature is full of it and from the earliest times we find traces of it. Egyptian, Babylonian and Chaldean writers mention them. Nor indeed is the scientific consideration of the subject new. Aristotle speaks of them and it is evident that many of the old writers thought of them as psychic incidents on some physical basis, or at least due to some predisposition in the individual or in some special state of his senses. Two generations ago Johann Müller, the great German physiologist, discussed the whole subject at length in a monograph, and considered it of so much importance for physicians that he introduced a résumé of it into his great text-book of physiology. His explanation of the occurrence of visual hallucinations is not only a striking illustration of the thoroughly scientific character of his treatment of the subject, but it serves to show how well men considered these subjects long before the present fad for the study of abnormal psychology or mental influence came in. His discussion of the subject is sufficient of itself to make any patient understand his hallucinations and keep them from bothering him better than anything else I know: The subjective images of which we are speaking have sometimes, however, both color and light; different particles of the retina, of the optic nerve, and of its prolongations to the brain, being conceived as existing in special states of action. This happens rarely in the state of health, but frequently in disease. These are the true phantasms which may occur to the sense of hearing and other senses as well as to that of vision. The process by which "phantasms" are produced, is the reverse of that to which the vision of actual external objects is due. In the latter case particles of the retina thrown into an active state by external impressions, are conceived in that condition by the sensorium; in the former case, the idea of the sensorium excites the active state of corresponding particles of the retina or optic nerve. The action of the material organ of vision, which has extension in space, upon the mind, so as to produce the idea of an object having extension, form and relation of parts, and the action of such an idea upon the organ of vision so as to produce a corresponding sensation, are both equally wonderful; and hence the spectral phenomena or visions are not more extraordinary than the ordinary function of sight. (Vol. II, p. 1393, Eng. transl., 1842.) Apparitions and their Explanation.--In spite of suggested explanations on physical grounds, some of these apparitions that appear to people seriously disturb them. They cannot get them out of their minds. They are sure that they portend evil. Hence worries, and the more nervous the people are and the more worried already, the more likely is such a thing to recur and then to be made much of. Only through their minds can these people be treated, and it must be made clear to them not only how common are hallucinations, but that there is an easy psychic explanation of most of them. Sir Arthur Mitchell, K. C. B., in his book "About Dreaming, Laughing and Blushing," [Footnote 47] tells a story and then gives his explanation of it in such a way as to illuminate many of these occurrences: [Footnote 47: Longmans, London, 1900, page 21.] {608} Perhaps I should illustrate how I think that apparitions may be nothing more than dream hallucinations. A. B., a gentleman of culture and strong character, called one hot day, after a hearty lunch, on an ecclesiastic in a high position, who happened to be engaged in his library at the time of the call. A. B. was shown into a room opening off the library, and requested to wait. He sat down beside a table, and with his elbow resting on it, he leant his head on his hand. While in this position he saw a man in clerical costume come through the door communicating with the library, without any opening of the door. A. B. was absolutely certain that he had seen an apparition, and was surprised and hurt when I expressed a doubt. He called on me to explain, and I said that it was at least possible that he had been asleep for some moments, that if he had slept at all, however short the dream of the sleep, he must have had a dream, if I am right in thinking that there is no dreamless sleep, and that thus what he regarded as an apparition might be nothing more than a dream hallucination. He assured me persistently that he was continuously wide-awake, but I assured him that these moments of sleep often occurred without any consciousness that they had occurred. He refused to be deprived of his ghost, and I refused to believe in the supernormal when the normal was sufficient. Such wraith-like appearances are supposed to occur especially in connection with the deaths of persons at a distance. Startling stories are told, particularly of those who are very near relatives, husbands and wives, mothers and sons, and, above all, twins, who have been very closely associated with one another during life. There are a large number of stories of this kind, however, that have been collected by the Psychic Research Society and other agents with strong evidence in their favor, in which the appearances have had no ulterior significance at all and have evidently been mere figments of the imagination, the externation of images from memory so vividly that they seem to be the reseen. Reassurances in this matter are the best possible source of relief from the sense of impending ill for many patients. The physician who wishes to relieve such symptoms must familiarize himself with some of the many stories that have been investigated and that serve to prove that these and like appearances must not be taken as significant of anything more than a definite tendency, that exists in human nature at moments of day dreaming or when one's attention is suddenly turned from a book in which one has been absorbed, to see externally what is really passing through the imaginative memory. A Disappearance.--A very interesting commentary on some of these appearances is to be found in Mark Twain's story of a disappearance, which could probably be duplicated many times if experiences in this line were collected and collated. Mr. Clemens, sitting on the porch of his residence one day, saw a stranger of rather peculiar appearance come up the walk toward the front door and he expected to hear him ring the bell and have the servant come to the door and usher him in, and then perhaps be called to see him. About the middle of the walk, however, the stranger disappeared and Mr. Clemens was quite surprised to come to himself, rub his eyes and conclude that he had had one of these curious visions or hallucinations, in which the Psychic Research Society would surely be interested. He had plainly seen the stranger enter the gate, come up the walk, and then disappear. He was so impressed by the disappearance that he roused himself to go into the house to get his notebook, so as to make notes of what had happened before the details escaped him. To his surprise he found the stranger in conversation {609} with the servant in the house. There had simply been a lapse in Mr. Clemen's vision of him. He had had a disappearance phenomenon instead of an appearance. The story will be found to amuse patients who complain of appearances disturbing them, though Mr. Clemens always told his disappearance story very seriously, and it is as interesting a psychic phenomenon as any told of the wraith-like appearances. Treatment.--Considering how frequent are such phenomena, the physician must be prepared to treat those who are disquieted by them. A wraith-like appearance, for instance, will disturb many people very seriously and often for days, sometimes for weeks, make them nervous, excitable, and impair their appetite, disturb their digestion and sleep and often such unfortunate occurrences are prone to come just when they are run down in weight and when they need the help of every factor that makes for improvement of health. Simply to dismiss such an appearance as if it were quite imaginary, that is, non-existent in some form of reality, or quite baseless and trivial, serves no good purpose, for, as a rule, the persons concerned are deeply impressed with what they have seen. The only way to remove the unfavorable impression produced by it is to discuss it straightforwardly on the basis of what we have come to know as the result of recent investigations and the collation of the literature which has been published by the various psychical research societies and authorities on the subject. We know now that while occasionally such wraith-like appearances seemed to have a definite significance, because of something that happened simultaneously or shortly afterwards, this is mere coincidence and there are literally thousands of such cases in which a well authenticated wraith-like appearance was followed by no serious consequence, was never shown to mean anything beyond a curious psychic phenomenon, and was evidently merely due to some personal subjective influence, some externation of an image in the memory, unusual, but not at all unique, or even very rare, and evidently due to a curious peculiar externalizing power with which certain intellects are gifted. Auditory Hallucinations.--Hallucinations of hearing are more common than those of vision. Many people have had the experience of waking up thinking that someone was calling them. A great many people are sure that they have, at some time or other, heard a voice when no one was near enough to them to have said anything. They have even recognized the voice. Some people, when thinking deeply about a person, have the voice of that person occur to them so clearly that they cannot quite make out whether they have actually heard it or whether it has only been very vividly reproduced in their memory. Such experiences are so common as to be well known, though many people hesitate to tell the stories of them, for hearing voices is rightly looked upon as a frequent preliminary symptom of insanity. Hallucinations of hearing are the most common early symptom of insanity. The hearing of voices must always arouse suspicion at once. It must not be forgotten, however, that a great many recognizedly sane people who have remained so for life, have thought that they heard voices. Of course, we have no definition for insanity, and it is difficult to draw the line. We have no definition for health either, yet we have a practical working standard for the recognition of it, as also for insanity. These hallucinations then, both of vision and hearing, deserve to be discussed seriously, and in {610} nearly every case, even though there is some mental disturbance, the physician can in this way benefit his patients and keep them from being overmuch distressed by their hallucinations. There is an expression in such common use that it is evidently the result of an almost universal experience, according to which men sometimes explain, after having acted in a particular way, that "something told them to." What they mean, of course, is that a conclusion formed in their minds the reasons for which they could not understand, but which yet had force enough to cause them to follow it to a practical application. When we hear of Socrates being advised in life by a demon, a so-called familiar spirit, we are apt to wonder whether by this term is meant anything more than just this curious feeling of aloofness from ourselves that we sometimes have when we are trying to make up our minds, or, indeed, not infrequently when we are deeply engaged in any intellectual occupation. As discussed in the chapter on Unconscious Cerebration, our minds seem in a certain way to act independently of us. Occasionally they draw us to conclusions quite different from those which we previously expected to reach. There seems to be a something within us that works quite of itself and beyond our will. Whether under these circumstances there may not occasionally come so vivid a feeling of this power within us impressing itself upon us, that it seems to come from without, must always be taken into account in the effort to get at the real significance of these curious hallucinations. Only thus are we able to come to the relief of patients who are bothered by them. _Explanation by Sound Reproduction_.--Auditory hallucinations are probably not more than reproductions of sounds heard before recalled vividly and apparently heard again at moments when attention is not attracted to actual auditory sensations and we are in receptive mood. Some of them are very startling because they are apparently warnings of future events, as is proved by their fulfillment. These, however, do not seem to be more than coincidences noted with regard to similar events connected with Premonitions, Dreads and Dreams (see chapters on these subjects). There is, for instance, a well authenticated story published by the English Psychic Research Society of a woman who was about to take a dose of what she thought was some ordinary home remedy, when she distinctly heard a voice telling her to taste it. The dose to be taken was a tablespoonful, and when she tasted it she found that by mistake she had placed her hands on a bottle containing a rather strong poison and a tablespoonful of it would almost inevitably have killed her. Unfortunately, such occurrences are so rare and the reason for them is so hard to find that their consideration as anything more than coincidences seems out of the question. Every medical journal almost brings the story of someone who has taken a dose of medicine that proves fatal, and there is no warning. If such warnings came with definite frequency, it would be easier to appreciate their significance. There are similar stories with regard to other warnings. There is the story of the young man who in a storm drove under a shed for protection. Just as he did so he heard his mother's voice--she had been long dead--distinctly say "Drive out!" Ho drove out at once in the teeth of the storm, so deeply impressed was he, and was scarcely beyond the entrance when the shed fell, crushing everything within it. Similar warnings of impending {611} accidents are rather frequent in certain people's minds, yet it is hard to think of them as anything else than premonitions. These somehow take on the character of auditory hallucinations in certain sensitive minds. Compared to the whole number of accidents, however, such incidents are extremely rare and follow no law, and while there are those who like to think that perhaps such phenomena are due to the solicitude of some being in the other world, this is extremely doubtful. In that case, as St. Augustine suggested, they would be much more frequent and have a clearer significance than is at present the rule. St. Augustine, discussing the possibility, was sure that he would have had communications from his mother. Most men would re-echo his feeling. Coincidences.--Most of these stories as they have been analyzed by careful investigators are indeed such trivial unmeaning things that it would be too bad to let people be bothered by them. They have occurred, however, from time immemorial. Veridical warnings are a commonplace in the literature of all countries. Undoubtedly some may suggest the action of a Higher Power, but the more one knows of the conditions in which they happened, the people to whom they came and their ultimate effects, the less will they seem providential. It is evident that under certain conditions they may be produced even at moments when men are not particularly excited and when they think that they are perfectly calm and self-possessed. Each story must be discussed in its own merits. The only thing to do, then, is not to make too light of them and, above all, not to treat them as merely imaginary or as utterly illusory; for they are often natural phenomena, the reasons for which and the conditions of their production we do not as yet fully understand. If patients can be brought to this viewpoint, they may even become interested in searching out just what it was that caused each particular hallucination. Over and over again it has been found that a moonbeam or a peculiar unexpected reflection of the sun, or the light shining through an unnoted aperture, or any or several of these in connection with a mirror has been the main cause of the wraith-like appearance. When they happen during the day it is sometimes at the moment of passing from very bright light to a darker hall that the occurrence takes place and evidently there is some physical occasion for the appearances in the eye itself. Unusual noises of various kinds are responsible for the auditory hallucinations. Dangers of Serious Considerations.--There is one serious aspect of these hallucinations and supposed warnings--they tend to paralyze action. If a person allows himself to become firmly persuaded that doubts and premonitory possibilities must be weighed and solved before he may dare to act with assurance, then action becomes almost impossible. Premonitions may serve to bring people into danger, or at least keep people from having such presence of mind as will enable them to get out of it, as they otherwise would. Doubts lead to inaction and make a state of mind that is eminently miserable. The patient's one hope is to put aside resolutely such hallucinations if they rise to the level of a disturbing doubt or a paralyzing premonition and to discipline himself against being influenced by them. In many persons this is a difficult matter, but it represents the only efficient path to the regaining of mental health and strength. {612} CHAPTER III DREADS In any discussion of the influence of mind over body, favorable and unfavorable, too much emphasis cannot be placed on the hold that dreads have over a great many people and how much they mean, not alone for the mental state, but also for the physical sense of well-being or of ill-feeling in the individual. The expression attributed to the old hermit who had lived to the age of one hundred and had spent some sixty years of existence in the solitude of the desert, with all the opportunities for introspection that this afforded, is the best illustration even in our day of what dreads signify in life: "I am an old man," he said to the young solitary who came to him for advice, "and I have had many troubles, but most of them never happened." We are nearly all of us, or at least those of us who spend most of our time in sedentary mental occupations, prone to fear that something untoward is preparing for us and in many cases to dread lest some serious ailment or other is just ahead of us. We are afraid that certain feelings, though we like to call them symptoms, due to some trivial cause or other as a rule that deserves no notice, may mean the insidious inroads of a constitutional disease destined to shorten existence. A little fatigue, over-tiredness of particular muscles, the straining of joints, the discomforts due to overeating and undersleeping, that are meant as passing warnings of nature for the necessity of a little more care in life, are exaggerated into symptoms that have a more or less serious significance. DEFINITE DREADS Besides these rather vague dreads, however, there are certain special disquietudes peculiar to individuals, even more groundless, if possible, than the generic apprehension just spoken of and that have been dignified in recent years by the name of phobias. Phobia means only "fear" in Greek, but the term is much more satisfying to nervous people than the shorter but too definite English term, dread, or fear. There is acrophobia, or the fear of looking down from a height; claustrophobia, or the fear of narrow places, as the dread of walking through a narrow street because of the sense of oppression that comes with the shut-inness of it. Then there is agoraphobia, market-place dread, or the fear to cross an open space because one has, as it were, grown accustomed to be near buildings and misses their presence. There are many others, indeed as many as there are dislikes in human nature, for any dislike apparently may be exaggerated into a dread. I mention a few at the beginning of the alphabet and some of special significance. There is aerophobia, dread of the air, a symptom sometimes mentioned in connection with hydrophobia; aichmophobia, the dread of pointed tools; ailurophobia, the dread of cats; anthrophobia or the dread of men; pathophobia or the fear of disease, microbophobia or bacillophobia; kenophobia or the dread of emptiness; phthisiophobia or the dread of consumption; zoophobia or the dread of animals; sitophobia or the dread of food, and even phobophobia, the dread of {613} dreading. Neuropsychologists seem to take a special pleasure in inventing some new phobia or at least giving us a fine long Greek name for a set of symptoms by no means new and that might well be explained in simpler terms. The most familiar examples are: the fear of lightning, which is more frequently brontophobia, the fear of thunder. These learned words are all formed on the same etymological principle as hydrophobia, but they are entirely psychic in origin, while hydrophobia, as it is well to explain to patients who think of the word phobia in connection with their symptoms, is, of course, a misnomer for an infectious disease--rabies--which develops as the consequence of a bite of a rabid animal, and the principal symptom of which is not fear of water, but the impossibility of swallowing any liquid because of spasm of the esophageal muscles. Almost any function of the body may become the subject of a dread or phobia that may interfere even seriously with it. Any disturbance of any function is likely to be emphasized by such dreads. The French have described the basophobia, which makes the patients suffering from beginning tabes dread so much walking that it becomes a much greater effort than it would otherwise be and often interferes with walking rather seriously. Then there is the fear of tremor which exaggerates a tremor due to some organic cause, but yet not necessarily of grave import, nor likely to increase rapidly. Many of the hysterical palsies are really due to dreads, consequent upon some incident, motor or sensory, which produced a profound effect upon the patient's mind. A patient who has been surprised by a digestive vertigo while descending a stairs, even though nothing more happened than the dizziness which required him to grasp the balustrade, will sometimes develop a fear of vertigo that will actually make it difficult for him to go down stairs without such an effort of will as is very exhausting. Even the slightest functions may be thus disturbed. Pitres and Regis described some ten years ago what they called the obsession of blushing, or erythrophobia, the fear of turning red. Patients make themselves extremely miserable in this way. Only training and self-control will help them. These names are long and mouth-filling and consequently satisfying, and most people who are suffering from a particular phobia are almost sure to think that they have a very special affliction. When the word dread is used instead of the word phobia they are less likely to misunderstand the character of their affection and to realize that it is not a disease but only an unfortunate mental peculiarity that needs control and discipline, and not fostering care. Neurasthenia only means nervous weakness, as we have pointed out, but most people are rather rejoiced when informed that they have so high-sounding a disease as neurasthenia, while to be told that they are nervously weak or suffer from nervous weakness seems quite a come-down from their interesting Greek-designated affection. Most psychiatrists feel that it is better not to give the long Greek term, but to state in simple short Saxon words just what is the matter with the patient. They are suffering from the dread of a height, or the dread of a narrow street, or the dread of open spaces, or the dread of dirt, or of cats, or of whatever else it may be. This makes it easier for them to begin to discipline themselves against the state of mind into which they allow themselves to fall with regard to these various objects, and mental discipline is the only therapeutic adjuvant that is of any avail in {614} lessening these conditions. With reasonable perseverance most people can, if not cure themselves of these affections, at least greatly lessen the discomfort due to them. A consideration of particular dreads brings out the specific suggestions that may be made with regard to each and the directions that may be helpful to the patients. Probably the commonest is acrophobia, so that the detailed consideration of it shows the indications for other dreads. Dread of Heights.--Almost without exception men have a sort of instinctive dread of looking down from a height. In most people this can be conquered to such a degree that almost anyone, if compelled by necessity, can learn to work on a skyscraper and continue to do good work without much bother about the height, though he may have to go up ten to twenty stories, or even more. When he takes up the work at first every workman finds it difficult. It gives most of us a trembly feeling even to sit in our chair and think of looking down from such a height. To see pictures of men standing on the iron frames of skyscrapers twenty or thirty stories up in the air looking down 300 to 500 feet below them gives one a series of little chilly feelings in the back and in many people a goneness or sense of constriction around the abdomen that is almost a girdle feeling. To sit at a window opposite where a skyscraper is going up and to see the men lean over the edge of a beam calling directions of various kinds to workmen below will give most people, even those who are not nervous or especially sensitive, creepy feelings with sometimes a little catch in the breath and an iciness in the hypochondria. It would seem absolutely impossible that we should ever be able to perform these feats of looking from a height, yet experience shows that most of us, after a little training, learn to do it without difficulty. Even the men who work most confidently have some creepy feelings return to them whenever they stop and think about this and let their eyes wander to the distance below them. It is not difficult for us to walk across a plank raised a foot or two from the ground, though to walk across the same plank at a height of ten feet may be quite a trial and at thirty feet may become quite impossible. This is all due to lack of confidence on our part and there is no reason in the world why, if the plank is amply wide for us at two feet from the ground, it should not be just as wide and safe at 30 or 60 or even 100 feet. This is what the men who have learned to work on skyscrapers have disciplined themselves to. They have learned to disregard the wide vacant space around them and the yawning chasm beneath their feet; they keep their eyes fixed on something in the immediate vicinity, excluding thoughts of all that might happen if they should lose their balance. _Physical Basis_.--There is a physical basis in many of these cases that constitutes the underlying occasion, at least, for the development of the psychic dread. Our eyes have grown accustomed to being fixed on near objects. Whenever they are not so fixed we get a feeling of trepidation. Even those who have done a little day-dreaming know that sometimes when they have been looking into space, objects around them have suddenly seemed to be transferred to a long distance and at the same time a curious sense of insecurity came over them. Anyone can get this feeling experimentally by making two large dots on a piece of paper about two inches apart and then gazing between the dots into vacancy beyond the paper as it were, until the dots have a tendency to become four because of the fact that each eye sees {615} each of the dots on a part of the retina not corresponding to that on which the other eye sees it (see Fig. 25). [Illustration: Fig. 25. (Two solid black dots about 1/2 inch diameter and 4 inches apart.)] When the experiment is successfully performed the dots begin to float before the eyes, then they may coalesce into one or become three, but any number up to four may readily be seen. This will give the sense of insecurity that comes from the eyes not having any fixed object to look at and illustrates the discipline of the eyes that must be learned in order that looking down from a height may not be productive of the usual dread. _Dread of Small Heights_.--It is often thought that acrophobia, or the fear of a height, concerns only great heights and that ordinary elevations produce no discomfort. I have had patients, however, who, when compelled by circumstances over which they had no control or at least by social obligations that were hard to break, to sit on the front row of even a low balcony, have been extremely uncomfortable. There was a sense of tightness and oppression about the chest that made it difficult for them to breathe, that disturbed their heart action and gave them a general sense of ill-feeling. I have had a curiously interesting series of cases in clergymen who found it trying to say Mass or conduct services or to preach from the step of a high altar. One would be inclined at first to make little of their description of their utter discomfort. There is no doubt at all, however, of their real torture of mind and of the extreme effort required to enable them to support themselves in the trying ordeal. They are often so exhausted because of the effort required that only with difficulty can they do anything else during the day. To most people such a state of mind is inexplicable. There are deeply intellectual men who, in my experience, are quite disturbed by apparently so simple a thing as having to say Mass on an altar that has three or four steps to it and is elevated five or six feet above the surrounding floor. As for higher altars, like the main altar of a cathedral, they usually find it quite impossible to conduct services unless they are in company with others, when their feelings are much relieved. This same thing is true of agoraphobia in some people. To go alone across an open place or square is agony, but even the company of a little child is sufficient to relieve them to a great degree. I told a distinguished American prelate of this curious dread in priests so often called to the physician's attention, and he said that he had never heard of it. To his surprise some of his clergymen present at the table told him that there were two examples of it in brothers in his own diocese. _Mental Discipline_.--The lesson of the many men who, by discipline, have succeeded in conquering the aversion and the dread of heights that everyone has to some extent at least, shows the possibility there is for even those who are extremely sensitive in this matter to so lessen their timidity and the uncomfortable oppression that comes over them, as to make it possible to accomplish whatever is in their line of duty. It is no more difficult for the sensitive clergyman to learn by practice and discipline to walk with confidence on a reasonably high altar or platform, than it is for the workman to learn to {616} walk a beam on the top of a twenty-story building without a thought of the dangers of his position, or at least putting the thought away from him so that it does not interfere with his work. At the beginning he cannot do it, but he disciplines himself to form a habit that makes it easy. Yielding to his feelings makes it difficult to withstand the discomforts that come to him. After an accident on a high building, as a rule, men have to be sent home for the day to get their nerves settled by the night's sleep before they can work with sufficient confidence, and yet accomplish their usual amount of work. So-called Misophobia--Dread of Dirt.--Misophobia, or the fear of dirt, has grown much more common in recent years, and the spread of the knowledge of the wide diffusion of bacteria has added to the unreasoning dread that possesses these people. Some of them wash their hands forty to fifty times a day, and one young man who was brought to me with the worst looking hands, because of irritation from soap and water, that I have ever seen, seemed to be always either just plunging his hands into water or wiping them dry. These people make themselves supremely miserable. They do not care to shake hands with friends and, above all, with physicians, and they invent all sorts of excuses so as to wait outside of doors till someone else opens them so as to avoid touching the knob or door pull, "which" with a poignant expression of repugnance they tell you "is handled by so many people." When the patients are women, getting on and off cars becomes a nightmare to them, because they do not want to touch the handle bars and unless they do they find it difficult to ascend and descend. The curious excuses they offer for their peculiar actions in avoiding the touch of objects around them are interesting. Claustrophobia.--This sort of dread seems quite irrational to most people and many would probably conclude that individuals thus affected could not possibly be quite in their right minds, or must surely be rather weak-minded. On the contrary, many of the people who are affected by these curious dreads are above the average in intelligence and sometimes also in their power to do intellectual work. A typical example, for instance, of claustrophobia, or the fear of closed spaces, is found in the life of Philip Gilbert Hamerton. He was a distinguished painter and essayist, editor and novelist. Few men of his generation were able to do better intellectual work than he. His book on "The Intellectual Life" was more read perhaps than any work of its kind in the last generation. He was not a profound thinker, but he was a very talented practical man. The fact that besides being a writer whose books sold he was a painter whose works were in demand, shows a breadth of artistic quality that is quite unusual. His was not the sort of genius, however, that is so often supposed to be allied to insanity, for he was rather a worker who obtained his effects by plodding, than a brilliant genius that got his thoughts by intuition. In a word, in spite of the fact that he was just the sort of man that one would not think likely to be affected by a phobia, he had a series of attacks of claustrophobia, some of which were intensely annoying to him and seriously disturbing to his friends. His wife has described some of them in his "Life and Letters." Once after crossing the English Channel, he had a severe attack in the railroad carriage on the way up to London. He had not been nervous {617} on the voyage and had not been seasick. He was returning from a vacation and was in the best of health and spirits, yet suddenly the feeling of inordinate dread that he was shut in came over him and he could scarcely control himself or keep from plunging out of the window in order to get into the open. His wife says that "His hands became cold, his eyes took on a far-reaching look, his expression became hard and set and his face flushed." He seemed "as if ready to overthrow any obstacle in his way; and indeed it was the case, for, unable to control himself any longer, he got up and told me hoarsely that he was going to jump out of the train. I took hold of his hand and said I would follow him, only I entreated him to wait a short time, as we were near the station. I placed myself quite close to the door of the railway carriage and stood between him and it. Happily the railway station was soon reached, when he rushed from the train and into the fields." His wife followed him like one dazed, and almost heart-broken. After half an hour he lessened his pace, turning to her and said, "I think it is going." For two hours they continued to walk, at the end of which Gilbert said tenderly in his usual voice, "You must be terribly tired, poor darling. I think I could bear to rest now. We may try to sit down." Dread of Cats.--One of the most interesting of dreads, very frequently seen and producing much more discomfort than could possibly be imagined by anyone who had not seen striking cases of it, is the dread of cats which has been dignified and rendered more suggestively significant by the Greek designation ailurophobia. While the great majority of individuals suffering from this unreasoning dread of cats are women and usually of a delicate nervous organization, it must not be thought that it is by any means confined to them or has any necessary connection with hysterical symptoms. One of the most striking cases of this dread of which I know personally occurs in a large, rather masculine-looking woman, who cannot abide being in a room with a cat, and who is quite unable to do anything while one of these animals is within sight. Yet she is not at all what would be called timorous and she has more manly than womanly characteristics in every way. She once proceeded to thrash within an inch of his life a small burglar who entered her house and she rather prides herself on being able to protect herself. Nor is this dread necessarily associated with any other disturbances of mind or nervous system. Some of the patients I have seen, who confess to suffering from it, were thoroughly sensible, brave little women, able to stand suffering well, not at all hysterical in nature, and who in the midst of worries found time to be thoughtful of others and not to have that selfishness which, even more than physical symptoms, is so apt to characterize hysterical patients. I have had men confess to me their dread of cats, and while, as a rule, they were of delicate constitution and inclined to be nervous and did not have the phobia to an inordinate degree, there was no doubt that they were extremely uncomfortable whenever a cat was near them. On the other hand, some of them were vigorous, husky men with strong aversions. One of the most marked cases of ailurophobia that was ever brought to my attention was in an army officer who had exhibited bravery in battle on many occasions, and what requires much more strength of mind, calm fortitude in difficult campaigning, yet for whom a cat had many more terrors than the battery of an enemy or even an ambuscade of Filipinos. More cases of this particular {618} aversion seem to occur in clergymen than in other men, yet one of the worst cases I ever saw was in a priest of great moral courage, who had served a pest-house over and over again in smallpox epidemics. All that can be said about such a dread is that it exists, that it is unreasoning, that some patients have been known by discipline of mind to overcome the abhorrence to a great degree but never quite entirely. In this regard, however, it must not be forgotten that there are many things abhorrent to human nature that seem impossible to overcome the aversion for, yet discipline does much to relieve them. For instance, the handling of dead bodies so familiar to physicians brings with it an aversion that we never quite get over and which resumes most of its original strength with disuse, but that can be overcome to such an extent as to make pathological work produce very little aversion. Even Virchow, after all his years of occupation with pathological material, confessed toward the end of his life, that whenever he was away from his work for a few months his aversion had to be overcome anew. _The Spectator on Dreads_.--There might be a tendency to think that these curious dreads came only as the result of the individualistic over-occupation with self and the introspective sophistication of the modern time, but the dread is not confined to our time nor special to it in any way, for we find Shakespeare talking of those who cannot bear a harmless, necessary cat. A number of other writers of different periods refer to it. As in so many other things _The Spectator_ reflects his time in this and so we have a letter with regard to the dread of cats. It would not have been a subject for discussion in one of these popular communications only that the writer felt that a good many people would realize how like it was to things that they themselves knew of. In number 609 the following letter, supposed to be from a correspondent, seems worth giving in full, because it touches on other subjects in which uncontrollable, unreasoning feeling plays a role: I wish you would write a philosophical paper about natural antipathies, with a word or two concerning the strength of imagination. ... A story that relates to myself on this subject may be thought not unentertaining, especially when I assure you that it is literally true. I had long made love to a lady, in the possession of whom I am now the happiest of mankind, whose hand I should have gained with much difficulty without the assistance of a cat. You must know then that my most dangerous rival had so strong an aversion to this species, that he infallibly swooned away at the sight of that harmless creature. My friend, Mrs. Lucy, her maid, having a greater respect for me and my purse than she had for my rival, always took care to pin the tail of a cat under the gown of her mistress, whenever she knew of his coming; which had such an effect that every time he entered the room, he looked more like one of the figures in Mrs. Salmon's wax-work than a desirable lover. In short, he grew sick of her company, which the young lady taking notice of (who no more knew why than he did), she sent me a challenge to meet her in Lincoln's Inn Chapel, which I joyfully accepted; and have, amongst other pleasures, the satisfaction of being praised by her for my stratagem. _Cat Fear and Furs_.--This dread of cats is sometimes exhibited to a surprising degree under rather unexpected circumstances. For instance, it is not unusual, since the fashion for the longer-haired furs came in, to find that some of these patients cannot wear certain supposedly elegant furs, since they are really dyed catskin. At times this is not suspected until other possible causes for the discomfort have been eliminated. Some women cannot even bear to be near catskins in muffs and other such furs, though the imitation {619} may be so good as to deceive any but an expert, and they apparently had no suspicion at the beginning of the presence of cat fur near them. I have been told by a physician the story of a man, poignantly sensitive to cats, who purchased a fur-lined coat and found it quite impossible to wear it because of the sensations it produced in him, though he had no suspicion of any connection between cats and the fur when he purchased it. _Recognition of Presence_.--Why this dread of cats occurs and, above all, the reason for the ability to know that a cat is near when the animal is concealed and others are not at all aware of its presence, or that its fur should produce a disagreeable sensation, is not easy to decide. Its discussion is suggestive for other forms of dreads, for there are probably like refinements of sensation, normal and abnormal, connected with them. Much has been said about this as a reversion to powers possessed by man in a savage state when there was necessity for guarding against animal attacks. Unfortunately for any such supposition as this, these people, who are most fearful of cats, that is, of the ordinary domestic animal, have no uneasiness in the presence of the huge cats in the menageries--the lions and the tigers. It is with regard to these that such a specialization of scent would be particularly valuable for men. There seems no doubt but that it is an odor or a sensation allied to an odor, though perhaps below the ordinary threshold of recognition as such, that enables these people to detect the presence of a cat. Dr. Weir Mitchell in his article on "Ailurophobia and The Power to Be Conscious of the Cat as Near While Unseen and Unheard," in the _Transactions of the Association of American Physicians_, 1905, discusses odor in this connections as follows: To be influenced by an olfactory impression of which (as odor) the subject rests unconscious, may seem an hypothesis worthy of small respect and beyond power of proof. Nevertheless it seems to me reasonable. There are sounds beyond the hearing of certain persons. If they ever cause effects we do not know. There are rays of which we are not conscious as light or heat, except through the effects to which they give rise. There may be olfactory emanations distinguished by some as odors and by others felt, not as odors, but only in their influential results on nervous systems unusually and abnormally susceptible. No other explanation seems to me available, and this gains value from certain contributory facts. We must admit that all animals and human beings emit emanations which are recognizable by many animals and are in wild creatures protectively valuable. This delicate recognition is commonly lost in mankind, but some abnormal beings like Laura Bridgeman and a perfectly normal lad I once saw, have possessed the power of distinguishing by smell the handkerchiefs of a family after they had been washed and ironed. In this lad I made a personal test of his power to pick out by their odor from a heap of clean handkerchiefs mine and those of others, the latter two belonging to his father and mother. I have seen a woman, well known to me, who can distinguish by mere odor the gloves worn by relatives or friends. This lady, who likes cats as pets, is able to detect by its odor the presence of a cat when I and others cannot. Two French observers believe that they have proved the sense of olfaction to be nine times more acute in women than in men. So far as the present paper might serve in evidence, I should be inclined to say that the sense of smell was keener in women than in men, but as to this there is extreme diversity of opinion and the whole question awaits further investigation. [Footnote 48] [Footnote 48: This question of the varying acuteness of smell in different people is very interesting to the psychotherapeutist for diagnosis and therapy. We have a number of striking cases of very acute olfactory power. This is what might be expected since animals whose respiratory and smell apparatuses are very like our own show extreme differences. The extent to which human power to recognize odors can go is marvelous. In his "Thinking, Feeling, Doing," Prof. Scripture says: "I have a case--reported by a perfectly competent witness who lived for years with the person mentioned--of a woman in charge of a boarding school who always sorted the boys' linen after the wash by the odor alone." Personally, I have sometimes wondered whether this power, like that of feeling in the blind, could not be developed. The blind are supposed actually to bring about an evolution in their nerves of feeling. No such thing happens, however. An examination of them by means of an esthesiometer shows that their nerves are no better developed than those of other people, though they may be able to recognize much minuter differences between the "feel" of things and may be able to read raised type, which the seeing cannot. This is all due to a training of their attention to note slight differences in sensation, however, and not to improvement in the nervous apparatus. ] {620} Dread of the Dark.--The discipline suggested with regard to overcoming the dread of heights must be applied to any of these dreads if patients are to be made comfortable. They can form the opposite habit and by refusing to yield to their fears can do much to lessen them. Nearly everyone who is unaccustomed to sleeping in a dark house alone has dreads that come over him when he first tries to do it. Every noise is exaggerated in significance and the creaking of stairs and rattling windows and doors and the wind through the trees are all made significant of something quite other than what they are. Nearly everyone knows, however, that this can be overcome simply by refusing to pay any attention to the idle fears that come over us as a consequence of the tension due to loneliness, and after a time, sleeping in a strange room and a strange house in the dark is not a difficult matter. It is harder for some people to accomplish than others, but it is impossible for none. Here is the lesson that all the sufferers from dreads must learn. Gradually, quietly, persistently, they must resist the dreads that come over them, must deliberately, without excitement, do the opposite to that suggested by their apprehension, until habits are formed that enable them to accomplish without discomfort what was before a source of even serious ill-feeling. The dread of darkness that so many people have is usually supposed to be cowardice. It is not, however, in most cases, but is due to idiosyncrasy or to certain special physical factors in the environment. If children have been brought up so that when they were small a light has been constantly shining in their eyes, even though only a dim light, it will often be difficult to accustom them to be quite comfortable in the dark. Much depends on habit in this matter. I have known men, who, when they came from Ireland, feared the darkness of the coal mines very much and their dread was increased by the awful horror of possible ghostly appearances, since so many accidents had taken place where they worked. After some years, however, they were quite placid about it and would calmly go into the mine as fire bosses at three and four in the morning, long before others were to go in, examining absolutely dark passages by the mile, with no human being near them and with the creaking of the pillars, the dripping of water, the rumbling of the sides and the occasional fall of a small particle from the roof, besides the noises of rats to add to the disturbing factors. Like going up on a high building, one may get entirely accustomed to it so as scarcely to notice it at all. When the fear is allowed to take hold of one, however, and no effort is made to overcome it, it may prove quite seriously disturbing. The unaccustomed, however, means more than anything else in this matter. Sometimes, {621} indeed, people have a dread of the dark that seems to be inborn and that apparently cannot be overcome, that, like the fear of cats or of lightning, may be quite beyond rational control. Hobbes, the English philosopher, was so perturbed by darkness that he kept a light in his bedroom all night. I know this to be the case in a clergyman who had been quite undisturbed about darkness until he was awakened one night by a burglar. He demanded "who's there?" and received as answer without further parley a bullet that fortunately struck only the head of the bed, but so close that it singed him. The burglar escaped, but the clergyman was never afterwards able to sleep without a light. Rousseau, the French philosopher, was also much afraid of darkness. Ordinarily it is presumed that superstition has something to do with this fear and that the victim of it has ghosts in mind or at least dreads spirit manifestations. Neither Hobbes nor Rousseau, however, was likely to be timorous about ghostly visitants. It was with them a physical idiosyncrasy. Associated with dread of darkness is the fear of finding some one in a dark room whose presence may startle us. Sir Samuel Romilly, famous for his labors for the reform of the English criminal law, and who must be considered one of the great humanitarians of the nineteenth century, had this dread to an acute degree. It went so far that whenever he slept in a strange place he carefully examined all the possible hiding-places in the room and in wardrobes or closets connected with it and, as a last precaution, never failed to look under the bed. He did this even when he was in his own house. [Footnote 49] This, however, is not so unusual, even among men, as might be thought. Most women who sleep alone want to investigate under the bed and in a hotel closets and wardrobes and even bureau drawers are likely to be examined. Habit in this regard may make one quite miserable and over-solicitous. I have had patients whose sleep was seriously disturbed by the remembrance that they had not looked under the bed and who feared to get up and light a light to do so lest there should be someone there. Indeed, the idea of putting their feet on the floor before the light had come to reassure them seemed quite out of the question. [Footnote 49: Curiously enough. Sir Samuel Romilly, in spite of his dread of the dark, committed suicide and went prematurely into the darkness of the beyond, apparently without his usual tendency to precaution.] Dreads Connected with Water.--Strange as it may seem, water constitutes a source of dread for some people. We have the records of it in the peculiarities of great men and it is not unusual to meet it in common life. Dropping water is a source of disturbance for most people. It is quite impossible for the majority of men and women to go on writing or reading with any comfort if water is dropping near them. Dropping water, when one is trying to go to sleep, is one of the worst of awakeners. The Chinese are said to put people to death in horrible torture by having a drop of water fall at regular intervals on their heads. Robert Boyle, the great father of chemistry and a very sensible man in many ways, is said to have been thrown into convulsions by the sound of water dropping from a faucet. The splashing of water on some people is a poignant source of torture. I have had a woman patient who could not go to services where there was a sprinkling of water, for it seriously disturbed her and gave her a sense of depression that would not be overcome for some time. Peter the Great, though the father of the {622} Russian navy, and though he passed many years of his life in Holland, used to shudder at the sight of water, and if, when out driving, his carriage passed near a stream or over a bridge, he would close the windows and be overtaken with terror that brought the perspiration out all over him. Dread of Death.--The fear of death is one of the dreads that bothers young as well as old, and, curiously enough, as its inevitable approach becomes more certain, men are prone to dread it more. Long ago Sophocles said: None cleave to life so fondly as the old, -- and this has remained true for all the centuries since. A young man is quite ready to throw his life away, but the old man hesitates and even in the midst of suffering, if it is not absolutely continuous, craves that death shall not come. Sophocles' great rival, the elder Greek dramatic poet AEschylus, had said: How far from just the hate men bear to death Which comes as safeguard against many ills, -- but his message was only for those with the character to face the worst. One may reason with the dread of death, however, and patients can be given motives from philosophy, literature, religion and experience that will help to relieve, though it will not entirely cure them. Shakespeare said in "Julius Caesar": Cowards die many times before their deaths. The valiant never taste of death but once, -- and people may be aroused to appreciate this. _Fear of Early Death_.--Many fear that if they have shown symptoms of delicacy of constitution at some time in life or suffered severely from some serious disease, that they are not likely to live long and, above all, that they are almost sure not to be able to accomplish anything worth while in life. The old proverb is "a healthy mind in a healthy body." This is, however, the ideal. There are very few ideals realized in life. Just because a man has a weak body is no argument at all that his mind may be weak and some of the world's finest work has been accomplished by men whose bodies were always delicate. Metchnikoff is the apostle of old age to our generation, but it is he, also, who has pointed out that many distinguished workers in science, in poetry, in art, men who have left a precious heritage in succeeding generations, were delicate all their lives. He cites such typical examples as Fresnel, the great French physicist; Giacomo Leopardi, the distinguished Italian poet; Weber and Schumann, the great German musicians, and Chopin, the Polish composer and pianist, all of whom did work that the world would not willingly miss, in spite of delicacy of health and weakness of body which shortened their lives. Intellectual power is not dependent on bodily energy and accomplishment is not a question of years of work, but intensity of work. It would not be difficult to add many other names to those mentioned by Metchnikoff. Naturally his thoughts recurred to men of distinction on {623} the Continent, but in English-speaking countries we have a number of typical examples of strong minds doing fine work in weak bodies. Robert Louis Stevenson is the best remembered by our generation. Elizabeth Barrett Browning, delicate all of her life, a neurasthenic during the precious adolescent years that are supposed to mean so much for future accomplishment, always an invalid to some degree at least, did some of the best work that was given to any woman to do during the nineteenth century. J. Addington Symonds, the historian of the Renaissance and of Italian literature, is another striking example of a man who had to do his work under great physical difficulties, yet who left a long bookshelf of large volumes after him as the product of the hours that he could cheat from caring for his health. Henry Harland, whose recent death all too young was a blow to the English-speaking world, is another striking example. The names of such men and women and their stories must be made familiar to people who are themselves delicate in health and who fear for their future and, above all, are despondent about the possibility of ever doing anything worth while. Dread of Insanity.--People who have relatives who are already sufferers from such severe forms of insanity as require asylum treatment are often likely to be much disturbed over the possibility that they themselves should become insane. Of course, there is no doubt but that these people are much more liable to suffer from insanity than others, but their worrying over the matter is sure to do them harm rather than good. There are quite enough sources of worry in life without the additional one of dread of a future event that may not occur, and this must be made as clear to them as possible. The people who have no obligations on them, who have nothing to do that they feel they have to do, are especially likely to suffer from such obsessions. The best possible relief for them is afforded, not by the effort not to worry about their dread, which usually has exactly the opposite effect and emphasizes their fear by the constant effort which they make to put it aside, but by getting something else to interest them. This must not be merely a passing interest, if possible, but a serious attraction of some kind that fully occupies the mind. A hobby is an excellent thing for this, but alas! a hobby must be cultivated for many years, as a rule, to become powerful enough to bring relief in such serious matters. Occasionally the thought of the insane asylum or the sight of an institution of this kind passed even at a distance in the train is enough to give some people a fit of depression that may last for some time. The thought of going to visit their ailing relatives is enough to make them even more depressed. I have sometimes found that in chosen cases, especially among women and those of sympathetic disposition, the apparently heroic remedy of making them visit their relatives in the asylum was excellent for them. It is the usual rule for people who are themselves sane to consider that it is the greatest hardship of asylum confinement for the patients to be associated with those whom they recognize to be insane. Exactly the opposite effect is the usual result. To be among people, many of whom are more irrational than themselves and some of whom are quite beside themselves, proves a stimulus and an encouragement. Contentment has been defined by a cynic as the feeling that things might be worse. {624} DREADS OF MEN OF GENIUS The insane are particularly prone to suffer from dreads, so that some people argue from their dreads to the thought of insanity. It is quite a mistake, however, to think of dreads as necessarily connected with insanity in any way. They are irrational though they will commonly be found to be dependent on some special physical condition. This is usually some exaggeration of attention to a sensation natural enough in itself but disturbing when dwelt on to such a degree that it produces a much greater reaction in these individuals than in other people. These dreads have existed in all sorts of people. It is said that they are more frequent in the highly intellectual, especially in the class known as geniuses, and they are often said to represent the definite evidence of a relationship between genius and insanity. I have always felt, however, that they are quite as common among ordinary people who have no genius and no signs of it as among the so-called geniuses. They are not so much spoken of by ordinary people, however, because they are rather ashamed of them. Genius, on the contrary, is quite willing, as a rule, to exploit its peculiarities for the benefit of the public, or what is even more true, its peculiarities are remembered and commented on as details of history. With this in mind the following paragraph from Dr. Dorland's book on "The Ages of Mental Virility" [Footnote 50] deserves to be recalled. He has gathered a number of examples that are very interesting: [Footnote 50: The Century Co., New York, 1908] Fear has played an important rôle in the development of the antipathies of the great--fear that was often groundless in its origin and inexplicable in its manifestation. The unaccountable fear of dogs is not so common as ailurophobia, although it is said that De Musset cordially detested them, and Goethe despised them, notwithstanding, forsooth, he kept a tame snake. Much more frequent is the fear of spiders, centipedes, and other insects. Charles Kingsley, thorough naturalist though he was, entertained an unconquerable horror of spiders, even the common house spider; Turenne became weak when he saw a spider; while the author of the "Turkish Spy" once asserted that he would far prefer, with sword in hand, "to face a lion in his desert lair than to have a spider crawl over him in the dark." Lord Lauderdale, on the contrary, while declaring that the mewing of a cat was "sweeter to him than any music," had a most intense dislike for the flute and the bag-pipe; and Dr. Johnson was so fond of his cats that he would personally buy oysters for them, his servants being too proud to do so. There are curious contradictions to be found in these matters. Montaigne confesses that he did his best writing and was in the best humor for keeping at his Essays while stroking his favorite cat with his left hand, his other being occupied with his writing. This would be seriously disturbing to many people, but apparently occupied certain distracting sensory tendencies and enabled him to concentrate his mental energies. To many people the very thought of doing anything like this would put all ideas for writing out of their mind. Other of Montaigne's peculiarities are quite as interesting. He always refused to sit down with thirteen at table, his liking for odd numbers was so great that he made all sorts of excuses in order not to use {625} even numbers and his aversion for Friday made the quota of work that he could do on that day much less than any other day of the week. OBSESSIONS There are many curious obsessions that disturb people and that are often extremely difficult of explanation even by themselves. Dr. Johnson, one of the most sensible men in many ways in his time in England, could not, it is said, pass a post on the street without touching it. At least if he did so he felt that somehow he had omitted to do something that he ought to have done and it would make him uncomfortable. There are many people who have some idea that it is lucky to touch posts as they pass along and the number of people who do things like this is larger than might be imagined. Many people put themselves out of the way in order to avoid letting a post come between the person with whom they are walking and themselves because it is said to be unlucky. Most of them will laugh at it, but still they continue the practice in spite of the bother it may occasion them. Occasionally there is some incident in their past life which accounts for such obsessions, though the patients themselves are occasionally not quite conscious of them. Dr. Boris Sidis tells the story of a man who could not take a car with an odd number. Psycho-analysis showed that he had once seen a child run down by an odd-numbered car. In such cases there has been a long series of suggestions that have created a dominant state of mind. The only way to overcome this when it becomes a serious annoyance is to undo the influence of the suggestions by a continued series of counter-suggestions, and by such discipline of mind as will prevent the former suggestion from exerting itself. The cure can be accomplished in this way, though, as a rule, the patient will need the help of someone else. FORGOTTEN FRIGHTS AND DREADS Dreads founded on terrifying or seriously disturbing incidents of the past, the details of which at times have gone out of the patient's mind, are not infrequent. It is probable that many of the unreasoning dreads have some such foundation and occasionally, if patients' memories are carefully searched, the whole story can be reconstructed. All that is needed, as a rule, is to get the patients interested in conjunction with the physician in tracing the origin of their affliction and not infrequently an interesting story will turn up. Hypnosis used to be considered of great value for such reconstructions, but unfortunately patients then become so suggestible that it is often difficult to decide how much of what is brought out by questioning is due to the suggestive quality that cannot well be kept out of questions, and how much to a true redintegration of memory. Frights in children may for a time be forgotten and yet the memory of them may come back, or a dread connected with them develop, that will make the patient profoundly miserable. One of my patients slipped and fell on a smooth steel plate at the head of a coal breaker and was only saved by good fortune from falling a long distance. This happened when he was a {626} boy of ten. There were times when the memory of this recurred so vividly as to set him all atremble and he could not look down from a height without something of the feeling of goneness coming over him that he felt at the time of the accident. The calling of his attention to the fact that his memory probably exaggerated the danger he had been in as a boy led him to go back and have another look at the conditions in which he had fallen some thirty years before. He found that they were not so dangerous as he thought and that while he would have been scratched and his clothes would probably have been soiled and torn, he would not have been seriously injured. This has greatly diminished his dread of heights. Various physical manifestations may be due to dreads which are often supposed to be the result of some physical process in the nervous system. Occasional fits of trembling, for instance, are, in sensitive people, due to more or less forgotten memories of dangers or frights. Occasionally even slight convulsive seizures may follow such recurrent dreads. Not a few of the cases of so-called hystero-epilepsy in the borderland between hysteria and epilepsy but always one or the other, are due to such mental states rather than to any physical conditions. Such incomplete memories are sometimes spoken of as subconscious. The word subconscious has been so much abused, however, that I prefer not to use it. The reminiscences have been obscured by an accumulation of other facts but may with an effort of attention and concentration of mind be recalled. Hypnosis, or the milder form of it spoken of as the hypnoidal state, may enable the patient to recall them more vividly by enabling him to concentrate his attention, but there are always risks that suggestion will vitiate the old story in these cases. With care all the details can usually be recalled and the patient is thus given renewed confidence in himself and his own powers and does not learn to lean on someone else in the process. TREATMENT The most important psychotherapeutic factor for the relief of the discomfort due to dreads is the knowledge that there are so many and such different varieties of them and that so many people suffer from them. Many of those afflicted are inclined to think that their cases are almost unique. To have them know that there are all forms and phases of these curious aversions is to make them laugh a little at their own because they laugh so readily at others, and it gives them new courage for the attempt to conquer them. The aversion cannot be entirely overcome, but it can be prevented from seriously influencing sleep or appetite or occupation. This is after all the important feature of the case from the standpoint of psychotherapy. Besides, patients are encouraged not only to take up, but, above all, to continue, the practice of that mental discipline and self-control which will enable them to lessen their natural aversion, if not to remove it entirely. I have many cases in which patients' aversions have been entirely overcome. Curiously enough, there are rather often relapses when the patients are run down in weight, or are in an irritable condition from worry or emotional stress, and then something of the former mental discipline has to be reinstituted to make them once more free from disturbance. {627} I have sometimes found that the recommendation to patients suffering from dreads to read Mary Wollstonecraft Shelley's "Frankenstein" has proved an excellent therapeutic agent. This is particularly true when the patients are women, for it is likely to bring them close to the sad lives of the Shelleys. The circumstances in which the book was written add to the appeal. "Frankenstein" itself is interesting, so that the mood created by this combination of interests is excellently therapeutic. It will be recalled that in "Frankenstein" the inventor seeking to make a man does make an automaton that is able to move and to talk, but that then haunts its inventor, demanding of him a soul. It proves a plague to him, but he cannot escape from it. Fly where he will his creation follows him and bothers the life out of him, killing a friend, strangling his bride, and making existence intolerable. The symbol is complete and to the point. The things that bother us in life are to a great extent of our own invention. The dreads that make so many people miserable are practically always without any groundwork in reality, figments of our imagination without the soul of real life, but capable, as was Frankenstein's monster, of making their creators intensely miserable and with them, to an even greater degree, their friends. CHAPTER IV HEREDITY There are so many false and, indeed, from a scientific standpoint, utterly groundless notions with regard to heredity which, as a result of the popularization of science, have become widely diffused, that notions about inheritance are a most copious source of dreads and discouragement and even produce inhibition of resistive vitality against disease on the part of many patients. At first it seemed to me as though the subject should be treated in the chapter on Dreads. It is so much more important than the other dreads, however, and there are so many people with so many different notions as to the evil influence of heredity that it seems advisable to devote a special chapter to it in which to provide contrary suggestion. Many patients are constantly suggesting to themselves that, because they are suffering from certain symptoms due to real or supposed hereditary conditions, there is little or no hope of their recovery or of any effective relief. In the old days, when tuberculosis was considered to be hereditary, it was almost hopeless to try to rouse patients into a state of vital resistance to their disease because of this overhanging dread. Such a prepossession of mind must be overcome. In spite of all that has been said about the power for evil of heredity, and in this as in every other phase of pseudo-science, the reason why there are false popular notions is because the medical profession first cherished them and then they spread popularly, we now know that it means comparatively little in pathology. The false notions will continue, however, to be popularly diffused probably for another generation, at least, and will have to be combated. Their force must be lessened, for they are a heavy incubus on the patient's mind, imposing a burden on vitality that inhibits normal, vital reaction. This can only be done by a frank and complete statement of {628} our present knowledge of heredity, which is even yet not nearly so definite as we would like to have it, but which contradicts entirely most of the older impressions. In the matter of disease what we know of heredity, instead of being a source of distress and discouragement for patients, provides rather new incentives for vigorous reaction, since nature helps rather than hampers the effort of the individual to throw off disease from generation to generation. False Impressions and Expression.--Probably the commonest expressions that the physician hears from his patients, though we hear many stereotyped phrases in our time when patients so freely discuss their ills and their physicians' opinions among themselves, are such as: "My father suffered from rheumatism, and I suppose I must expect to be bothered by the same ailment." "My mother died of heart disease and I think I have a weak heart; I suppose that we have weak hearts in the family." "I have had three relatives die of cancer in the last three generations, so I presume that cancer is in the family, or at least we are much more liable to cancer than the generality of people." And, finally, what used to be the commonest of all, but fortunately we have changed that at least, though we sometimes hear it still: "Tuberculosis runs in our family, my mother and an uncle died of it and one of my brothers is suffering from it, so I suppose I must just make up my mind that I, too, am sure to get it." Even the rarer affections, like kidney disease, liver disease, various nervous troubles, stomach and intestinal disturbances of many kinds, flatulence, constipation or diarrhea, are all supposed to be hereditary and patients explain their ill feelings by an appeal to the supposed principle of heredity and its application to themselves and their families. In many chapters in this book the subject of heredity has been considered with regard to specific affections. We have no evidence at all, or the evidence is so trivial as to be quite negligible, that anything acquired by the individual, be it for good or evil, is ever transmitted to the next generation. That acquired characters are not transmitted is now almost a universally accepted principle among biologists. The more a biologist knows of recent biological research and investigation the more will he be likely to consider this principle of the non-transmission of acquirements as definitely settled. According to this, then, no disease is ever transmitted to the next generation. This is such a complete reversal of former opinions, such an open contradiction of popular beliefs, that the subject merits thorough discussion from this newer standpoint for medical applications. We must not forget that popular medicine, even when egregiously wrong, is founded on opinions held by the medical profession aforetime and, indeed, on this subject of heredity many of the medical profession still cling to the former opinion. Tuberculosis, which used to furnish the most serious argument in this matter, has now come to be the best possible explanation that we have for the fallacy of the transmission of anything acquired. The disease followed families so constantly that it seemed impossible to explain it unless the principle of its heredity was conceded. Now that we know its contagiousness, however, it is comparatively easy to explain its occurrence in families. When we recall how carelessly people coughed and even expectorated around the house, while children crept on the floors and carried the germs of the disease to their mouths on their hands, the wonder is, not that so many members of the family acquired the disease seeing the manifold opportunities for contagion, but that {629} any of them ever escaped. We know now that practically every adult above the age of thirty either has or has had tuberculosis. Careful autopsies show us remains of the disease even in the bodies of those who, without any history of tuberculosis, die from other diseases. One out of eight of the population dies of tuberculosis, but the remaining seven are quite capable of resisting the disease and so we find healed lesions at autopsies in this proportion of cases. Family History Favorable.--It is certain, then, that tuberculosis is not hereditary. On the contrary, as we have learned more about the disease in recent years, it has been recognized by specialists that patients who have a family history of tuberculosis are notably less likely to succumb to the disease early than those who have no such history. An acute case of tuberculosis with considerable loss of weight has a very unfavorable prognosis unless there is a history of the disease in the preceding generation, when at once the outlook becomes more hopeful. This newer view is confirmed by what we have learned from the ethnological pathology of the disease. Peoples exposed to the disease for the first time rapidly succumb to it. This is practically true for all the infectious diseases. Our American Indians succumbed in large numbers not only to tuberculosis but also to smallpox and even to measles when each was first introduced among them. The same thing was true in the South Sea Islands. Where nations have been exposed to the disease for some time they have acquired not an immunity, but at least they possess a greater resistive vitality to its ravages and while they still may be susceptible they are not so subject to the fatal forms of the disease, and even if they acquire it they live on for many years. Many people may insist that this immunity or comparative immunity to tuberculosis and increased resistive vitality against the disease is transmitted and illustrates the principle of heredity. The reaction of the system to the disease increases in each generation and this increase is an acquired character which passes down with the family strain. This immunity should be viewed from another standpoint, however. Certain families possess a resistive vitality to the disease; others lack it. The resistant families do not succumb to it, and propagate themselves. The others gradually die out. What caused the resistant families originally to possess this quality we do not know. We have no trace of its being acquired. Like so many other characters by which men differ from one another, we do not know the beginning of it. Once it comes in as a family trait it is transmitted. In successive generations we have no evidence that it is stronger, only the danger is recognized from experience and better precautions are taken; the consequence is that the original resistive vitality has a better chance to make itself felt and so the family is preserved. This is as true with regard to the conquest of the tendency to excess in the taking of toxic substances, as alcohol and opium, as with regard to disease. It is not the transmission of an acquired character, but the descent of a family trait the origin of which we do not know. Hereditary Syphilis.--Many physicians will protest that, at least, we have ample evidence for the transmission of syphilis by heredity. We have for many years talked of hereditary syphilis as if it were absolutely sure that its transmission by inheritance took place. There is no doubt, of course, that the disease is conveyed from mother to child. If a mother is actively syphilitic, {630} then her child will surely have syphilis when it is born. This, however, is no argument for the hereditary transmission of syphilis. We know now that if a mother is tuberculous, in an active stage of that disease, her child will almost surely have the disease, but this is a question of contagion not of inheritance. If a mother with active tuberculosis nurses her child she is likely to give it tuberculosis. Usually the idea is that the milk is not infective unless there are tuberculous lesions in the breasts, and in cattle it is well known that such lesions in the milk apparatus inevitably bring tubercle bacilli into the milk. The demonstration of tubercle bacilli in the blood of patients in the active stage of the disease is now much more frequent than used to be the case and there seems no doubt that the bacillus can pass through glandular structures into the secretions. In the same way syphilitic nurses are likely to infect nurslings, though, of course, in this case there are usually syphilitic sores on the nipples which directly communicate the disease. It is almost impossible for a syphilitic woman to nurse a child, if she is in an active stage of the disease, without the production of such infective sores on her nipples. When children are born with syphilis it means only that in the process of feeding the child through the placental tissues, a mother has infected her child quite as she might infect it by nursing afterwards, in case she acquired syphilis after the birth. Lesions corresponding to those on the nipple occur in placental tissues and can be demonstrated without much difficulty. Congenital syphilis, however, can always be traced to contagion and the being born with the disease or having the manifestations of it occur shortly after birth is no argument for heredity at all. It merely emphasizes the danger of contagion. _Mothers of Syphilitic Children_.--But there are some cases in which the child who shows symptoms of syphilis after birth is born from a mother who never had any manifestations of syphilis and therefore it has been supposed that the infection must have come from the sperm, and that in these cases, at least, there is a true heredity. It is perfectly possible, however, that syphilitic infective material may accompany the spermatozoon and so bring about the occurrence of syphilis in the offspring. Even this would be infection, however, and not heredity. Much more frequently it would seem that the disease in the infant was contracted from the mother while suffering from a latent form of syphilis, rather than from the paternal contributory particle to its existence. The mother gives no sign of the disease, but Colles' Law is that the mother of a syphilitic child may, without danger to herself, be allowed to nurse her own infant even though she herself has never had any symptoms. This can only mean that she is thoroughly protected against the disease. We would not think for a moment of allowing an ordinarily healthy women to nurse a syphilitic child. Such immunity in the mother of the syphilitic child can only come, so far as the present state of our knowledge goes, from her having had the disease. It has been said that as the result of the intimate communication with her child in utero she has acquired an immunity by the passage across the placental membrane which separates maternal and fetal blood of protective substances of various kinds due to the reaction against the disease already beginning in the child. As a matter of fact, however, there is no evidence of any such reactive substances in the blood of the child which after birth proceeds to have a series of acute lesions that are, as a rule, indicative {631} of almost complete lack of resistive vitality. Maternal immunity is evidently due to the occurrence of the disease in some form within the maternal tissues which produces the usual protection against the disease in a briefer time than usual. This certainly seems to be a more satisfactory explanation than that of a transmission of an immunity from the child to the mother which the child itself does not possess. It is easier to understand the transmission of an infection that does not manifest itself externally than of an immunity which there has been no time to acquire. Both explanations leave a mystery, but the mystery in the second case can be explained more in consonance with what we know about syphilitic transmission and immunity than in the other case. It does away with the transmission directly from the father almost completely, of course, leaves practically no ground for the heredity of syphilis, but it accords much better than older explanations with biological principles. _Late Lesions and Heredity_.--Many physicians will be likely to insist that the late developments of syphilis in children, in which not only three or five years afterwards, but even fifteen or twenty years after birth, there are syphilitic manifestations, are beyond all doubt examples of heredity. In the last twenty-five years, however, our ideas with regard to the after-effects of syphilis have been entirely modified by what we have learned of such diseases as locomotor ataxia, paresis and the like. These are undoubtedly parasyphilitic diseases in most cases, yet they not infrequently develop from ten to twenty years after any manifestation of syphilis and they seem to occur, by preference almost, in cases where the preliminary symptoms have been very mild. In not a few cases, indeed, the symptoms of syphilis have been so transient in these patients that the true significance of them was missed until the later developments showed their real character. Krafft-Ebing, at the International Medical Congress at Moscow in 1897, detailed some experiments that he had made on paretics in Vienna. They were patients in whom no history of syphilis could be found, yet they were suffering from typical paresis. As they were in the ultimate stage of the disease it did not seem unjustifiable to inoculate them with syphilis, and in most cases it was found that they would not take the disease, showing that they were probably protected by a previous attack, though there was no history of it. The development of the late symptoms of syphilis in the second generation can then be much more satisfactorily explained on the basis of a mild infection with very few primary symptoms, almost lacking in secondary symptoms, yet followed by subsequent symptoms of great severity consequent upon the deterioration of vitality produced by the disease. As for the manifestations in the third generation, they are not directly syphilitic, but are, whenever they occur, due to conditions consequent upon the degeneration that had been effected in the preceding generation and which directly weakened the offspring--on the same principle that weak parents give birth to weak children, and starving parents cannot have strong, healthy children--but not because of any direct influence of the disease. It is worth while to discuss this subject from this standpoint, since it disposes of the only supposed evidence left for the hereditary transmission of disease that we now have, though only a few years ago most diseases were supposed to be hereditary. Heredity in Cancer.--With regard to other diseases, the evidence for any inheritance has been founded entirely on coincidence. All the human race {632} dies and must die some way, and so in families a certain number will die of the same disease. The argument for heredity in cancer is extremely weak. When all the relatives of a person afflicted with cancer as far out as the third generation are taken into account, only about one in five of them are found to have suffered from cancer. When we remember, however, that more than one in thirty of all those who die, die of cancer and that the death-rate of this disease is greater than that of typhoid fever, smallpox, scarlet fever, measles, and all other infectious diseases put together, it is easy to understand how large a role coincidence plays in any such set of statistics, and how little the significance of the occurrence of cancer in different members of the same family means, unless possibly there is an occasional element of contagiousness which must not be left out of the reckoning. Heredity in Other Affections.--Other ailments present much less possibility or probability of any element of heredity. For instance, over-indulgence in meat or drink may readily bring about various ailments of the gastro-intestinal tract. These are, of course, definitely acquired conditions, some of them temporary and some persistent, that will continue to give trouble so long as the patient continues to produce irritation of them. They may, of course, lead to permanent pathological conditions. To say that any of these are likely to be inherited would be quite as absurd as to say that a corn could be inherited, or the permanent deformities produced in toes by wearing badly-fitting shoes could be transmitted to the next generation. We do not think for a moment that because a man has lost a finger his children are likely to be born without a finger, and still less if by some accident or abuse he has been deprived of the use of an arm or leg, that that is likely to be transmitted to the next generation. Yet people calmly talk of the heredity of similarly produced conditions within the body, and even physicians are not entirely free from the superstition, for such it is, of the influence of heredity in producing pathological conditions. Habits of various kinds, physical and mental, are calmly accepted by many people as influenced by or having their origin in heredity. Under Alcoholism and Drug Addictions we have discussed this phase of the subject, but a word or two more may make it clearer. A tendency to form the same habits may be a family trait and descend from one generation to another. That a specific habit should be the subject of heredity or transmission is as much out of the question as that a facility for doing anything should be transmitted. The son of an acrobat must practice quite as faithfully as did his father in order to secure his father's skill. He may inherit from his father that particular constitution of body, that specific combination of muscle and sinew and bone that enables him to become an acrobat by practice, though with a different kind of body it would be impossible, but his father's acquired facility influences in no way the son's ability. We often hear of a man being the descendant of a series of generations each of whom has gone to the university, as if that somehow assured him a readier and better facility for education, but we know very well that this is not true and that the boys straight from the soil are often the best students and far ahead of the scions of long-time academic families. Inheritance of Defects.--Acquired characters are not transmitted, though family traits are the subject of inheritance. Disease is not hereditary, but {633} defect is. Crossed eyes occur very commonly in families and are evidently a subject of transmission. Family noses are often very peculiar and may be traced for many generations. The Hapsburg lip has been noted in sixty per cent. of the Hapsburgs since the family came into prominence in the thirteenth century. Features of all kinds are inherited, as anyone who has ever spent some time in a family portrait gallery where the ancestors were genuine and the paintings reasonably true to life, knows very well. Certain features of European families can be traced for many generations. The tendency to have six toes or to have an extra finger runs in certain families. So small a thing as a patch of white hair in a particular part of the head may be the subject of hereditary transmission. Moles on a particular part of the body are inherited. All these, however, are characters with regard to the acquisition of which we know nothing, but that have somehow found their way into the family strain and have become subjects of transmission from generation to generation. They provide no evidence, however, as to the transmission of acquired characters. Variation.--What is even more surprising in biology, however, is that there is another marvelous force at work quite as incomprehensible in its way, perhaps even more so, than that of heredity. This is variation. All creatures have a tendency to vary from their parents. A very small proportion of the offspring resemble parents so closely as to be quite similar. The great majority of them, however, have noteworthy, individual, distinctive qualities. Occasionally these qualities may be traced to the less immediate ancestors and then we talk about reversion. Occasionally there appears in a child some trait or anomaly supposed to be remotely ancestral and it is spoken of as atavism. Whenever there is a tendency of the offspring of exceptional parents to regress toward the racial average, we talk of regression. Tall parents often have tall children, some of them may, by a special tendency of heredity, be taller even than themselves. Most of them will be shorter, however, and tend to regress toward the racial average. Few people understand what a wonderful power among living things is exerted by this very opposite of heredity--variation. All the possibility of improvement not only in humanity but among all living things is dependent on variation. It does not seem difficult to understand how offspring resemble parents. They are of them, therefore they are like them. When we analyze the problem of heredity, however, and find that the connecting link between offspring and parents is always only a single cell of less than one one-hundredth of an inch in diameter, the mystery of heredity looms up in all its immensity. This minute bit of protoplasm, so small that it requires a rather strong power of the microscope to see it, somehow contains compressed within itself all the qualities that characterize the parent and are to be transmitted to the offspring. Among animals, the color of the eyes and hairy covering, the form and height of the animal, its generic characteristics, and its individual characters--all are contained within this minute spherule. The white blaze on the horse's hind leg, the black blotch on the puppy's face, the white lock on a human head, are all carried over from one generation to another with all the other qualities in this small package. That is the mystery of heredity. To this must be added another mystery quite as great and even more {634} difficult to understand--variation. This tendency to vary is the basis for whatever evolution there is in the world. Some living things vary in such a way as to be better suited to their environment than they were before and then these outlive others because more favorably situated, and natural selection brings about a maintenance of the favorable variation. Instead, then, of patients being impressed with the unfavorable influence of heredity, they should rather be made to feel the weight of the idea that whatever evil tendencies the parent has the child is more likely to have less of them than more, so that variation tends to make the race better. We have had too much stress laid on the heredity of unfortunate qualities and entirely too little made of the variation tendency, which is constantly lifting the race up. It is, of course, only what happens in everything else, unfavorable are likely to have more weight than favorable suggestions, and unless these latter are emphasized their influence becomes swamped. This has happened with regard to variation. It is quite as important a biological element as heredity and it makes for the removal of unfortunate qualities, yet it has never become a popular idea and is little appreciated even by physicians. Patients who are worried about their heredity will, after a frank discussion of our present knowledge of heredity and its co-ordinate factor of variation, lose most of their dread of this specter of supposed evil influence which so often proves the source of discouragement and failure to react properly against pathological conditions. There is probably no phase of modern biology in which the so-called popularization of science has done more harm by providing an abundant source ol unfortunate suggestions. Whatever influence heredity has in relation to disease is favorable to the human race. It is true that this is exerted by the elimination of the unfit, yet the very consequence of this is that the children of parents who have suffered from a particular disease are likely to have greater average resistance to it than the generality of mankind, since their parents passed the age up to reproductive activity without succumbing to it. For cancer, tuberculosis and syphilis this teaching is of special value and is probably more effective than any other single means could be to prevent the ravages of the disease if it should occur, since it keeps the patient from interfering with his own resistive vitality by the discouraging conviction that there is no possible hope for him because his parents also suffered from the disease. CHAPTER V PREMONITIONS A state of mind that disturbs many people seriously, sometimes even producing physical results, because of the burden of dread that hangs over them, is that in which attention is paid to premonitions of evil. There are two of these general conditions to be considered. In the one there is a definite feeling that some special evil, occasionally very particularly outlined in the mind, as a railroad accident, fire, or a street accident of some kind, is to occur. In another mental condition there is a generic premonition of evil, {635} as if the worst were sure to happen and the patients must be constantly preparing for it. Occasionally this takes on some such form as an assurance of early breakdown in health, or of death at an untimely age, or of some crippling infirmity. This represents, of course, only one form of lack of control over the mind, but it is surprising how much physical suffering it may occasion. Only those who have had much to do with patients who suffer from this state of mind realize it. Sympathetic knowledge of the conditions that bring it about and of the real significance of premonitions will do more to help patients than anything else. Every now and then newspapers tell the story of someone who had an impending sense of danger, perhaps of a particular form of accident or misfortune, which he could not shake off and which finally came true. Sometimes it is a fire that was anticipated, though without any reason except the dread, and precautions that eventually proved life-saving to the patient were taken, or at least friends were told of it so that the person seemed actually to have had some warning beforehand of the danger that was to come. Sometimes it is the story of a railroad accident, which some particularly fortunate individual escaped, because of a premonition that made him take another train or make a happy change of cars. Nothing is said of the times when premonitions failed, nor of the disappointments of such dreads. Most people laugh at the stories, but a few individuals become seriously impressed with the possibility of such warnings and then make themselves miserable by having frequent premonitions. Etiology.--As to the origin of these premonitions it is hard to say. They occur more frequently on dark days than in bright weather and are complained of much more in spring and fall than during the cold brisk winter or during the summer time. A succession of very hot days, however, brings a series of premonitions, especially with regard to accidents by heat, that is not surprising since the newspapers have many accounts of sunstrokes and there is every suggestion of the possibility of danger of this kind. How large a role suggestion plays in the matter can be realized from the fact that after some particularly serious railroad accident many people have premonitions that they may be hurt and occasionally they put themselves to considerable inconvenience in choosing the car in which they will sit, if the last serious preceding accident of which they have heard happens to have brought death mainly in a particular car of a train. It is always suggestible people who are likely to have premonitions. The thought comes very simply at first, they dwell on it a little unwillingly, then they find it impossible to banish it and finally it may become a positive obsession. The soil and the seed for suggestion are both needed to produce premonitions. Royce suggests that many of the supposedly fulfilled premonitions are really only pseudo-presentiments and represent an instantaneous and irresistible hallucination of memory, which may give rise to the impression that there has been a previous dream or other warning presaging the facts, though no such phenomenon actually took place. In other words, there would be an auto-suggestion consequent upon the hearing of other fulfilled presentiments that sometime some such thing must also occur to us, and then when a happening that reminds us of something in the previous stories of {636} presentiments comes there is the sudden responsive feeling "why, this is what I saw or must have seen in my dream." Podmore suggests an illusion of memory magnifying or rearranging the details of a recent dream or premonitory impression, so as to make it fit into the happenings. Dreams are so vague that unless they have been written down we are not quite sure of them an hour after they occurred and a day or two later we have only the merest hint of what they were. If this can be made to have any connection with a casualty of any kind that happens subsequently we may very readily recreate the dream with its details concordant to the event. Certainly no reliance can be placed on a story of a dream fulfilled unless the dream was told before the happening. Premonitions of Death.--Certain premonitions are common and are frequently brought to the physician's notice. Among old people it is not unusual to find that a premonition of death will hang over them for days, seriously disturbing them and their friends, hampering often a healthy reaction against disease and always lowering resistive vitality. Many of them have heard stories which make them credit the belief that such premonitions are likely to come true and therefore they cannot shake them off. They have heard stories of people who have become convinced that they were going to die at a particular time on a particular day and whose conviction has been proven by the event. Like all the other premonitions, whatever truth there may appear to be in them, is due entirely to the fact that nearly everybody has premonitions and occasionally, therefore, one of them must come true. Those that are fulfilled create such an impression that they are remembered, while those that fail are forgotten, until, though it is not realized, it becomes true that fulfilled premonitions represent exactly that much misunderstood principle that the exception proves the rule. The rule is that premonitions fail. Exceptionally, however, a premonition comes true. Instead of proving that premonitions mean anything, the rarity of their fulfillment proves the rule of their non-significance and demonstrates that they are merely coincidences. Persuasion of Short Life.--Much mental suffering occurs in nervous people as a consequence of a premonition or persuasion which comes to them in middle life that they are destined not to live very long. This is a commoner impression than is usually thought and comes to nearly everyone at some time in life. Especially is it likely to come to those who have suffered some severe illness and who know how weak they were during their convalescence and, in spite of their thorough recovery of strength, cannot quite persuade themselves but that an ailment which made them so weak must surely have sapped their vitality so as to make long life for them impossible. It is, of course, one of the vague dreads that men always seem to be harboring, but there are times that it becomes so prominent and so influential in the production of depressive feelings that it is worth while to have the means at hand to counteract it as far as possible. In the last ten years I have made it a practice to ask, not only all my patients but most of my acquaintances above 70 years of age whether they had ever experienced such a premonition. I have particularly asked what were their feelings with regard to the hope of long life for them when they were in their forties and fifties. Without exception I have been told by all those who had the education and leisure to {637} be at all introspective, that they had felt sure that they would not have long life. Most of the men consulted took out life insurance in such a way as to benefit their families after their death rather than themselves during life. Indeed it seems not an unusual thing for men to have some experience with an ailment between 40 and 55 which makes them realize their mortality much more than the deaths of their friends around them had succeeded in doing. Premonitions and impressions, then, of this kind evidently mean nothing, so far as the prospect of long life is concerned. Practically everyone has them, and since, of course, the great majority of men do not live to die of old age, it would seem that their premonition of comparatively short life was fulfilled. Occasionally a man will be found at the age of fifty unwilling to take up further work or develop his business because of the dread that has come over him that he may not live long enough to make it worth the while. Where there is serious kidney or heart trouble such an abstention from business is commendable, but in many cases it leaves a man without occupation or with insufficient occupation and he becomes short-circuited on himself with more serious results from worry than would have come from work. Publication of Fulfilled Premonitions.--The publication of fulfilled premonitions has always seemed to me to be an especially fertile source of premonitions for other people. Every now and then someone goes to bed in a hotel having communicated to friends the idea that he fears there may be fire before morning. I do not suppose that one out of ten people who sleep in a strange hotel fail to have some such thought, they do not consider it a premonition, however, but only a suggestion for the taking of proper precautions so as to know where exits and fire escapes and other means of escape are situated, so that in the excitement of the fire they may not have to do any thinking, but may have already made up their minds what they shall do. This sort of premonition, if we call it by that name, has a definite useful purpose. Occasionally it seems marvelously provident. The other makes its possessor toss sleepless a portion of the night, does no good and much harm. If, however, the premonition has been communicated to someone else and then a fire should occur, the reporting of the fulfilled premonition comes to a lot of weak-minded people as a confirmation of their worst fears. It is, of course, only a question of coincidence in a succession of events by no means connected in any causal relation, yet by the unthinking set down as showing the possibility of such premonitions being supremely significant. If we had all the stories of unfulfilled premonitions also published then the true significance of the others would be clear. An Unfulfilled Premonition.--There is an excellent story of a strong but unfulfilled premonition told by Carl Schurz in his "Recollections," which seems to me such a good antidote to the influence of supposed premonitions, that every physician should know its details for their psychotherapeutic value with patients prone to be troubled in this way. The ease with which the depression consequent upon the premonition was relieved as soon as another forcible suggestion that the danger was past took possession of him, shows how such states of mind can be altered with no more real reason for the alteration than there was for the original depression. {638} On the morning of the battle of Chancellorsville General Schurz awoke with the absolute persuasion that at last his time had come and he was to be killed that day. He had never had such a premonition before. He had heard of many cases in which such premonitions proved the forerunner of death. He realized how ridiculous was the idea that he should know anything about what the future held for him, even vaguely, and he tried to shake it off. He found it impossible to do so. He thought that after he took up the routine work of the day the force of the premonition would be lost. It was not, but, on the contrary, seemed to increase in power over him. Finally the idea became so imperative that he sat down and wrote letters of farewell to his wife and friends, telling them that he had been tempted to do so because of this premonition of danger. When he went into battle--and it may be recalled that the Eleventh Corps did some fighting at Chancellorsville that day--he was sure that now the end was not far off. It did not take away his courage, however, and though he was well in the zone of danger, he issued his orders and kept his troops well in hand as we know from the history of the battle. Finally his aide-de-camp, riding toward the front of the line beside him, was killed by a cannon ball. All in an instant the thought came over him that this was the only danger that was likely to be near him for the day. The burden of premonition lifted from him as if the fact that a friend had been killed beside him gave him an assurance that he himself was not to be taken. There was absolutely no reason for his thinking so, but his feelings of solicitude with regard to himself and his fate faded completely and at once. He continued in the thick of the fight and of danger and was untouched. He himself called attention to the fact that if his premonition had come true, as well it might in the midst of the very serious danger which he faced, it would have seemed a strong confirmation of the impression that premonitions have a meaning other than that of coincidence. It was, however, a magnificent example of a failed premonition quite as striking as any of the stories that are told about premonitions that came true. Rôle of Coincidence.--This must be remembered in many of our arguments in medical and other scientific matters. Most diseases are self-limited, therefore anything that is given as a remedy for them just about the time that nature has succeeded in conquering the virulence of the disease and bringing about the cure of the patient, seems to be curative. Such cures, often remedies of supposed wonderful potency, come and go in medicine by the hundred every ten years. Such curious doctrines as that of the influence of maternal impressions in producing deformities and defects in the unborn child are founded on nothing better than these coincidences. They are often very startling, but the rule by which they must be judged is the number of times in which in spite of similar conditions no premonition takes place. Literally thousands of people go to bed every night who are to be waked by the danger of fire before morning and yet have no premonition of it. Literally millions of people have gone to bed in recent years without any premonition of earthquake, yet have been wakened before morning with their houses tumbling around them. If a few people have premonitions in these cases it is easy to understand that it is coincidence and not anything else, for these are exceptions, and this again is a case of the exception proving the rule. {639} Premonitions and Superstitions--Thirteen.--Occasionally premonitions are connected with certain events that are themselves, even though happening quite accidentally, supposed to be portentous. How many people, for instance, feel quite uncomfortable if they sit down thirteen at a table. The very fact of the gathering of thirteen is supposed to be a spontaneous or automatic premonition that is a forewarning of evil that has to come to some of them. Unfortunately, this superstition continues to have a vogue and an influence over people's minds because stories are told that are supposed to confirm it. Needless to say, when these stories are true, they are merely coincidences. Out of any baker's dozen of people who sit down to dinner it is not surprising if one should die or be killed during the year. Some of the stories, however, are merely sensational inventions worked up to be given to the public because a number of people are interested in this sort of thing. Probably one of the stories that has gone the rounds most and that has served to confirm many people in their uneasiness over the number 13 is that which is told as happening to Matthew Arnold and some friends, supposedly the year the great English litterateur died. The story runs that just as Mr. Arnold and his friends were about to sit down to the table it was discovered that there were thirteen present. According to the old tradition in the matter it is the one who first gets up from table under these circumstances that is likely to be affected by the malignant influence. When the end of the dinner had arrived, by previous arrangement Mr. Arnold and two very healthy friends, brothers, arose simultaneously. According to the widely diffused newspaper account of years afterward, Mr. Arnold himself died within the year and one of the brothers was lost in the wreck of an English passenger vessel off the coast of Australia in six months, while the other brother committed suicide before the end of the year. Careful investigation of the details has shown, however, that the story was made out of whole cloth. Mr. Arnold himself, who was suffering from heart trouble towards the end of his life, was not likely to take part in any such arrangement because of the constant danger, well-known to himself, of sudden death in his case. This might happen at any time and might seem to confirm the superstition. The dates of the story, moreover, are all wrong. Matthew Arnold's death and the loss of the English passenger vessel in Australian waters, referred to, do not occur within five years of each other. The story has gone round the world. The correction will never reach so far. The story is startling; the explanation commonplace. Many people will continue to believe that here, at least, was one striking confirmation of their superstition. It is curious how the force of this "13" superstition has continued in spite of education and enlightenment. Most passenger vessels now built have no staterooms numbered thirteen. On certain streets in large cities one finds the number 12-1/2 (until this year it was so on my own) substituted for thirteen. Sometimes one finds "twelve a" or something similar. In the large hotels, where they have immense banquet halls with the tables numbered so that guests may be able to find their places, I have often noted that there was no table number thirteen. It is said that in some of the new skyscraper buildings twenty stories and more in height there has been question of skipping the thirteenth floor as a designation, because while most {640} people would be quite undisturbed about it, some do not care to have an office on the thirteenth floor, giving as an excuse that clients or patrons do not care to come to the thirteenth floor. In automobile races men are willing to risk their lives by going a hundred miles an hour on roads never intended for such performances, but they refuse to race behind the fell number thirteen. This, after all, can be readily understood. The slightest thing that takes away a man's complete confidence in himself may be serious in an automobile going as fast as these. Men must not think of fear or they lose some of their power and control over themselves and their machine. They must simply forget everything except the task before them. The belief in the thirteen superstition is one form of acceptance of premonitions. That of itself should be enough to enable sensible people to throw them off. Above all, it must be remembered that such supposed malignant influence, when allowed to affect people, impairs their presence of mind and may thus lead up to the accident or mishap which it is supposed to foreshadow. This is the serious feature of such premonitions and dreads. Unless people can be persuaded sensibly to be rid of them they handicap themselves whenever they are placed in danger that causes them to recur to the thought of the premonition or dread. While there is absolutely nothing but coincidence in even the supposed true stories, and many of the stories are merely sensational inventions, yet people need to be persuaded to rid themselves of the incubus that settles over them because of such ideas. Premonitions and Telepathy.--There are many people who think that premonitions have something to do with telepathy. Somehow the future event is supposed to be able to send some message to specially susceptible minds. Either that, of course, or there is some being in another world whose interest is sufficient to convey some inkling of the future. A little consideration of this subject, however, shows the utter lack of rationality in any such opinion. Future events, having as yet no existence, cannot in any way influence intelligence. Such future events, when dependent on human free will, are quite impossible of being foretold and, as has been said, no being except the Creator Himself knows anything about them. It would be only from Him, then, that information might be supposed to come and it would be hard to think such information would be so vague and indefinite as to leave room for doubt and, besides, often defeat its purpose of protection by seriously disturbing patients and lessening their presence of mind. There is no reasonable explanation by which a human being can be supposed to obtain knowledge of a future event unless there is a complete overturning of the ordinary laws of nature and then it would be reasonably supposed that no doubt of the significance of the event would be left. Nearly all of us have premonitions that fail. Only a few especially introspective people who are constantly afraid of what will happen to them, and who are sure that the worst is always preparing for them, have their premonitions come true more than once or twice in life. The striking fulfillments of a few premonitions could be paralleled by an endless number of just as striking failures, only that most people dismiss the idea completely from their minds as too foolish to be further talked about. It is quite the same with dreams. All the world dreams and there would be a serious violation of the theory of probabilities if some dreams did not come true. The great {641} majority of mankind, especially after the age of thirty, is fearful lest something ill is going to happen to them and their premonitions are rather frequent. If some of these did not come true then the mathematics of coincidences as based on the theory of probabilities would prove false. CHAPTER VI PERIODICAL DEPRESSION Fits of periodical depression, familiarly known as "the blues," occur in the experience of practically everyone. In some people they are only slight and passing. In others they last for hours and make the individual quite miserable. In still others, without actually running into melancholia, they produce serious discouragement and continuous discomfort which persists even for days and makes life intolerable. They come and go quite unaccountably. During their occurrence all vitality is lowered, appetite lessened, aches and pains are emphasized, sleep may be disturbed, exercise becomes distasteful, and they usually present an interval when health is at a low ebb. Ordinarily when described as "the blues" they have no definite connection with any known physical cause. They are passing incidents which seem to recur at irregular intervals. When connected with physical ills they are thought of directly as symptoms of these ills. All forms of disease may be associated with such fits of depression and many physical symptoms seem to be due to the fact that during these periods there is a distinct lowering of physical vitality so that the nerve impulses which ordinarily enable functions to be performed without interference are interrupted, or at least are inhibited, to a noteworthy degree. While to a certain extent the condition is a mental disease, it may be modified by the correction of physical derangements, by stimulation and, above all, by suggestion and a change in the point of view. Serious Pathological Conditions.--Of course, such periodical fits of depression are associated with various serious progressive ailments and then are primarily physical, and are only secondarily psychic. From the standpoint of psychotherapy it is important to remember that certain serious organic lesions may show their first signs in the patient's mental state. It is not unusual, for instance, for the disposition of a patient suffering from kidney disease to change so materially that the attention of friends is called to the change before any physical symptom of the nephritis has been noted. Sometimes for a year there will be a progressive clouding of what had previously been a rather happy disposition. Decisions will be made more slowly than before. The judgment will be impaired. There are some striking examples of this in history, of which the unfortunate Athenian general, Nicias, put to death for incapacity that was undoubtedly pathological, is one. Pleasures will be taken half-heartedly; men who have been bright and jovial will now become saturnine. Men who have been the life of parties will try to hold the place they acquired before, though all around them will perceive how difficult it is for them to maintain the role they have set for themselves. Whenever there is a notable change in disposition, it is well not to attribute it to some passing mental condition and, above all, not to dismiss {642} it as a peculiarity unamenable to treatment, but to look for the underlying pathological basis of the new condition. In this way physical disease will sometimes be discovered long before it otherwise would be. This must be particularly noted when there have been a series of worries. Occasionally it seems enough to many people to ascribe a change of disposition to the troubles that have come over a patient. If a business man fails or passes through a crisis in his affairs in which failure is very near, or he has many business worries over a prolonged period, these are sometimes thought to be quite enough to explain a change of disposition. They are, but not to the degree that is often noted, for, in excess, melancholic tendencies are always pathological, that is, they have some basis in a serious mental or physical change. If there is an insidious nephritis already at work, its symptoms will be much exaggerated and its progress accelerated by the worries and disquietude of such a time. If a wife loses her husband, or an only son, or a favorite child, the occurrence of a prolonged period of depression should lead to a careful investigation of physical conditions and of the underlying mental state in the hope of guarding against serious developments. _Heart Disease_.--Periods of depression are also common in heart disease and are often the first symptom of the beginning of a break in compensation. This effect is not so simple and direct, however, as in the case of the kidneys. Probably the first physical symptom of a break in compensation, where there is real valvular heart disease, is a decrease in the amount of urine. This points to an insufficient elimination of the products of metabolism and to the retention in the circulation of toxic substances. The reason for this is the lessened circulation through the kidneys because of the diseased heart. There is also a lessened circulation through the brain. This impairs the function of the brain and quite naturally leads to mental depression, slowness of decision, and unwillingness to occupy one's self with many things. Besides, because of the lessened function of the kidney the circulating blood not only does not nourish so well but it tends still further to depress the brain cells by the toxic substances that are in it. Depression in such cases is rather to be expected and at the beginning is not continuous but comes in ever longer periods with shortening intervals as the disturbance of the circulation progresses. At first, like other diminutions of function, it is conservative in order to spare the heart work. _Respiratory Affections_.--Very curiously an affection of the lungs has exactly the opposite effect and is likely to create in the patient an artificial sense of well-being. _Spes phthisica_, the characteristic hope of consumptive patients, is well known, and has been described by many a careful observer from Hippocrates and Galen to our own time. A lessened amount of oxygen in the blood produces a certain sleepiness, but this seems to be preceded by a period of slight excitation. The most familiar example of this occurs at the beginning of the inhalation of laughing gas. Practically the only direct physical effect of the inhalation of nitrous-dioxide is to shut off our oxygen and it is a slight period of deoxygenation that produces the anesthesia by this agent. Whether we have not in this the explanation of the feeling of the consumptive, so that often on the day before his death he plans a number of things that he is going to do next year, may require more careful {643} investigation, but the suggestion may serve to show how much disposition, both lively and serious, depends on physical factors as well as on the natural state of mind. MENTAL STATES OF DISAPPOINTMENT Quite apart from these serious ailments, however, there are passing phases of depression that come to nearly everyone after adult life is reached that are likely to be somewhat more frequent as years go on, but that are not entirely unknown even in early years. They are more likely to come to those who feel that life has been somewhat of a failure and that they have accomplished very little in spite of all that they have tried to do. Not infrequently they come, however, to those who in the estimation of other people have made a magnificent success of life. The rich man, after he has made his fortune, unless he continues to engross himself with some time-taking and interest-claiming work, may be the subject of repeated attacks of mental depression. Social leaders among women who begin to feel something of the emptiness of social striving, after they have made what is called a success in society and at the time when they are the envy of many on the social ladder below them, are particularly likely to be subject to attacks of "the blues." The only men and women who are free from them to a great extent, and even they not absolutely, are those who are busily engaged with some occupation not entirely selfish in which they can see that what they are doing is accomplishing something for the people around them. Very often an attack of depression is ushered in by some small disappointment. As a rule, however, this is not the causative factor but is only an occasion which makes manifest the depressed state that has existed for some time and that now declares itself openly. In the same way only a slight occasion is necessary apparently to dispel clouds that hang over a person in the milder attacks of depression, because, for some time before, relief has been preparing itself and a livelier phase of existence has been gradually coming on. Relief can be promised with absolute assurance, but freedom from relapse cannot be assured and the only true source of consolation that is helpful is the frank recognition of the fact that these are successive phases of existence quite as likely to be periodic as certain physical facts in life. Depression is likely to be a little more manifest in the morning than at other times, partly because the interests of the day have not yet come to occupy the mind, but mainly because the physical life as indicated by the pulse and the temperature is lower during the morning hours than in the afternoon and evening. Just as soon as people realize the physical nature of certain dispositional changes they give much less depressive significance to them. Occupation of Mind.--The most important feature of the treatment of depression of mind is to secure somehow such occupation as will catch the attention and arouse the interest. This is not always an easy matter. How effective it is, however, can be best judged from what one notes of the effect of such things as physical pain or great solicitude for someone else besides themselves. I have known a mother, whose fits of "the blues" were getting deeper and the intervals growing shorter to be roused from her condition when all means had failed by the elopement of a daughter who had been partly pushed into leaving because things had become so unpleasant around home {644} during her mother's depression, and any change seemed welcome. On the other hand, I had a doctor friend who felt quite alarmed about his growing depression and who even had some fears lest, if it continued to deepen, he might commit suicide. He was completely lifted out of his increasing depression by the occurrence of pneumonia in his boy of sixteen. The pneumonia did not end by crisis but by lysis and for weeks he had very little sleep. He confessed that the intense preoccupation of mind had completely driven away his blues and had even done much to relieve him of various digestive symptoms to which he had previously attributed his depression. Again and again I have known men who, in the midst of prosperity, found life dull and rather hard to bear, and who just as soon as a crisis in their affairs compelled them to pay attention to other things than themselves and the state of their feelings, grew better mentally and physically. It seems almost a contradiction in terms to say that it is the man of little occupation, as a rule, or at least of occupations that are not insistent, who is likely to be troubled with insomnia, while the very busy man, especially the man busy not about one or two narrow interests, but about a number, is seldom so bothered. Nothing contributes more to the depression of mind than loss of sleep or supposed loss of sleep. Even women who, while living in ease and comfort, had much to complain of as regards depression, often lose entirely their tendencies to "the blues" or have fits of them at much longer intervals, when necessity compels them either to earn their own living or, at least, to occupy themselves much more with absolutely necessary duties. _Provision of Occupation_.--It is a hard matter to create such occupation of mind as will be satisfactory. Patients have to be tried by various suggestions. The tendency to periodic fits of depression deep enough to be called to the physician's attention is much more noticeable in recent years than it used to be, and seems to me at least to bear a corresponding ratio to the decrease of home life. Home duties usually mean joys and of late there has been a neglect of the joys of life while seeking its pleasures. Certain phases of city life are responsible for much dissatisfaction with existence and depression of spirits. Most of the women who live in apartment hotels have practically no serious occupation of mind. They need not get up if they do not feel quite right or quite rested--and who after the age of forty ever does feel quite all right in the morning hours unless sleep has been in the open air? Nothing is so likely to start a day of depression than failure to get up promptly, lounging around with forty winks here and there, reading in bed, and the like. If breakfast is taken in bed, then some reading indulged in, and then some sleeping, and only an hour or two of dawdling around comes before lunch, that meal is not properly enjoyed and the afternoon is started badly; unless there is some special diversion of mind depression is almost sure to get the upper hand. _Place of Children in Psychotherapy_.--Where there are children the interests are much more urgent and there is little time for such preoccupation with self as gives one "that tired feeling." We are very interesting to ourselves, but just as soon as we have no other subject to occupy us than ourselves we soon grow very tired of the subject. Children are the best interest that one can think of, for women particularly. When they have none of their own an interest in orphan asylums, in day nurseries, in various children's {645} institutions, and, above all, in the adoption of a child, will do more than anything else to relieve the tendency to blues. Of late years the adoption of children has been much less frequent than used to be the case in childless families, and doctors see the result in mental depression. Children are a great care, but they are a great blessing to women, and while the present trend of social life eliminates them as far as possible, this elimination, beginning with their relegation to nurses when they are infants, to nursemaids as they grow a little older, and then to the kindergarten up to six years of age, far from adding to comfort rather increases the discomfort of many mothers. Nature takes her revenge. The reason why the mothers of past generations could stand the suffering that they must have borne with patience before gynecology developed to relieve them, was that they had their children around them, and their minds and their hearts and their hands were so full that they had no time to think of themselves, to brood over their ills, and consequently these troubled them much less than would otherwise have been the case. Delicate mothers really interested in their children undoubtedly suffer very little compared to delicate women who are alone in life, and what is thus true of the mother is true also of those who have the care of children. It is not alone a satisfaction of the maternal instinct, but it is an occupation of mind and heart with cares for little ones. Other people's children serve just as good a therapeutic purpose, if only their necessities are imposed on the attendant. The reason why women in religious orders have such happy peaceful lives and are happier in spite of a routine of life that would seem to be fatal to happiness, is that their minds are filled with the interests of others, every moment of their time is occupied, and, above all, they have to care for children, the ailing, the poor, sometimes the vicious, who make many demands on them, many calls on their sympathies and keep them from thinking about themselves. _Occupation with Living Things_.--After occupation with human beings the most important therapeutic factor against periods of depression is occupation with living things of various kinds. Horseback riding is an excellent remedy for the blues and the outside of a horse in the old axiom is literally very good for the inside of man or woman. There is a sympathy between man and animal that in itself means much, but the most important element is the absolute impossibility of preoccupation with oneself and one's little troubles and worries while one is trying to manage a somewhat restive animal. If the horse, however, is old and very quiet--so that one can throw the reins on his neck and allow him to jog on for himself, then horseback riding may mean very little. Where the care of the animal is entirely taken off the rider's shoulders by a groom who brings him to a particular place and takes him afterwards, then, also, much of the benefit of horseback riding is lost. Care for other animals as well as the horse is of great service and especially is this true if the owners feel the duty of exercising the animals. Many a downhearted person finds that to take an animal out for a stroll will do much to lift the clouds of depression. With the disappearance of children from the families of the better-to-do classes, pet dogs have grown in favor mainly because of this influence. They awaken sympathies and so keep people from thinking too much about themselves, For many an elderly woman who is alone in the world her dogs or her {646} cats or a combination of both are the best possible remedies for depression. At times it will be found necessary to prescribe them. There is no better way to get an elderly person to go out at certain times than to have them feel that their pets need exercise. _Garden Cures_.--After animals the next best thing is the care of a garden. Here once more human sympathies with living things are aroused and it is easier to cultivate a forgetfulness of self while cultivating flowers and plants. Growing plants do not arouse the interest that growing animals do, but still they have advantages over things that do not vary, and their growth is a subject of day-to-day interest and the effect on them of vicissitudes of the weather arouses feelings of solicitude which help to dissipate the little insistent cares for self that depress. The care of a garden is the very best thing for the "pottering old." Younger people are too impatient to get much benefit out of a garden, but after middle life many an hour of depression will be saved in the care of plants. _Intellectual Occupations_.--It might be expected that intellectual occupations would serve to brush away "the blues" for educated people. They are perfectly capable of doing so, but they must be of the kind that grip attention and must be undertaken seriously, usually with an appeal quite apart from mere cultural interests. Hobbies of various kinds, especially the making of collections, even of such trivial things as stamps, will often serve the purpose of distraction from gloomier thoughts. Unfortunately, a hobby cannot be created all at once and usually does not take a strong enough hold to be available for mental therapeutic purposes unless it was acquired when the person was comparatively young and has been indulged in for many years. Reading and study utterly fail unless there is some end in view apart from the reading and study itself. The reading of novels and newspapers is particularly likely to be a failure. The gloomier thoughts obtrude themselves in the midst of the reading and very often what is read proves suggestive of melancholic thoughts and all the time the mind and the person are not occupied seriously enough to push away the state of depression which exists. The mind must be interested, not merely occupied superficially, or the depression will continue. It might be thought that the reading of books that concerned human suffering might have a similar appeal to that to be obtained from real touch with human suffering. This is true to a certain extent when the books concern real and not fictitious suffering. For this reason the trials and hardships of travelers at the North and South poles or in the heart of tropical Africa--Nansen and Peary and Stanley and Livingston--have all been excellent therapeutic agents. The stories of mountain climbers have something of the same effect. Adventures in Alaska and in the Far North, especially, come in the same category. Novels, however, even though they use the same material, soon fail to have a corresponding effect. Even when the novel does touch the emotions deeply it is prone to make the reader forget the suffering around him and does not prove a good diversion from his own feelings. In his play, "The Night Asylum," Maxim Gorky, the Russian novelist and playwright, brings this out very well. One of his characters, a young scrubwoman, wears her fingers to the bone during the day for a miserable pittance and sleeps in a squalid night lodging house, yet this comparatively young creature, {647} crouched near the only light in the room, sheds tears over the imaginary sufferings of the fictitious people that she reads about, while the real human suffering around her fails entirely to arouse her sympathy or affect her emotions, except to anger her if lodgers come in between her and the light or when the complaints made by some of those who are suffering around her annoy and distract her from her reading. In younger folks, study, provided there is some definite object to be attained by it, is often helpful. Correspondence schools are of value by setting a definite purpose before the mind. In a number of cases I have found that the suggestion to make translations from a foreign language when the patient knew that language even tolerably well, afforded excellent relief from that over-occupation with self which was the real cause of the depression. There are many people who know enough French to be able to translate fairly well and there are many articles and books a translation of which may at least be submitted to editors and often proves available for publication. To have some such end as this in view is of itself one of the best means that can be provided for these people to relieve their tendency to depression. Occasionally even the suggestion to write stories may prove helpful. One hesitates to add to the number of story-writers in this country, but it may be remembered as a last resort. I know at least two people saved from themselves by even a very moderate success as writers of short stories. _Consolation from History_.--Perhaps the most serious thing about depression is the feeling of those afflicted by it that they are singular in this respect and that other people who seem gay never have depressed states. There is probably no one who has not periods of depression. They may not be very deep and "the blues" may be only of a light tinge, but they are there. The higher the intelligence, as a rule, the more tendency there is to feelings of discouragement and depression at intervals when one is not occupied. Those who have the artistic temperament and the striving after the expression of the beautiful as they see it, whether it be in art or in letters or in the betterment of humanity, usually suffer more than others because they realize poignantly their failure to reach their ideals. This is well illustrated by the experience of writers and artists. As a rule, most men and women look forward to the completion of any intellectual work with confidence that after it is finished they will have a period of rest and peace. Commonly just the opposite is true. The completion of any work leaves one with a sense of dissatisfaction with what has been done, for no man of real intelligence ever thinks that he has so realized his ideals as to be satisfied, and only the foolishly conceited fail to feel the many defects that there are in their work. There is abundance of evidence, however, that it is not alone artists and writers who thus feel the hollowness of life and the tears there are in things. Many of the men who have accomplished great things in science and in politics have been prone to times of depression. Virchow told me there were moments when life seemed very empty to him and that he had to shake off feelings of depression in order to be able to go on with his work. At one time in the sixth decade of his life he suffered considerably from what we would now call neurasthenic symptoms, gave up his medical work and spent a long time with Schliemann in the Troad. His presence was valuable to the excavator in his work at Troy, and the change gave Virchow back his health. {648} Even more striking is what we know of Von Moltke, who seemed in many ways to have an ideally happy life. He had had the fulfillment of all his desires or, at least, the fruition of all his hopes, and the successful accomplishment of what he worked for beyond what is usually given to man. He had come to be one of the most highly respected men of Europe and was the subject of veneration on the part of his own German people and of intimate affection from his sovereign, who loaded him with honors. He was a man who had probably no enemies and many, many firm friends. It was said that "he could keep silence in eleven languages" and so he had avoided most of the pitfalls of life. His domestic life was ideally happy and his letters to his wife for over fifty years read like those of a lover, before all his great battles his last thought and written word was for her, after them his first thought and message was for her. In spite of this, towards the end of his life, when the question of reincarnation was a subject of discussion in Berlin and it was brought particularly to his attention, he declared that looking back on his career, in spite of all its good fortune, there seemed to him to be so many chances in life, so many possible sources of failure, so many springs of discouragement, that he would prefer not to have to live again. Surely, if anyone, he might be expected to be ready to take the chances of re-incarnation after such happy experiences of life, yet he was not. Such an expression could only come from a man who had looked depression often in the face, who had shaken off the blue devils and who knew that even the joy of success was followed by the gloom of uncertainty as to the future and solicitude as to the real significance of accomplishment. _Literature and Life_.--We have many examples of this tendency to depression that come to the literary man in the lives and letters of distinguished writers that have been published so frequently in recent years. Perhaps one of the most striking is to be found in the life of Robert Bulwer Lytton, the second Lord Lytton, so well known as a diplomatist in European circles and throughout the English-speaking world as a poet, under the pen name of "Owen Meredith." [Footnote 51] It might be thought that Lytton would be one of the men safely harbored from storms of depression and discouragement, for his life seemed ideally situated to enable him to get the best out of himself without worry or dissipation of energy in occupation with mere personal matters. His father had made a distinguished success as a literary man and a politician, had been raised to the peerage and the son began life with every possible advantage. He made a distinguished success in literature so that he even converted his father to praise him and as a diplomatist he occupied nearly every important post in English diplomacy and had hosts of friends all over the world. [Footnote 51: Personal and Literary Letters of Lord Lytton, edited by Lady Betty Balfour. New York, 1909.] It is all the more surprising, then, to have many passages in his letters refer to periodic attacks of depression. He says, for instance, "My physical temperament has a great tendency to beget blue devils and when those imps lay siege to my soul they recall those words of Schopenhauer's and say to me 'thou art the man.'" Perhaps the price that the artistic temperament pays for the satisfaction that it gets out of life in other directions is this occasional tendency {649} to depression because achievement does not equal aspiration. Certainly the price often seems excessive to those who have to pay it. In the same letter to his daughter, Lytton continues: When my blue devils are cast out, and I recover sanity of spirits, then I say to myself just what you say to me in your letter--that the main thing is not to do but to be; that the work of a man is rather in what he is than in what he does; that one may be a very fine poet yet a very poor creature; that my life has at least been a very full one, rich in varied experiences, touching the world at many points; that had I devoted it exclusively to the cultivation of one gift, though that the best, I might have become a poet as great at least as any of my contemporaries, but that this is by no means certain to me for my natural inclination to, and unfitness for, all the practical side of life are so great that I might just as likely have lapsed into a mere dreamer; that the discipline of active life and forced contact with the world has been specially good for me, perhaps providential, and that what I have gained from it as a man may be more than compensation for whatever I may have lost by it as an artist. It is surprising to think of a man of this kind becoming so depressed by the death of a son that all the world and the meaning of life took on a somber hue for him. In 1871 Lord Lytton lost a young boy by a very painful illness which had probably been more painful for sympathetic onlookers than for the patient himself. The incident proved sufficient, however, to make the father think that there could not be a beneficent Providence ruling over the world. He felt sure that somehow God's power must be shortened, if such suffering, for which he could see no reason, had to be permitted. He was much depressed after this and never was quite the same in his outlook upon the world and the significance of life. It was easy to understand that this was due rather to his character than his intellect, but it illustrates forcibly how much a deeply intelligent man may be affected by something that seems after all, only the course of nature. It is sometimes surprising to find from the life stories of men how often those who would be thought least likely to suffer from periodical depression were victims of it. Few Americans in our time have apparently had a more satisfying career than that of James Russell Lowell, a successful author as a young man, then a successful editor, a teacher whom his students appreciated very much, and in later life the subject of many honors and such honors as provided him with splendid opportunities for the exhibition of his special genius. He would seem to be the last who should suffer from depression. His post as Minister to Spain gave him an opportunity which he took magnificently to study the great Spanish authors and to store up material for writing about them. As Minister to England few men were so popular. He was constantly in demand for occasional addresses and his special style enabled him to respond to these demands with brilliant success. Here in America no great occasion was complete without Lowell. In spite of all this that would surely seem ample to satisfy the aspirations of any man, Lowell was often depressed and sometimes even talked about the possibility of suicide. Life seemed at times very empty to him. The story of the lives of such men, if made familiar to patients, proves a source of consolation, for it makes them realize that they are not alone in their experiences, that depression at some times is the lot of man, and that very few people are without the sphere of its influence. {650} Depression an Incident, not a State.--This suggestion may, in the case of some of those inclined to longer periods of depression, lead to indulgence in the luxury of being depressed and so putting off the doing of things. It must be pointed out, however, that just inasmuch as depression has this effect it is pathological. It seems to be natural to man to suffer from periods of discouragement and depression which keep him from devoting himself too persistently to lines of work that may be insignificant and make him take cognizance of the real values of what he is doing. Depression, however, that continues after the recognition of this takes place is morbid and must be actively resisted. Just inasmuch as depression precedes and prepares patients for a reaction, it is an incident in practically all lives. Indulged in as a luxury, it is abnormal. Suggestive Treatment--The most important thing for patients who suffer from periodic depression is to make them understand that this state of mind, far from being personal to them or very rare, or even uncommon, is an extremely frequent experience of men and women. There are certain men and a few women eminently occupied with the external life, busy with many things, though often they are trivial enough, and even when they are important, significant only in a financial or a social way, but meaning nothing for the great realities of life, who seem during their younger active years to escape the periodical attacks of depression that come to most people and come almost without exception to people who think seriously. Some of the best thoughts and inspirations of men come to them as the result of the serious mood that follows an attack of depression. A butterfly existence lacks these sources of inspiration. Far from being objectionable then, attacks of depression, if not allowed to proceed too far, and if kept from paralyzing activity, prove to be intervals when life values are seriously weighed and when a proper estimation of such values is come to. Men are prone without such interruptions to get too interested in trivial concerns that seem to them important because they are occupied with them to the exclusion of other ideas, but that prove to be of no real import when seen on the background of a certain hollowness that there is in human life, if lived merely for its own sake. The occurrence of periodical depression is a part of the mystery of life and it affords us a better opportunity to get a little closer to the heart of the mystery than almost anything else. It is out of such periods that men have risen "on stepping-stones of their dead selves to higher things" and have even risen to the highest that there is in life. Geniuses have nearly always had deep periods of depression, but in the midst of them have read new meanings into life and have read the lessons of humanity in their own souls better than at any other time. Depression throws a man back on himself and makes him think deeper than in his mind--in what has been called his heart. "The fascination of trifles obscures the good things in life" are words of old-time wisdom and men are weaned from this by fits of depression that are really moods of precious dissatisfaction with their work inasmuch as it falls short of the best accomplishment. Without periodic depression, apparently, a man never gets as close to the heart of life as he otherwise would. Far from being an unwelcome visitant, it should be rather welcome as a stimulus to the possibility of further study of self and the realities of life. {651} CHAPTER VII INSOMNIA To the minds of many people insomnia is one of the most serious ills to which human nature is heir. Most of this quite false impression is due to the sensational cultivation of dreads with regard to insomnia by newspapers and in general conversation. If we were to credit such impressions, there is a certain number of unfortunates who, for some unknown reason, find it impossible to sleep and who, night after night, drag out the weary hours wooing sleep that does not come, until when daylight dawns they are in despair, distracted by lack of rest. This is presumed to occur night after night, until finally the worn-out mind succumbs to the intolerable anguish of being kept constantly on the rack of wakefulness and the patient becomes insane or saves himself from that by suicide. No wonder, then, that many a one of these patients takes to the use of habit-forming drugs to produce sleep. These, though effective only to a small degree, soothe him for the time, but finally render him such a wreck that there is not even will power enough for him to take his own life and end his intolerable suffering. Such gruesome pictures of the awful effects of insomnia run rife and produce dreads in the community until just as soon as the ordinary nervous supersensitive person loses an hour or two of sleep two or three nights in a month, he begins to conjure up the specter of insomnia with its awful terrors and still more awful possibilities, and begins to bewail the fate that has chosen him as an unfortunate victim. This exaggerated dread that slight losses of sleep, for which there are often excellent reasons, will develop into an incurable condition of persistent wakefulness has more to do than any other single factor with the production of the state called insomnia which is, however, never half as bad as it is pictured. Absolute Sleeplessness.--A certain number of patients insist that they sleep very little at night and some tell their friends and even their physicians quite ingenuously that they sleep none at all, and that this has been the case with them for a prolonged period. Practically every physician has heard such stories, and at the beginning of his professional career has usually wondered how the patients continued to live and enjoy reasonably good health in spite of the lack of absolutely necessary brain cell rest. After the physician has the opportunity to investigate some of these stories he understands them better. Patients in hospital, who insist that they are wakeful all the night, prove usually when faithfully watched by a nurse to be wakeful for an hour or two at the beginning of the night and then to sleep for hours at a time, and all of them sleep for intervals more or less prolonged, though they may wake a number of times during the night and may think that they have not been asleep because they hear the clock regularly or some other recurring noise. It is improbable that patients ever spend several nights in succession without sleep and their story is only an index of the persuasion that they are under that they do not sleep, though they are having so many thoroughly restful intervals that their brain cells suffer but little from {652} the need of sleep. _Indeed, the principle source of nervous wear and tear for them consists in their persuasion that they do not sleep and the resultant impelling suggestion that a breakdown must before long be inevitable._ Individual Differences.--There are too many safeguards in nature's ordinary dealings with human beings for us to think that people can pass many nights absolutely without rest. Brain cells may apparently be very wakeful, they may be quite ready to take up at once and seemingly without a break trains of thought interrupted sometime before, yet somehow they succeed in obtaining their needed rest. In this matter, as is well known, though it needs to be emphasized again for the benefit of nervous individuals, different people have very different needs. Some require many continuous hours of sleep or they soon begin to have symptoms of nervous exhaustion. Others live on only with snatches of sleep at intervals, or with interrupted sleep during a limited portion of the twenty-four hours, yet enjoy good health for many years. A few seem to be able to live in health and strength with but a few hours of sleep. It may possibly be thought that those who are living their lives with a small amount of sleep are drawing drafts on their future vital powers, and that what they make up in intensity of activity now by shortening sleep, they will discount by shortness of life. How utterly untrue this impression is, however, will be best understood from the fact that many of the men who have worked hardest and slept the least number of hours in the day, have lived to be eighty or even ninety years of age and some of them have even been centenarians. Cell Rest.--The great differences in the brain cells of different individuals in what concerns sleep becomes more readily intelligible when we recall the extreme differences as regards the need of rest of the various cells in the same individual. While the brain cells seem to require for healthy life, as a rule, nearly one-third of the time, and a man who is constantly taking much less than eight hours of sleep is probably hindering rather than helping his productiveness, especially if his work is intellectual, there are cells in the body that need no such amount of rest as this. Peristaltic movements occur in the digestive tract almost constantly, with only short intervals, and these cells get their rest between their movements. Pulmonary cells and tissues must do the same thing, and are able to do it without any special strain being put on them. The extreme example of the lack of need for prolonged rest is found in the heart. Two-fifths of every second the cells of this organ have a rest during the diastole, but during the remaining three-fifths of every second for all of life they must not only be ready to work but actually engaged in it or serious symptoms ensue. The cells in the brain that subtend cardiac and respiratory activity must be even more able to do without rest, since their action is ceaseless during life. By analogy with these it is not difficult to understand that the brain cells which are involved in consciousness should on occasion be able to stand prolonged periods of activity, or at least of wakefulness. Persistent wakefulness does not appeal to us as so surely destructive after this consideration. Solicitude Over Sleep.--For those who are much disturbed by the loss of even slight amounts of sleep and who are prone to complain rather bitterly if they are not able to get more than five or six hours a night, I find it a useful preliminary to any more formal treatment of their so-called insomnia {653} to recall the examples of some of the great workers who succeeded in accomplishing marvelously good work though they took much less sleep than the amount the patient secures, yet seems to think inadequate. In spite of such lack of sleep, these workers lived to advanced old age. There are many well-authenticated illustrations of this in recent times. Perhaps the most striking testimony to the power of the human mind to continue work without requiring the refreshment of sleep, except for very short periods, is that of Humboldt, the great traveller, scientist writer and diplomat. Max Müller, in his autobiography tells the story. It was when he himself was about forty. Humboldt said to him: "Ah! Max, when I was your age I had time to accomplish something, now I find that I must take at least five hours of sleep every night." At the moment Humboldt was over eighty. Müller said to him: "But, Your Excellency, how much sleep, then, did you take when you were my age?" "Oh!" he said, "I used to turn the light down, throw myself on the lounge for a couple of hours, and then get up and go on with my work again." Humboldt, after a life full of the hardest kind of work of many kinds, lived well past ninety in the full vigor of his intellectual powers. There are many other examples that might readily be quoted. The traditions of the University of Berlin contain many illustrations of men who did very little sleeping, yet succeeded in accomplishing an immense amount of work and lived far beyond the Psalmist's limit. Virchow, whom I knew very well, did not take more than four or five hours of sleep on most nights in the year. He would be in the Lower House of the Prussian Legislature, which, like the House of Commons, holds its meetings late at night, until one A. M. or later and would be at his laboratory shortly after seven. There was a tradition at the University of Berlin in my time there of one of the older professors in the theological department who went to bed only every alternate night. He had a forty-eight-hour day for work with a seven-hour break. He lived to the age of eighty-five. I know one of our most distinguished workers in medicine here in America who was so busy and so tired at the end of his day that he could not write his book. He would fall asleep on his chair at his desk to wake up only when the milkman came in the morning. He had constructed for himself a special stool without back or sides, shaped like a bench, so that whenever he fell asleep on it he fell off. The fall would wake him up and he would then go on with his work for some hours. He did this sort of thing for many years, and yet he is alive and in the full possession of intellectual health at the age of eighty-three. He learned this expedient from a German professor of medicine who told him of it and at the same time told him that it was no uncommon practice among German professors. Indeed, most of the famous long-livers of the nineteenth century were also well known for the small amount of sleep they required, and apparently there is no need of being anxious lest loss of sleep should prove serious, unless one is adding to whatever detriment to health it may be by worrying about it find so setting two damaging factors at work. TREATMENT Probably the most important immediate assurance that can be given to those who come complaining of insomnia is that practically no one has ever {654} been seriously hurt by the wakefulness called insomnia. Patients suffering from brain tumors, from serious disturbance's of cerebral circulation that give objective signs, from various organic diseases, as of the heart or liver, or certain constitutional diseases, have been made worse by the wakefulness induced by their affections. In the cases where there were no definite objective signs and wakefulness was the only symptom we have no cases on record of serious injury resulting. Men have come complaining of wakefulness for days or weeks and sometimes, though it is strange to understand it, for months or even years, and yet have lived their lives without serious developments and have neither gone into insanity nor into any premature loss of vitality, much less a fatal termination. It is not subjective symptoms but objective signs that are of value for the diagnosis of the serious organic conditions. This reassurance lifts a load from patients' minds at once and does more than anything else to relieve them of the burden of solicitude which is the main factor in the continuance of their insomnia. Suggestive Treatment.--The psychotherapy of sleep consists in changing the patient's attitude of mind toward his sleep. It is quite impossible for him to sleep normally and regularly if he worries much about it and if the afternoon and evening hours are mainly spent in wondering whether he will sleep, anxious as to when he is going to sleep like other people, marvelling how long he will last in health and sanity if his tendency to wakefulness continues. There is no factor so strong in insomnia as getting one's self on one's mind. It weighs as an intolerable burden, an incubus that is sure to keep its subject awake. Insomnia is a mental and not a physical ailment in much more than nine out of every ten cases. It is not the brain but the mind that is at fault. Patients must be made to realize that if they go quietly to bed, confident that if they do not sleep the early part of the night they will sleep later, and that in case they should lose considerable sleep, so long as they lie quietly for eight hours in bed, their physical organism is not likely to come to any serious trouble. They must be quiet, peaceful and unworried. They must not begin to toss at the first sign of not going promptly to sleep for by so doing they may put off completely the possibility of falling to sleep. Finally they must prepare for sleep by passing a quiet evening, as a rule, occupied with diversions of various kinds. There are many factors which inhibit sleep that must be removed or at least obviated. These are very different in different individuals and the suggestion of getting them out of the way helps a great deal in making people realize that they are better prepared for sleep than before. They have been keeping themselves awake by contrary unfavorable suggestions. They must be taught to aid themselves in going to sleep by a series of favorable suggestions attached to the doing of certain things that are helpful and, above all, avoiding acts of various kinds that have an unfavorable suggestive influence. In this way an accumulation of suggestions can be secured that will prove helpful. Drugs.--Of course, patients must be warned with regard to the taking of drugs. Certain drugs may be taken for an occasional loss of a night's sleep, where the loss of sleep is regular and frequent, however, drugs are sure to do more harm than good. Opium leads to a serious habit, chloral is dangerous because it must be increased, most of the coal-tar somnifacients produce {655} serious after results and their physical effect is in the end probably more deleterious than would be the loss of the sleep which they are supposed to counteract. This is true for even the vauntedly least harmful of them, and it is important to make patients understand it. External Conditions to be Inhibited.--In the treatment of insomnia two sets of inhibitory conditions are particularly to be looked to, those external to the patient, and those internal. Unless every possible obstacle is removed there can be no assurance of the relief of sleeplessness, while very often the careful regulation of a few conditions that are disturbing the patient will bring sleep fully and promptly. It is curious what small annoyances will sometimes prove disturbing. _No Pillow_.--I have found patients who had heard somewhere the idea that it was natural for man to sleep without a pillow. The pillow in this theory was supposed to be an added refinement of men in a state of luxury, but a real degeneration opposed to nature, and the many presumed benefits of sleeping on a perfectly level mattress with the head no higher than the rest of the body was emphasized. While in ordinary health these patients had found that after the preliminary discomfort of getting used to sleeping without a pillow, they were apparently the better for it. People will feel better for almost anything if they are only persuaded that they ought to. After a certain length of time, however, worry or work had a tendency to keep them more or less wakeful and then insomnia came on, that is, for several hours at the beginning of the night they did not go to sleep and became very much worried about it. In several of these cases I have found one of the most helpful adjuncts to more direct treatment of their wakefulness was the restoration of the pillow. Just how the hygienic theory of pillowless sleep originated, or on what it is supposed to be founded, I do not know. The only theory of sleep that seems to have many adherents at present is that it is due to brain anemia. With the head a little higher than the rest of the body the force of gravity tends to help in the production of this brain anemia. The experience of mankind seems to confirm this. Certainly, from the earliest records of history men have slept with something under their head, even though they could find nothing better than a log or a stone. To sleep without a pillow is, owing to the conformation of the head and neck and shoulders, almost inevitably to sleep mainly on the back. From the anatomical relations of the internal organs it is easy to understand that sleeping on the side is more comfortable and healthy than sleeping on the back and hence most people naturally take this position. Relaxation is much more complete and comfort is greater. What the majority of men do is almost surely dictated by instinct, and instinct is the most precious guide we have in the natural functions of life. We are not so differently formed from the animals that the analogy from their habits should not have some weight for us. Patients should then be advised always to sleep with a reasonably firm pillow, not too low, so that the head is a little higher than the body and the lateral position perfectly comfortable. _Too high Pillow_.--There is an abuse in the other direction of too high a pillow that deserves to be noted. Occasionally the physician hears complaints of waking up with tired feelings in the large muscles of the back of the neck near their insertion into the occiput. This is sometimes complained of {656} as an occipital headache. Not infrequently it will be found that these people are sleeping on pillows that are too large, or that they pile up several of them. Most physicians have found in their experience that having the head quite a little higher than the rest of the body materially aided sleep, especially in elderly people. This is true even when there is no distinct heart lesion, but this favorable position is best secured not by means of one or more high pillows, but by raising the head of the bed, or by the insertion of bolsters beneath the mattress, so that there is a gentle slope upward from the hips to the head. High pillows should, as a rule, be discouraged, especially in young folks where the assumption of the strained positions which they cause, may encourage various deformities in the anatomy of the head and shoulders so that stoop shoulders or a craned neck result. On the other hand, before attempting to give drugs to elderly people, the arrangement of the mattress so as to put the head a foot, or even more, higher than the body should be tried and will often be found to give relief where other things fail. _Discomfort Due to Cold_.--In order to sleep well patients must be thoroughly comfortable in bed. In recent years as the very hygienic practice of having a window in the sleeping apartment open has become a rule among intelligent people, sleeping rooms have been much colder than they used to be. Care must be taken lest the active factor in causing wakefulness should be cold. Over and over again I have found that patients who complain of wakefulness, in the latter part of the night particularly, that is, in the early morning, were awakened by the increasing cold because they were insufficiently clothed. Whenever the sleeping room becomes very cold, then, the patient should not sleep between cotton or linen sheets which are likely to induce sensations of chilliness, but in a light woolen nightgown. It is curious what a difference in the patient's feelings is produced by the touch of wool to the skin in cold weather as compared with cotton. Thin, anemic patients are especially likely to suffer from chilliness. It must not be forgotten, however, that some stout people, in spite of an accumulation of fat, are really anemic. Their red blood corpuscles and hemoglobin are distinctly below normal. These constitute some of that large class of stout women in whom reduction cures fail because of the anemic tendency. They must be as carefully protected from cold as thinner persons, yet they need fresh air for their comfort and health almost as much as tuberculosis patients. The experience of sanatoria in the Adirondacks and at altitudes generally shows that for quiet, undisturbed sleep, if the room becomes distinctly cold during the night because of an open window, a hood or night-cap and gloves, as well as the wearing of woolen underclothing, even to stockings, is almost indispensable. In older times, when houses were not well heated, many persons very sensibly wore night caps. Now that a return to cold fresh air in the sleeping room has come many will have to resume the old night-cap habit in spite of cosmetic objections to it. These may seem little things, but they count very much in relieving disturbed sleep. The curious thing about them is that patients themselves seldom realize that certain common-sense regulations are more important for sleep than formal remedies. They want to be "cured" of their insomnia, not relieved by suggestion. _Cold Feet_.--A large number of people have their sleep at the beginning of the night seriously disturbed by cold feet. Some cannot get to sleep for {657} an hour or more, because their feet are cold. If the patients become worried over this loss of sleep, a real insomnia may develop. It is for these people that the old-fashioned warming-pan was invented and it should not be forgotten that the symptom can be relieved very promptly by means of a hot-water bag or a hot brick wrapped in flannel at the foot of the bed. An excellent practice for very sensitive persons, is to have the sheets warmed thoroughly for a couple of hours before bedtime. This is especially important in damp weather. The distinguished English surgeon. Sir Henry Thompson, who lived well beyond eighty years of age (when surely he would seem to have some right to do so), wrote a little book on how to be well and grow old and describes a habit which he had acquired and that I have often recommended to patients and friends as well as used myself with advantage when there is a tendency to cold feet, either habitually or occasionally. It is, moreover, useful whenever there is a tendency to insomnia because some exciting occupation has preceded going to bed. Before retiring Sir Henry used to sit beside his bath tub and let the hot water flow into it over his feet, gradually becoming warmer and warmer, until he could no longer stand the heat. A temperature well above 120 degrees may be borne with comfort after a while, though at the beginning it would seem entirely too hot. The feet are kept in the hot water at least five minutes. When taken out they should be thoroughly red and show evidence of a good deal of blood having been attracted to them. If they are now carefully wiped and rubbed vigorously there will usually be no further tendency to cold feet that night and sleep will come naturally. Sir Henry said that when he had been out at meetings where he had to make an address or had to take part in business of any kind that inclined to make him wakeful, he found this an excellent method of preparing himself for immediate sleep. It must not be forgotten that the worst forms of cold feet are found among those suffering from flatfoot. The dropping of the arch interferes with the return circulation and also with lymphatic circulation. These individuals feel very tired because of their foot condition, yet their cold feet often disturbs their sleep at the beginning of the night. The only effective relief for this is afforded by proper treatment of the feet. (See the chapter on Foot Troubles.) _Lack of Air_.--On the other hand, occasionally it happens in spite of all that has been said in recent years about fresh air in sleeping rooms, windows are hermetically sealed and even then people cover themselves with many thicknesses of bed clothing and are too warm. I have found over and over again that where people could not be persuaded to leave a window open all night (and when they are old and deeply prejudiced in the matter I do not insist, for the suggestion of possibly catching cold would almost surely keep them awake), the thorough airing of rooms before retiring made a great difference in the sleep of elderly people. When patients are young, I simply insist on the window being wide open for some time before they go to bed and slightly during the night, except in extreme cold weather. Many a patient who complains of waking several times during the night and being awake for some time on each occasion will begin to have longer periods of sleep without a break if such a change in the ventilation of the room is effected. {658} Anyone who has seen fever patients who had been restless, disturbed and wakeful, sink into a quiet slumber after the room has been thoroughly aired and the temperature of it reduced ten or fifteen degrees, will realize how helpful this same method of treatment will be in nervous, wakeful irritability. How important air is for the obtaining of the power to sleep for many hours every day can be best understood and appreciated from the habits insisted on for patients in tuberculosis sanatoria as a result of experience. When there is any tendency to a rise in temperature in these patients they are kept absolutely without exercise. They are either in bed or on a lounging chair all day, but they are out in the air or at least close to an open window. As a rule, they sleep some in the morning and then they sleep again in the afternoon. This would ordinarily be fatal to sleep at night in even healthy people taking considerable exercise and therefore presumably tired and more likely to sleep than these patients who had made no exertion during the twenty-four hours; but it is not often, after patients have been for ten days or two weeks at the sanatorium, that there is any complaint of lack of sleep at night. This is true in spite of the fact that patients are often wakened by coughing during the night, yet after a comparatively short interval they go to sleep again and sleep until morning. This is not true when patients do not pass most of their time in the open air and when their rooms are not well aired. Sleep at Sea.--I know nothing that is more effective in doing away with insomnia than a sea voyage. The passengers sit on their lounging chairs all the morning in the open air, usually sleeping for some time, often for several hours. During the afternoon this is repeated. In spite of this extra sleep they turn in, not long after ten, and sleep well until morning. There is practically no exercise and the air usually excites such an appetite that five and even six meals a day are consumed. There is no disturbance of digestion unless some special excess is indulged in, and, above all, sleep is rather favored than impaired by the large amount of food taken. This experience which is so common, is very valuable as indicating just what is the best pre-requisite for sleep. It is not exercise and tiredness to such a degree that one fairly drops from fatigue, but such an oxidation of all tissues by the breathing of pure air that there are no toxic waste products left in the system to act as excitants for disturbance of sleep. Cold Water.--In summer, when wakefulness is due to heat, a cool bath, or at least a rub down with cold water and going to bed without drying is an excellent method of inviting sleep. Under these circumstances the sheet acts as a soothing cool pack and people who have been wakeful for hours before, or at least have found considerable difficulty in getting to sleep, sleep promptly. The mechanism of sleep-production is easy to understand. There is less blood to go to the brain when the little capillaries at the surface are pretty well extended and after the application of cool water the reaction which follows the closing of the capillaries in response to cold leaves them of sufficient size to accommodate a large amount of the blood of the body. Of course, in both cases there is the suggestive value of a proceeding of this kind so well calculated to predispose the patient's mind to go to sleep without solicitude. {659} Diet.--As has already been outlined in the hints that precede, the first thing in the treatment of insomnia is to remove any causes that may be at work in producing wakefulness. Among the most common of these in our modern life is the taking of coffee or tea, important in the order mentioned. Every physician has frequent experiences of people who complain of insomnia, yet who take a cup of coffee late at night. A large proportion of humanity cannot do this with impunity and expect to go to sleep promptly. Occasionally one finds that patients complaining of sleeplessness are taking three to five cups of coffee a day. This must be stopped. A physician may be told by such patients that they cannot get along without their coffee. I have only one answer for this and it is meant to show patients that if they want to sleep they must take the means to secure it and, above all, must remove all disturbing factors. I tell them that if they cannot do without coffee they may continue to do without sleep. If they want to sleep they must give up coffee or at least must limit the amount. I have found it comparatively easy to get people to limit coffee-taking by the suggestion that there should be one tablespoonful of strong coffee taken to a cup of hot milk. This gives the taste, or rather the aroma of coffee, for coffee has properly no taste to speak of, and while, at first, patients crave the stimulation they have been accustomed to, it takes but a few days to overcome this craving entirely. Usually it is easy to get people to confess that they are taking too much coffee. For some reason not easy to understand it is harder to get them to acknowledge that they are taking too much tea. Coffee is taken with a certain amount of deliberation. Tea may be and often is taken at odd intervals for friendliness' sake and sometimes patients do not know how much they are taking. Six or seven cups a day may be their usual quota, yet they do not realize it and at first are inclined to answer that they take it only two or three times a day, forgetting the little potations between meals. Tea is not so prone to cause wakefulness as coffee, yet the toxic irritant principle in both is the same and when the amount of tea and its strength are sufficient, the same results follow. The tea habit must always be given up if there is complaint of lack of sleep, especially early in the night. There is a very common persuasion that the eating of food in any quantity shortly before going to bed, and especially the eating of certain materials, will keep people awake. It is well known, however, that there are a great many people who can eat anything and sleep well after it and young children sleep best when their stomachs are full. There are undoubtedly idiosyncrasies in this matter that must be respected, but many patients are deceiving themselves. They are eating too little and their wakefulness is more due to the mental state than to anything else. As this contradicts a very prevalent impression, I may say that it is said deliberately and only after much experience with people inclined to be over-solicitous about their diet and their health generally and who were actually producing wakefulness or at least very light dreamful sleep, by their elimination from their diet, and especially from their evening meal, of many nutritious substances. I make it a rule to insist with patients that if it is more than five hours since their last meal they must take a glass of milk and some crackers or a cup of cocoa and something to eat before going to bed. This is particularly important if they have been out in the air much between their last meal and bedtime. {660} The Evening Hours.--The use of the hours after the evening meal is an extremely important factor with regard to insomnia. If the patient tries to read the paper or some conventionally interesting magazine or book, thoughts of the possibility of his not sleeping will surely obtrude themselves and he will fail to get to sleep when he lies down. As a matter of fact, he will have so disturbed himself as to predispose to insomnia. Some quiet occupation, interesting yet not too interesting, that diverts the mind from the thoughts about itself and about sleep possibilities, yet does not excite it, is the best possible auxiliary and preparation for sleep. Prof. Oppenheim has, as usual, said this very well in his "Letters to Nervous Patients," to which we have turned so often: A great deal depends upon the right use of the evening hours. On no account let yourself occupy them with anxious forebodings about the night. But, on the other hand. It is not at present wise to take up your mind with too exciting thoughts, as the strong after-impression of feeling and fancy may counteract the tendency to sleep. You must find out for yourself whether a quiet game (cards, halma, chess, or patience), the reading of a serious or an amusing book, the perusal of an illustrated paper, or a chat with a friend will be most certain to give you that tranquillity of mind through the vestibule of which you will pass into the temple of sleep. Direct Sleep Suggestions.--Many plans are suggested by which people are supposed to be able to get to sleep. A favorite and very old suggestion is that of counting sheep go over a fence or something of that kind that is merely mechanical, yet takes the mind from other thoughts. As a rule, any plan involving mental occupation that is meant to produce sleep is likely to react and do harm rather than good. Sleep must not be wooed deliberately but must be allowed to come of its own sweet will. It is extremely important that exciting thoughts and bothering interests be put aside, not at the moment when we want to go to sleep, but some considerable time before. This is not always an easy matter and often requires careful planning. It is worth while doing it, however, in order to secure sleep promptly and not allow a prolonged period to pass while one is lying awake, for if nervous irritability ensues wakefulness is still further prolonged and the patient may begin to toss and so disarrange the bedclothing and disturb himself as to prepare for several hours of sleeplessness which would not have occurred if there had been an appropriate interval given to preparing the mind for sleep. Diminishing Solicitude.--Patients must not be too anxious for sleep. If they worry themselves over the possibility of not sleeping then they will almost surely disturb their sleep, or at least delay its coming. The ideal state of mind is not to bother one's head about it, to lie down habitually at a given hour, compose one's self to sleep with assurance and then wait its coming without solicitude. Many people will say this is not easy to do, but habit makes it easy. Most of our animal life is lived by habit. We are hungry at certain times by habit. Our bowels move at a particular time by habit. We can sleep by habit. If we try to use our intellect solicitously with regard to any of these habitual functions we do much more harm than good. The more anxiety there is about sleep the more likely it is to be disturbed. When the habit of sleep at a particular hour has been broken the best way to regain it is to lie down at that particular hour and then wait patiently for {661} the advent of sleep. If impatience gets the better of us sleep is kept off and will not come for hours. If the patient can lie down feeling "Well, if I do not sleep now I will to-morrow morning" then there is usually little difficulty about sleep. _Dread of Consequences_.--Many people who suffer from insomnia fear that their loss of sleep will injure their intellectual capacity or make them prematurely aged, or drain their vitality so that they will not have health and strength of mind and body when they grow old. This adds to their solicitude about themselves and inveterates their condition. There is only one answer to this dread, which has no foundation in what we know of actualities, and that is, to tell them the experience of certain persons which absolutely contradicts such a notion. One distinguished physician who, at the age of seventy-five, is writing books that are attracting widespread attention and is doing an amount of work that many a younger man might envy, has told me of all that he suffered from insomnia between the ages of thirty and fifty-five. His mental productivity was much hampered at that time by his wakefulness and anxiety with regard to it. He feared the worst as regards advancing years, yet he is in the full possession of mental and bodily strength well beyond the Psalmist's limit. His is not an exceptional case, for there are many others in my own personal knowledge. Virchow once told me of years when he suffered from insomnia, yet he lived to be well past eighty and then died, not from natural causes, but from an injury. A man who accomplished an immense amount of work in his day in the organization of a great university suffered from insomnia in his younger years to such a degree that his friends and even he himself feared for his mental stability, eventually overcame this symptom completely and went on to years of great active work, dying in the end, not from his head, but his heart. We have records of a number of such cases. Few of the hard students of the world went through life without having some bother from insomnia. It is well-known, however, that many of the great thinkers, investigators and discoverers in philosophy and in science have lived long lives well beyond the age of the generality of mankind. Mental Diversion.--The main thing is to banish the thoughts of one's ordinary occupation as far as that can be accomplished without laboring so intently at this as to give the mind another bothersome occupation. Many people find that a game of cards just before going to bed takes their thoughts off business and worry almost better than anything else. Something like this is needed in many people. Most people must not write for some time before retiring, because writing proves so absorbing an occupation, as a rule, that the mind becomes thoroughly awake and then remains so for some time afterwards. Reading is better, but the reading must be chosen with proper care. An exciting story, for instance, may serve to keep one awake for hours, as everyone knows who has tried and found himself still reading at three in the morning after having begun an interesting book. The reading of works of general information, of travels, of description of places, where it is comparatively easy to stop at any place, of short stories which do not hold the interest beyond a brief period, is much better. Osler's recommendation to have a classic author beside one's bed to be read for a few minutes every night after retiring as a preparation for sleep is an excellent remedy for the milder forms of insomnia, as well as a stepping-stone to scholarship. {662} William Black in one of his books has a description of an old man who had suffered from insomnia very severely until he discovered a plan of his own to enable him to get to sleep. This consisted in reading the Encyclopedia Britannica. He began at the beginning and read straight ahead, article after article, and volume after volume. He never even by any chance departed from this routine either to look up cross references, or read anything further about men who were mentioned in the article he was going through at the moment and whose names occurred in another volume. He read straight on until his eyes got heavy and then he went to sleep. At the time he was introduced into the story he had already read the whole work through twice and was, I think, at "D" on the third reading. He had had considerable bother about getting to sleep before he adopted this plan, but it proved an always efficient somnifacients. There is a story about an old American farmer who said that he read the dictionary over and over again for the same purpose. The stories were short and disconnected, but they never bothered his sleep, while his wife and daughters were sometimes kept up more than he thought was good for them by their interest in the story paper. Treatment of Early Morning Wakefulness.--With regard to the disturbance of sleep in the early morning hours there are certain instructions to patients that have always seemed to me extremely important. Most of the patients who complain of wakefulness in the early morning hours are really suffering from hunger at that time. This is especially true with regard to those who stay up rather late at night. They have their last regular meal about seven or a little earlier, they get to bed at eleven or even later, and some of them, following the old maxim that eating before sleep is likely to disturb it, go to bed on an empty stomach. Whenever more than four hours have passed since the last meal the stomach is quite empty, and after the preliminary fatigue has worn off and the sleep has become lighter and the lack of nourishment more pronounced a vague sense of discomfort in the abdominal region wakes them, though most of them do not realize that they are disturbed by a craving for food. In a large number of these cases I have found that the recommendation of a glass of milk and some crackers, or some simple cake, just before retiring does more than anything else to lengthen sleep and prevent what has been learnedly called matutinal vigilance. After emptiness of the digestive tract, the most prominent cause of wakefulness in the early morning is anxiety about the hour of rising or about some engagement that has to be kept in the early morning. I have known patients who worked themselves up so much thinking over the necessity for rising at a particular hour to catch a train, that they were awake for several hours before they needed to be. Some are much more inclined to this over-anxiety than others. If they move to the country where trains have to be caught regularly, their sleep may be seriously disturbed by this circumstance. If the trouble becomes acute they must simply change their residence. If it is absolutely necessary that they stay, then they must have someone to wake them at a definite time. This must be someone on whom they can absolutely depend, otherwise the old solicitude will reassert itself. This seems a small matter, yet I have known serious cases of neurasthenia with annoying digestive symptoms due to nothing else than this morning wakefulness consequent upon overanxiety with regard to trains and other morning engagements. {663} Habits.--In the correction of troubles of sleep one of the difficulties that the physician has to contend with when patients have grown accustomed to staying up late and finally have so disturbed their sleep mechanism that symptoms of insomnia develop, is the declaration that there is no use for them going to bed early since they cannot sleep. If a man has been accustomed for a long period to go to bed between midnight and 2 a. m. and his habits are suddenly changed so that he goes to bed at ten or even eleven, it is very likely that for some time after retiring he will not sleep. If he grows over-anxious he may toss and become somewhat feverish and then, even when the accustomed time for sleep comes, he may not secure it. Besides, the depression consequent upon failure to sleep when he has fulfilled his physician's directions and when he knows that this is considered an important adjuvant in his treatment, acts as a distinctly discouraging factor. Under these circumstances it is important to recall to him that one habit can only be removed by the making of another. It may be necessary to send him to bed for awhile only an hour earlier than before until he has grown accustomed to going to sleep somewhat sooner, and then this habit, in turn, be changed to an earlier hour so as to secure all the sleep that is necessary. In a word, insomnia is not a definite affection to be treated by giving one or the other of one's favorite drugs, or if these should fail trying still others, but it is a condition of mind very often predisposed to by certain conditions of body. If this condition of mind can be adjusted by careful attention to the correction of whatever may be physically out of order, then there is every reason to look for definite improvement very soon and complete cure without any delay. Insomnia is not the awful ailment that it is sometimes pictured, nor all that it appears to the excited imagination of the young person who loses a few hours' sleep; but a manifold condition to be dealt with very differently in different individuals, according to the indications of the case. If the patient's confidence can be secured that means more than almost anything else that can be done. If a little patience is exercised in obtaining such definite details of the mental state and of certain physical factors as may seem quite trivial to the patient yet are really predisposing elements for his affection, the therapeutics become comparatively simple. It is the use of tact and judgment in this matter that means most, however, and then very few drugs will be required. Between the habits consequent upon the opiates and certain of the serious hemolytic conditions due to the abuse of coal-tar products, this is a consummation that may well be worked for assiduously. CHAPTER VIII SOME TROUBLES OF SLEEP Certain annoying incidents in connection with sleep annoy those affected by them so much as to arouse them very completely from sleep and make them wakeful for a time. Nothing disturbs most people so much as the thought that some passing incident, a little out of the common, is quite individual and peculiar to them. If they are at all nervous they are likely to think that it portends some serious ailment, either present or about to {664} develop. Nothing reassures them more than to learn that these incidents are not so uncommon as they imagine, indeed that many of them are quite frequent, and, above all, that many people who have had them are still alive and well beyond threescore and ten, and laughing at the fears of their earlier years. Starting.--Perhaps one of the most annoying of these incidental troubles is starting in sleep. It occasionally happens that just about the time a person is dozing off he suddenly starts and, almost before he realizes it, is fully awake, his heart beating emphatically and there may even be a little feeling of oppression on the chest. The cause is not the same in all cases and individual differences are worth investigating. In most people this starting means that there is, for the moment, some mechanical interference with the action of the heart and that a systole has been delayed and has been pushed through with more force than usual because of this delay. A full stomach will occasionally cause this, especially if patients lie on their left sides. In some people even a drink of water taken just before retiring will be sufficient weight to cause this interference with heart action. An accumulation of gas in the stomach will do it by pushing up against the diaphragm. Where there is a distinct tendency to the accumulation of gas in the stomach I have sometimes been sure that the expansion of the gas consequent upon the cozy warmth of the patient in bed, or its greater effect upon the stomach because the relaxation of sleep affected even the stomach walls slightly, was the cause of it. It happens more frequently in the old than it does in the young, but it is observed at all ages and patients are usually quite disturbed about it, as, indeed, they are likely to be with regard to anything that affects their hearts. The thought that this forcible beat must mean some serious pathological condition will obtrude itself on many people, and if it does sleep is sure to be disturbed. Even though there may be no discoverable lesion of the heart, these patients often, though they are physicians, will worry lest some underlying condition should be developing. The first patient who ever described this symptom to me told me of it while I was a medical student and he is still alive and in good health, though he is past seventy. At the time I went over him rather carefully with the idea that there might be an organic heart lesion, but found none. The prognosis of these cases is always favorable, for there are many who suffer yet live long. I have found if to occur particularly in elderly people when they were a little overtired on going to bed, or in anemic young people when they had had somewhat more exertion than usual during the day. Unless there is really some demonstrable heart lesion the start does not mean anything and patients can be reassured at once. They should be counselled against lying on the left side, though in some of them it will occur even while lying on the right side and then the mechanism of its production seems to be the gaseous over-distention of the stomach. Patients may be told at once that it occurs in a large number of people and then, instead of lying awake and worrying about it as they often do, they learn simply to place themselves in a more comfortable position and go to sleep again without solicitude. They would learn this for themselves in the course of time, but the physician's reassurance will enable them to anticipate the lessons of experience and they will thus be saved worrying. At times this starting from sleep seems due to some unusual noise. In {665} certain nervous states even slight noises produce an exaggerated reaction and there seems to be a surprising, almost hypnotic, acuity of hearing just at the moment when all the other senses are going to sleep. Any of the small noises that sound so loud in the stillness of the night may serve to wake the patient so thoroughly after a preliminary doze that sleep is disturbed for some time. As a rule, however, such noises would not disturb people if they were in normal healthy condition, or at least the disturbance would be only momentary. The solicitous effort that some people make to get away from every possible noise is an attempt in the wrong direction. We have heard of people building special houses, or noise-proof rooms in the center of houses where they hoped it would be impossible to be disturbed. What is needed is not so much an effort to secure absolutely noiseless surroundings, which is almost impossible in any circumstances, be it city or country, but to change the patient's physical condition so that slight noises are not reacted to so explosively. There are many general directions for this and certain drugs, as the bromides, are of distinct service. On the other hand, the taking of cinchona products seems often to emphasize it. I have found that two classes of nervous patients particularly were likely to be disturbed by these starts in their sleep. The first class is perhaps the larger. They are the patients who do not eat enough. They will usually be found to be underweight and to be nursing some thought with regard to their digestion, or some supposed idiosyncrasy towards food that is keeping them below the normal weight for their height. Nothing makes sleep lighter than a certain amount of hunger. This hunger may be disguised so completely, or so covered up by the patient's persuasion that more food cannot be taken without serious gastric disturbance, that it may pass utterly unnoticed. When such patients are disturbed early in the night, it usually means that besides taking a not quite sufficient amount of food they are taking more tea or coffee or some stimulant than is good for them. I say some stimulant because in several cases that I investigated rather carefully the cause seemed to be the alcohol taken with one of the largely advertised patent medicines, a supposed digestive tonic, consisting mainly of dilute alcohol, and really about as strong as whiskey. When the tendency to be startled occurs in the early mornings, then people need to eat something simple just before they go to bed. The other class of cases who are likely to start at night in their sleep are those who do not get out into the air enough during the day or who sleep in rooms insufficiently ventilated. At the beginning of the night the lack of ventilation makes the sleep light and easily disturbed. After a certain number of hours have been spent in a badly ventilated room the patient sinks into a rather deep sleep, which is likely to be dreamy, however, and then he is rather hard to waken, but wakes not feeling rested, but on the contrary often heavier and more tired than on retiring. In these cases an investigation of the amount of air the patient is allowing to enter his sleeping room or that his circumstances provide him with is extremely important. As for those who do not get out enough during the day, it is easy to understand that their sleep may be light. To them, as a rule, it will be a surprise to find how much depth is added to their sleep by an additional hour or two in the air. Commonly, people who do not get out much during the day are shivery and {666} suffer from cold, especially in the winter time, and so they are likely to keep their rooms rather tightly closed. In this case they have two reasons for a tendency to be wakeful, which is emphasized if there are noises near them or if there is anything that disturbs their sleep. In young children, of course, it must not be forgotten that starting in sleep may be due to the twitching pains of a beginning tuberculous joint disease. At times the children are so young, or the symptoms so vague and the tenderness, if there is any, so deep, that the real significance of this may not be recognized. The most successful treatment for these starting pains in children that has thus far been found, forms a striking commentary on what we have just been saying with regard to fitful sleep when ventilation is insufficient or when the patient has not been out of doors enough during the day. The children from the New York hospitals who in recent years were taken down to Sea Breeze during the autumn and winter and made to live in wards, the windows of which were constantly open so that the temperature was often below fifty, so that doctors and nurses had to wrap themselves up warmly and sometimes cover their heads and their hands, had all been sufferers from these starting pains before this experience, but gradually they lessened in frequency until after a few months the crying of a child at night because of these pains was extremely rare. The lesson is evident, and abundance of air not only cures tuberculous conditions, but also makes the nervous system so much less irritable that starting pains do not so easily affect it. Noise.--Slight noises often make it impossible for nervous people to sleep. This is much more a question of personal sensitiveness and anxious expectancy and over-irritability than anything else. One distinguished physician whom I knew was extremely sensitive to noise and would be awake for hours if wakened up early in the night by the slamming of a door or a call in the street or anything of the kind. He suffered from insomnia to a noteworthy degree and found to his surprise that he could sleep better on a train than anywhere else. After he had lost two or three nights of sleep he actually used to make arrangements to take a berth on an express train going out of his city, ride until the morning and then come back. He usually slept well amidst all the noise and jar of the train, though he would be quite sleepless at home as the result of even slight noises. I have known people suffering from insomnia who took a long ocean trip on a slow vessel and who slept well amidst all the noises of shipboard, but were light sleepers after landing, and felt that they missed the noise and bustle. Of course, in these cases the rocking movements sometimes predispose to sleep. It is not the custom now to rock infants to sleep and a very definite agreement seems to have been come to among pediatrists to forbid the practice as harmful. It is probable, however, that the instinct of the race in the matter was not at fault. Rocking seems to relax a certain tension of muscles that of itself prevents the brain anemia which is the physiological basis of sleep. It is extremely difficult for nervous people to relax themselves completely, and the rocking movements, by tending to help them in this matter, are excellent predisposing factors. A rocking chair or a hammock furnish abundant proof of this. Noise in general, as regards its relation to sleep, is an extremely individual matter. Habit plays the largest role in the matter. We all know the {667} stories of men who have gone to great expense in order to build noise-proof rooms and yet have found afterwards that they did not sleep well. The rustle of the bedclothes as their thoraxes rose and fell in respiration was enough to disturb them when they allowed themselves to become over-sensitive about noise. We all know how impossible sleep becomes with a rustle of a mouse in the wastepaper basket, or the scratching of one on the wainscoting. On the other hand, anyone who has lived in a large city where past hundreds of thousands of homes the elevated trains thunder every few minutes all during the night, or the trolley goes rolling by within a few feet of the bed, knows, too, that a great many people become accustomed to noises so as to be utterly undisturbed by them, though at the beginning any such insensitiveness to noise seemed out of the question. I remember having a patient who insisted that he could not sleep so near the elevated. At the end of a week he had lost so many nights of sleep that he was almost in despair. If he did get sound asleep he said he used to hear the thunder of the elevated train coming toward him in his dreams and he would begin to pull his feet up so as to get them out of the way of the train, yet always with the feeling that he could not get them quite far enough, until his knees were almost to his chin. Under the influence of a little bromides, two hours more of outdoor air than he had been accustomed to before, and some reassurance that noise need not disturb sleep at all if taken philosophically, he learned in the course of two weeks to sleep quite peacefully and now has lived for ten years where the elevated passes within ten feet of his window, which is wide open for seven months in the year and always at least slightly open, except in the most stormy weather. It is a question, then, of the individual much more than his surroundings. The problem is to predispose the mind to sleep and then the senses will not disturb it except under special circumstances. As a matter of fact, noises usually disturb people very little at night. The most surprising things can happen between 12 and 3 o'clock and attract no attention. Burglars calmly blow up a safe in a hotel confident that if there is no one awake when the explosion occurs there will be no investigation, because even though people wake up at the noise, they will wait for its repetition in order to see what it means, will not get up to investigate, especially in cold weather, and usually promptly go to sleep again. Lying Awake.--There are many people to whom lying awake carries with it a sense of discouragement and dread. They seem to forget that lying awake and occupation with pleasant thoughts may be made a very agreeable pastime by those who are not over-anxious to sleep and who let the pleasant thoughts that may be suggested by the environment or the noises that are heard flow through consciousness. Everyone knows how pleasant it is or may be to listen to the rain patter on the roof of a country house, or to hear the murmur of the ocean or of the wind through the trees when there is not too much anxiety about to-morrow and to-morrow's occupations and the necessity for sleep to be ready for them. Stewart Edward White, in his series of essays on "The Forest," has a chapter on Lying Awake at Night that can well be recommended to the attention of those who complain bitterly of an hour of sleeplessness. Of course, in his case the lying awake is in the midst of the forest with all the witchery of wind in the trees and the {668} unusual sounds of forest life, while ordinary lying awake is in the rather monotonous environment at home, but still there is much that can be said for his insistence that in peaceful brooding, faculties revive while soft velvet fingers are laid on the drowsy imagination and you feel that in their caressing vaster spaces of thought are opened up. The impatience that comes to so many almost at once if they fail to go to sleep promptly only serves to keep them awake just that much more surely. Very often, as suggested by Mr. White, this wakefulness occurs just when a good night's rest is surely expected. There is sometimes even a preliminary period of drowsiness. Then some little noise that ordinarily would not be noticed at all floats into the consciousness with a vigor that indicates that one sense is thoroughly awake. The very surprise of it wakes up the other senses with a start and then comes the thought that there is to be no sleep for some time. If this is resented, the period of wakefulness will be all the longer. If, when it has proved to be inevitable, one sits up quietly, reads a book for a time, plays a quiet game of solitaire, it may be on a board kept beside the bed for such purposes, or in some quiet way succeeds in bothering away the thought of insomnia, then almost surely sleep will come after a time, quietly and restfully, and the lost period will not prove harmful. If nature does not want to sleep she must not be forced into it, but gently led and after a time the wakefulness will disappear. Night Terrors.--One of the troubles of sleep that is more often called to the attention of the physician than almost any other, is the so-called "night terrors" of children. Little ones wake with a scream, sit up in bed, evidently terrified, usually trembling, and ready to seek refuge from something that has seriously disturbed them. Under Dreams we have called attention to the fact that usually these terrors are due to a dream. Sometimes the dreams are the ordinary experience of supposed falling in sleep, from which the patients wake very much startled, or they are repetitions of exciting scenes through which they have passed, or of stories that they have heard, or, above all, plays that they have seen. Ghost stories, for instance, told shortly before they go to bed will often disturb children. Fairy stories and the ordinary myths of childhood, usually with a happy ending and without any serious terrors in them, are not so likely to disturb them. Melodramatic theatrical performances to which children lend themselves and their attention with great concentration of mind, have nearly as much effect on them as if they passed through the actual scenes. Every physician knows how much a fright is likely to disturb a child and cause it to wake many a night afterwards in a state of terror. Respiratory Interference.--It is particularly important to remember that any interference with breathing will almost surely wake the child in a seriously startled condition. Adults are often affected by this same sort of dream, due very often to some pathological condition in the throat around which a series of dream ideas collect with somewhat poignant results. I have known a man suffering from elongated uvula wake up thinking that he was suffocating because, as he thought, he had nearly swallowed his tongue, or at least had been trying to do so. The sensation was so startling that it brought him to his feet at once. I have known a patient traveling a long five-days' railroad journey and suffering severely from train catarrh, come to the {669} persuasion that he might suffocate during sleep because his nose was completely stopped up and he had not the habit of sleeping with his mouth open. As a result his sleep was as much disturbed by his mind as his breathing. If these affect adults so strongly, it is easy to understand why children should be so frightened by them. Children who are mouth-breathers from adenoids or nasal obstruction, and still more those whose nasal breathing apparatus is not completely stopped up, but who are frequent intermittent mouth-breathers, are especially likely to be troubled in this way. The neurosis known as nervous croup, due to a spasm of the vocal cords, occurs oftenest in this class of children and is an associated phenomenon to that of night terrors. Sleeping in the Light.--The habit of accustoming children to sleep with a light in the room nearly always lessens the depth of their sleep. They are more easily wakened and their sleep is not so refreshing. Besides, if they do not grow accustomed to the dark when they are young, they may always retain a dread of the dark and will require some light in the room where they sleep. Nature intended that the eyes and the optic nerve should have as complete a rest as possible and even with the lids lowered some light stimulus, if it is present, finds its way to the nerve fibers. Hence the desirability of having as far as possible an absolutely dark room. For some very timorous children, this may seem impossible. Many mothers will recall how awful the dark seemed to them and what shadowy shapes loomed up in it. It will usually be found on inquiry, however, that in these cases the children, after having been accustomed to sleep with some light and after having had all sorts of exciting pictures shown them and stories told them, were asked to sleep in the dark. From the very beginning they should be accustomed to sleeping in the dark and then it has none of the terrors thus pictured. CHAPTER IX DREAMS Dreams, that is, thoughts and illusions and mental phenomena of various kinds that occur during sleep, have always been interesting to the psychologist, and have usually been related to physicians by patients either because they were thought to have a significance related to disease, or because something in them disturbed the patient's mind. This is almost as true in the modern time as it was long ago. It is curiously interesting to note that the very latest development of psychotherapy includes the use of hints obtained from dreams in order to determine the origin of psycho-neurotic conditions and certain of the minor psychic disturbances, and also as a foundation for treatment. The oldest stories of therapeutics that we have are those of patients waited on by the priest physicians of the olden times in the temples, who were supposed to be greatly helped by information obtained from the patient's dreams. It is interesting to read such recent studies as that of "Incubation in the Old Temples," by Miss Ingersoll, with the thought in mind that we are once more analyzing dreams in order to accomplish a similar purpose. {670} Dreams are so often a source of disturbance of mind for patients, lead to such disturbed sleep, or even so affect the bodily health that it is important for anyone who wants to influence patients through their minds to know the significance attributed to dreams by the most recent studies of them. This is all the more important because dreams are such a universal phenomenon. From our earliest years we dream. The night terrors of children are probably due to dreams and show that even as early as the age of three we dream vividly. Doubtless some of the terrifying dreams of childhood are similar to those that we experience later. Dreams of falling, dreams of being cold, of being out of breath, with vivid repetitions of exciting scenes through which they have gone during the day, or which they have seen in picture or been told in story, form the substance of these dreams. Children are likely to be much disturbed by them. They wake in a terror of anxiety, in cold sweat, and crying bitterly because of their dream visions. Older people are not so much disturbed at the moment, but often brood over dreams and may be seriously affected by them. It is difficult, however, to persuade many people that their dreams have no special significance, either of present or of future evil, and to many the fact that they dream much becomes a suggestion of wakefulness that disturbs sleep and makes them quite unequal to the next day's work, because they have the feeling that, as they have been dreaming all night, they must be quite tired. Tiredness in nervous people is often a matter of the mental state rather than of physical exhaustion or genuine mental weariness. The actual place of dreams in psychology, then, becomes an important consideration in psychotherapeutics. Our real advances in the knowledge of the significance of dreams have come from the study of the dreams that are common to most people. These show us exactly how and why dreams occur and just what their meaning is. Probably the most familiar dream common to all the human race is that of falling from a height. Everyone has been wakened with a startled sense of intense relief that the sensation of falling was illusory. The waking came just before the bottom was reached. There is a tradition that if one ever did strike the bottom in one's dream it would be the end and that death would result as surely as if the fall were real. So far we have had no one come back to tell us of that, and the tradition is reasonably safe from direct contradiction. It serves without any reason, however, to disturb timorous people and make them dread to fall asleep again. Often this dream-falling so seriously affects sensitive individuals that they do not get to sleep for an hour or more and occasionally those with an inclination to insomnia may even suffer for the rest of the night from the effect of it. It is important to explain, then, what we know about the causation of the dream. In nearly all cases the subject on waking finds himself on his back, and then the inclination is at once to turn over to the side with a sigh of relief. Commonly the dream occurs rather early in the night, when a rather heavy meal has been taken shortly before retiring. The weight in the stomach, particularly if considerable liquid has been taken, seems to press upon the abdominal aorta and interferes, to some extent at least, with the circulation to the legs. This deprives little nerves at the periphery of the body of some of their nutrition and causes a tingling feeling in them. This is quite different from pressure {671} on nerves, which gives the sensation termed "being asleep" to a limb. This tingling feeling resembles that which we experience when going down rapidly in an elevator. It is the falling sensation. This sensation tries to force its way into the consciousness and in this process does not completely wake consciousness up, but brings about an association of ideas connected with falling--hence the dream of being on a height and of falling therefrom out of which we wake so startled. The whole process instead of being injurious is really conservative. It is important that the aorta should not be pressed upon and this is the mode by which awakening is brought about and the position shifted so that further interference is stopped, though we ourselves are quite unconscious of the real purpose that has been accomplished. An explanation of this kind usually makes people who suffer from such dreams and have been disturbed by them much more tolerant of the phenomenon and more ready to go to sleep again, since evidently nature can be trusted to care for them even during sleep. After the sensation of falling probably the commonest dream that humanity has, at least in the civilized state, is that of being out in some public place without sufficient clothing. Usually we wake just to find that some portion of our anatomy has been exposed to the air and that it is cold. It is this sensation gradually forcing its way into consciousness that has gathered around it a group of ideas that form our dream. Among men, a familiar dream is that of running for a car, or away from something, or to catch someone, and finding that it is almost impossible to move. We are so out of breath that we are scarcely able to drag one foot after another and, indeed, sometimes we seem to be actually rooted to the spot. We cannot move at all. When we wake after this dream we find that, because of a cold in the head, our nose is stopped up by the secretion and that our mouths are shut and consequently we were getting no air. When that sensation tries to break into the consciousness there gather around it certain familiar ideas usually associated with being out of breath and hence we have the dream of trying to run without being able to move. Frequency of Dreams.--Nervous people often complain that they dream all night or else very frequently, and that as a consequence their sleep is not restful. It is probable that there are always ideas in the mind and that literally we dream without ceasing. These ideas, however, do not get into our consciousness except just during the process of waking. All those who have investigated the subject of dreams are practically agreed on this. In subsequent paragraphs we quote a number of good observers on this subject. Certainly this is what we should expect from what we all know about day-dreaming. We can never catch ourselves during the day without finding some thought wandering through our minds. If we want to understand dreaming during sleep this day dreaming is instructive. We jump from one idea to another, apparently without a connection; yet there is always some connecting link. We have just read in the paper of someone in Cairo, and we think of old Egypt, and then of old Babylonia, and the Code of Hammurrabi, and the laws of the Medes and the Persians, and Xenophon and our school days, and of an old schoolmaster now a missionary in Japan, and of Japanese art and of an American artist much influenced by it, and of one of his great windows in a church in New York and of social work in connection with that church, {672} and of settlement houses and then Hull House, Chicago, and then of the Adamses in Massachusetts, and so on. Thus, also, do our minds go flitting round apparently during the night. We remember only such things as are brought into our consciousness directly and emphatically during the process of wakening. During our day dreaming we recall only those things which for some reason led us to think consciously about them and then follow out our thoughts to definite conclusions. It is an interesting study to follow back our day dreams through their wanderings to the origin. As a rule, however, we lose track of the connections and after a time remember only some of the wonderful transformations and transmigrations of thought; and so it is in our dreams. With regard to the frequency of dreaming. Sir Arthur Mitchell in his book "Dreaming, Laughing, and Blushing" (London, 1905), insists on the great probability of the constancy of our dreaming during sleep. He says: It seems to me that there is no such thing as dreamless sleep. During the whole continuance of sleep, the mind, I believe, is occupied with a certain kind of thinking which works round what I have called hallucinations. I do not expect to be able to prove the correctness of this opinion as to the persistence of dreams all through sleep, but I think that it can easily be shown to be possibly correct. I go further, and say that many things show that it is probably correct. I may not be able to prove absolutely its correctness, but it is proper to bear in mind that it is quite as difficult to prove absolutely that it is not correct. My difficulty is frankly avowed. Many things, however, are taught in biology as being certainly true. In regard to which a like avowal could be made but is not made. There is what has been called a "conjectural biology." We do not and we cannot remember much of what we have been thinking about while we are awake. This is unquestionably true in a large sense. But, nevertheless, we do not doubt that we have been thinking continuously. We do not suppose that at any time all thinking had ceased, though we may be completely unable to recall what it was about. He shows further that many writers on dreams and careful students of the subject in the past have come to the same conclusion. Robert Dale Owen, for instance, deliberately endeavored to find out whether he had always been dreaming just before he awoke. After months of observation he records that in every instance he was conscious of having dreamed. Hazlitt, a century ago, tried the same thing for a prolonged period and notes that whenever he was waked, and immediately recollected himself as to possible dreaming, he was always aware that he had been dreaming. Sir Arthur Mitchell himself has tried this same experiment on himself and for a considerable time has scarcely ever failed to put to himself this question about dreaming when he awoke and always got a satisfying affirmative answer. Personally, for several years, I have been interested enough in this subject to recur frequently to it immediately on awaking and I cannot say that I have ever, under those circumstances, failed to find that there had been some vague dream fancies at least running through my mind before I was fully awake. This opinion as to the constancy of dreaming during sleep has many authorities in its support. Sir Arthur Mitchell has quoted a number, some of them distinguished physicians, who add the weight of their testimony to this view: It is not a new thing to hold that there is no sleep without dreaming--in other words, that dreaming goes on unceasingly all through sleep. I have stated my own {673} opinion strongly, but the same opinion has been nearly as strongly expressed by others. Sir Benjamin Brodie, for instance, may be said to express it when he writes, "I believe that I seldom if ever sleep without dreaming." Sir Henry Holland expresses it still more plainly when he says: "No moment of sleep is without some condition of dreaming." Goodwin says much the same thing when he asserts that "sleep is not a suspension of thought"--in other words, that dreaming is sleep-thinking. Dr. John Reid still more clearly holds the opinion, though he does not furnish me with a short apt quotation. Hazlitt, too, may be taken as holding that there is no such thing as dreamless sleep. Descartes and his followers may, perhaps, be regarded as holding that the mind is unceasingly at work in sleep--even in the "profoundest sleep," though "the memory retains it not," and Isaac Watts says that "the soul never intermits its activity," and that we may "know of sleeping thoughts at the moment they arise, and not retain them the next moment." Hippocrates, Leibnitz, and Abercrombie have also been quoted as holding that there is no dreamless sleep, and so far as they express themselves on the subject they appear to do so. A strong weight of opinion in all ages favors the view that during sleep dream-thoughts are constantly running through our mind, though we recollect only those which are impressed upon us at the moment of awaking. We do not even recall those unless, for some reason, we have paid special attention to them. That is just exactly what is true of day dreaming. After it is over we have no idea at all of the thoughts that occupied our minds for hours, though we are all aware that at any given moment, if we turned our consciousness inwards we found that there was something that we were thinking about. Short Duration of Dreams.--This view of the constant occurrence of dreams during sleep is confirmed by other things that we have come to know as to dreams and dream states. Probably the most interesting of these is with regard to the length of dreams. As our memory of dreams is only such as we have from the thoughts of sleep getting into our consciousness just at the moment of awaking, dreams are never as long as they sometimes seem to be. As a matter of fact, they occupy but a few moments, though in that time a long story may seem to unroll itself. Probably nothing gives more assurance to people who are persuaded that they are losing much rest because of their dreams than this explanation of the brevity of the phenomena. Nervous people wake frequently. Whenever they wake they find themselves dreaming. As a consequence, they acquire the persuasion that they have been dreaming "all the night long," and it is not hard for them to suggest to themselves in the early morning that they are not rested. Nervous people seldom feel rested in the early morning, it is their worst time, and with the occurrence of dreams as a suggested reason for this, they exaggerate the feeling of tiredness with which they get up. A frank discussion of this question of the duration of dreams is often the best possible therapeutic auxiliary for such cases. It gives them a new series of suggestions and, above all, relieves them of unfavorable suggestions. Prof. Maury of the University of Paris tells a striking story of a very brief dream of his own which shows how short may be the time occupied by what seems surely a long dream. He had been reading before going to bed a very striking book on the Reign of Terror. He dreamt that he himself was arrested during the Terror, taken to prison, that his name was called on the list of the condemned, that he was carried to the guillotine, fastened to the {674} board, pushed beneath the knife and that he woke just as the knife struck his neck. Of course he awoke with the usual sense of thankfulness and relief that comes at such times. When he awoke he found that a light curtain rod had fallen from the bed above him and had struck just across his neck. His dream evidently had all come to him during the extremely short time necessary for him to become fully awake after the rod had hit him. His mind was occupying itself with the history that he had read before going to bed. When the rod struck him the long story of his arrest and imprisonment, the journey to the place of the guillotine and the preparations for execution, all came to him as a series of rapid ideas during his coming to consciousness. It is probable that most of our dreams are not much longer than this. One of my earliest recollections is of an old gentleman coming into the country school during my first year as a pupil and telling us the story of a dream of his of the night before quite as brief as that of Professor Maury. He had fallen asleep after dinner in his chair and, having a cold that stopped up his nose and his mouth being shut, he had the usual dream of being out of breath from running. It took him back to the story of the massacre of Wyoming, near the scene of which the school was situated. He dreamt that for hours he had been running away from the Indians and seemed at last utterly unable to escape them because he was out of breath. He made such efforts in his chair that his wife awakened him and then he found that he had been asleep altogether only a very few minutes. Significance of Dreams.--Many people are quite sure that their dreams have a definite significance quite apart from any mere wandering of the mind or the suggestion of half-waking and the ideas that gather round sensations not fully in the consciousness. A number of people, for instance, have dreams of events that are happening at a distance at the moment that they dream. The Psychic Research Society of England has gathered a number of these and it is indeed difficult to understand many of them. There seems no doubt, however, that in many cases there is an illusion of memory, by which, after an event, dreams that might be taken to refer in some vague way to the happening, are clothed with a wealth of detail which appears to make them wonderful premonitory representations of future events or repetitions of simultaneous events. One of the most familiar of this form of dreams is what has been called a phantasm of the dying. People dying at a distance seem to have some wonderful power of making themselves appear to very near friends, especially brothers and sisters, and, above all, twins, and to friends with whom they have been very intimately associated. Occasionally such phantasms are seen during waking hours, or what are supposed to be waking hours, though it must not be forgotten that dreams may come very easily and almost unconsciously in short naps, but much more frequently in what are known to be dreams. Nearly always these partake of the nature of the ordinary dream, as can be seen by a careful analysis of their conditions, and are mere coincidences occupying a very brief space of time. A typical example of this is to be found in one of the stories told by Camille Flammarion, the French astronomer, in his book "The Unknown." A young man who had fallen in love with a young woman was deeply grieved to be parted from her by the injunction of parents. Separated by a long distance, they kept up a clandestine {675} correspondence for more than a year. For a considerable period, however, he had not heard from her, and he was beginning to be anxious lest anything had happened to her. One night she appeared to him in a dream in his room in white garments with a pale face and, placing her cold hand in his, she bade him good-bye. He awoke with a start. He found it difficult to sleep and was very anxious about her. The next day he learned that she had died the night before and concluded that his dream was a last message from her. The end of the story, however, as it is told, spoils this nice sentimental conclusion. When he awoke he found he had in his hand a glass of ice water which had been standing on the table beside him. The grasping of this had awakened him. During the awakening process the thoughts of her in his mind gathered round the cold sensation in his hand and gave him the dream of her and the last farewell. There are many instances in which dreams of future events seem to come true. Indeed, so many of these stories have been told that it is hard to persuade some people that dreams have no meaning and can have no meaning. By this we mean that they can by no possibility represent prophetic foresight. What patients need to be made to understand is that dreams represent only straggling sensations trying to get into our consciousness, just barely succeeding, and then arousing trains of ideas unconnected in themselves, but which we connect afterwards when we recollect our dreams. This whole subject has been studied so thoroughly in Maury's work on _"Le Sommeil et les Rêves"_ about the middle of the last century and Freud _"Ueber den Traum"_ and Sante de Sanctis' _"I Sogni"_ Turin, 1899, at the end of the century, that there can be no further doubts about the matter for those who are open to conviction. Most people, however, want to believe that their dreams mean something. They like to think that they are in some way picked out from the multitude and that their dreaming has a significance more than is accorded to other people. It is, indeed, this self-centeredness that makes for the belief in premonitions and prophetic dreams and, as in all cases, these feelings work out their own revenge. If they will listen to reason, however, most people may be rather readily convinced that their dreams cannot have any serious significance. In the chapter on Premonitions we have already called attention to the situation that exists with regard to the possibility of future events giving information of themselves in advance of their happening. Simultaneous events may perhaps in some way give warnings. The possibility of action on the mind at a distance, especially where minds are involved, has been discussed and admitted. The cases in which it is supposed to have happened are, to my mind, all dubious and are mere coincidences. For future events, however, there is no possible physical explanation. When we turn to explanations in the borderland between spirit and matter we find nothing satisfactory. The future event exists nowhere. No spirit even knows it; it is dependent on human free will. To the Creator it is known only as a contingent possibility dependent on free will. The information does not come from Him, for then there would be more design in these incidents. Such dreams would effect some serious purpose, while usually they have but minor significance in the stories as told and they often concern only the most trivial things. What is thus true of premonitions can readily be applied to dreams. {676} There is no reasonable source of information with regard to future events. What, then, are we to say of the dreams that come true? There is no doubt that dreaming is extremely common. Probably, as was said, we never sleep without dreams. There are a billion dreams at least, probably many billions of dreams every night, then, in this little world of ours. When these are startling they cling to us. It would be surprising if some of them did not come true. Indeed, it is inevitable, according to the theory of probabilities, that some of them will connect themselves directly with future events. We have a few thousands of such startling coincidences in the history of the race. Out of these have been made all the data supposed to underlie the teaching that dreams have a prophetic significance. It is much easier to understand with regard to dreams than even with regard to telepathy coincidence explains all the supposedly wonderful warnings of events that actually happen after we have had apparently premonitory dreams. An interesting example of a premonition that did not come true, the subject of which was sure that it was a waking premonition and not a dream, though it seems more likely that it was as suggested by the narrator a sleep vision, is told by Sir Arthur Mitchell in his "Dreaming, Laughing, Blushing" (London, 1905). A number of scientists who discussed the story declared that if it had only come true it would have been one of the most startling manifestations of premonition and of the clairvoyant power of dreams, or at least of their telepathic significance, that we have ever had. It involved so many distinguished scientists that there could have been no doubt about it. It was so detailed and those details were known to so many authorities in science, that it would have carried great weight and it would have been extremely difficult to have people accept it as a mere coincidence. It is easy to see now after the event that, if it had been fulfilled, it would have been, in spite of its startlingness, a mere coincidence. Since it was not fulfilled, however, it represents one of the best evidences that we have for the insignificance of premonitory or telepathic dreams. Sir William T. Gairdner, K. C. B., whose interesting typhus delirium experience appears in the paper by Professor Coates on "Sleep, Dreams and Delirium" (_Glas. Med. Jour.,_ Vol. xxxviii, 1892, pp. 241-261), has written to me about his dreams generally, and he concludes his letter with the narrative of a dream, which, as he correctly says, "if it had only fulfilled itself, might have become famous." He prefaces the narrative by this statement: "In all my individual experience, now extending over more than the usual term of life, I have never met with anything suggestive in the remotest degree of telepathy or second sight, or of dream prophecies or any other fact bearing on the marvellous." He then goes on to tell the dream to which I have referred. "In crossing the Atlantic In 1891," he says, "in delightful weather and perfect bodily health, and without a shade of anxiety on my mind so far as I was aware (in waking consciousness), I was suddenly aroused in the very early morning, say, three or four a. m., out of a perfectly sound, and, as I should call it, dreamless sleep, by the apparition of a telegram written on the usual paper, and presumably from home, in these words: 'Miss Dorothea died at ----,' all the rest being blurred and indistinct, but these words having a startling distinctness and a vivid sense of reality. I was not, I think, in the least degree alarmed at first, and certainly had no superstition about it on discovering that it was only a dream; but, failing to get any more sleep, I rose early, took my bath as usual, and went on deck, where I had to repeat the story of my dream to each one of some three or four companions who were on board, of whom I will only mention Sir. John Batty Tuke, Professor Young of Owens College, and Professor {677} Cunningham, then of Trinity College, Dublin. Any of these gentlemen will confirm my saying that I attached no special importance to this dream in the way of a scare or a superstition, but in this way it got abroad to a certain extent within a small circle on board in such a way as would have ensured it a widespread fame had it only come true. In discussing the matter at breakfast I remarked (alluding to telepathy) that the telegram was clearly, judging from its terms, not from my wife or any member of my immediate family, and could only have been despatched by a servant or some one with whom I could not be supposed to be in telepathic rapport. From this point of view it clearly refuted itself, and yet the effect upon my mind was such that, upon arriving at New York, I at once despatched a telegram announcing my arrival and making inquiry, the reply to which showed that the family were pursuing a quite undisturbed course at St. Andrews." Sir William describes himself as aroused out of sound sleep by the apparition of a telegram, but I think this only means that he became suddenly awake on seeing the telegram during sleep. He does not say whether he knew in his dream that he was a passenger on a great ship on the mid-ocean, but he says that the telegram was written on the usual paper by which I take it that he means the paper used here on shore. If it happened that the death of Miss Dorothea took place about the time of the appearance of the telegram to so distinguished a man as Sir William in his sleep, I scarcely think there would be any more startling record of a so-called telepathic message. But most happily the death did not take place, so that the story of the dream will be forgotten. Tens of thousands of similar dream stories have that fate. Children's Dreams.--There is an old tradition that to tell our dreams causes them to come back, or at least to recur in some other form. This tradition is so old and so universal that probably there is more in it than might at first be thought. This emphasizing of certain forms of unconscious cerebration probably encourages their repetition, or, at least, the repetition of further processes of the same kind. There seems to be no doubt, too, that the reading of certain kinds of imaginative writing and the looking at exciting pictures sometimes leads to dreams about them. Certainly children should not be told terrifying stories and the more nervous they are and the more affected they are by such stories, which to some people make renewed temptations to tell them, the more should they be avoided. Any physician who has had much experience with city children, especially in New York City, is likely to know how exciting, tragic and, above all, melodramatic scenes serve as the basis for disturbing dreams and night terrors. They will not, of course, in vigorous, healthy and strong-minded children, but these are the ones who are most prone to play out of doors and so are likely to be less bothered. Just the nervous, old-fashioned, delicate children who prefer the theater to sports of other kinds, are likely to be most affected in this unfortunate way. The scenes become so real to children that they impress them very deeply and are readily rehearsed in the unconscious cerebration of sleep. Many a child sees in its dreams someone, often a near relative, fastened on the carriage of a sawmill and inevitably approaching a buzz-saw, or fastened inextricably to the rails while an express train thunders down on them. That they should wake up with a start and a scream of terror and lose most of their night's sleep and disturb that of others, is not surprising. It is well known how witnessing actual danger, as of an automobile accident, or a railroad wreck, disturbs a child's imagination for long after; and its theater experiences are almost as actual as the reality. {678} Many of the colored supplements of Sunday newspapers seem to be particularly undesirable literature for children in this respect, though, of course, there are many other reasons why children should not be encouraged to look at them. It is not unusual for the newspapers to give lurid pictures of wonderful dreams or things that happen in dreams. This is undoubtedly a suggestion that acts in causing nearly all children, but especially those of nervous organization, to dream much more than would ordinarily be the case. It recalls the old warning about telling dreams. These sets of pictures certainly serve to develop the imagination of the child along undesirable lines. Possibly some of them which emphasize the fact that after eating certain very undesirable foods, dreams are much more likely to come than at other times may not be without their prophylactic sanitary value, but this is a doubtful advantage compared to the psychic harm that they bring. I am not of those who would limit the fairy stories and other pleasant essays in imagination which delight children so much and form a desirable part of their education, but artistic effort that is terrifying or deterrent, whether with pen or brush, should be kept away from them until after their mental control is well established. Children will probably dream anyhow, and, therefore, should have a pleasant fund of imaginative material as a basis for their dreams. CHAPTER X DISORDERS OF MEMORY Many patients suffering from various nervous symptoms insist that they are losing their memory or that it is becoming notably deficient in some ways. If they are a little on in years they are sure that their memory is not as good as it used to be and that they now forget many things that were formerly remembered without difficulty. Especially are they likely to assert that the names of people and certain words will not come to them when they want them, that they often have to seek for facts and dates that should be quite familiar, that they fail to remember acquaintances and the like. These symptoms of which they complain are often sources of considerable worry and serve to emphasize in them the idea that there is something serious the matter with their general health, or some pathological condition developing in their brain. They have heard much of loss of memory as a sign of degenerative nervous diseases and they are prone to think that their own special loss of memory, be it real or imaginary, must be a forerunner, or perhaps even an early symptom, of some important organic lesion. This idea of progressive memory disturbance as a preliminary of nervous breakdown often becomes so firmly fixed as to be of itself a profound source of anxiety to patients, and an almost unspeakable dread. So it is important to make them understand what the real nature of their condition is and what their loss of memory, supposed or real, is due to. As a matter of fact, what many of these patients need is not treatment for a diseased memory, but reassurance from what we know about the psychology of memory, that their troubles are only quite natural incidents in the life history of their particular memory {679} faculty. Many a man who is worrying about his supposed loss of memory or, at least, impairment of it in some way, is not suffering from a true pathological condition, but is usually the victim only of some functional disturbance of the nervous system with the neurotic anxiety and heightened introspection that accompanies such a condition. Reasons for Memory Difficulties.--Nervous patients particularly complain that they do not remember what they wish to as easily as they used to a few years before. They say that it is much more difficult for them to impress things upon their memories and, in addition, that it is much easier for them to forget. There are three quite natural reasons for these phenomena as far as they actually exist, which should be pointed out to these patients. The first and most important is that they are incapable of that concentration of mind which they had in earlier years and which enabled them to give themselves up so completely to the consideration of a particular subject that it could not help but be impressed on their minds. They are now so much occupied with many other things, and, above all, most of these patients are so preoccupied with themselves that they cannot hope to have the concentration of mind that was comparatively easy when they were younger and is now impaired, but which is so necessary for the enduring remembrance of things. Secondly, their over-anxiety to remember things sometimes acts as an inhibitory motive in securing that deep, impression that will enable them to remember details very well. Thirdly, their supposed impairment of memory is due to a false judgment with regard to themselves. They are not comparing their power of memory now with what they used to have, but owing to anxiety about themselves they have taken to comparing themselves with others and, after all, the faculty of memory acts very differently for different people and it is well known that what one man remembers with ease another recalls with difficulty, or only because of special attention. _Attention and Memory_.--The first of these causes for supposed impairment deserves to be discussed further. It is often said that as we grow older our memory is not so retentive as it used to be, and that while we remember the events of boyhood and the things we learned in the early years of school life, our recollection of recent events and things learned in later years is much less vivid. This is all very true, but the reason usually given, that in the meantime our memories have failed in power is inconclusive. What we learned in early childhood came to us with the surprise of novelty and for this reason we paid close attention, it was new and impressed us with its importance, it was dwelt upon for long periods and often, because there was little else to think about, has been frequently recalled since and, of course, is indelibly impressed upon our memories. The same thing is true with regard to early acquaintances. We got to know them so well that, of course, we cannot forget them. What we have learned in later life, however, has come in the midst of many other things, has not been dwelt on very long, has not been often recalled and, of course, occupies much less place in the memory than the things of earlier life. That is not, however, because of any defect in memory, but because of lack of attention and repetition that means so much for memory. _Age and Memory_.--It is often said that people do not learn so readily when they get older. This is, of course, a truth of common experience, but {680} it is not because of dullness of the faculty of memory, but failure to concentrate the attention sufficiently for memorizing. I have known old men who could learn things just as well as any young man and indeed better than most of them. They were men who had been accustomed all their lives to concentrate attention on the subject they had in hand and who did not allow the cares and worries of life to intrude on their studies. Cato learning Greek at eighty is often quoted as an exceptional example, but I have had some dear old friends who could learn things quite as readily as younger men and whose minds were just as bright and clear. Whenever they devoted as much attention to anything that they wanted to remember as they did when they were younger men, I am sure that they remembered quite as well. It is a question of attention and not of any loss of faculty that makes the difference between the memory of the young and the old until, of course, senile impairment actually comes. _Solicitude and Memory_.--Everyone who has had to depend much on his memory knows that over-anxiety with regard to the recollection of anything may seriously inhibit the power to recall it. Public speakers know that to hesitate is to be lost. If they want a particular name or word which they know often escapes them, they must with confidence begin the sentence in which it is to occur, though perhaps wondering all the time whether the word will be on hand or not for them to use it. Occasionally it will not come, but as a rule it turns up just in time. If they allow themselves to be disturbed by the thought that the word or expression may not come, then they know the hopeless vacant blank that stares them in the face when they want it. They have to make a circumlocution in the hope that it may turn up. Some let it go at that, but many start another sentence in the hope to tempt it to come and often it will eventually come, but sometimes it persistently refuses to come. That is not a loss of memory but a failure of neuron connections. There are some of us who know that certain words will always do that with us. Archimedes has bothered me for years and his name will often not come when I want it. Then there are certain words with regard to which transposition is likely to take place. We involuntarily and unconsciously substitute one word for another. We call one man by another's name. We have done it before and we know that we are likely to do it again. Somehow the connections in memory exist along these wrong lines and are constantly mismade. The name of something a man has written comes up instead of his name. This heterophemia is often noted in men of excellent memory. Peculiarities of Memory.--Memory is an illusive and elusive function at best. All of us have had the sensation of having a word, and particularly a name, on the tip of our tongues. We often know the first letter and sometimes the first syllable of it. What memory brings to us, however, may not always be the first syllable of a word or name, though we are prone to think it must be, and we may go looking for it in the dictionary of names only to discover after a time that we are many letters away from its beginning. Very often we have to give up seeking in sheer inability to get a hint of it and then of itself it will come a little later. Sometimes it will come when we no longer want it. As a rule, words that have escaped us once in this way are prone to do so again. Over and over again the experience will be that {681} a particular word or group of words escapes our memory, or at least fails to be at our command, as most other things are. Those of us who are not much given to introspection take no notice of these difficulties which are common-place experiences enough, but the man or the woman who is looking for symptoms, who is prone to believe for some reason or other that his or her memory is failing, will take these hints of the more or less natural fallacy of memory as confirmations, strong as direct proof of the fact that memory is seriously deteriorating. Such pauses and lapses of memory are much more likely to occur if we are nervous and over-anxious about possible loss of memory. I was once asked to attend for a few hours before the time fixed for his oration one of the greatest orators of this country, who was about to talk at a university commencement. What surprised me was that this practiced speaker, who had often appeared before very large audiences, took a very light meal in considerable trepidation, immediately after asked to have certain books brought to him and certain facts looked up for him, took notes in a hurried, feverish way and generally displayed all the over-excitement of the schoolboy about to make his first oration. He was a magnificent occasional speaker, often called upon, yet he assured me that it was always thus with him and that the reason for it was that in spite of previous preparation--and the finish of his orations made it clear that he had devoted much thought to them beforehand--certain of his facts and names and dates had the habit of slipping from him in the midst of the development of his theme, unless he had refreshed his memory with regard to them immediately before, and that he feared that sometime he would find himself in the midst of an address with an absolute blank before him and that he would be compelled to sit down in disgrace. He had never done so and never did in the many years that he, lived afterwards, though always with this dread, never trusting his memory as most people do. _Name Memory_.--There are certain circumstances in which memory may fail and yet no significance of a pathological nature can be attributed to the fact. All of us probably have had the disturbing experience of undertaking to introduce two friends whom we had known for many years and yet having to ask at least one of them for his name before we could make the introduction. It is not that we did not know the name, but at the moment we were utterly unable to recall it. After this has happened once or twice it is prone to happen again, because when we set about introducing people the thought of the previous unfortunate occurrences of this kind comes to our mind and acts as an inhibition of memory, making it impossible for us to recall names. Not infrequently if we are brought to the pass of having to ask one of the parties for his name we have to ask the other, though it was on the tip of our tongue a moment before, because in the meantime the disturbance of mind incident to having to ask has interfered with the train of recollection. Men have been known to forget their own names under circumstances of great excitement and such a forgetting is not pathological, but only a physiological disturbance of function because of secondary trains of association set to work in the brain which disturb ordinary recollection. Of course, some people have an excellent memory for names and never have such experiences, but they are very rare, though practice in recalling names does much to keep {682} people from such embarrassing situations. On the other hand, there are some people especially gifted with name memories. Napoleon could recall all his soldiers' names. Fatigue and Memory.--Occasionally it happens quite normally that when we are very tired certain portions of our memory at least become vague and indefinite and may even fail to respond to any excitation on our part. Under these circumstances we seem to be able only with considerable effort to exert the effort necessary to bring about such connections of brain cells as will facilitate recollection and reproduction and we may fail entirely. In a foreign country it is, as a rule, much more easy to talk the language in the morning when we are fresh than in the evening when we are tired. Especially is this true if we are asked to pass from one foreign language to another, which always requires a special effort. Everyone who has traveled must have had the experience that on crossing the frontier suddenly to be addressed in German after he has been talking French for weeks, may quite nonplus the traveler, even though he knows German as well or even better than French. This is especially true if much depends on the answers, if he has been addressed by a railway official or customs inspector. Apparently there must be a momentary wait until some shifting operation takes place in the brain before the German memory can get to work to establish the connections necessary to enable him to talk German. After a man has been talking to a number of people in one foreign tongue he is likely to be quite lost for words for a moment if he has to use another. The effects of fatigue and excitement and unusualness upon memory then must be remembered in order to be able to reassure patients who pervert the significance of the phenomena. Ribot gives an excellent personal illustration of this peculiarity of memory in his "Diseases of Memory," which is worth recalling here. He says: I descended on the same day two very deep mines In the Hartz Mountains, remaining some hours underground in each. While in the second mine, and exhausted both from fatigue and inanition, I felt the utter impossibility of talking longer with the German inspector who accompanied me. Every German word and phrase deserted my recollection; and it was not until I had taken food and wine, and been some time at rest, that I regained them again. Sensations and Memory.--Just as soon as people compare their memories with others, as they do when they worry and begin to grow introspectively self-conscious, they find noteworthy differences and because of differences they will be prone to think that their memory is pathologically defective when it is only different, or, still more, that because they are not able to remember some things, as others do, their memory must be failing. It is well known that some people have a good memory for things seen, others for things heard, and still others only for things in which they have taken actual part. These are spoken of as visual, auditory and action memories. Memories for things seen are divided into special classes. Some people remember forms very well, while others remember colors. It is evident that our memories are somehow dependent on the special mode in which sensation affects us and that our acutest sensations are the sources of our longest and best memories. Color vision defectives are not affected much by colors and easily forget them. The tone-deaf have no memory for tunes. Every sense defect affects the memory. Sense defects are often unconscious. Their effect on memory may {683} only be noted when introspection begins to bring out the special sensation and memory qualities of the individual. Nature, not disease, may be the basis of some memory troubles thus brought to recognition. All these curious phenomena with regard to memory need to be recalled whenever there is question of a supposed deterioration of it, for it is not easy to decide such a question. Limits of Normal Forgetfulness.--Curious instances of forgetfulness may occur in the experience of men with excellent memories, which, when they happen to persons morbidly inclined to test their every act, are interpreted to signify something much more serious than they really mean. Nearly everyone has had more than once the experience of telling a story to a particular group of people and then forgetting all about having told it and coming back a few days later to tell it over again. Occasionally a teacher hears the same lesson a week apart and yet does not remember that he went over it before, though the class is almost sure to do so. A man may repeat a lecture that he has given before to the same audience without realizing it. The story has been told more than once of a clergyman delivering the same sermon on two Sundays in succession and, though such lapses are very rare, they do not necessarily indicate a failing memory, but may only mean a lack of concentration of attention on the part of the human mind. Prof. Ribot in his "Diseases of Memory" tells the story of one such case in which the subject was quite alarmed lest it should indicate that he was beginning to suffer from some serious memory disturbance due to brain disease, though there was no ground for his fears: A dissenting minister, apparently in good health, went through the entire pulpit service one Sunday morning with perfect consistency--his choice of hymns and lessons and extempore prayer being all related to the subject of the sermon. On the Sunday following he went through the service in precisely the same manner, selecting the same hymns and lessons, offering the same prayer, giving out the same text, and preaching the same sermon. On descending from the pulpit he had not the slightest remembrance of having gone through precisely the same service on the preceding Sunday. He was much alarmed and feared an attack of brain disease, but nothing of the kind supervened. Attention not Memory.--When patients come with complaints of the loss of memory, the most important thing is to analyze their symptoms carefully. This will usually enable us to give patients ample reassurance. I have known men who were convinced that they were losing their memories because of their failure to recall important details in their business affairs in the midst of much hurry and bustle in the winter time, find that when they were living a simpler life in the course of travel or life in the country during the summer time under conditions different from the ordinary, their memory could be absolutely depended on for trains and travel details and all important matters to which they were now devoting attention. Cultivating Looseness of Memory.--Many people complain of loss of memory in the sense that they do not now remember when things took place as well as they used to. For instance, I have had men of fifty tell me that they were sure that their memories were growing weaker than they used to be because a number of times within a year they had found that events which they thought had taken place only a year or two ago really dated four or {684} five or even more years in the past. Some are considerably disturbed by this. As a matter of fact it is only another instance of lack of attention. Most of what we read in newspapers attracts so little of our serious attention that it is no wonder that we do not recall with exactness when events took place. Events crowd each other out of memory. Newspaper reading is, indeed, the best possible cultivation of looseness of memory that we could have. We do not expect to remember what we read. We would probably grow distracted if we did. At the end of the day if you ask a man what he read in the morning paper he will have no idea at all, unless something especially startling or particularly interesting to him has turned up. After a week we could no more separate Monday's from Tuesday's news of the week before than we could recall a random list of events, having heard it but once. We cultivate looseness of memory with great assiduity. Let us not be surprised if, to some extent, we succeed. Memories Individual.--People are often much worried over children's memories and may communicate this worry and anxiety to the children themselves, making them solicitous. It is probable that our memories are like our stature. They are what they are. By thinking we cannot add a cubit to the one nor facility to the other. The training of the memory is a very small element compared to the natural faculty. It must not be forgotten, however, that many distinguished men have been noted for rather bad memories when they were young and yet these faculties have developed quite enough to enable them to accomplish good work afterwards. The memory is, after all, a comparatively unimportant faculty in itself and other intellectual faculties surpass it in significance. It is the faculty that first develops, however, and so a child is often thought to be intellectually slow when it has not so bright a memory as its companions, though a little later its other faculties may develop so as to put it on a plane above its fellows. Memories, too, are very individual and may not retain any of the ordinary subjects, while they may be very attentive for certain special lines of thought. This form of the faculty is better, for the encyclopedic memory is usually of little use and, except in high degrees, encourages superficiality rather than real knowledge. As a matter of fact, few of our greatest thinkers have had what would be called brilliant memories and it would almost seem as though the diversion of mental energy to this faculty rather disturbed the development of the others. Many a distinguished man has been rather notorious as a child for bad memory, so that in the early days when memory was the only faculty called upon at school he was set down as a dunce. Perhaps the most striking example of this was Sir Isaac Newton, who was actually called a dunce, and yet the world would welcome a few other such dunces. Thomas of Aquin, the great medieval writer on philosophy and theology, who still influences philosophy so much, was so slow as a young man that he was called by his fellow pupils "the dumb ox." His great teacher, Albertus Magnus, recognized the depth of mind that his fellow students could not see and declared that the bellowings of that "ox" would be heard throughout the world. Sir Walter Scott was spoken of as a very backward child. This is all the more surprising to those who know and appreciate the wealth of information that he put into his Waverley Novels. Goldsmith, than whom we have no more brilliant writer in English, seemed not only a dunce as a child, but all his {685} life, so far as outward appearance went, was a numbsknll. This was due to a lack of readiness rather than any lack of wit. Tricks of Memory.--Some tricks of memory may be very disturbing to those who are over-occupied with themselves and with the possibility of losing their memory. For their consolation it is well for the physician who hears their complaints to have at hand some stories that illustrate certain of these curious tricks of memory. I had been trying to persuade a literary woman for some time that it was not her memory that was playing her false, but merely her habit of attention and lack of concentration of mind on things because she is occupied with a great many interests, when one day she came to me with what she thought was absolutely convincing proof that her memory was going. She had read a passage in a newspaper the day before which she liked very much, but after reflection it sounded strangely like some of the things that she had thought along these lines herself. It was a quotation, but there was no indication to tell whence it came. A little inquiry, however, showed that the quotation was from an article of her own written only two years before. Here was definite proof of a failure of memory. Strange as it may seem, however, this experience is quite common. I feel sure that there is not a single writer for periodical literature who has not had similar experiences. Anyone who writes much editorially, where the articles are unsigned, finds it rather difficult two or three years later, as a rule, to be absolutely sure which editorials are his. Occasionally it happens that even by the time the proof comes back for monthly periodicals, say six weeks or two months, some at least of what was written may seem quite unfamiliar. This will be particularly true if phases of the same subjects have been treated in successive articles and thus repetitions are caused. There is plenty of good warrant for such occurrences in the lives of distinguished writers. Scott once heard a song in a drawing-room that he did not care for very much and he said rather contemptuously, "Oh! that's some of Byron's stuff." His attention was called to the fact that he was the author of the stuff himself. Carlyle confessed to Froude when Froude went over some of the passages of Carlyle's own autobiography with him, that he had quite forgotten some of the things written down there. Manzoni, the distinguished Italian writer, whose "I Promessi Sposi" has probably been more read throughout Europe than any novel written during the nineteenth century, except possibly some of Scott's, tells some stories of his own lapses of memory and, above all, of having once quoted a sentence of his own to confirm something that he was saying, though he confessed that he did not know by whom the quotation had been written. Memory and Low Grade Intelligence.--There are many people who complain of their memory and of their inability to recall many things which others recall without difficulty. They are prone to think that this is some defect in them and not infrequently, as a consequence of comparisons, they persuade themselves that their memory was better and that it has lost some of its qualities. Until they became familiar with some of the feats of memory possible of performance by others, they were quite satisfied, but now they find in every instance of forgetting a new symptom of an increasingly deficient memory. I have found in these cases, that setting before such people some of the curiosities of memory, and especially the fact that memory is by no {686} means necessarily connected with profound intelligence, so that, indeed, its presence is quite compatible with a low grade of intelligence or even with what is practically idiocy, will do much to rob these gloomy forebodings of their terrors with regard to their own supposed deterioration of intellect. Ribot, in his "Diseases of Memory" [Footnote 52] has an excellent passage in which he sums up a number of these peculiarities of memory that are likely to be especially consolatory to people of ordinary memory who are worrying about themselves. [Footnote 52: International Scientific Series, D. Appleton & Co., New York.] It has long been observed that in many idiots and imbeciles the senses are very unequally developed; thus, the hearing may be of extreme delicacy and precision, while the other senses are blunted. The arrest of development is not uniform in all respects. It is not surprising, then, that general weakness of memory should co-exist in the same subject with evolution and even hypertrophy of a particular memory. Thus certain idiots, insensible to all other impressions, have an extraordinary taste for music, and are able to retain an air which they have once heard. In rare instances there is a memory for forms and colors, and an aptitude for drawing. Cases of memory of figures, dates, proper names, and words in general, are more common. An idiot "could remember the day when every person in the parish had been buried for thirty-five years, and could repeat with unvarying accuracy the name and age of the deceased, and the mourners at the funeral. Out of the line of burials he had not one idea, could not give an intelligible reply to a single question, nor be trusted even to feed himself." Certain idiots, unable to make the most elementary arithmetical calculations, repeat the whole of the multiplication table without an error. Others recite, word for word, passages that have been read to them, and cannot learn the letters of the alphabet. Drobisch reports the following case of which he was an observer: A boy of fourteen, almost an idiot, experienced great trouble in learning to read. He had, nevertheless, a marvelous facility for remembering the order in which words and letters succeeded one another. When allowed two or three minutes in which to glance over the page of a book printed in a language which he did not know, or treating of subjects of which he was ignorant, he could, in the brief time mentioned, repeat every word from memory exactly as if the book remained open before him. The existence of this partial memory is so common that it has been utilized in the education of idiots and imbeciles. It is worth noting that idiots attacked by mania or some other acute disease frequently display a temporary memory. Thus, an idiot in a fit of anger told of a complicated incident of which he had been a witness long before, and which at the time seemed to have made no impression upon him. Training Memory.--In recent years in many departments of therapeutics training has been found to be of value. This is especially true with regard to nervous defects. Probably one of the greatest surprises that nervous specialists have had in the last twenty-five years in the domain of therapeutics came from the introduction of Frenkel's methods of retraining the muscles in locomotor ataxia. This idea of retraining has been found useful in such distinct departments as the use of the eye muscles, the co-ordination of the muscles of speech, so as to get rid of stuttering and stammering, and the muscles of the hand for writing. We are only just beginning to realize that retraining can be of great value in psychic affections also. Patients may be disciplined against their dreads and tremulousness due to over-apprehension and against even certain defective uses of their intellect. Urbantschitsch of Vienna showed that by training defective hearing it might in many cases be very much improved. What he accomplished, however, was not {687} any better use of the external auditory apparatus, but a more intense attention of mind which enabled the patient to catch and understand sounds which had hitherto been so vague that their significance was lost. In a number of cases of complaint of loss of memory I have deliberately set patients to retrain their memories and have at least relieved their apprehensions if I have not always succeeded in increasing their actual memory power. It has even seemed, however, that in old people some actual improvement of the memory faculties was thus brought about. Under the head of Occupation of Mind I have referred to the exercise of memory in younger people as representing an excellent form of mental diversion. When the idea first suggested itself it seemed as though patients would not take to it at all, and yet I have found that with a little persuasion they become much interested and find a great deal of pleasure in their gradually increasing power to recall the great thoughts of great authors in the literal original words. A reference to that chapter will tell more of my experience. This made me more confident of the possibilities there were of making people understand that if they were losing their memories they could bring them back by proper exercise. In this way many of the modern evils of lack of attention and of failure of concentration of mind can be corrected. My rule now is to tell patients who come complaining of loss of memory that if there is any real loss of memory it is due to their improper use of the faculty, or perhaps to their failure to exercise it sufficiently, for the proper performance of function depends on adequate exercise. They are then instructed to take certain simple classical bits of literature and commit them to memory. At the beginning such short poems with frequently repeated rhymes of the modern poets as are comparatively easy to learn are set as memory exercises. Later Goldsmith's "Traveler" and "Deserted Village" are suggested. Then passages from Shakeaspeare are given. Just as soon as the patient finds that he can commit to memory as he used to, if he only gives himself to the task, a change comes over his ideas with regard to the loss of memory. For many of these people the occupation of mind is an excellent therapeutic measure. Besides selections can be made in such a way as to keep before their minds the thoughts they most need in the shape of memory lessons. It is a discipline of memory that revives it and also a constant exercise in favorable suggestion. Gregor in the _Monattschrift für Psychiatrie und Neurologie_, Band XXI, has detailed some of his experiences with the retraining of the memory of patients suffering from Korsakoff's Psychosis--alcoholic neuritis with psychic disturbances, especially of memory. The patient was required to learn words and then after a certain length of time was tested to see if he could learn a similar series with fewer repetitions than at first. The memory increased in capacity with the exercises and there was evidently a definite gain in the faculty. In this disease patients have also lost the power to some degree at least of recognizing objects. After exercises in recognition they are much more capable in this matter, however, and it is evident that in every way the memory can be improved. This experience, with a serious form of disease that gravely impairs the memory, shows how much can be accomplished in circumstances far more unfavorable than are those which usually bring patients to the physician complaining of deficiencies of memory. {688} CHAPTER XI PSYCHIC CONTAGION The term psychic contagion is often thought of as merely figurative. It is, however, quite literal. Many minds are influenced by what they see happening round them and induced to imitate the activities of others. The term psychic contagion is so thoroughly descriptive of what happens that it deserves the place that it has secured. Everywhere and at all times we find historical traces of psychic contagion compelling people to perform in crowds or groups the most curious and inexplicable and sometimes the most horrible things. Even in the old myths before the times of the Trojan War, we have the story of hysteria spreading among the daughters of King Proteus, so that the famous old physician, Pelampus, had to administer white hellebore in goat's milk in order to relieve them. It is probable that this rather heroic remedy with its definite effect upon the bowels produced such a revulsion of feeling as to cure the hysteria. Anyone who has read the awful tragedy that Euripides has written in the _Bacchae_ will have had brought home to him a typical example of psychic contagion. The queen mother in the midst of one of the Bacchic orgies kills her own son in the frenzy that has come from the religious excitement exaggerated by the association of a number of women in the religious rites of the god Bacchus. It is well understood that this was not a case of drunkenness, but of psychic intoxication. Phrygian Bacchantes are described as overcome from time to time by paroxysms of curious uncontrollable automatic movements with or without disturbance of consciousness. This represents the earliest form of what came to be known afterwards as St. Vitus Dance when it spread among a number of people. Such manifestations were not at all uncommon in the East in the earlier days and they have continued during all history. In Hindustan epidemics of automatic movements, evidently choreic in character, have been known for many centuries under the name of _lapax_. Outbreaks of this kind were common in the Middle Ages and Paracelsus has described them as happening early in the sixteenth century. At any time the occurrence of an hysterical seizure in a crowded hall, and especially in a schoolroom, will lead to other hysterical manifestations. A case of chorea will induce imitative movements in susceptible bystanders that may be quite uncontrollable. Tics of various kinds are readily picked up by children and special care must be exercised to prevent their spread. In general the state of mind is extremely important in all these conditions and they can be influenced favorably only through the mind. Contagions Trifles.--Perhaps the extent to which psychic contagion influences us can be seen better in little things than anywhere else. Everyone knows how contagious yawning is. Again and again observations have been made while actors were yawning upon the stage. Nearly everyone in the theater begins to yawn in a few minutes and, in spite of the most determined {689} efforts, every now and then even the most serious-minded elderly gentleman in the audience finds himself unconsciously joining in. It seems foolish and to an onlooker appears almost prearranged. It is only necessary, however, to yawn a few times in a street car, especially at night, to have many imitators. Nearly the same thing is true of all respiratory phenomena. Sighing, for instance, is quite contagious. Coughing is often as much the result of imitation as anything else. At certain pauses in church services a preliminary cough is heard and then some scattering coughs here and there, like the musketry of scouts, and then a whole battery of coughs is let off, especially if it is in the winter time, because nearly everybody within hearing is tempted to cough. To talk about yawning or coughing or sighing before some people is almost sure to produce a tendency to these manifestations. These apparently trivial happenings help to explain many phenomena of human imitation in more serious things. Most of the phenomena associated with expression are liable to be initiated as the result of imitation. Laughing, for instance, is particularly contagious among young folks and is especially likely to be insuppressible when they wish to be particularly solemn. At religious services it takes but little to make people laugh and giggle, no matter how much they may wish to be dignified and reverential. A few giggling girls will sometimes disturb a serious service. Extremes are particularly prone to meet in this matter and the sublime easily becomes the ridiculous. A titter will set off even the best intentioned of young folks in spite of resolutions to the contrary. Crying has something of the same contagious nature, though it is not quite so strong, but among women tears are particularly likely to evoke tears. The epidemic of curious manifestations of expression, usually of an hysterical nature, that we know by tradition to have spread in communities in the Middle Ages and much later, are only typical examples of this tendency for modes of expression to be contagious to an exaggerated degree. Expectoration is largely dependent on imitation, sometimes conscious, of course, but often quite unconscious. In the recent crusade organized to prevent the spread of tuberculosis the question of expectoration as a diffusing agent of the bacilli has given a new importance to observations on this subject. It is recognized that we have "a spitting sex" and that men spit from force of habit, boys imitate them, while women and girls almost never spit. There is no reason in the world why when men and women are engaged in the same occupations there should be any difference in this regard between them, yet employers know how hard it is to keep corners and by-places in the rooms where men work free from expectoration, while no such difficulty is found where women work. We have a spitting sex because of psychic contagion, and in spite of the fact that there are serious dangers connected with the habit. What is true of spitting may also be true of other habits relating to the respiratory passages. Hawking and blowing the nose more frequently than is needed are spread by psychic contagion and certain habits in these matters that are injurious to the respiratory apparatus often require considerable effort to break. Fads and Health.--Enlightened as we think ourselves, we have many more examples of psychic contagion in the present than we would perhaps care to admit, unless the facts were called to our special attention. {690} At a particular period in the modern time it becomes the fad to do things in a special way. We write alike, we build our houses after a common type. We take our recreation in a particular fashion. Bicycling comes in and goes out; roller skating attacks nearly every one of the young folks and then is abandoned. There are fashions in everything and fashions, after all, are recurring instances of psychic contagion. The mental influence spreads from one to another. It may be that a particular fashion, as in houses or in clothes, is especially ugly. That makes no difference. After a time taste revolts against it, but in the meantime the psychic contagion is enough to overturn the canons of taste. There are fashions in literature, or at least what is called literature. The nature novel comes and goes, then the novel of adventure has its place, then the detective novel, after a time the little-country prince or princess and their romance comes into fashion. After a time we realize that these are passing fancies, but in the meantime they have influenced many people. Some of these fashions bring conditions that are deleterious to health. The moving-picture show in places that almost never have a stime of sunlight in them and are, in their way, quite as bad, especially for respiratory troubles, as the dust-laden atmosphere of the roller-skating rink, become the fad of the moment in spite of knowledge or ignorance of hygiene. Just now we are in the midst of a fad for fresh air, that, unfortunately, goes and comes with the centuries and we have no guarantee that people will not learn again to live in closely sealed houses. High heels come and go, as do corsets of various kinds, more or less injurious, in spite of the admonition of the physician. In fact, one of the most interesting studies in psychic contagion is the history of the fashions. A particular fashion, especially in its exaggerated forms, will probably look well on about one-fifth of the women at a given time. About four-fifths of them, however, adopt it in spite of the fact that on three-fifths it emphasizes certain qualities that it would be well to keep in the background. It is woman's principal desire to please, yet this is completely perverted by the psychic epidemic of fashion which causes people to follow after others quite as much as did the medieval people in various fads that attracted attention and have come down to us. Our enlightenment, at least in as far as that word means general diffusion of the ability to read, has rather added to the power of psychic contagion. People accept ideas from others almost as unconsciously as they catch disease from those suffering from it. The psychology of advertising shows how easy it is to make people accept things just by insisting on them and by frequent repetitions of statements. The psychology of the proprietary medicine business in modern times is about as typical an example of psychic contagion induced deliberately as one could well imagine. Those who stop to reason do not fall victims. Most people, however, do not stop to reason. They have not the mental resistive vitality to render them immune to the influence of certain irrationalities and so literally hundreds of millions of dollars have been spent on perfectly useless, oftentimes harmful drugs, which people had become persuaded through the psychic contagium of printer's ink were sure to do them good. The psychology of the mob has been studied somewhat in recent years and it shows how clear it is that men follow after one another in doing foolish things even more than in doing wise ones. Psychic contagion is a prominent factor in life, it always has been, is now, and evidently always {691} will be, and must be reckoned with by anyone who wishes to recognize the principles that underlie psychotherapy. Suicide Contagions.--It is with regard to much more serious things than fashions, however, that psychic contagion is most manifest. For instance, there is no doubt that suicide is frequently the result of such psychic influence. Seldom does it happen that a very queer suicide is reported without there being certain imitations of it more or less complete in various parts of the country afterwards. There is no doubt that the reporting of suicides has a serious effect in this matter. Perhaps the most striking example of this that we have ever had in America was the well-known suicidal epidemic at Emporia, Kansas, which reached its height just about the middle of June, 1901. Two or three well-known people in town committed suicide at the end of May and the beginning of June. A veritable epidemic of suicide broke out as a consequence. Nothing seemed to stop it and the authorities were much disturbed. Finally it was agreed that the most potent influence in bringing about the imitation of the epidemic was the publication of the details of the suicides in the papers. The Mayor of the city, after consulting with the Board of Health, decided to issue the following proclamation: I have consulted the Board of Health, and if the Emporia papers do not comply with my request I shall have a right to stop, and I will stop summarily, the publication of these suicide details, under the law providing for the suppression of epidemics. There is clearly an epidemic in this city, and although it is mental, it is none the less deadly. Its contagion may be clearly shown to come from what is known in medicine as the psychic suggestion found in the publication of the details of suicides. If the paper on which the local Journals are printed had been kept in a place infected with smallpox, I could demand that the Journals stop using that paper, or stop publication. If they spread another contagion--the contagious suggestion of suicide--I believe the liberty of the press is not to be considered before the public welfare, and that the courts would sustain me in using force to prevent the publication of newspapers containing matter clearly deleterious to the public health. Murder.--In almost the same way murders prove contagious. Especially is this true of murder and suicide together. These occur notably in groups. A man who is downhearted and for whom the future looks blank, will, out of a sense of pity for those who are dependent on him, murder them and himself; then the brutal story is reported and another tottering intellect gives way and a similar story has to be told within a few days. A mother who is melancholic about her health and includes her children in her gloomy outlook makes away with them and herself. Within a few days a similar story is reported because of the influence of psychic contagion. Very often there are distinct imitations of the methods employed in the first case. Often, however, it is only the idea itself that has proved contagious. There is no doubt that this suggestion brings about subsequent cases when otherwise such an awful thought might not occur. The connection is too clear for us to doubt the reality of it or to think that it is mere coincidence. As in Emporia, doubtless the suppression of the description of such events would have a beneficial effect. There are many disequilibrated minds, apparently just tottering on the verge of an insane act of this kind, that are pushed over by the suggestion furnished by the details of another story. {692} Place of Psychic Contagion.--The physician who would treat nervous patients successfully and use psychotherapeutics to advantage must recognize the place that psychic contagion has in influencing the generality of mankind. We know that direct suggestions are profoundly influential. It must be constantly kept in mind, however, that indirect suggestion, suggestion that does not come by any formal method, but that is represented by the examples of those around, also has great weight. Favorable Influence.--Fortunately it is not alone for evil that psychic contagion is manifest. People in a crowd stand fatigue better than when alone. Soldiers marching in step do not notice their tiredness to such a degree and even forget their sore feet. People suffering from hunger, so long as there is a good spirit among them, will help each other to bear it. The accidents in coal mines in recent years in which men have been imprisoned for considerable periods have shown that in groups they stand the hardships of confinement and of lack of food and water better than they do when alone, men live longer, they do not suffer so much or at least their suffering is not so insistent, and they bear up better. This has been particularly noticed in the cures at various watering places. The very air of the place takes on a favorable suggestion that is helpful to patients. The routine, the hopefulness of those who are completing the cure, the stories of improvement, the evident betterment, all these things combine to give a psychic contagion of health. Health is, in this sense, quite as contagious as disease. This must be taken advantage of just as far as possible for the advantage of patients. On the other hand, ideas are contagious for ill and patients may derive from their environment notions that prove auto-suggestive and against which it is extremely difficult to work. Ideas derived from the general feelings of those around, without any direct suggestion, may become obsessions. The physician, therefore, must be ready to secure prophylaxis against psychic contagion and then by counter-suggestion relieve the patient, who has become afflicted by it, of the resulting disturbance of mind. It must not be forgotten that, instead of being less susceptible as education and civilization progress, people really become more susceptible. Psychology of the Mob.--The most interesting instance of psychic contagion is the tendency just hinted at for crowds to run away with the sober judgment of serious sensible people that happen to be among them and do things that may be extremely regrettable. A mob always follows the suggestions of the worst elements in it unless perchance there is some extremely strong character who asserts himself and imposes his views on the rest. The tendencies to panic, to cowardly flight, sometimes to destructiveness, that come over crowds represent the power of psychic contagion to override reason. An alarm of fire will, if a few persons lose their heads, lead to the most serious consequences. Persons trample over one another, pull and maul one another, sometimes even pulling out hair or pulling off ears in their insane efforts to escape what is often an imaginary danger, though a few moments before they were rational beings and they will be quite reasonable a short time after. It is possible, however, to overcome even the worst tendencies in human nature by the suggestive power of discipline. Fire drills in schools enable children to get out in a few minutes without confusion when without them the most serious results could be looked for. Discipline and training, {693} following commands and observing tactics, helps an army almost more than the individual courage of soldiers. The suggestive influence of the thought that now is the time to do something that has often been done before at the word of command is enough to enable the soldier to control his panicky feelings. The difference between the trained soldier and the raw recruit is great, but it consists only in this mental discipline and self-control. Prevention.--Evidently, then, in the many circumstances in life in which psychic contagion manifests itself it is perfectly possible to overcome its influence by such discipline and mental training as gives the individual control over himself. In children corporal punishment is often not effective in breaking up habits and tendencies and the motive of fear often lessens self-control and makes conditions worse. In older people the fear of punishment is likely to be forgotten, whereas the suggestion of discipline will assert itself powerfully. Psychic contagion can be neutralized by psychotherapy, but its force in life must be recognized and its unfavorable influence guarded against. While it concerns mainly the less serious things of life, it may affect the most serious and imitation leads even to such serious criminal acts as suicide and murder. The modes of psychic contagion, then, must be constantly under surveillance. With this before us it is extremely interesting to realize how unfavorably suggestive for human health and happiness are our newspapers. They are constantly suggesting disease and suicide and murder and sex crimes and crimes against property, by giving all the details available with regard to these subjects. Such news can do no good, only excites morbid curiosity which requires still further satisfaction in the same line, and keeps thoughts with regard to these things constantly before the mind. We have had many burglaries and holdups and stealings of various kinds as a consequence of boys and even girls seeing the pictures of crimes in the moving-picture show. The saturation of mind with disease and crime produced by daily reading of unsavory and sensational newspaper accounts is sure to produce evil effects. There seems to be consolation for some people in reading of the crimes and punishments of others because they feel that, bad as is their own state, there are others who are worse. This _schadenfreude_, "harm-joy" as the Germans call it, is not satisfying to think of for human nature and it has an inevitable reaction through the unfavorable suggestion of these crimes. I have found over and over again that the prohibition of reading the newspapers for a time did many nervous people much good. This is particularly true for sufferers from such forms of psychasthenia as bring down on them dreads and premonitions of evil in fears for the development of disease and in general a sense of instability with regard to the future, lest dreadful things should happen to them. At first patients object strenuously and seem to be deprived of a great satisfaction. After a time, however, they are invariably persuaded of the fact that the absence of mental contact with human misfortune, in this morbid way, is doing them good and that their dreads and premonitory feelings of evil drop from them. {694} SECTION XIX _DISORDERS OF WILL_ CHAPTER I ALCOHOLISM In recent years so much has been said about addiction to alcohol as a disease rather than as a habit that the treatment of it frankly as a disease in psychotherapeutics, even though there be not entire readiness to agree with those who emphasize exclusively the pathological interest of these cases, will not seem surprising. It is with regard to the various habits, drug and alcoholic, occurring in neurotic subjects that psychotherapy proves most effective and has secured some of its real triumphs. As a matter of fact, it has long been conceded that all of the so-called cures for alcoholism are dependent for their success upon the mental effect produced upon the patient. Most of them emphasize the necessity for building up the physical condition of the patient as a necessary preliminary to any lasting cure. There is no doubt that the powers of resistance of a man whose physical health has been seriously impaired by over-indulgence in alcohol and the lack of food and irregular sleep and exposure to the elements that so frequently accompany it, will not be sufficient to enable him to break off the alcohol habit, nor afford him the ability to inhibit the craving for stimulants, that he would have in a state of health. On the other hand, even in good health, unless his moral character is braced up, there will surely be a return to his old habit. Historical Résumé of Cures.--We have had many different cures for alcoholism exploited during the last half century. The older method of the first inebriate asylums founded in this country was to give a man a disgust for liquor, as it was then called, by putting a small amount of alcohol into practically everything that he consumed. This did not give him enough to satisfy his craving, but it did create in him an intense distaste for it by constantly keeping the flavor before him. There was a drop or two of whiskey in his tea, there was some whiskey in his milk, there was a taste of it in the water that he drank, there was some of it mixed even in the gravy of his meat, and he always had weak brandy sauce on his dessert. The consequence was, in most cases, such a complete disgust for liquor that men were sure that they would never touch it again. Of course, in the meantime they were fed well and heartily, they were kept in an environment free from temptations to excessive indulgence in alcoholic drinks, they had brought home to them what a mess they were making of their lives and their health, they had time to reflect what ruin they were bringing on themselves and their families and usually they {695} recognized that they were the kind of men who must stay away from alcohol absolutely, for whom there could be no such thing as a moderate indulgence in stimulants. This, with the intense distaste for alcohol, amounting almost to nausea at the sight of it, acquired from the system in vogue, started them well on the road to reform. _Moral Cures_.--It was the moral elements in the cure, however, that were the most important, though its inventors were sure that the physical elements played the largest role. The physical disgust for alcohol consequent upon having its taste constantly recur in everything at table passed off in a few weeks or at the most a few months. It was then that the moral uplift came in and had to be effective if the patient was to be preserved for the future from his old habit. If he was of a weak and flabby character, if, unfortunately, he was placed in circumstances where temptations were frequent, if, owing to the enforced absence in the inebriate asylum his business affairs had become involved and he was subject to many worries, then almost surely he dropped back. As a result his case was even more hopeless than before and, indeed, second cures were seldom of much benefit, for the man's confidence in himself was gone. All in all, however, this old-time, simple method probably produced as large a proportion of "real cures" as any other method, even the much advertised and discussed scientific discoveries of modern times. All of us have heard stories of men who had seemed to be hopeless drunkards, who were thus reformed and hundreds of men who appeared to be drifting into hopeless inebriety were reformed to such an extent that they became not only useful members of society and supports to their families where they had before been a drain, but even became leaders in the work of uplifting the character of others to resist the temptation of over-indulgence in stimulants. _Modern Cures_.--Of late we have had a number of "cures" for alcoholism widely exploited by well-directed advertising in the hands of men who realized what a fortune there was in this sort of thing and who actually have made immense sums of money out of them. Needless to say these "cures," though supposed to be secret, did not long remain so. Perhaps the most famous of them, the one whose institutes were found all over the country, was said to have used only two drugs, strychnin and apomorphin. The strychnin was given as a needed and well-chosen tonic for the physical condition of the patients who came to the institution usually in a rather seriously broken down condition. When patients began the treatment they were distinctly told that if they wanted whiskey at any time they could have it, but that the next injection of the "cure" after they took the whiskey would show how directly opposed to alcohol the ingredients of it were, by producing vomiting and prostration. As a rule, the patients came in perfectly confident of the effect of the remedy they had heard so much of. The strychnin injections made an excellent tonic for these nervous wrecks, bracing them up at once so that they felt better from the very beginning and this betterment was confirmed by the growing assurance from the physician and the patients around them that now, at last, they were to be relieved of their degrading habit. To those whose craving for alcohol returned in spite of the favorable condition in which they were placed and the stimulation of the strychnin, which made up so well, as a {696} rule, for the absence of their accustomed alcohol, whiskey was actually allowed. When the next time for their injection came, however, these patients who had been given whiskey on their request did not now receive an injection of strychnin but instead a small injection of apomorphin. The apomorphin acted promptly in making the stomach relieve itself and produced a complete and immediate sense of prostration. The limpness and discomfort of seasickness is as nothing compared to the state that, as a rule, develops after such treatment. Anyone who has ever had to handle, in a hospital, a wildly drunk, long-shoreman, whose brute strength in his irrational condition made him a dangerous object for patients and physicians, who has seen even large doses of morphin fail to produce quiet, and then has felt bound for the patient's sake as well as those around him, to administer a tenth of a grain of apomorphin with the result of having an eminently tractable patient in a few minutes, will have a good idea of what happened to the poor alcoholic who got apomorphin instead of strychnin. After that the inebriate knew that any further indulgence in liquor would be followed by this extremely unpleasant result and so he had a new argument for avoiding it. After a month or six weeks of careful treatment, the preliminary rest that would restore physical health and strength being followed by a course of exercise in the open air with plenty of good food, pleasant surroundings, and hope constantly held out to them, it is no wonder that these patients went out of the sanitariums as a rule confident that their habit was conquered for good. In many cases this proved to be true. It was soon found, however, that there were many relapses. This hurt the prestige of the "cure" and the gradual diffusion of this idea spoiled its effectiveness. It still continued to do good, however, and though it has been modified in various ways, and, indeed, in various parts of the country is said to be applied quite differently, there are still many reformations worked by these cures every year and they undoubtedly do good. The secret of its success, however, is not any marvelous drug or other mode of treatment that is employed, but is because the victims of alcoholism are given an opportunity to retrieve their physical condition and then to brace up their moral characters so as to resist their craving for alcohol. _Mental Influence_.--Other so-called cures and treatments have followed almost exactly similar lines. The main element in the cure has been the producing in the mind of the patient a definite idea that he can stay away from liquor if he really wishes to and then helping his run-down physical condition so that he craves stimulants less than before. Whenever such "sure cures" are used on the worst forms of alcoholic patients as we see them in the large general hospitals of our greater cities, the bums of the streets, the drunkards of a score of years or more, they have practically no effect. The man must have moral stamina, he must have some character left, besides, as a rule, he must have some good reasons in worldly interest to help him to brace up and then he may get away from alcoholism if he sincerely wills to reform. The important element, however, is the will to do so. If he is firmly convinced that he cannot stay away from liquor, if he feels in spite of all that has been done for him that he cannot resist his craving, then, of course, he will not reform. Men, however, who have sunk to the lowest depths, who, according to their own and others' testimony, have scarcely drawn a {697} sober breath for ten or even twenty years, sometimes have something happen to them, often it seems very trivial to everyone but themselves, that stiffens their relaxed moral fiber, that wakens their sense of manhood, that serves quite beyond expectation to give them a new purpose in life, and they reform and never drink again. It is this successful phase of the cure of alcoholism, however it may be explained, that is most interesting. It represents the most encouraging aspect of the whole question. Probably nothing more harmful has ever been done than the public proclamation that alcoholism is often an hereditary disease against which it is hopeless to struggle, and that the poor victims of it are to be pitied and not blamed. Except in those of low mentality, whether of intellect or will, or in the actually insane, there never was a case of alcoholism that did not deserve at least as much blame as is usually accorded to it. This is said after making due allowances for temperament. It is quite clear that for one man alcohol has no attractions at all, while for another the craving for it is almost an insuperable temptation. It is idle to say that these two contrasted men are equally free as to whether they shall take alcohol or not. Of course they are not equally free. If the man who has no craving for alcohol prides himself on his power of resistance against the vile habit, he is simply fooling himself. He probably knows nothing about the real nature of the temptation of alcohol. The Spaniards have a proverb: "He who doesn't drink wine and doesn't smoke, the devil gets by some other way." There is probably something else with regard to which the non-alcoholic has quite as little freedom as the poor victim of alcoholism and the great law of compensation comes in to make up to both of them, for their failings. Man has the defects of his virtues. Supposed Inheritance.--No man is such a slave to the habit, however, that he cannot correct it if he will. We have heard much about the inheritance of this disease. We have heard even more about its essentially morbid character, though people used to think it a moral defect. It must still be considered a moral defect, however, even though we all concede that there is an element of the pathological in it. We are getting away entirely from the ordinary idea of inheritance of disease. There is no inheritance of acquired characters. The fact that a man's father acquired the drinking habit because he was placed in circumstances where it was easy for him to indulge himself and because he did not have the moral stamina to resist, is no reason why his son should have an unconquerable or even a very strong craving for alcohol. One might as well say that because a father lost a finger when he was young his son would be born without that finger. Alcohol destroyed certain cells in the father's body and injured certain others, but produced no change deep enough to lead to hereditary influences. _Contagion More than Heredity_.--Perhaps some tendency to take alcohol runs in a family, that is, perhaps there is lessened resistance to the craving for stimulants that awakens in every human being if it is once aroused. This is what is true in tuberculosis. Some people have less resistive vitality to it than others. Careful autopsies show that practically every man who lives to be over thirty has or has had living tubercle bacilli in his tissues. Seven-eighths of us are thoroughly able to resist them. The other eighth succumbs. Their lack of resistive vitality may in some degree be due to hereditary taint, {698} but that is doubtful and we know that they acquire the disease by contact with others who have it already and, as a rule, it is able to work its ravages because they are not living in conditions that would help them to resist it. If they live in the free open air and have plenty of good, simple food, the disease will not run its fatal course, but nature will cure it. If the craving for alcohol is lighted up by association, aroused by indulgence, rendered strong by environment and by exposure to temptations of all kinds with regard to it, then the resistive power of the individual is so lowered that the alcoholic habit rules him instead of his being able to command it. _Inherited Resistance_.--The most curious fact that has come out in our studies of heredity in recent years has been that far from heredity working its will in causing degeneration and deterioration of mankind, immunity, for the race at least, is acquired in the course of subjection to disease and to various morbid habits. Nations, for instance, that have been subjected to diseases for long periods no longer display the susceptibility to them which they formerly possessed. After a disease has been endemic among a people for many generations that people gradually becomes quite insusceptible to its effects and suffers much less from it than before. Just this same thing is true of alcoholism. Nations that have been the longest in a position to be subject to the temptation to use alcohol in its stronger forms suffer least from the ravages of alcoholism. The southern nations of Europe using wine daily and knowing well the process of distillation to help them to make stronger drink for many hundreds of years, now exhibit much less tendency to over-indulgence in strong drink than the northern nations whose ancestors have only in comparatively recent times been subjected to the temptation of craving for strong alcoholic liquors. The attitude of any nation toward alcohol is a function of the length of time that nation has had a chance to procure strong drink easily. Our American Indians discovered, as has every people at some time, that intoxicating liquor could be made by allowing solutions of starch and sugar to ferment. It was only with the coming of the European, however, that they were provided with "fire water"--strong drink--in quantities. Its effect on them is a matter of history. Two things the white man brought his Indian brother to which the Indians were unaccustomed and that gradually obliterated the original inhabitants of this country--infectious diseases and strong alcoholic liquors. They proved equally fatal because of Indian susceptibility to them. From these considerations it is clear that just such an immunity to the effect of alcohol is produced in a people exposed to its effects in concentrated form for a long time as with regard to an infectious disease when they have been correspondingly exposed to it. Heredity, then, instead of playing a role that brings about deterioration in the race, on the contrary, carries on the higher qualities and gives us, as might be expected in the course of evolution, a better, that is, a more resistant, race. Most of what is commonly said as to alcoholism, and unfortunately most of the recent so-called popular scientific articles on this subject, seem to point to just the opposite conclusion to this. Men are supposed to be condemned by heredity to an inevitable craving to take alcoholic drinks that, in certain of them at least, cannot be overcome by any natural power of resistance. At this stage of our western civilization this is not true for anyone, as the more susceptible families have been long {699} since eliminated and it is a personal weakness and not a family characteristic that leads people to indulge this appetite to their own destruction. _Unfavorable Suggestion of Heredity Idea_.--An alcoholic patient, or even a man with only a moderately strong tendency to take alcohol to excess, who harbors any such notion as this, has a serious impediment to the full exercise of his will in overcoming the difficulties that he encounters in any attempt at reform. In going counter to so much that has been written and still more that has been said and generally accepted on this subject I feel it necessary to quote a good recent authority on the matter and so here insert these passages from "The Principles of Heredity" by Dr. Archdall Reid. [Footnote 53] He says (p. 157): [Footnote 53: Author of "The Present Evolution of Man," "Alcoholism," "A Study in Heredity," etc. Chapman and Hall, London, 1905. ] Formerly all the world believed in the transmission of acquirements, and consequently all the world was constantly finding conclusive evidence of its constant occurrence. To-day there is hardly a rag of that evidence left, and, with rare exceptions, only certain French medical observers are able to discover fresh evidence. It is a remarkable fact, however, that the problem of evolution--of adaptation--has excited singularly little interest in France, and it is equally curious that these French observations relate almost entirely to laboratory work which it is not easy to repeat. In Great Britain or Germany, you may cut off the tails of a thousand dogs, or amputate the limbs of a thousand men, or observe the non-infected offspring of a thousand tuberculous patients, and get no evidence of transmission. With regard to alcohol Dr. Reid in the same volume insists on the proposition that alcohol does not cause degeneration of a race, creating, as is claimed, ever more and more a tendency for people to take it because their immediate ancestors have taken it, but, on the contrary, there is a distinct evolution against it, and that what is hereditary, not by acquisition, but by family trait, is an immunity against the disease which eventually protects the nations that have been longest exposed to the effects of alcohol from the evil consequences of the substance. He says (p. 196): How, then, has alcohol affected the races that have used it? Are the Jews and the races inhabiting the South of Europe the most degenerate on earth? Are North Europeans only less degenerate? Are the races that have never used alcohol, the Terra del Fuegians, the Esquimaux, and the Australian blacks, for instance, mentally and physically the finest in the world? We have only to state the proposition to see its absurdity. There is no evidence that the hereditary tendencies of any race have been altered by alcohol circulating in the blood and acting directly on the germ plasm. Once again the sufferings of the peoples have produced no effect, but the deaths among the peoples have produced an immense effect. Every race that has had experience of alcohol is temperate in the presence of an abundant supply in proportion to the length and severity of its past experience of the poison. The South Europeans and the Jews are the most temperate peoples in the world. West Africans also are very temperate. North Europeans are not drunken. Those savages, and those only, who have had little or no experience of alcohol--Esquimaux, Red Indians, Patagonians, Terra del Fuegians, Australian blacks--are beyond all the peoples the most drunken on earth. Lest it should be thought that this discussion of the subject is only of significance with regard to nations and does not touch the individual, and, therefore, has but little significance for the problem that we are treating here. Dr. Reid's succeeding paragraph deserves attention: {700} Stated in this brief and direct way, the thesis is apt to excite incredulity. It is sharply opposed to popular beliefs, though that need not trouble us. Popular notions on abstruse points of science are occasionally erroneous. Of more importance is the fact that a mass of statistics purporting to prove that the children of drunkards tend to be degenerate has been compiled, especially by medical men in charge of lunatic asylums. But no "control" observations appear to have been made. We know that many drunken parents have normal children; certainly, therefore, parental drunkenness is not invariably a cause of filial degeneration. We know also that many temperate parents have defective children. There is nothing to show that the proportion is greater in the one case than in the other. Even were it established that the proportion of defective children is higher in the case of drunken parents, it would still have to be proved that the relation is one of cause and effect. People who have an inborn tendency to mental defect, who are abnormally depressed, nervous, restless or irritable, are often so constituted as to find solace in drink. Their children are liable to inherit their inborn mental defects with spontaneous variations--that is, to inherit the defect to a greater or lesser extent. The unborn child of a drunken and pregnant mother is practically another drunken person, as liable, or more liable to suffer from the effects of drink; but in such a case the resulting defect, though a mere acquirement, is tolerably certain to be regarded as a congenital (i. e. inborn) defect by the medical man who sees it. Mere acquirements, also, are the defects due to the ill-treatment, want and neglect to which the children of drunken parents are particularly exposed. Indeed, were it fully established that drunken parents, other than pregnant mothers, tend to have an excessive number of their children "congenitally defective," it would still be a question whether the filial defects were not mere acquirements. Prof. Cossar Ewart's observations on diseased pigeons renders this not unlikely. All these sources of error render the success of a statistical inquiry peculiarly difficult, if not impossible, but there is no indication that they ever occurred to the minds of the compilers. Warnings as Suggestions.--I have a case in my notes in which a rather prominent professional man insists that he is quite sure that the alcoholism from which he suffered during the ten years between twenty-five and thirty-five was entirely due to suggestion. As a boy of sixteen he had gone off to boarding school, but not until his mother had taken him aside, told him that his father had drunk himself to death, had done it by secret tippling, and that they had found that for many years he had been accustomed to have whiskey near him in his office and take it rather frequently. He had never tasted spirituous liquor at this time and his mother begged him not to, for she felt sure that if he did his father's craving would awaken in him and would become uncontrollable. The day that he went away his father's eldest brother took him aside and said practically the same thing to him. A maiden aunt was not quite so emphatic, but she, too, pleaded with him to understand all the dangers. For his first year at school he did not touch liquor, but in his second year he tasted it once or twice but had no particular craving aroused in him. By chance when he was home at Christmas time some college mates who were visiting him gave his mother the impression that he belonged to a rather jovial set. Once more he was warned by mother and uncle. Above all they told him never to keep strong drink near him because that was what his father used to do. During his college years the fear of this hung over him. He resented it and probably took more liquor than he would have so far as actual craving went. After getting out into active life once more he suggested himself into the habit of taking an occasional glass of whiskey by himself. After a time he was constantly taking too much. For {701} ten years he hurt all of his prospects, broke his mothers heart, and was looked upon as a hopeless alcoholic. Then one day the thought came to him that it was not that he craved alcohol so much, but that his thoughts turned on it constantly and at first he dreaded it overmuch, then wondered what attraction there could be and then acquired a habit by suggestion. Once this train of thought worked itself out in his mind, he quit spirituous liquors for good. For ten years he has not touched them, he does not care for them, they do not constitute a temptation. It must not be forgotten that many warnings may so preoccupy the mind with regard to a danger as to constitute temptations by suggestion. This is eminently true of alcoholism, the drug habits, sex habits and the like, in spite of the foolish present-day notion that information and warning must necessarily be helpful. In all these, teaching may be suggestively harmful. Prophylaxis.--The most important part of the treatment of alcoholism through mental influence is by prophylaxis, and that, to be effective, must begin very early. Just as with regard to overeating, as I have pointed out in the chapter on Obesity, it is extremely important not to permit children to acquire habits with regard to alcohol when they are young. During the growing years the system, indeed one may say all the systems of the body--the nervous, the muscular, the digestive and the mental systems--are all more or less unstable. Deep impressions may be produced on them then, and if children are allowed, much less encouraged, during their growing years (and this includes practically all the years up to twenty-five) to indulge in alcohol, then one can look for the development of a craving very hard to eradicate later in life. Many of them will be able to conquer the desire thus awakened, but a great many of them will not. We have some very definite evidence on this point and some of it collected here in America is very valuable. Dr. Alexander Lambert of New York made a study of over 250 cases of alcoholism seen in the wards at Bellevue Hospital, paying special attention to the age at which the patients remembered they had begun the use of alcoholic liquors. If anyone doubts the influence of youth in this matter, then his statistics should be read: Of 259 instances where the age of beginning to drink was known, four began before six years of age; thirteen between 6 and 12 years; sixty between 12 and 16; one hundred and two between 16 and 21; seventy-one between 21 and 30; and eight only after 30 years of age. Thus nearly seven per cent. began before 12 years of age, or the seventh school year; thirty per cent. began before the age of 16; and over two-thirds--that is, sixty-eight per cent.--began before 21 years of age. Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this subject in his article on "The Scientific Solution of the Liquor Problem," [Footnote 54] states emphatically the conclusion so inevitable from these statistics that more than anything else alcoholism is the result of habits and occasions created in early years. He adds some remarks that are worth noting for those who are interested in the prevention and cure of alcoholism, not only in particular cases, but also for the community: [Footnote 54: _McClure's Magazine_, February. 1909.] {702} In the light of such facts, it is clear that the drink problem is essentially a problem of adolescence. The cumulative effects of alcoholic poisoning frequently fail to declare themselves fully until later in life; but the youth who does not taste liquor till his majority minimizes the danger of acquiring the habit in its most insistent form; and the man who does not drink until he is thirty is in no great danger of ever becoming a drunkard. As to the man who has passed forty--well, according to the old saw, he must be either a fool or his own physician. His habits of mind and body are formed, and if he becomes a drinker now he can at most curtail by a few years a life that is already entering upon the reminiscent stage. As factors in racial evolution, the youth of each successive generation, not its quadragenarians, are of interest and importance. Treatment.--The conclusions that naturally flow from the historical introduction to this chapter which show mental influence as the basis of all cures, simplify very much the treatment of alcoholism on psychotherapeutic principles. There is no doubt that moral means are the only really effective remedies in this matter. They fail often, not because of any lack of power, but because of lack of co-operation on the part of the patient. There are men whose mentality and responsibility is breaking down, and who are on the way to the insane asylum for various causes, who cannot be thus influenced. They are, however, not alcoholics, but incipient insane patients likely to go to excess in any line. There is no pretense that psychotherapy will cure mental disorder that rises to the height of real insanity. On the other hand, just as after several relapses of tuberculosis due to the foolishness of the patient, further improvement by sanatorium treatment is usually out of the question, so each relapse of the alcoholic patient makes it increasingly difficult to bring about noteworthy improvement. There are examples, however, which demonstrate that even after seventy times seven relapses men may still encounter something that rouses their dormant wills to real activity and then their alcoholism is a thing of the past, for good and all. _Sanitarium Question_.--There always comes the question whether these cases need to be sent to a sanitarium or can be treated at home. The answer to this question is the same for alcoholism as it is for tuberculosis or, indeed, for any of the exhaustive diseases. It all depends on the individual's physical condition and his circumstances. If tuberculosis is discovered, as it should be, at a very early stage in the disease--not when the patient is coughing up bacilli in large numbers and already has many physical signs in his lungs, but when he has a slight unproductive cough and over-rapid pulse and some prolongation of expiration at one apex--then he may be cared for at home, if the physician is confident that he can make his patient feel the absolute necessity for following instructions and can make him realize the seriousness of his condition in spite of the few symptoms that are present. If his environment is unfavorable, in a crowded tenement house or where an abundance of fresh air cannot be readily obtained, the patient may have to go to a sanitarium for proper treatment even at this early stage, or at least he will have to change his living conditions. This question has received a very different answer in recent years from what used to be given to it. Formerly the physician hesitated to say "tuberculosis" to his patient until the disease was well advanced and then he advised the distant West or some other change of climate, though, as a rule, this brought only a palliation of symptoms, the case being too far advanced, and {703} the fatal termination came in the course of two or three years. Now the careful physician diagnoses tuberculosis much earlier, detects the disease in its incipiency, and is able to treat the patient at home quite successfully, if conditions are at all favorable. It is true he has to make him give up fatiguing occupations, and especially those in dusty places; he has to insist on his living out of doors a good part of the day, even though there should be no better means of securing this than the roof or a fire-escape, and on keeping his windows open all night. He has to watch his nutrition carefully and see that he gains in weight. If all this can be accomplished, however, there is no reason why a tuberculosis patient in the incipient state should not get better at home almost as well as he would at a sanitarium. The only difference between the two methods of treatment is that in a sanitarium the patient realizes that his one duty in life is to care for his health and he does not bother about other things, as he is likely to do if he remains at home. If this precious development of teaching with regard to tuberculosis, which is founded on such thorough-going common sense and the application of good therapeutic principles to the treatment of the disease, be transferred to the sphere of alcoholism, then the answer to the question whether there shall be sanitarium treatment or not is practically arrived at. If the patient is in an early stage of his alcoholism, if the pathological character of his tendency to take intoxicants has been recognized and made clear to him early, then there is little difficulty in treating him at home. The crux of the problem is just that which occurred with regard to tuberculosis years ago. The physician does not take the early symptoms of the affection seriously enough. He does not want to disturb his patient's equanimity by the suggestion that he is in the incipient stage of alcoholism any more than a few years ago the family physician cared to suggest the awful thought of tuberculosis until the condition had reached a serious stage. But this is the essential preliminary to the successful treatment of alcoholism just as it is to the successful treatment of tuberculosis. It is almost useless to send advanced cases of tuberculosis, in which cavity formation has already occurred, to a sanitarium. The course of their disease may be delayed for a while, but scarcely more than that. Their resistive vitality has been so overcome by the ravages of the disease that their ultimate cure seems beyond hope, yet not infrequently wonderful results are obtained even in these cases. Just this same thing is true with advanced cases of alcoholism. No one can do anything with them, though careful treatment in a sanitarium may, on a number of occasions, afford them opportunity to brace up and be themselves, i.e., their better selves, for several months. Just as with tuberculosis, however, even the quite advanced cases will sometimes be so much bettered by sanitarium treatment that, though their prognosis seemed absolutely hopeless and was so pronounced by good authorities, all the symptoms are relieved and the patients get a new lease of life that may last for many years. In the same way some apparently hopeless cases of alcoholism will brace up after sanitarium treatment and have many years of useful sober life without a break. In alcoholism, as in tuberculosis, the will of the individual is the all-important consideration. Someone has said that tuberculosis takes away mainly the quitters. Those who have the courage to insist that they {704} _will live_ in spite of everything being apparently against them, pull through crises that seem absolutely hopeless and survive for years. Robert Louis Stevenson bravely doing his work, living on in spite of fate and disease, is the typical example. Alcoholism completely overcomes only the quitters. If a man wants to give up drinking even when he seems practically a hopeless wreck from the effects of alcohol, he can do so if he has a physician in whom he has confidence, who will relieve him from depressing symptoms due to previous excess, who will lift him up and strengthen him by food and stimulation, and, above all, by faithful, unending, never discouraged assurance that he can conquer the craving which has such a hold of him, if he only persists a little and does not give up the struggle. The victory is worth while and it is not hard to lift a man up if he has any remnants of character left. _Confidence_.--In the treatment of alcoholism, then, just two things are necessary. One of these is that the patient has confidence in himself, the other that he has confidence that his physician can help him over the hard spots on the road. There is no doubt that many drugs can be used that will lessen the patient's irritability, increase his nerve force, stimulate organs which are depressed by the reaction against over-stimulation, arouse appetite and correct disturbed functions. All these things must be done. It is no use laying down any set of rules as to how they shall be done, for they must be done differently in individual patients. It is not alcoholism that is treated nor the effects of alcoholism, but an individual alcoholic patient, and a set of symptoms that are very different in every individual. The more physiological disturbance can be relieved by proper drug, dietetic, hydropathic and remedial measures, the more chance is there for the patient to get over his habit without trouble. Every ill feeling that he has tempts him to think of alcohol. Above all, he must be made to sleep, his bowels must be thoroughly regulated, and he must be made to eat heartily. For stimulation full doses of nux vomica, not less than thirty drops three or four times a day or even oftener, are probably best. For cases of alcoholism in the earlier stages there is but little difficulty. Those who try the effect of favorable suggestion, of confident assurance, of constantly repeated encouragement on individuals who have begun to be afraid that they cannot break the habit, will frequently have the most gratifying results. The important point to remember is that men are suffering from alcoholism who are indulging in alcohol every day and to whom it has become more or less of a necessity, though even as yet its effect upon their business is not marked and they are not known, even among their acquaintances, as drunkards. Whenever a man must have three or four whiskeys a day or he cannot do his business and his appetite fails him and he does not sleep well, he is an alcoholist. He has the cellular craving that later may become an absolute tyrant. If we can educate the community generally to realize this as we are gradually educating them to the knowledge that tuberculosis must be caught in its incipient stage and that pulmonary consumption begins in very mild symptoms after a person has been exposed to it, we shall have little difficulty in curing tuberculosis or in treating alcoholism successfully by suggestion. For alcoholism, as for the drug habits and also the sex habits, moral influences are all-important. Hence the necessity for exercising them {705} frequently. It is probable that the best way to break any of these habits is to have the patient come regularly to the physician's office, at least once, and at the beginning twice a day. In cases of alcoholism the method of giving for the first week, at least, the dose of the stimulant drug which replaces the alcoholic stimulation directly to the patient is often of great service. It seems a good deal to ask the patient to come three times a day just to get a drug (tonic), but it is comparatively easy to resist the craving for liquor for four or five hours, that is, until the doctor is seen again, while sometimes twenty-four hours will seem a long while. The personal element in this matter is extremely valuable. It is this that has made the efficiency of all forms of cures, and it is only this that can be successfully used. How much can be accomplished for even the worst forms of drunkenness and under extremely unfavorable circumstances once a really strong impression is made on the individual's mind and his will is aroused to help himself seriously may be readily learned from the lives of any of the great temperance advocates. Their experience is illuminating. It shows clearly that strong personal influence will do more than anything else for these sufferers. Sometimes their efforts are supposed to affect only certain classes of individuals who have character but who, for some reason, have fallen into an unfortunate habit. A little investigation will show, however, that they affect all classes and kinds of individuals and, indeed, may reform a whole community. The story of Father Matthew is very interesting in this regard because there is some striking testimony as to his reformation of whole neighborhoods that had been given over to drink before and that among a people especially emotional and susceptible. The movement that he initiated still lives in the temperance societies of the English-speaking peoples everywhere which help by prophylaxis in youth and the moral force of association in later life. After-Treatment.--In alcoholism the most important feature of the treatment is what has come to be known in our time as the after-treatment. This department of therapeutics has taken on great importance in recent years in every form of disease. For early and middle life most diseases have a definite tendency to get better, though many of them leave distinct pathological tendencies. The after-treatment, then, has become much more important than the cure for the patient during the existence of the acute or sub-acute stage. Even in children's diseases it is now generally recognized that while measles and whooping cough are not dangerous affections as a rule, they may prove the forerunners of tuberculosis, because of the weakened pulmonary resistance consequent upon their invasion. For scarlet fever, the possibilities of injury to the kidneys after the great irritation to which they have been subjected, is now recognized and convalescence is prolonged. In typhoid fever we realize that not weeks but many months of convalescence are needed to put the patient beyond the risk of various degenerative processes that may be serious. There is even question in the minds of many observant physicians whether the weakness incident to typhoid fever may not, if a premature return to work is allowed, prove a potent cause of precocious arterio-sclerosis. In a word, after-treatment has become one of the most interesting subjects of modern therapeutics. It will not be surprising, then, if we insist that the after-treatment of the alcoholic is the most important part of the remedial methods to be employed. If a man who has suffered from tuberculosis because {706} he was working in one of the many dusty trades and living in a badly ventilated tenement house is restored to health or at least has all his symptoms disappear as a consequence of sanitarium treatment, it is almost needless to say that he must not be allowed to return to the conditions in which his disease originally developed. If he does, he is absolutely certain to have a relapse. This phase of tuberculosis has been much discussed in recent years. It is often said that it is impossible to keep working people from a return to their occupations. Just so far as that is impossible, so far will any real hope of keeping their tuberculosis in abeyance be reduced. They are much more likely to suffer from the disease, as a rule, after their return from the sanitarium than they were before they originally contracted it, because apparently some of their immunity has been destroyed by the invasion of the bacillus. It is only recently that we have thus planned for the after-treatment of tuberculosis. If we are to be successful in the after-treatment of alcoholism, at least some of this same thoughtfulness must be exercised. The victims must be discouraged from going back into the conditions in which their habit developed. It is comparatively easy, especially at the beginning of his alcoholism, to stimulate a man back to normal physical condition, to reduce his craving for intoxicants, give him back his appetite and set him on his feet again. The affection is quite curable. If a man returns to the conditions in which it originally developed, however, it will develop again quite as inevitably as tuberculosis does under similar conditions. We do not blame the sanitarium if, after having given a man a new lease of life in spite of tuberculosis, he resumes the unsanitary life in which his disease originally developed and has a relapse. It is not the fault of the system of treatment for alcoholism if men relapse, but the blame is upon them that they do not take their danger of relapse seriously enough, permit themselves to get into an unfavorable environment, and, as a consequence, suffer once again from their affection. _Religious Motives_.--More and more we are realizing the place of the higher motives of life in the reform of alcoholic patients. Religious motives probably form the best possible source of suggestions that enable a patient to lift himself out of the slough of despond of chronic alcoholism. Many of the best workers for the reform of the drunkard were themselves drunkards for many years. The motive of helping others is particularly important in its effects upon any alcoholic. Some motive apart from himself is more helpful than any appeal to his selfishness or even to what he can do for his children and his wife. It is the newer motive that appeals most strikingly. In recent years certain church movements have done much for alcoholic patients. In this they are only repeating the effect of other great church movements and the effect of the lives of apostles of temperance in recent generations. Without these higher motives cure is probably impossible in many cases. With them it not only becomes possible but even comparatively easy in the most hopeless-looking cases. In the light of what we have heard recently of the success of the Emanuel movement in the treatment of alcoholism, it is interesting to recur to what was said in this relation by Prof. Forel of Zurich on the treatment of alcoholism, in a communication read to the South German Neurologists and Psychiatrists at its meeting in Freiburg over twenty years ago. Prof. Forel, who is not what {707} would be called a particularly religious-minded man, insisted that "an inebriate asylum can only with great difficulty be successful without religious auxiliaries, since most inebriates, and especially at the beginning of their reformation, are entirely too weak to get along without religious consolation. To secure this, however, the nicest tact is required in order to permit the practice of all the different nuances of faith that men have, in peace and comfort. This can only be secured if in practice faith is subjected to charity for one's neighbor as the basis for religion." Many such expressions have been used before and since in practically every country in Europe. The assertion that physicians have failed to recognize the part that religion plays in such cases is entirely without foundation and can only be made by those who are quite ignorant of our medical literature. CHAPTER II DRUG ADDICTIONS Much of what has been said with regard to alcoholism finds ready application to the treatment of drug addictions. At the very beginning it must be realized that there is no specific remedy that will enable the patient to overcome his craving for a drag to which he has become habituated. There is no method of treatment that will infallibly and without serious and prolonged and determined effort on his part enable him to overcome his craving. The first and most important thing in any system of treatment is the patient's good will. If the patient is not ready to give up the drug, then nothing that a physician can do for him will make him do so, or will turn him against it; above all, nothing will make the process of cure so easy that there will be no trouble involved or only a passing period of struggle required to accomplish it. There have been many claims made in this matter. We have wanted such remedies and methods of treatment so much that it has been rather easy to persuade us sometimes that they have been discovered. It is like the question of specifics in medicine. For centuries men devoted themselves to trying to find a specific remedy for each disease. It was thought they must exist in nature. Now we know that they probably do not exist, though those who claim to discover them find an easy livelihood exploiting the credulity of those who still cherish the belief in them. Scientific students of medicine have practically given over the search for them in order to devote themselves to strengthen the patient to resist the disease rather than spend more time trying to find something to give him that cures it. Treating the Patient rather than the Habit--This principle holds with special force with regard to drug addictions. We do not treat the patient's habit, but we treat the patient. He must be braced up, must be made to understand that if he wants to quit the habit, no matter how slavishly he is addicted to it, he can do so. He must be told of men who had habits like his, often of longer duration and to a greater degree, yet gave them up when firmly resolved and properly stimulated. It is not hard to find such examples, since medical and even ordinary literature abound with them and every physician's experience furnishes him with instances. The first and {708} most absolutely necessary preliminary of the treatment is to lift up the patient in his own eyes and make him understand that, low as he has sunk, his case is not hopeless, that his degradation is not at all uncommon nor so rare as he might think, and that men and women have succeeded in lifting themselves out of conditions worse than his. The psychotherapeutist must, above all, not be of those who insist that human nature is degenerating and that people are much weaker physically and morally than they used to be, though of course he must be thoroughly aware that drug habits are more frequent than they were and are quite alarmingly on the increase. This is not due to any deterioration in human nature, however, but mainly to the excitement of modern life and its inevitable reaction, the strenuousness with which men now take existence and the consequent craving for artificial relief from over-activity, and then, above all, the facility with which the habit-forming drugs can be obtained. Prophylaxis.--This last point accounts for the frequency of drug habits in our time more than anything else. Men have always been ready to do something for the sake of novelty and excitement. Everyone is curious to experience for himself the effects produced by drugs that can make people such slaves to them. We hear too often of the intense pleasure that the drug habitué gets from his use of drugs. The curiosity thus aroused constitutes the suggestion that has led many to try the effect, confident that he or she would be able to resist any craving just before it became seriously tyrannous. Psychiatrists agree that one of the worst elements in modern social conditions is the impression generally maintained that there is such intense pleasure in the taking of drugs. A clear statement of the reality of the case is eminently desirable. It is not positive pleasure that the drug habitué has, but mere negative pleasure, as a rule. His "dope" does not so much add to his good feeling as take away the bad feelings that he has because of depression or ennui at the beginning and later because of the craving for the drug. Physicians to whom many drug habitués have told their experience frankly are not at all inclined to think that the usually accepted opinion of pleasure in drug taking is true. It is not that it is heaven to have the drug so much as it is hell to be without it. The patient's system has learned to crave it so much because of the surcease of painful consciousness of self it gives and this it is that compels these unfortunates to go back to ever-increasing doses. The pleasant side is a very dubious affair at all times, accompanies only the earliest steps of the formation of the habit at most, and usually whatever agreeable feelings there are are accompanied by such a nightmare of solicitude and anxiety as a background that the pleasure is more poignant than agreeable. As a prophylactic against the formation of drug habits this aspect of the experience of drug habitués deserves to be emphasized and knowledge of it widely diffused. Of course, the morphin fiend brightens up after his dose of morphin, his eye lightens, his expression becomes happy, and his nerves get steadier, but that is only because the depression in which he was sunk before has now been stimulated away, the struggle with his worst feelings is over and the consequent reaction has developed. Of course, the cocain-taker is pitiably helpless and downcast without his "dope," but it is only by contrast with this previous state that his succeeding condition can be said to be pleasant or agreeable, even to himself. {709} _Favorable Suggestion_.--One of the most helpful sources of favorable suggestion for these patients is to be found in the stories of cured drug habitués. These may be used tactfully to bring confidence to patients that they, too, can be broken of their habit if they are willing to take the pains to do so. De Quincey, taking his thousand drops of laudanum a day, represents one of the most encouraging examples of this since he succeeded eventually in breaking away from his habit. Coleridge succeeded, also, in breaking his habit more than once, but unfortunately returned again and again, and illustrates the danger of the almost inevitable tendency to relapse, if the patient permits himself to think that now that he has once conquered the habit he is too strong ever to let it get hold of him again. If he ventures to think complacently of his self-control and that consequently he may with impunity--always for some good reason--take a dose or two of his favorite drug in order to tide him over some crisis of mental worry or some spell of physical pain, relapse is certain. The tendency of patients to fool themselves in this way is too well known to need special emphasis, but it is as well to say that there is scarcely a single cured case that does not relapse. The relapse is due not so much to craving for the drug, as to the memory of its previous effects in relieving discomfort and the unfortunate confidence that the patient has developed that now, knowing the dangers, he will be able to resist the formation of the habit before it gets a strong hold of him. It is curious how even highly intelligent patients will slip back into their old habits, sometimes deeper than before, on this reasoning, in spite of the lessons of experience, even their own as well as others. Like the drunkard, they persuade themselves that just this once will not count, and when it would have been comparatively easy for them to say no they yield once or twice and make self-denial for the future increasingly difficult. This is especially true if patients have the drug near them, so that it is not difficult for them to have recourse to it. Hence doctors and nurses are not hard to cure of such habits, as a rule, provided they are away from their professional duties, but they almost inevitably relapse when they go back to work. Every time the relapse is due to the fact that tired feelings, because of irregular hours or some physical pain, prompt them to seek relief and they yield to the temptation of taking the old drug, sure that they need it, only for the moment. They will all assert that they could just as well resist as not, that, indeed, had not the drug been so handy, they would not have taken it, and that if anyone had been near to help them by a word in the matter even then they would not have indulged in it. If patients are to be kept from relapsing, all this must be set before them frankly. After they have been told once or perhaps twice or perhaps many times and yet relapse into their habits, they must simply be told it again a little more emphatically, more encouragingly, up to seventy times seven, if necessary. Patience is needed more than anything else in taking care of these cases. Over and over again their confidence in their power to overcome their habit, if they really wish to do so, must be reawakened. Without this confidence in themselves success is hopeless. It matters not how often they have relapsed, they can still break off the habit, and if they will not fool themselves into over-confidence in their power to keep away, they need never be slaves to the habit again. There will be quite as many disappointments in {710} treating drug addiction as in the treatment of alcoholism. Those who have most experience insist that there are even more, but there are some wonderfully encouraging examples of men and women who have broken from their habit, even after a number of bad relapses, and have for many years lived absolutely without any of their drug and, though still not over-confident in their power to resist if once they should yield (such confidence, it cannot be repeated too often, is always fatal), do actually keep away from the drug without any other bother than the necessity of living a regular hygienic life and exercising a little self-control. In drug addictions as in alcoholisms, the question of sanitarium treatment comes up in every case. Much more rarely than in the case of the alcohol habit is it necessary to send a drug habitué to a sanitarium. Here once more, however, the patient's circumstances and the possibility of diversion of mind with reasonable freedom from temptations to take the drug and from ready access to it, are the most important considerations. If a patient really wants to break off the use of a drug, it can be done gently and without much bother in the course of three or four weeks. I have seen cocain fiends who have tried many remedies and many physicians completely cured in five or six weeks without serious trouble. The important thing is perseverance in the effort and in the treatment and the definite persuasion of the patient that it is not only perfectly possible to get rid of the habit, but that it is even easy with good will on his part. If certain other milder stimulants are supplied for a time so that all the symptoms due to the physiological effects of the excessive use of the drug are minimized, the physical trial need not be severe. The patient's mind, however, must be occupied. Time must not be allowed to hang heavy on his hands and all physical symptoms must be treated promptly. Drug addictions are indeed more curable than alcoholism and the danger of relapse is not quite so imminent. The social temptations do not exist for drug habitués as they do for alcoholics. As I have said, however, in the cases of nurses and physicians almost a corresponding state of affairs obtains and in them the danger of relapse is great. Early Treatment.--It is quite as important for drug victims as it is for alcoholics that the case should be taken under treatment early. Every physician knows how curiously easy it is for some people, indeed for most people, to acquire a drug habit. I have seen one of the solidest men I ever knew, with plenty of character that had been tried by many a crisis in life, recommended cocain for a toothache when he was past fifty years of age and in the course of ten days acquire a thorough beginning of the cocain habit, so that he was taking several grains a day. He had no idea that he was unconsciously slipping into a drug habit. When the druggist refused any longer to supply the cocain solution without a prescription he was quite indignant. It was not until he had forty-eight hours of nervous symptoms and craving that he realized that he had created a need for stimulation of his nervous system by the mere taking of cocain by application on his gums. This habit was broken up at once and there has never been any tendency to its recurrence. He had his warning, fortunately, without evil effects. If the cocain habit can be formed as unconsciously as this, there should be little difficulty in treating it. It is not a profound change in the organism, but only a habit. It is not the habit itself that is hard to break, but the effects {711} upon the nervous system of the patient are such as to create a series of symptoms that can only be soothed by the drug. It is these symptoms of depression, irritation, sleeplessness, lack of appetite, constipation and the rest that it is the physician's duty to treat in order to help the patient. The patient breaks the habit by his will-power when properly persuaded and when it is made clear to him that it is neither so difficult as he thought, nor is he so likely to fail in the matter as he has imagined, and as has perhaps been suggested to him even by physicians. The mental treatment consists in making him realize that he can do it and that if he wants to get rid of his habit he must do it for himself. With this must come the assurance that every annoying symptom will be met, that he need not recur to his favorite drug for this purpose, that his appetite will be gradually restored and that, though perhaps for a week he will have considerable inconvenience to bear, after that it will be plain sailing. Usually three days can be set as the term at which his craving ceases to be so disturbing as to make the possibility of his relapsing into the habit a positive danger. As in alcoholic and sex habits, the patient to be helped in breaking the habit should be seen once a day at least, usually oftener. If he can be made to understand that whenever the old tendency seems about to get the upper hand is the time to see his physician, and if something physical as well as moral is done for him, the breaking of the habit is comparatively simple. This method of treatment looks too simple to be quite credible to those who have so often tried and failed in the cure of drug habits. It is not the doctor, however, who fails, but the patient. We cannot put new wills into a patient, but we can so brace up even an old and tottering will as to make it possible for the worst victims of drug habits to reform. The doctor, too, easily becomes discouraged. He has not confidence enough in his own methods to make assurance doubly sure for the patient as to his cure. This is what many of the pretended specific purveyors of drug habit cures have as their principal stock in trade. They assure patients with absolute confidence, while the physician only too often says the same thing, but half-heartedly. A half-hearted physician makes a hesitant patient, and success is then very dubious from the beginning. Every patient can be cured. They may relapse, but then they can be cured again. This is the essence of the psychotherapy of drug habits, but it is also the only successful element in any treatment of the drug habit that is really effective. Specifics come and go. Sure cures cease to have their effect. The only really effective element in any cure is the absolute trust of the patient. In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington Sainsbury, Senior Physician to the Royal Free Hospital of London, has emphasized all these points that can only be touched on very briefly here. He has called particular attention to the fact that the victim of one drug habit is rather prone to acquire another if by any chance he should once begin to take another habit-forming drug. The original drug habit has broken down the will. It is not so much the craving for a particular drug as the lack of will power that proves unfortunate for the patient. He suggests "incidentally, if this explanation hold good, it proves the solidarity of the will that it works as a whole and not by compartments." He has dwelt on recoveries from the most discouraging depths and insists "we must teach that {712} no one is ever so enslaved by a habit as to be incapable of relief--this alone is _right_ teaching, justifiable moreover by records well substantiated of recoveries from desperate plights." Heredity and Unfavorable Suggestion.--As to the suggestion, sometimes encountered, of the influence of heredity and its all-powerful effect in making it practically impossible for the son of a man who has taken drugs to keep from doing the same thing, we must recall very emphatically here the principles discussed elsewhere. So far as concerns heredity, opium and the other drugs are exactly in the same position as alcohol in their effect upon the human race. Instead of being justified in saying that by heredity individuals of succeeding generations are rendered more susceptible to them, just the opposite is true and, if anything, an immunity is produced. This is not only racial and general but is personal and actual. In recent years we have come to realize that individuals born of tuberculous parents who care for themselves properly are much better able to resist the invasion of the tubercle bacilli than those who come from stocks that were never affected by the disease. They are the patients who, in spite of the fact that their disease reaches an advanced stage, sometimes live on for years with proper care. Just this is true for drug addictions so far as we know anything about it. The whole subject is as yet obscure, but heredity rather favors than hurts the patient in these cases. Hereditary Resistance.--Instead of being discouraged by the fact that his father took a drug to excess and that therefore he is weaker against this than other people, a man should rather be encouraged by the thought that a certain amount of resistance to the craving has probably been acquired by the particular line of cells through which his personality is manifested. Dr. Archdall Reid has said that "the facts concerning opium are very similar" (to those that concern alcohol). Then he continues: That narcotic has been used extensively in India for several centuries. It was introduced by the English into China about two centuries ago. Quite recently the Chinese have taken it to Burma, to various Polynesian Islands, and to Australia. There is no evidence that the use of opium has caused any race to deteriorate. Indeed it happens that the finest races in India are most addicted to its use. According to the evidence given before the late Royal Commission on Opium, the natives of India never or very rarely take it to excess. When first introduced into China it was the cause of a large mortality; but to-day most Chinamen, especially in the littoral provinces, take it in great moderation. On the other hand. Burmans, Polynesians and Australian natives take opium in such excess and perish of it in such numbers that their European governors are obliged to forbid the drug to them, though the use of it is permitted to foreign immigrants to their countries. In exactly the same way alcohol is forbidden to Australians and Red Indians in places where It is permitted to white men. After-Cures.--I have said so much about the after-cure of alcoholism that applies directly to drug addictions also, that it does not seem necessary to repeat it here. Patients must be warned that if they become overtired, if they lose sleep, if they are subject to much excitement, if they put themselves in conditions of anxiety and worry, if any form of recurrent pain develops--headache, toothache, stomach-ache--they are likely to be tempted to take up their old habit. If they are in a position where they can easily get the drug it is almost inevitable that something will happen to make them feel that {713} they are justified in taking one or two doses and from this to the reestablishment of the habit is only a small step. Often these patients need a change of occupation. Some of them are over-occupied, some of them have not enough to do. In either case it is the doctor's duty to know enough about his patient to be able to give directions. We do not treat a drug addiction with the hope of curing it, but we treat a patient suffering from a particular drug habit and we try so to modify that patient's life that after we have succeeded in getting him away from his habit, which is never difficult, he will not relapse into it. The after-cure is the more important of the two. CHAPTER III SUICIDE In spite of the gradual increase of comfort in life and its wide diffusion--far beyond what people enjoyed in the past--there has been a steady progressive increase in the number of suicides in recent years. It is as if people found life less worth living the more of ease and convenience there was in it. This increase in suicide is much greater (over three times in the last twenty years) than the increase in the population. Surprising as it may seem, prosperity always brings an addition to the number of suicides. Stranger still, during hard times the number of suicides decreases to a noteworthy degree. It is not those who are suffering most from physical conditions who most frequently commit suicide. Our suicides come, as a rule, from among the better-to-do classes of people. While suicide might seem to be quite beyond the province of the physician, it is a duty of the psychotherapeutist to prevent not only the further increase of suicides in general but to save particular patients from themselves in this matter. A careful study of the conditions as they exist, moreover, will show that he can accomplish much--more than is usually thought--and that it is as much a professional obligation to do so as, by the application of hygienic precautions and regulations, to lessen disease and suffering of all kinds and prevent death. The same two modes of preventive influence that we have over disease in general can be applied to suicide. The physician can modify the mental attitude in individual cases and thus save people from themselves and then he can, by his influence in various ways upon public opinion, lessen the death rate from suicide. For this purpose, just as with regard to infectious disease, it is important for him to appreciate the social and individual conditions that predispose to suicide, as well as the factors that are more directly causative. The more he studies the more will he be convinced that what we have to do with in suicide is a mental affliction not necessarily inevitable in its results and that may be much influenced by suggestion. Indeed, unfavorable suggestion is largely responsible for the increase in suicide that has been seen in recent years. Favorable suggestion might be made not only to stop the increase, but actually to reduce the suicide rate. For this purpose it is important to know just what are the conditions and motives that predispose to suicide and, above all, to realize that it is not the result of insufferable pain {714} or anguish, but rather of the concentration of mind on some comparatively trivial ailment, or exaggeration of dread with regard to the consequences of physical or moral ills. Suicides are often said to be irrational; in a certain sense they are. No one who weighs reasonably all the consequences of his act will take his own life. This irrationality, however, is nearly always functional and passing, not of the kind that makes the commission of suicide inevitable, but only produces a tendency to it. This tendency is emphasized by many conditions of mind and body that the physician can modify very materially if he sets about it. Many of the supposed reasons for suicide are founded on the complete misunderstanding of the significance of symptoms and dread of the future of his ailments, often quite unjustified by what the individual is actually suffering. Indeed, the desperation that leads to suicide is practically always the result of a state of mind and not of a state of body. It is exactly the same sort of state of mind which sometimes proves so discouraging in the midst of diseases of various kinds as to make it impossible for patients to get over their affections until a change is brought about in their ideas. This makes clear the role of psychotherapy with regard to suicide, and there is no doubt that many people on the verge of self-murder can be brought to a more rational view and then live happy, useful lives afterwards. For this purpose, however, it is important that the physician should come to be looked upon as a refuge by those to whom the thought of suicide has become an obsession. A well-known social religious organization not long since established a suicide bureau, that is, a department to which those contemplating suicide may apply with the idea that they would there find consolation and perhaps some relief for their troubles and thus the idea of suicide might be dissipated. Many a suicide would be avoided if the reasons that impelled to it had been known to one or two other people beforehand, so that some relief might have been afforded to what seemed an intolerable condition. This suicide bureau is said to have done much good. There is no doubt that the mere act of giving one's confidence to another is quite sufficient of itself to diminish to a marked degree a burden of grief and trial. If anything in the world is true, it is that sorrows are halved by sharing them with another, while joys are correspondingly increased. The fact that there is someone to whom they might go, who would look sympathetically at their state of mind, who would appreciate the conditions, who had been accustomed to dealing with such cases, would be enough to tempt many people from that awful introspection and concentration of mind on themselves which, more than their genuine sufferings and trials, whatever they may be, make their situation intolerable. There has always been a suicide bureau, however, in the office of every physician who really appreciates the genuine responsibilities of his profession. More than any others we have the opportunity to alleviate physical sufferings, to lessen mental anguish and to make what seemed unbearable ill at least more or less tolerable. Unfortunately in recent years the change in the position of the physician in his relations to the family has somewhat obscured this fact in the minds of the public. The old family physician occupied to no slight extent the position of a father confessor, to whom all the family secrets were told, from whom indeed, as a rule, it was felt that they should not be kept; to whom father went with regard to himself and mother, to whom mother {715} went with regard to all the family as well as herself, to whom the boy confided some of his sex trials and the girl some of the secrets that she hid from almost everyone else, so that to go to him for anything disturbing became the first thought. We must restore something of this old-fashioned idea of the doctor's place in life if all our professional duties are to be properly fulfilled. If those contemplating suicide learn to think of us as persons to be appealed to when all looks so black that life is no longer tolerable, we shall soon be in a position to confer increased benefits on this generation that needs them so much. Physical Factors.--As a rule there is a physical element as the basis for nearly all suicides. With the unfortunate, unfavorable suggestion that has come from the supplying of details of pathological information--the half-knowledge of popular medical science--without the proper antidote of the wonderful compensatory powers of the human body for even serious ailments, a great many nervous people are harboring the idea that they have or soon will have an incurable disease. Physicians have abundant evidence of this. All sorts of educated people come to us to be reassured that some trivial digestive disturbance does not mean cancer of the stomach, or, when they are between forty and fifty, come to make sure that some slight disturbance of urination is not an enlarged prostate. Brain workers of all classes come over and over again to be reassured that they are not breaking down because of organic brain disease, of which they show absolutely no sign. Sometimes they have been making themselves quite miserable for a long period by such thoughts. It is easy to understand, then, how many less informed people, yet provided with the opportunities of quasi-information that modern life affords, are apt to think the worst about themselves. _So-called Insomnia_.--The correction of such preconceived notions will always greatly alleviate the mental sufferings of these patients. For this purpose there are many chapters of this book which point out how various symptoms and syndromes that are often amongst the factors in the production of suicide may be managed. Perhaps one of the most frequent of these is so-called insomnia. Most people are insomniac, mainly because they are overanxious about their sleep. A few of them are wakeful because of bad habits in the matter of work and the taking of air and exercise. Essential insomnia is extremely rare and symptomatic; insomnia is not mental, but is usually due to some definite physical condition that can be found out and, as a rule, treated successfully. There is always some other symptom besides loss of sleep. If men will live properly and rationally there is no reason why insomnia should be a bane of existence, nor even any reason why the morphin or other drug habit should be formed which is so likely to come if inability to sleep is treated as if it were an independent ailment. In the forms in which it incites to suicide it owes its origin to a nervous superexcitement with regard to sleep in people whose daily life in some way does not properly predispose them for the greatest of blessings on which there is no patent right. Additional suggestions as to these insomniac conditions are made in the chapters on Insomnia and Some Troubles of Sleep which make it clear that suicide, because of insomnia is due to a delusion. _Headache_.--Persistent supposedly incurable headache is another prominent feature of the stories of suicides and here once more we have to deal rather {716} with a delusion of over-attention of mind and concentration of self on a particular part than a real physical ailment. Most of the so-called headaches that are supposed to be so intractable are really not headaches but pressure feelings and other queer sensations in the head originally perhaps partaking of the nature of an ache but continued through over-advertence. Severe pain within the head occurs in cases of congestion and brain tumor, and without the head in cases of neuralgia, but most of these are only temporary and long-continued headaches are rather neurotic than neuritic or due to any real disturbance of the nervous system. This is discussed in the chapter on Headaches. People commit suicide who have for a long time been sufferers from headache because they fear that they may go crazy. There is absolutely no reason in the world to think this probable, and in the one case of continuance of severe intermittent headaches for years already mentioned--that of von Bülow, the Austrian pianist and composer, in which we have the autopsy record--it was found, after a long life, that his severe intracranial headaches were due to the pinching of a nerve in the dura and not to any organic change in the brain itself. Mental Factors.--While physical factors enter into the suicide problem to a marked degree, it would be a great mistake to think that physical conditions or material circumstances are the main causes or occasions in suicide. It is supposed, as a rule, to be due to depression produced by incurable disease, oppressive weather, financial losses and the like. There is no doubt that these are contributing causes, but the physical conditions have very little influence compared with the attitude of the patient's mind toward himself. As a rule, it is not those who are in absolutely hopeless conditions who turn to this supposed refuge of a voluntary exit from life in order to get out of trouble, but rather those who are momentarily discouraged and who have not sufficient moral stamina to face the consequences of their acts. There was a time when it was considered brave to fight a duel and cowardly to refuse to do so. Looking back now, we know that they were the real brave men who dared to refuse when a barbarous civilization would force them into a false position and who, in spite of disgrace, ventured to be men and not fools. There are those who used to say that it was brave to take one's own life rather than bring disgrace on loved ones, but the mitigation, if there be any, of the disgrace that suicide brings with it, comes from that lowest of all motives, pity for the survivors, and the cowardly suicide leaves to others the thankless task of making up for his faults. _Suicide and the Weather_.--An investigation of suicide records shows, as we have said, that it is not nearly so often bodily or material hardships that lead men to it as mental states. These mental states are not mental diseases, but passing discouragements in which men are tempted beyond their strength and do irretrievable things for which there is no rational justification. It is not in dark damp weather that men commit suicides most, though this was supposed to be a commonplace in our knowledge of suicide. Recent investigations show that quite the contrary is true. Professor Edwin T. Dexter of the University of Illinois published a very important study of this question in a paper entitled "Suicide and the Weather." [Footnote 55] He followed out the records of nearly 2,000 cases of suicide reported to the police in the City of New York {717} and placed beside them the records of the weather bureau of the same city for the days on which these suicides occurred. According to this, which represents the realities of the situation, the tendency to suicide is highest in spring and summer and the deed is accomplished in the great majority of cases on the sunniest days of these seasons. [Footnote 55: _Popular Science Monthly_, April, 1901. ] His conclusions are carefully drawn and there is no doubt that they must be accepted as representing the actual facts. All the world feels depressed on rainy days and in dark, cloudy weather, but suicides react well, as a rule, against this physical depression, yet allow their mental depression to get the better of them on the finest days of the year. Prof. Dexter said: The clear, dry days show the greatest number of suicides, and the wet, partly cloudy days the least; and with differences too great to be attributed to accident or chance. In fact there are thirty-one per cent. more suicides on dry than on wet days, and twenty-one per cent. more on clear days than on days that are partly cloudy. What is thus brought out with regard to the influence of weather can be still more strikingly seen from the suicide statistics of various climates. The suicide rate is not highest in the Torrid nor in the Frigid zones, but in the Temperate zones. In the North Temperate zone it is much more marked than in the South Temperate zone. Civilization and culture, diffused to a much greater extent in the North Temperate zone than in the South, seem to be the main reason for this difference. We make people capable of feeling pain more poignantly, but do not add to their power to stand trials nor train character by self-control to make the best of life under reasonably severe conditions. With this in mind it is not surprising to find that the least suicides occur in the month of December, when the disagreeable changes so common produce a healthy vital reaction, though the many damp dark days that occur would usually be presumed to make this the most likely time for suicides. On the contrary, it is the month of June, the pleasantest in the North Temperate zone, that has the most suicides. It is important to remember this in estimating the role of physical influences on the tendency to suicide. Social Factors that Restrain Suicides.--_War_.--A most startling limitation of suicide is brought about by war. For instance, our Spanish-American war reduced the death rate from suicide in this country over forty per cent. throughout the country and over fifty per cent. in Washington itself, where there was most excitement with regard to the war. This was true also during the Civil War. Our minimum annual death rate from suicide from 1805 (when statistics on this subject began to be kept) was one suicide to about 24,000 people, which occurred in 1864 when our Civil War was in its severest phase. There had been constant increase in our suicide rate every year until the Civil War began, then there was a drop at once and this continued until the end of the war. In New York City the average rate of suicide for the five years of the Civil War was nearly forty-five per cent. lower than the average for the five following years. In Massachusetts, where the statistics were gathered very carefully, the number of suicides for the five-year period before 1860 was nearly twenty per cent. greater than for the five-year period immediately following, which represents the preliminary excitement over the war and the actual years of the war. This experience in America is only in accordance {718} with what happens everywhere. Mr. George Kennan in his article on "The Problems of Suicide" (_McClure's Magazine_, June, 1908), has a paragraph which brings this out very well. He says: In Europe the restraining influence of war upon the suicidal impulse is equally marked. The war between Austria and Italy in 1866 decreased the suicide rate for each country about fourteen per cent. The Franco-German War of 1870-71 lowered the suicide rate of Saxony 8 per cent., that of Prussia 11.4 per cent. and that of France 18.7 per cent. The reduction was greatest in France, because the German invasion of that country made the war excitement there much more general and intense than it was in Saxony or Prussia. _Great Cataclysms_.--Even more interesting than the fact that war reduces the suicide rate is the further fact that a reduction of the number of suicides takes place after any severe cataclysm. The earthquake at San Francisco, for instance, had a very marked effect in this way. Before the catastrophe suicides were occurring in that city on an average of twelve a week. After the earthquake, when, if physical sufferings had anything to do with suicide, it might be expected that the self-murder rate would go up, there was so great a reduction that only three suicides were reported in two months. Some of this reduction was due to inadequate records, but there can be no doubt that literally hundreds of lives were saved from suicide by the awful catastrophe that levelled the city. Men and women were homeless, destitute, and exposed to every kind of hardship, yet because all those around them were suffering in the same way, everyone seemed to be reasonably satisfied. Evidently a comparison with the conditions in which others are has much to do with deciding the would-be suicide not to make away with himself, for by dwelling too much on his own state he is prone to think that he is ever so much worse off than others. If life were always vividly interesting, as it was in San Francisco after the earthquake, and if all men worked and suffered together as the San Franciscans did for a few weeks, suicide would not end ten thousand American lives every year, as it does now. Individual Restraints.--_Religion_.--It seems worth while to call to attention certain factors that modify the tendency to suicide and limit it very distinctly, because it is with the limitation of it that the physician must be mainly occupied. There seems to be no doubt that certain religious beliefs, which affect the individual profoundly and occupy his thoughts very much, furnishing, both by tradition and heredity as it were, sources of consolation for evils in this life by the thought of a future life, notably lessen the suicide rate. All over the world the Jews who cling to their old-time belief have perhaps the lowest suicide rate of any people. This is true in spite of racial differences. People who retain the confidence in prayer, that used to characterize members of all religions a century or more ago, are likely to be able to resist the temptation to suicide. This is true particularly for the more or less rational suicide. Oppenheim has recalled attention to the power of prayer against depression and in the insane asylums of England its efficiency in this way is well recognized. It is well-known that Roman Catholics the world over have much less tendency to suicide than their Protestant neighbors living in the same {719} communities. It is true that where the national suicide rate is high many Catholics also commit suicide, but there is a distinct disproportion between them and their neighbors. The suicide rate of Protestants in the northern part of Ireland, as pointed by Mr. George Kennan, is twice that of Roman Catholics in the southern part. He discusses certain factors that would seem to modify the breadth of the conclusion that might be drawn from this, but in the end he confesses that their faith probably has much to do with it and that, above all, the practice of confession must be considered as tending to lessen the suicide rate materially. It is the securing of the confidence of these patients that seems the physician's best hope of helping them to combat their impulse and Mr. Kennan's opinion is worth recalling for therapeutic purposes: In view of the fact that the suicide rate of the Protestant cantons in Switzerland is nearly four times that of Catholic cantons, it seems probable that Catholicism, as a form of religious belief, does restrain the suicidal impulse. The efficient cause may be the Catholic practice of confessing to priests, which probably gives much encouragement and consolation to unhappy but devout believers and thus induces many of them to struggle on in spite of misfortune and depression. _Disgrace as a Restraint_.--It is curious what far-fetched motives, that appear quite unlikely to have any such influence, sometimes prove able to affect favorably would-be suicides and prevent their self-destruction. Plutarch tells the story, in his treatise on "The Virtuous Actions of Women," of the well-authenticated instance of the young women of Milesia. Disappointed in love, they thought life not worth living. Accordingly there was an epidemic of suicide among the young women and it even became a sort of distinction to prefer death to matrimony. Some perverted sense of delicacy entered into the feeling that prompted the suicides, as if sex and its indulgence were something belittling to the better part of their nature. The authorities in Milesia must have been psychologists. They issued a decree that the body of every young woman who committed suicide would be exposed absolutely naked in the market-place for a number of days after her death. This decree, once put into effect, immediately stopped the suicides. The young women shrank from this exposure of their bodies, even though it might be after death, and the suicide fashion came to an end. It might be thought perhaps that this incident represented ancient feeling and that a similar condition in the modern times would not have a corresponding effect. It so happens that something similar has been tried. In some of the cities of South Central Europe in which the suicide rate is almost the highest in the world, it was decided about a generation ago by the Church authorities of the towns that suicides would not thereafter be buried in the cemeteries near the bodies of those who died in the regular course of nature, but must be interred in a separate portion reserved for themselves. Strange as it may seem, just as in the case of the young women of Milesia, this proved a great deterrent to suicide. The suicide rate was reduced one-half the next year. As a matter of fact, it only takes some reasonably forceful countervailing notion to set a train of suggestions at work that will prevent suicide. If those contemplating suicide are made acquainted with some of these curious facts we know, then the notion of suicide loses more than half its terrible {720} attraction by being stripped of all of its supposed inevitableness. Almost any motive that attracts attention, even apparently so small a thing as disgrace after death, makes these people realize the littleness and the cowardice of the act. Favoring Factors.--_Psychic Contagion_.--A prominent factor in suicides that must constantly be borne in mind is the influence of example or, as we have come to call it learnedly in recent years, psychic contagion. It is discussed more in detail in the chapter on Psychic Contagion, but its place here must be emphasized. It has often been noted that certain peculiar suicides are followed by others of the same kind. If a special poison has been used, others obtain it and put an end to their lives in that way. Even such horrible modes of death as eroding the jugular vein by drawing the neck backward and forward across a barbed-wire fence have been imitated. If the story of jumping off a high building is told with lurid details, special care has to be taken in permitting unknown people to go up to the same place for some time afterwards. The imitative tendency is evidently a strong factor. Plutarch's story of the young women of Milesia brings this out, and it has been noted all down the centuries. In any discussion of the prophylaxis of suicide the effect of newspaper descriptions of previous suicides must be looked upon as very important. The influence of suggestion of this kind on people who have been thinking for some time of suicide is very strong. There comes to them the impelling thought that the suicide's miseries are over and they wish they were with him. From the wish to the resolve and then to the deed itself are only successive steps when suggestion is constantly prodding the unfortunate individual. If we are going to reduce the suicide rate materially or, indeed, keep it from increasing beyond all bounds, this question must be squarely faced. Accounts of suicides are not news in the ordinary sense of the word and while they might find a place for legal and other purposes in a few lines of an obituary column, the present exploitation of them by the papers makes them a constantly recurring source of strong suggestion to go and do likewise. These suggestions come to persons already tottering on the edge of disequilibration in this matter, and it is like tempting children to do things that they know are wrong, but that look irresistibly inviting when presented under certain lights. The very fact that their death will produce a sensation and will give them so much space in the newspapers attracts many morbidly sensation-loving people. Physicians must work as much for this prophylaxis as we have for the prevention of infectious diseases. Child Suicides.--Probably the worst feature of the suicide statistics of recent times in all countries is the great increase of self-murder among children. Arthur MacDonald in discussing the "Statistics of Child Suicide" [Footnote 56] has shown that there is a special increase of young suicides everywhere. In France there are nearly five times as many suicides at the end of the nineteenth century as there were at the beginning of it. In England there is almost as startling an increase. Though the statistics are not as well kept, child suicide has increased not only in proportion to the increase of suicide among adults, but ever so much more. In Prussia the condition is even worse. [Footnote 56: "Statistics of Child Suicide," _Transactions of American Statistical Association_, Vol. X., pp. 1906-1907. ] {721} The French child suicide rate is especially interesting and disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the subject of suicide among young people and shows how rapid has been the growth of the number of such suicides in the last 100 years. The first statistics available for the purpose that, in his opinion, are exact enough to furnish a basis for scientific conclusions, are from 1836 to 1840. Altogether during that period in France there were 92 suicides under the age of seventeen years, 69 of whom were boys and 23 girls. In 1895 this number had increased to such a degree that in a single year there were almost as many suicides (90) as there had been in five years, only fifty years before. In 1895 the proportion of suicides less than ten years of age was a little more than one in twenty of the total number of suicides in France. There are countries in Europe in which the suicide rate among such children is even higher than it is in France. In every country it has gone on increasing and the awful thing is that the suicide rate is increasing more rapidly among children than it is among adults, though among adults it doubles every twenty years. _Causes at Work_.--The causes for the increase in suicide among children were pointed out even by Esquirol, the great French psychiatrist, nearly a century ago. They are the same to-day, only emphasized by the conditions of our civilization. He attributed it to a false education which emphasizes all the vicious side of life, makes worldly success the one object of life, does not properly prepare the child for constancy in the midst of hardships, nor make it appreciate that suffering is a precious heritage to the race, that has its reward in forming character and fixing purpose. He thought that there were two very serious factors for the increase of suicide among children not usually realized. They were in his time literature and the theater. He said: "When the theater presents only the triumphs of crime, the misfortunes of virtue, when the books that are in common circulation because of the low price at which they are issued, contain only declarations against religion, against family ties and duties towards our neighbor and society, then they inspire a disdain of life and it is no wonder that suicide rapidly increases even among the very young." He was commenting on the case of a child of thirteen who had hanged himself, leaving this written message: "I bequeath my soul to Rousseau and my body to the earth." Cowardice of Suicide.--Of course, the strongest motive for dissuasion from suicide is the utter cowardice of the act. As a rule, the man who contemplates suicide is not a sufferer from inevitable natural causes, but one who for some foolish act has put himself into what seems to him an intolerable position out of which escape without disgrace is impossible, and he is afraid to face the consequences of his own acts. It is from the fear of mental worry and of the condemnation of others rather than from any dread of physical suffering and pain that men commit suicide. The suicide leaves those who are nearest and dearest to him to face the battle of life alone, with all the handicaps that have been created by their foolishness. Running away in battle is as nothing compared to the cowardice of the suicide. The deserter is deservedly held in deepest dishonor, and if there is some little pity for the suicide, it is because of the supreme foolishness of his act and the feeling that it only can have been dictated by some defect of mental equilibrium. A frank recognition of these conditions in their real significance probably will do more than anything {722} else to make the prospective suicide realize the true status of his act better than anything else. Men sometimes seem to persuade themselves that it is a brave thing thus to face death. The shadowy terrors of what may come after death are too little realized to deter a man from his act when compared with the real disgrace that he is so familiar with and that he has often witnessed in actual life. It is the man, as a rule, who has most condemned others when something has gone wrong, who has found no sympathy in his heart for the slips of his fellows, who discovers no courage in himself when he has to face disgrace. He does not realize that for most men there are so many extenuations of any evil that a man may do, that the large-minded man is ready to forgive and eventually to forget almost anything that happens. "To know all is to forgive all," and the more we know of men the readier we are to forgive them. Little men do not forgive and cannot forget the failings of their fellows and they think that everyone else looks upon men's failings in the same way. It is only the small, narrow man who contemplates suicide as a refuge from disgrace, and the fact that he can complacently plan the abandonment of others not only to the disgrace which he himself is not ready to face, but to all the suffering consequent upon it, is the best proof of his littleness of soul. The utter pusillanimity of suicide is the best mental antidote for the temptation to it. Besides, the thought that deterred Hamlet may well be urged: There's the rub; For in that sleep of death what dreams may come. When we have shuffled off this mortal coil, Must give us pause; . . . who would fardels bear, To grunt and sweat under a weary life; Cut that the dread of something after death.-- The undiscovered country, from whose bourn No traveller returns.--puzzles the will; And makes us rather bear those ills we have. Than fly to others we know not of? It is sometimes said that this is the argument of a coward, but such cowardice is as reasonable as the dread of touching a wire that may be carrying a high charge of electricity. Besides it is only such an argument that will properly suit the man who, in his cowardice, is ready to let others bear the brunt of his disgrace, flying from it himself. [Footnote 57] [Footnote 57: Is life worth living? How old this argument as to suicide is can perhaps best be appreciated from the fact that it is discussed very suggestively in a papyrus of the Middle Kingdom the date of which is probably not later than 2500 B. C, which is now in the Berlin Museum and is recognized to be the most ancient text of its kind that has been preserved in the Nile Valley. I have referred to this in the initial historical chapter. I think that I have more than once turned men's thoughts from the serious contemplation of suicide--always a dangerous thing--by discussing with them this fact that men have at all times in the world's history argued just the same way on these subjects. Men prefer not to resemble the dead ones, and a motive is all that is needed. ] There has sometimes been an erroneous tendency to confuse suicide and heroism, but Chesterton, in "Orthodoxy," [Footnote 58] has well expressed the difference: [Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John Lane Co., 1909. http://www.gutenberg.org/ebooks/130] {723} A soldier surrounded by enemies, if he is to cut his way out, needs to combine a strong desire for living with a strange carelessness about dying. He must not merely cling to life, for then he will be a coward, and will not escape. He must not merely wait for death, for then he will be a suicide, and will not escape. He must seek his life in a spirit of furious indifference to it; he must desire life like water and yet drink death like wine. No philosopher, I fancy, has ever expressed this romantic riddle with adequate lucidity, and I certainly have not done so. But Christianity has done more: it has marked the limits of it in the awful graves of the suicide and the hero, showing the distance between him who dies for a great cause and him who dies for the sake of dying. And it has held up ever since above the European lances the banner of the mystery of chivalry: the Christian courage, which is a disdain of death; not the Chinese courage, which is a disdain of life. The feature of incidents in life that bring with them disgrace and punishment which needs to be insisted on for those to whom the thought of suicide comes, is that the sensation which the revelation of such acts causes is but a passing phase of present-day publicity, and that after all it is not even a nine-days' wonder, but a two- or three-days' wonder, and then it is forgotten and replaced by something else. The facing of the condemnation for the moment may seem an extremely severe trial. The world's blame, however, is largely a bogey, a dread that is phantom-like and that disappears, or at least diminishes, to a great degree as soon as it is bravely faced. Besides, as practically every man who has been carrying around a guilty secret with him for years is free to confess, there is an immense sense of relief once the worst is known. At last the effort at concealment, the nervous tension, the fear of the moment of exposure are all past and a new set of thoughts can be allowed to come. Those may be unpleasant and yet they are not so bad as the dread of discovery that hung over the unfortunate. If a man can be braced up to meet exposure, usually he will find in a very few days that there are sources of consolation that make it much easier for him to live than he thought possible before. Real Suffering a Tonic.--Probably the best remedy for a man or a woman who talks of suicide and seems to fear lest the temptation should overcome them is, if possible, to give them an opportunity to see some real suffering. I have on a number of occasions had the opportunity to note the effect on a discouraged man or woman of the sight of a cancer patient suffering severely, yet bearing the suffering patiently, wishing that the end might come, yet ready to wait until it shall come in the appointed order of nature. Suffering, like everything else, becomes much more bearable with inurement to it. The old have learned the lesson of not only not looking for pleasure in life, but of being quite satisfied with their lot if no pain comes to them, and they even grow to consider that they have not much right to murmur if their pain is not too severe. It is not among those who have to suffer severe pain that one finds suicides as a rule. It is true that young, strong, healthy persons who suddenly find that pain is to be their lot for a prolonged period may grow so discouraged and moody over it as to take their lives. The patients that I have seen suffering from incurable diseases have expressed no desire at all that their life should be shortened, except during the paroxysms of their pain, unless they feel that they are a serious burden on others when they may express the wish to be no more. Euthanasia.--Every now and then there is a discussion in the newspapers {724} of the justifiableness of euthanasia, that is, the giving of a pleasant death to those who are known to be incurably ill and who are doomed to suffer pain for most of what is left of their existence. The question usually discussed is whether patients have the right to shorten their own existence and then, also, whether their physician might have the right or, even as some people say, the duty, to lessen human suffering by abbreviating existence for such incurable cases. The discussion has always seemed to me beside the realities of things, because physicians do not see many patients, I might almost say any patients, who really want to shorten their lives or would want to have them shortened. I have known many physicians die of cancer, but very seldom is it that one tries to shorten his own existence, or that even his best friend in the profession would consider that he was justified in doing this for him. This, it seems to me, should be the test of the problem. It is true that not infrequently, in the midst of their paroxysms of pain, patients wish they were dead, but there come intervals of surcease from discomfort to some degree at least that make life quite livable for a time again and even occasionally there is real happiness in these intervals, deep, human, natural happiness in heroic forbearance and example. We can recall AEsop's fable of the old man who, gathering wood for the fire in the winter that he needed so much, finds the burden of his labor and the wood too much for him and calls loudly for death to come to him. Promptly Death makes his appearance and asks what the old man wants. "Oh! nothing," is the reply; "only I would like you to help me to carry this bundle of sticks." This is the attitude of mind of practically all who have grown old in suffering. They have learned to bear with patience, and that patience gives even something of satisfaction. After all, it is not so often the pleasant things in life that we look back on and recall with most satisfaction as the difficulties and trials. Virgil said long ago, _"Forsan et hoc olim meminisse juvabit"_--perhaps at some future time we shall recall these, our trials and pains, with pleasure. It is the conquering of difficulty that means most for men and even the standing of pain is not without an aftermath, if not of pleasure, at least of broad human satisfaction. When we talk about euthanasia, then, it would be well to ask some of these old people whether they want it or not. Seldom will the answer be found to be that which is so often presumed, by those in good health and strength, to be inevitable under such conditions. Physicians have all seen incurable cancer patients who were approaching their end inevitably and with the fatal termination not far off, have hours and days of alleviation of suffering and even of enjoyment that made up for the prolongation of life almost in the midst of constant agony. The distinguished New York surgeon who had the pleasure a few years ago of listening once more to his favorite singer and fairly seemed to get renewed life from the inspiration of her voice and who for days after had the pleasant consciousness of smooth running life in improvement so characteristic of convalescence, is a typical example of what may happen under such circumstances. I shall not soon forget Dr. Thomas Dunn English, the well-known author of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the University of Pennsylvania, that, like Bismarck, he used to think that all the joys of life's existence were in the first eighty years of life, but of late years he had found {725} that many of them were also in the second eighty years of life. He was at the time 83. He made the most joyous and happiest speech on that occasion. He was quite blind, was almost deaf, had been reported dying some months before, and had gone through prolonged suffering, yet he was by his cheeriness and whole-hearted gaiety on that occasion a joy and inspiration to all the younger men at the table. Dread of Suicide.--There are patients who come to the physician worked up because they fear they may commit suicide. Every now and then the thought comes to them that some time or other they will perhaps throw themselves out of a window, or be tempted to drop in front of a passing train, or over the side of a steamboat, or impulsively take poison. Some nervous people become quite disturbed by these thoughts. Every physician is sure to have some patients who must be reassured, every now and then, that they are not likely to commit suicide. Their nervousness over the fear of this may serve to make them supremely miserable and it evidently becomes the doctor's duty to reassure them. It is not difficult to do this, as a rule, provided the physician will be absolutely confident and unhesitating in his declaration that there is no danger that they will commit suicide, since it has almost never been known that patients who dread it very much and, above all, those who dread it so much that they take others into their confidence in the matter, take their own lives. The very fact that the thought produces so much horror and disturbance in them is the best proof that they will not impulsively do anything irretrievable in this way. Prof. Dubois has discussed this subject in his usual thoroughly practical way and his words serve as an authoritative confirmation of what has been already said, though as a matter of fact the expressions and experience of nearly every nervous specialist thoroughly justify the position here assumed. Besides, it must be realized that this confident assurance is the best possible prop that doubting patients can have with regard to the actions they dread, and by positive declarations the physician will accomplish more than in any other way. There are patients who are subject to strange obsessions. They are afraid that they will throw themselves out of the door of a car, or climb over the parapet of a bridge. They are afraid that they will throw their relatives out of a window, or will wound somebody with a knife or a gun. There are some with a strong impulse to open their veins. But if there is a certain attraction in such things, it is really a phobia. It tends to make one shrink back and not to act. Nothing quiets these patients like the frequently repeated statement that they will not do anything. It is necessary to show them the vast distance there is between the impulse toward suicide and murder and the phobia which, however distressing it may be, is a safeguard. One must keep at this education of the mind with imperturbable persistence and use the most forceful and convincing arguments that one can think of to correct the judgment of his patient, in order to make the strings of moral feeling and reason vibrate in unison. It is through lack of courage and perseverance that we err in the treatment of these psychoneuroses. We wait too long to distinguish the morbid entities that bear on a certain etiology or a different prognosis. We do not see clearly enough the bond which unites these different affections. It may seem to some physicians as though they would be assuming too much responsibility in giving patients such positive assurance that their dreads {726} will not be fulfilled, but as a matter of fact the experience of physicians is quite sufficient to justify the confident statements here suggested. It is true that occasionally a person who afterwards commits suicide talks the matter over and hints at the possibility of taking his own life. He does not, as a rule, speak of it with dread, however, but as one of the alluring solutions of his difficulties that he sees ahead of him. He is much more likely to write a letter to his physician telling him that all his arrangements are made and that by the time this letter reaches him he will be already dead. The prospective suicide is usually quite secretive about this purpose, not only to friends, lest he should be prevented from accomplishing it, but even with his physician, in whom he has had absolute confidence and to whom he has told practically everything else. The patients who fear the possibility of committing suicide, who tell how much they dread the horror of it, and who rush to consult the physician to help them against themselves, show by the very fact the unlikelihood of action on their part. The Physician and Suicide.--By mental influence, then, the physician may lessen the tendency to suicide in the individual and in the community. To do this is to save suffering and to help in the solution of one of the most serious social problems in modern times. It can only be accomplished by a sympathetic attitude towards the whole subject and a tactful understanding of each individual case. Every effort in the matter, however, is well worth while, for there is no more hideous blot on our modern civilization than the startling increase of suicide. It is particularly important to bring about improvement in this regard among young suicides, and fortunately it is here that the influence of the physician for good is likely to be most felt. The saving of life is the noblest part of the mission of the physician and nowhere, perhaps, can this be accomplished more successfully than with regard to some of these patients whom a rash resolution, due to a momentary fit of depression and a sense of suffering exaggerated out of all proportion to their actual pain, is hurrying out of life. CHAPTER IV GRIEF Grieving would seem at first glance to be one of the conditions for which the physician, especially if the etymology of the name of his profession be taken strictly, should not be called upon to minister, nor his remedies be expected to relieve. Grief is usually supposed to be due to moral ills and, therefore, at most to come under the care of the alienist, with the feeling that even he can accomplish very little for what is an affective rather than a true mental disorder. There is no doubt at all, however, that grieving, especially in the excess that shows it to be pathological, is always associated with certain physical and mental conditions for which the physician can accomplish much. Indeed more often than not the physical condition of the grief-stricken person is a prominent factor in the production of the state of feeling which causes grief to be exaggerated, while, on the other hand, this state of mind {727} itself reacts upon the physical being so as to make it more sluggish in all its functions, and as a consequence a vicious circle of cause and effect is formed affecting unfavorably both the mental and physical conditions. It is when patients are run down in health that grief becomes extremely difficult or apparently impossible to bear and grief itself still further brings about a deterioration of health that makes the mind's reactionary power against its gloomy feelings still weaker than they were. Viewed in this way, grief is an ailment that should properly come to the physician for treatment and with regard to which that important principle is eminently true that the physician cannot always cure, but he can nearly always relieve, and he can always console his patients. On the one hand, an improvement in the general health always make grief easier to bear because it increases the resistive vitality of both mind and body. On the other, any diversion of mind that lifts the burden of grief even to some degree, releases new stimuli and physical powers for the restoration of bodily function to the normal and this brings about an immediate lessening of the depressive condition. In a word, for the vicious circle of unfavorable influences ever pushing the victim farther into depression, a virtuous circle, in the Latin sense of the word virtue, meaning courage, favoring strength, must be formed, that brings about an immediate improvement in the patient's mental and physical well-being. This is not a pretty bit of theory but is the result of the experience of every physician who has ever taken seriously the problems of caring for the grief-stricken. Natural and Pathological Grief.--It is, of course, not easy to distinguish between grief that may be called morbid in the sense of a melancholy, that is, more than natural--a true mental disease--and that which represents only an affective state accompanied by depression from which there will be complete reaction. A mother loses a favorite, it may be an only son, and is plunged into grief. For days, even weeks, she refuses to take any interest in life, she thinks moodily about the awful affliction that has come to her and how blank the future is, and she cannot be aroused to attend either to her own affairs or to the duties of life around her. Such a grief is, in many cases, not more than the normal depression incident to such a loss. If after months, however, the mother still continues to refuse to take interest in life and the things around her, especially if, besides, she now talks of having been visited with this punishment because of some unpardonable sin in her own life, or because the Deity has been offended beyond all hope of propitiation, then the case verges over into one of true melancholy in which the mental depression is not merely a symptom of a passing condition, but partakes of the nature of a mental disease, or is the consequence of a profound neurotic condition. It must not be forgotten that there is always the danger that exaggerated grief, as it seems for the moment to be, may be only the first symptom of a true melancholic condition. Only too often friends and physicians have been deceived by this. Some of the sad cases of self-destruction and a few cases of homicide and suicide have followed a condition that seemed to be only abnormal grief for the loss of a relative. Etiology.--The cause of exaggerated, prolonged grief is, in a considerable proportion of the cases, a melancholic tendency, that is, a failure on the {728} part of the mind to react against depression. The weakness of mind that predisposes to this may be inherent or acquired. Sometimes no special loss is needed to produce melancholia in susceptible individuals, while occasionally it is precipitated by some misfortune, inasmuch as this is a mental disease, very little can be done directly, and yet the patient can be helped and diversion of mind may bring a good measure of relief. More often, however, the reason for persistent grieving is that before the disturbing loss came into the life of the individual there had been a serious deterioration in health. This was due to the conditions preceding the unfortunate event. Wives sometimes have worn themselves out physically and mentally while nursing husbands, or mothers their children, and this has produced a lack of physical force which prevents them from reacting with healthy mentality against the subsequent shock of loss. Prophylaxis..--For the melancholic tendency prophylaxis cannot be special, but must be general. We cannot prevent people from suffering serious losses, but we can foresee the possibility of a loss proving very depressing, and can, therefore, try to keep the individual in reasonably good physical condition. If this is done the subsequent depression will be much less than it otherwise would be. Very often there is little or no recognition of the fact that there is a definite tendency in some patients to too great an inclination toward melancholic thoughts, and it is not until an exaggerated manifestation of it comes that the danger is realized. It is not easy to make patients realize the dangers, but where the physician talks with assurance and points out definite things to do in order to prevent serious developments, patients, or at least their friends, can be made to appreciate the dangers. The best demonstration that I know of the value of work as a remedy for grief is my experience with members of religious orders. For them, as a rule, there is no interruption in life no matter what the loss may be. Their work goes on the day after the funeral just as before. This is the most precious possible arrangement, time and occupation of mind are the two factors that will dull the edge of grief and while humanly we may resent the consolation that is thus brought by such conventional things as the passage of time and humdrum occupations, they represent nature's resources. Above all, patients must be given something to do and if that something concerns other suffering human beings, there is every reason to expect relief. Treatment.--The most important element in the treatment of grief cases is to prevent physical running down as far as possible and to build up the physical condition. Depression that comes to patients who have lost considerable weight, even though it may show some of the signs of melancholia, is always hopeful. Where patients are twenty or thirty pounds under weight the recovery of weight up to the normal condition will often mean the relief of their depressed condition. The one hope lies in this physical improvement. Mental treatment by diversion of mind must, of course, be practiced. This does not mean getting the patients interested once more in trivial things, but to be successful it means arousing the deeper feelings of their nature. Above all, the solace of tears will often save depressed and grieving persons from themselves. An interest in the sufferings of other people that awaken their sympathy will do the most to end exaggerated grieving over their own loss. The self-centeredness of their grief is the principal reason for its exaggeration. {729} It is because of overestimation of their own importance and of the importance of their loss that these people suffer severely. _Motives of Consolation_.--The main resource of the physician who would employ psychotherapy for the treatment of those who are grieving beyond the limit of what is normal, is to supply motives by which they can understand the real significance of their loss. Very often, especially in young folks, there is no proper estimation of values in life and no recognition of the fact that human life was evidently not meant for happiness since that comes to but few, while suffering and partings are inevitable. They come to all, and apparently will always continue to do so. It is the young or, at least, those under middle age, who are most likely to be affected by exaggerated depression over losses and disappointments. Older folks have grown more accustomed to such incidents. These patients must be made to see how many motives there are to take their grief philosophically and while permitting themselves the luxury of sorrow, not to let this interfere either with their physical condition or their mental state to such a degree as to prevent them from taking the proper interest in their duties in life. The ethical motives that may be urged to keep people from grieving over-much are many, but there is sometimes the feeling in the physician's mind that it is scarcely his business to emphasize them in any way. It is supposed that to the clergyman must be committed the task of consoling people for losses in life. This has always seemed to me a serious mistake. As physicians we know how much the mind influences the body and since it is our duty to care for the body, we must, above all and first of all, care for the mind as far as we can. _Mens sana in corpore sano_ is a very old motto and is usually taken only in the sense that to have a healthy mind one must have a healthy body. In its Latin form, however, it might very well also be taken to mean that to have a healthy body one must have a healthy mind. Since grief has an untoward influence on the body, physicians are bound to learn what to do for it in any and every possible way and to exercise every faculty they have for its relief. This is all the more true because in recent years many persons have no regular religious attendant who would come to offer them consolation or to whom they would go in their trouble. It is not at all with the idea of infringing on the rights of the clergy or invading his territory that I would insist not only on the right of the medical man, but even his duty, to afford consolation to the mind as well as relief for the body. _The Family Physician_.--In older times the family physician was a friend of the family to whom people turned in all troubles where he might possibly be of aid, with just as much confidence and as promptly as they did to their religious attendant. Unfortunately, in the progress of medicine, though still more because of the social vicissitudes that have taken place in recent years, this relationship of the family physician has been largely diminished, but that constitutes only one more reason why every physician, to whose attention the grief of a patient for any loss is presented as a cause of ill-health, should know all the means and be ready to employ them for the amelioration of the condition. As a matter of fact, there is often a feeling on the part of patients that it is more or less the business of the clergyman to afford consolation and that the performance of his duty in this matter is somewhat conventional, not {730} as if he performed it less thoroughly because of this, but as if the feeling of the routine practice detracted from its effectiveness. Some of the motives for consolation advanced by the clergyman, then, lose in significance, in some persons' minds at least, because of this feeling, while motives presented by the physician rather gain in weight because of the impression that he is a thoroughly practical man, deeply interested in life's problems from a common-sense standpoint, and who knows the motives for consolation because he has realized that losses are inevitable, suffering unavoidable, and grief sure to come, though somehow we must learn to bear up bravely under life as we find it. Physicians have always done this in the past, but in more recent years either they have lost the habit, or have considered it unworthy of their profession, or else, perhaps, only too often they themselves have had no motives to offer that might seem sources of consolation for those in suffering and especially those who are grieved for the loss of friends. If life were a mere chance, if there were not an evident purpose in it, if, as Lord Kelvin insisted, science did not demonstrate (not "suggest" but "demonstrate" is the word he used) the existence of a Creator and a Providence, Who, while caring for the huge concerns of the universe, can just as well employ Himself with the little details of human life, then there would be some reason for physicians thinking that their science kept them from seeking consolation from the ordinary motives. Even if they occupy an advanced agnostic position, however, they may still find sources of consolation that, if not so effective as those attached to the old beliefs, at least will provide something for the forlorn to take hold of, that will mitigate their grief and sense of loss and make the present and the future look not all too blank. Few men have been so thoroughly agnostic as Prof. Huxley, yet on the death of his wife he found that some of the thoughts of the old beliefs might prove a source of consolation. Huxley had loved his wife very dearly and their separation by death meant very much. The epitaph that he wrote for her sums up his doubts yet plucks out of them something to console, expressed in old Scriptural language: And if there be no meeting past the grave. If all is darkness, silence, yet 'tis rest. Be not afraid, ye waiting hearts that weep. For God still giveth His beloved sleep; And if an endless sleep He wills, so best. _Attitude Toward Death_.--The ordinary attitude of people toward death is a very curious one. Death is the one absolutely certain thing in life after birth, yet most of us live our lives without much regard to it, and whenever it comes and under whatever circumstances, at whatever age, it is always a shock to us. No matter how old people are it always comes a little before it is expected. When death comes it is always a shock and all that can be said of it is what Hamlet resents when the commonplace consolations for the loss of his father, who also lost a father and so on all down the course of history, are offered to him. Perhaps, however, as much the reason for his resentment was the person who offered the consolation as the form of the consolation itself, which, after all, exhausts nearly all that we can say in this matter for grief for near and dear ones: {731} King. 'Tis sweet and commendable in your nature, Hamlet, To give these mourning duties to your father: But, you must know, your father lost a father; That father lost, lost his; and the survivor bound In filial obligation, for some term To do obsequious sorrow: but to persevere In obstinate condolement, is a course Of impious stubbornness: 'tis unmanly grief: . . . Fie! 'tis a fault to heaven, A fault against the dead, a fault to nature. To reason most absurd, whose common theme Is death of fathers, and who still hath cried, From the first corse, till he that died to-day, "This must be so." _Death and Pain_.--One of the most effective consolations in our day for all classes of people, quite apart from religious affiliations or beliefs, is the sociological import of death and suffering in the world. Life, without suffering and death in it, would be a riot of selfishness. Men, as a rule, would not care for others at all, the weak would go to the wall, the individuals who possess less efficiency than others would simply have to make out as best they could, and bad as social conditions are now, they would be intolerably worse. As it is the young and strong and vigorous have very little of true sympathy. Nothing makes a man feel for others like having gone through some suffering himself. On the other hand, nothing makes him feel the impotence of struggling ceaselessly for vain success and the futile rewards of life than to lose near and dear friends whose share in that success and joy over the rewards would constitute their only real value and justification. As a man grows older and has gone through some of the sufferings and has had to bear the losses of life, he learns more and more to feel for others, he is ready even to make sacrifices that others may not have to suffer as he has suffered, he has charity for them for the sake of his own suffering and that of near and dear ones, and things are much better than they could possibly be without suffering and death. _Therapy by Example_.--Many men have taken losses so seriously as to think that life held no more for them, and have foolishly given up their occupations, yet have found that Time, the great healer, could work his marvels in their case as well as in most others and that new interests and, above all, their life work, could arouse them to a sense of duty and bring them back to the old routine of life. Dr. Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how even that veteran surgeon gave up everything at the death of his wife and yet found, after a year of idleness, that he had to come back to the old life again. Dr. Mumford says: "Sir Astley Cooper was an emotional man. In 1827 his wife died, and the event prostrated him with grief. He felt that all the interests of life were over for him. He fell into an acute physical decline, sold his town house, threw up his practice and other professional employments, and retired to his country place to pass his last days. Within a year of the sad event he had returned to town, taken another house, resumed practice with increased vigor, and married again. He was then sixty years old, he lived on until 1841, and died in his seventy-fourth year." {732} A typical example of how much a strong man whose diplomatic ability had stamped him as one of the large men of his generation may yet be afflicted beyond measure by a loss of this kind is to be found in the life of the second Lord Lytton. I have told it somewhat in detail in the chapter on Periodic Depression. After the death of his boy Lord Lytton, who for more than a week of anguish had watched unceasingly at the death-bed of his dying son, came to the conclusion that God was not in His world or, at least, that the arm of Providence was shortened if such (as it seemed to him) needless suffering was permitted. The boy had probably suffered much less than the bystanders thought and much less than he seemed to, for in these cases nearly always there is a merciful deadening of the senses that to a great extent eliminates suffering, but Lord Lytton could not understand and refused ever to look at life from the same standpoint afterwards. This is, of course, only what happens in many cases, but it represents an exaggeration of grief since death and suffering have always been in the world and sometimes they will come to those near and dear to us, much as we may resent it. Neither profound intelligence nor the sympathetic genius of the poet or artist is sufficient to safeguard men against the severer forms of griefs for loss. Louis, the distinguished French physician (to whom we in America are indebted so much as the Master of the Boston and Philadelphia schools of diagnosis, and, above all, for his teaching of the differentiation between typhoid and typhus fever), suffered so much from the loss of his son that he could scarcely be consoled. Dante Gabriel Rossetti was so much affected by the death of his wife that he put into her coffin the only manuscript copy of his poems that he possessed. It is interesting to learn that some years later he had the coffin exhumed and took out his manuscript at the urging of friends, and published the poems. Many other examples of this kind might be given, for exaggeration of grief affects all classes and conditions in life. They are practically always pathological, usually on a basis of somewhat disturbed mentality, though often the real underlying and predisposing condition is the physical exhaustion that has preceded the loss and which makes patients unable to bear the strain of it after weeks of care, solicitude, anxiety and neglect of eating and sleep. CHAPTER V DOUBTING In recent years the attention of physicians has been called to the fact that many people are made profoundly miserable by an unconquerable tendency to doubt about nearly everything that has happened to them, or is happening, or is about to happen. This is not a new phenomenon, but introspection has emphasized it, leisure gives more opportunity for it, and so physicians hear more of it now than they did in the past. This doubting tendency sometimes makes serious inroads on the peace of mind of sufferers from it because they cannot make up their minds to do things, even to take exercise, to eat as {733} they should in quantity or quality, and to share the ordinary life around them sufficiently to get such diversion of mind as will keep their physical functions normal. The state used to be described as a neurasthenia (nervous weakness), but in recent years has come better to be designated as in the class of psychasthenias (lack of mental energy). It is always a mental trouble in the sense that it is difficult for these patients to make up their minds about things, yet it is not a mental disease in the ordinary sense of the term, and these people are often eminently sane and thoroughly intellectual when their attention has been once profoundly attracted. They may even, under favorable circumstances, be active and useful helpers in great causes, yet there is always to be observed in them a certain noteworthy difference in mentality from the normal. The physician can do more for an affection of this kind than is usually thought, and he is probably the only one who can thoroughly appreciate and sympathize and, therefore, be helpful in the condition. Sufferers are often laughed at by their friends and relatives and are likely to be the subjects of at least a little ridicule if they take their troubles to their physician. As a matter of fact, however, doubting is a typical case for psychotherapeutics and not only can much be done for its relief, but it can be kept from disturbing the general health, which it is prone to do if neglected, and by mental discipline and acquired habits of self-control, the doubting habit may be almost completely eradicated. Exaggeration of Ordinary State of Mind.--The first thing absolutely necessary to impress upon the minds of these victims of their own doubts is that their condition is by no means unique, it is not even very singular, but is only an exaggeration of that hesitancy and tendency to put off making decisions that practically every person finds in a lifelong experience. This frame of mind is rather cultivated by education and by a large accumulation of knowledge. The less one knows the easier it is to come to decisions about difficult problems and to form conclusions without hesitancy. The young man will decide anything under the sun, and a few other things besides, almost without a moment's hesitation, and after but slight consideration. Twenty years later he looks back and wonders how he did it, and having done it, how he succeeded in turning the practical conclusions to which he came to advantage. The scholar is eminently a doubter and a hesitater, and we recognize that he loses certain of the qualities that would make him a practical man of affairs, though he gains so much more that broadens and deepens life's significance that there can be no doubt about the value of his liberal education. "Hamlet" is just the story of one of these doubters and hesitaters. He saw his duty clearly and that duty was imperative. In spite of cumulative evidence, however, he refused to go on to the performance of that duty, urging to himself now one and now another reason of delay, until finally he wonders whether it would not be worth the while to take his own life, rather than try any longer to solve the problems that lie around him demanding solution. When he finally does something, his hand is forced and circumstances have so arranged themselves that instead of one clean-cut punishment for a great crime, there is the tragedy that involves six lives, including his own. The play seems to involve such exceptional characters and to be written around such an unusual set of circumstances that it might be thought {734} that it would prove uninteresting for men and women generally. As a matter of fact, however, "Hamlet" is the most popular of Shakespeare's plays and probably the most popular play, both for readers and auditors, that was ever written. There are commentaries by the hundred on it in nearly every modern language. Men have been more interested in this figment of Shakespeare's imagination than in any man that ever lived. Caesar and Napoleon have not attracted so much attention. Only Homer and Dante have been perhaps more written about than Hamlet. Shakespeare has emphasized the condition of Hamlet by showing us an eminently well educated man. His deep interest in literature, and especially in dramatic literature and all that relates to the stage, can be appreciated very readily from his speech to the players. No one but a man of profound critical ability and deep intellectual interests could have so summed up the actors' relation to the drama. Of course, this is Shakespeare himself talking and unthinking people have said that this was a purple patch fastened on the play because it gave the author an opportunity to express his views with regard to actors and their ways. Instead of that, it is of the very essence of the development of Hamlet's character and shows us the scholarly amateur who knows so much about many things that he has become quite unable to make up his mind about the practical problems that lie before him. James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg, though Wittenberg was not founded until centuries after Hamlet existed--and Shakespeare probably knew that very well--because Wittenberg in Shakespeare's time, on account of its connection with Luther and the religious revolt in Germany, had the widespread repute of occupying men's minds with doubts about many of the things that had been deemed perfectly settled before, and its popular reputation serves to give an added hint as to the character of Hamlet as the dramatist saw it. Once those who are perturbed by doubts learn that the reason for the universal human interest in Hamlet is that there is a large capacity for doubt of self in every man and woman, that we all put off making decisions whenever possible, sometimes refuse to open letters when they come if we fear that they will contain some disturbing news, put off writing letters because we have to state ideas definitely, apparently hope that the day and the night will bring us counsel and that somehow the decision will be made for us without the trouble of making up our minds, then they lose their sense of discouragement over their condition and appreciate that they are suffering only from an exaggeration, probably temporary and quite eradicable, of a state of mind that comes to practically every human being. This is the important thing, because on it can be founded the only really hopeful therapy of the condition. Doubting is a habit that may be increased by yielding to it, but that can be diminished to a very great extent by constant discipline, which refuses to permit doubts and hesitancy and bravely makes decisions, even though there may be the feeling that they may prove to be wrong. Extent of Affection.--If such discipline is not instituted, then the lengths to which the doubting hesitant habit may go are almost incredible. I have had patients tell me that they doubted about nearly everything in the past. A very dear friend once confided to me that it was always a source of bother {735} to him that he was not quite sure whether he was married or not. His marriage I knew had been a public ceremonial, and he had led his bride down the aisle to the strains of the "Wedding March" in quite conventional style, but he was hesitant of speech, especially under excitement, and he was not sure that he had ever said "I will" to the question of the clergyman, for there was a constriction at his throat at the moment and he could utter no sound. The absence of any audible sound from the groom is not so unusual as to attract attention and, of course, his intention and his bodily presence and everything else gave the assent without the necessity for the word, but he could not get out of his mind the thought that possibly he was not married and at times it gave him poignant discomfort. He was a thoroughly intelligent man, a teacher and a writer, with no abnormalities that attracted attention, and his tendency to doubt was only known to very near friends who laughed at it and had no idea at all of the annoyance that it often gave its unfortunate victim. I have a clergyman friend who has had some serious scruples with regard to his ordination. He is a Catholic priest and at a certain part of the ceremonial of ordination it is considered necessary for the candidate for orders to touch at the same moment the paten, the small metal plate on which the Host is placed, and the chalice. This clergyman is not sure that he had done this simultaneously. As a rule, great care is exercised in seeing that all the details of the ordination ceremonies are carried out very exactly and as there are a number of attendants on the altar whose duty it is to see that the absolutely necessary details are properly fulfilled, it is quite improbable that any mistake in this matter was made. The young clergyman, however, had not made an act of conscious attention at the moment when he was supposed to do this, and consequently he could not be sure afterwards whether he had done it or not. He thought of it as the very essence of his ordination and he feared that all his subsequent acts as a clergyman might be impaired by this negligence. Trivial Doubts.--It is not alone with regard to important things, however, that people may doubt and are disturbed by doubts, but with regard to every trivial thing in life, if they permit the habit to grow on them. Doubting is, after all, one of the phobias, that is to say, it is the fear that something may happen if the decision they make is wrong, that causes people to hesitate so much. There is a tendency in all of us which, if undisciplined, may make us put off the doing of things until the last moment. It is easy to resolve the night before that we will do certain things the next day, but when the next day comes we find excuses to put them off. I have already suggested as a symptom that some people put off the opening of letters. There are probably more who do this than anyone has any idea of. Delay in answering letters is probably much more often due to hesitancy of decision than to actual laziness. We doubt as to what we should say about certain things, and we do not care to take the trouble of making up our minds, and we fear if we do make up our minds it may be wrong, so we adjourn the whole matter to another time and keep on adjourning it. Many people are quite ready to confess that they do not do things until they have to, though few are ready to acknowledge that it is due to hesitancy or doubting about themselves and their decisions. {736} Of course, the man who doubts whether he has locked the door of his house after he gets to bed can only satisfy himself by getting up and actually investigating the state of affairs. Then there is the man who doubts whether he has locked his safe at the office. He may get his doubts just as he reaches the foot of the elevator and then if he is wise he will go back and determine the matter. If he is wise with experience he will also deliberately determine while he is there whether the office window is closed and locked and will make a conscious act when he comes out as to the locking of the office door. If he does not do all this he will have further doubts on the way up town and at his home during the evening which will make the doing of anything else a matter of discomfort and he will spoil the restfulness of his after-dinner hours. Some men conquer their first doubt, make their way home only to be beset by so many doubts that at the end of an hour they go back to their office and determine whether the safe is locked or not. Finding it locked they may forget to notice other things about the office and then they will surely have doubts about these, and they may have to go back again and see about them. Then there is the man who doubts whether he posted a letter or if he did post it, who doubts whether it found its way down to the bottom of the mail box, or whether it may not have caught on a projecting screw or bolt or some portion of the upper part of the box and so fail of collection; he may go back several times to determine this. Doubts about even more trivial matters than this, however, annoy some people. I have known widows on whom the responsibility of managing the financial affairs of the household had been thrown for the first time after their husbands' death, who constantly doubted whether they could afford to spend this or that, though they were regularly saving money from their income. Over and over again they would have to go over all their recent expenditures to decide whether they could afford certain expenses. Such little things as the sort of paper to use in their correspondence, the wages they paid their servants, the amount of waste in the food in the household, all aroused in them doubts and set them to calculating once more just what was the relation of their income to expenditure, all to no purpose, for they would have the same doubts the next week or month. Then there are people who doubt whether their friends really think anything of them. They think that though they treat them courteously this may be only common politeness and they may really resent their wasting their time when they call on them. They hesitate to ask these people to do things for them, though over and over again the friends may have shown their willingness and, above all, by asking favors of them in turn, may have shown that they were quite willing to put themselves under obligations. They doubt about their charities. They wonder whether they may really not be doing more harm than good, though they have investigated the cases or have had them investigated and the object of their charity may have been proved to be quite deserving. They hesitate about the acquisition of new friends, and doubt whether they should give them any confidence and whether the confidences that they have received from them are not really baits. This is, of course, a verging on suspicion as well as hesitancy and doubt, but the stories of how these people try to conquer themselves, yet have to make decision after decision, each one requiring time and a certain resolution of mind, are quite {737} pitiable. It gets worse rather than better unless a definite discipline of opposition and control is organized. What ordinary people do habitually and easily and without any effort of mind, these people must waste time and mental energy over so that it is extremely difficult for them to accomplish anything. Training of mind, as of hand, consists in making certain actions so habitual that they are accomplished quite automatically. If we have decided that we are to get up at a certain hour we get up at that hour and do not have to make up our minds about it again, though this is one of the actions in which we all have the most lapses and the most need of renewal of resolution and habit. We make up our mind what we are going to eat and gradually acquire the habit of eating a certain quantity and a certain variety at meals and then we do not have to make up our minds about it every time. We go out, to do whatever must be done in our occupation quite automatically and there is no need of wasting mental energy over decisions about it. It is this that the doubter cannot do. He or she calls every trifling act before the supreme court of last decision, the bar of intellect, to decide whether it is worth while doing, whether it is to be done or not, how it is to be done, and then there is a doubt whether after it is done it may not prove to be quite the wrong thing to have done. This adds so much to the friction of life that all the surplus energy is used up in the settling of trivial matters, and nothing worth while is accomplished. Sir James Paget once expressed all the realities of the situation of many of these people in a few terse phrases. It is probably the best explanation of its kind that we have and it deserves to be in the notebook and often before the mind of physicians who treat neurotic patients. Sir James said: "The patient says 'She cannot'; her friends say 'She will not'; the truth is she cannot will." The expression, of course, applies to many other phases of so-called nervous disease besides doubting and especially to the psychasthenias. It represents, indeed, the keynote of many of these puzzling affections. The fact that it was uttered more than half a century ago shows how much better these affections were understood two generations before ours than we are likely to think, and how well physicians then got to the heart of them. From this to the re-education of will, that mental discipline and relearning of self-control which constitutes the essence of the treatment of them, is but a short step. Prophylaxis.--_Serious Occupation_.--Of course, the real way out of the trouble is to have to do certain important things that occupy the mind and require the doing of many other things as subsidiaries which must be accomplished in order to carry out the greater resolution. Men who have important affairs on their hands seldom are bothered by doubts and hesitancy. Women who have not much to do make mountains out of the molehills of their little occupations and every trifle must be adjudged. The larger interests must be cultivated, the smaller ones must be turned over to the automaton which every one of us can develop in our persons if we only set about it resolutely. Each thing that comes up must be settled at once and action must replace contemplation. The Hamlet in us all must be put down and resolution must not be allowed to be sicklied over with the pale cast of thought. We must do {738} things and not think about them too much. The doubters can learn this lesson. They will never be entirely without hesitancy, but they can remove many of their difficulties, and live to accomplish much in spite of their make-up. Physical Treatment.--The physical treatment of the doubting state consists, of course, in bringing the individual's physical condition as near as possible up to the normal. When the state occurs in people who are under weight its betterment is rather easy. The special feature of the physical condition that needs seeing to is an ample supply of fresh air. People who live in ill-ventilated places, or who do not get out into the air enough, are almost sure to suffer from the tendency to avoid the making of decisions. The man of decision usually is a vigorous outdoor-air individual. Even the perfectly healthy man who has been in the house for some reason for days together gets into a state of mind where the making of decisions becomes objectionable. He wants to push things away from him. In individuals who already have a natural tendency this way this is greatly exaggerated by confinement. Arrangements must be made, therefore, that will ensure getting out for some time, not once but twice every day. The regular making of decisions for this purpose is of itself a good mental discipline. It must not be omitted even for rain or snow, unless there are additional reasons of some kind. An abundance of fresh air in the sleeping-room is extremely important and must be secured. Mental Treatment.--The mental treatment consists in diversion of mind. Usually the doubters have no interests that appeal to them deeply and in which they have to make prompt regular decisions. If possible, these must be secured. They must form habits of doing things regularly and of making up their minds to do them, and then not have to repeat the adjudication and resolution. In recent years people realize, quite apart from its religious significance, the value of what older religious writers called examination of conscience. Regularly before they go to sleep these people must be told to call up what they have done during the day and to note their faults in the matter of putting off doing things and making decisions slowly. They must, however, not only realize their faults, but they must make up their mind to correct them during the following day. They must not leave the arrangement of what they shall do next day to chance, but must decide just how and when they shall do things and then, as far as possible, keep to this program. The program must, of course, be sensible and considerate. This preliminary arrangement can be made to mean much more than might be thought. Some people thus learn to correct entirely their tendency to doubt whether they should do things or not and lessen greatly the difficulties they have in making decisions. CHAPTER VI RESPONSIBILITY AND WILL POWER The development of science (meaning by that term knowledge with regard to physical nature in contradistinction to philosophy or the relation of nature to man) in modern times has brought about in some minds a hesitant, if {739} not frankly contradictory attitude towards the question of free will. There are many scientists who not only doubt the existence of free will, but insist that there cannot be such a thing. For them, man like the animals is determined to do things from without rather than from within. The stronger motive compels him. There may be a weighing in the balance of motives, but that is a question of intellect and not of will. It is true that the stronger motive may be one that is less alluring to nature or to sense than some of the others which clamor for a hearing, but it is eventually the stronger motive that compels. A man may desire something that does not belong to him very much, but the consciousness that it does not belong to him and that to take things that do not belong to him is unworthy of him will override his covetousness and so he remains honest if he has been trained to regard things that way. After all, the old maxim, "Honesty is the best policy," is founded on some such reasoning as this, since only one who is at heart dishonest would consider men as swayed by the thought that to be honest is the most profitable, instead of being the right, and therefore the only proper thing. The argument for free will that appeals to most men is the consciousness that we are free and that at any given moment we can do a thing or not do it, just as suits us. If two things are presented to us we can do that one which seems right to us to do, or we can do both of them, or we can permit ourselves to be led into the wrong, though always acknowledging to ourselves that it is the wrong and feeling downcast, or at least disturbed, that we should let ourselves be led away from higher motives. Even in this case the determinist insists that we are determined from without by motives due to our training, to our education along certain lines with the influence of the environment in which we live, to the special sentiment that we have within us as a consequence of the influences of preceding life. Such determination, however, does not come from without us, but from within. It is the result of the formation of our wills in a particular direction. The argument is, therefore, a begging of the question. A man may have formed the habit of doing evil things and then finds it easy to do them without compunction. On the other hand, the exercise of his will in doing what he considers right, in spite of the fact that it may not be pleasant at the moment, is a training of the will founded on its essential freedom. There is an essential distinction between right and wrong, and we have it in our power, as many a man has done, to follow the right even though it costs our life. Bad Temper.--A typical example of supposed determinism, which proves exactly the opposite of what is sometimes urged, may be noted with regard to exhibitions of temper. As Clouston declares in his "Unsoundness of Mind" (Methuen, London, 1911), "an uncontrollable temper is in many cases very like and nearly allied to an unsoundness of mind. It is certain that bad temper may gradually pass into technical insanity and that a considerable number of persons who are passing or have passed into insanity exhibit as the most marked symptom morbidness and violence of temper. 'It's just temper. Doctor,' is one of the most common remarks that I have heard made to me by patients' friends. I think that it is quite certain that in most cases much might be done in youth to establish a reasonable control over temper where it is inclined to be uncontrolled, so preventing serious discomforts in life both to its possessor and to others. In many cases I am satisfied that {740} this education would have the effect of preventing unsoundness of mind also, arising out of uncontrolled temper." There are many examples in the literature of hagiology particularly, from which it is clear that men have learned to control even violent tempers and by self-discipline and training in self-control have even become rather quiet, gentle individuals. The truth of such examples is attested too well to be discredited. This question of training, then, is extremely important. It has been pointed out that the consciousness of freedom to which an appeal is made in this argument for free will is shared with us by the insane even in the performance of many acts that we know are compelled in certain ways. Insane persons reason themselves into a peculiar state of mind, in which they represent to themselves that they have been persecuted, for instance, by a particular person and then they become persecutors in turn and do harm. As they see their act, it is often a species of self-defense. They themselves have no consciousness, or, at most, a very dim and hazy realization of the inner compulsion to which they are subjected at the time of the act and sometimes talk quite rationally and discuss the motives which impelled them to do things, just as if they were free. We recognize, however, the distinction between this delusion of the insane and the rational state of mind of the sane. We have no definition for insanity, that is, no formula of words, which will absolutely include all the insane and at the same time exclude all the sane, but we have a practical working knowledge that enables us to judge rather well between those who are compelled to do things by delusions, and those who do them from motives that are rationally weighed and that influence a will that is free to follow them as it pleases. We hold the rational man responsible for his acts because he knows he was free not to do them. We punish him partly because he should not have done them and partly because we want him not to do them again, and we know that punishment will help him to keep from committing crime, because it will support his free will against his inclinations, when the time of trial comes again. Above all, we are conscious of our own responsibility. We know that when we do wrong we are worthy of blame. We know that when we allow covetousness to lead us into the appropriation of what does not belong to us we are deserving of punishment, because we need not have done it, but we yielded to unworthy motives. We know that while anger may be blind we can control it, at least those of us who are fully in possession of our intellectual and voluntary powers, so as to keep from doing violence, even in the heat of it. This dealing with ourselves is the best proof that we have of our recognition of our freedom of will. We are responsible, and what we genuinely do not will to do is not accomplished. Our will may be bent by many attractions, but we know that these motives are not compelling unless we allow them to be. When a child tells us that he did something because he could not help it, we either feel sorry for him because he is not yet in possession of his full faculties or else we laugh at this excuse. There is a tendency to admit this excuse as having a meaning, but only by those who themselves come into court with hands assoiled in some way and who are looking for pardon from others for offenses, and who, above all, want to feel that they can pardon, or at least excuse, themselves. In recent years we have seriously impaired the idea of responsibility in {741} the minds of the general public by a foolishly sentimental mercifulness to criminals. If a man under indictment for murder can show that he has ever previously in his life acted even slightly irrationally, or if he has been peculiar in certain ways, provided, of course, he has money enough to pay for the opinions, there will be an abundance of expert testimony to declare that he is irresponsible and should not be punished. As a consequence, in many cases justice fails. We are reaping the harvest of this pseudo-scientific invasion of law. Human life is cheaper in no country in the world than it is in America. Our murder rate is going up by leaps and bounds, while that of Canada remains almost stationary, and the reason is that while nine out of ten of all our murderers do not receive the death penalty and many of them escape serious punishment of any kind, nearly as large a proportion of Canadian murderers are punished by death. A man may have his responsibility somewhat impaired and yet retain sufficient free will so that he deserves to be punished for serious crimes. It is hard to decide in certain cases, but in most cases the decision is not difficult if, with the right sense of justice, morbid sentimentality is put aside. [Footnote 59, the following lengthy citation is from an article on "Responsibility and Punishment," in the _American Journal of Medical Science_, 1909.] While the doctrine of free will is so clear it is still true that the question of responsibility for actions, and above all for criminal actions, is not so simple as many people used to proclaim it in the past. No two men are free to perform an act or not to perform it in quite the same way. Familiar examples are ready to hand: One man finds no difficulty at all in resisting the inclination to take spirituous liquor to excess; another finds it a most difficult feat, often apparently impossible for him to refrain from indulging to excess almost whenever the opportunity offers, or at least whenever he gets a taste of liquor. This difference between the two men is founded in their very nature. It would be utterly a mistake to praise the one for his abstinence or to blame the other under certain circumstances for his indulgence. Between these two classes there are others quite different individually. Some of them have a slight tendency, and, fearing the worst, do not indulge in it; some of them have a marked tendency which they are able to resist under most circumstances without very much difficulty once they have made up their minds; some are sorely tempted, fall occasionally, yet never become habitual drunkards. For each of these men there is a different responsibility, and so far as they are to be punished a different punishment must be meted out, for it is our effort in the modern time to make the punishment fit the criminal and not the crime. This same thing holds true for many other forms of crime. Some men readily lose sight of the distinction between mine and thine, and possess themselves of their neighbors' goods almost without realizing that they have done wrong. They are rare, and we have been accustomed to call these people kleptomaniacs. Between these and the man who hesitates to steal, even when starving or for his starving children, there are many degrees of inclination and disinclination toward stealing. The same thing is true to a more noteworthy degree with regard to anger. Anger, the old saw says, is a brief madness. In America we say very frankly that a man who is very angry is mad. In this brief madness he may be led to do things which he would not do at all in his sober senses. Some men easily get into one of these awful fits of anger in which their responsibility is lessened, while others have a calm phlegmatic disposition from which they are scarcely aroused even by the worst forms of abuse or injury, or even physical suffering. It is evident in all these cases that in order to measure how much of punishment ought to be meted out for acts committed it is more necessary to know the individual than his act. This often becomes an extremely difficult matter, for {742} after the commission of crime every effort is made to make out as little responsibility as possible for the criminal. The easiest way to do this has been to use the insanity plea. As already stated, we have no definition of insanity. It is easy to understand then that there will be a disagreement among physicians as to who is or is not insane, and the result is almost sure to create doubt which tends to obscure the principles on which are based the proper punishment of crime. Now this system is founded on certain wrong principles as regards the administration of Justice. While it is difficult to decide with regard to a man's insanity or sanity, it is not difficult to decide with regard to his punishment when the ordinary purposes of punishment are kept well in view. The old idea of punishment used to be that of revenge. A man had done a wrong, and what would ordinarily be held a wrong had to be done to him in order that the scales of Justice should be maintained level. At the present time we have no such idea at all. Punishment has two main purposes--the prevention of further disturbance of social order by the particular criminal, and the deterrence of others from like acts. If a man takes away the life of another we do not take away his because thus Justice will be obtained, but we take it away to prevent him from ever doing anything of the same kind again. A man who has committed murder is more likely to do it again than another. He has committed one breach of social order; we shall prevent him forever from committing another of the same kind. This is the very best deterrent to such crimes that there is. It will be said, of course, that these men could not refrain from doing their acts. It is doubtful, however, whether this contention is true in the great majority of cases, and the proper punishment of such as occur furnishes the best possible motive to help others from the commission of like acts. This holds true for children at a time when their sense of responsibility for their acts is as yet undeveloped. They can be taught, even very early in life, by properly applied punishment, that need not be severe, that they must not do certain things, and then they will not do them, or at least, will do them much less. This is true not only for perfectly rational children, but also for those that are to some degree irrational. Punishment is of great importance in the training of children of low grade intelligence, and there is scarcely any child, however wanting it may be in intellect, that cannot be disciplined into conduct that makes it much less bothersome than would ordinarily be the case. This is well known and it is also well known that the attempt to manage such children without punishment would be extremely difficult, not to say impossible. They do not reason about the thing, they are not quite responsible for their acts; but they do connect punishment with what they have done, and are in many cases deterred from doing it again, especially while they realize that authority is near them and that punishment is inevitable. These are the principles on which the adjudication of punishment for crime must be measured. There is nothing else that can be done if society would preserve itself and its members from those who are irresponsible even in minor degrees. In this matter practical experience is well worth the while. The lower order of creatures, the animals, we do not consider responsible for their acts in the same way as human beings. We know the value, however, of punishment in deterring them. A dog, for instance, by being whipped a few times when he is young, can be taught not to steal things to eat, and taught that there is an inevitable connection between the taking of such things and the infliction of such punishment. I shall not soon forget my first lesson in philosophy from a dear old professor, who, talking of the memory of animals, demonstrated that they had a memory, from the ordinary experience of mankind with regard to them. "If a cat does something naughty in your room," he said, "you rub its nose in it, and it will not do it again." The cat had no idea that it was doing wrong. According to its way of life it was not doing wrong. It learned, however, from sensory experience that it must not do this sort of thing under special circumstances, and after the lesson has been once thoroughly learned there is no more trouble of this kind. Individuals who are of less mental stability than normal require, indeed, more careful discipline than average men. The rational may be managed by sweet reasonableness. The defective child must be made to realize that certain actions {743} will surely be followed by painful punishment, though, of course, the main purpose of modern care for such children is to watch over them so diligently as to prevent them getting into mischief. This is after all what we do with the animals, and we realize the necessity for it. Defective human beings approach the animal in their lessened power to resist impulses, and they must be treated in the same way. If we were to save the animals in an excess of tenderness toward them, because we held to the notion either that they did not know any better or else could not resist their impulses, and then permitted them to do things without punishment, we should either have to get rid of animals entirely, or else life would be one continuous readjustment of things to animal ways. Since defectives occur in the general population, it must be realized that far from being less rigid with them in the matter of meting out punishment for things they do that are harmful to others, we must be even more strict with them. Otherwise, we will have to take the bitter consequences of our own foolishness. It does not make so much difference if the thoroughly rational individual occasionally escapes punishment for something done, but whenever the subrational escapes, he is encouraged to do it again. More than that, the example of his punishment is needed for others. So far as possible, punishment must inevitably follow crime in the world, in order to impress the subrational and deter them from yielding to impulses. Far from being less deserving of punishment in every sense in which a modern penologist cares to inflict punishment, these individuals are more impressed by it, and, above all, need to be more impressed by it. When the subrational know that they can do things without being severely punished for them, they will always abuse that state of affairs. The thoroughly rational man may be depended on to do his duty as a rule without the need of punishment hanging over him. This is not true for the others, and hence the greater increase in crime, and above all in murder, which has made human life cheaper in this than in any other country in the world, as the direct consequence of recent abuses in our penal system. It has become very clear now that in recent years we have come to take entirely too lenient a view in these matters, and that many criminals who deserved to be punished, both because in this way they would be prevented from future crime and others deterred by the knowledge of their punishment, have been allowed to escape Justice. The tendency is toward too great mercifulness, which spoils the character of the nation, just as leniency to the developing child spoils individual character. Men may very well be insane, in the broad meaning of that term, in the sense that they have done irrational things, but then there is almost no one who has not. The responsibility of most men for a definite action is quite clear in the sense that if they are punished they will not do it again, or will be less likely to do it again, while if they are not punished their escape becomes a suggestion to themselves and to others to repeat such acts. It is for the subrational that we most need to insist on punishment. The cunning of the insane is proverbial, and this extends also to the subrational, and many of these folk realize that their difference from others, their queerness, as their folks call it, is quite enough to make a verdict of insanity in their case assured with the present lax enforcement of law. If the present state of affairs continues in this matter, we are simply allowing ourselves to be led by the nose by these cunning people into the perpetuation of a state of affairs in which they may do what they like because we have become foolishly oversensitive in the matter of inflicting punishment. On the principle that punishment deters, a man who has killed another man, even under conditions that seriously impaired his responsibility for the act and with evidence of previous lowered mentality, must never again be free to live the ordinary life of men. He must be under surveillance, and should be confined for life in an institution for the criminally insane. For the subrational such a sentence, if known to be inevitable, would usually be more deterrent than even imprisonment in an ordinary prison for life with all the possibilities for freedom which are presented by executive clemency, pardoning boards, and the like. It is absurd to say that a man may have such an attack of mental unsoundness as will lead him to do so serious an act as taking away human life, and then be expected to get over his mental condition so as not to be likely to do the same thing again. {744} Every alienist knows that this is not true. Such acts, when really due to mental instability, occur either in depressed or maniacal conditions, and these, as is now well known from carefully collected statistics, inevitably recur, or in weakened toxic conditions in susceptible subjects, and a return to the old mode of life may at any time bring recurrences. It is in the treatment of disorders of the will of various kinds that the physician is brought to realize how much harm is done by the teaching that determinism and not free will rules life. It is true that we often find cases in which men and women cannot use their wills or at least seem not to be able to use them. They are lacking in some essential quality of human mentality. We find many human beings, however, doing things that are harmful for them and that are so inveterated by habit that it is extremely difficult to get away from them. In every case the sane person can conquer and break the habit, no matter how much of a hold it may have obtained. We have heard much of the born criminal and of the degenerate and his inevitable tendencies, but most of the theories founded on this phase of criminal anthropology have gradually been given up as a consequence of more careful and, above all, more detailed observation. Many criminals bear the stigmata of so-called degeneration. Many of them have irregular heads, uneven ears, some fastened directly to the cheek and some with the animal peak, many have misshapen mouths and noses, but, on the other hand, many people having these physical qualities are good men and women, perfectly capable of self-control, honest, efficient members of society, and it is evident that the original observations were founded too exclusively on the criminal classes, instead of on the whole population. It is important, then, to get away from the notion of irresponsibility in these cases. While men are free, yet each in a different way and the freedom of their wills is as individual as their countenances, it must not be forgotten that the freedom of the will is a function of the human being, and, like all other functions, can be increased or decreased by exercise or the lack of it. The old idea of "breaking the will" was as much of a mistake as that other old-fashioned notion contemporary with it of "hardening" children by exposing them to inclement weather and severe physical trials. The will may be strengthened, however, by the exercise of it and if not exercised it may not be expected, by analogy, at least, to be as weak and flabby as muscles would be under similar circumstances. The training of the will by self-denial and self-control is extremely important. When there is an hereditary influence, a family trait and not merely an acquired character, by which the will rather easily passes out of control, there is all the more need for the training of it in early youth. Without such training men may find it impossible to make up their minds to deny themselves indulgence of many kinds, but this is not because they have not free will, but because this function has never been exercised sufficiently to enable them to use it properly. A man who attempts to do gymnastic feats without training comes a cropper. A man who is placed in circumstances requiring hard muscle exertion will fail if his muscles have not been trained to bear it. The same thing will happen with the will. Unfortunately this training of the will has been neglected to a considerable extent in modern education, and, above all, in modern families, where the presence of but one or two children concentrates attention on them, {745} over-stimulating them when young, leading to self-centeredness and, above all, discouraging self-denial in any way and preventing that development of thorough self-control which comes in the well-regulated large family. Besides, unfortunately it is just the neurotic individuals who most need thorough training in self-control and whose parents suffer from the same nervous condition (for, while disease is not inherited, defects are inherited), that are deprived of such regular training in self-control because of the inability of their parents to regulate either themselves or others properly. Here is the secret of the more frequent development of neurotic symptoms in recent years. It is not so much the strenuous life as the lack of training of the will so that the faculty of free will can be used properly. Lacking this, hysterical symptoms, unethical tendencies, lack of self-control become easily manifest. The training that would prevent these should come early in life, and when it does not it is very difficult to make up for it later. Just as far as possible, however, it is the duty of the psychotherapeutist to supply by suggestions as to training and discipline for the education of the will that has unfortunately been missed. {746} SECTION XX _PSYCHOTHERAPY IN SURGERY_ CHAPTER I PSYCHOTHERAPY IN OLD-TIME SURGERY Surgery, a name derived from chirurgy--handwork--might seem to be dependent almost entirely on mechanical and technical skill, yet there has always been the conviction that the patient's attitude of mind towards an operation is almost as important a factor in the success of surgery as the surgeon's skill. Astrology in Surgery.--From the earliest history of surgery we, find that astrology was mainly employed in order to determine what days were likely to be favorable, and what unfavorable, for the practice of such surgical procedures as were in vogue at that time. Certain conjunctions of the planets were declared to be particularly unfavorable, and some of them, indeed, were declared almost absolutely fatal; others were said to be especially favorable. As astronomical and anatomical knowledge grew, more and more details were added in this matter. Definite portions of the body were supposed to be under the occult influence of certain constellations. It was only with careful reference to these constellations then that surgical procedures or, indeed, the application of remedies of any kind, might be undertaken. All remember the picture in old almanacs of a man with the signs of the zodiac around him, and the indications that referred certain of these signs and the corresponding constellations to the different parts of the body. _Venesection and the Stars_.--When venesection became a frequently used remedy, the question of the favorable and unfavorable influence of the stars was an important element in it. In old Babylonia, noted for its knowledge of astronomy, which was then called astrology without any of our derogatory meaning in the word, certain positions of the planets were absolute contraindications for the performance of venesection. Indeed, astrology often furnished the best possible excuses for the failure of what were thought to be absolutely specific remedies. When the remedies did not succeed, their failure was attributed to their being taken at unfavorable times and not to the remedies themselves. These astrological ideas continued to influence medicine, and, above all, surgery, down almost to our own time. Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the influence of the stars on human constitutions. In fact, very few important patients of the seventeenth and even eighteenth centuries were treated medically or surgically without due reference to the stars at the time. All this had a profound influence on {747} the patient's mind. He felt that every precaution was being taken to preclude the possibility of failure and assure favorable results, and he, therefore, submitted to the operation absolutely confident that so far as human knowledge could go, everything was favorably disposed in his regard. Mental Influence in Old Hospitals.--It is rather interesting to realize how much the history of medicine illustrates the profound attention that was given in the old times to the question of the occupation of patients' minds as an eminently helpful factor in the treatment of disease and, above all, in convalescence. In the great health resorts, the temple hospitals like that at Epidaurus, or even the city hospital, the AEsculapeum at Athens, the question of recreation of mind was evidently considered very important. At Athens, the two city theaters, the larger one seating perhaps 50,000, and the smaller, Odeon, were not far from the hospital. At Epidaurus, a theater seating probably 12,000, in which the great Greek classic plays were given; a Stadium, seating nearly 10,000, in which athletic contests were conducted, and a Hippodrome, seating 6,000, in which animal performances might be witnessed, were all in connection with the temple hospital. Outdoor sleeping apartments were provided; that is, the patients slept under a colonnade, and, in general, the mental and physical hygiene of modern times was thoroughly anticipated. All of this was considered particularly important for convalescents. Patients were occupied, while in bed, with various interests. Just as soon as they could be moved, their minds were occupied with all sorts of interests external to themselves, and especially such as had the readiest appeal to humanity. (See bird's-eye view, facing p. 9.) Medieval Hospitals and the Mind.--It is not difficult to trace the development of similar conditions in the hospitals of the Middle Ages. While we are inclined to think of these older hospitals as surely lacking in everything that we have developed in our modern hospitals, they prove, on the contrary, to have anticipated most of our hospital improvements. They were of single story construction, with large windows high up in the wall so that there could be no drafts, with a balcony on which patients could sit in the sun, with arrangements for procuring privacy rather easily by means of sliding partitions, with tiled floors, and, above all, with pictures on the walls, some of them the products of the brush of the great artists of the old time and which would serve to occupy patients' minds. Probably nothing is worse for patients who are convalescing from illness or operation than to be left to their own thoughts. Often they must not be talked to overmuch, or permitted the exertion of conversation or of reading, yet they must have some occupation of mind. The frescoes painted directly on the walls of the old hospitals were eminently psychotherapeutic in this respect, and we shall probably have to imitate them. Besides, the patients had the opportunity every morning to hear Mass, which was said at an altar at an end of the ward, and certain religious exercises were conducted by the sister nurses each afternoon. How much of consolation this was to believing patients at a time when all were believers is rather easy to understand. Medieval Surgeons and Mental Influence.--Some of the insistence on this favorable state of mind for operations during the Middle Ages is extremely interesting. One of the great surgeons of the fourteenth century was Mondeville, whose text-book has recently been published in both France and {748} Germany. I have translated in "Old-time Makers of Medicine" [Footnote 60] some of his emphatic expressions, which show how important he deemed it to keep the patient in as favorable a state of mind as possible before and after operations. He went so far as to suggest that someone should be deliberately called in to tell him jokes. He said, "Let the surgeon take care to regulate the whole regimen of the patient's life for joy and happiness by promising that he will soon be well, by allowing his relatives and special friends to cheer him, and by having someone to tell him jokes, and let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred, and sadness in the patient, and remind him that the body grows fat from joy and thin from sadness. He must insist on the patient obeying him faithfully in all things." He repeats with approval the expression of Avicenna that "often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies." [Footnote 60: Fordham University Press, 1911.] Mondeville was but one of the great surgeons of the medieval period who dwelt on this. It would not be hard to find corresponding expressions in the books of such men as Guy de Chauliac, Hugh of Lucca, Theodoric, or even earlier among the great Arabian physicians and surgeons. Rhazes, for instance, declared that "physicians ought to console their patients even if the signs of impending death seem to be present, for the bodies of men are dependent on their spirits." He considered that the most valuable thing for the physician to do was to increase the patient's natural vitality. Hence his advice: "In treating a patient, let your first thought be to strengthen his natural vitality. If you strengthen that, you remove ever so many ills without more ado. If you weaken it, however, by the remedies that you use, you always work harm." Another of his aphorisms seems worth while quoting: "The patient who consults a great many physicians is likely to have a very confused state of mind." For him a confused state of mind evidently meant a lessened tendency to recovery. Surgical Lesions Influenced.--The King's touch in England, which so often proved beneficial for scrofulous patients, illustrates very well how much strong mental influence may avail even in cases where surgery seems surely indicated. Many cases of epilepsy were also greatly benefited by the King's touch, and, indeed, in this matter there are probably many more cases of the cure of epilepsy, or at least relief of the worst symptoms of the affection, reported as following the King's touch than after operation in the modern time. In both sets of cases we are now confident that the good effects produced came through the minds of the patients. When, during the eighteenth century, Mesmerism began to attract attention, investigators and experimenters on the subject were able to show that many pains and aches could be greatly benefited by psychic treatment. The painful conditions following fractures and sprains proved to be particularly amenable to mental influence exerted in this special way. As we approach the modern time, there comes to be a definite recognition of the fact that the mind may produce many pains and aches which seem due to purely physical conditions that might be expected to yield only to physical treatment. A corresponding recognition of the power of the mind to lessen and even suppress actual physical pain is almost a corrollary of this. {749} Sir Benjamin Brodie declared, as I have quoted in the section on "Diseases of the Muscular and Articular System" that a large proportion of the painful joint conditions that he saw among his better-to-do patients were of the hysterical or neurotic type. Sir James Paget thought this expression of Brodie an exaggeration, but acknowledged that one-fifth to one-fourth of all his cases in both hospital and private practice were due to hysteria. In those days most of the painful conditions were considered to belong rather to surgery than to medicine, so that these opinions represent very well the practice of medicine in these cases during the early nineteenth century. During the nineteenth century great practical surgeons, and especially those who have taught us how to treat individual patients rather than their diseases--for it is quite as true in surgery as in medicine that the patient is more than his disease--have made distinct contributions to the department of psychotherapy in surgery. Dr. Hilton's great book on "Rest and Pain" is full of psychotherapy. His cases illustrate the fact that when patients' minds and bodies are set at rest, all sorts of serious conditions proceed to get better. The rest of mind, the cessation of worry, the presence of a feeling of confidence in recovery, is quite as important as the physical measures. Young surgeons particularly probably could not do better than follow the advice of the old Scotch surgical professor at Edinburgh who suggests to his pupils that they should read Hilton's "Rest and Pain" at least once a year. CHAPTER II MENTAL INFLUENCE BEFORE OPERATION Much may be done during the preparation for operation to put the patient in the most suitable condition for the manifestation of healthy reaction of tissue and of normal convalescence. Many patients do not come for operation until their health has been somewhat impaired at least by the condition requiring operation. Not infrequently a good proportion of this impairment of health is due not so much to the lesion that is present as to the worry over it and the anxiety and solicitude which its development has occasioned. If the lesion is in connection with the digestive tract, this is particularly likely to be true, and nutrition will often have been sadly interfered with, not so much by direct influence of the pathological condition as by the unfavorable mental influence developing in connection with it. We know now that it is perfectly possible for an indigestion which is entirely above the neck to make rather serious inroads upon the health of the patient, by producing dislike for food or at least such loss of appetite as leads to considerable reduction in weight. In such cases there are often complications, such as tendencies to constipation, that still further impair health or at least reduce vitality and therefore hamper that healthy reaction which should occur after operation in order to assure normal convalescence. Accessory Neuroses.--In many of these cases, even where there is a definite lesion present, the patient can be brought up to normal weight, or at least his condition can be greatly improved by medical treatment accompanied {750} by such attention to his state of mind as will neutralize its unfavorable influence. If he can be made to understand that a definite effort to increase weight and to bring back his strength will be of assistance in recovery from the operation, and that the reestablishment of certain habits of eating and caring for himself will do much to help in this, very desirable changes for the better in his general health may be brought about. This is illustrated very well by what happens in certain incurable cancer cases. The patients often have lost considerable weight, even thirty to forty pounds, before an operation is decided on, and then when the operation is performed their cancer is found to be inoperable. After the exploration the patient is not told this, but is mercifully spared and is assured that now he ought to get better, since an operation has been performed. Such patients have been known to gain twenty, thirty, and in one case I believe over forty pounds as the result of the mental influence of this suggestion and the resumption of former habits of life to some extent at least, consequent upon the neutralization of the unfavorable state of mind into which they had sunk before through over-solicitude about themselves. If even the depressing effect of the toxins of cancer can thus be overcome, it is easy to understand how much can be accomplished when there is no such physical factor at work. Dominant Ideas.--As a general rule, it must be recognized that patients may be, and indeed frequently are, besides their definite pathological conditions, under the influence of dominant ideas which must be recognized and as far as possible neutralized. Some of them have persuasions with regard to food and the amount that they can eat, others have removed many important nutritious articles from their diet and are quite sure that any attempt on their part to take such articles is sure to be followed by indigestion, and still others have habits with regard to the amount and the kind of fluids that they take at meals and between meals and, above all, the lack of fluids in their diet which need to be overcome. Unless such ideas are counteracted there is difficulty even in convalescence, and very often they have brought patients into physical conditions in which whatever pathological condition is present is emphasized by that over-attention which the nervous system is so prone to give to even slight sensations when the organism is in a state of lowered nutrition. In not a few of these cases the bringing of the patient up to the normal condition of weight and health, and the removal of the influence of dominant ideas, will perhaps also remove many of the indications for operation. There are many patients, and especially such as are reasonably educated and have some leisure, who get certain of their organs on their minds and produce symptoms or emphasize such symptoms as are present until it seems as though an operation is the only thing that can lift their burden of discomfort and permit them to go on again with their work. We have all known of physicians who felt sure that they ought to be operated on for such conditions as gastric ulcer or duodenal ulcer, though subsequent developments in the case, when they were persuaded to put off operation and made to reform certain ill-advised habits, proved that no such lesion as they suspected had ever been present. Indeed, some of these physicians and even surgeons have insisted so much that surgical friends occasionally have operated on them and have found nothing to justify the operation. {751} Some of these states in connection with discomfort of various kinds in the abdomen have been discussed in the chapter on Abdominal Discomfort, and some illustrations of useless operations given. We must not forget that there is a constant stream of pathological suggestion in the air at the present time, not only in medical journals, but even in the secular press, and that this concentrates the attention of patients on comparatively slight discomforts and leads to the exaggeration of them until even an operation seems a welcome relief for them. Operative Persuasions.--While surgical operations are in practically all cases mutilations, they are absolutely necessary under certain circumstances, are often, indeed, life-saving, and there is no doubt that they have saved mankind a great deal of discomfort. Surgeons are agreed, however, that they are not to be performed unless they hold out a definite promise of physical relief. It is extremely important, then, that patients must not become persuaded of the need of an operation in their cases unless surgical intervention is really necessary. This is as true for physicians and even surgeons themselves, as I have said, as it is for the general public. Women are much more susceptible than men to operation suggestions, and since it has become fashionable to talk about _their_ operations, not only has the deterrent idea of surgical mutilation been greatly lessened, but there has actually developed in many of them a morbid fascination for a similar experience with all its attraction of attention and promised occupation of mind for the woman of leisure. This phase of the necessity for favorable mental influence has been especially emphasized in the chapters on Gynecology. Unless, therefore, there are very definite indications, operations must not be performed, for they will relieve, as a rule, only for the time being, and further operations may have to be done to no purpose. Any physician of reasonably large experience has seen such cases. Patients get the idea of an operation as their one hope, and then nothing less than that will produce such diversion of mind as will bring relief of symptoms. It is important in these cases that such patients should not have operations suggested to them. Once the suggestion takes hold, they do not use their reserve energy in such a way as to help out effectively other remedies that may be given. They distrust all remedial measures, think that at most they can be only palliative, and so do not add to other forms of therapeutics the power of psychotherapy to cure them. Besides the abdominal conditions, there are certain tuberculous conditions with regard to which this seems to be particularly true. I have seen enlarged cervical glands disappear without discharge when patients have taken up the outdoor life, and, above all, when they have gone out of the city and have lived the regime proper for those in whom tubercle bacilli are growing. If such patients, however, once become persuaded that their glands must be operated on, they are likely to need, if not active intervention, at least the discharge of material from their tuberculous lesions before they get well. Operations of a radical character for tuberculosis used to be much more popular than they are now, when we are likely to think that nature can do more for tuberculous lesions in nearly all cases than the most skillful surgery. Fractures and the Mind.--In such surgical conditions as fractures and dislocations, a change has come about in the mode of treatment, at least in many hands, that seems entirely physical in its effect, yet has undoubtedly {752} exerted important psychic influences favorable to recovery which deserve to be noted. In dislocations and fractures, and particularly the latter, it was the custom in the past to do the fractured limb up in bandages and then leave it until knitting of the bones, or, in dislocations, healing of the soft tissues, had taken place. Apparently it was forgotten that this eminently artificial condition was not conducive to that healthy reaction of tissues for reparative purposes which must be expected in these cases. Circulation was not so good because of the constrictive effect of the bandages; vitality not so high because of failure of nervous activity in absolute immobility; the return venous circulation was somewhat hampered because there were no contractions of muscles; and all the conditions were distinctly unfavorable, though nature was expected not only to maintain the health of the part, but bring about the added functions of repair. In spite of the more or less unfavorable conditions, nature was able, as a rule, to do so. Prof. Lucas Championére reintroduced the older method of treating fractures and dislocations more openly and of even using certain manipulations, passive movements, and massage in order to encourage the circulation and the natural vitality of the limb. There is another phase of the influence of this mode of treatment that deserves to be recalled. When the fracture is hidden away for many days and the patient is not absolutely sure whether it is getting on well or not, solicitude or anxiety is awakened in some minds that prevents, or at least delays, normal healthy repair. It is well known by surgeons that fractures do not heal so well after accidents in which there has been considerable shock, or in which the simultaneous death of a friend seriously disturbs the patient's mind. Nor do fractures heal so well if the patient is worried about business affairs or seriously disturbed over family matters. Among sensitive patients, a state of mind not unlike that produced by worry or shock may develop as a consequence of the dread that the fracture may not heal properly, or that there may be deformity, or that when the surgeon removes the bandages he may find it necessary either to break it again or do something that would involve considerable discomfort. These patients need reassurance. If the surgeon sees the broken limb occasionally, and, by manipulation and passive movements such as may properly be used, assures himself as to its condition, the patient's mind is much better satisfied and that inhibition of trophic processes which otherwise sometimes occurs is prevented. Incisions and Suggestion.--Something of this same psychotherapeutic influence is noted with regard to the healing of incisions when these are not left without inspection too long. The newer surgical customs of comparatively few dressings, so that the wound may easily be inspected and the patient may be completely assured with regard to it, has undoubtedly had a good influence in bringing about more rapid repair. Air is the best environment for a healing as well as a healthy skin, and mental trust is best for the patient's power of repair. In vigorous individuals such repair will occur anyhow. It is in those of delicate health, neurotic disposition, and psychoneurotic tendencies, that reassurances are needed. Often their physical condition is such that they need every possible aid in bringing about complete repair. Their state of mind, then, must be noted carefully, and any inhibitory ideas that may be present because of over-anxiety as to how the incision is getting on must be removed. This does not mean that patients' whims should be yielded {753} to in the matter of over-solicitude about their condition, but that proper care should be taken to prevent inhibition of trophic influences through unfavorable mental states just as far as is possible. Most surgeons of experience do these things in the proper way by instinct from the beginning, or by a tactful habit, which develops in their surgical experience of adapting themselves to individual patients. It is well to realize, however, that such mental attitudes are extremely important and must be deliberately treated by the surgeon. Pseudo-rabies.--Certain conditions usually treated of as surgical have mental relations that are very interesting. There seems no doubt that in a certain number of cases pseudo-rabies occurs; that is, persons are bitten by a dog, become seriously disturbed over the possibility of rabies developing, and after brooding over this for a time their mind gives way and there is either a neurosis simulating many symptoms of true rabies, or a state of collapse from fright in which even death may take place. These cases are not frequent. Their occurrence is taken by some of those who are opposed to animal experimentation as a proof that rabies is always some such delusion, and that it is due to the exaggeration of the significance of dog-bites by the medical profession that the symptom complex known as rabies has come into existence. This is, of course, nonsense, and many true cases of rabies occur. Since, however, these other cases provide the opportunity for argument in the matter, it is all the more necessary that they should be recognized for what they are. When a patient has been bitten by a dog that has not died from rabies within three weeks after the bite, there is practical certainty that the animal did not have and could not communicate rabies. The cases of hydrophobia with long incubation periods are rather dubious, and the general impression now is that there has been subsequent infection. Patients who are in the midst of overwhelming dread of the development of rabies must be taken seriously and their cases treated by mental influence. Suggestion, instruction, and the neutralization of wrong ideas by reference to authorities in the matter, must be used to overcome the unfortunate state of mind which may, if allowed to continue and, above all, to develop, prove serious for the individual. Pseudo-rabies is but a type, though the most serious and perhaps most frequent of what may be called surgical psycho-neuroses. There are others. Imaginary syphilis is an affection that often causes worry and trouble to patient and physician. _Herpes preputialis_ with mental symptoms is almost as bad. These are mental infections of various kinds. There are many neoplastic persuasions and toxic suggestions that must be treated with tact and firmness. CHAPTER III MENTAL INFLUENCE IN ANESTHESIA Nowhere in the domain of surgery is the influence of the mind more important than in the production of anesthesia for surgical purposes. It is well known that intense preoccupation of mind will make an individual completely anesthetic even for very severe injuries. In battle men frequently are severely wounded, yet do not know it, or at least have no idea of the extent of the wound and of the pain that ordinarily would be inflicted by it. In the {754} midst of panics, as during fires, or when crowds are trying to get out of buildings rapidly, people often suffer severe injuries and know nothing about them. The story of the woman who lost her ear in the theater panic and was quite unaware of it until her attention was called to it, is only one of many striking examples. Men have been known to walk round even with a broken leg, or with a dislocation with which it proved quite impossible for them to move, once their mental preoccupation for others ceased and they had time to think about themselves. Anesthetic incidents under conditions in which great pain might well be expected are not uncommon. It is evidently possible so completely to occupy the mind that pain sensations cannot find their way into the consciousness. Pain and Diversion of Mind.--From very old times, attempts have been made to use this power of the mind to prevent pain, and often with some results. In preanesthetic surgery, minor operations were performed rapidly, beginning just after the patient's attention had been attracted to something else besides the thought of the operation. Pain is, of course, much less tolerable and seems to the sufferer at least to be much more severe whenever the attention is concentrated on it. Specialists in nervous diseases, during the process of eliciting complaints of pain or tenderness while employing movements or manipulations, usually try to attract the patient's attention as much as possible to something else, in order to determine just how much genuine pain or tenderness is present. Often it is found that, while a part of the body is complained of as exquisitely tender or it is averred that a joint cannot, be touched or a limb moved without severe pain, when the patient's attention is attracted strongly to something else, deep palpations may be practiced and rather extensive manipulations can be made without complaint. In these cases very often the pain is not imaginary, but is slight, due to some physical basis, and has been very much increased by the concentration of attention on it. This part, at least of the pain, may be removed by an appeal to the mind. The principle is valuable when there is question of minor operations. Surgeons have often taken advantage of this power of distraction of attention to relieve pain in surgical manipulations. The story is told of the French surgeon, Dupuytren, that he was called one day to see a lady whom he knew very well in order to determine the form of injury from which she was suffering. He found that she had a dislocation of the shoulder, and during the manipulations, in order to make his diagnosis, he almost inevitably inflicted considerable pain. She complained very bitterly and told him that she understood that he was very rough with his hospital patients, but he must not be rough with her. He had hold of her hand at the moment, and, just before grasping the arm in such a way as to make the manipulations necessary to reduce the dislocation, he slapped her face and told her that she must not talk to him while he was treating her. Needless to say, she was deeply shocked. Before her shock had passed away, Dupuytren had completed the reduction of the dislocation, and in her preoccupation of mind she felt almost no pain. She remarked afterwards, however, that she had suffered so much mental anguish from his unexpected roughness that she was not sure whether, after all, she had been really spared in her feelings. Hypnotic Anesthesia.--When, in the first half of the nineteenth century, {755} scientific attention was seriously attracted to hypnotism, it was hoped that this would prove an effective means of producing anesthesia during surgical operations or at least of greatly lessening pain. The hope was not disappointed. There was a discussion on the subject before the Medical Chirurgical Society of London in 1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous Cases of Surgical Operations Without Pain in the Mesmeric State." In 1846 Sir John Forbes wrote in his Review that "the testimony as to the value of hypnotism as an anesthetic is now of so varied and extensive a kind as to require an immediate and complete trial of the practice in surgical cases." At the end of that same year, ether as an anesthetic was introduced into England, and the first case was reported under the caption "Animal Magnetism Superseded," which shows how much attention the previous attempts at hypnotic anesthesia had attracted. After this, hypnotism was given up for anesthetic purposes except by a few enthusiastic students of it. These, however, succeeded in accomplishing much with it. Dr. Esdaile, in India, succeeded in doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in "Hypnotism, Its History, Practice and Theory" (London, 1906), lays down the rules for hypnosis for anesthetic purposes. They are eminently practical. While hypnotism can be used to produce anesthesia, it has many disadvantages. The length of the hypnosis cannot always be arranged so as to assure anesthesia during the whole of an operation, while in some cases it will continue after the operation for some time in spite of every effort on the part of the hypnotist to bring the patient to himself. Besides, the depth of the hypnosis cannot always be assured, and sometimes some sensation remains. Patients will groan and wince and move, though, of course, under ether or chloroform such manifestations may take place, yet the patient afterwards will give every assurance that not the slightest pain was felt. In some cases, however, even where the pain sensation is not severe during an operation under hypnosis, it may, nevertheless, prove sufficient, when continued for some time, to bring the patient out of the hypnotic state. For short operations of minor character, undoubtedly hypnosis can be employed successfully. As we explain in the chapter on Hypnotism, anyone can produce hypnosis who has confidence in his own power and in whom the patient has trust. There is no need of a special hypnotist, and there is no special faculty required. There should be some familiarity with procedures, but any man has just as much hypnotic power as another. The influence does not pass from the operator to the subject, but is due to the subject's concentration of his attention so that there is a short circuiting of association tracts within the brain very probably, which does not permit the entrance into consciousness of sensations through any path except one or two, usually that of hearing, and sometimes of sight, less frequently of other sensations. Concentration of Attention.--In a great many cases of minor operations, such as the opening of a boil of a small abscess, the pulling of a tooth, the lancing of a gum, or other such procedures, a surgeon who is confident in his own mental power over his patient can rather easily produce a state of mind in which the discomfort of the surgical procedure is greatly minimized. There are certain physical helps for this. For instance, if patients are asked to breathe rapidly and deeply for a few minutes, there is a hyperoxygenation {756} of the blood which seems to obtund sensibility. If patients are told of this, and then made to breathe rapidly for a half a minute in order that they may continue consciously their deep, rapid breathing even when pain is noted, a state of mind is produced from concentration of attention on their breathing in which painful sensations are greatly obtunded. The effect is probably more mental than physical, and is well worth while trying because of the amount of pain it often saves. Waking Suggestion.--Without resort to hypnotism, much can be accomplished by mental suggestion in the waking state to lessen the pain of surgical operations and maneuvers. This is particularly true as regards nervous persons, who will otherwise emphasize their discomfort, and for those of lesser intelligence, children, and the like. Esdaile's experiences in India show how much can be done in this way. Often the hypnosis was so slight that the patients were perfectly cognizant of everything that went on around them, yet under the compelling influence of the assurance of Dr. Esdaile, whom they trusted completely, they did not complain of pain nor wince even when considerable surgical intervention was practiced, and they always assured their friends afterwards that they had felt nothing. I know an American physician who has an almost similar power over negroes. Ordinarily it requires more of an anesthetic to produce insensitiveness to pain in the negro than in a white person. By personal assurance, by the absolute securing of their confidence, and through their trust in him, this man is able to produce anesthesia without the use of more than a minimum quantity of the anesthetic. He is able to do the same thing with children, and, of course, it is well known that mental influence over them is extremely important in limiting the amount of anesthetic that will be necessary. Personality of Anesthetist.--Some anesthetists by their personal influence are able to bring patients under the influence of an anesthetic with much less excitement and, as a consequence, with the use of much less of the anesthetic than others. It is the same question of personal influence that extends through all medicine. Some men seem to have it naturally, and others not, though to some extent, at least, it may be cultivated. Of course, it is now well understood that, under no circumstances, should a patient be forced to take an anesthetic. This is as true for a child as for any other patient. Only a little management is required to secure the cooperation of even a young child. Above all, there must be no struggling, and while there may be a passing stage of excitement, which cannot be entirely controlled, this can be eliminated by those who are skillful. It may be necessary, especially in the case of children, for the little patients to become familiar with the anesthetist. They should see him on several occasions and should be made to feel that they know him. The presence of a stranger is enough of itself to excite children and make them suspicious and resentful of any manipulations. It may be well for them to have breathed through the cone on several occasions and to play a sort of game with it. In this way children will often go under an anesthetic without any struggle or excitement. It seems a little childish to suggest similar procedures with grown patients, but even surgeons of long experience with the older methods who have insisted on the trial being made on their patients have found much benefit from it. Familiarity with the anesthetist and even with the inhaler {757} and the breathing through it on several occasions beforehand, when no anesthetic is being administered, helps many patients not a little. This preliminary is particularly of help with regard to nervous patients and especially women. It is very seldom necessary to use nitrous oxide as a preliminary to ether if this mode of procedure is practiced. Mental Diversion.--It is well to concentrate the mind of the patient on something else besides his sensations. One element that is extremely important for anesthesia is deep breathing. The patient must then have his attention called to the necessity for deep breathing and should frequently have the suggestion to this effect repeated in his ear as he comes under the anesthetic. There should be some practice in deep breathing deliberately beforehand, with the idea of accustoming the respiratory mechanism to take deep breaths by habit even when not entirely under the control of the will. This may be done with the inhaler on a few occasions at least. The occupation of attention necessary for deep breathing during the taking of the anesthetic lessens the concentration of mind on the feelings, and actually makes the discomfort much less. Besides, deep breathing distributes the anesthetic over the lungs, leads to its absorption more rapidly, and makes the irritation of the anesthetic less by diffusing it over a larger surface. On the contrary, short, rapid breaths lead to an intensity of irritation and much slower absorption. Skilled anesthetists have found it of decided advantage to keep the patient's mind fixed on something else besides the breathing. Perhaps the easiest recommendation is that of locking the hands over the abdomen just above the umbilicus and asking the patient to hold tight. This gives something very definite to think about and to occupy the mind with. I have seen patients of rather nervous organizations go under the influence of even a very small quantity of an anesthetic when required to hold their hands thus and when the command was constantly repeated, "Hold your hands tight," whenever there was the slightest sign of struggle or excitement. Where this was done tactfully and regularly, I have seen patient after patient go into anaesthesia without struggle or excitement and usually without any noise or even a loud word. I realize how much the personality of the anaesthetist means in such cases, and I feel sure that anyone who is confident in his own power in the matter will produce a corresponding feeling of confidence in the patients. Fright in Anesthesia.--There seems good reason to think that occasionally the deaths reported from anesthesia have really occurred from fright or at least have been greatly influenced by emotional factors. It has often been noted that these deaths occurred particularly at the beginning of the administration of an anesthetic and before anything like a sufficient quantity to produce a toxic effect had been administered. In other cases it has been noted that patients were allowed to come out partially from under the anesthetic, and as they recovered consciousness were disturbed by some incident. Sometimes the pain seems to act as an inhibitory agent on the heart. In more than one reported case the patient told afterwards of hearing very distinctly some remark that seemed to be of bad omen. In one case in my own experience the breathing and heart stopped (though the patient fortunately was resuscitated) as a consequence of hearing a series of rather loud goodbyes said at the door of the elevator leading to the operating room during the {758} course of an operation just at a moment when the anaesthetic influence was very much lessened for a while. In some cases where there has been great fear of the anesthetic which has been talked over beforehand by the patient, even a few whiffs of the ether or chloroform have given rise to serious symptoms from stoppage of the heart. It is evident that it is extremely important properly to predispose such patients. The well-known surgical warning not to make remarks during the course of an operation that might prove disturbing to the patient, needs to be emphasized. By a very curious psychological anomaly some patients, though thoroughly anesthetic as regards pain, are able to hear and understand very well remarks that are made near them. Fortunately, such patients are few in number, but they are sometimes rather seriously disturbed by chance observations that for the moment at least seem to have an unfavorable bearing on their case. Besides, certain patients sometimes have their special senses come out from under the influence of the anesthetic before their sense of pain. They may also hear and be disturbed. These cases illustrate very well the place of mental influence and how much deliberate attention should be given to this phase of the treatment of surgical cases coming out of anesthesia, as well as while more or less under its influence. Local Anesthesia.--In local anesthesia it has come to be generally recognized in recent years that the personality of the operator is one of the most important factors for success. A number of local anesthetics have been introduced, and in some hands only comparatively small quantities of them are needed in order to produce complete absence of pain during operations. In other hands, however, considerable and even toxic quantities may have to be employed and sometimes without entire satisfaction. Infiltration anesthesia depends for its success largely on the personal influence of the administrator over the patient. It is extremely important that the patient should have complete confidence and not have that confidence disturbed in any way. For instance, he needs to be warned that he will feel the slight prick of the needle when it is first introduced, for otherwise he will be disturbed by even so slight a pain at the very beginning and will magnify subsequent feelings until satisfactory local anesthesia becomes impossible. Without thorough command over the patient and complete trust, local anesthesia never succeeds except in very minor operations. There are some men, however, who can do even severe and extensive operations with comparatively small amounts of local anesthesia. Others cannot perform satisfactorily even minor operations with large amounts. It is the operator, his personality, and mental influence over the patient that counts. Vomiting After Anesthesia.--The vomiting that comes after anesthesia, especially with ether, often constitutes not only an annoying but sometimes a seriously disturbing complication. It must not be forgotten that vomiting in neurotic individuals, and especially women, may be largely due to a neurosis. In the section on Psychotherapy in Obstetrics we discuss the vomiting that occurs in connection with pregnancy and suggest that it is nearly always neurotic in character. The best-known European obstetricians are now agreed in this. While ether produces a tendency to vomit in everyone, in some the actual vomiting is very slight or completely absent. If patients expect that there is to be vomiting, if they are of the neurotic temperament that not only {759} vomits easily but has a tendency to secure sympathy by fostering this symptom unconsciously perhaps, then the vomiting may become even a dangerous complication. If there is no expectancy in the matter, however, but if, on the contrary, it is made clear to these patients before the anesthetic is administered that, while there may be some nausea, there need be no vomiting unless they yield too readily to their feelings, much can be done to lessen the vomiting. A single suggestion may not mean much in this matter, but a series of suggestions properly given beforehand, especially if the patient has seen others vomiting after operations and is worrying about it, may prove of excellent contrary suggestive value. If there is no expectancy, the physician must be careful not to arouse it by over-solicitous anxiety in the matter. A plain statement should be made on several occasions, however, so that the patient will have in mind a good basis for contrary suggestion when coming out of the anesthetic. Many remedies have been suggested for this post-anesthetic vomiting, but, just as with regard to the vomiting of pregnancy, the most important element in all the cures that have been reported has been the influence upon the patient's mind. Whenever we have a number of remedies for an affection, it is almost sure that it is not their physical but their psychic effect that is of most importance. CHAPTER IV MENTAL INFLUENCE AFTER OPERATION Every surgeon feels the necessity of having his patients as quiet and restful as possible after operation. Any unfavorable mental influence will surely hamper the curative reaction of tissues and delay convalescence. We all know how fear blanches tissues, and anxiety causes hyperemia, and how solicitude with regard to any part of the body interferes with the normal control of the sympathetic nervous system and sets up vasomotor disturbances. Either a lessening or surplus of blood in a particular part interferes with the normal and healthy curative reaction of tissues. The patient's mind should therefore be as much as possible diverted from attention to the part that has been operated on in order to leave nature to pursue its purposes without disturbance. For this, of course, pain must be relieved and every possible measure taken that will add to the comfort of the patient. In spite of the fact that opium may interfere with certain natural processes, it is always useful after severe operations, because it represents the lesser of two evils. The pain of itself would produce more detriment than does the opium which relieves the pain. There are, of course, other anodynes which may be used and that have less disturbing sequelae. In this matter, routine is unfortunate, for individual patients react very differently to opium and its derivatives, the disturbing effect upon the mind being greater than the quieting effect on the body. Many patients stand the coal-tar derivatives much better because of their lack of effect on the mind. Removal of Worries.--Worries of all kinds not associated with the operation must have been thoroughly removed beforehand and must not be allowed {760} to obtrude themselves afterwards until convalescence is well established. Business is quite another matter. Whenever it does not imply worry but only means occupation of mind and distraction of the attention of the patient from himself, it may very well be permitted, after only a comparatively brief interval after operation. Within a few days a business man may certainly be allowed to dictate letters for an hour or so, and an author may even be allowed to dictate notes of some of the fancies that came to him during anesthesia. When a man has the opportunity to look forward to even a short interval during the day when he can do something that is useful, it serves as an excellent distraction for many hours beforehand and as a satisfactory memory for hours afterwards. Pleasant Visits.--It used to be the custom to keep visitors from patients after operation much longer than is at present the custom. There has come the realization, however, that short visits from pleasant friends may mean much for the patient. It is hard to make the selection, for certain friends and especially relatives disturb and annoy rather than help the patient. Anyone who shows much solicitude and, above all, fussy over-anxiety, must be excluded, no matter how nearly related he or she may be. Psychic Conditions of Hospitals.--The atmosphere of the hospital must all conduce to peace and quiet of mind. It is surprising the differences that may be noted in this respect. I have been in a hospital where only a dozen of operations were done a week and have scarcely ever been there without hearing complaints of pain and discomfort that were surely disturbing to others. On the other hand, I have been in a hospital where twenty capital operations a day were done, and have heard no complaint, and at nine o'clock at night have found in it the peace of a religious community. I knew that it was all due to the personality of the surgeons and their lack of power in one case to impress their patients' minds and a very marvelous power in the other of impressing patients favorably. The success of many a surgeon in a material way depends on this power to impress his patients. It is they who send others to him, and in general there is a feeling that if he cannot cure them no one can. Of course, it is extremely important that circumspection should be employed as regards chance remarks that may be seriously misinterpreted and prove unfavorably suggestive. Patients should not, as a rule, be allowed to see their own charts whenever there are disturbing developments in pulse and temperature. During dressings the conversation should be cheerful, distracting to the patient, and should not contain remarks that may be disturbing. The surgeon and his assistants must know how to control their expressions so as not to reveal any solicitude that may be occasioned by the patient's progress or by the state of his wound when these are not satisfactory. Surgeon's Visits.--Practically every time that a surgeon visits a patient after operation there is something that the patient has to ask or have explained. A good deal depends, as far as regards the comfort and peace of mind during the interval until the coming of the surgeon again, on the satisfaction derived from the surgeon's explanation. He should be prepared, therefore, to answer in such a way as will leave no haunting doubts in the patient's mind. Some patients are very prone to find unfavorable suggestions in even simple expressions of the physician. He must be prepared for {761} this, therefore, and be sure to say nothing that can possibly be misunderstood. In spite of this, at times patients will draw unfavorable inferences and then the nurse should have the confidence of the patient sufficiently to set the matter right or at least to give reassurance that will keep the patient's anxiety from disturbing until the next visit of the surgeon. All of this seems trivial from a certain standpoint, but even surgery is as yet an art and not a science. Art depends on personality and the influence of it and the power to express itself. The personality of the surgeon must be felt in the patient, and the more he can make it felt the better the convalescence and the less discomfort even though there should be more of pain. The amount of pain actually felt depends on how much of it gets above the threshold of consciousness. Almost any surgical patient, especially if he has gone through a serious convalescence, will tell you how much good the visits of his physician used to do him, though a glum and over-serious surgeon may have exactly the opposite effect. Sometimes busy surgeons neglect to visit their patients daily, and nearly always this has an unfortunate effect. In serious cases, the seeing of the surgeon several times a day, when it is well understood that his visits are not due to over-anxiety with regard to the patient, may hasten convalescence materially. Comfort, Mental and Physical.--Everything must be done to make the patients as physically comfortable as possible. It must be well understood, however, that comfort lies much more in variety and response to feeling than in any continuous condition. Patients will have little complaints and there must be always something novel to do for them. This does not necessarily imply medicine or even troublesome external applications, but the rearranging of bed clothing, the use of a hot-water bag or of an ice bag, the relief of pressure, sometimes mild applications of pressure, the lifting of the head, slight turning, even small changes of position and the like. Whenever a patient can be relieved by some means so simple as these external trifling remedial measures, confidence is awakened that the discomfort they feel is not due to any serious condition, but is only such achy tiredness as comes from confinement to bed. Without relief afforded in this way, they are likely to let unfavorable suggestion accumulate until their dread of something serious may inhibit convalescence or at least interfere with sleep and greatly enhance their discomfort generally. It is the state of mind that develops as a consequence of continued trifling discomforts and not the physical results of those discomforts that must be carefully looked to in post-operative patients. Nursing.--In the general management of patients after operations it would be eminently helpful to the surgeon if surgical nurses were supposed to read at least once a year, Florence Nightingale's "Notes on Nursing," [Footnote 61] written half a century ago, and if the surgeon himself should have read it through once at least and dip into it occasionally afterwards. In her chapter on Noise there are many remarks that I should like to quote, but the whole chapter is so valuable that it is hard to know where it stops, and so only a few expressions may be given here. For instance, "Never to allow a patient to be waked intentionally or accidentally, is a _sine qua non_ of all good nursing. If he is aroused out of his first sleep he is almost certain to have no more sleep." "The more sleep patients get the better will they be able to sleep." "I have often {762} been surprised at the thoughtlessness (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him." "Everything you do in a patient's room after he is 'put up' for the night increases tenfold the risk of his having a bad night. Remember, never to lean against, sit upon, or unnecessarily shake or even touch the bed in which a patient lies." [Footnote 61: American edition, Appleton, N. Y.. 1860.] Miss Nightingale, as might be expected, insists emphatically on the state of the room, the arrangement of the furniture and the cheerfulness of surroundings as important factors for the cure of patients. One of the most important elements is, of course, the nurse. She must be gentle, patient, quick to understand, often ready to anticipate wishes, and always as noiseless as possible. Slowness may be neither gentle nor noiseless. Patients, particularly men, often grow impatient at the slowness with which things are done for them. Chattering Hopes.--There is scarcely an element of mind in the patient's environment that Miss Nightingale has not thought of and touched with very practical wisdom. She deprecates, as does anyone who knows anything about the care of patients, the "chattering hopes" of those who try to cheer patients by simply telling them that they ought to be more cheerful, that of course they will get well and that they must not be anxious. She says: "I would appeal most seriously to all friends, visitors, and attendants of the sick to leave off this practice of attempting to 'cheer' the sick by making light of their danger and by exaggerating their probabilities of recovery." Cheerfulness and kindness towards the sick are one thing and foolish attempts at encouragement not founded on good reasons quite another. Variety of Thoughts.--From the chapter on Variety the following quotations show the very practical character of Miss Nightingale's persuasion as to the value of influencing the patient's mind: "To any but an old nurse or an old patient the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceilings, the same surroundings, during a long confinement to one or two rooms." "The nervous frame really suffers as much from this lack of variety as the digestive organs from long monotony of diet." "The effect in sickness, of beautiful objects, of variety of objects, and especially of brilliancy of color is hardly at all appreciated." As Miss Nightingale insists, flowers are remedies of great value for the ailing and especially for those who are confined to their room for a long period. She pleads for having the bed placed near a window in order that they may see out into the fields and the scenery around them, to which I would add with emphasis, and so that, if it is possible, they may see the occupations of human beings. Miss Nightingale adds: "Well people vary their own objects, their own employments many times a day; and while nursing (!) some bedridden sufferer then, they let him lie there staring at a dead wall without any change of object to enable him to vary his thoughts." Quite needless to say, variety is more important for the ailing than the well. Pain Psychic Conditions.--Pain after operation is an extremely common symptom and often causes much disturbance. Every surgeon knows how {763} individual are patients in this respect, and how much depends on the personal reaction to pain. There are men and women who have very serious lesions, from which much pain might be expected, who complain very little. There are, on the other hand, many men as well as women who complain exaggeratedly after even trifling surgical intervention. We have probably had some of the most striking examples of the influence of mind over body in these cases. Many a patient who complained bitterly of torment that made it impossible to rest has, after being given a preliminary dose of morphine hypodermically, subsequently been given less and less of that drug, until finally, after a few days, he was getting injections of only distilled water. Without their injection he was in agony. After it he settled down to a quiet, peaceful night. Very often it is noted that these pains are worse at night and there is a tendency for such patients to attract attention only at such times as may be productive of considerable disturbance of the regular order and as may call special attention to them. We used to call such conditions hysteria, though, of course, they have nothing to do with the uterus and must be looked for in men quite as well as women. Psychoneuroses.--These neurotic conditions, to use a term that carries no innuendo with it, may affect other functions besides that of sensation. Occasionally a neurologist is asked to see a patient in whom, following an operation, usually not very serious, some paralytic symptoms have developed. There is an inability to use one or more limbs, and the suspicion of thrombosis is raised. It is rather easy, however, to differentiate thrombotic conditions from neurotic palsies. The ordinary symptoms of the psychoneurosis are present. There is likely to be considerable disturbance of sensation, with patches of anesthesia and hyperesthesia, some narrowing of the fields of vision, and anesthesia of the pharynx, sometimes even of the conjunctiva. Often there is something in the history that points to the possible occurrence of a neurotic condition. Sometimes it is extremely difficult to get such patients over the mental persuasion that is the basis of their palsy, but usually it can be accomplished by suggestion in connection with certain physical means. Electricity is often of excellent effect in demonstrating to these patients that their muscles react properly under stimulus and that it is only a question of inability to use them because of mental inhibition. Such conditions as astasia-abasia may develop quite apart from surgery, but there is always some "insult," as the Germans say, that is some physical basis for them, and so they are often considered to be surgical. Psychic Disturbance of Function.--Besides motion and pain, other functions may be affected through the mind. After operations within the abdomen it is sometimes difficult to move the bowels when it is desired to do so. It must not be forgotten that not infrequently in these cases the patient's mental attitude of extreme solicitude with regard to his intestines is inhibiting peristalsis. Such constipation will sometimes not yield to even rather strong purgatives, and yet will promptly be bettered by something that alters the mental state. It must not be forgotten that it is in cases of neurotic constipation that _pittulae micarum panis_ have proven particularly useful. In the chapter on Constipation there is a discussion of this subject that will often prove suggestive to surgeons. This same thing is true with regard to post-operative urination. In women, {764} particularly, there may be difficulty of urination after vaginal operations, which may be attributed to some lesion of the urinary tract and yet only be due to failure of the patient properly to control muscles in these cases. As in obstetrical cases, position, the presence of others, and the mental disturbance, may inhibit urination. The subject is discussed more fully in the section on Psychotherapy in Obstetrics. Surgeons are not so inclined now to insist on absolute post-operative immobility, and even a slight change of position may enable patients to gain control over their bladders without the necessity for the use of the catheter, which always carries an element of danger with it. The influence of the mental attitude with regard to both of these functions--intestinal and vesical evacuation--must not be forgotten. There are many persons who find it extremely difficult to bring about such evacuations in the lying position. Everything is unusual, and their exercise of the coordination of muscles necessary to accomplish these functions is interfered with. It is somewhat like stuttering and the incapacity of an individual who may be able to talk very well to close friends and yet stammers just as soon as strangers are present or he is placed in unusual conditions. It has even been suggested that there should be some exercise of these functions in the lying position before operation, in order to accustom patients to the conditions that will obtain afterwards. They thus become used to their surroundings and the newer methods required, and, above all, if there should be any post-operative difficulty, they realize that it is not due directly to the operation, but rather to the unaccustomed conditions. This proves helpful in saving them from solicitude and consequent unrest and adds to the rapidity of convalescence. Food Craving.--When food is to be given in small quantities and there is likely to be craving for it, much can be done to save the patient disquietude and disturbance by giving small portions rather frequently, rather than distributing it over three times a day, as the routine of life sometimes suggests. When water has to be denied, small pieces of ice may occasionally be used with excellent advantage. Patients learn to look forward to breaks at the end of comparatively short intervals in their craving, and the accumulative effect is greatly lessened. It is well understood that whenever people are absolutely denied anything, they are likely to let their minds dwell on that fact and crave it much more than would otherwise be the case. If they can look forward to having even the minutest quantities of anything that they want, however, craving is much less likely to be insistent, and the state of mind is much easier to manage. In all of these cases the confidence of the patient and the lessening of neurotic tendencies by suggestion means more than most of the physical remedies that have been recommended. There are some patients who respond almost in a hypnotic way to suggestion from a physician in whom they have great confidence. Position and Peace of Mind.--The patient's general comfort is very important for the maintenance of a favorable state of mind. It used to be the custom to keep patients rigidly in one position for days, sometimes more than a week, after operation. We know now that this is almost never necessary, and that, of course, it is most fatiguing to the patient. Keep the ordinary well person absolutely in one position, without the opportunity to change from side to side even during a single night, and there will be justifiable {765} complaint of tired and achy feelings as a consequence. To enforce such a state for forty-eight hours in those who are well will produce a highly nervous state, consequent upon the fatigue and soreness of muscles induced. Hence, the importance of taking every possible means to provide even slight changes of position for those who have been operated upon. A number of regular-sized pillows should be provided so that the head may be raised and lowered, and a number of smaller pillows should be at hand which can be so placed as to relieve pressure at various parts and permit the patient to make at least slight changes of position during the first forty-eight hours. After this, usually definite alterations of position may be allowed without danger. The surgeon must think of these elements in the treatment and insist on them with his nurses, or they will not be carried out. It is possible now to permit patients to sit up much sooner than before, and, indeed, in pelvic operations, this is said to be definitely beneficial by preventing the spread of any infectious material that may be present into the general peritoneal cavity, and in older people it prevents the development or, at least, greatly facilitates the dispersion of congestion or such beginning pneumonic areas from hypostatic congestion as may be present. {766} APPENDIX I ILLUSIONS A physician who wishes to use psychotherapy effectively should know something about physiological psychology, or analytical or experimental psychology, as it is variously called, because of the help that he will derive from it in understanding many of his patients' symptoms. Fortunately this branch is now being taught in some of the medical schools, and the greater requirements for preliminary training bring to the medical school men who have already had a course in this subject. The chapter on Illusions is particularly important because it affords many illustrations of how easy it is to be deceived by the senses and, therefore, how many precautions have to be taken in order to be sure that impressions produced on patients' minds that seriously disturb them may not merely be due to exaggeration of the significance of information brought them by their senses. These illusions are of special interest because they represent not only failures of the senses to convey truth, but because they illustrate how easy it is for the mind to be led astray by the senses. People often declare that they have seen things with their own eyes or in some other way have definite sensory knowledge of them, yet these illusions make it clear that it is perfectly possible for such sensory phenomena to convey quite mistaken information. People who are suffering from many symptoms are persuaded that they must pay attention to their sensations. The main purpose of the psychotherapeutist often is to have them neglect their sensations and correct them by means of information gathered from other sources. We do this with regard to our sensory illusions, why not also with regard to many sensations which are probably quite as mistaken, in certain individuals at least, as these universal illusions of mankind. The argument from analogy holds very well and can be used to decided advantage in many cases. A startling illusion which makes it clear that care is needed in interpreting our sensations, is the so-called tube illusion or experiment. If a sheet of note paper be rolled into a tube of something less than an inch in diameter and then held close to one eye, both eyes being kept open, while the hand opposite to the eye before which the tube is held is placed palm faceward against the side of the tube about its middle, a hole will be seen, as it were, through the palm of the hand. This false vision is as clear as can be and persists after any number of repetitions of the experiment. It merely illustrates two-eyed vision. We have a picture in each eye and we combine them. When the pictures cannot be combined for any reason, optical illusions result. There are many more optical illusions than we think and there are many reasons besides two-eyed vision for them. Other illusions of two-eyed vision may be illustrated rather easily. If {767} two dots are made on a sheet of paper about two inches apart and the eyes look at them in a dreamy way, looking far beyond the paper, with vision more or less fixed between them, after a few moments a number of things happen. Usually the two dots exhibit a tendency to float together. [Illustration: Fig. 26 (two dots about two inches apart)] After an interval four dots will be seen--each of the dots having a picture in each eye. Then only one dot may be seen because the pictures combine. Sometimes three dots will be seen. When the dots swim toward one another, a curious feeling of insecurity comes over the experimenter, showing how much our sense of stability is dependent on vision and illustrating why vision from a height is so disturbing because objects cannot be properly fixed on the distant background. [Illustration: Fig. 27 (from left to right--an empty bird cage, a vertical line, a bird)] Just as the two dots may be made to come together, so, after a little practice, a bird may be made to go into a cage (Fig, 27) or an apple made to go onto a plate (Fig. 28), [Illustration: Fig. 28 (from left to right--an apple, a large plate)] These illusions show how many things that people {768} "see with their own eyes" are not so. All depends on the attention and the state of mind at the time when the seeing is done. In day-dreams these illusions often occur and may be the basis of delusions. [Illustration: Fig, 29 (Several complex line figures)] There are, however, a number of optical illusions which illustrate certain defects of our vision that cannot be corrected, no matter how much we may desire to see correctly. We continue to see them not as they are but as they seem, and we must correct our vision by information from other sources. The Müller-Lyer lines are familiar and are given here (Fig. 29) because {769} they show how easily the senses may deceive us, even that most acute of our senses, vision, as to the sizes of things. [Illustration: Fig. 30 ( Two identical figures, one above the other; each is like a funnel cut parallel to its axis and laid flat. )] Figure 30 illustrates how easy it is to be deceived by the juxtaposition of different portions of objects. I have had a woman who had cut out high collars for children and who happened to put them in the juxtaposition of the sketch here given think that she was either losing her sight or her judgment was being affected by the nervous condition in which she was. Nothing would persuade her that some serious development was not taking place until I showed her this illustration. In this illusion the juxtaposition of the short curved line to the long curved line of the other figure produces all the disturbance of judgment of size. The illusions of filled and unfilled space are interesting and are quite inevitable. They are due to physiological visual effects and are very strikingly illustrated by what is known as the sun and moon illusion. Both these luminaries seem larger at the horizon than they are at the zenith. This is entirely an optical illusion. The horizon seems farther away than the zenith because vision to it is interrupted. The heavens appear not to be a half sphere, but more like an old-fashioned watch glass. [Illustration: Fig. 31 (A--a square consisting of closely spaces vertical lines; B--a square consisting of closely spaces horizontal lines; C--a empty square with only its exterior boundaries.)] Since the sun and moon occupying the same space on the retina are, because of this apparent difference of distance, judged to be farther away at the horizon than they are at the zenith, we are inevitably forced to the conclusion that they are larger in size than when in the other position. The over-estimation of filled space as compared with {770} the unfilled is mainly due to the interrupted muscular action of the eyes in traveling over the space requiring more effort. This makes it seem longer. Probably physiological processes on the retina also contribute to the illusion. A series of objects, even dots, will cause a greater physiological excitation of the retina than an equal amount of space, the boundaries of which alone are brought to our attention. Illusions of size are even more startling than illusions of distance. It is perfectly possible to take three spaces, each exactly a square inch, and by drawing lines in two of them in different directions to make the figures appear of {771} very different size. This is a rather disturbing illusion, particularly for women who are apt to think that perpendicular lines make them appear tall and thin, while horizontal lines have the opposite effect. This is true if the lines are not placed quite close together. The reason why women wear many ribbons, however, whether they themselves recognize it or not, is that the attraction of attention to these makes the space in which they are seem longer. Hussars are dressed in uniforms with many rows of gilt cord or braid running across their chests in order to increase their apparent height. As a rule, a cavalry man must not weigh over 140 pounds or his horse will break down in long, forced marches. Such men are often of small stature and their apparent height must be increased by their uniform, so as to make them look formidable. Advantage is taken of this optical illusion of filled space to produce this effect. [Illustration: Fig. 32 (several complex curved figures,)] Other illusions of size are quite frequent. It is rather hard for the ordinary observer to think that the half circles, _a_ and _a'_ (Fig. 32), are the same size, or that _b_ and _b'_ in the same chart are the same curve. The interruption in the circles _c_ and _c'_ produce very curious erroneous impressions which require a knowledge of this illusion to correct. Optical illusions with regard to directions of lines are extremely common. Quite unconsciously we translate directions into special meanings. This is what enables perspective to be effective in drawings. It has many disturbing features, however. Some of these are striking illustrations of the defects of our vision. [Illustration: Fig. 33 (tall, narrow rectangles covering diagonal lines passing under them.)] [Illustration: Fig, 34 (a large black square with several parallel diagonal white lines; each diagonal line has several intersecting lines; the upper left diagonal has horizontal intersecting lines, the next diagonal has vertical intersections; etc.)] Poggendorf's illustration of the displacement of oblique lines (Figure 33) {772} and Zöllner's distortion of parallel lines as illustrated by Figure 34, make it very clear that our judgment of direction must depend on many factors besides our vision, if we are not to make serious mistakes. These optical illusions might seem to be of little significance, but the Greeks thought them of so much importance and recognized so thoroughly that they could not be corrected, and that the distortions and displacements would inevitably take place, that they deliberately put certain optical corrections into their great architectural monuments in order to avoid these false appearances. These have been traced very accurately in the Parthenon, for instance. In a word, the Greeks, knowing of these optical illusions, in order to make the lines of their buildings appear correct, deliberately made them wrong to a sufficient degree to correct the optical illusion; This frank mode of yielding to a limitation of human nature is a fine lesson for patients to learn if they can only be made to learn it from these illustrations. It is with regard to colors, however, that we have the best examples of optical illusions depending on the individual and his special anatomy and physiology. Color-blind people are quite sure that they see color, just as other people do, until their defect is demonstrated to them. A man who is color blind for red thinks that he sees that color as other people do, while all that he sees is a particular shade of brightness which, because other people call it red, he has come to call red. When asked to pick out red from a series of other colors he may often succeed. When asked, however, to take a skein of red wool selected for him to a basket containing a number of different colored wools, and to bring back all those that are of the same color, he will select grays and browns and sometimes greens as well as reds, and present them as all matched colors. A man who is color blind for all colors will still think that he sees colors as other people do. The ingenious illustration of the American flag as it appears to people suffering from different forms of color blindness, though they are all persuaded that they see the same kind of flag, is an interesting example of how different may be people's sensations, though their conclusions are the same. It may be seen in many of the text books of analytical or experimental psychology. {773} Dalton, to whom we owe the atomic theory, was himself color blind for red and made the first investigations in that subject. He was of Quaker origin and found that a great many of his brethren were deficient in color vision. It becomes much easier from this to understand why they resolved to wear nothing but gray. They did not see colors as other people do and therefore could not understand nor sympathize with the joy of other people in color. Dalton tells the story of a Quaker prominent in his sect who once went to town to buy a gray waistcoat and purchased instead one of bright red. When he appeared at meeting in this he was promptly tried for heresy and violation of church regulations. There is an interesting tendency on the part of people who are themselves defective in certain faculties of sensation, to conclude that when other people are wrapt in admiration of something that they cannot perceive, it is because these other people have some mental defect that leads them to enthuse too easily over their sensations. A story is told of a newspaper man who used to insist that all that was said about the beauty of the song of birds was due to the vivid imagination of the writers, for he could find nothing to admire about the songs of birds. He was placed in a room with a number of fine song birds all round him and it proved that he could not hear any of the higher notes at all. It was easy, then, to understand his condemnation of the enthusiasm of others as hysterical and imaginative. Nearly this same thing is true of many quite intelligent people with regard to music. They hear ordinary sounds, as did the newspaper man, very well. They are tone-deaf however, that is, they are quite unable to hear and appreciate combinations of sounds or even to catch melodious successions of single notes. They cannot recognize one tune from another and often do not know "Yankee Doodle" from the "Doxology," or, at most, know only the most familiar tunes, but they set themselves up very calmly as judges of the intellects of others and conclude that music lovers are really a hysterical set of people who go into ecstasies over certain quite insignificant sensations. These interesting tendencies are helpful in enabling the physician to understand his patients better. They often serve as texts from which the physician can explain curious things to patients who are prone to draw wrong conclusions from them and often suggestions unfavorable to their health. These illustrations and their discussion serve to make very clear the distinction between illusions, delusions and hallucinations, which are often confounded. Illusions are deceptions of the senses. If a man walking along a country road where he fears the presence of snakes sees in the gathering twilight a piece of rope coiled, he will almost surely mistake it for a snake. This is an illusion produced by the conditions in which the object is seen. If walking along the same road the next day, more timorous than ever as to snakes, he should see in broad daylight the same coil of rope, he might in his fright not stay long enough to decide whether it was a snake or not, and his illusion would continue, though it would partake somewhat of the nature of a delusion due to fright disturbing his judgment. If, in spite of careful examination, however, of it, such as would satisfy any ordinary mind that it was a coil of rope and not a snake, he should still insist in believing that it was a snake, this would be a delusion. There is always a mental element in delusions. If, having seen nothing, he should insist, owing to fright and {774} nervousness or to some other cause, that he sees a snake where there is nothing at all resembling a snake and where evidently whatever is the basis of his idea of the presence of the snake, is within his own mind, then he is suffering from an hallucination. Illusions may be quite inevitable. Most of the optical illusions continue to appeal to us as truths even when we know that they represent errors of vision. In spite of the fact that we know that the sun and moon are not larger at the horizon than they are at the zenith, by optical illusion we continue to see them of larger size. It is our duty to correct such illusions by information gathered from other sources. To follow an illusion, that is, to give it credit, when we should correct it, is a delusion. To think that because we cannot see red that therefore there is no red, or because we do not hear the sounds of notes of birds that they do not utter any notes, in spite of the fact that we have the testimony of nearly the whole human race to the contrary, is a delusion. When, using the verb in its broadest sense, as "perceive," we seem to see things very differently from the generality of people around us, there is every reason to suspect that there is some specific or individual limitation of our senses which makes us fail to perceive these things as others do. We have to suspect our sources of information then and to correct them by what we can learn from the experience of others. These are important considerations for many of the ideas that patients cherish with regard to themselves and their ills. Hallucinations are entirely mental. But the phenomena that sometimes appear to be hallucinations may be due to illusions of the senses within the organism. For instance, those who indulge in cocaine often have the feeling of having a veil over the face, or of having run into a cobweb or something of that kind. The presence of the veil or the cobweb on the face is probably not an hallucination, but is due to certain disturbances in the circulation, or perhaps in the nerves themselves, which affect the nerve endings of the face, causing them to tingle in a particular way, and this sensation is translated as coming from without in terms of something that has been felt before. Some of the appearances of _muscae volitantes_, or of specks before the eyes, or occasionally of wavy lines, are due to disturbances of the circulation within the eyeball which cause corresponding disturbances of the optic nerve, with consequent apparent visions. When the eyeball is pressed upon, the sensation first produced is that of light and not of pain, because whenever a nerve of special sense is irritated, it produces its own specific sensation in the brain. The chilly stage in malaria is a typical example of a physical condition having an effect upon sensory nerves that more or less necessarily produces a delusion. The patient is actually at the height of his fever when the chilliness and shivering come on and when he demands a larger amount of covers in order to protect himself from the cold he will often have a temperature of 104 degrees Fahrenheit, or even higher. What has happened is that the little blood vessels at the surface of the body are shut up by the effect of the plasmodium upon the system. Whenever we are cold these little blood vessels shut up in order to protect the blood from being chilled by the external atmosphere. The shutting up of the little blood vessels deprives, for the time being, the terminal nerves in the neighborhood of some of their nourishment. Their response is to set up a tremor or shivering, which will mechanically tend {775} to open the blood vessels so that they may have their nourishment once more. Whenever we have a set of sensations that correspond to this connected set of events, we translate them as feeling cold. The outer air does feel cold to the body because the blood is not flowing through to the surface as it would normally in order to warm it. Hence the chilliness. This is not an hallucination; but an illusion with something of a delusion in it; until we know how things are. Nervousness may set our teeth chattering just as it may cause tremor through our sympathetic nervous system, disturbing the flow of blood through muscles and so disturbing control of them. Vehement emotion, anger, fright, and even those of less violence may cause similar effects. All these phenomena illustrate the close relation between mind and body. {776} APPENDIX II RELIGION AND PSYCHOTHERAPY Religion and psychotherapy have, of late, come to have many relations to each other and many interests in common, at least in the minds of a number of clergymen, and in popular estimation. There is no doubt but that religion can do much to soothe troubled men and women, even when their troubles are entirely physical in nature and origin. It at least lessens the unfavorable effect of worry in exaggerating such pathological processes as are at work. All diseases, functional and organic, are rendered worse by solicitude, while many troublesome symptoms become quite bearable if only the patient does not dwell on them too much but takes them as they come, carefully refraining from emphasizing them by over-attention. That is the very essence of psychotherapy. Religion, in the sense of trust in divine wisdom, can do much to originate and maintain this imperturbed frame of mind. People who are without religion, that is, without the feeling that somehow all their ills are a part of the great plan of the universe, the mystery of which is insoluble, but the recognition of which is demanded by reason, and who lack the assurance that somehow, in Browning's phrase: "God's in His Heaven- All's right with the world!" -- are more prone to give way to over-anxiety and consequently to make themselves suffer more in all their ills, than is necessary or even likely in the more favorable state of mind of those whose trust in Providence is thorough and efficient. In recent years there has been in the general population a distinct loss of faith in the great religious truths that are so helpful in engendering a peaceful state of mind in suffering. Many have come, if not to doubt of the Providence of the Creator, at least to feel that we do not know enough about it to place any such supreme dependence on it in the trials of life as would make it a source of relief, or at least consolation, in suffering. This same spirit of doubt has paralyzed faith in the hereafter and in all that trust in it brings, to sufferers, of consolation to come for their ills if these are borne as becomes rational creatures whose suffering has a purpose, though we may not comprehend it. Some people are destined by their physical make-up or by accidental conditions to considerable suffering. There are many ailments that are incurable and are definitely known to be incurable. Some of these entail great suffering of body and even more suffering of mind. Such suffering becomes quite unbearable unless the patient is of a very stoic disposition, or unless the thought of a hereafter in which the sufferings of this life will have a meaning is present to console. {777} Great scientists in the midst of all our advance in science--one need but mention here such men as Lord Kelvin, Clerk Maxwell, Johann Müller, Laennec, Pasteur, Claude Bernard, though the number might easily be multiplied--have insisted that the existence of a Creator is absolutely demanded by what we know of the physical universe. "Science demonstrates the existence of a Creator," is Lord Kelvin's expression. The existence of a Creator implies, also, the existence of laws made by Him, by which His universe is regulated in every detail, nothing being left to chance. Chance is indeed only a term which indicates that we do not know the causes at work. If somehow the Creator's power has been sufficient to bring the manifold things of the universe into existence according to a plan in which there is no such interference with one another as would cause serious disturbance of the universal order around us, then He can be trusted also to care for even the minutest details of creation and of human life. In the gradual disintegration of the religious sense which has come as a consequence of certain materialistic tendencies in nineteenth century education and science, these religious sources of consolation have been shut off from a great many people. They have come to the feeling of being portions of a machine that moves hopelessly on, somehow, on the old principle, "The mills of the gods grind slow, but they grind exceeding fine." The sufferings of humanity then, are, for these people, only a portion of a great universe of suffering that is constantly going on but for which they can see no reason and no purpose. Lucretius's lines which make human sufferings the butt of the jokes of the gods who look gleefully on from their Elysian happiness, would represent the feelings of these doubters better than any religious expression. We have come back in this age, when evolution has so much influenced the thought of the time, after the curious cyclic fashion in which human thought repeats itself from era to era, to the attitude of mind of the old Roman poet who almost singly among his contemporaries, had been deeply affected by the same doctrine of evolution. The pessimism he was prone to as to the significance of human life has become once more the fashion. Such pessimistic thoughts do not come, as a rule, while people are in good health, but they assert themselves with double emphasis in moments of trial and suffering. Lucretius himself is said to have committed suicide. The result of the diffusion of this materialistic pessimism in our time has been a gradual preparation for a revulsion of feeling in many minds. One manifestation of this reaction has been seen in a form of religion which denies entirely the existence of evil. God the Creator is good and therefore there can be no evil in His world. Whatever of evil there is, is only due to man's failure to see the entirety of things. Evil is an error of mortal mind--only that and nothing more. In spite of the manifest absurdity of the underlying principle, if people can only be brought to persuade themselves that there is no such thing as evil or suffering, then many of their discomforts disappear, all of their symptoms grow less and a sense of well-being results. It is, indeed, surprising how many even physical ills will be relieved by this state of mind if sincerely accepted. It is the highest possible tribute to psychotherapy and the curative influence of mind over body. Another phase of this revulsion of feeling has been the institution of a church movement that would make sufferers realize once more all the {778} consolations there are in religion. The sufferer is brought to a renewed lively sense of the presence of the Creator in the universe and of His care for His creatures. The great purpose of suffering in making people better and stripping them of their meanness and selfishness is brought out. Anyone who has ever had called to his attention the difference between two brothers, one of whom has been chastened by suffering above which he has risen by character development, and another who has enjoyed good health and prosperity all his life, will realize how much of good suffering means in the world. Pain is not in itself an evil, but a warning, and most of the trials of life can rather readily be shown to partake of this character. A man who can be made to submit himself, then, to the will of the Creator and be persuaded to acknowledge that somehow we must try to work out our part in the great scheme of things behind which the Creator stands, is somewhat like the soldier ready even when tired and worn out, to go in on a forlorn hope, because he has confidence that he is executing a part of the plan of his general for his country's welfare, though he does not know how, and he is quite well aware that it is going to cost him much in pain and suffering, and perhaps his life. There is no doubt that an abiding sense of religion does much for people in the midst of their ailments and, above all, keeps them from developing those symptoms due to nervous worry and solicitude which so often are more annoying to the patient than the actual sufferings he or she may have to bear. While religion is often said to predispose to certain mental troubles, it is now well appreciated by psychiatrists that it is not religion that has the tendency to disturb the mind, but a disequilibrated mind has a tendency to exaggerate out of all reason its interests in anything that it takes up seriously. Whether the object of the attention be business, or pleasure, or sexuality, or religion, the unbalanced mind pays too much attention to it, becomes too exclusively occupied with it, and this over-indulgence helps to form a vicious circle of unfavorable influence. While many people in their insanity, then, show exaggerated interest in religion, this is only like other exaggerated interests of the disequilibrated, and religion itself is not the cause but only a coincidence in the matter. Clouston, in his book on "Unsoundness of Mind" (Methuen, London, 1911), put this very well when he said, "It is true that religion, touching as it does, in the most intense way the emotional nature, and the spiritual instincts of mankind, sometimes appears to cause and is often mixed up with insanity. But in nearly all such cases the brain of the individual was originally unstable, specially emotional, over-sensitive, hyperconscientious, and often somewhat weak in the intellectual and inhibitory faculties and, if looked for, other causes will usually be found." He had said just before, "To talk of 'religious insanity' as if it were a definite and definable form is in my judgment a mistake." On the contrary, there is now a growing conviction that a deep religious feeling, a sense of dependence on and trust in the Almighty, will do more than anything else to keep people from those neurotic manifestations which so often are seen in our day and are growing more and more frequent as life becomes more strenuous and more attention is paid to the material side of things, to the exclusion of the spiritual. How true this is may be judged from expressions that have been used in recent years by well-known specialists in {779} nervous diseases and in psychology. These have included men who were often not believers in religion themselves but who recognized its influence for good for others. Such expressions are to be found in the writings of men of every nationality. Not infrequently, in spite of their own religious affiliation, they acknowledge what a profound influence certain forms of religion have over people. These testimonies have been multiplying in our medical literature in recent years, because apparently physicians have come to appreciate much better by contrast the influence for good of religion over some of their patients, since so many of the sufferers from nervous diseases they see have not this source of consolation to recur to. In America we have a number of such testimonies. In his "Self Help for Nervous Women" Dr. John K. Mitchell of Philadelphia, who may be taken to represent in this matter the Philadelphia School of Neurologists, to which his father has lent such distinction, said: It is certainly true that considering as examples two such widely separated forms of religious belief as the Orthodox Jews and the strict Roman Catholics, one does not see as many patients from them as from their numbers might be expected, especially when it is remembered that Jews as a whole are very nervous people and that the Roman Church includes in this country among its members numbers of the most emotional race in the world. Of only one sect can I recall no example. It is not in my memory that a professing Quaker ever came into my hands to be treated for nervousness. If the opinion I have already stated so often is correct, namely that want of control of the emotions and the over-expression of the feelings are prime causes of nervousness, then the fact that discipline of the emotions is a lesson early and constantly taught by the Friends, would help to account for the infrequency of this disorder among them and adds emphasis to the belief in such a causation. Prof. Münsterberg, who may be fairly taken to represent the German school, but whose long years of residence in America have made him a cosmopolitan, is quite as positive in his declaration of the place that religion may hold in making human suffering less. In his "Psychotherapy" he devotes considerable attention to the subject. The religious discipline, that is, the training of human beings from their earliest years to recognize that there is a higher law than their own feelings and that they must suppress many of their desires and take evil as it comes as a portion of human life, is of itself, he insists, an excellent preparation to enable the individual to bear up under the physical and mental trials of life and to make many symptoms that would otherwise be almost intolerable, quite bearable. It is from earliest years that this training must make itself felt, and Prof. Münsterberg insists that from early childhood the self-control has to be strong and the child has to learn from the beginning to know the limits to the gratification of his desires and to abstain from reckless self-indulgence. A good conscience, he says, a congenial home and a serious purpose, are, after all, the safest conditions for a healthy man, and the community does effective work in preventive psychotherapy whenever it facilitates the securing of these factors. Self-denial has always been one of the main elements of religious training, and indeed was declared a chief source of merit for the hereafter. The modern psychotherapeutist, however, preaches self-denial almost as strenuously as the religious minister of the olden time, only now not for any religious {780} merit or reward, but because it makes life more pleasant and by that much happier. When men and women have learned to deny themselves in their younger years, it is not hard to stand even pain when they grow older, and pain is inevitable in every human life and the training to stand it is therefore worth while. Pain borne with equanimity is lessened by one-half if not in its intensity then at least in its power to disturb, and since religion will do this it possesses an important remedial value. Here is where religion is particularly valuable and the passing of it from many minds has thrown them back on themselves and left them without profound interests, so that they occupy themselves overmuch with the trivial incidents of life within them and disturb the course of many of their functions by giving exaggerated thought to them. Religion adds a great purpose to life and such a purpose keeps men and women to a great extent from being disturbed about trifles. Of course, it would be too bad if religion should do no more than this. This, however, is the only phase of it with which we are concerned here. We may think very strongly with Prof. Münsterberg, that it would be quite wrong to assign to it only this place in life. He says: "The meaning of religion in life is entirely too deep that it should be employed merely for the purpose of lessening the pains and aches of humanity and the dreads that are so often more imaginary than real." He insists that "It cheapens religion by putting the accent of its meaning in life on personal comfort and absence of pain." He adds, "If there is one power in life which ought to develop in us a conviction that pleasure is not the highest goal and that pain is not the worst evil, then it ought to be philosophy and religion." Present-day movements, however, tend to subordinate religion to this-worldliness rather than to other-worldliness, and by just that much they take out of religion its real significance. We are here on trial for another world is the thought that in the past strengthened men to bear all manner of ills, if not with equanimity, at least without exaggerated reaction. It has still the power to do so for all those who accept it simply and sincerely. {781} INDEX. Abdominal discomfort, 302; from coffee, 306; from tea, 30; from tone factors, 306. Abdominal viscera, 176. Abernethy, 268. Abortion, frequent, 457. Abracadabra, 61. Absence of occupation, 219. Absent treatment, 141. Abstraction, 129. Academy, French, telepathy and, 147. Accidents, telepathy and, 144. Aches, filing, 397; occupation, 390; sawing, 397; sweeping, 397; writing, 396. Acid, lactic, as a bactericide, 247. Acquirements not transmitted, 628. Action, integrative, 123. Addictions, drug, 707. _Adiposus panniculus_, 299. Adjuvants, 163. Advertising, psychology of, 690. Aerophobia, 612. AEsculapius, 7. Affairs, knowledge of, 177. "After dinner sit awhile," 180, 182. Afternoon fever, 180. After-treatment, of alcoholism, 705; of tuberculosis, drug habits, 705. Agassiz's dream, 137. Agate, 62. Age, fasting and, 298. Agoraphobia, 612. Agrippa, Cornelius, 15. Aichmophobia, 581, 612. Ailurophobia, 612. Air, appetite and, 268; fresh, comfort and, 356; in dyspepsia, 262; in intestinal rumbling, 284; in intestinal troubles, 284; rather than exercise, 203; swallowing, 284. Alchemy, 40, 41, 56. Alcohol, 3; in pneumonia, 31; in tuberculosis, 30; in vague affections, 31; milk and, 30; night workers and, 175; suggestive influence and, 31. Alcoholism, after-treatment in, 705, 706; beginning of, 704; confidence in, 704; contagion in, 697; cures of, moral, 395; cures of, old and new, 694; frequent treatment in, 704; heredity in, 698; inherited resistance to, 698; mental influence in, 696; moral influences in, 704; national, 698; occupation pains and, 398; prophylaxis in, 701; real cures of, 395; religion and, 706; sanitarium question in, 702; supposed inheritance of, 697; "sure cures" of, 696; treatment of, 702; tuberculosis and, 703; warnings as suggestions in, 700; youth and, 701. Alexander of Hohenlohe, Prince, 75. Alexander of Tralles, 13, 61. Alexandria, 11. Alteratives, 100. Ambrosia, 59. Amenorrhea, ductless glands and, 439; dread and, 439; fright and, 437; home sickness and, 437; inanition and, 439; mental causes of, 437; mode of living and, 437; reputed remedies for, 440; suggestion in, 440; tuberculosis and, 437. Amethyst, 60. Amputation stump, pain in, 86. Amulets, 15, 60. Amusements, diversified, 9 182; mind and, 227. Anatomy of melancholy, 61. Anemia in Porto Rico, 106. Anesthesia, 111; clasped hands in, 757; deep breathing in, 757; fright in, 757; from fixed attention, 755; game for children, 757; hearing during, 758; hypnotic, 754; local, 758; mental diversion in, 757; mind and, 733; occupation and, 754; rapid breathing: in, 755; suggestive, 756; vomiting after, 758. Anesthetist, familiarity with, 756; personality of the, 756. Anger, brief madness and, 741. _Angina pectoris_, 27, 334; Broadbent on, 339; Charcot on, 337; coffee and, 336; false, 338; in woman, 339; neurotic, 338; psychotherapy and, 337; reflected pains in, 335; spurious, 336; tea and, 336; tobacco and, 336; true and false, 336, 339. Anicetum, 59. Animal emanations, 375; horse and dog, 244. Animal hypnosis, 161. Animal magnetism, 142; malicious, 142. Animal risibile, 105. Anise seed in lichen, 251. Anthropology, criminal, 744. Anodynes, useless, 219. Antidotes, suggestion and, 33. Antimony, 3; suggestions and, 26. Antiochos, 12. Antipathies, gastric, 245. Apartment hotels, 183. Apoplectic habitus, 518. Apoplectics, examples encouraging, 521; new associations for, 521; new interests for, 521. Apoplexy, Bacchus and, 517; cerebral, 513; change of occupation in, 519; complications in, 523; daughter as nurse in, 520; exciting occupation and, 517; heredity and, 517; hypochondriac, 514; lack of air and exercise in, 519; life-direction in, 519; mind before and after, 514; misplaced sympathy in, 522; neuroses and, 522; nurse, choice of, in, 520; outings and human interests and, 522; precocious, 510; preliminary motor symptoms in, 516; premonitory symptoms in, 514; prognosis in, 520; prophylaxis in, 517; pyramidal tracts and, 524; sympathetic cure of, 520; strokes, number of, in, 523; thinking and, 517; trained nurse in, 520; treatment of, 513; Venus and, 517; Vulcan and, 517. Apparatus, brain, insulating, 123; switching, 123. Apparitions, explanation of, 607. Appearances, wraith-like, 608. Appendicitis, chronic, 252; recurrent attacks of, 282; simulant, 587. Appetite, 262, 592; air and, 268; emotion and, 264; feeling of, 264; food preparation and, 266; habit and, 265; increase in, 263; increasing, 301; indoor life and, 264; instinct and, 264; in the morning, 266; nervous loss of, 267; will and, 263, 592. Appetizer, frequent eating as an, 267. Appetizers, 264. Application of psychotherapeutic principles, 104. Arabian mental medicine, 13. Arabian Nights, 12, 46. Arch of the foot, yielding of the, 415, 417. Areas of pain transfer, 252. Argyria, 36. Aristides, ancient hypochondriac, 73. Aristotle, 10. Arm, pitcher's, 397; motorman's, 397. Armless men's foot powers, 419. Arnold, Matthew, and number 13, 639. Arrhythmia, 322; gastro-cardiac, 329; longevity and, 323. Arterial sclerosis, diagnosis of, 514. Arteries, calcification of, 512; longitudinal degeneration of, 515; premature degeneration of, 518; tortuous, 515. Arterio-sclerosis, 512; dizziness in, 515; dread of, 516; over-eating and, 518; stimulants in, 518; tobacco and, 518; vertigo in, 515. Artery of cerebral cortex, 125. Arthritis, acute, 379; acute progressive, 423; "acute rheumatoid," 422; chronic, course of, 425. Arthritis deformans, 421; climate and, 428; chronic, 424; diet and, 427; electricity and, 427; exercise and, 427; in old persons, 426; knitting and, 427; mechano-therapy and, 427; mental attitude and, 426; muscle disturbances in, 424; nerves and, 422; neurotic additions in, 425; occupation of mind in, 428; symmetrical, 422; treatment of, 426; usefulness in, 426; weather and, 428. Arthritises, hysterical, 429. Arthropathy, nervous, 422. Asafetida, 69. Association fibers, diversion of, 601. Association of ideas, 123. Astasia-abasia, 86. Asthma, brothers and, 377; cardiac, 364; cat, 374; cigarettes and, 366; climatotherapy and suggestion in, 368; cubebs and, 366; cures for, 366; cyanosis in, 365; drugs and suggestion in, 368; dust and, 369; emphysema in, 365; essential, 364; eye strain and, 367; horse, 376; horse serum and, 377; horse sensitization and, 377; human emanations and, 377; lavage and, 367; mental influence and, 365; mental shock and, 366; mouth breathing and, 367; neurotic, 364; picture of hayfield and, 375; renal, 364; saltpeter paper and, 366; suggestion in, 366; symptomatic, 364; varied cures for, 367. Astrology, Hippocrates on, 38; in surgery, 746; reassurance and, 40; suggestion and, 38; venesection and, 746. Ataxia, accessory symptoms of, 526; back knee, 524; depression in, 525; emotional, 572; flat-foot and, 524; from emotion, 572; in talking, walking, etc., 571; locomotor, 524; loose joints and, 524; suggestions, favorable and unfavorable, in, 525. Athens, psychotherapy in, 8. Athletes, pneumonia and, 202; typhoid and, 202. Attacks, auto-hypnotic, 541. Attention, concentration of, 755; conscious, 129; memory and, 679; process of, 127; power of, 124; Ramon y Cajal's theory of, 126. Attitude, mental, 100. Attitudes, influence of, 100; of mind, 103. Augustine, St., on warnings, 611. Authorities on tuberculosis, American, 359. Auto-hypnotism, 161. Auto-intoxication, intestinal, 172, 270; supposed, 270. Automatism, inhibition of, 601. Auto-suggestion and the will, 148. Avalanche in nerves, law of. 111. Avalanche, law of, 585. Aversion to cats, 617; to dead bodies, 617. Avicenna on mental influence, 14. Awake, lying, 667. Awaking, mode of, 165. Axis cylinders, 112. Axon hillock, 114. B Babies, fat, 292. Bacchae, 688. Back ache, 174. Bacon, as food, 249. Bacteria, lactic, 247. Ball for constipation, 278. Balneo-therapy, 5. Barometer, pains and, 382. Baseball interest, 228. Basedow's disease, 500. Basil, Valentine, 9, 26. Basophobia, 613. Bath, cold, 166; hot, 166; morning, 166. Bathing, abuse of, 166; overfrequent, 167. Berkeley, Bishop, 57. Bernard, St., 74. Bernheim, hypnotism and, 159. Biliary colic, pseudo, 588. Billiards, 180, 182. Binet, 153. Biographic Clinics, 258. Bishop, the mind-reader, 147, 194. Bismarck's second eighty years, 724. Bismuth, milk of, 285. Bladder, emptying the, 470; evacuation of the, position in, 212. Blanched fingers, 63. Blanching, 190. Bleeding, old-time, 381. Blind and deaf training, 215. Blind, color recognition in the, 214; training of feeling in the, 213. Blood, child's not mother's, 462; turning of the, 64. Blood letting, patient's mind and, 14. Bloodstone, 60. Blue glass, 44. Blue light, 44. "Blues, the," 641. "Bluidy Jock," 357. Blush, intestinal and vesical, 282. Blushing, 190; obsession, 613. Body, influence of, on mind, 100. Boerhaave, 17, 71. Bonaparte, 85. Bouchard, 270. Bovary, Madame, 243. Bowels, over-attention to, 287. Bowling, 182. Boyle, Sir Robert, 35. Bradycardia, 342; case of, 343. Brain, anatomy of, 18; capillaries in the, 125; cells of, vital energy of, 131; cells of, number of, 132; cortex of, 109, 117; complexity of the, 109; intellect and, 549; machine, 132; number of cells in the, 110. Brain workers, 601. Brains, as food, 244. Bramwell, Dr. Byron, 374. Bramwell, Dr. J. Milne, 160. Bread pills, 88. Breakfast, a full, 299; before, 168; company at, 170; habits, 169; mail before, 170; newspaper at, 170. Bridgeman, Laura, 214. Bright's disease, insidious, 558; latent, 558; neurotic symptoms of, 558. Bringer of Peace, 7. Broadbent, Sir Wm., 319, 326; on angina, 339. Brodie, Sir Benjamin, and hysterical joints, 386, 589, 749. Bronchi, dilatation of, relief in, 210. Bronchiectasis, position in, 210. Brontophobia, 612. Brown-Séquard, 48, 67. Bunion, formation of, 417; gout and, 416. Bunions and flatfoot, 416. Bursa, housemaids', 399; miners', 399; organ grinders', 399; sitters', 399. Bursae, discomforts of, 399. Business, anxieties in, 184; habits of, 178; knowledge of, 177; light, air, and position in, 177; walk to, 171; worries in, 185. Butter, microbes in, 95. Buxom, etymology of, 297. C Cabanis, 84. Cagliostro, 47. _Calamus scriptorius_, 12. Calculi, preputial, 485. Calculus, biliary, simulation of, 282. Calmady, Sir Richard, case of maternal impression in fiction, 221. Calomel, 3; in pneumonia, 22; suggestion and, 27. Campbell Thompson and cuneiform inscriptions, 38. Canals, semi-circular, 97. Cancer, abdominal, 303; heredity in, 631; latent indigestion and, 255; mind and, 750; nursing tonic in, 222. Capillaries, congestion of, 126. Card playing, 182. Cardiac conditions, diagnosis of, 316. Cardiac exercise, 325. Cardiac inhibition, 313. Cardiac neurosis and prognosis, 321, 322. Cardiac palpitation, the intellectual life and, 323. Cardiac stomach disturbance, 333. Carlsbad, 278. Carlyle's Miscellanies, 47, 685. Carminatives, 285. Carnelian, 62. Cassius, lean and hungry, 297. Casts, intestinal and tubular, 286. Catalepsy, hypnotic, 159. Catarrh, 39, 59; seasonal, 368. "Catarrh spring," 369. Cathay, cycle of, 517. Catherine of Siena, 74. Cato learning Greek, 680. Cats, conjunctivitis and, 375; consciousness of presence of, 618; coryza and, 374; digestion disturbed by presence of, 254; dread of, 374, 617; dread from memory of killing, 375; fear of, and furs, 618; intolerance of, 374; odor of, 619; smell of, 374; urticaria and, 374. Cautery, actual, 68; psychotherapeutics and, 408. Cells, complexity of brain, 131; Golgi, 131; of the ventral horn, 133; perivascular, 121; pigment, 121; rest, 652; spindle, 112. Cerebral artery, control of, 125. Cerebration, unconscious, 128, 132, 134. Cervical ribs, 400. Chair, comfortable, 210. Chamois garments, 168. Champneys, on painful menstruation, 445. Chance, 776. Character, and suffering, 222; in therapeutics, 358; upbuilding of, 222. Charcot, Dr., 71; on menstrual mental states, 434. Charcot crystals, 364. Charms for erysipelas, 22, 60. Charmides (Plato), 11. Cheese, habituation to, 246. Chest protectors, 167. Chesterfield, Lord, 225. Chesterton, on suicide, 722. Chestnuts, horse, for rheumatism, 385. Chewing in tuberculosis, 355. Cheyne, Dr., 314. Child, diversion of the, 228; first years of the, 230; recreation of the, 228. Childbirth, dangers of, 458; natural, 458; over-zeal to help in, 458. Children, care of, 221; fat, 267; increase of suicide among, 721. Chilliness, 773. Chloral in hypnotism, 156. Chorea, anemia and, 562; endocarditis and, 562; etiology of, 561; expectant treatment of, 563; colds and, 562; consciousness in, 562; cures of, 562; fright in, 562; growing pains and, 562; pathology of, 562; prophylaxis in, 563; pure neurosis and, 561; simple life and, 564; subsequent habit after, 563; treatment of, 562. Cicero, 189. Circle, vicious, 51, 251. Circulation, favoring return of, 208. Cirrhosis, alcoholic, 175. Civil War, Reports of, 286. Clairvoyant, 147. Claude, Bernard, 20, 313. Claudication, intermittent, 512. Claustrophobia, 612, 616. Clavus _hystericus_, 547. Clergyman's knee, 411; sore throat, 411. Clinics, biographic, 601. Clitoris, removal of, 488. Clothing, 167; warm, 356. Clouston, 191; on religion, 777. Coccydynia, 428. Coccygodynia, 68; causes of, 428; hysterical, 429; labor and, 428; neurotic, 429; over-attention to, 429. Coffee and abdominal distress, 307. Cohnheim, 251. Coincidences, 144; telepathy and, 146. Colds, fat and, 298; fresh, 350; fresh air and, 350; more sleep and, 350; night air and, 350; quinine and whiskey for, 349; rational treatment of, 349; settled on lungs, 358; taking, 167. Colitis, cures for, 288; excess of salt in, 284; in Civil War, 286; increase of, 287; muco-membranous, 286, 288; resorts, 289; suggestion in, 288; surgery for, 288. Colles' Law, 630. Color blindness, 771. Columbus, 42. Comedy, musical, 227. Comfort, mental and physical, 761. Compensation, 213. Concussion of the brain, 118. Conditions, mechanical, in pains, 174. Confession in sex habits, 486. Confidence, 15; of the patient, 14; of the physician, 4. Conjunctivitis, cat, 375. Constipation, 268; exercise in, 276; fats and sugars in, 276; in obesity, 296; in the stout, 278; oriental, 271; position in, 276; prophylaxis in, 269; reassurance in, 271; tolerance in, 272. Contagion, coughing and, 688; expectoration and, 688; fashion and, 691; favorable mental, 692; giggling, 688; health, 692; laughing, 688; moving pictures and, 693; murder, 691; not heredity, 298; psychic, 688; sighing, 688; suicide, 691; yawning, 688. Contagious trifles, 688. Co-ordination in the organism, 132. Copenhagen, Perkins in, 49. Copremia, supposed, 270. Cornelius Agrippa, 15. Corns, soft, 418. Corpulency, 290. Cortex, diagram of, 113; pyramidal cell in the, 122; visual, 110. Coryza, cat, 375; vaso-motoria periodica, 369; yearly, 372. Cough, as tic, 348; habit, 347; hemorrhage and, 346; intestinal, 348; in tuberculosis, 348; irrational, 349; mental control of, 361; ordinary, 345; ovarian, 348; reflex, 347; remedies for, 345, 349; stomach, 348; stopping a, 210; suggestion and, 345; unproductive, 345; uterine, 348. Coughing, control of, 361. Counter irritation in nervous disease, 511. Courting and telepathy, 143. Coventry Patmore, Mrs., 144. Coxalgia, hysterical, 429. Cramp rings, 61, 80. Cranberries in erysipelas, 22. Creator, existence of, 776. Crises, gastric, 526; intestinal, 526; tabetic, 526. Critias, 11. Cromwell, 81. Crooke's theory of telepathy, 142. Croup, nervous, 669. Cure-alls, 3. Cure houses, 10; magnetic, 55; relieve, console, 186; smiling and laughing, 104. Cured cases as evidence, 52, 60. Cures, 50; faith, 78; for colitis, 288; for tuberculosis, 351; hayfever, 373; supposed, 51, 387. Curschmann's spirals, 364. Cutten, on faith cures, 81. Czermak, Prof., on inhibition, 313. D Dalton, color blind, 772. Dangers of hypnotism, 161; Dr. J. K. Mitchell on, 161. Darkness, dread of, 620, 668; Romilly and, 621; Rousseau and, 620. Dawdling, 182. Dead bodies, aversion to, 617. Deaf, training of the, 215. Death, AEschylus on, 622; After, What? 88; attitude toward, 730; captain of, 350; dread of, 621; fear of early, 622; impending, 336; life and, 89; mind and, 90; moment of, 147; premonition of, 636; put off, 91; socially, 731; Sophocles on, 622. Defectives, sexual, 474. Deformities, coincidences and, 464; etiology of, 466; falls and, 467; missteps and, 467. Degeneration, stigmata of, 744. Delusions, 603. _Dementia praecox_ and paresis, 532. Dendrites, 112. Dentist's limp, 398. Depression and disease, 641; and diversion, 643; and dyspepsia, 233; and hobbies, 646; and indigestion, 233; an incident, 650; benefits of, 650; care of ailing a cure for, 645; care of animals a cure for, 645: care of plants a cure for, 645; feminine, and children, 644; frequency of, 647; garden cures for, 646; heart disease and, 642; historical examples of, 647; insomnia and, 644; Lord Lytton and, 648 Lowell, James Russell, and, 648 nephritis and, 642; periodical, 641 reading in, 646. De Puysegur's instruction in hypnotism, 154. Dermatotherapy, the mind in, 495. Descartes, 41. Desks, comfortable, standing, 176. Determinism, 744. Deterrent materials and suggestions, 34. Deterrent taste and smell, 68. Deterrent therapeutics, 63. Diabetes acidosis, 500; air and exercise in, 499; causes of, 496; danger of over-treatment in, 497; eczema in, 496; frequent in obese, 294; general condition in, 497; incurable, 496; interval treatment of, 498; oatmeal and, 498; over-treatment of, 497; pancreatic changes in, 496; physician and patient's, 497; potatoes and, 498; rigid diet and solicitude in, 499; secondary symptoms of, 497; individual, the, and, 498; unfavorable suggestion, 496. Diagnosis, announcing the, 354. Diancecht, Irish physician, 58. Diaphragm, excursions of the, 362; movements of the, 362. Diarrhea, emotional, 283; fright and, 279; habitual, 280; nervous, 558; nervous, and urticaria, 281; neurotic, 279; worry and, 280. Diathesis, uric acid, 380. Diet, _do not_, 257; dyspepsia and, 256; fads, 171; limitation of, 275; mixed, 275; restrained, 298; rules, harmful, in, 256; tinkering, 380. Diffusion, laws of, 132. Digby, Sir Kenelm, 56. Digestion, brain workers and, 258; chemistry and, 242; contrary suggestions and, 251; disgust and, 243; influence of mind upon, 242; mental changes and, 247; of cat, disturbed, 254; prejudices and, 242; study and, 253; worries and, 253. Digitalis and mental influence, 313. Directions to physicians, suggestion and, 197. Disappearances, 608. Disappointments, mental states of, 643. Discipline, of mind, 196; of self, 223. Discomfort, digestion and, 253; with eating, 301. Discontinuity of the nervous system, 118. Discoveries, scientific, 46. Discovery, supposedly wonderful, 192. Disease, American, 380; incurable, 186; individual, 224; patients and, 163; suggestion of, 94; thinking, 99. Disease suggestions, 250. Diseases of ductless glands, 496. Dislocations, after-effects of, 388. Disposition, suggestion and, 101; dual, 150. Distension, 332. Disuse, atrophy and pain, 394. Diversion, 182; children's, 228; from pain, 225; of mind, 9; true, 224. Divinity, medical, 7. Doctor, "conjure," 64. Dog and hog, 243. Dominant ideas, 750. Donne, Dr., 37. Doubting, 732; daily review in, 738; habit, 733; marriage and, 735; opening letters and, 735; ordination and, 735; outdoor air and, 738; prophylaxis in, 737. Doubts, Hamlet's, 735; program for day in, 738. Dread, 2, 612, 613; habit of control of, 615; mental discipline in, 615: of arterio-sclerosis, 515; of death, 621; of dirt, 615; of heights, 614; of indigestion, 306; of insanity, 623; of small heights, 615; of the dark. 620; of water, 621; physical basis of, 614; subconscious, 625. Dreads, heredity and, 626; men of genius and, 623. Dreaming, "all the night long," 673; by day, 671; constant, Hazlitt, Mitchell and Owen, 672; Laughing, Blushing and, 607, 672. Dreams, 8, 78, 669; and children, 678; and digestion, 100; and fright, 677; and reading, 678; and sensations, 575; art in, 136; children's, 677; erotic, 479; frequency of, 671; insufficient clothing in, 671; life and, 136; mathematical, 136; mercy's, 136; of falling, 670; out of breath, 671; poems and, 136; prophecy fails, 676; prophetic, 675; rearrangement in, 635; short duration of, 673; significance of, 674; suggestions and, 678; telepathic, 674; therapy and, 669. Drug addictions, 707. Drug habit, after-cures for, 712; confidence in, 711; cures for, 709; curiosity and, 708; early treatment in, 710; forming, 290; heredity and, 712; individual, 707; over-confidence in, 709; pleasant, 708; prophylaxis in, 708; relapses in, 709; sanitarium question and, 710. Drugs, 8; effects of, imaginary, 88; in sufficient doses, 4. Drunkenness, 117. Dualism of disposition, 151. Dumas, 47. Dumb-bell, a parody of exercise, 204. Dundrearyisms, 464. Dupré, Giovanni, 136. Dupuytren's slap for anesthesia, 754. Dust and disease, 172. Duval and neurons, 114. Dwarf of French king, 314. Dysmenorrhea, constipation in, 442 cystic ovaries in, 446; extragenital 445; extrapelvic organs in, 442 fisherwomen and, 444; individual 446; lack of occupation in, 443 membranous, 445; minor lesions in, 446; moral fiber and, 443; operation idea and, 443; running down and, 442; spasmodic, 445; suggestion and, 445. Dyspepsia, 301; abdominal muscles and, 261; air and, 262; American, 179; depression and, 233; from diet regulation, 256; mental work and, 253; sleep and, 262; state of mind in, 250. Dyspeptics, exercise for, 261; longevity of, 259. E Eat, the will to, 263. Eating, dread of, 264; enough, 299; more, 301; slow, 231; uncomfortable feelings after, 263. Eddyism, 60, 386. Edema, angio-neurotic, 283. Education and discipline, 196. Efficiency experts, 179. Eggs, biliousness and, 246; idiosyncrasy for, 245; persuasion as to, 248; repugnance to, 246. Egypt, psychotherapy in, 8. Electric belts, 62. Electric insoles, 63. Electrical contrivances, 43. Electricity, 5. Electro-therapy, 5; suggestion and, 42, 43. Elijah returned, 82. Elixir of life, 44. Embryo-complexity, 466. Emissions, seminal, alcohol and, 478; constipation and, 478; full bladder and, 478; nocturnal, 477; prophylaxis in, 478; spices and, 478. Emotion, heart and, 311. Emotions as remedies, 17. Encyclopedia Brittanica on mummifies, 64. Energy, reserve, 108; law of, 92. English, Dr. Thomas Dunn, on life, 724. Environment, favorable, 188. Epidaurus, 8. Epidemic, suicidal, 691. Epilepsy, 15; anise seed for, 25; attitude of mind in, 537; Byron and, 536; Caesar and, 536; colony system and, 535; cures for, 537; dread of insanity in, 535; emotion and, 535; fright and, 535; individual in, 536; influence of suggestion in, 535; mental "cures" of, 541; Mohamed, 536; Napoleon, 536; neurotic simulation of, 536; occupation in, 537; operations for, 505, 535; quiet life and, 537; rings in, 61; royal touch and, 79; suggestion in, 25. Equilibrium, training in, 215; unstable intestinal, 286. Erasistratos, 11. Erotic, 480. Erysipelas, 3, 21. Erythrophobia, 613. Esophageal stricture, 676; neurotic, 574. Esophagus, constriction of the, 575. Esquirol, on child suicide, 721. Ether in telepathy, 142. Euripides, 688. Evacuation, habitual, 273; simulated, 285. Evil, denial of, 776. Evolution, Lucretius and, 776. Excrement, goose and chicken, 34. Excretions as remedies, 66. Exercise, 198; air and, 203; for heart irregularity, 327; for sake of exercise, 204-7; fun and, 203; graduated, for heart, 328; in dyspepsia, 261; in early years--English and German customs, 199; interest and, 203; mental diversion and, 207; regulation of, 202; sport and, 203; sufficient, 199; treatment for heart and, 328. Exhaustion, mental, 138. Exhibitionism, 490. Exosmosis, 132. Expectancy, mental, 46. Expectoration, difficulty in, 210. Expert in health, 179. Expression and feeling, 101. Extensors and hate, 194. Extra-systole, big beat and, 333; conscious, 333; long-pause, 333; prognosis in, 333. Eye, oblique muscles of, 102; superior recti of, 102. F Fabricius Hildanus, 54. Facial expression and feeling, 101. Faddists, fruit, milk-product and nut, 258. Fads, bathing, 167; harmful, 166; health and, 689. Faith, 14, 15; cures by, 61; healing and, 196; power of, 196. Familiarity with drugs, 4. _Fascia dentata neuroglia_, 120. Fashion contagion, 690. Fasting ages, 298. Fat, anemic, 298; in sick hogs, 303; lack of, 298; useless, 201. Father John of Cronstadt, 75. Fats in constipation, 276. Fatty vicious circle, 292. Fearing the worst, 98. Feeling, expression and, 101; occupation and, 129. Feelings, transferred, 251. Feet above heart, 173. Femero-coxalgia, 68. Feré, 153. Ferrier, Chancellor, 323. Fever, afternoon, 180; typhoid, 3. Filaments, terminal, 117. Fish, coloration practice in, 494. Fissure, calcarine, 110. Flammarion, 607. Flashes of heat, 773. Flatfoot, 174, 383; circulation in, 419; prevention of, 419; relief for, 209; runs in families, 390; secondary consequences of, 420; sprains and, 420. Flatulence, 332. Flaubert, 243. Fletcher, 231. Flexors and liking, 194. Flourens, 543. Fluid, daily, 274; ingestion of, 274; in obesity, 296. Folin, 231. Food, amount of, 273; angle worms as, 244; brains, liver and spleen as, 244; caprice and, 266; chewing, 260; craving for, after operation, 763; custom and, 244; dislikes for, 245; dyspepsia and, 301; elimination of, 250; idiosyncrasies and, 282, 301; increase in, 273, 301; natural residue of, 275; preparation of, appetite and, 266; reduction of, 296; sleep and, 207; temptations to, 293; values and habits, 263. Food faddists, 258. Foot, exercise for the, 420; noises with the, 419. Foot troubles, deformities in all classes, 413; mechanical factors in, 413; rarer, 418; significance of, 421; unfavorable suggestions and, 415. Force, vital, 133. Ford Robertson, 110. Forel, Prof., 190, 706. Foreskin, long, 484. Forgetfulness, limits of normal, 683. Formulas, word, 566. Fox hunting, 205. Fractures, after-effects of, 388; immobilized, 388; manipulation of, 388; massage of, 388; mind and, 751; of the clavicle, 89. Francis of Assisi, St., 74. Francis Xavier, St., 74. Frankenstein, 626. Free will, 148, 152, 739; argument for, 739; individual, 741. Frenkel's method for tabes, 528. Frenkel's treatment, origin of, 528. Frere, Robert 36. Freud, 595. Friedländer on quackery at Rome, 58. Fright, epilepsy and, 535; heart and, 315; in chorea, 562; in Graves' disease, 500; in paralysis agitans, 542; loss of bowel control and, 279; tremors from, 581; white hair and, 494. Frights, forgotten, 625. Fumigation, 60. Fun and health, 203. G Galen, 12; on proprietaries, 59. Galen's theriac, 20, 46, 51, 59, 71. Gallstones, 80. Galton, Sir Francis, 36, 601, 606. Galvani, 43. Gambling, 182. Garments, chamois, 168. Gas, 15. Gassner, 15, 153. Gastralgia, tabetic, 526. Gastric crisis, 526, 586. Gastric dilatation, 330. Gastric fauna, 462. Gastric motility, 176, 307. Gastric muscular tone, 262. Gastric reflexes, 251. Gastric secretion neuroses, 586. Gastric self digestion, 303. Gastric sensations, 306. Generalization of visceral pain, 252. Genitalia, over-attention to the, 430. Genius, De Musset, 624; Goethe, 624; idiosyncrasies and, 245; investigating, 130; Kingsley, 624; Montaigne, 624. George Eliot, 135, 141. Gerhardt, Prof., 317. Ghosts, 605. Gilbert, 42. Gilles de la Tourette on tics, 564. Ginseng, 35. Giving up, 93. Gladstone, 225. Gladstone's chewing, 231. Glands, intestinal, over-action of, 288. Glycosuria, alimentary, 496; psychological, 291; neurotic, 496. Goclenius, 55. Gold, chloride of, 61. Goldsmith, 223. Golgi, 110, 131. Gordon Holmes, 151. Gordy, Prof. J. P., 230. Gould, Dr. George, 258, 601. Gout and flatfoot, 415, 416; rheumatic, 421. Gowers, Sir William, 556. Gowers' rule in writing, 396. Grahamism, 256. Grass scorpion, 35. Grasset, 597. Graves' disease, cures of, 504; diagnosis of, 502; diarrhea and, 501; diet and, 506; diversion and, 506; emaciation and, 501; emotion and, 500; etiology of, 500; _formes frustes_ 500, 502; fright and, 500; genital incidents and, 501; larval forms of, 341; menopause and, 502; mummy and, 504; operations for, 505; parathyroid and, 504; prognosis in, 502; responsibility and, 500; serums and, 504; sex incidents and, 501; sleep and, 506; snake skin and, 504; suggestion and, 504; sympathetic, 502; symptomatology of, 501; thyroid in, 469, 504; thymus in, 469, 503; touch of hanged in, 504; women and, 501. Gravitation, 41. Greatrakes, 81, 153, 386. Greece, decadence in, 107. Grief, Astley Cooper and, 731; consolation in, 729; Lord Lytton and, 731; melancholia and, 727; motives of consolation in, 728; pathological, 727; physical conditions in, 726; prophylaxis in, 728; Rossetti and, 732. Grouch, perennial, 233. Gymnasium director, 206. Gymnastics, 181, 203. Gynecology, dominant ideas in, 432; functional diseases in, 456; mental factors in, 433; mental healing in, 430; reputed remedies in, 431; self-control and, 433; suggested factors in, 431. H Habit, 125; appetite and, 265; business occupation and, 178; following chorea, 563; formation of, 229; in constipation, 273; is second nature, 229; non-inheritance of, 632; saves reflection, 235. Habits, air and exercise, change of, 232; bolting, 231; law of, 230; mental, 233; physical, 231; sexual, 482. Hack Tuke, Dr., 190; on warts, 493. "Hacks," 361. Hahnemann, 41. Haldane, Prof., 132. Hallucinations, 78, 141, 603, 773; auditory, 609, 773; cocaine, 773; disturbing, 611; dreams and, 606; explanation of, 607; frequency of, 604; insanity and, 609; significance of, 604; statistics of, 605; telepathic, 605; touch, 773; visual, 604. Head, discomfort in, local, 552; over-attention to the, 547; raising the, 210. Headache, 59; air and, 554; anemic, 553; at Epidaurus, 554; attention, 547; coffee and, 553; congestion, 549, 551; cures for, 546; direct mental treatment of, 553; distraction and, 548; drugs and, 553; exercise and, 554; extraneous, 550; eye strain and, 550; fear of brain lesion and, 549; frequency of, 546; lack of distraction and, 548; local conditions and, 550; loss of meal and, 551; mental treatment for, place of, 554; mental work and, 550; occipital, 552; occupation of mind and, 546; sense of pressure in, 547; source of pain in, 549; spirits and, 553; tea and, 553; tenderness and, 552; weight and, 553. Head's studies in sensation, 252. Healers of the nineteenth century, 81. Healing, irregular mental, 209. Health, central nervous system and, 191; good, and happiness, 234; muscle development and, 200; thinking, 99. Health resort, 184. Hearing, training of the, 686. Heart, action of, after dancing, 324; action of, after Marathon, 324; action of, irregularity of, 322, 323; anxiety about the, 311; arrhythmia of the, 322; athletes', 324; coffee and the, 329; crowding of the, 323; cures, faith, and the, 312; defects of the, and quiet lives, 316; difficulties of the, 319; emotion and old physiology of, 311; fatty, and exercise, 326; fright and the, 315; functional affections of the, 321; gastric influence on the, 334; general condition and the, 318; German and Irish schools on the, 318; Indian fakirs and the, 311; in difficulties, 322; individual and the, 317; inhibition of action of the, 313; introspection and the, 327; irregularity of, not to be treated, 327; irritable, 324; limitation of diet and the, 335; listening to the, 317; meat-eating and the, 335; mental influence on the, 310; missed beats of the, 322; muscular, 322; nervous, Morgagni and Lancisi on, 331; nervous system and the, 311; occupation of mind and the, 320; palpitation of the, 322; physiological work for the, 326; reassurance and the, 334; remedies and suggestion and the, 312; shock and the, 314; sorrow and the, 315; sounds, impure, in the, 324; stimulants and the, 326; stomach distension upward, effect of, upon the, 330; stomach gas and the, 329; suffering and the, 332; surveillance over the, 322; sympathetic, 319; taking, 312; tea and the, 329; therapy of the, psychic factors in, 315; tobacco and the, 329; training, 216, 326; trouble of the, consciousness of, 312; vaso-motors and the, 319; voluntary inhibition of action of the, 314. Heart disease, consumption and, 321; declaration of, 321; diagnosis in latent, 316; exaggeration of seriousness in, 317; mental influence and, 311; prognosis in, 315, 316, 332; prophylaxis in, 315; symptoms of, in the young, 321; symptoms of, neglect of, 320; symptoms of, simulated, 319; symptoms of, subjective, 321. Heart failure, 334, 341. Heart murmurs, significance of, 317; uncertainty of, 318. Heberden's nodes, causes of, 422; longevity and, 423; progress of, 423; solicitude over, 423. Heels, high, 410. Hell, Father, mental influence practised by, 153. Hemorrhage, cough and, 346; mind and, 360. Hen hypnotization, 160. Herbal medicine and mental influence, 140. Hereditary resistance, 712. Hereditary syphilis, 629. Hereditary tuberculosis, 629. Heredity, alcoholism and, 629; disease and, 628; drug habits and, 712; false impressions concerning, 627; habits and, 632; Hapsburg lip, instance of, 632; mystery of, 633; resistance and, 352; principles of, 699; suggestion and, 251; tuberculosis and, 628; variation and, 633. Hermaphrodites, partial, 489. Hermaphroditism, mental, 490. Herophilus, 11. Herpes and mind, 492. Hertz, Arthur, 270. _Hexenschuss_, 391. Hildanus, 54. Hilprecht's sleep vision, 137. Hilton on Rest and Pain, 52, 188. Hippocrates, 10, 71; on astrology, 38. Hives and diarrhea, 281. Hobbies, 224; Virchow on, 226. Hobby, 601. Hog's meat, 243. Holmes, Oliver Wendell, 4, 48, 50, 54, 56, 311. Home work, 182. Homo-sexuality, 490. Hook-worm, in Egypt, 107; in Porto Rico, 107; in the South, 107. Hope, renewal of, 91. Horace, 223. Horseback riding, 204. Horse, outside of a, the, 204. Hospitals, mind and, 747; psychic conditions of, 760. Hours of diversion, 182. Hudson, 251. Humor, 105. Hunger and sleep, 665. Hunter, John, 17. Hunyadi Janos, 278. Hydrophobia, 613. Hydrotherapy, 5. Hygiene, personal, 178. _Hyperemesis gravidarum_, 457; postanesthetic, 758. Hypersecretion, gastric, 586. Hypnoidal state, 198, 626. Hypnosis, anesthetic, 755; animal, 160; of self, 161. Hypnotism, accessories in, 155; Danger and Uses of, 162; drugs in, 156; effects of, 152; essence of, 152; explanation of, 118; for exhibitions, 162; influence of, 76, 111; in obstetrics, 458; lights in, 155; miracles of, 152; mystery of, 151; not mysterious, 158; practice of, 156; sensations of, 156; sound in, 156; stroking in, 156; susceptibility to, 159; three stages of, 158; valuation of, 152; uses of, 162. Hypnotizers, Bernheim, 154; Braid, 154; De Puysegur, 154; Liebault, 154; Mesmer, 154. Hypochondria, 287. Hypochondriac, 94; sympathy with the, 335. Hypochondriac organs, 335. Hypochondriorum, _ex consensu_, 331. Hypothesis, Duval's, for brain mechanism, 123; Ramon y Cajal's, for brain mechanism, 127; for sympathetic system, 127. Hysteria, 80, 585, 590; dual personality and, 149; organic change and, 190; secondary personality and, 149. Hysterical cutaneous conditions, 495. Hystero-epilepsy, 538, 626. I Idea, single, 195; tends to action, 194. Ideas, dominant, 97, 239; body and, 195. Idiosyncrasies, food, 282; genuine food, 245; individual and heat, 329; intestinal, 282; physiological, 231. I-Em-Hetep, 7, 71. Ignatius Loyola, St., 102. Ills, imaginary, 191; not fancied, 191. Illusions, 603, 764; delusions, hallucinations and, 773; in connection with dots, 776; in connection with a tube, 764; of distance, 769; of size, 769, 770; of the sun and moon, 768; optical, 770; universal, 764. Image, wax, and distant effects, 141. Imaginary ills, 191. Imagination, 14, 15. Immunity, acquired, 358; inborn, 358; lack of, 108; maternal, in syphilis, 629; of nursling, 461. Impedimenta, 201. Impotence, organic, 476; psychic, 475. Impotency obsession, 476. Impressions, mental, 346. Incisions and suggestion, 752. Incubation, 554, 669. Incurable, care of the, 223. Incurable disease, relieving, 510. Incurability, so-called, 48. Indigestion, above the neck, 257; auto-suggestive, 250; cancer, latent, and, 255; correction of, 259; depression and, 233; differentiation of, 254; diversion of mind and, 258; dread of, 305, 306; early tuberculosis and, 255; lack of sleep and, 254; neurotic, 169; prevention of, 259; unfavorable states of mind and, 250. Individuality, 133. Individuals, human, 224. Infections, mental, 753. Influence, malign, 141; of the mind, 2, 84; of the stars, 39; telepathic, 141. Inheritance of defects, 632. Inhibition, 46; cardiac, 313; menstrual, lack of, 434; nervous, 87. Injuries, old and painful, 387; unconscious, 85. Insane, cunning of the, 743. Insanity, dread of, 623; genius and, 536; hallucinations in, 609; Perkinean, 49; plea of, 742; religious, 777; self abuse and, 484. Insomnia, 125; coffee and, 659; cold and, 656; cold bath and, 658; cold feet and, 656; diet and, 659; direct suggestions and, 660; dread of, 651; drugs and, 654; encyclopedia reading and, 662; evening hours and, 660; food before retiring and, 659; hot foot bath and, 657; Jacinth and, 37; lack of air and, 657; lack of occupation and, 644; not serious, 651; persuasion of, 651; pillow and, 655, 656; sea voyage and, 658; solicitude about, 654; suggestion and, 654; tea and, 659. Inspiration, 135. Instinct, appetite and, 264; disturbed, 267; not theory, 256. Interest, human, 206; in others, 221. Intestinal control, 280. Intestinal tolerance, 271. Intestinal unrest, 255. Intestine, 269. Introspection, morbid, 302. Invalids by profession, 184. Irish school on heart, 318. Irregularity, functional, of the heart, 327; myocardial, 327. Irresponsibility, 744. J Jacinth for sleep, 37. James, Prof., 16, 92. Janet, 597. Jew's ear, 35. John of Cronstadt, 75. Johnson, Samuel, 80. Joint affections, position in, 212. Joint conditions, differentiation of, 381; hysterical, 239; hysterical, frequency of, 387; neurotic, frequency of, 386; old, injured, and dampness, 387; painful, 379. Joy and pleasure, 104. K Ka (Egyptian soul), 9. Kaltenbach, 456. Keller, Helen, 214, 234. Kepler and astrology, 39, 41. Khou (Egyptian mind), 9. Kidney, abnormal fixity of, 307; backache and, 308; calculus of, 80; floating, operation for, 308; loose, 302; movable, 307; movable, mechanical treatment for, 308; movable, weight, and, 297, 308; of pregnancy, 307; position of calculus in, 209. Kidneywort, 35. King, Prof., on natural obstetrics, 459. King's evil, 79, 81. King's touch, 748. Kircher, S. J., Father, 42, 160. Knee, after loose cartilage, 412; foot troubles and the, 410; high heels and the, 410; hip and the, 410; housemaid's, 39; lumbar discomfort and the, 411; muscle disuse and the, 412; unusual occupations affecting the, 410. Knee jerk, 556. Kneipp, Father, on hydrotherapy and psychotherapy, 72. Kneipp societies, 73. Know, I do not, 466. Kocher, 505. Korsakoff's psychosis, 687. Krafft-Ebing, 631. Kronecker, 269. Kronig, 456. L Labor, at the ninth month, 454; delayed, suggestion and, 454; natural, 459; patient helps, 459; postures after, 459. Labouchère, 147. Lachesis, snake venom, 66. Laennec pearls in asthma, 364. Lancisi, 17, 331. Lapax, Indian chorea, 688. Larrey, Baron, 68. Lauder Brunton, on inhibition, 313. Laugh and grow fat, 297. Laughing, diaphragm and, 105. Laughing cure, 104. Laughter, hearty, effect of, 297. Law of avalanche, 111. Laxatives, abuse of, 287. Layer, plexiform cerebral, 126. Lead in muscle aches, 398; poisoning from, 172. Learn, by heart, 223; failure to, 129. Leg exercises in constipation, 277. Legs, inequality of, 410 Leisure, use of, 181. Leisure classes, 184. Letters, cross, 140. Leyden jar, 42; "cures" by the, 42; effects of the, 42; suggestion and the, 42. Lichen, anise seed in, 25; snakes in, 25. Liebault on hypnotism, 407. Life, aimless, 220; and death, 89; dangerous, 512; intellectual, 125, 134, 302; interests in, 169; natural, 267; out-of-door, 358; persuasion of short, 636; principle of, 191; regulation of, 220; worth living, 722. Light, and psychotherapy, 44; in hypnotism, 155; lack of, 173. Lightning, fear of, 612. Lincoln's steamboat, 253. Liniments, suggestion with, 29, 393. Liquor problem, scientific solution of the, 701. Literature and life, 648. Lithemia, 380. Litton's diaphragm phenomenon, 361. Liver, business and the, 253; gastric symptoms from the, 177. Liverwort, 35. Lloyd Tuckey on mental influence, 156. Lobe, occipital, 116. Local anaesthesia, personality of operator and, 758. Locomotor ataxia, 524. Lombroso, 88, 130. Longevity and delicate health, 202. Looking forward, 183. Looking up, 102. Lord Bacon, 54. Lord Kelvin on the Creator, 730. Louis', grief, 732. Love, Greek, 482. Lowell, James Russell, 649. Lucas Malet on maternal impressions, 221. Lucian on warts, 493. Lucretius' pessimism, 776; evolution and, 776. Lumbago, 402; adhesive plaster for, 407; cautery and, 408; electric equilibrium in, 408; etiology of, 404; hypnotism in, 407; paper on loins and, 407; piles and, 403; seminal vesicles and, 403. Lunar caustic, 36. Lunch, hurried, 171; women's, 180. Luncheon, in Vienna, 179. Luncheon clubs, 180. Lung at rest, 361. Lungs not laboratories, 132. Lytton, Sir Robert Bulwer, 648; grief and, 731. M McDougal, 123. McGuire, John Francis, on Father Mathew, 75. Machines, electrical, 43. Mackenzie on the heart, 323. Magnan, Prof., on sex perverts, 480. Magnetics, 15; application of, 42. Magnetism, human, 41; malignant, 142; personal, 14, 70; suggestion and, 41. Magnets, 15. Malaria, degeneration and, 107; mental, 93. Man, of one idea, 195; without habits, 230. Manners and disposition, 234. Manzoni and memory, 685. Martyrs, 112. Massage and exercise, 206. Mastication, stomach and, 261; wearying, 355. Maternal impressions, in old literature, 461; superstition and, 465; supposed examples of, 463; time of, 463. Mathematical medicine and suggestion, 41. Mathew, Father, and alcoholism, 75. Meal, midday, 180; principal, 180. Meat, dog, 244. Mechanism, of influence of mind on body, 107; of mental influence, 108; peripheral ganglionic, 190. Mechano-therapy, 5. Médecine, La, des Âmes, 90. Medication, 2. Medicine man, 78. Medicine, minus mental influence, 192; plus mental influence, 192. Medieval mind healing, 14. Melancholia, neurasthenia and, 556; suicide and, 556. Memories, individual, 684; vertigo and, 516. Memory, age and, 679; attention and, 679; auditory, 682; brain cells in, 128; Carlyle's, 685; committing to, 223; cultivating looseness of, 683; definite location of, 128; diseases of, 682; disorders of, 678; disturbance of, 124; exercise of, 687; fatigue and, 682; genius and, 684; Goldsmith's, 684; groping, 127; hallucinations of, 635; improvement of, 687; in defectives, 686; intellect and, 684; intimate mechanism of, 128; laxative and, 270; low grade intelligence and, 685; Manzoni's, 685; name, 681; newspapers and, 684; Newton's, 684; of animals, 127; of words, 127; pauses and lapses of, 681; peculiarities of, 680; process underlying, 133; psychotherapy of, 679; public speakers and, 127; Scott's, 684; sensations and, 682; sense defects and, 682; solicitude and, 680; supposed loss of, 679; tone deafness and, 682; training the, 686; tricks of, 685; visual, 682. Menière's disease, 516; vertigo and, 516. Menopause, air and, 452; benefits of, 452; definite prescriptions for, 451; diversion of mind and, 452; exercise and, 452; family cares and, 451; Graves' disease and, 502; lack of occupation and, 451; old-fashioned attitude toward, 451; pseudo-epilepsy and, 540; unfavorable suggestions and, 450. Menorrhagia, favorable disposition in, 449; fibroid and, 448; individual and, 449; menopausal, 448; mental factors in, 447. "Men's diseases," 474. Menstrual condition, 59; disturbance through brain in, 190; hyperemia and, 436; irritability and, 441; over-attention to, 441; over-reaction in, 436; psycho-physical factors in, 436. Menstruation, air and, 436; dreads and, 434; emotion and, 438; lack of inhibition in, 434; misophobia in, 434; psychic states of, 434; sensitiveness in, 435. Mental attitude, 4. Mental energy, law of, 16. Mental exhaustion, 599. Mental healing, 386; in the Renaissance, 14; 3,000 years of, 81. Mental incapacity, 597, 598; functional, 599. Mental influence, anesthesia and, 753; before operation, 749; distant, 140; in surgery, 747; medieval, 747; on organs, 87; post-operative, 759; therapeutics and, 196; with digitalis, 312. Mental medicine, law of, 99, 251. Mental short circuit, 5, 601. Mentality, physical basis of, 133. _Meralgia paresthetica_, 405. Mesmer, 51, 153; methods of, 154, 386. Mesmerism, "Christian Science" and, 55; surgery and, 748. Message, telepathic, 145. Metabolism, fatty, 291. Meyer, 105. Michelangelo on trifles, 164. Microbophobia, 612. Milk, asses', 246; bovine, humanity and, 461; dislike of, 246; goats', 246; mares', 246; maternal supply of, mind and, 460; more than food, 461: sour, 96, 247. Mind, absorption of, 130; abstraction of, 129; body and, 233; brain and, 549; concentration of, 124, 130, 197; diversion of, 182, 224, 225; fractures and, 751; heart and, 311; herpes and, 492; making up, 737; menstrual, Charcot and Möbius on, 434; mortal, evil of, 776; motility and, 86; preoccupation of, 130, 136; relaxation of, 228; urticaria and, 491; vacant and distressed, 219. Mind healing, in Greece, 10; novelties in, 5. Mind reading, 141. Miner's elbow, 399. Mirabeau, 27. Misophobia, 615. Mitchell, Dr. John K., 161. Mitchell, Dr. S. Weir, 136, 572. Möbius on menstrual mental states, 434. Mommsen, 130. Monastic work intervals, 226. Mondeville, mental influence and, 747. Monotony in diet, 296. Moodiness, 233. Moral, influence of the, on the physical, 84. Morgagni, 16, 331; and venesection, 27; on nervous heart, 331. Morning, dawdling in the, 165; walks in the, 169. Mother and child, distinct beings, 462. Mothers of syphilitic children immune, 680. Motility, gastric, 261. Motion and will, 109. Mouth breathing, 105. Movements, habitual, 173; pain and, 396. Movements, passive, 207. Moxa and suggestion, 68. Müller, Johann, 18, 607, 678. Müller-Lyer lines, 767. Müller, Max, 243. Mummies in therapy, 64. Münsterberg, Prof.; on Pastor Gassner, 778; on psychotherapy, 75. Murmurs, heart, 318; extraneous sounds and, 318; significance of, 318. Muscle reading, 195. Muscles, exercise of the, heart stimulation and, 328; gastric, 261; health and, 200; internal secretions in, 328; overtiredness of, 392; relaxation of, 197; thought and, 194; unconscious regulation of, 230; useless, 201. Muscular exertion, unaccustomed, 392. Muscular pains and aches, atrophy and, 394; causes of, 391; counter-irritation for, 393; habits and, 392; lead and, 398; local conditions in, 389; treatment of, 406. Music as recreation, 139. Musk, 69. Mutism, hysterical, 574. Myotatic, 556. Mysteriea, natural, 109. N Names, euphonious, 59. Nancy, hypnotism at, 154, 159. Napoleon, 85. Narcosis, nervous mechanism in, 123. Narcotism, 111. Nature, human, 359. Natures, two in man, 148. Nature's compensations, 508. Nauheim, baths at, 328; exercise at, 328; suggestion at, 216. Nectarium, proprietary medicine, 59. Nephritis, insidious, 642. Nerve currents, 123. Nerve explosions, 564. Nerve fibers, plexuses, systems, 109. Nerve impulses and electricity, 110. Nerve pressure, anesthetic for, 401. Nerves and tissues, 88. Nervous diseases, organic, 508. Nervous weakness, 555. Nervousness, Jews, Quakers, Roman Catholics and, 778. Neuralgia, 59. Neurasthenia, an American disease, 559; arteriosclerosis and, 557; Bright's disease and, 557; concentration of mind and, 560; diabetes and, 559; due to over-attention, 559; hysterical, 561; in the old, 557; melancholia and, 556; nervous weakness and, 555; paresis and, 532; rheumatism and, 555; significance of, 555, 556; simulation of, 557; splanchnic, 36, 297; substitution of symptoms and, 561; too satisfying, 555. Neuritis, deltoid, 397; ulnar, 398. Neuroglia cells, perivascular, 122; plexiform, 126; pseudopods of, 122; spinal, 122; subcortical, 122; superficial, 126. Neuroglia theory, 86, 119. Neurokym, 111. Neurons, from optic lobe, 117; in psychic states, 117; movement of, 114, 119; motor, lower, 114; peripheral, 118. Neuroses, accessory, 749; biliary, 586; intestinal weight in, 285; motor, 589; secretory, 586; sexual, 472. Neurosis, cardiac, 321; exercise and, 326; muscular, 393; neuritis and. 398. Neurotic joints, 589. Neurotic simulation, forms of, 585. Neurotic tendencies, 480. New Englanders, religious, 82. News, bad, 85. Newspapers at breakfast, 170. Newton, 130. Night air, 450. Night duty, 175. Night terrors, ghost stories and, 668; melodrama and, 668. Night workers and alcohol, 175. Nightmare, 339. Nihilism, therapeutic, 5. Nissl bodies, 114. Nitrate of silver, 36. Nitrous oxide, 18. Nodes, Heberden's, 422. Nomenclature of disease, 556. _Non nocere_, 187. Norman, 42. Nosology, preputial, 475. Nostrum promoters, 56. Nostrum venders, 3, 59. Nothing to do, 184, 218. Nursing, cheery, 760; suggestions and, 460. Nurslings' immunity, 460. Nutrition, intrauterine, 465. Nux vomica, 5. O Obese, 290. Obesity, alimentary, 293; constipation and, 296; early treatment of, 292; essential, 293; examples and, 293; exercise and, 294, 296; frequency of, with diabetes, 294; heredity and, 293, 295; pathological, with diabetes, 290; prophylaxis in, 293; sleep and, 294. Obsession, sexual, 476; subconscious, 476. Obsessions, 624. Obstacle sense, 214. Obstetrics, posture in, 459; suggestion in, 452; sympathy harmful in, 452. Occupation, alcohol and, 398; diversion of, 226; dual mental, 139; dusty, 172; feminine, 183; finding mental, 223; lack of, 219; mental condition in, 177; pleasant, 84; position during, 176; sedentary, 302; standing, sitting, intervals of rest in, 173. Occupation pains, 396. Ointment, expensive, 59; weapon, 54. Old-maid, psychasthenic, 221. Olfactory acuity, 619. Operation, idea of, 751; mental influence after, 759; suggestive, 306, 431; visits after, 760; work after, 760. Operations on the abdomen, 303; series of, 304. Opium, in hypnotism, 156; mind and, 192. Oppenheim, Prof., 323, 511, 512, 527, 660. Optic thalamus and dual dispositions, 151. Orchitis and epigastric reflex, 252. Ordure in therapy, 34. Organic disease, mental influence and, 190. Organic nervous diseases, 508; adventitious symptoms of, 509; compensation and, 508; incurable, 509; prophylaxis in, 509; unfavorable influence and, 508. Organs, feminine, out of pelvis, 430. Osler, Sir William, 11, 323. Osteoarthritis, 424. Osteopath, 52, 381. Osteopathy, success of, 207, 385, 386. Overcautiousness, 189. Overeating, habit of, 266, 291, 297. Oversensitiveness, neurotic, 239. Overseriousness, 218. Overweight, prevention of, 295; short life and, 294. Ozena, 98. P Paget, Sir James, 589; on hysterical joint, 749; on neurotic joints, 386. Pain, after operation, 761; a stimulus, 240; bearing, reconstructive, 235; character and, 238; consciousness of, 236; conservative, 240; contraindication to treatment, 394; deterrent, 68; differentiation of, 241; diffusion of, 238; discipline for, 238; dispelling, 130; distraction and, 754; diversion and, 225, 754; equanimity in, 779; in life, 237; location of, difficult, 251; memory of, pleasant, 238; 724; neurotic and organic, 240; on motion, 241; over healthy lung, 362; overattention and, 236; power to bear, and the individual, 441; preoccupation and, 235; psyche in, 761; radiation of, 240; relief of, in gynecology, 431. Pains, barometer and, 382; company in, 10; in rainy weather, 382; muscular aches and, 389; occupation of mind in, 395. Paladino, Eusapia, 88. Palpitation from over-attention, 324. Palsies, musculo-spiral, 401; neurotic, 589. Palsy, infantile, training for, 216. Panniculus, 299. Paracelsus, 15, 688. Parallels, distortion of, 770. Paralysis agitans, 579; cord stretching in, 544; cures of, 544; drugs in, 544; Frenkel's method in, 544; mental control in, 542; mental influence and, 543; organo-therapeutics and, 544; psychic factors in, 542; psychotherapy and, 545; suspension and, 544; vibration and, 544. Paranoia and paresis, 532. Paraplegia, mimicry of, 590. Paresis, alcohol and, 530, 532; consoling hesitancy in diagnosis of, 533; difficulty of diagnosis of, 534; exciting life and, 530; hereditary factors in, 532; low grade nervous system and, 530; paranoia and, 532; parasyphilitic, 530; psychic influence in, 533; simulants of, 534; sparing relatives in, 533; syphilis and, 631; worry over syphilis in, 530. Paris, Dr., 16. Parry, old Dr., of Bath, 163. Parthenon, optical corrections, 772. Pâtés de foie gras, 291. Pathology, humoral, 57. Pathophobia, 612. Patient, individual, 10; his disease and, 163. Patients, objective and subjective history of, 164; no incurable, 184. Paul of AEgina, 13. Paul, St., 148. Pawlow on digestion, 269. Payot, M. Jules, on will, 220. Pelvic discomfort and attention, 430. Peristalsis, attention and, 270; experiments upon, 269; psychic influence and, 269. Perkins' tractors, 5, 48, 51, 386. Perversions, sexual, 489. Personal influence, 69; place of, 77; relationship and, 77. Personality, deeper levels in, 150; dual, hypnotism and, 150; dual, hysteria and, 149; human, 607; impressive, 70, 147; in therapeutics, 69; other. 135; primary, 148; secondary, 149; supernumerary, 149. Pessimism, 233. Pets, fat, 291. Pettigrew, 61. Phantasms of the dying, 147. Pharmaceutics, father of modern, 15. Pharmocopeia, 1. Phenomena, healing, 78; hysterical, 149. Philip Neri, St., 74. Phobophobia, 612. Phthisiophobia, 612. Phthisis, exaltation in, 642. Physicians, abdominal discomfort and, 302; as patients, 191; family and, 729; old family, 714; personality of, 191. Physiognomy, 106. Pictet, 18. Pieta, 36. Pigmentation, neurotic, 493; psyche and, 494. Pills, bread, 88, 281; ground biscuit. 281. Pinel, 8. Planes, intermuscular, 393. Plasters, medicinal, 63; suggestion of, 34. Plato, 10, 94, 99. Play and exercise, 204. Pleasure, joy and, 104; pain ingredient in, 240. Pleural adhesion, 401. Plexuses of nerve fibers, 109. Pliny, on proprietaries, 59; the elder, 59. Plombières, 287. Plutarch on suicide, 719. Pneumogastric pressure, 315. Pneumonia, 3, 22; depression in, 23: heart failure in, 23; hereditary, 383; in athletes, 202; nursing in, 23; suggestion in, 23. Podmore, 55, 605, 607, 635. Polypharmacy, 41. Pomponatius, 14. Ponto, 68. Pope, 223. Pope Leo XIII, 223. Pork and cabbage, 249. Position, after meals, 176; changes of, 210; in constipation, 276; in emptying the bladder, 472; in therapy, 207; post-operative, 763; relief and suggestion and, 213. Pott's disease, 68. Poultices, of crushed lice, 34; of deterrent materials, 34; of insects, 34; of moss from mummy skull, 34; ordure, 34; signatures and, 34. Powder, sympathetic, 56. Power to choose, 149; will, 740; will, responsibility and, 738. Practice, metallic, 50. Precious stones, signatures and, 36; suggestions and, 36. Precordia, pain in, 339. Predisposition to tuberculosis, 354. Pregnancy, 453; abortion for vomiting in, 455; air in, 453; exercise in, 453; habits of life in, 454; natural life in, 454; obesity in, 454; termination of, natural, 454; vomiting in, 455; vomiting of, remedies for, 455. Premonition, 78, 634, 675; fulfilled, 637; memory hallucinations and, 635; paralyzing, 611; suggestion and, 635; superstitions and, 638; unfulfilled, 637. Premonitions, coincidence and, 638; telepathy and, 640. Prepuce, long, pathology in, 475. Preputial cleanliness, 485. Prescriptions, earliest, 60; favorite, 3; Latin, 191; many ingrediented, 41; secret, 192. Pressure discomfort, abdominal, 252. Principles, chemical and physical, 132; vitalistic, 132. Prognosis in Graves' Disease, 503. Prophylactic psychotherapeutics, 237. Prostate and self-abuse, 484. Prostatism, 468; castration and, 468; individual, 471; organotherapy and, 468; palliative treatment for, 471; position in, 471; seminal vesicle tissue for, 468; suggestion and, 270; vasectomy and, 469. Prostatitis and epigastric reflex, 252. Proteus, daughter of, 688. Providence, trust in, 775. Pruritus, air bath and, 494; diversion of mind in, 495; mental factors in, 494; occupation and, 495. Pseudo-angina, 338. Pseudo-cyesis, 438. Pseudo-epilepsy, 538; auto suggestion and, 539; dread and, 539; menopause and, 540; mental cures of, 541; neuronic disturbance and, 539, 597, 693. Pseudo-Messiahs, 81. Pseudo-paresis, memory disturbance in, 531; tremor in, 531. Pseudopods of neuroglia cells, 127. Pseudo-pregnancy, 438. Pseudo-presentiments, 635. Pseudo-rabies, 753. Pseudo-rheumatism, 379. Pseudo-science, 43, 61, 81, 35; mental healing and, 38. Psychasthenia, heredity and, 603; natural and acquired, 598; post-critical, 602; retirement and, 602. Psychic research, 144. Psychic states, neurons in, 117. Psycho-analysis, 77, 595, 625; dreams and, 595; hysteria and, 595; instruction in, 596; mesmerism, etc., and, 595; reversion and, 595; sex and, 595. Psychology of advertising, 690; of the mob, 690, 692; of patent medicines, 690; old and new, 58; principles of, 201. Psycho-neuroses, 239, 281; after-treatment for, 591; appetite and, 592; asafetida and, 593; bread pills and, 593; business worries and, 593; children in, 592; disappointments and, 593; diversion and, 592; dominant ideas in, 593; drugs and, 593; love and, 593; lumbar, sciatica and, 406; mental impression and, 591; motor, 589; occupation and, 592; painful, 589; post-operative, 762; quinine and pepper for, 593; sorrow and, 594; subconsciousness and, 594. Psychotherapeutics, unconscious, 19. Psychotherapy, abuse of, 6; Alexandrian, 11; at Rome, 12; concealed, 192; frank use of, 192; general principles of, 185; history of, 2; indeliberate, 3; individual patient and, 163; Münsterberg, Prof., on, 778; religion and, 775; skin diseases and, 491; surgical, 746; systematized, 192; tact and, 191. Pulse, intermission of the, 339; morning, 343. Pulse, rapid, hereditary, 340; paroxysmal, 340; persistent, 340; prognosis in, 340. Pulse, slow, athletes and, 344; congenital, 344; Napoleon and, 344. Punishment, deters, 743; of sub-rational, 743; responsibility and, 740. Purgatives, abuse of, 287. Purgings, old time, 381. Purifiers, blood, 57. Pyramid, 7, 112. Pythagoras, 26. Q Quack, 3. Quackery, history of, 53; mind cures and, 46. Quakers, color blindness in, 772; nervousness among, lack of, 778. Quinine, as a febrifuge, 28; as prophylactic, 28; in fever, 28; suggestion and, 28. R Radiation of pain, 241. Radium, 5, 45. Rainy weather pains, 382. Ramon y Cajal, 110; on attention, 126. Rattlesnake bite, 65. Raynaud's disease, 63, 492. Rays, actinic, 44; ultra-violet, 45. Razor, dread of, 195. Reaction, exaggerated, 360. Reading, for insomnia, 139; in bed, 139; mind quiescent during, 139; muscles during, 195; of newspapers, 138. Recreations, 9; mental, 13; music and, 139; social, 139; theater and, 139. Re-creation, 124, 138. Reduction in weight, alcoholism and, 293; a life task, 293; without effort, 293. Reflexes, cardiac, 330. Regulation, monastic, 104. Reid, Dr. Archdall, on heredity, 230, 699. Reil, Island of, 18. Relationship, personal, of physician and patient, 164. Relaxation, abdominal, 209; mental, 140; of mind, 138; sessions of, 198. Relief, in severe injuries, 85; natural, 188. Religion, cheapening, 779; insanity and, 777; meaning of, 779; psychotherapy and, 775. Religious sense, disintegration of, 776. Remedies, new, 19; plus suggestion, 19, 197; proprietary, 59; repugnant, 66; secret, 53; secret, origin of, 53; specific, 186; various, 1, 349. Reserve energy, law of, 18, 92, 93, 310. Reservoir of energy, 93. Residue, intestinal, 274. Responsibility, 738; differing, 741; of defectives, 743; personal, 148; punishment and; 740; will power and, 742. Rest, genuine, 224, 237; pain and, 52, 188; wear and, 602. Restlessness, conservative, 211. Retention, mental, 143. Reutergehem, 159. Rhazes, 13. Rheumatism, 44, 98; acute, 382; anodynes for, 406; classic symptoms of, 406; derivation and relationship of, 380; foot troubles and, 414; heredity of, 382; muscular, 391; no lasting effects in, 379; old injuries and so-called, 387; recurrence of, 384; sequelae of, 384; so-called, 385; so-called chronic, 383; subacute, 384; treatment, abuse of, in, 381; unfavorable suggestion and, 385. Rhinitis _sympathetica_, 369. Rhythm, nodal, 342. Ribot, 138. Richardson, Benjamin Ward, 16. Riding, horseback, 204. Ring-worm, 61. Robert Boyle, 61. Roberti, S. J., Father, 65. Robertson, Dr., 16. Roger Bacon, 466. Roman life and manners, 58. Rome, 8; patent medicine men in, 58. Röntgen, 44. Rose, catarrh suggested by, 372. Rose cold, 369, 375. Rose fever, artificial, 372. Rossetti's grief, 732. Routine, weekly, 183. Royal Society, 50. Royal touch, Charles I and II and, 79; Edward the Confessor and, 79; James I and, 79; Queen Anne and, 79; Queen Elizabeth and, 79; William III and, 79. Royce on premonitions, 635. Rubber, 52. Rules, dietetic, 256. Rumbling, intestinal, 284. S St. Ives, R. L. Stevenson, 357. St. John Long's liniment, 29, 381, 402. St. Moritz, 357. St. Vitus' dance, 688. Sacrocoxalgia, 68. Sacro-iliac joint, tuberculosis of, 403. "Safe cure," 58. Saleeby on gymnastics, 203. Salicylates, as specifics, 387; in old and young, elimination of, 387. Salivation, pregnancy and, 457. Salmon, not tortoise, 338. Salpêtrière, 154, 159. Salt, excess of, 283; mucous colitis and, 284. Sanatoria, modern and ancient, 10. Sardonyx and suggestion, 62. Sarsaparilla, 5; suggestive value of, 57. Sauerkraut, 248. Sausage, blood, 77. Scheidemantel on psychotherapy, 17. Schools, teaching of pathology and physiology in, 95. Schopenhauer, 648. Schrenk-Notzing and hypnotism, 159. Schurz, Carl, and failed premonition, 637. Sciatica, 402; acupuncture for, 408; etiology of, 404; hot needles for, 408; intra-pelvic causes of, 405; position at work and, 405; pressure and, 404; stretching and, 408; treatment for, 405. Science and a Creator, 776. Seasickness, 97; remedies and suggestion, 97. Secretions as remedies, 66. Sedentary life, preparation for, 200. Self, over-attention to, 600; subliminal, 148; the other, 148. Self-abuse, after-cure of, 487; air and, 487; breaking off the habit of, 486; cleanliness and, 488; confession and, 486; confidence and, 486; effect of, on prostate, 484; exaggerated effects of, 483; female, 488; habit of, 482; insanity and, 484; occupations and, 488; preputial concretions and, 485; reading and, 488; relapse into, 486; sleep and, 487; times of danger and relapses into, 487. Self-consciousness, in clergymen, 582; in teachers, 582. Self-control, 148; for obesity, 294. Self-denial, 240. Self-discipline, 146. Self-hypnosis, 161. Self-indulgence, 148. Self-watching, 600. Sensations, ideas and, 109; manifold, 560; missed, 129; over-attention to, 560; simple painful, 131; transfer of, 252; uncomfortable, 218. Sense of pressure, 262. Sepsis and alcohol in suggestion, 30. Serpents in therapeutics, 65. Sex, cultivation of, 481; curiosity concerning, 489; exaggerated significance of, 479; expectorating, the, 346; in the background, 481; "mad," 480; on the mind, 479; perversion of, bathing and, 489; ugly habits and, 481. Sexual afflictions trivial, 473. Sexual neuroses, 472. Sexual perversions, 489. Sexual solicitude, 477. Sexual symptoms, exaggerated, 472. Sherrington on nerve mechanism, 123. Shilling, live on a, and earn it, 268. Shivering, 773. Shock, anesthesia and, 754; the heart and, 314. Shoe-maker, magic, 414; present day, 418. Shoes, old-fashioned, 418; sloppy weather, 414. Short circuit, mental, 223, 225. Shoulders and feelings, 103. Sidis, Boris, on psycho-analysis, 270. Sight, lapse of, 129. Signature, tremor in, 584. Signatures, doctrine of, 21, 34, 35; psychotherapy and, 35. Simpson, Sir James, 147. Simulation, psycho-neurotic, 588. Sitophobia, 264, 612. Sitting on foot, 405. Skin lesions, artefact, 495; mind and, 493. Sleep, 111, 122, 123; amount of, 165; at sea, 658; communications during, 136; encroachment on, 183; habits and, 660; how much necessary, 653; Humboldt on, 653; hypnotic, 152; hypnotism and, 159; loss of, longevity and, 661; mental diversion and, 661; monastic rule and, 295; not dreamless, 672; noise and, 666; on trains, 666; prevention of, 653; solicitude over, 652; starting in, 664; troubles of, 663; troubles of, hunger and, 665; vibration and, 566. Sleeping in the light, 669. Sleeplessness, 651. Smaragdum and suggestion, 62. Snake, bite of, suggestion for, prostration and, 32; in stomach, 13; skin of, in lichen, 25. Society, Perkinean, 49; Psychic Research, 146. Socrates, 11; diversion and, 610; headache cures and, 554. Solicitude and prognosis, 237. Somnambulism, 138; hypnotic, 161. Somnambulistic, 137. Sound in hypnotism, 156. Sound reproduction, 610. Space, filled, illusion of, 768. Spasm, expiratory, 364; inspiratory, 364. Specialist, advertising, 476, 482. Spectacles properly fitted, 258. Speech, tricks of, 566. _Spes pthisica_, 642. Spinal cell, 133. Spine, typhoid, 403. Spirit rapping through foot tendons, 419. Spiritualism, 78. Spitting, unnecessary, 346. Spleen as food, 244. Sport, 228; for its own sake, 229; indoor, 204; winning, 229. Sprain and fractures, 387. Sputum as a remedy, 67. Station, tremor in, 581. Steak, camel and elephant, 245. Steppes, 23. Stereoscopic vision, 766. Stevenson, Robert Louis, 356. Stew, cat, 245; dog, 245; lion, 245; rat, 245. Stigmata, hysterical, 590. Stomach, attention and the, 306; dilatation of the, 330; mental states and the, 243; motility of the, 261; not test tubes, 132, 242; resonance in, fifth interspace, 332; snake in the, 13. Stout people, constipated, 278. Stroke, "third fatal," 523. Stroking the forehead, 156; hypnotic, 153. Students, medical, 99; symptoms in, 93. Study, 125. Stupidity, bodily conditions and, 106. Stuttering, 570; attention to, 577; breathing and, 578; correction of respiratory defects in, 573; cures of, 576; distraction of mind in, 79; forms of, 570; hindrances to speech and, 577; inserted letters in treatment for, 578; in the young, 573; in women, 573; Itard's fork and, 578; Kingsley's cork and, 578; Leigh methods and, 578; mental influence and, 572; practice in self-control for, 573; regulation of respiration in, 577; singing in treatment for, 577; state of mind in, 57; suggestion for, 579; tongue against teeth in, 578; tongue lowered in, 578; treatment for, 576; type of loss of control in, 570; walking and, 571; writing and, 571. Subconscious self, 145, 148. Südhoff, 38. Suffering, a tonic, 723; real, 222. Sugars in constipation, 276. Suggestion, 2; antimony and, 25; as to symptoms, 360; coincidence and, 20; death and, 91; for colitis, 288; for surgical lesions, 748; in cold, 21; influence of, 76; in rheumatism, so-called, 385; in tuberculosis, 362; mechanism of, 109; neutralizing contrary, 186; not heredity, 251; pathological, 93; physiological, 260; seasickness and, 97; unfavorable, 186. Suggestions, optimistic, 511. Suggestive operation, 306. Suicide, 713; among children, 720; bureau of, 714; burial in disgrace and, 719; cataclysm and, 718; Chesterton on, 722; confession and, 714; contagious, 691, 720; cowardice of, 721; disgrace and, 719; dread of, 714, 726; earthquakes and, 718; epidemic of, 691; functional irrationality and, 714; Hamlet and, 722; headache and, 715; insomnia and, 715; justification of, 9; melancholia and, 556; mental factors in, 716; most frequent in June, 717; pain and, 723; prevention of, 713; problems of, 718; physician and, 726; prosperity and, 713; rarest in December, 717; reassurance and, 725; religion and, 718; social factors in, 717; suggestion and, 713; underweight and, 297; unexplained, 195; war reduces, 717; weather and, 715; women of Milesia and, 719. Supernatural, naturalizing the, 607. Superstition concerning "13," 639. Superstitions connected with medicine and surgery, 62. Suppression of reaction, 86. Supreme Being, 78. Surgery, astrology in, 746; suggestion and, 748. Surveillance, heart, 323; inhibitory, 600; insistent, 269; of function, 269; self, 600. Swallowing, 575. Sydenham, 16, 71. Symonds, J. Addington, and consumption, 357. Sympathetic powder, 66. Sympathy, 188; as a remedy, 222; heart and, 319. Symptoms, hysterical, 590. Synapse theory of fatigue, 123, 124. Syncope, neurotic, 540. Syphilis, curability of, 630; congenital contagion and, 630; heredity and, 629, 631; imaginary, 753; maternal immunity from, 630; paresis and, 631; worry and, 509. System, sympathetic, 127. Systems of nerve fibers, 109. Systoles, extra, 333. T Tabes, complications in, 527; "cures" of, 529; diphtheria serum in, 529; drugs in, 530; magic shoes and, 529; mental attitude and, 527; mild course in, 527; muscle control in, 528; normal lifetime and, 527; over-stretching the spinal cord in, 530; reassurance in, 528; relearning muscular movements in, 528; suspension in, 530; urethral treatment for, 529. Tabetic neuroses, 527. Table, leaving the, hungry, 299. Tachycardia, 340; essential, 342; Mackenzie on, 342; paroxysmal, 341; Wood's case of, 341. Tails, expressions in, 141. Talismans, 60. Talking, co-ordination and, 230. Tar water, 56. Taste, cloying, 131. Tea and abdominal distress, 307. Teaching, disease, 95. Tears, 66; grief and, 103; joy and, 103; relief of, 103. Telegraphy, wireless, telepathy and, 142. Telepathic premonition, 640. Telepathy, accidents and, 145; in trade, in ordinary life, and in juries, 143; investigation of, by French Academy, 147; negation of, 144; negative tests of, 147; on the stage, 144; social life and, 143; supposed examples of, 144; twins and, 147; wireless telegraphy and, 142. Temper, bad, 739; uncontrollable, 739. Temperature, variations of, 203, 354. Tennyson, 35. Tension, relaxation of, 197. Tenting in tuberculosis, 369. Thackeray, 35. Theater fires, 85. Theory, Duval, 123. Therapeutic persuasions, 26. Therapeutics of position, 208; popular, 186. Theriac, 20; Bernard's, 20; Galen's, 3. Thick lips, meaning of, 106. Thinness, physical disadvantage of, 298. Thompson, Francis, 357. Thompson, Prof. J. J., 139. Thompson, Sir Henry, 494, 657. Thomson, Dr. Wm. H., 505. Thoreau, 357. Thought, for others, 221; New, 209; original, 135; pale cast of, 737; transference of, 141. Thunder, fear of, 612. Tics, 230, 564; as types of nerve explosions, 564; children's, 568 drumming with the fingers, 567 emotional, 565; expletives and, 565 facial, 565; familiar expressions and; 565; gestures and, 565; heredity and, 569; in games, 567; jerking, 565; mental treatment for, 569 motor, 569; prophylaxis in, 569; shrugging, 565; speech, 565, 566 squinting, 565; swearing, 568 teachers' habits and; 566; winking, 565; writers', 567. Time is money, 179. Tissues, nervous, changes of, 89. Toes, claw, 418; hammer, 418. Tolerance, intestinal, 217. "Tommyrotic" and erotic, 480. Torcular Herophili, 12. Torticollis, 393. Tortoise and salmon, lives of, 338. Touch and sight, 214. Tozzi twins, 229. Tractoration, 48. Tractors, Perkins', 49; in yellow fever, 51. Training, 213; appetite, 216; equilibrium and, 215; facial muscles, 101; feeling and, 215; for pain, 217; for weight, 217; hearing, 215, 636; heart, 216; infantile palsy and, 216; in self-control, 745; intellectual, 218; memory, 686; movement, 686; muscles, 215; of defectives, 743; sight, 215; touch, 215. Trains and intestinal disturbances, 280. Treatment, absent, 5, 141. Tremor, senile, longevity and, 580; premature, 580; prognosis of, 580; significance of, 580. Tremors, 579; actors and, 582; clergy and, 582; dread and, 581; fright and, 581; hypnotism and, 584; in intention, 581, 583; mental control and, 583; self-discipline and, 584; shaving, dread of, 581; standing, 581; suggestion waking, 584; teachers', 582; types of, 579; writing, 584. Treves, Sir Frederick, on alcohol, 30. Trifles, fascination of, 651; in health, 164. Troubles that do not happen, 233, 612. Troy, 62. Trudeau, 359. Tuberculosis, classes of, 188; contagion and, 353, 628; courage in, 356; "cures" for, 351; early diagnosis in, 354; early stage in, 353; heredity and, 352; heroes of, 356; immunity from, 629; incipient, 348; incurable, 352; predisposition to, 354; prevalence of, 351; protective, 629; pulse and, 354; quitters and, 355; remedies for, 351; slow, 352; stimulating, 356; suggestion and, 362; temperature range in, 354; unfavorable prognosis in, 352; vital resistance and, 351; whooping cough and, 346. Tumors, pelvic, sciatica and, 405. Twain, Mark, disappearance story of, 608. Types of expression, 102. Typewriters' fingers, 89. Typhoid fever, antisepsis in, 24; in athletes, 202; mental symptoms in, 93; nurses in, 24; spine in, 403; suggestion in, 24. U Unconscious cerebration, 128. Unconsciousness, 119, 123. Underclothing, variety in, 167. Undereating, 297. Underweight, correction of, 300. Unguentum _Armarium_, 54. Unknown, the, 189, 607. Urbantschitsch, hearing training, 686. Uric acid diathesis, 270. Urinary worries, 470. Urination, position in, 459, 472. Urticaria, diarrhea and, 281, 282; mind and, 491. Use and abuse, 196. V Vacuum cleaning, 174. Valerian, 68. Valerianate ammonium, 68. Van Eeden and hypnotism, 159. Van Helmont, 15, 55, 64. Van Swieten, 17, 71. Variation, 633. Varicocele, 473; depression, mental, and, 474. Varicose veins, 208. Varicosities, feet elevated in, 208; occupations and, 208. Vascular pedicles, 126. Vaso-motor disturbance, 492. Vegetarianism, 256. Venesection, for eye diseases, 28; for migrane, 28; mental influence and, 28; mind and, 14; suggestiveness of, 28. Version, by heel in perineum, 459; natural, 459. Vertigo, Menière's, 516; over-attention and, 512; significance of, 512. Vest, 168. Vibrations of cells, moments of, 142. Viper venom, 66. Virchow, 62, 226, 618, 647; on hobbies, 226. Virility, The Ages of Mental, 624. Viscera, sensitive nerves and, 560. Vision, illusion of two-eyed, 764; stereoscopic, 766. Vitalism, 191. Vitality, resistive, and muscle, 108, 201. Volta, 48. Voltaic pile, 43. Vomiting, abortion and, 456; after anaesthesia, 758; distraction of mind and, 456; frequency of, 456; neurotic, 455; non-suggestion of abortion and, 456; of live mice, 462; of snakes, 462; pernicious, 455; pregnancy and, 456. Von Bülow's case of headache, 550. Von Leyden crystals, 364. Von Moltke, 647. Von Monakow, 115. Von Retzius, 121. W Wakefulness, matutinal, 662; persistent, 652. Waking, suggestion method for, 197. Walking, 205; complexity of, 229; coordination in, 3. Walks, morning, 169. Warming up, 92. Warning, coincidences and, 611 Warts, counting of, 493; Lord Bacon and, 493; mental influence and, 493. Wash water of little babies, 67. Water, dread of, 62; drinking, 232; hypodermic, 88. Waters, mineral, 45. Waves of nervous energy, 110. Weak foot, 391. Weakness and discomfort, 299. Weapon ointment, 54. Weapon salve, 55. Weight, abdominal distress and, 309; for height, 299; gain in, 301; good feeling and, 297; in intestinal neuroses, 285. Weir Mitchell's disease, 492. Wessex Tales, mental influence, instance of, 64. Whewell, 14. Which? (dream poem), 136. Whiskey, in hypnotism, 156; in snake bites, 32. White hair and fright, 494. Whoop, habit, 25. Whooping cough, 24; diphtheria serum in, 25; mine air in, 25; more air in, 25; sea water in, 25; tuberculosis and, 25. Wiggs, Mrs., of the Cabbage Patch, 234. Will, appetite and, 592; breaking the, 744; disorders of the, 694; education of the, 220; motion and the, 109; over the heart, 313; re-education of the, 737; to live, 90; training the, by punishment, 742, 744. Wimshurst machine, 43. Wind, second, 92; third and fourth, 92. Wine and the doctrine of signatures, 36. Winkel on vomiting at pregnancy, 457. Witchcraft, 141. Woman, average normal, 433. Women, feed hearts of, 221; home-keeping, 169; working, 169. Woodward, 286. Wordsworth, 135. Work, at home, 182; latent intellectual, 134; monastic division of, 227; night, 175; six hours of, 182; social, 221; the day's, 165, 171; two-hour periods of, 227. Workers, night, 175. Working woman, 183. Worldliness, this, 779; other, 779. Wraiths, 608. Writers' cramp, 396, 572. Writing rule, Gower's, 174, 396. X X-rays, 5, 44. Y Yawning, contagious, 688. Z Zöllner's distortion of parallels, 771, Zoöphobia, 612.